Can’t AND won’t

by Jon G. Allen, PhD on June 15, 2012 · 2 comments

in behavior,philosophy

In “Can’t or Won’t?” I wrote about the challenge of making judgments about whether persons struggling with psychiatric disorders are best regarded as being unable to do better (can’t) or unwilling to do better (won’t). Should we think of the alcoholic as being unable to stop drinking or unwilling to do so—can’t or won’t stop drinking? Regarding the depressed person: can’t or won’t get out of bed? We should be wary of such either-or dichotomies; we need to make room for can’t and won’t.

In framing this dilemma, I am putting us therapists and patients in the territory of the problem of free will. Beware: As philosopher John Searle1 wrote,

“The problem of free will is unusual among contemporary philosophical issues in that we are nowhere remotely near to having a solution.”

But we have a way forward that is helpful for us mental health professionals, owing to the work of another philosopher, Peter Strawson, who made what I consider something of an end run around the problem of free will.

Juggling causes and choices

Strawson’s seminal paper, “Freedom and Resentment,” was first published in 19622 and remains a subject of continuing discussion.3 As I will explain, when responding to problematic behavior—associated with mental illness, for example—we must juggle two perspectives, scientific and moral. In short, we must juggle causes and choices, pitting determinism against free will. Strawson helpfully distinguished two contrasting attitudes toward behavior: emotionally detached (i.e., scientific, objective, based on causes) and emotionally reactive (i.e., moral, subjective, based on choices). We must accommodate both attitudes in the field of mental health and elsewhere.

Science deals with causes and laws. To take the extreme determinist position, owing to the laws of physics, the course of the universe—including all our behavior—was set in stone with the Big Bang: all causes, no choices. The deterministic idea that, in principle, the future is entirely predictable from the past has been undermined by quantum indeterminacy and chaos theory, but randomness and unpredictability in our behavior hardly gives us free will (genuine choice).

Strawson4 summarizes the detached, scientific-deterministic view as follows:

“To see human beings and human actions in this light is to see them simply as objects and events in nature, natural objects and natural events, to be described, analyzed, and causally explained in terms in which moral evaluation has no place.”

From this perspective, treatments for psychiatric disorders, based on scientific research, constitute an additional set of causes, changing patients’ thoughts, feelings and behavior in the grand causal chain of determinism. As Strawson2 put it, from the standpoint of treatment, the person is to be “managed or handled or cured or trained.” This emotionally detached approach has the advantage of avoiding condemnation of patients with psychiatric disorders and stigmatizing them in the process. With alcoholism in mind, consider Strawson’s point:

“What from one [reactive] point of view is rightly seen as a piece of disgraceful turpitude, an appropriate object of a reaction of moral disgust, is, from the other [detached] point of view, rightly seen as merely the natural outcome of a complex collocation of factors, an appropriate object of scientific, psychological and sociological analysis and study.”

Not so fast! Strawson2 made the compelling argument that we naturally respond to others as persons with intentions who are free agents, make choices and are responsible for their behavior. Indeed, he proposed that we cannot altogether avoid the emotionally reactive attitude. Of course, as Strawson made clear, in our judgments and feelings, we take into account the possibility of accidents and unwitting actions—it makes a big difference if someone steps on your foot on purpose or not. And he also allowed for factors that limit the capacity for freedom of action, including compulsions and psychiatric disorders; in such situations, we might “suspend our ordinary reactive attitudes toward the agent, either at the time of his action or all the time.” And he allowed for degrees of mitigation; in suspending the ordinary reactive attitudes, we might feel less perturbed rather than not at all perturbed.

In contrast with our scientific detachment, our reactive attitudes are embedded in our engagement with each other. Such engagement is based on our natural proclivity to mentalize, that is, to interpret others’ actions as based on intentions, desires, feelings, and beliefs—with the implicit assumption that their actions reflect at least some degree of free agency and choice. Freedom of choice always comes in degrees; our choices always take place in the context of constraints5—we are constrained by external circumstances and by personal limitations, for example, in capacities or vision. I like philosopher Daniel Dennett’s6 view of freedom as our remaining elbow room in the face of constraints; plainly, psychiatric disorders such as alcoholism and depression limit the individual’s elbow room, but I believe that these disorders do not entirely eliminate elbow room—certainly not at every moment.

No either/or

To return to the starting point, we must not be caught in a forced-choice way of thinking about can’t and won’t; as Strawson2 maintained, we must be able to straddle the detached and reactive attitudes. Strawson took the psychoanalyst as an example of such straddling; he pointed out, ironically, that the aim of adopting the detached attitude and suspending the morally reactive attitude is to “make such suspension necessary or less necessary” by virtue of “restoring the agent’s freedom.” Wisely, he made the same observation regarding parents, who must straddle the two perspectives to support the “progressive emergence of the child as a responsible being.”

In sum, as we use our scientific knowledge to better understand the constraints associated with psychiatric disorders (the “can’t”), we must find the arenas of elbow room and use our psychotherapeutic influence to help transform “can and won’t” into “will.” I find that when patients know that we fully appreciate their limitations—the extent of “can’t” and the sheer difficulty of “can”—they are less resentful and oppositional and thus more willing to use their elbow room to do what they can.

 

References

 1. Searle JR. Freedom and neurobiology. New York: Columbia University Press; 2007.

2. Strawson PF. “Freedom and resentment.” In: Watson G, ed. Free will. New York: Oxford University Press; 1982:59-80.

3. Russell P. “Moral sense and the foundations of responsibility.” In: Kane R, ed. The Oxford handbook of free will. Second ed. New York: Oxford University Press; 2011:199-220.

4. Strawson PF. Skepticism and naturalism: Some varieties. New York: Columbia University Press; 1985.

5. Ayer AJ. “Freedom and necessity.” In: Watson G, ed. Free will. New York: Oxford; 1982:15-23.

6. Dennett DC. Elbow room: The varieties of free will worth wanting. Cambridge, Mass: MIT Press; 1984.

Be Sociable, Share!

{ 2 comments… read them below or add one }

Suzanne June 20, 2012 at 11:50 am

This came at an opportune time for me in that I am dealing with a young person who will only eat a very limited menu. The issue of “can’t” or “won’t” is a conversation I have been having with the parents and am still exploring with the client. Your article helped me with the vocabulary of our conversations. Thank you once again.

Debi June 18, 2012 at 9:27 am

As someone who struggles with depression on a daily basis, I think that the “can’t vs. won’t” question is hugely affected by the patient’s personal knowledge and understanding of the issue.

When in the throes of depression, with no previous experience with “can’t vs. won’t,” I don’t think one can see the issue clearly due to that “Catch 22″ you often refer to: the depression itself blinds us to the possibility that we have any agency at all in our illness.

However, once supported in an intensive therapeutic environment and exposed to the possibility of self-agency, I think willingness becomes seen as a real option where it wasn’t seen before. And once a patient actually steps out on a limb and tries to apply agency along with the will to get better, and it works, a cycle of positive reinfocement can be created.
So I think there are several factors that need to come together to make the “can’t” into a “can,” and the “won’t” into a “will”:
1) a strong therapeutic alliance; 2) environmental support (e.g. milieu therapy); 3) exposure to the reality that one can truly affect one’s illness in a positive manner; 4) and taking the step to actually create that reality in one’s own experience (which involves another level of self-agency and willingness somewhat higher than the initial willingness to simply imagine/hope for the possibility).

Bottom line, in my experience: it takes an extraordinary amount of knowledge, effort, and willingness on the parts of both the therapist and the patient, coupled with an extremely supportive environment, to bring about any true measure of healing in a person with long-term, chronic/acute depression. But it IS possible.

Leave a Comment

Previous post:

Next post: