Drawing on philosophical arguments, I have clarified what impulsive behavior is so that it can be better understood in clinical contexts. We can understand it as unvoluntary action due to an irrational but intractable belief or a gap between belief and motivation; or an inability to act on higher order desires due to irresistible desires; or to act on desires that are very, very hard to resist but are minimally resistable. Impulsivity doesn't necessarily mean ‘unplanned.’ Rachel and Maggie are impulsive, but Rachel is more so. Although impulsive behavior may involve risk-taking, it needn't do...
Drawing on philosophical arguments, I have clarified what impulsive behavior is so that it can be better understood in clinical contexts. We can understand it as unvoluntary action due to an irrational but intractable belief or a gap between belief and motivation; or an inability to act on higher order desires due to irresistible desires; or to act on desires that are very, very hard to resist but are minimally resistable. Impulsivity doesn't necessarily mean ‘unplanned.’ Rachel and Maggie are impulsive, but Rachel is more so. Although impulsive behavior may involve risk-taking, it needn't do so. Furthermore, spontaneous behavior is also risky. It is also unplanned, but occurs within the context of self-monitoring for the limits of the domain. I introduced the Olaf principle, which is that some of our commitments are indefeasible, identity-conferring commitments. The Olaf principle might explain a difference between spontaneity and impulsivity in that the latter is an overriding of one's unconditional commitments. The worry here, though, is that this way of understanding impulsivity raises the ‘mad or bad’ problem discussed in the Introduction. To remind readers, this problem is one of determining when a psychiatric judgment of pathology has identified a genuine psychiatric condition and when, instead, such judgment contains moral values of social or cultural disapproval.5 The issue, as John Sadler sets it out, is what degree of social deviance or unconventionality is enough to count as a mental disorder (cf. Sadler 2005, Ch. 6). An example from psychiatry is whether to include behavior such as pedophilia as a psychiatric condition or just a criminal one. In thinking about one impulsive BPD behavior, casual sex, we see this problem more clearly. Norms for femaleness lead us to judge women who engage in casual sex much more harshly than we do men. Casual sex is not necessarily impulsive. But, because of those gendered norms for sexuality, when we find women who engage in casual sex or sex with multiple partners, we look for an explanation. Are they sluts (morally bad) or can't they help themselves (impulsive and mentally ill)? Or are they deliberatively and deliberately violating norms for gendered sexuality that they see as confining and oppressive?
Again drawing on the Olaf principle, I suggest that one thing that might help in distinguishing female casual sex as impulsive versus spontaneous would be to know whether or not the person holds an Olaf principle about casual sex. This principle might be something like, ‘I will only have sex with someone after I've gotten to feel affection and closeness with him or her,’ or ‘I will only pick up people to have sex with once a year.’ If they do hold such a principle and then they violate it, we might conclude that their behavior is impulsive. Here the connection between spontaneity and the Olaf principle is clear: behaviors are chosen – sometimes sudden and unexpected ones – within the context of self-monitoring and attention to a broader landscape of aims and directions. This may be applicable whether we are talking about jazz or sexual behavior.6 However, if women who have casual sex don't hold an Olaf principle about it, it is an open question whether or not they are doing so impulsively. Clinicians should take into account the gendered sexual norms that set up an expectation that women who say they ‘just can't resist’ casual sex must have something wrong with them – cultural norms don't indicate this about men. Maybe women just really like sex and like it to be spontaneous. Are they exempt from being judged as morally bad? Maybe not, but that isn't in the domain of psychiatry.
As we have seen, sexual activity is only one way that BPD patients may be either impulsive, thereby exhibiting symptomatic behavior, or more deliberately transgressive, expressing defiance of cultural norms. Rachel is impulsive by taking off on her run, and what makes her behavior impulsive rather than spontaneous is that she doesn't seem to be engaging in any self-monitoring as to how this particular move will affect a larger picture nor does she seem either to consider her late night run an aspect of a defeasible commitment or a considered and chosen violation of an unconditional commitment. Maggie's cutting is more complicated; if we use the framework of the defeasible and unconditional commitments, Maggie might be seen as struggling with defeasible commitments rather than with irresistible desires, where the therapeutic aim might be to shift a defeasible commitment not to cut to an unconditional commitment not to self-injure any more. Whether or not Maggie can be said to be struggling with competing commitments or with competing desires may depend, at least in part, with the degree to which Maggie considers her options for action within the context of a larger life plan. Or consider someone who becomes hostile and aggressive in the face of opposition to her expectations or aims, or (a messier problem) someone who is in substance abuse treatment and picks up that drink anyway. A person with such behavior must be considered not only in the light of a clearer understanding of what impulsivity is but also in light of that person's life context, aims, and defeasible and unconditional commitments if she holds them. My working theory of impulsivity, therefore, will need to be particularized to given patients, and then the theory modified in the light of grounded and everyday therapeutic experience.
Chapter. 8676 words.
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