Dehumanizing Therapy
I have been reading several books on the practice of psychotherapy this week, and have been struck by how the changes in that field parallel those in the university. In both, there is a good deal of cheerleading about increasing ‘diversity’ and access by the ‘marginalized’ which masks the ever greater encroachment of external corporate control (via an administrative class) over both the choices of individual practitioners and the values and structure of the field as a whole. Therapists have lost autonomy not only in determining how to work with their clients, but also in understanding what psychotherapy is meant to be. In both cases, corporate demands for efficiency and cost effectiveness have fundamentally altered the nature of the profession.[1]
Kottler, for example, notes in his book On Being a Therapist that “the climate for being a therapist has changed so dramatically that the field is all but unrecognizable to those who began their careers … 30 years ago.”[2] He, like those in the academy, begins by noting what he takes to be the moral progress achieved by this change. In the past therapists dealt primarily with white upper and middle class women, but now psychotherapy serves “more indigent, immigrant, and working class clients.”[3] Kottler explains that
“Whereas once upon a time therapists followed Freud’s lead of specializing in the so-called worried well or the neurotic middle class, we now reach a far more diverse population, representing every conceivable cultural, age, ethnic, racial, religious, socioeconomic, and sexual orientation background. Whereas it had once been the case that therapists must master the intricacies of a handful of different theoretical orientations, with increased blending and integration of models into more pragmatic, evidence-based practice, it is now just as important to learn the unique and most significant aspects of the various cultural backgrounds of our clients.”[4]
But under the smokescreen of this seemingly positive shift, there has also been a fundamental loss of autonomy for both the psychotherapist and the client. It is, for instance, telling that this shift towards diversity over the last 30 years has come from the top down through the demands of those controlling professional organizations and accrediting agencies. One can see this in Kottler and Carlson’s description of this shift, in their book On Being a Master Therapist.
“In the past 30 years, therapists have been mandated by their ethical codes and professional roles to adapt their work to become responsive to clients who represent minority groups, and especially those whose cultural values are quite different from the privileged. There has thus been an overwhelming emphasis on issues related to cultural diversity and client ‘differentness.’ We are expected to adjust our roles and responsibilities, not to mention our approaches, to make them better suited to the context of each client’s experience. We are required to demonstrate particular ‘multicultural competencies’ that highlight skills and knowledge that are most appropriate for members of certain backgrounds. This has led to all kinds of impressive innovations that have finally made the helping professions accessible to a much greater number of potential clients. Although there is a long road ahead in this regard, there is still an overarching and pervasive movement to increase our sensitivity and awareness of cultural differences and how they influence client worldviews, self-narratives, and behavior. That is why most professional conferences, scholarly journals, invited papers, accreditation reviews, curricular standards, and licensing requirements now mandate that participants demonstrate clearly that they have met the standards for responding to diversity issues.”[5]
The shift has been mandated in the ethical codes of professional organizations, in accredited educational programs, and even in licensing.
And these professional mandates are just one of the more minor encroachments on autonomy of therapists and clients. Perhaps one of the most brazen examples of this is the fact that now “many caseloads are filled with court-ordered and involuntarily referred clients.”[6] Likewise, therapists are now supposed to treat an ever widening scope of problems such as domestic violence, substance abuse, and sexual identity (which have not been “particularly amenable to therapy in the past”) and to do so in considerably less time.[7] “Whereas long-term therapy once was measured in the span of 5 to 10 years, not it is often restricted to the same number of months or even weeks.”[8] This shift has been exacerbated by the growing reach and influence of the insurance industry. Kottler observes
“Managed care has completely restructured the ways we operate as therapists, not only limiting the time we spend with clients but also dictating what sorts of things we are permitted to do. In most managed care situations, the course of treatment is strictly limited, and any extension of allowable number of visits must be approved by some external authority. Everything is about accountability, empirically supported evidence-based treatments, and measured outcomes, all within specific time parameters.”[9]
How long a patient stays in therapy and what his or her treatment should consist in is now decided neither by therapist nor client, but by the policies of a corporation.[10]
JoEllen Patterson speculates that in the future individual practice will diminish in importance, and that therapists will work as parts of health care teams (teams properly managed by the health care and pharmaceutical industries).
“Providing quality care for common problems in the least expensive way will be fundamental to the new healthcare organization. Family therapists are likely to practice on a team with clinical psychologists, psychiatrists, and primary care physicians in order to address the healthcare needs of a population. The closer the family therapist is to the primary care physician, the better a biopsychosocial approach to healthcare can be maintained.
When the primary care physician and the family therapist work together, a greater efficiency of care will augment service delivery. New models of integrating mental health providers with primary care physicians could flourish. …Most models of collaborative care share a problem-solving focus, are brief (five to seven sessions), and may or may not include psychotropic medications as part of the treatment.”[11]
As a result, the family therapist will need to hold “treatment efficiency, effectiveness, cost, client satisfaction, utilization, and access” as primary concerns.[12] This will, Patterson admits, result in a loss of autonomy for the therapist.[13] Like professors being beholden to administrators looking at student evals, therapists will need to prove their effectiveness by returning client satisfaction reports which “can be measured using brief questionnaires”.[14] In the therapist’s office as in the classroom, the customer is always correct, so long as the right people can extract profit from him or her.
In both fields we see an elimination of the genuinely human dimension of the profession and the institution of a corporate machine. Psychologists and teachers are now thought to be human algorithms delivering the approved “best practices” when confronted with the right stimuli. The ultimate goal, it seems, is to ready the fields for automation so that the human element can be entirely eliminated. We already have some therapy apps, and it doesn’t take much imagination to envision a day in which, 1984 style, phones monitor behavior and recommend through AI “proper” psychopharmacological interventions to ensure maximal output from workers.
We thus see working itself out in psychotherapy the exact opposite of what earlier practitioners such as Viktor Frankl intended. He warned that the atrocities that he suffered in the camps in WWII were “ultimately prepared not in some Ministry or other in Berlin, but rather at the desks and in the lecture halls of nihilistic scientists and philosophers.”[15] This nihilism, he claimed, was expressed in their defective view of man, one which reduced him to “the product of heredity and environment…of blood and soil.”[16] If Frankl believed that such an animalistic reduction of man resulted in bestial war crimes, what would he think of a worldview in which man is now not even an animal but merely an abstract locus of debt in the world of global finance? Frankl had hoped to rehumanize psychology and promote what he called medical ministry, encouraging doctors to grapple with the spiritual nature of man.[17] What we have today is, in fact, the exact opposite. Medicine has not expanded to include humanity’s spiritual aspirations, but has contracted so that even issues of biological health have become subservient to the demands of financiers.
Heidegger was prophetic when he spoke of these demands as implicit in the essence of modern technology:
“The revealing that rules in modern technology is a challenging [Herausfordern], which puts to nature the unreasonable demand that it supply energy which can be extracted and stored a such…A tract of land is challenged in the hauling out of coal and ore. The earth now reveals itself as a coal mining district, the soil as a mineral deposit. The field that the peasant formerly cultivated and set in order appears differently than it did when to set in order still meant to nurture and care for [hegen und pflegen]. The work of the peasant does not challenge the soil of the field. In sowing grain it places seed in the keeping of the forces of growth [Wachstumkräften] and watches over its increase [Gedeihen]. But meanwhile even the cultivation of the field has come under the grip of another kind of setting-in-order, which sets upon nature. It sets upon it in the sense of challenging it. [Inzwischen ist auch die Feldbestellung in den Sog eines andersgearteten Bestellens geraten, das die Natur stellt. Es stellt sie im Sinne der Herausforderung.] Agriculture is now the mechanized food industry. Air is now set upon to yield nitrogen, the earth to yield ore, ore to yield uranium, for example; uranium is set upon to yield atomic energy, which can be unleashed either for destructive or for peaceful purposes.
This setting-upon [Das Stellen] that challenges [herausfordert] the energies of nature is an expediting [ein Fördern], and in two ways. It expedites in that it unlocks and exposes. Yet that expediting is always itself directed from the beginning toward furthering something else, i.e., toward driving on to the maximum yield at the minimum expense. [Dieses Fördern bleibt jedoch im voraus daruaf abgestellt, anderes zu fördern, d.h. vorwärts zu treiben in die grösstmögliche Nutzung bei geringstem Aufwand.]. [18]
Here Heidegger claims that the essence of modern technology compels us to look at Being in a particular way, to see it as always and everywhere something to be used and exploited. Something to be set upon as a standing reserve [Bestand]. One might be tempted to view this as a picture in which man stands over nature as its lord, using it for his purposes. But Heidegger claims that within this perspective, which he calls enframing [Gestell], man is himself set upon.[19]
“Only to the extent that man for his part is already challenged to exploit the energies of nature can this revealing that orders happen. If man is challenged, ordered, to do this, then does not man himself belong even more originally [ursprünglicher] than nature within the standing reserve? The current talk about human resources, about the supply of patients for a clinic, gives evidence for this. The forester who measures the felled timber in the woods and who to all appearances walks the forest path in the same way his grandfather did is today ordered by the industry that produces commercial woods, whether he knows it or not. He is made subordinate to the orderability of cellulose, which for its part is challenged forth by the need for paper, which is then delivered to newspapers and illustrated magazines. The latter, in their turn, set public opinion to swallowing what is printed, so that a set configuration of opinion becomes available on demand [um für eine bestellte Meinungsherrichtung bestellbar zu werden]. Yet precisely because man is challenged more originally than are the energies of nature, i.e., into the process of ordering, he is never transformed into mere standing reserve [Doch gerade weil der Mensch ursprünglicher als die Naturenergien herausgefordert ist, nämlich in das Bestellen, wird er niemals zu einem blossen Bestand.]. Since man drives technology forward, he takes part in ordering as a way of revealing. But the unconcealment itself, within which ordering unfolds, is never a human handiwork [ist niemals ein menschliches Gemächte], any more than is the realm man traverses every time he as a subject relates to an object.”[20]
Heidegger, in this manner, foresaw the forces working more and more explicitly to shape the world we inhabit, forces that demand ever further dehumanization. Die Wüste wächst: weh Dem, der Wüsten birgt! [The desert grows: woe to him that harbors deserts!]
Peter Yong, Ph.D.
[1] It is well worth asking the question: efficient and cost effective for whom? It appears to be neither for the client nor the therapist.
[2] Kottler, On Being a Therapist, vii.
[3] Ibid.
[4] Ibid.
[5] Kottler and Carlson, On Being a Master Therapist, 182.
[6] Kottler, On Being a Therapist, vii.
[7] Ibid.
[8] Ibid.
[9] Ibid. vii-viii.
[10] It is also worth noting for all their talk of evidence based treatment, the strength of this evidence has been called into question by the replication crisis in psychology and the biomedical sciences. See also Irvin Kirsch’s The Emperor’s New Drugs: Exploding the Antidepressant Myth and Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.
[11] JoEllen Patterson et al, Essential Skills in Family Therapy: From the First Interview to Termination 3rd ed. 280.
[12] Ibid.
[13] Ibid.
[14] Ibid., 281.
[15] Viktor Frankl, The Doctor of the Soul, xxvii.
[16] Ibid.
[17] Ibid., 270.
[18] Heidegger, “The Question Concerning Technology” in Basic Writings, 320-321.
[19] “We now name the challenging claim that gathers man with a view to ordering the self-revealing as standing-reserve: Ge-stell [enframing]….Enframing means the gathering together of the setting upon that sets upon man, i.e., challenges him forth, to reveal the actual, in the mode of ordering, as standing-reserve. Enframing means the way of revealing that holds sway in the essence of modern technology and that is itself nothing technological. [Ge-stell heisst das Versammelnde jenes Stellens, das den Menschen stellt, d.h. herausfordert, das Wirkliche in der Weise des Bestellens als Bestand zu entbergen. Ge-stell heisst die Weise des Entbergens, die im Wesen der modernen Technik waltet und selber nichts Technisches ist.]” Ibid., 324-325.
[20] Ibid., 323-324.