Psychotherapy, Society and the Individual

David Smail

Talk given at the 'Ways with Words' festival of literature, Dartington, 12th July,1999

There is no doubt that psychotherapy can be – perhaps usually is – a very powerful experience. Like many other kinds of experience, however, its power – the weight of conviction it imposes – is no guarantee of its validity.

There are of course many kinds of psychotherapy, frequently radically incompatible with each other, theoretically irreconcilable and technically mutually inconsistent. And yet nearly all share one crucial characteristic: they involve an on-going – often indeed protracted – closely intimate relationship between two people. (Group therapy is quite a different kettle of fish, and I’ll not be talking about it for present purposes.) It is this relationship, technicized by the psychoanalysts as ‘transference’ and ‘counter-transference’, which gives psychotherapy its experiential power. It’s really quite difficult to spend many hours of your life cooped up in the consulting room of someone who is intently trying to understand you without emerging with the feeling that something momentous has happened.

It’s very nearly impossible to discount the conviction of significance which our personal feelings so often carry with them. An example which may be familiar to people here who haven’t experienced psychotherapy may be that of writing. Many professional writers speak with awe of the magical experience of writing, of the way it seems to take place through them, almost as if their words were being written by the hand of God. Portentous accounts of creativity have been grounded on this experience. Indeed, I have experienced it often myself and can vouch for its capacity to leave one feeling deeply moved.

It wasn’t until a man I knew told me how his short stories came to him that I began to get an idea of what this experience is about. His eyes misting with emotion, he told me how his stories seemed eerily to write themselves, how they poured themselves from the end of his pen faster than he could control the muscles of his hand. He positively glowed - humility and pride in equal proportions - that the mystery of the creative act should have been vouchsafed to him.

The trouble was, his were without question the worst short stories I have ever seen committed to paper. Chaotically constructed, banal, misspelt and ungrammatical, they were in fact barely literate.

What this reveals, I suspect, is merely that for anyone, creatively gifted or not, writing tends often to carry with it a different kind of experience from talking, without the same kind of illusion of control: one is more aware, with writing (rather perhaps as with dreams), that the ego is not as central as we often take it to be. That’s all.

The experience of psychotherapy is rather like this. No matter what the content of what passes between client and therapist, the relationship generates in both a conviction of profundity and significance which leads not only to a (most often) erroneous belief that fundamental changes have taken place in the client but also a widespread certainty in the truth of the theory employed and the efficacy of whatever technique the therapist claims to have used. Once you’ve experienced this you are more than likely to be hooked. Perhaps this is why (though probably not consciously) so many schools of psychotherapy insist on acolytes’ going through the therapeutic experience themselves. Most religions and cults make the same kind of requirement. The power of personal experience is not to be underestimated, and (as well, of course, as more noble human sentiments and achievements) prejudice and bigotry depend upon it.

If we take a step back from personal feelings, difficult though that may be, we are likely to get a more sober view of the significance and efficacy of psychotherapy. Taking this kind of step back is of course precisely what science is supposed to be about, and although the social sciences can scarcely be considered as a unified and uncontentious field (if it wasn’t such a cliché I’d say they were riven with dissent) it is still true that over half a century of intense scientific examination of psychotherapy, producing countless volumes – indeed libraries – of evidence, provides little support for the confidence most therapists, as well as many of their clients, have in their procedures.

So far as a scientific consensus is possible, we might be able to agree that the helpfulness of therapy, such as it is, has more to do with the personal qualities of the therapist than with any particular theory or technique; that such personal qualities are not a matter of training, so that many people who are not ‘qualified’ therapists are likely to be as good or better at it than people who are; that fairly obvious forms of commonsense enquiry and advice (ponderously baptised ‘cognitive-behavioural’) are likely to be more effective in alleviating psychological distress than are the more recondite procedures of, for example, ‘dynamic psychotherapy’.

The best thing for psychotherapists faced with this kind of evidence to do is to look around for grounds for dismissing it. Human ingenuity being what it is, that is not too difficult, especially in ‘postmodern’ times when the whole boring nature of so-called ‘positivistic’ science is discredited at some of the highest intellectual levels. But that’s not what I want to do, not least no doubt because my own experience of getting on for forty years as a clinical psychologist accords rather well with the scientific evidence (and of course I am as vulnerable as anyone to personal conviction!).

What seems to me important is to understand why psychotherapy is not as effective as people feel it to be and, more important, to develop a more satisfactory idea of how psychological distress comes about and how it might best be dealt with.

I am making some assumptions here which need to be spelt out if misunderstanding is to be avoided. I am assuming that the principal aim of psychotherapy is to alleviate distress and that the question of its effectiveness may legitimately be raised. These assumptions are, I think, linked; that is to say, the question of its effectiveness can be raised only if psychotherapy is seen as a technical procedure for the relief of psychological or emotional distress.

Many psychotherapists, especially of the ‘psychodynamic’ variety, reject the idea that what they do constitutes a form of ‘treatment’, preferring to characterize it as a procedure of enquiry and self-understanding. This is fair enough in my view, but puts psychotherapy in the same camp as religion, say, or astrology. The procedure is self-justifying, and one need seek endorsement for it no further than the participants’ own feelings. If, for example, you want to spend fifteen years five days a week (and several thousand pounds) coming to understand yourself and your conduct in the terms set out by Sigmund Freud, without necessarily expecting it to make any significant or observable difference to your personal suffering or the way you conduct your life and relationships, that is entirely your business and that of your (in this case) psychoanalyst.

Though I wouldn’t choose it for myself or particularly recommend it to others, I am not, as a great believer in freedom, against this kind of activity; it may even have some things to be said for it. One thing most forms of therapy do is champion the individual and his or her personal feelings and experience. That is to say, they privilege subjectivity. Indeed, I suspect that this is one of the main secrets of the success of psychotherapy as an enterprise: from its outset psychotherapy challenged objectifying forms of authority which sought to impose on people explanations for and meanings of their conduct which resided outside their own experience and potential control. This is not to say that psychotherapy itself doesn’t in many of its aspects quickly become just such and objectifying authority, but at best it furthers at least an illusion of subjective, personal freedom and responsibility.

Even this, though, has its own attendant set of dangers: a defence of subjectivity and celebration of individuality can quickly develop into a pervasive orgy of interiority in which people become so exquisitely sensitive to their own feeling-states and intuitions, etc., that they are virtually removed from the public world of spontaneous social action. Absolutely nothing is more boring and futile than focussing to the exclusion of almost everything else on the quality and finer meaning of one’s own sensations and experiences – not to mention dreams. Therapy junkies can easily find themselves in that kind of condition, and spend far more time than is good for any of us writing about it.

But I think what most people understand by ‘psychotherapy’ is precisely a form of treatment for psychological disturbance, and certainly by far the majority of the practitioners of the myriad forms of therapy available today at least imply that that is indeed the nature of their game even if they don’t openly claim it. In other words, what most psychotherapists are offering at least tacitly is a professional service involving established and validated procedures for the relief of distress. In this situation, it seems to me perfectly legitimate to ask for evidence that such procedures do indeed exist and that they work. And it is precisely here, of course, that psychotherapies become unstuck in a big way. Now I don’t at this point want to get embroiled in a dispute about ‘evidence’ and what may legitimately be said to constitute it: social scientists can (and will, nothing is more certain) go on squabbling about that kind of thing for ever. Pretty well everyone not having directly vested an interest in a particular therapeutic brand name is agreed that the evidence for the effectiveness of therapy is overall weak. What I do want to do is suggest some reasons why this isn’t such an outrageous or dismaying circumstance as some may feel it to be. In fact it’s pretty well to be expected.

Psychotherapy is, when one comes to think about it, a curious phenomenon: one very much of the twentieth century and indeed particularly suited to these supposedly ‘postmodern’ times – which is perhaps why it is currently booming as never before. We have become so familiar with the ideas explicit and implicit in psychotherapy, it chimes in so harmoniously with the Zeitgeist – indeed in part it is definitive of the Zeitgeist – that it becomes quite a struggle to see how curious a phenomenon it is. But what it does, I would suggest, is something quite radical – even violent – to the nature of our personhood and our relations with the world. To be more specific: it disembodies us and it dissociates us.

Through its focus on the individual and its limitation for the most part of its analysis to the individual’s relations with a) his or her family and b) the therapist, psychotherapy lifts the person out of the physical and social contexts which actually shape and maintain him or her as a person. It simply ignores the main factors and influences which make us the people we are. The aim, of course, is to free us, to give us power over our lives and the ability to change their course when things go badly. But it is an illusory freedom and one which in the long run does us much more harm than good. In fact, if only it could speak for itself, the consensual core of psychotherapeutic thinking would find much to agree with in Margaret Thatcher’s dictum that there is no such thing as society, only individuals and families. It might even go further in maintaining that, its ‘all being in the mind’, there are no such things as bodies either. Let me just take the factors of disembodiment and dissociation one at a time.

Disembodiment

In nearly all its varieties, psychotherapy tends to think of bodies as unproblematic, as secondary to mental influence; in many respects the mind is seen as constitutive of physical structures. This is seen at its most extreme in the view that, through the operation of ‘imaging’ a person can organize a kind of biological attack on pathogenic physical processes such as the production of cancer cells. (Apart from its absurdity, this kind of thinking can lead to very unfortunate consequences, for what starts out as a half-baked notion of the magical power of thought ends up in people feeling responsible for their inability to cure their cancer.)

The privileging of the mental is rarely as extreme as this, but is still widespread in psychotherapeutic thinking. Psychoanalysis, of course, gives colossal power to ‘the Unconscious’ and its ability to shape our bodily experience and reactions, and ideas like that of ‘psychosomatic’ illness can quickly slide into a view that psychological events cause physical ones. Such ideas may be harmless enough – even quite fruitful – as a kind of rhetorical counter to an unthinking biological mechanism, but they too easily come to underpin a received – and utterly erroneous – notion of the power of mind over matter.

In run-of-the-mill therapeutic work the factor of disembodiment is encountered most frequently, albeit somewhat indirectly, in the pervasive notion of ‘insight’. At first glance the idea that we can act freely on the basis of what we see to be the case and that the identification of misconceptions is enough to enable us to change our ways seems innocent enough, and indeed forms one of the principal pillars of everyday ways of thinking. Psychotherapy is built around this idea. In order to change their neurotic ways, people have to see into their reasons, conscious and unconscious, for clinging on to them, and having done so will be able to take a different course.

‘What’s the matter with that?’ you may say. Well, the matter is that our learned patterns of thought and action are not merely mental acquisitions, but are embodied. It is no easier for people, for example, to throw off anxiety and lack of self-confidence merely through having seen into its history than it is for them to speak anything other than their mother tongue simply by being given an account of how they came to speak it. Psychotherapy tends in this way to represent our personal characteristics and conduct as matters of choice, as though we were, from infancy on, disembodied wills, selecting (even if unwisely or unconsciously) what suited us from a kind of hypermarket of possibilities.

But experience is embodied. Wired in. We may if we are lucky be able to an extent to choose our influences (good parents will do this for us as we grow up, and the more resources they have at their disposal the more successfully they will be able to do it) but we cannot choose whether or not to be influenced, or to become uninfluenced once we have been influenced. As I’ve found myself saying over and over again to people, you can’t choose to forget how to ride a bike. The same is true with so-called ‘psychological’ influences: you can’t just divest yourself of their consequences merely because it now suits you (having gained ‘insight’) to do so.

Dissociation

Because psychotherapy focuses almost exclusively for the derivation of its theory and practice on the two occupants of the consulting room, looking beyond for the most part only to the members of the patient’s immediate family, the result is a dissociation (social dislocation) of the individual which has profound implications for the understanding of how, among other things, psychological distress comes about. A world is created in which it seems as though persons are made solely through the interplay of wilful action among those with whom they are most intimately involved – that is to say in the ‘proximal’ relations with their family and some others with whom they have close, intense, relations, including of course their psychotherapist. It is their relations with the latter which are seen as crucial to their psychological transformation. Left unanalysed in this situation, and very possibly not considered at all, are the influences of the wider culture and social
environment.

In mainstream psychotherapeutic thinking there is nowhere to look for the meaning of action beyond the actors themselves, and so the potent factors in the process of becoming a person and the struggle to change are likely to be seen as intention, will, desire – those factors which in fact all of us in our day-to-day lives take for granted as the sources of our conduct. However, because it is every therapist’s experience that people cannot change merely because they intend to or want to, another dimension has to be added to the equation to explain their apparent recalcitrance, and that of course is the dimension of the ‘Unconscious’ which becomes a repository for intentions and desires of which the person is unaware. What you then end up with is a kind of voluntarism at one remove, where therapists can hint at what people ‘really’ (unconsciously) desire and intend, and chide them (though obliquely) with a kind of concealed moralism: ‘now you’ve seen what you’re really up to, don’t you think you’d better change your ways?’ As an account of human conduct this really is extraordinarily inadequate.

In many areas of our lives we are in fact shaped by forces well beyond the reach of our will and even in some respects of our understanding. Very significant parts of what we take to be our personal individuality are quite literally culturally determined. Socio-economic influences affect us as intimately and as uncontrollably as the weather. As people we are locked into a network of social power-relations which sets the strictest limits on what we are able to achieve purely through the action of our own will (it was of course Michel Foucault’s particular achievement to elucidate the nature of this apparatus of social power). What aspects of our personal and interpersonal conduct may be controlled by powers which we cannot even see, let alone influence, is far from clear, largely because our individual-centred psychology has for the most part failed to pay them any attention. However, what is clear, I think, is that the influence upon us of such ‘distal’ powers is far, far greater than we have so far been able to understand and severely limits what can be achieved through such ‘proximal’ undertakings as psychotherapy.

We are through and through social creatures, and our happiness and unhappiness are conditioned by our relations with each other not just as face-to-face individuals but through highly complex networks of social organization. And that organization is above all structured by power. How much we are able to alter our circumstances, and so perhaps affect the balance of our happiness and unhappiness, will depend not on our being able to tap sources of ‘will power’, hitherto perhaps buried in our unconscious, but on what forms of social power are available to us from without.

Please let me remind you at this point that I am not trying to say that psychotherapy as an undertaking or as a vocation (the preferred term of Paul Gordon, who will be speaking this afternoon and whose version of psychotherapy I have little quarrel with) is intrinsically invalid. What I am saying is that in its guise as technical procedure of change, the disembodiment and dissociation of human beings which psychotherapy so easily brings about ends up inevitably in a – very probably unrecognised – belief in magic, for the material means of causality have been removed from the picture. We are not the kind of self-creating, self-changing entities that psychotherapy so often assumes us to be. Our conduct is shaped and given meaning by a social world and mediated by biological structures which we cannot change simply by seeing the necessity for doing so or desiring to be otherwise. There is in fact no such thing as ‘will power’ – if we are able to will an action it is because the power is available to us to perform it, and that availability of power originates from without, not from within. We can transcend the reality of social power (of its facilitating as well as of its constraining effects) and of the capacities and limits of our own biological structure only in our imagination, and when it comes to affecting the circumstances of our lives which cause us pain, imagination is not the most potent instrument.

I am not saying anything new with this. I’m sure that to many it seems, as it does to me, so obvious as to verge on banality. What I am doing is taking a side in a debate which runs right throughout the history of culture. In view of this, it always surprises me how upset with what I’m saying some people seem to get. Apart from sheer abuse from some fellow professionals (e.g. that I’m suffering from ‘clinical depression’), the most frequent accusation aimed at me is that I am depriving people of hope. But this is the case only if the version of psychological suffering and its ‘treatment’ offered by the therapeutic paradigm is the only valid possibility. I am indeed saying that ‘psychotherapy’ as a technique or set of techniques for the treatment of psychological distress can only be of limited value (not that it is valueless). This is because by far the greater part of psychotherapeutic theory has failed to progress beyond the most naïve psychology of personal development and essentially magical ideas of change. I don’t see anything particularly hopeful about reliance on magic as a cure for distress. Hope lies in other directions. Perhaps I should take just a little time to give an indication of what kind of other direction might be worth following.

From a psychological point of view the Twentieth Century has been a colossal diversion (certainly in the West) from an examination of the way individuals are created and maintained by their environment. The quality of thought Plato gave in his Republic to the kind of cultural diet most suitable for its future leaders is barely conceivable now, where about the most we get is cursory studies or literature reviews to show, for example, that television has no influence on violence. Our emphasis, as I have already indicated, is very heavily on the inside, on mental factors such as choice and will, and moral factors mostly seen as personal, such as ‘responsibility’. Because of this, our gaze is diverted from the social world around us and our preoccupations are with self-transformation of the personality rather than political transformation of the society beyond the boundaries of our skin.

The logical culmination of this – one whose lineaments are already clearly discernible – is that our world becomes virtual rather than actual, and in place of a materially created reality we are immersed in an ideality which is spun by its various doctors into all manner of marketed wishfulness. At the political level exhortation and the avowal of ‘values’ come to be seen as an acceptable substitute for material action.

The costs of pretending that we are immaterial beings capable of self-transformation into shapes and conditions of our own choosing, as essentially free of the limitations of the body as of the constraints of society, are I believe already to be seen in the forms taken by the psychological afflictions of the young, some of whom have become prey to a kind of anxiety in which they are panicked by, for example, the experience of their own bodies; they have simply not been taught what it is to be a human being and do not recognize feelings which are the common lot of ordinary mortals.

We have become absolutely to depend on the notion that it is possible to change aspects of ourselves we find inconvenient, to erase the inscription upon us of the environmental influences which surround us. Rather than accepting that experience marks us for good and all, we wish to insist – indeed have come to expect and demand - that its effects can be counselled away.

But would it really be so terrible if psychotherapy didn’t work in the way we seem to expect it to? Perhaps if we were shaken out of our bewitched fascination with imagination and ‘virtuality’, the wishful invention of interior worlds which have no embodied substance, we might come to see that paying sober attention to the realities of social structure and of our relations with each other as public, not simply private, beings is an option. A difficult one certainly – not so easy as dreaming and wishing – but at least a real one. What this would entail is a recognition that maybe prevention is more possible than cure; a down-grading of psychology in favour of an up-grading of politics.

Where, though, would this leave individuals? Would we not, for example, be in danger of depersonalizing ourselves and risking becoming part of a grey, undifferentiated mass, prey to totalitarian solutions of the kind too often experienced already in this now dying century? I really don’t see why this should be. Politics doesn’t have to be dishonourable. There is no reason in principle why we shouldn’t be able to resurrect a politics whose central concerns are with such things as liberty, justice and equality. Very difficult, certainly; naïve, Utopian, idealistic, I can’t deny. But at least not, like the psychology of self-creation and self-transformation, impossible.

Our disillusion with and widespread rejection of what passes for politics these days – that is, for the most part, the acquisition and manipulation of power by large interest-groups – leave us exposed to ideologies at least as dangerous as those recognized as political. For the marketed ideology of interiority, the world of ‘third ways’ where public opposition is supposed to be at an end and the interests of all can be reconciled, where exhortations to ‘personal responsibility’, ‘naming and shaming’ and other forms of sanctimonious moralizing take the place of government, all these take us in to a realm of make-believe where there is only an illusion of control, and where the real, material principles of social reality threaten to run riot.

I hope it is clear from what I’ve said that I am absolutely not meaning to suggest that the lives, interests or feelings of individuals be sacrificed to some idealized political notion of the common good. Perhaps psychotherapy’s greatest contribution (though by no means always and everywhere) has been, as already suggested, to support and sustain individual subjectivity, to respect individual feelings and to respond compassionately to individual pain. But these humane aims and impulses did not originate with psychotherapy and are in fact not realizable by it in any other context than that of a personal relationship. That is to say, psychotherapy is incapable of bringing about change on a wider social scale if only because it hasn’t the powers available to it to do so. The kind of moral aim which underlies the best psychotherapy cannot be achieved by a procedure of personal transformation or ‘cure’ (on an analogy with medicine), but by constructing a context of ‘taking care’ which, as I argued in an earlier book, can be furthered only politically, i.e. as a collective social undertaking.

Even the respect for individuals which lies at the heart of the best psychotherapy can too easily become submerged in a pernicious moral and aesthetic prescriptiveness by no means dissimilar from political totalitarianism. For it is easy for therapists to slide from a compassionate interest in how people are into a superior judgement of how they ought to be. In part it is this phenomenon which feeds the whole culture of personal ‘change’ to which psychotherapy is so prone. It is impossible to be exposed for long to the privileged insights which the role of psychotherapist offers without becoming aware of the darker and more depressing sides of human experience and conduct, and so hard to resist an impulse to moral exhortation (in however veiled a form) and to holding up to people a model of ‘normality’ or ‘being’ to which they should strive to conform. But this is just another form of tyranny, disguised victim-blaming in which people are asked to do the impossible. Impossible because the vast majority haven’t in fact got the powers available to them to effect the changes considered necessary.

We would do better, I think, to see that the kind of changes which might improve our lives are matters of social, not personal concern and action. If we need to change anything it is the social environment in which we are all located and embodied. This leads to a very different psychology from the one we are used to, a very different way of conceiving experience and action (ways that, unfortunately, I haven’t the time to develop now, but which I touch on in my books The Origins of Unhappiness and How to Survive Without Psychotherapy).

It leads also to a very different way of conceiving of ourselves and each other, but not one which is totally unfamiliar to us. Rather than seeing ourselves as free agents, able in principle to pick and choose the ways we want to be, we could, I suggest, see ourselves as characters, not unlike characters in novels (I should probably say some novels): fixed, predictable, often caught tragically on paths not of our own making and from which diversion is not an option. Characters we can identify with whether through love, pity or fear, but also characters created by sets of circumstances and worlds which maybe it would have been possible to influence, characters whose experience means something by virtue of pointing to ways in which sets of circumstances and worlds could be. Characters, that is to say, who exist not just for themselves, but for a future.