Many years ago, I came to believe that two factors never mentioned in textbooks predict whether a patient is likely to get significantly better: courage and a good heart.
Significant change generally requires looking at some unpleasant truths and taking some risks that we really can't be sure will pay off. Both take courage.
As for the need to have a good heart-well, I think people really only take on the hard stuff out of a desire to be decent people. We want to respond to others honorably, to be mindful of our impact on their welfare. We want to handle our needs and impulses with dignity and integrity. We want to earn the admiration of the people we care about. We want to be treasured, not tolerated.
Courage and a good heart are matters of virtue, not simply ordinary human nature. You can be a perfectly healthy coward, or a perfectly healthy jerk. And you can be fairly "unhealthy" but possess these, and other, virtues. Indeed, you need to have them before you do much hard personal change.
Few subjects in mental health care provoke as much heated controversy as the relationship between therapy (including medication) and morality. For instance, conservatives rail against our alleged promotion of self-indulgence, and leftists indict us for helping reconcile individuals to corrupt social structures.
The historical record of our moral impact is decidedly mixed. On one hand, we have successfully fought many repressive, life-constricting social conventions that masquerade as moral imperatives. We've done much to promote autonomy and vitality. But we've also done a great deal to enforce social convention-the feminists, in particular, have done a good job cataloging the sins of psychiatric (and related) care. And arguably, we've done much to undermine obligations, and to tear the social fabric.
Historically, we've tended to dodge the issue. We've claimed that we're about health, not morality. The patient's values, we claim, are something we take into account, but we try to stay neutral. What people do with the health we help them gain is not our concern. We only oppose moral strictures, we've generally said, where they are misguided: where they thwart growth and well-being.
We should stop claiming such things, because they're just not true. We do direct our patients' attention to moral concerns, and we give them permission in various ways to act one way rather than another. We just tie ourselves in knots, and often do a bad job, because we pretend that's not what we're doing.
(I talk about this in my "Wise Counsel" interview.)
When I think of our work as secular pastoral care, one thing I have in mind is that we should consciously, deliberately, and carefully accept our role as moral guides. We're already playing that role, and we would do a better job if we actively thought about what we're doing - including getting much better training in how to do it soundly.
Because religion and morality have always and everywhere been closely linked, secularists go to great lengths to argue that one need not be religious to be moral. And that's true. But the link between religion and morality is real, and it matters. A consensus is developing among evolutionary theorists that both religion and morality emerged to mediate, support, and enforce our social ties. Religion has been the custodian and steward of solidarity (though often just the solidarity of the tribe, not the human race).
That's one facet of a nice change in the social sciences-and with some biologists who study animal and human behavior-in the last couple of decades. Many social scientists, and some biologists, now recognize that human nature is not fundamentally individualistic. They've begun to take seriously that our social ties are essential to who we are. Our relationships are part of our identity. (William James said this over a century ago, and Aristotle a couple of millennia before that. Sometimes scientists are a bit slow.)
Jared Diamond has made this point in several of his books, as has Franz de Waal. Among psychologists, Paul Bloom and Jonathan Haidt have gotten a lot of attention. John Cacioppo, in his excellent book "Loneliness," gives a nice overview of much of this research. David Sloan Wilson, in "Darwin's Cathedral," makes the case for the universal instinct for religion as an evolved trait that serves to create and enforce community. In "Dependent Rational Animals," the philosopher Alasdair MacIntyre lays out a strong case for virtue as essential to community, and thus to human functioning.
Nietzsche said that we all believe we are experts on good and evil. We do, and we're wrong.
Too many mental health types smuggle their personal ethical self-confidence into their work without sufficient education and reflection. That's a bad thing, and that's one reason the mental health professions have insisted that we should root out our biases. But rooting them out doesn't work, unless we have something with which to replace them - because our patients cannot help looking to us for guidance, and we can't help giving it.
We've tried to replace our biases with ideas of "health," but that hasn't worked, either. We need to accept our role as moral guides, to learn that no one-including patients-gets an exemption from responsibility to others, or from our need to acquire and exercise moral competence.
We need to become better educated, and more thoughtful, in helping our patients understand exactly how the moral qualities of our actions influence the quality of our experience.
We need to understand how virtue is essential to change. We need to support our patients in exercising and nurturing those virtues.