The Ethics of Psychology in the Age of the Globalized Therapeutic Culture

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Doing Psychology under New Conditions

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Chapter 25

The ethics of psychology in the age of the globalized therapeutic culture

Ole Jacob Madsen

University of Bergen, Norway

SUMMARY Psychology in the late 20th and early 21st centuries is often depicted as a globalized therapeutic culture, existent in evermore niches of late Western society. How can this “everywhereness of psychology” be dealt with by the discipline of psychology in a responsible manner? The article maintains that whereas in previous decades the debate has been whether psychologists should refrain from any extra-laboratory activities, or should actively take the role of promoters of human welfare in society, this distinction is no longer meaningful, as psychology already finds itself in the center of Western culture. I highlight the new challenge for psychology under new conditions by the recent rise of cosmetic surgery in Norway, which is embedded in the therapeutic culture, and thus avoids criticism by advocating that surgical interventions is mainly directed at gaining self-esteem. I conclude that the present challenge might be considered the final argument for societal ethics rather than traditional professional ethics, in order to sufficiently deal with the present psychologized state of affairs.

INTRODUCTION

Hermann Ebbinghaus (1908) famously remarked that psychology has a long past but short history. The division between the broader cultural continuities and the discipline of psychology has also been captured in the separation between large-P psychology and small-p psychology. One of the first historians of psychology, Edwin G. Boring, later dubbed “the discipline builder” (cf. Cerullo, 1988), introduced this helpful distinction in his influential textbook History of Experimental Psychology (1929). Big-P psychology denotes the formal, institutionalized discipline of Psychology, including the academic departments, journals, organizations and other trappings of professionalization (Pickren & Rutherford, 2010). Small-p psychology denotes the psychological subject matter itself and contains the everyday psychology that has always existed as people make sense of their lives. Yet, as Wade Pickren and Andrea Rutherford (2010) underscores in a recent social history of psychology, this relatively straightforward distinction quickly becomes complicated when we add that Psychology has been actively involved in creating its own subject matter, altered it and ultimately created constructs that would not (most likely) have existed without it. Kurt Danziger (1997) has likewise made the astute observation that Ebbinghaus’ division differs in the sense that the objects studied by psychology were deemed natural objects, whereas “the distinction between capital-p and small-p psychology implies that the phenomena studied are not natural at all, but historically constituted objects” (p. 139). The discipline of psychology is only possible when people at a certain time in history come to develop a psychological understanding of themselves and their everyday conduct. Furthermore, this implies that the future of


220 Ole Jacob Madsen

the discipline of psychology presupposes that people continue to contain psychological constructs in their outlook on self and society. The liquid, but intimate reliance between small-p and large-P psychology presents the psychology profession with some interesting and troubling questions regarding its social responsibility for the broader cultural representations of psychology. In fact, the relationship between ethical professional responsibility and the wider implications of psychology have its own history which I now briefly consider.

In September 1969, George A. Miller, APA’s 77th President, in the annual presidential speech held in Washington D.C. strayed off the anticipated topic—his own research the previous year. Miller (1956) is among the most cited psychologists in the whole history of psychology for his work on working memory. Yet, instead Miller (1969) decided to address the wider implications of psychology for society. There were several historically significant incidents at the time which provoked a testing assessment of the proper relationship between science and society; e.g., in March 1967 a student, Bob Feldman, discovered documents in the International Law Library detailing Columbia University's institutional affiliation with the Institute for Defense Analyses (IDA), a weapons research think-tank connected with the U.S. Department of Defense. This association had never before been publicly announced, and provoked a lengthy student protest and anti-war campaign, in light of the enduring Vietnam War. Miller’s (1969) appeal to his colleagues was that psychology up until then, despite its remarkable success, had not successfully realized its full potential in promoting human welfare—“the psychological revolution,” and worse, was unevenly distributed, and often in the hands of men of power who misused the psychology of control to gain profit for the few. Miller (1969) draws attention to how wealthy industrialists and bureaucratic leaders use behavioral principles like control to create a work- and organizational-life dominated by external control and threats, instead of self-direction and self-control so that people can use psychology principles (on) themselves to stimulate creativity and ingenuity. Hence, Miller (1969) therefore gives a historical call for the democratization of science, “giving psychology away,” yet, appear to face a silent majority of large-P psychologists whom preferred to continue their laboratory life indifferent to the societal processes that goes on outside. In a sense this is also the classic conflict in science (see Lubchenko, 1998), between the scientist who accepts the wider implications and consequences of his work, and the ones whom maintain that such considerations cannot be implemented in the research process, which out of necessity must be in ignorance of any practical application.

In the decades that followed, Miller’s “psychological revolution,” was more or less realized when psychology became widely available for the masses to practice on themselves. I will mainly draw on the concept of “self-esteem” in the following to highlight this development. From the perspective of “governmentality” self-esteem is a form of specialized knowledge of how to esteem, calculate, evaluate and discipline ourselves. Barbara Cruikshank (1996), for instance, maintains that “self-esteem” becomes available for the increasingly empowered citizen, so that they can act on themselves, so that the psychologists, police and doctors do not have to. The psychological revolution meant that psychology was reachable for more people through self-help manuals, popular psychology books, expert advice in magazines, TV-shows, therapeutic reality television, online personality tests, etc. The leading scholars on the therapeutic culture in the 90s and 00s, like Nikolas Rose (1996, 1999) and Eva Illouz (2007, 2008), despite dissimilar critical backgrounds, are in agreement over the notion


http://en.wikipedia.org/wiki/Institute_for_Defense_Analyses

http://en.wikipedia.org/wiki/Think-tank

http://en.wikipedia.org/wiki/United_States_Department_of_Defense

The ethics of psychology in the age of the globalized therapeutic culture 221

that psychology could not have expanded had it not helped a majority of people coping with their struggles and ambitions and making sense of their individual freedom and human suffering in their everyday life.

DOING PSYCHOLOGY UNDER NEW CONDITIONS The “everywhereness of psychology” (Jarzombek, 2000) in the globalised culture in the late part of the 20th and early part of 21st century also means that psychology is now practiced by a range of experts and counsellors who are not authorized professional psychologists. This is perhaps the most obvious case of how large-P Psychology finds itself confronted with small-p psychology, when it is visibly practiced by another profession or various types of therapeutic expert. The President of the Norwegian Psychological Association Tor Levin Hofgaard (2011) recently wrote a thought-provoking article in which he considers the responsibility Norwegian psychologists holds for this tendency where psychology is practiced by non-psychologists. He maintains that part of the professional and ethical conduct is to raise and secure the quality of psychological activity; how psychological knowledge is applied by non-psychologists is therefore of importance for the discipline of psychology. Like his American predecessor Miller, Hofgaard argues that Norwegian psychologists must concern themselves with psychology outside Psychology, and take on an active role as educators of personnel, nurses, doctors, coaches and pedagogics, and whoever fills the role of practicing psychology. Thus, the ethical dilemma—to take on an active societal role or not—becomes the primary moral challenge for psychologists once again. However, as I will seek to demonstrate through the utility of self-esteem and cosmetic surgery within the therapeutic culture, we now find ourselves post the psychological revolution, yet the development may not automatically end in an enlightened heaven, which Miller perhaps latently hoped for. Miller’s conception of psychology as something neutral in society that does not automatically have positive effects is quite extraordinary when representing a labor union like APA; nonetheless his dream of a psychological revolution appears glanced in the Enlightenment belief of discovering universal laws and manipulating nature in order to maximize happiness for mankind (cf. Bacon, 2009). “The psychological revolution” has been a central part of, or even a necessary condition for the empowerment movement, yet the desire for individual health and well-being under neoliberalism appear to take unforeseen turns many psychologists would label unhealthy and obsessive.

The case of cosmetic surgery Cosmetic surgery has during the 00s manifested itself in the Norwegian society. The number of private clinics and single person enterprises that offer cosmetic surgery has since 2003 increased with over 50% on a national basis. Eight years ago there were 49 businesses, today there are 76. The number of doctor specializing in plastic surgery increased from 73 candidates in 2003 to 120 in 2009. In 2003 the commerce of the nerve poison Botox used to straighten out facial wrinkles amounted to a total of 2.9 million NKR, while the numbed had improved to 8.2 million NKR in 2009. According to Statistics Norway latest quality of life survey 5% of the populations reported to have undergone cosmetic surgery paid for privately, 7% of the women and 3% of the men. The tendency of a normalization of cosmetic surgery in Norway is also evident in the



general public’s attitudes towards it. When the popular cosmetic surgery show Extreme Makeover (ABC) first was broadcasted in Norwegian television back in 2003 it caused moral outrage and much public debate, and people’s attitudes towards cosmetic surgery in general was often negative. A decade on, nobody raises an eyebrow to the multiple cosmetic surgery shows widely available (The Swan (FOX), I Want A Famous Face (MTV), Nip/Tuck (FX) etc.), commercials for clinics are frequent in newspapers and magazines and having an operation appear to have become largely normalized in more layers of the population than in previous years. Still, critical voices are not silenced. A favorite explanation and scapegoat for critics and concerned commentators, and even the business themselves, is the media. The common narrative is that the media is much more fixated on how you look than before, and the sight of perfect (and Photoshopped) bodies in multiple magazines and television shows, makes people more likely to have a makeover themselves. Particular findings among American College Students support this notion to some extent (Albright, 2007), and reality television in general is often commented for providing the script of how we live our lives in an ever more medialised society (see Bratich, 2007). However, there is arguably still a deeper set of cultural and symbolic factors, which recent televised displays of cosmetic surgery only come to reflect and symptomize.

The real you behind the layers of fat Representatives from the cosmetic industry frequently defend themselves from critical media scrutiny by pointing to the fact that we live in a society which has become extremely bodily fixated. Hence, they only provide the means to gain a release of tension from this common vanity. Yet, cosmetic surgeons appear less likely to talk about smoother face skin, bigger breasts or thicker lips, but tend to refer primarily to self-esteem issues. Numerous examples from Norwegian media about cosmetic surgery demonstrate this. Sissel Engen, the director of the Ellipse Clinique told a reporter: “We sell self-esteem and nothing else” (Overn, 2010, p. 8). While cosmetic surgeon Bjørn Tvedt gave the following account of what you could expect from an operation: “You will not necessarily become happier after having surgery, but it might help you gain self-esteem” (Førsund, 2010, p. 18) The tendency to address issues of mental well-being like self-esteem, rather than pure physical measures (“Get a slimmer body”) or aesthetical arguments (“We make you look beautiful”) might seem odd at first, but is not really that surprising if one considers a conceivable cultural explanation of cosmetic surgery recent success in Norway.

Cosmetic surgery has ever since its modern birth among the rich and famous Hollywood-stars going under the knife in the 1920s found an helpful legitimation alliance in psychology, most notably Alfred Adler’s (2009) inferiority complex which quickly was associated with having a to marked nose-bone or protruding ears. The early plastic surgery industry knew to capitalize on this. Norwegian psychologist Nina Østby Sæther (2006) noticed back in 2006 that attitudes towards cosmetic surgery in the population was shifting to a more welcoming climate, and less likely to embrace a moralizing critique, in particular if the reason for having an operation was to do with “something psychological.” The moral lesson is apparent: Being concerned for your appearances is shallow, but being concerned for your self-esteem because of how you perceive your body is not. Judith Franco (2008) has focused on how the body under neoliberalism undergoing cosmetic surgery on reality TV like Extreme



Makeover becomes the most visible expression of a happy, successful self. This notion easily expires to ideas of corporeal authenticity, that somewhere underneath the layers of fat lies “the real you”. Complete makeovers involving cosmetic surgery are therefore in reality a therapeutic process about self-realization, finally redeeming the inner self.

Now, many psychologists remain critical of this tendency (cf. Orbach, 2009). One of the primary consumer groups of cosmetic surgery are teenage girls whom for instance seek a round of Restylane treatment to get richer lips. The 20-year old Kristina Anderson, one of Norway’s most popular bloggers with 28.000 unique readers every day, has taken this treatment and also written about her contentment with it on her blog. The questions from her young female readers are typically: “Did it hurt?”, “How much did it cost?” and “Do you think I should get a similar treatment?” (Overn, 2010, p. 8). The implications are potentially troubling. A frequent concern from a psychologist point of view would often be that the industry capitalizes on adolescent teenagers and women’s insecurities about being normal and desires to look as best as possible.

DISCUSSION Concerned psychologists cautions against the cosmetic industry promise of improved self-image and self-esteem from going under the knife (Olsen, 2010). However, what if people who are subjected to cosmetic surgery gains a little bit of self-esteem from their enhanced bodies? For instance an investigation by Sarwer et al. (2008) of postoperative satisfaction and changes in psychosocial status following cosmetic surgery found that patients reported improvements in overall appearance and body image 24 months after surgery. The study also stated that patients reported improvements in self-esteem and a decrease in depressive symptoms following surgery, but neither of these changes where statistically significant. Of course, it is possible to question the long-term effect, as the reasons for having low self-esteem in the first place might only temporary be solved by a more positive body- or self-image. From the point of view of responsibility, the problem is that this critique is primarily methodological—psychologists and cosmetic surgeons are still in agreement that increased self-esteem is one of “the therapeutic culture’s” most valuable assets. This means that both groups become therapeutic agents and rivals in the therapeutic market, in offering the right remedy—the talking cure or the cutting cure—towards a state of mental well-being. In fact, Franco (2008) reports that anticosmetic surgery shows like Say No To The Knife (BBC) are now on the market where a psychologist encourages women to recognize their problems as psychological (low self-esteem and/or perfectionism). However, the problem of a proper platform to direct critique from stems from the fact that psychologists no longer find themselves in an exterior position as in the time of Miller’s presidency. On the contrary the ontological center the surgeons operate on so to speak is fundamentally psychological (Madsen & Brinkmann, 2011). Hence, the whole topography is altered since Miller’s toil to convince his reluctant peers that they should join him in the quest of making society a better place trough equally distributing psychology. The problem in the case of cosmetic surgery is the opposite: Everybody now practices psychology, different groups of experts and teenage girls have grown up on a diet of popular psychology, and practice it on themselves. “Giving psychology away” makes little sense as a responsible strategy here.



Professional ethics versus societal ethics

From the perspective of professional ethics (American Psychological Association, 2010) the argument can be made that psychologists should criticize cosmetic surgeons for misusing psychological concepts like self-esteem, and exploiting young females who already suffer from low spells of self-esteem and self-images of their bodies. Still, the urgency to do so is not likely overwhelming, if somebody outside professional psychology misuse psychology then that is unfortunate, but not really something psychological professionally can be held accountable for. Their primary responsibility is towards their clients. Prilleltensky (1990) maintains how psychologist often have institutionalized a narrow concept of ethics that results in a preoccupation with obligations towards the individual client at the expense of proactive moral behavior directed society at large. This bias is reflected in the American ethical principles for psychologists where there was little explicit mentioning of duties towards society (the 2010 amendment now enlists “social responsibility”). The Canadian principles devotes an entire section towards society, still Prilleltensky (1990) concludes that this obligation is considered the least important when in conflict with other principles. The Norwegian ethical principles for psychologists mentions responsibility towards society, yet only briefly, and as the last clause after responsibility towards the client and the organization is listed (The Norwegian Psychological Association, 1998).

From the standpoint of professional ethics the solution is perhaps to professionalize society, and possibly even the selection of consumers buying into cosmetic surgery. This has recently been suggested by psychological researchers in Norway as they found that psychological problems pre cosmetic surgery could inhibit the positive effects of cosmetic surgery like appearance satisfaction and improved self-esteem (Von Soest et al., 2009). Professional psychologists can make a difference by securing measuring the motifs and levels of self-esteem for potential customers, and also by lurking out any possible clientele with psychiatric diagnosis. In general the professional ethical stance is modeled on the belief in giving psychology away, which means being in authority and talking to the media about psychological concepts like self-esteem issues, or being responsible by writing a psycho-educative book about self-esteem. Yet, the trouble is that this continued well-meaning “feeding” from large-P psychology upholds and strengthens the therapeutic culture where cosmetic surgery currently thrives. The cosmetic surgeon effectively incorporates the therapeutic jargon.

From the perspective of societal ethics (Prilleltensky, 1990) where the distinction between large-P Psychology and small-p psychology is of less importance the whole cultural premise of cosmetic surgery and self-esteem, the therapeutic culture, is much more available to be taken into account. Of course, what it means is also to take a critical and perhaps painful look into how concepts from psychology comes to play an important function in the late capitalist consumer culture and economy of desire (cf. Wittel, 2004). Whenever cosmetic surgery has relied on psychological concepts from the inferiority complex to self-esteem, this is not just an expression of an industry that takes from psychology and is guilty of professional misconduct, but perhaps a more universal expression of the utility role psychology has come to play in Western society. Namely as a technology of the self (Rose, 1999), that sometimes lets people act on themselves and let others operate on themselves for futile causes. Psychology, from the professional branch to the outmost popularized versions of small-p psychology, now



provides men and women with a range of options, but unlike what Miller envisioned, they choices made are no guarantee to have a happy outcome.

Miller (1969) envisioned a psychology naturally inclined to promote human welfare five decades ago, and Prilleltensky concluded the following two decades ago: “Psychologists are not and cannot, be insulated from inculcation. Yet, it would seem as if we were operating under the premise that we can exclude ourselves from the ubiquitous nature of the hegemonic process” (1990, p. 311). So why is this responsibility in the present still necessary to argue for? A possible explanation stems perhaps from the fact that both professional ethics and societal ethics are moral positions embedded in a certain view of the relationship between ‘psychology’ and ‘society’. Professional ethics is recorded along the lines of the large-P psychology with distinct lines drawn between the therapy office and the psychological experiment in the laboratory. Social responsibility towards psychology outside psychology is easily the most fragile ethical horizon as it is the most peripheral to the professional’s everyday practice. Whereas societal ethics more naturally leads to a holistic view of psychology completed assimilated with the rest of the culture. The problem is that since this position deals with wider, long-term consequences of psychology, and not chiefly face-to-face dilemmas and conflicts, it needs to be argued for and defended to a greater extent than professional ethics that looks as if to come more naturally when working with vulnerable human beings on a daily basis (cf. Levinas, 1969). Perhaps cases like the peculiar alliance between self-esteem and cosmetic surgery can be of help as a vigorously reminder of how psychology in the widest sense is already out there—in the form of the therapeutic culture—which unnoticed offers human suffering new forms and shapes.

CONCLUSION The ethical terrain in which psychology finds itself is fundamentally altered in the global therapeutic culture that Western man (and rapidly Eastern man) currently inhabits. For psychology to become less generous and more antidemocratic again seems both unethical and futile, yet the theme “taking psychology away” seems more appropriate than running empty on Miller’s former model of responsibility. A more fruitful angle of incidence is perhaps to start acknowledging that psychology cannot avoid reflect on its own enterprise as it is a fundamental contributor of self-technologies deeply embedded in the therapeutic culture. The everywhereness of psychology means that the old borders of large-P and small-p psychology are not as meaningful. Even if the psychology profession is still limited, its ethical horizon of responsibility is not. It looks as if there is quite some time before this moral lesson is widely accepted. What is often forgotten is that ‘ethics’ etymologically stems from the Greek “ethos” which means “habit” or “according to common practice.” And common practice for most psychologists still means clinical work in demarcated psychological spaces.

In this article I have discussed the ethics of psychology in the age of the globalised therapeutic culture by showcasing cosmetic surgery and issues of self-esteem in Norway. This particular instance demonstrates that the distinction between small-p psychology and large-P psychology is increasingly porous, and more importantly outdated if professional psychologists want to prove themselves as responsible for what goes on outside the therapist office, academic desk or experimental laboratory. Before the «psychological revolution», to prefer not to engage in promoting human welfare and



shut the door, was perhaps somewhat defendable as an ethical position, whereas of now psychology’s penetrative expansion is so extensive, that non-psychological spaces are virtually non-existent. A societal ethic of psychology must therefore be recognized as a necessity in the therapeutic culture, rather than a free choice for the overly socially engaged professional.

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