On Saturday I was at the UKCP Research Conference to present my paper “Whose line is it anyway? Voice, presence and meaningful choice”. This paper in a nutshell was about trying to think about how psychotherapy research practice is affected by some of the current policy trends and to begin to point to how this might impact counselling and psychotherapy in practice.
For me counselling and psychotherapy, in part, is about creating a space to be thoughtful in, to be able to think through desires, wants, needs and behaviours. This often encompasses risks, particularly when what we might begin to talk about is painful and difficult to acknowledge. An extreme example is when working with memories and emotions that link to unconscious thoughts; which on one level we would rather keep unconscious, but on another we recognise that these are likely to be contributing to our suffering in the world. In practice this often means that the starting of therapy represents a kind of void where we know something is not ‘right’, but we can not put our finger on what it is. At times we me may be certain about what the ‘problem’ is and have a clear idea of what to do, at these points thoughtful practice can help us think about this and may even lead to some surprises.
In many ways my paper was trying to understand whether current policy trends support or prevent this. Increasingly and quite rightly talking therapies need to be able demonstrate their effectiveness – that they do what they intend and claim, for instance, reduce distress, help people to live ‘better’ and more fulfilling lives. Tensions arise however when this ‘effectiveness’ becomes defined in narrow terms. For instance, many researchers have challenged how talking therapies are treated similarly to drug treatments where a specific ailment is addressed by selecting the correct treatment. These researchers however go to great lengths to argue that talking therapies do not work in this way and that the experiential world of the client, the therapist and how they relate to one another creates a particular dynamic that is not captured through the so called medical model.
I wanted to think about this through some major social trends. The medical model represents a one-size fits all model in which everyone gets ‘prescribed’ a treatment according to certain criteria; often related to the ‘symptoms’ that one possesses. This represents a kind of mass production model where “you get what you are given” and in terms of the NHS “what you deserve”. Drug treatment represents the clearest example of this where a medical practitioner listens to your symptoms, makes a diagnosis and prescribes a suitable medication. This kind of support can be invaluable for people, but unless one’s problems are temporary the drug will not help you to understand why your symptoms have emerged. This drug-treatment model follows very closely the liberal economic model where a market gives you what you need and what you need is much the same as what everyone else needs.
An alternative model is the relational model where the client is not diagnosed, they do not get prescribed a particular treatment and they are not treated as though they are diseased. This perspective looks to the uniqueness of each individual and attempts to respond to this by creating a relationship that is helpful. This model in contrast to the drug treatment model follows the post-Fordist economic model, this moves a way from something imposed by an expert, to a more collaborative model involving a personal, customisable and configurable system of relations.
The relational model might seem a positive development; however it seems to place increasing significance upon the role of the individual whereupon all a person needs to do is make the ‘right’ choice in terms of the various kinds of treatment options available. Therapists’ responsibility within this is to provide the right kinds of information for clients to be able to make a ‘good’ decision. This is situated in a larger context where mental illness is increasingly being considered in economic terms through lost work days and through the impact on benefits. In these circumstances peoples’ distress and suffering is sometimes considered to be the result of faulty thinking and the role of therapy is to correct this (see CEPMHPG, 2006). From my experience of working with people who have suffered or who are suffering from anxiety and/or depression this is a simplistic reduction. What this reflects is a situation where it is increasingly seen as unacceptable to be ‘incapacitated’ (economically), Galvin refers to chronic illness in particular:
it is becoming less acceptable to…remain in a[n]…incapacitated state: it clashes too uncomfortably with the image of the ‘good citizen’.
People who are experiencing mental distress are facing further difficulties in that in this optimistic post-Fordist model individuals are seen as being the architects of their own happiness and presumably of their own misery and that it is their sole responsibility to address and overcome this in order to attain ‘happiness’. This is summed up by Ferguson as a:
relentless optimism about the capacity of individuals to improve their own mental health…combined with a contempt for “pessimistic” ideas or theories which suggest that this capacity might be subject to any constraints whatsoever, whether these be the effects of negative childhood experiences such as abuse or neglect…or of structural oppressions, such as racism and sexism.
This strikes me as creating a situation for even greater levels of isolation and alienation that can leader to increased suffering. In my view counselling and psychotherapy provide an alternative by challenging, questioning and exploring ideas around:
- self and others
- responsibility, individual and collective
- the historical and cultural dimensions of suffering
- conscious and unconscious processes
You can view the presentation for my paper here – I’m hoping to post some audio to go with this at a later date.
CEPMHPG (2006), The Depression Report: a New Deal for Depression and Anxiety Disorders (Centre for Economic Performance’s Mental Health Policy Group, LSE).
Ferguson, I. (1997) ‘Neoliberalism, happiness and wellbeing’, International Socialism: Neoliberalism, happiness and wellbeing, 117. <available from: http://www.isj.org.uk/?id=400>
Galvin, R. (2002) ‘Disturbing notions of chronic illness and individual responsibility towards a genealogy of morals’, Health, 6:2 pp.107-137