Psychotherapy as Ethics

Abstract

Talk of matters ethical is, in the psychotherapeutic context, typically relegated to therapy’s preconditions and setting, i.e., to its ‘frame’. What goes on within that frame, i.e., therapeutic action itself, gets theorised in psychological rather than ethical terms. An explanation for this is the frequent therapeutic imperative to extirpate self-directed moralising. Moralising, however, constitutes but a phoney pretender to the ethical life. A true ethical sensibility instead shows itself in such moments of life as involve our offering humane recognition to one another and to ourselves. Being offered such recognition not only allows a patient to internalise it as a remoralising dignity or healthy pride. It also enables the patient to know herself by animating within herself a range of virtue concepts—courage, probity, repentance, etc.—which can then function as regulative ideals for a well-functioning psyche. Inchoate anxiety now takes shape as intelligible guilt. Repentance and the repair of damaged relationships now replace blame’s repression or projection. Conscience now becomes a motor for therapeutic change. In such ways, ethical concern constitutes not merely the frame but the living flesh of the therapeutic project.

1. Introduction

Ask a psychotherapist about the significance of ethics for their practice and typically they will tell of the framing conditions without which their patient cannot experience such safety as is required for the real business of psychotherapy to proceed. We find mention of these conditions in the profession’s codes of conduct: do not discriminate against, seduce, exploit, break confidentiality with, or otherwise abuse your patient. Suggest however that psychotherapeutic action must itself be understood in ethical terms, and you will likely meet with a sceptical reception. For this, there are good and bad reasons—we shall consider some shortly. But, to first advertise the paper’s direction of argument, what follows proposes that much of what matters for psychotherapeutic action can in truth only be made clear when brought under ethical description. Whether this should be understood as ethical rather than psychological is another consideration, the answer turning in part on the further matter of whether any viable understanding of the human psyche can be offered which does not itself deploy an ethical lens. At any rate, the claim on our table is that psychotherapy is caught up in self-misunderstanding to the extent that it disavows an understanding of its ownmost action as essentially ethical.

But first, why has psychotherapy typically denied being an intrinsically ethical enterprise? One reason may be traced to the very concept of “mental illness”, an essential function of which is to protect its sufferer from unhelpful moral judgement. The person who stays in bed rather than goes to work is, when they are suffering ordinary illness, to be shown understanding rather than moral condemnation. And part of the warrant for that conceptual extrapolation from the bodily to the rational which gives us the concept “mental illness” is the value of construing its sufferers as blamelessly ill rather than culpably immoral. To the extent that psychotherapy is in the business of treating mental rather than moral disorder, then, its proper activity might also be thought non-moral in character. …And yet it is worth noting that judgements deploying conceptual metaphors (such as “mental illness”) need not be taken to issue all the same inference tickets as do judgements deploying the source concept in a literal fashion. Perhaps, then, matters moral may still enter into our treatment of mental illness in a way which they ought not were it ordinary, i.e., physical, illnesses that were here being treated.

Another reason for psychotherapy’s deprecation of matters ethical has I think to do with the indisputable fact that many of the depressed and anxious patients we meet in our clinics bring unwarranted moral judgement down upon themselves. Thus, they castigate themselves as morally stupid and weak, lazy, shameful, and unworthy in ways which seem, to fair-minded others, to be quite unjust. Perhaps, for fear of disrupting valued relationships, they suppress their anger at those who (it seems clear to us) wrong them, instead painting themselves as deserving of the treatment they receive. (This suppression of moral outrage is a major driver of depression.) Here, the therapeutic work clearly does require the remobilisation of moral concepts: he, not I, is being thoughtless. Even so, it might be thought, the principal task, alongside ‘getting in touch with’ one’s anger, will be the relaxation of excessive inner moral stricture.

One origins story for psychoanalytic psychotherapy goes like this: Victorian and Edwardian society was replete with pathogenic moral reproof. Such reproof was ripe for internalisation—where, in the internal world now, it formed the edict-providing superego. Formed, that is, that ‘part of the personality’ which involves bringing repressive moral judgement to bear upon the self—in particular upon the expression of such sexual and aggressive drives as, not yet being integrated into the mainstay of the personality known as the ‘ego’, instead constitute that remainder known as the ‘id’. Freud saw this ‘civilising’ process as essential to human flourishing—the psychotherapeutic project being one of making its effects conscious and mollifying them where necessary. Others—perhaps the prime example here is Wilhelm Reich—saw libido’s suppression as at the root of all neurosis, and promoted its free flow as essential to human wellbeing. (Out of this developed the ‘free love’ countercultural movement of the 1960s–1970s.) Central to this Freudian story is the equation of superego and conscience. Conscience here is a fear-driven faculty—the underlying fear being that, unless one tows a pro-social line and reins in one’s instincts, one will be shunned and lose valuable familial care and affection. The question arises, though, whether such a conception of conscience does not collapse morality into a punitive moralism, and guilt into shame—or, to put it otherwise, whether we might do better not to equate but to contrast conscience and superego, and to instead locate true conscience properly ‘within the ego’. (The matter has been fully addressed in the literature: [1,2,3,4]). For true conscience, one might say, speaks with the voice not of fear but of love; it manifests a concern-driven, allocentric, recognition of our (being in danger of) traducing others—rather than a fear-driven, egocentric, concern with losing them or receiving admonishment. Now, none of this retrieval of morality from moralism means that psychotherapeutic action should be understood in ethical terms. It does however suggest that a key reason to separate them had more to do with an impoverished conception of ethical life that took root in psychoanalysis than with what is essential to the therapeutic project.

2. Humane Recognition

The claim on our table, to recall, is that psychotherapeutic action is inadequately understood if approached in a psychological-as-opposed-to-ethical spirit. The ‘as opposed to’ is important; the claim is not that matters psychological and ethical are readily separable, nor that we can really understand the significance of matters psychological without engaging our ethical sensibilities. It is rather that much of what is central to therapeutic action is left out if we ignore how such action is properly characterised in an ethical sense. We can begin to see this by distinguishing ethical from non-ethical senses of terms such as recognition, understanding, individuality, and validity.

Take recognition. Kant’s second formulation of his categorical imperative, the ‘humanity formula’, has it that you should so “act that you use humanity, whether in your own person or in the person of any other, always at the same time as an end, never merely as a means” ([5] 4: 429). If I see you only as a means to realising my own ends, you do not fully show up for me as a human being, i.e., as someone with intrinsic worth, as someone whose preferences and determinations are worthy of consideration simply because they are yours. To acknowledge this, to—in the morally charged version of the concept—recognise you as a human being, is not simply to grasp your species. Here, we instead have to do not merely with that (merely epistemic) kind of recognition which a naturalist brings to bear on the denizens of the shoreline (“that’s a roseate tern”), or for that matter which a psychopath has of what a human being is, but also with that (fully ethical) kind of recognition that we properly offer one another. You offer it to me when, say, you take my needs and desires seriously, or when you show me such respect and consideration as is not born of your own fear or ambition. In these moments, you treat me—to borrow Buber’s [6] terminology—as a Thou and not, or not only, as an It.

Now, a child develops her capacity to mentalise—i.e., to understand herself and articulate her feelings—at least in part because she has first experienced others articulating their recognition of her feelings (“Ah, you’re scared of Felix! But don’t worry, he won’t bite; let’s stroke him together”. Later, “Mummy, I’m scared of Fido!”). Textbooks on developmental psychology, psychopathology, and psychotherapy sometimes give the impression that what most matters either for healthy development or for successful psychotherapy is having someone to relate to who can help you develop this capacity to mentalise, sometimes by first containing and digesting such of your feelings as at first overwhelm your ability to think. And such processes are indeed developmentally essential, but what reference to them alone leaves out—and what I want to instead draw attention to here—is the child’s or patient’s experience of another’s recognition not of the facts of their psychology but instead of them. What in particular is missing from the aforementioned developmental picture is the child’s experience of the mother as wanting, and taking care, to understand her. It is one thing to internalise the other’s accurate reflection of your experience into a robust and useful scheme of self-understanding. It is another to internalise their desire to understand and bear with you—to say nothing of their ability to delight in your existence, or of their wanting the best for you—and to thereby develop a robust sense of self-worth.1

Just as recognition may, depending on its (merely epistemic, or instead more fully ethical) form, be either achieved or offered, so too may understanding be either developed or shown. My psychopathic neighbour perhaps understands all too well all manner of things to do with my psychology. But where my psychotherapist hopefully differs from my neighbour is in also showing me understanding. The psychopath does not draw on his understanding to bear with me in my struggles, nor offer care when I am upset, nor take care to withhold moral judgement when appropriate. But my psychotherapist does, and as he offers me recognition and shows me understanding, I begin to internalise a sense of my own value and of what is sometimes called the ‘validity’ of my feelings, responses, tastes, desires, preferences, concerns and delights. By none of this is the thought intended that the neighbour transcends the psychopath’s cognitive grip on me by adding an essentially non-cognitive evaluative element. My psychotherapist’s understanding of me need not be seen—and I would not see it—as a merely subjective matter, i.e., as not in the business of correctly apprehending what is true about me. (That I am someone to whom it is proper to offer recognition or show understanding is a fact about me if anything is.) Their humane vision, we might say, is not one that confers validity on me in my thoughts and feelings, but rather one that reveals the validity which I already enjoy.

What is it to experience oneself as valid, or to experience being invalidated by another? We can usefully begin by thinking on what it is not. Thus for me to profess your opinion invalid is not by that token alone to invalidate you. Nor do I invalidate you whenever I ignore, misunderstand, or deem inappropriate your thoughts, feelings and behaviours.2 Rather, I invalidate you when I ignore you when I should not, misunderstand you because I have not made the effort, and deem inappropriate such of your attitudes and behaviours as in fact are not. Such personal invalidation extends far beyond matters of what has become known as ‘epistemic injustice’. Thus, to be sure, you invalidate me if you fail to take my opinion seriously even though you have no good reason to think it lacking. Invalidation can also be seen when, say, a female student’s question at the end of a public lecture is given short shrift, the lecturer’s misogynistic presumption being that it is born of ignorance, only for a male professor’s later voicing of the same concern to be taken seriously. But I also invalidate you when I intrusively and mindlessly presume that you must surely enjoy whatever tastes I enjoy, or when I (a man) do not even ask what food my date (a woman) cares to eat, instead just ordering for her at the restaurant. Or you invalidate me when, for no good reason, you simply fail to listen to me, talk over me, pay no heed to my suffering, or see who I am but walk past without a greeting (recognition without recognition). We meet with invalidation too when a boy’s mother laughs at him and calls it a childish trifle when he falls in love and has his heart broken. Finally, I invalidate you when I hurt your feelings and then, when you complain, double down with ‘but it was just a joke! You are not being a good sport!’—even though it was very far from just being that. In all such ways might someone fail to acknowledge another’s worth or value, such value not being a matter of the contribution the other can make to the meeting of one’s own ends but, rather, something you see them to possess ‘in themselves’.

Now it is in his or her individuality that a person is properly met with moral recognition. (To engage someone as a token of a type—as a white or gay person, say—or to engage them merely as an instance of homo sapiens rather than bringing them fully under the concept “human being”—is not per se to offer them humane recognition.) But what is the character of this individuality? An answer we frequently meet with references the highly unique sets of qualities people possess, the idea being that I recognise you in your individuality to the extent that I pay attention to that distinctive array of personal qualities that make you you. Gabriel Marcel, for example, tells us that ‘What exists and counts is … the real individual I am, with the incredibly minute detail of his experience, with all the specifications of the concrete adventure that belong to him to live and to him alone, not to another being’. [10] (p. 19). And in a paper entitled ‘Psychoanalysis as the idiosyncratic science of the individual subject’, Peter Caws offers: ‘Every new patient… is a new world, whose laws it is the task of the analyst to establish and apply. No generalisation from one case to another can be assumed a priori’ [11] (p. 618). A similar sentiment is voiced by such psychotherapists as stress the impropriety of applying any general understandings of psychological difficulties to individuals ‘because everyone is different’.

A difficulty for such approaches is that, as T S Eliot had it, ‘all cases are unique, and very similar to others’ [12] (p. 97)—or, to reference now that great philosopher Miss Marple, ‘That is where you make a mistake, dear … Everybody is very much alike, really’ [13] (p. 129). In some ways, we are similar; in other ways dissimilar; how useful it is for a psychotherapist to take the same approach with two patients with similar difficulties is therefore an empirical matter—so not one to be pronounced on a priori. And yet, it is perhaps possible that such philosophers and psychotherapists as plead for our ‘all being different’ have attempted to make a valuable point about the importance of being ‘treated as an individual’ but done so in the wrong (psychological rather than ethical) mode. Let us now consider what that right mode might be.

One way to understand the acknowledgement of individuality is through the notion of irreplaceability [14] (p. 152). Perhaps I have an intelligent and charming friend who has a warm character, is well-educated, and takes delight in medieval philosophy and avant-garde music. And then one evening down the pub I meet someone who, I notice, shares all the same marvellous characteristics but, conveniently, lives rather closer. If I were to simply transfer my affections I would rightly be said to have failed to understand what it so much as means to have a friend. To value a friend is, one might say, to value them not for but in their qualities. Or, to now consider another way in to the question of what it is to be met with as an individual, think on what it is to take heed of another’s particular tastes and preferences. To meet you as an individual, in the sense I am here stalking, is not so much to recognise that you have a particular, maybe even a unique, set of these. It is rather to respect these in you because they are yours.

Bearing this distinction in mind helps us understand how easy it was for the aforementioned psychotherapists to slip between two senses of ‘individuality’ when they spoke of not using general findings to guide treatment ‘because everyone is different’. If I am to respect my patient’s individuality, I must indeed pay accurate attention to her troubles and her wishes, but doing so does not exhaust such a respect (even my psychopathic neighbour can do this). Rather, I achieve that when my attention to such details is in the service of honouring her, of wondering at her existence, of not impinging on her, and of not simply assuming that she has the same desires as I do—but instead clearing myself oneself out of the way so she can shine forth in her particularity as (to speak with the Kantians) a setter of ends. It is this to which Simone Weil’s and Iris Murdoch’s distinctly ethical conceptions of love—as ‘belief in the existence of other human beings as such’ [15] (p. 113) or as ‘the extremely difficult realisation that something other than oneself is real’ [16] (p. 52)—give able voice.

With an ethical and not merely psychological conception of recognition, individuality, and validity in view, we are I believe in a better position to appreciate the true force of the following remarks made by three psychoanalysts. Hans Loewald makes much the same point as do Weil and Murdoch but now in terms of ‘detachment’: ‘detachment in its genuine form, far from excluding love, is based on it’ [17] (p. 297). And Warren Poland gives the same general claim a fuller expression: “When I passed the 50-year marker, I asked myself what was the most important thing I had learned in that half century. … I was surprised to recognise that the hardest thing for me to learn was the most obvious. It is that the patient is somebody else! Not me, not part of me, but really somebody else, somebody with a full life that does not include me” [18] (p. 6). But the most particular expression of the notion, and one that also helps makes clear the relation between (a) psychological and ethical forms of attention to people in their particularity, and (b) developmental and psychotherapeutic growth, is met with in Christopher Bollas’s refashioning of the concept of ‘idiom’.

‘Idiom’, as Bollas means it, refers to what is expressed by the totality of someone’s particular gestures, manner of walking, sitting, smiling, playfulness, seriousness, how he arranges things about him, his turns of phrase and typical associations, etc. It is that in which his distinctive selfhood finds expression. A mother, Bollas says, ‘loves her infant’s precise nature, and she works to meet this idiom, to give the infant what he needs to be himself.’ She must, NB, work to recognise her child in his distinctive particularity: she must strive to realise an ambition of not impinging or intruding, and of offering a reading response in which the infant can recognise himself. Parents, it is fair to say, do typically want the best for their child, want to share of what they have with them, and to enjoy time together—yet can sometimes have little practical sense of how to bring the child into view in their particularity. That task can then belatedly befall the psychoanalyst who, as Bollas writes, must now help ‘establish the right of idiom, which [right they] represent, not only through the content of [their] remarks but through [their] relation to subjectivity itself’ [19] (p. 113). This relation is one which values the patient in her subjectivity, i.e., in those of her personal qualities of heart and mind that find expression in her idiom.

Bollas’s talk of idiom enables us to put some flesh on what otherwise can be the rather dry Kantian bones mentioned above. It has been said that to acknowledge another’s humanity is to see them as someone who could be another’s friend [14]. So too we might, I suggest, say to treat someone as an end in herself can in part be understood as meaning to see her as a being with an idiom worthy of a mother’s loving attention and appreciation. (Whether or not you could yourself be their friend, or whether their mother was in fact capable of appreciating their idiom, is not to the point.) Now the psychotherapist’s attention, whilst highly focused, is of course far more limited—occurring as it does later in life, and typically only once or twice a week. Even so, the first claim on my table is that it is the psychotherapist’s attention which honours the individuality of the patient in manifesting a desire to know and show recognition to them in their idiom which gets internalised by the patient as the kernel of their self-esteem. As Bollas put it in the above quotation, it is the parents’ or psychotherapist’s recognition response which helps establish the ‘right of idiom’ in the child or patient. The further claim, to be established in the essay’s remainder, is that this self-esteem can begin to blossom into a fuller form as a morale-sustaining dignity in part because the psychotherapist, and then the patient too, brings the latter’s thought and motivation under that further range of morally significant concepts which we shall now explore.

3. Virtue and the Inner Life

We began by noting how therapeutic progress often requires helping release the patient from unwarranted internally imposed moral stricture. The next claim on our table had it that by offering the patient a recognition he can internalise, he comes to rely less on moralising superego edicts, and more on a healthy sense of worth, to manage himself in his relationships. The further claim now on that table is that the recovery of mental health can sometimes proceed through the refinement of virtue.

Now, I have no reason to believe that psychotherapy patients are any less virtuous than those who already enjoy good mental health. Even so, it has been my clinical experience that a failure to grasp the significance for one’s flourishing of living in accord with what we might call existential virtues—i.e., with such virtues (like courage, responsibility and pride) as must, as we say, be actively taken—has sometimes impeded the flourishing of various of my patients. Example: Graham is a young man who comes to psychotherapy utterly overwhelmed with anxiety about his forthcoming examinations. He is already seen a sympathetic counsellor; he has tried meditation classes and breathing techniques to help him calm down. Unfortunately none of this helped. During psychotherapy, Graham comes to see that, whilst before he had been trying to calm down, what in his particular case is required is instead to ‘power up’. That is, he comes to see the value of taking up the virtue of courage as a regulative ideal, not soothing his anxiety but instead binding it with his will—or ‘steeling himself’ as we say, boldly rising to the task at hand, and thereby vanquishing the exams (which he successfully went on to do). Here, Graham shifts from a non-ethical psychological self-management approach to an ethical approach. The object of his concern is no longer double (managing himself whilst also sitting his exams), but now simply the noble task of courageously doing his best. As he comes to understand the importance of taking courage, Graham also comes to understand and know himself better. He understands, that is, more of what is required from him by way of successfully living a distinctly human life.

Courage is of course but one of the virtues. I will shortly consider the relation of the virtues of repentance and forgiveness to mental health. First, however, a short note on the different forms that this relation may take. Consider that, so long as we distinguish hope (a courageous willingness to populate the future with potential meaning; an eager readiness for the good) from a shabby Pollyannaish optimism, its relation to morale and hence to mental health is pretty much analytic. Temperance, by contrast, so long as it does not veer off into a joyless self-denial, can be seen to make for mental health in part because it allows the temperate one to avoid the sickness and poverty that arise from greed. In the aspects just outlined, hope’s relation to mental wellness is internal, whilst temperance’s relation to mental wellness is external. But we should also note that our various virtue concepts typically condition our very understanding of what makes for human flourishing, including mental health.3 The virtuous life, that is, is a workable life in part because of the organisational power of bringing one’s conduct under those regulative ideals that are virtues—but its workability is also in part a function of the fact that what we shall anyway so much as count as a human life ‘working’ is that it is regulated thus. Furthermore, and as I will spell out in the final section, part of what makes a virtuous life workable is the remoralising sense of worth that arises as and when a person takes a healthy pride in their virtuous conduct.

When we think on the anxieties that arise from inner conflict, we often have in mind such cases as the clash of love and unconscious hate toward the same person. What is less often appreciated is how such anxiety can also be constituted by the voice of a conscience which has lost, or never fully gained, its self-understanding. A detail from the life of Orval Hobart Mowrer is illustrative: Mowrer (1907–1982) was a north American psychologist who found himself riddled for a long time with an anxiety and depression which he could neither understand nor treat using the behaviour therapy in which he specialised. He then happened to confess some guilty secrets (an affair while married; adolescent sexual behaviour of which he was not proud) to his wife—and his depression straightway lifted! Impressed by the power of the ‘pathogenic secret’, the repression of the call of conscience, and the significance of confession as the way out, he went on to set up the ‘integrity group’ movement whose members practiced confession and holding each other to account so as to thereby live with dignity rather than collapse in shame [22]. Integrity, we might say, is for such cases the lynchpin of their psychological integration. Looking back at the debauchery of his younger days, Oscar Wilde commented that ‘I ceased to be captain of my soul’ [23] (p. 40). If, rather than freely choosing the good, I cheat, am duplicitous, break promises, have one law for myself and another for others, etc., I no longer enjoy the boons of a unified personality [24] (p. 105). In truth, it is hard to see how dissolution can, unless one has utterly destroyed one’s conscience, lead to anything other than inner strife.

Now, in order to meaningfully confess one’s guilt one must first be able to bear the feeling of it—i.e., both own and stay in touch with it, rather than have it either slip into that unconscious form which manifests now only as anxiety, or project it into others (‘it is you not I who is in the wrong!’). The psychotherapist’s task here is to help the patient remain in touch with a sense of their value and to know that their guilt need not shamefully define their entire identity. Also essential to psychotherapy’s maturational work is that one’s guilt not now regressively precipitate self-punishment (as if that really helped anyone) but instead properly eventuate in contrition, apologies, and reparations [25]. By taking, instead of shirking, responsibility one can also reap the rewards of dignified action (‘I am now doing as I ought’). Here, the therapist can sometimes lead by example, since there is typically plenty of opportunities, as it were, for underestimating the patient, for getting him wrong in ways that do him wrong, and for inattention, in the therapeutic work. It bears noting that some patients have experienced their acknowledgements of their wrongdoing being used against them, rather than having those acknowledgements respected and valued. The political regime, so to speak, of their moral emotions is then built more strongly around the avoiding and the relocation of guilt and blame. The result is a world full of anger and recrimination—and, when the externalisation of blameworthiness is unconscious, paranoia, since now the world will seem full of hostile forces. And the work of therapy is then one of militating for regime change through the experience of trust, acknowledgement and ordinary admiration for being able to own wrongs, and the boons of forgiveness for both guilty and wronged parties.

It is worth pausing to say something about forgiveness because there exists considerable lack of clarity about it both in patients and in schools of psychotherapy. Thus one both finds secular clinicians highly sceptical of the value of forgiveness for psychological recovery [26] and religiously minded counsellors promoting it in forms which potentially risk the resumption of toxic relationships and the entrenchment of depression. Yet, by reflectively distinguishing between two overlapping but different forms, we stand a better chance of achieving the ambitions and avoiding the pitfalls of both.

In one paradigmatic form, forgiveness finds its meaning as a relationship-restoring response to apology and reparation. Maria cheats on her husband James, but makes a full and sorrowful confession and does everything she can to rebuild his confidence in her. At first her breaking of the bond of their love disturbs James considerably and he cannot contemplate letting Maria back in. At this stage, James uses his psychotherapy to help him get truly in touch with his anger. Later, however, he comes to think on his own temptations and errors, acknowledge the sincerity of her apology and her contrition, and recall the significance of the love they have shared. His forgiveness of Maria now consists of his placing trust in her again, resuming their loving relationship, not holding her transgression against her, and relinquishing his anger. He does not forget what happened in the sense of develop amnesia about it. Instead the work of love which is his participation in their relationship now makes space for what Maria did within its telling of the story of what they have suffered and overcome.4

In another form, something many of us feel to still be worth the name of ‘forgiveness’ can be given despite repentance, apology and reparation being unforthcoming (because, say, of death, immorality or ignorance). John leaves Matilda for a much younger woman, showing no remorse. His casual phone calls to her manifest no recognition of what they had built together nor of how his actions have trashed this; in them he blithely talks as if they could now simply be friends. At first, in therapy, Matilda is simply devastated, but soon enough her anger provides her personality with enough binding force for her sense of self and self-worth to return. She then falls into an intermittent depression during which she is preoccupied by the thought that she should, in line with the teachings of her Christian faith, forgive John. During therapy, however, she comes to see that to forgive in that above-articulated sense which includes trusting, and opening her heart to, him again would truly be an act of self-harm. Her depression, in fact, was itself partly a function of the self-devaluation which would be required if such a reconciliation were to so much as seem possible to her. At this point, however, Matilda remains stuck, oscillating between depression and anger. The breakthrough for her happens when she comes to acknowledge that her continued anger has been functioning as dishonest defence against her sadness, a defence that prevents her from grieving the relationship. Rather than take responsibility for her feelings by staying in touch with her sorrow and rebuilding her sense of self-worth independently of John, she has been indulging hateful and unbecoming fantasies in which she continues to hold him responsible for her present state of mind. For Matilda to inwardly forgive the unrepentant John, what is required is not the restoring of loving relationship but rather her putting down her anger, the cessation of her ongoing blaming, her moving on from her preoccupation, and her truly grieving what she has lost. In that sense of ‘forgetting’ which involves not amnesia about the facts but the ceasing of agitated moral preoccupation, Matilda ‘forgets about’ him.

4. Conclusions: Virtue as a Condition of Dignity

Dignity, we might say, comes in varieties. Inalienable is that form which a person enjoys simply by virtue of being human, which underpins such of his rights (e.g., to not be enslaved or eaten) which are also inalienable and which makes him an apt object for recognition. Of concern in this concluding passage, though, is an alienable form, one which may be lost, say, by dissolute living, capitulating to bullies, turning a blind eye to wrongdoing, cheating, etc. The dignified woman both knows her value—i.e., she appreciates that the first form of dignity belongs to her inalienably—and is clear in her values, and lives according to these values, and for these reasons may take a healthy pride in herself and manifest self-respect. The final claim now on our table is that living according to the virtues can restore mental health not simply because of the boons of living in a courageous, repentant, forgiving, etc., manner but because, in addition, such living is restorative of this alienable form of dignity.

Consider if, when it is truly warranted, we carefully issue a patient with a gentle rebuke and invite him to ‘be serious’, we are showing that we respect him as someone who it so much as makes sense to judge in such terms [14]. The recognition we thereby afford involves calling him to be his better self—and thereby to take himself, us, and others, in a morally serious manner. In this way he may—so long as the shame which attends the recognition of not living up to such standards is carefully handled—not only more truly inculcate the virtue of thoughtfulness, but also come to a practical understanding of how such thoughtfulness can be part of his dignity. That is to say, he may now invoke the concept of thoughtfulness as a regulative ideal by which to live—and, because of thereby living by it, now hold himself in a healthy esteem. Imagine that I am procrastinating with various tasks because the thought of doing of them makes me anxious. I have got into the habit of telling myself that ‘I really ought’ to do them—nagging myself, if you like; only to put them off again. But if instead I remind myself of the intrinsic dignity of stepping up and taking courage, I am now rather more likely to act. For now I am no longer inwardly riven, scattered into the sundry ego positions of scared child, nagging parent, and rebellious adolescent. Instead, I have reminded myself, in stepping up, of what I most truly desire for myself. And in and through my bringing my predicamental reaction under the concept of dignity I become inwardly unified, experiencing myself now more squarely as on my own side in my struggle with life’s difficult moments.

It is of course not only the therapist who can invite the patient to ‘be serious’ or ‘be honest with yourself’; the patient may issue the invitation to himself. Example: Ted, a middle-aged software engineer, has attended therapy for 15 months. He often talks of being frequently overwhelmed by anxiety, and this is clear in the session too: he readily becomes agitated, his guts become tight, his breathing is disrupted, he wrings his hands; clear thought becomes difficult. In particular he gets caught up in ‘what if…?’ worries about work: what if his coding embeds a serious error? What if he cannot figure out how to solve the next problem that comes his way? He also worries about how his colleagues see him. As a result of the anxiety he often only works a couple of hours a day. Over time we discuss to good effect many ways (e.g., exercise; cultivating mindful awareness of when he is catastrophising; clearly distinguishing between what is and what is not within his control, and directing his thought only at the former) of managing anxiety, yet some of his anxiety still remains. One day, though, Ted surprises me by saying ‘You know, I sometimes wonder if my anxiety mightn’t be my brain’s overdramatic way of preserving me from a job I find dull.’ I am intrigued by this new idea and, adopting—as psychologists are encouraged to do—a spirit of curiosity, wonder out loud how we could test whether his idea might be true. And yet, rather than take up that enquiry, Ted keeps silent for thirty seconds—before saying, in a moment of honesty, ‘No: I actually just know this is what I’m doing’.

You may have already noticed two things about this exchange beyond the step from the ‘might’ to the ‘is’. First, Ted starts by talking about what his brain might be doing; he ends by talking about what he is doing. He takes ownership of his difficulty, that is. (This is also reflected in the switch from the modal ‘might’ to talk of what is actually the case.) Second, I set out down the wrong track by inviting the pursuit of what turned out to be the wrong kind of knowledge. I suggested an ethically neutral enquiry into the facts about Ted’s mind. Ted, however, approaches the matter of self-knowledge in an ethically charged manner. He is still in the knowledge business, but the form of his knowledge is more acknowledgement than discovery; he is not so much learning as admitting what is the case. As such his self-knowledge requires no grounds since it has more to do with the relinquishing of a defence than with the learning of a fact. He follows the Delphic injunction—to know thyself—and in so doing becomes honest with himself, stops disowning his boredom, shows what at one and the same time is a greater moral integrity and a greater psychological integration, and steps up to the existential demand of living in an authentic and dignified manner—which in his case includes stepping out of his comfort zone to find work that is more truly interesting to him.

To return now to the matter of the use of virtue concepts as regulative ideals to foster such self-knowledge, consider how the concepts of ‘therapeutic neutrality’ and ‘locus of evaluation’ help promote a therapeutic growth of remoralising dignity. ‘Neutrality’ refers to the psychotherapist’s attitude, and is wrongly taken to mean the foreswearing of moral judgement in the clinic. It refers rather to an attitude in which the therapist abstains from coaching or advising the patient, abstains from taking sides in his inner wrangles—to the end of helping him come to decisions which are truly his own. This, after all, is one of psychotherapy’s prime ambitions: to help the patient know himself and become self-possessed so that he may take genuine responsibility for such actions as are now more properly his. Being the beneficiary of this therapeutic attitude in turn helps the patient rise above the disposition to give over his ‘ego functions’—the moral and psychological acts that ought properly to be his own—to others to perform, which giving over depletes and thereby demoralises him. It aids the patient, that is, in developing what Carl Rogers [27] called an ‘internal’ rather than an ‘external’ ‘locus of evaluation’. It is in fact an intrinsically ethical moment since the ‘neutral’ attitude conveys within it a message regarding how the patient ought to behave qua adult. And now, in listening to the implicit message, so no longer referring to values other than his own to guide him, he instead takes ownership of his acts and decisions. He can, furthermore, and just so long as he lives according to his ownmost values, feel good about himself. And so long as these values are virtues he can also experience a healthy pride; now he can, without in any way putting his nose in the air, nevertheless hold his head up high.

Part of the value of developing this internal locus of evaluation is that one’s sense of worth is less swayed by circumstance, fortune, and the real or imagined judgements of others. Socrates’ dictum that ‘no evil can come to a good [i.e., virtue-instantiating] man, either in life or after death’ [28] (p. 145) is hyperbolic; soul-destroying labour, and certain cruelties and tragedies, can indeed damage the very core of our morale. Even so, when my sense of worth comes from my knowing that I am living as well—as virtuously—as I can given my life’s circumstances, however dreadful they might be, I will naturally suffer less from that demoralisation which arises when we encounter misfortune or the critical judgement of others. For now, I step up and take such action as can be taken, that being part of my dignity, and in this way experience myself as an active self-determining agent. And even when I must suffer externally imposed fates, I can take satisfaction in doing so with forbearance and courage. The criticism of others means less to me.

It should, hopefully, go without saying that a life free of mental illness can hardly be guaranteed by virtuous living. The dangerous (‘victim-blaming’) consequences of such a view are obvious, as should be the fact that mental illness and vice are rather different, albeit sometimes overlapping, domains [24]. (Mental health (resilience, self-understanding, inner buoyancy, perspective-taking, etc.) can indeed arise from the remoralising effects of a life of virtue. Such health, though, is not simply the absence of mental illness; it instead has to do with the positive presence of self-understanding and emotional resilience—which in turn have a prophylactic effect on mental illness. And mental illness is neither simply the absence of mental health nor the positive presence of vice, but instead has to do with the positive presence of runaway self-maintaining backfiring pain-avoidant irrational spirals of thought, feeling and behaviour.) My argument has been different. To recap, its first part had it that a central part of what in the psychotherapist’s activity is therapeutic must be characterised in ethical terms—i.e., in terms of the virtue of such recognition as we offer one another. The second part had it that not only does virtue-guided activity sometimes itself makes for mental health, but also that such activity can engender a self-respect which further enhances mental health. ‘How can I live in such a way as will engender healthy pride in me?’ is the relevant question for us here. Equipped with that sense of worth which has been instilled in her by her recognition-affording psychotherapist, able now to tolerate and move beyond her shame and guilt, now truly knowing herself rather than defending against the acknowledgement of her moral emotions, the patient can also now more readily grasp the value and necessity of actively taking that pride which sustains her self-worth. All going well, the result is a virtuous cycle; a life of health-engendering virtue, self-possession, dignity and resilient self-worth.

Conscience, i.e., the call to virtue, whether in its perverted (superego) or true (love-based) forms, is a powerful influencer of moral emotion, motivation, and morale. All psychotherapists know this full well when it comes to the damage that can be done by an overweening superego formation, i.e., by the demoralising ‘shoulds’, ’oughts’ and ‘musts’ which their patients bring down upon themselves in the most unhelpful of manners. The third section of this paper has made a plea for the fuller recognition of the valuable transformational potency that virtue concepts have for us when these concepts are healthily animated as regulative ideals in our self-conceptions and lives. Doing something because it is the right thing to do; this is intrinsically motivating. It is also intrinsically remoralising since it both enables the agent to hold her head up high and is also naturally generative and restorative of a well-regulated psyche. To aim at enhancing self-possession, remoralisation, and psychological functioning without tapping into the freely available impetus of the call to virtue is, therefore, to miss a considerable trick.