Psychotherapy Training, Standards and Ethics

By Alan A. Mooney

Psychotherapy is an emerging profession. A great deal of energy and time has been spent in the last number of years in Ireland to try to determine what is the profession of psychotherapy, who are psychotherapists and what are the standards that characterise the profession? (See: Inside Out, Winter 91, IAHIP Conference Report on Accreditation)

Most people who read Inside Out will know that a number of years ago the Irish Standing Conference for Psychotherapy was set up to bring together the various approaches to the work of psychotherapy. There are five branches to this young tree. These are: Humanistic & Integrative, Constructivist, Family & Systems, Behavioural and Psychoanalytic Psychotherapy.

Each of these branches has its standards for training and each wants those standards to be good enough to stand the test of scrutiny. However there are differences in philosophy and outlook such that some schools of thought give greater weight to particular aspects of training than do others. For example, the Humanistic & Integrative branch believes very strongly that it is essential for anyone training in its style of therapy to have engaged in per­sonal and group therapy themselves for at least the duration of their train­ing. The likelihood is that someone drawn to train in this ‘way’ of therapy will also have engaged in their own journey of personal growth and self dis­covery prior to training. Some, but not all of the other branches insist on personal therapy or analysis. I like the way D.W. Winnicott affirms the need for personal therapy both in training and afterwards, as a practitioner: “I am not saying that the analyst’s analysis is to free him from neurosis, it is to in­crease stability of character and maturity of the personality, this being the basis of our ability to maintain a professional relationship.” (D.W. Winnicott. “The Maturational Process and the Facilitating Environment”, London, Hogarth, ’65)

Professions set standards of inclusion and by implication, standards of exclusion. Therefore the standards and ethics of training are very important. Since any profession wishes to enjoy the respect of the public and other professions these standards must be credible and strong enough to deserve the trust and confidence of people who will use services provided. They need to be transparent.

It is easy to lay down quantitative criteria for inclusion in training pro­grammes, for example, entry age, previous qualification etc. It is not so easy to determine qualitative criteria – what kind of person is acceptable for training?, what level of maturity is expected?, what are the subtle factors of their development that qualify them? There is a danger that psychotherapy train­ing could exclude innovative people by having too strict quantitative criteria.

On a cautionary note I quote James Strachey who became a prominent psychoanalyst and official translator of Freud, commenting on the application forms for the Psycho-Analytic Association in the 1960’s: ‘Documents of this kind fill me with bloodcurdling feelings of anxiety and remorse. How on earth could I fill up one of them? A discreditable academic career with the barest of B.A. degrees, no medical qualifications, no knowledge of the physical sciences, no experience of anything except third rate journalism. The only thing in my favour was that, at the age of thirty, I wrote a letter to Freud, asking him if he would take me on as a student. For some reason he replied, almost by return of post, that he would …

Whether it is possible for it to become over-institutionalised is an open question. Is it worthwhile to leave a loophole for an occasional maverick?”

One of the difficulties the ISCP has to face is the range of training offered by its different elements. There are great variations between the different courses in length, breath, and depth. Are all courses equally useful? How does one accredit a training process? (See: Inside Out, No.75 Win 93, ISCP Conference Report).

The ISCP is asking these questions because there is a need to create a register of psychotherapists and there is a need to know what kinds of courses can be accredited by the Conference. Each of the different schools of therapy, also operating with integrity, is looking at its training courses with a view to establishing good quantitative criteria. These can most easily be agreed upon but then each must look to the qualitative criteria which in a sense are the real determinants of each psychotherapy style’s particular ethos. (See: Inside Out, No 11, Winter 92, Europe: The Way Forward, by Ed. Boyne)

These issues are important for training because ultimately the profession of psychotherapy wants to be confident in its members and to be in a posi­tion to enhance public confidence in the work. It is also important because at the moment anyone can call themselves a psychotherapist and set up in practice without reference to professional or statutory control, IAHIP Code of Ethics (1993), arts. 8.5, 8.7)

Ultimately registration of psychotherapists commences with the kind and quality of training, therefore, it is becoming increasingly necessary to define the title of psychotherapist without confining it to a particular approach. It would not be reasonable to say that only those with a Humanistic and Integrative training could call themselves psychotherapists. It would be reasonable to say that those who have not completed a psychotherapy training should not call themselves psychotherapists. (A useful discussion of this and other issues may be found in P. Sieghart, “Statutory Registration of Psychotherapists. A Report of a Profession’s Joint Working Party”. Cambridge: E.E. Plumridge. ’79).

It is not enough for a training course to have a high academic standard. It is possible to have a Ph.D in Counselling and Psychotherapy and never to have engaged in any form of personal therapy. From the perspective of the Humanistic & Integrative understanding this is not enough because working with clients cannot be just skills based or theoretical knowledge based. The process of therapy is like an accompaniment on a journey of personal self-discovery with a client. The therapist needs to have made his or her own journey so that all attention can be given to the client and not used to admire or be terrified by the view of one’s own self-discovery, or indeed to become lost in the client’s world. (IAHIP Code of Ethics (1993) art. 8.2)

When clients come to do therapy, they are usually in some distress or confusion, so it is clear that the relationship is an unequal one and therefore a very powerful one for the therapist. Therapists need to be aware of the inequality of the relationship and to have a clear ethical stance.

The code of ethics of the Irish Association for Humanistic & Integrative Psychotherapy talks about the therapy relationship being “a meaningful relationship between equals”, (IAHIP Code of Ethics (1993) art. 2.3), while this aspiration is a good one it is important for the therapist to remember this equality and hold it on behalf of clients.

This is only possible if therapists are clear about who they are, since the whole process is about enabling clients to empower themselves in the world. The training of psychotherapists must include a real development of the individual so that the ‘will to power’ is understood as it manifests itself in their own experience, otherwise there is a real danger that clients will experi­ence exploitation by therapists who are unclear about what they are doing.

There is an anecdote told by Gordon Allport in his autobiography. He visited Freud, was ushered into the office and was greeted with silence. To fill the vacuum he began to tell of an episode that occurred on the tram on his way to visit Freud. A small boy kept complaining he didn’t want to sit on the dirty seat and he didn’t want to sit beside ‘that dirty man’. “When I finished my story”, Allport says, “Freud fixed his kindly, therapeutic eyes on me and said, ‘And was that little boy you?’ “

This anecdote illustrates two things for me for the purposes of this article. The first is that psychotherapists and trainers need to switch off from the roles they play in their professional lives and secondly (without prejudice to Freud), good training is necessary to reduce the possibility of inappropriate and undermining ‘interpretations’ of clients’ stories.

Psychotherapy is about people and that which makes them individual, unique and different. The variety of training offered is naturally diverse. In a real sense that is the nature of the discipline. People’s needs from the pro­fession are varied and broad and consequently there will be a need for different kinds of therapy.

It is not so much that one is better than another, it is more a tribute to the complexity of individuals that some will choose one approach rather that another. Different ways of doing therapy appeal to different people because of their way of interacting with the world, some will want to work at an emotional level, some at a behavioural level etc.

From the very moment an individual applies for inclusion on a training course in psychotherapy there is a moral and ethical responsibility on the trainers to ensure that trainees are suitable and not using training to bring their own psychological or emotional distress into greater focus and to the detriment of prospective clients.

Just as it is important for a code of professional ethics to protect clients against bad practice and exploitation so it is important that training courses should have a code of ethics to protect both the integrity of the training and the trainees. Because psychotherapy training is by nature a very personal and deep interaction between the trainees, their peers and their trainers, clear guidelines need to be available to all concerning the responsibilities of both the trainees and the trainers in respect of the hoped for outcome of the training process.

Transference and counter-transference issues need to be addressed regularly and openly, especially in training programmes whose final out­comes are not entirely determined by clearly objective evaluation criteria. And all processes need to be transparent. I like some people, I am attracted to some people and there are others with whom I would not choose to associate. Unless training institutions have a clear idea of the qualities they are looking for, and a clear idea of what assessment procedures will help them to get people with these qualities, they will choose people with whom they are comfortable. Evidence of a candidate’s abilities is important other­wise the concentration will be on less relevant things like ‘the impression he made on me’ or ‘her voice grated on my nerves’ etc..

Donald Winnicott’s assertion ‘there is no such thing as a baby’ (i.e. only a baby-mother couple) (D.W. Winnicott, “The Maturational Process and the Facilitating Environment”, London, Hogarth ’65), can be applied to the essential nature of psychotherapy training. The candidate and the trainer engage in a process that is both academic and maturational especially for the trainee and in this case it is the responsibility of trainers to understand that they have a ‘mothering’ or ‘parenting’ responsibility toward their trainees.

While the ‘adult’ candidate can take responsibility for the acquisition of knowledge and skills, the trainer is responsible with the trainee to help him or her ‘mature’ into a healthy and ‘safe’ psychotherapist.

It is clear then that there is a significant difference between training a candidate to be a psychotherapist and training someone to be an accountant. Since the therapist will be working with the delicate and subtle realities of other people, training needs to help him or her to encounter his or her own vulnerabilities. In a sense, and a very real sense, trainers are in the role of psychotherapist for the duration of the training and to that extent no other role is appropriate. (IAHIP code of ethics (1993) art’s. 2.7;3.5)

A good training in psychotherapy will emphasise the need to ‘hold’ the candidates so they have the safety and space to mature through a process of self-discovery and learning. During this process the trainee will attribute qualities to the trainers that are appropriate within the ‘learning and emerg­ing’ environment. One of the obvious attributes that will be applied is the role of parent. This is an easy role for the trainer to exploit since at times the need for ‘parental approval’ in the trainee will be high. There is also the possibility that within such an environment the trainee will suspend usual personal or sexual boundaries. It is the responsibility of the trainers to help trainees explore these phenomena and to ‘hold’ the boundaries while the process unfolds. Just as in a professional psychotherapy setting, it is the responsibility of the therapist to ‘hold’ the safety of the environment for the client.

While some elements of the training of psychotherapists involve a didactic approach others involve a truly educational one, where the original meaning is to “draw out”. The process of training a psychotherapist involves letting trainees discover for themselves their strengths and blind spots. Ultimately, whatever the assessment process, the quality of training should enable the candidate to have a clear insight about themselves and whether they are in fact, capable of being a therapist. The last thing any training programme wants to engender is an unhealthy dependency in its trainees. A genuine development of autonomy in the individual is a good hallmark of training since it means that the person is capable of self-government and free choice.

To return to the starting point, psychotherapy is an emerging profession and as a result there are tensions within the various disciplines that make up the Irish Standing Conference for Psychotherapy. These tensions are good and useful because they are about maintaining standards both in training and in the profession generally.

Each of the branches has much to offer the future of psychotherapy and it is important that as much contact and cross-fertilization as possible takes place. Polarization of training processes will not help the future of psycho­therapy. It feels right to say that, because much can be offered by each ISCP member organisation and much can be gained by making the effort to agree essential elements of all trainings and allow for the distinct ethos and direction of the individual schools. One of the major key elements of the successful emergence of psychotherapy as a profession will be trust. Trust between trainers and trainees. Trust between trainers of different disciplines and trust between trainers and a course accrediting body in the future.

Reference

1.   Quoted in Holmes J. & Lindley R.: The Values of Psychotherapy Oxford University Press; 1989.

Select Bibliography:

Irish Association for Humanistic & Integrative Psychotherapy: Code of Ethics andPractice 1993 & ’94. Available from the secretary c/o ‘Inside Out’.

Laing R.D. “Self and Others”, London, Tavistock 1960

Laken M.   “Ethical Issues in Psychotherapy”, OUP 1988

Rowan J. “The Reality Game”, Routledge & Keegan Paul, 1983

Sieghart P. “Statutory Registration of Psychotherapists – A Report of a Profession’s Joint Working Party, Cambridge”, E.E. Plumridge 1979

Winnicott D.W. “The Maturational Process and the Facilitating Environment” London, Hogarth, 1965.