Submission to The Minister of Health on Regulation of Psychotherapies: October 2016 (2 of 4)

In recent times I have noticed a tendency on the part of some public representatives in Ireland to try to politicise the issue of psychotherapy. Some, not confined to any one party, have made a habit of calling for the “regulation” of psychotherapy, & have criticised past & present governments for not having done this. Invariably, these calls are accompanied by reference to one or more of the many ills in our society – suicide, or depression, or addiction, or whatever. The implication is that the occurrence of such problems is unacceptably high somehow because psychotherapy has not been “regulated”. We are to understand that “regulation” will in some unspecified way ensure these ills are no longer aggravated unnecessarily.

These exercises in popular rhetoric are ill-judged & they are unhelpful.

The purpose of psychotherapy is not to minimise any of these well-known social ills. Any legislation we introduce for psychotherapy, whatever form it takes, will have no impact on the rate of suicide, or sexual abuse, or drug misuse, or domestic violence, or addiction to pornography, or alcohol dependency, or depression, or divorce, or single-parent families, or days lost to psychosomatic illnesses, or any other of the many ills that can be associated with emotional instability. These problems are part of living in a modern secular society & psychotherapy neither can, nor does it aspire to, diminish them.

So what then is the task of psychotherapy?

The task of psychotherapy is, first of all, the cultivation of greater emotional honesty. This is very difficult. Anyone who thinks that it is not should undertake a year or two of serious psychotherapy & see how he finds it. Such a course of educational therapy should be a minimum requirement for any politician or civil servant who has ambitions to contribute to the framing of legislation for it. Only someone who has made a committed personal engagement with psychotherapy, & has genuinely tried to clarify his own motives, can begin to grasp just what a remarkable capacity we all have for lying to ourselves, & how ingenious we are at dressing up our narrowest self-interests in the guise of respectability & altruism. If we can achieve any degree of honesty with ourselves, we are achieving a very great deal.

The first thing we need to be honest about in the context of the present discussion is that none of us has the capacity to improve the mental health of society overall. Responsible governments do have some influence to see that people with manifest mental illness & disability are treated humanely & well. But they do not have the power to improve the mental health of society as a whole. Politicians who encourage the public at large to believe that they do have this capacity, & that we can as a society legislate ourselves into mental health, will only provoke false expectations.

Let us take one concrete example that illustrates this point. In principle, much the most effective contribution any government could make to overall mental well-being would be to increase the duty on alcohol to a level where consumption was significantly reduced. At the stroke of a pen, overnight, the mental stability of society would begin to improve. The incidence of serious accidents, domestic & public violence, depression, unemployment, divorce, & suicide would all, almost certainly, decline.

But this isn’t going to happen. It isn’t going to happen because every government fears the electorate. Any political party that was complicit in an increase in the price of alcohol sufficient significantly to impact on these social problems could comfortably forget about returning to government for the foreseeable future.

Here then is our first lesson in mental health, & it is an awkward one. Taken overall, society has no inclination to recover from its emotional illnesses. And it will not do so.

It will not do so, because what you regard as the signs of my mental instability I will defend (even if I do not entirely believe it) as the chosen style of life that best suits me. And, so long as we are living in an open democratic society, there is no way you can impose your view of the matter on me.

This is the flaw in the proposal to “regulate” psychotherapy. We all agree what physical health is. But we don’t agree what mental health is. Mental health, in a society that adheres to the principles of liberty & free inquiry, will always be a matter of personal judgement & taste. What it is, & where it exists, will never be subject to general agreement. And if we cannot agree how something is to be defined, then we cannot make a law for how it is to be achieved. We cannot regulate a process if we cannot specify what the outcome of that process is supposed to be.

To legislate for mental health, so as to make people more mentally healthy in a general sense, is as pointless as to legislate for personal happiness, & for the same reason. What is health & happiness to me might be hell on earth to you.

It is true there are circumstances when mental illness is unequivocal, in the form for instance of the kind of manifest psychosis that Shakespeare gives to Ophelia after the death of her father. In a case like this, there will be no dispute that the sufferer needs to be protected from herself & taken into care.

But in only a tiny percentage of cases is the decision about mental health like this. Most of the time it is impossible to decide, in any kind of objective way that will command general consensus, whether an individual is generally well or generally unwell.

For instance, many people suffer from occasional or even frequent delusions, in the form of visual hallucinations or imagined voices, & yet they lead perfectly “normal” lives, raising families & holding onto productive employment. Should we say such people are mentally ill? Perhaps we should. But who is going to decide? And what of the much larger number of people who do not suffer delusions but who suffer still all the neuroses, & anxieties, & depressions that are the everyday human lot? Should they be classified as sick too? Or should they be regarded as well? Or should just some of them be viewed as sick & others well? Should you be regarded as well? Should I? What criteria are we going to use for such a distinction? And who is going to decide?

The truth is that it is impossible to draw a line between the mentally healthy & the mentally unwell in a way that will command general agreement. This is because as a culture, once we gave up adherence to religious authority & doctrine, we also gave up the capacity to define mental health. We lost this, because our conception of mental health was derived from the moral presuppositions, underpinned by religion, that told us what was the purpose of life & therefore what a man & a woman should be. It is because we can no longer define mental health that psychotherapy exists.

To anyone with a passing acquaintance with the issues raised by psychotherapy this is all common knowledge. If it is not familiar to the would-be “regulators” then the question is: why is it not?

What these confused people propose is to use the law to prescribe certain outcomes for psychotherapy, & to proscribe certain others. A psychotherapist is to be allowed to help a client to achieve some conceptions of health, but she is to be forbidden to help him to achieve others. We are to legitimise some forms of mental health, & delegitimise others. The law, in short, is to be made a substitute for religious & moral doctrine.

In a society that adheres to open democratic principles, this simply won’t work. It is a fantasy.

We need to be clear here. If any psychotherapist is behaving in an abusive way towards a client or, for instance, if a psychotherapist is encouraging a client to commit an act that is itself criminal, then he or she is already in breach of existing laws, & should be dealt with under existing laws. Every psychotherapist is & should be bound by exactly the same laws as every other citizen.

What is proposed by the “regulators” is something quite different.

What they want is to specify laws for psychotherapy as such, & therefore for mental health as such. They want to establish an authority, sanctioned by law, with the power to determine what the end goal of psychotherapy may be, & what it may not be. They want an authority with the power to demand what a psychotherapist must be & must do & must say, not as a citizen, but as a psychotherapist.

Since however we cannot define what mental health is, & therefore cannot define what the outcome of psychotherapy should be, it would be an impossibility for any such authority to do what it was nominally supposed to do. It would, therefore, do things it was not nominally supposed to do.

The establishment of such an authority would, in effect, grant monopoly power to certain privileged individuals within the profession to determine who was & who was not allowed to practice. And since the desired result in psychotherapy cannot be determined beforehand, & since therefore we have no objective measure of the ability of a psychotherapist, the decision to grant the right to practice, or deny the right to practice, would have to be based by these privileged individuals on something else.

It would be based, of course, on the internal politics of the profession itself.

No candidate for psychotherapy can be assessed on the basis of what she knows, because no one can say what a psychotherapist should know. Therefore, in any assessment of a candidate, of her ability & of her qualification to practice, the crucial question is always who she knows, that is to say, who is willing to vouch for her & endorse her. This is how candidates for psychotherapy have always been assessed since the profession originated at the end of the nineteenth century, in the work of Freud & his associates. There is no other way they can be assessed. And this is why since its inception the profession has been characterised by the generation of multiple factions & rival schools.

As long as such a selection process does not have the force of law, it remains relatively benign. A candidate who is unacceptable to one school will usually, if she has any potential at all, find a place in another. This is why preserving a multiplicity of independent schools is so important to the well-being of the profession as a whole. We must have free, competing schools of psychotherapy, because there is no other field in which the knowledge of everyone working in it is so limited & so imperfect & so subjective.

This cannot be emphasised enough. Psychotherapy is wrestling with the core problem of our species, the one that the decline of religion has made manifest & urgent again: What is man? This is the oldest question, & it is the last question we shall be able to answer, if indeed we ever can. No one knows what man is. Every culture has been an attempt to answer this question & every culture has failed to answer it; that is why culture keeps changing. Psychotherapists are the ones who are aware of this. They are distinguished from other men & women not by some specialist expertise but rather by an awareness of how little we know of ourselves & how most of our energy is expended in trying to hide from how little we know.

It is disturbing to see how little appreciation of these fundamental problems the would-be “regulators” of psychotherapy seem to have. First, they propose to give certain schools absolute power within the profession. Second, they want to give to what of necessity can never be more than an informal & highly imperfect selection procedure the force of legal statute.