[BPS Psychotherapy Section Newsletter, no 20, Dec 1996, pp 3-13; also in House, R. & Totton, N. Implausibe Professions. Arguments for Pluralism and Autonomy in Psychotherapy and Counselling, pp 159-170. Ross-on-Wye: PCCS Books.]
Increasingly, it seems to me that psychotherapy lives in a world of its own.
I'm not entirely sure why this should be. Perhaps its just that I'm getting older, callused by the years, and less susceptible to idealistic visions. The explanation I prefer, though, is that the end of the Twentieth Century has yielded up a very different world for most of us than did the middle, when perhaps the real boom in therapy could be said to have got under way in earnest (when, that is, a largely esoteric set of psychoanalytic mysteries began to give way quite rapidly to a luxuriant crop of therapies widely available and understandable to non-initiates).
However this may be, the contrast between the world outside the walls of the consulting room and that within them has, for me, become so stark that what goes on inside seems to have almost no relevance any more for what goes on outside. Unless, I suppose, you occupy one of the more protected ghettos of the metropolitan middle class and/or are able to surround yourself with the excited make-believe generated by the information and publicity media of so-called 'postmodernity'.
During what Eric Hobsbaum calls the 'Golden Age' of this century, which stretched roughly from the end of the Second World War until it began to unravel in the mid-Seventies(2), occupants of the developed Western world enjoyed a relative social and economic stability and prosperity which enabled us to believe that the choices open to us in the conduct of our lives were fundamentally matters of psychology. For example, if you wanted to work, you did, and, what's more, in the field of your choice. Personal relationships could be established and their continuance anticipated in a setting where the essentials of livelihood - money, housing, health care, pensions, etc., etc. - seemed to have a predictably stable future. So the variability in what we did - the triumphs as well as the catastrophes, the joys as well as sorrows, seemed to be more a matter of our psychology - our personal inclinations and understandings, our 'insight' and our 'will' - than of the influence of any factor external to us. In this setting, if things were going wrong, it seemed entirely plausible to assume that it must be because of mistakes one was making oneself; one looked inside rather than outside for the reasons for failure and unhappiness, and in that situation the assistance of psychotherapy seemed an entirely natural recourse.
However, for most people the past fifteen years or so have, progressively, undermined our security. The future has become uncertain, relationships troubled. The distal economic and political influences which provided the taken-for-granted structure in which we could, so to speak, exercise our psychology have undergone incalculable and apparently uncontrollable changes. The (albeit paradoxically) stabilizing cold war has given way to, at worst, chaos, criminality and nationalist genocide, and, at best, economic privation for the most vulnerable members of society, ruthless opportunism and the construction of a new morality centred entirely on the values and standards of Business. Nation-states have become relatively impotent in a rapidly globalizing economy so that not only individuals but also their collective political institutions are barely able to influence events. Suddenly we are confronted with the realization (even if dawning only slowly) that it is not we who control our lives through the personal choices we make, but powers whose operation we can often not even see, let alone understand and influence.
For many, many people the world has become bleak, and cold and dangerous in ways which we would have been hard put to it to imagine twenty years ago. The psychological consequences of this are a deep and pervasive sense of insecurity; multiple crises of identity (as a person, a worker, a sex, a nationality); the disintegration of 'relationship'; an increase in the desperate opting for the reassurance of magic, religion and make-believe; a withdrawal into privatism as well as a tendency to violent tribalism. And so on.
Small wonder perhaps that psychotherapy should be a major growth industry in this context. Walking into the cosy warmth of the consulting room provides a refuge from the cold, threatening world outside which is hard to resist. Psychotherapy, certainly, could opt to become one of a number of comforting illusions which, like astrology, born-again religion, or the racial mythology of fascism, offer a corner in which to escape from the privations of a cruel world, and no doubt psychotherapists could in the process make a reasonably decent living. But if so we'd certainly have to give up any scientific pretensions. What strikes me most about psychotherapy in the context of the current world is, I must say, what I can only describe as a kind of deranged optimism.
For what the past decade or two show us in ways we can no longer ignore is that people are injured, psychologically as physically, not essentially by errors of their own judgement, the vagaries of their consciousness, lack of insight into their own motives or failures of their will, but by the operation of basically material powers and influences in the world around them. What really upsets the apple-cart and buggers up people's lives and relationships is threatening their livelihood, throwing them out of work, stripping them of social meaning, depriving them of health and education, pillaging and destroying their environment, and so on. (Note that, from the perspective of the peaceful corner of the world we occupy here, I'm not even mentioning, starving, torturing, shooting and bombing them, killing their relatives, etc.)
The idea implicit in so much of psychotherapy that individuals can be lifted out of this context, ignore all the influences bearing down on them from the wider world and somehow work out their own destiny just no longer seems credible. The wounds people are coming to us with can no longer be seen as self-inflicted, and certainly not within their power to mend themselves. The lesson which impresses itself on the late Twentieth Century psychotherapist is, I submit, not so much that our clients' difficulties represent an id to be converted to ego, an existential responsibility to be grasped, or even, pace Freud 1895, an 'hysterical misery' to be transformed into 'common unhappiness'(3). What confronts us inescapably, I suggest, is that life is tragic.
By this I mean that the ills which beset us are not in our own power to eradicate or control; that is to say, there is usually very little, if anything, the individual can do successfully to act on the forces which blight his/her life, whether these stem from powers greater than him/herself or from the flaws of his/her own character.
It is not, of course, that this is a new development, and the last thing I want to do is suggest that it is only in the last twenty years that our lives have become tragic. (From Aeschylus in the 6th century BC to Thomas Hardy in the 19th AD, tragedians have portrayed the helplessness with which the individual has so often to become the spectator of his/her own destruction.) It is more that economic and political developments over the last few years have worked to dispel the illusion that, as psychological entities, we have power over our own destiny. The author of the Encyclopaedia Britannica's (15th edition) entry on 'Tragedy' notes that:
The absence ... of a great tragic theatre in the 20th century may be explained by the pantheon of panaceas to which modern man has subscribed. Politics, psychology, social sciences, physical sciences, nationalism, the occult - each offered a context in terms of which he might act out his destiny, were it not crowded out by the others... In the dramas of Athens and England, tragedy was born of the impossibility of a clear-cut victory in man's struggle with powers greater than himself.
On a personal note, I find this vision the more persuasive since I come to an appreciation of tragedy because of rather than despite my experience of psychotherapy. For it has been wrestling with the difficulties and contradictions of psychotherapy which has convinced me that there is too often an almost fateful inexorability about people's troubles for them to be seen as 'curable', or at least as lying within their own power to ameliorate. Quite often positively embarrassed by the blandness and glibness of the verbiage of so much therapeutic theory and practice, it was with tremendous relief that I came to the pathetically belated realization that the view I was developing of the enormous impediments to 'change' in my own and my clients' struggles with life was in some respects one that I shared with Sophocles and Shakespeare.
I'm sure I'm not alone in this. Many psychotherapists, I know, are sobered as well as moved by the plights experienced by their clients, and some, as for example Roy Schafer(4), have explicitly acknowledged the tragic dimension of their undertaking. But the vast bulk of the therapeutic literature - whether 'dynamic', humanistic' or 'cognitive-behavioural' - betrays an extraordinarily facile optimism about what people can achieve by, essentially, tugging fairly hard at their own boot-straps with a bit of encouragement from the sidelines by their therapist.
There's something very paradoxical about people who sit listening to the deepest pains and sorrows of others day in and day out, and witnessing as well the all too frequent failure of their best and most courageous efforts to overcome them, ending up with the promotion of fatuous
notions like 'interpretation of the transference', 'taking responsibility' or 'cognitive restructuring', etc., etc.
But if psychotherapy has very little to say about how people are to escape the tragic inevitabilities of their lives, it certainly provides us with endless material showing how tragedy comes about, even if the significance of this is mainly to confirm what human beings and the chroniclers of their tragedies have known from the very beginning. I'd suggest in fact that the actual experience of psychotherapy emphasizes in particular the two themes which are given most prominence in literary tragedy: the unavoidable outcome of fatal flaws of character, and the inexorability of social power. Ironically, it is precisely the inevitability of these two types of adversity which psychotherapy underlines in the very process of setting out to 'cure' them.
If psychotherapists really were able to alter character we'd surely by now be a society of clones. Contrary to the nightmares of Huxley or the daydreams of Skinner, the lesson which seems to me to be drawn from the practice of psychotherapy is that it is extraordinarily difficult for people to change the psychological characteristics which become, as they grow up, part of their embodied make-up. It is, for example, no easier for you to change your basic self-confidence than it is to start speaking Chinese. It may even be more difficult. The impress of power stamps upon us at the most vulnerable stages of our development experiences of and attitudes towards reality which - as tragedians often show so movingly - we spend the rest of our lives working out(5).
This kind of process has of course not escaped our attention, but rather than take it seriously as a given of the human condition, we tend to psychologize it with facile notions like 'repetition compulsion' or 'unfinished business' which carry with them the entirely unjustified assumption that past experience is a kind of mistake which can be corrected. We encourage a view of the often agonized knowledge that people acquired of the world as children as 'baggage' which can somehow be jettisoned. With the best will in the world, and having for decades struggled to realize the therapeutic dream of relieving people of their painful pasts, I can find no evidence that the possibility of doing so is anything more than wishful thinking.
When it comes to looking at the problems that beset people in the present, we do not find ourselves on very much stronger ground. Beyond acting as a kind of personal sponge to soak up people's distress, psychotherapists have no power to act on the social influences which give rise to that distress in the first place, and quite often are in no position even to see where it's coming from. William Epstein, in a damning critique of the claims of psychotherapy, makes the point more forthrightly than anyone so far(6) that psychotherapy's privatizing of what are in fact public deficiencies has absolutely no rational evidence to support it and is maintained only because of its political convenience to those who want to maintain the material advantages which they already have. Psychotherapy, he suggests:
is an immensely attractive strategy for a society that is reluctant to allocate substantial funds to address its problems. If it were effective, then psychotherapy would offer efficient, low-cost remedies. Yet, even apart from the issue of its effectiveness, psychotherapy still provides a useful vehicle to proselytise the ideology of social efficiency in evading more productive and expensive approaches to social problems...
The ideology of therapeutics is ... consistent with a conservative social ideology that is unwilling to accept broad-based social expenditures to provide greater social equality through government action.
It is not of course that psychotherapists are politically motivated villains deliberately trying to pull the wool over the eyes of their unsuspecting clients. It is more that, sheltered by a politico-economic climate which has its uses for us, we are at present enjoying a fools' paradise. In a wonderfully funny article in Changes a while ago, Simon King-Spooner likened psychotherapy's position to that of the white dodo(7), a native of the island of Réunion in the Indian Ocean. Described by a contemporary as 'a great fat fowl of the bignesse of a Turkie, and so short-winged they cannot flie, being white, and in a manner tame', the white dodo came to grief, King-Spooner points out, because it failed to keep itself in trim to cope with the predators who, inevitably, eventually found their way to the island. Psychotherapy, likewise, needs to pay careful attention to its critics if it is not suddenly to find itself overtaken by events.
Critiques like that of Epstein are already casting very hawk-like shadows over us, and may well proliferate as the future unrolls. If psychotherapy is to avoid the risk at some perhaps not too distant point of becoming dismissed as an irrelevance, it is going to have to address itself to the contradictions involved in claiming to be a 'treatment' for ills which are in fact the result of societal pressures far out of our personal reach to influence.
In my view, therapeutic psychology has at the end of the Twentieth Century to make fundamental adjustments to the philosophy it instituted at the beginning of it. In a fascinating passage in one of his Introductory Lectures, written, interestingly, only a year or two before the outbreak of the First World War(8), Freud chides Sophocles for the 'amorality' of his treatment of the Oedipus legend. I've often wondered how Freud managed to derive his version of the 'Oedipus Complex' from Sophocles's tragedy, since, apart from the name, there is so little resemblance between the two. But this passage makes it plain: Freud simply dismisses the tragedian's concern with the relation between Oedipus and powers (the gods) greater than and outside himself, and wrenches the structure of the work into a form which will support his own, entirely contrary notion of internalized will and unconscious morality. Completely disregarding the fact that Oedipus is overtaken by his fate despite the best efforts of all to avoid its coming to pass, and tries, desperately and unsuccessfully, to discharge his duty by obeying the dictates of superior power, Freud maintains instead that there is a 'secret sense and content of the legend' to which the auditor reacts.
He reacts as though by self-analysis he had recognized the Oedipus complex in himself and had unveiled the will of the gods and the oracle as exalted disguises of his own unconscious. It is as though he was obliged to remember the two wishes - to do away with his father and in place of him to take his mother to wife - and to be horrified at them. And he understands the dramatist's voice as though it were saying to him: You are struggling in vain against your responsibility and are protesting in vain of what you have done in opposition to these criminal intentions. You are guilty, for you have not been able to destroy them; they still persist in you unconsciously.' And there is psychological truth in this. Even if a man has repressed his evil impulses into the unconscious and would like to tell himself afterwards that he is not responsible for them, he is nevertheless bound to be aware of this responsibility as a sense of guilt whose basis is unknown to him.
What is particularly interesting about this, I think, is its demonstration (to be found throughout Freud's work) of the out-and-out moralism of the man who, in his 'scientific' guise, is so often credited with the invention of 'psychic determinism'. What we witness in passages such as this - portraying the repression of 'evil impulses' for which 'we like to tell [our]selves afterwards that [we] are not responsible' - are not scientific observations, but precisely the laying of the foundations of the 'conservative social ideology' of which Epstein writes. Indeed, so far from maintaining scientific detachment, Freud has positively to mutilate Sophocles's play in order, like a cuckoo, to install within it his own brain-child.
Freud was quick to see - if only unconsciously! - that the raison d'être of psychotherapy as the treatment of private individuals would be very hard to maintain if patients were not to be seen as at least in some sense responsible for their predicaments and able, once id had been transformed to ego, to will the appropriate changes to their conduct. As with Sophocles, so with the individual patient: the tragedy had to be taken out of life and replaced by responsibility. It is with the reversing of this reversal, I submit, that psychotherapists should now concern ourselves if we are not to waddle off dodo-like into extinction.
The best hope of rescuing a life from tragedy - certainly of the 'flawed character' variety - may well be the exact opposite of attending to and working on its origins within the private individual. Once character has been fatefully impressed upon as relatively powerless infants by the overwhelmingly much greater powers around us, there is not a great deal to be achieved by our trying to turn ourselves inside-out in a desperate attempt to reconstitute ourselves as other than we are, by trying to replace the forces that created us by optimistic but impotent myths, or by rejecting the truths we have learned about life for falsehoods we would prefer to believe.
Much more to the point might be trying collectively to create a world which could receive and make sense of what we have learned about it. Suffering is a form of knowledge. It tells us what is wrong with our world. But society is more willing to listen to some messages than to others. The kinds of things people whose distress takes them to psychiatrists and psychotherapists have to tell us are often exactly what we are least willing to hear. What happens in these circumstances is that the voice of suffering is simply ignored, treated as without meaning, or as a 'personal problem' for which the person him/herself has to 'take responsibility'.
There will always be suffering, for some things which are wrong with the world are just inevitable and some, such as our biological mortality, are even necessary. The tragic element cannot be escaped. But that does not mean that we should not struggle to provide a world which makes use of what people have to tell us. What may rescue the most tortured or damaged private existence is, ideally, finding meaning within a public world which acknowledges and makes use of the experience of pain.
If the worst comes to the worst we could compensate for personal privation and disadvantage by treating people as more than mere psychological entities (more, that is, than the sum of their private experience) and as having a possible function in public space. Increasingly in the world as it is, people are just reduced to their private selves, so that there is no possibility of their escaping the ravages of their past by being able, not to deny it or erase it, but to overcome it. In this way, if we're not careful, the principal contribution of psychotherapy becomes to inflate the importance of private experience and help imprison people within it.
What I'm suggesting, then, is turning from the inner to the outer. Precisely the opposite of Freud's manoeuvre. In many ways this is a matter not for psychotherapy, but for politics. And indeed I do think, as I have argued for many years now, that the best hope for improving the lot of 'ordinary people' - psychologically as in every other respect - is through the building of a re-dignified politics. There is precious little sign of that happening at the present time.
But, if we started to take seriously the view that what damages people are the powers of a social world which bear down upon them, and if the influences of childhood all too often constitute the tragically unalterable casting of dice, where does this leave the practice of psychotherapy?
I must admit that I don't think the implications of this view are all that encouraging for psychotherapy, but neither are they disastrous. They are least encouraging for those who would hope to make the case for psychotherapy - whatever the particular brand - as constituting some kind of, if not cure, then technical recipe for change to be achieved through the knowledge of the therapist as professional expert. The most that a therapist who aspires to this kind of role can hope to achieve, I suspect, is to engage with patients in a kind of strategic review of the options open to them to make a difference to their lives. This assumes of course that the patient has options.
No doubt most of the patients who formed the clientele of the originators of the principal therapeutic schools were pretty well-resourced individuals whose material advantages afforded them a range of choices in the conduct of their lives. Certainly, what little research there is in this general area suggests that psychotherapy is indeed most effective with YAVIS patients (young, attractive, verbal, intelligent and successful(9)). In any case, psychotherapy on this view has to relinquish any claim, explicit or implicit, to the transformation of its clients, and becomes merely a procedure through which their assets and liabilities are audited. There is of course no shame in providing such a service, but it is unlikely to be of use to anyone whose assets are strictly limited.
Psychotherapy may also have quite a useful role in demystifying its clients about the origins of their distress. Although I think psychotherapists often perform this function unawares, it is not on the whole a conscious and deliberate part of their purpose. The (not-always-stated) aim of most approaches to therapy is to confront patients with the unconscious intentions or faulty attitudes, etc., through which, supposedly, they create and maintain their problems. In fact, on the other hand, quite a lot of the work in therapy of clarification of the causes of distress may well concentrate on the past and present circumstances which gave rise to it and which were in fact in no way attributable to the patient's agency.
If this could become a deliberate and central, rather than an accidental, feature of psychotherapy it might certainly have its uses in relieving some of the distress which goes with people's feeling responsible for their own predicament. To draw people's attention to the noxious structure of social power in which their troubles are generated could thus be a possibly comforting and mildly subversive activity, but it wouldn't of course change anything at all basic. Psychological pain might be slightly the less painful for having an accurate explanation attached to it, but it is certainly not eradicated thereby, and the actual causes of distress still lie well beyond the therapist's sphere of influence.
But if therapists can't solve their patients' problems, at least they can offer their sympathy and their solidarity. If to suggest that we cannot 'change' people may be seen as a defeat for the therapeutic enterprise, we may yet come to see the converse - that we accept people as the characters they inevitably are, without diagnosing or pathologizing them - as one of its principal potential strengths. An existence already marked by tragedy is rendered the more intolerable by suggestions that, either morally or aesthetically, the person could or should be otherwise.
The nature of the relationship between therapist and patient has of course been a matter of intense concern throughout the past hundred years, with just about every shade of opinion being represented, from the advocacy of the therapeutic aloofness of orthodox psychoanalysis, through the emphasis on warmth, empathy and genuineness of the Rogerians, to the unabashed avowal of therapeutic love (the most eloquent expression of which probably being Ian Suttie's(10)).
I think it is in fact extremely difficult to escape the conclusion that the most potent aspect of psychotherapy is the solidarity afforded patients through their relationship with someone taking an intense, on-going interest in their welfare. Having someone on one's side makes a genuine, material difference to one's ability to do battle with the world. This, indeed, is what 'relationship' is all about. But this is an uncomfortable notion for psychotherapists to accept, and it is little wonder that they regard it as uneasily as they do, for the questions to be asked are obvious.
If, after all, the most useful thing therapists do is offer patients their support, what distinguishes them from anyone else in this respect? How could the provision of solidarity in this way justify professional training and status? What are the ethics of providing, in essence, love for money? What limits should be placed on such support? What about issues like 'dependency' and so on? Wouldn't such an approach lead to the provision of open-ended 'therapy' which would simply defeat its own object by rapidly becoming unavailable on any significant scale?
Perhaps, as much as anything, it is the democratization of therapy which has embroiled us in these paradoxical tangles. For therapy on the original analytic model of five-times-a-week for as long as it takes comes very close to constituting the purchase of a kind of personal confidant who really does become a significant figure in the individual's landscape, someone who can share with him or her the unavoidable tragedies of life, offer consolation and attempt to give them meaning. There would be little point in trying to persuade the few who can afford that kind of attention that the theoretical ideas underlying it didn't hold water. It would be a bit like telling an octogenarian billionaire that the beautiful twenty-year-old he'd just married didn't really love him for himself - the entirely understandable answer would probably be 'so what?'.
But psychotherapy has now become a technicized industry in which through-put has become a central aspect of its processing of people in distress, and we are if anything more wary than ever of acknowledging that our principal and most potent function lies in accepting people as they inevitably are and providing solidarity in the face of tragedy. That would be a modest aim indeed, and certainly wouldn't change the world. But neither, surely, would it be dishonourable.
1 First read as a paper at a conference in April 1996 of the British Psychological Society's Psychotherapy Section in memory of J. Richard Marshall.
2 Hobsbaum, Eric. 1994. Age of Extremes. The Short Twentieth Century 1914-1991. Harmondsworth: Michael Joseph, Penguin Books.
3 Pelican Freud Library, Vol. 3, Studies on Hysteria, 1974, 393.
4 Schafer, R. 1976. A New Language for Psychoanalysis. New Haven and London: Yale University Press.
5 For a fuller account of the role of social power in the generation of psychological distress see Smail David, 1993, The Origins of Unhappiness, London: HarperCollins, and, 1996, How to Survive Without Psychotherapy, London: Constable
6 Epstein, William. 1995. The Illusion of Psychotherapy. New Brunswick & London: Transaction Publishers. Both quotes p. 6.
7 King-Spooner, Simon. 1995. Psychotherapy and the white dodo. Changes, 13, 45-51.
8 Freud, S. 1973. Introductory Lectures on Psychoanalysis. Vol I, p. 374. Harmondsworth: Penguin Books.
9 W. Schofield (1964). Psychotherapy: The Purchase of Friendship, Prentice-Hall.
10 Suttie, I. 1960. The Origins of Love and Hate. Harmondsworth: Penguin Books.