Hanna Pickard

The Purpose in Chronic Addiction.

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.

Responsibility Without Blame: Empathy and the Effective Treatment of Personality Disorder

Effective treatment of personality disorder (PD) presents a clinical conundrum. Many of the behaviors constitutive of PD cause harm to self and others. Encouraging service users to take responsibility for this behavior 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.

How therapeutic communities work: Specific factors related to positive outcome

Background: Therapeutic communities (TCs) are becoming increasingly widespread as a form of treatment for entrenched mental health problems, particularly addictions and personality disorders, and are equally used in educational, prison and learning disability settings. Despite growing evidence for their effectiveness, little research has been conducted to establish how TCs work to produce positive outcomes. We hypothesize that there are two specific factors that in combination contribute to TC effectiveness: the promotion of a sense of belongingness and the capacity for responsible agency. Although both factors are found in other therapeutic approaches and are important to the psychosocial aspects of psychiatric care more generally, we argue that their combination, extent and emphasis are unique to TCs. Material: Drawing on social and experimental psychology, we: (1) review research on a sense of belongingness and the capacity for responsible agency; (2) establish the mechanisms by which TCs appear to promote them; (3) draw lessons for TC practice; and (4) suggest why they may contribute to positive outcome. Discussion: A sense of belongingness is correlated with improved self-esteem and overall well-being. The capacity for responsible agency is central to behavioural change. TCs are typically used in fields where positive outcome requires both personal growth and behavioural change. We suggest that TCs are uniquely placed to demand such growth and change of their members because the sense of belongingness engendered by TC methods protects against the risks engendered by this demand. Conclusion: Empirically informed, evidence-driven research is necessary to understand how TCs work and how TC practice can be improved. This understanding may offer lessons for the improvement of psychosocial aspects of psychiatric care more generally.

Finding the will to recover: philosophical perspectives on agency and the sick role

Recovery from a range of common medical conditions requires patients to have the will to change their behaviour. The authors argue that the proper recognition of the role of willpower in recovery is necessary for effective treatment.

From the Consulting Room to the Court Room? Taking the Clinical Model of Responsibility Without Blame into the Legal Realm

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.

To Blame or to Forgive? Reconciling Punishment and Forgiveness in Criminal Justice.

What do you do when faced with wrongdoing—do you blame or do you forgive? Especially when confronted with offences that lie on the more severe end of the spectrum and cause terrible psychological or physical trauma or death, nothing can feel more natural than blame. Indeed, in the UK and the USA, increasingly vehement and righteous public expressions of blame and calls for vengeance have become commonplace; correspondingly, contemporary penal philosophy has witnessed a resurgence of the retributive tradition, in the modern form usually known as the ‘justice’ model. On the other hand, people can and routinely do forgive others, even in cases of severe crime. Evolutionary psychologists argue that both vengeance and forgiveness are universal human adaptations that have evolved as alternative responses to exploitation, and, crucially, strategies for reducing risk of re-offending. We are naturally endowed with both capacities: to blame and retaliate, or to forgive and seek to repair relations. Which should we choose? Drawing on evolutionary psychology, we offer an account of forgiveness and argue that the choice to blame, and not to forgive, is inconsistent with the political values of a broadly liberal society and can be instrumentally counter-productive to reducing the risk of future re-offending. We then sketch the shape of penal philosophy and criminal justice policy and practice with forgiveness in place as a guiding ideal.

The moral content of psychiatric treatment

Psychiatric treatment can enhance human morality. It can promote the emergence of moral motives and intentions, aid in the acquisition of skills essential to moral action, and help to develop the ability to apply moral understanding and skills in particular circumstances. Good psychiatric practice demands an honest appraisal of its moral dimension.

Responsibility without Blame for Addiction

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.

The instrumental rationality of addiction.

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 & Schumanns (M&Ss) instrumental framework may explain addictive, as well as non-addictive consumption.

The Chimera of Proportionality: Institutionalising Limits on Punishment in Contemporary Social and Political Systems

The concept of proportionality has been central to the retributive revival in penal theory, and underlies desert theory’s normative and practical commitment to limiting punishment. Theories of punishment combining desert-based and consequentialist considerations also appeal to proportionality as a limiting condition. In this paper we argue that these claims are founded on an exaggerated idea of what proportionality can offer, and in particular fail properly to consider the institutional conditions needed to foster robust limits on the state’s power to punish. The idea that appeals to proportionality as an abstract ideal can help to limit punishment is, we argue, a chimera: what has been thought of as proportionality is not a naturally existing relationship, but a product of political and social construction, cultural meaning-making, and institution-building. Drawing on evolutionary psychology and comparative political economy, we argue that philosophers and social scientists need to work together to understand how the appeal of the idea of proportionality can best be realised through substantive institutional frameworks under particular conditions.