Talk Therapy’s Moral Morass
Should mental-health care strive to be ethically neutral?
Despite the furious divisions and disagreements riving the mental-health industries, they do agree on one thing: Mental-health care can and should be ethically neutral. Moral transgressions, convictions, and decisions are none of the therapist’s business; therapists should leave matters of conscience to the client. At most, therapists will “help” clients “clarify their values.” A therapist must not try to “impose values,” and certainly not evaluate, nor attempt to remedy, patients’ moral shortcomings. The “nonjudgmental therapist” stands as an undisputed imperative of mental-health practice.
In one sense, this describes therapy fairly accurately: therapists generally refuse to pass moral judgment or take clients’ moral deficiencies as objects of treatment. In another, it is blatantly false: all schools of thought and their therapists smuggle into care notions of what counts as proper thought and behavior—but they do it without moral argument or justification. In both senses, as we shall see, therapy has pursued ethical neutrality into a moral morass.
Given the near-panicked announcements of a mental-health crisis saturating the media, and clarion calls for more access to mental-health care, this is not a trivial matter. Meeting a mental-health crisis with yet more moral confusion cannot be good. Therapists cripple their own effectiveness, undermine patients’ moral lives—hence their lives—and contribute to the unraveling of society rather than bringing the best resources of the scientific and scholarly disciplines to bear on wellbeing, all in pursuit of a confused ideal.
The notion of ethical neutrality developed sensibly enough. The mental-health professions arose when physicians convinced the public they can provide the best care for persistent, perplexing psychological suffering. Ethical neutrality followed, as night follows day. When we understand suffering as a failure of health, the patient’s ethics become a non-issue.
A healthy arm, after all, is a healthy arm, whether it is used to caress a child, lift up the downtrodden, or strangle the innocent. A healthy kidney is a healthy kidney, whether it cleans the blood of an altruistic saint or a sadistic killer. A healthy brain is a healthy brain, whether it plots the course of the stars or a war of aggression. Healthy people can be dishonorable. Virtuous people can suffer.
Health and virtue seem independent. If you’re in the business of restoring health, your client’s moral character is simply none of your concern. We know by now that the first century of mental health was kidding itself, and us, in claiming ethical neutrality. From enforcing gender roles to “curing” homosexuality, the early mental-health industries’ endorsement of social norms under the guise of health has become conventional wisdom.
Contemporary mental-health professionals pride themselves on a more sophisticated understanding of what counts as “imposing values” on clients—and write into their regulations and codes of professional ethics strict requirements against such nefarious activity. They do better at neutrality now, they believe.
Not really—as we’ll see. The big problem, though, is that the basic premise makes no sense in mental-health care—certainly at present and probably forever. The mental-health industries have righteously pursued a mistaken notion into a moral morass.
What’s the Problem?
We can say a lot about what healthy kidneys, arms, hearts, and so forth look like—and in those cases, the distinction between health and ethics makes practical and empirical sense. But in mental-health care, the distinction makes neither empirical nor practical sense.
Biological psychiatry can make a dubious claim to hold on to the distinction, remaining resolutely amoral—its proponents try, after all, to locate and remedy errant brain chemistry, and nominally they offer no recommendations on how to live, beyond thinking of one’s self as sick and taking one’s meds. In talk therapy, though, where we concern ourselves with the full panoply of thought and behavior, we can’t even make a credible case for ourselves.
Though we can identify some gross aberrations from ordinary mental functioning—schizophrenia, autism, severe depression, and the like—we know very little about “mental health,” for all the blather to the contrary. Our knowledge is far too conflicted and uncertain for us to limn the outlines of the correctly functioning psyche. Look at any respected “Handbook of” personality psychology, social psychology, self-knowledge, self-regulation, memory, emotion—whatever. Better yet, look at two consecutive editions of the same handbook, or two handbooks on the same topic from different prestigious publishers. The lack of consensus shows itself in stark relief. Though we know a fair amount about some aspects of human psychology and social life, we simply lack any authoritative account of the properly configured mind. We have nothing resembling a scientific—or other intellectually proven—concept of health.
Therapists know some things about relieving suffering, and anything that relieves suffering, they call “health.” They spin out a theory of why the thing worked, then blow it up into a whole “school of thought,” inventing permutations, extensions, and (putative) implications, with scarcely a scientific test of any of these fanciful elements. All this baroque embroidery on what’s really just a rough relief-giving rule of thumb gets sanctified as “health.” Since different “schools of thought” relieve distress differently, they spin out different “approaches” and call different things “health”—each claiming to be ethically neutral, while socializing clients into what amounts to a worldview that tells them how to understand themselves and how to live significant parts of their lives. “Healthy” is a weasel word to justify whatever a given school of thought—or individual therapist—thinks people should live. When therapists proclaim their methods “scientifically validated” or proven to “work,” generally all they’re saying is that their methods relieve distress. In no school of thought has the explanation of distress, the psychological principles, or the account of “normal” been scientifically “validated.”
Indeed, much of what clinicians call pathological we know quite well to be perfectly normal. For instance, the “cognitive distortions” so invidiously regarded by cognitive-behavioral therapists are simply how minds work, as anyone with half an ear attuned to work in cognitive science and behavioral economics knows. The wandering eyes and faithless behaviors of Lotharios diagnosed with a variety of maladies are simply hardwired into our species, as normal as hunting for food. Thus, we don’t actually know when clinicians are restoring health—or just doing something that (sometimes) helps people, or some people, feel better.
That doesn’t stop therapists from saying all sorts of things about how people should live—in the name of an imaginary “health.” They believe, and urge on their clients, innumerable intellectually unfounded notions of the “healthy” life. From Freudian ideas about sex to Sixties notions of assertiveness to Nineties notions of the inner child to contemporary notions of mindfulness, they propagate ideals born of hope and imagination, not science, while claiming that they’re stating facts about proper human functioning.
That accomplishes something, of course. Exhaustive research shows that all of the mainstream therapies do help people feel better. But that entails that choosing between them would require, of an ethically responsible profession, assessing their respective moral ramifications. If two techniques make a person feel better, but one of them is morally suspect, the suspect technique is morally unacceptable, however good it makes the client feel. When we, in effect, equate “health” with “makes the client feel better,” “health” ceases to be a decisive criterion.
Sadly, and tellingly, clinical research never evaluates the moral ramifications of techniques. Look at research on therapy effectiveness and you see that moral consequences simply are not investigated—which is precisely analogous to ignoring the side-effects of medications. Why is this not researched? Because clinicians generally take for granted that ethics are irrelevant to mental health.
That is not merely an academic or conceptual failing. Therapists tell clients they need to do, or be, X, Y, or Z to be healthy—though nothing resembling credible inquiry has established that X, Y, or Z define health, and whether X is morally preferable to Y or the like has never even been evaluated. The clients, in turn, justify their behavior to friends, colleagues, and loved ones (or soon-to-be-former friends, colleagues, and loved ones) as something they have to do for their health.
The claim of “health” as morally neutral thus morphed from a plausible concept—a concept that failed to prove out—into “health” as an ethics-exemption. Therapists shape clients’ lives using ill-founded notions of health to justify their admonitions and assessments, while insisting they needn’t—and clients shouldn’t—concern themselves with the ethical ramifications of their views. In effect, they claim therapeutic counsel to be beyond ethical evaluation. “Do it for your health” trumps ethics.
The first problem with ethical neutrality, then, is that it is a factually empty distinction, and therefore results in unfounded claims of freedom from moral scrutiny.
But the situation is far worse. Much of what therapists teach won’t pass ethical muster, and a great deal undermines ethical competence.
Consider that, for decades, therapists have preached opposition to “the tyranny of the ‘shoulds’.” But ethical “shoulds” are tyrannical: obligations are binding, and individuals have no standing to pick and choose which ones they find “reasonable.” In the realm of the personal, of course, we can care about what we wish, demand of ourselves or not what we find suitable. But in the realm of the moral, what is required of us is not ours to say. More or less by definition, refusing to fulfill one’s obligations is wrong—and rightly induces shame or guilt. Rather than helping clients understand correctly where they do and do not need to govern their actions and self-assessments by moral judgment, therapists elide moral concerns altogether. Opposing the “tyranny of the ‘shoulds’” nurtures, at best, obtuse ethical judgment.
Or think about how routinely therapists admonish clients to care less about what others think, to affirm their own self-esteem regardless of how others esteem them, not to “give others power” over our judgments and evaluations, and so forth. How can this but undermine the central importance of reputation in moral life? Scientists who study human evolution and morality as a social phenomenon are fairly close to unanimous: reputation is essential for social functioning, served as a central selective force for the emergence of human intelligence, and fuels the functioning of conscience—which, on any account, is the capacity to internalize norms and to imagine accurately the social status our actions deserve. Denigrating concern for one’s reputation denies basic facts about being human at all.
Another strange, morally counterproductive therapeutic convention teaches clients to pay attention to what they’re “comfortable” with, to resist what is uncomfortable to them, without much regard to a stone fact of moral life: whether or not someone is “comfortable” with something has little or nothing to do with its ethical value. As if subjective comfort carries decisive weight in deciding what to think and do! Ethics generally constrains what we do; no one ever needed ethical injunctions to force them to do what’s “comfortable,” and ethical injunctions often insist—tyrannically—that one should ignore one’s comfort and do the right thing.
Beyond being fundamentally mistaken and ethically harmful, the practice of ethical neutrality robs the client—and the therapy process—of some of the strongest motivators of change known to humankind: concern for one’s impact on loved ones, a sense of honor, sensitivity to principle, the need to be valued by one’s community, and the passions for fairness, truth-telling, and self-respect. By systematically excluding, rather than supporting and nurturing, such motivators, or reducing them to optional “values” one may choose to hold (if they do not conflict with one’s comfort!), ethical neutrality effectively delegitimizes them, undermining the client’s confidence in, and facility with, those motivations.
The distinction between health and ethics creates a truncated picture of the properly functioning mind that lacks even prima facie credibility. By any reasonable account, human nature includes all of these motivators, and thus one cannot assess proper functioning—that is, mental health—without attending to them. Only the professional needs of mental-health professionals could lead one to believe otherwise. The professional need to maintain a posture of ethical neutrality forces clinical work to ignore plain facts about moral sensibilities, rather than investigate and understand them, because therapists proscribe the very idea that a properly functioning mind includes moral concern as fundamental and integral.
Clinicians even ignore good science. Psychologists—though generally not clinical psychologists—and anthropologists, among others, have been studying moral phenomena for decades, but one finds scant use of their work in clinical “science” or practice. The ideology of neutrality, eschewing the obvious fact that human life cannot be understood apart from moral concerns and capacities, drives talk therapy into a stance of willful ignorance. In the last 20 years or so, the study of moral psychology proper has made immense strides in identifying the moral sensibilities inherent in being human, and social psychology and anthropology have shed remarkable light on the crucial functions of moral practices in maintaining human life. You would never know this from the talk-therapy literature, and talk therapists generally do not evaluate the moral vigor or failings of clients.
Finally, ethical neutrality forces mental-health professionals to work in bad faith. Every clinician in the world sees bad behavior that he or she simply cannot countenance—gratuitous aggression, malicious intent, deliberate deception, callous indifference, intimate betrayal, and more. Rather than calling it what it is, they prevaricate, calling bad behavior “inappropriate” or “unhealthy,” or categorizing it as “acting out.”
But “inappropriate” simply means violating conventional expectations—or the therapists’ sensibilities. No one would seriously claim that conventional expectations or therapists’ sensibilities define health, so “inappropriate” is just a weasel word when it’s used to evaluate rather than describe. “Unhealthy,” in the absence of an account of “health,” is simply vacuous, as informative as a groan or a yelp.
“Acting out” is a technical term that simply means taking action without, or in order to avoid, conscious experience of one’s troubling feelings, or to distract from awareness of one’s actual motivations. To use it as synonymous with bad behavior is inaccurate and unenlightening. Acting out can take virtually any form—including (most often, for most people) conventionally appropriate or even salutary behavior. Were acting out not so often socially valued, there would be no such thing as secondary gain.
Thus, by making moral objections in amoral terms, therapists end up talking nonsense. The notion that clients’ health can be secured without concern for their moral lives, then, is just—well, bad. It’s intellectually unsound, morally corrupt, and practically debilitating.
A History of Bad Faith
Not necessarily for nefarious reasons, but mental-health professionals have never been ethically neutral. Therapy notions of “health” are themselves moral ideals, not truths of human nature.
All of our ideas about separation and individuation, autonomy, and the importance of happiness to wellbeing, for instance, are simply applications in the clinical setting of cultural ideals of expressive individualism. Our ideas about “healthy” sex lives, “healthy” marriages, “healthy” friendships, and the like are simply applications of contemporary cultural aspirations. We, no less than previous generations of professionals who enforced standard gender norms, purvey current cultural preferences under the guise of health. Recommendations that are idiosyncratic to mental health practice—like the “true self,” secure attachment styles, assertiveness, “living in the moment,” and countless others—are simply idiosyncratic values of mental health’s own cultures. They’re not truths about human nature. Many of these may well be excellent—but we haven’t bothered to make the moral case for them.
Take, for instance, the notion of “boundaries”—surely one of talk therapy’s most ubiquitous and solemnly invoked normative notions. You would think a concept as central to mental health ideology as “boundaries” would have a fairly strong scientific basis. You would think we could point to the scientists who discovered boundaries, who delineated sound from ill instances, and to the experiments or studies through which they did it. And you would be wrong.
Steve Salerno
The problem is not that boundaries are theoretical, invisible entities. Notions like “cognitive schemata” or personality types or mental modules or extraversion or introversion—and on and on—are all theoretical and invisible, but we have vast industries of empirical investigation devoted to them. The problem is that “boundaries” are a contrivance. Boundaries, as mental-health types use the term, are ways we imagine the world would be better, if only we lived by them. When we talk about “healthy boundaries,” we are really saying: Here’s how (we believe) people should relate to each other. We are smuggling moral imperatives into our assessments and recommendations.
Hence the outrage, condescension, and pity characteristic of discussions of “boundary problems”—and the near-beatific promise of redemption with which therapists and patients speak of “getting better boundaries,” and the air of inviolable imperative with which they speak of “setting boundaries.”
Generally, the concept is used to say, “We’d like to see life arranged in just this particular way. We’d like relationships to be divvied up thus-and-such. People’s autonomy gets to function like this. People have these rights, but not those, to require various things of each other, and to refuse various things of each other. And since that’s the way we want it, that’s the way nature requires it. If you don’t do it like we say, you’re a sick person. Get with our program.” All while claiming to convey facts about health!
For another example, we claim to be “nonjudgmental,” but this is at best disingenuous. We do judge—often without mercy, when we evaluate the parents, spouses, employers, friends, and enemies of our patients. We hide our judgments behind the bad-faith rubric of “health,” claiming an authority to pronounce on “healthy” relationships, parenting, and so forth. In fact, little of what we require of parents, partners, colleagues, or clients themselves has any such basis.
We judge our patients, too, under the guise of helpfully urging upon them our particular notions of “health.” We applaud them mightily when they achieve the virtues we support—“growth,” we call it, hiding moral evaluation behind an inapt metaphor. We support, urge, and even require them to make all manner of life decisions with such subterfuge.
The mental-health professions could just come clean. We could admit we’ve been making bad-faith moral claims all along—and we should reverse course. Society should demand this. At least some of what we recommend may well be justifiable, even admirable, when examined within proper ethical inquiry. But that’s how we should make our case—not by claiming esoteric knowledge of “health.”
How, then, would mental-health professionals decide what to do? How would we decide what remedies to urge on clients, what remedies to support or caution against? How would clients decide which to heed? The answer is quite simple: any effective remedies that accord with good ethical action in the client’s actual life, with its obligations and allegiances and fellow travelers.
Relieving suffering, ameliorating distress, is not enough. Simply relieving people’s distress can do them—and certainly their loved ones and communities—as much harm as good, in the long run. We have to consider more than people’s moods and immediate activities—we have to consider how our work fosters or impedes their capabilities, enriches or impoverishes their relationships, enhances or degrades their involvement with and standing in their communities. We have to consider whether communities would be well- or ill-served if our principles were generally accepted. That is, we have to make ethical judgments.
The trouble is, the influence of over a century of “ethical neutrality” has confused us, crippled our efforts, and insured that we do this less well than we might. The task before us, then, is to do better what we’ve been doing badly all along. The task is to drop the pretense of ethical neutrality, admit that we’ve always been judges evaluating how life should be lived, and become competent at the moral dimension of patients’ lives.
We will thereby become much better at what we try to do. Life’s problems, and sustainable solutions, simply can’t be grasped without moral concern. For most people, in most if not all circumstances, a viable life requires a well-functioning, well-informed conscience. We cannot be good helpers if we omit from consideration the client’s moral life—if for no other reason, because no one else is going to grant such exemption.
We can justifiably leave moral concerns out of our therapeutic considerations only on the assumption that clients are all already morally competent, hence in need of no moral help, when they come for care—that their moral faculties are unproblematic. But that notion rests on an absurd assumption: that confused, conflicted, bewildered people—from troubled circumstances, hampered by emotional pain—miraculously suffer no confusion, conflict, bewilderment, or compromise of their moral faculties. That’s simply not plausible.
To be competent helpers, honestly addressing what it means to be a well-functioning person, we should pay as much attention to peoples’ problems of ethical sensibility, knowledge, and judgment as we would to any of their other faculties.
That doesn’t mean that we should assume our clients’ problems to be the result of moral failings. But it means that we can’t assume they’re not. We certainly cannot assume that choosing between the various ways a patient might come to feel better is a matter of no ethical moment. Among the ways to relieve one’s distress, many different grades of moral wisdom will generally obtain.
It doesn’t mean we should police our clients’ behavior and tell them what to do. But it does mean that we absolutely should not encourage, support, or help them rationalize behavior that anyone in his or her right mind would know is wrong—anyone, that is, whose bad behavior isn’t abetted by a therapist.
It doesn’t mean that we should become ham-handed and censorious. Being intimately familiar with the vagaries of self-knowledge and self-deception, the inevitable conflicts within and between persons, the damage we suffer and the nobility we inspire in our influence upon each other, and the vicissitudes of intention, we should be more, not less, sophisticated and nuanced at ethical understanding than the average soul.
It doesn’t mean that moral concerns should supplant all the other bits of knowledge and riches of practical wisdom we already bring to bear on behalf of our clients, or that moral remediation would necessarily be a constant focus. Rather, as we help our clients become more competent at living satisfying lives, we should help them recognize the moral dimensions of their difficulties and of whatever solutions they consider. We should help them make morally sound decisions.
We should become expert helpers in moral no less than instrumental dimensions of life, bringing to bear on clients’ lives exactly the categories of mind they already bring to bear—including moral concerns—but doing it better than they could do alone and untutored. Our work should require of us, and encourage in our clients, moral as well as psychological and social expertise.
Generally, we needn’t be didactic—clients learn to think in the manner we think on their behalf, internalizing the discourse we have with them. More often than not, drawing attention to the right considerations and asking the right questions will convey moral competence in practice. But all therapists must always have such things in mind as we listen and formulate our interventions—our job is to think, on the client’s behalf, as he or she would think if already able.
Moral life is complex. But the body of human knowledge includes vast and sophisticated studies and explorations, dating back thousands of years. And the last 50 or so years have seen remarkable developments in the professional study of ethics. Positivism has died. The fact/value distinction has been rendered moot. In every field that studies the ethical life of humans, from philosophy to psychology to biology and beyond, extraordinary strides have been made. Indeed, the body of human knowledge on good and evil is far richer, deeper, and sounder than the swirling conceptual effluvium passing as knowledge of mental health.
It’s time for the mental “health” industries to get with the program. Therapists should drop the crippling pretense of ethical neutrality and do what’s needed to become as competent in ethical matters as we are in psychosocial ones. We should, on our clients’ behalves, devote ourselves to mastering the best that has been thought and said on moral life, no less than on other dimensions of human well-being, and bring it to bear as we sort out each client’s distress.
Therapists serve our clients best when we do more than help them feel better. We serve them best when we help them live better lives. Not infrequently—for ourselves as well as most people who consult us—that means we need to help them become better people.
