Cultures of Healing: Correcting the Image of American Mental Health Care, by Robert T. Fancher, W. H. Freeman,  pp. 355

Freud Scientifically Reappraised: Testing the Theories and Therapy, by Seymour Fisher and Roger P. Greenberg,  John Wiley, pp. 353 

MANY SCHOOLS OF PSYCHIATRY and psychotherapy are perceived by adherents as being founded on a body of scientific knowledge. In the view of Robert Fancher, himself a psychotherapist, such claims should be treated with scepticism. For one of the characteristics of the various competing approaches to mental health is a tendency to claim scientific validity for ideas science has not validated. A more accurate view, he suggests, is to regard the mental health profession as being made up not of different forms of science, but of competing ‘cultures’ of healing. If we are to evaluate these we must do so not as clinicians but as social and cultural critics.

Fancher’s interesting and ambitious book is an attempt to do just this. It begins with a lucid essay on the historical evolution of the idea of ‘insanity’, in which Fancher traces the almost accidental emergence of the profession of psychiatry out of the old asylum system in America and suggests that psychiatry did not originate with medical discoveries being taken into the humanitarian field; it originated with ‘humanitarian ideals over which certain medical men came to exercise stewardship for economic and social reasons’.  

He goes on to offer critiques of four of the most influential ‘cultures of healing’ in the mental health profession today: psychoanalysis, behaviourism, cognitive therapy and biological psychiatry. The most valuable of these critiques is the last, where Fancher brilliantly tackles the logical fallacies on which modern biological psychiatry is almost entirely based. The weakest is the first, for, perhaps because he was himself originally trained in psychoanalytic psychotherapy, Fancher's view of psychoanalysis seems to lack perspective. His account of the relationship between the ideas of Charcot (whom he describes oddly as ‘the great French hypnotist’) and the theories of Freud is simply mistaken and his general description of psychoanalysis seems thin and lacking in depth.

When he turns his attention to behaviourism and behaviour therapy Fancher is, as might be expected, more robust. A few critics of behaviourism have long suspected that somewhere inside the bag of behaviourism is a Cartesian cat trying to get out. Fancher helps it to do so by repeatedly and accurately pointing to the hidden mentalism of behaviourism and to the muddles that result when behaviourists attempt to ‘shoehorn mind into a theory based on denying it’.

Fancher suggests that ‘contemporary behaviourists who use ideas of mind sound like theologians who have accepted evolution’. The objection to this formulation is that it seems to have turned the problem upside-down. For some behaviourists bear much more resemblance to a hypothetical evolutionary theorist who has accepted the literal truth of Genesis. The point here is that it is the concept of mind which belongs historically to the realm of theology. One of the main features of all mentalistic approaches to human nature, including psychoanalysis and structural anthropology, is their sweeping disregard for the extraordinary complexity and richness of human behaviour.

One of the most interesting features of behaviourism is that, originating as it did as a kind of inside-out mentalism, it perpetuates this theologically traditional contempt for human behaviour under the guise of subverting it. Fancher's critique does not recognise this, and, by chastising behaviourism for covertly embracing an impoverished concept of mind, instead of recognising the deep impoverishment of its concept of human behaviour, he keeps his critique firmly moored within the harbour of orthodoxy.

Fancher's relationship with orthodoxy, however, is never a simple one, as his treatment of cognitive therapy suggests. Having accurately described cognitive therapy as the ‘hot’ field among talk therapies and having implicitly conceded its seeming therapeutic effectiveness, he goes on to offer a sharp and revealing critique of what he calls in his chapter-heading ‘The middlebrow land of cognitive therapy’.

In Fancher’s view the fundamental value of the culture of cognitive therapy is ‘approval of and conformity to the conceptual and social status quo’. Its basic norm is this: ‘Except for how the patient thinks, everything is okay. Reality is not pathogenic. Just think straight and life can be good enough.’ In the course of contesting one of the central tenets of cognitive therapy, ‘that one cannot rationally hold sweeping negative beliefs about oneself, one's world and one's future’, Fancher produces an argument that is complex and interesting and should be widely read.

All this and more needs to be said loudly and clearly of the most valuable of all the sections in Cultures of Healing – Fancher's critique of biological psychiatry. It is here that his original training as a philosopher is put to its most effective use, as he deftly dissects a series of logical fallacies that constitute the foundation myths of modern biological psychiatry. Central to his argument is the recognition that, even if it could be proved that psychopathology is rooted in biological abnormality, it would not follow that drugs are the treatment of choice. ‘Once we accept the falsity of dualism, we have to accept that everything is physical – and that includes talk therapy, new experiences and changes in one’s habits of life. All of these have biological effects. There is no a priori reason to think that the biological changes needed to treat psychopathology cannot be effected by non-pharmacological regimens. Anyone who has fallen in love (or felt betrayed by a lover) knows that psychosocial factors have biological effects.’ And, as Fancher wryly notes elsewhere: ‘One does not need to be a scientist to understand that drug companies do not want to discover that the changes brought about by talk therapy include the stabilisation of neurotransmitter regulatory systems.’ 

This is but one part of a complex and perceptive argument about biological psychiatry that ought to be compulsory reading for all those concerned with promoting clear thinking about mental health. It should immediately be said, however,  that, having run his marathon of scepticism, Fancher almost immediately collapses into tired orthodoxies. He recklessly toys with the possibility of prescribing psychoactive drugs to relieve ‘normal’ people of the consequences of leading difficult lives. He also makes bland and unhelpful generalisations about the probability that therapy will augment our lives if we approach it in the right spirit. Nevertheless, despite frequent relapses into orthodoxy and conformity, Cultures of Healing contains enough genuine dissidence to make it well worth reading.

The same cannot be said of the latest book from the hands of Seymour Fisher and Roger P. Greenberg. Their Freud Scientifically Appraised is, in effect, a sequel to their 1977 work, The Scientific Credibility of Freud's Theories and Therapy. Once again, they have failed to recognise that Freud was at least right about one thing: that psychoanalytic theories, being based on the psychoanalyst’s unique access to the hidden realm of the unconscious, are not susceptible to empirical investigation. In an attempt to gainsay this orthodox psychoanalytic position, Fisher and Greenberg have trawled the literature for ‘empirical’ research on psychoanalytic theories and invented a number of fiendishly ingenious studies of their own.

In an effort to discover whether Freud’s penis=baby equation was correct, and whether it is indeed true that some women have babies to supply themselves with the penises that they lack, Fisher and Greenberg tell us that they ‘reasoned that if pregnancy is somehow a penis equivalent for women, they should have increased unconscious phallic sensations or feelings at that time’. Omitting to consider the equally plausible Freudian hypothesis that pregnancy, by supplying a ‘real’ phallic substitute, might lead to a decrease in phallic fantasising, our intrepid researchers go on to devise a ‘phallic scoring system’ based on a count of responses to the Holtzman Inkblot Test involving ‘projections, protrusions and elongations’ that Freud would have deemed phallic.

Having administered this remarkable test to a group of presumably puzzled pregnant women, they concluded that (though no data are given) ‘the findings were nicely congruent with the hypothesis’. No doubt they were also nicely congruent with all manner of other hypotheses that Fisher and Greenberg, intent on looking at the world through Freudian spectacles, never paused to formulate.