[Talk delivered at the Critical Psychiatry Network conference The Limits of Psychiatry, London, 13 June 2003]

Psychotherapy: How Can We Help?

David Smail

Over the years I have, I think, earned modest notoriety mainly as a critic of psychotherapy. Since occupancy of this role has not been entirely comfortable, I thought I might take the opportunity offered by this occasion to try to win back one or two lost friends. For although I do believe that marketized therapy is one of the plagues of our time, I can also, I hope, understand why many people of good faith see in psychotherapy an antidote to the alienating impersonality so often experienced in other approaches to emotional distress - in particular, of course, conventional psychiatry.

Having a perspective on the development of twentieth century psychological therapies that is now, alas, well longer than the average, I find it personally instructive to reflect on how my feelings about them have changed over time.

For most of the first two decades of my experience as a clinical psychologist – i.e. the 1960s and 70s - psychotherapeutic approaches offered a spiritual home for those wanting to escape the orthodoxies of the medical as well as the behavioural models. For the earliest years I worked in what was to all intents and purposes a Victorian lunatic asylum where psychologists weren’t really supposed to talk to patients at all in any significant respect, and in this atmosphere psychotherapy - then largely synonymous with psychodynamic approaches - was a kind of arcane practice undertaken almost furtively, and certainly defensively, by one or two brave psychiatrists prepared to risk the gentle (usually) ridicule of their colleagues. Psychotherapy felt like a promised but slightly dangerous, and certainly inaccessible land, where the banalities of medical psychiatry gave way to altogether more profound mysteries of human experience.

As the success of ‘behaviour therapy’ began to bite, and to provoke a critical reaction from reflective, articulate and intelligent psychologists like George Kelly and Carl Rogers, suddenly the whole field opened up into one in which we were, at least, allowed to think and to develop practices which were - even if reluctantly - accepted as more or less legitimate by our employers. Psychological therapies, though still in a minority and not by any means widely available in the British NHS, became a focus of serious discussion and research. What are now largely known as ‘humanistic’ approaches offered a hopeful, and genuinely exhilarating prospect of taking patients’ experience seriously and treating them decently. The therapeutic community movement, moreover, brought political factors into the arena and called into question the oppressive authority that permeated so much of conventional psychiatry.

But then, as, during and following the late seventies, therapy and counselling began to form an orthodoxy all of their own, the enchantment seemed, for me anyway, to evaporate. Training courses, accreditation, scrambling for exclusive forms of licensing, a flourishing, competitive market in therapy - all these seemed to blight the possibilities for a liberated understanding of human distress that therapy had seemed to offer. Those aspects of psychotherapy that had always been questionable seemed to come to the fore and those that distinguished it positively, both intellectually and ethically, seemed to retreat into the background.

Let me first consider what seemed, and still seem to me the good things about psychotherapy. Above all, psychotherapy takes an interest in people as subjective beings. It enquires into their circumstances and experiences and, more often than not, seeks to unravel the confusions that these have created over the years. Most psychotherapists and counsellors, furthermore, adopt a compassionate stance towards their clients, listen to them patiently, open-mindedly and non-judgementally. People are given the time to reflect on their past, present and future with another person who has, usually, their interests at heart. Additionally, therapists and counsellors who have the necessary perceptiveness and experience will stay with the client, offering support and advice while s/he struggles to make adjustments to his/her circumstances. Therapists, that is to say, may offer solidarity to their clients. In this way it seems to me that the positive contributions of psychotherapy may be summed up as providing clarification, comfort and encouragement.

With the possible but by no means universal exception of comfort, these qualities are often conspicuously lacking in conventional, biological psychiatry, which for the most part makes little attempt to understand its patients as subjective beings and where the circumstances of people’s lives are rarely seen as of much significance for their ‘illness’. Indeed, the brevity, impersonality and – as far as the patient can see – irrelevance of their experience of psychiatry are frequent factors in making the psychotherapy option seem so much more attractive.

It is important to note that the components of psychotherapy I have picked out so far – i.e. those I see as its most valuable contribution – are not simply features of an established method of ‘treatment’, but have implications for the way we understand emotional distress. Acknowledging the subject and taking seriously his/her experience of the (social) environment, offering solidarity while s/he struggles as far as possible to make adjustments to that environment, points away from the individual as the source of the difficulty to shift attention to the society that gives rise to it. Somewhat paradoxically, perhaps, the validity of psychotherapy as a two-person interaction depends on its orientating the participants toward an understanding of the societal origins of subjective distress.

Given that the influence of both therapists and patients over the environmental circumstances of their lives is very limited (which in my view is the reason for the scant demonstrable success of psychotherapy as a method of treatment) the principal lessons of psychotherapy are, I think, political. In other words, psychotherapy teaches that people are damaged by their experience of the world. Though the aid and comfort of another individual is always welcome, it is rarely enough—especially when limited in time—to alter the circumstances which cause distress in the first place. Like all other living things people need a benign environment in which to flourish. This is ultimately a political, not a pseudo-medical issue.

Now I realize that a lot of people may be hard put to it to recognize their own view of psychotherapy in the picture I have given. This may be in part because I have left out a whole host of factors which are often seen as definitive of psychotherapy. I have done so, however, because many of them contribute to what seem to me the bad things about therapy.

Although, I think, most forms of psychotherapy involve elements of clarification, comfort and encouragement as outlined above, most also subscribe in theory or practice to principles that I think are less rationally and/or empirically sustainable. These can be divided into two main branches: inappropriate, and indeed invalid, technical aspirations on the one hand, and an impossible philosophy of what I call magical voluntarism on the other. Many brands of therapy commit both these sins.

Technicizing their practice has always been a temptation of professional psychotherapists and counsellors, and is inevitably hard to resist for anyone wishing to represent their enterprise as in some way analogous to a medical procedure. So-called psychodynamic approaches, in which therapist expertise and training in technical mystique are at a premium, are particularly guilty in this regard: concepts such as ‘interpretation’ and ‘transference’ are good examples of the kind of thing I mean. But the ‘humanists’ are often not much better: it was no time at all before Rogers’s insights about warmth, empathy and genuineness were converted into supposedly trainable ‘skills’ that could be ‘delivered’ with dependable results. The very idea that different therapeutic approaches can be subjected to comparative research assumes that they are essentially technical undertakings, like, say, alternative surgical procedures.

Alongside technical assumptions in the history of psychotherapy – and indeed almost contradicting them – there has run a strong theme of individual responsibility. Patients, that is to say, are seen as somehow ultimately in charge of their own fate. They may be led by ‘insight’ to an accurate account of the reasons for their problem, but whether or not they do anything about it is up to them. If properly ‘motivated’, no doubt they will, but if ‘resistant’, maybe they won’t. Either way, this is not seen as anything much to do with the therapist. This is what I mean by magical voluntarism, for, even if not explicit, the idea that people can choose a way of being involves notions of ‘will power’, freedom and ‘responsibility’ that do not, in my opinion anyway, bear critical analysis in an even remotely scientific context. The fact that the clarifying element of therapy may expose in stark relief the reasons for someone’s distress in no way necessarily provides him or her with the means of putting them right, and in fact, in the vast majority of cases, the noxious influences giving rise to them will be well out of reach in time, space or both. Therapy frequently simply glosses over this difficulty with an implicit moralism that, ultimately, makes the person the author of his/her own predicament.

Now I think it’s fairly obvious why approaches to psychological treatment tend to go down these paths, and that is so that therapy can be justified as a professional undertaking: professionals need technical qualifications, and they need to hold out the promise that the clients’ problems can be resolved from within the consulting room (which must in the end mean through their own—i.e. the clients’—efforts). These requirements, however, have exactly the opposite implications to those flowing from what I characterized as ‘good’ elements of therapy. Instead of pointing out towards society, they point inward, towards the client’s ‘inner world’. They create a privatized market around the demand for and supply of ‘skills’. Psychological salvation becomes a contra-political matter of personal adjustment from within.

Pretty well throughout their history, in this way, the psychotherapies have (with one or two honourable exceptions) played a confusingly contradictory role: on the one hand they offer an explanation of psychological distress in terms of its social origins – even if these are limited to the microcosm of the family – while on the other they place the burden of ‘cure’ on the sufferer him or herself. (One should perhaps note in passing that Freud early on spotted the inconsistency here, and responded by making the whole works, causes as well as cure, intrapsychic). The upshot of this confusion between outer and inner, social cause and personal ‘responsibility’ has, in my view anyway, been hopelessly to mystify the whole notion of ‘psychotherapy’.

Much of this has come about, it seems to me, through an all-too-understandable confusion of understanding with interest. Were they freed of the necessity of making a living from their activity and of having because of that to hold out to their clients the possibility of ‘cure’ (in however veiled a form), I suspect that most therapeutic theorists would place far less emphasis on the importance of the client’s own efforts and far more on the need for social change. In a kind of reverse way Freud himself provides an instructive example in this respect: his letters to Fliess,1 over the period during which he shifted his perspective from real to imagined sexual trauma betray a constant preoccupation with threatening poverty, a corrosive anxiety over the health of his practice. In view of this, one can well sympathize with his difficulty in having to present the fathers and uncles of his young female clients with the bill for a treatment that unmasked their abuse; it would be extremely hard for anyone in such circumstances to resist a theoretical development that obviated such embarrassment.

In a rather similar way, it is, I suggest, our interest that leads us to try to professionalize psychotherapeutic practice. We need to establish the credibility of what is in fact, from a scientific point of view, a somewhat dubious undertaking, by associating it with the endorsement of the appropriate sources of authorization in our society: that is to say, with university degrees, boards of accreditation and, if at all possible, statutory licensing. The trouble is that the project of professionalization leads, as I have suggested, to the mystification and indeed contradiction of the most valuable understandings of emotional distress that psychotherapy has to offer.

Personally, I think that the political implications of psychotherapeutic experience are the most significant and the most important, but that’s not to say that the activity itself is valueless: far from it. If therapy cannot coherently be a technical undertaking, a professionally replicable method, it can certainly constitute a form of human help and solidarity embodying an essential alternative to the impersonal, industrialized forms of processing that so many patients experience at the hands of the health services. As writers such as Peter Lomas2 and Paul Gordon3 have emphasized, psychotherapy is essentially a personal undertaking, a vocation that has no particular authorization beyond the criteria which we might apply to any constructive human relationship. In this respect, the lessons psychotherapy has to teach need not be limited to the practice of psychotherapy itself.

Indeed, in fairness to many of those who work in any capacity with the so-called ‘mentally ill’, not to say countless individuals at every level of society, public and private, the lessons of psychotherapy are not and never have been restricted to psychotherapy itself. Patience, kindness, attentiveness, honesty, unsentimental compassion, not rushing to judgement, giving practical help where possible: these are not just features of good psychotherapy, but are the relational ingredients that make the world go round!

Notes

1. Masson, J.M. (ed). 1985. The Complete Letters of Sigmund Freud to Wilhelm Fliess 1887-1904. Cambridge, Mass. & London: Harvard University Press.

2. Most recently: Lomas, Peter. 1999. Doing Good? Psychotherapy Out of Its Depth. Oxford: Oxford University Press.

3. Gordon, Paul. 1999. Face to Face. Psychotherapy as Ethics. London: Constable.

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