But we have a great talk for you today, we think, really interesting topic. We're going to go over some areas of psychiatry that are relevant to the philosophical concept of free will. So the first thing that I need to orient us to, by the way, my name is Wren Belcher. Our colleague, Dr. Scott, Alex Scott, is not here because on Tuesday he had a baby. So he has other things going on. This had to fall by the wayside. But we're going to divide up portions that were originally his, and we'll do our best to do justice to them. So Dr. Aftab is going to start us off by talking about some neuroscientific and philosophical considerations in free will. And then I'm going to talk about therapy and free will. So how free will is a concept in psychotherapy and theories of change related to psychotherapy. And then how some of the different brands, if you will, of therapy incorporate theories of free will. And then we're going to talk about some forensic psychiatry elements that are relevant to the topic. And we're going to talk about some very broad clinical considerations in mood, psychotic, and substance use disorders as free will relates. So with that, I'll turn it to Dr. Aftab. Good afternoon, everyone. Thank you so much for being here. And I hope you'll find this session intellectually stimulating and will give us something to talk about and discuss. So this is my portion. I'll be talking for about 35 minutes or so. And we'll be taking a look at the neuroscience of free will and agency and how that intersects with the philosophical question of free will. And some of the conceptual and philosophical considerations and controversies that are involved. And the goal would be to set the scene where when my colleague, Dr. Belcher, presents the clinical material and sort of like the clinical issues, we have some sort of systematic or rigorous conceptual, conceptually rigorous thinking, way of thinking about free will so that we can make sense of those clinical issues. So that's my goal. And as the slide says, I'm a clinical assistant professor of psychiatry at Case Western Reserve University. Can anyone hear me okay? Is the mic voice consistent? Okay. So a little bit about me. I've been very active in the area of philosophy of psychiatry and conceptual and critical issues around psychiatry for many years now. I led an interview series for Psychiatric Times called Conversations in Critical Psychiatry for three years. And there's a book adaptation from Oxford University Press coming hopefully sometime early next year. I'm associate editor for Current Psychiatry, one of the senior editors for Philosophy, Psychiatry, and Psychology. And I'm also very active online. These days on my Substack newsletter, Psychiatry at the Margins. Anyone is welcome to subscribe and follow. So I'm going to start this discussion by a very seminal neuroscientific experiment. And the reason why I do that is how many people who would look at neuroscience of free will are going to get exposed to it. So it provides a useful starting point for us to think about what are some of the issues involved. And in particular, what are some of the traditional ways in which neuroscientists have empirically studied the phenomena of free will. And the cornerstone of that is the seminal experiment done by Benjamin Libet, who was a neuropsychologist at UCSF. And this was in the early 1980s. And the basic setup was that he had subjects and they were, they had a device in their hand. Sort of like, you know, they could press a button and they could decide when they wanted to press the button. And at the same time, they had a screen in front of them on which there was sort of like a circular figure, but sort of like, you know, with measurements on it and there was a dot moving around. And the task for the subjects was that they had to make a decision regarding when they're going to press the button. And they had to note the position of the dot on the screen. So they had to sort of like mentally figure, all right, I've made the decision now that I'm going to press the button. And they sort of like, you know, they know what sort of like what position the dot was. And then they press the button. And while that is going on, they're hooked up to sort of like the EEG leads and the brain activities being closely monitored. And what the experiment revealed was that there was brain activity several hundred milliseconds before people sort of like became conscious of their sort of like, you know, desire or intention to press the button. And this is sort of like what it looked like. If you map the activity, this is what we get. So you can sort of like, you know, the different sort of like relevant time points are here. So you can sort of like see that the EEG activity itself sort of like it's rising, sort of like rises, peaks, sort of like falls down. So that's sort of like, you know, pretty kind of familiar. And sort of like here is when the actual movement sort of like takes place. So this is like, you know, when they press the button. This is the point at which they become aware. This is sort of like the point at which they sort of like, you know, make the conscious decision that they're going to press the button. And this is sort of like when the sort of like a brain activity sort of like actually starts happening. So Libet became interested in sort of like what's going on here. Sort of like this whole thing became sort of like known as the readiness potential. So by the time the subject consciously decides that they're going to press the button or sort of like, you know, take that action, there's already sort of like, you know, activity building up in their brain. Sort of like, you know, neurons are already sort of like, you know, somehow beginning to respond to that. So that's sort of like the classic interpretation sort of like what Libet thought was happening was that the decision had already been made. Sort of like, you know, the brain sort of like, you know, a circuitry or sort of like, you know, neurologically speaking, the decision was simply determined. It had already been determined sort of like what was going to happen. It's simply that at a certain point, the subjects became aware of it, but their conscious intention was an illusion. It had sort of like it had nothing to do with whether they were going to sort of like press the button or not. It was simply they became aware of it, but it was an action that was determined already by the activity of the neurons. Now, obviously, this was, you know, in the early 80s, and the setup of the experiment was, you know, somewhat crude. You know, we're using EEG, sort of like, you know, there are methodological issues around, you know, how accurately can you sort of like, you know, exactly to the precise second note, you know, when you made the decision. So it generated a lot of discussion, and some of the discussion was focused on methodological issues. And since then, a number of research teams have replicated and have modernized Libet's experiment in a variety of different ways. So one of the more popular ones that got a lot of attention in the neuroscientific community as well as outside was this paper that was published in 2008 by a team that was led by Haynes. And what sort of like what they did was that they basically performed the same sort of experiment, except they use sort of like fMRI. So instead of EEG, they have a much more robust monitoring of brain activity. They also sort of like looked at the whole brain activity. And the setup they used was that subjects were in the brain scanner, and they had a display screen which flashed a succession of random letters. So sort of like in rapid succession, different random sort of like letters are appearing. And again, sort of like they have to press a button, and they sort of like, you know, made it a little bit sort of like, you know, a little bit more complicated than Libet's one where they had to sort of like use either their right index finger or their left index finger. So they sort of like they had to choose between are they going to do right, are they going to do left? And then sort of like, you know, they had to note that when they made the decision or when they felt the urge that they're going to press right or they're going to press left, they note what was the letter on the screen. So that way you're identifying the time at which they made the decision. And then you're also sort of like, you know, through the monitoring that is going on, you're noticing the exact kind of like, you know, the time at which the action happens. And again, sort of like they found sort of like that there was brain activity that preceded the conscious decision to sort of like, you know, press either the right sort of like, you know, press the button using the right hand or the left hand. And it also seemed to predict whether the person was going to go for right or left. Now, in this experiment, their predictive accuracy was not that high, it was 60%. So better than chance, but still sort of like, you know, not quite that impressive. But it seemed to establish the general principle that there is brain activity already happening before we make a conscious decision. And that in some ways, that brain, that pattern of brain activity predicts what we're going to do. So the neuroscientists were all against sort of like, you know, like, is it all an illusion? Sort of like, you know, are we simply becoming aware of something that has already been decided? So if you look at the literature, sort of like, you know, this experiment has now been replicated multiple times. Multiple times, independent team using a variety of methods, more accurate scanning techniques, brain electrodes doing surgical procedures. And they've also done more complex tasks, such as instead of pressing a button with right or left hand, they have done experiments where you have to decide whether you're going to sort of like, you know, sort of like do addition mathematically with a mathematical problem, or you're going to subtract two numbers. So sort of like, you know, somewhat more complicated than simply pressing a button. And in all cases, uniformly, researchers detect activity multiple seconds before subjects are conscious of, you know, what they're going to decide. And for simple tasks, such as pressing a button, if you have sensitive enough equipment, like for example, in one of the research experiments with Freud et al. in 2011, they used implants, brain implants, during epilepsy surgeries. And they were able to predict the timing of the decision with 80% accuracy. Again, sort of like a simple decision, a simple action, you know, pressing a button or not pressing a button. But they could predict that, you know, with the sort of like that sort of close monitoring of the neurological data. So the neuroscientists, as I mentioned, you know, their takeaway from this kind of, this whole series of experiments was that basically free will is an illusion. Sort of like, you know, we simply, we think that we make a conscious decision, but the decision has already been made. The brain sort of like activity is already in motion. We simply become aware of it. We think we have control, but we don't. That was sort of like, you know, and many prominent neuroscientists, they gave like press releases and sort of like other things. So that was sort of like the general tone, sort of like, you know, of the way in which the neuroscientific community interpreted the experiments. And this generated sort of like a series of debates with philosophers, with philosophers of science, philosophers of mind, who pointed out that things are actually a lot more complicated. And not only there are certainly many sort of like, you know, methodological issues to consider in these experiments, but also there's this matter of how to interpret the results and what do they actually mean. So one of the, I think, best discussions around interpretation of Libet experiments comes from this paper in 2019, sort of like by philosophers and sort of like, you know, it's a multidisciplinary group. And I'm going to read sort of like this passage, you know, this one and on the next slide, basically kind of concluding what they think is going on with the Libet experiments and what it tells us. So they say, more than 35 years ago, Benjamin Libet published his seminal work on the relationship of conscious intentions and preceding neural activity. He concluded that the brain decides on our behavior and we are only informed about this decision in retrospect. His findings have been taken as evidence for a kind of neural determinism and have strongly influenced the free will debate in philosophy, psychology, and neuroscience. However, a careful review of more than three decades of research on the Libet task shows that this interpretation is highly problematic. Recent research suggests that neural activity preceding conscious reports of intention presumably reflects the decision process itself rather than the results of an unconscious decision. The decision is only taken when a decision threshold is crossed at which moment participants become aware of their decision. This interpretation, however, is very close to the common idea or feeling that we decide at the moment of conscious intention. Rather than showing that free will does not exist, the Libet task demonstrates that some decisions are the result of conscious conditional intentions that configure a decision process that partially unfolds unconsciously. Whether free will exists or not remains an open question. So they basically sort of like, you know, to simplify that a little bit, what they say is that the decision process itself is unfolding across the readiness potential. And part of that decision making process happens unconsciously and at a certain point our conscious intention figures into that. But it is not the case that the moment of conscious intention is a product of, it's not the case that a decision has already been made and we are becoming conscious of it. But rather it is an ongoing process which has both unconscious and conscious elements. And sort of like, you know, I'm taking their conclusions. I would encourage you to kind of look at the whole review because the research can get quite technical and there are subtle methodological issues involved. And there's also sort of like, they mention a decision threshold where it seems that there's a certain threshold of neural activity that sort of like, it has to be crossed before the sort of like, the conscious decision making element comes to that. And sort of like, you know, if that certain threshold is not reached then sort of like, that process never reaches sort of like the point of conscious decision making. Another thing that this series of experiments highlighted was what exactly are we talking about when we talk about, you know, free will and talk about agency. So are we talking about like, some kind of like a spooky substance entity that is, you know, making a decision that is not bound by the laws of physics and that is not bound by the activity of the neurons? Like, is this like, you know, is this some kind of a soul or something like, you know, that is making a decision? Because that obviously is, you know, from a scientific, physicalist, naturalist kind of worldview that sort of thinking has gone out of fashion. It's, you know, it's incoherent in a lot of different ways. So if that's not what we are talking about, if we give that up, if there is no spooky substance that is, you know, making a decision that is not governed by the activity of the neurons then obviously anything we're doing, obviously any behavior we are sort of like, you know, acting is going to be a result of the activity of the neurons. I mean, what else is going to be a result of? You know, it's going to be a result of the activity of the neurons. It's going to be neurally determined and it's going to sort of like, you know, it's going to be bound by the laws of physics so it's going to be physically determined. So it challenges a certain idea of free will. It is this sort of idea that we can transcend and violate somehow the laws of physics and the laws of neuroscience. But that's the sort of free will idea that is deeply problematic and that's the sort of free will idea that is challenged by the Libet experiments. But what philosophers have outlined over the many decades of these discussions is that there are many different concepts of free will at play and this is partly what causes a lot of confusion because it's the same word, it's the same term, but there are different coherent notions at play here. So for example, I start with this somewhat standard definition from Encyclopedia Britannica. It says, Disposed power or capacity of humans to make decisions or perform actions independently of any prior event or state of the universe. So we can see that it's hinting at two different sorts of ideas that are clarified in the next two bullet points. One is this idea that a decision is being made that is not causally determined by the laws of physics. And that sort of idea of free will is what most scientists find quite problematic because what would that even look like? A decision that is not governed by laws of physics. So there's this idea that if the universe is physically determined, if the laws of physics describe everything that is happening, then there's nothing that can violate it. The second is our more commonsensical idea that a decision that is not coerced. We're not being coerced in what we're doing, but rather we are acting on our intentions and our desires. It's sort of like Wikipedia describes free will, for example, as the ability to choose between different possible courses of action. And it does seem like to us that we can choose. In the experiment, for example, people could choose between right or left. Many of you chose to register for this conference. You had many different options of sessions happening in parallel. And you chose that, hey, this topic looks interesting. I'm going to attend this one, and not the other ones that are happening at the same time. So the challenge becomes how do we reconcile that? How do we reconcile this very commonsensical idea that we have the ability to choose, we have the ability to make a decision, that we have the ability to form intentions and act on them with the idea that everything that happens is determined by laws of physics and laws of science. Another strand of this, of the free will debate, is the issue of moral responsibility. Because if free will does not exist, if the universe is deterministic, then how can anyone be responsible for their behavior? And so the free will debate gets enmeshed with the debate of moral responsibility. And it gets enmeshed to a point where some philosophers say they define free will with reference to moral responsibility. They basically say that if moral responsibility exists, then free will is what provides the grounds for that moral responsibility. Because it would be incoherent to say that there is moral responsibility, but there is no free will. If you look at the philosophical literature, there are two somewhat hard-line positions on this issue. One is this idea of libertarian free will, and the other is the idea of hard determinism. And the libertarian free will captures this idea that there is something happening that is not entirely determined by the laws of physics. That we are truly deciding, we are truly making a choice and choosing a course of action that is not determined by laws of science. The other position is hard determinism, which basically says that if everything is determined by the laws of physics and everything is determined by laws of science and neural activity, then there is no such thing as free will because everything is determined. Over the years, a middle-ground position has emerged in philosophy of mind and philosophy of moral responsibility, and that is known as compatibilism. And compatibilism is the thesis that free will is compatible with determinism. And they do so by rejecting the libertarian free will idea. They do so by rejecting this idea that a course of action can somehow transcend the laws of physics and laws of science. So the task for compatibilism is to articulate a notion of free will that is compatible with determinism, which is why it's called compatibilism. And then in a manner that it also provides a basis for moral responsibility. So all of the compatibilist philosophers, they agree that determinism doesn't matter. We can be in a deterministic universe, but we can still have free will. But what exactly is the positive account of free will? Why is it that we can say that we have free will? Philosophers differ on that. And there are many different accounts. Later on in this presentation, I will present an account of what is called reason responsiveness. So we'll get a sense of what that looks like. But just to say that there is diversity among philosophers in this, but the most recent survey that was done of philosophers that was in 2020 by Phil Papers, and majority of philosophers in that survey, 59%, accepted compatibilism. So that is currently the more popular position among philosophers, that free will and determinism are compatible, that we can nonetheless have free will and are deterministic in error. So how is that possible? How can that be? And to try to make sense of that, we have to examine some of the relevant work that has been done. One philosopher of science that has written extensively about is Daniel Dennett. And what he argues for is that when we are trying to understand, explain, or predict the behavior of any kind of object, entity, agent, we can view it at different levels of abstraction. And this is a little bit similar for those folks who attended my talk yesterday, this is similar to the idea of levels of explanation. But Dennett specifies three levels of abstraction at which we can look at different entities. The first is the physical stance, where we're looking at basically fundamental particles, we're looking at laws of physics, we're looking at laws of chemistry, we're looking at how chemical reactions happen, how billiard ball causality happens. If you have one particle bumping into another, how does that change their momentum, how does that change their velocity acceleration, et cetera. The second stance is the design stance, where we are looking at things like organization, we're looking at purpose, we're looking at function. And this is the domain, this is the stance that emerges in the biological realm. We don't think of biological processes in the same sort of way as we think of physical processes. When it comes to biology, we're thinking of how is this process unfolding, what is the organization that takes place, what is the purpose of that? Suddenly we're using the language of teleology. And you can think, for example, of Krebs cycle. You can't understand the Krebs cycle that drives metabolism in the same sort of way as you can talk about two molecules bumping into each other. And then the intentional stance is the realm of beliefs, desires, intentions, and computations. And this is a realm of psychology and this is the realm of computer science and artificial intelligence. We're talking in terms of agents having certain beliefs, should we talk about agents having certain desires, or we can talk about computations and we can talk about information. And Dennett's point is that none of that is incompatible. We're just looking at this complex, multifaceted reality at different levels of abstraction. And all of the organization talk, purpose talk, it doesn't violate the laws of physics. In fact, it emerges from it. And in the same sort of way, all of the intentional stance, beliefs, desires, intentions, et cetera, they emerge from the physical reality. And I think we can think of it by looking at the example of what happens in artificial intelligence and computer programs. Let's say we have a chess program. And it makes a certain, you're playing chess with the computer and the computer makes a certain move. Now, you can look at it at a physical stance. You can look at what are the voltage changes happening in the capacitors and transistors in the circuits of the computer, right? But that's not really gonna inform you much why the computer made that certain move. You could talk about purpose and design. You can talk about the way the game of chess is designed, what are the rules according to which it's operating. And then you can talk about the purpose of the moves. What is the goal of moving this piece to this sort of log? Or what is you're trying to take over, right? So even when it comes to something like a chess program, which is, everyone agrees, completely deterministic, no laws of physics are being violated, you can understand a chess program through three different levels of an abstraction and the same way about human behavior. And this is just kind of articulating a similar kind of thing, sort of like is that there are different shades of determinism and different shades of causality. There's the sort of classical Newtonian billiard ball causality, sort of like two balls bumping into each other and sort of like how their trajectory changes, how their momentum changes, velocity changes. But then there's organizational causality. New things emerge when fundamental particles organize in a certain way. And with different sorts of organization, different properties happen. Again, I mentioned Krebs cycles, sort of like you can think of other forms of biological organizations, brain circuitry, sort of like even though we're looking at the same neurons, but if they organize differently, you will have very different properties and very different outcomes. And then there's a sort of more nebulous realm of information processing. How is it that these systems that have been organized a certain way process information? And that is somewhat sort of like still, we don't have a clear account of how information processing happens. Even when it comes to artificial intelligence, we don't quite know. How does an artificial intelligence chooses between one course of action or another course of action? It is obviously taking into account input and it's sort of like probabilistically comparing them in some way, but how exactly does information get processed? We don't know, but we know that it does happen. It happens in physical systems and it happens in our brains and none of that violates the laws of physics. It's still sort of like indeterministic, but it's of a very different sort of causality. So our notions of agency are grounded in these higher forms of causality. If you talk about sort of like the neurobiology of decision-making, there are a number of sort of like things that are relevant, a number of sort of like aspects of brain systems that have an impact. There's executive functioning, of course, sort of like frontal lobe, prefrontal lobe, and other sort of like other areas that are involved in problem solving and sort of like Wisconsin card sorting, sort of like trail making, et cetera. There is reward processing. What are the sorts of goals that sort of like that motivate us? What do we find pleasurable? What do we find meaningful? And these systems sort of like, you know, can be altered. You know, a person who is dependent on substances has very different sorts of reward processing than someone who is not dependent on them. There's issues of impulse control. How well can we control our impulses? Self-reference, what is our sort of like sense of self? How can we reflect on our own past decisions? There's imagination, sort of like, you know, what can we imagine ourself doing? What sort of possibilities are open to us? And learning and memory, what sort of behaviors we have learned? What do we remember? And then how that sort of like that changes our future course of action. So decision-making emerges in the brain through a coordination of these multiple systems. And depending on how sort of like these systems are influenced, the decision-making can be distorted in this or that direction. If your impulse control sort of like is disrupted, that's gonna affect your decision-making, you know, as might, for example, happen in mania, for example. You know, if your reward processing is affected, let's say in severe depression, substance use, that's gonna affect your decision-making. If your sense of self is affected, right? So all, it's happening through a complex coordination of systems. And depending on sort of like how we alter these systems, our decision-making would be affected. There's also terms like this, just sort of like, you know, to highlight this, because I think what people, there's a vast gulf between the realm of physics and the realm of human behavior. And I think biology is kind of somewhere in the middle and helps us try to make sense of what is going on. So that's why emphasizing sort of like, you know, biological agency. And this is Phil Paul, it's sort of like a recent publication, he's talking about it. And he says that even for relatively simple and well-studied biological phenomena, such as bacterial chemotaxis, the movement of bacteria in response to a chemical gradient in chemical concentration, the exact function and mechanism of such agential goal-directed behavior is not fully understood, nor is it wholly predictable on the basis of stimuli alone. And he says the distinction between physics and biology is sometimes illustrated via the thought experiment of repeating Galileo's, almost certainly epigraphical, Tower of Peace experiment by dropping a cannonball and a pigeon. The trajectory of the cannonball is wholly predicted by the Newtonian laws of motion. The same cannot be said for the pigeon, even though it does not violate any physical laws. To the extent that we can predict what the pigeon will do at all, we implicitly invoke its agency. To explain why it does not simply plummet, it is not enough to invoke aerodynamics. We must also, in effect, also allow that the pigeon does not want to plummet. It benefits its agency by virtue of having goals. So this sort of highlights, again, what Dennett is talking about by the intentional stance and sort of like the agential stance. A lot of work in neuroscience is focused on predictive processing, sort of like there's this idea that the brain constructs models and hypotheses about the causes of sensory input. And then it uses those models to make predictions about future sensory inputs. And the brain continuously updates and refines these models based on what is called prediction error. And in this sort of framework, human agency arises from our ability to construct and update models of the world based on our experiences and sensory input. So conscious awareness of agency, in this sense, arises from brain's ability to monitor and predict its own actions. So free will is a notion that kind of straddles this concept of biological agency and its more complicated forms, information processing, while at the same time, sort of like the other leg being moral and legal responsibility. We want a sort, it has to be the sort of agency that permits us to say that someone can be held responsible morally or legally for the behavior. So that's, I think, sort of like, you know, it's a concept that straddles these domains, the domain of agency and the domain of responsibility. And one account of sort of like free will that is quite popular among philosophers is agency as reason responsiveness. That an agent's actions are free, sort of like if the manner in which they are brought about is responsive to the reasons available to the agent at the time of action. And sort of like, you know, volitional features of agency are sensitive to an appropriate range of reasons. Sort of like, you know, we would act differently if we had different reasons to act. So instead of asking, sort of like, you know, is there another world in which the laws of physics are same and the person acts differently, we might ask, sort of like, you know, is there another world in which, if the reasons were different, the person would also act differently? So for example, sort of like, you know, think of severe agoraphobia, you know, manifesting as an extreme fear of leaving one's home. Our ordinary behavior is responsive to a wide range of reasons. Sort of like, you know, if a friend calls me, you know, say, hey, I'm outside your house, I'm down the street, come meet me, I have a reason to go outside. I have a job interview, I have a reason to go outside. So my behavior is responsive, but someone who has severe agoraphobia, their responsiveness to these reasons becomes severely limited. The person may not leave the house even if it means losing a job, losing a relationship, getting criminal charges. And this is actually a patient I treated myself with severe agoraphobia who ended up violating parole and got new criminal charges because he wouldn't leave the house out of agoraphobia. So this sort of, you know, so we can begin to think of our, you know, reason responsiveness as being compatible with a deterministic universe, yet at the same time, we can understand how agency might exist and how it might be compromised. And this kind of accords, sort of like, you know, with the legal view of the person, which is articulated, for example, by Morse in this article, is that the law's view of the person is a creature capable of practical reason, an agent who forms and acts on intentions that are the product of the person's desires and beliefs. The law does not treat persons generally as non-intentional creatures or as mechanical forces of nature. It could not be otherwise. Laws could not guide people unless people were the type of creatures who could use laws as premises in their practical reason. If people couldn't take the law into account and modify their behavior, there would be no point of having laws. So the law's model of the person fully fits people, you know, even with mental disorders, you know, even sort of like, since in most cases, they are capable of that sort of, sort of like, you know, engaging with, in sort of like reasons available to them and that sort of practical reasoning. Now, Morse also sort of like talks about what is called like free will confusion syndrome. And here he's talking about sort of like the more metaphysical sense that, you know, are we in a deterministic universe or not? Sort of like, you know, do we have free will in that sense? And Morse makes it clear that that debate is entirely irrelevant to the legal and clinical question. Sort of like, you know, what matters sort of like in the clinical sense, in the legal sense, is that are we reason responsive? Are we capable of practical reason? And to the extent that we are, we have free will. So I'm gonna sort of like, you know, I just have sort of like, you know, these two slides for conclusions. So free will is a higher order concept. It is in the realm of folk psychology and in the realm of the intentional stance, as Danita said. Compatibilism allows for free will and moral responsibility in a causally deterministic universe. It is a concept that connects scientific notions such as biological agency and information processing to social concepts such as practical reason and moral responsibility. Conscious decision-making involves coordination of multiple brain networks, and it is influenced to the extent that these networks are affected. Neuroscientific experiments do not disprove free will, but rather they reveal the complex interplay between conscious intention and unconscious brain processes. Our ordinary decision-making is reason responsive. We act in a certain way because we have reasons to do so, and we would act differently if reasons available to us were different. Our agency, decision-making, and reason responsiveness is constrained and negatively influenced by a variety of factors, including mental illness and psychopathology, and the neuroscience of decision-making doesn't nullify the legal view of the person, but it forces us to consider how to take causal factors into account when it comes to blame and punishment. So with that, I'll pass it on to my colleague, Dr. Belcher, and then we'll have a general Q&A at the end. Thank you. Thanks. All right. I never get tired of that. That is such an awesome talk. So my name is Ren. I am a forensic fellow at Case Western. I'm gonna sit because I can't really see the screen. And so we're gonna talk about some of the ways in which psychotherapy relates to this whole thing, and to pull upon something that Oase mentioned, there's this big question of how do we reconcile the idea that we have some degree of choice, and yet we are governed by the laws of physics, and I think that, in particular, psychotherapy has a lot to say about this and often sort of works with this kind of directly. Before we go on, I'll say that, in addition to not having any disclosures, I am actively seeking conflicts of interest. If anyone has any board memberships, honoraria, stock options, there's a 7-Eleven on Howard Street. I'll be there at midnight. So let me begin by setting a little bit of a frame for what we're actually gonna talk about, and so I'm gonna shamelessly cite myself here. This is my definition of psychotherapy, and so to just be consistent intellectually, what I mean by psychotherapy is all of the deliberate interactions that might be thought of as talking cures, which take as axiom that we can bring about change in a patient's experience by sharing in it. And we're gonna allude a little bit to the concept of therapeutic action, which is basically any theory of how and why therapy works, or a particular type of therapy works, and it has a particularly strong tradition in psychoanalysis. Numerous analysts of acclaim have written a book or multiple books about therapeutic action with their own wrinkle on the idea, and in analysis, it's often some combination of insight into oneself gained from the work, and then something that comes from the relationship itself. So there's multiple buckets, but those are kind of the two big ones is the insight that comes apart, and then the relationship. But for our purposes, I would suggest that we think about the therapeutic action in psychotherapy related to free will in this way, that there are two converging things going on in the course of a therapy that can affect someone's free will. So the first on the left is the reduction of symptoms. So treating a syndromic illness with an evidence-based psychotherapy, symptoms go down, free will goes up. So in the example that Oase gave with agoraphobia, if we have an exposure therapy, and we're using a manualized treatment for that that leads to a significant improvement in that person's ability to leave the house and lead the life that they want to lead, we have potentially increased their free will in that way. And then the second, the other arrow, is some aspect of therapeutic action that actually works on a person's locus of control, that tackles free will sort of by the horns. And this could be just a stance that a person has an essential belief or an essential ability to set goals and create change for themself. Put another way, we could modify their sort of constitutional belief away from determinism and toward some degree of agency, nudging them in either a said or an unsaid way. And so before we get into some of the specific types of therapy that we're all familiar with, people have probably heard of the common factors explanation of psychotherapy, that the majority of what's effective in therapy is trans-theoretical. You know, maybe we could throw into the list of things that have been suggested for what are the common factors in therapy that, you know, an effective therapy may hold a stance that someone is able to change. And so, you know, that there may be a belief in agency or empowerment, and that that is potentially part of the sort of mysterious common effect. Haven't tested this, just an idea. But what I'm gonna do for the rest of this section is sort of be a librarian and walk you through the bookshelf about what are some of the major therapies saying about free will, because many of them address it head on. And, you know, they each have a literature of their own. All we can do is barely scratch the surface, but try to whet everyone's appetite. So starting with DBT, you know, Marcia Linehan, who we know, in her memoir wrote that in a state of illness she lost her ability to regulate her behavior. So she's essentially saying, you know, I had no free will, or I had free will at a lesser degree than I thought I was supposed to. And she described this state of lack of agency as a complete descent into hell. And this was a, you know, one of the impetuses for the development of DBT. And then, you know, I like to acknowledge this book in particular. This is the book that, you know, I had in residency that sort of introduced the ideas of DBT, and it is just such a helpful book. So if you are interested in learning a little bit more, I highly recommend it. So the author Kelly Corner talks about how DBT has an emphasis on freedom. And she points out that the therapist takes a dialectical stance, embracing a worldview in which the therapist can simultaneously hold the positions of accepting the client and moment completely as they are and moving concomitantly toward change. And by virtue of doing this, the client is free to choose their own behavior, but they can't stay in DBT if they do X, Y, and Z. That's sometimes part of the treatment arrangement. You know, an example would be intentional self-injury. So we come to this interesting paradox, and I just love the way that Corner puts it, that we use these highly controlling techniques in DBT in order to increase a client's freedom. And I guess to sledgehammer the obvious here, the idea is that a person's freedom can be increased. That's baked into some other principles of DBT. And another book I'm sure a lot of folks are familiar with, the excellent worksheet book. This is very on the nose with issues of free will. So one of the indices that patients use to sort of self-assess and to track progress in treatment is the wise mind values and priorities list. And one of those items includes having freedom of thought and action, and being able to act in terms of my own priorities. Now the DBT book also reiterates several times that mindfulness of current emotions is the path to emotional freedom. This line actually shows up several times in the book. And then finally, there are a few instances where some exercise is actually assessed by the patient asking themselves, is blank likely to increase your freedom or decrease it? So an example of this is used in talking about observing the moment without reacting to it. So a patient can ask themselves, is observing the moment without reacting to it likely to increase my freedom or decrease it? And then they can use that as they see fit. And now let me speak about ACT, acceptance and commitment therapy. Of the generation of behavioral therapies that it's a part of, I think ACT has, you know, particularly a lot to say about free will. And there's a certain irony there because, you know, the therapy is very much rooted in acceptance of certain intrinsically limiting conditions or circumstances in one's life, including mental circumstances. But the big idea with ACT is that developing psychological flexibility, that's the center of the hexaflex we're gonna see in a second, is the way to move toward valued behavior. So another article about ACT describes psychological flexibility as contacting the present moment more fully as a conscious human being, as it is, not as what our mind says it is, and based on what the situation affords, changing or persisting in behavior in the service of freely chosen values. So freely chosen values, speaking to free will. And I mentioned before some of the DBT indices that patients can use to assess where they are in their treatment response. One of those that's in ACT is the psychological flexibility scale. And a couple of the items, you know, address free will again right on the nose. So one would be a rating from zero to 10 of a person's sense of ability to take action towards something valued. So zero would be, I don't manage to act on the things I care about at all. And 10 would be, I identify the actions I need to take to put my values into practice and I see them through. So this is a person sort of taking stock of their own ability to be a free agent. And then related to that, maybe an underpinning of it, is the self as observer. So zero would be, the person I call me is my thoughts and feelings about myself. There's not a whole lot of freedom in that. And then 10 would be, the person I call me knows what I am thinking and feeling, but is distinct from that process. So in other words, there's room for movement, change, flexibility, action, free will. Now the concept of Freud and free will, this is depending on which secondary source you read. Some people argue that Freud was very deterministic. Some argue that he actually had a very significant belief in free will. I'll just give you his words and you can interpret it however you want. So in 1910, he said that analysts are marked by a particularly strict belief in the determination of mental life. For them, there is nothing trivial, nothing arbitrary or haphazard. They expect in every case to find sufficient motives where as a rule, no such expectation is raised by the patient. And then six years later, he asks, are there occurrences, however small, which might just as well not happen as happen? If anyone makes a breach of this kind, it means that he has thrown overboard the whole Weltanschauung, which I think roughly means world view of science. Now in 1984, there was a really nice review, sort of, there's a lot of secondary literature on Freud and free will, but this is a particularly good one, I think, 1984 in the Journal of the American Psycholitic Association by a Boston psychologist named Winn Schwartz. And I think he kind of sets the record straight on this. He says first that free will versus determinism is a false issue that obscures the central claims of psychoanalysis, which is that behavior has multiple determinants and can be said to be overdetermined. So the useful distinction is between motivated and unmotivated behavior, with the big idea of analysis being that nothing or at least not much is unmotivated. And the motivation may be out of awareness. So when Freud is talking about free will, he's not talking about the rational pursuit of a goal in the way that we've been alluding to in some other senses. He's talking about how our thoughts and correspondingly our behaviors are not random. That's kind of what he was getting at. It's a little bit different. And this is another helpful concept from the psychoanalytic literature. This is a paper about 10 years ago by Joy Weisel-Barth. It's called Stuck, Choice and Agency in Psychoanalysis. And she introduces this concept that I really like about big D and little d determinism. So setting the frame, she's talking about how the questions that arise in therapy relate to determinism and human freedom, to the possibility of self-agency, choice and responsibility, and to the necessary conditions for self-generated change. Now, big D determinism, that's the sort of ultimate question. That's the physics. That's whether our behaviors are determined, whether they're dusted, faded, whether constructs of self-choice and action are illusory. But then there's this whole other world of little d determinism. And that's our subjective experience of effectiveness and agency, or helplessness and fadedness. And it reminds me a little bit from civics class in high school. We learned about the idea of political efficacy or political agency, which is if you have a sense that you can be effective in the political system, you're more likely to vote. Whereas if you have a sense that your vote is pointless, you're not particularly inspired to vote. So little d determinism gives us something to work with in therapy, and is probably very implicit in a lot of what we do. Now, the paper asks the question, in addressing little d questions, may we analysts simply ignore the big D issue? Which, you know, not terribly surprising. That's kind of what has been done historically. And points out furthermore that if the constructs of self and choice and intentional action are illusory, our analytic efforts to help patients make and take responsibility for meaningful life decisions seem clearly absurd. Now, unfortunately, I wish I could tell you that this paper comes to some beautiful, compatibilist understanding that we can just really write down on an index card and prescribe to our patients. But ultimately, she doesn't come to a strict conclusion. But she suggests that many, we can just say psychiatrists, many psychiatrists or psychotherapists helping people, many of whom may not even think about big D free will, nevertheless, behave with their patients as though it exists. And so she's paraphrasing a philosopher singer saying we must, we have no choice. And if you want to look at the original paper, she gives some context for where that comes from. Now, this is a cutting edge. I added this this morning based on something that I learned from Oase's other talk on Saturday about conceptual competence. So this is a paper that looked at language markers of progress as people progress in therapy. And it looks at things like the active voice versus the passive voice and the way that we use pronouns like I, which get to the way that people feel empowered or stuck. And, you know, we don't need to belabor this particular point just to illustrate the results. They look at what they call the alpha and omega position of first person pronouns. So the alpha position is using a pronoun, for example, I, as the owner of a relation. Whereas the omega position is occupancy of the accidental part of a relation. Passive, done to, right? That's another concept in analysis, doer and done to. And so in both I chased the dog and the dog was chased by me, I is the alpha position, right? Whereas if we rephrase that, if we said the dog chased me or I was chased by the dog, then the dog is in the alpha position. So they looked at, in a cohort of 70 cases, they looked at the 10 cases that were assessed to be the most successful and the 10 cases that were assessed to be the least successful. And they found that in the best outcome cases, most of them, 8 out of 10, showed a decrease in use of the passive or done to pronouns. So they're literally looking at transcripts of these sessions and they're saying that over the course of therapy, in something that was determined by some other measure to be effective, that this is what we see. People talk about themselves differently, they use language and pronouns differently, they indicate that they have more free will. And most of the worst outcome cases had an increase in the use of the passive or the done to I. So that's a therapy where potentially someone is, I don't want to say getting worse, but it was less effective. So they concluded, our results provide quantitative evidence to support the clinical observation that recovery brings about a change from a passive position to a more active or agent position. So if we revisit the paradigm from earlier, where therapies can address free will either by virtue of their impact on the illness or by somehow getting at free will per se, I'll just remind us that, other than the agoraphobia example, we haven't talked at all about the left arrow, but to bring home the idea of the right arrow, we might say that if we hold this stance trans-theoretically and trans-diagnostically, that a person can be empowered, can bring about change in their own life, and that free will is sort of an outcome of a good therapy, then we can look at what that belief in free will does for us. And for that, again, being your librarian, I would suggest this podcast is really excellent, Dr. Pewter's Psychiatry and Psychotherapy podcast. And it is a ton of topics, but there's a three-part series, episodes 84, 85, and 86, that talks about free will. And Dr. Pewter and a, I think his name is Matthew Hagel, who was a fourth-year med student at the time with a philosophy background, they analyzed the literature in great depth and looked at all of the ways in which people who believe in free will versus don't, what's the impact of that on their life? And they, you know, in the show notes, they have the original citations for these, but, you know, people who tend to believe in free will, just constitutionally, are less racially prejudiced, they have more personal goals, better job performance, higher life satisfaction, less stress, better relationships, better academic performance, more gratitude. And then the flip side is that people who are sort of curmudgeonly and Eeyore-ish with regard to free will, people who doubt free will, seem to have less willingness to help, more selfishness, more cheating, more antisocial behavior, less adjustment to themselves after error. So I always mention the Wisconsin card sorting test, you know, where people who doubt free will actually respond slower to feedback that, you know, that they need to make a change in the way they're interpreting data and less meaning in life. And it's not just where people are at the sort of a priori, there's also, there's an experimental element to this where there are certain ways that experimental interventions can modify free will and by modifying free will, it actually seems to elicit change in the expected directions. So if you can convince someone experimentally that free will doesn't exist, you can actually make them do more antisocial behavior than they did before. So I think, you know, if you want to look up the original papers, that's a great podcast. So look at that handsome mug. That's our co-fellow, Alex Scott. And the remainder of the presentation was written by him. So, you know, like we said, he's a new dad. He's not able to be with us today. But I'm going to skirt by some of his ideas. I cannot do them justice to the degree that he would, but we'll do our best. So a sentiment that he shares, and I agree with this, is that forensic psychiatry is fascinating because we're applying both philosophical ideas and psychiatric science to societal problems. So the legal system asks forensic psychiatrists not simply to discuss the human condition or mental illness in abstract terms, but rather something like, how exactly has this person before the court been affected by mental illness? So motives, intent, rational decision-making, awareness of one's concept, or sorry, conduct, are concepts that are centrally important in the judicial system. So things like capacity to make medical decisions or an example that comes up a lot in forensic psychiatry is the ability to make a waiver. So in the law, if you're going to waive something important, so for example, waiving your right to counsel, has to be a voluntary, intelligent, and knowing waiver. So there's all sorts of ways in which a mental illness can make a person's waiver of counsel not voluntary, not intelligent, not knowing. And so, you know, fortunately, I think, the law makes that not valid. So if you're incapacitated by virtue of an illness, then that's the end of the story. Likewise, Miranda writes, if a person is unable to comprehend the Miranda rights when they're pulled over by a police officer in question, then that evidence is not admissible. So these are sort of some of the ways in which this can come up in the law. Okay, so curious what people think about this. Which area of mental health law most explicitly references free will? Is it the insanity defense, competency to stand trial, civil commitment for sexual offenders, or capacity to write a will? If you think it's insanity defense, raise your hand. If you think it's competency to stand trial, you think it's civil commitment for sexual offenders? Testamentary capacity? Interesting, yeah. So, you know, all four of these have elements of free will, and, you know, the surprising answer in terms of what the language reads is actually civil commitment for sexual offenders. So, you know, every state has different statutes, but where we are in Ohio, the language for sexual offenders, and this is the case in a lot of states as well, is very much oriented on volition, sort of action control. So we'll get to that, but a critical point that we have to make as we go through this is that as psychiatrists, you know, we're not the ultimate arbiters of truth. We're not the ultimate sort of judgers. And we're hardly ever opining on free will per se. We evaluate it through the lens of mental illness, similar to a capacity evaluation that a CL psychiatrist does or that anyone would do, you know, assessing someone's capacity. You know, we don't have some special God-given ability as psychiatrists to assess capacity as a concept. What we have is we have the ability to assess whether a mental illness is impeding it, and so that's the same thing with this. And fortunately, you know, we don't have to decipher every forensic evaluee from the ground up and construct a summary of their mind for the court. But all the same, the law recognizes that mental phenomena like anger, mania, psychosis, cognitive impairment may lead people to lack free will and thus act in an illegal manner, but they're not criminally responsible, or to make a decision that isn't legally acceptable because it was not free, like waving your Miranda rights when you shouldn't have or something like that. And so, you know, the law doesn't really ask us to make definitive statements about exactly how much free will a person had at a time. It's more of a threshold, sort of, did they have enough? That's usually how the law works. Now, let me introduce a basic principle of the law, which is that all criminal behaviors have both an actus reus and a mens rea. So actus rea is a guilty act or a guilty hand, and mens rea is a guilty mind. Now, there's always a catch. There is a catch that certain types of crimes called specific intent crimes, it's usually murder and rape, simply doing the act is the crime, but most crimes are not like that. Most crimes, you have to have the actus reus and the mens rea. So in other words, if I was sleepwalking in the conference hotel tonight and I hit a waist upside the head while I was sleepwalking, that's actually not a crime. It's not even an issue of criminal responsibility. It's not a crime because I haven't assaulted him because I didn't have the mens rea. So now, of course, you know, the prosecutor could charge you with the crime and that'll end up in your defense later on, but strictly speaking, you have to have the act and the guilty mind, okay? So likewise, there are gradations of culpability based on just how guilty a person's mind was, how intentional they were being, how much free will did they have at the moment. So this is the difference between manslaughter and murder. So involuntary manslaughter implies a negligent or reckless level of mens rea, whereas aggravated murder requires a purposeful mens rea. So, you know, as we go from less free will to more deliberate free will, you know, negligent, reckless, knowing, and then purposefully is usually what you need for the highest level of crimes. In fact, some purposefully statutes require that you have a moment of deliberation. I think California, for example, in order to have an aggravated murder charge, the prosecutors have to show that you had a moment to consider your actions and you did it anyway. So this is sort of a concept that the law has run with. Now, we talked a little bit about the, or we alluded to the insanity defense. So, you know, of course, this is another thing that could be a talk of its own, but, you know, as it relates to free will, insanity defenses usually have cognitive and or volitional prongs, okay? So you can qualify for an insanity defense if you have a mental illness that causes you to not know the wrongfulness of your actions and or be unable to control your behavior. Now, the second, or really the third part of that, the not able to control what they were doing, that's called the irresistible impulse test. That is in some states. It's not a majority of states, but that gets very much to free will. This is not a perfect map, but the more restrictive insanity standards, which are knowing the wrongfulness of their actions, tends to be a little bit more of a red state law. And the blue states, again, this is not perfect, but it maps a little bit, tend to include the element of free will control. So volitional control, if you can demonstrate that you didn't have control over what you were doing. And then let me mention a bit about Powell v. Texas. This is an interesting case. So in 1968, a man, I think his name was Anthony Powell, was in California, no, he was in Texas, hence the name, and he was arrested for some kind of public drunkenness. And his attorneys challenged him and said, you know, you can't arrest someone for drunkenness. That's not a crime, that's not a behavior, it's just simply a status, and so it's making a status illegal. And it got all the way to the Supreme Court. And the Supreme Court said, well, actually, if you look at the way the crime is written out, you know, that what was being criminalized was the behavior, and the status is not what matters. But it was vigorously dissented. I mean, this was not like a slam dunk by any means. And so it raised the question of how do you handle people that, you know, that do things while intoxicated? What does that mean about their free will? But for the moment, in general, we tend to have the understanding that people make a free decision to use the substances, and everything thereafter is kind of caught up with that. Okay, so sexual disorder, civil commitment we talked about. And just to back way up, most states now have a way to civilly commit sexual offenders so even after their sentence is complete, there is often a mechanism by which someone can even indefinitely be contained. And sometimes you hear about sexually violent predators SVPs, that's kind of how states refer to these people. But the point is that many states have what's called lack of volitional control as a criteria for this. So there's a couple court cases that challenge this. Both came from Kansas, actually, in 1997. The Kansas statute was taken to the U.S. Supreme Court. Their law allowed people to civilly commit sexual offenders after their prison terms based on a mental abnormality. And that was a very inclusive and vague phrase. What does that mean, a mental abnormality? And it turns out that the definition elsewhere in the statute in Kansas was that it had anything that affects your emotional or volitional capacity. So in other words, it's a little tautological. In the Kansas law, anything that affects your free will could be a mental abnormality and could thus get you civilly committed. They only apply this to sexual offenses, which is a whole other world of its own. And then in Kansas v. Crane five years later, they reiterated the same finding, and they said that part of what makes someone civilly committable has to be some lack of control. Some lack of control. So that's like, I don't know how the jury solves that, but that's what they're told to look at. Okay, now in the final section of the talk, Dr. Scott wanted to describe some ways that free will appears as a critical idea in various scenarios in clinical psychiatry. And, you know, I think the idea is just to remind us, as Dr. Sadler said in the conceptual competency session on Saturday, that the most important aspect of educating trainees on conceptual issues is to just help them recognize when a conceptual issue has actually come up sort of in vivo. And that's kind of what this is going to be talking about. So substance use disorders, you know, are they free will problems? This is a really big and complicated question. So, you know, we've got here a picture of Pandora and her box. It's maybe a story that has some similarities to substance use, the idea being that, you know, we're absolutely confident that the disorder begins once someone takes the substance after the first time. It's, you know, how do we think about a person's decision to use a substance that very first time, you know, even if they have a predisposition to an ongoing problem after that. So, and then the quotes here are from a review article from 2021 by Heilig and colleagues that described a brain disease model of addiction and sort of poked some holes in it. So the top quote here describes that the idea that changes in the addicted brain likely influence the probabilities of given behaviors, but don't cause them. And there is some evidence for this model in animal work, but for the purposes of this talk, the bottom line is that compulsive behavior and addiction might not really be fully accurate. I am not an expert in this, and I don't have Dr. Scott here to further explain it, so I present it wrapped in caveats. And then in the bottom quote, the authors acknowledge that one's ability to choose does appear to be preserved in those with substance use disorders, but they cite evidence that through disordered brain circuits, maladaptive drug use becomes more likely even when there are normal reward contingencies for other things in life, socializing, exercising, playing, working, eating, sleeping, et cetera. So how do we cultivate the idea of free will in substance use disorder treatment? Well, first, we think briefly about medication. So medications attempt to reduce cravings for or the rewarding effects of a substance through receptor agonism and antagonism. You know, maybe we could think about those as sort of leveling the playing field, removing that extra element that a person has with a substance use disorder so that they're kind of back to some baseline amount of free will the way that another person would be. You know, are we removing the neurotransmitter hunger that some people just have ravenously that others don't? Another possibility is that keeping in mind that avoidance of withdrawal is a common motivation for people to continue using drugs. If you can take that away, that probably helps with their ability to make a fully informed decision as well. Now, the 12-step program. So what's the first step in AA? Powerless, I think I heard. So admit you're powerless over alcohol. It's actually sort of interesting and it's a little bit ironic that, you know, we're gonna talk about how 12-step programs may have some built-in idea of free will, but point number one, step one is, you know, you admitted you were powerless over alcohol. But that's not the whole story. There's implied a retained whole person with preserved free will who recognizes an immense vulnerability to the substance and then begins to build a life around that. And then motivational interviewing, you know, we're all familiar with this, Miller and Rolnick in the 90s. A big emphasis there is attending to alternative goals. So it's not just not using a substance, but choosing to do something else. And then CBT, you know, involves modifying dysfunctional thinking and behavior. Here being able to recognize conditions or situations that prompt substance use or avoid them helps patients to utilize their free will to the greatest degree that they can. And then finally, we have mood and psychotic disorders. So Alex grouped these together because, of course, they describe different symptoms, but when we consider a person's autonomy, you know, either a mood or a psychotic disorder could absolutely lower a person's free will in very convincing ways. So first, there is evidence that belief in free will is negatively correlated with depressive symptoms. Okay, so, you know, believing in free will tends to be a little bit protective, is another way of putting that. And then belief in determinism or fatalism or, you know, something in that realm is more likely to engender depressive symptoms. And that relationship turns out to be mediated by a search for meaning. And so this first citation there is what discusses the search for meaning as a mediator of that relationship. And then similarly, you know, people with a predilection to become manic may find themselves in situations where they don't have that moment of deliberation that we talked about under some of the criminal statutes. And so they lose their free will because they're, you know, they're driven to such a pace that they don't have an ability to actually stop and deliberate. And then psychotic disorders, just one point to add to that is that, you know, a classic negative symptom is a motivation. And so, you know, certainly people with psychotic disorders have some degree of impairment and free will. I think that speaks for itself. So we'll wrap up here. Let's just imagine a case report here. This is a woman, we'll call her Ms. Davis. She's 35. She has bipolar disorder. And she's had four hospitalizations over her life. She's currently in outpatient treatment. She's working the night shift. She's a nurse on a med-surg floor. And over the past two months, she's been asked to cover night shifts, although she usually works in the daytime. We know this can sometimes be a bit of a trigger for someone to flip. So she takes lithium, but she has a lot of side effects from it. Despite that, she says to her doctor, I think, you know, I think I better increase the lithium. I think I better go on something else. The doctor puts her on Seroquel. Now, what prompts this whole thing on day zero when she goes to her doctor is she says, I don't wanna go back to the hospital. Do whatever we can to prevent me from going back to the hospital. I'll take more medication. But then she forgets to take the Seroquel and the lithium over a few days. You know, she's on this new schedule. It's hard for her to keep track of everything. And then she decides, after missing it for a few days, ah, you know, I actually don't really need the medicine anymore. I think I'm fine. She's beginning to feel better, even though she's actually not really sleeping. But she thinks, well, maybe I just didn't really need to sleep. Maybe I was sleeping too much before. And, you know, the classics sort of ramp up into mania. So she stops taking her medications altogether. She becomes floridly manic. She's hospitalized for mania. And at the admission intake interview at the hospital, she tells the admitting psychiatrist that she's alive again and has found enlightenment in her true source of power. So the question for us is, has she lost her free will or did her free will change? You know, what was she able to control and what was she not? And where, if at any point in the sequence of events, did it switch to being more one versus the other? So why don't we stop here? And we would invite any comments on this case in particular or reflections on free will from your own clinical practice or any questions. And thank you for listening. Thank you. I thank you for a great talk. I had a question about a possible tension between the scientific worldview that you mentioned and the sort of folk psychological worldview that has given birth to the law as we know it and criminal law in particular. So you talked about how a majority of philosophers embrace compatibilism and probably some percentage also embrace hard determinism. So like libertarian free will is a very small percentage of what elite philosophers and scientists probably accept. On the other hand, the people in juries and judges and I'm willing to guess like the majority of the Supreme Court believe in libertarian free will. So does that lead to tensions? I know Morse says, oh, you have reason responsiveness, so that's enough. But it seems to me that the whole criminal law is built upon the idea of libertarian free will and then forensic psychiatrists are going in there and maybe like not saying this, but suddenly thinking like the whole criminal law is sort of based on a lie. Just how you think those kind of tensions play out. So I think if you sort of like look at the literature and you sort of like talk to experts, including sort of like Morse in this, they would say that the law is agnostic on the matter. The law does not take a position on whether libertarian free will exist. The law does not take a position on whether the universe is deterministic or not. The law is interested in the realm of agency and reason responsiveness. Are we the sort of people that we can take reasons into account and modify our behavior? That's what law is interested in. It's, you know, how does that sort of phenomena emerge and whether that phenomena is compatible with some kind of a deterministic universe. The law simply doesn't care. It's sort of like it's agnostic on that. So I think it is a general misunderstanding that the law requires libertarian free will. The law, in essence, even though it doesn't sort of like endorse it, the law essentially is compatibilist because it recognizes that we are agents capable of practical reason and uses that as a starting point. And I think the challenge is that it's really self-defeating to think otherwise. You know, it's like saying that we shouldn't hold people responsible because the universe is deterministic. It self-assumes that we have a choice in whether we can hold people responsible or not. And if that doesn't exist, if our common sense understanding of agency is an illusion, then it's not even a question. You know, it's not a question at all whether we should hold people responsible or not. That's going to be an illusion. So I think when it comes to sort of like this practical aspect of moral responsibility and legal responsibility, hard determinism ends up in a self-defeating position. Let me add one thing to that, which on the note specifically about the court's interest in neuroscience and things like the scientific contributions, there was a case about 10 years ago at Kinsvey, Virginia. This was the case where the Supreme Court held that executing a defendant under 18, even if they were tried as an adult, was unconstitutional. That was an example of a case where some really terrific neuroscientists wrote amicus briefs for the court, and it was clear in the opinions that the court was very moved by that data. And so, you know, when we have scientific information, if we find ways to disseminate it to the court, they have indicated a willingness to take that into consideration. Great. Thank you so much for the great talks and the talk yesterday as well. Like, super interesting. A lot of thoughts. I just want to get your thoughts on a couple of things and I wrote a lot of notes, so I apologize. I'm just distilling stuff. I think that when I think compatibilists are often changing the definition of free will just away from our libertarian conception, and that's kind of how we get around it. But I think that most people have this intuitive feeling that libertarian free will, that's actual free will. And that, you know, my making a free decision is as epistemologically immediate to me as anything else, I think. Like, I intend to raise my hand, I raise my hand as like kind of like a G.E. Morian argument. And that I don't think that I could, the reason to not kind of accept this would be, I think, for a couple of reasons which I would want to get your thoughts on. That you're a scientific realist and that you kind of skirt the hard problem. Like, when you talk about Dennett's like multiple levels of explanation and your exploratory pluralism, you can describe these events in many different ways, but really at the end of the day, we're saying physics is really what's going on. And I think, I don't know if you would say that, but I think Dennett would definitely say that. He's a limited materialist. Like, really the intentional stuff is really kind of an illusion. It's really a kind of a fiction almost, I would say. And there's a bunch of problems with that too. But going back to this kind of believing that our scientific theories are actually giving us this truth would be the reason to believe that. I have a lot of reservations about that. I think science gives us empirically adequate theories, which work in highly limited and restricted settings. So we'd love to get your thoughts about that. I can see in the area of fundamental physics where it would be more attractive to be a realist given our successes there. But like, when we get to some things like psychiatry and cognitive neuroscience, you know, there's just so much variety. You have like integrated information theory, orchestrated OR, computational theories. Like, there's simply no consensus on a working model of consciousness or behavior. And so I'd be highly suspect for basing a metaphysical claim based on that. And so that hard problem, anti-realism. Yeah. So the general, the popular idea of free will is libertarian. So you're right. And so in a certain sense, when we're talking about compatibilism, we are articulating a somewhat newer concept of free will. And I think the central philosophical insight is that there are different coherent ways in which we can articulate that concept. One of which is the libertarian one, but there are also other coherent notions. Now, someone might say, well, you know, I take the libertarian one to be the real account of free will. The other ones are not real, not free will. So in that sort of situation, you could say, all right, you know, we don't have free will in the libertarian sense, but we have agency and we have moral responsibility. So then we can articulate these other concepts, you know, in other ways. So, you know, we can still articulate a coherent notion of agency without using the word free will, for example, you know, libertarian free will. Secondly, I think, you know, the idea that physics is what is really going on, that's true in a certain way, but I think not in the way that makes what's happening at higher levels illusory. I think I would consider that to be sort of like the reductionistic bias. And I think that's a misrepresentation of the relationship between the folk psychological level and the physical level. I think the real scientific challenge is showing how the folk psychological emerges from the physical. How is it that biological agency and information processing emerge from physical processes? I think that's the real sort of like problem that philosophers and scientists are tackling. I personally think that sort of like the idea that what's happening at higher levels is illusory. I personally think that's a mistake. Okay, thank you. I mean, I would be, sorry, I'd just be curious that like, you know, but you would say that at an ontological level, physics is what's really there. The intentional states aren't really there. They may be super be, you know, they're dependent on those states. But then when we get to the realm of folk psychology, it has all this rational structure and all this logic to it. And like, where does that come from? How does it possibly come from particles, you know? Well, I think it comes from organization. I think there's a reality to organization. I think the ways in which those fundamental particles organize, that sort of like leads to dramatically different sorts of phenomena. And I think what we sort of like forget is that we look at sort of like the breaking down of bigger stuff into smaller stuff, but we forget that the ways in which that little stuff is organized in itself is a very potent phenomena. So, but it's a complex debate and we can, I'd be happy to talk more. We're not going to solve the hard problem here, but yeah, thank you. Well, anyway, I guess I was just wondering, aren't there really three ways of looking at this? One is determinism, which is, you know, physics, whatever, reductionism. The other one is sort of like the Heisenberg principle. It's uncertain, it's unpredictable, it's, you know, and so forth. And the last one is determinism by the agent, the person, which is the libertarian one. Because if it's, you know, sort of like if it's just by chance, you're not really free either. It's just a matter of, you know, what the random, you know, whatever the particles in your brain are doing, whatever you want to call it. It's sort of like a car accident versus running into somebody on purpose in a way. So I think there's really three possibilities here. But I mean, in terms of the compatibilism, I mean, to me, that's just a way of philosophically trying to, you know, may address the obvious, which is really we have no choice. We have to live as though we have free will. I mean, you can't just get up in the morning and say, I'm not going to make a choice about what I'm going to have for breakfast. You've got to choose. So I mean, it doesn't really make any difference. It's all moot point in a lot of ways, except in a criminal justice system and in terms of holding people responsible when they obviously, you know, if somebody has, you know, metabolic encephalopathy and they do something violent, they're not going to go to prison, you know what I mean, and so forth. But is that any more, less free than somebody who does premeditated murder? You know, you can make an argument that they're not any, you know, more free, but we have no choice because holding people responsible and so forth works. I mean, it makes us safer. So we really have to go about doing it that way anyway. So thank you for the detailed comment. So one is, you know, when it comes to discussions of determinism, at the physical level, there is this issue of, you know, to what extent outcomes are determined, fixed, and to what extent they are probabilistic and subject to randomness. But it's clear that whatever the ratio between determinism and randomness is, it doesn't help free will because randomness is not choice either, right? So I didn't go into that for reasons of time and complexity, but it's clear that sort of like Newtonian sort of determinism or quantum sort of, you know, probability, neither of them provide grounds for free will in a libertarian kind of sense. I think there's a tendency to think that, oh, sort of like, you know, this, you know, the compatibilist position is really trivial. We're sort of like, you know, we're just, you know, trying to redefine things or save things, but, or that it might be relevant for the legal system. But I think it's really relevant even for our sort of like day-to-day lives, and it's relevant for our, you know, for our relationships. You know, it's very different. Our experience of the world would be very different if we sort of like, you know, if we did not think our agency to be real. And again, I think there's a strong temptation for us to think that our agency is not real if it doesn't exist at the physical level. And that is the intuition that compatibilism is challenging. It's sort of like, you know, it's forcing us to consider that our agency is real, yet we are in a deterministic universe. That is sort of like, you know, sort of like the power of it. So I do not think this is simply a trivial philosophical position to take. It has serious consequences for our everyday life, for our emotional lives, for our moral lives, and also, of course, the legal matter as well. Thank you for the great talk. I'm Mohamed, a second year psychiatrist, and actually a case. I did my forensic rotation in December, if you remember me. So when I started residency and I had a psychotic patient with agitated behavior in the ED and I gave them antipsychotics, I changed the molecules in their brain and I thus changed their behavior, right? So they did not have the free will to do certain things, right? So by giving them certain molecules, I'm able to change their behavior, okay? So before then, they had certain number of dopamines in their certain circuits in their brain making them do those behaviors. So basically, I think this, I mean, after this encounter, I felt like there cannot be free will because there's just an imbalance, like there's a, I cannot say an imbalance, like there's a certain number of things in the brain that make them do certain things. And going back to that point that the other person made, I think our genes predispose ourselves to do certain things, right? So if we cannot make a decision that is like 50-50, that is not even free. So I have certain genes that were passed by my mom and dad to me and I am predisposed to certain things like substance use, for example. So I'm not free in a sense that you are free to not become addicted to certain things. So that itself is something that is being predetermined. Like if it's not 50-50, it is not free. It's already skewed to a certain thing. And that was a very interesting podcast that you mentioned. I think, I mean, I was thinking about it and then you just put it there. I think, I'm also interested in evolutionary psychiatry and I feel like the illusion of free will was selected by natural selection. And those who maintain that are the people who are less depressed, they have a goal in their life and are able to live longer and pass the genes to the people that are going to be there. So I think that was selected by natural selection and it fits the whole model. I mean, that's what I think so. So I think we have to, there are obviously causal influences on our behavior. I don't think sort of like, you know, any account of agency or free will sort of like, you know, denies that. Obviously sort of like, you know, there are influences. So for example, you know, genetics produces tendencies, sort of like, you know, genetics predispose us to sort of like, you know, certain tendencies versus others. So it changes the sets of possibilities that are available to us. But genetics by itself is non-deterministic about behavior. So there are influences, there are tendencies, but by itself, you know, genetics doesn't determine behavior. I mentioned sort of like, you know, how agency arises as a coordination of multiple different brain networks, you know, sort of like executive functioning, impulse control, reward processing, et cetera. And what we're doing with psychopharmaceuticals and psychotropics is that we are tweaking this or that system in a certain sort of way. With one medication, we might be changing sort of like the impulse control. With another, we might be changing the reward processing. With another, we might be changing the executive functioning. But there's still that coordination between those systems is needed. And sort of like, you know, because that coordination is complex, it doesn't mean that just because we tweak a certain system in a certain way that we can sort of like, you know, we can fix what the outcome is going to be. So when it comes to medication, certainly sort of like, you know, that's a powerful influence on behavior. That's a powerful influence on the decisions the person is going to take. But that decision is still going to arise from this complex coordination of different brain networks that is each trying to optimize a different thing. So to reiterate my point, I think we have to give up this idea that agency doesn't have causal influences. Sort of like, you know, it does. How could it not be? How could it be otherwise? There are obviously causal influences. And because of the complexity of sort of like, you know, different things that are involved, we have to give up the idea that simple causes sort of like determine outcomes. They don't, because sort of like, you know, the whole process is complex and requires the interaction of multiple different causal factors. And we're happy to continue taking questions, but we should say that everyone may exercise their free will to leave if they so choose. And we will not be the least bit disappointed. Thank you so much. If you have any questions, please, you're also free to ask us more.

free will

psychiatry

neuroscience

Benjamin Libet

determinism

libertarian free will

compatibilism

moral responsibility

psychotherapy

forensic psychiatry

DBT

ACT

personal agency