[Clinical Psychology Forum, no. 28, 2-10, 1990]

Design For a Post-Behaviourist Clinical Psychology

DAVID SMAIL, Nottingham Health Authority

The closest clinical psychology has got to having a theoretical position is probably that denoted by the self-contradictory term "cognitive behaviourism". This, however, is less of a theory than a rag-bag of empirical findings strung together loosely, if at all, by methodological doctrine (for a thoroughly disheartening recitation of these see, e.g. Brewin, 1988).

Clinical psychology has thus never developed a theory truly its own, but has tended to borrow eclectically from a range of academic, humanistic and psychodynamic neighbours. This is a pity, because clinical psychologists are in a very privileged position from an observational point of view and could have made more than so far they have of the opportunities open to them for theoretical reflection on what they see; their position in a public health service provides a range of insights and experiences not readily available either to academic psychologists or to practitioners of private psychotherapy, and while such insights and experience are often implicit in the practice of clinical psychology, they have not so far been articulated in an adequate theoretical form.

With hindsight, it now seems that behaviourism as a theory was simply too limited to account for the phenomena it addressed itself to and as an ideology had become too corrupted by its own power to preserve any real scientific integrity. Power corrupts ideas as much as it does people, and though behaviourism provided a handy ideological base for clinical psychologists to become professionally involved in the treatment of so-called mental illness, its protagonists, with the exception perhaps of B.F. Skinner and one or two of his henchpeople, never really made any attempt to address the serious - indeed probably fatal - objections which were raised against it by psychologists such as Sigmund Koch (see, e.g. Koch, 1964).

However, now that behaviourism has become a dead duck as far as academic psychology is concerned and in therapeutic psychology so compromised by cognitive approaches as to become unrecognizable, I begin to feel an unexpected loss. For in its most radical form behaviourism stood for something not to be found in any other psychological theory: an uncompromising environmentalism. During the development of behavioural theory the profound significance of this environmentalism quickly became lost in the power politics of scientific legitimation (issues of "objectivity", measurement, etc.) and we now seem to have forgotten that behaviourism's situation of psychology in the world, i.e. as the product of an outer reality rather than of some kind of inner space, was the most fundamentally challenging thing about it.

What rendered behaviourism an unreliable intellectual vessel was not its environmentalism, but its dogmatic scientism and its identification with simplistic ideas about conditioning. What finally sank it was its inability to handle concepts of human experience and meaning. Because these could not, without extraordinary intellectual contortions, be unpacked into concepts of "contingencies of reinforcement' etc., clinical behaviourists finally abandoned themselves to the first shaky life raft that came along, which happened to consist of the kind of "cognitive" psychologies we know so well.

Most psychological theories contain strong environmentalist elements, for example, psychoanalysis certainly does not deny that the person's world shapes his or her psyche, but it has never been unambiguous about this and indeed often retires into mystifying ideas about "fantasy", "transference" and so on which serve to give a definite, if rather incoherent, substantiality to "inner worlds". Cognitive approaches, however, in emphasizing the centrality of the ways in which people see their worlds, are about the least environmentalist of all and in espousing them behaviourism has, in my view, lost its one claim to serious attention.

By "environmentalism" I mean the view that people's "inner worlds", their psychology and indeed their emotional distress, are the products of and directly traceable to the influences of material structures of the "outer world". In the clinical field, therefore, the person's psychological difficulties may be understood as the result of current and historical influences upon them. This much, it seems to me, is almost forced upon anyone who has spent any significant amount of time with people in a large public health service such as the NHS (though someone who had developed a psychotherapeutic approach in the private sector could easily overlook the materiality of the context of emotional pain).

The environmentalist or materialist stance rules out the possibility that reality could be constituted by things like attributions, constructs or cognitions, though it does not rule out the use of such terms as valid names for psychological operations: we do attribute, cognize and construct (place constructions upon) but we do not in the process bring anything at all into being (i.e. these are epistemological, not ontological operations).

In eschewing "mentalism" and all its works, and in insisting on seeing behaviour as explicable in terms of influences upon "the organism" of forces located outside it, behaviourism set out on a radically environmentalist path followed by virtually no other psychological theory; if it had not become ossified in the rigidities of its own dogma it might have proved theoretically. very much more helpful to clinicians than in fact it has.

But environmentalism alone is not enough to underpin an adequate clinical psychology. When it comes to considering the relation between person and world there are two aspects to any clinical psychological theory: the first is aetiological, the second practical. The first asks how human distress arises, and the second what one is going to do about it. In the first, aetiological, aspect radical behaviourism is alone in taking an uncompromisingly environmentalist stance; in the second, practical, aspect it shares with every other theoretical approach in the field an assumption that human character is malleable and that human society is given.

It is of course not surprising that therapeutic psychologies should focus on assisting people to change in such a way as to make their occupancy of the world more comfortable. After all, the psychologist or psychotherapist is confronted by an individual who is seeking help in order to feel better. It seems self-evident, then, that it is the individual who is to be worked on by the therapist and it seems inescapable that the form this work should take is to try to change the person so that they achieve a better fit with their environment. But there are two difficulties with this "therapeutic assumption". The first is that it can be ethically dubious; the second is that it may be false.

There is nothing about the therapeutic assumption that conflicts with environmentalism, and, as I have said, behaviourism shares the therapeutic assumption with pretty well all other therapeutic approaches. In doing so, however, it has perhaps fallen particularly foul of ethical objections. This is not because there is any essential difference between the behaviourist therapeutic assumption and that of, say, psychoanalysis, client-centred therapy, transactional analysis, Gestalt therapy or any other therapeutic schools, but because the therapeutic assumption combined with the simplicities of conditioning theory results in some very blatantly and superficially manipulative approaches to people's difficulties. It is probably this aspect of behavioural therapy more than any other that has driven practitioners into the arms of competing schools. These, however, are probably just as manipulative, but only less blatant about it; at bottom they are no less ethically questionable than behavioural approaches.

For in assuming that human character is malleable and human society given (the essence of the therapeutic assumption), a very definite ethical stance is implied and has indeed proved to be one which has given quite a bit of discomfort to "radical" therapists over the years. This discomfort has usually been expressed in doubts about "sticking plaster" remedies, moulding people to an oppressive society, etc., but on the whole has been unaccompanied by any clear idea about what alternative therapeutic strategies might be applied. However, important though ethical arguments are, I think there are even more fundamental empirical difficulties with the therapeutic assumption.

While there is nothing essentially inconsistent in associating an aetiological environmentalism with the practical idea that character is malleable and society given, such an association does entail some rather strange conceptions of the nature of the environment. On the one hand, we have psychologists analysing people's problems in terms of the events of their life history and the influences of their current circumstances, on the other we have the spectacle of their trying to change the person by providing him or her with a kind of therapeutic micro-environment in which the operation of these forces is somehow magically suspended. Various ways have been conceived of describing this therapeutic micro-environment e.g., as the "therapeutic relationship", the "transference", the "corrective emotional experience", "reparenting", "contingencies of reinforcement" such as "desensitization" and so on. In every case we see the therapist struggling to conjure up a set of micro-environmental forces powerful enough to bring about lasting changes in the ways people relate to their worlds.

Now it seems to me, and I suspect it may be the experience of many psychologists and psychotherapists, that this is a bit of an unequal struggle. Therapeutic micro-environments look pretty puny when compared to the kinds of wider environmental difficulties which are bearing down on most of our patients. Years of abuse of parental power, deprived cultural, economic and educational circumstances, limited or non-existent opportunities to find reasonably remunerated and (perhaps most important) useful employment, at least semi-entrapment in destructive personal relationships, debilitating living circumstances, and so on and on. Some or all of these serve to shape distress and attend people still as they emerge from the consulting room. Small wonder, perhaps, that we tend to drift into one form or another of magical idealism which implies that if people try hard enough to see worlds as different they will actually be different.

But quite apart from its desperation, such idealism flies in the face of everyday experience, consideration of which should alone cast doubt on our assumptions about the malleability of human character. Just as a matter of commonsense observation, people do not change very easily, even in the most trivial of ways, unless the environment provides them with powerful reasons to do so. We are the organic creatures of space and time - we form in and are held in place by a socially structured, spatio-temporal world whose relative constancies all but determine that we act, speak, think, perceive and feel this year very much as we did last year. In the face of these relatively constant and very powerful influences, psychotherapeutic encounters are likely to be pretty limited in their impact.

Now this, you might say, is precisely a reason for taking human society as given, i.e. as something psychologists can't do much about. But I do not think so. It may indeed be true that the psychologist cannot do much about human society, but society is certainly not given in the sense that it is not the construction of human beings, and in any case the fact that it is hard to influence doesn't in any way imply that human character, once formed, is any easier to change.

What therapeutic psychologies have failed to confront, then, are the practical implications of an environmental theory of distress. We cannot combat the influence of the wider environment through the creation of artificial micro-environments and we cannot magically alter people's worlds by getting them, to think about them differently. So what can we do?

I think we have to hang on to an essentially scientific faith that if we follow through an unflinching examination of the implications of our observations and experience we may well find useful practical paths opening up to us. If we put aside the mystifications of the likes of Kleinian psychodynamics, we may discover wide unanimity among psychologists that emotional and psychological distress is the result of environmental influences. If we are then able to show (and in this process there would certainly be more debate and disagreement) that human character is significantly changed only through significant changes in human society, we may end up with a clinical psychology something along the lines I shall now attempt to describe (reference to figure 1 may help to orient the reader in some of what follows).

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The theoretical onus on clinical psychology is considerably heavier than on academic psychology, which is not necessarily confronted by the task of having to understand the whole person in the context of the whole spatio-temporal, social environment. Academic psychologists can occupy themselves in various corners of investigation and speculation concerning relatively minute aspects of psychological functioning, but clinicians cannot afford to ignore the almost dismayingly wide implications of their subject matter if they are to say anything sensible or helpful about it. Though some clinical psychologists have broken new ground both theoretically and practically (notably Holland, 1988), mainstream clinical psychology has for the most part failed really to come to terms with the scope and importance of its own undertaking, and would in fact need to extend its theoretical foundations very much more widely than it has (e.g. into territory conventionally regarded as more sociological than psychological) to do itself justice.

A thoroughgoing environmental psychology has, of course, to posit some "thing" which the environment is the environment of: a variable dependent on all the independent environmental variables which surround it. This "thing" has in my view to be the human body. It is from the interaction of the body with the environment that human psychology is formed; to start with minds, or persons, or even behaviours rather than bodies at the centre of the environment would be to presuppose what an environmentalist psychology must set out to prove, because the concepts "mind" or "person" assume the action of a socializing environment (which is why in fig. 1 "environment" is shown as stretching into "mind"). It is the fact that we all share bodies remarkably similar in remarkably many respects which makes possible all our human undertakings and understandings. It must be the body, the one necessary condition of being human, which is "given" at the centre of an environmentalist clinical psychology.

It is debatable how much psychology need concern itself with the workings of the body. Clearly, individual genetic differences in physical structure cannot be irrelevant to the way environmental influences will be registered and mediated, and neurology too is likely to be a neighbour of some interest, but an environmental psychology will be able to get a long way just by treating the body as a black box. We cannot do without it; we know a lot about how being a body feels subjectively; we can safely assume that we share that knowledge with other similar bodies. What is of absolutely central significance to the clinician is that it is the body which ultimately registers pain, and it is essential to recognize that, in the absence of indications to the contrary, a body's registration of pain doesn't necessarily mean that there's anything wrong with it. Indeed, if a body does not register pain in painful circumstances, we would question whether something was wrong with it.

We do not have dogmatically to insist on substituting "body" for "mind" or "person" however, since bodies quickly become persons and develop minds and there is no harm in talking about minds and persons as long as we remember that these are the results of body-world interactions and not entities independent of their worlds.

Bodies and minds, and persons develop in a world which is structured by power. Some of this is natural power but most of it, for most people, is social power. I follow Runciman (1989) in distinguishing between three types of social power: coercive, economic and ideological. A clinical psychology cannot afford to ignore any of these.

Power is exercised upon the developing person in a complex variety of ways, and the person also, of course, learns to exercise what powers become available to him or her in the form of action. These processes are mediated conceptually, perceptually, linguistically, and so on, in a bewildering infinity of ways - many of them purporting themselves to be psychologies. In this sense, of course, everyone is a psychologist and subscribes to a theory, implicit or explicit, about what makes us tick.

For present purposes I have almost grotesquely to cut through the subtleties and intricacies of the interaction of the embodied person with the power structures of the social world to sketch out very broadly and crudely the variables which are likely to be of particular concern to a clinical understanding of adults. In order to try to frame these considerations in a reasonably manageable and familiar way, I shall place them under three main headings: the causes of distress; the facilitation of change; implications for help.

The causes of distress

The questions to be answered here are: what kinds of environmental influences operate on individuals to generate the types of distress we encounter? and how do they operate?

What I suggest might help is to rearrange the fairly familiar observations of clinicians into a schema which takes as basic the operation of (social) environmental influences. These may be divided into two kinds: proximal influences and distal influences. The first will be more familiar to psychologists and the second to sociologists, but both need to be taken into account in any clinical psychology.

PROXIMAL INFLUENCES

Examples of proximal influences operating on individuals would be family relations, personal/ social relations, domestic circumstances. All these, of course, are structured by a time dimension and their operation may become, so to speak, organically embodied in the individual forms commonly referred to as expectancies, sets, traits, conditioned responses, transference phenomena, etc. (few of which in my view do justice to the extraordinary tenacity and stability of much historically acquired experience).

DISTAL INFLUENCES

Examples of these would be the influences of culture, class and ideology. If clinical psychology has anything to thank "Thatcherism" for, it may be the clarity with which the operation of societal forces such as these have been revealed as generating pain and distress in individuals. Not, of course, that Thatcherism has been the first political ideology to wield power over the lives of individuals, but it has done so so ruthlessly and with so little attempt at disguise that few perceptive clinical observers could for long remain in doubt about the source of their patients' troubles.

As well as taking account of distal influences in themselves, it may be important for the clinician to note that many proximal influences are derived from distal ones. For example, a full understanding of the operation of power within family relations is unlikely to be possible without a consideration of the legitimation of such relations within the wider society (Lacan's modifications of psychoanalysis come to mind in this respect; see for example, Frosh, 1987).

No psychology, of course, is going to rest content merely with noting the operation of social power upon the individual; it is likely to concern itself centrally with studying how this process is mediated. It would thus be very much the business of a clinical psychology to explicate the mediating function of cognitive-emotional processes such as dreams, metaphors or symptoms (e.g. "obsessionality"), but it should take care not to limit its analysis to such mediating processes themselves, for example as the arbitrary or pathological phenomena of "internal worlds"; it must always bear in mind the two poles of its enquiry, at one end the "given" of the intact human body, at the other the infinite variability of the environment.

Facilitation of change

It goes without saying that psychological help is principally concerned with the question of change. The main effect of a radically environmentalist theory, i.e. one which takes seriously the spatio-temporal powers of the wider environment, is to shift attention from trying to effect change from within the person or by means of the manipulation of artificial microenvironments, to focus on the power relations between people and their worlds. In order for the person to change, i.e. in order to be able to feel differently, in particular to feel less pain or distress, something has to change in the structures of power by which his or her world is organized.

Most of the major changes which overtake us in the course of our lives are probably ones over which we have little or no control. For obvious reasons, these are the ones likely to cause us particular distress. You cannot choose where and when you are born, who your parents are, the shape of the social and cultural influences which bear upon you. How much you can change, therefore, will depend upon how much you can control things, i.e. what powers are available to you.

The extent to which people can change themselves, then (that is to say the extent to which they can alter their relation to the world), will depend on the extent of their access to powers or resources originating in a material reality (external environment). Such powers or resources assume a variety of forms (Bourdieu, 1984), for example: economic, cuitural, leducational, ideological (including class advantage), physical (socially valued bodily characteristics which may be invested in or traded for social power of various kinds), social ("relationships", solidarity, association with powerful "others", etc.)

Possession of or access to such powers will often appear superficially as personal characteristics or qualities, which is perhaps why psychology has so often and so easily been deflected into a postulation and examination of "inner worlds" and immaterial personal resources. For practical purposes it will certainly not always be meaningless to talk as if there is a faculty of, for example, will, or of exercising "responsibility", etc., but an accurate psychological understanding will always need to unpack such concepts into an analysis of resources external to the individual.

Implications for help

An adequate clinical psychology developed somewhere along the lines indicated does not have to (indeed could not) identify itself with treatment or therapy. In fact, of course, clinical psychology is not, and never has been synonymous with "treatment". In its infancy it had virtually nothing at all to do with treatment, and though in recent years the emphasis has shifted very markedly onto individual "cognitive-behavioural" therapies, there are still many clinical psychologists whose work takes them either more "inward" towards the body (as in some aspects of neuropsychology) or more "outward" into the environment (usually environments limited by age or handicap to an extent which make them in fact realistically amenable to alteration). Even in the conventionally "therapeutic" sphere, however, an environmentalist analysis of distress will frequently have to acknowledge that it cannot change what it can explicate. In so far as direct work with individuals is concerned, access to effective powers on the part of both patient and psychologist is necessarily limited.

In thinking about how people may be helped, the implications of this limitation on treatment are however by no means as catastrophic for an environmentalist clinical psychology as might at first be feared. What happens, rather, is that the scope of such a psychology is changed - in fact broadened - to encompass a wider range of social relevance if not of application.

It is the business of a clinical psychology to take as its point of departure the individual person in distress. If it is to avoid the mistake of earlier attempts of earlier environmentalist psychologies in trying to cure the ravages of the wider environment by manipulating artificial (and inefffective) micro-environments, its conceptualization of change (i.e. of the alleviation of distress) must map more closely onto its conceptualization of cause. That is to say, it must in its ideas about change take account of the same environmental influences as are postulated as causing difficulties in the first place.

In this respect, then, an environmentalist clinical psychology should envisage the alleviation of distress as requiring help at any or all of three possible levels: (1) personal, (2) social, (3) political.

Clarification consists in establishing with the person what the nature of his or her difficulties really is. This, of course, corresponds to a version of "insight' and while frequently (but perhaps not always) a necessary step in coming to grips with the person's predicament, is certainly not one sufficient to its solution. The point of clarification is to arrive at as accurate a description as possible of what the past and present environmental factors are which give rise to the person's distress. Knowing what the trouble is will often be essential to doing something about it.

Encouragement is the process through which the psychologist helps the person to achieve that which may be done. This means encouraging people to bring to bear available resources to alter the structure of powers by which they are, so to speak, held in place in their world. Obviously enough, the greater someone's resources, the more the power available and the more he or she is likely to be able to effect such alteration. Hence, no doubt, the frequent observation that better resourced people ("YAVIS") respond better to psychotherapy.

Comfort is a powerful factor common to almost all forms of humane provision of help. Association with a relatively and benignly powerful "other" who for a given unit of time takes an exclusive interest in one's welfare is almost always experienced as empowering and comforting. A feature of such comfort is that it is dependent on contact with the comfort-giver. If one considers therapy as a time-limited, cost-effective "treatment", the efficacy of comfort is likely to be seen as a potential liability since it may well be (like tranquillizers) dependency-creating and addictive. If, on the other hand, one sees comfort-through-relationship of this kind as (like food) one of life's necessities, its provision through professional therapy might, in the absence of any other widely available source, have very startling implications indeed (good news for the therapy and counselling industry: profound questions about the nature of the society we live in).

The kinds of environmental influences involved at this level are likely to shade most proximally into the exercise of more private powers at the personal level just discussed and most distally into powers operating at the political level. What distinguishes them from the latter is the greater likelihood of their being manipulable at least to some extent through the contact of the person with professional helpers (not necessarily psychologists of course), and from the former their greater dependence on more or less formal involvements with social groups or institutions.

If psychologists are unable to influence directly the effects of political power on their patients (and one would certainly not wish to see the remaining shreds of the ordinary citizen's political role becoming appropriated by any professional caste), making available analyses of how the exercise of political power can become transformed into the experience of personal pain would certainly not be irrelevant as a theoreticalcontribution to be made use of by the citizenry as it saw fit.

I would like to finish by spelling out what seems to me the most fundamental and significant implication of a radical environmentalism in clinical psychology. This is that it up-ends the usual way in which psychology, psychiatry and psychotherapy have conceived of the relation between individuals and their worlds, namely that the former have to be fitted to the latter, or that, as I put it earlier, the former are malleable and the latter given.

It is, in truth, much more nearly the other way round. People can be changed only through environmental change. If we have their interests at heart, we should seek with them ways of changing their worlds such that they become more comfortable places to inhabit. Rather than seeing our patients as manipulable deviants from unassailable norms, we might come to see them as characters in search of public structures which are generous enough to accommodate them, appreciative enough to profit from their talents without exploiting them, caring enough to maximize their opportunities and minimize their handicaps, honest enough to acknowledge their private pain and take account of the lessons it teaches.

References

BELL, L. (1989) The politics of clinical psychology in adult mental handicap. Clinical Psychology Forum, 20, 3-5

BOURDIEU, P. (1986) Distinction. London and New York: Routledge

BREWIN, C. (1988) Cognitive Foundations of Clinical Psychology. Hove and London: Lawrence Erlbaum Asscciates

EDWARDS, G. (1989) Finding the Broad Street pump: primary prevention in mental health. Changes 7, 2, 61-64

FOUCAULT, M. (1979) Discipline and Punish. Harmondsworth: Penguin

FROSH, S. (1987) The Politics of Psychoanalysis. London: Macmillan

HABERMAS, J. (1987) The Philosophical Discourse of Modernity. Cambridge: Polity Press

HOLLAND, S. (1988) Defining and experimenting with prevention. In S. Ramon with M.G. Giannichedda (eds) Psychiatry in Transistion, the British and Italian Experiences. London: Pluto

KOCH, S. (1964) Psychology and emerging conceptions of knowledge as unitary. In T.W. Wann (ed.) Behaviourism and Phenomenology. Chicago: University of Chicago Press

RUNCIMAN, W.G. (1989) A Treatise on Social Theory, Vol II. Cambridge: Cambridge University Press

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