[Universities Psychotherapy Association, Review No. 7, 35-42, 1999]

PATIENTS’ POWERS AND THE IMPOTENCE OF PSYCHOTHERAPY

David Smail

Psychotherapy - leaving aside behavioural approaches, which in any case cannot properly be said to constitute psychotherapy - has as far as I can see no account to offer which is both rigorous and coherent of how it brings about change in its clients. If one is to explain how someone moves from state A to state B, one must surely invoke some kind of dynamic of change, i.e. the application of some form of power capable actually of supplying the required momentum.

Freudians, it’s true, at least addressed this issue centrally, and even today might if pressed wheel out the to me somewhat mysterious concept of ‘cathexis’ as a way of explaining how someone might move from a ‘neurotic’ to a more ‘commonly unhappy’ form of adjustment, but that aside it is left for the most part to the enquirer’s own imagination to fill in the gaps between the explanation of ‘pathology’ and its subsequent rectification.

For the most part this doesn’t seem particularly to have troubled the majority of therapeutic practitioners, their clients, nor indeed those simply, so to speak, consuming therapeutic ideas at a distance. After all, it looks simple enough: your therapist lays before you the origins of your condition - so that, as clients so often say, you know what ‘it’ is - and you just get on with adjusting your life accordingly.

Now this would be absolutely fine if that’s what actually happened in therapy. If everything went according to plan and clients acted positively on the insights afforded them through therapy to stop misinterpreting their experience, the motives of others, etc., and generally tidy up their acts, we’d probably never even need to think about what it actually is that makes behavioural change possible.

But the trouble is - and I think this is borne in particularly strongly on those working in public health services - that’s not how it always happens. Indeed, in my experience, not how it often happens. What seems more commonly to be the case is that therapist and patient arrive at a brilliantly illuminating formulation of how s/he got to be in his/her particular predicament, but the latter finds that, despite valiant effort and earnest desire, s/he fails miserably to put matters right.

It’s important to note at this stage that most approaches to psychotherapy fall fairly distinctly into two parts: the development of some kind of account of how the client’s predicament came about, and then the setting into motion of some kind of therapeutic technique or procedure for changing things. The first of these constitutes in my view psychotherapy’s greatest contribution to our understanding of the generation of distress. Patient enquiry into the person’s current predicament and its antecedents in his/her social and familial background does indeed further our understanding of how distress comes about very considerably. But when it comes to changing things with the individual client, we hit difficulties.

For a start, what are we trying to change? Well, since all the therapist has in front of him or her is the client, the effort has usually been to change clients themselves in some way or other. But how? In fact, of course, the very notion of professional therapy implies some kind of technical mechanism of change. The client pays to have something done to him or her which will ease the pain which prompted consultation in the first place. If the therapy ‘works’, then no one is too unhappy and no one enquires too closely into why it works and just assumes that it was indeed the therapeutic technique. However, when, as is so often, it doesn’t work, then questions have to be asked.

In the earlier days of psychotherapy, insight seemed a pretty potent concept. However, it was of course quickly noticed that of itself insight didn’t bring about change. In response to this, and rather naively, different types of insight were invoked: ‘intellectual’ and ‘emotional’ insight, with the latter thought to be more potent, though God knows why. Still no change.

Now an element of irritation with recalcitrant clients starts to creep in, and there may be talk of ‘resistance’ or ‘dependency needs’, etc. What seems to be happening here is an implicit recognition that therapy isn’t at all a technical procedure which somehow operates on clients, but actually requires some kind of effort from them. Some forms of so-called ‘humanistic’ therapy make this quite explicit. What clients need to do is ‘assume responsibility’ for change. Clients could be forgiven for seeing this as a colossal piece of cheek. I can’t think of another profession whose members justify taking their clients’ money by telling them to sort their problem out themselves.

Now the difficulty here, I believe, is that underlying our notions of change is a very simple and unsophisticated view of how conduct is powered. Indeed, this view seems to be indistinguishable from the unspoken assumptions of popular culture. Roughly, this is that the individual sees what’s needed and applies will-power to bringing it about. It’s probably in so-called cognitive therapy that this kind of notion is most conspicuous: behavioural change is brought about through billiard-ball-like events going off in people’s heads. ‘Cognitions’ are structured or ‘re-structured’, decisions get made, will somehow gets in on the act, and the person is shunted into activity.

On this model - which, as I say, seems to lurk at the heart of most approaches to therapy - the therapeutic process constitutes a kind of invitation to individuals to exercise their will appropriately. If they don’t, then that must be because of their own ulterior motives (the kind of therapeutic recalcitrance alluded to above) for which therapists can’t reasonably be held to account.

Therapists do of course talk about types of power other than simply will-power (indeed they don’t actually talk about will-power at all) but at the end of the day the facilitation of therapeutic gain, as well as the obstacles to it, reside in the application or otherwise of the client’s will. There may be operating in the therapeutic arena the power of ideas (although I am prepared to argue that ideas have no power), the influence of the therapeutic relationship, the potency of transference interpretation, etc., etc., but when all is said and done whether or not the client actually does anything different will depend on his/her willing the necessary changes.

Now the odd thing about all this in my view is that it is precisely the kinds of problems - the so-called pathological conditions - which clients bring to therapists every working day of their lives (well, many therapists) which demonstrate the inadequacies of the notion of will-power. Therapists know this, and that I’m sure is why they never do talk about will-power. They are the first to recognize that it is useless to exhort clients to pull their socks up, etc. Nevertheless, the concept of will nestles at the centre of their unspoken theory of human action, and that is why they end up with talk about ‘assuming responsibility’, etc. Our experience, though, is that people can’t change their conduct even when it pains them, even when they desperately want to change, even when their inability to change renders them speechless with misery, even when they struggle to change with courage and tenacity far beyond the commonplace. Psychotherapists know all this, but they haven’t yet worked out an explanation for it.

The answer, I think, is almost embarrassingly simple, and indeed quite obvious to many people other than practising psychotherapists, including in particular politicians and sociologists, not to mention the reflective lay person. The point is that the power to change doesn’t some from within, but from without. We are quite right not to speak of will-power, because in fact there is no such thing - it’s just a convenient way of referring to people’s ability or otherwise to do things. Whether or not you can do anything to make a difference to your circumstances, to acquire new abilities, etc., will depend not on mysterious powers inside you, but on the availability to you of powers and resources which have their origin in the context which surrounds you - in other words in your social environment. Admittedly, once we have acquired powers of various kinds - one thinks in particular of cultural and educational advantages, but these are by no means the only ones - they may become part of one’s embodied equipment in a way which makes it fairly plausible to speak of them as personal, or even ‘inner’ or ‘spiritual’, and they’re certainly likely to feel that way, but in fact their origin was outer, impersonal and very often linked to pretty crude material advantage. As a matter of fact we buy, or had bought for us, a lot of the personal advantages we may over time come to see as spiritual gifts or forms of virtue.

There are, I believe, two reasons why all this has been overlooked in mainstream psychotherapy. The first, though far from unimportant, need not be dwelt on for long, and has to do with professional self-interest. To be credible as a therapeutic undertaking, psychotherapy must lay claim to powers which will bring about change in its clients, who are of course for the most part individuals. I strongly suspect that it was this problem that led Freud to back off social explanations for his patients’ neuroses (i.e. real sexual traumata) in favour of personal wishes and fantasies, as documented so ably by Jeffrey Masson. Unlike Masson, though, I don’t think this represented some kind of moral cowardice on Freud’s part, but the sheer necessity to make a living. The need to make a living is after all one with which most of us get pretty preoccupied, and Freud, as his letters to Wilhelm Fliess around this time testify, was positively obsessed by it. The point is, anyway, that if therapists are to persuade clients to part with their money, they have to postulate a dynamic of change which can be controlled from within the therapeutic relationship. This leads them to pay less attention than they might to what’s going on outside the consulting room.

Which brings me to the second reason why I think psychotherapy has overlooked the significance of the social environment. This is what one might call the micro-environment of psychotherapy itself, or at least of those psychodynamic and humanistic therapists who may be credited with inventing the principal therapeutic brand names. There are two aspects of this typically to be discerned, as illustrated in the following figures.

Environment of the consulting room
Fig. 1 Environment of the consulting room

Environment of 'psychopathology'
Fig. 2 Environment of 'psychopathology'

It’s scarcely surprising that the powers operating in the micro-environment of the consulting room - those of ‘transference and ‘counter-transference’, the influence of the therapist’s personal characteristics, etc. - should have been given so much prominence in therapeutic theory, but when all is said and done these boil down to little more than the powers of personal influence. This is not to say that they are necessarily unimportant, but in the grander scheme of things they are almost certainly pretty limited.

It is also inevitable in the consulting room environment that as far as the social world does get talked about, it is likely to be in terms of those aspects of it which are, so to speak, right up against the patient’s skin. It is these aspects which are likely to be identified in the therapeutic process as principally responsible (directly or indirectly) for the patient’s ‘pathology’. There may, however, be far more important social factors at work than these, and it is perfectly possible that neither of the occupants of the consulting room has the least awareness of them.

Unless we’re talking about classical psychoanalysis, which might go on very frequently and almost interminably, the therapist isn’t around in the patient’s life all that much, and outside the consulting room, and particularly after the termination of therapy, his or her influence in the patient’s life is likely to fade dramatically. A trouble shared, certainly, may be a trouble halved, and patients are likely to respond very positively to the initial benefits of having the therapist on their side dispensing appropriate comfort and understanding. But there is a world of very much more potent influences outside, and it’s unlikely that even the most dedicated therapist can buffer patients for long against its demands.

A rather more accurate representation of the relative importance of the social influences on the client’s life would look like this.

The social environment

The most significant feature here is the large empty space labelled ‘social environment’. For what goes on in the individual’s life is not simply determined by personal experience and relationships coming into being out of nowhere. The family, the ‘significant others’, indeed the therapist him or herself, are of course not themselves free agents wilfully operating on the patient for or against his/her own good. They themselves are in turn constrained by social influences over which they have, in all probability, no control. If we try to fill out the total picture a bit more, it might look something like this:

The impress of power

The mistake that psychotherapy makes is to attempt to abstract the experiential aspect of the person on the assumption that it can be manipulated independently of the context of power which holds it in place. Certainly, as individuals, we have psychologies, meaning-systems, but they can’t simply be lifted out of us like some kind of diseased organ and replaced with more satisfactory ones. If you want to change people - and how well, for example, Margaret Thatcher understood this (so, incidentally, did Plato) - you have to change their environments.

What I’m suggesting, then, is that if one wants to get some idea of whether and how much clients can get some kind of purchase on the factors which are and have been giving them distress, one needs to shift one’s gaze from a notional ‘inner space’ (filled, usually, with all kinds of moral and aesthetic judgements) back onto the environment which, as a rule, we originally searched for the causes of their problems. The reason - or at least one reason - we haven’t done this arises, as I’ve already suggested, from our fear that this might negate the role of therapist. It might seem, for example, that it would no longer be appropriate to deal with individual people, but that we would need rather to involve ourselves with sociological or political analyses or activities. The therapist might become redundant.

However, I don’t think this is really so. Even though sociological and political analyses and activities would certainly be highly relevant to the understanding, and no doubt the prevention, of emotional and psychological distress, even though, indeed, they may constitute in principle the most effective ways of dealing with the problem, individual people in pain still need someone to turn to who can offer them an accurate explanation of their predicament and point them to whatever resources are available for its alleviation. So, how might this be done?

What we have to do, I think, is switch our ‘clinical gaze’ from the individual to the individual’s world. It is not people’s psychologies which are pathological but their worlds which are noxious. If we’re going to analyse anything, it should be the ways in which the environment damages the people who consult us.

In collaboration with Teresa Hagan in Sheffield, we’ve worked out a very simple and basic, schematic way of looking at the kinds of things in people’s environments which tend to become the focus of clinical enquiry.

Terrain of proximal powers

If you impose a very simple grid over this ‘terrain’, you can, obviously enough, turn each of the segments you’ve identified into a simple rating scale which allows you to quantify your observations.

Power-mapping

This radical shift in perspective from the person to the environment immediately renders irrelevant some of the most vexed questions of traditional clinical approaches. For example, questions of 'normality' or 'pathology' are no longer asked of people themselves, but rather of the situations they occupy, and imputations of the kinds of therapeutic recalcitrance mentioned earlier (that is to say concepts such as 'resistance', 'lack of motivation', 'inadequate personality', 'dependence', and so on) may be translated into much cooler and less morally loaded considerations of the way, and extent to which, powers and resources become available to people.

This has profound significance for the way we think about change and outcome following clinical intervention. Rather than focusing on the 'mental health' characteristics of individual sufferers, we can try to measure the extent to which they are subjected to damaging social influences (what is presumably often meant by 'stress') as well as the availability to them of powers and resources which may be exerted in their own interest. 'Treatment' becomes the process of analyzing the effects of and attempting to increase access to environmental influence, and 'improvement' is the measurement of the extent to which such attempts are successful. In this way, those aspects of the 'illness model' which have so long plagued us without our having been able to find a suitable replacement are removed at a stroke. We are not talking about 'patients' or 'treatments', we are not having to 'diagnose' people, and we are not doing 'therapy'. We are, rather, clarifying the effects of environmental damage and advising and where possible helping to marshal resources which might counteract such effects.

Another, in my view, huge benefit of this way of looking at things is that patient and practitioner relate on the same moral and epistemological level. By this I mean that there is no need - it would indeed be inappropriate - for the practitioner to maintain either a patronizing professional superiority or a mystifying theoretical secrecy or opacity. The analysis of the patient's environmental predicament and the explanation of the theory behind it can be laid before the patient with complete openness. This does not mean, of course, that normal tact and discretion should not be employed in introducing what may well in some cases be painful or delicate questions, but it does mean that the kind of pomposity and superiority which can if we're not vigilant taint the role of 'psychotherapist' are almost automatically avoided.

I have always felt uncomfortable with the priest-like or guru-like aspects of the so-called therapeutic role. Even if we manage to avoid communicating an implicit moral superiority in relation to our patients, there are often aesthetic judgements to be detected at the heart of our activities; that is to say, we frequently operate with some kind of model of how the ‘fully functioning’ human being ought to be. I don’t think this is any of our business. What we’re there for is to explain our clients’ distress and do what we can to help them (and maybe others) alleviate it. This makes our professional relationship with our clients no more complicated or mysterious than that of, say, architects with theirs. If you were having a house built you wouldn’t expect your architect to criticise your taste or call your morals into question, and, once we see that our focus is not so much the person as the person’s world, not what people should do but what if anything they could do, then we might find ourselves in a much more balanced and equal relationship with the people who consult us.

It may well be that this would be a rather less potent role than many psychotherapists would wish to settle for, but it might also be a lot more realistic. I don’t think we should be afraid to shed an illusory potency in favour of a sober realism, not least because the latter is in the long run likely to prove more helpful to our clients. Better to offer a modest degree of solidarity than a mystifying - and ultimately disappointing - form of patronage.

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