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Systemic Means to Subversive Ends: Maintaining the Therapeutic Space as a Unique Encounter

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Systemic Means to Subversive Ends “The first duty of a revolutionary is to get away with it.” Abbie Hoffman (1971) ‘Steal this Book’. “Debunking pseudo-neuroscience so you don’t have too” @Neurobollocks (2013) Twitter Account Description Psychotherapy has become a market place for an increasing number of approaches, over 400 at last count, with wildly different perspectives on what it means to suffer and whether an approach focused on cure is possible and advisable (Cooper & McLeod, 2010). Within this market-place, Cognitive Behavioural Therapy has become the dominant approach, as has an ideology revolving around notions of ‘illness’, ‘cure’, ‘regulation’ and ‘evidence-base’. This is problematic for the critical practitioner who finds that maintaining space for more subversive approaches is increasingly difficult as an ideology that techniques can be writ on the therapeutic space in advance of the unique encounter between any given psychotherapist and patient saturate the field (e.g. Loewenthal, 2011). This chapter has a simple aim - to argue that rather than be slave to such changes, we can and must develop and train new generations to maintain spaces in the public arena for multiple approaches to storying distress and treatment. To this end, I will demonstrate how systemic techniques, influenced by Chapter submission for Critical Psychotherapy Book: Jay Watts 1
Transcript

Systemic Means to Subversive Ends

“The first duty of a revolutionary is to get away with it.” Abbie Hoffman (1971) ‘Steal this Book’.

“Debunking pseudo-neuroscience so you don’t have too”@Neurobollocks (2013) Twitter Account Description

Psychotherapy has become a market place for an increasing number

of approaches, over 400 at last count, with wildly different

perspectives on what it means to suffer and whether an approach

focused on cure is possible and advisable (Cooper & McLeod, 2010).

Within this market-place, Cognitive Behavioural Therapy has become

the dominant approach, as has an ideology revolving around notions

of ‘illness’, ‘cure’, ‘regulation’ and ‘evidence-base’. This is

problematic for the critical practitioner who finds that

maintaining space for more subversive approaches is increasingly

difficult as an ideology that techniques can be writ on the

therapeutic space in advance of the unique encounter between any

given psychotherapist and patient saturate the field (e.g.

Loewenthal, 2011). This chapter has a simple aim - to argue that

rather than be slave to such changes, we can and must develop and

train new generations to maintain spaces in the public arena for

multiple approaches to storying distress and treatment. To this

end, I will demonstrate how systemic techniques, influenced by

Chapter submission for Critical Psychotherapy Book: Jay Watts 1

post-Foucauldian theory, were incorporated into a doctoral

training programme subject to increasing pressures to mainstream.

Such ‘critical competencies’ allowed trainees to situate

themselves in an alternative story of the future of psychotherapy

- one where we ally closely with the psychiatric survivor

movement, and use ourselves as sites to question norms whenever we

come across them be that on social media or in a team meeting. I

aim to show that techniques for playful subversion of mainstream

ideas outside the consulting room can maintain room for a

practice-driven psychotherapy, and empower trainees to feel they

can influence what happens next.

Let us start with the dominant bleak story that can be heard

wherever critical practitioners congregate.

The Dominant Story

Most practitioners working in mainstream services are feeling

bleak about the future of psychotherapy right now (e.g. Quality

Psychotherapy Services in the NHS, 2013). One reason for this is

the rise of what Power (1999) has labeled The Audit Society. This

book showed how techniques which have their origin in accounting

firms have been transferred to public services. What has become

2

more commonly known as the ‘audit culture’ rests on the unspoken

assumption that making people’s activities visible is both

possible and a good thing - as if the goal for every patient was

the same and could be measured. Within the psy professions, this

audit culture has taken the form of the ‘social movement of

evidence based medicine’ (EBM - Pope, 2003). The most emblematic

example of EBM and the move to ‘regulation’, ‘audit’ and

‘evidence base’ is the English NICE guidelines (NICE, 2006) which

are positioned as the best treatment guidelines for a number of

conditions and diagnoses. Though relatively recent, these

guidelines have had a constitutive effect in the restructuring of

service provision (Flynn, 2002), and rewarded professions and

professionals who comply.

The NICE Guidelines operate through placing ‘evidence’ in a

hierarchical position in relation to professional opinion. The

move to privilege ‘evidence’ can be read as an attempt to de-

locate judgment at a time where trust in authorities is at an all

time low (Power, 1999). It is important, then, to see how they are

constructed as objective. The personal investment and lenses of

the members of the Guideline Development Groups (GDG) who write

the report, for example, are cleansed from a charge of

Chapter submission for Critical Psychotherapy Book: Jay Watts 3

subjectivity by the ‘declaration of interests’ at the front of

each document. This type of ‘discursive move’ can also be seen in

the surface recognition of the problematic construct validity of

the conditions covered in the NICE guidelines, such as ‘bipolar

disorder’ and ‘depression’. By stating a critical objection or an

interest briefly, without citations or details of critical

alternatives (e.g. Moncrieff & Timimi, 2013), the dominant

argument comes be constructed as ‘common sense’.

Yet the assumptions in such documents are hardly common sense if

looked at in any detail. Consider the archetypal diagnosis of

psychiatry, ‘schizophrenia’. As Bentall sums, and as even the

National Institute for Mental Health acknowledge (NIMH, 2013),

schizophrenia “consists of no particular symptoms, has no

particular outcome, and responds to no particular treatment. No

wonder research revealed that it has no particular cause.”

(Bentall, 1988). Or consider the privileging of Randomized

Controlled Trial design (RCT) as the ‘gold star’ of the evidence

base (Slade & Priebe, 2001). RCTS have no reliable construct to

study, do not effectively follow basic principles of ‘double

blinding’, are subject to publication bias and use participants

who cannot be generalized to real ones in routine care who do not

4

tend to have distinct problems (e.g. Guy et al., 2011; Goldenberg,

2006); Slade & Priebe, 2001). RCT design becomes even more

problematic in the field of psychotherapy where the goal of a work

is not pre-decided or pre-decidable (Guy et al., 2011), where

there is no clear distinction between therapeutic modalities (Guy

et al., 2011), where ‘researcher allegiance’ to a model and trans-

modality factors explains the variance in outcome between

different therapies (Luborsky et al., 2002) and where branded

therapies which are compared to one another are at best an

umbrella term for a number of different techniques which will not

be used on everyone, and which stem from wildly different and

contradictory epistemological groups (e.g. Herbert et al., 2013;

Richardson, 2006).

Yet any protest of the mystical, unconscious, unpredictable nature

of the psychotherapeutic encounter (e.g. Van Deurzen, 1997) are

storied as old-fashioned and non-progressive, as if a personal

insult to the governmental push of finance into EBM-fluent

services such as IAPT. Unable to work within such discourse,

critical psychotherapists are leaving the NHS in their droves

(e.g. Quality Psychotherapy Services in the NHS, 2013). However,

the problems outlined are not unique to the NHS. The voluntary

Chapter submission for Critical Psychotherapy Book: Jay Watts 5

sector, private sector and academia are also effected by the

backcloth of audit culture and the branding of therapies and the

problems that this encourages. This backcloth constructs common

sense around mental health and illness; it influences how people

approach funders, who gets funding, who gets tenured academic

positions, how private therapists advertise themselves and how the

public medicalize their suffering (e.g. Cookson, McDaid, &

Maynard, 2001).

As the worker, the skills they have, and the techniques they might

teach to new generations comes under the eye of surveillance and

regulation (e.g. Butcher, 2002), the tacit nature of

psychotherapeutic knowledge becomes more and more impossible.

Tacit knowledge does not lie in a person to be explained, but is

accrued through a ‘practice of doing’, through an ‘indwelling’

that allows us to ‘know more than we can tell’ (Polanyi, 1966: 8).

This clashes with the increasingly professionalized therapist who

has to comply with performance measurement systems whilst

maintaining some autonomy (Power, 1999). Maintaining this autonomy

becomes more and more difficult as treatment adherence measures

get introduced, CORE measurement scales are used to assess how

many of one’s patients meet certain expectations of getting

6

better, and one’s proficiency in ‘core competencies’

decontextualised from the writer’s politics and vested interests

become the norm (e.g. UCL Core competencies - UCL, 2011; Skills

for Health core competencies - Skills for Health, 2011).

Compliance with these measures effect not just opportunities for

CPD and promotion, but a chance of keeping one’s job or, if more

junior, gaining a placement that will allow one to finish a

psychotherapeutic qualification. Pressures to show ‘performance’,

‘governance’ and ‘information sharing’ are balanced by a ‘rhetoric

of support’ involving ongoing training, new jobs, continuous

professional development, and a focus on supervision which make it

difficult to protest as one is storied as getting more (e.g.

Nettleton, Burrow & Watts, 2008).

Academia is no longer a safe place for critical psychotherapists

who are subject to a demand to score well in the REF (Times Higher

Education, 2013). The REF is a relatively new way for academic

departments to be rated according, predominantly, to how many

publications their academics get in ‘high impact’ journals. The

journals which have the highest impact tend to be ones which

publish articles based on diagnostic criteria and using the EBM

starred RCT design. Such studies solidify and naturalize Big

Chapter submission for Critical Psychotherapy Book: Jay Watts 7

Pharma diagnoses and claim the distinctiveness of different

therapies. The easily demonized managers and politicians are

subject to the impossible demands of the system they have helped

create. Thus, there is a constant pressure for things to be ‘new’,

‘improving’, and ‘innovative’.

The fascination and lust for this can be seen in the public’s

thirst for neuroscience. The latest collection from the uber cool

designer Christopher Kane, by example, consists of images from

fMRI scans pasted across shirts, skirts and dresses and now

literally in Vogue. If the new was genuinely innovative and

appealing, this might be of interest. However, the history of

innovation in psychiatry is littered by discoveries which become

less effective than they initially seem to be, and it has been

persuasively argued that there has been no real progress across

psychotherapy, pharmacotherapy and service design in the past 30

years (Priebe et al., 2013). If we take the example of the

'Improving Access to Psychological Therapies programme', their

implementation tends to lead to an increase in demand at more

complex levels of service provision as the treatment is not good

enough (Cairns, 2013). Managers, commissioners and politicians,

unable to acknowledge a fundamental lack in what could ever be

8

achieved, and with jobs existing because of their perceived

competence in ‘risk’, ‘innovation’ and ‘cure’, are forced into a

complex and generally unconscious game of smoke and mirrors which

burnout staff at record numbers.

Public discourse can often reinforce this emphasis on ‘illness’,

‘cure’ and ‘disorder’, with mainstream stigma campaigns insisting

mental distress is “an illness like any other” (Link & Phelan,

2013). This biomedical insistence is partly precisely because

mental distress is a ‘contested illness’ not readily associated

with a discernible biomedical abnormality (Barker 2005; Brown

2007), and thus not taken as seriously as physical illness. The

desire to convince the Other that mental distress is an illness is

partially because of the severe lack of a rhetoric of suffering,

such that to doubt the validity of mental illness is often taken

as an attack on the legitimacy of someone’s distress. This lack of

available discourses on distress links to the history of

increasing individualism and emergence of the ‘psy complex’ (e.g.

LaFrance, 2007) across the 20th century. The psychotherapist-

fueled self-help culture, which emerged from the 1970s, has been

especially pernicious in its implication that anyone can get over

anything, placing responsibility for not doing so with the

Chapter submission for Critical Psychotherapy Book: Jay Watts 9

individual (Rimke, 2000). Lacking a culturally sanctioned

discourse of how symptoms can be manifestations of familial and

cultural problems (e.g. Lai, 2004), claiming an uber-medicalised,

diagnosable mental illness is one of the only ways to speak

legitimately without blame, and get what Parsons (1951) originally

called a ‘certificate of exemption’ from the horrors of day to day

life. This quest from the public for the legimitization of psychic

distress through medicalization fulfills the governmental drive

for consumer satisfaction. It also masks the government’s

responsibility for the social factors - from poverty to racism -

which so clearly link with mental distress (e.g. Marmot, 2012).

Is this tale of doom and gloom the only way to construct the

current moment?

An Alternative Story

The rise of the audit culture, and EBM as a manifestation of that,

can be read as an attempt to protect power for those in authority

within a culture where the traditional arbiters of truth - the

police, television, doctors, politicians, journalists, judges - no

longer enjoy the same level of trust. This is not just related to

the succession of recent scandals; rather, the societal move has

10

resulted from a a wider, postmodern, focus on moral pluralism, and

a horizontalisation of power (e.g. Haraway, 1996)1. Though notions

of ‘lack of insight’ can still shut down this voice within the

confines of a particular psychiatric care system (e.g. Harper,

1994), identity politics (Sampson, 1993), and the wider cultural

focus on the rights and responsibilities of the consumer (e.g.

Salzer, 1997) have radically changed who gets to speak about what.

The best example of how these cultural shifts benefit our work is

the rise of the psychiatric survivor voice, from the initial ‘fish

manifesto’ (Crossley, 1999) to ‘Mad Pride’ (Mad Pride, 2001), the

‘recovery movement’ (e.g. Romme et al., 2011) and service user

forums in cyberspace. The exponential rise in social media means

psychiatric survivors and critical thinkers have access to more

people than was ever imaginable. If a Community Mental Health Team

treats you badly and you blog about it, it might well go viral.

Knowledge presented as fact is now subject to surveillance and

scrutiny by critical thinkers in cyberspace. Consider

@neurobollocks (2013). @neurobollocks has thousands of followers

and troubles reports and commentary that come out dazzled by fMRI

technology. Crucially, @neurobollocks critiques both from a1 The manner in which the psy professions have lapped up the audit culture through the idea of ‘evidence’ can be storied as a way of sidestepping the considerable post-positivist critiques of psychiatry (e.g. Hanson, 1958; Kuhn, 1970 and Feyerabend, 1976)., such as post-Foucauldianism (Rose, 2006) social constructionism (e.g. Gergen, 1999), phenomenology (e.g Spiegelberg, 1972) and feminism (Ussher, 2002).

Chapter submission for Critical Psychotherapy Book: Jay Watts 11

critical perspective and from a mainstream perspective which means

his tweets are read and responded too by those in dominant

groupings. Also of note is the playful irreverent nature of his

chosen moniker which allows access to those less interested in

‘science’. It is, perhaps, no coincidence too that of all the

newspaper articles against the new DSM-V, it was the playful

parody of DSM-V as a Borgesian Dystopian Masterpiece that went

viral (Kris, 2013).

All of us have a possibility to write, link and connect with

people that cultural forces might have blocked us from contacting

even a couple of years ago. For example, editors of the

psychiatric stalwarts The Lancet and The British Journal of

Psychiatry routinely get into long debates with service users over

twitter. This is not for show; behind the safety of the computer

screen users feel able to challenge and critique in a way power

dynamics might stifle in embodied discussion (Watts, 2014). As an

example of this, one prominent professor was recently on the

flagship BBC radio programme Start the Week arguing psychology is

a science, against a philosopher of mind. Though he stuck to his

argument, after the discussion continued on twitter he changed his

position. This can lead to very real material changes.

12

Recently, critical tweeters have joined together to campaign

against the ‘Psycho’ Halloween costume the supermarket chain Asda

was selling (BBC, 2013). This led to the removal of the item, and

a public apology. Lastly, critical thinkers do not need to gain

grants or academic postings to gain the money for such activities.

The cash-starved trainee can use the social media app Kickstarter

to get tens of thousands of pounds of donations to video an idea

(e.g. Entrepreneur, 2013), the app Meetup can be used to organize

a philosophy meeting at the local pub. Conrad may have written

blistering academic papers on the sociology of mental illness

(e.g. Conrad & Barker, 2010), but I would bet - at over half a

million viewers - Eleanor Longden’s TED talk about being admitted

to psychiatric hospital as a voice-hearing 18 year old has changed

the world more (TED, 2013).

How can we incorporate some of these activities into our training

programs? Can we use them to challenge ideas of EBM which threaten

psychotherapy as a subversive site?

Power and Language

Chapter submission for Critical Psychotherapy Book: Jay Watts 13

As I hope to have shown, psychotherapy has been placed in a

vertical, and vertiginous, relation to various discourses such as

‘evidence’, ‘performance’ and ‘skills’. This vertically inferior

position is relatively new to the profession, but is one known to

most psychiatric patients, whose subjectivity and individuality

have long been crushed by discourses such as that of the

‘insightless patient who cannot be believed’ or the ‘axe wielding

schizophrenic’ (Watts, 2005). To be able to breathe, to be able to

maneuver, to be able to influence, it is crucial to have skills to

subvert the mainstream discourse, and create sites where different

thinking and feeling is possible. To theorize this, I turn to

social constructionist and systemic principles around discourse

(e.g. Gergen, 1999).

Discourse communities are “groups of people who share common

ideologies, and common ways of speaking about things” (Little et

al., 2003: 73). Bakhtin (1981: 263) argued that ‘discourse

communities’ such as psychiatry create an especially ‘monoglossic’

way of speaking, which insist on the power of the ‘authoritative

word’, and which “demands that we acknowledge it, that we make it

our own; it binds us, quite independent of any power it might have

to persuade us internally” (Bakhtin, 1981: 342). This monoglossic

14

discourse of fixed meaning is in opposition to ‘heteroglossia’

where “a multiplicity of social voices and a wide variety of their

links and interrelationships” (Bakhtin, 1981: 236) are used,

allowing ‘counter stories’ of resistance to emerge (Nelson, 2001).

Stories we tell ourselves and that we are caught within from

outside are constitutive of what we feel, and what ‘subject

positions’ (e.g. Harré, 2002) we are allowed to take up in ‘joint

action’. For example, if one is storied as insightless and thus

irrational, any communication one makes is subject to being

discarded and not heard. Thus, the positions we hold and are given

discursively “ascribe rights and duties to think and act in

certain ways work as constraints on human thought and action”

(Harré, 2002: 611).

Social constructionism is interesting on paper, but it is in using

its principles within action that it comes alive. One school of

therapeutic thinking that has done this is systemic psychotherapy,

a progression of family therapy incorporating postmodern thinking

(e.g. Jones, 1994). This approach uses the core systemic

principles of ‘hypothesizing’, ‘circular questioning’ and

‘curiosity’ (after Cecchin, 1987) to provoke heteroglossic

discourse at an individual and familial level. Interest in

Chapter submission for Critical Psychotherapy Book: Jay Watts 15

unpicking the discursive realities in which people are located is

supplemented by a concern with the relationship between discourse

and material realities (Ussher, 2002). For example, the habit of

patients being excluded from a pre-discussion of their case in

ward round would be troubled from a systemic perspective, with an

attention to what discourses make this material act appear

justifiable.

Systemic psychotherapy with individuals and their families has

some similarities with the linguistic focus of other talking

therapies (e.g. Donovan, 2003). My aim in this chapter is not to

present it as another, better, therapy for such work. Rather, my

intention is to use its principles to deconstruct the type of

discourse which prevents a patient reaching a psychotherapist in

the first place, or which has had such an influence on the

psychotherapists' ideas of what he or she should do therein that

the patient's unique experience and words are lost. There is

strong evidence that systemic principles can be used to influence

psy organizations, and the wider ‘discursive backcloth’

(Wetherell, 1998: 404) from which and through which it gets

decided who can do what. The shining example is the ‘Open

Dialogue’ approach, developed in Scandinavia to change cultures

16

around first episode psychosis. This approach emphasizes the need

for discursive challenging within the ‘micropoetics’ of

organizations (Seikkula & Olson, 2003), such as within team

meetings, information leaflets, and public communications.

Usefully, Open Dialogue has an unparalleled evidence base -

changing the culture of meetings and speech around first

admission greatly improves the prognosis after eighteen months

(Seikkula et al., 2006). This is generalizable to the English

context for research shows implementation of even a colossus like

the NICE guidelines is subject to social and political influences

at the micro as well as a macro level (e.g. Spyridonidis & Calnan,

2011).

A Critical Training in Mainstreamed Times

To show how this might work in practice, I will outline some ways

in which systemic thinking was added to a doctoral training

programme in counseling psychology just prior to a first Health

and Care Professions Council (HPCP) accreditation, after years of

pressure to mainstream the curriculum. The compression of

regulation and institutional politics meant this had to be

achieved through ‘code switching’ (Auer, 2002): switching between

two language systems, in this case that of ‘meeting the need of

Chapter submission for Critical Psychotherapy Book: Jay Watts 17

the consumer’/NICE regulations as desired by HPCP’ (broadly EBM)

and ‘a critical, subverting perspective’ (broadly post-

Foucauldian). Critical ‘core competencies’ were legitimatized

through being added to multiple modules and ratified through

university committees. As they were added to multiple modules,

they were more difficult to get rid of than a stand alone critical

module would have been. In addition, alternative evidence of the

effectiveness of critical thinking was collected: high ratings on

module feedback with qualitative feedback stressing the value of a

critical approach; stories and posters of the community projects

trainees had carried out; and so on. To pass the training,

trainees needed to show competencies in critical thinking,

engagement and practice, alongside knowledge of mainstream

discourses, in different forms of assessments. These included:

essays and case reports, group experiential exercises and

supervisions, and placements assessments. In addition, trainees

had to complete a community project in small groups or

individually over year 2. Thus, systems were put in place such

that the HPCP and British Psychological Society as regulators

would have to be informed and investigate if the critical elements

of the programme were removed from the program!

18

What core competencies were developed, and how?

Towards Heteroglossia

One of the main aims was to teach skills to slow down groups

reaching a conclusion too early - to facilitate a “tolerance of

uncertainty” (Seikkula & Olson, 2003). Expanding discursive

possibilities relies on listening outside what is being meant to

be said. Thus, the trainee works to draw out hesitations,

interruptions and alternatives which threaten to leak out, but do

not quite, just as they would in an individual session. This

allows other voices to emerge, from within the individual or

within a group. Thus, in a family meeting, a silenced patient

might be bought in by ‘positively connoting’ (e.g. Jones, 1994)

what a dominant member of the group is saying, using ‘curiosity’

to unpick where it comes from, and then passing the baton to the

service user by saying ‘I wonder what your thoughts are on

this...’. Similarly, in a meeting about how a service is to be

reconfigured to privilege CBT as a treatment, one might joke about

pesky service users insisting on saying its the relationship that

matters, and using that discursive move as a springboard to a

wider conversation about the evidence base for integrative

therapies.

Chapter submission for Critical Psychotherapy Book: Jay Watts 19

Such training often consisted of practical exercises. As an

example, before going on placement in a particular area, or with a

particular group or treatment modality, trainees were asked to

write the main discourses on a large piece of paper. These were

then troubled using the deconstructionist questions shown in Table

1.

---- INSERT TABLE 1 ABOUT HERE ---

Trainees were then asked to build up a list of ‘rhetorical

devices’ used in argument (e.g. Harris, 2002), both from the

literature and from everyday observations. The classic example of

this is Mary Boyle’s work on the power of ‘simple assertion’ (“Of

course, Schizophrenia exists” - Boyle 2002), a parallel to which

might be the assertion “Of course its better to have IAPT than

nothing”). Trainees were then asked to counter these discourses

both from within EBM and from a critical perspective. The

‘thickened discourse’ and territory the trainee then had (White &

Epston, 1990) allowed trainees to think and act outside the

monoglossic discourse. They were then encouraged to wear these

knowledges lightly, so as to develop skills in the timing of when20

to ‘code switch’ between different forms of knowledge so as to be

“the difference that makes a difference” (Bateson, 1972: 459),

i.e. to introduce more new ways of talking and thinking without

being so different to the culture one is part of that one is

thrown out, psychically or physically!

Locating Speakers

One of the aforementioned problems is the de-contextualisation of

speakers through an appeal to ‘Evidence’. Trainees were introduced

to the GRRAACCEESS acronym (Burnham et al., 2008) to prompt

thinking about what differences might be present between people,

be that in a therapy, a meeting or wider cultural space.

GRRAACCEESS stands for: Gender, Race, Religion, Ability, Age,

Class, Culture, Ethnicity, Education, Sexuality and Spirituality.

Before and after encounters, trainees were encouraged to link

these differences with hypothesized scripts at the level of the

individual, family, profession and culture (Pearce, 2005). For

example, one might hypothesize a manager has a script ‘CBT is

evidence based and NICE compliant so is the treatment of choice’

which might conflict with a script ‘Choice is important’, and an

individual script ‘Some traumas are impossible to get over’. As

soon as there is more text, more contexts through which a person

Chapter submission for Critical Psychotherapy Book: Jay Watts 21

thinks and a symptom speaks, there is opportunity for

contradiction and challenge which, if bought in benevolently, can

open the way for something new. These approaches were used, then,

not to impose a new truth on a setting, but to prime trainees

‘third ear’ (Reik, 1948) to the bits that miss the dominant story,

to skill them to knit a text with more open ‘subject positions’

for psychotherapists and patients alike.

The systemic principle of ‘curiosity’ was used to expand trainees

knowledge of differences. Thus, a trainee working with a female

Eritrean patient might be encouraged to explore the history of the

formation of Eritrea, and gendered experience therein, to be

primed to the traces of such histories in the discourse of the

patient. This was especially important for trainees who held

identities of the dominant group, or where a specific struggle was

echoed in the identities of two or more speakers (e.g. a civil

war). This listening for what may pulsate at the borders of speech

and the sayable, opens up what is hearable.. Crucially, it was not

just used with patients, but in group-speak about policy and

guidelines. Accordingly, trainees were encouraged to locate

members of the Guideline Development Groups’s for the NICE

Guidelines and DSM, as well as the authors of influential papers,

22

those chairing committees and user forums, and so on, to show the

subjectivity implicit within it.

Attention also focused on the contexts from which and through

which trainees think and speech. In addition to reflective groups

and personal therapies, trainees were involved in groups to

discuss their ‘transference to authority’, and ‘transference to

knowledge’ to explore how this effected how they positioned

themselves within bureaucratic groups and the psychocultural

discourse around ‘psy’. The intent here was to encourage trainees

to take up multiple positions within groups, and see these as

important sites of influence, indirectly effecting the culture

patients inhabit.

Challenging Mindsets

Changing mindsets is at least as influenced by emotional and

stories as rational argument through the EBM, or indeed post-

positivist critique. Consider the classic example of the Ken Loach

movie Cathy Come Home. This story changed homelessness policy

through its evocativeness far more than all the academic

statistics on homelessness (e.g. Donaldson, 2006). To this end,

trainees were encouraged to read and have access to as many

Chapter submission for Critical Psychotherapy Book: Jay Watts 23

stories as possible, from the Dialectic Behaviour Therapy Founder

Marsha Linehan’s account of her incarcerations (New York Times,

2011) to Rufus May’s account of his need to disengage from

psychiatric services to start a recovery (e.g. Independent, 2006)

to psychiatrist Sonia Johnson’s account of how she would not take

antipsychotic medication after a first or even second episode of

psychosis given the evidence-base (e.g. Johnson, 2011). If and

when these popped into trainees heads in group settings, they were

invited to speak them without triple thinking why.

Trainees were encouraged not to glorify their own training and

profession. The aim here was to disturb the tendency to divide the

world into goodies who understand critical theory and baddies who

maintain the status quo (e.g. Steiner, 1987), whilst recognizing

groups hold different power and privilege. Constructing a ‘straw

dog’ may help with one day’s fight, but rarely leads to culture

change and the long-term horizontalization of power relations. To

this end, having some information about the histories and politics

of different professions can facilitate what Minuchin & Fishman

(1981) have called ‘joining’ the system, to then be able to differ

from it. Table 2 shows an example of work on this within a

seminar.

24

---- INSERT TABLE 2 ABOUT HERE ---

Trainees were roused to continue their learning into how language

gets opened up and shut down outside the consulting room, for

example keeping an ear out for how this works in favorite films,

and bringing in clips to show this in action. Lastly, trainees

were encouraged to own their own personalized positions, should

they so wish, and use these in psy arenas and wider psychocultural

spaces. Thus, linking to the importance of emotions and stories in

producing change, an account of a personal experience of lack of

hope or trauma can allow people to connect outside the roles and

titles they hold. Accessing a personal experience often helped

deconstruct a ‘them and us’ dichotomy within a professional team,

and between professional and patient (Independent, 2010).

Connecting with Critical Allies

Such alliance building is crucial. Counseling psychology and

psychotherapy courses appear to have engaged less with the

survivor movement than some of the state-funded trainings, perhaps

because the requirement for personal therapy and analysis mean all

trainees can story themselves as service users. Yet, there is a

Chapter submission for Critical Psychotherapy Book: Jay Watts 25

great difference between someone who has had their own, chosen

privately funded psychotherapy and someone who has been subject to

injected medication, restraint and forced incarceration (though a

number of trainees will have had these experiences too). Trainees

were required to access radical psychiatric spaces, be that

attending a Mad Pride gig, campaigning against ATOS, or writing a

piece for Asylum magazine.

This contact served the triple purpose of linking trainees with

the survivor movement, which is not without its excitements and

power basis, as well as having one’s practice subject to the gaze

of those who have experienced the psychiatric system at its worst,

and lastly forged recognition of the relative social power

psychotherapists have, even today. These encounters often

inculcated a sense of responsibility to open up and speak out more

in monoglossic spaces though scary - be that the Daily Mail

comments section or a team meeting - for if one has met the

victims, can silence be so justified? Trainees were encouraged to

find out about critical groups within the area they work, such as

Hearing Voices Groups, Philosophy in the Pub groups, Civil

Liberties Groups, and so on. This was a part of joining with the

local community, visiting the sink estates white, middle class

26

professionals would not normally go too, asking advice for how to

make more inclusive services from the local imam or pastor, and so

on.

Lastly, trainees were asked to think about what were the local

blocks to an inclusive service, be that a ‘low cost psychotherapy

service’ that charges £30 per session, an information leaflet

about psychosis that fails to attend to culturally specific fears,

or a family interventions service that closes at 5pm. Trainees

then created a community project of their own choosing across the

span of a year. As part of the induction session for this, they

were asked to re-access how they wished to change the world when

they were little, or first embarking on their psy career. This all

sounds terribly serious - but the frame was much more one of play

and empowerment rather than prescription. The aim, throughout, was

to give a sense of what might be possible, and to story

psychotherapy as a profession that influences outside of the

consulting room, as well as within.

Conclusion

There are thanatonic and triumphant stories that critical

psychotherapists can tell about the present moment. We now have a

Chapter submission for Critical Psychotherapy Book: Jay Watts 27

choice. Either we see ourselves as trapped, submerged, excluded by

the EBM culture of the time, and retreat to private practice or

the few remaining critical pockets within academia. Or we

recognize the extraordinary subversive work that is going on in

the survivor movement and cyberspace, and use systemic skills to

draw these into the space of everyday psy interactions both within

organizations and within the wider psychocultural sphere. If we

choose the latter, we can produce spaces that can incorporate

multiple stories on ‘evidence’, ‘illness’ and the other signifiers

that threaten to colonize us otherwise.

28

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