Forty years in clinical psychology has brought me to the provisional, but not exactly world-shattering, conclusion that the most important factor in creating psychological distress is the environment more specifically, the social environment.
This is not to say, of course, that other factors are not extremely important in making us who we are: the biopsychosocial model seems a fairly safe bet in covering most of the angles, even if so inclusive as to risk vacuity. For myself, I do think that, as clinical psychologists, we for the most part rather neglect biological aspects and, paradoxically perhaps, I think we overemphasize the psychological ones, which, I would say, are frequently epiphenomena: spin-offs of biological and social influences rather than carrying equal causal weight to theirs. But it is the environment as socially determined that has the greatest impact on us and gives rise to most of the kinds of psychological distress that we are familiar with from our clinical practice.
Although it often seems obvious from our informal talk that clinical psychologists have quite a well-differentiated understanding of how social influence works on our clients, it seems to me that this is less apparent from our official theorizing and professional literature. In these we tend to have looked for our understandings to interiorizing, individualistic theories such as those derived from dynamic and humanistic psychotherapy on the one hand or cognitive- behaviourism on the other, rather than to sociological or even politico-economic approaches which take more account of societal structure as a determinant of conduct and consciousness. Our informal talk very frequently acknowledges that peoples problems derive from the world in which they find themselves, whereas to read our literature you would often think that our clients are the more or less wilful authors of their own misery.
So when I talk about the social environment, I mean to refer to events and influences far beyond the individuals and their families that appear to have formed the psychotherapeutic horizonas well of course as Margaret Thatchers. While, inevitably, what we as individuals are mainly aware of, and so principally concentrated upon, is experience of the proximal relations arising from the occupations and interactions of everyday life, these latter are in turn shaped by cultural, political and economic forces often way beyond our ken. The fact that, whether as psychologists or subjects, we are often blithely unaware of these distal powers and influences in no way detracts from their importanceif anything it magnifies it, for the less we are aware of the influences that shape us, the less we are likely to be able to do anything about them.
Many of the assumptions that seem to underpin much of orthodox clinical psychology still retain a voluntarism, a kind of moral and spiritual independence for human beings which, scientifically, we accord no other entity, animate or inanimate, on earth. For we frequently characterize people as self-creating, self-choosing subjects able, through processes of self-examination and insight, to alter the course their lives have so far taken through, essentially, acts of willsometimes simply through some sort of perceptual adjustment (narrative therapy, for example, seems to suggest that all you have to do to make a better world is tell yourself a different story about it). This kind of process is of course often dressed up in pseudo-scientific language appealing to various kinds of internal psychological events, but at the heart of it all does seem to lie the idea that there is in human beings an independent source of will that can, in principle, be reached, appealed to or manipulated, if only through the intercession of an expert. This, I believe, is an inheritance from the religious and magical systems of thought from which psychologyin its therapeutic guise at leastderives in Western culture (Keith Thomas, 1991 Religion and the Decline of Magic). It may seem strange that such views should persist in the twenty-first century, but there are I think fairly obvious reasons why they do. Not the least of these is to be located in the interests of those involved.
To challenge the idea that the psychological ills brought about by the way our society operates can be alleviated, if not cured, through some kind of therapy tends to provoke the same kind of disapproval that blasphemy once did. This, it seems to me, is because so many of those involved indirectly as well as directly have a stake in maintaining the myth.
To start with, those at the top of the pyramidal power structure of society, who benefit from as well as influence it most, clearly have an interest in preserving an ideology which encourages those at the bottom to interpret the ills that beset them as in some way their own responsibility, remediable through their own actions. Furthermore, for the vast majority who experience their lives within the compass of the proximal influences they can see and touch and talk about, it is reassuring as well as plausible to believe that they have the chance of mitigating their pain through techniques of self-adjustment. The idea of therapy keeps a feeling of helplessness at bay. As for therapists and psychologists ourselves, it seems that our very livelihood is likely to depend on our being able to facilitate such adjustment by working directly with or on individual sufferers.
As a life-long critic of what I would call therapeutic mythology, I have at times been accused (not, I hasten to say, by everyone) of various kinds of apostasybeing a traitor to my professionas well as being a pessimist, a nihilist, a cynic, even clinically depressed. I think this must be because people see what Im saying as some kind of threat to the very practice of clinical psychologythat if Im right, then there could be no basis for continuing to try to help individual people, and we would all have to resign and become sociologists or politicians instead.
I dont see it like that at all, however. One of the central tasks of clinical psychology, it seems to me, is to explicate individual subjectivity. We cannot hope to do that without taking account of the social environment in which we are all located. If doing so indicates the limits of voluntarism and the importance of social structures over which we have no immediate influence, we may indeed have to switch much (but certainly not all) of our effort from therapy into other, possibly more taxing, implications of our insights, but that doesnt mean well be out of a job. Whats more, I think the job could become vastly more interesting, though that may just be a matter of taste.
Belief in the power of the psychological, that is to say in the possibility of choosing ones actions and responses in the light either of an insight into ones unconscious processes and/or of a rational analysis of ones cognitive structure, even if contingent upon the services of a therapist, is only really plausible for people who have available to them a whole range of biological and social possibilities that they are very likely completely unaware of. The fatuous notion that you can do or achieve anything if you really really want to (the kind of philosophy often professed in talk shows by celebs of one kind or another at the height of their popularity) is only tenable for those unable to see the physical and social advantages that have been available to them.
It is no accident at all that pretty well all the mainstream approaches to individual therapy have been developed in private practice with relatively advantaged and well-resourced clients, and so have been able to subscribe in only slightly modified form to the folk psychology underlying our everyday, unreflective, commonsense view of life, in which evaluation and choice seem to be the principal features of human conduct. That is to say, it seems from psychotherapeutic theorizing as much as from naïve introspection that what we do when faced with a problem or a dilemma is identify the difficulties, way up the pros and cons of possible courses of action, and then decide what to do. This commonsense view is not so much challenged by therapeutic psychologies as sometimes slightly mystified by them. Psychoanalysis, for example, simply bundles up our usual rational and moral procedures and exports them from one sphere (consciousness) to another (the Unconscious).
Practice in a public health service provided on the basis of need rather than ability to pay, immediately, in my view, opens up rather different vistas and calls into question many of our most cosy assumptions. So does getting old.
NHS practice forces on clinical psychologists, among others, the recognition not only that for people at the base of the social pyramid life is frequently hard, but also that they have little choice and little freedom of action. I dont believe that as a profession we have made the best use of these insights in our formal theory and practice, but thats a question I dont want to elaborate on now.
Getting old is of course another limitation, or rather set of limitations, on our freedom of choice and actionone that people here will be very well aware of from a professional point of view. But the interesting thing about ageing (from a professionally detached standpoint!) is that, except for those who escape it through premature death, it is one none of us can avoid personally. The comfortably-off middle class therapist may never get forced into sharing the circumstances of his or her less advantaged patients, but no one can stop the passage of time (which is not to say, of course, that the worst effects of old age cannot be cushioned through privilege).
For the rest of this talk, I will take up the luxury that has been offered me of indulging in some personal reflections on the ageing process.
Getting old presents some fairly unadulterated biological and social disadvantages. For some time after round about the age of fifty, theif ones luckygradual decline in physical functioning, ranging from skeletal creaking to mild word-finding difficulties, may be experienced as somehow remediable. It is as if ones experiencing some mild form of illness that, if one waits patiently, is going to get better. It takes maybe ten years or so for the realization to sink in that one is not going to get better, but is in fact on a downward slide with only one ultimate destination. One becomes aware of oneself as an ex-breeding machine that, having passed its biological use-by date, is gradually going haywire: rising blood pressure, swelling prostate (Im taking a male perspective here), declining hearing, aching joints, disintegrating teeth, diminished energy. Not to mention cosmetic deterioration like hair whitening and disappearing from customary places while simultaneously sprouting from unaccustomed ones; the blooming of liver spots and sebaceous warts (cemetery flowers, as Guy de Maupassant characteristically called them). And so on. All this is if one is lucky: one is at the same time aware from the casualties that increase rapidly in ones own generation that ones body has become a target for all kinds of degenerative and malignant disease that start to pick off ones friends and acquaintances apparently at random.
Well, all thats pretty obvious and unambiguous.
Similarly with some of the social changes that take place with retirement. Having availed myself shamelessly of the advantages to be gained from MHO status, I was able to work half-time from fifty-five to sixty on what amounted to full pay, and so break myself into retirement gently. Even when I did retire fully, four years ago, I cant say I missed life in the NHS all that much. Or at all, if Im honest. What used to be a relaxed, engrossing and civilized jobas well as highly productivehad become a bit of a nightmare. My last day at work was highly symbolic: I ended the day sitting in an empty office from which everything had been stripped bar just one chair. All the rest had been transported back to the psychiatric establishment from which we had escaped about ten years previously, and whose management had just regained control over us. If I had not got the prospect of other things to do, and had not the solidarity of many good and long-standing colleagues, Id have felt like cutting my throat, and I can well see that for many people the sudden termination of their working life must be a trauma of the first order.
In my own case I had, and to an extent still have, professional interests and activities which are not dependent on a formal NHS role. I still read quite a bit and manage to write a little, and there are still pockets here and there of people who seem interested in what I have to say. I also keep up a half-day-a-week voluntary clinical input at the University Health Centre which keeps me in touch with reality (in particular with what the world is doing to young people). Without those activities I would have felt very strange and dislocated indeed. Only recently have I at times wonderedand then not oftenwhether it wouldnt be quite nice to give up more or less everything and just potter. This is usually after our own or the US government has done something particularly despicable, or after reading or hearing something in the media so crass and insightless as to make just about anyone wonder why they bother.
These issues are again, no doubt, all pretty obvious, and it should not take any great feat of empathy to see how difficult retirement must be for many people whose jobs were not simple drudgery from which escape could only bring relief.
There is of course another issue of absolutely fundamental significance that I havent so far mentioned, because again it doesnt really figure in my personal landscape, and that is money, or rather the lack of it. Being cushioned by a very adequate Health Service pension, I can only imagine the desperation of people whose retirement is more or less synonymous with penury, and I watch the current attack on pensions which is taking place in the wider society with a sense of outrage that is, thankfully, not fired by personal experience. But nevertheless it makes me uneasy: one becomes aware of what a vulnerable target the elderlywe pensionersare. (Its interesting to note in this respect that the onslaught is not so much on present pensioners, undervalued though they are, as on future onesa particularly cunning move in view of the fact that most people are not very good at anticipating the privations of pensioner status until it is close to overtaking them.)
From a psychological point of view, what is most interesting about becoming old is the interplay of biological and social factors that affect ones subjectivity, ones sense of who one is and what is ones place in the world, i.e. how one feels. Some of these phenomena are, again, fairly obvious, but some are quite subtle. Ill just run through a few of those that occur to me.
Almost inevitably, the consumerist world is constructed around the needs and preoccupations of younger people, in particular ambition, recreation and enjoyment, and sex. Economic and biological potency are in a sense the dynamos of modern society and are reflected centrally in just about all of its institutions. Even, though older people dont necessarily feel old in the sense of having somehow abandoned or moved beyond the interests and desires of a lifetime (I feel much the same as I did when I was six years old), there is no escaping the sense of exclusion that declining physical powers and the economic restrictions of retirement impose.
One becomes aware of occupying a shell that others perceive differently from how they used to. This is of course not universal, and there are still lots of people who treat one like a human being, but its hard to get through a week without being reminded that one occupies, as a person identifiable as old a new and not terribly comfortable social stratum. At its most benign this can occur in the form of kindness expressed not quite delicately enough. For instance: the Sainsburys checkout assistant who asks would you like some help with your packing, sweetheart?. At first you wonder who shes talking tois there a child standing next to you you havent noticed? And then, with a slight shock, you see yourself as others see yourather like catching sight of yourself in the mirrored pillars of the shopping mall. Look at that shabby-looking old man wandering along in that distracted way. Oh my God, its me!
I begin to understand why self-respecting old men often dress with such scrupulous, brushed-and-ironed care: in a young or middle-aged man a slightly scruffy casualness can of course be positively attractive, but if you persist too long with it, you may get asked, as I did by a dental receptionist, whether youre on income support. Inevitably then, you find yourself sliding into self-respecting-old-mannishness. And that in its turn may well attract comment: I asked my ten-year-old granddaughter if she like my new shoes. Well, not really, she said as tactfully as she could. Asked to elaborate, she said well, theyre a bit grandpa shoes. Im not wearing them today, I can tell you.
Much more unpleasant than the well-meant kindness one encounters is the unmistakable sense one gets from time to time of, as an old codger, simply not counting any more. There is for example a variety of young saleswoman whos eyes go dead when she sees that a) you are outside the range of her sexual magnetism, and b) probably havent got much money either. Its like somebody switching a light out: that mysterious bond of warmth, or interest, or solidarity that connects people even in the most trivial and fleeting of human interchanges suddenly just isnt there, and its a fairly profoundly deflating experience.
Experiences such as these make it easy to see how, for people whove led their lives enthusiastically embracing the values of the modern consumerist world, especially for those who have achieved fame and fortune within it, prosthesis and plastic surgery, as they get older, are just about the only option. If youve put all your eggs in the basket of youthful beauty and vigour, and the activities associated with them, that feeling of cancellation in the gaze of others must truly be a fate worse than death, since in death you are at least not forced to experience your own non-existence. No wonder that so many ageing celebs spend fortunes on preserving the illusion of youth. Some, indeed, are so successful at it that I sometimes find myself getting quite envious, wondering if they really have discovered some magical elixir that protects them from the physical and mental ravages of old age. No wonder we put so much energy as a society into preserving and extending lifeand trying to disguise the results of our success. One day, perhaps the celebs will truly become the Olympians they already partly are, having bought themselves an immortality that will be well out of the range of the rest of us.
As it is, the world an older person finds him or herself in requires no active seeking. You dont have to try to occupy the context of the elderly: it happens entirely automatically, indeed almost mysteriously. Ive often been surprised, looking round the pub or restaurant Im in for example, to find myself one of the youngest people in it. I dont deliberately avoid the haunts and pursuits of the youngits more that I dont really know where to find them. Its no old fogys pose that I dont know the names or faces of the stars who appear on the chat showsthey seem rather to manifest from some parallel universe.
Of course there are perfectly good reasons for all these things, but largely one is unaware of them. They illustrate quite well, I think, the way in which people are shaped by their environment even when they feel that their lives are somehow a matter of personal choice. Retirement changes the spatio-temporal framework of ones life such that one drifts away from the common concerns that form the fabric of the working world. One gravitates into contexts and activities in concert with others of ones own generation if for no other reason than that they are the only people around at that time of day. Even the TV advertsfor stair lifts, releasing the equity in your property, and worry-free funeralsare tailored specifically for your world.
In some ways there is something almost cosy about this sort of thinga kind of solidarity of the pensioners in which we can count on a degree of shared experience with our comrades and know that we can speak the language of our years without being met with blank stares or barely concealed contemptuous smirks.
On the other hand, one is also painfully aware that this is a relegated world split off from the economic and ideological hub of things, where the only clout possessed by its inhabitants is that afforded them by the generosity and empathetic imagination of younger people. We depend for our self-respect on societys holding together on a moral (as opposed to an economic) plane, and that looks increasingly fragile. The elderly are third class citizens who know how vulnerable they are to the attitude behind the message I saw on the tee-shirt of a youth striding along with his girl friend in Nottingham: I hate old people cos they smell of wee.
Older age reveals the importance of time in shaping our subjectivity. In childhood, so far as I can remember, an insufficiency of years limits ones powers and possibilities, breeding an impatience with the slowness of the passage of time; one cant wait to grow up. Its the opposite as you start to become old. A superfluity of years brings a sense of panic at the speed with which time passes; youth recedes at an exponential rate and one finds oneself deploring the careless way in which one squandered it, longing wistfully for a Faustian opportunity to combine the knowledge of ones years with the possibilities and passions of youth: if only I could do it all again knowing what I know now!.
Now, when I see old men leaning on walls or sitting on benches gazing into space, I have a pretty shrewd idea of what theyre doing: theyre shuffling and re-shuffling their memories. The passage of time, for a mortal subject, changes the perspective from anticipation to memory, and everyday events dont stir up, as in the young, wants and resolutions, so much as longings and regrets, and sometimes little squalls of grief that seem to assail one out of the blue, blown up from inevitable reminders of the tragedies that are accumulated in any reflective lifetime. There can be an incontinence of sadness in the elderly which has nothing to do with clinical depression and everything to do with a compassionate outlook on the pastones own as well as that of ones fellow passengers to the grave, in Dickenss poignant phrase.
There are of course some compensations to the backward perspectivethe sweetness of nostalgia even offers possibilities for commercial exploitationbut on the whole modern Western society has little use for the viewpoint of the ageing. In a society that depends economically on the perpetual re-inventions of fashion, the fraudulent recycling of old ideas as new, the revision of history, people who remember what used to be the case are a positive nuisance. So what could be a real asset of ageing, i.e. the accumulation of knowledge, becomes instead a social liability. Being old is synonymous with being out-of-date. Knowledge which could contribute to wisdom just becomes a bore and an impediment to change (that panacea of the movers and shakers of the modern world). In this way it is quite difficult for older people to take any satisfaction or pride in the length of their experience; rather, they are likely to feel that the world has passed them by and that, not quite knowing how, they have lost touch with what is important to the rest of the world and so have themselves become unimportant to it, simply repositories of useless knowledge like an old bus timetable.
It is of course important to remember that there is nothing natural about all this: in other times and places the elderly were and are deeply respected, even revered. Given that theres no fool like an old fool, generalized reverence toward old age may be no more appropriate than generalized contempt; growing old certainly doesnt guarantee wisdom. But what is clear is that the unavoidable spatio-temporal consequences of biological ageing, among which is the acquisition of a long perspective on the past, depend for the positivity or negativity of their evaluation on social conditions over which as individuals we have no more control than we do over the processes of ageing itself.
As things are, we are rushed through childhood so that we can enter the commercial world as soon as marketing ingenuity can fix it, and we are to most intents and purposes discarded once we have ceased to have significant economic value. The psychological condition of the elderly is thus a consequence of biological and social conditions, and can in my view no more be treated by merely psychological procedures than can (in my experience, anyway) the phenomena of distress to which the social environment of younger adults give rise. Indeed, because of the restricted powers and resources available to most older people as compared with most younger people, psychological treatment for the distress their situation causes is even less appropriate.
This is a problem for psychologists only if we identify our role with therapy. The more I think about it (i.e. the older I get!) the more unfortunate and misleading a term therapy seems to me, and the further I think we should distance ourselves from it. To do so would in no way negate the central concern of clinical psychology with the individuals subjectivity, in particular of course the experience of psychological pain. Our task in my view should be to develop an accurate account of how such psychological pain comes about and if necessary spell out the implications of our observations. But we neednt take upon ourselves the responsibility for curing it.