PSYCHOANALYSIS OR MENTAL HYGIENE?
Despite its many vicissitudes since the early 1980s, the project to regulate the talking therapies now looks set to happen in 2008. The Department of Health has commissioned both UKCP and BACP to carry out survey work, much of which is now available. The regulator is assumed to be the Health Professions Council, although there have been several questions raised about its appropriateness. The UKCP, for example, is sceptical of HPC as a regulator in its present form. Although a major issue involves the compatibility of therapy and counselling, does psychoanalysis have a place here? Does analysis share enough of its aims, training outcomes and practices to sit alongside therapy and counselling?
To explore this question, we can start by asking what the reasons are for regulating the talking therapies in the first place. The October 2005 Report prepared by UKCP for the Department of Health states these as follows: to protect the public, to ensure good practice and to promote the scientific development of the profession (p.11). These three objectives might seem immediately obvious and unproblematic. Practitioners from all areas of the professions involved would surely agree that these aims are desirable and, indeed, imperative. However, as we examine them one by one we will see how this clarity is perhaps illusory.
Protecting the Public
Philosophers and political theorists with no knowledge of or interest in psychoanalysis have long urged detailed scrutiny of rationalisations for social initiatives that claim protection of the public as their grounding. This has been used for such a disparate range of projects that its context and meaning must be unpacked in each case. Rational explanations must replace rationalisations here. And this is where things become more complex. When we speak of protecting the public, what aspect of the public do we mean? A basic feature of psychoanalytic approaches to theory and practice is that the human subject is a divided one. No longer an autonomous, freely-choosing individual or agentive self, the subject posited by psychoanalysis is split between conscious wishes and demands and unconscious desires, phantasies and forces which may in fact be quite opposed to conscious volition.
When a patient asks for help with a specific problem, the analysis may uncover the fact that the unconscious desire is to leave the problem unresolved. Or, that the problem is actually a vital factor in that person's survival and is thus best left unanalysed. Or, that remaining true to a desire may cause pain and disturbance in that person's relation to others. More generally, psychoanalysis posits that conscious demands and unconscious desires rarely coincide. Should the analysis, therefore, remain faithful to the conscious or the unconscious side of the patient's psyche? This is made more difficult by the facts of resistance, defined by Freud as a central feature of any analytic approach. According to this view, people not only wish to ignore the unconscious dynamics of mental life, but they actively pursue a passion for ignorance: they desperately do not want to know.
This means that any extensive analytic process will interfere with the patient's view of both their own well-being and their best interests. Analysis also supposes that many of our unconscious ideals and phantasies deliver a yield of pleasure which we are loathe to give up, despite the fact that this pleasure is often experienced consciously as pain and suffering. This paradoxical aspect of mental life was emphasised by all the major psychoanalysts, from Freud to Klein and Lacan. Should the analyst, then, act in the best interests of the patient's unconscious or conscious sources of pleasure? The further these questions are pursued, we see how the notion of the protection of the public is hardly transparent.
The obvious solution here is simply to define symptoms and health in terms of independently observable symptoms. Then an external observer will be able to tell what is a dysfunction and what isn't, and hence what should be cured and what shouldn't, thus ensuring protection of the patient. We see this already in the UKCP document's references to "psychiatric disorder". This is often mentioned as a variable separate from any other pathology, yet it is not defined beyond the implication that it is an independently existing entity. This is antithetical not just to an analytic approach but to any perspective which privileges a patient's experience of their life. A symptom is not an observable feature of behaviour but what a human being experiences as symptomatic. This is a fundamental fact of all demands for therapy: people see some aspects of their lives as problematic and others as less so. But it is for them and not an external agent to determine what is felt to be symptomatic. Here is a significant difference with the medical discourse, where symptoms can be externally classified.
This brings us to another well-known problem. Medical approaches, and many therapeutic ones, set a premium on removal of symptoms. Yet psychoanalysis has never been aimed at symptom-removal. Rather, it aims at accessing unconscious structure, generally via an analysis of symptoms. In many cases, this accessing will have therapeutic effects, but the removal of the symptom is never considered a primary goal. In some cases, it may be quite dangerous (eg the attempt to 'remove' a phobia in a monosymptomatic adult patient). This sets psychoanalysis aside from other health-related endeavours, and poses a real question as to the viability of the HPC framework for psychoanalysis. It is in no sense a health profession, focussing instead on individual exploration with the very uncertain results this will produce rather than the neat goals of symptom-removal favoured by cognitive styles of therapy.
To speak of good practice automatically introduces the technology of inspection and evaluation. Although psychoanalysis should never be shy to scrutinise its results and suppositions, today's popular evaluative apparatuses always set norms against which individual paths and practices can be measured. Measurement otherwise has little sense in these frameworks. Yet psychoanalysis, as an exploration of unconscious structure, has results which vary from one individual to another. Each subject is deemed unique, and no standardised result of analytic treatment is sought, a point emphasised by Freud, Lacan and Winnicott.
Ratings scales also tend to have features rendering them inappropriate for psychoanalytic frameworks. Self-rating has well-known problems, and these will only be augmented when transferential situations are taken into account. Psychoanalysis cannot be separated from its embedded context, and it is not a technique that can be applied to a patient. Rather, it is a property of a relationship between two people. Unlike a pill or an injection, it can't be given by one person to another. It supposes transference, the mobilisation of unconscious forces which forge the details of the lived, affective experience of other people and processes such as any form of therapy. These transferences are a central motor of analytic treatments, and are learnt from, analysed, interpreted and worked with. But in themselves, they cannot be regulated. They generate a dangerous chemistry, which a skilled clinician will not aim to 'manage' but to work with in the most fruitful way possible. Since transferences shape our experience of reality, according to all the major analytic theories, standard evaluations and ratings become useless. There is no neutral observation language with which to distance oneself from a situation which one is actually immersed in.
This is not to say that psychoanalysis should not and cannot be tested for good practice. This involves a making explicit of clinical aims in the context of an individual case, and giving accounts of one's practice. These may be subjected to comment and criticism, just as different schools of analysis regularly engage in critiques of each other's theories and practices. Good practice must be evaluated from within the context of particular modalities, rather than via a norm imposed from the outside which relies on measurable, observable features which are no those germane to analytic treatment.
The central place of transference to analytic work poses another question here. Anxious to achieve objective standards, the report recently submitted by UKCP of its recommendations to the Department of Health recommends that a trainee only enter their personal therapy with a member of a group different from their own, yet belonging to the same modality. Given the framework of 'objective standards' externally imposed, this makes perfect sense. Yet it means that the whole dimension of transference is neglected. Without transference, there is no analysis. The choice of analyst should be made according to the direction of one's transference, and this is an individual matter which can never be externally directed. Trying to do so breaches a basic human right: the right to have false beliefs. If transference is a belief system, regulation implies that the State can tell someone what to believe and what not to believe. The next logical step would be to determine which are the good and which are the bad religions, and then to instruct the public.
The third and last aim of regulation is described as the scientific development of the discipline. This is linked to what is surely one of the greatest success stories in the history of public relations: evidence-based practice. The report can tell us that we have to move away from authority and group pressures to base our judgement on real evidence. Yet a century of history and philosophy of science and sociology is simply ignored here. The lesson of that century is that the distinction between authority and evidence is hardly a simple one: to see something we have to be inclined to both look at it and then see it AS the something we have been told to observe.
Evidence-based medicine derived largely from the theories of David Sackett and his associates of McMaster University in Ontario. It aimed to undo irrational appeals to authority in medicine in favour of a judged consideration of evidence, which comes in the form largely of epidemiology and statistical approaches. Since psychoanalysis treats individuals and their unique histories, epidemiology is automatically ruled out. Where epidemiology can learn from the presence of the same groups of symptoms in a population, psychoanalysis posits that the same symptoms can have radically different causes from one person to another, and even at different moments in the life of the same person.
Evidence-based research has now become a rhetorical feature of the contemporary landscape of professional practice. It had been most successfully manipulated by attachment theorists, who have claimed to adhere to an unproblematised concept of evidence in their research. Psychoanalysis, on the other hand, questions the idea of a neutral observation language that is uncontaminated by the effects of transference and unconscious phantasy. It also rejects normative views of human development. These views, in fact, have become increasingly popular today among practitioners of talking therapies. Clinical intervention is justified simply to patch up problem areas in the developmental process. The evidence appealed to stems from simplistic accounts of development and brain chemistry, as if the goal of therapy becomes to affect changes in the brain. Naïve and poorly informed references to neurotransmitters and brain structure jostle with the more traditional concepts of therapy. This recent trend indicates less the richness of the biological hypotheses than the poverty of the theories of talking therapies: outside help has to be sought in the form of 'science' to confer legitimacy.
The other flagship of evidence-based research is the clinical trial. But how could a clinical trial operate in a psychoanalytic framework? There is no such thing as a control subject, since each case is a unique one. To reply that someone may be found who has the same symptoms is to miss the point, since the symptom for psychoanalysis is defined by the patient's experience of the symptom and not by any objective measure. Psychoanalysis does conduct its own clinical trials, but these involve just one subject. In a well-established procedure used on the Continent known as the pass, an analysand will talk about their case in detail to a number of designated listeners, who then discuss what they have heard with a small group of other analysts. The aim is to enable research into how changes have taken place in an individual case, and there is now a substantial literature on this question.
What effects will the pressures we have discussed above have on psychoanalysis? We can already point to certain trends in contemporary psychoanalytic discourse which indicate that a new 'adapted' version of analysis is emerging. In a recent book by two well-known analysts, the self is defined as "a rational agent with understandable desires and predictable beliefs who will act to further his goals in the light of these beliefs". This extraordinary definition is in fact identical to that found at the start of textbooks on rational economics. The calculable subject is the subject of modern market societies. What has happened to the Freudian unconscious? What has happened to the split between conscious demands and unconscious desires? And what has happened to the Freudian thesis that a large part of human activity is not directed to instrumental goals such as the pursuit of wealth, power and happiness?
This sanitised definition of the self leads inevitably to a sanitised version of psychoanalysis, one with no unconscious or transference to speak of unless they are construed as errors in learning which can be undone by cognitive methods. This version of analysis, emptied out of subjectivity, is of course perfect for regulation. With no real subjectivity, it becomes simply a process involving the transfer of knowledge and skills: to unlearn symptomatic behaviour, to learn how to analyse from one's analyst, and to enlarge the field of self-knowledge. These new aims are completely antithetical to Freudian psychoanalysis, which privileges instead the encounter with what we don't know. Analysis is not about acquiring knowledge, but about putting knowledge and its effects in question. If anything, the subject's very relation to knowledge will change during the course of analysis.
Conceiving analysis in terms of the transmission of knowledge and skills will also have significant effects on how supervision is regulated. It seems likely that the less personal analysis shows suitability to regulatory intervention, the more this will shift to the field of supervision. Already, most recent discussions of supervision take it to be a process of management of the supervised case. The more that poorly trained mental health workers are drafted in to deal with waiting lists, the more supervision will function to extend the chain of clinical responsibility. This is once again consistent with the knowledge-skills idea of analysis, and contrasts with the stated aims of other currents of Freudian analysis which focus on lack of knowledge. Analysis, on this model, aims at a point where the analysand realises that the analyst knows precious little about him or herself, and that knowledge as such has decisive limits.
The three issues we have discussed all move psychoanalysis in the direction of mental hygiene, and this, after all, is the only thing that the State can really regulate. Personal anguish and pain become desubjectivised and transformed into variables that can be externally verified and measured: that is, sets of observable behaviours. These will then be classified and linked to developmental problems which the analysand must be taught to unlearn, reducing the gap between observed behaviour and desired behaviour. Lost is the subjective truth articulated in the symptom, and the formative powers of the transference. Analysts must decide which of the two paths they wish to follow: psychoanalysis or mental hygiene.
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