Chapter

How do I learn to be me again? Autonomy, life skills, and identity

Grant Gillett

in Autonomy and Mental Disorder

Published on behalf of Oxford University Press

Published in print April 2012 | ISBN: 9780199595426
Published online February 2013 | e-ISBN: 9780191754739 | DOI: http://dx.doi.org/10.1093/med/9780199595426.003.0040

Series: International Perspectives in Philosophy & Psychiatry

How do I learn to be me again? Autonomy, life skills, and identity

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Autonomy is a key concept in contemporary ethics and particularly the ethics of mental healthcare. But what is it? When we ask about the term we are faced with related concepts like ‘the will’, ‘volition’, ‘self rule’, ‘reason’, and ‘competence’.

Under this last guise, autonomy as an ethical value can function as the legitimation of what is effectively a search and disable policy aimed at those who are differently oriented in the human life-world. This policy can affect both the elderly and mental health survivors both of whom may be considered to suffer from a defect of volition due to mental incompetence. For many, experiences of marginalization have caused a re-evaluation of the values around which their lives are organized and that distances them from an all-in conception of reason-governed action in terms of the choices regarded by most as normal rather than pathological.

Autonomy, as many note, means self-rule and is often taken to imply that autonomous decisions are made according to consciously endorsed reasons or principles. But many reasons that are well within the range of ‘normal’ (in developed societies) can be so seriously distorted in favour of self-interest and individual economy that a psychopath can look normal and rational despite his obvious social dysfunction.

The idea of self-determination, wherever it leads, and whatever value or preference structure is in play, is a widely accepted norm in our understanding of autonomy despite the fact that none of us is an island and that some life plans are inadequate in terms of the realities of human well-being and our relational needs involving support, recognition, dependence, and so on. In fact, being ‘held’ in life can be the key to living well for many human beings (Nelson 2002). The mean and lean view of autonomy as self-determination falters, for instance, in the (sometimes skeletally thin) face of anorexia where a steely will drives an apparently rational person to die from starvation. The common take on responsibility and agency, based on an individualist ethos, has it that a person owns his or her own actions so that s/he is responsible for them, in the sense of having opted for them as a conscious expression of self and identity. A more inclusive or relational view relates responsibility and responsivity or right awareness and sensitivity to the life situation in which one finds oneself.

The individualist model has a further defect in that it often fails to distinguish between means-end reasoning where a person endorses pathological ends (reflecting desires and other inner states no matter how dysfunctional they are), and the autonomy of a strong-willed human being who exhibits self-governance such that s/he constructs a life that is sustainable. A sustainable life, richly aware of and appropriately in tune with others, is plausibly a healthy mode of being-in-the-world-with-others in which responsiveness to reason or argument informs projects and interactions (Nussbaum 1990). One might, for instance, think of the kinds of reason exhibited in anorexia (Giordano 2005) or psychopathy (Gillett 2009), as not showing this feature in very different ways. However, the difficulty with constructing an “ought” for autonomy that goes beyond plain matters of truth and ventures into prescriptions for a good life is that health and well-being are intrinsically evaluative concepts and, given the variations in human ways of being, permit a wide range of choices (Nussbaum 1994).

I will therefore discuss the notion of autonomy by trying to determine what constitutes a life that is genuinely meaningful and worthy of a human being and ask what is the proper role of reason in such a life. Phillipa Foot has described such a life as requiring a person to enlist in a collective of ‘volunteers banded together to fight for liberty and justice and against inhumanity and oppression’ (Foot 1978, p. 167), so that certain guiding values come into play.

The question of argument and the will allows me to examine the concept of the will within a neo-Aristotelian framework that grounds a discussion of Foucault’s cura sui (care of the self). An interpretation of autonomy and cura sui, compatible with a journey metaphor, can then be developed such that autonomy, in mental health particularly but also on a wider stage, emerges as a collaborative project of acquiring the skills to translate the results of formative conversations (or ‘argument’, broadly construed) into effective action so that one makes sustainable and realistic decisions and, in the process, learns to participate in and take strength from the lives of others.

Chapter.  7147 words. 

Subjects: Psychiatry

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