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The Failed Assassination of Psychoanalysis: The Rise and Fall of Cognitivism

Author(s) : Agnes Aflalo, Translator : Adrian Price

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Celia Goto on 20/01/2016 20:50:33

(5 out of 5)

The Couch Bites Back
by Celia Goto

I am grateful to the patient who brought to my attention an extraordinary book title that she found rather amusing as it passed through her hands; The Failed Assassination of Psychoanalysis: The Rise and Fall of Cognitivism. This book, written by Agnes Aflalo, was originally published in French (2009) and only recently in English by Karnac Books (2015). It is essential reading for concerned clinicians because it follows the course of a battle with the French government that raged from 2003-2009 over the Accoyer Amendment, a bill that sought, under the guise of regulating psychotherapy, to dismantle psychoanalysis within public services and beyond.

Aflalo identifies the developments in mental health provision that created the opportunity for this to happen, including the "noxious ideology of evaluation" and "cognitive behavioural scientism". With incisive intellect and cutting wit she discusses the "commodification of knowledge", "mental hygienism" and "statistical diagnostics". Her considerations extend to the wider issues of racialist discourse and civil liberties. Aflalo's treatise on the French experience is vehement regarding "the new tyranny" and the need for a vigorous counter offensive. Her attitude has implications for the situation here in the UK. However much one might disagree with her conclusions, and allowing for a very different cultural milieu in France, the issues raised here are deadly serious.

The counter offensive in France was spearheaded by the Lacanian Jacques-Alain Miller. Within days of the Accoyer Amendment (October 2003) being set in motion by the government Miller had made a formal complaint about the absence of consultation with any of the professional disciplines concerned, and had established a movement dedicated to raising both public and professional awareness of the issues at stake. The panel of "experts" originally set up by the government to oversee regulation did not have a single psychoanalytic representative, "only exponents of CBT". The situation was headlined in the media, and eventually over the course of six years the bill was revised to legitimate the inclusion of psychoanalytic psychotherapy as a treatment modality in public provision.

At the very heart of psychoanalysis is the singularity of its discourse and practice. It evokes fear and loathing in others because they can't stand the closed consulting room door and not knowing what's going on between the patient and the therapist, despite the extensive amount of detailed case histories and qualitative research available. It's improvisational form and uncertain outcome make it vulnerable to attack even by other "psych" disciplines. Aflalo's text is littered with specific examples of professional prejudices against psychoanalysis but she is also generous in her acknowledgement of the vital support that does exist within closely allied disciplines. In the market place of audit and evaluation, psychoanalysis is massively disadvantaged. Cognitive behavioural therapies tend to fare better because they are considered to be "transparent, measurable, simpler, faster and cheaper". Aflalo clearly sees CBT and psychoanalysis as fundamentally incompatible both clinically and theoretically. Consequently applying the same measures to both cannot be anything other than an attack on the latter. The situation is further confused by the many different types of therapies that have emerged in the wake of psychoanalysis. She asserts that most contain only a small portion of psychoanalysis but claim otherwise.

Aflalo savagely attacks those who misrepresent cognitive behavioural therapies as a panacea displacing the need for all other forms of treatment. CBT dressed in "scientism" becomes a "utilitarian ogre", which Aflalo warns is critical to withstand. She describes scientism as not a true science but a phenomena "that follows science like a shadow, spreading its harmful effects in its name". It employs the questionnaire, "a pompously named research tool", in an "obsessively ritualized and uncontrollable practice" that masquerades as an empirical scientific method that can calculate symptoms and determine short term preformatted treatments with clear cut targets. It convinces patients that "their symptoms are a result of their thinking being askew" and aims to educate them "to think right".

Manipulative management governed by political and financial imperatives, make highly selective use of database material, including questionnaires, to dictate, distort, and eliminate types of treatment, imposing conformity and control of patients, and indeed clinicians who are stripped of their professional autonomy.

Far more than psychoanalysis is under attack, in fact all the thinking professions are at risk. The disciplines and settings may be different but the language and methodology of dismantlement have much in common. Those who can't escape are under duress, feeling horribly compromised whilst doing their best to preserve their own integrity as well as that of their work. Aflalo highlights the way that the "epidemic" of evaluation has likewise contaminated universities. In the preface to her book, Bernard-Henri Levy describes how French researchers' performance is crudely evaluated by the quantitative weight of citations, which he describes as "the Google method applied to the life of the mind". Marina Warner in her article "Why I Quit" (London Review of Books, 09/2014), concerning her forced resignation from a prestigious British university, comments on the management methods employed. She writes about the "new brutalism" in academia and the way "enforcers rush to carry out the latest orders from their chiefs in an ecstasy of obedience to ideological principles which they do not seem to have examined, let alone discussed with the people they order to follow them, whom they cashier when they won't knuckle under". The sadistic overtones of this kind of regime are strong and powerful, their sham justification data driven. In 2007 I myself quit a child and adolescent post on encountering the new brutalism in the NHS.

Psychoanalysis was until quite recently at the centre of CAMHS multidisciplinary teams, contributing to a productive and creative dialogue with other highly trained colleagues; social workers, family therapists, art therapists, psychologists, and psychiatrists. Psychoanalytic ideas were given much prominence in the collaboration and were understood and used fruitfully across all the disciplines. Through ongoing tutoring and supervision of the next generation of psychoanalytic psychotherapists, I remain close to what's happening in CAMHS teams. From what I can see, Child & Adolescent Psychotherapy seems to have lost its platform amidst the other disciplines. Posts are fewer, therapists (especially trainees) are far more isolated and unsupported, funding for training has been much reduced, generic work takes precedence over analytic work in the consulting room, intrusive monitoring systems interfere with treatment, managerial roles and priorities involve some therapists in the active disassembly of their own profession. Meanwhile, the potentially profitable parts of mental health provision are being softened up for payment-by-results and future privatization.

A lot has changed in the last decade. Psychoanalysis seems to me to be silently disappearing from the NHS. Barely visible in adult services and now seriously endangered in child/adolescent services, it's not a CBT vs Psychoanalysis war, but a fight to preserve psychoanalysis as an entity in itself. The market conditions are against the deep and slow treatment that it provides but it's the political agenda behind the financial one that is so brilliantly highlighted by Aflalo. So I welcome her anger and passion as she rails against the expurgators of psychoanalysis. It's good to see that the couch can have teeth and bite back. This situation is not just about psychoanalysis, as French intellectuals seem to recognize, but about the world of ideas, the essence of culture itself.

There's a lot at stake. Freud said that psychoanalysis is about the mind and culture. Speaking out about what's happening is critical if psychoanalysis is to remain in the public domain. I fear it may already be too late.


Celia Goto
Psychoanalytic Psychotherapist
Child & Adollescent `psychotherapist
Oxford
December 2015

First published in New Associations British Psychoanalytic Council Issue 19 Autumn 2015