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The therapeutic society

Misanthropic prejudices lie at the root of today's victim culture.

Dr Michael Fitzpatrick

Topics Politics

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From humanitarian interventions in international conflict situations to welfare initiatives at home, a therapeutic ethos now dominates relations between the state and its citizens. But far from empowering people, the therapeutic state promotes victimhood and diminishes individual autonomy.

The despatch of counsellors to visit 24 people who may have been exposed to a theoretical risk of Creutzfeldt-Jakob Disease (CJD) at Middlesborough General Hospital is a typical initiative of the therapeutic state (1).

Officials in the Department of Health overreacted to the (highly remote) possibility that CJD had been transmitted by seeking out these individuals and offering them ‘support’ – lifelong if necessary. They believe that counselling would help them cope with the information that they might – but more likely might not – over the next 30 years, experience symptoms of this untreatable neurodegenerative disorder.

Given the popular impact of the therapeutic ethos, one could expect that most of the 24 would, rather than sending these emissaries of doom on their way, welcome them and play out their designated role as victims in this contemporary psychodrama. A visitation from a counsellor is all that it takes for an active citizen to be transformed into a victim, in perpetuity.

In the interaction between an insecure government seeking to show authority and concern and vulnerable individuals craving recognition and reassurance, mediated by professional counsellors, the Middlesborough incident reveals the fateful dialectic of the therapeutic society. When UK prime minister Tony Blair claimed the 24-hour telephone help-line NHS Direct among the greatest achievements of his first term, he signalled the centrality of cultivating a therapeutic relationship between government and citizens to the New Labour project.

NHS Direct provides a symbolic link between the weak and helpless individual and a state keen to offer ‘support’ – so long as this support does not imply any commitment to provide resources or services.

A number of commentators have drawn attention to the increasing role of ‘psycho-social’ initiatives in Western intervention in wars and disasters in the South – and in conflicts closer to home in the former Yugoslavia and Northern Ireland (2). In her critique of ‘therapeutic governance’ – based in part on studies of programmes in Kosovo and interviews with refugees from Bosnia and other parts of the former Yugoslavia – Nottingham University lecturer Vanessa Pupavac notes that ‘the psychological state of war-affected populations has come to the fore in international policy’. Looking further afield, Pupavac observes that ‘trauma is displacing hunger in the West’s conceptualisation of the impact of wars and disasters in the South’ (3).

The presumption underlying psychosocial intervention is that war traumatises entire populations, producing universal psychological damage, leaving deep emotional scars that predispose the affected society to enduring cycles of violence. This tendency to ‘pathologise distress’ is apparent in the uncritical application of the diagnosis of ‘post-traumatic stress disorder’ (PTSD) in such conflict situations.

Thus psychiatrist Derek Summerfield cites a survey conducted by Médecins Sans Frontières in Sierra Leone, using a checklist of symptoms drawn up in Western clinics, which concluded that 99 percent of the population was suffering from severe PTSD. Yet, as Summerfield indicates, ‘features of PTSD are often epiphenomenal and not what survivors are attending to or consider important: most of them remain active and effective in the face of continuing hardship and threat’. He concludes that ‘uncritical use of PTSD check-lists generates large over-estimates of the numbers needing treatment’ (4).

For Pupavac, ‘the cornerstone of the international psychosocial model is its assumption of the vulnerability of the individual’. Whereas in the past psychiatrists had assumed a society of robust and resilient individuals and sought to diagnose individual susceptibility to psychological disorder, the PTSD approach assumes universal vulnerability.

The diagnosis of universal psychological morbidity justifies psychosocial interventions at the population level. These take the forms of trauma counselling, peace education programmes, peace and reconciliation projects and self-esteem building initiatives: children and women, who are deemed to be in greatest need of such interventions, are particular targets. These services are generally delivered through non-governmental organisations (NGOs) such as the Red Cross, Oxfam, CAFOD and Save the Children. These groups often operate under the supervision of various United Nations (UN) agencies, if not under the auspices of some state authority.

The best that can be said of such psychosocial interventions is that they are likely to be ineffective. Recent research suggests that counselling or debriefing after distressing experiences may lead to worse outcomes by undermining people’s own coping strategies (5).

As Summerfield comments, ‘health professionals should beware of looking at responses to war through a Western medico-therapeutic prism. “Recovery” is not a discrete process: it happens in people’s lives rather than in their psychologies’.

More importantly, this kind of psychosocial intervention treats the subjects of initiatives as ‘half savage, half child’ – in the words used by Rudyard Kipling to characterise the targets of an earlier, but analogous, colonial discourse. Treating people as psychological casualties means diminishing their autonomy as rational individuals – it implies a denial of their capacity to act as responsible citizens.

Hence psychosocial intervention justifies the assumption of political and civil authority in these areas by Western powers. ‘Effectively, the psychosocial model involves both invalidation of the population’s psychological responses and their invalidation as political actors, while validating the role of external actors’, says Pupavac. ‘An indefinite suspension of self-government in post-conflict societies or so-called “failed states” becomes thereby legitimised.’ (6)

The suspension of civil and democratic rights commonly proceeds in parallel with the advance of psychosocial intervention. For example, Bosnia is currently being run by ‘King’ Paddy Ashdown (aka ‘high representative of the international community’) and an army of counsellors. The turnout in recent elections to an assembly whose powers have been compared to those of Britain’s schools’ parliament was scarcely above 50 percent; in similar elections in Serbia, a turnout of 45 percent meant that the vote was declared void.

It may seem far-fetched to compare advanced Western societies to the current state of the Balkans. Yet the recent congressional elections in the USA were observed by thousands of lawyers in a style strikingly parallel to the requirement for numerous impartial observers of polls in the former Yugoslavia – and the turnouts were often even lower (7).

Throughout the Western world, the advance of the therapeutic state is accompanied by the decay of democratic institutions. As the Conservative Party implodes, Britain is now in danger of becoming a one-party state, headed by a leading promoter of the politics of emotion.

A few examples illustrate the scope of the therapeutic ethos that now engulfs the political and social life of British society:

— The latest episode in the Royal soap opera recalls the impact of the life (and even more, the death) of Princess Diana in promoting the culture of victimhood and the ascendancy of emotion over reason in public life;

— The epidemic of work-related stress reveals the transformation of workplace issues that might once have been the focus of collective trade union activity into issues of personal psychopathology that are now the domain of counsellors, doctors and the courts (8);

— The concept of mental illness has expanded to such an extent that, according to estimates widely promoted by the Department of Health and leading psychiatric authorities, it now affects around 25 percent of the population. As everyday unhappiness has been brought under the banner of depression, this diagnosis alone has been extended to cover from 10 to 20 percent of the population, according to the scale used. Once people are labelled with a psychological disorder, they can be subjected to psychotherapeutic intervention or medication;

— At every level of the education system, counselling is considered necessary to overcome psychological barriers to achievement;

— Social problems, from teenage pregnancy to family breakdown, are attributed to low self-esteem requiring special therapeutic programmes.

Over a short period of time, the culture of therapy has achieved a wide reach and a deep penetration. Confessional TV programmes have popularised a vulgarised therapeutic discourse that has now become universally familiar. Yet the therapeutic culture has spread even beyond the reach of the mass media, to some of the most inaccessible parts of British society. For example, the Hassidic Jewish community, whose members continue to dress and live in the style of eighteenth century Poland (rejecting newspapers, radio and TV) now has its own counselling organisation – the Talking Matters Association. A number of orthodox rabbis have undergone training in counselling and ‘stress prevention’ and now recommend ‘talking therapies’ to their communities.

In the criminal justice system, treatment programmes are regarded as a progressive alternative for people convicted of drugs offences and are now being recommended for men found guilty of domestic violence. In the prisons, those convicted of sexual offences – even when, like many who claim they are victims of false allegations, they continue to assert their innocence – are expected to engage in counselling programmes (as a condition for early release). Whereas traditional custodial regimes were satisfied with detaining the prisoner’s body, the therapeutic regime seeks to control his soul too.

‘Debased views of fellow human beings are widespread’ writes George Williamson, a leading campaigner against false allegations of abuse (9). The prevalence of misanthropic prejudices is indeed at the root, not only of the promotion of false allegations of abuse, but of the wider therapeutic culture of which this is a particularly insidious and destructive aspect.

The loss of confidence in the individual subject over the past two decades, as a result of a combination of political and social forces, is the key to the emergence of the therapeutic state (10). The paradox of the Thatcher era in British politics was that the individual that emerged after the retreat of the welfare state and the defeat of the labour movement was not the robust entrepreneur of the Tory imagination, but the feeble victim of post-Diana Britain.

What was the key event in the demise of the old left and the emergence of the new therapeutic sensibility that became consolidated under New Labour? Some might say the defeat of the miners’ strike in 1984/5 or the collapse of the Eastern Bloc in 1989/90. In retrospect, I would cite the Cleveland child sexual abuse scandal of 1987. This was the first major public controversy on this issue and it led to a public inquiry and to a series of further cases – some of which have led to the launch of campaigns against false allegations of abuse.

Cleveland was significant in that the initiative for the wholesale removal of children from their homes came from social workers and doctors influenced by radical feminism – in defiance of the local police. In the subsequent controversy, opinion polarised along familiar left/right lines, as radicals and feminists broadly supported the social services, while the local MP (a Labour right-winger), the clergy and others broadly supported the police.

The fact that feminists and left-wingers could endorse the presumption of the Cleveland inquisitors that sexual degradation was a virtually universal feature of family life in the area reflected the extent to which radicals had abandoned a humanistic outlook. It revealed that they had abandoned the politics of liberation for the politics of victimhood – a process in which feminism, which originated in the left, had led the way. (Although, for the left, Labour’s third general election defeat in the same year was a far more important event. As subsequent developments confirmed, once the left had lost its faith in the human subject, a Labour victory would not restore the possibility of social advance.)

The central significance of the degradation of subjectivity helps to explain an otherwise mystifying feature of a number of sexual abuse scandals of the 1990s: the convergence between fundamentalist religious groups and radical feminists, notably around allegations of ritualised or satanic abuse. In the Christian tradition, the concept of ‘fallen man’ or of humanity tainted by ‘original sin’ has deep roots; it can be invoked to explain man’s proclivity to commit evil deeds, and his need for redemption.

From the feminist perspective, the shift from the assertion of women’s equality to demanding special treatment for women to compensate for their subordinate status led to the reinterpretation of all human relationships in terms of abuse and violence. In some ways the feminist outlook is even more bleak than that of the fundamentalists: whereas Christians promise salvation in a future life, the culture of therapy offers only the prospect of ‘one day at a time’ recovery in a lifelong process of suffering.

Though the therapeutic society is currently ascendant, its hegemony is far from secure. The great victory won by the Shieldfield nursery workers in July 2002 was a cause for celebration, not only for all those fighting against false allegations of abuse but also for all those who recognise the dangers of the therapeutic society (11).

Critics in a number of different fields are beginning to challenge the assumptions and the activities of the therapeutic state. Taking a broad view of the advance of the therapeutic ethos is the essential precondition for successful resistance.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

This is an edited version of a speech to the conference of the United Campaign Against False Allegation of Abuse, Conway Hall, 9 November 2002.

Read on:

Child protection questions, by Jennie Bristow

Training doctors as therapists, by Dr Michael Fitzpatrick

The ‘Death of the Subject’, by Dr Michael Fitzpatrick

(1) See Infected by panic, by Dr Michael Fitzpatrick

(2) See Derek Summerfield, ‘Effects of war: moral knowledge, revenge, reconciliation, and medicalised concepts of “recovery”‘, British Medical Journal 2002; 325: 1105-7, 9 November; ‘War and mental health: a brief overview’, British Medical Journal 2000; 321: 232-5;

Vanessa Pupavac, ‘Therapeutic Governance: Psychosocial Intervention and Trauma Risk Management’, Disasters 2001: 25(4): 358-72

(3) Vanessa Pupavac, ‘Therapeutic Governance: Psychosocial Intervention and Trauma Risk Management’, Disasters 2001: 25(4): 358-72

(4) Derek Summerfield, ‘Effects of war: moral knowledge, revenge, reconciliation, and medicalised concepts of “recovery”‘, British Medical Journal 2002; 325: 1105-7, 9 November; ‘War and mental health: a brief overview’, British Medical Journal 2000; 321: 232-5;

(5) M Deahl, ‘Traumatic stress: is prevention worse than cure?’, Journal of the Royal Society of Medicine 1998; 91(10): 531-3;

Wessely, S, Bisson, J, Rose, S, ‘A systematic review of brief psychological interventions (‘debriefing’) for the treatment of immediate trauma related symptoms and the prevention of PTSD’, in M Oakely-Browne et al (eds) Depression, Anxiety and Neurosis Module of the Cochrane Database of Systematic Reviews, The Cochrane Library, Issue 3, Update Software, Oxford

(6) Vanessa Pupavac, ‘Therapeutic Governance: Psychosocial Intervention and Trauma Risk Management’, Disasters 2001: 25(4), p367

(7) See Florida syndrome, by Jennie Bristow

(8) See David Wainwright and Michael Calnan, Work stress: The Making of a Modern Epidemic, Open University, 2002

(9) ‘Pointers to the problem of false allegations of sexual abuse’, Autumn 2002, AAFAA

(10) See The ‘Death of the Subject’ Explained, by James Heartfield, Sheffield Hallam University Press, 2002; and The ‘Death of the Subject’, by Dr Michael Fitzpatrick

(11) The ‘Lessons of the Shieldfield’ was the subject of a speech to the UCAFAA conference by Bob Woffinden, the investigative journalist who played a central role in exposing this grievous miscarriage of justice. See Child protection questions, by Jennie Bristow and lRichard Webster’s website for more details

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