Humanizing Mental Illness: Enhancing Agency through Social Interaction 9780228007340

Table of contents :
Cover
Copyright
Contents
Acknowledgments
List of Abbreviations
Introduction
1 Stigma and Dehumanization
Part One Constraints on Agency
2 Mental Impairments :Direct Constraints on Agency
3 The Isolating Effects of Mental Illness: Indirect Constraints on Agency
Part Two Social Interactions
4 Moral Address and Response
5 Interacting with People who Have Mental Illness
Conclusion
Notes
Bibliography
Index

Citation preview

H u m a n iz in g M e ntal I llness

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Humanizing Mental Illness Enhancing Agency through Social Interaction

A b i g a i l G osselin

McGill-Queen’s University Press Montreal & Kingston • London • Chicago

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©  McGill-Queen’s University Press 2021 isb n isb n isb n isb n

978-0-2280-0678–7 (cloth) 978-0-2280-0679–4 (paper) 978-0-2280-0734–0 (eP DF ) 978-0-2280-0735–7 (eP ub)

Legal deposit third quarter 2021 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free

Library and Archives Canada Cataloguing in Publication Title: Humanizing mental illness: enhancing agency through social ­interaction  /  Abigail Gosselin. Names: Gosselin, Abigail, 1977– author. Description: Includes bibliographical references and index. Identifiers: Canadiana (print) 20210183047 | Canadiana (ebook) 20210183101 | IS BN 9780228006787 (cloth) | I SB N  9780228006794 (paper) | IS BN 9780228007340 (eP DF ) | IS BN  9780228007357 (eP U B ) Subjects: L CS H: Mental illness—Social aspects. | L C SH : Mental illness— Public opinion. | L CS H: Mentally ill—Social conditions. | L C SH : Mentally ill—Public opinion. | L CS H: Stigma (Social psychology) | L C SH : Agent (Philosophy) Classification: L CC RC455 .G 67 2021 | DDC 362.2/042—dc23

This book was typeset by Marquis Interscript in 10.5/13 Sabon.

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To Deborah and Marc Gosselin

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Contents

Acknowledgments ix

List of Abbreviations  xi

Introduction 3   1 Stigma and Dehumanization  11

P art O n e   C o n s t r a in t s o n Agency  53   2 Mental Impairments: Direct Constraints on Agency  55   3 The Isolating Effects of Mental Illness: Indirect Constraints on Agency 106

P art T wo   S o c ia l In t e r ac ti ons  147   4 Moral Address and Response  149   5 Interacting with People who Have Mental Illness  182 Conclusion 233 Notes 241 Bibliography 273 Index 295

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Acknowledgments

I want to thank first and foremost my editor, Khadija Coxon, who supported me every step of the way. The success of this project is due partly to her. Thank you to Jason Taylor, Karen Adkins, Ted Zenzinger, Becky Vartabedian, Anandita Mukherji, Ron DiSanto, Julia Brumbaugh, Fred Gray, and Nick Kallan for friendship and encouragement and for being amazing colleagues. Thank you to Tom Bowie and Janet Houser for workplace support. Thank you to John Romeo, Dr Samuel Clinch, and Ethan Selvig for putting me back together after my recent bout with psychosis. As you can see, I have learned a lot from you. Thank you to Dr David Weiss, Dr Michael Weitzner, and Bex Baker for helping me through past mania and depression. Thank you to Derrick, Rhea, and Phoebe for everything. I could not have done it without you. An earlier version of chapter 1 appeared in Social Philosophy Today. See Abigail Gosselin, “Mental Illness Stigma and Epistemic Credibility,” Social Philosophy Today 34 (2018): 77–94.

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List of Abbreviations

act a dhd apa c b t db t dsm, ds m-I V ,  and d sm-5 ic d oc d r ft who

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acceptance and commitment therapy attention deficit/hyperactivity disorder American Psychiatric Association cognitive behavioural therapy dialectical behavioural therapy Diagnostic and Statistical Manual International Classification of Diseases obsessive-compulsive disorder relational frame theory World Health Organization

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H u m a n iz in g M e ntal I llness

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Introduction What I rather wish to say is that the humanity we all share is more ­important than the mental illness we may not. With proper treatment, someone who is mentally ill can lead a full and rich life. What makes life wonderful – good friends, a satisfying job, loving relationships – is just as valuable for those of us who struggle with schizophrenia [and other mental ­illnesses] as for anyone else.1

Mental illness is a major problem throughout North America and worldwide. This is evident when we look at United States statistics. According to the US Centers for Disease Control and Prevention, 50 per cent of Americans will be diagnosed with a mental disorder in their lifetime, while 20 per cent of Americans are diagnosed with a mental disorder within a given year.2 And 4.5 per cent of Americans have serious mental disorders such as schizophrenia, bipolar disorder, or major depression.3 This means that in the US, over eleven million people have a serious mental disorder, with women being diagnosed at about twice the rate as men. Rates of mental illness diagnosis are similar in Canada.4 In the US, more than two and a half million people who have a serious mental illness live below the poverty line and another two and a half million live just over it.5 More than one million people in the US who have a serious mental illness have no health insurance, not even Medicaid.6 Almost everyone is impacted by mental illness, either directly or indirectly. Many people are personally affected by mental illness, whether they experience it themselves or have family members or close friends who do. Nearly everyone is impacted in a society in which a third of all homeless people in the US have mental illness and about half of all US inmates do.7 Mental illness is both a personal issue, touching the lives of many families, and a social issue, as people

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Humanizing Mental Illness

with mental illness comprise a disproportionate amount of the populations that are homeless or imprisoned. While there is greater public awareness of mental disorders than ever before, certain stigmas remain high due to beliefs that people have about mental illness and to fears about the impact mental illness has over a person’s life. When people close to us have mental illness, we tend to worry about them and care about them; we often fear what their illness will do to them and sometimes fear the illness and even the person themselves. When we hear about public figures having mental illness, we might think their illness sums up their behaviour, or we might be derisive of them for not being able to hold their lives together, or we might not believe them if we think they are using their illness as an excuse. When we hear that a person needs accommodations for their mental illness, we might wonder whether they “really” need the accommodations or if they are gaming the system. When we encounter people we do not know who appear to have mental illness, such as homeless people or people making a disturbance in public, we are more likely to fear not only the illness but also the person who has the illness. We easily reduce people to the trait that we fear or feel disgusted by and we ignore everything else about their identity. We erase their particularity so they are no longer individuals to us. We treat them as less than us, or as the Other. When we stigmatize people, we dehumanize them. Stigma of mental illness is understandable. We fear mental illness for good reasons, as mental illness creates mental impairments that constrain our agency. Having agency is arguably what characterizes us as human. Reasoning capacities, free will, and subjective awareness are all necessary for agency, yet any of these can potentially be compromised by mental illness. Mental impairments that constrain our agency thereby threaten our sense of ourselves as human. We fear for good reason the cognitive, rational, affective, and volitional impairments mental illness causes. Nonetheless, our fear of mental illness worsens the situation for people who actually have mental illness. In fearing mental illness, we stigmatize people who have such illness. People with mental illness already have constrained agency due to the mental impairments their illness causes. When people are subject to stigma, this stigma further constrains their agency by preventing them opportunities to engage in social practices crucial for exercising agency. Stigma leads to social exclusion. The shunning, prejudice, and discrimination involved in

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Introduction 5

stigma results in excluding people from social activities and from social life as a whole. Stigma obstructs people with mental illness from being recognized by others as members of the moral community, as moral agents with moral identities. When we exclude people from our social practices, we do not recognize them as moral equals, as having something valuable to offer, as being like us. This book has two primary aims. One is to increase understanding of the way mental illness symptoms and stigma work together to constrain people’s agency, primarily by increasing social isolation. Understanding how people’s agency is diminished helps us interact with them more intentionally and productively to increase their agency. Part 1 addresses the first aim of the book by analyzing both direct and indirect ways that mental illness constrains agency. Chapter 2 examines some of the impairments in moral reasoning that result directly from mental illness symptoms and the ways that these impairments can lead people to make bad choices and carry out bad actions (by which I mean harmful to self or others). For example, mental illness can impair moral reasoning by shifting moral boundaries so that right and wrong no longer make sense, by unduly narrowing or widening the range of plausible reasons for action and the scope of options available to a person, and by creating an unorthodox context for valuation. Stigma around mental illness impacts agency indirectly but no less significantly. Chapter 3 examines ways in which people with mental illness are subject to social isolation, primarily through the social withdrawal and self-absorption caused by their mental illness symptoms and the social exclusion caused by stigma. In a negative feedback loop, mental illness symptoms and mental illness stigma each worsen the other, as symptoms can have behavioural effects that make people appear strange, leading to further stigma, while stigma makes people more self-conscious, leading to further mental illness behaviours as coping mechanisms. Social isolation also constrains people’s agency by preventing them opportunities to engage in moral and epistemic practices. In order to show what a loss this is for people who are socially isolated due to their mental illness, chapter 3 also looks at some of the ways that social interaction is necessary for epistemic and moral agency. Our agency is transactional with the agency of others. We develop our epistemic and moral capacities and skills through engagement with others, and we acquire knowledge, make meaning, make decisions,

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Humanizing Mental Illness

and respond to others and the world within a social context. Social isolation, therefore, prevents people from acquiring knowledge; making meaning; making rational, free, and meaningful choices; and engaging in moral address and response. Understanding the ways symptoms and stigma work together to constrain people’s agency can help us as we make intentional decisions about how to respond to people who have mental illness. The second aim of the book is to encourage people to interact intentionally in ways that help enhance the agency of people who have mental illness by creating opportunities for social engagement and making it easier for people to participate in moral and epistemic practices. Part 2 of the book makes a normative assessment of ways that we should respond to and engage with people who have mental illness so as to increase their agency. While stigma is a natural response to mental illness, it worsens the condition of people who have mental illness. We should instead respond in ways that improve their condition. For example, consider how we respond to bad actions. When people do bad actions, we may be inclined to respond with reactive attitudes of blame or objective attitudes of pity. These approaches tend to do more harm than good, for example by eliciting defensive reactions. If we want to respond to bad actions with intentionality, we need to find ways to respond more productively. Philosophers writing on mental illness and agency tend to be concerned with the issue of how to assign responsibility to people who have mental illness, treating mental impairments as test cases, to test the limits of agency and responsibility. They think the most important question here is how much and what kind of responsibility a person has. I, on the other hand, think that the most important question is how we can enhance the agency of people who have diminished agency. Chapter 4 argues that our primary goal in responding to people with mental illness should be to create conditions that increase their agency by making it easier to participate constructively in moral and epistemic practices. Responding to people’s bad actions with disappointment and forgiveness is one way we can help create the conditions that enable people to change their behaviour and act better in the future. Increasing social interaction with people who have mental illness provides more opportunities for them to exercise their agency, while approaching them with open-mindedness and a commitment to seek out shared meaning enhances social engagement. Moreover,

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Introduction 7

interacting with people while holding other-oriented virtues like charity, compassion, humility, and generosity makes engagement with us easier. Chapter 5 argues that we should be open-minded and seek out shared meaning so that we better understand people who have mental illness, and we should adopt other-oriented virtues of charity, compassion, humility, and generosity. Upholding these dispositions in our interactions helps us create the space that allows people who have diminished agency to be able to interact with us in positive ways that enhance their agency.

N o t e s o n M e t h o d and Approach This book provides a philosophical analysis of the ways that mental illness symptoms and stigma work together to constrain people’s agency, and makes practical suggestions on how we can interact with people who have mental illness so as to counter those constraints and increase people’s agency. While the book engages with numerous texts across multiple literatures both within and beyond philosophy, it is written in the philosophical style of the analytic tradition. Terms are clearly defined, careful distinctions are made within the analysis, and arguments are given with reasons to support claims. In writing this book, I aim to make the content both philosophically rigorous and accessible to people outside of philosophy. While the book makes an original contribution to the philosophical literature, its abstract arguments are discussed in as clear and straightforward language as possible. Philosophy involves abstract reasoning, and philosophical literature is necessarily abstract in its approach and language. In fact, philosophers have a habit of treating all of their subject matter as abstract puzzles to be solved. We like to deal with hypothetical considerations, other possible worlds, bizarre thought experiments, and theoretical reasoning that can (in theory) be applied to real-world problems. I resist treating my subject matter here as simply an abstract puzzle to solve. Because I am writing about a topic that connects with many people’s personal experience, I ground the philosophical analysis in the lived experience of real people. Throughout the book, I offer quotes from the memoirs of people describing their experience with mental illness. These quotes illustrate some of the points I make so that they are less abstract and more rooted in real-life experience. While philosophical analysis is necessarily abstract, it is most meaningful when it connects to people’s actual experiences.

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Humanizing Mental Illness

Partly because we philosophers value abstraction so much, our standards for good research require us to take a third-person, disinterested position on our subject matter, as if we had no personal connection to it. Of course, we frequently do have a personal stake in what we are writing about, but we are obligated to conceal it under the guise of objectivity. When we take this third-person perspective exclusively, without mention of the connection we have to our topic, we give the illusion of presenting a God’s eye point of view. We do this on purpose to help establish ourselves as experts in our field. By presenting a wholly objective perspective we establish credibility and authority. Occasionally, philosophers will break the third-person wall and disclose their connection to their subject matter, but such examples are rare, particularly in philosophy of psychiatry and related areas. This may be because people writing in this area do approach the topic as an abstract puzzle to be solved and do not have personal connection to the material. More likely it is because disclosing personal connection to the subject matter – mental illness – reveals a potential threat to one’s credibility as a philosopher that is, the mental impairments caused by mental illness can impede a person’s ability to employ good philosophical reasoning. As professionals we hesitate to expose our own vulnerabilities in this way and to open ourselves up to judgment by our peers.8 Despite this risk, I think it is important for philosophers to identify personal connections to subject matter where it is relevant, because that is how we humanize philosophy. Philosophy is not just about solving abstract puzzles; it is also about analyzing and assessing issues that impact our daily lives. Disclosing personal connection to subject matter puts a human face on our philosophical work and makes the motivations for our work transparent. Because my subject matter includes stigma and one of my goals in this book is to destigmatize mental illness, it is important that I disclose my own connection to the topic by identifying myself as someone who has had mental health problems all my adult life and who has multiple mental disorder diagnoses, including generalized anxiety disorder, bipolar I disorder, and a separate psychotic disorder. The only way we eradicate stigma is by talking about stigmatized topics in ways that are not stigmatizing. Being open about having a mental illness is part of my effort to destigmatize mental illness.

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Introduction 9

N o t e s o n L anguage In this book, I intentionally choose first-person and third-person plural pronouns (“we” and “us,” and “they” and “them”), though I acknowledge the potentially problematic power relations that these terms may invoke. I use “we” language because its informality draws you, the reader, in, even though this sometimes means I have to use “they” language. I try to structure my sentences so that my pronoun use does not seem to suggest a “we/us versus they/them” power dynamic between people who have mental illness and people who respond to those who have mental illness, since this is absolutely not my intention. In fact, personally I belong to both groups, as I have mental disorders and I am also someone who responds to people who have mental disorders; many readers of this book will belong to both groups, too. I do not want my language to imply that I believe there is a metaphysical or moral difference between people who have mental disorders and people who respond to those who have mental disorders, as this is opposite to what I argue in this book. Unfortunately, the inelegance of language does not easily allow me to avoid this (mis) interpretation, and so I hope readers regard my use of language charitably, understanding my intention, however awkwardly it may be executed at moments. In addition, for the sake of gender neutrality I use the widely accepted singular “they, their, theirs,” as exemplified by the New York Times’ use in the context of transgender individuals. My reason for using gender-neutral pronouns is that readers of early drafts of chapters remarked on the gendered stereotypes that gendered pronouns evoke, including stereotypes of women having mental illness because they are weak and of men with mental illness as being violent. Because one of the purposes of this book is to address stereotypes about mental illness, as much as possible I want to avoid invoking them.

A T u r n towa r d H umani zati on Humanizing people who have mental illness involves enhancing aspects of their humanity, in particular their agency, and resisting practices like stigma that dehumanize them. We ought to consider it a moral imperative to increase where possible the agency of people who have diminished agency. If our interactions with people can help

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Humanizing Mental Illness

create conditions that enable them to have greater agency, then we ought to be intentional about interacting in ways that do this. Before we look at how we ought to interact with people, however, we must examine our current interactions. We must see the ways that we dehumanize people before we can work on alternate approaches that humanize them. This includes examining the ways that we perpetuate stigma and the effects stigma has on people. To this I now turn.

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1 Stigma and Dehumanization

In t ro du cti on One night a few years ago, I was walking with my husband in downtown Denver on our way back to our hotel after seeing a show. We live in the suburbs of Denver, and we were spending a night in the city while the grandparents watched our children. It was right after Christmas, and the temperature in the late night was extremely cold. Surprisingly (considering that we were downtown), there were few people around on that particular street. One of the few people we did pass was a man, slightly older than me, who spoke loudly and aggressively, seemingly to himself. In the midst of his monologue he addressed me (“Hey, lady”), but what he said did not make sense. I was not sure if he was drunk or schizophrenic or both. I clutched my husband’s hand, and we walked fast trying to ignore the man as we continued our conversation that was now forced. Partly because I am female, and partly because the man did not seem fully connected to reality, I was glad I was not walking alone at night. How many times do we pass individuals who appear to be not fully connected to reality so we do our best to ignore them, especially those of us who live or work in cities that have a large homeless population? How often are we uncomfortable with someone’s behaviour so that we do our best to pretend they are not there? I feel as if I should know better. For one thing, I have been studying mental illness as an academic subject for many years. Also, in college, one of my favourite jobs was working in group homes with adults who had schizophrenia. These were adults who, when in public, would appear as if they were homeless because of their speech, dress, and comportment. In fact,

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most of them needed such intensive care in their daily activities that it was only by the grace of state-funded community care that they had a home. Moreover, I myself have multiple mental disorders, including bipolar I disorder; through support groups and such, I have met many other people with the same illnesses, and no matter how much or little we have in common, I feel like there is always some basis on which we can relate to each other. And yet. Even though I know better, even though I am deeply empathetic to people with mental illness, and even though I am not generally frightened of them (of “us”), I did not want to be alone in the dark of night with that man speaking incoherently. I did not even want to talk to him. I wanted to pretend he was not there. We try all the time to pretend that people with severe mental illness are not there; we avoid eye contact and literally cross the street in order to avoid interaction. We bemoan the large homeless population and convince ourselves that most of them are homeless by choice, so we do not need to feel bad for them or feel as though we have any obligation toward them. We are surprised that the prison population is so large, but we are afraid of people who act bizarrely, who break laws because they do not see the world and its rules the same way we do, and who are unpredictable and, therefore, possibly violent. We do not want to give money to homeless people because we assume they will just use it to buy drugs, and why should we support their bad habits? Even though some of us know that one source of the large prison population is petty drug laws that (together with prejudice) incarcerate too many Black men, we still want something to hold people accountable for their bad actions, and what are public drunkenness and incoherent behaviour but bad actions that make people uncomfortable? We are especially derisive of people who have drug addictions, because we think that they should be able to control themselves, or at least get help when they need it. We do not consider the fact that many people with drug addictions are using substances to cope with their mental health issues. Approximately 40 per cent of adults who have a substance abuse disorder also have a mental disorder,1 and for many of those people using drugs or alcohol is a way to cope. Whether it is a homeless person who might use cash to buy alcohol or a celebrity who spends their earnings on cocaine, a person who is struggling with a serious mental disorder often self-medicates with drugs or alcohol because they are more easily accessible (especially to people

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Stigma and Dehumanization 13

who do not have health insurance) and their effects tend to be quicker and stronger than prescription medicines. People with mood disorders have especially high rates of dual diagnosis. While about one-third (32 per cent) of people who have mood disorders also have substance use disorders, more than half of those who have bipolar disorder (56 per cent) in particular have substance use disorders, commonly with alcohol and/or cocaine.2 People who use drugs to self-medicate are clearly in a lot of pain and misery that they are trying to deal with the best they can. Yet, our typical reaction to a homeless person who drinks to numb their pain or a celebrity who ingests cocaine to stave off depression is derision and disgust, even loathing. It is hard for us to feel sympathy toward people with drug and alcohol problems, those who are chronically homeless, or those who are incarcerated. It is hard for us to feel sympathy toward people with serious mental illness, especially sympathy that does not lean toward pity, objectification, or condescension. This is because we would rather they not be among us. Journalist Ron Powers titled his recent book after a statement made in an email by an administrative aide trying to downplay mismanagement of a mental health unit: “No one cares about crazy people.”3 Indeed. We do our best to ignore people with serious mental illness, to write them off as subhuman, to explain their actions in ways that remove any responsibility we might have toward them. Severe mental illness in particular serves as a limiting case for what it is to be human. The actions of people with mental illness are used as fodder for comedy, because they are still a group of people we can objectify safely. Television shows about law and crime regularly use mental illness as a plot device to explain irrational actions: Why did the character commit such grisly murders? Because they were insane! Of course. As if that explains everything. For millennia, philosophers have used “madmen” as the line over which a person ceases to be human and becomes a beast. People with mental illness are not seen as people; we treat them as objects, and their mental illness serves particular needs we have as we define ourselves in opposition to them. In this chapter, I examine stereotypes of mental illness and explore the reasons why mental illness is stigmatized and the problems created by this stigma. Mental illness symptoms cause mental impairments – including impairments to subjective awareness, rationality, and free will and action – that diminish our ability to be epistemic and moral agents. Mental illness therefore threatens the conditions

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that characterize us as human and thus threatens our ontological identity as human beings. Because we are right to be concerned about losing our humanity, feeling fear or disgust toward mental illness is  understandable. Mental illness stigma, however, exacerbates the problems people with mental illness face, further dehumanizing them and further diminishing their agency through both social exclusion and worsening their mental illness symptoms. Mental illness stigma and mental illness symptoms thus exist in a feedback loop in which each exacerbates the other, both with the result of divesting people of their humanity.

S t e r e o t y p e s o f M e ntal I llness Mental illness stigma begins with stereotypes, which are generalizations about people based on a shared attribute, and they comprise beliefs as well as affective attitudes.4 According to social scientists, we develop generalizations in order to process quickly and efficiently our understanding of people. If an individual has at least some of the traits we associate with a particular stereotype, we can understand almost immediately something about who that person is based on the stereotype.5 Stereotypes may be positive, negative, or neutral, and their veracity can vary from being partially true to not true at all. Regardless of how positive and/or true they may be, stereotypes are only generalizations and cannot account for all the nuances that make individual people individuals. For this reason, relying on stereotypes for understanding, even when they are positive, is epistemically harmful. Moreover, negative stereotypes cause moral harm to those who are stereotyped, and false or misleading stereotypes can be employed in ways that cause all kinds of harms. We have many stereotypes about people who have mental illness. Consider the following. The madman who guns down people in a shooting spree for no discernible reason. When news coverage identifies a shooter as having a mental illness, people think, That explains it. Think of Florida nightclub shooter Omar Mateen, who was thought to have bipolar disorder; Virginia Tech shooter Seung-Hui Cho, whose mental health records indicated depression and anxiety; or Aurora theatre shooter James Holmes, who was diagnosed with schizophrenia. These examples reinforce the stereotype of people with mental illness as dangerous and violent. Even outside of mass shootings, news media constantly

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Stigma and Dehumanization 15

pairs mental illness with perpetrators of murder or other crimes, and this pairing is part of what makes us afraid to be near someone who is talking to themselves. The lunatic locked up in an asylum. Historically, people with mental illness were institutionalized, mostly in asylums that had abysmal living conditions and permitted abuse and exploitation. The notorious images of “Bedlam” – London’s centuries-old Bethlem Royal Hospital psychiatric asylum, where people lived in squalor and chaos while being chained, naked, abused, and observed and mocked by paying visitors – persist in our collective memory and serve as inspiration for Hollywood portrayals of asylums and mental hospitals. A recent cartoonish depiction of “crazy” people in the asylum is the Arkham Asylum in the television show Gotham. While the entire show is outrageously ridiculous, Arkham Asylum pushes every stereotype of madness, from psychotic killers to incoherent babblers to the doctor who is as insane as his patients. While no one who watches a show like this can mistake its over-the-top characters for people who actually have mental illness, such unbelievable depictions obscure and trivialize the real conditions of people with mental illness who are housed in treatment facilities or prisons. Some state mental hospitals, juvenile detention centres, and prisons are still hotbeds for abuse and exploitation.6 The homeless person shuffling down the street muttering to themselves and trying to bum a cigarette or money for alcohol. At least one-third of people experiencing chronic homelessness and more than half of those who are incarcerated have serious mental illness.7 In the Denver area where I live, it is estimated that two-thirds of the homeless population has serious mental illness.8 According to the Denver Post, “On average, people with severe mental illness die 25 years earlier, and the homeless die 31 years sooner than people with homes.” And yet, do we care? No. We walk past them as quickly as possible, averting our eyes and trying to avoid them. And we get indignant or even angry when they ask us for money. The celebrity whose drug use is legendary and who has been hospitalized for unspecified behaviour or jailed for violent acts or drug possession. Excess seems to be part and parcel of celebrity lifestyles, and we are fascinated with sensationalistic stories about musicians and actors “gone bad.” We mock Lindsay Lohan and Britney Spears for their stints in mental hospitals; we get angry at various actresses and models who are “too thin”; we are nonplussed by the legions of

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musicians and actors who go to rehab (again?); and we share collective sadness for Robin Williams, Philip Seymour Hoffman, Carrie Fisher, Amy Winehouse, Chester Bennington, and many others whose lives ended much too soon. Sometimes we are contemptuous of celebrities who have seemingly messed up their lives because they have more opportunities and resources than most, and yet, we presume, they still could not get it together (What is wrong with them?). The mad genius whose suffering and special insight inspire creativity in art, music, literature, science, mathematics, and other realms. In visual art, consider the passion of Vincent Van Gogh, Jackson Pollock, Georgia O’Keeffe, and Mark Rothko, all of whom suffered from depression or madness. In literature, consider David Foster Wallace, Kurt Vonnegut, Sylvia Plath, Virginia Woolf, and Ernest Hemingway, all of whom tried to exorcise their demons through writing. In classical music, Ludwig van Beethoven and Robert Schumann were both brilliant and mad; in rock-and-roll/pop music Syd Barrett, Brian Wilson, Lou Reed, Kurt Cobain, Scott Weiland (my personal favourite), Chris Cornell, Eminem, Pete Wentz, Demi Lovato, among many, many others have struggled with mental illness and some have died as a result of it. In addition, there are plenty of “mad geniuses” whose mental illness seemingly inspires insight and creative thinking in other areas, such as science and technology; consider John Nash, Sir Isaac Newton, and Nikola Tesla. The seemingly high rate of mental illness among artists and other extraordinary thinkers makes us wonder if being tortured by inner demons is somehow necessary to being creative. Research on mental illness stigma indicates that our stereotypes about mental illness converge around a few dominant types. We tend to regard people with mental illness as: • •

•

Dangerous and violent (the mad shooter) Incompetent and needing to be taken care of (the “crazy” person in the asylum or the homeless person muttering to themselves) Having a character flaw, and in particular lacking willpower (the celebrity who messed up their life, and any drug addict, whether celebrity or homeless)9

In addition to these common negative stereotypes about mental illness, we also have benign or even romantic views, regarding people who have mental illness as “seers” who are receptive to knowledge

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and experience that others tend to lack access to.10 Stereotypes of the “mad genius” fit here.11 Because the mad genius typically has a dark side – where insight becomes psychosis, energy becomes out-of-control mania or agitation, and existential angst becomes suicide – it is not a complimentary stereotype, even if it is romanticized. Media representations of mental illness reinforce all of these negative stereotypes, and consequently stigma, in various ways. News articles and television shows that emphasize the mental illness of a perpetrator of crime reinforce the association of mental illness with violence, as do television shows and movies that attribute crime to a character with mental illness. Portrayals on television or in the movies, the news, or other media sources of celebrities and historical figures who have or had mental illness perpetuate the idea of the celebrity mess-up or mad genius. Television shows and movies that depict a character with mental illness with pity often reinforce the stereotype of the crazy lunatic, or perhaps a version of the homeless bum or the person whose coping skills messed up their life. Media frames how we see people, and media that does not take responsibility for how it depicts people tends to perpetuate negative stereotypes that in turn perpetuate stigma.12 We frequently hold contradictory beliefs about mental illness simultaneously, viewing people with mental illness through the lens of multiple stereotypes at once without noticing or caring about their incompatibilities. Stereotypes about mental illness are not all easily reconcilable with each other, however, in part because they rest on conflicting beliefs we have about the moral agency of people with mental illness. Underlying the first two stereotypes in the preceding paragraph seems to be an assumption that people with mental illness have little or no control over their actions, they may not even understand the moral nature of their actions, and are therefore not appropriately responsible for their actions. Underlying the third stereotype, on the other hand, is the belief that people with mental illness are capable of having sufficient control over their behaviour as to be morally responsible for it and so are blameworthy when they fail to exercise or develop self-control and willpower. We tend to feel what philosophers call “objective attitudes” of pity, fear, and/or repulsion toward people whom we regard as lacking sufficient agency, and we tend to have what they call “participant reactive attitudes,” such as outrage and blame toward people who seem to have sufficient agency yet act badly.

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When we assume that people with mental illness are dangerous and potentially violent, we are often thinking of a deranged person who has no control over their actions and who may not even understand the moral nature of their actions. Because we believe such a person lacks self-control, self-awareness, and an awareness of the moral environment in which they operate, we also tend to believe such a person does not have free will because it seems that they could not have done otherwise. For especially atrocious actions, such as murder or mass shootings, we may blame the person even if we believe they did not act out of free will, because the nature of the crime was so heinous that we believe blame must be attributed somewhere. In such cases, we willingly conflate moral responsibility with causal responsibility, and we are often willing to entertain conflicting beliefs, wanting to believe the person could have exerted some control over themselves (and so wanting to believe the crime could have been averted) even when we are aware that mental illness may have made that impossible.13 Most of the time, however, when we believe a person cannot control their actions, we tend to withhold blame. What justifies our treatment of the person is the harmfulness of the acts. If a person acts in harmful ways toward others, we try to contain or manage their behaviour, whether through the ways we interact with them, through the rewards and sanctions they “earn” in a behaviour modification treatment program, or through legal punishment like prison or home surveillance that removes them from society. The stereotype that people with mental illness are dangerous and potentially violent is thus consistent with the stereotype that they are incompetent and need to be taken care of. In either case, whether we believe the person has control over their actions or not, the belief that a person with mental illness is dangerous and potentially violent instills in us fear, and a strong desire to avoid interacting with them, as well as the belief that management of their condition – or of the person – is necessary. With the stereotype that people with mental illness are incompetent and need to be taken care of, we assume they lack sufficient agency to be able to control their actions on their own, and so we regard such people as not appropriately responsible for their actions. This justifies paternalistic response, including managing behaviour. The belief that at least some people with mental illness are not morally responsible for bad actions but need to be contained or managed leads to holding what Peter Strawson calls “objective attitudes” toward

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people with mental illness.14 Objective attitudes are dispositional responses of pity, and sometimes fear, repulsion, or certain forms of love. With such attitudes, we absolve people of full moral responsibility, treating them as objects rather than as agents. We hold what Strawson calls “participant reactive attitudes,” which cover the range of human emotional response, toward people we regard as full moral agents with free will and sufficient rational capacity (presumably like “us”). We hold objective attitudes, on the other hand, toward people who seem like objects of deterministic force (and so presumably different from “us”) rather than like agents with free will. When people are rightful recipients of objective attitudes, this seems to justify techniques of management such as institutionalization, whether this is hospitalization or incarceration. Strawson says, “To adopt the objective attitude of another human being is to see him, perhaps, as an object of social policy; as a subject for what, in a wide range of sense, might be called treatment; as something certainly to be taken into account, perhaps precautionary account, of; to be managed or handled or cured or trained; perhaps simply to be avoided …”15 In holding objective attitudes, we dehumanize a person. (I discuss objective attitudes and participant reactive attitudes in detail in chapter 4.) On the other hand, when we assume the third stereotype, that people with mental illness have a character flaw such as lacking willpower, we believe they are capable of having sufficient control over their behaviour as to be morally responsible for it, and that if they do not have such control then it is their fault for not having developed it or for not exercising it. The belief that some people with mental illness use their illness as an “excuse” to seek advantage (for example, the belief that people claim to have attention deficit/hyperactivity disorder, or a dhd, in order to receive an unfair advantage at school by having longer testing time) or to avoid responsibility (for example, the belief that people “blame” their illness on their actions) rests in turn on this belief: such people are capable of sufficiently controlling their behaviour but either do not want to or do not want to take responsibility for doing so.16 Because with this stereotype we believe people with mental illness have control over their actions (if they only tried), we regard them as morally responsible and blameworthy for bad actions. We may deny them services and resources that would benefit them, because we believe they do not really “need” or even deserve them, and we may endorse sanctions or punishment for

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particularly egregious or harmful actions because moral responsibility entails desert of appropriate consequences. As an overview of these three predominant stereotypes of mental illness shows, mental illness is regarded as a negative trait, even though what is deemed as negative and marked as shameful differs among different stereotypes. In summary, some stereotypes are negative because they assume the person lacks free will and self-control, while others are negative because they assume the person has free will but does not exercise it sufficiently. The predominant stereotypes of mental illness are therefore stigmatizing, even though the nature of their stigma differs. Regardless of the specific beliefs we hold about the agency of people with mental illness, we regard them as subhuman, either intrinsically so or due to their defective character. How are we to make sense of the fact that our stereotypes about mental illness rest on conflicting beliefs we have about the moral agency of people with such illness? I want to suggest that, in many cases, we attribute different stereotypes about people – and different assumptions about their agency and responsibility – based on what kinds of mental disorders we believe they have. When we endorse the stereotype that people with mental illness are dangerous and potentially violent, or the stereotype that they are incompetent and need to be taken care of, we tend to be thinking of severe mental illness, especially mental disorders with episodes of psychosis that affect people’s perception of reality and relationship to the world (particularly schizophrenia, bipolar disorder, severe depression, and severe obsessive-compulsive disorder, or o c d ). When we endorse the stereotype that people with mental disorders have a character flaw and a lack of willpower, we tend to be thinking of mild or functional mental disorders (what used to be called “neuroses” like anxiety and mild depression, as well as disorders like ad h d and mild o cd ). I would argue that this distinction partly results from the different intuitions we have about the causes of mental disorders and the relationship between mind and body – or, more properly, mind and brain. We typically believe people with severe mental illness have a brain disease that prevents them from having control over their behaviour, while we tend to believe people with milder mental disorders have a psychological problem that they are able to – and ought to – learn how to deal with.17 Our conflicting beliefs about the moral agency of people with mental illness therefore rest on different conceptions about “who” people

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with mental illness are. Sometimes our beliefs merge in illogical ways, allowing us to be inconsistent in how we attribute certain stereotypes and characteristics to different groups of people. This creates a lot of conceptual confusion both in people who endorse stereotypes and in people working to destigmatize mental illness. For example, while many mental health advocates support a biomedical model of mental disorder in order to reduce stigma associated with blaming people for their mental illness, studies have shown that this model actually increases the stigma associated with fear of people whose behaviour seems out of control and potentially violent, the stigma that people with mental illness are incompetent and need taking care of, and the stigma that they are intrinsically defective due to faulty biology and are therefore wholly Other.18 As another example, I sometimes hear college students doing mental health outreach on campus, trying to dispel myths that people with mental illness are violent and dangerous by describing their own experiences with depression and anxiety as examples to destigmatize mental illness. No one I am aware of believes that college students with depression or anxiety are dangerous. Fear of those with mental illness as dangerous and violent arises in thinking about people with untreated schizophrenia or bipolar disorder, who murder neighbours or commit mass shootings. It is true that people with severe mental illness are much more likely to be the victims of violence than instigators of it.19 But dispelling the myth that severe mental illness causes violence requires directly responding to representations of severe mental illness – not conflating different forms of mental disorders as if our images of and beliefs about them were all identical. Effective mental health education and outreach requires some conceptual clarity about what exactly people believe and fear when they stigmatize mental illness and response to those beliefs more specifically. Teasing out the conceptual confusions in our stereotypes and stigmas about mental illness is important for clarifying our understanding of the range and scope of agency of people who have mental illness and for determining the most just and appropriate ways to treat such people. No matter how confused our beliefs are about people with mental illness, those beliefs affect how we treat them in moral and legal spheres, and they affect how we interact with them more generally through our epistemic practices. Our beliefs affect what we expect of people who have mental illness and what we enable them to do interpersonally and socially. For this reason, specifying “who” we are

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talking about when we talk about mental illness is crucial to more accurately and appropriately make judgments about and respond to the subjects of our inquiry.

C o n t e x t ua l iz in g Mental I llnes s Throughout this book, I use the term “mental illness” more frequently than the term “mental disorder”; however, my usage varies depending on context because the book is concerned more with the experience of mental impairment rather than the cluster of symptoms that constitutes mental disorder or the underlying biological mechanism that constitutes mental disease. Let me explain these terms. “Mental disorder” is a term with both psychological and philosophical meaning. Within a psychological framework, mental disorder refers to the clinically significant cluster of symptoms that constitutes a particular diagnostic category, and it is the unit of diagnosis of psychological problems. Mental disorder is the term the American Psychiatric Association’s (a pa) Diagnostic and Statistical Manual (dsm) uses in its classification scheme. The most recent version, dsm-5, defines a mental disorder as “a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.” The dsm goes on to identify conditions that are excluded from its definition: “An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders. Unless the deviance or conflict results from a dysfunction in the individual, as described above.”20 The d s m -5 definition identifies what kinds of disturbances are relevant (cognition, emotion regulation, or behaviour), associating them with specific causes in the individual (psychological, biological, or developmental process). Mental disorders are characterized by experiences of distress or disability in various life activities, but neither distress nor disability is necessary or sufficient to constitute a mental disorder.

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The d s m -5 definition of mental disorder differs slightly from the definition given in d s m - I V . The beginning of the d s m - I V definition describes mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.”21 The greater emphasis on distress and disability here is significant. Distress is characteristic of many mental disorders, though not everyone experiences distress with their symptoms. Disability is understood here as impairment in at least one crucial area of functioning such as work, school, relationships, and everyday social interaction. Unlike dsm-5, the d s m - I V definition includes risk of suffering death, pain, or disability alongside current experience of distress or disability. In addition, the d s m - I V definition includes loss of freedom as one of the significant consequences of the mental disturbance that constitutes a mental disorder. d s m -5 may have eliminated these features from its definition because they are difficult to measure and assess, in part because they are somewhat subjective and/or involve projections into the future. As a philosopher, I prefer the d sm -I V definition because the concepts it includes are significant aspects of the experience of having a mental disorder; in other words, they are important to our understanding of what makes the condition pathological, or a condition worth treating medically or psychologically. Even though the dsm-5 omits these features from its definition of mental disorder, however, the concept of mental illness experience captures these features effectively, as I explain shortly. Before delineating what mental illness is (in contrast to mental disorder), consider how philosophers use these terms. In their writings, philosophers use both “mental disorder” and “mental illness.” Occasionally they distinguish between the two terms intentionally, but, confusingly, they often use these terms interchangeably. Philosophers discuss mental disorders mainly in the context of ontological, nosological, and etiological inquiries, seeking to understand the essential nature of mental disorder (ontological), how mental disorders should be classified (nosological), or seeking the causes of mental disorders (etiological).

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From an ontological perspective, philosophers generally understand mental disorder as a breakdown of meaningful connections – or, as I describe later on, a loss of intelligibility or a failure of making sense. “Meaning” can be understood broadly to include intelligible action and reason-giving; rational thought process; perception that coheres with others’ perception, affect and behaviour that is appropriate to the circumstances and context.22 “Breakdown” of meaning does not typically mean “absence” of meaning (as in stereotyped views of schizophrenia), but more often maladaptive meanings that do not serve a current or useful purpose, or inappropriate meanings that do not fit a shared context recognized by others in the relevant social milieu.23 Even in psychosis, after all, delusional utterings and hallucinatory perceptions that appear random and pointless may have meaning within the context of the person’s experience, both subjectively (as symbols) and objectively (in terms of the person’s life story and cultural framework).24 Philosophers writing in the area of philosophy of mind and action analyze the breakdown of meaning that occurs in mental disorders as a failure in the chain which links meaningfulness, mental states, and action. Examples of ways that this chain can be disrupted include: having an inappropriate mental state (for instance, perceiving a stimulus incorrectly or perceiving a stimulus that is not present); having a mental state occur beyond a person’s control (such as random mood states caused by excessive neural firings); having an inability to act (such as on account of weakness of will or volitional disability); or taking inappropriate action (in virtue, for example, of being unable to understand a social context and norms about how to act).25 Such breakdowns in meaning indicate disorder in a person’s mental activity – that is, mental disorder. When understood as a breakdown of meaning, the term “mental disorder” is broad in scope, covering a variety of mental abnormalities, dysfunctions, and challenges which may range in severity from mild to severe. This is consistent with the scope implied by the apa’s definition of mental disorder as “a clinically significant disturbance in cognition, emotional regulation, or behavior.” In both philosophical and psychological conceptions, the concept of mental disorder covers a wide range of experiences. While symptoms must be “clinically significant” in order to constitute a mental disorder, some experiences of clinically identifiable mental disorders nonetheless cause more distress and/or problems with functioning than others. For example,

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two people can be appropriately diagnosed with obsessive-compulsive disorder and suffer in radically different ways. One person may need to rearrange the room every time someone sits down, while another person (whose hands might be rubbed raw and bloody from overwashing) cannot leave their house because their fear of germs makes such action impossible. Both have a mental disorder – a mental disturbance stemming from psychological, biological, or developmental dysfunction (as defined by the a pa ) and a “breakdown in meaning,” broadly construed (as understood by philosophers) – but the latter has an illness, I want to suggest, which the former lacks. While “mental disorder” refers to the clinically significant cluster of symptoms that constitutes a particular diagnostic category, “mental illness” refers to the illness experience that some people feel as a result of having the cluster of symptoms.26 Because people typically do not experience major problems with functioning when they have mild mental disorder symptoms, the distinction between mental illness and mental disorder also maps onto a difference in severity. When people are bothered by their symptoms but not seriously impaired, they experience the disorder without the illness. When their symptoms seriously affect their ability to function in important life domains such as work, education, relationships, and general social interaction, people experience mental illness as a result of their mental disorder.27 The term “illness” thus suggests a level of dysfunction and distress that interferes with basic functioning. By “basic functioning” I mean bodily processes necessary for survival like eating and sleeping as well as psychological capacities such as means-ends reasoning, accurate perception, appropriate affect, and directed focus. Mental illness is an experience of profound dysfunction in a person’s psychological competencies and often bodily processes that causes disability and that frequently (though not necessarily) causes significant distress.28 Areas of psychological functioning that can be seriously impaired by mental illness include perception, experience of space and time, body awareness, awareness of reality, feelings and other affective states, volition, awareness of self, attention, and memory. In turn, these affect communication, behaviour, responsiveness, empathy, self-care, and the ability to recognize opportunities (options for alternative actions) – all of which are essential for moral agency.29 In addition, areas of physiological functioning that are typically impacted by mental disorders include motor activity, speech and communication, sleep, and appetite.30 Psychological competencies

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and physiological functioning are necessary for basic tasks such as taking care of personal hygiene, wearing appropriate clothing, going to a store, making purchases, cooking, doing laundry, and paying bills. Impairments to these areas of functioning impact a person’s ability to take care of themselves independently and to do necessary tasks to carry forth on a daily basis. Because certain psychological capacities are preconditions for social capacities, profound psychological dysfunction impairs a person’s social existence, or their ability to be a social being. It is easy to see how impediments to any of the psychological competencies required for functioning can make everyday interaction and the ability to carry out occupational, caretaking, or other responsibilities challenging. When mental illness impedes multiple social capacities – such as the abilities to maintain meaningful family relationships, to maintain or develop friendships, to access an education, to hold down a job, and to fulfill caretaking duties such as caring for children or elderly parents – it prevents flourishing, causes a decline in functioning, and may even threaten dehumanization. The conditions that I classify as “mental illness” thus stand in opposition to those we might call “mental health.” In a sociological context, the “illness” aspect of mental illness also suggests embodying what Talcott Parsons identifies as “the sick role.”31 In essence, patients adopt a role in relation to their illness and to the medical professionals who treat them. In this role, patients are exempted from the usual social responsibilities, but in return patients are expected to work on getting better so they can eventually move out of the sick role; they get better by consulting the medical professionals who have the expertise to treat them. In the context of mentally ill patients who embody the sick role, they are relieved of many social responsibilities but must work on getting better, in part by receiving mental healthcare treatment from mental health professionals including psychiatrists and therapists. Because my focus in this book is on addressing impairments to agency that people with mental illness experience, and not on their experience as psychiatric patients receiving mental healthcare treatment, my reference to mental illness in this book is philosophical, concerning the way people experience profound psychological dysfunction, rather than sociological. This book is concerned not with people who receive diagnoses of mental disorders for having specific clusters of symptoms, but rather people who experience illness, and the consequences of that illness, as a result of their symptoms. Because this book focuses on the ways

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that mental impairments and stigma diminish agency and make people vulnerable to dehumanization, it is concerned with the more severe manifestations of mental disorder that constitute an experience of illness. Because this book focuses on the experience of people who have mental illness, it is also not concerned with the causes of the underlying mental disorders but rather with the effects of mental ­illness experience on agency and social existence. In using the term “mental illness,” I am not necessarily referring to the experience of specific illnesses like schizophrenia or bipolar disorder, though these are typically thought of as the most severe (and biologically based) of the mental disorders. Many cases of schizophrenia and bipolar disorder do fall under this narrower category, but very mild cases of bipolar disorder (such as cyclothymia) may not. Major depression, severe ocd, crippling anxiety, or severe adhd that impair a person’s ability to maintain personal hygiene, hold down a job, carry out caretaking responsibilities, or engage in normal social activities falls under the category “mental illness.” Depression, anxiety, oc d, or a dhd that is bothersome but does not create a barrier to functioning may be a disorder without being an illness. There is no bright line here, and all mental disorder experiences exist on a continuum of impairment from mild to severe. People experience mental disorder symptoms in different time frames (chronically, persistently, periodically, regularly, randomly, occasionally, or once), and the severity they experience can vary at different points in their lives. Manifestations of specific mental disorders that impair a person’s ability to function in important life domains constitute what I am categorizing as mental illness, especially when this impairment in functioning is severe and chronic or recurring. Now that I have explained what I mean by mental illness, let us examine why we have the stigmas around it that we do.

S t ig m as a ro u n d Mental I llnes s Stigma is a negative reaction toward a group of people who share a trait that has been socially identified and marked as negative. People adopt stigmas when they endorse negative stereotypes of the group based on the shared trait.32 As stigma leads to prejudice and discrimination, it has harmful consequences for those who share the trait, leading to social isolation and experiences of injustice. Prejudice involves a cognitive reaction of endorsing negative stereotypes and/

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or an emotional reaction of having a negative affective reaction like fear or disgust. Discrimination involves behaviours that people adopt as a result of their prejudice, which typically lead to social exclusion, marginalization, and oppression.33 Mental illness stigma typically takes the form of fearing the person with mental illness or feeling disgust toward their inability to be “normal.” Certain behaviours by people with mental illness can be very “off-putting” because they are not easily understandable, especially irrational and unpredictable behaviours, and especially those that stem from psychosis.34 Behaviour by people with mental illness may defy social norms, making social interactions difficult and unstable, and invoking fear, curiosity, and revulsion. Remember that Peter Strawson identifies fear and repulsion as some of the objective attitudes we sometimes hold toward people whom we believe have diminished agency. When people behave in ways that are not understandable and that defy social norms of appropriate or rational social interaction, we tend to treat them as less than or other than human, deserving pity, perhaps, but not our respect or regard as equals. Responding with stigma to people whose behaviour does not make sense to us is understandable. Yet stigmatization is a form of dehumanization. People are prejudicial and discriminatory toward those with mental illness when they endorse stereotypes such as those described above (in this chapter’s section titled “Stereotypes of Mental Illness”). In multiple studies, people have demonstrated such prejudice and discrimination leading to decreased housing and education access, decreased employment opportunities, and increased incarceration rates for those with mental illness. According to studies, people are less likely to rent apartments to people who have mental illness than to people who do not; they are more likely to deny employment or career advancement to people who have mental illness than to those who do not; and they are more likely to press false charges for violent crime against people who have mental illness compared to those who do not.35 People with mental illness report frequently experiencing negative attitudes directed toward them and prejudicial actions resulting in social exclusion.36 While people with severe mental illness usually experience the worst effects of stigma, the effects of stigma on those with milder mental disorders can also be devastating. Because they are more common and seemingly more understandable, milder forms of mental disorders (such as those that seem to stem from stress) may be subject to less

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stigma, particularly stigma associated with fear of and revulsion toward the Other. At the same time, because they are less noticeable, milder forms of mental disorders may appear to be more controllable, and so they may also be subject to greater stigma, particularly stigma associated with derision for character defects.37 People with mental illness experience constant vigilance in response to the perpetual potential that they may be stigmatized.38 In reaction to or in anticipation of others’ judgment, people with various kinds of mental disorders are often self-judgmental or self-censoring in ways that prevent them from socializing or pursuing employment or other opportunities. Stigma leads to decreased help-seeking and decreased resilience,39 and it reinforces the belief a person may have that their identity essentially revolves around or is reducible to their illness.40 Many people with mental disorders of all kinds internalize stigma and become filled with shame and disgust for themselves, which can develop into a form of self-loathing that easily leads to depression and even suicide. Mental illness stigma occurs both in response to being labelled mentally ill (whether through self-report or known diagnosis) and in response to being thought to be mentally ill.41 Social psychologists have studied whether the label of mental illness is more or less stigmatized than the actual behaviours associated with mental illness, and they have found no discernable difference; both appear stigmatizing as people are prejudiced against both.42 For many people, specific symptoms associated with mental illness – inappropriate affect and behaviour, language and speaking irregularities, social skills deficits (including those concerning eye contact, body language, and conversation topic), and lack of personal hygiene and care of appearance – signify mental illness independently of whether a person is known to be diagnosed with a mental illness. The occurrence of these traits, especially in combination, indicates for many people mental illness and invokes various (negative) stereotypes of mental illness and corresponding feelings of fear or disgust. It is worth considering why we would react to mental illness with fear or disgust. What we fear most, perhaps, is the loss of our humanity, and mental illness threatens features of humanity like no other condition. What is arguably distinctive about being human is that we have consciousness, rationality, and free will and action. I do not mean that these features are necessary to being human but simply that they are characteristic of being human. Because these features

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characterize our humanity, the loss of these features frightens us, and we might feel disgust toward people who lack these characteristics. Let me elucidate what I mean in identifying consciousness, rationality, and free will and action as characteristic of being human. By consciousness I mean that we have a sense of ourselves as selves. We have an internal perspective of the world based on our unique subjective experiences, and we need to have an accurate understanding of the world in order to situate ourselves correctly within it. By rationality I mean that we have reasoning capacities necessary for being epistemic and moral agents. Epistemic agency involves participating in practices associated with seeking knowledge and making meaning. Capacities required for epistemic agency include using logic, seeing how parts relate to each other and to the whole, organizing ideas, and evaluating claims based on evidence. Moral agency involves making free choices based on reasons intelligible to others and being responsible for those choices. Capacities required for moral agency include recognizing the moral salience of particular situations, distinguishing different options, weighing and ranking them, and giving reasons for choosing one course of action over others. By free will I mean that we can make intentional choices about how to act, choices which we personally endorse and for which we can give an account based on reasons intelligible to others. Free will enables us to have control over and, therefore, be responsible for our behaviour. In order to act freely, reason must guide our motivations, choices, and actions. A large part of mental illness stigma comes from our own fear of “losing our mind,” of being uncontrollably irrational or deluded, of not having control over ourselves or our mental states. Mental illness can disrupt our understanding of the world and the connection to reality that constitutes what we might think of as sanity, thus impairing our consciousness. Mental illness can interfere with a variety of reasoning capacities and thus potentially compromise epistemic and/ or moral agency. Mental illness can also rob us of our free will by unduly limiting our options for action; by making it seem as if we are given commands from a source external to ourselves; or by overruling reason with uncontrollable emotions, obsessions, compulsions, or impulsivity. Threats to these features of humanity – consciousness, rationality, and free will and action – are understandably, even justifiably, feared because the loss of these features diminishes our agency and ultimately our sense of ourselves as human beings.

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Many authors have powerfully characterized this fear of losing our sense of ourselves as human beings. Janet R. Nelson argues that our fear of mental illness is ultimately the fear of a loss of self, namely a human self. She states, “The great fear of mental illness lies in the possibility of losing what we hold so dear, yet at times feels so tenuous – our sense of ourselves as a meaningful self.”43 Along the same lines, T.M. Luhrmann notes, “We are right to be terrified by psychosis and depression [among other mental illnesses], because mental illness distorts the defining features of personhood, and, seeing that, we are reminded that the foundations of our being are built on sand.”44 Robert Kendall notes that our fear of losing our sense of self and personhood creates not only fear of and revulsion at mental illness but also mockery. He remarks, “Our concept of ourselves as rational beings guided by reason and intelligence is crucial to our self-­ confidence and self-esteem; and encountering a fellow human being who has lost their reason and whose behaviour is no longer rational is profoundly disturbing, because it implies that the same might happen to us. That is why the mentally ill are mocked as well as feared, for mockery reduces the implied threat they pose. It is also why we are so keen to establish a clear gulf between the mentally ill and normal people like ourselves.”45 The fear of such a profound loss of selfhood and personhood is what generates stigma toward those who are mentally ill. Mental illness reminds us of our vulnerabilities as human beings – as beings privileged to have consciousness, rationality, and free will and action, yet always vulnerable to their loss.

O n to l o g ic a l V ulnerabi li ty a n d   D e h u m a ni zati on Mental illness dehumanizes people in at least two ways: directly, by threatening the conditions of humanity through internal constraints on agency, and indirectly, by provoking fear and disgust that leads people to regard those with mental illness as less than or other than human. In order to explain these processes of dehumanization, first a few more words about what it is to be human. As I have just explained, mental illness is stigmatizing because it threatens the features we consider characteristic of being human, namely consciousness, rationality, and free will and action. These features are significant because they are preconditions of moral and epistemic agency, and

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the fact that we are agents distinguishes us as humans from the rest of the animal world. In other words, mental illness interferes with our ability to be epistemic and moral agents and thus to be meaningful selves. In impairing our agency, mental illness dehumanizes us. An agent is the doer of an action, and agency describes the kind of activity we do as humans. To be a moral or epistemic agent is to be someone who acts, or who has the capacity to act, in moral or epistemic contexts. Moral agency involves the capacities to understand right and wrong, to make moral judgments based on this understanding, and to act according to our judgment. Moral agency requires free will and implies moral responsibility, as the ability to make and act upon moral judgments requires volitional control over our decision-making and action. We generally regard moral agents as responsible for their actions because the source of action is “internal” to themselves (i.e., in their will), and/or because they endorse actions as their own. Moral agency also requires epistemic agency, for a person must have some degree of control over the epistemic conditions of their experience in order to be able to understand right and wrong and to make appropriate judgments based on that understanding. Epistemic agency involves the capacities to participate in epistemic practices such as making claims, giving reasons, asking questions, analyzing theories, synthesizing disparate ideas and information, and revising beliefs based on evidence.46 The activities encompassed by the terms “moral agency” and “epistemic agency” are so critical to any activity we do as humans that it is easy to see why there is a long tradition of regarding agency as characteristic of being human. Mental illness can cause a range of mental impairments that affect epistemic and moral agency. Psychotic disorders and dissociative experiences change the way a person experiences reality and impair a person’s ability to connect to the world in the right way; cognitive disorders in general impair a person’s ability to maintain true beliefs and use reason correctly. Mood and anxiety disorders can overwhelm a person’s emotional response to the extent that it overruns rational deliberation, making action more a product of passion than of reason. Volitional disorders such as addiction or ocd can diminish the ability to act from rationally willed choice, as they limit the space of reasons from which a person chooses, making certain choices seem disproportionately compelling and discounting other choices unwarrantedly. Mental disorders that impair a person’s connection to reality or their ability to

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reason can cause problems for epistemic agency most directly. Mental disorders that impair the ability for rational deliberation grounded in reality, freely willed choice, or the ability to act on our free and rational choice are threats to moral agency and responsibility. Through the various mental impairments that result, mental illness diminishes moral agency and, in so doing, dehumanizes or at least threatens to dehumanize us. Mental illness makes us ontologically vulnerable by disrupting our conception of ourselves as human beings. Jonathan Lear describes ontological vulnerability as vulnerability to ontological loss, or vulnerability to conditions that threaten our identity as human beings or as members of certain social groups. As finite creatures that “reach out” to the world, our lives are filled with continual risk of various kinds of losses.47 What it is to be human is to find ways that navigate those potential losses – to find ways of living lives of value and meaning despite the uncertainty and imperfection that is inherent to a human life. One way we are ontologically vulnerable, which Lear explores in depth in his book Radical Hope, is that we risk losing the meaning given by our concepts and conceptual frameworks. Another way, which is my concern here, is that we risk losing aspects of epistemic and moral agency. The loss of meaning threatens our identity as members of a social group, while the loss of agency threatens our identity as human beings. This loss of agency underlies many of our stereotypes about mental illness, and our fear of this loss undergirds stigma. Consider the stereotypes described above. The crazy person in the asylum appears to us a beast and the mad shooter appears a monster as their mental illness takes over their mind and self. The homeless person muttering to themselves appears subhuman, little more than an animal. The celebrity mess-up has reneged on their responsibility to live a decent human life and has become the cause of their own descent, a lesser human being. The mad genius has a supernatural spark that can illuminate or explode. In all of these stereotypes, there is a loss of humanity: mental illness turns the person into a beast, a monster, an animal, a mess, an object, maybe something divine, but definitely something less than or other than human. Because being alive as humans carries inherent risk to loss, we cannot eliminate our ontological vulnerability. We can, however, assess the sources of various kinds of risks and mitigate against the risks we have some control over. The more that we protect ourselves from the risks that threaten our identity as humans – and the more resources

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we find to navigate those risks and transcend the limitations they impose – the more that we can resist forces of dehumanization and even work to humanize vulnerable people. In his analysis of Indigenous Crow identity, Lear focuses on the significance of radical hope in enabling people to transcend the limitations caused by changes in conceptual frameworks, so that these changes lead not to loss but rather to transformations of meaning. Radical hope has the capacity to humanize us when we are under threat of dehumanization. In the present project, I want to examine ways that we can protect each other from the risks that mental illness pose in diminishing our agency and consequently threatening our identity as humans. In changing the ways that we interact with people who have mental illness, and in providing resources, support, and opportunities that enable rather than disable, we can humanize people with mental illness despite the ontological threats that mental illness symptoms themselves pose. Our focus in trying to humanize people who have mental illness must be to consider the social conditions that enable them to function and thrive rather than simply to consider individualistic solutions of effective treatment. Since medical and psychological treatment of mental illness is not the focus of this book, I do not explore the effectiveness of these kinds of treatment. I am convinced, however, that for at least some people mental illness is an existential condition that persists despite the most effective treatment possible. Symptoms of mental illness can be managed, and people can find ways of functioning despite their illness, but I see no evidence that mental illness can be cured. This is in part because, even if we address the disease aspect of the condition (the underlying biological substrate, such as problems with neurochemical transmission), the experience of having had the disease impacts who a person is by affecting how they see and respond to the world, to other people, and to themselves; and how others see and respond to them. Because of its impact on mental processes and the mind, mental illness affects psychological development, personal identity, and a person’s way of being in the world in unique ways. Eliminating the disease would not eliminate the process by which a person’s character and identity have been formed; no matter how much a person’s symptoms can be controlled, the agency and identity of a person who has mental illness have been shaped by that illness experience. For this reason, we should regard mental illness, at least for some people, as a persistent and formative experience. My concern in this book is to

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consider the agency, needs, and social experience of people who have, and have had, persistent and formative mental illness experience. An important social aim, and one of the primary aims in this book, is to determine what social conditions will enable people with mental illness to function better in society and to live lives of meaning and value. Philosophers typically assess the moral agency of people with mental illness in terms of desert and blame as a way to test the limits of agency and responsibility. My approach here is not to figure out how to assign responsibility to people with mental illness but rather how to enhance their agency. In our attempts to humanize people with mental illness, we may not be able to do anything about the direct effects of mental illness. We can, however, mitigate against these effects in a variety of ways, especially in our interpersonal interactions with people who have mental illness. More significantly, eliminating stigma and treating people with mental illness as members of our moral and epistemic communities will go a long way toward humanizing them. In the next sections I discuss ways in which stigma dehumanizes people by exploring some primary effects of stigma: the loss of epistemic credibility, diminished moral agency, and social isolation. Even though I discuss these effects separately, they are inextricably linked. First, let’s consider the way stigma dehumanizes people by reducing their credibility, which delegitimizes their participation in epistemic and moral practices and diminishes their authority as epistemic and moral agents.

E f f e c t s o f Sti gma: L o s s o f E p is t e m ic Credi bi li ty Stigma toward a specific group of people can lead to credibility deficits in those people, causing harms that include epistemic injustice, unfair and burdensome expectations, and social exclusion. Epistemic discrediting based on stigma is damaging on many levels, and the damage extends beyond the person who is discredited to include the epistemic community, which loses the knowledge and perspective that the person would have been able to provide. Epistemic discrediting based on stigma constitutes testimonial or other epistemic injustice. According to Miranda Fricker, testimonial injustice occurs when a person’s testimony is not considered credible due to stereotypes based on an arbitrary feature of their identity like

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race or gender.48 People who endorse a stereotype that undermines the credibility of those who share a certain trait will regard a person who has that trait as having diminished epistemic credibility. Discrediting a person’s ability to participate fully in epistemic activities based on stereotypes typically involves counting that person’s contribution as less relevant than the contributions made by others. In turn, being treated as having less epistemic credibility can cause a person who has the stigmatized trait to internalize that deficiency, where they regard themselves as less credible and as a result refrain from participating in epistemic practices they would otherwise participate in. Thus, this discrediting frequently undermines the person’s confidence and can lead them to willingly refrain from participating – that is, to silence their own voice.49 Sometimes there is a justifiable reason to discredit a person’s contribution to epistemic discourse, such as when there is evidence of relevant rational impairment, delusion, or manipulation. The homeless person muttering to themselves may be mistaken that the fbi is after them, and the mad genius may not have solved all the world’s problems. What distinguishes mental illness from many other stigmatized traits is that it directly impairs a person’s agency, independently of the impairments to agency caused by stigma. In other words, the harm of many stigmatized traits is due solely to the effects of stigma, as there is nothing intrinsically harmful about stigmatized traits such as gender or race. Mental illness, on the other hand, is intrinsically harmful in that it interferes with psychological and sometimes physiological functioning, and in so doing, it impairs characteristically human features of consciousness, rationality, and free will that are necessary components of epistemic and moral agency. Many symptoms of mental illness create cognitive, perceptual, rational, affective, volitional, behavioural, communicative, and social impairments that can hinder a person’s ability to participate meaningfully in epistemic practices and to make productive contributions to epistemic discourse. Symptoms of mental illness that cause epistemic impairments include poverty of thought, grandiose ideas, disorganized thinking, a privatization of subjective experience that makes it unshareable with others, an idiosyncratic use of “logic” that makes no sense to others, deficiencies in comprehension of others’ ideas, hallucinations or paranoia (inaccurate perception), delusions (false beliefs or false understandings of the world), lack of self-awareness, lack of awareness of others and of social norms (typically resulting

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in poor social skills). These impairments to epistemic agency also impact a person’s moral decision-making. Because mental illness can result in epistemic impairments due directly to the illness, it can seem justifiable to discredit or at least be cautious in granting epistemic credibility to a person with mental illness, especially when there is evidence of actual impairment. Even when there is evidence of mental impairment, however, epistemic injustice is still a danger. A person interacting with someone who has mental illness may have justifiable reason to believe some aspect of the person’s epistemic agency is impaired, yet overgeneralize or otherwise form a false or misleading judgment about the scope and severity of the impairment. Making falsely broad assumptions about impairment is a typical element of mental illness stigma; in holding negative stereotypes about mental illness, a person magnifies and misapplies the trait they fear and feel disgusted by. While mental illness can indeed cause specific impairments in reasoning, therefore, someone who has stigma against mental illness can easily make falsely broad assumptions about the nature and scope of impairment. Mental impairments are usually not global; typically they are specific to a given moment, they regard a specific content, and/or they involve only a specific mental process. For example, a person with anorexia may be completely irrational regarding food and weight but be rational on all other topics; a person with schizophrenia or bipolar disorder may experience delusions of hearing messages emanating from objects yet have normal perception and reasoning ability in contexts and at times where such delusions do not arise. Overgeneralizing or misunderstanding the nature and scope of impairment can result in epistemic injustice when the discrediting that occurs as a result of these judgments is unfair and unjustifiable, particularly when it occurs in conjunction with stigma. The motivation for not taking due care in specifying the scope and severity of mental impairment may be related to the psychological need for people to separate themselves from those whose moral and epistemic agency are compromised in order to preserve their own ontological and social status. Linda Martín Alcoff notes that testimonial injustice and other forms of epistemic injustice are motivated not only by people’s “faulty regard toward others” but also by “their overarching regard for themselves and their social position,” whereby they can maintain the illusion that their social, career, and personal success is purely meritorious.50 This is analogous to Patrick W.

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Corrigan’s and Petra Kleinlein’s claim that people maintain certain stigmas around mental illness – namely that it arises as a result of not taking care of oneself, as a result of moral weakness or character flaw – in order to support their belief that their own success is a product of their own action, with the implication that the development of mental illness is in a person’s control.51 When we discredit those who have mental impairments, we separate ourselves from the person being discredited, creating a hierarchy of social status and privilege that reproduces the hierarchy of epistemic privilege. This social hierarchy permits the belief that people who have mental impairments deserve to be epistemically discredited and excluded from practices of knowledge and meaning-making as well as from social interaction. In particular, the act of discrediting allows the person doing the discrediting to regard themselves as a fully rational and autonomous agent in contradistinction with the person being discredited. This need to separate ourselves from others as a way to affirm our own status is a way of preserving not only our social status but also our ontological status. A failure to specify the scope and severity of mental illness occurs not only in the presence of stigma but also in the presence of benign or well-intentioned attitudes and can result in other epistemic harms besides the epistemic injustice described here. While stigma can lead to unjust epistemic discrediting, other problematic attitudes toward mental illness can lead to different unfair treatment of a person as an epistemic agent. Instead of responding with stigmatizing attitudes, people interacting with someone who has mental illness may downplay the person’s mental impairment due to ignorance of mental illness, beliefs that romanticize mental illness, or beliefs about the person which reject the possibility that they have a mental illness impairment. In these cases, people interacting with someone who has mental illness diminish the impairment in false or problematic ways by failing to acknowledge or address it sufficiently. Ignoring or explaining away the impairment trivializes or minimizes it, making it seem unimportant and unworthy of addressing. If people fail to address the impairment, this can lead the person who has mental illness to believe others do not want to acknowledge the impairment and so believe they need to hide it; this probably also generates a lot of shame. The person may feel the burden of having to perform optimally while hiding their significant challenges as best as they can. Regardless of whether stereotypes and beliefs about mental illness exaggerate or trivialize its impairments, holding such beliefs without

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accounting for the nuance and complexity of individual experience can lead to a variety of harms. Overemphasizing impairments can lead to not taking seriously a person’s epistemic contributions through ignoring, discounting, patronizing, disparaging, speaking over, or speaking for them. At the same time, stereotypes that trivialize mental illness and downplay its mental impairments can lead to a failure to recognize genuine limitations and impairments and consequently a failure to accommodate or mitigate for them. It can result in unreasonably high expectations for how a person can contribute epistemically and a greater (and unfair) burden of responsibility that they might experience as they try to meet these unreasonably high expectations. Avoiding the harms that result from stigma, ignorance, and other beliefs requires moving beyond generalizations and seeking to understand individuals in all their particularity. The knowledge that a person has some potentially impairing trait such as mental illness may provide a justifiable reason for regarding a person as possessing insufficient epistemic agency to engage meaningfully in epistemic activity, but whether such knowledge counts as a reason to discredit depends on the specifics of the impairment and our ability to know those specifics. Typically we believe we have more information that is sufficient for judgment than we actually do. Our lack of understanding about specific mental illnesses easily leads us to overgeneralize about the nature and severity of the impairment they cause – or, contrarily, to diminish falsely the impairment by failing to acknowledge or address it sufficiently. In chapter 4 I discuss the importance of epistemic humility and openness to nuance and complexity in our understanding, and suggest more inclusive ways of interacting with people who have mental illness, which give them more opportunities to exercise agency given the constraints of their illness. Even when there is justification for discrediting a person’s epistemic contributions, such discrediting should never take the form of shunning the person or of blanket exclusion from epistemic discourse and moral interaction.

E f f e c t s o f Sti gma: C o n s t r a in t s o n Agency People who have mental illness face both internal and external constraints on agency. In chapter 2, I explore how mental impairments that result from mental illness symptoms create internal constraints on agency. In addition, stigma creates external constraints on agency

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by leading to prejudice and discrimination, which decrease opportunities and resources available to people with mental illness. This diminishment of opportunities and resources creates constraints on agency by decreasing the options for action available to a person and by narrowing the scope of reasons from which a person makes choices. Prejudice and discrimination also lead to abusive behaviour and oppressive and exploitative practices that further diminish agency and dehumanize people. Stigma induces many behaviours and practices that create external constraints on agency. Part of the way that stigma diminishes agency is through prejudicial attitudes and behaviours that cause social isolation and impede people’s ability to engage in moral and epistemic practices. Stigma nearly always involves an emotional reaction to the stigmatized trait, such as feeling fear or disgust, and such affective response is necessarily aversive, causing people to avoid those who have the stigmatized trait. This avoidance occurs in interpersonal interactions – such as crossing the street to avoid having to interact with a homeless-looking person talking to themselves, or failing to make eye contact with a customer or colleague who is acting bizarrely – as well as in more regularized patterns of behaviour, institutional practice, and discriminatory policy. When a group of people are systematically avoided, they are prevented from having the kinds of interactions that allow them to participate in the epistemic and moral practices that enable the development and exercise of agency. In other words, prejudice restricts people’s opportunities to become, and to be, epistemic and moral agents. At a cognitive level, prejudice involves endorsing negative stereotypes. When people endorse a negative stereotype, the stigmatized trait is seen as the central feature of the person who has the trait, effectively erasing the identity of the particular individual. The person is reduced to the negative stereotype and is denied opportunities to express themselves and to act in ways that go beyond the stereotype. In the context of mental illness, people reduced to a negative stereotype are regarded as simply irrational, insane, crazy, mad, even monstrous (when they commit heinous acts) – or, contrarily, deviant, devious, calculating, or taking advantage. Prejudice, which literally means “pre-judging,” denies people the ability to participate in meaningful action and discourse because, in being pre-judged, their action and discourse are rejected as having any value beyond the confines of the stereotype. If a person is simply deemed crazy, their actions can be dismissed; if a person is considered simply devious, their actions will

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be interpreted as dishonest or dishonourable. Prejudice works to diminish moral agency by preventing people with mental illness and other stigmatized traits from having several epistemic goods. These include having the same opportunities for moral interaction that other people have; having their actions interpreted in charitable, nuanced, and meaningful ways; having their actions recognized as intelligible within, and responsive to, context; and being taken seriously in how they are responded to. In addition to the more abstract ways that stigma diminishes agency, stigma also induces discrimination, which constrains agency in more concrete ways. Discrimination involves behaviours and practices that treat a group of people differently from others based on their shared trait, on account of prejudicial attitudes and beliefs. People with mental illness are vulnerable to prejudice and discrimination in all life domains. One significant area where people are subject to prejudice and discrimination is employment. People who have mental illness are much more likely to be unemployed than the general population.52 Studies demonstrate that employers hold prejudices against people with mental illness and are more likely to deny a job to an applicant with known mental illness or to demote or fire an employee who discloses mental illness. People who have mental illness often live in fear that their co-workers or supervisor will learn of their illness and thus go to great lengths to hide their illness, causing significant stress and problems with developing valuable work relationships. People who take a leave of absence related to their illness often return without support, yet have to face questions, assumptions, even mockery and derision. After a leave due to illness, employers may give a person easier tasks with less responsibility; even if this is for their own benefit (to reduce stress), a person may feel underutilized, underappreciated, and even humiliated.53 Similarly, people with mental illness face barriers in education due to their illness. Students who have mental illness may find it more difficult to get accommodation than students with physical disabilities or learning disabilities, as their needs tend not to be as standard as extended testing time or supplementary auditory materials, and are sometimes idiosyncratic based on particular needs. Teachers are not always sympathetic, especially when a student’s mental illness causes behavioural issues that impact the classroom or when teachers believe students should be able to take more responsibility for their work

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than they do. In addition, policies that prevent students from returning to school after receiving a mental disorder diagnosis, after taking a medical leave of absence, or after a suicide attempt create different hurdles than those experienced by students who take medical leave for physical health reasons. These policies are intended both to ensure that students have sufficient psychological capability to succeed in school when they return and to limit a university’s liability. However well-intended, they have the unintended consequence of students with mental illness feeling that the university deems them unworthy to be in school as a result of their illness.54 This is one of many areas where good intentions aimed at protecting the safety and well-being of people with mental illness can lead to effects that are experienced as stigmatizing. Because the differential treatment inherent to a policy like this is justifiable, it is not truly discrimination, but it can nevertheless feel discriminatory to those who are subject to it. People with mental illness are more likely to lack stable, safe housing. In part, this is a consequence of the poverty that results from lack of employment or underemployment as well as the special economic vulnerability of people with mental illness to financial catastrophe, such as expensive healthcare bills. In part, this is also a consequence of housing discrimination. Studies have demonstrated that landlords are less likely to rent to people with known mental illness and more likely to evict or not renew contracts with people who disclose mental illness.55 People with severe mental illness who in the past were institutionalized in state hospitals are now entrusted to community care, which varies dramatically state to state in terms of quality and access and is generally underfunded.56 The majority of people who in the past would have been institutionalized are now either homeless or incarcerated (or, alternately, both). Nearly a third of the population of those who are chronically homeless and a fifth of the total population of homeless have serious mental illness.57 When community care facilities or facilities for homeless individuals are proposed, they are frequently met with hostility from would-be neighbours, who fear living near these populations. Would-be neighbours voice concerns about safety and property values in public forums like city council meetings, newspaper editorials, and organized protests. 58 This “­n i m b yism” (not in my backyard attitude) stereotypes, demeans, and ostracizes people with mental illness. People with mental illness face substantial prejudice and discrimination in the criminal justice system. They have a relatively high

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chance of getting shot at or killed by police who do not take the time to ascertain whether they are mentally ill, or who simply do not know how to deal with people who are mentally ill and so act out of fear and stigma.59 They also have a high rate of incarceration. According to a Stanford Law School study, people who have mental illness “account for more than 350,000 inmates in US prisons, more than ten times those in psychiatric hospitals.”60 According to the US Bureau of Justice Statistics, 45 per cent of federal prison inmates have serious mental illness, as do 56 per cent of state prison inmates and 64 per cent of jail inmates.61 These figures are astounding. Police, lawyers, judges, and other professionals within the criminal justice system tend to treat people with mental illness harshly, with disgust, or condescendingly, with pity. Either they believe people “deserve” this treatment (and are responsible for their behaviour) or they believe people are less than human (and are not responsible for their behaviour) – or sometimes, paradoxically, they believe both. People who work in prisons – as well as fellow prisoners – tend to have similar paradoxical attitudes, believing that people with mental illness both “deserve” brute punishment and are less than human, and abuse by prison guards and by fellow inmates (while prison guards turn a blind eye) is rampant.62 People who have mental illness have great difficulty accessing healthcare. They face barriers in receiving health insurance, especially in markets where quality health insurance is primarily an employee benefit rather than a human right, since so many people with serious mental illness are unemployed or underemployed. When individuals do have health insurance, the insurance carrier determines what services are covered. Insurance coverage typically emphasizes drug therapy because it is cheaper than talk therapy, even though many people with mental illnesses of all kinds find the latter extremely helpful, and insurance often does not cover hospital stays or other expensive treatment, except in extraordinary circumstances.63 In addition, people with mental illness have many social impediments to accessing healthcare, including ambivalence about the value of treatment, not wanting to be identified as a psychiatric patient, wanting to avoid perceived bias on the part of medical professionals, and dissatisfaction with care already received.64 While we might think that mental health professionals would be more sympathetic and understanding about mental illness than the average person, even psychiatrists, physicians, and other medical

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professionals are guilty of holding prejudices against people with mental illness generally or against certain conditions like schizophrenia more specifically. This can lead psychiatrists and other medical professionals to ignore the complaints of people with mental illness, to downplay their symptoms, to think that people with mental illness do not feel the same things that other people feel (for example, pain or extreme temperatures), to ridicule people whose behaviour or diagnosis makes them appear less than human, or to blame people with mental illness for their own problems.65 People with eating disorders and people who have attempted suicide are often the most stigmatized by medical professionals, when they believe these individuals have control over their condition and that their condition stems from acts of will for which they are therefore responsible.66 Besides causing external constraints on action, stigma also creates internal constraints that can be just as damaging. People with mental illness frequently internalize stigma (what is sometimes called “selfstigma”), which leads to reduced self-esteem, loss of hope, diminished empowerment, and reduced self-efficacy.67 In practical terms, this means people who internalize stigma against mental illness are less likely to seek out medical treatment and to generally take care of their basic needs.68 This is because when people think less of themselves they typically feel powerless over their situation and feel less motivated to try to change it. Studies of public health campaigns that try to reduce unhealthy behaviours through shaming demonstrate that the internalization of stigma impedes behavioural change.69 Internalized stigma causes people to feel more passive, as if their experience were determined by forces outside their control (both the mental illness itself and people’s reactions to it); as a result, they become more passive. People who have mental illness are subject both to the internal constraints caused directly by mental illness symptoms and to the external constraints caused by prejudicial and discriminatory behaviours, practices, and policies. With respect to the latter, people with mental illness have reduced opportunities and resources because of prejudicial and discriminatory actions in the realms of employment, education, housing, and healthcare access. People with mental illness are also vulnerable to abusive, oppressive, and exploitative treatment in hospitals, prisons, and other institutions, and by police, lawyers, judges, prison guards, medical professionals, and others in positions of power. Stigma circumscribes the lives of those stigmatized in extraordinarily harmful and unjust ways.

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E f f e c t s o f S t ig m a : Soci al I solati on In compromising epistemic credibility and in diminishing agency, stigma creates social isolation, due both to social exclusion by others and to self-imposed withdrawal and avoidance behaviours. The prejudicial and discriminatory actions by others, as described above, exclude people with mental illness not only from specific opportunities and resources available to others but also from the more general ability to participate in normal areas of social functioning such as work, education, family responsibilities, the development and maintenance of friendships, and civic life. Many symptoms of mental illness occupy a person’s attention to such a degree that they create selfabsorption, and many symptoms make social interaction too difficult or painful; such experiences lead to social withdrawal. When people with mental illness believe they are stigmatized by others, they may avoid others so as to not provoke and consequently have to deal with stigma. The internalization of stigma, moreover, creates intense shame that causes people with mental illness to withdraw further. Many factors contribute to the social isolation of people with mental illness, and stigma causes or exacerbates all of them. People who have mental illness typically struggle with maintaining normal relationships. While friends and family members can be extremely supportive, they can also be stigmatizing, and when the stigma comes from someone close, such as a parent, this is especially damaging. After a person has had an episode of mental illness that includes aberrant behaviour, friends may feel uncomfortable and may wonder who the “real” person is and whether the person will ever be as they once were. When a person has behaved in ways that are hurtful to others, dealing with the aftermath can be difficult, as the person must atone for behaviour they do not necessarily identify with or even remember. Friends and family can come to distrust a person whose behaviour becomes erratic and unpredictable. It is not unusual for people with mental illness to lose friends and become estranged from family members due to irrational, unreliable, and disturbing behaviour. People who have severe mental illness are less likely to marry, and, when they are already married, the behaviour that justifies diagnosis may be distressing enough for their spouse to leave them.70 People who have mental illness are typically regarded as less fit parents and more likely to lose child custody cases upon divorce.71 People with severe mental illness are more likely to be single or divorced, to

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not be primary caregivers even when they are parents, and to lose friends and be estranged from family.72 The longer a person has been socially isolated, of course, the harder it becomes for them to develop new relationships. The less practice a person has with social interaction, the harder it will be for them to interact in ways that others will respond to meaningfully. People who have been hospitalized or who have received other intense mental health treatment may get to a point where all the people they interact with are mental health professionals or other people connected to their treatment. People with mental illness may find it too difficult to try to interact with people who do not know about or understand their illness, and they may (understandably) not want to share information about their illness with people they do not know. In summarizing some of the relevant research, Graham Thornicroft notes that “people with more severe forms of mental illness have smaller social networks than others, have relatively more family members than friends in their social circle, and have relationships that are more dependent rather than interdependent.”73 Social isolation breeds social isolation. Stigma leads people to seek social distance from those whom they stigmatize. When people stigmatize mental illness, they try to avoid situations that would require them to interact with those who are mentally ill. People who associate mental illness with psychosis, in particular, “are less willing to live near, socialize, or work with people with psychiatric disorders, to have a group home for the mentally ill nearby, or to have someone with mental illness marry into their family.”74 Social avoidance leads to segregation. When people avoid socializing with, working with, living near, or simply walking near people who have or appear to have mental illness, those with mental illness have very little interaction with people who do not have mental illness and who are not associated with mental healthcare treatment. This segregation is also self-reinforcing. The ways that people with mental illness continue to be socially segregated from society are astounding. Historically, people with mental illness were locked up in asylums and tortured and abused, sometimes in the name of treatment,75 and sometimes in the service of power and domination over the vulnerable. In the early twentieth century, warehousing in asylums shifted to “care” in state hospitals, supposedly for the sake of more humane and effective treatment; in actuality, for most people it was simply a shift in type of housing, not in type of care. In the 1960s and 1970s, the deinstitutionalization

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movement took hold, and people with severe mental illness were entrusted to community care centres funded by states. Because such funding was unreliable and often poor, many people fell through the cracks and were never given care by their community. For many people, especially those estranged from their families and/or unable to access the workforce, this resulted in homelessness. It is difficult for a person to be a law-abiding citizen when they are homeless, especially when they also struggle with connecting to reality in an appropriate way, and so many people who have mental illness end up committing crimes. These crimes could be anything from sleeping in the wrong area, to begging in places where it is prohibited, to urinating in public, to defending themselves aggressively against people whom they believe to be harming them, to possessing or selling drugs to get by. It is nearly unbelievable that people with mental illness comprise one-third of the chronic homeless and more than half of all inmates.76 But jails and the streets have replaced state hospitals as the places where people with severe mental illness go. We exclude people with severe mental illness from the most basic human interactions, but we also subjugate these people to structural constraints that systematically deny them their humanity. Extreme social exclusion even results in what is called social death, which occurs when people who share a trait like mental illness are excluded from society on account of that trait to such an extent that it is as if they were dead. Society does not recognize them as people; they may be represented as stereotypes only, but not as individuals; they have their rights removed or disrespected; they are forbidden access to resources and opportunities that others have; they are not recognized as members of any relevant community. They are denied any epistemic credibility, and, because their actions are not taken up by others, any agency. Lisa Guenther describes social death in the following way: “Social death is the effect of a (social) practice in which a person or group of people is excluded, dominated, or humiliated to the point of becoming dead to the rest of society. Although such people are physically alive, their lives no longer bear a social meaning; they no longer count as lives that matter. The social dead may speak, act, compose symphonies, or find a cure for cancer, but their words and deeds remain of no account.”77 Social death does not result from any single action; it is the result of systemic exclusion and interference over time. Guenther says, “It takes a whole network of interconnected obligations, both in the present

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and extending into the past and future, to create and sustain social personhood, and it takes a whole network of exclusions, interruptions, and violations, not only against individuals but against the social and temporal horizons of their lives, to destroy that personhood … To be socially dead is to be deprived of the network of social relations, particularly kinship relations, that would otherwise support, protect, and give meaning to one’s precarious life as an individual.”78 It would be an exaggeration to say that all people with mental illness, even severe mental illness, experience social death. However, for millennia people with mental illness, especially severe mental illness, have, en masse, had their personhoods destroyed in multitudinous ways, enough so that we can say that a great many people who have mental illness have not had their lives count as lives that matter. People with mental illness may not be completely dead to the rest of society, but many of them are close. Social exclusion creates a negative feedback loop, whereby people shunned and avoided on account of their mental illness react in ways that increase the social exclusion that shunning and avoidance also cause. When people are aware of being stigmatized, they often try to hide the stigmatized trait or – when they cannot – they try to hide themselves through social withdrawal to avoid being visible to others. When people are self-aware enough to know that others shun and avoid them, they often retreat to avoid having to experience that social rejection. This social withdrawal compounds their isolation. Even when people are not that self-aware, they often react – consciously or unconsciously – in ways that exacerbate their symptoms, so that their behaviour becomes even stranger, causing other people to avoid them to an even greater degree. For example, a person with depression who perceives themselves as rejected by others may try to avoid others in order to avert potential rejection; a person with an eating disorder or drug addiction may binge/purge or ingest their drug in order to avoid feeling shame in being shunned (or to punish themselves pre-emptively before others judge and punish them).79 A delusional person may misinterpret others’ attempts at distancing themselves and try to engage in ways that disrespect personal boundaries; a person already “lost in their head” may become further self-absorbed, perhaps losing interest in interacting with others. These responses only magnify how strange they appear to others.

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While stigma leads to social isolation and a variety of ills that result from social isolation, addressing social isolation directly helps us address stigma. The best way to reduce stigma is to increase interpersonal contact with people who have mental illness. Studies demonstrate that interpersonal contact with people who have mental illness is more effective at decreasing stigma than education about mental illness.80 When we interact with someone, we acknowledge their humanity, and we more easily see them as particular individuals. This makes it harder to reduce their identity to their illness or to see them as less than or other than human. Social isolation is a major problem for people with mental illness not only because of the loneliness and alienation it brings but also because it provides further constraints on agency by making participation nearly impossible in epistemic and moral practices with others. Social isolation thus further dehumanizes people who are already deeply vulnerable to dehumanization. In chapter 3, I explain the inherently social nature of epistemic and moral practices, where meaningful participation requires recognition by others as a member of the relevant epistemic and moral communities. The legitimacy and meaningfulness of a person’s action or speech can only be judged by other people who engage in the same practices and who, through that engagement, set norms about that practice and assess the contributions of others by those norms. In order to be a member of an epistemic or moral community, a person has to be recognized as such by other members in the community. Social isolation prevents the interactions that enable a person to exercise agency by participating in moral and epistemic practices, by having the person’s contributions recognized as good or meaningful, by having a say in the construction of epistemic or moral norms, or by having the opportunity to assess others’ contributions or even their own contributions in a meaningful way. A person who only interacts with mental healthcare professionals, for example, is frequently not recognized as having something legitimate to say about many things, even things concerning their own life, due to the power dynamic in these relationships, which renders the person more as an object than as an agent. The inability to have social interactions with others prevents the exercise of agency but also, since agency is constituted through ongoing actions, the development of agency. People who are socially isolated, as many who have mental illness are,

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therefore have severe constraints on their agency. Social isolation is yet another way that mental illness symptoms and mental illness stigma dehumanize people.

C o n c l u s ion Because mental illness threatens the conditions of agency by impairing consciousness, rationality, and free will, and because these conditions are characteristic of being human, mental illness makes us ontologically vulnerable to the loss of our humanity and our sense of ourselves as selves. The stigma that people hold against mental illness is quite understandable, as we are justified in fearing such a profound loss. Yet stigma exacerbates the problems that people with mental illness face, worsening their mental illness symptoms and increasing the constraints on agency that they already experience. With the loss of epistemic credibility that accompanies stigma, the contributions to knowledge and meaning-making that people with mental illness make are discounted; their views are dismissed; they are regarded as having nothing valuable to offer. They are not recognized as epistemic agents and are consequently excluded from epistemic practices. While people with mental illness already experience internal constraints on agency due to the symptoms that impair their reasoning, volition, and other mental processes, they are subject to external constraints as well due to the prejudice and discrimination accompanying stigma. Prejudicial and discriminatory actions and policies prevent people with mental illness from having the same opportunities and resources that others do, and they permit injustices like oppression, exploitation, and systematic abuse. Stigma and prejudice lead to social behaviours that create social distancing, leading to social isolation. Prejudicial and discriminatory actions and policies weaken any potential social capital that people with mental illness could have – such as social networks, education and employment, resources like housing and adequate healthcare – and reinforce the stigma that underlies the prejudice and discrimination. People with severe mental illness are likely to experience significant social isolation on account of stigma, and this not only causes loneliness but also creates further constraints on agency and, in circular fashion, reinforces the stigma that underlies a major aspect of the social isolation. Mental illness stigma dehumanizes people who have mental illness through several compounding processes.

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Moreover, mental illness stigma dehumanizes all of us. Insofar as we and the people we care about are all vulnerable to mental illness, mental illness stigma threatens the humanity of every one of us. We are all fragile and vulnerable to the loss of features that are deeply important to our identity as humans and our sense of ourselves as selves. We do not have to actually experience the loss of humanity to be dehumanized by the threat of this loss. As Jonathan Lear reminds us, we are all ontologically vulnerable to the loss of our humanity by virtue of being human – finite, imperfect, yet constantly reaching out with desires, aims, and purposes. Specific conditions that subject us to this ontological vulnerability are potentially dehumanizing. When conditions that subject individuals to this ontological vulnerability are within our control and preventable, yet we fail to do anything to change them, we commit injustice. Mental illness stigma dehumanizes all of us because it subjects us all to ontological vulnerability that is unnecessary, within our control, and (with effort) preventable. In the rest of this book, I further develop these arguments about how mental illness symptoms and stigma work to dehumanize people who have mental illness, and I argue that although we may not be able to do much about the symptoms that people experience, there is a lot we can do to address dehumanization by confronting stigma, and to humanize people by increasing their opportunities to develop and exercise their epistemic and moral agency. I develop specific proposals for how we should interact with people who have mental illness that decrease stigma and enhance agency. In mitigating against our ontological vulnerability to mental illness, and in humanizing people who have mental illness, the goal is not only to avoid stigmatizing people with mental illness in our interactions and social practices but also, more strongly, to welcome them as members of our communities, as one of us.

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P art O n e Constraints on Agency People who have mental illness experience several constraints on their agency, primarily through social isolation. Symptoms of mental illness create direct constraints on agency by leading to such mental impairments as rational, cognitive, affective, and volitional. These impairments impede a person’s ability to participate in epistemic and moral practices, such as giving reasons that others find intelligible and making choices based on reasonable options. Stigma around mental illness also creates indirect constraints on agency by leading to social exclusion that prevents people from having opportunities to engage in the social practices that allow them to exercise their agency. In a negative feedback loop, symptoms and stigma reinforce the social isolation caused by each. Some mental illness symptoms lead to social isolation by causing social withdrawal and self-absorption; the social exclusion caused by stigma exacerbates this isolation, and vice versa. People with mental illness typically have diminished agency stemming from multiple sources. Chapter 2 explains some of the mental impairments that arise from mental illness symptoms and demonstrates the ways that they impair moral reasoning, leading to diminished agency. Cognitive impairments can shift moral boundaries so that right and wrong no longer make sense; impairments to emotional capacities can unduly narrow or widen the range of plausible reasons for action and the scope of options available to a person; the experience of mental ­illness can create a context for valuation that differs from the norm. Understanding the ways that these mental impairments impact moral reasoning can aid us in interacting with people

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who have mental illness in more intentional and productive ways that help increase their agency. This also helps us respond productively when people act in ways that are harmful to ­themselves or others. Chapter 3 explores how mental illness symptoms and stigma both contribute to social isolation, focusing on the ways that stigma results in social exclusion. The chapter also examines ways that social interaction is crucial for developing and exercising agency, arguing that the social isolation caused by mental illness symptoms and stigma is particularly damaging to the agency of those with mental illness. The transactional nature of reasoning, valuing, and choosing requires that we do these activities in relation to others; we must therefore have the opportunity to interact with others so as to participate in these processes. Understanding the significance of social interaction on agency helps us to decrease stigma around mental illness, increase our social interaction with people who have mental illness, and interact in ways that are more intentional to enhance agency.

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2 Mental Impairments: Direct Constraints on Agency

In t ro du cti on The crazies are coming back. I tell Dr. Fried during our weekly appointment today about my fantasies of committing a mass murder or shooting at Esmor [the community corrections center he was sentenced to for selling art forgeries]. The target of the murders is usually the staff, but most of the time it doesn’t ­matter and I think of killing anyone in the building. These feel a lot more like well-thought-out plans than fantasies. Dr. Fried increases my Risperdal, which seems to alleviate some of the problem.1 I’m coming to understand the impact the manic depression has had on me over the last ten years, informing nearly every poor choice I made, leading me to risk, danger, and trouble.2 In his memoir Electroboy, Andy Behrman recounts his experiences selling counterfeit art while manic. In the throes of manic depression (or bipolar disorder), Behrman made many ethically questionable decisions in his career as a public relations consultant and art dealer, some clearly morally wrong and some at least illegal. Since Behrman made intentional choices to perform these actions, it would appear to the unsympathetic eye that he acted as a sufficiently rational and free agent who was rightfully subject to disapproving reactive attitudes and who should have been held responsible for his actions. To a more sympathetic eye, however, his actions seemed to have been shaped by his mania, making sense and feeling justifiable to him in the clouded vision of manic obsession and impulsivity. Such a perspective does

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not imply that he was not responsible for his actions, but it does suggest that his agency was more complicated, impaired as it was by mania, complicating his responsibility as well. The purpose of this chapter is to explain some of the ways that mental illness symptoms can impair moral reasoning and consequently agency. My hope is that greater understanding of how these impairments operate will lead us to have greater understanding of how the agency of people who have mental illness is complicated and in in some ways compromised. This, in turn, will allow us to respond to people with mental illness with more empathy and efficacy, both humanizing them and helping them have greater agency. For if we can better understand the ways that people’s agency can be compromised, we can more easily figure out how best to respond in order to mitigate against impairments. Philosophers tend to get hung up on the question of how much responsibility a person with mental illness has for their action and assess the limits of agency with the question of responsibility in mind. I am not as interested in assigning responsibility as I am in creating conditions that enhance people’s agency. Effective interaction with people who have mental illness helps create these conditions. In chapter 5, I explore what effective interaction looks like. Here I explain some of the constraints on agency that we should be mindful of. It is important to consider some of the direct constraints on moral agency to show how people with mental illness are already vulnerable to having impaired agency even before they encounter stigma, which then exacerbates these impairments. Moreover, understanding some of the impairments to agency that people with mental illness face helps us be more intentional in our interactions with them. Improving our understanding of how agency is complicated, and in some ways compromised, thus helps us achieve the goal of enhanced agency.

M o r a l A g e ncy Moral agency is the capacity to engage in moral practices, or the capacity to respond appropriately in moral situations. Moral agency requires the capacity to reason well, and it requires free will, free action, and clear understanding. In order to be moral agents, we must be able to act on reasons that are intelligible to others. We must be autonomous and make our own choices rather than being compelled externally, moved purely by instinct, or directed like automatons. We

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must have a relatively accurate understanding of the world and of ourselves so that we can situate ourselves appropriately within it as a subject having consciousness, subjective experience, and self-awareness. We must be able to develop a valuation system, which we can do only in relation to others as part of a community of valuers who together determine what is of value and how best to value it. Impairments to reasoning, perception, emotional regulation, free will and action, therefore, compromise a person’s moral agency internally, while social deficits create external impediments to agency. Mental illness interferes with many of the mental activities and social conditions that are necessary for agency. Mental illness may directly impair reason, volition, affect regulation, and perception in a variety of ways. In some cases, mental illness can interfere with a person’s ability to act on desire appropriately, constraining even the minimal rationality of means-ends reasoning (reasoning about how to achieve one’s desired end). Depression, for example, famously impairs motivation; it can impede a person’s ability to form or rank desires, creating a state of apathy which makes choice and action impossible. Mental illness may interfere with a person’s ability to develop or act on a valuational system in a variety of ways: it can impede the ability to reason in the ways necessary to think about values, the ability to give reasons that are intelligible to others or that have normative weight, and the ability to rank or prioritize values and use them as reasons for choosing one option over another. Delusions involved in psychotic conditions can impact how a person understands the nature of action, the nature of specific reasons, the causal and motivational connections between reason and action, and the causal relationships between action and outcome. Overwhelming or inappropriate emotions involved in mood disorders can cloud a person’s understanding of the relevant context for action, including its causal relation to specific outcomes, and obscure a person’s judgment about what values are worth valuing, or what reasons for action should dominate. Excessively strong desires can make a person act against their better judgment and obfuscate what they value so that they organize their valuational system in such a way as to justify action that goes against their self-interest or their second-order desires. In sum, through various mechanisms, mental illness impairs rational free choice that is grounded in reality and that is recognizable and intelligible to others. Frequently this results in “bad” choices, which hinder flourishing or actively harm the individual and/or others.

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To be clear, people who have mental disorders are not necessarily or always impaired by their symptoms; arguably, a person may experience various symptoms while keeping their cognition, reasoning, and valuing intact. However, people whose mental disorders are severe enough to constitute illness – whose functioning is impeded by their mental illness symptoms in various ways – do experience some relevant mental impairments to some degree at least some of the time. While not all people who have mental disorders are impaired by their disorders, therefore, people who have mental illness as I defined it in the previous chapter experience some degree of mental impairment at least some of the time, which may impact moral agency. Understanding what this impairment looks like helps us understand why people make the choices they do so that we can respond to them more productively. This chapter explores three ways that mental illness can constrain agency, focusing on the way that mental illness interferes with the social conditions necessary for agency. I begin this analysis by outlining the processes involved with valuing and choosing as aspects of agency. What It Is to Make a Choice Gary Watson describes the process of deliberation: In thinking about what to do … I am of course not trying to ­predict my future but determine it; I am trying to determine which of what I take to be my (feasible) options I shall take … The relevant notion of an “option” from this standpoint is roughly this: my options are those courses of actions whose ­realization depends on what I determine to do – on my decision, choice, or intention (as the case may be). To learn that something is not an option, not within my capacity in this sense, is to learn that it does not stand in this relation to my choice.3 Watson explains that when we make a choice among several options, we make this deliberation as if we are viewing our options, and our reasons for action, on a deliberative screen. Options for action that do not make it on the screen are not even under consideration: “The unthinkability of accepting [a] proposal consists in its being ‘out of the question,’ in its being altogether off the deliberative screen. To have ideals and principles is to be committed to not taking certain

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considerations seriously as reasons in certain contexts.”4 Options that are off the deliberative screen may be unknown; they may be rejected. A person can only perform an action that is within the scope of their deliberation. The presence or absence of reasons for action are therefore not only performance conditions, in other words conditions for intention or choice, but also enabling conditions, in other words conditions for the physical possibility of action.5 The set of reasons that are present constitute what Watson calls “the space of reasons”6 from which one acts, while those reasons that are absent are “off the deliberative screen.”7 What constitutes a person’s space of reasons in a particular context of deliberation is central to how they decide to act. It is important to emphasize here the relationship between rationality and volition: the process by which reasons for action become present or absent is central to whether one’s action is free. Impairments in rationality are thus frequently linked to impairments in volition. Since impairments in emotion, perception, or belief affect what reasons are present or absent on one’s deliberative screen, these frequently cause impairments in rationality and volition as well. People can be rational in different ways and to different degrees. Jon Elster gives an account of rational action as action that emerges from the right kinds of relationships between our desires, beliefs, and information.8 Action is minimally rational when it is sensitive to rewards. Most action of people with mental illness is at least minimally rational. Beyond rewards-sensitivity, there are three levels of optimality where action is more robustly rational. Action that is rational must satisfy a person’s desires, given their beliefs. More robustly rational action must satisfy desires based on beliefs that are grounded in the information that is available to a person. Maximally rational action must satisfy desires based on beliefs that are grounded in an optimal amount of information.9 Impairments to reasoning typically involve obstacles to satisfying our desires, to formulating desires based on our beliefs, or to accessing sufficient information to develop accurate beliefs. Elster sums up his account of rationality with a couple of principles: “people do as well as they can,” or at least “as well as they believe they can”; and “people make the most out of what they have.”10 (I return to these principles when I look at moral judgment and empathy in later chapters.) When we frame rational thinking in this way, we are able to be more empathetic to the various decisions people make when they are reasoning through choices, even if we

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disagree with the value of those choices. People do the best they can; how can we fault them for not doing better? How we decide to act depends on what we believe our options are. We can only act on the options available to us, and we can only deliberate based on the reasons that appeal to us. If we believe an option is not possible for us, it will not show up on our deliberative screen even if it is in fact possible for us; in rejecting it as a possibility, we make it impossible by discarding it from the possibilities under consideration.11 Some options and reasons for action may show up on the periphery of the deliberative screen rather than in its centre; such options are regarded as possible, but the reasons counting in favour of them may not appear particularly weighty, or they may seem less consequential. The options in the centre of the deliberative screen are those that have especially compelling reasons for them; perhaps they have the most desirable outcomes, or they bring the most intense pleasure, or they are the easiest and most convenient, or they fit within a larger scheme of motives that support their selection. The more rational we are, the more that we are able to examine the different reasons for different options, evaluate their consequences, assess the costs and benefits of each option, determine whose interests and what kinds of interests are served by the different options, appreciate their broader contexts, and weigh them accordingly. If we are particularly rational, for instance, we will not always choose what is most pleasurable or even what brings about the best consequences because other factors that we value may weigh more heavily. If we are rational, we are able to make appropriate judgments about what constitutes “good” consequences and what fits within our broader self-concept and character, and we will be able to make accurate judgments about the conveniences, challenges, and consequences of particular courses of action. If we are rational, we will be able to do the mental activities involved with choosing well, with logic and accuracy, and based on an accurate understanding of reality. Moral Values and Commitments The relationship between choice and value goes in both directions: through our choices we develop our moral values, and from our moral values we make choices on how to act. In choosing how to act, we learn what is worth valuing: other people’s responses to our actions (such as praise or blame) either reinforce or sanction what we do,

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and this affects how we choose to act in the future. Over time, we develop habits of acting in certain ways in certain situations, and through these habits we develop what philosophers call our moral “character.”12 While some philosophers have claimed that our choice expresses what we value,13 I think it is more accurate to say that our habits of action express what we value. Through our learned behaviour, we develop what Gary Watson calls a “valuational system”: a set of moral values and commitments that set the parameters for how we should act.14 When we have developed a set of moral values, our reasons for action come from our values, and we choose to act based on these values. When we have a solid valuation system, we find certain actions to be undesirable or even “unthinkable” because they conflict with our values. Moral values that are held strongly in this way constitute moral commitments. Watson says, “Statements of normative necessity assert not only an inconsistency between certain courses of action and certain considerations but also express a commitment to certain normative priorities.”15 According to Watson, we develop volitional necessity around choices that seem morally required or morally impermissible based on our actions: we find that we must act in certain ways and we must not act in other ways. To do otherwise would be, in his words, “unthinkable.”16 Doing something that is “unthinkable” would be a deep violation of moral integrity, a violation of who we are as moral selves. Another way to think about this is in terms of courage and shame. Because they internalize the moral ideals of their community, a courageous person finds what is shameful to be morally repulsive and, in Jonathan Lear’s words, “rule[s] it out as impossible.”17 The unthinkability of an action, as Watson says, “consists in its being ‘out of the question,’ in its being altogether off the deliberative screen. To have ideals and principles is to be committed to not taking certain considerations seriously as reasons in certain contexts.”18 We can only perform an action that is within the scope of our deliberative screen – it must be an option that is “on the table,” so to speak. To be committed to not doing certain actions involves intentionally limiting our reasons for action and intentionally removing certain options from the deliberative screen, based on reasoned considerations of what we value. Watson observes, “Judgments of impossibility of this kind are often deliberative starting points rather than conclusions; they indicate the boundaries of the space of reasons in which deliberation takes place. In either case such judgments involve normative

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reflection about the structure of reasons and what is eligible for deliberation [i.e., what is an option for action].”19 When we reflect and choose which reasons to act upon and decide which actions we should take, we rationally and intentionally determine what options are in our deliberative screen. Options that violate our principles are off the screen: “To say a proposal is impossible is to give it a certain status: it means that it is not eligible for consideration.” Watson goes on to say, “This defines a narrower sense of option from that given by the basic concept of what a person can do – only some among the courses of action whose realization depend on the agent’s choice are what we might call deliberative options.”20 Having moral commitments thus narrows our options for acting to include not all of what is logically possible but rather only what is open to deliberation. This narrowing of options that occurs through having moral commitments affirms our moral integrity. Notice that the way that moral commitments circumscribe a person’s options differs from the ways that mental impairments, which artificially narrow the scope of reasoning, circumscribe options. By short-circuiting the reasoning process, impairments like overwhelming emotion, compulsion, volitional disability, and delusion preclude certain options for action and so limit the space of reasons from which we choose to act. When we act out of volitional necessity, on the other hand, we choose to limit our space of reasons in a way that is consistent with our values and character. We use reason to determine what our values require us to do, morally speaking, and thus use reason to limit our space of reasons intentionally.21 Because volitional necessity reflects our character and values, compromises to volitional necessity are therefore violations of integrity. When what was once “unthinkable” becomes “thinkable” due to factors that do not involve reasoning about values, we may make choices that do not reflect who we are (in terms of our moral character) and what we value. These choices and actions lack integrity. Mental illness compromises a person’s ability to act upon moral commitments in several ways. First, a person may lack the capacity to develop moral commitments, especially if their mental illness manifests in their youth. Second, a person may have developed moral values, but mental illness disrupts them so that the person forgets or ignores them, or they no longer make sense. Third, a person may hold moral commitments that remain meaningful, yet mental illness may

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prevent the person from being able to act on them. Fourth, a person may lose the moral commitments they once held. The longer they are ill and socially isolated such as through homelessness, unemployment, or estrangement from family and friends, the more likely they are to lose their moral commitments. Since a person’s capacity to engage meaningfully with others depends on their ability to practice such engagement, the longer they are isolated from the world of shared experience and shared context for meaning, the more they lose the ability to be an agent interacting with others. Fifth, a person’s values may change as a result of marginalizing experiences that make a person see the world differently and that cause them to have to respond to their environment differently, especially under conditions of stress. For example, a person might experience a shift in their temporal focus toward the present due to living constantly in the mode of having to meet their basic needs; a constant focus on survival may make thinking about the future impossible. Moral commitments are made within a context or framework: within a certain understanding of the world and of ourselves, and an assumption of the stability of that world, ourselves, and our understanding of the world. Intelligibility, likewise, is contextual: what makes sense makes sense within the given context. When the context changes – when the self feels alienated from the world, or when the world no longer appears as it once was – what is intelligible, and what moral commitments make sense to hold, may change too. The moral standards that a person espoused when the world appeared “normal” and familiar may make no sense when mental illness symptoms change their perception of reality and their relationship to the world. Actions that seem to compromise our moral integrity may appear to others to be unintelligible. When people act in ways that go against their moral values – or that go against what it seems any “decent” person should value – such action does not seem to make sense. Such judgment, however, is made within a context of shared meaning that allows those with relevantly similar worldviews to interpret actions in a certain way. In what follows I examine some cases of seemingly unintelligible action to show how, given certain mental frameworks and social conditions, such action may make sense to the person doing the action. If we can understand a radically different context for choice than the one we tend to assume, we might be able to make some sense of an otherwise unintelligible action.

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Mental Illness and “Bad” Actions People who have mental illness notoriously make bad choices. By this I mean that they frequently make choices that thwart their self-interest (in other words, they are self-destructive rather than promoting flourishing) and/or that cause harm to others in some significant way. People with mental illness often make choices that diminish their physical health (such as smoking cigarettes), are life-threatening (suicidal actions), counter efforts to improve their mental health (for example, staying in abusive relationships), harm relationships with others (such as having an affair), or directly harm others’ well-being or even life (violent or deadly actions). Such choices often appear unintelligible. It does not make sense why someone would choose to act in certain ways when the outcomes of the action are so clearly bad or the action itself is so obviously inherently bad. Because such action is generally unintelligible, our typical response is either to assume the person had sufficient agential control to be fully blameworthy for their action, even if we do not understand their motives, or to assume the person was too “out of their mind” to exercise agential control and so is excused from responsibility by their mental illness. In other words, when we encounter unintelligible action, we do not have enough evidence to make a careful judgment about the nature of a person’s agency and so we compensate for this by making assumptions. Of course, our assumptions about the nature of a person’s agency tend to rest on stereotypes. In this way, stigma heavily influences the ways that we attribute agency and responsibility to people with mental illness and the ways that we judge specific actions. In my attempt to destigmatize mental illness in this book, I want to increase our understanding of the complexity of the ways that mental illness manifests and the effects it has on the people who suffer from it. In what follows, I want to shed light on some of the particular constraints that people with mental illness experience when they make decisions about how to act. The more we understand how a person with mental illness chooses to act in the way that they do, the less unintelligible their action is and the more accurately we can respond to their specific situation, rather than depending on stereotypes and assumptions that overgeneralize or falsely represent their actual experience.

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How M e n ta l Il l n e s s C onstrai ns Agency In this section, I explain how agency is constrained by symptoms of mental illness as well as by the objective conditions of suffering in mental illness experience. I focus on three primary constraints. Two are mental impairments caused by mental illness symptoms: the shift in moral boundaries that occurs in delusions and thought disorganization, and the undue narrowing or widening of reasons and options for action caused by inappropriate affect. The third constraint on agency is caused by the need to deal with the suffering of mental illness experience as best as one can. Let me elaborate on these constraints. First, mental illness can change the structure of meaning in such a way as to shift moral boundaries so that what was once recognized as right and wrong may no longer make sense. Cognitive impairments involving disorganized thinking, delusion, and paranoia can radically alter the way a person sees the world, and their relationship to it, disrupting whatever moral values they may have once had. Second, mental illness symptoms constrain choice and action by unduly narrowing or widening the range of plausible reasons for action and the scope of options available to a person. Mental illness can create many kinds of rational impairment, inhibiting the full use of reason in choosing between options of action. Both volitional impairments like compulsion and impulsivity and affective impairments like overwhelming, misplaced, or absent emotion can shortcircuit reason by making some options for action more appealing than others without good justification. In this chapter, I focus on the ways that inappropriate affect (emotions that do not fit the situation, or lack of emotion where emotion is called for) unwarrantedly shape reasons for action and live options available to a person. Third, mental illness creates a context for valuation that differs from the context many people develop their value systems from, especially those privileged by their mental health status and who typically have other kinds of privilege as well. Here, a person’s process of reasoning is intact, but the available options for action are fashioned by a set of values that has been developed in the context of living with mental illness. For many people, mental illness experience causes particular forms of suffering; living with this suffering for extended periods of time – or having it worsen to a great degree – can

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affect what a person values and what seems reasonable to do in dealing with their situation. While the first constraint has to do with how a person with mental illness is connected to reality, and the second constraint comes from the way mental illness makes a person irrational, this third constraint is a product of the stress of living with mental illness. Note that the first two constraints are direct effects of mental illness symptoms, while the third constraint is an indirect effect of having mental illness, coming from the way that a person is oriented in the world as a result of the interface between mental illness experience and the social and environmental factors that condition that experience. These three constraints on choice and action are certainly not mutually exclusive and are not even necessarily distinct from each other; they easily overlap and accompany each other depending on a person’s specific experience. It is important to recognize that every person’s experience with mental illness is unique, and that even people who have the same diagnosis may have very different manifestations of symptoms. My explanations here do not apply to all people who have mental illness, nor do they comprise an exhaustive account of the ways mental illness constrains choice and action. What they do, I hope, is to provide a starting point for deeper and more nuanced understanding of the nature of agency of those who have mental illness. Psychosis and Shifts in Moral Boundaries During my second hospitalization, I had the terrible delusion that if my youngest child lived to maturity he would grow up to be mentally ill like myself but would, because he was more lovable than myself, suffer even more. I must therefore kill him.22 This description of one person’s reasoning when she was in psychosis illustrates the lack of logic in delusion, even though to the person holding it, the delusion seems to makes sense. When under a delusion, people can reason in ways that are not based in reality, relying on perceptions that other people do not share, and either using logic in idiosyncratic ways or failing to use logic and common sense at all. Their conclusion about what to do does not logically follow from the premises, even though in their delusional state it seems to them that it does. In a delusional worldview, ideas may make sense to a person

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given the way the world appears to them, even though the ideas are meaningless or unintelligible to others who do not share the same understanding of the world. Involving a misattribution of meaning, delusion is a form of psychosis. Psychosis is a condition of not being able to connect to reality in the right way. Psychosis involves perceptual and cognitive symptoms that affect how a person sees and knows the world, namely symptoms like hallucinations, delusions, paranoia, de-realization, de-­personalization, and thought disorganization. Psychosis causes many cognitive and perceptual impairments that impact moral reasoning, judgment, and decision-making. The mechanism I focus on here is the way that psychosis can cause shifts in moral boundaries, so that otherwise “unthinkable” actions become “thinkable.” This shift occurs within a person over time, where the person has moral commitments that their mental illness erodes. For example, a person who might never have inflicted violence on others may do so in the throes of delusion; a person who never developed a strong set of moral commitments may be open to committing violent acts when severe paranoia strikes. Members of shared moral communities recognize that, given the values of the community, certain actions are clearly wrong and “unthinkable.” Acts that cause significant harm to others like murder, torture, and rape are prime examples of this. Acts that cause significant harm to oneself – like suicide, stabbing oneself, or swallowing poison – are also generally regarded as “unthinkable,” not least because we generally have an instinct of self-preservation. Yet mental illness can override our moral conscience and self-preservation instincts by making what would have been impossible now possible, in some cases even compelling. The primary way that mental illness causes shifts in moral boundaries is through cognitive symptoms like delusion and disorganized thinking, which are the two aspects of psychosis I focus on here. Sometimes this problem of connecting with reality is episodic, even brief, such as in a manic episode, while other times it is chronic and persistent, as when a person with schizophrenia experiences ongoing psychosis. Regardless of duration, during the time that a person cannot connect with reality in the right way, their epistemic capacity is reduced and impaired: they are not able to share the same understanding of reality that others do. Sometimes the problems of connecting to reality in the right way are local, specific to one object or context (such as a belief that a specific telephone emanates messages from

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God), or occurring only in specific contexts (such as paranoia that occurs only when interacting with authority figures); other times the problems are global, for example perceiving a general atmosphere of strangeness or sinisterness, as in the experience of “uncanniness” described by Karl Jaspers23 (discussed below), or believing that other people are robots. In psychosis, people’s capacity for shared meaning and for shared understanding of the world are diminished, negatively impacting their epistemic agency. This diminishment can result in other impairments to epistemic agency, including decreased responsiveness to evidential norms, impaired ability to take up multiple perspectives and have deep self-understanding, and diminished trust. Because epistemic practices are integral to moral reasoning, judgment, and decisionmaking, impairments to epistemic agency impact moral agency as well. In the next sections I describe the impairments caused by delusions and disorganized thinking. Delu sio ns Delusions are cognitive states that do not match reality. In philosophy, delusions are typically understood in one of two ways: as doxastic states or as attitudinal states.24 Let me start by examining what it is to say that a delusion is a doxastic state. Analytic philosophers generally regard delusions as doxastic states, either false beliefs (beliefs with false propositional content) or beliefs that were formed through a faulty process (an irrational process not based on or responsive to evidence). This corresponds with the folk epistemology understanding of delusion as a belief developed in inexplicable ways and accepted as true despite the bizarre conditions under which it was formed.25 In this model, a delusion is a belief formed through a faulty process as a way to explain an unusual experience that has no obvious explanation.26 A common way to understand the faulty process by which a delusion forms is as a breakdown in reality testing. Normally, when we try to explain to ourselves an unusual experience, we would abandon a false interpretation before it develops into a belief because we are capable of reasoning about our interpretation of what we perceive. When we engage in reality testing, we are able to use common sense and logic, and we consider other beliefs we have about the world and review counter-evidence. In cases of delusion, this process of reasoning does not occur, and the provisional interpretation of experience then

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develops into a false belief. According to this account of delusion as a failure of reality testing, people maintain their false beliefs tenaciously when the unusual experience occurs repeatedly and the reality test continues to fail; the more that unusual experience occurs and reality testing fails, the more that a belief is confirmed, and at some point the belief may become unrevisable.27 Philosophers have explained delusions such as thought insertion (the belief that some other entity is putting thoughts in one’s mind) and alien control (the belief that an alien is controlling one’s movement) in terms of failure of reality testing, arguing that these delusions arise from confusion between the sensory consequences of self-­ generated versus externally produced movement.28 As long as the confusion persists, the interpretation given for the experience – that an alien is controlling one’s movement, or that someone else is putting thoughts into one’s head – gets confirmed. For an example of how this works, consider common delusions where the source of thought is experienced as external to the self, such as in thought insertion, perceiving messages in objects, hearing voices, and receiving commands. Elyn Saks describes this phenomenon vividly: At some point, I began to realize that the houses I was passing were sending messages to me: Look closely. You are special. You are especially bad. Look closely and ye shall find. There are many things you must see. See. See. I didn’t hear these words as literal sounds, as though the houses were talking and I were hearing them; instead, the words just came into my head – they were ideas I was having. Yet I instinctively knew they were not my ideas. They belonged to the houses, and the houses had put them in my head.29 Normally we experience our thoughts as self-generated; it is quite difficult for most people to imagine what it is like to feel as if the source of one’s thought is outside of oneself. Because of the first-person nature of consciousness, any conscious thought we have seems almost by definition to originate from within us. The attribution of an idea which is present in our consciousness to an external source seems to reflect confusion in how we experience the origin of the idea. Such externalization of self-generated activity results from a failure of source monitoring, where a person lacks the ability to differentiate internally generated

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cognitive states from externally generated ones.30 When we repeatedly experience an idea as emanating from an external source – however we reason to ourselves that certain interpretations do not make sense – the reoccurrence of the experience confirms whatever interpretation we give to it, in spite of any counter-evidence we can entertain such as logical reasoning or previous beliefs about the world. In Saks’s case, she had an unusual experience of feeling that thoughts not her own were in her head, and she formed a belief that they emanated from the houses she passed. As she came to have more of these kinds of experiences, the belief that other objects were inserting thoughts into her head and sending her messages became cemented. In part because of this confirmation of experience, private “knowledge” attained from subjective experience can carry as much if not more epistemic weight as objective knowledge about the world. A person can come to trust their private “knowledge” more than knowledge that comes from outside their personal experience.31 This has consequences on action: if a person trusts their private “knowledge,” and their private “knowledge” indicates to them what they should do, their trust in the private “knowledge” provides enough reason for them to act. In cases of command hallucinations, a person might even feel obligated or required to act in the way indicated by their experience. Elyn Saks describes her experience with command hallucinations: In my fog of isolation and silence, I began to feel I was receiving commands to do things – such as walk all by myself through the old abandoned tunnels that lay underneath the hospital. The origin of the commands was unclear. In my mind, they were issued by some sort of beings. Not real people with names or faces, but shapeless, powerful beings that controlled me with thoughts (not voices) that had been placed in my head. Walk through the tunnels and repent. Now lie down and don’t move. You must be still. You are evil. The effect of those commands on me during those nights and days was powerful. It never occurred to me that disobedience was an option, although it was never clear what might happen if I disobeyed. I do not make the rules. I just follow them.32 Because of the primacy of subjective experience as a source of knowledge, people who experience command hallucinations feel pressure to act as they are commanded regardless of what other

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knowledge they have that would provide different reasons for action. In this way psychosis limits and changes the information set available to a person as they make decisions about what to do, which in turn affects the beliefs that serve as a basis for their decision. As Saks’s experience illustrates, command hallucinations can make disobedience feel impossible. Moreover, private “knowledge” can feel more certain and trustworthy than knowledge coming from outside one’s experience. This feeling of certainty and trust in the knowledge attained through subjective experience easily leads to distrust in the world and in other people, especially when they challenge a person’s subjective experience. This can lead to a solipsistic view of the world, and to an erosion of intelligibility as the person retreats from the external world into the internal world of their mind. The result is further isolation from others and further loss of shared meaning and a shared understanding of the world, leading to multiple impairments in epistemic agency. While analytical philosophers tend to regard delusion as a doxastic state, continental philosophers tend to view delusion as an attitudinal state, or what Karl Jaspers calls an “atmosphere” or a sense of “uncanniness.” This view of delusion is rooted in phenomenology and is based largely on Jaspers’s description of delusion. Jaspers argues that delusion involves “a transformation in our total awareness of reality,” which includes a diminished sense of being and false perceptions (hallucinations) but also encompasses more global distortion in one’s entire experience.33 Delusions manifest in false judgments, which have the characteristics of being held “with an extraordinary conviction, with an incomparable, subjective certainty”; of being impervious to counter-evidence; and of having impossible content.34 Because delusions manifest as judgments, they are often taken by others to be what delusions actually consist of – hence the common view (particularly in analytic philosophy) that delusions are incorrigible false beliefs. Jaspers emphasizes, however, that delusions actually constitute the experience on which such judgments are made, an experience that is so alien as to be unintelligible even to those whose experience it is. Such experience is both unshared and fundamentally unshareable, representing profound alterations in how a person encounters and sees the world. Because the experience can be so strange that it cannot be described with words, the propositional content of an accompanying false belief is almost irrelevant because it may not reflect even an attempt at trying to make sense of experience.

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This unintelligible experience is difficult, if not impossible, to understand for people who have not experienced it, and Jaspers cites patient reports in trying to describe it. His description is worth quoting here: We find that there arise in the patient certain primary sensations, vital feelings, moods awarenesses … Patients feel uncanny and that there is something suspicious afoot. Everything gets a new meaning. The environment is somehow different – not to a gross degree – perception is unaltered in itself but there is some change which envelops everything with a subtle, pervasive and strangely uncertain light. A living-room which formerly was felt as neutral or friendly now becomes dominated by some indefinable atmosphere. Something seems in the air which the patient cannot account for, a distrustful, uncomfortable, uncanny tension invades him.35 Jaspers describes this feeling of uncanniness as lacking content and thus filled with uncertainty, and he acknowledges that “this general delusional atmosphere with all its vagueness of content must be unbearable.”36 As a result of the unbearableness of the vagueness of the experience and uncertainty of its meaning, the person experiencing the delusional atmosphere is susceptible to attributing the experience with meaning of any kind of content, whatever it is, as this can provide a fixed point of reference and thus provide some specificity and certainty of meaning. Whatever meaning is attributed to experience, however, and whatever content is given to explaining that experience, is arbitrary. As a result, the scope of what could count as meaning is boundless, which is why delusions can take extraordinary forms. Moreover, the lack of fixed reference of meaning can result in inconsistency in meaning or changes in content, which obviously can cause great confusion in the person who has the delusion. This arbitrariness of meaning makes the content of delusional judgments irrelevant, and it can make communication with other people very difficult, as there may not be enough shared meaning for language and concepts to make sense to others.37 As the indeterminate feeling of uncanniness develops a determinate content in the form of specific delusional ideas, a person may experience these ideas as revelatory and as aimed directly, personally, and intentionally at oneself.38 Thus arises the phenomena of hearing

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messages and receiving commands. John Custance’s experience illustrates this: Perhaps I might just remark here in parenthesis that gradually all the associations of my environment came to confirm the ideas which were being forced upon me. When the wireless happened to be on, it often seemed to be speaking to me; something would be said to confirm or increase my fears … Every word, almost every letter, of a newspaper I might chance to look at, would contain some dire message of evil. To illustrate this, I will try to put myself back in the condition of mind I was in at the time, and then take the first suggestive association that comes to hand. In front of me is a pad of Basildon Bond writing-paper, blue. Looking at it with my eyes of eight years ago I see St Basil damning me (D) o n a blue bond. Blue stands for Heaven, which is Blasting me (i.e. yoU). Eternally. I hope this makes the associations clear.39 Custance’s example demonstrates the arbitrariness of meaning as it gets reassigned through determinate content. As the feeling of uncanniness develops into a specific idea with determinate context, that idea can be experienced as coming to a person from a special place (such as “from God”) or in a special way (such as “sent just to me”). Observers sometimes find it puzzling that a delusional person will explicitly acknowledge that they know they are hearing something that others do not hear. How, the observer wonders, can a person know that yet still espouse the belief? The answer is easily explained: the message is experienced as something special, and so it makes sense to the person who has the delusion that the message is aimed solely at them and that no one else can hear it. Delusions can interfere with a person’s ability to perceive the moral quality of actions correctly or even to understand the nature of an action in general. For this person, a choice to harm others or themselves may not appear bad because they see it in a different way than others do. In manic or paranoid states, for example, the world looks different; values and beliefs get turned upside down and shaken out, and the way they get reordered may have no logic that can be understood from the outside. The person may be able to give reasons for their choices that are somewhat intelligible, given the worldview in which the person is operating, but such reasons can be totally

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misguided if the worldview is false or seriously distorted. The person’s reasoning may ignore important factors or contexts that should be taken into account, or inappropriately prioritize irrelevant factors. Delusions help shape a person’s action by making present some reasons for action and options available to act upon that would otherwise not be present, and some absent that would otherwise be present. For example, consider the way hallucinations shift the moral boundaries of what constitutes possible, morally acceptable, and even morally required actions. Many memoirists write about the way that auditory hallucinations create suicidal impulses. Kristina Morgan describes the conversation that “the Voices” have with her: “We’re your worst nightmare and your best friends, Kristina. We are everything to you. We don’t care that you’re weird. We don’t care that you’re ugly. We’ll accept you just as you are, Kristina.” His mouth doesn’t move when he says any of this. It’s all telepathic. I try to remember if I had ever seen any of their mouths move. I shut my eyes with the thought that maybe if I couldn’t see him, I wouldn’t be able to hear him, either. “I think you’re desperate, Kristina. I think you want out of this little life of yours. No one will miss you. I promise. You’ll have us. Go ahead, Kristina. Swallow those pills you’ve been ­hiding in your desk drawer. It’s so easy, Kristina. You won’t know that you’ve even died. You’ll wake up with me and the others. And I told you we can go anywhere. Do anything. Our world is beautiful. It’s not polluted with emotion. You won’t have hives anymore. People won’t tease you anymore.”40 Similarly, Lori Schiller describes the way “the Voices” caused fantasies of suicide: I tried desperately to dodge these fantasies. Planning on jumping off the top of the Galleria Mall? Then keep away from it. Don’t even drive by it. Thinking about dumping all my capsules into a McDonald’s shake? Never go to McDonald’s again. Not even for French fries. As frightening as the scenarios were, however, they gave me a chance at eternal peace. The Voices would alternately chant, “To die! To die! To die!” and then “Peace! Peace! They are waiting to

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give you peace!” There was only one route to peace. The pressure was building. Finally, it became unbearable. I had to act.41 For both women, a suicide attempt is experienced as the object of compulsion or desperation, not as a freely willed choice determined through rational deliberation. For both women, their auditory hallucinations circumscribe what options for action are available to them, and their ability to act with adequate moral capacities is thwarted. Shootings by people in the throes of a psychotic manic, depressive, or psychotic episode also illustrate vividly the way that delusions can shift moral boundaries. Consider James Holmes, whose mass shooting at a movie theatre in Aurora, Colorado, left twelve people dead and fifty-eight injured. Holmes, a young man in his early twenties, was enrolled in a neuroscience graduate program at the University of Colorado. Very smart, he could be socially aloof, but he also had friends. On 20 July 2012, he opened fire in the movie theatre at a midnight showing of the Batman movie sequel The Dark Knight Rises. He purportedly believed that his self-worth would increase with every murder he committed. He kept a notebook which included “highlighted pages of runic symbols; nonsensical equations about life and death, infinity and ‘negative infinity’; and pages covered with the word ‘Why?’”42 A notebook like this suggests the loss of shared meaning and the attribution of arbitrary meaning that occurs in the experience of attitudinal delusion. Holmes was diagnosed with schizophrenia and schizoaffective disorder by psychiatrists who testified at his trial.43 While Holmes’s defence lawyers argued that he did not deserve the death penalty by reasons of insanity, prosecutors tried to argue that he was not sufficiently insane to be exempted from the death penalty. Prosecutors pointed to the extensive planning Holmes did in preparation for the shooting, as well as to actions that could be interpreted as indicating he knew that what he was doing was morally wrong. Although our stereotype of an insane person is a person who acts randomly, without anything that could be construed as reason, it is important to understand that a person can experience delusions that cause major disconnection from reality while retaining certain reasoning processes. Having a severely delusional worldview is perfectly compatible with planning and other executive functions, as impairments in perception and belief acquisition and maintenance are separable from impairments in means-end reasoning.

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Moreover, it is important to note that a seriously delusional worldview can make a person act for reasons unintelligible to others, based on nonsensical beliefs, even if the actions appear to be explainable by intelligible factors. While prosecutors believed that Holmes’s actions appeared to demonstrate concern for his victims, it is possible that the actions in fact stemmed from reasoning that had nothing to do with moral concern. We would have to know more about the state of his delusion to be able to assess this. However, as is the case with much action done by people with mental illness (or by anyone for that matter), it is probably not possible for us to have the kind and amount of knowledge needed to make an accurate and fair evaluation. I discuss what we should do about this inherent epistemic limitation in chapter 4. A less dramatic example of action performed under delusion is the common behaviour of many people with mental illness to stop taking their medicine. Many people with serious mental illness do not recognize that they are ill and may develop delusions such as viewing the medicine as poison or a means of control by others. Based on these beliefs, a person may choose to stop taking their medicine. These beliefs have false content, are developed through faulty processes, and are often incorrigible, held tenaciously despite argument and counter-evidence. These beliefs can arise from the loss of shared meaning and attribution of arbitrary meaning in attitudinal delusion, but they can also stand alone as delusional doxastic states. Disor g a ni z e d T hi nk i ng In her memoir about schizophrenia, Elyn Saks describes this experience of what she calls “disorganization”: My awareness (of myself, of him [her father], of the room, of the physical reality around and beyond us) instantly grows fuzzy. Or wobbly. I think I am dissolving. I feel – my mind feels – like a sand castle with all the sand sliding away in the receding surf … Consciousness gradually loses its coherence. One’s center gives way. The center cannot hold. The “me” becomes a haze, and the solid center from which one experiences reality breaks up like a bad radio signal. There is no longer a sturdy vantage point from which to look out, take things in, assess what’s happening. No core holds things together, providing the lens through which to see the world, to make judgments and comprehend risk. Random

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moments of time follow one another. Sights, sounds, thoughts, and feelings don’t go together. No organizing principle takes ­successive moments in time and puts them together in a coherent way from which sense can be made. And it’s all taking place in slow motion.44 It is easy to see how having perceptual experiences like this can create corresponding disorganization in the mind, affecting thought and action. Disorganized thinking, or thought disorder, occurs when a person’s thoughts do not connect logically as they should. It is primarily evidenced by speech patterns, but it can be recognized phenomenologically as well. Examples of speech patterns that evidence disorganized thinking include associating words by sound rather than meaning, giving excessive unnecessary detail, linking ideas that have no apparent connection recognizable to others, repetitive speech, making illogical connections, incoherence, new word formations or uses, pressured speech (common in mania), and excessive tangentiality. Other forms of disorganized thinking include poverty of thought (common in depression); seeing meaning where there is none (or at least where others do not see meaning); seeing the world infused with a meaning that connects everything; an inability to recognize formal structures already existing, including rules, roles, boundaries, and customs; and an inability to recognize the normative force of social norms, moral principles, or justificatory reasons for why structures exist as they do. When a person’s thought process is disorganized and illogical, they have difficulty seeing the organization and logical connections in the world around them. This impairs many cognitive abilities – including analytical capacities to make relevant distinctions, to give justificatory reasons, and to reason from premises to conclusions – and synthetic capacities to organize an array of information in meaningful ways, to group together relevant concepts, and to connect ideas in fruitful ways. Arnhild Lauveng describes how psychosis impedes a person’s ability to understand reality and consequently compromises the person’s ability to reason: It is difficult to understand the world when you are psychotic. Many of the regular reference points fall apart; the ones you are used to relying upon no longer work, you can’t trust your eyes or ears, and the rules have crumbled. Your head, which should be

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able to help you out of crisis, has become the cause of the crisis, and none of the solutions you once knew work anymore. All of the complicated strategies fall apart and leave only the simple.45 Being trapped in one’s own mind can make it impossible to connect with or communicate with others. In the hospital, Pamela Spiro Wagner describes freezing into a state of catatonia as someone asks her if she went somewhere. Wagner writes: I don’t answer. Other patients pass the room and look in, curious, but self-consciousness no longer motivates me. Only inner life is of concern: Gray Crinkled Paper, the voices. I am caught up in the sense that something dire will happen if I move or speak … I am aware of everything, yet I am connected to nothing, able to hear without responding, to think without pursuing any train of thought. I have forgotten any reason to stay conscious, to stay in touch. Though I feel the pressure of hands, the cold burning that guides me back to bed and positions my body for sleep, I am not equal to the task and the terrible fatigue of living in the real world.46 While psychosis can lead to many states, catatonia being only one of them, all of those states can make connection with reality and with other people difficult, if not impossible, which impede in various ways how a person can know and act in the world. These problems with organization and logical connection that are the foundation of disorganized thinking can lead to an inability to recognize structures and their justifications, for example power relations or social roles and the factors that underlie them. The solipsistic tendency of psychosis to distance a person from reality and shared meaning makes recognizing objective or intersubjective meaning particularly difficult. As norms, principles, roles, relations, and justificatory reasons are objective or intersubjective in nature, psychosis particularly impairs a person’s ability to recognize these for what they are, as having normative force. When these are recognizable, they are so more as social conventions with random or arbitrary meaning than as norms or structures with normative force. Disorganized thinking and delusion commonly occur together. They shift moral boundaries because the loss of meaning loosens and untethers the normative force that distinguishes and justifies actions as morally required, permissible, and impermissible. The change in

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meaning structure that occurs with loss of meaning and with consequent arbitrary reassignment of meaning also changes the context of moral understanding and can even destroy it. When rules, roles, and various categories and boundaries no longer make sense, the reasons for why some actions are prohibited or why others are obligatory no longer make sense. Prior to the experience of thought disorganization and delusion, a person may have recognized the normative force of the rules about the wrongness of deceit, theft, assault, and murder, and about the obligatory nature of taking care of one’s children, being loyal to one’s spouse, being kind to one’s friends, and helping others in need. The person may have had a general understanding of what was right and wrong for them to do in given situations. But when the person’s thoughts become disorganized and they are plagued by the indeterminate uncanniness of delusion, it may no longer make sense why certain actions are wrong and others are morally required. This is true even if the person retains the recognition that other people think certain actions are wrong and certain other actions are morally obligatory, and the recognition that they themselves used to think certain actions are wrong and certain other actions are morally required. Disorganized thinking can make it difficult to recognize norms of any kind, not only moral norms but also epistemic norms, such as evidential norms. Evidential norms attach value to truth, making evidence have normative weight. Evidence that counts in favour of, or proves, a belief should lead us to adopt or consider adopting the belief, while evidence that counts against, or disproves, a belief should lead us to reject, revise, or at least consider rejecting or revising the belief.47 Evidential norms, therefore, give evidence the weight to inform practical reasoning by circumscribing what we ought to do epistemically – that is, in relation to adopting, revising, or rejecting belief. Moreover, since beliefs inform our moral judgment about what we ought to do, a breakdown in the ability to adhere to evidential norms can compromise moral agency. Since recognizing evidential norms is necessary for reality testing of belief, disorganized thinking that makes norms lose meaning enables reality testing to fail, thus causing or supporting doxastic delusions. Through our interactions with others, we put our beliefs “out there,” outside of ourselves, and subject them to a reality test of sorts: intersubjective dialogue. Depending on how others respond to our beliefs – to what extent they support or object to the beliefs – we maintain or revise our beliefs in response. If we fully and fairly

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participate in this process, we act as sufficiently free and rational agents who abide by evidential norms about when to adopt, revise, or reject beliefs based on evidence. In engaging in this process, we also assume that the people with whom we converse are sufficiently free and rational agents who adhere to these same evidential norms. We assume our conversational partners will recognize that any belief they hold has content that is subject to evidence of its veracity, and that they will regard evidence as having the normative weight to make it right or wrong to hold a given belief. When a person is unable to revise their belief based on these evidential norms, we are unable to treat them as a true conversation partner and are likely to regard them as irrational.48 Impaired in their ability to revise their beliefs based on reason and evidence, and consequently their ability to act from an effective will based on examined beliefs, the person is impaired as a moral agent as well. Disorganized thinking can hinder a person’s ability to adhere to evidential norms because it can prevent the person from being able to recognize the relevance of evidence, truth-value, and logical relations in evaluating and acting upon beliefs. Yet this recognition is necessary for assessing beliefs and developing understanding. The lack of this recognition impedes a person’s ability to make epistemic and moral judgments, which can guide action. Because moral reasoning requires recognizing the relevance of logic, truth-value, and evidence, disorganized thinking can threaten a person’s moral as well as epistemic agency in a profound way. Psyc hosi s a nd A ge ncy Psychotic symptoms such as delusions and disorganized thinking impact many aspects of epistemic and moral agency, which I develop in detail in the following chapter. Psychosis changes both the content of deliberation and the process of reasoning. To use Watson’s metaphor of a deliberative screen, we can say that psychosis creates reasons for acting and options for action that would not be available to the person if not for the psychosis, and it enables a process of reasoning that may be unintelligible to those who do not share the same worldview as the person under psychosis. Additionally, psychosis blocks reasons for acting and options that would otherwise be apparent, and it masks the rationality of a reasoning process that is intelligible to others, so that the person under psychosis views what others see as rational to be irrelevant, false, or unintelligible.

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When a person acts in ways that were previously “unthinkable” to themselves, or in ways that are generally “unthinkable” to others (such as violent acts that cause harm to others or self), the person disrupts whatever moral integrity they may have had previously, and they act incongruently with general moral norms. With such action they violate their own values and commitments and violate the moral norms of the moral community of which they are potentially members. If this disruption persists, and they continue to act in ways that were or should be “unthinkable,” this constitutes a loss of moral integrity.49 In enabling people to act in ways that would otherwise be “unthinkable,” delusions and disorganized thinking can profoundly compromise moral agency. It is easy to make a judgment about a person when they perform bad actions, focusing on the badness of the action without taking into account the mindset behind the behaviour. We must consider, however, when it is fair to hold a person responsible for actions performed while their reasoning was seriously impaired, as in the case of psychosis. One proposal is that psychosis may exempt a person from moral responsibility when the person is unable to participate in relevant epistemic activities, including giving reasons that are intelligible to others, and adhering to evidential norms by revising beliefs according to available evidence.50 In the examples discussed in this section, this criterion is certainly met at least sometimes. At the same time, we might be wary of excusing a person for bad behaviour even when we know their thinking was compromised by mental illness symptoms, because we want to treat the person as an agent, as a deserving recipient of reactive attitudes, and not as an object of objective attitudes like pity. The problem is that we often do not – and cannot – know how much agency a person actually has. This possibly unavoidable lack of knowledge can make knowing how to respond to people and knowing how to hold them responsible for their behaviour very difficult. In chapter 4 I return to this thought and make some suggestions about how we should deal with this kind of epistemic limitation. Inappropriate Affect and Changes in the Scope of Options In their case study of “Mr M,” Andrew Moore, Tony Hope, and K.W.M. Fulford describe a man diagnosed with bipolar disorder who seems to have a very different personality when he is taking lithium

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versus when he is not. When he does not take lithium, he exhibits symptoms of hypomania, including pressured speech, flight of ideas, increased goal-directed activity, recklessness, and impulsivity. Notably, during hypomania his affect changes – not just his emotional states, but how he is oriented toward the world. This changes what he values. More, Hope, and Fulford write that when he went off the lithium, “He found his wife and family boring, and claimed that his marriage had never been good.”51 On the other hand, “During the periods when he was taking lithium, Mr M described his relationship with his girlfriend as superficial and unimportant, and he stopped seeing her. He said that he wanted to stay with his wife and family, and insisted that this had always been important to him.”52 Summing up the tension Mr M lives with, More, Hope, and Fulford write: At one point Mr M wrote to his physician reporting that after stopping lithium he had come to think that he had been living a double life, both aspects of which seemed “real”: one was his life with his wife and children, the other his life with his girlfriend and his song writing.53 Mr M feels different emotions toward his family and toward his girlfriend when he is off lithium and presumably hypomanic, compared to when he is on lithium with his condition presumably managed. He experiences different valence toward these emotions depending on the presence of lithium, valuing his family when on lithium and finding them boring while off. Emotions impact our cognitive states, and his different emotions and valences cause him to see the world differently in each state. When overstimulated and powered with excessive energy and creativity while mildly manic, Mr M sees certain other people as obstacles and experiences greater irritation toward them. When his energy and stimulation levels are subdued to a “normal” level, he sees other people, especially the people close to him, as ends in themselves with their own subjective experience. This of course affects what and how he values. While overstimulated, energetic, and creative, he values people and activities that further stimulate and further increase energy and creative impulse. When his stimulation and energy are under control, he values the closeness of his family and the way that he can be more productive by completing tasks more easily. Mr M’s

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experiences under the influence of hypomania and under the management of lithium are confusingly dualistic, and they demonstrate the radical role that affect can play in reasoning, valuation, and even connection to reality. Mental illness frequently compromises agency by changing the range of what options for action are available. Many symptoms cause mental impairments that short-circuit reason, changing the boundaries that circumscribe what a person feels they can or cannot – or must or must not – do. Consider the way obsessions narrow a person’s focus to a single object, while both adhd and mania scatter a person’s attention, making it challenging to think carefully and logically about their options and follow through on their professed second-order desires and values. Compulsions force a person to do certain behaviours regardless of the outcome or available alternatives, and impulsivity causes a person to act unthinkingly, based on emotion, impulse, or whim, without regard to consequences. Volitional impairments like compulsion and impulsivity make acting on desires and obsessions particularly compelling, crowding out other important considerations that should impact decisionmaking, while affective impairments such as the overwhelming emotion and intense feeling that accompany mood disorders can override reason and self-control. Volitional and affective impairments narrow, widen, or shift the bounds of what reasons for action are worth considering, and what options seem available, in problematic ways. Because philosophers have written at length about the relationship between rational and volitional impairments, particularly in the context of addiction,54 my focus here is on the relationship between moral reasoning and affective impairments caused by inappropriate moods and emotions, in other words moods and emotions that do not fit the relevant context. Affective impairments inhibit the cognitive skills and emotional capacities necessary for moral reasoning and general normative competence, including the ability to recognize normativity (what is worth valuing) and the ability to act on one’s values and commitments. Emotio ns a nd Moods I start my discussion about the inappropriate affect that mental illness may cause by distinguishing several related terms. Emotions are intentional, directed at specific objects, while moods are non-intentional, or at best intentional toward multiple objects (perhaps toward

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“everything”).55 Most philosophers (and lay people) regard emotions as a type of feeling, a category that includes other states like visceral reactions (such as hunger or thirst),56 and which Laura Sizer defines as “a phenomenally conscious, sensation state that one occupies (as opposed to an action one performs).”57 Emotions have a unique qualitative feel, and having an emotion is a phenomenon that happens to us rather than an action we undertake. Emotions have specific onsets and offsets and can come upon us suddenly or gradually. They can be triggered by thoughts and beliefs and they can also induce thoughts and beliefs. They have physiological expressions, and we learn what appropriate emotions are in part by observing other people’s expressions of them. Emotions also induce specific action tendencies, causing us to act in certain ways in order to maintain an emotion we like, get rid of an emotion we do not like, or respond to a given situation in a certain way. Emotions have a valence; we experience them as pleasurable or desirable, or painful or undesirable.58 Some philosophers regard emotions as cognitive states like desires, beliefs, and judgments; like these other cognitive states, emotions serve epistemic functions in drawing our attention to salient features of a situation, helping us sort through all the information we receive to focus on what is worth our attention.59 Some philosophers compare emotions to perceptions: like perceptions, they are representations of their objects; they inform us about what is in our environment; and they constitute reasons that justify our beliefs or judgments.60 Insofar as emotions are akin to perceptions, they can be assessed as veridical: they are correct or incorrect depending on whether they “fit the facts” of the given situation. Emotions may even be expressions of what we value, constituting normative reasons for action.61 Emotions thus serve many functions, particularly epistemic functions of providing information or alerting us to what is salient, but also normative functions of serving as justificatory reasons or reasons for action. Moods, too, are functional. John Searle describes mood as “a certain flavor to consciousness, a certain tone to one’s conscious experiences.”62 Moods have global effects on our cognitive processing. One theory is that they help us maintain a balance between demands on our energy and the energy we actually have, regulating our energetic output in relation to what we perceive to be demanded of us.63 Another model regards moods as dispositions toward certain emotions, illuminating and activating latent emotions.64

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Like emotions, moods occur in relation to our cognitive states, both impacting and responding to our beliefs.65 Moods affect our cognition in a variety of ways, producing several kinds of cognitive biases. For example, positive moods increase creativity and increase speed in processing ideas, categorizing, and making connections; they enable “big-picture” thinking and taking a broader perspective; they conjure positive thoughts and memories; and they spur “positive” emotions like happiness. Negative moods, on the other hand, increase analytic thinking; they decrease speed and increase caution in decision-making and formulating judgments; they focus attention on details; they conjure negative thoughts and memories; and they dispose one to “negative” emotions like sadness or anger.66 Because of these cognitive biases, moods affect how we do moral reasoning, form moral judgments, and make moral decisions.67 Emotions and moods can be non-functional, or what I call “inappropriate,” when they fail to serve normal functions and when they do not fit the relevant context. Emotions are “inappropriate” when they do not “fit the facts” of a given situation, or when there is an incongruence between what is represented and what actually is, for example when we are sad under conditions that should make people feel happy. Emotions are non-functional when they fail to help us sort through information and fail to illuminate salient aspects of a situation. Likewise, moods are “inappropriate” when they are not in any appropriate relationship to the environment, failing to fulfill functions such as regulating energy levels. In Mr M’s case, for example, rather than regulating his energy level in relation to the environment, his mood regulated the environment by causing him to act in ways that changed his circumstances. “Inappropriate” moods occur despite our circumstances, and they may not always be responsive to changes in the environment. In a pprop r i at e A f f e c t Emotions serve important roles in our moral reasoning and decisionmaking. In helping us sift through all the information we receive, emotions draw our attention to what is morally relevant so we can discern what a situation calls us to do. Emotions that fit the situation thus guide us in figuring out how to respond to the situation. Discussing our emotional reactions to a given situation with others can help us determine the appropriateness of our emotion as well as the relevance

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of the information we are drawing on and the cogency of the moral principles we are using.68 Emotions are appropriate when they fit the facts of the situation in a way that is observable by others, and when they can serve as reasons to justify beliefs or judgments, or serve as normative reasons for action when their justificatory or normative force is intelligible to others. Inappropriate emotions and moods can impair moral reasoning in a variety of ways. For example, overwhelming emotion and other feelings can wash out reason so that a person may be aware only of their intense feeling. Reason may become irrelevant, unseen. Thus we say that people may act on “blind” passion (passion that is blinding, that blots out reason) or be “driven” by rage or obsession (which are seen as directing the will regardless of other reasons for action).69 Emotions can distort our perceptions and consequently our use of practical reasoning.70 Strong emotions can constitute reasons for action that override competing reasons.71 While emotions can sometimes be expressions of what we value, they can also obscure what we value, causing us to act against our values. Affective impairments can also lead to volitional impairments. When we are driven by intense feeling, we may be unable to see reasons for alternate actions, and we may be inclined to act impulsively (without regard to reason) or with a weak will (with insufficient self-control). Inappropriate affect can also affect moral motivation, inhibiting our motivation to act in desirable ways and encouraging motivation to act in undesirable ways, such as by serving as a reason to refrain from acting in ways that would be good for a person or by impelling a person to act on impulses that would be better left alone. Additionally, inappropriate affect inhibits moral knowledge. While developing our emotional capacities can enable empathy, allowing for more effective interaction with others, inappropriate affect can create barriers to empathy, preventing us from appreciating what others are feeling or experiencing, which in turn can prevent us from responding to others appropriately. Jon Elster provides a rough taxonomy of emotion that serves as a helpful guide. He includes states that we typically regard as emotions (including self-regarding emotions like pride; other-regarding emotions like resentment; and common emotions like happiness, sadness, anger, love, and jealousy), as well as some usually not considered emotions such as nostalgia, hope, and daydreaming.72 To his taxonomy I would add feelings that are specific to mental illness

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experience as well, such as agitation (both physical restlessness and “inner” mental restlessness); a sense of structural stability (tied to the belief that the world will persist in a certain way that makes sense) versus instability; a sense of psychological security (tied to the belief that one has the resources to deal with change) versus insecurity; a feeling that the world is as it should be; a sense that something is not quite right (uncanniness); a feeling of being pressed down upon versus feeling light; the feeling of needing to be low to the ground, underneath something, or hiding (a physical sensation typically accompanying paranoia); the feeling that one’s head will explode or implode; the feeling that everything is floating, untethered (a sensation associated with thought disorganization), versus being firmly grounded within metaphysical and social structures; the pain of too much mental intensity, such as that caused by overstimulation and/or racing thoughts; the mixed manic feeling of being simultaneously exhilarated and desperately despairing (“on top of the world” while that world is crumbling under one’s feet). I have no doubt that people who have other mental illness experiences could add other feelings here that are not quite captured in a taxonomy or list such as Elster’s (or mine). Moreover, people with different experiences would no doubt describe some of the feelings I am trying to describe here with different language, which only indicates the nebulousness of many powerful feelings that are probably not universally shared (being specific to conditions like mental illness), yet serve the epistemic and moral functions that other more universal feelings do. Emotions can have positive or negative valence and be experienced as pleasurable or painful, desirable or undesirable, or something to be happy or unhappy about.73 Any type of valence accompanying emotion can motivate action. In fact, I would argue that it is not the specific valence (positive or negative) that matters in terms of motivating action but rather its intensity or lack thereof. Nostalgia for the past is for some people a terribly intense feeling, whether the past is remembered positively or negatively, and the intensity itself can feel very painful, even when the memory is a positive one. Shame, regret, and guilt are obviously painful feelings, but for people who experience them acutely they can become all-consuming. Agitation has a physical component as well as a mental component, and the two are not always distinguishable; the “feeling” of agitation can take over other feelings a person may have.

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For people with mood disorders, feelings, valence, and their effect on motivating action can become disordered. For example, positive feelings like happiness, pride, and love can be so intense that they are experienced as painful; or, alternatively, they can be accompanied by indifference. In mania, for example, exhilaration, the “rush” of feeling “on top of the world,” can be unbearably intense, however pleasurable, and make a person want to obliterate their consciousness, whether through drug use, suicide, or other means. A person may develop a preoccupation with negative feelings like sadness, anger, shame, or regret and seek these out rather than having the usual aversion that we have to these. For some people, especially those with mood disorders, feelings with positive and negative valence can easily mix with each other so that one may be experienced alongside the other in confusing ways. People with mental illnesses like mood disorders may feel emotions in ways that are too excessive, misplaced, or inappropriate given the context. This especially occurs when one feeling is so intense that it overwhelms other feelings. Intense feeling can be paralyzing, as in the case of depression, where intense numbness or sadness breaks the will to act.74 Intense feeling can also spur action and creativity, as in the case of mania, where intense exuberance drives action that is excessive, quick, sometimes productive, but frequently unfocused.75 When intense feeling is experienced as pleasurable, a person may seek out constant and excessive stimulation that perpetuates the feeling.76 When intense feeling is particularly painful, a person may be willing to do anything to alleviate it, from taking drugs that would numb the pain to suicide. For a person who has a mood disorder, feelings and reason may become detached from each other so that they may have “objective,” reasoned views about something yet have subjective, intense feelings that conflict with those reasoned views. Typically in this situation a person acts in a way that violates their own values, which they are sometimes, but not always, able to recognize; when they do recognize this, even if it is long after the fact, this can cause great suffering. Mood disorders famously compel people to make poor decisions because the overwhelming emotion and intense feeling they can produce can “crowd out” reasons for alternate action. People with bipolar disorder, especially in a manic phase, commonly engage in impulsive action like cheating on one’s partner, overspending, and other risky behaviours that can cause great harm to self or others

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because these individuals are overwhelmed by the intense feelings – as well as the cognitive distortions and delusions – that constitute mania. As Jon Elster points out, emotions can generate intentional action that is reward-insensitive, not changeable regardless of incentives and consequences.77 Some philosophers have argued that we need to take seriously “inappropriate” emotions that do not appear to fit the context, as they can serve important moral and political functions of drawing our attention to moral or structural features of a situation that would otherwise be ignored. For example, emotional tension may arise as a way of trying to situate oneself within a reality context that does not make sense, and the “inappropriateness” of the emotion may highlight something morally wrong with the situation, which is what gives rise to the tension.78 Some emotions are deemed “inappropriate” because they defy cultural norms, such as the emotion of anger in women when our stereotypes of them support feminine passivity. While culturally sanctioned “appropriate” emotions reinforce cultural norms that connect behaviour to specific emotional response, “outlaw emotions” that defy cultural norms can bring attention to and thus highlight injustices that, operating as background conditions, would otherwise go unnoticed. In light of the moral and political functions of outlaw emotions, Alison Jaggar redefines what constitutes fittingness, describing emotions as “appropriate,” “if they are characteristic of a society in which all humans (and perhaps some non-human life too) thrive, or if they are conducive to establishing such a society.”79 While outlaw emotions can serve useful moral and political functions in highlighting salient features of a situation that might otherwise go ignored, not all “inappropriate” emotions serve such a useful purpose. Sometimes emotions do not fit the context and do not highlight anything morally or politically salient, but they do cause considerable suffering and circumscribe action in unnecessary and even harmful ways. These are the emotions I am concerned with here. For example, consider the rage and agitation that Mary Weiland experienced shortly before lighting her husband’s clothes on fire in their driveway. After days of being jacked up without sleep, Weiland performed one erratic act after another, often while fighting with her husband. “I picked up a pair of scissors and began to cut the dress to shreds – while I was still wearing it.” Later, after consuming alcohol and Vicodin: “I tossed the bedside lamps into the television set and

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pitched the clock radio into the wall. Anything in the room that could be broken, I broke.” After passing out, being taken to the police station and processed, and having her children removed from her care, Weiland returned home and fought with her husband over the phone. Then she took all of her husband’s designer clothes – eighty thousand dollars’ worth – and set them ablaze in her driveway. When her friend tried to soothe her, Weiland yelled, “‘Don’t you get it? I can ’ t calm down. If I could calm down, I’d calm down!’”80 Weiland’s rage and agitation, caused by a manic episode, was excessive given her situation and inappropriate to her circumstances. This intense emotion circumvented her reasoning and caused her to act impulsively and with grandiosity. Emotions impact moral reasoning in part by unduly narrowing or widening the scope of reasons for action and the scope of options available to a person by influencing the information, beliefs, and desires that a person has. Emotions can change the information set available to a person and change the motivation a person has to acquire relevant information. Emotions can direct a person to believe things they would not otherwise believe, inducing partial, misleading, and false beliefs. Emotions also set the bounds of desire and shift the moral bounds of what is worth valuing, directing a person to desire certain things and not others and to value a certain range of objects but not others as worthy. Powerful or overwhelming emotions can draw excessive attention to one feature, leading to a lack of attention and interest in other features, for example focusing so much on the despair of loss when change occurs that a person ignores the curiosity and joy of new experiences. In this example, the person’s emotions narrowly constrain their reasons for action to focus only on minimizing or protecting themselves against their loss; within this framework, the only options for action may seem to be to retreat into one’s shell so as to not care about or be moved by the loss. This constrains possible action more narrowly than is necessary and leaves little room for the person to consider positive aspects of change. In another example, a person may be so overcome by love and the pleasure of being with a specific person that they ignore other people they care about and other interests they have. Here a person’s emotions constrain their reasons for action to focus just on maintaining pleasurable experiences with the object of adoration to the exclusion of all else; within this framework, the only options for action appear to be those which produce these

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pleasurable experiences. This has both a narrowing and a widening effect, excluding actions that maintain other interests while at the same time opening the door to actions that might previously have been “unthinkable,” such as having an affair. In addition to narrowing reasons for action and options available, emotions can also widen these, sometimes helpfully, as when the expansiveness of love allows a person to consider possibilities they did not consider before, and sometimes harmfully. When emotions draw attention to salient features, this expands the reasons for action that one would consider, adding more options to the realm of possibilities. Emotions can play a constructive role here. Sometimes emotions broaden reasons and options in destructive ways, however, particularly when they move from what was once “unthinkable” to become now “thinkable.” Powerful and overwhelming feelings of love, lust, anger, jealousy, despair, and joy can broaden the scope of reasons and options available to a person in an unhelpful way. While such feelings narrow a person’s focus to exclude other objects of interest, they also expand the realm of possibility to include what would have previously seemed impossible. Mr M’s situation, described above, comes to mind here. Many experiences of mania in particular demonstrate this. In her memoir Manic, Terri Cheney describes an early morning adventure at a writer’s retreat when her car broke down; as she was waiting for the repair, she found a kite shop and impulsively decided to buy kites for every member of the writing workshop. On the way back to the retreat site, it started pouring and in her manic state she thought it would be a good idea to fly kites in the storm. She says, “I reached back to tie them [the kites] down, and it struck me: what better time to fly a kite than in a storm? Why should anything ever be tethered?”81 She “set the kites free” before getting back in her car and returning to the retreat, soaked. With this story, Cheney describes the way that the manic feeling of being untethered, not quite touching reality, led her to pursue options she would not otherwise have thought of – such as buying kites for everyone – thus widening the options yet making this option so bright and shiny that other possibilities for action were unnoticeable and other reasons for action were overridden. Her giddy, flighty emotion influenced how she used reason and changed the structure of her rational deliberation. When emotions open up or close down options for action, they change the reasoning process. The person is still

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minimally rational, sensitive to rewards that could change the choice that is made, and uses means-end reasoning appropriately, making choices based on their desires and choosing what appears to be the best means of satisfying those desires. But their ability to reason more robustly as they make choices is compromised, as they choose options based on faulty beliefs or flawed or incomplete information. “Inappropriate” emotions can prevent a person from seeking out or using relevant information and can support beliefs that are not grounded in reality. Another example of the way overwhelming emotion can both narrow and widen simultaneously is suicidal ideation. While there are many different contributing factors to suicide, many suicides, especially those driven by a mood disorder like bipolar disorder or major depression, are the product of overwhelming emotional states or other intense mental states such as despair, sadness, loneliness, and hopelessness. When these feelings are too powerful, they crowd out other feelings, such as pleasure, and other reasons for action, such as the interests of family members. Such intense feelings both widen and narrow. These feelings widen the realm of possibility by making what was otherwise “unthinkable” now “thinkable,” leading to impulses to kill oneself. And these feelings narrow the realm of possibility as they become the dominant reason motivating action, thereby precluding some responses (such as getting professional help) so that suicide appears to be the only option left. Our reaction to suicide is typically confusion, as we try to attribute rational causes for the act. But the mechanism of reasoning here is typically more complicated than straightforward logical thinking, due to the influence of intense emotion. Our typical way of thinking about reasoning as arguing from premises to conclusions or as weighing pros and cons in order to come to a decision about how to act does not often capture what occurs in suicide. A story will illustrate. A couple of years ago, a recent graduate from the school where I teach had killed himself. At his funeral, the priest who was leading the service said that it was okay for this man’s family and friends to be angry at the young man, angry because they – his loved ones – were not enough reason for him to stay alive. What this priest did not realize, or at least acknowledge, is that this young man’s suicide had nothing to do with his loved ones. Their interests and their care for the young man probably fell off his deliberative screen completely. I do not know his mental processes as he committed his act, though

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I do know that he suffered from a mood disorder. For some people with mental illness who end up attempting or committing suicide, overwhelming emotions or intense feelings become unbearable, and this unbearableness is the “reason” upon which they act, crowding out competing reasons and alternative actions. In some suicides a person is driven by an obsession with death and an unbearable intense state; at some point it might seem to the person that the only way they can alleviate these is to carry out the act with which they are obsessed. Van Wyck Brooks describes this obsession vividly: I was possessed now with a fantasy of suicide that filled my mind as the full moon fills the sky. It was a fixed idea. I could not expel this fantasy that shimmered in my brain and I saw every knife as something with which to cut one’s throat and every high building as something to jump from. A belt was a garotte for me, a rope existed to hang oneself with, the top of a door was merely a bracket for the rope, every rusty musket had its predestined use for me and every tomb in a graveyard was a place to starve in. I could see an axe only as lethal and every bottle meant for me something to be swallowed in splinters or to slash one’s wrists with, while even a winter snow fell in order to give one pneumonia if one spent a night lying on the ground.82 With such an obsession, a person might feel compelled to kill themselves, perhaps even perceiving a directive or hearing a voice demanding that they do so. Compulsions like these may push other options for acting off the deliberative screen, to the point that reasons against suicide – including the effects it will have on other people, such as loved ones – become irrelevant. However much a person who attempts or commits suicide uses means-end reasoning to make their decision about killing themselves, it is important to keep in mind the context in which they are reasoning and the role that emotion plays in narrowing or widening the scope of possibility. When a person’s suffering is unbearable and they see no way out, they do what they think is the only thing they can do. And if they feel compelled to act, especially if that compulsion seems to come from a source external to themselves, like a voice occupying their head, they may feel they have no other option but to obey. Reasons for acting which we believe should be motivating – such

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as the effects of our action on others – may have no bearing on an individual’s decision if the reasons do not show up on the person’s deliberative screen. Overwhelming emotions easily crowd out other reasons for action. Can we judge a person for not taking into account factors they are not capable of considering, as the priest suggested to the young man’s family and friends? This seems unfair. Should we be angry at a person for not considering the effects of their actions on others, or for feeling like our feelings were not “enough” of a reason for the person to stay alive? Again, this seems unfair. Emotions like anger directed at someone who killed themselves are valid to the person experiencing them. But when anger is connected to a judgment about a person, holding anger and judging someone who was not capable of accounting for certain factors in their reasoning seems unfair. In a ppro p r i at e A f f e c t a nd A ge n cy Inappropriate affect impacts epistemic and moral agency, which I develop in detail in the following chapter. Insofar as we use emotions to develop knowledge and understanding, having emotions that do not fit the context, or failing to recognize others’ emotions for what they are, or being unable to respond in emotionally appropriate ways, impairs our ability to acquire knowledge and make meaning. This can blunt a person’s capacity for intelligibility, shared meaning, and shared understanding of the world, as well as make it more difficult for a person to take up multiple perspectives and develop deeper self-understanding. In addition, inappropriate affect directly impairs the emotional capacities required for moral motivation and for deep understanding and sophisticated discernment in moral reasoning. In challenging a person’s epistemic competence, inappropriate affect can impair a person’s ability to understand what is of value and why, making moral engagement more difficult. These impairments of epistemic and moral capacities can threaten a person’s moral integrity by causing the person to act in ways that conflict with their values, by disrupting whatever unity they might have as a moral agent, and by interfering with a person’s ability to respond appropriately to moral claims. A person with severely inappropriate affect may be regarded as too strange to be recognized as a member of the moral community. When the badness of an action is apparent, we tend to want to assign blame for the action and so we assume that the person who

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acted had sufficient rationality and control over the action. This is true whether we are talking about actions such as Mr M’s infidelity, Mary Weiland’s burning thousands of dollars’ worth of clothing, or a killing committed in rage. Yet, when a person has a serious mental illness such as a mood disorder, they likely have affective impairments that compromise their reasoning and volition. Serious mental illness predisposes people to inappropriate moods and emotions that unduly widen or narrow the scope of a person’s reasons for action and the options available to them. We want to assume they have sufficient agency so we can assign blame to them, but in fact their agency may be severely compromised. One problem with this is that we cannot know with any certainty the kind and degree of agency they actually have. As noted above, and as I discuss further in chapter 4, we must be mindful of our epistemic limitations as we decide how to respond to and hold someone responsible for their bad actions. Self-Harming Behaviour and Different Contexts of Valuation Even today I vividly remember what it was like to organize my whole life around smoking. When things went well, I reached for a cigarette. When things went badly, I did the same. I smoked before breakfast, after a meal, when I had a drink, before doing something difficult, and after doing something difficult. I always had an excuse for smoking. Smoking became a ritual that served to highlight salient aspects of experience and to impose structure on what would otherwise have been a confusing morass of events. Smoking provided the commas, semicolons, question marks, exclamation marks, and full stops of experience. It helped me to achieve a feeling of mastery, a feeling that I was in charge of events rather than submitting to them. This craving for ­cigarettes amounts to a desire for order and control, not for nicotine.83 For Jon Elster, smoking was a way to achieve control that he desired. It was a rational and effective means for the end he sought; it served a purpose that he could explain intelligibly to others. While to my knowledge Elster does not have a mental illness, his explanation of his smoking is one to which I believe many smokers, including those who have serious mental illness, can relate. Since people who have mental illness are particularly likely to feel that many aspects of

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their lives are outside of their control, this need for mastery may be especially acute. People engage in behaviours for reasons that are sometimes intelligible, though they may seem misguided to others. In other words, sometimes our behaviour is rational, yet seems morally wrong. A person may use reasoning correctly, trying to attain something that they value, such as happiness or tranquility, based on beliefs they have about how they can best attain what they value, which in turn are based on the information available to them. And yet, we may judge their choices as wrong, not because they are irrational, but because they are based on a valuation system, and corresponding beliefs and information, we do not share. When people’s actions violate values in an egregious way, this can make us question whether a person is a fit recipient of reactive attitudes, whether they are able to make autonomous choices, whether they are capable of taking responsibility for themselves, and even whether they can have a meaningful moral identity that makes them a recognizable member of the moral community. When people act in ways that seem to violate important values, we may question whether they are capable of moral integrity. C on tex t s o f V a l uat i on Different contexts of experience affect what people value and what choices they make in how they behave. Consider the decision to smoke cigarettes. Many people, especially those who are reading this book, would never smoke cigarettes and would regard smoking as both unhealthy and disgusting. Due to successful anti-smoking campaigns, we now make judgments about smoking based not only on health but also on aesthetics; both of these extend into a moral judgment about the nature of the person’s character. We associate smoking with low class, and for many reasons. Smokers disproportionately have lower income, and smoking is an expensive habit that contributes to people’s impoverishment. We believe that educated people “should know better” about the long-term health impacts, and that educated people are more rational and more invested in the future in a variety of ways and so should care more about long-term impacts. People with higher income also tend to care more about the aesthetic dimension of an activity and the status associated with good aesthetics because they can afford to do so, and they do not want to engage in something that is deemed disgusting. People who seem to not care

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enough about aesthetics, who do not regard smoking as disgusting, who are not wholly motivated by their long-term interests, and who spend so much money on something so bad for one’s health are typically judged as having a bad character: stupid, lazy, weak-willed, and oriented toward the ugly rather than the beautiful. Almost all people, including almost all people who smoke, know that smoking is bad for physical health.84 Yet some people choose to smoke anyway. Why? Because smoking fulfills certain needs: it can produce pleasure, but it also calms anxiety, reduces agitation, lessens psychosis, and provides a general feeling of well-being. It is an easier drug to take than most other drugs because its effects occur almost instantly upon inhalation; its effects last for a specific, relatively brief length of time and in this way are controllable; and it does not have side effects that interfere with daily functioning the way nearly every other drug that can produce similar effects does. People who have reason to discount their long-term interests may find that these shortterm benefits outweigh the long-term costs of smoking. Long-term health risks seem irrelevant to decision-making when a person is just trying to get through the day or even just the moment. Kurt Snyder explains the function that smoking served for him: Smoking cigarettes was an escape for me. I had started smoking a few years earlier … When I was psychotic I would sometimes smoke four or five cigarettes in a row while I was trying to sort out what was real from what wasn’t. While I was sucking on a cigarette, I would forget about the turmoil in my mind. The effect never lasted longer than the ­cigarette, but it was a few minutes of calm, or at least a reduced state of anxiety.85 To people who suffer from severe anxiety or depression, or who are agitated, psychotic, or suicidal, smoking in order to relieve those symptoms and help them feel tolerable seems like a pretty good idea. To people whose lives are filled with hardship, pain, and suffering, smoking in order to feel like they can deal with their lives and make their lives manageable seems reasonable. Is it fair to judge such people as “bad” people? I submit that it is not fair to judge them as “bad” people, considering the context for their action. People who have mental illness, especially chronic and severe illness, live with daily stresses that may be foreign to those without such

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illness. For example, the mental anguish that accompanies many symptoms and the physical agitation experienced by many who are extremely anxious, severely depressed, suicidal, manic, or psychotic can be hard to comprehend for those who have not had these experiences. The pressures of trying to hide one’s symptoms, of trying to fit in socially, and of trying to interact with others who are afraid of or disgusted by oneself are taxing. When people experience overwhelming emotions like rage or anxiety, intense feelings such as one’s head is exploding, distressing symptoms of psychosis, or unremitting obsessions of things like other people or death, they might do almost anything to relieve those intense experiences. Lori Schiller describes her cocaine use as a way to relieve the voices in her head: All I was trying to do was to feel better. Those medications they gave me in the hospital were useless. I took them because people told me they would make me better. But lots of times I didn’t know why I bothered. The only thing those fistfuls of stupid pills did was make me fuzzy and disoriented, as if I were at the bottom of a swimming pool. And the Voices still raged away at me, mocking the drugs, the doctors and me. Cocaine, on the other hand, helped me ignore the Voices. For as long as it lasted, cocaine made me feel alive. It made my senses feel sharp and clear again. When I did a line, I felt good, I felt real, I felt vital in a way I hadn’t since long before the Voices entered my life. Cocaine directed my attention outside of myself. As long as I was high, I had enough strength to ignore those Voices calling me back into their world.86 Although Schiller describes her motivation for cocaine use, the same motivation can apply to the use of any drug, including nicotine, and even any self-harming behaviour. When experiences of mental illness symptoms overwhelm people’s mental awareness and wash out all other mental experiences they could have, those experiences – and trying to relieve them – might be the only thing they can think about, and these experiences might condition all the person’s action. When people live with such constant mental and physical anguish, they typically focus on daily survival, trying to get through the day by minimizing their distress as much as possible.

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People who have mental illness live not only with the daily stresses caused directly by their illness but also the stresses caused indirectly by having to live with their illness in a society that does not accommodate them well. People with chronic and severe illness are more likely to be poor, under- or unemployed, and have substandard housing if not homelessness. People with chronic and severe mental illness have high rates of incarceration, typically for petty crimes, such as loitering, vandalism, drug use, or petty theft, that stem directly from their illness. Because people with severe mental illness are typically poor and live on the margins of society with respect to employment, education, housing, and the criminal justice system, they typically live day-to-day, focusing on their daily survival as they try to meet their basic needs as best as they can. Moreover, stigma exacerbates smoking and other self-harming behaviours, as people try to mask their shame with their coping method of choice, which is the harmful behaviour in question. Stigma also exacerbates self-harming behaviours by leading to judgment, blame, avoidance, and social exclusion. All of these inhibit a person’s ability to access resources that could help reduce self-harming behaviour and their ability to participate in opportunities to learn and develop alternative behaviours. Fu tu r e v e rsus P r e se nt I nt e r e s t s When people focus on daily survival, they focus on relieving present suffering and meeting current needs. In this state, it can be very difficult to think realistically about future needs and well-being. People might not be able to see themselves as living in the future, especially if they are suicidal or otherwise obsessed with death; their suffering and agitation may be so great that it overwhelms their ability to imagine themselves as having a future beyond the immediate present. Because caring about long-term health or saving money for retirement or some other goal requires imagining a future self who will experience this health or gain from meeting one’s goals, people whose mental experience keeps them focused on current needs and present suffering will be unable to be motivated by long-term health or saving for the future. They will be unable to value the same things that people capable of imagining a future self can value. In an economic model of rationality, this lack of consideration for long-term interests, even when they are significant in comparison to

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short-term interests, is called “time discounting.” This phenomenon occurs when we discount a larger reward in the future because the smaller reward in the present dominates our reasoning.87 Philosophers disagree about whether choices made while discounting the future are rational, but surely they are not maximally rational.88 In typical models of rationality, a maximally rational person can consider what their interests would be at different times in their life, take all of these into account, and make choices based on this. A person who is unable to see themselves in the future and unable to account for long-term interests sufficiently reasons from what we might think of as a “timeslice” perspective, looking at their interests during a single snapshot of their life rather than over a duration. This view of rationality provides important insight into why we value taking into account long-term interests: we account for more perspectives and so we develop a more “objective” view of our interests from which to reason. This view, however, is also privileged in that it assumes an ideal not everyone is capable of. Moreover, it is not even clear that everyone should account for their long-term interests in the same way. From the vantage point of the person who does not suffer from mental illness, failing to account for long-term interests seems like a rational impairment. From the vantage point of the person who does suffer from mental illness, not caring about long-term health, safety, or financial security seems perfectly rational: it seems pointless because the future is not relevant. How we assess the rationality of the person who chooses to act in ways that damage their long-term interests for short-term gain depends at least in part on where we stand in comprehending their context for decision-making. There are many behaviours besides smoking that people with mental illness engage in to try to relieve their suffering, including substance abuse, disordered eating, and self-mutilation. These behaviours are functional for people who engage in them; they serve needs such as regulating emotions, gaining control over experience, and relieving distress. People engage in these behaviours because at the time of acting these behaviours seem the best way to solve their problems; long-term and indirect effects may not appear at all on the deliberative screen. People who do not engage in self-harming coping behaviours typically find it hard to understand why a person would engage in them when the potential for harm is so great. Even if we can understand the effect of the behaviour on alleviating suffering, we may still

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struggle with understanding how that relief of suffering can be worth the greater damage the behaviour causes. Similarly, we may struggle with understanding how someone could want to hold onto symptoms that seem to cause problems and distress. People capable of imagining a future self have difficulty understanding what it is like to not be able to imagine a future self, and judgment arises from assuming that everyone should (and everyone can) imagine a future self. A person may make decisions that are self-defeating in the long term or have greater indirect effects but seem to make sense when viewed through a time-slice perspective of the present, for example taking drugs that obviate their awareness of their suffering.89 Many mental illness symptoms support a time discounting of the future that leads to selfharming behaviour, such as smoking cigarettes. Differ e nt C ont e x t s of V a l uat i o n an d Ag e n cy One might argue that in prioritizing short-term alleviation of suffering over long-term health and well-being, the smoker values the wrong things. It may be argued that while the reasons for a person’s action are intelligible when time discounting is taken into account, the person who engages in self-harming behaviours reasons from a faulty valuation system, one that does not adhere to cultural norms. Members of a shared moral community are expected to adopt the community’s values, and their actions and character are assessed by those values. To the degree to which a person’s actions seem to stem from faulty values – values that defy social norms – the person may be marginalized from the moral community, not accepted as a member, and not recognized as a full moral agent. To at least some degree, people who engage in self-harming behaviours like smoking are indeed marginalized by their community, disparaged, and ostracized. This ostracism compounds the effects of stigma experienced by the populations more likely to engage in smoking, particularly people with mental illness. Stigma against smoking exacerbates stigma against mental illness. The criticism that a person values the “wrong” things is made from the vantage point of someone who has the capacity to value the “right” things by imagining a future self. To evaluate someone’s action according to a standard that they are not capable of accepting seems unfair, however. It seems wrong to judge someone who fails to value longterm health or savings as being morally “bad” when the judgment is made from a perspective that the person being judged is incapable of having or would simply not accept.

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A person who acts from a different context of valuation is impaired in a way that is distinct from the ways that one might be impaired by psychosis or inappropriate affect. This is because reasoning from a different context of valuation is not necessarily irrational; in fact, it can be quite intelligible when the reasons for action are understood. A person who acts from a different context of valuation fails to recognize or prioritize the moral norms of their community, in this case moral norms prohibiting harmful behaviours that lead to long-term costs. The person’s connection to reality and their ability to develop and use appropriately epistemic capacities is variable; they may be capable of taking up multiple perspectives and developing deeper self-understanding, as well as trusting in the world and in other people. A person who acts from a different context of valuation may or may not have their unity as a moral agent disrupted, depending on whether the values underlying their reasoning – such as the value of alleviating immediate suffering – conflict with other values they hold dear. Regardless, they may be marginalized from a moral community, especially if their defiance of social norms is seen as egregious.

Con c l u s io n : H ow O t h e r People Can Help Mi t ig at e A g a in s t C o n s t rai nts on Agency Most people who have mental illness – whose functioning is impeded by their mental disorder symptoms – experience various mental impairments like those I discuss here. I have personally experienced the mental impairments described in this chapter at various times in my illness. In the throes of mania, I have performed actions that I would never do when not manic, some of which embarrass and shame me. I have been suicidal for long stretches of time and was hospitalized for severe psychotic depression a couple of years ago. At various times I have engaged in self-harming behaviours in a misguided effort to soothe myself. When manic I have sometimes taken up smoking, something I would normally not do. I have performed actions that inadvertently caused harm to others and to myself. When manic, depressed, or psychotic, my thought processes change dramatically; my beliefs change as I take outlandish ideas seriously; even my values change. What once made sense no longer does when I am actively ill, but what makes sense in my idiosyncratic frame of mind will later appear misguided, if not nonsensical. I cannot explain, never mind justify, some of the choices I have made. When manic, depressed, or

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psychotic, I cannot see myself or the world around me clearly, and I am sometimes unable to be adequately rational in my thinking about what I should do and how I should behave. In this chapter, we have seen so far some of the ways that mental illness impairs aspects of epistemic and moral agency. While the impairments I discuss here are mainly due directly to illness, a person’s social experience plays a significant role in mitigating or exacerbating such impairments. People who have meaningful social relationships and ample opportunities for social interactions are able to develop and draw upon epistemic resources and moral capacities that people lacking these relationships and opportunities for social interaction do not, as I explain in the next chapter. Other people help provide a reality check that a person may be unable to accomplish in their own head. A psychotic person may have a difficult time believing others and accepting their perspectives, but when other people repeatedly confront them with the shared understanding of reality, their view of the world may begin to change. If they never have the opportunity to interact with others who can offer the shared understanding of reality, however, they never have the external stimulus that could drive change. While people do not always change in response to external factors, external factors nonetheless provide the conditions for the possibility of change. Other people can broaden or narrow options more appropriately. For example, a person contemplating suicide may feel so overpowered by emotion or even psychosis that they cannot see the range of options available to them; they may see suicide as the only way out of their suffering. Meaningful engagement with a person considering suicide may allow them to see possibilities and options that were clouded over, and it may make reasons against suicide seem more real and present in contrast to the cloud of depression that shrouds and distances those reasons. I want to be clear that talking with someone contemplating suicide may certainly not be sufficient to change their behaviour, and we should never blame ourselves for not having succeeded in talking a person out of such an act. But engaging with a person considering suicide does allow the opportunity for a change in outlook, an opportunity that person may not have when they are thinking only in their own head. The external stimulus of talking through reasons and options may not be sufficient for a person to change, but it does create an opportunity for change that might otherwise not be present.

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Engaging with someone who is manic can be difficult in a different way because they are more likely to have the cognitive and perceptual impairments of psychosis and so be less rooted in reality, even as they believe their actions make sense. Communication with others, however, can help a person recognize when their emotions are excessive, misplaced, or otherwise inappropriate, and help them see that what they are doing is unreasonable or nonsensical. Other people can help calm a person so they can think more clearly and identify and have some control over what they are feeling. Other people can also help the person recognize actions that are inappropriate and contemplate actions that would not otherwise be considered. No matter how irrational a manic person may seem, communication with them can be instrumental in moving them out from the state of irrationality. Other people can also engage with a person who reasons from a different context of valuation in order to understand that context better and to seek shared meaning and values. We cannot make a person who does not see themselves in the future value their future interests; however, we can treat the person with respect and dialogue with them about what is important to them in order to establish shared meaning and develop credibility. With shared meaning and the granting of respect and credibility, we open up the possibility for transformation – for ourselves as well as for them. If I were taking a paternalistic approach, I might suggest that a person who engages in self-harming behaviours may not recognize the reasons for not engaging in such behaviours, or at least recognize them as sufficient to act upon; I might also propose that engaging with a person who self-harms may change what options are available to them as a means of coping with their situation. But this approach demeans the person who engages in these behaviours by failing to take seriously their own reasons for acting. People who engage in these behaviours know that other people think they should not do so, and they understand the reasons why, at least according to others, they should not do so. The problem is not a lack of knowledge but a difference in valuation and its effects on reasoning. These behaviours serve particular functions for the people who engage in them and make sense within that functional framework. The appropriate response, therefore, is not persuasion but respect. We would serve a person in this context better by trying to understand their reasons, thereby creating the conditions for an open dialogue, than by trying to change them. In addition, as I describe in some detail in the following chapter, other people can help a person develop epistemic resources and

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normative capacities, including the cognitive and emotional skills necessary for moral reasoning, judgment, and decision-making. This is crucial because if a person already has a solid set of skills and resources, then they have more to draw upon when they are vulnerable and impaired by illness. Similarly, if a person is generally good at recognizing a moral situation and discerning what it calls them to do in response, they will have an easier time doing this, even when they are impaired. Having a high level of epistemic resources and normative competence gives a person more in reserves that they can use when their impairments create difficulties accessing or maintaining these resources and capacities. Other people are also essential for providing individuals with the recognition they need as moral agents. A person can better mitigate against the impairments caused by their mental illness if they are recognized and accepted as members of a moral community who can make moral claims with authority, who can respond to others in appropriate ways, and who can help set the standards of the community and evaluate themselves and others according to those standards. While people with mental illness may be impaired in some of these respects, as we have seen in this chapter, recognition of their general moral agency, despite specific instances of impairment, will go a long way in helping people preserve what moral agency they have as opposed to having it withered away through disregard and lack of exercise. Treating people as moral agents in general, despite whatever specific incapacities they have, is crucial for the preservation and possible development of their agency. People who have mental illness experience direct constraints on their agency due to both internal factors (their mental illness symptoms) and indirect constraints arising from external factors (stigma and social isolation). I now turn to an examination of some of the external factors that indirectly constrain agency. In the chapter that follows, I delineate the ways that mental illness symptoms and stigma work together to produce social isolation in people who have mental illness. I show how devastating and dehumanizing this social isolation can be by explaining how important social interaction is for the development and exercise of agency. I develop an account of agency that is essentially relational, requiring us to be recognized by others as members of moral and epistemic communities and capable of speaking and acting in legitimate and meaningful ways. Our sense of ourselves as agents and as human beings rests on our ability to be, and to be recognized as, social beings.

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3 The Isolating Effects of Mental Illness: Indirect Constraints on Agency

In t ro du c t i on Confused, exhausted, buffeted by voices … I begin to stay in bed all day and night. I no longer make an effort to join people for supper or to walk to the library. Now when there are midnight bull sessions … I stay in bed under a heap of blankets, my face covered and my presence unacknowledged.1 In college, Pamela Spiro Wagner’s symptoms of schizophrenia slowly took hold of her. In the above passage she describes the self-imposed isolation she experienced while the symptoms overcame her. Her symptoms, which included hallucinations, delusions, and paranoia, affected her sense of reality and made interacting with others nearly impossible. – The weeks passed, and I was quite isolated. I occasionally got out of the house to play pool with friends, but I felt I could not trust them. At home I smoked incessantly and spent a lot of time petting my dog out on the back porch and drinking coffee. Animals were a welcome relief. The voices outside my window became a nightly occurrence, and I would listen to get the next clues as to what I should do. To an outsider, I may have come across as just shy and a bit withdrawn, and I was able to carry out my day-to-day life like anybody else. Nobody knew about the real discord in me.2 In this passage, Richard McLean describes the loneliness he felt as a young man with schizophrenia, becoming more and more paranoid

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and delusional. He notes that other people observing him might not (at this stage in his illness) notice anything wrong with him because he still appeared functional, but inside he felt cut off from others in a fundamental way. – Paid helpers surrounded me every day, for many years. For six or seven years of my life there was no one, except my closest family, who spent time with me for free, voluntarily, or without receiving payment. That did something to my self-image.3 For several years Arnhild Lauveng lived in mental institutions, interacting only with mental health professionals and institution staff. As her only experience was through the institutional setting, Lauveng was largely socially isolated, lacking anyone in her life that she could consider a friend. – Experiences like these of social isolation are not uncommon for people who have mental illness. In this chapter, I explain how and why this social isolation arises, and why it is so detrimental, focusing on the ways it diminishes agency. People with mental illness often face isolation, sometimes extraordinary isolation, from at least two sources: the self-absorption that their illness causes and the social exclusion that results from stigma, prejudice, and discrimination. These internal and external sources of isolation frequently exacerbate each other, creating a particularly high barrier for people with mental illness to overcome as they try to develop and exercise moral and epistemic agency. Since humans are essentially relational and social beings, and our agency and identity are constituted in part by our interpersonal interactions and our relationships with others, extreme social isolation that constrains the development and exercise of agency threatens to dehumanize us. Being an agent requires being part of a community. Engaging in epistemic practices requires that there are others who are engaged in the same practices of knowledge-seeking and meaning-making; only in relation to others can we develop a meaningful understanding of the world and of our relationship to the world. Being able to perform rational and freely willed action for which we are responsible requires that there are others from whom we learn what we ought to do and why, and who determine and enforce the moral standards by which we are appraised. In order to be capable of responsibility, we need others to be accountable to, and to be able to give an account to. In

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order to be capable of rationality, our reasons for action must be intelligible to others, and only others can determine their intelligibility. Moreover, we can participate meaningfully in epistemic or moral practices only when we are accepted by others who engage in these practices as people able to participate meaningfully. In other words, we are only members of a community if we are accepted as such by other members in that community. Extreme isolation, therefore, prohibits us from opportunities to be recognized by others and to engage in the social interactions necessary for agency. While a person with mental illness experiences isolation directly due to their illness, stigma exacerbates this isolation by excluding the person from being recognized by others as a member in a shared community and consequently from being able to interact with others in meaningful ways. A person who is not accepted as a member of any epistemic or moral community lacks the ability to engage meaningfully in epistemic or moral practices and so lacks the ability to develop and exercise agency. A person who is extremely socially isolated, therefore, lacks the conditions that enable them to be an epistemic and moral agent and to be recognized by others as fully human. I begin this chapter by examining the ways that symptoms of mental illness often promote self-absorption and isolating behaviours and reminding the reader of the ways that stigma around mental illness frequently leads to social exclusion. I analyze how self-absorption and social exclusion operate to produce extreme isolation. This isolation creates barriers for people with mental illness to develop and exercise agency, barriers which are in addition to those caused directly by the mental impairments that characterize their illness. I explain some of the ways that being members of epistemic and moral communities allows us to develop and exercise many aspects of agency by enabling us to develop a meaningful understanding of the world, to understand and apply evidential norms to reasoning, to gain recognition by others, to develop the emotional acumen to respond to others appropriately, to develop an understanding of what counts as intelligible action, to develop a valuation system, to be able to give an account and be held accountable, and to have integrity. Because mental illness frequently leads to social isolation, people with mental illness have reduced opportunities to engage in the epistemic and moral practices that enable them to develop and exercise agency. In order to humanize people with mental illness, therefore, it is paramount that we create opportunities for social engagement.

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M e n ta l Il l n e s s Symptoms , S oc ia l W it h d r awa l , a n d Self-Abs orpti on Mental illness frequently causes people to adopt isolating behaviours. Social withdrawal and apathy, for example, are common symptoms of many disorders, including schizophrenia, depression, and eating disorders. Delusional or otherwise psychotic people tend to avoid others or they develop strange behaviours that cause others to avoid them. Because of symptoms that make them feel essentially different from other people, those who have schizophrenia, for example, generally prefer social situations that have specific goals and clearly defined roles rather than the organic interactions involved with more natural (less defined) social relationships like friendships.4 People who are depressed typically find social engagement too much effort; they may have trouble getting out of bed; they may feel too worthless to be able to have a conversation with others. People who have problems with eating disorders or addictions may avoid social situations that trigger compulsive desires, or they may avoid situations where they feel they will be watched or judged by others. Moreover, mental illness frequently causes people to be selfabsorbed, and this self-absorption is typically isolating. Many of the symptoms of mental illness occupy a person’s attention so much that they have little attention left to give to anyone or anything else. A person who is paranoid, obsessive, compulsive, anxious, depressed, or manic may spend a lot of time ruminating, worrying, planning, connecting ideas, developing beliefs, or obsessing over things. There may not be much room left in the person’s mind to turn outward to others. Mental illness can put a person into a state of being “too much in their own head.” Self-absorption occurs not only due to symptoms but also due to the therapeutic process of healing. People in the process of treatment or recovery often spend a great deal of time and attention being introspective about their thoughts, feelings, and behaviours, as they try to develop better cognitive and emotional skills and better habits and responses. This extreme focus on the self as a person works toward mental health or recovery can make them quite self-absorbed. People with mental illness are also frequently self-absorbed due to a lack of self-worth they develop in response to their illness. While some people with mental illness have inflated self-esteem (such as in narcissism, mania, delusions of grandeur, and psychopathy), many

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others have very poor self-esteem. This is sometimes a direct symptom of illness – such as in depression or anxiety – but is often also an indirect consequence of living with the illness. Many people with mental illness have internalized stigmas against mental illness, adopting self-stigma. They may feel as if they have little or no control over their illness and so feel defeated by the illness; recognizing their diminished self-control, they see themselves as having diminished moral agency and thus view themselves as less than fully human. They may know that others look down on them for being self-absorbed and possessing symptoms that are often unlikeable and fearful, symptoms that they have little control over, and they may develop a sense of self-loathing.5 It is difficult for people filled with self-loathing to interact well with others, because their preoccupation with their perceived badness interferes with their ability to turn their attention outward to others. Self-absorbed people effectively isolate themselves from others because in turning and keeping their attention inward, they fail to connect in meaningful ways. Even when they are physically in proximity with others and nominally in relationships, their self-absorption prevents them from interacting in socially meaningful ways. When a person is mentally ill for a long time, the long-term self-absorption that typically accompanies their illness can damage their relationships and their ability to form new relationships such as friendships or acquaintanceships. Family members, spouses, and children of people with chronic, severe mental illness often find it difficult to maintain what they perceive as a one-sided relationship and sometimes sever the relationship or let it drift away. People with chronic, severe mental illness frequently become estranged from family members and lose friendships.6 In all of these ways, mental illness frequently and easily leads to isolation. This is highly problematic because not only does a person lose existing relationships and the possibility of new ones, but they also lose the ability to interact with others in meaningful ways. This loss of interaction affects them in multiple ways. The longer that they are without meaningful communication with others, the less they are able to develop their own views of the world in relation to others, and the more solipsistic (and potentially delusional) they are likely to become. Without meaningful interaction they fail to engage in epistemic practices that affirm their ability to make meaning and

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contribute something of value; they fail to act in ways that promote a shared understanding of the world; and they fail to make themselves, and their actions, intelligible to others. Without meaningful interaction, they fail to engage in moral practices such as recognizing moral norms and what is morally salient in a situation, discerning what a moral situation calls one to do, and responding to others appropriately. Adding insult to injury, the longer that a person lacks meaningful interaction, the more reinforcing their solipsism becomes, making it harder to overcome even when opportunities to interact do present themselves. In short, without meaningful interaction, a person with mental illness fails to develop and exercise their epistemic and moral agency – and finds it increasingly difficult to do so when given the opportunity. A good example of how this solipsism is self-perpetuating is the way that the inner world of people hospitalized for a long time becomes smaller and smaller, as they interact only with other patients and with medical professionals. When their world is the hospital, their inner world comes to revolve around their symptoms and whatever interpersonal drama may occur within the hospital. Insofar as illness is iatrogenic, this constant focus on their symptoms arguably exacerbates the symptoms. When a person who has been in a closed environment like this for a long time finally leaves that environment, they often find they lack the abilities to make themselves understood by those outside the hospital, to share with others recognition of what is important, and to respond to others in appropriate ways – in short, to interact meaningfully with others.7 Self-absorption is an epistemic vice that has effects on moral agency. Self-absorption is an epistemic vice because, in directing a person’s attention and energy nearly entirely toward herself, it limits their capacities as a knower. We need others in order to engage in the epistemic practices that enable us to pursue knowledge and make meaning; most, if not all, epistemic practices could not be occur without engagement with others. Consider the following activities: perceiving and understanding accurately other people’s views and reasons, taking into account multiple perspectives, revising one’s own view, being responsive to reasons given by others, and giving reasons for one’s own view which are intelligible to others. If a person can see the world only from within their own internal perspective, this greatly limits what understanding they can have of the world and of

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themselves. Such narrow perspective can have damaging effects on moral agency in greatly limiting a person’s options for action, guiding moral action incorrectly, and hampering moral responsibility. In limiting a person’s ability to engage in epistemic practices, therefore, selfabsorption is an epistemic vice with consequences for moral agency as well.8 In order for a person with mental illness to participate meaningfully in practices of pursuing knowledge and making meaning, the person must be able to overcome at least to some degree the self-absorption that their illness tends to cause. Those who want to enable the person with mental illness to be an epistemic agent must find ways to help the person transcend this self-absorption. I discuss this further in chapter 5.

M e n ta l Il l n e ss Sti gma a n d S o c ia l E xclus i on In chapter 1, I explain how stigma leads to prejudice and discrimination. While the prejudice and discrimination that accompanies stigma can cause many harms and injustices, including abuse, neglect, oppression, exploitation, and marginalization, one of its major harms – the one I am focusing on here – is social exclusion. Social exclusion largely comes from our fear of the unknown and our reaction to the inherent strangeness of some of the behaviours and experiences of people who have mental illness as we respond with stigma. Social exclusion occurs through both informal reactions such as avoidance and discriminatory behaviour, and through formal responses such as discriminatory policy and rejection from important life domains like work and housing. Social exclusion involves everything from people crossing the street to avoid having to speak to someone who seems to have mental illness to the systematic social exclusion involved with the homelessness, incarceration, and other forms of institutionalization that many people with mental illness experience. People who have mental illness face social exclusion that creates strong barriers for them to develop and exercise their agency, as social exclusion impedes their ability to participate in the epistemic and moral activities that enable agency. In the rest of this chapter, I explain the ways in which social exclusion diminishes many important aspects of agency.

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A g e n cy As initially discussed in chapter 1, agency involves a set of capacities required to act in certain realms, and being an agent means being the kind of person who has these capacities. We are moral or epistemic agents when we have the ability to engage in moral or epistemic practices and thus be knowers or doers. Being a moral agent and having the ability to act in moral contexts requires many skills and competencies. These include the ability to understand norms and to identify and examine morally salient features of a situation; the ability to discern other people’s emotions and to respond in emotionally appropriate ways; the ability to acquire sufficient knowledge about a situation, in order to understand it well enough to make judgments about how to respond to it; the ability to care about others; the ability to understand reasons for action and to assess those reasons; the ability to make decisions based on reasons; and the ability to carry out one’s decision and to act in the ways one chooses. There is a wide range of capacities involved with being a moral agent, and this list is in no way exhaustive. Being an epistemic agent means having the ability to participate in epistemic practices, particularly in the pursuit of knowledge or the creation of meaning. Epistemic practices that a person may engage in include observing, describing, interpreting, analyzing, synthesizing information, organizing information, putting ideas in order, reasoning from premises to conclusions, asking questions, giving reasons, providing evidence, making claims, brainstorming, forming beliefs, revising beliefs in response to evidence, trusting, doubting, being aware of others, being self-aware, discerning others’ emotional states and body language, and many others. Again, this list shows the wide range of what constitutes epistemic practices while being in no way exhaustive. The capacities and skills involved with moral and epistemic agency are mostly learned and developed through practice, although they can be stunted by mental impairments and other obstacles (both internal and external to a person) that prevent them from being developed or exercised sufficiently or in some cases at all. For example, a person with a cognitive disorder may be unable to organize information or put ideas in order; if the disorder is brief and treatable, the person may regain these capacities without problem, but if the disorder

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is chronic, the person may never regain these capacities fully (and may never have developed them fully in the first place if the disorder set in during mid-adolescence). In general, a person tends to get better at these epistemic and normative skills and tends to increase their moral and epistemic capacities the more that they practice them and the more that they see others practising them. When mental impairments hinder the development or exercise of these capacities, however, or when social impediments prevent a person from having the opportunity to exercise these skills, practice may not be enough or may not even be possible. People who face obstacles in developing or exercising their moral and epistemic agency may need additional resources to overcome or at least compensate for these obstacles. The degree of agency a person has depends on the extent to which they have the relevant skills and capacities. A person may lack certain capacities or have underdeveloped skills but still have agency, albeit a minimalist agency, insofar as they can make choices based on their desires and act according to those choices. A person who has greater and more complex capacities has more robust agency. The significance of this is that the person who has more robust agency is more free, rational, and autonomous and has greater control over their mental states and actions. Having greater agency, therefore, is a good thing. We should care about the plight of people who face obstacles to developing and exercising their agency, not because they are “less” human (because they have “less” agency), but because if they are able somehow to have more robust agency they will be better off. Consequently, we should do whatever we can to remove obstacles over which we have some control, such as social barriers and lack of access to effective mental health treatment, and to find ways for people who have deficient capacities to compensate for their limitations. We should also be very careful about how we respond morally to people whose agency is impaired, a point I develop in depth in chapters 4 and 5. The obstacle to agency that this chapter focuses on is social isolation of people with mental illness. To whatever extent we can decrease their isolation through social interaction, we ought to do so in order to provide them with greater means of developing and exercising their agency. Besides eliminating stigma, this is one of the most important ways that we humanize people who have mental illness.

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A Transactional Metaphysics of Agency In order to make sense of certain concepts related to agency that I use in this chapter, I need to give a brief overview of two metaphysical frameworks that undergird my understanding of agency. First, in order to make sense of some of the key features of concepts like agency, knowledge, and identity, we need to understand them as transactional. Things that are transactional are “dynamic entities that are continually undergoing reconstitution through their interconstitutive relations with others.”9 Agency, knowledge, experience, and identity are transactional in that they are continuously reconstructed in relation to other things also undergoing continuous change. Agency, knowledge, experience, and identity are more like processes than objects in the ways in which they are co-constitutive with each other.10 Three processes in particular are important here: the process of change over time, the process of change in relation to other types of things, and the process of change in relation to other things of the same type. The first process regards the temporal dimension, in which things are continuous even as they change over time, having both a history and a future. The agency of a person, for example, is different now than ten years ago, and will be different again ten years into the future; yet, there is a sense in which the agency of the person is ontologically the same, because it is the same thing even as its makeup differs. The second process refers to the way that a thing is reconstituted in relation to different types of things, a relation which tends to be bi-directional or multi-directional rather than unidirectional. For example, knowledge is reconstituted in relation to experience, and vice versa. The third process has to do with the way that a thing is reconstituted in relation to different things of the same type. For example, my agency – my ability to act and respond – is reconstituted in relation to the agency of others. These three processes occur concurrently and continuously, giving these processes a particularly complicated relationship with respect to each other. To illustrate: my knowledge is reconstructed in response to my experience, which – because it is situated in time – continuously changes, and this change occurs also in relation to the knowledge and experience of others, all of which also continuously evolve. If these processes of transactional co-constitution are not yet clear, they will

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become so as the chapter unfolds and I develop the concepts of knowledge, agency, and identity in more detail. The second metaphysical framework that undergirds my understanding of agency is the framework of narrative, which is useful in illuminating some of the key aspects of the transactional nature of things like agency, knowledge, and identity. Thinking about these things in terms of narrative highlights the way these things are continuous even as they change – how, for instance, Point B follows from Point A, and leads to Point C. A narrative framework also demonstrates the way a thing is necessarily contextual, both in terms of how it is constituted (its identity as a thing) and in terms of how it is intelligible (how it makes sense). Understanding a thing as a narrative can help illuminate the background conditions that enable it to be as it is, and in a way that makes sense to us, when normally we take these background conditions for granted, and thus we fail to notice or acknowledge them. Understanding a thing as a narrative also helps us understand how it relates to other things of the same type or other types of things, as these create interlocking, embedded, and/or competing narratives whose relationships we may tease out. In considering agency or identity as a narrative, I am not endorsing a narrative framework as the best way to understand agency or moral identity – I do not in fact think that it is – but I do so as a way to bring out certain features that are worth paying attention to as we understand these concepts. Why Social Interaction is Important for Agency Our moral agency is transactional with the moral agency of others; in other words, who I am and what I can do as a moral agent is transactional with who others are and what others can do. Because of this transactional quality, developing moral agency requires social interaction. People who have mental illness have internal obstacles in developing moral agency, as impairments in cognition, perception, affect, and volition constrain their actions and the kinds of responses they can make to others in multitudinous ways. Because of these internal obstacles, people with mental illness must be given additional resources and opportunities for meaningful social interactions that can increase the actions and responses available to them. Unfortunately, however, people with mental illness are routinely socially excluded through

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stigma, shunning, discrimination, institutionalization, imprisonment, homelessness, and other avenues. To whatever extent the mental impairments caused by their illness limit their capacity for action, social exclusion further constrains and determines them to the point where they may have little control over their actions at all. While in a transactional model it does not make sense to say that a person lacks moral agency, people with mental illness who are deeply socially isolated have extremely limited agency and may lack the ability to develop it in ways that might be beneficial to them. There are many reasons why interacting with others, developing relationships with others, and being recognized as members of moral and epistemic communities along with others is essential to developing and exercising agency. Here, I focus on the ways that interacting with others contributes to our capacities for epistemic agency (including our understanding of reality), our capacities for moral agency (including features of normative competence), and our capacities for moral integrity (including responsibility for ourselves).

C a pac it ie s f o r E p i s temi c Agency Interacting with others is necessary to develop meaning and ­understanding. Part of being human is that we live in a world among other people, and, in order to interact with others, we must share an understanding of the world and of our place within it, including an understanding about how we ought to act. All of moral theory rests on the assumption that we have the epistemic capacities required to develop a shared understanding of the world, that we are capable of bridging our individual private conscious experience with what we know of the world outside of ourselves, and that we are capable of transcending our subjective experience to see the ways in which we share and understand the world with others. Without these epistemic capacities we would be solipsistic, trapped in our own minds, incapable of interacting with others, incapable of self-reflection, incapable of any kind of meaningful agency. People with severe mental illness frequently experience this very problem, due both to symptoms like delusions and paranoia, and to the social exclusion that results from stigma, ignorance, and social apathy. Having adequate epistemic capacities allows us to develop epistemic competence, in which we can use our epistemic capacities in ways that lead to epistemic success.11 When we have epistemic

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competence, we are good knowers capable of engaging productively in practices of knowledge inquiry and meaning-making. We begin learning epistemic capacities at a very young age, even as toddlers,12 and if we grow up in the right kind of environment we develop these capacities through our interactions, through observing adults’ epistemic engagement, and through engaging in developmentally appropriate epistemic practices such as the learning that occurs in school. Observation, practice, and experience are key to developing and maintaining epistemic capacities. Below I explain some of the epistemic capacities required for understanding reality and for interacting with others and the world in epistemically appropriate ways. Capacity for Intelligibility (Shared Meaning) Interacting with others is necessary to develop an understanding of the world that makes sense. Something makes sense, or is intelligible, only if it fits within and flows from some recognizable, relevant context.13 My understanding of intelligibility borrows heavily from two general sources: Wittgensteinian philosophy, which regards meaning as consisting of use or practice, and teleological ethics/narrative theory, which regard action and human experience as intelligible only when strung together with what came before and after (temporal coherence) and only against a background of shared knowledge and beliefs as well as the social structures and practices that sustain these. Let us first examine intelligibility from a Wittgensteinian perspective that understands meaning, particularly with respect to language, in terms of use or practice. According to Ludwig Wittgenstein, language only has meaning as a practice with normative rules that govern correct and incorrect usage. This normativity is constructed through regular participation in the practice by members of a community and who, in engaging in the practice, set the standards of good practice and evaluate each other’s participation according to those standards. Through this participation, standard-setting, and evaluation, members of a community recognize the importance of the practice (as something worth engaging in) and the normativity of its rules. Community members are able to make judgments about whether to recognize someone else as a member of that community – as one who engages in the practice appropriately – or not. Since membership in a community is defined by engagement in that community’s practices, and

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members of a community evaluate whether individuals’ participation in practices meets standards the community has set, a person is a member of a community only if others recognize them as such. A person cannot meaningfully by themselves create rules for a practice, set the standards for good practice, or evaluate whether a particular instance of the practice satisfactorily meets those standards. A sound or squiggle or idea does not have meaning just because I say it does; a rule ought not to be followed just because I claim it should be. Regular use of a word or concept by multiple members of a community whose members recognize each other as participants in a shared practice is necessary for the word or concept to have meaning. Idiosyncratic use creates at best arbitrary meaning. This may create a phenomenological feeling of significance to the idiosyncratic user (“this feels meaningful”), but this does not translate to being intelligible and making sense to others. Intelligibility is a necessarily public phenomenon, for it requires a shared context of meaning and interlocutors other than oneself to create and recognize that shared context. Therefore, we need to be able to participate in shared social practices in order for our actions and experiences to be rendered intelligible.14 From a teleological perspective, action and experiences are intelligible only in relation to certain contexts, including temporal, metaphysical, and epistemological frameworks, which provide the basis for coherence. Teleological ethicists like to use narrative ethics as a framework for understanding how fit within greater contexts is what fixes meaning. My story only makes sense to you, for example, if we share enough of a framework of meaning to make the story coherent. Telling one’s story is simultaneously a way of giving an account of our action and a way of imposing order on what would otherwise be chaos.15 But whether a framework does indeed create order (rather than simply a different form of chaos or disorder), and whether an account of experience does in fact constitute an account, depends on others’ seeing and accepting these as such. What counts as reasoning and order that is recognizable to others depends on others recognizing them as such – and this shared recognition is based on shared background knowledge and beliefs, and the shared social structures and practices that sustain them. The upshot is that intelligibility is based on sharing human experience, and it consists of what others find intelligible. Mental illness experience (particularly that which consists of “madness”), bizarre behaviour, and inexplicable action may not be intelligible because

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they do not fit within or flow from a relevant context of shared meaning. In particular, mental impairments such as delusions or other cognitive problems that distort meaning can destroy any shared context and make action or experience unintelligible. False beliefs are easy to understand here: if I believe my colleagues are trying to fire me, then I will interpret their behaviour through that lens, and my response to their actions will be unintelligible to them because it does not flow from a context of meaning that we share. Uncanny experience is more subtle but just as destructive: if I sense a sinister presence emanating from the sun’s rays, then the pain and terror that I feel in response will cause me to act in ways that do not make sense to others who do not see what I see. For example, my need to hide under something and cover my head may make no sense to someone who does not feel this sinister presence. People who have mental illness frequently have experiences that are fundamentally unintelligible to others, and act in ways that do not make sense, and are socially situated in ways that prohibit them from trying to connect with others in intelligible – or recognizably human – ways. Shared Understanding of the World Interacting with others is necessary to develop a shared understanding of the world. In order to understand the significance of the impact of social isolation on how we see the world, we must understand the ways in which knowledge is “transactional.” To say that knowledge is transactional is to say that it is continually reconstructed through processes of interaction and relationship; in other words, knowledge is constituted relationally, in the context of other knowledge and in relation to experience, and thus is also situated with respect to knowers. What is crucial in understanding knowledge as transactional, rather than as simply relational and situated, however, is that it is dynamic rather than static: it changes constantly, but its changes are in relation to knowers (and their relationships with others), and in relation to experiences (which occur continuously) and other knowledge. Moreover, knowledge is more like a process rather than (merely) an object: it is not simply content that one “discovers” and “collects”; rather it is an orientation one has toward the world, a way of being that enables continual efforts of processing stimuli and developing holistic and contextual understanding.

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Also importantly, the constitution of knowledge is not a one-way relation but a relation of multiple co-constitution. For example, while what we know changes and expands in response to what we experience and observe, what we experience and observe also changes in response to changes in our knowledge and understanding. Another way to put this is that it is through continuous epistemic practice that we develop a shared understanding of the world, an understanding which must continuously evolve in relation to how other people understand and experience the world. People who do not have meaningful ways to engage with others will not be able to develop an understanding of the world in relation to other people’s understanding and experience. At most, their knowledge will be transactional only in relation to their own personal experience. Constraints on a person’s ability to connect with others encourage a solipsistic and even delusional mindset in which a person fails to assess their beliefs and understanding of the world against external criteria, including the beliefs and understanding of others. This greatly impedes agency, of course, making it difficult for a person to act in ways that are intelligible to others. This also promotes the negative feedback loop whereby – whether due to discomfort, stigma, fear, or something else – other people avoid interacting with someone who is solipsistic and possibly delusional, in effect socially excluding the person. Consequently, this reduces opportunities and makes it even more difficult for the person to interact in a way that allows them to develop an understanding of the world in relation to others’ understanding, further magnifying their solipsistic mindset. This impediment to agency is compounded by the fact that knowledge is transactional with epistemic resources like language, concepts, criteria, and categories. We develop these epistemic resources in relation to our experiences in the world and our present knowledge. Social isolation, therefore, hinders a person from developing these resources, putting them at a disadvantage compared to people who have good social relationships and interactions that allow them to develop sophisticated epistemic resources. How people are situated affects what resources they have access to, the ways in which they have access, and the ways in which they can shape resources. Socially isolated people have fewer opportunities for acquiring a broad spectrum of language and concepts, for example, and will only be able to draw from a narrow range of options as they try to understand the world

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and themselves. They lack access to the understandings of others and lack power in shaping understanding. Those socially isolated, therefore, have impoverished language and concepts for understanding their experience or understanding features of the world. People with less access and power over epistemic resources are less able to identify salience in the world in a way that is recognizable by others and not merely idiosyncratic,16 as may occur in mental illness. To sum up, socially isolated people have less capacity to develop, maintain, and draw upon a context of shared meaning from which to understand the world. Responsiveness to Evidential Norms Checking the validity of beliefs and understanding, including selfunderstanding, is essential in order to have beliefs and understanding that cohere with reality. Epistemologists call this checking process “reality testing,” where a person tests a belief in various ways. For example, a person tests a belief against other knowledge they have in order to make sure that it fits within the general web of beliefs, and against common sense and logic, in order to ensure that the belief “makes sense.” They also test it against the beliefs of others, in order to make sure that their belief rests on a shared understanding of the world rather than an idiosyncratic – and potentially false – one. When a person’s belief fails reality tests, then we say it is a false belief. If the person holds onto the belief despite it failing reality tests, we say that the person is delusional, at least in the doxastic view of delusion (in which a delusion is regarded essentially as a false belief, or a belief with false content). A person who fails to submit their belief to reality testing may or may not be delusional in this doxastic sense, but they certainly have no reason to assume their belief is accurate; and, if the belief was not formed in reference to the world and to the beliefs of others, the belief will be narrow at best. With respect to self-understanding, a person who does not engage with others’ views is not able to form a more comprehensive, and in some sense more accurate, self-understanding. Consequently, the ways in which the person can be self-aware and reflect critically on their own mental states and processes is narrow and likely to be false or at least misleading, as their capacities for self-awareness and critical reflection were developed without meaningful context.

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Multiple Perspectives In order to form beliefs, develop self-conceptions, and reflect critically, it is crucial that we do so with others. Epistemic interaction helps broaden our perspectives, which expands our agency. Other people can help us see alternate options for action that we would not have otherwise thought of; other people can help us think through possible outcomes, showing us possibilities that we would not have imagined on our own; other people can even give us hope in looking toward positive outcomes that we did not see, or see as positive, ourselves. Other people can also help us recognize moral reasons that we would not have recognized on our own, help us understand other people’s behaviour and possible motivations differently than we would on our own, and help us understand our own behaviour in ways that we might not see by ourselves.17 Seeing the world through other people’s eyes gives us a much broader understanding of the world and of ourselves as agents. In having this greater understanding, we can be more attuned to situations, make better decisions, be better able to justify our action, and be more effective in acting to create the outcomes we desire. In other words, interacting with others provides great epistemic benefit in increasing our understanding, and this epistemic benefit can often be put to good moral use in increasing our agency. Self-Understanding Interacting with others, and taking on multiple perspectives, is necessary to develop reflexive skills of self-awareness and critical reflection, which are necessary for taking responsibility for oneself and changing what one determines needs changing. Being able to see ourselves requires being able to see ourselves through the eyes of others. We can only have proper perspective of ourselves if we can put our own perceptions in the context of the perceptions of others. Otherwise we are being solipsistic, assuming that the self we see through our own eyes is the only self there is.18 We could observe what is in our own mind solipsistically, describing the contents without reference to an outside world. But then we would have no way of checking its validity. Seeing our beliefs and ideas from the standpoint of others illuminates aspects of them which would otherwise be obscure. In particular,

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seeing ourselves from the standpoint of others allows us to see the background beliefs and assumptions that underlie our conscious beliefs, which we normally so take for granted that they are in effect hidden from us.19 For example, I might see myself as shy or humble, but through the eyes of others I may learn that I am not as shy or humble as I think I am. Or I might see myself as having no worth and nothing to contribute to society, but through the eyes of others I may see that I have value and can make contributions that I normally do not recognize. One way that we achieve this capacity to see outside of ourselves through the lens of others and, therefore, develop self-understanding, is through empathy. Empathy is best understood here as feeling with another person through imaginative reconstruction of that person’s experience, in other words other-oriented perspective-taking in trying to understand what it is like to be that person in their experience. (I explain this in more detail in chapter 5.) This is undertaken generally for the sake of trying to better understand the person and possibly for the sake of trying to help them or respond to them in appropriate ways.20 Through empathy we are able to get outside of our own subjective awareness, our own minds, in order to relate to and connect with others. Empathizing well requires that we understand others’ experience as their own and not simply as copies of ours; it requires that we note the particularity and perhaps uniqueness of their experience so that we relate in the right ways: noting the points of connection (for example, a certain type of suffering) while acknowledging the differences in subjective experience.21 This perspective-shifting gets us outside of our own heads, so to speak, and allows us to see ourselves from a different vantage point. Empathy thus facilitates our ability to “step outside of ourselves” to see ourselves outside of our immediate subjective experience, in other words to have second-order awareness. In being able to empathize with others, we are better able to see ourselves. Empathy thus has dual epistemic functions: it allows us to see the experience of others through a point of connection, and it allows us to take the standpoint outside of ourselves to be able to see our own experience from the outside. Empathy allows us to recognize, and in a sense “feel,” other people’s suffering, for example, in seeing others’ suffering it allows us to look back at ourselves from that vantage point and see our own. Through this we are able to see ourselves from the perspective of others, and we are able to recognize ourselves as

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moral agents in the way that others would recognize us. This selfrecognition is crucial for our self-conception as having moral agency, and even as having a moral identity. Trust Interacting with others is necessary in order to build and maintain trust, both epistemic and moral. Epistemic trust is trust that the world is a certain way and will continue to be so reliably for the near future, a way that is supported by evidence and the experience of others. Moral trust is trust that people in general, and sometimes specific individuals, can be counted on to act and to be present in certain ways. Trust is necessary for knowledge, because we cannot acquire enough knowledge to be functional human beings if we are wholly self-reliant in our epistemic inquiry.22 Trust is also a foundation for the social relationships that undergird our moral interaction and enable our agency.23 When we trust that the world is a certain way, we are trusting that something is the case, and this consists of holding a belief that the world is a certain way, being able to communicate this belief through epistemic practices, having confidence in the belief, and having evidence that supports the belief (reliability).24 Sometimes, we trust the world is a certain way because we trust someone else who claims that the world is that way. This form of epistemic trust in someone’s testimony enables us to accept their knowledge as our own. When we trust in someone, we have confidence in their epistemic abilities, and we find them reliable and dependable as epistemic sources. Through previous behaviour they have repeatedly demonstrated their epistemic competence, making them trustworthy.25 Developing trust, therefore, requires ongoing and consistently positive interactions with others, both in general and with respect to specific individuals. When we trust in a person, we stand in a particular relationship with the one we trust. When we trust someone, we are epistemically dependent on them, and this puts us in a position of vulnerability.26 The standard for trust must be neither too high nor too low. We must allow ourselves to be vulnerable so that we can gain the knowledge and social relationships that enable us to participate in epistemic and moral practices and thus exercise our agency. Yet, because trust makes us vulnerable, we want to be sure that we place our trust only where it is truly warranted. For the most part, we are not very exacting in

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assessing other people’s reliability and tend to trust based on instinct or common sense reasoning.27 For this reason, it is important that our common sense and gut instincts are not impaired and that our basic epistemic capacities are reliable. It is not enough for us simply to be confident in our epistemic capacities, or to have what philosophers call self-trust;28 it is necessary that we actually have objectively reliable capacities. Not having trust makes many daily tasks of functioning challenging. Simply in order to get through the day, people usually need to act as if they trust others and trust that the world will be a certain way, even if they do not feel or believe it. Richard McLean describes the difficulty of not having trust: I had to ignore my perceptions to live day-to-day. I trusted no one. I would find sanctuary in new people and hang out with them, as I felt they had been untouched by the conspiracy, but it was always just a matter of time before they too were one of the enemy.29 As McLean’s remarks demonstrate, trust can be very difficult for people who have mental illness, whether their illness involves paranoia and delusions, depression or anxiety, or addictions or other secretive behaviours. People who have mental illness struggle with trust in various ways. People who have perceptual or cognitive impairments, such as hallucinations or delusions, may believe the world is a certain way but not be warranted in this belief. If they are self-aware enough to know that they cannot always trust their belief about the world, they may not be able to tell whether their view of the world is true, and they may lack trust in their epistemic capacities as well as trust in how the world is. Even if they are not self-aware, they may not believe other people when others tell them that their hallucination or delusion is false, and they may develop distrust against other people’s views. Trust that the world is a certain way can be hindered not only by cognitive or perceptual impairments but also by emotional and volitional impairments, such as those caused by addiction, mood disorders, and anxiety disorders; these impairments may shake how a person knows the world and create conditions of distrust. Trust in other people – both finding them trustworthy and feeling comfortable anticipating their behaviour as reliable – may also be challenged by

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mental illness experience, both as a result of cognitive and emotional impairments that make it difficult to develop trust and as a result of being on the receiving end of inconsistent, negative, and/or harmful responses to mental illness. Distrust can fuel paranoia, as the person’s own view of the world becomes more and more separate from the views of others. Trusting in particular others can be an important epistemic lifeline for people with mental illness who may not know whether they can trust their own views and perceptions, but trust in others develops from social relationships and takes time to establish. If a person trusts someone else enough to accept their interpretation of the world, the person can hold onto that interpretation – even if they do not personally believe or even see it – as a basis for rejecting false views and developing true views. In order for trust in someone to be warranted, it must develop over time as a result of the person repeatedly having views about the world that are true, thus establishing reliability. A person could trust in someone whom they do not know well, and who has not demonstrated reliability in their views, but such trust would be unwarranted and misplaced. A person who interacts with other people in overly familiar ways due to delusions is an example of how misplaced trust can manifest. A person who does not recognize anyone’s views as consistently reliable, on the other hand, may never develop sufficient trust. This occurs in paranoia but can also occur in other conditions where distrust is manifest. In order to have the capacity to trust, a person must have had the cognitive capacity to develop epistemic skills and opportunities to develop and practice those skills. Much of this should occur in childhood, but continuous practice in adulthood is also essential.30 By continuously participating in epistemic practices we develop epistemic competence, which includes the capacity to monitor our epistemic processes to ensure that our trust is not misplaced.31 Social relationships that enable repeated interactions allow us to practice our epistemic skills with specific individuals. If those repeated demonstrations show reliability, this allows us to establish trust.32 Trust is an epistemic virtue because it has to do with how a person is oriented as a knower, but it has both epistemic and moral effects. Having trust that the world is a certain way and trust in people allows a person to have knowledge they would otherwise be unable to have, and it allows a person to respond to the world and to others in intentional ways based on warranted assumptions. Being confused about

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the nature of the world or of others, or finding the world or others inconsistent or unreliable in some essential way, prevents a person from having the knowledge they need in order to act. People who have mental impairments that impede their ability to trust may find themselves unable to act appropriately – leading to behaviour like social withdrawal, paranoia, and bizarre actions – because of this lack of fundamental knowledge.

C a pac it ie s f o r M o ral Agency Interacting with others is necessary to develop and exercise moral agency. Part of being human is that we live among other humans, and we have to figure out how we are going to interact with them. There is an ethical imperative that we ought to act in good ways, in ways that treat others well. In order to do this, we need to be able to reason well and to be able to choose and act with a free will. We need to be able to exercise moral capacities, such as understanding the moral salience of a situation and discerning what the situation calls on us to do in response to it. Without the capacities for moral agency, we would be acting more as animals or machines, acting on our instincts and drives or on a program or algorithm, rather than our reason and will. People with severe mental illness struggle with having sufficient moral capacities and using them in morally appropriate or required ways. Having adequate moral capacities is necessary for normative competence. Normative competence involves having the moral skills, facility, and resources that enable moral success, by which I mean the ability to discern successfully how to act in morally appropriate and required ways, given particular situations. Adequate moral capacities also allow us to have good characters and be generally good people. People who have severe mental illness struggle with attaining and exercising the moral capacities that are important for normative competence. Impairments in reasoning, perception, affect, and volition all interfere with the ability to develop and exercise the capacities needed for normative competence. Below I explain some of the capacities required for moral agency. Cognitive Skills Interacting with others is necessary for developing the cognitive skills involved with what philosophers call normative competence. These

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cognitive skills include the ability to recognize a situation as morally significant and to ascertain when we are being called to respond to such a situation, along with the ability to recognize morally salient features of a situation and to account for these in one’s reasoning. These skills also involve the ability to consider possible courses of action and their potential outcomes, the ability to weigh different outcomes and to consider the pros and cons of particular courses of action, and the ability to make normative judgments about how one should act in a given situation. Possessing these cognitive skills is a precondition for responsibility. Most accounts of moral responsibility require that a person is capable of having enough control over their behaviour as to be responsive to reasons. By this I mean that a person is largely receptive to reasons that someone might give for or against an action, recognizing them as relevant reasons, and is at least somewhat reactive to those reasons, able to translate them into choices and then action.33 In other words, in order to be capable of responsibility, I need to be able to understand your reasoning when you tell me that I should not take recreational drugs, and I need to recognize that your reasoning applies to me. While I may disagree with you, I must be able to give counter-reasons that I can articulate to you. In responding to the reasons you give me, I need to be capable of explaining why I agree or disagree with your reasoning. In other words, I must be capable of giving an account of my own view in a way that is intelligible to others and connects meaningfully with others’ accounts, based on some shared understanding of reality. Reasons-responsiveness is a complex capacity that requires the presence of many cognitive skills involved with processes of reasoning, including understanding, applying, developing, and explaining reasons for action. We develop cognitive skills by observing what other people do, testing what happens and how other people respond when we one thing versus another, and practising these skills in multiple situations over time. In other words, we learn through practice what is intelligible to others.34 If we do not have the opportunity to practice skills involved with intelligibility, we do not develop or maintain an understanding of what others find intelligible. Children learn cognitive skills of moral competency through their moral development as they observe what adults do, and what the consequences are and how others respond when adults do these things; they learn these skills as they see how adults respond when they test

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out different courses of action, and as they practice acting in particular ways when in particular circumstances. If children are raised in such a way that they do not have adults whom they observe making moral decisions or who react in morally appropriate ways to their good or bad behaviour, or if they grow up without encountering situations that call them to respond morally to particular situations, then they will not develop these cognitive skills of normative competence. Children raised in neglect or abuse typically have deficient moral development because they have not been exposed sufficiently to adults trying to act morally or teaching them to be responsible, and they have not encountered enough situations from which they can learn appropriate moral response.35 Adults also need to be exposed to other people who make moral decisions and who respond to their own moral choices, and they need to be exposed regularly to situations that call upon them to make moral response. They need to practice cognitive skills of normative competence in a variety of real-life contexts in order to develop the flexibility and adaptability that allow them to respond in specific ways to particular situations, rather than simply following moral or behavioural rules by rote, as if they applied universally and programmatically. Adults who have had normal moral development as children may lose these skills or never acquire them fully when obstacles prevent them from practising these skills. Obstacles may include mental impairments that impede the exercise of these skills, such as those resulting from mental illness symptoms, and social isolation that precludes people from encountering the social situations that enable the practice of these skills. Adults who do not have the capacity to observe and learn from what other adults do, or who do not have the opportunity to respond to morally significant situations, or whose actions are not responded to as moral actions by others, will not be able to practise the cognitive skills of normative competence and will fail to develop adequately as moral agents. They may even lose whatever moral development they once had. Emotional Capacities Interacting with others is necessary to develop emotional capacities, including knowledge of emotions and facility with appropriate emotional self-expression and response to others. Emotions serve many functions. Some of the cognitive functions of emotions include shifting

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and focusing our attention so that we can recognize patterns of salience that help us better understand a situation,36 bringing to our attention reasons for doing something that we ordinarily might ignore, narrowing or widening the scope of reasons on which we make choices, narrowing or widening the scope of action that appears to us to be live options, supporting social norms (which play some role in guiding our action), and supporting behaviours that we do without thinking (“instinctively”).37 Among other things, emotions fulfilling these functions allow us to ascertain the morally salient features of a situation, and to discern when a situation calls upon us to respond and how. We can better understand the nature of a situation and what it calls us to do in response, when we understand what is appropriately feared or loved; or when it is appropriate to be happy, sad, or angry; and what other people’s joy, confusion, curiosity, or distaste look like. Facility with emotions also provides more moral motivation than cognitive skills alone. While we can observe a situation and logically reason about its moral nature and what moral response should be, logical reasoning does not create a particularly pressing motivation to act. When we perceive other people’s fear or distress, however, our empathy toward them – or at least our desire to not want them to suffer – creates a compelling motivation for action. Knowledge about emotions is thus very important for normative competence. While philosophers writing about autism have noted that knowledge about emotions is not necessary for understanding moral reasons or exercising most other cognitive skills described above, it does seem necessary for robust moral motivation involved with critically reflecting on our desires, making decisions based on that reflection, and acting according to our choices.38 Moreover, insofar as emotions are ways of situating ourselves within reality, other people’s reactions to our emotions influence how we respond to situations in the future and thus help construct our moral identities.39 We develop facility with emotions only through interactions with others. Knowledge about the emotions that can be gained through observation and logical reasoning alone is pure abstraction; robust knowledge of emotions requires experience of emotions, and encounters with the experience of other people’s emotions. When people are unable to experience appropriate (or any) emotions themselves, or unable to interact with other people experiencing appropriate (or any) emotion, they fail to gain and may even lose knowledge of what it is to have certain emotions or what appropriate emotions and

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emotional response look like. They are then unable to draw upon such knowledge in interpreting situations or in deciding how to act. Some mental illnesses directly interfere with people’s ability to experience emotions in context-appropriate ways (such as mood disorders or borderline personality disorder), or to perceive their own emotional experience correctly (such as schizophrenia or eating disorders), or to identify or interpret other people’s emotional expression or behaviour correctly (such as schizophrenia or antisocial personality disorder). In addition, social isolation prevents people from being in situations that call upon them to identify and interpret other people’s emotions, or from being in situations in which other people respond to their own emotional behaviour or expression. It is through interactions with others that we develop empathy; and, while empathy may not be necessary for moral agency and perhaps even for moral motivation, it is nonetheless an important aspect of normative competence. Empathy matters because it enables us to see others as people like ourselves. When we are capable of feeling what they feel, and when we are capable of discerning that they feel a certain way, we see them as relatable in a deep way, and this point of relatability creates a strong pull on us to respond. When we see that other people are capable of suffering in similar ways that we are, we can appreciate their vulnerability to features of the world outside their control, and we can help them deal with their vulnerability and help them through their suffering. We may be moved to try to help them overcome their vulnerability and alleviate their suffering, but in some cases we would be just as wise to help them accept their vulnerability and endure their suffering. We might even be able to be gentle enough with ourselves to recognize our own vulnerability and accept it as part of being human rather than as something to fight against. The point is that empathy allows us to make contact with people, especially at the level of vulnerability and suffering: through empathy we see that we are all vulnerable, and all prone to suffering, and thus essentially relatable. Empathy is thus valuable not only for how a person interacts with others, but also for how they regard themselves. I discuss empathy further in chapter 5. Valuation Capacities Interacting with others is necessary for us to learn how to recognize moral norms as moral norms and as being binding on us; we develop

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our sense of value, and our views about what is of value, in relation to a moral community. Value is not mere preference, and determining what is of value is not merely an individualistic exercise of deciding what we want as if we were atomistically acting independently of others.40 Things only have value if they are recognized as having value. Just as language only has meaning insofar as it is practised, publicly, within a community, things (“goods”) only have value if they are valued, publicly, within a community. Just as the meaning of words is constituted through practices of language use, which are accepted as practices by their participants, normativity is constituted through practices of valuation, which are accepted as practices by their participants insofar as they occur within a moral community of people who participate in activities of valuing together. It is through our shared moral practices that we fix the value of things as valuable. In other words, it is through our moral interactions that we establish certain rules, virtues, and other moral constructs as having normative force, and certain activities and ways of living as being choiceworthy.41 Through moral practices that support and encourage some behaviour and that sanction and blame other behaviour, members of a moral community determine what moral values they hold and what moral ideals they will strive for. Moral justification is thus necessarily interpersonal, as it involves giving an account to others in the context of shared understandings about what is important and why.42 Consequently, having the capacity to recognize certain things as having normative force requires that we engage in the moral practices that help constitute things as normative and choiceworthy. Someone who has little or no opportunity to interact with others, and thus to engage in moral practices, will not recognize things as having value or normative force in the same way that other people do, because they played no part in constructing them as having normative force. For these people, moral rules and virtues may appear arbitrary and non-binding, mere conventions, and whether a person values one thing or another may seem to be of no consequence. Recognizing norms as having normative force or goods as having particular value can be challenging for people with mental illness, especially people who experience delusions, paranoia, and other cognitive distortions or deficits that impede a person’s ability to have a shared understanding of reality. If a person does not see the world in a way that is relevantly similar to others, they may not be able to see

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moral constructs as having any meaning or objects as having any particular value. Lack of fundamental shared meanings can hinder moral agency. Moreover, if they lack the cognitive or emotional skills necessary for normative competence, they may be unable to participate in the moral practices that co-constitute normativity. Social isolation further constrains people’s ability to recognize normativity when it precludes people from participating in the shared moral practices that help constitute meaning and value.

M o r a l In t e gri ty Moral integrity describes a certain relationship that a person has to valuing. When we have moral integrity, we can determine what is of value and live consistently and reliably according to our values.43 (Some philosophers describe this determination of value as choosing one’s ends for oneself, or determining the good for oneself.44) In being able to choose and act according to what we value, we are also able to give an account of what we do – and why we choose and value as we do – that is intelligible both to ourselves and to others. Moral integrity thus involves not only doing good things consistently and reliably, but also having knowledge of why certain things are important and why certain actions are good, demonstrated by the ability to articulate intelligible reasons. There are two audiences for our articulation of intelligible reasons: other people and ourselves. As discussed above, other people ultimately determine the intelligibility of our reasons, for we share with them an epistemic community in which we construct meaning together. If our reasons did not have to be intelligible to others, our activity would be empty, meaningless, and arbitrary. In addition, it is also essential that we can give reasons that are intelligible to ourselves. Giving an account to oneself is an important aspect of a moral conscience. Generally speaking, having a moral conscience means having a proclivity for moral behaviour.45 When we act in good conscience we can look ourselves in the mirror, knowing that we acted to the best of our ability to do what we thought was right. But we are only capable of this if we have knowledge of right and wrong. In order to have such knowledge, we must be capable of articulating what is important, and why. If we are unable to articulate to ourselves why we act, and what is of value, then we lack this moral knowledge. And if we lack this moral knowledge, then we cannot know that our actions

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are morally appropriate or required of us, and thus we cannot act with good moral conscience. Because moral integrity involves acting consistently and reliably, one necessary condition of moral integrity is sufficient rational control. Having moral integrity goes beyond having the capacity for being responsible for one’s actions, however. When we have moral integrity, we act in intentional ways to become a certain kind of person – or to develop a certain kind of character, with corresponding attitudes and dispositions – which enables us to express what we value through our actions and behaviour. Moreover, while moral integrity nominally consists of an individual’s relationship to valuing, the capacity to value comes from participating in the shared moral practices of a community, where members of the community recognize a person as a member, or as someone who can make and respond to moral claims in a legitimate and meaningful way. Having moral integrity therefore requires ongoing interactions with others. Autonomy Interacting with others is necessary to achieve autonomy, or selfdetermination. The word “autonomy” comes from the ancient Greek and literally means legislating the law for oneself, or self-governance; self-determination, therefore, is directing oneself to act according to one’s moral principles. Self-determination is necessary for moral integrity, as a person can only act according to, and consistently with, their values if they can formulate their values and direct themselves to act accordingly. I endorse Diana T. Meyers’s conception of autonomy as a competency, embodying a set of skills that a person can adapt and apply flexibly to various situations.46 These skills include introspective skills, communication and listening skills, memory capacities, imagination capacities, analytical and reasoning skills, capacities for selfnurturing, volitional skills, and interpersonal skills.47 When we understand autonomy as involving these capacities, we can see that agency and autonomy are transactional with each other, each reinforcing the other: engaging in moral and epistemic practices helps us build the skills involved with autonomy, while having skills of self-determination enables us to engage in epistemic and moral practices more meaningfully. The evaluation of whether a person is competent is determined by members of the community of which they are a part. Moreover, as discussed above, learning the relevant skills

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of autonomy competency is a process of moral development that occurs in relation to others, preferably beginning in childhood, and that requires practice through ongoing moral interactions. Interacting with others as part of a moral community is thus necessary to learn how to achieve autonomy competency, to practice the necessary skills, and to be judged by others as having achieved this competency. Autonomy can be thought of in both episodic and programmatic terms.48 Episodic autonomy is self-determination with respect to a specific situation or decision: deciding what to value and how to act in a particular circumstance. Programmatic autonomy is self-­ determination regarding the direction of one’s life: discerning what commitments a person will organize their life around and making a series of choices with respect to those commitments. Through programmatic autonomy a person decides what kind of person they want to be and what they want their life to amount to, and they organize their activities accordingly. Sometimes this is described as developing and carrying out a “life plan.”49 In many conceptions of autonomy, valuation, choice, and action are largely regarded as unidirectional: a person determines their values, makes choices based on these, and acts accordingly. In reality, valuation, choice, and action lead to each other in multiple directions. Sometimes people act without consciously choosing, but they formulate choices afterward, sometimes choices that demonstrate regret about the actions that were undertaken, but sometimes also choices that affirm their actions. Sometimes people choose without knowing in a deep way what they value with respect to the relevant situation, and they discern their values through that choice. Sometimes people act independently of their values, but their action helps construct who they are and what they value. The philosophical ideal of autonomy and free will has us believe we can only be full moral selves if we formulate our values first so that we can choose and act based on those values. This ideal seems pretty far removed from the reality of how people participate in moral activity, however. As long as discernment occurs somewhere in the process, there is at least some element of autonomy, no matter how messy the process of moral engagement. People who have mental illness may have either their programmatic or their episodic autonomy compromised by mental impairments that affect reasoning and volitional skills. People with mental illness may have great difficulty formulating or acting upon a “life plan”; they may be able to articulate what they value but not necessarily in a

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systematic way; they may have great difficulty organizing their lives around their commitments. I propose that we adopt a non-ideal conception of autonomy that allows us to have a more complicated and nuanced understanding of what programmatic autonomy can look like for someone with mental impairments. People who have mental impairments caused by mental illness experience challenges not only with big-picture autonomy but also with more localized autonomy. In particular, their episodic autonomy may be compromised if a person has significant cognitive impairments that make it difficult to form intentions and make plans. If severe enough, such an impediment may exempt a person from responsibility.50 Moral Identity Interacting with others helps us develop and maintain our moral identity, which is critical for agency. Our identity is formed through and shaped by our interactions with others, our relationships with others, where and how we are socially located, how we move through the world in our particular bodies, and our socio-historical circumstances. We are necessarily embodied, embedded, relational, situated, and socially positioned. All of these factors go into who we are as persons,51 and they form us as knowers and doers, determining what and how we can know and do. The factors that shape our identity are thus also essential in defining our agency. Some philosophers like to think about moral identity in terms of a narrative.52 In this view, our life is a story that has a past, present, and future, and our motivations, intentions, choices, and actions flow from what came before and shape what is to come. The narrative framework captures the ways that our moral identity is ongoing: continuous, dynamic, and co-constituted with other people’s moral identity. Our own life story is interlocking with other people’s life stories and embedded within larger narratives and genres. In this narrative framework, we are moral selves when we are capable of giving an account of our actions, of giving reasons for them that are intelligible to others. According to this narrative framework, our ongoing narrative of identity is expressed through whatever patterns of valuation we may have. We have a past history of what we have cared about and how this has been expressed in our action; we have a history of how we have responded to others and what we have learned and changed

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along the way.53 An ongoing narrative of identity does not just describe what we have done, however; it also shapes what we will do by directing us to do what is in accordance with our values. Our patterns of valuation shape what values we continue to hold, and what values we expel or adopt in relation to changing circumstances or new knowledge. Moreover, what we value shapes our experience – how we act, interpret, and respond – and it shapes what we know, just as what we know and experience shapes what we value. In other words, valuation is transactional with experience and knowledge. Thinking of moral identity as a narrative allows us to see how what we value and how we act is continuous, as well as transactional, and that there is a sense in which it all adds up to something, namely ourselves as moral agents.54 Valuation is learned through a process of moral development, just as cognitive skills and emotional capacities are. We need social relationships and interactions in order to develop our moral identity by allowing us to balance our own sense of ourselves against others’ sense of us. Identity formation is an ongoing, dynamic, dialectical process of continuously balancing our self-projected identity (how we see ourselves) against others’ projections of our identity (how others see us).55 Part of this involves making our self-conception intelligible to both ourselves and others so that our conception of ourselves is not simply a solipsistic vision, and that it is connected to reality in the right way.56 We develop our sense of ourselves as agents, as human beings, and as particular individuals by balancing our selfunderstanding with the understandings that others have of us. To be ourselves, and to know ourselves, we need others to interact with, so that we can see ourselves through their eyes. As discussed above, moral identity requires the ability to acquire and take into account multiple perspectives. Moral integrity requires other epistemic capacities besides the ability to see and account for multiple perspectives, however. Moral integrity also requires empathy, which here should be understood as feeling with others, trying to feel what others feel by imagining what it is like to be them in their situation, and by communicating about these feeling with others.57 Empathy gives us experiential knowledge, and it enables us to see ourselves from the outside.58 In relating to others emotionally, we can take on their perspective as well as our own, including their perspective on us. This allows us to see ourselves

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through their eyes, and consequently to recognize ourselves as moral selves from the outside. Empathy is important, therefore, for us to develop into the kind of people we want to be. Through empathy we can better understand ways of being in the world and make choices about how we want to be in the world. This enables us to be intentional in how we act and respond in the world – how we carry ourselves as human beings. Recognition by Others Interacting with others is necessary to achieve recognition as a moral agent, as a moral self, as someone who is fully human. We only become persons, and moral agents, by being treated as such by others.59 An important part of our moral identity, therefore, is being recognized by others as having a moral identity, as being a moral agent who can make moral claims on others, and respond appropriately to others’ moral claims. Recognition by others is a recognition of authority, of being a person whose moral claims, and responses to others’ moral claims, will be regarded by others as legitimate. A person is capable of making a moral claim on others only if others accept their claim as binding. If a person is regarded as less than or other than human, they are not recognized as having this authority, and they will not be able to make a moral demand in any meaningful way because others will not regard their claim as carrying any force. When someone is recognized as having a moral identity, on the other hand, and seen as a moral agent, they are regarded as a member of the moral community and treated as such in the ways that others interact with them; their determinations about what is of value are seen as legitimate and worth taking seriously. Recognition as a moral agent is important because it enables us to interact with those who recognize us, which in turn enables us to develop and maintain the capacities for valuing and discernment about how to act.60 Valuation is thus transactional not only with one’s own experience and knowledge, but also with the knowledge, experience, and valuation of others. Just as we develop knowledge by learning what others know, and virtues by observing how virtuous people act, we learn what we value in part by learning what others value. And we learn what others value by participating in moral activity within a community in which members recognize each other

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as moral agents and interact with each other as such. Through this participation we become valuers, developing our own sense of what is worth valuing and how we ought to live and act. Recognition by others is essential for moral agency, as moral agency is a status that can only be granted by the reciprocal recognition of others in a shared moral community who hold the same moral status: of being agents. Gary Watson describes this moral recognition in terms of the abilities to make moral demands on others’ conduct and to react accordingly, and conversely, to understand and respond to the moral norms and expectations of the community.61 Making moral claims and responding to the claims of others are aspects of moral communication, which occurs in many ways. Most obviously, moral communication occurs through processes of approval and disapproval, for example blaming and praising people for their behaviour, as blame discourages undesirable behaviour through sanctions, while praise encourages desirable behaviour. As I discuss in chapter 4, some philosophers describe moral communication as occurring through reactive attitudes, the moral emotions we hold toward those whom we regard as moral agents responsible for their actions. Moral communication is essential for recognition by others and, therefore, for having a moral identity and being regarded as a moral agent.62 A person who lacks the ability to make meaningful moral claims and expressions cannot participate in the moral communication and interaction required for recognition by others as a member of a moral community and, therefore, cannot be regarded as a moral agent.63 People with mental illness struggle with moral recognition because they are often seen as Others, aliens and outcasts rejected by the community. People who exhibit symptoms that suggest psychosis, like disordered speech and bizarre behaviour, are rejected most strongly. Typical social responses to people with severe mental illness are social avoidance and exclusion, both formal and informal. These make moral recognition nearly impossible for people with serious mental illness. Responsibility Interacting with others is necessary for having the capacity for responsibility, not only in terms of being held responsible but also, and more importantly for my purposes, in terms of taking responsibility. There are at least two senses in which we can be morally responsible. One sense of responsibility is about having obligations due to certain

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connections we have to an action and its outcome. This may be understood in a strictly causal sense (I am responsible for a certain outcome just because my action caused it, whether or not I intended it); in terms of intentions or will (I am responsible for an action because it emanated from my will or was the product of my intention); in terms of partiality (I am responsible to those to whom I am “closest,” emotionally or physically); in terms of benefit (because I benefited from something, I have an obligation with respect to that thing in return); or in terms of capability (because I can create certain desired outcomes, I have a responsibility to do so). These kinds of responsibility have meaning only insofar as there are others to whom we are responsible. We must have opportunity to interact with others in order to be capable of responsibility. The other sense of responsibility is about “owning” certain actions as “ours,” or endorsing certain actions as expressing our values and commitments, in a sense expressing who we are. Gary Watson identifies this form of responsibility as “answerability” or “attributability.” Answerability is being answerable for my character, for what kind of person I am; attributability means that an action is attributable to me, in other words it can be properly said to be mine. Watson describes this form of responsibility as “aretaic” (from the Greek word for “excellence,” a word connected with virtue and character), as it involves appraising what a person finds “excellent” or of value; it is an “appraisal of the individual as an adopter of ends,”64 and it is concerned with “what activities and ways of life are most choiceworthy.”65 A person who has moral integrity is responsible in an aretaic way; since their actions are expressions of their values and commitments, they are answerable for the values and commitments they adopt. What a person capable of aretaic responsibility is answerable for is the set of values and commitments they have endorsed as structuring their choices and actions and orienting their way of being in the world. Watson remarks, “If what I do flows from my values and ends, there is a stronger sense in which my activities are inescapably my own: I am committed to them. As declarations of my adopted ends, they express what I’m about, my identity as an agent.”66 Having the capacity for being responsible in this second sense means having the ability to choose (in a sufficiently free way) what we want to value and how we will express what we value through our actions. If we do not have this capacity, then we do not have the capacity for responsibility in this second sense.

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We commonly hold people responsible for bad actions in the first, typical sense of responsibility, whereby we judge that they caused a bad outcome and/or had bad intentions, and we assign blame as a result. There is more to the responsibility story than this, however. We also commonly believe it is only fair to hold someone responsible, and assign blame to them, when they had sufficient rational control over their action such that it seemed to come from them in some relevant way. The problem, as I discussed in the previous chapter, is that it is not always clear that a person’s actions, choices, or reasons for action are wholly “up to them.” Many factors influence how a person develops their reasons for choosing one thing over another, including their past history and childhood, as well as present constraints and conditions of duress, such as various mental impairments. There is some sense in which it may be fair to blame a person for bad actions, even when various negative factors influenced their choices. But there is another sense in which it seems unfair, because the person may not have had the opportunity to develop into someone who can freely choose what kind of person to be. What we come to value, and who we come to be, depends a great deal on the people we have known and the interactions we have had. What kind of person I am, and what I come to value, is based in part on the ways that I am socially situated, as my socio-historical circumstances, my social locations, my relationships with others, and the specific interactions I have had with others structure what choices I have and what are considered plausible reasons for acting. Through interactions with others we learn what can be chosen, how to make a choice, and what reasons for acting are intelligible to others. In other words, we learn what can be of value and what others value, and it is in relation to this that we develop our own evaluative framework. Adopting good values, choosing from good choices, and acting on good reasons, is predicated on being part of a moral community, having the opportunity to participate in its moral practices, and being recognized as having a moral self (being a member of that moral community). Watson describes this necessary social context for moral identity and responsibility: “Holding people responsible is not just a matter of the relation of an individual to her behaviour; it also involves a social setting in which we demand (require) certain conduct from one another and respond adversely to one another’s failures to comply with demands.”67 To be answerable for one’s actions is to be

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answerable for who one is, and such a judgment is made by and within one’s moral community, according to its norms, which one has participated in constructing.

C o n c l u s i on People whose functioning is impeded by mental illness tend to experience social isolation and benefit greatly when others make the effort to interact with them. When I am psychotic, I have a difficult time thinking clearly and am often a little paranoid as well, so I avoid social interactions as much as possible. When there is too much noise in my head, it is too difficult to follow what people are saying – or sometimes even to hear them – and it seems impossible to try to think of what to say in response. In this psychotic state, there appears to be a wall I cannot surmount between myself and everyone else. When I am manic, on the other hand, I overrelate to people, believing that we are cosmically connected, and I overwhelm people with my ideas and enthusiasm. I am not a good listener in this state because I cannot slow down enough to take in other people’s ideas, and I cannot reciprocate as good friends do. When I am depressed, however, I feel a huge disconnect between myself and others and find it too much effort to try to bridge that gap through conversation. Despite these problems when I am actively ill, my moral agency is generally well-developed because I have had many periods in my life when I have not been actively ill and when I have been able to engage with others appropriately, developing friendships and engaging in everyday interactions with people. But this all becomes very difficult when my mental illness flares up and I find interacting with people to be too problematic. Then I avoid social interactions and stop performing the actions necessary to maintain important relationships with others. This causes dents in these relationships that I have to try to repair when I am well enough again. I have suffered from many of the impairments to epistemic and moral agency described in this chapter during my bouts with depression, mania, and psychosis. When friends and family members have been able to interact with me in positive ways, this has helped me think more clearly, make decisions, and choose options that are of value. In order to be an agent, we need to be able to have interactions with others that enable us to develop and exercise our agency. Epistemic and moral agency requires ongoing interactions with others in many

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ways. We learn from others what and how to know and make meaning, how to act appropriately, and how to be in the world. In being part of a community that recognizes us as agents, we are able to participate in the epistemic and moral practices that enable our agency. Unfortunately, people with serious mental illness face several constraints on their agency because of the social isolation they experience due to their illness. This isolation is a result partly of their mental illness symptoms, which often lead to isolating behaviours including withdrawal and self-absorption, and partly as a result of the social exclusion they experience due to stigma, prejudice, and discrimination. Some of the isolation that people with mental illness experience, therefore, is internal, due to the illness itself, and some of it is external, due to social factors within human control. Because isolation seriously impacts agency, it is very important that we address the factors we have some control over. We must eradicate prejudice and discrimination, and deal with our negative stigma so that we no longer try to avoid or otherwise stigmatize people with mental illness. Interacting with people who have mental illness will go a long way toward reducing stigma. As discussed in chapter 1, studies demonstrate that interpersonal contact is the most effective way to address stigma.68 In addition, in response to the isolation that mental illness itself causes, we must mitigate against it by increasing opportunities for people with mental illness to participate in social and civic life and to make meaningful contributions to society. In increasing these opportunities, we make it easier for us to recognize people as agents, as members of our moral and epistemic communities like us. Addressing social isolation is therefore good for multiple reasons: it decreases stigma and increases opportunities for people to develop and exercise their agency. While part 1 of this book examines many of the ways that mental illness constrains agency both directly (through mental illness symptoms) and indirectly (through stigma and social isolation), Part 2 considers how we should respond to people who have mental illness, both in light of bad actions they may commit and more generally. We learned in chapter 2 some of the ways that mental illness symptoms can cause mental impairments that impact moral reasoning and choice. Based on these impairments, it may be unfair to hold people with mental illness responsible for bad actions, particularly when their choices seem to be heavily constrained by these impairments. In chapter 4, I examine the tension between treating people as agents while

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being respectful of their incapacities, arguing that we need to take an asymmetrical approach in how we treat them. This is largely due to the inherent epistemic limitations we have in knowing how much and what kind of agency someone has, as I have indicated throughout this chapter. I am much less concerned about holding people responsible for bad actions, however, than I am about increasing people’s agency so that they can make better choices in the future. The best approach to how we treat people with mental illness is the approach that most effectively meets our goal. With our goal of enhancing agency, withholding blame and treating people with respect is the most effective approach. In the following chapters 4 and 5, I make several specific proposals for how we should interact with people who have mental illness in order to enhance their agency.

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P art T wo Social Interactions As we saw in chapter 3, social interaction is necessary to develop and exercise agency because it is only through interacting with ­others that we are able to participate in the epistemic and moral practices that comprise our agency. Because people with mental ­illness are particularly prone to social isolation, due to both their symptoms and stigma, they are in especial need of social interaction that counterbalances this tendency toward isolation. Confronting and reducing stigma is one important way that we can increase social interaction; in the absence of stigma people would not be subject to as much social exclusion as they currently are. As we have seen, one of the most effective ways to decrease stigma for people who have mental illness is to increase interpersonal contact, thus enhancing agency in multiple ways, providing opportunities for people to participate in epistemic and moral practices. Chapter 4 examines how we should respond to people who have mental illness when they do bad actions that cause harm to others or themselves. As we saw in chapter 2, people who have mental ­illness are vulnerable to mental impairments that impact their moral reasoning; thus, they are more likely to engage in bad actions that cause harm. If our goal is to enhance the agency of people with mental illness by giving them more opportunities to develop and exercise their agency, then we must be intentional in how we interact with them. While we might be inclined to blame people for doing bad actions, it is actually more constructive if we look at the larger psychosocial context in which a person acts and replace reactive attitudes of blame with non-blaming attitudes like disappointment or sadness. Adopting attitudes of epistemic

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humility and charity helps us take this nonjudgmental approach and makes it easier for people to want to engage with us rather than shutting down or responding with defensiveness. Such positive engagement helps create conditions that allow change to occur so that people act differently in the future as well as take responsibility for their actions. Humility and charity are thus key components to intentional interaction here. Chapter 5 considers how we should respond more broadly to people who have mental illness. Several intellectual and moral ­virtues are considered. Open-mindedness and epistemic conscientiousness help us understand people more deeply and to seek out shared meaning where possible. Other-oriented virtues help us ­connect with people who have mental illness in meaningful and constructive ways; they also help us model the other-oriented ­disposition we might wish those who have mental illness and may be prone to self-absorption would adopt. In this chapter, I return to charity and humility, but in a moral context, and I also consider the importance of compassion and generosity. With these virtues we can interact in ways that make it easier for others to engage with us, and thus provide more opportunities for people with ­mental illness to participate in the epistemic and moral practices that define agency.

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4 Moral Address and Response

In t ro du cti on When people do bad actions, we tend to feel angry, resentful, disappointed, even shocked. Depending on the action, we may feel that we have been violated, betrayed, or used. Consider how the people who bought counterfeit art from Andy Behrman (in the previous chapter) felt upon learning of this deception. Ponder the emotions and reactions of all the people affected by James Holmes’s mass shooting in the Aurora, Colorado, movie theatre on 20 July 2012. Reflect on how Mr M’s wife must have felt when she learned of his affair and how she, and his colleagues, probably reacted to his personality changes when off lithium. Think about how Mary Weiland’s husband must have reacted when she burned eighty thousand dollars’ worth of his clothing. Contemplate the emotions of everyone impacted by suicide. Consider the ways we respond when people we care about abuse drugs or alcohol, or engage in self-harming behaviour. When we have knowledge or a belief that a person has a mental illness, which may cause mental impairments that constrain their agency in one of the ways described in chapter 2, this may complicate our judgments and feelings about these bad actions. The presence of mental illness can render unclear to what extent a person acts with agency, that is, with rationality, self-awareness, and intentional control. We might wonder: Are they responsible for their speech and action? Do they have control over what they say and do? Do they act and speak based on a shared understanding of the world? Could they have helped bad actions they committed? The answers to these questions would illuminate how we should respond to people. The problem

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is that often we do not – even cannot – know the answers to these questions with any degree of certainty. How we respond to people whom we know, or believe, have mental illness when they do bad actions depends on what stereotypes we hold and what beliefs and assumptions we have, particularly around agency. When we believe a person has control over their behaviour, we tend to react to bad actions with blaming attitudes and other emotional responses that communicate our disapproval. We feel anger, resentment, indignation, and the like, wanting the person to feel guilty or even ashamed. If we believe a person’s mental illness did not unduly influence their action, or that they should have control over their behaviour despite having a mental disorder diagnosis, we treat them as fully responsible agents and hold reactive attitudes toward them when they act badly. When we believe a person did not have control over their action, on the other hand, we might associate the person with the stereotype of the “crazy lunatic,” the mentally ill person who has little control over, or even awareness of, their behaviour. Such a person, we assume, has little agency because they are incapable of acting with sufficient rationality, free will, and self-awareness. As a result, we judge that it would be unfair, and maybe even pointless, to hold the person responsible for their action; lacking agency, they also lack the conditions of responsibility. The “crazy lunatic” is not reasons-responsive; there is no amount or kind of reasoning that would enable them to change their behaviour. Holding a person responsible for behaviour they had little control over has no purpose, as there is no positive end to achieve. The person could not have acted differently by willing themselves to act differently; they may not even be aware that they acted badly, or that a particular action was theirs. Even if they are aware, and even if they feel embarrassed or guilty about what they did, such feelings seem misplaced since there was little under their control that they could have done differently. The person who has little control over their behaviour seems to deserve sympathy rather than reactive attitudes like anger or resentment. To hold reactive attitudes toward someone who is not a fit candidate for them – who does not “deserve” them due to their lack of agency – may appear callous and mean. I want to propose that neither of these responses is fully appropriate because the agency of a person with mental illness, even when in severe psychosis, is more complicated and nuanced than these responses presume. People engage in moral address, participating in

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the moral practices that would enable them to be recognized as members of the moral community, in a variety of ways. Agency is not an all-or-nothing concept, and even to say that it admits of degrees does not adequately capture its complexity. We express agency in different ways, based on many factors, including the specific circumstances in which we act. If we are to treat people with mental illness fairly, we need to acknowledge the complexity of their agency, thereby recognizing them as members of our moral community, even as they have specific constraints on their agency due to their illness. Acknowledging this complexity leads us to an epistemic quandary regarding the inability to have sufficient knowledge of the kinds and degrees of agency a person has that allow us to make a confident judgment about the nature of their action and agency. Rather than making an assumption about agency that would lead to one of the two judgments above, I suggest instead embracing our uncertainty with epistemic humility. We ought to respond to people in ways that acknowledge our uncertainty, yet treat people in as best a way as possible that gives them opportunity to change bad behaviour, however much or little control they have over it. My argument in this chapter is that we should take an asymmetrical approach in our interactions with people who have mental illness. On the one hand, we should withhold judgment when they perform bad actions, due to our inherent epistemic constraints: we are unable to know with any certainty how much and what kind of agency they had, and to what extent and in what way their agency may be constrained due to impairments caused by their illness. To treat people most fairly, we should be charitable in our interpretations of their actions and forgiving of bad actions. On the other hand, we should hope and expect that people are capable of change, and that they can act better than they currently do if given the opportunity and the means. We should do what we can to help people develop their capacities for better social interaction and support any effort they make by engaging with them in meaningful ways. Chapter 5 develops this latter argument. In considering the agency and responsibility of people who have mental illness, our biggest concern should not be whether, in what ways, and how much a person with mental illness is responsible for their actions in order to determine desert and assign blame. Rather, our goal should be to create the conditions that enable a person to change their behaviour and to act better in the future. In other words,

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I am not so interested in a backward-looking assessment of the person’s agency and whether they are a fit candidate for reactive attitudes; I am more interested in a forward-looking assessment of how the person’s agency can be enhanced. Maintaining this tension between hoping that people can be better than they are and withholding judgment and blame when they behave badly is essential for meeting this goal. The aim of creating the conditions that enable people to change their behaviour is lofty, and no single person’s interaction can do all the work required to create such conditions. It is unrealistic to expect that one person’s interaction with someone who has mental illness can create large, global changes in behaviour such as increasing reliability, modulating emotional response, or increasing self-awareness and social awareness. One person’s interaction, however, can contribute to changing a person’s experience and so help contribute to the creation of conditions where change is possible. This chapter and the next explain what effective interaction should look like. In this chapter, I make two arguments. First, I argue that it is inappropriate to blame people for bad action when their action was likely constrained due to mental impairments caused by their illness; instead, we should withhold judgment and forgive bad behaviour because that is what allows change to occur. Second, I argue that, while people almost always act with some kind and degree of agency however constrained it might be, we cannot know the nature of and extent to which a person’s mental impairment constrains their agency; humility requires us to accept our inherent epistemic limitations and withhold judgment in fairness, while charity requires us to interpret people’s action in the best light possible and to forgive bad actions.

W h at M o r a l R e s p o nse Looks Li ke Moral response consists partly of holding certain attitudes toward people based on what we think or how we feel about their action. When we think a person acted badly, and we believe they are related to the causal history of their action in the right way, then we regard them as candidates for desert, in other words we regard them as deserving blame. Then we hold reactive attitudes like anger, resentment, indignation, and contempt toward them. When we think a person did not have sufficient control over their behaviour or knowledge about the nature of what they were doing, however, then we

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consider whether the person is exempt from responsibility due to general incapacities in areas such as moral reasoning, self-awareness, and affective response. Sometimes we excuse a person from responsibility because they lacked control given the particular conditions of the action in question, for example, if a person were to act following a seizure or blackout. But in the case of mental illness, what we are really concerned with is whether the person is capable of acting with sufficient agency in general, whether they have the general capacities required for agency and responsibility. If we believe their abilities fall short of the threshold for agency, then we typically respond to the person with objective attitudes like pity, sympathy, or other detached response; if we are feeling more negative and judgmental toward the person, then we might respond with objective attitudes like fear or disgust. Our attitudes toward people as judgments of people’s actions constitute part of the moral address we engage in with members of our moral community. Moral Address and Intelligibility In examining Peter Strawson’s original formulation of the reactive attitudes, some philosophers interpret him to have meant that reactive attitudes are themselves a judgment about someone’s responsibility, the very act of holding someone responsible.1 Other philosophers interpret reactive attitudes as expressive of one’s judgment, communicative of the intuitive and rational judgments we make within ourselves.2 In the latter view, reactive attitudes are cognitions with representational content regarding facts about the world. This fits the cognitive model of emotion discussed briefly in chapter 2. In this view, holding reactive attitudes is a way of expressing moral demands toward others. Reactive attitudes like resentment and indignation, for example, express demands for respect or recognition, demands that the person holding the attitudes does not feel have been met yet.3 I endorse this cognitive view of reactive attitudes because I think it is a helpful way to think about the role that reactive attitudes play in the moral practices we engage in with other members of our moral community. In order to express or adequately receive moral demands, a person must be able to understand and see them as applying to themselves and/or to the person with whom they are interacting. (We might think

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of this person as their interlocutor.4) There must be sufficient shared understanding in what constitutes an appropriate demand and when it is appropriate to express the demand; a person must be able to make their demands intelligible to others and to understand the intelligibility of the demands made by others. This involves being able to track certain standards: to recognize the epistemic and moral norms and standards that others hold, to accept that one has to meet the expectations set by these standards, and that one will be judged according to how well they do so.5 To illustrate this, consider how Mr M did not recognize the requests by his wife and others to conform to behavioural norms; he did not believe these norms applied to him (they made his life “boring”), and perhaps he did not even find them intelligible in his lithium-free state. Certainly the people around him did not find his own behaviour and reasons for action intelligible, nor did they regard his requests for artistic freedom and liberation from relationships to be reasonable. In his lithium-free state, Mr M could not track standards appropriately. A person who is unable to participate in moral address – who is unfit as a conversational partner – is unable to be responsible for themselves. A person can be an unfit conversational partner if they are “incapable of understanding the complexity of the [moral] practices and the emotions of those in the moral community holding responsible.”6 But, and perhaps more importantly, they can also be unfit if they are unable to participate in moral address and hold reactive attitudes toward others appropriately, in other words if they lack the capacity to hold others responsible. Michael McKenna summarizes this nicely: Exempted agents who are incapable of understanding the forms of moral communication put to them via our practices of holding morally responsible are incapable of participation in the practices. It is not (just) that they do not understand what others communicate to them within those practices. It’s that they are impaired in such a way that they cannot communicate within those practices. They are not in a position to hold others responsible by way of those practices. It is this inability that impedes their status as morally responsible agents.7 McKenna clarifies that a person is a responsible moral agent if they have the capacity for moral address, or the capacity to participate in

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the moral practices that would enable them to be recognized as members of the moral community. Responsibility does not require them to actually engage in moral address, in other words, as long as they have the capacity for it.8 It is unclear whether Mr M in his lithium-free state has the capacity for moral address. Certainly, his ability to participate in moral practices that enable others to recognize him as a member of their moral community is tested by his manic state. To the extent that his mania diminishes his abilities to make moral claims that are credible and to respond to others’ moral demands with integrity, he may not be recognized as a moral peer. When we respond to a moral demand that someone expresses to us, we affirm their moral identity and recognize them as a member of our moral community. By this I mean that we recognize them as having the ability to make moral claims with authority, as being able to respond to others’ moral claims in legitimate ways, as helping create the standards of the community through their own moral practices, and as enforcing those standards by holding others accountable and by taking responsibility for themselves so as to uphold those standards themselves. When people behave in ways that do not make sense for us, and which are not based on intelligible reasons – everything from inflicting violence to setting kites free – we have a difficult time recognizing their ability to make moral claims or respond to others in credible ways. Such action fails to contribute to the creation of standards of the community and fails to enforce the community’s norms. When people act in ways that do not make sense, we find it hard to recognize them as members of our moral community. It can be argued that reactive attitudes are how we enforce the moral standards of the community. We assess others’ participation in moral practices through the attitudes we hold toward them, and we learn what the standards are and how we ought to behave based on what reactive attitudes are held toward us. But we must already be recognized as members of the moral community in order for us to hold and receive reactive attitudes in any meaningful way. To hold objective attitudes toward someone, in contrast, is to deny that person is a member of our moral community. To pity someone for being unable to reason about and control their behaviour is to refuse to recognize their moral identity, and in particular to refuse to recognize them as members of our moral community.

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Many philosophers propose a high standard of capacities the person must meet to have sufficient agency to be a member of the moral community and a fit recipient of reactive attitudes. Presumably, this results from thinking of the communities that they themselves belong to, including the community of other philosophers, as they are writing. For example, Susan Wolf suggests that in order to be a fit recipient of reactive attitudes, a person must be what she calls an “intelligent self”: “a self that can perceive, understand, and appreciate the world in the same way and as well as we can, a self, in other words, that has the same or better powers of perception, reason, and imagination that we do, so that when she responds to the world, it is the same world as ours to which she responds.”9 This standard is too high a threshold for moral agency, however. A person can see and respond to the world differently from us and still have some moral agency. We might have to work harder to understand them so that we can engage in intelligible moral address with them, but the fact that we need to work harder does not mean the task is impossible or unworthy. I return to this idea shortly. Moreover, this standard is elitist. Wolf assumes that “we” are the pinnacle of moral agency, where “our” understanding of the world sets the standard for what others’ understanding should be. As someone who is both a philosopher and a person with mental illness whose understanding of the world does not always fit dominant models of understanding, I find such elitism troubling. Wolf’s assumption that all or most of her readers (“we”) are moral agents who see and respond to “the same world” dismisses readers whose understanding of the world differs, especially those who have serious mental illness, as not being moral agents. Such a dichotomous view – that people are or are not moral agents based on the degree to which they share an understanding of the world – is oversimplistic, ignoring the complexities of moral agency, and is ultimately untenable. Moral recognition does not require seeing and responding to “the same world” as others; it only requires making a minimal connection on which we can establish shared meaning. This typically requires effort in establishing such a connection and creating the foundation on which shared meaning can develop. I elaborate on the subject in the section titled “Epistemic Conscientiousness” in chapter 5. To recognize others as moral agents, it is not necessary that others make themselves intelligible to us, as if all we have to do is show up to the interaction seeking shared meaning. To recognize others as

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moral agents, we must at least sometimes put in a little work to learn others’ frameworks of meaning in order to establish the shared meaning that enables moral interaction. It is our obligation as moral agents to recognize others as moral agents by putting in the effort to establish shared meaning where necessary and where we are capable of doing so. As I explain below, this effort does not require completely matching our understanding of reality so that we see and respond to “the same world,” as Wolf says; it only requires that we establish a minimal connection such as through shared language that allows for minimal overlap in our understanding of reality. Participating in moral address with others does not require a high threshold of agency and shared understanding. People with radically different understandings of the world and highly constrained agency may still be capable of moral address, at least in some ways and to some degrees. People with mental illness, even severe illness, are appropriately viewed as part of our moral community. When we engage with them, as with everyone, we have certain expectations for how they will respond in turn. What We Expect of Others When We Respond to Them When we respond to others as moral agents, we generally have certain expectations for how they will take responsibility for themselves. We make moral demands on them, expecting that they will recognize and respect us, and we expect that they will acknowledge and meet these demands. We expect that people will own their behaviour, viewing it as the outcome of their intentions and motivations, however compromised their rationality, intentional control, or self-awareness was in acting. Even if they had little control over their behaviour, we still want them to acknowledge it as theirs. We also generally want people to atone for bad actions they have done and change their future behaviour as warranted. As we have seen in chapter 2, all of these expectations can be thwarted when a person’s mental illness impairs them in certain ways. The expectations that people will change their behaviour in the future so they do not repeat bad actions, and that they will atone for bad actions (by seeking forgiveness and making amends for instance), are distinct. A person may be capable of one but not the other. It is fair for us to hope that a person will accomplish both of these aims. But it might not be reasonable to expect that they will or can. This is

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why maintaining a tension between treating people as agents capable of change while considering that their agency may be heavily constrained is so important: it allows us to create some of the conditions that enable change, while not blaming people for being unable to change. We do not have control over the degree or kind of impairment a person suffers from due to their illness, so we cannot necessarily make it so that a person can take responsibility for themselves in these ways. Our challenge is to create the conditions where these changes are possible, so that a person might accomplish them to the extent of their ability. In order for a person to have more robust agency, they must be capable of taking responsibility for their actions, having sufficient rationality and volition to be able to control their behaviour in the future. They must be responsive to reasons, capable of shaping their behaviour where they judge it is appropriate, based on morally sound judgments they make through moral reasoning. John Martin Fischer and Mark Ravizza identify three criteria that a person must meet in order to take responsibility for themselves. First, they must see themselves as an agent, “as the source of certain upshots in the world.”10 Second, they must see themselves as a fit recipient of reactive attitudes; in other words, they must accept others’ judgment of their behaviour through the reactive attitudes held toward them. And, third, these must be based on appropriate evidence.11 Through these considerations, a person asks others to acknowledge them as a conversational partner, as eligible to engage in moral address, and as a legitimate participant in moral practices.12 A community acknowledges a person as a moral agent when the person engages in the social practices of the community.13 In order to be a conversational partner, a person must be able to engage in conversation, be addressed, and be held responsible. But they must also be able to engage others, to address others by making moral claims, and to hold others responsible through reactive attitudes. Moral agency requires the ability to be on both ends of moral address. Moral agency does not require, however, that we are on both ends of moral address all the time, or even that we must have the capacity to be on both ends regularly or consistently. It only requires that we are sometimes, to some extent, even in the smallest of ways. And this is something that nearly every person – no matter how constrained their agency – is capable of at some point, to some degree.

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Just as some philosophers assume that moral recognition and moral address require high thresholds for shared understanding, many philosophers also assume that high thresholds must be met as conditions for agency. Philosophers make these assumptions, I suspect, because they theorize abstractly about an ideal moral reasoner and agent, and ignore the nuance and complexity of the ways that people actually reason and act. So, for instance, in describing what it is to take responsibility for oneself, some philosophers propose that a person must be moderately reasons-responsive and must be able to act on a valuational system that they adopted through reflection.14 These are conditions of the ideal moral reasoner, but they do not necessarily reflect how many people actually conduct moral reasoning. As I noted in chapter 3, many people reason, value, and choose in non-linear ways that are not captured by these abstract ideals. Because of the constraints on their agency, people with mental illness in particular may reason, value, and choose in non-linear ways. As a result, they may be capable of taking responsibility but not in ideal ways standardly assumed. Reasoning, valuing, believing, choosing, and acting are transactional with each other. How a person reasons affects what they value, believe, and choose, and how they act. What they value influences their reasoning, moral beliefs, choices, and action. What a person chooses helps create their values, forms their moral beliefs, directs their reasoning, and guides their action. What a person believes impacts their moral reasoning, valuing, choosing, and acting. How a person acts helps constitute what they believe and value and how they reason and choose. In other words, reasoning, valuing, believing, choosing, and acting are processes that collectively co-constitute each other, and changes in one affect the others. Agency and responsibility do not require acting on choices based on well-thought-out reasons, which in turn are based on previously determined values and well-formed beliefs. A person’s ability to take responsibility for themselves requires only that they are able to make some kind of transactional change, but where it occurs is not particularly important since it has effects on the other areas. Contrary to what many philosophers suggest, a person does not need to be deeply self-reflective, to reason through their options prior to choosing, to choose how to act based on reasons they have reflected on, or to base their reasoning on deeply held values in order to be moral agents capable of some degree and kind of responsibility. They

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only need to be able to be somewhat reflective, to reason in at least minimally rational ways, to make some non-determined choice, and/ or to have some values that underlie what they do. The threshold for each of these is low because it has broader effects due to its transactional nature. For example, a person who reasons with minimal rationality develops their values through their choice and their beliefs through their action; a person who has some valuational system can use that to guide their action, regardless of their reasoning capacity and perhaps even counter to their beliefs; a person who chooses how to act may develop their reasoning and their beliefs in the process of acting. Participating in some moral processes, to some degree, has broader effects than it might first appear because each process also has effects on other moral processes. People with impairments in cognition, reasoning, affect, and volition may be able to take responsibility for themselves in ways that are not obvious to philosophers looking at the “ideal” reasoner, though the ways and degrees to which they can take this responsibility may vary and may be constrained in ways we might not be able to see clearly or understand fully. Some therapeutic approaches recognize and build on this transactional nature of reason, value, belief, choice, and action. For example, relational frame theory (r f t ) and acceptance and commitment therapy (ac t ) both operate from the premise that a person can change the function that a belief serves in their lives without changing the content of their belief; consequently, a person can change their behaviour without necessarily changing the content of their beliefs first.15 (A person’s belief may change subsequently, after the belief no longer serves the purpose it once did.) In other words, a person need not develop beliefs and reasons for action prior to making changes in their behaviour; instead, they may simply experiment with acting differently. A person may in fact act intentionally in ways contrary to their belief or value, for example taking care of their physical needs despite believing that they are not worthy of such care, or taking steps to practice loving themselves when it goes against their entire self-­ conception and the way they value (or fail to value) themselves. If they continue with the experiment over time, the new behaviour might become a habit or a practice, and they may come to make changes to their beliefs and reasons for acting. The transactional nature of reason, value, belief, choice, and action suggests other pathways to change as well. For example, a person may have a poor valuation

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system but develop values in the process of changing their action. Such action over time can result in changing their beliefs. We need not be the ideal moral reasoners that some philosophers seem to assume in order to be “good enough” reasoners to be moral agents capable of change. Because people always have some kind and degree of agency, no matter how constrained it may be, they have the capacity to change given the right conditions. People who have mental illness are therefore capable of taking responsibility for their actions in some way, even when their agency is constrained. What that way is varies considerably and may be minimal or idiosyncratic, for example, acting as if nothing has happened instead of offering an apology or engaging in a ritual that they believe will keep them from causing more harm. Given that change is possible under the right conditions, what we must do in interacting with people is to create the conditions that enable change to whatever extent we can. The Complexity of Moral Agency I have already mentioned in this chapter that moral agency and responsibility are not all-or-nothing concepts. People do not need to meet a high threshold of sharing understanding in order to recognize each other as moral agents and to participate in moral address with each other. Participation can be partial and can vary in its form. People also do not need to be ideal moral reasoners, making choices based on reasons that are in turn based on reflected-upon values, in order to take responsibility and make changes in their behaviour. People can make choices based on flawed or insufficient reason; they can reason without relying on a set of values they have already reflected upon; they can value things without having chosen those things; they can act in ways that go against their beliefs or conscious reasons for action. The ideal theory of much moral philosophy does not adequately account for the complexity and nuance involved with the way people actually reason, value, believe, choose, understand each other, and interact. The all-or-nothing views that arise in some of the ideal theory of moral philosophy are examples of dualistic frameworks of understanding. In dualistic frameworks, there appear to be only two options, and these two options are typically assumed to be exclusive of each other. This dualistic thinking also shows up in the ways that

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philosophers tend to write about reactive and objective attitudes. In writing about reactive attitudes, philosophers tend to frame the choice of holding reactive or objective attitudes toward people as a dichotomy: we can hold either one attitude toward a person or the other, but not both, nor can we hold aspects of each combined together or hold alternative attitudes to these. Since reactive and objective attitudes are presented as dichotomous, they appear exclusive of each other; it seems that some philosophers writing in this area assume that we can take the personal standpoint of caring what the other person thinks about our reaction to them, or a third-person objective standpoint of not caring, but not both simultaneously. This is wrong. When people do not meet the conditions of agency that would make them fit recipients of reactive attitudes, we tend to hold objective attitudes such as pity if we have positive feelings toward them or disgust if we have negative feelings toward them. When we hold objective attitudes, we take an objective standpoint in assessing their action, looking at it from a third-person perspective of seeking to understand the action as if it had no bearing on us personally. With this perspective, we treat them as natural objects in the world, as if we are trying to understand the mechanics of how the world works. When we take the objective standpoint, we do not care in a personal way what people do, or whether they care about how we think of them, because they are simply objects in the world. In contrast, we hold reactive attitudes toward people when we take the personal standpoint and assess people’s actions as they relate to us personally. Here we treat them as agents who made choices and acted intentionally. In the personal standpoint, we care that they care what attitudes we hold toward them. In holding reactive attitudes, we want the people to whom we are reacting to hear the claims we are expressing with our responses and to respond accordingly in turn. We want them to care what we think so that they will respond or change their behaviour. This contrasts with holding objective attitudes, where it does not matter whether the people we are reacting to care what we think, because we do not expect any particular response from them, and we might not expect that they can or will change their behaviour. While it is easy to think about our moral response in these dichotomous ways – as taking either a personal standpoint or an objective standpoint – it is not accurate. In real life, we commonly take personal and objective standpoints toward people simultaneously, holding both

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reactive and objective attitudes at the same time. For example, we may feel both pity and resentment when we think that a person’s action was properly their own even if we know they did not have full control over their behaviour. Anyone who has children knows that we can feel angry when our children misbehave, while at the same time being sympathetic to their lack of self-control. As I explain below, other emotional responses that seem more detached than blame but less objectifying than pity – emotions like sadness, disappointment, and frustration – may be just as appropriate, if not more so, in circumstances that could call for blaming reactive attitudes. Reactive and objective attitudes are not exclusive of each other, nor do they capture the range of emotional responses we can have toward others. We can see people from a personal or first-person standpoint and an objective third-person standpoint simultaneously. Some philosophers argue that adopting an objective third-person standpoint, rather than holding only reactive attitudes toward others, is a sign of empathetic maturity. As I explain in the chapter 5, if we take a generous approach in our interactions with people, we will adopt a third-person perspective at the same time that we have our first-person perspective. In this third-person perspective, we seek to understand people’s behaviour within relevant contexts, including a psychosocial framework that understands behaviour in terms of ­motivations and interests. Anne Arber and Ann Gallagher call this third-person perspective “empathetic maturity.”16 In order to have empathetic maturity, we must use our imagination and look beyond what is apparent on the surface in order to see the larger, more complicated picture. If we also hold an attitude of charity toward people, we interpret their actions as rational and intelligible and give them whatever benefit of a doubt seems appropriate. As judgments about a person’s action, reactive attitudes are only justified when they meet certain conditions. The condition that most interests me here is the epistemic condition: that we must have certain facts about a situation in order to make a judgment that is justifiable. The problem in cases of complicated agency, such as the cases we are considering here where a person’s mental illness seems to have compromised their agency in a significant way, is that we typically do not have sufficient knowledge to be warranted in feeling certain about any judgment we make, and in many cases we are not able to have sufficient knowledge. At best we can make an educated guess. But passing judgment on someone based on an educated guess seems

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unfair and can in some cases be harmful when the consequences of such judgment are significant. I return to this thought momentarily.

R e s p o n d in g W it hout Blame So far, I have argued that people’s moral agency and their ability to take responsibility are more complicated than they might initially appear, and that even people with seriously constrained agency still have some kinds and degrees of agency and are therefore capable of change. In this section, I want to consider what role blame plays in our moral economy. I argue that it is inappropriate for us to blame people who act badly due to impairments caused by mental illness symptoms, because blaming has no worthy function in this circumstance and is actually counter-productive. If our aim is for people who act badly to change their behaviour so they act better in the future – which I want to suggest should be our aim – we need to respond in ways that encourage this change. Blaming people does not accomplish this. Because I do not think blame serves a productive function in our moral interactions, I am going to set aside the question of when blame is warranted, in other words when a person is a fit candidate for blame. Instead, I want to consider what role blame plays. Even if a person is a fit candidate for blame, we may not want to express blame because it can be unproductive and even harmful. Blame does little to change people’s behaviour, and it frequently perpetuates antagonistic response rather than reconciliation. Consider how people react to being blamed. When people do not see themselves as deserving of blame, typically they do not care about being blamed or they react with defensiveness and resentment; in these cases, blame has no positive effect. When people do see themselves as deserving of blame, on the other hand, typically they develop shame and guilt that can often distract from efforts to change. Someone may be eligible for blame because they “deserve” it based on their relationship to the causal history of their action; nevertheless, there may be good reasons for wanting to avoid blaming attitudes. Blame is not necessary for judgment and response. Erin Kelly proposes that we separate judgment from blame and focus instead on judgment, which plays the more important and productive role in our moral practices.17 The purpose of blame is to assess desert, and blame is assigned when the person stands in the right causal history to their

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action. While blame requires an assessment of the causal history of an action and the person’s capacity for reasons-responsiveness, judgment requires only assessing the quality of the act itself. And while blame is backwards-looking, judgment is primarily forward-looking, with the purpose of guiding present and future action.18 I take a pragmatic approach and endorse Kelly’s view that, because of the important guiding function of judgment, what is more valuable in moral assessment is judgment rather than blame. Judgment and blame are forms of moral criticism. Kelly identifies four ways that moral criticism can promote shared moral interests: it can serve as a deterrent, it can be instructive, it can aim at reconciliation, and it can promote solidarity.19 Blame may aim at the first goal but rarely achieves it; blame does not address the other aims at all. While one might argue that holding someone responsible through blaming should motivate a person to atone for their bad actions and change their behaviour in the future, it rarely actually accomplishes this purpose. What blame typically does is perpetuate antagonistic attitudes like defiance and anger, or self-absorbed focus on shame and guilt. While defiance, anger, and contempt are themselves antagonistic, they tend to perpetuate further antagonistic attitudes as people respond to these in turn; shame and guilt usually lead to an inner focus on oneself. Both of these approaches distract a person from focusing outwardly on their future action. From a pragmatic standpoint, assigning blame is not very productive. We cannot change what people have done in the past, and assigning blame is often counter-productive. Blame also does not serve a useful function in positively shaping how we act in the future. What we should care about is how people act in the future, looking at the most effective means for achieving instruction, reconciliation, and solidarity; if blame does not help us achieve these, then it is not productive in a forward-looking way either. If we are going to eliminate blame from judgment at least some of the time, how can we justify this, and what does this look like? Let us consider three proposals for how we can respond to bad actions without blame. First, some philosophers propose that we “overcome” blaming attitudes in order to achieve forgiveness and work toward peace.20 In arguing for the appropriateness of overcoming blaming attitudes, one proposal is that reactive attitudes are permissive rather than obligatory. In this view, reactive attitudes are underdetermined: when the evidence indicates the appropriateness of certain reactive responses,

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such responses may be given but they need not be. A person could choose to act differently, such as by granting forgiveness.21 Reactive attitudes could thus be seen as a capacity, as something we are capable of doing in the right circumstances, rather than as an obligation, as something we must do at any time they are called for. Philosophers who defend the value of blame would counter that blaming responses are indeed obligatory, that we ought to hold attitudes like blame and resentment when these attitudes are called for, because this is what it is to treat people as agents.22 In their view, to fail to blame candidates fit for blame is to fail to respect people as agents and to treat them as objects instead. I think this idea rests on an impoverished view of agency, however, especially if we accept the idea that adopting a third-person standpoint toward other people’s actions is a sign of empathic maturity, as I mentioned above and a position which I develop further in chapter 5. A second proposal is to distinguish the cognitive judgment involved with blame from the emotional response of blaming. Hanna Pickard agrees that blame is important but proposes that we distinguish between affective blame and detached blame.23 Affective blame involves holding the moral emotions that constitute reactive attitudes toward a person when the person’s action warrants it, while detached blame involves holding a person responsible for their action but without accompanying moral emotions. Affective blame has a “sting” that detached blame lacks. Pickard argues that some mental disorders, especially personality disorders, are more effectively treated when people with these disorders are not blamed for their behaviour through emotional responses but instead are treated with compassion. They may still be “blamed” in the sense that they are held responsible for their action, but it would be inappropriate and ineffective – perhaps even unfair – to hold blaming emotions toward them. Pickard argues that affective blame comes with a sense of entitlement: the blamer feels entitled to have and express whatever moral emotions they have because the person who is blamed “deserves” it. Detached blame is blame without the entitlement, without feeling entitled to any particular moral emotions.24 In other words, detached blame is simply a cognitive judgment. To treat someone with compassion here is to detach one’s emotions from judgment. We can be benevolent toward someone, and want them and help them change, without taking personal offence at their behaviour – and more pointedly, without feeling entitled to take such

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offence. To feel entitled to take offence is to assume that a person’s action has something to do with oneself, as in its intention or its effects, and that this connection to oneself is morally salient. But in many cases a person’s action may be connected to oneself only tangentially or superficially. I may be affected by someone’s actions but only indirectly or accidentally; or, a person may claim to intend to hurt me, but because the person was not sufficiently reasons-­ responsive, their claimed intention actually had little to do with the performance of their action or its effects. I am not entitled to feelings of offence in these cases because the person’s behaviour is insufficiently connected to me. I can make a judgment about the person’s action but it would be inappropriate for me to react emotionally. Pickard focuses on the attitude of the mental health clinician, and compares it to the parental attitude of nonjudgmental benevolence. We could argue that we ought to extend this detached blame to be appropriate not only for clinicians aiding their patients but also for anyone interacting with people with mental illness where blaming attitudes may be inappropriate. I generally endorse Pickard’s proposal; however, I think it does not go far enough, as I think blaming attitudes are rarely, if ever, appropriate by themselves. Blame may be unavoidable when we feel deeply hurt, but blaming attitudes ought always to be accompanied by objective attitudes, especially compassion, when we can find it within ourselves to take a third-person perspective of trying to understand the context of a person’s action. I shall explain this approach further in the next chapter. A third proposal for how we can respond to bad actions without blame involves replacing blaming attitudes like anger, resentment, indignation, and contempt with attitudes of sadness and disappointment. David Goldman argues that non-antagonistic attitudes like sadness, especially sadness as a form of disappointment, can fulfill the same function that antagonistic attitudes like resentment do.25 He identifies one of the most important functions that resentment serves: as communicating “an emotional and deeply felt distress over wrongdoing.”26 Blame is based on a belief that one has been wronged and a judgment that one should not have been wronged, that one’s claim to respect or recognition has been violated. We can hold this belief and judgment while expressing a different affective response, however. Sadness can communicate distress over wrong­ doing equally well.

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Erin Kelly elaborates on the idea that sadness performs the same important functions that resentment does in proposing that the most appropriate reactive attitude toward someone who acted badly is disappointment. Disappointment is separable from desert; we do not have to assess whether a person “deserves” disappointment, only whether their action was disappointing. How much control they had over their action and how responsive they were to reasons are irrelevant. Kelly describes the attitude of disappointment vividly: When persons fail, we feel disappointment in their shortcomings. Our disappointment is measured by our sense of the possibilities and opportunities lost, and is not, like resentment, fixed by a notion of what a person deserves. Even our anger need not depend on our sense of how responsible persons are for having turned out as they did: what part exactly they played in their own failure. We may be sad, regretful, or angry that a person, for whatever reasons, did not turn out to be the person we hoped she would be, or thought she might have been.27 Kelly’s description of disappointment aptly describes the response we may feel when people act badly and their action likely was constrained, at least partly, by factors outside their control, such as impairments caused by mental illness symptoms. When people with mental illness act badly, we are rightfully disappointed in their behaviour. We regret the possibilities and opportunities that are lost by a person’s action, and we are disappointed that they were unable, at least in the moment of acting, to be the person we wanted them to be or thought they should be. Kelly’s description of disappointment captures the way that we are upset with someone’s bad action even when we are not sure that they are fit candidates for blame. It also captures the way that we can still be upset with someone’s action even when we are capable of a third-person perspective of trying to understand the context of their action. Kelly’s proposal fits with the principle I introduced in chapter 2: people do as well as they can, or at least as well as they believe they can, given their beliefs and the information available to them. Jon Elster presented this principle as a way to summarize his account of rational action as action that satisfies one’s desires based on beliefs that are grounded in available information.28 To the extent that this principle is correct, blaming someone for doing badly, when it was

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the best they could do given the information and beliefs they had, seems misplaced. Being disappointed in their bad actions, on the other hand, can be an appropriate response. Some philosophers are concerned that refraining from blaming attitudes in contexts where a person is a fit candidate for blame treats people as objects rather than as agents. In this view, eliminating desert and the reactive attitudes that express judgments of desert is a way of not treating people as human beings but rather as objects in the world. Insofar as holding reactive attitudes is a form of moral address, we would not be able to make claims on others to respect our dignity if we could not hold the full range of reactive attitudes toward them. Moreover, in this view, feeling the full range of reactive attitudes is essential to maintaining personal relationships, such as romantic partnerships or friendships, for we could not feel sufficiently close to someone and interact in the most personally meaningful ways if we were not able to feel resentment or indignation when they do something we find wrong.29 In order to maintain close relationships, we must care that others care what we think of them and their actions. In other words, when we care about someone, we want the person to value us in a certain way: we want them to care about what attitudes we hold toward them.30 Moreover, we need reactive attitudes for their communicative function: we must be able to make claims on those with whom we share personal relationships to respect and recognize us, and we must be able to enforce these claims through our reactions to others’ responses to us. In this view, eliminating reactive attitudes would eliminate personal relationships. This response seems to come from the dualistic thinking I criticized above. There is often an unevenness within friendships and even intimate relationships, based in part on the complexity of agency and our inherent epistemic limitations to know how and to what extent other people’s agency – and our own – is constrained by factors outside our control. The kinds of claims we make on those with whom we share a relationship can vary, and they do not need to be the same kind of claims that our friend or partner makes on us. I can love someone and be in a close personal relationship with them and yet question whether they have sufficient rationality, free will, and self-awareness over their behaviour to be responsible for it, whether in discrete instances or more generally. I can be close friends with someone of whom I do not feel I can make significant moral demands.

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Even people who have highly constrained agency still have agency of some kind. Even if I can only make small moral demands on people who have self-control only about small things, like what to eat for dinner, I can still consider these people my friends. They may be able to meet some of my needs – for example I may enjoy their company – even if they cannot meet other needs. On the other hand, there may indeed be some significant demands I can make on them, such as asking them to listen when I need to talk, but not others, such as showing up when we plan to meet or doing what they said they would do. Taking a third-person perspective of seeking to understand the context of a person’s action helps. I can withhold blaming them for not showing up or not following through while still treating them as agents and still maintaining a meaningful friendship with them. In the throes of a manic episode Terri Cheney or Mr M might not be a reliable friend, but they may be a good listener, for instance, despite their mania; therefore, they may be a good friend in some respects but not in others. This is true of many of our friendships, whether or not our friends have mental impairments. People are likely to be good friends in some respects but not in all respects. We value what they can offer to the friendship rather than regretting what they cannot. We seek to have our social needs met through multiple friendships and other relationships, not just one. Agency is complex, and our evaluation of our friends’ agency must account for this complexity. Constraints on agency do not necessarily entail constraints on personal relationships, though of course they may. While it may be natural to blame our friend for failing to be a good friend in some respect or our husband or wife for not showing up in some important way, blaming is largely unproductive and serves little purpose. If we choose to withhold blame, this does not in any way threaten our ability to maintain a meaningful relationship with the person whom we have chosen not to blame.

E p is t e m ic L im itat io n s i n Our Abi li ty to A s s e s s a P e rs on’s Agency In the previous section, I argued that blaming attitudes, especially when held by themselves, are morally problematic. By perpetuating antagonism and misplacing attention, they are ineffective in shaping future behaviour and serve no productive function. Here, I want to make a different argument for why blame is inappropriate, and why

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charity and forgiveness are better approaches in responding to people when they act badly. This epistemic argument proposes that we ought to be careful in how we act because we must make choices based on insufficient knowledge and uncertainty about our judgments. Because as humans we are inherently fallible, we cannot help but make decisions about how to respond to others based on insufficient information. In many cases, we form judgments we cannot be absolutely certain about, but we must respond based on educated guesses. Most of the time this probabilistic reasoning works suitably. In some cases, however, the extent of the lack of information and the consequential uncertainty about judgment are high. Making judgments on insufficient knowledge is often unwarranted and can even be harmful. The problem here is that we have inherent epistemic limitations in our ability to know what kind and how much agency a person has. (This is one reason why we are capable of holding seemingly contradictory attitudes concurrently, such as anger and pity, or resentment and sympathy.) Our response to a person’s behaviour depends on a judgment we make about their agency. But we generally make such judgments without being able to know all the facts of the situation. This is not because we did not make enough effort to attain sufficient information; this is an inherent limitation in how we can know other people’s minds, and even our own. We simply do not know the extent of rationality a person has, and the degrees to which and ways in which they are capable of moral reasoning; we do not know the extent to which a person can act with sufficient volition for an action to be properly “their own.” And it is not only that we do not know; it is that we cannot know. Such knowledge goes beyond our epistemic capacities because we cannot know the depths of a person’s mind. Although we have privileged access to first-person knowledge of our own mind, we are not always able to know the depths of our own mind, and how or the extent to which we have capacities for rationality and free will. These epistemic limitations are inherent to the mysteriousness of the human mind. While our knowledge always runs up against these epistemic limitations, we can make judgments based on achieving a threshold of relevant information. Often we know enough about a situation to make a reasonable judgment based on the information available; with practice and experience we are often correct in our judgment. In some situations, we are not able to gather enough relevant information to make a reasonable judgment that is, in probability, correct. When we

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know that people’s actions are likely constrained in some way, such as by mental illness, our usual way of judging a situation does not work. We need more information than we are capable of getting; we need to understand the nature of the constraint, and the ways in which and degree to which it is constraining. But since we are unable to acquire this information, we typically fall back on preconceived beliefs, including stereotypes, to help fill in the information we lack. Jonathan Adler argues that because we cannot avoid making moral assessments based on insufficient evidence, we ought to modify our reactive attitudes as a result.31 It is particularly difficult to justify blaming attitudes like resentment and indignation when they rest on insufficient evidence, because so much is at stake when we employ them, as we risk the perpetuation of antagonistic response. I take Adler’s suggestion a step further to propose that when we have insufficient evidence for judgment, our uncertainty about the justification of the judgment may be high enough to warrant withholding judgment altogether. Withholding judgment may take several forms. First, we could refrain from certain kinds of judgments, particularly those about the kind and degree of agency a person has. As suggested by Erin Kelly and David Goldman, we could feel sadness or disappointment that the person did not or could not act differently without making a judgment about their agency. This allows us to have first-person affective responses that are not blaming attitudes. Second, we could refrain from any affective response, making only a cognitive judgment about the act. The cognitive judgment could be first-person observation about the effect of the action on oneself, but without the “sting” of accompanying emotion. For example, we might observe that a person’s inability to get their work done gives us extra work to make up for it, without feeling resentment or other emotion. Refraining from affective response could also take the form of a third-person judgment about effects of the person’s action on the person themselves or on others. For example, we might observe that a person who bought a lot of items will have difficulty paying for them, without feeling disappointment or other emotion. These cognitive judgments are made intellectually, without corresponding feelings, even of sadness or disappointment. Third, we could withhold judgment altogether, merely making an observation of the facts as we see them. For example, we might observe that a person destroyed a lot of clothing, as Mary Weiland did (in an

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example in chapter 2), or that a person did not show up to a meeting at a planned time. Here we do not judge that these actions are bad or problematic; we simply observe the actions as they are. Making an observation while withholding judgment is probably the hardest for us to do, and the one that defenders of blaming attitudes would object to the most. But refraining from judgment is valued within certain philosophical and religious traditions, including stoicism and Buddhism, and can be regarded as a sign of emotional maturity, or a display of empathic maturity. In a worldview that is less egoistic and individualistic, and that sees the self as part of the natural order of things, refraining from judgment is prized as a different way of relating to the world and to others. I submit that this way of relating to others does not preclude friendships and other close relationships, as I discussed above. People with mental illness often experience constraints on their agency due to the mental impairments caused by their illness. Due to the inherent epistemic limitations we have by virtue of being human, we necessarily lack sufficient knowledge to make a warranted judgment about the nature and degree of constraint a person experiences. If we accept our epistemic limitations, then we see that it is only fair to withhold judgment based on our fundamental uncertainty about others’ agency.

E p is t e m ic A t ti tudes Certain epistemic attitudes help us adopt an approach of withholding judgment. If we have epistemic humility and accompanying honesty, we recognize the limitations of our knowledge and we are committed to not overreaching by way of acting on knowledge we do not actually have. With epistemic humility we recognize that a person’s actions are part of a much broader context than simply the interplay between the person and ourselves. We can accept that there may be much we do not understand about the action, including its motive, and that we ought not to rush to judgment because there is so much we do not know. If we have charity, we interpret a person’s action in the best light possible, meaning that we give them the benefit of a doubt, that we try to understand the larger context of which their action is a part, and that we assume they have good intentions. With charity we can be forgiving of actions that cause us harm or in some other way

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disturb or bother us. With charity we can accept the mysteriousness of agency. We can accept that there is some mystery in people’s actions and that we may never understand how people can act in ways that cause harm. With these epistemic attitudes, we find that withholding judgment is the best moral response we can make to people’s actions. Epistemic Humility and Honesty Withholding judgment in any of the three ways described above because we lack sufficient knowledge to make a warranted judgment is an act of epistemic humility and honesty. Epistemic humility is an epistemic virtue involving an awareness of our epistemic capacities and limitations. Recognizing and accepting these limitations, we do not claim to know more than we actually do. When we have epistemic humility, we are able to see ourselves in a larger perspective and see our own knowledge in relation to the knowledge of others. We recognize the inherently interdependent and collaborative nature of knowledge inquiry and making meaning, and we see that our own knowledge and meaning are just one piece of a much larger picture. This recognition and acceptance of our limitations leads us to seek out further epistemic resources by pursuing other people’s perspectives and voices as we try to make sense of the larger picture.32 When we recognize that we do not fully understand the nature of someone’s agency, and the kind and degree of constraints they have on their agency, we are epistemically humble by not claiming to know more than we do. We try to gain greater understanding by asking them for their own perspective on their action and by discerning the larger context in which they act, including the mental impairments, for example, that created constraints on their agency. But we also accept that there is a lot we can never know, no matter how much inquiring we do. Epistemic honesty, furthermore, requires us to avoid overreaching by acting on knowledge that we believe is more certain than it really is and to refrain from acting in cases where lack of uncertainty affects how we might act. When we have epistemic humility and honesty, we recognize the inherent mysteriousness of a person’s action and accept that mystery for what it is. Epistemic humility and honesty require us to acknowledge the inherent uncertainty about other people’s agency and to act appropriately as a result, namely to refrain from judgment.

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Charity and Forgiveness Treating someone with charity in an epistemic sense means that we interpret the person’s action in the best light possible, trying to understand the larger context for their action, and assuming they had good intentions. For my definition of charity here, I am drawing on the idea of the principle of charity, which has us interpret an argument as rational and in the strongest, most persuasive way possible. When we hold to the principle of charity, we give people the benefit of a doubt. I want to broaden the definition of epistemic charity here to mean that we interpret people’s speech and action as rational and in the best possible light. Interpreting speech and action in a good light and seeing them as intelligibly as possible often requires us to understand the larger context for the speech or action. Charity involves an aspect of kindness, too. When we are kind in our interpretation, we assume that people acted or spoke with good intentions and react to them accordingly. Given our uncertainty and lack of knowledge about how much and what kind of agency a person has in acting, it is most fair that we interpret people’s actions charitably. This means in part that we should adopt a third-person perspective of trying to understand the psychosocial context for a person’s action. It also means that we should try to comprehend the action from the person’s own perspective: why the action seemed like a good idea or what function the action served. Charity allows us to accept Jon Elster’s principle of rational action that people do as well as they can, given their beliefs and the information available to them. Charity enables us to see that people typically do things because it makes sense for them; the action seems to serve a function of which people may be more or less conscious. Charity also enables us to see that sometimes people simply act, and their actions may have no meaning. With charity we try to discern the broader context in which an action may make sense, or we accept the inherent mysteriousness of action. Frequently, we must do both. Charity may ask us to consider what volitional control a person had over their behaviour. In cases of atrocities, especially those that seem to serve no purpose, charity may suggest that a person could not have helped what they did. Interpreting an atrocious act in the best light possible may mean assuming the person had little control over it. According to a charitable view, it may be proposed that no one who was sane and had sufficient rational self-control would

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commit a crime like murder.33 I do not think that charity has to have us make any particular assumptions about volitional control, however. Charity only has us recognize that actions occur in a much broader context, and we can try to fathom their meaning by understanding what function the act served or we can accept that there is an inherent mysteriousness to the action that no amount of fathoming will solve. When we take a third-person perspective of trying to understand the psychosocial context for a person’s action, or we accept the inherent mysteriousness of action, it is easier to forgive someone for their bad action. While I do not want to argue that we have a duty to forgive, I do want to argue that forgiving has practical value for us, because it allows us to move beyond a particular moral action so that the process of moral engagement and moral address can continue. There is much debate about whether it is always good to forgive; it can be argued that some actions are so heinous that they ought not to be forgiven.34 I want to suggest, however, that whether forgiveness benefits the person being forgiven and whether the person being forgiven deserves this benefit are beside the point. Philosophers disagree as to whether forgiveness is ultimately about the forgiver or the forgiven, but I tend to think that forgiveness matters most to the forgiver. While forgiveness involves the giving of a gift – being the recipient of this attitude – the person who receives the most from this giving is not the recipient but the giver. Forgiveness is an attitude of charity and graciousness that creates inner peace. When we can forgive bad action, despite its harm to us, we can be at peace. We can move on with our lives and focus on other things besides the harm that was committed to us. Insofar as forgiveness is good for the forgiver in providing peace, there is value in forgiving even atrocious acts. Forgiveness is important first and foremost for its effect on the forgiver, but it also has a valuable effect for the person who is forgiven: it helps create the conditions that allow change to occur. Forgiveness, unlike blame, is thus valuable in a forward-looking way. Forgiving people provides them an opportunity to change their behaviour because it softens the tone of moral address. It is easier for people to work on doing better when they are forgiven for past bad actions than when they are the target of anger and resentment. Reactive attitudes tend to get in the way of change, promoting further antagonistic responses like defensiveness, as opposed to fostering productive attitudes like earnestness and commitment. Forgiveness provides a person with motivation to do better, as they try to live up to feeling

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worthy of being forgiven. Being treated with respect rather than resentment, love rather than loathing, and forgiveness rather than blame motivates a person to be respectful, loving, and forgiving of others in turn. Philosophers typically provide several conditions for forgiveness, including the condition that a wrongful act must have been perpetuated by a person deliberately or negligently, which has caused harm to another.35 When people who have mental illness have constrained agency due to mental impairments caused by their illness, it is unclear whether actions they commit are deliberate or negligent in the right sorts of ways. Epistemic humility would have us recognize our uncertainty about this issue, and charity would have us assume that people’s actions are deeply constrained by their impairments. In any case, it is unclear whether actions committed which caused harm to others satisfy this condition of deliberateness or negligence. If such actions do not, then, in a typical understanding of forgiveness, forgiveness does not apply; there is nothing to forgive. In my view, forgiveness is an attitude of charity and graciousness that brings inner peace. With this conception, forgiveness is always appropriate for actions that cause harm, offence, disturbance, or other undesirable effects regardless of the mental state of the person who committed the action. Forgiveness is an attitude we hold that comes out of our humility and reverence for humankind, as I discuss further in chapter 5.

H ow W e S h o u l d Treat People How we treat people affects how they act. When we treat people well we help create the conditions that allow them to adopt those same qualities. If we want a person to be kind and generous, we must treat them kindly and generously. Moreover, we can treat people as already embodying the traits we wish them to adopt, and that also helps create the conditions that allow them to adopt these traits. So, for instance, if we want a person to be autonomous, we should treat them as if they already are autonomous, while forgiving them for not yet living up to those expectations. The reason we should treat people in these ways is that through our interactions with others – how we are treated and how we respond in turn –we develop our moral agency. We learn how to treat others by how we are treated. E.M. Shackle argues that for the sake of this educational purpose we ought to treat

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people better than their behaviour may suggest. “So much more is it important (as an antidote) to treat the person as a person when we are also seeing him or her as behaving as less than a person. We do not teach politeness by being rude to rude people.”36 Rather, we teach people to be charitable, compassionate, humble, and generous by treating them charitably, compassionately, humbly, and generously. We are more likely to become a certain way when we are treated as if we are already that way. So, for instance, we teach people to be responsible in changing their behaviour by treating them as capable of being responsible and of changing. Even when a person’s behaviour suggests otherwise, we ought to treat a person as an autonomous, responsible moral agent, not necessarily because the person “really” is one underneath the compromised behaviour, but rather because they can learn to be an autonomous moral agent, capable of taking responsibility for themselves in part through how they are treated. This is because people have a tendency to fulfill the expectations set for them. If we expect less of one another, we will be less; but if we expect more of one another, we will often rise to the occasion and be more. Punishing a person for being bad, or for making bad choices, does not teach a person how to be good, or how to make better choices. When we interact with others in the ways that we want them to act with us, we are modelling for them a way of acting. Given that we are the ones who are doing the acting, the action appears (to them) to be what we find acceptable, normal, or admirable, for our performance of the action puts our endorsement on the action. How we act with others, therefore, affects their behaviour. If we treat people as capable of rationality and free choice and capable of making good choices, we open the door to allowing them to do so. If we treat people as incapable of being moral agents, however, our treatment creates an obstacle to their ability to do so. Since our interactions with others help us develop our moral agency, whether others treat us as having moral agency or not, affects how we respond to others, what beliefs we form about ourselves and about others, and even what character traits we embody. Treating people as better than their actions suggest actually enables people to improve their behaviour, as people often try to match the behaviour associated with how they are treated. Sometimes, this happens because other people’s treatment of them demonstrates a belief in their capacities, which they themselves might not have; seeing

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themselves through other people’s eyes in a better light than how they see themselves illuminates possibilities previously not considered. I might not know that I am capable of making good choices unless someone has shown me that they believe in my ability to do so; then it becomes a possibility that shows up on my “radar” or deliberative screen, when it was not there before. Believing or not believing that I have a certain capacity can make a difference to whether I am actually able to develop and exercise the capacity. If I believe I am incapable of doing something, that thing will never show up as a possibility on my deliberative screen. But if you believe I can do it, and I can see this belief through the way that you treat me, then I will know that doing it may be possible, at least from one perspective (yours). Since our own worldviews are constructed in relation to the worldviews of others, the external perspective that your action demonstrates may impact my own way of seeing the world, and myself – and the possibility of doing something may show up on my deliberative screen as I consider it an option. (This also shows the extreme importance of engaging with people who are too inward-looking, to help them see the world outside themselves by offering external perspectives, which they must then use to incorporate into or revise their own perspectives.) We also teach people how to do activities by engaging them in those activities. We teach people how to engage appropriately in moral address by engaging them in moral address. We teach people how to take responsibility for themselves by holding them responsible, and we teach people to change their behaviour by expecting them to change. However, we must always also recognize our inherent epistemic limitations and approach our moral behaviour with appropriate epistemic humility, recognizing and accepting that we can never fully understand someone else’s action and the constraints they have on their agency. We must be careful about judging others’ action or refrain from judgment altogether. We must try to understand people’s action from third-person psychosocial perspectives and accept the inherent mysteriousness of agency. And we must forgive people for being unable to change or to live up to our expectations when they are unable to do so. It is important that we hold people responsible and expect them to change, because by doing so we help create the conditions that enable change to occur. In recognition of our epistemic limitations and out of charitable concern, however, we must also forgive people when they are unable to change, take responsibility for

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themselves, or otherwise live up to our expectations. The most appropriate moral response we can make to people, especially when they may have considerable constraints on their agency, is to maintain a tension between holding expectations for them and forgiving them when they are unable to meet those expectations.

C o n c l u s ion As I mentioned in chapter 2, I have done plenty of actions while I was mentally ill that I am not proud of, that I can hardly explain, let alone justify, and that I would not do if I were not sick. At times, I have not been a good friend, wife, or mother; I have not always been there for people when they needed me; I have performed actions that were unintentionally but avoidably hurtful to others. When people have blamed me for my behaviour, I have felt guilty or defensive and I have found it difficult to atone for my actions appropriately or even to change my behaviour. When people have forgiven me, I have found it easier to be appropriately responsive: to recognize that what I did was wrong, to change my reasoning and values, and to exert some control over trying to change my behaviour. When people have given me the opportunity to be a better person, I have tried to rise up to their expectations as best as I could. At the beginning of this chapter, I asked us to consider the responses people have to many bad actions first discussed in chapter 2. I suggested that people typically respond to these actions with anger, resentment, disappointment, or shock, for example. I now want us to imagine what alternative responses would be like. What does it look like for the people who bought counterfeit art from Andy Behrman to regard his behaviour from a third-person perspective of seeking to understand the larger context in which his behaviour made sense to him? What does it look like for Mary Weiland’s husband to recognize his limitations in trying to understand his wife’s behaviour and so to refrain from judgment? What does it look like for the survivors of the Aurora theatre shooting to feel disappointment rather than anger at James Holmes? What does it look like for those impacted by suicide to acknowledge their inherent epistemic limitations in trying to understand the motives behind it? What does it look like for Mr M’s wife to forgive him in order to regain her own peace of mind and help create the conditions in which he could change his behaviour?

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I do not claim that adopting epistemic humility and charity is easy or even always possible. But I do think these approaches are more productive in serving useful functions both in terms of enabling people to change their behaviour and taking responsibility for themselves, and in terms of making possible the continuation of moral interaction and moral address. These approaches treat people as the moral agents they are, while recognizing the complexity of their moral agency and our own inherent epistemic limitations in trying to understand that agency. In the following chapter, I move beyond looking at how we should respond to people whose mental illness may have contributed to their bad actions to look at how we should interact more generally with people who have mental illness. I examine several character traits we should adopt to help us interact in ways that increase people’s agency, including open-mindedness, epistemic conscientiousness, charity, compassion, humility, and generosity. By interacting in intentional ways, we can create the conditions that allow people to develop and exercise their agency, and thereby create the conditions for people to change.

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5 Interacting with People who Have Mental Illness

In t ro du c t i on So far in this book, I have identified two primary goals with respect to enhancing the agency of people who have mental illness: to increase their social interactions in order to counter the social isolation that mental illness and stigma frequently cause, and to create the conditions that enable change, so that people with mental illness are able to act better in the future and adopt attitudes and dispositions that allow them to flourish. These goals are good for all of us, but they are particularly important for people whose agency is constrained by mental impairments and stigma stemming from mental illness. In order to achieve these goals, we must interact in intentional ways with people who have mental illness. We must adopt certain attitudes and dispositions ourselves that facilitate meaningful interaction and that help create conditions conducive for people to change, grow, and ultimately flourish. It can be difficult to interact with people who have mental illness, however, because their illness can constrain in several ways how they engage with people. Because of various constraints on their agency, people with mental illness sometimes commit bad actions like those described in chapter 2. Due to mental illness, people also sometimes adopt demeanour and generally behaviour that can be inappropriate, offensive, or otherwise problematic. In addition, friendship can be difficult with someone who has mental illness, when they do not carry out the normal expectations for such a relationship. There are many reasons why people who have mental illness may engage with others in problematic ways. People with mental illness

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often struggle with self-awareness and are more likely to be selfabsorbed or preoccupied with their mental states, so they are not always courteous in their interactions. Because they may have diminished self-awareness, as well as difficulty reading social cues caused by their illness, they may be unaware when their behaviour is inappropriate, harmful, or bothersome. Because they frequently see the world differently, sometimes in idiosyncratic ways, they can be prone to misunderstanding other people’s intentions. Their emotional wiring may be such that they are slow to react positively to others, such as through praise and gratitude, but quick to react negatively, such as through indignation, resentment, or contempt. Because their mental experience often preoccupies them, and because their internal world can be so chaotic, they may have trouble being reliable and consistent with their behaviour, and they may not be able to be counted on to be there for someone or to get things done. Certainly not all people with mental illness, even severe illness, exhibit these undesirable traits, and even those who do tend not to do so all the time. Nonetheless, these traits are not uncommon due to the cognitive, rational, and emotional impairments caused by mental illness symptoms. In this chapter, I consider what attitudes and dispositions are most helpful when interacting with people who have mental illness. While in chapter 4 I focused on appropriate moral responses when engaging in moral address, particularly in the context of bad actions, this chapter looks at moral interaction more broadly. When we are looking at what goes into good interactions, we must always keep in mind that we cannot control what other people do; we may want an interaction to go a certain way, but we have limited control over its direction. What we do have control over in interactions is our own action. In chapter 3, I argued that people who have mental illness are especially prone to social isolation due both to internal factors caused by their illness and external factors caused by stigma. Social isolation increases difficulty for a person to develop and exercise moral agency and thus in some fundamental sense threatens a person’s ability to be fully human. In this chapter, I want to take up the call that we ought to engage people who have mental illness by interacting with them in intentional ways. Through our interactions we can break down the barriers caused by social isolation and we can give people opportunity to develop and exercise their moral agency. It is through our interactions with others that we, in a sense, humanize them.

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After some general considerations about how to interact with people who have mental illness, this chapter explains several intellectual and moral virtues that, when we adopt them, enable us to have more meaningful interactions with others. These virtues include the intellectual virtues of open-mindedness and epistemic conscientiousness, and otheroriented virtues of charity, compassion, humility, and generosity.

H ow to In t e r ac t wi th S omeone W h o   H as   M e n ta l I llness When we think about how we can interact better with people, we are in part considering the nature of our character and considering how we can be better people. This consideration casts the question of how to interact well with others as a question of virtue ethics. A virtue is an excellence, or a trait, which when possessed makes us a better person and helps us live flourishing lives. A virtue can also be understood as a disposition or orientation that enables a person to act well. To interact well with others, we need to display certain excellences of character. The virtue framework is as important for considering how people who have mental illness should interact, respond to others, and take responsibility for themselves as it is for thinking about how we should interact with them. We want people with mental illness, as we want everyone, to act as well as they can. In particular, we want people who acted badly, and whose bad actions may have been unduly influenced by mental impairments caused by their illness, to act better than they did by making better choices in the future, and perhaps even to acknowledge their past bad actions and atone in some way. This is in part an issue of character: we want people to be better than they were or are, and we want them to develop and display excellences that help them flourish. Making good choices and acting in good ways helps further people’s well-being. People learn how to be better than they are through a process of moral development. Some of the same processes that children undergo as they develop moral reasoning also occur in adults. People of any age must be able to see adults around them who can serve as models. A person developing their moral reasoning must see other individuals engaging in moral reasoning so that they know what it looks like. They must have the opportunities to practice moral reasoning in relevant settings. They must be subject to other people’s reactions so

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they learn how people respond to different kinds of behaviour and so they can use that to guide their own behaviour. People working on enhancing their moral agency thus need to be around those who have relatively robust moral agency, to have opportunities to engage in the practices of moral agency, and to have others respond to them. What this means for people with mental illness is that they need to be around other people, some of whom do not have mental illness and do not have similar constraints on agency, so that they can observe and interact with those who do not have the same limitations they have. This will help them look beyond their own constraints to see further possibilities for action. People with mental illness need to have opportunities to engage in moral practices and, therefore, must have opportunities to interact meaningfully with others rather than being socially isolated. And they need to have others meaningfully respond to them in ways that allow moral engagement rather than having others treat them as objects to be avoided, shunned, feared, or loathed. People with mental illness, therefore, need to have opportunities for social interaction and for the development of relationships in order to be, and to be recognized as, agents. We can create the conditions that allow people to flourish by addressing stigma to eliminate prejudice and discrimination. As discussed in chapter 1, the most effective way to reduce stigma is through interpersonal contact with people who have mental illness. Confronting our own stereotypes about mental illness and actively seeking out counter-narratives that challenge these conceptions are essential. We need to get to know individuals who have mental illness, hear their stories and understand them in their particularity, in order to move beyond the generalizations and negative stereotypes we tend to hold. Interpersonal contact helps us see people as human beings and as particular individuals, making it harder for us to reduce them to their mental illness or to see them as less than or other than human. Adopting epistemic attitudes that help us with this, such as openmindedness and epistemic conscientiousness, is key. A second way we can create the conditions that allow people to flourish is by adopting traits to make our own communication and interaction easier so that people with mental illness feel comfortable in our company. The best thing we can do to help someone in distress is to be there for them in their suffering. They will want us there if we portray ourselves in the right ways: as someone gentle, kind, compassionate, giving, and humble. If we adopt these traits, we can

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make it easier for people with mental illness to be willing and interested in talking with us. Given that one of our goals is to increase social interaction of people who have mental illness, it is important that such people feel comfortable with us and have opportunities to engage with us. Because of our relative power when we are not mentally ill, and because people who have mental illness are vulnerable by having diminished credibility and authority, we tend to be in a position of privilege when we interact with those who have mental illness. Because of this privilege, the burden is on us to make that engagement as easy and comfortable as possible. Adopting such traits also leads us to a third way to create the conditions that allow people to flourish: by developing and exhibiting traits or virtues ourselves, we become role models. In role modelling the qualities we wish others to have, we show that embodying these traits is not only possible but worthwhile. We show what it looks like when someone has a certain trait, and we demonstrate the value of possessing that quality. We help create the conditions that allow people to change. A fourth way we can create the conditions that allow people to flourish is to treat them how we want them to be. In previous chapters, I have argued that we develop our moral agency through our interactions with others, including how we are treated and how we respond in turn. In chapter 4, I argued that, as a consequence of this, we should treat people as we want them to become because that helps create the conditions that allow change to transpire. If we treat people as though they are annoying, frustrating, or simply bad, they will likely be annoying, frustrating, or bad in response. If, on the other hand, we treat people as better, more virtuous, than they are, they may be motivated to live up to our conception of them. How do we want a person with mental illness to be? What does it look like for them to be more virtuous than they are? In order to move out of the self-absorption caused by their illness, we would like them to broaden their worldviews, to be open to new ideas, and to seek out shared meaning. In order to have meaningful engagements with others, we would like them to be compassionate, giving, and interested in learning from others. In order to encourage people to be virtuous in these ways, we must create the conditions that enable them to adopt these traits in part by adopting them ourselves. This chapter focuses on the virtues we ought to develop in order to engage meaningfully with people who have mental illness. These

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virtues help us connect with people who have various mental impairments and enable the social interaction people need in order to develop and express their agency. Moreover, in possessing these virtues we model what it is to have these virtues, and we make it possible for others to adopt these virtues. While no empirical research has been done to confirm the idea that developing certain virtues can help enhance the agency of people with mental illness, I want to argue here that it can. The virtues that I focus on here are the intellectual virtues of open-mindedness and epistemic conscientiousness, and otherdirected virtues, which include charity, compassion, humility, and generosity. I discuss each of these in turn.

In t e l l e c t ua l Vi rtues In chapter 4, I discussed some intellectual and moral virtues that are important in our moral address with people who have mental illness. Epistemic humility, honesty, charity, and forgiveness are all important aspects of how we should engage meaningfully with others. Here I want to focus on two additional epistemic virtues: open-mindedness, including seeking out new ideas and counter-narratives, and epistemic conscientiousness, specifically the trait of seeking out shared meaning and understanding, which sometimes involves working to make intelligible what appears unintelligible. With these epistemic virtues we can engage more deeply and meaningfully with people who have mental illness. Open-Mindedness I begin with the epistemic virtue of open-mindedness. Broadly speaking, open-mindedness involves being receptive to new or alternative ideas. In other words, we are not overly attached to our current views; we are able to take seriously alternate ideas and to transcend our default ways of understanding. In a truth-seeking context, openmindedness can be understood as recognizing our fallibility and taking challenges to our beliefs seriously in order to test for error. However, open-mindedness can also be understood in a broader epistemological context as a willingness to understand more deeply by appreciating complexity and nuance.1 Open-mindedness is central to addressing and overcoming stigma. Being open-minded and capable of acquiring deeper understanding

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requires, among other things, that we are self-aware of how we use stereotypes to organize information about people. It also requires a commitment to rely on stereotypes as minimally as possible, replacing generalizations about people with specific details of particular individuals wherever possible.2 While generalizations can give us shortcuts to understanding common epistemic impairments, they should never substitute for understanding specific individuals’ experiences. It is important that we are open to recognizing the complexity and nuance of each case of mental illness impairment, and to understanding each person’s specific abilities and limitations. For example, it matters that I understand that someone with depression is not simply choosing to avoid making a decision because it is difficult, but rather that they lack the ability to value different outcomes and so struggle to make a choice informed by reason. Knowing this, I may be less judgmental of the person, and I may try to help them think through the significance of different outcomes. Open-mindedness can help us broaden our worldview and knowledge base. If we ourselves do not have experience with mental illness symptoms, a significant challenge in interacting with individuals who have mental impairments is that we may have no context for understanding certain symptoms or the nature of certain impairments. It is tempting to try to make sense of experiences foreign to us by viewing them through preconceived frameworks such as media depictions and culturally imagined stereotypes. With this, we tend to treat symptoms that we have no personal knowledge of in one of two dichotomous ways: either as wholly “Other” or as something reducible to common experience. The former diminishes the humanity of the person who has these experiences, such as by objectifying the person with the symptoms as “crazy,” while the latter trivializes the experience of the person with mental illness through an inapt or inaccurate comparison. The virtue of open-mindedness requires us to go beyond not only stereotypes and generalizations but also knowledge based on our own experience. Open-mindedness requires that we try to understand someone else’s phenomenological experience in order to appreciate the specific details of it, with its complexity and nuance, for the sake of better understanding their epistemic capacities and limitations.3 In practical terms, this requires us to engage with others’ phenomenological experience through direct means, like conversation, as well as through indirect means, like reading first-person accounts in

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memoirs. We should make it a point to read books and attend talks by people who have very different experiences than our own in order to learn from people’s first-hand accounts. In one of my endeavours to teach my students to be open-minded, I have them participate in a “Listening Project,” where, in small groups of four to five, they listen to a person telling their story about mental illness (in my Philosophy of Mental Health class) or drug addiction (in my Drugs and Society class). Hearing people’s first-hand accounts provides a unique learning experience that cannot be replicated through academic study. Seeking out people’s stories in both formal and informal settings is a valuable way of opening one’s mind. We need to make ourselves aware not only of stereotypes we hold and assumptions and generalizations we make about mental illness, but also, of course, of any prejudice and implicit biases we may hold. Implicit biases are negative attitudes that we hold unconsciously or unknowingly toward people when we internalize culturally dominant negative stereotypes about them.4 Implicit biases get expressed through various behaviours, including our body posture and positioning with respect to others, our interpretations of others’ actions and speech,5 the language we use, how we grant epistemic credibility, and how we regard people when we make decisions that affect them (such as hiring). Biased attitudes are implicit when they are not held consciously, when they are unintended,6 and when they are automatic and not subject to rational considerations.7 While people are often conscious of their stigma against mental illness, people also often have implicit biases against mental illness of which they are not consciously aware. While there is debate about whether we are responsible for holding implicit biases, when we are unaware of them8 and when it is unclear how much control we have over developing them,9 it seems fair to say that we are responsible for becoming aware of our biases and for working on changing them.10 In other words, we should be attuned to any negative beliefs or negative affective reactions we may have based on stereotypes, and we should actively resist or correct these as much as possible. Examining the stereotypes discussed in chapter 1 would be a good place to start. We should consider our immediate reaction to hearing about someone identify as having a mental illness or someone whose behaviour or appearance suggests to us that they have a mental illness. Moreover, it is crucial to instigate practices that address shared reality bias and that foster hermeneutical sensitivity. Shared reality

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bias is the convergence of beliefs and attitudes that become so dominant that they crowd out other perspectives.11 Stereotypes about mental illness are consequences of a convergence of beliefs and attitudes about mental illness, some of which are very socio-historically specific (e.g., those regarding the “advantages” that a person supposedly gains or seeks through claiming illness) and others which span over millennia in the Western world (e.g., those about the loss of control that occurs in “madness”). Shared reality bias can make the voices of the Other incomprehensible to those who share the dominant views, and so the experiences of people with mental illness are frequently interpreted through a lens of familiarity rather than taken up in their own right. Being open to understanding the experiences and views of marginalized people requires actively challenging shared reality biases and developing what José Medina calls “hermeneutical sensitivity,” which involves being alert, attentive, and responsive to “eccentric voices and styles as well as to nonstandard meanings and interpretive perspectives.”12 This involves intentionally seeking out voices of marginalized people, in this case intentionally seeking out opportunities to converse with people with mental illness, including severe mental illness. We must be alert, attentive, and responsive in actively listening to and trying to understand people whose mental experience may be very different from our own. We should seek out dialogue with people who have serious mental illness that challenges our beliefs and understandings, moving us beyond our epistemic and social comfort zones. For the large part, this means connecting with homeless or institutionalized people, especially those in prisons. An obvious way to dialogue is to strike up a conversation with these people where they are: we could volunteer in a soup kitchen, shelter, or day centre for homeless individuals, or get involved with a program that connects people to those in prison such as through ge d training or other classes. We should consider working in psychiatric hospitals, and we should be willing to hire people who have felonies on their record. We need to make intentional efforts at connecting with people who have serious mental illness, including them in society, and conversing with them as fellow members of our shared moral community. Moreover, it is important to continuously work on getting outside of our comfort zones. Knowing a friend with major depression or a student who has generalized anxiety disorder is not enough. We must

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continuously challenge ourselves to further seek out voices of people who have different experiences, in order to expand our knowledge and augment our understanding. Epistemic Conscientiousness To others it may seem as if you have totally lost it, yet I have found throughout my illness that there is a rhyme and reason to madness that people around the affected person usually will not understand.13 Richard McLean observes what many people who have mental illness know: their mental experience, however bizarre or nonsensical it appears to others, makes sense within their own mind. What appears to be unintelligible often is in fact intelligible, if we only make the effort to understand it in its context. Epistemic conscientiousness is, very briefly, the desire to pursue truth. More broadly, epistemic conscientiousness is the commitment to engage appropriately in epistemic practices that enable the pursuit of epistemic aims like seeking truth, developing knowledge, and making meaning.14 One aspect of epistemic conscientiousness involves seeking out shared meaning and understanding. In doing so, we can find connections with others that deepen our understanding of them and their worldview, thus allowing us to engage with them more deeply and meaningfully. Sometimes this requires significant effort on our part. Sometimes seeking out shared meaning involves working to make intelligible what appears unintelligible. As I discussed in chapter 4, engaging meaningfully with someone means participating together in shared moral practices like making claims on others, and acknowledging and responding to others’ demands and needs. It means engaging in moral address and treating each other as conversational partners. In general, participating together in shared moral practices requires that certain expectations are met. Both conversational partners must be responsive to evidential norms, whereby they would change their beliefs and judgments if presented with evidence that warranted it.15 Both conversation partners must be at least moderately responsive to reasons, whereby they would change how they chose to act if they were presented with sufficient reason.16 And in order for these scenarios to occur, both conversation partners must be able to make claims that are reasonable, intelligible,

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and based on a shared understanding of reality, and they must be able to respond to others’ demands in ways that are also reasonable, intelligible, and based on a shared understanding of reality. As we have seen in chapter 4, there are many ways in which a person with mental illness may have trouble meeting these expectations and so may not be an ideal conversational partner or be able to engage in moral practices in a robust or even sufficient way. One response to this problem would be to decide that if a person cannot meet these expectations (e.g., by not having enough shared understanding of reality), then they simply are unable to be a conversational partner, and so we should not bother engaging with them in morally meaningful ways. I am loathe to take this approach, because it diminishes what agency a person does have, treating their agency as an all-or-nothing element, and it gives up on a person by refusing to bother engaging with them. This approach is easy because it does not demand anything of us besides simply not engaging. In contrast, I propose an approach that actually demands a lot of us. I propose that we should attend to the impairments to agency that people with mental illness have by doing whatever we can to bridge the gap between what is expected of them and what they are actually capable of doing. So, for instance, if I am trying to engage with a person who does not share the same sense of reality that I do, then it is my responsibility to try to understand how they perceive reality, to learn their language and their way of seeing the world, so that I can interact with them on their level. I saw a beautiful illustration of this once when I witnessed a fellow patient in a psychiatric hospital learn to speak the language of a young man with severe schizophrenia, who constantly referenced the “frequencies” of things. The language was beyond my understanding, but the woman did not hesitate in adopting it. She translated what staff asked the patient to do in to his language of frequencies so that he was able to make sense of what was asked of him and could respond appropriately. This was only possible because the woman made the effort to understand the young man’s sense of reality and was not shy about adopting his language to converse with him. My proposal is that we should all do this to whatever extent we can when we are interacting with people who do not share the same sense of reality. With our stereotypes of mental illness, we tend to treat people with severe mental illness, especially those in the midst of florid psychosis,

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as unintelligible, as incapable of saying anything we would deem meaningful. Their sense of reality may be so different from ours that we tend to assume it cannot be bridged. But such bridging is possible if we exert the effort. Even people with severe psychosis make some sense if one really pays attention to what they are saying. And we can make ourselves understood by people whose framework of meaning differs greatly from our own. The evidence for the idea that it is possible to create bridges of intelligibility with people who have psychosis, even severe psychosis, is the fact that delusions can change based on certain kinds of interactions with others. While traditionally, delusions have been regarded as incorrigible, impervious to counter-evidence, studies show that even people with severe psychosis can change their delusional stance using some form of cognitive behavioural therapy (c b t ).17 In c b t, individuals examine their thoughts and do their own reality testing, as it were, testing whether their thoughts cohere with the facts of the world. Even without the formal approach of c b t, general psychodynamic therapy (“talk therapy”) can help individuals see their delusional views differently; talking through delusional beliefs with others can help them learn to identify, examine, and change their views. Acceptance and commitment therapy (ac t) teaches individuals to distance themselves from their thoughts and feelings through mindfulness, to learn to recognize what roles thoughts and feelings play in their behaviour, and to make behavioural changes independently of the person’s beliefs and perceptions.18 While, according to act, changing beliefs is not necessary to alter behaviour, people tend to find that changing their behaviour affects their relationship to their beliefs and consequently impacts the beliefs. The fact that cbt, act, and other forms of therapy can be effective in changing delusional views demonstrates that engagement with others is possible, despite the presence of delusions, even when examining the delusions themselves. Some shared meaning must be established in order for this examination of delusion to occur. When interacting with people who have delusions, it is not necessarily our job to encourage them to change their delusion or to behave differently in spite of it, so we do not have to do the work of cbt, ac t, and other therapies. But what we can take from these studies is that shared meaning is possible, even in the case of severe delusion; we just have to make the effort to establish that meaning.

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Larry Davidson suggests a cross-cultural model of psychosis, where we view psychosis as a different culture that we try to understand by learning the culture’s language, customs, and frameworks of meaning. He says that in the case of serious mental illness, we have two options for how we can regard and interact with someone with psychosis: Option one is to be afraid of this person based on an assumption that he or she is irrational and unpredictable, concluding that we cannot understand his or her behavior because it does not abide by our cultural, linguistic, and other predetermined rules. Option two is to at least tolerate this person based on an assumption that his or her behavior does make sense within the context of his or her own culture, but that for the moment she or he is a “fish out of water.”19 In this anthropological model, we must do some work as we try to learn another culture; we have to invest time and energy in a process that can be challenging, even daunting, and that requires us to bear discomfort as we engage in the process of learning. In learning another culture, we become the one who is the “fish out of water” as we try to orient ourselves in strange new territory. Understanding someone who is psychotic may be difficult, but it is nonetheless feasible; it just requires effort, patience, and a tolerance for discomfort. Davidson argues that through learning another culture, we can build “empathic bridges,” developing empathy for people whose experiences may differ greatly from our own.20 This empathy can motivate us to develop greater understanding as well as compassion and concern for others, and to act in ways that improve the well-being of others. But in order to develop this empathy, we must do some preparatory work. First, we must incorporate into our own awareness elements of a person’s experience that help us make sense of that experience, for example learning about the person’s work, education, and family life. In the context of serious mental illness, this preparatory work might involve learning what psychiatric hospitals are like and learning how processes work, such as diagnosis, crisis intervention, and inpatient and outpatient treatment. Second, we must bracket our own experience so that we do not make the mistake of interpreting other people’s experience through our own lens. Davidson says, “In order to come to occupy the perspective of the other, we have to be willing to place our own

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perspective in abeyance, to place it squarely and securely within phenomenological brackets. If we cannot suspend our own cultural, historical, and personal signposts, we will be unable to explore this foreign territory in its own terms.”21 When we encounter a person’s experience that is unlike our own, we tend either to interpret it through our own lens of experience, making the unfamiliar seem more familiar, or we regard it as utterly foreign, alien, and incomprehensible. Davidson argues that psychotic experience is not incomprehensible, but we cannot make sense of it as if it were simply a different version of our own experience. We must develop comprehension by accepting its unfamiliarity, bracketing our own experience, and tolerating being a “fish out of water” while learning the foreign language and foreign customs of psychosis. María Lugones’s use of the “world-travelling” metaphor is helpful here. She argues that bridging understanding between differences like race or gender requires “travelling” across different “worlds,” immersing ourselves in “cultures” different from our own;22 bridging understanding with people who share a different mental world than one’s own requires similar travelling. Part of travelling across worlds to learn the experience of others involves trying to understand their motivation, why they say what they say and do what they do. In order to understand other people’s motivation, we must try to reason along with them, understanding their own framework of meaning, their value system, and their interests. But, again, we have to understand all of these not as extensions of or different versions of our own, but rather in their own right. We have to let go of what we value and how we see the world so that we can learn what they value and how they see the world. We have to let go of our tendency to make judgments about other people’s experience and accept it on its own terms. In doing this, we might develop the capacity to see why smoking makes sense to some people, why Mary Weiland burned her husband’s clothing, why Mr M sometimes preferred his girlfriend over his wife, and why some people attempt suicide. Only when we bracket our own experiences and frameworks of meaning can we develop this understanding. So, for instance, to communicate with John Custance (from chapter 3) we must seek to understand the particular way the world holds meaning for him, by trying to understand the symbolic system through which he makes associations of meaning. Communicating with Elyn Saks in the throes of her psychosis is made easier if we understand

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the rules and commands she perceives, which direct her action. Communicating with Lori Schiller about her drug use requires taking her Voices seriously and responding to the Voices as well as to her. It is important that we recognize Custance, Saks, and Schiller as members of our moral community, just as Mr M, Terri Cheney, and James Holmes are. Their agency is heavily constrained, and there may be a sense in which they do not have control over their actions or their actions are not properly their own. But what appears to be unintelligible can be made at least a little intelligible if enough effort is given. Action that appears nonsensical may make sense in a convoluted way given the right meaning framework. However, making action a little intelligible by understanding it in the right meaning framework may be insufficient for the person doing the action to meet the conditions for responsibility. But it is enough for the person doing the action to be recognized as a member of a shared moral community and as participating at least in some basic ways in shared moral practices. Reasoning along with someone – understanding their reasons for action, how they see the world, and why they do what they do – is a great gift both to them and to ourselves. If we act with generosity, as I argue below that we should, then we will appreciate both giving and receiving this gift. Sven Nyholm argues that reasoning along with someone is an intrinsic good, as it is a form of recognition, regarding others as reasoning creatures or, in other words, as moral agents.23 Learning someone else’s language, or someone else’s framework of understanding, can be quite difficult. Nonetheless, the effort is worth making, for the benefit of both the person whose speech and action can be made intelligible, and our own benefit as we receive the gift of the intrinsic good that is recognition of another as human like ourselves. People are conscientious when they really try to open themselves up to other people’s perspectives. While sometimes this involves trying to discern what initially seems unintelligible, other times it simply involves deep listening. For example, my husband is conscientious when he does not leap to judging me or my condition but instead tries to listen and understand as best as he can. He used to do what most people who care about someone do: he would see that I was suffering and try to “fix” it by offering potential solutions to my problems. This was well-intended but misguided. Solutions were not what I was looking for; what I sought was someone to listen deeply, without judgment, and to just be there for me in my suffering. Over

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time, my husband learned how to do that, and his conscientiousness in trying to understand me without trying to jump in and fix my problems has helped me in my suffering more than any proposed “solution” could. I propose conscientiously learning how others see the world and understanding their own needs not as a supererogatory action, as something nice to do to help out, but rather as a moral obligation, as something we ought to do in order to be more inviting and engaging with people whose way of being in the world differs widely from ours. We have an obligation to go beyond our comfort zone, where we interact only with people whose participation in moral practices is similar to ours and, therefore, familiar and recognizable, to interact with people unlike ourselves, whose participation in moral address may be very different from what we are familiar and comfortable with. We tend to assume that when people do not do things the same way we do, then they do not really do them at all; in other words, if someone acknowledges or responds to us in a way that we do not recognize, we tend to assume that they are not acknowledging or responding to us at all. In fact, people very often do acknowledge, respond, and participate in moral practices in a wide range of ways. We just need to be open-minded enough to see what we do not expect, and we must be open to seeing that strange behaviour is not always so strange once it is interpreted.

O t h e r- O r ie n t e d Vi rtues In addition to open-mindedness and epistemic conscientiousness, there are several other virtues we should adopt when interacting with people who have mental illness. These include the epistemic virtue of charity and the moral virtues of compassion, humility, and generosity. These latter four virtues I group together as “other-oriented” virtues, meaning that they enable an orientation toward the other. When I talk about an orientation toward the other, I am referring to a general demeanour or a tendency to be concerned with others: to care about the well-being of others, to care what others are thinking or feeling, to want to share a common goal with others, to want to work with others. This otherdirectedness is in contrast to the self-directedness, even absorption, common in mental illness. In order to be virtuous, to decrease stigma, to increase meaningful social interaction, and to help create the conditions that enable change to occur, we should develop an orientation

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toward the other and encourage people with mental illness to do the same. It is particularly important for us to develop an orientation toward others who seem on the surface to differ greatly from ourselves in order that we see our common humanity. We want people who have mental illness to develop an orientation toward the other as well, because it is through this that they can engage meaningfully with others. This will help combat the isolation they typically experience as described in chapter 3. Two goals for our interactions with people with mental illness are, first, to help create the conditions that allow them to overcome their self-absorption, symptom preoccupation, and shame so that they can orient themselves toward the other, and, second, to help create the conditions that eliminate stigma and all of its harms. An orientation toward the other allows us to engage socially when given the opportunity. While people with mental illness need to have opportunities for social engagement with others, they also need to have the capacity to interact well when the occasion arises. Because we learn how to engage in moral practices by actually practising them, it is imperative that we give people with mental illness the opportunity to practise being oriented toward others through the ways that we engage with them. (This helps us develop our own capacity for social interaction as well.) If we intentionally act in ways that draw people outside of themselves, outside the preoccupations of their own minds, we can help them develop the capacity to be other-directed. A person who is other-directed is concerned about and responsive to others. This concern for others must start with a concern for oneself, but in a way that is not self-absorbing. Other-directedness requires that we have a certain relationship to ourselves, holding certain attitudes and treating ourselves in a certain way. We must be able to see ourselves “objectively,” at least from the perspective of others, recognizing and responding to our own needs and treating our own suffering with tenderness. Only when we can do these things toward ourselves – when we are oriented toward ourselves in the right sort of way – can we do these things properly toward others. Four virtues that help foster other-directedness include the epistemic virtue of charity and the moral virtues of compassion, generosity, and humility. Charity Although I discussed charity in chapter 4, I want to revisit it here as part of a package of other-oriented virtues that help us get outside of

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our own heads and connect with others. As discussed earlier, charity in an epistemic context involves interpreting someone’s argument in the strongest, best way possible.24 I broadened this idea to say that, as an epistemic virtue, charity involves interpreting a person’s action in the best light possible, trying to understand the larger context for their action and assuming they had good intentions. Charity has both epistemic and moral benefits. Charity in how we interpret and understand people’s actions and behaviour helps us focus our attention on the other and try to understand them in their own context, rather than interpreting their behaviour through our own framework of understanding. Charity also helps us break through the social isolation commonly experienced by people who have mental illness because it softens our attitude and approach with them, making it easier for them to want to engage with us. It is easier to make a connection and engage in moral address with someone when both parties assume the best in each other, interpreting the other’s action in as positive light as possible and assuming the other has good intentions. Self-absorption is a significant barrier to connection, and charity helps diminish this barrier. Self-absorption sometimes takes a form that is difficult to sympathize with, coming across as selfishness, arrogance, inconsiderateness, standoffishness, or even hostility. When a person is sad, their self-absorption is easier to understand and their distress is easier to sympathize with; on the other hand, when a person is standoffish or angry, their self-absorption is much more difficult to deal with. A person who is selfish, arrogant, inconsiderate, standoffish, or angry may in fact be any one of those things, and not in special distress; on the other hand, self-absorption may result from being consumed by suffering or being preoccupied with other mental states. Often, we cannot tell whether there is deep suffering underneath a person’s demeanour or behaviour, and we have to choose how to respond regardless. In dealing with a person who is self-absorbed, it is more charitable to err on the side of assuming that the person’s self-absorption stems from distress, so as to allow ourselves to sympathize, responding gently and caringly no matter how prickly or standoffish their demeanour, rather than assuming that they are simply a vicious and unlikeable person and responding accordingly. Even if the person simply is inconsiderate or arrogant, when we treat them as someone in distress with whom we can sympathize this may allow the person to soften, allowing in turn the possibility of behaving better in their interactions. This connects to the idea discussed in chapter 4 that people who act badly

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are more likely to change when we treat them well and forgive them rather than blame them. One way to be charitable in our dealings with a person is to tell ourselves a story that explains possible reasons for their actions in a way that elicits our sympathy, patience, and kindness. For example, when I first started on lithium I walked very slowly, with a shuffle. It took me some time to walk across a street. Drivers who thought to themselves, “Maybe she has difficulty walking due to health reasons” might have had more patience with me than drivers who thought I was being lazy. Or, when I have asked for accommodations at work – namely help with certain tasks I could not complete on my own – my colleagues might have found it easier to make the requested accommodations when they have known they were due to my mental illness symptoms and not because I simply did not want to carry out the task. Developing an understanding of why a person does what they do, or at least imagining a story to account for that, can help us respond to others more charitably. Charity is frequently coupled with compassion, as interpreting someone’s actions in the best light possible encourages us to respond to those actions with compassion or sympathy. A person who is selfabsorbed due to their mental illness typically cannot see their way out of their suffering without the help of others, because the nature of their self-absorption, insofar as it stems from illness, draws them inward, deeper into the illness. For this reason, it is not fair to attribute intention to the person for their self-absorption; there is an important sense in which they cannot help it. Acts of compassion are primarily how a person who is drawn inward by illness and consumed by suffering is drawn outward by others. An initial way to draw a person out from their suffering is to recognize and acknowledge their suffering. While this does not alleviate suffering, it can comfort the person, providing a buffer, and it can connect the person to others and to the world outside of their mind – a first step toward reframing one’s worldview. Compassion for another’s suffering transforms it from a purely internal phenomenon inside a person’s mind to an intersubjective, relational one, which can be the basis for connection with others. Such connection is essential for the self-absorbed person who struggles with getting outside of their own mind. To a person who is self-absorbed, the benevolent and compassionate person models a worthwhile moral ideal. Compassion by another shows

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the self-absorbed person that such other-directedness is possible – and, insofar as such compassion is welcomed, that it is worthy of emulating. Being treated tenderly by another person provides motivation for moral action and for connecting with something greater than oneself. When we are treated with compassion by others, it is easier for us to respond in kind, and to treat ourselves with compassion as well. Compassion Compassion is concern for the welfare of others or caring about a person and their well-being. It is an open-hearted response to others’ suffering and a desire to help alleviate the suffering.25 Philosophers differ on whether compassion is more like sympathy, which involves feeling “for” someone, or more like empathy, which involves feeling “with” someone. Some philosophers regard compassion as a form of empathetic understanding, using the imagination to feel what another feels, while others regard it more as sympathetic understanding, where, like sympathy, it does not require feeling the same emotions as someone else but only requires caring about them.26 What is central to compassion is caring for others’ well-being. My own view is that empathetic understanding can be helpful but is not necessary for developing compassion. (This fits with my argument below that empathy is helpful but not required for sympathy and moral action.) Compassion, therefore, is very similar to sympathy, but sympathy, like empathy, is a feeling, whereas compassion is both a feeling and a virtue.27 Compassion is a virtue because it aims at the good, it can be developed and exercised voluntarily, it is action-guiding in specific circumstances, and we should always try to exhibit it.28 Moreover, compassion provides moral motivation: compassion involves caring about the well-being of others, which motivates a person to act in order to further the well-being of others. Because compassion is closely related to both empathy and sympathy, I will explain each of these in turn. Although they each play a different role in our moral response, all three are important dispositions to adopt when interacting with those who have mental illness. Empathy and sympathy are defined differently by different philosophers,29 but here I shall define them as other-oriented or selforiented perspective-taking, and concern about another person’s ­well-being, respectively. I first explain the concept of empathy, which I initially introduced in chapter 3.

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Empathy Empathy literally means “feeling with” someone. Empathy can be understood in cognitive terms as a process of imagining what it is like to be someone else; or it can be understood in affective terms as emotional contagion, or emotional “matching” through involuntary imitation.30 Empathy can be other-oriented, imagining what it is like for someone else to be in their situation; or self-oriented, imagining what it is like for myself to be in someone else’s situation.31 Other-directed perspective-taking is both epistemically and morally fruitful and so is the most useful way of conceptualizing empathy, given that it captures what is most important about empathy. I do not find emotional contagion to be a useful concept for either epistemic or moral purposes. In addition, self-oriented perspective-taking is morally problematic, because it tends to cause the person doing the perspective-taking to focus more on their own feelings (especially feelings of distress) than on the experiences of others. Thus, it is often not morally motivating, as it does not impel people to act on behalf of another. Instead, people tend to become self-absorbed or try to escape from painful feelings by numbing themselves, avoiding the stimuli that caused the other person to suffer, or avoiding the person altogether.32 This is morally problematic when people confront other people’s experiences of suffering, such as trauma, or difficult situations like homelessness. Other-oriented perspective-taking, in contrast, is both epistemically and morally useful. Peter Goldie is right when he criticizes otheroriented perspective-taking as problematic because we cannot get inside other people’s minds to understand their motives and situation fully or perfectly adequately.33 I suggest, however, that full and perfectly accurate understanding is not necessary for other-directed perspective-taking to be useful. Imagining what it is like to be someone else in their particular situation can give us insight into the person, and their situation, that we would not otherwise have. When we do this carefully, we maintain an awareness of the differences between ourselves and others and do not confuse our own experience, or our own imagining ourselves in their experience, with the person’s actual experience.34 Other-directed perspective-taking is epistemically valuable because it provides us with greater understanding. Some philosophers have noted the way that empathy enhances phronesis, or practical wisdom, the kind of knowledge we need when moral

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decision-making.35 Although this understanding might be incomplete, or even wrong in some ways, such understanding, however imperfect, gives us more epistemic resources to draw on as we pursue knowledge and make decisions.36 Imagining what it is like to be someone else living that person’s situation also allows us to connect with others in ways vitally important to them. Sometimes people who are suffering do not want others to do anything on their behalf, perhaps because they are comfortable with their suffering, or they think it is no one’s business, or they believe nothing worthwhile can be done. But they do often want to be understood, if for no other reason than it makes them feel less alone, existentially speaking. People with mental illness may have a variety of feelings about how they want others to responded to them; many people want at least to be understood in some way, to some degree. People who feel particularly set apart from others by virtue of their mental illness, such as through psychosis or severe suffering, may have greater need to be understood. If someone takes the time to imagine what it is like for the person with mental illness to be psychotic or to suffer from mental impairments or stigma, then there can be some understanding that bridges the imaginative experience of the empathizer with the actual experience of the person with mental illness. When people resist empathy, they fail to make a meaningful connection with others. They make assumptions about others that are untrue and ignorant; they fail to make the effort to find shared meaning. Consider the difference between an approach that resists empathy and one that embraces it. A failure to empathize is demonstrated here: I was trying to say good-bye to crazy people in a heart-felt way, as if they were old school chums, as if we had been living in the same world and had survived the same experiences. As if we all spoke the same fucking language. What kind of craziness was I trying to make work here? Whatever my attempts to believe otherwise, you don’t get to “know” the insane – not at all, not in the way others are used to. You can get to know their behavioral patterns, and recognize them that way, but you never really know who’s behind those eyes. Especially the people on meds, as most of these people were. There wasn’t anyone behind those eyes to know.37

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Jim Knipfel describes the distance he felt between himself and others on the psychiatric ward where he was hospitalized. He experiences patients as alien Others who are fundamentally unintelligible. He writes his memoir as someone trying to navigate the absurdity of unintelligibility in this ward. He sees himself as set apart from others, as inherently different from the other patients. In my opinion, he has just as much stigma toward his fellow patients as would many people who are not themselves patients. Knipfel does not seek out the common humanity he shares with them or make efforts to connect meaningfully with them. Contrast Knipfel’s approach with Ken Steele’s experience of getting a roommate. Steele and his friend Alec both have schizophrenia and are trying to develop a life of meaning outside the numerous hospitalizations they experienced. “He [Alec] liked having me around, he said. It kept him from being alone with his voices.”38 They connect with each other despite both hearing voices. They understand each other’s situation and accept each other as they are. Neither feels superior to the other. Steele and Alec make the effort to find shared meaning. With empathy and humility, they succeed in making a meaningful connection with each other. Because Steele himself had schizophrenia, it was easier for him to empathize with Alec’s experiences and vice versa. But we could easily imagine Alec getting a roommate who did not have schizophrenia and liking that person around to keep him from being alone with his voices too. Can we imagine ourselves being that roommate? Could we be empathetic enough to reconstruct imaginatively what it is like to be Alec in his situation and then use that to form a connection with him? Imagine the power in that if we could. Imagining what it is like to be the person who is psychotic can be epistemically fruitful as well as morally good, in that through the process we treat the person whose situation we are imagining as someone worth understanding; other-directed perspective-taking is therefore dignifying. It is important to note here, however, that imagining what it is like for us to be psychotic can be dangerous, especially if we ourselves have no experience with psychosis. This imagining can amplify whatever seems fearful or loathsome about psychosis, and it typically causes a person to be concerned with their own feelings, such as fear and disgust, rather than the situation of the other. Despite its role in contributing to knowledge, this

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imagining is also easily prone to fostering misunderstanding about psychosis when we get it wrong. Imagining what it is like to be someone else in their situation is both epistemically valuable and fraught with danger. The epistemic danger of other-oriented perspective-taking is in claiming that we know more than we do: in claiming that because I can imagine what it is like to be someone else in their situation I may assume that I therefore know what it is like to be them. If we retain epistemic humility, however, we need not commit this error. We can claim to have some understanding, through an imaginative process, without claiming absolute knowledge. Above I noted that when we encounter people’s experiences that differ from our own, we tend either to regard them as wholly foreign to us or to subsume their experiences under our own, interpreting their experiences through our own lens. Self-oriented perspective-taking very clearly commits this error, as it is too easy to assume that what it is like for me to be in your situation is the same as what it is like for you. But otheroriented perspective-taking, when done carefully, can avoid this error when we make the effort to understand deeply someone else’s situation, worldview, and motives in the ways that Larry Davidson suggests (in the above section 3.2 titled “Epistemic Conscientiousness”), and when we are careful not to claim to know more than we do. Some people may worry that the risks inherent in imagining what it is like to be someone else in their situation should lead us to avoid this practice. Such an approach does more harm than good, however. In avoiding other-oriented perspective-taking, we recuse ourselves from trying to understand people already misunderstood. Out of worries of getting it wrong, we fail to make the effort to seek greater understanding and to treat people as worth trying to understand. In avoiding other-oriented perspective-taking, we fail to engage with people in a particularly meaningful way. If we are careful with our perspective-taking, we can do great moral good in paying attention to someone who tends to be ignored or shunned and treating them as a person worth understanding. People sometimes feel that their experiences are so unique that no one could truly understand them; but, at the same time, people usually want to be sufficiently understood by others to be able to make meaningful connections and to be seen as someone worth understanding. Kay Redfield Jamison describes the impact of the empathetic

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connection her boyfriend David makes with her after she hesitatingly discloses her bipolar illness, fearing that he would respond with stigma and shunning: David could not have been kinder or more accepting; he asked me question after question about what I had been through, what had been most terrible, what had frightened me the most, and what he could do to help me when I was ill. Somehow, after that conversation, everything became easier for me: I felt, for the first time, that I was not alone in dealing with all of the pain and uncertainty, and it was clear to me that he genuinely wanted to understand my illness and to take care of me.39 Trying to understand someone is a way of recognizing them as a person, as someone with a moral identity and as having moral agency. I wager that people who feel fundamentally misunderstood or ignored by others often appreciate the effort of being understood through imaginative processes; they would rather that someone else make the attempt and be mistaken (and be open to dialogue about their mistake) than not make the attempt at all. Other-oriented perspective-taking can be understood as a form of third-person perspective-taking, the kind involved with empathetic maturity. Third-person perspective-taking involves understanding the larger context of a person’s action, particularly the psychosocial context in which the action makes sense. Other-oriented perspectivetaking enables us to try to understand a person’s motives, what the situation they are in looks like to them, and the psychological context in which they make choices about how to act. The empathy of otheroriented perspective-taking helps us achieve empathic maturity by providing us with an epistemic route to greater understanding, which enables us to respond morally in “mature” ways – in ways that are oriented toward the other rather than revolving around ourselves. Even though care and concern for others is not intrinsic to empathy, empathy does have a tendency to inspire care and concern in many people. Because of their own experiences, people who have mental illness have the potential to have a great capacity for empathy, especially empathy for other people who have mental illness or are otherwise vulnerable in their suffering. A person who has mental illness has to be able to see outside of themselves in order to see other people’s perspective; as long as they can do this, they have a wealth

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of experience they can draw upon as they imagine other people’s perspective. For some people, this empathy inspires the care and concern of sympathy and compassion toward others in their suffering. Some people with mental illness are inspired to help others who have mental illness due to this empathetic connection. Sy mpat hy Both empathy and sympathy serve important purposes. Empathy is important as a way to build understanding, to recognize the dignity and humanity of a person, and to connect with a person so that they are not so existentially alone; empathy can also inspire care and concern for others. Sympathy is another important way to motivate caring and ethical response. Sympathy means literally “feeling for” someone, and it involves caring about someone else and being concerned about their welfare. It is a recognition of other people’s difficulties (and the feelings associated with this recognition) and motivation to alleviate those difficulties.40 What I call sympathy here can also be called compassion, though sympathy is chiefly a feeling and compassion is both a feeling and a virtue.41 While sympathy involves feelings associated with this recognition, it does not involve having the same feelings as the person who is the target of sympathy the way that empathy characteristically does.42 Unlike empathy, which is arguably amoral, sympathy is an ethical outlook toward the world, and it is necessarily other-regarding in a way that empathy sometimes is not.43 Sympathy is important for moral motivation, to act well for the sake of others. When we care about others’ well-being, we want to do what we can to increase their well-being and decrease their suffering. Sympathy toward people with mental illness is important to motivate us to do well by them and to motivate us to better understand their situation. Sympathy is thus both morally and epistemically motivating. When we sympathize with someone, we care about their interests and are concerned when they are in distress, and this care and concern leads us to try to respond in efficacious ways. Elyn Saks indicates the power of sympathy in describing her boyfriend’s response to a psychotic episode: This was Will’s first major experience of me as wildly delusional. He didn’t get too scared, he didn’t go away, and he never treated me with anything less than kindness and tender care. Afterward, he did admit to being shaken to see me so disturbed and

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unhappy, and feeling frustrated at not being able to comfort me or calm me down. “But I still want you to tell me when you start to feel like that,” he insisted. “I’m not much use if you don’t let me know what’s going on.”44 When we sympathize with someone, we want to understand better what they are going through. This insight allows us to better identify what they need and what we ought to do in response to their situation. Sympathizing with people who have mental illness motivates us to understand their condition better, and the ways that their illness impacts them, and it motivates us to discern their needs and ascertain the best ways that we can respond. Sympathy requires us to overcome our stigma by replacing fear and disgust with care and concern. Sympathy makes us want to improve the condition of people who are misunderstood, shunned, and suffering. In so doing, sympathy encourages us to interact and engage with people unlike ourselves, including people with severe mental illness. While sympathy does not necessarily lead us to seek to understand systemic and justice issues that underlie people’s suffering, it does promote this as part of our overall inclination to care and respond. Moreover, sympathy motivates us to do something about people’s suffering; it motivates us to act. Sympathy is very closely connected to the virtue of compassion, to which I now turn. C ompass i o n as A c c e p ta nc e of S u f f e ri n g Compassion is a trait we can develop and exercise as we interact with others. As a virtue, compassion is a disposition or orientation of care and concern toward others. As I noted above, some philosophers regard compassion as a form of empathetic understanding, using the imagination to feel what another feels; others regard it more as sympathetic understanding, where, like sympathy, it does not require feeling the same emotions that someone else has but only requires caring about that someone. Having a compassionate attitude involves having equanimity, or a sense of peace and acceptance in contexts that might otherwise inspire fear or distance, such as in the face of pain, suffering, despair, death – and, in our context, psychosis.45 Equanimity involves an acceptance of the world as it is. This is an important perspective to adopt in therapy. One of the principles of dialectical behavioural

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therapy (db t ) is acceptance of the “perfection” of the world, not in the sense that the world meets an ideal standard but in the sense that the world is exactly as it should be, everything that has occurred in the past has led exactly to where we are now.46 Equanimity requires both cognitive and affective acceptance of suffering. Compassion is a social virtue because it involves looking beyond our own experience to try to understand the experience of others, and to acknowledge others’ suffering without fear or other emotional distance. Some philosophers argue that compassion, therefore, involves some element of empathetic understanding, and that imagination is required to understand people very different from ourselves.47 Compassion can be understood as sympathetic understanding and acceptance, in contrast to pity and other emotionally distancing attitudes. People can show compassion in a variety of ways. When I was deeply depressed several years ago, I met someone whose compassion stands out to me. At the time, I would cry uncontrollably for hours on end, not necessarily about anything particular; it was simply an expressive behaviour I could not stop. I was crying uncontrollably the first three times I met this person; we managed to have meaningful conversations through my tears, and he remains a good friend today. His compassion – his acceptance of my suffering and his care and sympathy toward me – allowed our friendship to blossom. On a more everyday basis, when people have sincerely told me they were glad to see me, it has meant a lot to me. Their acceptance of me in whatever state I happen to be in has warmed me and made me feel loved and valued. The compassion of other people can be very fortifying. C ompassi on as A c c e p ta nc e o f S e l f -W o rt h Since compassion involves identifying with others through the recognition of shared vulnerability, true compassion requires acknowledging our own suffering. Having the equanimity involved with compassion requires an understanding and acceptance of our own pain and distress just as much as that of others. Self-absorption is an obstacle to compassion, however, because it traps us in our own subjective mental experience so that we cannot see outside of ourselves. As a result, we cannot see ourselves from the perspective of another, and so are unable to see ourselves from a more objective rather than purely subjective standpoint. In this way, self-absorption impedes our ability to see our condition with honesty. Self-absorption thus blinds us just as much to ourselves as to others.

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The self-absorption of shame is particularly detrimental to our ability to accept our own suffering and to be compassionate toward ourselves. Shame is based on a perceived negative judgment of oneself by real or imagined others. The feeling of shame arises when we feel exposed, and judged; shame presumes an audience of either real or imagined others, and it involves an act of judging, of evaluating us according to some standard.48 The person who feels ashamed puts themselves in the imagined position of their audience, casting judgment on themselves as if by another, in essence turning themselves into an object.49 Shame involves a hyper-self-consciousness, where instead of being immersed in their normal activity the person who is ashamed is overly conscious of, and critical of, what they are doing and may find it difficult to act “naturally.”50 Shame is a global self-judgment, aimed at the person as a whole. While guilt pertains to specific actions, shame pertains to the person.51 When people are ashamed, they are judged by real or imagined others as inferior or unworthy.52 While guilt inspires actions intended to alleviate it, such as reparations or apology, shame has no corresponding actions that would alleviate it. Instead, shame typically leads people to withdraw from or avoid situations that may trigger the emotion, particularly social situations. Shame has certain physiological expressions, and it affects how people interact with others, as self-consciousness can create distance through features like poor posture, a bowed head, and low or monotonous voice tone.53 People who have mental illness commonly feel guilt or shame on account of having their illness or on account of specific symptoms or consequences of the illness.54 Whether real or imagined, they perceive being judged by others for their illness or for its features. Through this shame, they internalize real or hypothetical stigma, resulting in self-stigma. Self-stigma frequently leads to self-sabotage, as people feel so bad about themselves that they think their fate is to live out the poor lives that are presupposed by and feared in stigma. People may even feel they deserve to live out these poor lives, and consequently they behave in ways that lead them to do so.55 Self-acceptance, on the other hand, can counter self-stigma. If a person can develop compassion for themselves and adopt the equanimity of acceptance of suffering, they can develop self-acceptance and nullify self-stigma. Compassion for one’s own suffering is important for self-esteem, especially in people who have mental

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illness whose suffering may cause them to be self-absorbed, ashamed, or self-stigmatizing. Developing compassion involves acknowledging our own suffering as well as the suffering of others and responding to the suffering of others as well as oneself with tenderness. Compassion is aided by both humility and generosity. The ability to see things in their proper perspective helps a person have compassion for themselves and others. In allowing us to see suffering as it is, humility helps us accept it; by allowing us to see suffering in a larger context humility leads us to be in awe of suffering and motivates us to respond by serving those who are suffering. In addition, compassion is one of the greatest gifts we can give both to ourselves and to others. I now turn to the virtue of humility. Humility In the previous chapter I discussed humility in an epistemic context. Here I address humility more broadly in a moral context as an orientation toward the self, others, and the world. Humility is described in many ways by philosophers. Philosophers have defined humility as having self-knowledge, as underestimating or over-estimating one’s abilities or characteristics, as being indifferent to other people’s judgment, as exhibiting humble behaviour, and as self-abasement.56 Humility can best be understood as a complex orientation toward oneself, others, and the world which encompasses many of these features. This orientation involves having “realistic self-insight,” where a person assesses themselves, and along with this their constitutive relationships, accurately.57 Part of this assessment involves acknowledging their dependence on (and interdependence with) others, and the ways that many of our accomplishments and successes are due to factors beyond our control.58 A large part of humility is the recognition of ourselves in broader perspectives. Hu milit y as a Mat t e r of P e rs p e ct i ve In the process of understanding and assessing ourselves, we situate our achievements and mistakes, our excellences and flaws, and our behaviour and character within in a larger perspective. In order to do this, we must see the world as it is. For some philosophers, seeing the world as it is also involves appreciating it, particularly when

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humility is coupled with the graciousness of generosity. Humility thus involves extending beyond ourselves to recognize and appreciate a world that is bigger than ourselves. Some theorists have focused on this spiritual dimension of humility, characterizing humility as a readiness to serve out of faith,59 or as reverence for nature and the world.60 Understanding and assessing ourselves is an ongoing process that involves continuously trying to understand the world of which we are a part; in this way, humility inspires learning. Appreciating our place in the world shows us how little we know; humility involves being receptive to new ideas as we seek to gain understanding.61 Humility thus has epistemic benefits to us. Humility and compassion are intertwined. While the equanimity of compassion involves accepting the world as it is, humility involves recognizing one’s proper place in it and taking a proper perspective of oneself and others. Humility coupled with compassion has us recognize our place in the world and accept it for what it is. Having humility is good for us. Psychological studies have linked humility to other positive traits, including respectfulness, modesty, fair-mindedness, conscientiousness, appreciativeness, and a commitment to social justice.62 Humility is correlated to increased mental health, stronger motivation and work ethic, and greater achievement and productivity. Most importantly for our purposes here, humility has many pro-social effects, enabling positive interaction and the development and maintenance of relationships. Showing humility toward others is a way of appreciating their value and is thus conducive to friendships and other relationships. Showing humility toward people with mental illness involves seeing and appreciating them as they are, with all of their achievements and mistakes, and all of their excellences and flaws. This includes both accepting their bad actions and celebrating their accomplishments. Having humility means seeing how we are connected to and interdependent with people who have mental illness, seeing them as part of “us” and one of “us” rather than an alien Other. It involves seeking out greater understanding of their experiences, such as through dialogue and memoir-reading, in our c­ ontinual quest for knowledge and understanding. Like generous-heartedness, humility is connected to deference. Having humility involves acknowledging that we do not know all there is to know about a person and their experience, and we do not always know what is good for them; consequently, it involves deferring to other people’s

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self-understandings, even when people have mental impairments, such as those caused by psychosis. Having humility also means promoting other people’s well-being over our own, at least sometimes, for example, by caring about the comfort of someone with a mental illness more than our own comfort. Thus, humility would invite us to overcome our discomfort talking with homeless people in order to strike up a dialogue that treats them as fellow human beings. Having humility can even mean feeling reverence toward other people, including people with mental illness, and being willing to serve them by meeting their expressed needs and desires. Hu milit y as R e v e r e nc e Let us consider the idea of humility as a form of reverence. Nancy Snow distinguishes narrow humility, which pertains to specific personal traits and weaknesses, and existential humility, which is humility in the face of our finitude.63 Existential humility involves a recognition of our own smallness in relation to something much greater than ourselves, such as humankind, living creatures, the Earth, or God. When we see the greatness of such a thing, it puts our own life and experience into perspective as we recognize our relative smallness; our own life and experience appear minuscule in comparison. There are several different affective responses we may have to our finitude, including awe and reverence but also terror and despair. When we speak of humility toward humankind, living creatures, the Earth, or God, however, we generally mean a positive response of awe, as we feel wonder and amazement at something so much greater than ourselves. This awe easily inspires reverence, which is a deep appreciation, sometimes even involving spiritual worship.64 This awe can also inspire servility, a desire to give for the sake of that which is revered. When we appreciate what we are in awe of, we do not feel fright or despair in relation to it but rather a positive regard that can involve a spiritual connection. Aware of our own finitude in the face of something so much greater than ourselves, we may want to put our own small efforts to work for the sake of that which is much greater, to be part of something bigger than us, to contribute to a larger effort. When we are in awe of humankind, for example, we might feel a worshipful sense of reverence or deep appreciation toward other people, a sense that their presence is a gift to us that we must cherish.

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This might lead us to want to serve others as part of our appreciation of them. We might wish to serve in whatever way we are needed as a way of appreciating those who are in need. The idea of feeling reverence toward vulnerable people such as those who have serious mental illness may seem strange. It seems easier to revere people whose greatness we admire, such as saints, geniuses, artists, or even celebrities; the idea of revering people who lack in greatness, who might even be seen as “deficient” because of significant personal or moral failings, might be off-putting. But I challenge us to think more deeply about what we revere and why. Do we revere people based on their accomplishments, or do we revere them based on their humanity? If we revere people based on their humanity, who demonstrates more humanity than those who are so-called flawed? It is when we have foibles, make mistakes, show weaknesses, have deficiencies, and make bad choices that we are most human. To feel reverence toward humanity is to embrace humans in all their humanness, which includes all of their errors, weaknesses, deficiencies, and even bad will.65 If we only honoured people when they are accomplished, this would deny them an important aspect of their humanity. We revere humanity more richly when we embrace our so-called flaws and revere all humans, even those who may suffer from seeming deficiencies or defects of various kinds, in spite of and perhaps even because of their flaws. A feeling of reverence toward vulnerable people such as those with serious mental illness is, indeed, admirable. When I was hospitalized a couple of years ago for psychotic depression, I was first put on an “intensive treatment” unit where all the patients were psychotic and/or suicidal. While I heard a voice telling me to kill myself, some of the other patients experienced much more florid and constant psychosis and were difficult to communicate with. Nonetheless, I felt an immense sort of reverence toward them. While my psychosis differed from theirs, I felt like I understood them in an important way and I was filled with awe at how they carried their burdens and faced life as best they could. I felt like I had so much to learn from them. I felt an incredible sense of love and caring toward them. My reverence for them was based on my empathy with them. This is not everyone’s attitude when they encounter psychotic patients in a psychiatric unit, of course, even when they are a patient themselves, but it was my way of seeing my fellow patients as humans in all of their wonderful, beautiful flaws.

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The idea of serving vulnerable people may strike some as misguided. While it is not uncommon for people to serve vulnerable people, such as in soup kitchens or homeless shelters, many people who do so think of their activity as serving God, or serving humankind in general, rather than as serving particular vulnerable individuals. But reverence toward others is not simply an abstract idea of reverence in general; it is a feeling of awe with specific targets, namely the particular individuals who are the embodiment of “humankind.” When we serve vulnerable people, we are serving vulnerable individuals themselves, not (only) God or humankind through them as if they were a vehicle for something greater. When we reframe our serving toward specific individuals and not merely an abstract idea, we may find that we take a different approach. Instead of holding high aspirations in serving a lofty idea, we serve concrete, particular individuals with specific needs. In serving vulnerable individuals themselves, we may find it easier to be attentive to their actual needs rather than simply our idea of their needs; we may find it easier to ascertain their needs more precisely and to discern more accurately how best to meet them. Because this approach enables us to be more specific in our actions, we may find that we in fact do a better job in serving people. Our social interactions may be more concrete and rooted, and our engagement more connected to individuals’ daily realities. We may value more deeply the presence of the particular vulnerable people we serve, as well as their stories and histories. We may come to care about them as individuals. We may even find that friendly social interaction becomes more like friendship. In friendship, we serve our friends by being present to them and being there for them when they are in need. When we are present to vulnerable individuals and are there for them in times of need, we may develop such friendship. Humility toward others can lead us to recognize that we can learn a lot from them. Humility should lead us to seek out other people’s stories and perspectives, to understand who they are and where they come from, and to see the world through their eyes. Humility creates an epistemic motivation, inspiring us to want to understand more of the world and in more ways. Humility also creates a moral motivation, to value those from whom we can learn and to value their unique contributions in the world. Reverence goes hand in hand with generosity, which I explain below. When we truly honour someone, we recognize that they have a lot to

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offer, and we willingly accept the gifts they give us. Reverence leads to an acceptance of what is given by the revered. When we revere individuals, we see and appreciate what they have to offer, the contributions they can and want to make. We willingly accept their gifts, and we even encourage and foster their ability to give. True friendship is not simply about being present to someone else and being there for them in times of need; it is also about letting that person be present to us and there for us in our need. Revering a person involves appreciating what they have to offer as a human being, including their social engagement. It involves accepting the invitation to engage. Revering vulnerable people involves appreciating the particular kinds of social engagement they are able to provide and accepting any invitation to engage that they offer. It means respecting them as moral equals potentially worthy of the reciprocal relationship of friendship. Hu mility as Se e i ng t he Se l f P ro p e rly Since humility is in part a matter of seeing oneself from the perspective of others and of the world, it requires an ability to see ourselves wholly and accurately, including our flaws, weaknesses, and deficiencies alongside our strengths and capacities. Judith Andre defines humility as “the ability to recognize and be at ease with one’s flaws,”66 meaning that one is able to “respond to one’s failings in such a way that the self regains harmony and finds strength and hence is less likely to fail in the same way in the future.”67 Andre notes that a precondition of humility is adequate self-worth. Humility “is most possible if one has a solid sense of worth, in the moral or existential sense mentioned earlier. The more one is threatened by information, the harder it is to acknowledge and live well with it. A deep conviction of one’s dignity, or moral standing, provides a steadiness and can weather storms.”68 For people who think poorly of themselves or who are morally deficient in some way, thinking well of themselves may be a way of expressing humility because it involves an accurate self-assessment that can be hard to sustain in awareness of their flaws.69 People who have mental illness may struggle with humility if they are unable to see outside of themselves properly. People who have exaggerated self-worth may be incapable of recognizing their flaws, while people who have little self-worth – including those consumed by shame – tend to perceive their flaws inaccurately, finding faults in themselves that others do not see. People with little self-worth

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may be filled with such self-loathing that they are not capable of incorporating positive self-knowledge into their identity in a way that brings them peace. Success in exhibiting humility requires certain epistemic preconditions to be met. Humility requires us to see the world “as it really is,” meaning in a way that is more or less objective. This involves the ability to take up multiple perspectives, including the perspectives of others, seeing ourselves as others do and not merely through the subjective lens of our own mental states. In this way, we can have more accurate self-understanding. Humility also requires that we accept what we see and that we incorporate it into our self-knowledge and perception of the world in a way that maintains the stability of the self. Humility thus requires the capacity to step outside of our own head and to take up the perspectives of others in such a way as to see our own actions and experiences through their eyes. Such distancing from one’s own subjectivity is very difficult for people prone to self-absorption or preoccupied with their own mental states; it can be impossible for people in paranoid or other psychotic states, where their experience is of utter subjectivity. The more that we can see ourselves as we really are, from the perspective of others, and the world, the more capable we are of humility, and the more charitable, compassionate, and generous we can be as well. When we can see ourselves as we really are, we do not feel threatened by others, and it is easier to interpret others’ behaviour in the best light possible. Moreover, we can draw on our own inner strength and experiences to show compassion to others. And when we can see ourselves as we really are, we have enough inner resources to enable us to give to others. Humility thus enables the expression of other virtues, including generosity, to which I now turn. Generosity Generosity involves the giving of gifts. Generosity can take different forms, including the material generosity that we might be most familiar with, but also what we might call spiritual generosity, or generosity of spirit. While material generosity involves the giving of money or objects, generosity of spirit involves giving gifts of the spirit and heart, so to speak, such as positive judgment and forgiveness.70 Generosity of the spirit is the form I am concerned with here.

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G en erosi t y o f Sp i r i t Joseph Kupfer describes two dimensions of generosity of spirit: generous-mindedness and generous-heartedness. Generous-mindedness is giving a favourable judgment, giving more than what is owed, or giving more than ordinary effort for the sake of someone else.71 We are generous-minded when we pay attention to a person’s positive characteristics or focus on the positive aspects of a situation; we are generous-minded when we have faith in people or the idea that things will work out or that things are as they should be.72 We are generousminded when we give people the opportunity to act well and to pursue their needs and interests, for instance by having faith in them, but also by creating the conditions that allow them to develop, practice, and exercise their agency. Being there for them meaningfully, asking them to help us, and giving them the space to do what they need to do are some of the ways that we create these conditions. These are vitally important ways that we can be generous toward people who have mental illness. Generous-mindedness also involves interpreting other people’s behaviour in a positive light by understanding their actions in a larger context in which the actions make sense. In the context of healthcare, Anne Arber and Ann Gallagher contrast the first-person perspective of viewing a patient’s aggressiveness as being “difficult” with a third-person interpretation, viewing their behaviour in a psychosocial framework in which the behaviour makes sense given the circumstances. This third-person perspective provides a generous interpretation that allows for softened reactions rather than the resentment, irritability, and defensiveness that typically results when antagonistic emotional responses are met with more antagonistic responses. As I noted in chapter 4, Arber and Gallagher describe this perspective as “empathetic maturity,” which requires imagination and a willingness to look beyond what is directly in front of one in order to see the larger picture and give people the benefit of a doubt. The other form of generosity of spirit, generous-heartedness, involves giving up claims against people and giving up the right to make demands of them. Sometimes this involves forgiving people when they have done something we feel they should not have done, as through generous-heartedness we relinquish our claim of resentment toward them and let go of expectations of atonement. We are also generous-hearted when we are deferential to others: when we let

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others take credit for our achievements, for example, or when we do not expect praise from others or ask them to admit when they are wrong. Generous-heartedness is thus a form of graciousness. We are generous-hearted when we prioritize other people’s well-being and psychological and emotional needs over our own, such as when we defer to others’ tastes or desires, when we accept a gift gratefully, or when we are thankful and demonstrate appreciation. Deference, acceptance of another’s gift, and thankfulness are all gifts that we give to others.73 Being treated with generosity can help us move beyond reflexes of defensiveness and move us into different thought patterns, feelings, and behaviours. Ken Steele describes the impact of the generousheartedness that his friend’s response had on him: In desperation, I placed a call to Rob. My resistance to tell him just how stupid I had been was overcome by the strength of my desire to get out of this snake pit [hospital]. Rob’s response was warm and more generous than I deserved. He never said, “I told you so,” never demanded more details than I was willing to ­provide. He told me that he was glad to get my call, that everyone had been worried about me, that he’d do his best to get me out, and that I still had a room and a job. I sobbed when I got off the phone.74 Had his friend taken a different attitude, Steele may not have been able to soften up enough to do the necessary emotional work to do to get himself out of the hospital. Through his friend’s generousheartedness, Steele was able to see that he was loved and cared for and that he had support waiting for him. This motivated him to do what he needed to do to get out of the hospital. We are generous-hearted toward people who have mental illness when we are gracious and deferential toward them, not patronizing or pitying; when we do not ask of them what they may not be able to give; and when we refrain from asking or expecting them to thank us for interventions or other actions we take on their behalf. We are generous-hearted when we do not ask them to apologize for or repair wrongs they may have committed while impaired, when we allow their tastes and desires to dictate the course of conversation or activity, and when we express our appreciation of what they do and even who they are.

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G en erosi t y a nd Mor a l A d dr e s s Critics might worry that generous-mindedness and generous-­ heartedness diminish the agency and responsibility of people who are the targets of these attitudes. Adopting a third-person perspective rather than simply a first-person view might seem to treat a person, such as the aggressive patient described by Arber and Gallagher, as an object rather than an agent. Not asking someone to apologize for or repair wrongs they may have committed, and not expressing moral claims or making moral demands more generally, might seem to deny the person the ability to engage in moral address. This worry relates to the worry that withholding blame from someone who is a fit candidate for blame, and holding objective attitudes instead, fails to recognize the person as a moral agent. I think these are misplaced worries, however. First, adopting a third-person perspective need not exclude a first-person perspective. The “empathetic maturity” that Arber and Gallagher advocate for requires trying to see a person’s situation from their own point of view. The larger understanding of the person’s behaviour comes from both a first-person empathetic understanding from the person’s point of view as well as a third-person perspective that situates the behaviour in specific psychosocial conditions. In fact, a first-person perspective is necessary, because a third-person perspective without the first-person view would easily be objectifying, patronizing, and pitying. What is not necessary or helpful is when medical professionals respond to the aggressive patient with emotional reactive attitudes like blame, anger, and resentment. Not only are these inappropriate in the pursuit of providing healthcare, but they are also unproductive for the reasons described in chapter 4. I reiterate that blaming attitudes serve little productive purpose and can be dispensed with, even though other emotional attitudes like sadness or disappointment may be appropriate. In order for generosity to be truly useful to both the recipient and the giver, it must occur within healthy boundaries. The giver must have enough self-awareness to know where their boundaries are and what would constitute an overextension of giving that crosses some important line. Giving more than what is reasonable – for example, devoting excessive time or attention to a person that detracts from other valuable aspects of a person’s life – can harm the giver and lead to depletion, exploitation, resentment, or loss. It also harms the recipient, for the gift they receive is tainted through that harm and

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cannot be appreciated wholeheartedly; excessive gifts can undermine or even destroy a relationship. Determining what constitutes reasonable boundaries can be very difficult, but these are important to establish so that we do not cause harm to ourselves or to our recipient and so that our gift of generosity can be accepted wholeheartedly as a true gift. Relinquishing claims against someone and giving up the right to make moral demands on them does not thwart the person’s ability to engage in moral address, nor does it change the nature of moral address in any significant way. Generous-heartedness does not require or expect apology or reparation, but these would be accepted with graciousness if they were offered. If a person finds it within themselves to atone for bad actions, they are exercising their agency in an important way but without the pressure of expectation. Atonement must come from within. An individual has to come to the decision to make atonement on their own, for their own reasons, not because it is expected or demanded of them. If we are being generous-hearted and nonjudgmental, then we see that whether a person atones or not just depends on where they are in their journey as moral agents. If a person does not atone, they are not demonstrating a failure of agency or of taking responsibility, but rather simply not exercising it in this way at this time. Generous-heartedness entails withholding judgment, which I propose we adopt in our interactions with others. We must accept that people participate in moral address in the ways in which they are able and not judge them for failing to participate in ways we think they should. Moreover, my giving up a claim against someone or the right to make a moral demand on them does not mean that they are incapable of fulfilling a claim or meeting a demand that they perceive ought to be made. The capacity for participating in moral address remains, even if I do not insist on certain types of moral address be made. G en ero si t y as Unc ond i t i ona l Acce p tan ce Being truly generous to someone, and not just doing something to feel good about ourselves, involves meeting the person where they are and responding to them accordingly. This requires seeing the person as they are and knowing them through empathy as best as we can. Moreover, it requires us to have the epistemic capacity to seek truth and understanding, and the moral capacity for empathy, in other

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words, to imagine what it is like for a person to be in their own situation. Generosity thus has both epistemic and moral dimensions. Being truly generous to someone involves giving the gift of unconditional acceptance: accepting the person wholly as they are, including both strengths and flaws, their achievements and errors, and their good and bad choices as well. The ability to give this unconditional acceptance is based on our capacity to see that our own choices and the choices that others make, however “good” or “bad”, arise from the same structural social conditions.75 These shared social conditions determine what options are available to people depending on how they are situated in relation to each other. In other words, the structural conditions that determine the options for a person who has mental illness, for example, are the same conditions that determine our own options, even if the actual options we have differ. When we take a third-person perspective of trying understand the context for people’s choices, we are capable of seeing the social conditions that make certain actions – even what I have been calling bad actions – make sense in their given context. With this perspective, we accept that people do as well as they can, given their beliefs and the information available to them, and we seek to understand how the world seems to them, to have led to this action. Once someone’s actions make sense, it is difficult to judge them for choosing those actions. Accepting a person unconditionally, therefore, means accepting their bad choices as well as their good ones and withholding blame. Recognizing the shared social conditions that enable our different sets of options and reasons for action is important for having insight into a person’s situation. This insight is crucial for the practical wisdom with which we make moral decisions and moral judgments. Recognizing shared social conditions is thus an epistemic condition of practical wisdom and moral decision-making. Recognizing shared social conditions also makes true generosity possible. When we see how we are connected with others through the social conditions that we share, we recognize that although there are real differences between us there are also some important commonalities. This allows us to recognize the humanity of others despite their different choices and ways of being in the world. Arthur Frank emphasizes the importance of recognizing alterity, of acknowledging difference without trying to subsume it into one’s own framework of experience, as a way of truly accepting others.76 Our challenge is to accept other people as they are, in all their difference, wholly and

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unconditionally, and through recognizing their alterity also recognizing their shared humanity. This acceptance involves the equanimity of compassion and the perspective-taking of humility. When we are able to accept people wholly in this way, we are able to be truly generous in our acceptance of others. G en ero si t y as H osp i ta l i t y Being truly generous also means that we appreciate the contributions made by others. Generosity is enabled by humility, as appreciation of others’ contributions is made possible by a recognition of our own limitations and a recognition of the value of what others have to offer. Some theorists describe this aspect of generosity as radical hospitality.77 We open our doors to others, inviting them in. We offer to listen to their story, giving their telling of their story our full attention. We offer to be there for them in whatever (reasonable) ways they need, both in times of need and in less pressing ways. We offer them our time and our attention, and we let them know that their presence is welcome. When we exhibit radical hospitality, we are invitational and welcoming, and we keep our door open to the unexpected, open to whatever might happen, to whatever calls we might be asked to respond to. With radical hospitality we are open to having moral claims be put to us, and to having moral requests or demands to be made on us. We welcome the opportunity to be asked to respond. In this way, we enable ourselves to participate in moral address more frequently and more deeply – whenever we are called upon. We make ourselves available to others and to the world. People have shown me generosity through my illness in a variety of ways. Sometimes people are generous in small ways that mean a lot, like the acquaintance in graduate school who loaned me The Wind in the Willows when I was suicidal or the friends who ask me how I am doing and really want to know. Sometimes people are generous with their time and attention, engaging me in conversation that helps me feel connected to the world. There are both big and small ways to keep our doors open. Sometimes people go above and beyond in their generosity, like my friend who several years ago allowed me to use his office to work when I found being by myself unbearable. Sometimes people show their generosity in how they regard me; some of my friends have seen me behave in bizarre ways, yet have been generous in always seeing me through a sympathetic eye and caring perspective.

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Radical hospitality is about keeping our door open to the needs of others and being fully invitational and welcoming of their presence; it is also about accepting and appreciating the gifts of others. Being invitational and welcoming means not only being open to others’ moral claims and moral demands (i.e., what they ask for) but also open to others’ gifts (i.e., what they offer). There are few gifts we value more than the receiver appreciating what we have given. Everyone wants to have something valuable to offer others. Having our offering accepted and appreciated is crucial to having our contribution matter. In other words, to be able to give something of value requires that others value it. Radical hospitality means that we value what others give: sometimes people contribute through work of various kinds, both paid and unpaid, and sometimes they offer their presence and perhaps their story. Generosity thus demands that we value the presence of others, and that we take the time to simply be with them. In other words, we not only accept them wholly and unconditionally, but we do so by being present to them. We spend time with them without any other goal to the activity, other than simply being present to each other. Being generous in the sense of radical hospitality means that we appreciate the presence of others, we value hearing their story, and we value their various contributions. When I have been deeply depressed, I sometimes felt that I had nothing worthy to contribute, nothing of value that was worth sharing. And I felt like I was too needy myself to be able to meet other people’s needs. During these times, when friends asked me for help with a work problem or wanted my opinion on something, I felt flattered as well as dumbfounded. I was amazed that they thought I had something worth sharing, and I felt honoured that they came to me. It lifted my self-esteem considerably. My friends’ act of valuing what I had to offer was one of the greatest gifts they could have given me during those times. Radical hospitality can lead to friendship. The person who showed me compassion and hospitality when he engaged me in conversation, despite my uncontrollable crying, made it possible for us to develop a friendship. People vulnerable to social isolation are in special need of friendship,78 not only because they need the companionship of others, but also because they need to have others to whom they can be companionable. Friendship involves, of course, extending ourselves to others and inviting them in, being there for them in times of need, and being present to them. But it also involves a friend being present

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to us and being there in times of our need. Friendship is reciprocal. This reciprocity need not be even; I do not need to give and receive exactly the same thing as my friend gives to and receives from me. But there must be some reciprocity, where gifts of some kind are both given and received by each person in the relationship. Giving the gift of friendship means not only making ourselves available to our friends but also letting ourselves receive what our friends offer. For vulnerable people, who are typically regarded as not having something valuable to offer, it is very important to be regarded as someone with something valuable to give others. The generosity involved with friendship is the generosity of appreciating what is valuable in others, of welcoming what is offered, and of letting ourselves receive what might be given. Giving the gift of friendship to vulnerable people, such as those who have mental illness, means, of course, being present to them and there in times of need, but also, just as importantly, letting them be present to us and be there for us as well. In concrete terms, radical generosity suggests that we go out of our way to be inclusive and welcoming, for example, by inviting people with mental illness to gatherings and events. Even when people reject invitations, or promise but fail to show up – and even if they do so repeatedly – we should continue to extend the invitations and to be as inclusive as possible; the continuous invitation, even if it is not accepted, helps create the conditions that enable change to occur. We must keep in mind to not take refusals personally; with a generous mind we can look at the greater context for the person’s action and recognize that the person has difficulties with socializing due, at least in part, to the constraints caused by their illness. With empathic maturity we can put the refusal of invitations into greater perspective. It is important to keep the door open through continuous invitation because this creates continual opportunity for a person to accept the invitation. In other words, we should not rescind invitations or stop offering them just because in the past the person has refused them. If the door closes, they will never have the opportunity to accept. At the same time, we must be respectful and not force people to accept. A person must come to accept an invitation on their own. They must find it within themselves to be willing to take a risk, to try something uncomfortable, to challenge their sense of shame or low self-esteem, to see outside of their own experience. Radical generosity requires that we keep the door open, being as invitational and inclusive

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as possible, so that we can give people the opportunity to accept the invitation when they are ready to do so. G en erosi t y as R e c i p roc a l Gi v i n g an d   S e l f -G i vi n g True generosity is reciprocal, reflecting our inherently interdependent nature. This reciprocity is not necessarily a one-to-one relationship between giver and receiver, but rather a more complicated web of relationships in which we are sometimes and in some ways givers and sometimes and in some ways receivers. Judith Andre defines generosity as “the disposition to give something with the intention of benefiting the receiver, and reliable success in doing so; the disposition to give easily, yet with an appreciation of what is surrendered; and to give beyond one’s inner circle.”79 Generosity requires recognition of the ways in which we are interdependent, so that a person can see that at certain times, with respect to certain things, they may be a recipient of gifts and in a position of need, while at other times and with respect to other things, they may be in a position of being able and willing to give gifts to others. People vulnerable to self-absorption, as people with mental illness often are, have difficulty with the reciprocity that generosity entails. Self-absorption can impede a person from recognizing other people’s needs and suffering, as they may be so consumed by their own suffering or other mental states that they are unable to look outside themselves. Sometimes people who have mental illness are in continuous and intense need, and their own psychological suffering can overshadow their awareness of other people’s suffering. Even when they are aware of the suffering of others, their position of need can make them feel as if they have nothing to offer anyone else. A person’s own neediness can drain them so utterly that they have no emotional energy to pass along to others. (Correspondingly, other people can find the self-absorption and intense need of a person with mental illness equally emotionally draining, which is one reason why forming or maintaining deep relationships with people with mental illness can sometimes be difficult.) Yet, as I explain in the concluding chapter, everyone needs to feel as if they have something to contribute that others find valuable; vulnerable people who have few social connections and less selfesteem have this need more so than others. The interdependent reciprocity of generosity is particularly difficult for people who face the challenges of mental illness, and yet this interdependent

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reciprocity is more deeply needed by these very people because of those challenges. People who have difficulty looking outside of themselves and who have lower self-esteem and greater shame would be better able to be generous in their approach if they were also able to be compassionate – not only to others but also to themselves. One of the greatest gifts we can give ourselves is the gift of self-compassion, of being gentle with and accepting and forgiving of ourselves. When we care about ourselves and treat ourselves well, we create the inner resources that allow us to share that care and concern with others. When we address low self-esteem and shame so that we think well of ourselves, we find that we have more to offer other people. Self-compassion enables generosity, allowing us both to give more to others and to be able to accept the gifts that others give to us. Self-compassion also enables the compassion toward others that motivates and inspires us to want to give to others. With a generous heart and mind, we are better able to be compassionate and more motivated to care and to act on behalf of others; with compassion, especially compassion toward ourselves, we are better able to be generous-minded and generous-hearted. G en ero si t y as Sup p ort As a form of gift-giving, generosity also involves offering support to people. Support can take many forms, including giving emotional support of friendship, spending time with someone, providing needed material objects, giving financial support, and providing jobs and other opportunities. Given our interdependence, support is essential for all of us, as none of us can be truly or purely self-reliant. Support is crucial for people dealing with mental illness. Ken Steele describes the impact that support from his friends and co-workers had on him when he was hospitalized: The most important part of this hospitalization for me was that I had visitors every day, sometimes twice a day. They brought me books. They brought their friendship, which helped to combat the maleficent messages of the voices. People actually cared about me and wanted me to get well. As a result, I was able to leave the hospital after only five weeks, and I had a room, a job, coworkers, and friends to be discharged to. If they could care that much about me, I told myself, I could care enough to try to fight the voices and hallucinations.80

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Elyn Saks describes a similar experience when she was hospitalized: Two of my law school classmates, who’d heard what had happened, came by one afternoon, and although it was obvious to me that they were struggling for the right things to say, I was both comforted and moved that they’d come at all … It was so easy to feel isolated and alone here; each one of these people who cared enough about me to come and visit gave me reason to hope that I was worth saving.81 People who have mental illness benefit greatly from friends checking in on them, being there for them, and maintaining the friendship despite the challenges mental illness may impose. People with mental illness are aided greatly when people help them with small things (like bringing books to read in the hospital) as well as big things (like helping to pay bills). When employers maintain jobs for people who have mental illness throughout their acute episodes, this helps enormously, as jobs do not just provide wages but also structure, competence, and self-esteem. Support in all areas of life is crucial for people who have mental illness; it can make the difference between being incapacitated by the illness or being able to manage the illness properly. Kurt Snyder explains how multiple sources of support helped him in his recovery from schizophrenia: The improvement in my life is not entirely due to medication, though. I was lucky to have the continuous support of my friends and family. My roommates (with whom I shared a house until I became psychotic) forgave my overdue rent. My parents allowed me to live at their house while I was ill (actually they demanded that I live there). Dan and Helen [friends and employers] have continued to offer me steady emotional support, even though I rejected them in my illness, and Dan helped me kick-start a new career by providing me with financial support. Another friend gave me numerous reference books to help me with my education, and he supported me by hiring me to do some handyman chores that he could have done himself. I was also recommended for my current job by someone who knew I had schizophrenia. This person didn’t stereotype me as

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a lifelong lunatic. After I got the job, my boss allowed me some time off work when I was experiencing heavy anxiety. My fellow members of the fire department who know about my illness have pushed me forward and encouraged me to assume more responsibility as the years have passed. I’m now their president! Don’t be ashamed to accept help from anyone. No one can be successful in recovering from a serious illness like schizophrenia without the help and support of others.82 People with mental illness who find ways to manage their illness almost always say they succeed in part because of the support of others. Generosity coupled with compassion can allow us to provide the various types of support that help people with mental illness thrive. The Fe c undi t y o f Ge ne ro si t y In its perpetual giving, generosity implies exuberance and fecundity. Generosity breeds more generosity, inspiring it in others. When we appreciate what we have been given, we often want to demonstrate our thankfulness by giving to others. When someone has opened their door to us, and been there for us in times of need, our gratefulness often leads us to keep our own door open, and to be there for others as they have been there for us. People who have received much in times of need – for example, those who have been made deeply vulnerable in an acute episode of their mental illness – sometimes feel the need to pass along what they have been given by trying to connect with similarly vulnerable others in their great need. They are not experiencing a debt to be repaid or an obligation to be fulfilled; rather, they are experiencing the exuberance of gratitude for the gifts they have been given, an exuberance that inspires more gift-giving in others. Generosity that inspires more generosity and other virtues in others may be called generosity of virtue. Joseph Kupfer explains several ways that fostering virtue in others can occur. In some circumstances, we may be able to engage with people and give advice or suggestions on how they might deal with difficulties. In many other circumstances, however, direct advice-giving is undesired and can even thwart our aims, as the person may bristle and resist our efforts. Presenting ideas with epistemic humility can be helpful, for example, saying something like, “I don’t know if you think it is a good idea, but when I’m depressed I sometimes find it helpful to talk to someone,” or

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recommending physical exercise, and so on. Acknowledging that we do not know what it is like for other people to experience their suffering can also help, for example, by saying something like, “I don’t know what it’s like when you’re depressed, but when I’m depressed I feel as though no one can possibly like or respect me.” Offering ideas with epistemic humility usually makes them more palatable and comforting and can inspire people to respond positively. Focusing less on what others should do and more on what we can do ourselves is usually most effective. For example, when we are open about how we deal with our own flaws, mistakes, and deficiencies, we demonstrate to others what dealing with these can look like. In essence, we become role models for dealing with vulnerability. Kupfer describes further ways of encouraging generosity in others: Forgiving individuals who injure us or forgoing opportunities to criticize wrong-doers might open new channels of thought and feeling in them which foster their capacity to love. Similarly, by being kind or patient with people who are neither kind nor patient with us, we may unobtrusively strike a responsive chord. When we are generous with our virtue and not merely by means of it, we further the acquisition or flourishing of the virtue in other people.83 If part of what we wish to accomplish in our interactions with people who have mental illness is to encourage the adoption of other-directed virtues, we must exhibit those virtues ourselves. Generosity requires that we be our best selves in order to inspire others similarly.

C o n c l u s ion Adopting the virtues described in this chapter helps us meet some of the goals outlined in this book. We can decrease stigma by seeking greater understanding of people who have mental illness and by interacting intentionally with those with severe illness. We can increase social interaction of people with mental illness who are socially isolated and/or stigmatized by facilitating interaction with us. If we are kind, gentle, compassionate people, who are also charitable, humble, and generous, others will want to interact with us. We can also help people become better and flourish by creating the conditions that allow them to do so. We cannot make people change or be the way

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we want them to be, but we can make it easier for people to act differently and to develop attitudes and dispositions that help them to flourish by changing how we act. There are many barriers to adopting the virtues described here. One significant barrier is simple discomfort. Many of us do not like to stretch outside our comfort zone and do not want to make the effort to understand something difficult, overcome preconceived ideas, or risk of getting things wrong. Many of us are uncomfortable keeping our door open and extending the possibility of friendship to people unlike ourselves. We are more comfortable doing things our own way, interacting with people like ourselves and whom we more easily understand. Interacting with people in the ways I have described here takes courage, a virtue I have not discussed in this chapter. Courage is the willingness to take risks and endure hardship for the sake of the good. Courage requires practical wisdom, the ability to understand a situation as it is, and make good judgments in the face of the situation.84 Interactions with people who have mental illness can also involve emotional risk. But this risk is for the sake of much greater goods: the good to us of engaging with people unlike ourselves, and the good to people who have mental illness of interacting socially. These goods are connected to the goods of decreasing stigma and enhancing the agency of people with mental illness. Risk and discomfort are well worth enduring for these greater goods. Another significant barrier is self-absorption, both our own and that of the people with whom we are interacting. How we relate to ourselves is just as important as, and perhaps fundamental to, how we relate to others. We cannot be virtuous to others without also being honest with and virtuous toward ourselves. While a person who is self-absorbed may be preoccupied with their own mental experience, this preoccupation distracts them from attaining true knowledge of themselves, from accurately perceiving the world outside of their mind, and from having a proper perspective about their place in the world. Self-absorption thus impacts the relationships we have with others, with the world, and with ourselves. Insofar as we are relational beings, that is, our identity and agency are co-constituted in relation to others and through our interactions with others, self-absorption also circumscribes who we are and what we can become. Addressing self-absorption is not only a matter of addressing how we relate to others, therefore, but also just as significantly how we relate to ourselves.

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Addressing self-absorption requires developing an orientation toward the other. But this leaves us saying that a barrier to otheroriented virtues is self-absorption, and the way out of self-absorption is to develop other-oriented virtues – a tautology. The way out of this tautology is to think of the development of virtues as involving experiments of behaviour, which may lead to developing habits and then a practice. Remember that behavioural change need not follow from particular changes in reasoning, beliefs, or values. We can learn to overcome our self-absorption by experimenting with other-oriented behaviour. We can try out humility and generosity and persevere despite our discomfort. We can stay committed to the behaviour even though it feels uncomfortable.85 When we maintain this behaviour it becomes habitual, and then we find that through our experimenting and practice we have developed an orientation to the other. Similarly, we develop a more positive relationship with ourselves when we practice behaviours of positive self-engagement. Adopting other-oriented behaviour through the virtues described in this chapter allows us to meet our goals of decreasing stigma, increasing opportunities for agency, and creating the conditions that enable change to occur. Addressing our own self-absorption is necessary if we want the people with whom we interact to overcome their self-absorption. By adopting other-oriented behaviour we model it for others, showing the value of such behaviour and demonstrating that it is possible. Treating people well through our other-oriented behaviour inspires people to want to live up to our conception of them and to act well themselves. When we treat people well through our other-oriented behaviour, it softens the tone of moral address and makes us into people with whom others would want to interact.

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Conclusion

In the beginning of this book, I explained ways in which stereotypes affect how we interact with people who have mental illness, often causing people to be socially isolated. It is too easy to see people who have mental illness, especially psychosis, as fundamentally unintelligible and, therefore, unlike us. It is also too easy to see them as incompetent and needing taking care of, when we believe they do not have control over their condition, or having a character flaw, such as weak will, when we believe they do have some control. In holding these views, we stigmatize people who have mental illness as less than or other than us, and we feel fear or disgust toward them. This perception easily leads to prejudice and discrimination, and ultimately to exclusion and social isolation. The difficult thing about stigma as it applies to mental illness is that, unlike stigma toward people based on racial, gender, or other characteristics, the stigma attached to mental illness is in some ways reasonable. Mental illness can affect people’s cognitive, rational, emotional, and volitional capacities, sometimes profoundly, with consequences for behaviour and speech. Since reasoning, valuing, and choosing are quintessential human activities, conditions that threaten the capacities to do these things also threaten a person’s humanity. Thus, there are sound reasons to feel aversion toward mental illness: symptoms of mental illness threaten some conditions of being human, namely certain capacities for agency. Many stigmas are toward traits that are not inherently bad but are only deemed bad according to social norms. Stigma of mental illness, however, attaches to traits that are inherently bad, at least to some degree, insofar as they threaten the conditions of being human.

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Stigma against mental illness exacerbates the bad effects of mental illness itself. However mental illness symptoms impact a person’s capacities to reason, value, and choose, stigma compounds this impact, diminishing these capacities even further. This is due to several factors, including the social isolation that typically results from stigma, which prevents the development and exercise of agency, as well as the exacerbation of symptoms that typically results when a person responds to stress (experiencing stigma is certainly a stress). Although we may have authentic reasons to fear or feel disgust toward mental illness in the way that it can threaten the conditions of being human, we have even stronger reasons to resist stigmatizing it so as not to exacerbate the difficulties with various capacities for agency that people already face due to their illness. Resisting stigmatization requires intentional action, including intentional forms of interaction with people who have mental illness. An important part of addressing stigma involves recognizing people with mental illness as full moral agents having a moral identity, and as members of our moral community able to meaningfully contribute to society and the greater good. This recognition must manifest in how we interact with people who have mental illness: we must treat them as moral agents able to make meaningful contributions to the community. It is important, however, that we accept them as moral agents in all of their complexity, which means also accepting the ways that their agency may be constrained by their mental illness symptoms. Accepting the complexity of people’s moral agency requires us to maintain a tension between perspectives that do not neatly go together. This is similar to the kind of dialectic described in DBT, which teaches people to maintain a tension between alternative viewpoints so that they can hold multiple perspectives simultaneously. Maintaining alternate viewpoints can make us uncomfortable, as we prefer to seek out resolution between them. Holding multiple perspectives is necessary, however, to see the world accurately and to deal with the world as it is. We must hold the perspective that people with mental illness are capable of some degree of control over their behaviour and so are capable of change, with the perspective that these individuals may experience significant constraints on their agency, which severely limit the control they have over their behaviour. Both perspectives are true. We must also hold the perspective that all people, including those with mental illness, have some degrees and kinds of agency and ought to be regarded as responsible for their behaviour in some way, along with the perspective and awareness that everyone acts in psychosocial

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contexts that influence their action in understandable ways. In maintaining this latter tension, we can affirm the complexity of human agency, the complexity of our understanding of people’s agency, and the complexity of our responses to people’s actions. Accepting the complexity of moral agency requires that we accept our inherent epistemic limitations in how we know the extent and nature of the constraints on a person’s agency. This should affect how we interact with people who have mental illness. On the one hand, we should treat them as capable of change, in other words capable of being agents who have some degree and kind of control over their behaviour; on the other hand, we should be mindful of their potential constraints and our epistemic limitations, being careful not to hold them to unreasonable standards and being forgiving when they are unable to act or change in accordance with our expectations. In order to provide greater opportunities for people to exercise their agency, we should interact in intentional ways, being open-minded and seeking shared meaning in trying to understand them, and adopting otheroriented virtues of charity, humility, compassion, and generosity. During the writing of this book I experienced an episode of psychotic depression during which I was hospitalized. I needed to receive accommodations at work in order to fulfill my responsibilities appropriately. When my mental health issues did not resolve themselves in a timely manner, I participated in an intensive outpatient program that taught me tools related to mindfulness, regulating my emotions, and tolerating distress. While receiving treatment in both inpatient and outpatient settings, I met many fellow patients who were made deeply vulnerable by their illness just as I was. All of us were made vulnerable by virtue of the limitations placed on us in our reasoning, valuing, and choosing capacities. In the hospital, I was on two different units. In one, many patients struggled with psychosis, and the most floridly psychotic patients believed themselves to be vessels of God or were fairly incoherent. In the other unit, patients struggled with depression, anxiety, and trauma. Most patients were amazed to find themselves in a psychiatric hospital and some were convinced they had been committed wrongly. I was self-aware of my own problems and knew I needed to be there. But I felt as vulnerable as if I had been walking around naked the entire time. In the hospital we had few freedoms and few areas where we could make choices. I was rendered virtually helpless by my illness and the situation it had put me in. All I could

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do was try my best to take care of myself so I could heal. That was my primary responsibility. Being a patient in a psychiatric hospital is an extraordinarily humbling experience. I interacted with other patients, including patients with florid psychosis, as equals. We were all in the same position of vulnerability. Regardless of whether we thought we ought to be in the hospital, we recognized each other as fellow patients (some might say “inmates”) with the same moral status. Each of us wanted to make decisions over the small matters we had control over (e.g., which cafeteria selection to choose for lunch, where to put our items in our half of the shared room). Even people with severe psychosis maintain some form of agency. In recognizing each other as members of a shared moral community (literally, the hospital), we generally respected others’ choices. Since we patients all shared the same vulnerability and so saw each as fundamentally equal, it was easy to make friends with other patients. Being hospitalized does not automatically make a person more empathetic or compassionate, or more willing to try to find shared meaning and seek out intelligibility with others. Recall Jim Knipfel’s stigmatizing remarks about his fellow patients: “There wasn’t anyone behind those eyes to know”1 (in chapter 5). Plenty of hospitalized people see themselves as separate from the other patients; while the other patients clearly have problems, they do not, so they assume, or at least not as extreme. This distancing of oneself from others protects a person from recognizing the severity of their own illness, and it serves the same purposes as other forms of stigma: it protects a person from identifying with the seemingly unintelligible Other, and in so doing it preserves a person’s sense of themselves as a moral agent and human being. Stigma of mental illness held by people who have mental illness is not uncommon, and it tends to lead to the shame and selfstigma discussed in chapter 3. My own approach, and what I saw in others in the hospital, was different. I knew I had a problem that needed treatment, and I saw that even though my symptoms differed from those of some fellow patients, I was no better than they and I essentially had the same problems with them: mental impairments that made me unable to function. In fact, because of our shared experiences of deep vulnerability I felt I had more in common with my fellow patients than I did with people outside the hospital, including my colleagues. Other patients with whom I interacted seemed to feel this same deep

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connection forged by shared vulnerability. It was easy for me to be friends with my fellow patients because it was easy for me to relate to them. Recognition of others’ vulnerability can lead to the stigmatizing attitudes and actions I describe in this book, but it can also lead to respect. I was impressed, during my hospital stay, with the level of respect that not only patients had toward each other but also doctors and staff seemed to demonstrate toward patients. While the power differentials undeniably created a gulf between doctors and staff, and us, the separation was not as wide as it could have been. For instance, one thing that impressed me to no end was that doctors and staff sat with us patients to eat meals in the cafeteria. There is always a gulf between “them” and “us,” but we have choices in how wide we choose to make it. There is always a power differential between people in a position of vulnerability and people who make decisions about those who are vulnerable, but we can choose how to respond to that vulnerability. In spring 2018, I was on the patient side of the wall that separates “them” from “us”; a year later, I was on the other side, when I visited a local county jail and observed inmates in the special management unit who had mental illness. They looked very much like some of the people I met at the hospital, and the unit reminded me of one of the inpatient units I was on. It was strange to be on this side of the physical wall that separated inmates from the police officers, who kept watch over them, when the other side of the wall looked so familiar. I saw how police officers talked about the inmates with mental illness – with what appeared to me a mixture of respect and stigma – and wondered how staff at the hospital where I stayed had talked about us. Being on this side of the wall now, I had the unsettling experience of feeling both identification with the inmates with mental illness, who were in a position of all too familiar vulnerability, and separation from the inmates, who were obviously in a very different place in life than I was. What I could not stop thinking about was that I am only one crime away from where they are. We share more in common than what makes us different from each other. This would be true even if I did not have a mental illness. It would be easy to imagine a hospital environment where patients were stigmatized and treated poorly because staff and doctors feared or were disgusted by mental illness.2 It may very well be that at the hospital where I stayed doctors and staff spoke about patients with

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the same mixture of respect and stigma that I observed from the police officers at the jail. But at least we saw what appeared to be respect. Perhaps doctors and staff knew that they, simply in being human, were vulnerable to the possibility of mental illness as well. We are all vulnerable to the possibility of illness diminishing our mental capacities. We can respond by treating people who have such illness in ways that dehumanize them, or we can respond in ways that recognize their humanity and even enhance their agency. While during my illness I was made as vulnerable as anyone else receiving inpatient and outpatient treatment, I also had certain privileges that some people lacked. I had a professional job, a nice home, and a supportive family. I did not have to worry about being laid off from work or having my hours cut; I did not have to worry that hospital bills would make me lose my home; I did not have to worry that I would come home to find that my family had abandoned me. When I needed accommodations at work to take care of my mental health needs, I had a boss who was extraordinarily supportive and ensured I got whatever I needed. I have resources, opportunities, and support that many people with my illness lack. These privileges allow me to function better in general so that when my agency is diminished by my illness, the overall effect is less severe than it would be if I had fewer privileges. Many people with serious mental illness struggle with accessing adequate resources, having appropriate opportunities, and having meaningful support. In the hospital, I met people who had come from being homeless and who would likely return to being homeless when they left. I met people who were facing jail time after hospitalization due to crimes they committed while ill and others who had been jailed in the past. In the outpatient program, I met numerous people who struggled with having employment that accommodated their illness. Some were unemployed because their illness had rendered them unable to work; others were trying to work as best as they could but faced significant challenges due to their illness. In some cases, employers were unwilling to accommodate people’s needs for time off to take care of their mental health, and some were downright hostile toward employees who made it known they had mental healthcare needs. I met many people who were poor and whose ability to pay for their mental health treatment was questionable. In both inpatient and outpatient treatment, I met people who were estranged from their family members, who had very few people in their lives at all. I also met others who, like me, had good jobs, supportive family members,

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and stable housing. But plenty of people struggle in one or more of these areas. My awareness of my own privilege has led me to want to be an advocate for social change with respect to mental illness. I am cognizant that I have some credibility as a professor, and I chose a long time ago to be open about my mental illness on my campus. I share my story with students in my Philosophy of Mental Health class every year, and I have shared my story in other venues on campus, including public talks. Sharing one’s story is much more difficult when the experiences are raw and one still feels very vulnerable. But sharing is an important way that people who have mental illness can contribute to the efforts to destigmatize it. I decided to share in this book my experiences of having mental illness in part to contribute to the efforts to decrease stigma. It is only when we talk about the experiences that people tend to find secretive and shameful that we can reduce stigma around them. There is no shame in having a mental illness or in getting whatever treatment is deemed necessary. Having a mental illness does not make a person less than or other than human; getting treatment for it does not mean that a person is weak; needing accommodations does not mean that a person has a character flaw or is unfairly trying to take advantage. Coming to terms with stigma means truly accepting these ideas and letting go of prejudice. Some readers of this book will have had experiences with mental illness, including perhaps hospitalization, while many readers will not. To all readers, and especially those who have not had relevant experiences, I strongly recommend developing the other-oriented perspective-taking of empathy. Empathy allows us to connect with others in their suffering. From empathy we can develop the motivation and capacity for being open-minded toward, and seek shared meaning with, those who have mental illness. With empathy we can interact with people who have mental illness with charity, compassion, humility, and generosity. In order to do the imaginative reconstruction of empathy, we must seek out the stories of other people so that we can better understand what it is like to be them, in their situation. We cannot simply make up how we think we would feel if we were experiencing the situation. We must seek out details, understand context, and really try to make sense of other people’s experience. We must read memoirs and other narratives and hear speakers tell their stories. We must get to know individuals who have mental illness, ask them about their experience,

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and listen to whatever story they tell, in whatever form that story takes. We must be open-minded enough to make sense of experience that on the surface appears unintelligible, and we must seek out points of connection without interpreting others’ experience through our own lens. We must not be afraid to talk about a topic that seems personal. There is no shame in mental illness experience, and we must not treat it otherwise. People who have mental illness are complicated beings with complex agency; their mental illness symptoms cause various mental impairments, which show up at different points in life and in various ways. We are particular individuals with unique experiences not generalizable to others yet form part of a broader shared experience among those who have serious mental illness. Sometimes people with mental illness have great difficulty with various aspects of functioning, but this should not be held against us as if we were lesser human beings, or lesser in our roles such as, in my case, being a philosophy professor or parent or spouse. Our impairments do not define us but are simply another, albeit important, aspect of us. Our mental illness plays a bigger role in our experience, identity, and capacity for agency than most other aspects of our identity, but it does not make us lesser. We need to be recognized as members of the community, both the general moral community and the professional and other specific communities to which we belong. Potential constraints on our agency should be recognized, but we should be treated as moral agents regardless. I hope that people will forgive those of us with mental illness when we act badly and also help us to be better. I hope that people will be open-minded in trying to understand us and to make efforts at establishing shared meaning. And I hope that people will treat us with charity, kindness, compassion, and generosity. People who have mental illness have particular vulnerabilities but are as human as anyone else. We need to recognize them as members of our moral communities and as epistemic and moral agents like us. Although they experience mental impairments and other constraints, they are still capable of agency. And although people who have mental illness are agents, they are subject to flaws and limitations, just as all of us are, and ought to be treated with the same consideration we all would like to be treated with. By respecting people as the complicated agents they are, by maintaining an open mind and a desire to seek shared meaning, and by interacting with people in kind, compassionate, and generous ways, we humanize one another.

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Notes

I nt roduct i o n  1 Saks, The Center Cannot Hold, 336.   2 Centers for Disease Control and Prevention, “Learn about Mental Health.”   3 Substance Abuse and Mental Health Services Administration (sa mhsa ) Center for Behavioral Health Statistics and Quality, “Results from the 2017 National Survey on Drug Use and Health: Detailed Tables.”   4 Centre for Addiction and Mental Health, “Mental Illness and Addiction: Facts and Statistics.”  5 sa mh sa Center for Behavioral Health Statistics and Quality, “Results from the 2017 National Survey on Drug Use and Health: Detailed Tables.” See also Canadian Mental Health Association, “Poverty and Mental Illness.”  6 sa mh sa Center for Behavioral Health Statistics and Quality, “Results from the 2017 National Survey on Drug Use and Health: Detailed Tables.”  7 sa mh sa , “Homelessness and Housing”; James and Glaze, “Mental Health Problems of Prison and Jail Inmates.”   The rate of inmates who have mental illness is slightly lower in Canada, comprising about 13 per cent of male inmates and 29 per cent of female inmates. However, the unemployment rate for people with severe mental illness in Canada is 70–90 per cent (National Union of Public and General Employees, “No Health without Mental Health: The Way Forward”).   8 For more discussion of the difficulties of disclosing personal connection to conditions like mental illness that may impair reasoning, see Gosselin, “Philosophizing from Experience.”

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C ha p t e r O n e   1 According to a 2014 survey titled “Mental and Substance Use Disorder” by the Substance Abuse and Mental Health Services Administration, 20.2 million adults in the US had a substance abuse disorder; of these, 7.9 million – well over a third of the total – had a co-occurring mental ­disorder diagnosis.   2 Quello, Brady, and Sonne, “Mood Disorders and Substance Use Disorder.”   3 Powers, No One Cares About Crazy People, xviii.   4 Miranda Fricker defines stereotypes as “widely held associations between a given social group and one or more attributes” (Fricker, Epistemic Injustice, 301).   5 Coleman, “Stigma,” 145–6.   6 For example, see Olson, “California Mental Institutions’ Physical, Mental, and Emotional Abuse Published in Government Report.”   7 The US government agency sam hsa in a report titled “Homelessness and Housing” estimates that about one-fifth (20 per cent) of the entire homeless population in the US has serious mental illness (this is counted independently of the one-fifth [20 per cent] of the population that has a substance abuse disorder), but of the population of chronically homeless that number jumps to almost one-third (30 per cent). This indicates that mental illness creates a strong barrier to overcome for people trying to exit homelessness. These numbers include only the people counted during a data-gathering night in 2016 by the Department of Housing and Urban Development and only those known to have mental illness such as through self-report. Actual numbers are probably much higher than this estimate indicates.   8 Brown, “For Colorado Homeless with Mental Illnesses, Housing is Health Care.”   9 Most of the recent literature converges around these stereotypes, which are summarized in Corrigan and Kleinlein, “The Impact of Mental Illness Stigma,” 16; and Rusch, Angermeyer, and Corrigan, “Mental Illness Stigma.” 530.   An additional noteworthy stereotype is that people with mental illness are permanently defective, with a condition that is chronic or even lifelong, potentially degenerative, and ultimately incurable. This stereotype is connected to the other three, particularly the person who is incompetent and needs taking care of. The permanently defective example is identified as a separate stereotype in Eminson, “Personal Responses to a Lack of Shared Perception,” 123.

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  Studies of stigmas people hold toward those with mental illness include many variants on these themes. For example, the Royal College of Psychiatrists’ survey assessed negative public opinions, including people with mental illness are: dangerous, unpredictable, hard to talk to, feel different from the way we all feel sometimes, have only themselves to blame for their condition, have the ability to pull themselves together if they only wanted to, have the ability to improve if they were given treatment, and are unable to recover fully. People’s responses differed considerably, depending on the specific mental disorder they were asked about, but each of these rated fairly high as a belief for at least some mental disorders (Gelder, “The Royal College of Psychiatrists’ Survey of Public Opinions about Mentally Ill People”). 10 In the 1950s and 1960s, the romantic view of mental illness took the form of capitalist critique. During this period, psychoanalysts such as R.D. Laing viewed schizophrenia as “split personality” arising from social ills of conformity and consumerism. This conceptualization of the disorder likewise made schizophrenia a white, middle-class disease, suffered by sensitive “seers” who perceived the hypocrisy and harmfulness of dominant capitalist culture more accurately than those without the illness (Laing, The Divided Self; The Politics of Experience).   More recently, the romantic view of mental illness takes the form of a cultural critique of power. Advocates in the postpsychiatry and critical psychiatry movements, and certain groups of individuals who experience what psychiatrists would identify as mental disorder symptoms, embrace a view that “madness” is simply a different way of experiencing the world, not a pathological condition requiring treatment. Inspired by philosophers like Michel Foucault, members of groups like Mad Pride, Mad Chicks, the Hearing Voices Network, Intervoice, and the Icarus Project view psychiatry as a force of power and domination with the goal of extinguishing eccentricity in favour of conformity (Bracken and Thomas, Postpsychiatry; Longden, Corsten, and Dillon, “Recovery, Discovery and Revolution”; Rashed, Madness and the Demand for Recognition, 165–7; Romme et al., Living with Voices; Romme and Morris, “The Recovery Process with Hearing Voices”; and Thomas and Bracken, “Power, Freedom, and Mental Health). See discussion in Powers, No One Cares About Crazy People, 156–69. 11 Kay Redfield Jamison explores the stereotype that people with manic depression (what is now diagnosed as bipolar disorder) are particularly creative, with her historical overview of literary, visual, musical, and other artists who had manic depression (Jamison, Touched with Fire). Alice

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Flaherty also explores the linkage between creativity and depression, including manic depression (Flaherty, The Midnight Disease). 12 Sieff, “Media Frames of Mental Illness.” 13 Gary Watson discusses the conflicting responses we have toward someone who committed a heinous act: sympathy for the person who had little ­control over their behaviour, whether through upbringing/environment or biology, on the one hand, and outrage for the person for the nature of their act, on the other hand. He attributes this tension, in simplistic terms, to the conflicting beliefs we have about the extent to which actions and character are determined by external factors versus the product of freely willed choices. I explore this more in the fourth chapter (Watson, “Responsibility and the Limits of Evil”). 14 Strawson, “Freedom and Resentment.” 15 Ibid., 79. 16 See the controversies over adhd diagnosis and the role that a dhd plays in the treatment-enhancement debate, for example, Diller, “The Run on Ritalin”; Harré, “The Logical Basis of Psychiatric Meta-Narratives,” 300–1; and Schermer, “The Dynamics of the Treatment-Enhancement Distinction.” 17 I am grateful to Sean Wilson, who helped me think through the ways our beliefs about groups of people are informed by “who” we imagine those people to be. 18 Corrigan and Watson, “At Issue”; Glannon, “The Blessing and Burden of Biological Psychiatry”; Hinshaw, The Mark of Shame, 85–91; Read et al., “Prejudice and Schizophrenia”; and Thachuk, “Stigma and the Politics of Biomedical Models of Mental Illness.” 19 According to the US Department of Health and Human Services, only about 3–5 per cent of violent crimes in the US are attributed to people with serious mental illness, while people with serious mental illness are more than ten times more likely to be the victims of violent crime than the general population (US Department of Health and Human Services, “Mental Health Myths and Facts”). For discussion of the perceived versus actual relationship between violence and mental illness, see Corrigan and Cooper, “Mental Illness and Dangerousness”; Thornicroft, Shunned, 125–49; and Tidmarsh, “The Need for Risk Assessment.” For discussion of the threats to personal safety that people with mental illness face, see Thornicroft, Shunned, 74–6. 20 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (ds m -5), 20. 21 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision (dsm-IV -TR ), xxxi. The full ­definition given is as follows:

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In d s m -I V, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or patterns must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above. Note that most of the meaning conveyed is the same as in the definition in d s m-5, even though the wording is different. The first sentence introduces some concepts not found in ds m -5, however.   In its section “Definition of Mental Disorder,” the dsm-IV -TR explains that there is no adequate definition of mental disorder which is consistently operational, in large part because medical conditions in general, and the concept of mental disorder itself, rest on a range of concepts with varying levels of abstraction. Nevertheless, the dsm must proceed from a working definition of mental disorder, which is what is given here. For philosophical analysis of the concepts embedded in this definition, see Stein et al., “What is a Mental/Psychiatric Disorder?” 22 Derek Bolton describes “meaning” as including “appropriateness of affect and behavior, rationality of belief and action, functionality of behavior, strategy, and regulation by information processing” (Bolton, What is Mental Disorder?, 182). 23 See discussion in Bolton, What is a Mental Disorder?, 182–9. 24 Philosophers disagree about the kind of meaning delusions may have and whether it is content-specific or not. For example, in separate articles Michael Musalek, and Peter Kinderman and Richard P. Bentall argue that delusions always have content-specific meaning that make sense within the framework of the individual having the delusion. In contrast, Louis Sass argues that delusions in schizophrenia typically have no reference, where the only meaning they have is the promise or hint of meaning. Sass describes such experiences of meaning as “‘symbol symbols’ – symbolic vehicles whose only real referent is that most general phenomenon, the tantalizing presence of meaning itself.” This distinction somewhat tracks the different ways that analytic versus continental philosophers

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conceptualize delusion – as doxastic and, therefore, the province of e­pistemologists, or as fundamentally perceptual, and, therefore, the domain of phenomenologists. I discuss this more on pages 68–76 of this book, in the section titles “Delusions” in chapter 2 (Kinderman and Bentall, “The Functions of Delusional Beliefs”; Musalek, “Meaning and Causes of Delusions”; and Sass, The Paradoxes of Delusion, 106–7). 25 For example, see the accounts by Bolton and Hill, Mind, Meaning, and Mental Disorder; and by Nordenfelt, Rationality and Compulsion. 26 My use of the terms “mental disorder” and “mental illness” are consistent with Derek Bolton’s uses. In his book What is a Mental Disorder?, Bolton examines the ontology of mental disorder. He analyzes the components of the definitions of mental disorder given by the American Psychiatric Association in their Diagnostic and Statistical Manual (dsm) and by the World Health Organization (w ho) in the International Classification of Diseases (i cd). Consistent with the definition given by the American Psychiatric Association (above in the text), the who describes “disorder” as “a clinically recognizable set of symptoms or behavior associated in most cases with distress and with interference with personal function.” Quoted in Bolton, What is a Mental Disorder?, 165.   More specifically, according to Bolton, the term “mental illness” is “­typically used to signify conditions that are severe and enduring, and qualified accordingly” (Bolton, What is a Mental Disorder?, 277). 27 My thinking about the difference between mental disorder and mental ­illness is inspired by Lennart Nordenfelt’s distinction between disease and illness. In simple terms, he defines disease as the physiological part of a condition, which tends to impair a person’s ability to meet their vital goals, while illness is the subjective part of this condition, involving the social effects and phenomenological experience of such an impairment. In other words, disease is the physiological problem while illness is an experience of that problem (i.e. the effect of the disease) (Nordenfelt, On the Nature of Health, 109–11; Rationality and Compulsion, 54–9). 28 Notice the way that my understanding of mental illness overlaps with the d s m- I V definition of mental disorder. 29 George Graham provides a more specific list of psychological competencies required for flourishing which are threatened by mental illness: • The ability to locate one’s body position in relation to one’s environment. • The ability to locate oneself historically and temporally, requiring an accurate and meaningful sense of time. • The ability to generally comprehend the world and oneself, involving knowledge that is situated and contextualized.

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The ability to communicate, both as a listener and as a speaker, which includes many aspects of epistemic agency. • Responsiveness and the ability to care about and be committed to ­persons and things. • Self-care and the ability to be responsible for oneself. • The ability to recognize opportunities (i.e., options for alternative actions). These items are my rewordings of the items on his list (Graham, The Disordered Mind, 147–50). 30 A list of psychological and physiological areas of functioning that can be impaired by mental disorders is easy to find simply by perusing a comprehensive text of psychology. The primary source of the list here comes from the contents pages in Jaspers, General Psychopathology. 31 Parsons, The Social System, 436–7. 32 Some good descriptions of stigma include Courtwright, “Stigmatization and Public Health Ethics”; Hamilton et al., “Discrimination against People with a Mental Health Diagnosis”; Livingston and Boyd, “Correlates and Consequences of Internalized Stigma for People Living with Mental Illness”; Manzo, “On the Sociology and Social Organization of Stigma”; and Rusch, Angermeyer, and Corrigan, “Mental Illness Stigma,” 529–39. 33 Corrigan and Kleinlein, “The Impact of Mental Illness Stigma,” 16–17; and Wahl, “Stigma as a Barrier to Recovery from Mental Illness.” 34 Hinshaw, The Mark of Shame, 143–4. 35 Studies cited in Rusch, Angermeyer, and Corrigan, “Mental Illness Stigma,” 530. See also Wahl, “Stigma as a Barrier to Recovery from Mental Illness,” 9–10. 36 Angell, Cooke, and Kovac, “First-Person Accounts of Stigma”; and Dinos et al., “Stigma.” 37 Hinshaw, The Mark of Shame, 155–6. 38 Whitley and Campbell, “Stigma, Agency and Recovery amongst People with Severe Mental Illness.” 39 Crowe, Averett, and Glass, “Mental Illness Stigma, Psychological Resilience, and Help Seeking.” 40 Cruwys and Gunaseelan, “‘Depression is Who I Am.’” 41 Corrigan and Kleinlein, “The Impact of Mental Illness Stigma,” 13–14. 42 Ibid. 43 J.R. Nelson, “Bioethics and the Marginalization of Mental Illness,” 191. 44 Luhrmann, Of Two Minds, 270. 45 Kendall, “Foreword,” xxi.

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46 Christopher Hookway gives many examples of relevant epistemic activities, including recognizing what is relevant to inquiry, asking questions, brainstorming ideas, considering alternative possibilities, making suggestions or assertions, offering counter-examples, treating arguments as valid or invalid, trusting judgments of plausibility and reasonableness, formulating new ideas, and revising them in response to experience (Hookway, “Some Varieties of Epistemic Injustice”). 47 Lear, Radical Hope, 119–23. Lear argues that we human beings are ontologically vulnerable by virtue of the fact that our desire to know and act in the world exceeds our capabilities. He describes the human condition as one of vulnerability and risk-taking, adopting a Platonic view of human beings as finite and erotic. We are finite in the sense that we are limited in a variety of ways, including epistemologically, metaphysically, and ethically. We are erotic in the sense that we aim at ends through our action, and we make choices based on our desire for goods. Being inherently ­limited even as we must “reach out” to the world makes us essentially ­vulnerable; the necessary limitations and constraints we face in simply ­living as human beings create inherent risk with all of our actions and pursuits. Lear says: As finite erotic creatures it is an essential part of our nature that we take risks just by being in the world. As finite creatures we are vulnerable: we may suffer physical and emotional injury, we may make significant mistakes, even the concepts with which we understand ourselves and the world may collapse – and yet as erotic creatures we reach out to the world and try to embrace it. For all the risks involved, we make an effort to live with others; on occasion we aspire to intimacy; we try to understand the world; we aim toward living (what we take to be) a happy life. As finite, erotic creatures it is a necessary aspect of our existence that our lives are marked by risk. We are familiar with the idea that we are creatures who necessarily inhabit a world. But a world is not merely the environment in which we move about; it is that over which we lack omnipotent control, that about which we may be mistaken in significant ways, that which may intrude upon us, that which may outstrip the concepts with which we seek to understand it. Thus living within a world has inherent and unavoidable risk. (120, italics original)   One risk we live with as humans – whose consciousness, rationality, and free will and action characteristically distinguish us from other animals – is the potential loss of these characteristics. Such a loss would change our conception of ourselves as humans. We are ontologically vulnerable to conditions like mental illness, which pose threats to our identity as humans.

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48 Fricker calls this “identity-prejudicial credibility deficit” (Fricker, Epistemic Injustice, 17–29). 49 Kristie Dotson calls this sort of self-censoring that occurs when a person believes they will not be believed or taken seriously “smothering” (Dotson, “Tracking Epistemic Violence, Tracking Practices of Silencing”).   Christopher Hookway gives the following example of how certain groups of people can be excluded from philosophical discourse due to identity-prejudicial credibility deficit: The shy and retiring can find it hard to contribute to such discussion; as can those belonging to groups that are associated with stereotypes that lead hearers who doubt that their contributions can be trusted. Their perceived failure to make a contribution can lead to the widely held expectation that they have nothing to offer. If success in participating in such activities is perceived as a mark of success as a philosopher, and if someone is perceived, perhaps due to stereotypes of shy (or female) behaviour in such debates, then prejudice can lead to someone being perceived as a poor performer at the activities that are supposed to be definitive of her identity. This example demonstrates the way that stigma not only reduces epistemic credibility in the eyes of others, affecting an individual’s self-perception and self-assessment, but also creates an actual loss of epistemic agency by creating real constraints that limit the person’s ability to participate in epistemic practices. In other words, stigma does not just cause problems in how a person is perceived, but also poses problems regarding what options for action are actually available to the person (Hookway, “Some Varieties of Epistemic Injustice,” 159). 50 Alcoff, “Epistemic Identities,” 134. 51 Corrigan and Kleinlein, “The Impact of Mental Illness Stigma,” 24–5. 52 Heather Stuart summarizes the results of several surveys as indicating that people with mental illness are three to five times more likely to be unemployed than the general population, and that 61 per cent of adults with mental health disabilities are excluded from the labour force compared to 20 per cent of the general population. While employment rates vary for different mental disorders, the employment rate for people with the most severe mental illnesses, such as schizophrenia, is 80–90 per cent (Stuart, “Mental Illness and Employment Discrimination,” 523). 53 Stuart, “Mental Illness and Employment Discrimination,” 522–6; and Thornicroft, Shunned, 50–8. According to Stephen Hinshaw, “Each year in the United States between 5 million and 6 million individuals with mental disorders lose, fail to seek, or cannot find employment as

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a consequence of their mental illness” (Hinshaw, The Mark of Shame, 124). 54 Hartocollis, “They Sought Help on Campus but Were Sent Home Instead.” 55 Hinshaw, The Mark of Shame, 123. 56 For a history of deinstitutionalization and the processes that led to the current failure of community care, see Powers, No One Cares About Crazy People, 187–204. 57 See note 7 in this chapter. 58 Hinshaw, The Mark of Shame, 130; Thornicroft, Shunned, 14–15; and Wilson, “The Social Impact of Stigmatisation on Users and Carers,” 73–4. 59 A.C. Watson et al. analyze the way stigma operates among police in their article “Stigma and the Police.” 60 Powers, No One Cares About Crazy People, 202. The study Powers ­references is Steinberg, Mills, and Romero, “When Did Prisons Become Acceptable Mental Health Care Facilities?” 61 James and Glaze, “Mental Health Problems of Prison and Jail Inmates.” While these statistics are over a decade old, incarceration rates have only increased over time, so it is fair to assume that rates of incarcerated people who have serious mental illness have increased as well. See also note 7 in the introduction of this book. 62 In his book Crazy, journalist Pete Earley chronicles many of the problems people face in the criminal justice system, focusing in particular on the ­system in Miami-Dade County. Through shadowing and interviewing, he finds that people with mental illness are routinely discounted and ignored; exploited by the legal system; abused and ridiculed by police officers and prison guards; mistreated by medical professionals, even well-meaning psychiatrists who do not have enough time to give them adequate medical treatment; and oppressed through a system that treats them as objects, as less than human, and yet demands they stand trial as competent agents (Earley, Crazy: A Father’s Search Through America’s Mental Health Madness). 63 Hinshaw, The Mark of Shame, 124–5. 64 Thornicroft, Shunned, 87–99. 65 See discussions in Thornicroft, Shunned, 93; and in the remarkable anthology Every Family in the Land, edited by Crisp, which includes numerous articles that detail stigmas, prejudices, and acts of discrimination by ­medical professionals. 66 From Every Family in the Land, see in particular the chapters by Shelley, “An Insight into the World of Anorexia Nervosa, with Particular Reference to the Resulting Stigmatisation and Social Isolation”; Armson,

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“Stigmatisation and Suicide”; and Russell, “The Stigmatisation of Eating Disorders.” See also Hinshaw, The Mark of Shame, 120–3. 67 Corrigan, “The Impact of Stigma on Severe Mental Illness”; Link et al., “The Consequences of Stigma for the Self-Esteem of People with Mental Illnesses”; Livingston and Boyd, “Correlates and Consequences of Internalized Stigma for People Living with Mental Illness”; Thornicroft, Shunned, 151–63; and A.C. Watson et al., “Self-Stigma in People with Mental Illness.” See also Corrigan and Calabrese, “Strategies for Assessing and Diminishing Self-Stigma.” 68 Courtwright, “Justice, Stigma, and the New Epidemiology of Health Disparities”; and Crowe, Averett, and Glass, “Mental Illness Stigma, Psychological Resilience, and Help Seeking.” 69 Public health campaigns, such as anti-obesity and anti-smoking, that function by shaming people who engage in those behaviours are self-defeating because internalized shame results in loss of self-esteem, hope, motivation, advocacy, and empowerment (Abu-Odeh, “Fat Stigma and Public Health”; Courtwright, “Stigmatization and Public Health Efforts”; Dean, “Stigmatization and Denormalization as Public Health Policies”; and Vartanian and Smyth, “Primum Non Nocere”). 70 Thornicroft, Shunned, 35–7. 71 Ibid., 37–9. 72 Ibid., 25–46. 73 Ibid., 27. 74 Markowitz, “Sociological Models of Mental Illness Stigma,” 135. 75 For example, common treatments for mental illness in early mid-twentieth century included the water bath treatment and insulin coma treatment. While there was no evidence that these treatments directly receded ­symptoms, they did subdue people to be more passive and compliant – probably because they were literally in shock and sometimes half braindead (Whitaker, Mad in America, 73–96). 76 See note 7 in the introduction and note 7 in this chapter. 77 Guenther, Solitary Confinement, xx. 78 Ibid., xx–xxi. 79 Jon Elster nicely describes the role of shame in perpetuating and exacerbating addictions and harmful behaviours in general; shame can also worsen mental illness symptoms by increasing anxiety, shutting down, or other responses (Elster, Strong Feelings, 38–9 and 125). 80 Corrigan et al., “Challenging the Public Stigma of Mental Illness”; and Couture and Penn, “Interpersonal Contact and the Stigma of Mental Illness.” Education about mental illness, values self-confrontation, and

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changing media representations of mental illness are all also helpful to reduce stigma. See Byrne, “Stigma of Mental Illness and Ways of Diminishing It”; and Mayville and Penn, “Changing Societal Attitudes toward Persons with Severe Mental Illness.”

C ha p t e r T wo  1 Behrman, Electroboy, 208.   2 Ibid., 256.   3 G. Watson, Agency and Answerability, 91.   4 Ibid., 107.   5 Ibid., 92.   6 Ibid., 108.   7 Ibid., 107.   8 Elster, Strong Feelings, 141.   9 Ibid., 141–5. 10 Ibid., 143 and 145. 11 G. Watson, Agency and Answerability, 91. 12 Likewise, the relationship between action and character goes in both directions: through our action we develop our character, and from our character we choose how to act. In acting in the ways that we do, we become a certain type of person and develop certain virtues and vices through these actions. For example, if I repeatedly take risks in situations where something substantive is at stake and I have a realistic understanding of the possible outcomes and options for action, then I develop the ­virtue of courage and my character is, among other things, courageous. If I am a courageous person then I will have a tendency to act in courageous ways. Aristotle discusses the way that we develop virtue through habituation and how it is up to us what kind of person we are in Book II, chapters 1 and 5 in Aristotle, Nicomachean Ethics, 26–7 and 51–4. 13 For example, Sartre, Existentialism and Human Emotions, 17–33. 14 G. Watson, Agency and Answerability, 25. 15 Ibid., 103. 16 Ibid., 107. 17 Lear, Radical Hope, 85. 18 G. Watson, Agency and Answerability, 107. 19 Ibid., 108. 20 Ibid. 21 What primarily distinguishes the two cases is the process by which the limiting of reasons for action occurs, and whether that process involves

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rational deliberation or not. Because rational deliberation must occur within in the context of one’s values, and in relation to social norms, ­however, this also has a substantive aspect. A person’s deliberation about their action is only rational if the values they reference cohere with social norms about what constitutes a “choiceworthy” life. If a person deliberates about action that they feel reflects their values, but those values are seen as socially reprehensible (for example intense hatred of specific groups of people), they are not judged as acting out of volitional necessity, because their deliberation about their actions is not fully rational. 22 Anonymous, “An Autobiography of a Schizophrenic Experience,” 108. 23 Jaspers, General Psychopathology, 93–108. 24 For a summary of these two views, see Radden, On Delusion. 25 Murphy, “Delusions, Modern Epistemology and Irrational Belief.” 26 Gold and Hohwy, “Rationality and Schizophrenic Delusion”; and Langdon and Coltheart, “The Cognitive Neuropsychology of Delusions.” 27 Hohwy and Rosenberg, “Unusual Experiences, Reality Testing and Delusions of Alien Control,” 147. 28 Jakob Hohwy and Raben Rosenberg analyze the delusion that an alien is controlling one’s movement in their article “Unusual Experiences, Reality Testing and Delusions of Alien Control.” Similar analyses have also been done with related delusions such as thought insertion (Campbell, “Schizophrenia, the Space of Reasons, and Thinking as a Motor Process”; Frith, The Cognitive Neuropsychology of Schizophrenia; and Gold and Hohwy, “Rationality and Schizophrenic Delusion”). See also the discussion in Maes and Van Gool, “Misattribution of Agency in Schizophrenia.” 29 Saks, The Center Cannot Hold, 29. 30 Bentall, Madness Explained; Garrett and Silva, “Auditory Hallucinations, Source Monitoring, and the Belief That ‘Voices’ Are Real”; and Gawęda et al., “Impaired Action Self-Monitoring and Cognitive Confidence among Ultra-High Risk for Psychosis and First-Episode Psychosis Patients.” 31 People with mental illness sometimes describe their subjective experience as “more real than reality.” Beavan, “Towards a Definition of ‘Hearing Voices’”; Cockshutt, “Choices for Voices”; and Karlsson, “‘More Real than Reality.’” 32 Saks, The Center Cannot Hold, 84 (italics original). 33 Jaspers, General Psychopathology, 93–4. 34 Ibid., 95–6. 35 Ibid., 98. 36 Ibid.

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37 Jaspers says, “The content in these cases is perhaps accidental; it is ­certainly not meant literally and is quite differently experienced from ­similar content in the case of a person whom we can fully understand” (Jaspers, General Psychopathology, 99).   For more discussion on this understanding of delusion as delusional atmosphere, and how it differs from the doxastic view of delusion, see Parnas, “Belief and Pathology of Self-Awareness”; Schlimme, “Paranoid Atmospheres”; and Troube, “Understanding Schizophrenic Delusion.” While these texts identify delusional atmosphere specifically with schizophrenia, the same or a closely related phenomenon arguably occurs in some cases of manic psychosis. 38 See description in Troube, “Understanding Schizophrenic Delusion,” 235. 39 Custance, “Wisdom, Madness and Folly,” 266. 40 Morgan, Mind Without a Home, 31–2. 41 Schiller and Bennett, The Quiet Room, 132. 42 Healy, “Diary’s Pages May Help Jurors Decide if Theater Gunman Was Methodical or Mad.” 43 There is much newspaper coverage of the mass shooting, of Holmes himself, and of Holmes’s trial. See, for instance, Goode et al., “Before Gunfire, Hints of ‘Bad News’”; Healy, “Gunman’s Life Crumbled Before Carnage at Theater, A Colorado Jury is Told”; Ingold and Steffen, “Mind State Still Key”; and Steffen and Nussbaum, “Doctor Found Severe Illness.” 44 Saks, The Center Cannot Hold, 12–13. 45 Lauveng, A Road Back from Schizophrenia, 101. 46 Wagner and Spiro, Divided Minds, 195. 47 Philip Pettit and Michael Smith state, “To believe that a certain proposition – a certain potential belief content – is true or is supported by the ­evidence or is entailed by something that is itself accepted is to believe, in effect, that it is right to believe the proposition, wrong to disbelieve it: it is to believe that there are norms that require the attitude, at least when other things are equal” (Pettit and Smith, “Freedom in Belief and Desire,” 393, emphasis mine). 48 Ibid., 388–407. 49 MacIntyre, “Social Structures and Their Threats to Moral Agency,” 317. 50 Scholten, “Schizophrenia and Moral Responsibility,” 205–25. 51 Moore, Hope, and Fulford, “Mild Mania and Well-Being,” 167. 52 Ibid. 53 Ibid. 54 I am indebted to Gary Watson’s discussion of the ways that addiction and other compulsions create rational impairments by crowding out other

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potential objects of value, thereby creating volitional impairments (G. Watson, Agency and Answerability, 71–2 and 81–3). Other discussions of the relationship between rational and volitional impairments include Morse, “Hooked on Hype”; and Waal and Morland, “Addiction as Impeded Rationality.” 55 DeLancey, “Basic Moods,” 528–9; Mendelovici, “Intentionalism about Moods”; and Rosfort and Stanghellini, “The Person in Between Moods and Affects,” 260. 56 Much of what I say here about emotion also applies to other feelings, including visceral factors. See George Loewenstein’s discussion of visceral factors in his essay on their relationship to addiction (Loewenstein, “A Visceral Account of Addiction,” 235–42). 57 Sizer, “What Feelings Can’t Do,” 110. 58 These characteristics of emotions come from Elster, Strong Feelings, 25–41. Laura Sizer discusses some of these characteristics in relation to feelings more generally (Sizer, “What Feelings Can’t Do,” 108–35). 59 Evans, “The Search Hypothesis of Emotion.” Michelle Maiese calls this epistemic function of emotion “affective framing” (Maiese, “Moral Cognition, Affect, and Psychopathy”). 60 Brady, “Emotions, Perceptions, and Reasons,” 135; and Tappolet, “Values and Emotions,” 120. 61 Betzler, “Expressive Actions,” 272–92. 62 Searle, Mind, 97. 63 Wong, “Towards a Theory of Mood Function.” 64 Wong, “The Mood-Emotion Loop,” 3062–3; and DeLancey, “Basic Moods.” 65 DeLancey, “Basic Moods,” 530. 66 See summaries of the relevant literature in Sizer, “What Feelings Can’t Do,” 129; and Wong, “The Mood-Emotion Loop,” 3064. 67 Studies have been performed to assess whether mood affects moral reasoning and decision-making. While studies have conflicting outcomes, the cognitive biases caused by mood indicate global effects on cognitive ­processing and decision-making that surely affect moral reasoning and decision-making in particular. For discussion, see Barger and Derryberry, “Do Negative Mood States Impact Moral Reasoning?”; and Guzak, “Affect in Ethical Decision Making.” 68 Molewijk, Kleinlugtenbelt, and Widdershoven, “The Role of Emotions in Moral Case Deliberation,” 386. 69 Plato provides some of the metaphors we use here. For example, he depicts reason as “light” and “blindness” as the state of lacking reason (Republic 518b-c). His chariot metaphor of the spirit being driven by

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reason and appetite helps us understand the ways that emotions, desires, and other affective states can pull the will in certain ways, especially when the pull of these is significantly stronger than the pull of reason (Phaedrus 246a-b). Plato’s colourful and visual way of depicting the mechanisms of reason, desire, will, and emotion remain helpful ways to understand these mechanisms even over two thousand years later (Plato, “Phaedrus,” 197). 70 Goldie, “Imagination and the Distorting Power of Emotion,” 127–28. 71 Greenspan, “Craving the Right.” 72 Elster, Strong Feelings, 20–5. 73 Ibid., 40–1. 74 In his phenomenological study of depression, Matthew Ratcliffe describes depression as an experience, in part, of lacking will in the world, an experience of diminished agency involving a loss of a fundamental project, a loss of enticing possibilities, a loss of practical significance from experience, or an all-consuming feeling of passivity. These forms of diminished agency emerge from a loss of the experience of freedom that is connected to bodily phenomenology as well as a sense of meaning in one’s choices and actions. The heaviness of depression changes the bodily phenomenology and the cognitive dulling of depression changes the meaning structure, both resulting in a loss of the experience of freedom (Ratcliffe, Experiences of Depression, 155–73).   Gary Watson describes the inability to will oneself to act, specifically as it relates to depression, as “volitional disability” (Watson, Agency and Answerability, 90–100). 75 See discussion in Jamison, Exuberance, 118–28. 76 Neuroscientists describe this phenomenon when it occurs in drug addiction as activating the central reward pathway. Because the high of manic pursuit can feel like a cocaine or amphetamine high, I assume that the central reward pathway is activated similarly in mania. 77 Elster, Strong Feelings, 155. 78 Maclaren, “Emotional Metamorphoses.” 79 Jaggar, “Love and Knowledge,” 168. 80 Weiland with Warren, Fall to Pieces. Quotes are on pages 241, 242, and 245 successively. 81 Cheney, Manic, 149. 82 Brooks, “A Season in Hell,” 84. 83 Elster, Strong Feelings, 64. 84 Ibid., 174–5. In a strange twist, people who smoke have a more accurate understanding of the risks of smoking. Because of the success of antismoking campaigns, almost all people believe the risk of getting lung

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cancer to be much higher than it is, but smokers discount risk due to selfserving biases, resulting in a more accurate perception (though based on incorrect reasoning). 85 Snyder, with Gur and Andrews, Me, Myself, and Them, 82. 86 Schiller and Bennett, The Quiet Room, 107. 87 Elster, Strong Emotions, 139 and 170–1. 88 George Ainslie explains addiction as primarily a problem of temporal preference, as the result of rational choice governed by preference for immediate interests and diminishment of the value of long-term interests. Philosophers disagree about whether this constitutes “rational” choice. Ainslie regards addiction as a product of rational choice, employing a model of rationality as sensitivity to rewards. At any given moment, the addict makes a choice based on weighing the expected rewards/outcomes of alternate options. Gideon Yaffee, on the other hand, argues that hyperbolic discounting is irrational, because the consistent discounting of the future precludes the ability to assess reasons for action at different time slices (versus only the present) (Ainslie, “A Research-Based Theory of Addictive Motivation”; and Yaffee, “Recent Work on Addiction and Responsible Agency”). See discussion in Elster, Strong Feelings, 170–2. 89 Jon Elster points out that drug use – and presumably other self-harming behaviour – also serves to obviate the awareness that how one acts contributes to one’s suffering, such as using drugs in a way that perpetuates addiction and the harms arising from addiction (Elster, Strong Feelings, 125).

c h a p t e r t h re e  1 Wagner and Spiro, Divided Minds, 105–6.   2 McLean, Recovered, Not Cured, 64.   3 Lauveng, A Road Back from Schizophrenia.   4 Salice and Henriksen, “The Disrupted ‘We.’”   5 Philosophical and scientific literature on stigma recognizes this link between the internalization of stigma and deflated self-esteem. The stigma that mental illness is something to fear, coupled with the belief that mental illness is outside of a person’s control (e.g., its presence, manifestation, or course is determined by biological factors), easily leads to self-defeating attitudes as well as social withdrawal and low treatment adherence. Link, et al., “The Consequences of Stigma for the Self-Esteem of People with Mental Illnesses,” 1621–6; Livingston and Boyd, “Correlates and Consequences of Internalized Stigma for People Living with Mental

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Illness,” 2150–61; Thornicroft, Shunned, 151–63; and A.C. Watson et al., “Self-Stigma in People with Mental Illness,” 1,312–18. See also Corrigan and Calabrese, “Strategies for Assessing and Diminishing Self-Stigma,” 239–56.   6 Graham Thornicroft discusses many problems that people with mental ­illness face in their relationships with others. It is worth noting that people who have schizophrenia have marriage rates of less than 20 per cent in many countries, and one large-scale study demonstrated that prior mental illness in one partner substantially increases the risk of divorce (Thornicroft, Shunned, 25–46; the studies are discussed on pages 35 and 37).   7 For illustration of the way long-term hospitalization promotes solipsism and self-absorption that impedes the ability to interact meaningfully with others outside the closed environment of the hospital, see the detailed account by Mindy Lewis of her own experience and the discussion by Arnhild Lauveng of the effects of institutionalization on her development (Lewis, Life Inside; and Lauveng, A Road Back from Schizophrenia).   As a side note, from personal observation during my experience being hospitalized for psychotic depression, it seems to me that even short-term hospitalization (one week, for example) can promote a harmful solipsism and self-absorption that impacts people’s ability to interact meaningfully and appropriately with others.   8 In describing self-absorption as an epistemic vice, I am making a descriptive statement of what people who are self-absorbed are like as knowers, not a normative judgment about the blameworthiness of their character. As Roger Crisp points out, “vice” can describe states of pity as much as blameworthiness; it is the badness of the state that fixes the vice rather than the nature of control a person had over attaining that state. I am using the term “vice,” therefore, to describe a character state that is undesirable, or, more pointedly, an epistemic orientation that hinders (rather than helps) a knower in their pursuit of knowledge and understanding. This hindrance is bad regardless of whether a person had control over it, and it is the badness of the hindrance that makes the character state a vice (R. Crisp, “Virtue Ethics and Virtue Epistemology,” 32).   9 Sullivan, Living Across and Through Skins, 13. For detail of Sullivan’s account of knowledge as transactional, see pages 133–56. 10 While Shannon Sullivan analyzes the transactional nature of bodies and their relation to agency, I do not focus on the relevance of bodies here. This is not because they are not relevant – they clearly are, as minds, ­mental impairments, and mental illness experience are deeply entwined with embodied experience. My concern in this book, however, is on the

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more analytical philosophy concerns of agency and responsibility, and their relationship to stigma and social interactions, rather than the more phenomenological concerns of the ways in which these are felt and embodied. 11 Henderson, “Testimonial Beliefs and Epistemic Competence.” 12 See Koenig and Harris, “The Basis of Epistemic Trust.” 13 My understanding of intelligible action borrows heavily from the account given by Alasdair MacIntyre in his book After Virtue, 200–25. 14 I draw heavily on Peg O’Connor’s work in Wittgensteinian philosophy here, which her two books lay out in great detail and connect this approach with feminist and social philosophy in extraordinarily helpful ways (O’Connor, Morality and Our Complicated Form of Life; O’Connor, Oppression and Responsibility). 15 See Alasdair MacIntyre’s discussion of intelligible action as the ability to give an account (MacIntyre After Virtue, 200–25).   There is a prolific literature on narrative ethics. Some books that describe narrative as a way of imposing order on chaotic experience, ­particularly experiences of illness, include Brodie, Stories of Sickness; Frank, The Wounded Storyteller; and Nelson, Damaged Identities, Narrative Repair.   While narrative ethicists often explain narrative as a way to impose order on externally chaotic experiences (for example, experiences that fail to fit the expected story arc), they rarely explain what role it can and does play in attempting to make sense of experiences that are internally “­chaotic” (read: essentially strange or unintelligible). The role narrative can play in trying to put into words and greater context of meaning ­experience that ultimately defies articulation and shared meaning is ­underexplored in narrative theory. 16 Pohlhaus, “Relational Knowing and Epistemic Injustice,” 718. 17 Keller, “Autonomy, Relationality, and Feminist Ethics,” 157–8. 18 McGeer, “The Moral Development of First-Person Authority.” Some ­philosophers write as if assertion of one’s first-person authority is itself authoritative regarding the experience that is the object of the assertion, but this claim is problematic in the context of mental impairments that impede self-understanding, intelligibility, and shared meaning. For ­example, see Parrott, “Expressing First-Person Authority.” 19 Drawing from feminist epistemologist Sandra Harding, Shannon Sullivan describes this function of seeing ourselves from the standpoint of others as “background-revealing,” enabling a certain kind of objectivity. Sullivan observes, “Becoming objective requires the ability to see the background

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Notes to pages 124–9

beliefs that inform one’s position, beliefs that are so familiar to, and thus hidden from, oneself that it takes another to help one identify them.” People are not “self-transparent” and so “they need the perspectives of others to root out the biases that exist in their world views” (Sullivan, Living Across and Through Skins, 135). See also Peg O’Connor’s discussion of backgrounds in her book Oppression and Responsibility, 1–14. 20 Meyers, “Commentary on Entangled Empathy by Lori Gruen.” 21 Barrett Emerick describes this form of empathy as an other-oriented ­imaginative process that must occur dialogically rather than monologically. He emphasizes the experiential knowledge that empathy provides, but it is important to note also the valuable self-knowledge that emerges from empathetic perspective-taking (Emerick, “Empathy and a Life of Moral Endeavor”). 22 Hardwig, “The Role of Trust in Knowledge.” 23 Bernstein, “Trust.” 24 McCraw, “The Nature of Epistemic Trust.” 25 Ibid., 416–17. See also Belli and Broncano, “Trust as a Meta-Emotion.” 26 Tobin, “The Relevance of Trust for Moral Justification.” 27 Shieber, “Against Credibility.” 28 Goldberg, “Self-Trust and Extended Trust.” 29 McLean, Recovered, Not Cured, 69. 30 Henderson, “Testimonial Beliefs and Epistemic Competence,” 207. 31 This monitoring involves, in part, checking the reasons that others have for holding the views that they do, and ensuring that they meet criteria for warranted belief. It is fine for our default position to be that we accept other people’s testimony as true unless we have reasons to believe otherwise, but we had better investigate any such potential reasons (Henderson, “Testimonial Beliefs and Epistemic Competence,” 197–207). 32 Simone Belli and Fernando Broncano discuss the temporal aspect of trust as a meta-emotion that arises from a relationship, which develops over time (Belli and Broncano, “Trust as a Meta-Emotion,” 435). 33 John Martin Fischer and Mark Ravizza, S.J., argue that moderate reasonsresponsiveness is necessary for moral responsibility. They define moderate reasons-responsiveness as being strongly receptive to reasons, able to ­recognize reasons as sufficient for action, and weakly reactive to reasons, showing an understandable pattern of making choices based on sufficient reasons and then acting from those choices (Fischer and Ravizza, Responsibility and Control, 41–6 and 69–76). See also McKenna, “Assessing Reasons-Responsive Compatibilism.”

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Notes to pages 129–37

261

34 This is analogous to how we learn to be virtuous, according to Aristotle: by observing what virtuous people do, modelling our behaviour after theirs, and practising virtuous behaviour continuously (Aristotle, Nicomachean Ethics, book 2, chapter 1, 26–7). 35 Tiboris, “Blaming the Kids.” 36 Zimmerman, “Thinking with Your Hypothalamus.” 37 Jon Elster describes many cognitive functions of emotions in his extra­ ordinary account of the intersection of emotion, rationality, beliefs, and­ ­culture, focusing on the context of addiction (Elster, Strong Feelings). 38 See Damm, “Emotions and Moral Agency”; and Shoemaker, “Moral Address, Moral Responsibility, and the Boundaries of the Moral Community.” 39 Maclaren, “Emotional Metamorphoses,” 39–41. 40 See Gary Watson’s classic essay on the difference between desire and value in relation to their role in moral agency. G. Watson, “Free Agency.” 41 G. Watson, Agency and Answerability, 266. 42 O’Connor, Morality and Our Complicated Form of Life, 129–31; and Walker, Moral Understandings, 114. 43 Alasdair MacIntyre considers integrity, along with constancy, to be the two core virtues that underlie all other virtues. My view of moral integrity here encompasses what he identifies as constancy in its criterion of living consistently and reliably according to one’s values (MacIntyre, “Social Structures and Their Threats to Moral Agency,” 317–18). Margaret Walker also describes moral integrity as “reliable accountability” or “moral ­reliability” (Walker, Moral Understandings, 106 and 115). 44 Rawls, Justice as Fairness, 21–2; and Sandel, Democracy’s Discontent, 5. 45 Howard, Conscience in Moral Life, 12. 46 Meyers, Self, Society, and Personal Choice, 55. 47 Meyers, Being Yourself, 31 and 174–5. Meyers has at least two separate lists in different essays in this book. The lists focus on different frameworks for understanding autonomy, namely self-definition (31) and self-­ narrativity (174–5). The lists are largely overlapping, however, and can be summed up together as encompassing the autonomy competency that Meyers discusses in her earlier book Self, Society, and Personal Choice. 48 Meyers, Self, Society, and Personal Choice, 48. 49 Ibid., 49–51; and Walker, Moral Understandings, 131–52. Charles Larmore gives a nice critique of the concept of a life plan and the role it plays in moral theory (Larmore, The Autonomy of Morality, 246–71). 50 Scholten, “Schizophrenia and Moral Responsibility,” 221–3.

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Notes to pages 137–9

51 There is much discussion of the ways that our interactions with others, the moral communities we are members of, and the various ways that we are socially situated shape our moral identity. See, for instance, Liaschenko and Peter, “Fostering Nurses’ Moral Agency and Moral Identity.” 52 See, for instance, Meyers, Being Yourself, 159–79; and Walker, Moral Understandings, 103–29. 53 Walker, Moral Understandings, 112. 54 Viewing identity as a narrative does not imply that identity is always continuous and integrated. It often is not, especially in the context of mental illness. Bethany Ober Mannon demonstrates this fragmented and discontinuous experience in her analysis of two memoirs of women’s experiences with bipolar disorder (Mannon, “Identity, Bipolar Disorder, and the Problem of Self-Narration in Kay Redfield Jamison’s An Unquiet Mind and Ellen Fornay’s Marbles”). 55 Baylis, “‘I Am Who I Am,’” 518. 56 Mackenzie, “Personal Identity, Narrative Integration, and Embodiment,” 110. 57 Emerick, “Empathy and a Life of Moral Endeavor,” 171–86. 58 T.M. Luhrmann emphasizes the role of emotions, particularly emotions experienced in response to and directed toward others, in how we develop and exercise moral agency: That – the way we imagine people to be, how we imagine ourselves to be with them, how we come to feel deeply that something is right and good and true – is the cornerstone of human relationship, of the strenuous demand to be a certain kind of person in a certain setting. And that involves empathy, because empathy is the name for the local process through which people carry their implicit assumptions of one another as people with hopes and needs that are meaningful and worthy of respect in their community … Our moral instincts rest on a complex foundation in which we have expectations about who we are with, the kind of person we would like to be when we are with them, and the right way to behave throughout … People in a community learn to relate to one another emotionally and to use their emotions to interpret, judge, and shape those relationships as good or bad. And the way we conceive ourselves as and are conceived of as moral agents affects our agency –even when we struggle with schizophrenia [for example] (Luhrmann, Of Two Minds, 282). 59 Sherwin, “Relational Existence and Termination of Lives,” 151. 60 Strauss, “The Role of Recognition in the Formation of SelfUnderstanding,” 47.

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Notes to pages 140–59

263

61 G. Watson, Agency and Answerability, 229–30 and 262–3. 62 Gary Watson says, “The boundaries of moral responsibility are the ­boundaries of intelligent moral address. To regard another as morally responsible is to react to him or her as a moral self” (G. Watson, Agency and Answerability, 258). 63 Ibid., 230–1. 64 Ibid., 263. 65 Ibid., 266. 66 Ibid., 270. 67 Ibid., 262. 68 See note 80 in chapter 1.

C ha p t e r F o u r  1 Deigh, “Reactive Attitudes Revisited”; Dwyer, “Moral Development and Moral Responsibility,” 184; and Tognazzini, “Blameworthiness and the Affective Account of Blame.”   2 Angus Ross describes reactive attitudes as expressive of moral demands; Coleen Macnamara proposes that they are communicative; and Michael McKenna explains their role in the process of moral address and conversation (Ross, “Rationality and the Reactive Attitudes”; Macnamara, “Reactive Attitudes as Communicative Entities”; and McKenna, Conversation and Responsibility.) For criticism, see Glazer, “Can Emotions Communicate?”   3 Ross, “Rationality and the Reactive Attitudes,” 50.   4 McKenna, Conversation and Responsibility, 84.   5 Pettit, Rules, Reasons, and Norms, 266–9.   6 McKenna, Conversation and Responsibility, 77.   7 Ibid., 78.   8 McKenna, “The Limits of Evil and the Role of Moral Address,” 132.   9 Wolf, “Responsibility, Moral and Otherwise,” 140. 10 McKenna, “Assessing Reasons-Responsive Compatibilism,” 101. 11 Fischer and Ravizza, Responsibility and Control, 210–13. See summary and discussion in McKenna, “Assessing Reasons-Responsive Compatibilism,” 101; and Sridharan, “Rational Action and Moral Ownership.” 12 Fischer and Ravizza, Responsibility and Control, 214. 13 McKenna, “Assessing Reasons-Responsive Compatibilism,” 104. 14 There is an abundance of philosophical arguments that moral agency involves in some sense the ability to act on a valuational system that one has adopted through reflection. Some examples appear in Fischer and

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Notes to pages 160–78

Ravizza, Responsibility and Control; McKenna, Conversation and Responsibility; G. Watson, Agency and Answerability; and Wolf, “Sanity and the Metaphysics of Responsibility.” 15 Luoma, Hayes, and Walser, Learning act , 27. For more on act and r ft see Hayes, Strosahl, and Wilson, Acceptance and Commitment Therapy; and Törneke, Learning rft . 16 Arber and Gallagher, “Generosity and the Moral Imagination in the Practice of Teamwork,” 781. 17 Kelly, “Doing without Desert.” 18 Ibid., 188. 19 Ibid., 194. 20 Allais, “Dissolving Reactive Attitudes”; and Hamilton, “‘Hate the Sin but Not the Sinner.’” 21 Allais, “Dissolving Reactive Attitudes,” 17. 22 See, for example, Ross, “Rationality and the Reactive Attitudes”; Tognazzini, “Blameworthiness and the Affective Account of Blame”; and Shabo, “Incompatibilism and Personal Relationships.” 23 Pickard, “Responsibility without Blame.” 24 Ibid., 218–19. 25 D. Goldman, “Modifications of the Reactive Attitudes.” 26 Ibid., 3. 27 Kelly, “Doing without Desert,” 198. 28 Elster, Strong Feelings, 141–5. 29 Shabo, “Incompatibilism and Personal Relationships”; “Where Love and Resentment Meet.” 30 Leite, “Second-Personal Desire.” 31 Adler, “Constrained Belief and the Reactive Attitudes.” 32 Wardrope, “Medicalization and Epistemic Injustice,” 350; Ho, “Trusting Experts and Epistemic Humility in Disability,” 117. 33 A critic might argue that such an assumption treats crime as a symptom of, and evidence for, mental illness, rather than as a separate phenomenon. I am not worried about reducing violent crime to mental illness and other conditions that unduly influence rational choice, as I do think crime is generally a systemic effect of certain social problems, including mental illness. 34 For example, see Boss, “Throwing Pearls to the Swine”; Potter, “Is Refusing to Forgive a Vice”; Quinn, “On the Virtue of Not Forgiving.” 35 See distillation of the literature in Cantens, “Why Forgive? A Christian Response,” 218. 36 Shackle, “Psychiatric Diagnosis as an Ethical Problem,” 133.

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Notes to pages 187–9

265

C ha p t e r f i ve   1 See Baehr, The Inquiring Mind, 148–54; Kwong, “Epistemic Injustice and Open-Mindedness”; Spiegel, “Open-Mindedness and Intellectual Humility.” The truth-conducive nature of open-mindedness is also ­discussed in Waring, The Healing Virtues, 36–7.   2 Open-mindedness is not merely concerned with doxastic contexts; it is a willingness to change not only one’s belief (to correct for error) but also one’s action (to respond more appropriately based on deeper knowledge). Moreover, open-mindedness is more than just a willingness to transcend one’s usual way of thinking; it involves actively seeking out different ways of thinking by engaging people in conversation and by reading about their firstperson experience through memoir. Catherine Elgin distinguishes “knowledge,” which includes facts and information, from “understanding,” which is more comprehensive and relational. While in some contexts the goal of being open-minded is to seek truth, in other contexts the goal is to deepen understanding. Open-mindedness, therefore, can involve correcting for error in order to gain truth, but it can also involve deepening understanding by including more perspectives. Elgin, Considered Judgment, 123.   3 Listeners should also be open to hearing a variety of perspectives that individuals with mental illness may have regarding their illness and symptoms. Not everyone feels impaired by cognitive limitations caused by their illness (e.g., disorganized thinking). A symptom may be experienced as a harm, a benefit, neither, or both. A person may be distressed by or frightened of their cognitive impairments, or they may welcome them or feel apathetic toward them. The person may or may not recognize that they have certain symptoms. Listeners should be open to understanding individuals’ own perspectives.   4 Gendler, “On the Epistemic Costs of Implicit Bias”; Holroyd, Scaife, and Stafford, “What Is Implicit Bias?”   5 Implicit bias can even affect how we hear the sounds in utterances. Because of stereotypes we hold of African-American men being dangerous and violent, we might interpret an African-American man’s utterance as, “I have a gun,” when in fact he said, “I want some gum.” Prejudice and implicit bias go even deeper than we might think they do. Peet, “Epistemic Injustice in Utterance Interpretation.”   6 Holroyd, Scaife, and Stafford, “What Is Implicit Bias?” 4.   7 Holroyd, “Responsibility for Implicit Bias.”   8 For example, Neil Levy argues that we are not responsible for mental states like implicit biases when we are not aware of them, because without

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Notes to pages 189–99

our awareness they cannot express who we are; Michael Brownstein argues oppositely that implicit biases do reflect who we are because they emanate from our dispositions and from what we care about, and thus we are responsible for them. Brownstein, “Attributionism and Moral Responsibility for Implicit Bias”; Levy, “Consciousness, Implicit Attitudes and Moral Responsibility”; Levy, “Expressing Who We Are.”   9 Jennifer Saul believes that because we did not have control over developing our implicit biases, we cannot be responsible for having developed them; whereas, Jules Holroyd notes that we are capable of having indirect control over our beliefs, since we can control how we interpret and weigh the evidence our beliefs are based on, and we can make commitments to reject prejudicial beliefs. Saul, “Implicit Bias, Stereotype Threat, and Women in Philosophy”; Holroyd, “Responsibility for Implicit Bias.” 10 Holroyd, Scaife, and Stafford, “Responsibility for Implicit Bias”; Riggs, “Culpability for Epistemic Injustice.” 11 Anderson, “Epistemic Justice as a Virtue of Social Institutions,” 170. 12 Medina, The Epistemology of Resistance, 114. 13 McLean, Recovered, Not Cured, 36. 14 James Montmarquet discusses the virtue of epistemic conscientiousness as trying one’s best to attain truth and avoid error. Montmarquet, Epistemic Virtue and Doxastic Responsibility, 21. See also Zagzebski, Virtues of the Mind, 174–5. 15 Pettit and Smith, “Freedom in Belief and Desire,” 388–407. 16 Fischer and Ravizza, Responsibility and Control, 41–6 and 69–76; see also McKenna, “Assessing Reasons-Responsive Compatibilism,” 89–124. 17 Hutton, Morrison, and Taylor, “Brief Cognitive Behavioural Therapy for Hallucinations”; Kinderman and Bentall, “The Functions of Delusional Beliefs,” 279; Morrison, “Should People with Psychosis be Supported in Choosing Cognitive Therapy as an Alternative to Antipsychotic Medication.” 18 For more on how acceptance and commitment therapy can be used in treating people who experience psychosis, see Morris, Johns, and Oliver, eds., Acceptance and Commitment Therapy and Mindfulness for Psychosis. 19 Davidson, Living Outside Mental Illness, 119. 20 Ibid., 121–5. 21 Ibid., 122. 22 Lugones, “Playfulness, ‘World’-Travelling, and Loving Perception.” 23 Nyholm, “Reason with Me,” 323–4. 24 Charity has a different meaning in a moral context and is typically identified with compassion or sympathy. For example, Loren Lomasky states,

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Notes to pages 201–2

267

“The disposition to be moved by and respond to distress is the virtue of charity.” What underlies both the moral and epistemic conceptions is the idea of thinking the best of someone or doing the best by them. Lomasky, “Justice to Charity,” 32 (italics original). See also Lichtenberg, “What is Charity?” 25 Andre, Worldly Virtue, 68–9. 26 For example, see discussions in Boleyn-Fitzgerald, “Care and the Problem of Pity”; Gelhaus, “The Desired Moral Attitude of the Physician: (III) Care”; Miller, “Empathy as the Only Hope for the Virtue of Compassion and as Support for a Limited Unity of the Virtues”; Simmons, “In Defense of the Moral Significance of Empathy”; Svenaeus, “The Relationship between Empathy and Sympathy in Good Health Care.” 27 R. Crisp, “Compassion and Beyond,” 233. 28 Simmons, “In Defense of the Moral Significance of Empathy,” 108. In response to Martha Nussbaum’s analysis of Aristotle’s view of compassion, some philosophers have discussed compassion as an Aristotelian v­ irtue, concluding that his view (and Nussbaum’s) is too narrow. Carr, “Pity and Compassion as Social Virtues”; Nussbaum, “Compassion”; R. Crisp, “Compassion and Beyond,” 233–46. 29 For lists of definitions of empathy, see Battaly, “Is Empathy a Virtue?”; Coplan, “Understanding Empathy,” 4; Svenaeus, “The Relationship between Empathy and Sympathy in Good Health Care,” 268. 30 Coplan, “Understanding Empathy,” 7–10. For more on the motor mimicry or bodily simulation involved with emotional “matching,” see Currie, “Empathy for Objects”; and A. Goldman, “Two Routes to Empathy.” 31 Peter Goldie calls other-oriented perspective-taking “in-his-shoes imagining” and identifies self-oriented perspective-taking as empathy. He describes empathy as “a process or procedure by which a person centrally imagines the narrative (the thoughts, feelings, and emotions) of another person.” Goldie, The Emotions, 195 (italics original). 32 For more on the potential harm of empathy, particularly self-oriented empathy or emotional contagion, see Goldie, The Emotions, 215; Kaplan, “Empathy and Trauma Culture”; and Prinz, “Is Empathy Necessary for Morality?” 33 Goldie objects to other-oriented perspective-taking because we do not have access to other people’s minds and so cannot give an adequate characterization of their motives such that we can truly take their perspective. Goldie, “Anti-Empathy.” 34 Jackson, “Patronizing Depression.” Jackson notes in the same paper (372), “Empathy does not attempt to feel the same way as the other, but rather

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Notes to pages 203–10

to understand the difference between the experience of oneself and the other. Although there are similarities between myself and the other, our differences matter considerably.” 35 Hooker, “Understanding Empathy”; Stohr, “Minding Others’ Business”; Svenaeus, “Empathy as a Necessary Condition of Phronesis.” 36 Derek Matravers argues that empathy with a person in their situation is more important epistemically than having true beliefs about the person’s situation. Matravers, “Empathy as a Route to Knowledge.” 37 Knipfel, Quitting the Nairobi Trio, 253. 38 Steele and Berman, The Day the Voices Stopped, 177. 39 Jamison, An Unquiet Mind, 145. 40 Goldie, The Emotions, 180 and 214. Fredrik Svenaeus argues that sympathy and empathy are so closely tied together that it does not make conceptual sense to talk about one without talking about the other. Svenaeus, “The Relationship between Empathy and Sympathy in Good Health Care,” 267–7. 41 See Petra Gelhaus’s description of the virtue of compassion for comparison. Gelhaus, “The Desired Moral Attitude of the Physician: (II) Compassion.” 42 McFee, “Empathy,” 190 and 200; Prinz, “Is Empathy Necessary for Morality?” 211. 43 Goldie, The Emotions, 213–15. 44 Saks, The Center Cannot Hold, 321. 45 Boleyn-Fitzgerald, “Care and the Problem of Pity.” 46 This principle of accepting that the world is “perfect,” or that it is as it is and as it should be, comes from a Zen Buddhist approach. Heard and Swales, Changing Behavior in DBT, 17–19; Swenson, DBT Principles in Action, 45–7. 47 Carr, “Pity and Compassion as Social Virtues,” 425–6. 48 Deonna, Rodogno, and Teroni, In Defense of Shame, 27–30; Kostopoulos, “‘People are Strange When You’re a Stranger,’” 306–7; Pattison, Shame, 72; Taylor, Pride, Shame and Guilt, 57–68.   Matthew Rukgaber proposes that shame applies more broadly and is not simply a negative self-judgment but can also arise from actual or ­possible exclusion from social relations that are accepting. Rukgaber, “Philosophical Anthropology, Shame, and Disability.” 49 Pattinson, Shame, 70; Taylor, Pride, Shame and Guilt, 70. 50 Deonna, Rodogno, and Teroni, In Defense of Shame, 31; Dolezal, “The Phenomenology of Shame in the Clinical Encounter,” 570; Taylor, Pride, Shame and Guilt, 67.

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Notes to pages 210–16

269

51 See discussions in Kostopoulos, “‘People are Strange When You’re a Stranger’”; and Taylor, Pride, Shame and Guilt. 52 Pattinson, Shame, 76. 53 Dolezal, “The Phenomenology of Shame in the Clinical Encounter,” 570–1. 54 McCann and Clark, “Embodiment of Severe and Enduring Mental Illness,” 788. 55 Matthews, Dwyer, and Snoek, “Stigma and Self-Stigma in Addiction.” 56 For some recent discussions, see Byerly, “The Values and Varieties of Humility”; Garcia, “Being Unimpressed with Ourselves”; Green, “Disability, Humility, and the Gift of Friendship”; Nadelhoffer et al., “Some Varieties of Humility Worth Wanting”; Sinha, “Modernizing the Virtue of Humility.” 57 Jaskolla, “The Puzzle of Self-Abasement,” 593–4. 58 Kupfer, “The Moral Perspective of Humility,” 252. 59 E. Kelly, “On the Rehabilitation of Virtue.” 60 Gerber, “Standing Humbly Before Nature.” 61 The way that humility is conducive to learning is particularly valued in Chinese culture. See Li, “Humility in Learning”; and Yaohuai, “The Tradition of the Virtue of qian and Its Contemporary Fate.” For the value of humility in the process of learning, see also Hare, “Humility as a Virtue in Teaching.” 62 See summaries of relevant studies in Hill and Sandage, “The Promising but Challenging Case of Humility as a Positive Psychology Virtue,” 138–40; and Li, “Humility in Learning,” 149. 63 Snow, “Humility.” 64 Humility, awe, and reverence are often defined in relation to each other; different philosophers see each as primary. For example, Paul Woodruff defines reverence as “a sense that there is something larger than a human being, accompanied by capacities for awe, respect, and shame.” Woodruff, Reverence, 63. 65 Along these lines, Paul Woodruff says, “Reverence begins in a deep ­understanding of human limitations; from this grows the capacity to be in awe of whatever we believe lies outside our control – God, truth, justice, nature, even death. The capacity for awe, as it grows, brings with it the capacity for respecting fellow human beings, flaws and all.” Paul Woodruff, Reverence, 3. 66 Andre, Worldly Virtue, 117. 67 Ibid., 118. 68 Ibid., 122.

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Notes to pages 216–32

69 Peterson, “Humility in the Deficient.” 70 Generosity of spirit is sometimes identified as magnanimity, one of the ­virtues described by Aristotle, meaning being worthy of great things and being concerned in the right way with honour. Because I am not focusing on the honour aspect of generosity here, I do not use the term magnanimity in my discussion.   Aristotle discussed magnanimity and liberality or the appropriate ­giving of money or objects (also called here material generosity), in the Nicomachean Ethics. For discussion of Aristotle’s views of material ­generosity, or liberality, see Ward, “Generosity and Inequality in Aristotle’s Ethics.” 71 Kupfer, “Generosity of Spirit,” 358–9. 72 Arber and Gallagher, “Generosity and the Moral Imagination in the Practice of Teamwork,” 777. 73 Most of this description of generous-heartedness is from Kupfer, “Generosity of Spirit,” 360–1. See also the description in Arber and Gallagher, “Generosity and the Moral Imagination in the Practice of Teamwork,” 777. 74 Steele and Berman, The Day the Voices Stopped, 146. 75 Arthur Frank discusses this need to recognize the shared social conditions that underlie our different choices and actions in his discussion of physician David Hilfiker’s work. Frank, The Renewal of Generosity, 92–9. 76 Ibid., 92–9 and 116. 77 Ibid., 2. 78 Green, “Disability, Humility, and the Gift of Friendship”; Peterson, “Humility in the Deficient.” 79 Andre, Worldly Virtue, 86. 80 Steele and Berman, The Day the Voices Stopped, 141. 81 Saks, The Center Cannot Hold, 163. 82 Snyder with Gur and Andrews, Me, Myself, and Them, 134. 83 Kupfer, “Generosity of Spirit,” 367. 84 See the description of courage in Lear, Radical Hope, 109–12. 85 Committing to behaviour that makes us uncomfortable and that goes against our beliefs or perceptions is a key component of acceptance and commitment therapy (ACT), which I describe briefly in the section titled “What We Expect of Others When We Respond to Them,” in chapter 4. A C T teaches individuals to experiment with small changes in behaviour that challenge unproductive beliefs and feelings in order to produce the desired outcomes that such beliefs and feelings fail to produce.

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Notes to pages 236–7

271

A C T  acknowledges that acting in ways that challenge beliefs and feelings is uncomfortable. It requires that people persevere with their behavioural changes, despite the discomfort involved, so that new behaviours become more habitual. This can potentially lead to changes in the beliefs and feelings that supported the old behaviours. See Hayes, Strosahl, and Wilson, Acceptance and Commitment Therapy; and Luoma, Hayes, and Walser, Learning ACT .

C onc l us i o n  1 Knipfel, Quitting the Nairobi Trio, 253.   2 In her book Of Two Minds, T.M. Luhrmann shows that stigma occurs in the mental health field when clinicians fear mental illness, seeing it as the dominion of the Other, and want to distance themselves from it. Clinicians who regard mental illness as a condition that anyone could develop under the right circumstances tend not to fear and stigmatize it, at least not to the same extent. Luhrmann, Of Two Minds,” 119–57.

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Index

acceptance and commitment ­therapy (act), 160, 193 action, 29–30; rational action, 59–60. See also bad actions; options for action; reasons for action; unthinkability of action Adler, Jonathan, 172 affect. See emotion affect regulation. See emotional regulation agency, 113–16; impairments to, 56; loss of, 33–4; obstacles to, 113–14, 116–17, 130. See also constraints on agency; epistemic agency; moral agency Alcoff, Linda Martín, 37 alien control (delusion), 69 alienation, 49 alterity, 222, 267–8n34 Andre, Judith, 216 anorexia, 37. See also eating disorder answerability, 141–3 anthropological model of interaction, 194–5 anxiety, 27, 32, 97, 98, 109, 110, 126

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Arber, Anne, 218, 220 asymmetrical approach, 151 atonement, 157–8, 165, 221 attention-deficit/hyperactivity ­disorder (adhd), 19, 20, 27, 83 attributability, 141 autism, 132 autonomy, 135–7; episodic, 136–7; programmatic, 136–7. See also self-determination bad actions, 64, 81, 142, 147, 149–52, 157, 176, 182, 184, 221 bad choices, 57, 64, 88, 178 behavioural change, 151–2, 157–8, 160–1, 176–8, 181, 184–6, 193, 230–2, 235, 270–1n85 Behrman, Andy, 55, 149, 180 beliefs, 20–1, 32, 41, 59, 68–9, 76, 79–81, 84, 90, 96, 120–2, 124–5, 159–61, 172, 179, 187 bipolar disorder, 12, 13, 20, 27, 37, 55. See also depression; mania blame, 18, 19, 35, 64, 94–5, 99, 142, 147, 150, 152, 164–70,

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296 Index 176, 180, 199–200, 220; affective, 165; detached, 165 borderline personality disorder, 132 Brooks, Van Wyck, 93 Buddhism, 173 capacities, 113–14; emotional, 130–2; epistemic, 113, 117–28; moral, 113, 128–34; valuation, 132–5, 139 charity, 41, 148, 151, 163, 173–7, 181, 197, 198–201, 230, 235, 239–40, 266–7n24 Cheney, Terri, 91, 170, 196 choice, 30, 57–60, 136, 141–2, 159–60 cognitive behavioural therapy (cbt), 193 cognitive disorder, 32, 77, 113. See also psychosis; psychotic disorder; schizophrenia cognitive skills, 128–30 commitments, moral, 60–3, 67, 81, 137, 141 community, 49, 117; epistemic, 49, 107–8; moral, 49, 61, 67, 94, 101–2, 104, 107–8, 118–19, 133, 135, 139–40, 143–4, 151, 154–5, 196, 233, 240 compassion, 148, 165, 178, 181, 185–6, 194, 197–8, 200, 212, 227, 230, 235–6, 239 competence: epistemic, 94, 117– 18, 125; normative, 83, 104–5, 128–30 compulsion, 62, 109 conscience, 134–5 conscientiousness: epistemic, 148, 181, 185, 191–7, 266n14

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consciousness, 29–30, 36, 57, 69–70 constraints on agency, 39–44, 56, 65–102, 159, 233–4; direct, 53, 55–105; epistemic, 151; external, 39–44, 105, 106–145; indirect, 53, 105, 106–45; internal, 39, 44, 55–105 control, 17–18, 32, 38, 95–6, 129, 135, 142, 149–50, 175–6, 183. See also free will; volition conversation partner, 80, 154, 158, 191–2 Corrigan, Patrick, 37–8 courage, 221 credibility, epistemic, 35–9, 50, 104, 189 crime, 28, 47, 99 criminal justice system, 42–43, 250n62 Custance, John, 73, 195 Davidson, Larry, 194–5, 205 dehumanization, 19, 28, 31–4, 40, 49–51 deliberative screen, 58–62, 80, 93–4, 100, 179 delusion, 36, 48, 57, 62, 65, 66–76, 78, 80, 117, 120–1, 126, 133, 193, 245–6n24; as attitudinal states, 68, 71; as doxastic states, 68–71 delusional atmosphere. See uncanniness depression, 20, 27, 48, 57, 77, 87, 97–8, 109–10, 126, 143, 188, 235, 256n74. See also bipolar disorder desert, 35, 152, 164, 168–9 desire, 57, 59, 84, 90

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Index 297

Diagnostic and Statistical Manual (dsm), 23, 244–5n21 dialectical behavioural therapy (dbt), 208–9, 234 disappointment, 167–9, 172, 180 discrimination, 28, 39–40, 41, 44–5, 50, 185 disorganized thinking. See thought disorganization dissociative experience, 32 distress, 25, 100. See also suffering drug addiction, 48, 126, 242n1 drug use, 12–13, 15–16, 88 dualistic framework, 161–3, 169 dysfunction, 25 eating disorder, 48, 109, 132. See also anorexia education, 41–2 effects of mental illness symptoms, 66 Elster, Jon, 59, 86–7, 89, 95, 168, 175 emotion, 24, 53, 62, 83–95, 130–2, 262n58; taxonomy of, 86–7. See also mood emotional regulation, 57 empathetic maturity, 163, 218, 206, 220, 225 empathetic understanding, 201 empathic bridges, 194–5 empathy, 124–5, 132, 138–9, 194, 201–9, 221–2, 235–6, 239–40, 262n58 employment, 28, 41, 99, 238, 249n52, 249n53 epistemic agency, 30, 32, 35–40, 50, 67, 94, 113, 117–28 epistemic injustice, 35–9 epistemic limitations, 152, 171–3, 235

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epistemic resources, 104–5, 121–2 equanimity, 208–9, 212, 223 evidential norms, 68, 79, 81, 122, 191 excuses, 153–5 fecundity of generosity, 229 feedback loop, 14, 48, 53, 121 first-person perspective, 162–3, 220 Fischer, John Martin, 158 forgiveness, 175–7, 180, 199–200, 218, 221 forward-looking, 176 Frank, Arthur, 222 free will, 18–19, 29–30, 32, 36, 56, 169, 171. See also control; volition Fricker, Miranda, 35 Fulford, K.W.M., 81–2 functioning, 25–6, 246–7n29 future, acting better in, 164–5, 177–8, 184 Gallagher, Ann, 218, 220 generalized anxiety disorder (gad), 12, 20 generosity, 148, 177–8, 181, 197–8, 215, 217–30, 235, 239– 40; as hospitality (see hospitality); and moral address, 220–2; as reciprocal giving and self-­ giving (see reciprocity); of spirit, 218; as support (see support); as unconditional acceptance, 221–3; of virtue, 229 generous-heartedness, 218–19, 221 generous-mindedness, 218, 225 gentleness, 185, 230 gifts, 216, 217, 219, 224–5. See also also giving

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298 Index giving, 176. See also gifts Goldie, Peter, 202 Goldman, David, 167, 172 graciousness, 177 Guenther, Lisa, 47 hallucinations, 36, 70–5 health insurance, 43 healthcare, 43, 238–9 hermeneutical sensitivity, 190 Holmes, James, 75, 149, 180, 196 homelessness, 15, 42, 47, 190. See also housing honesty, 173–4 hope, 151, 157 Hope, Tony, 81–2 hospitality, 223–6 housing, 28, 42, 99, 238–9, 242n7. See also homelessness humility, 148, 178, 181, 185, 197–8, 211–17, 223, 230, 235, 239–40; epistemic, 151, 173–4, 181, 205, 230; existential, 213; narrow, 213; as reverence (see reverence); as seeing the self properly, 216–17 impairments, 36–7, 53, 57, 116, 120, 240; affective or emotional, 36, 53, 57, 59, 65, 81–95, 116, 127, 128, 233; behavioural, 36; cognitive, 36, 53, 59, 65, 67, 75, 77, 116, 127, 233; communicative, 36; mental, 32–3, 37–9, 62, 130, 142, 147, 149, 212–13; perceptual, 36, 57, 59, 67, 75, 116, 128; rational, 36, 57, 59, 65, 75, 128, 233, 158; social, 36; volitional, 36, 57, 59, 65, 83, 86, 116, 128, 233

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implicit bias, 189, 265n5, 265–6n8, 266n9 inappropriate affect or emotions, 57, 65, 81–95, 131–2 incarceration, 43, 47, 99, 190, 237–8, 241n7 information, 32, 39, 59, 71, 77, 84–6, 90, 92, 96, 113, 151, 171–3 institutionalization, 42, 46–7, 107, 111 intelligent self, 156 intelligibility, 24, 65, 71, 118–20, 129, 153–7, 191–6, 204–6, 233, 235–6, 240; of action, 41, 64, 76, 111; of moral commitments, 63; of reasons, 56, 73, 79–81, 96, 107–8, 134, 155. See also meaning interests, long-term versus shortterm, 97, 99–101 interpersonal contact, 49, 144 Jaggar, Alison, 89 Jamison, Kay Redfield, 205–6 Jaspers, Karl, 71–2 Kelly, Erin, 164, 168, 172 Kendall, Robert, 31 kindness, 175, 177, 185, 230 Kleinlein, Petra, 37–8 Knipfel, Jim, 203–4 Kupfer, Joseph, 218, 229–30 Lauveng, Arnhild, 77, 107 labelling, 29 Lear, Jonathan, 33, 51, 61, 248n47 live options, 65, 131 loneliness, 49

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Index 299

loss, of agency, 33–4; of epistemic credibility, 35–9; of normativity, 79 Lugones, María, 195 Luhrmann, T.M., 31 mania, 55, 67, 73, 77, 81–2, 83, 87, 90, 91, 102, 104, 109, 143, 155. See also bipolar disorder McKenna, Michael, 154 McLean, Richard, 106, 126, 191 meaning, 65, 72–3; breakdown of, 24–5; shared, 78, 117–19, 156– 7, 191, 204–6, 235, 240. See also intelligibility meaning-making, 30, 32 media, 17 mental health professionals, 43–4, 49, 167 mental illness versus mental disorder, 22–26, 58, 246n26, 246n27 mood, 83–85, 255n67. See also emotion mood disorder, 32, 126, 132 Moore, Andrew, 81–2 moral address, 149–81, 191, 197, 199, 220–2, 223 moral agency, 30, 32, 33, 40, 56–64, 79, 94, 104, 113, 139–40, 143–4, 149 moral boundaries, 65, 66–81, 83 moral character, 60–2, 101, 135, 184, 252n12 moral claims, 94, 105, 139–40, 155, 158, 223–4. See also moral demands moral communication, 140 moral demands, 153–5, 169–70, 191–2, 221, 223–4. See also moral claims

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moral identity, 137–9 moral integrity, 63, 94, 96, 134–43, 261n43 moral judgment, 32, 68, 79, 85, 129 moral knowledge, 134–5 moral reasoning, 53, 56, 68, 81–95; without blame, 164–70 moral response, 149–81, 223 moral values, 60–3, 65, 81, 84, 86, 90, 132–4 Morgan, Kristina, 74 Mr M, 81–3, 91, 95, 154–5, 170, 180, 195–6 narrative framework, 116, 118–19, 137–8, 259n15 negligence, 177 Nelson, Janet, 31 normativity, 118–19, 132–4 Nyholm, Sven, 196 objective attitudes, 17, 19, 81, 150, 153, 155, 162–3, 220 obsessions, 83, 109 obsessive-compulsive disorder (ocd), 20, 27, 32 ontological vulnerability, 33, 51, 248n47 open-mindedness, 148, 181, 185, 187–91, 239–40, 265n2 options for action, 58, 60–2, 64, 81–95, 131 other-oriented perspective-taking, 201–6, 239, 260n21, 267n31, 267n33 outlaw emotions, 89 paranoia, 36, 65, 67, 73, 117, 126, 128, 133, 217

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300 Index Parsons, Talcott, 26 perception, 24, 57, 84 personal standpoint, 162–3 perspectives, 123, 138, 234, 259–60n19, 265n3 perspective-taking, 68, 124, 206, 211–13, 217, 223. See also otheroriented perspective-taking; self-oriented perspective-taking Pickard, Hanna, 165 poverty, 99 prejudice, 27–9, 39–41, 44–5, 50, 185, 189 private “knowledge,” 70–1 psychosis, 24, 57, 67–81, 97, 98, 104, 140, 143, 150, 193–5, 203, 212–13, 135–6 psychotic disorder, 12, 20, 32, 102 See also cognitive disorder; schizophrenia radical hope, 33–4 radical hospitality. See hospitality rationality, 29–30, 36, 57, 65–6, 99–100, 149, 169, 171 Ravizza, Mark, S.J., 158 reactive attitudes, 17, 19, 81, 150, 152–6, 162–3, 165–6, 169, 263n2 reality: connection to, 65–6; ­distance from, 78, 91 reality testing, 68–70, 79–80, 103, 122 reason-giving, 24, 30, 32, 111 reasoning capacities, 30, 129 reasons for action, 59, 90, 81–95 reasons-responsiveness, 111, 129, 150, 158, 165, 191, 260n33 reciprocity, 226–7

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recognition, 139–40, 156, 159, 206; of vulnerability, 237 recovery, 109 relational frame therapy (rft), 160 relationships See social relationships respect, 177, 237–8 responsibility, 18–20, 56, 64, 129, 135, 140–3, 149–53, 158. See also taking responsibility reverence, 212–16, 269n65 Saks, Elyn, 69, 70–1, 76, 195–6, 207–8, 228 Schiller, Lori, 74, 98, 196 schizophrenia, 20, 27, 37, 106–7, 109, 132, 192 Searle, John, 84 self-absorption, 45, 48, 53, 107– 12, 143, 148, 182–3, 186, 197– 202, 209–11, 217, 226, 231–2, 258n8 self-awareness, 36, 48, 149, 169, 182–3, 188, 220–1 self-determination, 135. See also autonomy self-harm, 95–102 self-oriented perspective-taking, 201, 205, 267n31 self-reflection, 159–60 self-stigma, 29, 44, 210–11, 235 self-understanding, 68, 123–5, 212–13, 217 self-worth, 44, 109–10, 209–11, 216–17, 227 Shackle, E.M., 177–8 shame, 38, 87, 164, 210, 227, 235, 240, 251n8 shared reality bias, 189–90

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shared social conditions, 222 shared understanding of reality, 117, 120–2, 129, 133, 191–2 sick role, 26 Sizer, Laura, 84 smoking, 64, 95–7 Snow, Nancy, 213 Snyder, Kurt, 97, 228–9 social capital, 50 social death, 47–8 social exclusion, 48, 53, 99, 107, 112–13, 117, 143 social interaction, 28, 46, 106–45, 147–8, 182, 197–8, 182–232 social isolation, 40, 45–50, 53–4, 106–145, 198–9, 234 social relationships, 45, 103, 108, 125, 127, 182, 215–16, 224–7, 258n6 social withdrawal, 45, 48, 53, 109–12, 128, 143 solipsism, 71, 110–11, 121, 138 source monitoring, 69–70 Spiro, Pamela Wagner, 78, 106 Steele, Ken, 204, 219, 227 stereotypes, 14–22, 33, 35–9, 40, 75, 150, 172, 185, 188–90, 192–3, 242n4, 242n9; dangerous and violent, 16–21, 150, 244n19; incompetent, 16–21, 150, 233; having a character flaw, 16–21, 233; mad genius, 16–17, 243–4n11; seer, 16, 243n10 stigma, 27–31, 35–50, 101, 143, 185, 197, 204, 208, 230, 234–9 Strawson, Peter, 18–19, 153 suffering, 65, 97, 131–2, 200–1, 203, 208–11. See also distress

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Index 301 suicide, 64, 74–5, 88, 97–8, 103 support, 227–9 sympathy, 13, 201, 207–9 taking responsibility, 158. See also responsibility teleology, 118–19 testimonial injustice, 35 testimony, 125 third-person perspective, 162–3, 165, 168–70, 175–6, 179–80, 218, 220, 222 Thornicroft, Graham, 46 thought disorder. See cognitive disorder thought disorganization, 76–81, 87 thought insertion, 69 time discounting, 99–100 transactional co-constitution, 115–16, 120–1, 135, 138, 139, 159–61, 231 trust, 45, 68; epistemic, 125–8; moral, 125 truth, 191 uncanniness, 71–3 uncertainty, 149–50, 151, 171, 175 unthinkability of action, 58, 61–2, 67, 81, 91 valence, 87–8 valuation, 57, 61, 132–4, 138, 96–9, 101–2, 137–8, 159–61; context for, 65–6, 95–102 vice, epistemic, 111 violence, 64, 67, 75 virtue, 182–232; epistemic, 127–8, 187–97, 199; intellectual, 148,

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302 Index 187–97; moral, 148; otheroriented, 148, 197–232 volition, 57. See also control; free will volitional disability, 24, 62 volitional disorder, 32 volitional necessity, 61–2 vulnerability, 235–40

weakness of will, 24, 97, 233 Weiland, Mary, 88–90, 95, 149, 172, 180, 195 willpower, 16–20 withholding judgment, 151–2, 172–4, 221 Wittgensteinian approach, 118 Wolf, Susan, 156 world-travelling, 195

Watson, Gary, 58, 61, 62, 140, 141

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