[ In King, Lucy (ed.) Committed Uncertainty in Psychotherapy. Essays in honour of Peter Lomas, pp 129-138. London: Whurr Publishers, 1999.]

A Century of Psychotherapy

David Smail

Exactly a hundred years ago Freud was anxiously toiling to make himself a precarious living with a procedure for the treatment of neurosis which, in accordance no doubt with his hopes but scarcely with rational expectation, was to become, in the eyes of many, one of the defining features of the century to come. However, towards the end of that century, one of its most prominent historians could write an account of it which makes no reference at all either to Freud or to his creation, psychoanalysis(1).

Herein lies the extraordinary paradox of psychotherapy: on the one hand it is one of the great success stories of the Twentieth Century; on the other it is so insubstantial as to become almost invisible alongside the momentous and often terrible events and influences of our times. In one form or another this paradox constitutes a seam to be found running through just about every question which can be raised about the nature and status of psychotherapy.

So far as the Western world is concerned, the paradox arises centrally from our having lived with both an enthusiastic investment in the ideology of ‘dynamic’ psychology and a contemptuous dismissal of it on ‘scientific’ grounds. In other parts of the world, particularly of course the former Eastern bloc, there was no such paradox because, in the form we understand it, there was no psychotherapy. On a global scale, in fact, for most of this century the paradox was resolved into a simple opposition: one ‘half’ of the world (the capitalist) more than tolerated a belief in dynamic psychology which was, by contrast, anathema to the dialectical materialism of the communist ‘half’.

Perhaps, indeed, this split throws some light onto the nature of our paradox. For the spectacular success of psychotherapy - never more so than at the present time - has been as a business enterprise. From early in its development psychoanalysis (and later of course all the myriad variants it spawned) gained its warmest welcome in the pragmatic, commercial culture of the USA, and in the current phase of ‘postmodernity’ it is more than anything the laissez-faire philosophy of Business which has loosened psychotherapy from the strictures of a hard-nosed scientism which could find little merit in its procedures. It can in fact scarcely be disputed that psychotherapy is enormously popular (not just its practitioners, but probably the majority of its recipients would swear by it) and at the same time devoid of any convincing demonstration of its efficacy as a form of treatment for psychological distress.

Rather than seeing that we are confronted with a paradox made almost inescapable by the cultural and socio-economic influences bearing down upon us, we have tended to view the field of psychotherapy as merely problematic, and we have tended to try to solve the problem by one or another form of partisanship. Some, for example, have sought to settle the issue by ever more rigorous and sophisticated research procedures, others by embracing a confidently unscientific assertion of the transcendent value of the spiritual. We have split into rival ‘schools’ with, at times, positively fanatical conviction in their own version of therapeutic truth. However, no matter how damning the research evidence or deep the theoretical splits, psychotherapy thrives. And the more impressive its growth as an industry, the more frantically we feel we have to show that it does or doesn’t ‘work’.

For anyone who truly wants to understand what is going on here, it is necessary to recognize that what we are confronted by is not just a problem which can, even if only in principle, be resolved, but a paradox which can be escaped only if we manage to ‘re-frame’ it quite radically. I don’t think this is nearly as challenging as it sounds, and will in fact demand of us no great intellectual sophistication. What is required, I believe, is a recognition that a) so far in our preoccupation with psychotherapy we have been influenced more by interest (of the vested variety) than by intellectual honesty, and b) that as far as ‘scientific’ understanding goes, most of the horses we have been flogging have long been dead. Further, it is precisely the interests which have been vested in psychotherapy which have fired the scientific zeal to ‘prove’ (or discredit) it, for in order to justify their making a living by their trade, therapists have for most of the past hundred years had to appeal to the judgement of the regnant intellectual power, and that power has of course been Science.

Right from the start therapists have been deeply ambivalent about the essential nature of their undertaking. In seeking to establish the ground for his enterprise Freud himself wavered between a late-nineteenth century mechanism, a barely suppressed belief in magic (see in this respect his letters to Wilhelm Fliess on the wonders of numerology(2)) and an authoritarian cult to be run by the inner circle of his beringed disciples. In fact, of course, psychoanalysis is now and always was above everything a business - an up-market brand which is careful to distinguish itself from cheaper and less exclusive forms of ‘therapy’ (a term regarded by many analysts as immediately indicative of an inferior product). Psychoanalysis, moreover, has as brand leader set the mould for pretty well all its competitors. Therapeutic schools are run more like businesses than sub-branches of science, and far from opening themselves up to a Popperian search for scientific validity, they seek to protect their hold on the market by all the forms of exclusivity known to the most insecure and self-seeking professions.

In their unremitting search for authority (‘credibility’, as our more cynical age calls it) the founders and leaders of the psychotherapeutic schools have proposed marriage to just about every available form of powerful intellectual ideology. If the phenomena of psychological distress had really turned out to be validly classifiable into the neat categories of medicine (and the temptation to adopt the medical model has never been wholly absent from the psychotherapeutic scene) they would no doubt by now have become the sole property of an exclusive and highly protected medical specialism. If the huge research efforts which have been made to wring from the data some indication of the unequivocal effectiveness of therapy had paid off to any consistently reliable extent, it is not difficult to imagine the nature of the ritual and rhetoric which would now surround therapeutic practice.

It is by now abundantly obvious that psychotherapeutic procedures are not amenable to any kind of conventional - or come to that unconventional - scientific appraisal if only because it is impossible to define ‘psychotherapy’ in any reliable way or to determine with the remotest chance of consensus what its goals should be. Having become an industry in its own right, psychotherapy research will not go away, but no coolly rational mind can plausibly expect it to come up with any real enlightenment. However, even though the difficulties with it have long been recognized by thoughtful observers of the scene, there is no doubt that science has been the scourge of psychotherapy, and there is no doubt either that psychotherapists remain vulnerable to the kinds of attack launched by H.J. Eysenck in the fifties and which find their echo much more recently(3).

It may be true that at the present time, in the ‘anything-goes’ culture of so-called ‘postmodernity’, therapists and counsellors can begin to breathe a little more easily - but this is a precarious security indeed, and, as Simon King-Spooner points out(4), the field remains exquisitely vulnerable to the first ruthless policy-maker who shows up on the political scene determined to use science to undermine the position of psychotherapy. It is this kind of scenario which makes it impossible for psychotherapists to be honest about the ethical and epistemological dilemmas and contradictions of their undertaking.

Nowhere does this dishonesty become more apparent than in the hoops which therapists prepare for themselves and (more important) others to jump through on the question of becoming a registered profession. The unceasing efforts of psychotherapists to form themselves into some kind of guild which will protect their professional interests suggest that they are unlikely to follow the advice to live and let live(5) of that minority amongst them which eschews professionalization altogether. Sooner or later the more powerful groups among the wide diversity that is psychotherapy will come up with some formula or other which establishes their exclusive right to practise, and it will be built, precisely, on power, not on reason or reality.

As things for the most part are, and certainly have been, apologists for psychotherapy have had to adopt a number of rhetorical devices to underpin their cause. For example, the scientific validity of therapy has been hard to establish, it is maintained, not because there is none, but because the scientific procedures so far used in the investigation have been inadequate; once our techniques are sufficiently refined, the proof will no doubt be forthcoming. An alternative is to dispense altogether with the services of scientific method and to invoke instead other criteria of the validity of knowledge - the mysterious East, for example, may yield suitably impressive belief systems upon which we can ground our activities. For it does indeed seem that we are, with one or two notable exceptions, reluctant to practise therapy simply as a human undertaking to be evaluated in its own terms. We are uncomfortable without an Authority.

Another aspect of the paradox: the lessons of therapeutic practice teach possibly better than any other what it is to be human, and yet when we come to explicating and grounding the experience of therapy, simple humanity is not enough. More than anyone, it is probably Jeffrey Masson - that psychoanalytic renegade so reviled by his ex-colleagues - who puts his finger on why psychotherapy cannot be professionally practised as ‘merely’ a human undertaking.

In his book ‘Against Therapy’(6), having documented persuasively enough for anyone without a vested interest some of the abuses which inevitably attend the activities of those who conduct ‘therapy’ on the basis of a supposed superior insight into what is good for people, Masson goes on to suggest that if, as might reasonably be concluded, psychotherapy can at best consist in no more than a positive, beneficial human relating, then this is not something that can legitimately be professionalized.

It is at this point that even the most honest and best-intentioned psychotherapist gets stuck and is likely to find him or herself falling in with the ranks of those who castigate Masson for his ‘nihilism’. For the most honest and best-intentioned therapists are likely to be involved in professional practice, and, precisely because of their good intentions and honesty, are likely to experience their practice as not only fulfilling for themselves but beneficial for their clients. In the light of their own experience, and however much they may agree with a lot of Masson’s other strictures, they are likely to find that in seeking to deny them professional validity, Masson is simply wrong.

But Masson is not wrong. He has indicated precisely the crux of the paradox: it does not make any sense to try to professionalize what is after all only a kind of human relating. It would be as sensible to try to professionalize marriage.

Does this mean, then, that nobody should practise psychotherapy? I don’t think so. What it does mean is that we have to reconsider the practice of psychotherapy and the role of the psychotherapist in the light of what has already been established about them from a century of intensive activity and investigation. We need to see, I think, that what we have come to consider the defining properties of professions - accreditation, training schemes, public registration, degree courses, etc., etc., - are not and could not be relevant to the practice of psychotherapy. The resolution to the paradox is to realize that psychotherapists can honourably practise their trade without being professionals. This, however, is no simple realization. It brings with it a host of implications of what would constitute the honourable practice of psychotherapy.

Psychotherapy is the distillation of certain aspects of human concern. It cannot be so much defined as indicated, discussed, exemplified. Nowhere is this done better or with greater honesty than by Peter Lomas(7), whose favourite analogy for the therapeutic relationship is that of parents and children (though quite without the paternalism that this might be thought to imply). Though many analogies can be made, and all with an element of truth - psychotherapist as parent, friend, doctor, priest, lover, prostitute - none is quite right because no other setting and purpose is quite the same as that in and for which therapist and patient meet. And because it is like no other, one can but point to and describe what happens in this setting, what are its rewards and limitations, its freedoms and constraints. All attempts at reduction, regulation, definition and stipulation fail because they try to turn the therapeutic relationship into something it is not; above all, they try to render it impersonal.

Irreducibly central to the practice of psychotherapy is the psychotherapist him or herself. This is just about the only consistent finding, consistently ignored, of the vast research literature on psychotherapy. It has been ignored, of course, because it does not fit in with the principal aim of the research effort, which is to establish a sound professional basis for therapeutic practice.

Even though the personal characteristics of your solicitor, surgeon, architect or accountant might not be a matter of complete indifference to you, you would probably not be wise to make them the first criterion of your choice of adviser. When it comes to psychotherapy, however, you would almost certainly be foolish to give overriding consideration to any other factor.

The psychotherapist reacts with the patient on the same plane of human relating, that is to say at the same moral and intellectual level. The one cannot, so to speak, encompass the other as, for example, the scientist can encompass the mentally inert data of his or her subject matter(8). This immediately introduces into the undertaking an indeterminacy which is not only practically, but logically necessary - a personal indeterminacy of the kind written about so convincingly, though in another field of course, by the far too neglected philosopher of science Michael Polanyi(9). In psychotherapy, however, the personal factor looms very much larger than in the natural sciences: it is absolutely central and overshadows the entire procedure. The therapist him or herself personally the instrument of the process of psychotherapy.

Though, again, the analogy is not perfect, this makes psychotherapy more like an art than a science. The author of a work of art brings to it a variety of unique and unspecifiable components. No doubt techniques of painting and drawing can be taught, but ‘being an artist’ cannot be taught - even less ‘being a Picasso’. The essence of being an artist is personal style. All that the leaders of the various therapeutic schools have done is describe, and then attempt - unsuccessfully - to codify and prescribe for others their own personal ways of dealing with life and relating to people. Freud, Jung, Rogers, Perls, Berne, Ellis have all tried to found professional dynasties based on what was in fact their personal style.

The absurdity of this lies precisely in the professional element. An artist might indeed become the focal point of a school of art of a certain kind, but no one in their right mind would attempt to patent the output, establish its scientific validity or set up a professional training course for its propagation. One need not quarrel with there being Freudians or Jungians or Rogerians as admirers and imitators; what is incredible is the notion that Freud, Jung, Rogers or anyone else embodied the way of therapeutic relating. This would be like asking which of Rembrandt and Goya was right.

There are lessons here which have been lost on all but a tiny minority of psychotherapists, and among that minority Peter Lomas stands out like a beacon. For example, though perfectly prepared to instruct others in his art, he has scrupulously avoided any temptation to try to professionalize it and has unswervingly insisted on its essentially personal foundation. Consistent with that position, he has been far more prepared than most to allow those personal qualities, and their interactions with other persons in the process of psychotherapy, to be, through his writing, open to inspection. Most significantly, perhaps, he has achieved this without the kind of sentimentality and sanctimony which are the inherent dangers of any such undertaking.

Rather as Polanyi establishes for even the procedures of scientific measurement, but to a far greater and much more visible extent, there are in the conduct of psychotherapy elements of the personal which cannot even be spoken. There is nothing mysterious in this, and nothing different from what happens in the indefinable play of subjectivity, the dance of the interweaving atoms of what Roger Poole called ‘ethical space’(10), which take place in almost every human exchange. I say they cannot be spoken; perhaps what I mean is that they should not be, for to speak of them is like shooting birds out of the sky or hammering butterflies to a board. However much psychotherapy may be studied and written about, much of what actually passes between therapist and patient - and probably most of the most potent influences and insights - are mediated by personal elements which there would be no point in pinning down even if they could be pinned down, because they are unique to those involved. The deadening effect of what happens when you try to transform personal style into a blueprint for psychotherapy training was well demonstrated in the Rogerian school of client-centred therapy, where acolytes’ attempts to emulate the master’s ‘reflection of feeling’, etc., quickly became reduced to truly grotesque parodies in which ‘mm-hmms’ and repetitious summaries of what patients had just said became so empty of real personal feeling as to be almost unbearably embarrassing to listen to.

It is not, I should say, that one cannot study psychotherapy and even draw some generalizations from the observations made. What one cannot do is turn such generalizations into prescriptions for the detailed conduct of therapy itself. A century of psychotherapy has no doubt taught us a lot about the components of human relating which people find broadly ‘therapeutic’ - elsewhere I have summarized these as clarification, comfort and encouragement(11). But these are not factors specific to psychotherapy: they are merely part of the outcome of a procedure itself unspecifiable in some essential respects but shared with many other procedures. Part of what makes the ‘good’ psychotherapist special are the kinds of personal qualities which s/he might well share with the good doctor, priest, parent or friend; the rest is contributed by the unique factors of the social environment of psychotherapy (which do distinguish it from the clinic, church, home, etc.).

Many of the most important elements of personal relating in psychotherapy can be read only between the lines. This is not really a disaster, and the fact that content cannot be rigidly specified doesn’t mean that important aspects of form cannot be identified. For example, though budding therapists may find it impossible to be, for example, a Peter Lomas, they may still be encouraged to be themselves. This is, however, not to say that simply ‘being oneself’ will inevitably have a therapeutic effect on others. How beneficial being oneself is will depend on the nature of the self that one is being, and while it is true that the therapist’s ‘self’ is the instrument of therapy, the constituents of that self certainly cannot be ignored.

The central importance of the therapist as person not only demolishes the prospect of therapy as profession, but also presents a huge problem for the practice of psychotherapy altogether. For, if therapists cannot be manufactured, how are they made and how may we recognize them? In an age which has come to depend on, on the one hand (though decreasingly), official credentials and, on the other, advertising and public relations hype, choosing a psychotherapist on the grounds of what kind of person s/he is becomes an extraordinarily difficult, perhaps impossible task. I cannot see any reliable way in which the process of choice could be formalized, and this because we have as a society destroyed the basis of trust upon which formal choices could be made - there are no institutions, sacred or secular, political or academic, where one can be assured of receiving the best available, informed and unbiased advice.

This leaves us with the informal channels of who we know, who’s heard of someone, who we trust personally, or, God help us, who has the most credible website. There is no formal training in how to exercise personal judgement except, perhaps, in the most rarefied and protected corners of the academic world which have managed so far to escape the effects of market forces. People depend for their knowledge and their beliefs on the machinery of persuasion of the mass media, which are certainly not run in the interests of the individual. Most ironically, the various registers of psychotherapists which have been and will be produced are likely systematically to exclude the kinds of people most suited to the practice of psychotherapy.

Not that there is any one definable type of ‘good’ psychotherapist. Whom people find helpful in trying to get to grips with their confusion and distress will vary greatly according to their own experience of life. Up to a point it may indeed be the case that ‘anything goes’ and that there is a niche for all in the market place. I have known people be significantly helped by religious fundamentalists, fortune-tellers and rabidly authoritarian medics. But it is not just a question of helping some; there is also the possibility of harming others, and it is finding rules for minimizing harm which is both so necessary and so difficult.

There is no escape from the uncertainties involved in choosing a psychotherapist, but in this it is no worse than in many other fields of human choice. For example, what goes into the ‘choice’ of a favourite artist?One is not uninfluenced, certainly, by the culture of which one is a part, but there are also indefinable personal elements involved which are felt rather than articulated. Indeed, there is an interaction in such situations between culture and person, public evaluation and private resonance, which is impossible to dissolve into its component parts. So with psychotherapy. It is likely that ‘good’ psychotherapists will have a public reputation, but it is also likely they will not be to everyone’s taste.

One thing which does seem certain is that ‘good’ psychotherapists are very, very much thinner on the ground than would be indicated in the currently booming market in counselling and therapy. I suspect that this is recognized most clearly by those themselves forming part of the industry: who would you go to if you felt in need of therapy? The answer to this question is likely again to highlight the personal element in psychotherapy. I can think of many eminent therapists I absolutely could not bear to confide in. Unlike the unfortunate user of the yellow pages, I already know who they are.

I can think of many qualities I would suggest for the good psychotherapist - experience, sensitivity, kindness, intelligence, knowledge, culture - none of which would be either necessary or sufficient as the basis of the therapeutic, but there is at least one which is both widely in evidence and absolutely fatal to effective therapy, and that is aggrandizement. Mystification, pomposity, the authoritarian certainty of the guru, moral or aesthetic superiority: these are the qualities which seem to me to militate most seriously against both the beneficial practice of psychotherapy and the furthering of psychotherapeutic knowledge. But, of course, such evils are prominent features of every human undertaking and probably always will be. In the field of psychotherapy one may know them best by their absence - again, Peter Lomas’s works are exemplary - but there is almost certainly no way of legislating against them. Human undertakings are vulnerable to all the human vices.

These, then, seem to me to be some of the lessons of a century of psychotherapy: psychotherapy is not and cannot be a profession; the practice of psychotherapy cannot plausibly or validly be accredited by training courses and university degrees; it is, above all things, a personal undertaking and cannot be reduced to a set of ‘skills’ to be transmitted on week-end counselling courses; the results of psychotherapy cannot be guaranteed.

This view of psychotherapy is of course one which is highly unlikely to survive in a world which is run according to the dictates of Business rationality, and the greatest danger is that the apparently inexorable urge to professionalize will stifle any further development of what I have called ‘good’ psychotherapy, if not kill it off altogether. The best hope for psychotherapy in these circumstances is that it can survive in the relatively informal practice of a small number of people with the nerve and the nous - as well as a number of the other rare characteristics mentioned above - to swim against the cultural tide.

Take heart! Was it ever any different? Nobody’s ever been able to manufacture wisdom.

1 Hobsbaum, Eric. 1994. Age of Extremes. The Short Twentieth Century 1914-1991. Harmondsworth: Michael Joseph, Penguin Books.

2 Masson, J.M. (ed). 1985. The Complete Letters of Sigmund Freud to Wilhelm Fliess 1887-1904. Cambridge, Mass. & London: Harvard University Press.

3 See for instance William M. Epstein, 1995. The Illusion of Psychotherapy. New Brunswick & London: Transaction Publishers.

4 King-Spooner, Simon. 1995. Psychotherapy and the white dodo. Changes, 13, 45-51.

5 See Richard House and Nick Totton (eds) 1997. Implausible Professions. Ross-on-Wye: PCCS Books.

6 Masson, J.M. 1989. Against Therapy. London: Collins.

7 See his The Case for a Personal Psychotherapy, 1981, Oxford University Press; The Limits of Interpretation, 1987, Penguin Books; Cultivating Intuition, 1994, Penguin Books.

8 In introducing concepts such as ‘the Unconscious’ some have of course tried to establish a higher moral and intellectual plane from which they can look down on and encompass the patient as an object of study. A hundred years of reflection and research have, if nothing else, at least rendered this gambit unsustainable.

9 See his Personal Knowledge, 1958, Routledge & Kegan Paul.

10 Roger Poole, 1972. Towards Deep Subjectivity. Allen Lane, the Penguin Press.

11 David Smail. 1993. The Origins of Unhappiness. London: HarperCollins.