Lucy Howe, 2013. The ethical implications of social class in the practice of CAT. Reformulation, Summer, p.36,37,38,39.
Research indicates that mental health cannot be understood without a considering the broader socio-political and economic context of our lives. More mental and physical health problems are reported amongst the socially and ï¬nancially disadvantaged (Sayer, 2005). A review of the literature conducted across the UK, USA, Canada, Australia and the Netherlands showed that increases in psychological conditions were associated with indications of inequality such as unemployment, low income and poor education (Melzer et al., 2004).
Research has indicated that therapists believe that working class people are likely not to want or are able to make use of therapy (e.g. Leeder, 1996; Smith, 2005). Sue and Sue (2003) found that clients who did not display middle class values were more likely to leave therapy prematurely.
To understand societal attitudes to poverty and class requires consideration of our political context. We live in a society which attributes ï¬ nancial and social advancement to individual achievement. Kearney (1996) points to the legacy of the Thatcher years and ‘Individualism’ where hard work was seen as being rewarded through progress, status and wealth. Kearney (1996) argues that the working class are by no means free from social constraints. The relatively recent Milburn Report (2009) found lower levels of educational attainment in lower socio economic groups. In 2010 the Home Secretary announced that a clause in the Equality Act (2010), which requires public authorities to consider social and economic inequalities when implementing policies, would be removed since it was tantamount to 'socialism in one clause'.
Given the links between class and mental health there is a surprising lack of research into these inï¬‚ uences within the provision of therapy.
My working life has predominantly involved counselling people with different class positions to my own. However, issues relating to class were rarely voiced (by me or others) in discussion or supervision and never given clarity or focus in any training. In the Handbook of Equality, Diversity and Human Rights (2010) given to employees of Sussex Partnership (my employer) very small mention is given to class when compared to disability, gender, race, religion and sexual orientation – on which there are compulsory training days.
Balmforth (2009) found that middle class therapists did not voice issues relating to class and the clients themselves did not mention these, even if they subsequently acknowledged that they were relevant to the problem that had brought them to therapy. Other research has found that in seeking reasons for ill health many will underplay social adversities and do not mention poverty (Blaxter, 1997; Cornwell, 1985).
Consequently psychotherapy fails to acknowledge the social oppression which is responsible for much personal distress since therapy itself is shaped by the same ideological forces. Ryle (2010) cites Freud's theory of the Superego as an internalised representative of 19th century ruling class: an internalisation of reciprocal roles of ruler to ruled and thus reï¬‚ects the ideology of capitalist culture of nineteenth and twentieth century society.
Welch (2000) argues that the way we understand the complex relationship between political and psychological forces is central to how we intervene with clients. A philosophical debate around how therapists view 'the self' is relevant here since this implies different interventions, therapeutic goals and research methodologies. There is a dilemma between an individualistic view of the self as an autonomous being or a Foucauldian view in which the ‘autonomous self’ is an illusion constructed by dominant discourses in liberal capitalist societies and that consciousness is created by social inï¬‚uences, beliefs and practices.
Contemporary society and popular culture encourages us to take an individualistic approach. Furedi (2003) illustrates how this culture persuades us that psychological distress may be relieved simply through therapeutic insight, motivation and a competent therapist and much of Western therapy is based upon this premise.
To take account of class and the embedded oppression, we need to consider an alternative view of the self i.e. the social, dialogic, non- individualistic understanding whereby subjectivity is wholly determined in line with social norms and values . Pollard (2001) questions how this may mean viewing mental health as a social concern rather than individual psychopathology, thus creating a 'double bind' for therapists around issues of knowledge and inï¬‚uence. Therapeutic endeavour could be rendered meaningless, with clients better served by community workers. Pollard (2002) goes on to suggest after Jellema (1999) that taking this view in its extreme form would mean not accounting for theories of motivation as well as individual concerns e.g. around attachment and loss.
Although CAT may be considered an individualistic approach, its theoretical inï¬‚ uences and speciï¬ c tools have potential to consider the impact of class on the therapeutic process and thus provide an exit from the above dilemma. Drawing on Vygotsky's understanding of social formation of the individual self it encourages consideration of the wider inï¬‚ uences that create social norms and values. These inï¬‚ uences suggest a post- modern subjectivity whereby the self is socially created and dialogic. However CAT theory also subscribes to the cognitivist information-processing model of the procedural sequence model. Thus, in relation to class, CAT can acknowledge the impact of social oppression and adversity upon working class people and also support individual change in ways of relating to that oppression.
Ryle and Kerr (2002) propose that the unconscious contains values relating to external social and political reality as learnt through parents and teachers experienced as reciprocal roles. They also question 'who does the therapist speaks for?' and acknowledge how a therapist may internalise societal values: 'the neutral therapist is a myth, tacitly he or she is either challenging or identifying with current social power'. Ryle (2010) goes on to propose that becoming aware of our 'tacit social assumptions' is as important as any self knowledge acquired through personal therapy.
However, they also suggest that 'all psychotherapists should aim to be free of normative cultural values’ - a contradiction noted by Toye (2003) and Brown (2010). Brown (2010) argues that Ryle fails to see the relationship between political and psychological internalised oppression: that he calls for awareness of social context power and injustice but seems to see social controls as 'enforced by psychological rather than material means' (Ryle, 1990). Further she argues that there is no consideration of the potentially damaging aspects of occupying a privileged social position in the therapy relationship as described below.
Several have commented on how therapy overlooks the issue of power within the counselling relationship (Smail, 1999; House, 2003). Strawbridge (2003) argues that ‘far from being value free, therapy plays a key role in constructing and maintaining socio-political structures and power relationships’. Thatcher (2006) proposes that the British Psychological Society Code of Ethics does not give sufï¬ cient attention to the political impact of power within our society and consequently inherent in the therapeutic relationship. Although it states that psychologists should have 'sensitivity to the dynamics of perceived authority or inï¬‚ uence over clients', Thatcher points out that this implies that 'authority' is seen as a 'perception' rather than a fact, which is a point of debate.
Proctor (2002) describes how therapists who are traditionally from a more powerful social group carry ‘role power’ within the counselling relationship. This exacerbates a power imbalance already in place; the client is vulnerable and has come for help and on the therapist's territory. Moreover, a working class client seeking counselling on the NHS has no power to choose who they see, what type of therapy and for how long.
Although CAT advocates collaboration between therapist and client, therapists inevitably carry social power especially when a middle class therapist is working with a working class client. Toye (2003) warns of a superior to inferior reciprocal role evolving that may privilege a therapist's conceptualisations and understandings which are seen as the norm and, if left unchallenged, may undermine the therapeutic task. Without self-reï¬‚ ection a therapist may fail to recognize class issues and related discomfort may mean they are not explored collaboratively.
As a School Counsellor, children were instructed to see me as a response to poor behaviour and, as a middle- class professional employed by a powerfully normative institution, it seemed that children could easily be disempowered by the relationship before counselling began. I can also see now how, new to this post, my work was hindered by class-based meaning structures. Often, I would ï¬ nd minimal response to my early questions around 'feelings' and would interpret this response as resistance or even deï¬ ance. Only with time and experience did I begin to consider alternative reasons for this lack of response e.g. that children felt silenced and potentially intimidated in front of another middle-class professional from the predominantly middle-class institution from which they were being excluded. Alternatively, it was possible that these children and young people were unable to have a dialogue around their feelings. The ability to respond is not a spontaneous talent but subject to the impact of adults and wider culture in early years (King-Spooner, 1990). Many of these children did not have experience of this type of dialogue and therefore were potentially equally silenced by questions that they did not know how to answer.
Despite its potential to do so, Brown (2010) argues that CAT does not sufï¬ ciently consider the impact of social adversity on our clients. Unlike other theoretical approaches, CAT has epistemic psycho-political validity (Prilleltensky and Fox 2007), since it recognizes the relationship between political and psychological factors in mental health. However, Brown proposes that it lacks transformative validity whereby this recognition is incorporated into techniques.
Through developing a Psycho-social checklist, Harris, Lucas, Pollard and Toye, (2004) aimed to facilitate discussion about the impact of social positioning and invite clients to reï¬‚ ect on social and political factors in relation to those that brought them to therapy. This encouraged CAT therapists to think beyond an object relations approach which may impact on reformulation and the therapeutic relationship. By helping clients become more politically aware of social injustice, it is hoped that feelings of responsibility for their own mental distress will diminish and the complex links with reciprocal roles be made clearer.
The Power Mapping technique developed by Hagan and Smail (1997) similarly aimed to diminish a sense of personal responsibility through conceptualising and measuring the relative 'power' held by an individual. In doing so it clariï¬ ed the experience of individual distress as an outcome of social processes whose origin may lie beyond the awareness of the individual. The technique takes account of 'distal inï¬‚ uences' including social and political context as well as 'proximal' inï¬‚ uences. Consequently, reformulation would highlight 'distal' explanations and shift focus from personal responsibility, to an acknowledgement of distress caused by social oppression and adversity, thus relieving feelings of deï¬ ciency and guilt. Hagan and Smail (1997) acknowledge that these inï¬‚ uences may be difï¬ cult to separate and may also be beyond an individual's power to alter. However this awareness may provide a more realistic view of what might be achieved.
Brown (2010) advocates the need for greater psycho-political literacy of therapists and clients. She highlights the challenge of ï¬nding a shared language to describe social inequalities relevant to a client’s reformulation. As a professional from the dominant class, I believe a part of me had internalised notions of classlessness and therefore did not pay heed to important class- related perceptions that could affect the quality of my work with clients. Further, a secondary gain of this internalisation was it allowed me to avoid issues around which I did not feel entirely comfortable e.g. a more to less privileged reciprocal role that could engender an urge to 'rescue' my clients.
Writers on the socio-political inï¬‚uences on therapy have suggested ways CAT tools can be used collectively to help our clients and resist the structures that maintain social oppression within our society. Welch (2000) proposes how reciprocal roles can serve as connecting tools offering insight into wider patterns of responding to social oppression that may engender hope for social change. Brown (2010) proposes collective action through participant led groups focusing on challenging and resisting social oppression, ï¬nding inspiration through a shared experience of adversity. She also suggests that clients of CAT could be represented within ACAT to promote collaborative dialogue and therefore potentially enhance the epistemological and transformative, psycho-political validity of the profession as a whole.
I think that as therapists we have an ethical duty not to collude with the ideologies of our time related to individualism and class oppression. In practice, this means exploration of our own internalised political framework of ideas, which, left unchallenged, would be likely to be a reï¬‚ection of the dominant ideology. There is therefore a need to recognize the reality of institutional classism (Liu & Ali 2005) and to see therapy as a moral, political and existential activity rather than a scientiï¬c, expert-led one (Rogers, 2004). Several have argued that this exploration needs to be instigated in training. Sue and Sue (2003) call for training to expose political implications of therapeutic practice at every level and require students to own their personal value positions
Pop and Arthur (2009) advocate the need to devote more time to reï¬‚ective practice and supervision in order to address internalised stereotypes and social stigma while Smith (2005) calls for more discourse around how professional prejudice interacts with treatment failure.
Finally it may be argued as Hagan and Smail (1997) that this duty extends to exposing social and political sources of personal suffering regardless of whether there are immediate solutions available. These sentiments are echoed by Welch (2004) who calls for collective action to make public private miseries so that we can collectively transform conditions that give rise to individual distress.
I have tried to highlight what I consider to be the crucial ethical importance of considering issues relating to class when engaging in therapy and show how therapeutic research, knowledge and practice have so far provided little guidance for working with these issues. I have argued that therapy has been dominated by contemporary ideologies relating to individualism and classlessness. Consequently therapy has failed to place a client’s distress within a social and material context and thus may unwittingly have contributed to the social oppression that continues to exist in modern society.
CAT theory and tools can provide ways of acknowledging the social constraints that restrict people's lives and the personal costs of overcoming them. The lively dialogue amongst CAT Practitioners that exists around these issues reveals a commitment to recognizing, attending to and exposing the political sources of personal distress. Suggestions have been put forward for increasing awareness through reciprocal roles and reformulations that encapsulate 'distal' inï¬‚uences on mental health. However, there is undoubtedly opportunity for further research and ideas that focus on integrating this class awareness into CAT practice, speciï¬cally perhaps with regards to power imbalances within the therapeutic relationship.
Over time I have realised how my own work has been inï¬‚uenced by the social and political ideology of our time. I have become aware that often I have placed issues relating to class as external to the counselling process. Considering issues relating to class within therapy has meant recognizing the social causes for problems brought to therapy within reformulations, restricting class based interpretations and counteracting power relations being played out within the therapeutic relationship. This has also meant reï¬‚ection on my own class and my relationship to it. In developing this awareness I have learnt the importance of considering class when engaging in CAT.
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