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Human Nature Review 2002 Volume 2: 402-405 ( 19 September )
URL of this document http://human-nature.com/nibbs/02/therapy.html
Why Therapy Doesn’t Work and What We Should Do About It and The Nature of Unhappiness
by David Smail
Robinson, London 2001
Reviewed by Roy Sugarman PhD, Senior Clinical Neuropsychologist, Glenside Campus/RAH, Clinical Lecturer, Dept of Psychiatry, Adelaide University, P O Box 17, Fullarton SA 5063, Australia.
By now, most of us in psychology have heard of David Smail, who works in the United Kingdom within the National Health Service, as both of the above works are compilations of previous works, now published as compilations by Robinson. The first comprises Illusion and Reality (1984) and Taking Care (1987), the second, The Origins of Unhappiness (1993) and How to Survive Without Psychotherapy (1996).
What is not immediately evident from the titles, and from assuming one knows something about clinical psychologists, is that Smail’s books are about social capital, and its intricate relationship to psychopathology, and hence to the phenomenology of illness and treatment.
Reading the preface to “The origins of unhappiness”, one must assume that either Smail is a little wrong, or perhaps less current in some ways. He writes, on page xvii:
... Current approaches to psychological distress tend to split into the biological on the one hand and the magical on the other. Biological psychiatry, which at times in the 1970’s looked to be a dead duck, is back with a vengeance.
I am not too sure many would agree with that point, and many models, even of that time, were certainly less biological and more biopsychosocial, even if they were perhaps increasingly neurobiological. Nor did they ignore the social aspects that Smail speaks about afterwards, the social determinants of wellness. For example, Gabbard writes in the British Journal of Psychiatry Vol 177 in 2000:
The implications for psychotherapy of this view of the interaction between the genetic/biological substrate and the environment are complex and exciting…….This model allows us to broaden our understanding of psychiatric interventions by regarding all of them as having a biopsychosocial nature. In other words, medications have a ‘psychological’ effect in addition to their impact on the brain, and psychotherapeutic interventions affect the brain in addition to their ‘psychological’ impact. (page 119).
This mainstream neurobiological view is clearly supportive of Smail’s view that our “Our predicament is the social environment in which we live, and our suffering arises from our relationship with it” (page xvii again). As Eric Kandel would agree, we are what we experience, as multiple changes related to long-term potentiation reflect our complex interactions with, well, the extent to which we have or have not, social capital on our side. Social capital and glutamate/serotonin interactions all intertwined, and do not really “obscure our predicament” as Smail will show later in the volumes.
Of course, the difference lies in what one considers a context or social environment, which of course occurs even at a cellular level (cells have social environments too).
Psychiatry and psychology of course have been characterised (unlike other aspects of medicine) by conceptual pluralism, meaning a number of competing paradigms (sometimes incompatible) have coexisted within these fields (Abed, same issue of the British Journal of Psychiatry, 177, 2000 quoting McGuire and Troisi 1998). Of this kind of idea, Smail (op cit) notes:
Were it not for our anything-goes era of ‘post-modernity’, the cheerful existence of these drug-and-body-based, apparently scientific certainties with the equally successful approaches of ‘alternative’ therapies would be bizarre. But they do of course share an important function, and that is to obscure the reality of our predicament
By which he is referring to the aforementioned social environment. By pages 297-298 of “Why therapy doesn’t work”, we see that therapy is being branded as an agent of social control. This it does by shaping our thoughts, allowing us to meld with the social environment that is producing pathology in us via the strings of social capital. This is seen as a method of chaining us internally, straight-jacketing us via individual guilt and accountability. In this way Smail acknowledges, psychotherapy may indeed have the outcome-measured skills that alleviate the stress, and thus ‘works’ in that fashion, but in the process it forces the patient to avoid criticising the aspects of social reality that are causing the harm in the first place, comforting them in a cruel world.
Now Smail never mentions social capital. Perhaps social capital is like Penis Envy, one may not want it, but one can admire the social advantage that possessing it gives the owner, to quote, I think, Betty Friedan. Like castration, one may miss it when one doesn’t have it,
There is of course a familiar dualism, social capital both causes misdiagnosis and treatment, and of course also causes psychological distress in the first place. The have and the have-nots suffer differently. Empowerment of course increases social capital. Reading Smail is like reading feminist author’s criticisms of Freudian thinking and the philosophies of family therapy, or of Susan Faludi’s more recent works. The argument hasn’t changed much, and the argument is there in “The nature of unhappiness” pages 342-onward, where he begins defining the interaction between gender role and identity, and the “property of culture”, which looks much to me like social capital and Betty Friedan, but not nearly as evolved or sophisticated as these Feminists. Here he says:
In pointing out that the culture determines aspects of people that they cannot change--aspects usually regarded as ‘personal’ and ‘psychological’ - I am not arguing that they are unchangeable. The point is, rather, that they cannot usually be changed just by the individual in whose interest it may be to change them. They can certainly be changed through the operation of social power on a larger scale (343-344).
Whilst I am happy to see that he acknowledges that the personal is the political, this is not news, and his superficial statement that the women’s movement has been influential in redefining gender roles is rather trite in that it ignores the vast complexity beyond such linear formulations of cause and effect in the western world (see Faludi’s works again). He says there is not very much we as individuals can do about it, but really the argument about self-actualisation is clear for the rest of us: self-efficacy is a vital component of modern psychotherapeutic care. Let us take the Lawrence Diller approach, or the William Miller approach to self-efficacy in Motivational Enhancement Therapy, now showing at a drug rehab unit in your neighbourhood. In brain injury for instance, we know that therapeutic enhancement of a sense of self-efficacy is vital. Patient’s have to know that what they can do CAN make a difference, the Festinger cognitive dissonance pressure is too much otherwise, and leads to resistance and sustained distress-laden attempts to reduce the level of distress, by, e.g. social withdrawal or substance abuse. We are not setting out to make the patient “doubt the validity of our own experience” (pg 344), this would be the opposite of self-efficacy and attempts to address an imbalance of social capital. Too much contradiction here which I did not find a good explanation for in my reading and re-reading around this point. He doesn’t define self-efficacy. Empowerment is another word I could not find in Smail’s four books in these two volumes.
Likewise, I felt his discussions around will-power and morality in the opening pages of the early 400’s lacked the elegance of a writer such as Carol Gilligan, who discussed so fluently the social determinants of different moral voices, eschewing as she did the biological determinist model that Smail didn’t like in the preface (was it only 700 pages ago???).
Sometimes his discussions can be downright irritating, such as on page 89. From a reasonable discussion of feminism and its impact on the individual, personal-political agenda, we meet Pam. Pam has had pills and ECT for depression:
There is nothing really wrong with Pam. For one reason or another her parents failed to communicate some essential forms of feeling to her. They didn’t (no doubt for the best of motives) want her to be hateful, so they never taught her how to hate, or what hatred was, thus left her all alone with a feeling which is just a terrifying mystery to her…..but the failure….never was inside her. It was a failure of form. (page 89).
I thought he just said it was a failure of parenting, oh, so it was a failure of her parents, there clearly was something wrong with THEM. Good, I am glad I got that straight.
Apart from parent bashing, he can also make wonderfully reductionistic and at the same time sweeping statements:
Socially, politically, recreationally, intellectually, educationally, and academically, in every sphere and department of life, it is towards money and its power that our conduct is orientated (“Why therapy doesn’t work”, page 259).
Okay, now I get it, the love of money is the root of all evil, we are all envious of penises/Porches and the social advantage that possessing one gives the owner. So we get ill when we can’t get with the programme at the local health and racket club, so, unable to hate the guy with the Beemer, owing to mom and dad forgetting to send us to Hate 101 at college, we become ill and visit the shrink, who, ignorant of social capital, makes us happy that we were, with G-d’s help, born poor and stoopid, and that is not a good thing.
With all due respect to the author, apart from hardly being revolutionary philosophy, this is not really giving its due to the wonderful intricacies of human drives and emotions, and certainly Maslow would try and be a tad more philosophical about all of this.
So why should we rush out and buy the Smail 2x4, when we can’t afford the 4x4 with which we are obsessed, owing to the social determinants of advertising and sex?
Well for many reasons. Smail is angry about something, but I am not sure what. His parents taught him to hate, everyone’s a critic, me included. In doing these four books, and in getting Robinson to publish them, he is offering the narrow minded and blinkered amongst us to get with the programme and think about the process of what we do, not just the content of what we do. In juxtaposing the four volumes into two thematically, despite the dated-ness of some of this, he does make the arguments accessible, and this is a good thing. He is asking us, and then instructing us, to think outside of the room, and outside of the brain, a good thing. He is asking us to understand that what we do does work, but we are not doing the work we think we are, this is good too. If we stand aside, as we all should, and look with a jaundiced eye (this I got from my mum, not hatred, that I got next door), then there are remarkable social determinants of psychopathology, real causes, if not THE real causes.
Every abused and battered woman and child has a keen idea of what social capital means, every psychiatric patient labeled with something or other from the DSM-IV-TR (with mag wheels) knows what power and control are all about, but only if they think, and Smail’s gift is the wonderful breadth he manages, albeit with only stabs at depth, and that will make patients and naïve professionals, think, think, think.
None of us on these webpages lacks cynicism, none of us is naïve, all of us, watching the dialogues that wander across our screens, are aware of how dreadfully imperfect we are.
But every day too, I come across patients who have suffered along in grim silence with diagnoses and treatments that do not make sense, who have spent their lives in awe of our novel science, within which we have abandoned so much of our medical, Talmudic thinking, and for all of those, these four books in two bindings are an absolute must. Who cares if he is not perfect? Smail is ‘agin the government and we need him and his ilk to keep us honest. Smail, “The nature of unhappiness, page 462:
The whole point of this book has been to emphasise the fact that we are all in boats not of our own making, and hence that there are other ways of understanding personal distress than merely seeing it as the kind of failure to cope with, or ‘manage’, our personal life and relationships which is best addressed by some variety of therapy or counselling. It is not only far truer, but also, I think, more productive, to see psychological distress as an indication that there is something wrong with the world than it is to interpret it as a sign of inadequacy or deficiency of the self. This is not a cop-out, and in no way absolves us from the struggle. It just indicates that our struggle should be directed at other targets than our ‘selves’.
In another book: “It is simply too much to expect people to take on the moral burden of their own suffering, however much therapy we may offer them” (“Why therapy doesn’t work”, page 445).
I would like to see David Smail take on the concepts of self-efficacy and empowerment, social capital and self-actualisation, in the modern day, and in a new set of books. I would indeed buy these new offerings, not for the likely academically-intense nature of their philosophical arguments, he is not Susan Faludi after all, but because they are still important training for the uninitiated patients and naïve therapists. If these consumers take up these issues with us in therapy, we will all be better for it.
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© Roy Sugarman.
Sugarman, R. (2002). Review of Why Therapy Doesn’t Work and What We Should Do About It and The Nature of Unhappiness by David Smail. Human Nature Review. 2: 402-405.