Impediments to Voluntary Action in Disease

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Most of us think we have free will, and most of us realize that there are limits to free will. If someone has, for example, a lesion in the brain, he or she might behave differently than normal without realizing what is happening. Aristotle discusses the case of a drunk person who commits a crime while drunk without realizing at the time what he was doing. He says that the wrong action itself is not voluntary; however, since the decision to drink too much was voluntary, the drunk person is responsible for his action.

Nature and nurture both cooperate in limiting our practical range of choices. Our heredity can set basic personality traits, environment can modify them, and we have learned that environment can modify a person’s genetics. A person’s own decision can modify his genetics as well–this discovery and others is the reason why epigenetics is a hot field in current biology.

Someone with schizophrenia who behaves in a destructive way due to the disease process in his body is making choices based on the fantasy world view characteristic of schizophrenics. The choice is voluntary in a way, but since it is based on an illusion caused by the illness, the choice is ultimately so constrained as to be involuntary. The same is true of other psychoses as well as most of the Class B personality disorders. Voluntary choice is constrained due to traits that sometimes result in the disintegration of the personality. A person does not have to reach the extreme of dissociative identity disorder to suffer from a fragmented personality. Overwhelming emotions characteristic of the Class Bs can interfere with voluntary action; the impulses can cause an adrenaline rush that can interfere with judgment, and in extreme cases a temporary dissociation can occur. I have struggled with my views on this matter over time. I have met psychologists who say that these persons have free will and have decided to focus on the self, and that such focus is characteristic of egotism and is evil. I once believed this was the case; however, on reading accounts of recovery from some of these conditions, including recovery from the notorious borderline personality disorder, I have reconsidered. J. R. R. Tolkien considered the Rin to be too great a temptation for anyone to bear–a temptation that a person could not resist. Perhaps overwhelming waves of emotion can temporarily limit the scope of voluntary action. The situation would be similar to those who are drunk or on drugs and have impulses they often cannot control. The difference is that in the case of mental illness, environment (and in some cases heredity) have molded a person into unhealthy patterns of behavior that may be too difficult to voluntarily resist. What are the options for such individuals?

It seems to me that the option is to seek treatment, just as alcoholics who are not forced to do so by the criminal justice system must voluntarily decide to be treated if they have any chance to be helped. I am not sure that a schizophrenic recognizes the need for help. If someone with one of the Class B personality disorders avoids denial and seeks treatment, it is possible, with a patient therapist and a long-term therapeutic relationship, for that person to be successfully treated. Dialectical behavior therapy, for example, has been useful in treating borderline personality disorder. The alternative, at least for this condition, is grim. BPD individuals do not intend to hurt others–not for sheer “meanness.” It stems from splitting (which I call “individualized Manicheanism” that puts a person into the “all good” category one moment and the “Satanic evil” category the next moment. Much of the behavior is the attempt of the fragmented personality to survive. Jesus said that “A house divided against itself cannot stand.” Could it be that a personality divided against itself can cause the body to be divided against itself? Some people with various mental conditions are in poor physical health. While that may be due to poor eating and exercise habits, I wonder if a mental disorder can be in a one-to-one correspondence with a physical disorder. Is it possible, for example, for a divided personality to cause the body to be divided against itself? If so, would the physical disease be eased or reversed if the disparate patches of personality could once again join into one? I suppose that is possible. Such a task would involve a skilled therapist with top-notch skills and the wisdom, as well as the knowledge, to help a person become whole again. My hope and prayer is that, with God’s help, all those who suffer from actions that are, at least in part, beyond their control due to illness, physical and/or mental, will heal.

Borderline Personality Disorder

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Borderline Personality Disorder Awareness

Borderline Personality Disorder is a disorder I have been blessed not to have, though I’ve known individuals, some close to me, who were borderline. BPD is essentially a problem of emotional control. Borderline people have wild mood swings, though they are not usually bipolar. They can love you and think you are the most wonderful person in the world one moment, then turn on you, demonize you, and hate you. Those shifts can be unpredictable and can happen quickly, leaving family members hurt and wondering how to react. Borderline individuals tend to put people they know into lose-lose situations. If the borderline person is angry with you, whatever you say will be the wrong thing. You will, as one bestselling book on BPD alludes to, be “walking on eggshells.”

Borderline people can be manipulative, just like narcissists, but unlike sociopaths or psychopaths, they do have a conscience and are capable of love. Often, however, their love is twisted, oriented more to feeding their egos (like narcissists receiving “supply”) than truly focusing on the other person. They are good at making themselves look “too good to be true,” seeming to be interesting in everything you are. Some borderline individuals will lie about their accomplishments in order to impress others; other borderline individuals find it difficult to tell the difference between appearance and reality. The latter group can go into a dissociative state and not remember what they did during that state. If you quote the borderline’s statements to you to his family and friends, often they will stare at you as if you are crazy–because the BPD person told you that something happened that, in truth, did not happen.

BPD individuals, like narcissists, psychopaths, and sociopaths, often have a great deal of charm, which they use to their advantage. But the advantage is only temporary as people pick up on the fact that the BPD person “ain’t quite right” as we say in the South. Instability in jobs and instability in relationships may lead to the BPD going through multiple jobs quickly, moving many times, and going through multiple marriages. All relationships are unstable. The borderline person is afraid to lose anyone in his life, yet does not realize that his behavior drives people away. Sadly, the BPD individual is usually miserable inside and lonely, desperately wanting a friend. Most BPD persons do not recognize that their behaviors drive away other people; others may recognize that fact, but believe that their traits are essential for their emotional survival. That points to the greatest problem borderline individuals have in overcoming their disorder: a failure to take responsibility.

So many mental problems are due, in part, to someone believing they are the slave of fate, that given one’s background, one cannot help the way he is. For that reason, he refuses to take responsibility for his actions and blames others for bad things that happen to him. The most difficult obstacle psychologists and psychiatrists have dealing with borderline people is the borderline’s refusal to take responsibility. The borderline often tries to manipulate the therapist. Sadly, many affairs with therapists occur that way. One psychologist told me that of his fellow therapists who fell into affairs, probably over 95% of the lovers were borderline individuals. Since flirtation gains the borderline attention and helps with low self esteem (which only masquerades as high self esteem), many borderlines are extremely flirtatious. Not all will go to the point of a full-fledged affair, but many do.

BPD usually has its origins in childhood. Oftentimes, childhood sexual abuse by a parent or stepparent is the cause–though this is not the only cause. BPD usually manifests in a person’s teens. Some borderline individuals spontaneously recover in their forties; others never recover. Therapy is notoriously ineffective, although newer cognitive methods work better than previous therapies. It is a joke among psychologists that the way to harm an enemy psychologist is to refer a borderline patient to him. If the psychologist can get the borderline person to admit that he is not the slave of forces beyond his control and that he is able to change, the major step toward recovery has occurred.

Are borderline individuals sick or evil? Some borderline behavior seems to be evil: the lying, the manipulation, the willingness to say or do almost anything to get what one wants, the sudden turns toward absolute hatred. I know of one therapist (not my therapist) and one person who works in the criminal justice system who consider borderline people to be evil. In my opinion, most of them do not begin as evil, though, like any human being, they may become evil due to habituation. They are trying to survive something that hurt them so much as a child that they believe that their behaviors are the only way they can survive in the world. They may believe that if they did not behave the way they do that they would fall apart–indeed, their personalities seem to be fragmented. These sad, frightened people need to be guided toward healing–but they must be willing to get help and be serious about it. To anyone who may have this disorder: I pray for them to get help, to engage in positive behaviors that support solid relationships with others, and to find peace in their lives.

The Boundary Between Mental Illness and Evil

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"Satan Sowing Seeds" by Felicien Rop...

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Was Jared Lee Loughner, who allegedly murdered six people in Tuscon and wounded 13 others, including Congressman Gabrielle Giffords, insane or evil or both? Leonard Pitts and other columnists and bloggers have openly wondered whether “evil” is a more appropriate description of Mr. Loughner than “insane.” Psychiatry and psychology tend to medicalize deviances in human behavior, sometimes to the point that they tone down the role of human responsibility. For example, classifying alcoholism as a disease alleviates the moral responsibility a person may have for engaging in the heavy drinking that made him dependent on alcohol.  Classifying mass murderers as “psychopaths” may be accurate as a descriptive label for their condition (no empathy, no conscience), but such classification does not address the issue of whether psychopaths are evil. There are several bad arguments that someone who medicalizes terrible human actions may use. For example:

1. If person x has a mental illness, and that mental illness contributes to x’s destructive behavior, then x is not morally responsible for x’s actions.

2. Person x has a mental illness.

3. That mental illness contributes to x’s destructive behavior.

4. Therefore, x is not morally responsible for x’s actions.

The weakness of this argument is premise 1. Just because a person is mentally ill, and that mental illness causally contributes to his behavior, does not imply that the person is not morally responsible for his actions. The reason is that the mental illness may be a necessary but not sufficient condition for x’s destructive behavior. X’s evil moral character may still play a causal role as well. Or x’s evil moral character may have causally contributed to his mental illness.

Another bad argument goes as follows:

1. Deviations from normal brain structure are correlated with psychopathy and other personality disorders.

2. If deviations from normal brain structure are correlated with psychopathy and other personality disorders, then the individual with such deviations is not morally responsible for his actions.

3. Psychopathic [mass murderer, swindler–take you pick of crime) individual x has deviations from normal brain structure.

4. Therefore psychopathic individual x is not responsible for actions that are due to his psychopathy.

One problem with this argument is that correlation is not causation. Even if a causal relation could be established, this does not answer the question of which direction the causation goes (the “chicken-egg problem”). Do the deviations from normal brain structure cause psychopathy or does psychopathic behavior cause deviations from normal brain structure? Unless one accepts reductive or eliminative materialism, then one cannot automatically claim that a twisted mind and behavior are caused by an abnormal brain. To make such a claim would be to beg the question on the complex metaphysical issues surrounding the mind-body problem.

I do not know where the exact boundary between evil and mental illness. A rough answer that seems reasonable to me is that if a person’s mind is utterly divorced from reality, then he is not as responsible for his actions as someone who has a firm or even partial grip on reality. Where should that line be drawn? This is the difficulty. It seems to me that psychopaths are evil people. Borderline personality disorder is (and I’m not trying to be “facile”) is a borderline case–but if a person suffering from borderline personality disorder destroys another person’s life, emotional health, and/or reputation due to manipulation and lies, then the person seems as much evil as having a medical disorder. The refusal of many borderlines to get help or take responsibility for their actions are basic elements of an evil character. Munchausen’s Syndrome and Munchausen’s by Proxy fall in the same category–the drive for attention is twisted to the point of doing evil and manipulative actions. I know that many professional psychologists and psychiatrists would disagree. But they do not know everything any more than I as a philosopher know everything. I know there is a level of mental illness that totally removes a person’s moral responsibility for heinous actions.  But since evil is by nature a distortion of the personality, there may be some individuals who are considered to be mentally ill but who are actually evil, or some individuals who suffer from mental illness and have an evil character.  Human beings are a mixture of good and evil, and that battle, as Alexander Solzhenitsyn said, is fought in every human heart.