From the author ‘David’:
“The impression of healthy competition among a wide variety of counselling and therapy approaches that this picture may give is, in my view, in itself misleading, for in fact they all share one very important assumption. What’s more, despite the appearance of radical contrast, they share it also with psychiatry. This is the assumption that psychological disturbance has its origin within the individual, whether the latter is conceived of as mind or body.
The principal causes of emotional distress are in this way thought to be traceable either to the person’s physical structure—genes, biochemistry, etc.—or to their psychological makeup. It follows logically enough from this that cures will be effected, or at least adjustments made, by ‘treating’ those physical or psychological aberrations within the individual that careful diagnosis reveals.
The arguments in the psychological camp are not over whether this basic picture is right, but rather over how psychological aberration might best be understood: whether as a mechanical difficulty on the one hand or as a moral or aesthetic difficulty on the other. For example, is someone’s ‘obsessive-compulsive disorder’ the upshot of a faulty interpretation of experience reflected in neural connexions in the brain (an essentially mechanical problem), or is it the result of morally unacceptable repressed wishes overwhelming the person’s ‘ego’? Many approaches to therapy – especially perhaps those falling within the so-called ‘humanistic’ schools that flourished in the second half of the last century – have an at least implicit model of how human beings at their best ought to be, whether as ‘fully analyzed’, experientially ‘congruent’, ‘self-actuating’, and so on. These set up aesthetic standards against which it is all too easy to be found wanting.
This concentration on internal faults and shortcomings leads almost inevitably to a subtle or not-so-subtle emphasis in treatment on individuals’ ability to change themselves. Having, through patient enquiry, clarified how the patient came by his or her problems, the therapist can in the last analysis only leave it up to the individual to make the necessary changes. Therapy thus becomes a matter of leading horses to water, but whether they drink or not is up to them.
Over the years, the psychotherapies have attempted to deal with this difficulty in various ways, often by trying to represent the movement from diagnosis to cure as somehow automatic. The psychoanalyst’s interpretations, etc., will lead through the process of ‘insight’ to an adjustment of the internal, unconscious processes that were causing the trouble. At the other extreme, it will be incumbent on the client of cognitive therapy actively to undertake the learning regimen prescribed by the therapist such that the offending ‘cognitions’ may be ‘restructured’. It’s usually not long before the inadequacy of these ideas (principally, the observation that they don’t work) leads to the conviction that nothing much can be achieved without the patient’s willed co-operation in the process of cure. This boils down in the end to the frank acknowledgement that whether or not someone gets better is a matter of their own ‘responsibility’, and indeed the notion of ‘responsibilty’ became a central pivot of humanistic approaches.
Now I think we’re operating with a very strange, essentially pre-scientific model here, one in fact that has more in common with seventeenth century magic and astrology than it does with modern scientific medicine (not that that’s always everything it’s cracked up to be). Indeed, I think one could call the philosophy that underlies most present-day psychotherapy and counselling one of ‘magical voluntarism’. Distressed people, that is to say, are supposed, via a short but perhaps intense period of interaction with a practitioner, to transform themselves into people no longer feeling distress.
Now a lot of people, I’m sure—and especially counsellors and therapists—will see nothing much the matter with this, but in my view it does begin to suggest that there is something really rather important that we have been leaving out of the picture. We seem to have been assuming, that is to say, that ‘there is no such thing as society’—or that if there is, it has no particularly significant role in determining how we feel.
With a few honourable exceptions, the idea that people suffer psychologically because of the way the world is has not greatly preoccupied mainstream psychological and psychiatric theorists. Even though those who have taken society seriously may have enjoyed a voguish success in their time (I’m thinking of the obvious names like Alfred Adler, Erich Fromm, Karen Horney, Harry S. Sullivan, R.D. Laing), their fate seems to be to end up in the margins, where also are to be found minority disciplines like social psychiatry and community psychology. It is not that, throughout, there have not been profound, even compelling, critiques of therapeutic orthodoxy, struggling to bring to the fore the surely not contentious notion that social organizations and structures, political, economic, ideological and cultural influences can and often do adversely affect the individual’s subjective well-being. The cause for wonder, in my view, is that such observations and critiques have been, ultimately, so consistently and persistently ignored. Why should this be?
To understand this, I think one has to have recourse to a set of concepts that do not normally figure prominently in our everyday thinking about ‘motivation’, etc. Popular psychology (i.e. the assumptions we take for granted when we start to think about why people do things) does not really allow us to think beyond processes like desiring, willing, intending, deciding, and so on: all mediated by inferred internal structures like unconscious impulses, cognitions, beliefs, fantasies, etc., etc. At the centre of our picture is always the individual—thinking, wanting, deliberating, willing, choosing. And then, at long last, acting!
This kind of picture not only receives strong intuitive endorsement from everyday introspection (in most people’s experience it seems obvious that that’s the way it must be), it is also extremely convenient.
For a start, it is convenient and reassuring for the person-in-the-street to believe that they are at least potentially in control of their own fate. Even if the going’s a bit rough at the moment, at least we can in principle choose to live how we like and be who we want. If we’re suffering, the means to relief lies ultimately in our own hands.
It is also convenient for those who have a controlling influence over our lives (e.g. politicians, big business) that we should interpret any personal pain that results from their activities as the product of defects in our individual makeup. Many are the patients I saw during the cruel Market take-over of the 1980s and 90s who attributed their subjective distress to personal weakness and inability to keep up with the exacting demands of modern life and work.
Last but not least, it is convenient for those who make their living from the treatment of personal distress for their clients to believe that it can be alleviated through the intervention of a ‘trained professional’.
What we have at work here, I suggest, is an interweaving of interests. And it is precisely concepts like interest that point us towards explaining both our conduct and our consciousness in social rather than individual terms.
Outside the hermetic bubble in which theory and research in the psychological therapies have been conducted, a great deal of thought has gone into trying to account for what we do and feel in terms of the social structures and processes in which we are embedded. Sociology, philosophy, even to some extent neuroscience have all contributed to a view of the person as social being, constrained to act within the parameters set by power and able to experience ‘self’ only within the strict limits determined by culture and political economy. On this view, we are not the free agents we think we are, able to choose the kind of life and experience we want, but rather, so to speak, atoms in social space-time whose sense of freedom is largely illusory.
My experience of practice as a clinical psychologist is far more consonant with this society-based understanding than with the individualistic theories of the psychological therapies, and it is this that I have tried to elaborate in my writing over the years. All I have time to do this evening is to sketch out very briefly, and of course inadequately, what a theoretical alternative to the current orthodoxy might look like.
First let me say very quickly how I think ‘clinical experience’ reveals the inadequacies of current approaches.
People who come for ‘therapy’ don’t necessarily ‘change’ even when they:-
a) can see the need to (i.e. ‘have insight’)
b) desperately want to (are ‘fully motivated’)
c) try really hard and courageously to (are fully ‘compliant’)
Although a therapist can be an important source of comfort and support, the beneficial effects of that solidarity very often do not extend beyond the period of treatment itself.
What does—sometimes—permit people to change tends to be alterations in their circumstances outside therapy: new or different personal relationships; new or altered work, educational or financial opportunities; improved living conditions (e.g. housing); developments in their social lives opening up new areas of solidarity with others.
The ‘sometimes’ above is important—early social injury is not necessarily reparable whatever later environmental opportunities may arise: we are embodied as well as social creatures, and what happens to us early on may get indelibly ‘wired in’.
The alternative to what I have called ‘magical voluntarism’ is to investigate and elucidate the influences which hold us in place as social entities. Those which are closest to us—the influence of family and immediate social environment—may be relatively easy to identify, but they will in turn be held in place by ‘distal’ influences that are much more difficult to spot, and of which individuals affected may indeed be entirely unaware. It is important to remember too that these distal, fundamentally shaping influences may be a long way from us in time as well as in space.
Society, I suggest, is structured by power, and power is transmitted largely through the operation of interest. A decision made in a corporate boardroom may end up as the most intimate private pain of, say, the call centre worker who loses her job as the result. The biggest mistake she can make is to attribute her despair to her personal inadequacy. (It is, of course, fairly easy to see where responsibility lies in a case such as this, but there are many others where the chain of influence is very much harder to identify.)
What ‘clinical experience’ teaches, in my view, is that we are as individuals not freely-choosing originators of action, but rather the hosts of influences which impinge upon us or flow through us. There is no faculty of pure ‘will power’ upon which we can call in times of trouble, and what we are able to do about adverse circumstances will depend upon the powers that are or have been available to us in the outside world. The almost irresistible feeling of free choice and moral independence that subjectively accompanies our everyday activity is an illusion that stems from our singular embodiment (that is to say, we can only be directly aware of what is happening physically and psychologically inside us, and so we accord it undue causal prominence). This illusion is endlessly exploited by those who benefit most from it. Individual blame, for example, finds a ready reception in the tender conscience cocked and primed to receive it.
Let me just end by saying that I don’t regard any of what I’ve said as invalidating the practice of counselling and psychotherapy per se, though I do regard it as cutting back fairly radically the kinds of claims that can legitimately be made in the name of ‘treatment’. My own feeling is that ‘therapy’ needs to recast itself as a way of helping people to understand their predicament in terms of the social environment in which they find themselves. In some important respects this is a liberating project – one that frees the person from a burden of personal responsibility for their distress, even if it does so at the cost of denying them magical powers of self-cure.”