Saturday, 25 October 2014

against objectivist understandings of psychotherapeutic action

Is my psychotherapy working? Or perhaps it's just the light getting brighter now in the springtime that makes me feel better?
Was my psychotherapy really working, or was it just that I had some hope for a while that here was something, finally, that could help me? Hope that has now been spent, now that I'm back facing the same old depressing realities of the same old life and the same old misery-generating nervous system with which to encounter it?
Does psychotherapy work better than a placebo? Is it a placebo? Does psychotherapy work?
Well, perhaps psychotherapy does sometimes work. But, now: what works and for whom? And: how does it work?
Depressed patient complains to therapist: "This just isn't working for me! Why aren't you helping me?"
In clinical psychology we ask and encounter such questions all the time. We tend to simply assume that they are good ones. The suggestion that they are not straightforwardly, or at least not obviously, good questions - the suggestion I will be pursuing here - can seem simply preposterous. What more important questions, what more natural an assumption, could there be? Why would we waste precious resources, the state's or the individual's or our own, on something that doesn't work? That inner interlocutor of mine - an uppity clinical psychologist with his empiricist head-set on - gets really impatient with me when I even raise such a question!

So let me start by setting out my psychotherapist's stall. I claim here that the idea of psychotherapy working (or not working) involves something of a category mistake. To be sure, good work may be being done in the therapy (by you, by me, by both of us together), and I may find helpful something my therapist says or does. And there is surely room, at particular junctures, for explicitly causal talk in relation to subjectivity: thus it certainly makes sense to say that my mood can be caused to improve or drop off by taking a certain pill, or you may say something that causes me to become anxious. And in relation to the 'what works for whom from whom?' question, well: it may be that some therapists' patients typically make more progress in therapy than other therapists' patients. It may be that therapists who have certain beliefs about therapy, including that it works in this or that specific ways, and whose beliefs are reflected in their actions and utterances in the therapy room, have patients who do better or worse than those of other therapists with different beliefs and practices. (But, wait, don't give up now saying grumpily: well, that's all that I meant by saying that therapy works in this or that way... Please! Have a little patience, it really might still be that something important is at issue here!) Yet I still want to claim that if psychotherapy has effects this is all for the bad, because the very idea of engaging in psychotherapy is engaging in an encounter with someone in which I aim to become more of an active agent and less of an affected patient. It may be that certain therapist practices offer me more of an opportunity to reclaim agency. But surely no one would want to describe the offering of an opportunity to someone, and their taking one up in this, as the causing of an effect in them.

There are contrasts between our concepts of actions and events, doings and happenings, undergoings and undertakings, an agent and a patient. These conceptual contrasts surely contribute essentially to the sense of the contrasted concepts. Martin Buber captured something of this when he wrote: '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.' (Naturalists often suppose that we can only avoid appealing to supernatural elements in our understanding of what we are if we somehow account for agency in terms of causality and deny that the everyday conceptual contrasts run particularly deep. To my mind that seems topsy-turvy: the only reason one might be spooked by agential language is if one assumed it was somehow after all a matter of causality in the first place - and then it would look like one has to do with spooky causes beyond the normal range (which then have to be reduced to non-spooky causes).) At any rate: we have a natural distinction between being caused to do something, and doing something, as we say, 'of our own free will'. And naturally, as an English speaker, I want to respect this, and also to point to the essential fact that in psychotherapy I am healed to the extent that I become more of that agent that I can be, something that I must do rather than something that I can be caused to do, something that I do to the extent that I take courage and relinquish my defences. You may point them out to me, but I have to relinquish them. That is something that I must actively do: it cannot - and here the cannot is logical rather than empirical - be done to or for me. (It can't be done by giving me a disinhibiting compound (cocaine for example): I may then feel more confident, to be sure, but this is not really a growth or change in who I am (since the character who I am is still the person with those habitual defences which have just been temporarily put out of action by the drug.)) I take advantage of your solicitude, I gradually trust you, and coming to know what in my perception is you and what is my transference is a bloody great mess. But this is the thing: the psychotherapy does not work on me; rather: I do work (with you) in my psychotherapy.

In a recent paper Jonathan Lear tells us, propos outcome studies in psychotherapy, that the aim of psychoanalysis is psychoanalysis, and that nothing achieves that aim better than psychoanalysis. Lear understands psychoanalysis to be about self-understanding undertaken for its own sake: this involves us willingly becoming more of a person - where 'person' means: a being whose being is at issue for it, a self-interpreting animal in Taylor's phrase. Lear is both saying something important, and telling a joke (a la Wittgenstein). But to be a bit un-funny about it for a moment, there's a sense in which we don't achieve psychoanalysis by doing psychoanalysis. We don't pluck the chicken by plucking the chicken. Or, better than 'don't': talk of means to ends is here out of conceptual place. We simply have an activity that is properly undertaken for its own sake. Trying to understand oneself better is not best taken to be the cause (or not the cause) of understanding oneself better, for unless something is getting in the way of the trying, the trying simply is, one could say, the act itself.

Consider the saying in psychotherapy: 'you only get out of it what you put into it'. Jon Frederickson tells his patients 'I can put in 100% of effort, but if you put in just 20% you will only get a 20% result'. I suggest that these are 'grammatical' rather than 'empirical' remarks. It is after all pretty hard to know what it would be to measure any kind of relationship between effort I put it and result I get when it comes to psychotherapy. (If you were not offering psychotherapy, but instead some kind of behavioural or educational or occupational program, I can imagine trying really hard to get up each morning and go for a run, under the belief that this by itself will improve my mood (perhaps my explanation makes reference to hormones, neurotransmitters, endorphins etc.). Here we can readily imagine measuring a relationship between the effort I make (the number of runs I undertake) and my change in mood.) If you do actually deploy your agency, if you open yourself to my gaze, then you are being active and open - which is in fact precisely the aim of psychotherapy. The aim is the same as the method. There truly is a sense in which 'only you can fix your internal problems'. I cannot fix you, not because I am an inept therapist, but because my doing anything to you would be precisely an interference with your agency, and what we are working towards is a decrease in the extent to which you are a patient, and an increase in the extent to which you are an agent. (This is why hypnotherapy is simply a completely different animal than psychoanalytical psychotherapy, and not a different method towards the same end.)

Some people try to do justice to the idea of subjectivity - the idea of the human as constitutively self-interpreting - by suggesting that the problem I'm describing here comes from deploying a linear, non-loopy, understanding of causality in the human situation. (You know how it goes: the idea is that you can get virtuous circles of causes and effects when we consider the way that our interpretation shapes our experience and action and vice versa - in other words if you model human agency and subjectivity as a dynamical system a la cybernetics.) This, I suggest, actually makes matters much worse - since it offers some kind of passing acknowledgement to the intuition that there is something wrong with the very idea of therapy working or not, only to reinforce and cover over the actual problem. The actual problem has to do with the language of causality and its opposition to agency. For whilst the human nervous system, coupled with the body and the proximal environment, is undoubtedly a dynamical system, the human being in its humanity is not any kind of system at all. A system has components in causal interaction. But contra the constitutively depressogenic vicious circle models of CBT, the human being in her full agency and subjectivity is not self-constituting in some kind of recursive causal manner. Rather she is self-constituting in a far more intimate manner - in that my self-understanding does not cause my self to be a certain way; rather my self's being a certain way consists in my understanding myself thus.

So here is my thought. Clinically we can, I submit, intuitively sense that a question like 'is my psychotherapy doing me any good?' is simply off. It is a depressed person's question. The depression shows in the question's form - in its diminishment of agency. The question is not: 'Is my psychotherapy working?' but rather: 'Does this person offer me an opportunity to understand myself better? Do they afford me the requisite recognition such that I can meaningfully here undertake that project of opening myself, of becoming who I am?' The entire register of this question is different. Unsurprisingly someone's 'theoretical orientation' is not entirely pertinent here; what matters more is probably the therapist's relation to their theory (does it enhance or diminish their ability to offer their patient humane recognition, to hold them to account, to invite them to rise to the challenge of being and becoming themselves? etc.). Can they help me see my defences, habits, 'safety behaviours', more clearly - can I recognise myself in the mirror they present to me?

The conflation of depression with sadness is a depressive conflation. Depression is a state we are in; sadness is how we are now moved and not a mood. The CBT practitioner's models of the mind as a causal system to be intervened in is also a depressive modelling. Coming to psychic wellness is coming to fuller agency and enriched subjectivity. Freud and Buber can agree on this: where It/id was there I/ego will be. Id is by definition unintegrated drive and desire. Thus unintegrated id is indeed a domain of happening rather than doing - since the ego is, again by definition, the domain of agency and subjectivity. But when the heaven of Thou is spread out over me, and when I accept the responsibility of its calling, I become what I am qua I. This is us working together in therapy; it is not therapy working on me. Overcoming depression, living in ongoing connection with truly integrated good internal objects: that is just what being a true subject means. I have to maintain this contact: it isn't something that can be done to me.