A Review of:
Holmes, Jeremy & Lindley, Richard: The Values of Psychotherapy, OUP 1991, ISBN 0- 19-286127-1
House, Richard & Totton, Nick, eds: Implausible Professions – Arguments for Pluralism and Autonomy in Psychotherapy and Counselling, PCCS Books 1997, ISBN 1-898059-17-9
It would be hard to find two books on psychotherapy which offer a greater contrast with each other than The Values of Psychotherapy by Holmes & Lindley, and Implausible Professions, edited by House & Totton. I found reading the two of them in close proximity a most provocative and stimulating experience in a way that I doubt whether reading either alone would have been. It certainly radicalized my own thinking and made me realize how little consideration I had really given to the issue of the regulation of psychotherapy, and its ‘professionalization’. Yet since the early 1990s, there have been such important changes, at a deep level, instigated by government or by the requirements of EU membership, that I feel strongly that psychotherapists should look very seriously at the entire question all over again, whether they have done so before or not, now.
Holmes & Lindley’s book is by no means new; but even when it was written, it would have appeared moderate and temperate in its approach. They claim to take a broad view of psychotherapy:
“Psychotherapy is enormously diverse… Our aim in this book, however, is to consider the whole spectrum of psychotherapy and, as far as possible, to be impartial and non-sectarian. We therefore define psychotherapy in the broadest terms…
“They view psychotherapy as potentially very helpful and effective, but “yet to take itself, or to be taken, seriously.” Their theme is that, for psychotherapy to become ‘serious’ in their sense, it must become a ‘profession’; by which they intend comparison with medicine or the law and in particular, they argue that psychotherapy should be available under government funding (the NHS in Britain). They are quite clear about this from the start, setting out on their second page the questions they mean to answer –
“Is psychotherapy worth taking seriously? Does psychotherapy work? Should it become more widely available, especially to the less well-off? Who should be responsible for paying for psychotherapy? What role should psychotherapy play in society? How should consumers be protected against being harmed by exploitative or incompetent therapists? What sort of ethical code or code of practice should govern the conduct of therapists? These are the central questions asked in this book”
I don’t doubt that these are important questions, but I would invite you to consider them critically for a moment. For example, what effect does the interpolation of ”especially to the less well-off?” have in this context? Doesn’t it lead one to feel what good chaps the authors must be, trying to help the poor? Or again, how about the question of “protecting consumers” from “exploitative or incompetent therapists”? Isn’t that rather a leading question? In short, I think that these questions are essentially rhetorical; Lindley & Holmes are asking the questions to which they believe they have the answers. But do they?
It seems to me that they are implying that psychotherapy cannot be taken seriously unless it becomes a ‘profession’ in their sense of the word, that is, unless it is government regulated and included in the governmentally funded services to the public. This is more or less exactly the same point made to psychotherapists here. I recall, at a Workshop in September 1992 hosted by the Irish Standing Conference on Psychotherapy (their first, I think – reported in Inside Out Issue 10, Autumn 1992), where there was considerable suspicion expressed by people attending the workshop about becoming members of the organization then calling itself the European Association for Psychotherapy. [The current EAP is not the same organization, I believe.] Against that European organization, the ISCP was presented as speaking for Irish interests, on the grounds that it was vital that the Irish profession of psychotherapy should speak with one voice in Brussels. Without that, it was inferred, nobody would be taken seriously. This kind of threat is the essential appeal also of Holmes and Lindley’s argument. Briefly, it is based on fear. I feel that this explains the extremely reassuring manner which Holmes & Lindley employ throughout the book, whatever they may be discussing. For example, they are quite unruffled by attacks such as the famous one by Hans Eysenck, who asserted that the placebo effect worked as well as psychotherapy:
“Readers of this authoritative statement by Eysenck might be surprised to learn that the authors of the study from which he derived his conclusions, Smith, Glass & Miller, summarize their evidence as indicating the ‘consistent, positive and large effects of verbal psychotherapy compared to placebo treatment’…”
Yet later in the book they discuss the idea that the placebo effect itself may be vital to the effectiveness of psychotherapy. Similarly, they assert as a fact that
“the effective therapist is objective but not cold, warm but not seductive…”, which ties in with their earlier assertion that “tape recordings of therapeutic sessions reveal that what therapists actually do often differs significantly from what attempts to formalize their practices would suggest they do.”
This sounds reassuring, but by the end of their book they have turned around the difference so that it represents a danger to clients. By then, their argument is that therapists should have a “Code of Practice” book, approved by the professional psychotherapy body they wish to see established, in their waiting rooms so that their ‘patients’ who are credulous and vulnerable, can refer to an authoritative version of what should be going on in the consulting room. This is a completely different approach, I feel, from what they claim. What I feel it reveals, however, is the complete dominance of the ‘medical model’ in their view of psychotherapy.
Equally reassuring is the tone they take when discussing transference and counter- transference. In Chapter 6 they discuss this at some length, without ever hinting that transference issues could be present within the case they are making themselves. They consider “falling in love with your analyst”, “the psychotherapist as parent”, “as doctor”, and the counter-transference the therapist may feel by being “caught up in a powerful emotional field” of the patient’s. But the very idea that their own work could embody any transferential or counter-transferential issues is absolutely not there. They consider that they can boil down the problem to “the question of truth- telling, the issue of therapist self-revelation, and the problem of the proselytizing therapist.” It seems to me that all three of these transference issues are markedly present in their work, and never acknowledged. Of course, they can counter that they are offering a book about therapy, and not therapy. But a little more thought will show the superficiality of such an idea.
In describing their view of ‘transference’ they apparently accept that it is not limited to the therapeutic situation but is “everyday” and can colour all sorts of relationships. There is no acknowledgement that the kind of institutions of professionalism which they recommend would involve transference issues. Instead, the professionalization of psychotherapy is naively presented as a means of protecting the vulnerable and credulous public from exploitative psychotherapists. Having opened with the reassuring message that psychotherapy is “diverse” and that anyway therapists don’t do what they say, but are “effective” more because they are warm and empathetic than for any other reason (the children in this family are all alike really), they move on to postulate a potential victim-patient who needs to be protected from the therapists who are not like us (the good children) – unsurprisingly, their solution is to institute a parent to refer to, who will control or expel the bad therapists (children). Briefly, it seems to me that their understanding of the issues of transference is very flawed.
At the end of reading The Values of Psychotherapy, I felt as if the real question was: How can psychotherapy become an accepted part of the National Health Service? This absolutely begged the question of whether being taken into government service was acceptable to psychotherapy. However, I feel that I am really only seeing the flawed nature of Holmes and Lindley’s book so vividly because I was lucky enough to read it in tandem with Implausible Professions. As the sub-title makes plain, the editors intend this collection of essays to open up the arguments about the regulation of psychotherapy and counselling:
“What we initially wished to oppose can be summarised as the ‘professionalisation’ of psychotherapy and counselling in Britain… The project of this book originated as one of opposition; but it has developed first into one of refoundation, and then into one of innovation.”
In complete contrast with the list of questions which Lindley and Holmes set out in their first chapter, so that they could go through and answer them in the body of their book, the sense of this book is of genuine enquiry, generating new ideas and affirming certain basic principles which I think most humanistic therapists would hold. It was in stark contrast with the seemingly pragmatic approach of The Values of Psychotherapy, and I found myself warming to it at the very first chapter, which is an essay by John Heron on ‘The Politics of Transference.’ In this chapter, Heron faces directly the question which Holmes and Lindley constantly circle around, which is the function of psychotherapy in society. He does not take it for granted that psychotherapy, like medicine, is a Good Thing (which good people believe should be available on the NHS). He says: “good psychotherapy does not and should not involve a treatment and cure model.” The inequality between the client (‘patient’) and the practitioner which such a model predicates is completely avoided by Heron, who argues that:
“The phenomenon of transference is very widespread throughout our emotionally repressive society, whose rigidity is sustained by distorted and unprocessed psychosocial dynamics. People carry around a great deal of buried infantile distress which drives them to act out in adult life submissive and dependent behaviours in the presence of those on whom they unawarely project oppressive parental status. If the insecure child within psychotherapists drives them to use this whole distorted system to legalise a new, exclusive, highly trained and protected profession to handle transference, they too will fall foul of their own introjected authoritarian parent – which will subtly contaminate the way they theorise about, and work on, their clients’ transference material…”
This article was originally published in 1990 in Self and Society, but I feel that the points it is making have really not been integrated into the arguments about the legal status of psychotherapy yet. Unlike Holmes and Lindley, Heron clearly believes that psychotherapy is not just some kind of adjunct to medical practice; they seem only to view the argument from the standpoint of ameliorating the condition of the unfortunate. But for Heron, the processes of psychotherapy are normal – vital, in fact, to every individual’s emotional competence’ within society. He considers that the placing of psychotherapy within the medical sphere produces “the absurd anomaly that the majority remains emotionally incompetent, and only patients with problems qualify for affective growth”
It seems to me that the concept of ’emotional competence’ is critical here; Heron is inferring that it is the true challenge of psychotherapy to bring about such competence within society, and in that process also to enable social change. Such change would stem from the individuals within society who would learn how handle their own transference issues and would become effectively autonomous, with the result that they would no longer accept parental (patriarchal or matriarchal) forms of organization and no longer be motivated mainly by transferential fear of authority. Heron regards it as the right of the individual within society now to acquire this emotional competence’:
“the right to be emotionally competent, which includes the ability to understand and master the dynamics of transference – is the birthright of every person in society.”
He compares this right with the right to learn literacy and numeracy, which is fundamental in our society. He considers one role of psychotherapy to be ’emotional education’. Thus Heron proposes a humanistic basis for psychotherapy, not a pathological one.
The essays which follow this powerful piece of writing open out the subject in many ways, each serving to increase the reader’s understanding of the work of psychotherapy within a social framework. They do not all take Heron’s view by any means, but in different ways they reflect deep concern with the ways in which state regulation is affecting their work. There is, for example, a very personal and moving account by Robin Shohet of his own feelings around a particular client, called Reflections on Fear and Love in Accreditation’.
“Now I know that I often made mistakes with her. I often wondered about the whole issue of dependence, the dangers of collusion, over identification. I think I might have failed an accreditation process with her as a case history. Certainly I would be very reluctant (frightened) to really name how important she was in my life…”
I feel it took immense courage to write this piece and publish it – and the questions it left me with, about where and how it is safe to make mistakes – to go on learning – to be true to our own process – were very troubling.
In contrast with the assumption which is made by Holmes and Lindley, that they could come up with a ‘definition’ of psychotherapy to stand at the start of the book and never need to be reviewed, the essays in Implausible Professions constantly explore the meaning and work of psychotherapy, challenging and refreshing the reader. For instance, in Training: A Guarantee of Competence?’, Richard House quotes J.D. Frank as follows:
“traditional scientific methods are not well suited to investigating the phenomena of psychotherapy, since they deal exclusively with facts, whereas psychotherapy transpires in the realm of meaning.”
[I am reminded how Holmes and Lindley so often make ‘facts’ clinch their arguments… but how can the ‘warmth and empathy’ of a therapist be a fact? How can it be stated ‘objectively’ and without reference to the particular relationship in which the warmth and empathy are experienced?] Many of the essays are concerned with finding appropriate ways of researching therapy, and the bibliographies which follow them would make an excellent starting point for anyone who wants to undertake humanistic research.
There is also a substantial amount of exploration of the philosophical bases underlying psychotherapy (which again, Holmes and Lindley mention but in no way seek to explore, far less to carry forward). In a strong piece about the nature of pluralism, Andrew Samuels sets himself the task of considering the political and social implications of psychotherapy and counselling:
“Everybody these days says they want to work with the political and social dimension in therapy… yet there are absolutely no detailed texts on how to do this. So I am trying to write such detailed texts that explicate the political person as he or she appears in the clinical situation.
In this illuminating article, he does away with the mere tolerance of difference which is commonly taken as adequate and describes his idea of ‘pluralism’:
“By concentrating on debate, dispute and difference, we can get the best possible conception of what psychotherapy really is… A clash of doctrines is not a disaster; it is an opportunity… Pluralism is an attitude to conflict which tries to reconcile differences without imposing a false resolution on them or losing sight of the unique value of each position… It would not be pluralistic, us I understand it, to assert that there are many diverse truths but that these are but aspects of one greater Truth…”
His argument against centralized bodies to regulate psychotherapy is a very interesting one; he analyses the way in which these central bodies themselves become elements in the situation. Such a body, like the UK Council for Psychotherapy (UKCP) is, he says,”itself a special interest group.” I felt his analysis of this particular aspect of political life was very trenchant. I felt that Samuels’ point was of paramount importance at least for discussion among therapists. Yet, political though his essay is, it also shares the common ground of understanding with other articles in the book of the nature and work of psychotherapy itself – undefined though it may be. When he says, I want us to get beyond either maternal or paternal models for our professional organizations…” and “there may be too much obedience in psychotherapy”, I felt his grasp of transference issues was congruent with Heron’s, with Shohet’s, with that of the other contributors. In short, a lucid understanding of the ground was emerging for me as I read on.
But possibly the most important essay in the collection is the second one by John Heron, ‘A Self-Generating Practitioner Community’. It heads the final section of the book, a group of essays which are all about other systems of checking on our practice than government-approved bodies. There is a great deal in this section to think about, discuss and to integrate, regardless of legal status, etc I feel that it should be required reading! But Heron makes a particular point which provides a lever against the transference fears roused by the threats to therapists livelihoods by governmental and EU bodies:
“The public, of course, cannot be protected by the statutory regulation of any profession. The public can only be educated to be self-protecting… so that it becomes empowered to relate effectively to practitioners of any kind, whether legalized or not.”
The lever is slipped neatly in below the assumption that a regulation can stop something from happening – when in fact, it can only take effect when it has been broken, or in this case, failed to protect. I think the more humanistic stance of empowering people to take care of themselves, and not fall victim to any sort of professional, shows much greater real concern to prevent abuse. Heron seems to have taken to heart Shaw’s observation that “every profession is a conspiracy against the laity.”
Another element in this collection is the inclusion of very personal and direct accounts of training and practice where the writers are strikingly open and honest about their experiences. This has the effect of deepening the more dialectical articles and making the issues they raise come to life. Work from new therapists is particularly welcome here, bringing the freshness of their perceptions to complement the views of well-known protagonists like Heron and Samuels. I did not find a single essay in the collection dull or predictable, and though I think the whole is greater than the parts (and I really like that), still the parts are all interesting in themselves. The penultimate essay, ‘Learning by Mistake’ by Nick Totton, is an impassioned statement about the need for truthfulness with ourselves:
“mistakes are invaluable because they bring us up against reality… This work demands of us, I believe, not that we are perfect, but that we fail impeccably - honestly, openly, over and over again…”
For me at least, it is voices like this which have made psychotherapy “serious”, and not the possibility of a position of social status and recognition.
There is one last, very telling contrast to be drawn between these two books, in the way that they choose to handle opposition. In The Values of Psychotherapy, the assumption is made that Holmes and Lindley will prove their case by disproving that of the opposition. They choose, particularly, the work of Thomas Szasz, to exemplify that opposition. This has the effect of narrowing down the notion of freedom to that of free trade:
“If basic therapeutic care were provided according to user need, therapists who wished to remain Nozickian gardeners would be free to do so. But one could hardly expect society to invest in their services. On the other hand, those paid by public funds would have a social responsibility to provide a need-based service, and there would be no injustice to them in requiring that they provide a socially useful service.”
They seem to think that about wraps it up for ‘serious’ psychotherapy outside regulation! In contrast with this, the contributors to Implausible Professions often speak from their experiences of the introduction of the changes towards ‘ professionalization’ which have taken place over the last few years. Several describe how they were either quite enthusiastic about joining a body like UKCP, or else that they believed it could be constructively integrated within the psychotherapeutic community. In fact, only a few of the contributors would utterly oppose the second of these ideas. The essays show them struggling to achieve some kinds of clarity and integration around the question; Samuels, for instance, suggests that the ‘special interest’ of such a body should be acknowledged and that this could tree up the process. I feel that this difference in approach is absolutely critical; whereas the aim of Holmes and Lindley’s book is actually to deny the opposition. House and Totton choose work which clearly acknowledges the importance of the conflict and seeks to value it and learn from it. The first of these I suggest is a typically hierarchical stance within an unquestioned power-structure. The second seems to me to be humanistic in the most straight forward sense of being inclusive and egalitarian. It is perhaps ironic that both books rely so much on the word “autonomy” when they seem to mean such different things by it.
[Although The Values of Psychotherapy is easily available, published by OUP, I suspect that you may need to order a copy of Implausible Professions, which is published by PCCS Books. Llangarron. Ross-on-Wye HR9 6PT, Wales: Ph 0044 1989 77 07 07. House and Totton have some acerbic words to say about the difficulty they had in finding a publisher for this important book.]