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Is it possible that the human capacity for moral condemnation is valuable enough that eliminating it as you seem to suggest will do more harm to humanity as a whole than good to any one individual human? Perhaps people who do evil should feel bad about themselves. The fear of moral condemnation, both by ones self and by others has probably deterred a great deal of evildoing. I agree that the evil human beings do to others is conditioned by the evil previously done to them, but it is still evil. That renouncing moral condemnation will reduce the amount of wrongdoing and harm in the world is not self-evident.

This is very interesting. I wonder if you could say a little more about the relation between attributions of responsibility, attributions of desert, and expressions of reactive attitudes. One might think, for example, that exactly because it is difficult for PD patients to avoid certain behaviors, they are not *fully* responsible for what they are doing, and so not appropriate targets for the full range of reactive attitudes. One might also think that even though these individuals are in some sense appropriate targets of reactive attitudes because of what they do, that doesn't mean that it is appropriate to express indignation towards them: even if someone is the appropriate target of an attitude, that doesn't mean that the circumstances are appropriate for expressing that attitude.


It sounds to me like you are doing very good work, and I believe that your experience can shed great light on what I think are under-appreciated aspects of moral responsibility. I think your characterizations of responsibility ("about the patient/prisoner and ... their behaviour") and blame ("about you and how you respond") make an excellent starting point.

The division of blame into 'detached' and 'affective' also strikes me as important, tho' I'd make the split between cognitive/emotional and reactive elements. (I'd say that the reactive part is not even part of blame, but that's a mere terminological complaint.) How you react is up to you in the same way that the PD patient's actions are up to them -- and likewise the responsibility. So much talk about desert in particular seems to me to be trying to blame our reactions on the people we are reacting to.

As your work shows, certain reactions can be counter-productive. When you know what these people have been thru, you know that you need to react in a different way than you feel would be appropriate. Nevertheless you are reacting, and it is a responsibility-enforcing reaction. Your responses are measured and helpful -- and sometimes include punishment. This is how we should always react to wrong-doing, and we should hold ourselves responsible for doing so.

Having said that, tho', I think your final question reveals that you are not making another distinction that I think is important. One of your stark alternatives is that we hold that wrong-doers deserve our affective blame and so indulge ourselves. "Deserve" is superfluous there: the stark choice is between indulging and not indulging. We can think they deserve the blaming reactions but not indulge them anyway. It's always open to us to give someone "better than they deserve" -- and it is a tenet of Christianity that doing so is a good thing (within reason). The goal is to get people to repent of their wicked deeds -- much the same as yours is -- and only to give them their deserved punishments when repentence is ultimately rejected. Perhaps I can call it "desert without punishment", which I hold as dear as "responsibility without blame".

Hi Hanna,

Great post! Really interesting stuff. The clinical work you're doing sounds awesome. I do, however, have a couple of theoretical questions and worries.

First, I was wondering if you could say a bit more about what you mean, or what clinicians mean, when you (or they) say that the behavior of PD patients is 'voluntary'. Do you mean, for example, that, difficult though it may be for the patients, it is within their power to refrain from the problematic behavior? In my idiolect voluntary behavior is easy to come by, and is not equivalent to 'the sort of freedom or control required for blameworthiness'.

Second, since I'm not a clinician, I wouldn't presume to say what should be done in these settings, but at least in principle affective blame seems compatible with a "supportive, respectful, understanding and compassionate [environment] – [an environment] that maintains dialogue and good relations...opening up the possibility for reflection, and listening with concern…", etc. I think Susan Wolf does a good job of bringing this out in her recent paper "Blame, Italian Style".

Finally, assuming that patients with PD can do otherwise and know that the relevant behavior is immoral, I would say that they are blameworthy for that behavior, though their blameworthiness might very well be mitigated, perhaps even significantly mitigated, by the difficulty they have refraining from it. Moreover, as long as we're willing to acknowledge (as we most definitely should be) that there might be decisive reasons not to overtly blame someone who is, in fact, blameworthy, mightn't we describe what you're doing in the clinical setting as follows: PD patients often are worthy of at least some blame for their bad behavior (though perhaps much less than they might otherwise be), but it would be counterproductive to overtly blame them, so we don't.

Hi Hanna, thanks so much for joining us! Your experiences are a breath of fresh air into our overly constrained considerations about freedom and responsibility. I'll add just one question to the many you're already getting.

As I was reading your eloquent description, I was thinking that the treatment of PD patients you describe (which sounds compassionate and effective) reminds me of the way we should probably be raising our children. (Sorry if that sounds paternalistic towards PD patients--I don't mean we should treat them just like children.) And I was thinking that PF Strawson's account nicely (if too briefly) describes these attitudes and behaviors towards those (like children) whom we think are not fully free and responsible but whom (1) we do not think merit the "objective attitude", (2) we aim to help attain more developed capacities for freedom and responsibility, and (3) we have moral concern for.

Do you think this analogy is on the right track (even if perhaps some PD patients have less potential than children to develop these capacities)? And if so, do you think your suggestion that "responsibility without blame" puts pressure on Strawsonian accounts might be misplaced?

Thanks for very much for these really interesting comments. Let me try to answer at least some of the issues you’ve raised together, so that they link (and I'll write some separate answers too, in a moment):

Justin: First, to say something about voluntariness. I chose that word as a kind of catch-all. What we talk about more than anything else in the clinic is choice. The clinical position is that patients have the power to do otherwise: they could choose not to act as they do and they have sufficient control to make that so, so that they not only make a different choice but effectively enact it. So it’s a pretty robust (and traditional) condition on responsibility.
As an aside, one of the things I’ve always found really thought-provoking about this is how potent the idea of choice is. You don’t get very far telling patients about all the good reasons they have for behaving otherwise. They probably know them already, and you easily get stuck in an argument where you say something and they say ‘Yes, but ...’ and you say something else and they say ‘Yes, but ...’ On the other hand if you say: ‘Bottom line, this is your choice, what you’re doing is incredibly destructive, how can we help you choose different?' they agree and often become motivated to do the work they need to.

Gunnar: Now to say something about responsibility. Yes, it’s sometimes reduced, if control or the capacity to enact what choice they’ve made is reduced. But not always, sometimes a patient's behaviour is as controlled as any of our behaviour ever is. And equally, sometimes it is not reduced enough for much difference to be made with respect to degree of responsibility. However, we often excuse from blameworthiness (as distinct from blame) in the clinic not by appeal to lack of control but by appeal to justification. If the problem behaviour is a habitual way of coping with distress, then we might hold that they are responsible yet justified in doing it if they haven’t yet really learned other ways of coping, because we don’t expect people to tolerate that level of distress without relief. Of course, excuse by justification will depend on how much harm and to whom the behaviour causes. Some levels of harm and perhaps most levels when it is inflicted on third parties mean that you are not justified in acting that way, no matter the distress.

Justin: Blame Italian-style. I think the answer to this is that it’s a matter of degrees, not black-and-white. A key example in Susan Wolf’s paper is the blame she feels towards her teenage for a fairly minor misdemeanour. When you love someone and are committed to the relationship and even more they are your child so you are actively involved to helping them grow into becoming a good person, they and the relationship may well be able to tolerate episodes of affective blame. I guess something like that parent-child relationship is part of what we try to achieve in the clinic. But without standing familial ties, it’s much easier for an episode of affective blame to transform into a standing state, where you break off dialogue or the relationship and end up judging the person and maintaining negative affective attitudes towards them in an enduring way. I’m going to post about this more in relation to criminal justice, but I think part of what matters here is the kind of attitude we take towards our emotions. How much does affective blame involve the second-order attitude that our Italian-style anger is morally right and something we are entitled to have because of what the person has done? This connects to the points Mark made in his comments: do we try to justify our emotions and burden the other person with them, as it were? In so far as affective blame involved that kind of attitude, it's not likely to be good for the kind of environment we need in the clinic to support behavoiural change.

Finally a quick reply to both Gunnar and Justin about norms for expression of blame as distinct from norms of experience of blame. Yes, it makes sense to think that it feeling blame is understandable (NB: that is not to say it is morally right!), but that we might not think it appropriate relative to the circumstances or one’s role in relation to the person blamed, or instrumentally desirable, to express it. That’s important, because we of course don’t always manage to avoid feeling blame in the clinic, and when we do, we have to try not to express or act on any blame we feel. So Justin, the position you end up suggesting is what we have to revert to by default, if we fail to avoid blame. However we often do succeed in avoiding not just expressing or acting on blame, but experiencing it in the first place. And that’s certainly the ideal I think we clinically aspire to. One reason is practical: it’s safer not to feel it, than to feel it and have to hide it. But the more interesting reason is what I think of as a deep commitment to the idea that we should question these norms, especially when holding to them has bad instrumental effects and especially given facts that might undercut our sense of self-justification or entitlement. The point about the difficult backgrounds faced by many people who have PD is relevant to this last thought: those backgrounds may not undermine responsibility and the right to hold to account, but they may undermine our right to blame.

Just a quick final comment to say I seem to be struggling a little to moderate things and keep up! E.g. Eddy thanks very much for your contribution which alas I only read after posting the reply to the others, or I would have said more about parents and children and linked it to what you raise. Give me a little time to get back to you ... more soon ...


Thanks very much for this very interesting post. I especially like and appreciate the emphasis on the distinction between moral responsibility and the *further* question of whether blame should be engaged (as it were). I have always emphasized that these are two separate (although of course related) issues. For me, moral responsibility is a matter of meeting certain epistemic and freedom-relevant conditions; the latter is (for me) "guidance control". It seems as if the members of PD are indeed morally responsible, having met these minimal conditions. They have then become "apt candidates" for the reactive attitudes. But I fully agree that it is now a *further* question whether such attitudes ought to be applied. I think you have given good reason why in some contexts morally responsible agents should not be the subjects of certain of the reactive attitudes, and this is very helpful. In my view, this is all further reason for to capture the nuances of the terrain in our theorizing.

Finally, by "PD" I know you mean "Personality Disorder", and not "Philosophy Department", but I couldn't help but notice some similarities... (Ha! I hope a joke is ok, even a feeble joke [as is my wont])

Thanks again for enriching our discussion with such thoughtful material.

Michael: Thanks for the comment. Just a few points in response. First, renouncing blame is not the same as renouncing condemnation on my account: it's really important that we can still judge people to have done wrong and hold to account. Second, I agree that it's not self-evident what the actual effect of anything we do or don't do will be. That's an empirical question, and an incredibly important one. What I've tried to do is offer some empirical reason for thinking renouncing blame might have a good effect. I think it's up to people who disagree to offer empirical reason for thinking the opposite. Finally, on evil. I don't myself like to talk about evil except in the most extreme cases, if at all. Why? Evil is largely about people's character. If someone's evil, the implication of an essential, bad core is pretty strong. Responsibility on the other hand attaches not to character but to behaviour, which people can change. Part of how we can help them do that is, in my view, not to judge them as of evil character, because that understandably makes them feel ostracised, despairing, and hopeless, so unlikely to do the work they would need to do to address immoral behaviour and tendencies.

Mark: Thanks for the comment. Your end point strikes me as really helpful, and not something I'd seen quite that way before. I don't think blame is 'deserved' in the way we use that term (I'm planning to post more about this in relation to criminal justice). But you're right that there's another position, which is that it may be deserved but we still don't have to choose to indulge in it or inflict it. That's right, and an interesting and useful sort of fall-back for me, if I fail to convince people it's not deserved in the first place.

Hi Hanna -- I’m struck by your ‘stark choice’ question: “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.” I definitely sympathize with the underlying idea, partly because I want to reject desert attributions. So do you think that your stark choice applies to non-clinical cases? If you do, suppose that Eddy is right, that in non-clinical cases desert attributions are nevertheless true. Even then, would it turn out on your view that such desert attributions, even if true, should have no role in how we in non-clinical cases react to bad behavior, since our aim should be to reduce the amount of wrongdoing and harm in the world?

Thanks for the post Hanna, this is really interesting and illuminating! I find what you say about the inability of people with PD to productively deal with being blamed to be especially compelling in motivating the view that they don't deserve blame, or at least that they're less deserving. That's an aspect of blameworthiness I haven't thought about much before, but it seems important. Many of us (myself included) understand deserving blame in terms of being an apt candidate for the various reactive emotions you describe. If being the target of various reactive emotions really is counterproductive and causes the kinds of harms that you described for PD patients (and especially if it causes those harms because of factors that are outside of their control, as you describe), then does seem plausible to suggest that they aren't really apt candidates for that kind of blame.

Very interesting, Hanna. Thanks for posting. I have three small questions. First, you suggest a separation between responsibility and affective blame, where this is sometimes glossed as "holding to account." But I assume you do feel and express, say, gratitude and other positive emotions when the PD patients do something gratitude-worthy, yes? Or do you (implausibly, I would think) maintain that emotional reactions across the spectrum are to be withheld here? As I think "holding accountable" has both negative and positive variants, if your answer is the former, then perhaps you would want to restrict the view to *negative* accountability. Of course, if it is the former, I would also be interested in the methods by which one feels/expresses only the positive emotions but not the negative ones. One might think the repression of only the bad would require a failure to fully engage interpersonally with these people (just like being a true fan of a team requires one's misery at their failures, not just one's elation at their victories).

Second, the responses you have described could still, I think, fall under Scanlon's rubric of "blame," described as altering relationships in light of a judgment of blameworthiness in the way that judgment renders appropriate. In such circumstances, the appropriate responses to the judgment could simply be respectful expressions of one's judgments of wrongdoing.

Third, one might think that the examples of therapeutic responses aren't really counterexamples to a Strawsonian theory by focusing on the *aims* of reactive attitudinal expressions like resentment. The anger of which resentment is a species has a *to be communicated* component, that is, it doesn't count as anger unless one has the motivational impulse (overridable) to communicate it to the offending party. But what does anger communicate? It seems at its foundation that it is a demand for *acknowledgment*, that the offender take up the perspective of the angry party to feel what she was made to feel by the offense. Anger very dramatically communicates this demand, and it tends to be very effective. But sometimes, as in the cases you have documented and experienced, it can be counterproductive in communicating that demand. In such cases, then, it makes sense to adopt a different communicative method, as you have done. But then if communication of that specific demand is the core aim of the Strawsonian range of attitudes, then different methods for achieving it won't constitute a counterexample after all. (Sorry to have blathered on so long. Very interesting stuff!)

An additional point, if I may. A very nice feature of your view is that it charts a felicitous (in my view) "middle way" between "mere therapy" and blame. Theorists such as Herbert Morris tend to distinguish "therapy worlds" from "responsibility worlds". A therapy world involves treating others as merely subject to manipulation or positive and negative reinforcement, whereas a responsibility world involves the full panoply of Strawsonian reactive attitudes. What you are charting is a nice middle ground, sometimes missed by Morris (another well-regarded philosopher/therapist). In this space there is more than "mere" therapy; indeed, the therapy in PD cases (that you describe) presupposes moral responsibility, just not blame.

If I may be allowed a reply to Ryan: I would distinguish being an apt candidate for the reactive attitudes (which I think the PD folks are) from its being the case, all-things-considered, that any particular reactive attitudes ought to be applied in a given case.

John: That joke hits way too close to home! And I’m doubly implicated: not only a member of a Philosophy Department but also a clinician working with Personality Disorder ... in the clinic we often “joke” that we all somehow end up working with patients whose pathologies we know from the inside ... More seriously, thanks for the supportive comment and interest.

Derk: I think your comment relates not just to Eddy’s view but also to the comment John posted. The reason why I put the question in ‘stark choice’ terms is really to make vivid the idea that our reactive attitudes may undermine outcomes we value. Now there is a complication here: which is that we may also value our reactive attitudes. (Also, unless and until there is a whole-scale cultural shift, avoiding reactive attitudes may also dis-value an individual person in a sense, in so far as it treats them not as ‘one of us’ or not as our equal. I have always loved the way Angela Smith puts this point: that being treated as a responsible agent is a privilege, not just a burden, because of the way it keeps the person with us, as a participant in our community.) So if we want to import the clinical stance into a more ordinary context, we are going to have to think about what we value more, and what goods are worth forsaking for other goods. If for the sake of argument you accept my ‘stark choice’ hypothesis as empirically real, then, when we are dealing with severe harm and wrongdoing, yes, I don’t think we should privilege our reactive attitudes over the elimination of that harm. I am happy to be consequentialist and outcome-focussed here. Things are different if the harm is less severe so it competes more with whatever value people may think the reactive attitudes have. (And also, of course, the whole thing rests on an empirical assumption, which is that importing the clinical stance to more ordinary contexts would reduce harm in those contexts, too. Obviously this need evidence and argument.)

Eddy: What you say about the clinical attitude to patients being similar to the relationship between parents and children is right in my view. There are differences. Sometimes, and no doubt because of their childhoods and the fact they haven’t been appropriately loved and cared for by their parents, patients with PD struggle to act as they need to given that they are adults. To put this in psyco-dynamic terms, they often get stuck in ‘child mode’ perhaps because they are looking for the love or care that was absent. As a result, it is sometimes important to help a patient step out of that mode, and see that the way they are behaving is inappropriate, because they are now an adult. But that said, the kind of environment we try to create in the clinic and the attitude we try to adopt towards patients can be seen as a kind of caring, safe, context, to explore the past, express your feelings, and try out new ways of thinking and acting in the present. In that way, it is a lot like being in a loving and tolerant family environment, where mistakes are accepted and judgement is not passed.

It seems to me the key issue about whether or not this puts pressure on a Strawsonian-style account is first, how exactly we cash out what that account commits to, and, second, the extent to which patients with PD are like children in not yet being ‘fully free’ as you put it but only ‘on the road to freedom’ as it were. Strawson is hard to pin down, but I’ve always thought the main take-home message is that we simply can’t make sense of the idea of responsibility except via the way we hold people to account in our ordinary practice of having and expressing reactive attitudes – what ‘can’t make sense’ means here is hard to specify, maybe it’s that such holding to account is ‘constitutive’, maybe it’s that questions of whether someone is or isn’t responsible only arise within these reactive practices. I think the clinic is a counter-example to this *if* patients with PD are ‘fully free’.

So are they? I honestly don’t know how to answer this question in a way that really satisfies me. There are ways in which underprivileged backgrounds with limited opportunities directly impact on the development of psychological capacities, like executive function or emotional self-management, which may mean patients with PD are less free than others of us in certain situations e.g. less able to manage their behaviour when gripped by strong, overwhelming emotion. We all struggle with that of course, but they do so more, and part of what therapy does is help patients develop this capacity in all sorts of ways, as good parenting and good environments do for children. So in this respect, I think you’re right, they may be like children in that they are both developing freedom and also in-between reactive and objective attitudes. On the other hand, in other respects, and on many occasions, they are as fully free as any of us ever are, and they just act – as we all sometimes do – in ways that harm themselves and others. In many cases with patients, a typical reactive attitude response would appear to be totally justified if ever it is justified – and yet we try to take a different approach in the clinic while yet holding responsible.

That said, I think the way Strawson tries to find room for things not being black-and-white, for movement and shifting between taking up a more reactive and taking up a more objective attitude towards others, is right and important. Indeed, he even says we sometimes take up a more objective attitude out of fatigue and strain, not because it’s right or warranted. So his attention to the subtleties and complications within our typical reactions to others when questions of responsibility for harm or mistreatment arise seems to me very much in line with the clinical attitude of enquiry towards our own responses – where they come from, what purpose they serve, and what in fact they achieve. But that’s shaky ground to build good responsibility-ascription practices on – I think that’s partially why, in the clinic, we try to distinguish so sharply between what’s true of the person who did something wrong, and how we do or should emotionally react in response.

Hi Hanna-

Welcome to the wonderful world of free will blogging and the feelings of despair that quickly follow in the wake of the challenge of keeping up with interested commentators!

To answer your question, sure, let's reduce wrongdoing and harm if all we are giving up is some deserved retributive attitudes. I take it, though, that one of the issues is whether those deserved retributive attitudes do any work outside of non-clinical populations.

FWIW, I'm leery about supposing that PD populations tell us much about whether non-PD populations are typically well-served by a moral ecology that includes exposure to blaming. If I've understood things rightly, in your characterization, part of the explanation for why blame is so corrosive to these folks is that it evokes associations of extraordinarily hard treatment at vulnerable ages, and to the extent to which non-PD populations lack those associations, it seems like the particular corrosive features of blame lose some (but not all, perhaps) of their corrosive effects. I can't make out, though, whether you think the responsibility-without-blame view is sensible outside PD populations.

A quick question on a different point: what's the content of the judgment that someone is responsible? Is yours a view on which those judgments (i.e., blame in the detached sense) are ones whose content is limited to something like "the agent voluntarily is a cause of some bad outcome," or if there is something else to the judgment (e.g., that the agent is a prima facie candidate for blame, or that he or she deserves blame). At least sometimes, I'm inclined to think one doesn't have a responsibility judgment without the latter (or something comparable) because there isn't any normative content there worth the name "responsibility."

ps: I like the distinction between detached and affective blame; I make a similar distinction between blaming judgments and blaming (affective) reactions in my own work; I suspect we construe the content of blaming judgments a bit differently, though.

pps: I shared Eddy's question about whether PD cases are, in some ways, similar to children in that their emotional resilience is not like that of normal adults. It sounds like a salient difference is that in the case of kids, though, there is a kind of receptiveness to being moved by blame reactions/affective blame in a way that, with time, builds to normal emotional resilience. In contrast, in PD populations are past that developmental window (perhaps?) and so blame can't work in the standard ways on them.

John: I find that distinction plausible; there could be lots of different reasons not to apply the reactive attitudes to a person in a particular case even when that person is an apt candidate for the reactive attitudes. But I'm not sure about the PD patients. If it's really the case that their condition deprives them of the ability to respond productively or appropriately to being the target of reactive attitudes, then (to me at least) it starts to sound plausible to say that they aren't apt candidates for those attitudes.

Great stuff, Hanna (and the rest of you chumps). I had the same reaction as Eddy (and others) about the connection between our responsibility behaviors toward children and those suffering with PD. And this leads me to wonder about the teleology of the therapeutic approach to responsibility that you are very reasonably recommending in the case of PD populations. At some points, it seems like the goal of the therapy is simply to get the bad behavior stopped. And if that is so, then is does seem like an important difference from the parenting case, wherein, presumably, we are also hoping to bring our children into the full moral life with us, complete with a healthy responsiveness to full-blown blame. My guess, however, is that the PD scale is such that there are some folks for whom any hope of bringing them into the full moral life with the kind of stable psyche that can properly process blame is practically unrealistic—but then there are others for whom we are able to hold out hope for something like normal moral responsibility. Does this sound right, from the point of view of the clinician?

Hi Hanna,

Thanks for a super stimulating post (and welcome to Flickers!) :-))

I want to amplify a point made by John and suggested by David S. and Justin C as well. A Strawsonian says the following:

S: Being morally responsible means being an apt candidate for the reactive attitudes (or put in a slightly different way, if a person is MR, then there is a reason to express reactive attitudes to her). It seems like the Strawsonian should then say the following two claims are incompatible.

1. PD patients are morally responsible
2. We ought not express reactive attitudes to PD patients (i.e., there is most reason to not blame them).

But I think a Strawsonian needn’t say 1 and 2 are incompatible. The key is to recognize that the reasons cited in S are different than (actually, just a subset of) the reasons that are relevant for 2. The reasons that are relevant for S are internal to our holding responsible practices, and are linked to certain kinds of moral demands and expectations. The reasons that are relevant to 2 are a wider set that includes reasons to punish and pragmatic/prudential reasons as well (e.g., our goals of helping the patient get better and furthering the therapeutic alliance).

Another way to put this is that there seems to be a “wrong kind of reason problem” lurking here, of the kind that Dan Jacobson discusses. Strawsonians intend S to say that being MR generates certain *specific kinds* of reasons for the expression of the reactive attitudes, and the fact that other kinds of reasons might exist that pertain to whether these attitudes should be expressed shouldn’t count as a problem for S.

Manuel’s definitely right: I can’t keep up! Thanks everyone for all these interesting and challenging comments. I’m going to write one more reply before signing off for the night. I’m sure I won’t speak to all the concerns that have been raised but hopefully I’ll address some of them, and I will try to come back to some of the things I’ve missed as my stint as Featured Author progresses.

Let me start by replying to some of the questions David raised about what we actually do in the clinic. First, yes absolutely, we do offer lots of positive re-inforcement and feedback, in emotional and other terms. So it’s right this is about the negative reactive attitudes, not the positive ones. But just to be clear: we hold to account for negative behaviour in a non-blaming way (even if part of how we hold to account for positive behaviour, if I can so put it, is through positive reactive attitudes).

How do we manage to avoid negative reactive attitudes? That’s a huge, complicated question. And of course we don’t always succeed. But here’s a list of some of what I think helps. First, culture. We create a different culture, in which we and are patients get enculturated. Whatever the processes of enculturation of emotions, they apply in the clinic as much as elsewhere. So in a sense, our reactive attitudes are re-fashioned by this process over time. Second, behaviour. It’s a clinical truism that emotions and motivations follow on from behaviour as much as they other way around. Certainly in my case, I started by managing my behaviour. That included not acting out of negative reactive attitudes towards patients, not speaking dismissively of them to colleagues, etc. Over time, I think my emotions and motivations have shifted, although I’m far from perfect. Third, roles and responsibilities. The clinical aim is to help. We don’t help by blaming. Keeping that in mind and trying to actively think and work to structure practices and ways of interacting within the group which are non-blaming just does have an effect on your feelings, again over time. Fourth, the second-order attitude we take towards emotions. I was planning to post about this when writing about criminal justice, but I’ll say a little more here. We really try not to think of our negative reactive attitudes as responses to others which are deserved by them – to which we are entitled or which are right. In general, we treat emotions – not just in the clinic but outside them! – as quite liable to be irrational or arational and to do as much with a person’s past history and personality-style than with anything in the world that objectively warrants them – there’s not much right and wrong here. So e.g. if you do affectively blame, it does not mean you are right to affectively blame, even if the responsibility conditions are met – that helps you quell or manage it. Fifth and connected, part of the morality of the clinic, as I like to think of it, is that it’s never so black-and-white as you think, that everyone has a part in difficult interpersonal encounters, and that it’s rare for it to be the case that someone is wholly in the wrong and the other party wholly in the right. Quite often we blame others in order to avoid responsibility for our part ourselves. I could add more to this list, but that’s probably more than enough to get going with!

Manuel and Dan both asked about the recovery prospects for people with PD. Dan’s right: there’s a lot of individual variation, which we’re only just starting to track in any systematic way (but e.g. there’s a lot of good evidence for effective treatment for Borderline PD, which certainly is my experience). ‘Recovery’ though is complicated, in that PD is a threshold concept, with people with PD being on a continuum with the rest of us as opposed e.g. to suffering from a discrete, underlying disease, which you either have or lack. People get better, but they may also struggle when times get tough, reverting to past patterns. This is one reason why you might think that, if blame is counter-productive in the clinical population, so too it may be in the non-clinical population. There’s not really an us and them, just a continuum. So yes, part of why blame is so corrosive in the clinic is the terrible upbringing patients with PD have often had, which has affected their resilience. That’s one reason why it’s not productive in the clinic. But I still think we need empirical evidence about whether it’s productive outside of the clinic, especially given that there really is no divide here.

On the connection between resilience to blame and good parenting, I’m not sure quite what to say. I want my children to be morally good and psychologically robust for sure – but I don’t conceive of that specifically as wanting them to be able to process affective blame. What I want is for them not to do the kinds of things that make people affectively blame them! And, of course, to have resources to deal with what the world throws at them, so much of which is hurtful and unjust and unfair. I take it that many of you wouldn’t want affective blame to be part of that litany (although on my view, it too often is)! Anyhow, being part of ‘our moral life’ as Dan nicely puts it or being morally responsible really is at core for me behavioural – it is about not harming others, or, even better, actively thinking about what would be good for them. So, in response to Manuel’s question about the content of moral responsibility ascriptions for me, yes, it’s thin, and I’d like it to be understood without appeal to the negative reactive attitudes. You are morally responsible if you meet various cognitive and volitional conditions and what you do causes harm and you have no excuse.

So finally about Strawson. Here’s the basic way I understand the clinical world to offer a counter-example. It shows that we can get by in terms of making responsibility-ascriptions without linking them and accountability for wrongdoing to the reactive attitudes – it shows that it is conceptually and practically coherent to prise responsibility apart from these attitudes. As Chandra points out, the reasons for doing this are indeed what I think of as instrumental – doing so helps us achieve various ends we value, like helping patients and reducing harm to them and others. So yes, our culture typically links responsibility and accountability with the reactive attitudes, but there is no necessity here, never mind the reasons we may have not to (although as I have said, how far to extend the clinical stance to our ordinary practice is in part an empirical question, and we need evidence about what in fact is the case - what effect blame has on the non-clinical population who struggle to behave well). Maybe the right way to put this point is as a challenge: given the existence of this alternative clinical culture, why think Chandra’s “S” or anything like it is true, as opposed to just a good description of our current cultural practices? I've never understood Strawson to be arguing only that we *can* link the meaning of responsibility to our reactive attitudes, but rather that in some sense we *must* - if the very idea is to make sense or be possible.

Thanks to everyone for welcoming me so warmly to the blog and for all your great comments! Good night from the UK and see you tomorrow ...

I am not a clinician, so regarding the effect of blame on individual clients I will defer to your professional skill and experience. I also wish to thank you both for this discussion and for the work you do in your practice. It makes the world better than it would otherwise be.

I think the suggested analogy between your clinical practice and child rearing leads me to ask if the goal of your practice is to encourage the growth of moral responsibility in clients and thereby encourage them to refrain from doing evil because it is evil or to encourage discretion so that clients refrain from doing things that will get them into further trouble, so to speak.

My intent in my previous response was to suggest the possibility that the clinicalization of good and evil is eroding our capacity as a society to make moral judgements and thereby encouraging more evil-doing than would otherwise be the case. To be fair, to the extent that this phenomenon exists it is more Dr. Phil's fault than yours. Techniques that are safe and effective when used by professional clinicians in clinical environments can be harmful when used by TV talk show hosts. The danger I see in your techniques lies in our inability to limit them to their proper environments, not in the techniques themselves.

Regarding freedom and moral responsibility, I think that people who were raised in toxic environments are (other things being equal) as free from external compulsion as those who were raised in healthful environments. If one claims that the former are less free to refrain from doing evil than the latter, their diminished freedom must be due to an internal compulsion to do evil or equivalently, a diminished internal capacity to refrain from doing evil. Whether their diminished freedom is ascribed to compulsion to do evil or inability to refrain from doing evil, the question arises whether their diminished freedom results in diminished moral responsibility.

I don't think there is such a thing as 'moral responsibility' in the abstract. I think that moral responsibilities are obligations to act, or refrain from acting, in particular ways toward particular people or groups of people. This notion of moral responsibility suggests that responsibilities have reciprocal rights. If I borrow money from a friend I have a responsibility to pay her back. She has a right to be repaid. Similarly, I have an obligation to refrain from driving while drunk, and the people with whom I share the roads have a right not to have their lives unduly endangered by a driver who is not fully in control of his vehicle. The fact that I am an alcoholic and powerless over my drinking does not diminish their right. In general, my diminished capacity to govern my behavior does not diminish the obligation I have to my fellow human beings to do so. (This is an example only. I am fully in control of my drinking.)

If I'm driving while drunk, ignore a stop sign extended from a school bus and kill a child coming home from school I don't think anyone would deny the legitimacy of his parents' moral outrage or of their right to express it at my sentencing hearing. The moral outrage others feel and express toward me is likely to be driven by empathy with the dead child and his parents. I think that in general the outrage felt and expressed by third parties toward evil-doers is a surrogate for the outrage of the victims, assuming they have survived to feel it. When we try not to express or not to feel this outrage we are siding with the perpetrators rather than with the victims.

A clinician's first obligation is to the well being of her client, and I do not intend to imply that such should not be the case. I do believe that clinicians should be mindful of the effects that their practice and the theories underlying their practice have on the wider world.

Hanna: I was wondering if you could say a bit more about your claim that patients with PD are "not mentally ill." Having worked with PD patients myself (in both an outpatient and inpatient setting), PD patients were known in my workplace as among the *most* mentally ill of all the patients that we faced (rivaling, if just a bit below, schizophrenics). My experience was that PD patients' sheer inability to control their emotions or regulate their behavior was no less of a genuine illness than the overwhelming emotions (and behaviors) associated with major depression or bipolar disorder. Anyway, I worry that saying that patients with PD do not suffer a mental illness threatens to place responsibility on these patients where it does not belong. It is not their fault that they suffer (and they do suffer) from such a disorder.

Marcus: Thanks for the important question. I was using the term ‘mental illness’ partially as it is used colloquially, to mark a distinction between psychosis or “madness” and what people used to think of as neurosis or any number of “problems of living” that cause severe distress and dysfunction. No doubt I also had in the back of my mind the way this distinction between psychoses and neuroses is partially tracked by the division between Axis I and Axis II disorders, with e.g. schizophrenia and bipolar disorder being Axis I and PD being Axis II. These distinctions are certainly crude and vague as opposed to well-defined. From a scientific perspective, my view is that the evidence does not suggest that psychiatric classifications carve the world at its joints, but rather blend together and tend to be most helpfully understood via the notion of spectrums or continuums. So e.g. you might think borderline PD and bipolar disorder are on a spectrum. Certainly in the UK borderline patients are often misdiagnosed with bipolar. Equally, from a clinical perspective, co-morbidity (as opposed to misdiagnoses) between many different Axis I disorders (schizophrenia, depression, OCD, and again perhaps especially bipolar disorder) and PD is high, which means that it is often really hard to determine which symptom or problem is to be understood as stemming from the personality component and which from the Axis I component. But I think there are still some differences worth marking. One is the inadvisability of medication as a form of treatment for most cases of PD, in contrast to most Axis I disorders. The other is the kind of underlying neurobiological aetiology that appears associated with each (genetic and environmental factors of course are associated with of all these conditions).

In any case, the main thing I meant to be doing by claiming PD patients are not “mentally ill” was flagging to a non-clinical audience the lack of delusions as a core diagnostic criterion. You are absolutely right, however, that beyond doubt levels of distress and dysfunction can be comparable between PD and Axis I conditions. Even more, level of risk (e.g. of self-harm, overdoses, suicide) with PD is typically higher. This puts a huge strain on staff working with patients with PD, who have to deal not only with the distress and dysfunction but also manage the risk (and their anxiety around it) in a way that is both safe but also respects the fact that the patient is not deluded and may well have decisional capacity.

The worry you raise about how mental illness excuses from "fault" in our culture is of course real. What I would like is for us to be able to acknowledge that we should care for all people who suffer from mental disorders, without having to deny their agency and responsibility, which I think is in some cases both inaccurate but also unhelpful to them for their treatment. That requires public education to address the stigma that attaches to all kinds of mental disorder, a really important but difficult task. In my service, we employ ex-patients who have competed their therapy to help deliver training and educate mental health professionals about PD, which has proved a really effective way to increase awareness and shift attitudes, at least among professionals. Their perspective is really invaluable.

Hanna (if I may)--

A great post and terrific thread. I'm learning a lot.

As I've posted here before, as a matter of public policy the USA has been particularly overall incoherent with respect to how to treat mental illness and legal responsibility. No doubt one reason for this is the multiple jurisdictional structure of law and law-making in the US, resulting in some states abolishing the insanity defense entirely--thus maintaining in effect that people can be responsible irrespective of mental condition, while other states explicitly have laws that one can be guilty but legally insane; some of the latter also allow pleas of not guilty by reason of insanity. If the law is supposed to track attributions of moral responsibility (and that's arguable), then the US is not a good litmus test of how to assess responsibility in legal terms.

I know these remarks have no direct bearing on clinical practices and particularly with the kind of PD cases you are dealing with, though I do see your distinction of affective and non-affective responsibility as not just useful therapeutically, but in wider public policy and potentially as something transformative. Thom Brooks in his recent book Punishment advocates for something like this with respect to a "unified theory" of punishment that features the concept of restorative justice, which does assign blame, but within the context of a larger process that attempts to restore rights as far as possible to all parties involved, including the perpetrator. Replace your goal-emphasis on restoration of health with rights, and the two approaches seem very much parallel.

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3QD Prize 2014: Marcus Arvan