Behavioral science versus moral judgment

George S. Patton, Jr. commanded the Seventh United States Army, and later the Third Army, in the European Theater of World War II.  General Patton, a brilliant strategist as well as larger-than-life fount of harsh words and strong opinions, was also infamous for confronting two soldiers diagnosed with "combat fatigue" — now known as post-traumatic stress disorder, or PTSD — in Sicily in August of 1943.  (One such incident was depicted in the classic 1970 film "Patton" starring George C. Scott.)  Patton called the men cowards, slapped their faces, threatened to shoot one on the spot, and angrily ordered them back to the front lines.  He directed his officers to discipline any soldier making similar complaints.  Patton's commanding officer, General Eisenhower, firmly condemned the incidents and insisted that Patton apologize.  Patton did so reluctantly, always maintaining that combat fatigue was a pretext for "cowardice in the face of the enemy." Seventy years have passed, yet as a society we still feel the tension between moral approval or disapproval on the one hand, and value-neutral scientific or psychological description on the other.  Cowardice is a character flaw, a moral lapse, a weakness.  PTSD, in contrast, is a syndrome that afflicts the virtuous and the vile alike.  We similarly declare violent criminals evil — unless they are judged insane, in which case our moral condemnation suddenly feels misplaced.  Likewise, a student who is lazy or careless needs to shape up to avoid our scorn; a student with ADHD, in contrast, is a victim, not a bad person.

Personality descriptors — brave, cowardly, rebellious, compliant, curious, lazy, perceptive, criminal, and many more — feel incompatible with knowledge of our minds and brains.  It seems the more we explain the roots of human behavior, the less we can pass moral judgment on it.  It doesn't matter if the explanation is biological (e.g., brain tumor, febrile delirium, seizure) or psychological (e.g., PTSD, childhood abuse, "raised that way").  However, perhaps because we feel we know our own minds best, it does seem to matter if we are accounting for ourselves versus others.  We usually explain our own behavior in terms of value-neutral external contingencies — I'm late because I had a lot to do today, not because I'm unreliable — and more apt to tar others with a personality judgment such as "unreliable."  This finding, the Fundamental Attribution Error, has been a staple of social psychology research for decades.

Will we eventually replace moral judgments of others with medical or psychological explanations that lack a blaming or praising tone?  It appears our inclination to judge others will not pass quietly.  Much of the rancor between the political Left and Right concerns the applicability of moral language.  Are felons bad people, or merely raised the wrong way?  Are the poor lazy and entitled, or trapped in poverty by circumstance?  Was General Patton disciplining cowards who were shirking their duty, or was he verbally and physically abusing soldiers who had already been victimized?

The Left and Right disagree over where to draw the line.  But no matter how far we progress in our brain and behavioral sciences, we will still want to voice judgments of others — and negative judgments seem the more compelling.  Humans are notoriously inventive in the use of language to denigrate.  Originally neutral clinical terms like "idiot" and "moron" (and "retarded" and "deluded" and many more) eventually became terms of derision.  Euphemisms like "juvenile delinquent" didn't stay euphemistic for long.  While it may blunt the sharpness of our  scorn in the short term, "politically correct" language won't change this aspect of human nature in any lasting way.

Even logic doesn't stop us.  For example, terrorists are routinely called cowards in public discourse, although it isn't clear why.  Many terrorists voluntarily die in their efforts, an act considered heroic, or at least brave, in other contexts.  They often attack civilian rather than military targets.  But we did that in WWII, and we weren't cowards.  They use guile, sneak onto planes, employ distraction and misdirection — like our "cowardly" Special Forces do.  The point is, we find terrorists despicable, but that isn't a strong enough putdown.  If we didn't call them cowards, we'd have to call them something else to humiliate them.  Mama's boys?

Humans are a funny species.  Uniquely striving for intellectual understanding, yet not so far from the other beasts who purr or growl or screech their approval or protest.  Balancing the aims of morality and science is the stuff of constant, and perhaps endless, political debate.  Ultimately it's irresolvable, yet we do our best to pay homage both to our hearts and our heads.

"Have you seen a therapist yourself?"

Recently a patient asked whether I'd ever been in therapy myself.  Without answering his question directly (see my post on psychotherapist disclosure and privacy), I replied that many of us have, and asked what it meant to him.  It would be a bad sign: "How can you help if you need help too?"  We went on to discuss his feeling that being in psychotherapy marked him as defective or deficient.  He would naturally prefer a therapist who did not share similar defects and deficiencies. Many patients take the opposite view.  They believe a doctor who knows what it's like to be a patient can better empathize with them.  So this patient's concern stood out in my mind — he truly feels his psychotherapy is a mark against him, a kind of declaration or admission that he is damaged.  I later reminded myself that professionals — and others, everyone really — regularly use services offered by others in the same field.  Lawyers have their own lawyers, doctors see their own doctors.  Chefs eat meals made by other chefs, barbers get haircuts from other barbers.  The only problematic examples that come to mind are when the condition being treated is shameful or morally repugnant, or when the condition could directly affect the service being offered.  Examples of the former: police officers who require the "services" of other police officers after committing crimes, and clergy who need spiritual or moral counseling for their own transgressions.  Examples of the latter: a neurologist with brain damage, and a business consultant who cannot maintain his or her own business and needs outside help.  How does this apply to psychotherapists, and what light does it shed on patients' feelings about seeing therapists themselves?

The need for psychotherapy feels to many people like a sign of defect/deficiency/damage.  In speaking with patients I often highlight the "need" in that sentence, and contrast it with "want" or "could benefit by."  Some patients make themselves feel worse by telling themselves they "need" therapy, when it would be just as accurate to say they are apt to benefit by it, or even that they desire it.  I don't believe it devalues psychotherapy, or psychiatric medications for that matter, to note that they're frequently optional.  Most depression improves on its own eventually, and people may choose to muddle along in life dissatisfied, angry, or in a series of bad relationships.  Remembering that psychotherapy is a choice may take some of the shame out of it.

That's only part of it, though.  No one worries or cares if one's proctologist also needed to see a proctologist at some point, even though proctological conditions feel shameful to many people.  In addition to shame, there is moral repugnance associated with mental illness, even, or perhaps especially, the apparently milder problems that lead people into psychotherapy.  Often unstated is the notion that one chooses to be emotionally weak, distraught, hotheaded, or whatever, and that this choice is selfish, unfair to others, or otherwise immoral.  Moreover, that seeking professional help to "snap out of it" or pull oneself together is self-indulgent and akin to laziness.  While the idea isn't totally groundless — there is some choice in how to act, and even how to feel sometimes — it assumes far too much conscious choice.  Most troubled patients would give anything to be happier, at least consciously.  In returning to my patient's question, perhaps he would not trust a doctor who willingly made himself dependent on others to help steer his life back on course.  It may feel as morally suspect as the corrupt police officer or clergyman: a character flaw in the traditional sense.

Alternatively, there may be concern that a psychotherapist who needed therapy ("needed" in scare-quotes as noted above) cannot perform well as a therapist.  This would be analogous to the brain-damaged neurologist or the business consultant whose own business is failing.  The logic may be pragmatic:  A psychotherapist should have his or her own life in order before claiming to be able to help others.  Or it may be fear that residual pathology lurking in the therapist may be harmful to the patient.  Or it may be a transferential need for an idealized, faultless therapist.  Each of these can be addressed as it arises.  We each have our blind spots, and can help others without necessarily being able to help ourselves.  It is better to have sought treatment for potentially hurtful pathology, than to have ignored or denied it.  No therapist is perfect.

Any or all of these concerns about the therapist may also apply to the patient himself.  Being in therapy may make a patient feel ashamed, or morally bad or wrong.  It may highlight a fear of incompetence or harmfulness.  It may clash with a need to be perfect.  Asking the therapist "Have you seen a therapist yourself?" may be an easier way for the patient to broach sensitive feelings about his or her own participation in therapy.  This seemingly simple question can carry a lot of meaning, and if explored in detail, can help a patient understand himself better.

If I accused you of being a Martian...

Cross-posted from "Sacramento Street Psychiatry". In dynamic psychotherapy, patients often say how hurt and victimized they feel as a result of unkind judgments or criticisms by others:

"My coworker called me a hypocrite!"

"My mother told me I neglect her by not visiting enough."

"My husband complains I'm too self-centered."

Although sharing such complaints with a caring listener is basic human nature, in therapy it is also recognized as a defense mechanism called externalization. A fundamental tenet of psychotherapy is that change comes from within. The hurtful coworker, mother, or husband is not present in the room, and cannot be influenced directly by the discussion. It is the patient's reaction that can be examined and perhaps modified.

I tend gently to move things along in therapy, as opposed to letting them unfold at their own pace. I often question this in myself, sometimes wondering if I am too results-oriented. On balance, though, I believe it saves time, money, and tedium for both of us if I focus on issues that can actually make a difference. With this in mind, I don't let externalizations just sit there. I playfully illustrate how harsh judgments only sting if the patient accepts or endorses them at some level: The hurt is really self-criticism, and the solution is really a new self-appraisal.

If I accuse you of being a dirty rotten Martian, it isn't apt to have much impact. You may question my sanity, but you are not put on the defensive or moved to offer a spirited rebuttal. Nor do you engage in sober soul-searching to assure yourself I'm mistaken. You already know you are not a Martian, so the putdown rolls off your back.

In contrast, what if I accuse you of being selfish? This charge is harder to dismiss. We are all selfish to some degree; it's a judgment call where to draw the line between self-interest on the one hand and self-sacrifice on the other. Moreover, as Sigmund Freud describes in Civilization and its Discontents, humans are able to live together in society because we repress many self-gratifying urges into the unconscious. We are, in other words, more selfish (and narcissistic, and greedy, and hypocritical, and childish...) than we like to think.

The criticisms that sting are the ones that stir up our own self-doubts. Maybe we are hypocritical, neglectful, self-centered. Perhaps our shameful defect has been exposed. This is what calls up anxiety, reactive anger, and defensiveness.

Such self-criticism is unpleasant when made conscious in therapy. Yet this is the path toward change. For the problem is not in the external world after all. It resides in the mind of the person in the therapy room, a person who now more clearly sees where his or her troubling feelings originate.

I really do use the Martian example all the time in my work with patients. It's a thing of joy to watch how something so apparently frivolous can shift the focus from unhelpful externalization to honest insight.