Beyond the promise of the quick fix

I’ve just been reading Michael Sinclair’s book on corporate stress Fear and Self-Loathing in the City.   What’s interesting about this book is that it gives a fascinating insight into the psychology of City workers from a clinical perspective.  Sinclair discusses a range of problems including anxiety, depression, alcoholism, eating disorders, and depersonalisation.

But for me, what’s even more interesting about this book is that it gives a really good overview of how CBT is applied in ‘real life’ situations.  Just to be clear, although Sinclair does draw upon systemic, person centred and psychodynamic ideas, his central approach is cognitive-behavioural, with the focus on helping the client challenge his or her thought patterns.  Where I start to part company from Sinclair is his perspective on the environment within which his clients are working.  In a number of places in the book he makes it clear that the working environment or culture is of secondary interest.  For example he writes:

Many of my patients complain about the pressures of work. In many cases, it is the work culture that demands that they work late, and avoid taking lunch breaks, or days off. It is almost that the workplace doesn’t allow for human emotion. However, in spite of how we feel about our working culture, it is more about how we manage our own experience that counts. If we learn to develop a certain amount of self awareness around our psychological states, be more assertive, and look after our own needs in a productive way, then we can deal with the pressures of the office —on our own terms.

Note my emphasis (underlined):  the culture is not the problem, it’s how we experience it, and how we manage that experience, that matters.  In other words, you just have to accept the environment you are working it (assuming you want to remain in a job) and somehow you have to adapt your experience (which from a CBT perspective means adapting your thinking).  This is the secret of a happy and fulfilled life, even within such stressful environment as the City.

For many people (which presumably includes Sinclair’s City clients) this approach suits them fine.  They want to remain in their job, and quite likely within the City working environment, and they may quite possibly enjoy many aspects of it.  However, for some reason they are troubled, they are feeling dis-stressed, they suffer.  Such suffering can manifest itself in many different ways, as mentioned in the first paragraph, e.g. through anxiety, depression, etc.  The goal of therapy is to help the client feel less troubled, less dis-stressed, to suffer less.  This way they can carry on as before, but feel more in control of their lives.

This sounds great, and as I said just now, this works for many people – not just in the City but a wide range of situations.  However, there are some serious problems with this approach – both philosophically and clinically.

Philosophically, CBT (and ironically perhaps, many humanistic and person centred approaches to therapy) is a form of idealism.  What this means is that ‘reality’ is seen as a construction, a construction of thought (in the case of CBT. In the more humanistic approaches, emotions play a much more central role in constructing ‘reality’).  However, this is based on the idea that the ‘self’ or ‘ego’ is the centre of such a reality (variations of the Cartesian cogito).  This raises a number of ontological problems, including the status of other people, who presumably are also constructing their own realities through thought and/or emotions…..

However, there is an even more fundamental, clinical, problem: much, if not all, of human psychical suffering, what people are troubled by, what dis-stresses them, relates, in some way or another to other people or to other things.  Furthermore, the ego, the self, which is the centre of the idealist’s universe, is itself a construction, based on a set of imaginary identifications with others.

So ‘reality’ cannot equal one’s thoughts about it.  In other words, other people, other things, the ‘outside world’’ do matter and, in fact, have a great bearing on one’s subjectivity.  Of course, it’s even more complicated than this: to start with the whole question of ‘inside’ and ‘outside’, ‘internal’ and ‘external’ is deeply problematic – ‘outside’ of what?  The ‘self’, the ‘ego’?  But the if the ego is a construction…….

However, what’s of more interest clinically is the way that CBT and other idealist therapies attempt to resolve such ontological difficulties.  Basically they collapse reality into self, into ego.  Reality becomes thought, feeling, emotion.   More precisely, the thoughts, the feelings of the self.  But what then of other people, of the ‘outside’ world?  They become shadows, nothing more than reflections of the ego, of the self.  From a Lacanian position this is the world of the Imaginary, of smoke and mirrors.

The problem, however, is that this changes nothing.  Reality – or perhaps at this point it might be better to say the Real, does not disappear.  Rather, it becomes sidelined, repressed.  It takes on the status of the unconscious, of the Other.  Now, of course, psychoanalysis makes the question of the subject’s relation to the Other, to the Other’s enjoyment, to the Real, central to its practice.   However, this is the complete opposite of attempting to sidestep such a question, of repressing it.   CBT and other idealist therapies may offer the possibility of a (quick) fix, a chance to get back to ‘normal’ life, to (a self constructed) ‘reality’.   Psychoanalysis offers the possibility of something else………