This post is by Olivia Siegfried, currently studying for a Master’s degree in the School of Psychology at the University of Birmingham. Olivia is interested in youth mental health, personality disorders, and forensic psychology, and adopts a social constructionist perspective to understand these issues.
This is part of a series of posts by students of the Philosophy and Ethics of Mental Health and Wellbeing module at the Institute for Mental Health. They share some of their views on key topics discussed in the module.
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| Olivia Siegfried |
Responsibility without blame
As personality disorders are notoriously hard to treat, Hannah Pickard has put forward the ‘responsibility without blame’ approach (Pickard, 2011) for clinicians to adopt to foster the best clinical outcomes. Although sounding inherently paradoxical, we can hold people responsible without blaming them by segregating responsibility from morality and instead defining it through a person’s agency.
Taking responsibility for their actions allows patients to own their behaviour and emotions and provides them with the foundation to make changes in the future. Blaming them, however, strips them of their agency and encourages therapeutic nihilism.
Pickard advocates for clinicians to treat people with compassion and view adverse behaviour as the result of great psychological distress. She emphasises that considering the patient’s history of trauma (which is common in people with personality disorders) allows for this compassion to develop, which in turn counteracts the impulse to blame.
People with antisocial personality disorder (Fisher and Hany, 2019) who possess high levels of antagonistic personality traits (e.g. callousness) come closest to our understanding of a ‘psychopath’. I will outline here how psychopaths differ from other personality disorder patients and thereby put into question the viability of the ‘responsibility without blame’ approach for cases of psychopathy.
Trauma?
According to the ‘responsibility without blame’ framework, clinical compassion is fostered through understanding a patient’s behaviour as the result of severe psychological distress stemming from past traumatic environments.
However, not all psychopaths have experienced trauma in their lives. Blair and colleagues (2006) argue that psychopathy predominantly arises through genetic pathways, and is less closely linked to social environments. For example, a twin study (Viding et al., 2008) found that the heritability of antisocial behaviour for children with co-occurring callous-unemotional traits was far greater than for those without them.
Furthermore, the reactive aggression observed in other personality disorders is not always mirrored in psychopaths. They tend to demonstrate instrumental aggression (Blair et al., 2006) which is motivated by egocentric goals rather than being the result of hypervigilance.
Thus, it is hard to envision how clinicians can adopt a compassionate approach to psychopaths’ aggressive behaviour if it does not constitute a coping mechanism for psychological distress stemming from trauma.
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| Aggression in psychopaths is more goal-directed. |
Prospection?
Neil Levy (2013) argues that psychopaths show impairments in mental time travel. This means that their ability to visualise themselves in past or future environments is diminished.
The present is more salient to them, which is demonstrated through their nomadic lifestyle and ever-changing relationships. Thus, the DSM-5 (American Psychiatric Association, 2013) has included impulsivity and irresponsibility as diagnostic criteria for APD. Moreover, ‘temporal inefficacy’ (Petrican and Burris, 2011), a construct characterised by displeasure about the passing of linear time is associated with a reduced capacity for mental time travel and greater levels of psychopathic traits.
Pickard states that holding patients responsible provides them with the agency to make future changes. However, this approach is unlikely to have the same merit for psychopaths who lack such prospection.
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| Psychopaths have difficulties looking into the future |
In conclusion, the ‘responsibility without blame’ approach may be inappropriate for psychopaths, as they lack the personality disorder characteristics that the framework assumes. Although blaming them is unlikely to be the answer, it is important to be aware of these differences between personality disorders.