Responsibility Without Blame in Therapeutic Communities: Interview with Philosopher Hanna Pickard

Hanna Pickard is a Bloomberg Distinguished Professor of Philosophy and Bioethics at Johns Hopkins University. She is also appointed with the William H. Miller Department of Philosophy, the Berman Institute of Bioethics, and the Department of Psychological and Brain Sciences.

Her expertise is deep and spread across a wide variety of disciplines. As an analytic philosopher, she specializes in philosophy of mind, philosophy of psychiatry, moral psychology, and clinical ethics. She also worked for a decade at The Oxfordshire Complex Needs Service, a specialist service in the NHS for people diagnosed with personality disorders and complex needs. Her work tends to address the sticky debates that arise in clinical practice.

She has over 35 academic publications and has co-edited The Routledge Handbook of Philosophy and Science of Addiction. Pickard maintains an important thread between clinical work in the real world and her philosophical writings, attending to topics like the nature of mental disorders, delusions, agency, character, emotions, self-harm, violence, placebos, therapeutic relationships, decision-making capacity, the self and social identity, and attitudes towards mental disorder and crime.

In this interview, she discusses her novel and possibly controversial model for understanding addiction, the numerous shortcomings of the neurobiological model, the importance of centering patient agency, and her work in therapeutic communities.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Dhar: Dr. Pickard, you have written about the ‘responsibility without blame’ model for addiction. Could you tell us about this model?

Pickard: My experience of clinical work in a therapeutic community in England for 10 years is the basis for the model. I was a philosopher who found myself in a personality disorder clinic. I had very little clinical experience working with vulnerable and high-risk patients. What struck me was how my senior colleagues related to our patients, who we called members of our community.

I was really inclined to call that way of relating “holding somebody responsible but without blaming them.” It’s important that I hit it quite naive and innocent because it allowed me to see something that maybe people who work their way into clinical work become accustomed to.

When we are confronted with a person who does things we think of as morally wrong and seems responsible for doing them, we are incredibly inclined to blame them and become critical, judgmental, and write them off as a person to punish. We tend to withdraw from the relationship. What I saw in the therapeutic community that was so profoundly reorienting was that there was nothing inevitable about that response. It was perfectly possible to recognize that someone was responsible for wrongdoing, hold them responsible, and yet behave towards them with compassion, care, and concern.

This bringing together of responsibility and blame, which I had always taken for granted and which is very prominent in our society, suddenly felt unnecessary. The ‘responsibility without blame’ framework attempts to articulate this alternative way of relating that struck me so forcefully when I first hit this distinctive clinical context (therapeutic community).

 

Dhar: Could you tell us more about what therapeutic communities are, how they work, how are they different?

Pickard: They are really distinctive clinical environments. I have been in the US just a couple of years, and the model of psychiatric treatments strikes me as more medicalized and pharmaceutically based than in the UK.

Therapeutic Community is an approach to treatment that has proven effective for what I call disorders of agency—disorders where an important part of the diagnostic symptoms involves ways people behave. Some disorders like personality disorders or addiction are diagnosed through patterns of behavior. Therapeutic communities have proven to be effective for them.

I think they are wonderful, incredibly egalitarian. There is a flattened hierarchy to get beyond the power asymmetry between the doctor and the patient. We are all in it together. People are typically in therapeutic communities for a long time, so they have a journey. We call people members of the community, not patients. Some are more senior, others junior. The senior members often take an active leadership role.

Everybody’s part of each other’s therapeutic journey. On the one hand, they have responsibility for themselves and their behavior, but also responsibility for others in the group. The model is about creating a community where people can do the therapeutic work they need within a supportive environment that creates strong and authentic relationships between people. The idea is to help people be less dependent but more interdependent.

 

Dhar: What would it look like for a person with an addiction issue or problems with self-harm to be in a therapeutic community with the ‘responsibility without blame’ model?

Pickard: One of the techniques we use is contracts with the group. It’s a behavioral contract that involves an undertaking to stop doing whatever is the problem for you, whether that’s drinking or cannabis, or self-harm. People have to write that they will stop doing this and that if they find themselves wanting to, they will make a support call. They will reach out to somebody else in the group for support.

Typically, the first draft of the contract would say, “I will try not to self-harm or drink,” and the group would say, “No, you have to get rid of the word ‘try.’ You have to commit to doing it.” There’ll be a discussion. Eventually, the person would sign a contract that said they would stop, and if they were struggling, they would reach out for help. Then the entire group signs it and writes messages like “I’m here for you,” “call me if you need me,” “this is going to be hard”—messages of support, care, and solidarity. The person would go away and quite regularly stop the behavior and draw on the group for support.

But if a model sees this behavior as compelled by neurobiological pathology, then the idea of a contract stopping this behavior makes no sense. People carry around this piece of paper, read every day; it would be worn from use. Whatever it is doing for a person to help them, it’s not a cure for a neurobiological disease.

This is an example of how asking someone to take responsibility, that is, making changes they want to make and supporting them, has a tremendous clinical effect. We’re asking someone to stop a behavior, taking responsibility for doing that, asking for support if they need it. Asking for support is also key because there’s no blame; there’s concern, support, and compassion.

Of course, not everyone succeeds as these behavioral patterns are hard to kick. People lapse, but there’s no immediate blame, condemnation, and punitive attitude in the face of a lapse. The real question is what happened that, for example, after not drinking for three weeks, you lapsed—what was going on? The reason to understand that is so that lessons can be learned.

This idea of responsibility is fundamentally forward-looking. We’re thinking about responsibility because it helps people learn and change, not because of the way it licenses blame, punishment, or ostracization. It has a different function within a therapeutic community.

 

Dhar: About the neurobiological model of addiction, you write that partly it is scientifically unsound because the evidence doesn’t corroborate that it’s a simple brain disease in all cases. Secondly, we often use the neurobiological model, thinking it will help people reduce stigma, but it does the opposite—it leads to increasing levels of alienation, dehumanization, perceptions of dangerousness. Could you speak to the neurobiological model?

Pickard: Let me start with stigma. The brain disease model of addiction was most famously developed by Alan Leshner, who conceived of it both as scientifically credible but also as an antidote to stigma. If addiction is a brain disease of compulsion, then people who use drugs can’t help it. Rather than punish them through the state’s coercive tools of criminal justice, we should treat it as a public health problem.

The model assumes that when we apply a label like ‘disease,’ it has this de-stigmatizing effect. The findings of empirical studies on the effects of biogenetic labels on mental disorders, including addiction, are that they do help friends and family sometimes maintain relationships as removal of responsibility can remove blame. But in terms of the impact on public perception, they can increase ostracization, a sense of dangerousness, and a sense of otherness. Think how incredibly stigmatized other diseases are—leprosy, HIV, or even cancer. That something is a disease isn’t an obvious way in our society to reduce stigma.

But also, we as a society need to interrogate our own moral attitudes towards drugs and drug users, which the brain disease model doesn’t do. I personally don’t think there’s anything wrong with you for using drugs. Being real about moralism and condemnation in relation to drugs is something we need to approach directly. I don’t think you need the brain disease model to combat stigma effectively.

The evidence suggests that however hard it is for people to manage drug use, thinking that they’re completely powerless and that the concept of compulsion applies to addiction is a mistake. There is increasing evidence, both from animal and from human studies, that they respond to alternative reinforcers when they’re available. This means that if you give people a better choice than using drugs, they take it. So too with rodents.

This is extraordinarily important to recognize, given that we know that many people who struggle from addiction live in contexts where they don’t have many alternative goods. Addiction is associated with long-term mental health problems, socioeconomic adversity, poverty and suffering, and living in contexts of hopelessness and humiliation. Sometimes, the answer to addiction is not to fix something supposedly wrong with someone’s brain but to lift them out of poverty, giving them a chance for a meaningful life.

It’s incredibly difficult to stop using once you’re addicted, but compulsion is not an apt characterization. It stops us from looking at other interventions like socio-economic and educational interventions. It also disempowers the person.

 

Dhar: What does the neuro-biological model do to a person? This refers to Ian Hacking’s idea of the looping effect—the way we categorize things can change the experience of people. When you think you have a brain disease, and that’s how now you identify, it begins to shift your experience, so even if you had some level of control initially, you lose it over time. What happens to a person who’s told, “You, of course, have a brain disease”— where do you go from there? How do you work with someone if they have identified with the neurobiological model?

Pickard: What we empirically know about the impact of the brain disease label is that it often doesn’t help the patient. If you have a brain disease of compulsion, there’s nothing you can do; you’re stuck waiting for a doctor to fix you.

If we go back to that distinction between interdependence and dependence, it’s very much an idea of dependence. A sense of agency, potential, and possibility are important for people to stop using and make changes. That focus on agency, which the ‘responsibility without blame’ framework tries to support, is crucial.

But that’s not true for everyone. Some people seem to have found good in the brain disease model to understand their condition; they find it helpful. What I’m going to say is a bit controversial, but there’s a distinction between whether somebody’s self-conception, especially about their own relationship with their disorder, is helpful to them and whether it’s true.

From a clinical perspective, if I genuinely believed that the brain disease model was helping a person, the last thing I’d do is displace it. Your aim is to help people and not make them believe only what you think is true.

But that said, in my experience in therapeutic communities, some of the most important work people did was to give up on the biogenetic understanding of what was wrong with them. I don’t think that just because somebody believes they have a brain disease, therefore we should, without having a conversation, simply accept that. That conception about themselves can block them from making the changes they need.

Helping people put aside what sociologist Talcott Parsons called the sick role and find some agency was important to recovery in most cases, but not all cases. There is a lot of heterogeneity in experience, and the brain disease model has not recognized the heterogeneity. The etiology of what’s actually going on and what the person is struggling with may differ from person to person.

 

Dhar: This reminds me of a linguistic difference between English and Hindi when it comes to addiction. In India, the common perception of addiction is not as a disease or as something you are, but something you do. Often people who drink too much just stop drinking, and then they go back to drinking occasionally—it’s not considered a relapse.

Pickard: People self-label, and their sense of who they are and their identity becomes fashioned by whatever the label contains. The power of identifying as an addict, or being labeled as an addict, can keep you in a place where you’re an addict because if you stop using, then there can be this profound existential question which is, “Who am I if I’m not an addict.” And a language like Hindi, which doesn’t enable that essentializing, wouldn’t produce that kind of effect. That’s amazing!

 

Dhar: We know that most people simply age out of addiction, but stories of these people are never seen in the popular narrative in the broader culture. What factors keep some people from aging out and stopping while many can’t stop drug use?

Pickard: There are different reasons for different people, but here are some things we know.

First, many people who don’t mature out, as it’s called, are those with comorbid psychiatric disorders who come from socioeconomic positions of poverty, limited opportunities, discrimination, and ostracization.

Second, drugs have tremendous benefits. We pretend this isn’t the case. People take drugs for reasons; they provide relief from suffering when nothing else does.

Third, the best predictor of addiction severity is ‘coping motive,’ which means people who are severely addicted tend to be those who acknowledge that they use it because it helps with suffering. So, the reason why people don’t mature out is that they live really harrowing lives and drugs are the one thing that gives them some relief, some escape, and they know that.

But this does not apply to everyone, and here we should go back to identity. This is an important and unrecognized factor in why people don’t remit. There is the power of our identities and what feels comfortable because it’s familiar. People may not spontaneously remit because they don’t know who they would be or what they would do if they didn’t have that identity.

In addition, as a culture, we might not support them; we are stigmatizing and ostracizing drug users. People may have communities of users who are friends, have real bonds and relationships. Then, in giving up the drug, you give up not only your sense of self but also your community, maybe those who supported you when others haven’t. This is a really important piece which the brain disease model obscures.

 

Dhar: The ‘community of users’ reminds us of the experiments with rats who were made addicted to morphine and placed in community playrooms versus alone. Many ended up de-addicting themselves based on the environment.

Pickard: You’re referring to Bruce Alexander’s famous experiment called Rat Park. There have been difficulties replicating that, but the take-home messages have been absolutely confirmed by more well-controlled animal models, which offer rodents a choice between the drug and an alternative good.

One of the most amazing recent studies was by Marco Venniro, who gave a choice between any number of drugs, heroin, methamphetamines, versus social reward. These were socially housed rats and not deprived of social reward. Quite extraordinarily, 100% of them opted for the social reward over the drug.

What’s so interesting is that experimentalists effectively impose this choice on a rat: either a drug or a social reward, and the context of a ‘community of users’ is the opposite of that —you don’t get the social reward unless you have the drug. That’s part of why sometimes drugs can be so powerful because they’re so connected to our communities, our identity.

 

Dhar: Let’s talk about a potential conflict. On the one hand, you have talked about the structural determinants like poverty making addiction worse. But you also write about inculcating a sense of responsibility and agency. How do you reconcile this idea for people who have very little power? For example, how do you deal with a single mother of two kids, who has no health insurance, three jobs, takes the bus to work, and is trying to manage her addiction to prescription medication? Does she have any agency? Because there is a huge difference between making someone feel empowered and them actually being empowered.

Pickard: I worry that some of the language that the model uses, like responsibility, can be hijacked for blaming purposes. People make choices and have agency relative to their circumstances. It’s not just about other people’s choices and responsibility, but our own.

In the kind of context you described, to say you need to take responsibility is absurd. We need to give this person the choices to which any human being is entitled. The last thing this model is supposed to do is always put the emphasis on a person to sort things out. It’s on us to let people live in contexts where basic human needs like home, work, food, warmth, and care are not met.

With any theory, we end up making general claims as if it’s always true. There will be exceptions. The theory does not say that there’s never a case where someone has no agency. Of course, there are. The question is whether that’s a good model for understanding the majority of the cases.

 

Dhar: So, some things work sometimes for some people, and experience comes before theories, and we have to be able to appreciate the diversity of experience rather than stick to our pet theories.

Pickard: I feel we use biogenetic labels to protect us from two things. Those of us who care about our patients don’t want to blame, so we use a biogenetic label to protect us from that tendency. But we also use them as a defense mechanism to protect us from our own collective responsibility in creating conditions that allow mental disorders to flourish.

These labels put our focus squarely on the idea that something’s wrong with the person’s brain, as opposed to something’s wrong with the material and social conditions in which we are complicit. They’re much more for us than they are for the person.

 

Dhar: Have you ever received any pushback for this model where people erroneously conclude that you are blaming people?

Pickard: When I first came to the US, I was really surprised at how angry people were that I even questioned whether addiction, in all cases, is a brain disease. That’s one place, but it really has to do with a mistaken belief that we stigmatize everybody if we don’t blindly cleave to the brain disease model.

I never had much pushback from people with mental health problems. It’s really important to articulate the model with nuance—responsibility comes in degrees because agency comes in degrees. That’s something I emphasize, and my experience with people is that they’re glad to have their choices recognized. It can be incredibly empowering to finally have someone acknowledge that there is a choice, even if it’s limited.

I haven’t had much pushback from clinicians or psychiatrists. I have had pushback from philosophers. I think part of the reason is many philosophers don’t have clinical experience or spend time with a diverse population of patients. Maybe most of their experience with mental disorders comes from family or friends, and that’s where excusing someone from responsibility is productive to a personal relationship.

Here’s another explanation: the philosophers often don’t believe that it’s possible to have a forward-looking notion of responsibility that’s divorced from blame. If you don’t buy that, maybe for philosophical reasons, then you’re going to be very loathed to attribute responsibility because it immediately leads to blame.

 

Dhar: When I came to the US, I notice people sometimes had difficulty negotiating contradictions; it’s built into a lot of the philosophy. There is a whole argument about science versus religion, whereas, in India, scientists will send Mars Rovers into space after a religious ceremony. Responsibility without blame might seem like a contradictory idea, but they are not if you understand that the nature of things is rather fluid and dynamic.

Pickard: A lot of the work I’ve done is trying to find the middle ground. Much Western thinking, particularly in the US, is quite black and white. It’s unhelpful, and we find it in the discourse around drugs.

One group thinks drugs are just bad, typically advocates for the brain disease model. Another emphasizes only the benefits of drugs. The truth is in between.

Drugs have tremendous benefits and tremendous risks and costs. Any individual or society needs to think about how to manage both and get the most out of them while protecting against the costs. That nuance is missing from public discourse.

 

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MIA Reports are supported, in part, by a grant from the Open Society Foundations