From Theory to Practice: Patient-Related Virtues in Psychotherapy

Let’s apply the triadic analysis. (1) We have a problem that can be elucidated in self- and other-regarding ethical terms. In self-regarding terms, the patient lacks a sense of personal worth. His self-contempt obstructs his ability to love and respect himself, appropriate measures of which are crucial to feelings and behavior that reflect care and respect for others. In other-regarding terms, his anger is emotionally and occasionally physically harmful. These ethical terms can be reflected in an “official” diagnosis of mental disorder. There could be clinical deliberation using the DSM about whether the patient’s volatility should be distinguished from the aggressive behavior that can occur in either antisocial or borderline personality disorder. If a diagnosis of one of these disorders is made, then we revisit the Cluster B personality disorders that can be construed as character faults that the patient can be reasonably held responsible for changing. If the patient’s volatility is so distinguished, then he might be diagnosed with intermittent explosive disorder, one of the DSM’s impulse control disorders not elsewhere specified.56 (2) We have psychotherapeutic goals that can be elucidated in virtue ethical terms. The goals are greater self-love, respect for others, and anger management. The treatment goals involve ethically desirable changes in dispositions of emotional response, and in a cognitive understanding of how one should treat oneself and others that is expressed in better behavior. Thus, impulsive feelings and displays of anger ought to be replaced by stable degrees of measured emotional calm and behavioral restraint, as well as an improved understanding of why managing one’s anger is a better way to live. The goal is for the patient to modify his feelings, cognitions, and behavior in ethically desirable ways. (3) The efforts the patient makes to work through his problems will involve the affective, cognitive, and practical facets of generic ethical self-improvement. This working through is a concerted effort to replace character faults with character strengths or virtues.

Now let’s apply ideas from Swanton’s virtue ethics. Her notion of “hypersubjective vice” arguably captures much of this patient’s problem. His childhood traumas set the conditions for a failure in self-love. His angry way of responding to the world was expressive of this failure and resulted in a twisted sense of himself as despised by others.57 Swanton might say that his distorted affective and cognitive dispositions typify a conception of egocentricity that owes much to Adler and Horney: his childhood left him with “a peculiarly sharp sense of life’s hostility” which he subconsciously exaggerated. His interest in the “bitterness” of life was predominant. The patient remained in a juvenile phase reminiscent of a spoilt child. Understandable wishes or needs, such as finding his keys or efficiently using his computer, turned into claims or demands that he made on the world. The non-fulfillment of these demands caused resentment and much more than “normal frustration.” It was felt as an offence about which he was entitled to feel indignant. “The desire to escape a self seen as defective or contemptible ... [can] cause difficulty in the acknowledgement of necessities, restrictions, losses, or deprivations.”58 I am reminded again of Seneca’s Angry Man whose “every sense of grievance grew into self-torture.” The patient thus fueled his hostility by either suspecting what was untrue or by exaggerating what was unimportant.59

I think this case places virtue ethics in a therapeutic context. We can understand the patient’s striving to overcome personal deficiencies as an exercise in working toward self-love and empathic concern and respect for others, and establishing modes of moral responsiveness that comprise a more virtuous disposition. These are two of the “recovery virtues” that I elaborate further in chapter six. Given the wide range of distortions wrought by his internalized anger, self-love was a virtue he sought to attain.60 We can see that these distortions affected his receptivity to the demands of the world. To paraphrase Iris Murdoch, his mind was constantly active in fabricating an anxious, self-preoccupied, and often falsifying veil of hostility that obfuscated his moral vision.61 Swanton defines self-love as an essentially bond-centered, psychological phenomenon that reflects a Kantian distinction between coming close to and keeping an appropriate distance from oneself. Coming close involves bonding with oneself to express one’s “strength, vitality, and energy” in undistorted ways that should “make room for both self-respect and respect for others.”62

Keeping a balanced distance from oneself involves self-respect, i.e., a recognition that, out of regard for oneself as a person, one does not act as if one lacks worth.63 This equilibrium can be tilted toward egocentricity by internalized self-hate. The Angry Man, notes Seneca, is hurled headlong by his “inner tumult” and loses his balance. As if on a “stormy sea,” he sees nothing clearly.64 This egocentricity is invasive to the self through its suffocating effect. It distorts the expression of one’s vitality by leaving little room to breathe easily with, or be accepting of, oneself. One loses distance from oneself if one is blinded by a narrow preoccupation with one’s own “ego problems.” In this case, the patient went through much of his life choking on his anger. In seeking therapy, he began, however dimly, to see beyond his falsifying veil of hostility. He sought to put some distance between himself and his anger and to acquire a better bond with himself. Swanton sees perseverance as a “virtue” that “requires self-love if a healthy bonding with one’s projects is to be possible.”65 I think this case illustrates an alternate reading that would not be at odds with Swanton’s theory: where this healthy bond is decidedly lacking, striving for appropriate measures of self-love can require perseverance.

Although Swanton claims that self-control is an “admirable” trait that will not always count as an ethical virtue, I think this case epitomizes a striving for the virtuous self-control of anger. In reconceiving his persecutory view of the world, the patient slowly became more open to and trusting of others. In wanting to be that kind of person, he came to express a finer inner state, i.e., a background motivation to act from the virtues of self-love, respect for others, and anger regulation.66 I do not intend this case to illustrate a Jamesian conversion to supreme healthy mindedness. The patient had drunk too deeply from the cup of anger to ever forget its taste, but through therapy he had realized a finer internal state that calmed its affective edge.67 His proclivity to anger slowly became less forceful and he learned eventually to manage his reactions to quotidian frustrations fairly well. Further, he came to feel closer to the more open and empathic person he thought he should be. If psychotherapy was not going to completely eradicate his anger, it was aimed at enabling him to “at least ... rein it in and check its violence.”68

I noted previously Swanton’s claim that the process of resolving problems requires the application of her three virtues of practice. I think these virtues are relevant to this patient’s striving for self- and other-regarding ethical improvement. Like perseverance, these are some of the “healing virtues” that I discuss in chapter six. First, this patient needed virtues of focus so plights could be discerned and addressed. A shared focus with the therapist motivated his involvement and provided an operational context for “dialogical virtues” of relevant information. Where that information is “difficult or embarrassing,” virtues of focus involve “not just acumen, discipline, [and] sensitivity,” but may also involve “courage and persistence.” This patient brought propitious character traits to psychotherapy. He did not have “wisdom, experience, and localized expertise”69 in resolving psychological problems, but he gradually acknowledged that his therapy would involve ongoing work. This required initial dispositions to honesty and perseverance. These traits gave the therapist much to work with but they also enabled the patient to work on, with, and for himself.

We can say the patient began therapy with incipient traits that could be strengthened and developed as virtues of focus. He revealed a fledgling disposition to sustain a shared, concentrated effort to unravel the thorns in his psyche. This disposition grew in strength as the psychotherapy progressed. He faced his difficulties in disclosing his past with laudable measures of courage and persistence. His initial reluctance to confide was eventually supplanted by a steadfast fixity on providing unvarnished revelations about “shameful” behavior that evinced his growing commitment to valid information. In Swanton’s terms, we can say that he worked through a dialogical process of feedback, learning, and modification by which virtues of focus could be cultivated and strengthened in effecting a good enough solution to his problems in living.70

Second, we can apply Swanton’s analysis that problem resolution proceeds via integrating constraints, i.e., dealing effectively with the impediments to the problem’s solution. Constraints can include relevant values, material resource levels, time, energy, and existing practices which a solution must accommodate. Hence some of the patient’s constraints were external, e.g., he was limited to two-weekly sessions and had to occasionally cancel them for work-related travel. He was also faced with the challenge of integrating the following internal constraints: (1) initial confusion about the origins of his condition and his motivations for perpetuating it; (2) behavioral embeddedness, i.e., the extent to which his angry reactions and self-loathing had become “wired” into his personality; (3) initial discomfort in re-examining his traumatic past and accepting responsibility for having sustained his violent behavior; and (4) initial discomfort in accepting the psychotherapist’s challenge to assume responsibility for changing the frame of mind that informed his behavior. An effective psychotherapy must accommodate these constraints and enable the therapist and patient to gradually work through them. We might view psychotherapy as the process by which the patient progressively specified and re-specified the constraint structure of his problem, moving from a problem that initially appeared intractable to one that was transformed to “take on a more tractable air.”71

Swanton claims that “insight, depth of understanding, creativity, and commitment to valid information” are “central” to the virtues required for integrating constraints. Other virtues include dispositions to assemble and acknowledge relevant data, to examine and evaluate assertions made during the process of resolving the problem, to trust and acknowledge expertise, and “to change one’s beliefs on the strength of evidence” and admit mistakes. In these ways, the patient developed “the imaginative and analytic virtues required to facilitate constraint integration.”72 His disclosures facilitated the testing of his outlook through the scrutiny of the therapist. His insight into his anger grew along with his creativity in dealing more effectively with it. Hence his eventual understanding that psychodynamic dialogue would only take him so far and his propitious involvement in cognitive behavioral therapy. The latter mode of treatment “re-specified” his persecutory attitudes as negative schemas and his destructive reactions as amenable to modification.

The way the patient integrated constraints need not have been fully excellent. Remember, he vacillated about remaining in therapy, was initially not forthcoming and candid about his childhood and marital misconduct, and succumbed to intense guilt when his efforts to control his anger failed. He thus had to develop resolve to remain in therapy, had to work on being completely honest with the therapist, and had to work even harder to accommodate setbacks in his efforts at anger management. Yet the patient strove to overcome his weaknesses and meet the targets of the virtues of practice in a right, reasonable, and good enough way.

Third, given the need to integrate constraints having due regard to the perspective of the psychotherapist, this patient needed “virtues of dialogue” to overcome his limitations and participate adequately in therapy. The strong therapeutic alliance in this case enabled the cultivation of these virtues. Psychotherapy was thus an ongoing conversation in which both parties contributed thoughts on how the patient had acquired his attitudes and reactive behavior patterns and how he should go about the task of removing the traumatic past from his present.73

It is interesting to note that some of the patient dispositions that are thought to facilitate psychotherapeutic benefit might be seen as implicitly describing virtues of practice. Three researchers come to mind. I am thinking first of Hanna and Puhakka’s notion of a patient’s “resolute perception" which they define as “the steady and deliberate observation of or attending to” an intimidating, painful, or stultifying experience. This involves an “openness” to that experience and a “readiness to honestly examine it, evaluate it, and, if need be to change it with therapeutic intent” A therapeutic intention means that the resoluteness aims at promoting the patient’s well-being, which is “variously described as personal growth, adaptive behavior, [or] authenticity”74 I am also thinking of Arthur C. Bohart’s work, in which he notes several variables that can be correlated with personality traits that have been shown to enhance the probability of patients “doing well in insight-oriented psychotherapy,” such as psychological mindedness, ability to participate in interpersonal dialogue, openness and receptive listening, creative flexibility, perseverance, and courage. His model of the activities of productive patient thinking in psychotherapy has some intriguing parallels with Swanton’s three virtues of practice that I think merit further research and reflection.75

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