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Personal responsibility, abnormality, and ethics: psychotherapy as moral understanding
Broader issues
Personal responsibility, abnormality, and ethics: psychotherapy as moral understanding
‘owned’ by us (‘I did this’) and, furthermore, that the intention was ours and we chose to carry it through (‘I wanted this to happen’). The principle of respect for autonomy implies that we are free to carry out our intentions. Personal freedom then has two senses: freedom to act in ways that we choose, and freedom from interference.1 The civil law concept of ‘consent’ is the legal enactment of respect for autonomy: no-one can do anything to you without your consent, and, if they do, this is a legal wrong. Inherent in this also is the Western cultural attention to individual personal identity as a paramount value. However, freedom is not licence. As Mill2 put it, ‘My freedom to swing my arm ends where your nose begins’. In any group of people there is an inevitable tension between the interests of the individual and the welfare of the group as a whole: there are behaviours that cause little harm on an individual basis, but that would be problematic if done in a group. Hence, we often say to children about certain behaviour, ‘What would life be like if we all did that?’. This tension between individual freedom and group living is managed and regulated in a number of ways. The main way is through sets of group rules, which set boundaries around group identity. Keep the rules, and you remain within the group. Break the rules, and the tension between the rule breaker and the group will increase and become uncomfortable. Rule breakers may be avoided, or stigmatized in terms of social experience. If the tension between the individual and the group develops into anxiety, fear, or distress, the criminal law will be involved as a regulator. Not all rule breaking is criminal, but all criminal behaviours are detailed in statutes that also indicate what the social sanction is for breaking the statute. Although rule breaking can sometimes be admired, for acts that cause fear, shame, and distress the rule breaker will be expelled from the group, in a variety of ways (of which prison is one). Part of the expulsion process will be a naming of the offence that broke the rule, and condemnation of it. Essential to this public naming and blaming process is the concept of ‘moral responsibility’ – of ‘owning’ (up to) the rule-breaking action and accepting the guilt (and punishment). Rule breakers are blameworthy only if they chose to do what they did – if it reflects their own choices. A criminal rule breaker who is coerced to break the rules, or who breaks the rules in ignorance or by accident, will not be blamed in the same way as one who knowingly sets out to break the rules.
Gwen Adshead
Abstract A central principle of medical ethics is that personal autonomy be respected. This article discuss what this means in relation to psycho dynamic psychotherapy. Many psychodynamic therapists argue that the purpose of psychotherapy is to help the patient become more autono mous in their choices – that their choices represent their ‘real’ selves. This may mean that the person has to take responsibility for feelings and thoughts that they find uncomfortable, and which they may not have anticipated when they started the psychotherapy process. This may be a particular issue for patients who break the criminal law or in other ways behave antisocially.
Keywords agency; autonomy; consent; forensic; responsibility
Introduction ‘In the future, I plan on taking a more active role in the decisions I make.’ ‘I have opinions … strong opinions … but I don’t always agree with them.’ These two quotes come from two people who have both have been judged to have behaved antisocially. They serve as a good introduction for an article about the complexities of human agency and responsibility, and what the role of psychotherapists might be in any exploration of personal responsibility.
Autonomy, agency, and responsibility One of the major principles of biomedical ethics is the principle that personal autonomy be respected. ‘Autonomy’ literally means ‘self-rule’, and each individual is assumed to ‘own’ his or her own mind and thoughts. When we say that we take responsibility for our actions, we are saying both that these actions are
Psychiatry, autonomy, and rule breaking Autonomy may be broken down into autonomy of will, action, and thought,3 to which may be added personal identity. The legal concept of ‘capacity’ refers to the capacity to exercise one’s own autonomy, and many, if not most, medical conditions (both physical and mental) compromise autonomy in some way.4 Psychiatric disorders usually compromise autonomy by affecting personal identity, choice making, affect regulation, and interpersonal relating (Table 1). A significant philosophical problem for psychiatry has been the issue of how psychiatric disorders affect the capacity to keep social rules. Psychiatric patients break rules in many ways. It is usually assumed that there is a relationship between feeling
Gwen Adshead MA FRCPsych is a Forensic Psychiatrist and a Psychotherapist at Broadmoor Hospital, West London Mental Health Trust, UK. After training in forensic psychiatry, she trained as a psychotherapist and group analyst. She has a particular interest in attachment theory, and moral philosophy as applied to forensic psychiatry. She was previously Chair of the Royal College of Psychiatry Ethics Committee, and is a member of the Psychotherapy Faculty Executive and the Board of the Philosophy Special Interest Group. Conflicts of interest: none declared.
PSYCHIATRY 7:5
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© 2008 Elsevier Ltd. All rights reserved.
Broader issues
However, causes of events are not the same as explanations for events, and the more complex the event, the truer this is.6 We may say that a man’s hostility to his partner is caused by his depression, but it may be better explained by his interpretation of her facial expression, which may rest on other factors. The point here is that mind events are way too complex to be adequately explained by brain events, even if they are to some extent caused by them. What we seem to lack is an account of why most people have the capacity to be rule keepers, especially of criminal rules, and how this relates to a sense of agency.
Psychiatric disorders and disorders of autonomy/ personal identity • Disorders of reality testing: psychotic states, hallucinatory states, deliria, dementias • Disorders of choice-making: eating disorders, addictions, phobias, and obsessive compulsive disorder • Disorders of affect and arousal regulation: impair decision making, reality testing, memory • Disorders of interpersonal functioning: all of the above plus personality disorders affecting empathy, threat perception, and pro-social emotions
Psychotherapy as moral understanding How could psychotherapy assist in understanding when we should blame people for rule breaking and when we should not? Here, I want to make a distinction between psychotherapy as (a) a theory of agency, and (b) a therapeutic intervention that promotes agency. All the psychological therapies can be understood in this way; the account I give here is a psychodynamic one, which assumes the following: • that both conscious and unconscious aspects of mind are considered important • that feeling and thought are interlinked phenomena • that human mental experience is evolutionally primed to be social and interpersonal. In terms of theory, psychodynamic theory argues that early childhood attachment relationships foster the capacity for mentalization that is necessary in order to develop and experience an agentic self, that experiences autonomy and can be responsible for actions. ‘Mentalization’ is a mental process that enables an individual to ‘keep mind in mind’;7 it has a number of components, which are listed in Table 2. Although childhood attachment experiences are not the only way in which mentalization capacity develops and is maintained during the lifespan, these early experiences set the initial regulatory parameters for selforganization that give rise to a sense of self. Highly insecure attachment relationships in early life tend to result in a highly disorganized sense of self. Without a secure and integrated sense of self, there is a much reduced capacity to manage ordinary fears and anxieties associated with group and social living. Without an organized sense of self, the individual is likely to fall back on mental strategies for managing anxiety that rely solely on archaic brain structures, such as the limbic system and amygdala.8 These strategies include cognitive schema that tend to see other people as either predators or prey, and favour
Table 1
‘well’ and keeping social rules, so that people sometimes argue like this: • Sam has broken a rule (i.e. behaved antisocially) … • he is not normally an antisocial person … • he is not himself … • he must be feeling unwell … • when he feels better, he will either stop behaving antisocially and/or start keeping the rules. There are a number of points to notice here. First, mental illness might be one cause of rule breaking, but it does not follow that all rule breaking is caused by mental illness. Second, this argument assumes that all rule breaking is bad, whereas it may be a necessary and valuable motor for change. It may be rational to break the rules in the interests of group development, or in protest at the group rules. As Szasz5 suggested, this argument would medicalize all political protest into biological deviance or disease. Deviance from group norms or rules should not, in Szasz’s view, be seen as evidence of individual pathology, and it should not be controlled unless it causes harm to others. Even then, there is no reason to make harm to others a ‘symptom’ of an illness: it could just be managed, without any reference to ‘being well’. It might be said that the success of the argument outlined above depends on the type of rule being broken. Examples of social rule breaking could include: (a) not using cutlery to eat, (b) swearing loudly in public places, and (c) smearing excrement. It is clear immediately that some of these rules are culture bound (like the use of cutlery), some are contextual and interpreted flexibly (like swearing), and others are held pretty strictly whatever the culture or context (smearing is not welcome anywhere). Homicide, for example, is forbidden in most cultures and contexts; there may be a variety of responses to it, but it is still forbidden. If a social rule is generally held everywhere, regardless of culture or context, then if it is broken, it is reasonable to raise the question of mental disorder in the mind of the rule breaker. Such a view is apparently supported by research findings that appear to indicate a link between brain abnormalities, neurochemical deficits, genetic vulnerabilities, and criminal behaviour. An extreme elaboration of this view suggests that all behaviour is caused by genes interacting with neural environments; if so, when this interactional milieu is ‘well’, all will be well and all will feel well, and all manner of behaviour will be well (with apologies to St Julian of Norwich).
PSYCHIATRY 7:5
Components of the capacity for mentalization • Theory of mind • Empathy • Symbolic function (including language function) • Narrative competence • Reality testing • Establishment of mature psychological defences: humour, hope, altruism, and sublimation Table 2
226
© 2008 Elsevier Ltd. All rights reserved.
Broader issues
instant relief of anxiety at times of stress. Rule breaking of various sorts will therefore become a more likely option at times of anxiety, especially as there is very little sense of social belonging when other people are there to be either avoided or exploited. In terms of therapeutic interventions, psychodynamic therapy attempts to increase the capacity for mentalization through a variety of techniques. Psychodynamic techniques, in particular, emphasize a living learning process in the here-and-now relationship with the therapist. Group therapy is particularly effective both for enhancing a sense of other people as thinkers and feelers like oneself, and for helping to develop a sense of belonging, which promotes identity.9 It is a paradox that has been long known to those organizing human groups that, if you want to get to know yourself, you need to belong to a community.
Finally, to change a person’s opinions and beliefs, which make up such a vital aspect of personal identity, is a political act. Consider the quotes at the beginning of this article. Both hint at a divided mental life, where there is a lack of coherence between different aspects of the self; they also beg a question about the meaning of the word ‘I’, being used in the context of actions and decisions. Feminist theory argues that the personal is political, that the act of developing personal agency helps develop political empowerment. The author of the first quote is apparently a convert to feminist theory – her name is Paris Hilton. The author of the second quote, who is apparently so unsure of his own mind at times, is the current president of the USA. ◆
References 1 Berlin I. Two concepts of liberty. Oxford: Clarendon Press, 1958. 2 Mill JS. On liberty and other essays. Oxford World Classics. Oxford: Oxford University Press, 1998. 3 Gillon R. Autonomy and the principle of respect for autonomy. BMJ 1985; 290: 1806–08. 4 Raymont V, Bingley W, Buchanan A, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors. Lancet 2004; 364: 1421–27. 5 Szasz T. Psychiatric diagnosis, psychiatric power and psychiatric abuse. J Med Ethics 1994; 20: 135–38. 6 Bolton D, Hill J. Mind meaning and mental disorder: the nature of causal explanation in psychology and psychiatry. Oxford: Oxford University Press, 2005. 7 Allen J, Fonagy P, eds. Handbook of mentalization-based treatment. Chichester: John Wiley, 2006. 8 Shore A. Affect dysregulation and disorders of the self. New York: WW Norton & Co, 2005. 9 Bateman AW, Fonagy P. Mentalization-based therapy of BPD. J Personal Disord 2004; 18: 36–51.
Critique and conclusion There are two critical issues raised by a mentalization-based therapy (MBT) approach to autonomy and agency. First, it is highly culturally relative: there are cultures that do not privilege individual agency in the same way as European culture, where the sense of self is not indexical but referential. The referential self is socially constructed and maintained: individual choice and identity threatens the social group. An MBT approach may be useful only in European cultures. Second, the political problem described by Foucault and Szasz has not been dealt with. The psychodynamic approach still implies that only flawed or damaged people choose to break the rules, and that feeling better about oneself will lead to more social behaviour, and this is good thing. There is no room in this account for creative rule breaking that might have negative consequences; for instance, Nelson Mandela would presumably be assessed as having poor mentalizing capacity just before his imprisonment for terrorist activities.
PSYCHIATRY 7:5
227
© 2008 Elsevier Ltd. All rights reserved.
Personal responsibility, abnormality, and ethics: psychotherapy as moral understanding
‘owned’ by us (‘I did this’) and, furthermore, that the intention was ours and we chose to carry it through (‘I wanted this to happen’). The principle of respect for autonomy implies that we are free to carry out our intentions. Personal freedom then has two senses: freedom to act in ways that we choose, and freedom from interference.1 The civil law concept of ‘consent’ is the legal enactment of respect for autonomy: no-one can do anything to you without your consent, and, if they do, this is a legal wrong. Inherent in this also is the Western cultural attention to individual personal identity as a paramount value. However, freedom is not licence. As Mill2 put it, ‘My freedom to swing my arm ends where your nose begins’. In any group of people there is an inevitable tension between the interests of the individual and the welfare of the group as a whole: there are behaviours that cause little harm on an individual basis, but that would be problematic if done in a group. Hence, we often say to children about certain behaviour, ‘What would life be like if we all did that?’. This tension between individual freedom and group living is managed and regulated in a number of ways. The main way is through sets of group rules, which set boundaries around group identity. Keep the rules, and you remain within the group. Break the rules, and the tension between the rule breaker and the group will increase and become uncomfortable. Rule breakers may be avoided, or stigmatized in terms of social experience. If the tension between the individual and the group develops into anxiety, fear, or distress, the criminal law will be involved as a regulator. Not all rule breaking is criminal, but all criminal behaviours are detailed in statutes that also indicate what the social sanction is for breaking the statute. Although rule breaking can sometimes be admired, for acts that cause fear, shame, and distress the rule breaker will be expelled from the group, in a variety of ways (of which prison is one). Part of the expulsion process will be a naming of the offence that broke the rule, and condemnation of it. Essential to this public naming and blaming process is the concept of ‘moral responsibility’ – of ‘owning’ (up to) the rule-breaking action and accepting the guilt (and punishment). Rule breakers are blameworthy only if they chose to do what they did – if it reflects their own choices. A criminal rule breaker who is coerced to break the rules, or who breaks the rules in ignorance or by accident, will not be blamed in the same way as one who knowingly sets out to break the rules.
Gwen Adshead
Abstract A central principle of medical ethics is that personal autonomy be respected. This article discuss what this means in relation to psycho dynamic psychotherapy. Many psychodynamic therapists argue that the purpose of psychotherapy is to help the patient become more autono mous in their choices – that their choices represent their ‘real’ selves. This may mean that the person has to take responsibility for feelings and thoughts that they find uncomfortable, and which they may not have anticipated when they started the psychotherapy process. This may be a particular issue for patients who break the criminal law or in other ways behave antisocially.
Keywords agency; autonomy; consent; forensic; responsibility
Introduction ‘In the future, I plan on taking a more active role in the decisions I make.’ ‘I have opinions … strong opinions … but I don’t always agree with them.’ These two quotes come from two people who have both have been judged to have behaved antisocially. They serve as a good introduction for an article about the complexities of human agency and responsibility, and what the role of psychotherapists might be in any exploration of personal responsibility.
Autonomy, agency, and responsibility One of the major principles of biomedical ethics is the principle that personal autonomy be respected. ‘Autonomy’ literally means ‘self-rule’, and each individual is assumed to ‘own’ his or her own mind and thoughts. When we say that we take responsibility for our actions, we are saying both that these actions are
Psychiatry, autonomy, and rule breaking Autonomy may be broken down into autonomy of will, action, and thought,3 to which may be added personal identity. The legal concept of ‘capacity’ refers to the capacity to exercise one’s own autonomy, and many, if not most, medical conditions (both physical and mental) compromise autonomy in some way.4 Psychiatric disorders usually compromise autonomy by affecting personal identity, choice making, affect regulation, and interpersonal relating (Table 1). A significant philosophical problem for psychiatry has been the issue of how psychiatric disorders affect the capacity to keep social rules. Psychiatric patients break rules in many ways. It is usually assumed that there is a relationship between feeling
Gwen Adshead MA FRCPsych is a Forensic Psychiatrist and a Psychotherapist at Broadmoor Hospital, West London Mental Health Trust, UK. After training in forensic psychiatry, she trained as a psychotherapist and group analyst. She has a particular interest in attachment theory, and moral philosophy as applied to forensic psychiatry. She was previously Chair of the Royal College of Psychiatry Ethics Committee, and is a member of the Psychotherapy Faculty Executive and the Board of the Philosophy Special Interest Group. Conflicts of interest: none declared.
PSYCHIATRY 7:5
225
© 2008 Elsevier Ltd. All rights reserved.
Broader issues
However, causes of events are not the same as explanations for events, and the more complex the event, the truer this is.6 We may say that a man’s hostility to his partner is caused by his depression, but it may be better explained by his interpretation of her facial expression, which may rest on other factors. The point here is that mind events are way too complex to be adequately explained by brain events, even if they are to some extent caused by them. What we seem to lack is an account of why most people have the capacity to be rule keepers, especially of criminal rules, and how this relates to a sense of agency.
Psychiatric disorders and disorders of autonomy/ personal identity • Disorders of reality testing: psychotic states, hallucinatory states, deliria, dementias • Disorders of choice-making: eating disorders, addictions, phobias, and obsessive compulsive disorder • Disorders of affect and arousal regulation: impair decision making, reality testing, memory • Disorders of interpersonal functioning: all of the above plus personality disorders affecting empathy, threat perception, and pro-social emotions
Psychotherapy as moral understanding How could psychotherapy assist in understanding when we should blame people for rule breaking and when we should not? Here, I want to make a distinction between psychotherapy as (a) a theory of agency, and (b) a therapeutic intervention that promotes agency. All the psychological therapies can be understood in this way; the account I give here is a psychodynamic one, which assumes the following: • that both conscious and unconscious aspects of mind are considered important • that feeling and thought are interlinked phenomena • that human mental experience is evolutionally primed to be social and interpersonal. In terms of theory, psychodynamic theory argues that early childhood attachment relationships foster the capacity for mentalization that is necessary in order to develop and experience an agentic self, that experiences autonomy and can be responsible for actions. ‘Mentalization’ is a mental process that enables an individual to ‘keep mind in mind’;7 it has a number of components, which are listed in Table 2. Although childhood attachment experiences are not the only way in which mentalization capacity develops and is maintained during the lifespan, these early experiences set the initial regulatory parameters for selforganization that give rise to a sense of self. Highly insecure attachment relationships in early life tend to result in a highly disorganized sense of self. Without a secure and integrated sense of self, there is a much reduced capacity to manage ordinary fears and anxieties associated with group and social living. Without an organized sense of self, the individual is likely to fall back on mental strategies for managing anxiety that rely solely on archaic brain structures, such as the limbic system and amygdala.8 These strategies include cognitive schema that tend to see other people as either predators or prey, and favour
Table 1
‘well’ and keeping social rules, so that people sometimes argue like this: • Sam has broken a rule (i.e. behaved antisocially) … • he is not normally an antisocial person … • he is not himself … • he must be feeling unwell … • when he feels better, he will either stop behaving antisocially and/or start keeping the rules. There are a number of points to notice here. First, mental illness might be one cause of rule breaking, but it does not follow that all rule breaking is caused by mental illness. Second, this argument assumes that all rule breaking is bad, whereas it may be a necessary and valuable motor for change. It may be rational to break the rules in the interests of group development, or in protest at the group rules. As Szasz5 suggested, this argument would medicalize all political protest into biological deviance or disease. Deviance from group norms or rules should not, in Szasz’s view, be seen as evidence of individual pathology, and it should not be controlled unless it causes harm to others. Even then, there is no reason to make harm to others a ‘symptom’ of an illness: it could just be managed, without any reference to ‘being well’. It might be said that the success of the argument outlined above depends on the type of rule being broken. Examples of social rule breaking could include: (a) not using cutlery to eat, (b) swearing loudly in public places, and (c) smearing excrement. It is clear immediately that some of these rules are culture bound (like the use of cutlery), some are contextual and interpreted flexibly (like swearing), and others are held pretty strictly whatever the culture or context (smearing is not welcome anywhere). Homicide, for example, is forbidden in most cultures and contexts; there may be a variety of responses to it, but it is still forbidden. If a social rule is generally held everywhere, regardless of culture or context, then if it is broken, it is reasonable to raise the question of mental disorder in the mind of the rule breaker. Such a view is apparently supported by research findings that appear to indicate a link between brain abnormalities, neurochemical deficits, genetic vulnerabilities, and criminal behaviour. An extreme elaboration of this view suggests that all behaviour is caused by genes interacting with neural environments; if so, when this interactional milieu is ‘well’, all will be well and all will feel well, and all manner of behaviour will be well (with apologies to St Julian of Norwich).
PSYCHIATRY 7:5
Components of the capacity for mentalization • Theory of mind • Empathy • Symbolic function (including language function) • Narrative competence • Reality testing • Establishment of mature psychological defences: humour, hope, altruism, and sublimation Table 2
226
© 2008 Elsevier Ltd. All rights reserved.
Broader issues
instant relief of anxiety at times of stress. Rule breaking of various sorts will therefore become a more likely option at times of anxiety, especially as there is very little sense of social belonging when other people are there to be either avoided or exploited. In terms of therapeutic interventions, psychodynamic therapy attempts to increase the capacity for mentalization through a variety of techniques. Psychodynamic techniques, in particular, emphasize a living learning process in the here-and-now relationship with the therapist. Group therapy is particularly effective both for enhancing a sense of other people as thinkers and feelers like oneself, and for helping to develop a sense of belonging, which promotes identity.9 It is a paradox that has been long known to those organizing human groups that, if you want to get to know yourself, you need to belong to a community.
Finally, to change a person’s opinions and beliefs, which make up such a vital aspect of personal identity, is a political act. Consider the quotes at the beginning of this article. Both hint at a divided mental life, where there is a lack of coherence between different aspects of the self; they also beg a question about the meaning of the word ‘I’, being used in the context of actions and decisions. Feminist theory argues that the personal is political, that the act of developing personal agency helps develop political empowerment. The author of the first quote is apparently a convert to feminist theory – her name is Paris Hilton. The author of the second quote, who is apparently so unsure of his own mind at times, is the current president of the USA. ◆
References 1 Berlin I. Two concepts of liberty. Oxford: Clarendon Press, 1958. 2 Mill JS. On liberty and other essays. Oxford World Classics. Oxford: Oxford University Press, 1998. 3 Gillon R. Autonomy and the principle of respect for autonomy. BMJ 1985; 290: 1806–08. 4 Raymont V, Bingley W, Buchanan A, et al. Prevalence of mental incapacity in medical inpatients and associated risk factors. Lancet 2004; 364: 1421–27. 5 Szasz T. Psychiatric diagnosis, psychiatric power and psychiatric abuse. J Med Ethics 1994; 20: 135–38. 6 Bolton D, Hill J. Mind meaning and mental disorder: the nature of causal explanation in psychology and psychiatry. Oxford: Oxford University Press, 2005. 7 Allen J, Fonagy P, eds. Handbook of mentalization-based treatment. Chichester: John Wiley, 2006. 8 Shore A. Affect dysregulation and disorders of the self. New York: WW Norton & Co, 2005. 9 Bateman AW, Fonagy P. Mentalization-based therapy of BPD. J Personal Disord 2004; 18: 36–51.
Critique and conclusion There are two critical issues raised by a mentalization-based therapy (MBT) approach to autonomy and agency. First, it is highly culturally relative: there are cultures that do not privilege individual agency in the same way as European culture, where the sense of self is not indexical but referential. The referential self is socially constructed and maintained: individual choice and identity threatens the social group. An MBT approach may be useful only in European cultures. Second, the political problem described by Foucault and Szasz has not been dealt with. The psychodynamic approach still implies that only flawed or damaged people choose to break the rules, and that feeling better about oneself will lead to more social behaviour, and this is good thing. There is no room in this account for creative rule breaking that might have negative consequences; for instance, Nelson Mandela would presumably be assessed as having poor mentalizing capacity just before his imprisonment for terrorist activities.
PSYCHIATRY 7:5
227
© 2008 Elsevier Ltd. All rights reserved.