This paper traces how Christian representations madness and moral choice impacted Anglo-American healthcare models in the 19th and early 20th century. Theological associations between autonomy as self-governance and self-management framed modern psychology as a moral endeavor, shaping the management of psychiatric conditions as primarily related to controlling the will against the passions. Christian participation in residential schools and hospitals endorsed the utility of early psychology for the primary purpose of rehabilitating and normalizing individuals. Within this moral lexicon, psychiatric conditions are associated with compromised personhood, marking the borders of sanity through antithesis. Normalcy, sanity, and health function not only as the absence of flaw or psychosis, but as lack of dependency. The independent moral chooser is shaped as responsible for self-governance, literally auto nomos, while in contrast the person who displays traits of madness is shaped as morally irresponsible and unmanaged. In this way, madness is at the foundations of how Christians in modernity shaped moral choice, because madness demarcates the borders between health and illness, morality and immorality, freedom of choice and diminished capacity.
The legacy of psychiatric moralization impacts modern healthcare strategies today when treatment or management privileges independent self-assessment and the surveillance of individual choice over collaborative alternatives. However, by utilizing ethnographies of group therapy, I focus on how even daily management protocols for mood disorders contain ableist messaging that revolves around the association between self-management and moral individualism. For example, Talia Weiner observes that when people with psychosocial disabilities are asked to self-assess daily mood on a scale, they are required to approximate a non-disabled perspective of self, a type of self-reflexivity which is compromised by mood disorders themselves. This means that in the daily lives of persons with mood disorders, they are asked to attempt a type of self-assessment that is often outside the scope of their abilities. Yet, because the expectation of the moral individual is that independency is natural and self-management is a sign of independent decision-making, the default construction of care strategies for mood disorders often communicates that to be healthy is to be non-reliant.
However, I argue that not only is independent, individual decision-making not an ideal standard for persons with psychosocial disabilities, it derives from moral philosophies that do not relate to how people with disabilities make complex choices. This means that ableist philosophies are at the heart of the Christian representation of moral choice, not empirical or observed data about how persons actually make decisions in context. To address this ableist structure for moral choice, I argue that a model for distributed agency and participatory decision-making is required to place disability-positive choices models at the core of how we perceive psychosocial disabilities. I pull from Talia Weiner’s ethnographies of group therapy to explain key operational differences between independent choice models and what she calls distributed agency. She observes that in group therapy for bipolar disorder, daily self-management scales are not an effective strategy for rating mood. However, in her ethnography some persons thrive using self-assessments—people with robust support systems. Weiner observes that these individuals use the individual rating scales differently than intended, grafting in trusted others to help them assess daily fluctuations in mood. People who included trusted others in their self-assessments displayed a dramatic decrease in stigma stress, especially related to medical interventions like maintaining medications and accessing in-patient psychiatric care when necessary. This subgroup regarded their symptomology as morally neutral because they received destigmatized support from trusted others, meaning that they not only distributed some of their own agency to others when making choices, they also enjoyed a distribution of others’ agency into their decision-making. This participation of trusted others in the daily assessments and decisions of people with psychosocial disabilities augmented positive self-regard and other markers of wellbeing.
While persons without diagnosed conditions enjoy reliance on others in decision-making without the accusation of diminished capacity, persons with disabilities face castigation for social reliance, especially when making complex medical choices for their own care. By advocating for the recognition of distributed agency in moral choice, I argue that to overcome the legacy of negative disability representation in Christian theology and bioethics, we need to re-examine the expectations for how we choose. Human beings do not make complex choices in isolation. If we were to establish moral choice as a collaborative event rather than an individual capacity, this would allow Christian ethics begin with observation rather than philosophical expectations based on early modern models of moral choice.
By empirically assessing choice models in action, Christian ethics can then ask how the person chooses, by which model, and to what degree social cooperation with trusted others is available to the individual. How is the person facilitated? Is the social or material environment adequate to provide support for this person’s moral choice? This is an alternative approach to the status quo which assigns to those who exhibit greater social reliance a lessened moral status when it comes to personal and medical choice. I conclude that by reconsidering how people with psychosocial disabilities choose, we can shift decision-making paradigms to reflect how this population makes decisions. Such a change begins the work of reimagining symptom management models around the capabilities of people with psychosocial disabilities themselves, taking self-management out of the world of philosophical personhood and into the space of lived experience.
This paper traces how Christian representations of madness and moral choice impacted Anglo-American healthcare in the 19th and early 20th century. Theological associations between autonomy and self-management framed modern psychology as a moral endeavor and the management of psychiatric conditions as control of the will. Normalcy, sanity, and health function not only as absence of psychosis, but also as lack of dependency. Using ethnographies of group therapy, I examine how self-management models for mood disorders require individual and self-reflective capacities which are outside the grasp of a person with a mood disorder. Rather than reflecting lived experiences of people with psychosocial disabilities, many self-management strategies assume a self-governing and independent moral agent. I argue that distributed agency and participatory decision-making better describe how people with psychosocial disabilities display agency, structuring moral choice as a collaborative event rather than an individual capacity.