The Trouble with Therapy II. Institutional Dimensions

by Barbara Dowds

“Specialists without spirit, sensualists without heart; this nullity imagines that it has attained a level of civilization never before achieved”. Max Weber

I was attracted to psychotherapy as an escape from the dry soullessness of academic science. I was excited, expanded and nourished by a decade of experiential ‘work’ from co-counselling, Gestalt, and psychodrama to shamanism and meditation. Despite my frustrations in one-to-one therapy, I persisted and sampled several trainings before committing to one that suited me. However, my experience since graduation has been a progressive slide into disillusionment as I encounter the increasing impingement of instrumentalising (I-it relating) reason into the therapy establishment; the sanctuary that therapy offered has been invaded.  I wrote a forerunner to this article for a previous issue of Inside Out on what is wrong with therapeutic practice. I now want to examine what I think is wrong with the ‘institution’ of therapy. Berman (1984) and Tarnas (1991) write about the disenchantment of the world wrought by the separation of reason and knowledge from values, creating “an iron cage of bureaucratic rationality that permeates every aspect of modern existence” – a “mechanized petrification, embellished with a sort of convulsive self-importance” (Tarnas 1991:412). Berman (1984: 271) calls it the “great metaphysical problem of our age” – how to reconcile what we know in our heads with what we know in our hearts. It goes without saying that I didn’t expect heart-knowledge to enter the scientific endeavour, but I had great hopes – hardly unreasonably – that this might be the central focus for the project of psychotherapy. Instead what I find within the ‘institution’ of therapy is a great influx of bureaucratic regulation, anxious legalism and instrumentalisation – so-called ‘professionalisation’ – that conflicts with and negates the values inherent in humanistic or transpersonal therapy. Because of the current moves towards professionalisation without any general debate within the therapy community, this article will examine some of the consequences and implications of the direction we appear to be taking. The arguments against professionalisation have been discussed in detail in Mowbray (1995), House and Totton (1997), Bates and House (2003) and House (2003) and there will only be space to examine a few of them here.

Training and Therapist Efficacy

One of the characteristics of a profession is its possession of unique, expert knowledge.  It seems to me that in our hurry to acquire the status of a profession, we are pretending to know a great deal more than we do and ignoring some of the things that we tentatively do know. In the last century and more, we have accumulated theories, but few empirically demonstrated facts about development, the self, relationship, ways of working, etc.  There are numerous methodological difficulties associated with the study of therapeutic effectiveness: there is no satisfactory control (would the client have ‘got better’ anyway?), and it is extremely difficult to generalize from outcome studies where a great deal of contradictory information is lost through the averaging effect. The often undefined, gradually emerging and manifold aims of therapy mean that it is frequently not clear what outcome is being assessed, and the time at which the result is determined is critical, therapy possibly appearing beneficial during the process, but having other less desirable long-term effects such as generating social isolation. Then, there is the thorny problem of who evaluates the outcome – the client or an external ‘objective’ assessor.  Some of the more recent forms of research such as cooperative inquiry are more tailored to the needs of humanistic therapy and partially avoid many of the above problems.  However, the information gleaned is unlikely ever to translate into universal laws of the kind that obtain in the physical sciences because these approaches explicitly recognise that knowledge is created as much as discovered and is constructed in a communal process.

Notwithstanding the problems of doing therapy research and the fact that most research so far has been on short-term counselling (Rowan 2005:27), it is striking that one result that has been demonstrated over and over again in repeated studies is being ignored by those pushing towards professionalisation, with its attendant regulation of standards, training and accreditation. This is the finding that the outcome of therapy is equally successful with lightly-trained paraprofessionals as with ‘fully-trained’ therapists (see references and summaries of findings in Bates 2006:193-197; McLeod 2003:137; Rowan 2005:25; Mowbray 1995:122). There is no correlation between therapist effectiveness and levels of training or academic qualifications. Despite this, we go ahead with more and more training, pushing it up from a couple of weekends a few decades ago to a year, then two, then three, then four. We are asked to demonstrate ‘professional development’ in order to gain or renew accreditation. Training is not only being lengthened, but it is becoming far more academic and moving relentlessly into the realm of university degrees, though the training in critical thinking that used to be part of academic discipline appears to be missing from most therapy courses. Not only theory, but also skills training is of questionable validity, since research has repeatedly shown that the effectiveness of therapy does not depend on the school to which the therapist belongs (Mowbray 1995:122).

‘Of all the influences making for success in therapy, the greatest is the readiness of the client for change’; in addition there is a correlation between the strength of the therapeutic alliance and outcome (Rowan 2005:26; Mowbray 1995:123). The effectiveness of the practitioner does not depend on length of training, but is correlated with degree of experience and personal qualities, including acceptance, genuineness, warmth, trust and understanding (Mowbray 1995:123). Despite this, there is less and less screening of trainee-therapists. As long as applicants are not barking-mad, actively unnerving, dangerous or completely without self-awareness or the ability to attend to the other, they are accepted onto the course. Unfortunately, I observe here what Totton (in Bates and House 2003:122) has noted in the UK: “people are training for the wrong reasons, coming from the wrong place internally, … concerned with the job rather than the work, and with looking into others rather than into themselves”.

The question arises as to whether the empathic qualities that correlate with therapist effectiveness can be enhanced by personal development.  The Russell survey of research results shows that “personal therapy undertaken as part of a training process has not been found to relate to increased competence of the practitioner” (Mowbray 1995: 122). This interesting result begs the question about the value of personal development within the context of trainings.  If undertaken without the desire for change, but merely to satisfy the course requirements, clearly therapy does not lead to personal development. Group therapy with trainers assessing the student’s ‘progress’ is even more problematic, as the situation is likely to evoke left-brain, competitive, defensive behaviour and the individual may have a legitimate fear of revealing their shadow or vulnerability in case they are failed. All of this suggests that personal development must occur before training is contemplated and that course applicants should already embody the necessary inner attributes before embarking on training.

The therapy establishment is ignoring these oft-repeated research findings in its drive towards academicisation of trainings and regulation of standards. It seems highly unlikely that any of the current moves in that direction will do anything except produce more alienated, disembodied and bureaucratic practitioners. Those who believe in training – particularly the need for extensive theory and skills work – display instrumental beliefs about therapy. (See references to Rowan 2005 in my first article for his differentiation between instrumental, authentic and transpersonal ways of doing therapy) It is this instrumentality – even in the non-instrumental orientations – and the deadening hand of regulation that is causing therapy to lose its soul.  As House (2003: 28) says: we need to “ ‘re-ensoul’ the healing experience by reclaiming those essential values and ways-of-being which modernity, materialism and professionalization are threatening to extinguish”.

Aspiring towards an authentic approach as I do, it seems to me that the task of trainings is to de-program and undo the character structure instilled by our current society and culture. Otherwise, we simply replicate our cultural pathologies – which, more than the individual, may be the location of distress (House 2003:33) – within the therapeutic community. This task would require a high level of commitment to personal development on the part of the student before embarking on training. Applicants to trainings could then be assessed (e.g. in a weekend workshop) for the capacity to relate in an I-thou manner, availability for contact, empathy, acceptance, authenticity and autonomy, the privileging of love relative to power (over others) and the desire for more spiritual growth. Trainings would comprise a mixture of personal development, theory and skills as at present, with an emphasis on the first in the context of relationship. I believe that real learning in therapy is derived from an experiential apprenticeship, the trainee being apprenticed to their own therapists, both individual and group. The task of trainings should be to individuate the trainee into the only therapist they can be (and into the therapist that only they can be). You cannot train Rogers into Perls or Perls into Rogers, nor should we want to.

Bad therapy appears to emerge from inappropriate trainings, lack of adequate screening of applicants onto trainings, inexperienced therapists and bad fit between therapist and client. The fitting of clients to compatible therapists could perhaps be carried out by supervisors. When I started out as a client 20 years ago, I feared GPs, drugs and psychiatrists and resorted to the Yellow Pages to find a psychotherapist.  I rang one of the few people then listed, who asked me to meet him in the lobby of the Shelbourne Hotel – I didn’t go!  Matters have improved since then, but it is still an un-signposted jungle out there for the uninformed – or even the informed – in which to find the person with whom one can build a therapeutic alliance.

Is therapy a profession or a vocation?

I contend that therapy is more like a vocation (e.g. the priesthood) or an art or craft (e.g. painting), not a profession; one’s competence to practice is more about who one is than what one knows and is promoted by (genuine, not rules-driven) personal development and apprenticeship, not by intensive academic training.  The capacity to be present, open, warm, empathic, engaged with the other or challenging in a non-destructive way cannot be trained into somebody. As a discipline, it is very unlike, say science or medicine.  It is not positivist in that it does not rest on the myth of objectivity and it is as much concerned with potential (what does not exist ….yet) as with current reality. Its outcomes are not predictable and cannot be systematized into universal laws, and unlike – say, psychiatry, which can pathologise dissent and creativity – therapy must not be normative.  It is essentially an exploratory and hermeneutic enterprise, about interpretation and meaning-making in the context of relationship. Bennett (2005:155) makes the distinction that professions are defined by career, status and material rewards and a commitment that is calculated and contingent on delivering benefits. In a vocation or calling, by contrast, ‘one gives oneself to learning and practicing activities that in turn define the self and enter into the shape of its character’.

Much of the appalling in-fighting between different therapy schools or accrediting organizations arises from each of them making the claim to have the absolute truth – like wars of religion or inquisitions to root out heresies. I am shocked by the petty rifts, defensiveness, competitiveness, dishonesty, paranoia, snobbery and protectionism (the ‘closed shop’) of the therapeutic establishment, the shadow of everything we supposedly believe – something I never encountered in the scientific community, local or international. What I see amongst groups of therapists in Ireland is clearly not restricted to this country. Nick Totton (2006), for example, writing about the UK and the USA, laments the ‘fragmentation, dishonesty, authoritarianism and rivalry’ within the institutions of psychotherapy (Totton 2006:108).  He suggests four factors that seem to create and maintain the problems: (a) professionalisation; (b) occupational stresses; (c) factionalism generated by transference onto trainers; (d) the impossible expectations combined with the deep distrust of wider society towards psychotherapy. The positioning of therapy as a profession generates distress because there is no general agreement about theory or practice. These rifts are rare in science because there is a solid basis for theoretical models – hypotheses can be supported or disproved by experimental testing and a general (though temporary) conclusion can be reached. Therapy rests on different foundations: ‘…the knowledge of psychotherapy, albeit real and powerful, is mostly not the sort of thing it is pretending to be. The great bulk of it is encoded inextricably in the embodied practice of psychotherapists, unavailable for examination or testing. Hence the professional institutions of therapy are in a state of permanent masquerade’ (Totton 2006:112).

How much Regulation is Appropriate?

Professionalisation implies developing self-regulation and setting standards around such matters as trainings, accreditation, supervision and ethics – all apparently unassailable ideals. However, “there is simply no evidence to suggest that a registered counsellor will be any less damaging than a non-registered one” (Bates in Bates and House 2003:112).  Instead, regulation intensifies competition and the focus shifts from issues of common good towards strategies for bulwarking the self-interests of the organization or the individuals running it (Totton 2006:112; Kay 2007), thus opening itself to “corruption, stagnation and lack of accountability” (Kay 2007). While acknowledging the need for some regulation to counter the havoc created by lack of boundaries in some therapists in the past (e.g. mixing the therapeutic relationship with friendship or sexual relationships) we not only delude ourselves but also severely damage the potential for authentic relationship, if we go down the route of professionalisation, particularly statutory regulation. Too much regulation stifles creativity, spontaneity, genuine relatedness and any joy or soul in the work.  If working today, would Perls have complied with the ethics regulations? Would Rogers have been refused accreditation for not having done enough theory modules? Would Jung have been blackballed and dismissed as a madman for his interest in alchemy?

One possible place where more regulation might be desirable is in the arena of training schools. Accreditation associations are in a position to regulate the numbers of therapy graduates produced each year, not just to reduce the flooding of the market (how many of these trainees realize that there is no work for them when they decide to commit four years of their lives and perhaps 20–30,000 euros to a therapy education?) but, more importantly, to eliminate the current practice of accepting any bum to fill the seats – unless the individual is grossly unsuitable.  There is undoubtedly a demand for degrees in therapy at present, and perhaps still some demand for personal work, so therapy schools could offer two streams in addition to practitioner training: one purely academic and the other in experiential emotional education. Graduates of the latter two strands would not become therapists, but might benefit themselves, society and their families or workplace through their emotional awareness.

There are problems also in the current accreditation criteria. There needs to be a more realistic evaluation as outlined above of the actual requirements for an effective therapist, instead of the current reliance on the completion of a certain number of hours in a classroom and with clients. This is an infantile and insulting practice, which bears no relationship to what the person actually knows, to the individual’s former life experience, or the amount they have read, written or thought about. If hours in the classroom were what counted, we would have Oxbridge graduates queuing up for places in RTCs (ITs) to remedy the ‘deficiencies’ of their courses (which are based on self-directed learning instead of spoon-feeding). Likewise the testimony of a supervisor who has never actually witnessed the therapist practising seems a poor basis for accreditation.

Other implications of professionalisation that would benefit from debate are whether it is desirable that the occupation of therapy is a full-time job and whether the one-to-one relationship is meeting the primary needs of many clients in the increasingly lonely, fragmented society of the western world.

Shadow of Professionalisation: role behaviour

The shadow of professionalisation, even in occupations which can lay claim to expert knowledge, lies in the loss of authenticity and humility. This loss accompanies role behaviour and identification with a powerful group – just look at the state of the professions of medicine and law, where the thirst for power long ago overshadowed the primary concerns with health or justice! I contend that in “profession-centred therapy” (House 2003), we become rigid, self-important, complacent and arrogant, we begin to think we know things that we don’t, we stop questioning or being spontaneous, we develop role behaviour and most of all – we lose our soul. It’s like what happens when people put on uniforms – they become bullies unless they have adequate ego strength to resist the temptation.  The psychic baggage that comes with professionalisation destroys an open, questioning, authentic, equal, I-thou relationship.  The more the individual props up their ego through identifying with their professional status, the more the client becomes objectified and the relationship unreal and unequal. The less personal work the therapist has done, the more fragile the ego, the greater is the danger of generating role-driven behaviour. All role behaviour blocks contact, authenticity, congruence and genuine compassion.

The Unconscious of the Therapy Establishment

It is interesting to speculate about the real reasons for the drive towards professionalisation. One obvious reason is materialistic: there is a huge industry providing training, therapy for trainees, supervision for all of us, supervision courses, further professional development, etc.  Another is status and the desire for inclusion. We would like to be invited out of the kitchen into the front parlour with the quality: the medical profession and psychologists, who are better organized but who pathologise and objectify their clients. So, of course, we are upset about this injustice; but there is, I think, another more subconscious process going on. The psychoanalyst Arno Gruen (2007) shows how we surrender autonomy in childhood in exchange for ‘love’ (in reality, approval) from the adults who wield power over us. Gruen argues that the infant, in renouncing his true self, embarks on a search for power, which masks the emptiness and self-hatred engendered by his self-betrayal. The pursuit of power leads to the dehumanization and destructiveness we see all around us. We carry this trade-off of autonomy for acceptance into our adult lives, when we seek admission into hierarchical institutions. I wonder to what extent his thesis explains the defensiveness, anger, power-mongering and sheer snobbery that I detect in the therapy establishment in Ireland? In our authoritarianism and compliance respectively, we display the peculiarly Irish underbellies of both masculinity and femininity – like John McGahern’s bullying Daddy and his submissive daughters in Amongst Women!

Statutory Regulation

Thorne (in Bates and House 2003:149) lists the arguments usually presented in favour of statutory regulation : (a) it’s inevitable; (b) it’s necessary to protect the public; (c) it will guarantee effective practitioners. I have already dealt extensively with (c) and it would be disastrous now, while the evidence base for the theory and practice of therapy is still growing, to implement the uniformity that statutory regulation would require. In terms of (b), Thorne argues that statutory regulation would enhance the power of the professional therapist and therefore attract those who are seduced by, and more likely to abuse, power.  If we accepted argument (a), nothing would ever change in society and it is clear that established practices and incipient threats have been eliminated or halted time after time (e.g., the abolition of slavery and the defeat of Le Pen in the French Presidential election a few years ago).

Statutory licensing is already in place in the USA and Lazarus (in Bates and House 2003: 151-157) exposes a horrifying picture of the totalitarian nightmare that has ensued. The law in that famously litigious country permits licensing boards to act as investigator, prosecutor, judge, jury and appeals court – and in many cases as complainant as well. A psychologist may be summoned to a hearing without prior knowledge of the testimony against him; and with many boards, there is no statute of limitations. The defence costs are enormous and as Lazarus says: “the biggest myth is that only those who have done something wrong are accused and only those who deserve sanctions get sanctions” (p. 153). The USA may (or may not) be an extreme case, but the prospect of complaints being tried on the adversarial battleground of a law court – where the subtleties of therapy are neither understood nor respected and where witnesses are treated as punchbags – would murder the therapeutic relationship.  I, for one would cease practising and never attend a therapist as client again.

In response to the pressure for compulsory registration of therapists in the UK and to provide an alternative to “the formal, top-down qualification basis of accreditations” with the UKCP or BACP, an Independent Practitioners’ Network was formed in 1994 (Totton 2006: 119).  It is organized in groups of five to ten practitioners, who process problems that arise in the work of group members. Each group produces its own ethical statement and must form links with at least two other groups. It sounds like an awful lot of work, but provides a genuine, rather than bureaucratic, basis for monitoring and support of the therapy enterprise. It encourages diversity of approach in its recognition that there are many ways of becoming an effective practitioner.

Therapy inc. or a counterweight to society?

Counselling and psychotherapy are beginning to espouse the values and practices of late capitalism: standardization, form over content, client as consumer, businessification, competitiveness and legalism. Bennett (2005:156) asserts that ‘the move to professionalization and the associated process of accreditation can be seen as part of the process whereby counselling and psychotherapy become normalized and lose their radical disengagement from the dominant culture which creates many of the symptoms their clients are struggling with’.  Both our actions as a body and the feelings from which they stem are at odds with our stated values and beliefs about therapy.  The vast majority of us purport to adhere to Rogers’ core conditions, we claim to believe in personal empowerment, authenticity and autonomy as some of the desirable outcomes of therapy.  But, what are we in fact modelling?  We have placed our future in the hands of those who understand nothing about what and have little respect for what we do – the medical, psychological and academic establishments and the government. We appear to be ready to cravenly accept, or even ask for inclusion into, establishments whose values are radically at odds with what we profess. To do this we become more and more instrumentalised in the way we treat clients, students and ourselves.; we permit the colonizing of our psyches with “coping strategies and a managed sense of self” (Bennett 2005: 157).  As David Smail says: “Psychotherapy is impossible as a profession, and can operate authentically only as a particular kind of human relationship” (in Bates 2006: 163).  It’s time we stopped the in-fighting and going cap-in-hand to the gentry; it’s time to take our future into our own hands. We should by now have matured beyond Kohlberg’s or Gilligan’s conventional stages of human ethical development to the post-conventional, and if we can’t take clients’ needs more seriously, we should at least care for our own souls. The essence of psychotherapy is self-interrogation and self-awareness, so who more than the therapy establishment should be better placed to challenge the pathologies of the society we inhabit. We must critique those values, not cravenly adopt them.

By now it will be apparent that I am in mourning for the human potential movement. We need to resurrect it.  Am I a voice crying in the wilderness, or is there anybody out there who will join me?

Barbara Dowds, Ph.D. IACP. is a psychotherapist in private practice, lecturer and member of the editorial board of Eisteach. She was formerly a university lecturer and researcher in molecular genetics.

References:

Bates, Y. (ed) (2006) Shouldn’t I be Feeling Better by Now? Client Views of Therapy.  Basingstoke: Palgrave Macmillan.

Bates, Y. and House, R. (eds) (2003) Ethically Challenged Professions …enabling innovation and diversity in psychotherapy and counseling.  Ross-on-Wye: PCCS Books.

Bennett, M. (2005) The Purpose of Counselling and Psychotherapy.  Basingstoke, Palgrave Macmillan.

Berman, M. (1984) The Re-enchantment of the World. Toronto: Bantam Books.

Gruen, A. (2007) The Insanity of Normality: Towards Understanding Human Destructiveness.  Berkeley: Human Development Books.

House, R. (2003) Therapy Beyond Modernity: Deconstructing and Transcending Profession-Centred Therapy.  London: Karnac.

House, R. and Totton, N. (eds) (1997) Implausible Professions: Arguments for Pluralism and Autonomy in Psychotherapy and Counselling.  Ross-on-Wye: PCCS Books.

McLeod, J. (2003) Doing Counselling Research (2^nd edition).  London: Sage.

Mowbray, R. (1995) The Case Against Psychotherapy Registration: A Conservation issue for the Human Potential Movement.  London: Trans Marginal Press.

Rowan, J. (2005) The Future of Training in Psychotherapy and Counselling: Instrumental, Relational and Transpersonal Perspectives.  London: Routledge.

Tarnas, R. (1991) The Passion of the Western Mind: Understanding the Ideas that have shaped our World View.  New York: Ballantine Books.

Totton, N. (2006) ‘The Institutions of Psychotherapy’ in N. Totton (ed) The Politics of Psychotherapy: New Perspectives.  Maidenhead: Open University Press.