Psychotherapy in an Age of Narcissism

Modernity, Science, and Society

J. Paris

• Publisher: Palgrave Macmillan
• Year: 2012
• Print ISBN: 9780230336964
• eBook ISBN: 9781137291394
• Topic: Psychology
• Subtopic: Mind & Body in Philosophy
• Index: Psychology

Adopting a friendly but critical approach to the talking therapies, this book places psychotherapy in a social and historical context, exploring its relationship to contemporary culture and recommending a different way of thinking about practice.

Part I

The World of Psychotherapy

1

The Birth of Psychotherapy

Millions have sought psychotherapy. Talking as a way of healing that is psychotherapy, has become an important part of contemporary culture. Yet the ideas behind this kind of treatment are modern. Psychotherapy as a formal discipline and procedure was only invented a little more than a hundred years ago. We need to understand why talking therapy appeared at a particular moment of history and what function it serves in modern society.

In the course of history, every society has developed its own way of providing solace for psychological distress. In the past, people found help in other ways. They obtained comfort from religious institutions, community, and social networks. In traditional Western societies, troubled individuals could confess to a priest. In non-Western societies they might go through healing rituals with a shaman. But while all societies carry out some form of mental healing, these procedures cannot be termed as psychotherapy, and their effectiveness has never been tested empirically.

What is new today is that people are prepared to talk about personal problems to a professional. No one in a traditional society would have dreamed of doing so. But in the modern world, as older ways of healing stopped working, a new method had to be invented.

Modernity, individualism, and narcissism

The appearance of psychotherapy corresponded with the emergence of a different type of society. The term modernity describes cultural changes associated with a decline in traditional norms (Giddens, 1998). The modern world prizes the individual, and encourages people to look inward rather than outward for guidance. In this way, talking therapy is a product of modern culture. One of the principal characteristics of modernity is individualism, a preference for what benefits the self over the collective (Rieff, 1966). This social value has greatly shaped the psychotherapeutic enterprise.

At the same time, psychotherapy too has contributed to modernity. Several observers have commented on this relationship. Gross (1978) described the development of a “psychological society”, and Rieff (1966) spoke of a “triumph of the therapeutic”. One common thread in the observations is that values have come to depend on inner states rather than on external reality. Furedi (2004) observed that in the modern world, our very sense of identity and self has come to depend on the state of our psyche. One question that this book will address is whether the cultural role of psychotherapy has overshadowed its use as a healing procedure.

The modern celebration of the individual is a prerequisite for conducting formal psychotherapy, in which patients focus more on inner states of mind than on filling social roles. But focusing too much on the self has a “dark side”. Narcissism is a psychological construct that describes the self-love and self-absorption that arise from an excess of individualism.

Sigmund Freud (1914–1959) was the first person to use this term, which is derived from a Greek legend, in a consistent theoretical paradigm. Freud conceived of narcissism as more of a universal psychological mechanism than as a problem. But later writers used narcissism to describe a pathological personality structure (Kohut, 1970). Since narcissism is a personality trait that varies from one person to another, it is possible to study it empirically (Thomaes et al., 2009). Finally, Lasch (1979) introduced the concept of cultural narcissism to describe how excessive focus on the self can undermine personal and social cohesion.

The concept of narcissism is not really new. Vanity has always been considered by religions to be sinful. Few approve of people who are excessively conceited or self-centered. But the modern world has given narcissism a new twist. As an extreme version of individualism, it has come to be celebrated by a culture that rewards and values ambition, celebrity, and “self-esteem”.

Psychotherapy, by its very nature, runs the risk of promoting narcissism. This is an inevitable result of spending many hours talking about oneself to a sympathetic, non-judgmental listener. By losing sight of social roles and social networks, psychotherapy in the 20th century became a subversive force. In summary, the role of psychotherapy in modern society is historically contingent. Thus, its rise can only be understood in the context of the social changes that accompanied modernity.

Filling a niche

Psychotherapy did not emerge all at once. Its 19th-century precursors were various methods for the cure of “nervous” ailments (Ellenberger, 1970; Shorter, 1997; Caplan, 1998; Engel, 2008). Such treatments, usually prescribed by physicians, included rest cures at spas to recover from nervous exhaustion, which was called “neurasthenia” (Schuster, 2003). Obviously such an option was open only to the wealthy. And many of these healing procedures lay outside of medicine and were based on religious principles, often assuming a prior commitment to Christianity (Moskowitz, 2001).

In fact psychological treatment in the 19th century lacked most of the features that have, ever since Freud, characterized the “talking cure”. Patients were not invited to sit down and talk without explicit direction. They were not “heard” in the way that psychotherapists now take for granted. Instead, they were directed to activities designed to distract them from their problems. These procedures did not always work. There was room for a radically different approach.

The Austrian neurologist Sigmund Freud is generally acknowledged to be the founder of psychotherapy. He deserves great credit for this. Even if his specific theories and methods are now obsolete, it was Freud who made talking therapy influential, it was he whose ideas caught on with a wide public, and it was he who had the greatest influence on modern culture. All psychotherapies that explore the mind through active listening are derived from him.

But why did psychoanalysis emerge at the turn of the 20th century? What was special about that time? One possibility is that this was the historical moment when modernization reached a tipping point. Over several centuries, modern society gradually replaced traditional social structures, and individual values became predominant over collective values. Thus psychotherapy (and the ideas behind it) had its greatest success in societies in which individualism and modernity were most prominent, particularly in the United States (Caplan, 1998).

Talking therapy succeeded because it filled an empty niche. Community, tradition, and faith were in decline. Many felt lost in a world they had not made. People had to establish their own roles and their own social networks. Most found a niche, but many remained alienated. Moreover, in capitalist society, strong individualistic values became associated with a level of social inequality that made many unhappy (Wilkinson and Pickett, 2009).

But the most serious problem was that as external guidelines for behavior weakened, people had to look inward. Older methods of healing had lost their power. Talking therapy promoted the idea that exploring, understanding, and controlling the mind was the best way of meeting personal goals. In this way, psychotherapy became a necessary part of modern culture. It has even been conceptualized as an answer to the human condition—a kind of “civil religion” (Epstein, 2006).

Mental symptoms and traditional healing

Mental symptoms have been described since the first written historical records were created. In the Bible (Psalm 38) one finds this description of melancholic depression: “I am troubled, I am bowed down greatly; I go mourning all the day long. … I groan because of the turmoil of my heart.” In the 4th century BC, Hippocrates described a depressed patient in this way: “A woman of Thasos became morose, and although she did not take to her bed, she suffered from insomnia, loss of appetite … she complained of fears and talked much; she showed despondency and talked at random” (Adams, 1939).

Psychological symptoms are universal, and serve a purpose in communicating distress (Nesse and Williams, 1995). But when symptoms interfere with functioning, those who suffer from them require help. In Shakespeare’s play with the same title, Macbeth, troubled by his wife’s depression, asks a question that might be put to any modern psychotherapist: “Cans’t thou not minister to a mind diseas’d; Pluck from memory a rooted sorrow … ?” The physician replies: “Therein the patient must minister to himself.”

In spite of Shakespeare’s doubts, healing rituals have been documented in virtually every culture. But to understand traditional healing, we need to imagine a very different world from the one we live in. People in traditional societies did not see themselves as much as individuals as they saw themselves as part of a social community (Kirmayer, 2007). Most people in the course of human history have lived in villages, where they have probably known less than a hundred people over a lifetime. They have been more deeply engaged with their community than with people in modern urban society.

Comfort for the afflicted has always been one of the primary functions of religion. In shamanism, “evil spirits” are banished through an extended ritual. But the real function of such procedures is to mobilize family members and the larger community to support the sufferer (Kirmayer, 2004). Prior to modernity, suffering was understood in a religious context, and healing rites were carried out in the context of a shared belief system. Relief from psychic pain could occur if symptoms were given meaning, and if social support could be increased. This process still goes on at places such as the shrine of Lourdes (Frank and Frank, 1991).

In contrast, modern methods of healing are totally secular. There are still rituals, as in the schedule and routine of a psychotherapy session. But healing is now rooted in a different worldview. Traditional attachments to community and shared belief systems tend to be attenuated rather than supported, leading to an increased focus on personal needs (Westen, 1988). Psychotherapy makes people more, not less, individualistic.

People also experience distress in different ways than they used to do in the past. Research shows that those who are less integrated with their community tend to have fewer internalizing problems, that is distress within the self, but more externalizing problems, that is behaviors with other people (Paris, 2004). But inner suffering is what talking therapy was designed to deal with.

For most of human history, little has been done for people who have suffered from severe mental disorders—other than confinement. Today while medical treatment is highly useful for severely ill patients, these methods have only become available in recent decades. Treatment for psychosis in the past was neither benign nor helpful—the mentally ill were often mistreated and abused (Shorter, 1997; Wallace, 2008). And if recovery did not occur quickly, the community could reject them.

The view of Michel Foucault (2001) that serious mental illnesses were tolerated and widely accepted in the past and that traditional societies viewed psychosis as little more than eccentricity was an unhistorical fantasy. Such ideas are based on a sentimental view of the past—a modern version of the old conundrum that life used to be simpler and happier.

Most people in distress experience mild symptoms that affect their states of mind without seriously impairing their social functioning (Kessler et al., 2005a). People with these problems may not seek professional treatment (Kessler et al., 2005b). And they are not wrong to decline to become patients. One way or another, most of us pull out of a temporary tailspin. Time does heal—as does the support of family, friends, and community. That is how people have dealt with distress throughout history.

How psychotherapy was born

Formal psychotherapy began with psychoanalysis. Its theories may initially have been startling, but they had many historical precedents (Ellenberger, 1970; Hale, 1995). What was really new was the psychoanalytic method, based on the idea that talking can heal psychological conflict and distress. Freud was the first therapist to advocate listening to people in an open and unprejudiced way. He was also the first to understand that psychotherapy encounters are emotionally charged and personally meaningful. Finally, he was the first to read between the lines of personal discourse and to take into account the discrepancy between what people say and what they really think.

Freud’s ideas were developed at a time when organized religion was already in decline. Confession in the Catholic Church has a certain similarity to psychoanalysis in that people obtain solace by confiding in a trusted person. It may not have been an accident that Freud, who lived in a Catholic society, kept out of sight behind a couch, much like a priest. But confession is a very different procedure from psychotherapy.

The common thread is that people feel better after confiding in someone who listens and understands. Not everyone can find that kind of support outside of psychotherapy. When you explain your feelings to a friend or a family member, they may stop you to give their opinion or tell their own stories. The idea of sharing your troubles with a professional about whom you know nothing but in whom you confide everything, and who empathizes with your feelings and also sometimes offers solutions to problems, was novel indeed.

Methods of psychotherapy

Psychoanalysis is the form of psychotherapy that has had the greatest cultural impact. Freudian theories paralleled developments in culture and the arts, sharing a focus on hidden but powerful emotions. These ideas were, and still are, attractive to intellectuals (Wilson, 2003). The success of psychoanalysis was, at least in part, due to good timing. Its ideas had few serious competitors and were seen as reflecting the most advanced concepts in psychology (Hale, 1995). Moreover, treatment in the early days of psychoanalysis was not prohibitively expensive. Even struggling artists were able to afford the fees. Along with appreciation of the latest trends in art and literature, being “in analysis” may have made people feel “modern” (Hale, 1995).

But there was a deeper reason for the popularity of psychoanalysis. The British philosopher Ernest Gellner (1993) suggested that this form of treatment was designed to address a problem particular to the contemporary world: insecurity in relation to social status and attachments. This helps to explain why it appeared at the same historical moment as rapid social change and modernity.

The movement that Freud founded (as well as its descendants and variants) had its greatest success in the United States, but aroused greater resistance wherever tradition remained strong. Freudian ideas took a long time to catch on in Europe, where the culture was more stable and where people retained a greater sense of belonging. Only recently, as Europeans became as modern as Americans, did psychoanalysis become popular there (Zaretsky, 2004).

Psychoanalysis, unlike traditional healing, did not aim to reintegrate people into a collectivity, as religion had done. Instead, it encouraged them to become more successfully individualistic. Its thrust was to make people become less dependent on their social environment. Yet as Cushman (1995) was the first to observe, that is precisely the reason why talking therapy always runs the risk of worsening the very problems it sets out to solve. The more people focus on the self and inner feelings, the less sensitive they tend to be to others. In this way, talking therapy runs the constant danger of supporting narcissism, at both the individual and the cultural levels.

And that is only one of the several downsides of the social impact of psychotherapy. As Furedi (2004) has observed, the culture of therapy has come to redefine what it means to be a person. This culture tends to view the self as emotionally vulnerable and powerless in the face of circumstance. But seeing every dilemma through the lens of therapy turns social issues into psychological problems. It is a point of view that threatens to turn history into therapy, trivializing real social problems.

How psychotherapy became a profession

To be seen as legitimate, psychotherapy had to become a profession. Professionalization was necessary to separate formal treatment from lay advice. Even now, the boundary is not always clear. Since the middle of the 19th century, advice columns have enjoyed enormous popularity in the media (Cushman, 1995). It is hard to imagine people in traditional societies seeking help for life problems from complete strangers. Yet today, hardly any newspaper lacks an advice column. While therapists have sometimes taken these columns over, the most popular ones in the United States, such as “Dear Abby”, “Ann Landers”, and their successors, offer advice by savvy journalists.

Professionalization was a long and complex process. In 19th-century medicine, there was no such thing as a specialty of psychiatry (Shorter, 1997). Physicians treating inpatients admitted to mental hospitals were called “alienists” or “neuropsychiatrists”. For outpatients, there were neurologists who focused on “neurotic” patients. Freud was one of them, as was George Miller Beard, an American physician who developed a rest cure for what was called “neurasthenia”. Psychiatry as a separate specialty emerged later, only gradually separating itself from neurology (Berrios and Porter, 1995).

Clinical psychology was also slow to define itself as a profession (Benjamin, 2007). At the turn of the 20th century, the discipline was founded by Lightner Witmer (who initiated the child guidance movement) and by G. Stanley Hall (who developed educational psychology and the modern concept of adolescence). But for many years, clinical psychologists were more interested in assessment than treatment. Academic departments of psychology, which focus on research, have rarely been very interested in training clinicians. Even today, there is controversy as to whether psychologists who do therapy really need a PhD or whether they should have experience in research (Dawes, 1994).

The involvement of social workers in psychotherapy is a more recent development (Strean, 1974), but these professionals have come to form the largest single group of practitioners (Weissman et al., 2006). To claim a separate identity, social workers originally described their approach as “case work”. Some went on to train as psychoanalysts, but others focused on family therapy (a field they continue to dominate). Most social workers pride themselves on their focus on practical, here-andnow issues, rather than on grand theories.

Therapists can come from backgrounds that are far removed from medicine or psychology, sometimes having no previous background at all in the mental health professions. In recent years, professors of literature have been allowed to enter psychoanalytic training, mainly to keep training institutes open in an era when few psychiatrists or clinical psychologists choose to become analysts. In rare but prominent cases (for example Erik Erikson), a therapist might have no university degree at all.

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Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Preface
• Acknowledgments
• Part I: The World of Psychotherapy
• Part II: Modernity
• Part III: Practice
• References
• Index