Wednesday, 13 August 2008

Smail's Canards

David SmailCraig NewnesTwo days of teaching from my clinical training stick firmly in my mind above all others. The first was provided by Craig Newnes, the second by David Smail (click on their images for information about their work). Both are champions of the (to my mind on target) views that psychological therapies are often at best a poor and pretentious substitute for a client having a decent friend and a decent job. Both have found a home within the movement known as 'critical psychology' that they helped to develop in the UK. I don't want to engage here with their general critique of the psychotherapy industry, and their alternative focus on malign social forces. In many ways I'm persuaded; but, suffice it to say, whatever one thinks of their critique, clinical psychology desperately needs critical voices such as these, to keep the critical intellectual tempo up (off the floor). (Newnes also taught me two of the most valuable personal lessons of the whole of my training, for which I am eternally grateful, so I oughtn't to be grumbling...)

What I do want to focus on is what I believe are certain fairly evident straw men in certain of their arguments (in what follows I shall however just focus on Smail's contribution). To call them straw men is not to say that they never obtain - sometimes one's opponents (or their self-understandings at least) really are made of straw. But I do think that on the whole these reallly do involve fairly obviously false characterisations of much of the mainstream they question. I also think that Smail himself would agree that his own best understanding of his opponents' beliefs would contradict what he says they believe when he provides his critique. This is of a piece with my belief that there is often something rather uncritical about critical psychology despite its many criticisms of the mainstream. (For example, the fact that genetics has a partly dodgy history is taken to mean that it has a dodgy present, or that its theories are theoretically dodgy. Or the fact that psychiatric classification can be used for social oppression is taken to mean that psychiatric classification has no straightforwardly valid, phenomenological, non-oppressive use. More generally, I am sure I am not alone in believing that critical psychologists often throw out valuable theoretical babies with the bathwater of pretentious psychobabble they rightly wish to dispose of.) Here, at any rate, are some claims made by critical psychology about which I have my suspicions:

1. Psychological problems are really just, a la Szasz, 'problems in living'. Terms like 'neurosis' are pretentious pseudo-science; there's no difference between feeling down and being depressed, feeling anxious and having an anxiety neurosis. Or, if there is a difference, it is just one of degree - i.e. a merely quantitative difference. The psychoanalysts in particular are wrong to imagine that there is a special class of psychological problems (neuroses), which have their maintaining factors located in the 'inner world' (i.e. in the habitual and distorted pre-understandings that we bring to the situations we find ourselves in). Instead there is just anxiety, or depression, maintained by shit relationships and shit jobs (or loneliness or unemployment).

2. Psychotherapy theorists take psychotherapy to depend on insight, where what 'insight' means is as follow. It is either a coldly intellectual realisation, or perhaps an emotionally charged realisation, of the nature of one's difficulties. That is, insight amounts to either the client's agreeing with the therapist's correct formulation, or their coming themselves to a correct formulation, of their difficulties. Having got this insight they can now work to resolve their difficulties.

3. Psychotherapies tacitly depend upon the idea that, after you have your insight (understood as in 2), you can use something called your will power to resolve your difficulties. This Smail calls the 'myth of magical voluntarism'.

4. Psychotherapies depend on the bizarre idea that material causes can be undone by psychological solutions. And this is just 'magic'.

Let me take these one at a time, in reverse order:

4. Here is what Smail says:

When ... we move from 'analysis' to 'therapy', we quickly become aware that there is no way the activities of the therapist can impinge directly on the social world in which the person exists. Though the causes of distress may lie in events in the outside world, the 'cure' can be effected only by working on the person him or herself. This is not, when you think about it, terribly coherent from a logical point of view, and trying to present it as such has led us into a variety of intellectual contortions which are in my view still far from satisfactory.

For what we are trying to do in the 'therapeutic' part of psychotherapy is reverse the influence of solidly material environmental causes through the psychological processes of the individuals who have been affected by them. People have of course tried to do this throughout recorded time. It used to be called 'magic'.

This, to my mind, is not a good piece of reasoning.

First, the kinds of causes from the 'outside world' which we may take an interest in, in therapy, are usually from the past. They therefore cannot be changed for the person in question, even by directly working on the outside world. All that could be worked on is the relationship that the person now has with these past events.

Second, let us for the sake of argument take it that we are interested instead in current 'external' causes and maintaining factors. If these are sufficiently traumatic or distressing, they may of course hijack any therapy whatsoever. It may be therapeutically advisable to wait until one is in an externally better situation, before working to undo the ways in which one's neurotic character elements aim to protect against but actually exacerbate everyday miseries (see below). But in any case, I know of no psychotherapy school which would say that everyday miseries are not best addressed through everyday solutions, or that it is only by a person's working on him or herself that they can be addressed. And Smail doesn't name one.

Third, we are not, in therapy, trying to reverse the physical processes themselves which caused psychological distress, but rather to undo their influence through engaging with the way this influence is kept alive in the mind. (Examples: the way that trauma are kept alive in PTSD; the way that complex bereavement issues are maintained.) What would be illogical or magic would be the belief that we can somehow undo the physical processes that have already occurred (the accident; the death).

At any rate, if it is magic to work on these maintaining factors, then so is the following: You are caused to go into a psychological state (believing there is a cat in the garden) by a purely physical phenomenon (my trompe d'oeil painting of a cat in the garden, sitting in the window of your room). Later I tell you that I've left this picture in your room, and you (psychologically) come to revise your belief. Is this magic? If it is, then magic is good enough for me.

(In brief: Smail's distinction between what is physical and what is psychological seems both unargued and unmotivated. He talks about 'solidly material environmental causes' but neglects to mention that he is not talking about, say, bacteria which might cause brain disease, but rather, the various things we see, hear, interpret, have an emotional reaction to, etc. And why on earth shouldn't we try to help someone with their emotional reactions to events through psychological means? We know that learning occurs through teaching, that opinions change through discussion, that emotional breakthroughs occur now and then in our own lives, that our habits sometimes change, that in some ways some aspects of our psyches are immature compared to other aspects but that growth can occur in the right circumstances. These are the kinds of 'common sense' bits of knowledge so prized by the critical psychology movement, not arcane bits of putative psychotherapeutic science. So what is the problem with the very idea of a psychological solution to a problem which arose out of the impact of the environment upon the mind? To put it another way: isn't the therapist's consulting room, the verbal and non-verbal interactions, part of the environment too?)

3. On the myth of 'magical voluntarism': Smail says:

in much psychotherapeutic thinking, 'insight' has a silent conceptual partner which is assumed but never directly referred to: will power. At the back of our minds, I believe, we are fully paid up subscribers to what one might call the popular philosophy of action, which goes something along the lines that, to do something, first the alternatives are considered (the pros and cons weighed), then a decision is made, and finally the appropriate course of action is willed. We tend to regard the important part of this process as the weighing of pros and cons, somehow expecting that the rest follows on more or less automatically ...

Although this notion seems to provide the motive power for turning insight into action, as far as therapeutic theory is concerned it is, as I say, silent, and this because therapists know perfectly well that appealing directly to the application of 'will' is absolutely fruitless. ... Therapy, on this kind of view, would be aimed at clearing the path to the person's unencumbered application of will.

... But there is a much more serious objection to what I suggest is our silent subscription to the notion of will, and that is an empirical one: there really does not seem to be any such thing as will power.

Now I take it that Smail and Newnes' empirical critique of certain versions of what the will consists in is perfectly well founded. (I particularly enjoyed, too, Newnes' calculation that his mother had lost just over 2 tonnes of weight during her life from diet programs - and put on just slightly more than 2 tonnes.)

But, first: We do need to be a bit more nuanced about what we mean by 'will' and 'freedom'. Smail aptly criticises a pop-philosophical view of what intentional action consists in (decision followed by act of volition). But we may need to remind ourselves not to fall into pop-philosophical views of what conation (the will) consists in too.

So let's begin by sorting out some notions of 'will power'. On the one hand, there are applications where we are happy to say: "I willed myself to mark the tedious exam papers", "I struggled but overcame my desire to run away from the spider", or what have you. These do not presuppose a dubious philosophical notion of 'the will', but instead provide us with an everyday, meaningful, use of 'will' against which any theory ought to be tested. What we mean is that we felt a desire to avoid the task, but did it anyway. This happens, sometimes, and it would not be clear what someone would be meaning if they denied that it happened. To be sure, it is not to be explained in terms of some already understood notion of will; rather, any attempt to articulate such a meaning must itself be responsive to such primary non-theory-driven uses of the term.

But rather than continue to urge that we can rehabilitate a perfectly non-problematic sense of 'will power', I want to urge that today's psychotherapies are, by and large, perfectly in agreement with Smail on this issue. That is, they do not tend to accept that 'will power' is part of the solution; instead they may usually see it as part of the problem. Let's consider some in turn:

a. Acceptance and Commitment Therapy - ACT - urges precisely that we come to accept the thoughts or feelings that course through our minds and bodies, and give up our previous hopeless control agendas. It points to the ways in which attempts to control what goes on in our mind, overcome our desires, will ourselves not to have certain thoughts, etc., usually result in poorer rather than better outcomes.

b. Behaviour Therapy holds that therapeutic change occurs not through thought nor through will, but through the direct (re-)conditioning of our behaviour. The common idea that therapeutic change (in, e.g., depression) occurs partly through 'behavioural activation' is another example. Here the direction of putative causality (I say putative because I don't believe the relations are aptly framed as causal) from the mental to the behavioural is reversed. Desire and positive affect are constructed through activity, not the other way round.

c. Whilst some Psychodynamic Therapies claim to work by 'building up ego structure', and whilst that claim could be interpreted in a way consistent with Smail's critique, others claim to work by 'reducing the harshness of the superego'. And this I believe runs counter to his critique.

I don't want to get caught up in a theoretical debate for which Smail (and Newnes) would have no patience (although I just don't share their avowed lack of patience for such debates). So let's try and put the matter in simple terms. I may be someone who is caught up in a lot of internal battles. I tell myself I ought to be doing what I am not doing. Perhaps these 'oughts' take the form of an internalised parental prohibition, but perhaps they don't. Because I end up in internal battles, the energy is sapped from my life. I get less and less done, and am less and less satisfied with myself, and tell myself that I 'must' change. I punish myself, internally or externally, to get myself to do what I believe I am supposed to be doing.

Rather than build up my will power to enable me to win these internal battles, I take it that psychoanalysis, like ACT, aims to encourage self-acceptance. Through an engagement with a therapist who confounds one's projections (doesn't act like the harsh father one expects him to be, for example), and if all goes well, the edge is taken off the harshness. The idea that wishing one's (sometimes very irritating) child dead may be perfectly natural, a passing thought and not a sign of deep malevolence, can be taken on board. Does it need 'will power' to take this on board? I doubt it; what it probably needs is a therapist who, through their continued loving attention despite being acquainted with what one feels are unacceptable thoughts and impulses, demonstrates an alternative, accepting, way with vulgar thoughts, angry impulses, disposition to laziness, or what-have-you.

2. On what 'insight' might mean. Ok, so lets bite the bullet: some therapies really have seemed to suppose that change is supposed to occur through intellectual insight. Versions of CBT with their unashamedly Noddy and Big Ears style of psychology (disguised by their dressing up of terms like 'thought' or 'idea' in pseudo-scientific garb ('cognitions' etc.)) are clear candidates. Early psychoanalysis (cathartic 'chimney sweeping' as Anna O. called it) is another. But, hey, these therapies have in enlightened corners long since been abandoned - haven't they? (Well, ok, probably not everywhere and always...)

Complete alternatives to insight & will driven therapy models have already been canvassed in a-c above. But let's pause to consider what 'insight' might mean if not simply the patient's intellectual awareness of their difficulties. Here is Smail being critical of the very:

idea that people can act on insight. Various attempts have been made to get round the fact that they obviously can't, the most familiar perhaps being the idea that the important thing is not 'intellectual insight', but 'emotional insight'. However, as I've suggested in the past, there is no obvious reason to suppose that changes of heart are any more potent than changes of mind, and it is far from clear why feeling that something needs to be done should be any more effective than thinking that it should.
I think a good case could be made for suggesting that Smail is quite simply just wrong in what he says here, and that this could be demonstrated simply by looking at what is commonly meant by a 'change of heart'. So let us accept that someone may carry on engaging in a behaviour they find distressing even after they have come to 'intellectually understand' why they are doing it. (I am however a little suspicious of this idea of what 'intellectual understanding' is, since I think it is evident that the criteria for understanding, even of an intellectual sort, do not reside simply in, say, being able to uninhibitedly parrot, or sincerely avow, what we have been informed is, and what really is, the truth about ourselves. To put it in psychoanalytical terminology: are we entirely confident as clinicians when we say, as we ordinarily do, that someone may still predominantly operate under the influence of a phantasy even when they have perfect insight into the role of this phantasy in their lives? That however is an issue for another post.)

The question, however, is whether we find it even coherent that someone may carry on engaging in the same behaviour after what we would consider a genuine 'change of heart'. Doesn't a change of heart however, just mean here that one is no longer so disposed? If someone said they had a change of heart but carried on in the same way, wouldn't this itself be logical grounds to question their affective self-ascription?

(To avoid red herrings, let us imagine the following case: James comes to therapy because he can't get on with his work. During the therapy we discover he is often very harsh on himself. Because of the therapy he has a change of heart and stops being so harsh on himself. (This is what is meant by saying that he is now not so 'internally divided'. Super-ego and ego become, to some degree, united, and to that extent the superego ceases to exist as a separate 'intrapsychic entity'.) Sometimes he now gets on with his work better (since he's now not spending his time in rebellion against a harsh superego); sometimes he doesn't (but doesn't care about it so much).

The issue is not whether he has a change of belief over whether it matters him not getting on with his work, but whether he has a change of heart about it. If he avows a change of heart, but we see no evidence of this changed self-relation in his behaviour, then we don't take this supposed change of heart to be genuine. Similarly, to offer a comparison case: if we are dealing with intellectual insight into non-personal matters (e.g. into probability theory), and someone says they have the insight, but then constantly get the sums wrong, we say they are wrong about having the insight.)

Some insights are hard to hold on to. Emotional insights may stay with us a while, but we may then lose them. I am not denying this - although I would deny (on logical grounds) that one could have an emotional insight for, say, just one second. (The grammar of 'emotional insight' shows it to be constitutively woven into the fabric of our affective and behavioural lives, not to consist in something that could be captured by a photograph.) (The relevant philosophical discussion here is Wittgenstein's on how understanding can be something that can obtain in a flash, but which nevertheless consists in distributed and extended behavioural dispositions.) What I am denying is that it is just obvious that we may keep the emotional insight intact, yet still engage in the behaviour.

I do here, and now, wish to make a partial rapprochment with Smail. For whilst it seems to me that insight is important, it is not, I believe, best understood as instrumentally important. And perhaps a more charitable way of reading Smail would be as not criticising the importance of insight per se, but only criticising a certain theoretical view of why it is important. To the extent that we can identify a form of insight that can be ontologically hived off from (individuated without reference to) our behavioural dispositions, to this extent this form of insight is largely therapeutically irrelevant. But to the extent that we can identify a form of insight that is simply of a piece with changed behavioural dispositions, and so much therefore to the very essence of therapeutic change, it is clearly not instrumentally effective. (If we do not have to do with two separate things in the first place, then we can't think in terms of one thing having an effect on something else.)

1. This is the idea that there is no valid qualitative distinction between anxiety neuroses and regular psychological distress. I am not entirely confident in ascribing it to Smail. It is an impression that I get from reading his writings, and it is of a piece with what in critical and community circles is a worthy attempt to destigmatise and normalise psychological problems. (I personally would rather we pursued this destigmatisation campaign through admitting that we all suffere from some degree of neurotic as well as non-neurotic difficulties, rather than making out that neurotic difficulties are just the same as non-neurotic difficulties, since this way we wouldn't have to swap ethical gains for clinical losses.) Here is something that he writes:

Freud's view that the point of his procedures was to replace 'hysterical misery' with 'common unhappiness' is frequently quoted. What he actually said, in the form of an imaginary dialogue between a patient and himself, was as follows:

Why, you tell me yourself that my illness is probably connected with my circumstances and the events of my life. You cannot alter these in any way. How do you propose to help me, then?' And I have been able to make this reply: 'No doubt fate would find it easier than I do to relieve you of your illness. But you will be able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness. With a mental life that has been restored to health you will be better armed against that unhappiness.1

Now this is about as direct and frank a statement of our problem as one could wish to find. 'Illness' is 'connected with' the 'circumstances and events' in the sufferer's life, and it is acknowledged that fate would relieve it better than therapy. Even so, with the kind of charming sleight of hand which is so characteristic of Freud's style, it turns out that the 'illness' can be relieved through a 'transformation' into common unhappiness.

But let's not quibble. Let's accept that Freud could reasonably claim to be altering the person's perception of his or her predicament such that a neurotically distorted view of it becomes simply the experience of an unavoidable unhappiness.

Now I confess I really don't understand this - and my suspicion is that this is because it is not truly intelligible. First, why should it be described as a 'sleight of hand' for Freud both to admit that fate or circumstances may do better at removing neurotic distress than he himself, and that if a patient came to see him, they could hope to do the (perhaps albeit slower, more painful) psychological work needed to transform neurosis into ordinary misery? Aren't there several different ways to skin a cat? And if we don't have access to the effective big skinning knife of fate, then we can at least work away with the slower little scalpel of analysis.

(Recall the oft-quoted statistics for factors efficacious in 'successful' therapeutic outcomes (I put in the scare quotes because clearly there may be many different criteria for success, and it may well be too that different criteria would result in different factors being found important): the largest part being factors external to therapy in the life of the patient, then alliance and allegiance factors, finally technical factors. Recall too the other oft-quoted statistics to the effect that therapy of whatever modality tends to 'work', compared with none at all.)

Next, what does Smail mean by:
Let's accept that Freud could reasonably claim to be altering the person's perception of his or her predicament such that a neurotically distorted view of it becomes simply the experience of an unavoidable unhappiness.

For one thing, why the 'unavoidable'? Let's recall some of the basic characteristics of, say, anxiety neuroses. James doesn't want to go to his boring job, and doesn't want to confront his miserable boss about her behaviour. But he is terrified of the consequences of leaving the job or of talking to his boss. Maybe she reminds him of his mother who always terrified him. So (according to a typical Freudian account, which is what we are talking about here) his anxiety gets displaced onto something else at work. Perhaps instead, by 'symbolic substitution', he becomes agoraphobic or acrophobic about the lift to get to the office. Or let's make up another example: Anna struggles with the natural human dilemma of feeling cross with her partner but feeling terrified of him leaving her if she expresses this (as her father left her and her mother). Perhaps much of this struggle remains unconscious; who knows. Anyway, she ends up becoming depressed: it becomes safer to not have feelings at all than to risk having angry ones which might have catastrophic consequences.

James or Anna's therapy would, we might imagine, involve two aspects. On the one hand, they develop insight into the real objects of their fears, together with an understanding - insight - arrived at through the experience of a new relationship with a therapist who is highly attentive to (and hence able to resist) their transferences - of their origin. On the other hand, once aware of their real fears, and once these have been understood and discussed in a way which feels tolerably safe, they can be addressed. These real fears are still real. We all fear being left; people are left by their partners, and this does hurt. But, yet, they may have been exacerbated by their anxiety neuroses.

Or perhaps we work with a broader, less Freudian, more existential, notion of neurosis. So we accept that our mood and sense of meaning is sustained by our direct, praxical, meaningful, future-directed, engagements with our environments and with others. And sometimes the going gets tough in these environments. And so we turn inwards, develop strategies to deflect painful emotions, develop avoidance strategies. We ruminate to try and solve our problems. We cut ourselves off from others in order to prevent being hurt by losses. We cut ourselves off from our own feelings (and so get left in emotional limbo) to avoid experiencing 'unbearable' affects. And in the process we unwittingly cut ourselves off from whatever sources of meaning there were in our lives. (Better to have loved and lost, than... etc.) Defence mechanisms (like drug use) may work in the short term, but in the medium term, they suck. They sap the life from us worse than ever. (People who tell us glibly that 'we all need our defences' are, to my mind, to be treated with suspicion (by the way, Smail doesn't say this!). Do they realise how much more damage these defences can do to the soul than can the problems they were set up to help us avoid?)

Conclusion

I hope I have made my case; please let me know if I have done an injustice to Smail's arguments. I want to conclude by commenting on one final thought that I believe is implicit in much critical psychological thinking (including other broadly Marxist strands, e.g. community psychology). This can be approached by tackling the idea that psychological disorders are overwhelmingly caused by environmental factors.

I don't want to deny that; that would just be empirically dumb. (Although let's all recall the (admittedly relatively smaller number of) psychologically well ordered, happy or miserable as they may be, people who work in shit jobs, and the miserable neurotic people who have all the wealth we could have dreamed of.) I want to comment instead on the way the discussion gets framed. The point I want to make is, I believe, easily misunderstood. And it comes out of a rather ad hominem observation I have made - about the apparent underlying depression of some of the community and critical psychologists I have met. So, well, don't take me too seriously here...

Martin BuberMartin Buber wrote, in I and Thou, and in his admittedly fanciful way, that
So long as the heaven of Thou is spread out over me, the winds of causality cower at my heels and the whirlpool of fate stays its course.
What I take it Buber was getting at was the way in which treating people just as if they were objects on which material or social or economic forces act, as merely causal nexi, prompts a particular and limited vision of the human, and a particular response from the recipient of such treatment. I am not saying, of course, that human beings and their feelings are not subject to causal forces; that that vision is wrong. Nor am I saying that I believe that human beings can somehow magically intervene 'from the outside' in the causal order of things. There are of course, and in fact, a lot of things that I am not saying. What I am saying, however, is that there is more to be said than the Marxist psychologist seems prepared to say. To think of oneself as only a recipient of forces, rather than as an agent or as a subject, is to risk submitting to powerlessness and helplessness, to risk creating rather than being an active force resisting depression. To see ourselves under the aspect of causality is to risk seeing ourselves as a puppet of unstoppable fate. To see ourselves under the aspect of intentionality is to situate ourselves, instead, in an order of meaning, purpose, agency, subjectivity. Neither aspect is, it seems to me, the 'right' description. It is no more 'right' or 'wrong' to see what is in the back of our wallet as a single rectangle of flattened out wood pulp, or as an exchangeable bill worth one dollar. But if we are to figure out how to go about this business of getting by in the human world, it will be worth our while reminding ourselves of the latter meanings lest they get lost from view.