I came across this online on accident. Someone else had posted it but it kinda changed so much for me and I wanted to share and see what you guys thought. Knowing the cluster b ended up in the DSM for political reasons shocked me. Here are some quotes from the article:
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“Moral considerations do not appear to play a large role in discussions of the DSM-IV personality disorders...Yet philosophical analysis reveals that the Cluster B personality disorders, in particular, may in fact be moral rather than clinical conditions…Successful treatment in this case is tantamount to a moral conversion.”
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“…DSM classifications are highly vulnerable to political and economic influences and interests, a fact that even sympathetic insiders freely admit. Personality disorders have proven especially vulnerable to these forces. As Lee An Clark states, "it is no secret that the offcial classification of personality dlisorders...embodied in the DSMs represents a compromise among the often competing interests of clinicians, researchers, educators, and statisticians with various training backgrounds and orientations…Others are even more critical, stating that in many ways, the DSM-IV classification of personality disorders is more like a political or philosophical statement than a scientific classification.”
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“It is impossible to imagine a successful "treatment" for the Cluster B disorders that does not involve a moral commitment to therapy.
The central issue is whether there exists a moral willingness to change together with a sustained readiness to make the moral effort to make and sustain that change. Thus it is impossible to imagine a successful "treatment" or "cure" for those conditions that does not involve some sort of conversion or change in moral character.
On this basis, it can be argued that these are fundamentally moral conditions and, consequently, that their treatment requires a sort of moral treatment.
None of this should be taken to imply that Chuster B disorders cannot or do not admit of treatment using other means. Rather, the point is simply that those other treatment interventions can never be sufficient for complete treatment or recovery.
A full cure requires moral willingness, moral change, and moral effort. Of course, these moral desiderata are not mentioned in most standard psychotherapeutic interventions recommended for the treatment of personality disorders.
Scientific objectivity does not permit it.
But the point is that those desiderata are ultimately required for successful treatment and cure.
To see why, consider very briefly the nature of the individual Cluster B disorders.
Antisocial personality disorder is said to involve a "pervasive pattern of disregard for and violation of the rights of others" (APA 1994: 649).
Narcissistic personality disorder is said to involve a "lack of empathy" (661).
The moral nature of histrionic personality disorder is more implied than explicit but is clear nonetheless. Here the "excessive attention seeking" and "inappropriate sexually seductive and provocative behavior" referred to is flatly inconsistent with a pattern of empathy and regard for others (657-58).
Finally, the "inappropriate, intense anger" and instability in interpersonal relationships" cited in the diagnostic criteria for borderline personality disorder again imply clear moral deficits in empathy and regard for others.
There is therefore no escaping the conclusion that, either by explicit mention or by implication, persons diagnosed with Cluster B personality disorders exhibit morally objectionable and reprehensible behavior toward others.”
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“Clearly, moral shortcomings of some sort appear to be necessary conditions of the DSM Cluster B personality disorders. It follows that unless those moral problems can be overcome or eliminated, successful treatment and cure are impossible.
Someone who is empathic and caring of others cannot logically be said to suffer from antisocial or narcissistic personality disorder in the way these are presently characterized in the DSM.
Likewise, someone who has reached the point of being morally committed to being more respectful and considerate of others can plausibly be said to be improving and recovering from histrionic personality disorder.
The case of borderline disorder is more difficult, but here as well it is plausible to imagine that a moral commitment to being patient and loving with both others and oneself is an essential ingredient of any serious treatment and cure.
Note that the same cannot be said of psychotherapeutic interventions for many other sorts of conditions. There are no such moral presuppositions for desensitization behavioral therapy for phobias or even cognitive therapy for depression.
Willingness, commitment, and effort are of course required for therapy to succeed in these and many other cases. But moral willingness, commitment, and effort of the sort we have been discussing are not required.
In addition, successful pharmacological interventions to reduce conditions like depression and anxiety for the Cluster B disorders may well help foster positive growth and development, but without a moral commitment to change, those interventions are doomed to remain insufficient and will elude any thorough cure.”
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“…you cannot be fully "cured" of antisocial, borderline, histrionic, or narcissistic personality disorder and regularly intend to be systematically cruel, dishonest, and indifferent to the feelings of others. Successful treatment here requires a moral commitment and character change of a significant sort.
This invites the question why treatment should be administered by medical professionals.
The issues go to the heart of the professional status of psychiatry as a medical discipline and the conditions it claims to treat. The situation is also reminiscent of the ideological and professional disputes associated with the eighteenth-century practice of moral treatment.”
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“Strictly speaking, the moral treatment of the Cluster B disorders falls in the province of what psychiatrist David Healy calls the quest for authenticity."
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Edit: added notes (below) that summarize the article
Cluster B pds are best understood as primarily moral/character disorders that manifest through deeply ingrained patterns of how a person treats other people—patterns that involve consistent ethical deficits like exploitation, entitlement, lack of genuine remorse, disregard for others’ rights and feelings, chronic deceit/manipulation, and one-sided empathy demands.
The mainstream psychiatric/psychological framing that treats them as purely (or even primarily) medical/brain-based conditions is:
• intellectually dishonest
• pragmatically convenient
• protective of institutional legitimacy
• enabling of continued harmful behavior
The diagnostic criteria themselves are saturated with moral language and normative judgments about interpersonal conduct. They are not describing value-neutral physiological malfunctions in the same way as, say, epilepsy or schizophrenia.
Pretending otherwise requires a level of compartmentalization that becomes increasingly strained the longer one observes real-world outcomes.
Genuine, lasting change in Cluster B presentations requires building morality/character-level ethical re-orientation:
• developing actual (not performative) empathy
• internalizing accountability for harm caused
• choosing to prioritize others' welfare and boundaries over self-gratification/entitlement
• accepting that one's own feelings do not automatically override others' rights.
Very little in the standard “evidence-based,” non-judgmental, validation-heavy therapeutic world reliably produces that kind of transformation. When profound change does occur, it is usually because some combination of the following happened:
• rock-bottom consequences (loss of relationships, legal trouble, ostracism)
• exposure to clear, consistent moral boundaries (people who refuse to enable or be manipulated)
• development of genuine guilt/remorse (not just shame about being caught or abandoned)
• voluntary commitment to living by a different set of ethical rules.
The medical model can sometimes manage symptoms or teach surface level coping skills, but it rarely produces the core ethical shift that is required to stop being chronically destructive to others. That shift is MORAL in nature.
The psychological/psychiatric insistence on a primarily medical framing is regarding cluster b is sustained more by professional self-preservation, fear of liability, desire to appear “scientific,” and ideological commitment to destigmatization-at-all-costs than by fidelity to either conceptual clarity or real-world therapeutic outcomes.
Cluster B is moral first, medical second (if at all). Treating it otherwise tends to protect the system and the sufferer more than it protects the people around them.