The Impossibility of Specifying 'Good' Psychotherapy

The Impossibility of Specifying 'Good'
Psychotherapy

David Smail

Talk given at the Universities Psychotherapy Association Annual Conference, University of Surrey,
November 1999

Let me start by reading you a list of personal qualities:-

Kind, sensitive, intelligent, cultured in the arts and humanities, intuitively perceptive, supportive without being obtrusive, attentive rather than talkative, attractive, faithful, loves children, clean and an excellent cook.

It may have taken a while for you to realize, with a mounting sense of outrage, that what I am attempting to specify here are the characteristics not of a good psychotherapist, but of a good wife.

Now, quite apart from the nature of the characteristics selected (not to mention the extremely politically incorrect odour of the whole enterprise), what makes the specification of good wifeliness particularly patronising and offensive is the embedded assumption that all women need to aspire to a particular stereotyped role, as though there were only one way of being a good wife.

My bet is that most people who would find this to be a thoroughly distasteful exercise would be less appalled at the notion of trying to enumerate the qualities of a good psychotherapist. As far as I can see the only reason for so feeling would be if there was lurking in the back of our minds the idea that there is, precisely, only one way of being a good psychotherapist, or one delimitable set of characteristics which would define, as we are so horribly prone to say these days, excellence in psychotherapy. I suspect that this notion is indeed deeply rooted in our thinking about psychotherapy.

When I think back on the numerous patients I’ve seen in my time, however, this is a notion which doesn’t seem to be borne out by experience. Not only have I not been able to help everyone I’ve seen (which, I acknowledge, may indicate no more than that I’m not a good psychotherapist), but I have also encountered many patients who have been quite clearly helped by therapists of vastly differing kinds.

It is true that I have a vagueish idea of the kind of therapist I would like to see when in difficulties, and I suspect that the qualities I could adduce for such a person would tally quite well with lists drawn up by many (but not all) other professional therapists. It seems likely to me, though, that this is more than anything a ‘people-like-us’ phenomenon: we would like to be seen by people we could identify as being like we like to think of ourselves as.

But when I come to others in my experience, many of them have been helped by people extremely unlike me and extremely unlike I would like to be. I can remember patients being ecstatically appreciative of help given by people who have sounded to me: arrogantly dogmatic, directive and certain of themselves; toe-curlingly sugary and sentimental; deeply and blindly religious; immersed in rigidly impervious magical systems of some kind; homespun and commonsensical well past the point of banality. You could of course say that such people could not properly be called psychotherapists, and you might be technically right, I suppose, but, in the cases I can think of, the help people have derived from these diverse characters has been, as far as I could see, very real and very important and at least as profound and as lasting as the improvements identifiable through more conventional psychotherapeutic approaches.

The only way I can see that would permit us to specify, if not one single type of good psychotherapist, at least a limited range of such, would be if psychotherapy were a technical procedure with clearly recognizable aims and well understood means of achieving them. Many psychotherapists, of course, do maintain that this is precisely what psychotherapy is like, and even the majority of those who don’t, act as if it is: after all, we have degree courses and schemes of accreditation, registers, etc., all of which suggest there are indeed ways of specifying good psychotherapy.

The focus here, of course, is mainly on the procedure, not nearly so much on the people who carry it out. Despite the considerable body of evidence (arguably the only consistently persuasive evidence) that it is the personal characteristics of therapists rather than therapeutic technique which achieves such improvement as can be identified in the field, we continue resolutely to select candidates for training in particular schools or brands of therapy and we defend these brands, and
seek to register them, with a ferocity utterly inexplicable on the grounds of demonstrable validity. Any impartial observer of our conduct in these respects would very understandably assume that psychotherapy was a quasi-medical, technical procedure which practitioners could be trained to perform more or less interchangeably. This, of course, is precisely what the general public, guided by the media, do assume.

In the guilds we form, the training courses we set up, the registers we propose, the papers we write and the research we conduct it is overwhelmingly the assumption of psychotherapy as professional technique which guides our thought and our actions. And yet, I suspect, in the privacy of our own minds, revealed often in unguarded talk in conference bars and so on (what one might call professional parapraxes), we know that psychotherapy is not really like this, and that the relation between therapist and patient is much more a personal than a technical one.

So why do we cling so tenaciously to a view of psychotherapy which is not only counter to our own experience but also in fact unsupported by the vast bulk of the research literature?

The short but inescapable answer to this question is: because it is in our interests to do so. It is in the interests of those who wish to earn a living by the practice of psychotherapy to set up professional frameworks of authorization. It is in the interests of potential recipients of our services to have available to them some way of simplifying the path to relief of their distress. It is in the interests of those in the academic market who wish to build an honourable reputation for themselves as bona fide scientists to conform to conventional models of research using objectively specifiable variables. It is in the interests of a society which causes immense damage to huge sections of its population to represent that damage as the consequence of essentially individual psychological aberration, in principle curable through therapeutic intervention.

For the most part, it seems to me, we are, if not blind to, then extremely confused about the role of interest not only in our own motivation but in our understanding of motivation generally. In this respect I can’t resist a brief digression concerning the role of interest in the origins of our discipline. In this I am largely quoting from a paper I wrote a few years ago(1).

When I first read them, it struck me how revealing Freud’s letters to Wilhelm Fliess(2) were of the pressures on Freud to come up with some kind of viable treatment, the practice of which would earn him a living. What we seem to be dealing with here, all too understandably, is not so much a dedicated man of science single-mindedly pursuing truth whatever the personal cost (a distinctly nineteenth century myth), but, to switch to the hideous modern business argot, a man with some innovative ideas seeking to establish a niche for them in the marketplace. If his patients were motivated by sexual impulses and wishes, Freud himself seemed activated more by the need – starkly familiar, I suggest, to all of us – to keep his head above water financially.

Let me offer some evidence. The following quotations from the Freud-Fliess letters are selected for their poignancy; there are in the correspondence many other instances of Freud's anxious preoccupation with the means of earning his livelihood.

In his letter of 2.11.1896, for example, Freud expresses worry about 'the state of my practice this year on which my mood always remains dependent' (my emphasis in this and subsequent quotations).

Things have improved somewhat by 6.12.1896, 'after having for once enjoyed the full measure of work and earnings that I need for my well-being (ten hours and a hundred florins)...'

A couple of months later things are even more promising (8.2.1897):

I now have ten patients in treatment, including one from Budapest; another one from Breslau is due to arrive. It is probably one hour too much, though otherwise I feel best precisely when I am working a lot. Last week, for example, I earned 700 florins
- you don't get that for nothing. Getting rich must be very difficult.

In one of the most interesting letters (21.9.1897) in the collection - that which announces to Fliess the beginnings of a shift in Freud's theory of neurosis from seduction to fantasy - there is a continuous theme of financial insecurity running alongside his reasons for abandoning some of his previously key contentions (e.g. that fathers could so often be involved in 'widespread perversions'). The letter opens with Freud's observation that he is '...impoverished, at present without work', and acknowledges later on that: 'The expectation of eternal fame was so beautiful, as was that of certain wealth, complete independence, travels, and lifting the children above the severe worries that robbed me of my youth.' Towards the end he regrets that 'it is a pity that one cannot make a living ... on dream interpretation!'.

Perhaps most revealing is the confession which, among other things, discloses Freud's evident habit at this time of referring to rich patients as 'goldfish'. It is made in his letter to Fliess of 21.9.1899:-

A patient with whom I have been negotiating, a 'goldfish', has just announced herself - I do not know whether to decline or accept. My mood also depends very strongly on my earnings. Money is laughing gas for me. I know from my youth that once the wild horses of the pampas have been lassoed, they retain a certain anxiousness for life. Thus I have come to know the helplessness of poverty and continually fear it. You will see that my style will improve and my ideas will be more correct if this city provides me with an ample livelihood.

Although the complex and conflicting relations between truth and interest are constantly before us – in some ways as plain as the noses on our faces – there seems at the same time to be an extraordinarily confusing atmosphere surrounding them. One might say, almost, an atmosphere of repression. We are ashamed of our interest and seek to hide it behind protestations of another kind of motivation (e.g., the search for truth). We do not publicly proclaim our interest, but cloak it in rhetorical devices which in the end blind us to the meaning of our own actions. (This is, obviously, not the case always and everywhere. There has come into being a conscious art of the distortion of truth by interest, practised by its own accredited doctors. This is of course the art of ‘spinning’, an art which, very strangely, is minutely analyzed, admired almost, even as we allow it to take us in.)

In modern times – but perhaps it has always been so – truth is the servant of interest. Indeed, in so-called ‘postmodern’ times, the distinction between truth and interest becomes obliterated: truth becomes an entirely pragmatic concept, knowledge becomes indistinguishable from power. However, this development, I strongly suspect, is no more than a convenient intellectual conjuring trick, helping to legitimate the liberation of whatever corner of the market you find yourself in to the fullest potential for exploitation.

In the end, giving free rein to the operation of interest destroys our capacity to understand what we are doing. In the case of psychotherapy, our blinkered pursuit of our professional interest, our obsession with shoring up our credentials and refining a rhetoric of credibility has taken us up a blind alley in which we are no longer able to discern the real features of our undertaking. In fact, we haven’t really got a clue as to what constitutes good psychotherapy not because the question is unanswerable but because we steadfastly refuse to pose it in the appropriate way. We insist on there being only certain kinds of answer to this question, i.e., those which conform to our notion of psychotherapy as trainable, quasi-medical technique. When we perceive the answers which begin to take shape as we research into our activities, we panic and retreat into denial.

Those answers are, of course, that psychotherapy is not appreciably more effective than any other approach to emotional distress; that technique has virtually nothing to do with such success as therapy does enjoy; that the personal characteristics of therapists are more important to outcome than any theoretical allegiance; that training of practitioners is largely irrelevant and untrained volunteers can often do just as well or better.

Now I acknowledge that all this does indeed constitute quite a threat to our interests as a broad professional group, but it also raises some very interesting questions about the nature of an undertaking which we are all convinced from our personal experience does have some kind of validity.

Our problem is that we have been far more concerned to specify the characteristics of good psychotherapy than to recognize them. The former concern tends inevitably to focus on techniques, the latter on people. Even the Rogerian approach, which started out with a recognition of the importance of personal qualities, quickly fell into the trap of trying to technicize them via procedures of training. Rather than merely qualities to be identified, warmth and empathy became matters for fabrication.

Psychotherapy – surely we all know it in our hearts – is not a technical procedure like, say, dentistry, which can be carried out interchangeably by people who have been trained to an acceptable level of competence. More like marriage, in fact, the sphere in which psychotherapy belongs is much more personal as well as relational. Not only does whatever success it enjoys depend on the personal qualities of those taking part – patients as well as therapists – but also on the interactions between them. Research looking into these aspects is very sparse indeed in comparison to the relentless search for the replicable effects of measurable variables such as therapist orientation, length of treatment, etc., etc.

In fact, we have barely begun to ask the interesting questions about what makes for good psychotherapy, and even then it is, I think, very uncertain whether those questions could be cast in conventional research terms, any more than could questions about what makes for a good marriage. There are, for example, going to be many different kinds of ‘good’ psychotherapy. If some individuals turn out to be in some sense ‘better’ at it than others (which is one very obvious research question we have resolutely avoided pursuing), it by no means follows that their personal qualities will be capable of emulation.

We are obsessed with the model of the production line and are unlikely, I imagine, to remain satisfied simply with the recognition of good psychotherapy when we encounter it. There is no self-evident reason why this should be so: we are able, for example, to appreciate good musicians or painters without feeling driven to manufacture more exactly like them.

In all the vast literature on psychotherapy, there is very little, in my view, which truly takes seriously and illuminates its nature as personal and relational. Two writers who do spring to mind in this respect are Peter Lomas(3) and Paul Gordon(4). The lessons they, and some others, no doubt, have to teach are very different from the kind of intellectual straitjacket (and professional bad faith) which conventional scientific rhetoric attempts to force us into. In contrast with the largely specious picture shaped almost exclusively by our interest in developing a marketable product, we are presented with a view of psychotherapy as a quintessentially human undertaking full of uncertainty, frailty even, in which a kind of healing may emerge – perhaps – from the exquisitely vulnerable endeavours of two people acting in the best faith they can muster. This is not really the stuff upon which a large and lucrative industry can be built.

My own view is that we cannot possibly even begin to attempt a definition of good psychotherapy or good psychotherapists without first radically revising our assumptions about psychotherapy itself. This revision comes not merely from some kind of ideological stance, but from observation and experience of a century of psychotherapy during which, as Hillman and Ventura have written(5), the world’s been getting worse.

The largely unelaborated model of human action which underlies the vast bulk of orthodox psychotherapeutic thought is, I would argue, both dissociated and disembodied.

By ‘dissociated’ I mean that the therapeutic protagonists are considered in the context only of the consulting room, so that the salience and importance of their own personalities and the relations between them are hugely overemphasized in relation to the in fact much more powerful social forces which surround them. Because of these wider, more distal influences, individuals are unlikely to be free to act on the basis simply of insights gained in therapy. Characteristics and repertoires of conduct which we take, in a very limited sense, to be ‘personal’ (and so in principle voluntarily alterable), are, like the very language we speak, in fact held in place by socio-economic and cultural influences over which we have no control at all, conscious or unconscious.

Similarly, by ‘disembodied’ I mean that the recipient of psychotherapy is treated as an unencumbered will who can change course on important issues simply on recognition of the desirability of doing so. That is to say, insight, it is supposed, can result in voluntary changes of direction by means of a simple cause-and-effect process – mental cause and physical effect – which offers no account at all of the way bodies acquire and maintain the mechanics of activity. Along with this kind of thinking there frequently goes another, very possibly unrecognized, assumption that simple perception of the undesirability of a particular kind of thinking, feeling or conduct is sufficient to erase it from the individual’s repertoire. However, our physical structure – our embodiedness – does not permit us to work like this. We are just not free to wipe out experiences of the past which imprint themselves physically upon us, any more than we are free, again, to wipe out the language we speak.

The idea which haunts so much of psychotherapeutic thinking – that we are ‘responsible’ for ourselves, that we can ‘choose’ ourselves, and so on, assumes degrees of independence from both the social structure which surrounds us and the physical demands and constraints of our own bodies which could not conceivably be enjoyed by anyone – which would in fact, if true, place us beyond the horizon of a scientific world-view into a universe of pure magic.

Psychotherapy is indeed a personal and a relational undertaking, but it is one which takes place in a social context which greatly limits its scope for effecting change. At its best, to be sure, it provides people in distress with the comfort and encouragement which is to be derived from solidarity with another person, but how far any given individual will be able to make use of whatever lessons have been learned once the relationship comes to an end will depend on powers and resources either available in the social world beyond or acquired bodily in the past.

Psychotherapy is not, thus, a panacea for emotional and psychological ills which in fact have their causes in highly complex interactions between human bodies, social worlds and individual consciousness. Rather, it is but one form of help, based on the refinement of a certain kind of human solidarity aimed at what it is possible for the sufferer to understand and act upon. There are many routes to the achievement of this kind of help which, if we manage to free ourselves from the blinkers of interest, we may be able to recognize, though not to specify.

We may have had a hundred years of psychotherapy, but learning to recognize what makes for good psychotherapy is a task we have so far barely begun. If we do manage to achieve it, we shall find in doing so, I suspect, that the muddied flood which psychotherapy and counselling have become will ebb to a more modest, but also a more wholesome and sustaining stream.

David Smail
Guildford, November 1999

(1)Smail, David (1995). Power and the origins of unhappiness: working with individuals. Journal
of Community and Applied Social Psychology, 5, 347-356.

(2) Masson, J.M. (ed). (1985a). The Complete Letters of Sigmund Freud to Wilhelm Fliess
1887-1904. Cambridge, Mass. & London: Harvard University Press.

(3) His most recent book being: Lomas, Peter. 1999. Doing Good? Oxford University Press.

(4) Gordon, Paul. 1999. Face to Face. Psychotherapy as Ethics. London: Constable.

(5) Hillman, J. and Ventura, M. 1993. We’ve Had a Hundred Years of Psychotherapy and the
World’s Getting Worse. HarperCollins.