The Deep Moralism of Mental Health Care

Bob Fancher came of age in Mississippi during the Sixties. With the utter upending of “the Mississippi way of life” during the civil rights ...Read More

The strangest thing about the myth of therapeutic neutrality is this: we’re not even remotely neutral. We’re inveterate moralizers, and morals pervades our work – and our mission.

Take, for instance, three commonplaces of care: guilt, shame, and self-esteem. Every mental health practitioner in the world, including biological psychiatrists, deals with those issues and addresses them. When a patient talks about any of three, whatever response we make-other than a parody of a Rogersian, “So I hear that you are feeling [whatever]” – involves our judgment of whether the guilt, shame, or self-esteem are well-founded.

For instance, if a patient feels guilty when, in fact, he or she is guilty, we handle it differently than if the sense of guilt is misguided or disproportional. If a person’s self-esteem has suffered because, in fact, he or she has proven to be less than praiseworthy in action, we handle that differently than if the self-reproach reflects neurotic problems.

Similarly, when cognitive behavioral therapists (like psychoanalysts before them) take it on themselves to tell patients that their “shoulds” are wrong, they’re directly making moral evaluations.

But we’re moralizers in a much more important way. Nearly everything we say about “health” reflects a vision of how people ought to be, how we ought to think, feel, and act-how it would be good for life to be. We move people toward living one way rather than another, in various particulars. That’s moral recommendation, not neutrality.

We pretend otherwise – we say that we are about health not morals. But in mental health care, at least at this point in history, that’s a specious distinction.

An internist or surgeon or most (but not all) other physicians outside mental health care can usually distinguish between health and morals. A healthy thyroid gland, kidney, liver, and so forth each work the same way in saints and monsters.Equally important, how well one’s thyroid, kidneys, etc., work generally has nothing to do with whether one is a saint or a monster.

In principle, it might be possible to draw a similar distinction in mental health care. Healthy people should be able to do evil things. If we knew the difference between healthy and unhealthy mental functions, in the same way we know the difference between healthy and unhealthy kidney functions, we could credibly-perhaps-say that our job is to restore health, and what patients do with it is none of our concern.

As an empirical matter, we certainly cannot say that at present. In matters of mind, we do not know the difference between health and un-health as we know them in the mechanisms of meaty organs. (Contrary to what psychiatrists and pharmaceutical company marketers tell you, we do not know any significant correlations between mental health problems and brain dysfunctions.) We certainly do not know that the actions of mental health professionals, of any sort, restore healthy mental functions.

Most of what we teach our customers is fiction, myth, or engineering. (By “engineering,” I mean that we teach them how to construct certain habits of mind that would not exist if we did not build them.) Whether we talk about “boundary problems,” “cognitive distortions,” “insecure attachment,” “developmental arrest,” or most any other nostrum of the mental health professions, we’re talking about conceptual constructs that have precious little empirical confirmation. When we talk about good boundaries, CBT’s middle-America notions of sound cognition, attachment, developmental appropriateness, or most any other positive vision advocated by mental health types, we are talking about visions of how it would be good to be-none of which are known to be ordinary characteristics of the healthy human mind. When we claim that following the direction of mental health professionals restores health, we are talking about wishful thinking.

That’s not to say those wishes are bad. That’s not to say they won’t help mental health consumers toward more satisfying lives. That’s to say that we’re socializing patients into particular ways of life because we think those ways of life are good. We’re purveying morals.

Could it be otherwise? Could we, in reality, ever have a distinction between health and morals that would justify the mental health professions’ claims to be exempt from moral responsibility for the changes they deliberately make in patients’ lives?

Maybe not. Few, if any, changes in our habits of mind lack moral significance.But that’s a question for another time.

For now, at least at this stage in the development of mental health care, our notions of “health” do not contain much that’s known to be characteristic of the ordinary, well-functioning mind. They contain our notions of how we wish life to be.

We should be self-aware and honest, and just stop pretending to be neutral. We should make clear and decisive arguments as to why the things we recommend to patients are good. Not “healthy,” because we don’t know that, but good – because on that, we can make a sound case, or fail to, and people can act accordingly.

Keep Reading By Author Robert "Bob" Fancher, Ph.D.
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