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Paper 3: Clinical Psychology and post modern thought.
Joe Kiff, Dudley South PCT
In this paper I wish to review recent developments philosophy, particularly in Critical Theory and establish their relevance to the work of clinical psychologists. In particular I will want to argue that the reflective practitioner model is an appropriate extension of such a view and that the model can be said to be solidly rooted in an alternative intellectual tradition, and an alternative science, that provides advantages when compared to a simple positivist scientist practitioner model.
This is an area of philosophy that has developed over the last 100 years and grown in influence in many areas of intellectual life. Initially this was a continental European development but it has made increasing inroads in the Anglophone world during the last 20 years. In a sense clinical psychology has been unusually immune from its charms for reasons that may become clearer later, and this paper may be seen as part of a necessary catching up process. Critical theory is an umbrella term that covers a number of related strands of thought addressing a postmodern sense of the world. These strands include structuralism, post structuralism, post modernism, feminist theory, queer theory etc.
At its heart is the notion that, of logical necessity, human thought is bound by the basic assumptions of any position and that useful things can be gained by thinking outside the box. It is as though, as civilisation has developed, we have reached an important stage reflecting on our own limited worldviews. To my mind the reflective practioner model is psychology’s expression of a widespread cultural trend towards greater reflexive thinking. For example, prior to the Enlightenment the worldview of most people was structured around the existence of God and the literal interpretation of the Bible. With the Enlightenment, these religious assumptions and explanations within society altered and scientific approaches gradually came to replace them. In contrasting that modern worldview, with the now post-modern world, it is argued that further fundamental shifts are currently underway within Western culture of similar fundamental importance.
Following Flax ( ) the old ‘modern’ view of psychology can be characterised as follows:
- 1. There is a stable, coherent, knowable self. This self is conscious, rational, autonomous.
- 2. This self knows itself and the world through reason, or rationality.
- 3. The mode of knowing produced by the objective rational self is "science," which can provide universal truths about the world, regardless of the individual status of the knower.
- 4. The knowledge produced by science is "truth," and is eternal.
- 5. The knowledge/truth produced by science (by the rational objective knowing self) will always lead toward progress and perfection. All human institutions and practices can be analyzed by science (reason/objectivity) and improved, as can individuals.
- 6. Reason is the ultimate judge of what is true, and therefore of what is right, and what is good (what is legal and what is ethical). Freedom consists of obedience to the laws that conform to the knowledge discovered by reason.
- 7. In a world governed by reason, the true will always be the same as the good and the right (and the beautiful); there can be no conflict between what is true and what is right (etc.).
- 8. Science thus stands as the paradigm for any and all socially useful forms of knowledge. Science is neutral and objective; scientists, those who produce scientific knowledge through their unbiased rational capacities, must be free to follow the laws of reason, and not be motivated by other concerns (such as money or power).
- 9. Language, or the mode of expression used in producing and disseminating knowledge, must be rational also. To be rational, language must be transparent; it must function only to represent the real/perceivable world which the rational mind observes. There must be a firm and objective connection between the objects of perception and the words used to name them (between signifier and signified).
- 10 As rational entities people can be persuaded to change their behaviour through rational discussion and the application of rationally scientifically derived advice.
In contrast to this model of reality and truth is a growing tradition, that has been labelled Postmodernism. At its heart is a widespread cultural critique, which concludes that we cannot know reality, and that statements of so called truth, can only be taken as statements made within particular assumptions, frames of reference that inevitably bias such statements. The most obvious example of this in science itself is in quantum physics, which has reached the point where the uncertaincy principle rules and statements about the position of fundamental particles depend upon qualities in the observer rather than in ‘reality’. But the criticism is reflected throughout other areas of intellectual life.
If we summarise the main points of the postmodern position we can list the following features:
- 1. That the self is to a degree fluid and contextual, values and attitudes paradoxical, reflecting social circumstances.
- 2. That rationality is so often complicated by emotion, if not consistently subverted.
- 3. It is not possible to make statements about the nature of ‘reality’, that universal truths seem to require ever more qualification.
- 4. That accounts of reality expounded by experts are bound within a set of assumptions that limit the relevance of their account.
- 5. These assumptions are often maintained in the interests of power and influence.
- 6. That the experimental methods of positivistic science are limited and that other methods, particularly quantative methods should be employed as tools in a tentative post modern version of science.
- 7. The emphasis in changing society or individuals is upon programs of collaborative construction of reality rather than the imposition through authority of any particular view.
- 8. In this context the flexible negotiation of the meaning of thoughts, feelings and behaviour is central to change.
- 9. We are guided by intuition rather than reason in our choice of right and wrong. Often because logic cannot deal with the mass of data at our disposal.
- 10. Language is seen as creating context, of hiding and limiting as much as it reveals. It is seen as an instrument of metaphor and multiple layered meanings that are inherent in its structure.
The advantages of a post modern background to our practice include:
The account of clients is given equal status to the accounts of the clinician. This underpins a respectful, collaborative style of working, which defuses so much of the power imbalance that traditional mastery modes of working generate. This is particularly important in a world that expects agreed individualised treatment plans that are sensitive to issues of difference. As the u-curve model suggests not all cases of agoraphobia require the same treatment. But until patients are allowed to share their stories without prejudice it is not always easy to negotiate the appropriate way forward.
That one account of reality is not valued more than another, this opens a way for clinical psychology to explore the ways other cultures help people. The scientist practioner model is not very flexible for working with people from other cultures who may have quite a different worldview and be less convinced by science. Buddhist psychotherapy and Taoist approaches can have much to say to the modern psychologist, but need to be accepted on their own terms rather than put to the sword of science.
etc The main thrust of its relevance in clinical psychology has come through sociology, feminism and the gay rights movement and what is known as social constructionism. If we take the old view that homosexuality is wrong, or that women are inferior to men. This was over turned by arguments that said such values were promulgated and maintained by power blocks within society that socially colluded in maintaining a value picture of gay men and women that boosted further the status of the members of these power blocks (e.g. straight men could dominate the job market and control the wealth and resources of the community.) Once the bluff was called and women and gay men redefined their social position and worked actively to to establish themselves in the work place, the media etc they helped to redefine their valuation within society. Such movements redefine the social reality of many of us and within the profession this changes our clinical practice.
These changes can be profound. For example when I trained, towards the end of the 70’s in Birmingham, the course was run by Feldman. One of his main claims to fame was that he had been quite prominent in the experimental study of aversion therapy. This man had actually done experiments in which he had administered electric shocks to the genitals of homosexual men when pylysthmograph readings indicated the were getting erections in response to sexually explicit pictures of men. This of course was to treat their homosexuality which was a well known psychiatric illness! etc etc, Feldman( ).
In this vignette are many of the main points I wish to illustrate about the value of the postmodern understanding to clinical psychology and by extension the importance of the reflective practioner paradigm.
Firstly we have the socially constructed definition that homosexuality was an illness. Only forty years later, not only is it not an illness, it is a perfectly socially acceptable lifestyle. This illustrates clearly how the ‘reality’ of our profession is not fixed but shifts with time. Where are Freud’s hysterics and neurasthenics? Where are monosymptomatic phobics of the 60s research? What about Mary Bolyle’s wonderful attempt to deconstruct ‘schizophrenia’? Clearly there are extreme dangers in expert clinicians unreflectively colluding in socially defining disorders, researching them and then treating them. It may make careers, give social advancement, pay mortgages, even get you jobs running clinical training courses but its not ‘reality’!
If it is not reality is it relevant? In the case of Dr Feldman’s work it clearly isn’t. Even if he and his colleagues were able to prove that aversion therapy ‘cured’ homosexual men, would any of us be interested in using the treatment in the current social context? In fact at one level it is almost a rhetorical question, which underlines the point. If we look at a less obvious example, that of desensitisation as a treatment for specific phobias we might run into similar problems. Is there such a thing as a monosymptomatic phobia? In my own practice I see them rarely. Are they the real problem, or has it been structured by society and the medical profession? This is an old question, in a slightly new guise but it refuses to go away. In my own practice I invariable reach a point with the people referred to me where we redefine the problem as one of relationships. For example a woman referred for agoraphobia may come to understand that the symptoms have helped her resolve a problem she had about leaving her unsatisfactory marriage. Having been brought up to have little self confidence and having married at 16 to escape an unsatisfactory home life she had never had to cope on her own etc
Make the point about intra personal aspects of construction of our worlds. Personality variables etc Reflexive nature of the relationship between postmodernism and psychological theory Lacan etc
Explore the power issues in the profession. The dominant rhetoric of positivist science etc, the power blocks in the universities and managment that construct our work
The importance of liberating the psychotherapists amongst us and starting the process of redefining the public face of our profession, and the way it is taught.
Pave the way for a psychology of psychologists (paper5) and re-emphasise the intellectual roots of reflective practioner view (Paper2)
This paper has clearly argued for the view that a post modern approach to knowledge and science has particular relevance to present day clinical psychologists. In particular the way such ideas underpin the developing notion of the reflective practitioner, suggest that it is possible to establish firm intellectual ground on which to build a sophisticated clinical psychology that perhaps complements and/or goes beyond the intellectual limitations of a positivist, scientist practitioner model. In the next paper in the series I will contrast and compare the two models.
- Feldman, M. P. Aversion therapy for sexual deviations: A critical review. Psychological Bulletin, 1966, 65, 65—79.
- Feldman, M. P. & MacCulloch, M. J. The application of anticipatory avoidance learning to the treatment of homosexuality. I. Theory, technique, and preliminary results. Behaviour Research and Therapy, 1 965, 2, 165—1 83.