Chapter 9
THERAPY: OPIUM OF THE MASSES OR HELP FOR THOSE WHO LEAST
NEED IT?
GILLIAN PROCTOR
The rise of therapy serves a very convenient purpose for those in power and who benefit
from a capitalist and patriarchal society, keeping a few with a lot of power and money at
the top and the many underneath. The more people who identify therapy as the solution to
their life problems, which are caused by these inequalities, the more these inequalities are
concealed and dealt with individually and internally. Karl Marx argues that religion used to
be a way to control the population by their belief in a higher moral order or reason to
control their behavior and to accept hierarchies of power with the ultimate male patriarchal
figure of God at the top. However in an increasingly secular society, therapy has come
along just in time with a great replacement, similarly perpetuating the hierarchical order of
things. In addition, the `psychologization' of life's problems also provides an answer, a
meaning, and a purpose in life in the form of `self-fulfillment', `self-awareness' and such
goals of therapy, as a substitute for the meaning historically provided by religion.
Additionally, as with religion, therapy helps people to believe they have more control or
power over their lives than they often have in reality by offering the belief that problems are
internal, and we can change our internal feelings and thoughts and therefore feel better.
We thus have a justification for why we have suffered-we were thinking or feeling wrongly,
and if we try harder we can avoid future distress. This way of thinking is not dissimilar to
the `will of God' arguments that led people to accept hardship in the past, or the belief in
prayer to change life. Therapy has become the new Opium of the Masses.
Why when most obvious causes of psychological distress are environmental, do all models
of individual therapy treat distress as intrapsychic, in that the individual is the focus of
change? Therapy tries to change the individual whilst leaving inequalities in society the
same. This is despite the effect of inequalities on those oppressed being one of the main
causes of psychological distress. At the same time, the institution of therapy perpetuates
the inequalities of society. I argue that therapy mainly helps those who are least
oppressed-i.e. those who least need it. So why and how do I continue to be a personcentered therapist?
In this chapter, I shall firstly discuss the relationship of powerlessness and oppression to
the experience of psychological distress, and discuss briefly psychiatric responses to this. I
shall then turn to psychological responses and present my argument that therapy
perpetuates inequalities for four reasons. Finally, given this critique of therapy, I will
explain why and how I continue to be a therapist.
POWERLESSNESS AND INEQUALITIES
The experience of powerlessness is one of the most significant causal factors
contributing to the experience of psychological distress (see Proctor, 2002a). Power,
control and the experience of powerlessness are frequently mentioned in
understanding all kinds of psychological distress. Particular manifestations of
psychological distress have also been strongly associated with issues of power and
control. One of the functions of self-injury, for instance, can be to feel more in control
and cope with a feeling of powerlessness (Arnold & Magill, 1998; Spandler, 1996).
Eating distress is also often explained as a way to regain a sense of control over one's
body and has been related to feeling powerless (e.g. see Troop & ,Treasure, 1997).
With respect to depression, Gilbert (1992) also explains this experience as a response
to powerlessness. 13yrne and Carr (2000) found that depression in married women
was associated with a weaker psychological and financial power base (economic and
personal assets enabling her to have control over her partner) and less ability to
determine the outcomes in decision making. The experience of psychosis can also be
understood as not having control over one's sense of self and identity (see )Johnstone,
1999). Similarly, the experience of anxiety can be understood as being a result of fear
about uncertainty and lack of control over one's environment; again, clearly related to a
subjective feeling of powerlessness. I have not found a manifestation of psychological
distress that can not in some way be related to the experience of powerlessness.
SOCIETAL STRUCTURAL I'ONVER
Higher prevalence of members of oppressed groups in psychiatry reflects the positions
of power of the groups involved, and there is much evidence to associate the likelihood
of suffering from psychological distress with the individual's position in society with
respect to societal structural power.
The relationship between poverty and distress has been well documented (e.g. Bruce
et al., 1991; Gomm, 1996). Work problems, economic stress and unemployment have
been found to be instrumental in precipitating suicide and related to rates of diagnosis
of schizophrenia (Ahlburg & Shapiro, 1983; Warner, 1994). Stressful l ife events are
more common amongst people in lower socioeconomic groups and have been
implicated in raised prevalence of stress-related and physical illness within these
groups (e.g. Coates et al., 1969).
The higher rates of diagnosis for women compared with men of many `disorders', such
as depression, anxiety and eating disorders, reflect women's position in society with
respect to power (see Baker Miller, 1976; Williams et al., 1993; Williams, 1999;
Wenegrat, 1995; Brown & Harris, 1978; Johnstone 2000). Feminists have long argued
that women are both driven mad by oppression, abuse and expectations in society and
labeled mad by the male-dominated psychiatric profession, particularly those women
who deviate from gender role expectations. It can be argued th at the diagnosis of
Borderline Personality Disorder is the latest in obvious ways to label deviant women
mad following a long history through witchcraft and hysteria (see Shaw & Proctor,
2005).
The higher rates of diagnosis of Black and Minority Ethnic groups can be analyzed
in the same way (see Fanon, 1986; INlercer, 1986; Fernando, 1991). Similarly,
particularly young lesbians and gay men are more likely to suffer psychological distress
and are still likely to come across homophobia in the mental health s ystem (Proctor,
1994).
RELATIONSHIP OF OPPRESSION TO DISTRESS
There is much more evidence for environmental causes of distress than for example
biological or genetic causes (e.g. Bentall, 2004). Common factors associated with
distress are poverty, deprivation and abuse (e.g. Pilgrim, 1997). All these factors are
associated with being a member of an oppressed group. There are two processes
through which being a member of an oppressed group could be related to the
experience of psychological distress. These are social causation and social
construction.
Social causation
It makes sense that experiencing oppression in society can lead to or cause physical
harm and psychological distress. Reduced access to material resources and wealth are
usually related to oppression which reduces choices and options in life and can lead to
anger or hurt at the injustice of seeing others enjoying so much more privilege.
Assumptions and stereotypes can lower expectations and limit peoples' choices.
Experiences of oppression are often invalidated making it difficult to form a positive
sense of identity and may lead to isolation and silencing resulting in depression and
low self-esteem. The real fear of violence, intolerance and rejection can lead to high
levels of anxiety.
The experience of oppression is associated with an increased likelihood of being
subjected to violence and abuse. The experience of oppression includes being in a
relatively powerless position in relation to people in majority groups who can use their
power over oppressed people. For example, women are far more vulnerable to physical
and sexual abuse, in the form of domestic violence and rape. Black and Minority Ethnic
groups are vulnerable to racist attacks; gay men and lesbians to homophobic attacks.
The experience of abuse is a significant causal factor in all types of psychological
distress, with the numbers of survivors of sexual abuse alone being very high among
survivors of the psychiatric system (for example Williams & Watson, (1994) suggest a
figure of at least 50 per cent).
Experiencing abuse is a profound experience of powerlessness. Finkelhor (1986) identifies
four major dynamics following the experience of childhood sexual abuse, one of which is
powerlessness. Surviving experiences of abuse is likely to involve regaining power and
control (Kelly, 1988).
As Small (1987: 398) states, clients of the mental health system are `people upon who the
world has impinged in any of a variety of painful ways. They are less people with whom
anything is wrong than people who have suffered wrong.' Yet, psychiatric and psychological
understandings of distress position the individual as someone who is disordered, ill or
distressed; the problem is located in the individual rather than society.
Social construction
This individualization of distress is reinforced by the social construction of distress or
madness. The norms of what is mentally healthy are defined by those with power in society;
research has shown that people define norms of mental health with respect to White, middleclass and male norms. The concept of madness is constructed to label those who deviate
from `normal' by society's definition of normal being those with power.
Using the specific example of gender, the argument that discourses of (ways of talking
about) madness arc used to pathologies women follows feminist critiques of psychiatry.
Chesler (1972) used the term 'double-bind' to describe the processes by which women can
be pathologized both for conforming to, and for falling to conform to, expectations of
feminine passivity.
Also useful here is the anti-psychiatric critique exemplified by Szasz (1972). Tracing the
history of the modern concept of madness back to the pre-modern discourse of witchcraft,
Szasz describes how women whose behavior threatened social norms were positioned as
outsiders and labeled `witches'. A woman positioned in this way, he argued, could be
contained and punished for her deviancy, and the threat that she posed to social norms
could be controlled. In tracing the movement from this pre-modern, religious world-view to
the current scientific, rational paradigm of modernism, Foucault (1967) described the
emergence of a scientifically determined and controlled concept of insanity. This reflects the
shift from `witchcraft' to label women's deviancy, to the emergence of the concept of
`hysteria' in the nineteenth century.
Hysteria occupies a central position in the history of women's madness as a diagnosis long
used to indicate behaviors which are disapproved of, and specifically employed as a male
term of abuse for 'difficult' female behavior. More recently, hysteria has been theorized as a
response to powerlessness; a reaction to expectations of passivity and an attempt to
establish self-identity (Showalter, 1985). The concepts of both `witchcraft' and `hysteria'
position `difficult' or `deviant' behavior as symptomatic of a disturbed personality and
therefore dismiss these behaviors as individual pathology and obscure the social context of
gendered power relations which give rise to these behaviors.
Shaw and Proctor (2005) argue that the modern discourse of Borderline Personality
Disorder (BPD) operates in much the same way. According to a social constructionist
model, BPD (like witchcraft and hysteria) is constructed as a deviation, in this case from
the concepts of rationality and individuality. Feminists have argued that psychiatry-far from
being a branch of medicine which categorizes disease-is constructed around concepts and
expectations that are fundamentally gendered and which profoundly affect how a patient's
behavior is evaluated and responded to. The gendered consequences of the psychiatric
preoccupation with 'rationality' have been well explored in feminist theory: women are
`typically situated on the side of irrationality, silence, nature and the body, while men are
situated on the side of reason, discourse, culture and mind' (Showalter, 1985: 3-4).
THERAPY: A RESPONSE TO INEQUALITIES?
It is usually assumed that counseling or therapy is more benign, less coercive and powerbased than psychiatry. Indeed, in counseling and psychotherapy, the legal position with
respect to power is different from that held by a psychiatrist or psychiatric nurse. There is
potentially more choice in how the therapist uses or chooses not to use the power given to
them. However, as Sanders and Tudor point out:
Just as it is dangerous to assume that psychiatry is a benign force in social policy or that
Home Secretaries know anything about personality disorder, neither should we accept or
assume that therapy is in itself benign, useful or effective. (2001: 157)
Miller and Rose emphasize that `we should be wary of celebrating psychological
approaches as alternatives to psychiatry' (1986: 42). Psychological approaches can also
be used as part of the armory of power and control over the population, as Foucault
particularly explains (see Proctor, 2002a).
IGNORING INEQUALITIES
As in medical models of mental illness, models of therapy, including the personcentred
model, conceptualize the client's problem as internal to themselves, as intrapsychic, thus
ignoring the social causes of distress. Person-centered theory theorizes distress as
incongruence or internalized conditions of worth, clearly placing the problem as internal.
Thus, therapy tries to change the individual whilst leaving society and the inequalities in
society unchanged (see Proctor (2004) for more examples of how person-centered therapy
ignores the effects of patriarchy on women). How often does therapy become a process of
oppressed people learning to accept their oppressed position and keeping quiet about
their powerlessness? When therapists ignore the links between social inequalities and
psychological distress, they serve the interests of privileged social groups rather than
those of their clients.
PERPETUATING INEQUALITIES
In focusing on the individual, therapy leaves society's inequalities unchanged.
Furthermore I contend that the institution of therapy actually perpetuates these
inequalities. I shall justify this argument by considering how people are defined as in
distress, by examining the inequalities and dynamics of power in the therapy
relationship, by examining the structural societal inequalities perpetuated by the
different identities of therapists and clients, and finally by considering who therapy
helps.
How do you become a client?
Even clients who voluntarily seek counseling or therapy do not make the decision that
they need therapy by identifying some internal distress. It is not like feeling you have a
headache and therefore taking a painkiller. Around us everywhere the media, Internet,
and `information' from mental health services have ever been increasing the remit of
what counts as a mental health problem or something needing therapy (see Hansen,
McHoul & Rapley, 2003). We are each influenced by all this such that the percentage
of the population who would consider going for therapy is much greater than 10 and
certainly 20 years ago. The effect of this media publicity of mental health is the
increasing medicalization and individualization of life's problems, which diverts
attention more and more from conditions in society and separates people from each
other as they consult `experts'. Whereas in the 1970s, women went to consciousness raising groups and discovered their commonalities in distress due to their treatment as
women, now most women go to individual therapists and see all their problems as
internal.
The dynamics of power in therapy
I conceptualize three aspects to power in the therapy relationship (Proctor, 2002a). The
first is the power inherent in the roles of therapist and client resulting from the authority
given to the therapist to define the client's problem and the power the therapist has in
the organizations and institutions of their work. I call this role power. In our society, all
counselors and therapists are given authority and role power. Various microenvironments also affect how much role power a counselor/therapist has in any one
situation or work environment. This aspect of power is also dynamic and relational;
different therapists use this role power in different ways and have varying attitudes to
the effect of role power on the client. Each client that the counselor/ therapist interacts
with will have different views about and reactions to this role power of the t herapist and
their own role power as a client.
The second aspect of power is the power arising from the structural positions in society
of the therapist and client, with respect to gender, age, etc. I call this societal power.
The final aspect of power in the therapy relationship is the power resulting from the
personal histories of the therapist and client and their experiences of power and
powerlessness. I will call this historical power. The personal histories and experiences
will affect, and to some extent determine, how individuals are in relationships and how
they think, feel and sometimes behave with respect to the power in the relationship.
Role power: There is a clear political agenda in person-centered therapy (PCT) to
eliminate the therapist's power-over the client and it is revolutionary in the extent to
which it manages to do this.' But however equal the therapist behaves in the therapy
relationship, therapy is still an institution and the role of `therapist' still has power
attached to it in society.
Feminist authors also help us to understand the power in the institution of therapy.
Chester (1972) reminds us that the therapeutic encounter needs to be understood as
an institution beyond how individual therapists are with individual clients and h ow this
institution re-enacts the relationship of girls to their father figure in a patriarchal society.
Although individual PC therapists challenge this hierarchical expert-based idea of
therapy, therapy itself as an institution remains unnoticed, which is likely to be a major
factor in clients not perceiving the therapy relationship as equal however the therapist
behaves. There is a clear inequality in the roles of therapist and client which is not
removed by any kind of therapist behavior as a person.
Historical power. Historical power is the power resulting from the personal histories of
the therapist and client and their experiences of power and powerlessness. We have all
been influenced by society's messages about inequalities and absorbed stereotypes ,
assumptions and unspoken expectations or messages about how society is ordered.
The awareness of our own socialization can help a therapist to understand their own
conditions of worth in a social and political context and how their current behavior and
ways of relating are likely to be influenced by gender and other identity role
expectations. I am not saying that the differing impacts can be predicted or generalized
about. However, our structural identities have a big impact on who we are, how people
treat us and how we relate to people, and understanding society 's messages about
these identities and how these are internalized (although responded to differently) by
everyone may help us to understand an individual more accurately as situated within
their cultural context (see Proctor, 2004). As society's messages are for the most part
implicit and often denied, it is likely to be difficult for clients to be able to explain their
impact on their way of viewing the world and themselves. If these messages are not
understood as part of the implicit context in each of our lives, we run the risk of taking
for granted socialization of inequalities and what is `normal' as an unquestioned part of
our culture.
Who are the therapists and who are the clients?
The evidence is well documented showing the inequality of the social structural
positions between therapists and clients (e.g. Garrett & Davis, 1995; Binnett et al.,
1995). Therapists are more likely to be white and middle class, whereas clients are
generally poorer, more disabled mentally and physically, older, younger, more
dependent and less socially supported. In the UK these differences are particularly in
evidence for therapists working with clients as part of the NHS. Sadly these differences
are unlikely to reduce, given that opportunities for education and thus class migration
for working-class people have decreased due to huge reductions in educational grants
available. An appreciation of the social and material realities of deprivation may be
hard for a therapist from a privileged background to achieve.
Outcome of therapy
The results of 40 years of psychotherapy research have consistently discovered two
things. The first is that the most effective consistent factor with regard to the therapist
is the importance of the quality of the therapy relationship for effective and good
therapy. Summaries of the research outcome studies over the last 35 years (e.g. see
Bozarth, 1998; Paley & Lawton, 2001; Mearns & Cooper, 2005) demonstrate that the
effectiveness of psychotherapy depends primarily on the therapy relationship and the
inner and external resources of the client. The most consistent relationship variables
related to effectiveness are the therapeutic alliance, goal agreement and empathy
(Norcross, 2002).
Secondly, research has consistently demonstrated in effectiveness studies a figure of
around two-thirds of clients who `improve' on scales to measure what is considered
mental health, and therapy is thus seen to be effective (Lambert & Ogles, 2004). What I
am interested in here is the 33 per cent of people who don't `improve'. Of course these
figures are only based on clients who complete a course of therapy, completely missing
those who drop out along the way. These statistics can be criticized by person centered therapists on the basis of how `improvement' is measured and that clients
could benefit from therapy without showing any difference in `symptom' ratings.
However I worry that this is a defensive response from therapists who do not like to
believe that therapy may not help people. What is more worrying is that within this
group of people who do not demonstrate any `improvement' in therapy, there is a
smaller group of people who actually demonstrate an increase in `symptoms', i.e. they
get worse during therapy (see Proctor, 2005). Furthermore, research shows that if
people start to get worse they usually continue, challenging the usual myth that people
do get worse before they get better (e.g. Lambert et al., 2001). This research suggests
that therapy can be damaging-it is not always benign, and that even therapists with
the best intentions may damage clients. However much person-centered therapists
try and intend to convey the attitudes of unconditional positive regard, empathy and
congruence to the client, there is no guarantee that this is how the therapist will be
perceived by the client. There is still a danger in person-centered therapy as human
relationships are so complex and idiosyncratic that it is unlikely we could ever predict
the many ways in which relationships can hurt or damage people as well as help or
heal people. All we can do is trust the stories of those people who do speak up about
the negative effects of therapy on them (e.g. Sands, 2000; Heyward > 1993).
Who does therapy not help? There is little evidence about who the people are who do
not show a change in therapy. I suspect therapy is most likely to help those people
who are most like their therapists, i.e. the most privileged, in the main. I argue this for
three reasons: that the people who are most oppressed are least likely to access
therapy, that we are better at understanding people who are most like ourselves, and
that the most oppressed people are most likely to say they feel better to please the
therapist.
People who are most oppressed are simply least likely to be referred and have
access to therapy at primary care level. If you are articulate or educated, experience
shows that you are much more likely to ask for and be referred to counseling or
therapy. Most therapists work in private or primary care settings (where usually only
short-term work is offered) and thus work with the least distressed and most
privileged people by definition. Access to therapy at secondary or tertiary levels in
mental health services is very poor and often characterized by the most controlling
and expert-led types of therapy. From my experience in forensic settings, access to
exploratory therapy in those settings is usually again for the most articulate, judged
`psychologically minded'. The voluntary services that provide free counseling services
and are often most accessible to those most oppressed often have therapists who are
least trained and least valued, usually working voluntarily. How many therapists or
therapy services work with interpreters? Most do not, whether due to lack of
resources, training, knowledge or a belief that they cannot. Yet one of the most
marginalized groups in our society is people who cannot speak the dominant
language in our country well. Thus accessing therapy when belongi ng to an
oppressed group is often much harder.
In comparing clients who are like their therapists with clients who are unlike their
therapists in terms of life experiences, identities and oppression, which people are
therapists likely to find it easiest to understand? With whom will they feel most
relaxed, most genuine, honest, and easiest to be themselves? With whom will they
feel least judgmental? Most people spend most of their time with people very like
themselves, working in similar jobs, living in similar areas. It is likely for most
therapists to find that those clients most like themselves are those with whom they can
most easily create the relationship characteristics necessary for therapy to be effective. As
therapists are more likely to be from privileged groups (e.g. Garrett & Davis, 1995), this
means the more privileged clients will on the whole receive the most effective therapy.
Inequalities in society are set up such that those at the bottom have to submit to the
authority of those above them. This inequality is always present in the therapy relationship
due to the roles of therapist and client but it is exacerbated when the therapist has more
power than the client due to other aspects of their identity as well. The more
characteristics of authority exhibited by a therapist (e.g. being male, well-spoken,
articulate, etc.) the more likely the client is to agree with what the therapist says and the
more likely the client is to want to please the therapist. So even for the supposedly
`objective' measures of `symptom' relief, it will be obvious to many clients how to fill in
these questionnaires so they look like they've improved. Most clients will know that their
therapist would like to think they have improved as a result of therapy, so it is possible that
a large percentage of the two-thirds of people who look, according to these measures, like
they have `got better' as a result of therapy are simply clients who did not want to let their
therapists down. The more accustomed a client is to submitting to authority the more likely
they are to not question a therapist's perspective or to question the therapist's
misunderstanding. Even when a therapist is trying their best not to take power-over a
client, if a client generally relates by submission, the therapy relationship could be based
on compliance, submission and acquiescence rather than being a mutual empowering
healing relationship of two people who have equal respect for each other.
SO WHY DO I STILL DO IT?
Now it's time to admit that despite everything I have said I still practice as a therapist! How
can I justify that? Sometimes I feel I cannot, and have had constant debates with myself
and others over the time I have been practicing as a therapist. However, each time I
decide that therapy is a doomed institution and rife with unsurpassable inequalities, I
realize that so is the whole of society, and all relationships. Foucault summarizes this
position saying:
I do not think a society could exist without power relations. If by that one means the
strategies by which individuals try to direct and control the conduct of others. The problem,
then, is not to try and dissolve them in the utopia of completely transparent communication
but to acquire the rules of law, the management techniques, and also the morality, the
ethos, the practices of the self, that will allow us to play these games of power with as
least domination as possible. (Foucault, 1980: 298, citied in Fish, 1999: 67)
I hope that in individual therapy people will feel understand enough for them to have the
confidence to work to change their own situation and that of the world. I have seen this
happen enough to help me believe in what I try to do. I believe that our job as therapists is
to take responsibility for our position of power and be constantly mindful about how
dynamics of power play out in therapy relationships. At the same time, I believe that our
responsibility is also to understand the wider society and how inequalities affect all of us.
Knowing the limits of therapy due to its focus on individual change, I also work politically to
try and change wider society With these broad aims, I hope responsible personcentred
therapists can be aware of the following checklist of ways to think about the political
implications of their own practice.
• Work to be increasingly aware of inequalities in society and the realities of the lives of
those people most oppressed. At the same time working to become increasingly aware of
our own privileges.
• Work to try and make therapy accessible to people who most need it, both in individual
practice and in structures within which we work.
• Be aware of and informed about environmental and material causes of distress and work
with people to try and change their environments, using our power to help wherever
possible, e.g. to advocate for people to get better housing etc., awareness of how to get
information about benefits etc.
• Work to be ever aware of dynamics of power in therapy and disempowered people in
therapy as little as possible.
• Be aware that therapy can be damaging and listen to, trust and believe clients and what
they say about our relationships. Be honest that we cannot say whether or not therapy will
be helpful for a particular client, and only they can decide whether it helps, whilst having
hope that it will help.
• Think about whether it is possible to facilitate the existence of alternatives to therapy,
specifically self-help groups or community groups where people with similar experiences
can meet and learn from each other in a non-hierarchical way.
• Can you become involved politically with campaigns to change inequalities in a material
way and to challenge the way mental health systems work, to perpetuate inequalities
and diagnose individuals?
SUMMARY AND CONCLUSION
It is imperative that we do not forget that we are all part of an inherently unequal society;
with structures of power and inequalities that damage us all. The therapy industry has
mushroomed, taking advantage of the increasing numbers of people who are hurt by this
society and looking for meaning in a world increasingly ruled by consumerism. Being part
of this industry and institution means we have responsibilities to take account of our part in
this and examine ways in which we may contribute to these inequalities and causes of
distress, rather than hide behind the naive hope that we are benign healers. I hope this
chapter has begun to take apart ways in which we need to examine this and ways in which
we can militate against furthering the harm perpetuated by our sick society.