Introduction

In this paper I offer a polemical critique of the ideology of audit and cost-effectiveness as currently conceptualised in the 'outcomes' field. I then go on to explore the conditions which must be satisfied if the inadequate conception of efficacy that currently holds sway is to be transformed into a more human/e/istic and less unconsciously pathological approach to counselling evaluation.

For reasons that will be become clear later, I invite the reader to be aware of her or his own particular emotional response to the ideas and arguments as they unfold in this paper.


Efficacy, quantity versus quality, and positivism

Men develop a capacity for mastering the universe and a compulsive preoccupation with what can be predicted, possessed, piled up and counted in order to deny the strength of their early physical and emotional link with the mother.
(M. Maguire, 1995, p. 60)

A technocratic mentality is holding increasing sway as technological rationality runs rampant through our culture and institutions; yet comparatively little consideration has been given to the splitting of intuition and feeling from rationality, of quantity from quality, which seem to be defining features of the modern age. A few (all-too-rare) Western philosophers have attempted to heal the split between the intellect and the emotions, between head and heart, that is so endemic and entrenched in the modern Western psyche (see, for example, McGill, 1954; Solomon, 1976), yet the current Zeitgeist is unambiguously one of schizoid splitting, ever-increasing specialisation and dis-integration.

Despite our heavy preoccupation with quantity rather than quality, with price rather than value, there is extensive research evidence demonstrating that despite the apparently insatiable human striving for material aggrandisement, rated levels of human subjective satisfaction or happiness by no means necessarily increase correlatively with higher material living standards (House, 1984, Chapter 3). There is now a rapidly growing 'alternative economics' movement which is questioning orthodox, conventional measures of income and wealth in a quite fundamental way, and attempting to incorporate more qualitatively meaningful, sensitive and realistic representations of people's quality of life.

In an extraordinary paper, David Wasdell (1991b) argues forcefully that the defining features of capitalism and the free-market economy can be traced back to the underlying unconscious dynamics of pre- and peri-natal developmental traumata. For Wasdell, these underlying dynamics constitute what he terms the 'normal pathology' of human psychological development (Wasdell, 1990), in that they are species-wide, and provide the seed-bed for much of our common beliefs, attitudes and behaviours.

I do not subscribe to an over-simplistic reductionist and psychologistic view which would crudely reduce culture and ideology to underlying psychodynamic processes, for it seems much more plausible that the specific characteristics of cultures and ideologies are substantially overdetermined. Nonetheless, the argument, based on psychodynamic thinking, for some kind of causal link between species-wide psychopathologies of human development on the one hand, and our ideological belief systems on the other, is a logically and evidentially compelling one.

Wasdell's argument can be extended to embrace human psychological development more generally. Thus, the effects of post-natal object-relations distortions and deficits, 'wounded child' issues, and the 'deformations of mind' that result therefrom must surely be directly implicated in both the genesis and maintenance of dysfunctional ideological belief systems. To quote Wasdell (1991b, p.1) at length, 'Unresolved trauma laid down at any stage of human development drives a subsequent cyclic pattern of repetition. Fixatedly frozen at a point in time representing the last tolerable moment before being overwhelmed by hyper-stress, the person continues to act in the here and now as if facing the next moment of the there and then.... Where the primary trauma is shared in common, the cyclic psycho-drama is enacted in common. With the common ground collusively denied, the dynamic process is corporately constructed. It is supported by symbolism and mythology and socially reified into an unquestionable ideology' (my emphases).

I believe that the artificial and mechanistic splitting of quantity from quality, and the mindless and disembodied empiricism which sometimes accompanies it, is but a special case of the more general formulation articulated by Wasdell. If it is the case that the splitting of quantity from quality does such violence to the world that it cannot give us anything approaching a realistic description of reality, it follows that we should subject our current 'scientific' methodologies and ontologies (meaning 'beliefs in what exists') to searching and highly critical scrutiny.

From a humanistic or existential standpoint, it can be argued that those aspects of counselling which are most important for client well-being, and which clients themselves repeatedly report as being of central import, are inherently and IN PRINCIPLE unquantifiable (Spinelli, 1994) - factors like existential aliveness, the quest for personal identity, spiritual well-being, the enhanced meaningfulness of lived experience, and the experience of being loved, for example. Storr (1968, p. 76) has written that 'it is love which really heals the patient'. And if this is so (House, 1995b), then the technique-oriented approaches of 'scientifically-based' evaluation (of which cognitive-behavioural approaches are currently the crowning glory) may well substantially miss the point in their attempts 'objectively' to measure therapeutic outcomes purely in terms of measurable variables such as symptom removal and the like. It simply makes no sense to evaluate humanistic, dynamic or existential counselling in terms of symptom modification or removal alone.

Those commentators who insist upon 'symptom removal' as the universal criterion of counselling efficacy (e.g. Fahy and Wessely, 1993) are making the quite unwarrented assumption that their world-view of what constitutes successful therapeutic change has some kind of universal scientifically based authenticity, rather than being just one (highly partial and unavoidably ideological) way of apprehending the world. Storr (1968, p. 51) writes that 'the exploration of... symptoms inevitably leads on to a consideration of the whole person, his development, temperament, and character structure'.... 'abolition of [a] single symptom..., even if this were possible, would not relieve the patient of the bulk of her emotional problems. The same is true of by far the majority of neurotic symptoms' (p. 56, my emphases). And later, 'the term "cure" is... meaningless when we come to consider the manifold problems of the human condition, and the difficulties we all have in living' (p. 82). And in similar vein, Donald Winnicott (1986, p.120) writes that 'In terms of society's sickness, the care-cure may be of more importance in the world even than the remedy-cure, and all the diagnosis and prevention that goes with what is usually called a scientific approach'.

To the extent that the prevailing Zeitgeist and its associated methodologies are preoccupied with quantification and measurability, symptom removal and mechanistic conceptions of the person more generally, then it is arguable that those methodologies will quite possibly yield results, lead to policy prescriptions and feed ideologies whose values are totally antithetical to the development of the truly human(e) society which, I assume, we all so long for. Lather (1992) outlines a postmodernist critique of the human sciences (and of psychology in particular): 'scientific thought is now an archaic mode of consciousness' and 'truth is viewed as at least as rhetorical as it is procedural' (p. 89). A new 'model' of science is beginning to emerge, in which 'Binary either/or positions are being replaced by a both/and logic that deconstructs the ground of both reductionist objectivism and transcendental dialectics. Linearity and teleology are being supplanted by chaos models of non-linearity and an emphasis on historical contingency. Power is assumed to permeate all aspects of our efforts to know, and language is theorised as constitutive rather than representational, a matrix of enabling and constraining boundaries rather than a mirror' (p. 90).

The positivist model of science is thus coming under increasing criticism from a variety of quarters (House, forthcoming), even from within the physical sciences themselves, and has long since been discredited in the 'philosophy of social science' literature (e.g. Keat and Urry, 1975). The positivist approach to 'scientific' evaluation adopts an extremely limited stance on what a scientific research procedure might actually consist in. Recently, the psychoanalyst Cornelius Castoriadis (1995) has persuasively shown that positivist methodologies which emphasise the cannons of replicability, predictability, substitutability and falsification are in principle quite inappropriate for studying and understanding the human psyche and the therapeutic change process. Thus, for example, the phenomena of paradox, overdetermination, contradiction, both/and logic and dialectical reasoning describe aspects of human experience which a positivist ontology, constricted as it is within the confines of its Aristotelian-logical structure, is quite incapable of encompassing.

A more pluralistic approach to scientific investigation is open to a range of approaches, and there is a substantial literature on qualitative methodologies which attempt to respond to at least some of the shortcomings of positivist and empiricist approaches (e.g. Rowan and Reason, 1981; Moustakas, 1994).

So what are the implications of these arguments for the policy-making process? How can we even begin to integrate what is so deeply personal with the political process?


Policy-making, change and the dynamics of pain and victimhood

Certain social and cultural developments... have weakened our capacities for working through the processes of psychological separation, and have rendered people more prone to seek regressive solutions to the pains of life. (B. Richards, 1994, p.16, citing Lasch, 1979)

How, then, might the attitudes of policy-makers change such that they are able to 'hear' and be influenced by these arguments? My answer to this question is, perhaps, sobering and far from optimistic. For just as, in the process of psychotherapeutic change, I believe that an experiential, deeper-level shift in 'the self' must occur before the ideologies and belief systems which are founded upon that deeper self can change in any sustainable way, just so, it is only when policy-makers discover a far greater capacity for an open, non-defensive self-awareness of the deep unconscious forces that underlie their beliefs, attitudes and behaviours, that any meaningful changes of the kind advocated in this paper can take place.

The cognitive level of human beingness, with its associated belief systems and ideologies, far from being independent of, or even relatively autonomous from, the person, is, I believe, founded upon, informed by and indissolubly linked with the whole person - by which I mean body and spirit, feelings and emotions. It follows that any approach to attitude change which focuses purely on the cognitive-intellectual level, and confines itself to 'cognitive restructuring' alone, can give no guarantee of lasting, sustainable change. And to face the full reality of personhood and being human inevitably entails engaging with our deepest pain and betrayals in our earliest object relationships.

Scott Peck has recently written that 'much disease is actually the result of the attempt to avoid the necessary pain of living.... most disease may best be defined as a failure of the healing process' (Peck, 1993, p.17). If it is true that the existence of pathological belief systems is substantially the result of our extreme resistance to facing the unavoidable pain of living, then it is only by addressing directly and experientially integrating our unresolved pain (whether it be pre-, peri- or post-natal) that we will be able to evolve towards a more healthy, integrated human polity and society.

What Jill Hall has recently called 'the archetype of victimhood' in her tellingly titled book, The Reluctant Adult (Hall, 1993), is surely a central feature of Peck's 'necessary pain of living'. The experience of being a victim, and the desperate attempt to avoid it, seem to foment distortions of life at all levels, both within the individual person her/himself ('organic' disease, dysfunctional behaviour and belief systems, unhappy and destructive relationships, and so on), right up to the macro, societal level, in our institutions (Menzies Lyth, 1988); culture (Alford, 1989); politics and international relations (Wasdell, 1991a); the operation of global capitalism (Wasdell, 1991b); the environmental crisis (Wasdell, 1991a), and so on.

From a humanistic and depth-psychological standpoint, the task of changing our dysfunctional belief systems is unavoidably experiential in nature. It is only when we have been able fully to face up to and integrate our own deeply personal 'necessary pain of living', and to transcend our deeply entrenched tendency to avoid, repress and deny our pain, that there can be hope for a sustainable future for our species (Grof, 1988).

Conclusion: Implications for practice

there can easily be a smell of grandiosity about the idea of a [cultural critic]....It is not on the whole favourable to making an effective intervention in debates in the public sphere to have as a major premiss that, to put it crudely, we are living in a madhouse.(B. Richards, 1994, pp. 22, 160)

It is crucial to consider the constraints that are likely to be encountered by anyone attempting to raise the questions addressed above in their working environments. The fundamental point here is that there will tend to be enormous resistance to these ideas, both at the individual and the institutional level, precisely because they touch the deepest, most vulnerable and potentially most shaming places in all of us.

Wasdell (1989) argues that there is a 'social transference' reaction to the psycho-social analyst, such that there is a desperate attempt to repair the breach in the social defences occasioned by the psycho-social analyst's analytic breakthrough, with the analyst being identified with the repressed precipitating traumata which generated the now deeply repressed and denied psychotic levels of anxiety, against which the defences of the social system were subsequently reified (p.3). In other words, the denied elements of the 'common unconscious' are projected on to the psycho-social analyst, and progress in the psycho-social field tends to be 'slow, painstaking and exhausting' (p.4).

The taking of an awareness of these questions into our work cannot help but have an effect in raising the general level of understanding of these crucial issues; and at least as important is that practitioners make an on-going and open-ended personal commitment to work with our own 'reluctance to become adults' and 'psychic pain of living', such that we minimise the extent to which those with whom we relate in our professional and personal lives are constrained in becoming aware of these issues by our own resistance to integrating this most difficult and challenging material.

I am aware that I have risked 'the smell of grandiosity' by setting out the foregoing arguments in such stark terms. Yet as all of us who have explored our personal histories in therapeutic settings will surely testify, the 'work' of fully facing and integrating the reality of our deepest pain and betrayals is a hugely challenging task, and one which is at times subject to the most intractable denial, evasion and resistance. The task of our individually and collectively evolving towards a world in which policy-makers, managers and researchers are able to make 'healthy' decisions and adopt fully humanistic methodologies, rather than perpetrating ideological actings-out from unconscious and repressed psychopathology, is indeed an enormously daunting one..

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