The Moral World of Personality Disorder Assessment

When asked about her behavior during a psychiatric assessment for personality disorders, one patient’s response included this description:

”It was completely crazy. I’m not quite that bad anymore.”

In the medical psychiatry, psychiatric diagnoses are often presented as neutral objects. Professionals assess and diagnose the disorder situated in a patient’s mind so that interventions can be targeted to alleviate the disorder. Professionals are expected to be neutral and understanding in the face of a patient’s struggles. When assessing patients through interviews and questionnaires, the professionals orient simply to gather information to evaluate whether the diagnostic criteria are being met.

But why would a patient then answer the question as quoted above when interviewed about her behavior in a personality disorder assessment? She calls her behavior ”crazy” and reassures that she is not ”that bad” anymore. These terms imply that she sees her past behavior not only as a medical issue, but as something wrong in a moral sense.

The neutral approach of the psychiatric assessment obscures the fact that psychiatric diagnoses are intertwined with the moral norms of our society. They are connected to our understanding of what is considered normal, what kinds of feelings and behaviors are desired, and so on. This is particularly pronounced in the case of personality disorders, which are seen as reflecting a person’s core traits. In this sense, they are treated differently from mood disorders, which can be considered as transient states that do not define a person’s character.

The Moral Underpinnings of Psychiatric Assessment

Personality disorders are defined by long-standing, inflexible, and pervasive personality traits that cause impairment and suffering. From a medical standpoint, this justifies to treat them as psychiatric disorders. However, it is interesting that the evaluation of personality disorders depends so much on the questioning of behaviors that violate social norms. In this way, the moral aspect is already coded into the assessment procedure.

The SCID-II (Structured Clinical Interview for DSM-IV Axis II Personality Disorders) is a commonly used assessment tool. The semi-structured interview begins with general open-ended questions, followed by a series of scripted polar questions. Patients are asked questions, such as “Have you often volunteered to do things that are unpleasant?” and “Do you flirt a lot?”. But what exactly qualifies as often volunteering for unpleasant tasks? How much flirting is a lot?

The assessment involves an evaluation of the line between the normal and abnormal behavior, with the idea that there exists the healthy or correct amount of such behavior. It does not take much to realize that these conceptions are very much shaped by the cultural understandings of the desired social behavior; they cannot be defined solely by some medical facts. Patients frame their answers and professionals interpret these responses based on their own moral and social understandings. There are no psychiatric assessment methods that are free from interpretation.

The Need for More Research on Psychiatric Interactions

What psychiatry needs more of is research on face-to-face interactions between professionals and patients to show how diagnoses are made on a practical level. How do the participants negotiate understandings of pathology?

In my article “‘It Was Really Sick:’ Managing Moral Evaluations during Personality Disorder Interviews,” published in Symbolic Interaction, I explored the role of morality in personality disorder assessment interviews in two Finnish psychiatric outpatient clinics. The data come from 12 patients who were interviewed by nurses using the SCID-II procedure. The article is part of my doctoral dissertation. The dissertation is mainly based on the conversation analysis method, which examines interaction turn-by-turn in great detail. Conversation analysis highlights not only what is said but how it is said — and how meanings are constructed collaboratively.

I also applied a theory of frame analysis by the famous sociologist Erving Goffman. It examines how people orient themselves to and interpret situations. A frame helps answer the question “What is going here?” In most situations, several things are happening simultaneously. For example, in a medical setting, patients usually interpret intimate questions as part of a medical assessment rather than an intrusion, because they are applying the frame of a medical encounter. However, if a question seems inappropriate, the patient may add another frame to the situation: that of a harassment. Similarly, in psychiatric interviews, patients may switch between frames to which they orient themselves, orienting themselves to a neutral clinical information gathering in one moment and to a moral judgment of their behavior or character in another.

Morality in interviews is a broad and ambiguous topic. I used frame analysis because it offers a solution for structuring the topic; it helps to distinguish moral orientation from other possible orientations. In this way, my work makes visible the often overlooked moral underpinnings of psychiatric assessment. Understanding these hidden dynamics can facilitate reflection on psychiatric institutions — and increase the awareness of the social and cultural factors embedded in mental health assessment.

Three Overlapping Frames

There has not been much research on how moral issues arise in psychiatric assessment and treatment. However, there are some exceptions. Sociologist Jörg Bergmann argues that instead of dismissing the issue, mental health professionals should actively reflect on and acknowledge the presence of moral aspects in their work. Doing so, he suggests, would greatly enhance their professionalism.

In my work, I have found that moral aspects are intertwined with the assessment process. At various points, either the patient, the nurse, or both oriented themselves to and made explicit the moral world underlying the SCID-II interview. This led me to identify the moral frame as one of the frames present during the assessment interviews.

Two other frames were the information-gathering frame and the everyday interaction frame. The information-gathering frame is the foundational structure of psychiatric assessment. It refers to the task that the participants are expected to perform: to gather the necessary information to evaluate a patient’s symptoms. This frame thus works as the guiding principle for the participants to interpret the situation.

The everyday interaction frame means orientation to the rules of non-institutional social contact. In addition to their roles as nurse and patient, the participants are also two people navigating the social situation using their lifelong experience of interpreting social interactions. This frame focuses on maintaining each other’s faces and ensuring a pleasant flow of interaction. These three frames are not mutually exclusive; rather, they often overlap, with one frame becoming more dominant depending on the context.

Moral Orientation in Practice

So what does this moral orientation mean in practice? I focused on sequences with clear moral connotations. My final data set consisted of 13 cases from ten different patients and four different nurses. Each case began with a nurse’s question and included the subsequent sequence in which a moral stance was expressed. The exchange included some form of evaluation of whether a behavior conformed to moral norms. The moral stances varied: in some cases, a moral stance meant that the patient admitted to having violated a moral norm, while in other cases, the patient defied the norm. The moral stances could originate from either the patient or the nurse.

In one instance, the nurse was interviewing a patient about paranoid personality disorder. The patient had previously indicated on a questionnaire that she “often suspected that her spouse or partner has been unfaithful.” The nurse pursued clarification to determine whether the suspicion was unfounded and thus indicative of paranoid tendencies. The patient admitted that her suspicions were not based on her partner’s actual behavior. The participants continued to process the issue. The following excerpt illustrates this discussion:

(The excerpts are streamlined for ease of reading and thus do not include the transcription symbols used in conversation analysis. The numbers in brackets indicate pauses in seconds.)

Nurse: “What kind of suspicions have you then had?”
(1.0)
Patient: “Well (0.2) totally crazy. So well, that first relationship was by far the worst that then I browsed through the other person’s phones and emails and everything and like it was really sick […]”

In such cases, the patient does not merely report their behavior but continues with a strong self-judgment. The patient labels her suspicions as “totally crazy” and “really sick”. With these kinds of extreme case formulations, it is evident that the patient is treating the issue as emotionally and morally charged.

Another type of option is when a patient attempts to prevent the negative implications of their response. In one example, the nurse seeks elaboration on the patient’s affirmative response to the questionnaire question “Is it insignificant to You what other people think of You?” This question belongs to the category of schizoid personality disorder.

Nurse: “Then you have marked that is it insignificant to you what other people think of you. You have marked that yes.
(0.8)
Patient: “Myeah.”
(1.2.)
Nurse: “But so like.”
(2.0)
Patient: “Not of course every – I do have that kind of boundaries. I not, I do know how to behave well or like I do attempt to behave well.”

In this excerpt, the nurse cites the affirmative questionnaire response. The patient first offers a minimal acknowledgment, followed by a pause indicating that she will not continue. The nurse’s incomplete turn (“but so like”) suggests that she sees the response as requiring further clarification. After a two-second pause, the patient denies the possible negative reading of her response — that she lacks boundaries and behaves in a socially unacceptable manner. In this way, the nurse’s turn, beginning with a contrastive “but”, signals to the patient that there may be something problematic in her answer: that, in this context, not caring about others’ opinions is not necessarily a desired quality.

After this excerpt, the patient goes on to present another interpretation of her answer: due to her appropriate behavior, she does not need to worry about what other people think of her. This explanation aligns with general social norms — one should not be neurotic about other people’s opinions, but still take others into consideration.

Nurses’ Participation in the Moral Frame

Each sequence begins with the information-gathering frame, in which the nurse poses a SCID-II interview question in a neutral manner. However, as previously noted, the SCID-II questions themselves carry implicit moral undertones. In these data, it is mostly the patients who make these moral aspects explicit. I have paid particular attention to how the nurses respond when this happens.

I have identified three ways in which nurses participate in the moral frame: supporting the patient, maintaining neutrality, or challenging the patient.

1. Supportive responses

In some cases, after the patient’s self-evaluative turn, the nurse adopts a supportive stance, helping the patient to present themselves in a positive light. This approach aligns with the everyday interaction frame, as it is consistent with the norms of friendly communication.

2. Neutral responses

In the second set of cases, the nurse remains rather neutral, acknowledging the gist of the patient’s turn without taking a clear stance. This is a neutral position. It is consistent with the information-gathering frame, where the primary goal is to gather diagnostic information rather than to engage in moral evaluation.

3. Challenging responses

In this third type of response, the nurse challenges the patient in some way. This is the most complex option in terms of frames. While challenging seems to happen in the service of information-gathering, I argue that in practice, it also falls within the realm of the moral frame. This is because the nurse focuses on something in the patient’s behavior that deviates from moral norms and holds the patient accountable for that behavior.

An example of this is a case in which the patient had affirmed the question, “When you are asked to do something that you don’t want to, do you say ‘yes’ but then you work slowly or badly?”. This question belongs to the category of passive-aggressive PD (no longer an official diagnosis). After some exchange, the following discussion takes place:

Nurse: ”Yeah but how do you take an attitude like usually like to these kinds of professional and social actions? That do you feel that you can just drop out from important tasks (1.0) if you don’t feel like it or do you think that everyone must take responsibility here?”
Patient: ”I do think that everyone must take responsibility and just like […]”

In this excerpt, the nurse explores the patient’s underlying motives. She offers two choises: a) that the patient’s attitude toward responsibilities is to ”just drop out from important tasks if you don’t feel like it” or b) that everyone must take responsibility. This type of question formulation clearly enters the realm of moral framing.

The verb “drop out” sounds irresponsible and antagonistic. The definition “important tasks” shows that the question is about something that should be taken seriously. The phrase “if you don’t feel like it” clearly disapproves of the wrong attitude. As for the alternative, “Do you think that everyone must take responsibility”, conveys a solid moral rule. To present oneself as a morally decent person, it seems clear which option to choose. Indeed, the patient complies with the moral expectation of choosing responsibility. This is a clear example of how the nurse actively reinforces the moral nature of SCID-II questions.

Discussion

This research highlights how moral connotations naturally emerge in the psychiatric assessment of personality disorders. Furthermore, it demonstrates how professionals work with patients to clarify their responses and, in doing so, collaboratively define the moral nature of their behavior. Recognizing the presence of the moral frame —alongside the information-gathering and everyday interaction frames — provides a more nuanced understanding of psychiatric encounters. While psychiatric assessments are primarily structured around data collection, moral considerations inevitably influence how both patients and professionals navigate the conversations. Acknowledging this interplay offers deeper insight into the social dynamics of psychiatric interviews.

From the patient’s perspective, a psychiatric assessment often involves highly sensitive matters. Questioning about a patient’s non-normative behavior is potentially face-threatening. Therefore, it is essential for professionals to consider how to approach these issues carefully. Protecting the patient’s face when dealing with sensitive matters can help them to gradually confront potentially problematic aspects of their behavior. Failure to do so may lead patients to withhold some challenging aspects of their experience. Furthermore, preserving a patient’s face is not just about eliciting open communication — it is also important for the sake of good working alliance.

On a different note, Jörg Bergmann has demonstrated that speaking about an event or behavior cautiously signals that the speaker treats it as a delicate and morally dubious matter. In psychiatric interviews, recipients of such cautious formulations may interpret them as considerate and sympathetic invitations to share their experiences, but sometimes they interpret them as conveying moral judgments. This dual scenario underlines the need for professionals to strike a balance between face-saving practices on the one hand and direct, transparent communication on the other.

Beyond gathering clinical data, a psychiatric assessment situation also serves as a space where patients process their problems and construct their identities: how they appear as persons, have they failed in some way in their lives, and so on. If professionals do not provide patients with the time and space for this reflection, they risk disregarding issues that are deeply significant to patients. Perhaps mental health professionals need to engage in moral discussions to some degree to maintain a strong working alliance with their patients. As Erving Goffman has noted, people use talk not only to exchange information, but often to justify the approval and sympathy they seek for themselves. Sensitivity to patients’ identity concerns is crucial for practitioners to keep in mind for humane psychiatric practice.

There is still an important question left unaswered: how should we understand the interplay between psychiatry and medicine as a whole? Some philosophers of medicine have criticized the psychiatric diagnostic system for its entanglement with moral values, while others defend the medical legitimacy of diagnoses despite their moral connotations. My research focuses on practical manifestations of morality in real-life psychiatric assessments rather than the ontology of diagnoses themselves. However, I do have some thoughts on the issue.

It seems evident that psychiatry is inherently value-laden. Determing which conditions qualify as disorders requires value judgments, as disorders can only be assessed in relation to a measure of normality. Jörg Bermann, among others, has argued that in psychiatry this notion of ”normal” is more random and historically contingent than in somatic medicine. Psychiatric diagnoses are closely tied to societal expectations of normative behavior and ideals of a good life. Recognizing this, I would argue, challenges the credibility and validity of psychiatry as a purely medical discipline.

However, the issue is complex. It would be an oversimplification to treat all psychiatric diagnoses as a single category in terms of their moral implications. For example, individuals with certain personality disorders who have the capacity to make choices yet act in ways that deviate from social norms might be seen as experiencing a moral failure rather than a medical condition. At the same time, it would be cruel to blame someone suffering from severe depression for laziness. While all psychiatric diagnoses involve normative assumptions — such as what constitutes a ”healthy” level of energy — the nature of these value judgments differs.

The key issue here is agency: does the person have the ability to choose otherwise? Many individuals diagnosed with personality disorders may lack this freedom due to their history, genetics, or other factors. But this raises the broader and more difficult question of free will itself — do people, in general, have free will? As a society, we operate on the assumption that they do. If we reject this assumption for individuals with personality disorders, on what grounds do we continue to hold others accountable for their actions? The fact that a diagnosis such an antisocial personality disorder does not prevent a person from facing legal consequences suggests that we implicitly maintain the assumption of agency.

In summary, morality is an inherent part of psychiatry and should be actively reflected on to improve both practices and classification systems. It is particularly important for professionals in the field to recognize psychiatry’s connection to social norms rather than portraying it as a neutral branch of medicine.

Final Note

The diagnostic system and assessment of personality disorders evolve over time. My data that were collected in 2019 were based on the SCID-II interview, which followed DSM-IV criteria and was still used in Finland at the time. In Western countries, two psychiatric manuals are used: the ICD (International Statistical Classification of Diseases and Related Health Problems) by the World Health Organization and the DSM (American Diagnostic and Statistical Manual of Mental Disorders), published by the American Psychiatric Association. Both have since been updated. While the ICD is the official system in Finland, DSM-based diagnostic tools can still be used, with information subsequently converted into ICD diagnoses.

The DSM-5 introduced SCID-5-PD, a revised version of the SCID-II interview. However, the DSM-IV personality disorder criteria remain unchanged. The ICD-11, the newest version of that manual, is currently being implemented in Finland. Notably, the ICD-11 replaces the categorical model of personality disorders with a trait-based continuum, aligning more closely with contemporary scientific understanding.

Although my data are based on the older classification, this research is valuable in addressing general interactional dynamics of personality disorder assessment. Once the newer model is fully implemented, further research will be essential in examining communication in its practical application.