The Importance of What Psychiatrists Care About

Christopher Bailey's account of his conversation with Colin, an unhappy man who feels regret about the absence of heroism in his own life, is both poignant and evocative. The emptiness that Colin feels illustrates aspects of the human condition central to definitions of psychotherapy for the past century or so. In this brief commentary, I have three observations. First, the life of the therapist intertwines, however briefly, with the life of the patient. The light brought by the therapist may be like a candle, beacon, or flashbulb. Regardless of the therapist's strategic decisions and elected action, the patient may still end up in the dark. Second, I believe that this vignette illustrates the value of Professor Harry Frankfurt's ideas as expressed in his essay, “Freedom of the Will and the Concept of the Person.” And third, the tortuous journeys of psychotherapy may frighten and excite even the most temperate, contemplative clinician. In this third realm, where therapists create strategies for conversations about life, I also want to mention the work of Otto Rank.

We have only a glimpse of Colin's life, but Dr. Bailey raises an issue of universal importance in helping others. The concept of moral heroism dates from the stoics, but the twentieth century merged psychology, theology, and philosophy in addressing the importance of significance, self-affirmation, and anxiety.

Colin feels as though he has missed an opportunity for heroism, and Dr. Bailey is trying to help him feel better. Setting aside the technical problems imposed by a clinical setting, let us stipulate that there are two distinct aspects of psychiatric care: one is medical, formal, and biological; and the other is interactive, personal, and philosophical. With regard to the former, the psychiatrist is uniquely qualified to assist with medication, refinement of diagnosis, and remediation of illness. Regarding the latter, the psychotherapist may see the patient as an object, treated behaviorally, which is not necessarily bad or wrong, and solutions may be fairly procedural and simple. Dr. Bailey, however, sees Colin's problem as somewhat deeper than that, and I agree.

Having a theory of human nature is one thing, but being in a relationship with another person requires action as well as contemplation. Like the parable of the two monks meeting in the forest, one turns to the other and says, “I’m lost.” The other monk replies, “I am also lost!” After a moment, the first says, “I don’t know the way out, but I know some ways that don’t lead out.” The second monk thinks for a moment and adds, “Me too. Perhaps we can find the way out together.”

When Harry Frankfurt (1988) first wrote about the importance of what we care about, he observed that conscious beings (as opposed to young children, who have not fully developed the capacity for self-reflection) exhibit conflicts of will. The concept of the person, he says, includes more than the nature of our knowing (epistemology) and the matter of our behavior (ethics). Those who are uniquely human have the capacity to consider and understand what they really care about, what matters most. In an elegant lecture series he sums this up as “taking ourselves seriously, and getting it right.” His work is valuable, not only for his keen insights and observations, but also because his thought is so accessible to those of us who are not trained philosophers.

Frankfurt rightly points out that philosophy has largely neglected the study of personality, leaving that to the psychologists and social scientists. He never ventures into the world of diagnosis and treatment, and rightly so; he defines his interests narrowly and effectively, assuming for the sake of his arguments that he is describing someone not burdened by mental disease or defect. At the same time, he engages head-on the complexity of life and personal will. He offers a way to think about human will, but he does not say what we should necessarily do, nor for that matter when we should intervene, when it comes to the will of...