Chair's Address at the AGM of the British Psychological Society Psychotherapy Section, January 1996
Most approaches to psychotherapy, it seems to me, embody two central concerns. These are, first, the formulation of an explanation of why someone comes to be distressed, and, second, the construction of some kind of technique whereby their distress can be 'treated'. These are in fact two very different enterprises, and I have for some time been preoccupied with certain contradictions which seem in practice to arise between them in almost all forms of what we broadly call psychotherapy. What I would like to do this afternoon is enquire a little more closely than I think we are often happy to do into the nature of this contradictory relation between investigation of cause on the one hand and technique of cure on the other.
To anticipate my conclusion absolutely bluntly, the problem seems to be that what psychotherapy has the perspicacity to understand it hasn't the power to put right. The rest of this talk will be concerned with trying to show how that conclusion seems inevitable, and to suggesting what it might imply for therapeutic practice.
What draws so many of us to psychotherapy in the first place, I suspect, is both the richness and the accuracy of its theories about how people come do be suffering as they do. In comparison with the often crude biologism of psychiatry and the banal oversimplifications of some of the more radical behavioural approaches, psychotherapy - whether of the broadly 'dynamic' or the broadly 'humanistic' variety - shows a respect for individual experience and a readiness for patient and sometimes lengthy enquiry into people's personal backgrounds. These, more often than not, arrive at an explanation of the person's problem which is not only acceptable to both the person concerned and the therapist, but actually does seem to constitute an advance on conventional or commonsense understandings. In other words, there seems to be something special about the psychotherapeutic approach which leads to 'insights' of a depth and accuracy less likely to be gained in other kinds of approaches.
Now I do realize that to say the broadly psychotherapeutic approach to enquiry results in greater accuracy than other approaches is not uncontentious, and that different theoretical perspectives within psychotherapy might in fact find quite a lot of room for disagreement in their formulation of a particular individual's difficulties. But I have often been struck by the relative ease and unanimity with which therapists - say in supervision groups or seminars - can agree about the antecedents and dynamics of a person's distress, and I would suspect that what unites us most is our conviction - however difficult it might be to 'prove' scientifically - that we have a firmer handle on 'truth' than many of our - so to speak - non-psychotherapeutic competitors.
There is quite a lot of job satisfaction in the exercise of the kind of skill and experience which leads to insight. Not only is it something which competent and experienced therapists are good at, but it can also be pretty impressive from their clients' point of view. People who have been mystified all their lives about the reasons for their suffering are quite likely to find the scales falling from their eyes after a relatively brief period of therapy, and in some cases it may seem to them that the therapist's powers are almost magical in this respect. We of course know that there is no magic involved, but even so it is hard to resist capitalizing here and there on the mystique which a certain degree of expertise affords us.
This is also the point, however, where we begin to run into difficulties: having arrived at accurate insight, we are faced with the problem of what to do about it. For what insight tends to reveal is that our clients' distress arises in time and space over which neither they nor we have a great deal of control.
It is precisely the hallmark of psychotherapeutic approaches that they offer an explanatory account of the person's difficulties which refers to present and past experiences and relationships in that person's social environment. Psychological states are thus linked to events in an outside world in a way which makes sense of them, and it is this 'making sense' that we particularly appreciate about psychotherapy.
Of course, different therapeutic approaches tend to focus on different aspects of the person's social environment, but almost all lay particular importance on family relationships in one form or another, and most are prepared to take account of major events and difficulties in the person's wider world of work, education, etc.
When, however, we move from 'analysis' to 'therapy', we quickly become aware that there is no way the activities of the therapist can impinge directly on the social world in which the person exists. Though the causes of distress may lie in events in the outside world, the 'cure' can be effected only by working on the person him or herself. This is not, when you think about it, terribly coherent from a logical point of view, and trying to present it as such has led us into a variety of intellectual contortions which are in my view still far from satisfactory.
For what we are trying to do in the 'therapeutic' part of psychotherapy is reverse the influence of solidly material environmental causes through the psychological processes of the individuals who have been affected by them. People have of course tried to do this throughout recorded time. It used to be called 'magic'.
An uncomfortable, if not totally conscious, awareness of the contradictions involved between 'insight' on the one hand and 'therapy' on the other can, I think, be traced in most approaches to therapy. Let me take psychoanalysis as an example.
Freud's view that the point of his procedures was to replace 'hysterical misery' with 'common unhappiness' is frequently quoted. What he actually said, in the form of an imaginary dialogue between a patient and himself, was as follows:
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. With a mental life that has been restored to health you will be better armed against that unhappiness.1
Now this is about as direct and frank a statement of our problem as one could wish to find. 'Illness' is 'connected with' the 'circumstances and events' in the sufferer's life, and it is acknowledged that fate would relieve it better than therapy. Even so, with the kind of charming sleight of hand which is so characteristic of Freud's style, it turns out that the 'illness' can be relieved through a 'transformation' into common unhappiness.
But let's not quibble. Let's accept that Freud could reasonably claim to be altering the person's perception of his or her predicament such that a neurotically distorted view of it becomes simply the experience of an unavoidable unhappiness.
Well, that's OK with me. But if that really is all that can be expected of therapy, it would seem to suggest that there might be more fruitful approaches to the kinds of 'illness' which arose from 'circumstances and events' in people's lives. The obvious thing to do would be to look to see if anything could be done about the circumstances and events themselves.
The 'circumstances and events' of which Freud himself became aware are of course well known: they were the sexual traumata which his patients appeared to be undergoing at the hands of various male relatives, etc.
Now the most interesting thing about this famous quote concerning 'hysterical misery' and 'common unhappiness' is when it was published. This was in fact in 1895, very early in Freud's psychoanalytic career, towards the end of his collaboration with Breuer and just before he began to move from the idea that patients' 'illnesses' were the upshot of 'circumstances and events' in their lives to see them instead as productions of their own fantasy.
It was precisely through this shift in theoretical position that Freud was able to escape the logic of an environmentalist account (which would be to look for social cures to social problems) and concentrate instead on a purely psychological theory which encapsulated patients' problems within their own skulls, or at least within that sphere which he was able to refer to as their 'mental life'.
The vast bulk of the orthodox psychoanalytic enterprise has in fact had very little truck with the idea that people's distress is connected with the circumstances and events of their lives, and, in common with many other approaches to therapy, overlooks the significance of its own enquiries to concentrate instead on the purely psychological magic which can be worked in the encounter between patient and therapist. It is patients' perception of their world which therapeutic technique tends to concentrate on, and one may at least credit Freud with more consistency than many when, in eventual contrast with his 1895 formulation, he tried to make patients' perception of their world the source as well as the solution to their difficulties.
Another device particularly characteristic of psychoanalysis has been to affect a lofty disregard for 'therapy' and to assert that it makes no claims beyond the process of analysis itself. Analysis, these analysts will say, does not attempt, indeed has no interest in, 'curing' people, but is simply a method of laying the truth of their condition before them.
Well, this is fine by me as well, but I think one has to see it as pretty disingenuous. Few patients consult therapists, I suspect, purely out of intellectual curiosity about their condition, and in any case, the vast psychoanalytic literature, including of course the writings of Freud himself, are stuffed to bursting with essentially therapeutic claims.
In order to side-step the environmentalist implications of the environmentalist account achieved in most formulations of 'insight', therapists resort to a range of strategies. In one way or another, these make use of the actual social situation which exists in the consulting room. The consulting room is, so to speak, lifted out of any kind of wider environmental context and invested with a potency taken to be sufficient to work the necessary therapeutic change.
For example, a technical process such as 'interpretation of the transference' is taken to be the essential ingredient of change; or the relationship between patient and therapist is seen as the essential factor (the therapist's 'warmth, empathy and genuineness' providing the humus for personal growth, perhaps); or the experience of therapy itself is seen as a potent form of 'corrective' learning. All these notions, and others like them, constitute attempts to deal with the impotence of insight; they recognize, that is, that something more than insight itself is needed to power the process of change.
The solutions offered, however, seem to me both inadequate and rather grandiose, and this because they necessarily inflate the importance of what goes on in the consulting room out of all proportion to its actual place in the social space-time of clients' lives. It would, as just one example, take a very hefty 'corrective emotional experience' indeed to compensate for the kind of havoc a destructive parent can wreak over a period of fifteen or so years, and I know of no therapist who would be prepared or indeed able to make the kind of investment of time and emotional energy necessary to make such an impact, even were it possible to do so in theory.
But one does have to acknowledge that the postulation of mechanisms of change at least takes seriously the task of offering an account of 'therapy' which tries to improve in 'credibility' on that of 'insight'. In much of their day-today activity, I suspect that most therapists and counsellors rely heavily on an unanalyzed notion of 'insight' which simply tacitly hopes that 'seeing what the problem is' (which, as I've said, we're on the whole very good at establishing) will somehow lead automatically to clients' being able to do something about it. Sometimes of course they can, but quite often they can't, and I believe we need a much better theoretical account than we have managed to produce so far of what are the processes leading to either success or failure.
The question we need to be able to answer, then, is: 'what makes change possible?'
Looking for a moment beyond the sphere just of psychotherapy to consider approaches to 'treatment' more generally, and discounting those which could be characterized as purely magical, one can perhaps discern three broad strategies of bringing about change.
The first, practised most obviously in conventional psychiatry, is simply to alter embodiment. Recognizing accurately enough that distress is a physical phenomenon and is experienced through our embodied structures, biological approaches attempt to interfere, so to speak, directly at this level. Fair enough up to a point, but it is precisely the investigative side of psychotherapy which reveals that people's problems have origins in the world around them, and not in their bodies. Physical treatments are acceptable in the same way that having a drink when you feel down is acceptable, but taken as solutions to life's problems they are unsatisfactory in the same way that staying permanently drunk would be.
The second broad strategy of change for those in distress is to learn to be different. This is not so closely identified with any particular approach or profession, and probably plays a part in most, but obviously most explicitly in the 'learning theory' approaches growing out of behaviourist psychology. The idea that to make differences to one's life one has to learn new strategies and tactics of dealing with people, etc., no doubt has a lot to recommend it, but the real problem comes in stipulating how this is to be done. Since it is not the central focus of this talk I don't want to go into this issue in very much more detail at the moment, but that is not to say it is not centrally important to understanding what is and is not possible in therapeutic change.
The third broad strand is the one that we have already been considering, that is the idea that people can act on insight. Various attempts have been made to get round the fact that they obviously can't, the most familiar perhaps being the idea that the important thing is not 'intellectual insight', but 'emotional insight'. However, as I've suggested in the past, there is no obvious reason to suppose that changes of heart are any more potent than changes of mind, and it is far from clear why feeling that something needs to be done should be any more effective than thinking that it should.
What is happening, I think, is that, in much psychotherapeutic thinking, 'insight' has a silent conceptual partner which is assumed but never directly referred to: will power. At the back of our minds, I believe, we are fully paid up subscribers to what one might call the popular philosophy of action, which goes something along the lines that, to do something, first the alternatives are considered (the pros and cons weighed), then a decision is made, and finally the appropriate course of action is willed. We tend to regard the important part of this process as the weighing of pros and cons, somehow expecting that the rest follows on more or less automatically.
According to this philosophy, 'will' is regarded as a kind of internal, semi-moral property, an in-built component of human nature. Some people, certainly, we see as having more 'will power' than others, but we tend to be reluctant to contemplate the idea that anybody could have none. In this way 'will power' could be thought of as rather like petrol, stored in a kind of moral fuel tank somewhere inside us. Even if the tank is nearly empty (i.e. if we see somebody as having 'almost no will of their own'), we seem to be able quite readily to entertain the idea that it can become filled up again through an appropriate therapeutic-type experience (for example we talk quite a bit these days about the 'empowerment' which can be brought about through therapeutic intervention).
Although this notion seems to provide the motive power for turning insight into action, as far as therapeutic theory is concerned it is, as I say, silent, and this because therapists know perfectly well that appealing directly to the application of 'will' is absolutely fruitless. 'Pull yourself together' is not a piece of advice any therapist is likely to find themselves giving, and yet, I suspect, few would say that this was because their client had absolutely no will power. Rather, they would tend to feel that the person is out of touch with his or her power to will changes, perhaps because of some unconscious block or impediment or competing desire to will something else. Therapy, on this kind of view, would be aimed at clearing the path to the person's unencumbered application of will.
Although, again, psychotherapists almost never talk directly about 'will', the concept is, in my view, implied in much of the language of action they are prepared to use. For example, I have certainly come across therapeutic talk of 'internal reserves' and patients' being able or unable to call upon them in a way which is very strongly suggestive of fuel tanks. Humanistic approaches in particular frequently make 'responsibility' an absolutely central plank of their theoretical structure, and it would be very hard to explain how someone could 'take responsibility' for their lives or their actions without the exercise of will.
The problem with the concept of will is indicated, I think, in the difficulty which therapists have in talking about it. Although on the one hand they would be unlikely to admonish a patient to 'use a bit of will power' I have at the same time met very few therapists, if any, who would be prepared to say that there is no such thing as will power. But difficult though this position may be, it is not fatally inconsistent. It could indeed be the case that therapy is precisely about releasing or making available the faculty of will - unblocking the line from the fuel tank if you like. It could be that therapists don't talk much about will power only because there isn't much point in doing so as far as clients are concerned.
But there is a much more serious objection to what I suggest is our silent subscription to the notion of will, and that is an empirical one: there really does not seem to be any such thing as will power.
In our own lives we are likely to observe this only at times of acute conflict or crisis, and most of the time - possibly all of it if we are extraordinarily lucky - our own experience may work to convince us of the reality of will. It may seem to us, for example, that precisely what we do do is weigh up the pros and cons, decide what to do and then will the appropriate action. But clinical experience, if no other, is likely to cast a great deal of doubt on this kind of account. Over and over again, it seems to me at any rate, one is confronted with people who, perhaps after a period of therapeutic clarification, have total insight into the reasons for their predicament, have weighed all the pros and cons for the desirability of change, absolutely desperately want to do things differently, 'decide' to take the appropriate action... and find that they are completely unable to.
This is very frustrating for therapists, not least because they haven't developed the theoretical equipment to deal with it and so cannot really understand why people should find it apparently so impossible to make what seem to the outsider to be relatively simple changes to their lives. As we all know, the likely outcome of frustration is aggression, and it is not uncommon for therapists faced with patients who cannot change to resort to imputations of 'resistance', derogatory diagnostic formulations about 'inadequate personalities' etc., and even to get quite ratty with them - insisting on punitive clauses in 'contracts', etc., etc.
All in all, I think it's difficult to escape recognition of the fact that 'will' is not really a viable psychological concept. However indispensable it may be for the daily conduct of our relations with each other from a moral point of view, it does not really serve to give a coherent account of the way people effect changes in their lives, even when they have full insight into their motives and are truly desirous of making the necessary changes. To say that there is no such thing as 'will power', which I would be inclined to do in an unashamedly positivist manner, is not, however, to say that the concept is meaningless. Obviously, we all know very well what we mean by it, and it has perfectly proper uses in our everyday parlance. But it cannot be used as, dare I say it, a scientific concept: for a psychologist to refer to 'will' as the reason for someone's doing or not doing something has no explanatory value whatsoever.
When, therefore, we come to considering the ways in which people may bring about significant changes to their lives, we have, I believe, to give up an implicit reliance on the notion of 'will' and develop instead an explicit account of the much more acceptable concept of power. If it is not through the application of 'will power' that people change, by what power or powers is it?
Many of the established approaches to psychotherapy have been able to avoid a head-on confrontation with this question largely because they have been able, probably more unconsciously than consciously, to take for granted the possession by the vast majority of their clientele of a wide range of powers which should enable individuals to make some necessary changes to their lives once they are convinced of the importance of doing so.
If the educated, well resourced, middle class clients of the principal schools of psychotherapy appeared to be able to 'will' the changes in their circumstances and relationships that insight revealed as desirable, this was because of the powers, resources and advantages available to them as occupants of a relatively privileged social stratum. It very easily happens - indeed, because of the way we are constructed it is almost unavoidable - that advantages and privileges we acquire virtually without trying come to be experienced as internal moral qualities rather than entirely material resources originating well beyond the boundaries of our own skin.
The language you speak and the way you speak it, your education, the knowledge of social structure you have effortlessly acquired as you grew up in a middle class household, your immersion in 'culture' and the marks of distinction you may have gained from it, are easily, if unreflectingly, seen as personal properties which somehow contribute to your worth as a human being. I don't imagine many here would see themselves or others in quite this light, but it is fairly obvious that many people do: possession of power and veneration of it are intimately related in our society, which is of course the phenomenon through which robber barons have always managed to clothe themselves in respectability.
But when you get down to it - and as psychotherapists I think we really do need to get down to it - pretty well all the powers and resources by means of which we are able to gain a purchase on the world are not at all the result of internal moral virtues, but of material advantages which have in one form or another been wrested (not necessarily by the individual him or herself, of course) from the outside world, and often at the expense of others.
So long as psychotherapists dealt with a relatively uniform social grouping of the middle class, the affluent and the intellectual avant garde, the importance of material powers and resources could escape more or less unnoticed. But when we became involved in the provision of psychotherapy within a public health service, we were faced with a very different situation, and it was then, I think, that we began to become more uneasily aware that the fruits of insight might not be so abundant as we had supposed. And as, during the last fifteen or twenty years, what little in the way of powers and resources which had been available at the less privileged base of our social pyramid has been systematically stripped from its occupants and re-distributed to those higher up its structure, the need to understand what makes it possible for people to act upon their circumstances and their fate becomes really pressing.
One would hardly have thought it possible for us to avoid any longer recognition that what ails people are precisely the 'circumstances and events' of their lives that Freud put his finger on almost exactly one hundred years ago. And having at last accepted that this is so, one might have thought, we would by now be turning our attention to trying to do something about the 'common unhappiness' our social environment gives rise to by attacking its causes in that environment.
Sadly, however, that still doesn't seem to be happening, except here and there on the periphery of our discipline. Rather than seeing that the logic of our analysis of malign social environments as the cause of our clients' distress would be to focus our attention on what could be done about those environments, we appear to be retreating instead into a kind of psychotherapeutic 'theologism' which simply asserts the value of therapy and relies on a mystique of training and accreditation to justify procedures which verge in some cases on the frankly magical.
We construct complex edifices of self-justificatory rhetoric and set up procedures for professional protection and licensing whose dogmas we elaborate and defend with all the controlled authoritarian ferocity of the mediaeval church. We define orthodoxy and censure heresy with truly impressive confidence, and we battle for our corner of the market with a mixture of competitiveness and anxiety which we hide behind an aura of professional certainty.
All this, I think, is no more than a sad demonstration that we, like our clients, like Freud a hundred years ago, are all prey to the same divisive and destructive social forces, which in our case makes intellectual honesty and disinterested enquiry a pretty fragile element of our activity.
If our blinkers slip enough to allow us to catch a glimpse of the implications of our essentially 'environmentalist' analysis of people's distress, what spooks us, I suspect, is that it seems that the professional practice of psychotherapy becomes more or less redundant. It might seem, for example, that any significant 'therapeutic' result would be achieved only through remedial action at the societal or political level. Being honest about the outcome of our investigations of individual distress turns out, so it seems, not to be in our own interest.
Well, I don't think we can duck this issue, but while it places fairly strict limitations on what the practice of psychotherapy can achieve in the way of change, it does not destroy either the moral or the practical legitimacy of psychotherapy. It requires of us a modesty about what we can achieve, and it certainly makes nonsense of much of the professional posturing and squabbling about accreditation, etc., which preoccupies us so centrally at the present time. But it does not demolish us altogether.
Individuals still find themselves in distress and they still need help. In offering what help we can, however, it behoves us not to obscure the fact that the best ways to influence the 'events and circumstances' of people's lives are unlikely to be found in the consulting room. As far as our practice is concerned, we should in my view consider very seriously the possibility that what people need is not an analysis of their 'psyches' so much as one of their circumstances and the powers and resources available to them to try to effect changes to the malign influences bearing down on them.
Now how one might set about this is a very big subject, and there is not the time on this occasion to go into it in detail (I have in fact just finished a book which attempts to do just that), but there are one or two points I should make.
One is that, whether or not we explicitly acknowledge it, most of us already do spend quite a lot of time with our patients or clients in puzzling with them what they can do about the predicament they find themselves in. As far as 'cognitive behaviourism' enters into our practice, that may indeed be a very central plank of our activity. In any case, most research into the practice of experienced therapists suggests that helping patients formulate strategies for dealing with problems in their lives occupies a not insignificant part of the process even if frowned upon from the perspective of orthodoxy.
The good news, then, is that we already have an at least implicit basis for considering in a more focused way the extent to which people have the powers and resources necessary to effect changes, and, if not, whether they can acquire any. The bad news is that nowhere so far are these sufficiently developed for us to make convincing professional claims about what clients can reasonably expect therapy to achieve, and in this I would include 'cognitive-behavioural' approaches which, though in many ways on the right lines, still tend to espouse a stuntingly simplistic scientism which defies clinical experience and trivializes human suffering.
Another point I want to make is that a very significant resource available to the patient is the therapist him or herself. Again this is something many therapists realize, but I think on the whole we fail to follow through its implications. One of the most important powers available to anybody in their battles with a cruel world is that of solidarity with others. It is precisely such solidarity which the availability of a therapist provides, but only while he or she is there.
On the whole psychotherapists have been uncomfortable with the idea that their presence in the therapeutic relationship alone should be considered a significant and legitimate therapeutic factor. Certainly for those of us pressured by NHS management to increase our 'through-put' of patients, the idea that simply making oneself available to someone as a resource of comfort, advice and solidarity is not one seriously to contemplate. But even in that more luxurious end of the market where years long, five-times-a-week private analysis is regarded as perfectly viable, it would still be thought important to discourage patient 'dependency'; therapy, in other words, would still be seen as being about something other than just the provision of the relationship itself.
For some people, however (and they will of course be those least able to pay for five-times-a-week therapy!) it may well be in the world as it is today that the only source of power available to them would be that to be derived from solidarity with a therapist or counsellor. To talk of 'dependency' in situations such as this is simply to overlook one of therapy's greatest assets.
I think there is a great deal for us to ponder on among these issues, and if we did I think we might be led to revise a great deal of what we currently take for granted about psychotherapeutic practice. However this may be, I think perhaps I've said enough about them to be going on with!
1 Pelican Freud Library, Vol. 3, Studies on Hysteria, 1974, p393.