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Psychotherapy,
Society and the
Individual
David Smail
Talk given at the 'Ways with Words' festival of literature,
Dartington, 12th July,1999





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There is no doubt that psychotherapy can be perhaps usually
is a very powerful experience. Like many other kinds of
experience, however, its power the weight of conviction it
imposes is no guarantee of its validity.

There are of course many kinds of psychotherapy, frequently
radically incompatible with each other, theoretically
irreconcilable and technically mutually inconsistent. And yet
nearly all share one crucial characteristic: they involve an on-
going often indeed protracted closely intimate relationship
between two people. (Group therapy is quite a different kettle of
fish, and Ill not be talking about it for present purposes.) It is
this relationship, technicized by the psychoanalysts as
transference and counter-transference, which gives
psychotherapy its experiential power. Its really quite difficult to
spend many hours of your life cooped up in the consulting room
of someone who is intently trying to understand you without
emerging with the feeling that something momentous has
happened.

Its very nearly impossible to discount the conviction of
significance which our personal feelings so often carry with
them. An example which may be familiar to people here who
havent experienced psychotherapy may be that of writing.
Many professional writers speak with awe of the magical
experience of writing, of the way it seems to take place through
them, almost as if their words were being written by the hand of
God. Portentous accounts of creativity have been grounded on
this experience. Indeed, I have experienced it often myself and
can vouch for its capacity to leave one feeling deeply moved.

It wasnt until a man I knew told me how his short stories came
to him that I began to get an idea of what this experience is
about. His eyes misting with emotion, he told me how his
stories seemed eerily to write themselves, how they poured
themselves from the end of his pen faster than he could control
the muscles of his hand. He positively glowed - humility and
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pride in equal proportions - that the mystery of the creative act
should have been vouchsafed to him.

The trouble was, his were without question the worst short
stories I have ever seen committed to paper. Chaotically
constructed, banal, misspelt and ungrammatical, they were in
fact barely literate.

What this reveals, I suspect, is merely that for anyone, creatively
gifted or not, writing tends often to carry with it a different kind
of experience from talking, without the same kind of illusion of
control: one is more aware, with writing (rather perhaps as with
dreams), that the ego is not as central as we often take it to be.
Thats all.

The experience of psychotherapy is rather like this. No matter
what the content of what passes between client and therapist, the
relationship generates in both a conviction of profundity and
significance which leads not only to a (most often) erroneous
belief that fundamental changes have taken place in the client
but also a widespread certainty in the truth of the theory
employed and the efficacy of whatever technique the therapist
claims to have used. Once youve experienced this you are more
than likely to be hooked. Perhaps this is why (though probably
not consciously) so many schools of psychotherapy insist on
acolytes going through the therapeutic experience themselves.
Most religions and cults make the same kind of requirement.
The power of personal experience is not to be underestimated,
and (as well, of course, as more noble human sentiments and
achievements) prejudice and bigotry depend upon it.

If we take a step back from personal feelings, difficult though
that may be, we are likely to get a more sober view of the
significance and efficacy of psychotherapy. Taking this kind of
step back is of course precisely what science is supposed to be
about, and although the social sciences can scarcely be
considered as a unified and uncontentious field (if it wasnt such
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a clich Id say they were riven with dissent) it is still true that
over half a century of intense scientific examination of
psychotherapy, producing countless volumes indeed libraries
of evidence, provides little support for the confidence most
therapists, as well as many of their clients, have in their
procedures.

So far as a scientific consensus is possible, we might be able to
agree that the helpfulness of therapy, such as it is, has more to
do with the personal qualities of the therapist than with any
particular theory or technique; that such personal qualities are
not a matter of training, so that many people who are not
qualified therapists are likely to be as good or better at it than
people who are; that fairly obvious forms of commonsense
enquiry and advice (ponderously baptised cognitive-
behavioural) are likely to be more effective in alleviating
psychological distress than are the more recondite procedures
of, for example, dynamic psychotherapy.

The best thing for psychotherapists faced with this kind of
evidence to do is to look around for grounds for dismissing it.
Human ingenuity being what it is, that is not too difficult,
especially in postmodern times when the whole boring nature
of so-called positivistic science is discredited at some of the
highest intellectual levels. But thats not what I want to do, not
least no doubt because my own experience of getting on for
forty years as a clinical psychologist accords rather well with the
scientific evidence (and of course I am as vulnerable as anyone
to personal conviction!).

What seems to me important is to understand why
psychotherapy is not as effective as people feel it to be and,
more important, to develop a more satisfactory idea of how
psychological distress comes about and how it might best be
dealt with.

I am making some assumptions here which need to be spelt out
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if misunderstanding is to be avoided. I am assuming that the
principal aim of psychotherapy is to alleviate distress and that
the question of its effectiveness may legitimately be raised.
These assumptions are, I think, linked; that is to say, the
question of its effectiveness can be raised only if psychotherapy
is seen as a technical procedure for the relief of psychological or
emotional distress.

Many psychotherapists, especially of the psychodynamic
variety, reject the idea that what they do constitutes a form of
treatment, preferring to characterize it as a procedure of
enquiry and self-understanding. This is fair enough in my view,
but puts psychotherapy in the same camp as religion, say, or
astrology. The procedure is self-justifying, and one need seek
endorsement for it no further than the participants own feelings.
If, for example, you want to spend fifteen years five days a week
(and several thousand pounds) coming to understand yourself
and your conduct in the terms set out by Sigmund Freud,
without necessarily expecting it to make any significant or
observable difference to your personal suffering or the way you
conduct your life and relationships, that is entirely your business
and that of your (in this case) psychoanalyst.

Though I wouldnt choose it for myself or particularly
recommend it to others, I am not, as a great believer in freedom,
against this kind of activity; it may even have some things to be
said for it. One thing most forms of therapy do is champion the
individual and his or her personal feelings and experience. That
is to say, they privilege subjectivity. Indeed, I suspect that this is
one of the main secrets of the success of psychotherapy as an
enterprise: from its outset psychotherapy challenged
objectifying forms of authority which sought to impose on
people explanations for and meanings of their conduct which
resided outside their own experience and potential control. This
is not to say that psychotherapy itself doesnt in many of its
aspects quickly become just such and objectifying authority, but
at best it furthers at least an illusion of subjective, personal
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freedom and responsibility.

Even this, though, has its own attendant set of dangers: a
defence of subjectivity and celebration of individuality can
quickly develop into a pervasive orgy of interiority in which
people become so exquisitely sensitive to their own feeling-
states and intuitions, etc., that they are virtually removed from
the public world of spontaneous social action. Absolutely
nothing is more boring and futile than focussing to the exclusion
of almost everything else on the quality and finer meaning of
ones own sensations and experiences not to mention dreams.
Therapy junkies can easily find themselves in that kind of
condition, and spend far more time than is good for any of us
writing about it.

But I think what most people understand by psychotherapy is
precisely a form of treatment for psychological disturbance, and
certainly by far the majority of the practitioners of the myriad
forms of therapy available today at least imply that that is
indeed the nature of their game even if they dont openly claim
it. In other words, what most psychotherapists are offering at
least tacitly is a professional service involving established and
validated procedures for the relief of distress. In this situation, it
seems to me perfectly legitimate to ask for evidence that such
procedures do indeed exist and that they work. And it is
precisely here, of course, that psychotherapies become unstuck
in a big way. Now I dont at this point want to get embroiled in
a dispute about evidence and what may legitimately be said to
constitute it: social scientists can (and will, nothing is more
certain) go on squabbling about that kind of thing for ever.
Pretty well everyone not having directly vested an interest in a
particular therapeutic brand name is agreed that the evidence for
the effectiveness of therapy is overall weak. What I do want to
do is suggest some reasons why this isnt such an outrageous or
dismaying circumstance as some may feel it to be. In fact its
pretty well to be expected.

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Psychotherapy is, when one comes to think about it, a curious
phenomenon: one very much of the twentieth century and
indeed particularly suited to these supposedly postmodern
times which is perhaps why it is currently booming as never
before. We have become so familiar with the ideas explicit and
implicit in psychotherapy, it chimes in so harmoniously with the
Zeitgeist indeed in part it is definitive of the Zeitgeist that it
becomes quite a struggle to see how curious a phenomenon it is.
But what it does, I would suggest, is something quite radical
even violent to the nature of our personhood and our relations
with the world. To be more specific: it disembodies us and it
dissociates us.

Through its focus on the individual and its limitation for the
most part of its analysis to the individuals relations with a) his
or her family and b) the therapist, psychotherapy lifts the person
out of the physical and social contexts which actually shape and
maintain him or her as a person. It simply ignores the main
factors and influences which make us the people we are. The
aim, of course, is to free us, to give us power over our lives and
the ability to change their course when things go badly. But it is
an illusory freedom and one which in the long run does us much
more harm than good. In fact, if only it could speak for itself,
the consensual core of psychotherapeutic thinking would find
much to agree with in Margaret Thatchers dictum that there is
no such thing as society, only individuals and families. It might
even go further in maintaining that, its all being in the mind,
there are no such things as bodies either. Let me just take the
factors of disembodiment and dissociation one at a time.

Disembodiment

In nearly all its varieties, psychotherapy tends to think of bodies
as unproblematic, as secondary to mental influence; in many
respects the mind is seen as constitutive of physical structures.
This is seen at its most extreme in the view that, through the
operation of imaging a person can organize a kind of
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biological attack on pathogenic physical processes such as the
production of cancer cells. (Apart from its absurdity, this kind of
thinking can lead to very unfortunate consequences, for what
starts out as a half-baked notion of the magical power of thought
ends up in people feeling responsible for their inability to cure
their cancer.)

The privileging of the mental is rarely as extreme as this, but is
still widespread in psychotherapeutic thinking. Psychoanalysis,
of course, gives colossal power to the Unconscious and its
ability to shape our bodily experience and reactions, and ideas
like that of psychosomatic illness can quickly slide into a view
that psychological events cause physical ones. Such ideas may
be harmless enough even quite fruitful as a kind of rhetorical
counter to an unthinking biological mechanism, but they too
easily come to underpin a received and utterly erroneous
notion of the power of mind over matter.

In run-of-the-mill therapeutic work the factor of disembodiment
is encountered most frequently, albeit somewhat indirectly, in
the pervasive notion of insight. At first glance the idea that we
can act freely on the basis of what we see to be the case and that
the identification of misconceptions is enough to enable us to
change our ways seems innocent enough, and indeed forms one
of the principal pillars of everyday ways of thinking.
Psychotherapy is built around this idea. In order to change their
neurotic ways, people have to see into their reasons, conscious
and unconscious, for clinging on to them, and having done so
will be able to take a different course.

Whats the matter with that? you may say. Well, the matter is
that our learned patterns of thought and action are not merely
mental acquisitions, but are embodied. It is no easier for people,
for example, to throw off anxiety and lack of self-confidence
merely through having seen into its history than it is for them to
speak anything other than their mother tongue simply by being
given an account of how they came to speak it. Psychotherapy
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tends in this way to represent our personal characteristics and
conduct as matters of choice, as though we were, from infancy
on, disembodied wills, selecting (even if unwisely or
unconsciously) what suited us from a kind of hypermarket of
possibilities.

But experience is embodied. Wired in. We may if we are lucky
be able to an extent to choose our influences (good parents will
do this for us as we grow up, and the more resources they have
at their disposal the more successfully they will be able to do it)
but we cannot choose whether or not to be influenced, or to
become uninfluenced once we have been influenced. As Ive
found myself saying over and over again to people, you cant
choose to forget how to ride a bike. The same is true with so-
called psychological influences: you cant just divest yourself
of their consequences merely because it now suits you (having
gained insight) to do so.

Dissociation

Because psychotherapy focuses almost exclusively for the
derivation of its theory and practice on the two occupants of the
consulting room, looking beyond for the most part only to the
members of the patients immediate family, the result is a
dissociation (social dislocation) of the individual which has
profound implications for the understanding of how, among
other things, psychological distress comes about. A world is
created in which it seems as though persons are made solely
through the interplay of wilful action among those with whom
they are most intimately involved that is to say in the
proximal relations with their family and some others with
whom they have close, intense, relations, including of course
their psychotherapist. It is their relations with the latter which
are seen as crucial to their psychological transformation. Left
unanalysed in this situation, and very possibly not considered at
all, are the influences of the wider culture and social
environment.
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In mainstream psychotherapeutic thinking there is nowhere to
look for the meaning of action beyond the actors themselves,
and so the potent factors in the process of becoming a person
and the struggle to change are likely to be seen as intention, will,
desire those factors which in fact all of us in our day-to-day
lives take for granted as the sources of our conduct. However,
because it is every therapists experience that people cannot
change merely because they intend to or want to, another
dimension has to be added to the equation to explain their
apparent recalcitrance, and that of course is the dimension of the
Unconscious which becomes a repository for intentions and
desires of which the person is unaware. What you then end up
with is a kind of voluntarism at one remove, where therapists
can hint at what people really (unconsciously) desire and
intend, and chide them (though obliquely) with a kind of
concealed moralism: now youve seen what youre really up to,
dont you think youd better change your ways? As an account
of human conduct this really is extraordinarily inadequate.

In many areas of our lives we are in fact shaped by forces well
beyond the reach of our will and even in some respects of our
understanding. Very significant parts of what we take to be our
personal individuality are quite literally culturally determined.
Socio-economic influences affect us as intimately and as
uncontrollably as the weather. As people we are locked into a
network of social power-relations which sets the strictest limits
on what we are able to achieve purely through the action of our
own will (it was of course Michel Foucaults particular
achievement to elucidate the nature of this apparatus of social
power). What aspects of our personal and interpersonal conduct
may be controlled by powers which we cannot even see, let
alone influence, is far from clear, largely because our
individual-centred psychology has for the most part failed to pay
them any attention. However, what is clear, I think, is that the
influence upon us of such distal powers is far, far greater than
we have so far been able to understand and severely limits what
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can be achieved through such proximal undertakings as
psychotherapy.

We are through and through social creatures, and our happiness
and unhappiness are conditioned by our relations with each
other not just as face-to-face individuals but through highly
complex networks of social organization. And that organization
is above all structured by power. How much we are able to alter
our circumstances, and so perhaps affect the balance of our
happiness and unhappiness, will depend not on our being able to
tap sources of will power, hitherto perhaps buried in our
unconscious, but on what forms of social power are available to
us from without.

Please let me remind you at this point that I am not trying to say
that psychotherapy as an undertaking or as a vocation (the
preferred term of Paul Gordon, who will be speaking this
afternoon and whose version of psychotherapy I have little
quarrel with) is intrinsically invalid. What I am saying is that in
its guise as technical procedure of change, the disembodiment
and dissociation of human beings which psychotherapy so easily
brings about ends up inevitably in a very probably
unrecognised belief in magic, for the material means of
causality have been removed from the picture. We are not the
kind of self-creating, self-changing entities that psychotherapy
so often assumes us to be. Our conduct is shaped and given
meaning by a social world and mediated by biological structures
which we cannot change simply by seeing the necessity for
doing so or desiring to be otherwise. There is in fact no such
thing as will power if we are able to will an action it is
because the power is available to us to perform it, and that
availability of power originates from without, not from within.
We can transcend the reality of social power (of its facilitating
as well as of its constraining effects) and of the capacities and
limits of our own biological structure only in our imagination,
and when it comes to affecting the circumstances of our lives
which cause us pain, imagination is not the most potent
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instrument.

I am not saying anything new with this. Im sure that to many it
seems, as it does to me, so obvious as to verge on banality. What
I am doing is taking a side in a debate which runs right
throughout the history of culture. In view of this, it always
surprises me how upset with what Im saying some people seem
to get. Apart from sheer abuse from some fellow professionals
(e.g. that Im suffering from clinical depression), the most
frequent accusation aimed at me is that I am depriving people of
hope. But this is the case only if the version of psychological
suffering and its treatment offered by the therapeutic paradigm
is the only valid possibility. I am indeed saying that
psychotherapy as a technique or set of techniques for the
treatment of psychological distress can only be of limited value
(not that it is valueless). This is because by far the greater part of
psychotherapeutic theory has failed to progress beyond the most
nave psychology of personal development and essentially
magical ideas of change. I dont see anything particularly
hopeful about reliance on magic as a cure for distress. Hope lies
in other directions. Perhaps I should take just a little time to give
an indication of what kind of other direction might be worth
following.
From a psychological point of view the Twentieth Century has
been a colossal diversion (certainly in the West) from an
examination of the way individuals are created and maintained
by their environment. The quality of thought Plato gave in his
Republic to the kind of cultural diet most suitable for its future
leaders is barely conceivable now, where about the most we get
is cursory studies or literature reviews to show, for example, that
television has no influence on violence. Our emphasis, as I have
already indicated, is very heavily on the inside, on mental
factors such as choice and will, and moral factors mostly seen as
personal, such as responsibility. Because of this, our gaze is
diverted from the social world around us and our preoccupations
are with self-transformation of the personality rather than
political transformation of the society beyond the boundaries of
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our skin.

The logical culmination of this one whose lineaments are
already clearly discernible is that our world becomes virtual
rather than actual, and in place of a materially created reality we
are immersed in an ideality which is spun by its various doctors
into all manner of marketed wishfulness. At the political level
exhortation and the avowal of values come to be seen as an
acceptable substitute for material action.

The costs of pretending that we are immaterial beings capable of
self-transformation into shapes and conditions of our own
choosing, as essentially free of the limitations of the body as of
the constraints of society, are I believe already to be seen in the
forms taken by the psychological afflictions of the young, some
of whom have become prey to a kind of anxiety in which they
are panicked by, for example, the experience of their own
bodies; they have simply not been taught what it is to be a
human being and do not recognize feelings which are the
common lot of ordinary mortals.

We have become absolutely to depend on the notion that it is
possible to change aspects of ourselves we find inconvenient, to
erase the inscription upon us of the environmental influences
which surround us. Rather than accepting that experience marks
us for good and all, we wish to insist indeed have come to
expect and demand - that its effects can be counselled away.

But would it really be so terrible if psychotherapy didnt work in
the way we seem to expect it to? Perhaps if we were shaken out
of our bewitched fascination with imagination and virtuality,
the wishful invention of interior worlds which have no
embodied substance, we might come to see that paying sober
attention to the realities of social structure and of our relations
with each other as public, not simply private, beings is an
option. A difficult one certainly not so easy as dreaming and
wishing but at least a real one. What this would entail is a
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recognition that maybe prevention is more possible than cure; a
down-grading of psychology in favour of an up-grading of
politics.

Where, though, would this leave individuals? Would we not, for
example, be in danger of depersonalizing ourselves and risking
becoming part of a grey, undifferentiated mass, prey to
totalitarian solutions of the kind too often experienced already in
this now dying century? I really dont see why this should be.
Politics doesnt have to be dishonourable. There is no reason in
principle why we shouldnt be able to resurrect a politics whose
central concerns are with such things as liberty, justice and
equality. Very difficult, certainly; nave, Utopian, idealistic, I
cant deny. But at least not, like the psychology of self-creation
and self-transformation, impossible.

Our disillusion with and widespread rejection of what passes for
politics these days that is, for the most part, the acquisition and
manipulation of power by large interest-groups leave us
exposed to ideologies at least as dangerous as those recognized
as political. For the marketed ideology of interiority, the world
of third ways where public opposition is supposed to be at an
end and the interests of all can be reconciled, where exhortations
to personal responsibility, naming and shaming and other
forms of sanctimonious moralizing take the place of
government, all these take us in to a realm of make-believe
where there is only an illusion of control, and where the real,
material principles of social reality threaten to run riot.

I hope it is clear from what Ive said that I am absolutely not
meaning to suggest that the lives, interests or feelings of
individuals be sacrificed to some idealized political notion of the
common good. Perhaps psychotherapys greatest contribution
(though by no means always and everywhere) has been, as
already suggested, to support and sustain individual subjectivity,
to respect individual feelings and to respond compassionately to
individual pain. But these humane aims and impulses did not
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originate with psychotherapy and are in fact not realizable by it
in any other context than that of a personal relationship. That is
to say, psychotherapy is incapable of bringing about change on a
wider social scale if only because it hasnt the powers available
to it to do so. The kind of moral aim which underlies the best
psychotherapy cannot be achieved by a procedure of personal
transformation or cure (on an analogy with medicine), but by
constructing a context of taking care which, as I argued in an
earlier book, can be furthered only politically, i.e. as a collective
social undertaking.

Even the respect for individuals which lies at the heart of the
best psychotherapy can too easily become submerged in a
pernicious moral and aesthetic prescriptiveness by no means
dissimilar from political totalitarianism. For it is easy for
therapists to slide from a compassionate interest in how people
are into a superior judgement of how they ought to be. In part it
is this phenomenon which feeds the whole culture of personal
change to which psychotherapy is so prone. It is impossible to
be exposed for long to the privileged insights which the role of
psychotherapist offers without becoming aware of the darker
and more depressing sides of human experience and conduct,
and so hard to resist an impulse to moral exhortation (in
however veiled a form) and to holding up to people a model of
normality or being to which they should strive to conform.
But this is just another form of tyranny, disguised victim-
blaming in which people are asked to do the impossible.
Impossible because the vast majority havent in fact got the
powers available to them to effect the changes considered
necessary.

We would do better, I think, to see that the kind of changes
which might improve our lives are matters of social, not
personal concern and action. If we need to change anything it is
the social environment in which we are all located and
embodied. This leads to a very different psychology from the
one we are used to, a very different way of conceiving
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experience and action (ways that, unfortunately, I havent the
time to develop now, but which I touch on in my books The
Origins of Unhappiness and How to Survive Without
Psychotherapy).

It leads also to a very different way of conceiving of ourselves
and each other, but not one which is totally unfamiliar to us.
Rather than seeing ourselves as free agents, able in principle to
pick and choose the ways we want to be, we could, I suggest,
see ourselves as characters, not unlike characters in novels (I
should probably say some novels): fixed, predictable, often
caught tragically on paths not of our own making and from
which diversion is not an option. Characters we can identify
with whether through love, pity or fear, but also characters
created by sets of circumstances and worlds which maybe it
would have been possible to influence, characters whose
experience means something by virtue of pointing to ways in
which sets of circumstances and worlds could be. Characters,
that is to say, who exist not just for themselves, but for a future.