The Making Of Psychotherapists
An Anthropological Analysis
James Davies
First published 2009 by Karnac Books Ltd.
118 Finchley Road London NW3 5HT
© James Davies
The moral right of the author has been asserted.
All rights reserved. No part of this book may be reproduced or utilised in any form or by any means, electronic or mechanical, without permission in writing from the publisher.
British Library Cataloguing in Publication Data A C.I.P. is available for this book from the British Library.
ISBN-13: 978-1-85575-656-4
The process of writing a book is rarely free of all difficulty. To the following people I owe a great debt of gratitude for helping me through the more demanding times. I first wish to thank Professor David Parkin for his kindness, goodwill, and invaluable guidance, as well as for providing me with the priceless example not only of how a scholar should work (but also, unbeknown to him) of how a scholar should be. What a precious model he provided. I am also greatly indebted to my discussions with Dr Matias Spektor—a most dear friend and always a positive force behind the scenes. Important others who challenged and/or helped me were especially Dr Ben Hebbert (a true companion), Dr Audrey Cantile, Dr Elisabeth Hsu, Professor Wendy James, Professor Roger Goodman, Dr Maria Luca, Professor Tanya Luhrmann, Professor Andrew Samuels, Professor Peter Fonagy, Joe Yarbourgh, Rob Waygood, Professor Roland Littlewood, Dr Adrianne Baker, Dr Simcha Brooks, Professor Richard Sholzt, Mark Knight, Nancy Browner, and, more recently, Rev James Wilkinson. To all of you I offer my deepest gratitude. Finally, I owe especial thanks to Dr Karem Roitman who gave me the great benefit of her close reading of the text, her sensible advice, astute commentary, as well as her tireless encouragement and support.
I must also thank the training institutes that allowed me access to their staff and students, and all the interviewees and informants who kindly gave up their time for the benefit of this research. I wish to thank for their assistance the librarians at Regent's College
School of Psychotherapy and Counselling, the Institute of Psychoanalysis, Oxford University, Senate House (University of London), Cambridge University. My gratitude also to my colleagues and students at Roehampton University, and especially to Professor Del Lowenthal for his constant backing and encouragement.
Financial help for this book came through the generous assistance of the Equity Trust Fund (John Fernald Award), and from various sources from St Cross College and the University of Oxford —to all these benefactors I am greatly indebted. I also owe deep gratitude to the staff and members of St Cross College, Oxford, whose kind and stimulating company (often during a lunch) offered solace during the dips in research.
Finally, I wish to thank my parents and family for their support, encouragement and love. If this book is to be dedicated to anyone at all, then let me dedicate it to them.
In this book I shall analyse from an anthropological perspective the training of psychoanalytic psychotherapists. I undertake this anthropological task since psychotherapy not only constitutes a clinical practice, a professional association, and a way of making a living, but also a moral and cultural community with wide social influence and standing. If we wish to study how the values, practices, and knowledge of this distinct community are maintained and reproduced over time, we must investigate the sites, the training schools, where these cultural forms are transmitted. In this book I offer a detailed survey of the hidden institutional devices used in psychoanalytic training to help reproduce this world of shared practice and meaning. I ask why and how such devices are used, I discern their meaning and consequences, I explore how they profoundly alter the outlook of trainees and practitioners, and finally I show how they shape the fortunes and functioning of the therapeutic community itself. By taking the reader by the hand through the core stages of therapeutic training, while at the same paying close attention to what trainees do, say and feel as they pass through these stages, we will see how professional training not only grooms trainees as practitioners, but as specific types of persons who also become the main agents of community maintenance. We will see how trainees are coaxed into supporting an avowedly secular enterprise that can offer rewards (i.e. a new orientation to life, increased status and a deep sense of belonging) reminiscent of certain political or religious movements; an enterprise
which also advances behind its professional fagade a robust 'political' and 'ideological' regime of wider social ambition and significance. We will see, then, how these training institutes, or what I refer to as institutions of affirmation, work to create practitioners who will sustain the values and hegemony of the psychoanalytic tradition itself, usually vis-a-vis other therapeutic institutes and schools. Whether institutes are successful in their aims, and whether these aims are actually proving to undermine the status and standing of the profession itself, are other important questions I shall explore.
This book, then, is not only written for social/cultural anthropologists interested in the new field of 'professional socialisation' (the study of how professional institutions transform persons and social practices, as well as create social structures), and for psychotherapists who wish to understand why their community is divided internally as well as set against more powerful social institutions (medicine and academe), but also for current and prospective students of psychotherapy who wish to understand the formidable institutional forces to which they are invariably subject; forces which leave their inevitable imprint not only upon their clinical/professional practices and beliefs but also upon their deeper subjective selves. Finally, it is hoped that for those with a general interest in psychotherapy this book will offer a stimulating introduction to the behind-the-scenes features of this alluring professional world.
Anthropology of Professional Socialisation
Studying how powerful institutions (training or otherwise) transform the subjectivities of those individuals passing through them has always had an important place in anthropological enquiry. As this book therefore falls within this established field of study, let it first be seen as providing an example of how this particular species of social enquiry proceeds. By reviewing some of the work already written in this area to familiarise the reader with this existing research, not only will we see the relevance such work has for understanding psychotherapeutic training, but we will also uncover the central methods and deeper aims underpinning this book.
To start, from the early days of the American 'culture and personality school' (Bateson and Mead 1954; Benedict 1934; Kardiner 1939) to the more recent British work in the anthropology of learning and cognition (Tyler 1969; Dougherty 1985; Bloch 1998) there has always been an anthropological interest in how individuals adopt the cultural beliefs and practices of their specified group; beliefs and interests that ultimately come to guide their lives in particular and predictable ways. While most of this research has admittedly focused on how children are socialised into their social group, a smaller collection of anthropologists have studied 'adult' socialisation: including adult conversions, transformations, and 'cognitive restructuring' (Heelas 1996; Luhrmann 1989, 2001; Goff-man 1961; Gusterson 1996). Within this smaller body of work we find investigations of professional training, or what I shall refer to here as 'professional socialisation'. These studies by and large explore how individual subjectivity is shaped and transformed in professional training contexts, largely with the aim of socialising trainees into the particular professional group. They further investigate how the 'transformed persons' these professional trainings produce come to support and perpetuate the existing institutional practices that underpin the professional community at large. These researchers thus study not only what professionals produce and reproduce (i.e. the artefacts—linguistic, symbolic, material—left by individuals), but also the social factors and institutional devices that precede and fashion us as individuals who produce in prescribed directions (Gusterson 1996: 3).1 In exploring psychoanalytic socialisation, then, I investigate this interplay between individuals and the training institutes to which they are subject; institutes that through strategies of self-survival seek to self-perpetuate over time.
Anthropological Ethnographies of Professional Socialisation
Investigating how individuals are transformed to help construct and maintain social reality is a common thread binding anthropological studies of professional socialisation. Simon Sinclair's (1997) anthropology of medical training is a case in point. He starts by showing how medical training takes place not only in the obvious 'official' and 'front-stage' educational contexts (e.g. in seminars, lecture rooms, and on ward rounds), but also in many 'backstage' and 'unofficial' locations—in the bar, on the games field, and during more 'theatrical' social events. Students' lives are thus inundated by institutional demands and directives (p.16). It is this more penetrating education that leads students to acquire deep professional 'dispositions' (professional habits of thought, feeling and action), which 'fit' with their profession's existing norms and expect-ations—a 'fit' which ensures that these professional mores are transmitted and maintained (p.32). At the end of Sinclair's work he calls for the reform of medical training, largely because the 'dispositions' being transmitted to trainee doctors support a medical system that undermines the health of both trainees and doctors. But since the trainee's capacity and willingness to undertake reform is largely weakened by the ordeals of training, he concludes that changes to the medical system must come from without. One vehicle for change consists in educating doctors to become more critically and sociologically aware of what they do and how they do it; this, he believes, will increase the young doctor's awareness of the side-effects that medical training not only produces in the medic and the medical profession, but also in society at large. Sinclair advocates that cultivating critical awareness of the taken-for-granted norms and practices of medical culture is the first step in reforming those aspects of biomedical training, practice and belief that generate harmful consequences for self and society (p.326).
Tanya Luhrmann (2001) in her highly acclaimed anthropology of psychiatric training is also interested in the effect professional training has upon self and society. Unlike Sinclair, Luhrmann does not use the language of 'dispositions' to define that which professional socialisation instils in trainees. Rather she prefers the language of 'moral and technical instincts'—these are the qualities trainees need to develop in order to enter with the professional community. While still retaining an approach similar to Sinclair, she seeks to understand how sets of authoritative practices and ideas change how persons subject to them feel, act, and think. By following the training of young psychiatrists in the United States she arrives at an understanding of why psychiatrists come to think, diagnose, and practice in the world as they do. Psychiatry in recent decades has become a divided profession, creating almost two different and competing kinds of practitioner. She shows comparatively how the biomedical and psychodynamic traditions each produce very different moral and technical instincts in psychiatrists. This has led to competing perceptions of illness, disease, prognosis, and treatment within the one psychiatric social space. By studying socialisation at the local level she explores the interplay between practitioner, system, and society: as biomedicine is ever more wooed by corporate pharmacology, old psychodynamic practices die away. Psychiatric socialisation is thus adapting to the wants and aims of powerful insurance and pharmacological companies. And as new trainees are subtly socialised into complicity with corporate and 'pharmacological' aims and interests, not only does a new clinical hegemony prevail, but a new kind of practitioner is produced.
In many ways both these studies presuppose Goffman's (1961) early idea that institutions (themselves pressured by outside forces) transfigure persons via 'direct assaults on the self.' With this phrase he was describing, albeit in the case of asylums, how individuals adapt to institutional expectations and demands simply in order to acquire the security and rewards that conformity brings. One of the unintended consequences of such 'fitting in' is to accept as 'normal' the institutional imperatives that bear upon the individual. People often prefer to remain in warm accord with their social surroundings than to suffer the difficulties non-conformity can create. Conformity when 'naturalised' legitimates actions which are rewarded by institutional paybacks; this sets in place relationships of mutual confirmation and constitution between persons and the systems in which they operate.
As we shall see, and as both Becker et al (2002 [1977]: 437) and Sinclair (1997: 327) assert to be the case in medical socialisation, psychoanalytic institutes prefer a student body that conforms with authoritative demands; and the institutes clearly resist any kind of autonomous student culture or sub-culture which might challenge the status quo.2 Institutes, by and large, prefer a trainee community that is predominantly compliant with the wishes of the leadership. Revolt against established procedures is institutionally resisted by processes of what I come to call 'exclusion', 'secondary elaboration', and by the fashioning of 'imaginations' and 'dispositions' sympathetic to institutional demands. These devices attempt to render trainee innovation into a form of dissent, to brand trainee protests as symptoms of pathology, and to exile any inconsistent student ideas behind walls of private doubt. Thus through a variety of strategies trainees' intellectual and cultural life becomes subject to institutional expectations. This stimulates a mood of conformity in which the inculcation of dispositions that 'conserve' rather than 'challenge' the tradition is easily performed; inculcations which, from the standpoint of the institutes, keep any threats to their 'regime of truth' at bay.
How and why the rewards of conformity can lead individuals to embody contradictions, warranted or unwarranted certainties, or new ways of seeing, practising, and imagining, has its history of interest in anthropology.3 For instance, Hugh Gusterson (1996) in his anthropology of science offers a detailed account of the moral transformations nuclear physicists undergo as their professional training proceeds: he sets out to discover how once politically liberal young men, hesitant about nuclear arms proliferation, were gradually transformed by their training into keen weapons scientists. As they progressed through their studies the adventure of entering a secret group, of making light of their work, and of developing a sense of technical mastery, were principle instigators of their personal transformations. For Gusterson, the rewards these acquisitions brought gradually dulled the concerns that were once impediments to their becoming professionals—such new acquisitions, because of their allure, prompted individuals to rationalise their old objections away.
Like the process of becoming a physicist, becoming a psychotherapist offers attractive and seductive rewards: those of belonging, of a new identity, and of new mastery—namely, it offers incentives as desirable as the 'economic and status rewards' identified by certain sociologists of the professions (see Rustin 1985). Professions first and foremost need new recruits—thus investigating what inspires newcomers to train is to unearth alternative sources of community maintenance. One of my contentions is that psychotherapeutic training transforms more than just 'cognitive processes' and instils more than just 'clinical expertise', it also initiates persons into a moral and social community. Learning is then not simply a process of 'knowledge acquisition' or a process of 'technical and cognitive instruction' but a process of 'becoming'— becoming a full participant, an accepted member, and finally, a kind of person.4
Pierre Bourdieu—A Point of Theoretical Orientation?
To make explicit one theoretical tradition influencing my analysis of psychoanalytic training, let me offer a brief sketch of Pierre Bourdieu's socio-anthropological theory in order to highlight which of his concepts may usefully illuminate hidden aspects of psychoanalytic socialisation. Although Bourdieu's work is notoriously difficult to understand, principally because of the language he uses (Jenkins, 1992: 162-72), there is no doubt that once we have understood his concepts of 'habitus', 'disposition', and 'cultural field' we will find them useful aids in our analysis of psychoanalytic training.
Let me start with Bourdieu's concept of 'habitus'. This refers to a collection of habits of thought, feeling and action that 'dispose' individuals to behave in certain socially and culturally predictable ways (Bourdieu 1977a: 78-9). For example, an individual whose habitus was developed within an individualistic and capitalistic society may well display actions, thoughts and feelings that are consistent with the values and aims of that society—he may be industrious, competitive, and keen on making profit, he may display a marked capacity to sever ties in order to move with the demands of market etc. The particular habits of thought and action that comprise the individual's 'habitus' Bourdieu refers to as 'dispositions'. 'Dispositions' are ways of being and acting which help individuals to 'fit' with the 'fields' in which they are located—this is to say, dispositions are those embodied actions, thoughts and feelings that his or her community rewards and expects. But what does Bour-dieu mean by 'field'? He is not talking here about a geographically bounded concrete space, such as a nation state or a city state. Rather he uses the word 'field' as a kind of metaphor to denote an area in which people and institutions engage in shared practices and behaviours—thus we can speak of the fields of 'academe' of the 'media' of 'politics' and indeed of 'psychotherapy'. Such fields are not circumscribed by geographical bounds but rather by bounds of interest, shared values, knowledge and belief.5
In sum, a 'habitus' (an orientation to life) consists of a set of 'dispositions' (acts and feelings) which generate 'practices' (social actions) characteristic and supportive of the shifting and dynamic 'fields' (e.g. academe or politics) with which they are congruent.
The first step in using these concepts to help our analysis of psychotherapeutic training is to note that certain education theorists have employed them to understand other educational con-texts.6 For instance, students can be taught to develop certain thoughts and acts (i.e. dispositions) by means of either 'overt' or 'covert' modes of learning.7 This is to say, many of the strategies or 'devices' used in institutes to transform trainees into professionals are not necessarily overt educational tools nor clear pedagogical strategies or techniques. Rather they are often hidden, covert or 'unintentional' educational devices that operate outside the awareness of both learners and teachers, and which can therefore only be revealed through close analytical enquiry. As I intend to expose such hidden devices at work in therapeutic training, I shall follow Lave and Wenger's (1991: 40) distinction between 'learning' and 'intentional instruction'. That is to say, as people learn things beyond what they are openly and 'intentionally' taught, intentional instruction can never account for all that is learnt, for far more is learnt than what is intentionally taught—things always seep in through the back-door, so to speak.
As we shall see, psychotherapy students learn by overt and explicit educational 'devices', but more importantly by devices that are covert, insensible or hidden from both they and their teachers: I shall show that through shrouded devices that work to 'transfigure the trainee's imagination', to 'socially induce anxieties and uncertainty', to 'alter the trainees sense of personhood' and to 'instil a sense of clinical mastery', that is, I shall show that through devices not always explicitly recognised by the trainees and institutes as such, trainees learn to accept as true the professional reality with which they are presented. In fact, we might go so far as to say that it is these covert and insensible modes of learning (rather than overt and intentional devices) which constitute the most powerful factors and forces facilitating the making of psychotherapists.
Divergences from Bourdieu when Studying the Psychotherapeutic Context
While Bourdieu's ideas are therefore helpful, as I am predominantly interested in how individual dispositions are established in trainees, it is necessary to go beyond his work and analytic standpoint. As Sinclair points out (1997: 22), Bourdieu's study is mainly concerned with the adult practice of dispositions (how dispositions shape adult behaviour), rather than with how dispositions are transmitted to new generations. Bourdieu is therefore less attentive to the various devices by which persons are inculcated with dispositions that transform them to both 'fit with' and perpetuate existing institutional norms and preferences. For example, by focusing on the practice of established dispositions, Bourdieu's work resembles Ernest Gellner's (1985) study The Psychoanalytic Movement. Gellner investigated how the theory of psychoanalysis constitutes a self-protecting 'anatomy of belief'—namely, a system of intellectual props and practices which tries to protect the psychoanalytic system from external critics or internal dissent. Like Bourdieu, he was less concerned with the institutional devices used to transmit these systems over time, preferring instead to analyse how such systems maintained their dominance in the present.
Gellner thus studied the transformed practitioner, whereas it is with the processes of transformation that I am concerned. For if we are truly to understand why professionals practise in the world as they do (why individual lawyers, doctors, academics, actors, psychotherapists, and so on, all bear the idiosyncratic stamps of their particular professional regime) we must investigate the sites where their professional dispositions are officially transmitted. Through exposing the overt and covert devices that facilitate learning, then, we will uncover the idiosyncratic 'type' of graduate the psychoanalytic institute seeks to produce; a type largely complicit with and supportive of existing institutional structures and interests. A type therefore, and as I shall argue, which may be securing the demise of the community so far as the values and structures with which the trainee is compelled to comply may well be the very values and structures that are serving to undermine the vitality of the profession itself. In other words, are these institutes, despite their avowed intentions, sowing the seeds of the therapeutic community's own demise?
Agency—Is There Any Space?
How far trainees are mere pawns in the hands of more powerful institutional and social forces will also be a theme of my research. While it is clear that trainees have a good deal of influence over how their transformation into 'professional status' proceeds, it is also clear that they are never entirely free from influential social and institutional forces which shape their development in a prescribed direction. For example, along with social theorists such a F. Furedi (2004), R. Sennet (1976), E. Gellner (1985), and Heelas (1996) we can argue that the erosion of traditional 'communities of belief' in modern society has led many individuals to seek security in new systems of meaning. For such individuals the psychotherapeutic calling offers a surrogate moral and professional home. What is precisely appealing about the therapeutic system as taught in the institutes, is that it is cast as a bounded configuration of ideas: pure, discrete, and logically consistent. It is taught as a circumscribed, totalising body of knowledge that provides a comprehensive explanatory system in terms of which self, society and other can be understood. The 'modernist' manner in which the psychoanalytic world-view is transmitted discourages the uncertainly and 'the doubt in discourse' characteristic of the post-modernist period. It is this totalising aspect of the psychoanalytic project that could appeal to those dislocated from old social allegiances (to state, community, church etc.), as it replaces lost frames of orientation with a new conceptual system which is itself buttressed by authoritative and powerful symbols and institutions.
If the demise of traditional communities and belief can help make the assimilation of psychoanalytic dispositions more attractive to candidates, and can thus be said to more smoothly aid their transition into a surrogate professional and moral home, then we must, in the first place, partly locate one factor bearing upon the practitioner's transformation in this fall of traditional communities in modern society. The second external factor aiding the trainee's transformation is located in the institutes themselves, which aim to create practitioners who will support and perpetuate the wider psychoanalytic cause.
To say that trainees are influenced and transformed by these powerful, external forces, however, is not to say that trainees have no influence over their own transformations—for indeed many trainees do resist the smooth and total assimilation of the psychoanalytic world-view. To invoke David Parkin's (1995: 145) insight for a moment—individuals find it difficult to completely convert to new modes of meaning and thought, for old meanings and ideas resist total disavowal and often re-emerge for re-integration. However, those individuals in training who resist the unquestioned assimilation of psychoanalytic knowledge, and who to some extent therefore assert their own vision of things, often encounter institutional opposition. For these trainees there is a clear struggle between the official practice that they are taught to adopt, and the integrated practice that they might privately believe. For them the knowledge that the institutes impart, instead of being assimilated purely and completely, is often latticed or integrated with existing knowledge to create something entirely new. Old knowledge that resists complete disavowal can therefore affect and colour what is being taught. These influences often confound the kind of pure assimilation which institutes everywhere seem to prefer.
While the training institute therefore may wish for the smooth and unruffled transformation of its trainees, for some this does not occur successfully. For these trainees there may be opposition and dissent which on occasion may be formalised in innovation. This is to say (and to take issue with Sinclair's contention [1997: 321-27] that rigid forms of training produce professionals unlikely to change the system), the more formal and firm the training structure, the more likely dissent, fracture, and on occasion some kind of defiant and creative innovation. Ironically, rigid institutions may ultimately beget their own transformation via the opposition they invariably generate. By asserting this position I also depart from Bourdieu who speaks of agency as arising only from the cultivation of 'cultural literacy' (awareness of the world one is in): it may also arise from rigid structures which create the subjective conditions for inevitable opposition—rigidity, so to speak, is often the source of its own demise.8
In the end, in discussing psychotherapeutic training it goes without saying that questions pertaining to the truth or falsity of psychotherapeutic ideas are of anthropological interest only in so far as what people believe (both inside and outside the community) has a bearing upon the social reality of the community it-self.9 Thus the psychologist's, intellectualist's or philosopher's concern about whether a given theory or belief is objectively true is replaced here with a phenomenological concern about the social significance of beliefs that are held to be 'true' (Kapferer 1983: xix). As Mauss and Hubert tell us, 'beliefs exists because they exist objectively as social facts' (Hubert and Mauss 1981 [1964]: 101), implying that the objective truth of a belief and the social consequences of its being believed to be true are quite separate things. In this work I am concerned with the social implications of a set of beliefs held to be true, not with making epistemological or normative judgements about their truth or falsity.10 In fact, if this study offers critical comments at all, then these do not pertain to the ideas the profession believes and expounds, but only to the institutions which purport to protect, steward and transmit these ideas.
Why This Book Matters
In this monograph, and within the broad parameters of the orientation outlined above, I wish to make use of an older and deeply insightful body of anthropological theory by applying it to this novel contemporary context. With this method, rather than breaking with traditional anthropological approaches, I seek to affirm the worth of tested anthropological ideas by reworking them in the context of a critical 'repatriated anthropology' (Gusterson 1996: 3). But before I proceed to outline why I believe this book matters, let me first provide a brief outline of each chapter in turn.
In chapter one I provide a history of the institutional development of psychotherapy in Britain, identifying three broad historical trends that have influenced the state of the community today: the expansion of psychotherapy during the twentieth century; the proliferation and stratification of training schools that has accompanied this growth; and the growing attack psychoanalytic psychotherapy has sustained during the last quarter of the twentieth century.
In chapters two and three we move into the first stage of psychoanalytic socialisation: pre-training therapy (i.e. the personal psychotherapy all candidates undergo before entering the institute). In short, we learn that the therapeutic encounter, like any ritual encounter, takes place in a bounded 'psychotherapeutic frame' which delimits the spatial, temporal and relational dimensions of the session. We further learn how within this frame trainees come to imagine themselves and the world differently. This cultivation of a 'psychoanalytic imagination' constitutes a form of 'institutional vetting' ensuring that only those who have taken to the therapeutic experience self-select to proceed into the institute.
In chapter four I show how the 'psychoanalytic imagination' is appealed to within the institutes to legitimate the training they offer. By studying the next phase of training, the seminar encounter, we will see how status imbalances within institutes are legitimated by analytic ideas, and how the transmission of 'text-based', 'secret', and 'personal' knowledge shields this knowledge from criticism. In short I argue that the educative atmosphere in seminars is by and large more 'affirmative' than 'critical', more 'sectarian' than 'academic'.
In chapter five we focus on how institutions manage trainee dissent, describing how trainees are taught to direct their doubts away from the system (the ideas) and onto other receptacles (patients, outsiders, competitors). I then illustrate through selected case studies instances where trainee doubt, being unsuccessfully redirected, settles on the paradigm itself causing 'dissent' from the orthodox position. How dissent has been managed historically by the institution provides insight into why the community lies in a fractured state today.
In chapter six we turn to the next phase of training—clinical supervision, focusing especially on the psychoanalytic understanding of aetiology. By analysing an extended case study ('the case of Arya'), and the socio-historical biases shaping Freud's early thinking, I illustrate how and why the analytic understanding of aetiology can be seen as limited. I further show how such aetiological assumptions are subtly affirmed in clinical supervision, leading practitioners to treat patients in predictable ways.
In chapter seven we will see how covert institutional pressures make trainees susceptible to the instruction on offer. By linking the ordeals and stresses of socialisation to trainees' dependency on seniors, we find that the social conditions of the institute covertly render trainees susceptible to embodying the commitments, preferences, and the expansive ideology that seniors embrace.
Finally, in chapter eight I reveal that the psychoanalytic habitus not only supports a species of clinical practice, but a way of life. Here we acknowledge three 'projects' that the psychoanalytic myth supports: the ethical, the political, and the communal. By analysing the core values analytic training inculcates, and by exploring the profound personal meaning therapy comes to have for practitioners, I provide the background against which the deeper significance of training can be revealed—initiation into a 'self-redemptive', socio-political movement of wide social aspiration and influence.
In all chapters I make use of a wide variety of anthropological concepts to illuminate the core stages of therapeutic training. In this sense my work is less a 'case-study' showing where existing anthropology is mistaken, than an 'example' of how existing anthropological theory can unravel social phenomena in the psychotherapeutic context. In Jeremy MacClancy's (2002: 11) phrase, I 'study up' with anthropological insights in hand, showing how individuals are socialised into systems of meaning that support and which are refracted in the community's social structure. In other words, I show how institutes can train individuals to recreate and sustain the social structures of the community itself.
Applying the anthropological imagination to the psychotherapeutic context, along with contributing to the growing ethnographic record of professional socialisation, I offer a novel perspective on certain problems afflicting the psychotherapeutic profession itself. Many psychotherapists have traditionally sought to understand the fracturing and inter-rivalry within their own community by means of psychoanalytic ideas. To use Needham's phrase, such psychotherapists have reverted to a theoretical 'psychologism' to analyse community dynamics: applying ideas devised to study individuals to investigate social life and institutions. In this sense they mistakenly by-pass what sociological or anthropological theory could tell us about their social and community dynamics.
For instance, Cremerius (1990: 125) explains the inter-school rivalries that beset the profession in terms of unresolved Oedipal rivalries. 'To the extent to which [they] remain unresolved,' says Cremerius, 'intellectual powers are eroded and hate, jealousy and phallic rivalry define the relationships within the association (p.125). Lousada (2000: 470), alternatively, suggests that the inability of psychotherapy schools to create working partnerships is due to their inability to form libidinal cathexis—if such cathexis could take place then partnership might ensue. Frattaroli (1992: 132-42) argues that psychotherapy's history of schism and factionalism is due to the institutionalisation of an internalised split Freud never resolved between the contradictory views that neurosis is primarily intra-psychic (repressed drives) or inter-psychic (insufficient relationships). If this split could be reconciled then these divisions might fall away. While Bruzzone et al (1985: 411), stress that the regression students experience in their therapy (making them use words such as 'mummy' and 'daddy' to refer to their therapists, and use phrases such as a 'good feed' to refer to a good training experience) is replicated during their training in the institute. Students then may feel persecuted and paranoid in the institute just as they might in therapy when in regression. Finally, Figlio (1993: 326) argues that because trainees internalise key figures—such as the therapist and the institute—when they encounter others holding onto different (often opposing) internalised figures a mutual hostility ensues.
I could continue to pile up many more examples of how community dynamics have been explained by psychotherapists in terms of psychoanalytic concepts.11 This fact tells us not only something about the community in question, but that therapists themselves, as so many expressed to me, hold deep concerns about the warring and fractured state of their profession; an institutionalised rivalry not only impeding the process of statutory regulation, but also the cross-fertilisation of ideas necessary for theoretical development and reform, and—one might add—improved practice.
Not all therapists, of course, have resorted to explaining community dynamics in terms of psychoanalytic ideas. Some have understood wider tensions in more practical terms of how candidates are selected and trained (Cremerius 1990; Kleinman 1998); and how creativity is discouraged in training institutes (Kernberg 2006, 1996). Indeed, in recent years a new body of literature has proposed reforms to psychoanalytic education more broadly (Gaza-
Guerrero 2002a, 2002b; Kernberg 2006; Levine 2003; Mayer 2003). This literature is unified in suggesting that many of the problems it believes the community now faces (diminishing creativity, ongoing conservatism and interschool rivalry) must be challenged at the institutional level either by divesting self-interested groups of any legal authority to define what is legitimate or illegitimate practice (Whan 1999: 312); by introducing openness, pluralism and authenticity into training institutes (Samuels 1993); by diversifying and broadening the curriculum to facilitate in candidates better em-pathetic and introspective perceptiveness (Berman 2004; Samuels 1993); or by establishing institutional mechanisms by which the power of executive and educational committees can be devolved (Kernberg 2006). Strategies such as abolishing the traditional training analysis (Mayer 2003), undermining retrogressive dependency upon the theoretical faiths of the past (Garza-Guerrero 2002b), developing more objective criteria for training assessment (Tuckett 2003), and strengthening the intellectual, scholarly and research context within which psychoanalytic education takes place (Auchincloss & Michels 2003), have all been championed as possible remedies to the demise of creativity in the institutes, and to the rise and entrenchment of rivalrous relations between different psychotherapeutic schools.
While this project is not directly about making sense of such problems and the rivalries as well as the entrenched positions they engender, it is my belief that an anthropology of psychotherapeutic socialisation can bring fresh light to old troubles while avoiding being prescriptive or normative. Anthropologists have long known that much human conduct is orientated to, and shaped by, the demands and pressures of the environments in which people find themselves. If institutes harbour definite expectations in relation to which trainees must organise their behaviour and professional aims, then what these expectations demand of trainees (either openness or antipathy toward 'other' schools) will influence how they act as professionals, and finally whether the community will move towards a more creative pluralism or simply remain in its fractured state. Indeed, if change is to occur in the community then what may require alteration are the circumstances and situations people have to contend with. '[I]f this were done', as Becker has stated, 'students would probably adapt to the changed situation and develop quite different kinds of perspectives' (Becker et al 2002: 442). What Becker, Samuels, Sinclair, Luhrmann and others have shown is that any kind of community reform must start with a deep reflexive inspection of the sites or places where the community's values, practices and beliefs are transmitted and sus-tained—and in so far as this study comprises such an investigation it may thus indirectly inform and contribute to the unravelling of these social problems.
Psychoanalytic / Psychodynamic Psychotherapy Explained
Before discussing my fieldwork methods, I would first like to identify the exact kind of practitioner and training upon which my research is focused. The most obvious confusion I must first anticipate concerns the differing roles of psychologist, psychiatrist, and psychotherapist. A psychologist is someone whose professional life involves researching and applying psychology (e.g. in the different fields of education, forensics, criminality, etc.). Psychological theories charter different aspects of mental life such as cognition (memory, perception, learning), and behaviour (social and individual). Thus psychologists are not clinicians. If they see patients at all they only do so if they have submitted to an additional doctoral or postgraduate training in clinical psychology, in such instances they are referred to as 'clinical psychologists'.12 Psychiatrists, on the other hand, are medical doctors who specialise in diagnosing and treating mental illness. They concentrate mainly on pharmacological intervention. Like psychologists, some psychiatrists have had an additional psychotherapeutic training, usually at one of the independent psychotherapeutic institutes that I have studied here, but most have only a rudimentary training during their own psychiatric residency. As to how much psychotherapy psychiatrists study and employ is largely at their own and their supervisor's discretion, although psychiatric departments now insist that trainees undertake some form of psychotherapeutic instruction during their residency.13
To turn now to the psychotherapist, he or she is a clinician who is usually a trained member of a psychotherapeutic training body recognised by one of the two major accrediting bodies: the BPC (British Psychoanalytic Council) or the UKCP (the United Kingdom Council for Psychotherapy). A psychotherapist need not be a psychiatrist or psychologist, and the majority of psychotherapists are neither, although all must have some form of undergraduate or 'equivalent' experience (i.e. in nursing, social work, or teaching etc.). The fact that the British psychotherapeutic field is wide, diversified, and unpredictably protean, comprising myriad schools and contending traditions, makes the term 'psychotherapist' greatly unspecific. It denotes an array of practitioners from 'psychoanalysts' to 'cognitive behavioural therapists' to 'humanistic therapists' and 'existentialist therapists'. In Britain alone there are eight traditions of psychotherapy recognised by the UKCP, each one comprising an assemblage of varying schools. With this tangle of divergent forms it is crucial to define the precise kind of psychotherapy upon which my research will chiefly focus. Broadly put, I focus on the training and practice of practitioners within the psychodynamic or psychoanalytic tradition which is by far the largest and most established psychotherapeutic tradition in Britain.
'Psychodynamic' psychotherapy is the term I shall use in this book to characterise all those psychotherapies stemming from Freud's original teaching. Under the rubric of 'psychodynamic psychotherapy' I shall include 'psychoanalytic psychotherapists' and 'psychoanalysts'. Thus in this book I shall uses the terms 'psychodynamic' and 'psychoanalytic' interchangeably. Psychoanalysts can be distinguished from all other psychodynamic psychotherapists in Britain by virtue of being trained at the Institute of Psychoanalysis. The term 'psychoanalyst' then, in Britain today, denotes an institutional affiliation rather than a species of psychotherapy distinct from other psychodynamic forms. Where psychoanalysis is most obviously distinct clinically is in requesting that its trainees (and often patients) submit to five-times-weekly analysis (a practice which is supposed to facilitate a 'deeper' analysis), while other psychoanalytic and psychodynamic trainings request only three-times-weekly contracts or less. The social significance of these distinctions, and there are many, I will return to at a later point.
The mainstream tradition of psychodynamic or psychoanalytic psychotherapy includes the great pioneers of psychotherapy such as Sigmund Freud (1856-1939), Carl Gustav Jung (1875-1961), Melanie Klein (1882-1960), Karen Horney (1885-1952), Donald Win-nicott (1896-1971), Jacques Lacan (1901-81) and Erik Erikson (1902-1994). Thus it comprises many schools which have links both institutionally and theoretically. As I shall focus on these institutional linkages at later points, here I shall very briefly focus on the theoretical.
The common thread linking the psychodynamic or psychoanalytic tradition (in distinction from, say, the humanistic or cognitive / behavioural tradition) is that its numerous schools all agree that mental functioning is a 'dynamic' phenomenon (deriving from the Greek dunasthi 'to have strength or power'). The psyche is seen as structured into permeable segments (e.g. ego and unconscious) which interact dynamically to the degree that thought, emotion, and behaviour, both adaptive and psychopathological, are believed to be influenced by these interactions. For instance, Freud believed that we have strivings, feelings, and wishes of which we are not entirely conscious, but which we resist coming into our awareness —mainly because we fear losing our group's approval if such stifled elements are felt and expressed. As the 'repression' of these fearful and socially unacceptable elements largely occurs in early childhood, childhood is posited as the key phase of human bio-graphy—hence the psychoanalytic mantra 'the child is the father of the man'. That these strivings are largely repressed does not mean that they cease to exist. Rather they retain their dynamism and if not adequately sublimated they express themselves in distorted ways. Hence Freud's explanation of neurotic symptoms as repressed strivings that resurface in disguised forms—although we may be aware of the suffering they bring, we may remain oblivious as to their origins and meaning. Part of the therapist's task is to make these forces and their meaning conscious to the patient so he or she can be freed from the destructive compulsions they establish in the personality.
Different psychodynamic schools have emphasised the centrality of different aspects of psychodynamics. For purposes of clarity I shall summarise these approaches under a broad distinction largely adopted by the British community today (a distinction I elaborate in appendix one). This is between the analytical psychodynamic psychotherapists (classical Freudian psychoanalysts who stress the instinct theory—e.g. Freud, Ernest Jones, K. Abraham), and the interpersonal psychotherapists (including the 'Kleinians' and the 'Independents' otherwise known as the 'object relations' therapists—namely Donald Winnicott, Harry Guntrip, and William Fairbairn). However, such is the common ground of both perspectives that in the BPC they fall under the broad category of the 'psychoanalytic'.
To Whom I Restrict My Research
In this paper I restrict my research to the institutions of psychodynamic or psychoanalytic psychotherapy, which are largely integrative (teaching both the analytic and interpersonal approaches). Despite this integrative approach, which is the hallmark of modern British psychodynamic and psychoanalytic training, some institutions lay special emphasis on the teaching of one key school (e.g. the Lincoln Centre is integrative with a special emphasis on Kleinian therapy, while the Institute of Psychoanalysis is integrative with a special emphasis on the analytic approach).
As my fieldwork focused on psychodynamic and psychoanalytic institutions, in what sense might my research apply to the Institute of Psychoanalysis, the only institute that refers to its graduates as psychoanalysts? I believe my research is largely applicable for the following reasons: firstly, the model of psychoanalytic psychotherapy training that I am investigating is based on that offered at the Institute. Most of the teachers at these schools are psychoanalysts, while most members of their senior committees comprise psychoanalysts. Thus most of the people I interviewed and befriended were being taught and schooled by psychoanalysts, while many of my interviews were conducted with analysts or with those trained by them. Furthermore, as many psychoanalytic schools are seeking psychoanalytic status (so they might join the IPA—the 'International Psychoanalytic Association'—and call their graduates 'psychoanalysts'), they are careful to bring into alignment their methods of teaching with those of the Institute of Psychoanalysis. Finally, the major psychodynamic training institutes belong under the same accrediting body, the BPC (British Psychoanalytic Council) which standardises trainings across the board, including the Institute of Psychoanalysis. Thus structurally speaking these trainings are largely comparable. For these reasons, although my research is strictly speaking an ethnography of psychoanalytic socialisation, my research has considerable applicability to the understanding of psychoanalysis.14
Fieldwork and Methodology
The practical and—one must say—difficult business of gaining entrance to, and conducting fieldwork within, psychodynamic training institutes, is something I must now address. Previous anthropologists who have sought entrance have commonly met with rejection. Ernest Gellner's proposal to study ethnographically the British Psychoanalytic Society, for instance, was never given approval. According to the then president, D.W. Winnicott, the institute would rather arrange some such investigation at a later date with a social scientist of their specification than hand this role to a self-appointed researcher (their investigation has yet to material-ise).15 Dr Audrey Cantile's proposal some years later was also rejected on similar grounds—it seems that the institute was again reluctant to trust a non-therapist and thus possible antagonist with research responsibilities.16 However, things were different for Dr D. Kirsner, himself a sociologist and psychologist, who was more successful in gaining access to institutes in the United States and Australia, perhaps because of his 'clinical psychologist' status. But again in the case of the British institute he met with rejection. For this reason his subsequent book Unfree Associations (2000), regrettably enough, is empty of data concerning the British context.
While the doors of the Institute of Psychoanalysis remained closed to these scholars, I too, when approaching this and other British psychodynamic institutes, experienced my share of standing out in the cold17—a fact raising an important question: With the obvious reticence of psychoanalytic institutes to open their doors to outside investigation, which is itself an interesting social fact, how then did I gain access? The answer is best made by my immediate admission that I was not always an 'outsider', for my story begins with my formal training in psychodynamic psychotherapy at a well-known training institute in London; a training that I put aside after two years to pursue other interests. At the point of leaving, although my interest in psychotherapy and my desire to train remained alive, I had little intention of returning to study the process anthropologically, this idea only materialised some time later.
The fact that I was already affiliated with the therapeutic profession made my returning to train and my gaining access to other trainings a more straightforward affair. This does not mean that there were no ethical concerns regarding my return, which was participatory and observational in the truest sense, but that my previous training put stoppers on open doors that would have otherwise closed shut. Before looking at the ethical issues surrounding my return, let me first outline the particular form my participant observation took.
My fieldwork has included two years of formal training (not counting first years of previous study) at a psychotherapeutic institute in London. This incorporated my attending weekly seminars at the institute and sitting more than 200 hours of clinical supervision (psychoanalytic). Accompanying these commitments I have engaged in a full three years of individual psychotherapy. Along with these institutional activities, in the second year of my fieldwork I took up the activity of seeing patients (three patients weekly for outpatient psychodynamic psychotherapy in the NHS). My NHS placement also included my attending weekly psychodynamic peer supervision, and frequent one-on-one supervision with the centre's senior supervisor (a psychoanalyst).
During the second year of my fieldwork I resided in London for ten months. This enabled me not only to become more immersed in these formal commitments, and also to observe and attend seminars at a neighbouring institute as a 'guest', but also to spend countless hours in informal discussions with psychoanalytic trainees. At this point I was also able to conduct many hours of formal interviews with both training and qualified practitioners, which I have supplemented with 200 surveys sent out to psychoanalytic practitioners around the country. Alongside my participatory activities I undertook a thorough inspection of two psychoanalytic trainings, one within the BPC, and one in the UKCP. This inspection included interviewing trainees and tutors as to the structure and experience of training; inspecting curricula, assessment criteria, institutional histories and theoretical preferences, institutional relations with neighbouring institutes, as well as interviewing trainees as to their experience of the training to which they were subject.
In all these encounters whenever possible I have made known my research intentions.18 That I was both insider and outsider seemed rarely to place me in an ambiguous position in respect of my colleagues. From those accepting me as an 'insider' to the profession (e.g. those with whom I worked and trained) I experienced much help and openness; it was only when approaching those who did not know me that I was treated more warily (at worst, surveys would not be filled in, interviews not granted, and requests and queries turned down or ignored). Naturally, it could be argued that what I interpreted as suspicion of my outsider status might have had its cause in one of many variables. But since how I construed my role (as predominantly a researcher or as a member of the profession) seemed to influence people's reactions to me, the conclusion emerged that where I was placed (by others and by myself) had a significant impact upon how I was received.
A Final Note on Names
To protect the informants of this research I keep their names and the institutes to which they belong confidential. I take this measure because many of the informants I interviewed made disclosures that at the worst might compromise their relationships with seniors and colleagues, or jeopardise their positions in the community. Naturally, if this were a species of investigative journalism such 'exposing' (of seniors at least) would be a legitimate task, but as my objectives are academic and anthropological, that is, as I primarily work to understand the reasons for such comments and what they tell us about the community, I believe such discretion does not affect the deeper aims of my project. Also, if respecting anonymity protects informants, by promising them confidentiality I also gave them licence to speak on matters more easily revealed from the safe ground of anonymity. As I now find myself in the position of honouring my early pledges, I revert to pseudonyms where necessary.
As for the names of various psychotherapeutic institutes, I only mention these when not speaking from the standpoint of an ethnographer. On other occasions when referring to historical data I use the names of the institutes freely. In other words, I do not reveal the names of my places of fieldwork, whereas when using historical data from documentary sources to illustrate the institutional developments within the community itself, I freely disclose names as any historian might. Again, as was the case when approaching individuals, when approaching the institutes the promise of confidentiality was an indispensable precondition for gaining entry; which itself was a precondition, it must be added, for undertaking this piece of anthropological research.
Chapter One The Rise and Fall of the Psychodynamic
Before moving headlong into the arena of therapeutic training, in this opening chapter I shall first offer an introductory account of the expansion of British psychotherapy during the twentieth century. By this means I shall provide some historical background to the modern psychodynamic training institute while identifying certain historical factors which have deeply influenced the plight of the profession today. My aim is to show that our understanding of therapeutic socialisation will be significantly deepened if we relate this process to the grander movements within the therapeutic community, and between this community and the wider socio-cultural scene. This analysis will explore three broad themes: the expansion of psychotherapy throughout the twentieth century; the proliferation of training schools that has accompanied this growth; and the growing challenge to psychodynamic psychotherapy in the last quarter of the twentieth century.
The Expansion of the Therapeutic
Why psychotherapy hugely expanded during the twentieth century is a question that resists being answered with precision and exactitude. The rise of any socio-cultural tradition may just as likely originate in the movements and actions of surrounding social institutions than in any expansive forces inherent to the tradition under scrutiny. This makes the project of identifying clear casual factors as to the rise of psychotherapy a complex affair. Nevertheless, when chartering the 'why' and 'how' of the ascending therapeutic culture in Britain a number of themes present themselves for serious consideration. Some of these themes have been discussed by earlier commentators on this expansion. Theorists such as C. Lasch (1979); E. Gellner (1985); P. Berger (1965); R. Sen-nett (1976) and F. Furedi (2004) have emphasised the decline of religion, the decline of tradition, and the decline of the political sensibility as contributing factors to psychotherapy's expansion. As I shall focus more closely upon these theories in chapter eight, noting how their authors differ in where they precisely locate the social causes of this expansion, here I shall only concern myself with what all such theorists accept: that such expansion has undoubtedly occurred. It is from this starting point that I shall trace an expansion which has entailed a number of highly significant consequences for the practice and training of individual practitioners.
The Birth and Expansion of British Psychotherapy
From the first psychotherapeutic institution in Britain to the founding of the most recent institute in the present day, one characteristic stands out in the history of psychotherapy—its meteoric growth during the twentieth century. The genesis of this expansion we could locate as early as 1910 when the first group of analysts who were in part responding to the mounting success of psychoanalysis in America, began to actively establish psychoanalytic institutions outside of Vienna (Freud 1986 [1914]: 102). This early movement comprised a number of young physicians and psychologists who gathered around the charismatic figure of Freud with the intention of learning and practising the new medical craft. This company of minds, not happy to leave the movement there, worked to assure the group's continuity and the succession of its leadership. The Nuremberg congress was held in March 1910 to achieve this. It was here where the IPA (International Psychoanalytic Association) was first formed with the purpose of both safeguarding and proliferating what had been so far achieved (Freud 1986 [1914]: 103): K. Abraham was entrusted the chair of the Berlin group, Alfred Adler, the chair of the Vienna group, while Carl Jung oversaw the Zurich group. A year later the Munich group was set up by Dr L. Seif and in the same year the first American group was formed under the chairmanship of A. A. Brill. In 1913 two further groups were established: Budapest formed a cell under the leadership of Sandor Fer-enczi, while in England the first group was formed by Freud's closest ally and tireless apologist, Ernest Jones. The founding of the British Psychoanalytic Society in London in 1913, containing eight members in total, marked the inauguration of the first psychotherapeutic institution in Britain.
After this first British institute was established there was little institutional expansion within psychotherapy until post-war Britain. As M. Jacobs has told us:
Apart from the founding of the Society for Analytical psychologists, the founding of the Tavistock [1920]... and the rise of the Portman clinic in 1939, the only significant developments mid-century were the foundation of the Association of Child Psychotherapists in 1949... and the wider accessibility of training (and indeed of therapy for the wider public) through the foundation of the Association of Psychotherapists. (Jacobs 2000: 456)
In fact by 1936 all the principle psychotherapeutic organisations were in place: the British Psychoanalytic Society (1913) (later called the Institute of Psychoanalysis); the Tavistock Clinic (1920), and the Analytical Club (1936)—now called the Society for Analytical Psychology.
During the pre-First World War period, and to a lesser extent through the inter-war years, that psychotherapy's expansion remained modest was something largely welcomed within British psychiatry. Many hostilities within medical psychiatry to the new 'talking cure' were deeply entrenched; partly because at that time medical education still instilled a sceptical empiricism that kept watch on what it felt to be ungrounded methods and their proliferation, and partly because these psychiatrists preferred the physical-ist leaning of traditional psychiatry that tried to effect cure through direct bodily intervention (Holmes 2000: 389).19
It was not until the First World-War that the initial step to bridge the division between psychiatry and psychoanalytic therapy was taken. The war was the most significant factor in launching this rapprochement as publicly funded psychotherapy was developed in an effort to treat victims of shell-shock and war fatigue. Many outpatient services were opened by middle class intellectuals who offered treatment for neuroses, while psychotic disorders were treated in the larger hospitals (Pines 1991). In London the Tavistock clinic and the Cassel Hospital were among the first institutions to offer the new psychotherapeutic treatment, setting up services in 1920 and 1919 respectively. At this time psychotherapy began to leave its imprint on psychiatry in another way as the use of psychodynamic group therapy in military hospitals obliged many psychiatrists to become skilled in the new psychodynamic techniques.
If during these initial years dynamic therapy only made modest inroads into psychiatry, outside of medicine psychotherapy was gaining growing favour in the public imagination. By the 1920s Freud had joined the likes of Einstein and other contemporary scientists by being portrayed in the US and UK daily papers and weekly reviews as a charismatic scientist who was revolutionising our understanding of human nature (Forrester 1994: 183). That Freud assumed this enigmatic role is supported by many retrospective studies that detail the early expansion and growing popularity of psychoanalysis. These studies, as Forrester tells us, show that during the 20s and 30s Freud took on iconic status. Henri El-lenberger's (1970) study broadly records the Euro/American expansion, while Rapp's (1988) exploration of the same expansion in 1920s Britain offers a more situated analysis of the mounting fascination with all things Freudian. Another important study by Gabbard and Gabbard (1987) documents how psychotherapists were portrayed by Hollywood from the 1930s to the 1980s, emphasising how from the early 1930s interest in psychotherapy proliferated in the middle-classes. The rise of therapy in cinema, as Forrester puts it, constituted 'one dream industry feeding off an-other'—a mutual exchange that served the expansion of psychotherapy very well (Forrester 1994: 183).
The status of psychoanalytic therapy was also improved by the kind of cultural icons who gave it their endorsement. In England in the 20s and 30s many notable literary and scholarly figures extolled the uncanny attraction of the talking cure. Bertrand Russell, T.S. Eliot and Thomas Mann were just some of the admiring few, while W. H. Auden in his In Memoriam Sigmund Freud elevated him to a kind of modern Moses:
so many long-forgotten objects
revealed by his undiscouraged shining
are returned to us made precious again;
games we had thought we much drop as we grew up,
little noises we dared not laugh at,
faces we made when no one was looking
(Auden 1950: 59)
Other studies chartering the rise of psychotherapy show that by the mid-century the therapy's allure was endemic. Eva Moskowitz (1990) in her book In Therapy We Trust: America's Obsession with SelfFulfilment shows that it was at this time when the popularity of psychoanalys really took root in the US. While N. Rose's (1990) study, which traces a like development in the UK, shows that after the Second World War the therapeutic ethos had gained influence with policy-makers and business managers who were keen on converting the application of therapy into economic reward.
Along with these more popular endorsements, there also followed approval from many quarters of the academic community. To focus on American anthropology, for example, the culture and personality school headed by such well-known figures as Ruth Benedict (1934), Linton and Kardiner (1939) and Margaret Mead (1943), embraced psychoanalytic assumptions and argued that every culture has a distinctive pattern of child-rearing which produces a distinctive personality type—one consistent with that culture. Despite this kind of cultural analysis being resisted in British anthropology, psychoanalysis was still being publicised in Britain by anthropologists from W. H. R. Rivers to the current S. Heald and D. Parkin (1994).
Post-Second World War Expansion
As popular acceptance of psychotherapy increased after the First World War, by the end of the Second World War psychiatry's characteristic hostility towards psychoanalysis was loosening in certain quarters. This was partly influenced by the growing acceptance of dynamic therapy in American psychiatry,20 not to mention that after the two world wars, as Lousada reminds us, 'the disturbance, guilt, and the experience of such immense destructiveness left psychiatrists with much to think about' (Lousada 2000: 471). If preSecond World War British psychiatry was in the main hostile to dynamic therapy, then in the post-war climate and through the 1950s its institutional fortunes were to change. By the early 1960s consultant and psychotherapy posts had been established in a few psychiatric departments, and junior psychiatrists, along with training in the traditional diagnostic methods, were being routinely introduced to psychoanalytic techniques.21 During the next decade there was a steady increase in psychotherapy departments throughout the UK, with key centres being established in Nottingham, Oxford, Manchester, Birmingham, and Newcastle—these joining the slightly more established units of Edinburgh, Bristol, and London.22
The acceptance of the therapeutic was thus expanding through the 60s and 70s both inside and outside established institutions. This can be seen from an assessment of the statistics compiled on therapeutic attendance around this time, statistics which, although not focusing on dynamic therapies in particular, nevertheless show that demand for some kind of talking cure was growing at a rapid rate. To start with the American case, Donna Lafromboise stated that by the 1960s 14 per cent of the American public had received some form of therapy at least once in their lives, while by 1995 nearly half the population had experienced some form of therapeutic intervention. And it is estimated that by the turn of the century this figure will have increased to 80 per cent.23
The impact on British society was also significant. As Furedi points out, since the 1980s (when counselling became one of Britain's little growth industries) the number of people practising the talking cure and receiving treatment has rapidly grown. For example, just as the amount of registered therapists has dramatically
increased in recent years (e.g. the UKCP Register of Psychotherapists grew from 3,500 in 1997 to 5,500 in 1999—see table 1), so too has the amount of therapy hours being conducted in Britain. For instance, an independent research carried out by Counselling, Advice, Mediation, Psychotherapy, Advocacy Guidance (CAMP) concluded that the number of therapeutic encounters taking place each month in Britain was in the region of 1,231,000, a far cry from the handful of analytic hours being yearly practised by the early analysts (Furedi 2004: 9).
Total 550 2,203 11,604 16,149
Table 1. Comparative numbers of psychotherapists, counsellors and psychologists25
The expansion of the therapeutic was reflected in the proliferation of new kinds of psychotherapy being contrived. As Grunbaum (1984) noted, in 1959 a study was published listing thirty-six different kinds of therapy; while a later work by Wilby (1977) reports no fewer than 200 conceptually different psychotherapies. Current informants in the profession put the number of therapies in existence around the 400 mark. Despite the fact that only a minority of these 'therapies' enjoyed institutional support, their proliferation evidences the growing need to accommodate the increasing interest in therapeutic intervention.
The growth in the years after World War Two brought a vogue for do-it-yourself therapy. As Roy Porter notes, 'pop Freudianism, exemplified in the works of Eric Berne's (1964) The Games People
Play... helped people in their quest for self-understanding' (Porter 1996: 388). Other books such as Eric Fromm's (1955 [1942]) Fear of Freedom, Karen Horney's (1942) Self Analysis, and more recently Scott Peck's (1978) The Road Less Travelled seemed to offer new and exciting ways of understanding old dilemmas: 'Old fashioned religious, moral, and material principles were replaced by psychological categories', says Porter, 'the single example of this was the reception of psychoanalysis' (Porter 1996: 396)
The growing trend within post-war Britain to recast social or religious problems in psychological terms, a trend often resisted in the social sciences and particularly by Marxist theorists, was spotted as early as 1949. At this time the director of clinical research at Crichton Royal Hospital, Willy Mayer-Gross, noted that 'during the last 30 years the interest in psychiatry has shifted from the major psychoses, statistically relatively rare occurrences, to milder and borderline cases, the minor deviations from the normal average' (quoted in Porter 1996: 360). Surveys that originally focused on 'abnormal' populations when tabulating mental disorder began to include what had not hitherto been regarded as pathological: 'Psychiatric attention was thereby being extended to "milder" and "borderline" cases, and mental abnormality began to be seen as part of normal variability' (Porter, 1996: 360). The threshold of what people defined as illness dropped further in the coming decades, increasing the overall volume of psychological complaints (Shorter, 1997: 289). With the expansion of the therapeutic, problems that might have previously been considered economic, social, or moral in kind were gradually interpreted psychologically, usually in terms of illness, neuroses, or other injurious psychological problems. Social theorists such as Littlewood and Lipsedge (1987 [1982]), and Furedi (2004: 6) partly locate the higher rates of depression not in an actual rise in pathology, but in our tendency to over-diagnose the phenomena.26 Our cultural imagination has been socialised to reconfigure ever more experience as 'traumatic' and then to trace the aetiology of current mental states back to these traumatic and psychological origins.27
The trend towards 'medicalisation' or 'psychologisation' of discontent was promoted by the interests of the pharmacological companies. As suffering was ever more reconfigured in psychological terms, causes of distress were increasingly located within the person, and what better device to alter the very bones of subjectivity than psychotropic intervention. As the successes of drug therapy began to be publicised and as requests for prescriptions soared, it dawned on pharmacological companies that here lay the future. As one commentator claimed, in the scramble to corner the market these companies would distort psychiatry's diagnostic sense and increase the number of illness categories: 'A given disorder might have been scarcely noticed until a drug company claimed to have a remedy for it, after which it became an epidemic' (Shorter 1997: 319). The availability of treatments, both psychotherapeutic and pharmacological, led to an increase in the recognition of 'problems' that might benefit from these new treatments. This proliferation of problems naturally created a market for therapeutic services, which in turn endowed these services with ever more importance and power.
Therapy expanded in ways that Freud perhaps would not have approved of, because its expansion in Britain was not confined to the rise of the dynamic therapy of psychoanalysis. By the 1970s the talking cure that was once practised in a few scattered private consultancies, now permeated British institutions at many levels in some altered guise—universities, prisons, military institutions, out-patient units, schools, big business and corporate industry, had all to varying degrees institutionalised some version of psychotherapy or counselling. That many of these 'new' psychotherapies were not authentically psychodynamic many conservative psychotherapists would continually lament, but as expansion unfurled relentlessly, it seemed that neither their voices were heard nor their protests heeded. After the 1970s new psychotherapies gradually infiltrated that province once monopolised by the dynamic psychotherapist: the domain of private practice. Soon integrative therapists, counsellors, and clinical psychologists started establishing private consultancies which today far exceed in numbers the private clinics of psychodynamic practitioners.28 The growth of contending therapies also had many consequences for the more established institutions. One such implication was that new tensions and relationships were steadily forming between the growing number of trainings; trainings that came to order themselves into a complex training network. This complex network I shall now describe, largely because it is the turbulent context in which each individual institute must manoeuvre.
Centre and the Periphery—The Proliferation of Therapeutic Trainings
Accompanying this 'triumph of the therapeutic', as Philip Rieff (1966) would call it, from the 1960s onward there came a dramatic increase in the number of psychotherapeutic training schools being founded in Britain. As the number of these training schools gradually multiplied, a complex network of trainings began to emerge. Each training school, or training 'institute', as I shall refer to them here, whilst naturally related to wider social institutions, now also found itself related to neighbouring training institutes. Thus no single institute could be said to reside in de facto isolation.
As the network of trainings expanded in the 1970s and 1980s, individual institutes began to order themselves into their respective psychotherapeutic traditions (e.g. psychodynamic, behavioural, or humanistic traditions). Boundaries began to form between these traditions, the breaching of which became a serious matter. These boundaries were soon protected by one of two national psychotherapeutic accrediting bodies—the UKCP (United Kingdom Council for Psychotherapy) founded in 1989, and the BPC (The British Psychoanalytic Council, once called The British Confederation of Psychotherapists) founded in 1992. Thus any one training institute through its relationship to a particular tradition was linked to the authority of a wider accrediting body. A diagrammatic representation might look like the figure on the facing page.29
All the institutes, traditions, and both accrediting bodies are in turn related though dynamics of consensus or conflict not only to each other, but to wider social pressures residing beyond the boundaries of this training network.
Clarifying this assemblage of psychotherapeutic factions will be helped by identifying any structural patterns that could be said to exist between them. Not only will describing this structure help illuminate any shrouded order inhering in what on the surface appears a disorder of discrete institutions, but by exposing this hidden order we may reveal how it precisely affects the individual training institute, and in turn the individual trainee.
The Genealogical Structure
One way of clarifying this structure is to notice that the proliferation of psychotherapeutic trainings in Britain follows a historical trajectory that bears the mark of each new school founded at each historical point in time. To understand this concretely we might picture an upturned pyramid with the wide base representing the myriad schools in the present, and the bottom point the birth of the first training school in the past. From point to base unfolds an ever-expanding genealogical structure, which documents the naissance of every disparate school and training (see appendix two). Each of these trainings has its particular history and can claim ascendancy from either one or more founding individuals who, in the first place, would have themselves passed through a given training, and in the second, would certainly possess more or less recognised individual prestige. As with any member of a kinship system, if I may speak analogously, a given institute might trace it roots (via its founding members) from a previous institution whilst simultaneously providing roots for some newer descendent organisation, whether this 'descent' is approved by the mother institute or not. Each institute, then, sits spider-like at the centre of its own web of links and relations, always functioning in reference to its adjoining parts.
Another important feature of this genealogical structure is that between its constituent institutes we find relations of authority and status, a continual jostling for power, and a hierarchical ordering not always characterised by harmonious accord. For instance, more established training institutions such as the Institute of Psychoanalysis (IPA) or the British Association of Psychotherapists (BAP)— namely, those usually claiming the most illustrious founder-figures or current members, tend to have more say in how the particular 'tradition' to which it belongs functions and proceeds—in this case the psychoanalytic tradition. On the other hand, newer institutions which champion more novel therapeutic techniques, which belong to younger traditions (e.g. humanistic or integrative traditions), and which claim less illustrious figures as their founder-members, might have to struggle more arduously for status in the genealogical structure.
All such institutes whether fledgling or well-known have the opportunity to appeal beyond themselves for the ratification conferred by social institutions possessing higher and more established authority. These authoritative institutions might be either more high-prestige training institutes or traditions within the genealogical structure, or they may be non-psychotherapeutic institutions (e.g. medical, political, or academic institutions) sitting beyond the fringes of the genealogical bounds. This is to say, the struggle to acquire 'symbolic capital' of the kind that grants distinctive status need not be fruitless for fledging institutions if only they can align themselves to an accepted and authoritative institution, whether or not this lies inside the genealogical system.
The Institute of Psychoanalysis—A Case in Point
Within this network of trainings, or what I have referred to here more analytically as the genealogical structure, the Institute of Psychoanalysis is a key centre in terms of power and prestige, for it was the first and only British institute to be founded by Sigmund Freud. It is the oldest, largest, and best-known institute in Britain having for many the most venerable symbols and individual associations attached to it. Such is the mystique of this institute within the profession that only its graduates call themselves 'psychoanalysts' despite there being no legal bindings prohibiting anyone from calling himself a psychoanalyst. This institute then is a symbol that within the genealogical structure holds special prestige. Dynamic therapists trained at institutions other than the Institute of Psychoanalysis must alternatively take up the title, as I mentioned earlier, of 'psychodynamic' or 'psychoanalytic' psychotherapist, a title which, for many within the profession, lacks the formidable overtones of the label 'psychoanalyst'. Thus for the majority of psychotherapists, especially those within the psychodynamic tradition, this Institute is an authoritative centre, one often appealed to for both affiliation and endorsement. From this powerful centre proceed ever more peripheral institutes often experiencing decreasing levels of status. For example, a general consensus within the psychotherapeutic community seems to be that after the Institute of Psychoanalysis, there follow in prestige the psychoanalytic trainings within the accrediting body the British Psychoanalytic Council (BPC). Next in the hierarchy come the psychodynamic trainings within the accrediting body of the United Kingdom Council for Psychotherapy (UKCP); following these, the more humanistic and integrative trainings within the UKCP; below these come 'alternative' traditions within the UKCP; and finally come the manifold counselling trainings that are regulated by the British Association of Counselling and Psychotherapy (BACP).30
The hierarchy of the genealogical structure appears thus:
1. Psychoanalysts in the BPC
2. Psychodynamic or psychoanalytic psychotherapists in the BPC.
3. Psychodynamic psychotherapists in the UKCP.
4. Humanistic or integrative psychotherapists in the UKCP.
5. Other psychotherapists in the UKCP.
6. Counsellors in the BACP.
The traditions nearing the bottom of the list are often those that are newer in conception (see Table 2) and lack the status that comes with having a long tradition of authority behind them. It cannot be said that many institutes belonging to these traditions rest happily with their relatively low status (and indeed many would vigorously dispute the structure I have outlined above). And by observing their manoeuvrings their search for legitimacy can easily be inferred. One such manoeuvre is to acquire status by appropriating symbols from traditions with higher prestige. An example of this can be seen in the British Association for Counsellors' decision to alter its name in September 2000 to the 'British Association for Counselling and Psychotherapy'—apparently including the term 'psychotherapy' within the heading, a term with more symbolic capital than 'counselling', improves the standing of its member institutes in the eyes of the public.31
|
c. 1950 |
c. 1980 |
c. 2005 | |
|
Cognitive Behavioural |
0 |
2 |
30 |
|
Humanistic / Integrative |
0 |
9 |
22 |
|
Psychodynamic / Psychoanalytic |
3 |
21 |
44 |
Table 2. The Proliferation of Three Traditions and their Composite Institutes in the Genealogical Structure32
Another device peripheral institutes employ to gain recognition is to attempt aligning themselves with institutes of higher prestige. This presupposes that the prestige one group might experience is often rooted in its proximity to more prestigious centres. This has been attempted by two institutions in Britain, themselves possessing high status but who are at present appealing for higher status still from the International Psychoanalytic Association.33 If this acceptance is conferred then these training institutes will be permitted by the International Psychoanalytic Association to call their graduates 'psychoanalysts.'
As the central groups enjoy ownership of powerful symbols, the boundaries of these central groups often become sites of contestation. These high-status institutions fight to maintain the legitimacy of their values, symbols, and standards. There is a constant threat that if these symbols are appropriated by alien institutions and become therefore 'overused', the power they possess will be diluted. This dilution may have a negative impact on those institutions which at present enjoy the rewards—economic, professional —of such symbolic ownership. Evidence of the fight to both protect and appropriate dominant symbolic media is scattered throughout the history of British psychotherapy. A brief assessment of the rise of the UKCP and the BPC, the two major accrediting bodies for psychotherapy in Britain, can attest to this.
The UKCP versus The BPC—A Case in Point
The United Kingdom Council for Psychotherapy was inaugurated in 1989.34 The birth of this organisation was largely due to the publication of the Foster Report of 1971. That Report was the outcome of a government-commissioned investigation which recommended that the psychotherapeutic community open a national register in order to regulate and document professional activity. In 1989 the UKCP was founded for this very purpose and now registers all trainings and practitioners that fulfil its training and practice standards. Until the founding of the UKCP, psychotherapy trainings were almost completely unmonitored, most trainings being private ventures run by a largely volunteer staff and dependent on fees from their trainees for survival. Any institution might set itself up as a training centre without being subject to official scrutiny as to its ethical and training standards.35 Until the founding of the UKCP, if a training establishment either housed or proved to produce competent therapists engaged in publication and sound practice, it could win some recognition from neighbouring institutes and often some institutional affiliation, which in turn elevated the value of the diplomas it conferred. Once the UKCP was founded, this body attained the right to confer legitimacy on training institutes by granting them registration. The new UKCP register also held the names of all psychotherapists who had attained professional status by passing through one of the trainings it ratified.36
From 1989 to 1992 the UKCP was the sole registrar for all psychotherapists in the United Kingdom, and also registered all trainings from the most illustrious (the Institute of Psychoanalysis) to the smallest just newly opened. After 1992, however, the UKCP's role as the principle regulating body was usurped by a collection of the most established psychodynamic trainings within the UKCP. Following the lead of the Institute of Psychoanalysis many established trainings decided to break off to form an independent accrediting body, the BCP (British Confederation of Psychotherapists) now called the BPC (British Psychoanalytic Council). This new body, at that time comprising only four training institutes, nevertheless took with it what were regarded as the most prestigious trainings in the United Kingdom, including the Institute of Psychoanalysis (founded under Freud in 1913), the British Association of Psychotherapists (founded in 1951), The Society of Analytical Psychology (founded under Carl Jung in 1936), and the Tavistock Clinic. The cause of the split seems to have been the reluctance of the UKCP to allow the Institute of Psychoanalysis to have a veto over all decisions made by the UKCP committee. When asking the Chair of the BPC (at the time of writing) as to the reason for this split, she responded:
The Institute of Psychoanalysis is over 90 years old, so this and the other institutes that went with it are very established training societies which when put in the UKCP found themselves alongside some trainings that were ill-considered and still at their early stages.
In a sense the BPC was set up to distinguish the established psychodynamic trainings from these other institutes. (Interview 2004)
By not permitting the Institute of Psychoanalysis to veto any decision in the UKCP, power was stripped from this authoritative centre. And because power lies with whoever manages to define the situation, the oldest institute decided to break away. As the BPC Chair further explains:
We struggled with the UKCP wanting to include everybody, we felt that you actually had to learn to exclude organisations—we felt that they had to reach to the standard that we have set and until they could do so they weren't to be included... the UKCP wanted to level down to a common denominator what are in reality unequal groups. (Interview 2004, italics added)
The desire to have this inequality respected by the committee of the BPC was justified, as one senior psychoanalyst in the BPC argued, since,
the institutes that separated were elite institutes, and beyond in training and reputation other trainings in the UKCP... the shared label 'UKCP registered therapist' does not recognise these differences—it served them, but I don't think the same can be said for us. (Psychoanalyst 2004)
As can be seen from my interview with the Chair of the BPC, many in this accrediting body outwardly defended their separation from the UKCP as a move to protect standards and legitimate hierarchies. Other practitioners, on the other hand, more sceptical as to the real politics of the separation, argued that behind these public explanations actually sat concerns for 'power, patronage, and economics' (Young 1996: 2). However we decide to interpret what was behind this separation, one fact stands out: this act of segregation initiated by the dominant centres served to safeguard their ownership of dominant symbols and their right to legislate their view of what constitutes 'correct training and practice'. From the perspective of many within the BPC, the history of a given training institute, the kind of psychotherapy it endorses, the kind of practitioners associated with it, as well as the standards of training it expects (e.g. whether it demands once, twice, or five times weekly analysis for trainees), are matters deciding its standing in relation to other trainings. Within the BPC there is a prevalent belief that good practitioners are more likely to come from good trainings, and good trainings are those that appeal to the values of the dominant centre. By not having a veto on the machinations at the UKCP, the leading psychodynamic organisations felt they were literally handing over their power to define correct training and practice (i.e. the kind of training and practice conducted in their organisations), a power which in the hands of another might be used to their detriment.
Diachronic and Synchronic Appeals for Legitimacy
To turn now from assessing the struggles between the UKCP and the BPC, when looking at the wrangling between various institutes and traditions it is interesting to observe that the struggle for status appears to take place mainly on two fronts: status can be gathered either diachronically, via appealing for prestige from an illustrious past (i.e. from a consecrated history), or synchronically, through appropriating symbolic media from dominant present-day centres either inside or outside the genealogical structure. In many respects the more established institutes, which are mainly psychodynamic and those within the BPC, at present appear to gather status 'diachronically' by appeals to their various founding members, traditions, and their previous associations with more established cultural institutions such as the centres of academe and especially medicine. Institutional histories are thus contrived in such a way as to 'naturalise' the hegemony of BPC institutions.37
Newer psychotherapies that are without history enough to appeal diachronically for their legitimacy, including those within the humanistic and integrative traditions, largely appeal synchronic-ally for status. For example, as these newer groups have struggled to find acceptance from dominant centres within the genealogical structure, in recent years many have redirected their efforts to winning prestige and legitimacy from alternative centres outside this structure—i.e. establishing alliances with local universities who confer degrees on successful candidates. Such graduates receive not only the usual professional diploma on graduation but also have the opportunity to further acquire masters and in some cases doctoral degrees.38
We cannot explain the desire of these newer groups to seek acceptance away from the dominant centres only in terms of the unwillingness of the dominant centres to grant it, since many of these new units oppose the very premises of these central groups and only profess to share their values and symbols to a small extent.39 It could be said that the growing ability of these newer units to form alliances with centres outside of the genealogical structure has emboldened their opposition of the traditional centres as they are no longer entirely dependent on these for recognition. This emboldening has led some units to harbour beliefs that they are the depositaries of the proper values of the real tradition as the central group has somehow been led astray. These new units manipulate old symbols in different ways—for example, they may call upon tried and tested Freudian principles to illustrate the need for new institutional trainings.40 Thus they may attempt to develop new interpretations of existing symbols and norms so as to strive for a change in the very basis of the institutional order. This struggle for institutional legitimacy fosters what Max Weber called 'antigroups' within the genealogical structure itself: groups which create tensions between themselves and the dominant centres.
Segmentary Patterning of the Genealogical Structure
If at moments we might have glimpsed through my representation of the genealogical structure what anthropologists call a 'segmentary patterning', let me now open up this viewpoint to explain how this patterning seems to work. Training institutes are continually forming alliances with other institutes that at other times they might have opposed. For instance, the hot-headed wrangling that once characterised relations between Jungian and Freudian institutes (i.e. the Institute of Psychoanalysis and the Society for Analytical Psychology) has today receded to allow an amicable alliance under the umbrella of the BPC. In fact beneath the canopy of the BPC now lie a myriad of psychodynamic schools that at one point resided in angry relationship.41 Unravelling the problem of this change, this softening of enduring rivalries, I believe is assisted by noting that all segmentary alliances imply the proximity of a greater external danger. For nothing better resolves the enmity of old adversaries than a new, shared, and nearing threat. If the segmentary interpretation is applicable in this instance the next question we must ask is what form or forms can this threat be said to take.
From our discussion we can infer that a threat is posed to the higher psychodynamic centres by those lower down in the genealogical structure. As the BPC / UKCP split illustrates, many psychodynamic institutions have closed ranks to protect ownership of key symbols that have always assured their dominant position, a position which, as sociologists of the professions might argue, secures definite economic, professional, and employment rewards. But this threat from below cannot alone explain this sudden 'coming together' of once disparate and rival schools, for in the first place, one could argue that this threat from below is not yet strong enough to override such perennial divisions, and in the second, that this merging can trace its origins to a time before the rise of the 'peripheral' and 'anti-groups' in the genealogical structure. For the whole answer to the question as to why new alliances are being formed between old foes, we must look beyond the genealogical structure to the wider social scene in which the structure is embed-ded—that is, we must look to extra-psychotherapeutic institutions whose alterations have consequently challenged the authority of the psychodynamic.
The Threat to the Psychodynamic
Although with the expansion of the therapeutic during the twentieth century the psychodynamic tradition experienced much institutional growth, this expansion was not accompanied by either an increase in this tradition's status or a solidification of its early hegemony. In fact, despite having located the psychoanalytic institutes at the head of the genealogical structure, it is important to note that these particular 'centres' hold onto their privileged position with increasing difficulty. This becomes more understandable as soon as we look beyond the genealogical structure itself in order to observe the wider public perceptions of psychoanalytic therapy. By this method we will recognise that since the 1970s the psychodynamic has come under increasing threat due to a number of shifting factors, which I shall now enumerate—the first being the fall of the psychodynamic within psychiatry.
The Rescinding of Psychiatric Approval
A centre outside of the genealogical structure to which psychoanalytic therapy has always appealed for legitimacy is the psychiatric establishment. The main founders of dynamic psychotherapy, S. Freud, C. G. Jung, and A. Adler, were all psychiatrists themselves and it was through them that the practice came to bear the unmis-takeable imprint of the physician's consulting room—a fact evident not only in the terminology of psychodynamics but also in the framework of its theory. Dynamic therapy, then, despite its struggle for acceptance from psychiatry during the early twentieth century in Britain, had nevertheless a place in psychiatry from its outset. If early on those approving of psychodynamics were few, from the First World War onwards, and as we have seen, this number was to increase. With this growing acceptance came the rewards of being favoured by medical science. Laymen who trusted in the authority of medicine would also trust the practices it endorsed—psychoanalytic therapy was growing strong from its association with medicine. As Julian Lousada tells us:
[this association gave psychoanalysis] the tremendous advantage of being close to, even if not exactly being at the heart of the [psychiatric] establishment... The development of psychoanalytic psychotherapy has throughout this century grown then, at least in part under the protection of an influential faction within psychiatry... In my view it is not just the independence of British society and the psychotherapy organizations or the freedom associated with private practice that created the capacity for the growth... but rather the protection and inclusion that was offered by psychiatry that enabled such rich development, both organizationally and intellectually, to take place. (Lousada 2000: 471)
This powerful centre not only provided a roof under which practitioners could safely develop their craft, but was also an authoritative ally under whose patronage, in the eyes of the layman at least, the sanction of medical science was conferred. This strengthening association between psychoanalysis and psychiatry was growing even stronger in the United States. Between the end of the Second World War and the beginning of the 1970s psychoanalysis became dominant in American psychiatry (Luhrmann 2001: 203-38). As Bertram Brown (director of North America's National Institute of Mental Heath) tells us: during this period 'it was nearly impossible for a non-psychoanalyst to become chairman of a department or professor of psychiatry' (Brown 1976: 492). As early as 1952 dynamic therapists were heavily represented in the American Psychiatric Association and by the early 1960s they held key positions on its membership panel, and, more crucially, on its diagnostic committee (p.299). This second detail is important as this committee decided how and in what way pathology was to be defined. These definitions, made concrete in the Diagnostic and Statistical Manual, were thus heavily under the influence of the psychoanalytic thinking of the day. This proved to further consolidate the hold of dynamic therapy in American psychiatry throughout the 1950s and 1960s. As Shorter says:
The DSM-II reflected this [psychodynamic] sway. Six of the ten members of the drafting committee were analysts or belonged to sympathetic organizations.
The nomenclature mirrored this predominance: Psychoneurotic problems were no longer called 'reactions' but 'neuroses.' The sturdy Freudian term 'hysteria' appeared, replacing 'conversion reaction' and 'dissociative reaction'. (Shorter 1997: 299)
British psychiatry during these years was freer of psychoanalytic influence than its American counterpart. However, when psychiatric opinion began to turn against dynamic therapy, although British psychodynamics had less distance to fall, it felt the impact nonetheless. From the late 1970s onward psychoanalytic psychotherapy across both sides of the Atlantic was to find itself ever more peripheral to medical psychiatry. This meant that a key centre to which psychoanalytic therapy had always appealed for legitimacy began to rescind its approval. A few factors can account for this change: first was the mounting criticism both inside and outside of psychiatry as to the scientific status of psychoanalysis. This was compounded by psychiatry's need to prove itself scientifically to other departments of medicine, which by implication led psychiatry to dissociate itself from 'unverified practices.' There was also the rise of new therapies that appeared to have a stronger evidence base, and that also seemed to better fit the structures of modern medical institutions. And finally, there was the rise of organic psychiatry in the 1980s with its championing of psychotropic over therapeutic intervention.
If we start with the criticisms levelled against the scientific respectability of psychoanalysis we find in the 1950s a series of studies which, when being fully acknowledged by the psychiatric community in the 1970s, were to irrevocably wound the psychodynamic cause. Rather than arguing the case for or against the efficacy of psychoanalytic psychotherapy, these studies pitted psychoanalysis against other 'therapies' to conclude that in terms of successful therapeutic outcomes psychoanalysis produced no better results than did behaviourist, humanistic, or existential alternatives. In fact, in the majority of cases, as Han Eysenck the director of psychology at the Maudsely Hospital argued, psychoanalysis appeared to have lower success rates than its newer counterparts. For example, Eysenck's (1952: 321) study found that only 44 percent of psychodynamic patients improved by the end of their analysis while other therapies could boast improvement rates of 64 percent. While this general conclusion was highly questionable to many psychoanalysts, for many psychiatrists it was seen to be supported by other studies—e.g. Fred Fiedler's (1950) influential investigation which found, firstly, that experienced therapists of different modalities actually behaved more similarly in a technical sense than did therapists from the same modalities who had different levels of experience, and, secondly, that of the several very different sorts of therapy assessed all seemed to work equally well. This second finding, along with Eysenck's, by challenging the claimed supremacy of dynamic therapy had a considerable impact on the field of psychiatry as a whole. As one informant mentioned, it was generally regarded in the hospital corridors as the 'equivalence paradox'. This paradox meant that 'results' (whatever 'results' might be felt to be) for various approaches to psychotherapy were equivalent in spite of the avowed theoretical and technical differences between therapies. Elsewhere the equivalence paradox was supported by researchers such as Nagel and Hook (1964); Lubor-sky and Luborsky (1975); Farrell (1981); and Williams and Spitzer (1984)42—all of which asked for the supremacy of psychoanalytic psychotherapy to be re-appraised by mental health professionals.
That these and other findings made many scholars, among them anthropologists, claim that if psychoanalysis worked it was not for the reasons that analysts stated, is a matter I shall take up again in chapter two.43 For now, however, what is relevant about these research findings is that for those who accorded them any kind of authority (and many in psychiatry did), the claim that psychoanalysis was the premiere therapy was now severely undermined. These detractors reasoned that if the dynamic therapists were correct in thinking they had got it right, surely they would enjoy higher outcome rates than did therapists offering 'alternative' approaches. Many psychoanalysts responded to this, as Professor Peter Fonagy mentioned to me in interview,
by arguing against the value of evidence-based research. These therapists turned their backs on this research as on an enemy, which led to the unfortunate consequence of their becoming increasingly anti-empirical, an attitude that in a climate demanding evidence-based practice has jeopardised the position of psychodynamic on the British wards. (Interview 2004)
If these studies sought to humble psychoanalytic therapy via academic wounding, then others were less forgiving and moved in for the kill. Key intellectuals launched strong attacks on the scientific standing of psychoanalysis, while old critiques, once thought long-buried by the psychotherapeutic community, resurfaced to remind readers of the questionable nature of its design. Karl Popper argued that as psychoanalysis was 'non-testable' it was therefore non-scientific. Adolf Grunbaum (1984) criticised Popper's conclusion and went forward to show that psychoanalysis could be tested, proceeded to test it, only to conclude it was false. Ludwig Wittgenstein (1988 [1946-7]) launched searching questions regarding the nature of Freud's understanding of the symbolic, while Ernest Gellner (1985) exposed the dynamics by which psychodynamics rendered itself beyond criticism. Newer and more popularist studies exposing the underside of the profession were also published in abundance: Richard Webster's (1995) Why Freud Was Wrong re-analysed the symptomatology in Freud's early case studies and argued that he misdiagnosed as psychic pathology many organic diseases; J. M. Masson (1984), an apostate psychoanalyst, argued that Freud deliberately obscured the importance of childhood sexual abuse, representing patient's complaints as manifestations of a 'false memory disorder'; while Thomas Szasz (1979), the iconoclast practitioner from the anti-psychiatry movement, compared dynamic therapy to a species of spiritual healing thus undermining its pretensions to scientific credibility. And within psychiatry itself, anthropologists such as Roland Littlewood (1982; 1992; 1999) in Britain, and Arthur Kleinman (1988) in the United States, argued that much psychodynamic practice was culturally biased, urging for it to become more culturally-reflexive.
These criticisms compounded a general unease within British psychiatry as to the merits of the psychodynamic. An unease which took practical effect when by the 1980s other therapeutic options surfaced that were more congruent with the requirements of the NHS. A psychoanalyst and NHS Director of psychotherapy services mentioned to me in interview:
What we now call the BPC-trained dynamic therapists have since the 1980s steadily lost ground in psychiatry. What seems to have happened is that tension has grown within psychiatry between those who have had BPC training and those who do not... the non-BPC-trained psychotherapists would characterise those trained there, especially at the Institute of Psychoanalysis, as elitist, out of touch, too specialised, and operating a model that is not applicable to the NHS... There is a cultural and organisational move away from valuing psychodynamic approaches and this is furthered by the rising prominence of CBT [cognitive behavioural therapy] which fits well with evidenced-based intervention and satisfies the political pressure on managers to cut waiting times. This can be done by offering short-term therapy, which CBT therapy is all about, unlike dynamic therapy which is a more long-term option. (Interview 2004)