Re-Solving the Self-Illness Ambiguity

Abstract

The self–illness ambiguity – the difficulty of distinguishing between the self and the effects of mental illness – remains a core conceptual and clinical challenge in psychiatry. In “Solving the Self-Illness Ambiguity,” Sofia Jeppsson rejects the Realist view that a pre-existing boundary between self and illness can be discovered, proposing instead a Constructivist model in which patients define this boundary in ways that best promote recovery. However, Şerife Tekin critiques Jeppsson’s solution for overestimating patients’ narrative capacities, ignoring the multiplicity of conflicting narratives, and offering little procedural clarity.

In response, this paper proposes a scalar model of agency drawn from Jennifer Hornsby’s work on action explanation. Instead of treating agency as all-or-nothing, Hornsby sees it as existing in degrees, shaped by how alienated or involved a person feels in their own actions. I refine this model by identifying three interrelated dimensions: normative engagement (the extent to which an action is guided by values), reason-responsiveness (the agent’s ability to evaluate and be motivated by reasons), and identification or avowal (first-person ownership of one’s motivations). Rather than requiring a fixed boundary between self and illness, this model invites patients to assess their degree of alienation from particular actions along these axes.

I support this approach through philosophical and psychiatric literature, drawing from Gloria Ayob on normative practices, Richard Moran on avowal and attribution, and Judit Szalai’s account of compulsive behavior in OCD. I also address Tekin’s concern about narrative complexity by incorporating Gerrit Glas’s model of layered self-referentiality, which allows for partial and evolving self-understanding. Finally, I argue that focusing on bounded, momentary actions, rather than demanding coherence across a life-narrative, offers a more realistic and clinically useful framework for navigating self-illness ambiguity.