The goal of therapy is to put therapists out of business
Note: this is a previuosly unpublished adaptation of a presentation originally made as part of a panel, Ethics of Alterity: Implications of Levinas for Psychotherapy, at the Third Annual Conference on Counseling and Spirituality: Trends, Traditions and Ethics, Gannon University, Erie, PA, September 22-23, 2000. I decided to include it after reading Louis Hoffman's incisive critique of the "Business Model" of psychology.
The title of my portion of the presentation is "Putting Ourselves Out of Business: Implications of Levinas for Psychology." I want to make the case that a psychology and psychotherapy based on a Levinasian ethics is a psychotherapy that does not exist to perpetuate itself. Rather, it is a psychotherapy for the Other. And not only is it a psychotherapy for the Other, it recognizes that its responsibility for the Other is bestowed not just for the Other but by the Other. Our freedom as psychotherapists is a freedom given by and for the Other. If it weren't for the Other, we would not be given the privilege of our responsibility as psychotherapists. In other words, our profession is a gift from the Other.
Psychotherapy as a social institution necessarily has its roots in the face-to-face encounter with the Other. It is appropriate that we face our clients in therapy. However, precisely because it is a social institution, there is always a danger that psychotherapy will forget that it is an institution bestowed by the Other for the Other. Psychotherapy, in becoming institutionalized, forms its own code of ethics, as well as procedures for the selection, preparation, and socialization of psychotherapists as professionals. In the process of becoming institutionalized, psychotherapy both preserves itself as an institution while also risking inertia. It becomes much more difficult to respond to the ethical call of the other in the face-to-face. Why so? Because at the level of institution, moral codes and professional accountability become abstracted from the concrete face-to-face encounter with the client. In Ivan Illich's (1976) terms, the more we move away from the everyday, "vernacular" world of face-to-face encounters and enter into bureaucratic systems, we run the risk of creating "paradoxical counterproductivity." Psychotherapy can become the source of the problem rather than the cure. That's obviously a big problem, and it is a problem that we face today, particularly in the era of managed care. As David Schwarz (1997) points out, the term "managed care" is an oxymoron. The moment "care" becomes "managed," it is no longer "care." Care is not something that can be produced or ordained from the above as a third party, but happens instead from the above of the Other in the face-to-face.
So what I would like to suggest is that psychotherapy is being called by the Other to put itself out of business.
Levinas (1969) shows us that all learning comes from the Other. To uphold the ethical responsibility of our call to be psychotherapists, our learning-to-be-psychotherapists must ultimately come from the client. We learn from our patients. It is the patient who teaches us how to put ourselves out of business.
Carl Rogers was a therapist who had an uncanny ability to learn from his patients. As he recounts in his now classic On Becoming a Person, Rogers (1961) developed his person-centered therapy because he was commanded by his patients, taught by his patients, to do therapy otherwise. In his early career, for example, Rogers found himself struggling with the mother of a child patient. He writes of this memory:
"I had been working with a highly intelligent mother whose boy was something of a hellion. The problem was clearly her early rejection of the boy, but over many interviews I could not help her to this insight. I drew her out, I gently pulled together the evidence she had given, trying to help her to see the pattern. But we got nowhere. I finally gave up. I told her that it seemed we had both tried, but we had failed, and that we might as well give up our contacts. She agreed. So we concluded the interview, shook hands, and she walked to the door of the office. Then she turned and asked, "Do you ever take adults for counseling here?" When I replied in the affirmative, she said, "Well, then, I would like some help." She came to the chair she had left, and began to pour out her despair about her marriage, her troubled relationship with her husband, her sense of failure and confusion, all very different from the sterile 'case history' she had given before. Real therapy began then, and ultimately it was very successful" (p. 11).
It was this incident, among others, that led Rogers to the conclusion that "it is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried" (p. 12). Rogers learned from the command of the Other, and the result was the birth of client-centered psychotherapy.
Like all institutions, humanistic psychology began to develop into a formal system, which held certain essential principles humanistic scholar-practitioners believed they held in common with one another. One such principle was an exaggerated emphasis upon individuality. Abraham Maslow (e.g., 1998), for example, emphasized the notion of "self-actualization" in his work. Gordon Allport (e.g., 1955) saw personal fulfillment as central to the goal and purpose of humanistic approaches. And, in general, the humanistic orientation became associated with an emphasis upon the person's need to individuate. To individuate, for the most part, meant to be autonomous, to be your own person.
Unfortunately, despite a few exceptions, such an emphasis upon individuality often led humanistic psychology toward an ego-centered psychotherapy based on an economy of the same. While there were therapists such as Viktor Frankl (1998) arguing that self-actualization is actually self-transcendence--and even Maslow's (1998) research showed that supposedly self-actualized people were more other-directed than self-directed--in practice, humanistic therapy often promoted a kind of self-indulgence characteristic of the late 1960's and 70's counter-culture movements. The whole "I'm okay, you're okay" version of self-actualization seemed to promote a psychology based purely on enjoyment, often forgetting that enjoyment is always from the other for the other (Levinas, 1969). Such self-indulgence, perhaps not surprisingly, led to different kinds of indulgences during the Reagan years of the 1980's. Enjoyment is good, yes, but it is good for me because it is for the other. When I am nourished, I have the strength to address the command of the Other. I can give to the Other the goodness I have been given. It is in the giving as a response to the call of the Other that I discover my authentic freedom (Levinas, 1969; see also: Davis, 1997; Kunz, 1998).
The over-emphasis upon individuality is closely related to another central tenet of humanistic psychology as a formal system: the emphasis upon privacy and subjectivism. Bugental (1978), for example, wrote that the "basic subjectivism of all experience" and "the privacy of the subjective" is actually "the cornerstone of humanistic psychology." This subjectivism relies upon the assumption that all knowledge comes from "within," from the economy of the same, rather than from the Other. The implication is that human reality is actually constituted by the individual subject, whose inner experiences are considered to provide the bedrock foundation for the world. This assumption is tragically ironic, I think, for in the beginning, Rogers developed his method of doing therapy by learning from his patients. However, once that system was formalized, it became abstracted from the face-to-face engagement from which Rogers originally responded to the needs of his clients. At this level of formal abstraction--what Levinas (1998) would call "the Said" as opposed to the "Saying"--humanistic psychology forgot its obligation to the Other. It forgot that what it learned came from the Other, not the Self, and certainly not a private self who constitutes the world. It forgot the original lesson that Carl Rogers had learned: that his job was to put himself out of business.
I was at first hesitant to use humanistic psychology as an example, because of all the formal systems of psychology, humanistic psychology has been the most concerned with learning from the patient. But, for this very reason, it is a valuable example, because it shows that what, at the level of practice, is an answer to the command of the Other, can become, at the level of formal system, precisely a way of refusing to answer this command. In short, I submit that the emphasis upon an exaggerated, self-indulgent individuality and an encapsulated subjectivism is self-serving for psychology: it keeps us in business.
The emphasis upon individuality and subjectivism ironically usurpts us of our freedom in a real and tangible sense by permitting formal systems to take over our responsibility while we are busy self-actualizing. If my genuine freedom comes from my service to the Other, an emphasis upon self-indulgence robs me of my opportunity to discover my authentic being-for-the-Other. And I find that when I am commanded by the Other, very much in agreement with Levinas, it is in the face-to-face of the informal, vernacular world. When I enter into formal, bureaucratic systems, I find that my freedom to serve the Other is often usurped. Many others have told me that they share this feeling. My wife, for example, works in a County-funded Long-Term Care Facility. Within the past 3 years, she has found herself overrun with mounds and mounds of paperwork and with less and less time to be with her patients. Many of us have been coerced by superiors to lie about our patients. We are told to exaggerate a patient's diagnosis in order to get the funding from managed care companies necessary to provide the care our patients need. We find ourselves digging up dirt on our patients rather than focusing on their health.
When I worked in community-based group homes with mentally retarded adults, I knew that my job was to integrate my patients into the community. Such programs were developed to root my patients in a vernacular world where they would be held and sustained by a community of other responsible citizens. The idea was that these patients would no longer need to rely on formal systems. Yet when a staff person wanted to take a patient home for a holiday, they were told it was a liability and against policy. When a neighbor wanted to take on responsibilities of staff members, the organization I worked for said it was too risky. And I began to realize that the original meaning of my job had been lost, swallowed up in the exasperating stupidity of a large bureaucratic machine. Examples such as these are what Ivan Illich (1976) referred to as "paradoxical counterproductivity." Modern institutions tend to produce the opposite of their stated purpose, and they also tend to eliminate possibilities for other kinds of action. In such cases, the institution becomes a "radical monopoly" which robs us of our freedom to serve the Other, because it is too concerned with keeping itself in business.
If we are to have a kind of community which fosters a responsibility for the Other, it would be a community of neither individuals nor large, bureaucratic machines, but a community, as Schwartz (1997) suggests, which fosters mediating structures, "social groups that stand, or mediate, between large entities like national governments on the one hand and autonomous individuals on the other. Originally embedded in kinship and locality, these structures--such as extended families, churches, voluntary associations, village governments, and a rainbow of related entities--have for most of human existence formed the primary units in which one dwelled, pursued one's life, and was known" (pp. 43-44). Such mediating structures are informal, vernacular and organic. They spring up spontaneously in response to the command of the Other.
Yet when we look around, we see that such mediating structures are drying up in our culture. Ironically, it is in our culture, which speaks so loudly about individual autonomy, that we find fewer and fewer spaces for such informal systems to flourish. Sociologist Robert A. Nisbett has suggested, in fact, that it is precisely our emphasis upon individuality, autonomy and subjectivism that has led to our predicament. He writes:
"What is crucial in the formation of the masses is the atomization of all social and cultural relationships within which human beings gain their normal sense of membership in society. The mass is an aggregate of individuals who are insecure, basically lonely, and ground down, either through decree or historical circumstance, into mere particles of social dust." (Nisbett, p. 62, in Schwartz, p. 44)
The assertion of self-indulgent individuality fuels a Capitalist economy by creating a yearning for connection, and we try to fill up the emptiness with commodities. When that no longer works, and all the informal systems have disappeared, we the masses turn to the only thing we have left, the false community of the state. And that can only lead to totalitarianism. There is a vicious cycle at play. With the absence of a community of Others for Others, as articulated by Levinas (1998) in his philosophy of social justice, we place increasing demands upon formal national and state governments to fulfill our needs. And, of course, these governments respond by expanding bureaucratic systems, which only continue to usurpt the authority of local, informal systems.
If psychotherapy as a profession is to answer to the command of our patients, I feel it must face the command to put itself out of business. For too long, psychotherapy as a formal system has emphasized that the patient turn inward and look backward. Yet as long as we insist that the patient look inward and backward, we disempower them. When one is looking in and back, one is not looking around. We sit with our patients in our sealed rooms, closed off from the world, and teach them to become politically and socially disconnected from the world outside. And that keeps us in business (See: Cushman, 1995; Hillman & Ventura, 1993; Hillman, 1992).
But there are other alternatives. If we are to put ourselves out of business and answer the command of the Other--their yearning for the vernacular, for community and connectedness--we have to re-image what psychotherapy is all about. A psychotherapy for the Other would be a psychotherapy that builds community rather than contributing to the break down of community. Psychotherapy must become a cultural therapeutics.
How can we imagine such a psychotherapy? We can look to others who have already answered this call. Consider psychiatrist Ross Peck: As a psychodynamic therapist, he was at a loss as to how to deal with schizophrenic patients who repeatedly failed to respond to therapy. When the families of these patients would reach a breaking point, Peck began to ask the family to invite 50 or 60 people they knew to a gathering at their house. Peck would arrive and, in the presence of this organic, potential community, he would tell them of the family's problems, and, lo and behold, out of this vernacular network of relations would emerge active members discovering their own ability to grapple with and resolve seemingly intractable situations or even pathologies. Peck called this process "retribalization." Peck is one example of a therapist who knew how to put himself out of business. Perhaps you may know of others.
One thing is for certain: time is running out. Spaces for the development of informal, organic community systems are quickly disappearing, perhaps even faster than the rainforests of South America. If you are like me, you are hearing a command from your clients to help them fill their yearning for something more, for a connectedness to others and a recovery from their sense of loneliness and isolation. At the same time, there is an increasing pressure from within the formal systems of our profession to build more and more alienating bureaucratic structures to fill such needs, and there's more and more talk of individuality and autonomy, whether couched in terms such as individuation, self-actualization or internal locus of control. If we really listened to the command of our clients, we'd do whatever is in our power to put a stop to all that. And if we really did a good job, we'd find ourselves out of a job. And that's the point, isn't it?
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