Aristotle, virtues, and psychotherapy

Homer tells the story of Odysseus passing by the deadly Sirens as he sails home to Ithaca. These creatures are renown for the power of their songs to entrap sailors passing close to their shores. Odysseus, eager for new experiences, has his men block their ears and strap him in place while they pass the Sirens’ shore.
The account has more subtlety than might be appreciated at first glance. It is not the song the sirens sing that draws men; it is their promise of knowledge. As Odysseus passes, he hears them tell of their perfect knowledge of him: they know well his past and the pains that he has endured.

We see in the world around us the effects of knowledge — is there any problem in the real world that we do not hope that, with time, we will have the knowledge to solve? The entire external world is present to us as ready matter for our problem-solving minds. This is true for us as a culture, and it is true for us as individuals: we have highly developed problem-solving minds.

When it comes to the internal world of our thoughts and feelings the kind of knowledge that solves problems is called insight. Insight is a powerful lure. There is an assumption that if we could only figure out what’s going on with a thought or an emotion, we would be able to solve it. If one is feeling sad, one will experience the lure of insight: if only I can figure out “why” I am sad, it will go away; or if only I can figure out exactly what I did wrong, she’ll come back to me; or if I get the origins of my problems, I’ll be able to deal with people again. The benefit of this approach is that, if it works, it will probably be quick, and cheap; we have all we need to do it by just sitting there and thinking. This is what many patients seek help in doing when they come to their psychiatrist’s office — they hope that the psychiatrist will help them to think through things more insightfully, until they get cured. It’s the explicit goal of Freudian insight-oriented psychotherapy:

“Insight is the term used to describe a person’s understanding of his/her psychological function and personality. Treatment within an insight-oriented psychotherapy framework involves the therapist assisting patients to gain new or improved understanding and insight into the possible explanations for their feelings, responses, behaviors, and current relationships with other people.

It also places some emphasis on the patient developing insight into his/her responses to the therapist, as well as those that occurred with important individuals during the patient’s childhood.”

(http://www.infrapsych.com/content/general/InsightOrientedTherapy.html)

This in some cases could involve the emotional equivalent of the Socratic fallacy — thinking that life will be better if we just have more insight, just as Socrates supposedly taught (according to Aristotle) that all men will act rightly if they just had enough knowledge.

Yet this lure is the engine that drives depression, for it is what leads people to ruminate (to think repeatedly) about their failures or their feelings. It’s a big portion of what’s going on in the minds of a person with a blank stare on their face. The other thing going on is similar: worry, where one thinks that figuring things out in advance will prevent problems and anxiety in the future. (This is a big part of the force that drives anxiety disorders.) When a person is worrying or ruminating, they are trying to use problem-solving skills (and ultimately, knowledge) as a way of dealing with emotions. The unsolvable problem with this approach is that emotions are not problems, and cannot be solved.

If Freud is Socrates, then Aaron Beck is Aristotle. Cognitive-behavioral therapy, like Aristotle, does not claim that insight will produce behavior change; in fact, many times insight follows behavior change. But the bigger issue is that the ultimate goal of CBT — especially in its most current formulations (DBT, ACT, MBCT) — is living well, not having insight or feeling good (despite the unfortunate title of an early CBT work!); and so if insight and good feelings don’t help one lead a life worth living, a “good life,” then CBT is not so interested in trying to attain them.

In CBT, the emphasis is on the values that constitute a good life. Living in a way consistent with one’s freely chosen values is the ultimate goal in this therapy — called eudaimonia, or happiness — very different than the feeling of happiness which is an emotional reaction to a pleasant situation (see Learning ACT, Hayes et al, 142). This is precisely the way Aristotle describes happiness in the Nicomachean Ethics 1102a5: happiness is an activity of the soul in accordance with complete virtue, and virtue is defined as a habit disposed toward action by deliberate rational choice. In modern therapy parlance, we speak of values more than virtues, but the end is the same; and so are the means.

The Way to Virtue
In Book II of the Nicomachean Ethics, Aristotle says that the work is not meant just for contemplation, but so that we may know how to become good ourselves, “otherwise there would be no benefit from the inquiry” (1103b29); still, the work does not exactly read like a self-help book. The formula for acquiring virtue can be put succinctly as learning to enjoy the right pleasures and endure the right pains. The two stages of transition from intemperance to temperance are called incontinence and continence.

In the case of anxiety disorders, if the person fears being contaminated with feces to such a degree that they cannot touch doors in public places, we would all agree that they have disordered fear. If they think this fear is reasonable and act accordingly, they would be in the state of intemperance; if they knew it were unreasonable but still acted on the fear, they would be incontinent. This is usually where they come to therapy for help, and the first goal is to help motivate them to act against the fear, and do reasonable exposures, which is continence; and finally, after practicing this, their fears will habituate until they are themselves made reasonable, which is the essence of temperance. The emotions are made reasonable by habituating them through reasonable actions. The same applies to the emotion of desire (e.g. addictions), sadness (depression) and so on. (The divisions into precontemplation, contemplation and preparation, action, and maintenance follow precisely the divisions from intemperance to temperance in Aristotle.)

The source of emotional disorders is the person’s unwillingness to experience the unwanted emotion. To avoid feeling fear, the person with obsessions about contamination will avoid anything remotely contaminated, but they are not ultimately afraid of the contamination — they are afraid of the fear they will experience if they get contaminated.

In addictions, the person is unwilling to feel cravings for the activity or substance. Each time the craving is triggered, the person will seek to nullify the cravings and so end their painful experience.

Unwillingness to experience an emotion is the basis for the powerful effect called tunnel vision. Perhaps this is easiest to see in an addict: when strongly craving the drug, they describe the onset of tunnel vision, a recruitment of all the person’s powers of attention to fixate on obtaining the drug.

Selective Attention

To fully appreciate the power of unwillingness, we need to understand its relationship to attention.

In a study at Cornell University, a researcher went on campus pretending to be a visitor who was lost. The visitor would ask a student for directions to a building, but then in the middle of their conversation (after 15 seconds), workers carrying a door would walk directly between the visitor and the student. Another researcher, with different clothing, different voice, different height, quickly switched places with the first, while the student couldn’t see them; and then they resumed getting directions. Later they asked the students if they had noticed the change in questioner; in experiment 1, only half noticed the change; in experiment 2, only a third noticed the change.

Another study had a video of a basketball game, with one team that had white shirts, and one with black shirts; the participants were asked to count how many times the white team passed the ball. In the middle, a person in a gorilla suit walked into the middle of the court, waved at the camera, and then walked off; it was on screen for 9 seconds; half the participants did not see the gorilla.

These incidents all highlight the power of selective attention; it allows us to focus on one thing, while tuning out everything that is not salient. The part of the brain that has the largest role in this process is the thalamus — the gate controller for what stimuli reach the cortex.

The thalamus acts to help you translate unwillingness into action: it kicks you into action, so you can fix whatever thing about the experience you are unwilling to have. Maybe you have had an experience when dating or in married life: at first you don’t notice any annoying habits; but gradually one or two emerge, and you then seem to notice the habits all of the time. We notice we are unwilling to have; the more unwilling we are, the more we notice; the more we are willing to notice anything, the less we notice it. It’s a perverse inverse rule of attention.

Unwillingness is used by the thalamus to kick us into motion. The result is often so strong that we have automatic behaviors: you feel something crawling up your leg, and before you can even wonder, “What is that thing?” you’re already shaking it off. This works in real-life situations that have a quick fix, like having something crawling up your leg; but when the unwillingness deals with something inside of us — an emotion, or a thought crossing our mind — then problems start. A person unwilling to have cravings keeps using drugs; the craving kicks him into drug-seeking behavior. A person unwilling to feel hunger will automatically engage in food-seeking behaviors. A person unwilling to have anxiety will automatically avoid things that provoke anxiety, or will engage in worry (which helps them avoid the feeling of anxiety). The greater the person’s unwillingness, the more automatic the behaviors become. Unwillingness is behind every automatic behavior; the automatic behavior is an attempt at problem-solving (the problem is having a craving, hunger, anxiety).

Unwillingness to experience an uncomfortable emotion is the general trigger for automated behaviors; this means that the general solution to automated behaviors is to willingly accept discomfort. This discomfort may feel like a problem, but in reality it is part of the solution. As a person learns to approach and stay with this discomfort as they pursue their values, they cause the discomfort to habituate.

As Aristotle would point out, continence is not an end in itself. One can habituate any passion in a myriad of ways, not all of which would be useful. The true value of continence is as a stage toward virtue. Virtues are intentionally chosen for their own sake, and they give meaning to the struggles of continence. Ultimately the goal in treating OCD is not to get people to touch public door handles — the inherent value in such an act is minimal. Being able to touch door handles is itself only a goal, a concrete step that can be checked off in a hierarchy of exposures. To have meaning for the patient, it must be in the service of something with inherent value, chosen for its own sake, that the fear impeded. Somehow the person must live life more fully as a result.