To begin, some background: I work part of the week in a Therapeutic Community (which is a distinctive kind of group treatment programme) for patients with personality disorder (PD). PD is diagnosed by extreme and overwhelming emotions, maladaptive and somewhat irrational beliefs, and “problem” behaviour like self-harm, aggression, violence, crime, alcohol and drug misuse, and severe difficulties in maintaining good relationships and fulfilling social roles and duties. Some of this behaviour is straightforwardly criminal, much of it is immoral, and almost all of it does real and lasting harm, to patients themselves, and to their families, friends, and others who may find themselves in the wrong place at the wrong time. Perhaps as you might then expect, patients with PD have long been stigmatized within mental health services as the patients “no one likes”. They’re challenging and hard to work with because – to put it straight – they can behave so badly.
But we can really help these patients if we adopt a stance that I call “Responsibility without Blame”. Here’s what this means. The problem behaviour is voluntary. Patients with PD are not mentally ill and they know as well as most of us do what they are doing when they act. They have choice and control over their behaviour at least in the minimal sense that they can refrain – which they will often do if sufficiently motivated. That does not mean that refraining is easy. Here a little more background is important: PD is associated with extreme early psycho-socio-economic adversity. Most patients come from dysfunctional families or they may have been in institutional care. Rates of childhood sexual, emotional, and physical abuse or neglect are very high. Socio-economic status is low. Additional associated factors include war, migration, and poverty. Problem behaviour is often a learned, habitual way of coping with the distress caused by such adversity, and patients may have hitherto lacked decent opportunities to learn alternative, better ways of coping. So, until the underlying distress is addressed and new ways of coping are learned, restraint is hard.
Despite being hard to refrain from, the problem behaviour is still voluntary. This means that the basic way to help patients change it is to get them to “take responsibility” for it by expecting and encouraging them to choose differently and holding them responsible and to account when they don’t. We do this through a variety of means – I can tell you more about these if you want – but crucially for our purposes here, these means include making clear that the behaviour is unacceptable and creating a group culture in which the patient is expected to reflect and talk to the group about why they did it, undertake not to do it again, potentially make amends, and even on occasion accept the imposition of negative consequences in response.
But this treatment is only effective as a way of facilitating behavioural change if we do it in a supportive, respectful, understanding and compassionate way – a way that maintains dialogue and good relations with patients, opening up the possibility for reflection, and listening with concern to their perspective and voice. In other words, we need to do it, and create a group culture that does it, without blaming patients.
When I first started working with PD patients, this culture was like an alien world. I saw what my colleagues were doing, but I couldn’t even really make sense of it conceptually, let alone do it in practice. If a patient got angry and threatening towards me for no good reason, I would get angry, scared, and judgemental back: I resented them, I didn’t like them, and I didn’t want to work with them. How, let alone why, not? I could make sense of the idea that perhaps, despite appearances, my patients were not in fact responsible for their behaviour because they had PD, and so they shouldn’t rightly be held to account or blamed (so, my reaction was out of place). And I could equally make sense of the idea that they were responsible despite having PD, as so should be held to account and blamed (so, my reaction was on the mark). But the idea that they were responsible and should be held to account but not blamed struck me as a philosophical, never mind practical, conundrum.
When I train prison officers to adopt the clinical stance of Responsibility without Blame, I explain it in the very simplest terms I can. Responsibility is about the patient/prisoner and whether their behaviour is voluntary. Blame is about you and how you respond to the patient/prisoner. As philosophers, we want to understand and articulate both responsibility and blame in more nuanced terms, but this simple distinction is the core of the clinical stance. We can substitute in a more sophisticated set of conditions than ‘voluntariness’ to give an account of responsibility (choose your favourite). And we will need to say a lot more about what exactly it is to respond to someone with blame (for a start, see below). But in effect, the clinic offers a real-world counter-example to a Strawsonian-style account that understands the idea of responsibility itself and/or our practice of holding responsible in relation to the reactive attitudes: we divorce responsibility and accountability from the attitudes we commonly feel towards those who do wrong. And this allows us to make judgements of responsibility and hold to account in the presence of other feelings and attitudes, like e.g. respect and compassion. The pay-off of doing this is real: we help people change so that they do less harm to themselves and others.
A final bit of background before I end by saying a little more about the nature of blame: obviously reactive attitudes can’t be turned on and off at will – there’s a lot to say about what allows clinicians and other group members to avoid blaming patients when they do wrong. But I cannot emphasise enough how real a risk is inherent in blame. We all have some experience ourselves of what it feels like when we do something wrong and then get blamed for it – it can be pretty awful, and you may need to be psychologically robust to deal with it productively. In the case of patients with PD, most of whom are already vulnerable and marginalized and not psychologically robust, being blamed can trigger childhood memories and feelings of rejection, anger, shame, and indeed self-hatred and self-blame, which increase the chance they disengage from treatment and fall into hopelessness and despair, potentially leading to self-harm or attempts at suicide.
There’s a lot to be said about the nature of blame and what it is to respond to someone with it. Here I want really to make one crucial initial point, which is that blame comes in two forms, that I call ‘detached’ and ‘affective’. Detached blame is just a judgement or belief that a person is responsible for harm or has done wrong (blameworthy, as we often say, but since I’m arguing that we shouldn’t blame even when a person is responsible for harm, you can see why I don’t want to use that term!). We can make that judgement or have that belief without feeling or doing much of anything (e.g. imagine you make it in a history lesson at school about a ruler from the distant past). Affective blame on the other hand involves emotions (e.g. anger, resentment, disgust, contempt, hatred), harsh and negative character judgements (e.g. writing someone off as bad, worthless, a disgrace to the human race), and actions that express these emotions and judgements (e.g. acting aggressively by punishing and retaliating, or passive-aggressively by rejecting and ostracizing). Detached blame is OK in the clinic – indeed, we form these detached judgements all the time when we hold patients to account. Affective blame is not OK – it counters effective treatment.
Very crudely, anti-blame arguments usually derive from determinism plus incompatibilism: blame is not deserved because free will and therefore responsibility is an illusion. In the clinic, we treat responsibility as real and indeed essential to our purposes but we are anti-blame nonetheless because blame, unlike responsibility and accountability, is instrumentally counter-productive to effective treatment and therefore also to the moral ends I hope we all endorse, namely, reduction of the amount of wrongdoing and harm in the world. So here’s a question to end on. Suppose there’s a stark choice. You can either hold on to the idea that the emotions, thoughts, and actions constituting affective blame are deserved by those who do wrong and indulge in them, or you can give them up and reduce the amount of wrongdoing and harm in the world. Remember you get to hold wrongdoers responsible and to account if you give up blame – you just need to do it with a different, gentler attitude! What would you choose?