2026 Annual Meeting of the Association for the Advancement of Philosophy and Psychiatry (AAPP), online
Self-illness ambiguity (SIA) refers to the difficulty of distinguishing „who I am“ from „what my disorder does,“ as expressed in statements such as „It wasn’t me; it was the illness.“ Early descriptions of this phenomenon in illness narratives (Karp 1994) and in psychiatric-philosophical reflections on the „blurring“ of the personal self and mental illness (Sadler, 2007) have recently developed in more constructivist and practice-oriented directions. According to some, SIA-talk lacks a discoverable target and primarily functions as narrative positioning within therapeutic and social practices (Jeppsson 2022; Ballesteros et al. 2025). However, I argue that this conclusion is premature.
My core claim is moderate realism. In many cases, there are objective facts about whether and to what extent a particular episode is illness-driven. This realism does not necessitate a clear distinction or the belief that psychiatric categories are distinct natural entities. Rather, it only requires facts about impairments in agency that constrain correct attributions (Kendell & Jablensky, 2003; Hyman, 2010). Building on the growing importance of reasons-responsiveness in contemporary theories of mental disorder (especially Dembić, 2023), I argue that these facts can be modeled using counterfactual reasons-responsiveness relative to the agent’s blueprint state. An episode is illness-driven if the agent would have been more responsive to the relevant normative reasons if their psychological capacities were functioning as designed, all other things being equal. This proposal also clarifies why SIA is closely linked to questions of responsibility and control (Fischer & Ravizza, 1998).
I then address the primary objections of constructivism. The „never-ending questioning“ concern targets introspection as a method of discovery (Jeppsson 2022). However, it does not demonstrate that nothing can be discovered. In practice, clinicians and patients routinely use triangulated evidence, such as symptom profiles, stability across contexts, diachronic patterns, and treatment response, to estimate counterfactual functioning. The „healthy self is inaccessible“ objection overreaches. Epistemic limitations support fallibilism, not anti-realism. Ethical-clinical deliberation can proceed under uncertainty (Kennett 2009). Finally, the normativity objection equivocates; evaluative standards (e.g., agency and impairment) can constrain functioning objectively rather than being mere choices.
If SIA is treated as purely constructed, we risk losing sight of what motivates the discourse. Patients and clinicians often aim to identify genuine breakdowns in agency that are relevant to responsibility, self-management, and treatment (Dings & Glas 2020; Dings et al. 2025).