The Therapy Industry

The Irresistible Rise of the Talking Cure, and Why It Doesn't Work

Paul Moloney

• Publisher: Pluto Press
• Year: 2013
• Print ISBN: 9780745329864
• eBook ISBN: 9781849648776
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

Across the world anxiety, stress and depression are on the increase, a trend which looks set to continue as austerity measures bite. The official response tells people that unhappiness is just a personal problem, rather than a social one. Written by a practising psychologist, with nearly thirty years' experience in the fields of mental health and learning disabilities, The Therapy Industry offers a concise, accessible and critical overview of the world of psychological practice in Britain and the USA. Paul Moloney argues that much therapy is geared towards compliance and acceptance of the status quo, rather than attempting to facilitate social change. The Therapy Industry fundamentally challenges our conceptions of happiness and wellbeing. Moloney argues that therapeutic and applied psychology have little basis in science, that their benefits are highly exaggerated and they prosper because they serve the interests of power.

Part I

 

Evaluating Psychological Techniques

1

Misery, Mind Cures and Fashion

So persuasive is the power of the institutions that we have created that they shape not only our preferences, but our sense of possibilities.

Ivan Illich¹

At the start of the eighteenth century, if you raged at voices that no one else could hear, saw things that nobody else could see, especially if you annoyed or frightened other people at the same time, then your sufferings could be construed as demonic possession, brain fever, or as the just deserts for your moral backsliding. You might find yourself detained in the public madhouse, regarded as not far above a wild animal. You would most likely be tamed and managed with varying degrees of harshness or, if you were luckier, with the stern compassion of the philanthropist.

As the Enlightenment gathered pace, medical explanations of madness began to compete with supernatural ones, and fee-paying asylums were built across the land in out-of-the-way places. Some of these institutions were little better than the warehouses for the ‘feeble minded’ that went before. Others aimed to restore sanity with a mixture of crafts and manual labour, fresh country air, communal living, personal cleanliness and Christian instruction. This regime came to be known as ‘moral management’, its architects mainly laymen – and very often Quakers. The profits were not as high as for other industries but they could be substantial. By the mid-nineteenth century, the moral managers found themselves in competition with the alienists or ‘mad doctors’, medical men who saw madness as the outward sign of tainted hereditary, or of degenerate habits. They asserted solid scientific knowledge and expertise in the treatment of the brain, and believed that gathering the afflicted together under one roof would lead to a new understanding of insanity and to its eventual cure.² These claims to a unique scientific insight into madness were questionable, even by the lights of mid-nineteenth-century medicine. Lay observers had argued for a hidden logic behind the delusions of ‘madness’, as, for example, fantasies that grew from excessive passions or that served to deny the humiliation and disappointment that blighted some peoples’ lives.³ In the end, however, none of these arguments mattered, because the alienists could back their claims with the professional status of medicine and a Royal Charter. They fast succeeded in ousting the moral managers and their well-intentioned amateurism.⁴

Asylums also served a larger purpose within the new industrial order. In the new factories and workshops, there was a growing need for docile and dependable workers, prepared to turn up on time and do as they were told. For the labouring classes, the uncertainties and brutalities of rural life had at least been familiar ones, but the new urban existence imposed a unique blend of rootlessness and anonymity. As the smoky, warren-like cities and towns grew, so the poorest districts became packed with factory labourers. These were places of sprawl, overcrowding, noise and filth. The products of the Industrial Revolution included hundreds of thousands of disturbed people, as well as millions of tons of cotton and steel. The asylums joined with the prisons and workhouses to make a great system that ensnared the feckless and the indigent and that, without any deliberate intent, none the less served as a warning to anyone tempted to stray from their daily drudgery. At the close of the eighteenth century, there were only around 40 asylums in England and Wales; 60 years later, there were over 400, most of them crammed with the urban poor.⁵

Outside of the asylum walls, the Victorian middle classes suffered mental ailments of their own. In Europe and North America, many middle-class women were prone to insomnia, sleeplessness, fatigue, phobias and more rarely (but spectacularly) to trance-like states and to flights of ecstasy or paralysis that had no physical explanation. These disturbances had long been ascribed to the mobile female womb. But this account of ‘hysteria’ had fallen out of favour by the 1870s, because it could not be squared with the new anatomical and functional knowledge of the nervous system. Widely viewed instead as signs of the obvious weakness of the female sex and of their overwrought nerves, these ‘symptoms’ can be more accurately seen as an unconscious rebellion against the gilded cage of respectable middle-class femininity. Clinical treatments – which at their most extreme included barbaric genital surgery or enforced confinement – were in truth an effective means for keeping women in their place.⁶ It was not that men lacked ‘neurotic tendencies’. Rather, the bewhiskered elders of the medical community had long ignored, downplayed, or misdiagnosed the emotional torment that they sometimes saw in their male patients. The economic and political rise of the middle classes (and of the white man’s claim to racial and cultural superiority in the age of empire) had been founded upon a singular vision of strong, self-possessed and rational manhood: not to be undermined by medical recognition of ‘rampant neurotic weakness in the male sex’.⁷

Nevertheless, by the closing decades of the nineteenth century, it became harder to deny that a great number of men were also suffering from psychological problems, largely in the guise of irritability, anxiety and lassitude that could echo the recalcitrant mental and physical exhaustion – or chronic fatigue syndrome – that is a familiar (and controversial) diagnosis, in the early twenty-first century. Once again, no biological cause was apparent, but this did not prevent these symptoms from quickly coming to be seen as the condition of ‘neurasthenia’, as formulated by the Manhattan physician George Miller Beard.⁸ The demands of modern civilization, Beard declared, especially the pressures of commercial leadership and intellectual work, were straining the nerve fibres of businessmen, administrators, academics, bookkeepers, solicitors and the like. Neurasthenia became a popular diagnosis because it enabled the growing number of male ‘hysterics’ to be viewed in a dignified and even heroic light, the casualties of their own success as striving go-getters in the world of corporate enterprise. None of this prevented their wives and daughters eventually being diagnosed with it too, notwithstanding the huge overlap between the symptoms of this condition and those of hysteria. It was certainly in the interests of neurologists, psychiatrists and even religious and ethical thinkers to promote this catch-all illness – because it endorsed their authority and expertise, and gave the last two groups an up-to-date language in which to talk about the evils of the modern age.⁹

Meanwhile, the sufferer might receive a cornucopia of treatments – from hypnosis, and moral instruction to physical therapies, including massage, bathing, rest cures and ‘galvanic stimulation’ – but one treatment that grew in popularity was psychoanalysis. As a set of theories and techniques, it chimed with the risqué conviction of the educated classes that sexual repression contributed to mental disorder. Psychoanalysis offered an altogether more intriguing and dramatic take upon personal troubles, and had the added benefits of absorbing every symptom of neurasthenia into its own landscape – under the heading of ‘neurosis’.¹⁰ Above all, psychoanalysis purported to offer a cure for hysteria, as illustrated by the dramatic account by Freud and his colleague Josef Breuer, of Breuer’s work with the patient that they named ‘Anna O’ (real name: Bertha Pappenheim), an account that subsequent scholarship has shown to be entirely mythical. Pappenheim in fact remained so disturbed after seeing Breuer that she had to be quickly re-institutionalised into a Swiss sanitarium, the first of several such episodes, and she continued to experience her symptoms for years afterwards.¹¹

Originally a doctor and a neurologist by training, the young Freud turned his attention to the causes of mental illness, especially the hysterical paralyses that were afflicting middle-class women in mid-nineteenth-ccentury Vienna and throughout Europe and the United States. Freud made himself an understudy of the French physician Charcot at the Saltpêtrière Institute in Paris, where this charismatic teacher used hypnotism to restore seemingly paralysed patients back to normality. Charcot suspected that sexual and emotional tensions underlay many of these illnesses. Back in Vienna, Freud had experimented with cocaine and even nasal surgery as potential cures for mental disturbance, but under Charcot he became increasingly interested in the idea that the surface symptoms of mental illness might be the patient’s way of concealing unconscious desires and conflicts from themselves as much as from everyone else.¹² Drawing upon clinical observation and the idea of developmental stages from embryology, he began to formulate his famous tripartite theory of the mind – divided into the super-ego, the ego and the id; this scheme has been colourfully, if irreverently, described as a dark cellar, in which a well-bred spinster and a sex-crazed monkey grapple in combat, refereed by a nervous bank clerk.¹³

Freud’s favoured treatment method required the patient or analysand to express whatever came into their head. This technique of ‘free association’ often required them to lie down on a couch, although things were not always this formal and Freud sometimes analysed people while they were seated, or even while they were walking with him through the Austrian countryside, in the case of his disciple, Ferenczi.¹⁴ Wherever the analysis took place, the task of the analyst was to decode the client’s uncensored utterances for the hidden symbols that offered clues to their unconscious conflicts. The resulting dose of truth would banish the need for further painful repression and evasion, or neurotic misery, leaving the analysand free to get on with a life of ‘ordinary unhappiness’. Freud always claimed that these analytic skills were arcane and self-taught in the unique instance of their author, but otherwise to be mastered by undergoing an expensive course of analysis once or more a week, for several years and beyond. This, combined with Freud’s initial insistence that each analyst be a medical doctor (a view that he relaxed somewhat in his later years), ensured that the whole world of analytic training and practice was available only to the wealthiest of individuals. Freud proffered psychoanalysis as an experimental and investigative procedure, a route to self-knowledge and control more than a cure for misery.¹⁵ However, this did not prevent him from crediting himself as the cause of sudden improvements in the condition of his patients, should they occur, or from eschewing the benefits that came with psychoanalysis being perceived as a branch of medicine.

The popularity of psychoanalysis helped to dispel the idea of neurasthenia as a literal form of wear-and-tear upon the hardware of the brain, and it cast a similar question mark over hereditarian views of mental illness, displacing them with an entirely functional view of disturbance, as a breakdown in mental organisation. Less well remarked upon was psychoanalysis’s penchant for directing attention away from the world that gave rise to personal ills, in favour of a journey into the inward depths of the psyche.

The First World War and its aftermath contributed to these changing views of emotional illness. This conflict was unusual for the huge numbers of psychological casualties, and for the officer class being among those who suffered the highest rates of breakdown. It would have been unthinkable to blame these ills upon the inherited weaknesses of these elite men, and in search of a convincing explanation, psychiatrists were forced to look to the horrors of trench warfare.¹⁶ Electric shock treatment had been tried on some of these hapless casualties, but to little effect, other than as perceived punishment. The ideas of Freud suggested new and seemingly more humane remedies, including psychoanalytic therapy for shell-shock victims, pioneered by psychiatrists like A.J. Brock and W.H. Rivers, at Craiglockhart War Hospital for Officers, in what is now a suburb of Edinburgh.¹⁷

In the interwar years, the Freudian doctrine was disseminated and developed by his followers, who split into numerous warring schools, almost every one of them declared apostate by the master. These have been given the generic term ‘psychodynamic’ psychotherapies. Famously, the Swiss analyst Carl Jung rejected Freud’s atheism, and his view that neurosis was the result of sexual repression or trauma. In a more humanistic vein, Jung saw the search for personal wholeness and integrity – or ‘individuation’ – as the key to most psychological distress. He thereby added a focus on spirituality into a psychoanalytic practice that pointed toward the wisdom and healing power of the collective unconscious. This was the repository of all of the mythological symbols and yearnings of humankind and of the ‘archetypes’ – recurrent images and themes that surfaced in dreams and visions and that, according to Jung, addressed the clients’ dilemmas. The archetypes had power to restore lost meaning and vitality, if only the client would heed their advice. Jung’s interest in non-western cultures and in arcane subjects like alchemy have given his ideas an enduring appeal to New Age thinkers in the twenty-first century, notwithstanding his fondness for seeing Africans and other non-white ‘races’ as essentially childlike, and his publicly pronounced views on Jewish mental and emotional life during the 1930s, which sometimes veered rather too close to those of the Nazi regime.¹⁸

It is often said that wars lead to cultural and social innovation, and so it has proved with the talking treatments. The large numbers of casualties from the Second World War gave birth to group psychoanalytic therapy, the more economical batch treatment of several soldiers at once, pioneered at institutions like the Northfield Hospital in Birmingham, and Mill Hill, in London.¹⁹ Freudian-inspired treatments spread into the fields of child and family guidance at a slow and piecemeal rate in the years between the wars; but more swiftly in the decades after the Second World War, as welfare states established themselves throughout western Europe, and American insurance-based health care turned toward outpatient treatment for disturbed or unruly children.²⁰ The object relations school of analysis, developed by British practitioners such as Melanie Klein and Ronald Fairbairn, was well suited to these changes, because it held that cure could be achieved through building good relations with others (with what Freud had termed the ‘objects’ of unconscious desires) rather than via the management of internal drives. This outlook chimed well with growing scientific curiosity about infant development, as the foundation for adult personality and well-being. Exponents like Donald Winnicott and John Bowlby emphasised the importance of the environments in which children are reared, the emotional unity of mother and child, and the need for consistent care and nurture, themes that did not appear much in Freud’s account. Both of these clinicians advised the British government about the potentially harmful effects of the separation of evacuated children from their mothers; their concerns echoing contemporary male anxieties that women, who had run the factories during the war, should now be returning back to the home, where they supposedly belonged. This emphasis on the importance of maintaining ‘secure emotional attachments’ has found its way into many strands of current psychodynamic treatment, where the therapist strives to provide a place of safety, a ‘secure base’, in which the client can express and come to terms with their deepest fears, and perhaps mend their latent capacities for emotional attachment and trust, that had been frayed or broken in their formative years. This concern with emotional protection can extend to the minutiae of therapy, including the requirement that the client and therapist always meet in the same room and at the same hour.²¹

By contrast, American psychoanalytic psychology – largely the product of the diaspora of central European analysts before the Second World War – retained the traditional Freudian focus upon the enclosed world of the individual psyche. In this ‘Ego psychology’, the task of therapy was to help the individual to adjust better to prevailing social conditions via the strengthening of the super-ego, in essence, through the application of will power. Though psychodynamic therapy in the United States fell into decline from the early 1970s,²² this belief in the apparent desirability and ease of self-transformation has diffused into a wide range of other therapies in the US, and beyond.

This spread of psychological thinking and techniques ensured that, by the 1950s, neurosis came to be diagnosed across all levels of society, tightening its grip upon the popular and professional imagination.²³ (The language of neurasthenia or of ‘weakened nerves’ lingered on in the popular culture of the West: in films, novels and commercial ‘nerve tonic’ remedies, only to re-emerge in late twentieth-century maladie...

Table of contents

• Cover
• Title page
• Copyright page
• Contents
• Acknowledgements
• Introduction: The Light at the End of the Tunnel?
• PART I EVALUATING PSYCHOLOGICAL TECHNIQUES
• 1 Misery, Mind Cures and Fashion
• 2 The Psychopathology of Everyday Life
• 3 The ‘CEO of Self’ ... ?
• 4 Does Therapy Work?
• 5 ‘I’m not ill, I’m hurt ...’ – The Hidden Injuries of Social Inequality
• PART II THERAPY IN SOCIETY
• 6 Sweet Medicine – Talking Therapy as Control
• 7 Theory Into Practice – The Programme for Improving Access to Psychological Therapies (IAPT)
• 8 The Therapy Market – From the Third Wave to ‘Happiness’
• 9 Towards a Psychology that Reflects what the Therapy Industry Will Not Tell Us
• Notes
• Index