On the unexamined presence of psychotherapeutics- an interview with Sarah Marks

From the mid-century up to the present, psychoanalysis has had some extremely militant challengers to the throne, which have, in some cases, exceeded it in terms of institutional power. Behavioural and cognitive approaches are the obvious candidates here, especially in the way they have mobilized trials and ‘evidence base’ for their cause. But there are others: Rogerian counselling has been ubiquitous at particular moments, and, increasingly, Mindfulness-based approaches. And there is an excellent emerging literature coming through that is beginning to address some of these gap. But the fact that non-psychoanalytic approaches have had very little historical interrogation, thus far, has quite significant implications given the status they’ve acquired.

We were delighted in April 2017 to publish a special issue of History of the Humans Sciences, ‘Psychotherapy in Historical Perspective,’ edited by Sarah Marks, currently based at Birkbeck, University of London, as part of the Wellcome Trust-funded Hidden Persuaders project. HHS Web editor, Des Fitzgerald, spoke to Sarah about the special issue – and about how we might (re-)think the history of the psychotherapeutic complex today. 

Des Fitzgerald (DF): Sarah, thanks for taking the time for this interview. Why a history of psychotherapy, now, in 2017?

Sarah Marks (SM): The history of psychotherapy does seem to be having something of a moment right now. There’s recently been the Other Psychotherapies conference at Glasgow, the Transcultural Histories of Psychotherapy conferences at UCL, special issues of this journal, and forthcoming issues of History of Psychology and The European Journal of Psychotherapy and Counselling. So I’m happy to say that this seems to representative of a blossoming field.

The seed for this issue came about a few years back, though. As a graduate student I was very surprised at how fractional the literature seemed to be by comparison with work on, say, psychiatric diagnostics and the ‘Diagnostic and Statistic Manual of Mental Disorder,’ psychopharmaceuticals, or asylums and institutions. I thought there must be others out there working on it, and there were. It’s probably particularly relevant that I came to it initially from trying to figure out how Cognitive Behaviour Therapy become such a significant force in the UK. I don’t especially privilege ‘histories of the present’ as an approach, but I think psychotherapies as interventions – and psychotherapeutic knowledge in broader terms – do have something of an unexamined presence in contemporary society and policy, in various forms. I note that there is currently a growing critique, or even backlash against this in Britain, including from therapists themselves.  So taking a historical approach now makes good sense – it reminds us that these are by no means timeless, value-free techniques, about which there is a clear consensus. And it also helps us to excavate their intellectual foundations, which aren’t always that transparent.

But beyond the ethical or political motivations for historicizing psychotherapy, there’s a fascinating variety of stories to be unearthed. Even just in this special issue, there are vastly different models of mind, debates about cultural or moral decline, questions of identity or normality and pathology, ideas about cure or the nature of human relationships, resistance movements, and the political spectrum across left and right, to name but a few. And that’s just from looking at predominantly West European and North American examples.


DF: For many I think, a Venn diagram showing intersections between the history of psychotherapy and the history of psychoanalysis will more or less form a circle. But I get a strong sense that this special issue wants to prise these two apart somewhat. Is that right? And why, if so?

SM: Yes, you’re right about that. I’m not of the opinion that the history of psychoanalysis has reached its end point, as some have begun to argue. I’m working myself on its legacies in the Soviet sphere during the Cold War at the moment. There still is much to be done there. But it really has overshadowed other approaches in the literature quite drastically.

This could be because psychoanalysis has been very a productive interpretive strategy in the arts and humanities: we’re all familiar with it, and it has been very successful at captivating audiences outside of its clinical setting. It would be hard to say that about, say, behaviourism, or Gestalt. So it’s understandable that we have more histories of it. But its popularity in these spheres, and as an actual clinical movement in the 20th century, has led to a sort of Whiggish dominance of this one particularly successful approach. This has been at the expense of lots of other therapeutics or frameworks, which also had a real impact in their time, but that have now – for multiple, usually contingent reasons – been forgotten. A number of the contributions to the special issue uncover such stories: from late Victorian psychotherapeutics, to some quite peculiar Viennese competitors to Freud, or ways of understanding art therapy and psychosis.

The striking thing, though, is that from the mid-century up to the present, psychoanalysis has had some extremely militant challengers to the throne, which have, in some cases, exceeded it in terms of institutional power. Behavioural and cognitive approaches are the obvious candidates here, especially in the way they have mobilized trials and ‘evidence base’ for their cause. But there are others: Rogerian counselling has been ubiquitous at particular moments, and, increasingly, Mindfulness-based approaches. And there is an excellent emerging literature coming through that is beginning to address some of these gaps: the work of Rachael Rosner on Aaron Beck, and Matthew Drage’s forthcoming PhD on the history of Mindfulness in particular. But the fact that the ‘non-psychoanalytic circle in the Venn diagram’, as you elegantly put it, has had very little historical interrogation thus far, has quite significant implications given the status they’ve acquired.

I would be curious to think more about the nature of the overlap of the two circles. Is there a degree to which we can say that most modern psychotherapies are indebted to psychoanalysis in some sense, in terms of how we have come to structure an interpersonal therapeutic relationship? How have some of the norms of analytic training, or its ethical framework, been kept up by other approaches, which have otherwise emphatically broken away from psychoanalysis? And how have other traditions been formed in explicit opposition to, or in dialogue with Freudian thought? Perhaps we should actually draw out your suggested Venn diagram on a blackboard and see where it leads…


DF: There is of course a well-known view – coming especially from scholars in the wake of Georges Canguilhem and Michel Foucault –that the history of ‘psy’ science tends towards recurrence: that to (as Nikolas Rose puts it) work ‘within the true’, as a psychotherapeutic practitioner, is also to work with a history of the truthfulness of one’s own practices, and vice versa. Do you agree with this view? And where does it leave the historian?

SM: There is something to it. I mention in the introduction to the special issue the question of therapeutic traditions, and Laurence Spurling’s comment that the texts of the founders can come to play an almost Talmudic role in particular professional communities, which can at times lead to a sort of conservatism, or I suppose a ‘recurrence’, to use your quotation. There certainly are dogmatic ‘believers’ out there in the therapy world, for whom the history of the profession is mainly useful for the purposes of legitimising their ways of seeing, which are wholeheartedly assumed to be true. But that’s not a universal stereotype at all.

Working at Birkbeck, I’m currently surrounded by clinicians, many of them psychoanalytic (see this short video, for example). I do observe with curiosity the way they sometimes read or teach historical texts as sources for contemporary practical inspiration. But, at the same time, they also step outside and approach these ‘truths’ as culturally or historically situated, and examine them from a position of critical distance. This isn’t exclusive to the academy either: from interviewing full-time therapists in cognitive traditions, too, I’ve often seen this reflexive tension at play. But, from the historian’s perspective, the problem here is that we’re talking about practitioners in the way they behave and present themselves outside of the consulting room. What actually goes on when they work as clinicians is still mostly a black box to me – and that’s the case for those I am able to talk to, as well as those historical actors that I can only trace via their textual or archival paper trail. This has huge implications for what it means to write about the history of psychotherapy: mostly we’re just reconstructing the edges, without ever actually getting at the therapeutic interaction itself.

So I’m not sure I can fully agree with Rose, that we can say they are ‘working within the true’. One could infer from the evidence that this is probably what is going on, sure. But I often wonder whether it could be the norm that there are slippages around such ‘truths’ in practice, (perhaps especially in a health service where policy dictates that clinicians deliver a particular brand of therapy, which they themselves might be critical of). Therapists might integrate different approaches that contain conflicting truth claims, or they could respond to a situation in a manner which might be guided by more banal or common-sense assumptions, or personal values, that have nothing at all to do with their professed psychological worldview. Or they might tailor a ‘therapeutic alliance’ around the belief system of the client, and work in such a way that necessitates the suspension of their own truths. There could be ways to research this question, to test the theory out a bit better. But as it stands, the historian, as usual, can only tell a partial story.


DF: One of the things that especially strikes me about the special issue – you gesture at this in the introduction – is that the patient or service-user is much more present, as an experiencing subject, than we are perhaps used to in histories of psychology and psychotherapy. How should we think about his shift in the literature (if indeed it marks a shift)?

SM: I’d say the recipient of therapy as an experiencing subject isn’t by any means as present as it should be. Patrick Kirkham’s article in the special issue really does place the service-user (or in his particular example of autistic self advocates and their objections towards Applied Behaviour Analysis, the service-resister) at the centre. And it’s interesting to note that Patrick came at this topic not from an interest in the history of therapeutics, but somewhat tangentially, from conducting his dissertation research on neurodiversity and the autism rights movement.

Despite the fact that the service-user-as-subject is the very point of most therapies, they are usually only implicit subjects in historical writing on psychotherapy. I’m as guilty of reiterating this in my own writing as anyone else, I admit. It’s something that really struck me when I was writing the introduction, looking over what literature existed. It is incredibly problematic, that we have this looming blank space with regard to the experience of the recipient of the treatment, who is often only seen refracted through the gaze of the therapist.

It’s obviously not difficult to account for this imbalance: there are many more archives and published primary sources from practitioners than there are from patients. It’s a classic problem in the history of medicine, but I think historians of other medical fields – even psychiatry – have been doing a better job of addressing it. So I think it’s a shift in the literature that definitely should happen, and which I will look to follow through in my own work. There are some good sources of inspiration in neighbouring fields in terms of more contemporary, ethnographically orientated research. Ilina Singh’s work on children’s understandings of their ADHD diagnosis springs immediately to mind, or Juliet Foster’s monograph, Journeys Through Mental Illness.

On the other hand, there certainly is a theorized, or perhaps imagined, service-user that has cropped up in the work of sociologists, philosophers and historians. I’m thinking here of Nikolas Rose again and his autonomous, liberal ‘self’ who governs themself through psychological technologies. Equally, Ian Hacking’s patient who becomes therapeutically labelled with, and then reinterprets themselves through, a ‘human kind’ such as multiple personality disorder. Or Sonu Shamdasani’s individual who might opt in or out of an ‘optional ontology’ offered to them by psychotherapy, or who may well present to a therapist having already defined themselves in such terms in the first place.

All of these seem to capture something about the psychotherapeutic subject, and intuitively I’d say they are productive concepts to think with. But the interesting question would be to see whether, or how, they hold true in actual service-user experience, and how subjects do – or indeed do not – act in these terms. What might be the nuances of the individual case, or the particular variant of psychotherapy? How might these differ across time period or culture, or down to the level of the particular kind of institution, clinic, or private practice? Or even by the mode of delivery of self-help intervention, which can be many and varied these days? I’d love to see more work on these questions.


DF: The special issue is composed of many (I mean this term, as I guess you do, in its most positive sense) emerging authors in the field – was this a deliberate decision as an editor? And why, if so?

To be honest, it’s because a high proportion of the people doing good work on this topic are at an early career stage, and they were the ones who came my way, by various means. So it feels as though the history of psychotherapy itself is something of an emergent field, even though there have been some really key publications from senior scholars in previous years, as I mention in the introduction. It wasn’t necessarily a deliberate editorial choice from the outset. But there is something to what you have noticed, as this isn’t the only edited volume I’ve been involved with which specifically foregrounds early career researchers. There probably is an implicit ethic there, in terms of wanting to open up space for newer authors, because there is a lot of inspiring new work out there. I have often thought this at recent conferences, that it bodes well for the future of the field.

In other editorial work I’ve done, I’ve also sought to encourage authors from non-anglophone academic backgrounds to publish. I think we can be incredibly North American and West European focused in our field. This doesn’t by any means reflect the quality of research that is being done by scholars elsewhere – it’s just that the latter doesn’t always make it into English-language publications.


DF: You yourself are (if I may use a deeply problematic term) an ‘early career’ scholar working in the history of mental health. I’m wondering, if it doesn’t make you groan too much –what advice would have for others entering the field (I’m think e.g. of those who have recently entered graduate study)?

SM: It’s interesting that you’re so apologetic about the use of ‘early career’. A number of colleagues, probably myself included, have found it quite a helpful designation: it can create a sort of solidarity amongst the precariously employed, and it at least implies that you might be en route to having a career! I’ve been part of a writing group within my department, made up of early career historians, which has been enormously galvanising, both creatively and in terms of pooling advice and information, and mutual support. So I’d advise those entering the field to get organised with those around you, within your own institutions and across the field more broadly. There’s a lot on offer already to help enable this, for postgraduates especially: conferences organised by the British Society for the History of Science, the Society for the Social History of Medicine, the Institute of Historical Research’s ‘History Lab’ etc.

I think another key thing is to start becoming an active member of the research community earlier rather than later. Don’t be shy about submitting work to journals (such as History of the Human Sciences!) once you have a good argument to make, and a strong research base to support it. Peer review can be gruelling, but it does help you shape your work for the better, and responding to that kind of critique is good preparation for the viva, not to mention job interviews. Put in for conferences, or organise your own conference if there’s a theme or question that you think really needs to be talked about more. That’s how this special issue originally came about, from putting out a call for conference papers during my PhD at University College London.

I’m often heartened by how supportive academics in this particular field can be towards fledgling researchers actually, in terms of advice and encouragement, from across different institutions. So I’d say it’s a very good community to be part of.

Psychotherapy in Historical Perspective is available now at the HHS website.

Sarah Marks is a postdoctoral researcher at Birkbeck, University of London working on the history of the psy-disciplines during the Cold War and after, with the Wellcome Trust funded Hidden Persuaders project . She is co-editor (with Mat Savelli) of Psychiatry in Communist Europe

Des Fitzgerald is social media and web editor of History of the Human Sciences, and a lecture in sociology at Cardiff University.