Making therapy more transparent: On Kevin R. Smith’s therapeutic ethics

The Ethical Visions of Psychotherapy

The Ethical Visions of Psychotherapy starts by arguing against mainstream views that understand psychotherapy as a nonnormative treatment for mental disorders and/or see therapeutic practice as a straightforward application of psychological science. Challenging such views, Smith sets out to show that therapists are less involved in neutral scientific practice than in a social dialogue that enacts some perspective on what constitutes a good life, human well-being, or human flourishing (Chapter 2). For example, the treatment of depression by aiming to decrease the patient’s harsh self-criticism, Smith explains, is not only a scientific treatment of a disorder aimed at symptom reduction but also an ethical invitation to reexamine their standards for moral self-assessment—that is, “an intervention in ethics that aims at a better life through less exacting moral standards” (Smith, 2021a, p. 10). However, he continues to argue, as long as therapy practitioners and theorists, psychotherapy researchers, historians, and social critics fail to acknowledge such implicit normative commitments, the debate on what therapy is and what aims it serves or ought to serve will remain a kind of “blind battling” (p. 8).

Smith’s account of the deep links between therapy and “ethics” is based on a broad conception of the ethical as involving not only moral obligation but also the assessment of what is worthwhile in living one’s life—what makes for a fulfilling or exemplary life. Building on the moral philosophy of Charles Taylor, Smith elaborates on this broad conception of ethics by showing not only that notions of what we owe to each other cannot be separated from wider ideas about human fulfillment, flourishing, and the good life, but also that it is in the nature of human beings as “self-interpreting animals” and “strong evaluators” to understand themselves in terms of qualitative distinctions between higher and lower value—a sense of what “matters” to us as sentient, purposive agents.

In the remainder of this book, Smith lays out the benefits of employing a broad definition of ethics for understanding the normative nature of psychotherapy. With this broad conception, even “technical,” supposedly purely scientific therapies (such as exposure therapy for eating disorders and cognitive therapy for depression) are involved in promoting ethical ideals (Chapter 3). Furthermore, to understand ethics beyond mere duty and obligation brings forward how different types of therapy involve different views of human well-being, the articulation of which helps to clarify what is at stake between different therapies or even within a certain type of therapy, such as in the different brands of psychoanalysis (Chapter 4). Regarding psychotherapy research, Smith’s view of therapy as an ethical practice not only exposes different misunderstandings of social holistic approaches to therapy when considered from within an individual atomistic framework, but also helps to correct them (Chapter 5). The result is an extended definition of therapeutic efficacy that includes not only evidence-based standards but also reflection on what picture of flourishing the therapies serve, and an extended definition of the therapist as being both an expert in treating disorders and “a fellow traveler who is also a seeker of the good life” (p. 81).

Therapeutic Ethics in Context and in Dialogue

The Ethical Visions of Psychotherapy stresses the pervasive role of ethics in therapy. Smith’s additional book, Therapeutic Ethics in Context and in Dialogue, continues this discussion by exploring the follow-up question of what it would mean to directly engage the different ethics of different therapies. In Smith’s view, the first step in answering this question is historical—that is, if therapeutic ethical ideals take on specific meaning only within specific contexts, we must ask: Where do therapeutic views of flourishing come from? Carefully reflecting on the roots of therapeutic aims in reference to Taylor’s (1989) seminal work Sources of the Self, Smith distinguishes four distinct ethical ideals derived from cognitive behavioral, psychoanalytic, and humanistic therapies: rational self-mastery, honest self-exploration, particularity liberated from social expectation, and attunement to the complexities of emotion and motivation in relationships with others (Chapters 2–3). In so arguing, Smith emphasizes the influence of philosophers such as Descartes, Locke, and Montaigne on western moral self-understanding in a way that makes sense of psychotherapy’s overall concern for individual particularity and promoting autonomy. More importantly, however, he shows how many practicing therapists, therapy theorists, and researchers gloss over these cultural roots altogether in getting caught up in the details of practice and technique, the rationales for various orientations, and demands for evidence-based evaluation of therapeutic efficacy.

As valuable as such aims may be, engaging therapeutic ethics in Smith’s sense does not stop at explicating the contrasting ethics of different therapies or even exposing therapy’s blindness to its implicit ideals. Once it has been established that therapy involves ethics (the major point of the first book) and where the ideals of therapeutic ethics come from (the central theme of the second book), Smith continues to ask: How do we engage in therapeutic ethical dialogue? And is there any recourse when different therapies lead in different ethical directions or even clash (Chapter 4)?

In one way, this topic seems to require moving beyond psychotherapy into moral philosophy. In another, it can be seen as delving deeper into psychotherapy by taking due account of its inherent ethical nature. Taking inspiration from Taylor’s (1995) model of practical reasoning as “comparative reasoning” or “reasoning in transitions,” Smith’s final plea is less about arbitrating between contrasting therapeutic ethics than about stressing the importance of recognizing the value of each. Such pluralism is important because prioritizing one single ethic (to focus narrowly on rational self-mastery at the expense of self-exploration or one’s relationship with others, for example) can become insulated and self-reinforcing to the point that it “puts a stop to growth and development” and blurs “what is at stake between competing visions of flourishing, what the dangers and obstacles are to the achievement of any one of them” (Smith, 2021b, pp. 75–76).

Evaluation

On the whole, Smith’s approach draws attention to an essential and often neglected dimension of psychotherapy, and it is admirable for that reason alone. Perhaps the most significant achievement of the approach developed in these two books is that they lay bare the limits of an overinvestment in scientistic notions of psychotherapy as an acultural, “evidence-based” practice that could do without ethical ideals and conceptions of human flourishing altogether. In this respect, Smith’s (2021a) point that a view of gratitude exercises as a “technique for feeling happy” misses the very point of what “gratitude” means is highly revealing—psychologically, ethically, and philosophically (p. 82). Another strength of Smith’s view is that it opens up the question of whether there is not almost inevitably a high degree of delusion involved in the fundamental reticence of therapists to explicitly promote ethical ideals in order to respect patients’ moral autonomy. In fact, if there are indeed “intra-therapeutic contexts,” such as how therapists listen and what therapists are capable of hearing or interested in hearing, which shape both the meaning of what a patient is saying and experiencing and what patients will say and experience (p. 76), then a therapy that neglects such details is not only poor but also destructive of the hermeneutic process. In this regard, Smith is entirely right to doubt the capacity of atheistic therapists who remain silent about their own atheistic commitments in helping patients who talk in explicitly religious terms about their problems, insofar as the clash in worldviews first needs to be articulated in order to be able to move forward in dealing with the patient’s problems and self-understanding:

To speak with the patient in terms of a myth that is believable to the patient but that the therapist is skeptical about or appalled by—would this not undermine the therapist’s capacity to engender the positive expectations of improvement that boost therapeutic success? (p. 84)

However, if Smith’s aim is not merely to lay the “groundwork” for dialogue in therapeutic ethics but to participate in such dialogue, it seems clear that this requires more than just “recommending reflection on one’s implicit view of what is central to human well-being” or highlighting “ethical aspirations of therapy beyond the scientific treatment of disorders” (Smith, 2021a, p. 18; 2021b, pp. 2, 19). In this respect, it is somewhat of a letdown that the question of how to evaluate contrasting therapeutic ethics is dealt with in detail nowhere in Smith’s analysis. While he rightly notes that arguments for one therapeutic ideal over another are “more likely to take the form of persuasive narratives than objective data” (Smith, 2021b, p. 65), much more could be said about the hermeneutic kind of logic involved here.

For one thing, insisting on the narrative character of ethical dialogue does not mean that issues of truth cannot arise in relation to these narratives. Whereas we cannot feel physical pain mistakenly, we can be wrong about our interpretations of meaning and value—that is, as self-interpreting beings, we could always be deceiving ourselves. Moreover, we can become aware of such misinterpretations because (a) we feel the demand to be consistent in our self-understanding and (b) we have the capacity to examine and criticize our judgments for their lack of consistency. If there is one area where such self-deceptions and misinterpretations take center stage, it is precisely in Smith’s (2021a) idea of therapeutic conversation as an ethical dialogue:

What’s at stake in such conversations are basic ideas that both say something about people (they offer descriptions and explanations) and propose aims for people (they include prescriptions, norms, or aspirations). These two aspects come as a package, each implicitly depending upon the other. (p. 69)

To be sure, the first step of simply seeing this “package” is to dispel the myth of therapy’s ethical neutrality, as Smith convincingly demonstrates. As long as therapies continue to covertly offer ethical proposals while denying that they are doing so (even if based on a valid concern for the autonomy of the patient), such therapies are not only incomplete but also actively limit the capacities of therapeutic practice. Yet, while Smith’s main focus of attention lies in the implications of therapy’s ethical significance for the patient–therapist relationship, his analysis indicates that the real challenge lies elsewhere—namely, in the way in which therapists relate to themselves. While he touches on this issue only tentatively—for example, by saying that “therapists are drawn to a particular therapy because it seems right, because it seems to make more sense of who people are, or addresses more important aspects of who people are” (Smith, 2021a, p. 86)—a more thorough elaboration of this topic would definitely have strengthened Smith’s case for therapeutic ethics, above all because it is Taylor, again, who has been explaining how such an elaboration could be developed. By way of constructive criticism, allow me to give an initial impetus to that effect.

Therapeutic ethics: Additional resources in Taylor’s work

For Taylor, there is a getting it right and a getting it wrong in the domain of human self-understanding. Therapeutic conversations, like all ethical conversations, are interpretations of meaning in that they are attempts to make clearer the meaning things have for us (patients, therapists, and human beings more generally), but such clarity cannot be achieved at will by simply articulating our experience. As potentially identity-shaping statements, interpretations of meaning allow that our experience can be faulty and need correction. This means that, from Taylor’s (2016) perspective, there are at least two dimensions (a “package,” in Smith’s terms) that together constitute human identity: a factual dimension, which concerns “the adequacy of our descriptions, of self and others, and our situations” (p. 194), and a normative dimension, which concerns “the validity of what we value, of the norms, goods, virtues we want to seek” (p. 195). As this suggests, getting it right in understanding ourselves is more than a matter of having true beliefs by getting the facts right. It also requires being able to grasp how such beliefs relate to our sense of our life as a whole and the direction it is taking as we lead it.

But how does such an intricate process work? What might be involved in “unpacking” the package that constitutes our moral identities? The upshot of Taylor’s hermeneutical reasoning is that moral self-interpretations judge the significance of one’s own desires, goals, actions, and identity as part of a certain reality. This is because he sees interpretations of meaning both as expressive of our nature as “self-interpreting animals” and as tracking “some reality” (Taylor, 1985, pp. 45–76; 2011, p. 297). To clarify the first point (about human beings as self-interpreting animals), Taylor (1985) marks a distinction between what he calls “immediate feelings,” such as physical pain, and “import emotions,” which differ from brute feelings because they involve “a sense of our situation” (p. 48). His examples of import emotions are fear, shame, indignation, and admiration, emotions through which we experience our situation as bearing a certain “import” or meaning—it being frightening, shameful, insulting, or admirable. Whereas a situation is painful “just because we feel pain in it,” the feeling of fear (etc.) is a response to what has happened, which makes explicit some judgment about the situation that gives the emotion its character (pp. 48–49). In this respect, Taylor argues, there is a qualitative difference between human sensibility and nonhuman emotion:

Not only is there a great range of human emotions like indignation or admiration which are “thought-dependent” in the sense that they can only be attributed to language users; but it also seems plausible to say that even the common core which animals also feel, like fear and anger, are qualitatively different with [humans] in that they are linked with an awareness of their objects which is open only to beings with language. (p. 158)

While we only speak of an animal’s fear or anger to speak about a quality of the animal in question—namely, its behavior or “response”—we can think of human feeling as making a further claim—one about the “object” of our awareness and response. In this sense, then, import emotions are expressive of our nature as uniquely linguistic, self-interpreting animals.

More broadly—and this is where psychotherapy’s contrasting ethics comes to the fore—the articulation of import emotions opens us onto “the domain of what it is to be human” to the extent that the import or meaning they incorporate becomes explicit only by articulating “a picture of our moral predicament, according to which some goods are higher than others, while still others are false or illusory” (p. 63). This means that, in Taylor’s view, some normative understanding of right and wrong is inherent in being able to express the relevant import emotions at the heart of therapeutic dialogue. For example, a feeling cannot be one of pride or shame unless there is a sense of my having done well or wrong. But, Taylor argues, from the very fact of our feelings being articulated, the question cannot but arise of “whether this characterization is adequate [emphasis added], whether it is not incomplete or distortive . . . whether we have properly [emphasis added] articulated our feelings, that is, whether we have properly explicated what the feeling gives us a sense of” (p. 64). The parallel with therapeutic conversation is clear.

Taylor elaborates on the second point (about the nature of the reality that our self-interpretations seek to define) by considering what is happening when we find the right words for our feelings and motives. As Taylor (2016) argues, our nature as self-interpreting animals brings out something essential about human reality indeed:

The “right word” here discloses, brings the phenomenon properly into view for the first time. Discovery and invention are two sides of the same coin; we devise an expression which allows what we are striving to encompass to appear. This is a crucial facet of our language capability, which I will call “articulation.” (p. 178)

Unlike expressing our immediate feelings, import emotions are such that articulating something with the term “shameful” inflects our sense of meaning in a new direction. Because of this, new expressions “open up new ways of being in the world” (p. 189). We are concerned here with a particular constitutive force of human self-understanding, which puts us squarely in the domain of psychotherapy because it reflects on us as self-interpreting animals seeking moral orientation through articulation:

Prior to the articulation, the as yet unnamed import may be felt in a diffuse, unfocused way, a pressure that we can’t yet respond to. After articulation, it becomes part of the explicit shape of meaning for us. As a result it is felt differently; our experience is changed; it has a more direct bearing on our lives. . . . Articulation here alters the shape of what matters to us. It changes us [emphasis added]. (p. 189)

The resulting view is that the articulation of meaning creates not merely new realities, but also a new sense of self as part of that reality. When I come to understand my agitated state as envy or jealousy, I am already living it differently. I have taken the first step out of confusion; my situation already has a shape for me. In this way, new articulations allow the world to impinge on us, to move us, in new ways. That is why Taylor calls them “constitutive.” An initially vague, “unpleasant” feeling emerges as a recognizably distinct experience of envy, jealousy, vanity, indignation, remorse, or whatever, when we find the right words. The strongly evaluative descriptions carry the constitutive force.

Taylor’s view of the distinctive kind of facticity and objectivity involved in normative language resonates deeply with Smith’s therapeutic ethics. Taylor (2016) rejects the idea that facts and values lie in different realms as question-begging, precisely because this requires the additional assumption that normative statements are not really “factual” (p. 193n14). Rather, his view is that the objectivity involved in the interpretation of meaning is utterly different from the self-standing objectivity of evidence-based therapies. As noted, while the meanings involved in interpretation are deeply dependent on our modes of articulating them, we can still be wrong or mistaken about what these meanings are.

To return to the earlier example, where the patient’s harsh self-criticism leads to depression, the therapist’s proposal to be more charitable toward oneself may begin to work on the patient to the point that they come to see that their self-image is not a fair assessment at all. Even when they initially pride themselves for upholding high ethical standards, the question can always be asked: Is clinging to narrow and unforgiving moral principles really consistent with that? Asking such a question is by no means random or optional. As self-interpreting beings, we are looking for the right words to describe our situation. We want to know, in other words, what the world is really like. The point is that there is a reality here, to which our judgments are answerable.

In this sense, then, there is a getting it right and getting it wrong in the domain of human self-understanding: “our moral reactions suppose that they are responses to some reality, and can be criticized for misapprehension of this reality” (Taylor, 2011, p. 297). Human beings are receptive to the demands of reality itself. This realism is informed, first, by a demand for “undistorted, not-too-self-indulgent self-description” and, second, by a claim to “strong value, that is, value independent of our recognition,” which together put a burden on us to “get things right” (Taylor, 2016, p. 195).

Perhaps the most fundamental implication of Taylor’s view for psychotherapy (or psychology more generally) is that the constitutive force of human language has transformational power as well. As we have seen, one way of making sense of the reality that our interpretations seek to articulate includes the explicit articulation of conceptions of human well-being and flourishing. Such conceptions appeal to some sense of human life as worthy of our concern, which might be characterized in terms of an account of human dignity, rationality, particularity, autonomy, and so on. Taylor calls such accounts “moral ontologies” (1989, pp. 8–10) or “etiological” accounts (2016, p. 196) because they offer fundamental explanations for our experienced motivation—they each present an explanatory background that supposedly underlies our moral views. As Smith has shown in detail, the articulation of these ethical visions by no means offers a scientifically detached explanation: as moral ontologies, they constitute and color meanings in a way that gives them a profoundly normative character. Consequently, any change of description effects a change in reality—that is, “the pattern of meanings we live by, the ‘landscape’ as we live it and feel it” (Taylor, 2016, p. 197). In Taylor’s (2016) view, then, making therapy more transparent by articulating its underlying ethics involves a double call: the factual one “to get it more clearly in focus” and the normative one “to live up to this sense of what is important” (p. 196). These two transformations involve changing both patient and therapist in a deeply holistic way: part of the fruit of articulating better is getting better, and vice versa.

To conclude, following Taylor’s reasoning further shows that the debate on the ethical visions of psychotherapy is ultimately a debate on possible or impossible ethical transformations. It is a debate on what ethical emancipation demands. This takes us to the heart of Smith’s idea of therapeutic ethics: How do these therapeutic ideals strengthen us? How do we bring about ethical transformation, however conceived? While this process of moral growth through articulation could be examined in more detail, Smith’s analysis contains all the necessary elements to meet this demand. The result is nothing less than a renewed view of therapeutic success as requiring that the patient identifies their more important values and purposes, and resists or overcomes desires and goals that do not authentically reflect themself. As this indicates, despite my reservations regarding the limited use of Taylor’s philosophy as a resource for therapeutic ethics, I do not intend to deny the overall importance of Smith’s inventive approach, either for challenging “blind” psychotherapies that ignore or suppress ethical reflection or for drawing attention to the cost of such therapies. My restricted aim here has been to highlight the need within Smith’s analysis for a fuller account of the nature of ethical reasoning, and its implications for therapy. Indeed, if there are prospects for a genuine therapeutic ethics, Smith’s hermeneutic model seems to be the way to go.