Towards transcultural histories of psychotherapies – Sonu Shamdasani
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European Journal of Psychotherapy & Counselling
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Towards transcultural histories of psychotherapies – Sonu Shamdasani
We will build a groundbreaking psychological therapy service in England. Backed by new investment rising to £170 million by 2010–11, the service will be capable of treating 900,000 additional patients suffering from depression and anxiety over the next three years. Around half are likely to be completely cured, with many fewer people with mental health problems having to depend on sick pay and benefits. Gordon Brown, 10 October 2007.1
The so-called Improving Access to Psychological Therapies which Gordon Brown announced had been the result of an initiative by Richard Layard, an economist and Labour peer, and a Cognitive Behavioural Therapist, David Clark.2
The argument that Clark and Layard put forward was recently restated in their book, Thrive: The Power of Evidence–Based Psychological Therapies.
They begin by marshalling an array of statistics, noting that in 2008, the World Health Organisation estimated that in wealthy countries, ‘mental illness accounts for nearly 40% of all illness.
By contrast, stroke, cancer, heart disease, lung disease and diabetes account for under 20%’.3
More than half of this is comprised of depression and anxiety.
As to the proportion of the population thus afflicted, they cite statistics which claim that 27% of the pop- ulation in the EU suffer in some way from mental illness.4
They further noted that in the UK, the economic cost of mental illness amounted to 7% of national income, but we spend 1% of national income to treat it.
Only 13% of the health budget is spent on mental health, which constituted a ‘system-level discrimination’.5
The solution to this lay ready to hand in the form of Cognitive Behaviour Therapy, which, they claimed has brought ‘psychological therapy to a point where it can claim scientifically to be able to transform lives’.6
The persuasiveness of their argument was based on the claim that a short course of CBT would easily pay for itself through reducing economic costs borne by the state due to mental disorders.
The history of psychotherapy that Clark and Layard provide is a simple tale with a happy ending:
Chapter 1. ‘In the beginning was Freud. He was the founder of talking therapies – and in particular of listening therapies. He, more than anyone, taught therapists how to listen …. However psychoanalysis has not been shown to be effective’.7
Chapter 2: Aaron Beck rides to the rescue with the formulation of Cognitive Behaviour therapy, which is the first form of psychotherapy to demon- strate its effectiveness via the evidence-based gold-standard of randomised clinical trials.
By 2011, IAPT had been rolled out to treat 400,000 people and a further £400 million was pledged, with the aim to treat a further 2.6 million by 2015.
The depart- ment of health claimed that the £400 million expenditure would result in savings of £700 million to the public sector in health care, tax and welfare gains.8
CBT was thus one of the coalition’s more unusual means of trying to reduce the deficit.
As has readily been apparent, such massive state investment in and legitimation of one particular form of psychotherapy above others has had massive implications for the ecosystem of the wider psychotherapeutic field, imbricating its micropolitics with the macropolitics of government.
In the field of mental health, we are familiar with the use of statistics for rhetorical purposes, without indicating precisely how they are derived, and the often questionable assumptions behind them.
However, the scale of these figures, coupled with the mass-rollout of the antidote in the form of psychotherapies renders timely historical inquiry into psychotherapies, and the study of how they have come to occupy the positions that they hold within contemporary societies.
In short, to replace Clark and Layard’s legitimating myth of origins with historical inquiry and interrogation.9
First, one may ask, what is psychotherapy?
The term has been applied to almost any form of conversation between two individuals with an aim to enabling a thera- peutic change in one of them.
In 1973, Thomas Szasz attempted to gather together the plethora of definitions of psychotherapy into one: ‘We have come to accept as psychotherapy all conceivable situations in which the soul, spirit, mind, or personal- ity of an individual who claims to be a healer is employed to bring about some sort of change called “therapeutic” in the soul, spirit, mind or personality of another indi- vidual, called the“patient.”’10
This would encompass almost any encounter between two individuals.
The definitional problem poses particular challenges for histories of psychotherapies: not only is one faced with the difficulty of selecting one’s object of study, this choice may play an active role in determining the very identity of the object itself, akin to a historical indeterminancy principle: witness, for example, the active role of historiography in constituting psychoanalysis.11
In the twentieth century, the therapeutic encounter became a site where individ-uals not only were cured, or not, as the case might be; but also learnt to articulate their suffering in new idioms, reconceive their lives (and those of others around them) according to particular narrative templates, and to take on conceptions concerning the nature of the mind and reality.
These were not only illness narratives in Arthur Kleinman’s sense,12 but also what one could call ‘wellness narratives’. Psychotherapy became not only as a palliative for psychological disorders but a form of life enhancement.
As such, it has increasingly become a lifestyle choice. Consequently, histories of psychotherapies must by necessity overflow discrete disciplinary trajectories, and broach broader sociocultural transformations that these practices have given rise to.
Furthermore, psychotherapeutic idioms have come to inhabit the vernacular, and seep into other spheres.
Suspended between science, medicine, religion, art and philosophy, the advent of modern psychotherapies represents one of the distinctive features of twentieth-century Western societies, and they are increasing being exported to the rest of the world.
However, their historical study glaringly lags behind their societal impact and the role they play in contemporary mental health policies in a number of countries. In recent years, a small but significant body of work has arisen studying histories of psychotherapies in discrete local contexts throughout the world, which is expanding and reframing our knowledge of them.
However, little has been done to draw this work together within a comparative setting, and to chart the intersection of these connected histories and transcultural networks of exchange of knowledge and healing practices.
There are signs that this situation is changing.13
But how should this study be undertaken?
Some of the complexities can be seen through considering the current situation in China.
In 2012, China past its first mental health act, which placed in statute the task of promoting psychological well-being and preventing mental disorders.
The act provided state recognition of psychotherapy and psychological counselling, and required medical facilities to provide psychotherapeutic services.
The act was clear that psychotherapy was to be regarded as a medical speciality, but was silent on providing further details as to what psychotherapy is, leaving the task of the ‘technical regulations for the pro- vision of psychotherapy [to] the administrative departments for health under the State Council’.14
Anthropologists have spoken of a ‘psychotherapy fever’ currently spreading across China.15
In recent decades, it has been a burgeoning export market for European and American styles of psychotherapy, subject to complex patterns of interpretation and adaptation.
This in turn has posed numerous questions concerning the relation of Western psychotherapy to Chinese thought.
Some have argued that ‘indigenous forms of psychotherapy have existed in China for centuries’, retrospectively recategorising Chinese medical traditions.16
Such questions are not only historical: witness the mirror developments of mindfulness-based therapies in the West, and of Daoist Cognitive Psychotherapy in China.
In such contexts, the question pressingly rises, what exactly is being imported?
If one looks to the proponents of the import drive, one can get some clear answers: psychotherapy, it is maintained, represents universally applicable methods of treat- ment based in turns on universal and scientifically validated models of the mind.
As we are familiar ‘the West’ has been taken as a synonym for ‘the universal’.
From this angle, the task of a global history of psychotherapy 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, in developing a transcultural perspective on the history of psychotherapy, rather than a global history, what is required is a provincialising approach, to borrow a term from Dipesh Chakrabarty.
As he put it: ‘to provincialize 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’.17
Only by excavating the cultural and temporal embeddedness of Western psycho- therapy is one in a position to understand what is subsequently being transferred and adapted to radically different cultural contexts.
In the practice of translation, one commonly regards the integrity and identity of the source text as sacrosanct.
Paradoxically, in case of cultural transmission, the very act of translation can confer a stable identity to an object which it lacks in its original cultural context.
Here, one cannot presuppose the existence of a stable source ‘text’ to be unproblemati- cally transferred to a target ‘language’, particularly as what is being transferred are not only theories but practices embedded in particular cultural nexuses, involving tacit assumptions, implicit ‘know how’, cultural cues and ritualised forms of hieratic transmission of what Michael Balint memorably referred to as the ‘apostolic func- tion’.18
Consequently, what replication can mean in such situations is rendered quite muddy.19
In place of a centre to periphery model, what is required is the study of, as Kapil Raj puts it, reciprocal processes of circulation and negotiation.20
Thus, com- parative provincialising provides productive opportunities for reciprocal reworkings of monadic histories.
I have argued elsewhere that by the beginning of the twentieth century, the word ‘psychotherapy’ had become firmly established, but it was not the exclusive preserve of anyone figure or school.21
It was variously adopted to refer to a variety of procedures, ranging from mesmerism, hypnosis, suggestive therapy, moral therapy,
Mind-Cure, mental healing, strengthening of the will, reeducation, the cathartic method, rational persuasion, to general medical practice or the ‘art’ of medicine. Histories had started to be written, and contested.
A heterogeneous cluster of ther- apeutic practices had to come to be grouped together under the term, identified as a modern, rational, scientific discipline.
This pre-staged its development in the twentieth century and the vast range of denotation that it acquired.
The term was adopted by an array of divergent practices and disciplines, a development facilitated by the fact that it never was one thing.22
Thus psychotherapy has no one origin, no one clear genealogy, no one father (despite the long-standing rewriting of history by the Freudian faithful).
One can begin a history of psychotherapy almost wherever one likes – which is reflected in the literature on the topic.
We find no consensus regarding which millennia to com- mence with, let alone century.
We are confronted then with a series of ‘connected histories’, to adopt Sanjay Subrahmanyan’s term, which come together, intersect and branch apart.23
‘Psychotherapy’ is a set of historically situated practices, which both embody and produce specific cultural values. Consequently, transcultural his- tories of psychotherapies would at the same time chart how psychotherapeutic practices have come to transform cultures.
Rather than presupposing an essence at the level of the referent, one needs to follow the circulation, exchange and shifting modalities of a network of related practices in different domains.
The papers that follow trace some of these routes, highlighting nodal points and intersections, while remaining mindful of the manner in which histories have been used to construct the very identity of the field.
What emerges is no single narrative, but rather a series of connections and contrasts, conjunctions and disjunctions, which jointly fracture monolithic narratives of the rise of psychotherapies.
These papers arose from a conference at the UCL Health Humanities Centre in 2016, ‘Towards Transcultural Histories of Psychotherapies’, made possible by the support of the UCL Global Engagement Office.
I would to thank the contributors and Akihito Suzuki for their participation.
The conference marked the inception of the Transcultural Histories of Psychotherapy Project, which seeks to promote research in this field through convening workshops and conferences, fostering exchanges and collaborations.
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