[In D. Braine & H. Lesser (eds), Ethics, Technology and Medicine. Avebury, 1988.]
Psychotherapy covers an extremely broad and varied field of endeavour and takes many forms, which depend for their nature as much as anything upon the particular context in which they are set. It would for this reason almost certainly be misleading to attempt to develop any kind of general critique of psychotherapy, and I should acknowledge at the outset that what follows is based upon a personal knowledge of psychotherapy as it is practised within clinical psychology in the British National Health Service. This is, however, not an inconsiderable area: clinical psychologists, through their influence on theory if not through their practical intervention, have had an enormous impact on the way so-called 'neurotic' patients are 'treated', and it is also reasonable to expect that many of the issues relevant to psychological therapies in this area will be relevant also to psychotherapy more generally. I would however ask the reader to bear in mind that in any discussion of psychotherapy there are very few rules and many exceptions.
Despite attempts here and there to experiment with procedures of 'automated therapy', intrusion onto the psychotherapeutic scene of the paraphernalia of high technology has so far been insignificant. Patients do not sit behind banks of electronic machinery, nor, in established therapeutic practice, do they yet interact with computers. Though some therapists may make quite extensive use of audio or video recording, and a tiny minority use machinery for the registration of physiological variables, the setting in which psychotherapy takes place is, to all outward appearance at least, a matter of human intercourse. This is not to say, however, that psychotherapeutic theory and practice are not deeply imbued with technological values, and there is probably little doubt that, if these could be realized in the form of the reliable procedures and techniques which therapists dream about, financial and managerial interests would quickly establish a computerized therapy industry which would threaten to make the therapists themselves redundant. However, despite the fact that there is an enormous demand for psychotherapy and counselling for almost any conceivable kind of 'problem', and an already evident entrepreneurial interest in this potentially lucrative market, it would, for the time being anyway, be beyond the resources of money and ingenuity of even the most determined advertising campaign to persuade people that 'we have the technology' to cure their psychological ills automatically. On the other hand, the technological assumptions which underpin so much of psychotherapeutic thinking are widely and uncritically shared by both practitioners and patients, and it is upon such assumptions that I want to concentrate in this essay.
Although it is a statement which I am sure many psychotherapists would want to challenge, I can think of no major school of psychotherapy which does not view its task as finding out what is the matter with people and putting it right. In this way, therapy is seen as practical and empirical, and patients as, fundamentally, disordered mechanisms. Psychological symptoms or emotional disturbances are seen as signs that something has gone wrong inside the person which needs changing or adjusting (in his or her experience or 'cognitions', if not exactly in some physical structure). I have, of course, stated the matter crudely, but this essentially technological view of 'psychological disorder' and its 'treatment', though clothed in a wide variety of conceptual disguises, is what provides the justificatory rhetoric for all those therapeutic approaches which the average patient is likely to encounter.
Had I couched the preceding paragraph in language more sympathetic to the therapeutic enterprise it would be hard even to guess what objection I could have to it. Our culture is so saturated with technological values and ways of thought that to view an individuals disturbed behaviour as the projection of some kind of internal psychological problem seems not only reasonable, but the purest common sense, as does any attempt to ameliorate the disturbance by enquiring into and trying to change the internal psychology. It seemed obvious to the early psychoanalysts, for example, that the patient's discovery of why he or she reacted neurotically should, through the process of 'insight', lead more or less automatically to the resolution of the neurosis. Similarly, it seems obvious to the behaviourist that identification of the faulty conditioning process which has led to certain responses keeping company with the wrong kind of stimuli will indicate the correct programme of 're-conditioning' to put matters right. However, it seems to me that even in using terms like 'psychological disorder' (let alone 'neurosis' and 'treatment') we are being deceived by a technological mythology which threatens almost totally to obscure - perhaps indeed is designed to obscure - an understanding of the roots of human distress. Furthermore, the actual experience of psychotherapy teaches lessons about the nature of such distress which quite directly contradict the technological assumptions which therapists, despite their continuous exposure to those lessons, persist in trying to buttress.
There is a vast literature on research into psychotherapy which testifies to a tireless search on the part of practitioners and interested academics for potent therapeutic factors and techniques which can be relied upon to 'work' predictably (see Garfield, 1978, for just one representative tome).
There is some recognition in this literature that human factors may be of importance in producing those benefits which do sometimes seem to follow from psychotherapeutic involvement, but these are regarded with some suspicion. It is, for example, quite often grudgingly admitted that the Idnd of relationship which develops between patient and therapist, the ldnd of people they are and the way they affect each other may have significance for the final outcome, but such factors as these are typically characterized as 'non-specific', and seem disappointingly unlike the hoped-for discoveries of technical procedures which would more reliably deliver the goods. The usual conclusion for researchers in this predicament to reach is that, interesting though human factors may be, what is really needed is a much finer differentiation and measurement of the 'variables' which enter the therapeutic equation; we have not, so it seems, been able to elaborate a technical understanding of therapy only because our methodological tools have not yet been made sufficiently precise - but that day, it is confidently assumed, will not be long in dawning. Since we have yet to develop and apply a suitably sophisticated research methodology to the phenomena of psychotherapy, we need not worry over-much, it is argued, that so far nobody has really been able to demonstrate to the satisfaction even of the relatively gullible that psychotherapy actually does any good.
However, not everyone has been so impervious to the lessons which psychotherapeutic experience and research do seem to teach. There have always been strong therapeutic voices raised against the mechanist or technical approaches to therapy, though they have always been in a minority and even then have, in my view (which is elaborated in greater detail in Smail, 1978, 1984), for the most part failed to take account of the implications of their own criticisms. For example, Jung's objections to the impersonality and sexual reductionism of Freudian psychoanalysis did not preserve him from a kind of occult mechanism (e.g. in the operation of archetypes, the compensatory dynamics of dimensions of personality, etc.) and certainly not from a highly individualizing approach to psychological distress - for Jung it is the 'inner' world which is almost exclusively of interest. Suttie's (1960) correct identification of love as the single most potent therapeutic influence did not lead him closely to trace the implications of contracting to dispense it professionally, and Rogers' (1957) 'humanistic' elaboration of the necessary and sufficient conditions of therapeutic 'personality change' led to one of the most mechanistically ambitious programmes yet to isolate, train, and even build into computers, the requisite therapeutic 'skills' (such as warmth, empathy and genuineness) with whose discovery he is credited. In recent years there have been some excellent books written about psychotherapy which demonstrate its nature very clearly, testifying even movingly to the human nature of the undertaking (e.g. Lomas, 1981, Hobson, 1985) but it is perhaps only Thomas Szasz (1973) who has really challenged the most fundamental technological assumption of psychotherapy, that through tinkering in one way or another with people's psychological mechanisms you can alter their experience of the world.
For the fact we have to face, and which is in my view revealed directly by the experience of psychotherapy as well as indirectly by the inconclusive nature of a massive research effort, is that human beings are not machines and their distress (their 'emotional problems' and their 'symptoms') is not caused by 'dysfunction' located, if not physically inside their own individual skins, then psychologically inside their own individual 'heads'. Why is it that this fact seems so hard for us to assimilate?
I could not possibly try to provide anything like a comprehensive answer to this question within the scope of this essay, and even the very partial answer which I shall attempt contains a strong component of conjecture. I realize, of course, that I have as yet indicated no evidence to suggest that a technological approach to emotional distress, i.e. an approach which concentrates on the technical adjustment of an essentially mechanical fault, is not in principle viable. I shall attempt shortly to make good this omission, but first I should like briefly to suggest what one or two of the factors may be which contribute to our reluctance to abandon a technological stance.
Technology is magic, and as such represents an investment Western society has made in the fulfilment of its dreams over at least the past five centuries. The expectation expressed by Francis Bacon that scientific enterprise would bring to concrete realization what formerly had been the merely empty claims of magicians has in large part proved more than justified. As Keith Thomas (1973) writes:
Francis Bacon listed as desiderata the prolongation of life, the restitution of youth, the curing of incurable diseases, the mitigation of pain, the speeding up of natural processes, the discovery of new sources of food, the control of the weather, and the enhancement of the pleasures of the senses. He wanted divination put on a natural basis so that it would be possible to make rational predictions of the weather, the harvest, and the epidemics of each year. His aspirations were the same as those of the astrologers, the magicians and the alchemists, even if the methods he envisaged were different.
Such achievements, however, have almost all been made in the fields of the physical sciences and the technologies which they have spawned. Scientific activity is no doubt informed by an age-old yearning for control of the environment and personal enrichment, but its methods are by now significantly different, and infinitely more effective, than those of the magicians and alchemists who first attempted to realize them. In the psychological field, however, this is far less obviously the case, and Thomas's fascinating book is full of striking parallels between the practices and claims of, in particular, sixteenth and seventeenth century 'cunning men' and astrologers and those of modern psychologists and psychotherapists. In this way, the procedures of therapeutic psychology, while employing a 'scientific' vocabulary and laying claim to technical efficacy, seem to have evolved but little from those of would-be healers of former times (there are also uncanny resemblances between, for example, present day procedures of psychometric testing and the descriptions Thomas gives of the construction and functions of seventeenth-century horoscopes). The expectation that someone can be significantly changed through weekly (or even daily) visits to a therapist in which all that takes place is talk no matter how emotionally charged - does indeed seem on the face of it no more or less credible than a belief that a person may be psychically transformed through exposure to a witch's incantation.
We have always been and no doubt will always be credulous in such matters, and for this reason alone psychotherapists may rely upon a plentiful clientele. (I should hasten to say at this point that I do not in any way wish to accuse therapists of charlatanism - we are all subject to the illusions of our culture. Psychotherapists are as genuinely convinced of the efficacy of their procedures as astrologers were of theirs.) We are also, of course, extremely vulnerable to the play of interest. In an age when technology enjoys practically unassailable prestige, it is scarcely surprising that psychotherapists should wish to associate themselves with its benefits, and indeed it is becoming increasingly difficult for ordinary people to think of themselves as anything other than complicated machines (e.g. as bundles of programmable 'skills'). In this way both our history (the impetus of our culture) and our interest push us in the direction of a technological approach to our emotional distress.
There seem to be times, and this is one of them, when what we take to be true is determined almost solely by our interests, and our standards of reality are set by our collective !immersion in a kind of communal fantasy. The 'progress' over the last forty years or so of psychotherapy reflects this process, in my view, particularly clearly. Psychotherapy, along with several other aspects of applied psychology, established itself as a 'credible' discipline largely on the grounds of a willingness on the part of its practitioners to submit their activities to a (largely self-initiated) scientific scrutiny. Although, of course, Freud's claim to a fair hearing for psychoanalysis was always made, and not by any means entirely unjustifiably, on the grounds of its scientific status, nevertheless, until about the end of the Second World War, procedures of psychotherapy had relied for their acceptance, whether knowingly or not, on a very distinct aura of mystique. This was successfully punctured by the criticism, and indeed derision, of a number of advocates of the self-consciously hard-headed 'scientific' school of psychology, particularly behaviourists such as H.J. Eysenck. The real take-off point for professional psychotherapy, and a dramatic increase in the extent to which it became available to 'ordinary' people, came with the ensuing rush of therapists of all kinds and persuasions to demonstrate their effectiveness according to criteria generally accepted as 'scientific'. Many schools of psychotherapy, indeed, actually grew out of or became established through this burst of activity. However, the most important and tangible result of this interest in and proliferation of psychological therapies was in fact not a scientifically satisfactory demonstration that all or any of them 'worked', but rather that a whole new profession, or collection of professions, of psychotherapists and counsellors became firmly established and meshed in with a network of interests - their own, their clients', and those of the wider society.
Psychotherapists in the 1980s are in fact no nearer demonstrating the efficacy of any form of psychological treatment than they were in the 1940s, and, interestingly, they now for the most part seem far less interested in doing so. The reason for this lies in there being no longer any pressing reason to do so: psychotherapy and counselling - 'therapeutic skills' and 'counselling skills' - have become an accepted feature of our technological landscape and their efficacy, though unproven, is taken as beyond question. What in fact seems to have happened is that psychotherapy was borne along on a sustained wave of scientific/technical rhetoric to a point where it became established within the structure of technological 'credibility' which pervades our society, and at this point the scientific rhetoric - that which purported to enquire into the truth of claims made - was quietly dropped. To ask scientific questions about the efficacy of psychotherapy or the accuracy of theoretical claims made now invites one's being regarded by practitioners with a certain confusion and puzzlement, as if one is committing an embarrassing anachronism or even offending against an unspoken rule of etiquette. For now a new rhetoric has become established, a semi-professional, semi-managerial rhetoric which assumes or tacitly asserts the efficacy of therapeutic 'techniques', and concerns itself only with questions of their suitability for particular cases or their applicability to particularly interesting problems of social engineering.
This predicament of psychotherapy, if one may be permitted to see it as such, seems to me to do no more than reflect a set of attitudes and beliefs which are deeply and pervasively rooted in our culture. We are gripped by a dream of technological power and success which will allow its dominance to be challenged by no amount of evidence of its fallibility. Too much is at stake, too many interests are involved, too many jobs as well as too many illusions depend upon the validity of our faith in technology for us to be able epistemologically or even morally to be able to challenge it.
And yet it is challenged, over and over again, in the experience of ordinary people, among them precisely those people who present themselves to professional helpers for some kind of treatment or therapy for their emotional distress. For it is not only the voluminous research which has been conducted into the outcome of psychotherapy which suggests that in fact, in the way that we want it to, it does not 'work' - it is also the experience of those who submit themselves to its procedures. This is not to say that psychotherapy is not valuable or of benefit to people, nor even that it is not a useful and necessary resource in modern society (I shall turn presently to a consideration of its positive contribution), but only that it does not cure people of what they expect to be cured of or change them in ways they hope to be changed.
Psychotherapy does not 'work' in this way precisely because human beings are not machines. Technological procedures of fault finding and repair are entirely appropriate to mechanical systems, but, as any gardener knows, other methods of care and cultivation are necessary for organic structures. Only a deeply rooted dogma of individualistic mechanism permits us, against all the evidence, to persist in seeing the pain and despair our society inflicts on people as the result of some kind of personal 'dysfunction' inside them. It is, I am sure, not without significance that adherence to that dogma also permits us, or some of us, to continue the 'pursuit of happiness' enjoined upon us by our culture without worrying too much about the casualities created along the way. After all, broken-down machines can be mended.
Despite the fact that in the heyday of its 'scientific' rhetoric psychology used to refer to people as 'organisms', pscyhologists and psychotherapists have always been too fascinated by the machine model to take seriously the organic nature of human psychological life and experience. The mechanist analogies to be drawn from medicine and surgery, and more recently from electronic and computer technology, have always made it almost impossible to think of people's 'symptoms' and 'problems' as anything other than the result of the malfunction of bits and pieces of 'psychic' or 'cognitive' machinery inside them; bits and pieces, furthermore, which can at least in principle be excised and replaced. While it is true that we continue, despite evidence to the contrary (e.g. Illich, 1977), to persuade ourselves of the soundness of the fields from which these analogies are drawn, there are still psychological aspects of our conduct which are so recalcitrant to mechanical forms of interference that we would not dream of trying to treat them in the way that we do our 'mental disorders'. For example, we seem to have a clear tacit understanding that the acquisition of language or of practical abilities like swimming or bicycle riding is not something which can be implanted by experts (whether magicians, surgeons, hypnotists, etc.) nor indeed something which can be simply erased or replaced. These are things which have to be learned by the subject, often painfully, and once learned cannot but for exceptional circumstances be forgotten. One cannot cure people of knowing how to swim, and though a native speaker of English can certainly learn Chinese, knowledge of the latter cannot replace or be swapped for knowledge of the former - one cannot eject the English programme and pop in the Chinese one. And yet this is precisely what we expect to be able to do with whatever structures of learning and experience underlie the 'symptoms' of emotional distress. Through 'insight', or 'corrective emotional experiences', 'catharsis', 'abreaction', 'interpretation', 'positive self-talk', 're-conditioning', 'systematic desensitization' and so on and on, we nurture the illusion that somehow we can clean up the psychic machinery so that it will respond in an 'adjusted' way to a world which is, presumably, taken as simply given, 'there', and to be adjusted to.
But human beings are embodied organisms who are located in a world which is as much the creation of social praxis as the creation of God or Nature. Despite frequent ritual acknowledgement of the philosophical problems presented by psycho-physical dualism (again a feature of scientific rhetoric never really taken seriously), psychologists and psychotherapists have always found it difficult to escape from conceiving of people as anything but, on the one hand, minds inhabiting bodies, or, on the other, only bodies or only minds. Thus behaviourists take up a precarious posture on the 'physicalist' horn of the dualist dilemma, while 'dynamicists', humanists and some 'cognitivists' still cling to the 'mentalist' horn; uncomfortably trying to get a purchase on both are those who are willing to envisage some form of philosophical hybrid like 'cognitive behaviourism'. We do not seem to be able to see that mind is body (and body mind), and that the pain and suffering we feel as somehow inside us are inflicted through our bodily relation to a world from which we can only pretend to escape. Our ,psychic experience, has been, as it were, inscribed upon our living tissue, just as has our knowledge of a mother-tongue. Since it has been inscribed by something, or perhaps better through our relation to an inescapable world, it makes little sense to try to treat our distress by rummaging around inside our bodies or, by the use of drugs for instance, blunting our awareness of the world we inhabit by interfering with the chemistry of our perception of it. Nor does it make any sense to try to alter the way we see or think about things through the use of some form of 'positive' self-suggestion. It is only the legacy of magic in our thinking which permits us seriously to entertain the idea that by some kind of process of insight or self-instruction we can change our experience of a reality which is none the less real for having been created in part by us. You cannot learn to speak Chinese or to play the piano merely by thinking about it or imagining yourself able so to do. Even though he appears still to believe in the possibility of a relative freedom from the past which I am unable to accept, Roy Schafer (1976) approaches the problem of 'cure' with unusual honesty:
...while the past may be partially re-experienced, reviewed, and altered through reinterpretation, it cannot be replaced: a truly cold mother, a savage or seductive father, a dead sibling, the consequences of a predominant repressed fantasy, years of stunted growth and emotional withdrawal, and so forth, cannot be wiped out by analysis, even though their hampering and painful effects may be greatly mitigated, and the analysand freed to make another, partly different and more successful try at adaptation. The analysand whose analysis has been benignly influential retains apprehensions, vulnerability, and characteristic inclinations toward certain infantile, self -crippling solutions, however reduced these may be in influence and however counterbalanced by strengthened adaptiveness.
A person acquires his or her experience as a plant acquires the structures of its growth. One may strive to correct the conditions of an environment which leads to, say, a tree's weak or stunted growth, its withering from lack of shade or moisture, its leaning before a prevailing wind, but one cannot (sensibly) correct such eventualities merely by concentrating on the body of the organism itself. The kinds of misery which lead people to seek psychotherapy would best be prevented through the development of a society in which values of care and justice were central. This, of course, is Utopian, and one can envisage no society from which confusion and cruelty will be absent, but at least we could stop pretending that the ravages they cause can be put right by technical intervention after the damage has been done. Even the most ruthless factory farmer has a more accurate knowledge of the importance of the conditions in which his produce is raised.
If psychotherapy 'worked' technically, in the way we would like it to, somehow to change the conclusions people draw (and act upon) from the painful lessons their embodied experience of the world has taught them, it would indeed constitute a magical panacea, a blessing of unimaginable proportions. But only in the right hands. For if what people feel and think and do were really so amenable to the technical 'skills' of therapists and counsellors, one need have little doubt that the interests of power would quickly conceive of ways in which such technical mastery could be put to 'good' effect. In this way the tough resistance to change of our organically rooted experience may be a blessing in disguise, and perhaps even lend a kind of positive significance to our suffering. Even if we cannot realize the dream of being able to soothe away the scars of a wretched childhood, nor can we all that readily persuade those who have been through its mill that our social order is based on the values of fairness and sweet reason. Psychological distress is a tangible reproof for the way we treat each other.
What psychotherapists do, and what they achieve with individual patients, need of course bear no resemblance to their rhetorical claims or theoretical fantasies, and the fact that we do not change or cure our patients in the way both we and they would like need not be all that dismaying. For psychotherapy can legitimately have other purposes than the technical adjustment of people to a society uncritically accepted as given, and it is probably the case that in fact, whatever their conscious intentions, psychotherapists do very often render services of great value to their clients. For example, psychotherapy can clarify the mystery which surrounds people's experience of distress, and the 'therapeutic relationship' can be one from which people derive great comfort, as well perhaps as the encouragement to confront difficulties from which previously they had shied away.
The technological rhetoric of psychotherapy buttresses a society based on exploitation, since it promises painlessly to heal emotional injuries incurred by people in their struggle for 'happiness', but it contrasts strongly with what is often the 'demystifiying' effect of psychotherapy, which is to clarify for people that their distress arises not from some kind of personal fault or inadequacy, but rather from their having been situated in an unavoidably difficult set of circumstances. Very few psychotherapists trace the evils that beset their patients to the economic and political structure of our society, but even so most will be concerned to guide their patients gently and sympathetically to an appreciation that their 'problem' is not one of personal moral failure, but one which in fact stems from their embeddedness in a world outside their own heads. (The irony, of course, is that therapeutically this is a largely unconscious process, most therapists happily believing that what they are engaged in is a technical procedure of individual adjustment.) Very few people become psychotherapists who are not fundamentally affiliative towards their fellow creatures and hence tolerant of their sins and compassionate towards their pain. Because of this, patients are likely to find considerable comfort from their relations with their therapist, and indeed for many their experience of therapy may constitute the first time in their lives that they have been able to command the attention of a truly concerned and competent human being who is willing, even if only in circumstances strictly limited by professional boundaries, to place his or her resources at their disposal.
If there is no possibility of curing, there is no shame in comforting. Psychotherapy, whatever hopes and claims are expressed for it, will never cure the emotional injuries which we inflict upon each other. Avoidance of such psychological damage will not be achieved by technological means, but only through our developing a society in which we treat each other with greater care and kindness.
Garfield, S.L. 1978, Handbook of Psychotherapy and Behaviour Change, New York: Wiley.
Hobson, R.F. 1985, Forms of Feeling. The Heart of Psychotherapy., London: Tavistock Publications.
Illich, I. 1977, Limits to Medicine, Harmondsworth: Penguin Books.
Lomas, P. 1981, The Case for a Personal Psychotherapy, Oxford: Oxford University Press.
Rogers, C.R. 1957, The necessary and sufficient conditions of therapeutic personality change, Journal of consulting Psychology, 21, 95-103.
Schafer, R. 1976, A New Language forPsychoanalysis, Yale University Press.
Smail, D. 1978, Psychotherapy. A Personal Approach., London: Dent.
Smail, D. 1984, Illusion and Reality. The Meaning of Anxiety., London: Dent.
Suttle, I.D. 1960, The Origins of Love and Hate, Harmondsworth: Penguin Books.
Szasz, T. 1973, The Myth of Psychotherapy Oxford: Oxford University Press.
Thomas, K. 1973, Religion and the Decline of Magic, Harmondsworth: Penguin Books.