Psychopathology as ideology: a review article

Ian Parker and others, Deconstructing Psychopathology, Sage, London, 1995, 167 pp, ISBN
(paperback) 0 8039 7481 7, price #11.95


Richard House
Magdalen Medical Practice, Norwich


...not only are psychology's claims to an objectively valid understanding of and a therapeutically effective concern with the ills which beset us false, but it is more than possible that psychology, far from minimizing, actually compounds our difficulties.... [Psychology] serves the interests not only of its practitioners, but more importantly of those who have actually achieved power within society and constructed an apparatus to maintain it....(Smail 1987: 45, 47, original emphases)
We would insist that psychology is still a pre-paradigmatic science with no agreed methodology; hence its ability to provide a secure basis for a practitioner remains suspect.
(Pilgrim and Treacher 1992: 66)
...everything [in psychotherapy] depends upon the dialectical process between two personalities.... Under these circumstances any organization that proposes collective methods seems to me unsuitable, because it would be sawing off the branch on which the psychotherapist sits.(C.G. Jung, letter dated 23/1/60)

Since Freud, the odd voice has been raised from time to time against the conventional taken-for-granted assumptions of the 'psychopathologising mentality'. Sandor Ferenczi was one such voice in the early development of psychoanalysis (Dupont 1985, Masson 1988); and more recently, Ronald Laing and Thomas Szasz have produced blistering and well documented critiques of the theory and practice of the modern psychiatric treatment system and its medical-model ethos. Yet those practices, and the ideological assumptions that underpin them, remain largely in place, apparently relatively impervious to the devastating critiques to which they have been subjected over the years. Here, for example, are some quotations taken from the published writings of leading practitioners in the psychotherapy field, all published in 1996 (my emphases):

(1) Digby Tantam, Chair of the United Kingdom Council for Psychotherapy: 'episodes (in a person's life when they are failing to deal effectively with their life-situation) are generally marked by... what I am tempted to call, as a doctor, emotional disorders.... psychotherapy is a therapy, a treatment [which is] particularly concerned with people experiencing episodes of emotional disorder' (1996: 39);

(2) Michael Gopfert, Consultant Psychotherapist (in a review of Mowbray 1995): 'I was particularly alarmed by the author's belief that non-drug treatment alternatives for patients with acute psychotic episodes fail to flourish largely due to problems of funding.... I felt reassured... that the author might be prevented from putting his views regarding the treatment of patients with acute psychotic disorders into practice by the obligatory registration of core professionals in the mental health field' (1996: 156); and

(3) Simon Wessely of the Institute of Psychiatry: 'there is no evidence that non-directive counselling is effective for [non-psychotic mental] disorders, in contrast to the evidence for the effectiveness of other treatments... delivered by psychologists or community psychiatric nurses.... It seems improbable that counselling will prove superior to more directive treatments for obsessive compulsive disorders, habit disorders.... the need for psychiatry to remain part of medicine is acute' (1996: 158-60 passim).

Such language (highlighted in the quotations above), which is essentially typical in the broad field of the 'psychological treatments', displays an assumptive ontology about the nature of the 'necessary pain of living' (Peck 1993) and the 'therapeutic process' which is, according to a recent book by Ian Parker and others (1995), philosophically invalid and quite unsustainable. It seems that a kind of perverse alchemy occurs, through which process the ordinary everyday difficulties and problems of living are surreptitiously transformed into a mechanistic, professionalised lexicon of quasi-medical terminology that has the effect of legitimating a professional ideology that self-fulfillingly, becomes the guarantee of its own existence. It is over twenty years since Kunnes (1974: 21) wrote that 'The existence of therapists and therapy, in part, produces the demand for it'. Similarly, Szasz refers to 'the semantic inflation - indeed, hyperinflation - that has given us our rich store of psychopathologies - that has... resulted in the transformation of the ordinary behaviors of ordinary persons into the extraordinary and awe-inspiring symptoms of mental diseases' (1978: 194).

Essentially, what Parker er al. do in their book Deconstructing Psychopathology (hereafter, DP) is deconstructively to analyse the notion of 'psychopathology' through the language and institutions that hold it in place, subjecting it in the process to a withering and unrelenting philosphical critique, and then to suggest alternative, philosophically sustainable and fundamentally more human(e) ways of conceptualising the experience of emotional difficulty and distress. In this sense, Parker et al.'s project is fundamentally humanistic (i.e. person-centred, non-pathologising, emphasising human uniqueness rather than deviations from a putative norm, and so on).

Although DP is centrally concerned with the underlying assumptions and practices of psychiatry, the arguments invoked in their deconstructive critique are equally applicable to the whole field of 'psychopathology' - i.e. to psychotherapy and clinical psychology, and to the so-called 'neuroses' of the 'worried well' as well as to the so-called 'psychoses'. The authors pose the question, 'how did our ideas of psychological distress become current and what are their implicit assumptions and implications?' (p. 47). They are quite explicit about the wrong-headedness of conventional 'scientific' approaches to psychopathology: for 'knowledge, theoretical and scientific, does not describe a pre-existing reality but constructs realities' (p. 131). Thus, whereas 'Standard psychiatry thinks it uncovers new "facts"' (p. 133), Parker et al. 'deny the myth of scientific progress, according to which the more recent the research, the closer to the truth and reality it is' (p. 132). It is worth noting that some commentators writing from within the clinical field have also severely questioned modern psychology's pretensions to 'scientific' status (e.g. Pilgrim and Treacher 1992: 64-6). Michel Foucault's work is central to the authors' argument, not least the way in which 'language is organized around different systems of meaning which offer positions of power to certain categories of people and disempower others' (p. 10). Thus, in a very real sense professional elites self-fulfillingly create reality through the very clinical language they use (p. 59); and the authors systematically and convincingly demolish the view that language is a neutral and transparent way of observing and describing an independently existing external reality (p. 93).

A deconstructive perusal of the theory and practice of psychiatry and 'the psychopathologising mentality' reveals a whole host of unarticulated and highly problematic assumptions. Thus, for example, and following Lacan, the conventional distinction between reason and unreason, on which modern psychiatry is founded, is seen as being socially and culturally constructed, rather than an 'objective' truth of human experience. And the validity of the conventional taken-for-granted oppositions between ilness and health, and normality and abnormality, are thrown into severe doubt when they are subjected to a deconstructive analysis (I return to this aspect of the authors' argument below).

A notable feature of the book is the authors' questioning of the distinction between 'lay' or common-sense knowledge, on the one hand, and professional knowledge on the other. Thus they write, 'it is impossible to separate different realms of knowledge since all are thoroughly embedded in cultural practices of one kind or another' (p. 57); and a bit later, 'there is no real distinction between professional and lay knowledge.... professional knowledge too is deeply embedded in wider cultural stories' (p. 63). Such an argument clearly has massive implications for the professionalisation process in the field of psychotherapy and counselling; for if in the field of emotional difficulties there cannot be assumed to exist privileged 'expert' knowledge that is somehow demonstrably superior to other forms of knowledge, then this in turn throws into severe question the very possibility of a legitimate professionalised structure for the broad 'psychological treatments' field based on generalisable or didactic criteria of competency derived from a corpus of so-called 'expert' scientific knowledge. For as Mowbray (1995) suggests, one of the necessary preconditions for a unified profession to form and have a sustainable existence is that there exist an intersubjectively agreed and internally coherent body of expert knowledge that is distinguishable from and superior to 'lay' knowledges, and which plays a central role in constituting both the boundaries and the raison d'etre of the designated profession. The epigaph from Carl Jung (written near the end of his life) that introduces this paper is, of course, extremely germane to this argument.

The authors subject the psychiatric diagnostic systems to a detailed and withering critique (Chapters 3 and 4), arguing that 'Perhaps the irrationality of diagnostic systems is more of a problem than the problem those systems seem so obsessed with' (p. 49). Later they write, 'professionals could be said to bring forth or construct psychopathology by recourse to a language with which to point to disorder. Thus, diagnostic criteria could be said to be justificatory arguments rather than objective signs' (p. 66). The nature of clinical discourses, further, itself has a major influence on the self-experience of 'patients' (p. 73), such that the clinical discourse 'makes it impossible for their subjects to think or even imagine an "elsewhere"' (p. 75). Most damning of all, however, is the tautological nature of the diagnostic enterprise, whereby a 'disorder' is assumed to exist (e.g. 'abnormal' speech) and then 'research draws on existing clinical categories and... its results are fed back into the diagnostic systems...; [and] Psychiatric Language, embedded in research and clinical practices, constitutes the very "pathological phenomena" it seeks to explain' (p. 93). In general, then, 'the practice of diagnosis is not appropriate to human difficulties' (p. 62) - certainly in the emotional/psychological realm in which the objectifying clinical gaze of the diagnostic mentality cannot but render the 'patient' into an object rather than joining her/him as a co-creating subject (again, compare the 'dialectical process between two personalities' referred to so beautifully by Jung, quoted earlier). It should be cautioned, however, that if we do accept the validity of 'diagnosis' in the realm of physical/organic illness and disease, then it is important for all practitioners to be aware of the possibility that physical illness or disease can sometimes manifest as 'psychological' symptoms (Striano 1988, quoted in Mowbray 1995: 182-3).

Perhaps most important from the standpoint of psychotherapy as an alleged profession is the philosophical demolition job that Parker et al. do on the notions of 'normality', 'abnormality' and 'psychopathology'. They write, 'The very idea of "normality" is founded upon the idea of "abnormality", of that which lies outside the definition of the norm' (p. 104). It makes far more sense to see 'abnormality' not as some objective statistical generalisation falling outside of a normal distribution, but rather as a fear-induced, socially constructed category whose unconscious, and therefore unacknowledged, function is to reduce anxiety in the face of others' difference. Thus, as Parker et al. so poignantly write, 'for those who diagnose others as pathological a position of normality is secured' (p. 61). Canguilhem (1991) has similarly argued that notions of the normal and the pathological, far from being scientifically or statistically determined, are concepts of value deeply embedded within political, economic and technological imperatives. And here again is David Smail (1987: 55): 'who does not know for him- or herself the savage tyranny of the "norm"? Being different, standing out, feeling differently from others, experiencing oneself as conspicuous in some way... are at the very core of much of what gets called "psychiatric disorder", and indeed of the everyday terrors of us all' (original emphasis).

Mowbray (forthcoming) has argued that although Parker et al. are philosophically correct to problematise the normal/abnormal distinction, 'Socially constructed reality... is nonetheless "real" - as a metaphor - for the society in question.... Thus, the metaphor of "mental illness"... still has some utility'. Mowbray agrees that a deconstructive perspective on ab/normality is useful and important in 'challeng[ing] a claim to the "factual" status of a distinction [between normality and abnormality] which is used to bolster a position of authority and political power'; but equally, for him, 'Socially accepted (constructed) distinctions do "exist"... [and] the need for a line is part of the social (and legal) reality' (ibid.). Thus, supporters of the psychiatric treatment model might respond to Parker et al. that they (the psychiatrists) are merely responding heuristically and pragmatically to the everyday categories of the culture at large - for example, 'patients' often want to 'return to normal', and it is very typical for people to think in terms of the categories of normality and abnormality as part of their subjective experience of the world. The issue here seems to be one of whether we work with the taken-for-granted, ideologically and socially constr[u/i]cted status quo, or whether we problematise cultural and professional norms (including the norm of 'normalisation' itself) in the hope of reaching more human(e), realistic and ultimately fulfilling ways of being and understanding.

Clearly, Parker et al. would vote for the latter course, and will inevitably incur the charge of unrealistic puritanism as a result. Yet perhaps their purist critique is necessary if the 'clinical centre-ground' is to move nearer towards the emancipatory position they espouse. Certainly, I share with the authors a profound distaste for 'normalisation', and its overtones of social control and an associated uncritical acceptance of behavioural norms and 'naturalised' distributions of power. And if Parker et al. are right in arguing that 'How we reflect upon and define ourselves is determined and constrained by the structures of knowing available to us' (p. 88), then it follows that the clinician-practitioner's assumptions about the relative importance of normalisation versus self-actualisation and individual uniqueness will have a profound influence upon who their patients/clients will have the space to become in relation to those practitioners.

For Parker et al., then, far from being an objective, scientific notion, 'abnormality' is a fundamentally ideological, socially constructed and culturally relative concept. And it therefore becomes very difficult to justify invoking notions of 'abnormal psychology' and 'psychopathology' to legitimise the existence of professionalised domains of activity called 'psychiatry', 'clinical psychology' and 'psychotherapy', where the latter are viewed as essentially 'a treatment and cure business focusing on the illness or problem to be alleviated (i.e. a medical model activity)' (Mowbray 1995: 14). It also becomes extremely difficult to find any convincing theoretical rationale for demarcation lines to be drawn between the practices of psychiatry, clinical psychology, psychotherapy, counselling and personal growth work. And further still, if, with Parker et al., we eschew the medical model's implicit adoption of what Mowbray (1995: 180) calls an 'underlying malfunctioning machine metaphor' and its associated 'normalisation' ethos, then it follows that in the broad field of 'psychological help' the emphasis should be on individual authenticity and uniqueness, and the core humanistic value of self-actualisation and fulfilment.

Furthermore, the current preoccupation with 'professionalising' the fields of psychotherapy and counselling (Mowbray 1995) by no means remains unscathed by these radical arguments: for if we set the argument of the previous paragraph alongside Parker et al.'s view that no clear distinction is sustainable between lay and professional knowledge, then it becomes extremely difficult to see how the creation of a professionalised domain called 'psychotherapy' or 'counselling' can have any legitimacy or theoretical justification over and above the economic and/or career interests of the practitioners themselves.

In the wake of Parker et al.'s deconstruction of '(ab)normality' and 'psychopathology', the use of the term 'psychotherapy' to define a coherent and legitimate professional domain (as currently claimed by the UK Council for Psychotherapy) also becomes very difficult to sustain. Mowbray, Breggin and Szasz, for example, have variously subjected the term 'psychotherapy' to damning critiques. Mowbray (1995: 168) shows how the term 'psychotherapy' was first used in 1803 in a medical-model context: '"psychotherapy" is a nineteenth century medical model word' (p. 168), and the term 'therapy' is used in the medical and psychiatric world to mean 'remedial treatment' (ibid.). For Breggin (1993: 463-4), 'psychiatry... has medicalized and corrupted the word ["psychotherapy"] to mean "the treatment of mental illness"'.

Szasz goes even further: 'There is... no such thing as psychotherapy. Like mental illness, psychotherapy is a metaphor and a myth' (1978: x); and he goes on to refer to the use of the term 'psychotherapy' as a 'debauchment of the language of healing in the service of dehumanizing and controlling persons by technicizing and therapeutizing personal relations' (ibid.: p. 208). Szasz suggests that it may be time to find a new term to replace the medical-model term 'psychotherapy'. Certainly, in the light of the foregoing arguments it seems clear that explicitly humanistic practitioners who adhere to core humanistic values in their work will surely be very hard-pressed to justify using the term 'psychotherapist' to describe what they do; and there are increasing signs in the field that practitioners who call themselves 'humanistic' are in fact only paying lip-service to humanistic values, while their actual practice is in effect akin to a medical model, remedial activity (cf. House 1996a: 55). And if Parker et al. are right in arguing that, even in the realms of the so-called 'psychoses' and 'madness', notions of abnormality and psychopathology are unsustainable, then the use of the term 'psychotherapy' in any context must be open to very severe doubt.

Altogether, I would suggest that practitioners' use of the self-descriptor 'psychotherapist' has much more to do with their need to experience themselves as bearers of distinctive expertise and professional knowledge than it has to do with any rationally sustainable belief in the legitimacy of an authentic professional identity.


Some conclusions
On the back cover of DP Dorothy Rowe is quoted as saying that DP is 'essential reading for all students of psychology'. I would go much further still, for it would be a tragedy if the influence of this extraordinary book were limited to the arm-chair ivory towers of Academia. In my view this book should be compulsory reading for every trainer, practitioner and student/trainee in the fields of counselling, psychotherapy, clinical psychology and psychiatry; and if it were so, then before long we would surely be witnessing a wholesale Kuhnian paradigm shift or philosophical revolution in the way in which the 'object of knowledge' of our field is conceptualised, thought about and approached at the level of practice.

Yet defensively rooted ideologies are notoriously impervious to rational argument - which could conceivably leave the compelling arguments so lucidly laid out in DP quite unable to be assimilated (compare the way in which the formidable anti-psychiatry critiques of the 1960s and 1970s were defused, diffused and assimilated into mainstream psychiatry with no discernible effects upon actual treatment practices). Here is psychosocial analyst David Wasdell on the dynamic origins of ideological belief systems:

'Unresolved trauma laid down at any stage of human development drives a subsequent 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.... When the primary trauma is shared in common, the cyclic psychodrama 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' (Wasdell 1991: 1, my emphasis).

And I am claiming here that in a very important sense the ideology of psychopathology and its associated practices fit squarely within such an explanatory framework - with the common and collusively denied fear underlying the pathologising ideology being rooted in the fear of others' radical difference; fear of the inherent uncertainty and unknowability of human relationship - indeed, perhaps of life itself (Groddeck 1951); and fear of the intimacy of a relatively undefended I--Thou therapeutic encounter (House 1996b).

If you are not prepared to have your 'therapeutic' world-view rocked to its foundations, then read DP at your peril; but if you are the kind of practitioner who is always questioning your own practice, and the ideological foundations that underpin it, then this book is probably the most important and potentially revolutionary critique of the 'therapeutic and pathologising mentality' currently in print in the English language. Once the essential message of DP has been digested and culturally assimilated by a critical mass of practitioners in the field, 'therapeutic' practice will surely never be quite the same ever again.


References

Breggin, P. (1993) Toxic Psychiatry, HarperCollins, London

Canguilhem, G. (1991; orig. 1966) The Normal and the Pathological, Zone
Books, New York

Dupont, J. (ed.) (1985) The Clinical Diary of Sandor Ferenczi, trans. M.
Balint and N.Z. Jackson, Harvard University Press, Cambridge, Mass.

Gopfert, M. (1996) Review of Mowbray 1995, British Journal of Guidance and
Counselling, 24 (1), pp. 155-7

Groddeck, G. (1951; orig. 1930) The Unknown Self, Vision, London

House, R. (1996a) Letter to the editor on Professionalisation, Self and
Society, 24 (3), pp. 54-5

House, R. (1996b) 'Love, intimacy and therapeutic change', Self and
Society, 24 (1), pp. 21-6

Jung, C.G. (1976) C.G. Jung Letters, Volume II, ed. G. Adler, trans. R.F.C.
Hull, Routledge and Kegan Paul, London

Kunnes, R. (1974) 'Detherapizing society', in The Radical Therapist/Rough
Times Collective (ed.), The Radical Therapist, Penguin, Harmondsworth,
pp. 20-7

Masson, J. (1990; orig. 1988) Against Therapy, Fontana/Collins, London

Mowbray, R. (1995) The Case Against Psychotherapy Registration: A
Conservation Issue for the Human Potential Movement, Trans Marginal
Press, London

Mowbray, R. (forthcoming) 'SAFAA in reality: the adult mode of
consciousness and the argument of the beard' (mimeo)

Peck, M.S. (1993) 'Salvation and suffering: the ambiguity of pain and
disease', Human Potential, Summer

Pilgrim, D. and Treacher, A. (1992) Clinical Psychology Observed,
Routledge, London

Smail, D. (1987) Taking Care: An Alternative to Therapy, J.M. Dent, London

Striano, J. (1988) Can Psychotherapists Hurt You?, Professional Press,
Santa Barbara, Calif.

Szasz, T. (1978) The Myth of Psychotherapy, Syracuse University Press

Tantam, D. (1996) Letter to the editor, Self and Society, 24 (2), pp. 39-42

Wasdell, D. (1991) 'The pre- and perinatal ground of capitalism and the
free-market economy', Unit for Research into Changing Institutions, 115
Poplar High Street, London (mimeo)

Wessely, S. (1996) 'The rise of counselling and the return of alienism',
British Medical Journal, 313, pp. 158-60