|IF THEY DON'T MAKE YOU HAPPY, SUE THEM
Contribution to the conference of The College of Psychoanalysts-UK ‘Are you fit to practise? From ethical framework to model of good behaviour’- London, 6 June 2009
The very idea that psychotherapy needs a regulation focussing on the health and character of the practitioners as well as their competences and skills is a typical sign of our times. This means that this idea goes much further than the field of psychotherapy. Today, we are putting all our hope in a behavioural regulation combined with a bureaucratic and technical control, because there seems to be no alternative. Unfortunately, as a sign of the times, of our times, this need for a behavioural control is both necessary and wrong.
It is necessary because we are confronted with gross misconduct on every level of our society. In the UK, you have your apparently corrupt MP’s and even your Speaker had to resign, we have ours in Belgium. Bank managers are not to be trusted any more, and every priest and teacher is a possible threat to his pupils. Violence in the street is virtually everywhere. On top of that, we are confronted with unbelievable illustrations of incompetence – private IT-data are left behind in train cabins, which in itself is not that serious since they are accessible to 14 year old hackers. Medical doctors perform the right surgery on the wrong patient and even to get new plumbing in your house is just asking for trouble. It seems as if nobody cares about doing a decent job any more and that everybody is only looking out for number one, often enough to the detriment of all the other numbers. This explains the ever growing need for public control. In spite of this necessity, the need for a behavioural control is wrong for at least two reasons.
If we consider this situation from a philosophical point of view, it is obvious that our society is suffering a loss of ethics on a mass scale, and tries to remediate this loss on a behavioural level. Well, every psychologist can tell you that this will not work. Putting your hope in a purely behavioural regulation is an illusion if there is no psychological back-up in the people that you want to regulate. A lack of ethics can never be remediated by a big brother system, even on the contrary.
Moreover, offering a forum for complaints on psychotherapists is just asking for trouble. I predict that a considerable number of patients will use this kind of regulation to shoot the pianist, i.e., the therapist. The denomination of the official URL is very telling in this respect (http://www.hpc-uk.org/complaints/making/nothappy/) as it seems to convey the message that therapists should make the client happy and if this is not the case, the client has the right to complain. This will create what I would ironically call a super Dalrymple syndrome.
Before going deeper into the reasons why such a system will not work, I want to address yet another issue. The very idea that it is possible to regulate psychotherapy on a behavioural level testifies to a very particular interpretation of what psychotherapy is. I think it is very important to make this clear, because this interpretation concerns a very limited number of psychotherapies, whilst it creates the impression that it goes for all psychotherapy as such. Indeed, today a growing number of people are convinced that a psychotherapeutic practice is more or less similar to a medical practice. You diagnose a patient in an objective and scientific way, and then you pick the most appropriate form of treatment that is considered the best practice for this particular disorder. In this kind of reasoning, a control system in terms of competences and skills seems perfectly feasible. The trouble is that this kind of reasoning is a purely academic one, both in the literal and the metaphorical sense of the word. As always, we have to study its history if we want to understand what is right and what is wrong.
This is not too difficult, because it is a very recent history. At the end of the previous century, there was an increasing demand for psychotherapies to prove their effectiveness. Nobody with a sound mind can be against such a demand, but the trouble is that the way in which this question was answered might very well mean the end of psychotherapy as such.
When researchers in the academic world were asked to set up a design to measure the usefulness of a certain kind of therapeutic approach, they copied the methodology that was originally developed for the evaluation of medical and pharmacological treatments. This means that they tried to compose at least two large research groups of exactly the same patients, who were treated with two different methods, one of them being the target method that needed evaluation, whilst the other group received the standard treatment. In order to make the comparison possible, the therapy given to all the patients within one group has to be completely identical, hence the need for a strictly manualised treatment – the therapist has literally to follow the book. This is the philosophy of Evidence Based Medicine and Randomized Controlled Trials: identical patients, identical therapists, identical treatments.
Such an approach has enormous implications, because it means that in this approach a psychotherapeutic method can only be researched on its effectiveness if it meets at least two criteria beforehand. Firstly, it must be possible to standardize the treatment completely, in order to rule out the impact of the individual therapists. Secondly, the treatment has to be short; ideally it takes only 6 to 16 sessions, in order to rule out other influences. I think it is obvious for everyone with knowledge of the field that only a very limited number of psychotherapies meet these criteria, meaning that all the other forms cannot be evaluated within this approach. On top of that, this research design can only be applied to a very limited number of patients as well, because of another inherent requirement. Indeed, the patients that can be used in this kind of research are only allowed one diagnosis based on the DSM, co-morbidity is out of the question.
Let us take a closer look at these requirements. First is the need for a manualised treatment based on a protocol-like approach. This means that the therapist is reduced to an executive who has to follow the book – as a matter of fact, he or she is turned into the university professor’s research assistant who is not allowed to take any initiative during the treatment. Anyone with clinical experience knows that therapy doesn’t work this way, that each individual treatment is different because each client is different. In case there are people in the audience who think that this is only the case for psychoanalysis, I have a convincing anecdote. A couple of years ago, there was a big conference in my country at the occasion of 25th anniversary of the organisation for psychiatry and psychotherapy. I was one of the five keynote speakers; everyone of us had at least 20 years of clinical practice and each speaker represented a different psychotherapeutic school: behavioural, cognitive, systemic, experiential and psychoanalytic. In spite of our different backgrounds, we had at least one thing in common. During the panel discussion, it became obvious that not one of us followed his or her own book, let alone a manualised one. The explanation was very simple: we can’t predict beforehand what will be important during a particular treatment, and a good therapy is always to a certain extent tailor made to a particular client.
The second requirement concerns the need for a limited and preferably fixed number of therapeutic sessions. The insurance companies love this idea. Well, long term follow-up research has demonstrated what every experienced clinician knows: the effect of a psychotherapy is among other things determined by its length, and although most short term psychotherapies might initially be successful, there is an enormous relapse within one year. Again, the conclusion is quite clear: psychotherapy doesn’t work that way.
The third requirement is even more baffling, because the exclusion of every patient who suffers from co-morbidity means that about two thirds of the potential clients are excluded from these studies. I am always wondering where these researchers find these kinds of clients, I never see them! The moment you start listening to a patient with a supposedly “simple phobia” or an isolated “panic disorder”, things very quickly get more complicated, and the idea of “single” or “isolated” disappears quite fast.
Let us now return to the obligation for psychotherapy to prove its effectiveness. For the time being, the most accepted way to test it is by using the Evidence Based methodology. As I explained, this methodology can only be applied to a very limited number of psychotherapies and even then, for only a very limited number of patients. It is at this point that we meet a perverse twist with a disastrous effect. Instead of concluding that this methodology is too limited to do the job, the message is that every therapy that cannot be tested by RCT is simply not scientific or effective. This is what I call a perverse reversal and the perversity doesn’t stop there, on the contrary. The next step is that the insurance companies refuse to refund those therapies that are not tested. Next and consequently, the teaching institutes tend to focus nowadays almost exclusively on those few therapies that do match the criteria of the Evidence Based approach!
As a result, a growing number of psychotherapies are banned from the forum and a very limited number of short term and protocol-based treatments are promoted as the supposedly only reliable ones. As they are short term and protocol-based, they are easy to teach and easy to apply, and indeed, today, they are everywhere.
There is only one tiny problem: they don’t work. First of all, they don’t work because they are used with the wrong patients, meaning: with real patients. Remember: these methods were tested with those very rare clients who have only one problem. In real life, what in these studies is called “the naturalistic treatments”, half of the clients don’t fit DSM-diagnoses and about two-thirds of them suffer from so-called co-morbidity. Secondly, there is growing evidence that by 18 months post-treatment, the initial positive outcome of brief psychotherapy is indistinguishable from a placebo-effect.
In summary, the scientific testing of psychotherapeutic effectiveness has resulted in an impoverishment of psychotherapy to protocol-based short term treatments. The growing evidence that the initial positive effects of the latter don’t last is leading more and more to the conclusion that psychotherapy as such doesn’t work. This is perverse, because the correct conclusion is that firstly, the larger part of psychotherapies cannot be tested with the RCT-methodology because of the limits of that methodology, and secondly, that the larger part of our clients cannot be treated by those treatments that can be tested via RCT.
Nevertheless, the damage has been done and the perverse conclusion operates as a self-fulfilling prophecy. It is perfectly possible that in the near future the British Health Professions Council will concentrate on those manualised treatments, because they are the only ones that can be evaluated in a simple way on a behavioural level. With the other psychotherapies, this is not possible. The irony is that in case the council focuses on these manualised and supposedly evidence based treatments, chances are great that the council will receive a growing number of complaints. To put it in terms of the website: these forms of would-be psychotherapy don’t make people happy at all.
So, in summary: it is impossible to evaluate genuine psychotherapeutic treatments in terms of predictable skills and competences, because they are not predictable. If we are talking about manualised treatments, this kind of evaluation is possible and will reveal bad outcomes and unhappy patients. In its turn, this will increase the idea that psychotherapy as such doesn’t work, and that salvation has to come from the pharmacological or even the neurological department.
Based on what I have said so far, I might have given the impression that a behavioural control system will fail in the field of psychotherapy, because of the typical characteristics of our job, but that it might be feasible in other instances. This is not the case, on the contrary. As I said in my introduction, it has to do with something that goes much further than the field of psychotherapy. This need for external control, evaluation and assessment is everywhere. To give you an example: unfortunately enough, I am the head of a university department. There used to be a time that people in my position were paid to read and study and to teach what they had read and studied. Today a big part of my time goes into management, including the obligatory performance and evaluation interviews and the filling in of reports in a standardized manner. I am myself controlled in the same way by a controller above me who is in his turn controlled by yet another controller.
The net result of such a system is an ever growing anonymous bureaucracy in combination with ever growing levels of distrust. This is an infernal spiral, because the system creates its own transgressions. To put it in clinical jargon: a focus on a behavioural control will shift very soon from an obsessive compulsive to a paranoid system. How many cameras do we need in the streets? And why should we limit cameras to the street, we’d better put them in the class rooms and the offices as well. And doesn’t the ever raising threat of terrorism oblige us to put them even in private homes? Etc.
In this way, the world is turned into a generalized panopticon. Every added level of control aggravates the original problem: there is a growing lack of trust in the others, we can’t run up “the usual suspects” anymore because everybody is suspected. This is without any doubt THE contemporary problem: the loss of ethics, and behavioural control isn’t the answer to that kind of loss, as it is a consequence of it.
If we want to do something about this loss, we have to look for the causes. From a psychoanalytic perspective, this cause can be summarized as the disappearance of the big Other, as an abstract denomination for the symbolic order that contains shared meanings, ideals, obligations etc. Based on this big Other, every subject acquires two very important things: his identity and his conscience. In Freudian terms: his ego and his super-ego. In contemporary scientific lingo, it is said that identity development and affect regulation are the combined result of mirroring processes. But of course, there has to be somebody to provide that mirror, and this is no longer the case.
For lack of time, I have to be brief. The cause of this disappearance is without doubt an effect of neoliberalism. A couple of decades ago, Margaret Thatcher proclaimed “that there is no such thing as society.” Well, there used to be one, but now, it is gone. Its disappearance means that the traditional basis for identity formation, drive regulation and meaning has disappeared as well, meaning that we are left with huge problems on these respects. Just think about the identity disorders in borderline patients and the loss of identity in cases of depression. In matters of drive regulation, we are facing today a very perverse super ego, because it obliges every one of us to enjoy ourselves until we drop dead, without regard for the others.
This is an effect of 25 years of ‘new capitalism’ – the term is from Richard Sennett, an MIT sociologist. Because of the dominating power of the economy, this discourse was soon enough taken over by the state administration, especially in matters of health care and education. Its combined effects on society, family life and finally the individual are enormous and illustrate perfectly how economy, politics and subjectivity are intermixed. I will give you a few examples of this mixture.
Contemporary management aims at short term profits, just like our politicians are only thinking in terms of one legislative period. This means that short term fluctuations on the stock market have the same effect on economics as pop polls on politics: fast and drastic interventions in function of the “market”. It won’t take long before continuity and stability become dirty words, indicating what you shouldn’t aim for. On the individual level, this creates insecurity and exhaustion. Everybody has to keep growing, every evaluation interview has to result in ever higher aims and it is specifically forbidden to stay at the previous level. ADHD has become the norm and flexibility its credo.
This explains why such an economy cannot cherish experience and knowledge; such assets cause too much stagnation and resistance to change. Instead of that, the accent shifts towards so-called competences and skills. The combination between a tendency towards short term profits and a decreasing appreciation of knowledge results in the dissolution of the glue that held groups together, i.e., loyalty and solidarity. In the light of what is happening today, the previous generations knew a far reaching loyalty between “upstairs” and “downstairs”. A worker was more or less assured of a life long job with the same boss, and consequently he was prepared to engage in that job and for “his” boss – indeed, he was part of it. This boss would engage himself for “his” people, because that was to the best of his interests. This has almost disappeared today, together with the company and the boss. A multinational company is invisible, has no contact with its workers and will displace, cut down, increase jobs in function of the stock market. Consequently the workers don’t have any feeling of loyalty anymore, and the relationship between upstairs and downstairs is one of distrust. And that of course creates a necessity for continuous control and evaluation.
When the vertical loyalty is lacking, the horizontal solidarity will disappear very fast as well. An almost exclusive tendency towards fast or simply more profit implies the rejection of everything that stands in the way. Consequently, everybody is confronted with the threatening image of potential redundancy – there is always somebody who is better, faster and cheaper. In such a discourse, it is inevitable that colleagues become rivals and that solidarity is a luxury that you can’t afford. The next step is that this combined disappearance of loyalty and solidarity is felt on the level of the smallest group, which is the family. Our contemporary love life is a very strange one. Partners distrust each other from the start; try to protect themselves against possible fraud via complex marriage contracts, keeping separate saving accounts from day one, etc. In case of a conflict, negotiations are no real option, get packing and go, because flexibility is better, and more often than not, a new and supposedly better product, that is, a new partner is already waiting. Indeed, there is always somebody better, faster and cheaper than you.
The resulting balance is rather pessimistic. Durability is bad, elaborating a common long term project is impossible. Distrust is obligatory and solidarity is nothing but a tax deductible item. The whole thing bathes in a sphere of general tiredness, chronic lack of time and, most importantly, in a sense of loss and distrust in the other. This leads to another conviction: if something goes wrong, if I don’t get the right answer, it is the other who is to blame. This idea is today very wide spread, meaning that the contemporary mean mental age is about three, that is: pre-oedipal.
I have to conclude. This general distrust is indeed general. The Health Professions Council doesn’t trust the professionals. The professionals don’t trust the council. On top of that, the clients don’t trust the professionals. As a client they want to be helped immediately and completely. On top of that, they are convinced beforehand that if things don’t work out as expected this is because of the incompetence of the other. So, if you are offered the opportunity to put in a complaint, just do it! The next step will be that they will have complaints about the council and vice versa, thus joining the contemporary spiral of control and super-control etc.
Instead of participating in that kind of spiral, we should stop it as soon as possible. We don’t need additional control, we need to put our trust in the already existing evaluation systems.
Firstly, the state needs to trust its educational system and the professional societies. If somebody graduates, it means that he or she is competent. If this fails on a large scale, then you will need to invest more in your educational system.
Secondly, the state should trust its own legal and jurisdictional system. If somebody breaks the law, he or she should be put to trial following the normal standards. Creating extra rules and extra controls adds to the idea that the law in itself is failing.
Finally, the state should avoid at all costs creating a further opportunity for individuals to put the blame on others. If not, it will be blamed itself, and this for a good reason.
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