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REVUE DE PSYCHIATRIE

Beyond the paradigm war : good psychotherapy is sociological

dimanche 12 août 2012.
 

Par Petra Bueskens.

As someone trained as both a sociologist and a psychotherapist, one of the key problems with the Illouz/ Levy, Palgi-Hecker and Rolnik debate aired in Haaretz last month is the “group think” or disciplinary policing that is implicit in their replies to each other. Levy, Palgi-Hecker and Rolnik accuse Illouz of being ignorant and prejudiced, and she in turn accuses them of being defensive and hostile. There is a problem of disciplinary difference in this exchange such that their respective insights are lost to each other, rather like the connotations of words or the nuances of meaning that are so often lost in translation. A good example is where Illouz’ critique of the privatisation of troubles is misread as an attack on Freud or psychoanalysis in particular, where it is more properly a sociological critique of contemporary “therapy culture” as a whole. Conversely, it is true, as the psychoanalysts say, that Illouz lumps together disparate and ultimately anathema forms of therapy and thereby does a disservice both to her own analysis and to the psychoanalytic model she (mostly) addresses. Illouz writes as if there are no existing syntheses of these disciplines (perhaps it was not the focus of her article, but in light of the subject matter, it seems a curious omission). As Levy, Palgi-Hecker and Rolnik point out, the Frankfurt School of sociology were intellectually indebted to Freud and developed remarkably enduring and influential accounts of the social system using a synthesis of Freud and Marx. Interestingly, Illouz’ own intellectual debts lie most obviously here in her analyses of pop-culture and the intersections between emotions and capitalism. Numerous sociologists, including several who concurrently trained as therapists, have analysed society using the lens of psychoanalysis. Most notably : Erich Fromm, Talcott Parsons, Nancy Chodorow, Jessica Benjamin, Neil Smelser and Michael Rustin. The political philosopher Carole Pateman and various feminist epistemologists have also used psychoanalysis to develop complex and compelling accounts of the social order - including, especially, the social order of patriarchy, liberal democracy, and science. For Illouz who acknowledges Freud as the “greatest and most enduring cultural innovator of the 20th century” this intellectual or purely theoretical use of psychoanalysis is not the problem (I suspect). The problem lies rather in the contemporary manifestation of psychotherapy as a “cure all” for personal troubles. It is the mass rather than elite use of psychoanalysis and its derivatives that poses a problem. Her specific truck with therapy has been stated by a number of sociologists before her beginning with Phillip Reiff and Christopher Lasch and, more recently, by Frank Furedi. The argument runs something like this : therapy privatises feelings and troubles at the expense of politicising them. Therapy increasingly - and conveniently - blames individuals for structural injustices rather than collectively tackling the sources of these injustices (patriarchy, capitalism, racism, war etc.). Therapy also leads to undue emphasis on experts to define, manage, guide and direct “the self”. These same experts are keen to develop their client base, and so continue to expand into new fields. Consequently, new pathologies are being invented everyday and once “normal” behaviour is being redefined as illness (shyness as anxiety, sadness as depression, boisterous children have “Attention Deficit Disorder”, disoriented new mothers have “Post Natal Depression” and so on). This leads to a decline in both public opposition to injustice and to the psychological autonomy of individuals.

For the more conservative sociologists such as Reiff and Lasch there is also a related concern about the loss of decorum in the undisciplined “tell all” culture of therapy. The injunction to “let it all out”, to disclose one’s secrets and expose one’s emotions, collapses the public/private boundary and the sense of reticence that defined earlier (and, it needs to be said, more patriarchal) phases of modernity. As a sociologist Illouz is interested in how psychological language - the “psy discourse” to use Nikolas Rose’s apt expression - reconstitutes the social and shapes relations of power. In her view, psychology is a system ultimately in service of the neo-liberal, capitalist status quo ; it both mutes and redirects opposition to structures and institutions of dominance, violence and/or inequality and it typically re-directs these problems onto and into the self. The “sick individual” here introjects social pathology and identifies with it as a manifestation of his or her own psyche and, in particular, his or her own failings. She provides a number of compelling examples : Imagine that you begin couple therapy and come to the psychologist with the angry view that your selfish and uncaring husband never helps with the laundry, never does dishes, never takes care of the children. You are very likely to hear that your moral condemnation is an inadequate response to your husband’s indifference to your hard domestic work, and that this condemnation in fact prevents you from taking control of the situation and from understanding that he is only reenacting childhood scenarios of dependency ; or that your anger is the result of your own need to punish him. You would not hear from your psychologist anything about patriarchal control − as a form of social control − or about your husband’s moral character. Or this : If you explain your difficulty in keeping a steady job by citing your lack of self-confidence or a selfdestructive tendency, you will think of your workplace and the economy very differently than if you explain them by citing labor laws that make it easy to fire workers or the ruthless competitiveness of market economies.

Such an emphasis on structures, institutions and actions is not at odds (at least not by definition) with psychotherapy. One could be both a political activist - say at a rape crisis centre - and in therapy and/or working as a therapist. These are not mutually exclusive or necessarily antithetical courses of action. They are different levels of action corresponding to different domains of experience. While Illouz exhorts us to return to the public sphere with our troubles, and this is a laudable assertion in principle ; in practice the very victims of bombing, sexist violence, or mundane inequality she evokes are the least likely to speak publicly or tolerate mass exposure. Often it is grief work, individual understanding, and emotional support that is the first port of call for those afflicted by injustice or serious psychological injury. Sometimes this understanding happens in a consciousness raising group (as with feminism in the 1960s) ; at other times in a private setting with a therapist or, if one is fortunate, with an understanding friend or family member. In either case, psychotherapy may assist an individual to develop the very strengths that enable greater public participation and engagement. Moreover - and this is a critical point - everyday addictions or grief over loss are not necessarily linked to any specific political problem or injustice (unless we think of the many injustices of fate or the broader social structure of modernity that deprives individuals of meaning) ; and while it is necessary to think through the social construction of mental illnesses, this does not alleviate the suffering of the individual in the moment. As Katie Wright, an Australian sociologist who writes about therapy culture, questions : where else is a pained individual to go ? Psychotherapy offers understanding and empathy through relationship and talk ; at its best it recreates a relational world through which the patient can re-experience and re-construct his or her internal script. This, in my view, has radical potential for it gives individuals a space to reflect upon and reconstruct “the self” beyond the purview of power (their boss, parents, partner, an abuser or, more abstractly, social norms). It allows for the spectrum of fantasies, feelings, memories and emotions with a concentration on individual biography. It is a unique space that is neither public nor private and, in its ideal-typical form, allows an individual to be truly him or herself.

This is a space in which sociology is not always welcome or useful. In my psychotherapy practice, which actively incorporates a sociological perspective, (which means I do bring up the problem of patriarchy when clients speak about domestic inequity with partners ; and I do discuss the exigencies of fate, inequality, injustice and power), I have had one patient say they found this perspective de-humanising because the uniqueness of her situation was lost in the abstraction of social structure. Linking her individual circumstances to a larger “social system” made the client feel less important and therefore less valued, as if she - her internal world - was quite literally lost in the crowd. I am more careful now with introducing sociological analyses and typically wait until a client has moved into a space where s/he is not absorbed in the immediate pain and/or details of their own story. It’s not simply that sociologists have something important to offer psychotherapists, then (clearly they do), psychotherapists also have something to offer sociologists. As the famous sociologist/psychoanalyst Erich Fromm put it, “what psychoanalysis can offer to sociology is the knowledge - though still imperfect - of the human psychic apparatus, which is a determinant of social development alongside technical, economic and financial factors, and deserves no less consideration than the other factors ...” If we take this seriously then psychoanalysis - including both its developmental and drive theories, and more recent “relational turn” - offers us a theory of human subjectivity that provides an important piece in the puzzle of human motivation and action. This is an historically and culturally specific conception to be sure - and therefore contingent on the social system, including family system, from which it derives.

However, and this is precisely my point, if we want to understand human action, agency and meaning, both perspectives are required - we need both “structure” and “agency” to use the sociological parlance - to do justice to human experience. We need an understanding of society and the individual, and a recognition that the relations between the two are mutually constitutive not unidirectional. Importantly, one does not trump the other and, if it does, we end up with a truncated understanding of the human condition. Despite their differing foci, and associated theoretical and practical commitments, psychoanalysis and sociology are complimentary paradigms. In addition to the privatisation of suffering, Illouz’ second key issue with therapy culture is with its role in collapsing morality (although, interestingly, she notes that this is also its key strength since it allows individuals to question oppressive traditions). Psychology involves a secular worldview where anger, infidelity, impulsivity, alcoholism and the like are redefined as “symptoms” or “disorders” rather than moral problems. She cites the example of a patient from the television series “Be Tipul” who has been involved in bombing Palestinians. There is a gap in his morality that the therapy (or perhaps just the therapist ?) cannot address given the therapeutic injunction to be understanding and non-judgemental. I have not seen the Israeli version but in the US re-make “In Treatment” it is precisely Alex’s (Blair Underwood) inability to voice his buried guilt that constitutes the core of the therapy. Early on Dr. Paul Weston (Gabriel Byrne) recognises that Alex has an exterior of bravado that conceals a sensitive and, in many respects, guilt ridden core. He acts blasé about accidentally killing Iraqi school children on one of his missions, but it becomes increasingly evident that this is not the case. In other words, it is not the absence of guilt that is the problem ; it is the transformation of guilt from an unconscious (repressed) feeling into a symptom - extreme exhaustion, problems in his marriage and so forth. Admitting his guilt - and, by association, his moral culpability - is the crucible on which the therapy will succeed or fail. This requires that Paul, his therapist, tread a very careful line - to instantly moralize would be to sabotage the therapy and therefore foreclose the very insight Alex seeks and avoids ; it might also lead to Alex becoming overwhelmed with repressed content (which is, in the end, what happens) ; however, to ignore the moral problem would be to fall for Alex’s lie (to himself) and collude with the symptom. Both Alex and Paul wrestle with this problem through-out the entire treatment. The point is : therapy can and does address moral lacunae - I have certainly challenged clients to think through moral or ethical deficits and, in turn, used supervision to reflect upon my own. Alternatively, in situations of powerlessness and abuse, it is often the case that individuals (particularly women) blame themselves. This too I have challenged in patients, albeit carefully. To challenge established defences, especially where one’s life is built around them, is risky business. To suggest, as Illouz does, that this is beyond the purview of therapy is incorrect and supports the assertion made by Levy, Palgi-Hecker and Rolnik that her conflation of widely disparate therapies - New Age, CBT, pop-psychology, self-help, life-coaching and psychoanalysis - means she can’t see the trees for the forest. While many contemporary “quick fix” treatments may in fact conform to Illouz’ cynical rendition, this is most definitely not the case with psychoanalytic or psychodynamic therapy. Third, Illouz makes a critique of psychology and, by association, therapy as both an industry - linked to powerful economic interests - and a worldview. She sets this against a sociological world view which is founded in the recognition of a “social unconscious” that is defined by power and interests. She claims to identify the very social forces that operate outside psychologists’ awareness drawing a strategic analogy with analytic practice. While I am in broad agreement with her argument here, she fails to consider how psychotherapy is indeed an outcrop of the very social structure she sets up as its opposition. In this she denies contemporary innovations in sociological theory. Let’s look at this more closely. While it is true that sociologists emphasize the social or collective meaning of individual actions, and the power that lies behind them, it is also true that there is an entire tradition concerned with individual action. As the great sociologist Max Weber observed, the “fact greedy gullet” of structuralist sociology with its reliance on statistics and social facts, often missed the meaning of social action especially subversive social action. It is this that inspired Weber, and many key sociologists after him, particularly in America, to stress agency as integral to the sociological project. It is for this reason too that perhaps the most well-known structuralist after Durkheim, Talcott Parsons, developed fruitful links with psychoanalytic theory in his own work. For Parsons psychoanalytic theory contributed significantly to an understanding of human motivation, and provided a developmental explanation - specifically in the theory of the super-ego - for why individuals conform to social norms (and the implications for those who don’t). He also acknowledged that while sociologists stressed the rational reasons for action - power and interests for example - psychoanalysis identified and helped us to understand the “irrational” dimensions of human motivation. Psychoanalysis better than sociology explains why people sabotage themselves ; why they fail to act on their “best interests” ; why love and reason make uneasy bedfellows ; why unfinished business in our families of origin can appear again and again in our adult relationships and so on. Another key point here is that structures and institutions are themselves socially produced concepts as much as they are “objective things”. They are derived through sociological study, they are not - as Durkheim was at pains to say in his establishment of the discipline - observable to the naked eye. Structures of class, gender, race, ability and so forth are discerned (and therefore also created) through systematic study ; they are not simply a mirror reflection of “reality”. Sociology is a reflexive enterprise that constructs as much as it reflects the social order. This is precisely what is meant, in more recent sociological theory, by “reflexive modernisation”. We are now at a stage in our collective social development where that abstract entity we call “society” constantly reflects, acts upon and transforms itself. In late modernity, we are not only in the business of transforming nature to build culture, but also transforming culture to rebuild culture. This, in the words of the sociologists Anthony Giddens and Ulrich Beck, is our “second modernity”. One of the most interesting and compelling directions of the “structure/agency debate” in the light of this theory is that structures are themselves dissolving. Wherever we look - the economy, the family, marriage, the nation-state, the labour market - we see accelerated change and a new fluid, mobile, reflexive, globalised, “post-traditional” order. Ulrich Beck and Elisabeth Beck-Gernsheim identify a process of “individualisation” running through this change such that our very collectivity is, paradoxically, defined by individualism (not to be confused with freedom). So, the solidity of structure Illouz speaks of is itself a chimera. Structures are dissolving and reformulating in contemporary society. As a result we are required to make choices about our identity, education, religion, partner, occupation, place of residence, diet, whether to have children or not and so on. These are not handed to us in the form of non-negotiable traditions that specify and constrain our place in the world. It’s not only that people want to “get a life”, then, it’s that increasingly they have to. We are, in turn, required also to make sense of our biographies without (in most cases) the signposts or certainty of tradition. So, where does psychotherapy fit into this liquid social structure ? Its emphasis on self reflection, on meaning and truth, on realising one’s potential, on honest appraisal of one’s life circumstances and so on, is uniquely suited to - and indeed produced by - the demands of modernity. If we are increasingly required to “get a life”, and feel confused, uncertain or undermined in our ability to do so, psychotherapy - not only for the sick but also for the well - can be of great benefit. If we are “stuck in a rut”, grieving a significant loss or, like our “In Treatment” protagonist Alex, in an unconscious symptomatic struggle with ourselves, psychotherapy can and does help. This is somewhat different to the immediate treatment of severe mental illness or trauma, where therapy is, of course, also useful. However, Illouz is spot on with many of her points : the problematic nature of redefining normality as illness ; the mainstream therapeutic emphasis on “happiness” rather than truth ; the medicalisation of suffering ; the ongoing importance of public expressions of discontent ; and, at the more theoretical level, her contention that the neutralisation of the emotions of anger and sadness constitute a political problem (assuming that anger is a consequence of injustice rather than the continuation of a pattern of dominance). What she doesn’t see, or perhaps realise, however, is how in agreement many, if not most, psychoanalytically oriented practitioners are with her argument. She has largely ignored a growing body of literature by those who challenge these very same problems, albeit from within a psychoanalytic paradigm (I’m thinking of Darian Leader and Robert D Stolorow on sadness ; Allen Frances on the expansion of mental illnesses in the DSM V ; Jonathan Shedler on the benefits of psychodynamic therapy as opposed to pills and quick fixes). Indeed, the much maligned field of psychoanalysis - that is, in the world of psychotherapy practice rather than the ivory towers of academia - is fighting a losing battle against the bureaucratised, managed care model that prevails in most western countries today. It is precisely its depth, complexity and time commitment that makes psychoanalysis incompatible with contemporary conceptions of “the cure”. It is unlikely Illouz understands the full resonance of what Levy, Palgi-Hecker and Rolnik mean when they say, Prof. Eva Illouz certainly has the right to join the chorus of those who are not interested in psychoanalytic thinking, but not to turn her blissful ignorance in the field into a tool for a hatchet job on it. This, too, is a matter of ethics. Psychoanalytic/dynamic clinicians are on the defensive (ironic, given Freud invented the concept) precisely because this theory and its associated practice is beyond the infotainment, quick fix, heavily medicalised, pop-a-pill, happiness diatribe that so saturates popular psychology and, in a less crude form, so many manualised brief therapies. To be conflated with this is rightly offensive to psychoanalysts, perhaps as much as it would be for a sociologist to be called ignorant in her chosen field of research.

Petra Bueskens lectured in Sociology at The University of Melbourne and Deakin University in Australia between 2002-2009. She concurrently trained as a Psychotherapist and has been in private practice since 2009. She is the incoming editor of the new Psychotherapy and Counselling Journal of Australia and the book Mothering and Psychoanalysis : Clinical, Sociological and Feminist Perspectives, forthcoming with Demeter Press in 2013 (an excerpt from Eva Illouz’ Saving the Modern Soul is included in this book).


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