Drug use and drug addiction are severely stigmatised around the world. Marc Lewis does not frame his learning model of addiction as a choice model out of concern that to do so further encourages stigma and blame. Yet the evidence in support of a choice model is increasingly strong as well as consonant with core elements of his learning model. I offer a responsibility without blame framework that derives from reflection on forms of clinical practice that support change and recovery (...) in patients who cause harm to themselves and others. This framework can be used to interrogate our own attitudes and responses, so that we can better see how to acknowledge the truth about choice and agency in addiction, while avoiding stigma and blame, and instead maintaining care and compassion alongside a commitment to working for social justice and good. (shrink)
Addiction is standardly characterized as a neurobiological disease of compulsion. Against this characterization, I argue that many cases of addiction cannot be explained without recognizing the value of drugs to those who are addicted; and I explore in detail an insufficiently recognized source of value, namely, a sense of self and social identity as an addict. For people who lack a genuine alternative sense of self and social identity, recovery represents an existential threat. Given that an addict identification carries expectations (...) of continued consumption despite negative consequences, there is therefore a parsimonious explanation of why people who identify as addicts continue to use drugs despite these consequences: they self‐identify as addicts and that is what addicts are supposed to do. I conclude by considering how it is nonetheless possible to overcome addiction despite this identity, in part by imagining and enacting a new one. Importantly, this possibility requires the availability of social support and material resources that are all too frequently absent in the lives of those who struggle with addiction. (shrink)
When philosophers want an example of a person who lacks the ability to do otherwise, they turn to psychopathology. Addicts, agoraphobics, kleptomaniacs, neurotics, obsessives, and even psychopathic serial murderers, are all purportedly subject to irresistible desires that compel the person to act: no alternative possibility is supposed to exist. I argue that this conception of psychopathology is false and offer an empirically and clinically informed understanding of disorders of agency which preserves the ability to do otherwise. First, I appeal to (...) standard clinical treatment for disorders of agency and argue that it undermines this conception of psychopathology. Second, I offer a detailed discussion of addiction, where our knowledge of the neurobiological mechanisms underpinning the disorder is relatively advanced. I argue that neurobiology notwithstanding, addiction is not a form of compulsion and I explain how addiction can impair behavioural control without extinguishing it. Third, I step back from addiction, and briefly sketch what the philosophical landscape more generally looks like without psychopathological compulsion: we lose our standard purported real-world example of psychologically determined action. I conclude by reflecting on the centrality of choice and free will to our concept of action, and their potency within clinical treatment for disorders of agency. (shrink)
I argue that addiction is not a chronic, relapsing, neurobiological disease characterized by compulsive use of drugs or alcohol. Large-scale national survey data demonstrate that rates of substance dependence peak in adolescence and early adulthood and then decline steeply; addicts tend to “mature out” in their late twenties or early thirties. The exceptions are addicts who suffer from additional psychiatric disorders. I hypothesize that this difference in patterns of use and relapse between the general and psychiatric populations can be explained (...) by the purpose served by drugs and alcohol for patients. Drugs and alcohol alleviate the severe psychological distress typically experienced by patients with comorbid psychiatric disorders and associated problems. On this hypothesis, consumption is a chosen means to ends that are rational to desire: Use is not compulsive. The upshot of this explanation is that the orthodox view of addiction as a chronic, relapsing neurobiological disease is misguided. I delineate five folk psychological factors that together explain addiction as purposive action: strong and habitual desire; willpower; motivation; functional role; and decision and resolve. I conclude by drawing lessons for research and effective treatment. (shrink)
My first experience as a clinician was in a Therapeutic Community for service users with personality disorder. As well as having personality disorder, many of the Community members also suffered from related conditions, such as addiction and eating disorders. Broadly speaking, these conditions are what we might call ‘disorders of agency’. Core diagnostic symptoms or maintaining factors of disorders of agency are actions and omissions: patterns of behaviour central to the nature or maintenance of the condition. For instance, borderline personality (...) disorder is diagnosed in part via deliberate self-harm and attempted suicide, reckless and impulsive behaviour, substance use, violence, and outbursts of anger; addiction is diagnosed via maladaptive patterns of drug consumption; eating disorders involve eating too much or too little. If a service user is to improve let alone recover from these disorders, they must change the diagnostic or maintaining pattern of behaviour (cf. Pearce and Pickard, 2010). For instance, service users with borderline personality disorder must stop self-harming; addicts need to quit using drugs or alcohol; anorexics must eat. (shrink)
I clarify some ambiguities in blame-talk and argue that blame's potential for irrationality and propensity to sting vitiates accounts of blame that identify it with consciously accessible, personal-level judgements or beliefs. Drawing on the cognitive psychology of emotion and appraisal theory, I develop an account of blame that accommodates these features. I suggest that blame consists in a range of hostile, negative first-order emotions, towards which the blamer has a specific, accompanying second-order attitude, namely, a feeling of entitlement—a feeling that (...) these hostile, negative first-order emotions are what the blamed object deserves. (shrink)
I argue that denial plays a central but insufficiently recognized role in addiction. The puzzle inherent in addiction is why drug use persists despite negative consequences. The orthodox conception of addiction resolves this puzzle by appeal to compulsion; but there is increasing evidence that addicts are not compelled to use but retain choice and control over their consumption in many circumstances. Denial offers an alternative explanation: there is no puzzle as to why drug use persists despite negative consequences if these (...) consequences are not straightforwardly known. I describe the nature of the causal knowledge that one's drug use is causing negative consequences; map the conceptual landscape of denial and explain how it can block such knowledge; and explore some of the processes and mechanisms that have been studied by philosophy and the cognitive sciences and which may underpin denial in addiction, including well-established information-processing biases, motivational influences on belief formation and self-deception, and cognitive deficits with respect to insight and self-awareness. I conclude by suggesting that addiction is as much a disorder of cognition as a disorder of conation. (shrink)
Within contemporary penal philosophy, the view that punishment can only be justified if the offender is a moral agent who is responsible and hence blameworthy for their offence is one of the few areas on which a consensus prevails. In recent literature, this precept is associated with the retributive tradition, in the modern form of ‘just deserts’. Turning its back on the rehabilitative ideal, this tradition forges a strong association between the justification of punishment, the attribution of responsible agency in (...) relation to the offence, and the appropriateness of blame. By contrast, effective clinical treatment of disorders of agency employs a conceptual framework in which ideas of responsibility and blameworthiness are clearly separated from what we call ‘affective blame’: the range of hostile, negative attitudes and emotions that are typical human responses to criminal or immoral conduct. We argue that taking this clinical model of ‘responsibility without blame’ into the legal realm offers new possibilities. Theoretically, it allows for the reconciliation of the idea of ‘just deserts’ with a rehabilitative ideal in penal philosophy. Punishment can be reconceived as consequences—typically negative but occasionally not, so long as they are serious and appropriate to the crime and the context—imposed in response to, by reason of, and in proportion to responsibility and blameworthiness, but without the hard treatment and stigma typical of affective blame. Practically, it suggests how sentencing and punishment can better avoid affective blame and instead further rehabilitative and related ends, while yet serving the demands of justice. (shrink)
This chapter offers a novel defence of Szasz’s claim that mental illness is a myth by bringing to bear a standard type of thought experiment used in philosophical discussions of the meaning of natural kind concepts. This makes it possible to accept Szasz’s conclusion that mental illness involves problems of living, some of which may be moral in nature, while bypassing the debate about the meaning of the concept of illness. The chapter then considers the nature of schizophrenia and the (...) personality disorders (PDs) within this framework. It argues that neither is likely to constitute a scientifically valid category, but that nonetheless their symptoms can be scientifically explained. It concludes with a discussion of the way in which Cluster B or ‘bad’ PDs involve failures of virtue or character, and argues that this does not preclude them from being appropriately treated within contemporary, multidisciplinary, mental health services. (shrink)
This paper argues that perception of one's body ‘from the inside’ provides one with an awareness of acting, and that this awareness explains a previously overlooked feature of one's knowledge of one's own actions. Actions are events: they occur during periods of time. Knowledge of such events must be sensitive to their course through time. Perception of one's body ‘from the inside’ allows one to monitor one's actions as they unfold, thereby sustaining one's knowledge of what one is doing over (...) the period of time in which one is doing it. (shrink)
Extant philosophical accounts of schizophrenic alien thought neglect three clinically signiﬁ cant features of the phenomenon. First, not only thoughts, but also impulses and feelings, are experienced as alien. Second, only a select array of thoughts, impulses, and feelings are experienced as alien. Th ird, empathy with experiences of alienation is possible. I provide an account of disownership that does justice to these features by drawing on recent work on delusions and selfknowledge. Th e key idea is that disownership occurs (...) when there is a failure of rational control over one’s mind. Th is produces a clash between the deliverances of introspection and practical enquiry as ways of knowing one’s mind. Th is explanation places disownership on a continuum with more common aspects of our psychological life, such as addiction, akrasia, obsessional thinking, and immoral, selﬁ sh or shameful thoughts. I conclude by addressing objections, and exploring the relevance of my account to questions in the philosophy of psychiatry concerning the validity of our current taxonomy of symptoms, and the nature of psychiatric classiﬁ cation.. (shrink)
Popular and neurobiological accounts of addiction tend to treat it as a form of compulsion. This contrasts with personality disorder, where most problematic behaviours are treated as voluntary. But high levels of co-morbidity, overlapping diagnostic traits, and the effectiveness of a range of comparable clinical interventions for addiction and personality disorder suggest that this difference in treatment is unjustified. Drawing on this range of clinical interventions, we argue that addiction is not a form of compulsion. Rather, the misuse of drugs (...) and alcohol is like many of the problematic behaviours associated with personality disorder: it is typically a way of coping with psychological distress. We suggest that a satisfying explanation of why many addicts struggle to control their use can be given without departing from concepts employed in our basic folk psychological understanding of agency. In particular, we appeal to five rough-and-ready folk psychological factors to explain addiction: (i) strength of desire and habit; (ii) willpower; (iii) motivation; (iv) functional role; and (v) decision and resolve. (shrink)
The problem of addiction is one of the major challenges and controversies confronting medicine and society. It also poses important and complex philosophical and scientific problems. What is addiction? Why does it occur? And how should we respond to it, as individuals and as a society? The Routledge Handbook of Philosophy and Science of Addiction is an outstanding reference source to the key topics, problems and debates in this exciting subject. It spans several disciplines and is the first collection of (...) its kind. Organised into three clear parts, forty-five chapters by a team of international contributors examine key areas, including: the meaning of addiction to individuals conceptions of addiction varieties and taxonomies of addiction methods and models of addiction evolution and addiction history, sociology and anthropology population distribution and epidemiology developmental processes vulnerabilities and resilience psychological and neural mechanisms prevention, treatment and spontaneous recovery public health and the ethics of care social justice, law and policy. Essential reading for students and researchers in addiction research and in philosophy, particularly philosophy of mind and psychology and ethics, The Routledge Handbook of Philosophy and Science of Addiction will also be of great interest to those in related fields, such as medicine, mental health, social work, and social policy. (shrink)
“Don’t be jealous of your sister.” “Don’t be angry with your father.” “You should be more forgiving.” “You ought to feel terrible for what you’ve done.” “You ought to feel ashamed of yourself!” It is common practice within our society to morally reprimand people for their emotions, thereby expressing a kind of moralism: the idea that there are morally right and morally wrong ways to feel. Drawing on an alternative way of engaging with emotions derived from my experience working clinically (...) with people with personality disorders, I argue against the value of this common practice and the moralization of emotions that underpins it. Stop telling people what to feel! (shrink)
The problem of other minds is a collection of problems centering upon the extent to which our belief in other minds or other's minds can be justified. Swedish psychologist, Gunnar Borg has developed a principle called "the range principle" which helps fill out our "knowledge" of other minds. Borg developed this principle partly in response to the skeptical challenge of Harvard psychophysicist S S Stevens. Stevens claimed that the intersubjective comparison of experience was scientifically impossible. Borg postulates that the range (...) of individual experience is roughly identical for all individuals. We can test Borg's principle or theory is we include the similarity of physical range for individuals. We have an interesting case of experimental work casting light on a traditional philosophical problem. (shrink)
The landscape of addiction is dominated by two rival models: a moral model and a model that characterizes addiction as a neurobiological disease of compulsion. Against both, I offer a scientifically and clinically informed alternative. Addiction is a highly heterogenous condition that is ill‐characterized as involving compulsive use. On the whole, drug consumption in addiction remains goal directed: people take drugs because drugs have tremendous value. This view has potential implications for the claim that addiction is, in all cases, a (...) brain disease. But more importantly, it has implications for clinical and policy interventions. To help someone overcome addiction, you need to understand and address why they persist in using drugs despite negative consequences. If they are not compelled, then the explanation must advert to the value of drugs for them as an individual. What blocks us from acknowledging this reality is not science but fear: that it will ignite moralism about drugs and condemnation of drug users. The solution is not to cleave to the concept of compulsion but to fight moralism directly. (shrink)
Can consideration of the emotions help to solve the problem of other minds? Intuitively, it should. We often think of emotions as public: as observable in the body, face, and voice of others. Perhaps you can simply see another's disgust or anger, say, in her demeanour and expression; or hear the sadness clearly in his voice. Publicity of..
Moral and legal philosophy are too entangled: moral philosophy is prone to model interpersonal moral relationships on a juridical image, and legal philosophy often proceeds as if the criminal law is an institutional reflection of juridically imagined interpersonal moral relationships. This article challenges this alignment and in so doing argues that the function of the criminal law lies not fundamentally in moral blame, but in regulation of harmful conduct. The upshot is that, in contrast to interpersonal relationships, the criminal law (...) cannot lose its standing to blame through institutional analogues of hypocrisy, complicity, and meddling. Rather, certain forms of structural and severe historical and contemporary injustice point to the question of the overall legitimacy of state authority. (shrink)
The DSM-IV-TR (American Psychiatric Association 1994, 689) defines personality disorder (PD) as: An enduring pattern of experience and behavior that deviates markedly from the expectations of an individual’s culture. This pattern is manifested in two (or more) of the following areas: 1 Cognition (i.e., ways of perceiving and interpreting self, other people, and events); 2 Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response); 3 Interpersonal functioning; and 4 Impulse control. B The enduring ..
Can consideration of the emotions help to solve the problem of other minds? Intuitively, it should. We often think of emotions as public: as observable in the body, face, and voice of others. Perhaps you can simply see another's disgust or anger, say, in her demeanour and expression; or hear the sadness clearly in his voice. Publicity of mind, meanwhile, is just what is demanded by some solutions to the problem. But what does this demand amount to, and do emotions (...) actually meet it? This paper has three parts. First, I consider the nature of the problem of other minds. Second, I consider the publicity of emotions. And third, I bring these together to show how emotions can help to solve the problem. (shrink)
In a welcome broadening of the discussion surrounding responsibility in healthcare, Rebecca Brown and Julian Savulescu propose that standard philosophical accounts of responsibility are too narrow to be useful. Although these accounts of course differ with respect to the exact conditions they posit as necessary and sufficient for responsibility, they are nonetheless relatively united in their focus on a single individual at a single moment in time. Suppose a subject S performs an action a at a time t that has (...) harmful consequences for their health. Is S responsible for a and derivatively their condition? Brown and Savulescu argue that answers to this question that fail to consider both what S was or was not doing at times other than t and what people other than S were doing to encourage or discourage S from performing a cannot do justice to actions which are habitual and socially influenced—such as unhealthy patterns of eating, exercise and substance use. Given that it is precisely these kinds of patterns of behaviour that typically inflame the discussion of responsibility in healthcare, Brown and Savulescu’s insistence on the need for a diachronic and socially contextualised account of responsibility is essential— if we are to consider the issue of responsibility in healthcare at all. But should we and, if so, why? With respect to this question, Brown and Savulescu hope to sit on the fence. This is both because they recognise the complexity and balance of arguments for and against the view …. (shrink)
Effective treatment of personality disorder (PD) presents a clinical conundrum. Many of the behaviours constitutive of PD cause harm to self and others. Encouraging service users to take responsibility for this behaviour is central to treatment. Blame, in contrast, is detrimental. How is it possible to hold service users responsible for harm to self and others without blaming them? A solution to this problem is part conceptual, part practical. I offer a conceptual framework that clearly distinguishes between ideas of responsibility, (...) blameworthiness, and blame. Within this framework, I distinguish two sorts of blame, which I call ‘detached’ and ‘affective’. Affective, not detached, blame is detrimental to effective treatment. I suggest that the practical demand to avoid affective blame is largely achieved through attention to PD service users’ past history. Past history does not eliminate responsibility and blameworthiness. Instead, it directly evokes compassion and empathy, which compete with affective blame. (shrink)
The claim that non-addictive drug use is instrumental must be distinguished from the claim that its desired ends are evolutionarily adaptive or easy to comprehend. Use can be instrumental without being adaptive or comprehensible. This clarification, together with additional data, suggests that Müller & Schumann's (M&S's) instrumental framework may explain addictive, as well as non-addictive consumption.
Philosophy of psychiatry is on the rise. The last decade has seen an explosion in philosophical interest in psychiatric disorder, supported by ﬂourishing research in adjacent disciplines, particularly clinical and cognitive psychology, neuroscience, and, of course, psychiatry itself. The publication of the ﬁrst edition of The Mind and its Discon- tents in 1999 helped spark this explosion. The publication of this second edition is a welcome addition to OUP’s blossoming International Perspectives in Philosophy and Psychiatry Series.