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In the process therapy was jolted out of an orientation towards increased personal autonomy and enhanced levels of well being, and was converted into a psychic Band-Aid intended to return the worker to the shop floor or the office suite at the lowest possible cost. Patients began to cycle through therapy, authorized to receive treatment when in significant distress, but only until a barely optimal level of production could be re-established, with an increasing substitution of pharmacotherapy for psychotherapy. Once "stabilized" the third-party payments dry up, until the next crisis. Client/consumers are treated like so much machinery, receiving periodic maintenance and tune-up. Given the change in the nature and purpose of the therapeutic relationship, it is not surprising that severe erosions of confidentiality and privacy accompanied it. In addition, standards of care were recalibrated to the new economic mission, resulting in forms of practice which would have been deemed unethical only a few years earlier. In the process, the practice of psychotherapy has altered radically. Deeper structural analysis prior to striking this Faustian bargain could have at least ameliorated this degradation, providing a more conscious entry to the system of industrial and corporate production, allowing for negotiation of more beneficial modes of operation.
Given the assaults of managed care on psychotherapy it is vital that we look at the structure of production/consumption under and through the Internet in deciding whether psychotherapy should ally itself closely with the medium. At the first level, this allows us to anticipate what is likely to be a revolutionary change in the relation between therapist and client, which will occur regardless of our actions as therapists. This involves the power dynamics of the therapeutic relation under the new regime of consumption. While client empowerment is valid, and vital to the therapeutic process, power per se is not necessarily so. The question as to whether the prospective changes bode ill or well therefore needs to be addressed. The deeper issue is how far we wish to go in converting ourselves into net providers.
The New Client-Consumer
Several weeks ago, I was involved in a discussion with several postmodern practitioners concerned with how they could deconstruct their role as expert/authority for their clients. The issue of therapy over the net was raised. At this point it was observed that they need not agonize over their deconstruction-their clients will be only too happy to do so in the course of the next decade, particularly if therapist's go on line. The stock market is a good case study of the Internet's role in the deconstruction of expertise. The ranks of brokers have been decimated, as individual traders have become their own experts, using the twin engines of the new economy, computers and telecommunications. These new traders have cast the old rules of trading overboard due to the speed with which massive numbers of small self directed traders are able to swing the market with almost unprecedented volatility. The damping mechanisms previously institutionalized for containing oscillations have been seriously undermined. The basis for all the foregoing is access to markets, information and quick communication. These same factors will be brought to bear on the therapeutic relation in the near term.
One may argue that therapy is different, we will not meet with this anarchism of the unbridled free market, as our assistance is being sought for more arcane reasons, where the subject's problem is opacity to the self, skewing the ability for simple information to provide assistance. Ask a medical doctor what she or he thinks of that argument. Increasingly patients are appearing at their doctors' offices with reams of internet "research", and a tentative diagnosis, in hand, frequently accompanied by suggested or demanded treatment protocols. Some doctors, unable or unwilling to practice under such a system, are leaving practice. Others are adapting, and have been thrust into the position of collaborator rather than expert. This all happened without any need for the profession to deconstruct itself. As with the stock market, rapid access to large quantities of data and the marketplace of service providers resulted in a consumer revolt. Again, this is not to say that such collaboration is a negative, and in fact, there are significant positive aspects. However, the shift does not stand in a vacuum, and many revolutions eat their own young. So who is this new consumer?
The end of the Fordist economy of mass production in the 70's gave rise to the boutique economy of the present, with increasingly fragmented markets that are intensively cultivated, supported by techniques such as just-in-time production and distribution. These rely upon telecommunications and computers. On the net, the individualization of consumption is maximized. For example, when I hit the hypertext for an author or book in an item I am reading on the net, it is a common occurrence for me to be shunted to Amazon.com, where I will be personally greeted, and my one stop shopping icon will appear on the screen. The shift is instantaneous, and happens in some timeless/spaceless domain where, for example, a site at the University of Texas, Austin, Amazon and I all share a singular position in cyberspace. In this process the world "virtually" caters to me, trying to anticipate my every desire, in a domain of condensation and displacement outside the strictures of "normal" time and space.
One is likely to have residual tendencies towards narcissism and omnipotence reinforced by a steady diet of these occurrences. And steady diet there is. Similar experiences occur on a minute to minute basis, as the ever increasing rate and speed of consumption is driven by producers who utilize computer and communication technology to "individualize" the marketplace for each consumer. The promise that you will "have it your way" begins to become a reality. Is it this illusion, this narcissistic inflation, that is driving some patients in their demands that medical doctors simply ratify and prescribe their personal treatment plans, that is driving stock prices to stratospheric P/E ratios?
Under these conditions it is to be expected that as a therapist I am going to encounter a number of prospective patients suffering from this culturally reinforced narcissism, or, as Marcuse put it, repressive desublimation. A banner in a Nike store last December with the exhortation, "Want It! Buy It!", is illustrative of the bold pervasiveness of the reinforcement of narcissism in our culture. A number of our future clients, shaped by these cultural forces, are likely to demand a strong hand in diagnosis and treatment planning. They will not be culturally well acclimated to the frustration of wishes or delay in attainment of desires. The ability to form a therapeutic alliance under these conditions will be exceedingly difficult. In effect, much of our future caseload will resemble persons with serious personality disorders. They will come to us after having researched available therapists (market survey), probable diagnoses, and treatment models (product specifications) in hand. They will be used to getting their demands as a commodity consumer met, and our conversion to commodity status has already occured under managed care. Dissatisfied with one commodity they will seek another without hesitation. The result is that competent, ethical practice becomes ever more difficult. This has already begun to happen with attorneys and medical doctors. There is nothing inherently immunizing about the practice of therapy.
If you wonder if I am exaggerating the impact of the new zeitgeist of narcissistic consumption, consider the rising incidence of road rage. The term is serendipitous, for like other forms of rage it is narcissistically grounded, arising out of the belief that I should not have to share the road/world with others, but am entitled to swift and easy ingress and egress from any point on the map. Should another object impede my progress, or "attack" my sense of entitlement, the reaction is swift and powerful, aided in extreme cases by the mechanical body of a car or firearm. This growing phenomena speaks to the virulent, and ultimately destructive, institutional inculcation of narcissism with which I am concerned.