An auto-ethnographic introduction
Like an ethnographer perpetually shifting between two cultures, for the last twenty years I have spent my professional life moving in and out, through and between the distinct life-worlds of social anthropology and psychotherapy. By the time I first became interested in anthropology in my early twenties, I had already spent two years undergoing psychotherapy myself as well as some years reading psychotherapy literature in an attempt to further understand myself, others and the psychotherapeutic process I was passing through. In particular, I read representative works in therapeutic traditions such as the analytic/relational (S. Freud; D. W. Winnicott; H. Kohut); the cultural (K. Horney; E. Fromm; H. S. Sullivan); the humanistic (C. Rogers; F. Pearls; A. Maslow); and the analytical psychological (J. Hillman, S. Jeffers; C. G. Jung). In fact, it was the more anthropologically informed writings of the latter school, and in particular the deep cultural preoccupations of Carl G. Jung, which helped me gravitate to social anthropology when choosing my undergraduate degree.
Enrolling at the School of Oriental and African Studies in the late 1990s, I embarked on what turned out to be an intensely post-structuralist education, replete with French relativistic and American post-modernist thought. What arose as a consequence was entirely unexpected: a thorough recalibration of the broadly individualistic and internalising psychotherapeutic weltanschauung I had previously adopted. Those formal studies unexpectedly changed my relationship to therapeutic ideas. I no longer regarded them as more or less scrupulous depictions of reality but as cultural artefacts, ideological supports, or social responses, liberating or enslaving, depending on whom and by whom they were used – as bearing, in short, a social life of their own. Ideas, for me, now fell from their glittering sphere of objective revelation to join that earthily panoply of cultural phenomena ripe for anthropological analysis. My intellectually naivety had passed, and much psychotherapeutic lore, including my attachment to it, was demystified as a result.
While many psychotherapeutic ideas had for me lost much of their potency (at least as totalising explanatory tools), the notion that psychotherapy could be a useful social practice remained robust – something evidenced by my decision, after graduating in anthropology, to begin formally training as an adult psychotherapist. Once I had put this decision into effect, however, new and unanticipated problems soon arose. The highly critical and expository culture that I had become familiar with as an undergraduate was now supplanted by what felt like an asinine vocational training that taught us, in almost seminarian fashion, what to believe and what to do, without requisitioning any inquiry into the social construction of belief and action. I soon learned that the critical atmosphere of my anthropological training was less welcome in the therapeutic academy. And internal tensions ensued as a result.
As such tensions would soon only escalate, I decided to place my psychotherapeutic training on hold to pursue graduate studies in social and medical anthropology, which, after encountering for the first time many fascinating works in psychological and psychiatric anthropology, culminated in my writing a dissertation on the nature of psychotherapeutic belief: what enabled psychotherapists, in the post-metanarrative era, to make an almost modernist commitment to operate within a set mode or schema of thought – to defer and maintain faith in a mode or practice that was, after all, under increasing sceptical onslaught? In particular, I became interested in what role professional socialisation played in deflecting powerful post-modern headwinds: in preserving an enclave of decided belief and practice where the newly initiated, upon accreditation, could find a secure professional, moral and ideological home.
Such questions underpinned my decision to pursue my anthropology doctorate on essentially the socialisation of psychotherapeutic professionals, largely focusing on persons and institutions within the psychodynamic/psychoanalytic tradition. With my supervisor’s support, I therefore took up my psychotherapeutic training again, but this time as both trainee and ethnographer – becoming a psychotherapist while at the same time studying this process of becoming anthropologically. My therapeutic training became part of my field site – my peers, patients, therapist and trainers, my informants. My oscillations between the two traditions, previously swaying languidly between distant points, now pitched and veered ever closer – almost to vibration.
My qualifying as a psychotherapist in the very same month I submitted my anthropology PhD on psychotherapeutic socialisation symbolically signalled the comingled world I would come to inhabit: a coterminous life that still lives on. Within three months of qualifying, I had begun my first university lectureship – this time largely teaching, it transpired, anthropological insights to psychotherapeutic trainees. Within twelve months my anthropology doctorate had been published by a psychotherapy publisher (Davies 2009) and was therefore being mostly read by psychotherapists. Within three more years I was now also lecturing in anthropology. Two years later I had taken up a full-time anthropology readership. For the past seven years I have continued teaching, practicing, supervising, researching and writing within both disciplines, in what at times feels like either a protracted season of fieldwork or a prolonged therapeutic relationship with anthropology on the couch.
The upshot of this alloyed position has been my distanced-affinity for both traditions. Like a child pulled by parents at cross-purposes, I inhabit a compromise somewhere in-between. Perhaps a similar sense of liminality is what Vincent Crapanzano recently referred to when saying he has ‘always felt tangential to the [anthropological] field … always tangential to everything’ (Crapanzano 2015). Most anthropologists will understand this sentiment, whatever the admixture of variables from which their marginality is hewn – professional, ethnic, religious, political. But perhaps fewer will share this feeling with respect to the homeliness of their own discipline, feeling sometimes comfortable, sometimes not.
The above is more than mere biographical indulgence. It provides the context out of which my absorption in the relationship and interplay between anthropology and psychotherapy has dominated my professional life: one I have expressed through exploring how anthropology and psychotherapy, broadly defined, are and can be creatively and mutually informing. Whether using psychotherapeutic ideas to inform anthropological practice (e.g. in the domain of fieldwork; Davies and Spencer 2010), using anthropological theory to understand facets of psychoanalytic culture (e.g. the transmission of psychoanalytic knowledge; Davies 2009) or integrating both perspectives in the study of any social or human phenomenon (e.g. emotional suffering; Davies 2011), I have perpetually struggled to work at the interface, attempting to chisel spoils from that space in-between.
The argument
In what follows, I shall continue in that effort, this time by bringing anthropological insights to bear on a central theme of this current volume – how the concept of ‘culture’ as it is currently used guides or misguides contemporary therapeutic theory, training and practice. My aim in this chapter is to scrutinise anthropologically a growing trend within contemporary therapeutic provision, especially with respect to how culture should be understood, managed and responded to in the therapeutic setting. My aim is to articulate a series of propositions, informed by anthropological theory but broadly inconsistent with today’s increasingly manualised psychotherapeutic trainings, whether such trainings operate in universities or through NHS/IAPT initiatives or private training institutes. My argument is that, apart from in some specialist anthropologically informed corners, such as the Nafsiyat Intercultural Therapy Centre, manualised psychotherapeutic training, which aims to attain consistency in results and conations across practitioners, has in this pursuit become increasingly culture-blind. Not through failing to articulate a concern for culture, or as is usually put, cultural difference, but through having become wedded to a concept of culture as something possessed – as something one has, rather than as something one does.
When consulting the relevant literature on culture and psychotherapy, in recent years there has been a shift toward foregrounding the development of ‘cultural competency’ as an essential matter in training – whether that training occurs in standard counselling work (Ahmed et al. 2010); IAPT-based CBT (Bassey and Melluish 2012; Department of Health 2011; NICE 2011); or long-term therapeutic work (Stanley et al. 2009; Tummala-Narra 2016). This narrative largely frames cultural competency as the capacity to negotiate skilfully the cultural differences existing between members of the therapeutic encounter – i.e. developing cultural ‘sensitivity’ to dissimilarities of ‘language’, ‘concept’, ‘behaviour’, ‘perception’ etc., in view of facilitating practitioner understanding and a deeper therapeutic alliance (Collins and Arthur 2010). The dominant assumption of the cultural-competency narrative, in other words, is that culture resides in practitioners/client/patients – in persons who have culturally rooted responses and reactions, which interact, intermix, clash or cohere with those of others. What matters in any consideration of culture, therefore, is developing competency in negotiating these interactions, differences and embroilments in service of understanding, through the deployment of a cultural skill-set absorbed through one’s specialist training.
While the competency narrative may, in important ways, both highlight and help people better navigate difficulties encountered in the process of negotiating difference, I argue that the institutional move towards a focus on developing ‘cultural competency’ has a flipside by concealing a powerful ideological shift away from considering therapy itself as a work of culture, as an embedded culture practice on its own terms (Furedi 2004; Seeley 1999; Klienman 1988; Littlewood and Kareem 1992; Smail 2001; Luhrmann 2001). Rather, culture, from the cultural-competency standpoint, is increasingly configured as a thing possessed by clients and therapists, as something with which and on which therapy works. This subtle splicing of culture from practice to persons, from something one does and enacts as an outcome of therapeutic acculturation, to something one has in the most colloquial sense, wrongly elevates therapy above that with which it works, and in consequence denies persons-in-practice certain vital ways of thinking about the work they do.
What I shall therefore argue is that the vision of culture assumed by the competency narrative is at variance with an almost axiomatic principle in social anthropology: that practice is culture, and that by extension therapy is profoundly context making and thus constitutes, when exercised on trainees and clients/patients, a highly specific form of acculturation. My aim here is to offer a series of propositions through which to explore the notion that therapeutic practice is culture enacted: propositions to be illustrated by way of previously unpublished ethnographic material gathered from fieldwork largely undertaken in 2007.
The materials pertinent to this current chapter derive from six months’ participation in clinical group supervision as a participating psychotherapeutic practitioner. These weekly sessions comprised three trainee psychoanalytic psychotherapists, one consultant psychiatrist and one psychoanalytic group facilitator, all of whom worked within a context where cultural competency was expected from practitioners. These sessions thus provide a useful context in which to analyse cultural-competency strategies at work. With respect to other observations made in this chapter about the state of training today, these are derived from my role in the community as practitioner and therapeutic educator; from anthropological fieldwork carried out in the psychotherapeutic community between 2003 and 2005; and through many subsequent ethnographic ‘fieldwork expeditions’, to use Emily Martin’s (2009) phrase, that my professional role in the therapeutic community habitually affords.
Proposition one
Therapeutic nomenclatures (theoretical, diagnostic) are just as much proscriptive (i.e. context creating) as they are explanatory and descriptive (i.e. context referring) – culturally scripting how suffering is understood, managed and thus experienced.
I wish to illustrate the above proposition by way of some general reflections on the diagnosis of mental health problems. I choose not to use the term ‘psychiatric diagnosis’ because over the last thirty years, mental health diagnosis has ceased to be only used by psychiatrists and is increasingly used by a wide array of psychotherapeutic, counselling and mental health professionals. In the NHS today, people cannot access mental health/psychological services without first undergoing a diagnostic test (Johnstone and Watson 2017), obliging diverse mental health professionals to work and think within a common medicalised diagnostic framework. The proliferation of diagnostic thinking across mental health provision is now reflected in the number of psychotherapeutic trainings, of differing modalities, teaching the rudiments of diagnostic thinking and practice or else legitimising the diagnostic act (Johnston 2014). While these trainings may differ in the extent to which they acknowledge the culturally constituted nature of diagnostic categories (these categories, after all, are not rooted in any known biomedical markers), and while also they differ in the extent to which they acknowledge certain adverse effects of diagnosis (i.e. social and self-stigma it can generate), there are still certain effects of diagnosis passed over in most clinical and training contexts today. To aid facing these squarely, let us consider the following ethnographic vignette. Here, I present to my peer-supervisory team a case study concerning my therapeutic work with a 30-year-old man:
During group supervision I report to the team that Patient X, who had a diagnosis of bi-polar disorder, suggested to me in our previous therapeutic session that other patients in the psychiatric day centre, sharing the same bi-polar diagnosis as him, were often playacting. They would receive the diagnosis, and then begin to exaggerate the relevant symptoms and behaviours deemed characteristic of the condition. He surmised that this probably occurred because they would read up on their condition after being diagnosed and then adapt to what they read. Other patients, he noticed again and again, were becoming more bi-polar after being so labelled. He was adamant this kind of subterfuge was going on widely in the NHS, and was baffled why doctors seemed largely oblivious to it.
When discussing this matter with the supervisory team, the professional response was to doubt Patient X’s perceptions. Even if some instances of subterfuge did occur, this behaviour was surely not as widespread as Patient X alleged. Was Patient X becoming paranoid? Was he somehow envious of other sufferers? Was he trying to impress himself as the only authentic patient? What, in essence, were the psychodynamics of his assertion? While such lines of enquiry may be expected in a supervisory context, it was never considered that Patient X could in some sense be correct: that the people he observed were indeed becoming more bipolar after their diagnoses were issued, a phenomenon that has been noted elsewhere in the ethnographic record (Martin 2009). When we inquire as to why this possibility was not considered, we espy the work of certain assumptions about diagnosis at play: in particular, the idea that diagnostic categories essentially describe emotional and behavioural states. While this view is pivotal in diagnostic manuals such as ICD and DSM, as well as permeating various diagnostic tools widely used in training and practice (e.g. PHQ9 and GAD7), it of course obscures a central component of diagnostic labels: that they are highly proscriptive cultural symbols, helping shape and direct the forms of suffering they purport to disinterestedly describe.
To verify the proscriptive effects of diagnostic labels, ample ethnographic and epidemiological data have revealed how such categories pattern and shape suffering in both its collective and individual forms. With respect to collective suffering, for example, we know that when new descriptive categories take hold of a group, they can direct how it experiences and expresses its suffering. This fact has been richly illustrated by work ana...
