IV
After it adopted a psychoanalytic approach in the middle of the 20th century
psychiatry needed to become a new kind of ethical & scientific profession. But rather than doing
this & developing into an autonomous discipline governed by its own
principles it reverted back again to being the dependent child of medicine. As a profession psychiatrists
lacked the understanding & the self-confidence to persuade their colleagues
that mental illness is different from physical illness. As a consequence
psychiatry lost its way & it remained trapped in competition with the rest of medicine for prestige & for funding. Instead
of doing what it needed to do to be true to its own problems & challenges it
confined itself to reacting to what was going on in the rest of medicine. So, as medicine made ever more
impressive progress in the decades after The Second World War psychiatry felt it had to show that it could make progress
too. As a result the pressure on psychiatrists
who had adopted a psychoanalytic approach became ever greater.
In general terms it is easy to state what is the final objective of
physical medicine. It is to extend the time frame over which the physical
machine that is the human body functions in an efficient & effective manner. This is a simple, straightforward
objective. It presents no conceptual complexities or ambiguities because the
health of one part of the body does not conflict with the health of another
part. A weakness or injury in one part weakens all parts. As a consequence
everything in medicine is subordinate to this one overall objective. All the
subsidiary aims of particular medical interventions can be subsumed directly under
this larger aim. This objective gives us also our definition of physical
ill-health: it is any development within the body that diminishes the physical
efficiency of the body or is likely to shorten the time span over which the
body will function efficiently.
What this means is that objectives in
medicine are profoundly stable. We always know what the endgame is. It has never changed at any
time in history & it never will. In any sphere of medicine we are either
moving closer to the larger aim of extending the duration of physically healthy
life or we are not. Throughout the treatment of any physical disease or injury our
specific objectives are contained always within this larger objective. As any
given intervention proceeds we may of course consider more effective means of
reaching the larger objective than those we considered at the beginning. But the
objective itself does not change. It is the same at the end of the treatment as
it was at the beginning. Assessing the progress we are making therefore
presents no conceptual problems. We are all agreed what progress means, we can
measure it, & we can achieve it.
The treatment of
mental illness is nothing like this. Here, we have no idea at all what the
larger aim is, i.e. what is the purpose of human life. So we have little idea
before the treatment begins what the subsidiary aims of this particular intervention
should be. Every human life is an experiment; it is an adventure in discovering
new possible meanings that life can take for itself. The objectives in the
treatment of mental illness are therefore profoundly unstable. In the treatment
of physical illness we always know where we want to go. In the treatment of
mental illness we are never sure where we want to go. At every step we face
dilemmas & doubts. And indeed acknowledging this lack of certainty is a
large part of what being mentally healthy means.
And it is here that
the perennial attempts to apply the principles of physical medicine to the
treatment of mental illness come to grief. They look scientific & rigorous
& objective & modern & enlightened. They seem to promise us a
freedom at last from the tiresome subjective complications those old-fashioned
un-scientific psychoanalytic therapists are forever introducing. They appeal to
public policymakers who want to be seen to be “doing something” about mental
health. They attract what limited public funding there is for mental health.
And they always fail.
The claim that we
are ever making “progress” towards mental health, like the
claim that we are failing to make “progress” towards mental health, is meaningless, because
it implies that the goal is something fixed, & not, as it actually is,
something forever evolving. Mental health is not a state that we ever reach, it
is a process of development that we maintain. It is a creativity that requires
a continual
questioning & review of our goals &
objectives. The first step in emotional health is the recognition that the
objective is moving & uncertain.
We don’t know what an emotionally healthy
state for man is. Each of us has to wrestle with this puzzle every day for
ourselves. Exactly where we are going is subject all the time to re-examination. It is therefore never clear
when we are being successful at achieving it & when we are failing. Indeed
it is just when we are congratulating ourselves on a success that we are most
likely to be creating the conditions for new self-deception. And it is just
when we are agonizing over a failure that unknown to ourselves we have set the
scene for new discoveries about ourselves. The whole thing far more closely resembles
a Bildungsroman by Goethe or Dickens
or Proust, with misunderstandings, wrong turnings, mistakes, reversals,
disappointments, fresh starts, surprise successes, chance developments, &
so on, than it does anything that happens in a medical operating room. If you
set out in this endeavour with the aim of competing with physical medicine you have
profoundly misunderstood what it is you have to do.
Among the most important of the patient’s symptoms to attend to in psychotherapy are his initial assumptions &
assertions on entering treatment about what being cured & being healthy will look like for him. If we are not at the least
questioning those assumptions then whatever we are doing it is not psychodynamic
therapy. At every stage we question again what progress means. The patient,
& the therapist too, should always unlearn some of what they thought at the outset health would mean. Ideally,
every psychoanalytic session should involve some overturning of our ideas about
health. We should always be thinking afresh about where we are going.
In the context of mental health, development
is marked always by this abandonment of former goals & aims for new ones. We
must be able to leave behind less fruitful objectives for more fruitful
objectives. Anything other than this is dogmatism, or what Freud calls defence.
But clearly of course, seen from the perspective of the objectives given up,
such a process is not going to look like progress. The objectives given up
never relinquish their power over us without a fight & they will struggle
as hard as they can to persuade us that our work represents failure. Mental
illness always has an army of propagandists working on its behalf, both in the
mind of the patient & in the wider society. And they are subtle &
powerful propagandists, very adept at recruiting the forces of respectability
& good sense to their side & at persuading us that we should be more
moral, or medical, or scientific, or God only knows what.
Progress in short is what other people like
to see us making. But development is something we do for nature within us,
& it represents a higher & healthier imperative. This is where our true
responsibility as human beings lies, not in organizing our lives to try to
maintain the approval of others. So long as we are intent on demonstrating progress,
& so long as our support for others is conditional upon them demonstrating
progress, we are still the slaves of aims & values inherited & acquired
from those around us. Emotionally, we are still children. In such circumstances
we have nothing of real value to offer other people since we are simply
reflecting their own prejudices back to them. When we begin to develop, on the
other hand, & begin to think critically about the aims of our life, then we
do start to have something genuine to give them, because we are showing by our
own lives the essential vitality & creativity of nature that is in them
also. You do not help another by sacrificing your individuality to his foolish
anxieties & superficial preconceptions.
This is why there is no genuine development in
psychotherapy in which the patient does not become more indifferent to the
immediate approval of those closest to him. He would of course like their
approval tomorrow if that is possible; but to achieve that he may well have to bear
with their irritation today. It will in any case be a short-lived irritation
because it is founded on short-sightedness.
Often the parents, families & partners
of patients undergoing psychotherapy are unhappy with the course of development
taken by the patient. This is the reason we make every effort to insulate
knowledge of the therapy from other people in the patient’s life – something
that is quite unnecessary in physical medicine. What everyone close to the
patient wants – inevitably – is for the patient to become more co-operative
with what they take to be their own present needs today. It is always very
difficult for the patient to resist this pressure. And it is the therapist’s
first responsibility to
help him to do so. Therefore the therapist
must always be indifferent to any pressure he himself may feel or come under to
make progress with his patient. When third parties like parents or employers
are involved directly in sponsoring & funding the therapy this indifference
can be difficult for the therapist to maintain.
Of course, that part of the patient that
resists demonstrating progress is unlikely to meet with much favour from an overworked doctor or an
ambitious & insecure psychotherapist who is keen to chalk the patient up as
another “cure”. The therapist who lacks confidence in himself can readily fall into the trap of becoming irritated by such resistance & dismissing it as obstructive & childish.
On the contrary, this resistance, however it manifests itself, must be attended
to with the greatest care because
it has things of the first importance to teach us about how this patient must find autonomy &
maturity.
We don’t have an objective measure for how
much progress any individual is making with life & we will never have one
because we will never have a definition of mental health that we can finalize
& all agree on. The most we can achieve in this respect are broad anodyne
notions such as the famous criteria attributed to Freud by Erikson of the
capacity to love & the capacity to work. Not many people are likely to
disagree that an incapacity to love
& work is compatible with health. But even this formulation can be questioned: what if I
find that a life of leisure & abstract speculation free of personal
distractions is the best for me? Who is to say I am sick because I do not find
attractive the hypocrisies of career & relationships? We can argue about mental health,
but we can never define it.
Confronted with this assertion most people
get a little restless. The general reaction is, Surely there must be some way we can define it? But what they
really mean by this is, Surely the kinds of life that seem to me to be healthy must be correct? Is it
possible that I could be mistaken
about what is healthy? Everyone would like to see his own ideals for life adopted as the standard, & if this is
impossible then at least secured from doubt.
In fact, neither of these things is
possible. So in practice the attempt to set up standards of mental health means
falling back on those that enjoy the most popularity, or the least
unpopularity, or the ones that people are most afraid to question in public. The DSM criteria are a perfect example of the formalization of
this process. Definitions of mental health – as opposed to the reality of
mental health – are what we can get away with, at any given point in history,
without so many people raising objections that they become unworkable.
But such definitions are always shifting
because they paper over our essential ignorance of what is good for man. No matter how often we set up such
definitions as authorities, in the long run they end up proving unworkable
& have to be revised or scrapped. In contrast, although the progress of physical
medicine all the time results in the scientific re-categorization of particular
illnesses, illnesses are never re-categorized at a later time as health.
For example,
contracting the plague is as serious a physical condition now as it was in the Athens of Pericles. Pericles
himself died of it. Although we know a great deal more now about the causes of
various plagues & how to prevent them & how to treat them, their
conditions & consequences are the same now as they were in the fifth
century. You can die of them now in just the same way & with just the same
symptoms as you would die of them then.
On the other hand, suffering
the emotional traumas of combat, which we now regard as serious &
debilitating illness, was, in a society in which everyone had direct &
immediate experience of war, & faced the immediate danger of enslavement,
just another everyday experience. We can see many clear references to combat
trauma in ancient literature like the works of Homer & the Greek tragic
dramatists. These great writers knew that war shreds minds. But their world did
not recognize this as a specific illness or syndrome. Are we right to classify
it as such & the Athenians wrong? The question is meaningless. Conceptions
of mental health are inseparably bound up with ethical views on what human life
is about & what human beings should expect to have to handle in the normal
course of events. And these views change between communities, between one
historical period & another, & between different individuals.
This however is not accepted. Precisely because we are unable to define
what mental health is, public views on the matter swing from one untenable & unquestionable
extreme to another. The changes we have seen in the
attitude to homosexuality illustrate this well. Only a few generations ago
homosexuality was a hideous crime which no one could speak of in public
discourse. Then for
a relatively brief period some saw it as an illness to be cured. Now no one
dares suggest it is anything other than a perfectly healthy form of sexual
behaviour. Some jurisdictions have even outlawed the treating of it as an
illness. All these unthinking positions stem from an essential ignorance & the
fear that arises from essential ignorance. Homosexuality should certainly not
be a crime. But no more than heterosexuality should it be treated as a form of
sexuality that is always & everywhere healthy & beyond scientific
analysis & ethical criticism.
Modern attitudes towards trauma have
traversed the same mindless extremes. In The First World War men who were
physically unable to function as a result of combat stress were shot, on the
grounds they lacked “moral fibre”. Now, if someone suffers a fatal accident at
work or even outside work many employers feel compelled to send in “trauma
counsellors” to minister to their colleagues. Just as every manifestation of
homosexuality is now assumed to be beyond reproach, no matter how socially
disruptive or upsetting other people may find it, so every fatality is assumed to
send shock waves of trauma through the surrounding population, no matter how
tenuous their connection may have been with the deceased person. Underlying
these fashionable attitudes to emotional health you will search for any ethical
or moral coherence in vain. We have no idea what we are doing or what we are
trying to do with them. They are the societal equivalent of the involuntary
movements & obsessional symptoms of an over-anxious patient who does not
know what it is he is anxious about. And just like such a neurotic individual
we are as a culture too frightened of ourselves to be able to think
intelligently & critically about them.
As a culture we are very resistant to the
fact that assessing mental health requires the exercise of ethical judgement &
a sensitivity to human context. We are so because this is the kind of thinking
that human beings have always found the most difficult. We just don’t like
doing it. With science & technology we are superb in our reasoning. The
steady improvement in all aspects of physical health reflects this. But with
understanding & mastering our emotional make-up we are for the most part
quite lost. This is why our ever greater technological sophistication makes no
impact at all on our tragi-comic history. And it is why the problem of mental
health is immune to developments in medicine.
Attempts to set up general definitions of or propositions about mental health,
precisely because they inevitably ignore context, are always based on
self-deception & the projection of personal prejudices & fantasies.
Until you know, & know well, the particular individuals involved in any
given case, & are therefore in a position to discipline your own
assumptions in the light of empirical facts, you know nothing of importance on
which to base a judgement of emotional health or well-being.
But as a culture we are profoundly dishonest
about this. We don’t want to confront the fact that each of us must figure out
what health means for us, each day, afresh. There is no formula that can be applied.
We have continually to question our assumptions about what is good & right.
There is no pattern of life that we regard as healthy today that might not have
to be revised tomorrow.
In modern life we are not encouraged to
consider time-consuming & difficult ethical questions such as these. If a
question doesn’t have an obvious way of answering it we try to pretend it isn’t
there. So, as far as possible, we keep busy & tire ourselves with overwork
& when not working we prefer those distractions that help us evade the
tedious burden of reflecting on ourselves. Taking time for reflection &
contemplation on how we should be living is regarded at best as something that
may be forgiven if it can be shown to make us more socially productive & at
worst as a sign of weakness & ill-health.
And of all the professions none has signed
up more enthusiastically to these modern prejudices than medicine. Now
completely governed by the principles of technology, it has squeezed all
ethical questions about what the meaning of human health might be out of its
field. Psychiatry did start to explore these questions with psychoanalysis but
it then abandoned them again. In the longer run, its dependence on medicine proved stronger than
its identification with the problems of its patients. Slowly it dawned on psychiatrists that the better a patient is doing in psychoanalysis the less likely is he to
reflect a model of health that is suitably demonstrable to other doctors. In
physical medicine good patients become more co-operative with the doctor; they
come literally to embody his values. In psychodynamic therapy by contrast good
patients become more independent of the doctor; they come to reflect more &
more their own values & they care less & less about demonstrating
health to anybody else, perhaps especially to their doctor. Disturbed by this
trend, psychiatrists pulled back & gave up on psychodynamic therapy. It
just didn’t generate the kind of patients that a discipline dependent on
medicine for its self-image could handle.
To try to justify this abandonment of its
patients psychiatry attributed the failure of psychoanalysis to sign up to the
ideals of medical progress as a failure in it as a science. Psychiatrists
gratefully accepted the arguments, promulgated widely by many critics of Freud
in the last decades of the 20th century, that their colleagues in
the rest of medicine were being more rigorous at applying scientific methods
than were they.[1]
In consequence psychiatry went back to notions of science that look respectable
but miss the point of mental illness.
The models of mental illness endorsed by
modern psychiatry don’t acknowledge the essential ambiguity of most forms of
mental distress, whether we are speaking of depression, anxiety, phobias,
traumatic flashbacks, nightmares, or addictions. They regard all such
conditions as if, like physical illnesses & injuries, they did not pose fundamental
conceptual & ethical questions about what is the best way for a man or
woman to live. Rather than offering us a serious engagement with this question
psychiatry leaves us with the promise that one day, somehow, if we persist long
enough with nervous science, we will successfully divorce mental illness from the
problems & dilemmas we all face as human beings, the inevitable conflicts
we experience & the difficult choices we must make between different people
& values & aims. In the meantime, however, for those of us still living
in the real world, the marriage continues.
*
It would be remiss of me here not to note
that some forms of psychotherapy have gone out of their way to provide an
alternative model to that of psychodynamic therapy. The most important here is
“cognitive behavioural” therapy, or CBT.
In my experience this is now the only form of
psychotherapy to which
psychiatrists are willing to refer their patients. They favour CBT not because
it is remotely compatible with neurophysiology but because it has developed in
the decades since The Second World war specifically as a rival to psychodynamic
therapy. What brings psychiatry & CBT together is this common enemy.
The defining characteristic of CBT, the
thing that it shares with psychiatry & that distinguishes it from
psychodynamic therapy, is that it refrains from engaging with the patient in a critical
dialogue about the idea of health that he brings to the therapy. It does not
regard the health of the patient as something that he himself must come to define through an engagement with his own emotional history. It does not look at the place of the
symptoms in the developmental history of the patient & it discourages him
from thinking about what his symptoms mean to him. It ignores the struggle of the patient to individuate, refusing
to see his symptoms as what they are: injuries sustained in the course of his
attempts to work out which values are healthy for him.
With CBT the emphasis is on
efficiency & speed. The focus of the therapy is on the attempt to remove symptoms through the
inculcation of new habits of behaviour & thought. Where it succeeds in this it is,
effectively, sacrificing the future to the past, because it acts in such a way
as to suffocate the generative things in the patient that are seeking to be
heard through the symptoms. Where it fails in this it is because what is original in the patient is too strong. When this happens
the presenting symptoms either persist
in their initial form or
the conflicts underlying them find expression in some other
symptomatic pattern.
The fundamental aim of CBT is to cure the
patient by weakening his emotional autonomy. It discourages his critical
reasoning & encourages him to conform to the standards of health that
others are most comfortable seeing him adopt. In effect, it aims to purchase
the appearance of health today, at the price of genuine health tomorrow. The
philosophy of CBT is that it is better for the patient to be happy &
adjusted to whatever appears to be the conventional view of health now, rather
than develop a unique & personally developed pattern of health that will be
strong enough to stand when that conventional view starts to alter as the
constellation of relationships in his life evolves.
CBT lacks a historical perspective. It tells
us we should accept the consensus about what is healthy, whatever that might be
at any given time or place, & it gives assurance it will not cause trouble
for those who have most to gain from that consensus & most to lose from
seeing it challenged. For this reason it is popular with everyone who has some reason to want therapy to be useful – parents who are trying to cope with disobedient children, wives having to deal with uncommunicative husbands, employers handling potentially recalcitrant
staff, & politicians
hoping to be re-elected by bad-tempered electorates. This is why it styles itself as
an “evidence based” therapy. All this means is that the course & outcome of
the therapy are determined by someone other than the patient. It is not the
evidence that the patient himself sees of the success or otherwise of the
treatment that matters, it is the evidence that someone outside the therapy
sees of this. The patient is not to be trusted as the best judge of his own
emotional well-being.
The ostensible attraction of CBT is that it promises to be cheap &
quick. But the real source of its appeal is that it does not raise awkward questions
about what emotional health actually is. It reassures us we don’t have to think
about the meaning of mental health because such a question is old-fashioned
& unscientific &, anyway, we already know what it means for all
practical purposes, don’t we? There are always so many people who want to hear
this that any therapy that says it in a convincing manner will do well.
Of course, sometimes CBT is effective in its
aims, because each
of us is to some degree frightened of greater autonomy. A part of us would
always rather not have to face it. If you encourage that fear then learning to conform to conventional expectations may well feel like as good a solution to life’s complexities as any. Furthermore, for some people it
will be the best solution to life’s complexities. For some people, greater
personal autonomy will always be an unvisited country.
But for all that CBT is not benign. It is
not offered in a pragmatic way as an additional or supplemental approach to be
used where appropriate in place of other treatment perspectives, or in the
treatment of particular kinds of patient, but as something we can expect to be
more effective than other psychotherapies in most cases. It is portrayed as the
treatment of choice. Its advocates do not have a fair-minded attitude to
therapies other than their own, they are dismissive of other approaches, &
casually misleading in the claims they make for their own therapeutic efficacy.
Their appeal is not to people who are in emotional distress but to those who
are dealing with the impact of people in emotional distress. It is the only
form of psychotherapy that regularly seeks government funding.
Essentially, CBT is a reactive therapy, not
one that springs from its own inner resources. It lacks faith in the generative
powers of man. It sees the value of men & women not in themselves as unique
expressions of nature but solely in how far they efficiently serve existing
societal goals. It was born originally out of an antagonism towards the ideal
of emotional autonomy established by psychoanalysis & it remains dependent
on psychoanalysis for its self-definition.
Those who possess the potential to cultivate
greater autonomy within themselves & who are fighting to do so provoke
complicated feelings in those who possess this potential too but who have shied
away from the challenge it represents. They don’t want to be reminded of what
they have run away from in themselves, & yet something in them won’t let
them forget it. Those who have evaded the difficult war of self-conquest suffer
a mixture of fascination & revulsion, of fixation & resentment, towards
those who have not been able to evade it.
People who become emotionally unwell do so
precisely because they have not been able to escape this war. A combination of
their innate character, their history, & the traumas they have experienced
has generated a conflict around autonomy inside them & it cannot now be
quenched. Something inside them is pushing them towards greater emotional
independence, & something inside them is frightened of greater emotional
independence. Those who because of this internal conflict can no longer fit in comfortably
with whatever is the dominant ethical perspective of any group, whether it be a
neighbourhood, a church, a profession, a school, or a family, will not only
have to cope with the pain of their internal divisions but will also have to
contend with the unhappy reactions on the part of those around them to what
they are going through. They will encounter hostility, of course, but always
also in some measure there will develop an intricate co-dependence in which
those of the surrounding ethos both condemn them & start emotionally to
feed off them. The one who is seen not to fit in may be an object on the part
of others of envy, or an object onto which self-loathing is projected, or a
convenient lightning rod for sadism that would otherwise be hard to control, or
indeed he may be viewed as a saviour or redeemer of the group as a whole.[2] And he
may be many other things besides all this at the same time. For the one who is
the object of such feelings they will of course offer a difficult but
nevertheless often addictive mixture of attention & punishment. We see
profoundly unhealthy co-dependencies like this in all fields of human activity
& they can sustain themselves for many years. But such feelings, especially
in small intimate groups like families, are naturally expressed only ever
indirectly. “Why must you always cause trouble for the family? How often have
you rejected the help we have arranged for you? Why can’t you just brace up
& get on with it, like the rest of us who are all working so hard to help
you?” Such is the typical refrain in the household where someone is emotionally
unwell.
The objection to CBT is that instead of
working to analyze & help resolve these convoluted & difficult
attitudes of dependent resentment towards the best in human beings – the best
being that which compels them to be original & creative – it merely
re-iterates them & gives them a gloss of clinical justification. In the
guise of healing it perpetuates pathology. Under the surface, the cultivation
of CBT, with its facile certainties & its unresolved ambivalence towards
what is unique in each of us, is only another part of the perennial war that is
waged in culture by those who have run away from themselves against those who
are unable to run away from themselves. What we need in the field of
psychotherapy is a new honesty about this war, not a further articulation of
it.
*
To sum up. There are two cardinal but
interrelated mistakes that have been made about psychoanalysis &
psychodynamic therapy over the last hundred years.
The first & most obvious mistake is
that of looking at psychoanalytic therapy as a discipline within medicine. The
history of the failure of psychiatry over the last century illustrates the
folly of this approach unequivocally.
Ultimately however
this mistake is only a particular instance of the second, broader mistake of
expecting psychoanalytic therapy to be functionally subordinate to aims
assigned to it from outside itself. This is the real error, & it is
constantly repeated in all sorts of different ways, by patients, by therapists,
& by those not involved in the therapeutic relationship.
Psychoanalysis,
& any psychotherapy that seriously applies a psychodynamic perspective, is
a sovereign discipline, one which explores in the case of one particular individual
what spiritual & emotional health may mean for the animal man. Its purpose
is the enrichment of the life of one human being only. It is animated by the
faith that the deepening of one life & the maximising of the emotional
autonomy of that one life will ultimately benefit all life. But it can never be
a servant to anyone or to any external interest. If it begins to be this it
ceases to be what it is & it becomes something else, no matter what it may
call itself.
The greatest danger
to genuine psychodynamic therapy at the present time comes from the
perpetuation of this mistake of trying to make it the useful servant of some
purpose emanating from outside the therapeutic process itself. This mistake is
being made both by those within psychotherapy & those without it. Many
therapists would like to see their professional & financial position given
greater security in exchange for making promises that they will only do certain
specific things with therapy that society deems to be valuable. And many
political & bureaucratic interests seek to justify & extend their own
power by presenting therapy as a potential danger to society unless they are
given a hand in regulating it & specifying what interests it may serve in
society. To the extent all this is not driven by simple material greed it stems
from the fear of the cultivation of the personal conscience within society
& an unacknowledged anger towards those who work towards this.
We live at a moment
in history when man has perhaps less faith in himself than he has ever had. He
no longer believes in himself as a creature in whom the gods have an essential
interest, indeed any interest at all. But he hasn’t outgrown this need for what
the gods once gave him. He waits still to be given his value by some source external to himself that can make use
of him. For this reason a process like psychoanalytic therapy that has no end
other than the cultivation of faith in the self, & in life, is hard for him
to understand. It seems strange & alien, & he keeps trying to
understand it in terms that are more familiar to him – specifically, in terms
of a world where what is good &
what is justifiable is assumed to be
what is necessarily useful to
something external to itself.[3]
Religious faith has not disappeared from
contemporary life but it has retreated from the centre of civilization to the
periphery. Behind it, it has left a backdrop of moral chaos. This chaos is
generated by our fear of our underlying urge to greater personal autonomy,
which the retreat of religion has enhanced in us, & our uneasy awareness of
the repeated demonstration of just how difficult autonomy really is.
To try to deal with this moral chaos we have
become addicted as a culture to attempts at ever more minute regulation of daily
life. Modern ethics are less & less about what a man or a woman should be & more & more about what he
or she should do – that is to say,
what he or she should not do. Our de
facto morality – the ethics of everyday life – is not about the cultivation of
creative & autonomous individuals but about the regulation of specific acts.
We mistrust ourselves. We fear man not as something formidable but as something
incompetent. We see man not as a promise to be cultivated but as an idiot to be
controlled. We speak not of health & resourcefulness, or of health &
courage, or of health & initiative, but of health & safety, as if the two terms were
synonyms.
In this atmosphere of moral panic the
pressure has grown for psychotherapists of every kind to demonstrate that they
too have signed up to our modern ethic of regulation & measurable progress.
This all sounds very reasonable & scientific & humane. But in fact it
is just a respectable-sounding way of saying that the task of therapy is not to
cultivate individuals, but to make them less likely to question the need for
external regulation in the rest of life.
As I have tried to show here, in physical
medicine, where there is no difficulty in measuring progress & where there
is no conflict between the well-being of the patient & the immediate
benefit to society, this emphasis on external measures & standards presents
no problem. The less physical illness there is in society, the more we all
benefit in easily measurable ways. What is important here is not that the physical
health of any given individual impacts at once on the well-being of society, it
is that it is recognized at once as
doing so.
But in mental health, where the well-being
of the patient always involves the capacity to depart from the prejudices of
others, things are much more complicated. One of the fundamental criteria of
mental health is the ability to question what others perceive to be good for
us, & for themselves. The mental health of one individual impacts on the
well-being of the rest of society immediately, but it is only ever acknowledged
as having done so after an interval of
time. The emotional health of tomorrow is always engaged in a war to free
itself from the emotional health of today, because tomorrow always has
different tasks from those of today. Trying therefore to impose external
measures & aims on this process, which means trying to impose the measures &
aims of today onto those of tomorrow, is fundamentally mistaken.
Nevertheless, in many countries now there
are moves afoot to give the State greater control over all forms of
psychotherapy. This includes the country where I practice as a psychotherapist,
The Republic of Ireland. Here in Ireland, the current proposal is that all
psychotherapy should be controlled by The Department of Health of the
Government. It is painfully clear that almost no one has thought through what
the implications of such an arrangement would be & that as it stands it is
simply another iteration of the ancient mistake of seeing psychotherapy as
subordinate to the objectives of medicine.
Essentially, those of us living in
democratic societies have to make a fundamental decision about what we want
from psychotherapy. Is it to be treated as an autonomous sphere whose value to
society lies in the cultivation of the individual conscience? Or is it to be a
subordinated function with its aims & means prescribed for it by the State?
If we choose the latter course then our
definitions of mental illness, the criteria we use for treating it, the
legitimate aims of treating it, & the specification of who may treat it,
will all be determined by the political process. In other words, they will be
determined by the outcome of a struggle for ascendancy between those sectors of
society that are able to claim an interest in them: medical doctors,
psychotherapists as a profession, school teachers, employers, & the
pharmaceutical industry, among others. Each of these groups will seek to define
things in a way that serves what they take to be their own best advantage. And
the criteria that are given the final stamp of the authority of the State will
be decided ultimately by those groups that are best able to manipulate the
political process in their own interest.
Inevitably, the politically weakest
constituency of all, & the one that will have the least say in the process,
will be those who have the deepest interest: the patients themselves. Though,
of course, everyone else will claim loudly to know best what their interests
really are.
If however we do choose to go down this road
of trying to control psychodynamic therapy by subordinating it to the political
process only two outcomes in the long run are possible. Either the State will
successfully impose the political aims of today, in which case psychodynamic
therapy will disappear in all but name. Or – much more likely in my view – the
State will be unsuccessful in this attempt, & genuine psychodynamic therapy
that takes as its primary objective the increased emotional autonomy &
independence of the patient will indeed continue, but as an essentially covert
& perhaps quasi-illegal activity.
But I hope & indeed I expect to see a
happier outcome than this. The aspiration for personal autonomy, though it
always has to contend with contrary forces – anxiety, on the part of those who
feel it, & resentment on the part of those who have denied it in themselves
– is in fact very strong in human beings. It can be delayed certainly but it
cannot I think in the long run be arrested. There is, in short, no reason we
cannot make a recognized place within a civilized society for a psychotherapy
that is liberated both from the illusions of misplaced medical analogies on the
one hand & the relics of a religious morality that seeks an authority over
itself on the other. Let us begin now to work to construct that place.
July 2014.
[1] On the question of the scientific status
of psychoanalysis, see my own The Last
Resistance, SUNY Press, 2002.
[2] Anyone who doubts this may be unaware how
frequently one member of an unhappy & disturbed family enters therapy
essentially as the proxy for the family as a whole.
[3] This way of thinking about what is morally good owes
its long history above all to the influence of Plato.
