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Muddling Through
a weblog about knowing believing and getting better

The Strange Idea of "Therapeutic Neutrality"

Robert "Bob" Fancher, Ph.D. Updated: Sep 21st 2010

Mental health professionals claim to be neutral on moral issues. Those, the official line goes, are matters of patients' personal choice, and we should not "impose our values" on patients. We're about health, not moral judgment.

figure between two arrows pointing in different directionsThis is a very strange idea - but so ingrained in the culture of mental health care that most mental health types don't even realize how utterly peculiar it is.

To start with, the vast majority of humans consider moral beliefs less, not more, a matter of personal choice than other sorts of beliefs.

Outside mental health care, people generally allow each other much more variance on beliefs about how the world works than beliefs about what's right and wrong. Indeed, we etch requirements for moral behavior into laws, which we never do with beliefs about physics, psychology, politics, history, and so forth. In the world, matters of fact are open to personal opinion; huge areas of moral behavior are not.

Furthermore, the mental health notion about moral beliefs is exactly backward. Morals are not matters of preference. A moral dictum is something you have to obey whether you like it or not. An obligation, for instance, is something I have to do whether or not I want. That's the whole point, the very meaning of the term 'obligation.'

Indeed, we only have moral dictums in areas where our personal preferences need to be reined in or rendered moot. All of our "Thou shalt nots" refer to things we really find appealing - there's no need to prohibit things we naturally avoid. Our positive moral requirements tell us what to do, with no reference to whether we want to or not. "Do unto others as you feel inclined" hasn't made the cut into any major moral code.

It would seem then, that mental health types' standard view of moral beliefs and behavior is exactly backwards, by comparison to the overwhelming opinion and practice of humankind, and by reference to the very meaning and function of moral principles.

Strange, huh? Well, it gets stranger. Mental health types adamantly, enthusiastically, and insistently "impose" on patients life-changing beliefs and practices far more dubious than most moral judgments. We don't think we should be neutral in our beliefs about what's healthy and what's not, or how the mind works, or what causes or relieves suffering. We're happy to "impose" our beliefs. (And charge large sums to do it!)

We don't hesitate to offer our counsel with more firmness and assurance than the evidence warrants. Respect for diversity doesn't stop us from holding specific beliefs and practices that we offer to patients as true.

Indeed, the diversity of therapeutic beliefs makes the diversity of moral codes look rather trivial. A fair number of moral principles span the globe, even span human history - for instance, the imperative to keep promises, tell the truth, avoid gratuitous aggression, protect one's community norms, and treat one's neighbor as one's self. Therapeutic beliefs rarely even span an office building, and virtually none span more than a generation or two of practitioners.

Why do we "impose" with such fulsome self-confidence on life-defining topics of radical uncertainty - namely, our therapeutic ideologies and folkways - yet grow adamantly "non-imposing" when it comes to issues of moral responsibility, many of which are universal, or nearly so, and not controversial at all outside of the mental health world?

Four different issues combine to give us this odd stance: a simple-minded notion of the "medical model" of health, an archaic set of beliefs about moral versus scientific discourse, curtailing the moral stigma of professional help, and keeping patients happy (and paying).

I'll talk about these over the coming weeks. For now, I'll just say that moral matters cannot be extricated from mental "health," that we can reason about morality at least as well as we can reason about anything else in mental health care, and the moral stigma of help should be fought by better moral arguments rather than by trying to avoid morality. As for our keeping patients happy by supporting their disregard of their obligations-well, that's one of the temptations we should just have the courage to resist. But more on that another time.

 

Robert "Bob" Fancher, Ph.D.

Bob Fancher, Ph.D., is the author of Health and Suffering in America: The Context and Content of Mental Health Care and Pleasures of Small Motions: Mastering the Mental Game of Pocket Billiards. He is founder, CEO, CFO, marketing director, chief clinical officer, janitor, owner, and sole employee of Life Therapy Counseling Services in Portland, Oregon.

    Reader Comments
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    Moral relativity - - Jun 13th 2014

    I think some moral issues are absolute but others relative to a situation and culture. Don't therapists treat people who are addicted to illegal drugs helpfully and scientifically? Given that marital infidelity is fairly common, and more acceptable in some cultures than others. There a variety of reasons for them, including cases in which the unhappy, lonely clients finds happiness and support in an extra-marital relationship. There are others, such as parental behavior toward children, etc. Conforming to local norms doesn't seem like a moral imperative.

    I also think some therapists are not overly attached to one therapeutic approach.

    "Imposing" belief systems - Bob - Oct 3rd 2010

    It's certainly true that my article presupposes what I have demonstrated in my book--that the beliefs therapists teach people are not, in fact, things that are known, and that in teaching patients to think of themselves in one way rather than another, we enculturate them into our particular culture of healing.

    What works? - Lisa Correale - Oct 1st 2010

    Your article presumes that all therapists are in the practice of imposing some kind of belief system into the treatment. Some therapists practice the kind of therapy that does not involve interpretation, or offering advice unless the patient asks for it and/or it seems necessary in order to advance the patient into a new stage in therapy. For some therapists, the issue of imposing morality or any other belief system on the patient is unnecessary because they know that long-term, consistent, and respectful treatment will naturally lead to the patient behaving better socially, whether from a sense of moral obligation or because the patient figures out that it is in his/her best interest to do so.

    Giving Permissions - spiritual_emergency - Oct 1st 2010

    Bob: --we give our patients all sorts of "permissions" and directions. Some of those permissions are not, in reality, ours to give--permission to ignore obligations to others, for instance, or permission to make "feeling better" an overriding consideration.

    Just a bit of a sideline informal observation...

    I've noticed that some people prefer to be "clients" and some people prefer to be "patients".  Those who prefer to be clients are seeking a different kind of therapeutic relationship than those who prefer to be patients.  

    Clients seem to be seeking more of an egalitarian relationship.  They are very much aware that the therapist is "hired help" and are probably more demanding in a number of ways.   If the therapist doesn't meet their expectations, they are also aware they can let the therapist go and pursue a more satisfactory therapeutic partner. 

    Patients on the other hand, seem to place high value on "expert" or "authoritative" opinion.  They find it comforting to believe that someone out there has the answers, even if it's not them.  They want to feel guided.  They are actively seeking direction.  The therapist's opinion may be of grave importance to them. 

    I've got a hunch that those who self-identify as clients don't seek much in the way of permissions from their therapists.  Right or wrong, compassionate or cruel, they are going to do what they choose to do whether their therapist agrees with their decision or not.  Those who self-identify as patients however may be more open to following therapeutic promptings. 

    Perhaps part of the quandry you describe lies then within the therapist him/her self.  If they are personally morally opposed to a specific behavior (i.e., infidelity, abandoning a partner who is ill), can they comfortably tolerate supporting their client/patient in carrying out that behavior?  Human nature being what it is, I'm going to say 'no'.  Even if they never voice their objection however, those sort of underlying attitudes seem to worm their way into  relationships of all kinds.  When it comes right down to it, therapists are people too and people tend to lose respect for those who do not measure up against their own moral code.  Can a therapist still help someone they no longer respect?  Will that lack taint the therapeutic container?  Will it be sensed by the individual sitting across from them?

    Elsewhere you have spoken of the necessity of a good "fit" between therapist and client.  I have long joked that there needs to be an e-harmony of sorts that could successfully match therapist with patient/client, preferably without the cost of those early expensive dinners that end with no spark and $150 out of pocket.  (Yes, I've already noted that you charge less than half the going rate.)

    Anyway, my point in regard to seeking/giving permissions is that ultimately, it seems to me that this will be driven by the individual who is seeking the therapist's services, expertise, guidance, approval, understanding or what have you. 

    ~ Namaste

     

     

     

     

     

     

    Thanks SE - Bob - Sep 26th 2010

    I appreciate your taking the time and energy to "get" what I'm trying to accomplish here. Yes, I am trying to engender a critical view of care--in this instance, specifically, how we do a bad job by pretending to "neutrality."

    In fact, we are not neutral at all--we give our patients all sorts of "permissions" and directions. Some of those permissions are not, in reality, ours to give--permission to ignore obligations to others, for instance, or permission to make "feeling better" an overriding consideration.

    And we urge upon them concepts of "healthy" ways to live without subjecting those concepts to appropriate evaluation--in essence, claiming an exemption from moral evaluation because we're about "health," not morals.

    Our claim to neutrality is a form of self-deception. We are constantly making moral recommendations, even though we refuse to admit it. I am saying that we should admit it and do it better.

    But more on that as we go along.

    the book - spiritual_emergency - Sep 26th 2010

    [quote]

    All this and more needs to be said loudly and clearly of the most valuable of all the sections in Cultures of Healing – Fancher's critique of biological psychiatry. It is here that his original training as a philosopher is put to its most effective use, as he deftly dissects a series of logical fallacies that constitute the foundation myths of modern biological psychiatry. Central to his argument is the recognition that, even if it could be proved that psychopathology is rooted in biological abnormality, it would not follow that drugs are the treatment of choice. ‘Once we accept the falsity of dualism, we have to accept that everything is physical – and that includes talk therapy, new experiences and changes in one’s habits of life. All of these have biological effects. There is no a priori reason to think that the biological changes needed to treat psychopathology cannot be effected by non-pharmacological regimens. Anyone who has fallen in love (or felt betrayed by a lover) knows that psychosocial factors have biological effects.’ And, as Fancher wryly notes elsewhere: ‘One does not need to be a scientist to understand that drug companies do not want to discover that the changes brought about by talk therapy include the stabilisation of neurotransmitter regulatory systems.’ 

    Source: http://www.richardwebster.net/lettingoutthecartesiancat.html

    I ordered the book.

     

     

     

     

    It is a series - spiritual_emergency - Sep 26th 2010

    I went back and read it through and I have a better sense of what you're saying.  To a certain extent, you're questioning the morality and ethics of the "professional care community".   There probably is a need for a "critical psychology" movement, just as there has been a need for a "critual psychiatry" movement. 

    I did appreciate a number of your points such as the emphasis of cultural perspectives, differing value systems and the willingness to adopt some truths as "gospel" when just a bit of a cursory examination reveals that they're not.  One such example I draw on from my own experience is the concept that people with schizophrenia/psychosis do not ever recover.  There's such a wealth of evidence that demonstrates they do but I keep running across professionals who insist that they're right and I'm wrong on merit of them being the "expert" and me, not only the presumed "patient" but also the presumed "schizophrenic/psychotic"... at least, that's the presumption in this culture.

    The issue of morality and neutrality is an interesting one and a potentially dangerous one.  People do need and often seek guidance but isn't part of the goal of therapy to empower them to make their own decisions, their own choices and, when necessary, to find a way of dealing with the consequences of those actions?  I suppose it depends on the issue.  And the people.  And the context. 

    I'm not clear myself on how the issue of homosexuality became part of this conversation but here is the link to the other conversation that referenced your article: http://community.mentalhelp.net/showthread.php?t=5063

    When I saw the additional references to homosexuality in the comments section I assumed that had been part of your agenda.  Upon reading through your words, I'm not seeing that.  Nor did I see it at your website or in your interview. 

    ~ Namaste

     

    My apologies - spiritual_emergency - Sep 25th 2010

    Bob: I can't believe how this discussion has gotten sidetracked. This piece has nothing to do with homosexuality at all.

    Ah.  I had seen others mention it and thought this might be part of a larger series.  Somewhere, in the forum community discussions there was also a discussion related to morality and homosexuality that referenced back to an article written by you.  My apologies if I misunderstood.

    Meantime, this was the part of your article that I most enjoyed...

    [quote]

    Mental health types adamantly, enthusiastically, and insistently "impose" on patients life-changing beliefs and practices far more dubious than most moral judgments. We don't think we should be neutral in our beliefs about what's healthy and what's not, or how the mind works, or what causes or relieves suffering. We're happy to "impose" our beliefs. (And charge large sums to do it!)

    We don't hesitate to offer our counsel with more firmness and assurance than the evidence warrants. Respect for diversity doesn't stop us from holding specific beliefs and practices that we offer to patients as true.

    Indeed, the diversity of therapeutic beliefs makes the diversity of moral codes look rather trivial. A fair number of moral principles span the globe, even span human history - for instance, the imperative to keep promises, tell the truth, avoid gratuitous aggression, protect one's community norms, and treat one's neighbor as one's self. Therapeutic beliefs rarely even span an office building, and virtually none span more than a generation or two of practitioners.

    [/quote]

    I enjoyed that because I have experienced places in my life where others have tried to impose their standards upon my experience.  I don't think this is a domain that belongs exclusively to therapists.  I see it as more of a need to maintain control... which I don't care for.

    I look forward to reading more of your articles.

    ~ Namaste

    It Would Apply to Any Issue With........ - - Sep 23rd 2010

    But, it would apply the same for any issue that might have a variance when it comes to morals and there are many.  Gosh, there are so many issues related to morals/values for which people take a real beating when they are in public, at work or even among their own families.  I don't think anyone should mess with someone else's morals/values unless they are imposing a threat to that person or others and there should be enough of those people to go around without trying to change people who just need a little guidance to navigate the system of life.

    BIZARRE - Bob - Sep 23rd 2010

    I can't believe how this discussion has gotten sidetracked. This piece has nothing to do with homosexuality at all. I have absolutely no anti-gay agenda. None. Period. It never even entered my mind that anyone would consider this an issue.

    As I will be developing in later pieces--promised in the last paragraph of this one--we can and should reason about moral issues. I have never heard anyone give a sound moral argument that homosexuality is wrong. Ever. The problem with anti-gay therapists is not that they are "imposing morals." It is that they are being stupid, and hence morally wrong. Anti-gay is not moral. 

    Moral reasoning, not moral neutrality, is responsible for the very welcome gains that society has made in its stance toward gays and lesbians.

    I would point out that, as a matter of historical fact, the mental health disciplines were slow to recognize the MORAL NECESSITY of equality among sexual orientations. We insisted for until the 1970s that this was simply a mental illness--and did not remove "ego dystonic homosexuality" from the DSM until DSM-IV.

    "Moral neutrality" by mental health types never helped gays and lesbians. Only when the professions RESPONDED TO the moral revolution taking place outside our disciplines, when we recognized that our notions of sexual "health" actually embodied an immoral prejudice, that we changed our stance.

    I have absolutely no problem with therapists imposing good moral reasoning to the issue of homosexuality--because prejudice cannot stand up to sound reasoning. Indeed, demanding that therapists provide sound moral reasoning is a much better pro-gay stance than therapeutic neutrality.

    The people who have commented on this blog entry as if it could ever, possibly, in any universe be used to justify an anti-gay agenda have inserted that issue, for their own reasons, where it does not belong. 

     

    Homosexuality and morality - spiritual_emergency - Sep 23rd 2010

    I quite enjoyed this article and would hope it's not strictly related to an anti-homosexuality agenda.  If it is, then it would be against my own morals to oppose homosexuality in others.  Why?  How about because of this: Do unto others as you would have others do unto you.

    Morals don't always offer a strict code of adherence.

    red herring - Bob - Sep 22nd 2010

    This discussion about homosexuality is a red herring that is derailing the point of my remarks.

    As I have argued at great length elsewhere, cultures of care do, in fact, urge on patients all sorts of decisions without properly considering the ethical ramifications of those decisions. We do, in fact, "impose" all sorts of values, but we do it in a disingenuous manner--by pretending that we are simply recommending what's "healthy." Our misguided notion that we ought to be neutral on moral issues hamstrings us in thinking about our daily impact.  Some of our moral views (smuggled into care under the rubric of "health") are quite admirable; others are execrable. Because we have the misguided idea that we are neutral on moral issues, we are generally pretty bad on sorting out which is which.

     

    Re: Seems Simple to Me - Jennifer - Sep 22nd 2010

    Not everyone attends therapy because they have problems with their homosexuality, but like you said, they could be attending therapy because they're struggling with depression or anxiety as a result of the treatment they get from others who have problems with homosexuality. In order for the clinician to get an accurate picture of what's going on and why the person is struggling with depression the client would need to reveal that he or she is homosexual.

    I think what malign (and myself) are trying to get across is: if a client were receiving services already and revealed to the professional that he or she is homosexual and is having problems with depression, anxiety, or post-traumatic stress disorder as a result of the way they are treated in society, would the professional who takes a moral stance demoralize the client for being homosexual? 

    Also, not all people who attend therapy believe in God, or Allah, or Buddha etc...so involving morals pertaining to any religion in the therapeutic environment can lead to ethical violations for the professional (and the loss, or suspension of, their license to practice).

    Seems Simple To Me - - Sep 22nd 2010

    With homosexuality, I really don't understand where the other two people that are asking are going with that.  Does someone go to the therapist and ask "Is this behavior immoral?'  "Can I change an immoral behavior that I engage in?"  I would think if I were engaging in what I had been brought up to believe was an immoral behavior, I would seek religious counsel on that.  On the other hand, I think that if I were engaging in a behavior which I felt was moral but many in society disagreed, I would approach the therapist  saying "I engage in an activity/lifestyle that many others feel is immoral and it makes me feel bad about myself that they feel that way, the comments, the behaviors toward me, so since I can't change them, how do I deal with this."  I just think this would be the way it would go down unless the person was indeed troubled that the behavior was immoral, feared retribution from God and therefore either wanted to change, know if change would be possible or wanted the therapist to convince him/her that the activity/lifestyle was indeed moral which the therapist should not be doing.  If ultimately you feel you are doing something you should not be, the therapist's reassurance that you aren't probably won't tide you over for very long.

    power can be poison - - Sep 21st 2010

    Excellent and surprising article.  I look forward to reading the articles that follow.  Very few people have a "calling" anymore when entering a professional career and power can be poison for some, actually many.

    Religion, Morals, Ethical Situations, and the Mental Health Field - Jennifer - Sep 21st 2010

    What if a client (or potential client) had beliefs and morals that differed from a mental health professional who attended an institute that encourages religious traditions or morality being mixed with the mental health profession? What if someone that was part of the gay, lesbian, bisexual, or transgender community and that went against a professional's moral beliefs about right and wrong? I am in school and intend on entering the mental health field. How would those be handled ethically by a professional when religion and morality have been mixed into the therapeutic alliance?

    Jennifer

    I'm not sure I agree - malign - Sep 21st 2010

    Dr. Fancher,

    I'm not sure that I agree with you about the relative universality of moral codes.  The saying that "you can't legislate morality" exists for a reason:  our laws are at best a distillation of many individual moral codes, created by a majority vote of some sort and meant to apply to all.

    What you're dealing with, one on one with a patient, is one person's moral code.  Granted that in broad strokes, it probably shares a lot with the codes of other people (otherwise they'd probably be diagnosed with something "anti-social"), it's likely to be in the details that the person's unique struggles would come to light.

    For instance, while society as a whole still has difficulty accepting homosexuals, and in fact, many places have laws that discriminate against them in various ways, I hope you wouldn't venture to impose that morality on a client who came to you complaining of being bullied for being gay.

    I understand that I should probably hold this comment until you've had a chance to explain what you mean, in depth.  On the other hand, perhaps the comment will help you identify what needs to be expanded upon.

    I look forward to reading the rest of your series.

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