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The Impossibility of
Specifying 'Good'
Psychotherapy
David Smail
Talk given at the Universities Psychotherapy Association
Annual Conference, University of Surrey,
November 1999






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Let me start by reading you a list of personal qualities:-

Kind, sensitive, intelligent, cultured in the arts and humanities,
intuitively perceptive, supportive without being obtrusive,
attentive rather than talkative, attractive, faithful, loves children,
clean and an excellent cook.

It may have taken a while for you to realize, with a mounting
sense of outrage, that what I am attempting to specify here are
the characteristics not of a good psychotherapist, but of a good
wife.

Now, quite apart from the nature of the characteristics selected
(not to mention the extremely politically incorrect odour of the
whole enterprise), what makes the specification of good
wifeliness particularly patronising and offensive is the
embedded assumption that all women need to aspire to a
particular stereotyped role, as though there were only one way
of being a good wife.

My bet is that most people who would find this to be a
thoroughly distasteful exercise would be less appalled at the
notion of trying to enumerate the qualities of a good
psychotherapist. As far as I can see the only reason for so
feeling would be if there was lurking in the back of our minds
the idea that there is, precisely, only one way of being a good
psychotherapist, or one delimitable set of characteristics which
would define, as we are so horribly prone to say these days,
excellence in psychotherapy. I suspect that this notion is indeed
deeply rooted in our thinking about psychotherapy.

When I think back on the numerous patients Ive seen in my
time, however, this is a notion which doesnt seem to be borne
out by experience. Not only have I not been able to help
everyone Ive seen (which, I acknowledge, may indicate no
more than that Im not a good psychotherapist), but I have also
encountered many patients who have been quite clearly helped
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by therapists of vastly differing kinds.

It is true that I have a vagueish idea of the kind of therapist I
would like to see when in difficulties, and I suspect that the
qualities I could adduce for such a person would tally quite well
with lists drawn up by many (but not all) other professional
therapists. It seems likely to me, though, that this is more than
anything a people-like-us phenomenon: we would like to be
seen by people we could identify as being like we like to think
of ourselves as.

But when I come to others in my experience, many of them have
been helped by people extremely unlike me and extremely
unlike I would like to be. I can remember patients being
ecstatically appreciative of help given by people who have
sounded to me: arrogantly dogmatic, directive and certain of
themselves; toe-curlingly sugary and sentimental; deeply and
blindly religious; immersed in rigidly impervious magical
systems of some kind; homespun and commonsensical well past
the point of banality. You could of course say that such people
could not properly be called psychotherapists, and you might be
technically right, I suppose, but, in the cases I can think of, the
help people have derived from these diverse characters has been,
as far as I could see, very real and very important and at least as
profound and as lasting as the improvements identifiable
through more conventional psychotherapeutic approaches.

The only way I can see that would permit us to specify, if not
one single type of good psychotherapist, at least a limited range
of such, would be if psychotherapy were a technical procedure
with clearly recognizable aims and well understood means of
achieving them. Many psychotherapists, of course, do maintain
that this is precisely what psychotherapy is like, and even the
majority of those who dont, act as if it is: after all, we have
degree courses and schemes of accreditation, registers, etc., all
of which suggest there are indeed ways of specifying good
psychotherapy.
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The focus here, of course, is mainly on the procedure, not nearly
so much on the people who carry it out. Despite the considerable
body of evidence (arguably the only consistently persuasive
evidence) that it is the personal characteristics of therapists
rather than therapeutic technique which achieves such
improvement as can be identified in the field, we continue
resolutely to select candidates for training in particular schools
or brands of therapy and we defend these brands, and
seek to register them, with a ferocity utterly inexplicable on the
grounds of demonstrable validity. Any impartial observer of our
conduct in these respects would very understandably assume
that psychotherapy was a quasi-medical, technical procedure
which practitioners could be trained to perform more or less
interchangeably. This, of course, is precisely what the general
public, guided by the media, do assume.

In the guilds we form, the training courses we set up, the
registers we propose, the papers we write and the research we
conduct it is overwhelmingly the assumption of psychotherapy
as professional technique which guides our thought and our
actions. And yet, I suspect, in the privacy of our own minds,
revealed often in unguarded talk in conference bars and so on
(what one might call professional parapraxes), we know that
psychotherapy is not really like this, and that the relation
between therapist and patient is much more a personal than a
technical one.

So why do we cling so tenaciously to a view of psychotherapy
which is not only counter to our own experience but also in fact
unsupported by the vast bulk of the research literature?

The short but inescapable answer to this question is: because it
is in our interests to do so. It is in the interests of those who wish
to earn a living by the practice of psychotherapy to set up
professional frameworks of authorization. It is in the interests of
potential recipients of our services to have available to them
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some way of simplifying the path to relief of their distress. It is
in the interests of those in the academic market who wish to
build an honourable reputation for themselves as bona fide
scientists to conform to conventional models of research using
objectively specifiable variables. It is in the interests of a society
which causes immense damage to huge sections of its
population to represent that damage as the consequence of
essentially individual psychological aberration, in principle
curable through therapeutic intervention.

For the most part, it seems to me, we are, if not blind to, then
extremely confused about the role of interest not only in our
own motivation but in our understanding of motivation
generally. In this respect I cant resist a brief digression
concerning the role of interest in the origins of our discipline. In
this I am largely quoting from a paper I wrote a few years
ago(1).

When I first read them, it struck me how revealing Freuds
letters to Wilhelm Fliess(2) were of the pressures on Freud to
come up with some kind of viable treatment, the practice of
which would earn him a living. What we seem to be dealing
with here, all too understandably, is not so much a dedicated
man of science single-mindedly pursuing truth whatever the
personal cost (a distinctly nineteenth century myth), but, to
switch to the hideous modern business argot, a man with some
innovative ideas seeking to establish a niche for them in the
marketplace. If his patients were motivated by sexual impulses
and wishes, Freud himself seemed activated more by the need
starkly familiar, I suggest, to all of us to keep his head above
water financially.
Let me offer some evidence. The following quotations from the
Freud-Fliess letters are selected for their poignancy; there are in
the correspondence many other instances of Freud's anxious
preoccupation with the means of earning his livelihood.

In his letter of 2.11.1896, for example, Freud expresses worry
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about 'the state of my practice this year on which my mood
always remains dependent' (my emphasis in this and subsequent
quotations).

Things have improved somewhat by 6.12.1896, 'after having for
once enjoyed the full measure of work and earnings that I need
for my well-being (ten hours and a hundred florins)...'

A couple of months later things are even more promising
(8.2.1897):

I now have ten patients in treatment, including one from
Budapest; another one from Breslau is due to arrive. It is
probably one hour too much, though otherwise I feel best
precisely when I am working a lot. Last week, for example, I
earned 700 florins
- you don't get that for nothing. Getting rich must be very
difficult.

In one of the most interesting letters (21.9.1897) in the
collection - that which announces to Fliess the beginnings of a
shift in Freud's theory of neurosis from seduction to fantasy -
there is a continuous theme of financial insecurity running
alongside his reasons for abandoning some of his previously key
contentions (e.g. that fathers could so often be involved in
'widespread perversions'). The letter opens with Freud's
observation that he is '...impoverished, at present without work',
and acknowledges later on that: 'The expectation of eternal fame
was so beautiful, as was that of certain wealth, complete
independence, travels, and lifting the children above the severe
worries that robbed me of my youth.' Towards the end he regrets
that 'it is a pity that one cannot make a living ... on dream
interpretation!'.

Perhaps most revealing is the confession which, among other
things, discloses Freud's evident habit at this time of referring to
rich patients as 'goldfish'. It is made in his letter to Fliess of
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21.9.1899:-

A patient with whom I have been negotiating, a 'goldfish', has
just announced herself - I do not know whether to decline or
accept. My mood also depends very strongly on my earnings.
Money is laughing gas for me. I know from my youth that once
the wild horses of the pampas have been lassoed, they retain a
certain anxiousness for life. Thus I have come to know the
helplessness of poverty and continually fear it. You will see that
my style will improve and my ideas will be more correct if this
city provides me with an ample livelihood.

Although the complex and conflicting relations between truth
and interest are constantly before us in some ways as plain as
the noses on our faces there seems at the same time to be an
extraordinarily confusing atmosphere surrounding them. One
might say, almost, an atmosphere of repression. We are ashamed
of our interest and seek to hide it behind protestations of another
kind of motivation (e.g., the search for truth). We do not
publicly proclaim our interest, but cloak it in rhetorical devices
which in the end blind us to the meaning of our own actions.
(This is, obviously, not the case always and everywhere. There
has come into being a conscious art of the distortion of truth by
interest, practised by its own accredited doctors. This is of
course the art of spinning, an art which, very strangely, is
minutely analyzed, admired almost, even as we allow it to take
us in.)

In modern times but perhaps it has always been so truth is
the servant of interest. Indeed, in so-called postmodern times,
the distinction between truth and interest becomes obliterated:
truth becomes an entirely pragmatic concept, knowledge
becomes indistinguishable from power. However, this
development, I strongly suspect, is no more than a convenient
intellectual conjuring trick, helping to legitimate the liberation
of whatever corner of the market you find yourself in to the
fullest potential for exploitation.
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In the end, giving free rein to the operation of interest destroys
our capacity to understand what we are doing. In the case of
psychotherapy, our blinkered pursuit of our professional
interest, our obsession with shoring up our credentials and
refining a rhetoric of credibility has taken us up a blind alley in
which we are no longer able to discern the real features of our
undertaking. In fact, we havent really got a clue as to what
constitutes good psychotherapy not because the question is
unanswerable but because we steadfastly refuse to pose it in the
appropriate way. We insist on there being only certain kinds of
answer to this question, i.e., those which conform to our notion
of psychotherapy as trainable, quasi-medical technique. When
we perceive the answers which begin to take shape as we
research into our activities, we panic and retreat into denial.

Those answers are, of course, that psychotherapy is not
appreciably more effective than any other approach to emotional
distress; that technique has virtually nothing to do with such
success as therapy does enjoy; that the personal characteristics
of therapists are more important to outcome than any theoretical
allegiance; that training of practitioners is largely irrelevant and
untrained volunteers can often do just as well or better.

Now I acknowledge that all this does indeed constitute quite a
threat to our interests as a broad professional group, but it also
raises some very interesting questions about the nature of an
undertaking which we are all convinced from our personal
experience does have some kind of validity.

Our problem is that we have been far more concerned to specify
the characteristics of good psychotherapy than to recognize
them. The former concern tends inevitably to focus on
techniques, the latter on people. Even the Rogerian approach,
which started out with a recognition of the importance of
personal qualities, quickly fell into the trap of trying to
technicize them via procedures of training. Rather than merely
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qualities to be identified, warmth and empathy became matters
for fabrication.

Psychotherapy surely we all know it in our hearts is not a
technical procedure like, say, dentistry, which can be carried out
interchangeably by people who have been trained to an
acceptable level of competence. More like marriage, in fact, the
sphere in which psychotherapy belongs is much more personal
as well as relational. Not only does whatever success it enjoys
depend on the personal qualities of those taking part patients
as well as therapists but also on the interactions between them.
Research looking into these aspects is very sparse indeed in
comparison to the relentless search for the replicable effects of
measurable variables such as therapist orientation, length of
treatment, etc., etc.

In fact, we have barely begun to ask the interesting questions
about what makes for good psychotherapy, and even then it is, I
think, very uncertain whether those questions could be cast in
conventional research terms, any more than could questions
about what makes for a good marriage. There are, for example,
going to be many different kinds of good psychotherapy. If
some individuals turn out to be in some sense better at it than
others (which is one very obvious research question we have
resolutely avoided pursuing), it by no means follows that their
personal qualities will be capable of emulation.

We are obsessed with the model of the production line and are
unlikely, I imagine, to remain satisfied simply with the
recognition of good psychotherapy when we encounter it. There
is no self-evident reason why this should be so: we are able, for
example, to appreciate good musicians or painters without
feeling driven to manufacture more exactly like them.

In all the vast literature on psychotherapy, there is very little, in
my view, which truly takes seriously and illuminates its nature
as personal and relational. Two writers who do spring to mind in
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this respect are Peter Lomas(3) and Paul Gordon(4). The lessons
they, and some others, no doubt, have to teach are very different
from the kind of intellectual straitjacket (and professional bad
faith) which conventional scientific rhetoric attempts to force us
into. In contrast with the largely specious picture shaped almost
exclusively by our interest in developing a marketable product,
we are presented with a view of psychotherapy as a
quintessentially human undertaking full of uncertainty, frailty
even, in which a kind of healing may emerge perhaps from
the exquisitely vulnerable endeavours of two people acting in
the best faith they can muster. This is not really the stuff upon
which a large and lucrative industry can be built.

My own view is that we cannot possibly even begin to attempt a
definition of good psychotherapy or good psychotherapists
without first radically revising our assumptions about
psychotherapy itself. This revision comes not merely from some
kind of ideological stance, but from observation and experience
of a century of psychotherapy during which, as Hillman and
Ventura have written(5), the worlds been getting worse.

The largely unelaborated model of human action which
underlies the vast bulk of orthodox psychotherapeutic thought
is, I would argue, both dissociated and disembodied.

By dissociated I mean that the therapeutic protagonists are
considered in the context only of the consulting room, so that
the salience and importance of their own personalities and the
relations between them are hugely overemphasized in relation to
the in fact much more powerful social forces which surround
them. Because of these wider, more distal influences,
individuals are unlikely to be free to act on the basis simply of
insights gained in therapy. Characteristics and repertoires of
conduct which we take, in a very limited sense, to be personal
(and so in principle voluntarily alterable), are, like the very
language we speak, in fact held in place by socio-economic and
cultural influences over which we have no control at all,
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conscious or unconscious.

Similarly, by disembodied I mean that the recipient of
psychotherapy is treated as an unencumbered will who can
change course on important issues simply on recognition of the
desirability of doing so. That is to say, insight, it is supposed,
can result in voluntary changes of direction by means of a
simple cause-and-effect process mental cause and physical
effect which offers no account at all of the way bodies acquire
and maintain the mechanics of activity. Along with this kind of
thinking there frequently goes another, very possibly
unrecognized, assumption that simple perception of the
undesirability of a particular kind of thinking, feeling or conduct
is sufficient to erase it from the individuals repertoire.
However, our physical structure our embodiedness does not
permit us to work like this. We are just not free to wipe out
experiences of the past which imprint themselves physically
upon us, any more than we are free, again, to wipe out the
language we speak.

The idea which haunts so much of psychotherapeutic thinking
that we are responsible for ourselves, that we can choose
ourselves, and so on, assumes degrees of independence from
both the social structure which surrounds us and the physical
demands and constraints of our own bodies which could not
conceivably be enjoyed by anyone which would in fact, if
true, place us beyond the horizon of a scientific world-view into
a universe of pure magic.

Psychotherapy is indeed a personal and a relational undertaking,
but it is one which takes place in a social context which greatly
limits its scope for effecting change. At its best, to be sure, it
provides people in distress with the comfort and encouragement
which is to be derived from solidarity with another person, but
how far any given individual will be able to make use of
whatever lessons have been learned once the relationship comes
to an end will depend on powers and resources either available
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in the social world beyond or acquired bodily in the past.

Psychotherapy is not, thus, a panacea for emotional and
psychological ills which in fact have their causes in highly
complex interactions between human bodies, social worlds and
individual consciousness. Rather, it is but one form of help,
based on the refinement of a certain kind of human solidarity
aimed at what it is possible for the sufferer to understand and act
upon. There are many routes to the achievement of this kind of
help which, if we manage to free ourselves from the blinkers of
interest, we may be able to recognize, though not to specify.

We may have had a hundred years of psychotherapy, but
learning to recognize what makes for good psychotherapy is a
task we have so far barely begun. If we do manage to achieve it,
we shall find in doing so, I suspect, that the muddied flood
which psychotherapy and counselling have become will ebb to a
more modest, but also a more wholesome and sustaining stream.

David Smail
Guildford, November 1999

(1)Smail, David (1995). Power and the origins of unhappiness:
working with individuals. Journal
of Community and Applied Social Psychology, 5, 347-356.

(2) Masson, J.M. (ed). (1985a). The Complete Letters of
Sigmund Freud to Wilhelm Fliess
1887-1904. Cambridge, Mass. & London: Harvard University
Press.

(3) His most recent book being: Lomas, Peter. 1999. Doing
Good? Oxford University Press.

(4) Gordon, Paul. 1999. Face to Face. Psychotherapy as Ethics.
London: Constable.

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(5) Hillman, J. and Ventura, M. 1993. Weve Had a Hundred
Years of Psychotherapy and the
Worlds Getting Worse. HarperCollins.