One of the most important organizing principles of a person’s life, traditionally, was felt to be a clear sense of values — ideas to believe in and to be devoted to, a set of ideals more important than an individual life, which therefore could be relied upon as a way for an individual to make choices. This notion of values comes perilously close to the notion in CBT of beliefs, which have the potential to go wrong occasionally and lead an individual astray into a state of emotional disorder.
One difference is that values are acquired in social ways, from such sources as family life, education and religion. Arguably, values that are shared in these ways by many people over generations are much less likely to be harmful to the individual.
Beliefs, of the kind that can go wrong, tend to be acquired as the result of individual experience. Indeed, the ones that go wrong are often hidden from other people, and social interactions do not have the opportunity to correct them.
The pioneering humanistic psychologist Abraham Maslow wrote about this in his 1959 book, New Knowledge in Human Values. I could not find it online, but part of it is quoted in his Religions Values and Peak Experience (1964), where he explains the three aspects of his belief about values (p. 85):
…the belief, first that the ultimate disease of our time is valuelessness; second, that this state is more crucially dangerous than ever before in history; and finally, that something can be done about it by man’s own rational efforts.
By “rational efforts”, he meant psychotherapy, as traditional methods did not appear to be working (p. 64):
As a matter of fact, it is possible that precisely these ultimate values are and should be the far goals of all education, as they are and should be also the far goals of psychotherapy, of child care, of marriage, the family, of work, and perhaps of all other social institutions. I grant that this may turn out to be an overstatement…
Why, then, does he undermine his own proposal by granting that it may be an overstatement? Because the content of the proposal is unimportant. Maslow’s purpose was to sneak psychotherapy into that list of the basic institutions of society: education, child care, marriage, family, work. All this talk of values was a smokescreen. His propaganda message was that society as a whole should adopt psychotherapy as something everyone experiences.
That was back in the 1960s, and of course it didn’t happen. Psychotherapy was not adopted by society as a whole. It remains a specialized way to treat illness, and only a very few people make it a mainstay of their lives.
Maslow is widely claimed to have said, or written:
We may define therapy as a search for value.
I was not able to verify this quotation by finding its source, but it fits well in the context of Maslow’s beliefs about values. If only, he is really saying, we could redefine therapy as a search for value, then therapy would have a place as a core institution in society alongside the family, religion, etc.
Well, this widely-alleged quotation turned up last week in an article in Psychiatric Times. Psychiatrist Cynthia Geppert made a case for categorizing certain mental illnesses as disorders of values: Evaluative Disorders. She makes her case quite well, if you don’t think about it too much.
In one case study, a woman who has anorexia nervosa (AN) gets a lower grade than she hoped in an exam. She responds by restricting her diet for several days. Geppert suggests that this can be seen as a disturbance in the way the woman evaluates things that happen to her, and that this is a general characteristic of the illness:
Individuals with AN have a pathological need to disvalue positive input and to overvalue negative stimuli.
In another case study, a man is severly alcoholic. Comparing the importance of drinking in his life to the importance of his wife and children, he says:
Drinking is what matters most to me.
And again Geppert suggests that this disturbance in the ability to value is a general characteristic of drug addiction, where there are found to be:
…the overvaluing of drug reinforcers, the undervaluing of alternative reinforcers and deficits in inhibitory control for drug response.
The practical difficulty with Geppert’s proposal, though, is that diagnosing an “evaluative disorder” in a particular patient requires a deep analysis of the patient’s thinking. By the time a clinician has got that far with the patient, diagnosis is almost worthless because treatment is already far advanced. The practical purpose of diagnosis is to be able to make a reasonably useful classification of the disorder immediately the patient presents with a problem, not late on in treatment.
Geppert is confusing the classification of disorders for diagnostic purposes (which necessarily happens at a very early stage in treatment) with identification of the mechanism of the disorder (which can happen at a very late stage in treatment).
Furthermore, the classification “evaluative disorder” does nothing to help the patient. For example, in the case of the woman with AN, even if it is true that the way she values events is pathological, she and her therapist still have to understand the basis of her “need to disvalue” so that she can do something about it.
The theoretical difficulty with Geppert’s proposal is that it supposes “evaluation” to be a general ability that can become disordered. This is problematical. There certainly are patients who might be said to evaluate some things in their lives wrongly, but those same patients might evaluate other things perfectly sensibly — most other things, indeed, including very complex things.
For example, the alcoholic man who values drinking more than anything else in his life might still have admirable convictions about moral, political or religious matters and about other aspects of the life of his family.
The “evaluative disorder” proposal shows how difficult it is to define diagnostic criteria in a practical and logical way. Clinical practice depends on diagnosis being applied quickly and accurately so that an early decision can be made about how to treat the patient.
One way in which diagnostic criteria go wrong is when they fail to take account of factors that affect the early decisions made about a patient’s treatment. A case in point is the problem of reactive depression, which is not an illness but a normal depressed state that occurs as a reaction to life events. Diagnostic criteria must take account of life events that could lead to reactive depression, because otherwise people who are not ill would be subjected to medical treatment.
Diagnostic criteria can also go wrong in the opposite way, when they do take account of factors that have no effect on treatment. A case in point is the problem of post-traumatic stress disorder, which, for the purposes of treatment, can occur after any kind of traumatic event. But current diagnostic criteria insist that the trauma must have included the threat (not necessarily to the patient) of death or serious physical injury. As a result, people who are genuinely ill after some other kind of trauma might not receive appropriate medical treatment.
Geppert’s proposal would go wrong in the second way. It would mean that patients are examined on their ability to value, when that information does not affect their treatment.
So it turns out that statements about personal values in the context of psychotherapy are misleading. A fundamental of therapy is that it exists to help people to function better in the context of their lives, a context that includes their personal values. But therapy does not exist to create that context in the way that Maslow once envisaged. Therapy continues to have a much more limited role.
In the same way, statements about complex cognitive processes (like valuing) in the context of diagnosis are misleading. A fundamental of diagnosis is that it exists to help therapists to function better in their initial understanding of their patients. But diagnosis does not exist to create that understanding as a whole. It has a much more limited role.
It is intriguing to see a psychiatrist who makes the first error in relation to values, also make the second error in relation to diagnosis, because both errors come down to mistaking a part of a thing for the whole.