Disciplinary Brief

The Virtues in Psychiatric Practice

John R. Peteet

Associate Professor, Department of Psychiatry, Harvard Medical School

Dr. Herdt’s beautiful discussion of the virtues clarifies and resonates with my own recent thinking as a Christian academic psychiatrist. Virtues have been historically neglected within psychiatric practice. Reasons include concerns about scientific objectivity, realistic expectations, and therapeutic moralism.

Renewed interest in their clinical relevance has been stimulated by problems in sustaining professionalism, growing attention to virtue ethics, empirical support for the benefits of virtues such as gratitude, and the emergence of a fourth wave of growth promoting therapies (1). I recently edited The Virtues in Psychiatric Practice (Oxford University Press, 2022) (2), which considers the implications of virtues of self-control (accountability, humility, equanimity), benevolence (forgiveness, compassion, love), intelligence (defiance, phronesis), and positivity (gratitude, self-transcendence, hope) for clinical work. However, more work needs to be done to understand how to incorporate a virtues based perspective into diagnostic assessment, goal-setting, and treatment.

Diagnostic Assessment and the Need for Virtues #

In conducting a diagnostic assessment, mental health professionals aim to identify what enduring disposition and/or schema the patient has, and how this constitutes a strength and/or a vulnerability. Clinicians typically eschew the term “vice” as moralistic, but maladaptive personality traits or disorders reflect perhaps the most obvious example of a need for virtues—for example, compassion in antisocial personalities, or humility in narcissistic individuals. Since a depressive disposition is often marked by guilt, inhibition and impaired self love, it often reflects a need for virtues of forgiveness, courage and love (3). Similarly, anxiety and PTSD are often accompanied by fear and distractibility, reflecting a need for equanimity, courage/defiance, and practical wisdom (phronesis) - virtues fostered by approaches such as Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT). Substance use disorders are often complicated by impulsivity, irresponsibility and guilt over damage done to self and others, reflecting needs for accountability, gratitude, and self-forgiveness (as encouraged by the Twelve Steps). Repair of moral injury often entails self awareness, moral integration, and re-connection to community.

Patient Cultivation of Virtues #

In goal setting, a comprehensive formulation and treatment plan not only characterizes pathology, but envisions a desired, healthier version of the person and how the therapist can help them achieve it. Whether explicitly or by implication, a therapist develops some picture of the patient’s flourishing toward which to aim, through the acquisition and cultivation of needed virtues. The task then becomes how to engage the patient in this project. Can the depressed patient see a need for hope, or self-forgiveness, or do they need the therapist to lend them hope that a better state of things is possible? Can the anxious patient believe that they can become less obsessional, or do they need to lean on the therapist’s equanimity to begin to trust this possibility? Can the substance using individual accept that a sober, healthy self is worth aiming for, and benefit from the supportive experience of a group promoting virtues such as honesty, accountability and forgiveness?

In implementing a treatment plan through the use of medication, insight or support, a clinician tries to identify resources that can be recruited for the patient’s full recovery, resilience and flourishing—both within the therapeutic relationship and from outside it, e.g., in their community, mentors, exemplars, or experiences of faith. Within the context of treatment, psychodynamic approaches aim at character change through both insight and through corrective emotional experiences with the therapist. Schema therapy explicitly uses the therapeutic relationship to attempts to modify maladaptive ways of being in the world toward more virtuous ones. Cognitive behavioral therapy offers strategies such as practicing healthier perspectives and practices, if need be disputing the patient’s resistances, to achieve change. And fourth wave approaches aimed at growth foster interventions to support virtues such as forgiveness or gratitude (4).

Three Ways that Virtues can Enhance Treatment #

There are at least three ways that an emphasis on virtues can enhance treatment.

Other-Directed Virtues for a Worthwhile Life #

First, acknowledging the patient’s hopes for living well contextualizes them as a whole person, a task especially pertinent when trauma, adversity or illness focus attention on what matters most. Eliciting what the suffering patient most values and hopes to change, including the other-directed aims embodied in most virtues, helps to establish the therapist as a trusted ally in pursuit of not only symptom relief but a more worthwhile life.

The Psychiatric Care-giver as an Exemplar #

Second, transparency about what the therapist values through demonstration of the virtues she embodies can further enhance trust and foster the internalization of qualities important to the patient’s recovery. Radden and Sadler’s explication of the virtues of a good psychiatrist such as trustworthiness, empathy, warmth, self-knowledge, respect, patience and perseverance provide examples of how these inform the therapist’s skillful use of herself (5).

The Salience of Virtues when Dealing with Moral Dimensions of Issues #

Third, it can be helpful to explicitly acknowledge a place for virtues when the patient’s problem has an important moral dimension. Examples include a trauma survivor’s struggle with whether to forgive and reconcile; re-evaluation of the individual’s priorities and life direction after a significant loss; disabling shame and guilt with a need to appreciate the virtues one continues to possess; or a disabling lack of a virtue such as accountability.

Differing Moral Visions and Value Preferences #

Therapists can have differing moral visions, preferences for encouraging particular virtues, and different aims for their patients—e.g., improved functioning, less distress, greater adaptability, enhanced flourishing, greater freedom or deeper relatedness to others. For a therapist who believes that flourishing involves pursuit of the Good, understood as what is important beyond the self, relational virtues such as compassion, love and forgiveness will carry more weight than if they envision morality to center on individual rights, and the achievement of autonomy. Preferred virtues for Jews often include communal responsibility and critical thought; for Christians, love and grace; for Muslims, reverence and obedience; for Buddhists, equanimity and compassion; for Hindus, appreciation of Dharma and Karma; and for secularists, respect for scientific evidence, autonomy, and intelligibility (6).

That world views and conceptions of the good held by therapists and their patients also differ should encourage clinicians to both be aware of the values they bring to the treatment, and to engage patients regarding these concerns not as strangers imposing a technique guided by moral neutrality, but by discussing and seeking the patient’s good through wisdom, candor, and respect (7).

The Way Forward #

A focus on the virtues clarifies how clinical work is both inherently moral and in important ways spiritual, and specifically how treatment that aims to promote human flourishing involves the cultivation of a mature and ethical character. Two areas for future exploration are the dynamic relationship between the therapist’s and the patient’s virtues, and the recruitment of resources outside the treatment to cultivate virtues. A Christian clinician, rather than promoting therapy as the complete means of acquiring needed virtues, would want to both model and encourage these, and explore what hinders the patient in finding what they need in God.

References and Further Reading #

1. Peteet JR. The virtues in psychiatric treatment. Front. Psychiatry, Sec. Public Mental Health, 2023:14.|  A fuller description of the above, with case examples.
2. Peteet JR, editor. The Virtues in Psychiatric Practice. New York: Oxford University Press (2022). 6–10. Chapters consider the scholarship regarding virtues of self-control (accountability, humility, equanimity), benevolence (forgiveness, compassion, love), intelligence (defiance, phronesis), and positivity (gratitude, self-transcendence, hope) and their implications for clinical work
3. Waring DR. The Healing Virtues: Character Ethics in Psychotherapy: Oxford University Press, 2016. A clear explanation of how psychotherapy can entail fostering virtues, using the examples of The Demoralized Woman and The Angry Man
4. Peteet JR. A fourth wave of psychotherapies: moving beyond recovery toward well-being. Harv Rev Psychiatry 2018; 26:90-95. Reviews the psychotherapies that move beyond symptom relief to the promotion of growth and flourishing
5. Radden J, Sadler J. The Virtuous Psychiatrist: Virtue Ethics in Psychiatric Practice. New York: Oxford University Press, 2010. Discusses the virtues that characterize the good psychiatrist, and the reasons they are essential
6. Peteet JR. What is the place of clinicians' religious or spiritual commitments in psychotherapy? A virtues based perspective. J Religion Health 2014; 53:1190-1198. Highlights the preferred virtues of different spiritual and secular traditions, and their relevance to clinical work
7. Curlin FA, Hall DE. Strangers or friends? A proposal for a new spirituality-in-medicine ethic. J Gen Intern Med. (2005) 20:370–4. doi: 10.1111/j.1525-1497.2005.04110.x Calls for clinicians to move beyond a conventional ethic of autonomy, neutrality and competence to one of wisdom, candor and respect