As in many of the other European countries, psychoanalysis in Britain finds itself under an ever increasing pressure from the ideology of market society. The values of accountability and transparency are vaunted as the new ethical framework for all professional and personal relations. Psychoanalysis and the psychotherapies are expected to replace their antiquated speculative systems and outdated therapeutic aims with new standardised evidence-based models. Nowhere are these pressures stronger than in institutional settings. Let us look at the context of these developments and the specific form which they have taken in Britain.
Where so much of the psychoanalytically inspired social theory of the twentieth century construed subjectivity as a site of conflict, today the self is situated as a regulatory ideal. Rather than being the place of tension between, say, repressed desires and their inhibition, the self is a project to be realised. Rights and freedoms have replaced duties and obligations, together with the imperative to realise oneself, to actualise oneself through 'work'. People are encouraged to 'work on themselves', be it through therapy or visits to the gym. Flyers for psychotherapy are on display in local gyms next to advertisements for new body treatments. The psyche becomes like a muscle that needs to be developed and trained to release its full potential.
This colonization of the psyche turns symptoms into commodities. The Yellow Pages are now full of advertisements from therapists offering to treat specific problems, with lists of typical symptoms highlighted in bold to attract the reader's attention. With the rise of the therapy best suited to market society - cognitivism - symptoms are understood as behavioural deviations, pieces of learned conduct which can be undone by new courses in learning and unlearning. The difference between observed behaviour and desired behaviour must be reduced to a minimum, and maladaptive patterns must be turned into adaptive ones. It is no surprise that this discourse enjoys a great success here as elsewhere. The therapist becomes an agent with a product to sell, and his questionnaires and evaluation forms are well-tailored to find confirmation of the results sought.
What is perhaps surprising here is that many psychoanalysts have bought into this vision. A recent book by two well-known analysts intended for use by clinicians working in the National Health Service defines the self as "a rational agent with understandable desires and predictable beliefs who will act to further his goals in the light of these beliefs". This definition is quite extraordinary, and it matches almost word for word the definition of the subject to be found in textbooks of rational economics. What has happened to the Freudian unconscious? What has happened to the death drive? And more generally, what has happened to the idea that a large part of human life serves aims which cannot be described in instrumental terms such as the search for wealth, power or happiness?
The new notion of the subject is of course the subject not of psychoanalysis but of mental hygiene, and much of the current thinking in British psychoanalysis takes mental hygiene as an explicit goal. Childhood problems, for example, are seen less as the expression of a subjective truth than as indications of risk for future social disruption. The scales of attachment dreamt up by the attachment theorists have attained a huge popularity here, and if an infant is deemed poorly attached, the whole battery of mental health intervention is appealed to as preventive of future risks. Unlike other disciplines in the field, attachment theory has been highly successful at giving itself a pseudo-scientific gloss. Rating scales and evaluative technology are showcased, and other therapies berated for failing to attain this level of objectivity. Since evidence-based medicine supplies the ideology in nearly the whole of the NHS now, attachment theorists hold more cards than do the more traditional analysts and therapists who are cajoled into mimicking their methods.
The claims made by the attachment theorists also boast of another feature of the new market-led notion of therapies: the specificity of intervention. "The structured, manualised psychotherapy techniques of the future", the Freud Memorial Professor Peter Fonagy writes, "will be designed to specifically address empirically established developmental dysfunctions"(1). Dysfunction is made to exist independently of the person's experience of it, a bias that merely reinforces social, non-subjective criteria of normality. Symptoms are no longer subjectively experienced questions or sources of satisfaction, but independent, autonomous entities, the result of developmental dysfunctions which have affected the brain. Interestingly, all of the new handbooks of therapy for use in institutions sketch out explicitly a theory of 'normal' subjectivity and development.
This effort to completely remove the dimension of the subject from psychoanalysis and psychotherapy seems to be moving closer and closer to what resembles a dated picture of medicine, construed as a sum of external procedures to be applied to the organism to act against ill-health. Analysis and therapy are techniques to be applied, rather than properties of relations between parties. Even the outcome of therapy, we now learn, urgently requires "non-biased, non-subjective measures of outcome". If the patient says they're happier to live, this should be tested to see if he is telling the truth. And his accounts of shifts in symptoms and repetitions should be checked by an external observer.
This sinister programme, exemplified by Fonagy's vision of the future, becomes even more disturbing when it starts to advocate the use of brain-imaging techniques to evaluate therapeutic outcome. Fonagy even cites an experiment that purports to show neural correlates of the experience of social exclusion. Whether we find fault with the experimental procedure involved or not, the same basic problem still persists: can an experience be experimentally isolated and attributed to a range of subjects as if it were, fundamentally, the same 'thing'? The weakness of such views has long been in evidence, from the stimulus-response experiments aiming to induce a specific, isolated emotion in the 30s and 40s to the more mathematically sophisticated yet still equally naïve experiments of today. Can it be seriously argued that there is an emotional experience called 'social exclusion' that can be objectively found in the brain?
Yet things go from bad to worse. What comes next is an encomium to molecular biology that may remind readers of the eugenics apologia of the early part of the twentieth century. Fonagy is convinced that "biological vulnerability will become increasingly detectable", with combinations of genes accounting for different types of environmental vulnerability. In the example he gives, we learn that those with the S allele of the promoter region of the serotonin transporter gene SLC6A4 may benefit from "prevention intervention" more than those with the L genotype. Enhancing the capacity of those with the S genotype to cope with adverse life situations would lower the risk of major depression, and Fonagy is all in favour of the "impeccable logic" of prevention programmes. All this from the Freud Memorial Professor. One wonders what sense the word 'Memorial' must have here.
These advances achieved through molecular biology will allow individuals to learn that "reducing the impact of specific types of environments will protect them from the disease process". Will the infant learn to get new parents to avoid becoming ill later on? Will it learn how to best move through the depressive position or the Oedipus complex? Will it be able to tell which phantasy systems will make it happier in later life? Most worrying here is the tone of Fonagy's forecasts, which are echoed by much of the related literature. Subjective problems have now become disease processes. When a patient complains of their sexual orientation, or being disappointed in love or always wanting to please other people, this is construed as a result of brain dysfunction and disease process.
This view that psychological 'disorders' are correlated with specific brain dysfunctions is quite widespread in the British therapy environment. The function of psychotherapy is to provide a set of techniques that the mind can use to overcome a biological deficit. Neuroscience will help patients use "mental strategies to cope with weaknesses in their brain function". This new pseudo-science of subjectivity is encroaching further and further into the psychoanalytic groups, and certainly into the institutional settings. Conference interventions in both analysis and psychotherapy meetings are filled with references to the fight-or-flight response, to brain function, to catecholamines and especially to the demon cortisol, which is described in ways very similar to the 'bad mother' of the 50s and 60s. Analysis and therapy work by affecting brain chemistry, and it is a tragic and comic spectacle to see clinicians who know very little about either biology or chemistry start to use this new language as if it conferred a respectability and scientific dignity on their work. Rather than think through their own conceptual vocabularies, there is an appeal to the supposedly neutral vocabulary of 'observational' science. No one seems to notice that embracing brain chemistry to explain aims and results will render therapy itself obsolete, since the same changes can clearly be made more swiftly be chemical interventions.
The other main model which is gaining popularity and is even being force fed to those working in institutions is the theory of 'Other Minds'. This contemporary version of Piaget claims that the decisive moment in development is when the child realises that the mother has mental states which are different from his own. Suddenly the DSM Axis 2 becomes clear! These are unfortunate people who have not managed to develop a theory of other minds. Hence the task of the clinician is to teach them that they have mental states, and to name them. Interventions are specifically aimed at the 'here and now', and failures to be able to integrate the mind of the other are taken as shutdowns of the prefrontal cortex. It is curious that this theory was first celebrated as the explanation for autism in the 1980s. Yet today it is the explanation for all Axis 2 disorders and many others.
These developments are of course clinically dangerous. The therapist is pressured to make the patient focus on the therapist's mental states above all else. By interpreting the transference systematically, a theory of mind can be induced in the patient: he will learn what the therapist is feeling and also what he, the patient, is feeling. This process allows the patient "to find himself as he really is" in the therapeutic mirror. Completely lost here, beyond the question of interpreting the transference, is the possibility that 'other minds' doesn't just mean the child realising that the mother has mental states, but the child realising that someone else - the father, perhaps - can have a view of the mother which introduces further triangulation. The basic theory of other minds is anyway contained in (A/moins phi): the child realises that there is a signification at stake for the mother beyond him.
This rather bleak picture of the talking therapies in their institutional setting seems even bleaker with the new rise in the theory and practice of clinical supervision. Government initiatives aim to provide mental health care to anyone who seeks it within a set period of time. Since there are not enough therapists, psychiatrists, counsellors or clinical psychologists to go round, schemes have been put in place - vigorously protested by the above professions - to employ graduates to provide therapies. These will have had no more training than brief courses, and in many cases will be doing their training while actually seeing patients. This puts a renewed emphasis on supervision, with supposedly better trained clinicians giving management classes to the lesser trained. Supervision is now seen almost exclusively as a practice serving only the interests of the case 'under supervision'. One of the effects of this shift has been to find analysts and therapists reformulating their theories so as to adhere to this model: analysis becomes a knowledge-based procedure, with the aim of transmitting skills.
With the government intent on regulating the talking therapies in 2008, there is every danger that these changes, together with the emphasis on sanitation and mental hygiene, will produce a new 'adapted' psychoanalysis. Many analysts want this, and wish for little more than recognition and respectability. Others, from many of the different groups, protest and try to remain faithful to a model that does not see the aims of analysis as reduced to symptom removal and good mental hygiene. A conference organised by the College of Psychoanalysts will debate these issues in March next year, bringing together advocates of the different positions in this hotly-debated field.
(1) Peter Fonagy, 'Psychotherapy meets neuroscience, A more focused future for psychotherapy research', Psychiatric Bulletin, 28, 2004, pp.357-359.
Darian Leader is a psychoanalyst and writer working in London.
