The Strange Idea Of “Therapeutic Neutrality”

Mental health professionals claim to be neutral on moral issues. Those, the official line goes, are matters of patients’ personal choice, and we should not “impose our values” on patients. We’re about health, not moral judgment.

This is a very strange idea – but so ingrained in the culture of mental health care that most mental health types don’t even realize how utterly peculiar it is.

To start with, the vast majority of humans consider moral beliefs less, not more, a matter of personal choice than other sorts of beliefs.

Outside mental health care, people generally allow each other much more variance on beliefs about how the world works than beliefs about what’s right and wrong. Indeed, we etch requirements for moral behavior into laws, which we never do with beliefs about physics, psychology, politics, history, and so forth. In the world, matters of fact are open to personal opinion; huge areas of moral behavior are not.

Furthermore, the mental health notion about moral beliefs is exactly backward. Morals are not matters of preference. A moral dictum is something you have to obey whether you like it or not. An obligation, for instance, is something I have to do whether or not I want. That’s the whole point, the very meaning of the term ‘obligation.’

Indeed, we only have moral dictums in areas where our personal preferences need to be reined in or rendered moot. All of our “Thou shalt nots” refer to things we really find appealing – there’s no need to prohibit things we naturally avoid. Our positive moral requirements tell us what to do, with no reference to whether we want to or not. “Do unto others as you feel inclined” hasn’t made the cut into any major moral code.

It would seem then, that mental health types’ standard view of moral beliefs and behavior is exactly backwards, by comparison to the overwhelming opinion and practice of humankind, and by reference to the very meaning and function of moral principles.

Strange, huh? Well, it gets stranger. Mental health types adamantly, enthusiastically, and insistently “impose” on patients life-changing beliefs and practices far more dubious than most moral judgments. We don’t think we should be neutral in our beliefs about what’s healthy and what’s not, or how the mind works, or what causes or relieves suffering. We’re happy to “impose” our beliefs. (And charge large sums to do it!)

We don’t hesitate to offer our counsel with more firmness and assurance than the evidence warrants. Respect for diversity doesn’t stop us from holding specific beliefs and practices that we offer to patients as true.

Indeed, the diversity of therapeutic beliefs makes the diversity of moral codes look rather trivial. A fair number of moral principles span the globe, even span human history – for instance, the imperative to keep promises, tell the truth, avoid gratuitous aggression, protect one’s community norms, and treat one’s neighbor as one’s self. Therapeutic beliefs rarely even span an office building, and virtually none span more than a generation or two of practitioners.

Why do we “impose” with such fulsome self-confidence on life-defining topics of radical uncertainty – namely, our therapeutic ideologies and folkways – yet grow adamantly “non-imposing” when it comes to issues of moral responsibility, many of which are universal, or nearly so, and not controversial at all outside of the mental health world?

Four different issues combine to give us this odd stance: a simple-minded notion of the “medical model” of health, an archaic set of beliefs about moral versus scientific discourse, curtailing the moral stigma of professional help, and keeping patients happy (and paying).

I’ll talk about these over the coming weeks. For now, I’ll just say that moral matters cannot be extricated from mental “health,” that we can reason about morality at least as well as we can reason about anything else in mental health care, and the moral stigma of help should be fought by better moral arguments rather than by trying to avoid morality. As for our keeping patients happy by supporting their disregard of their obligations-well, that’s one of the temptations we should just have the courage to resist. But more on that another time.