Psychotherapy’s identity crisis: opening reflections on the historiographies of psychotherapies

Abstract

This article introduces the work of the transcultural histories of psychotherapies network. Reflecting on the comparative lack of work here, it traces psychotherapies’ identity crisis, focussing on nodal points such as the rise of the term, failed attempts to unify the field from Forel to Jung, and the rise of outcome studies. Finally, it situates histories of psychotherapies within the context of adjacent fields: the relation of the history of psychotherapy to the history of science, to Freud studies, to the history of religion and religious studies, to intellectual history, to the history of psychiatry, to the history of medicine, and its place within cultural history.

psychotherapy; historiography; science; medicine; religion

Resumo

O artigo apresenta uma discussão acerca da produção de histórias transculturais da rede de psicoterapias. Reflete sobre a ausência de trabalhos comparativos na área, delineia a crise de identidade das psicoterapias, focaliza pontos nodais, como o surgimento do termo, as tentativas fracassadas de unificar o campo de Forel a Jung e a aparição de estudos de resultados. Finalmente, situa as histórias das psicoterapias no contexto de áreas adjacentes: a relação da história da psicoterapia com a história das ciências, os estudos de Freud, a história da religião e os estudos religiosos, a história intelectual, a história da psiquiatria, a história da medicina e seu lugar na história cultural.

psicoterapia; historiografia; ciência; medicina; religião

Have you been in some form of psychotherapy or known someone who has? For many of us, the answer to this question will be in the affirmative. Consequently, to study the history of psychotherapy is to study ourselves – or to study something that immediately concerns us and those close to us. This gives both a point of relevance for historical research, but also presents a paradox. Psychotherapy touches us because of our own involvement with it. On the one hand, this provides more immediate access to the topic – i.e. it is a matter of personal interest, more direct, perhaps, than other areas of the history of science or the history of medicine. On the other hand, it is also in some ways too close, because we are engaged in some way with some form of therapy, or self-therapy, or therapy of others, or hearing of someone else’s therapy and being concerned about what is going on with them, or suggesting that they need some form of therapy. Consequently, while this proximity gives us a particular access to the subject, it also requires us to draw back and be aware of our involvement and stakes in it in a self-reflective manner. It also gives relevance to the history of the subject, because we are doing a history of the constitution of not only what forms our identity, our ailments, but also how we try to deal with and treat them.

The field of psychotherapy is a strange one, suspended between science, medicine, religion, art and philosophy. Modern psychotherapies are one of the most distinctive features in the healthcare field of the twentieth century. Being initially generated in what used to be called the West, they are increasingly being exported to the rest of the so-called developing world. However, the historical study of this field seriously lags behind its societal impact and the role it plays in the contemporary healthcare policies in many countries. This lacuna is currently being rectified. There is an increasing amount of work being done studying the histories of psychotherapies in discrete local contexts, which is expanding and reframing our knowledge of them. This meeting and this special issue are signs of this shift. They signal the need to draw together and put into relation the work done in the histories of psychotherapies in different cultural domains, and to see what comes out in the mix.

I’d like to begin by addressing what could be called psychotherapy’s identity crisis. The identity crisis of psychotherapy is as old as psychotherapy itself. Since its inception, psychotherapy has been a field in search of an identity. One of the earliest definitions, in 1893, by the Dutch psychiatrist Frederick van Eeden (1893 , p.99), ran as follows: “I call psychotherapy all curative methods which use psychic agents to combat illness through the intervention of psychic functions.” This was a wide, all-embracing definition, simply omitting somatic treatments. The question of what constituted psychic agents or psychic functions was left open. The indication was that this could include any form of non-somatic treatment. So this was in effect a negative definition of the field, defined against the increasing somatic orientation of clinical medicine.

By the beginning of the twentieth century, psychotherapy as a term had become firmly established, but it was not seen as the exclusive preserve of any one school or approach. It had been variously used to refer to a variety of procedures, ranging from mesmerism, hypnosis, suggestive therapy, moral therapy, Mind-Cure, mental healing, strengthening of the will, re-education, the cathartic method and rational persuasion to general medical practice in the “art” of medicine. Indeed, histories of psychotherapy had started to be written and contested (Camus, Pagniez, 1904). By the early twentieth century a heterogeneous cluster of therapeutic practices had been grouped together under the term “psychotherapy” and identified as a modern, rational, would-be scientific discipline.

Given the wide societal spread and impact of psychotherapeutic practices, but also increasingly agonistic competition of various claimants to be the sole arbiter of the field, the Swiss neurologist and psychiatrist Auguste Forel in 1908 thought the situation should be resolved by forming a general association of psychotherapy. Addressing the state of the discipline, he noted the undesirable presence of all sorts of pseudo-therapists, whom he called “Charlatans, magnetic healers, the New York Institute of Science, Lourdes miracle workers, Spas, Naturopaths and so forth” ( Forel, 1910 , p.308). These, for Forel, were not psychotherapists; they were pseudo-therapists. The first move of this Association was to differentiate psychotherapists – the real ones – from quacks. The spectre of quackery has long haunted the field of psychotherapy, and definitions of the psychotherapist have often sought to distinguish this figure from the quack ( Tuke, 1872 ). So we have here another negative definition. As Forel (25 Feb. 1910, p.42-45) put it:

Psychotherapy comprises, above all, therapeutic suggestion, psychoanalysis and analogous methods, based directly on a well understood psychology... But scorned and neglected in general by the faculties of medicine, psychology and psychiatry have been studied above all by autodidacts who have formed special or local schools, such as at Paris, Nancy, Vienna etc., schools which have each developed according to their special ideas, without contact with the others, without in-depth scientific discussions and without agreeing on terms. As a result of this situation, it seems to me that certain things are highly necessary:

Obtain an international agreement to help the scientific discussions in the domain which occupies us – agreement on the facts and on the terms;

Unify neurological science and make it known in all its branches by the faculty of medicine.

Forel (1910 , p.307) sought to create order in what he called this Tower of Babel by facilitating scientific exchanges and through establishing a “clear international terminology, capable of being accepted in a general manner by different people.” This was to be a true scientific international society of psychotherapy. In contrast to Freud’s soon-to-be-established International Psychoanalytic Association, this was to be open to all, and not dominated by any particular doctrine. The project was not a success. Several congresses were held, but it simply dispersed. However, it serves to highlight the problem of what psychotherapy was and how this field could claim to be a science, or claim to be part of medicine, if there was no consensus as to its very identity.

Instead of Forel’s vision of psychotherapy developing akin to other medical and scientific disciplines, the twentieth century witnessed an ever-increasing multiplicity of schools of psychotherapy at war with one another. Indeed, one could describe this, without too much hyperbole, as the war of psychotherapies ( Pignarre, 2006 ). In the twentieth century, competing organisations based on proprietary formulas became the dominant model for psychotherapies. The term was used for a vast array of divergent disciplines, a development facilitated by the fact that it never was one thing. It was intensely malleable; anything could in fact be called psychotherapy, and indeed was. Despite their efforts, no one school managed to conquer the whole field of psychotherapy, although in certain contexts, some schools achieved something like a hegemony in certain specific domains; witness the place of psychoanalysis in the 1950s in American psychiatry ( Friedman, 1992 ).

Attempts to resolve the identity crisis of psychotherapy through overcoming diversity and difference and enforcing conformity did not work; indeed, they made the problem worse. In 1938 there was a further attempt to unite the field of psychotherapy to resolve its identity crisis by another Swiss, C.G. Jung, at the Tenth International Medical Congress for Psychotherapy, at Oxford. He noted in his opening address that the Swiss Society for Psychotherapy had formulated 14 points upon which all psychotherapists using psychological analysis – except from those using hypnosis – could agree. So already, at the beginning, he excluded hypnotists – but he went ahead anyway with the 14 points. These points were as follows:

Psychotherapy, having been developed by physicians, makes use of medical techniques. Its first objective is a diagnosis, and to this end it has recourse to an anamnesis. The patient recounts his difficulties and on the basis of what he says together with the symptoms an attempt is made to find out the specific nature of the illness.

The results show that there are forms of illness which have nothing to do with bodily disturbances, but which are only intelligible in terms of the psyche or mind.

Therefore, this method of diagnosis does not focus on the seat of the illness but on the general psychic disposition of the sick person. The method of investigation is adapted to the study of the psyche and is put on a broader basis than that obtained in pathology.

It takes into consideration all possible ways in which a person may express himself: his premeditated speech, his free associations, his fantasies, his dreams, his symptoms and symptomatic actions, and his demeanour.

This investigation reveals an aetiology reaching down into the depths of the personality and thereby transcending the limits of the conscious mind.

Psychotherapy calls the dark portion of the psyche the unconscious. The investigation leads first to the discovery of unconscious fixations on crucial situations and persons significant in the patient’s childhood. These fixations have both a causal and a purposive aspect and set tasks for future fulfilment.

The illumination of the factors out of which the illness developed and continued is one of the tasks of psychotherapy.

Its method is the analysis and interpretation of all forms of expression.

The therapeutic development of the patient depends on the relationship between him and the physician. This relationship also forms the basis of the patient’s relationship to society.

In treatment this relationship takes on the specific forms of a transference, which is the projection of unconscious contents and appears as a transference neurosis.

The reduction of the transference neurosis shows it to have been laid down in the unconscious fixations of childhood.

Back of these individual fixations collective unconscious factors are assumed.

The new contents must be realised as parts of the personality because it is only in this way that the patient can feel his responsibility towards them (Medical Psychotherapy, 6 Aug. 1938, p.332).

This was an ambitious, but ultimately pyrrhic attempt to unite the whole field of psychotherapy. Why 14 points? One wonders whether this had anything to do with Woodrow Wilson’s Fourteen Points that ended hostilities at the end of First World War... Jung’s attempt however did not end the war of psychotherapies. The project did not get off the ground, and what one can almost call the spontaneous division of psychotherapeutic schools and ever-increasing conflict continued.

Subsequent decades saw the rise of outcome studies in psychotherapy, which were initially attempts to show the superiority of particular brands of psychotherapy, but they notoriously failed to do so ( Erwin, 1996 ). One of the longest running projects was the Psychotherapy Research Project of the Menninger Foundation, a study of 42 subjects over three decades. As Robert Wallerstein (1989 , p.195), then president of the International Psychoanalytic Association, summed up in his abstract of his first report on this:

Psychoanalyses achieved more limited outcomes than predicted; psychotherapies often achieved more than predicted. Supportive mechanisms infiltrated all therapies, psychoanalyses included, and accounted for more of the achieved outcomes (including structural changes) than anticipated.

It was a diplomatic way of saying the project failed to show the superiority of psychoanalysis. In effect, it showed that psychoanalysis had fared no better than what he called psychoanalytic therapies. ¹

In response to the competing claims of the myriad schools of psychotherapy, Jerome Frank in 1961 wrote the classic study P e rsuasion and healing: a comparative study of psychotherapy . ² He put forward the argument that if all forms of psychotherapy seemed to be effective to more or less the same degree, their success was unlikely to be due to a proprietary method or some sort of secret “Coca-Cola” formula, ³ but to generic common features, and it was these which should be studied. This initiative in effect opened up the possibility of a field of comparative psychotherapy, somewhat analogous to the field of comparative religion. But there were few takers for it, as one can understand within this context. What Frank was suggesting was that the resolution of psychotherapy’s identity crisis was the realisation that it had no identity, or its identity had to be on a generic level that encompassed the whole field, making the critical task one of identifying common curative factors. At the same time, the failures of attempts to unify psychotherapy or to converge around agreement on the efficacy of common factors did not stop its societal impact or spread. In fact, one could conjecture that it contributed to it, as there was no clearly defined limit as to what could constitute a psychotherapy, or who could be a psychotherapist.

The rise of psychotherapeutic practices led to the creation of the role of the psychotherapeutic patient, as distinct from the medical patient, neurological patient or church parishioner. This was a new sociological role in the twentieth century. Psychotherapy provided a new idiom of what Talcott Parsons (1991) called the sick role, and one that arguably enabled its extension. It led to the illness, health and well-being of citizens, regardless of whether they were in some form of treatment or not, being conceived on the model of the patient; i.e. we were all considered to be potential patients and our health and well-being were increasingly framed not just in psychological, but in psychotherapeutic idioms. In this manner, conceptions from psychotherapy permeated other discourses and spheres of life and became a fixture. Due to this, the effects of psychotherapy have been hard to escape, but it also renders its history all the more necessary. History can illumine, if not resolve, psychotherapy’s identity crisis by looking at how these clusters of disciplines have come to be, how they have taken up the positions that they have in contemporary societies.

However, this also poses further problems, because this identity crisis of psychotherapy has affected the disciplinary locations from where such histories have been undertaken. There is no journal for the history of psychotherapy; there are no associations for the history of psychotherapy. The first histories of psychotherapies were constructed by their protagonists, and could, in part, be considered as wars by other means. A prime example of this is Ernest Jones’ Life and work of Sigmund Freud (Jones, 1953-1957). This strand continues to be prominent in the works of Freudian apologists such as Elisabeth Roudinesco, Peter Gay and John Forrester. This has led to less take-up of the field of history of psychotherapy from broader historical fields, as the first task is one of de-mythification, undoing the legendary histories which had often been written by individuals that had access to documents which had been sequestered from others, particularly in the field of psychoanalysis (Borch-Jacobsen, Shamdasani, 2012). The study of the history of psychotherapy has been nestled within other, more prominent historical fields, often in the lower case, and has not been accorded the significance that it deserves. The following sketches the interface between the history of psychotherapy and seven such fields, indicating some possibly suggestive ways in which further study of the history of psychotherapy could have wider ramifications. This list is by no means intended to be exhaustive, nor does it present a comprehensive historiography: seven points have been chosen instead of 14 to avoid an unfortunate echo!

The history of psychotherapies in relation to the history of science

Despite decades of relativisation of the status of science, after years of the Edinburgh School, science studies, actor-network theory, the casting aside of demarcation studies and the notion that there is any atemporal or cross-cultural specificity to the word “science,” the discipline of the history of science still tends to concentrate on the study of the history of the established sciences, the so-called hard sciences, the natural sciences, paying much less attention to the history of the psychological disciplines. ⁴ However, it is precisely in these areas that this issue of scientificity takes on a particular role, as one actively debated, given the epistemic insecurity of the psychological disciplines. They themselves were concerned with establishing their own scientificity because they could never take it for granted, and so had to debate the issue of what constituted science within psychology. Within the psychological disciplines, while there has been some attention paid at a historical level to debates regarding the scientificity of psychology, this needs to be further extended to the psychotherapies. In particular, research needs to be done on how the emulation of science shaped the theoretical development of the field as well as granting rhetorical legitimacy to its conceptions. ⁵

The history of psychotherapies in relation to Freud studies

Within the psychotherapies, there has been a dominance of work in Freud studies. A great deal of significant work has been done, but there has been a Freudocentric trend within Freud studies, to the relative neglect of the wider psychoanalytic movement, as well as of the dissemination and deployment of psychoanalysis in different cultural contexts. Much work remains to be done in these fields, as well as on the agonistic interface between psychoanalysis and other forms of psychotherapy. ⁶

The history of psychotherapies in relation to the history of religion and religious studies

While there has been significant work on the rise of the New Age Movement and forms of contemporary spirituality and, more recently, on the mindfulness movement, ⁷ there has been little detailed study of the way in which therapeutic practices have promoted and helped give rise to new conceptions of personal spirituality, indeed to the redefinition of spirituality as a form of self-therapy. In other words, to the psychotherapeutic cast given to trends of spirituality in contemporary societies. The work of Chris Harding (2015) and Gavin Miller (2020) are prominent exceptions here. The complex interplay of new forms of spirituality and psychotherapeutic practices warrants further study.

The history of psychotherapies in relation to intellectual history

There continues to be comparatively less work done in intellectual history as compared to social or cultural history. While there has been significant work done on the history of the self, ⁸ and of the general manner in which psychological conceptions have shaped conceptions of identity, ⁹ there has been little detailed work studying the manner in which psychotherapeutic practices have promulgated new concepts of the self, consciousness, the unconscious and so forth through furnishing formative and transformative matrices. Indeed, without this as one of the motors of these new conceptions, it is hard to see how they would have taken root in contemporary societies. The mode in which psychotherapeutic practices led many individuals to acquire an unconscious deserves further study. ¹⁰

The history of psychotherapies in relation to the history of psychiatry

For many decades, much work followed what could be termed the Foucaldian highway, focussed on the birth of the asylum, asylum histories, and whether or not they followed the Foucaldian mantras of pouvoir/savoir, surveiller et punir or not. The focus on the asylum and on asylum histories came to dominate much of the work in the history of psychiatry for justifiable reasons, given their prominence in the field of psychiatry. They were also easier to study, given the nature of the accessible documents. Only relatively recently has more work been done on deinstitutionalisation. ¹¹ Less work has been done following what could be termed the Ellenbergian byways, or what Mark Micale (1993) once called the Ellenbergian tradition in the history of psychotherapy – the figures of the magnetist, the hypnotist, the dynamic psychiatrist, who became refigured as the psychotherapist – i.e. the whole sphere of private practice as opposed to institutionalised psychiatry.

The history of psychotherapies in relation to the history of medicine

The history of medicine is a developed field, but curiously not much work has been done comparatively speaking on the history of doctor/patient relations in the twentieth century. Nor has there been much study of how psychotherapy grew out of and then increasingly detached itself from general medical practice, nor of what Edward Shorter (1986) called the “informal psychotherapy” of the medical consultation, or the relation between the generation of the concept of the placebo effect and suggestion and autosuggestion in psychotherapy.

In the social history of medicine, little has been done on the place of psychotherapy in the health care marketplace, or choosing psychotherapy as an option for healthcare, or the place of psychotherapeutic practices within a burgeoning health, well-being and spirituality marketplace. Work needs to be done on this, somewhat akin to the work Roy Porter (1986) and others once did on the eighteenth-century medical marketplace.

The history of psychotherapies in cultural history

There is patently the need to study psychotherapeutic cultures, or the role of psychotherapy in forming and structuring cultures – the mode in which psychotherapeutic conceptions and practices have permeated societies. What scholars like Robert Darnton (1986) once did in his work on Mesmerism and the end of the Enlightenment in France for the cultural history of mesmerism has yet to be done for twentieth-century psychotherapies. It would be worth taking up once more the terrain of scholars such as Philip Rieff (1966) on the “triumph of the therapeutic” and replacing their overly broad moralisations and generalisations with detailed historical studies. ¹² There have been significant recent openings in this vein which need to be extended into wider transcultural comparisons. ¹³

What, then, is the specific interest, aside from these seven points, of studying histories of psychotherapies? As we are familiar, “the West” has become a synonym for “the universal.” From this angle, the task of a global history of psychotherapies would simply be one of mapping its origins and subsequent geographical spread. However, such a project would simply represent uncritically subscribing to the assumptions that underlie contemporary western psychotherapies. By contrast, the contributors here argue that in developing a transcultural perspective on the history of psychotherapies, rather than a globalising approach, what is required is a provincialising approach, to borrow a term from Dipesh Chakrabharty. As he put it, “to provincialise Europe is precisely to find out how and in what sense European ideas that were universal were also at one and the same time drawn from very particular intellectual traditions that could not claim any universal validity” (Chakrabharty, 2007, p.XIII). Only by excavating the cultural and temporal embeddedness of Western psychotherapies is one in a position to understand what is subsequently being transferred and adapted to radically different cultural contexts, and in a two-way dialectical manner, in forms of reciprocal networks of exchange. What is required are supple histories that are not encapsulated, but are set in relation to the work going on in the other disciplines indicated above, that both inform and are in turn informed by work in the transcultural histories of psychotherapies.

One of the most interesting and rich resources of the histories of psychotherapy is that the field itself constitutes a site of intersection between psychological theories, techniques and patients. Consequently, these histories have to be at the same time conceptual histories, histories of practitioners, practices and patients’ experiences of these. The aim is not one overarching global history, even if it could be achieved, but plural histories juxtaposed together, not presupposing any overall coherence but studying convergences and divergences, at the same time methodologically plural. Nor is it strictly comparative, in the form of a historical comparative psychotherapy, but it opens up the possibility of comparative insights through bringing disparate forms into relation and connection. This event – and now this special issue – attempts to further this exchange by setting into interrelation and juxtaposition different developments in different contexts without presupposing any unicity or identity to the field, or any monoculture in the way this should be studied. This forms a part of a significant historiographical transformation currently taking place. ¹⁴

In conclusion, we may return to our point of departure. Given our personal involvements and investments in psychotherapeutic practices and discourses, opening up this debate in a transcultural domain gives us the possibility of deeper insights into how we have come to be in this situation. This does not necessarily resolve anything concerning the problems we face as individuals or which face those we are close to. However, it may give us the possibility of a more informed view as to how we landed up in this situation and how we adopted such conceptions or turned to such practices to attempt to resolve them.

ACKNOWLEDGEMENTS

This paper was presented at the third international conference of the Transcultural Histories of Psychotherapies Project, at Fiocruz, Rio de Janeiro, in 2018. I would like to thank Cristiana Facchinetti for organising the event and Fundação Oswaldo Cruz, the UCL Global Engagement Office and the UCL Santander Research Catalyst Award for sponsoring it. The spoken form of the presentation has been retained.

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NOTES

• 1
  Indeed, if the statistics are any indication, 69% showed some degree of improvement in psychoanalysis, compared with 77% in supportive psychotherapy ( Wallerstein, 1986 , p.516).
• 2
  Frank was developing an argument which had been put forward by Saul Rosenzweig (1936) in “Some implicit common factors in diverse methods of psychotherapy.”
• 3
  As Thomas Szasz (1989 , p.149-150) noted in 1963 regarding Freud’s dispute with Alfred Adler, “it was as if Freud had patented Coca-Cola. He did not really care whether Pepsi-Cola or Royal-Cola or Crown-Cola were better. He merely wanted to make sure that only his products carried the original label.”
• 4
  For an overview, see Golinski (2005) .
• 5
  See for instance Woodward, Ash (1990).
• 6
  On the historiography of psychoanalysis, see Borch-Jacobsen, Shamdasani (2012). For notable exceptions to the Freudocentric focus, see Falzeder (2015) ; Ruperthuz, Plotkin (2017); Dagfal (2011) .
• 7
  See Heelas (1996) ; Carette, King (2004); Wilson (2014) .
• 8
  See Taylor (1989) ; Porter (1996) .
• 9
  See Rose (2010) .
• 10
  See Shamdasani (2017) .
• 11
  See Kritsotaki, Long, Smith (2015).
• 12
  For one productive example in this vein, see: Lears (2000) .
• 13
  See Illouz (2008) and Aubry, Travis (2015).
• 14
  See the following special issues and collections: Marks (2017) ; Rosner (2018) ; White et al. (2020) ; Shamdasani, Loewenthal (2019).

Publication Dates

• Publication in this collection
  06 Jan 2023
• Date of issue
  2022

History

• Received
  06 Apr 2021
• Accepted
  18 Jan 2022