Psychotherapy

A Personal Approach

 

D.J. Smail

 

 

Contents

    Acknowledgments
1   The Context of Psychotherapy
2   Approaches to Psychotherapy
3   Research in Psychotherapy
4   The Scientific Philosophy of Psychotherapy
5   Freedom and Responsibility
6   Self-Awareness and Self-Deception
7   Aspects of Negotiation
8   The Practice of Psychotherapy

 

Acknowledgments

The author and publisher wish to thank the following for permission to reproduce copyright material:

Feyerabend, P. To New Left Books for an extract from Against Method (1975).

Fingarette, H. To Routledge and Kegan Paul Ltd and Humanities Press for an extract from Self-Deception (1969).

Freud, S. For an extract from ‘The Unconscious’, to the Hogarth Press Ltd (Standard Edition of the Complete Psychological Works of Sigmund Freud, 1915. Trans. and ed. James Strachey. Vol. XIV) and to Basic Books, Inc. (The Collected Papers of Sigmund Freud, Vol. IV, edited by Ernest Jones, M.D., authorized translation under the supervision of Joan Riviere, published by Basic Books, Inc., Publishers, New York, by arrangement with the Hogarth Press Ltd and the Institute of Psycho-Analysis, London).

For an extract from ‘Femininity’ to the Hogarth Press Ltd (Standard Edition, Vol. XXII) and to W. W. Norton, Inc. (New Introductory Lectures on Psychoanalysis, 1965).

Hayek, F. A. To the Hutchinson Publishing Group Ltd and Random House, Inc., for extracts from ‘The Primacy of the Abstract’ in A. Koestler and J. R. Smythies (eds.) Beyond Reductionism (1972).

Jung, C. G. To Routledge and Kegan Paul Ltd and Princeton University Press for extracts from The Practice of Psychotherapy (1954).

Koch, S. To the Journal of Humanistic Psychology for an extract from ‘The Image of Man Implicit in Encounter Group Therapy’ (Fall 1971).

Landfield, A. W. To John Wiley and Sons Ltd, for an extract from the chapter by Landfield in D. Bannister (ed.) Issues and Approaches in the Psychological Therapies (1975).

Polanyi. M. To Routledge and Kegan Paul Ltd and University of Chicago Press for an extract from Personal Knowledge (1958).

Sartre, J. -P. To Methuen and Co. Ltd and Librairie Gallimard, and to Philosophical Library, Inc., for extracts from Being and Nothingness. Reprinted by permission of Philosophical Library, Inc. Copyright © 1956 by Philosophical Library, Inc.

 

1

The Context of Psychotherapy

There tends to be a certain mystique surrounding psychotherapy. This often occasions in the uninitiated that attitude of almost reluctant reverence - easily turning to derision - which is usually to be found in situations in which we invest others (priests, gurus, doctors) with powers and abilities more advanced than our own. With some notable exceptions, psychotherapists themselves have done little to puncture this mystique, and indeed many continue to further by all means possible an image of themselves as expert technicians in the alteration of human behaviour and psychological suffering, or as possessors of some kind of ultimate knowledge of how human beings should be, and how to get them to be it.

Our culture is saturated through and through with beliefs about human nature and society which provide a rich nutrient on which the psychotherapy industry can feed. Men and women should be happy - anxiety, depression, fear, panic and confusion are in no way acceptable, and, where they do arise, are to be banished as quickly as possible from the psychological scene. People must be competent to achieve those - largely materialistic - aims which fall within the range of possibilities determined by their social position. People must get on with other people. Love is good and hate is terrible. People must be sexually ‘adjusted’ and must enjoy sex. Families must be harmonious. People must find out what their ‘full potential’ as human beings is, and then realize it. People by and large cannot help the way they are: they are moulded by genetic endowment, the physical world and their relations (particularly in childhood) with others. You need an expert to see what’s gone wrong and to put it right.

The experts, certainly, are ready and waiting, and the credibility of their role is immeasurably reinforced by the confidence in its own institutions our society generates. Social institutions, indeed, are often scarcely seen as human creations, and hardly at all as the frail and fallible, transitory structures they are. They are seen rather as enduring realities, as tangible proof of the correctness of our social vision, as validations of our ideas about our own nature and conduct. And the claims to expertise of our experts are upheld by the very fact that they hold a position in the institutional network. For example, the very existence of schools and universities, professional teachers’ organizations, hierarchies of academic rank, and so on, tends to be taken by all but a handful of critics as a kind of tacit justification of our fundamental ideas about the nature of education (e.g. that knowledge is taught to pupils by teachers).

This kind of attitude is well exemplified by the remarks of a student psychiatric nurse which demonstrated her readiness to abandon her own experience in the face of institutional disconfirmation. Her impression of her patients was that their problems stemmed from social and material difficulties, but not from illness; but they must be ill, she concluded, ‘otherwise they wouldn’t be in hospital’. Obviously absurd, you might think, and representative of a kind of thinking scarcely worthy of consideration as a serious component in the formation of most people’s attitudes. And yet, look at the institution of ‘training’ and the ready acceptance given by even the most discriminating in our society to ‘trained’ experts. Just as the fact that somebody is in hospital means that he must be ill, the fact that somebody is trained means that respectable procedures must exist in which to have trained him. As long as your teacher, lawyer, doctor, psychotherapist has satisfactorily emerged from an official training, you can accept that he knows something worth knowing, something which gives him some kind of special authority to interpret the realities of his subject more competently than others. And yet no more than three-quarters of a century ago physicians, no less respected then than in the present day, were on the whole, despite their training, likely to achieve little more than a somewhat swifter demise for their weaker patients than might have occurred without their ministrations. (There are, of course, those who argue that in fact the situation is not so different today.1)

The point, anyway, is that, not always wisely, we accept a great deal from our experts on trust. I do not want to suggest that there is ultimately anything very much else we can do, but I do want to examine upon what, in the field of psychotherapy, that trust can be based, and above all I hope that, by means of such an examination, the nature of psychotherapy and the character of its practitioners can be rendered a good deal less mysterious.

The nature of psychotherapy has not been determined by scientific insights into the objective realities of human functioning. Nor could it be. It has on the whole been determined by a somewhat incoherent mixture of assumptions about what constitutes human health and happiness, combined with ideas about how one person can set about understanding, influencing and changing others. It is with these assumptions and ideas that this book will be centrally concerned, offering criticism as well as alternative conceptions.

The first task in this enterprise is to attempt an initial understanding of what is meant by ‘psychotherapy’, and to indicate the particular areas of our interest. There is, in fact, no such thing as ‘psychotherapy’, and to assume that there is is to make a mistake which, as we shall see later, has in the past caused a good deal of misunderstanding about the nature and value of psychological methods of treatment. The field loosely covered by the term ‘psychotherapy’ comprises, on the contrary, a wide range of philosophies, theories and techniques which are frequently in marked opposition to each other, and are defended and attacked from deeply entrenched, and contrasting, ideological positions. A closer look at some of these positions will be taken in the next chapter. For the moment we should note that ‘psychotherapy’ can range from the intricate and closely woven theories of human personality and mental functioning which led Sigmund Freud and his followers to develop the techniques of psychoanalysis, to brief commonsensical chats between medical practitioners and their patients (‘supportive psychotherapy’) which consist of little more than sympathetic listening and more-or-less considered advice. The aims of ‘psychotherapy’ can vary between the ‘cure’ of neurotic or other disturbances in individuals thought to be mentally ill, and the acquisition by mentally well-adapted and socially successful people of heightened states of self-awareness, ‘transpersonal consciousness’, ‘individuation’, and so on. The theoretical mechanisms of change which psychological therapists postulate to account for their practical activities can similarly vary from the operation of unconscious mental dynamics, to the conditioning of physiological reflexes, to which latter process the ‘mind’ is thought to be irrelevant. Psychotherapists may claim to be able to treat people individually, in families, in groups, or even by correspondence course. The arena could be a mental hospital, a private consulting room, your own home, a ‘growth centre’ for week-end ‘encounters’, or almost anywhere else. Psychotherapists themselves may be medically trained psychiatrists, psychologists (who do not have medical qualifications), social workers, or in general any of a wide range of people to be found in the ‘helping professions’; or they may be people who have trained in some particular psychotherapeutic creed without any other basic training, lay counsellors, or simply people who have bestowed upon themselves the title ‘psycho-therapist’ and nailed a brass plate to their front door.

Faced with such divergence, we shall for the purposes of this book inevitably have to be selective. Most of the serious thinking and research which has gone on in the field of psychotherapy has been in the context of the treatment of mental disorder, and that mainly concerned with so-called neurotic illness. Recent years have seen an explosion in the ‘growth’, ‘humanistic’, and ‘encounter’ approaches which often concentrate more on ideals of human psychological functioning than on the removal of neurotic symptoms. While we cannot afford to ignore the latter, we shall concentrate mainly on the former: because it is here that the issues concerning psychological disturbance, its causes and its treatment, are in sharpest relief; because this, at the present time at least, is the area of greater social significance; and, not least, because it is in this area that my own experience has largely been acquired.

It is not my intention in this book simply to educate the interested reader - even if I could - in the current status and background of psychological therapies, to put him or her in touch, as it were, with the most advanced thinking on the subject, or to offer a privileged insight into recent developments of the medico-psychological and social/behavioural sciences. On the whole, as already suggested, we tend to approach the subject-matter of our intellectual and scientific institutions with reverence, in the tacit belief that the very most we could hope to achieve would be to learn from them. In the case of psychological theories and therapies, the natural tendency to accept what experts say as valid (or at least as more valid than one’s own opinion) is reinforced by the enormous prestige that medicine and science command in our culture - and it is in medicine and science that most psychotherapies claim to have their roots. Science and medicine are endowed - and not only in the popular conception, but by many medics and scientists - with an authority which rivals that of mediaeval scholastic theology. It is my view, and one which I shall attempt to elaborate later, that this authority is ill founded, and indeed its acceptance perverts the development of human knowledge and undermines human experience. However this may be, what does seem absolutely clear to me is that, as things stand at present, the more or less unquestioning acceptance of the intellectual respectability, scientific soundness and clinical value of any of the psychological therapies cannot be justified on any grounds. For this reason, then, I feel that educating (or training) a person in ‘psychotherapy’ is not enough: such an approach could, and indeed does, (a) result in the creation of ‘experts’, semi-experts and technologists who promulgate theories or apply therapeutic techniques with very little critical understanding of the dubious nature of their conceptual foundations, and (b) reinforce a cultural attitude in which, in matters with which they are not acquainted at first hand, people simply accept what they find.

It is surely not possible for any disinterested observer to survey the contemporary scene in psychotherapy without, at least, bewilderment, or, at most, despair. There are so many approaches, so many competing claims, such differing appeals to scientific or moral authority, that we cannot simply take what we find and hope that sense will emerge from it all in the course of time. We have no alternative but to return at some stage to first principles, to examine critically the scientific and moral ideologies which underpin psychotherapy in its many forms.

In the course of this book, then, I shall be very critical of many current approaches to psychotherapy, and, in advocating the substitution of currently dominant conceptions of medical and scientific authority with the authority of the personal experience of those involved in psychotherapy (to be elaborated in later chapters), if I do not lay myself open to charges of mindless iconoclasm, I am at least likely to incur the displeasure of much of the psychotherapy ‘establishment’. This is unfortunate, but the risk must be taken.

Since the central focus of this book is to be theory and practice in the psychotherapeutic treatment of neurosis, it is necessary at this stage to sketch in the general background in which such treatment takes place.

Although psychotherapy has its roots in medicine, most modern psychotherapies are in many respects opposed to purely medical approaches to mental or behavioural disorders: few psychotherapists, for example, would believe that the main causes of neurosis are physiological, but would see them rather as residing in the individual’s acquired experience. Psychotherapy, again, is not, in Britain at least, the dominant approach to the treatment even of purely neurotic disorders (this would not so much be the case in the United States). The anxieties, phobias, obsessions and depressions which are held to constitute the symptoms of neurosis are most frequently treated by the use of tranquillizing and anti-depressive drugs, and the medically trained psychiatrists who prescribe such treatment see themselves most frequently as physicians, whose primary approach to the alteration of behaviour is via the body. It is perhaps true that few psychiatrists would claim that the neuroses primarily physical disorders, and most would pay lip-service to ‘influence of the environment’. This passing acknowledgment of environmental influence does not, however, alter the fact that the treatment they offer is most often exclusively physical in nature. The sheer extent of the problem of psychological disturbance coupled with the fundamentally medical nature of psychiatry means that, in the British National Health Service, psychotherapy is hard to come by, and where it is to be found, tends to be reserved for the more articulate and middle-class patients for whom research on the whole suggests it is most useful. Outside the context of the National Health Service, psychotherapy is often, though not always, a lengthy and expensive business, and its patients are far more likely to be found among an affluent middle class than elsewhere. In America, psychotherapy is seen as a more integral part of psychiatry, and this, combined with a much greater commitment to private practice, means that it is more readily available. However, it is important to realize that, in a global context, psychotherapy as an approach to psychological suffering plays only a very minor role, and is large restricted to the more socially privileged sections of society.

Despite its opposition, in many respects, to medicine, it is important to examine the legacy which psychotherapy has inherited from it, and the influence that medical assumptions have had on psychotherapeutic approaches. Some of that inheritance will already have become apparent in the early pages of this book: so far I have been using terms like ‘treatment’, ‘neurosis’, ‘patient’ largely uncritically, except for some use of inverted commas or qualifying clauses. These are, of course, terms which make no attempt to hide their medical origins. This is not the place to document the process by which medicine made the field of psychological disturbance its own - others, like Thomas Szasz, have done so very satisfactorily:2 it may for our purposes be sufficient to note that the founding father of psychotherapy and their intellectual mentors were doctors, and were imbued with an unshakable confidence in the conceptions of medical science prevalent at the end of the last century. You do not, for example, have to explore the writings of Sigmund Freud very far before stumbling across the most sweeping - indeed arrogant - assertions of the intellectually unassailable nature of mechanistic scientific inquiry and its primacy over all other forms of human spiritual endeavour.

Thus, a system of classifying psychological problems was rapidly constructed which reflected approaches which had proved useful in physical medicine, and the relation of the sufferer to his sufferings was modelled on the relation of the patient to his symptoms. Even today, psychiatry has little hesitation in characterizing psychological disturbance as ‘mental illness’, and indeed we are encouraged by the medical profession and the health authorities to think of mental illnesses as ‘illnesses like any other’. Partly, no doubt, some of the impetus behind this campaign is humanitarian, and it may be feared that the alternative to regarding somebody as mentally ill is to regard him as in some way intrinsically evil, stupid, or responsible for his condition.

There has been much criticism in recent years of the concept of mental illness (the main critic being Thomas Szasz, whose major work has already been referred to), yet nevertheless the concept has become deeply and concretely embedded in our society, and shows no signs of becoming less so. Psychological disturbance is mental illness, it is treated in outpatient clinics or mental hospitals, by doctors and mental nurses. The methods of treatment are, as already pointed out, largely physical in nature: mainly drugs, but also electro-convulsive therapy, which necessitates a general anaesthetic, and even brain surgery. Psychological disorder has given rise, in short, to a gigantic medical and pharmacological industry. For this reason alone it takes considerable nerve to suggest that alternative views of psychological disorder are possible.

In many respects it is towards alternative views that psychotherapy, in its various versions, points. Many therapists, for instance, reject at least some of the terminology of medicine - they prefer to speak, for example, of ‘clients’ rather than ‘patients’. Most psychotherapists have little or nothing to do with physical treatments, and prefer to see their clients as far as possible outside medical settings such as hospitals and clinics. Some forms of psychological treatment have their theoretical roots in entirely non-medical disciplines: those techniques loosely grouped under the heading ‘behaviour therapy’, for example, draw their inspiration from experimental psychology and the study of learning, although most have accepted to some extent the diagnostic classification built by the early psychiatrists and psychoanalysts.

It is hoped that it will prove possible in this book to crystallize an alternative to the dominant medical approach to psychological suffering, and to highlight those aspects of psychotherapeutic thinking which help us to do so. The task will be, then, to provide an account of how somebody can be ‘neurotic’ without being ill, stupid, evil or deliberately wayward. Our task will, however, be made doubly difficult by the additional contention that, while being none of these things, the neurotic individual is also not helpless.

So far I have betrayed clearly enough my objection to the medical approach, but I have not made clear the reason for that objection. It lies, in fact, precisely in the centrality to the illness conception of the helplessness of the person supposed to be mentally ill. The medical approach is par excellence a mechanistic approach to psychological disturbance: it characterizes the patient as a passive, helpless mechanism, whose only hope for recovery lies in the expert readjustment of the faulty parts.

In the first place, I object to this view because it seems to me simply to be wrong, and in later chapters I shall try to persuade the reader also that it is wrong. Second, because it is wrong, the view of man as helpless mechanism seems to me to have disastrous consequences. From a general point of view it generates social institutions which are designed to organize, manipulate and mould people to institutional ends and obscures from them that they can manipulate social institutions to their own ends. From a specific point of view it has the result that the psychologically disturbed individual is denied, at least from the viewpoint of ‘official’ theory the one most effective avenue to coping with his disturbance, i.e. helping himself. In practical terms, this most often means that he is left to fester psychologically in his fears, confusions and painful personal relations, while somebody tinkers with his body chemistry or stuns him periodically with electric shocks. Patients in the average mental hospital are discouraged from facing their psychological problems or questioning the values of the (usually) benevolently authoritarian regime which takes them in its charge and claims responsibility for their future psychological health. The patient is thus denied access to the means of helping himself, or at least his access to it is discouraged. For, to help himself, he must be able to examine, understand and change his psychological predicament. He may indeed need help in doing this, but that help will certainly not consist in diverting his attention from his predicament.

It is of course in this area that the psychotherapies hold out their promise. Superficially, at least, they seem to offer ways in which the individual can come to an understanding of his predicament and in which the predicament itself can be changed. And indeed it will be an argument of this book that from the psychotherapies can be distilled a way of conceptualizing how the individual can take charge of his own psychological functioning even when subjectively at his most helpless and ‘ill’.

And yet, if psychotherapies hold out hope of achieving such a liberating view of man and his psychological problems, it is often in the teeth of their own theoretical leanings. If psychotherapy has escaped from some of the more limiting medical assumptions touched on above, it still in large part shares with medicine about the most limiting assumption of all: that is, the assumption of mechanism. Psychotherapists of many, though not all, persuasions tend to have taken over unthinkingly the view common to early medicine and academic psychology that to be scientific you have to accept some mechanistic (though they might not actually use the word) constraints. The acceptance of some form of determinism, for example, is widespread among psychotherapists, and indeed is as central to psychoanalysis as it is to behavioural psychotherapy. Similarly, the doctor-patient, expert repairer-faulty machine relationship is characteristic of many forms of psychotherapy. Where therapists have departed from these models, they have often done so hesitantly and nervously - making ritual obeisance to determinism, perhaps, by speaking of the patient’s ‘sense of mastery’ rather than his freedom, and so on. In the next chapter the theoretical background of some of the major psychotherapies will be examined in much greater detail, and later in the book we shall hope to provide reasons for therapists to make the break from mechanistic assumptions more boldly. But it is important at this stage to note one particular consequence of the insidious invasion of psychotherapy by medico-scientific mechanism: namely, that even psychotherapists run into conceptual difficulties when they try to help patients with their helplessness.

Most patients - and certainly those who fall into the ‘neurotic’ class with which we are mainly concerned - come to the therapeutic situation equipped with a theory, or theories, about themselves which are not so different from those of the professional experts. Partly because of the expectations engendered by our culture and its social institutions, and partly because it is the most convenient belief for them to hold (since the unacceptable alternatives seem to be malice or stupidity), patients tend to see their psychological problems as outside their own control. They may find themselves in the grip of behaviours they seem unable to resist - for example, compulsions to keep clean and free of various kinds of contamination, or an irresistible urge to engage in repetitive checking that they have not committed some careless and potentially dangerous act; or they may feel unaccountably assailed by apparently baseless feelings of anxiety or panic; or such intense fear of apparently harmless objects or situations that they have to organize their lives round avoiding them. Or they may feel pervasive depression and lack of interest in life without being able to identify its source; or perhaps an inability sexually to consummate an otherwise apparently satisfactory relationship. The complaints, in fact, which people bring to their doctor or therapist can vary over an almost infinite range - from being compelled to eat coal to feeling sexually attracted to horses - but they tend to have in common that the person feels at their mercy and unable to help himself. The theory a patient holds, tacitly or explicitly, to account for his predicament may appeal to a mechanical disorder of his body, childhood trauma, financial problems or stresses at work, the malice of others, and so on; and in this he may find a ready echo in the theoretical beliefs of his therapist. Everything, including the very fact that his therapist exists as a socially accredited expert in his problems, suggests to the patient that he may submit himself to the therapist much as the host of appendicitis submits himself to the surgeon. Yet he will soon discover that, far from being the passive recipient of various technical procedures, he is engaged in a taxing struggle with his problems which makes great demands on his personal, active resources. The therapist also, while embodying the role of technical expert, will in fact (and possibly with an uncomfortable recognition of the dimly implied contradiction) be making demands upon his patient’s resources, and requiring of him his active participation in treatment.

This is one of the most puzzling and difficult of the theoretical problems which psychotherapy has to deal with, and one which may well cause the patient a lot of grief. He is encouraged by the mechanistic temper of the age to look for ‘the cause’ of his psychological problems. He no more knows why he is neurotic than I know why I am a psychologist, but the bits and pieces of popular medicine or psychoanalysis he has picked up will set him off in a diligent search for causal events, childhood experiences, etc., which he expects to ‘explain’ his condition, which in turn, having been explained, will presumably vanish. It may well become a source of anxiety, and even anger to him to discover that this approach proves fruitless, and it only confuses and further angers him that his therapist, while professing beliefs which apparently support his mechanistic strategies, in actuality seems to be demanding of him something else. We are here anticipating themes which will be developed in greater detail at a later stage. We can note, however, that the anxiety, anger and confusion which tends to arise in this situation frequently results in patients’ terminating psychotherapy and departing in disgust or despair, thereby adding to the statistics which demonstrate that, whatever else it is (and it is much else!) psychotherapy is not a sure-fire technical method of curing ‘neurotic illness’.

Much of the language, and some of the concepts, which the medical approach has contributed to the understanding of psychological disturbance is hard to dispense with without artificiality. The terms ‘neurosis’, ‘treatment’, ‘patient’, and indeed ‘therapy’ itself, as well as many others, cannot easily be separated from their medical connotations, and tend almost unavoidably to foster mechanistic assumptions about the nature of psychotherapy. The dilemma of the writer who wishes, as I do, to reject these assumptions without straining the reader’s patience by inventing an entirely new vocabulary is not easily solved. ‘Neurosis’, if it can be thought of without the implication it carries of being a medical diagnosis, a type of disease entity, can be usefully retained as a shorthand to describe a kind of strategy by which a person can deceive himself about the reasons for and aims of his conduct (a view to be elaborated later). If I could think of an equally succinct term which expressed what I mean and carried no medical implications, I should use it. Since I cannot, I shall continue to use the term in the slightly idiosyncratic sense given above, and hope that I am not too frequently misunderstood. The substitution of ‘client’ for ‘patient’ now frequently made by psychotherapists I do not myself feel to be particularly satisfactory. It is true that ‘client’ avoids the directly medical flavour of ‘patient’, but it does not escape - indeed it in some ways furthers - a view of the therapeutic relationship as one of professional expert and passive recipient. Further, while being in this respect no less mystifying and mechanizing than ‘patient’, it introduces a commercial tone to the therapeutic ‘transaction’ which, though many therapists feel the commercial aspect to be of central (rather than incidental) importance to therapeutic effectiveness, I for one find mildly unfortunate. Because of this, and because the repetitive use of the words ‘person’ or ‘individual’ tends to become irritating after a time, though basically I prefer them, I shall not shrink from using the familiar ‘patient’. ‘Treatment’, ‘therapy’, and so on, could I think be more usefully, and accurately, called something like ‘psychological guidance’ or simply ‘help’, but here again to do so single-mindedly would inevitably seem artificial. In time perhaps the context in which these words are used will establish their detachment from medicine and medical assumptions, and the presence in the language will depend simply on their convenience. That, anyway, is why I use them. I shall certainly not be talking about ‘mental illness’.

 

1 Illich, Ivan. (1975). Medical Nemesis. London: Calder & Boyars.

2 Szasz, T. (1962). The Myth of Mental Illness. London: Secker & Warburg.

 

 

2

Approaches to Psychotherapy

The approaches to therapy to be discussed in this chapter have been selected first for their general importance and influence, and secondly because they exemplify in one way or another theoretical, or even ideological positions which it is our aim to understand and make explicit. It is not the purpose of this book to provide a comprehensive review of the various kinds of psychotherapy practised today, or a full history of their development. The reader looking for this kind of information should consult one of the texts already available which are aimed at fulfilling this purpose.1 There is a particular class of approaches to psychotherapy - those involving groups of patients, families and marital couples - which I shall not be considering in this chapter. Their omission reflects a concern for economy of space and, more cogently perhaps, my belief that the central issues in psychotherapy can be raised by a consideration of individual therapy alone; it does not, however, carry any implication of relative therapeutic unimportance for these methods, many of which have great potential usefulness.

It is important to emphasize that in this chapter I am considering therapy from the point of view of what therapists say they do, and not from that of what they do do. In other words, my perspective is theoretical. As we shall see in Chapter 3, it is by no means the case that what therapists say they do always matches or describes accurately what they actually do. In that case, it may be asked, why concentrate on a theoretical perspective? Why not just describe what actually happens in therapy? My reason is that, though theories are often not (indeed, in some cases because of their fundamental absurdity could not be) put into therapeutic practice, they nevertheless have consequences for our view of ourselves and our relations with each other which are very far-reaching. I hope to demonstrate this later in this chapter.

One cannot, then, afford to ignore theory, however much it departs from practice, and however much practitioners may feel contemptuous of it. Ours is becoming a largely technological, rather than a scientific, culture. We are concerned with whether things 'work', not with how and why they do; we are more concerned with cost-effectiveness than with truth. In the field of psychotherapy this leads, particularly in some camps, to a Philistine dismissal of theoretical considerations; what matters to these therapists is simply whether or not the patient 'gets better'. It so happens that many of the therapists of this persuasion belong to the 'behaviour therapy' school (to be discussed below), which in origin springs from a theoretical position which is very easily demolished. Despite behavioural theory being in ruins, behavioural therapeutic technologists will happily carry on, because they believe that what they are doing 'works'. If you attack their theoretical position, as it is so easy to do, they will accuse you of attacking a straw man, gaining a hollow victory, etc., as they no longer really subscribe to that, or any other, theory. This would be all very well if it were not for the fact that the theory has not been abandoned at all, but carries on under cover, so to speak. For in the field of psychotherapy, in which by adopting some criterion or other of human health or happiness the therapist is putting forward values, he simply cannot escape having a theory about human nature and what is good for it. There is just no way of saying whether a patient is 'better' without having theory about how people ought to be, any more than there is a way of trying to change people without having a theory about how to do it. The fact that therapists exist who are unaware of their therapeutic theory is considerably more frightening than the existence of therapists who consciously subscribe to a theory which is, for example, absurd or self-contradictory. The latter, at least, are answerable for their values, while the former promulgate theirs without knowing what they are. This is no merely abstract intellectual problem, as we shall see shortly.

Psychotherapy as a formal procedure appealing for its justification to the accepted principles of science has its origins in Freud's psychoanalysis. Psychotherapy is of course not to be confused with psychoanalysis: the former is a much broader term than the latter, which refers specifically to the theoretical beliefs and therapeutic practices of Freud and his followers.

Most of the many variants of psychotherapy have moved very far indeed from psychoanalysis, and in not many of them would it now be felt that they owed all that much to it. There are also, certainly, many more psychotherapists of various persuasions - than there are psychoanalysts, and there is little doubt that psychoanalysis is no longer the power it once was in this field. But although 'pure culture' psychoanalysts may be relatively thin on the ground nowadays, Freud's ideas have had an enormous impact on our culture, and in the public mind Freudian analysis is often more or less synonymous with psychotherapy. In fact, in the professional spheres of psychiatry and psychology, Freudian psychoanalysis has probably had less influence than outside, but even so there can be few areas of professional concern which have not at least been touched by some aspect of Freud's thought.

It would be both arrogant and foolish to attempt to condense an adequate account of psychoanalysis into the space available in this chapter, but perhaps enough can be said to convey the general tenor of some of the debates within psychoanalysis and to indicate to the reader where further information might be found.2

The range and extent of Freud's output was vast. Among other things, he bequeathed to posterity a theory of the development of personality, a theory of psychological (mental) functioning, and a theory of neurosis together with a technique for its treatment. None of these would today be accepted without qualification by any but a small handful of highly orthodox psychoanalysts, but in the course of developing his position Freud elaborated a number of technical concepts which are still extremely influential.

Freud subscribed to a brand of mechanistic rationalism which was in his day thought by many to be characteristic of science, and he saw the 'discoveries' of psychoanalysis as opening the way to a more or less final understanding of the nature of man. Human nature could thus be reduced to a relatively small set of mechanisms, the nature of which it was the business of psychoanalysis to reveal. In this way, man could in principle be scientifically understood as an object, in much the same way as physical objects could be understood by the natural sciences. From this alone it is possible to appreciate how easily a mystique could come to be attached to psychoanalysis: the analyst becomes a subject whose knowledge encompasses and explains the conduct of those objects - people - to whom he turns his attention. Despite a certain mock modesty, it is evident from much of Freud's writing that to a great extent he revelled in this mystique.

One could caricature Freud's conception of psychological functioning as a whole, as a kind of vast steam engine, in which the motive power of 'libido' - sexual and aggressive energy - is forced through various valves (defence mechanisms) and chambers (levels of consciousness) until it is finally converted into observable activity. In many respects Freud does seem to have had this kind of model in mind. Behaviour is indeed reduced in the end to the way the individual has managed to deal with his sexual and aggressive energy, from the early vicissitudes of breast feeding and toilet training (the famous oral and anal stages of infantile development to the full flowering of genital sexuality, not to mention the enormous challenge of the Oedipal stage, at which the child has to cope with the threats posed by its sexual attraction to its parent of opposite sex. All later development, and in particular the formation of neurotic symptoms, was seen as hinging on the conscious and unconscious manoeuvres which were brought to bear in the attempted resolution of these sexual problems. In some ways the individual was seen as the embodiment of a moral struggle between the opposing forces of his psyche, his unconscious, preconscious and conscious minds providing the arena for battles between his 'id' (the naked impulse to sexual and aggressive satisfaction), his 'ego' (roughly corresponding to a consciously aware self) and his 'superego', or conscience. Through psychoanalysis the individual could become aware of some of the unconscious springs of his problems, particularly as these centred in his sexual relations childhood with his parents, and by working through them and the consequences in his relationship with his analyst, bring them under the conscious control of his ego. Since the problems were deeply rooted in the first place in the unconscious mind, the techniques of psychoanalysis were to focus on ways of reaching this inaccessible stratum. Having tried, and abandoned, hypnosis, Freud concentrated instead on free association and the analysis of dreams. For although the unconscious mind could clearly not be expressed directly by the patient, its influence, Freud felt, could be detected in the unmonitored drift of his associations, and in his dreams, where again the vigilance of conscious censorship was relaxed. The processes by which consciousness tries to exclude what is to it the very threatening nature of the unconscious sexual and aggressive impulses, were elaborated in great technical detail and with considerable sophistication by Freud. These are the defence mechanisms, of which the most important is 'repression', which is best characterized, perhaps, as a kind of intentional forgetting: the individual succeeds either in actively ejecting sexually or aggressively charged material from consciousness, or in preventing its initial entry into consciousness.

The nature of unconscious mental contents could often only be divined from the symbolic distortions they had undergone in dreams or free associations, and for this reason Freud developed what now appears to be a rather simplistic lexicon of symbolism, which, among other things, could be of service in the analyst's 'interpretation' to the patient of the meaning of his unconscious (dream and free-associative) productions. In this sense, the analyst would be able to tell the patient what his thoughts, fantasies and dreams really meant. This is a point we shall certainly be returning to, but it is scarcely any wonder that in the early days of psychoanalysis the hint of powers of this kind attracted to it, from some quarters anyway, a quality of almost religious awe.

A central belief of psychoanalysis and many of its later derivatives is that a person's perception of his present relationships - and in particular that with his analyst - is determined unconsciously by his earlier relationship with his parents. The role of the analyst in therapy therefore, at least in part, becomes one of providing a 'screen' onto which the patient can 'project' largely fantasized attributes which betray the psychological structure of his childhood parental relationships. To facilitate this process, the analyst excludes as far as possible any revelation of personal characteristics: he contrives to remain 'neutral'. This is one of the reasons why, in classical psychoanalysis, the analyst sits behind the prone patient, where the latter cannot see him. Feelings the patient has for or about the analyst are thus characterized as the 'transference' onto a neutral figure of qualities which have their origin in the patient's infantile past. The therapist's analysis of this transference, his demonstration to the patient by means of interpretation, etc., of the real significance of the latter's feelings about him, is the central plank in psychoanalytic technique.

There is much in Freud's original formulations which only a tiny minority of his present-day followers would be prepared to defend. His sexual reductionism, for example, cannot, in its more extreme form, command the serious attention of modern psychological theorists. Consider the following quotation from a paper of his on femininity,3 which, incidentally, makes the modern male chauvinist look like Joan of Arc:

The effect of penis-envy has a share . . . in the physical vanity of women, since they are bound to value their charms more highly as a late compensation for their original sexual inferiority. Shame, which is considered to be a feminine characteristic par excellence but is far more a matter of convention than might be supposed, has as its purpose, we believe, concealment of genital deficiency. We are not forgetting that at a later time shame takes on other functions. It seems that women have made few contributions to the discoveries and inventions in the history of civilization; there is, however, one technique which they may have invented - that of plaiting and weaving. If that is so, we should be tempted to guess the unconscious motive for the achievement. Nature herself would seem to have given the model which this achievement imitates by causing the growth at maturity of the pubic hair that conceals the genitals. The step that remained to be taken lay in making the threads adhere to one another, while on body they stick into the skin and are only matted together. If you reject this idea as fantastic and regard my belief in the influence of lack of a penis the configuration of femininity as an idée fixe, I am of course defenceless.

However, despite what now appear to be obvious weaknesses in Freud's original ideas, there are many aspects of his elaboration theory and practice in psychoanalysis which are still highly influential in psychotherapy. If his conception of infantile development in terms of an oversimplified set of crucial psycho-sexual stages has largely been rejected, his formulation of the nature of consciousness (and unconsciousness), repression and other defence mechanisms, has proved to be of fundamental importance.

Freud's view of science committed him to a theory which is, as has been pointed out, reductionist, determinist and mechanistic, and to a view of the therapist's role in analysis as neutral and impersonal. These are features which orthodox psychoanalysis shares with other brands of psychological therapy which place a similar emphasis on the 'scientific' nature of their foundations. It is to orthodox versions of these which we shall turn next, even though chronologically they belong to a much more recent period. We shall return a little later to the variations and developments which have occurred in the broad psychoanalytic field.

One of the most influential approaches to the treatment of neurosis in the present day is that of 'behaviour therapy'. The theoretical pedigree of behaviour therapy is different from that of psychoanalysis, and it owes little to turn-of-the-century medical thinking. There are perhaps two main theoretical sources of behaviour therapy which can be clearly identified. The first is Pavlov's work in the earlier years of this century on physiological reflexes and the acquisition of conditioned responses in laboratory animals, and the second is the anti-mentalism of J. B. Watson. The development within experimental psychology - largely a preoccupation of academic institutions - of the tenets of behaviourism, for the origination of which Watson is usually held to be responsible will be familiar to most readers of this book, and to chronicle them yet again here would be tedious in the extreme. For the uninitiated reader, however, a few words on the scientific ideology of behaviourism might not be out of place.

Behaviourism was a reaction to what many psychologists saw as the hopelessly subjective entanglements into which psychology as an academic discipline had got itself. Disputes over whether people thought with or without the use of visual images, how many instincts could be identified as motivating human behaviour, and so on, made use of techniques of argument and research which seemed uncomfortably distant from those which were being used with such apparent success in the natural sciences. Science, it was felt, must deal only with observables, and the experimental procedures of in terms of what psychological scientists must be clearly specifiable in terms of what they do, and what the outcome is. If only psychologists could get away from talking about what went on inside people (where no one but the subject himself could see - and not even he necessarily reliably) and measure their activity in terms of some objective criterion, psychology stood a chance of becoming really scientific. The objective criterion is, of course, behaviour. With great excitement, psychologists discovered that instead of talking about what people felt and thought, which was liable to subjective error, they could talk about, and actually measure (quantifiability being another worthy scientific aim) what they did. They could then specify their own experimental operations upon the subject (or 'organism', as he came to be called), and measure the result in terms of his reaction. It thus dawned on the behaviourists that you didn't have to talk about 'minds' at all. All pre-scientific, occult nonsense about thoughts, feelings, ideas and purposes could be scrapped and replaced by behavioural responses to experimental stimuli. Here at least was an exact, objective, quantitative psychological science which could, head held high, proclaim that its aim was 'the prediction and control of behaviour'. In place of mind the behaviourists put the reflex arc, which they borrowed from Pavlov. What happens when a human being learns, then, is that a behavioural response becomes conditioned to an environmental stimulus. The way it becomes conditioned is through 'reinforcement'; that is, the conditioned reflex between stimulus and response is established through the association of the latter with (usually) reward.

Much of the work of behaviourist psychologists was in the experimental study of learning. Because, for them, consciousness did not exist as a 'scientific' possibility, because the control and manipulation of experimental variables was essential to their model of experimental science, because in general it seemed the easiest thing to do, most of their work in this area was carried out with animals, particularly laboratory rats. A typical learning experiment would thus consist of rewarding an animal by means of food for achieving some goal (such as running correctly through a simple maze) previously determined by the experimenter. Ingenious permutations and manipulations of this basic situation have fill libraries, and the theoretical implications drawn from them held sway in academic psychology for decades. Incredible as it might seem, a view of man without mind, a model of learning built procedures which, however ingenious, were no more than techniques of training performing animals, seemed an acceptable price to pay for a 'scientific' psychology.

Behaviourism is now no longer the force it once was in academic psychology, but many of its scientific assumptions go marching on, particularly in its psychotherapeutic aspect, i.e. behaviour therapy. Although it is impossible to avoid questioning some of its practical defects, behaviourism has so dominated the psychological scene that psychologists tend to overlook the fact that the behaviourist theoretical principles which they took in with their mother's milk can be equally called into question. Thus, the aims of mechanistic reductionism (to stimulus and response), determinism (which permits 'prediction and control of behaviour') and objectivity still seem self-evidently necessary to many psychologists, and to many of those who are engaged in the treatment of neurosis. The behaviourist's antipathy for 'mentalism' expresses itself among behaviour therapists as a contemptuous hostility towards the ideas of psychoanalysis, with which, as has been said, it otherwise shares rather similar scientific aims. Unseen, unobservable things like unconscious minds are for obvious reasons anathema to the behaviourist.

In their original conception and purest form the techniques of behaviour therapy closely reflect behaviourist scientific ideology. Reasoning from his own, and others', experiments with animal conditioning, Joseph Wolpe, one of the founding fathers of behaviour therapy, concluded that neurotic behaviour was the result of anxiety responses having become conditioned to otherwise neutral stimuli. Due to some quirk in the history of his reinforcement contingencies, the phobic patient, for example, behaves neurotically (anxiously) in the presence of stimuli (e.g. travelling on public transport) which in the normal course of events do not evoke anxiety. The neurosis, therefore, can be understood as no more than its symptoms: one need no longer appeal to the mysterious operation of unconscious complexes or unresolved, and unobservable, sexual conflicts. Remove the symptoms, and you have removed the neurosis. The removal of symptoms is, naturally enough, achieved by the conditioning of a non-anxious response to the offending stimuli. This reasoning gave birth to the technique, widely practised by present-day behaviour therapists, of 'systematic desensitization'. This technique, originally established as viable by Wolpe with cats, relies upon teaching patients to relax, and then conditioning the physical responses of relaxation, which are held to inhibit anxiety, to a graded series of stimuli which represent - often in imagination only - the situations most feared by the patient. Thus the claustrophobic patient, for example, will be asked to imagine, in a relaxed state, a series of situations involving increasing degrees of enclosure or confinement. At the end of the series he will be imagining those situations which in actuality cause him most alarm. If successful, his anxiety will thus be inhibited, and the process of re-conditioning will be complete. The relaxation responses which have been conditioned in imagination will, by the process of 'generalization' (a construct invented by behaviourists to account for the fact that a behavioural response learned in one particular situation will also be evoked in other relevant situations), also obtain in actual, 'in vivo', situations. Wolpe claimed considerable success for this technique, a point which we shall return to in a later chapter when we come to consider scientific evidence for the efficacy of psychotherapeutic approaches.

'Aversive' techniques of behaviour therapy have also been arrived at on the basis of the conditioning model. In this case punishment (as opposed to the 'positive reinforcement' of reward) has been used to associate an unpleasant, aversive outcome with behaviours which are deemed 'maladaptive'. Deviant sexual behaviour - homosexuality, transvestism, etc. - and alcoholism have been the most frequent targets for this kind of approach. Thus homosexuals may be administered painful electric shocks when they show signs of arousal to homosexual stimuli, or alcoholics are given drugs which react with alcohol and bring about nausea and vomiting.

'Operant conditioning', the brainchild of one of the foremost apologists of behaviourism, B. F. Skinner provides the rationale for a further collection of behaviour therapy techniques (often known as 'behaviour modification', or 'behaviour shaping') which have been widely practised on chronic patients in mental institutions as well as with mentally handicapped or severely disturbed children. In these, reward is made contingent upon 'desirable' behaviours and the absence of reward upon 'undesirable' behaviours. First, an analysis might be made of what an individual patient finds rewarding. This might take the form of sweets, cigarettes, going for a walk, listen to music; having a bath or any one of a number of events activities. These rewards will then be withheld until the patient 'emits' the behaviour which is to be reinforced (e.g. talking rather than remaining mute, controlling bladder or bowel functions, behaving sociably rather than unsociably, and so on). His behaviour will thus be 'shaped' to acquire new standards of acceptability. The reader who wishes to pursue further the theory and practice behaviour therapy will find a voluminous literature awaiting him.4

As behavioural psychology reduces the person, so behaviour therapy reduces the individual patient to a mindless focus of stimuli and responses, a manipulable object to be predicted, controlled, and shaped to conform to current social norms.

There are crippling objections to behaviourism. Where there is no consciousness, no purpose, there can be no meaning, no values. How can the behaviour therapist decide what to do when he is, on his own theory, no more than the helpless result of his reinforcement history - how, indeed, can he account for his own behaviour subject-scientist when only objectivity is possible? He can only do so, of course, because he shuts his eyes to those aspects of his activity which fail to fit in with his scientific philosophy; he ignores his own experience, distorts that of others, and ends up as a kind of psychological fraud. This is not the place to develop a full critique of behaviourism. That has been done very adequately by others.5

Although greatly weakening the general acceptance of behaviourism in psychology as a whole, such attacks have not resulted in its total demise. The behaviourist reaction is often simply to shout louder its scientific credo, or, as often in the case of behaviour therapists, to retire into a kind of technological obscurantism which simply insists that, because behaviour therapy works, behavioural theory must be true. To object to behaviourism and its practical applications in terms of its implications for the freedom and dignity of man is liable to meet with sneering accusations of tender-mindedness and an ability to take one's scientific medicine: maybe people are reduced to junction boxes where stimulus meets response, but if that's what science reveals, that's just too bad. And it is just this question of the scientific status of behaviour therapy which seems to mesmerize its proponents, who do not seem to recognize that it is scarcely scientific to hold on to beliefs which contradict fundamental human experience, involve their holders self-contradiction and fly in the face of rationality. It is by no means my intention to argue here that behaviour therapy techniques do not 'work' - indeed I am convinced that they often do. What the behaviourist cannot provide, and what it seems to me we must earnestly seek, is a theory which explains why such techniques work. For people for whom values are presumably mentalistic cobwebs, behaviour therapists often seem to exude an almost evangelistic zeal:

The reason for the effectiveness of behaviour modification lies in its derivation from the experimental analysis of behaviour. No other approach in the history of psychology has demonstrated such refined prediction and control over its subject-matter with such scientific rigour, replicability and generality. It should not be surprising therefore that an effective behavioural technology emerges which is based on a powerful science of behaviour. The cumulative evidence is now sufficient to justify the conclusion that any approach to behaviour change, training, rehabilitation, teaching or education should be informed by operant principles. This means that practical wisdom which many trainers, teachers, rehabilitators and therapists have gathered, with experience in whatever framework they had available to them, can probably be applied more effectively when the laws of behaviour are explicitly recognized and implemented.6

But what are we to do with this powerful technology? Who is to decide to what human ills its attentions should be directed? Where at last are we to find a subjective person who is able to make decisions of this kind? It may be self-evident that people who don't want to be homosexual shouldn't be, and that a reasonable way of changing them is to ask them to masturbate to pictures of nude men, and electrically shock them when they ejaculate, but how can such self-evidence reveal itself to the blind product of environmental reinforcement? These are questions which cannot be answered by the behaviourist without self-contradiction or sophistry.

In his relationship with his patient, the behaviour therapist, from a purely theoretical point of view, finds himself in the uneasy company of the orthodox psychoanalyst, for, like him, he believes that it is the technique of therapy which is important, not the person of the therapist. Whereas the analyst is the vehicle of projected, transference reactions, the behaviour therapist is the scientific technician who juggles stimuli. As long as the juggling is done correctly, the identity of the juggler is immaterial. Many of the early behaviour therapists explicitly espoused this view, and indeed 'automated behaviour therapy', where the therapist is replaced by a machine, is a logical extension of it which some have not shied away from.

Like orthodox psychoanalysis, in short, behaviour therapy has done its level best to remain true to the inspiration of its conception of science. It is reductive, mechanistic, deterministic and impersonal. The practitioners of these forms of psychotherapy are, nevertheless, people, and their saving grace is that what they do in psychotherapy may bear little relation to what they say they do. Unfortunately for them, their conception of what it is to be 'scientific' makes it impossible for them to take into consideration those aspects of their own and their patients' activity which cannot be accommodated within a restricted and simplistic theoretical model. In these as in many other areas of psychology and psychotherapy, we seem in fact to have arrived at a curious inversion of scientific values. If science arose to confront theological dogma with what men actually experienced, psychological science these days too often ignores, distorts or denies experience because it does not square with the dogmatic principles of that science.

But by no means all psychotherapists have been afraid to this extent of permitting their personal experience to dictate their theoretical stance. The reductionism and impersonality of Freud's views quickly bred dissent in his own day, and psychoanalysis soon split into a variety of camps representing objections to one or another aspect of the orthodoxy. It is of course not possible fully to document these developments here, but it might be of interest to glance at some of their more salient features.

Carl Jung and Alfred Adler are of course the best known of the dissenters among Freud's contemporaries. Between them, they objected to the sweeping sexual reductionism, as well as the determinism and impersonality of Freud's psychoanalysis, and both formed well-established schools of their own - Jung's 'analytical psychology', and Adler's 'individual psychology'. Neither, however, has had an influence comparable to Freud's on the field of psychotherapy as a whole, although Adler's views had a significant impact in the United States, especially in the area of child guidance.

Adler is probably chiefly remembered for the emphasis he placed on the importance of feelings of inferiority for an understanding of neurosis, and the compensatory activity in which the person engages in order to overcome them. Hence the pomposity of the short man, the verbosity of the stammerer, and so on. In this, of course, can be seen the same kind of reductionism to which Freud appealed. Also, however, Adler placed great emphasis on the individual's responsibility for his actions and for changing them: for Adler, thus, the person is no longer solely determined by unconscious forces, but has the opportunity of consciously changing himself and recognizing that his actions are directed towards an end.

Jung was for a time Freud's closest collaborator, and in many ways his conceptual formulations are very similar to Freud's, and no less complex and far-reaching. However, he objected strongly to Freud's all-embracing sexual reductionism, and laid much more emphasis on the spiritual strivings of men to make sense of their lives and to develop fully their individuality. For this reason, a central focus of his interest was on religion and mythology, in which he felt he detected the most fundamental and pervasive of mankind's concerns, and he used his religious and anthropological studies as a basis for the elaboration of a view of the unconscious mind which emphasized the common spiritual foundations of man's experience (the 'collective unconscious'). In focusing in this way on what the person is to make of himself, how he is to grow to self-fulfilment, Jung anticipated by decades some of the present preoccupations of the 'growth movement' in psychotherapy. Jung also reacted to the impersonality of the analyst-patient relationship as conceived by Freud, and chose rather to characterize the situation as follows:

...twist and turn the matter as we may, the relation between doctor and patient remains a personal one within the impersonal framework of professional treatment. By no device can the treatment be anything but the product of mutual influence, in which the whole being of the doctor as well as that of his patient plays its part. . . . For two personalities to meet is like mixing two different chemical substances: if there is any combination at all, both are transformed. In any effective psychological treatment the doctor is bound to influence the patient; but this influence can only take place if the patient has a reciprocal influence on the doctor. You can exert no influence if you are not susceptible to influence. It is futile for the doctor to shield himself from the influence of the patient and to surround himself with a smokescreen of fatherly and professional authority. By so doing he only denies himself the use of a highly important organ of information. The patient influences him unconsciously none the less.7

Further, Jung clearly felt uncomfortable with the mechanistic over-generalizations in which many psychoanalysts seemed tempted to engage:

It is enough to drive me to despair that in practical psychology there are no universally valid recipes and rules. There are only individual cases with the most heterogeneous needs and demands - so heterogeneous that we can virtually never know in advance what course a given case will take, for which reason it is better for the doctor to abandon all preconceived opinions. This does not mean that he should throw them overboard, but that in any given case he should use them merely as hypotheses for a possible explanation.8

Jung was less interested than either Freud or Adler in the influences upon the individual which determine (or through which he determines) his character, and for elaborations of this area we have to turn to later variants of psychoanalysis. It soon became apparent that the more or less exclusive focus on few particularly salient features of infantile development (the oral and anal stages, etc.) was found wanting by thinkers and practitioners in the broad area of psychoanalysis. In America, H. S. Sullivan's 'interpersonal psychiatry', and in Britain Melanie Klein's 'object relations' theory paved the way for a much more minute and exhaustive analysis of the relations between children and those around them, and the mutual influences to which these give rise. Not only is a far wider range of events seen as important in influencing the child's development, but also an increasing awareness dawns of the importance of the meaning of these events for the individuals in whose world they occur: what is a psychologically significant event one family may not be in another, this being determined by the construction which is placed upon it by those involved.

This major step in the demechanization of psychoanalysis is matched by changes in the way such theorists tend to view the nature of the relationship between therapist and patient: the child acquires its view of itself in the context of its relations with its parents; the view can be changed only in the context of new relationships, in particular that with the therapist. Thus Guntrip,9 a modern exponent of the object relations approach, saw the effective factor in psychotherapy as 'not a "technique of treatment" but a "quality of relationship"'. It is interesting to note, however, that, far though they are from Freud's original formulations, there is often still more than a hint of mechanism and determinism to be found in the writings of these therapists. For example Guntrip, in the same paper, wrote that the unconscious 'is the accumulated experience of our entire infancy and early childhood at the hands of the all-powerful adults who formed us. We have no choice about its creation ...' This formulation ushers onto the scene the psychotherapist in his familiar guise as expert; for the answer, Guntrip felt, is for our culture to become imbued with the findings of depth psychology concerning the 'basic necessities in the personal care of children at all age levels'. He sees hopeful signs that 'this process has already begun in the increasing education of all the social work professions in the principles of psychodynamics'. However, he warns against this being done amateurishly, though expertly done it can nip in the bud a tremendous lot of trouble'. This brief look at some of the developments and divergences that have occurred in the broad area of psychoanalysis does scant justice to the range and complexity of ideas which are to be found in the literature, and I am aware that there are a number of important themes and people that have not been touched on. However, I hope that this discussion may prove useful in orienting the reader for the later development of themes which have been raised here. But before passing on to consider other major psychotherapeutic schools, we should perhaps pause to reflect upon the changes which have taken place in the sphere of behavioural psychotherapy. In some ways these are parallel to those in psychoanalysis. Behaviour therapy has not, of course, been on the scene as long as psychoanalysis, and so has not had as long, not only to change, but, more important, to reflect upon its changes and assimilate them theoretically. The major problem which faces the behaviour therapist is how to accommodate changes which are forced upon him by practical experience within a scientific dogma which is woefully inadequate for dealing with them. The close identification of behaviourism with science itself makes this problem particularly acute, for the behaviour therapist cannot simply abandon his behaviourism (discordant as it is with his experience) without risking the loss of his raison d'être as a scientist.

The way that some behaviour therapists seem to be coping with this problem is by hanging on to a scientistic behavioural jargon while at the same time quietly shuffling away from the basic principles of behaviourism. Thus, without any reference being made to the familiar mechanics of stimulus and response, conditioned reflex, and so on, 'modelling' will be invoked to explain learning by imitation, and 'cognitive restructuring' may be offered as an acceptable term for what seems to be more or less conventional non-behavioural psychotherapy. In this way the behaviour therapist is able to keep his scientific credentials while abandoning his principles, though not all have been quite as furtive about this as I may have suggested. Lazarus,10 for example, quite explicitly recognizes that the simplified models of behaviour offered by Wolpe and Skinner have proved inadequate for his therapeutic practices, and this despite the fact that Lazarus himself started out as an enthusiastic conventional behaviourist. Many behaviour therapists are willing now to admit that the nature of the relationship between therapist and patient is of considerable importance to the outcome of treatment, but this once again moves them, potentially, into areas of theoretical complexity which they are ill-equipped to handle. Behaviour therapy can, as has been suggested, carry on quite successfully as a more or less useful collection of treatment procedures, but when such therapists seek to legitimate the activities by an appeal to their scientific foundations, that appeal must be spurious. Still less does the success of their procedures legitimate their theories. There also exist important schools of psychotherapy, particularly perhaps that of the American psychologist Carl Rogers, which have started out from far less conventional scientific premises than either psychoanalysis or behavioural psychotherapy. Rogers, whose work has had an increasing impact on the whole field of psychotherapy in recent decades, puts forward a view of man as a self-creating, growing individuality who is far from being the helpless victim of deterministic forces or unconscious conflicts. Rogers' views11 are the whole optimistic: the man who is open to his own experience and feelings, and those of others, will naturally grow in a psychological healthy and fulfilling way. If this growth becomes blocked, if for one reason or another he is unable to remain open to his experience, perhaps because it conflicts with some kind of standards he internalized (so that his 'self' and 'ideal self' are in conflict), then the kind of therapeutic help which will prove most useful to him will be from a therapist who encourages him to trust once again his own potentialities and to allow the natural processes of growth to reassert themselves. Thus therapy becomes a matter of sympathetic, 'non-directive' exploration with the patient of his own experience and its meaning for him. Rogerian 'non-directive' or 'client-centred' therapy is quite clear about what the nature of the therapist's role in the therapeutic process should be, and this contrasts sharply with the traditional 'expert mechanic' role we have considered earlier.

Far from being there to fit the patient, one way or another, into his own conceptual framework, the Rogerian therapist is there to fit himself in with his client's. The latter will improve by elaborating his own solutions to his own problems in his own way, and the therapist's job is to help him to do so in his own terms, not to impose upon him an irrelevant (to him) psychological system which can only confuse or divert the course of his own experience. With this in mind, Rogers12 elaborated the conditions he felt necessary and sufficient for therapeutic change, among which were the empathy and genuineness of the therapist, as well as the 'unconditional positive regard' in which he holds the patient. In other words, the therapist must understand the patient from the latter's viewpoint, and be able to communicate this understanding to him; he must be a genuine person in the relationship, not merely a professional mask; and he must respect and accept the patient warmly and non judgementally ('unconditional positive regard' is often shortened simply to 'warmth').

Rogers' work is thus particularly important for its central focus on the personal nature of the therapist's involvement in therapy - not, one should note, that this had escaped the notice of Jung and of some other therapists in the more psychoanalytic tradition - and his views probably gained currency through his concern to back them with quantitative research. Being a psychologist himself, not only was he committed to providing some kind of 'hard evidence' for his views, but he also knew what kind of evidence would be countenanced by the social scientists whose background he shared, and it is largely the Rogerian school we have to thank for the impetus which gave rise to much of the research evidence to be discussed in the next chapter.

Rogers quite explicitly rejects mechanism, determinism and reductionism in his psychological theorizing, and yet in developing a view of psychology which will conceptualize man as 'a subjectively free, choosing, responsible architect of self'13, he still appears to hanker after generalities, seeking 'lawful and orderly relationships' in the 'private worlds of inner personal meanings'. It may be unfair to accuse Rogers, on this evidence, of attempting to subjugate subjectivity by means of the tools of objectivity, or at least of hoping to be able to do so. Nevertheless, there does seem to be something slightly inconsistent about studying subjectivity in order to render it objective in the form of laws which can be 'put to empirical test'. In many ways this kind of inconsistency is even more apparent among some of Rogers' followers. For example, observation of the importance of the therapist's empathy and genuineness in psychotherapy has encouraged some to attempt to train therapists to be genuine and empathetic, and thus, inevitably I should have thought, to convert personal qualities into impersonal acquisitions.

Again, modern work in the Rogerian field14 seems to be focusing on a linkage of some of Rogers' ideas with findings from the study of information-processing machines as models of psychological operation. There is of course no reason why this should not be done, except that it seems a strange direction for Rogers' anti-mechanism to take.

There are several schools of psychotherapy which, as with Rogers, emphasize the importance of the individual's own conception of his world and the necessity for taking this as the starting point for understanding him. Some of these are rooted squarely in the tradition of European existentialism, others represent distillations of a number of psychological and philosophical influences into a more or less original theoretical position. The work of Ludwing Binswanger, for example, takes an approach to 'existential analysis' which owes much to, among others, Martin Heidegger. Binswanger's approach is interesting for the thorough-going seriousness with which it treats the patient's subjectivity15 and attempts to unravel the patient's world in terms of his own meanings. Binswanger's work is, however, almost unknown in Britain, though he has probably had more widespread influence in the United States.

Viktor Frankl is another psychotherapist whose approach - 'logotherapy' - owes much to existential philosophy. Frankl, whose influence in the English-speaking world is again largely confined in the United States, makes several points of importance to psychotherapy as a whole which once again demonstrate the contrast between this and more traditional kinds of approach. He is, for example, concerned to stress the freedom of the individual and his ultimate responsibility for himself, as well as the importance of unself-conscious kind of engagement with the world. In this latter respect Frankl is to be contrasted with those therapists who have a central therapeutic aim increasing patients' self-awareness. This is a theme which we shall take up in much greater detail later.

Frankl, perhaps because of his long association with the pragmatic culture of the USA, does, despite his existential affiliations, show here and there the same kind of tendency to mechanism which we have already noted in the case of Rogerians. For example his observation of the disruptive nature of self-consciousness led him to advocate a technique ('paradoxical intention') by means of which the neurotic can disrupt his own neurotic behaviour by trying to perform it deliberately and consciously. In 'logotherapy' and 'paradoxical intention', I am afraid we may be seeing the foundations of yet another of the would-be patented 'systems' with which psychotherapy abounds, making technical claims which contrast sharply with the existential values which are supposed to provide their basis.

The 'personal construct' psychology of George Kelly16 provides the theoretical backing to a brand of psychotherapy which also Kelly's basic position bears a strong resemblance to the phenomenological school of philosophy: men build their world out of their personal experience, and the construction arrived at reflects a series of personal choices of ways in which to make sense of immediate experience. In other words, reality is not 'given' to us in some absolute and external sense, but constructed out of the interpretations we place upon our fundamental experience. These interpretations may vary within the individual at different times, and will certainly vary between individuals, since they are operating from different perspectives. Thus there is no single, objective reality, but a variety of constructions of reality which may be more or less satisfactory to the 'construers', Kelly's is certainly the most profound and sophisticated attempt so far to elaborate the phenomenological position in psychological terms, and his writings have been particularly influential in British social and clinical psychology. It is not possible to do justice to his theoretical views here, but we should not pass on without trying to convey a flavour of the kind of psycho-therapy they give rise to.

Since Kelly sees the basic activity of man in terms of his trying, rather in the same way as scientists are acknowledged to do, to make sense of his experience and increase his understanding and control of the events around him, it is not surprising that he likens the therapist-patient situation to that of the scientific research supervisor and his student. Therapy, for the patient, becomes a situation in which he seeks to increase his understanding of his experience and behaviour through reflection and experiment. The therapist's job is to facilitate this process of elaboration and experimentation as best he can. As with the Rogerians, the 'personal construct psychotherapist' will have no fixed idea about how people should be, and the course of therapy in this respect will be determined by what the patient believes, and discovers, about himself. In contrast with the Rogerians, however, there is perhaps a little more emphasis on the technical nature of the therapist's role (as opposed - though not totally - to its personal quality). Since in Kellian psychotherapy the therapist's job is to help the patient investigate, elaborate, and experiment with his personal construction of his world, he needs to build a repertoire of skills which, like those of a research supervisor, will help this process along, and this inevitably implies a degree of expertise not available to his patients in the procedures of therapeutic 'research'. The therapist may use his ingenuity in what procedures he devises, though some are suggested by Kelly himself as likely to be of value in some cases at least. One such technique is 'fixed role therapy', in which the patient is invited to construct a role for himself which departs from his usual self-characterization in certain important respects. He is then asked to play this role in real life for a certain period of time (perhaps a week or two). This is, of course, to be seen as an experiment in which the patient exposes himself to new experiences which may enable him to reassess certain assumptions that he had about himself and his world, and not simply as an attempt to change people through play-acting. In order successfully to facilitate such experimentation the therapist must, in Kelly's view as in Freud's, keep himself as a person resolutely in the background: if he is not exactly a Freudian 'screen for projections', he is something rather like it, and should be sure that he is 'interpretable by the client in a variety of ways'17. The difference between him and the psychoanalyst is that he may potentiate examination of these interpretations through the deliberate use of role-play; he may produce, that is, different personalities for different occasions, depending upon his judgement of the individual's experimental needs at the time.

This picture of the therapist operating, so to speak, 'within himself', consciously varying his self-presentation, together with the more general emphasis on role-playing in therapy, illustrates the important part played by consciously directed behaviour in Kelly's system. The central aim of therapy thus becomes one of increasing the person's awareness of what he is doing and how he is constructing his world. The ability to become aware of oneself and one's 'constructs', and hence to become more skilled in the elaboration of a complex and sensitive set of interpretations through which one's world can be ordered, is thus a fundamental value of personal construct psychotherapy. It is, however, important to recognize that self-conscious skills of this kind can only be used in a context, as a means to an end, and it is easy to slip into a view of them as ends in themselves. There can be no point in becoming more and more aware, more skilful in your construing of your world, if you are not increasing your skill and your awareness for something. Failure to recognize this - in any form of psychotherapy - leads to difficulties which will be discussed in a later chapter.

Most brands of psychotherapy which we have not so far considered - and there are still well over a hundred of them - rely for their credibility on focusing on one aspect or area of human psychology and making it central to their system. In this they are aided by the infinite variety of human concerns: whatever esoteric aspect of behaviour or motivation you annex for the basis of your very own patent therapy, there is bound to be someone to whom it makes sense and who will make a satisfactory disciple, if not a patient. The more important variants of psychotherapy, however, may gain impetus and influence by virtue of the fact that, though the same basic process is at work, the area of human psychology they highlight is one which has wide appeal and potential explanatory value, and yet has been so far neglected. Thus, though perhaps limited in terms of their general applicability, such therapies may combine novelty with insight in a way which promises considerable psychological utility. Though lightweight in relation to the monoliths of psychoanalysis and behaviourism, they are nevertheless forces to be reckoned with.

Berne's 'transactional analysis' provides an example of one such therapeutic school18. While there are some aspects of Berne's theory which seem to be little more than slightly modified and diluted psychoanalytic concepts, his central achievement was to bring to the attention of psychotherapists the importance of interpersonal strategy for an understanding of many of their patients' problems. (This was not, of course, a discovery of Berne's, but a view which he was particularly successful in articulating.) In essence, the kind of interpersonal strategies, or 'games', which Berne focused upon are those in which a person, through the covert manipulation of a social relationship, may arrive at a 'payoff' in which he extorts public acknowledgement of a role he is anxious to adopt. Martyrdom, for example, is particularly easy to achieve by means of suitable provocation, and, despite its necessary discomforts, offers rich rewards in terms of moral unassailability and self-righteousness. As with other modern variants of psychotherapy, transactional analysts emphasize the importance of the patient's taking responsibility for himself and his actions as part of the process of change.

'Rational-emotive psychotherapy', the creation of Albert Ellis19, seems to consist of an almost unbelievably eclectic set of techniques and theoretical justifications which Ellis nevertheless manages to organize around one or two more central ideas. In particular, he emphasizes the role played in neurotic behaviour by, the inappropriate (irrational) standards and values the patient holds, and to which, consequently, he over-reacts emotionally. Thus Ellis's aim is to attack 'magical' personal philosophies with the weapons of 'logico-empiricism'. His somewhat optimistic theory is that 'emotional disturbance is little more than another name for devout religiosity, intolerance, whining, dogmatism, magical thinking and anti-scientism; and if people rigorously follow the logical-empirical approach and forego all forms of magic and absolutism it is virtually impossible for them to be seriously disturbed'.

Ellis's therapeutic technique is to confront the patient's irrational beliefs and values in the most direct manner possible, even hectoring or ridiculing him if this seems the only way in which he can be made to see reason. Thus the patient who feels that sexual rejection is a catastrophe of major proportions and is thereby led to despair and impotence, may be exposed to the full blast of Ellis's rational scorn as he is persuaded that such rejection, though unfortunate and frustrating perhaps, has nothing to say about him as a whole person. We are here a very long way indeed from the neutral, opaque psychoanalyst, or the concerned and yet non-directive Rogerian. Ellis represents instead the embodiment of a supremely confident view of man, certain of its aims and its ethics, and ready to proclaim its values by any means at its disposal which can remotely be considered rational. Such means vary from argument to behaviour-shaping of the Skinnerian variety, from ridicule to 'shame-attacking' assignments which require patients to behave foolishly or absurdly in order to demonstrate that doing so in fact results in no great catastrophe. In rational-emotive psychotherapy we again meet factors which are common to several of the recently developed psychotherapies: the belief, for example, that the patient gets himself into a situation which only he can get himself out of, and that effective or convincing personal experience will be arrived at, often, only through the patient's actually getting into certain situations and, so to speak, rehearsing them behaviourally. Self-awareness is less of an aim for Ellis than the banishment of self-delusion.

'Gestalt therapy', the parentage of which is again attributable to one man - Fritz Perls,20 moves us further from the treatment of neurosis and more towards psychological 'growth'. Gestalt therapists are as concerned for the total well-being of the normal individual as they are with the cure of neurosis, and the therapeutic techniques they have devised are aimed at a number of areas of human functioning which are felt to be particularly important in the attainment of such well-being. Among these are a belief in the importance of bringing into awareness the present experience of the person as a whole. Thus not only what the person is thinking and feeling, but what he is doing with his body (how it feels to him, what he is expressing through it) now, in the present, will be the focus of therapeutic work. Again, there is a great deal of emphasis on the person's responsibility for himself, as well as upon the importance for him of self-acceptance, of allowing himself to become what he is.

Much of the therapist's activity will thus consist of devising activities and experiences which will put the individual in the position of discovering what he is doing and intending in the immediately present therapeutic situation.

Gestalt therapy is perhaps the most influential of a wide variety of approaches which tend currently to be assembled under the headings 'humanistic psychology' or the 'growth movement'. These are too many and varied even to be enumerated here, and attack psychological problems from widely differing angles. There are the 'body therapies', for example, which attempt to relieve psychological blocks and tensions by concentrating upon and manipulating their supposed foci of emotional and nervous energy in the body, perhaps by means of various types of massage and movement; there are also the myriad kinds of 'encounter group', in which 'authentic' meeting between individuals is engineered by a wide range of techniques, from verbal confrontation to, literally, naked exposure to the gaze of others. The rationale of these approaches usually appeals to some variety of Western or Eastern thinking, or a combination of the two, which stresses the importance of immediate experience, authentic, genuine relationships, and freedom. They tend to share a contempt for the narrow objectivism of orthodox Western psychology and philosophy, but beyond this, identification of common theoretical strands is difficult. Certainly, many of these approaches betray a fierce moralism which makes no secret of its aims for mankind. As Rowan21 states them: 'Self-understanding, greater autonomy, increased spontaneity and creativity, a higher ethical awareness, lowered defensiveness, clearer perception, greater ability to take risks.' One might be forgiven for thinking that such a programme marks a radical departure from the traditional scientism of behaviourism and psychoanalysis; that we have found at last a way out of the mechanism and determinism which is the hallmark of so much of psychology and psychotherapy.

And yet, curiously, this does not often seem to be the case, and the aspirations of humanistic psychology seem to reflect more a modification of the message than a change in the medium. There is, for example, a certain paradoxical quality about the work of Abraham Maslow,22 one of the high priests of the humanistic camp. For, having noted that some individuals seem to have achieved higher planes of psychological 'being' and creativeness than others, he goes on to suggest that a study of their methods, so to speak, will enable the rest of us to reach the same peaks. This uncovers a kind of crude, mechanistic pragmatism which surely, in fact, makes nonsense of human achievement. Again, the lofty aspirations terms of human goals one finds in humanistic psychological literature are sometimes found to mask a strangely contrast materialism. This, for example, is betrayed in a remark of Maslow's which Rowan quotes in his book. Having gone some way towards identifying his ideal person, Maslow suggests that 'the society which can turn out such people will survive; the societies which cannot turn out such people will die.' One is almost left wondering why Maslow did not enlist the support of B. F. Skinner in 'turning out' such people by means of conditioning techniques.

Neither are we, in the growth movement, freed from the mystique of the experts and their superior vision of what is good for us: they are always ready, it seems, to tell us what is, as Rowan puts it, 'more healthy and truly human than the average'. Malcolm Brown, for example, in a paper on 'the new body psychotherapies'23, informs us that: 'Any person who cannot acknowledge the importance, and directly listen to, the wisdom of his own body is psychologically crippled and neurotic.' A slightly longer quotation from this paper, in which Brown discusses Reichian therapy, will serve usefully to illustrate the extraordinary quality of mixed mysticism and mechanism which is often to be found in such approaches:

Reich discovered that the curtailment of the longitudinal life-energy flow went hand in hand with the active maintenance of the repressive forces of the ego-defences within the neurotic psyche, and that one very effective way to loosen these repressive forces was to directly attack the seven rings of muscular armouring which pervaded the tension-racked body of the neurotic. By systematically attacking each ring by various direct body-contact techniques the Reichian therapist discovered that the patient's ego-defence system could rapidly be blasted open from underneath.

Sigmund Koch, one of the most thoughtful observers of the psychological scene, states a view of this kind of approach in psychotherapy with which it is hard not to agree:

...the group movement is the most extreme excursion so far of man's talent for reducing, distorting, evading, and vulgarizing his own reality. It is also the most poignant exercise of that talent, for it seeks and promises to do the very reverse. It is adept at the image-making manoeuvre of evading human reality in the very process of seeking to discover and enhance it. It seeks court spontaneity and authenticity by artifice; to combat instrumentalism instrumentally; to provide access to experience by reducing it to a packaged commodity; to engineer autonomy by group pressure; to liberate individuality by group shaping. Within the lexicon of its concepts and methods, openness becomes transparency; love, caring and sharing become a barter of 'reinforcements' or perhaps mutual ego-titillation; aesthetic receptivity or immediacy becomes 'sensory awareness'. It can provide only a grotesque simulacrum of every noble quality it courts. It provides, in effect, a convenient psychic whorehouse for the purchase of a gamut of well-advertised existential 'goodies': authenticity, freedom, wholeness, flexibility, community, love, joy. One enters for such liberating consummations but inevitably settles for psychic strip-tease24.

The sad thing is that, having identified, so it seems, some of the major ills of traditional approaches in psychology and psycho-therapy, humanistic psychologists have lacked the intellectual discipline and moral sensitivity to provide a carefully worked-out alternative. While deploring the fruits of traditional psychology, they have not been sufficiently critical of its methods, and indeed have often mindlessly applied the same mechanistic and deterministic assumptions in pursuit of their own goals, without apparently becoming aware of the paradox involved in doing so. Thus the psychotherapist in search of a scientific formulation of what he is doing is likely to find in the humanistic psychologies either a disguised version of orthodox mechanism, etc., or a contemptuous dismissal of all intellectual discipline combined with a untrammelled moral fervour. The emphasis placed by humanistic psychotherapists on the significance of relationships, the importance of immediate experience to understanding and change, the responsibility of the individual, and so on, is undoubtedly valuable, and continues a tradition in modern psychotherapy which started with Jung. But the methods used to exploit these insights, and to reach towards the moral goals which seem so self-evident to the humanistic therapists, are too often simple-minded and artificial, and typify just that mechanistic use of technique to which one would expect their authors most to object. (I am thinking here, for example, of such things as the use of nudity as a token of psychological self-exposure; the ventilation of anger at somebody by hitting a pillow which represents him; the self-conscious use of embrace or eye-contact as a means of generating intimacy between strangers, and so on and on.)

Though theoreticians of psychotherapy of the stature of Rogers and Kelly have gone a long way towards issuing a fundamental challenge to the traditional psychotherapies, the implications of what they have said for a change in the basic scientific structure psychotherapy do not seem to have been accepted and elaborated, often even by their own followers, enough to lay the ghosts of objectivist impersonality, mechanism and determinism in psycho-therapy. And even the challengers themselves may not always have seen where their insights were leading them to, or, if they did, may have taken fright at the extent to which a rejection of tradition scientific values in psychology would have to go. For if he is become personal, subjective, dynamic and indeterminist, to give up the general for the particular, is there any sense at all in which the therapist can still consider himself scientific? If you see science as a method, the answer is probably 'no'. If, on the other hand, you see science as a certain kind of stance towards your own observation and experience, the answer may yet be 'yes'. My own view, already stated earlier, is that scientific method originated as a means whereby scientists could free their own experience from (largely religious) dogma. That means has, in psychology, now itself become dogmatic and places a barrier between the psychologist and his subject-matter, such that he can no longer take it seriously, but must distort what he sees in order to maintain the relevance of his methodology. Much of the rest of this book will constitute an attempt to suggest what changes we shall have to make in our view of scientific method if we are to regain a relationship of good faith with our experience psychologists. In other words, I hope to explore some of the conclusions psychotherapists may have to draw about the nature of psychotherapy if they are to take their experience with their patients seriously.

For there is no doubt that, despite the inroads that psycho-therapists have made into some of the more constricting assumptions of orthodox psychoanalysis and behaviourism, the dogmas of traditional science still haunt psychotherapy. But, to return to a question I have already raised earlier, why does all this matter? If, as is probably the case, psychotherapists have recognized that what they do may benefit their patients no matter what they say they do, why should we need to become so concerned with their scientific theorizing and the implicit values it contains? Am I not simply involved in attacking straw men and obtusely failing to acknowledge the great pragmatic advances which therapists of all kinds have made?

My answer is that these dogmatic scientific values, implicit and deeply buried in the infrastructure of psychotherapy as they often are, can, and sometimes do, wreak havoc in what we actually do to patients. I shall illustrate this answer with a cautionary tale.

In a paper entitled 'Septal Stimulation of the Initiation of Heterosexual Behavior in a Homosexual Male', Moan and Heath report a form of behavioural treatment for homosexuality which was published in the Journal of Behaviour Therapy and Experimental Psychiatry in 1972, and reprinted in Psychotherapy and Behavior Change 1972, an annual publication of the Aldine Publishing Company, Chicago, whose editors evidently thought the paper sufficiently important for inclusion among 'the most significant literature published in the field of psychotherapy' for that year.

'Patient B-9', as the authors named him, was a young man with a long record of disturbed behaviour, drug abuse and homosexual activity. Among many other things, the authors describe him as 'hypersensitive to criticism and unreasonably self-conscious in public', 'disdainful, arrogant and grandiose', demonstrating paranoia 'often of true psychotic proportions', 'a severe procrastinator', depressed and preoccupied with suicidal ideas. He was also diagnosed as suffering from temporal lobe epilepsy. The authors' aim was to change B-19's homosexual behaviour by reinforcing (rewarding) heterosexual responses - a procedure they took to be reasonable on the grounds of 'the large number of studies reporting the effectiveness of various operational forms of pleasure in altering or "counterconditioning" undesired human behaviors'.

The reinforcing stimulus was achieved by implanting electrodes into the septal region of the patient's brain; a number of electrodes were planted into other brain areas at the same time. Electrical stimulation of the electrodes in the septal region brought about subjectively pleasurable sensations for B-19.

Suitably wired up in this way, B-19 was next shown 'a 15-min. 8mm "stag" film featuring sexual intercourse and related activities between a male and a female' - an experience he did not appear to enjoy. Following this, he was introduced to septal stimulation, controlled both by the experimenters and himself. 'He likened these responses to the pleasurable states he had sought and experienced through the use of amphetamines', and indeed during self-stimulation sessions 'B-19 stimulated himself to a point that, both behaviourally and introspectively he was experiencing an almost overwhelming euphoria and elation and had to be disconnected, despite his vigorous protests'. Following this experience B-19 showed a 'notable improvement in disposition and behaviour, was less recalcitrant and more co-operative . . . and reported increasing interest in female personnel and feelings of arousal with a compulsion to masturbate'. On being shown the stag film for a second time, discreetly watched through one-way glass by the experimenters, he became sexually aroused during the performance, 'had an erection, and masturbated to orgasm'. For the next few days the patient showed increased interest in women and preoccupation with sex. In view of the success of the programme so far, the therapist/experimenters moved on to the next phase of the treatment, which was to introduce B-19 to 'a 21-year-old prostitute' for a two-hour encounter (carefully described by the authors) in a specially prepared laboratory, towards the end of which time he was able to reach orgasm in sexual intercourse 'despite the milieu and the encumbrance of the electrode wires', which latter enabled the experimenters to make physiological recordings of the proceedings.

The outcome of this treatment is viewed favourably by the authors, despite the fact that B-19, 'while he looks and is apparently functioning better... still has a complaining disposition which does not permit him readily to admit his progress'. He subsequently had a ten-month sexual relationship with a married woman, whereas, they report, 'homosexual behaviour has occurred only twice, when he needed money and "hustling" was a quick way to get it when he was out of work'. The authors feel that 'the success reported points toward future effective use of septal activation for reinforcing desired behavior and extinguishing undesired behavior', and they comment that 'plans for such treatment programs are under way and will be activated in the near future'.

The reader will, I hope, be able to draw his own conclusions from this rather bizarre story, and will be able to relate the account of it to the discussion preceding it. What is quite plain is that a passion for objectivity and impersonality, leading, for example, to the pointless use of the designation 'B-19' and the provision of details of the gauge and duration of the pornographic film, the age of the prostitute, etc., results in an almost total blindness to the human significance of the procedures used. We are not told, for example, why this patient's general homosexuality was considered 'undesirable' when, by contrast, homosexual 'hustling' for money is passed over as more or less all right. There is no discussion in the paper of how the experiment (which necessitated a potentially dangerous brain operation) was presented and justified to the patient, and indeed his apparent feeling that it had not done him much good is dismissed as characteristic of a 'complaining disposition'. Again, his former drug abuse is mentioned disapprovingly in his history as evidence, presumably, of more 'undesirable behaviour', and yet part of the cure consists in providing him with a direct means of stimulating his brain, which in fact reminds him most of the joys of amphetamine. We are, in other words, lost in a technological fairyland (or nightmare), the mechanistic and impersonal values of which are taken as self-evidently valid, and in which the individual's subjective experience is overlooked as of no consequence. The occupants of this technological world, since it precludes consideration of such things, have only an astoundingly crude and rudimentary understanding of human experience and ethics, and hence no possibility of being self-critical in these respects. It is no surprise, therefore, that they can unblushingly betray the extraordinary poverty of their own values, themselves totally untouched by any kind of rational scrutiny, in speaking of 'undesirable' or 'desirable' behaviour, or in preferring their own judgement of whether a patient 'looks better' to what he himself resists 'admitting'. What we are dealing with, it seems to me, is not science, but a set of dogmatic principles which shows signs of running riot and crushing our capacity to think. The above example may be extreme, but it is not atypical of a significant proportion of what passes for psychotherapy.

We already have, then, some hints of what an alternative scientific philosophy for psychotherapy must be: in contrast to the present dogmatic orthodoxy it must take account of the personal, the subjective, the dynamic and the non-deterministic. Before we explore whether such a scientific philosophy is possible, and how it might change the appearance of psychotherapy, we should perhaps look to the research literature on psychotherapy to see what lessons it may have to offer us. This will be the task of the following chapter.

 

1 For the current spectrum in psychotherapy see D. Bannister (ed.). (1975). Issues and Approaches in the Psychological Therapies. New York and London: Wiley. For an historical perspective see D. Wyss. (1966). Depth Psychology: a Critical History. London: Allen & Unwin.

2 A satisfactory initial source is J. A. C. Brown. (1964). Freud and the Post-Freudians. Harmondsworth: Penguin Books. The writings of Freud himself are by no means as impenetrable as the non-professional reader might suspect. The Introduction Lectures to Psychoanalysis and the New Introductory Lectures to Psychoanalysis, and The Interpretation of Dreams - perhaps Freud's major work - are titles available in a number of editions.

3 Freud, S. (1933). Femininity. In New Introductory Lectures on Psycho-Analysis. Published by W. W. Norton, Inc., 1965 (p.132) and in Penguin Books, 1973. Standard Edition of the Complete Works of Sigmund Freud(1951). Trans. and ed. James Strachey. Vol. XXII. London: the Hogard Press.

4 A readable initial source is V. Meyer and F. Chesser. (1970). Behaviour Therapy in Clinical Psychiatry. Harmondsworth: Penguin Books.

5 Criticisms of behaviourism in general psychology have been made by S. Koch. (1964). Psychology and emerging conceptions of knowledge as unitary. In T. W. Wann (ed.) Behaviorism and Phenomenology. Chicago Univ. Chicago Press. For a more recent work embodying similar criticism see R. Poole. (1972). Towards Deep Subjectivity. Harmondsworth: Allen Lane, The Penguin Press. In the field of psychotherapy particularly cogent criticisms have been put by L. Breger and J. L. McGaugh. (1965). Critique and reformulation of 'learning theory' approaches to psychotherapy and neurosis. Psychological Bulletin. 63, 338.

6 Cliffe, M. J., Gathercole, C. and Epling, W. F. (1974). Some implications of the experimental analysis of behaviour for behaviour modification. Bulletin of the British Psychological Society, 27, 390.

7 Jung, C. G. (1954). The Practice of Psychotherapy. Collected Works, Vol. XVI, p. 71. London: Routledge & Kegan Paul.

8 ibid.

9 Guntrip, H. (1971). The ego psychology of Freud and Adler re-examined in the 1970s. British Journal of Medical Psychology, 44, 305.

10 Lazarus, A. (1971). Behavior Therapy and Beyond. New York: McGraw Hill.

11 A good account can be found in C. Rogers. (1961). On Becoming a Person. London: Constable.

12 Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95.

13 Rogers, C. R. (1964). Toward a science of the person. In T. W. Wann (ed.) Behaviorism and Phenomenology. Chicago: Univ. Chicago Press.

14 Wexler, D. A. and Rice, L. N. (1974). Innovations in Client-Centred Therapy. New York: Wiley.

15 See the chapters by Ludwig Binswanger in R. May (ed.). (1958). Existence. New York: Basic Books.

16 Kelly, G. A. (1955). The Psychology of Personal Constructs. Vols. I and II. New York: Norton. See also D. Bannister and F. Fransella. (1971). Inquiring Man. Harmondsworth: Penguin Books.

17 Kelly, G. A. op. cit., Vol.II, p. 620.

18 For an entertaining introduction to 'transactional analysis' see E. Berne. (1964). Games People Play. New York: Grove Press.

19 See, for example, A. Ellis (1975). Rational-emotive psychotherapy. In D. Bannister (ed.) Issues and Approaches in the Psychological Therapies. London and New York: Wiley.

20 Perls, F. S. (1969). Gestalt Therapy Verbatim. Lafayette: Real People Press.

21 Rowan, J. (1976). Ordinarv Ecstasy. Humanistic Psychology in Action. London: Routledge & Kegan Paul.

22 Maslow, A. H. (1962). Toward a Psychology of Being. Princeton: Van Nostrand.

23 Brown, M. (1973). The new body psychotherapies. Psychotherapy: Theory, Research and Practice, 10, 98.

24 Koch, S. (1971). The image of man implicit in encounter group theory. Journal of Humanistic Psychology, 11, 109.

 

3

Research in Psychotherapy

It is unfortunately not possible simply to detail research findings in psychotherapy as if they were established 'scientific facts'. This is so, if for no other reason, because such 'facts' as there are more often than not tend to contradict one another, and also because research in psychotherapy is not carried out by disinterested, 'objective' automata, but by psychologists and psychotherapists who have a stake, not only in what they 'discover', but also in where they start looking. If, for example, your primary interest is to ascertain the degree to which your clients reach a higher state of 'being', your research strategies are likely to be very different from those you would adopt if your only aim is to rid patients of the neurotic 'symptoms' they complain of at their initial interview.

Psycho-therapists, in other words, have widely differing values, and these determine the context of their research.

In recent years there has been an explosion in research into psychotherapy which has resulted in a very extensive literature, a thorough review of which would not be feasible for this book. I shall therefore limit myself to a discussion of some of the problems which face the research worker in this area, together with an examination of some of the research results which are most germane to the central preoccupations of this work. Extensive reviews of the psychotherapy research literature are available elsewhere.1

For many years - most of the first half of this century - research publications on the nature and effectiveness of psychotherapy consisted for the most part of individual case reports written by practitioners of the more or less orthodox psychoanalytic school and its derivatives. A typical paper of this kind would thus consist of a description of the patient and a formulation of his problems, together with an account of the course of treatment and an assessment of the outcome. Quite clearly such reports must be selective in the sense that the analyst's view of what are the important events in therapy will be determined by what he is looking for, and by the theoretical framework in which he places his activity.

For this reason, case histories of the kind we are considering are not (indeed, could not be) purely objective descriptions of what happened between the analyst and his patient during the course of therapy and what befell the patient as the result (such a description would involve an infinity of observations, most of them trivial and boring in the extreme); rather, they assume the validity of particular theoretical standpoint, and describe the events of therapy in the terms allowed by that standpoint. In this way, a psychoanalytic case report would take for granted the validity of psychoanalytic thinking in some important and central respects - they might focus, for example, on the 'Oedipal conflict' evident in the 'transference relationship', feeling it unnecessary, in view of the work already carried out by Freud and others, to pause in their account in order to justify the use of such concepts.

The model on which this kind of research was based is obviously a medical one, and makes the same kind of assumptions that would be made, for example, in a report of the treatment of a case tuberculosis. It assumes that a diagnosis (or formulation) has been made which is reliably similar to diagnoses which can be made in a significant number of other cases; it assumes that an established treatment procedure has been carried out which could be reliably replicated by others, and which bears upon (in this case psychological) structures which the patient shares with others to an identifiable extent. It further assumes that the technical language used and the experiences described are shared by other professional workers to an extent sufficient to make their communication worth-while. Now all these assumptions, and others like them, may be justifiable in an account of the treatment of tuberculosis (though this, as we shall see, is debatable), but even a cursory exploration of the psychotherapy literature suggests that their justifiability does not extend to the psychological sphere. There are two sets of reasons for this, one of which I shall call radical, and the other non-radical. I shall deal first with the non-radical objections to the individual case report kind of research which we have so far discussed, since these are the ones which specifically apply to it. Radical objections apply both to the case study research and to the research methodology which has largely replaced it, and I shall consider these a little later on.

The main point of non-radical objections to the psychoanalytic case study approach is simply that it is not succeeding in what it sets out to do - not (which is the radical objection) that its aims are misconceived in the first place. Thus the non-radical critic will accept that the proper aim of research into psychotherapy is to arrive at findings which are generalizable to certain (possibly diagnostic) groups of patients in terms of the treatment techniques which must be applied to bring about amelioration or cure; he will not accept, however, that the proper approach to such generalizable findings is through the study and report of individual cases. His objections, furthermore, will have more or less equal application in physical as well as psychological disorder, and centre on the lack of objectivity inevitably involved in the case study approach.

The psychoanalyst, it might be argued, has an emotional stake in what he is doing, and hence may be biased in his perception of a patient's improvement. His view of what happens, therefore, needs to be backed up by objective measurement. The theoretical assumptions he makes have themselves not been objectively validated, and may (indeed, fairly obviously do) vary from those of his colleagues, so that different therapists only appear to be talking about the same things. The diagnostic criteria he uses may well be largely personal, unless the contrary can be objectively demonstrated, and so his results will not be comparable with those of others. He has no way of knowing whether what happens to his patient is the result of his intervention, or is due to other factors entirely; this could only be established through the use of a proper experimental methodology which makes use, for example, of matched groups of patients in which a treated group is compared with an untreated control group according to measurable criteria.

The therapist who relies on anecdotal accounts of what happens to individual patients in psychotherapy for the advancement of his knowledge has, in short, missed the scientific boat. To save himself, he must adopt more rigorously objective methods and submit his procedures to far more searching experimental scrutiny.

The type of research methodology relevant to these non-radical criticisms is in principle readily to hand in experimental psychology, which has long been concerned with just these kinds of problems.

And it is to behavioural scientists trained in the academic discipline of psychology that we largely owe the bulk of research findings, such as they are, in psychotherapy. Many of these people are, it is true, clinical psychologists engaged in the practice of psychotherapy; nevertheless, they owe a scientific allegiance to their parent discipline, and it is this which determines their approach to research. Before turning to some of the broader and more radical criticisms which can be made of psychotherapeutic research strategies as a whole, we should consider what the experimentally more rigorous and objective approaches have unearthed.

In a now famous (or notorious, depending on your perspective) paper in the early 1950s, H. J. Eysenck2 launched an attack on psychotherapy which was probably in large part responsible for the explosion in research work in this area which followed. Critical of the subjective nature of most reports upholding the effectiveness of psychotherapy, Eysenck showed that a consideration of such objective research studies as there were suggested no evidence in favour of a positive outcome, and indeed it seemed that psychotherapy could not be assumed to show any more beneficial effect than no treatment at all. Eysenck, whose preference is for treatment methods based on behaviourist approaches to learning theory, tended to use his findings as a basis for rejecting psychotherapy altogether as a valid undertaking (and by 'psychotherapy' he mainly meant broadly psychoanalytic methods).

Other research workers3, however, were quick to point out that even from the objectivist point of view that Eysenck himself adopted, this conclusion is not justified by his observations. While it was clear that, taking 'psychotherapy' as a broadly uniform procedure, and assuming comparability of patients across rather diverse research studies, psychotherapy could not be shown to 'work' better than no treatment at all, to make these assumptions of uniformity and comparability itself involved an inadequate degree of objectivity and experimental rigour. What was needed, so it was argued, was to make a much finer differentiation between the kinds of techniques used, the kinds of therapists practising them and the kinds of patients they applied them to. One could not simply take, for example, 'psychoanalysts' and see if their 'neurotic patients' improved' more than patients who had merely been kept on a waiting list. The reasons why this cannot be done are obvious: psychoanalysts vary amongst themselves both personally and in terms of the techniques they use; patients differ from each other, and diagnosis is more an art than a science; 'improving' involves a wide range of criteria which will vary from therapist to therapist and research study to research study - some might focus on the subjective feelings of the patients, others on a more objective criterion such as vocational, social or sexual adequacy.

It thus came to be recognized that any research study in this area should focus at least on the following: the personal as well as the technical and theoretical differences between therapists; the personal as well as the diagnostic differences between patients; differences in criteria for successful outcome; differences in the environmental circumstances of patients during treatment, and so on.

The initial flood of research reports claiming greater objectivity than the psychoanalytic case report approach came largely from the behaviour therapy camp. Flushed with what they saw as the success of Eysenck's damnation of conventional psychotherapy, it was not long before behaviour therapists were publishing strikingly dramatic claims for the success of their methods. Wolpe, for example, claimed a success rate of 90 per cent in the treatment by systematic desensitization of anxiety neurotics4. However, it soon became apparent that many of these claims were based less on the sober use of a thoroughly objective research methodology than on a kind of scientific virtue-by-association, as it were, with the behaviourist philosophy underlying the treatment methods, and it was not long before such claims were modified. At the same time, more and more voices were being raised in criticism of a crude 'outcome' approach to research in psychotherapy, and a proper respect for the kinds of problems mentioned in the last paragraph began to develop.

The unfolding of research strategies and findings cannot be traced in detail here, but it may be of interest to consider some of the most salient features to emerge.

What seems particularly evident is that, as I suggested at the beginning of Chapter 2, what therapists say they do in psychotherapy is less relevant, in terms of what actually happens, than what they do do (this, however, is most emphatically not to say that what they say they do is unimportant in a general sense, as I hope I have shown in the previous chapter). A number of studies, for example, suggest that experienced therapists of different theoretical persuasions are more likely to behave similarly in their relations with their patients than are inexperienced compared to experienced therapists of the same theoretical school5. Much of the work in this area was carried out in response to the criticisms and claims of the behaviour therapists, who can be seen (from the perspective of the non-radical critic) to have goaded their more 'mentalistic' colleagues into a more responsible research attitude. Again, however much therapists may focus on the technical aspects of their procedures, an increasing body of evidence suggests that it is the personal relationship between themselves and their patients which is experienced by the latter as the most potent therapeutic force. Whitehorn and Betz carried out a pioneering study in this area6 which showed that therapists of a particular personality type were more successful in the treatment of schizophrenics than therapists of a contrasting personality type. Research workers in the Rogerian camp similarly demonstrated in some detail7 that therapists who offered the therapeutic 'conditions' of warmth, empathy and genuineness tended to be more successful in Rogers' client-centred therapy than those who did not - the latter, indeed, could be positively harmful to their clients. Even some psychotherapists of the more orthodox psychoanalytic variety found in their research8 that technical procedures seemed relatively less important than personal factors. Such findings have been reinforced, if only indirectly, by further research evidence9 that the very orientation a professional therapist adopts is likely to be determined as much by factors related to his personal characteristics and social attitudes as by any cool scientific assessment of its validity.

In this way, some of the more obviously constricting mechanistic assumptions underlying psychotherapy have been subjected to great strain - indeed, can be said to have been cracked - by empirical scrutiny. Not, of course, that the debate has been carried on without rancour. Whatever may be the case in the natural sciences (and it may not be so different), psychological research certainly does not proceed in a uniformly disinterested spirit of scientific inquiry: almost any research study can be questioned on methodological grounds, and alternative hypotheses for its findings can be advanced. Because of this, few psychoanalysts will have abandoned their theoretical beliefs on the evidence mentioned above, nor will many behaviour therapists feel that the aseptic rigour of their scientific dogma will not emerge triumphant in the end.

There is little doubt, however, that the fervour of both sides has been modified by such findings, as is witnessed by the somewhat more temperate language in which they tend these days to express their views in the scientific literature.

The personal qualities of patients have perhaps received rather less attention in the research literature than those of their therapists.

This relative lack of attention may perhaps reflect the passive position which patients still tend to occupy in the therapeutic equation. The therapist is active, and hence his personal contribution is likely to come into focus; the patient is to be acted upon, and hence his personal features are likely to be rather less salient. Even so, most research studies make some effort at describing patients in greater detail than would be afforded by the bare allocation of a diagnosis. Most psychotherapists are probably agreed in rejecting the inappropriate medical framework implied by purely diagnostic preoccupations, and will tend to look at their patients in terms of objective descriptions of their sex, age and socio-economic status, as well as a more or less factual description of the kinds of problems and behaviours they present. In this way such terms as 'anxious', 'phobic', 'obsessional', etc., may be used more as broad descriptions of behaviour than as imputations of distinct types of illness.

Looking at patients in these respects has in a number of studies revealed a trend which is frequently noted by research workers with some concern, if not alarm, and that is that the kind of patient to enter psychotherapy with the best chance of success can be loosely characterized as (relatively) young, attractive, verbal, intelligent and successful. This leads many therapists to feel that their best efforts are spent upon those who least need them. There seems to be little agreement among research workers as to why such patients should do better than others, though these findings lead to the speculation that psychotherapies tend to be middle-class undertakings with middle-class values, and hence are likely to appeal most to those who are most like their originators and practitioners. There are indeed suggestions in the research literature that psychotherapy is most effective where values are shared between therapist and patient, but the business of matching one to the other on these grounds has not been taken far as yet. It does however seem possible that, just as the therapist may choose his orientation on the basis of what he finds appealing to his personal values and characteristics, so the patient may, so to speak, choose his 'symptoms' in accordance with his personal stance towards the world. In this respect a number of studies suggest10 that whether or not a patient experiences his problems as primarily psychological distress on the one hand or somatic discomfort on the other may depend upon a more generally 'psychological' or 'objective' personal orientation to the world. The implications this might have for matching patient to treatment may well prove to be a central feature of future orthodox research in psychotherapy11.

In general, the findings of research workers in the field of psychotherapy tend not to provide the kind of answers which one might naively have hoped they would. It is not possible, for example, to say whether Freudian psychoanalysis works better than Jungian analytical psychology, whether encounter groups are better than individual psychotherapy, whether systematic desensitization is more effective than interpretations of the transference (see page 17).

Not that studies have not been carried out to attempt such answers: they have simply failed to produce any consistent picture, in part at least because of the enormous complexity of the psychotherapeutic situation. What we have instead is a number of suggestions that what looked to be important in psychotherapy - the technique adopted, the orientation of the therapist - is in fact less important than the operation of factors, such as the personal qualities of the therapist, previously thought by many psychotherapists to be of no account.

In fact there is no indication that any one kind of therapeutic approach is overwhelmingly more beneficial than any other. All approaches, from the psychoanalytic to the behavioural, tend to result in an improvement of about two-thirds of the clientèle and a lack of improvement in about one-third. This is, of course, about the average for a great many studies, using widely different methods assessing improvement; while individual studies may differ significantly from the two-thirds/one-third ratio, there is no overall trend to support any particular technique or orientation against others. Perhaps this finding, as well as some of the other points that have been made, could best be illustrated by referring in a little more detail to one of the most recent, and in many ways one of the most adequate (of its kind) research studies to have been carried out.

The study in question was carried out by R. B. Sloane and colleagues, and subsequently published as a book.12 The central comparison made was between analytically oriented and behaviourally oriented therapists in terms of the effectiveness of their treatments with a group of patients typical of those requesting help at an outpatient clinic. The research was well designed in a number of respects: the therapists were experienced and respected representatives of their orientation; the patients were also genuinely representative of their group (many research studies rely on only mildly disturbed undergraduate volunteers for their subjects); the treated groups were compared to an untreated, waiting-list group; judgements of improvement were made from ratings given by psychiatrists who were not themselves involved in treating the patients; a number of objective measurements of symptoms and personality were made, as were measurements of the personal style of the therapists; patients were followed up over a period of two years. In short, the investigators took into account very nearly all the factors which previous research had suggested may be of importance to therapeutic effectiveness.

A thorough analysis by the investigators of the influence of all these measured factors on therapeutic outcome revealed only relatively minor differences between the two types of treatment. In fact, both kinds of therapy proved effective, and indeed more effective than previous research has often suggested. About 90 per cent of the total group of patients improved in respect of the main symptoms of which they originally complained, 75 per cent improved in their social adjustment, and 70 per cent in their work adjustment.

There were measurable differences between therapists in terms of the style of their work - how 'directive' they were, etc. - but these proved to have little effect on the overall outcome. Measurement of the personal qualities of therapists thought by Rogers and his associates to be important (warmth, empathy and genuineness) also failed to show significant effects on final outcome. In this respect, however, it is of interest to note that patients who perceived their therapists to be warm and genuine (irrespective, that is, of how warm and genuine they could be measured to be objectively) improved more than patients who saw these qualities as less characteristic of their therapists.

Thus, neither the technical approach of the therapists nor their personal characteristics as measured objectively showed any signs of making much difference to the degree of improvement of the patients, who, however, did improve significantly more than the untreated group. This kind of finding does, of course, leave the mechanistic psychologist in rather a quandary, hopeful though it is in many respects for the future of psychotherapy. His problem is that he still does not know what it is about psychotherapy that is effective. His natural reaction is that it must be some kind of 'non-specific' component of the therapeutic situation which he has so far failed to identify, something encompassed neither by the technical operations of the therapist nor by enduring and measurable features of his personality, but nevertheless something that diligent search cannot fail in the end to unearth.

The research workers in this case did not fail to ask the patients themselves what they found to be helpful in their treatment, though, not surprisingly (in view of their orthodox scientific scruples), they are somewhat reluctant to take the answers seriously. Nevertheless, the answers they did get, 'subjective' though they may be, are interesting. At least 70 per cent of the successfully treated patients, regardless of whether their treatment was analytic or behavioural, rated the following items as extremely, or very important: (1) the personality of your doctor; (2) his helping you to understand your problems; (3) encouraging you gradually to practise facing the things that bother you; (4) being able to talk to an understanding person; (5) helping you to understand yourself. Patients who did well in analytically oriented therapy also felt the following items to be important: (1) encouraging you to shoulder your own responsibilities by restoring confidence in yourself; (2) the skill of your therapist (3) his confidence that you will improve.

It is inevitable that issues such as these - issues of relationship understanding, encouragement, responsibility, and so on - should be treated with caution by conventional behavioural scientists (and there is no doubt that Sloane et al treat them cautiously). They certainly do not fit snugly into the orthodox categories of psychology and psychotherapy, challenging as they do any conception of psychotherapy as a procedure whereby the expert therapist 'changes' the passive patient. These are issues which must, if they are to be taken seriously, be translated into a language which takes due account of the necessary rigours of mechanism and determinism and which consequently enables them to be identified objectively and measurably as 'variables' in the behavioural equation.

Only after such identification could they be manipulated precisely enough to be of consistent benefit to patients. Whether or not such translation should be undertaken, furthermore, must depend upon the reliance which can be placed on what patients think to have been important in their treatment. What is important, from the standpoint of conventional psychology, is what has objectively taken place; what the patient thinks has taken place is, relatively speaking, neither here nor there.

Not all commentators on the psychotherapeutic scene, by any means, have failed to face the more obvious implications of the findings of this kind of research, even though they might not have seen just how far-reaching they could be. In what can perhaps best be described as an extremely sensible book on psychotherapy,13 Jerome Frank considers therapeutic methods as just some among many approaches to persuasion. What these approaches have in common, he feels, are precisely those 'non-specific' factors which such studies as that of Sloane et al tend to reveal. Some of these factors Frank identifies as, for example, the trust the patient has in his therapist, his expectation of positive results, his emotional commitment to the therapeutic process, the stamp of social approval which therapeutic procedures carry, the fact that therapy makes certain demands on patients that they change themselves by active response to therapeutic directions, and so on. He also takes (as indeed do several other theorists of psychotherapy) a relational view of neurotic symptomatology: the patient uses his symptoms, in a manner which he conceals from himself, to control the behaviour of the 'significant others' around him. 'The aim of therapy then becomes', says Frank, 'to support the patient until he gets the courage to face what he is up to. This may then enable him to modify his goals in a healthier direction or change his behaviour in such a way that he gains them more effectively.' In a nutshell, Frank believes that: 'Psychotherapeutic procedures can be viewed as forms of personal influence that aim to provide the patient with morale-enhancing experiences that enable him to shed maladaptive patterns and adopt more successful ones.'

Frank's view of neurosis as a strategy for attempting to control others while evading the responsibility for so doing, his conceptualization of the process of therapy as one in which the patient gains the courage to alter his behaviour, and his assertion of the therapist's role as one of personal influence, are, I would feel, likely to evoke a sympathetic response in most psychotherapists who take their experience seriously. These, certainly, are some of the factors which seem to me most central, and they have the added merit of according closely with what patients themselves seem to feel to be of importance in their therapeutic experience. In view of this, it is curious that Frank does not, as far as I can see, draw the obvious conclusion: that a thoroughgoing science of psychotherapy must take these 'non-specific' factors as absolutely central to its field of inquiry. It must, that is, make them 'specific'. The reason why Frank does not draw this conclusion is presumably because, like so many others in this field, he is hamstrung by his conception of what it is to be 'scientific'. In the context of mechanism, determinism and objectivism, it is simply not possible to provide an adequate treatment of such factors as courage, responsibility and personal influence (impersonal influence would be all right). The result, for Frank, is that he is left with psychotherapy as one of the 'healing arts' of medicine, unable to fit it into a truly scientific framework until, for example, neurotic symptomatology has yielded an increased understanding of its biological bases. How, on his own account of such symptomatology, it could do this, remains an enigma. Nowhere in his book does Frank's consideration of the research findings in psychotherapy lead to a critical evaluation of the research methods themselves, nor does he question the relevance of the assumptions they make. Conventional research methodology aims at identifying the precise, 'specific' factors which can be shown to be operating mechanically and determinately in psychotherapy.

The fact that it has failed to do so does not lead to a re-examination of the expectation that they can be identified, but to a vague dissatisfaction with psychotherapy as a scientifically understandable undertaking. Nor does a consideration of what findings there are in such research lead to the formulation of a theory that would account for them.

These observations lead us into what I called earlier a radical criticism of research methodology in the field of psychotherapy. The reason why psychotherapeutic writers and research workers are reluctant to undertake such a radical critique is because it is likely to change our conception of what it is to be scientific in this field. To many, the idea that this conception can be changed may appear merely ludicrous; to others it may seem to be a course that should be adopted only in the gravest extremity. In my judgement, that extreme has been reached. But before moving on to a consideration of what such an altered conception of science might look like, I should first indicate what my radical criticisms of psychotherapeutic research methodology are. They are not, I hasten to add, startlingly new or original. I merely wish them to be taken seriously.

Both the main orthodox approaches to research into psychotherapy - the individual case study as well as the group comparison approaches - make certain assumptions which, if they did not make them, would make nonsense of their own activity in the first place. It may be enough for our purpose to consider only three of these assumptions: (1) that the findings of research are generalizable; (2) that the subjects of research are static; (3) that the relation between researcher and researched is non-reflexive (i.e. the subjects of research must be manipulable by the research worker, but the latter must be immune to a similar kind of influence from the former).

It seems clear that if what you find to be the case with one patient could not be assumed to be the case with similar patients in similar circumstances, if what you find to be the case with a patient today no longer found to be the case tomorrow, and if what you find to be the case with a patient leads him to change what is the case with him, then there seems very little point to our research enterprise in the first place. And yet precisely these are the problems which face all research workers in this area. So far, most of them have dealt with the problems by shutting their eyes tight and carrying on as before.

The central problem, of course, is that psychotherapy does not involve one set of rational, intelligent creatures dealing with another set of inanimate objects, but does involve one set of people dealing with another set of people who are in turn having to deal with the first set! Furthermore, people deal in meanings as well as purely physical, determinate events. Thus the significance of what a therapist does to a patient will depend, at least in part, upon the way the patient interprets what he does. And patients interpret things differently. To complicate matters further, the therapist will himself interpret the patient's interpretation, which may (or may not) lead him to modify his original action, and so on. To treat this kind of process, for research purposes, as if it were an operation in physics or chemistry is simply absurd. What happens to one person in psychotherapy cannot be generalized (except with the greatest caution) to others, because one person's psychotherapy involves a unique combination of two people's sets of meanings (his own and his therapist's). Patients do not remain static and psychologically inert while therapists tinker with their 'behaviour': they manoeuvre in response to their therapists' manoeuvres, and two different patients will respond to the same therapeutic manoeuvre differently.

There is no way that the difficulties presented by this kind of situation can be reduced to the structural simplicity required by conventional research methodology. Don Bannister puts the problem well:14

The master chemist has finally produced a bubbling green slime in his test-tube, the potential of which is great but the properties of which are mysterious. He sits alone in his laboratory, test-tube in hand, brooding about what to do with the bubbling green slime. Then it slowly dawns on him that the bubbling green slime is sitting alone in the test-tube brooding about what to do with him. This special nightmare of the chemist is the permanent work-a-day world of the psychologist - the bubbling green slime is always wondering what to do about you.

The individual case report approach to research at least has the merit that some detailed consideration is given to the patient's individuality and special circumstances; but the view given is almost inevitably the view of one person (the writer of the report) who assumes that he is describing something 'objective', without taking into account the perspective which he describes it from, and assumes, wrongly, that another person in a similar 'objective' situation will reach similar conclusions. This is not to say that individual case reports are not interesting - they can be extremely illuminating in showing the kind of things which can happen in psychotherapy. What they cannot do is establish a particular I procedure as correct for others; they cannot, that is, show people what to do in psychotherapy.

The group comparison approach to research, despite, or perhaps because of, the greater sophistication of its methodology of experimental design, is the more simplistic in terms of assumptions made about people. People, that is, become exchangeable units, passively reacting to the various sorts of stimuli manipulated by the experimenter. In so far as your interest in people is precisely as exchangeable units (e.g. as election fodder, or consumers of instant coffee), this approach to research may have its uses, but as a potential method of clarifying what goes on in psychotherapy it is a disaster. This assumption of 'exchangeability' has led in the past to some glaringly silly research efforts, in which it was felt, for example, that a therapy for neurosis could be tested on students with fears of public speaking rather than genuine patients, or, again, in which therapists of one persuasion are trained in the techniques of another so that results of the two 'different' approaches can be compared.

But even in the absence of such crude mistakes as these, the methodological assumptions of such research mean that it can only be interested in the mechanical operation of certain invariant features of the therapeutic situation - ideally the techniques of the therapist, but if all else fails some invariant feature of his personality would do. This means that even if some insight is gained into the therapeutic process, it is quickly trivialized and rendered self-contradictory. The 'genuineness' of therapists is a good example: because this form of research must assume that 'genuineness' is an invariant quality that therapists do or do not 'have', research workers will, having discovered 'it' (in the first instance from what patients tell them), then set about training therapists to have it. Just to be sure of when its there and when it's not, they will then devise methods of measuring objectively the invariant property of genuineness they have (like ZX 14 in toothpaste) now isolated. In reality, of course, we then have a group of therapists trained in ingenuine genuineness (which nevertheless must be 'real' because it's measurable), but who, lo and behold!, are no longer thought by their patients to be genuine. Sadly, their now objectively demonstrable genuineness (never mind what their patients think) no longer proves to be therapeutically potent.

Objective research has now shown that the whole idea of genuineness as therapeutically important was wrong in the first place! Thus, if such research stumbles across an important feature of psychotherapy which is in fact not invariant and mechanical - such as the personal relationship between patient and therapist - it can deal with it only by turning it into nonsense of one kind or another, and ultimately losing it.

The repeated failure of conventional research in psychotherapy to come up with anything like what it expects it should be able to come up with has resulted in a kind of chronic frustration which expresses itself in what one might describe as scientifically degenerate squabbles over research methodology. Countless authorities can be cited for any particular view, countless hypotheses can be advanced to account for any set of data, countless errors of research design and statistical analysis can be advanced to destroy opponents' claims. Somewhere underlying this endless and singularly fruitless process is the myth of the 'crucial experiment': the belief that one day a study will be carried out of such perfect design, such faultless mathematical precision, such impeccable logic and such compelling empirical content as to silence all critics, who will instead be forced into mute reverence for the therapeutic truths revealed.

What psychotherapy research has done, then, is to draw attention to a number of phenomena with which it is not itself equipped to deal. As already stated, these are the phenomena centring on the personal nature of the relation between patient and therapist. If these personal themes are to be successfully pursued, it would seem that our research assumptions will have to be modified. Among other things, we shall have to recognize that strict objectivity is impossible, and that what happens in psychotherapy is a function of the perspectives of those involved in it. We shall also have to take account of the fact that therapist, patient, and research worker are all capable of functioning at the same conceptual level and may mutually influence each other. In the absence of any evidence that it is a viable concept in the arena of human affairs, we are also forced to abandon determinism, and we must grapple directly with the complexity of human meanings rather than trying to reduce them to scientifically attractive but entirely misleading behavioural or physiological stimuli.

To anticipate later themes for a moment, what this means is that the process of research in psychotherapy, just as the process of therapy itself, is to be seen as one of co-operation between researcher and researched (or therapist and patient) in the negotiation of a view of therapy which both can share. In the course of our inquiry into these processes we shall be encountering just those 'non-specific' factors in psychotherapy which are thought by patients, and by therapists like Frank, to be of significance: understanding, responsibility, courage, personal influence, and so on.

The scientist is, of course, usually seen as the possessor of great power, the unlocker of secrets which he can then use to bring Nature to her knees. He is not usually seen as having to co-operate with his subject-matter in order to negotiate the 'truth' with it. But then the situation in psychotherapy, and indeed in much of psychology generally, is not a usual one in this sense, and it may be that we have to change our idea of scientific methodology, and, even more drastic, modify our scientific aspirations of 'prediction and control', if we are to remain true to the higher-order scientific ideal of doing justice to our experience, of taking what we find in psychotherapy seriously. It will be our task in the next chapter to consider whether such an undertaking could be considered in any sense scientifically valid.

 

1 See, for example, E. Bergin and S. L. Garfield. (1971). Handbook of Psychotherapy and Behavior Change. New York & London: Wiley. Also, J. Meltzoff and M. Kornreich. (1970). Research in Psychotherapy. New York: Atherton Press.

2 Eysenck, H. 1. (1952). The effects of psychotherapy: an evaluation. Journal of Consulting Psychology, 16, 319.

3 See papers by A. E. Bergin. (1966). Some implications of psychotherapy research for therapeutic practice. Journal of Abnormal Psychology, 71, 235; D. J. Kiesler. (1966). Some myths of psychotherapy research and the search for a paradigm. Psychological Bulletin, 65, 110; S. Rosenzweig.(1954). A transvaluation of psychotherapy: a reply to Hans Eysenck. Journal of Abnormal and Social Psychology, 49, 298.

4 Wolpe, J. (1962). The experimental foundations of some new psychotherapeutic models. In A. J. Bachrach (ed.) Experimental Foundations of Clinical Psychology. New York: Basic Books.

5 Fiedler, F. E. (1951). Factor analyses of psychoanalytic, non-directive and Adlerian therapeutic relationships. Journal of Consulting Psychology, 15, 32.

6 Whitehorn, J. C. and Betz, B. J. (1954). A study of the psychotherapeutic relationships between physicians and schizophrenic patients. American Journal of Psychiatry, 111, 321.

7 Much of this work is summarized in C. B. Truax and R. R. Carkhuff. (1967). Towards Effective Counselling and Psychotherapy: Training and Practice. Chicago: Aldine.

8 Strupp, H. H., Wallach, M. S. and Wogan, M. (1964). Psychotherapy experience in retrospect: questionnaire survey of former patients and their therapists. Psychological Monographs, 78, no.11, whole no. 588.

9 See T. M. Caine and D. J. Smail. (1969). The Treatment of Mental Illness. London: University of London Press. Also, N. Kreitman. (1962). Psychiatric orientation: a study of attitudes among psychiatrists. Journal of Mental Science, 108, 317; D. J. Pallis and B.E. Stoffelmayr. (1973). Social attitudes and treatment orientation among psychiatrists. British Journal of Medical Psychology, 46, 75.

10 See for example D. J. Smail. (1970). Neurotic symptoms, personality and personal constructs. British Journal of Psychiatry, 117, 645; F. M. McPherson and A. Gray. (1976). Psychological construing and psychological symptoms. British Journal of Medical Psychology, 49, 73.

11 An interesting start in this direction has been made by T. M. Caine, B. Wijesinghe and R. R. Wood. (1973). Personality and psychiatric treatment expectancies. British Journal of Psychiatry, 122, 87.

12 Sloane, R. B., Staples, F. R., Cristoll, A. H., Yorkston, N. J. and Whipple, K. (1975). Psychotherapy Versus Behavior Therapy. Cambridge, Mass. and London: Harvard University Press.

13 Frank, J. D. (1973). Persuasion and Healing. Baltimore and London: Johns Hopkins University Press.

14 Bannister, D. (1966). Psychology as an exercise in paradox. Bulletin of the British Psychological Society, 19, 21.

 

 

4

The Scientific Philosophy of Psychotherapy

We inherited, say at the beginning of this century, a notion of the physical world as a causal one, in which every event could be accounted for if we were ingenious, a world characterized by number, where everything interesting could be measured and quantified, a determinist world, a world in which there was no use or room for individuality, in which the object of study was simply there and how you studied it did not affect the object, it did not affect the kind of description you gave of it, a world in which objectifiability went far beyond merely our own agreement on what we meant by words and what we are talking about, in which objectification was meaningful irrespective of any attempt to study the system under consideration. It was just the given real object; there it was, and there was nothing for you to worry about of an epistemological character. This extremely rigid picture left out a great deal of common sense.

The writer of these words1, written in 1956, prefaced them with the warning that 'the worst of all possible misunderstandings would be that psychology be influenced to model itself after a physics which is not there any more, which has been quite outdated'. These were not, moreover, the words of some disaffected critic of the scientific orthodoxy, disillusioned with his failure to find a productive corner for himself in the intellectual establishment; they were written in fact by Robert Oppenheimer, prestigious physicist, 'father' of that most awesome example of scientific achievement, the atomic bomb.

And yet his warning, like the arguments on which it was based, has largely gone unheeded by behavioural scientists, and, as we have been in the earlier chapters of this book, the model of science which Oppenheimer characterized as outdated even for physics continues to exercise great, and sometimes damaging, influence on the theory and practice of psychotherapy.

Over and over again, the most compelling features of psychotherapy are passed over because they do not easily fit in with our conception of what it is to be scientific - we cannot reconcile them with the objective, mechanical, determinate principles with which we feel we must comply if our activities are to be licensed by the authority of Science. As we have seen, this uneasy fit between the experience of psychotherapy and the orthodox scientific framework results in a number of strategies, none of them particularly helpful in furthering our understanding of psychotherapy. One course is simply to crush the phenomena of therapy into their constricting scientific mould, ignore the violence thereby done to them, and recite your scientific credo loudly enough to drown all protests. This, more or less, is the manner of orthodox behaviourism. Or, alternatively, you could decide sadly that psychotherapy cannot really be understood scientifically at all, and relegate it, as Frank appears to do, to the realm of the 'healing arts', awaiting the day when advances in biochemistry or physiology will render the whole business unnecessary anyway. Or again, one can lose patience with the whole intellectual 'scene', decide that science is hopelessly impersonal and dehumanizing anyway, and get on with the job of curing people and fostering their growth unencumbered by any rationalistic claptrap. A number of the 'humanist' psychologists appear to favour this course. Alternatively, and not all that different from this caricature of the 'humanist' solution, one can take what could be called a 'naive technological' stance, and simply support any therapeutic procedure which seems to 'work', rejecting as tiresome and irrelevant questions about why they work, how you know they are good for people, and so on. These alternatives exemplify fairly accurately what has happened in the field of psycho-therapy, and it is interesting to reflect that the resulting shambles is due almost entirely to the uncritical acceptance of precisely that model of science to which Robert Oppenheimer objects.

But if this is so, why has this scientific model not been abandoned long ago, especially since its weaknesses can seem obvious even to non-psychological scientists like Oppenheimer?

I think it at least plausible that the mechanist/determinist scientific model has dominated, and largely continues to dominate, psychology principally because of the authority it confers upon the psychologist. As we saw in the previous chapter, the psychologist, unlike his counterpart in the natural sciences, is dealing with a subject-matter (people) which is capable of answering him back. Not only is he open, as are all scientists, to the questioning and criticism of his expert colleagues, but he is also exposed to the scepticism of the very things he is supposed to be an expert about. One way he can make himself invulnerable to this form of attack is to espouse a philosophy of science which objectifies the people he is studying and renders them amenable to prediction and control. Any answering back they then do can easily be dismissed as a failure on their part to recognize the 'true' scientific state of affairs, and he will put his faith in 'behavioural laws' which he feels to be every bit as powerful as the laws of natural science on which, he feels, they are modelled. In other words, in order to escape his fallibility as a person - to which he can not claim to be any less prone than the persons he is studying - he has to associate himself with a body of knowledge which is impersonal. Having succeeded, in theory, in this enterprise, the psychologist is then caught in the dilemma that he can no longer deal adequately with his subject-matter, which is personal.

Perhaps, however, the project to objectify science could be made less attractive to the psychologist if it could be demonstrated that it is in any case not possible, even in the physical sciences; for then he need not feel quite so bad about having to work out an alternative.

If, that is, science can be shown not to be dealing in cast-iron certainties, its methods not sanctioned by the stamp of impersonal reality, we may begin to see ways in which we can come to terms with our personal fallibility.

At this juncture, there are a number of philosophers of science who come to our rescue. Foremost among these is Michael Polanyi, whose book, Personal Knowledge,2 deals precisely with these problems in the context of science generally. In this book, Polanyi demonstrates how all attempts to ground the scientific enterprise on some formal, objective method have failed. The reasoning behind such attempts runs something like this: the universe, or at least enough of it for our purposes, is determined according to the law of cause and effect. If we can find out enough about it at any one point in time, we can then calculate what it will look like at future points.

Science then becomes the refinement of the methods by which such calculations can be made, and 'being scientific' means rigorously applying these methods to the 'facts' of the universe which are revealed to us. Thus, all we need to do is to discover the rules by which deductions from hypotheses can be tested, proper measurements made, and so on. However, Polanyi shows that none of the rules yet advanced as embodying the scientific method accounts satisfactorily for all of the scientific discoveries we have made. What all of them leave out of account is the personal activity of the scientist himself. That such oversights should have been made by ‘men of great intellectual distinction' can be explained, Polanyi suggests, by their 'desperate craving to represent scientific as impersonal'. But, just as we have already noted in the case of the psychologist, the more the scientist succeeds in this project, the more he fails in the total scientific enterprise. As Polanyi puts it3:

This is how a philosophic movement guided by aspirations of scientific severity has come to threaten the position of science itself. This self-contradiction stems from a misguided intellectual passion - a passion for achieving absolutely impersonal knowledge which, being unable to recognize any persons, presents us with a picture of the universe in which we ourselves are absent. In such a universe there is no one capable of creating and upholding scientific values; hence there is no science.

The very word 'scientific' is still frequently used to convey a total freedom from values, a noble state of pure objectivity from which our wants, wishes, beliefs and prejudices have been purged by a disinfecting exposure to the rigorous checks of an impersonal reality.

The white-coated scientist is seen as a kind of high priest of truth, toughened by his exposure to the cold blast of actuality, immune to the subjective errors of bias and sentimentality to which the rest of us are prone.

Another philosopher of science, Feyerabend, suggests that this picture is a fairy tale4:

But the fairy tale is false.... There is no special method which guarantees success or makes it probable. Scientists do not solve problems because they possess a magic wand - methodology, or a theory of rationality - but because they have studied a problem for a long time, because they know the situation fairly well, because they are not too dumb (though that is rather doubtful nowadays when almost anyone can become a scientist), and because the excesses of one scientific school are almost always balanced by the excesses of some other school. (Besides, scientists only rarely solve their problems, they make lots of mistakes, and many of their solutions are quite useless.) Basically there is hardly any difference between the process that leads to the announcement of a new scientific law and the process preceding passage of a new law in society: one informs either all citizens or those immediately concerned, one collects 'facts' and prejudices, one discusses the matter, and one finally votes.

The solution to these problems is, then, for the scientist to put himself back into his picture of the world, and to recognize the essential part played in it by his own values, beliefs and commitments. As Polanyi says5:

For, as human beings, we must inevitably see the universe from a centre lying within ourselves and speak about it in terms of a human language shaped by the exigencies of human discourse. Any attempt rigorously to eliminate our human perspective from our picture of the world must lead to absurdity.

And again6:

If man died, his undeciphered script would convey nothing. Seen in the round, man stands at the beginning and at the end, as begetter and child of his own thought.

It is of course hard for the 'man in the street' to shake off the conviction that the world he perceives around him consists entirely of 'things in themselves', existing completely independently and objectively, and it is perhaps, therefore, not surprising that he is ready to grant the scientist, who appears to be able to penetrate this objective reality, a special kind of knowledge, a knowledge of things as they really are. Once the realization has been made, however, that the way things are cannot sensibly be detached from the way we see them (as Kant also reminded us), we can begin to see that the scientist's knowledge is not an especially privileged insight into reality, but a certain kind of knowledge, a particular way (and a particularly human way) of looking at the world.

Science, then, cannot be separated from the people who carry it out, nor can its methods and precepts. The nature of the world is not imposed upon man by virtue of its independent, objective characteristics, but men create a world within which they can perform their scientific operations. In an important sense, the world is man made; the scientist is responsible for his picture of the world.

The world is discovered in the experience of men, not in the revelation of some kind of final actuality.

What makes the scientific community different from other kinds of human association is the set of values shared by scientists. These probably cannot be stated formally in any very precise way, and almost certainly drift and change with the passage of time. For the most part, scientific values seem to focus on the ways in which personal knowledge can be shared and elaborated within the scientific community. Such personal knowledge is not acquired entirely passively through reading books or attending lectures, but rests, as Polanyi points out, on the active acquaintance of the scientist with his subject-matter - indeed, the very basis of his knowledge may be quite impossible to verbalize in any adequate manner. In this way the scientist may 'know' something in the same sense that one can be said to 'know' what honey tastes like: such knowledge cannot be acquired or transmitted outside the sphere of personal acquaintance, although it can be shared, and discussed those who have experienced it. What allows scientists to construct the intellectual edifice of science is their shared acquaintance with its subject-matter, and their shared evaluation of how to develop their understanding of it. Partly, no doubt, this may involve the use of certain methods to which scientists may give their assent, perhaps because, as with the principles of logic or mathematics, they find them personally compelling. But science cannot be identified with these methods: logic gives no guarantee of truth, and can be (and has been) associated with extremely unscientific undertakings.

There is, naturally, a sense in which objectivity and agreement are indeed important parts of the scientific value system, but this is not the dogmatic objectivity of behaviourist psychology, which is used an attempt to force a consensus among psychologists. It is, rather, a kind of shared subjectivity. Oppenheimer suggests that the criterion of scientific truth:

…must come from analysis, it must come from experience, and from that very special kind of objectivity which characterizes science, namely that we are quite sure that we understand one another and that we can check up one another.

For another physicist of great distinction, P. Bridgman7, even agreement of this kind becomes problematic, and the core of scientific activity becomes a matter of explaining the relation of individuals to each other:

I believe that in society as at present constituted the possibility of consensus, except with respect to the simplest situations and as a first approximation, is a mirage. There is no such thing as true consensus, and any ostensible reality supposed to be revealed by the consensus does not exist. To my mind this only underlines the importance of the individual and the importance understanding the relations of individuals to each other. It also underlines the necessity of making my own report in the first person.

However hard it is to achieve, a central feature of the scientist’s personal commitment is what Polanyi calls his 'universal intent', i. e. a commitment to a view of the world as shared. Thus scientists seek and work for objectivity on the basis of their personal acquaintance with their subject-matter; it is not imposed upon them from without, and cannot be set up as a test of the validity of scientific statements.

Specifying what scientific, as opposed say to religious, artistic, or indeed technological, values are is in any case by no means a simple task. A significant point seems to be that science seeks ultimately to convince us of a proposition's truth by referring us to evidence which we cannot in good faith deny, and that involves reference to a perceptual and experiential world which we find we have in common. The methodology of science seems, again in part, to be aimed at boiling down our more complex and questionable conceptions to simple and compelling ones.

If we are not to abandon psychology, and the procedures which, like psychotherapy, follow from it, to an undilutedly ethical domain in which theories are believed and practices practised simply because theorists and practitioners like or approve of them, it seems that we must indeed try very hard to find a scientific framework for them.

And this because scientific statements seem to carry a special kind of conviction which is not arrived at by other routes. If this conviction is not attainable through the formal application of objective, mechanistic methodology, what is its source?

As I have already implied, the conviction which scientific statements carry seems to me to stem not from checking them against evidence from an outside, objective 'reality', but from internal experience. We are convinced because we may, to test our agreement with a scientific proposition, freely and unconstrainedly consult our experience (from 'ourselves as centre', as Bridgman puts it); we are not asked to accept it on faith, or on outside authority.

What we do find compelling about scientific statements with which we agree is that we cannot in good faith deny the evidence of our own experience, and this is an experience which takes place within ourselves. And what makes this process so attractive is that we are compelled by nothing but our free acceptance of our experience; we choose to be bound by it. Just because of this, scientific inquiry carries with it a marked quality of freedom. We do not have to submit to a tyrannical intellectual authority, as in magical or religious systems, nor indeed do we have to accept the overbearing demands of an absolute objectivity. Our commitment to the values of science follows from the trust we have in the evidence of our experience and is willingly self-imposed. Not, of course, that there is anything infallible about personal experience, and it certainly cannot be used as a guarantee of any kind of objective truth or certainty. It does, however, constitute the permission we give ourselves to assent to or dissent from scientific statements.

The authority which the mechanistic psychologist seeks for his pronouncements is, then, a chimera, because the 'objective' world he wants to ground his authority in cannot in any case be divorced from the world of his personal experience. He keeps his 'objective’ authority at the expense of inventing an impossible world and a pseudo-science.

So that we can understand better the process of psychotherapy, and how it can be investigated scientifically, it is also important to examine a little further what is involved in the kind of objectivity which we can accept as valid and this, as we have seen, turns upon the ability of people who are involved in the scientific/psychotherapeutic exercise being able to agree with each other.

Scientists seek consensus, and make conditions for it as favourable as they can by, for example, using the same systems of measurement and agreeing on a common language.

But although consensus is clearly a highly important part of the scientific process, and without it, presumably, there would be no science, it also cannot be made a criterion of scientific truth. If, in the case of the natural sciences, our sensory impressions did not happen to match (if, for example, we did not all see, even after debate and argument, the same number of coloured patches on a microscopic slide) scientific progress would presumably be impossible; but that does not mean that such progress could be brought about by insisting on a consensus of some artificial kind.

Science capitalizes on the happy accident that, in some important respects, human being share a common experience of the world, and can build an intellectual understanding of it on that basis. If you are wondering who in their right mind would try to bring about an artificial consensus as a substitute for common experience, you do not, unfortunately, have to look far for examples. Much of the dogmatic insistence on 'measurement' in psychology and psychiatry is directed precisely at this end. There are systems of psychiatric diagnosis, for example, which seek a monopoly of the kind of questions people can be asked: thus if everybody used a certain diagnostic inventory in precisely the same way, the answers obtained, which of course could only vary within the range set by the questions, would be taken to reflect the presence of real disease entities. Again, there is the personality theorist who appears to try to extend the validity of the dimensions of personality he feels he has isolated by giving them a number in a 'universal index' (which he has in fact created himself). In other words, because one can measure what one can agree about, many psychologists and psychiatrists seem to feel that one can find something to agree about by inventing a system of measurement first and insisting thereafter that people fit their disparate experience into it.

Thus, one does not bring about a scientific result by insisting on consensus, but the consensus comes about through an honest assessment of the degree to which one man's experience coincides with another's. Consensus is in this way a personal discovery; we find that we agree. Of course, if I see what you do not see, I do not at the outset have to conclude that either of us is wrong: I may first check my own experience to make sure that I am not being misled by some (relatively) fleeting illusion or hallucination. I may even negotiate with you concerning our respective perceptions. But my ultimate check will be against further experience of my own. If I were to abandon my own experience in favour of a wider consensus (based perhaps on a dogmatic assertion of what is 'scientific'), if I were to deny what I see because others say they do not see it, or because in some sense I am not supposed to see it, I should thereby cease being scientific.

Truth becomes possible as a concept because we happen to share certain important areas of our experience. It is thus a social concept, a way of saying what we have in common; it is to be found in the areas of our private worlds which overlap.

How we come to acquire the rather fundamental kinds of experience which we seem able to share (in particular our experience of the physical world) is obviously an exceedingly complex question, and it is certainly not my intention to suggest that they just happen to be present in some neatly finished form in every new-born infant.

They may in fact be the result of complex negotiations between mother and child8, and they may vary from culture to culture. On the whole they seem to be relatively stable, and there is a limit set on the degree to which they are negotiable. That limit (though it may vary over time) is defined by the individual's personal acquiescence in them on the basis of what he finds at 'himself as centre'.

One reason, then, why the natural sciences have proved so powerful is because they are built on areas of human experience (basically sense experience) in which it has proved possible to find wide consensus on the basis of personal consent. For science to flourish, however, it is also necessary for men to value this approach.

If I value scientific truth, I value your free discovery that your experience overlaps mine, and if I value scientific method in a wider sense, I will value the possibilities for communication which this discovery affords us, and the fruits it bears in terms of further elaborations of our experience which we can, at least potentially, share.

I may of course not value these things. I may instead wish to make my views absolute by insisting that you see things my way, I may try to impose my 'reality' upon you either by force or by appealing to some other kind of value which I think may persuade you - for example, that my system is effective, or economical, or will achieve the greatest happiness for the greatest number. Appeals of this kind, as we have seen, are often enough to be detected at the heart of various psychotherapeutic approaches, which is all very well as long as they do not continue surreptitiously to be put forward as 'scientific'.

This discussion of the nature of the scientific enterprise introduces no revolutionary new concepts. It simply reasserts a view of science which has been advanced often in the past, frequently, as we have seen, by natural scientists themselves. This view, which can be summed up as making the personal role of the scientist central to an understanding of his activity has, however, been almost entirely neglected in psychology and psychotherapy, with consequences we have noted already often enough. That such a view of science exists does however suggest that the student or practitioner of psycho-therapy can cease glancing nervously over his shoulder at the tablets of the psychological law on which are engraved the dogmas of mechanism, and get on with the business of taking what he finds in his own experience, and that of his patients, seriously.

In many ways this means a depressingly fresh start, in which almost all the assumptions of traditional psychology, whether cherished or simply taken for granted, must be re-examined for the polluting effects they may be having on our psychological understanding and our ability to get to grips with our subject-matter. Because people are people and not things, the science we end up with may well not look very much like what we have come to expect, even if naively, from the natural sciences, and we may well find that we have to abandon all hopes of the control and predictability which once looked such an exciting prospect. But if there is disappointment at the failure of the original projects of 'scientific psychology', there may also be relief that we can be freed of its demands for objectivity, generality, and so on, and still remain scientific.

As far as psychotherapy is concerned, the most we can hope for, perhaps, is some understanding of our activities as people in relation to each other (patients and therapists); not, certainly, to predict and control them, but to provide a basis on which we can share experience, talk about what we are doing, and define the limits of our understanding.

Because our experience of ourselves, other people, and of society and the values it enshrines is infinitely more complicated than our experience of the physical world, we cannot expect quickly to find a common language in which we can discuss these issues, or more or less ready-made instruments with which we can measure them. This demands a tolerance of different perspectives, a good will towards the experience of others, a patient groping after shared under-standings, which will require a very different spirit from that in which psychological inquiry has largely been carried out in recent decades.

Even if what is required is a fresh start, it is fortunately not so necessary to make it with an entirely clean slate. The methodology of traditional approaches to research and practice in psychotherapy may have blinded many of those involved to the content of what they were dealing with, but the content is nevertheless there, and has, even if often passed over as 'non-specific', occasionally been examined with painstaking care by some observers.

In the chapters which follow an attempt will be made to draw together some of these observations, many of which are not to be found clearly stated in the mainstream of psychotherapeutic inquiry, and to add some of my own. The guiding aim of this inquiry will be to stay as close as possible to psychotherapy as a personal activity (and hence to be 'scientific' in the sense advocated in this chapter), and to arrive at an explication of some of its more puzzling features without resorting to the kind of mechanistic dogma which destroys understanding and undercuts experience. I certainly do not have a patented system, or a ready-made methodology, or a final solution to offer. More, I hope, a contribution to a scientific conversation about some aspects of psychotherapy.

 

1 Oppenheimer, R. (1956). Analogy in science. American Psychologist, 11, 127.

2 Polanyi, M. (1958). Personal Knowledge. London: Routledge & Kegan Paul.

3 ibid., p.142.

4 Feyerabend, P. (1975). Against Method. London: NLB.

5 op. cit., p.3.

6 op. cit., p.265.

7 Bridgman, P. W. (1959). The Way Things Are. Cambridge, Mass.: Harvard University Press.

8 See, for example, J. Shotter. (1974). The development of personal powers. In M. P. M. Richards (ed.). The Integration of the Child into a Social World. London: Cambridge University Press.

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