Talk given at the AGM of the British Psychological Society Psychotherapy Section, January 1995
I have to confess at the outset that I have rather cheated with this talk. When Eric1 asked me, on the basis of having heard me do it once before, to consider again the question of psychotherapy as prostitution, I thought that after a lapse of eleven years I'd probably have some reasonably new things to say about it. But on reading over the talk I gave then, I find that really very little has changed as far as I am concerned, and, rather than giving myself the labour of trying to find an entirely new way of saying mainly the same things, I decided I might as well just rework what I said then. In any case, the talk was given in Liverpool and was never published, although I have used the odd paragraph in other things I've written. So the chances are that Eric's the only person here who's heard it before, and I'd be surprised if he can remember the details!
My main contention, anyway, is that one of the principal things, and sometimes the only thing, psychotherapy - even good psychotherapy - offers its clients is a commodity which is not widely or plentifully available elsewhere: that is, love. My use of the word 'commodity' is quite deliberate, because it seems to me that precisely in offering love for money, psychotherapists are complicit, even if quite unconsciously, in turning love into a commodity.
Many therapists would of course be very uncomfortable about the suggestion that in some fundamental respects love is what psychotherapy is all about, even if they acknowledged that the nature and quality of the personal relationship between therapist and client is crucial to therapeutic success. There is a significant number, however, who would not balk at seeing the essence of this relationship as a form of love. But even therapists who do readily acknowledge the importance to their work of a conception of love on the whole fail to take seriously the implication that, in taking money for love, they are acting very much like prostitutes.
My intention in pursuing this analogy, which is of course not original, is not morally to condemn either psychotherapy or prostitution, which, if evils, are both necessary ones, but rather to gain a slightly more balanced view of the role of psychotherapy in our society than that which I think most of us have. I also think that the analogy with prostitution might just help to jolt us into a more honest acknowledgement of our own interest (i.e. financial interest) in the sale of love. While several therapists have been ready to acknowledge that they are indeed selling love, they seem remarkably unembarrassed about it, as if this is an activity without implications, just something that turns out to be the case and to which their own interests are irrelevant; indeed, some seem to suggest that this lends a special nobility to their calling, and drift towards what seems to me a dishonest sentimentalization of their work. I am quite ready to accept that, like prostitutes, we fulfil a need and to this extent perform a useful social function; at the same time, I think it important to recognize that, in being paid for providing people with something they can't get elsewhere, we have an interest in maintaining the social status quo, an interest of which we may not be conscious, and which may involve us in discouraging the evolution of a less noxious social world.
In an excellent book called The Origins of Love and Hate, originally published in 1935 but which I had only just discovered in 1983 (I think it may have been republished more recently than the 1960 Pelican version I have), Ian Suttie, writing in particular of psychoanalysis, suggests that as a procedure it:
'exhibits' far more love than is usually admitted, in the sense of a responsiveness which is unwearying, tolerant, and even appreciative, insighted, and alert. A true and full companionship of interest is offered to the patient which in all therapeutically essential respects reconstitutes the primary interest-relationship of mother and baby in baby and its affairs.
Suttie points out, as of course have many others, that Ferenczi wrote that it is the physician's love which heals the patient, while thirty years ago some of us will remember the impact of Paul Halmos's book the Faith of the Counsellors, in which he made a well argued and well documented case for the centrality of love to the therapeutic enterprise. Much more recently, indeed his latest book Cultivating Intuition appearing only a few months ago, Peter Lomas has argued persistently and in my view very persuasively that the therapeutic relationship, where it is effective, is most (though not entirely) like that of loving parent to child. Humanistic psychologists of a variety of persuasions would be happy enough to talk about love as an essential ingredient of therapy. So there really is nothing new, nor particularly startling, about the idea.
It is also surely no surprise that in a world in which 'Relationship' has become a vanishingly scarce resource, the lack of which is only poorly compensated for by the cultivation of image, love should find a ready market. The warming sense of validation which comes mainly through having rest upon us the approving gaze of, so to speak, an accrediting Other seems to be becoming harder and harder to find. The demands of life in the Business Culture, the struggle to sharpen our personal presentation and package our skills in ways which will successfully advertise our selves, the unrelenting competitiveness in which we are immersed, all militate against our addressing each other spontaneously with the kind of open, subjective, personal, intuitive, honest, sensitive, risk-taking lovingness which we crave but scarcely any longer dare to name. If you want to find the kind of 'unwearying, tolerant, appreciative, insighted, alert responsiveness' of which Suttie wrote, your best hope might be to buy it from a psychotherapist.
Psychotherapists, thus, offer a commodity available, with any consistency or predictability, almost nowhere else. Quite regularly, for about an hour at a time, you can go to your therapist and be listened to, concentrated upon, thought about, puzzled over, understood, questioned, encouraged. Here is someone who will, if only for the brief period of the therapeutic session, take an apparently exclusive interest in you, who will attend to and remember even seemingly trivial details of your life, who will sympathize with your pain even while gently remonstrating with instances of your intransigence, who will blame you for nothing and demand nothing from you, fob you off with no superficial or impossible advice, but open the way for you to tackle the difficulties of your life.
Put like this, surely, it is not hard to see the attraction of psychotherapy nor to understand its popularity (and scarcely necessary to invent for it any spurious technical justification). For a not insignificant number of people, visits to a psychotherapist may be just about the only source of warming concern in otherwise bleak and blighted lives, just as, for a number of people, the placement of their erotic encounters on a business footing may be their only way of ensuring an experience anything like sexual love.
There is, certainly, something very attractive, warming and rewarding about the therapeutic relationship for both patients and therapists, and it is far from my intention to suggest that therapists consciously feign a concern they don't really feel, though I am sure that, if the essence of therapy is love, it is not something which can operate at all times with all patients. Just as prostitutes, for the good of their business, will often have to fake an erotic enthusiasm far from their actual feelings, so psychotherapists will spend many hours of boredom, frustration and at times even irritation, that they will, quite properly, be at pains to conceal from their clients.
One must also take care that the sentimentalization of a 'deeply meaningful' therapeutic relationship does not distract us from a clear view of the real causes of our clients' distress outside the consulting room - nor indeed of our own. Certainly the therapeutic relationship can become a refuge for both patient and therapist, but that, surely, should not be its principal purpose. One might in any case question the curative powers of a love which seems impotent outside the artificially restricted therapeutic setting. For instance, are psychotherapists any the less vulnerable to pain and privation in their personal lives as the result of their practised basking in the warmth and significance of their therapeutic encounters? I have of course read accounts by therapists which paint a picture of fulfilment in personal life as well as wisdom in therapeutic loving, but I have yet to meet any of these individuals. Indeed, I'm afraid I, perhaps cynically, suspect that they are themselves victims of the myth they help create and maintain. The ideal of the wise therapist who, having drunk deeply of life's rich fabric, and having loved all his patients better, expires peacefully as the sun sets on his swimming pool, is not one I buy. Living in the world and among the other people in it, seems to me to be for most of us, much of the time, a pretty fraught and painful experience, and one which cannot be made sense of, but only sicklied over, by sentimental myths involving a self-indulgent and materialistic conception of 'love'. For somebody to be able to face and to some extent cope with the realities of their world it certainly helps if they can have recourse to the kind of loving interest and concern which may be found in psychotherapy, but it won't solve their problems, and we should be careful that it doesn't obscure our view of the problems altogether.
In fact, therapeutic love is but a pale and uncommitted version of what healing love between people in a more ideal world might be, but it is not always acknowledged as such. Patients, it's true, may sometimes ruefully comment that 'you wouldn't put up with me if you weren't being paid to', and few therapists would be likely to deny, at least to themselves, that that is indeed often the case, but most of the time they would feel that the love they offer their patients is more genuine, more worthwhile and respectable than the sexual love dispensed by prostitutes.
In as sense, though, it may be that therapeutic love, though involving no conscious deception, may in fact be embedded in a kind of duplicity far more destructive of our social fabric than the prostitute's guile. For hers (or, of course, his) is a very specific and frank service: though she may not feel love for her clients, she unequivocally makes her body available to them on terms which are clearly understood. She may well pretend an affection she doesn't feel, but the deception is relatively uncomplicated, even innocent, and likely to be clearly understood and accepted by the client.
The psychotherapist, on the other hand, may be tacitly using the healing power of an uncommitted love under the guise of offering a service of a technical nature. Just as behaviour therapies appropriate and technicize common sense, making it the property of a professional group, so 'relationship' therapies appropriate concern, tolerance, empathy, etc., and, as it were, hire them out to people for a fee. So far as we offer our clients technical justifications for our procedures, we mystify and estrange them from personal and interpersonal capacities and processes which are more rightfully their property than ours.
The therapist does of course often become a figure of enormous importance to his/her patients, often because s/he seems to them to be the only person who cares, and most competent therapists are aware of the dangers and responsibilities of this role. Very few therapists, of course, assume that in reality they could be that important, or would be willing to shoulder the responsibility of so being - rather, they have readily to hand convenient psychological mechanisms like 'transference' to 'explain' their patients degree of dependence, infatuation, etc.
Not least because of the financial incentives involved, it is no doubt possible for therapists - particularly perhaps those in the private sector - at least unconsciously to abuse their role. They may become, for instance, a kind of paid friend and confidant to patients, endlessly taking their money in exchange for an available ear, a tolerant acceptance of their transgressions, an interested but morally uncritical reception of their interpersonal and sexual worries and preoccupations, offering appropriately mysterious psychological 'interpretations' which provide a pseudo-scientific justification for an anxious or tedious, or even profligate or futile life. Much more likely, however, is the kind of situation where the therapist simply slides into the role or substitute parent or friend, thereby siphoning off from the world - absolutely without meaning to do so - people's ability to look after and support each other.
The longer one ponders this issue, the more, I think, one becomes aware that therapeutic 'love', such as it is, is indeed a bloodless affair, and perhaps not such an appropriate term for what forms the core of the therapeutic relationship as it seemed at first sight. But this does not necessarily detract from its value - indeed, it may well enhance it. For it is the very usefulness of the therapist's trade which makes it similar to that of the prostitute, and this similarity in turn which draws our attention to the dissimilarities between therapeutic and other kinds of love.
For precisely what justifies the prostitute's role is her - no doubt relative - lack of discrimination. She (or, again, he) does not pick and choose her clients on the basis of their sexual attractiveness or social skills, their experience or competence as lovers, the degree to which they light some spark of longing in her, but solely with regard to their ability to pay. And so it is with us and our clients, and so it should be (even, or especially, where payment is made on their behalf). It is of course frequently advocated in many forms of psychotherapy, though much less frequently achieved, that clients should not be judged morally or aesthetically, but accepted for the people they are, and it is precisely this lack of judgmentalism and discrimination which makes psychotherapy different from more familiar forms of caring.
Love is too personal, too discriminating and demanding, too reciprocal and dangerous a passion to be enlisted in the service of psychotherapy. Even the rather watery notion of agape implies a degree of selfless commitment only the barest handful of particularly saintly therapists would be able to manage. If we are to offer our services to all comers, as we should, we cannot really be expected to engage passionately with them (by this I of course don't mean erotically) to the degree that the idea of 'love' would suggest, and indeed the very context of psychotherapy, in which the balance of giving and receiving is so unusually skewed, protects therapists to a considerable degree from the kind of situation in which love, erotic or Platonic, might flare and flourish.
This is not to say, of course, that we may not feel things for our clients, sometimes very intensely (most often, perhaps, best called compassion) but we certainly don't have to, and what we feel may differ widely from person to person. What we feel, in fact, matters less than how we conduct ourselves, and there, in some respects, the prostitute may have something to teach us. The principal safeguard against either the abuse or the neglect of clients is, for psychotherapists and prostitutes alike, an appropriate professional attitude. As far as psychotherapists are concerned, this should include, I would suggest, politeness (no client of a professional service deserves less), respect (we have no reason to assume that we are in any way morally superior to our clients), kindness (because so many of our clients are in acute distress), attentiveness (because it is important that we listen closely to what people tell us) and understanding (because our purpose is to explain rather than condemn). We don't have to love, or even really to like or approve of our clients, and there are probably relatively few we would actually choose to spend an evening with outside the consulting room.
This doesn't mean, on the other hand, that no warmth will grow between therapist and patient. In fact, I think it very often does, and it may be this which is taken for 'love'. It is partly because the therapeutic relationship is such a protected one, from which the normal factors engendering threat as well as attraction (for example, competition, invidious comparison, admiration and self-display) have been excluded, that it is possible for the those involved to drop their defences and pretences and armoured social roles to become, at least more nearly than is usual, simply human beings. It is this which makes therapy so often a rewarding experience for both patient and therapist (and here, I would guess - though I'm by no means sure - is a difference between the therapist's situation and the prostitute's): the therapist is moved by the patient's humanity and by a view of his/her suffering which has no need or reason for blame; and the therapist's compassionate response to the patient's suffering in turn moves and comforts the patient. But once outside the consulting room the normal rules of social interaction are re-established, reciprocal demands, conflicting expectations and inevitable social stereotypes come into play, and the warmth of the therapeutic encounter gives way to all the influences which make it so difficult at the best of times for us porcupines to huddle together.
If all psychotherapy is doing is to offer a facsimile of loving comfort to people injured by their experience of life - and fairly often that may well be so - then the analogy with prostitution would in my view be very close. But surely, if it is to lay claim to the kind of professional validity it would like to, there must be more to psychotherapy than that, and here, perhaps, is (or should be) the most significant difference between psychotherapy and prostitution. The prostitute, after all, is offering nothing beyond a simulacrum of sexual passion, but the relationship between therapist and patient, however immediately comforting it may be, is merely the instrument which makes possible, which establishes the necessary trust for, the real work of therapy. The kind of qualities which I have suggested should characterize our interaction with patients - politeness, respect, understanding, etc. - and the nature of the therapeutic relationship itself - the protected warmth of the consulting room - merely comprise the setting in which our service is offered. The elements of the professional service itself should consist of something rather more tangible. But that's another story.
1 Eric Bromley, then Chair of the Psychotherapy Section