morality in psychotherapy

A great issue of our time is the struggle between two ways of thinking about human behavior: a philosophical mode that uses terms like “moral” and “immoral,” “good” and “evil”; and a psychotherapeutic mode, which uses terms like “normal” and “healthy” to the exclusion of any moral vocabulary.

I am aware that professional psychotherapists hold various views of morality. (For instance, see William Doherty for a very interesting defense of moral language in therapy.) But I maintain that the mainstream, everyday practice of psychotherapy assumes one or more of these anti-moralistic premises:

  1. A psychotherapist (someone who has had a specialized training based on science) has no means of knowing the difference between right and wrong.
  2. The patient has a right to his or her own values and should not be influenced morally.
  3. Moral pressures are psychologically harmful and should be reduced.

Note that these premises are mutually inconsistent. For instance, #2 and #3 assume that the psychotherapist does know right from wrong–it is wrong to influence a patient’s values or to put moral pressure on her. But the three statements get mixed up because they support the same conclusion: Do not tell patients what is right.

To support my generalization, I offer sample questions from real tests given to clinical social workers.

1. From socialworktestprep.com:

A 32-year-old man is referred to a social worker after his children were removed by child protective services due to allegations of neglect. He tells the social worker that he is not sure that he wants to fight to get them back. He states he doesn’t think he wants to go through all the things child protective services wants him to do only to not regain custody in the end. Which response is the best thing the social worker should say to the client?

  • The correct response: “You are free to choose whether or not you want to try to regain custody of the children.”
  • One of the incorrect responses: “Your children will benefit from knowing that you at least tried to regain custody, even if you aren’t successful.”
  • Official explanation:

A core principle of social work is the client’s right to self-determination. The NASW Code of Ethics is clear that social workers should support a client’s right to self-determination, unless a client is posing a risk to self or someone else. Social workers should set aside their own values and encourage clients to make their own choices based on what they think is right for them. Although it may be appropriate at times to discuss the pros and cons of a decision, clients need to know that ultimately the decision is up to them.

2. From socialworkinfo.com

Mr. J, is referred to the Social Worker after he is released from his first psychiatric hospitalization. His hospital admission occurred sometime after his return from a trip to Rome, where he had gone to give advice to the Pope. His family knew nothing of the trip until the bills arrived. A salesperson, Mr J. had called strangers in the early morning hours seeking sales. He was described as euphoric in mood, but his family reported that be became irrational when his wishes were thwarted. Mr. J. experienced a reduced need for sleep and was described as talking non-stop for long period of time. Based on the above information, which of the following DSMIV TR diagnoses seems most probable?

  • Correct answer:  “Bipolar I Disorder, Single Manic Episode.”

Just to put my own cards on the table: I think the 32-year-old man has a moral responsibility for his children. That does not mean that he should fight for custody. The kids may be better off without him in their lives. But the main issue he must consider is their welfare; custody is either good or bad for that end. His happiness is also an issue that he may think about, but the children count for more because: (1) there are more of them than him, (2) they are more vulnerable; (3) they have more of their lives ahead of them; (4) he brought them into the world; and (5) we should generally weigh others’ welfare more than our own.

The man who rushed off to advise the pope is probably mentally ill and needs treatment. But I would like to know what he told the pope. Maybe he was right, in which case I would hate to see his inspiration and euphoria medicated away. He reminds me of Saul Bellow’s Herzog and St. Teresa of Avila. I think I can demonstrate that Herzog is a misogynist, but it would surely be reductive to treat him as manic. His unsolicited letters to world leaders are outpourings of the sensitive modern soul. As for St. Teresa–I’m afraid I cannot accept the metaphysical underpinnings of her thought, but she was a great leader, reformer, and writer.

W.H. Auden eulogized Freud as a moralist who “showed us what evil is.” It is “not, as we thought, deeds that must be punished” but “our dishonest mood of denial.” There was some truth to that: dishonesty and repression are evils. But they are not the only evils; some deeds ought to be punished or at least reproved.

(See also: “insanity and evil: two paradigms.”)

About Peter

Associate Dean for Research and the Lincoln Filene Professor of Citizenship and Public Affairs at Tufts University's Tisch College of Civic Life. Concerned about civic education, civic engagement, and democratic reform in the United States and elsewhere.
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