In the introduction to The Virtue of Defiance and Psychiatric Engagement, Nancy Nyquist Potter warns her readers that the book may satisfy neither philosophers nor psychiatrists.  As an interdisciplinary effort, her project is ambitious – it is to update Aristotelian virtue theory in light of the complexities and injustices of contemporary life, especially with respect to persons with mental health problems; and then to persuade psychiatrists not only that patient defiance should be evaluated for virtuosity, but that psychiatrists need to cultivate in ourselves a newly proposed virtue to give it meaning, “giving uptake”. Dr. Potter warns us at the beginning that her theories of defiance and of giving uptake are incomplete, which I kept in mind as I read the book.  Twice. My impression after these two readings is that the book is not unsatisfying so much as it is provocative.  This is a rich and important book, a fascinating read that will spur further thought by both philosophers and psychiatrists. 

Potter starts orienting readers to the problem of defiance by reframing the phenomenon of medical noncompliance, teasing apart myriad reasons why someone might not choose to take medication prescribed for him. She situates the choice not to take medication as a decision made by someone who is socially disadvantaged by her mental health problems, problems often compounded by other socioeconomic ills, such as poverty, racism, gender, sexual orientation, and narrow cultural expectations. Potter builds her theory of defiance by reviewing Aristotelian virtues as cultivated dispositions that contribute to human flourishing, but quickly reminds us that ours is not the ideal society Aristotle imagined. Defiance for Potter is a response to authority, specifically to the way authoritative bodies use power to control subordinates. Potter builds her theory on political and literary examples, but consistently brings the discussion back to the fact that psychiatry is an authoritative body with entrenched norms and values, with a great deal of social power to limit individual freedoms and restrict patients’ flourishing. As Potter sees it, a cultivated disposition to defiance, together with proper reasoning about the situation at hand, can turn defiance into a virtue for the oppressed. The problem is that in psychiatry, defiance is often dismissed as a symptom of a problem to be cured, rather than an appropriate and effective expression of dissatisfaction with the power structure of psychiatry.

In order to make defiance plausible as a virtue, Potter dissociates it from Aristotle’s view of flourishing according to essential function.  For Potter, psychiatry’s tacit sense of essential human function (and dysfunction) is part of what makes it oppressive. Unchallenged, entrenched psychiatric attitudes and norms can lead psychiatrists to misinterpret behaviors that may be products of oppression, injustice, and adversity rather than mental illness. Further, these expectations about normal human functioning can lead psychiatrists to overgeneralize about cognitive, affective, or behavioral limitations that manifest in persons with specific diagnoses.

Potter also dissociates human flourishing from excellent reasoning. She argues that “good enough” and “post hoc” reasoning is sufficient for defiance to be a virtue. Since defiance, unlike classical Aristotelian virtues, entails acting spontaneously in situations in which proper phronesis is unsuitable, and since psychiatric norms of rationality may themselves be oppressive for persons with mental illness, strict standards of “excellent reasoning” need to be relinquished, or at least relaxed.

Potter modifies the Aristotelian conception of human flourishing with respect to persons with various mental health problems. Drawing on Tessman’s concept of “burdened virtues” –virtues that, even when cultivated and exhibited appropriately, do not contribute to a person’s flourishing – Potter provides a nuanced conception of flourishing that varies from Aristotle’s eudaimonia. Imperfect flourishing involves (1) giving and receiving attentiveness, sensitivity, and positive concern for great suffering without destroying the self; (2) an adequate recognition of interdependence that entails mutuality; (3) a reduction in moral damage; (4) a decrease in the existence of burdened virtues; and (5) access to the expression of basic capabilities [p. 66]. This set of conditions for flourishing under nonideal life circumstances is central to Potter’s argument that defiance can be a virtue. According to these elements, virtuous defiance addresses power inequalities that destroy the self, do moral harm, return at least some of the reward to a virtuous life, and allow the expression of personal strengths and abilities. The virtue of defiance lies in resisting moral harms in order to restore one’s own moral agency and equality, even if doing so requires spontaneity rather than conditioning, and post hoc justification rather than temporally prior practical reasoning.

The challenge, then, is to provide both psychiatric patients and providers the tools to recognize virtuous and vicious defiance. Potter recognizes that, especially in psychiatric settings, patients’ subjective experiences of moral harm are not always satisfactory signals for how and when to express defiance. Potter describes which circumstances for and expressions of defiance are virtuous, but at the same time recognizes that the conditions in which defiance is demonstrated are themselves normative, and thus also require social negotiation. As Potter puts it, “in order for our actions to count as reasonable ones to perform, we need to be able to give reasons for choosing a particular action. Giving reasons, though, turns out to require that those reasons follow certain norms for justification.” [p. 128] In other words, Potter sets herself a philosophical problem that borders on paradox: how do mentally and socially disadvantaged persons reasonably express defiance with spontaneity, passion, and yet dispositional conditioning, in a manner that can be justified within the social norms that partly sanction the oppression such persons experience in the first place?

Potter identifies six social norms that together make the difference between virtuous and vicious defiance, e.g., that make practical reasoning about the expression of defiance “good enough.”  These six norms of practical reasoning constitute the heart of her project. The first norm of practical reasoning is inclusivity – can one generalize or abstract one’s particular situation to a principle that might hold true across a set of cases, even if the principle is not fully generalizable? The second is domain specificity – can we take into account local norms that acknowledge the moral agency of defiant persons whose defiance is necessary for self-preservation? The third is intelligibility – can the practical reasoning that leads to defiant behavior be made comprehensible to others who may not share local norms? The fourth norm is followability – are the reasons for defiance ones that, given the particularities of the case, we would want others to adopt? The fifth norm of practical reasoning is accountability – can we express defiance in a way that expresses a willingness to be accountable to the larger society for that choice? Finally, the sixth norm is spontaneity – given that the nature of defiance requires spontaneity, can we cultivate a disposition for it that allows one to act defiantly in the moment, but not in a manner that is purely – “merely” – impulsive? Potter concludes that defiance is a virtue when it arises as a response to harm or injustice, is self-preserving, expresses at least some components of practical reasoning, expresses a mean (rather than an extreme) for affect and passion, is done from a dispositional state of spontaneity, and does not contribute to further harms that are themselves oppressive or unjust [p. 132].

Unfortunately, Potter says little about how a defiant individual might conduct such imperfect practical reasoning. How do I express defiance in a manner that makes clear that I am expressing a cultivated virtue by acting defiantly, when those around me already dismiss my agency, or reasoning capacity, or perspective or voice? In my defiance, how do I express my grievance in the correct voice, to a receptive audience, with the right degree of passion, in a way that I can justify, or at least make intelligible after the fact? Potter doesn’t address this question directly, but instead turns to how psychiatry can provide an environment that can discriminate virtuous from vicious defiance, and respond well to the virtuous.

In a single chapter, Potter introduces a new virtue for psychiatrists to cultivate, which she calls the virtue of “giving uptake”. Giving uptake is the reciprocal virtue that makes patients’ virtuous defiance meaningful. This section of the book is meant to persuade psychiatrists to understand our own socioeconomically and politically privileged positions, and appreciate how ignorance and resistance keep us from being fully receptive to patients’ virtuous defiance. Potter compels psychiatrists to cultivate in ourselves the epistemological and ethical virtue of being able to recognize when our own privilege makes it easier to ignore the experiences of our patients and the social forces that shape them than to acknowledge and empathize with them. Potter wants us to challenge our unconscious but “willful” ignorance of life circumstances and institutional oppression of those we want to help. She wants us to be willing and able to “decenter” ourselves from our own world views, and overcome our own discomfort, in order to recognize virtuous expressions of defiance – to be able to hear the self-preserving objections to injustices many psychiatric service users experience, and to overcome dispositional resistance to self-correction.

In Potter’s words: “By giving uptake, the psychiatrist indicates to the patient: you can count on me to take you seriously according to your idea of seriousness and not mine alone; you can expect me to treat your picture of the world seriously and take your defiance seriously. To take defiance seriously is to recognize the call another is making to the listener, a call that often requires the listener to suspect or critically examine norms that he or she is upholding and practices that may not benefit the defiant patient. Taking defiance seriously means that the psychiatrist is willing to consider the possibility that he or she is implicated in reproducing and reinforcing burdened virtues in ways that can be damaging to others. …The psychiatrist does not assume that the defiant one has a mental disorder or that a particular expression of defiance is merely symptomatic” [pp. 148-9].

I feel compelled by this description.  On the one hand, I want to be a practitioner who has the disposition, discernment, and patience to see beyond patients’ outrage, to refrain from taking outbursts personally, and to assist authentically with problem solving rather than forcing persons whose circumstances I cannot appreciate into a world of my own expectations and limitations. I want to cultivate the habit of giving uptake.

But on the other hand, I feel defensive. I feel defensive because giving uptake sounds not virtuous, but heroic. How do emergency psychiatrists give uptake when time is scarce and one’s other virtues and talents (e.g., efficiency) are also in high demand? How do inpatient psychiatrists give uptake while maintaining a safe environment on the ward, with consistent applications of ward rules and policies? How do outpatient psychiatrists give uptake when a defiant patient refuses to leave the office after a session? Are community psychiatrists better at giving uptake simply by virtue of being closer to the harms and injustices their patients experience? If so, is giving uptake still a virtue for them – is it still a disposition to cultivate, or is it merely part of the practice setting? I feel defensive because giving uptake sounds like what psychiatric professionalism already calls for, but in a manner that requires considerably more moral effort.

I know that Dr. Potter would respond to my defensiveness supportively. She would remind me that cultivating virtue simply is difficult; it requires that we strive to improve on our characteristics that may already be laudable traits, but are not yet virtues. She would remind me that giving uptake is a mean rather than an extreme: i.e., giving uptake to nonvirtuous defiance would not be a virtue, but rather a waste of time and effort. Dr. Potter would remind me that my psychiatric code of ethics already requires me to work to alleviate injustices in the world that affect my patients, so why not start with improving my own good habits of becoming aware of injustices and personally striving to minimize my perpetuation of them [American Psychiatric Association, Principles of Medical Ethics with Annotations Especially Applicable for Psychiatry, 2013 edition].

I feel temporarily appeased, but I want more. This is the beauty of Potter’s book. I want more because there is so much more to be said on the subject of how psychiatrists willfully ignore and perpetuate injustices, and how we might start making local changes. There is so much more to be said about how all people, but especially persons with mental health problems, can cultivate the virtue of defiance in a world that might not appreciate the virtuosity. This incompleteness is not the book’s failure, but its success. I want more because The Virtue of Defiance and Psychiatric Engagement raises questions that should captivate both moral theorists and psychiatrists. Potter has started the conversation for us to continue, whether or not we feel defensive about it. 

© 2017 Claire Pouncey

Claire Pouncey, MD, Ph.D., Philadelphia