Responsibility Without Blame: Empathy and the Effective Treatment of Personality Disorder

Effective treatment of personality disorder (PD) presents a clinical conundrum. Many of the behaviors constitutive of PD cause harm to self and others. Encouraging service users to take responsibility for this behavior is central to treatment. Blame, in contrast, is detrimental. How is it possible to hold service users responsible for harm to self and others without blaming them? A solution to this problem is part conceptual, part practical. I offer a conceptual framework that clearly distinguishes between ideas of responsibility, blameworthiness, and blame. Within this framework, I distinguish two sorts of blame, which I call 'detached' and 'affective.' Affective, not detached, blame is detrimental to effective treatment. I suggest that the practical demand to avoid affective blame is largely achieved through attention to PD service users' past history. Past history does not eliminate responsibility and blameworthiness. Instead, it directly evokes compassion and empathy, which compete with affective blame.