Are people with mental illness responsible for their behavior, and for how their behavior affects others? If so, to what degree? Does the degree of mental illness affect how we answer this question?
I've been thinking about this question for a long, long time. Many years, in fact. I've been thinking about it harder in the last year or so, since my father died, and since my most recent bout with depression. I've been thinking about it in terms of my own life and my own mental health; I've been thinking about it in terms of the lives and mental health (healths?) of my friends and family members who are dealing with mental illness, or who have dealt with it in the past. But mostly, I'm thinking about it in terms of my father.
My father died on Oct. 1, 2012. Dad was a pretty mixed bag: many wonderful qualities, many not-so-wonderful ones. Specifically, he was an alcoholic, a pretty bad one for many decades, and a significantly worse one as the years and decades wore on. And largely due to his alcoholism, he often behaved very badly. He wasn't abusive, but he was often selfish, irresponsible, callous, quick with a barbed comment or a cruel joke just for his own entertainment, dismissive of other people's feelings, unconcerned with how his actions affected others. It got worse, much worse, as the years went on and the disease of alcoholism progressed.
By the time he had his first stroke, the alcoholism had advanced to late-stage, brain-damage, memory- and speech-impairment territory, and the accompanying selfishness and irresponsibility got worse with the deterioration. (According to the doctors, the years of alcoholism almost certainly contributed to the stroke itself, and may have even been a primary cause.)
I don't want to get into the litany of the details of his behavior right now. It's too upsetting, and it's kind of not the point. The point — the question I've spent decades asking myself, as I kept taking step after step away from my father and it kept not being far enough — is this: To what degree are mentally ill people — including alcoholics and other drug addicts — responsible for their behavior?
On the one hand: We cut sick people slack. We don't hold them as responsible for their behavior as we do healthy people. We understand that sick people can't always keep promises; can't always do their share; get irritable; lose their temper. We understand that it's the illness causing this behavior. We get angry at the illness, not at the people. And mental illnesses — including alcoholism and other drug addictions — are illnesses.
On the other hand: There's a limit to that. We cut people some slack if they're sick, but we don't cut them infinite slack. We'd probably cut a sick person slack for losing their temper and snapping at their spouse, but we wouldn't cut them slack for losing their temper and beating their spouse with a tire iron. We would condemn that. And rightly so.
On the other hand: Mental illness is, in some sense, an illness of the will, an illness of the self in a way other illnesses are not. Addiction especially. So with mental illness, it's harder to distinguish between the illness and the person. The symptoms of cancer or diabetes or lupus don't include "loss of judgment," "self-involvement," "poor impulse control," "irresponsibility."
And the symptoms of cancer or diabetes or lupus don't include "inability to recognize the fact that you are ill," or "inability to take your illness seriously and get treatment for it." The symptoms of many mental illnesses, including addiction, do. Getting angry at an addict or a depressed person for having poor judgment is a bit like getting angry at a diabetic for losing a toe.
On the other hand: Some people do recover from addiction. Some people realize they're fucking up their lives and the lives of the people they love, and they get help. Other people don't. So isn't it reasonable to be angry at addicts, and other people with mental illness, when they — we — don't get help? We don't get angry at people for being sick, but we do get angry, and I think rightly so, when sick people don't do what they need to do to take care of themselves, and thus make themselves sicker, and thus make themselves more of a burden on the people who love them.
On the other hand: We don't really know why some people recover from addiction, and other people don't. (Any more than we know why, even with the same diagnosis and prognosis and treatment, some people recover from cancer and other people don't.) Again: Addiction and other mental illnesses are diseases of the will, of the self. They are diseases of the ability to perceive reality accurately, and to act appropriately.
The inability to see that you're an addict, or that you're depressed? The inability to see the effect that your illness has on others, or indeed on yourself? The inability to see yourself as worth taking care of, as someone who's worthy of help? The inability to muster the motivation to take action about it? These are among the symptoms of the illnesses. So getting angry at addicts and other mentally ill people for not taking action to get better … again, it's like getting angry at someone with HIV for getting lots of opportunistic infections.
In fact, we really don't understand addiction and other mental illnesses very well at all. Some addicts, and people with other mental illnesses, do seek treatment, and it doesn't always work. It often doesn't work. Some treatments work for some people and not others. We don't know why: we don't know whether the differences are neurochemical, psychological, environmental, whether these are even useful distinctions.
Some of the most popular treatments for addiction don't work any better than people just quitting on their own. And, of course, some people have better access to treatment than others, better support systems, easier environments to recover in, etc. So being motivated and committed to getting help is no guarantee of getting better. Just like with many non-mental illnesses.
On the other hand: If my father had actually made an effort to quit, other than that one time when he went dry for a while? If he'd tried treatment a dozen times, and just kept relapsing? If he'd shown some understanding of how bad his illness was, some concern for how hard it was on everyone around him, some sincere desire and willingness to get better? I think I wouldn't be as angry at him, or as hurt by him, as I am now.
My father had a somewhat unusual — although apparently not that unusual — version of denial about his alcoholism. It's very common, a clichÃ© even, for alcoholics to deny that they are alcoholics. My father didn't do that. He knew he was an alcoholic; he acknowledged it openly. He even dried up and got treatment for it, for a while. His denial took the form of denying that his alcoholism was a problem. He acknowledged that he was an alcoholic — but he denied that it was serious, that it was fucking up his life, that it was ruining his health and his ability to do the things he cared about, that it was hurting and alienating the people closest to him.
He knew he was an alcoholic. Doesn't that hold him to a higher level of responsibility? If you can't see yourself as an alcoholic, that's one thing. But if you do see yourself as an alcoholic, and you still shrug it off and say, "Yeah, it's no big deal, I don't really mind it and it's not worth the trouble of getting better," doesn't that make you responsible for your illness, and for how it affects others?
And yet … I've done much the same thing, at different times in my life, with my depression. My depression is intermittent, not chronic — so at times in the past when I've been depressed, I've had a strong tendency to say, "Sure, I'm depressed, but it's not that big a deal. I can manage this. I can pull out of it on my own. I don't need help." I was, among other things, very resistant to taking meds for it: partly because, as I've written before, I felt like it would stigmatize me, like once I start taking psych meds for depression I'd have “mentally Ill” stamped on me forever.
But it was also, partly, because I was resistant to seeing the illness as serious, as something I wasn't strong enough to handle on my own. I'm sure that I behaved badly to people I loved during those rounds of depression. And I'm sure that those rounds of depression lasted longer, and were more severe, because I wasn't getting treatment for them. Thus, again, I'm sure those depressions were harder on the people I loved than they needed to be.
Should I be held responsible for that? The denial of the seriousness of a mental illness, the refusal to get care for it, is often one of its symptoms. And the inability to see yourself as worth taking care of, as a person who is worth being helped and whose life is worth improving, is very often one of its symptoms.
The inability to see yourself as a person who other people rightly love and value and want to have a relationship with, the inability to see your mental health as worth taking care of so you and they can have those relationships, is very often one of its symptoms. If one of the defining characteristics of an illness is the inability to recognize that you have it, to take it seriously, or to be motivated to get help for it … should you be held responsible for not getting help?
And when mentally ill people are held responsible for our behavior … how does that affect our illness? Does it help, or hurt? When the people we love tell us that we're hurting them and driving them away, when they demand that we see the consequences of our behavior in their lives and in our own … what effect does that have?
Does it shake us into awareness and insight, help motivate us to take action? Does it shame us into feeling worse about ourselves, make us even less able to see ourselves as worth taking care of? Does it do some of both? Does the answer depend on the person, the illness, the degree of illness, the closeness of the relationship, the day of the week?
Patricia S. Churchland is a neurophilosopher who wrote Touching a Nerve: The Self as Brain. In the chapter, “Free Will, Habits, and Self-Control,” Churchland points out that self-control depends on physiological and neurochemical structures in the brain. “A network of areas," she writes, "rather widely distributed, partially overlapping, regulate self-control."
She argues that of course we have free will, and the ability to choose our behavior — in that we have the brain structures that let us do that. We're not barnacles, or bacteria. "If you are intending your action, knowing what you are doing, and are of sound mind, and if the decision is not coerced (no gun is pointed at your head)," she argues, "then you are exhibiting free will."
And she points out that self-control can be learned, in childhood anyway. Which, as I see it gives us that much more responsibility for acquiring that control. Especially if we can learn it in adulthood as well as childhood, to any degree whatsoever.
Useful information, and insightful. But to some extent, it's just begging the question: If the ability to choose our behavior (and thus our moral responsibility for that behavior) is part of our brain structure and brain chemistry … well, how much do we choose our brain structure and brain chemistry? Especially if we have mental illness?
How much of our brain structure is determined for us: by genetics, by in utero environments, by early diet, by parents and teachers and whatever crap was in the water we drank when we were three?
Of course we choose our brain chemistry in lots of ways: we choose to exercise or spend time in the sunlight or take medication for mental illness, or we choose to drink heavily or isolate ourselves or stay inside on the sofa all day. But if those choices are being made by a brain already shaped, by everything that's happened to it so far, to be crappy at making choices — how much responsibility do we have for that?
In fact, Churchland herself points out that the ability to choose is not a simple matter of either/or. She points out that exercising self-control is exhausting — and wonders if some of us simply exhaust more easily than others. Discussing a colleague, a surgeon with Tourette's Syndrome, who can perform surgery without the typical Tourette tics but can't restrain those tics on an everyday basis, she says, "It is not exactly that he is entirely out of control; nor is he fully in control. He is somewhere in between."
If we're all in between — and I would argue that we are — then where on that in-between spectrum do we no longer have responsibility for our actions?
If we wouldn't blame someone with Tourette's for not restraining their tics — and I certainly wouldn't — can we blame someone with depression for not getting off the couch? Or someone with alcoholism for not putting down the bottle?
I've been going back and forth about this for decades. I've been writing this piece in my head for years. And I realize the answer is probably not either/or. I realize the answer is probably some version of "to some degree yes, to some degree no, it depends on how serious the illness is, and how treatable it is, and how severely it's affecting other people, and a whole pile of other complicating issues that make it impossible to answer coherently and decisively."
But that's not very useful. Or maybe it is useful, and accurate … and it's just hard to accept.
Does anyone else have any thoughts on this? People who have dealt with addiction or other mental illness, either in yourself or the people you love … I would love to hear from you. I cannot tease this one out.
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