Objectivity and Pragmatism in Addictions Counseling: Towards the Resolution of a Dilemma
Studies have indicated that religious faith is a key protective factor in both preventing and recovering from addiction and mental illness (Wright and Pemberton, 2004; Van Der Meer Sanchez and De Oliveira, 2008).[1] That is, despite its questionable status with respect to objective truth and rational belief, religious faith seems to help people. In particular, it seems to help in preventing and recovering from addiction and mental illness. That’s good, isn’t it?
Not so fast. I believe there is a deep and pervasive problem at the heart of the counseling profession. It is a problem that is vividly exemplified in the case of religious faith[2], and forces us to make some hard decisions about some of our most fundamental commitments. At its most general level, it is a problem that requires that we adjudicate between two competing values: objectivity and pragmatism. As I argue throughout this paper, this overarching philosophical conflict quickly mutates into a network of mutually exacerbating sub-conflicts, none of which admit of any quick and easy solution.
Objectivity and Intellectual Honesty
Objectivity represents our best attempt to form rational, evidence-based beliefs about the world and our place within it; our commitment to objectivity is a commitment to ‘getting things right’, to having our beliefs ‘correspond with the facts’, and to maintaining our beliefs over time in accordance with legitimate epistemic practices—e.g. careful observation, controlled experimentation, disinterested inquiry, logical argument—rather than illegitimate ones—e.g. bias, prejudice, personal feeling, desire. At bottom, objectivity requires intellectual honesty: a sincere willingness to constrain what we believe, do, and value within the bounds of good evidence and good argument (Van Inwagen, 2002; Harris, 2002; Blackburn, 2005). In the field of addictions and mental health (hereafter: “ADMH”), part of our commitment to intellectual honesty is exemplified by our insistence on so-called evidence-based practices.
Pragmatism and Religious Faith
Pragmatism is the philosophical equivalent of a subversive rebellion against objectivism. At its core, it represents a commitment to believe, do, or value something solely because it is ‘paying off’ in some way, regardless of its objective status—i.e. regardless of whether it is intellectually honest to do so. In the case of beliefs, a committed pragmatist will categorically deny that we should aim to believe only true propositions—or at least, propositions we have good reasons to believe are true. It seems to be working, and that’s all that matters. Why fuss around with ‘rationality’, ‘objectivity’, ‘truth’, and all that highbrow, elitist snobbery if what you believe makes you happy, gives your life meaning and direction, gets you through the day, and allows you to deal with—or at least make some modicum of ‘sense’ out of—life’s vicissitudes and tragedies? (James, 1896; Blackburn, 2005 & 2007) Shouldn’t we just let people believe whatever they want to believe, so long as it ‘helps’ them in some way? Shouldn’t we encourage people to believe even patently absurd falsehoods provided that they’re benefitting from such beliefs, even if only temporarily?
The pragmatic approach takes all questions of this kind to be rhetorically self-evident: of course we should, the pragmatist says. In the ADMH field, a popular example of a pragmatic approach would be to support and encourage a client’s belief in the 12-Step philosophy, despite our knowing that the core assumptions underlying it are false, implausible, or unsupported by empirical evidence and logical argument. Another example would be to support—or again, openly encourage—a client’s belief in the power of lucky charms, Reiki stones, Feng Shui, Mystic Homeopathy, the predictive power of I-Ching—all of which, in varying degrees, have a highly questionable objective status.[3]
Intersection and Incompatibility
Objectivity and pragmatism, like many other pairs of conflicting desiderata, are not always incompatible. In fact, in many cases, we know that they must be compatible. If you want to build a bridge that will allow safe passage from point A to point B (pragmatic goal), you need to believe many essential truths about physics, engineering, architecture, and mathematics (objective requirement). More generally, the myriad ways in which science and technology have contributed to our wellbeing, goals, and projects is testament to the fact that objectivity and pragmatism often go hand-in-hand. Another example is our commitment to evidence-based practices in the ADMH field: they are both objectively legitimate and pragmatically useful. Moreover, as I argue in detail below, there are several less obvious reasons in which we should strive to promote greater convergence between our pragmatic goals and objective requirements. Insofar as we really care about our long-term wellbeing and the wellbeing of others, we should cultivate mental habits that line up more smoothly with objectivity—and assist others in doing so.
Now, while objectivity and pragmatism often coincide, it is equally clear that they are in many cases incompatible. In the ADMH field, countless examples abound in which objectively implausible propositions (e.g. “Reiki stones will give me the power to resist my urge to smoke crack”) seem to help those persons who believe them. How could this be the case? While we do not have a complete understanding of why irrational or objectively false belief helps in the prevention, treatment and recovery from illness, we know that part of the answer lies in the well-established placebo effect (e.g. Lidstone and Stoessi, 2007). To put the point somewhat indelicately: we can reap a staggeringly rich abundance of benefits—physical, emotional, social, or existential—by believing mountains of nonsense.[4]
But religious faith is the paragon of this incompatibility in action. Consider one of the most popular religious beliefs: there exists an all-powerful and all-loving God with whom I can share a personal relationship, and on whom I can rely for guidance. If a person really gets herself to believe this—for whatever reason, good or bad—it can have widespread, life-changing, beneficial effects on her emotional and existential wellbeing. Suddenly, her life is with infused meaning and direction; she’s happier and more disposed to treat others with kindness; she’s more conscientious of the impact of her behavior; she is more motivated and optimistic about her ability to achieve her goals (after all, she’s got a cosmic partner lending a helping hand). It is simply undeniable that beliefs of this sort can do psychological wonders for the people who hold them.
And yet, it is also undeniable that there is a gaping scarcity of good reasons to rationally believe such propositions. Indeed, this is often why religious persons explicitly refer to such beliefs as objects of faith—rather than ‘knowledge’, say. ‘Faith’ means different things to different people, but at its core it must involve belief—i.e. a mental representation of the world that purports to accurately represent what it is representing. In other words, to believe something, you have to take it to be true—not just want it to be true, or hope that it is true. Philosophers talk about this difference in terms of ‘direction of fit’: beliefs aim to make our minds fit the world, while desires aim at making the world fit our minds. There is a world of difference between believing that you have won the lottery and merely wishing or hoping that you’ve won the lottery.
Faith, then, involves belief—but it is a special kind of belief: it is belief in the absence of good evidence or good argument. Again, there should be nothing controversial here; indeed, in most religious traditions it is a virtue to believe in precisely this sense. But this is exactly why faith is incompatible with intellectual honesty. In fact, strictly speaking, faith is intellectually dishonest.[5] This is true even when faith leads to ‘good’ or beneficial results—for instance, when my belief that a personal God is lending a helping hand in my recovery leads me to work harder and behave more diligently. Regardless of the pragmatic benefits one receives, it is always intellectually dishonest—and hence objectively illegitimate—to believe anything exclusively on the basis of faith. As I argue below, the incompatibility between faith (or any kind of rationally unjustified belief) and the objective standard of intellectual honesty has tremendous implications for our role as counselors.
A Network of Problems
At this point, you might be thinking, “Well, who cares? If it’s helping someone right now, why should we meddle? In fact, why shouldn’t we—as counselors— encourage it, as long it’s doing something to make them happier and more motivated to achieve their goals? OK, so it’s not ‘objective’ or ‘intellectually honest’—but does that really matter? What harm could it do?”
I appreciate the force of this worry. After all, two of our ethical values as clinicians are beneficence (i.e. the promotion of the client’s wellbeing) and autonomy (i.e. the promotion of the client’s right to refuse or choose any intervention), which seem to allow at least some elbowroom for belief in objectively unjustified and-or unjustifiable interventions (Beauchamp & Childress, 2001). So at first glance, there seems nothing wrong with supporting or encouraging any intervention chosen by the client and from which she claims to be receiving a benefit.
But another of our ethical values is non-malfeasance (i.e. preventing or avoiding harm to the client); so at least in some cases, we may have an ethical obligation to dissent from, or even outright discourage, any intervention for which there is neither scientific evidence nor logical argument, if we have good reason to believe that such an intervention may be ineffective or even positively harmful (Beauchamp & Childress, 2001). I think this is right, but let’s keep things simple by assuming for the time being that in every case, no direct and immediate harm comes to the client[6]— pragmatically, it seems to ‘work’ for the client. But as we’ll see, even if we grant this much, a host of problems still remain.
Honesty and Double Standards
Yet another of our ethical obligations as counselors is truthfulness or honesty (Beauchamp & Childress, 2001). In the more common sense, this means that we cannot tell falsehoods—i.e. we cannot state as true what we believe to be false. But it also means that we cannot omit what we believe to be true, provided that the content of our belief is clinically relevant. That is, a clinician cannot omit relevant information regarding a client’s treatment, especially if such information would make difference with regard to informed decision-making. Such a practice would be no less dishonest than saying something that you believe is false. This should not be controversial, as it goes hand- in-hand with the principle of informed consent that is central to the value of autonomy: in order to make the most effective and meaningful use one’s autonomy in one’s best interest, one should have access to whatever relevant information is available.
Numerous implications fall out of this obligation. For example, imagine a client, Carl, who says that he plans to use nothing but Reiki stones to address his major depression, and that he will only attend AA meetings to address his alcohol dependence. He also claims that he “feels in heart” that his depression and alcohol dependence are unrelated. Now, the therapeutic utilities of Reiki stones and AA meetings have not been empirically justified (much less as ‘stand alone’ treatment interventions); at best, their therapeutic value is either anecdotal or highly questionable, especially as compared with other treatment modalities, such as pharmacotherapy (Ksir et al, 2008), motivational interviewing (Burke et al., 2002; Miller & Brown, 1993), cognitive-behavioral therapy (Butler et al., 2006), life skills training (Botvin et al., 1984), biopsychosocial case management (White, 2005), or even meditation (Rubia, 2009; Praissman, 2008).
What should you do? Carl clearly harbors a number of misguided beliefs about how best to address his depression and alcohol dependence. Assuming we are even minimally trained and educated as clinically proficient counselors, we will know that these beliefs—and the corresponding behaviors to which they give rise—are at best rationally unjustified, and at worst paradigmatic cases of phantasmagorical confusion.[7] Since we know this, and since we have an obligation to be truthful, we can neither state what we believe is false, omit pertinent information, nor endorse, recommend, nor encourage any intervention that we have good reason to believe lacks objective warrant.
If our commitment to these ethical and professional standards is warranted, then we appear to have a further obligation—namely, to critically evaluate Carl’s belief and corresponding prospective course of action. This might seem controversial, but we already do engage in this practice in other contexts. Take, for instance, the golden rule of cognitive-behavioral therapy: challenge cognitive distortions: this is ultimately just another way of insisting that we critically evaluate irrational beliefs or illogical reasoning patterns, i.e. objectively unjustified beliefs. Even motivational interviewing, which admonishes us to ‘avoid argumentation’, nonetheless requires that we develop discrepancies, thereby making a client aware of a conflict between her current behavior and what she reflectively values; this is also an irrevocably critical activity. But if we are willing to critically evaluate clients’ beliefs in some contexts but not others, we seem committed to a double standard.[8]
Of course, our circumstance seems—or at least feels—different in the case of religious faith, where we would need to critically evaluate beliefs that are existentially central: a person’s religious beliefs lie at the heart of their fundamental conception of who they are, what their place in the world is, and how they ought to live their lives.[9] Unlike almost any other class of belief, existentially central beliefs are deeply interwoven with an individual’s identity and values. As such, they are essentially personal beliefs. Even though the criticism of a belief is not a criticism of the person who holds the belief, the result is typically one of personal offense and insult.8 And of course, we do not want to risk hurting anyone’s feelings unless we have indefeasibly overriding reasons to do so. Should we just back off, then?
The Nature of Belief
Unfortunately, we cannot simply back off, for a number of reasons. To begin with, beliefs are representations of the world—they purport to be literally true.[10] To believe a proposition is to take it—whether consciously or unconsciously—to accurately describe what it says about the world. Furthermore, beliefs are not isolated from one another but interconnected. This is especially true in the case of religious beliefs, given their global and existential character—such beliefs both ground and constitute a person’s conception of the good and moral life, including views about the self, meaning and purpose, morality and values, wellbeing and happiness, and much more. Moreover, beliefs underlie our emotions: I can only be afraid of the Rottweiler approaching me if I believe that it presents a real and present danger. Also, beliefs underlie our behavior: I get on the 915 only because I believe it will take me to Durham College. Finally, beliefs tend to be acquired in certain ways or styles, which often subject to compartmentalization: someone might use the scientific method to acquire beliefs about the migration patterns of birds, but rely on the authority of a priest for her beliefs about the moral status of a fetus. But this compartmentalization has limits, for at least three reasons.
First, beliefs share logical and semantic connections. A well-studied consequence of this connectivity in empirical psychology is the phenomenon of cognitive dissonance, where a subject becomes aware of a tension or conflict among her beliefs (or between her beliefs and her behavior), which in some cases may result in emotional crisis (Festinger, 1957).
Second, since belief is connected to behavior, even compartmentalized beliefs will have behavioral consequences. Consider a physicist with a gambling problem. Typically, he requires good evidence for his beliefs (especially on the subject of physics), but when it comes to aspects of his gambling his standards loosen dramatically. He believes, among other things, that by wearing his ‘lucky’ belt, his chances of winning increase tenfold. As a result, he not only wears his ‘lucky’ belt, but while wearing it, he bets greater amounts and chases losses more frequently.
Third, if the compartmentalized beliefs are existentially central, they will bear relevantly on almost every feature of an individual’s worldview—which means, yet again, that they are only superficially isolated, if at all.
As we can see, then, compartmentalization represents a double-edged sword: on the one hand, it is harmful because it can lead to cognitive dissonance, which in turn can result in emotional distress[11]; but on the other hand, it is harmful because it is only superficial—a belief is not like a pair of pants that can be neatly tucked away in a dresser only to be worn on Sundays. Not only are beliefs interconnected, they have emotional and behavioral consequences. If the beliefs in question are existentially central, their influence is pervasive and critical to one’s fundamental concerns.
Imagine a client, Sara, who believes in a god with whom she shares a personal relationship. This belief, she says, gives her life meaning and direction; she is happier, more motivated, and more disposed to believe in her ability to overcome adversity. For Sara, prayer in particular offers her a kind of surrogate counselor: it helps her to release her worries and cope with the distressing whirlwind of life’s pains and disappointments. Sara has come to Pinewood Centre via referral from her family doctor, who is concerned about the variegated impact of her dependence on cocaine. However, Sara finds the referral utterly pointless. She believes that her dependence on cocaine is an exclusively spiritual or supernatural problem, the result of demonic possession caused by her having committed a grave sin against God, for which she is being justly punished. Thus, she also believes that her substance use concern can only be addressed by means of an exorcism followed by months of fasting, rigorous prayer sessions, and extreme social isolation (the demon, she thinks, feeds on the caring support of others). Consequently, she rejects any treatment intervention that isn’t targeted at ‘exorcising’ her ‘demon’: her condition, she insists, has no dimension other than the spiritual. She claims that she came to believe this after having prayed to God, from whom she received an unmistakable ‘sign’.
This case illustrates the thorny conundrum in which we find ourselves with respect to counseling religious clients. Our well-intentioned, but ultimately misguided attempt at an amorphous species of ‘political correctness’ and ‘respect’ for religious beliefs may often result in more harm than good. It is not merely a double standard; it may also prevent us from honouring our commitment to the values of beneficence, truthfulness, and autonomy. Furthermore, it shows clearly that the alleged benefits derived from religious faith are limited and may be short-lived, especially vis-à-vis ADMH concerns.
While it is true that religious faith can be a protective factor, it can be a risk factor as well (Pargament, 1998a, 1998b, 2004). Also, as the cognitive-behavioral model points out, most psychological disorders are rooted in distorted or irrational beliefs. When these beliefs are accepted as facts, they can cause excessive emotional distress (e.g. worry, fear, sadness, anger). In an effort to prevent or mitigate this distress, people often develop dysfunctional coping skills (e.g. avoiding situations associated with the distress). These negative patterns of thinking and behaving actually reinforce each other over time, leading to a vicious cycle of distorted beliefs, emotional distress, and maladaptive behaviors.
The problem may be even worse, owing to the distinctive character of religious faith: even if we somehow muster the wherewithal to critically evaluate the religious beliefs of clients insofar as such beliefs negatively impact their wellbeing and autonomy, religious faith seems intrinsically immune to direct rational persuasion of any kind—after all, it is belief in the absence of evidence and argument that forms the basis of an individual’s deepest personal, moral, and spiritual concerns. Needles to say, that’s a tough nut to crack. When we add to this the cognitive, affective, and decisional impairments resulting from ADMH concerns, the problem is exacerbated.
Religion and the Moral Model
If all this were not sufficient cause for concern, we face another problem. Religion is often associated with the moral model of ADMH, according to which substance dependence is a personal choice reflecting moral failure. It sees the person suffering from addiction as depraved and guilty of having misused their ‘free will’ in a selfish, shortsighted attempt to obtain a fleeting pleasure. On this view, the appropriate intervention is not one of compassion and understanding, but condemnation and punishment.
While most of us view the moral model as unequivocally wrong, its social, political and personal aftershocks can still be felt. Above all, it has contributed to a torrent of stigma and marginalization. In other words, it is not simply objectively false but pragmatically harmful. The so-called “War on Drugs”, for example, is predicated on viewing the ‘addict’ as one who freely indulges in the use of ‘evil’ substances—to say nothing of the brutal moral and legal prosecution carried out against those afflicted with addiction. Also, the 12-step philosophy shares much in common with the moral model, especially in its emphasis that recovery requires a “searching moral inventory”, which seems to assume—without evidence or argument—that a substantial portion of the problem is a function of immorality. Only a moral rejuvenation, it seems, will do the trick.
The moral model is a colossal failure—both objectively and pragmatically—but what does it have to do with religious faith? Most religions espouse a notion of distinctively religious immoral action, or sin. A sin is any act contrary to the will or dictates of God, whose nature is conceived as perfectly good and thus wholly incontrovertible. The moral model lines up squarely with this view, even if it need not always be religious in orientation: “the moral model for explaining the etiology of addiction focuses on the sinfulness inherent in human nature” (Capuzzi & Stauffer, 2008). If part of your conception of religious obligation includes the idea that certain forms of drug use are sinful, you will interpret your drug-related problems as a personal moral failing.[12]
This is a special case of what is known as the phenomenon of internalized stigma, whereby an individual has come to attribute to herself the negative attitudes and beliefs held by others in regards to her condition (Capuzzi and Stauffer , 2008). In this case, it is a more virulent strain of internalized stigma, given that the existential centrality of religious beliefs renders them more personally and emotionally entrenched and therefore resistant to revision by means of rational argument. For instance, as Capuzzi and Stauffer (2008) put it, “it is difficult to establish the sinful nature of human beings through empirically based research.”
Three implications seem to follow from this result. First, it shows that an initially benign and even beneficial belief system may be, on further reflection, potentially very harmful—it may grant immediate, short-term benefits while concealing long-term costs downstream. This is analogous to the notion of an apparently irrelevant decision (AID) in relapse prevention (Marlatt, 1985). Just as a decision may appear inconsequential with respect to a high-risk situation for relapse, a belief may appear initially inconsequential with respect to potential long- term harm.
Second, given its connection to internalized stigma, it clearly illustrates a specific instance of such potential harm: internalized stigma has been shown to be a risk factor for ADMH concerns. And as we have seen, it is a form of internalized stigma that seems dangerously insulated from rational revision, given its existential centrality and the fact that it is believed on faith.
Third, given its connection to morality, the issue is rendered even more delicate along the existential dimension, in light of its direct bearing on the question of how one ought to live.
A Way Forward
Thus far, I have argued that as counselors, we face a network of interrelated problems, none of which have simple and easy solutions. At this point, you might be asking yourself two questions: (1) “How do we deal with these problems?” (2) “Does all this really matter? Will most clients even present with these sorts of difficulties? Religious belief is not universal; and even if it were, a lot of religious people are not as ‘extreme’ or ‘literal’ in their faith in a way that would raise these kinds of worries.” These are good questions, and it would be unreasonable for me to set them aside. I’ll start with (2), since it addresses a higher-level concern—a “what’s the point?” question. Once I show that there is indeed a point, I can offer an answer to (1), which is a “how” question that presupposes a satisfactory answer to the “what’s the point” question.
What’s the point?
So, what is the point? First, it bears noting that even if it were true that the type of problematic case I have described is highly marginal, it would not relieve us of an obligation to address it. No one pretends that marginal populations ought to be ignored (indeed, to ignore them would only worsen their marginalization), much less that marginal populations do not matter or merit our serious consideration. In principle, we should do our best to be prepared to meet the needs of any client whatsoever. So, in a fundamental sense, it does really matter.
But we can say more than this. The type of case I have described is not (and cannot be) rare, given what we know about the prevalence of genuine religious faith (i.e. genuine belief as opposed to, e.g., mere ‘profession’ or ‘declaration’ of belief) and the fact that religious faith can be both a protective and a risk factor for ADMH concerns (Harris, 2002; Pargament, 1998a, 1998b, 2004). Moreover, the kind problem I am worried about falls on a very wide continuum. I am not at all suggesting that the only case destined to cause us ethical and professional trouble is one in which an individual unshakably holds a patently absurd and cataclysmically harmful belief. Nor is my case limited to religious faith—one can stubbornly maintain belief in an indefinite number of egregiously bad ideas for egregiously bad reasons. For instance, someone can believe that ‘all counselors are bad’ because of an unfortunate experience with a single bad counselor, or that ‘gambling losses are not really losses but signs of an imminent win’ because she believes that the probability of a win increases with the number of successive losses, etc. These are cases of belief in the absence of good evidence or good argument[13], and they are also apt to cause harm, especially in the long-term. Granted, there is a key difference in the case of religious belief, namely, its existential centrality, which means that such belief is more personally significant and resistant to revision, even in light of good evidence and argument.[14] But this simply redoubles our obligation: if we have an obligation to address gambling-related beliefs, which are rarely existentially central, then we have an even greater obligation to address religious beliefs.[15]
In any case, the point is that faith—religious or otherwise—is quite widespread and common. One reason we may not be as attuned to cases of religious faith as we are to cases of non-religious faith is that, quite frankly, we are too afraid to ask. This is perfectly understandable: after all, as the old admonition extols, ‘Never talk politics or religion at the dinner table!’ As Sam Harris (2002) points out, there is a powerfully influential societal taboo against talking openly and critically about religious beliefs. This taboo may be amplified in the domain of counseling, given our intention as counsellors to do whatever we can to avoid offending the cherished beliefs and values of our clients.
What Can We Do?
What can we do as counselors to address this problem? How can we strike a balance between objectivity and pragmatism? While more research on this problem is needed before we can say precisely how we should address it, there are several reasonable, evidence-based strategies upon which we can ground such efforts. In what follows, I will outline what I take to be the most promising overall approach. In essence, we need to aim for a middle ground between confrontational argumentation (CA) and uncritical acceptance (UA). What we need to bear in mind is that it is not just CA that we need to avoid; indeed, as I have argued throughout this paper, UA may be potentially far worse, despite its initial appeal.[16]
To begin with, we need to make a more diligent and concerted effort to gain knowledge of religious beliefs, values and practices, especially with respect to their potential bearing—positive or negative—on ADMH and the counseling process. For instance, there is simply no way that we can meaningfully empathize with a religious client unless we have an understanding of what matters most to them from their vantage point. Of course, this does not entail that we launch into rigorous, intensive research on all the minutiae of each and every known religion. In fact, most of our ‘research’ should be done with the client: rather than complex philosophical theology penned within the remote ivory towers of erudite apologists, our concern should reside almost exclusively with the client’s unique relationship to their religious faith. We should strive to understand what our clients believe and value; we need to start a conversation.
Apart from the peculiar uneasiness we feel in talking openly about religion, this is really no different from what we currently encourage and practice. For example, we take great pains to figure out what gamblers believe about odds, the role of skill in gambling activities, and the impact of their gambling on their family; we insist on openly discussing what an LGBTQ client believes about sexual identity and heterosexism; we find it crucial to determine what youth believe about the level of risk involved in their behavior (e.g. drug use, sex, etc.); we delve into the emotional shipwreck of traumatic memories of physical and psychological abuse. In many of these cases, the exploration is by no means conversationally easy and casual. But we engage in such conversation and exploration not merely for clinical purposes, but to gain a better appreciation of whom our clients are and where they are coming from. In my view, this aim is even more important in the case of religious belief, given its existential centrality—religious belief lies at the core of a person’s deepest sense of self, world, morality, and wellbeing.
Similarly, we need to foster and practice an active mutual-educational role within religious communities. It is a process of mutual education because the goal is both to ‘educate’ and ‘be educated’. There is much we can learn from the leaders of religious communities, especially as regards how best to interact with clients in a way that is sensitive and tailored to their religious identity. Moreover, since clients will frequently seek advice and counsel from their religious leaders, our role in providing accurate, myth-dispelling, de-stigmatizing information on ADMH is indispensible. As we saw in connection with the moral model, it is gravely unfortunate that many religious communities espouse unjustified and potentially harmful views concerning ADMH. If we can do anything to shift attitudes on this front, we should do so with the utmost energy and dedication.
But the more fundamental task is to learn directly from individual clients— we need to discover whom they are and where they are coming from. We have reason to believe that the best way to start this conversation is to build a strong therapeutic alliance. We cannot hope to start a conversation about existentially central issues until we first build a therapeutically sound foundation of trust. In my view, the best way to secure such trust is by means of a person-centered or Rogerian style, in which we convey to the client our willingness to non-judgmentally accept and understand them for whom they are. This should not involve high-level, sophisticated counseling techniques; ultimately, it is a matter of creating a safe and comfortable atmosphere by demonstrating genuineness, empathy and unconditional positive regard (Rogers, 1961, 1980; Cooper et al., 2007). The creation of such an environment has proven highly effective in allowing for exploration into less comfortable cognitive and affective territory (see, e.g.. Cooper et al., 2010; Ward et al., 2000; Schechtman & Pastor, 2005 for review and analysis).
Once this foundation has been set, a potentially fruitful strategy would consist of an integrative application of motivational interviewing and values clarification, with the possible addition of elements of narrative therapy.[17] ‘Values clarification’—the process of determining in detail what matters to the client—should be part of the task of learning what our clients believe and value. Now, recall the connection between beliefs, values, behavior, and cognitive dissonance. In cognitive dissonance, a subject becomes aware of a tension or conflict among her beliefs, values, and-or behavior, which in extreme cases may result in emotional crisis. Initially, I warned that this might be ‘bad’ in the sense of being a risk factor for potential ADMH concerns. But in fact, it is something we can employ for the benefit of the client. Cognitive dissonance is simply a special case of what is known in motivational interviewing as a discrepancy, which in turn is typically the proximate cause of ambivalence (Miller & Rollnick, 2002). If a subject discerns a discrepancy among (1) beliefs, (2) beliefs and values, (3) beliefs and current behavior, or (4) beliefs, values and current behavior, a state of ambivalence will emerge. Ambivalence, in turn, can serve as a powerful therapeutic catalyst for developing and solidifying intrinsic motivation to change. (Miller & Rollnick, 2002).
This is where the importance of objective critical evaluation comes into play. In order to identify and develop discrepancies for the purpose of instilling a state of ambivalence within the client, we must conduct an objective critical evaluation along the lines of (1), (2), (3) or (4). And this is precisely how we can strike a balance between objectivity and pragmatism: we employ objective standards with the aim of achieving a pragmatic result. This is not a process of confrontational argumentation (CA)—the point is not to engage in intellectual debate or personal criticism. But it also is not a process of uncritical acceptance (UA)—it would be impossible to ‘develop discrepancies’ if we uncritically accepted everything a client believes. The ideal is objectively assess the client’s situation by critically evaluating (1), (2), (3) or (4) in a respectful manner within a safe environment.
One source of potential discomfort with the idea of critically evaluating a client’s religious beliefs is built into the structure of counseling itself. We are admonished as counselors to respect the beliefs of our clients. Understandably, most of us would probably accord even greater respect to a client’s religious beliefs, given their existential centrality within a client’s belief system as a whole. Therefore, one might worry that by critically evaluating someone’s religious beliefs, we are being unwarrantedly—perhaps even maliciously—disrespectful.
There are problems with this position. First, strictly speaking, beliefs—as opposed to persons—are not at all worthy of our respect; they are not even possible recipients of respect. For instance, beliefs—unlike the persons who hold them—do not have ‘feelings’ that can be ‘hurt’, or sensibilities that can offended, etc. While we can and should respect the person who holds a belief, the same is not true of the belief itself. Granted, we might be disrespecting someone when we challenge her beliefs, but only if we do so disrespectfully in an unsafe environment.
Similarly, the notion of ‘respect’ assumed in this context might be seen as equivalent to uncritical acceptance, which is deeply mistaken. To genuinely ‘respect’ a person’s belief (and more importantly, the person herself), we must (at minimum) take it seriously, which often means being ready and willing to critically assess it, especially with the best interests of the person in mind. (This is close to what we mean by the idea of ‘constructive criticism’.) It is no sign of respect, for instance, to allow an individual to persist in potentially harmful delusions. To accept a person’s belief without thought or consideration is not respectful: it is tantamount to ignoring it, or refusing to consider it as an object worthy one’s time and attention. It seems akin to a type of disingenuous and callous indifference. As I have argued, our obligation to critically assess what a person believes is greater in proportion to the likelihood of potential harm associated with it. In some cases, it would not be merely disrespectful to refrain from do so; it might even constitute a species of moral and professional negligence for which we could justifiably be held accountable.[18]
It might be difficult to appreciate this difference, but it is really just an extension of what we are already doing in other clinical contexts. After all, how do we ‘develop discrepancies’ anyway? At minimum, it involves carefully guiding the client in becoming aware of a tension or conflict among her beliefs, values, and behavior. Depending on the client’s level of insight, we may need to adopt a more directive approach. Again, this is something we already do in other clinical contexts without any suspicion that we are failing to ‘respect’ the client. For example, a client in the so-called Maintenance stage for alcohol addiction believes that the risk involved in attending a friend’s retirement party at a local bar is very low—to which we might respond: “From what I’m hearing, it seems that on the one hand, you’d very much like to go to the retirement party; but on the other hand, you’ve identified ‘social events where others are drinking’ as one of your main high-risk situations.” This is paradigm case of critical evaluation of what someone believes (especially where it involves potential for harm to the client and her current goals), even if we are doing so in a subtle, gentle, and empathic way. In effect, we are pointing out a discrepancy or inconsistency between (1) what the client believes about the level of risk for relapse involved in a certain situation; (2) what the client values or desires; and (3) what the client herself has identified as one of her risk factors for relapse. This is not aggressive, confrontational or argumentative. Nor is it a case of uncritical acceptance, since we are responding in a way that we know is likely to engender some degree of doubt or reconsideration. Consequently, it is not in any way ‘disrespectful’.
In my view, it is important that we do this kind of work from the very beginning—i.e. during the early stages of change in which intrinsic motivation is being cultivated. Intrinsic motivation should rest on a secure, objectively sound foundation. Put differently, intrinsic motivation should be built on a foundation that is based—as much as possible—in reality. Lennon and McCartney once sang, “living is easy with eyes closed.” It may be easy—at least temporarily—but it is certainly not healthy over the long-term. One might, after all, bump into many walls, or even fall over a cliff.
Some clients may resist our best efforts to help them build an objectively sound motivational foundation. In such cases, it may be possible to adopt a modified approach. In this approach—which we can call Motivational Elbowroom—we allow, and in some cases even encourage, that the client build their motivation on whatever foundation happens to (pragmatically) ‘work’ for them. That is, we allow for and encourage whatever is necessary make the transition through precontemplation and contemplation. It turns out that this might be the most optimal solution for some clients, given the motivational force of existentially central beliefs and values. Such beliefs and values lie at the core of an individual’s orientation to life, and thereby may provide the strongest impetus to solidifying a commitment to change. However, once we grant this motivational elbowroom, a vital and necessary shift must be made. Upon securing motivational commitment, we have moved into the Preparation stage, where the aim is to design and develop a plan for the change(s) the client is already motivated to make.[19] It is at this crucial stage that objectivity needs to take center stage. And since preparation is partly a matter of reinforcing motivation, when an objective change plan is designed, it will tend to add supplementary, objective reasons to be motivated for change. To see how this works, consider the following example:
Rick reports having experienced severe problems—e.g. physical, emotional, social, and legal—related to his alcohol use for the past 15 years. You learn that Rick is a committed Catholic who views himself as having committed grave sins over the past 15 years in connection with his drinking; indeed, he views his drinking itself as sinful. He believes that his drinking is a kind of supernatural aberration within his soul. At this point, instead of (say) attempting to educate Rick regarding the biological, psychological, and social dimensions of substance abuse (let alone directly assessing his own beliefs about substance abuse)—which most of us would be uncomfortable doing—we could draw from his religious faith in building intrinsic motivation to change. Since these beliefs and values are existentially central, they matter to him deeply and form a substantial portion of his conception of himself and how he ought to live. Thus, they will constitute reasons for change with which he can easily identify.
At this point, Rick has transitioned from contemplation to preparation; it is precisely at this stage where objectivity enters the picture. Here the goal is to guide the client in determining the most realistic, attainable, and assessable plan as well as the most effective means by which to implement it. (To say that a plan is ‘assessable’ is to say that it can be clearly monitored and evaluated over time.) Of necessity, a realistic, attainable, and assessable plan, as well as a strategy likely to be effective in putting it into action, must be objective. This is true virtually by definition: a change plan could not be even minimally objective if it was based in wishful thinking, and-or ineffectual, unachievable, and impossible to monitor and evaluate over time.[20]
Suppose, for instance, that Rick’s plan is to do nothing but the following: each morning, he will apologize to God for his ‘sinful nature’ and surrender himself to His will; in this way, Rick believes that God will gradually decrease the level of sinfulness in his nature and, consequently, his problematic relationship with alcohol. Clearly, Rick’s plan is a far cry from being objectively sound: it is neither realistic, attainable, effective nor possible to clearly monitor and evaluate (to say nothing of the fact that the beliefs upon which it rests lack evidence). For this reason, it is a plan that should not be adopted. With respect to our position as counselors, it is not a plan that should be uncritically unaccepted, let alone endorsed, much less encouraged. This does not entail that we abandon our commitment to a client-centered model; it simply constrains it within reasonable limits. It does not entail, for instance, that at a certain stage we completely take over the reins and start authoritatively prescribing goals to the client regardless of her views and concerns; nor does it require anything like aggressive confrontation.
Critical evaluation is not inherently disrespectful; however, it can be done disrespectfully. But the same is true of every communicative interaction in any context whatsoever. Nevertheless, our commitment to a client-centered model must have limits. It is neither absolute nor insensitive to context, particularly in the case of religious faith. This is not an abandonment of client rights; it is an intelligent and realistic delineation of them.
But there may be something we can do when critical evaluation seems unlikely to produce positive results, despite our best intentions. Particularly in the case of religious belief, we may be able to adopt a central insight of the counseling approach known as narrative therapy. I will close my discussion with a brief exploration of what such an approach might look like.
Suppose that critical evaluation is getting us nowhere, or that we have failed to establish sufficient rapport to make such work less disconcerting. At this point, it may be helpful to remember that each of us, whether or not we are consciously aware of it, view our lives at least partly in terms of a story or autobiographical narrative that makes sense of our past, present, and future. Arguably, it is essential to our conception of personal identity. If you doubt this, imagine losing all of your autobiographical memories. Would you consider yourself to be the same person? Sure, you would be the same biological organism, but it is doubtful that such a dramatic break in psychological continuity would preserve your personal identity. Psychological continuity is at the forefront of one’s personal narrative or ‘life story’.
For many religious persons, one’s relationship to the religious tradition and community of which one is a part forms a central element of the story of one’s life. Indeed, for some religious persons, one’s personal narrative is framed almost entirely in the language and imagery of religious development. Unfortunately, one’s story can be written in an extremely negative, self-stigmatizing and self-effacing way (e.g. along the lines of the moral model). Rick, for example, views his alcohol dependence as a grave sin for which the God from whom he must now regain trust and acceptance is justly punishing him. Clearly, this is an extremely damning picture that presents him in a negative light and surely does significant harm to his self- image. If we can do anything to help Rick move beyond this view, we should.
In essence, narrative therapy recommends the technique of restorying, which is a kind of reframing exercise that is accomplished in collaboration with the client.[21] As we saw, Rick’s story describes him in an extremely negative fashion: not only does he have an intrinsic moral defect or character flaw; it is something for which he is personally responsible—it is his fault, all the way down. Indeed, the story makes it seem as though Rick freely indulged this inherent ‘evil’ within his ‘soul’ by drinking ‘irresponsibly’, which in turn simply amplified his preexisting ‘evil’ condition. Needless to say, such a story is not the kind of software that should be running on anyone’s brain, especially if personal change requires drawing on one’s perceived strengths and inner resources. Simply put, this story desperately needs to be rewritten. Specifically, it needs to be rewritten in a way that modifies the conceptualization of the relationship between ‘person’ and ‘problem’. In Rick’s story, Rick is the problem—the problem is inseparable from his nature.
A more therapeutically fruitful and personally empowering characterization would be one in which the problem is conceived as something with which one shares a certain relationship, but not something that intrinsic to one’s nature. On such a view, Rich has a problem, but he is not identical to it. This rethinking of the person-problem relationship is known in narrative therapy as externalization. By focusing on the problem’s effects on the person’s life rather than on the problem as inside or inherently part of the person, appropriate psychophysical distance is created. This externalization or objectification of a problem makes it easier to investigate and evaluate its multifaceted influences.[22] This strategy is particularly useful in the case of religious belief, since religious narratives often internalize problems as being in some sense intrinsic to the person afflicted with them. Such internalization—as we saw in connection with the moral model in particular—is a key ingredient in the phenomenon of internalized or self- attributed stigma. Thus, insofar as we can help an individual to externalize rather than internalize their problems—if we can help them rewrite their story in a way that does not depict them as intrinsically flawed—we can not only address the problems more effectively but also combat a powerful source of potentially debilitating stigma.
What is crucial is that this new story is not a confabulation; it does not deny the facts. Nor does it require a radical shift in orientation or worldview; it takes place within the client’s frame of reference, but selectively preserves its most positive elements. Again, this is something we already do, e.g., in the context of motivational interviewing, where we selectively attend to ‘change talk’—i.e. client statements that have some relevant bearing on the motivation for positive change (Miller & Rollnick, 2002). The aim is not to ignore, discount, or reject other types of talk (e.g. so-called ‘resistance talk’); rather, we simply focus on talk that is geared towards eliciting motivation for making positive changes.
Conclusion
As I cautioned from the outset, the dilemma between objectivity and pragmatism actually comprises a complex network of interrelated problems with respect to providing counseling services for religious clients. I have argued that these problems are sufficiently significant to warrant special concern, and that they entail certain moral and professional obligations from us as counselors. I have also defended a sketch of what I take to be the most reasonable strategy by which to respond to these problems. Looking ahead, one natural extension of my project would consist of a more detailed examination of specific counseling strategies tailored to particular religious belief systems, e.g. Christianity, Judaism, Islam, Hinduism, etc. After all, there are clearly numerous relevant differences between religious belief systems, and such differences should be reflected and honoured in our interaction with clients. The analysis I have offered in this paper proceeded on the basis of what I took be at the heart of most (if not all) religious belief systems: existentially central propositions believed on the basis of faith. Even though I have emphasized the importance of taking a close look at how individual clients interpret and engage with their religious belief system, the majority of the suggestions I have defended are based in what tends to unify rather than distinguish them.
2018 Carl Legault ©
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[1] However, there is a growing body of evidence for precisely the opposite view (e.g. Pargament, 2001 & 2004). Some of this evidence is discussed below.
[2] As I make clear throughout, the problem I discuss in this paper is by no means limited to religious faith, or even to faith—construed as belief in the absence of objective reasons—more generally.
[3] I am putting the point diplomatically, of course. To say that such practices have a “highly questionable objective status” is much like saying, “swimming in sulfuric acid has a very low margin of safety”.
[4] Note, however, that these ‘benefits’ may be superficial and short-lived, and they must be weighted against several associated costs—I defend this possibility in detail below.
[5] I’m not making any kind of moral judgment here. Whether intellectual dishonesty is immoral is an entirely separate issue. (I think it’s immoral in some, but not all, cases.)
[6] As we’ll see, this is an extremely implausible assumption.
[7] I’ll talk more about the connection between belief and behavior—including the special problem to which it gives rise—below.
[8] One of core strategies for dealing with this problem that I develop below is a kind of middle ground between the extremes of confrontational argumentation and uncritical acceptance.
[9] Aspects of what I’m calling ‘existential centrality’ have been researched empirically. Schumaker (1992), for instance, examined religion’s connection to critical life areas such as sexual adjustment, depression and suicide, anxiety and fear of death, self-esteem, rationality, self-actualization, meaning in life, and psychological wellbeing. Other areas of interrelation include: aging (Idler & Kasi, 1992; Owens, Berg, & Rhone, 1993; B. P Payne, 1990), stress and coping (Maton, 1989), AIDS, death and anxiety (Franks, Templer, Cappelletty, & Kauffman, 1990), community service work (Serow & Dreyden, 1990), and alcoholism (R. A. Johnson and Griffin-Shelley, 1987),. Clearly, the potential scope of religious faith with respect to areas of fundamental individual and social concern is quite broad.
[10] Representationalist accounts have been extensively defended, e.g., in Fodor (1975, 1981, 1987, 1990), Millikan (1984, 1993), Dretske (1988), and Cummins (1996).
[11] As we’ll see, it may not be so bad after all.
[12] Even worse, in the religious case, there is a Being to whom one will be held accountable—‘in this life or the next’, as it were.
[13] Sometimes the expression ‘cognitive distortion’ is used, but I tend to avoid it, since it seems to conjure up the image of an intrinsic mental defect or built-in flaw.
[14] Of course, existential centrality is by no means exclusive to religious belief. (In other words, it is distinctive of, but certainly not unique to, religious belief.)
[15] Another way to put the point is to say that we would have an “a fortiori obligation” to do so.
[16] Some clinical psychologists caution against a rigid challenging of a client’s religious beliefs. I agree, especially if the rigidity in question implies inflexibility and an unwillingness to work in cooperation with the client in the process of critical evaluation. Such an approach closely resembles CA.
[17] See the hypothetical example (‘Rick’) below for an illustration of the potential utility of narrative therapy in addictions counseling for religious clients. For helpful resources on narrative therapy, check out http://www.narrativetherapycentre.com. For an excellent discussion of the interrelations among cognitive dissonance, discrepancies, ambivalence and motivation to change, see Miller & Rollnick’s (2002) Motivational Interviewing (especially pgs. 3-30).
[18] This point connects to our ethical obligations with respect to dishonesty—which, recall, is not simply a matter of telling lies but omitting what one believes to be both true and clinically relevant.
[19] We also need to reinforce and sustain motivation, but the target goal in the preparation stage is not to build (additional) motivation—indeed, this stage presupposes sufficient motivation.
[20] Note that the same objective criteria apply to ‘well-formed treatment goals’, as emphasized in the Solution-Focused model (Insoo Kim-Berg & Miller, 2001).
[21] Since I can’t give it the full attention it deserves (something that would require a separate project altogether), I’ll limit myself to a brief glimpse at the strategy I take to be most applicable to the case at hand. For those with an expertise in narrative therapy, I apologize for any oversimplifications etc.
[22] Note that this strategy can also be effective with clients who have been disillusioned by the 12-step model’s insistence that addiction is an incurable disease that is intrinsic to an individual’s nature. Granted, unlike Rick’s story, which seemed to imply that Rick himself was responsible for at least the part of his intrinsic dysfunction, the 12-step model claims that while we are responsible for our recovery, we aren’t responsible for our disease. (There are still problems with such a view, but I’m simply distinguishing it from one aspect of Rick’s story.)
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