Review: The Therapy Industry – Paul Maloney
This is a review of Paul Maloney’s book criticising the Therapy Industry. Maloney is a practising clinical psychologist. His criticisms of therapy are those of someone who is engaged in clinical practice in the NHS. This grounding makes for a different kind of criticism than the kind based on cultural analysis, for example, that of Jeffrey Masson. For example; unlike Masson Maloney is quite willing to take up and examine the (inevitable) ‘studies’ which have found that ‘therapy works’ (See Chapter 4). He criticizes these from the point of view of clinical psychology.
The following is a brief summary of each of the chapters in the book together with some commentary where relevant.
Maloney sets the stage for his criticism:
These specialists [from the clinic to TV programmes] seek to persuade us that our troubles stem, not from the world in which we live, but from our lack of insight into ourselves and from our failure to take responsibility for what we think, feel and do. All might be well if their ideas were better grounded in science than their forerunners from even 50 years ago. The main task of this book is to show that this is not the case.
Maloney indicates that therapy is, like psychiatry, a ‘medicine’ for the individual. It is more seductive. It appears to take account of human subjectivity in a way which the bio-chemical model of psychiatry does not. To some extent it is free of the cruelly stigmatizing labels of psychiatry – linked at they are to a drug racket. But it remains a kind of ‘medicine’ aimed at ‘sick’ people. Absent from therapeutic discourse is any serious acknowledgement of social and economic conditions in which people find themselves and from which they have little practical prospect of escape. Many people are distressed because they have been abused. Therapy pays only lip-service to this reality. By ignoring social and economic factors therapy, even if only inadvertently, is an ideal ideology for the neo-liberal project which emphasizes ‘personal freedom’ – a ‘freedom’ – which means, in reality, huge wealth for a few, a high level of wealth for a number, and a life of precarious economic insecurity for millions.
Maloney also notes that the theories of psychotherapy and psychiatry – while presented as ‘science’ can readily be seen to be fads moving in relation to market conditions and demands for their services. (In passing an example of this is how the psychiatric profession has handled homosexuality. In the 1950s psychiatry assured everyone – with the authority of science – that homosexuals were dangerous degenerates who should not be allowed near children. Contemporary psychiatry assures everyone – with just the same claim to be speaking from a scientific research base – that all the evidence is that homosexual couples make just as good parents as heterosexual ones. Psychiatry has just adapted to market conditions out of its own self-interest).
This is a good start.
Part 1 – Evaluating Psychological Techniques
Chapter 1. Misery, Mind Cures and Fashion
In this chapter Maloney presents a whirlwind tour of the history of the talking cures from the 1700s to the present day. He discusses how Freud’s ideas became the foundation for subsequent developments in psychotherapy. He notes (as other writers such as Webster have done) that Freud’s claims for the efficacy of his treatments were largely fake. He discusses the competition (or perhaps more usually collusion) between psychiatry with its biological theories for mental distress and clinical psychologists with their adherence to technical competence and testing. He discusses more recent developments such as ‘person centred therapy’ (based on psychoanalytic ideas but placing greater emphasis on the ‘warmth’ of the therapist), and CBT. Maloney notes how all the different schools which now prevail politely gloss over their differences – hiding the theoretical contradictions which exist. He notes how all modern therapy grounds itself in two principles; a claim to have ‘regard for the client’ and an insistence on allegiance to a ‘professional’ body of some kind. The latter is simply an attempt to generate an aura of credibility and legitimacy.
Our only criticism of this chapter is that Maloney seems to be quite kind to modern psychotherapists and counsellors when he says for example that “many psychotherapists hold medical or other postgraduate degrees”. In reality – there is no requirement for them to do so and many (perhaps the majority?) don’t. Therapy training schools do not typically have academic entry requirements. When these people do hold (and often flaunt) their post-graduate qualifications they are often in unrelated or only partially related fields – such as social work. That is; these people are not academically qualified to do what they are doing. Maloney’s picture may be influenced by the fact that he works in an NHS setting and so the counsellors and therapists with whom he comes into contact are perhaps those who have come into the ‘profession’ from more medical or clinical routes.
Chapter 2. The Psychopathology of Everyday Life
In this chapter Maloney discusses psychiatry – the profession which remains at the apex of mental health ‘treatment’.
Maloney notes how the handbook of the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorder, is highly influential in determining treatment in the West. The number of ‘illnesses’ has grown with each edition. The ‘illnesses’ are determined by Committees of (chiefly) psychiatrists. The problem of causation (which would be the scientific test) is simply sidestepped – the manual avoids the question altogether.
Maloney offers a brief and obvious criticism of psychiatry. Psychiatric conditions are invented. There is no biological test for a psychiatric condition. (Compare measles where a diagnosis of measles can always be verified by a lab test for a specific virus). The drugs often create medical problems. The ‘chemical imbalance’ theory which is often cited in support of various psychiatric classification categories is at best a theory. Claims for the chemical imbalance theory often rely on experiments which show that lowered disturbance is associated with a drug-induced increase or decrease in a particular chemical in the brain. But these experiments show correlation and not causation. Maloney also cites evidence that long-term use of psychoactive drugs can impair mental functioning. Intriguingly he also cites WHO studies which show better prospects for ‘schizophrenic’ individuals in Nigeria and India than in the West; possibly because in these poorer countries there is both less drug treatment and also more possibility for some continued economic and social role for the severely distressed.
Maloney discusses how in psychiatry the diagnostic categories are created in order to sell the drugs. There was little diagnosis of ‘depression’ until the discovery of the antidepressant properties of certain compounds was discovered. Now the ‘disorder’ of depression turns out to be so widespread that (according to Maloney) one in ten Americans over the age of 6 are on antidepressants. The ‘research literature’ is manipulated to only show a few successful trials. Unsuccessful trials are quietly sidelined. Pharma has insidiously built a network of financial interests with psychiatry. At any event this is not strictly necessary; the professional prestige of psychiatrists over say psychologists depends on their license to prescribe drugs. Psychiatry’s lifeblood is ‘mental disorders’ which can be ‘treated’ pharmaceutically.
Maloney discusses how psychiatric diagnostic categories faithfully keep up with changing social fashions. For example; in an age of celebrity culture and where team-work is everything ‘shyness’ has moved from an allowable character eccentricity to being a treatable disorder; ‘social anxiety disorder’. PTSD – originally conceived of to help Vietnam veterans can now be ‘diagnosed’ (even it seems by psychotherapists) for minor stressful events.
Maloney reviews the shaky basis for the autism and ASD labels and suggests that one function of the ASD label (‘Asperger’s Syndrome” or Higher Functioning Autism) is a subtle reminder to people to keep up with the expectations in the modern workplace for ’emotional literacy’. Thus the psychiatric label has a similar function to the campaign to stigmatize people collecting unemployment benefit. These are all pressures to confirm to the requirements of the neoliberal economy. Maloney also notes the wide prevalence of ADHD drugging. ADHD is another diagnostic category of psychiatry which has no basis in physical science. (Beyond studies which post-hoc produce statistical correlations between various physical factors including quite a small genetic correlation).  Boys are far more likely to attract an ADHD label than girls. (A factor, incidentally, which is completely at variance with the attempts to claim the “ADHD is a genetic disorder”). Maloney suggests that the feminisation of modern schooling (and indeed the fact that it is very middle-class) with its emphasis on neat ordered conduct and careful regulation of anger and spontaneity is one of the social factors behind the ADHD diagnosis.
In this chapter Maloney makes two important points. The first is that arguing against mental health labelling is not callous. He acknowledges that in some cases a label can be useful – at least it can help someone gain access to support. But, overall; he suggests in a more tolerant and compassionate society it would not be necessary to label every last difference. The second is that he notes that one factor in the medicalisation of mental distress is that social (e.g. abuse of children) and economic factors (such as poverty) are elided from the picture. This is not entirely accidental.
Chapter 3. The ‘CEO of Self’…?
Maloney explains that our ability to accurately analyse and report on our own mental states is more limited than we might think. He cites some psychological studies in support of this view. This is an obvious problem for the ‘talking cures’ – which depend on the idea that people can accurately report on (and even ‘work with’) their internal states and mental processes. He also suggests that mental processes are too personal and subjective to be subject to the kind of quantitative statistical analysis that the social sciences like to produce. Ratings scales of, for example, anxiety; are essentially meaningless – because my sense of anxiety is not the same as yours. Rather than admit to this essential lack of self-knowledge people invent stories and accounts. Therapy works with these invented accounts. We can see that this will achieve nothing.
Maloney then critiques the idea that success in life is due to ‘personal will-power’. In doing so he is exposing the sordid link between psychotherapy (very largely an American invention in its current incarnation) and extreme free-market capitalism. In reality a more accurate determinant in personal success is social background. Capitalism prefers the ‘personal will-power’ theory because this justifies and permits inequality. If success or otherwise in life is a matter of personal willpower then there is no need to question existing social arrangements and inequalities. Therapists rarely discuss social and economic pressures.
Maloney offers a specific criticism of CBT. He cites studies which have found that people with a moderately depressive outlook have been found to score higher than those with a ‘healthy’ outlook in terms of whether or not their thinking is anchored in reality. Furthermore; studies which measure ‘improvement’ in patients undergoing CBT suggest that the improvement is greatest in the early period of the treatment – during the phase when the patient and therapist are getting to know each other and before any techniques have been applied. This is interesting because it supports the idea that human solidarity is what is missing from peoples’ lives and that finding this, even in a somewhat clinical relationship, is helpful. Maloney also cites a meta-study of CBT  which provides evidence that the most useful part of CBT is not the cognitive part but the behavioural part – where clients are encouraged to make some change in the external world, for example, make new friends or get a new job.
Ultimately; Maloney criticises the notion of free-will exercised by an autonomous agent. This notion is at the fount of all forms of therapeutic intervention. The idea is that this autonomous agent of free-will (the ‘CEO of self’) exists and is just waiting a nudge or kick from the therapist to make it burst into life. (This is a thoroughly American idea). As Maloney comments the ‘CEO of self’ is an idea derived from the idea of God. This is a somewhat Nietzschean critique. Man has first invented God and then has the hubris to imagine that he is ‘like God’. But such an idea, for a unitary and autonomous self with the power to act as first-cause, is not supported by an observation of biological reality. In a further parallel with Nietzsche Maloney suggests that the ‘self’ is in fact a post-hoc creation. We build up the idea of a controlling self after the events. We constantly adjust our own self-accounts of our actions in order to preserve the illusion of a unitary self and free-will
In this chapter then Maloney argues that there are two fundamental assumptions at the basis of the talking cure. One is that our mental processes can be accurately verbalised and thus ‘worked with’. The other is that there is such a thing as an autonomous agent to ‘do the work’. Both assumptions are false. Maloney cites various psychological studies as supporting his criticisms, for example, studies which can show that in some situations people can develop beliefs about having controlled situations which they palpably have not.
It seems that Maloney may be more familiar with CBT than with psychoanalysis. For CBT it is a disaster if we accept that people cannot offer accurate self-accounts. But this is not a disaster for psychoanalysis. A psychoanalyst would certainly respond to the first point, the argument that people offer distorted and made-up self-accounts, by accepting that it is true that no ‘true’ account of a person’s motives is readily accessible. But for the psychoanalyst this would not mean that the project – of working with ‘inner contents’ was not viable. Rather; they would make this the point of the ‘treatment’. They would argue that the treatment works in this inchoate world of hazy self-accounts (via interpretation of symbols and unconscious mistakes) to move the patient towards a more accurate narrative than the one they at first produced (and thus cure their symptoms). Maloney does not appear to offer a criticism of this view. (We would offer the criticism that this practice depends on putting the client into a regressed state and that this is fundamentally unhealthy. Furthermore; this view is historically derived from 19th century ideas about correcting the morally wrong views of madmen. For most people this approach is neither applicable nor helpful. A slight tendency to produce self-serving narratives is ‘normal’ and not at the root of their problems in the world). Maloney does, however, point out that even Freudian analysis depends on the idea of an autonomous self who can change. This is ultimately a moral idea – and has its roots in 19th century psychiatry which. Foucault has pointed out that psychiatry dressed up a moral project in the language of science.  We can see the origins of these kinds of ideas – of individual moral responsibility – in a concrete historical moment. Freud was interested in Charcot’s work with hypnotism of ‘hysterics’ in the Salpêtrière hospital in Paris and this formed a part of the development of Freud’s psychoanalytical theories. Richard Webster has argued Charcot’s case-studies were characterised by a willingness on Charcot’s part to ignore physical explanations – such as brain injuries caused by accidents – in favour of purely psychological explanations relating to trauma.  The majority of Charcot’s patients at the Salpêtrière were woman. Elaine Showalter argues that these women were being fitted into a male and patriarchal vision of ideal femininity. There crime was not to fit into this world. She supports her case by an analysis of hospital photographs taken of the ‘hysterical’ women in various classical poses . In any event; what appears to be missing from Charcot’s theories is any idea of the social and economic or even, if Webster is correct, simply the physical condition, of his patients. From the start psychiatry and thus psychotherapy is a project with an institutional a priori tendency to exclude the social and economic context of the ‘patient’. For example; while Charcot was concerned about ‘hysteria’ is male railway workers who had suffered accidents it is likely that a more effective preventative remedy would have been to improve safety so that these accidents did not occur.
Chapter 4. Does Therapy work?
In this chapter Maloney discusses whether or not therapy ‘works’. He engages with a body of literature which attempts to answer this question, that is social science studies of cohorts of people in therapy. Maloney notes that these kinds of studies have superseded the early case studies. These early studies were, Maloney notes, subject to bias. Webster is one modern author who has shown conclusively that early claims for success for psychoanalysis were faked; for example an other early progenitor of psychiatry, and a colleague of Freud, was Josef Breuer. Bruer presented a case study about a patient known as Anna O. Webster, and other authors, have shown that the claims that all Anna O’s symptoms were cured was false. 
Maloney notes that early studies in the 1930s and 1940s showed that 2/3s of people in therapy improved. This was initially claimed as a success until the behaviouralist critic of psychoanalysis Hans Eysenk showed that such patterns of ‘remission’ were also found in groups not undergoing treatment. This points to the main point about modern psychotherapy. The problems it ‘treats’ are part of the normal stuff of life and are problems which people move on from in the normal course of living. (An example would be ‘bereavement’. Bereavement is one of the numerous ‘conditions’ which modern therapeutic literature claims to offer help with. The fact is that people who have lost a loved one will feel terrible for a time. And the fact is that after about two years, or some similar period, they will begin to feel better about it. When therapy claims to offer to ‘treat’ bereavement and claims successes this is simply a fraud. They are exploiting the fact that people will ‘get better’ on their own accord anyway in time. The same can be said of almost all the ‘conditions’ which modern therapy claims to ‘treat’. Seen in this light it is perhaps amazing that anyone falls for therapy. But therapy takes advantage of the fact that many people experiencing the targeted condition will be doing so for the first time in their lives. To them it may seem an insurmountable problem which they will never get over).
Maloney accepts the challenge posed by studies which claim to show that therapy is effective. These studies use the procedures of Randomised Clinical Trials which are used to assess (or produce sales material for, depending on your point of view), new drug treatments. The basic idea is to compare two similar groups with similar ‘symptoms’ one of which receives the treatment and one of which doesn’t. To avoid rater bias raters should be blind to which group is receiving the treatment. As with clinical drug trials some of these studies have been collated in meta-studies which sift all the results from multiple individual studies in order to produce a convincing overall trend. Maloney accepts that such studies of therapy have produced results which show a substantial positive effect for therapy. However, he says, this overall effect is relatively modest – about 6 to 14% in the leading meta-analyses. 
Maloney argues that the nature of therapy is such that it is highly susceptible to placebo type effects; these effects generate the positive reporting from clients. Maloney points out that it is practically impossible in practice to deliver a treatment to a control group which they – and the researchers – might believe is therapy. This is not a question of identical pills one of which contains the drug and one of which doesn’t. In most trials then the subjects will know whether or not they were receiving the treatment. There are also structural pressures which promote positive client reports. Therapy has a strong moral undercurrent. There is a strong (albeit perhaps not openly promoted) view in therapy that if the patient does not ‘get better’ that is down to his or her own moral failing. They did not ‘work hard enough on themselves’. In this context it is inevitable that patients – who are always at a disadvantage in terms of the power balance in the relationship – tend to report that the treatment has ‘worked’. Maloney also references research material which acknowledges how in social science and psychology experiments subjects can feel under pressure to report the results which are clearly sought by the researcher. Maloney gives other reasons to exercise skepticism towards the meta-studies which claim to conclusively show that therapy is effective. These include the well-known phenomenon of publication bias (studies which show the desired result are much more likely to be published than those which don’t), preselection of subjects who are likely to believe in the treatment, preselection of subjects with trivial problems thus creating optimum conditions which promote positive results, other methods of creating artificial conditions which are designed to promote the positive result but which do not mirror real-world outpatient circumstances, failure to consider subject drop-out, questionable measurement methodologies, small sample sizes, statistical manipulations used to produce headline grabbing ‘results’, and reliance of interested parties in making the ratings. (All of these problematics will be familiar to anyone who has studied how ADHD drug-trials are rigged in order to produce pro-drugging results ). The sum total of these problems mean that the research literature is not credible.
Maloney cites material from within psychotherapy itself which suggests that the ‘warm relationship’ is more important than theory and technique in terms of producing ‘positive outcomes’. He backs this up by citing meta studies which have shown that length of training and therapeutic qualifications do not make any difference to outcome. In one meta study the best results were associated with treatment with the less qualified or amateur therapists rather than the more qualified therapists. There is a meta-study which produces a result that qualifications are associated with better results albeit at a small percentage. But here there was a strong compounding of qualifications and practical experience. As we have seen above much of the study data relies on artificial subject groups. Maloney cites a study  which specifically compared real life interventions, comparing a typical ad hoc experience of treatment with a formulated therapy intervention for a group of American adolescents. No positive benefit was associated with the organised therapy intervention. A smaller-scale replication study also produced the result that a control group who received no intervention at all did as well as those who had received both types of intervention.
Maloney notes that there is a tendency in policy makers and influencers who wish to promote therapy to simply ignore the deficiencies of the ‘evidence-base’. They simply ignore those parts of the evidence which are inconvenient. This approach – that policy goals determine how ‘research’ is reported rather than the other way around; namely that policy is informed by research characterises the relationship between policy and research in contemporary society. (Our own paper on ADHD shows this practice in operation. Already rigged ‘research’ is further massaged into shape by The Royal College of Psychiatrists and then used by NICE to legitimise ADHD drugging, no doubt with a strong nod to the interests of US pharmaceutical companies . The same process can be observed in many other fields of social policy).
Summing up the state of research Maloney notes that the only ‘scientific’ conclusion which can be drawn from the research literature on the effectiveness of therapy is that some degree of personal warmth can assist people. The implication of this is precisely (of course) the one that the therapy industry does not want to hear. It represents an argument for more social solidarity to be shown by each to each other. There is nothing in this research literature which supports a ‘profession’ of specialists in human relations or of experts in ‘events in inner space and time’. 
Chapter 5. “I’m not ill, I’m hurt…” – The Hidden Injuries of Social Inequality
The main thesis of this chapter is that the determining factors in experiencing mental distress are environmental and social rather than genetic. They come from without rather than from within. The author highlights sociological and social sciences studies which show links between low income and mental health. He discusses work (by Wilkinson and Pickett)  which argues that it is not being poor so much as being relatively poor which contributes to mental ill-health. Most interestingly (and rarely) the author discusses how questions of class can affect mental health. Being an owner – and having power – is a more desirable situation than being a worker with little autonomy and power. Income aside, the argument is, that powerlessness is a key contributory factor in mental ill-health.
To make the argument that mental illness is ’caused’ by environmental and social factors the author first has to dispose of the reverse argument; namely that being poor and being more susceptible to mental illness is a result of genetic factors. In this, genetic view, the reason that people who live in poor areas are found in surveys to be more likely to suffer from mental illnesses than those in richer areas is not the result of the effect of being poor. Rather, the genetically weak, have become ill and have then migrated into the poor areas. (The author discusses this argument in terms of people moving into poor areas in order to camouflage their ‘odd behaviour’. Of course the chain of events could also be: as a result of genetically ’caused’ mental health issues someone loses their well-paid job and is obliged to move into a poorer area. In which case the greater link between living in a poor area and having a mental illness could still be seen to be genetically determined). The author also tackles in general the view that ‘schizophrenia’ (and other psychiatric categories such as ADHD) are primarily ’caused’ by genetic factors. One of the main arguments used by geneticists in this regard is the evidence from twin-studies. The author correctly notes that twin-studies are overplayed. The conclusions drawn depend on a number of assumptions. For example; the ‘equal environments’ assumption assumes that parents will parent identical and fraternal twins identically. But this may not be the case. In general; it is certainly true that the genetic arguments for psychiatric conditions such as ‘schizophrenia’ are massively overstated. For example; geneticists have been promising for years that the gene responsible for schizophrenia will be found. While statistical studies continue to produce statistically meaningful correlations to genetic factors no single genetic causation pathway has been established. The situation is similar with ADHD. With ADHD the genetic correlations appear to be small and no more significant than those for other, purely, perceptual factors – such as the age of young people in a class.  At the present time the genetic and ‘biological’ explanation for mental ‘illness’, in general, is characterised by significantly over-stating the available evidence. The preference for a genetic explanation is not supported by the evidence.
However; Maloney does not fully consider the genetic argument which it is possible to make. Aberrations and severe mental illness aside it seems clear that genetic factors are determinant for social class. The children of middle-class parents do not simply rise to the top because of the extra ballet classes that their parents could afford. They rise to the top because they, like their parents, possess the genes which are determinant of qualities which are predictive of success in a competitive society. And, equally, the children of the poor (or relatively poor) do not find themselves trapped in the same socio-economic grade as their parents simply because of how they were brought up. There is a genetic factor at work too; their genes, which they have inherited, are not those which are predictive of the qualities needed to rise to the top of the socio-economic ladder in a competitive modern economy where those with certain intellectual abilities get greater rewards. It may well be that being poor or relatively poor in an unequal society is a determining factor in mental ill-health – but it is possible to argue that there is a genetic basis to social inequality in the first place. This view was prevalent in the 19th century. Essentially it uses the idea of the theory of evolution to explain and justify social inequality. We mention this point of view because for a complete picture it would be incorrect to exclude the determining role of genetic factors in social inequality (and thus in mental ill-health even if indirectly). That said; this argument – for social inequality from Darwinism – is an ideological post-hoc justification for social inequality which deliberately tries to avoid humanistic frames of reference. It is not a very attractive argument to make. Even if it represents a truth (in a competitive society the strong rise to the top) it doesn’t in fact constitute an argument against the value of creating a fair society.
In the above we have noted that Maloney argues (basing his argument on social sciences surveys) that there is a link between poverty and mental ill-health. He also argues that there is a link between relative poverty and mental ill-health. In this view it is not so much being poor which is a determining factor for mental ill-health but being relatively poor in a society where the ability to blatantly consume material goods and status symbols has become, culturally, the measure of a person’s value. Finally, Maloney presents an argument (again citing social sciences studies) that social class – whether one is a worker with no autonomy or an owner who has power – is determinant of mental ill-health. It is rare to see a link made to mental ill-health and powerlessness. However; on the face of it it seems highly plausible that that being in a position of powerlessness (regardless of actual income) could be a contributory factor to mental ill-health. While Maloney does not make the argument explicit, at least in this chapter, the implication of showing that there is a correlation between mental ill-health and relative poverty and economic powerlessness is that the solution to the present crisis in mental health is not more pills or more counselling but a social and political change. In making this argument (which he does in effect) Maloney is diametrically opposed to the whole trend of modern ‘treatments’ for mental ill-health. There are two industries at work here; on the one hand the psychiatric-pharmaceutical alliance and, on the other, the psychotherapy industry. Both propose explanations for mental ill-health which eschew social and political questions. Both are, essentially, neo-liberal (or capitalist) projects. At the risk of an over-simplification; they aim to make money out of the distress caused by capitalism. But the ‘root cause’ of the distress may be capitalism itself.
The one omission from this chapter we would argue is that when he mentions the studies which show an ever-growing incidence of ‘mental-illness’ in the West Maloney does not give full consideration (he gives some when he mentions how surveys can be loaded) to the way in which the mental health crisis is simply concocted by people who are selling the ‘treatments’. In a world of supply and demand demand can be stimulated and the demand for mental health treatments can be created in the same way that the demand for sweet fizzy drinks can be created. If you tell people often enough that they need it they will accept it. (Especially if at the same time they can partially have a real need met e.g. for attention from someone in a perceived position of authority).
Essentially; we accept the thesis of this chapter, as given in the title, that being relatively poor in a stratified consumerist society is itself a source of hurt. And this is layered on top of all the stresses which come from being economically insecure, not only unable to afford soothing treats but also suffering from worries about bills and debt as well as being talked down to routinely by officials, supervisors at work and the other indignities which (strangely) it is considered acceptable to inflict on the poor despite all our pretensions to being a democratic society. Genetic factors may play a part in mental ill-health but the greatest factors are social and economic.
Part 2 – Therapy In Society
Chapter 6. Sweet Medicine – Talking Therapy as Control
Maloney opens this chapter by citing the work of Phillip Rieff and Christopher Lasch. These authors see therapy as representing a cultural shift from a morality based around self-discipline and fulfilling one’s duties to others towards a new morality. In this new morality one’s primary obligation is to oneself – to find personal satisfaction. We can add; in this new system self-discipline is replaced with the new value of ‘openness’ to the therapist. It should be immediately obvious to anyone that simply ‘talking’, however ‘openly’, will achieve precisely nothing. Anything worth achieving requires effort and self-discipline. The lack of effort required in being a client in therapy is a clue to the uselessness of therapy. Furthermore, as the cultural commentator Frank Furedi has noted , the alleged “openness” of therapy is really based around a trivialization of emotions. In reality serious people – with serious passions – do not splurge them out at every opportunity. To do so trivialises feelings.
In this chapter Maloney reviews how the fields of education, criminal justice, health (in the form of health psychology), parenting and the management of refugees have all become saturated with an ideology and a practice which uses psychological techniques to attempt to reprogramme individuals to adopt the correct behaviours. (Correct behaviours being which those are good for social order and the elite). Maloney refers to the weak nature of the ‘research’ which is often said to lie behind these programmes. Against this research he offers other research as well as critical cultural studies. To evaluate the series of claims and counterclaims in the research it would be necessary to conduct a thorough review of all the papers cited by Maloney. Such an endeavour is costly in terms of time; and one which can only be done in practice by people who are supported by grants or government salaries. Having said that; Maloney’s claims about the fake nature of the ‘research’ used to support these ‘evidence-based’ interventions certainly ring true for anyone who has delved into the world of ‘research’ produced to support government policy, for example, into research for parenting programmes. Much of this research shows obvious workings to produce the required result. (Our own study of the NICE ADHD policy is a case in point).  Of course there may be occasions when a psychological intervention can produce a slight statistical result. Maloney is so focussed on discounting the (no doubt) shady nature of the ‘research’ behind this programme of control by pop psychology that he does not admit that sometimes perhaps psychological interventions (even pop ones) can ‘work’. However; were he to do so he could make the point that even in these cases a ‘result’ does not necessarily justify the programme. – That is these kinds of ‘research’ projects are based on the idea of efficiency. If something ‘works’ it is good. The argument is fallacious. Possibly it could be shown that people in a concentration camp who took CBT classes were ‘happier’ (said so on a survey administered by the guards) that those who didn’t. But, in the end, it would be better not to have concentration camps.
Two other points which are inherent in this piece of work but which Maloney does make explicit in this chapter are the effect of research bias and the underlying economic reasons for this shift towards psychological interventions as being the tool of choice to manage everything from crime and ill-health to poverty. As concerns the literature; is is obvious that the funding for the kind of ‘research’ cited in support of psychological interventions comes from a hand that is looking for a certain outcome. The ‘researchers’ duly produce what is required of them. (Sometimes one can see an attempt to maintain their own academic credibility – a cautious judgement is included in the text itself but then the headline – which is all the policy-makers are interested in – is fixed to get the right result. This way the researchers can satisfy themselves that they are not prostituting themselves completely and at the same time they can ensure continuing funding. Researchers after all have to eat). Secondly; we see the shift from a welfare policy which at least considered economic and social conditions to one which focusses exclusively on the psyche of the individual as being directly and deliberately about capitalism retrenching itself and cutting costs (so as to maximise returns on capital). Maloney does not make a direct connection to the question of profits. It is however entirely in line with Maloney’s argument to note that this shift represents a move away from a concept of a society which at least partly considers fairness and equality a worthwhile value. In this new world where all problems – of crime, health, poverty, lack of educational attainment – are explained in terms of psychological deficiencies in the individual there is indeed “no such thing as society”. The shift towards an (apparent) concern for the ‘well-being’ of the individual is a mask for an increasing lack of concern.
Maloney draws this Chapter to a close with a refreshing quote from US academic Elizabeth Throop author of a book critical of psychotherapy . Maloney is discussing how the shift towards psychological explanations for everything from bad health to crime results in interventions which are mostly targeted at the poor. Maloney writes: ‘The implication is that they [the poor] deserve what they get, because they are supposedly deficient in “character, in integrity, in impulse control, when in reality what they are lacking is money”‘. Yes. Say it!
Chapter 7. Theory into Practice – The Programme for Improving Access to Psychological Therapies (IAPT)
IAPT is a UK government programme to improve access to psychological therapies. In this Chapter Maloney, who himself works as a clinical psychologist in the NHS, criticises this programme.
The IAPT programme offers a graded level of ‘support’ and CBT style therapy to anyone who requests it. The focus is on ‘treating’ those with ‘mild and moderate depression’. There is an unashamed focus on getting people into employment.
Great successes have been claimed for the programme. However, as Maloney points out, these appear to be based on ‘user-satisfaction surveys’. The surveys are conducted by the practitioner using a questionnaire with their own client. The survey questions are repeated in the same form in each session. This is, as any reasonably astute observer can note, a funnel designed to produce ‘results’. Of course people will say they feel better when asked the same question at the end of each session. Not to do do would be rebellion. Very few people are natural rebels. Furthermore; to say that they do not feel better after several ‘treatments’ – directly in the face of the helper – would feel like they were breaking their connection to their helper, who, despite everything, may be at least some kind of vaguely interested human being in their lives. These questions cannot but be designed to generate the result they claim to have “found”. Yet; many educated and apparently intelligent people will jump up and down and talk about the ‘evidence for success’.
The programme is as Maloney points out a cruel hoax. A cruelty made more obvious when we consider that many of the people who are the intended recipients of this programme live in economically deprived areas of the country.
We would add; as with the whole ’employment training’ scam this is yet another layer of ‘professional’ middle-class jobs being created in the ‘managing people’ section of the economy. While little is done to address structural economic issues.
Chapter 8. The Therapy Market – From the Third Wave to ‘Happiness’
Maloney opens this chapter by pointing out that the therapy industry, both private and the ‘market’ within the NHS is subject to commercial pressures. It is of course blindingly obvious that this is so and therefore that ‘advances’ in psychotherapeutic ‘knowledge’ at the very least need to be strained through a device which can differentiate between marketing matters and genuine ‘knowledge’ (if such exists in the field at all). It says a great deal about what is going on here that people who promote psychotherapy never stop to consider this facet of the ‘knowledge’ on which their industry is based. Therapy is profoundly apolitical. At a profound level it simply accepts the current political and economic status quo. It may even exist specifically with the purpose in mind of distracting people from any possibility of changing their social and economic conditions. Like religion it too may be (quite intentionally) an opiate for the masses.
Maloney reviews the appearance in the therapy scene of ‘mindfulness’. Many modern therapies have hooked ‘mindfulness’ into their offerings. University departments with brain imaging equipment have conducted ‘experiments’ and (with no apparent trace or irony) ‘proved’ that ‘mindfulness works’. All of this adds to the claims that therapy is somehow based on ‘science’. Maloney comments that on the whole when considering physiological measures mindfulness fares no better than relaxation. He acknowledges that there is some evidence for a different effect (MRI scans) for mindfulness as compared to relaxation techniques and then falls back on the defence that mindfulness, (a borrowing from Buddhism), is only effective when practised in connection with “traditions, rituals and the ethics they embody”. In reality Buddhism does not place great stress on ritual and tradition.  Though it is the case that the practice of Buddhism requires mindfulness training to be accompanied by ethics and other forms of practice and usually these practices are based on community living. The problem for mindfulness and therapy however may not be so much that it is disconnected from “ritual and tradition” (an entirely Western misunderstanding of Buddhism) but that the form of mindfulness practised is a debased and shallow version of the real thing.
Maloney is no doubt correct that the ‘evidence’ for the efficacy of mindfulness based types of therapy is as connected as that for the more traditional forms (see Chapter 4) – a lack of control groups and tick-box surveys being administered by people giving the ‘treatment’ are some examples he mentions.
Maloney comments that one explanation for ‘mindfulness’ within modern therapy is a marketing one. ‘Mindfulness’ adds a nice allure of something Eastern and mysterious to the offering. (The academics who measure ‘meditation’ and ‘prove that it works’ are of course playing their part in this marketing operation).
Maloney then discusses “positive psychology”. This is a movement which promotes the idea that individuals can do more to increase their own happiness. Maloney comments, citing evidence such as quotations from a 19th century self-help advocate, that these ideas are not new. The key point about this movement is that it focuses on what the individual can do to “increase their happiness” and thus provides an alibi for a social change. To be fair one leading UK exponent of this school of psychology, Richard Layard does, according to Maloney, also propose social policy action to reduce inequality. Maloney’s strongest criticism of this movement is probably that he points out the intrinsic shallowness of an ideology which believes that virtue, economic security and happiness can all coexist. As Maloney points out a more authentic engagement with life may not lead to ‘happiness’ in the sense intended by positive psychologists. Maloney refers us to Nietzsche, Camus and Voltaire. We would point to Van Gogh as an example of someone who illustrates his point. Van Gogh’s life was probably not a “happy” one by the standards of positive psychology. But he grappled with life’s deepest questions and must, at times, have experienced a sense of meaning or some kind of profound fulfilment. A life which engages with existence may not be “happy” in the sense intended by positive psychology but it may be more real.
In essence happiness has become another commodity. In connection with this idea Maloney remarks that therapy is now replacing pharma as the drug which offers to fix life’s ills.
Positive psychology is blind to the real pressures that people can be under in the workplace. All problems that people have can be fixed by some ‘internal’ change. Or, if therapy acknowledges that there are ‘external’ problems then it claims that by fixing the alleged ‘internal’ problems in the person the person will be better able to deal with the external problems. But this rose-tinted view ignores the real pressures many (below management level of course) feel in the workplace. This reviewer (for example) works in a firm where a hand-scanner has just been installed. Workers have to clock-in and out using this biometric device. The presence of this device which symbolises the complete lack of trust which management has in them and which marks a real a breakdown in relations, a culture of surveillance and a demonstration of power (the managers do not have to present their palms) will impact on the morale and mental health of the staff. No amount of ‘talk therapy’ can do anything about this. If someone takes an assertiveness course and challenges this the most likely outcome is that they will lose their job. This is just a simple example of the kind of real-world problem which causes ‘mental ill-health’ and which therapy has zero to say about. In reality therapy simply ignores this kind of problem. Therapy, as Maloney rightly understands, is apolitical. Therapy is entirely middle-class we could say.
Chapter 9 Towards a Psychology that Reflects what the Therapy Industry Will Not Tell Us
In this chapter Maloney reviews the work of R. D. Laing. Laing was a maverick psychiatrist who operated in the sixties. Laing made a name for himself championing the rather obvious idea that people who had been ‘diagnosed’ as schizophrenic were still people with their own story – just like anyone else. Laing fell from favour amidst problems with alcohol which saw him being banned from practising medicine, and fallings out with colleagues. His small clique declared themselves (or were so named) as being “anti-psychiatry” and promoted themselves as some kind of humanistic alternative to clinical psychiatry – though, as Simone De Beauvoir pointed out, “at bottom anti-psychiatry is still psychiatry”.  Laing founded a charity called the Philadelphia Association. (While it claimed to be very radical and opposed to psychiatric labels in fact the defining charter of the charity mentions the alleviation of ‘schizophrenia’, with no mention that this is anything other than a valid medical condition).  Many of Laing’s followers are still active today. When we speak of Laing’s followers it is worth clarifying that these are people who are associated with the Philadelphia Association and who make some or part of their living from it but who are all it seems at pains to distance themselves from Laing. (One of the more clever variations on this theme is by one Leon Redler who distances himself by claiming that he is following the true Laing – that he is more Laingian than Laing!).
In an earlier chapter Maloney mentions Laing as being the progenitor of “briefly fashionable theories”. In the chapter just reviewed (Chapter 8) Maloney links Laing to the mindfulness movement in therapy, which he criticises. It is surprising therefore to find in this chapter that Maloney appears to have swallowed some of the propaganda put out by Laing and his followers. Maloney writes: “Good ideas never die completely, however. The work of Laing’s Philadelphia Association continues. Funded on a shoestring, it offers a haven where seriously distressed men and women are allowed to go through what they have to go through, in the company of others, at their own pace and without the well-intentioned intrusions of psychiatry of family”. Maloney appears to have obtained this perspective on a Philadelphia Association Community Household from a book written by a psychotherapist involved with the organisation. The reader of this review is directed towards two accounts by people who have actually stayed in one of these households. (See An account by a resident in a Philadelphia Association household and The Philadelphia Association). This reviewer is the author of the second account. Suffice to say that the story told by Maloney (whose source is a Philadelphia Association linked therapist) is baloney. This is the official narrative – the marketing ploy, and very far from the daily reality; which is much more mundane and cynical. It is disappointing that Maloney has chosen apparently to believe what he has read about the Philadelphia Association written by someone connected to the organisation without applying any of the scepticism which he promotes elsewhere in his book. Perhaps he had to believe in something.
Maloney also reviews the contemporary critical psychiatry movement (of which the mainstream but credible critic of ‘ADHD’ Sammi Timimi can count as a supporter) as well as work by feminist critics of psychiatry, developments in care for those with ‘learning disabilities’ and community psychology. He concludes that there is very little evidence (as always Maloney is interested in what could pass muster as a credible randomised clinical trial) that any of these interventions lead to significant reductions in distress.
Maloney then turns, or returns, to behaviouralism. There follows a rather too brief summary of the work of a variety of psychologists from which Maloney assembles his argument. Maloney refers to phenomenology (a philosophy undermined by Foucault who located it as just another manifestation of the 18th century episteme of finite man) in order to restore a concern for ‘inner’ feelings, meaning and interpretation. (In fact there is no need to bring in phenomenology; other writers, such as the behaviouralist Hans Eysenck found no problem accomoda poeting and the imagination into his vision of human life; he just didn’t see these areas as susceptible to scientific study).  He also refers to developments in neuroscience and refers to an idea that the ‘best decisions’ are made at a visceral level – and that it is disruptions at this level which cause people to be trapped in bad decision making (a surprisingly ’emotional’ theory to find in a book concerned to criticise the therapy industry). Regrettably, Maloney refers to ‘research’ based around giving ‘canines’ (dogs) electric shocks as part of his discussion about ‘learned helplessness’. (We would suggest that human misery will not be solved by causing dogs suffering in pointless experiments which essentially establish what can already be known from a combination of observation and intuition; in this connection Richard Webster has discussed how positive science needs to accept that imagination as well as plodding ‘rationality’ is an integral part of knowledge ). The point of this whirlwind tour of various psychological theories is to provide a context for Maloney’s chief point; mental ‘ill-health’ is not something which is ‘inside’ a person, a set of ‘bad thoughts’ which they carry around inside their head and which can be changed by the right therapeutic intervention. Rather; feelings and thoughts, and thus mental ill-health, are part of a fluid exchange between person and environment.
Maloney refers to the work of his colleague David Smail. Smail is also a clinical psychologist. Smail has put forward a theory which he calls a “social-materialist psychology”. As presented by Maloney we can note that (at last) there is an acknowledgement that power has something to do with all of this. People who are are subject to power, or, we should say, more subject to power than others, will experience more pressure to think and act in certain ways. The range of options open to them is more restricted. (For example; even a middle-level manager can ‘raise a concern’ with a colleague but if a worker were to ‘raise a concern’ with a manger this would be more likely to see him cast as a troublemaker). Thus the scripts that exist ‘inside our heads’ and which determine mental ill-health or not are in fact not an intrinsic part of the individual but are social phenomenon. Given this then it follows that if we want to address mental ill-health then we need to focus on just these social phenomenon.
Maloney is a voice crying in the wilderness when he speaks of how much mental ill-health may be caused by “officially approved torments” such as soul-deadening labour, squalid impoverishment, the boredom of joblessness, and the moralizing sermons of the privileged. This view alone overturns the whole therapy industry, private and state, which simply ignores all these permitted forms of human cruelty which directly cause some people to live more miserable lives than others.
Taking the above into account Maloney’s argument is that if we want to do something about the problem of mental ill-health we do not need to conjure up some new treatment fad. The problem does not lie ‘in’ the individual. It is a social problem. The solution is to remove the social and economic factors which engender mental ill-health. These include excessive economic inequality and the disempowerment experienced by the poor.
While he eschews (at least this is the implication of his argument) ‘treatment’ for mental ill-health Maloney is still concerned with mental ill-health. He is still concerned with the question of individuals who suffer from mental ill-health. There is a perspective (or multiple perspectives) from which this concern is itself still a construct of a certain kind. From the point of view of Foucault’s work on the modern episteme – in which the whole concern with ‘man’ is seen as a transient discourse not as the basis for an objective knowledge of either man or the world –  Maloney’s work appears as a modulation in a discourse which itself is far from objective knowledge. The epistme in which Maloney’s work is located is the one which Foucault has traced has having come into being at around the start of the 18th century. At this time interest shifted from the classical world of God and the rules of his creation to a new outlook which invented (according to Foucault who followed Nietzsche in this regard) the concept of ‘man’ in its place. For Foucault modern ‘knowledge’ is best understood as a discourse which is located in this episteme. If ‘man’ is not the objective entity he is taken to be then constructs such as that of mental illness fade by the wayside as well. Maloney is aware of the criticism that his work depends on the construct of mental illness. To say, as Maloney does, that to accept the idea that mental illness does not really exist (a simplification extracted from Foucault) would be to permit governments to avoid responsibility is a strange argument. It may be the case that some people could use a shallow interpretation of Foucault to argue for less generous welfare benefits – but this does not mean that Foucault was wrong. You don’t counter a thesis by citing how it could be potentially misread and misused. Why then not consider Foucault’s thesis about how ‘man’ is a ‘construct’? Nor is there is there reason why understanding Foucault more fully (i.e. not at a shallow level) is likely to lead to a harsher social environment. True, if we accept that ‘man’ will disappear from the scene as the 18th century epistme gives way to something else then a great deal of social policy which is ostensibly built around these ideas will also change. But then so would much else. And Maloney does not claim that this world would be a harsher place than today’s world. Like most English academics then Maloney dismisses Foucault without any engagement with his work.
It appears that perhaps Maloney is aware of a certain anarchist tendency implicit in Foucault. Maloney is critical of this because his idea for a fix to the problems which he has been discussing is to look to governments to adopt more benign social policies. (Perhaps more Sure Start centres and higher benefits?) This is something of a let-down. All the (largely convincing) argument that mental ill-health should best be understood not in terms of malfunctioning individuals but in terms of social and economic factors just leads us to a sort of Guardianista plea for better social policy and ‘wealth redistribution’! We can ask – if peoples’ mental ill-health is in part caused by disempowerment – they experience their lives in terms of being pawns in a wider socio-economic system which treats them badly and over which they have no control, is this really going to be fixed by increasing benefit payments and working tax credits? Will this not still treat them as disempowered subjects of power? Is it is not almost as humiliating to be kept as a subject in a moderate state of comfort as it is to be kept as a subject in a poverty-stricken state of life? Maloney himself has argued (see above Chp. 8) that an authentic life may entail struggle and engagement and be far more than just a certain level of security.
If we can accept Maloney’s chief thesis – that the mental distress (which he no doubt witnesses in the consulting room) is a product of social-economic conditions including disempowerment in the workplace, absolute poverty and income inequality, then perhaps we should be looking for a more substantial economic and political fix than a change in government social policy? As Maloney himself seems to acknowledge the economic forces which condition the modern social-economic environment for most of us are distant financial centres and ‘transnational corporations’. There is an idea prevalent in certain liberal circles that the more harmful social consequences of these distant and profit-calculating entities can be neutralised or at least ameliorated by a few social policies. This idea has been prevalent for some time and a lot of government policies do indeed reference these ideas. But the problems remain. The reality seems to be that governments (of all ilks) see their primary responsibility as being to create an environment in which finance capital and large corporations can make profits. This necessarily means that any regulation is limited and toothless. If Maloney wants to make the social changes he proposes (and indeed has shown to be necessary if we accept his evidence that linked mental ‘ill-health’ to income inequality) then in reality he needs to be looking for more radical social change than a change in government policy.
Maloney is a clinical psychologist. Whereas many critics of psychotherapy criticise it at a theoretical level Maloney treats it as a clinical practice which can be evaluated by relevant clinical studies. A large part of his book is given over to reviewing and assessing the “clinical evidence” for psychotherapy. These are studies which claim to “prove” that therapy has benefits. Maloney looks at these studies from the perspective of a trained clinician. He finds that the quality of the studies is very poor. They do not meet the standards expected of normal clinical trials, such as a control group who is similar to the group receiving the treatment but who do not receive the treatment, against whom results can be measured, and evaluation being carried out by (ideally blind) neutral observers and so on. The studies which are used to claim that “therapy works” on the contrary are often based on before and after questions given to the treated group with no non-treatment comparison group, and the people asking the questions are often involved with the treatment. Maloney says that after you remove these kinds of studies from the literature those that are left show very little or no benefits for psychotherapy. It is certainly worthwhile to show that the “clinical literature” for psychotherapy is of a poor standard. There are of course those who take the view that the whole field is so amorphous and the claims so obviously untestable that the best approach is to criticise therapy at the theoretical level. We tend to side this this viewpoint; but it is certainly worthwhile to see that when the “studies” are sifted with an eye to normal scientific standards they do not stand up.
Maloney argues from the basis of clinical evidence that individualised interventions for mental distress do not work. He argues that this is because mental distress while experienced by individuals is caused primarily by social, political and economic conditions. He produces some evidence to support this claim. (This material is more likely to be in the form of population surveys than clinical trials linked to a specific treatment). He concludes that the best solution to problems of mental distress will be changes in government social policy to create more income equality and less demeaning forms of employment (and unemployment). While taking issue with his proposed solution (a liberal-democratic idea that capitalism can coexist with caring social policies) we welcome the statement that mental distress is a social phenomenon with political causes.
There is one danger inherent in Maloney’s approach. In saying essentially, that the way to fix the mental health problems of the poor is to change the conditions in which they live, he is in danger of sounding somewhat contemptuous of the poor. Are the poor really to be seen as passive animals who will simply flourish if we put them in the right conditions? On the other hand; claims that the poor just need to change their beliefs and attitudes and that their social conditions have nothing to do with their distress are obviously cynical and expedient. There is no serious doubt about Maloney’s sincerity and commitment. However – we do not see much of the poor themselves in his proposed solution. It would be good to see more about what the poor themselves can do, politically, to fix their situation.
A second problematic is that while Maloney is undoubtedly right in saying that almost all therapy is ineffective at best, or harmful at worst, he is in danger of throwing out something of value. In Maloney’s criticism of the technology of self he does not distinguish between the way that ideas about self-change are used to drive short-term mass provided interventions from the application of these ideas in a serious way by an aware individual. Serious work has been done on the possibility of re-programming fixed beliefs (for example by John Lilly ) and Maloney in his (no doubt entirely correct) rejection of a simplistic application of such ideas in 10-week courses given in a hierarchical structure by someone who barely understands them, is in danger of rejecting a valid field of human knowledge and experience.
Overall however Maloney’s focus on the social, political and economic conditions which cause so much mental distress in individuals is to be welcomed.
2. Richard Longmore and Michael Worrell. Do we need to challenge thoughts in Cognitive Behaviour Therapy. Clinical Psychology Review. 27. 173-187. 2006
3. Michel Foucault. Madness and Civilization. Originally published in France in 1961. English edition: Routledge 1989 and subsequent editions.
4. Richard Webster. Why Freud was Wrong. Sin, science and psychoanalysis. HarperCollins 1995.
5. Elaine Showalter. The Female Malady. Virago 1987.
6. The Therapy Industry – Paul Maloney. Pluto Press. 2013. p76
7. Bickman, L., Breda, C.S., Foster, E.M., Guthrie, P.R., Heflinger, C.A., Lambert, E.W., Summerfelt, W.T. Evaluating Managed Mental Health Services. The Fort Bragg Experiment. American Psychologist. 51. 689-701. 1995
8. R. D. Laing’s claim about himself in the Politics of Experience. Penguin. 1967.
9. Richard Wilkinson and Kate Pickett. The Spirit Level. 2009.
10. Frank Furedi. Therapy Culture. Routledge. 2003.
11. Elizabeth Throop. Psychotherapy, American Culture, and Social Policy: Immoral Individualism. Palgrave Macmillan. 2009.
12. What the Buddha Taught. Walpola Sri Rahula. One World Publications. 1959.
13. The Female Malady. Elaine Showalter. Virago 1987. Chp. 9.
15. H. J. Eysenck, Decline and Fall of the Freudian Empire, 1985.
16. Ibid. 4. Chp .24
17. Michel Foucault. The Order of Things. Routledge. 1970 (Published in French as Les Mots et les Choses)
18. John Lilly. Programming and Meta-Programming in the Human Biocomputer. 1968