In memory of Rosie Parker
Many psychoanalytic psychotherapists today perceive their professional competence to be under threat as never before. A series of accusations is continually being made, coalescing around the notion that research in psychoanalysis is a waste of time. According to its detractors, psychoanalysis is out-of-date, irrelevant, ineffective, and only deserves to take a humble place in the footnotes of the history of mental health. In this view, research is narrowly defined as a scientific activity and empirical research is given pride of place.
It is notable that psychotherapists and psychoanalysts of all schools seem reluctant to engage with their critics, let alone respond in kind. Instead, the profession seems to be full of ostriches burying their heads in the sand rather than producing a carefully considered and coherently argued position from which to oppose these accusations.
In my recent writing I and a number of colleagues have been assembling a variety of responses. If looked at closely, the position of our critics has many weaknesses. Thus far, we have offered two counter-arguments. The Problems of Cognitive Behavioural Therapy (Hall & Iqbal 2010) examines the claims of currently fashionable ‘scientific’ cognitive behavioural therapy research. Using its own tools, we passed a critical eye over its statistical findings used in their largely empirically based arguments. Our book shows that the proponents of CBT have precious little statistically valid, reliable evidence to support a claim to be superior to any of the rival forms of talking cure. Rather, CBT is portrayed as a limited, sometimes useful method of treatment but not one which stands out in any way. Its claims to success are largely based on the view that it is quicker—a claim that only works in the case of people who need a mere six sessions of therapy. After sixteen sessions this initial
advantage fades. The other major claim of CBT—its superior efficacy—is also doubtful. Success rates of 50% and no clear water between CBT and its rivals suggest that its protagonists are over-optimistic in their claims. In fact, the empirical research relating to CBT is littered with the same problems as those which bedevil research into rival psychoanalytically oriented therapies. They are conundrums familiar to any statistician who works on populations connected with human activity: issues relating to reliability and validity of data are legion and many apparently large cohorts of experimental subjects land up with sets of data often containing numbers of people in single figures. The conclusion of our book is one that is uncomfortable for all the therapies—that, in truth, they all appear to operate as placebos. Empirically speaking, money might better be spent on research directed towards improving the efficacy of placebos and promoting their use in treating people with a wide variety of emotional problems. Since the effectiveness of a placebo at least in part depends upon whether it is currently fashionable, research in this area might have to start with the assumption that a talking cure which worked well in the 1890s might need at least some modification a hundred and twenty years later. Any assumption that there are universal truths which can be applied to particular versions of the talking cure is doubtful in the extreme.
A second approach involves questioning the philosophical underpinnings of research practice in from the 1960s onwards. This view is explored in both The Problems of Cognitive Behavioural Therapy and in The Problems of Psychoanalytic Psychotherapies. The key debates here are to be found in the work during the 1960s of Kuhn, Popper, Lakatos and Feyerabend.
The best known, and still the most popular work in the field, is Thomas Kuhn's The Structure of Scientific Revolutions. Kuhn suggested that in many fields of scientific endeavour there is a predominant method of thinking which often lasts for centuries. When a radically new idea is mooted, what Kuhn describes as a ‘paradigm shift’ takes place. Scientists then pursue and elaborate this new form of thinking. It is now notable in many fields that when a simple variant of an existing theory is posited, researchers are quick to hail it as ‘a paradigm shift’. However, what Kuhn arguably fails to account for is the logical (as distinct from historical or political) reasons for the substitution of one
paradigm for another. It is clear that the understanding of the nature of science itself changed dramatically between the end of the Middle Ages and the present day but Kuhn does not make clear why this should be so.
Kuhn criticized the work of Karl Popper. In Conjectures and Refutations, Popper suggested that much research is empirically based. This results in a circular set of arguments. A series of inductive propositions are set up which are then tested but who, Popper asked is, qualified judgement whether the initial assumptions are sound? From Popper's point of view sound research can only conducted using deductive processes. Examining a series of truth tables derived from the notion that a deduction follows from a premiss, Popper concluded that valid deductions only occur when a statement put forward as truthful turns out to be false.
A critique of both Kuhn and Popper is to be found in the work of possibly the most interesting writer on this topic, Imre Lakatos. Lakatos suggests that if Popper has removed the prop of inductive logic on which Kuhnian paradigm shifts usually depend, then the sole remaining prop—deductive logic—is not sound either. Here is his closely argued critique of the system of mathematical proof:
In deductivist style, all propositions are true and all inferences valid. Mathematics is presented as an ever-increasing set of eternal, immutable truths. Counterexamples, refutations, criticism cannot possibly enter. An authoritarian air is secured for the subject by beginning with disguised monster-barring and proof-generated definitions and with the fully-fledged theorem, and by suppressing the primitive conjecture, the refutations and the criticism of the proof. Deductivist style hides the struggle, hides the adventure. (Lakatos 1976:142)
Nevertheless, Lakatos has faith in the notion of a ‘research programme’, not such an over-arching concept as Kuhn's notion of a paradigm shift but allowing more flexibility and a wider definition of what constitutes research than Popper. His friend and rival, Feyerabend, was not sure that even this was sufficient to save us from the
view that the progress of science is not dictated by financial and political considerations rather than the merit of ideas in themselves. These debates are not conclusive and focus primarily on logic in the terms in which the discussion is couched although Laplanche in this issue, as Nicholas Ray remarks, makes distinctions between a Popperian version of science which could apply to psychoanalysis and one which is inimical to it.
The work of Stephen Toulmin, a philosopher of slightly more recent vintage, offers us a third possible response. Psychoanalysis, particularly as practised in contemporary formulations by many Site members and trainees and also by those of Lacanian or phenomenological persuasion, often privileges exploration of the speech and language of the analysand. Toulmin's research interests started in philosophy and then expanded into the related field of medical ethics. Many of his arguments turn on the role of language in the conduct of research, or more narrowly, the far from simple relationship between facts and words. Toulmin argues that one of the problems with current notions of research is the fundamental misunderstanding of the relationship between fact and theory. Thus description, content and process are inextricably intertwined with emotion, opinion and feeling; they are not discrete elements of fact, logic and argument.
In an early book, Wittgenstein's Vienna, co-written with Allan Janik, he sums up the dilemma precisely: ‘In science we want to know the facts; in the problems of life, facts are unimportant. In life, the important thing is the capacity to respond to the suffering of another’ (Janik & Toulmin 1973: 195). Toulmin commenced his career as a philosopher as a research student heavily influenced by Wittgenstein. Much of his work describes the divorce that has taken place between emotions and feelings on the one hand and facts on the other, leading to a corresponding divorce between research as a theory and research as part of a daily practice in living.
In Return to Reason (2001) Toulmin argues that the origins of this split are to be found in the wars which tore Europe apart during the Reformation, wars which decimated countries and peoples even more destructively than those of the twentieth century. In his account, the internecine relationship between the Catholic and Protestant religions heavily influenced the ideas of Descartes and the post-Cartesian philosophers;
over the centuries this led to an ever-widening dichotomy between mind and body. Thus, in Descartes' day, it was not just a matter of whether one idea was considered to be better or worse than another, it was also a question of finding a way of removing religion and its concomitant emotions so that the endless bloodshed might finally cease. A word or phrase with the ‘wrong’ emotional inflection could have literally fatal consequences for the writer or speaker. Thus the baby (emotion and feeling inextricably intertwined with bodily fact) had to be thrown out with the bathwater. ‘Desirable’ facts came to be untarnished by unreliable and disturbing emotion of any kind.
Interestingly, there is a similar purging of emotions and feelings in much of the current research programmes relating to mental health. There is a popular wish to ‘prove’ that a host of emotional problems—depression, stress, psychosis, to name but a few—are caused by genes and have no connection with the environment in which we live or our feelings about ourselves and the world. The division is made stark by giving these emotional problems, ‘problems in living’—we might say along with Toulmin and Janik—scientific labels.
It is interesting that the vast majority of psychoanalysts, psychotherapists and counsellors of all persuasions focus very little attention in their training courses, research and writings on the role of language—an indispensable component of their practice. Indeed, the last thirty years have directed us away from the importance of attending to our emotions as such and towards an analysis of behaviour as distinct from the nature of the language that produces it. Language, as a vehicle for the display of emotions and often also as an engine of behaviour, is often ignored. In Return to Reason, Toulmin takes philosophers to task for their similarly blinkered view:
Both Russell and Bradley thought of a Language as a mirror that reproduced and reflected the structure of Reality and Truth. Neither of them was happy to find that everyday language works in timely ways, lacking the timelessness of “eternal objects” … In the Cratylus, Plato asks if we cannot free the “meanings” of human language from convention and make them clearly “right” or “lifelike”… .
A warning—philosophical dreams are soap bubbles. (Toulmin 2001: 69)
The goals of empirical research are simply another species of soap bubble; Toulmin is unconvinced by soap bubbles. For him, the preeminent philosopher who sought to balance the theoretical and the practical was Michel de Montaigne. As he says:
…Montaigne's Essais show us how little has changed in the ways we lead our lives. Indolence, vanity, moderation, constancy, and not least cowardice—the mother of cruelty—are no different now from what they always were. Professional academics may dismiss Montaigne as a philosopher, because he ignores the technical issues they profess to find important For the rest of us, he remains the preeminent philosopher of everyday experience, the writer who succeeded in focussing on things that really matter. (Toulmin 201: 192–3)
Earlier in the same book, Toulmin formulates a series of brief precepts which should make researchers of all persuasions pause:
No formalism can interpret itself;
No system can evaluate itself;
No theory can exemplify itself,
No representation can map itself;
No language can predetermine its own meanings. (Toulmin 2001: 80)
There is a distinct possibility, therefore, that research into isolated properties of language is of extremely limited value; Toulmin is once again pointing to the self-referential nature of much of these arguments in a style reminiscent of Popper rather than Kuhn. Indeed Toulmin argues that Kuhn's work is far from revolutionary in itself. It simply points out that science is liable to ‘drastic reconstructions, after which they take on different axiomatic structures’ (Toulmin 2001: 6).
In the next part of this paper, I wish to revisit the 60s and 70s when the passivity of many therapists in the face of attack was not a widespread phenomenon; rather the Zeitgeist was one of curiosity, experiment and optimism. It was a time when in economic terms the ideas of
Keynes were still in the ascendant. Emotional literacy and emotional experience were taken much more seriously. Young people experimented with new ways of finding out about themselves. Sex, drugs and rock n'roll was often part of this experiment. It also marked the heyday of the ideas of R. D. Laing, the humanistic therapies, encounter groups, experiments in communal living, gay politics, and the women's movement; it was a time when money and fame were not as high on the wish-list of nearly as many people as now. All this was swept away by Mrs Thatcher and her trajectory continued under subsequent Labour Governments. The present Coalition looks set on the same tracks.
At present, we live in a world where people apparently really think that the pinnacle of achievement is to be reached either via study at Oxbridge leading to a job in the City earning vast sums of money or by appearing on a TV reality show and becoming famous for being famous. Success in this new narrowed-down view of life is measured by what kind of job you can get (if you can get one at all) and then by how much money you earn. Education of the more formal variety, which in the past was often provided usually at least competently and often brilliantly by the whole range of universities, not just the privileged few, has frequently been replaced by ‘training’. There is nothing wrong with training as such—but its uses are limited. Perhaps the hippies knew a thing or two. Finding yourself, following your dream, daring to believe in ideals, were all regarded as worthwhile pursuits. The gap between rich and poor, the well-educated and the less well-educated, began to shrink. Nowadays however, the condescension and incomprehension of the rich as regards the poor is returning and dumbing-down seems to be the order of the day not only in the media but often also in the psychotherapies where simple quick solutions are often preferred to more complex and thoughtful responses to emotional suffering.
So how does the new regime of ‘winner takes all’ play out in the consulting room and where does the notion of research fit into this rant about the shallow values of contemporary society? Before I attempt to answer these questions, I shall give some examples of what I consider constitutes ‘research’ in the context of psychoanalysis.
In the clinic, conversation with a new patient often starts with the current situation. However, gradually the empty spaces of ignorance in
the minds of both analyst and analysand are delicately half-shaded in. The result is hardly ever a clear black and white picture and does not remain fixed. This is not painting by numbers; rather, it is closer to the delicate lines of Chinese brushwork, fluid and implicit rather than explicit in meaning. I will try to demonstrate what I mean with a few verbal brushstrokes of my own:
A woman, ‘Rita’, in her twenties and unemployed, describes life in the family home. ‘My father and brother have the best beds; my mother only has a “put-you-up” bed.’ After some more talk about beds, I comment, ‘There seems to be a lot of talk about beds’. Rita glares at me and replies, ‘You think this is all about sex don't you, I don't think that's revelant.’ ‘Revelant?’ I query.
This is a classic example of the capacity of the unconscious to reveal itself in spite of the attempts of the ego to keep it under wraps. Research into the reasons for Rita's lack of work, obsessional misery and resentment of all the members of her family, differently expressed towards each of them, is now under way. This research does not measure Rita's brain activity, is not particularly interested in the details of her obsessional behaviour in relation to checking whether the gas burners on her cooker are turned off before she leaves her flat, or indeed in comparing how she was feeling last week with how she is feeling now or indeed how she might feel next week.
Here is another example:
A successful teacher ‘Bernie’ discusses the many compromises she has to make in her life; compromises at work, in her home life and above all with her highly problematic sister. Eventually I ask, ‘So what does the word “compromise” mean to you?’ Bernie grins at me and says, ‘Of course I know what the word means, but so far as I'm concerned, it means I've lost the argument!’
At this point we can both start reviewing together the multiple meanings of the word ‘compromise’ and its effects in her life. Research
into the complex array of meanings, hints, allusions, comparisons with other events in her life where ‘compromise’ has occurred, has now commenced.
Both of these examples are taken from work with clients where attention to the minutiae of the words they used led to further investigation of the problems which brought them to my consulting room in the first place. For reasons of both space and confidentiality it is not necessary to spell out their problems in detail and I have used old examples. In the first case there were problems relating to possible sexual abuse; the latter was never clearly established. The patient completed a training course, left home and found a job which she liked in another country. Later she wrote to tell me that she had met a man whom she was going to marry.
The woman in the second example came to see me about panic attacks that she had started to experience while teaching—a problem which if it had got worse would have resulted in her having to give up her job. After some months of analysis, it became clear that in fact her relationship with her sister was the cause of many of her problems. The panic attacks ceased of their own accord six months into the therapy which lasted a further two years.
So what do these examples have to do with research? Both illustrate the slippery nature of meaning. The neologism ‘revelant’ is of course a conflation of the words, ‘relevant’ and ‘revealing’. ‘Compromise’ is not a simple word in the hands of someone who has experienced oppression dressed up as compromise by her sister. In both cases there is an element of compression which serves to reveal the full range of meanings and to conceal them at one and the same time. Thus, Bernie's understanding of the word ‘compromise’ is a different kind of compression from Rita's. Rita reveals the fact that her thoughts do indeed have a sexual connotation even if it is disavowed. In Bernie's case, there is a whole series of meanings to be uncovered which apply to her and her alone. Assumptions that we have a shared understanding of the meaning of any word that seems important to our clients turn out, not exactly to be completely untrue, but clearly far less than the whole truth. Similarly we cannot assume that there can be a ‘one size fits all’ approach to the question of what our patients are talking about—or even what they think they are talking about.
These clinical examples both turn on a particular use of language that is picked up in the consulting room. Yet of course, idiosyncratic use of language is an everyday feature of ordinary life. It is simply something that is not normally remarked upon except within the consulting room where those who are indebted to Freud's ideas will pay attention to the words they hear ‘with evenly suspended attention’.
My own experiences of the 70s were heavily influenced by the women's movement. What did it mean to be a woman? Academic writers such as Sheila Rowbotham and Germaine Greer wrote about the experience of women. Spare Rib was a ‘must read’. Consciousness-raising groups were commonplace. Yet, just as much part of the cultural shift involved in addressing this question were meetings where women looked at their own vaginas (often for the first time) with a mirror: or in a completely different vein, prior to the advent of women's refuges, working-class women being beaten up and mistreated demanded of the middle-class Preston women's liberation group of which I was a member—’Well what are you going to do about it, what are you going to do for us?’ Nobody produced ‘evidence’ of the statistical kind; research involved any or all of the following: thinking through issues from first principles, writing articles and books, attending meetings, demonstrations, conferences. Above all at both a conscious and an unconscious level, research involved allowing oneself to be personally gradually, permanently and radically affected in body, mind and spirit. Returning to the present day, personal involvement is the key to any experience of psychoanalysis.
We cannot turn the clock back to the 1960s and 70s. Psychoanalysts and psychotherapists are often reluctant to engage with the contemporary demands for evidence-based research, partly perhaps because those of us who are older have a preference for the more intimate kind of research of the kind that takes place in analysis and occasionally still in everyday life. However, today's world is aggressive in its attempts to shut us up with demands for evidence, proof and results. A typical kind of encounter with someone who has no connections with the field runs thus, ‘So what exactly do you do? Wouldn't your patients get better anyway if they just talked about their problems with a couple of friends?’ If the enquirer is a little better informed, then the following kind of interrogation is more likely: ‘Evidence shows that cognitive behavioural
therapy works more efficiently and it's quicker—so why do you still bother with psychoanalytic ideas?’ Many psychotherapists fall back on an intrinsically defensive position. Standard replies are often anodyne. ‘Psychotherapy can't be measured; it's about the personal quality of the relationship’. Or, ‘You can talk to someone in confidence and tell them things you couldn't tell your friends’. As for sources of evidence, the standard reply is often to point out that even if psychoanalytic psychotherapy doesn't have a compelling evidence base it may still work better in the long run. Some psychotherapists try to evade the whole debate by claiming that psychotherapy is essentially about story telling—enabling someone to recount their particular journey through life. This argument does not cut much ice with those who wish to measure the effectiveness of a therapeutic encounter. They ask incredulously, ‘Are people really cured of their symptoms through story telling?’
All these muted responses are a far cry from the passions and sheer sense of exuberance that were a part of the 60s and 70s alongside the frustrations and unfairness of several aspects of an extremely unfair and imperfect society against which so many of us rebelled. In this paper I have sketched out a variety of more spirited rejoinders that can be made to the many critics of psychoanalysis. The Site is ideally located not only to take up the gauntlet thrown down by the critics of psychoanalysis but also to offer psychoanalysis—freshly and continuously reminted—as a discourse, both in the clinic and in contemporary culture.