From Psychiatry and Psychotherapy’s Grand Delusion Toward Constructions of a Post-Therapeutic State

Eugene Epstein

by Eugene Epstein, Manfred Wiesner, and Lothar Duda

Over the past 50 years, the psychiatric and psychotherapeutic discourses of the western first world have infiltrated practically every aspect of our culture and society.  The introduction of the new DSM-5 will only serve to further that expansion.  Ways of thinking and speaking about mental states and suffering are across the globe, becoming more and more uniform.   We are all potential patients from within this perspective.

Comparing the DSM-V to the film plot device Alfred Hitchcock termed a “MacGuffin”, one can see how psychiatric and psychotherapeutic treatments continue to grow within health care systems.  Pathologizing individuals as well as camouflaging social and political factors are two sides of the same coin that are helping to pay for this growth.

Against the global trend towards the homogenization of discourses about mental states and mental suffering, we propose the cultivation of diversity in description about such states and suffering.  To overcome the hegemonic tendencies of psychiatric and psychotherapeutic discourses, we sketch the outlines of a possible “post therapeutic world” 

More specifically, we examine possible changes in the training of workers in the helping professions that could result from such a vision.

The Globalization of Western Psychiatry and Psychotherapy

“…the regions of the world with the most resources to devote to the illness – the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions – had the most troubled and socially marginalized patients.” – Ethan Watters

“More than at any other time in history, mankind faces a crossroads.  One path leads to despair and utter hopelessness.  The other, to total extinction.  Let us pray that we have the wisdom to choose correctly.“  – Woody Allen

In her recent work Eva Illouz describes the many ways in which psychotherapeutic, psychiatric and psychological discourses have infiltrated all aspects of our culture and society:

For instance, corporations regularly utilize emotional language and concepts from psychology to optimize the leadership potentials of managers and to harmonize interactions within organizations, all within the larger framework of maximizing productivity and profit.  Illouz (2008) labels this “emotional capitalism” (see also Neckel 2006).  From insurance companies to courts of law, increasingly it is not possible to make decisions or pass judgements without making reference to notions of psychological states or psychiatric injuries.  Schools regularly offer prevention programs to students with the goal of promoting psychological and emotional health (Klasse 2000® 2012; Duttweiler 2013).  Whether one looks at popular American talk shows like Oprah or Dr. Phil, recent docudramas, or the daily tv soaps, one finds that topics revolving around psychological problems are very effective for increasing and maintaining viewer market share.

The multiplicity of creative ways in which pharmaceutical companies have inundated and inculcated us with messages such as ‘there is a pill for every problem’ or ‘better living through modern chemistry’ or ‘don’t worry, be happy!’ are so all pervasive (arte 2010/2011), that we have pretty much come to accept the view that normal emotional reactions to life events like unhappiness, sadness, anxiety or mourning are pathological and indeed correctable with the right combinations of pills (Greenberg 2010; Horwitz & Wakefield 2007, 2012; Kutchins & Kirk 1997).  The booming market for self-help books and psychological advice spurs us on to join the never ending quest for the optimization of our selves, our relationships and our families (Illouz 2008; Sieben, Straub & Sabisch-Fechtelpeter 2012; Straub 2012).

For many years Ken Gergen has written critically of the ever expanding vocabularies of psychological disease or what he has termed the “cycle of progressive infirmity” (Gergen 1990, 1994, 2006).  Viewing psychological discourse from a relational perspective, he raises critical questions of value (rather than truth) about how these terminologies maintain or change patterns of cultural life, how they function within the culture more generally and, whether such terms foster or inhibit more desirable forms of human relationship.

And these expansionist tendencies show no signs of abating any time soon.  Already in 2002, the British Nuffield Council on Bioethics declared the medicalization of everyday life a new megatrend and warned:  “One of the problems resides in diagnostic expansionism, or the tendency to define disorders so broadly that more and more individuals will get caught in the diagnostic net.” (Blech 2003, transl. by the authors).

The medical historian Roy Porter explains that there is an enormous amount of “pressure produced by medical doctors, the medical economy, the media, aggressive advertising by pharmaceutical companies, as well as concerned, and or directly affected lay persons – all pushing to extend the range of diagnoses for treatable illnesses.”  In this manner, doctors and patients increasingly have the sense that “everyone has something to be treated, and that everyone and everything is treatable.” (Blech 2003, transl. by the authors).

Nevertheless, with the promise of global application, the newest revision of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM-5) seeks to further colonize our cultural consciousness by creating a singular incontestable normative descriptive vocabulary for our psychological and social experiences and states.   The former chairman of the task force to develop the DSM IV Allen Frances (2009, 2010), has, in retrospect, become increasingly critical of some of the more negative (if unintended) consequences of his work:  “Our panel tried hard to be conservative and careful but inadvertently contributed to three false “epidemics” — attention deficit disorder, autism and childhood bipolar disorder.

Clearly, our net was cast too wide and captured many “patients” who might have been far better off never entering the mental health system” (Frances 2010, p.1).  More and more critical voices have predicted similar consequences resulting from the new DSM-5.  Based on past experience with psychiatric diagnoses introduced into earlier versions of the DSM, we can expect a stark increase in the stigmatizing identification, labelling and treatment resulting from this newly expanded collection of pathologies

Following the reasoning of Francois La Rouchefoucauld (1665/1988), who in pondering the concept of love, wrote that “There are some people who would never have fallen in love if they had not heard there was such a thing”, we are concerned about the consequences these new psychiatric vocabularies will have upon our daily lives.

Diagnosis as MacGuffin

“One of the most common diseases is the diagnosis” – Karl Kraus

The newest revision of DSM-5 follows the same positivist assumptions of previous editions (Strong 2012), which all serve to support the illusion that it is indeed possible to, with the appropriate technologies and terminologies correctly applied, accurately depict and describe inner states.  Presumably, stronger and more persuasive arguments will be used to legitimate this further “enhancement” to the descriptive repertoire on human psychological dysfunctions.  The prevailing story is one in which this manual will serve to improve the health and well-being of patients because more accurate descriptions and categorizations and diagnoses hold the promise of more accurate and effective therapies.

More uniform descriptions would thus lead to more accurate comparisons of pathological conditions, thus increasing the accuracy of research and therefore improving the health of the general populace.  Regions of the world not yet achieving the full benefit of modern Western (American and European) psychiatric practices, would also achieve improvements in the mental health of their peoples as these vocabularies are made available to their helping and health care professionals.

In a similar vein, critics of the DSM-V and the coming ICD 11 suspect the hidden collusion of the pharmaceutical and the health care industries.  Those who might be delimited as sick or as in danger of potentially becoming sick are of great economic interest to these industries, whereas healthy persons remain relatively uninteresting.

As early as 1923, Jules Romains (1997) wrote an ironic comedy in which a medical doctor successfully manages to turn a healthy community into chronically sick patients, thus presaging how the commercialization of medicine would contribute to the “diseasing” of the population (see also Wulff 1971, and Conrad 2007).  Stating this more pointedly, the Irish psychiatrist David Healy (2009) has described the pharmaceutically supported life with the title of a book chapter “Birth, Ritalin, Prozac, Viagra, Death”. This criticism applies not only to psychiatry, but also to psychotherapy.

Moreover, the field of psychotherapy itself has been heavily corrupted by the money coming from insurance companies, as Bob Fancher (2012) recently pointed out: “We must remember that before psychiatry won its battle to cast intense suffering as a matter of mental illness, the question facing our society – and people suffering intense distress – was not how to treat mental illness. The question was how to understand and treat debilitating distress. (…) For the most part, non-physicians understood themselves to be offering an alternative to medical treatment. They didn’t make the argument, >>We’re doctors, too,<< but, >>We have a legitimate way of understanding and helping human suffering, and people should have the option of looking at their problems as we do<<.”

“In pursuit of money, the professions of psychology and social work have largely abandoned their historical efforts to provide an alternative to the medical model of understanding suffering. Indeed, they have insisted upon, fought for, and funded lobbying battles on behalf of the medical model.” (Fancher 2012)  The idea of disorder-specific psychotherapy has, over the last few decades, established itself into the mainstream of therapeutic thinking and exemplifies the degree to which psychiatric discourse has come to dominate the theory and practice of psychotherapy.  The efforts of psychotherapists and their professional organizations to achieve legitimation (and billing rights) within the health care system have played a central role in this development.

Like Karl Kraus (see above), Jules Romains, who in 1923 suggested that “Healthy persons are those who do not know that they are sick” (Romains 1997, p.18, transl. by the authors), cautions us to maintain a skeptical attitude with respect to the notion of diagnosis.   It is perhaps appropriate at this juncture to pause and reflect critically upon the very idea of diagnosis itself as it is currently applied in the fields of psychiatry and psychotherapy.   Here we will borrow from the analytical perspective developed by the German sociologist Thomas Lemke in his critical reflection upon the concept of the gene in scientific discourse (Lemke 2004).  Lemke wanted to accentuate that it is the very lack of clarity in definition surrounding the term that enables the term to serve a wide variety of potential political and scientific functions.  Recursively, these functions then serve to mask the basic lack of clarity that the concept itself engenders.

In a similar manner, when we speak about psychiatric diagnoses and psychiatric disorders, we are not referring to naturally occurring entities that have empirical qualities or features which can be ascertained and measured with the appropriate scientific methods and instruments.  These diagnoses are not “things” in and of themselves, but rather epistemic entities – entities that cannot be uncovered or discovered, nor can they be simply invented.   Psychiatric diagnoses are the product of recursive interactional processes between technological-historical developments and cultural meaning-making practices.  They are not a starting point, but the result of a coming together of experimental arrangements, theoretical assumptions and discursive practices.

This does not mean, however, that diagnoses are wholly random or arbitrary theoretical constructions that can be changed and overhauled at will.  Rather, the scientific representation of “diagnoses” can be understood as a complex process, one in which cultural factors combine with seemingly technical tools like checklists and tests.  This heterogeneous and flexible web of relationships is then inevitably transformed, naturalized and reduced to something singular and inflexible, namely, the diagnosis.  And this diagnosis, which appears to be the thing that has created this web of relationships and interactions, is actually itself, a product of this very web of relationships (Lemke 2004).

In light of the scientific indefensibility of our current psychiatric diagnosis fetishism, we might question how mental “information” and its supposed predictability for diagnosis has achieved such tremendous standing and importance for the health care system.  Lemke’s perspective, though it might at first glance seem rather unorthodox, offers a possible answer in Alfred Hitchcock’s understanding of what he called a “MacGuffin”.

Hitchcock described the “MacGuffin” as a common plot device typically woven into film scripts.  For Hitchcock, a MacGuffin was a certain kind of object, one which although largely irrelevant in and of itself, was at the same time essential to the film plot.  These MacGuffins, according to Hitchcock, were on the one hand “ridiculous”, “non-existent”, “empty”, and inherently without meaning, and yet, at the same time, the central point around which the entire story turned.  Hitchcock described the mechanism of a MacGuffin using his film “North by Northwest” as an example:

“It’s a spy movie and the only question relevant to the scenario is: What are these spies seeking? Now, during the scene on the Chicago airfield, the man from the C.I.A. explains everything to Cary Grant about James Mason:  ‘What is that man doing?’ The other answers: ‘Let’s consider he’s in import-export of state secrets.’  ‘But what does he sell?’  ‘Oh… just secrets related to governments.’  See, here we have the MacGuffin, reduced to its purest form: nothing. ” (Truffaut 2003/1966, p.127 transl. the authors).

When we begin to think about psychiatric diagnoses as MacGuffins, the question then arises:  which narratives and characters do the MacGuffin or diagnoses serve?  How can we explain the expansion of diagnosis discourse from the time of Freud and Kraepelin until the present?  In keeping with the metaphor of a diagnosis MacGuffin, exactly which “state secrets” are to be found in connection with them?

In the same manner that Lemke critically questions the terminus “gene”, we would like to raise questions concerning the strategic roles played by, as well as the effects resulting from, psychiatric diagnoses in our culture today.  How do psychiatric diagnoses contribute to a general climate of anxiety about deviation in our society?  In what ways does the inflationary use of diagnostic categories serve to misdirect attention away from social problems and inequalities in our society and instead direct us to see individuals as being responsible for their own feelings of dis-ease?  In previous decades, many viewed emotional problems as occurring in conjunction with harmful environmental factors or working conditions, whereas today it is common to speak of “negative individual mental predispositions” or “harmful lifestyles” (such as frequent changes of partner, bad time management or coping strategies, etc.).

Along with increasing the dangers through the expansion of mental deviance discourse, happy endings are envisioned by the psychiatric and psychological research establishments, which promise successful prevention and therapies.   According to this narrative, the multiplicity of human vulnerabilities and frailties are to be combatted via a research-driven never-ending struggle to control and improve upon the mental facilities and mental states of individuals.   But do individuals really have a choice not to join the collective cultural bandwagon in making prevention and therapy the central theme in their personal lives?

Finally, although no one can really define exactly what is meant by the term “normal”, at the same time we experience immense social pressure to be exactly that.  And thus, in a recursive manner, the discourse of psychiatric diagnosis profits from the very anxieties that the expansion of psychiatric discourse in our culture largely caused.  At the same time, psychiatric discourse serves to anesthetize us from various forms of social critique.

And that is the “state secret” of the diagnosis-MacGuffin.  The institutionalized belief in the power of the diagnosis, combined with the idea of an individual psychological predisposition, along with the idea of the individual’s vulnerability to psychiatric illness, allow us to mask social inequalities in society.  If it is our psychiatric predispositions and the mental vulnerabilities which determine our existences, then our positions within the social hierarchy have less to do with inequalities of power and discrimination, but more to do with individual mental differences.

Heiner Keupp (2013), for instance, problematizes the “social amnesia” of current psychotherapy theories and practices.  Other criticisms that psychotherapy serves, on a sociopolitical level, to support and solidify the dominant capitalist social order, can be found in the professional literature of the last half century.

Culture, Language and Mental Distress 

DIE ZEIT: You don’t believe in therapy?

David Foster Wallace: let me put it this way: You cannot live in the world without being in pain, spiritual and physical pain. We have developed mechanisms to deal with these pains, to overcome them somehow. Therapy, religion and spirituality, relationships, material success.  All this can work, but also becomes a problem itself.

In the following, we will investigate alternatives to the discourse of the DSM-5, which fosters uniformity of thought with respect to mental states.  Instead we will describe examples of other possible perspectives, ones that foster diversity in descriptive alternatives.

In the same manner that the early Christian missionaries knew that language was the central and most effective tool for spreading their message, the “elites” of western psychiatry see the globalization of their vocabulary as the key to success.  The means of spreading this vocabulary is through the training of therapists and other helping professionals, who then in turn train lay persons and patients, and along with the help of the popular media, succeed in integrating this vocabulary into every day vernacular. For decades now, citizens of the western world have been schooled in the inclusion of psychiatric and psychological terms in everyday language for describing the self and others (Illouz 2008).  In our western culture, what it is possible to say about our selves and others in every day language has become more and more similar to the ways in which the discourses of psychiatry and psychology describe us.

Ethan Watters (2010) has criticized the global homogenizing of the various narrative options enabling us to describe mental states and suffering, as well as the dominance of western perspectives in this process.  He has warned that in so doing we are at risk for introducing a new form of cultural colonialism, one that negates and disrepects other possible, though non-western, narratives and coping strategies.  In the western first world psychiatric narrative of the so-called post-traumatic stress reaction, the trauma resides in the head of the individual, and it is thus the head that should be the locus of treatment efforts.  Other cultures, however, have developed other more socially oriented narratives of trauma, which point toward treatments that promote and strengthen the individual’s social ties and the person’s social role in the culture and community (Bracken 2010; Wulff 1978).

From within a cultural historical perspective (Frevert 2011; Illouz 2012), one observes an historical transformation of culturally accepted norms for the expression of emotion.  Our ways of dealing with suffering, for instance, have changed radically over the last century, so that the currently dominant psychological and psychiatric narratives, which ascribe a universal meaning and naturalism to the emotions, are called into question.  In contrast to earlier epochs, suffering in our current western culture, according to Frevert and Illouz, is less acceptable and more likely to be seen as disturbing and undesirable. Expressions of suffering today are more likely to be answered with a rather mechanistic reflex, expressing a desire to either help or to treat, to repair or to eradicate the suffering.  In contrast, during the Romantic Era, expressions of suffering would more likely have been closely associated with expressions of one’s personal character, and indeed have been encouraged, even proudly displayed, rather than rejected or annihilated.  In the Romantic Era, suffering helped to build character and expressions of suffering were viewed as signs of strong character

In the 1960’s and 1970’s, the fields of ethnopsychiatry and transcultural psychiatry were already investigating the many ways in which differences in culture and language influence the expression and treatment of mental suffering.  The psychiatrist Erich Wulff (1978a), for example, has described how the lack of a common term for “I” or “me” in the Vietnamese language is of tremendous consequence with respect to the diagnosis of and responses to deviant behavior. 

The American psycholinguist Lera Boroditsky (2010; 2011) has more recently presented research impressively illustrating how different languages, with their different grammars, can affect our ways of seeing and understanding the world and indeed our very selves.  Languages differ, for example, in the ways in which personalities can be described.  In Yiddish, one can find a large number of noun categories descriptive of the broadest range of personality types.  According to Boroditsky, linguistic descriptions using nouns such as these have a greater tendency toward permanence than descriptions using only adjective or verb forms.

Thus, the language people use can be a strong determinant for whether they assume personalities to be modifiable or not.  Gregory Walton & Mahzarin Banaji’s research on cognition and language also supports this perspective when they conclude:  „These results imply that language may be an important vehicle through which we create and maintain our sense of self: who we are, what our attitudes are, and perhaps even who we would like to be.” (Walton & Banaji 2004, pp. 208-209).

Coming from a more philosophical and historical perspective, Ian Hacking (2006) explores “how names interact with the named”.  He describes a “looping effect” or recursive process in which persons classified in a certain way tend to conform to or grow into the ways that they are described.  In addition they also evolve in their own ways, so that the classifications and descriptions have to, in turn, be constantly revised.

In light of this research, we might ponder the implications of the noun dominated diagnostic vocabulary upon the range of our possible experience of self.  What does it mean to “have” a depression or a paranoid personality disorder and what consequences do such descriptions have for the possible ways in which we can live our lives?  How does this vocabulary of character and personality traits influence our views on character or personality development and change?  With the addition of recent research on the nocebo effect, we might question how our commonly used language categories influence our expectations and also our feelings, thinking and actions.

What exactly might the perpectives described above imply with respect to our thinking about the DSM-5?

The idea that our current languages are full of assumptions hidden or otherwise (Boroditsky, 2011), that the possible meanings of words and sentences can only be ascertained from within the historical, cultural, societal, local and other discourses of which they are inextricably a part (Wittgenstein, 2011/1953), and that meaning might better be conceptualized as being constantly in movement and flux (Gergen, 2009), all these ideas appear to have been ignored by those promoting the DSM-5.

The DSM localizes so called psychiatric disorders within the individual and neglects societal, cultural and historical perspectives.

The DSM in its newest revision thus makes claims for its universal application, independent of these issues.  The move toward grammatical and cultural uniformity in the vocabularies about the mind and social interaction along the lines of psychiatric and psychological discourses results, in our view, in a closing down of possibilities with respect to our thinking about ourselves, others and the world in which we live.

Therapists and clients, whose ways of speaking become ever more similar, are in danger of maneuvering into a discursively reductive dead end.  Therapeutic questions become prompts for “educated” clients to produce the preferred therapeutic sound bites (BOAG 2010).  Any and all communications that are seen as unconnected to this particular language game/world become less and less desirable and thus less and less possible within this context.  Other possible systems of meaning generation lose their hermeneutic relevance within the therapist-client interaction.

The possibility that a client in psychotherapy could describe his or her perception of another person that only s/he can perceive, and not be understood as expressing some form of disturbed consciousness or mental disturbance or psychotic symptom, but rather be understood as expressing a particularly rich form of creativity, an inventive form of protection against loneliness, a way of creating other perspectives, or in short, as a unique talent, is within the realm of mainstream western psychiatry pretty much unimaginable.

The languages of psychology and psychiatry have become hegemonic, and that is their greatest flaw (Watters 2010, Illouz, 2008). Ken Gergen has, for many years, warned of the reduction of possibilities that results from the hegemonial dominance of preferred psychiatric discourses at the expense of other alternatives:  “… the strongest constraints about what can or cannot be said about mental events are linguistic in nature.  All that we might say about thinking, emotions, motivation and other such psychological phenomena is dependent upon our current language conventions.

And this notion confronts psychological theorists with a special difficulty.  When the theorist is forced to go beyond the current language conventions in order to explain something of particular interest, then s/he is forced to change the dominant ways of speaking.  From this perspective then, a change in the use of metaphors is required:  the introduction of speech conventions from alternative contexts.” (BOAG 1990, p.47).

The Evolution of a Post-Therapeutic State

“The world…can change from one moment to the next, for our reality is always but one possibility out of many.” – Etgar Keret

“In the post-modern narrative we can give up the modernist obsession with psychic measurement, diagnosis, classification and normative therapeutic intervention”. –Harry Goolishian

The assumption, that it is possible to capture and categorize with absolute certainty and singularity the experience of the psychological and the social, is indeed an assumption that we believe needs to be called critically into question.

In order to explore this question further, we look toward other academic disciplines and the arts for inspiration. Referring to the arts, for instance, it is our opinion that the film Brownian Movement (2011), represents a cineastic attempt to reflect upon our therapeutic culture and society, along with all its diagnostic and therapeutic instruments, as a very problematic delusion of grandeur.  The film’s main character, a medical doctor, begins to display very strange and inexplicable behaviors.  The psychotherapeutic methods and techniques geared towards understanding and repairing these strange behaviors simply don’t help.   This raises the interesting question as to how particular human behaviors might otherwise be described and discussed, if we reject the therapeutic vocabularies.

The idea of multiple subjectivity has been reflected in a great variety of current literary and artistic works and provides another perspective for appreciating ambiguity.

Taking an example from the writer Alexander Kluge, we should hold psychotherapy discourses open and welcoming for that which outside of these discourses might be of significance, even when that might appear to be something vague and impossible to decode, in order to provide the person or client with the possibility of retreat without becoming silent or acknowledging one’s insanity:  “My person is a palace with many rooms, and I can decorate each room such that it is always possible for me to withdraw there.  And at the same time I remain sociable and am in the chat room of our society.  I am more than a human being, I am many.  When the information continues to expand, then we will transform ourselves into polyphonic living beings” (Kluge 2009, transl. by the authors).

A cursory look towards other academic disciplines can provide a variety of ideas that might also prove useful in expanding and opening therapeutic discourses.  For instance, the sociologist and systems theorist Peter Fuchs (2011), in keeping with the views of Paul Valery, describes the fields of human interaction and the psychotherapies as fields dealing with vague things.  From this perspective it is exactly this non-specificity and uncertainty of meaning that is specific to the psychotherapeutic enterprise, not the production of clarity or certainty.

The sociologist Werner Vogd (2013) views our current society as a polycontextual society, in which semantic and cultural plurality are dominant features.  It is not our blind faith in the myths of our dominant culture, but rather the ability to move among all of these multiple discourses without clearly identifying with one or the other, that makes psychotherapists to be, from his perspective, modern “shamans”.  Such a helping professional “would grasp and maintain the complexity with respect to life.  This complexity is an important feature of our society, that which prevents our society being imprisoned within the dominant culture.”

In earlier times, Michel de Montaigne (1533 – 1592) too could be viewed as a wanderer between different intellectual worlds.  He applied his skeptical and anti-essentialist philosophical perspective toward the avoidance of generalizations, steadfastly upholding a perspective that was dependent upon cultural, contextual and individual factors (Montaigne 1998; Perler 2011).  It is with these ideas in mind that we would like to begin to question and envision just how constructions of possible post-therapeutic worlds might look, sound and feel, worlds that have evolved beyond the narrow limits of psychiatric and psychological discourses and that are self-conscious with respect to their possible social and political implications.

A critical reflection about our existence as “living beings in language” plays a particularly central role once more here:  “The original critique of language, which is today long forgotten, has to do with the question of what sentences can cause, independent of whether they are correctly or incorrectly written.  What was important, was which content and facts were glossed over, hidden or covered up by which senseless phrases and turns of speech.  What was important was what sentences silenced, as they were spoken.

And what was important, was what was hidden within the texture of a text, and what perhaps might forever remain hidden.  In the original critique of language, which is today long forgotten, the critique always contained a critique of those who have the power to speak, who are allowed to speak openly, who have the power to name and label and define.  An original critique of language is without a critique on the author of the dictionary unimaginable.” (Orheim 2008, p.13, transl. by the authors).

In a first attempt to delineate the outlines of a possible post therapeutic state we believe firstly that the training of psychotherapists needs to be conceptualized anew, so that cultural, societal, social, historical, linguistic and political aspects acquire a more central space.  Secondly, a university education would no longer be constrained by the confines of a particular discipline, be it medicine, psychology, social work or what have you.  Therapists, regardless of whether they will continue to be called therapists or not, will no longer be simple providers of a particular professional trade, but knowledgeable collectors of the widest range of possible reality narratives that our polycontextual society engenders.

They would be equivalent to curators from the art world, who can offer a range of possible reality narratives for every specific conversation.  They would take the specific problems and question of meaning that the clients bring to the situation and develop together a diversified range of meaning constructions, not constrained by psychiatric or psychological vocabularies and languages, yet offering, without pressure, certainty or need for consensus, to reflect together with these clients upon the possible consequences of such constructions.

In a never ending journey throughout one’s professional life and beyond, they would wander among the various and diverse language worlds, instead of narrowly specializing within psychiatry and psychology speech.  Such a reality curator should have had the opportunity to study in many fields (such as philosophy, literature, sociology, culture studies, history, art, anthropology, psychology, medicine, pedagogy, to name but a few).  Indeed, even the natural sciences along with their world views should not be neglected. 

The training of therapists would come to resemble more a comprehensive liberal arts education than training in a professional craft.

The linguist and ethnologist Daniel Everett (2012), who has become well-known for his research in the Amazon,  has cautioned that the diversity of languages to be found throughout the world are part of our cultural treasure, and that when a language dies, we lose richness and diversity with respect to range of possible worlds we might envision and create.  In a similar manner, we argue for a new conceptualization of the therapeutic state, a new conceptualization of psychotherapy that turns diversity in language and thinking into useful tools and agents, tools that in turn may be useful in our never ending search for meaning.

In closing, we make reference to a short dialog between Johnny Depp (Don Juan de Marco) and Marlon Brando (Dr. Jack Mickler) in the 1994 Hollywood film, “Don Juan de Marco”, in which Don Juan presciently points toward a post-therapeutic future beyond what the naked eye can see:

“B (Dr. Jack Mickler): Why don’t we talk about who I am.

D (Don Juan): Yes I know who you are.

B: Who am I?

D: You are Don Octavio de Flores the uncle of Don Francisco de Silva.

B: And where are we here?

D: I haven’t seen a deed but I assume this villa is yours.

B: What would you say to someone who said to you that this is a psychiatric hospital and you’re a patient here and I am your psychiatrist.

D: I would say that it is a rather limited and uncreative way of looking at the situation.  Look, you want to know if I understand that this is a mental hospital.  Yes I understand that.  But then how can I say that you are Don Octavio and I am a guest at your villa, correct?

B: Yaa…

D: By seeing beyond what is visible to the eye.  Now there are those of course who don’t share my perceptions, it is true…”


1 Maintaining consistency with their future vision of a “post therapeutic world”, the authors have adopted a narrative style that is not confined by the structure of scientific psychiatric and psychological discourses.

2 For Illouz, “Psychology is a cultural formation in which a mass of written texts come to organize and structure the practices and modes of speech of oral interactions.”  These texts “offer scenarios through which actors can cognitively rehearse their emotional experience and reflect on others’ emotional transactions and expressions.  By doing so, actors make sense of their own (and others’) feelings, subtly prescribe rules to manage emotions, and provide a vocabulary and a method of introspection.  This is exactly how psychological texts insert themselves into action.” (Illouz, 2008, pp. 17-18.)

3 See also Günter Burkart (2006):“The Individualism is a new form of transforming social events and interactions into individual motives and actions, individuals, in turn, integrate these individualized descriptions into their own self-awareness and self-description (…).  People experience themselves as individuals, responsible for their own fates and circumstances, individuals that have classified and interpreted themselves, and individuals that have, in end effect, constructed themselves (p. 17, transl. by the authors).

4 See for instance Horwitz & Wakefield 2007 and 2012, and Wakefield 2010.

5 See, for example, Angelika Meier‘s novel „Heimlich, heimlich, mich vergiß“, 2012.

6 “For drug companies, … unlabeled masses are a vast untapped market, the virgin Alaskan oil fields of mental disorder” (Kutchins und Kirk, 1997, p.247).

7 See Francois Truffaut’s interview with Alfred Hitchcock (Truffaut 2003/1966).

8 For a sampling of such criticisms see Zaretsky 1976/1986, Kovel 1981, Foucault 2006, Jacoby 1975, Deleuze & Guattari 1972/2004.

9 i.e. in the contexts of self help or pastoral counseling or prevention  programs (burn-out prevention at work or drug and suicide prevention efforts in schools)

10 For example, within the framework of psychotherapeutic conversations, psychoeducation seminars or health information brochures, to name but a few.

11Just how much the infusion of psychological and psychiatric vocabularies into other discourses like economics, law or health insurance, to name but a few, have in turn influenced the further spread and development of these psychological and psychiatric discourses themselves, has been illustrated in the works of various authors such as Illouz (2008), Duttweiler (2013) and Keupp (2013).  Stefanie Duttweiler, finds a strong resemblance between psychotherapeutic concepts like “self-actualization” and “self-responsibility” and concepts found within the language of neoliberal economics like “the entrepreneurial self”.  She questions whether the expansion of the therapeutic concept of prevention presents a danger, transforming the self into an “investment object”, one guided by market principles and mechanisms.

12 The notion that how we think about mental phenomena is culturally and historically embedded was proposed a century ago, by one of the founding fathers of modern psychology, Wilhelm Wundt (1913).  According to the sociologist Werner Vogd (2013), this idea has become lost as psychology rejected its original ties to philosophy while moving to develop into a scientific discipline over the last century.

13 See also Paul Valéry‘s (2011, pp. 141-165) thoughts on language. “The effect of language on thinking has received much less attention than the effects of language intermingling with thinking.  What I mean, and I have expressed this too, is that in the majority of cases, the preexistence of words and forms in any given language shapes our thinking more that it serves to express it, eventually developing our thinking in a direction different from that which it originally meant to take.  From a very early age we have incorporated these words and forms so deeply into our selves that we no longer distinguish them from our organized thinking – precisely because they are, as soon as thinking organizes itself, already a core part of our mental productions, thereby setting the tone for concepts that foster our illusion of being extremely clear, or extremely strong.” (ibid. p. 146).

14  Hacking describes this effect as follows:  „Being seen to be a certain kind of person, or to do a certain kind of act, may affect someone.  A new or modified mode of classification may systematically affect the people who are so classified, or the people themselves may rebel against the knowers, the classifiers, the science that classifies them.  Such interactions may lead to changes in the people who are classified, and hence in what is known about them.  That is what I call a feedback effect.  Now I am adding a further parameter.  Inventing or molding a new kind, a new classification, of people or of behavior may create new ways to be a person, new choices to make, for good or evil.  There are new descriptions, and hence new actions under a description.  It is not that people change, substantively, but that as a point of logic new opportunities for action are open to them.“ (Hacking 1995, p. 239)

15 See Barsky et al 2002; Di Blasi et al 2001; Rief et al 2006; and Spiegel 1997.

16 The American pharmaceutical industry launched a mega-marketing strategy to introduce „Depression“ into Japan at the beginning of the 1990‘s.  Inventing a phrase that fit well within the Japanese language and culture, they called depression a kind of common cold or “flu of the heart”.  This allowed the Japanese to transform this once rare psychiatric disorder into a description commonly incorporated into their everyday language.  Within a decade the market for anti-depressive pills grew from nothing to a multi-billion dollar industry (arte 2010/11).

17 Critics of the role played by psychotherapy in our society (Keupp 2013; Duttweiler 2013) have made the argument that the neoliberal economic and social orders are better served through the promotion of individualism than through other conceptions of the person.  For instance, it is easier to ascribe failure in personal or economic spheres as a personal failure of the individual than to ascribe it to political, social or economic factors.  Thus, it is the individual that is offered up as the target for “repairs”, and not, other factors or processes.  According to the sociologist Colin Crouch, “naïve neoliberalism” is not particularly successful as an economic theory, but it does “reflect the interests of the rich and powerful, and says exactly what they wish to hear (…).  It has to do with power, and interests, but not success” (Heppe & Mühlhausen 2012) and consequently, not really with the health of the individual either.

18In earlier times, psychological and psychiatric discourses were introduced into the culture and were viewed as novel and unusual and therefore, provided an alternative way of making sense or meaning.

19 Inviting and, at the same time, rather clever examples of deconstructing psychiatric diagnostic certainties may be found in the satirical and humorous writings about this theme from Martenstein (2012) and Levy (1992).

20 See for instance Weber, 2010; König 1981/1965; Mayröcker 1988; Pessoa 2003; Dix 2005; Gergen 2009; Reckwitz 2006; and Welsch 1990.

21 The German social psychiatrist Klaus Dörner (2001) has, in keeping with this idea, written about “philosophical counseling” as an alternative to therapy.

22 A triple pendulum functions in a manner that engenders unpredictability with respect to the future and one might posit parallels to the arena of the „therapeutic“ in which the therapy may be viewed as being closely associated with unpredictable futures (Hausa 1999)



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Eugene Epstein
Steps to a Post-Therapeutic Future: With a strong interest in how popular culture and psychiatry/psychotherapy reflexively influence one another, Eugene writes critically about aspects of the therapeutic era or therapeutic state in which we, (that is, those of us living in parts of the western first world), find ourselves.

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  1. Going beyond psychiatry’s delusions to a post-therapeutic state.

    Since I sometimes miss articles, I was going through some of the older/recent ones and I found this fantastic article by Eugene Epstein I hadn’t seen/read. It has a lot of food for thought about how the barren pseudoscience of psychiatry is used as a virus to infect all of us world wide to become the “therapeutic state” of stigmatized zombies, so we are silenced, terrorized and bullied to believe that all the environmental stressors, dictates and even so called “therapeutic language” inflicted by the corporate elite or current robber barons can be found in our faulty brains to force us to march to the tune of the same deadening drummers beating us into insensitivity and their “waste land” of “hollow men.”

    “If a man does not keep pace with his companions, perhaps it is because he hears a different drummer. Let him step to the music which he hears, however measured or far away.”

    Henry David Thoreau

    More great, inspiring Thoreau quotations great for psychiatric survivors trying to hang on to their own unique, precious selves:

    T.S. Eliot’s poem, “The Hollow Men”

    T.S. Eliot’s poem, “The Waste Land”

    • Wow. Donna’s quotes from Thoreau (I live only a few miles from Walden Pond), and from Tom Eliot (how about “putting on faces for the faces that we meet”?) meshes perfectly with Eugene Epstein’s remark:

      The training of therapists would come to resemble more a comprehensive liberal arts education than training in a professional craft.

      I was an English major (only made PFC in the American draft, where there are different ranking standards) but had chemistry, Greek history, music, four years of Public Speaking (an hour per week, mandatory). And even took Rats 11/12, a sobriquet we bestowed upon our illustrious fellow Alum, Burrhus F. Skinner. Those of us in the course were of the general opinion, affirmed later in life, that “psych” was a literary, words thing, having little or nothing to do with science BUT “desperately seeking science” cred by “quantifying” (as in “counting”) everything in the gestalt the science wannabes inhabited, wanting to free psych from “the ineluctable modality of the obscure,” if I remember the phrase correctly.
      This may be somewhat unfair, but given our People’s History of the United States: 1492 to the Present (Zinn, final ed, 2010 or so, which we’ll be forced to repeat if we fail to learn from it (learn about Invisible Gorillas in our midst, learn about The Creature From Jekyll Island, learn from the history of such fine scientific efforts as MK-Ultra, created/facilitated by a powerful Paperclip, we will have to eat it. Or repeat it, if GMOs are not your cup of genes.
      Our kinokunst appreciator, Dr Epstein, picked the perfect quote from Woody Allen, indeed–unending despair or extinction.
      I’m thinking that things like the “flyers” passed around by our “See Something/Say Something” gummint officials requires an immediate amelioration of DSM V–revision, more like, to DSM 0.0, written, like Zinn’s History, from the perspective of the 99% minority. (How can 99% be a minority? Turn to Liberal Arts and Animal Farm: All Animals Are Equal. But Some Animals (1% of ’em) Are More Equal Than Others.)
      We would have “Tourette’s ‘I’m Mad As Hell, And I’m Not Taking It Any More’ Extra-Fenestral Declamation Disorder.” (238.05). We could have “Lying Politician-Induced Reverse Peristalsis Syndrome.” (833.22?) (Surely someone has written a contrarian take-off on DSM, highlighting the”population control,” “Squelch All Dissenters Pathology,” the “Neutralize and Beat Petitioners for Redress of Grievances Reflex,” and concomitant “Restore Order Disorder,” (124.02, 3). You get the idea. (hafta come up with a bumper-sticker disorder, too. Esp. for things like “Question Authority,” and “Re-think 9/11” and “What WMDs?” Seems to me that people can “quantify” and “systematize” and “standardize descriptions” of human (and canine, and feline, for good measure–leave out the parrots, as they’re too lippy) conduct/behavior all they want, and they will not a science make. Unless they like weighing Fatty Zucker rats their whole life long. But the effect of nano-particulate aluminum accretion on the human brain, now maybe we have something worth studying.

  2. language in general is infinitely complicated. ‘health’ is not, or is not necessarily, separate from ‘distress’ or ‘disease’, especially when those words are used at their ‘rawest’ levels. there is nothing essential–that is, about us as people– to ‘correct’. there is nothing problematic with us; we are beautiful and gentle and biased all at once!