psychotherapy as ethics: the case of depression

In a month or so I’m to give a talk on‘psychotherapy as ethics’. The phenomena I wish to cover include making confession, calling someone out, calling someone to courage, therapeutic love, withdrawing projections of blame, and offering recognition. My guiding thought is that effective psychotherapy is therapy conducted precisely as what I call ‘an ethical relationship’. By this I don’t at all mean psychotherapy conducted in accordance with ethical practice guidelines. I also don’t mean psychotherapy conducted through moralizing – something against which, when met with in both self-directed and other-directed forms, psychotherapy has provided considerable bulwark. What I mean is psychotherapy which draws more from the understandings of what it is to be a human being living a human life we find in ethics than from what we find in psychology. What matters, I suggest, are the demands of love, the significance of accountability and responsibility, the value of truthfulness and sincerity, the meaningfulness of repentance and forgiveness.

In this post I want to explore a small part of the above - namely an important symbiosis of model and therapeutic practice (I hesitate to talk of technique) in the theory of depression, and how this alters significantly – including ethically - depending on the therapeutic approach. (I hesitate because, as I see it, such talk belongs more naturally to an instrumental conception of therapeutic action, and I should like here to take a stand against the impersonality of instrumentalism. However ‘technique’ may perhaps mean something different, and hence rather more valuable, within the context of ethical relationship.)

As the cognitive theory has it, depression is maintained by depressive beliefs, thinking habits, and passivity in life. I may for example think of others as untrustworthy, and so not engage with them, and thereby become isolated and lonely. Or I may imagine that whatever I do, nothing good will come of it. Perhaps this stems from aversive early experience. When I meet with others perhaps I habitually, maybe only semi-consciously, rehearse to myself what I imagine they really think of me, how they would like to treat me, etc. I am radically biased toward the negative in my views of self, situation and future (Beck’s cognitive triad). Furthermore, because I become inactive I no longer generate meaning, sense of efficacy, hope. As a consequence life becomes meaningless and depression becomes entrenched.

To combat depression the CBT therapist, in line with the cognitive theory, helps his depressed patient become better at spotting and defusing from or challenging their depressive assumptions, and to take action to generate meaning rather than passively wait for meaning to first appear before taking acting. (The ethic guiding this approach is, I believe, when all things go well, that of unpretentious accuracy and of collaboration in the therapeutic task. And so far so good – I hope we (therapists) all sometimes engage in such tacks and embody such an ethic.) But a difficulty is that depression often tends to relapse, and constantly challenging one’s own thoughts is itself tiring and demoralizing. And the depressive thoughts just seem so natural to the patient – they seem to flow effortlessly from the personality itself, and so questioning them seems to go against the grain, feels as if it itself manifests a lack of self-acceptance, courting further depression.

The psychodynamic theorist has a partly different model of depression. According to her there is within the personality a deeper psychological wellspring of depressive cognition than either core beliefs or the learning experiences from which, it is alleged, they sprung. And according to her this wellspring is motivational in character and hence characterological in instantiation: whilst the patient is (one imagines) honest about his suffering, and sincere in his conscious opinions and in his wish to not be depressed, there is yet within him something like an unconscious wish to be depressed. Not, normally, anything like a wish to suffer (contra the absurd-when-over-extended depressive masochism hypothesis), but rather a wish to avoid the challenges which not being depressed would present. I’m talking of the life-challenges of: allowing oneself to be constructively angry with someone who has wronged one, taking a strong and courageous stand for oneself; admitting one’s guilt and taking reparative action; facing the fear relating to uncertainty and living with existential courage; allowing oneself to truly mourn one’s losses and actually take one’s leave from people and ambitions who have taken their leave of you. Depression, as the psychodynamic theorist has it, is a narcissistic phenomenon: rather than face the unknowns and possible painful disappointments of Beck’s triad - the unknowns of whether one will be accepted by others, the unknowns of how the future will go, the unknowns of the opportunities or disappointments immanent within one’s situation – the depressive individual pre-empts fate and gets in there first. They trust in their own dismal appraisal far more than remain open to a world and a fate and an other beyond the safe horizon of their own mind. They choose to dwell in their own self-ratifying delusion-like ideas and thereby justify their withdrawal from the world. (Contrast the manic patient who more profoundly refuses to stay open to reality in its unknownness, instead choosing to refashion it according to his desire.)

There is a way to present the psychodynamic model which keeps it resolutely psychological rather than ethical in character. On such an approach what is avoided by the depressed patient are his feelings and their anxieties. On such a reading – which is what is met with in ‘affect phobia’-type reformulations – the avoided reality is intrapsychic. But such an approach falsifies the phenomenology. For what we encounter in depression is first and foremost someone turning away from the world, from others, from their responsibilities to themselves and to others, from the task of building something and continuing to build it in the future. This in particular is what involves us in an ethical, and not ‘merely’ a psychological, task.

If the psychodynamic theorist is right, then the reason why the depressed person often relapses after CBT treatment is because their changing their mind was not rooted in a change of heart. Challenge your thoughts and your beliefs all you like – but unless you challenge your motivationally-driven narcissistic disposition to form such beliefs in the first place, you’ll be left disposed to relapse. Unless, that is, you challenge yourself. (Challenging your self is ethical in a way that challenging one's beliefs is not.) Come to accept that, despite what you’d understood – i.e. that you were simply a victim of your depression – you are actually its perpetrator, latently motivated to espouse your depressed beliefs – and you have an opportunity for a genuinely existential choice. A choice to live differently. A choice to do better by oneself and others. A decision to make -  to live with more openness, with better grace, with less self-ratification. To take courage. To sow seeds not knowing if the rains will be good. To live according to an ethic of gratitude and risk rather than cautious self-reference.

What does this model inspire by way of therapeutic practice? Well for one thing, therapy now becomes a forum of ethical challenge from the therapist. The therapist’s job is to be collaborative, sure, but also gently, appropriately, respectfully, to challenge. The challenges will be ethical: do better by yourself! Do better with this life you’ve been given! Be courageous! Stop shirking! Don’t be such a scaredy cat! Be kinder to yourself! Be kinder to others! Be more open! Such challenges are a call to conscience. And so the patient has now to make choices, to make decisions. Therapy is no longer practiced in a collaborative fact-finding mode. It becomes an ethically fraught domain. Whilst the patient was unconscious of the motivationally driven character of his depression he had an excuse to not do better by himself and others. But now the therapist has pointed it out, he has no more excuse!

There will also be challenges regarding how the patient is treating the therapist. It’s here that the most potent work can happen. Imagine a psychoanalytic therapist who hid behind her expertise and simply offered descriptive transference interpretations regarding how the patient was treating her. Such a therapy would be a poor, bizarre and alienating thing. No doubt it’s respectful and potentiating to be maximally unintrusive on the patient’s agency – i.e. to ‘allow’ him to make up his own mind, take his own decisions, and thereby achieve a genuine self-possession, rather than having him bow before the expertise of the therapist and passively relinquish his moral authority. (For a patient to act thus would probably mean that he’d got sucked up in a positive idealizing transference – itself perhaps just a way to keep at bay, keep unconscious, a more troublesome negative transference.) But whilst accepting the value of this kind of therapeutic neutrality, imagine the disastrousness of a therapy which performatively took away what descriptively it proffered: i.e. which sapped any degree of emotional and ethical tenor out of the therapeutic relationship at just the same moment that it descriptively drew attention to precisely such dynamics. Which involved a therapist failing to offer any authentic degree of ethical engagement at just the same time she invites the patient to do better by her.

Here is the long and short of it. Patient: A patient has to decide to try to relinquish the negative transference and their other depressive tacit commitments. They have to make a choice – to try to step out of a world of dismal interpersonal expectation, and start to live as if love and meaning were real possibilities. The moment of trust to be taken is in a therapist they can't yet see, a good therapist, waiting off scene, screened by the transference. The patient who first wants reasons to live thus is missing the ethical point. Therapist: A therapist who hides behind a merely collaborative relationship, or who retreats into making de haut en bas interpretative pronouncements, is failing to offer an ethically alive relationship. Failing to meet the patient where he is. A therapy which doesn’t have the patient sometimes being angry and sometimes apologizing is probably no therapy at all. For any genuine challenge to a patient will involve an accusation: that he is actually not, despite what he is inclined to think, doing his best by himself/partner/therapist. And the therapist too will not always do well by her patient, becoming chummy or expert, becoming didactic or passively listening, and so does well to apologise as and when required and to constantly reorient herself to the good.