Mental(izing) Health
Newsletter #4
So far, my newsletters have taken aim at the cynicism coming from right-wing pundits in devaluing “caring for others,” specifically questioning the integrity of mental health professionals, which appears to be part of an agenda of skepticism toward expertise of all kinds. I have also spent time reflecting on the need for “self-care” among mental health professionals, affirming it in a qualified sense: recognizing that efforts at self-care can backfire, and urging us to regard self-care as a constant rather than as an occasional venture. Self-care is not as easy as it is often portrayed. The question that I would like to take up today is about the relation between caring for other and caring for the self. Are we dealing with a kind of zero-sum game? Or should we hypothesize that they are they both fueled by love, unlimited and overflowing, in nature? The nonchalant response is that both are critical to our work, dismissing the assumption that a choice must be made between one or the other. Ideally a professional must develop some degree of comfort in toggling between the two; however, it would be mistaken to ignore how caring for the other and caring for the self can come into conflict.
Caring for others has a long history in Western culture (and no doubt all human, and some animal culture).[i] Traditional forms of Christianity celebrate caring about others over caring about the self with the implication that affirming the former is best accomplished by not tending to the latter. All Abrahamic religions value humility and modesty, deferential virtues that naturally coincide with being wary of investing too much in self-care.[ii] Although ancient Greek culture is regarded as the foundation of Western culture, the ancient Greeks were more receptive to self-care and seemed less impressed by the argument that caring for others is threatened by self-care. The virtue of “temperance” is illustrative: it is one of the four main virtues, which for Catholics is linked to humility; but for the ancient Greeks the virtue of “sophrosyne” is about the regulation of pleasure—how to have the right amount—not the giving up of pleasure or the adulation of spiritual over bodily pleasures.
Our culture has moved to become more welcoming to self-care—just think of how your grandparents would react to such a notion![iii] Yet, as I inquire every year in the Ethics course I teach: what can we learn from the fact that there is a word for too much concern about the self (selfish) and too little concern about the self (selfless), but we happen to lack a precise word that characterizes the right amount of being concerned about oneself? So, we might be moving in the direction of being friendlier to self-care, but a residue of cultural ambivalence sticks to the self (and cause conflict). There remains a challenge to conceptualize how we might pay attention to the self in a way that is not neglectful to others. We can easily appreciate the value of cultivating care for the self as well as for others, but we need to probe why we believe this helps us to foster well-being, how therapy can make progress in this direction, and how to understand resistance in ourselves as well as in our patients.
Everyone faces decisions that have to do with negotiating the relation to self and others, even in cultures that place greater value on social harmony over autonomy. It seems likely that people who chose to become therapists possess some degree of comfort with caring for others, but this capacity can exist in different degrees; it can be excessive, and it might or might not sync with self-care. Someone who was not curious about others and disinclined to listen would not make a good therapist, and probably made a wrong turn into the field. Most therapists, I am guessing, have had experiences of being drawn beyond professional limits because they were so worried about patients, especially in the early stages of their career. Almost all therapists have some version of feeling pulled to agree to do something, let’s say, meet at 6am, only to have the patient no-show. I am reluctant to believe, though, that therapists have one dominant personality style, and it is worth throwing into this mix a further question: how caring for others professionally can have an impact on being able to care well for others in one’s personal life?
Some patients come to therapy precisely because they find themselves caring too much about others, and not enough about themselves. As therapists, we encourage such patients to undertake self-care experiments, less focused on catharsis and more on establishing ongoing practices. There is no guarantee, though, that our patients will err on the side of caring too much about others. Indeed, it has become increasingly more likely that some patients arrive to therapy, preoccupied with self-care, but lacking, whether they know it or not, in being able to care for others. The implicit conflict between therapists who are drawn to care for others and patients who are inclined toward self-care (and perhaps even dismissive about care for others) deserves more investigation. It is also common to encounter patients who have tried and failed at self-care and arrive with the expectation that you will help them immediately, which might well conflict with a therapist’s understanding of therapy.
Conflict between caring for the self and the other also exists within the therapist. Noticing the co-regulating that was occurring with a patient in which we were both were taking turns leaning toward the camera and away from it, I adjusted myself, semi-consciously, to be in a position, mirroring the patient, which seemed to facilitate greater vulnerability. As the patient moved into deeper material, I became aware of my neck aching. Like a good parent, it seemed better to endure the situation, rather than tend to my own needs. I am not sure how generalizable such a tiny interaction like that is, but it certainly reinforces that Zoom-life brings new challenges. Still: we face struggles between caring for patients and caring for ourselves on a daily basis—whether to eat lunch for longer than 10 minutes, workout during the afternoon, pick up your kids at school (if God-willing, they actually are in school), TikTok for no good reason, or just sit alone with your thoughts.
The overlap between my language of caring about others and caring about the self and the commonly used language of relatedness and narcissism is worth pausing over.[iv] I prefer not to introduce narcissism in this context, as caring about the self is a more neutral term, and less confusing in suggesting a pathological relation to the self (the connotation of healthy narcissism makes things even more confusing). Caring about the self has greater potential to be accepted as a term that designates a positive investment in the self: not defined exclusively in terms of positive feelings, but an openness to look honestly at oneself (not to ignore disparities between one’s actions and one’s ideals) and to sustain an ongoing curiosity about and faith that one’s welfare ought to matter. No neglect toward others is implied here. I also prefer to avoid the overused term relatedness, as it has been deployed in a myriad of ways, too often as a shield against scientific investigation. I recognize that there is more to say on the topic of caring for others/self in relation to diagnosis. For now, I propose that we understand this as a grounding of personality style and entertain how it might be useful in including in diagnostic formulation and treatment.
Humans have evolved and are designed to learn from others. Moreover, thriving is contingent upon the activation of caregiving from parents. The most important recent addition to mentalization theory has been the term “epistemic trust,” which denotes the benefit for children to look to caregivers as the path to valuing social communication more generally.[v] If epistemic trust is weakened by unreliable input or turned off because of manipulation and/or abuse, then children are forced prematurely to rely on their own resources. Without epistemic trust, life will be immensely more difficult, and, thinking in terms of psychotherapy, a patient might not be able to hear anything from a therapist as germane and genuinely motivated to be helpful. Developmentally, epistemic trust yields to epistemic vigilance, when children begin to come under the influence of others outside of home, and they need escalates to discern the difference between social information that is useful or not. Mentalizing is the capacity to weigh the intentions of others, and to realize that fathoming one’s own intentions can take effort and requires flexibility and a perpetual receptiveness to consider new evidence.
Let me dwell further on how we understand caring for others and caring for the self. We can begin with the just mentioned point that having others care about you is a spur to care about oneself. So, there is good cause to question the notion that caring for others and caring for the self are separate and unrelated. An alternative way to articulate this would be that we should add being “cared about by others,” to the heretofore acknowledged categories of caring for others and caring for the self. As with the absence of a term to characterize the right amount of caring for the self, it is hardly inadvertent that being cared about by others has entered belatedly. One of the most striking examples of cultural differences about emotions is that the Japanese have a word “amae,” which refers to the pleasure one takes in being cared for by others.[vi] We seem to have opted out of having a concept that recognizes this, perhaps because it is an uncomfortable reminder of our creaturely history (Dependencies R US).
While it is not impossible to care about oneself without having been cared about (or cared about in a less than optimal way), the likely result would be some missing elements and/or distortions in the capacity to recognize and negotiate normative social expectations. Some clarifying points are in order. In recognizing normative social expectations, I do not mean to imply that everyone must defer to them: cultures vary greatly on this point. With the addition of epistemic trust in mentalization theory, we must not overlook how epistemic mistrust can serve as self-protection, where the dominant culture persists in negative representations of minorities. I also would like to emphasize that in valuing the role of caregivers, I am not assuming that that must be a mom or biological parents. As Hrdy stresses in her wonderful book, Mothers and Others, throughout the majority of human history there was room for so-called ‘allo-mothers,’ extended family and friends, who fill in and support the role of parents.[vii] The nuclear family and the ensuing singular burden on motherhood that attachment theory relies upon actually is relevant to a narrow slice of human history. It is more accurate to construe the capacity to mentalize as based in social communication, rather than secure attachment per se.
Consider the larger implications of being cared about in relation to caring about others and caring about the self. Being cared for is so fundamental because it opens the path to a richer mental life. I am suggesting that the freedom to explore self and world is stimulated by not having to be too vigilant about the intentions and actions of others. Mental space is forged, which can be utilized in multiple kinds of ways. One can internalize knowledge from outside of oneself; one can withstand frustration and even failure; and one begins to develop a measure of reflection, which can serve to aid in determining whether to be leaning toward others or staying within self-care. Being cared for, we might realize, is the fire that kindles mentalizing skills that adjudicate between caring for others and for oneself and to be able to benefit from both.
We are now in a better position to elucidate the problem with patients who arrive caring about themselves but are less adept at caring about others. Pushed into self-reliance, it is not obvious to them what they might be missing, nor what they might gain by caring for others. Moreover, such patients can feel that in being encouraged to wonder about others, they are being asked to abandon a protective investment shell they have developed (and that might even be working for them in parts of their life). They are dubious that caring about others can feel good, that is, as gratifying to them. They are suspicious that joining shared experiences will turn out to be fraudulent; from this perspective, it is safer not to take the risk.
There are many unresolved issues about how therapy can truly repair the damage of neglect or abuse, in particular, whether this must occur through the means of the therapist acting in a parental way. There is no question, though, that therapists can help to activate the experience of being cared for and that this can lead to new developments in the way one cares about others and about the self. It is a consistent research finding that the quality of the relationship is the best predictor of success in psychotherapy. However, not all mental health professionals would concur with this, and, as I shall discuss in the next newsletter, we will be facing profound challenges and provocations from technology-mediated approaches. There’s no stopping the amalgamation of humans and artificial intelligence that is unfolding, as the historian Hariri has argued.[viii] There is, we may hope, the potential to harness this for the benefit of our patients and for ourselves. As mental health professionals, I am confident that we have the will to protest, but we also need to become more assertive in demanding that our voices are heard.
[i] Focusing on Western culture is a bias of my education: not only do other cultures deserve recognition, but Western culture itself is a contested category, especially concerning its impact on other cultures. See the recent article/audio by J. Davidann, The Myth of Westernization, in Aeon (https://aeon.co/essays/is-westernisation-fact-or-fiction-the-case-of-japan-and-the-us?utm_source=Aeon+Newsletter&utm_campaign=0089016a1d-EMAIL_CAMPAIGN_2021_02_11_04_59&utm_medium=email&utm_term=0_411a82e59d-0089016a1d-70720465)
[ii] I am sketching in broad strokes here, as there are major differences within and especially among these religions, for example, relating to the body and sexuality.
[iii] Here are links to three sources from Judaism, Islam, and Christianity respectively, that stress the legitimacy of self-care: https://reformjudaism.org/self-care-not-selfish-7-jewish-reminders-caring-yourselfhttps://muslim.sg/articles/3-ways-islam-teaches-us-to-care-for-ourselveshttps://erlc.com/resource-library/articles/what-does-the-bible-say-about-the-self-care-movement/
[iv] The Notorious Sid Blatt (or NSB) uses the terms “relatedness” and “self-definition,” which has stimulated my thinking. I honor him with this epithet: he was a lover of psychoanalysis as science and art and a huge influence on generations of students, colleagues and friends.
[v] Gergely, G. (2007). The Social Construction of the Subjective self: The role of Affect-Mirroring, Markedness, and Ostensive Communication in Self-Development. In L. Mayes, P. Fonagy, M. Target, L. Mayes, P. Fonagy, & M. Target (Eds.), Developmental Science and Psychoanalysis: Integration and Innovation (pp. 45–88). London: Karnac Books; Gergely, G. (2013). Ostensive Communication and Cultural learning: The Natural Pedagogy Hypothesis. In J. Metcalfe & H. S. Terrace (Eds.), Agency and Joint Attention (pp. 139–151). Oxford, UK: Oxford University Press; Sperber, D., Clément, F., Heintz, C., Mascaro, O., Mercier, H., Origgi, G., et al. (2010). Epistemic Vigilance. Mind and Language, 25(4), 359–393.
[vi] T. Doi 1971). The Anatomy of Dependence. Tokyo: Kodansha.
[vii] Hrdy, S. (2009). Mothers and Others: The Evolutionary Origins of Mutual Understanding. Cambridge, MA: Harvard (Belknap).
[viii] Hariri, Y. (2014), Sapiens: A Brief History of Humankind. New York: Harper.