 Hi. I'm a philosopher by training. I focus on moral and political philosophy, which means I spend my time using a particular set of theoretical tools or way of thinking about things to try and answer questions about a number of usually abstract concepts. So ideas like freedom and democracy, ideas that get used in our political morality quite a lot, I want to look at them and see well what do we mean by them? What is needed to be free or to be democratic or in this case to be autonomous? So what is autonomy? Strictly it means self-rule. You're autonomous if you're in charge of the way your life is going. It's a capacity which means you sometimes autonomous, sometimes not, but like thing like rationality or creativity, we think we all have the ability to be autonomous and it's also a value. We think usually it's good to be autonomous. Joseph Raz thinks autonomy is or increasing all our autonomy is largely the purpose of our political morality. John Stuart Mell thought that autonomy or something very like it is why we're not allowed to have paternalistic politics. So it's an important idea that's doing a lot of work in our moral thinking. Mental disorder is not directly related but very often we see the intuition that if somebody's experiencing mental disorder they will not be fully autonomous or their autonomy might be injured. Now mental disorder comes in a lot of different ways. There are a lot of different varieties. There's mood disorders that involve mania or depression and there can be psychosis and there's a million other ways a person might experience mental disorder. Despite this, we very often see mental disorder get taken as a category when it comes to conversations about autonomy. So Raz and Dworkin, two very important philosophers of autonomy, tend to say that mental disorder in itself has a chance of injuring your autonomy. Bochamp and Childress are important medical ethicists and their theory tends to say that mental disorder will almost necessarily injure your autonomy. But if we think autonomy means self-rule, it's tied up with your reasons, how you yourself are understanding your reasons, how you're motivated. The important question becomes does mental disorder prevent you from acting upon your own reasons? So let's have a think about a couple of examples. One case is OCD or obsessive compulsive disorder. This is quite an unfortunate condition that comes with usually powerful invasive thoughts that become obsessive, i.e. it's really, really difficult to get them out of your head. And with that comes compulsions, usually a drive to behave in a certain way because that's the only way you can get rid of the obsession. Now what we see here is a person's behavior seems to be explained not because they think they have a reason to carry out certain behaviors, but we want to explain it with reference to what they're experiencing in their disorder. So that's an unfortunate condition to be in and it does seem that the person's autonomy is injured because the disorder is driving their behavior. On the flip side we can see serious anxiety, debilitating anxiety that makes it hard for you to go out and engage socially or carry out certain data things you want to do. That means that you're not acting in the way you want to. Your reasons are not directing how your life goes. So these seem to be core cases of where mental disorders of certain types are injuring a person's autonomy. But I think there are other cases. I don't think we should take mental disorder to be a category that is almost always autonomy defeating or autonomy injuring. I think there are other cases like for instance, mood disorders, where we might say a person's reasons do survive, or at least if the reasons have changed due to a mood disorder, they can still be directed by them. I think if autonomy exists when certain mental states exist, so Dworkin says if there's harmony between your desires and you identify with the desires that are motivating your behavior, then you're autonomous. I think we can say maybe disordered mental states can do the same work sometimes. So here's an alternative view. Maybe autonomy can exist in certain disordered cases, and maybe mood disorders can be a prime example of that. So the research I undertook with the support of the society looked into the variety of ways different mental disorders might injure autonomy based on different theories. What we got at the end of that was a rather untidy picture. So there was a lot of variety in the different ways a disorder might injure your autonomy. For instance, things like dementia or Alzheimer's, particular degenerative disorders like that, typically seem to impair a person's reason. That makes it harder for them to judge how their life should go and make logical connections that would help govern their life. But we see completely other types of cases, like for instance, delusion, which doesn't necessarily damage a person's reason, but a person experiencing delusion often has a disrupted self narrative. The story they want to tell about their own life becomes disjointed and it's hard to make sense of, and that seems to injure their autonomy. If you don't have a cohesive story you want to tell, it can be a lot harder to guide your life. So we've seen there's a lot of difference in how mental disorders are damaging autonomy. But we see also there's different degrees of risk. Simply obsessive thoughts, which are a very, very common symptom, don't themselves seem to do a lot of work to injure our autonomy. It's certainly an unpleasant condition to be in, but you could in the end still direct your life rather effectively. This is not the cases we saw earlier with anxiety, which can broadly as common, but there's a lot more work to injure your actual ability to live autonomously. And again we see, depending on what theory of autonomy you use, if you believe Dworkin or Raz is correct, you might see quite a wide difference in what cases you think injure autonomy. Dworkin and Raz actually came to an outright disagreement as to which cases of delusion injure autonomy and which do not. So they both had a set of delusions that might injure your autonomy, but they had opposite views as to which ones were doing the dangerous work there. So we see this is a rather messy picture. Now I think what we want to look at here to start tidying up is take the flip view. Maybe certain mental disorder mental states can instantiate autonomy. Now what does this mean? It's a technical philosophical term. If you are instantiate something, it is an instance of that thing. So we thought about Dworkin's ideas earlier. Dworkin says that you're autonomous when there's the correct kind of harmony between your desires. I have a desire to be very, very lean and I have a desire to eat cake. I identify more, let's say, with my desire to be lean. As long as I can change my first order desires as Dworkin calls them and make sure my action is directed by the desire I identify with, then I'm autonomous. We see that relationship between our mental states is what instantiates our autonomy. Raz has a different idea. He says, yes, there's some mental conditions needed for autonomy to exist, but more than that, you need adequate options in front of you. You need to have a lot of different ways you could live your life that are not trivially different, but are importantly different, and which don't come with a penalty of death over some of them. So you need genuine choice and options in front of you to be autonomous. So in Dworkin we might say mental states instantiate your autonomy. Raz has to say mental states in combination with certain options or circumstances around you are needed to instantiate autonomy. I think, whichever view you look at, maybe disordered mental states can play a more active role on the mental side of things than we usually let them. So let's take an example I think is informative. The perhaps unfortunate soul in the top picture there has had a number of changes of heart it seems. Each time this person got a tattoo we want to say it was probably an autonomous decision. Now this person might regret their autonomous decision, but at the time they made that decision they did have a reason to get Anna's name then Roseanna's name then Jessica's name then several other names tattooed on them. At each time they were guided by their own reason, but what seems to have happened here is the person's reasons have changed over time. Now maybe you will regret decisions you made governed by prior reasons, but you're still autonomous here. You might even have strange reasons that are not immediately obvious to other people who assume your tattoo is bad because it doesn't have an R in it, but you just really can't stand egrets, birds native to Northern Africa. Now I think this is an interesting analogy, an interesting case, because it's analogous to certain kinds of mental disorder. Now I'm going to take the case of mania as a sort of prime example here. Mania is a mood disorder or it's a symptom of certain mood disorders. It frequently comes with a change in the reasons a person perceives himself to behave. I use tattoos as an example because if you spend any time on the support for online for various bipolar communities, people who have bipolar disorder trying to support each other through episodes, tattoos come up very very often. Mania comes with flurries of creativity and desires to take quite sometimes bold and drastic steps. Tattoos are very very commonly discussed, usually with context. I love the creativity, keep doing tattoo designs, but don't get the tattoo till the episode is over. I think generally quite good advice. But I think that's a quite a useful example here because we can say while a person is in an effective episode, that is their manic at that time or they are depressed at that time, I think we can say their reasons to do certain things have changed. That's how we can, part of what we can recognize as it being different from normal. And I think we can say that yes we might regret that you're, certainly regret you're in that state, but the decisions you make because of it are not necessarily losing autonomy, because they're still your reasons, they're just reasons that have changed over time. I think we understand mood disorders to alter our reasons. We can get insight into how they might and might not alter autonomy. So I think mood disorders are a good place to start here and I think we can get a bold, a better picture of mental disorder by looking at each case in more detail this way. So how do we, are we going to rethink mental disorder in this way? If tattoos are usually gotten autonomously, if we have a good reason to take it, we should probably take seriously what people say their reasons are even if we really predict they're going to regret it in future. So I think this might change how we should talk about mental disorder and particularly talk about mood disorders. So we have a problem sometimes where a person might be experiencing an effective episode, they might be depressed or they might be manic or hypomanic, and not feel much desire to get help, not want to engage very well with what support services are there. This is a very common problem and I think sometimes the language we use and the approaches we take aren't always the most helpful way to resolve this. We want people to be back to normal, especially if it's someone we care about, want them to get back to their old self. Very often what this means is I'd like you to be motivated by the reasons you were motivated by a month ago, two months ago. I want our friendship to mean as much to you now as it did back then. But there's a problem here. We saw earlier Dworkin do a distinction between the reasons you're motivated by, your first order of reasons, and these higher order reasons. I have a preference for cake, I have a preference for going to the gym, I have a preference regarding my preferences, I identify with the desire to be lean and the desire to go to the gym. That second order preference is doing a lot of work into working theory. I think it can do some work here. So we say you want to get back to your old self. I want you to be motivated by the reasons you were motivated by a month ago. If we're saying that's someone, we do need to give them a higher order reason. Why are those old reasons more important than the reasons you have now? I think thinking about that is uncomfortable in many ways. But it does lead us to a particular, the following place. Watch the point, the desire or nihilism, the attitude that doesn't engage with help, don't seek help. I think we have to take that as a serious question being asked and not treat it as we sometimes do just as a symptom or as a sign of disorder. I think understanding more deeply the mental states involved in altered mood and the reasons that come with it, the changes and reasons can help us understand mental disorder better. It can help us understand autonomy better. It can help us engage people with support a lot more effectively, particularly in cases where they aren't being engaged effectively now. So that's the research I undertook with the support of the society and a gesture towards research I'm hoping to undertake in the future. I want to very briefly say thank you to the society for their generous support. I would like to say thank you to Ben Colburn who was indispensable in his mentorship of me both during my MSc and dissertation and for the many years before that. I would like to thank you all for your attention. Please do enjoy the main event. Thank you.