Conceptualizing the Therapeutic Process

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A third major focus of the sociology of mental health is mental health care services. While the range of issues with which sociologists who study mental health care services are concerned are more numerous and diverse than what will be considered here, one major issue to which contemporary social theorists may provide insight is with the question of the sociocultural functions, meanings, and implications of mental health care. This issue is closely related to the discussion of the values implicit in definitions of mental health and illness in the last section. Psychotherapists themselves have called for recognition of the social, cultural, and ideological meanings implicit in various forms of mental health care (Fancher, 1995; Frank & Frank, 1991). In Cultures of Healing, for example, psychotherapist Robert Fancher (1995) evaluates the implicit cultural and political assumptions of four major "cultures of healing": psychoanalysis, behaviorism, cognitive therapy, and biological psychiatry. Reporting findings that type of therapeutic treatment makes little difference in the alleviation of the distress of patients, he argues that the type of therapy a patient receives is nonetheless important because each culture of healing promotes different beliefs, values, and ideals of living.

Concern with the political-ideological implications of mental health care, psychological discourse, and the emergence of what some have called the "psychological society" as well as, more particularly, with the basic question of the extent to which psychotherapeutic practices foster liberation from societal patterns of domination and social control or promote conformity to the status quo, as discussed in the previous section, has been pervasive in critical discourses on psychotherapy since the 1960s (see Prilleltensky, 1994, for a review of these critiques). A central theme is the indictment of psychotherapeutic practices and discourse for elevating individualistic understandings of personal problems and deflecting attention away from social structural bases of distress. Within the field of sociology, an early statement of this critique can be found in C. Wright Mills' (1959) classic The Sociological Imagination in which he argued that social and personal problems were increasingly being (inappropriately) understood in terms of the "psychiatric." Conrad and Schneider (1982) offer a similar sort of critique of the individualizing and depoliticizing impact of the "medicalization" of many sorts of deviant behaviors and personal problems.

Broadly, the central issue in these critiques and debates concerns the relationship between the psychotherapeutic process and social control. How is mental health care linked to societal systems of social control? Each of the three social theoretical perspectives I consider in this chapter speak to this issue in some fashion. For Foucault, however, the view of mental health professions as instruments of modern social control is most central, and so his work will receive the most attention in this section. The implications of critical theoretical perspectives for thinking about therapeutic practices were discussed in the previous section and will not be further discussed here. The theorists of individualization, however, interpret therapeutic practices differently than Foucault and question the applicability of Foucault's perspective in the contemporary period. Thus, I frame this difference of perspective as an important theoretical question for making sense of contemporary therapeutic practices.

Foucault's critical perspective on the emergence of psychiatry, psychology, and the human sciences is well-known among social theorists and sociologists of mental health, and has had a significant influence on historically-based analyses of mental health care (e.g., Caplan, 1998; Cushman, 1995; Herman, 1995; Lunbeck, 1994; N. Rose, 1989) as well as mental heath research within the constructionist tradition (e.g., Bayer, 1987; Figert, 1996; Scott, 1990). Foucault views the emergence of psychiatry and psychology as part of a larger modern transformation in the nature of discipline and social control. In Madness and Civilization (Foucault, 1965), he characterizes psychiatry as a "monologue of reason about madness" (p. xi). While psychiatry justifies itself as a humane and scientific endeavor, Foucault sees it as a method of social control aimed to induce the insane to judge themselves according to (social) standards of reason. Foucault views the insane as being subjected, via psychiatry, to a "gigantic moral imprisonment" (Foucault, 1965).

In Discipline and Punish, Foucault (1977) focuses on the emergence of modern disciplinary technologies after 1757, when moral control comes to be the primary means of social control. He identifies "hierarchical observation" and "normalizing judgment" as central mechanisms of modern discipline. Hierarchical observation involves intensive unilateral scrutiny of a subordinate (e.g., patient) by a superior (e.g., psychiatrist) and provides the basis for "normalizing judgment." Normalizing judgment entails evaluation of an individual's performance, behavior, characteristics, psychological makeup, etc. according to detailed standards of normality. Normalizing judgment aims not only at "offenses" or "infractions," as in prior disciplinary modes, but at any failure to perform optimally. Foucault saw these modern disciplinary processes as central to psychiatric social control. The psychiatric patient, for example, is judged and learns to self-monitor not only for "inappropriate" behavior but also for failure to realize optimal standards of mental health. Psychotherapeutic practices, thus, play a key role in constructing a self-monitoring and self-controlling modern subjectivity.

Foucault's (1976) critique of the "repressive hypothesis" in History of Sexuality, Vol. 1 has crucial implications for understanding his view of the psychotherapeutic process. Focusing his attention explicitly on Victorian-era understandings of sexual repression, Foucault criticized the idea that frank discussion about sexuality and, more generally, the probing of the depths of the human psyche, entailed a release of psychically-damaging repression and thereby enhanced personal freedom. Instead, he viewed the idea of repressed impulses as a fiction constructed with the aim of intensifying self-monitoring and self-judgment according to prevailing standards of psychological normality. Although modern persons may view themselves as self-liberating as they probe their psyches, this self-conception reflects a misunderstanding of the nature of power. A central theme for Foucault is that power is not simply repressive (saying "no") but also productive. As individuals come to be fascinated with sexual matters and take great interest in monitoring and confessing their own desires, fantasies, and responses, they are, in fundamental ways, subject to greater social control. The modern emphasis on "knowing" the psyche, in Foucault's view, intensifies self-monitoring and constructs subjectivity according to modern normative standards. Some (more often those of higher social classes) actively seek out such control, in the name of self-knowledge, self-expression, and personal authenticity. For others who find themselves subjected to it following the commission of socially unacceptable behavior, the social control may be more explicit and direct. But, for Foucault, the social control is more thorough to the extent to which the psychotherapeutic subject actively participates and does not experience it as an alienating and external judgment. Foucault's perspective is, on this point, consistent with Horwitz's (1982b) theory of "therapeutic social control." Such control, Horwitz argues, is persuasive rather than coercive, emphasizing control of personality rather than control of behavior.

If we examine psychotherapeutic practices and discourse through a Fou-cauldian lens, the question of their political implications comes to the forefront, although in a different way than it does for the critical theorists. Instead of understanding individuals as having authentic selves or distinctive human desires and capacities that may be either liberated or dominated, Foucault views subjectivity as socially constructed and psychotherapeutic practices and discourse as playing a fundamental role in its construction. The idea of the "authentic self" to be discovered, known, and acted upon is an ideological ruse that serves to motivate individuals' self-discipline and facilitates social control. Implicitly, however, some sort of conception of authenticity lurks behind his critique of modern disciplinary techniques, especially the normalization promoted by the psychiatry, psychology, and the human sciences. Otherwise, why see this normalization as a form of violence to the self, as Foucault does? In later work, Foucault contrasts the practices or "technologies of the self" of the "politically active subject," to the "passive" subject which had been the center of critique in his earlier works (Foucault, 1982; 1988; Rabinow, 1984); he came to view the relationship of "self to self" as a useful point of resistance to domination, and envisioned the construction of an alternative type of subjectivity to the "normalized" form he saw as linked to the institutions of modernity and as promoted by modern psychothera-peutic practices (Foucault, 1988). What, precisely, this alternative form of subjectivity might look like, and how we might distinguish its characteristics from the passive and normalized subjectivity that Foucault problematizes, however, is not clear.

Arguably, a limitation of Foucault's work for thinking about mental health issues is the failure to pay attention to the actual experiences of mental distress that individuals may suffer. If there is any implicit notion of mental distress in Foucault's work, however, it would be the misery of the person who has been coer-cively constructed as "abnormal," "sick," and worthy of psychiatric intervention by modern discourses of normality. Particularly important, in Foucault's view, is that the "psy" disciplines create a fundamental transformation in the relationship of individuals to their behavior. Modern psychological discourse accords behavior, thoughts, and desires a fundamental status in determining a person's identity and, hence, makes intensive self-scrutiny and normalizing judgment necessary. This normalization, and, in particular, the tying of the individual's identity to her every thought, behavior, and desire, might be seen to cause misery much more than it would help to alleviate psychological pain. Foucault himself says nothing about this, unconcerned as he is with mental distress. However, we might nonetheless consider the possibility that some portion of psychological distress is a product of cultural standards of psychological normality. As sociologists of emotion have shown (e.g., Hochschild, 1983), powerful social norms dictating the propriety or "healthiness" of particular emotions in various contexts cause individuals to "have feelings about their feelings." When individuals feel bad about themselves for feeling an "unacceptable," "inappropriate," or "immature" emotion, particularly insofar as such emotions have, as Foucault argues, come to be seen as fundamental to self-identity, an additional layer of distress is added to what might or might not be on its own a stressful emotional experience. Applying the insights of the sociology of emotions to mental health, Thoits (1985) has argued that the experience of "emotional deviance" is a common basis of individuals' self-attributions of mental illness and professional help-seeking. Thus, it may be useful to follow Foucault and sociologists of emotion in carefully examining the role of emotion norms and standards of normal psychological development or normal "identity," as purveyed by therapeutic practices and discourses, in producing distress in individuals. This view represents, at a basic level, a contrast to the view of the theorists of individu-alization that much contemporary distress could best be understood in terms of an absence of standards.

Foucault's ideas have significantly influenced the development of postmodern thought in general, but, in particular, his thought has significantly influenced postmodern approaches to understanding psychotherapeutic practices. Burr and Butt (2000) provide a concise analysis of the implications of the postmodern perspective for thinking about psychotherapeutic practices. The postmodern perspective questions the presumed expertise of therapists, challenging the idea that therapists know what is best for clients. Accordingly, the postmodern perspective problematizes the asymmetric power relation often characteristic of therapy. The more appropriate type of therapeutic relation, from a postmodern perspective, is one that follows a "research supervisor/research student model" (Bannister, 1983; Burr & Butt, 2000). According to this model, the "researcher" (client) is presumed to know most about her project (her own self and life), and the role of the "supervisor" is to provide guidance on different ways the project might be approached. Drawing on the insights of Foucault, the postmodern perspective calls for scrutiny of the ways in which psychological constructions of normality and pathology affect the self-constructions of clients. It also calls for recognition of human diversity both between and within people. Instead of seeking a "deep, real self to be mined," a postmodern therapeutic approach emphasizes the relational nature of human experience and seeks to help individuals live meaningfully with fragmentation. It calls attention to our "vocabularies of self" and urges the exploration of alternative vocabularies. Postmodern psychology, finally, emphasizes the social and relational sources of individuals' psychological problems and so focuses on helping individuals to resituate themselves or to resist debilitating constructions of themselves that they may have adopted through problematic relationships. In short, postmodern psychology may be seen as an effort to avoid the very forms of therapeutic social control criticized by Foucault. So, one might reasonably ask how "postmodern" contemporary psychotherapeu-tic practices may have become and whether or not Foucault's view of the mental health professions as an instrument of normalizing social control continues to be a useful way to understand mental health care in the contemporary age.

In contrast to Foucault's perspective, the theorists of individualization do not conceptualize psychotherapeutic practices in terms of social control. Instead, they see individuals with very real psychological distress turning to psychotherapy to find guidance no longer provided by society. The responsibility that individuals hold for the reflexive making of self-identity under conditions of late modernity is, in essence, Giddens' explanation for the proliferation of psychotherapies and counseling in contemporary Western societies. As he puts it quite simply: "Self-identity has to be created and recreated on a more active basis than before. This explains why therapy and counseling of all kinds have become so popular in Western countries" (Giddens, 2000, p. 65). In Bauman's view, individuals seek out experts to provide authoritative advice on how to escape from the uncertainty characteristic of contemporary social life (Bauman, 1995, p. 80). While the indi-vidualization of the contemporary age involves increased individual responsibility for self-formation, the paradox is that individuals increasingly turn over this responsibility to professionals who "recommend" identities and ways of acquiring and holding them (Bauman, 1995, p. 82). Beck and Beck-Gernsheim (1996), see the destruction of routine as a primary source of psychological distress and understand the proliferation of psychotherapies as a product of individuals looking to authorities to answer the question "Who am I and what do I want?" (p. 31). In the late modern age, decisions about lifestyles come to have great ethical, and anxiety-provoking, significance. "Everyday life is being post-religiously deified" (p. 32), and seemingly we need therapeutic experts to help us find our salvation.

Whereas Foucault views psychotherapeutic practices as part of a larger system of modern discipline, Bauman argues that Foucault's conception of social control is not appropriate to the contemporary context. In Bauman's view, such control is no longer necessary; there is no longer a need to control people's wants and desires, to keep them commensurate with objective possibilities. Ambivalence is no longer a public enemy, he states, because the proliferation of wants and desires in the broader population in advanced societies fuels consumerism and is therefore entirely non-threatening to powerful global interests. Further, Bauman suggests that there is less need for the imposition of moral discipline on such populations as criminals, homeless, and the unemployed, as they are no longer a reserve army of labor but instead are inessential "waste" to be kept out of sight as much as possible. Ambivalence, however, remains a powerful private enemy -a source of confusion and distress for individuals; people turn to therapeutic experts in hopes of receiving guidance and support. Therapeutic experts, he says, are only too happy to provide systems of meaning and guidance to their clients and help them to "settle" the vexing questions that plague them. Both Bauman and Beck and Beck-Gernsheim view therapeutic intervention as an unsatisfactory attempt to provide private solutions to systemic contradictions, but neither would find the concept "normalization" to be an appropriate way to characterize the help that therapeutic experts provide.

Instead of seeing therapeutic practices as promoting normalization, Giddens sees psychotherapy as promoting a greater degree of reflexivity in the individual's relationships, construction of self, and making of important life decisions. Giddens and Beck and Beck-Gernsheim, as we have seen, focus on the stress that individuals may experience in the face of responsibility for a seemingly infinite array of self-constructing lifestyle choices and note the possibility for anxiety to subvert autonomy. Accordingly, the therapeutic process may be understood as working to expand individuals' freedom in living their lives in accordance with conscious and free choices. Giddens also suggests that therapeutic conceptions may promote more democratic orientations towards life, greater questioning of prevailing societal standards, thawing of "frozen" patterns in life and in relationships, and greater expectations for equality (Giddens, 1992).

The key theoretical question that emerges from these contrasting perspectives is the question of the appropriateness of viewing contemporary therapeutic practices as normalizing and disciplinary. Have contemporary therapeutic practices instead become more "postmodern," and/or do the interpretations of the theorists of indi-vidualization make more sense? Two relatively recent studies that draw heavily on Foucault's ideas are helpful for thinking about this question. In Constructing the Self, Constructing America, Cushman (1995) provides a cultural history of psychotherapy in the U. S. that indicates that therapeutic practices in American society were never particularly focused on social control, at least not in the way we typically think of social control. The view of therapeutic practices as social control through self-discipline, he suggests, was appropriate through the early part of the 20th century in Europe. Freud's dictum, "where id was, there ego shall be," was indicative of the modern European drive for self-mastery through rational self-control. The ultimate purpose of exploration of the unconscious mind, characteristic of Freudian psychoanalysis, was, in the European context, to tame the unconscious. Transported into the American context, however, Freud's ideas were transmuted; instead of taming unruly impulses, Americans were more interested in liberating them. Cushman characterizes the focus of therapeutic practices in the first half of the 20th century in the U.S. as focused on self-liberation, not self-domination. Corresponding to the sense of promise and optimism that Americans enjoyed in the late 19th century, Americans conceived of the human interior as "inherently good, saturated in spirituality, and capable of controlling the external world" (Cushman, 1995, p. 118); the key to well-being and prosperity was liberation of this enchanted human interior. In the second half of the 20th century, Cushman identifies another shift in focus of therapeutic practices. Increasingly individuals, particularly middle-class ones, come to experience what Cushman calls "the empty self," an experience of "interior lack, absence, emptiness and despair, the desperate yearning to be loved, soothed, and made whole by filling up the emptiness" (Cushman, 1995, p. 245); this he links to 20th century social changes, particularly the growth of consumerism. As individuals turn to psychotherapists (and to consumer goods) to soothe and fill up the emptiness, psycho-therapeutic practices come to be understood accordingly. The emergence and influence of self psychology and object relations theory in the post-war period, in particular, is indicative of the view of the self as empty and of therapeutic practices as filling the void. Insofar as Cushman's interpretations of the cultural meanings of American psychotherapy are correct, then the view of therapeutic practices as agents of disciplinary social control does not fit so well in the American context and perhaps, also, not so well in the contemporary European context.

If we broaden our understanding of social control to fully grasp the meaning of Foucault's analysis, however, it would be misleading to argue that contemporary therapeutic practices, even if they do take the forms that Cushman suggests, do not function as instruments of social control. Cushman himself draws upon Foucault's thinking as one of the key theoretical foundations of his work; Foucault's key insight is, for him, that "each era produces a particular configuration of self and corresponding kinds of psychopathology" (Cushman, 1990, p. 600). The "empty self" is constructed by and contributes to the maintenance of a consumer-driven post World War II economy, thus illustrating rather than contradicting Foucault's perspective. While psychotherapists may see themselves as responding to and working to heal the individual's psychic emptiness, Cushman argues that psy-chotherapies (like advertising) also contribute mightily to reinforcing the conception and experience of the self as empty.

Hazleden (2003) similarly finds Foucault's perspective useful for understanding contemporary psychotherapeutic discourses, even when self-control is not a prominent theme. Despite the apparent tendency to emphasize self-love over self-control, Hazleden nonetheless believes that Foucault's concept "normalization" aptly describes psychotherapeutic discourse in contemporary advanced societies. Reviewing popular self-help books, she shows that these texts, while presenting themselves as guidebooks for discovering and properly nurturing the "true self" within, convey a set of specific messages about the proper relationship the individual should develop with oneself. They teach the individual to regard the self as of paramount importance, to consider love and nurturance of self a serious responsibility (not self-indulgence, but rather "hard work"), and to maintain self-sufficiency.

While these are not the sorts of messages we might associate with disciplinary social control, Hazleden argues (in a manner quite consistent with Foucault's perspective) that such messages do represent social control in that they define a right and a wrong way of relating to the self.

Drawing on Foucault, the key question is the extent to which contemporary mental health care functions as a system of social control, subjecting individuals to normalizing judgment. In actual therapeutic practice, is it common for therapeutic professionals to impose standards of psychological normality? If so, what is the nature of these standards? Do they involve ideals of living that reflect the therapists' own personal and cultural background? Do they, as the critical theories would lead us to ask, promote conformity or resistance to structures of inequality and domination in the broader society? Are they, as Foucault suggests, standards designed to maximize the individual's self-discipline and fitness for life within modern institutions? Or, might the standards of normality, at least in some therapeutic contexts, involve merely a therapeutic judgment that the degree of psychological pain and/or dysfunction experienced by the individual is not "normal"? It is not clear how appropriate it would be, in the face of debilitating mental illness, to understand a therapeutic judgment that a person's psychological functioning is impaired, to involve imposition of a problematic form of normalizing judgment. Waitzkin's (1989) work on ideology in medical practice, however, suggests that even such seemingly innocuous judgments may carry ideological freight. When doctors focus on symptoms and treatment, but ignore the troubled social reality at the root of a person's illness, the symptoms and treatment attain the aura of scientific fact while the problematic social relations become reified (Waitzkin, 1989, p. 224).

Drawing upon the theorists of individualization, the key issue is to assess their contention that confused individuals turn to psychotherapeutic experts for help in sorting out questions of identity, existential meaning, and life priorities. Even if some clients of psychotherapeutic services seek guidance from experts on such matters, to what extent are such questions a pervasive focus of therapeutic practices? Are some schools of therapeutic practice and or some practitioners more likely than others to emphasize such questions? Is confusion over identity, meaning, and life-purpose more relevant for understanding some types of mental distress more than others? Are those who seek therapy voluntarily more likely to focus on such questions than are those for whom treatment is involuntary? Further, are such questions more likely to figure into treatment with functional persons who seek therapy for help with ordinary problems of everyday living than they are in the treatment of individuals who suffer serious and debilitating mental illness? In short, are the anxieties and worries identified by the theorists of individualization simply those of the "worried well," or are they also useful in understanding serious mental illness? Further, if existential questions figure prominently in therapeutic treatment, what is the nature of the guidance that therapeutic experts provide? Is the mental health industry really an "answer factory," or are therapists more likely, in postmodern style, to eschew authoritative answers?

A tendency in social theory is to analyze psychotherapeutic practices, discourse, and ideology as a relatively monolithic entity serving a single function - e.g., challenging or supporting societal systems of domination, subjecting individuals to "normalizing" social control, providing individuals guidance as they make difficult life decisions - regardless of the type of therapy, the nature of the psychological problem, or the type of patient population. Within mental health professions, however, there is tremendous internal diversity that social theorists might take more seriously. As Fancher (1995) points out, there are somewhere between 50 and 500 different forms of psychotherapy, depending on how one counts; while there are likely common themes and orientations among many, surely also there are some differences in ideological implications or socio-cultural functions. Differences in the political/ideological orientations of individual psychotherapists, many of whom are "eclectic" in theoretical and practical orientations, are also important to consider (Fancher, 1995).

Severity of mental illness is another consideration, as well as whether or not treatment is voluntary or involuntary. Horwitz and Mullis (1992) argue that the rise of individualism has weakened the social control and social support for the seriously mentally ill, as the seriously mentally ill are less likely to receive long-term involuntary care in isolated mental health care facilities and are more likely to leave or be expelled from their families. Thus, Bauman's arguments about the impact of individualization in the lives of the socially marginal—the cutting adrift, the leaving to one's own devices, the lifting of moral control, the consigning to waste—are particularly apt for understanding the experiences of the seriously mentally ill in the contemporary period.

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