Social Power and Psychological Distress
Talk given at the Café Scientifique meeting, Nottingham, 14/10/02
The mental health industry has been going strong for just about 100 years, so the beginning of a century may be quite a good time to reflect on the course its taken.
In our culturei.e. principally that of the English-speaking world, but with a few important strands thrown in from continental Europethere have been two main approaches to the kind of emotional and cognitive disturbances that get labelled as in some degree mentally unhealthy: the biological and the psychological. As far as professional/academic disciplines go, these translate into psychiatric approaches on the one hand and psychological/psychotherapeutic ones on the other (though there are of course overlaps between them here and there). Since my expertise, such as it is, is in the psychological approaches, I shall have only a little to say here about psychiatry.
In Britain at least, psychiatry is a reasonably uniform discipline, held together by biomedical assumptions, procedures and professional organization. Psychiatry dominates as well as defines what one might call the mental health orthodoxy, informing official NHS and legislative procedures, and subject only to political controls exercised through government. Although psychiatry came under attack in the 1960s and 70s to the point where its dominance began to look quite vulnerable and shaky, it has since recovered with a vengeance, and it is now possible to assert the essentially biological and genetic nature of mental illness, of so-called diseases like schizophrenia, clinical depression and bipolar disorder, in the confident, and correct, expectation that these will be accepted as facts by most informed and right-thinking people.
One reason that psychiatry has been able to regain the ground lost 30 or so years ago is that it has to a large extent withdrawn from much of the territory it occupied until then, in practice if not in principle. Its focus now (again, in Britain) is serious mental illness, i.e. the kinds of disturbance, disorientation and despair that present individuals, their families and sometimes the wider society, with agonising problems of management. The vast area of what used to be called neurotic problemsi.e. subjective miseries whose disruptive effects on others are far less obviously evident, now often dismissed slightly contemptuously as the problems of the worried wellhas been abandoned to the huge army of therapists, psychologists and counsellors that has mushroomed over the past twenty years or so. These latter tend to take a rather different line in respect of their clients difficulties.
On the face of it, there is among the plethora of psychological approaches nothing like the uniformity that disciplines psychiatry. The psychotherapy and counselling field constitutes a kind of bazaar where a variety of brands squabble and jostle for consumers attention. There are in fact hundreds of such brands, each having started with its own entrepreneurial leader and seeking to establish its own system of training and accreditation in order to differentiate itself from the competition. In practice, about a dozen such brands have become sufficiently distinctive and successful (in business terms) as to constitute what one could call - very loosely! - a psychotherapeutic orthodoxy. While these might attempt to band together for marketing purposes, their claim to validity relies precisely on the distinctiveness with which they try to stand out from their rivals. This means that on the face of it choice seems to be a significant factor in the therapy/counselling field.
For example, psychoanalysis - the brainchild of Sigmund Freud, and in the view of many the Rolls Royce of psychotherapy - looks very different from the person-centred approach of Carl Rogers or the Rational-Emotive Therapy of Albert Ellis. Cognitive-behavioural therapy, the treatment of choice for British clinical psychology (and the one most likely to be encountered by NHS patients), looks different again. Thus, depending on whose hands you fall into, you may find the source of your difficulties attributed to your unconscious desires and impulses, your inauthentic interpretation of your experience, your irrational assumptions about yourself or your faulty cognitions and behavioural patterns.
An enormous amount of scientific bickering has taken place over the years to try to stake out convincing claims to competence and effectiveness for each of these approaches. While these research efforts have, to put it mildly, not met with unequivocal success, they have managed to give the impression that the approaches in question are indeed significantly different from each other and that it will only be a matter of time until careful research reveals the winner. Some would claim, of course, that we have already reached that point and that, for some types of disorder at least, cognitive-behavioural approaches come out ahead of the field. Even if one accepts the evidence on which this claim is basedand by no means everybody doesthe effectiveness of the treatments involved could still scarcely be considered overwhelming.
However, the impression of healthy competition among a wide variety of counselling and therapy approaches that this picture may give is, in my view, in itself misleading, for in fact they all share one very important assumption. Whats more, despite the appearance of radical contrast, they share it also with psychiatry. This is the assumption that psychological disturbance has its origin within the individual, whether the latter is conceived of as mind or body.
The principal causes of emotional distress are in this way thought to be traceable either to the persons physical structuregenes, biochemistry, etc.or to their psychological makeup. It follows logically enough from this that cures will be effected, or at least adjustments made, by treating those physical or psychological aberrations within the individual that careful diagnosis reveals.
The arguments in the psychological camp are not over whether this basic picture is right, but rather over how psychological aberration might best be understood: whether as a mechanical difficulty on the one hand or as a moral or aesthetic difficulty on the other. For example, is someones obsessive-compulsive disorder the upshot of a faulty interpretation of experience reflected in neural connexions in the brain (an essentially mechanical problem), or is it the result of morally unacceptable repressed wishes overwhelming the persons ego? Many approaches to therapy especially perhaps those falling within the so-called humanistic schools that flourished in the second half of the last century have an at least implicit model of how human beings at their best ought to be, whether as fully analyzed, experientially congruent, self-actuating, and so on. These set up aesthetic standards against which it is all too easy to be found wanting.
This concentration on internal faults and shortcomings leads almost inevitably to a subtle or not-so-subtle emphasis in treatment on individuals ability to change themselves. Having, through patient enquiry, clarified how the patient came by his or her problems, the therapist can in the last analysis only leave it up to the individual to make the necessary changes. Therapy thus becomes a matter of leading horses to water, but whether they drink or not is up to them.
Over the years, the psychotherapies have attempted to deal with this difficulty in various ways, often by trying to represent the movement from diagnosis to cure as somehow automatic. The psychoanalysts interpretations, etc., will lead through the process of insight to an adjustment of the internal, unconscious processes that were causing the trouble. At the other extreme, it will be incumbent on the client of cognitive therapy actively to undertake the learning regimen prescribed by the therapist such that the offending cognitions may be restructured. Its usually not long before the inadequacy of these ideas (principally, the observation that they dont work) leads to the conviction that nothing much can be achieved without the patients willed co-operation in the process of cure. This boils down in the end to the frank acknowledgement that whether or not someone gets better is a matter of their own responsibility, and indeed the notion of responsibilty became a central pivot of humanistic approaches.
Now I think were operating with a very strange, essentially pre-scientific model here, one in fact that has more in common with seventeenth century magic and astrology than it does with modern scientific medicine (not that thats always everything its cracked up to be). Indeed, I think one could call the philosophy that underlies most present-day psychotherapy and counselling one of magical voluntarism. Distressed people, that is to say, are supposed, via a short but perhaps intense period of interaction with a practitioner, to transform themselves into people no longer feeling distress.
Now a lot of people, Im sureand especially counsellors and therapistswill see nothing much the matter with this, but in my view it does begin to suggest that there is something really rather important that we have been leaving out of the picture. We seem to have been assuming, that is to say, that there is no such thing as societyor that if there is, it has no particularly significant role in determining how we feel.
With a few honourable exceptions, the idea that people suffer psychologically because of the way the world is has not greatly preoccupied mainstream psychological and psychiatric theorists. Even though those who have taken society seriously may have enjoyed a voguish success in their time (Im thinking of the obvious names like Alfred Adler, Erich Fromm, Karen Horney, Harry S. Sullivan, R.D. Laing), their fate seems to be to end up in the margins, where also are to be found minority disciplines like social psychiatry and community psychology. It is not that, throughout, there have not been profound, even compelling, critiques of therapeutic orthodoxy, struggling to bring to the fore the surely not contentious notion that social organizations and structures, political, economic, ideological and cultural influences can and often do adversely affect the individuals subjective well-being. The cause for wonder, in my view, is that such observations and critiques have been, ultimately, so consistently and persistently ignored. Why should this be?
To understand this, I think one has to have recourse to a set of concepts that do not normally figure prominently in our everyday thinking about motivation, etc. Popular psychology (i.e. the assumptions we take for granted when we start to think about why people do things) does not really allow us to think beyond processes like desiring, willing, intending, deciding, and so on: all mediated by inferred internal structures like unconscious impulses, cognitions, beliefs, fantasies, etc., etc. At the centre of our picture is always the individualthinking, wanting, deliberating, willing, choosing. And then, at long last, acting!
This kind of picture not only receives strong intuitive endorsement from everyday introspection (in most peoples experience it seems obvious that thats the way it must be), it is also extremely convenient.
For a start, it is convenient and reassuring for the person-in-the-street to believe that they are at least potentially in control of their own fate. Even if the goings a bit rough at the moment, at least we can in principle choose to live how we like and be who we want. If were suffering, the means to relief lies ultimately in our own hands.
It is also convenient for those who have a controlling influence over our lives (e.g. politicians, big business) that we should interpret any personal pain that results from their activities as the product of defects in our individual makeup. Many are the patients I saw during the cruel Market take-over of the 1980s and 90s who attributed their subjective distress to personal weakness and inability to keep up with the exacting demands of modern life and work.
Last but not least, it is convenient for those who make their living from the treatment of personal distress for their clients to believe that it can be alleviated through the intervention of a trained professional.
What we have at work here, I suggest, is an interweaving of interests. And it is precisely concepts like interest that point us towards explaining both our conduct and our consciousness in social rather than individual terms.
Outside the hermetic bubble in which theory and research in the psychological therapies have been conducted, a great deal of thought has gone into trying to account for what we do and feel in terms of the social structures and processes in which we are embedded. Sociology, philosophy, even to some extent neuroscience have all contributed to a view of the person as social being, constrained to act within the parameters set by power and able to experience self only within the strict limits determined by culture and political economy. On this view, we are not the free agents we think we are, able to choose the kind of life and experience we want, but rather, so to speak, atoms in social space-time whose sense of freedom is largely illusory.
My experience of practice as a clinical psychologist is far more consonant with this society-based understanding than with the individualistic theories of the psychological therapies, and it is this that I have tried to elaborate in my writing over the years. All I have time to do this evening is to sketch out very briefly, and of course inadequately, what a theoretical alternative to the current orthodoxy might look like.
First let me say very quickly how I think clinical experience reveals the inadequacies of current approaches.
People who come for therapy dont necessarily change even when they:-
a) can see the need to (i.e. have insight)
b) desperately want to (are fully motivated)
c) try really hard and courageously to (are fully compliant)
Although a therapist can be an important source of comfort and support, the beneficial effects of that solidarity very often do not extend beyond the period of treatment itself.
What doessometimespermit people to change tends to be alterations in their circumstances outside therapy: new or different personal relationships; new or altered work, educational or financial opportunities; improved living conditions (e.g. housing); developments in their social lives opening up new areas of solidarity with others.
The sometimes above is importantearly social injury is not necessarily reparable whatever later environmental opportunities may arise: we are embodied as well as social creatures, and what happens to us early on may get indelibly wired in.
The alternative to what I have called magical voluntarism is to investigate and elucidate the influences which hold us in place as social entities. Those which are closest to usthe influence of family and immediate social environmentmay be relatively easy to identify, but they will in turn be held in place by distal influences that are much more difficult to spot, and of which individuals affected may indeed be entirely unaware. It is important to remember too that these distal, fundamentally shaping influences may be a long way from us in time as well as in space.
Society, I suggest, is structured by power, and power is transmitted largely through the operation of interest. A decision made in a corporate boardroom may end up as the most intimate private pain of, say, the call centre worker who loses her job as the result. The biggest mistake she can make is to attribute her despair to her personal inadequacy. (It is, of course, fairly easy to see where responsibility lies in a case such as this, but there are many others where the chain of influence is very much harder to identify.)
What clinical experience teaches, in my view, is that we are as individuals not freely-choosing originators of action, but rather the hosts of influences which impinge upon us or flow through us. There is no faculty of pure will power upon which we can call in times of trouble, and what we are able to do about adverse circumstances will depend upon the powers that are or have been available to us in the outside world. The almost irresistible feeling of free choice and moral independence that subjectively accompanies our everyday activity is an illusion that stems from our singular embodiment (that is to say, we can only be directly aware of what is happening physically and psychologically inside us, and so we accord it undue causal prominence). This illusion is endlessly exploited by those who benefit most from it. Individual blame, for example, finds a ready reception in the tender conscience cocked and primed to receive it.
Let me just end by saying that I dont regard any of what Ive said as invalidating the practice of counselling and psychotherapy per se, though I do regard it as cutting back fairly radically the kinds of claims that can legitimately be made in the name of treatment. My own feeling is that therapy needs to recast itself as a way of helping people to understand their predicament in terms of the social environment in which they find themselves. In some important respects this is a liberating project one that frees the person from a burden of personal responsibility for their distress, even if it does so at the cost of denying them magical powers of self-cure.