Are Addicts and the Mentally Ill Responsible for Their Behavior?


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, apretty 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?

*****

Thus begins my latest piece for AlterNet, Are Addicts and the Mentally Ill Responsible for Their Behavior?. To read more about some of the many sides of this complicated and difficult question, read the rest of the piece.

Comments

  1. Lea says

    Oh dear, the Free Will question. One I’ve also thought about a lot and have developed some opinions on, but am still investigating. I love learning about brain/mind/consciousness and try to keep up with the latest research.

    It’s too big a topic for me to try and say much in a blog comment. I’ll just say that when it comes to how much control we have over our behavior, mentally ill people probably just exhibit more obviously the situation we are all in to one degree or another.

  2. Azkyroth Drinked the Grammar Too :) says

    My snap response was “OH I KNOW! 150% if the illness is an autism spectrum disorder, 0% if it’s anything else!” And I calmed down and remembered that Social Justice People, IE the commenter consensus on a handful of progressive blogs I read, has been slowly pulling their head out on this particular issue, but the first impression was so powerful… :(

  3. Shatterface says

    I’ve thought of this a lot since I was diagnosed with Asperger’s.

    I mean, because I’m not subject to the unconscious peer-pressure to conform that leads neurotypicals to riot or join gangs I think being non-autistic might be a legal defence.

    You know, ”My client admits to going along with the mob during the recent riots – but he’s non-autistic and can’t help it.

    Okay, I’m slightly taking the piss here – but it’s really an example of neurotypical privilege to assume that people with disorders are acting according to those disorders while neurotypical people are acting according to free will.

    Either we are all the products of our nature and/or environment or none of us are – enough with the double standards.

  4. triple3a says

    Are addicts and the mentally ill responsible for their behavior.

    This is a very good question, but I don’t actually think this question gets to the heart of the matter.  Addicts and the mentally ill aren’t responsible for their behavior while they’re in the immediate throes of their addictions and illnesses.

    However, I do believe that addicts and the mentally ill are responsible, when not in the immediate throes of their addiction and/or illness, for communicating to loved ones the help they need from others (be they individuals, medications, or institutions), to get and maintain help for the problem.  I’m not talking about enabling the addiction to continue unabated or let the illness to go untreated.  I’m talking about the person with the problem temporarily ceding authority to deal with it to a trusted friend who will do the necessary, possibly confrontational, work of ensuring medications are taken, appointments are met, and therapies are followed (an impermanent “I-get-to-kick-your-ass-for-your-own-good” power of attorney, so to speak).

    Yeah, in theory it sounds good and, yes, I can see how this could easily become taxing and burdensome to the friend in question, or even abusive in the hands of someone untrustworthy, but it’s at least a step in the right direction to treat a very difficult problem under very difficult circumstances.  Also, someone that is always in the throes of their addiction or illness is clearly not responsible for their behavior.  What solutions are reached under these circumstances isn’t for me to say, though.

    Your father had the responsibility to ask for help when he wasn’t laid low and to take the treatment seriously.  Of course he wasn’t responsible for his addiction (I don’t have to tell you that).

    Please feel free to tell me I’m full of shit if you think I’m off base or if you have a point of view I haven’t considered thoroughly.

  5. Shatterface says

    I think you need to separate people with neurological conditions from addicts. With an addict you have a baseline to compare someone too – their non-addicted self.

    ”Mr Whatever committed the act while addicted to crack but has submitted himself to therapy so we should be lenient” sounds reasonable because we have their previous non-addicted behaviour as a baseline for calibrating their responsibility.

    You can argue about what point they should have sought help but then you have to factor in the lack of support for people addicted to illegal drugs because that illegality is what prevents them being treated and locks them into relationships with people who are criminal by definition.

    You can’t do that with someone with a developmental disorder. I don’t have a pre-autistic self to compare myself to: I’m not someone ”in the throes” of autism any more than a homosexual is temporarily gay or someone is trying out left-handedness for a bit.

    It’s part of me, part of who I am; there’s no ”me” prior to my autism against which I my current behaviour can be measured, or towards which a recovery will take me.

    Okay, maybe you can calibrate a schizophrenic against their non-psychotic self but what about a psychopath? Psychopathy may lead many to a life of crime but to excuse them of their crime on account of their psychopathy makes as much sense as denying a psychopathic fire fighter or surgeon credit for being fearless or calm under pressure.

    And you can’t expect a schizoid to go looking for help because if they were the kind of person who looked for help they wouldn’t be schizoid.

    The problem isn’t with disorders; the problem is with the idea that people without disorders have free will when those with them do not.

  6. Shatterface says

    Actually, you could ask ”Are artists with mental illness responsible for their art?” Is Van Gogh a great artist or was his bipolar disorder the creator of his paintings? How about Beethoven or Virginia Woolf? Is Daniel Tammet’s mathematical skill something for which he should take credit?

    James Joyce and Albert Einstein had schizophrenic children – to what extent is their own genius attributable to a latent genetic predisposition to schizophrenia?

  7. M can help you with that. says

    I really don’t think “responsibility” is as clearly-defined a concept as it would need to be for this to be a well-formed question. And even when it is, the question shouldn’t be “yes/no” but “to what extent,” and the passive voice “should [person or group X] be held responsible” should be replaced by “to what extent should [person/group Y] hold [person/group X] responsible” — because really we’re talking about patterns in social structures instead of some clear and well-defined property.

    tl;dr — Assigning responsibility has to be sensitive to all sorts of context, and if it’s all-or-nothing you’re doing it wrong.

  8. True Fork says

    I think “responsibility” is an ambiguous term, carrying meanings of both ability and willingness to choose an outcome. So it has very different connotations to say someone is “not responsible” (not liable) versus “irresponsible” (unwilling to take control of an outcome). We tend to see irresponsibility as culpable, yet “not responsible” as not culpable. This ambiguity often tends to muddle discussions about responsibility.

    An alcoholic can be both not responsible (unable to take or refrain from certain actions) and irresponsible (unwilling to control actions they are able to control). We tend to view these differently, yet the extent to which a person is responsible for their irresponsibility isn’t clear-cut either (“My irresponsibility is your fault!”).

    Personally I believe we should question why it seems so important to us to judge others (and ourselves) all the time. What’s the point really? Does it actually advance mutual understanding or moral behavior or something? Or do we simply like to feel morally superior to others?

    I also think there are perverse effects to this conflation of responsibility and culpability, such as the bystander effect where people are reluctant to take charge (take responsibility) of a bad situation because they fear the liability that comes with it.

  9. Zugswang says

    As a pharmacist, and someone who’s married to a clinical psychologist, much of how the brain works is still one of those irritatingly mysterious enigmas that science still struggles to uncover to the point that we can use it to treat mental illness to the same degree we can treat things like . We do know how the brain works, but only very broadly. And this imprecision tends to lead to a perception that many kinds of mental illness are not real, both by patients and society at large.

    In addition to mental illness being viewed, collectively, as a subjective disorder, people also seem to have this false idea that different mental illnesses run along a continuum of severity, with things like depression and anxiety being seen as relatively benign, and schizophrenia, Alzheimers, etc. being viewed as “serious” kinds of mental illness. The fact is, they all fall on their own spectrum of severity. Biochemically, depression can be severe enough that it actually causes physical pain along the same nociceptive pathways that are triggered if we were stabbed with a knife (this is very real; I’ve known some patients who took Neurontin to treat their pain, in addition to the meds they used to treat the depression, itself). Likewise, someone with schizophrenia may only have mild auditory hallucinations early on in the disease that they can manage comparatively easily.

    The reality of mental illness, I think, is that you have to treat each person individually, and there’s no easy way to assign responsibility based on the type of mental illness a person has; the summation of experiences and personalities that make someone who they are cannot be excluded from consideration, and I think we all realize that to a degree. That may not be a satisfying answer (ambiguity in critical situations rarely is…), but in healthcare as in life, we should address the person, not just the disease. Otherwise we haven’t really done our jobs.

  10. serena says

    I struggle with this right now in my life; my mother has always been a cutting and unsympathetic person but since she had an aneurism, strokes and brain surgery she (seems to think) she’s allowed to say anything at any time and any discussions about who she was to me while growing up is blown off as irrelevant because she’s never supposed to be responsible for her personality.
    I struggle with my sense of justice which demands that everyone in my presence be responsible for the way they treat others because she is the #1 person I desire responsibility from but she’s the last person who will ever demonstrate it. So, do I forgive her with the “it’s just her brain” excuse (thus swallowing all my own emotional needs, never to be addressed) or do I fight to make a 59 year old woman who has had some of her brain removed, make her somehow recognize what projection and solipsism is? Meh :/

  11. Shatterface says

    I really don’t think “responsibility” is as clearly-defined a concept as it would need to be for this to be a well-formed question. And even when it is, the question shouldn’t be “yes/no” but “to what extent,” and the passive voice “should [person or group X] be held responsible” should be replaced by “to what extent should [person/group Y] hold [person/group X] responsible” — because really we’re talking about patterns in social structures instead of some clear and well-defined property.

    I think you just articulated something I’ve been struggling to formulate in my mind! Yes, of course – its not just about who is to be held responsible or culpable but by whom.

  12. says

    @Lea — it’s not the Free Will question. There’s no reason to suppose that free will exists. One way to put the question: “Should those of us who aren’t classified as mentally ill or addicts excuse the people in our lives who have [the benefit of] these classifications when they do hurtful things for which they would not be excused if they didn’t have the classifications?”

  13. says

    I’m going to take the seemingly simplistic way out and say that it does fall on a spectrum and the delineation can at times be difficult, but we do need to have the ability to assign legal culpability of criminal actions even if a mental illness or neurosis is present.

    One end of the spectrum I feel is pretty easy to see. Very obvious organic, neurological abnormalities can cause undesirable behavior. I remember on The Skeptic’s Guide to the Universe podcast, Steven Novella talked about a man who developed pedophilic thoughts and behavior as the result of a brain tumor. (The more interesting part is that upon removal of the tumor, the thoughts went away, and doctors were able to tell the tumor grew back when he developed the thoughts again.) Or sometimes, traumatic brain injury or a stroke can cause serious effects in decision making. These are (to me) obvious examples of when it’s not appropriate to assign individual responsibility to the one suffering from these conditions.

    I think it gets hazy when a person’s behavior doesn’t have such a distinct organic cause. And in these cases, behavior of the individual can be transferred to another agent, such as a designated caretaker. If we agree to relinquish responsibility from an individual, someone needs to in turn assume that responsibility, whether they agree to this reassignment or not. Like if a mother allows her VERY clearly disturbed son access to loads of assault weapons and he goes and shoots up an elementary school, I think we can reasonably reassign the majority of the responsibility onto her, even if we can’t say in flat numbers just how much.

    Unfortunately, these judgments can get messy and very rarely is there unanimous agreement. But I think that’s what separates us thinking, reflective people from those who see things only in black and white.

  14. says

    The question should really be can you do anything about behaviours you don’t like in other people or which you think are self harming; if you can then under what circumstances is it ethical to do so and if there is a choice of multiple reactions which is best? How does their circumstance, biology and history alter your decision and/or approach?

  15. outeast says

    @Shatterface – You make a very good point and put it very well (well, except for the phrase ‘neurotypical privilege’, which makes me wince!). It’s not a way I’ve thought to look at the issue before, and it’s most insightful. I’m going to enjoy thinking about that one. So, thanks :)

  16. says

    I was going to post my opinion, but @14 beat me to it. We shouldn’t think of “punishment”, “praise”, and the like as something that a person “deserves” or “doesn’t deserve”. Instead, the question is “If I did X to Y, would Y’s behavior change in a way that results in better outcomes?” (for some sense of “better” that hopefully you, Y, and the rest of society wholly or mostly agree on).

  17. Lea says

    Unree Polnetz @ #12,

    Well, the title and theme of the article is “Are Addicts and the Mentally Ill Responsible for Their Behavior?”, which is what I was addressing–the same question applies to all of us. The question as you phrased it is discussed, but the article indicates that the answer to that should be based on the question asked in the title.

  18. says

    @Lea 17, fair enough–but “free will,” though false on the ground, has social meanings with consequences. For example, many legal systems have an insanity defense that defeats criminal responsibility for violent crimes. These systems apply the defense very sparingly. Greta has broached the interesting question of where to draw a line between people who are held responsible (both formally and informally) for the harmful things they do and people who are excused (or are referenced in requests to be excused) because of their addiction or mental illness.

    The easy–and correct–answer to “Are Addicts and the Mentally Ill Responsible for Their Behavior?” is “No, and none of us are!” But that’s not how we live.

  19. Lea says

    Unree,

    Sure, I see the distinction you are making. Formally (legally), the question becomes “is the person capable of understanding and complying with the law?” If so, the standard treatment; if not, the alternative treatment.

    Informally, accept that you can’t control someone else’s behavior and decide/react accordingly– that’s the tricky part, that I imagine most of us have had or will have to deal with at some point.

  20. Shatterface says

    Like if a mother allows her VERY clearly disturbed son access to loads of assault weapons and he goes and shoots up an elementary school, I think we can reasonably reassign the majority of the responsibility onto her, even if we can’t say in flat numbers just how much

    I think you can assign some degree of responsibility to the people who manufacture weapons and allow unrestricted access to them.

    Someone going on a killing spree with a pointy stick is no less culpable than someone with an assault rifle – but they’re likely to be stopped a lot sooner.

  21. johnthedrunkard says

    Most addicts don’t comprehend what they’re dealing with, so the responsibility issue is sort of off in the corner.
    BUT:
    If someone grasps the nature of alcoholism: e.g. that once they start drinking they cannot predict their consumption or subsequent actions—that they may ‘freely will’ to drive, jump into the sack with a stranger, sign a contract, join the Foreign Legion etc. while in a complete blackout… Such a person IS responsible if they put alcohol in their mouth and swallow it.

    How to measure that responsibility legally is another question. People get multiple DUIs, not because they are unable to comprehend simple math, or because they are ‘weak willed,’ etc. but because they are simply insane to consume alcohol when they know the risk involved. Even if they only crash into a schoolbus once or twice out of every 100 incidents.

  22. Greta Christina says

    Well, the title and theme of the article is “Are Addicts and the Mentally Ill Responsible for Their Behavior?”

    Lea @ #17: Just a slightly off-topic FYI: It’s almost never a good idea to judge a writer’s intent based on the title of a piece. Magazines and newspapers routinely change titles, sometimes drastically. In this case, my original title was “Mental Illness and Responsibility: Some Difficult, Confused, Undecided Thoughts.” The AlterNet title isn’t as radical a change as I’ve often seen and experienced, but it’s not trivial, either.

  23. says

    Greta @ 22: Can I just say….. you are pretty much the FIRST blogger I have personally come across whose main topic of a blog post is essentially, “I don’t know what I think! Now you say something……” And I love it. It’s true skepticism at its core. People coming together to work tough issues out. How lovely!

  24. says

    There are some compelling arguments that “free will” as commonly understood is a fiction, or even that “the self” is an illusion and so there isn’t really anything to hold responsible. When Sam Harris discusses this I’m always nearly convinced… But one thing that always puzzled me about the matter is this; if nobody is really responsible for anything they do, then doesn’t it follow that we aren’t responsible for holding people responsible for their actions? I mean, how could we possibly derive guidelines for behavior from the premise that behavior is something we can’t control?
    Or put differently, if “tout comprendre est tout pardonner” then shouldn’t we also forgive our own inability to be forgiving?

  25. says

    I’ve been thinking about this question for a long time too, also because of a parent’s bad behavior. Personally, I hold people responsible for their behavior to the extent that they can control it enough to avoid embarrassing themselves in public. I realize that’s far from a perfect rule of thumb given that there are plenty of people dealing with depression, for example, who are able to “fake it” and appear normal in public but completely shut down when no one is looking because faking “normal” is so draining, but in general I think whether someone is able to put up a good front tells me a lot about their ability to control themselves. I admit I’m extremely biased, though. The idea that I’m not allowed to hold my mother responsible for any part of her extremely abusive behavior makes me want to flip tables and set the pieces on fire, so of course I’m going to come down on the side of being able to blame her for treating her children so badly.

    All that said, I find it extremely suspicious when people say they just couldn’t control themselves or that it was their illness talking when they’re never less than charming when people are looking. If my mother had ever lost control of herself and started screaming at my sister in a crowded shopping mall I’d be willing to buy that she really couldn’t stop herself. But since she was never abusive in public, I’m kind of stuck concluding that she knew what she was doing wasn’t okay and made rational efforts not to get caught.

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