Book Review

Constructing the Self, Constructing America: A cultural history of psychotherapy

N Engl J Med 1995; 333:1574-1576December 7, 1995

Article

Constructing the Self, Constructing America: A cultural history of psychotherapy
By Philip Cushman. 414 pp. Reading, Mass., Addison–Wesley, 1995. $25. ISBN: 0-201-62643-8

Deconstructionism is a philosophical approach to knowledge that has come to have a profound influence on American intellectual life, so it is not surprising that the tools of deconstructionist thought should be brought to bear on the history of psychotherapy. This book is an intriguing synthesis of history, philosophy, medical politics, and psychotherapeutic theory and practice.

In Constructing the Self, Constructing America, Philip Cushman, a psychologist at the California School of Professional Psychology in Alameda, contends that psychotherapy as practiced in the United States is best understood as a cultural artifact that has, in general, overemphasized individuality and the individual self. Cushman begins by recounting the history of the concept of the self in America. Cushman's most basic idea is that there is no constancy of the human “self” over time; that the “self” of a specific era is unique to that era; and as a corollary, that there are no mental illnesses that are universal. As Cushman sees it, “There are no universal illnesses any more than there is a universal self.” The self of a specific era is constructed by the social milieu of that era and thus develops certain particular characteristics. Building on this notion, Cushman traces the historical development of the idea of the self and psychotherapy in America.

In the United States, the earliest approach to therapy was that of the mesmerists, who used scientific discourse to address spiritual concerns. Mesmerism was a powerful and effective political force that used a combination of psychology, religion, and political “collusion” to aid the state in the political control of the citizenry. Later on, Sigmund Freud's dark view of human nature and human impulses came to America. But in America, psychoanalysis was transformed and became not a window into the darkness of the inner life, but a means through which an individual might realize the capitalistic ideal of personal improvement and greater productivity. It created a new vision of the interior life and provided the means by which the inner life could be explored. Psychoanalysis allowed the “medicalization” of the self and provided a scientific language for discussing inner events that were previously the exclusive subject of theological or philosophical discourse. In all of this, though, psychoanalysis promoted the illusion of the unique and individual self.

Certain psychological theorists, particularly Harry Stack Sullivan, developed a psychological approach that more fully acknowledged the role of human interrelationships in creating the inner life. But this approach was too radical for American psychology and psychiatry as a whole, and it was abandoned for the more palatable and individualistically oriented ideas of the object-relations theorists such as Melanie Klein, D.W. Winnicott, and Heinz Kohut. Their theories were unintentionally consumerist in nature and tended to promote the political and social status quo. By contrast, the hermeneutic approach to therapy that Cushman advocates sees the self as an unstable and changing product of cultural and political forces and social interactions. Such an approach views the self and psychotherapy in historical context, helps the individual to understand the way the self has been shaped, and empowers the patient to move beyond a limited world view.

Cushman sees all therapy as moral discourse, whether this is acknowledged by the therapist or not. A hermeneutic approach to therapy openly acknowledges the moral nature of therapy and allows the therapist to confront the individual with uncomfortable, though liberating, realities. Cushman describes his use of hermeneutic therapy in the latter portion of the book, but he struggles with how to implement a therapy that denies the reality of the individual while still treating an individual patient. There is no mention of things like efficacy, of course, though if one is to charge for therapy and implicitly promise some relief of symptoms, surely efficacy matters. As a sort of reprise, Cushman includes a brief and idiosyncratic history of the development of the idea of the self in the West. It was wise to place this material in an appendix, since it sullies the stronger arguments of the rest of the book.

The book is written in a vigorous style and is uniformly interesting, often entertaining, and in many ways offers a refreshing change in approach from the now commonplace social histories of psychiatry. Though Cushman paints with a broad brush, his observations are pithy and provocative and often ring true.

Cushman is critical of the all-encompassing psychoanalytic approach, but there is nonetheless a sense in which the absolutism of social constructivism is similar to the absolutism of psychoanalysis — and both are equally unsatisfying as total explanations. If the self is not constant over time, who is to say that the self is constant in different cultures in the same era? For that matter, who is to say that the self is constant in different communities or homes or members of families? Indeed, is there enough of the self that is constant among individuals that we can even speak of a construction of the “self” at all? The problem with this sort of radical critique is that it presents such an epistemological conundrum that it is hard to know whether you can be convinced of what Cushman is saying, even if you are. If you accept the premise that we are all so individually unique and different, for example, then the ideas we think we are accepting may be quite different from the ideas the speaker or writer intended us to understand.

Cushman is concerned throughout the book with the political meaning of psychotherapy, and his observation that psychotherapy often inadvertently colludes with the dominant political culture gives reason for reflection. Naturally, therapists must — and surely in the 1990s most do — recognize that they are not simply purveyors of an objective theory but, rather, are communicating to the patient a certain set of values that the therapists hold as meaningful and healthy.

Cushman's assertion that psychotherapy must be understood fundamentally as moral discourse is one of his most compelling, if not original, points. Yet his conception of morality largely involves political and social justice, and it must be pointed out that moral values of a variety of kinds are communicated in therapy, not just political values. Furthermore, Cushman has difficulty making a compelling argument as to why his particular set of values, having to do with political justice, should be universally accepted. The moral problems raised by this social-constructivist approach are surely greater than the ones they solve. Let us not forget that Martin Heidegger, the philosopher whose approach to “being” underlies much of what Cushman asserts, served in the cause of Nazi university “reform” in the early 1930s and was unable to use his philosophical approach to assume the necessary moral stance during that difficult time. The hermeneutic approach that Cushman advocates does not clarify the moral ambiguities of psychotherapy and its practice.

In addition, Cushman's approach to psychotherapy and psychopathology makes no allowances for the biologic continuities that shape the human mind. It assumes that the human mind at birth is enough of a tabula rasa that culture can have a radically formative impact. Although such an idea is wonderfully stimulating, it is difficult to reconcile with the 5000-year-old written record that humans have left of their thought in a variety of culture and times, since this record suggests many fundamental continuities of human experience.

If we really approached problems the way Cushman suggests we should, there would be few ways of curing or caring for others, because all experiences would be viewed as unique to the individual. This book offers stimulating insights into therapy and its philosophical underpinnings. It is less satisfying in its formulations of the nature of the human condition and in its view of the true purpose of the psychotherapeutic enterprise.

Samuel B. Thielman, M.D., Ph.D.
Mountain Area Health Education Center, Asheville, NC 28801