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.

Like the proverbial moth drawn to the flame, I am attracted irresistibly to unanswerable questions. I’m in good company; as philosopher Hannah Arendt stated, “Man’s need to reflect encompasses nearly everything that happens to him, things he knows as well as things he can never know.”¹ Yet we can benefit by thinking more clearly about our perplexity.

My colleague Roger Verdon’s brilliantly poignant blog post on Amy Winehouse’s fatal addiction inspired the present post. The question, “Can’t or won’t?” was an implicit subtext throughout Roger’s reflections: Can’t stop using or won’t stop using? 

This question pervades our clinical practice: Can’t or won’t stop smoking, drinking, drugging, spending, thieving, bingeing, worrying, obsessing, counting, checking, avoiding, withdrawing, cutting or attempting suicide? Can’t or won’t stop being arrogant, oppositional, obstructionistic, submissive, self-sacrificing, self-defeating, reckless or impulsive? In my view, this can’t/won’t question strikes at the core of a quandary about our professional identity: Are we technologists or ethicists?

Intending to be provocative, and expanding on a previous post,² I will state the polar extremes in caricature form in this post, hoping to evoke conflict. In a subsequent post, aspiring for moderation, I’ll search for some middle ground.

Can’t stop?

Ostensibly, we mental health professionals make our living on the “can’t” side of this quandary: You are ill; let us treat you with our scientific technology. The number of human problems we diagnose as psychopathology has increased with each new iteration of the Diagnostic and Statistical Manual of Mental Disorders, now in its fourth edition.³ This enterprise is scientific: Through research,

• we distinguish among disorders;
• we develop technology to treat them (i.e., treatment manuals); and
• we study the effectiveness of the treatments.

Neuroscience now drives home the point that these disorders are real—addictions included. All in your head, indeed, but increasingly evident in altered brain structure and function.

Won’t stop?

Now for won’t: not enslaved by illness but rather making bad choices. Here’s a book title that rankles me: Depression is a Choice.⁴ In this vein, decades ago, psychiatrist Thomas Szasz⁵ caused an uproar with his outrageously titled book The Myth of Mental Illness. If one had any doubt, neuroscience now demonstrates that mental illness is no myth. But I never thought we needed neuroscience to refute the idea that mental illness is a myth; clinical observation was enough to do so for me. Hence I couldn’t stand Szasz’s book—until I read it recently.

His extremism notwithstanding, Szasz made a compelling point in arguing that psychotherapy is not suited for treating (mythical) illness but rather for addressing problems in living. More specifically:

Psychiatrists are not concerned with mental illnesses and their treatments. In actual practice they deal with personal, social and ethical problems in living.

Here is a point I find persuasive: “Psychologists and psychiatrists deal with moral problems which, I believe, they cannot solve by medical methods.”

In light of Szasz’s provocative claim, I find it fascinating that, two millennia ago, what we now call psychotherapy was the province of ethicists. In her illuminating book The Therapy of Desire, philosopher Martha Nussbaum⁶ documented the venerable history of psychotherapy in the practice of ancient Greek and Roman philosophers, as exemplified by Socrates.

Using collaborative discourse as a therapeutic tool, the classical ethicist worked with individuals as well as groups. Consider the following problems in living addressed in ancient ethics: dependency, love, sexuality, jealousy, anger, resentment, loss, death and suicide. Sound familiar? Long antedating Freud in their struggles to promote self-exploration, the Romans and Greeks were attuned to unconscious conflicts, including unconscious resistances to self-knowledge and to change.

To put the point most provocatively, as philosopher Charles Taylor⁷ has done, we mental health professionals are part of a social movement that is converting sin into sickness. Karl Menninger⁸ made a similar argument earlier in his powerful book Whatever Became of Sin? Stating it somewhat less provocatively, we have aspired to put science and technology in place of philosophy and ethics. I have no doubt about the potential benefits of this conversion, but I worry that we’ve gone too far. I think our justifiable fascination with neuroscience can contribute to the imbalance to the extent that we become excessively enthusiastic and reductionistic, caught up in biomania.⁹ The extreme version of can’t: My brain made me do it (or prevented me from doing it).

In pursuit of scientific explanations, do we want to shed responsibility? With responsibility and choice comes dignity. Might we be better off opting for won’t?

References

1. Arendt H. The life of the mind: I. Thinking. New York: Harcourt; 1971.

2. Allen JG. “What’s become of sin?” SayNoToStigma.com. Houston: The Menninger Clinic; 2010.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, D.C.: American Psychiatric Association; 2000.

4. Curtiss AB. Depression is a choice. New York: Hyperion; 2001.

5. Szasz TS. The myth of mental illness: Foundations of a theory of personal conduct (Revised Edition). New York: Harper and Row; 1974.

6. Nussbaum MC. The therapy of desire: Theory and practice in Hellenistic ethics. Princeton, N.J.: Princeton University Press; 1994.

7. Taylor C. A secular age. Cambridge, Mass: Harvard University Press; 2007.

8. Menninger KA. Whatever became of sin? New York: Hawthorn Books; 1973.

9. Allen JG. “Biomania: A protest.” SayNoToStigma.com. Houston: The Menninger Clinic; 2010.

Jon Allen’s recent, illuminating post on sin reminds us of the limits of looking at human problems only through the lens of science: Research-informed theories and treatments can take us only so far in our effort to reduce the stigma of mental illness. Dr. Allen cautions that we must find ways to reduce blaming and condemnation, but beware lest we rob people of responsibility, a key aspect of human dignity.

Home sweet home

Easier said than done! How, indeed, are we to contain our reaction of disgust or even outrage about behaviors that we dislike? Indeed, most of us know first hand about the disdain that can be triggered by dysfunctional behavior, whether it’s a celebrity losing control of an addiction or a family member retreating to bed with depression. It is here that philosophy (psychology’s original home) shows its relevance to psychotherapy; indeed, it is here that we encounter the complex issue of human worth.

The practical question for therapists is how to teach patients to stop condemning themselves without excusing themselves of all responsibility for their decisions. Here we must make the philosophical issue clear and offer a choice.

The question, simply put, is this: Is the act the same as the actor? If I act stupidly, does that make me stupid? If I fail, am I a failure? If I treat others badly, am I bad, no good or even worthless?

Well, when someone treats us badly, doesn’t it follow that he or she is a jerk or an idiot? And doesn’t the same reasoning apply to me when I act badly? This is a philosophical question. However, research tells us that when such condemnation is directed at the self, emotional problems (notably depression and suicide risk) tend to follow.

Moreover, eliminating such self-labeling tends to promote recovery. Such therapeutic work helps the individual learn to stop the self-abuse and start practicing self-acceptance. The message is, “You may make mistakes, but you and your behavior are not the same thing. Human beings are more complicated than that. You are a human being who may behave well or badly on occasion but whose intrinsic worth never rises or falls as a result.”

Is this mere excuse-making? Mere psychobabble to let people do bad or stupid things with impunity? Far from pop psychology, the philosophical basis for this perspective can be traced back centuries to a variety of sources, including the Biblical injunction, “Condemn the sin but not the sinner.” More recently articulated by the humanist school of philosophy, this value system reminds us that science has been unable to discover a scientifically valid way to measure human worth, not by monitoring good and bad deeds, not by tallying up successes and failures, not even by developing a system for weighting the value of looks, wealth, intelligence, contributions to society or shoe size for that matter.

Our choice

This is, quite simply, a value judgment. And value judgments are rooted in philosophical systems, which are matters of choice. To illustrate: By one philosophical system, we could judge our children’s worth by their looks, grades or athletic prowess. By another system, we might reject such judgments and love them regardless of any of these qualities. There is no way to prove scientifically which perspective represents the “one true value system.” However, it takes most parents no time at all to figure out which of the two is in their child’s best interest.

So, what we are left with is a practical question: What is the impact of putting yourself down and calling yourself names? How’s that working for you? If it brings you happiness and success, then good for you – keep it up! Most often, though, our patients (and personal experience) teach us that not only is self-condemnation unhelpful, it tends to make matters worse by increasing self-hatred and prolonging depression and self-destructive behaviors. To make matters worse, people who condemn themselves for their problems are less likely to seek treatment for these problems.

But (and this is with a capital “B”), while this more forgiving perspective reduces blame and condemnation, it in no way excuses one from responsibility for past behavior or from doing something about the problem in the future. Even as I accept my self, problems and all, it is still my responsibility to address those problems: to seek treatment, get out of bed (even though depressed), resist destructive impulses and make reparations to those whom I have hurt.

If anything, the responsibility is greater now that an obstacle to change (self-hatred) has been removed. Far from excuse-making, “loving the sinner while hating the sin” can be a means of moving away from the paralyzing battle between blame and shame and toward a life that is more balanced, functional and healthy.