Hanna Pickard, D.Phil., is a professor and chair of philosophy of psychology at the University of Birmingham, and is a recently announced Johns Hopkins Bloomberg Distinguished Professor. Her work focuses on philosophy of mind, moral psychology and clinical ethics. Her philosophy is grounded in real-world issues, informed by her clinical experience and biomedical research, and is connected to criminal and mental health law and policy. She will be joining the Johns Hopkins University School of Medicine Berman Institute of Bioethics and the philosophy department this fall.

In this interview, we talk about how Dr. Pickard became interested in philosophy, how her experience in the clinic shaped her body of work, her perspective on addiction, pathology, the penal and health care systems, and so much more.

How did you become interested in philosophy?

I grew up with parents who were both law professors and politically engaged. My love of philosophy started at the family dinner table, where we had heated discussions about issues of social justice, but always approached with the kind of argumentative rigor found in law. Taking an analytic approach to questions that genuinely matter to people and society shapes my work to this day.

How does biomedical research shape your work?

Philosophy that engages with questions that matter needs to know the relevant facts, whether that is a new scientific or biomedical finding, or the lived experience of a person affected by an issue. I try to do philosophy in a way that I think of as “ground up,” so that philosophical problems grow out of real-world issues, and as a result, philosophical contributions to the solution genuinely feed back into the world.

You worked for a number of years at The Oxfordshire Complex Needs Service. How did your experience in the clinic shape your work?

This kind of “ground up” approach defines how I have tried to integrate my own clinical experience, of working with people with personality disorders and complex needs, with philosophy. I spent the last decade working part-time in a therapeutic community, learning about the lived experience of our group members and building relationships with them, as well as studying the relevant biomedical science and developing my own clinical practice. This experience raised a host of philosophical questions that I wanted to understand and solve. These questions dealt with the nature of mental disorder, agency, responsibility, blame, morality, rationality, the emotions, and the self and self-identity.

In particular, I was struck by the difference in the attitude we took as clinicians toward patients whose actions were morally wrong or seriously harmful, as compared to the attitude we tend to take in our society. Put very crudely, in my clinic, we treated people as responsible and accountable for their actions, but we did not blame them, despite the fact that the actions were harmful. This stance of “responsibility without blame,” as I came to call it, is in my view extremely important to effective intervention to help people change maladaptive behaviors, especially those characteristic of personality and substance use disorder (SUD).

Can you tell us a little bit more about your “responsibility without blame” framework?

When we are in a relationship with someone who acts in ways that are morally wrong or seriously harmful, it is easy to get trapped between two opposite kinds of response, what we might call a “rescue” stance or a “blame” stance. When we rescue someone, we typically offer help and show them compassion. But we don’t hold them responsible for their actions, and that can be disempowering and disabling. In contrast, when we blame someone, we typically hold them responsible, but we withhold help and compassion. Instead, we criticize, punish and stigmatize. So either we predicate the offer of help and compassion on the idea that the person couldn’t help it, or if we do acknowledge their agency and responsibility, then we become hostile toward them. The key idea of the responsibility without blame stance is very simple. Responsibility concerns the person themselves and their agency. That is, whether they had sufficient knowledge of what they were doing as well as choice and control to be accountable and able to change. In contrast, blame is about us and the nature of our response. Responsibility without blame allows us to occupy a middle ground. We can hold someone responsible and develop practices of accountability without criticizing, punishing and stigmatizing, but with compassion. This encourages them to do things differently in the future. In this way, a responsibility without blame stance is directed to a person’s future and how to support them to make their life better, rather than focused on condemning them for their past.

How does your responsibility without blame framework relate to addiction?

I developed the responsibility without blame framework working in a specialist service with people with personality disorder and complex needs, many of whom suffered from SUDs. Although SUDs raise many distinctive problems of their own, many of the clinical interventions we used for addressing behavior characteristic of personality disorders were also effective for addressing problematic drug use. In my view, the tendency to get trapped between a rescue and a blame stance is particularly pronounced in relation to addiction. This is because of a parallel polarization we currently find in contemporary society between a disease model and a moral model of addiction.

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Framing addiction as a neurobiological disease of compulsion removes responsibility by explaining drug use as compelled by pathological brain states. This can make it easier for others to maintain compassion for people with SUDs, and may also improve the prospect for funding for research and treatment. On pragmatic grounds, it is therefore highly preferable to the moral model of addiction, which treats drug use as a choice that is morally wrong and so, broadly speaking, advocates the punishment of people who use drugs.

I know my position is controversial, but despite rejecting the stigmatizing and punishing part of the moral model, I see problems and not just virtues in the disease model.

The first problem is that there is ever-increasing evidence both from human studies and animal models of addiction demonstrating that flexibility and goal-directedness is retained and that people (and rodents) choose alternative goods or abstinence across multiple choice settings even when addicted. Compulsion understood as the necessity or impossibility of not using drugs is simply not an apt characterization of addiction. However, having said that, I want immediately to follow it by saying that in no way do I want to underplay the strength of cravings or how difficult it is to choose not to use drugs if you are addicted. This is crucial to the lived experience of many people with SUDs. But if people with SUDs are not compelled but retain some choice, we do them no service by claiming otherwise.

Once we acknowledge that some choice is retained even when people are addicted, what we need to understand is why people choose to use drugs despite the multiple serious and harmful consequences that ensue. To answer this question, my research has argued that we need to take two kinds of consideration far more seriously than we currently do. The first point is that drugs have great value to people: Drugs have benefits, which is part of why people use them. This is true in many contexts, but especially when people are suffering and have no realistic hope for a better life or genuine and lasting alternative means to relieve suffering. The association between SUDs and factors like poverty, marginalization, unemployment, co-morbid mental disorders, and histories of abuse and mistreatment is not coincidental. The second point is that, in so far as addiction involves choice, it is a disorder of cognition. This means that we can use the models we have developed in cognitive science of human decision-making (and how it can be influenced and biased) to shed light on the nature of drug choices in addiction.

Both of these insights point to interventions that may allow us to better help people with SUDs: The first points to the need to address the socio-economic context and co-morbid disorders many people face, and the second points to the promise of developing interventions that counteract certain kinds of influence and biases in cognitive processes, promoting more positive choices.

The second problem I see with the disease model is that I believe that we do not yet understand enough about the idea of pathology, or have sufficient knowledge of the brain, for us to be certain that a disease label truly applies. Until we learn more, my own preference is to frame addiction as a disorder of choice — the concept of “disorder” being less committal than the concept of “disease.” Of course I would say this as a philosopher, but our words matter. Labeling addiction a disease may be preferable to a moral model of addiction, but it too has its costs. There is evidence that a disease label increases social ostracization and stigma, and reduces positive treatment outcomes — partially because it encourages people with SUDs to adopt a “sick role” and others to adopt a rescue stance, which is never a long-term solution when a disorder involves a person’s choices. So just as we need to find a middle ground between rescue and blame, we need to find a middle ground between a disease model and a moral model. That is part of why I see addiction as a disorder of choice.

What makes pathology difficult to define from a philosopher’s perspective?

A crude approximation of what we mean by pathology is that something is wrong with part of a person’s body. But wrong in what sense? One thing that is clear is that by “wrong” we do not simply mean statistically atypical. Diseases can be universal within a population, and many statistically rare conditions are not diseases. Rather, by “wrong” we mean something akin to the idea that a part of a person’s body is not functioning as it should. But to understand this we need an account of what it would be for that body part to function properly: only then do we have a standard by which to begin to measure dysfunction.

We have a good understanding of the proper function of some body parts; e.g., the heart. We have less understanding of others at this point in the history of biomedical science; e.g., the brain. I am agnostic about whether the cognitive states and processes that underpin drug choices in addiction are pathological or not. The reason is that I don’t think we yet know enough about how the brain is supposed to function, both in general and in particular in response to drugs. Although technological advances have increased both the potency of drugs and the speed of delivery, there is good evidence that drug consumption has long been part of our evolutionary history. I would simply like us to do more research, both theoretical and empirical, before we claim to know for certain that the brain states and processes that we find in people who have an SUD are pathological. This caution seems especially advisable to me given that the disease label has costs as well as virtues.

From your perspective, what changes to the health care and penal systems are needed to better address addiction? What changes are needed in our socially accepted understanding of addiction, and do these changes necessarily need to come first?

My view can be captured in three basic principles.

First, we ought to decriminalize all drug use and regulate it instead. I know of no good theory of the scope of the criminal law that justifies a criminal sanction on private individual conduct such as drug consumption. The state’s involvement in the drug use of its citizens should be regulatory only, and so involve the oversight and control of production and distribution, as well as the imposition of various kinds of safeguards and the provision of adequate drug safety education. Of course, this is easier said than done, and working out the details of the ideal forms of regulation is both complicated and necessarily a question of trial and error. But some of the successes and practices we find in countries like Portugal and Switzerland can provide some initial guidance.

Second, we must address the multiple forms of disadvantage and vulnerability that are associated with risk of developing an SUD. This is in any case a matter of social justice, so its importance to combating addiction is simply one more good reason among the many we already have to combat inequality, adversity and mistreatment, and create a society where all of us have the chance to flourish.

Third, we must offer more and better treatment for SUDs. There are innovative interventions that have been developed here at Johns Hopkins, including the Therapeutic Workplace model, which was developed by Ken Silverman, and the psilocybin-assisted therapy for addiction, which was developed by Roland Griffiths. But we must also remove barriers from all forms of currently available treatment, including harm minimization approaches such as medication-assisted therapy and clean needles. Too often in relation to SUDs, our willingness to offer treatment we know could make a difference to someone’s life is predicated on their compliance — not simply with the treatment itself but with our view of morality and how they ought to live. I think that one of the key reasons why we fail to help people and address the terrible damage that addiction inflicts on so many is that even those who adopt a disease model of addiction and care deeply about helping people with SUDs sometimes continue to moralize drug use and see it as wrong. We need to challenge that tendency to moralism in ourselves in order to both morally and clinically appropriately treat people who take drugs.

What are you most looking forward to about joining The Johns Hopkins University? What research directions are you hoping to explore?

There is so much I am looking forward to about joining Johns Hopkins, but two things stand out in particular.

The first is the opportunity to collaborate with so many excellent and innovative scientists, clinicians and scholars across the university. My own research has been deeply interdisciplinary as well as collaborative for a long time, and it’s so exciting to be taking up a Bloomberg Distinguished Professorship, where this approach defines the nature of the appointment. I’ve often said jokingly in the past that I have no respect for disciplinary boundaries. Now I don’t need to!

The second is the opportunity to be part of the philosophy department at this amazing time in its history, where thanks to the extraordinarily generous donation of alumnus Bill Miller, the department will be more or less doubling in size, and in so doing has the chance to develop its own distinctive style and culture of philosophy. It’s a wonderful time to be joining!

Coffee or tea?

Tea.

Spring or autumn?

Spring. I love the warmth and the blossom after winter.

If you were on an island for 100 days and could only bring one book, which would it be?

One book could never last 100 days. Could I bring swimming goggles instead?

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