[In Susan & Gavin Fairbairn (eds). Psychology, Ethics and Change. London: Routledge & Kegan Paul, 1987]

Psychotherapy and 'Change': Some Ethical Considerations

David Smail

However obvious and tiresome it may be to do so, one must acknowledge at the start of any discussion of psychotherapeutic matters that there is no such 'thing' as psychotherapy, and that therefore generalizations about 'it' have to be made with caution. This is particularly the case in present times, when we are witnessing an explosion in psychotherapeutic and counselling procedures of all kinds. In much of what follows I shall be criticizing the conceptual basis upon which the - often implicit claims for the effectiveness or value of various kinds of psychological therapy are made, and there is little doubt that such criticisms apply more to some varieties than to others; I shall not, however, differentiate between them unless I feel that any particular type of therapy (there are literally hundreds) merits special exemption from my criticism. I shall include under the banner of ‘psychotherapy’ even those approaches - for example the behaviour therapies - which have often been contrasted with the 'dynamic' and 'humanistic' approaches, since, while they may differ in many other respects, they all tend to share certain ethical as well as technical assumptions concerning the nature of psychological distress and its amelioration.

I am not for the purposes of this chapter concerned with what psychotherapy 'is' or how it operates in the sense of what correct scientific analysis of its processes and procedures might reveal. What I am concerned with, since they are clearly of considerable ethical significance, are the grounds, explicit or implicit, upon which therapists justify their activities, and the functions which, however unconsciously, the psychological therapies are coming to serve in our society.

There seems to be little doubt that the therapy industry is currently enjoying a boom. What was once a relatively esoteric set of procedures, practised by a small profession whose members were for the most part regarded by other professions and the public at large with, if not awe, then suspicion or amusement, has rapidly become a familiar and much more respected and 'credible' feature at all levels of the social scene. The jargon and the 'techniques' of therapy - much of them having spread from across the Atlantic have penetrated the popular culture far beyond the more traditional field of mental health, so that, for example, spheres of business and management training, and even leisure pursuits (evening classes, etc.) have become saturated with ideas about psychological approaches to 'stress', 'relationship problems', and so on. Somehow or other, a demand for therapy has arisen which a small army of therapists, counsellors and consultants is falling over itself to meet. This is a matter of some surprise to those of us who struggled for years to defend psychotherapy against the hostile criticisms of a ‘scientific’ community which seemed never to give an inch. Suddenly, it appears, we are the victors in this war without ever having to our knowledge won a single battle. The explanation of this seeming paradox must lie, I think, in the fact that our battles were fought on the rational grounds of evidence, whereas the war has been won through a shift in the (largely economic) interests of society. It no longer suits anyone very much to question the scientific validity of the psychological therapies, while it is in the interests of most to assert their social validity as more or less self-evident.

It is, I think, indisputable that so far nobody has been able to demonstrate to anybody's satisfaction but their own that any form of psychotherapy 'works'. In other words, and despite prodigious efforts on the part of research workers and their production of a huge and voluminous literature (for a summary of some of which see Garfield, 1978), there is no consistent evidence that the individual who approaches a psychotherapist in the hope of losing his or her particular psychological burden will thereby be likely to do so. This fact is, surprisingly perhaps, not one which has been found unduly inconvenient or embarrassing by therapists themselves, who, as long as it seemed to matter, were able to find a number of reasonably convincing arguments to the effect that psychotherapy is too complex a procedure to be judged in terms simply of whether it works or not.

However, the fact that nobody can show consistently and to the satisfaction of the scientific community that psychotherapy works does lead one to ponder the grounds upon which it could be justified. The 'does it work?' question was fended off by the profession long enough for people to lose interest in asking it, so that now psychotherapists are able either to assume or to assert the effectiveness of their procedures without too much fear of contradiction, and indeed the sheer numbers of psychotherapists on the scene probably deter all but the boldest from asking so apparently naive a question; after all, if it didn't work, how could there be so many people making a living from it? However, there must be some rather more rational explanation for psychotherapy's success, if, as I am sure is still the case, that success is not based on its ability to 'make people better'. (I should point out at this stage that there are those who question seriously the possibility, and even the desirability, of psychotherapy's 'working' – e.g. Schafer, 1976 but they are few and far between.)

My contention is that the success of psychotherapy is built upon a number of expectations, assumptions and beliefs which are subscribed to tacitly in our culture, as much by patients as by therapists, and which continue to support a belief in the curative power of psychotherapy in the absence of any objective evidence for it. The reason that such a belief continues to be sustained in the face of this lack of confirmation is because the assumptions and expectations which underpin it serve interests other than those which bear simply upon the effectiveness or otherwise of psychotherapy. Before discussing these tacit assumptions and expectations further, I shall first consider briefly the explicit justifications, such as they are, which tend to be put forward by psychotherapists for their practice.

The psychotherapy literature is not without its soul-searching aspects, but for present purposes it is, as it were, the public posture of psychotherapy which is of interest. Though some - perhaps even quite a few - psychotherapists may, in the comparative seclusion of the conference room or the pages of learned journals, be prepared to confess to doubts about the efficacy of their procedures or the validity of their techniques, they are scarcely likely to emphasize such doubts to their clients, to whom they present a much more confident front, if only by virtue of their very attachment to a professional institution. In fact, psychotherapists tend to justify their calling by means of two fairly distinct forms of rhetoric, the one technical, and the other professional.

I can think of no established and widely known school or variety of psychological treatment which does not appeal for its validity to an elaborated body of technical knowledge, and probably also an established technical procedure whereby that knowledge is applied to therapeutic ends. Psychoanalysis has its infantile fixations and complexes, its defence mechanisms, its transference neuroses and interpretations; behaviour therapy has its stimuli and responses, its contingencies of reinforcement, its procedures for desensitization, implosion, etc; Rogerians have their necessary and sufficient conditions for personality change; Kellians their construct systems and fixed role techniques - and so on, the list is virtually infinite. Any psychotherapist worth his or her salt will be able to offer you an account of your difficulties and what needs to be done about them in the concepts and language inculcated by the school to which he or she belongs. Since, as has been said, there is no compelling scientific justification for any of these approaches, one has to acknowledge the rhetorical nature of their conceptual language, at least as this is applied to therapeutic procedure, and it is surely no surprise that in just about every case the rhetoric is a technico-scientific one, for this is the form of rhetoric which has most 'credibility' in our culture. (I should state categorically at this point that I do not in any way wish to imply conscious charlatanism on the part of therapists, who for the most part are quite as, even if not more, gullible than their clients when it comes to being impressed by rhetoric.) The justificatory rhetoric favoured within any culture, where it is not supported rationally, presumably becomes no more than a kind of superficially plausible mask for the interests it serves; in this way the technical rhetoric of psychotherapy has, as I shall argue in a little more detail presently, more in common with magic than with a truly scientific spirit of enquiry.

The professional rhetoric made use of by psychotherapists is even more crudely persuasive, inasmuch as it relies for its effect upon an oblique appeal to what ought to be, but are not necessarily, professional virtues. Thus great emphasis may be laid on the thoroughness of training within a given school of psychotherapy, or the stringency of its selection procedures, or the impeccability of the qualifications it confers. The more exclusive the therapeutic club, so to speak, and the more rigorous the procedures through which one may be accounted a fully trained, paid up and approved member, the more confidence, one might reasonably think, might the public have in one's therapeutic prowess. Once again, however, this simply assumes the validity of the procedures in which therapists are trained. In the field of psychotherapy there are many different therapeutic schools with many, mutually incompatible theoretical allegiances, and many different forms of training. They cannot plausibly all claim the technical effectiveness their professional structure implies; the evidence, as far as it goes, is that none of them can.

It appears, thus, that the official rhetoric of justification for psychotherapy is far too thin to account on its own for the success of the therapeutic enterprise. What, then, does account for it?

Psychotherapy, in fact, serves a number of purposes. These are not only the purposes which can, as it were, be identified from within therapeutic theory and practice themselves, but include the wider social, moral, and political purposes which can be detected as maintaining the therapeutic enterprise from without. I do not intend to try in this chapter to give an exhaustive account of all the purposes psychotherapy serves, but to concentrate on two or three which have particular significance for the ethics of psychotherapy. These purposes, then, operate at different levels and in different contexts, and thus serve different ends. I shall argue that psychotherapy covertly, and partially, fulfils a need for love, by making use of a tacit expectation of cure (which in turn rests on a conscious but irrational faith in mechanism and an unconscious belief in magic), and serves an ideological view of human distress as arising out of the conduct and perceptions of the individual.

The interesting thing about all these purposes is that they are more or less inexplicit, as indeed are the interests of the therapists themselves (about which I intend to say no more here than is already implied in the discussion of justificatory rhetoric). It is a commonplace of individual psychology to observe that a person's account of his or her conduct need not and most usually does not bear any convincing relation to the actual reasons for it. On the whole, however, we do not extend the same scepticism to the official accounts given of their activities by professional bodies, especially those claiming a home within the scientific community. I suspect, though, that the accounts given by individuals and collectivities are extremely similar in being, often, rationalizations (persuasive rhetorics) of the barely perceived interplay of their own needs and interests in relation to those of the wider social context.

The principal service performed by broad-spectrum psychotherapy is in the provision of a commodity which is becoming increasingly scarce in our society - that is, love. (I have argued this point in some detail in Smail, 1984.) It would certainly not be fair to accuse all psychotherapists of performing this service entirely surreptitiously or covertly, and several therapists have avowed this aim and function quite openly, seriously and movingly (see, for example, Suttie, 1960). However, what they have not nearly so widely recognized is that by supplying love as a professional service they turn it into, precisely, a commodity. Therapists who write about the 'deeply meaningful' nature of the 'therapeutic relationship' tend to sentimentalize and obscure what is in fact a commercial transaction which has quite close parallels to that involved in prostitution. I use this analogy not to shock or denigrate, but merely to puncture humbug. I do not wish to say that psychotherapists should not provide loving attention to their clients, nor that to do so is dishonourable or unnecessary, nor that they should cease taking money for it. (Neither am I for the abolition of prostitution.) I merely wish to invite ethical reflection upon the nature of a society in which the provision of love becomes increasingly a matter for paid professionals.

A situation which practically all forms of psychotherapy offer is one in which the individual may, regularly and for reasonably long periods of time, receive the undivided attention and concern of someone who is solely concentrated on his or her life and the difficulties he or she experiences. Whatever the technical expertise claimed by therapists, they are inescapably involved as individual people in the 'therapeutic relationship' and most, nowadays, readily acknowledge the part played in therapy by their making available to their clients their own personal resources of concern and consideration. At a time when the battle between the sexes is raging as never before and families are, perhaps not entirely without reason, regarded by many as hotbeds of mutual hostility and rejection (see, for example, Lasch, 1980; Kovel, 1984), it is perhaps not surprising that therapists should find such a ready response to their offer of care and attention.

The most obvious ethical question to be asked about the therapeutic provision of love concerns the extent to which it actually is therapeutic. The ideal answer would be that the increase in the client's confidence and self-esteem which being the object of the therapist's attentive concern brings, enables him or her to take stock anew of the circumstances which necessitated therapy in the first place and to summon up the courage to tackle them. I would certainly not want to argue that people cannot be transformed by love (though neither am I sure that they can), but I would, without claiming it to be impossible, want to urge caution over extending such a possibility to therapeutic 'love', which is but a pale imitation of the kind of committed love which may transform, and, coming too little and often too late in the client's life, may simply prove addictive.

It may be that for many people in our society the only place where they can to some extent unburden their sorrows and find a sympathetic ear for the expression of the distress and despair of their lives is in the therapist's office, and many therapists count among their clients people they expect to be seeing for the rest of their lives for roughly this purpose. There is no problem about this as long as therapists are absolutely clear about what they are doing, and do not disguise it behind a mystifying technical rational or a grandiose programme of 'change'.

The provision of a kind of loving attention is not necessarily the only thing which psychotherapy may actually achieve; it may also be the case that in the course of therapy clients find that the nature of their predicament becomes clarified. Most of the more respectable schools of therapy do embody a theoretical psychology which to some extent informs their practice, and there is often involved in this an assumption that an aetiological theory automatically implies a therapy, i.e. that knowing what is wrong leads quite naturally to a technology of treatment or process of cure. It is this kind of assumption that I want to challenge here, since there seems to me in fact to be no reason to suppose that knowledge of cause leads automatically to prescription of cure, and one should not confuse a plausible or convincing - or even 'true' - psychology with an obvious programme for therapy.

The theoretical grounds of most 'dynamic' forms of psychotherapy, for example, strongly emphasize the importance of understanding symptoms of distress and experience of psychological pain or difficulty in terms of the client's personal history, and indeed it would be barely rational to deny that the way a person is now must depend to quite a significant extent on the course of his or her previous life and experience. On the other hand, there is absolutely no reason to suppose that laying bare the history of this experience will necessarily make any difference at all to the experience of psychological pain which it has engendered. Many therapists, of course, do recognize this, but even so the therapeutic potency of 'insight' is still something widely assumed.

A more obvious, but on the whole not frequently acknowledged function of investigation of the meaning of the client's distress in terms of his or her history is the demystification of 'symptoms', and it is presumably this that Freud meant when he talked of replacing neurotic misery with ordinary human unhappiness. However, not many patients, I submit, embark upon psychotherapy in either the hope or the expectation that they are about to swap one form of pain for another, and though my own view is that to do so is in fact not an unworthy ethical aim, it is one which should form an explicit part of the therapeutic procedure. To put the argument succinctly: the theoretical psychology informing many dynamic approaches leads to the demystification of symptoms, not to the cure of distress, and whether one regards this as 'therapeutic' or not is a question for ethical discussion and decision, but may not be assumed.

It is, then, perfectly possible to give a convincing theoretical account of how people come to be suffering the way they are without this having any necessary implications for what the individual may do about it. This may seem obvious, but in actuality most therapists and most patients do not seem to hesitate all that long at this logical hurdle. There are, I think, two reasons for this. One is the unquestioning confidence we have in technological solutions and our readiness to conceptualize ourselves as machines, and the other is an implicit belief in magic which is far more widespread than is usually thought. These two issues, in fact, may not be all that separable from each other: it may not be only in the popular imagination that technology is magic. For present purposes, however, I do not wish to attempt to substantiate this argument (a fuller treatment of which is to be found in Smail, 1984), but merely to address briefly each side of the equation in relation to psychotherapy.

The 'technological attitude' leads to the assumption that once you know what's wrong with something you can almost certainly put it right. As long as one is dealing with machines and mechanical systems (which is, of course, the proper province of technology) this does indeed seem a fairly warrantable assumption, for the obvious reason that machines are man-made, and, indeed, presumably made by men who knew how they made them, and therefore know how to repair them if they go wrong. It thus follows quite naturally that if psychologists and psychotherapists construct mechanistic models of human experience and conduct they will be able quite legitimately and without further thought to approach psychological 'dysfunction' with the same technical confidence as the electronics engineer approaches the faulty computer. And this, of course, is precisely what happens. Even those 'humanistic' therapies which loudly disavow a mechanistic approach, in fact almost without exception treat human beings as if they were mechanically constructed and understandable in terms of analogies with (depending on the history of the particular theory) steam engines, telephone exchanges or digital computers. In order to belong to the 'scientific' club it is virtually out of the question for psychological theorists to characterize people in any other way, and it is impossible to belong to any other club while expecting at the same time to gain professional 'credibility'. So saturated is our culture in a fundamentally mechanist world view that we can virtually not envisage any other which is not 'unscientific' and therefore invalid. Therapists must be experts in the mechanics of human nature. If we had to recognize that this is not the case, I suspect that our whole conception and understanding of therapy would change (for example, frighteningly regressive though the suggestion may seem, ‘expertise’ might have to give way to wisdom).

The upshot, anyway, is that human experience comes to be seen as being acquired mechanically, and as therefore in principle alterable mechanically. The 'program' can be replaced, experience erased and re-recorded in the manner of magnetic tape. It is in this kind of tacit belief that, for example, the plausibility of 'insight' lies.

Standing behind the 'expert' (and to some extent infusing him with his power) is the soothsayer or magical healer. Even very recently (within living memory) psychotherapists were more likely to be regarded (by the sympathetic) as possessors of essentially mysterious powers than as technical experts; the 'miraculous' and 'fantastic' achievements of technology have since transmuted and absorbed the magic of psychotherapeutic knowledge and given it new, technical form. But still there is the basically magical expectation (and every practising therapist meets it in his or her patients over and over again) that the patient will emerge from the therapeutic encounter transformed. In this sense, the therapeutic process, the 'talking cure' in which patient and therapist sit exchanging words in the emotionally charged sanctum of the latter's consulting room, begins to suggest a continuity with the incantations and spells concocted in the witch's parlour. In each case, the idea is that, without having done anything significant, and with no alteration to his or her world, the person emerges free of the burdens which prompted the initial consultation. There are, of course, also religious parallels - that of psychotherapy with the confessional being the one most frequently invoked.

These, then - our faith in technology and our belief in magic are what support our confidence in the power of psychotherapy to cure our ills. What we actually get, if we are lucky, is comfort and demystification. I want again to emphasize as strongly as possible that I do not see comfort and demystification as unworthy or invalid goals for psychotherapy. I only want to point out that these are virtually never explicitly avowed as major goals by therapists, and never anticipated as the major fruits of therapy by their clients. I do not want to say that psychotherapy cannot promise or achieve anything, but only that too often it promises to achieve too much, i.e. more than it can deliver.

To say that psychotherapy does not 'work' in the way that it is by and large anticipated that it should is not to say that people do not or cannot change in the course of their lives, but rather that they do not change in the way that the practice of psychotherapy tends to imply. In other words, people do not change by contemplating their histories or shuffling the contents of their heads or sitting for specified periods of time in earnest discussion with therapists or learning to see things in a new light. Nor do people change by having flashes of insight, turning over new leaves or making resolutions. All of these activities may contribute to a process of change, but they do not in themselves constitute significant change.

People live in bodies which inhabit the world. It is essentially these two facts which therapeutic mythology tends to overlook. By treating people, at least implicitly, as consciousnesses (or indeed as unconsciousnesses), wills, sets of constructs or cognitions, or computer programs, therapeutic approaches tend to disembody the person, and hence to fail to take proper account of the organic nature of human psychology. The experience which underlies the development of symptoms of distress is acquired bodily, organically, and not abstractly or mechanically. In this way, new ways of feeling, perceiving or 'behaving' must be built on and grow out of old ways, which are themselves not erased by the acquisition of new experience. Rather than being repaired like machines, people have to be cultivated like plants. The terrifying sense of draining subjectivity which, for example, so often underlies the 'symptoms' of anxiety is a physical response learned in actual bodily engagement with the world and the other people in it. The roots of anxiety, in this way, are embedded in the living tissue of the body, and cannot be eradicated by purely mental or verbal activity; cannot, in fact, be eradicated at all. Thus the fundamentally anxious character does not through any process become fundamentally non-anxious, but, through further bodily experience of the world may come, with much effort and hard work, to learn new ways of dealing with the world. But the old ways cannot be forgotten any more than any other form of experience (for example of language or other learned abilities and competencies) can be forgotten. Magical rebirth is not a possibility from a psychological standpoint, whether through psychotherapy or any other process.

Just as therapeutic mythology tends to disembody people, it tends also to dislocate them, i.e. it conceptualizes them as essentially out of relation to a world, with the result that a tremendous overvaluation is placed on the role of 'mental' operations in the explanation of conduct. Recognition of this kind of difficulty for psychology more generally was of course the main contribution of behaviourism, which, in developing the concepts of behaviour as response to stimulus, the 'contingencies of reinforcement' entirely outside the individual's skin, etc. tried to redress a situation in which psychology threatened to cut the person off from the world altogether. But, of course, in taking this line, behaviourism attempts to solve the dualist dilemma by embracing too tenaciously one of its horns and becoming so purely physical that it can offer no account of the kinds of concepts (intention, meaning, interpretation, etc.) it has banished along with mentalism. In the therapeutic arena, the difficulties caused by attempted solutions of a fundamental dualism are evidenced in the observation that behaviourists seem to leave out of account the fact that the world is experienced, while the cognitivists make the mistake of concluding that experience is not experience of anything.

In fact, though a person's distress will of course be interpreted in the context of his or her 'organic history', many of the reasons for it are to be located and understood in the social, moral and physical environment in which he or she is situated. Psychotherapy may, as part of a legitimate function of demystification, uncover the extent to which a person's unhappiness is the result of circumstances and events beyond his or her immediate control, but it cannot thereby remove them.

In so far as psychotherapy places an at least tacit emphasis on the eradication of distress as a function of purely personal 'change', it adopts an extremely demanding moral position, since it implies both that individuals are in some sense accountable for the ravages of a world beyond their control, and that to the extent that these ravages are attributable to the personal stance they have developed towards the world, they have somehow to reach inside themselves to transform their organically acquired experience.

There is nothing wrong with being morally demanding, as long as, alongside the provision of an intellectual context in which such demands can be understood, there is provided a practical one in which they can be met. Though some approaches to psychotherapy have the beginning of a theoretical psychology in which the origins of human distress can at least to some extent be traced, none so far has an adequate conceptualization of how changes may be made, and most vastly over-emphasize the possibilities for change which are open to people purely through their own efforts. Moral demands become, in my view, immoral demands if the only context they offer for their solution is basically a magical one. An even greater danger is the opportunity that what one might call the ‘psychotherapeutic ethic’ offers to those seeking support for an ideological view of social ills as personal responsibility; it is all too easy perhaps through the use of a version of the recently expressed ‘on your bike’ philosophy, to foster a view that social constraints (like high unemployment) are really personal shortcomings (like 'laziness'), and it is but a step from here to suggest that such shortcomings may be 'treatable'.

The professional interests of a rapidly growing army of therapists and counsellors most of whom entertain no other conscious aim than to help alleviate the pain of people's lives, threaten in this way to mesh with the ideological interests of a fundamentally repressive political order which seeks to promote a view of, in particular, economic failure, and the distress it gives rise to, as personal inadequacy.

I am afraid that I shall be misunderstood, on the basis of the foregoing, as arguing a number of things which in fact I am not. I am not saying, and I think have not said, that psychotherapy is useless, or immoral, or politically repressive. I am suggesting that, through becoming unthinkingly over-extended, it is in danger of being ethically misused or abused. In order to guard against such misuse, psychotherapists must beware of slipping into the role of established and technically sound professional experts, must rigorously examine the intellectual basis of their theoretical position, and above all question the grounds upon which they conceptualize the process of change.

REFERENCES

Garfield, S.L. (1978), Handbook of Psychotherapy and Behaviour Change, New York, Wiley.
Kovel, J. (1984),'Rationalization and the Family', in B. Richards (ed.), Capitalism and Infancy, London, Free Association Books.
Lasch, C. (1980), The Culture of Narcissism, London, Abacus.
Schafer, R. (1976), A New Language for Psychoanalysis, New Haven and London, Yale University Press.
Smail, D. (1984), Illusion and Reality: The Meaning of Anxiety, London, Dent.
Suttie, I. (1960), The Origins of Love and Hate, Harmondsworth, Penguin.

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