[The Psychologist: Bulletin of the British Psychological Society, 2, 61-65, 1991.]
At the heart of many of the best known and most influential schools of psychotherapy currently competing in the therapeutic marketplace there lies a division which gives rise to endless theoretical difficulty. This is the division between, on the one hand, the account given of how people come to acquire psychological disorder or distress, and on the other, ideas about the effective means whereby such distress may be cured or alleviated. While the former may make reference to aetiological factors in the material environment, the latter are likely to consist of procedures which, though often virtually patented through the process of an exclusive training, are derived more from constraints imposed by the therapeutic situation itself, and the expedient assumptions upon which it is constructed, than from any consistent theory about how therapeutic influence works. In this way, because knowing how someone became disturbed does not necessarily indicate how they may be "cured", a tension is set up between the aetiological and the practical/therapeutic aspects of theory.
If this tension does not always make itself sharply felt it is no doubt because those theories (the majority) which have been evolved in the context of therapeutic practice take it as axiomatic that distress is curable and, so to speak, work backwards from there. Freud's "defection" from his trauma theory of neurosis (see Masson, 1985) may provide an instructive example of the way the therapist's interest (in treatment and cure) may influence the way aetiological theory is conceived. The difficulty facing Freud was to see how the physician in private practice could alleviate the damage done to someone by sexual assault committed upon them years previously. He acknowledged this kind of difficulty (Freud, 1895) through the rhetorical device of an imaginary conversation with a patient:
"Why, you tell me yourself that my illness is probably connected with my circumstances and the events of my life. You cannot alter these in any way. How do you propose to help me, then?" And I have been able to make this reply: "No doubt fate would find it easier than I do to relieve you of your illness. But you will be able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness..."
It was not long, however, before Freud found that he could after all compete with fate: his "discovery" that the events of patients' lives turned out not to be events at all, but constructions of their internal worlds, rendered the whole business of psychoanalytic cure altogether more plausible.
Freud's resolution of the difficulty was, however, extreme, and few even of those psychotherapies which are built on the premise of the possibility of therapeutic cure go as far as to suggest that patients' traumatic pasts are the product of their own fantasy; they tend rather to have evolved somewhat haphazardly a mixture of ideas about the environmental genesis of psychological disorder with a range of procedures (conceived as technical) whose theoretical rationale, such as it is, is likely to consist of little more than a reflection of the personal style of the founder, the exigencies of professional practice and untested mythologies of "change". Therapeutic theory is thus frequently embarrassed by the inadequacy of its account of how people may in fact be changed through its patented techniques: having often given quite a persuasive account of how the ravages of a lifetime have left the patient in enduring distress, the structure erected to ameliorate that distress (usually some kind of artificial micro-environment) is held together by the force of nothing more than, for example, a "corrective emotional experience" or "warmth, empathy and genuineness" as somehow healing properties of a "therapeutic relationship". It is not so much that factors such as these are necessarily unimportant, but rather that the mode of their operation is left unanalysed, supported at most by inarticulate cultural assumptions concerning the essentially magical potency of certain kinds of relations between sufferers and healers (Thomas, 1973, provides fascinating insights into the roots of some of these assumptions; see also Smail, 1988).
What is usually lacking is a systematic elaboration of how the distress which therapists encounter in their patients becomes intelligible through being placed within the context which gave rise to it in the first place together with an account of how the therapeutic procedures may, in the light of the aetiological theory, be expected to result in anything approaching "cure". If Freud's solution to the problem was unusually radical, his statement of it was also, at the time, unusually honest, and echoes still as an unaddressed question for much of psychotherapeutic thinking: how can therapy alter the circumstances and events of patients' lives?
There are, it is true, some schools of therapeutic thought which may claim to stem at least as much from an academic background as from clinical practice and which may therefore suffer less from the kind of core division in theory which an interest in cure tends to set up. Approaches having their intellectual home in academic psychology - notably "cognitive-behavioural" approaches - might come into this category. The difficulty with these, however, is precisely that they are too one-sidedly psychological, and fail to take sufficiently seriously into account the world in which psychological subjects are located.
Psychology is, of course, quite properly centrally concerned with what goes on "inside" individuals in order to throw light on their behaviour and experience, but this is too partial a vantage point from which to study the kinds of distress clinical psychologists and psychotherapists see in their patients. In this context an approach informed by the psychological tradition will concern itself primarily with intra-, or at the very most, inter-personal processes, and when considering the distressed individual will naturally turn inward to what one might call the person's private space. A striking feature of the broadly clinical psychological approaches is thus their myopia - they too rarely look up from the individual's "inner world" to try to examine the context in which he or she is located, and even when they do they tend not to conceive of the relation between person and world as a serious one, i.e. one which cannot be manipulated from within an artificially created micro-environment. The sedulous accumulation of research fragments (to adapt one of George Kelly's telling phrases) in, for example, Brewin's (1988) overview of "the cognitive foundations of clinical psychology", reveals little more than how people react to sometimes quite bizarre experimental conditions. Understandably enough, the focus is on the internal processes of individuals since these are the dependent variables of artificial, manipulable "laboratory" worlds (evanescent micro-environments) which, far from embodying the isolation and refinement of enduring features of reality, reflect little more than the psychologist's powers of imagination.
The nature of the real world is, however, neither imaginary nor fleeting. We are beings fixed in space and time under the influence of factors most of them well out of the reach of personal control. Although they have certainly not escaped critical scrutiny in respect of their myopia (see, for example, Sennett, 1980; Stam, 1987) therapeutic theories have for the most part had surprisingly little to say about the nature of the material environment in which distress is generated, even less about how therapeutic technique may be expected to operate in such circumstances (Freud's question) and nothing at all about how the environment in which all this happens gets to be the way it is.
Sociology, on the other hand, has a great deal to say about the nature of the social environment, much of it of crucial relevance to those of us who concern ourselves with "clinical populations". How the almost impermeable demarcation between psychology and sociology has been maintained would be a study of considerable interest (its lack is presumably itself an indication of how tight the demarcation is), but it is certainly above all in the area of therapy that it needs most to be bridged. There is of course a noble tradition running from Adler to Laing which does place "the patient" in "society", but even here the kind of understanding which sociology has of the workings of power, ideology, class oppression, sectional interest, etc., is reflected in only the palest outline. On the other side, though sociologists make, often, inspired and instructive efforts at showing how such societal influences become reproduced in and through individual praxis, their exclusion from "clinical populations" means that they have little actual knowledge, beyond that of personal experience, of how, for example, oppression and mystification become translated into directly felt emotional distress.
It is perhaps not surprising that some of these issues have become more salient as significant sections of psychological help have moved out of the consulting room into the "community". The awareness of clinical psychologists and psychotherapists working in the public mental health field of the social context of distress has increased in proportion to the permeability of institutional walls (see for example Bell, 1989). But though recognition of issues to do with "empowerment" is heartening and important, there is still (with some notable exceptions - e.g. Holland, 1988) a kind of strangled theoretical silence when it comes to trying to articulate what we, as psychologists, can legitimately involve ourselves with as far as practice is concerned (we still, instinctively, strain towards "therapy"), and our collective voice tends to trail off once we have exhausted exhortations concerning people-power, the evils of (white, male) professionalism, etc. We can readily articulate a helping philosophy of prevention rather than cure and we can see without difficulty that such a stance has political implications, but since we are at the end of the day employed to involve ourselves professionally with people in distress, most of us still find ourselves confronted by Freud's echoing question: how can the ravages of the world be set right in the context of a therapeutic relationship?
We can begin to answer this question only if we allow ourselves to see that much of the conceptual baggage that comes with therapeutic psychology is simply not adequate for the task before us - whether derived from psychoanalysis, the humanist therapies or behavioural and cognitive approaches. What we need are not psychological theories evolved from the private spaces of individual therapy, but an environmentalist psychology which will bear implications for a whole range of measures which might improve the lot of people at the mercy of a harsh world.
Such a psychology would seek to locate and explicate psychological phenomena within and by reference to the structures of a real, material world; it would not deny meaning to, say, "mentalistic" concepts (as radical behaviourists are inclined to do), but would rather theorise them in terms of a "harder" materiality in which individuals are seen, most essentially, as organisms (the use of this term here is not simply a reflection of experimental convention, but is intended to exclude the idea of people as mechanisms) embodied in a (social) space-time maintained and organised by forms of power. The remainder of this article attempts to sketch out what might be some of the features of such an environmentalist psychology, focussing for present purposes particularly on the social context of individual distress (a rather more detailed exposition of some of what follows may be found in Smail, 1990).
Perhaps the most obvious, pervasive, inescapable, and - by therapeutic psychology - most overlooked influences upon us are cultural influences. While these have certainly not been neglected by everybody (the writings of Christopher Lasch, 1979, 1985, spring to mind) it is quite extraordinary that clinical psychologists and psychotherapists have so signally failed to draw attention to the ways in which superordinate cultural influences give rise to inevitable personal pain. The quite startling exfoliation in Britain over the last few years of a commercial-managerialist culture of competition and addictive market consumerism has left its mark on almost all the patients I see. In particular, it has demonstrated how dependent we are for a sense of self-worth and a degree of security (or at least those of us brought up to breathe different cultural air) upon a stable set of public values which acknowledges the possibility of our being able to contribute to society as well as simply consume its goods. "Culture" here is no abstract set of ideas, but, so to speak, the practical as well as conceptual reverberation of powerful material operations within society; much of the insecurity felt by many of my patients is directly traceable (via various managerialist enterprises) to the upheavals caused by the mergers and takeovers of international capital. Many of my older patients are shocked and bemused by the sudden devaluing of their social contribution and, sadly, tend to assume that the confusion and despair they feel is somehow their "own fault". The therapy industry does little to disabuse them of this interpretation, reinforcing through the use of concepts such as "stress management" and "coping skills" the idea that there is something lacking in them as people.
Ideological influences are also extremely important in shaping the understandings people have of themselves and their world, as well as controlling their access to forms of power whereby they might themselves influence features of their environment. Ideologies may be understood as those public "texts" which, accredited and mediated by power, come to constititue for individuals a description of their reality. The mass media not only give shape to what people take as the truth, but more importantly (because less corrigibly) determine what they can meaningfully and constructively talk about together. Just as, say, the student's conception of "psychology" is in large part determined by the texts upon which he/she will be examined (i.e. the version of psychology determined by power), so the sharable experience of people-in-the-street (their version of reality) will be set by television and the popular press. The extent to which a public text represents truth rather than ideology will depend upon what one might call its scientific integrity, i.e. the extent to which it strives to tell a story about the world which articulates the experience of knowledgeable people of good will (Habermas, 1987). The likelihood is, however, that public texts will be "written" by powerful interest groups of one kind or another, and it is essential to remember that a person literally cannot think beyond the concepts which are embedded in the language available to him/her.
The concept of class is of course not foreign to therapeutic psychologists largely because it features regularly as one of the "variables" that must be "controlled" in formal studies of the process and outcome of therapy. As an integral part of the person's experience of self, however, class seems to feature less prominently, if at all, as an object of therapeutic scrutiny. Just as explicit reference to class as a personal characteristic (ie. as an instantaneously readable index of relative social worth) tends to be repressed in social intercourse, so in therapeutic transactions the influence of class seems rarely to become a focus of discussion or interpretation. While it is considered quite in order to focus on, for example, the "irrationality" of the patient's "cognitions" and to imply thereby a voluntaristic psychology of "change" contingent upon professional criticism, it might seem almost indecent to explicate his or her predicament in terms of class disadvantage (perhaps partly because class is almost always outside the range of a person's choice and therefore could not be "therapised" away.) And yet there can be little doubt that, particularly perhaps in English society, occupancy of a negatively valued class position entails much more than mere economic deprivation: it establishes within the individual a (realistic) sense of inferiority which is almost organically rooted and which colours almost every aspect of his or her social conduct and awareness. How can any psychology purporting to confront personal distress fail to address this issue?
Culture, ideology and class represent what might be called the distal influences of powers which bear down upon the individual. More proximally is a whole range of environmental influences - schooling, work, housing, etc. which touch people's lives directly. Particularly important among these proximal influences are the interpersonal relations, both familial and more broadly social, in which the person is enmeshed, and it is of course with these that psychotherapists are often principally concerned. By no means all therapeutic approaches, however, have recognized the theoretical centrality of power to both the structuring and clinical implications of interpersonal relationships. A person's life is shaped negatively by the abuse of, in particular (but by no means only), parental and marital power and positively through association with benign power (parental love, social solidarity, etc.). Indeed the influence of the therapeutic relationship itself can best be understood in terms of the play of power which it involves (for a challenging analysis of how this may work for ill, see Masson, 1989). Although psychoanalysis in most of its variants has done a great deal to obfuscate the operations of interpersonal power, it is also probably from within the psychodynamic camp that some of the most enlightening observations have been made in this repect: Alice Miller's work on the abuse of parental power (e.g. Miller, 1985) does much to undo the mystifications of Freud's "fantasy" theory, and Lacan's work, despite its almost impenetrable obscurities, does point usefully to the derivation of personal from cultural power (see, e.g., Frosh, 1987).
As well as being the objects of power, people may of course also wield power as subjects or agents, and here again it is fruitful to consider what have often been regarded as personal, psychological characteristics (such as "will" or "responsibility") in environmental terms. How much someone is able to exercise choice or responsibility depends not on some kind of unanalysable internal attribute, but on the extent to which he or she has access to social powers. The more proximal the powers available to them, the more limited will people's influence over their environment be. (Among other things, this accounts for the greater emphasis on intimacy, family and "tribal" values among the socially less privileged; the greater access of middle class people to the operation of distal social powers means that they can afford to pay less attention to proximal relations, may be perceived as cold and formal and will be less disturbed by family feuding, "falling out", etc.)
Conventional psychotherapy operates very proximally, and while it can be an important and effective source of the kind of intimate social solidarity which provides comfort to the distressed, its ability to assist people to make significant changes in their lives will depend upon the extent to which they have access to resources within the environment. Most schools of individual therapy have been developed with a well-resourced clientele, and it is really only working within a public health service which opens the practitioner's eyes to the extent to which supposed "inner strengths" are really no more than the reflection of outer advantages. In thinking about the process of "therapeutic" change, I have found it helpful to consider people's access to resources in terms used by the French sociologist Pierre Bourdieu (1986) who suggests that a person's social power will depend upon the possession of a range of different kinds of "capital" - e.g. educational and cultural capital as well as economic capital. To this one can add physical capital, i.e. socially valued bodily characteristics which may be traded for other forms of social power (hence, for example, the powerless girl's ultimate recourse to prostitution, the powerless boy's to violence).
The practical implications of the kind of environmentalist psychology which could be built around the skeleton suggested here are, I think, considerable. Most of the mistakes, confusions and inadequacies arising from the theory and practice of conventional psychological therapies, exemplified often in unduly grandiose claims made for their effectiveness, are due to their mislocating the sphere of their influence within the social space-time of the environment. As "proximal" undertakings they can expect to make an important contribution to people's ability to clarify their predicament (and gain thereby a significant increase in ideological power) and obtain a degree of socially empowering comfort from the therapeutic relationship itself. People may also be encouraged to deploy what resources they can to influence the environment favourably. However, the powerful distal influences which bear upon patients to generate their distress are unlikely to be touched by therapy.
In this respect an environmentalist psychology could have a great deal to say about, for example, the kinds of social structure and political influences which affect people for better or worse. This does not mean that psychologists would need to become social engineers or, necessarily, political activists - and if they did do so they would almost certainly become agents of the "tutelary complex" (Lasch, 1985) rather than of the individual - but it does mean that an enormously wide field would become opened up to a reasonably systematic and theoretically coherent clinical enquiry. It is neither professionally necessary nor socially desirable that an environmentalist psychology of this kind should seek to control or patent the practical implications of its own observations. That would be everybody's business.
The most important practical implication of a radical environmentalist theory of personal distress would be to reverse the "disciplinary" relation of person to society which conventional psychiatry, prychotherapy and psychology support (even if unwittingly see Foucault 1979). The point is not to cramp people into the normative moulds constructed, often very much against their interests, by cultural and ideological forces, but to open up spaces which will more comfortably accommodate their particular experience and perspectives. The essential relation with which anyone trying to offer psychological help deals is that between the private and the public, individual experience and the social environment. The traditional way of dealing with this has almost always been to seek to fit the former to the latter, to "pathologise" idiosyncrasy and endorse "normality". This has the all too frequent effect of creating isolation, self-alienation and despair. For, in fact, we cannot escape our private experience in which, inevitably, there is hidden so much secret pain: we cannot help what we think and feel (we can only seek to deceive ourselves and others about its nature - such deception being, after all, at the heart of so many variants of so-called "psychopathology").
An alternative to traditional "therapy" would be to acknowledge and endorse (as saying something true) private pains and perceptions while taking proper notice of what they indicate about the nature of the environment which gives rise to them. It seems to me both more helpful and more accurate to consider people as characters to be understood and respected than as, so to speak, therapeutic targets to be analysed and changed. We need continuously to be evolving an environment able to make sense of what people have to say about it and to use what they have to offer to it.
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