It's Not Your Fault, But it is Your Responsibility

Alex chats about how our backgrounds shape us and how we can use different ideas psychiatry, psychotherapy and philosophy to make sense of it all. We'll break down the idea that "It's not your fault but it is your responsibility," and explore how finding the right balance between acceptance and responsibility can help us lead better lives.

Dr. Alex Curmi is a consultant general adult psychiatrist with a sub-speciality in addictions who completed his training in the South London and Maudsley NHS foundation trust. In addition to general adult psychiatry he has a special interest in psychotherapy and mindfulness meditation.

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Transcript

Welcome back to the podcast. My name is Alex. I'm a consultant psychiatrist. As I said last week, I'm traveling for a couple of weeks, but I wanted to share another quick idea for you this week, which is called It's not Your fault, but it is Your responsibility. When I started working in psychiatry almost ten years ago, it was quite a bewildering experience for lots of reasons. I'd already been a doctor for about three years at that point, so I'd already seen a lot of illness and suffering, but obviously when you go into psychiatry, it's a little different. And in that you see a lot of psychological and emotional suffering, which has a different tone altogether. And what became apparent very quickly is that when it comes to psychiatric and psychological problems, as with medical problems, a person's psychological and their social background plays a huge role as well as their biological predispositions. I was seeing people from deprived social areas, often people who had faced a lot of racial discrimination or economic challenges and so on. I saw people who came from broken and dysfunctional families, families, widows, crime, drug addiction, different forms of abuse, etc.. Often it felt that a patient's psychological problems were an almost inevitable outcome of the sum of all of these experiences. And as a psychiatrist, part of your job was to help them understand what happened and to make some sense of it, and gradually to begin to free themselves from the hole their past experiences had on them. But before I could do that, I felt I had to understand that myself. It was difficult to understand. It was mysterious to me. What I noticed about psychiatry was that although the research could easily describe the different biological, psychological, and social causes of mental health problems, psychiatrists themselves were often quite detached in terms of how they would discuss these causes with patients. Often they abstained from having matter of fact conversations about what in a patient's past may have contributed to their current situation, and they were even more agnostic about an attitude the patient should have in order to move forward with their lives. The psychiatrists I worked under would often prescribe lots of different solutions, like medications or a referral for therapy or sleep hygiene tips. But there was a distinct lack of an ethos, a set of principles that the patient could take with them in order to think about the roots of their suffering and how to move on from there. I began to understand that as a medical specialty, psychiatry had both the advantage and disadvantage of remaining coldly clinical about the causes of people's problems. This was often helpful when dealing with what was felt to be a largely biological problem, like a drug induced psychotic episode, or maybe a case of Alzheimer's dementia. But it felt like a starkly impotent approach when dealing with other problems like, for example, a middle aged man becoming depressed following a divorce or a 35 year old woman dealing with a ten year addiction to ketamine, or a 15 year old girl coming in to accident and emergency after taking an overdose? Often it felt like psychiatry had a pastoral nature to it. We were counselling people in the depths of their darkest moments, but it felt like we were priests without religion, or more specifically, without a way of making meaning of the difficulties of life. Being the person that I am. At that time I was reading many books about psychology. Different forms of psychotherapy like psychoanalysis, cognitive behavioral therapy, Gestalt psychotherapy and so on. And I was also reading books about eastern philosophy and Christian philosophy. And I was also trying to contextualize what I was learning in terms of my life and my own personal experiences, and what had until that point helped me to improve the quality of my own life. As part of our psychiatry training, we also have to see a patient for psychodynamic therapy for a year and the patient for cognitive behavioral therapy for three months, which were both very useful experiences to round out my training. What I found refreshing about reading these books and approaching patients in a bit of a different way was that rather than just providing a set of prescriptions for patients, it also offered a system that people could use to make sense of their lives and different ways people could begin to position themselves in relation to the ups and downs of life. There's obviously a huge amount to say about this, but one of the really salient points I found common to all of these ways of thinking was an emphasis on personal responsibility. The idea that, barring exceptional circumstances, you are basically the only person who can meaningfully take steps to significantly improve your life. This mirrors an idea we discussed in a previous audio essay about self-sabotage, in which we put forward the notion that you are probably the main obstacle to your life getting better. Fortunately, it works the other way as well. You are probably the only person who can make things better. I thought a lot about how all these contradicting ideas from psychiatry, psychotherapy and philosophy could be communicated to someone concisely in a patient consultation. On the one hand, people were clearly a product of the things that happened to them. On the other hand, there was no one better suited to make the decisions and changes necessary in a person's life than that person themselves. Eventually, after thinking about it for a while, I landed on a mantra which has been helpful for me, which goes something like it's not your fault, but it is your responsibility. Although I might not use this mantra explicitly in a consultation, although sometimes I do. It's a way of thinking that can help to inform how I might communicate different aspects of a patient's diagnosis or management plan with them. I think a statement like this can help to capture two fundamental aspects of everyone's predicament that to some extent, we are at the effect of what happens to us. Issues of chance and faith. What Martin Heidegger called thoroughness in his 1927 book Being on Time. There are certain unalterable facts of our existence, like our birth, our physical characteristics, our early environment, etc. the world we are thrust into with regards to mental health problems, there's a lot of debate about the relative importance of biological, social and psychological factors, but the thing that unites them all is that you don't meaningfully choose any of them, at least not at the start of your life. At the same time, we have agency in our lives and the ability to will certain things into existence to shape different courses our life could take. We can, once we become self-aware in our adulthood, alter certain aspects of our biology, psychology, and social environments. Generally speaking, in most situations we are faced with the choice of either accepting what is currently or trying to change or alter the circumstances in front of us. It's not always obvious what the right choice is, but what does strike me from almost ten years of clinical experience is that some people can take too much responsibility in some situations, and some are too accepting in other situations. For example, a people pleaser is unconsciously taking too much responsibility for how people react to them, and they live their lives bending over backwards in an attempt to try and get a positive reaction from other people. On an unconscious level they feel responsible for making sure everyone thinks about them positively. Conversely, a more narcissistic person may take too little responsibility for certain aspects of their lives, unconsciously feeling that they are entitled to a positive reaction from others because of their inherent specialness, or perhaps because they are outstanding performers in one particular area. For example, they make a lot of money, or they're very physically attractive. I'd also like to point out that this idea it's not your fault, but it is your responsibility doesn't just apply to the negative aspects of our lives, but the positive ones as well. You did not choose any of the valuable traits you came into the world with, like your intelligence, your physical attractiveness, how mentally or physically strong you are. Any of your personality traits you didn't choose, what country you were born into, or the psychological health of your family. But it is your responsibility to make the most of them for your own benefit and the benefit of others. So what's the best use of a statement like this? Probably the best use of a statement like this is to recognize these seemingly contradictory aspects of our existence, and to be more conscious of when you should a be more compassionate, accepting, forgiving of yourself, forgiving of the world, forgiving of others, and take care to not underestimate the importance of factors that you have absolutely no control of in influencing your wellbeing, your successes, as well as your failures and when you should be. Take more responsibility. Lead others. Will some form of change in your life shape the life that you want, and take care not to outsource your agency and the direction of your life to another person, to your family, to your community, your government, etc.. The right balance of acceptance and responsibility is going to be unique to everyone in whatever predicament they find themselves in. However, if in general you find yourself not having the life you want, the kind of relationships you want, the job you want, etc., there's a good chance you might need to take more responsibility for different aspects of your life, while conversely, if you make regular, strident efforts and exert a furious amount of energy to try and achieve what you want but find yourself still unhappy or exhausted. You might be taking too much responsibility or taking responsibility for things you shouldn't, and there might be more room for compassion and acceptance in certain aspects of your life. And if you have a particular situation you're struggling with right now, you might think to yourself, where might there be more room for acceptance and equanimity? And where might there be more room for responsibility and change? Which, incidentally, is very similar to what's called in stoic philosophy, the dichotomy of control and what's also mirrored in the Serenity Prayer. God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference. A few caveats to today's quick discussion. I'm not saying you shouldn't accept help from family and friends. Community is very important, especially with an attitude of taking responsibility and when appropriate, professional help is also important. The point of this idea is not to dismiss the importance of compassion. Compassion can be, in fact, a very important part of this process, but rather to highlight the limitations of compassion, particularly a more unsophisticated, immature compassion. The point of this discussion is also to highlight the limitations of responsibility that by taking too much responsibility, too much of the time, or by allocating responsibility inappropriately, you can end up in constant resistance to the world around you, which can make life a difficult and grating experience. So I hope you found this helpful. This was another quick idea I wanted to share while I'm traveling. You can tell me what you think by emailing thinking my podcast at gmail.com. Or you can reach out to us on social media, on Twitter at Thinking Mind, or on Instagram at Thinking Mind podcast. This is the Thinking Mind Podcast, a podcast all about psychiatry, psychotherapy, psychology and related topics. If you like it, do share it with a friend. Give us a rating, follow or subscribe on Apple, Spotify, YouTube, or wherever you watch or listen and we'll see you here next time. Thanks for listening.