The Politics of Psychological Therapy
David Mazure argues for a universal standard of training and a single title unifying all modalities of counselling, psychotherapy and counselling psychology in the UK.
Psychological therapy, as practiced by counsellors, psychotherapists and counselling psychologists, has evolved over the years through a process of sometimes-bitter struggle. This struggle has not refined its competing theories to reveal a single theoretically based practice with a clearly defined route of training. On the contrary, its theories, practices and trainings have multiplied, all claiming to achieve good therapeutic outcomes.
Our recent involvement with the government regulatory process rekindled the heated rivalry between our modalities, and exacerbated the issue around training standards and their meaning in terms of the work we all claim to do. How we are seen and how we see ourselves have also been impacted by the NHS, business and educational organisations, insurance companies and the academic institutions incorporating our trainings: we have been encouraged to fit into the medical model and become measurable and quantifiable. We have also been required to satisfy greater academic demands, apply a reductionist approach to the description of our competences, and accommodate economic restraints.
Many of the differences, struggles and tensions within our profession are clearly important and enriching, and the competitive discourse around them is rewarding and educative. Other differences, however, are not and lack the rigorous scrutiny a cohesive and integrated profession can bring to them. Some of our differences and tensions, for example between modalities, can be politically motivated, and others such as training standards are, in my opinion, unethical. The question whether we are, or can become, a cohesive comprehensive profession united around the same values and principles needs to be engaged with.
How psychological therapies present to the public
A cursory exploration of the Internet reveals that all psychological therapists (counsellors, psychotherapists and counselling psychologists) from all modalities offer therapy to people suffering from the same broad spectrum of emotional or mental symptoms. Organisations and individual practitioners are collectively telling potential clients that all three types of therapist and all their modalities are equally capable of helping them. No reference is made to the different levels of training they each undergo, nor is any concrete distinction made regarding the kind of work they each undertake or how their modalities inform it. Even for potential trainees the only difference that is concretely explicit is the duration and content of the training to achieve a qualification in counselling, psychotherapy or counselling psychology, and the academic level at which each is awarded. But no explanation is given as to why the duration or academic level of these trainings are different in terms of the work done with clients, or in terms of the capability of the therapist. When it comes to different modalities, many organisations give brief descriptions of them, but fail to inform clients in need how they might make use of that information.
Irrespective of our profession’s differences, disagreements and confusion, in the eyes of our clients we all do the same work. I believe the current situation challenges us, not just professionally or intellectually, but also ethically, because at the client’s end of the spectrum there clearly and unashamedly is no difference whatsoever. I believe we have a duty to be able to assure those wishing to use our services that we are all clear about what we do and that we are all adequately trained to do it. The best way to give such an assurance is through our willingness to adopt a single title. In this paper I want to look at the two important differences that contribute to this confusion and challenge our ability to adopt a single title: modalities and training standards.
Psychological therapy – working with symptoms
Research into psychological therapy is concerned to reveal the truth of what works; however, it is not clear whether we are all agreed about what it is we actually do. We certainly all agree about the symptoms: addictions, anxiety, autism, depression, disasters, eating disorders, financial debt, grief, illness, infertility, relationship problems, stress and many others. But does addressing all these symptoms involve the same therapeutic task? I don’t think it does; there is a fundamental difference that separates symptoms into two types.
Many symptoms are simply the responses to life events that might be difficult and painful, but are natural just the same: loss of a loved one for example, dealing with debt, coping with physical or mental illness, making career choices, coping with disability or disasters. These are straightforward issues for psychological therapists; they are not symptomatic of hidden underlying psychological causes. They certainly require emotional support and facilitation, which might also include medical and social services, and where emotional support has previously come from more traditional sources such as spiritual leaders, family, friends and communities, psychological therapy has stepped in because of its understanding of human psychology.
Other symptoms such as depression or addictions are symptomatic of conflicted or entangled internal psychological states. These internal conflicts certainly have external causes as their origin, however their principal nature is derived from a complicated relationship with those causes and an inability to respond to them straightforwardly. The causes of these symptoms are hidden and the way to alleviate them is to reveal their causes, disentangle the internal conflicts and refocus the energy creatively and constructively outwards. This is the task of psychological therapy, which is predicated on a view of the self as a system.
Seen in this way, psychological symptoms are indicators of systemic malfunctioning. Simple removal of the symptoms might leave the cause untouched and the person vulnerable to the re-emergence of new sets of symptoms. Psychological therapy is wholly reliant on our client’s subjectivity to access that system and thereby understand the meaning of their symptoms within it.
Working with symptoms as part of a self-regulating psychological system however is complex, costly and time consuming. Consequently, focusing on symptom relief is seen as an expedient alternative. Research that relies on controlled trials and quantifiable outcomes favours this kind of treatment. To the extent that symptoms and their removal is the focus of our work such research is useful, but that is a different approach from engaging with symptoms as opportunities to self-regulate, where the focus is on the person, not the symptom.
What psychological therapists do can therefore be divided into three categories: the facilitation of natural responses to life events, the removal of symptoms derived from internal conflicts, and the use of symptoms to improve the self-regulation of our psychological systems. The first category requires emotional support, not psychological therapy, and could be addressed by anyone with patience, compassion and the understanding that they are dealing with natural and healthy responses to life’s traumas. The second category is merely palliative and a poor substitute for proper therapy; however, I can understand that it might be all that is possible given restraints of time or money. The third category is psychological therapy at its best; it enables people to acquire a deep understanding of the psychological functioning of their subjective worlds and the capacity to self-regulate by monitoring their symptoms as a form of feedback. In fact, understanding the centrality of our subjective worlds in psychological therapy is crucial; it is our subjectivity that makes psychological therapy a viable course of action at all.
Subjectivity, narratives and truth
It should be self-evident that our subjectivity and our psychological lives are one and the same. After all, it is our clients’ subjectivity that we engage with, listen to, relate to, attempt to alter, and which judges our success and failure as therapists. Our subjective worlds comprise all our experiences woven together into a narrative – the story of our lives. We do not know if life has meaning, but each of us, and for that matter each culture, weaves a story with the experiences of our lives in such a way that it is meaningful to us. What our stories mean to each of us also conveys a sense that our lives have purpose, but this is all subjective. Words like subjectivity, meaning and purpose are very contentious. Concepts like consciousness, the self, materialism, spirit, and free will are problematic and the subject of heated debate; the truth of it all is unclear. Even the concept of truth itself is complicated and fraught with different theories.
The pursuit of absolute truth, that is the truth of things in themselves as distinct from our subjective experiences of them, has been a goal of philosophy and science for thousands of years. Some people believe that we can access objective or absolute truth, while others believe such an endeavour is beyond our human limitations: we are doomed to know only our experiences. This dilemma is with us to this day, and many, including myself, see it as fundamentally irresolvable. Discarding absolute truth leaves us to take a pragmatic approach and focus on what works. And when it comes to psychological therapy we should all be more concerned with successful practice and our clients’ successful living over and above any concern we might have about how closely our theories correspond with absolute truth.
Subjectivity is constructed from the interpretation and perception of our experiences, which have their own personal truth. We all tell subjective stories of our lives, stories that hold real and vital importance for us. Ensuring our narratives are truthful is what enables us to function effectively. It is through our subjective stories that psychological therapy ascertains the truth of our experiences and enables us, by that, to understand our personal world accurately and honestly, and thereby our capacity for effectiveness in it. For instance, if someone comes to me because they believe they are crying excessively I ask them if anything has happened to them that might cause them to be tearful and sad. If they say that someone in their lives who they loved has died, I describe the grieving process and its appropriateness and they respond with relief and a sense of entitlement to their grief. On the other hand, when someone comes to me in tears and describes how they have pushed their loved ones away because of an addiction, I describe to them the effect of hidden conflicts and their ability to wreak havoc in their lives, using their own stories to illustrate just what I mean. This too results in a sense of relief: the relief that their behaviour has meaning, and can be worked with successfully, given patience and resolve.
The task of psychological therapy is to relate the presenting problem to the stories our clients tell us of their lives in such a way that it becomes a meaningful whole and reflects their subjective reality and truth. Our clients’ narratives are, in fact, the royal road to the understanding of their symptoms, and determine the path the therapy will take. To that end, we help our clients tell as much or as little as is necessary of their stories, and we listen with curiosity, and challenge with compassion. Our clients are empowered in their lives in proportion to the subjective honesty of their narratives.
Modalities and narratives
Our modalities are also narratives; they tell the subjective stories of therapists’ experiences of psychological life and the meaning we derive from those experiences. Consequently some of our modalities are concerned with spirituality, while others are based on a materialistic view of the world; Existential therapists face meaninglessness, while Essentialist therapists reveal our hidden purpose; some of us prefer scientific descriptions of the psyche; some prefer mystical descriptions of the soul. Therapists might use art or drama, play or conversation; they may be poetic or concrete, political or not. In short, they reflect the enormous diversity of meaning, interpretation, perception, values and contexts common to all human subjectivity.
Of course, our modalities are not just the expression of our unique subjectivity, they also tell the story of our commonly experienced psychological life. Human culture is the best example of this in action. Music, literature, poetry, myth, religion, or any other aspect of cultural expression, expresses both the common core that comprises human existence, and the extraordinary diversity of our unique experiences. Our lives would be impoverished without the fabulous tapestry, woven with all the different threads of unique human subjectivity, that reveals our limitless capacity for creativity.
When it comes to psychological therapy it seems to be difficult to hold the tension between the differences of our subjectivities and the commonly held core of successful practice. Both are important and neither need threaten the other; in fact, research suggests that therapists from all modalities are capable of successful practice. The stories we weave around our practice serve our need for meaning, and will include our interpretations and values, but they must also contain the truth of successful practice. We should all be aware of this and accept that our successful practices do not depend on the personal meaning of our stories but on the excellence of our craft. All our modalities contain grand narratives that are wise and informative, and express universally understandable perceptions of all our psychological experiences. The differences of our stories enrich us; they must also contain, and not obscure, the common psychological territory we all navigate.
The common task of successful practice
Leaving aside the facilitation of natural responses to life events, and the expediency of symptom relief, all psychological therapy works by understanding the presenting problem as a key to an underlying problem of functionality. Our common task, and the one that surely unites us, is to help our clients understand how to transform a malfunctioning system into a well-functioning one; to enable them to self-regulate on the basis of the information revealed by their symptoms and become more effective in their lives. To that end we therapists all share further things in common.
All therapists acknowledge the complexity of human experience, both in our inner worlds and our external worlds. We all recognise the importance of emotion, cognition and behaviour in our work. We all bring attention to areas normally outside of awareness. When necessary, we all investigate the aetiology of those presenting problems from one or many perspectives. All therapists acknowledge the impact of early development, but also of later life experience, on all our lives. We all also understand that we continue to be moulded by our current experiences, hence the capacity for therapy to make a difference in our clients’ lives. We all acknowledge the enormous importance of our clients’ subjective experiences and the value to them of these being understood. We also all acknowledge that we create narratives that express our lives and include our thoughts, feelings, behaviours, beliefs, expectations etc. We know these narratives often become ossified, restrictive and acquire the quality of prophetic or fatalistic importance that are then transformed into prisons determining what is possible. We all acknowledge that we exist within a web of complex relationships that require careful navigation, compromise, sacrifice and adjustment to enable them to be fulfilling. And we all know that life is difficult.
Last, and most certainly not least, is the therapeutic relationship. It is now commonly accepted that the therapeutic relationship is an important ingredient in our successful practice. Psychological therapy might be limited to a relatively superficial exploration or it might involve going to hidden and forgotten depths of a person’s psychological life. It might require a brief critiquing of a client’s thinking or a deep and unique love. It might take a few sessions or many years. Invariably the process requires our clients to be open, vulnerable and honest, to be willing to feel pain, self-loathing, self-doubt, shame and more. The therapeutic relationship is the safe container that is required to hold such a potentially difficult and complex process and demands the therapist be empathic, honest, warm, understanding, skilful and more.
I doubt any therapist today denies that we all need an experience of deep self-exploration to facilitate such a process for another. A therapist’s self-awareness is of critical necessity when developing the kind of intimate relationship a client might need. In a demanding therapeutic process, trust is crucial. Clients need to discover that their therapists can be trusted and therapists need to know they themselves are trustworthy, which requires a sufficient level of self-knowledge. Central to all our trainings must be the development of just such a practitioner: someone who has explored their own subjectivity, their own narratives, who has experienced openness, vulnerability, and felt the impact of the therapeutic process upon them.
One task, one training standard
This single, indivisible task requires a single standard of training for all psychological therapists irrespective of modality. The current variety of training standards from correspondence courses to doctorates is an ethical shambles and demands regulation of some kind. Psychological therapy is a craft, and like all crafts, perfecting it takes a lifetime. Our trainings are an introduction to that craft; they have no intention of delivering a fully completed craftsperson. We can, and should, share the experiences, knowledge and wisdom of others contained in our vast psychological literature to aid us in understanding our craft, but our experiences will be our greatest teacher. Our lifelong development as therapists is implicit in the requirement for ongoing supervision. And, through supervision, we benefit from an accumulated depth of experience to help us all in dealing with our more difficult and complex cases.
All psychological therapy includes the above common territory. It might be expressed in language particular to the modality of choice, and some aspects given more importance than others, but it will all be there. It is what unites us as a single profession.
We need to agree upon a single, adequate level of training that ensures we are all prepared to accomplish the common task we all share. Achieving this might be difficult but, in my opinion, we are ethically bound to attempt it. Counsellors, psychotherapists and counselling psychologists are clear that they all offer the public a solution to their psychological problems – we need to be able to assure them that we are all adequately trained to do so.
The inclusion of all our modalities and narratives within a single title faces us with a different challenge. Currently there is fierce competition between us for power, authority and, of course, money. However the common ground of psychological life belongs to us all; it is accommodated within all our narratives and modalities. Contained within that ground are such things as the awareness of our need for good attachment, our intra-subjective life, the use of cognition, creativity, warmth, empathy, and so on. These things unite us. The differences of our narratives contribute the diverse, rich and deeply rewarding subjectivity that is so essential to all our psychological lives. I believe we all have an ethical duty to acknowledge the contribution all significant thinkers from all our modalities have brought to our field and to present the public with a profession unified around our subjective differences and not torn apart because of them.
It is my view that counsellors, psychotherapists and counselling psychologists across all modalities do the same work, address the same issues, should be trained to the same standard and therefore should all be included under a single title.
David Mazure is an Integrative psychotherapist and supervisor working in North London. He is a member of the Minster Centre’s staff and their representative on the United Kingdom Council for Psychotherapy (UKCP). [email protected]
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