The last few weeks have been quieter than I anticipated. I’ve been finishing my work both in my second Family of Origin group, and with the individual people I’ve been in conversation with at Jewish Family Services. Contact hours have gradually been replaced by paperwork, first for practicum, and then, in preparation for graduation, putting together my application for Registered Clinical Counsellor status with the British Columbia Association of Clinical Counsellors. The cherry blossom has come in waves in the West End, thicker than last year, and, with a lull in the COVID-19 infection rate, people have begun to emerge. The seawall, when we cycle, is already crowded with cyclists and walkers. In my final group session we unmasked for the first time, and it was to see faces that we’d only known from the eyes upwards take shape. As I write, in early April, it’s still cold, and the rain frequent, if not quite unrelenting. There’s a sense of tying up of loose ends, but of not quite being ready for the next stage of my life. A need to move slowly, to look around, to live in the moment, but not absolutely grind to a halt. As my Chinese teacher would say to me, all those years ago in a very different Vancouver, 不怕慢,就怕站 – don’t be afraid of going slowly, but do be afraid of standing still.
Yesterday I had my last counselling session, and my last class at UBC. I’m still processing the experience of practicum in a variety of ways: through reflection, through writing microfiction on the counselling process, and also through reading. In the last month I’ve finally had a chance to read up on sociological and anthropological work, as well as individual testimony, that looks critically at the “psy disciplines” of psychiatry, psychology, and psychoanalysis, and how their rise is connected to contemporary regimes of the self under neoliberalism. It’s something I’ve promised myself for a long time: a much deeper dive into the wider politics of what I’m doing, before I return again to practices of care.
I’ve been reading a lot, especially Nikolas Rose’s foundational Foucauldian Inventing our Selves: Psychology, Power, and Personhood of how psychiatry, psychoanalysis, and psychology are instrumental in the creation of our contemporary regime of self. I’ve followed Rose into his later work, and to writings by Elise Klein, China Mills, Alan Sugarman, and Glenn Adams (there’s only space to list first authors on multi-authored papers here) which focus on the imbrication of neo-liberalism and “psy-expertise.” As ever, this post is something of a placeholder for future reflection, but I thought I’d also include a mini-review of one book that I read that I found particularly thought-provoking.
As its title suggests, Horwitz’s DSM: A History of Psychiatry’s Bible covers the full story of the Diagnostic and Statistical Manual of Mental Disorders from its relatively unheralded first edition in 1952 through to the ongoing contests over its fifth edition today. In reading Horwitz’s book, I discovered much about my own education’s place within a history psychotherapy and counselling, and the fact that the current dominance of scientific paradigms drawn from medical models is only a relatively recent phenomenon. The first two DSMs, Horwitz notes, were largely influenced by what he calls “analytically oriented models” which relied on psychodynamic theory and practice and did not have the wide social role that later editions had. A crucial change came in DSM-III, which was massively expanded, and which attempted to define each mental disorder in terms of observable and measurable symptoms, independent of a person’s life history or sociocultural environment. DSM-III-R and DSM-IV attempted to improve on individual diagnoses, but kept the conceptual framework of DSM-III relatively intact. DSM-5, in Horwitz’s account, attempted to revolutionise this framework by incorporating insights from neuroscience, and also to consider a dimensional way of assessing mental traits, in which people would be placed on a series of continua rather than being given a single, or a number of diagnoses. Yet its failure resulted in a manual that is riven with conceptual contradictions.
Horwitz, however, concentrates not simply on the contradictions within the DSM, but extends this to a discussion of how the manual has become socially embedded. The first layer of the DSM’s social world is a struggle between researchers and practitioners of psychiatry and psychology, and various professional disputes, but the social context of the manual extends far beyond disciplinary issues. One key effect of the DSM—III’s gaining “hegemony,” in Horwitz’s terms, is that it became caught up in a much larger social world. DSM diagnoses became much more important for drug companies, who would often market a specific medication as treatment for a specific condition: benzodiazephnes such as Xanax, for instance, for panic disorders and later selective serotonin reuptake inhibitors such as Prozac for major depressive disorder, which in itself was a new disorder that amalgamated two previously distinct conditions. Not surprisingly, diagnoses for depression increased massively after the publication of DSM-III in 1980; in Horwitz’s account, depression as a condition was extracted from the context of individual lives, and antidepressants marketed as a cure for socially-embedded problems such as “empty nest syndrome” (105). Such pressure had the effect of essentially medicalising normal character traits such as shyness, by first identifying them as social anxiety disorder and then specifying pharmacological treatments.
Horwitz notes, however, that social use of the DSM did not just come from above, but also from below. Feminists pushed for recognition of posttraumatic stress disorder (PTSD) and multiple personality disorder (MPD) as a means of illustrating the effects of abuse. MPD also entered popular culture: Flora Rheta Schreiber’s Sybil: The True Story of a Woman Possessed by 16 Separate Personalities was a bestselling book and then a movie. It was later found to be to a degree fictional, but in the meantime MPD diagnoses had massively increased; a discomfort with this led to the reformulation of MPD as Dissociative Identity Disorder in the latest DSM. In my own work, I’ve found that clients will often self-diagnose with a disorder found in the DSM. In many ways this gives strength: what might have previously been seen as a character failing is now revealed to be a medical condition. What’s intriguing to me, and which Horwitz doesn’t fully explore, is how this is bound up with a politics of identity as resistance in contemporary global societies: psychiatrization from below, in Timo Beeker and his co-authors’ words, which carries with it both strategic possibilities and pitfalls, and is simultaneously resistant and complicit.
Where am I and the practices of care I am part of in all this? As I’ve written earlier in this blog, many counsellors and psychotherapists distinguish themselves from a medical model and, as Bruce Wampold suggests, see themselves as practitioners of a healing art. For many people I’ve been in conversation with, their encounters with systems of care have consisted of a brief appointment with an overworked psychiatrist, and then the prescription of medication. Whatever you view of the efficacy of medication – and there’s an intriguing new article regarding depression here that suggests the effect is small, and may actually result from unblinding in trials – it is clear that systemic issues in health care privilege such medication over other forms of care. Our sessions together, they say, is the first time they have been really listened to, rather than talked at. Approaches such as narrative therapy or feminist counselling go further in that they are consciously non-pathologizing, and address the whole person: they move beyond theories of the self to think about how the self is bound up in society. And yet, for me, it’s perhaps not so easy as it seems. The counsellor still dispenses expertise – “psychoeducation” as we’re encouraged to call it. And even narrative therapy, with its poststructuralist roots, seems often to simply replace one thin social narrative with another, preferred one: a woman who feels her life is a failure, for instance, externalises bulimia as a problem by establishing a narrative of power through her motherhood. That’s a better narrative, but it’s still a socially embedded one, and the therapist still makes a diagnosis and exercises judgment. And narrative therapy’s appeal to Foucault clearly also establishes a new hierarchy of expertise. Few narrative therapists have read Foucault in great depth, and so his work assumes an almost scriptural authority — it’s a sacred text held in reverence by the therapist and a shadow presence at best for the person in therapy.
My provisional solution for now is to begin to think more of non-directive and non-diagnostic forms of therapy, in which the therapist is genuinely decentred. Group work and peer work are two possibilities here, and a further one is making use of narrative thought, following Jerome Bruner’s concepts, in a genuine sense, in simply allowing the ability to retell a life story, and offering resources for people to do so, something that is therapeutic without fully presenting itself as therapy.
I began this blog by reflecting on a tension between critical and therapeutic knowledge. That tension’s still there for me, and always will be, but it’s a generative tension. In the next few months I’ll travel again, in a world which is beginning to open up again. I’ll be in the UK, and then for much longer Singapore. I’ll be thinking critically, writing, figuring out the trajectory of this later part of my life. And then, after a few months, I’ll return to counselling again.