Ahmadi, J., 2011. What are the most dominant Reciprocal Roles in our society?. Reformulation, Summer, pp.13-17.
This paper will develop reflections upon the issues engendering the most dominant Reciprocal Roles in our society from a personal political perspective. My reflections regarding the dominating characteristics of the contemporary relational environment and how they are structured and restructured through our individual experience will be based on my experience of participating in the ongoing process of bringing mental health issues to the forefront of any battle for social justice. This is an ongoing process that generations, not only of mental health professionals, but also of people supporting human rights, have actively promoted. I shall refer to personal experience and to two clinical vignettes in order to illustrate how the Reciprocal Roles that I have identified contribute to a shared understanding of patients’ difficulties.
In the ‘70s reforms to the Italian psychiatric system attracted considerable international debate and I was among a group of volunteers who campaigned for investigations to take place in some of our infamous asylums. Entering for the first time into an asylum in the South of Italy was an unforgettable experience. Patients were kept in large dirty rooms where they had no personal space, no personal objects or items of clothing, no furniture and no residual sense of their identity and dignity. They were wearing worn out, dirty gowns and some of them were kept locked in tubs filled with cold water and with their own body fluids. The investigating panel found evidence that physical, emotional and sexual abuse were long-established practices and massive doses of sedatives the only treatment option available to patients.
My work in mental health services and my understanding of Cognitive Analytic Therapy developed many years later. Therefore, only in recent years have I made sense of my early experience of mental health services using a CAT framework. I still remember my first impression when we were engaging in endless negotiations to try and gain access to the asylum where staff had barricaded themselves against the investigating panel. Although information had leaked out regarding the cruel situation of the patients in the asylum, when we finally gained access we were shocked and it was hard to witness what human life can be turned into when we barricade ourselves in what I shall define the Dominant Self State (see SDR 1). I felt as if the suffering ghosts populating that nightmare had been allowed only a no return ticket to hell.
After having been confronted with the incongruities of Italian society, and now facing with the ever-increasing challenges of the modern NHS, I often wonder if there was no return for me either after my experience as a volunteer, and whether I have been offered/have purchased a ticket of a similar kind.
More and more often we practitioners express our concerns about the gap between the theories underpinning our approach to patients’ care and the actual practice, and between policy making in Whitehall and delivery of care in the local community or in inpatient services. It feels as if organizational structures hinder innovation by switching rapidly from one Self State to another. The Dominant Self State traditionally supports the view of powerful professionals helping helpless and hapless patients and the idea that targets, aims, aspirations can be set without consulting patients and staff working directly with them, or without taking into account the outcome of any consultation process. This leaves us feeling repeatedly silenced, crushed and exploited.
As a result, some individuals resort to the Rebel Self State (see SDR 1) and, by threatening the organizational structures, hope they might experience a short-lived, turbulent sense of power. Alternatively, they might allow organizations to seduce them and their patients into their ruling order through the mirage of empowerment and safety by switching into the Acceptant Self State. (see SDR 1). “Change”, as defined by the latest policy/government papers, is blindly, fatalistically or/and opportunistically accepted or recklessly sabotaged.
“Empowerment” seems to be a key word to express the growing support for advanced directives, which might afford people a degree of influence over their lives, should they fall into psychiatric hands. It is often assumed that the capacity of an individual to empower himself is closely related to his willpower and to his capacity to influence the environment to his benefit. Psychotherapists are supposed to play a key role in helping individuals - at least the few who are offered therapy after a very long waiting time - to develop this capacity by submitting to anything of up to 1000 different supposed vehicles for change.
However, when looking at human well-being, a host of factors comes into play such as social organizations and structures, political, economic, ideological and cultural influences that can and often do adversely affect the individual’s subjective well-being. People suffer emotional harms engendered by damaging environments rather than by their damaged characters, emotional problems seated in social conditions rather than in inadequacies of the individual. It would take an extraordinarily inhuman therapist to exclude all social variables and, when this is the case, it contributes to an understandable growing distrust of miracle cures based mainly on willpower.
In 2005 Morrison et al. edited a series of papers, which illuminated the personal and social factors, especially in early life, which appeared to be related to problems commonly diagnosed as ‘psychosis’, describing at least two-thirds of people with a ‘psychotic’ diagnosis (such as ‘schizophrenia’) having experienced emotional, physical or sexual abuse. They also reported that, in almost every country where surveys have been conducted, the public believes the causes of psychosis are more likely to be adverse psychosocial events and circumstances (like poverty, trauma and abuse) than biogenetic factors. (Morrison A., Read J. & Turkington D., 2005)
In order to try and understand the role that psychotherapists might play in developing an understanding of mental illness through the construction of what Tony Ryle has defined, with a certain level of optimism, as
“an infinitely rich and complex critical and oppositional dialogue” (Ryle, 2010)
I shall refer to the ideas that Thorlindsson expressed in 1983. He wrote,
“the object of consciousness is a product of human activity and is apprehended as such. Knowledge is the knowledge of objects integral to people’s relations to the world, and these relations rest on practical human activity” (Thorlindsson, 1983).
He also expressed the need to reconstruct his theory to cover adequately the three-sided interface between macro and micro levels of social organization and cognition. Thorlindsson has expressed an alternative view to Chomsky’s (1986) and Levi-Strauss’ (2006) who have conceptualized cognition as being the foundation of social organization. He believed that cognition is influenced by social organization at both the micro and the macro levels, but he felt that whilst the micro level (constraint vs. cooperation, position vs. person-oriented interaction) can be fruitfully related to cognition, the macro level (modes of production, division of labor) couldn’t.
Vygotsky (1978) and Mead (Miller, 1982) expressed more positive views regarding the capacity of individuals to play a role in influencing modes of production and power relations in society, although they agreed that all elements of human activity must be objective before they can be made subjective. They viewed personality not as a product of social discourse, but a self-created aspect of concrete social dialogue. Their fundamental claim is that our awareness and capacity to reflect on social rules that determine our relation to the world can shape and define our internal and external activity and allow choices that seem almost impossible. But does this view retain any positive, credible potential in the present political climate?
If we view both the social situation that we are confronted with and the self that acts within it as a product and an agent of the social rules which structure the exchanges between individuals, it might not be difficult to predict the powerful symbolic representations produced through the imperative of “maximizing resources”, that is to provide improved quality services with up to £ 20 billions “efficiency savings” to be made in the NHS budget for the next four years (Department of Health, 2011). There is a legitimate suspicion that words and definitions are increasingly becoming a function of the asset-stripping plan, intended as a cynical ploy to opening up markets for private consortiums to fill. At the same time, the latest guidance document published by the Department of Health clearly states that healthcare professionals are ultimately responsible for the quality of care provided to patients, ratifying a radical shift from the ethos of collective responsibility for public health.
Therefore, we are more likely to be bombarded with information regarding the positive developments in cancer treatments, rather than offered explanations on the great difference in survival rates among cancer patients in England compared to other European countries (Coleman et al., 2003; Parkin et al., 2005) and on how this might relate to differences in funding of public healthcare services. Great emphasis is placed on differences in lifestyle as a major factor impacting on physical and mental health. Once again responsibility is given back almost entirely to the patient. Eat well, sleep well, do not smoke, stay active and do not drink excessively, the chanting feeds the blaming and self-blaming culture and legitimizes the possibility to deny care to those who are not able, cannot afford, do not have the knowledge, the motivation, the willpower to lead the perfect, healthy life in the perfect body-mind and, perhaps even to those who do and yet became ill.
In one of his latest articles Tony Ryle suggests,
“Our culture, although predominantly hierarchical, has many voices. We can replace a passive acceptance of the ideas of the socially dominant with an exploration of an infinitely rich and complex critical and oppositional dialogue.” (Ryle, 2010)
Also, he acknowledges that although
“psychotherapists are well placed to recognize the harmful effects on individuals of both current and internalized historical and social factors” (Ryle, 2010)
we often fail to explore these factors with our patients. Tony Ryle warns us against the temptation to join the sleepwalkers and encourages us all to attend to the ultimate as well as to the intimate. The question remains “Why don’t we?”. Has the explanation to do with our wish to stay in the no-longer-so-comfortable role of “experts” or with the inadequacies of our tools, and hence with a suspicion that therapy cannot make any claim for offering solutions to the difficulty of living?
When I was working in a medium-secure service with offenders diagnosed with a mental illness, I felt that the life histories and mental health difficulties of a number of patients were difficult to describe in terms of pathological symptoms or experiences. An example illustrating my difficulty refers to a young African man who was admitted following his attempt to commit suicide by setting fire to his bed on an acute psychiatric ward.
When he was ten years old he had witnessed the death of his parents when a truck exploded over a mine during a civil war. He had become a child soldier and the fighters had introduced him to the use of weapons, alcohol and drugs. As an adolescent he managed to escape and to reach a refugee camp beyond the borders of his country.
He suffered all sorts of infectious diseases that nearly killed him and he managed to survive until an international organization brought him to the United Kingdom. He felt finally safe and was planning to go to school and make a fresh start in life, when he was raped by a priest who was involved in the rescuing operation. He started again abusing alcohol and drugs and having psychotic experiences.
Fire had become intrinsically associated with life and death throughout his life; he understood that the fire that he had set could have potentially caused harm to many people. Nevertheless, he found it very difficult to make sense of the repetition of Punishing events in his life, leaving him always Punished for actions that he felt had been mostly out of his control.
Was there any kind of effective support that anyone could offer to such a wounded human being? What model of therapy could help him to come to terms with the enormity of his losses? He had not been allowed to take anything for granted in his life; his parents, his country, his childhood, his freedom, his physical integrity or his mental cohesion.
“in the absence of ‘high-tech’ and highly fraudulent medical explanations for (his) problems in living” (Szasz, 2001)
I could not see any point in going along with professionals who forcibly injected him with toxic chemicals, or in supporting those who attempted to brainwash him with psycho-education, while describing him as someone who gave them “the chills”. I felt powerless in the face of the patient’s extreme suffering, entrapped into the Rebel Self State, my dialogic perspective confined to the language of battle and struggle.
Despite developments in theory and practice which suggest that particular constructs of mental illness obfuscate society’s implication in its aetiology, in the present political and economic climate there is an increase in the use of medical explanations and of partial formulations of patients’ difficulties, focusing on the educational rather than on the relational aspects of therapy. This approach is supposed to be cost effective and to provide help targeting specific areas of need while promoting patients’ independence and self- reliance. In fact, the changes feel like nothing short of asset-stripping. Individuals suffering from severe problems in living causing depression, suicidal ideation, PTSD, etc. are instructed to “recover”, that is to return as soon as possible to a level of functioning consistent with the needs of an inefficient, resources wasting, profit-led society.
Our role seems to have become about claiming to get people back to work and off benefits. Someone with a potentially life-changing spell of madness or mortifying sense of estrangement will quickly and not so softly be pushed back into a job with the kind of pay and conditions of service the therapist and the policy maker likely left behind long ago. In order to contribute cost effectively to these operations of social engineering, services must operate with inadequate funding, no reliable research base and inconsistent and under-funded staff training.
On this perilous ground the possibility that an empathic human relationship might develop between pressurized professionals and disillusioned patients turns almost into a bet with little probability of success. Therefore, some professionals have chosen to be open with patients about limits imposed to their work. This level of disclosure has helped them to retain capacity for therapeutic work even when feeling Silenced, Crushed, Exploited, Precarious, Dispensable, Repudiated and Alienated (see SDR 1).
Furthermore, for this draconian plan to take effect, language is one of the main tools and the media through which politicians and policy makers gain influence over the behavior of others. The possibility that language retains its capacity to combine mediating and transformative qualities is threatened by the growing power of the media employed to manipulate language. The aim is to prevent it from reflecting the subjective experience of a large number of individuals in our society, who are finding it increasingly more difficult to transform the solo singing of their discontent into a well-orchestrated, powerful discourse. Should a reliable candidate aspire to the role of lone prophet crying in the desert, he would have very few chances to have his story published in any influential textbook or evidence based journal, and even if he were offered the possibility, would it matter when confronted with the power of the media employed to silence, dismiss and repudiate him? In the Internet era, the attempt to turn human voices into meaningless noises seems to proceed in a paradoxical parallel with the developing possibility for any author to instantly publish her/his writings on the net.
As a woman and a therapist working in frontline services, I have often struggled to find my position in such dilemmas. I have always endeavored to help patients to find a balance between a narrative focusing on painful, intimate experiences and a narrative to help us both to define our role in relation to the powerful historical and social forces contributing to the patient’s difficulties of living.
I feel that the process of mapping these forces allows patients an opportunity to become aware that a Blaming to Blamed Reciprocal Role has often been re-enacted in all its variables throughout their lives. On several occasions this prevents them from recognizing the real constraints impacting on their capacity to gain a sense of agency and authorship for their choices. Blaming others or the Self becomes instrumental in confirming a general sense of failure without having to name and define the powers at play.
I introduced these additional layers of meaning in my work with a patient diagnosed with Borderline Personality Disorder. During our first meeting she expressed her wish to become more Trusting of others and of herself, and that others would view her as someone who could be Trusted. The patient’s capacity to formulate an Exit during the first session and to express this in terms of a helpful Reciprocal Role made what seemed to be a very promising beginning for a course of CAT. After having struggled for most of her life against very adverse life conditions, she seemed determined to express her wish to break the cycle of marginalization and despair that she felt was entrapping her.
She manifested her determination to change through her commitment to mapping her unhelpful Reciprocal Roles and Procedures and to finding alternatives to what she defined as her Pressure Cooker Self State (Blaming/Hurt-Needy-Jealous).
She took several well-planned positive actions. She stopped abusing alcohol and drugs and tried to involve her partner in her choices. She spent a long time and great energy in establishing a healthy lifestyle including physical exercise, eating fresh food and structuring her day with constructive activities. Also, she became more assertive when negotiating her needs with her partner. Nevertheless, these plans seemed to be disrupted by major arguments leading to her taking large overdoses of medication and ending up at the A&E Department of her local hospital.
After her first crisis since beginning therapy, she began to describe how difficult it had been for her to admit that she had become more dependent on her partner. She had moved into her partner’s flat since her own council accommodation was in a state of severe disrepair following repeated flooding caused by her upper floor neighbour. Central heating and plumbing had been damaged and were not working. She described her neighbour as a drug dealer who organized parties for his customers almost every night, playing loud music and allowing his customers to behave without any consideration for other tenants’ needs.
On many occasions she had reported this situation to the Council and to the Police and she had asked for other tenants to sign a petition requesting an anti social behavior order against the drug dealer. None of the other tenants had joined in her efforts because they were afraid that the drug dealer would retaliate. Furthermore, representatives from the Council and the Police had dismissed her claims. She received a letter from the Council stating that they felt that they could not resolve the issue, since the conflict was caused by differences in life style due to her mental health needs (Manic Self State: Blaming/Guilty – Punishing/Cursed) (see SDR 2).
She recognized that she had started to spend longer periods of time at her partner’s following her unsuccessful attempts at resolving the issues with her accommodation. She came to realize that this had significantly affected their relationship and the way she saw herself within it. She felt increasingly powerless since she had taken on board the full responsibility/control of the practicalities of their lives. Her partner had responded to this by extending the time that he spent out with his friends abusing alcohol and drugs, and by disregarding her need for emotional and practical support during a very testing time of her life (Depressive Self State: Dismissing/Precarious -Pleasing/Repudiated – Distancing/Alienated) (See SDR 2).
These conflicts escalated to the point that she found herself back in her empty, cold, and noisy flat while her partner denied her access to his flat where she had moved her furniture and her belongings. This situation replicated her early experiences in life and brought back painful feelings of exclusion and rejection. When she was eleven years old she reported her father had sexually abused her from the age of six. She ended up being taken into care while her father had told her siblings and everyone in her village that this was happening because she was a troubled child, a family breaker.
She became painfully aware that every attempt that she had made to regain power and control over her life, her body, and her space had resulted in an ulterior loss of power. By mapping the areas of her life where she had been deprived of power and control, she could finally separate her responsibility from others’. She experimented with alternatives to her relentless self-deprecating procedures by coming to terms with her vulnerabilities and with her need for practical support and human solidarity. This gave her an opportunity to distinguish between the objective and subjective factors influencing her capacity to be Trusting and Trusted. At this point she was able to start planned actions to address her long lasting housing problems and to regain access to her belongings in her partner’s flat with the support of advocacy services (Exit: Protecting-Trusting/ Safe-Trusted-Valued) (see SDR 2).
Although each of my patients’ experiences is unique, common themes seem to emerge. Therapy can be instrumental in assisting individuals to gain an historical sense of the Self in order to understand the historical roots of their powerlessness and to define the early social context determining their vulnerabilities. The search for opportunities to extend the individuals’ capacity to exercise a level of control over their lives and their environments cannot be confined to a purely subjective experience of one’s difficulties, removed from an understanding of the power status of individuals in relation to their lived social experience.
As therapists we are constantly confronted with issues of power and powerlessness since they are an integral part of the way individuals negotiate their presence in the world. We work with
“real individuals, their activity and the material conditions under which they live are real, both those which they find already existing and those produced by their activity” (Marx, 1847)
Eric Fromm (1984) described powerlessness as a result of social and economic conditions and how this leads to escape in what he defined as the authoritarian or compulsive character when the subject at the same time conceives himself as free.
In order to prevent the risk of extreme dissociation, our constant shifts between the different Self States that I have defined as Dominant, Acceptant and Rebel must integrate through an active reflective perspective. I feel that we might be able to find Exits only by keeping a reflective eye wide open on our socially and historically constructed need to inhabit all different layers of meaning of those Self States and by continuing to be real individuals engaging in real activities through real roles. This might allow us to move between the dialectics of power, in which we are all more or less enmeshed, and the dialogic perspective to which we can aspire.
How further will an oppressive system violate our rights and the environment where we live and work before we begin to challenge the traditional definition of roles in psychotherapy and in society?
Psychotherapy as is more predominantly defined and as we are most often demanded to practice resembles
“the image of an oak tree planted in a precious pot (…). The roots spread out, the vessel is shattered” (von Goethe, 1796)
The potential limited and thereby negligent view of ourselves as self-sufficient means we deny our contribution to and dependence upon society. Long ago we hoped to reject the Cartesian notion of the primacy of self-consciousness with a secondary rank accorded to the perception of the external world and other people. I feel that only a more rounded culture of social Self might foster an ongoing integration of the experience in between Self States and between Self States and the realm of a collective subjectivity to be developed through Affirming/Participating/Transforming experiences (see SDR 1).
Perhaps, as an alternative to traditional psychotherapy, we need to focus our work more directly on
“the ordinary humanity of the therapeutic relationship and its role as a source of solidarity rather than a technology of change" (Smail, 2005)
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