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Therapy in the absence of psychopathology and neoliberalism

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Therapy in the absence of psychopathology and neoliberalism

Bernard Guerin

University of South Australia

Matt Ball

Rory Ritchie

The Humane Clinic

Short title: Therapy without psychopathology or neoliberalism

Correspondence to:

Professor Bernard Guerin

School of Psychology (Magill Campus)

University of South Australia

GPO Box 2471

Adelaide 5001

Australia

Email: Bernard.Guerin@unisa.edu.au

Phone: 0431477453
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Abstract

Therapies have developed over the last hundred years within a milieu of medical models

explaining the foundation of ‘mental health’, and within a modernist/ neoliberal milieu that

what counts as the goal of therapy is a functional and productive life within the current

society. The assumptions of these are currently being challenged and alongside this has been

a rise in different types of ‘alternative therapies’ which might seem radical, but this is only if

you stay within the two milieus. This paper provides rationales for some of these new

therapies when they are properly considered outside of the older medical models and

neoliberal imperatives. Details of some of the therapies are given along with rationales for

the types of therapeutic responses which seem antithetical to current therapeutic models.

KeyWords: Just Listening, Emotional-CPR, Client Centered Therapy, Suicide, Alternative

Therapies, Therapeutic Responses

 3

While many varieties of psychotherapies have evolved over the last century, there are

probably some core features (Frank, 1961; Guerin, 2017a; Heinonen & Nissen-Lie, 2019;

Marquis, Henriques, Anchin, Critchfield, Harris & Ingram, 2021; Norcross & Wampold, 2018;

Shedler, 2018; Wampold, 2015, 2018). But whatever these core features might be, all the

psychotherapies have developed (1) within a milieu of medical models explaining the foundation

of ‘mental health’, and (2) within a modernist or neoliberal milieu that what counts as the goal of

therapy is a functional and productive life within the current society. These are not necessarily

found in all older forms of therapy (Janet, 1925/1919), but the standard forms of therapy

developed over the last hundred years have been strongly shaped by both these milieus.

In recent times, however, both these milieus have been questioned by the social sciences,

by psychology, by mental health nursing, and by those directly experiencing the fallout and

problems from the ‘mental health’ systems. In particular, the medical models of ‘mental health’

and the DSM are both being seriously challenged and new approaches put forward of ‘mental

health’ without the medical pathologizing and the categorizations (Bentall, 2006; Barker &

Buchanan-Barker, 2005; Boyle & Johnstone, 2020; Cromby, Harper & Reavey, 2013; Davies,

2014; Guerin, 2017b, 2020a; Johnstone, 2014; Johnstone & Boyle, 2018; Kinderman, 2019;

Read & Sanders, 2010; Watson, 2019). And the way human behaviour is shaped by modern

societal structures, and neo-liberalism in particular, is also being challenged (Cosgrove & Karter,

2018; Davies, 2021; Graeber, 2015; Guerin, 2020a; Odell, 2019; Richardson, Bishop & Garcia-

Joslin, 2018; Verdouw, 2017).

The point for this paper is that as these new alternative models of ‘mental health’ and

alternative approaches of therapy develop into whatever new forms might eventually prevail, we

should also expect changes in what are considered to be the fundamentals of therapy, how
 4

therapy should be conducted, and what the outcomes of any therapy should look like. And

indeed, there are new approaches being put forward for doing therapy which currently seem

radical to many, but we will argue that these are radical only for those still following medical or

psychological models of how humans work. Indeed, new approaches are already incorporating

more explicitly the new ideas (Ball & Picot 2021; Seikkula, 2020).

The purpose of this paper is to examine some of the recent alternative approaches to

therapy in this light and show how they are arising from changes in the very foundations of

therapy as the concepts of ‘mental health’ and therapeutic goals get questioned. They are not

just minor tweaking of older therapy models, but whole new approaches.

The medical model of mental health and the neoliberal goals of therapy

The medical model of mental health makes assumptions which have been criticized over

many years in psychology and elsewhere. Some of these are shown in Table 1. In particular,

people are treated as self-contained individuals ultimately controlled by an ‘internal’ system,

such as cognitive processes, unconscious structures, the brain, associative processes, behavioural

habits, or some mixture of these (Guerin, 2016). In terms of a discourse analysis critique of this,

using these ‘internal’ models has meant that we cannot observe what determines people’s

behaviours, thoughts and feelings, and so the models become language-based and can be hedged

against any opposition. They are all metaphors, however, and are based on a ‘Fundamental

Attribution Bias’, that when you cannot observe a ‘cause’, the explanation must be made as an

essentialistic ‘internal’ attribution instead (Guerin, 2016).

[Table 1 about here]

The medical models also argue that ‘mental health’ issues are ‘caused’ by something

being wrong with internal physiology, in the same way that regular medical complaints have a
 5

physiological basis. Hence, there are theories of brain diseases, chemical imbalances, and

‘internal’ cognitive or unconscious dysfunctions which ultimately are said to be a problem of

physiology. There are also implications for the approach of the therapies offered. For example,

when a person is considered to have a biological or genetic condition, they have been found to be

treated less humanely compared with understanding of a person’s experiences as being related to

psycho-environmental condition (Pavon & Vaes, 2017). This in turn supports the idea that

changing the physiology through drugs is likely to help.

Neoliberal goals have likewise shaped people’s behaviours in modern society (Cosgrove

& Karter, 2018; Defehr, 2016; Graeber, 2015; Guerin, 2020a; Neysmith, Bezanson & O’Connell,

2005; Odell, 2019; Richardson, Bishop & Garcia-Joslin, 2018; Verdouw, 2017). The

administrative, policy, and bureaucratic enforcement side of modern neoliberalism is that: (1)

there is a problem to be fixed, (2) so this needs some sort of expert who is given government

power to use (3) a standard way of assessing what is wrong, (4) engaging a standard process to

fix the problem, (5) the person becoming a functional, working citizen or recipient of welfare.

These points all assume that societal norms are best and that the output of therapy will be a

person who can function and be productive within society, preferably being able to work and

engage in society as a citizen. Previously, ‘mental health’ issues were seen as being ‘irrational’

or losing one’s rationality, and a cure was to make the person ‘rational’ again with less

expectation of being socially functional (Foucault, 2009; Janet, 1925/1919; Scull, 2009). This

has now changed in modern society to the person being ‘dysfunctional’ with the ‘cure’ being to

make them functional and productive once more by using standard intervention procedures

which have been ‘proved’.

How therapies have been shaped by the medical models and assumed goals of therapy
 6

What we wish to explore first is how therapy is changing as ‘mental health’ changes from

being a problem hidden ‘inside’ a person, which must be diagnosed and then fixed, to a problem

with the person’s current and past life situations, environments and human relational dilemmas.

The medical models with their ‘inside’ problems have led therapies to make assumptions that the

person must be ‘talked’ into answering questions, revealing details about themselves (whether

invented or not) which have caused the ‘internal’ physiological problems, and then changing the

ways they talk (their ‘inner world’) to help fix their problems. It has also led to assumptions that

drugs and physiological changes can directly change the ‘internal’ mental health problem since

‘internal’ causes presumably mean brain and chemical problems. These assumptions have all

been strongly disputed over many years (Johnstone, 2014; Kinderman, 2019; Read & Sanders,

2010; Romme and Esher 2000).

This shaping of therapy by the medical models of ‘mental health’ and neoliberal goals

can be glimpsed in a recent ‘deconstruction’ of psychotherapies, in which Guerin (2017a) made a

study of 19 common psychotherapies by comparing their goals and their practices when their

different jargons were removed to equate the variety of seemingly different therapies (cf. Frank,

1961; Heinonen & Nissen-Lie, 2019; Norcross & Wampold, 2018; Shedler, 2018; Wampold,

2015, 2018). It was found that the main thrusts of almost all the western therapies for goals and

activities, once the varying jargons and theories were removed, were to: (1) form a quick

working relationship with a client within a stranger/ contractual relationship; (2) solve smaller or

more localized conflicts in the client’s life which are amenable through talk within an office; (3)

act as a new audience to train new behaviours and skills where appropriate; (4) find out their talk

and thinking around the problems and suffering they have; and (5) attempt to act as a new
 7

audience to change those thoughts and talking in ways that should be beneficial and reduce the

suffering, especially for broader life conflicts

Different mainstream therapies focus more or less on different aspects of these, and use

different jargons to ‘explain’ them, but they either all cover much the same ground when the

jargon is removed, or else they specialize in only certain types of problems and suffering. One

common critique, however, has been that without a strong social connection (Step 1 is often only

a few minutes for ‘rapport building’), the other 4 steps will fail. We will come back to this as

one impetus for some of the recent changes in therapies.

The point for this paper is that all these steps are shaped by the medical and

psychological models of human behaviour and ‘mental health’ and the imperative of neoliberal

values. In particular, the emphasis on talking and questioning the client is shaped by a belief that

a person’s problematic behaviours, talking, thinking and feelings are somehow contained hidden

‘within’ them and these must be spoken to ‘get them out’. Even emotional responses and

feelings need to be put into words in the majority of therapies. To change the ‘mental health’

problems, then, the clients’ ways of talking (their cognitions, Guerin 2020b) must be changed

almost exclusively through conversation with a therapist, who is a stranger because of

administrative and bureaucratic rules. But changing how people talk is varied and very diverse,

and we argue that it is this diversity in getting people to talk and answer questions in therapy that

has led to the current diversity of psychotherapies, nothing more. New ways of changing

people’s self-talk become new therapies, at least in their jargons. That is, the different jargons of

therapies merely reflect the different ways the proponents have managed (probably successfully)

to change the clients’ discourses.

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These different sounding strategies of therapy, shaped by the current medical models of

mental health, are also reflected in the common responses which are now made by therapists.

The top half of Table 2 shows some of the common ways in which therapists currently respond

in therapy. People like Carl Rogers and others changed these in many ways from the earlier,

more directly medicalized modes of questioning which purely focused on eliciting a DSM

diagnosis, but the general scheme still follows the same implicit medical model of human

behaviour (Carkuff, 1987; Rogers, 1951).

[Table 2 about here]

In the case of Rogers, for example, reflecting back what the client tells you instead of

interpreting what they say in terms of a theory (e. g., psychoanalysis) or category system (e. g.,

the DSM), while an improvement, is still about eliciting the person’s ‘inner’ conflicts and getting

them to talk about these in new ways (but with Rogers at least the client gets to construct these

new discourses rather than the therapist). The particular way of changing how people talk and

answer questions in Rogers’ case, for example, was to avoid strong direction or imposition from

the therapist on what the clients should say, and let the person develop the discourses. More

recently, CBT, ACT, FAP and DBT have used very different ways of getting clients to talk to

accomplish the same end.

New models of ‘mental health’ and hence therapy

What the models of ‘mental health’ now say

While there is no single replacement for the medical model of human behaviour yet, what

the new approaches all have in common is looking at the broader contexts of a person’s life to

find out what has shaped the behaviours being labelled as ‘mental health’ issues, rather than

attributing this to something ‘inside’ a person (as per the Fundamental Attribution Bias). This
 9

includes both a strong focus on past traumatic events in the person’s life (Johnstone & Boyle,

2018), and a strong analysis of the social, societal and cultural contexts which shaped a person’s

behaviours (Guerin, 2017b, 2020a, c). The common new element is that these bad life situations

are what are said to shape the ‘mental health’ behaviours, not internalized faulty cognitive

functioning, chemical imbalances, or brain diseases. To help someone, therefore, we do not need

to ‘fix the inside person’, since the person is not broken or damaged, but to ‘fix their situation’

instead, since it is their world which has been broken or damaged.

An early example of an alternative approach to thinking about ‘mental health’ was that of

R. D. Laing. Laing’s broad explanation of mental health focused on a person’s phenomenology,

social relations, and cultural environment (Laing, 1965; Laing & Esterson, 1964). As has been

suggested in this paper, as Laing’s model of human behaviour moved away from the medical

models he began with as a psychiatrist, so too did his ways of conducting therapy change to

match this. Laing’s existential phenomenological approach was more of an ethical enterprise, a

psychotherapy as a work of love, which is open to other idioms and meanings.

More recent proposers of these new positions have emphasized that external life contexts,

rather than any ‘internal’ environments, are driving human behaviour, but that they are difficult

to observe in practice without spending more time with clients, both listening to them and

getting more involved in their lives. This requires better and more detailed observations of a

person’s life world. Instead of asking “What is wrong with you?”, we need better observations

and inquiry of “What has happened to you?” (Johnstone & Boyle, 2018). This, of course, is

unwanted in an efficiency-driven neoliberal administration where finding a diagnosis is primary

(Aschebrock, Gavey, McCreanor & Tippet, 2003).

 10

So the recent switch has led to new models in which a person’s bad life situations shapes

their ‘mental health’ behaviours, not some hidden and faulty ‘internal’ processes (Cromby,

Harper & Reavey, 2013; Guerin, 2020a; Johnstone & Boyle, 2018; Read & Sanders, 2010).

More detail of these changes will not be given here, because the main point for this paper is to

show that when switching from the medical and psychological models of ‘internal problems of

‘mental health’ to the different contextual models, the ways of observing, listening and

questioning must also change, meaning that the whole way of doing therapy must change. Some

of these changes are shown in the bottom half of Table 2 and will be discussed below.

Along with the changes arising from how to conceptualize the shaping of ‘mental health’

problems, there can also be seen a move away from the neoliberal goals of therapy. Of most

importance is to support the person in crisis, and to work gradually at their own pace towards

them being able to fix their life situations. It is no longer of most importance to do this quickly

and efficiently, with a standardized, “one-size-fits-all” solution, nor to arrange that their resultant

behaviours are functional within modern society. Often the pain they have gone through from

their bad life situations, which is not of their own making, has left them unable or unwilling to

become model citizens in any case (Guerin, 2020a).

So, the new goals of therapy are changed to focus instead on developing a social

relationship which is more than just the minimum required to get information out of the ‘client’

and change the way they talk (in fact, the word ‘client’ is another example of neoliberal values

being imposed within therapy; McLaughlin, 2009), to support them over whatever time is

needed, and to help them discern those parts of their world which have shaped their unwanted

behaviours and might be changed. The person needs first and foremost to be given a space to

develop and change their life situations by whatever means and with whatever life outcomes they
 11

are led to, whether or not this fits an efficient neoliberal model. Ball and Picot (2021), for

example, refer to ‘non goal orientated’ forms of therapies.

How new therapies have been shaped by the new models and assumed goals of therapy

In the bottom half of Table 2 are some of the ways therapists now respond within the

newly developing therapeutic methods. Some are well known and used as adjuncts to regular

therapy, but some are newer. The first reflects the change towards looking at the person’s

context for what has shaped their behaviours, and the questioning moves away from blaming the

person for internal pathologies to hearing their stories of how their bad life contexts have

developed over time: from “What is wrong with you?” to “What has happened to you?”

The next few responses in Table 2 reflect moving away from the neoliberal-driven

approach in which there is a problem to be solved and we must quickly diagnose that problem

through questioning and then solve it in an efficient way. Instead, the goals are to develop a

good social relationship, currently called various names such as “a strong human connection”, or

“an authentic relationship”, and then to work with the person as they change their contexts and

discourses. As for Rogers (1951), the goal is not to impose the therapist’s ideas about what

should be done but help the person do this. Even traditional therapies rely on a good ‘therapeutic

alliance’ for ‘successful’ outcomes although it is not clear what this really means (e. g., Bourke,

Barker & Fornells-Ambojo, 2021; Martin, Garske, & Davis, 2000).

To these ends, responses just include normal ways in which human make social

connection, including hugging and some touching, joking where appropriate for the social

connection, and any other responses made in ‘normal’ life when building social connections.

Based on the new models of ‘mental health’ issues and the new goals of therapy, just sitting and

listening without actually trying to solve the person’s problems and ‘fix them’, is also entirely
 12

appropriate and there is a rationale for doing this with the new ideas about human behaviour. To

do otherwise shows the neoliberal shaping we all have learned through our lives. Finally, if the

person is in crisis, it is more appropriate with the new goals of therapy to not ask them questions.

The last thing a person in crisis needs is to be put through a large series of questions either to

build a diagnosis or to assess risk, nor develop a suicide contract. If these have to be done for

administrative purposes, they can be done at a later time.

The other responses in the bottom of Table 2 reflect some more specific responses

developed recently which we will explain and provide a rationale. For example, what is called

Emotional-CPR (E-CPR) is a mixture of many components of working with people, but all

reflecting the new models of therapy post-pathologizing and post-neoliberalism. E-CPR

advocates response techniques that can be used by any person responding to another in distress,

further challenging the bureaucratic enforcement side of neoliberalism that purports problems

exist within people that can only be ‘fixed’ by an expert or professional. But the mixture is very

unlike orthodox therapy practices (Myers, Collins-Pisano, Ferron, & Fortuna, 2021). The main

components are:

• the use of methods sometimes called “Just Listening”, in which the idea is to offer a sense

of justice to a person’s experiences by deeply listening rather than trying to instruct them,

give them information, diagnose them, reframe what they say, or discuss ideas: just let

them tell their own story, and treat them as the ‘expert’ in what is going on in their lives

(Browning & Waite, 2010)

• respond by saying how what the person said or did makes you feel: this requires honest

responding and some courage and is a main teaching outcome of the E-CPR ‘real plays’

used in training (Guerin & Thain, 2020a, b)

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• unlike almost all other therapeutic approaches, E-CPR does not focus on fixing the

person’s problems but on listening to them tell their story, and responding with how that

makes you feel, thus thwarting the common neoliberal-driven aspects of most current

therapies

The upshot of combining these three points is what some E-CPR proponents call “making a

human connection”. The experience and rationale of doing this is that from this human, social

connection, progress will be made more easily, perhaps in another session. The E-CPR critique

of ‘standard’ clinical responding is that without this strong human connection first, any

instructions, advice, referrals to other professionals, or attempts at interventions, will not be

heeded in any case. This again stems, we argue, from the changed models of ‘mental health’ and

the changed values of therapy and has a strong rationale within the new models of human

behaviour without neoliberal goals.

Finally, by removing the ‘mental health’ problems from inside the person or their brain,

therapeutic discourses are no longer serving the same functions as for mainstream therapies, in

which words are primarily used to build a quick rapport and to elicit ‘hidden’ information for a

diagnosis or solution to fix the person (Guerin, 2017a). Thus with the new models of ‘mental

health’ and the new goals of therapy, it is even more appropriate to use forms of language such

as poetry or story-telling, and also to use non-word based ways of having the person reflect their

life contexts when they cannot be put into words easily (such as dance, music, art, rhythms).

These can help the person discern their bad life situations, how they have been shaped, and how

they might be changed.

Many of these responses in the bottom half of Table 2 are already known from other

sources of therapy and relationship building, at least as components, such as Open Dialogue
 14

(Bergström, Seikkula, Alakare, Mäki, Köngas-Saviaro, Taskila, Tolvanen & Aaltonen, 2018;

Razzaque, 2019; Seikkula, 2020), ethnography (Bohannan & van der Elst, 1998; Cubellis, 2020;

Goulet, 1998), and Indigenous listening (Chamberlain, Gee, Gartland... 2020). They are also

widely found in forms of religious, pastoral, and spiritual guidance (Thich Nhat Hanh, 2001).

Rationales for how the newer therapeutic ways of responding might work

One thing in common with the methods in the bottom of Table 2 is that they are not

aiming to ‘fix the person’ but rather to engage with the person and hear their stories of ‘what has

happened to them’ thoroughly, their life contexts, without jumping in to fix things, and without

trying to interpret what they say into other words or jargon (Guerin, 2017a). They are also not

trying to ‘build rapport’ artificially but to let a relationship develop by attending and listening

(Just Listening) and letting the person know how the therapist has been affected (E-CPR), and

they can engage how they wish, whether this is words, music, drawing in the sand, or otherwise.

They are also not fixated on getting the person to say more and more and answer a large number

of questions posed by the therapist who then appears as the expert.

In the model proposed by Ball and Picot (2021), the approach is not to draw out more

from the person, but rather, the process is intended to create a ‘co existing same experience’, in

which both people can share their experience of the same moment without any threat of needing

to problematize, change, or even discuss the differences. In this experience it is suggested that

the person in distress may experience a new environment of relationship sufficient to develop

their own narrative of events, ideas and ways of being that is best for them (cf. Laing, 1965).

Most of these responses, therefore, do not make sense from the medical and

psychological models, since the therapist-client relationship is really only about asking questions

based on the narrow ideas of that something is wrong ‘inside’ the person and this needs to be
 15

elicited in words and fixed (Guerin, 2017a). Different current therapies do this to different

extents, with the most extreme perhaps being the psychiatric interview in which the main goal is

to ask questions to elicit answers from the client which will inform a diagnosis, and which does

not really need any more information beyond that (Aschebrock, Gavey, McCreanor & Tippet,

2003). Other therapies, such as those of Rogers, do less of all these but they are still priming the

client to be talking out loud about their ‘internal’ issues, problems and feelings.

While the therapeutic responses in the bottom half of Table 2 do not immediately address

changing the person’s bad life contexts, they work to form a less clinical social relationship

which, it is argued, will help more in the long run. In most cases, the immediate goal is not to

‘fix the person’, unlike the 19 psychotherapies discussed earlier (Guerin, 2017a). This is

especially important when a person is in crisis, since making demands is not the best form of

social interaction, and in these contexts, asking a lot of questions will be seen as making

demands. This will lead to shutting down of any interaction and social relationships

(dissociachotic, Ball & Picot, 2021). Involuntary hospitalization has similar effects (Dembo &

Hanfmann, 1935; Jones, Guis, Shields, Collings, Rosen & Munson, 2021). Even getting the

clients to put their emotions and feelings into words can be seen as demanding, since from the

context of their bad life situations, the emotions are there precisely because there are not words

for what the person is experiencing(Guerin, 2020b) . So, they should certainly experience their

emotions but not have to try and put them into words, as this will encourage escape, avoidance

and exiting strategies.

The E-CPR method is interesting, and we can begin speculating upon why it works

(Guerin & Thain, 2020a; Myers, Collins-Pisano, Ferron, & Fortuna, 2021). With E-CPR you do

not reflect back to the client what they have told you, as many forms of counselling and therapy
 16

teach. Instead, the idea is to (genuinely) let the person know how what they said has affected

you. For example, if someone said, “I feel like I am useless and my life is going nowhere”, you

would not respond with the standard, “What I hear is that you feel your life is a waste of time and

you can do nothing useful”. Instead, you might respond with, “You know, that makes me sad

when I hear you say that”, or, “I feel happy hearing that because I used to talk that way but no

longer do, so there is hope”. What is said depends upon the authentic way the therapist feels

after hearing the client speak, so you might even possibly say, “I laughed inside when you said

that, because it reminded me of Marvin the Paranoid Android”.

What is interesting in the E-CPR approach is that when someone is in crisis, they

probably have very few or no effects in their world. No one in their social relationships (maybe

these are few anyway) listens to them or pays attention, and no one does anything the person

might ask (or they would have changed their situation long before through talking). Whatever

they might say by way of bonding or getting people to do things, does not work. It is like their

language is functionally broken. With the standard therapy response of reflecting back to such a

client what they have said, while this does let them know that the therapist is listening and

awake, there is no indication that what they said had an effect or impact on the therapist at all.

Reflecting back can sometimes even sound like a parrot and can be programmed on computers as

we know (Eliza).

However, we believe that one of E-CPR’s benefits, no matter what response is made

(even that about Marvin), is powerful precisely because the person learns that what they said

actually had an effect or an impact in their world; someone was affected by something they said

or did, and this might be rare for them. This goes against most therapeutic methods of how

therapists should interact with their clients (top of Table 2), in that (1) the therapist talks about
 17

themself and their feelings when appropriate, and (2) they honestly say how they were affected.

But the rationale is that within the full context of the client’s bad and ineffectual life situations,

this can be extremely important to them.

What is important, then, in E-CPR and the similar responses is that the therapist is

changing what they themselves do, whereas much of the traditional therapeutic focus has been

about how a therapist may effect change in a therapeutic situation by applying their honed

clinical skills, interpretations and other ‘interventions. A more overarching way of understanding

the new, non-pathologizing approaches is dissociachotic responding, which places emphasis on

the effects when therapists change their own behaviour rather than that of the client at all.

Dissociachotic places the responding to be the responsibility for the therapist recognising and

managing their own experience before attempting to ‘change’ another person.

Understanding that any behaviour of a client is legitimate and understandable in any

environment that requires a response, the therapist can recognise their own role and

responsibility in creating or replicating the very environments that reduce the opportunities for

safety of the individual. Moving away from the ‘diagnostic’ guess work of “behaviour A means

this”, or “behaviour B means that”, that is used in psychopathology and neoliberal ideology of

what is well and what is sick, dissociachotic finds that changing the threats the therapist might

unwittingly be creating is likely to create better opportunities for the other person to express

themselves. In this way, the therapist’s role is not to change the client at all but to create

situations with them by changing their own behaviour.

The therapeutic responses identified in the dissociachotic framework are focussed

explicitly on developing human to human connections and, within those connections, being able

to discover that both individuals can be in relationship whilst experiencing different realities of
 18

the same moments – the “coexisting same experience” (Ball & Picot, 2021, p. 1). The

dissociachotic approach can be made with the responses already mentioned, such as E-CPR or

Just Listening. These can be understood as consistent with the dissociachotic framework of

discovering new environments for a person to narrate their story without the need for other goals.

The special case of ‘suicidal behaviours’

Because of the urgency with which mainstream treatment services approach suicide and

suicidal ideation, the same medical models and neoliberal values and goals have been

excessively applied. The current mainstream approaches to suicide, for example, usually require

asking a long series of ‘risk assessment’ questions, and this will not get what is wanted in a crisis

situations even with the best intentions (Guerin & Thain, 2020b). But as these models have

been whittled away, so too have alternative ways of understanding suicide and working with

suicide been developed.

The more recent and broader suicide research shows that the medically-based models of

‘suicidal behaviour’ need to be changed, but psychiatry and psychology are lagging behind in

this, just as for the medical and pathologizing models of human behaviour seen throughout this

paper. What is clear from this new ‘suicide’ literature is that the way you view or theorize the

very nature of humans and why they do what they do, changes the way you view and treat

suicide (Bantjes, Swartz & Cembi, 2018; Bornstein, 2006; Broz & Münster, 2015; Krishnamurti,

2020; Marsh, 2010; McQuaid, Bombay, McInnis, Humeny, Matheson & Anisman, 2017; Trout,

McEachern, Mullany, White & Wexter, 2018; White, Marsh, Kral & Morris, 2016).

For example, if you have a very western individualistic, medical way of viewing

humans, that they are self-contained individuals who choose (internally) for themselves and

make their own (internal) decisions (Table 1), then suicide is a matter of restraining their
 19

behaviour and thinking, and trying to correct their ‘faulty’ or ‘dysfunctional’ thinking. You also

might provide them with better information upon which to make their decisions, refer them to a

(neoliberal) ‘specialist’ in changing ‘human minds and thinking’, or give drugs to change their

assumed disease issues. These are the typical goals of most suicide preventing programs

currently, which directly follow from a medical model way of thinking and neoliberal goals:

calm the person down and refer them to a specialist to fix their ‘inside’ problems in a standard

and approved way (to avoid responsibility).

As we would at this point expect, alongside these new ways of understanding suicide

behaviours, so new therapeutic approaches have arisen. “Suicide Narratives” (Ball & Ritchie,

2021), for example, incorporates many of the elements in the bottom of Table 2, especially Just

Listening and E-CPR, and advocates these forms of responding as the most useful when the

person is in crisis or is ‘suicidal’. So, while this might seem from a medical model to be the

wrong approach, Suicide Narratives advocates just listening to a person in crisis and telling them

how you are affected by what they say, rather than just trying to stop their suicidal behaviours,

talk them out of it, or ‘fix’ them immediately.

According to Ball and Ritchie (2020) suicide can be better understood through a non-

medical model of dissociation. People become absorbed in the experience of suicide and begin

having de-realised experiences, with both absorption and de-realisation being recognised as

dissociative phenomena (Carlson & Putnam, 1993). These can be understood as dissociachotic

states (Ball & Picot, 2021) of a person at variance with their environment which is not conducive

with living. This requires a contextual understanding of suicide and not one that fits in any ‘fix

the person’ therapy approach (Ball & Ritchie, 2020). Rather than find a magi bullet standard
 20

therapy for suicide, therapists should be examining how their own responses to suicide are

dissociated from their clients.

So, E-CPR and Just Listening can be seen to be aligned with the new suicide literature

referenced above (Ball & Ritchie, 2021). This arises because they also mirror the more modern

approaches to how humans work (but developed independently) in which the medical models for

thinking are gone (Boyle & Johnstone, 2020; Guerin, 2017b, 2020a; Johnstone, 2014; Johnstone

et al., 2018; Kinderman, 2019; Watson, 2019). The basis to ‘mental health’ problems is not

‘faulty thinking or brains’ but ‘faulty life situations’. The case of suicide is extreme in which

almost all responses are blocked for the person (for different reasons in their idiosyncratic life

situations), and nothing they do or say has any effect to change their life situation.

This way of thinking means that the priority when non-medical and non-pathologizing

approaches are the foundation of what you do, is not to do a risk assessment through long

questioning and then make a referral, but (1) to establish a strong human connection with the

person which they do not have elsewhere in their lives, and (2) to show them that what they do

can affect, impact on, or change their world in some small way (bottom of Table 2). These are

clear in E-CPR methods but get thwarted by the types of responses made in standard suicide

protocols based on medical model ways of viewing suicide.

Conclusions

Exactly how the new non-pathologizing approaches to mental health mixed with new

methods of therapeutic responding will evolve over time, is still being played out at present.

What this paper has tried to show is that just as the one hundred years of therapy development

occurred in specific milieus of medical models and neoliberal goals of therapy, so these new

forms of therapy are developing outside of those constraints. Some are currently being vilified
 21

publicly by a few mainstream psychiatrists and psychologists, but they are only radical at all if

you still agree with mainstream models. We have tried to show that there are, in fact, strong

rationales for these new therapeutic responses once the medical models and neo-liberal

constraints are removed.

Once the mainstream medical models and neoliberal goals of therapy change, so we will

see exciting new developments in how we approach people in life crises, and how we frame and

carry out supporting and helping such people.

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Table 1. Some assumptions of mainstream and alternative therapies and their implications for

building therapies.

Background Assumptions made Implications for therapy

Medical models of Self-contained individuals Fix the individual

human behaviour Diseases cause ‘mental health’ Drugs help cure the disease

issues Need person to talk about their

An ‘internal’ dysfunction ‘internal’ issues because these

Cannot directly observe this are not observable

dysfunction so an expert’s Find out what is wrong with the

opinion is needed person

Respond to clarify and elicit

more ‘internal’ talk

Neoliberal goals of A problem needs fixing Documentation and

therapy Find the problem and use categorizations (DSM) used for

standard solutions to ‘cure’ administrative purposes

Produce a functioning 50-minute sessions

individual Done professionally within an

Produce a productive office

individual Talk to build a DSM

Assume societal norms within categorization of disease

the models Successful outcomes defined in

terms of societal norms

 30

Alternative Bad life contexts and historical Fix the person’s situation

approaches to human contexts shape human Drugs only distract or slow

behaviour behaviour down interactions with context

Brain is involved but does not Find out what has happened to

originate behaviour the person

Need to observe person’s

contexts where possible

Need to listen to person talk

about their context, only asking

for more detail

Increase the person’s own

contextual awareness in their

stories about their self, their

world and their problems

Alternative goals of The person is not the problem Fix person’s situation whether

therapy Change will occur when their locally or through social action

situation changes to change society

Person needs to be able to act Talk over the person’s own

in the world and have some goals and values

effects (which do not Respond to show they are

necessarily work) having effects

‘Non goal orientated’ (Ball & Work with them to have effects

Picot, 2021) in their world

 31

Table 2. What do therapists say to help?

Mainstream therapeutic responses to clients

Ask “How do you feel?”

Reflect back what the client says

Talk in ways to show respect

Talk in ways to encourage them to say more

Talk in ways to encourage them to give more detail or context

Talk in ways to show that you understand their experiences

Talk in ways to fix the person’s problems

Give advice and instructions to follow

Try to get them to put their emotional responses into word form

Nodding or saying “Hmmm”, “Yes”, etc.

Alternative therapeutic responses to clients

Ask “What has happened to you?”

Hug and touch

Joking

Just be there without doing or trying anything specific

To not ask questions but let them talk (especially in crises)

Reflect how what the client said made you feel (“Emotional CPR”)

Just listening and saying little (“Just Listening”)

Do non-language things (sing, rhythms, draw, sketch in sand)

Story telling

Dissociachotic

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