Cognitive behavioral therapy (CBT) has so inundated the mental health field that it has a monopoly over what most academics, health insurers, and governing bodies that oversee standards of care seem to believe constitutes psychotherapy itself. Framing psychological problems in terms of psychiatric diagnoses and their remediation along the lines of symptom reduction rules the roost. This tidy framework deceptively decomplexifies the convoluted nature surrounding the desperate ways human beings cope with unfavorable life circumstances, making this enterprise more conveniently researchable.
Telescoping complex human suffering into psychiatric diagnoses and defining progress in terms of symptom reduction might align well with the powerful sway of the medical model—by association giving it seductive curative appeal; however, when the general public is asked what they seek from psychotherapy it is something akin to the etymology of the term psychotherapy—“psyche,” meaning soul, and “therapeia,” healing, or soul healing—that they covet.
We know this based on the results of a recent robust meta-analysis published in The Lancet Psychiatry. More than symptom reduction, clients favor outcomes like “deeper self-understanding,” “enhanced self-agency,” and “greater social engagement,” from their psychotherapy experience. And, since across the various mental health professions client preferences (as well as clinical expertise and first-rate research) is viewed as one of the standards of care that practitioners should ethically commit to, it stands to reason that psychotherapy outcome monitoring should always prioritize what clients desire is good for their soul.
There is something to be gained by returning to the Ancient Greeks here. Aristotle saw character (“ethos”) as part of the “psyche,” or soul, and “arete” as the pursuit of excellent character that was good for the soul. One approach to helping clients be more volitional about and motivated to changing psychological difficulties is framing them and their improvement in terms of the absence or presence of character strengths or virtues. Character strengths or virtues are habits of mind and action that are praiseworthy because they represent what is good and wholesome for our own well-being and those we care about.
In the words of Blaine Fowers, the preeminent psychological scholar of virtue ethics, in his 2005 book Virtue and Psychology: “Virtues are, simply, excellences…the character strengths that make it possible for individuals to pursue their goals and ideals and to flourish as human beings.” They typically include human predispositions like honesty, courage, fairness/justice, generosity, perseverance, humility, and discretion. When they are actively and deliberately pursued as forms of self-improvement consonant with living a meaningful and worthwhile life, research shows such endeavors bode well for psychotherapy outcome. (https://doi.org/10.1007/s10879-021-09523-6 )
Some examples might clarify. A wife responds with self-righteous rage when she feels micromanaged by her husband. It is reminiscent of her childhood when her overprotective father did things like forbid her from dating and impose an early curfew leading to her missing out on fun times with peers. The intensity of the wife’s anger has its origins in the past, even if her husband’s present micromanaging behavior warrants a certain amount of frustration.
Framing this in terms of the virtue of justice or fairness can galvanize a desire to change: “Anabelle, something to think about, I suppose, is the fairness issue of going after your husband so intensely when he behaves like your father used to. Maybe its justifiable that you be frustrated, but the rage part may be more justifiably directed at your father and how you felt treated by him in the past. It was too emotionally dangerous to express anything resembling rage at your father back then, and not so emotionally dangerous to direct it at your husband now, but is that fair to him?
More generically, psychological problems can be conceived of as underdeveloped character strengths or virtues. Anxiety can be the upshot of being insufficiently emotionally honest about how one feels about the transgressive behavior of loved ones and veering away from showing the courage to express that honesty. Fearfully stuffing and stifling justifiable strong feelings simply leads to emotional unease.
Of course, discretion and prudence are other human virtues that need to be operating when it comes to remedying anxiety through pointed emotional honesty. That’s because those we are justifiably saddened or enraged by often have psychological limitations leaving them prone to implode or explode in the face of unvarnished expressions of emotional truths about their behavior. The psychological limitations of loved ones can make it emotionally dangerous for us to direct our honest feeling to them. A brief clinical vignette might clarify.
Twenty-six-year-old Michael describes himself as someone who has been susceptible to panic attacks as far back as he can remember. He self-identifies as the black sheep of the family because, unlike his siblings and parents, he is not obsessed with educational achievement, career advancement, and the accumulation of wealth. He wears his vulnerabilities on his sleeve, being overt with his somatic complaints when he has headaches, or his need for a sick day when he is feeling under the weather, all of which elicit thinly disguised disgust from family members who pride themselves on displaying stoic denial and hard work.
A few months into therapy Michael started tapping into the rage behind his shameful anxiety. It dawned on him that his parents were lousy at self-care, really did not know how to enjoy themselves, and were slaves to their careers. It enraged Michael that rather than admit to these imperfections, they twisted and inverted them, treating him as if he was deficient. Someone who was rudderless, feeble, and lazy. He composed a letter spelling all this out in great detail, with emotional fervor, which he considered emailing to them, though held back, because he surmised their psychological limitations would leave them reacting with unproductive confusion.
I commented: “Michael, what courage you are showing being honest with yourself about your real thoughts and feelings regarding your family situation. In my mind it is even wise of you to want to hold back, at least for now, with this type of letter, knowing your parent’s psychological limitations. I have every reason to believe that the more courageous and honest you can be with me about what you really think and feel about your family situation, not holding all this inside, the less anxious you will be over time.” Framing Michael’s anxiety reduction in terms of committing to greater emotional honesty and courage seemed to galvanize his use of psychotherapy in these ways. There was no need to mention anything about “virtues” or “character strengths.” Michael, like most human beings, seemed to implicitly grasp that these were praiseworthy actions that were noble to commit to.
In Virtue and Psychology, Fowers claims it is a human given for people to be innately knowledgeable about virtuous behaviors and aspire to enact them in order to actualize their full potential for goodness. Extrapolating from this, presumably there is dormant inherent desire that can be tapped into to motivate the acquisition of virtues whose underdevelopment cause psychological problems. Along these lines, it is surprisingly easy to imagine getting traction with a mildly narcissistic client who alienates others with entitled behavior by framing the issue in terms of working on humility; not in a moralistic or preachy way, but in terms of inspiring the client to aspire to be the best version of himself. And, with clients who are ADHD-like, who can be forgetful, disorganized, and distractable, the relevant character strengths to emphasize in psychotherapy would be conscientiousness and perseverance. As for the former, there would be a readiness during therapeutic conversations to genuinely praise clients when their efforts have paid off—planning in advance, returning texts and calls on time, clearing off desks before settling down to work, locating a permanent place at home to plonk down keys, purses, and wallets, and so forth. Commending them for staying motivated to act more conscientiously links up with supporting them to be that kind of person, not merely to function better in life, or deal with their ADHD symptoms, per se.
To wrap up, as for the virtue of perseverance, it may need to be liberally called upon throughout psychotherapy with most people to normalize how maddeningly difficult it is to attain and sustain meaningful change. On more than one occasion to encourage clients who are mired in discouragement about falling into old traps, repeating old hurtful patterns, failing to relinquish bad habits, I trundle out one of my favorite quotes by Samuel Beckett: “Ever tried. Ever failed. No matter. Try again. Fail again. Fail better.” The attainment of character strengths is a perpetual work in progress, a labor of love. More accurately, a labor of self-love.
Well said and I agree. As a clinician who focuses on shame as a significant driver of human psychological experiences, I often use interventions that help clients see how their primary moral emotions (shame, embarrassment, regret, indignation or disgust etc) can lead to secondary emotions/cognitions/behaviors that may or may not be in alignment with their values. For example, shame can cause anger when people lash out in defensiveness. Conversely, shame can cause people to self-blame and feel guilt in unhealthy ways that create anxiety and depression. I work very little with symptom management or CBT for the reasons you elucidate, because this is rarely permanent — like whack-a-mole.
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