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Affectivity and Identity in the Treatment of mood Disorders
1. Mood disorders and the “real self”
circumstances authentically identify with S3? In order to bring into focus what is at issue here, I will now explore It is not uncommon to hear patients who suffer one specific important aspect that is often reported to differ from depression complain that they are not themselves. Given that their lives during a depressive episode may be profoundly changed, it is often easy to agree. But what does it mean to agree here? “Not being themselves” in this context refers to qualitative changes that have occurred in 2. Medication and moral sensibilities
their way of being, including changes in personality and It has long been known that changes in mood can self-understanding. I will use the term “self” to refer to go together with changes in moral sensibilities. Moral periods of a distinguishable personality pattern in a scrupulosity is a frequent characteristic of depression, and person’s life, without further discussion of their there is typically some moral carelessness in persons who metaphysical status or the criteria for a distinction between experience mania. There is also evidence that some kinds of anti-depressant medication (e.g. Prozac) may affect not Given the person with a mood disorder who only mood, but also moral sensibilities, and promote shifts considers herself not really “herself” any more, what towards greater moral indifference (cp. Kramer 1997, Sobo happens when she takes medication and the symptoms 1999, 2001, Elfenbein 1995). That is, during the use of disappear? I will now assume for the sake of simplicity (but medication, the person seems to be more morally incorrectly)2 that patients generally consider their illness self S2 as alien to their usual self S1. Three different Such malleability of moral sensibilities is an possible reactions to medication can thus be distinguished: interesting phenomenon, especially in the context of (i) First, there are those who just seem go back from S2 to discussions of personal identity. Given that moral their usual self S1 that represents what they “really” are. commitments are generally acknowledged to be an They may have some side effects from the medication, but important part of a person’s identity, how will such changes do not consider these to be relevant. (ii) Then there are affect those who experience them? Empirically, reactions those who perceive the effects of medication as changing among patients who experience such changes seem to fall their personality. In this case, S1 is what they remember being before S2. However, instead of regaining their “real self” through medication, they are now left with S3, which (i) Some patients are rather disturbed when they despite many similarities to S1 still seems alien to them. notice these changes, and struggle to keep up their This can happen in the treatment of bipolar disorder with previous moral standards. Their current moral sensibilities lithium, as well as in the treatment of depression with some as S3 appear to them inadequate when compared with S1. antidepressants (e.g. Jamison 1995, Elfenbein 1995). (iii) Despite experiencing a certain degree of moral Finally, there are those cases in which patients again indifference now, the patients still think that they were perceive the resulting S3 as different from S1, but now see morally right when they perceived the moral demands of S1 as comparatively lacking. From the standpoint of S3, situations differently. Interestingly, just being cognitively they judge S1 as alien, while S3 is now considered to be aware of this experiential difference seems not to be their “real self”. This phenomenon has sometimes been enough. While using the medication, patients seem not to observed in the treatment of depression, usually with be able to fully make up cognitively for the experiential SSRIs, and famously depicted in Peter Kramer’s bestseller difference and act as they would think right. As a consequence, they may choose to rather go back to a Listening to Prozac (also Elfenbein 1995 and Thompson 1995). state of depression than compromise their moral standards (Sobo 2001). How should the difference between these cases be understood? The first case seems straightforward – a (ii) Alternatively, other patients may also be aware “mental illness” has interrupted the person’s usual way of of similar changes, but not be worried by them. Instead, being and behaving; once this disruption is under control, they consider their current moral sensibilities as more she can go on living her life as usual. The second case, adequate than their previous ones. That is, the more rigid again, does not seem mysterious. Psychotropic medication moral standards of S1 are now regarded as obsolete for has a pervasive influence on the patient’s nervous system. S3. Not only do these patients not experience the urgency Its use may be necessary for keeping the “mental illness” of certain moral demands any more, but they also explicitly at bay, however, it is not surprising that a person under its discount their validity now, despite being well aware that influence may not feel entirely the same way about herself previously they had thought otherwise about them (Kramer as before. However, the third case seems puzzling. How is it possible that a person can regard as her “real self” what she has only experienced under the influence of medication, and moreover only for a very brief time? The 3. Medication and the inauthentic self
worry behind this question seems to be above all a worry When confronted with such changes in personality about authenticity – can a person under these that have been brought about through medication, the first impulse seems to be to consider them as alien. That is, the 1 I do not want to discuss here whether such “selves” are e.g. Parfitian selves patient herself would be considered as suffering from (Parfit 1989). What I want to draw attention to resembles what Taylor refers to as “identity” (Taylor 1992), or what Quante cal s “personality” (Quante 1999 some kind of self-deception if she insists on identifying with S3. Different reasons can be given for this attitude: Some 2 For positive accounts of the experience of depression, cp. Martin 1999 or critics would assume that any interference which is not due Affectivity and Identity in the Treatment of mood Disorders - Heike Schmidt-Felzmann to internal or “natural” causes has to be alien to the “real motivated.4 I would want to argue that the kind of self”; others would only accept changes as authentic when authenticity that is at issue when the role of medication is they come about as a result of a process of rational concerned does not usually seem to imply a highly reasoning; others would claim that authenticity depends on demanding understanding of authenticity. At least for many the exercise of autonomous choice in a very strong sense of the critics, their worry is rather linked more specifically to the sudden appearance switch in value orientation, and the apparent causal role of medication in it. But is this really How is it possible that persons nevertheless come sufficient for a de-authorization of the personal to identify with S3 as their “real self”? First of all, the identification with S3? Sudden onset of value changes can influence of medication could be understood as be found at other times, e.g. in religious conversions. intoxication. That is, while patients are under the influence Should we discount these as well, despite their of the medication, they are presumably not in a state in considerable significance for those who experience them? which they can judge these matters correctly. While it may The main issue here is probably that these changes are seem to them that they have the ability to judge their due to the use of some specifiable chemical agent. former moral convictions as invalid, they are in fact However, given that the intoxication model is inadequate, mistaken, and just unable to acknowledge their what does the problem consist in? After all, chemicals influence everybody’s way of perceiving the world; human Another possibility is the hedonist explanation, psychological life is dependent on the action of exactly based on the assumption that people prefer feeling better such chemicals. Establishing a significant difference to feeling worse. Accordingly, patients may endorse S3 between medication and the usual brain chemicals that is because it suddenly turns out to be much nicer to live that relevant for the question of authenticity would require more way. However, while understandable, just feeling good will not be enough to warrant the endorsement of S3. In other What is perhaps most irritating in these cases, words, endorsing S3 is ultimately a sign of moral especially for philosophers, is the apparently non-rational weakness and not of authentic choice; it means to give in way in which values are changed. However, it is important to note that these changes are not to be understood in Alternatively, there is the explanation from social terms of chemical brain washing: None of the patients values: S3 may be endorsed because it is correlated with wakes up and finds that overnight a completely different enhanced fulfillment of certain social norms. Given the set of beliefs has been installed. Instead, it is their affective current cultural stereotypes, it is no wonder that it is experience that has changed, and with it the comparative Prozac, a medication that seems to bring about carefree, salience of morally relevant features in their experience. outgoing, assertive and socially adaptive behavior, that is Apparently, changes in affective experience can shape a particularly often involved in cases of endorsement of S3. person’s general moral outlook to a significant degree. Once the medication has enabled patients to receive social Interestingly, such experience seems to present itself to rewards, so the critic, the formerly accepted restrictive the person as having a certain intrinsic authority, so that moral norms may now seem insignificant. Identification following its demands may be perceived as justified in with S3 and rejection of S1 would again turn out to rely on virtue of its affective characteristics (and it will not e.g. be the wrong kind of motives and not support the claim that seen as giving in to a temptation).5 Nevertheless, this is an authentic endorsement of S3.3 accepting the evaluative authority of affective experience does not seem to be an automatism. Persons under the influence of anti-depressant medication are still able to 4. The possibility of authenticity
reflect rationally and may even come to the conclusion that their current experience does not do justice to their moral Is there any reason to assume that the critics may be mistaken in their diagnosis of S3 as inauthentic? As I want to argue, there is. The main worry in the criticisms in In the absence of serious impairments, it does not the previous section is concerned with the nature of the seem justified to discount the patients’ endorsement of S3 patients’ rejection of formerly held moral values. This is as inauthentic. The identification with S3 is apparently indeed a puzzling phenomenon, but I do not think the de- viable in the patients’ lives (Kramer 1997, Elfenbein 1995). authorization of the patients’ self-understanding is If the same value changes had occurred independently of the use of medication, de-authorization of the perspective of these fully competent persons would not have seemed First of all, there is little indication that the warranted. One may perhaps doubt the value of their intoxication model correctly represents the effects of anti- specific form of life, but one should be aware that this depressant medication. The medication brightens patients’ makes them no different from many other cases. If what mood and has some circumscribed side-effects, but does we mean by authenticity is not something that succeeds not usually lead to any significant impairment. (Also, only rarely and requires extraordinary efforts, then the neurophysiologically, these anti-depressants do not target specific causal role of medication does not seem to those transmitters usually involved in substances of provide sufficient reason against the possibility of abuse.) The observable changes at least will not be authenticity in this case. In being so visibly dependent on sufficient to establish the presence of an “intoxication” that the presence of affective factors, this case is perhaps just could justify discounting their judgments. a particularly clear example of what is more generally involved in the endorsement of value. What about the hedonist and social values explanations? Both assume that the nature of the value change is of a kind that justifies regarding it as inauthentic. 4 Arguably, some of the critics who take depressives to have special insight However, taking their criticism seriously would entail that authentic selves are extraordinarily hard to come by in This is also supported by observations in more extreme cases of depression and mania. While the episode lasts, patients with depression will frequently ordinary life, as apparently many people are similarly explain why they are indeed as moral y blameworthy as they feel, and patients with mania are usually convinced that acting on their impulses is fully justified. After the episode is over, both will usually revert to their former understanding of values. – For some neuroscientific evidence of the specific role of affective factors in moral reasoning see also the results of the recent fMRI study by 3 For other accounts of similar worries, see also Kramer 1997 and the Affectivity and Identity in the Treatment of mood Disorders - Heike Schmidt-Felzmann References
Elfenbein, D. (ed.) 1995 Living with Prozac and Other Selective Serotonin-Reuptake Inhibitors – Personal Accounts of Life on Antidepressants, New York: HarperCollins. Graham, G. 1990 “Melancholic Epistemology”, Synthese, 82, 399- Greene, J. et al. 2001 “An fMRI investigation of emotional engagement in moral judgment”, Science, 293, 2105–2108. Hastings Center Report 2000 “Prozac and Alienation”, Hastings Jamison, K. R. 1995 An Unquiet Mind, New York: A. Knopf. Kramer, P. 1997 Listening to Prozac, New York: Penguin. Martin, M. 1999 “Depression: Illness, Insight, and Identity”, Philosophy, Psychiatry, and Psychology, 6, 271-286. Parfit, D. 1989 Reasons and Persons, Oxford: Clarendon Press. Quante, M. 1999 “Precedent Autonomy and Personal Identity”, Kennedy Institute of Ethics Journal, 9, 365-381. Quante, M. 2002 Personales Leben und menschlicher Tod – Personale Identität als Prinzip der medizinischen Ethik, Frankfurt a.M.: Suhrkamp. Sobo, S. 1999 “Psychotherapy Perspectives in Medication Management”, Psychiatric Times, 16(4). Sobo, S. 2001 “A Reevaluation of the Relationship between Psychiatric Diagnoses and Chemical Imbalances”, http://ourworld.cs.com/ssobo2/myhomepage. Taylor, Ch. 1992 The Ethics of Authenticity, Cambridge: Harvard Thompson, T. 1995 The Beast – A Reckoning with Depression,

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