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From Morality to Mental HealthReview - From Morality to Mental Health
Virtue and Vice in a Therapeutic Culture
by Mike W. Martin
Oxford University Press, 2006
Review by Nancy Nyquist Potter, Ph.D.
Nov 7th 2006 (Volume 10, Issue 45)

Aristotle argues in the Nicomachean Ethics (1985) that we are jointly responsible for our characters and for the things at which we aim. The idea is that, although our capacities are given by nature--and even our temperamental abilities to be "naturally" placid or sociable and so on--we still must make ourselves and each other into the adults we become. We have help from a variety of social institutions in this; schools, religious affiliations, families, neighborhoods, and social services provide moral education (for better or for worse), but we are neither biologically nor socially determined. So Aristotle argues, the virtues and the vices are voluntary, and we cannot simply cry, "I can't help who I am!" Our characters are, in a complex way, up to us.

As a virtue ethicist, I am sympathetic with this view: our decisions do seem to add up to dispositions to act and feel in certain ways. Living the good life involves goods such as health, friendship, virtues, and material security, and we must actively pursue these things and face blame when we knowingly and freely make wrong choices. But as nuanced as Aristotle's work in moral psychology was for his time, he could not, in his account of character, moral responsibility, and the good life, make a place for those actions that are internally compelled yet apparently voluntary--or any other number of nasty questions about freedom and responsibility that continue to haunt our daily lives.

Mike Martin's new monograph on the relationship between mental health, morality, and therapy, can be read as a sustained discussion on how these themes can come together in our twenty-first century Western world. His thesis is that the "mad versus bad" dichotomy that so ensnares psychiatry, psychology, and the law should be rejected in favor of what he calls "the moral-therapeutic perspective." As Martin understands it, the therapeutic project is really an integrative one--integrating morality and character with healing. The language of "healing" implies sickness, he argues, but to do so does not require that we eschew holding people accountable for their actions and choices. Through numerous examples and in a variety of domains, Martin points out that the morality-therapy dichotomy prevents us from understanding how one can be both sick and irresponsible--but still held accountable for one's actions.

Martin's book addresses three themes: the moral-ladenness of health, responsibility for health, and healthy morality.† He emphasizes that concepts of health and sickness are not only value-laden, but are infused with moral values in particular. Martin states in criticism of current diagnoses that "the DSM defines many mental disorders by reference to moral values and harm caused" (56). This first theme is not particularly new, as people in the field of philosophy of psychiatry have been working in this area for at least two decades. (The culmination of these studies is found in John Sadler's Values in Psychiatric Diagnosis (2005). Sadler's work is a wonderful and dense examination of such values that includes an ingenious "moral wrongfulness test" whereby we can determine whether the values of moral badness in diagnosis can be translated into non-moral terms while preserving the meaning of the diagnosis.) ††

For the most part, though, Martin plumps for the place of moral values in therapy, so his criticisms of the DSM are slight. In the chapter on how moral and mental health intersect, Martin draws upon six criteria of positive mental health from Marie Jahoda and suggests that each has a correlative component in morality. For example, Jahoda claims that self-esteem is a criterion of mental health, and Martin adds that self-respect is the moral counterpart. I found most of his parallels to be a reach, though. The problem with this sort of chapter is that the philosophical literature is vast and Martin runs through very nuanced and complicated theories, arguments, and views in such short order that the richer meaning of either self-esteem or self-respect is lost.

Part II focuses on the relationship between mental illness and moral responsibility. Martin argues for a Kantian view of responsibility, where we have duties to ourselves that include not doing those things that might be self-harming, like drinking too much or developing a gambling habit. These are binding obligations we have, Martin says, and when we violate these obligations, we are to blame. Another way in which he incorporates moral values into his argument is in defending the place of guilt, love, and forgiveness in our lives. These positive values contribute both to healing while in therapy and to living a healthy life in general. I agree that it is important to consider the role that moral values play in psychotherapy, but I think Martin would do well to include concerns about matters such as the forgiveness push in therapy (cf. Lamb and Murphy 2002).

Because the idea that people can be both mentally ill and accountable is such a challenging one, I will focus most of this review on this argument. Martin is right to note that individual responsibility for bad habits must be considered in conjunction with the broader responsibility of citizens to maintain a decent society (11). He takes pains to insist he is not blaming people for their illnesses. Yet he repeatedly claims that people can be blamed for making choices that put them in the way of developing mental illnesses. Martin agrees with Peter Strawson that arguments about freedom and determinism are more interesting to philosophical theorizing than to ordinary life practices. Martin writes:

What matters is whether individuals have normal capacities to participate in moral practices, such as moral reasoning, guilt and shame when we fail to meet moral standards, gratitude for acts of kindness, mutual love among adults, resentment toward people who wrong us, indignation toward people who unjustly harm others, and forgiveness when others repent and make amends. (59-60)

Yet he disagrees with Strawson's broader point: Strawson "assumes that psychopathology undermines normal capacities," an idea Martin apparently does not hold. Martin asserts that addicts and others with volitional disorders "are not exempt from accountability."† He blames people for "acquiring" compulsions, although the reason is not clear why; it doesn't seem true for people with obsessive-compulsive disorder, who truly cannot stop repetitive and self-defeating actions such as washing their hands every hour. Furthermore, I have trouble seeing how his claims about responsibility apply to people with serious mental disorders such as schizophrenia or Alzheimer's. Martin states that "[a]lthough mental disorders can seriously impede moral agency, most do not make it impossible" (67). As someone who is part of a health care team at Emergency Psychiatric Services, I see patients who tear at our hearts for their incapacity, confusion, and distress when suffering psychoses or paranoid delusions. Martin goes so far as to say that platitudes such as "[w]e reap what we sow; old sins cast long shadows; what goes around comes around" (81) can be encouraging to people.† When I think of the patients at EPS, I can only think that such comments come from another world.

Martin is not considering that population, though. Instead, he is interested in addictions, stealing, violence, depression, and other problems in living. Take kleptomania, for example. In his view, people who have irresistible impulses to do immoral things are to blame for having created a moral handicap in the first place (18). Presumably, this is why he states that "it is also fair to hold individuals responsible for alcohol abuse, drug dependency, compulsive gambling, kleptomania, and myriad other mental disorders listed in the DSM" (55). Indeed, Martin faults the DSM for being too soft on what constitutes a volitional disorder. But a crucial point in any move to undermine the morality-therapy dichotomy requires a clear analysis of how impulse-control disorders or volitional orders develop, and Martin doesn't do this, beyond saying that people who develop impulse-control disorders should not have done so. Frankly, I just don't understand the overall argument unless I take an Aristotelian view where addictions are not understood as addictions but as vices.

Part III, entitled "Wrongdoing as Sickness" is a section that addresses specific mental disorders. Included in this section are alcoholism, pathological gambling, crimes such as kleptomania and use of illegal drugs, violence as evil, and bigotry as mental disorder. In the chapter on alcoholism, Martin argues that it is a "disorder of agency" and a sickness. It is unclear what he means by the former; I don't see the distinction between calling alcoholism a "disease" (the AA view) or a "sickness;" and still he maintains that we are responsible for the habits we form. In fact, Martin rejects the prevailing view that the one part of alcoholism one is responsible for is getting treatment (96.) Since Martin believes that we are to blame for becoming addicted, he would seem to suggest that we should never try something that "might" in the future, become an addiction. If Martin genuinely takes virtue theory seriously, though, he would seem to be advocating that people embrace one vice in order to avoid another: temperance, which has to do with our experiences of sensual pleasures and pains, calls for us to find the mean between avoiding pleasures altogether and wallowing in pleasures at any expense. Aristotle chastens the person who has the vice of being deficient in pleasures. If it is right to think that we should not avoid pleasure altogether, it also places us at risks we may not appreciate for our future relationship to similar pleasures. I wish Martin had said more about how the virtue of temperance is supposed to work both in contributing to the good life and to assisting us in avoiding addictions. On the face of it, it seems messy and difficult to sort out.

Part III gets repetitive, especially in light of the absence of genuine argument in each short chapter. For example, in the conclusion of the chapter on gambling he says, "Finally, does impaired agency remove responsibility for the harm done by gambling?...It does not." (106). I take it he thinks the morality-therapy dichotomy has been sufficiently undermined so he no longer has to argue for it. But I am not convinced. The chapter on violence and evil focuses on sociopaths but sheds little light on the mad/bad debate. Martin offers no evidence for the claim that sociopaths have the capacity to not kill or that cultural reactions of disapproval play a therapeutic role for sociopaths. But what I most missed was the omission of Claudia Card's (2002) rich and complex analysis of evil and accountability where she painstakingly analyzes evil doers, victims, and people who fall into both categories simultaneously. Incorporating Card's sophisticated philosophical arguments would have prevented this chapter from its sense of thinness.

Finally, I am unclear who Martin's audience is. For a philosophy of psychiatry, many of his points are too breezy. For example, in discussing models of mental disorder, he goes through five approaches in just a few pages--surely not enough to make sense of his claims that someone can be both mad and bad. If readers don't understand the complexities of conceptualizing mental disorder, they are not in a position to evaluate the strength of Martin's position. For example, he devotes just two paragraphs to what is arguably the most significant (if controversial) contribution to discussions of the concept of mental disorder--Jerome Wakefield's harmful dysfunction account (1992). Martin's brief explanation allows him to dismiss that account as "relativistic" because the "harm" component of the definition is culturally inflected. But Wakefield's account, with its attention to the dysfunction of an internal mechanism from what it was designed to do, may in fact make it less plausible for Martin to claim that someone with a mental disorder is still responsible for those actions caused by one's disorder. A more sophisticated discussion on matters such as this would have challenged Martin's argument more and his ability nevertheless to respond would then have been more persuasive.

 

Aristotle. 1985. Nicomachean Ethics. Trans. T. Irwin. Indianapolis: Hackett.

Card, Claudia. 2002. The Atrocity Paradigm: A Theory of Evil. Oxford: Oxford University Press.

Lamb, Sharon, and Murphy, Jeffrie, eds. 2002. Before Forgiving: Cautionary Views of Forgiveness in Psychotherapy. Oxford: Oxford University Press.

Sadler, John. 2005. Values and Psychiatric Diagnosis. Oxford: Oxford University Press.

Wakefield, Jerome. 1992. "The concept of mental disorder: On the boundary between biological facts and social values." In American psychologist 47(3): 373-388.

 

 

© 2006 Nancy Nyquist Potter

 

 

Nancy Nyquist Potter, Ph.D., Department of Philosophy, University of Louisville, is working on a book on a philosophical analysis of Borderline Personality Disorder.† She is editor of Trauma, Truth and Reconciliation (Oxford University Press, 2006), and is author of How Can I Be Trusted? A Virtue Theory of Trustworthiness (Rowman & Littlefield, 2002).


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