Preface
The therapeutic trend in ethics is the tendency to approach moral matters in terms of mental health, for example by pathologizing vices (alcoholism as a disease), psychologizing virtues (self-respect as self-esteem), and liberalizing attitudes (sex as good, guilt as suspect). The trend unfolded throughout the twentieth-century, although its roots extend to Plato and the Stoics. At its worst, the trend is a confused and dangerous attempt to replace morality with therapy. At its best, the trend integrates moral and therapeutic understanding to yield creative solutions to otherwise intractable problems. In this book I develop an integrated, moral-therapeutic perspective centered on three themes: (1) sound morality is healthy; (2) we are responsible for our health; (3) moral values are embedded in mental health and psychotherapy.
Part I connects Plato’s virtue-oriented ethics with psychiatrists’ definition of mental disorders. It also explores Freud’s and Nietzsche’s therapeutic critiques of sick forms of morality. I show how moral virtues overlap and interweave with the criteria for positive mental health—that is, psychological well-being in addition to the absence of mental disorders. Here, as throughout the book, I reject any general dichotomy between moral and therapeutic attitudes.
Part II develops a conception of responsibility for mental health and applies it both to therapist-client relationships and to moral accountability within society. I take seriously the criticism that the therapeutic trend in ethics fosters evasion of responsibility, but I recast the criticism as a caution rather than a basis for opposing the trend. I also respond to the concern that responsibility for mental health leads to blaming victims of mental illness.
Part III discusses responsibilities for health in connection with alcoholism, pathological gambling, serious crime, unjustified violence, and visceral bigotry.
In each instance, I make sense of how the same pattern of conduct can be both wrongdoing and sickness. The aim is to show why expansive definitions of mental disorders do not provide automatic excuses for harming others.
Part IV shifts the focus to positive health and personal meaning. I explore the confluence of morality and mental health in pursuing meaningful lives.
Topics include depression, self-deception, and philosophical counseling, as well as love, work, and philanthropy.
*******
Self-deception and hope
Ever since Socrates pronounced the unexamined life not worth living, ethicists have linked meaningful life and honesty with oneself.1Similarly, therapists regard honesty with oneself as integral to healing, and they regard contact with reality as a criterion for positive mental health.
Some recent psychologists, however, suggest that self-deception and unrealistic optimism might be good for us. I agree with them that self-deception sometimes contributes to hope and love, and thereby to meaningful life and healthy functioning. It does so in a limited way, however, and not to the extent that justifies abandoning contact with reality as a criterion for mental health. Even when self-deception advances psychological health, there is no fundamental clash between therapy and morality, for all the values involved—hope, love, and honesty—are both moral and therapeutic values that are sometimes in tension.
By reaffirming truthfulness within a moral-therapeutic perspective, morality and mental health once again emerge as interwoven.
Vital Lies
‘‘The life-lie, don’t you see—that’s the animating principle of life,’’ proclaims Dr. Relling in Ibsen’s The Wild Duck.2Life lies, or vital lies, are self-deceiving beliefs based on unfounded optimism, unwarranted hopes, and rationalizations about our failures. We rely on them in order to cope and to maintain happiness and health:
‘‘Deprive the average man of his vital lie, and you’ve robbed him of happiness as well.’’3 Dr. Relling fosters inflated self-images in his patients. In particular, he encourages Hjalmar Ekdal to believe he is on the verge of a revolutionary dis-covery in photographic technology, when actually he is tinkering with a bunch of useless gadgets. Ekdal is a cooperative patient who is already prone to self-deception. He believes he is the sole provider for his family, yet his wife balances their household budget by relying on large subsidies from the former business partner of Ekdal’s father. Ekdal also assumes he is the father of Hedvig, his greatest joy, when in fact she is the offspring of the former business partner.
The son of the former business partner, Gregers Werle, calls for complete honesty and encourages Ekdal to abandon his illusions about work and family. Yet Werle’s moralizing is self-righteous and neurotic, motivated by unconscious hatred of his father and shame at his extramarital affair and illegitimate child. When Ekdal learns that Hedvig is not his biological daughter, he immediately becomes estranged from her. Feeling disowned by the father she adores, the emotionally fragile Hedwig sinks into depression and kills herself. At least in this instance, honesty is apparently self-destructive, undermines love, and has dubious motives.
Most of us do not need a Dr. Relling to prescribe our vital lies. As self-deceivers, we have ample resources within. Like Ekdal, we need reinforcement from family and friends, but usually they are willing to indulge illusions that keep us buoyant with optimism—assuming we reciprocate. Beyond these social dimensions of self-deception, what mental activities and states are involved in deceiving ourselves? The question has generated a substantial literature in philosophy and psychology.4 The central issue is whether the paradigm, gar-den-variety, cases of self-deception involve purposeful evasion of truth. Or do they instead consist entirely of motivated irrationality—biased beliefs that are false and contrary to the evidence? I believe both kinds of self-deception exist and are commonplace.
To begin with motivated irrationality, we are all familiar with how biases, such as self-esteem and happiness, filter what we see and think. Thinking along these lines, Stanley Paluch concludes that ‘‘self-deception’’ is a metaphor for false and unsupported beliefs formed by biased assessments of evidence.5 More recently, Alfred Mele says that self-deception consists in forming false beliefs that go against the evidence, and doing so under the influence of a biasing desire or emotion.6 There is no intention to evade reality or to embrace a falsehood.
Suppose, for example, my physician informs me that I have a fatal and untreatable cancer, giving me six months to live. My doctor is well-qualified, and a second opinion confirms her diagnosis; on balance, I have every reason to believe my chances are slim. Yet, hoping against hope, I believe I will beat the odds. My belief is influenced by a desire to live and a fear of dying, but there are various possibilities. One possibility is honest hope, whereby I struggle to believe I will survive even though I am painfully aware of the evidence to the contrary. The other possibility is motivated irrationality, in which I downplay the contrary evidence (‘‘What do doctors know, anyhow?’’[that's very good question VB]) and highlight positive evidence. Self-deception occurs when I lose my grasp of what the evidence indicates.
I believe there is another possibility, however: purposeful evasion. Paluch and Mele reject this possibility because they believe it involves modeling self-deception on lying to other people, which generates two paradoxes. First, when I lie to another person, I know (or believe) something unpleasant and get the other person to believe the opposite. By analogy, when I lie to myself it seems I know (or believe) one thing and simultaneously get myself to believe the self-deception and hope opposite. But that seems impossible, for my knowledge would prevent me from acquiring the false belief. Freud offers one solution to this paradox: the unpleasant belief is kept unconscious, and the opposing belief is held consciously.
A different solution is that the unpleasant knowledge is held at a less-explicit level of consciousness and ignored.7 I believe self-deception can involve either unconscious beliefs or disregarded beliefs. Most purposeful evasion, however, does not involve self-contradictory beliefs at all, but instead one belief formed by evading unwanted evidence or its implications.
Turning to the second paradox, when I lie to another person I intend to mislead them. By analogy, when I lie to myself it seems I must be aware of an unpleasant truth and use that awareness to form an intention to flee the truth. But that is a psychological impossibility, except perhaps in cases of dissociative identity disorder (multiple personality). Here the solution is to specify that my intention is to evade a reality and its evidence, rather than (a muddled) intention to believe what I know is false. In addition, the intention is formed and acted on spontaneously rather than self-reflectively. As a self-deceiver, typically I have some suspicion of an unpleasant reality and use the suspicion to ignore the reality, discounting evidence contrary to what I want to believe.8 Selective attention, willful ignorance, and distorted use of evidence suffice to explain purposeful self-deception, without postulating a conscious intention to believe what I know is false. As Herbert Fingarette writes: ‘‘The crux of the matter . . . is that we can take account of something without necessarily focusing our attention on it. That is, we can recognize it, and respond to it, without directing our attention to what we are doing, and our response can be intelligently adaptive rather than merely a reflex or habit automatism.’’9 For example, we write on a computer without thinking about the specific motions of our fingers across a keyboard, and we drive a car while taking account of many details in the environment without attending to them, much less attending to our patterns of attention. Similarly, in self-deception we take account of unpleasant truths and evidence without attending to them. We do so as part of ‘‘a purposeful and skillfully pursued policy’’ in which typically we ‘‘secretly do know’’ or suspect the unpleasant truths and evidence.10 To sum up, self-deception includes both purposeful evasion and motivated irrationality. Both kinds might be involved in the same case, and often are. And both kinds are relevant to understanding the interplay of honesty and hope, as well as morality and mental health.
Healthy Self-Deception: Honesty versus Health?
Some recent psychological studies echo Ibsen’s insight that self-deception con-tributes to vitality and happiness.11 For example, an anthology of essays adopts the theme that ‘‘self-deception is a normal and generally positive force in human behavior.’’12 Again, Jonathon Brown cites an extensive body of psychological studies, including his own, showing that healthy, well-adjusted individuals healthy morality and meaningful lives ‘‘possess unrealistically positive views of themselves.’’13 And in Positive Illusions: Creative Self-Deception and the Healthy Mind, Shelley E. Taylor argues that ‘‘unrealistic optimism’’ promotes mental and physical health: ‘‘Normal human thought and perception is marked not by accuracy but by positive self-enhancing illusions about the self, the world, and the future.’’14 I focus on Taylor’s book because, by presenting the experimental literature to a wide audience, it enters into the therapeutic trend. Because she avoids moral language, she does not explicitly affirm mental health over honesty, but clearly she implies as much. Taylor groups healthy ‘‘positive illusions’’ under four headings: egocentricity, illusions of control, illusions of progress, and self-fulfilling beliefs.
Egocentricity. We are heroes in our own dramas, interpreting the world through a subjective lens. In doing so, we cast our actions, talents, achievements, and prospects in a favorable light in order to maintain self-esteem, hope, and happiness. We selectively ignore unpleasant evidence that goes against what we want to believe about ourselves. Failures and setbacks are conveniently forgotten, and painful events are affirmed as positive learning experiences.
Illusions of Control. Typically we exaggerate the control we have in our lives, thereby manifesting unrealistic optimism about the role of chance and external influences. Most gamblers, for example, think they can beat the odds and that they have skills in areas where pure luck dictates the outcome. They roll the dice gently when they want low numbers and more vigorously when want high numbers. Again, most drivers—about 90 percent in one study—believe they are above average in skill, including drivers who have caused major accidents. And we blame victims of all kinds by holding false stereotypes about them, thereby creating the illusion that we are protected against dangers because we are more careful than them.
Illusions of Progress. Most of us are optimistic about progress in our lives (as distinct from progress in the world). For example, in a study of college students enrolled in a special program that promised increased study skills and better grades, students reported dramatic improvements. Even when they failed a test they would reinterpret the failure as progress in learning how to do better next time. In fact, no differences in results were found between students enrolled and not enrolled in the program.
Self-Fulfilling Beliefs. Belief in the prospects of achieving a specific goal tends to bring about favorable results by strengthening motivation and bolstering hope. A familiar example is the placebo effect, which is any positive therapeutic impact due to patients’ beliefs about medical procedures. This includes sugar pills given to patients who believe they are taking an active drug, and it includes beliefs in the effectiveness of health professionals and their institutions. The extent of placebo effects is controversial, but many researchers believe it affects about a third of us. Positive beliefs and attitudes also encourage others to support our efforts.
Citing a wealth of studies in the preceding areas, Taylor concludes that self-deceptive positive illusions are healthy: ‘‘Increasingly, we must view the self-deception and hope psychologically healthy person not as someone who sees things as they are but as someone who sees things as he or she would like them to be.’’ The mentally healthy person has a positive self-image and abilities to be happy, to care about others, to work productively, and to continue to grow.15
Taylor vastly overstates her case. She does so because she equivocates between two senses of ‘‘positive illusions’’: unproven beliefs and irrational beliefs.16 Unproven beliefs are beliefs not shown to be true by the evidence, and which might be true or false. Using this sense, Taylor defends optimism: unproven positive beliefs in the form of hope, faith, and optimism promote mental health. This is an important insight, but hardly revolutionary. Common sense tells us that positive attitudes promote our ability to maintain self-esteem and to cope with work, personal relationships, and ambitious projects. Irrational beliefs, in contrast, are false beliefs contrary to the available evidence. In using this sense, Taylor successfully defends only some, not most, self-deception as healthy because it promotes hope, coping, and self-esteem. For example, she claims that irrational, self-deceiving beliefs are ‘‘normal’’ because most of us believe we are above average at everyday tasks such as driving.17 In fact, these studies merely show that unproven beliefs are ubiquitous. Drivers who hold unwarranted beliefs are not necessarily evading evidence about their rankings as drivers, for they are not provided with such evidence. The drivers value (affirm) their driving skills, endeavors, and future prospects, without having hard data about how to accurately evaluate (rank) them.
Sometimes Taylor says that positive illusions are false beliefs, but other times she suggests they can simply be unproven beliefs that cast reality in a positive light.18 Now, there is no basis for counting all unproven beliefs illusions— ’’unproven’’ does not mean ‘‘proven false.’’ Why, then, did Taylor count unproven beliefs, whether true or false, as illusions? I suspect she borrowed the deviant usage from Freud’s Future of an Illusion. Freud writes: ‘‘What is characteristic of illusions is that they are derived from human wishes. . . . Illusions need not necessarily be false—that is to say, unrealizable or in contradiction to reality.’’19 Freud’s odd notion that illusions can be true contributed to the polemical tone of his book in denigrating religion. In turn, by conflating unproven and false beliefs, Taylor greatly exaggerates the health benefits of self-deception.
Truthfulness and Mental Health The tendency to perceive accurately and to maintain justified beliefs is a traditional criterion for mental health, as we saw in chapter 2. The criterion is embedded in Freud’s ‘‘reality principle,’’ the norm of living in tune with reality. It is equally central to cognitive psychologists’ emphasis on realistic cognition. And Marie Jahoda assumed that ‘‘as a rule, the perception of reality is called mentally healthy when what the individual sees corresponds to what is actually there.’’20 In explaining the caveat ‘‘as a rule,’’ however, Jahoda emphasized the healthy morality and meaningful lives plurality of reasonable interpretations of the world. Equally important, she said mental health requires only ‘‘relative freedom’’ from distortion by our desires, together with a disposition to test reality to check whether it conforms to our wishes. Likewise, Taylor’s arguments should lead us to qualify, not abandon, truthfulness as a criterion for mental health.
Although Taylor’s main interest is in positive mental health, she devotes a chapter to psychopathology, focusing on pathological depression and mania. Mild depression and low self-esteem involve fewer positive illusions and more accurate beliefs than healthy states, an idea called ‘‘depressive realism.’’ Taylor suggests that therapy should encourage positive illusions.21 Once again, however, her suggestion is marred by ambiguity. Is she saying that the absence of self-deceptive beliefs contributes to depression, so that therapists should encourage self-deception in their clients? Or is she saying that the absence of unproven positive beliefs contributes to depression, so that therapists should encourage hope? The first claim is a Dr. Relling–like prescription for untruthfulness; the second claim is a morally responsible endorsement of honest hope.
Depression involves loss of caring about ourselves and our world. Depression is primarily a diminished valuing of ourselves, other people, relationships, activities, and life itself, regardless of whether it involves unwarranted evaluation. Accordingly, when therapists cure depression they are not encouraging untruthfulness. They are helping patients value themselves and their world by restoring honest hope, faith, and caring.
Taylor discusses mania more briefly, again focusing on mild cases. Mania is rarer than depression, and usually it is connected with bipolar disorder (manic depression). Mania interests Taylor as the exaggeration of normal positive il-lusions. Frequently, it contributes to the work of the creative artist, the daring leader, and the religious innovator. In discussing these ideas, she again fails to distinguish unwarranted evaluations from positive valuing. Either might be involved, of course, but blurring them exaggerates the contribution of self-deception to creativity. And by stipulating that mania is an excessive illusion that differs from ‘‘milder’’ positive illusions, she neglects how self-deception sometimes contributes to psychopathology.
Moving to more serious disorders, a few writers believe self-deception enters into psychosis, but for the most part self-deception is a different phenomenon than involuntary hallucinations, psychotic delusions, and other complete breaks with reality. Even so, there are continuities, not absolute differences, between psychosis and ordinary self-deception. Families immersed in untruthfulness breed pathology.22 Self-deception also plays a role in personality disorders, such as narcissistic and histrionic disorders defined by grandiose views of one’s talents, worth, and entitlement.
Addictions provide a more straightforward example of how self-deception contributes to pathology. Indeed, Alcoholics Anonymous portrays alcoholism as the disease of denial. And addiction specialist Abraham J. Twerski exposes the rationalizations used to maintain optimism about how much one drinks (‘‘I am self-deception and hope a social drinker’’), about the degree of one’s self-control over the addiction (‘‘I can stop at any time’’), and about the desirability of using drugs (‘‘They help me cope and cause minor problems at most’’).23 Addicts might also deceive themselves about their diminished self-respect and gradually lose a sense of who they are.24 Self-deception also enters into the neuroses, understood as the result of psychological defense against anxiety, although defense can also serve healthy ends.25 Thus, defense might undergird an artist’s fanatical devotion to her work, but only in the workaholic might pathology be involved. Psychological defense is often interpreted as self-deception, even though Freud rarely used the term ‘‘self-deception.’’26 Yet, psychological defense can be understood in two ways, paralleling the two varieties of self-deception. Sometimes Freud described repression, denial, projection, and other defense mechanisms as motivated biases that operate unconsciously and without any activity by the person. Other times he described psychological defense as purposeful and intentional activities.
Most likely, he thought defense might involve either or both. Moreover, defense ranges from activities that are partly conscious and preconscious (available to consciousness) to processes below the level of mental contents available to consciousness without special help from a therapist.27 Either way, removing repression can lead to both more realistic cognition and better coping.28 Finally, pathological self-deception is not an automatic excuse for wrong-doing. When we have, or should have, good reason to believe that unconscious motives are distorting moral understanding, we are obligated to take special precautions to ensure that we are meeting our responsibilities.29 Unconscious motivations are not automatically excuses, and they often lead to culpable negligence. The same is true of self-deception involving conscious activities. Here again, the therapeutic trend does not replace morality but instead integrates it with therapeutic understanding.
Moral Values in Tension If self-deception were always dishonest, then Taylor’s psychological studies would support a morality-therapy dichotomy: honesty condemns self-deception; health celebrates self-deception. Some philosophers do in fact condemn all self-deception as dishonest. Kant wrote: ‘‘By a lie a man makes himself contemptible—by an outer lie, in the eyes of others; by an inner lie [i.e., self-deception], in his own eyes, which is still worse—and violates the dignity of humanity in his own person.’’30 Jean-Paul Sartre condemned all self-deceivers as cowards and scum.31 And Daniel A. Putman says that ‘‘self-deception always works to destroy a fundamental virtue, integrity. Self-deception isolates part of the self and prevents that part from being integrated into consciousness.’’32
These absolute condemnations are too extreme, however, for not all self-deception is immoral. Despite its enormous importance, honesty is one virtue and one obligation among others, and it is not paramount in all situations. Thus, an instance of self-deception might be untruthful and yet justified by other moral values that promote meaningful lives—for example, hope and faith, self-esteem and self-respect, and love and friendship. Hence, the therapeutic contributions of some self-deception do not threaten morality in its entirety. To return to an earlier example, suppose I am a self-deceiving cancer patient who distorts the evidence about my condition. Untruthful, yes, but the self-deception might be embedded in a pattern of other virtues. Faced with great danger, including the danger of collapsing from fear, I might be courageous in keeping hope alive.33 Doing so manifests self-respect in trying not to fall apart, in struggling to carry on with dignity, integrity, and self-respect. It also helps my family cope with a difficult situation. Honesty and hope are sometimes in tension, but they are connected within a complex web of virtues.34 Not surprising, the occasional tension between honesty and hope parallels tensions between realistic cognition and coping as criteria for mental health. On the one hand, truthfulness and healthy cognition largely overlap; indeed, truthfulness is the primary moral ideal guiding realistic cognition. By definition, truthful persons care about truth: they try to perceive accurately, reason cogently, respond rationally to evidence, and expand understanding in light of new information. On the other hand, truthful persons need hope and mental health. Hope overlaps with healthy coping, social adaptation, and self-esteem.
Because moral values are embedded in mental health, we might expect wide congruence between healthy and morally permissible self-deception.
Finally, an instance of self-deception might be healthy in one respect, by contributing vitality or happiness, but unhealthy in other respects, by distorting reality. Perhaps that is true of Hjalmar Ekdal. This complexity parallels the moral complexity of self-deception. Hope, in many (though not all) forms, is just as much a moral value as honesty, and the tensions between them are as much moral as therapeutic.
To conclude, I have suggested that moral and therapeutic values are not inherently at loggerheads with regard to honesty, hope, and self-deception. The complexity revealed by therapeutic perspectives parallels and is interwoven with the complexity within morality itself. Self-deception, both motivated irratio-nality and purposeful evasion, does sometimes advance mental health, but it also advances moral values such as hope and love. Even so, self-deception is less beneficial than suggested by Taylor and others who conflate unproven beliefs and irrational beliefs, and frequently it is linked to unhealthy evasions of reality. And the tensions between honesty and hope reveal tensions internal to morality and mental health alike, not a basis for a morality-therapy dichotomy.
From Morality to Mental Health:
Virtue and Vice in a Therapeutic Culture
Mike W. Martin