The Therapeutic Relationship

A relationship of knowledge requires three components: someone who knows, something that is known and a context in which the knowing takes place. Knowledge requires a Subject and an Object, a knower and a known. A lepidopterist studies butterflies; he or she is the Subject and butterfly anatomy is the Object. A linguist studies grammar and syntax; the linguist is the Subject and language is the Object. A doctor is an expert on the human body and the illnesses that affect it. I see my GP and I describe certain symptoms, such as a metallic taste in my mouth or blood in my stool; the GP diagnoses a disease based on my symptoms and recommends some form of treatment. The GP is the Subject and, for both him and for me, my body is the Object. The technical term Heidigger uses, appropriate here, is 'conspicuous': the symptoms of a physical illness are conspicuous in that they have the effect of forcing me to realize that I am not my body, I am something else. I am a Subject and my body is the Object and my body is letting me down.

All science is based around relationships of knowing, about Subjects who know and Objects that are known. But scientific discourse tends to conceal or erase the knowing Subject. If I read a textbook on meiosis, for instance, I don't expect the author to describe to me how he or she came to learn what he or she has to tell me. I expect the author to keep out of it. Scientific discourse is quite literally 'objective'. It is concerned quite literally only with Objects. Scientists rarely concede that science has a subjective component as well, because to use the term 'subjective' implies that perhaps the scientific theory being described might not be correct. In common usage, the word 'objective' is taken to mean 'verifiable, true' and the word 'subjective' carries a connotation of relativism, of potential falseness. But arguably all knowledge is really subjective because no knowledge can exist outside the mind of a knower.

Psychiatry and psychology pretend to be sciences and consequently the Subject-Object relationship prevails here too. The shrink is the Subject and the patient is the Object. Suppose I somehow end up in a psychiatrist's office and tell him that I believe George W. Bush is talking with me telepathically or that the CIA has bugged my flat. The psychiatrist, who of course is a doctor, subjects me to his gaze, his scrutiny, and interprets these reports as hallucinations and delusions, as symptoms of an illness, definitely psychosis and potentially schizophrenia. The patient is psychotic. Psychosis is a disease and the appropriate treatment for a disease is medication.  If the patient doesn't want to take medication, the psychiatrist will find ways to force him to take it. The therapeutic relationship is a Subject-Object relationship again, one in which the shrink is the knowing Subject and the patient is the Object. The shrink knows the patient better than the patient knows himself. The patient may not even have sufficient insight to know that he is sick. The situation is different from a consultation with an ordinary doctor: an ordinary doctor tells me that the reason for my illness is a problem with my body. The psychiatrist by contrast tells me, in effect, not that I have a disease of the body but that I have a disease of the mind. He tells me that I myself am the illness. In this way, a psychiatric diagnosis is inescapably a form of moral judgement, and this is why psychiatry straddles the line between Medicine, and Law and Order. The Subject-Object relationship is also a relationship in which the Subject has power over the Object and some, such as Michel Foucault, have argued that there is always an element of sadism in this relationship.

To know something about other minds, to understand the soul rather than the body, one requires a discourse that makes sense of human personalities. In psychology and psychiatry, the method used to carry this out these days is to divide people into different kinds. The DSM 5, that bible of modern psychiatry, is a catalogue of labels, a sort of taxonomy of human kinds. A patient can be 'diagnosed' with any of many psychological conditions, such as Borderline Personality Disorder, Narcissistic Personality Disorder, Autistic Spectrum Disorder, and so on. Ordinary medicine deals with a taxonomy of diseases - as the result of reported symptoms, an appropriate diagnosis is made and an appropriate treatment advised. Psychiatry deals with 'abnormal' human kinds as if the people who are assigned to one group are all common sufferers of a single disease. The aim of medicine is to efficiently facilitate and expedite the most effective treatment –  although to be frank, psychiatrists and psychologists have almost no idea how to treat unhappy people effectively… But they love putting people in boxes. Patients become the objects of the discourse, while the psychiatrist himself remains apart, invisible, omniscient, God-like. A quote from  James Joyce conveys this idea well: "The artist, like the God of creation, remains within or behind or beyond or above his handiwork, invisible, refined out of existence, indifferent, paring his fingernails".

The therapeutic relationship is composed of a Subject (the shrink), an Object (the patient) and the context (the consultation and the room in which it takes place, the patient's records, family testimony, psychiatric discourse itself, and so on). It is within this situation that the patient's condition comes to be disclosed, comes to be known. And for Knowledge to occur, at least three things are required: the Object of knowledge must be stable over time, the Object of knowledge must be independent of the Subject's observations of it, and the Object must be independent of the theories created to describe it. (There is some overlap between these last two criteria because all theories, all systems of knowledge, belong to the Subject rather than the Object.) 

The problem, as I see it, is that within the therapeutic relationship, all three criteria are questionable.

Consider, first, the idea that personality types and categories are stable over time. This notion is indispensable to modern psychiatric practice. If someone is diagnosed with Autistic Spectrum Disorder, for instance, it is assumed that it developed either as the result of bad genes or as the result of the family situation during childhood and is set for life. How could psychiatrists perform their job if someone shows indications of autism at one time and then never again? I saw an idiot psychiatrist for a period who told me that delusions, by definition, are fixed. Why believe this obviously spurious notion unless it is convenient? Conditions are always assumed to be permanent. If someone is diagnosed schizophrenic, it is understood not only by the psychiatric community but by the general population that the diagnosis is life-long. I myself am under a Compulsory Treatment Order, having been officially diagnosed schizophrenic in 2013. Last year I requested and received an independent review of my status as someone 'subject' to community treatment. It went against me, of course. Afterwards, during a telephone conversation with my lawyer, I was told, "Andrew, I find it difficult to represent you because you admit you were ill in the past." I felt like saying, "Have you ever represented someone put under the Mental Health Act who was never ill at all?" But this is the way of the world. Despite considerable evidence that people often recover from schizophrenia (famous examples including John Nash, Janet Frame and Mark Vonnegut), the term 'recovered schizophrenic' is considered an oxymoron, a contradiction in terms. No one recovers from schizophrenia. By definition. Either a person must accept the label 'schizophrenic' for life or pretend they were never schizophrenic at all. This puts patients in an invidious position, an impossible position. Should I have followed my lawyer's suggestion – and lied? Surely the maddest response to psychosis is to pretend one was never psychotic at all.

Schizophrenia is an episodic condition and occasionally a particular episode can be the last. I'll give a second example that demonstrates the difficulty of assuming that personality traits and attitudes are stable over time. My relationship with my father is ambivalent and has fluctuated considerably over the course of my life. My negative feelings were not entirely baseless: my father's divorce from my mother when I was seven proved traumatic for me at the time. Around Easter 2013 I told a psychiatrist that I hated my father - I think that I needed to express deeply buried feelings of resentment towards him to someone in power, to get it out of my system. In late 2014, a psychologist I was seeing told me disdainfully, "You hate your father". He made this statement without any justification – I had never suggested this to him at any time. My attitude towards my father had changed by then. I must presume that my assertion about my dad in 2013 had gone into my record (as it should have) but had been misrepresented as an enduring hostility rather than as a transient outburst.

This brings me to my second criticism. As I have said, the therapeutic relationship consists of a Subject, the shrink, and an Object, the patient. A psychiatrist tends usually just to listen and very occasionally to ask questions; he or she doesn't look for signs that the patient has changed; he or she almost never discusses his or her own life or opinions. The shrink transcends the situation in a way that the patient does not: the shrink is the invisible objective observer. At least this is the aim, the ideal. In practice, the patient is to some extent himself or herself the Subject and the shrink is the Object. The patient is continually observing his psychiatrist's body language and looking for cues from the questions he is asked to make sense of the situation in which he has found himself. The question the patient is continually asking himself is, "What does this person think of me?" And the shrink is not a transcendental impartial observer. He or she is a person with his or her own personality traits, experiences and prejudices, his or her own potentially bogus theories, his or her own baggage, all of which is brought into the relationship.

No amount of training or research into best practice will prevent a psychiatrist who is an asshole from behaving like an asshole or being recognized as an asshole by his patients.

In an earlier post, Rationality vs. Mysticism, I claimed that schizophrenia is not independent of one's observations of it. The truth is that this thing we call 'schizophrenia' (or Aspergers Syndrome or Borderline Personality Disorder) is a condition invented in the doctor's office. I would go further and say that identity itself is constructed in the space between the Self and the Other… at least if a person does not have defense mechanisms in place to protect him from others' opinions. The doctor-patient relationship is reciprocal. And it can be arbitrary. An example… It seems that many people in the world hear voices who have not and should not be diagnosed schizophrenic. Likewise there are very many people in the world who are arguably delusional, Birthers for instance, or those who believe, like Donald Trump, that the theory of global warming is a conspiracy invented by the Chinese. If hallucinations and delusions are so common, a diagnosis of schizophrenia becomes capricious. How can one discriminate between a defensible belief and a delusion? Why assume that the devout Christian who has Jesus as his personal friend is crazy? It all depends on what the patient chooses to report and how the psychiatrist is feeling on the day. Psychiatry is concerned with 'abnormal' personality types - but who gets to decide what constitutes normality?

Finally, I want to tackle the idea that mental illness is independent of the theories we use to describe it. The philosopher Ian Hacking has described a process called 'looping'. (His essay "Making Up People" can be found in the London Review of Books.) His basic idea is that people are not passive objects; they interact with others and with the world, and if a person accepts a label, he or she seeks to find out what that label means. Hacking's focus is on Multiple Personality Disorder (a now widely discredited classification) but what he says about looping can be applied to those diagnosed schizophrenic as well. A person is labelled schizophrenic; he or she discovers that schizophrenics are frequently violent; his or her friends, family and acquaintances, who are also part of the world, start expecting the schizophrenic to become violent; consequently, unless the schizophrenic rejects this myth (and it is a myth) he or she may become violent as a result. He or she unconsciously seeks to conform to others' expectations. Or, to take a less extreme example, it is currently accepted medical wisdom that schizophrenics have difficulty obtaining boyfriends and girlfriends. The young schizophrenic learns this, internalizes it, and this expectation becomes a self-fulfilling prophecy. When the Object of a discourse is also a human being, he or she is not independent of the theories we invent to describe him.

The diagnosis creates the condition.

The essence of the problem is that it is doctors who run the Mental Health Services of all countries. Doctors tend to assume two things: that mental illness is literally an illness, and that the patient is unaffected by the therapeutic relationship itself. Patients are Objects of knowledge only and the doctor has no affect on the him or her. No attempt is made to ascertain the environmental and situational causes of a psychotic episode. No credence is given to the idea that psychiatrists inevitably, no matter how hard they try not to, influence their patients, for better or for worse. The only answer, people assume, is drugs. This is wrong. There is a better answer. But in order to change the world, we need to change everything – the discourse, the institutions and the people who run things. This is really the only solution.