Ghost in the therapy machine:

An interview with Kenneth Gergen

 

What do you believe are the key challenges facing the psychotherapy industry as we move into a new millennium?

I must admit that I would rather think of therapists as forming a community or profession rather than an industry. But at least within the US, I can well appreciate why the term "industry" might be appropriate. Many here would agree that perhaps the key challenge we now face is an economic one. How to remain viable under conditions of managed care economies, and the associated, economically driven trend toward psychopharmacology? Fees for therapy are continuously lowered or therapeutic services not covered by insurance; and the demand is increasingly for brief, and often chemically centred forms of treatment.

However, if you look at this challenge in a broader perspective, you might see it as a matter of self-definition within the therapeutic community. Will the community simply let the economic system call the shots - with all the associated bureaucracy, fee reduction, and treatment mandating that we now confront? Will the profession simply continue in its attempts to grab "part of the action" by gaining license to prescribe drugs? Or, on the contrary, is their sufficient vitality, self-regard, and creative ingenuity to resist these pressures and generate a more promising future? This is primarily a matter of self-definition - will therapy simply be an industry or can it further its definition as a unique and essential professional community?

How do you believe these challenges should be met by practitioners and by academics and thinkers in the field?

As you can guess from what I have just said, I would very much like to see these challenges answered in a way that would continue to give dignity and stature to the therapeutic community and sustain its special contributions to society. I think these latter aims can best be done by a concerted initiative in which both practitioner and academic voices are conjoined. In particular I would like to see this initiative aimed at "Defining therapy as a distinctly human process, and by this I mean a process that acquires its efficacy in a particular context of cultural meanings. Except in cases of tissue damage, the therapeutic process is not a biological one. Psychopharmacology, in this sense, must be viewed as an ancillary to human interchange - a support that under certain circumstances may render the process of human communication more successful.

However, if suffering, cure, and a fulfilling life are matters of cultural understanding and negotiation, then there is no way in which therapy can be reduced to biology, and in which one system of therapy can claim superiority over all others. Required is a range of endeavours in which therapist and client are mutually engaged in exploring the domain of human meaning - understandings of self, others, and cultural life that may be life transforming.

- Removing the existing demands for diagnostic categorisation, and enabling clients to receive therapeutic help without deficit labelling. Current practices of psychodiagnostics (i.e. DSM categorisation) represent the conceptions of psychological process shared by a small and rarefied sector of the population; they function without empirical warrant and essentially sustain the standards of "the good life" as defined by this sub-culture. Not only are these standards not shared by many other people, but to force clients into this system of representation is both oppressive and can function as a form of negative stereotyping. Increasingly these standards are being questioned within the population at large (consider for example the spate of books criticising the burdening of our children with the (Attention Deficity Hyperactivity) diagnosis, and undermining the public confidence in the profession. It is time now for the therapeutic community to move toward a diagnostic-free admission to therapy. The availability of therapeutic help should not depend on being assigned to a category of psychological deficit. Managed care delivery systems should be pressed into policies of "no fault" therapeutic care.

Removing universal criteria for measuring therapeutic outcomes, and developing alternative, dialogically based means of determining therapeutic efficacy. Because differing schools of therapy differentially define what it is to be "mentally healthy" and because these conceptions are linked to differing cultural values, there is little justification for pursuing general standards for assessing therapeutic outcomes. Imposing such standards not only functions as a form of cultural imperialism, but creates unfortunate conflict among the schools. In my view the profession would be far better served by establishing more dialogic means of assessing therapeutic outcomes. By this I mean setting in motion discussions among a number of persons representing different investments in a problem - including the therapeutic profession and others from the client 's milieu. Such procedures are being practised in Finland, in lieu of standardised diagnostics, and could well be expanded to include outcome assessment.

How do you suspect they will be met?

I am pessimistic enough to believe that a large sector of the profession will simply submit to the industrial pressures. This is Western culture, isn't it? But we also possess another Western tradition, more idealistic and opportunistic, more humanistically engaged than instrumental, and which offers meaning through accepting hardship in the service of a better future. My hope is that there are sufficient numbers of such therapists, who will conjoin with a broad range of similarly committed scholars, to form a unified and pro-active front.

Which thinkers, practitioners and schools of thought (or movements) do you believe are best placed and most likely to navigate us into a new century of psychotherapy?

If the response to these challenges is left to individual schools of therapy, I suspect there will be little success. There are so many competing assumptions about human functioning, the nature of deficit, the most effective forms of treatment, and the nature of optimal human functioning that a concerted effort is not likely to result. "Divided we fall." In my view it would be far more advantageous to locate a more overarching conception of knowledge, human understanding, and the nature of the good - a tent in which we can all gather, deliberate, and press toward action. Of course, here I turn to the dialogues on social construction as offering a resource of promising potential. From the constructionist standpoint, human action primarily issues from processes of meaning making. We act within evolving traditions of meaning; failing to do so we make no sense even to ourselves. This is the case for both our clients and our traditions of truth and morality within the therapeutic profession. In this view, there is no reason for competition among schools of therapy, no reason to "stamp out the opposition." Nor is there any reason to seek a unified form of therapy or to worry about the steady emergence of new forms of practice. In fact, the richness of the field and its capacity to change with the culture are essential to its efficacy. From the constructionist standpoint we are invited to recognise the ways in which various schools of therapy speak to various sub-cultures, and to be open to forms of therapy developing in other cultures. We may appreciate our differences, and move toward a more prosperous global dialogue. In effect, social constructionism invites unity but with an appreciation of diversity.

You have spoken of the need for "a multiplicity of self-accounts" (Therapy as Social Construction) for the postmodern practitioner. The same idea might be applied to the self accounts which the therapy industry as a whole bears. There appears to be a substantial camp in the therapy world (at least one member of which is a contributor to this feature) which is arguing for a more single-voiced, "scientifically-driven and more openly accountable" core to psychotherapy. To what extent would the therapy world, in your opinion, benefit from a multiplicity of self-accounts?

Perhaps you can see how I might answer this based on my preceding comments. Essentially I would argue strongly for multiplicity. Any singular view of diagnostics, therapy, or positive outcomes tends toward totalitarianism. It constructs the world in only one way, thus suppressing the multiplicitous traditions of the world. It is wrong to fall back on "science" as the saviour here. Scientific comparisons can only take place within a forestructure of meaning, and all such meanings issue from a particular cultural (or sub-cultural) standpoint. For example, once you have begun to tally the number of depressed patients, or the effects of Prozac on depression you have already accepted the biases of a particular sub-culture. Depression is a way of constructing the world, and it is only one way in a world of rich potentials. In effect, the research already presumes a worldview - an ontology and an ethics. I am not arguing against accountability here. What I am proposing is that insofar as possible, the therapeutic community moves toward mutually respectful, dialogic processes in determining decisions. It is within this context that the strongest hope lies for a profession that can add substantially to the distinctly human resources of the world.

Kenneth Gergen is Professor of Psychology at Swarthmore College. He is the author of, among hundreds of other works, The Saturated self (Basic Books, 1991) and, with Sheila McNamee, edited Therapy as Social Construction (Sage, 1992), a seminal work in the social constructionist therapy approach, of which he is a central exponent. More recent articles of Kenneth Gergen's can be found at http://www.swarthmore.edu/SocSci/kgergen1/recent.html.

 

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