Symptoms and Surface Psychology – Mad In America

Nobody likes experiencing painful symptoms. We dread the scratchy throat of a winter cold, or the bleak despair of a depressive episode. We wish they would disappear, yet at the same time we know they are our messengers—invisible laborers toiling in our bodies signaling that something has gone wrong. Symptoms are the language our body uses to communicate distress, both physical and psychological. That scratchy throat, despite being a nuisance, conveys crucial information about the state of the body. Similarly, without the black hand of depression pulling us down, we would not know we are depressed to begin with. As much as we would like them gone, symptoms refuse to be ignored.

For the sake of this discussion, it is worth noting that symptoms are not the same as signs. Signs refer to what can be objectively seen—a head wound, for instance, whereas a symptom is the subjective experience (“my head hurts”). In medicine, doctors can utilize both signs and symptoms to diagnose a variety of ailments, but ultimately rely on objective signs to make a clinical diagnosis.

But here we are talking about psychopathology—the ailments of the psyche, not the body (though the two can never be fully separated). Psychopathology has no signs, only symptoms. In other words, when we are talking about psyche, we cannot conduct objective tests to diagnose objective pathologies. Nevertheless, psychiatrists approach the mental in a similar way doctors approach the physical (remember, psychiatrists are ultimately medical doctors, and must go through the same core training). Like other physicians, they consult their manuals—in this case the latest edition of the DSM—and make their diagnosis accordingly. For instance, if an individual has a continuous low mood, trouble sleeping, and feelings of hopelessness, a psychiatrist will likely diagnose them with Major Depressive Disorder (MDD) based on these symptoms alone. Despite the lack of objective measures, these diagnoses are both conceptualized and treated as medical conditions, as captured by the following reassurance from the American Psychiatric Association: “Mental illness is nothing to be ashamed of. It is a medical problem, just like heart disease or diabetes.”

Of course, psychiatry is only one of the many disciplines that take on the task of healing the psyche. But because it is most respected in the scientific field, the psychiatric paradigm dominates the modern approach to psychopathology. What this means is that the majority of therapists operate under the approach of “treating mental illness”, which, given the lack of objective signs, can only ever be the treatment of subjectively distressing symptoms. Therapies such as Cognitive Behavioral Therapy (CBT) dominate the field of counseling, and target only the surface manifestations of underlying psychological issues. CBT in particular is highly standardized and often a short-term treatment which emphasizes coping with symptoms in the present moment. Though other forms of therapy may dig deeper and attempt to address underlying causes of distress, as a general rule mental health care considers symptom alleviation to be the ultimate goal of therapy, and therapy outcomes are often measured by the reduction in symptoms. Psychopathology, in this view, is considered cured only once the symptoms are no longer present, and both patient and therapist alike often consider the absence of symptoms to be representative of mental health.

Here I would like to suggest that much of contemporary psychology could be called surface psychology. This term is directly opposed to depth psychology—an approach that focuses primarily on deeper, often unconscious aspects of the psyche, and has not seen mainstream success since Freudian thought dominated the field. In short, depth psychology, which includes psychoanalysis, attempts to uncover the source of the pathology, whereas any surface psychology will focus only on conscious manifestations of a given disorder. In psychoanalytic terms, “surface” could be replaced with “ego”—in other words, a surface psychology is any psychology that does not look past the conscious part of the psyche. Therefore individual therapists may attempt to dig deeper and find the source of psychopathology in the family history or other past experiences, but so long as the unconscious is left out, and symptom reduction remains the goal of treatment, then they are engaging in surface psychology. Indeed, the fact that depth psychology is hardly recognized in mainstream psychology highlights the extent to which surface-oriented practices have come to dominate the field.

The problem of surface psychology

Surface psychology is not inherently a bad thing, and can be quite useful in many cases, especially for issues related to the many stressors of modern life. It is likely that we will always have some pathological symptoms related to the incompatibility of modern life with our instinctual makeup; Freud himself has discussed this at length in Civilization and its Discontents. The psychologist Bruno Bettelheim has pointed out that the original German edition bears the title “Das Unglück in der Kultur”, which more accurately translates to something along the lines of “The Uneasiness in Civilization”—a title that better captures Freud’s thesis that some psychological uneasiness will always be present in modern society. It is precisely this type of distress that I find surface psychology can help alleviate, as there is no root cause to be uncovered, no depth to be explored. Examples of this include the burnt out college student, the stressed out parent, or the anxious teenager. Such individuals are simply experiencing what we might call “problems of living”, and may benefit greatly from learning to manage their symptoms until their stressful situation has passed.

When it comes to pathology resulting from other factors, however, surface psychology falls short. Many of us bear more than just the problems of living, and much of living itself has become so far removed from human needs that symptom relief alone will not suffice. Here we must return to the view of symptoms as useful messengers of the psyche. What happens when these messages are ignored? Or, perhaps more accurately, what happens when these messages are intentionally blocked out through various targeted therapies and pharmaceuticals? It has become apparent that decades of such practices have not led to better mental health outcomes, as the mental health crisis has only worsened in recent years.

The failure of surface psychology is not difficult to understand. Once seen from a depth psychology perspective it becomes apparent that neglecting symptoms can be quite harmful. If we come to view symptoms as representative of underlying psychopathology in need of our attention—as depth psychology does—then drowning out the voice of the psyche is contrary to the nature of the psyche itself. Yet this is precisely what surface psychology does with its emphasis on symptom relief. This is the equivalent of putting a band-aid on an infected wound, in hopes that covering it up will prevent the inevitable spread of the infection. The psyche too can be infected; the DSM diagnoses which we now know by name can creep upon us unsuspectingly and spread through our minds. Our bodies detect organic pathology and send us painful symptoms in hopes of capturing our attention, and our psyche too cries out to be heard in times of mental distress—only to be silenced with an array of therapies and pharmaceuticals.

Now we must recall that the revolutionary idea that symptoms of psychopathology have their source in the unconscious part of the psyche—and consequently demand recognition and integration—was Freud’s great insight and the basis upon which psychoanalysis was established. Yet, in the rebellion against the so-called father of modern psychology, it appears that academic psychology has rejected the unconscious altogether in the name of science; we have thrown out the baby with the bathwater. The bathwater is not evidence-based, we say. It cannot be studied under controlled laboratory conditions. Therefore, we might as well toss the baby out too; the divine child upon whose shoulders the entire field was established. Yet if depth psychology has taught us anything, it is that the unconscious cannot—and will not—be ignored. We can rebel against the father all we want, but he still retains his authority. Freud’s unconscious did not simply go away just because it was not included in the clinical trials of CBT or a grad student’s dissertation.

Modern psychology and the rejection of the unconscious

It seems that psychopathology has left the unconscious and found its new home in the physical brain, albeit in a place that has yet to be fully determined. Under this new brain-based paradigm, the unconscious is nothing but an artifact from psychology’s primitive past, and symptoms are now expressions of neurochemical imbalances, not complexes in the psyche. Even dreams—the primary means of accessing the unconscious, according to depth psychologists—have been reduced to the brain’s method of processing junk.

Much of this stems from the reality that there can never be an evidence-based approach to the unconscious, as it cannot be studied objectively in the laboratory. Therefore the ego now dominates the psyche, as it is all that can be studied. This rejection of the unconscious has resulted in a new idolatry of ego-worship, forgetting that our ego is influenced by our unconscious just as much as our unconscious is influenced by our ego.

This one-sided approach to psychology entails the loss of the very same thing that established the field in the first place—the (re)discovery of the unconscious. Today’s psychologists have no choice but to resort to shallow behaviorist measures of surface-level distress. Symptom reduction is worshiped as if it is the only thing of value in the psyche, and any of the pesky symptoms that plague us can be alleviated with brief interventions already tested on a sample of college students. The results are published as scientific research, and thus the field gains credibility. Slips of the tongue, free associations, dream analysis—such ideas have become the flat Earth theories of psychology, embraced only by a few quacks who refuse to accept reality. Gone are the days of Freudian pseudoscience, now that science has entered the game.

Solutions to the unconscious problem

It should be apparent by now that any approach that claims to address issues of “mental health” must also include the issues that are not recognized by the ego. Yet as long as we continue to embrace the fantasy of a scientific approach to the psyche, no such thing is possible. Science does not like unknowns, and dealing with psyche—with people—always includes the unknowable. We are not predictable machines that can be tinkered with and adjusted, as much as surface psychology may wish we were. Our approach to human problems, however, very much embodies this roboticism. Today’s talk therapy offers the same kind of fix one would offer to a malfunctioning machine that simply needs some minor adjustment. But putting a new coat of paint on the human machine cannot fix what is rusting inside.

I would take this image even further and apply it to society as a whole. The modern age seems to embody this same peculiar concern with the surface image. Indeed, the entirety of the Western world is built upon a deteriorating foundation, yet we are able to ignore this by maintaining a false image. We keep our grass green so we can ignore the ongoing environmental devastation, and we proudly wear our “I Voted!” stickers like medals of honor, idolizing a new leader every few years, pretending that these heroes will save us. Little attention is given to what stews in the shadows, until glimpses of it creep into our newspaper headlines.

Perhaps Jung was right in his advocacy for individual wholeness as the starting point for the collective woes of society. How can we expect to fix the world’s problems if we are ignorant to the happenings of our own psyche? Any solution to healing the collective psyche—the world soul—must begin with each and every one of us; we must look under the surface both first in ourselves and then out in the world. And if the field of psychology would stand for wholeness, and not just mental well-being, then perhaps it could help us find this much-needed depth.