A Manifesto and an update
by Arran James
I have a new post up on syntheticzero on suicide, suicidality and possibility. Its fairly speculative and is based on a presentation I gave not too long ago.
And now for something completely different…the following is a group statement written by the Midland Psychology Group, a group that includes the excellent David Smail. Although not written by me, there isn’t much in it I would change:
DRAFT MANIFESTO FOR A SOCIAL MATERIALIST PSYCHOLOGY OF DISTRESS
authors; identifies the main assumptions of a social materialist psychology,
and sets out a manifesto showing what it might mean to consider distress
from a social materialist perspective.
What follows is aimed in part, but not exclusively, at people in the Psy professions who seldom have any other vocabulary in which to talk about these issues outside of psychiatry on the one hand, and talking therapy on the other. The article marshals a wide range of theory and research on the kinds of misery that get treated by mental health professionals.
We are a group of psychologists: clinical, counselling and academic. We have been meeting regularly since 2003. We call ourselves social materialist psychologists. This is not necessarily a formally worked-out philosophical stance. Most psychology is individual and idealist. It takes the individual as a given unit of analysis, and treats the social as a somewhat optional and often uniform context. And, in what is still at root a Cartesian move, it treats the material world as straightforwardly present, but simultaneously subordinate to the immaterial cognitions by which we reflect upon it.
It is by contrast to this that our psychology is social materialist. Social because we affirm the primacy of the social, of collectivity, relationality and community, because we acknowledge that individuals are thoroughly social: ontogenetically, in their origins, and continuously and non-optionally during their existence. And material because we acknowledge that the cognitions by which we reflect upon the world do not simply float free of its affordances, character and properties. Cognition is both social and material, rooted in the ring-fenced metacognitive resources we have acquired, the embodied capacities it recruits, and the resources and subjective possibilities our world supplies (Johnson, 2007; Tolman, 1994; Vygotsky, 1962).
By social materialist psychology, then, we do not mean to imply a me
re inverse reflection of the mainstream, a negation, a futile rush to its polar opposite. Individuals exist, but their experiences are thoroughly social, at the very same time as they are singular and personal. And cognitions occur, but their relation to the material world is neither determinate nor arbitrary. Our social materialist psychology is therefore aligned – in sentiment, if not content – with other contemporary initiatives that similarly refuse the naïve separations of individual and social, experience and materiality: psychosocial studies, studies of subjectivity, process philosophy, the turns to language and to affect. In each of these perspectives (and more besides) we find resources, echoes and inspirations.
We write as we act: collectively. In this, we align ourselves with a tradition of psychologists (Curt, 1994), political theorists and activists (The Free Association, 2011), writers and artists (Home, 1991) who reject in practice the notion that ideas are simply the achievement of individuals. At a moment when collectivity, solidarity and mutual trust are so sorely needed, this simple act may take on significances beyond the pages within which it appears.
This manifesto is unfinished, a work in progress, a direction rather than a destination. We hope you find the ideas useful. Moreover it may inspire you to join with like-minded others, spend time sharing ideas and interests as we continue to do.
1. Persons are primordially social and material beings
Before anything else, we are feeling bodies in a social world (Csordas, 1994; Merleau-Ponty, 2002; Schutz, 1970). Primordially, experience consists of a continuous flux of bodily feedback, or feeling. This feedback – which is the raw stuff of consciousness itself (Damasio, 1999) – reflects our embodied, material situation (hot, tired, hurting etc). It situates us in a particular setting, and furnishes an ongoing sense of our bodily potentials: an embodiment. This feedback is also continuously social (influenced by the changing social relations of the lived moment) and socialised (somewhat habitual, shaped by the impress of prior experience). Bodily feedback, in the form of feelings, is the most elemental stuff of our being human.
However, the ineffability of the body means that the centrality of feeling often eludes reflection (Langer, 1967). Consequently, the most prominent component of thought itself is frequently what Vygotsky (1962) called inner speech. This running commentary on our own and others’ actions has social origins: its cognitive aspects are secondary to the social, discursive relations that engendered it. It is also largely retrospective, serving to stabilise or represent what has just occurred. In doing so it can serve as a tool to guide our own (and others’) actions, and in this way have some relatively limited influence on future circumstances.
Bodily, despite our somewhat fuzzy edges, we are discrete individuals. But this individuality is relationally and socially produced: ontogenetically, in the fusion of egg and sperm; developmentally, in the experience-dependent construction of important neural assemblies (Schore, 2001); and psychologically, through relations and interactions that inculcate the implicit habits and beliefs of selfhood. Because social relations shape our being, experience is not only specific to a particular trajectory of relational and familial social participation, it is also reflective of our epoch (Elias, 1978), class (Bourdieu, 1984) gender (Fine, 2010; Young, 1990) and – no doubt – other important social divisions.
This is not a denial of individuality. No-one else will occupy precisely the same circumstances as you, with exactly the constellation of bodily capacities with which you are endowed: for this reason, we are each unique. But this uniqueness is constituted from elements of the same flesh, the same social relations, the same material organisations of tools, objects, locations and institutions, the same cultural resources, artefacts and norms, the same discursive signs and symbols. Uniqueness and individuality are thoroughly social and material accomplishments.
2. Distress arises from the outside inwards
Distress is not the consequence of inner flaws or weaknesses. All mainstream approaches to ‘therapy’ locate the origin of psychological difficulty within the individual, usually as some kind of idiosyncracy of past experience. A morally neutral ‘normality’ may thus be seen as having become ‘neurotically’ distorted via, for example, unconscious personal desires or errors of personal judgment (e.g., over-generalization of negative experiences). Certainly this is the way we often experience our distress since such experience is inevitably interior. But experience and explanation are two very different things Professional therapy tends to presume that both the causes and the experience of distress are interior, since this affords the therapist a legitimate ground of intervention: individuals can be worked on in ways that social and material circumstances cannot. Individuals thus quickly learn to see themselves as in some way personally defective when in fact their troubled experience arises from a defective environment (Smail, 2005).
Neither is distress the consequence of cognitive errors, or failures to process information correctly. Those therapeutic approaches that do not attribute distress to some kind of personal emotional defect (however acquired) often point instead to ‘cognitive’ failure. The possibility that individuals, through no fault of their own, have drawn the wrong conclusions from unfortunate eventualities may at least have the advantage of absolving them from the odour of blame or personal shortcoming that tends often to waft around more ‘psychodynamic’ approaches. Again, this kind of view allows the therapist an apparently legitimate field of operation in re-working the person’s cognitive processes. It does so, however, at the expense of a truly convincing account of human learning. There is, surely, enough evidence of what a distressing place the world can be for us to avoid the necessity of concluding that the distress we experience is somehow mistaken (Smail, 2001a; 2005).
So-called ‘individual differences’ in susceptibility to distress are largely the consequences of prior socialization. The fact that some of us seem to survive adverse experience unscathed while others are thrown into confusion or despair may be taken as pointing to ‘interior’, personal qualities: ‘self-esteem’, ‘willpower’, or most recently ‘resilience’. However, it is far easier, and more credible, to point to the embodied advantages someone has acquired over time from the social/material environment than it is to postulate essentially mysterious and unanalysable personal qualities that originate from within. To mistake the gifts of providence for personal virtues is an all-too-common category-mistake, and one that psychotherapies do little to rectify.
3. Distress is produced by social and material influences
Social and material influences are typically complex and multiple. None of them are either necessary causes or sufficient causes, but the more that they intersect the more likely clinical distress becomes. They include trauma, abuse and neglect; social inequality, (organised in hierarchies of class, gender, ethnicity, sexuality and disability); and, somewhat more randomly, accidents, disability, severe illness and ‘life events’.
For example, there is convincing evidence that we are more likely to experience diagnosable distress if we have experienced traumatic events, including abuse and neglect. Read, van Os, Morrison, & Ross’s (2005) meta-analysis suggests that at least 60–70 per cent of people experiencing visual, or auditory hallucinations were subject to physical or sexual abuse in childhood. This body of evidence has received much less attention than the dominant psychiatric view that portrays distress as a consequence of biological or genetic influences.
Similarly, social inequalities that exclude or marginalise contribute significantly to the potential for distress. Poverty, impoverished housing and diet, threatening environments, limited resources, restricted choices, demeaning or poorly-paid employment, discrimination, oppression and scapegoating all cause distress. People born in working class areas to parents in manual labour are 8 times more likely than controls to be given a diagnosis of schizophrenia as adults (Harrison, Gunnell, Glazebrook, Page, & Kwiecinski, 2001). Being born to poorly-educated parents doubles the risk of being given a diagnosis of depression; if neither parent is in skilled or professional employment the risk is tripled (Ritsher, Warner, Johnson, & Dohrenwend, 2001). Non-white ethnic minorities in the UK are more likely to be given a diagnosis of schizophrenia, but only if they live in majority-white areas (Boydell et al., 2001). Women are roughly twice as likely as men to be given diagnoses of depression or anxiety disorder; in part, this is seemingly due to domestic violence (Garcia-Moreno, Jansen, Ellsberg, Heise, & Watts, 2005). Distress is consistently associated with markers of social inequality such as unemployment, low income and impoverished education, in countries including the UK, USA, Canada, Australia and the Netherlands (Melzer, Fryers, & Jenkins, 2004). Wilkinson & Pickett (2009) have amassed extensive evidence showing that in societies where the gap between the richest and poorest is greater the prevalence of many health problems is higher.
We are more likely to experience distress the more our experiences are invalidated and the more isolated we become from one another. Equally, the further we are from supportive, nurturing relationships, the more that invalidation and isolation will engender distress. People stripped of ameliorative influences such as a loving, supportive family and friends; comfortable, safe environments; and the trust, support and solidarity of others, are increasingly likely to experience diagnosable distress. In other words, the effects of trauma, social inequality and life events contingently interact with the less visible, less quantifiable effects of parenting, friendship, nurturing and caring. This is one reason why ‘the same’ event causes distress in some, but not others.
4. Distress is enabled by biology but not primarily caused by it
Harré (2002) distinguishes between enabling and causing. All experience is enabled by the biological capacities which constitute our embodiment in the material world. For example, your experience of reading this paragraph is enabled by the musculature of your head, body and eyes, the light-sensitive cells of your retinas, the cortical pathways and neural assemblies that relay, collate and interpret the signals that these cells generate, and so on. But these biological capacities did not cause you to read it.
This distinction is useful in relation to distress, not least because it accords very well with the evidence. For a very small number of organic diagnoses (syphilis, respiratory or urinary tract infections in older adults, Korsakoff’s syndrome, dementia) consistent biological causes of distress are known (although even these always interact with other influences). But for the overwhelming majority of functional diagnoses – schizophrenia, depression, generalised anxiety disorder, personality disorder and so on – there is no such consistent evidence. Over a hundred years of extremely well-funded research using ever-more sophisticated technologies has so far failed to establish that any of these diagnoses denote biological diseases. In the words of eminent psychiatrist Kenneth Kendler (2005, p.434-5): ‘We have hunted for big, simple, neuropathological explanations for psychiatric disorders and have not found them. We have hunted for big, simple, neurochemical explanations for psychiatric disorders and have not found them. We have hunted for big, simple genetic explanations for psychiatric disorders, and have not found them.’
But this does not mean that biology should be largely ignored, as is so often the case in social science and (predominantly cognitive) psychology. Embodied capacities lend shape and texture to distress, by enabling activities and by co-constituting perceptions, thoughts and feelings. This means we should strive to understand how distress is produced by the adverse socialization of embodied, biological capacities, rather than by their impairment, disease or failure. This massively complex interdisciplinary undertaking will draw upon anthropology, social science, neuroscience, psychology and other disciplines. Despite some suggestive recent accounts (Schore, 2001) we have barely begun to conduct such research, nor address the many methodological and conceptual difficulties it will encounter (Cromby, 2007; Newton, 2007; Rose, 1997).
5. Distress is influenced by biological variation to the extent that this variation provides non-specific capacities
Some biologically enabled capacities may facilitate people’s transactions with the world and so help protect them from some forms of psychological distress or self-doubt. It may thus be an advantage to possess conventional physical beauty, sporting prowess, musical ability, unusual intellectual ability, and so on. More important, perhaps, (perceived) lack of such gifts may undermine a person’s self-worth and render them more susceptible to distress.
An example: less conventionally-attractive people encounter a more hostile social environment, have less chance of developing friendships and social skills, and experience fewer rewards (O’Grady, 1982). Meta-analyses by Langlois et al. (2000) suggest that conventional beauty – in children and adults – is associated with more favourable judgements by and treatment by others. Farina et al. (1977) found that female psychiatric inpatients were judged less conventionally attractive than women selected from either a shopping centre or a university, and Napoleon, Chassin, & Young (1980) showed that mental health service users were judged less attractive than high or middle income – but not low income – controls.
Another example: sensitivity to others is a trait that might have a genetic component. Ordinarily this trait is adaptive, associated with maintaining good relationships, being a better employee, functioning well in groups, and so forth. But when someone with this trait is placed in a traumatic or abusive environment, the trait becomes maladaptive because it means that the effects of this toxic environment are felt more keenly. Tienari’s (1991) adoption study found that, even amongst people with a family history of difficulties, the experiences associated with a psychotic-spectrum diagnosis emerged only in the context of unfavourable family dynamics.
This perspective is consonant with current molecular genetic research, which typically finds that effects are small, non-specific, produced by multiple DNA sequences, and always dependent upon environmental mediation (Joseph, 2006; Rose, 1997). Biological factors can influence susceptibility to distress, but this is not simply a matter of objective biological advantage which inevitably orders people along some or other dimension of human ‘excellence’. The value placed upon biological capacities is always a social valuation, and their effects always depend upon social and material circumstances.
6. Distress does not fall into discrete categories or diagnoses
The quaint notion that distress can be neatly partitioned into robust categories reflects the mistaken belief that it is caused by organic diseases or impairments. If distress is understood instead as a kind of socially and materially inculcated experience, there is no reason to presume that we should be able to classify it in this way.
This may be why psychiatric diagnosis is notoriously both unreliable and invalid. Evidence of unreliability is provided by the lives of service recipients, who frequently receive different diagnoses during their contact with services. Further evidence comes from studies showing that, even in reliability trials where normal variation is artificially constrained (by video presentations, special training and broad categories) psychiatrists frequently disagree about the ‘correct’ diagnosis (e.g. Bentall, 2003, 2009; Pilgrim & Rogers, 2010; van Os et al., 1999). Evidence that diagnosis is invalid comes from studies of comorbidity which show that patients who meet the criteria for one diagnosis most likely meet the criteria for at least one other (e.g. Boyle, 2002; Brady & Kendall, 1992; Dunner, 1998; Maier & Falkai, 1999; Sartorious, Ustun, Lecrubier, & Wittchen, 1996; Timimi, 2011). Other evidence comes from studies of symptom profiles which show (for example) that the symptoms of people given a diagnosis of bipolar disorder do not cluster separately from those of people given a diagnosis of schizophrenia (Bentall, 2003). Because psychiatric diagnosis is neither reliable nor valid, all of its claimed benefits – in respect of aetiology, treatment, prognosis, service planning, inter-professional communication, reassurance to service users and their families – are compromised.
As a kind of experience, distress is on a continuum and continuously responsive to all other experiences. Its intrinsic variability is reflective of the great complexity of our social and material worlds, the many interacting, mediated contingencies that co-constitute our experience, and the primordially socialised embodiments each of us have acquired. Nevertheless, since we all occupy the same planet and belong to the same species, there are also similarities in our experiences of distress. These reflect shared embodied capacities: to feel sad when abandoned, to feel angry when insulted, to feel ashamed about sadness or frightened of anger; to get so overwhelmed by such mixtures of feeling that our very perceptions of the world get distorted (Cromby & Harper, 2009). They also reflect similar – but never ‘the same’ – experiences of power relations, social relations, material circumstances, and the contingent, mediated affordances they yield.
7. Distress is an acquired, embodied way of being in the world
Cognitive psychology studies processes such as memory, perception, reasoning, and judgement, and has influenced recent attempts within clinical psychology to explain and develop interventions for distress. These attempts are broadly based on the assumption that distress is caused by some problem or dysfunction with ‘normal’ cognitive processes: for example, within cognitive therapy, depressed mood is attributed to errors in reasoning such as ‘overgeneralisation’. Therapy attempts to help correct such errors, and so restore normal psychological functioning. However, this approach overemphasizes individual psychology, and particularly consciousness; conflates (social and material) causes with (cognitive) effects; downplays bodily processes; and almost completely neglects those social and material causes of distress external to the person and their proximal situation. It also fails to address the ways in which cognitive psychology is itself an ideological construction, rather than a naturally-scientific field investigating independently-existing phenomena (Bowers, 1990; Sampson, 1981; Shallice, 1984).
Conversely, psychiatry tends to construe clinical distress as akin to a medical disease and focuses upon diagnosing and treating (usually with drugs) so called ‘mental illnesses’: depression, schizophrenia etc. Although this acknowledges the body as the site of distress, it fails to adequately address the ways in which bodily manifestations of emotional distress are produced by, and consistently responsive to, social and material circumstances. Instead, psychiatry traces distress back to biological impairments and dysfunctions for which there is no credible, reliable and consistent evidence (Lynch, 2004).
Core to most psychological therapies is the development of ‘insight’. For example, in cognitive therapy the therapist ‘helps’ the client become aware of cognitive processing errors, with the aim of helping to correct them. Research in neuroscience and social psychology, however, has shown that much of our experience, including emotional arousal, is not necessarily available to conscious introspection (Kahneman & Tversky, 1982; Schwitzgebel, 2011; Wilson & Dunne, 2004). Hence, when individuals from Western cultures are asked to talk about feelings of low mood they usually offer accounts that emphasise individual inadequacy and guilt, whereas those from non-western cultures offer very different accounts (Fancher, 1996; Kleinman, 1986; Watters, 2010). Rather than providing reliable, accurate, direct accounts of experience, introspection is always mediated by cultural norms and linguistic resources that regulate what and how we can notice and report.
It is frequently difficult for us to make sense of, or explain to others, how we feel and why we feel the way we do. Complex feeling states are often triggered involuntarily in response to subtle environmental features, related to past events that have been forgotten, or that we do not connect with our current experience (Damasio, 1999; Kagan, 2007; Le Doux, 1999). We are often unaware of the many social factors that influence us: due to their complexity, or sometimes – in the case of advertising, tabloid media or politician’s speeches – the conscious manipulation of feelings by those in positions of power, with the intention of concealing such manipulation (Caldini, 1994; Freedland, 2012; Jones, 2011). Perhaps one of the useful aspects of therapy is the opportunity to try to make connections between events, past and present, and the feelings they evoke.
Both psychiatric and mainstream psychological explanations of distress are at best partial, at worst ideological, because they fail to capture the way in which experience is shaped over time by a social world that is frequently oppressive. The acquisition of what could be described as an affective ‘default’ position is sensibly interpreted by the person as reflecting the way the world is, has been, and will always be. This enduring, embodied aspect of distress means it is very difficult for us to change the way we experience ourselves and our world.
8. Social and material influence is always contingent and mediated
The ability to act is always contingent on the particular social, material and embodied resources available. In turn, the effects of these actions are not simply dependent on our intentions. They are also a function of the intentions and actions of others, and of the variable capacities and affordances of the (constantly changing) social and material world.
Bradley (2005) offers a startling example: stepping out and knocking a cyclist off his bike. In one circumstance, the man is largely unhurt and cycles away; in another, he is knocked into the path of an oncoming vehicle and killed. Intrinsically unpredictable combinations of interlocking factors (choices about where and when to travel; velocities, trajectories and reactions of cyclist, driver and walker; traffic flow and density; road and pavement layout) mean that three lives continue much as before in the first circumstance but are radically transformed in the second.
Contingency necessarily means that social and material influences are always mediated. They are in constant flow and exchange with each other and with the human characteristics and resources (habits, perceptions, affects, discourses, narratives) by which we understand and respond to them. Vitally, this does not mean that social and material influence is random: the contingencies and mediations by which it gets enacted are always already structured in relays of power. Nevertheless, power’s influence therefore necessarily has an ‘on average’ character (cf. Bourdieu, 1977; Young, 1990). This means there are always potentials for movement, always immanent moments of becoming and change, even within what seem to be the most frozen and static regimes (Stephenson & Papadopoulos, 2007).
Adequate psychological accounts of causality therefore need to be multiple, complex and open-ended: they need to recognise the radical indeterminacy of social interaction (Shotter, 1993), the probabilistic character of social influence (Archer, 1995), and the influence of culture as a mutable system of normative guiding principles (Harre, 2002). But mainstream psychology is preoccupied with mechanistic notions of causality: consequently, it tends to read these indeterminacies, probabilities and norms in ways that consistently subordinate social and material circumstance to immaterial cognition. Social and material influence is therefore downplayed, in favour of individualistic conceptualisations against which these real influences typically appear only as mere context. When elaborated, this understanding provides further reasons why ‘the same’ events seemingly impact differently upon different people.
9. Distress cannot be removed by willpower
An at least tacit notion of ‘willpower’ inhabits just about every theory of psychotherapy. Having been led, one way or another, to confront their personal failings, mistakes, or cognitive errors, it is assumed that patients can make the necessary correction by an act of will. If not, they are being uncooperative, ‘resistant’, etc. Never explicitly theorized, the notion of willpower lurks within such concepts as ‘insight’ and is typically assumed as an obvious, everyday human faculty that can be called on by all in extremis. Willpower constitutes a mysterious, interior moral force that cannot be measured or demonstrated – because, whatever its social utility, it doesn’t exist (Smail, 2001a). To assume that it does, and to call upon patients to demonstrate it, can be positively cruel.
This does not mean that we are necessarily unable to choose a given course of action, nor that we are constrained to perform actions against our desires. ‘Freedom’, ‘will’ and ‘power’ are necessary and valid concepts. ‘Willing’ means choosing this or that; freedom means having the power to choose this or that. Whether or not we have the power to exercise our will depends upon the availability of the necessary social and material resources. Will and power are two distinct capacities: without resources, exercise of will is impossible.
So there is no immaterial force called willpower upon which we can call. The personal powers that make the exercise of will possible may be concurrently present in the world, or they may be acquired historically – embodied – from engagement with it. I will not be able to speak French (to ‘will’ a sentence in French) if I have not studied and practiced the language sufficiently for it to become an embodied skill. Similarly, I will not be able to behave confidently in a given circumstance if I have not acquired and embodied the kind of experiences which engender the appropriate confidence. Most therapies, whether explicitly or not, invoke boot-strap-pulling as a vehicle of change, but boot-strap-pulling is no substitute for the necessary personal power (Smail, 2005).
10. Distress cannot be cured by medication or therapy
Distress is not an ‘illness’, so cannot be ‘cured’. It is not bad genes, faulty cognitions or the Oedipus complex, but misfortune and the widespread abuse of power that mire so many in madness, addiction or despair. These are not symptoms of illness: they are states of being that encapsulate how most of us might respond to chronic adversity. The most widely cited evidence bases for psychiatric medication and talking therapy are overly-optimistic catalogues of error and bias, featuring inadequate recruitment and blinding procedures, unreliable clinical outcome measures of limited real life significance, and the selective publication of favourable results (Angell, 2004; Epstein, 2006; Kirsch, 2010). The more rigorous the study and the longer the post-treatment followup, the harder it is to demonstrate any superiority for the clinical treatment over dummy, placebo or alternative (Westen & Morrison, 2001). Neither drugs nor psychological therapies are magic bullets aimed at specific symptoms: whatever effects they have upon body and mind are quite general. The one reliable finding is that emotionally warm and attentive practitioners are more appreciated and get better results – an observation that applies equally to politicians, salespeople and prostitutes.
Indeed, the expectation that therapy or medication might ‘cure’ is itself harmful. Psychiatric drugs are marketed and prescribed relentlessly – cures for supposed chemical imbalances said to afflict up to a quarter of the population (Busfield, 2010). Likewise, the jargon and practices of over 400 schools of psychological therapy have invaded almost every corner of daily life: from the products of a lucrative ‘self help’ industry to the running of schools, universities, business, clinics and prisons. The UK government’s Improving Access to Psychological Therapies (IAPT) programme promises to make psychological treatment ‘available to all’, as prophylactic for distress and happiness bromide: therapy on an industrial scale.
But the majority of psychoactive drugs cause mental and physical harm, especially with long-term use (Breggin, 1991; Moncrieff, 2006; Whitaker, 2010). The over prescribing of so-called anti-psychotics has unleashed an epidemic of psychosis throughout the world, as dependency upon (and withdrawal from) medication has almost everywhere been mistaken for ‘mental illness’. Whilst the talking therapies appear more benign, too often they are just a more insidious form of control, fostering the illusion that misery is an internal failure or breakdown, awaiting correction from an expert (Illousz, 2008; Parker, 2007). And – when medication or therapy frequently fails to generate the profound changes that were implicitly promised – we then become those who simply cannot be cured.
11. Medication and therapy can make a difference, but not by curing
Sometimes, medication can usefully anaesthetize the distressed to their woes, yielding brief bubbles of respite or clarity. During these short, chemically induced holidays from their misery, those with the resources may initiate life changes that alleviate their problems and establish positive future trajectories. But whether this occurs is a function, not simply of the medication, but of the resources and circumstances within which it is ingested: consequently, medication can also make things worse (Moncrieff, 2008).
Therapy can also help, though again not by ‘curing’. Understood generically, therapy provides comfort (you are not alone with your woes), clarification (there are sound reasons why you feel the way you do) and support (I will help you deal with your predicament) (Smail, 2001b). In an atomised, fragmented, time-poor society, where solidarity and collectivity are derided, time limited, and relationships consistently infected with a toxic instrumentalism, these are valuable, compassionate functions.
At its best, psychological therapy can help the sufferer to understand distress, not as a (more or less wilful) failure of insight, motivation or learning, but as the inevitable result of living in a noxious world. Moreover, both medication and therapy can help people make better use of the powers and resources already available to them. Both may draw attention to unrecognized resources (e.g., solidarity with others); make it feel permissible to use available powers and resources; change the ways that people use available powers and resources; or explicitly support people to cease viewing themselves as ‘the problem’.
With the exception of iatrogenic poisoning and disciplinary self-regulation, neither therapy nor medication has any other significant influence.
12. Successful psychological therapy is not primarily a matter of technique
When therapy succeeds it seems to be primarily a matter of two kinds of influence: on the one hand relationality (ordinary human compassion and understanding); on the other, coincidence with social and material and circumstances and resources.
In the therapy literature is it well established that the clients who do best are generally young, attractive, verbal, intelligent and successful – YAVIS (Pilgrim, 1997). By contrast, the people whose needs are described as ‘complex’ and requiring long-term treatment are usually the poorest (Davies, 1997; Hagan & Donnison, 1999). Where people have (or can obtain) more resources then they will have more scope to act upon whatever insights they might have gained.
It is also well-established in this literature that so-called ‘non-specific factors’ are a consistent predictor of good outcomes: in other words, that the therapist and client are able to establish a good relationship (Mair, 1992; Norcross, 2010). Indeed, unlike professional therapists, service users frequently declare the most ordinary aspects of therapy the most helpful: listening, understanding, respectfulness.
Despite this, therapy is mostly presented as a matter of technique. CBT, psychoanalysis, and almost all other schools of therapy appear as specialist technologies of subjectivity, skilled interpersonal practices founded on specific assumptions, locked in place by particular theories and evidence bases. In a thoroughly commodified society it is perhaps understandable that some practitioners will want to have branded, marketable products, just as in a professionalised culture some will want to identify themselves as bearers of highly specialised knowledge and skills. Like everyone else, therapists must earn a living, so it is only to be expected that interest should influence how they present themselves and their work. Nevertheless, doing so distracts attention from the actual causes of distress by bolstering the belief that it is a mysterious state amenable only to professional help; it disables friends and family, who may feel that they could not possibly understand; and it negates the contribution of community, solidarity and trust. The presentation of therapy as specialised technique cheapens and oversells psychology itself; leads to resources being wasted comparing the marginal differences between this brand and that; and deflects effort and attention from the very real opportunities for psychological research and insight that are supplied by the highly privileged situation of the therapeutic encounter.
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