I opened the last chapter by noting that to fathom the psychody-namic concept of aetiology we must look to the specific socio-historical conditions out of which it arose. Emphasising how this concept is psycho-centric, I then illustrated through our case study how trainees learn to use such aetiological understanding to guide their clinical interpretations and actions. In this chapter, by contrasting psychodynamic aetiology with aetiologies found in other healing systems studied by anthropologists, I shall not only locate the psychoanalytic conception within a wider scheme of aetiologic-al classification, but also illustrate that the psychoanalytic notion of aetiology constitutes one basis for the practitioner’s conviction that psychodynamic therapy has something to offer any patient in emotional distress.
My second aim in this chapter is to note that as the theory and practice of psychotherapy is transmitted in the social space of the institute, the covert pressures of this space bend trainees’ subjectivities toward a posture of receptiveness. In other words, we will see how such receptiveness is nurtured by the various institutional stressors to which trainees are subject, stressors disposing novices to submit to the guidance and instruction of seniors.
Having in our possession the conceptual and empirical data of the last chapter, we are now in a stronger position to place psychoanalytic aetiology within a wider system of classification. The classific-atory system I would like to discuss is not an indigenous nosology (i.e. one created by the therapeutic community), since it is founded on anthropological rather than psychotherapeutic principles. However, as I offer it here to better understand, or more clearly translate, an aetiological outlook that practitioners embodied as a core disposition, for the purposes of my central argument its contrivance seems justified.
To understand psychoanalytic aetiology in relation to other aeti-ological systems let me first review some existing anthropological literature pertinent to this subject. Not only will this enable us to set psychotherapy down within a broader context, but it will also help us to illuminate through contrast and comparison the exact kind of aetiology psychoanalytic therapy embraces.
In surveying the ethnomedical literature on illness aetiologies one thing immediately arrests our attention: such systems look to orthodoxy (the concepts the practitioner holds) rather than orthop-raxy (the practice the practitioner undertakes) for the basis of classification. Since the early work of W. H. R. Rivers (1924) this criterion has served to clarify the aetiological idiosyncrasies of diverse healing systems. However, this‘concept-centred’ emphasis has led to a depreciation of praxis or clinical activity as an equally useful criterion by which different aetiologies might be classified and ordered.130 In what follows I hope to show why omitting to take praxis into account constitutes an oversight, one which for our purposes warrants rectification. Before I do this, I shall first look at some concept-centred classifications, paying especial attention to Young’s dichotomous classification of‘externalising’ and‘internalising’ systems.
The first classificatory system I shall discuss is from Seijas (1973), which classified non-Western aetiologies into‘supernatural’ and‘non-supernatural’. He explains:
Supernatural etiological categories refer to those explanations that place the origin of disease in supra-sensible forces, agents, or acts that cannot be directly observed [e.g. susto, evil eye, sorcery, spirit intrusion etc.]… Non-supernatural explanations of disease are those which are based entirely on observable cause-and-effect relationships, regardless of whether or not the relationship is mistaken because of incomplete or faulty observation. (Seijas 1973: 545)
A system similar to Seijas’ was earlier offered by Nurge (1958) who, discussing aetiology beliefs in a Philippine village, found a distinction between‘supernatural’ and‘natural’ causes. The former being caused by spirits and witchcraft etc., the latter by phenomena in the‘natural world’—i.e. changes in climate, diet, and bodily sensations.
A later study offered by Foster and Anderson (1978) takes issue with the work of both Seijas and Nurge on the grounds that they conflate under the category‘supernatural’ things quite distinct conceptually. They write:
[For Seijas and Nurge] The term‘supernatural’ refers to an order of existence beyond nature or the visible and observable universe that includes beings such as deities, spirits, ghosts and other nonmaterial entities. Witches and sorcerers do not belong to the supernatural world. Sometimes they draw on the supernatural, but their powers are best thought of as magical, consisting of spells charms, and black magic. To classify witches and sorcerers as supernatural—as Seijas and Nurge must do—seems to us to do violence to the concept. (Foster and Anderson 1978: 54)
Foster and Anderson thus offer an alternative classification based on what they term‘personalistic’ and‘naturalistic’ explanations. For them, the‘personalistic’ system is one in which illness is caused by an external agent who might be either nonhuman (ghost or ancestor), supernatural (deity or God) or else human (a witch or sorcerer). Alternatively in‘naturalistic’ systems illness is understood in impersonal, systemic terms. Here illness is a result of either external natural forces, disequilibrium in the body (e.g. between yin and yang), or disequilibrium between body and either the social or natural environment (p. 53).
In a real sense Foster and Anderson’s classification, which is offered as an improvement on earlier systems, has been subsumed under a more recent system of classification advanced by Young (1983) who defines all healing systems as either‘internalising’ or‘externalising’. Externalising systems are those placing the causes of ill-health outside the person—in precipitating social or metaphysical factors; while internalising systems do not look beyond the body and mind for the causes of distress. To illustrate this difference: a practitioner looking for external causes for a patient’s fatigue, will not locate the cause of the fatigue in the patient’s body, but will allude to variables outside the body and might ask, for example: whence the sequence of events causing the fatigue?—is there social tension or even some witchcraft at play? (Evans-Pritchard 1934: 70). Alternatively, an internalising practitioner such as a biomedical doctor will follow the chain of causal influences only so far—the fatigue may be traced to anaemia, anaemia to blood loss, blood loss to a bleeding stomach tumour, the stomach tumour to certain carcinogens in the diet. At this point the doctor’s inferences will usually stop, since although certain psycho-social factors might have influenced the sufferer’s diet, such factors are of little clinical relevance to a doctor trained to treat the body alone (Blaxter 1970: 160).131
Having now illustrated Young’s externalising and internalising system, let me indicate how it subsumes Foster and Anderson’s (which in turn replaced Seijas’ and Nurge’s):‘naturalistic’ explanations such as disequilibrium in the body could be classed as‘internalising’. On the other hand, the‘naturalistic’ explanation of disequilibrium between body and environment could be classed as either‘internalising’ or‘externalising’ (depending on which domain diverges from the socially defined norm). Finally,‘personal-istic’ explanations such as witchcraft and spirit possession, because of their external origins, fit neatly into the‘externalising’ category.
While Young’s classification can thus include the systems so far discussed, it is not without its own limits: i.e. it insufficiently accounts for systems that give equal weight to both domains in the aetiology of illness. For instance, Beatrice Whiting’s (1950) classic study of the Paiute offers a clear example of a system that is neither exclusively externalising nor internalising. For the Paiute the cause of a given disease can be traced to either the external or internal domain. This led her informants to claim that‘no layman could predict what the doctor’s power would tell him’ (Whiting 1950: 30). However, she did identify some diagnostic trends: any given disease could be caused by any one of four causal agents. She writes:
When they [the doctors] determine the cause as failure to obey one’s own power, the censure is on the patient’s own action [internalising cause]; in ghost sickness, the blame may be based on the deceased’s relatives [externalising cause] or on the patient for thinking of them [internalising cause]. In the case of sorcery, the blame is placed on someone else [externalising cause]. (Whiting 1950: 64)
For the Paiute healer, the cause of any disease can be traced to either external or internal events, depending on the person who brings the complaint. From Young’s standpoint, and in contradiction to his dichotomy, we must say that the Paiute system uses both types of aetiology.
Young’s response would be that his dichotomy is rather a continuum in whose middle ground can be strung systems that are both internalising and externalising, such as the Paiute’s (Young 1983: 1205). However, while this concept of the‘continuum’ can accommodate such middle systems, Young does not explain exactly the forms such middle systems might take, either conceptually or clinically: do all middle systems trace one disease to one causal domain (either external or internal), as the Paiute do? Or do some acknowledge that both causal domains (or possibly more) jointly entail the one disease?
In respect of the second question Robin Horton’s (1970) study of the Kalabari of the Niger Delta provides an instance of a system which sees both domains involved in the one disease. Kalabari diviners may first treat a disease with herbals in a purely unreligious way. But if this intervention produces few positive results there is believed to be‘something else in the sickness.’ The healer will then draw upon wider diagnostic knowledge and relate the disorder to a more comprehensive range of circumstances—often to disturbances in the sick person’s social relations. Whilst directing alleviat-ive action at the community (social drama), he or another healer will also offer appeasement to angered spiritual agencies, thereby administering a further type of treatment. As the diviner’s remedial action is multi-directed it also assumes multiple aetiologies (Horton 1970: 342-368).132 Thus individual, natural, social, and metaphysical causes are seen not as mutually exclusive, but as often working together to cause the particular instance of disease or discontent.
The usefulness of Young’s distinction would be deepened if it included a supplementary description of the various forms these‘middle systems’ can take. At present he neither describes how these middle systems conceptualise aetiology, nor acknowledges that middle systems must inevitably entail clinical action more diffuse than that found in strict internalising or externalising systems. That is, his study does not inquire as to the unique kinds of clinical action to which differing middle systems (or the polar systems) give rise. For example, in the internalising system of biomedicine, which assumes that biologic concerns are the more basic or‘real’ concerns, remedial action is largely directed at one domain alone— the body; whereas in systems such as the Kalabari’s, remedial action is directed at potentially many domains—at the body, at the relational field, at spiritual agencies, etc.133 Thus accompanying the multiple forms of aetiology in‘middle systems’, we can expect multiple forms of clinical intervention, just as in strict internalising or externalising systems we can expect intervention of a more circumscribed kind. It is this link between orthodoxy and orthopraxis that remains unexplored by Young. Yet as it is precisely this linkage that is crucial for understanding psychotherapy, it seems necessary for my specific purposes to advance a new system of classification that is less a replacement of, than an attempt to supplement, Young’s concept-centred model.
To devise this auxiliary model I shall use a different criterion by which to classify aetiological systems, basing it on healers’ clinical actions rather than on their causal formulations. This criterion not only builds a classificatory system upon the ground of instrumentality, but has the added merit of accounting for systems, as Hsu (2004) has shown, that do not follow a Western understanding of causation when making diagnoses (e.g. ancient Chinese systems spoke more of‘synchronous signs’ than of‘causation’)—systems that by implication would be misrepresented if classified by any of the concept-centred models discussed.134 By classifying systems according to the domain at which clinical practice is directed, we classify in accordance with what all healing systems unequivocally share: a healer who clinically acts.
In the light of this instrumental model, for my purposes I shall speak of mono-directive and multi-directive systems as auxiliaries to the externalising and internalising categories135 : mono-directive systems being those that level clinical action at one domain (e.g. the body); multi-directive being those that level action at two or more domains (e.g. at body, social relations, spirits etc.). These‘directive’ and‘externalising/internalising’ systems, I further argue, are compatible, and thus can be unified into a more comprehensive classificatory structure as the following summary will show:
Orthopraxis Orthodoxy136
Mono-directive—Internalising (e.g. Biomedicine—healing via medicine, surgery, etc.)
Mono-directive—Externalising (e.g. Forms of witchcraft—healing via sacrifice)
Multi-directive—Internalising (e.g. Psychiatry—healing via pharmacology [the body] and psychotherapy [the psyche])
Multi-directive—Externalising (e.g. Witchcraft—healing via social drama; prayer, oblation)
Multi-directive—Externalising / Internalising (e.g. Sorcery—healing via medicinal intervention [the body], and via social drama [external])
Although this classification is not exhaustive (i.e. it documents neither‘inconsistent’ systems nor healing ideologies underplaying causality) it is an attempt at a classificatory scheme which attends to both concept and action—a scheme, which, as I now intend to show, will help us better understand the practice of psychoanalytic psychotherapy.
Psychoanalytic psychotherapy, like certain forms of biomedical intervention, is a predominantly mono-directive, internalising system. It is internalising as its conceptual thrust privileges psychology in causal explanations (as theoretical description at the beginning of the last chapter demonstrates). It is mono-directive since alleviative action is primarily aimed at removing psychological impediments to health. Beyond altering the‘inner world’ of patients, psycho-therapeutic intervention has little to say: there is no direct intervention in the patient’s social world, there is thus no‘social work’, no suggestion or advice—as the facts of our case study illustrate. Rather there is a tendency to coax patients into interpreting their situations psychologically. This is not to say that psychotherapists‘intellectually’ ignore other influencing factors (e.g. our supervisor saw Arya’s immigration as implicated in her‘loss of identity’); but because the therapist does not stop here, but moves incrementally to consider either precipitating events or else to locate in subjectivity the inability to cope, we can speak of dynamic therapy as privileging a kind of psychological interpretivism which looks beyond the external causes to the internal‘masochism’ or‘objects’, so to speak.
In this sense the relevance of physical explanations of distress or of what anthropologists such as Comaroff (1985), Kleinman, Das and Lock (1998), and Sharp (1993) have called‘social suffering’137 are generally downplayed in all but the severest cases.138 In fact, concepts which trace emotional suffering to social causes (e.g.‘anomie’,‘alienation’,‘ennui’, and‘mal du siècle’139 ) are replaced by concepts consistent with psychodynamic interpretation (e.g.‘depression-affective disorder’,‘anxiety disorder’ or‘affective symptoms’ stemming from‘character disorders’); concepts which define subjective states in accordance with psychoanalytic interpretative understandings and modes of intervention.
Learning how to regard the patient’s presenting issue in psychoanalytic terms, as I have tried to show in our case-study, is at the heart of what it means to think and act psychoanalytically. In fact, whether or not therapists make sense of phenomena perhaps better understood from other interpretative standpoints is not much considered in training. Therapists are not taught to question whether they are simply‘recasting’ phenomena in psychological terms, and instead learn that they‘unearth’ them: unearth their roots and their shrouded meaning, which are concealed behind the brute incidences of life. This psychodynamic imagination, this intellectual strategy, justifies to the therapist the deployment of the mono-directive / internalising intervention even in what could be considered from other standpoints as‘problems’ not reducible to psychological causes and thus inadequately met if treated by psychological methods.
By means of inspecting case after case during the tenure of their training, trainees become expert in reading psyche into any script. That any patient’s narrative has its‘psychological layer’ is a conviction bolstered over years of honing one’s psychodynamic imagination to read into distress phenomena treatable by psychothera-peutic intervention. Such thinking, rooted in psychoanalytic theory, endows psychotherapeutic strategies with purpose and legitimacy, since it provides a basis to the widespread conviction that when patients are in any kind of emotional distress therapists have something vital to offer.
The therapeutic understanding of aetiology, discrete, neat, and pragmatic, is a pillar of conviction upon which practitioners can lean for support and confidence; confidence, as one therapist in the NHS disclosed to me, that is indispensable to successful clinical practice:
it is what allows therapists to act; to act in what are often stressful and uncertain situations, actually in face of unknowing… since we can always help and have some impact, it is just a matter of finding that specific entrée into the problem we encounter, and making sense of it—after this we can make use of our particular expertise. (NHS Psychotherapist 2005)
To trace something unknown back to something known is gratifying, reassuring, and endows the therapist with confidence and moreover with power. Hesitancy, reservation, and the anxieties of vacillation are largely eliminated by the conviction that one’s model can render the mysterious fathomable, the perplexing discernible, the strange familiar and routine. Because the embodied theory is felt as an authoritative guide, and since it therefore offers the practitioner a certain clinical orientation and security, we can understand why belief in its veracity, and consequently its‘applicability’, is dearly protected.140 To illustrate the conviction many therapists have in the applicability of their form of intervention, consider the following words of one senior therapist whom I interviewed during my fieldwork:
If I ever turn down patients, and I do this very rarely, I never do so because I don’t think therapy can help; it is because I think that this particular patient is not suitable for me, or on the rarer occasion that they are not quite ready for it. [‘Do you believe therapy has something to offer anyone in emotional distress?’] Therapy is about the belief that there is always something we can do once the patient is ready, even if the patient doesn’t know it. (Senior Therapist and Supervisor 2005)
How practitioners develop such a sense of conviction in the relevance of their particular form of intervention, has itself been the subject of much scholarly discussion. Renee Fox (1957), for instance, first identifies three kinds of uncertainty endemic in medical socialisation, before describing how students develop conviction in medicine in spite of these.141 She starts:
The first [kind of uncertainty] results from incomplete or imperfect mastery of available knowledge. No one can have at his command all the skills and all the knowledge of the lore of medicine. The second depends upon the limitations in current medical knowledge. There are innumerable questions to which no physician, however well trained, can as yet provide answers. A third source of uncertainty derives from the first two. This consists of difficulty in distinguishing between personal ignorance or ineptitude and the limitations of present medical knowledge. (Fox 1957: 208-9)
Fox (1980) continues in a later paper to describe the conviction that nevertheless emerges:
Students [despite these uncertainties] gradually evolved what they referred to as a more‘affirmative attitude’ toward medical uncertainty… in clinical situations, they were more prone to feel and display sufficient‘certitude’ to make decisions and reassure patients. (Fox 1980: 7)
Joan Cassell (1987: 242) when discussing Fox’s work shows how other anthropologists have interpreted it differently. Jay Katz (1984), for instance, noted that the students described by Fox experienced growing certainty in their chosen specialities as their training continued because medical socialisation was essentially about routing hesitancy and clinical irresolution. This kind of‘training for certainty’, as Sinclair has also shown (1997: 146), is something students happily embrace. For Katz, certainty was instilled by instructors who criticised any display of vacillation in students, urging that doubt would impair the student’s effectiveness with patients. Katz suggests that the pyramidal nature of medical training, moving from medical school, to graduate training, to the final goal of specialisation, was instrumental in securing this confidence. As the students progressed their conviction grew, since extended socialisation would not only‘foster beliefs in the superior effectiveness of treatments prescribed by one’s own speciality’ but would also‘tend to narrow [their] diagnostic vision’ (Katz 1984:188, italics added).142
This correlation between the development of‘conviction’ and the‘narrowing of diagnostic vision’ operates not only in biomedi-cine, but also, as I have argued, in psychoanalytic systems so far as therapists gradually learn to read into any script problems treatable by psychotherapeutic techniques. This raises the question: if in both these systems a mode of practice (e.g. mono-directional) is analogical with a mode of being (e.g. a disposition of conviction) can we suppose this correlation to be a general feature of mono-directional systems? Furthermore, if a general linkage obtains, do other aetiological systems (e.g. multi-directional) also bring their distinctive experiential correlates?—that is, would a practitioner of a diffuse‘middle system’ better cope with doubt and uncertainty than those practising in more circumscribed systems?143
Important as such questions are, they must remain subsidiary to the more pertinent matter I must now investigate—namely, a factor that both Katz and Fox’s work presupposes: the presence of‘susceptibility’ in trainee practitioners to move into a posture of conviction.
As the presence of susceptibility precedes both the‘affirmative attitude’ and that which this attitude affirms (i.e. conviction in the merit of the clinical system one employs), in the final part of this chapter I would like to explore not only the different kinds of susceptibility to which trainees are subject throughout the course of their training, but also the institutional conditions that engender such susceptibilities in the psychotherapeutic novice. These institutional conditions, I shall argue, provoke socially induced responses (stresses, inclinations) which in turn render trainees more susceptible to the internalisation of pivotal clinical dispositions, and in this case, to the embodiment of affirmative mono-directive / internalising practice.
In noting the importance of stress in facilitating processes which transform persons, we take our departure from authors such as Anthony Wallace (1961) and his idea of ritual learning, whereby stress is evoked in participants to secure a gradual reorganisation of experience resulting in far-reaching cognitive and emotional changes. Such learning may be found in tribal initiations (La Fontaine 1985; Herdt 1987; Richards 1956; Sarpong 1977), individual conversions to religious movements (Heelas 1996: 35-52), in the‘restructuring of behaviour’ that accompanies recruitment to messianic cults (Katcher and Katcher 1968), and in the stressful transformations persons undergo when becoming a nuclear physicist (Gusterson 1997), a psychiatrist (Luhrmann 2000) or a medical doctor (Becker et al 1977; Sinclair 1997). In what follows I shall describe the emotional atmosphere in which supervision of the kind outlined earlier transpires. I shall illustrate that the events of supervision never occur in an affective vacuum, but are rather shaped by the emotional conditions of training which evoke stresses in trainees that render them susceptible to conform to and accept the clinical instruction on offer. In this sense we follows Becker’s observation that:
Much human conduct is orientated to the immediate pressures and social controls originating in the situation in which the person is presently acting, and that he will organise his behaviour so as to take account of and in some way adjust to them. (Becker et al 2002 [1977]: 442)
As I have already touched on one‘susceptibility’ in chapter two —viz. the‘disposition of partiality’ which leaves trainees receptive to‘affirmative’ educational techniques, to this foundational disposition I now intend to add some new susceptibilities that arise at different stages of training as responses to implicit or explicit institutional stresses and demands. This is not to say that these susceptibilities are discrete, faithfully coming and going with the passing of their concomitant stages, but that each stage engenders a dominant susceptibility which can be re-experienced in mitigated form at other stages if the conditions of training demand it.
Finally, the susceptibilities described articulate the experience of trainees who fall within the parameters of the‘general experience’—that is, the most commonly shared experience by the majority of trainees I befriended. That this‘common experience’ is something one can clearly observe in the training institute means we can speak of it as‘collective’ rather than‘individual’. This in turn leads us to suppose that it is preferable to regard it as socially induced by the conditions of the training institute, rather than to see it as a product of individual psychology.
During the first stage of training candidates are rendered susceptible to the guidance of elders by the fear that they will be judged as unsuitable for the therapeutic profession. The evaluative gaze of the training committee is often experienced as intense and pervasive, mainly because at this stage of training candidates are subject to the continuous assessment of supervisors who are not so much judging trainees’ skills as practitioners, but themselves as persons. It is this inability to allow‘high grades’ and‘successful results’ to speak for their suitability that renders trainees so vulnerable. Trainees quickly learn that they are judged on something more intangible, less easily demonstrable or quantifiable than‘examination performance’—namely, on a vaguer kind of‘aptness’ as perceived by evaluating committee.
Whatever constitutes such‘aptness’ remains mysterious to many trainees until they are informed about how they are being perceived by their seniors. In the institution I observed, trainees were informed of their progress in one of the two tutorials which they attended yearly. These meetings on the whole tended to focus more on personal issues (the trainee’s‘traits’ and‘behaviours’) than on academic results. Despite the potentially upsetting turns these meetings could take, most trainees I spoke to found these‘relieving’ and‘reassuring’ affairs, occasions when pent-up‘fears’ and‘reservations’ about how they are being perceived were dissipated.‘You never quite know what the trainers are thinking’, mentioned one student of psychology training at the institute,
so there is always a part of you that expects the worst. So far the feedback I have received has been fine, but there is some internal saboteur that still anticipates problems. (First Year Trainee 2004)
This trainee later told me with some reticence that his ruling fear was that the committee would discover that the woman he lived with was not in fact his wife (his therapist who was affiliated to his training institution knew this, and so he was concerned this would be informally communicated). He feared that his position would prejudice them against him. He confessed to me:
I am 39 years old, and so I am not at ease with my situation… I sometimes think there is a quiet belief about where you should be in life at my age—they might at some level hold my situation against me, this is my fantasy at least. Maybe I am wrong, but you know I fear the response. (Third Year Trainee 2005)
While indeed this fear might well be a product of‘fantasy’, we also realise that these fantasies might be easily exacerbated given that assessment falls on the‘trainee as person’.
When asking senior members to characterise the apt candidate they often used terms such as‘responsive’ or‘relational’; they appreciated those who were able to adequately‘process’ their reactions (understand them), and‘reflect’ on their faults. Also those candidates who were highly prized displayed a‘personable’ manner in relation to peers and superiors. Showing a‘self-reflective’ stance which saw trainees‘willing to doubt their own positions’ was also something trainers desired. Because these appellations are vague enough to include under their rubric a wide range of meanings and behaviours, we might form a clearer definition of senior members’ preferences through negative definition: attributes less favoured were those that were overly‘questioning’,‘critical’ or‘defensive’, or, as one trainer put it, those that made one‘too confident and sure’. Another trait that was disfavoured was‘over-intellectu-alism’—candidates‘who use their intellect as a defence’—that is, who employed intellect to repudiate theory that, if accepted as commenting on one’s subjectivity, would expose unpalatable truths about oneself. In short, we notice that the rejection of these traits is largely congruent with the vocational rather than academic style of education the‘affirmative’ institute adopts. Trainers by and large value attributes complementing the smooth transmission of knowledge that it is the duty of the institute to facilitate.
To question now what sits at the base of evaluation apprehension we could first point out the fear of what a negative evaluation would mean or bring. Many trainees undergo considerable personal and economic sacrifices during the tenure of their training. Most maintain full-time jobs and many have families. Because of these circumstances candidates are often eager to move successfully through their training; and because of the understandable anxiety about the economic and personal losses that any extension of their training would entail, they fear being asked to‘take some time out’ or to repeat a year. And while such cases are rare (only about 5% of candidates) the fear of being stalled featured in a disproportionately high number of informants. Trainees expressed the prospect of being held back as‘unthinkable’ and‘awful’. Another called it‘something that would be shameful and embarrassing’. This last comment is interesting because it articulates another fear widely held. One trainee explains:
I would be ashamed because I’d feel judged to the core. People here [fellow trainees] are interested in how you are doing, but most people in your life know that you are training—you know, people are interested, they ask you how it’s going and so on. Well to turn round and say well, actually, they’ve gotten rid of me, I think would be difficult. I mean this is not like a pottery course or something, its about health and suffering and all that; it is about personality—these places have the last word on these things so to be judged negatively by them, well, this would say a lot about me now wouldn’t it? (First Year Trainee 2005)
Trainees often perceive trainers as they do their therapists—as endowed with special dexterity to uncover faults of which they themselves are unconscious (a fact consistent with the idea that leaders possess deeper‘secret knowledge’ and more‘personhood’ than novitiates). The atmosphere these beliefs generate renders trainees more vulnerable to trainers’ comments, for this‘asymmetry of knowledge’ means the power to define the trainee’s subjectivity rests almost exclusively in the hands of the evaluative body. Not that such power is necessarily abused, but that such asymmetry, more implicitly felt than explicitly acknowledged, engenders trepidation to test whether it might be. This dim trepidation fosters a disposition to conform to the image of the trainee they feel is appreciated, since trainees cannot be expected to win at a game in which their opponent controls the rules and the outcome. Jane spoke to me privately of her insecurity:
You actually do not know whether you are‘mature’ enough, or able enough—what is maturity exactly? This makes me feel very uncertain sometimes. I have one leader I just don’t agree with, but sometimes I feel he has my life in his hands, and so then I think I should just go along with things. But then I get confused because I just don’t know what he is looking for… [Jane fears he is dissatisfied with her.] If I knew I could adapt myself and things would improve. (First Year Trainee 2004)144
While not exploring the institutional conditions under which‘evaluation apprehension’ is furthered, authors such as Frank and Frank (1993 [1961]: 64) do note that this apprehension made students susceptible and‘pliant’ to trainers’ suggestions. This pliancy exhibited itself, as Charny asserted, through trainees adopting the hidden agenda‘of trying to show off and win approval of the authoritative supervisor’ (Charny 1986: 19); something confirmed by Ashurt’s observation that trainees’ insecurity provoked a need to‘impress the supervisor and be the “favoured child”’ (Ashurt 1993: 172). My own observations confirm both the presence of this apprehension, and of attempts to win its mitigation by strategies to secure ratification and‘official’ approval of the kind dissolving painful thoughts of being judged unfavourably. To these observations I add that this apprehension might be generated more by trainees’ fantasies than by evidence of real abuses, and thus is always a fear of the‘what if’, and the‘imagined’.
So far we can tease out three institutional conditions under which these fantasies (and the susceptibility to conform that they engender) are given added vitality. The first concerns the locus of judgement. At the early stages of training trainees are judged as persons not practitioners. This places them in a position of‘exposure’ and vulnerability, given the existence of the second condition: ownership of concepts. The debate about trainee suitability transpires in a discourse of concepts only the evaluators are qualified to employ, but whose authority both parties accept; a factor in turn entailing the third condition: the game favours the leader—namely, trainees are vulnerable to a discourse which can impute destructive unconscious motivations to their ostensibly innocuous acts; they are subject to a discourse within which they are socially positioned as‘novice’ and so as‘unqualified’ to wield these concepts in their own defence.
The fantasies and anxieties these conditions provoke, coupled with the fear of what negative evaluation will bring, constitute part of the subjective climate making trainees more susceptible to the suggestion and convictions of those ensconced in positions above them.
The next palpable set of anxieties to which students are subject arrives after they have passed key, initial thresholds (first year assessment; first series of seminars) and now sit in charged expectation of seeing their first patients. It is at this point that trainees, still being judged as persons, are now also judged as practitioners. With this new ground of evaluation, and with their new responsibility, comes a whole new set of apprehensions.
At this stage a widespread anxiety concerns their readiness to undertake the work of a therapist and whether they will succeed with patients. For many candidates training is not the bridge linking two domains; it is one domain, the institute, while the other resides far-off in the consulting room; there is always a gap, a stark dissimilarity. One prepares you for the other, but isn’t the other—a leap must be taken. Alison, a third-year comments:
Seeing your first patient was for me frightening and stressful—it was truly a‘first’ experience. I remember being remarkably nervous; you forget the books and you are suddenly with this person, who might be sad, lonely, despairing, avoidant or whatever. Here’s the human drama up close, and she looks at you with wide eyes, expecting guidance. If only they knew that you are thinking—that you had not done this before. (Trainee, London 2005)
Once the leap is taken new fears about one’s competence commonly surface. These fears can be compounded, firstly, by the length of therapeutic time often needed before any positive change in the patient occurs (something the novice awaits assiduously); secondly, by the common claims of patients that they feel little improvement or that things are getting worse; and finally, by the uncertainty about the outcome at the end of therapy. A fourth-year student, Morgan, discloses,
I think that some years ago, without even knowing it, I began to formulate an idealised image of the therapist (competent, mature, etc.). I suppose it was the image of the therapist I’d be by the time I’d start practising. I sort of regret this now because compared to this standard I am so far behind; and I have to say that I am now intimidated by my own creation as well as a tad guilty for not living up to it. (Trainee, London 2005)
The fear of being ill-prepared is linked to the fear of harming or losing patients. In terms of losing patients, the majority of trainees, when asked, awkwardly admitted to feeling anxious about what patients leaving precipitously would entail. As trainees have to treat patients long-term to fulfil assessment criteria, losing a patient after only one year would cancel that training case—this would mean starting from scratch with a new patient and having all that time and work not count. That this plays into concerns about extending training, and that these concerns might influence trainees’ clinical work, was something I put to one Dean of Training—she responded:
I think the problem about how this anxiety affects the training case has not been very deeply explored [by the community]… yes, we do not know how this anxiety might affect practice, especially during the first months. (Dean of Training, London, 2005)
Accompanying these concerns about readiness and fear of failure, are those relating to the patient failing, worsening greatly, or even committing suicide. These are concerns that afflict all therapists to some degree, but especially the novice. New therapists not only fear for the patient, but fear that failure will reflect badly upon them, constituting the definitive judgement on their competence and suitability. One psychotherapist says:
Therapists who worry that a patient will‘die on them’, really suffer. Most likely they are really trying to do their job, with all the thoughtfulness and energy this calls for, but they expend an enormous extra amount of energy worrying that the patient’s failure or dread outcome may hurt them—the therapist. This kind of worry can wear a therapist out. (Charny 1996, p. 23)
The following vignette shows in magnified form the kind of worries many trainees entertain. In a space of a few minutes this inexperienced trainee became subject to a series of stresses which play upon most therapists’ minds at one time or another:
I had been seeing a patient for only about five weeks. She was extremely depressed and would often talk of fantasies about jumping from the local quarry… On the sixth session I went out into the waiting area as usual to collect her—but she wasn’t there. So I went back to check after five minutes, then after ten, and again after fifteen—she still wasn’t there. Well with these passing minutes you can imagine my growing fear. I checked and re-checked the appointment book for a cancellation—there was nothing. I decided to wait a few minutes more before phoning the clinic’s manager… but it was while waiting that I became my most disturbed and frightened. I thought I’d lost her, I was so scared. I paced my room thinking—I should have done this or done that, my God! Maybe I should have made that intervention! A better therapist would have—I should have worked harder, or taken the threats more seriously… I also dreaded how this would reflect on me! Basically I panicked… these minutes have stuck with me; they woke me up to what we as therapists actually do. (Trainee, London 2005)
When tragedies occur, whether in the form of suicide or in less severe instances of‘backsliding’ or patient termination, an enormous amount of guilt may follow. Another therapist continues:
When a professional is entrusted with responsibility for stemming a patient’s bad fate and fails, there are actually several objective levels of guilt that are triggered… They are part of the job. One is—how can I enjoy my life and work when this human being—the patient—no longer can? Sometimes there is also guilt over hostile impulses that were (quite naturally) within the therapist’s soul and might have contributed to the patient’s sad outcome. Another is guilt for not really trying hard enough… (Charny 1996, p. 24)
The various stresses therapists endure are more testing for those lacking the armoury of experience. For trainees these encounters might be raw, formative, and powerful—striking deep into areas unprotected by the confidence won from years of practice. These stresses again can generate fantasies in abundance. Patient assertions that leave seasoned practitioners unruffled can easily unsettle novices. Perversions, dark fantasies, and confessions of self-hate resonate more forbiddingly in unaccustomed ears, filling the interstice of inexperience with trepidation. So while tested practitioners might‘just know’ when a suicide threat is critical, novices rarely trust whether they do. They are more wary, cautious, and fretful than their seniors, usually more to their own than to their patient’s detriment.
When facing these pressures, it is understandable that trainees look to elders for a steady arm—supervision provides opportunity for this. And so the regression that‘patients in need’ undergo in relation to the‘needed therapist’, is strangely replicated between supervisor and trainee—similar dynamics emerge; parallel gratitudes, allegiances, and dependencies crystallise. We thus envisage a chain of reliance from patient to trainee to supervisor to institute. For the first time trainees merge into a communal task—the united experience of healing. With this union they are now distinguished from outsiders. The trainee’s progress into the domain of practice is therefore also a movement into community, into an insider status won by experience alone. In Houseman’s and Severi’s (1998) terms, we might say that by embarking on practice trainees have taken a decisive step on their incremental movement towards‘inclusion’ in the dominant pole, the qualified, as their identity with the lesser pole, the non-ratified, is simultaneously being shed.
All these features (fear of failure, of readiness, of patient decline) I would argue constitute the second suite of subjective conditions, themselves generated by social conditions, rendering trainees more susceptible to the leadership and suggestions of the learned. In the next section I describe a third susceptibility—one not emerging from the many apprehensions and fantasies accompanying training, but one generated by the trainee’s desire to accrue clinical mastery and confidence as training proceeds.
The final susceptibility does not emerge from the many apprehensions and fantasies that accompany certain rites of training, but rather from the delight of accruing practical mastery as training proceeds. Authors such as Liberman (1978b), Bandura (1977) and Calestro (1972: 97-9) have shown that patients respond well to practitioners who are assured and confident in practice: as patients learn to understand and cope with their distress from an authoritative other they gain a sense of control over their problems, which is vital for healing. Other anthropologists, if only in passing, have referred to how‘developing expertise’ facilitates processes of professional transformation. Following authors such as Torrey (1986) and Ehernwald (1966), for instance, the anthropologist Kleinman (1988: 188) points out that therapists must believe in their power to heal if they are to embody the comfort essential to successful practice. As Samuels has said:
It is well-known that patients benefit when the analyst has conviction (or faith) in his theoretical ideas and clinical practices, no matter how deviant these may seem to be. (Samuels 1989: 7)
However, such comfort with, and conviction in, one’s theoretical beliefs and growing expertise, as Luhrmann has shown in the case of psychiatry (Luhrmann 2000: 203-30), on the flipside might encourage undue confidence in one’s ideas and abilities which in turn may support a kind of rigid or dogmatic form of practice. Cas-sell’s (1987) work also explores some negative consequences of belief in mastery: she shows that as a surgeon’s expertise grows, his or her propensity to deny or project doubt and paranoia onto unsuspecting‘others’ (nurses, junior doctors) develops proportion-ately.145
While these explorations of the merits and demerits of mastery differ in their points of emphasis, none of them overtly contradict the observation that to feel masterful in any given endeavour necessitates certain noticeable preconditions—and as these preconditions may be operative for the psychoanalytic practitioner let me elaborate on them further.
To start, a sense of mastery is rarely experienced by those doubtful of the worth of their craft. To use techniques that are sold as efficacious but that are felt to be coloured with falsehood engenders more disquietude than confidence. Distrust in one’s practice, as the psychiatrist in Peter Shaffer’s Equus laments, often endows practitioners with feelings of fraudulency. If my craft is questionable, and I sense its questionability, then I dispense it with great unease. And while it is true that this equation by no means universally applies—indeed, we can recall Lévi-Strauss’ discussion of the young sorcerer, Quesalid, who, despite his disbelief in the project of sorcery, managed to practice his craft with the veneer of conviction (Lévi-Strauss 1963: 175-178)146 —it is also clear that in most cases it is essential for practitioners to largely concur with the claims of their craft if they are to acquire the clear conscience needed to delight in its employment; for indeed, even Quesalid became a believer in the end.147
In all my formal and informal encounters I very rarely met therapists who denied to therapeutic claims any objective validity.
Therapists, philosophically speaking, were more‘realist’ than this, seeing their theoretical utterances as largely mapping psychic actualities. While in their public roles it is true that they often conceded that psycho-dynamics, as one therapist phrased it,‘could not be seen through microscopes’ and that therefore they were largely‘hypothetical’, it was also true that therapists privately attributed them with far more factuality than the term‘hypothetical’ denotes. Emotionally speaking, these linkages resonate for therapists to the extent that belief in them constitutes a kind of meta-belief, making the use of‘hypothesis’ a lip-serving device to appease those unconvinced by the reality of unconscious dynamics.
If believing in the merit of one’s system is a precondition for acquiring a‘sense of mastery’ then a further precondition is the belief that seniors perceive you as proficient in your craft. The fruits of being seen as possessing technical flair (e.g. peer respect; and, for the trainee, the privileges of the committee’s regard), is not only the inspiration prompting the novice onwards, but the incentive to submit to the instruction of the learned. The approval of seniors is crucial since perceiving oneself as competent is largely dependent on the agreement of those‘in the know’. It is in this sense that the subjective feeling of competency can be said to be socially ascribed, as it stems from the approval of those qualified to judge. Thus trainees are dependent upon such approval since without it they are in danger of experiencing their self-belief as illegitimate. Dependency is likely to make trainees more partial to the instruction of seniors, since, as we have seen, seniors are regarded as embodying the standards of good practice, and so trainees are more prone to emulate their ways as these are the ways proven to be effective. Thus a route to acquiring the elders’ approval is to follow their example and instruction.
To illustrate this fact let me now provide a concrete example of one technique trainees hope to master with the guidance of seniors.
One supervisor stated:
Knowing theory is just cerebration unless it can influence how you are with the patient… It’s about paying attention to significant moments which others would ignore, and then using these moments to give force to your interventions in ways that will shift patients towards insight and health… you have to expose to patients the aspects of themselves they are unable to see. (Psychodynamic Supervisor 2004)
Before illustrating the technique of using‘significant moments’ to draw the patient’s attention to hidden aspects of themselves as an example of a skill the trainee must master, here is a third-year trainee elaborating metaphorically on the means by which therapists encourage patients to apprehend hitherto concealed aspects of themselves; a technique formally known as‘confrontation’:148
It is as if you have a mirror which you must hold up to the patient at just the right time, to say—look, do you see! This is more difficult than it sounds as the reflection you show isn’t always pleasant—it can be grossly disturbing, actually demonic [for the patient] —and so you are never sure how the patient will react (defensively, psychotically, they might crumble, resist, or be illuminated). Things that have been repressed always return with an emotional charge. (Third Year Trainee 2005)
Shane, a fourth-year trainee, in the following extract provided an example of‘confrontation’ at work. This patient in question was a thirty year-old man who still lived with his mother. This patient to his own regret had never experienced a lasting intimate relationship. In what follows Shane recounts the moment when he leads his patient to apprehend the bearing living with his mother has had on his relationships with women:
Well it was during this one session when he was going on in a kind of monologue, but this time about a woman he’d met during the week, so I was alert—he was saying, she was this she was that, a‘bit fussy’, a ‘bit dull’, she was on the whole‘not right’. So I questioned him:
‘Not right?’
‘Well you know,’ he replied flippantly.
I was silent momentarily, and then said very carefully,
‘I know what?’
He responded again in an offhand kind of way,‘Well, you know.’
‘Actually,’ (I pushed a little harder now)‘I don’t know—why don’t you tell me?’
Now he looked visibly irritated and responded:‘If you don’t know I shouldn’t have to tell you.’
I was silent again and then said.
‘Again, tell me what?’
This was the final straw and he finally snapped:‘Look, isn’t it clear? I could never live with my mother and a woman like that!’
At this his hands went up to his mouth and his eyes looked about distractedly as it slowly dawned on him what he had actually said. (Fourth Year Trainee 2005)
Learning to seize opportunities to‘confront’ the patient is a subtle affair as such opportunities can easily be squandered. Another fourth-year student illustrated with palpable regret how she let one such moment pass:
I am struggling to get this one patient to feel things— he is so in his head. During a recent session he said that I judged him. Now this comment was significant because my patient had always felt severely judged and this feeling has inhibited him in many areas of his life. So now I had something important here, this confession, but instead of getting the patient to stay with this feeling, I said:‘Isn’t it interesting that you should feel this way about me!’ Now that was completely the wrong thing to say—the word‘interesting’ took him back into his head (he thought‘does she think I am wrong then?’—‘is this something I should be concerned about?’ and so on) and so I’d lost my opportunity to remain with the feeling… [and] encourage the projection… [and thus] make him confront through me the internal judge that has been plaguing him for so long. (Forth Year Trainee 2005)
This trainee conveyed this story to me with a self-recrimination that was illustrative of how crucial‘getting it right’ is for the therapist. The therapist feels the art of making successful interventions is so essential to master since opportunities to‘shift’ patients come by rarely—therapists can work for weeks or months struggling to gain the patient’s trust and to obtain the facts required to make effective interventions. Thus, instruction is sought-for not solely because it offers a means for winning approval (which is a precondition for feeling competent), but since it is also thought to offer genuine insight into how to succeed in the art of psychotherapy.
The institutional conditions so far identified provoke powerful subjective states disposing trainees towards conformity and dependence. This is consistent with Frank and Frank’s (1993 [1961]: 195) comments regarding dependency: that it inclines trainees to‘imitate’ supervisors and leaders. While such imitation or‘modelling’ has been shown to be one of the most powerful mechanisms of learning, especially in children (Bandura 1977), in psychotherapy this mechanism is activated by conditions unique to the training context: while supervisors’ guidance alleviates the anxieties of inexperience, supervisors also stand as the‘embodied answer’ to the question‘what do trainers want?’—Imitation, then, not only provides a source of learning, and a source for feelings of self-competence, but also a palliative for‘evaluation apprehension’ and its associated fears (i.e. fear of failing, of negative judgement [and what this means], etc.).
In sum, although I found no evidence that the conditions of training were consciously designed to arouse susceptibilities to conform to seniors’ expectations, deeper inspection of such conditions reveals how instrumental they might be in securing trainee conformity and re-organising the trainee’s subjectivity. That transformation occurs under stressful conditions is a fact long known by anthropologists (La Fontaine 1985; Richards 1956; Herdt 1987; Turner 1967), but what is particular to this context is not only the configuration of stresses aroused, and the tacit conditions which help to produce them, but the unique modes of practice and belief to which these institutional conditions give rise.
I commenced this chapter by cataloguing psychoanalytic aetiology within a wider system of classification. I did this to apprehend clearly, through contrast and comparison, the exact species of aetiology embraced. I then discussed how this understanding of causality guides psychoanalytic interpretation and intervention, endowing practitioners with conviction that they have something vital to offer the emotionally troubled.
Furthermore, I described some key stressors fostered by the conditions of the institute, noting how they render trainees susceptible to the convictions and leadership of senior members. By recognising‘institutional stressors’ as creating‘private susceptibilities’ I have indicated that clinical supervision cannot be read as a disembodied event, shorn from the subjective mood that the social conditions of the institute generate. Supervision, as with all other aspects of training, transpires in an atmosphere in which subject-ivies are largely poised in postures of receptiveness. This receptive-ness strengthens the therapeutic imagination and facilitates the embodiment of the internalising mono-directive practice characteristic of psychodynamic intervention.
To account for the existence of these susceptibilities by recourse to‘institutional stressors’ and the‘thrill of mastery’ in no measure exhausts the matter. As I recalled mid-way through this chapter, trainees enter the institute with a disposition of partiality towards the theories and techniques they hope to master. Owing to this we might say that trainees already possess a susceptibility to be susceptible to the conditions which facilitate the embodiment of psychoanalytic practice and belief. In the next and final chapter I wish to plunge headlong into an investigation of this primary susceptibility, one which makes psychotherapy so alluring to those who decide to undergo the trials of professional socialisation. What is it about the profession of psychotherapy that so appeals? How does the transformation it brings affect the new therapist’s life? And what do we mean precisely when we say that training transforms the individual?—to what effect, and in what direction? I shall now invest my energies in exploring these questions, for I believe that by doing so not only will we take one step further towards understanding the deeper meaning of psychoanalytic socialisation, but through this we will approach nearer to discerning the aims of the psychoanalytic movement itself.
130 W.H.R. Rivers (1924) was perhaps the first to argue that there was an invariant relation between belief and action (causation beliefs ex plained clinical actions). Rivers’ emphasis has entailed, firstly, a tradi tion of privileging belief over action (to understand the performative we must look first to the cognitive), and a further reluctance to ac knowledge the inconsistency between the two domains.
131 As Blaxter has said:‘Medical theory and medical practice are not ne cessarily the same, however. Though theory may encompass the social and the psychological, practice is more usually based on treating pathologies by physical intervention’ (Blaxter 1979: 160). Hsu (2005), contrasting T/CAM (Traditional Chinese Medicine) and biomedicine also writes:‘Whereas causative agents in biomedicine are often micro organisms or degenerative biological processes, T/CAM may find causative agents in variables like hot and cold, spirit loss or indulgent behaviour, which are often directly linked to social, religious, moral, political and ecological environment’ (Hsu 2005: 8)—paper forthcom ing.
132 The ethnographic record shows such multi-directional practice to be widespread. Turner’s study of the Nedembu doctor illustrates this: the doctor conducts an elaborate social drama to ascertain the source of communal tensions, coupling this on occasion with ritual exorcism (to expunge the soul of malevolent forces), as well as using certain herbs and potions to effect healing and calm in the body (Turner 1967).
133 It is important to note how the various‘domains’ at which action is directed are defined. We cannot expect a category such as‘body’ (or the classificatory system to which it belongs) to have universal applica tion. Thus any such system is always used for facilitating smooth translation, or in Evans-Pritchard’s terms, for writing a text rendering the unfamiliar familiar to us. I define the various phenomenological domains in accordance with Lock’s and Scheper-Hughes’ (1996) classi fication of domains—body / psycho / social. I only make one altera tion by adding the domain of the metaphysical.
134 See Elisabeth Hsu’s (2005) paper‘Other Medicines—Which Wisdom do they Challenge’ (forthcoming). In the Chinese text of the second cen tury BCE ideas of‘synchronous signs’ implied diagnosis did not de pend on establishing the given cause. Thus to assume biomedical pre occupations with causality are universal might be to impose and per petuate a Western Biomedical ideology that is less a priori than con structed.
135 Or we could say, following Hsu’s work on aetiology, where there is no external / internal conceptual system to be found we must take instru mentality rather than concept as the criteria by which to classify aeti ology.
136 An example of a mono-directive (internalising) system is biomedicine: it directs alleviative action at one internal domain, the body. Mono-dir ective (externalising) systems direct alleviative action at one external domain (at witchcraft or the relational field). Multi-directive (external ising) systems direct action at numerous external domains (sorcery, so cial drama, spirits etc.). Multi-directive (internalising) systems direct action at numerous internal domains (the body, the psyche). Finally, Multi-directive externalising / internalising systems direct alleviative action at multiple domains: the body (thorough drugs, herbs, potions) and the external environment (social drama, prayer), thus defying any strict external / internal dichotomy.
137 For example, Comaroff’s (1985) study sees Zionist body-healing as a shrouded attempt to heal the oppressive social order; Kleinman’s (1980) study exposes the social origins of so-called widespread‘psy chological’ suffering which emerged in the aftermath of the Chinese Cultural Revolution. And finally Sharp (1993) relates possession by tromba spirits in Madagascar to the growth of social anomie.
138 For example, where tissue damage or excessive trauma is unequivoc ally implicated.
139 Mainstream psychodynamic therapists increasingly following the dia gnostic criteria laid down in DSM IV where traditional sociological concepts of suffering do not feature.
140 For instance, during the course of my fieldwork I rarely heard the question asked‘is therapy right for this patient’. On the whole other questions were preferred:‘will this patient also need to see a social worker’,‘a psychiatrist’, or‘a pastoral healer’? Such alternative practi tioners were often seen more as auxiliaries than replacements. In many cases the applicability of therapy is assumed.
141 Quoted in Joan Cassell (1984: 242-3).
142 Such narrowing is‘legitimated’ by the discourse of rationality in which it transpires (Hsu 2004: 9), a legitimacy endowing practitioners with a sense of safety and competence needed for effective practice (Kleinman 1988: 160).
143 Such correlations, if found, would force other questions regarding the social systems in which their accompanying practice belong. Following Bourdieu (1998) in linking theory and practice to the struggles of the wider social field, we could ask how far certainty and other species of the dogmatic practice are socially induced responses to socio-historical factors of economic unknowing—that is, to the insecurity of competing with a plethora of contending traditions for resources that are scarce. If therapeutic professionals can sow the widespread belief that they have something unique to offer the emotionally distressed, then the concept of aetiology engendering this belief has economic and political correl ates so far as it supports the market for therapeutic services.
144 The fear of negative evaluation expresses itself in sinuous ways. A fur ther sign is the free-floating stress which often manifests itself somatic- ally. Many female trainees complained of‘feeling sick in the stomach’ or of experiencing‘butterflies’ before coming to the institute. Others spoke of‘not being able to sleep’ the night before a training weekend or workshop—there were other complaints of nervousness. The male students appeared to complain less about these reactions, but when questioned also admitted to experiencing feelings of‘nervousness’ or ‘trepidation’.
145 Finally, as noted in the introduction, Hugh Gusterton (1996: 157-164) has shown that young professionals’ growing sense of mastery gradu ally overrides some of the moral concerns they had about their profes sion. He believes that this partially explains how once politically liberal young physicists who were hesitant about the nuclear arms race, can over the course of their training be turned into keen weapons scientists —the thrill of growing mastery thus becomes the force prompting indi viduals to rationalise their old objections away.
146 However, it is also true that Quesalid suspends his disbelief in the end. As Lévi-Strauss says, after a period of carrying on with his craft con scientiously,‘[Quesalid] seems to have completely lost sight of the fal laciousness of the technique which he so disparaged at the beginning’ (Lévi-Strauss 1963: 178).
147 Indeed, in the same essay, Lévi-Strauss tells us that the senior sorcerer whose position Quesalid usurps, after admitting to Quesalid that his practice was fraudulent and that he was‘covetous for the property of the sick men’, became racked with guilt and grief, leaving the com munity out of shame only to return one year later as a madman. Three years later death takes him (Lévi-Struass 1963: 177).
148 The psychoanalyst, S. Pulver, defines the technique of confrontation as ‘the act of drawing the patient’s attention to some aspect of his beha viour or of reality that he has either been genuinely unaware of or has denied’ (Pulver 1995: 23).