Therapy Beyond Good and Evil

It appears innocuous at first. The psychologist writes one word at the center of the whiteboard: values. He circles the word, stands back, admires it, and turns to his audience — an audience of inpatients, bored, drugged-up inpatients, stretching like cats and yawning like hyenas.

I’m in psychiatric hospital in central London and the psychologist is taking us through a “values-clarification exercise.” I’m interested in what the psychologist has to say about values, because I used to teach ethics, at the University of Virginia. But now I’m the student, because I’m the patient. And I’m about to be given a strong dose of moral relativism. I’m about to be told that there are no objective values and, by implication, that good and evil are merely projections of our minds. This, apparently, is going to make me feel better.

“What does the word ‘values’ mean to people?” the psychologist begins. “What are some of our values?” Unfazed by an unresponsive group — a circle of depressives is not always the most forthcoming of audiences — the psychologist circulates a handout. It’s a list, including the following words:

swimming
honesty
wealth
honor
skiing

An odd jumble of hobbies and virtues, the psychologist asks us to circle the “values” we particularly identify with.

I find myself subjected to this because I have bipolar disorder: Bipolar II, to be precise. Not the most severe kind, no psychosis. As Saul Bellow wrote of Moses Herzog: “There were worse cripples around.” I’ve always coveted the more dramatic kind: Bipolar I. It would make my world aesthetically more justified — which makes me dubious about my moments of insanity. Maybe I was in my right mind after all. Maybe the naked dash around the city was a put-on, a bid for attention. All the more demeaning, and on police time.

Here the windows open only about four inches. My suitcase was carefully searched upon my arrival. Cables, chargers, razors: all had to be surrendered. There are no baths. They don’t let you shut your door. (To wedge them open, towels have to be slung over the top corners of the doors.) How many ways of suicide have been attempted here? They must have worked most of them out by now.

I’ve been in an asylum before. I’m back now because I’m not really functioning, not making it happen — life, that is. It’s proving too difficult for my family to manage. Emasculating, that. I’m sleeping all day, don’t want to venture outside — the eternal silence of the infinite spaces terrifies me! — and too jittery even to be alone with my children. The medications I’m on — a cocktail of mood stabilizers, anti-psychotics, anti-depressants, and stimulants — aren’t doing their job. So, my psychiatrist wants me to be in a place where he can oversee changes in dosage, which often trigger turbulent changes in my mood.

I still feel like a fraud here, though. I don’t have the backstory to justify the admission. My mood isn’t merited. The problems have been petty, the reaction disproportionate. The grief languishes without a decent cause, without warrant. I lack the cue for passion others have.

In my first group therapy session, one young woman bravely opens up about having been raped. She hates herself “for being such a cliché,” blaming herself for “freezing rather than fighting back.” The next person tells of being sexually abused throughout her childhood. By comparison with this, my disappointment that my articles haven’t been tweeted more seems preposterous.

This asylum, a particular favorite of mine, caters to all kinds. Some have been committed. Others, like me, have come voluntarily. Some need constant surveillance, a nurse following them round as they wander in drugged stupors the narrow corridors of this cramped, sprawling building in the middle of the city. There is a unit on the fourth floor for addicts, while a table in the canteen is reserved for those with eating disorders.

It’s not that bad a place, really. It’s far better than that asylum in the suburbs, where patients roamed the wards smoking spliffs with impunity. Here it’s often quiet enough to forget where you are. You sit in what could be a motel, reading Hilary Mantel dispose of Henry VIII’s next wife and listening (against the doctor’s orders) to Radiohead. At other times, though, I can still hear screams from agitated patients rise above Thom Yorke’s falsetto, reminding me that I am in the end holed up in what patients call “the loony bin.”

I find myself in a lesson this morning because, for those of us who can sit still, whose depression isn’t totally paralyzing and doesn’t preclude every kind of engagement, the hospital offers a full program each day. This includes morning classes on a range of subjects — sleep, managing depression and anxiety, the fundamentals of cognitive behavioral therapy, and distress tolerance — and then afternoon group therapy sessions. The exhaustive and exhausting schedule is designed to keep patients busy. But it also reflects the institution’s belief that restoration of health depends upon the marriage of psychiatric and therapeutic interventions. This place harbors the conviction that, beyond drugs, the patient also needs some psychology. Which is why I’m being inundated with ideas, theories, modalities, concepts, paradigms — and a conception of “values.”

Presented with the handout listing various values, we’ve been asked to circle the ones that resonate with us. Next, the psychologist, with a flourish, ventures an observation. Each of us, he says, has different values. What’s more, we often disagree about our values. “So,” he concludes, “values are subjective.” And our recovery, our restoration to sanity, hinges upon our willingness to choose our own values. He lets us know that while morality “is externally imposed by society,” it is imperative that we be the ones to pick which ideals, morals, judgments, precepts, and rules to live by.

Harmless, surely? Who would deny that it’s vital that my values be ones I’ve properly signed up for rather than had simply foisted upon me — by my parents, my teachers, my culture? But this truism — that I will more likely be able to live out a set of values if I have consciously adopted them — doesn’t exhaust the sense of what’s being said. My psychologist is implying something more radical when he insists on the pivotal importance of choosing your own values. When he claims that “values are subjective,” he is painting a picture of the world according to which the only values that exist are ones we have created. To say values are subjective is to say there is nothing independent of our own minds that answers to our talk of right and wrong. It is to say that our ethical beliefs do not track a reality which is “there anyway.” According to his picture, values are determined, not discovered, and selfhood — what it means to be a person — is therefore fundamentally about choice, not vision. It is about picking a course of action arbitrarily, not about seeing a reality that transcends you — goodness — and integrating with it.

It may seem that the relativism on offer here is just professional etiquette. In a pluralistic society, isn’t it right that psychologists stay neutral and refuse to impose particular moral systems, refuse to foist upon us what the political philosopher John Rawls named “comprehensive conceptions of the good?” Isn’t the psychologist, taking me through my values-clarification exercise, merely showing restraint in keeping with his discipline? Isn’t he simply applying the golden rule that therapists must suspend judgment? “The first duty of a psychotherapist,” writes Frank Tallis in his recent book The Act of Living, “is to create a safe space, a situation where difficult and sometimes dangerous truths can be articulated and explored without fear of judgment, rejection, or condemnation.” Indeed, wouldn’t any other approach open up the whole enterprise to abuse, returning us to an age when the cause of lunacy was simply put down to “laxity of morals?”

I don’t think so. I think the psychologists are up to more than suspending judgment. I think they really believe they’ve got straight on what is and is not the case in the world, that they’ve really uncovered the truth of the matter, which is that there are no moral facts, that good and evil are not part of the fabric of the world. This is not just wariness on psychology’s part. It’s radical skepticism. The idea that “we as therapists shouldn’t talk about right and wrong” has become the very different idea that there is no right and wrong in the first place.

Professional psychology has a long history of flirting with, or outright endorsing, skepticism about objective values. Psychoanalysis was profoundly shaped by Freud’s deflationary account of conscience. For Freud, guilt is no longer to be seen as a reassuring experience, evidence of our residual knowledge of good and evil, but rather as an impediment to be overcome, arising from our unhealthy internalizing of parental authority. In classical behaviorism morality appears to be merely the result of conditioning. And existential psychotherapy summoned patients to “responsibility” recast as a courageous confrontation with a world in which, as the psychologist Irvin Yalom put it, “there are no rules, no ethical systems, no values; there is no external referent whatsoever; there is no grand design.”

But in the twenty-first century, it is “Acceptance and Commitment Therapy” that has put values-clarification exercises front and center. Developed in the early 1980s by Steven C. Hayes, a psychologist at the University of Nevada, ACT (pronounced “act”) is widely used to treat mood disorders in a variety of clinical settings. It boasts a thriving association, currently numbering 9,200 professionals, and a growing evidence base — last year ninety-four randomized controlled trials using ACT were undertaken.

ACT’s focus on values stems from its clear-eyed diagnosis of depression as a disorder that estranges people from what they care about. People with depression, and I can vouch for this, are often listless and lost. ACT hopes that reconnecting people with their core values will re-awaken them in some way, inject an oomph into their daily lives. ACT is an approach insistent that the psychological techniques a patient learns — the strategies you are taught to better manage your negative thinking — must not trump issues of primary motivation. Clarifying your values is intended to keep you focused on, and inspired by, the bigger picture of your life.

In addition, values-clarification exercises aim to improve functioning by increasing psychological flexibility. The goal here is to help you work toward acting, amid pain and distress, in accordance with your values. Well, you’re only going to achieve these goals, Acceptance and Commitment therapists insist, if you really own your core values. And you only own your core values, rather than allowing outside authorities to define them for you, if they are presented as free choices, not as something required by reason. What Hayes writes on this is revealing:

In order for valuing to occur, it is critical that values not be confused with decisions and judgments — values must instead be choices. A choice is a selection among alternatives that may be made with reasons (if reasons are available) but not for reasons. Choices are not explained, justified, linked to, or guided by verbal evaluations and judgments.

Hayes may be driven to this organizing distinction between choices and judgments out of the best of motives — he wants to preserve the patient’s freedom, and thereby increase the chances of her sticking with the values she adopts. But the implication of what he says is nonetheless disastrous. By disavowing judgment and evaluation as playing any causal role in the adoption of values, Hayes, like Freud, ultimately banishes reason. The resulting relativism is stated bluntly by therapist and coach Russ Harris, ACT’s disseminator-in-chief:

Keep in mind there are no such things as “right values” or “wrong values.” It’s a bit like our taste in pizzas. If you prefer ham and pineapple but I prefer salami and olives, that doesn’t mean that my taste in pizzas is right and yours is wrong. It just means we have different tastes.

In this morning’s session, the psychologist’s take on values is supposed to buoy our spirits and help us orient our lives. It’s supposed to be empowering and motivating. Yet the lesson leaves me feeling more depressed and deeply disoriented. Why?

I should confess at this point: I was raised religious. It was an informal but earnest strain of faith, neither dull nor rigid, intellectually open yet shaped by an expectation that God talks back. For twenty years I have wrestled with the faith I inherited, unable to shake the thought that just because I was brought up believing it doesn’t make it untrue. (I was also brought up believing that 2 + 2 = 4.)

In the grip of depression, though, the intellectual edifice upon which I’ve built my life is shattered. A different vision crowds out the spiritual one of my youth, a vision eloquently espoused by the novelist Martin Amis in his memoir Experience:

The trouble with life … is its amorphousness, its ridiculous fluidity. Look at it: thinly plotted, largely themeless, sentimental and ineluctably trite. The dialogue is poor, or at least violently uneven. The twists are either predictable or sensationalist. And it’s always the same beginning; and the same ending.

Where once there was God, there is silence. Where once there was hope for the Resurrection of the Body, there is “at death you break up: the bits that were you / Start speeding away from each other for ever / With no one to see,” as Philip Larkin writes.

How do I try to survive that state of mind? I typically cast around for other convictions on which to reconstruct a workable conception of the world. And often the only thing I find myself able to hold on to are certain moral convictions. At every turn, at every juncture, I am haunted by the idea “that things could be better, more perfect, and so of course different, than they are,” as Harvard philosopher Christine Korsgaard puts it. These ideals were part of my first impression of things, and they “outstrip the world we experience and seem to call it into question.” I reflect on the fact that I tour the world and evaluate it as if it were not my home, as if some elsewhere underwrote my existence. And from this I deduce the intimations of an original goodness.

Less abstractly, when I am depressed, I alight upon certain realities and conclude that in any context, in any culture, they have to be wrong.

Consider this case. Justin was two months old when his fifteen-year-old mother left, eleven months old when his morbidly obese grandmother was hospitalized and died. Justin was left in the care of his grandmother’s boyfriend, Arthur, a dog breeder who decided to rear Justin the only way he knew. He kept Justin in a kennel. Fed and watered him. Rarely spoke to him. Rarely played with him. Never nurtured him. For five years.

Aged six, Justin was admitted to a pediatric intensive care unit — for pneumonia. He was unable to walk, unable to speak, and given a diagnosis of “static encephalopathy,” brain damage of unknown origin, unable to be treated because he tore out his IV, screamed at the staff, and threw his food and feces.

In moments of despair, I cling to my unshakeable belief that a child is not supposed to be treated that way, ever, in any world. It’s the only thing I know to be true, which is why the psychology I’m now being prescribed shakes me to my core. For the implication of what I’m being taught about values is that my deepest belief — that there are values which are not up for grabs — is untenable. This relativism, for someone who is depressed, doesn’t alleviate the problem; it compounds it.

Psychiatrist and Holocaust survivor Viktor Frankl insisted that we’ll never be able to treat mental illness properly until we acknowledge the existential dimension of depression. “Man’s search for meaning,” he wrote in 1946, “is the primary motivation in his life.” So long as we conceive of a patient’s suffering as resulting solely from a chemical imbalance that needs to be fixed with medication, we stand little chance of helping him. Even the most efficacious pharmacological regimen will not quell someone’s deepest questions about how to live.

Now in one way my psychiatric hospital grasps this, making space as it does for patients to make inquiries about which values are worth pursuing. But in another way the hospital’s therapeutic regime forecloses that search for meaning by denying the reality or importance of objective, transcendent truths by which men and women have historically navigated their lives. The provision of Acceptance and Commitment Therapy whets patients’ appetite for meaning only to deprive them of real nourishment by extracting the very substance on which meaning depends: its orientation toward the absolute.

Questions? I raise my hand. On this hot summer morning in this drab boxy room in psychiatric hospital, something has been gnawing at me.

I’ve no doubt that at times in my life I have suffered from narcissism — an inflated sense of my own value. I’ve thought I am better than I am, because I’ve thought I am better than other people. Right now I am experiencing the opposite problem. “I still feel — kind of temporary about myself,” as Willy Loman puts it in Arthur Miller’s play Death of a Salesman. I showed promise when I was younger. Doors seemed miraculously to open in front of me. So I felt special, chosen for something, “fortune’s minion.” Grown-ups took an interest in my progress. I had great expectations, and others had them of me. But then I found myself thwarted. And that knocked my confidence. My life doesn’t feel as though it’s amounted to much. So now, in my own eyes, according to my own perspective, I’m not feeling that I amount to much. I can’t see much worth in myself or in my life. Well, if value is subjective, and I’m struggling to behold any worth in my life, who can tell me I’m wrong?

In her memoir of depression, My Sh*t Therapist, the Welsh writer Michelle Thomas offers this compelling picture of the illness:

The depression I have experienced isn’t just feeling low or fed up. It’s the first thought to form on waking up, it’s dread of leaving the oblivion of an 18-hour sleep. It’s crying because you’re thirsty but you can’t summon the will to walk to the kitchen, take a glass, turn on the tap, fill the glass with water, turn off the tap, then drink. It’s the absence of any feeling, any drive. It’s collapsing onto bed, shutting the door on your parents, your loved ones, the people who want to help you, because you’re exhausted from carrying the weight of your own worthlessness.

Thomas is right: depression is bound up with low self-esteem. My point is simply that a psychology steeped in relativism stands little chance of relieving you of “the weight of your own worthlessness.”

In his compelling book A Common Humanity, the Australian philosopher Raimond Gaita tells the story of a pivotal moment in his life. Aged seventeen, he found himself working as an assistant in a psychiatric ward. The ward was very different from mine. It was housed in an austere Victorian building circled by a high iron fence. The scant external scenery (no grass or trees to speak of) reminded Gaita of a zoo enclosure. In terms of basic care, when patients soiled themselves, they would be ordered to undress, before ward assistants like Gaita would clean them down at a mop-handle’s distance.

The patients in this ward were different too. Some of them had been there for over thirty years. Friends and relatives, even parents, had long since stopped visiting them. Gaita writes:

The patients were judged to be incurable and they appeared to have irretrievably lost everything which gives meaning to our lives. They had no grounds for self-respect insofar as we connect that with self-esteem; or, none which could be based on qualities or achievements for which we could admire or congratulate them without condescension.

But the entire way that Gaita viewed these patients was changed by the arrival one day of a particular nun. The nun treated the patients very differently. “Everything in her demeanour towards them — the way she spoke to them, her facial expressions, the inflexions of her body — …. revealed that even such patients were … the equals of those who wanted to help them; but she also revealed that in our hearts we did not believe this.” Certainly, Gaita and his colleagues had been taught that they should respect these human beings. But in truth it depended on the love of this saint “to reveal the full humanity of those whose affliction had made their humanity invisible.” It required this nun’s behavior to disclose the patients’ irreplaceable value.

So here’s what I say to my psychologist. “The care I have received in this hospital is superb. The support, the understanding, the empathy. I am treated by your team as if I have irreplaceable value. When I am feeling worthless, you don’t act as if values are subjective. You don’t reply, ‘Yes. You’re right. If you feel worthless, you are worthless!’ No, you and your team always speak and act in ways that imply fundamental disagreement with my estimation of myself. Valuing my worth, you betray your proclaimed belief in the subjectivity of all values. You embrace truths far beyond any of our mere preferences.”

I finish my spiel. The psychologist pauses. I review the room. Even if I have a point, I’m still the patient. He’s seen my kind before. Probably even has a code for me. “We can discuss poststructuralism if you want,” he quips.

The reinstatement of good and evil in psychology would not mean the banishment of individual discovery. Actually, it would allow psychologists to make more sense of patient aspirations like “personal growth” — and indeed of the patient’s desire for real agency. At the start of Khaled Hosseini’s harrowing novel The Kite Runner, Amir’s old friend Rahim Khan asks him to come visit him in Pakistan. “Standing in the kitchen with the receiver to my ear, I knew it wasn’t just Rahim Khan on the line. It was my past of unatoned sins.” Rahim Khan says: “There is a way to be good again.” How can a psychology wedded to relativism make any sense of this possibility of finding a way to be good again, of moral transformation? What does progress or growth mean if there is no standard of goodness outside ourselves? Talk of “a way to be good again” makes no sense if “good” is merely whatever you decide it is. Goodness can function as a meaningful measure of our actions only if it is not a product of our minds.

This is how I come to realize that, in truth, my career has come at the expense of my children. I work all weekend. I am glued to my phone. I am never fully present with them. There but not there. This is because, in all honesty, my chief value has been “career,” not “family.” But then I begin to play out the trajectory I am on: Somewhere down the line my daughter tells me she hates me, that I was never properly available to her. Or, as a teenager she gets into trouble with the law and says my absence was a cause. Reckoning with a picture of this possible future precipitates a crisis for me. I realize that though I have lived up to my values (my career is doing fine), I am actually pursuing the wrong values. I have lost my way. I need to backtrack to where I went wrong, recognize a duty incumbent upon me, and alter my course. Not rationalizing the values I do have but thinking about the values I should have is what leads me to change.

What would it look like for psychologists to preach what they practice, to accommodate the intrinsic value they presuppose their patients to have? It would not, I think, necessarily entail a return to Victorian-style moralism, making patients stand on stools, like Jane Eyre at Lowood School on her “pedestal of infamy,” and branding them sinners and liars. Rather, it would see psychologists refusing to rule out from the outset a transcendent good that is the natural end of “man’s quest for meaning.” It would see psychologists encouraging patients to search for values beyond themselves, but making that quest for themselves. It would see psychologists echoing Iris Murdoch’s challenge, that each of us make “an attempt to look right away from self towards a distant transcendent perfection, a source of uncontaminated energy, a source of new and quite undreamt-of virtue.”

There are values and obligations and demands out there in the world that I may never have assented to, that simply come with the territory of being human. Any psychology that is going to be therapeutically beneficial, that is going to help people attain personal growth and become good again, will help us acknowledge and reckon with values — with truths — we may never have circled in an exercise.