The Virtues in Psychiatry Practice
Moderator: John Peteet, MD, Harvard Medical School
Panelists: Warren Kinghorn, MD, ThD, Duke University Medical School and Duke Divinity School; Michelle Bach, MD, PhD, Saint Louis University
Like much of modern health care, contemporary psychiatry privileges positivist and empiricist methodology. What is known is what can be measured, usually by using standardized rating scales or diagnostic criteria sets, and interventions are reified and validated as “evidence-based treatments” when they are associated with changes in rating scales that are judged by clinicians to be desirable. This in turn promotes technicist forms of practice in which “good care” is seen as little more than matching particular interventions, often medications, to particular diagnoses. But this is often unsatisfying to clinicians and patients alike, and the focus on the “what” of psychiatric practice all too often stunts reflection on the “how” of psychiatric practice—how people develop and live in the world, how change happens, how relationships can be agents of healing, and so on—that constitutes much of the traditional wisdom that psychiatry brings to the rest of health care. In this panel, three clinician-scholars will explore how virtue theory, as it originated in antiquity and was taken up by Christian and other religious interpreters, bears powerful resources for psychiatric practice. To what extent are psychiatric diagnoses normative in nature? How does a need for virtues fit into the processes of diagnosis, formulation and treatment? What patient problems and other factors should influence the therapist to promote forgiveness, gratitude, humility or accountability? What is the relationship between the therapist’s and the patient’s virtues? What is the relevance of religious or spiritual resources to the formation of virtue? How does the cultivation of a particular virtue relate to psychodynamic, behavioral, existential or spiritual approaches? What ethical questions does it raise, and what are its implications for psychiatric education?
The first presenter will give an account of virtue in psychiatry that aligns with and expands recent work on virtue within positive psychology and personality theory. The presenter will consider four basic capacities – self-control, benevolence, intelligence and positivity – that roughly correspond to the four cardinal virtues of Plato and Aquinas (temperance, justice, prudence, and courage), based on neurobiological evidence of potential for moral enhancement, and psychotherapeutic relevance. Nested within these capacities are specific virtues related to self-control (accountability, humility and equanimity), benevolence (forgiveness, compassion and love), intelligence (defiance and phronesis, or practical wisdom), and positivity (gratitude, self-transcendence, and hope).
The second presenter, challenging the work of positive psychology from a theological perspective, will discuss the virtue of hope as it relates to psychiatric practice. Clinicians often debate whether hope is adaptive or maladaptive for patients who are confronting serious medical and mental health challenges. But these debates, which focus on hope as belief and/or emotion, sidestep the question of whether hope can be a virtue, that is, an embodied disposition to act with ease in particular circumstances in ways that contribute to flourishing. Drawing on Aquinas’ account of hope as a virtue that sits between the twin vices of despair and presumption, the presenter will argue that hope as a virtue is not simply emotion, cognitive or intellectual belief, wishing, positive thinking, or optimism. Hope, rather, is the capacity to rest in a not-yet-present, difficult-to-attain good future that will be brought about by an agent outside the self. Hope in Aquinas’ sense is therefore an exogenous virtue that forms courage and perseverance in the subject. The exogenous nature of hope is vividly displayed in the work of the poet, priest, and civil rights attorney Pauli Murray, in the speeches of Martin Luther King, Jr., and in other Black American Christian witnesses to hope. Understood as an exogenous virtue, hope enables clear-eyed appraisal of evil, the capacity to discern and to trust in a coming good future made possible by another, human solidarity and community, and the courageous capacity to act toward a good and just future that is not yet present but that will surely come.
The third presenter will discuss the practical consequences of psychiatry’s inability to speak coherently about virtue, especially as it relates to the personality disorders. There is a long-standing debate within bioethics regarding the ontology of personality disorders: Should we understand narcissism, antisocial personality disorder, or borderline disorder as mere medical diagnoses? Or are they better understood as moral kinds of things? It has been argued that personality disorder diagnoses are a modern translation of virtue theory (or more aptly, vice theory). The presenter argues that personality disorder diagnoses can be construed as statements regarding virtue/vice because they approximate diagnoses of the self or what it is to be a self. Yet it is incorrect to argue that personality disorders are rooted in virtue theory because they make no appeal to teleology. However, this does not mean that psychiatry is a practice “after virtue.” Instead, personality disorder diagnoses fulfill a unique role in modern society: they act as bulwarks against what Alasdair MacIntyre called unfettered emotivism. In other words, in a time where there is no agreed upon standard of virtue, personality disorders nonetheless uphold the taboo against certain ways of being a self. This presenter has yet to see someone publicly censured for being “vicious”. But it’s not uncommon to see a politician or celebrity publicly decried for being a narcissist or sociopath. These are not virtue/vice statements but rather adjacent moral and even aesthetic circumscriptions of selfhood. Personality disorders do not tell us what we should be but they are rooted in a moral, aesthetic, and medical consensus about what we should not be. This poses psychiatry as a uniquely powerful moral and aesthetic voice that articulates substantive value claims about selfhood.
Finally, the panel will engage with the audience in a discussion of the importance of virtue in the therapeutic encounter.
The first presenter will give an account of virtue in psychiatry that aligns with and expands recent work on virtue within positive psychology and personality theory. The presenter will consider four basic capacities – self-control, benevolence, intelligence and positivity – that roughly correspond to the four cardinal virtues of Plato and Aquinas (temperance, justice, prudence, and courage), based on neurobiological evidence of potential for moral enhancement, and psychotherapeutic relevance. Nested within these capacities are specific virtues related to self-control (accountability, humility and equanimity), benevolence (forgiveness, compassion and love), intelligence (defiance and phronesis, or practical wisdom), and positivity (gratitude, self-transcendence, and hope).
The second presenter, challenging the work of positive psychology from a theological perspective, will discuss the virtue of hope as it relates to psychiatric practice. Clinicians often debate whether hope is adaptive or maladaptive for patients who are confronting serious medical and mental health challenges. But these debates, which focus on hope as belief and/or emotion, sidestep the question of whether hope can be a virtue, that is, an embodied disposition to act with ease in particular circumstances in ways that contribute to flourishing. Drawing on Aquinas’ account of hope as a virtue that sits between the twin vices of despair and presumption, the presenter will argue that hope as a virtue is not simply emotion, cognitive or intellectual belief, wishing, positive thinking, or optimism. Hope, rather, is the capacity to rest in a not-yet-present, difficult-to-attain good future that will be brought about by an agent outside the self. Hope in Aquinas’ sense is therefore an exogenous virtue that forms courage and perseverance in the subject. The exogenous nature of hope is vividly displayed in the work of the poet, priest, and civil rights attorney Pauli Murray, in the speeches of Martin Luther King, Jr., and in other Black American Christian witnesses to hope. Understood as an exogenous virtue, hope enables clear-eyed appraisal of evil, the capacity to discern and to trust in a coming good future made possible by another, human solidarity and community, and the courageous capacity to act toward a good and just future that is not yet present but that will surely come.
The third presenter will discuss the practical consequences of psychiatry’s inability to speak coherently about virtue, especially as it relates to the personality disorders. There is a long-standing debate within bioethics regarding the ontology of personality disorders: Should we understand narcissism, antisocial personality disorder, or borderline disorder as mere medical diagnoses? Or are they better understood as moral kinds of things? It has been argued that personality disorder diagnoses are a modern translation of virtue theory (or more aptly, vice theory). The presenter argues that personality disorder diagnoses can be construed as statements regarding virtue/vice because they approximate diagnoses of the self or what it is to be a self. Yet it is incorrect to argue that personality disorders are rooted in virtue theory because they make no appeal to teleology. However, this does not mean that psychiatry is a practice “after virtue.” Instead, personality disorder diagnoses fulfill a unique role in modern society: they act as bulwarks against what Alasdair MacIntyre called unfettered emotivism. In other words, in a time where there is no agreed upon standard of virtue, personality disorders nonetheless uphold the taboo against certain ways of being a self. This presenter has yet to see someone publicly censured for being “vicious”. But it’s not uncommon to see a politician or celebrity publicly decried for being a narcissist or sociopath. These are not virtue/vice statements but rather adjacent moral and even aesthetic circumscriptions of selfhood. Personality disorders do not tell us what we should be but they are rooted in a moral, aesthetic, and medical consensus about what we should not be. This poses psychiatry as a uniquely powerful moral and aesthetic voice that articulates substantive value claims about selfhood.
Finally, the panel will engage with the audience in a discussion of the importance of virtue in the therapeutic encounter.