‘There’s No Such Thing as Society’. The Moral Tyrannies of Therapy
Talk given by David Smail at the SCOS annual conference on ‘Organizations, Institutions and Violence’, Dublin, July 2001
There can, surely, be no disputing the observation that present day global society is neither just nor equitable. It is, in fact quite spectacularly unjust and inequitable, and apparently becoming more so.
One of the central tasks of modern ‘governance’ is to keep this fact from reaching and lodging in the forefront of our minds. In this enterprise it is extraordinarily successful, and is also apparently becoming more so.
Distributed throughout developed, Western society there is, as Foucault put it, an apparatus of power now all but perfected in obscuring from the vast majority not only the extent of injustice and inequity globally, nationally and locally, but also the ways in which injustice and inequity cause suffering.
Somewhat idiosyncratically, I fear, I see it as the role of clinical psychology to work away at demystifying one small aspect of this apparatus: i.e., to try to explicate the link between malign societal influence and the subjective experience of distress.
It has been the achievement of people like Michel Foucault and Christopher Lasch—among many others, of course—to show that we are no longer necessarily socially disciplined by violence so much as by the engineering of acquiescence and consent; even by the manipulation of pleasure. If it appears that I am stretching conventional meanings in associating much of what passes for psychotherapy and counselling with violence, I hope, then, it is apparent that I am doing so in the now well established Foucauldian sense of therapy as, so to speak, Ersatz violence.
As it has developed over the last hundred years, therapy has become one of the principal ways in which social injustice and inequity have managed to obscure their consequences. For, at least by implication, therapy maintains that there is no such thing as society, only individuals and their families. Margaret Thatcher’s notorious dictum could well be adapted as its slogan.
Just consider what the 20th century brought forth in the way of explanations of and treatments for emotional and psychological suffering:-
Organic psychiatry. Confronted by the distressed and confused, the desperate and the dazed, by people at one extreme driven out of their minds by wretchedness or at the other perhaps just cautiously trying to interpret and manage their sense of dread, psychiatry studiously ignores everything they have to say (explicitly or implicitly) about the world, and instead pokes around inside their bodies looking, for example, for unusual neural, chemical or genetic structures. Psychiatrists have been doing this resolutely for well over a hundred years without yet coming up with any explanatory formulae that satisfy any scientific group other than themselves. Psychiatric critics who have developed alternative views—as for example R.D. Laing—have, if they cannot be ignored, been marginalized and ridiculed.
Psychoanalysis. Not only did Sigmund Freud , as Jeffrey Masson1 so ably demonstrated, back away from his first tentative observations of the essentially social origins of so-called ‘hysteria’, he promptly thereafter tucked away virtually the whole of ‘psychopathology’ in a mysteriously inaccessible moral realm deep within a metaphorical ‘interior’ space. In this moral realm were packed all the deadly sins, plus the means of their redemption, plus the apparatus for transforming evil into good, unreason into reason. What went on in the outside world was a matter of supreme indifference—Freud even forbade his patients, so far as they could, to have anything to do with it. Despite laser-sharp critiques like that of Ernest Gellner2, the extraordinary structure which psychoanalysis became proved a huge hit with the Western capitalist world, and shows little real sign of wavering even now (though why should I say ‘even’ now, when unreason appears to have entered a new heyday?).
‘Humanistic’ therapies and counselling. The boom in therapeutic approaches that got under way about mid-century and has flourished so successfully since, inspired largely by Carl Rogers but with the assistance also of many a lesser guru, has at its heart the notion that personal salvation lies in the hands of the individual him or herself. The origins of distress lie in personal experience, and the solutions to it in the willingness of sufferers to ‘take responsibility’ in one form or another for their predicament and, ultimately, will the necessary changes to their way of life. We are, according to the philosophy of modern therapy, autonomous, self-creating individuals whose emotional pain is, when all is said and done, a matter of choice.
Cognitive-behavioural approaches. These form the core of a new scientistic theology which is supported by a strengthening doctrinal orthodoxy and an increasingly confident scholastic authority. Volumes of research into the effectiveness of psychological therapies, the product of decades of academic and clinical industry, lead to the in my view inescapable conclusion that there is no convincing, consistent or significant evidence for the technical effectiveness of any current therapeutic approach to psychological distress. This body of evidence is magisterially overlooked by the doctors of cognitive-behaviourism, who, with unblinking authority, cite instead the handful of research efforts that can be mustered to ‘demonstrate’ the effectiveness of their approach. At the centre of this creed is the idea that the kind of human suffering that brings us to the psychological clinic is the result mainly of ‘dysfunctional’ thoughts and mis-attributions as to the real reasons for our troubles. The glass is not half empty, but half full, etc. Once again, no sign of society.
The environment in which therapy works ca be summed up like this:-
In this environment of the consulting room, consideration of society extends as a rule no further than to the people inside the patient’s head (though there are approaches—e.g. ‘systemic’ ones—in which some of these figures do actually materialize in the room itself).
So deeply imbued are we with the autonomous individualism of twentieth century psychology that to question its accuracy is to risk apostasy from intellectual and moral probity. For it forms the heart not just of our approach to emotional distress, but is deeply rooted also in the wider culture: in literature, in art, in the almost unshakeable commonsense understanding of self that seems to underpin the experience of every one of us. Do we not run our lives by assessing our situation and making choices? Is not our daily experience one of the almost continuous exercise of freedom? Is it not self-evident that the answer to psychological unease must in one form or another be one of self-adjustment? Surely such a view is the very antithesis of tyranny.
In fact, I think, this view is informed more by a magical wishfulness than it is by any sober assessment of our condition. What seems common sense can I think better be understood as a highly misleading ideology that, though no doubt growing away quietly in previous centuries, has come to full bloom over the past hundred years and that, though it is most fiercely defended by those it most effectively enslaves, truly serves the interests only of those who profit most from the way our society is ordered. In fact, I submit, we do not as ‘ordinary people’ to any significant extent choose the conditions of our existence, and when, as we often do, we find that they hurt us, our ability to change them is very strictly limited. The apparent moral and epistemological autonomy that we mistakenly take as definitive of our very humanity helps to blind us, I think, to the societal factors which in fact very largely control our lives and our experience. We are, if you like, held in place by a largely invisible tyranny. One of the few places the workings of this tyranny come to light (to the critical eye) is in the psychological clinic.
Having spent my working lifetime in the British National Health Service, I have found that only a minority of patients enter my office feeling themselves subjectively the moral equal of their peers. In addition to the distress that brings them there, most people are apprehensively expecting to be judged. This, when you think about it, is an unusual state of affairs for someone consulting a professional adviser. For example, even though you expect a lawyer to be wiser than you in the ways of the law, you do not anticipate when consulting one that you will be treated as a morally inferior being, and any lawyer who treats clients as such is unlikely in the long run to prosper.
But not only do clients of therapy often expect to be treated as morally inferior, as a matter of fact they often are so treated. For a start, the whole therapeutic enterprise is built on an assumption of ‘abnormality’. The patient’s conviction that ‘there is something the matter with me’ is unlikely to be questioned by anybody he or she encounters in the clinic. But beyond this, the feelings patients often express, once they’ve spilled their beans, that ‘I know it’s me’, ‘I know nobody can do it but myself’, etc., reflect perfectly accurately the common therapeutic view that ‘responsibility’ for their cure lies in their own hands. Because, after all, they are free agents. Once the therapist has done the job of demonstrating to clients the errors of their conscious and unconscious ways, it’s then up to them to switch on their ‘agency’ and do something about it. If they don’t, they must be succumbing to an attack of ‘resistance’, evincing ‘inadequate personality’ or some such.
Even the somewhat sanctimonious Carl Rogers, with his quasi-religious belief in the essential goodness of the human soul, and despite his emphasis on therapeutic ‘warmth, empathy and genuineness’, placed a huge moral burden on the shoulders of his patients, for he left them with nowhere to look for the cause of their problems—let alone the cure—but in the recesses of their metaphorical psychological insides.
This kind of moral judgmentalism, which pervades psychoanalytic as well as pretty well all so-called ‘humanistic’ brands of therapy, leads quickly to a corresponding aesthetics of human being which is equally if not more oppressive. For captaincy of one’s own soul gives one admission to an exclusive club of the Chosen Ones of therapy: whether as ‘fully analyzed’, ‘individuated’, ‘self-actualized’, etc. These are the celebs of the psychotherapeutic world, and inability to gain entry to their club can become a matter for continuous self-reproach.
What, in my view, most clearly exposes the nonsense of this therapeutic moralism and aestheticism is, paradoxically perhaps, the experience of the practice of therapy itself. Theory and practice contrast in the following ways:-
Theory suggests Clinical experience teaches
Insight leads to change We are not in control of our conduct; therapeutic change is not demonstrable
People may ‘assume responsibility’ There is no such thing as ‘will power’
leads to action (‘behaviour’) The causes of our conduct are frequently mysterious, and rationally unalterable
Characteristics/actions (real or Patients’ conduct is controlled by more potent influences in their social environment
imagined) of the therapist are
central to change
(e.g. ‘transference’, ‘warmth,
empathy and genuineness’,
behavioural and/or cognitive
It seems to me that the only way we can resolve these difficulties is by bursting out of the consulting room and taking proper account of what goes on in the wider society. Something along these lines:-
In concerning itself as it has and does almost solely with what I have indicated here as the realm of ‘experience’, in which it locates all its causal as well as its phenomenal investigations, psychology cuts itself off from understanding the origins of our troubles, and limits us to a conceptual language that suggests in the end (or in Freud’s case more in the beginning) that all that befalls us is spun out of our imagination and our ‘cognitions’. For there is simply nowhere else to look, nothing else to talk about. To restrict someone who is struggling to understand their suffering to the concepts and language of ‘experience’ is indeed a kind of tyranny.
Take the example of a very intelligent young woman who periodically starves herself and/or cuts her arms and legs with razor blades. Everyone around her—family, boyfriends, doctors—insist that a) what she does is abnormal and pathological, and b) that at least potentially she should be able to give an account of why she does it. As things are, she absolutely cannot ‘understand’ why she does it; she just knows that when she does, it helps, it gives relief to distress, it doesn’t feel wrong. She is of course aware of cosmetic drawbacks, etc., and is not exactly surprised that others react with various degrees of shock and horror. But she is oppressed above all by a sense of moral failure which is conveyed to her by just about everyone. Every time she succumbs to the urge to cut, for example, just about the worst aspect is the sense of moral defeat and disapproval. She has ‘let everyone down’, and by extension, of course, let herself down. At times when things are going well and she feels reasonably happy, the dread of possibly ‘letting herself down’ in the future still hangs as an ominous cloud on her horizon.
She has read all the books and considered all the theories, but oh, if only she could understand!
She has had quite a lot of attention from various professionals, some of whom have been more helpful than others, and the consulting room environment has been thoroughly scrutinised, including her perceptions of her family background. Despite clear awareness of (‘insight’ into) difficulties in her family life which contributed to the causes of her unhappiness, she is still no further on with understanding her actions. The only conclusion she can come to is that she is simply morally inadequate in some way that is far from clear to her.
Now I hope you are not anticipating that I am going to pull out of the hat some magical solution to this puzzle. I can’t do that. What I do want to do is raise some questions about why this young woman’s predicament is such a puzzle, and why we have to oppress her with the demand that she ‘understand’ it within the psychological terms we insist on restricting her to.
One of the first things to note is the narrowness of the sphere in which we permit ourselves and her to conduct the investigation. It is outside social space-time. That is to say, it is both an essentially private realm and one that has no historical dimension. If we introduce public space and history into our considerations, the picture does indeed change a little. In other times, for example, mortification of the flesh, fasting and self-starvation have not only been familiar exercises of religious discipline, but have been positively admired by those too spiritually weak to embark upon them themselves. In other places, furthermore, many other young women are doing exactly as our patient does. She is not in fact caught up in purely idiosyncratic acts of self-destruction, but is one of hundreds of thousands (at least) of people doing exactly the same kind of thing.3
Hers, I would argue, is a social response to a social predicament. Our demand for an explanation in terms of private, internal motivation is in fact quite a strange and unusual one, and our response, I would suggest, is, unintentionally no doubt, a singularly punitive and unhelpful one.
First, the demand for an explanation. Though, I’m sure, we would have questions to ask, I think most of us would allow a degree of self-evidence to the actions of the religious mortifiers of the flesh which we are not ready to permit our young woman. (In the same kind of way, we insist that the ‘obsessive-compulsive’ is suffering from a psychological ‘disorder’, but we allow religions their superstitious rituals without turning a hair.) We do not, in other words, feel we have to extort an explanation for what people do when they do it in concert with others. Somehow we feel we know what they’re up to. When they do it on their own, we are more likely to accuse them of madness or badness.
Second, the reaction. ‘Therapy’ can all too easily become the worst kind of clinical gaze: relentless, penetrating, insistent, covertly judgmental. What might be a more appropriate reaction to the sufferer? Sympathy, comfort, affection, practical help. In a word, compassion. Anyone can do that.
If we are to arrive at a more adequate account of how emotional distress and psychological suffering come about, and to formulate more appropriate responses to it, we are, I believe, going to have to re-introduce society into the picture and develop a set of conceptual tools that accommodate better than does the language of interior psychological space the difficulties revealed by (among other things) the experience of therapy.
The challenge for this enterprise is to give a societal account of the origins of distress which neither sacrifices individual subjectivity to some kind of collective ideal nor violates the sense that each one of us finds so compelling of the reality of human agency. Let me end by giving a very brief and inadequate indication of the kind of thing I mean.
Just going back to my last diagram:-
Power is generated within and through social institutions. The institutions of power operate independently of particular individuals and at varying distances from them, affecting them via almost unimaginably complex lines of influence that travel through individuals as well as through other institutions. The further away from the individual person a particular social institution is, the more powerful it is likely to be and the more individuals it will affect. For example, the machinery of global capitalism has enormous effects on vast numbers of people in the world who are themselves in no position to be able to see into its operation.
The extent to which an individual can be said to ‘have’ power will depend upon the availability to him or her of power within the system, i.e. how much power is transmitted through him or her from outside sources. The diagram gives the impression that power flows only in one direction – from the more to the less powerful. This is of course somewhat misleading: it is possible both for proximal to influence distal institutions and for individuals to act back onto their environment. It is however the case that the flow of influence in this ‘reverse’ direction is strictly limited in scope and distance.
I suggest that an individual might in this way be defined as an embodied locus in social space-time through which power flows. People are held in place within the social environment by the influences which structure it, and their freedom to change position or influence people and events is strictly limited by the availability of power within the sub-systems in which they are located. In fact, no significant amount power is available to the individual beyond that which is afforded by the social environment either now or in the past.
In this diagram I’ve attempted to indicate some of the complexity involved in all this. A family floats in social space, the direction of influence between its members and some proximal systems shown by the arrows and its relative strength by their thickness. Rather as if each of the smaller spheres were like a neuron or system of neurons in a nervous system, the ‘electrical impulse’ of conduction is power and the ‘neurotransmitter’ is interest. But the diagram leaves out infinitely more than it can illumine. Quite apart from the different ways in which power can engage or coerce interest, it is impossible to convey the way it flows through the system. Power does not originate within the individuals, nor even—to any significant extent—within the institutions shown (e.g. work, school), but is generated much more distally within and between socio-economic and cultural systems whose all-pervasive influence defies intricate analysis.
What, then, of our sense of agency? Am I not putting forward here a determinist view that has all sorts of depressing implications for freedom and the independence of the human spirit, etc.? There are just two points I want to make about this.
The first is that I am not denying freedom, but I am suggesting that we are free to do only that which we have the power to do. Much of the time we have very little idea about what is in our power to do and what isn’t, and in this regard therapy and counselling are not only particularly deficient, but downright misleading and oppressive.
The second point is that much of our sense of agency follows necessarily from our nature as embodied creatures. As social powers and influences flow through us, we have an irresistible feeling of their originating within us, because that is all we could feel. We attribute all kinds of significance to our feelings in this respect, and to account for what we feel ourselves doing, we invent a language of autonomy and responsibility that does not in fact stand up to critical examination and analysis. If we want to understand what we are up to and why we suffer, we are going to have to pay far more attention than we have in the past century to the structure and dynamics of social space-time.
1 Masson, J.M. 1985. The Assault on Truth. Harmondsworth: Penguin Books.
2 Gellner, Ernest. 1985. The Psychoanalytic Movement. London: Paladin.
3 At the time of writing this I had not come across The Language of Injury. Comprehending Self-Mutilation by Gloria Babiker and Lois Arnold (1997, Leicester: BPS Books). This is in many ways a model work of clinical psychology, placing as it does the individual experience of self-injury within the broader cultural and historical context. The book is likely to be most helpful to anyone interested or involved in self-injury.