Therapy Futures

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* Book: Therapy Futures. Denis Postle. Lulu.com, 2012

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Description

"Therapy Futures introduces two benchmarks for therapy renewal, one is valuing love as the active ingredient of therapy and secondly, that we all inhabit a psyCommons, a thriving fountain of streetwise, savvy ‘know-how’, ‘know-when’ and ‘know-if’, through which millions of people get through life. Therapists distill expertise about the human condition from the psyCommons and sequester it in professions.

Therapy Futures tells how the psychological therapies diligently sought state backing for these professional enclosures and how this ambition failed. The case study that narrates this history is a story of ‘couch wars’, and a narrow escape from capture by a state agency.

These contests for terrain look set to run and run but do they have to?

Therapy Futures outlines an alternative, a transition that waves goodbye to professionalization and moves towards forms of psycho-practice based on inquiry, equipotency and love."

Review

Michael Riley:

"Postle’s book is about psychotherapy but it contains a back-story that should draw the interest of both organisational and identity theorists. It is a story of attrition that speaks directly to any discourse on the individual and groups. Here a bureaucratic institution and an organic network do battle over attempts by the former to conjoin the classification of psychological distress with occupational specification.

The social forces in play, power, legitimacy and identity, are woven into a coherent narrative that raises questions as to how a Weberian entity copes when what is at stake is both unquantifiable and contested and it asks how a network, without leadership, can successfully challenge an institutional policy."

Excerpts

The Emergence of the PsyCommons

An excerpt from chapter 1.

Denis Postle:

"This article attempts to set out a new context for therapy futures. A psyCommons, an existing commons of learnings about becoming a person, how to live, love and work in the world, is proposed as an addition to other commons resources such as air, oceans, acquifers, seeds etc. While the influence on the psyCommons of institutions such as politics, law, civil society, religion, media, and commerce is acknowledged, the article focuses on a re-evaluation of the ordinary wisdom of daily life, and the power relationships between this knowledge and professions’ enclosures of expertise in the psychological therapies.

In the last decade or so, as ecological and economic concerns have gained wider public attention there has been renewed interest in the notion of the commons, rediscovered as a sector of society, distinct from, but complementary to, the state and markets.

By the ‘common’ we mean, first of all, the common wealth of the material world – the air, the water, the fruits of the soil, and all nature’s bounty …

We consider the common also and more significantly those results of social production that are necessary for social interaction … such as knowledges, codes, information, affects, and so forth.

Michel Bauwens, David Bollier, Michael Hardt and Antonio Negri, Charlotte Hess and Elinor Ostrom, among many others have brought this to the attention of people seeking ways to protect and share common resources as varied as meadows, forests, water, academic knowledge and fisheries. Elinor Ostrom’s work included showing that common-pool problems are often better solved by voluntary organizations rather than by a coercive state. She was honoured with a Nobel Prize in 2009. The commons movement is a very diverse and world-wide phenomenon that has been greatly amplified by the Internet.

Key aspects of the collective actions that define a commons include access – who is entitled to share the commons resources, and governance – how the commons is managed, which requires trust and shared power. Another factor that makes the commons a relevant idea for the psychological therapies is the phenomenon of enclosure, the extent to which sectors of a commons are taken into private or corporate, or as in our present study, professional, ownership.

Over the last 100 years, a rich store of learnings about the human condition has been harvested and impounded in the professional enclosures of psychiatry, psychology, psychoanalysis, psychotherapy and counselling. One of the therapy futures that these professions could choose would be to fork away from consolidation of their professional enclosures and to find ways of opening them up to a process of power sharing – to embrace the psyCommons.


When we sit with friends and family how do conversations unfold? Through stories of our interests and needs – needs that are met, or not met – discussion draws on a collection of shared ideas, understanding, practice and knowledge about how to live life – about the human condition – birth, parenting, living together, householding and so on. Some of it may be haphazard, even hazardous, but it generally works, life goes on.

The basis of the psyCommons proposition is that this process of becoming a person, how to live, love and work in the world, is a matter of learning from experience and conversations with others about their experience. The psyCommons is a pointer to the commons of accumulated learnings about our own and others’ motivations, how we and they make decisions, and so on. It is an expertise commons that we tap into and add to, and on occasion, challenge.

The psyCommons is all around us. In caring for, and looking out for ourselves and others. In being ‘streetwise’. In being ‘savvy’ about promises and threats and prices. In making and keeping friends. In knowing when to say ‘yes’ and when to say ‘no’. The psyCommons, or more accurately, commoning, is a process, rather than a thing, a wildly diverse meadow of relationship, some of it face-to-face and skin to skin, some more distant, via wire, in rooms that are miles or worlds away.

Of course, along with direct learning from experience, the psyCommons takes from and nourishes a galaxy of sources which can only be briefly touched on here. Religions: validate some avenues of learning from experience and strongly invalidate others; education: is often preoccupied with the consumption and testing of received knowledge, while neglecting learning from experience and especially, learning how to learn; commerce: driven by capital’s insatiable need to accumulate, sells us a culture of shopping driven by advertising and marketing that generates and captures needs; the media: Internet, TV, literature, newspapers, film, art, theatre etc. are overwhelmingly shaped into tightening spirals of distilled popularity by positive feedback on what the famous think, feel and wear; and there is also the law, government and parliament. Lastly there is medicine, a catalogue of wonders but which, due to its emphasis on the concept of ‘mental illness’, casts a deep shadow on the psyCommons, of which more below.

Taken together these influences constitute a climate, an ethos, a restless ocean of values in which as psyCommons inhabitants we learn how to live, love and work. But isn’t this merely a catalogue of everything? Well not quite everything, some values are under threat.

The human potential, personal development movements and some forms of psychoanalysis have long provided the psyCommons with the means for self-directed human condition enquiry outside of hierarchical models of education, training and professional qualification. These egalitarian traditions are on the way to being eclipsed as the continuing professionalization of psychotherapy and counselling brings them closer to the state-endorsed scientific and medical professions of psychology and psychiatry.

Which brings us to ‘enclosures’, ‘the private appropriation of resources previously held in common’.9 The concept of ‘enclosures’ sharpens attention to how power is gained, held, distributed, and where and if, it is shared in a community.

Historically:

- The Enclosures … were fundamentally about bringing realms that had hitherto been exempted into the new and expanding commercial relationships that marked the growth of capitalism. Former ways of providing food and sustenance – strip farming, labour relationships based on obligation and deference, widespread access to, and availability of, common land for grazing, hunting and collection of fuel – were denuded and done away with in the name of efficiency, progress and private property rights.

Author David Bollier connects this past history of enclosures with present developments

- … by 1876, after some 4000 acts of Parliament, less than 1% of the population owned over 98% of the agricultural land in England and Wales (Bollier, 2002). Today we face an unprecedented situation where the private sector is drilling for oil in the oceans, releasing vast amounts of carbon into the atmosphere, patenting the genes necessary to cure diseases, privatizing water, and claiming seeds as its intellectual property. Its long reach now penetrates segments of society previously considered off-limits to commercial interests. This includes public education, scientific research, philanthropy, art, prisoner rehabilitation, roads, bridges, and so on.

Missing from this list is healthcare and psychology. Because adjacent to these incursions of capital has been the emergence over the last hundred years or so, and accelerating in recent decades, of public/private enclosures12 by the psychological professions. What the psychological therapies learned in their relationships with clients was distilled into expertise, knowledge assets which, as they accumulated privilege and status, were protected through claims to professional status. As a consequence, much of what could be freely and openly shared became increasingly walled off and enclosed in what amount to gated communities.

A consequence of this for the psyCommons, as with other enclosures, is the generation of artificial scarcity. Admittedly, if we know where to look, can understand the discourse, and can afford it, much of what can be written about and published from the psychological therapies is available, but this relative openness should not blind us to the scarcity behind it. The psychological professions are enclosures of persons, practitioners and their expertise, they are problematic because they create and maintain an artificial scarcity of the skilled processes of face-to-face enquiry – negotiated meaning-making and the experience of authenticity, trust and love. This scarcity is accompanied by mystification, the enclosees’ need to justify to themselves the nature, purpose and especially the necessity of the professional enclosure and its relationship to the wider community.

While there are hundreds of these enclosures of psychological expertise, the dominant groupings are those that derive from the medical origins of psychology. In psychiatry, medicine was allied with psychology in the generation of the concepts of ‘mental health’, ‘mental illness’, and the subcategories of ‘mental disorder’. An early fork in the development of psychology led to clinical psychology and its enclosures of scientific knowledge about human behaviour. Using measurement, and statistical analysis, clinical psychologists assess clients, psychiatrists diagnose and treat them. Both tend to be closely associated with bio/medical research and products of the pharmaceutical industry.

In this brief, broad-brush view, these large psychological enclosures that, perhaps unfairly, due to their integration in the NHS, might be held to be the most resistant to change, dominate the present psyCommons culture. Their ethos also overshadows the public presence of the large number of counselling, psychotherapy, psychoanalysis and psychology enclosures in the UK. However, clustered into a handful of professional associations that dominate the field, they have much greater possibilities for shape-shifting.

How is life in the psyCommons affected by these enclosures? Let’s look at them through the lenses of some generic qualities: access, governance, effectiveness, validity, and status.


Access

From a psyCommons perspective, the psychiatric and clinical enclosures create and sustain a very sharp divide between the ordinary wisdom that helps us through the ups and downs of daily life and ‘mental illness’. Their focus on pathology and disorder tends to mean that they are seen as an action of last resort, only relevant when someone has a personal crisis; as a colleague recently reported, ‘if you want to get attention from the mental health services, claim to be suicidal’. To be diagnosed as being ‘mentally ill’, which can result in a life-long stigma, is widely regarded with some horror. The divide between the mentally ‘well’ and the ‘ill’ sustains the false belief that most of the population, including psychologists and psychiatrists, never paint themselves into a corner in their lives, or are never beset by loss and grief.

While access to mental health services may occasionally be involuntary, usually it arises through referral via GPs, social workers or other healthcare practitioners. Access to psychotherapy and counselling services is also usually via referral, with direct open access limited to private practice and volunteer counselling. To summarize: access to the enclosures of professional psychological expertise typically requires a crisis. This feeds a public presumption that psychological insights are only relevant at such times and have no relevance for ongoing daily life; furthermore an expert diagnosis can inadvertently have the effect of relieving patients of responsibility, of any need for reflexivity, while reducing their participation to that of supplicant/dependant.


Governance

While the professional enclosures of the psyCommons have arisen more through accumulation than appropriation, their governance seems stuck in a previous era of patriarchal rivalry between clans, cliques and cabals. Like a client who gets stuck and says: ‘I always behave like this … I’m naturally lazy …’ the psychological professions are stuck with an archaic hierarchical view of power, and see themselves as a dominant elite, with the rest of the population in subordinate/supplicant status. The present book is an attempt to dislodge these apparent certainties and I won’t be tempted to repeat here the evidence in support of this perspective that is detailed in the case study which follows in Part II. Suffice to say that the sharply asymmetrical power relations between the professional psychological enclosures and the rest of the psyCommons continue to be reproduced in the governance of the professions themselves.


Effectiveness

The psychological professions collude with us in sustaining an unhelpful illusion – widespread in the psyCommons – that they are effective. Effective in the sense that if I have a ‘mental ill-health’ problem, then there will be specific expertise that can be applied to fix it. The dominance of the medical professions tends to mean that, too often, common human condition difficulties are met by a medical model of assess, diagnose, and treat, and all too often, treat means dispense pharma products. For example, in the UK, prescriptions for anti-depressants hit a record high of more than 31 million in England in 200613 – an indicator of the extent to which inhabitants of the psyCommons can be entranced by the promised benefits of such ‘expertise’. It is also a distraction from the development of psychological initiatives such as the public health programmes that, more than individual treatment as such, have transformed life expectancy in the UK.


Validity

Closely related to effectiveness is the validity of expertise in the psychological professions. Perhaps the most significant enclosures of the psyCommons, for instance psychiatry and psychology, are those that legally entitle professions to develop, hold, and occasionally to enforce, definitions of what is ‘human’ and ‘natural’. The psyCommons proposal is a reminder that along with this medico-scientific meaning-making, innumerable definitions of what is, or is not, ‘normal’, of what counts as a ‘disorder’, are walled off in the psychological professions enclosures. While the validity of these professional opinions is often vigorously contested, the discussions tend to be confined to inaccessible professional journals.

The dominant psychological therapy paradigm requires ‘treatment’ to be ‘evidence-based’. This reflects a scientistic hegemony in which funding for treatment is required to follow research based on randomized controlled trials and ‘meta- analyses’ of results. A process closely allied to pharma research. In a reflection of the enclosure ethos of the psychological professions, a handful of academic researchers venture forth over its boundaries and harvest data in the form of measurements of our behaviour. This is research on people in which asymmetries of professional power and privilege are diligently sustained. ‘Results’ are typically published in copyrighted professional journals, only available via subscription. Cooperative research deriving from peer relations, i.e. enquiries with people, is undervalued, and even regarded as invalid.


Status

The selection, education and training for the psychological professions in the UK tends to privilege people from white middle-class backgrounds and includes a very high proportion of women. In the last 20 years, as becoming a psychological therapist has increasingly come to be seen as a career/job option, this has been accompanied by a steady increase in requirements for academic attainment. As a government minister defined it,15 the pecking order is psychiatrists (MD), then psychologists usually (PhD), both of whom have had their status endorsed by state regulation, followed by psychotherapists (MA) and counsellors (Diploma) both presently on the way to being kitemarked by a state agency. A consequence of this hierarchy in the psyCommons enclosures is that an MA and/or a PhD costing tens of thousands of pounds, has become essential for a practitioner qualification that might result in a job. This is another factor that has sharpened the divide between the psychological professions and the rest of the psyCommons.

As the case study, Part II, demonstrates, if there is a spiralling need for enhanced status, recognition and the pay that goes with it, this can take the professional enclosure custodians into public/private postures that reveal how self-serving they are. As though tighter boundaries, higher academic requirements for qualification, euphemisms about ‘public protection’ and adherence to ‘standards’, served any other purpose than consolidating professional enclosures. Another damaging aspect of this shadow side of the professional enclosures is that they restrict practitioners to those who can survive, tolerate, (or fail to notice) the gated-community ethos they inhabit. So far as high levels of external direction shut out an internal locus of evaluation, survival is likely to mean shutting down reflexivity. Continued public enthusiasm for regulation of the psychological professions appears to reflect deep mistrust of this avid professionalism.

To again summarize, this chapter makes several proposals, among them: that the vast psyCommons of ordinary wisdom adequately sustains the daily life, love, and work of 65 million people in the UK. While it is enriched and supported by a multitude of para-psychological affinity groups and self-help facilities, the psyCommons is impoverished by the tightly controlled professional psychological enclosures of around 100 thousand16 UK psycho-practitioners. From a psyCommons perspective, i.e. from outside the professional enclosures, they support and sustain an artificial scarcity of the psychological expertise that has been learned and distilled from decades of contact hours with clients/patients/service users. There is some diffusion of what has been discovered in this work out into the psyCommons via therapy clients, however the commonly held perceptions of therapy as involving the stigma of being ‘treated’ for ‘mental illness’, coupled with the professionalized power relations between the enclosures and the rest of the psyCommons, contribute to preventing, or inhibiting wider power sharing of psychological knowledge and expertise.

These are of course headlines that could be held to merit a much longer, more detailed exposition. The task here is not however some attempt to demolish the psychological professions, rather to appeal to their generosity of spirit while pointing to some of the unintended consequences of how they manage care; to call for them to give a higher value to the ordinary wisdom that shapes daily life; to invite them to come down off the pedestal of professional status and privilege; to open up their gated communities of professional expertise; and to join with other psyCommoners in figuring out how better ways to survive, recover and flourish might become commonplace.

The identification of a psyCommons in this chapter is offered as an opportunity, a possible ‘therapy future’. If you see the value of it, how might it be embraced? There are things we can do right away:

Explore, acknowledge and value the vast range of psyCommons’ ordinary wisdom and shared power. Listen for it in daily life.

Value and support self-help/affinity groups such as 12-step programmes, co-counselling, re-evaluation counselling, ‘survivor’ groups, user groups, helplines, self-help manuals, meditation, infant massage courses, five rhythms dancing, befriending, mentoring, Social and Emotional Aspects of Learning in schools, and so on.

Take action to make porous the enclosures of professionalized psychological expertise. Open up access; make it easily available and willingly diffused and shared. Choose to publish in open access journals; add to the hundreds of thousands of books, tapes, CDs and DVDs about psychology, become a radio ‘agony aunt’. Revise the boundaries of professional therapy enclosures through finding ways of sharing power with clients and service users, perhaps by requirements that therapy clients and/or ex-clients are always included in professional governance and educational programmes.

Might there not however, be a point of difficulty here? Embracing the psyCommons could be an opportunity for the psychological therapies but will it not be seen by them as turning away from recognition and endorsement by the state? How might devotees of what we could call the ‘psyEnclosures’ respond? eIpnosis guesses that collectively they would say: “we have no problem with accepting all four of these bullet points, our liberal wing might even positively endorse them as means of extending our reach further into the psyCommons – the ‘psyEnclosures’ will still own everything of importance that we owned before – why would you doubt our interest in the psyCommons? We’d welcome this four point programme as re-invigorating our field(s).”

So far so good but wouldn’t it be reasonable to suspect that this was the voice of positional power and privilege? And speaking from a presumption of false consciousness, that the ‘psyEnclosures’ hold the power they do because there’s a widely held consensus that it’s right that they have it? In other words that power sharing should not and will not be on the professional menu? Too late. The psyCommons sends a signal to the psyEnclosures that power sharing is already here – to give only a couple of examples – around 100,000 people are in 12 Step Programmes in the UK – the Internet web-site Mumsnet – by parents for parents – has four million visits a month.

The psyCommons is not a utopian vision of what could or should be built, so much as a snapshot of what we already have; to the psyCommoners we are saying, ‘dare to know’; to the psyEnclosures we are saying step up, withdraw from further professionalization of psychological expertise – invest energy instead in its democraticization – shared power – and alongside this, undertake a comprehensive revaluation of our ‘ordinary wisdom’. Join us in the task of identifying, portraying, studying and giving voice to the psyCommons.

- the commons is one of the most potent forces driving innovation in our time. … Through an open, accessible commons, one can efficiently tap into the “wisdom of the crowd,” nurture experimentation, accelerate innovation, and foster new forms of democratic practice. This is why so many ordinary people – without necessarily having degrees, institutional affiliations, or wealth – are embarking upon projects that, in big and small ways, are building a new order of culture and commerce. It is an emerging universe of economic, social, and cultural activity animated by self-directed amateurs, citizens, artists, entrepreneurs, and irregulars.

To add a psyCommons to the existing lists of commons – oceans, airwaves, seeds, aquifers, bytes and silence – and suggesting it is in the same league, may seem an audacious step, but it is one, eIpnosis believes, whose time has come." (http://psycommons.wordpress.com/take-2-from-therapy-futures/)

Discussion

Fighting the PsyEnclosures of the Psychological Professions

Denis Postle:

"Enclosures of commons become problematic and often unjust when they involve claims of ownership:

  1. Privatised languages
  2. Sequestered knowledge
  3. Monetized relationships
  4. Social exclusion
  5. Despotic governance

These qualities tend to be strongly present (but not exclusively so) in professions such as law, the military, science, academia, medicine and the focus of concern here, psychology.

Is psychology worse than these other professions? Why is it being singled out here?

The cultures of the psy professions in the UK have been an object of study for me since the early 1990s. Lately I’ve become convinced that the psychological professions, psychiatry, psychology, psychotherapy, psychoanalysis and counselling have fenced off and taken possession of significant sectors of the psyCommons. Think of them as gated communities that embody to some extent all of the above list of five forms of commons enclosure. To put it another way, with various levels of state agency endorsement, they confidently assert that the psychological profession’s accumulated learnings about the human condition belong to them.

The professional qualifications that give access to these learnings are marketed with great attention to securing the enclosures within which they are held. Pecking orders of status, exclusivity and privilege are diligently pursued, tribalism and fiefdoms abound. In this the psy professions are perhaps no worse than other enclosure exponents except that, as I claim, their ownership distorts, disables, demeans, diminishes and makes the psyCommons less intelligent than it might otherwise be.

How so?

To argue that the psy therapies are problematic is not to deny that they are locally very valuable, and populated by caring and thoughtful practitioners. What then is problematic? I believe that the professional psy enclosures bring to the psyCommons a ‘therapy model’ of power relations, which generally privileges expertise about the human condition in a way that mirrors the ‘medical model’. Different yes but I believe equivalent in its deleterious effects on the psyCommons.

The extreme hierarchical knowledge and organisational styles in the medical universe, with its collusive handshaking with the pharma industries, still tends to makes health a matter of neglect in the first place and professional repair in the second place. And this tends to be reproduced by the psy professions. Power relations take the ‘power over’ form of expert/supplicant. Their foundation continues to be rooted in psychopathology, its treatment and alleviation. Access to psychiatry, psychology, psychotherapy is typically triggered by a crisis and therapy ends when survival or recovery has been attained.

So far so good I guess you could say. Doctors doctor and therapists therapise.

However let’s cast a glance backwards for a moment. Over the last hundred years or so there has been a huge accumulation of learnings from countless contact hours between therapists and clients as they navigated a passage through their human condition concerns. These learnings came from those of us in crisis, or those of us who had painted ourselves into a corner and felt trapped and who sought help or who found themselves with an unfulfilled appetite for joy and delight.

What happened to this learning? If we break a leg, we’d be likely to talk about with friends and family about how it happened and how it was treated. We would be much less likely to speak about our ‘mental health’ or ‘mental illness’, the outcomes, or any resolution that did (or did not) occur are unlikely to have been broadcast into the psyCommons but any generic process learning to be taken from our ‘mental illness’ treatment would have become the property of our practitioner. From a psyCommons perspective it disappears into a psy professions enclosure.

While it may seem unduly harsh to say so, the establishment of professional enclosures in the psyCommons and the sequestering in them of psy knowledge harvested from us, looks to have been a form of theft. Theft, in the sense that mining, quarrying, and oil extraction have been a form of theft from the global commons, often to the detriment of local populations. The ‘data-mining’ of the psyCommons by the psy professions looks to be a branch of this imperious culture, with an incremental growth of psy enclosures that, following the state regulation debates, has been easier to see. The notion of theft is appropriate for two reasons, as with the enclosures of common land in the UK over past centuries, the power relations have been crushingly disproportionate, think industrialized/corporate health care, ‘highly qualified’ practitioner elites, and big pharma, reciprocity/power sharing has largely been absent.

That this is more visible with hindsight doesn’t reduce the importance of this theft or data-mining from psyCommons, which has at least two important consequences. One is that due to their framing in the medical model of human functioning the human condition issues that have been historically coming towards the therapy professions have mostly arisen from people with a troubled, damaged or under-resourced life experience, and who are often in crisis. The psy professional learnings thus accumulated are overwhelmingly concerned with the recognition, diagnosis and resolution of hurt and harm and survival and recovery from them. When distilled into theory and practice concentrates, this experience tends to have a very strong bias towards deficits. The promotion of flourishing, well-being, co-creation, love and emotional competence tend to be off the professional agenda, or are dismissed as ‘emotional hygiene’.

A second problem that the psy-enclosers pose for the psyCommons is that as mentioned earlier, they have no place for shared power. Psy-enclosures arise from an approach to power relations that privileges and prioritises accumulated expertise. One consequence of which is that peer to peer relations with clients are commonly forbidden, with severe sanctions imposed where there are transgressions. The recent intense pressures in the UK towards professionalization have sharpened this boundary but might it not also be an unhelpful artefact of the general lack of peer to peer relations in the professions themselves? In recent decades progress as a psy leader has increasingly seemed to entail devising a psy enclosure and promoting it as a therapy brand. Added to this, the privileging of professional expertise tends to feed deference and undermines self direction so that expectations of professional expertise are likely to be way ahead of its capacity to deliver.

A further demeaning effect of the psy professions enclosures is that as guardians of the culture of ‘mental illness’ they attract projections of fear and dread. Thus exposure to psychological professionals is commonly regarded as something to be avoided, and not without reason, crossing the threshold into NHS diagnosis and treatment of ‘mental illness’ is likely to result in the casting of a difficult/impossible to erase shadow in our medical records. Access is scarce too; the Scottish government is currently trying to ensure that no one waits longer than 18 weeks for ‘treatment’.

What does this mean for the psyCommons?

If we come out from under the shadow of the psy professions enclosures and look at them as historical constructs it is possible to see that, through their warehousing of sequestered learnings, they have taken out a huge overdraft on the psyCommons and that it is time for this debt to be paid back." (http://psycommons.wordpress.com/take-3-paradigm-rising/)

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