Character, Personality Disorder, and Responsibility
As in our own society a scientific theory of causation, if not excluded, is deemed irrelevant in questions of moral and legal responsibility, so in Zande society the doctrine of witchcraft, if not excluded, is deemed irrelevant in the same situations. We accept scientific explanations of the causes of disease, and even of the causes of insanity, but we deny them in crime and sin because here they militate against law and morals which are axiomatic.
—E. E. Evans-Prichard, Witchcraft, Oracles and Magic among the Azande
Some psychiatric conditions can take over a person’s character and change it. They include some dementias and also schizophrenia. They come on after the person’s original character and personality have developed. We can (to some extent) oppose the person to the character-distorting illness.
Some other conditions go deeper, to shape a person’s original core. These “foundational” conditions, including autism and some personality disorders, are more fully present much earlier. They do not appear to strike people from outside. Even where early environment plays an important role, there is no alternative “real” person, remembered by friends and family but now submerged by the disorder.
As we saw in Part 1, some of the Broadmoor interviewees suggested that their childhoods may have strongly influenced the people they became. They did not choose that kind of childhood. Does this then mean that it is unfair to blame them for how they turned out and for what they did as adults? I want to look at this line of thought applied to a particular person, without describing a possibly identifiable Broadmoor patient. The person to be considered, although he never had a psychiatric diagnosis, clearly illustrates the combination of a cruel childhood with a distorted adult psychology.
Figure 25.1: Mr. H as a young child. Bundesarchiv Bild 183-1989-0322-506.
Mr. H, pictured as a baby in Figure 25.1, had an unhappy childhood. His father was strict and had a terrible temper. He was a “demon” about punctuality. He insisted on silence in the family. The children never dared speak in his presence unless spoken to and were not allowed to call him anything less formal than “Father.” When the father summoned his son, he never called him by name but always whistled for him in the way he called the dog. The father often beat the dog, his wife, and each of the children. The adult Mr. H remembered having once been given 230 strokes of the cane by his father. He also said he remembered seeing his drunken father rape his mother.
Mr. H grew up with a very rigid personality. As an adult he was obsessed with cleanliness, passionately hating any untidiness or dirt. He was also obsessed with wolves, sometimes thinking of himself as a wolf, and calling his Alsatian dog “Wolf.” He took the dog for exactly the same walk every day, throwing a stick for it at exactly the same place. Any suggestion of varying these routines made him agitated and angry. He hated being left alone at night, and hated the moon because he thought it was dead. He was obsessed with his own possible death from cancer, which his mother had died from.
Mr. H had difficulties in his love life. As a boy he had been terrified of being kissed. His first love affair came when he was 37. It was with a teenage girl, who tried to kill herself when he abruptly broke off the relationship. He then fell in love with his niece, who did not reciprocate his feelings. She killed herself with his pistol. At age 41 he had another affair, with an 18-year-old girl who made an unsuccessful suicide attempt early in their relationship. Mr. H seems to have been disgusted by normal sexual intercourse, saying he did not want it because he would become infected. His niece said his main sexual pleasure was getting her to urinate on his face.
Much of his emotional life seems to have been diverted to patriotism and politics. He fought in a war, with great patriotic enthusiasm. He was temporarily blinded in a gas attack, which left him with great resentment against those who did not fight in the war. He took up extreme right-wing politics and was passionately anti-Semitic. He was highly successful at appealing to the public. He became leader of his country. He started a world war. He ordered the systematic murder of millions of his fellow citizens. He killed himself when his country lost the war.
Now that Mr. H’s identity has emerged, there are questions about how, if at all, his childhood and its effects on his character and personality are relevant to our reaction to him and to what he did.1
Rigidity, sexual problems, neurotic health worries, obsessive racial hatred, extreme anger and resentment, fixations about dogs and the moon: these are things people are better off without. They perhaps suggest he was a candidate for being diagnosed with a personality disorder. But there is not much mileage in the idea that the real Mr. H is not reflected in all this. There is no reason to believe he had a quite different unexpressed personality. The anger and the anti-Semitism were characteristics as genuinely his as it is possible to find.
Mr. H raises in acute form the problem of personality disorder. The excuses that normally defend someone’s character from criticism all fail. There is no conflict in which a set of higher-order desires or deeper values is defeated. There is no alternative obscured “real” self. If blame is a negative evaluation of character on the basis of actions, it is hard to see how Mr. H can escape it.
And yet, as with the Broadmoor interviewees, this seems not quite the whole story. In the interviews, although I did not ask the interviewees about their early life, they often talked about childhoods of pain, rejection, and humiliation. It was natural to see them too as victims, to glimpse their life from the inside and to feel sympathy. The emotional responses to what they have suffered and to the terrible things they have done are hard to reconcile. Sometimes, going back from the hospital after hearing about both, I struggled to get the two perspectives into one coherent picture.
When a terrible childhood is offered as an excuse, people often reply with what can be called “the dismissive response”: most children treated in this way do not grow up to commit the rapes and murders that lead to Broadmoor, or crimes like those of Mr. H. The suggestion is that even people given a desperately bad start have a choice about how to respond to it. So those making worse choices than others with similar childhoods can be blamed for this. Environmental determinism is too crude.
The story certainly is more complex. Some of it is starting to be unraveled. One study followed the development of 442 males born in 1972–1973 in the New Zealand city of Dunedin. Terrie Moffitt, Avshalom Caspi, and others investigated how far either a particular genetic polymorphism or childhood ill-treatment are linked with later antisocial tendencies.2
Several measures were made of “antisocial” outcome: an adolescent diagnosis of conduct disorder; convictions in adulthood for violent crime, a personality assessment of aggression, or reports (by people who know them well) of symptoms of antisocial personality disorder.
The genetic variant they studied affected the gene that encodes monoamine oxidase A (MAOA). Low levels of MAOA are plausibly linked to aggression. It is the enzyme that metabolizes some neurotransmitters, including norepinephrine, serotonin, and dopamine. Early ill-treatment affects all these transmitter systems.
Of the male cohort studied, 37 percent had the “risk” variant linked with low MAOA activity. In childhood, 36 percent of the cohort were ill-treated—8 percent had maltreatment graded as severe, and 28 percent had maltreatment graded as probable. The study found that severe ill-treatment on its own increased the likelihood of the antisocial outcome, as did the “risk” genetic variant on its own. Neither increase was dramatic.
But there was a much higher increase in the probability of antisocial outcome when boys with the genetic risk were also rated as “probable or severe” cases of maltreatment. They were 12 percent of the population and had 44 percent of the convictions for violent crime. Moffitt and Caspi claim that, of those with the genetic risk who were also severely maltreated, 85 percent developed some sort of antisocial outcome.
It might be wondered if attempts to repeat the study would bring the very high figures down a bit. Terrie Moffitt quotes another study as supporting the impact on antisocial tendencies of combining genetic risk with maltreatment.3 This was a Virginia twin study, which showed the impact of the combination, but at less dramatic levels.4 In this study, combining the genetic risk with childhood adversity raised the level of diagnoses of conduct disorder (from 15 percent with childhood adversity only) to 35 percent. The contrast between the two results may be explained partly by differences between conduct disorder and the Dunedin measures of antisocial outcome. The Virginia study also used a different assessment of childhood adversity, based on parental neglect, violence between parents, and inconsistent discipline.
The considerable difference between the two studies’ methods and results makes it hard to assess the extent of the multiplying effect of combining genetic risk with adverse childhoods. But even if the figure were the much lower one of the Virginia study, the general conclusion would remain striking. Adding genetic risk to an adverse childhood would still more than double the level of conduct disorder.
Part of the complex emotional response to hearing about the childhoods of Broadmoor interviewees or of Mr. H. can be some secular version of “there but for the grace of God go I.” This looks less of a worry if the dismissive response is right: most people override bad childhoods.
If the claimed excuse is not a bad childhood alone but one combined with a genetic risk, though, the dismissive response looks less impressive. It is not so clear that most people can override this combination. Depending on how the figures finally settle down, it seems that the number who do not manage to override it may be somewhere between 35 percent and 85 percent. We do not know the full causal story that led to the crimes of the Broadmoor interviewees or to the crimes of Mr. H. So we cannot be confident that we would have responded differently to the upbringing they had. Of course we all hope that, given that terrible childhood, we would not have been like Hitler. No doubt many of us would not. But certainty here is overconfidence. This adds a disquieting perspective to our attitudes to Mr. H and to other possibly personality-disordered people who have done terrible things.
Suppose, for example, one’s values or “higher order” desires have been instilled in one in an unreflective, coercive way. Even if one is able to make one’s “lower order” desires march in step, there is a sense in which one’s whole harmonious will is an expression of enslavement … he is not free from his environment, for he has not engaged in a process of separation and individuation. His will cannot be free because it is not his will.
—Jonathan Lear, Love and Its Place in Nature
Despite skepticism discussed earlier, what most people intuitively believe seems likely: our deliberations shape our decisions, and our decisions cause our actions. But what is the full causal story behind our deliberations and decisions? Despite the growing contributions of genetics, epigenetics, perhaps quantum physics, neuroscience, psychology, and the social sciences, we still have large areas of ignorance about the springs of action. But scientific progress is reducing our ignorance. There seems no reason to expect this stop.
This suggests the thought that one day we could have a full causal account of decision and action. Some deny this. Those of us who accept the possibility divide over whether it is welcome. “At the whim of those chemicals” may be too simple. As I said at the end of Chapter 24, agency with a causal story is still agency. But the studies just discussed suggest a considerable narrowing of possibilities when an adverse childhood is combined with just one genetic risk factor. If just these two factors change the picture in this way, how may things look when we know about many more?
Might not a full causal account mean that we are, after all, at the whim of a combination of our DNA, epigenetic factors influencing its expression, our mother’s anxiety during pregnancy, other influences in the womb, our brain chemistry, early parenting, our degree of secure attachment, and thousands of other interacting biological and social factors? If one day this is all understood, will we not be looking at a totally determinist picture? And will that picture really leave room for genuine agency?
Some of those worried by this would like determinism not to be true. They hope that there will, in principle, be some gaps in the causal story, so that not everything about our decisions and actions is even in principle predictable. But indeterminism does not give much help to free agency. How can we tell the difference between an uncaused event—say at the level of neurochemistry—and one whose cause just has not yet been discovered?
Perhaps an answer to this question might emerge from quantum physics. Even if a decision could be shown to be partly uncaused, though, there is the problem identified in the eighteenth century by David Hume. How does lack of a complete causal story make a decision free rather than just random?5 On a pessimistic view, free agency is incompatible with indeterminist randomness and with determinism. As these seem to exhaust the possibilities, free agency appears impossible. Perhaps this is too pessimistic. But looking for uncaused events is less promising than aiming for an account of agency compatible with determinism.
The first step toward this is to recognize that determinism does not entail the fatalist view that things will be as they will be, regardless of what people do. Fatalism has absurd implications. If it were true, a person’s decision to drive when drunk makes no difference to anything: the accident would have happened whatever he decided. This view need not detain us.
There is a slightly more subtle picture. Our decisions issue in actions that do make a difference to the world, but our genes, neurochemistry, and so on in turn are causal influences on our deliberation and our decisions. As we have seen, it is implausible in most cases to think of our deliberation as passive or ineffective. Through it, we can change what we most want. We can look at the possibly coercive environmental influences that shaped our values, and decide whether or not to make those values truly ours. We actively decide many things on the basis of weighing reasons, and what we decide leads to one kind of action, or toward becoming one kind of person rather than another. This may well be a fully causal process, but that does not make it less ours.
It is self-defeating to give determinism as a reason for deciding never to make decisions based on reasons. In a determinist world, our reasoning can be (and usually will be) part of the causal process influencing decision and action.
There is a tension between two views expressed in comments already quoted from different Broadmoor interviewees.
The first is: “I mean, I chose the route I’ve took, solely myself … I’ve chose it, so really my destiny as such was laid out by me. It wasn’t laid out before and said, ‘Right, your destiny is to end up in Broadmoor in 30 years’ time.’ I mean I actually walked the road that led me here. You know, no one pushed me along.”
These thoughts are completely right. But in psychiatry, as in much of life, they are often only one side of the story. Sometimes even where a person does decide on an action and carries it out, it would have been difficult or impossible to have chosen an alterative. This comes out in the second comment, from another interviewee: “It worries me that eventually I will do these things and I don’t want to particularly want to—difficult for me actually to say no to them … They involve kidnapping, rape and violence, and murder, so … If you could choose not to have these thoughts? I am trying to. That’s a choice that I’ve already made, that I’m trying … At the moment I’m trying chemical castration, to work on the fantasies, which will do away with the sex and the murder/violence fantasies that I have, but I ain’t having a great deal of success with it.”
Understanding these issues needs both these viewpoints on agency. This is a central dilemma for anyone thinking about the responsibility of people acting under the influence of some psychiatric disorders. These two quoted thoughts do not sit comfortably together, but each expresses an important truth applying far outside the walls of Broadmoor. Acts influenced by addiction are not “fated” but really are the person’s choice. Accepting agency rather than fatalism can be crucial in escaping addiction and other conditions. But it is also true that such psychiatric problems can greatly impair the power to choose.
Are the reactive attitudes appropriate as responses to antisocial acts of people who have been diagnosed with antisocial personality disorder?
What counts against this is that the condition is still at least partly, and perhaps largely, a piece of bad luck. There are constraints on self-creation. If the condition was caused by having particular genes, or by what happened in the womb, none of this was under the person’s control. If it was caused by parental rejection, cruelty, or abuse, none of this was the person’s own fault. Such people are themselves victims. So blame and resentment seem unfair.
On the other hand, to withhold the reactive attitudes is to exclude those individuals from a central part of human relationships. This also seems unfair. And it may be that participating in human relationships, including the spirals of reactive attitudes, is the only chance those individuals have to transcend the limits of their original personality.
The reactive attitudes are not totally under our control. We cannot just switch them on and off at will to bring about the best consequences. But we have a degree of choice about how far we do or do not inhibit them. To the extent that we have a choice of response (say, to aggressive violence stemming from antisocial personality disorder), something complex seems called for. This includes retaining the reactive attitudes to the person’s own appalling attitudes toward his victims. But it also includes remembering that he is a victim too, that his character has been badly shaped by causes largely outside his control. This dual response is not easy, as I found in the interviews in Broadmoor.
It is probably right that we cannot entirely, or even largely, abandon the reactive attitudes. It is also probably right that, even if we could, life would be impoverished if we did. But there is also a determinist thought that should make us uncomfortable about these attitudes. It is about those of us who do not have personality disorders. As Aristotle saw, we shape our characters by our own voluntary actions. Yet there is likely to be some causal explanation of how we came to choose some actions rather than others. And these causal explanations may often go back to factors beyond our control: to early childhood, or further back to the womb or to genes.
For us, as for those diagnosed with antisocial personality disorder, some important parts of our psychology certainly belong to us yet are not mainly of our own making. In the long run, the dual response we develop to people with some psychiatric disorders may turn out to be appropriate to the rest of us as well.