For anyone interested in what is happening with counselling and regulation, this article by Steve Cox from 'Therapy Today' should be of interest.
Defining Moments by Steve Cox
To be born in ‘interesting times’ is said to be a Chinese curse. I certainly experience the current ‘regulation climate’ as an interesting time. As to whether these times qualify as a curse is down to us. I believe that the present regulation debate is very important and that the current climate presents a big challenge. I also think that these are defining moments and it is a time when each of us has a responsibility to fulfil. However, before saying more about aspects of responsibility, there are some observations I would like to make.
First, I want to comment on the coming together of the psychotherapeutic community. I don’t think that I have ever witnessed such a collective outcry from across the spectrum of the different schools of psychotherapy. And secondly, I want to talk about what our different approaches are uniting around and why this is.
I believe the key issue that regulation exposes is one of human rights and especially justice. This is true whether you are for or against regulation. Those in favour of state regulation are concerned that clients are protected by the law and that practitioners found guilty of malpractice or abuse towards their clients can be disciplined or struck off. One of the arguments against regulation is that abusive practitioners could easily hide behind the legitimacy of registration and that regulation would not ensure the protection of clients – indeed, it may well endorse many incompetent practitioners while at the same time imposing negative limitations upon the profession.
One example used against regulation, now familiar to most, is that being a licensed doctor did not stop Harold Shipman from murdering his patients, and current control and standardisation measures, such as the Care Quality Commission, divert resources away from care and towards bureaucracy within care-providing establishments. However, the bigger question seems not to be whether regulation is a good or a bad idea, but rather how regulation or non-regulation comes about – after all, as counsellors we expect process to play a central part in outcomes. Judging from the deluge of articles against state regulation in Therapy Today, how we are regulated and who regulates us seems to have provoked a huge outcry. Central to these questions underlies an even more fundamental question: what are counselling and psychotherapy? And I hear a resounding answer to this question, amplified in the form of what counselling and psychotherapy are not. For example, psychotherapy is not medical and counsellors are not healthcare professionals.
I have some sympathy for the Health Professions Council (HPC) which I have heard described as a ‘pretty benign organisation on the whole’. They must be wondering what on earth all the fuss is about? But concerning regulation, fuss and passion are in abundance. What seems to be coming to light is a fight to preserve an emerging cultural identity, an identity that professes that counselling and psychotherapy are the antithesis of the medical model. Months before the subject of regulation hit the fan, a number of prominent articles appeared in Therapy Today from across the spectrum of psychotherapeutic approaches, espousing a paradigm difference between therapy and the medical model. To me at least, this issue of difference reveals an essential understanding as to why so many therapists are saying that they simply cannot and will not work under the auspices of the HPC.
The fuss, therefore, goes to the very heart of elemental principles. For a very large proportion of therapists it appears that the paradigm difference that I allude to presents an ethical issue that underpins all. The medical model is an illness-oriented perspective, whereas psychotherapy tends to be a human potential model which embraces change, growth, emancipation, and adaptation; it is not a reductionist activity.
Some differences between psychotherapy and medicine
While I do not want to restate what has already been eloquently covered by others, it does seem helpful to articulate some key aspects of difference between the medical model and psychotherapeutic approaches to distress. The medical model can be described as an ‘ABC’ approach, where ‘A’ is diagnosis, ‘B’ is treatment, and ‘C’ is cure. The patient is recognised as being sick and, according to the presenting symptoms, given a diagnosis. The sick person is in need of an expert who will prescribe treatment, and the treatment will effect the necessary cure. Dysfunction and malfunction are synonymous with biochemical disorder which is evident in the presenting symptomology.
The point here is that the way we view human distress colours our actions towards it. If we view distress as an illness or something broken, we might say that it requires psycho-technological or pharmacological intervention. However, if we see distress as a reaction to an unhealthy environment or frustrated potential, then, from a different vantage point, a certain kind of relationship offering conditions for adaptation and growth would be seen as necessary.
From a psychotherapeutic viewpoint, diagnosis compromises the possibility of successful therapy because therapy requires uncontaminated, detailed, subjective experience as a fundamental starting place. Yalom urges psychotherapists to avoid diagnosis. It has, he says, ‘precious little to do with reality. It represents instead an illusory attempt to legislate scientific precision into being when it is neither possible nor desirable.’1 Sanders makes the point that ‘diagnosis requires an already vulnerable person to submit to the arbitrary, damaging “authority” of the expert diagnostician’.2 ‘Moreover,’ he says, ‘it is an unscientific, amoral authority borne out of historical precedent, political expediency, and maintained by professional interests.’
Regarding diagnosis, Rogers wrote: ‘In a very meaningful and accurate sense therapy is diagnosis, and this diagnosis is a process which goes on in the experience of the client, rather than in the intellect of the clinician.’3 Freeth states: ‘Assessment, diagnosis and treatment are at the heart of the medical model. This is at odds with relationship-centred psychological therapies – and raises many questions for those working in healthcare settings.’4 And Rowland points out that ‘diagnosis does not take into account the person’s process of feeling and function’.5
The psychotherapeutic community does not ignore the issue of biology; after all, biochemical phenomena affect and describe our every organismic action. It is well understood that environmental conditions shape and promote biological responses.6 It could be said that the counsellor is also helping to create a biochemical solution to problems. However, the counsellor’s effect on biochemistry is environmentally caused, by way of relational interaction, rather than pharmaceuticals.
Biochemical interventions are predicated on Newtonian science that specifically relate to genetic determinism.7 However, in stem cell research Lipton7 demonstrated that environmental factors affected the health of the cells under investigation. He showed that by (re)placing ‘sick’ cells (which he had made sick via an unhealthy environment) into a healthy environment, this caused the cells to recover. Lipton explains how this information translates to human biology: ‘Epi-genetic control is different from genetic control.’ He goes on to say: ‘Now we recognise that the nervous system is responsible for reading the environment and then selecting the appropriate genes that the organism can use to build a structure or create a behaviour that will allow it to survive in that environment.’7
Lipton states: ‘The reason this is important is because it signifies that you have a massive ability to modify your genes.’ However, he goes even further in pointing to the errors of medicine: ‘The problem is that conventional bio-chemists have completely ignored the role of energy fields and quantum mechanics.’ More recently he reports that bio-physicists have revealed that ‘the molecules that give us our structures and functions respond to quantum mechanical fields much more effectively than they respond to chemical information’.8 This information is important for psychotherapy because we act as part of the interactive catalytic force that promotes the ‘energy field’. Lipton concludes that: ‘Energy turns out to be 100 times more efficient at transferring information than chemistry’.7
A different philosophical perspective
I am conscious of not wanting to appear as though I am ‘medicine bashing’, while at the same time I want to address the issue of disproportionate power and authority held by medicine within our current health and social services. Proportionally the importance of medicine in relation to people’s health has been generally overrated. The main improvements that have affected health in Western history have come about as a result of environmental improvements, ie improved sanitation and nutrition.6 In part I address the current status quo or imbalance, given that the medical view dominates healthcare services. It is vital that counselling and psychotherapy does not become a subsection of healthcare, which is dominated by medicine, because it offers a different philosophical perspective.
Cooper9 brings together an impressive body of empirical research evidence regarding a wide range of psychotherapeutic practices that demonstrate efficacy. Research findings from King’s10 randomised control trial show that counselling is significantly more effective than conventional GP treatment (the use of antidepressants) in the treatment of depression. Cooper reveals that ‘from a wide range of controlled trials, meta-analytic studies have shown that, on average, counselling and psychotherapy have a large positive effect – greater indeed, than the average surgical or medical procedure. Put more precisely, 80 per cent of people will do better after therapy than the average person who has not had therapy.’9
By its very nature, medicine is expert or professional-centred and often institutional-centric. Psychotherapy, on the other hand, works via a partnership and requires the agency of the client and, therefore, it is relationship-centred. The difference in clinical philosophy is of primary importance. From quantum physics to social sciences, increasingly contemporary science accepts that knowledge is a human creation and we must account for the effects of our participation in our inquiry.11 Gaia theory12 embraces the world as a living system and therefore re-incorporates humanity as part of the interwoven texture of the planet – we are in nature, not outside of it. Leicester and O’Hara claim that: ‘Once human subjectivity is reclaimed as an essential and legitimate dimension of all knowledge, we can give the same kind of value to the qualities of subjective experience that we have up to now reserved for the abstractions of objective science.’11
Because of relational dynamics and understanding, psychotherapy moves increasingly towards wider inclusivity of interconnectedness, as Laing said: ‘Human beings relate to each other not simply externally, like two billiard balls, but by the relations of the two worlds of experience that come into play when two people meet.’13 Counselling and psychotherapy are therefore progressive in outlook and move from a self-psychology to a people- or species-centred outlook.
If we understand distress as the symptoms of a failing person, as medicine does, we enforce conditional limitations on all of humanity. Instead of encouraging people to understand and accept themselves, a label of illness such as depression invites people to disown their problems and encourages them to relegate the unwanted as discarded parts and to mask themselves with medication. Pathology implies that a certain way of experiencing equates to being ill. Therefore, these symptoms need treating to make them go away – it’s not me, it’s my illness – and this has a powerful and detrimental impact on all of society. In contrast, therapy encourages the application of nurturing attention and exploration. Schmid says: ‘The challenge is not so much what has gone wrong, but where the possibilities are to facilitate the process of life, ie the self-healing capacities.’14
The limitations of evidence-based practice
Our institutions already focus inquiry on symptom reduction rather than growth as the indicator of successful therapy (for example, in CORE evaluation). Evidence-based practice (research methodology) inhibits growth because it focuses on what is already known. Rogers put forward a very different view, focusing on the process of how truth is discovered: ‘It is not a confidence in truth already known or formulated.’15 Schmid asks the question: ‘How can we understand another person?’16 He states: ‘If we try to understand the other person from one’s own perspective we finally end up at something we know already (this is termed “epistemology of the same”).’16 Surely we would do better by pursuing practice-based evidence. Del Loewenthal draws attention to the limitations of evidenced-based practice options by saying: ‘...therapies which appear to work may be privileged – particularly in public services – because they lend themselves to current notions of evidenced-based practice. There is, however, the danger that narrowly defined demonstration of effectiveness has become more important than whether or not they are necessarily better.’17
At present regulation provokes a collision of competing psychospheres (see O’Hara18). By introducing state regulation, which seeks to standardise all psychotherapy in a way that appears to be medical and institutional-centric, the Government is geared to limit our capacities to grow. This is particularly alarming because at present counselling and psychotherapy are exhibiting such vibrant activity and creative expansion. Presently, we are expanding our understanding through practice-based evidence, scholarly publications, research studies (both quantitative and qualitative), and excellence in training (from diploma to doctorate levels). There is cross-fertilisation between approaches; increased validation of therapeutic practice and theory with developments in neuroscience; and meta-analysis shows counselling and psychotherapy to be more reliable than most medical procedures.
If we are to be regulated it is vital that we are regulated by an authority that understands the intricacies and dynamics of counselling and psychotherapy, by a body that understands the fundamental differences between ‘conservative’ traditions such as medicine, and ‘leading edge’ disciplines, such as psychotherapy. It is vital that counselling and psychotherapy stand outside of healthcare in order to work alongside it. Mearns asks: ‘Will the humanity of the counsellor corrupt the medical model of mental illness? Or will the medical model of mental illness corrupt the humanity of the counsellor?’19 I realise that psychological distress can be as painful as physical pain and that pain killers in the form of psychotropic medication may well be of benefit to some people, but as Moncrieff says, it is ‘better if we are honest that that is what we are doing, rather than trying to pretend that we are curing their illnesses’.20 Surely it is time to demonstrate the competencies of a different kind of profession, a profession that can effect change, growth, emancipation and adaptation and not just manage symptoms.
Our responsibility then is to make this interesting time count. Alarming as registration might appear, it also provides a golden opportunity to give our profession the ‘hard sell’. Now is the time to hit the campaign trail.
The psychotherapeutic community has within its grasp a powerful gift for a troubled world and we must be passionately proactive in ‘selling’ this gift. This is no time for a quiet revolution – we need to make as much noise as possible. I find myself wanting to echo Sanders’ passionate cry: ‘Let us campaign for the de-medicalisation of life, rather than the proliferation of new diagnostic categories for everything from relationship and sex to eating and shopping.’21
Steve Cox is a senior accredited member of BACP and has been a practising counsellor/psychotherapist since 1995. During this time he has worked as a counsellor, supervisor and trainer in the voluntary sector and in education. Currently he manages a bereavement service within a hospice in North Hampshire. His theoretical approach to therapy is person centred. Please email firstname.lastname@example.org
1. Yalom ID. The gift of therapy: reflections on being a therapist. London: Piatkus; 2002.
2. Sanders P. Principled and strategic opposition to the medicalisation of distress and all of its apparatus. In Joseph S, Worsley R (eds) Person-centred psychotherapy: a positive psychology of mental health. Ross-on-Wye: PCCS Books; 2005.
3. Rogers CR. Client-centered therapy. London: Constable; 1951.
4. Freeth R. Working within the medical model. Therapy Today. Lutterworth: BACP. 2007; 18(9):31-34.
5. Rowland B. Depressed process: a person-centred view of depression. Person-Centred Practice. Ross-on-Wye: British Association for the Person-Centred Approach. 2002; 10(1):27-34.
6. Kellehear A. Compassionate cities: public health and end-of-life care. Oxfordshire: Routledge; 2005.
7. Lipton B. The biology of belief: part 1. Intouch. Northampton: The Healing Trust. 2009; 4:4-6.
8. Lipton B. The biology of belief: part 2. Intouch. Northampton: The Healing Trust. 2010; 5:4-5.
9. Cooper M. Essential research findings in counselling and psychotherapy. London: Sage; 2008.
10. King M. Randomised control trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care. Health Technology Assessment. 2000; 4(19).
11. Leicester G, O’Hara M. Ten things to do in a conceptual emergency. International Futures Forum. Fife: Triarchy Press Ltd; 2009.
12. Lovelock JE. Homage to Gaia: the life of an independent scientist. New York: Oxford University Press Inc; 2000.
13. Laing RD. The politics of experience and the bird of paradise. Harmondsworth: Penguin Books; 1967.
14. Schmid PF. Back to the client: a phenomenological approach to the process of understanding and diagnosis. Person-Centered and Experiential Psychotherapies. Ross-on-Wye: World Association for Person Centered & Experiential Psychotherapy & Counselling. 2004; 3:36-51.
15. Rogers CR. Remarks on the future of client-centered therapy. In Wexler DA, Rice LN (eds) Innovations in client-centered therapy. New York: Wiley; 1974.
16. Schmid PF. The challenge of the other: towards dialogical person-centered psychotherapy and counselling. Person-Centered and Experiential Psychotherapies. Ross-on-Wye: World Association for Person Centered & Experiential Psychotherapy & Counselling. 2006; 5:240-254.
17. Loewenthal D. Case studies in relational research. Basingstoke & New York: Palgrave Macmillan; 2007.
18. O’Hara M. Psychological literacy for an emerging global society: another look at Rogers’ ‘persons of tomorrow’ as a model. Person-Centered and Experiential Psychotherapies. Ross-on-Wye: World Association for Person Centered & Experiential Psychotherapy & Counselling. 2007; 6:45-60.
19. Mearns D. The humanity of the counsellor. The Mary Kilborn Lecture, Strathclyde University, Glasgow; 17 May 2006.
20. Moncrieff J. Biological imbalance in the brain – does it exist? Therapy Today. Lutterworth: BACP. 2007; 18(8):28-31.
21. Sanders P. Decoupling psychological therapies from the medical model. Therapy Today. Lutterworth: BACP. 2007; 18 (9): 35-38.