‘What is therapy’s value, and how do we decide this?'

Rosemary's thinking draws on her wide reading and a hugely varied career. She initially studied the violin at the Royal Academy of Music, and later qualified as a music therapist. Her work in the field of music therapy led to an undergraduate degree in psychology followed by training in Counselling Psychology. She went on to complete a PhD and full training in psychoanalytic psychotherapy.

For over 25 years, she worked as a psychologist and psychotherapist within the NHS. I asked Rosemary to summarise her thoughts on the relationship between psychology, psychoanalysis and psychotherapy within mental health services.

Creating anxiety in a market for care

'Over the last few years, I have been developing a way of thinking about the intersection of psychology, psychoanalysis and psychotherapy in the organisational dynamics underpinning NHS mental health services. Psychological therapies services are incredibly important in society. Historically, people who are mentally ill or distressed have always been regarded with a degree of fear and anxiety. You could say that mental health services and institutions have been set up to help society deal with unwanted sources of anxiety; they are unconsciously tasked by society to act as collective "containers" for people who evoke anxieties about mental illness and "madness".' I asked Rosemary if mental health services actually achieve this. 'Unfortunately, they are often organised in ways that create anxiety rather than contain it.

For example, the NHS's Improving Access to Psychological Therapies programme (IAPT) has been developed and organised, not to deal with the rapidly increasing levels of anxiety and depression in society, but rather to promote "wellbeing", happiness and financial productivity. This agenda is undoubtedly creating anxiety, particularly in staff.'

Rosemary also feels that the NHS demands 'ever-increasing activity levels and ever-better clinical outcomes for ever-more complex clients, leaving practitioners themselves exhausted, burned out and depressed. We know this from the British Psychological Society's Workplace Wellbeing Survey. It seems to me that the underlying philosophy of neoliberalism promoting a market-driven approach to mental health care is itself driving the very rise in emotional distress for which people want help!'

I asked Rosemary how she felt this worked. 'The difficulty is that when people arrive at their local mental health service, they find the notion of "relationship" has been replaced with the notion of "transaction". They feel as if they are being treated more like a number than a person. The negative effect on people's trust in public institutions that are supposed to care for the vulnerable in society has been profound. We urgently need to find a different way of thinking about and providing therapy in the public sector – I examine many of these issues in my academic papers, and more recently in my book The Industrialisation of Care, which I co-edited with Catherine Jackson.'

Perhaps, Rosemary argues, we need to ask such questions as: Why has there been such an increase in psychological distress? Why do we need initiatives like IAPT? Is the medical model helping or hindering psychological care? 'I have recently tried to address questions like these in my capacity as Chair of a Working Group within the House of Commons All-Party Parliamentary Group for Prescribed Drug Dependence. I have been working with a large group of psychotherapeutic and psychiatric colleagues to examine the impact and cost of long-term anti-depressant, tranquilliser and other prescribed psychiatric drug use. We're developing guidance for psychologists, psychotherapists and counsellors who are working with clients struggling to manage or reduce their psychiatric medication.'

Given this context within which public sector psychologists work, what, in Rosemary's view, are the implications for the types of therapy used?

We resist knowing things about ourselves

'I find it remarkable when psychoanalysis is presented as old-fashioned, out of touch and unscientific! Of course, it's often used as a kind of "straw man" comparison with therapies that are promoted as more modern and more "evidence-based", such as CBT. Yet all contemporary forms of psychological therapy derive from psychoanalytic ideas and concepts. We take it for granted these days that traumatic experiences result in emotional and physical symptoms; that the sexual abuse of children is widespread and that it is extremely harmful; that we see in others the very things we don't like about ourselves; that we have difficult, ambivalent feelings about our parents and so on. All forms of psychotherapy take these and many other ideas – including the basic idea that mental distress can be helped by talking! – as given.'

Rosemary then says that the important thing about all psychoanalytic approaches, along with other insight-oriented therapies, is that they take the idea of depth work seriously. 'Psychoanalysis recognises that change is difficult, that we resist knowing things about ourselves; and as much as we want to change our lives, we may also find change frightening and anxiety-provoking. Recognising these complicated and often unwelcome truths is crucial to effective therapeutic work of all kinds.'  

'As far as the vexed issue of clinical outcome is concerned, there is now a huge amount of high-quality research demonstrating that psychoanalytic psychotherapy is in many cases more effective than other forms of therapy. For example, the Tavistock Adult Depression study in 2017 found that 44 per cent of patients given weekly psychoanalytic psychotherapy no longer met the criteria for a major depressive disorder compared to only ten per cent who were given treatment as usual. After a two-year follow up, 30 per cent of those who had received psychoanalytic psychotherapy continued to show improvements compared with only 4 per cent of those who had received treatment as usual. Those receiving the psychoanalytic psychotherapy also saw significantly more benefits to their quality of life, general wellbeing and social and personal functioning.'

Only part of the picture

One of the fascinating aspects of talking to Rosemary about these issues is the way she draws on different areas of knowledge and activity. Her interest in fiction informed the next stage in our discussion.

'The kind of knowledge that emerges from outcome research is only part of the picture. I've become very interested in a particular kind of knowledge that emerges from psychoanalytic work itself. This is what I call "in the room" knowledge, acquired when we are working with our clients. It seems to me it's very different from the kind of knowledge that is acquired from experimental studies or academic reports.'

Can you give an example, I ask? 'Countertransference is an experiential form of knowing that can help us understand something about the client's internal world. It's a form of lived experience that brings into existence a kind of "knowing" that is far more real, far more immediate and much more personal than the kind of "knowing" we acquire from scientific or intellectual study. Literature, particularly fiction, can really tell us something here. In some of my writing at the moment I use fiction – for example, novels by Henry James, Kazuo Ishiguro and Isaak Dinesen – to tease out what we can learn about this vivid, experiential, deep kind of "knowing". For me, literature can help to illuminate aspects of therapy in a particularly evocative way, and I see fiction as an important counterweight to the prevailing obsession with therapy as a medicalised, "evidence-based" practice.'

The two cultures?

Rosemary recently presented a paper to psychology and psychotherapy trainees called 'What is the value of therapy?', drawing on the 'Two Cultures' debate between F.R. Leavis and C.P. Snow. She gave me some background.

'Snow's original lecture in 1959 outlined what he saw as the existence of two, mutually exclusive cultures: the culture of science and technology on the one hand; and the culture of literature and the humanities on the other. Snow thought that advances in science and technology were the best way to ensure the UK's future prosperity, health and security. But the literary critic F.R. Leavis's rebuttal in 1962 critiqued this position, arguing that the kind of knowledge offered by literature is radically different from the kind of explicit, cognitive understanding privileged by the natural science model. He argued passionately that this is the kind of knowledge that underpins our experience, sense of identity and moral purpose in the world.'

Rosemary explained that the word 'value' in the title of her paper is key to her thinking. 'What is therapy for? What is its value, and how do we decide this? In our current neoliberal zeitgeist, it seems to be the "clinical outcomes" of therapy that determine its perceived value. But we might want to remember that outcome measures only reflect the kinds of values favoured by society – or indeed the values a government might want to promote, in the case of IAPT. This is why, in some services, there is a kind of "surveillance culture" constantly monitoring reduction of symptoms, activity levels and employment. But do we really think, as a profession, that therapy is all about returning people to work?'

In her paper Rosemary discusses the need for what Leavis calls the 'third realm': a space where informed debate and discussion can take place between different professions and disciplines as a way of consensually deciding on questions of value. 'Here at the University of Roehampton, we have an amazingly diverse range of therapy training programmes, so you could say the university itself is a kind of "third realm" where students can begin to critically engage with each other and with staff from a variety of different disciplines about issues that have a direct bearing on what we think therapy is for.'   

I suggested to Rosemary that some people might see this as a return to arguments about the art versus science debate in therapy. 'I don't think so. Of course evidence-based practice and scientific research are important. It shows us if something works. What it doesn't show us is whether something is worth pursuing in the first place. In my work, I try to speak up for a certain kind of sensibility, a certain kind of knowledge that I happen to think is worth pursuing. Depth is important and that's exactly what psychoanalysis offers: a respect for the deep complexity of the human being.'