Paper presented to the British Psychological
Society: Division of Counselling Psychology Annual Conference. University of Warwick. 11 July 2009
Our Rich Heritage –
are we building upon it
or destroying it?
Phil Mollon
[The views expressed here are the personal opinions of the author. It should not be assumed that any of his colleagues would share his views. Phil Mollon recognises that his own views, although sincerely held, may be mistaken]
A paradox haunts the
psychotherapy professions. Whilst talking therapies are ostensibly being
promoted within the NHS, Counselling (and Clinical) Psychology are being
destroyed. The rich and complex discourse of 120 years of psychotherapy, with
its attention to the nuances of individual experience, is collapsed into
comparisons of specific protocols for specific diseases. This trend currently
finds its zenith in the deeply malign NICE guidelines, which explicitly endorse
a medical model. Decades of deconstruction of 'mental illness' and examination
of the socio-cultural-political context in which mental distress evolves have
been discarded in a vulgar exuberance over favourable comparisons between CBT
and SSRIs. That psychologists, and the BPS, have colluded in this betrayal of
our professions through an endorsement of the crude medical model of NICE is
deeply puzzling - a phenomenon that itself deserves careful study. A further
paradox is that behind the tawdry glamour of IAPT and dumbed-down forms of CBT,
there are exciting developments that hold out the possibilities of real healing
of psychological distress.
Here is a vision of the
future, drawn from an editorial by Nick Totton in Psychotherapy and Politics
International:
"It was in 2023 that
‘traditional’ therapy and counselling finally became illegal under the new
Social Fraud Act, leaving New Therapy in command of the field. Looking back,
this had probably been inevitable since the state regulation of psychotherapy
and counselling…. once the state took on the job of policing therapy, its
definition of what was acceptable was bound to become increasingly draconian,
as therapy was adjusted to fit concepts and standards which the civil service
could comprehend and administer…. What happened to the discredited traditional
therapists? Some of them had been more or less underground since the later
2010s, changing their name to ‘psychological helper’, ‘emotional supporter’, or
some other dubious term, before this option was removed by the Act of 2023. A
very few served prison terms for illegal use of protected titles, or later for
illegal practice of discredited techniques. But the great majority either
silently retired or adapted to New Therapy – demonstrating, as the state saw
it, the feebleness and fraudulence of their practice: if they were not even
prepared to stand up for the value of their own work, then why should anyone
else take them seriously?....In 2025, of course, the Revolution began...."
(Totton 2008 p 1-2)
When I have read this to
colleagues, some have immediately understood and resonated with it, whilst
others have appeared puzzled, thinking it just sounded strange and paranoid.
My own original core
profession is clinical psychology. I feel counselling psychology is actually in
a healthier state and potentially more able to survive some very destructive
trends and forces that currently bear down – partly because of the humanistic
values that are at its heart, and partly because it is not dominated and owned
by the NHS and the government in the way that is the case for clinical
psychology.
Those who work within the
NHS will know, from tangible daily experience, that a huge agenda of control is
currently distorting therapeutic work with clients. It is dictated, in Stalinist
fashion, from the top – expressed through a variety of political mechanisms and
processes, including Improving Access to Psychological Therapies, current
commissioning procedures, but, above all, using the vehicle of NICE. It is my
perception that NICE is a most extraordinarily toxic and malign influence upon
psychological therapy in Britain. I have no problem with the idea of seeking
cost-effectiveness and for the rationing of limited resources – nor is my
concern that it recommends only therapies A & B and not C & D. The
problem with NICE is deeper and more insidious in its corrupting action – on
therapeutic practice and scientific discourse. It is an organ of the state that
consumes our psychological discourse, our rich heritage, our multifaceted gems of
brilliant theorising and observation around human nature and the human
condition, our charismatic and visionary pioneers – such as Rogers, Maslow,
Freud, Jung, Beck, Bowlby, Winnicott, Kelly – and homogenises all of this into
a bland and emotionally denuded prescription of CBT for everything. Within the
NHS we have a marketplace, where different providers compete – but it is not a
natural marketplace based on what services people wish to purchase. Instead it
is shaped by government targets, strange performance indicators, and
psychotherapeutic ‘products’ determined by NICE.
When I was a very young man,
back around 1974, training in clinical psychology, my behaviourally oriented
supervisor explained that he did not really find the concept of personality very
useful. He reasoned that people behave differently in different situations –
and that basic principles of learning theory indicate that behaviour is
determined by the reinforcement contingencies in the environment. BF Skinner
had outlined, in his novel Walden Two, his vision of a utopian society
organised on scientific behavioural principles, such that desirable behaviours
were reinforced and damaging behaviours extinguished through lack of
reinforcement. Today we have our government, through the vision of an
influential economist, promoting a different model of behavioural modification,
now based on training people to think differently.
My behaviourally oriented
supervisor was a friendly guy – a warm smile – he would convey empathy and
acceptance – explore people’s thoughts, feelings, and behaviours, suggest they
try out new behaviours – above all, he would be encouraging, rewarding his
students and clients for their stumbling efforts. He did not give his way of
working a fancy name.
However, some of the
behavioural thinking of the 60s and 70s seems in retrospect a mixture of the sophisticated
and the naive. It was a time when an electric shock box was standard equipment
for the clinical psychologist – and I recall being taught to apply this to a
lady with a nervous tic (it made her cry) and a young man who sexually
exhibited himself to children (I don’t think it helped). The shock box was also
used to ‘treat’ homosexuality (the lack of success gradually extinguished these
efforts). They could sound very scientific. For example, in the 1969 book
Aversion Therapy and Behaviour Disorders [by Rachman and Teasdale], in a
chapter on aversion therapy for sexual disorders, I found the following
equation used to account for the process:
E=H(D+K)
[where E is excitatory potential; H is habit
strength; D is drive; K is incentive motivation].
Before we laugh too much, we
might wonder how our colleagues of 50 years in the future might view our
present preoccupations and assumptions.
It was also during the 1970s
that a Chilean-born psychoanalyst in the US, Otto Kernberg, began to propose a concept of
‘borderline personality disorder. He presented some rather complex theorising,
based on Kleinian concepts of constitutionally elevated aggressive drive
combined with primitive defences, particularly splitting and projective
identification. This originally obscure and somewhat esoteric diagnostic
concept, created through an amalgam of South American Kleinian culture and
North American psychoanalytic ego psychology, has now become a commonplace
cliché (although its psychoanalytic roots are often forgotten). It is startling
to reflect on the shift, from the opposition to the notion of personality shown
by behavioural psychologists of the 70s to the ubiquitous concepts of personality
disorder and diagnostic categories that saturate the constructs of contemporary
cognitive-behavioural psychologists.
Now we are all regulated by
a body called the Health Professions Council – but are the psychotherapies
health care professions? In his monograph The Question of Lay Analysis [1926],
Freud wrote:
“Some
time ago I analysed a colleague who gave evidence of a particularly strong
dislike of the idea of anyone being allowed to engage in a medical activity who
was not himself a medical man. I was in a position to say to him: ‘We have now
been working for more than three months. At what point in our analysis have I
had occasion to make use of my medical knowledge?’. He admitted that I had had
no such occasion.” [p 255]
He goes on to add:
“Indeed,
the words, ‘secular pastoral worker’, might well serve as a general formula for
describing the functions which the analyst, whether he is a doctor or a layman,
has to perform in his relation to the public. [255-6]
Thus, Freud considered that
psychoanalysis is more a form of ‘secular pastoral work’ than a quasi-medical
activity. Freud’s first cases were those who presented with apparent medical
problems which turned out to be expressions of emotional distress and mental
conflict. They were to be resolved not by a medical intervention but by talking
– and particularly by talking to one who will listen
Part of the context for
Freud’s writing his paper on lay analysis was the resolution passed by American
analysts that the practice should be restricted to medical doctors. One might
reasonably surmise that such a resolution was motivated partly by concerns of a
financial nature and wishes to protect professional territory – and in the
1980s, the American Psychological Association successfully sued the American
Psychoanalytic Association for its refusal to train psychologists. However,
this medicalisation would also have helped foster the implicit idea that
psychoanalysts were ‘treating’ medical conditions – as opposed to engaging in a
‘secular pastoral’ activity. Medical treatment attracts higher status and fees
than pastoral work.
It seems to me that human
thought processes and attitudes are, to a greater extent than sometimes
appreciated, economically determined. The ways people think, and the views they
hold, are influenced, not entirely by a rational consideration of the evidence,
but by what is rewarding financially. Thus there are economic rewards, for
some, in espousing an implicit medical model even if its validity is dubious.
Similarly, those who harness their therapeutic products to certain statistical
and experimental methods, such as randomised controlled trials, may declare
that these are the ‘gold standard’ – an explicitly economic metaphor implying a
usurping of the fundamental standard of value against which all other
methodological currencies must be compared. This is done despite the otherwise
obvious point that one may often learn much more of clinical value from
detailed case studies.
Back in the 1950s, Hans Eysenck,
one of the first clinical psychologists in Britain, launched an attack on psychotherapy – and published
his famous study that appeared to show that the results of psychoanalytic and
other psychotherapies were no better than those of spontaneous remission. He
concluded:
Until
such facts as may be discovered in a process of rigorous analysis support the
prevalent belief in therapeutic effectiveness of psychological treatment, it
seems premature to insist on the inclusion of training in such treatment in the
curriculum of the clinical psychologist. [1952 Journal of Consulting Psychology, 16, 319-324.]
Slightly earlier, in 1949,
Eysenck had stated the Maudsley view of training in clinical psychology:
“It
is our belief that training in therapy is not, and should not be, an essential
part of the clinical psychologist’s training, that clinical psychology demands
competence in the fields of diagnosis and/or research, but that therapy is
something essentially alien to clinical psychology, and that if it is
considered desirable on practical grounds that psychologists perform therapy, a
separate discipline of Psychotherapist should be built up to take its place
alongside that of Clinical Psychologist.” [173]
Adding later in the same
paper:
“it
has been our experience that students who are interested in the therapeutic
side are nearly always repelled by the scientific flavour of research training,
while conversely, the students who are best suited and most successful on the
research side betray little interest in active therapy” [175]
The editor of a book of
Readings in Clinical Psychology [R.D. Savage], published in 1966, wrote of the
importance of “well standardised, valid, and reliable tests for diagnosis,
sound experimentally based techniques” and then adds “at the same time it must be
recognised that the task of the clinical psychologist is a difficult one,
because he has to confront patients … The Clinical Psychologist has to be in
contact with patients and this unavoidable complication complicates his work”.
This is not written in a tone of irony.
By contrast, looking at the
special edition of the Counselling Psychology Review of Feb 2006, celebrating
the first 10 years of the profession, I find Emmy van Deurzen describing
counselling psychology as characterised by a “commitment to an ideal of
psychology with a human face” [p 11] and by David Lane and Sarah Corrie as “a
value set that favours the personal and the subjective alongside scientific
values” [p 14], who also state that “At its core, counselling psychology
privileges respect for the personal, subjective experience of the client over
and above notions of diagnosis, assessment and treatment, as well as the
pursuit of innovative phenomenological methods for understanding human
experience.” - adding that “A move
towards a more medical model could threaten precisely those attributes that
make counselling psychology distinctive” [p 17].
Eysenck later promoted
behaviour therapy, based on Pavlov’s dogs and the model of neurosis in terms of
animal learning and classical conditioning. In the 1970s, the American
psychoanalyst Aaron Beck developed cognitive therapy (based on his listening to
his psychoanalytic clients’ free-associations).
This approach was subsequently joined with behaviour therapy to form CBT.
Whilst Beck’s approach was rooted in psychoanalysis, subsequent developers of
CBT have repudiated this link – and clinical psychologists have been attacking
psychotherapy ever since. It is like the left hemisphere attacking the right
hemisphere – denying the primary process creative communications of the
unconscious mind. In CBT, in its more simplistic and vulgar variants, the left
hemisphere of rational and logical thought is imposed on the right hemisphere.
Neurosis is replaced by thought reform. A temporary band-aid of positive
thinking, imbued with exhortations to ‘feel the fear and do it anyway’, is
applied over the deeper wound. Whilst cognitive therapy has a place, it does
not help to process emotional pain. I can think of several instances where I
have heard of a client being ‘challenged’ out of their emotional pain when
their presenting symptoms were obviously an expression of that pain – for
example, a young man with panic attacks, that had arisen as a result of his
attempts to suppress his grief about his mother’s death, being subject to
standard CBT for panic.
Over the last few years,
since the NICE guidelines in relation to mental health and psychological
therapies have gained in influence, I have often pondered how it was that
clinical psychologists, many of them seemingly intelligent and thoughtful
people, have colluded with the absurdity of the medical model on which the
guidelines are based. These are, after all, in the words of their mission
statement, guidelines for the treatment of ‘specific diseases’ within the NHS. However,
once again it is possible to see the underlying benefit financially and in
status. Those who claim to provide NICE-approved ‘treatments’ for psychological
‘diseases’ do indeed often appear to charge very high fees. There is money and
status to be made in marketing ‘treatments’. Compare the fees that tend to be
charged for CBT with those for psychodynamic or person-centred counselling –
even though the latter may have involved considerably more training and personal
demands. Counsellors do not usually market their services as treatments for
diseases - but practitioners of CBT can claim they are offering NICE-approved
treatments for anxiety, depression, and other diseases.
The medical model of
emotional distress becomes even more iniquitous when applied in court. I am
thinking particularly of family courts. Psychiatrists and psychologists are
drawn into pontificating on the ‘diagnoses’ and ‘prognoses’ of a mother, for
example, in the context of moves to have her child taken for adoption against
her wishes. One hears commonly of concepts such as ‘borderline personality
disorder’
being bandied about – these being used (misused) as predictive markers of the
mother’s future behaviour. Thus, in the discourse of the court room it may be
stated that a person has a diagnosis of ‘blah blah’ – as if this were closely
analogous to some real medical condition. Unfortunately, the impact on that
mother and her child may be all too real.
It is not difficult to see
the absurdly inappropriate nature of the disease model adopted by NICE when the
circumstances of real clients are addressed. Consider the following common
example. A single mother, living in a council flat in a tower block, is subject
to abuse by neighbours who play loud music all night, along with harassment by
drug users outside. She is anxious and depressed, seeing no easy solution to
her life’s difficulties. The NICE guidelines would recommend her ‘disease’ be
treated with either a Selective Serotonin Reuptake Inhibitor (SSRI
antidepressant) or with Cognitive Behaviour Therapy. These alternative
treatments are presented as if within a similar category of phenomena. Thus the
guideline on anxiety states:
“Any
of the following interventions should be offered
Psychological
therapy [CBT]; pharmacological therapy [SSRI], or if an SSRI is unsuitable or
there is no improvement, imipramine or clomipramine may be considered;
self-help bibliotherapy [based on CBT].” [abbreviated text]
Note that the notion of
‘disease’ and its quasi-medical treatment with either medication or CBT
forecloses a meaningful exploration of the client’s world. No doubt many CBT
practitioners would protest that this is not the case and that enquiry into the
client’s circumstances and experiences and inner mental world are all crucial
to their work. However, the NICE conceptualisation of the client’s problems as ‘disease’
inherently annihilates meaning and individuality by homogenising emotional
distress. Moreover, it implicitly reduces psychological therapy to a
standardised (manualised) product resembling a drug.
Are the clients we see
suffering from ‘specific diseases’ – the term used by NICE to describe their
remit? In
some cases the medical model has some relevance – where we are trying to help
people with the emotional aspects of physical illness, or where an underlying
biological condition is determining a person’s mental state. Moreover, some
states of mind may be abnormal enough to merit the term ‘ill’ – perhaps ones
which are beyond the scope of psychotherapy. Mostly, however, we are dealing
with people who are stressed by life events, adverse childhood experiences, and
developmental challenges. Mental health conditions, such as depression and the
various manifestations of anxiety, are essentially states of stress with
physiological concomitants. Early experiences of stress sensitize us to later
experiences and also lay down the templates for our characteristic ways of
trying to cope with stress and for our expectations of how others will respond
to us, Whilst there is certainly a place for science in all of this, along with
skills and knowledge from many other realms of human endeavour, there is
limited legitimate role for a medical disease model.
Richard Bentall, in his book
Madness Explained demonstrates persuasively that the Kraepelin-based diagnostic
system, which is still the basis of psychiatric classification today, has no
scientific validity. Whilst people can experience a variety of psychological
‘complaints’, in most instances, there is no underlying ‘disease’ causing
these.
In 1980, the DSM-III was
produced – a vast increase in size from the earlier DSM-II. The task force was
led by Robert Spitzer. He had been particularly concerned about the reliability
of psychiatric diagnosis since the famous 1973 study by the sociologist
Rosenhan called On being Sane in Insane Places. He had arranged for 8 non-psychotic
confederates to get themselves admitted to a psychiatric hospital by claiming
to experience a voice saying a single word (either ‘thud’, ‘hollow’, or
‘empty’). This was the only symptom presented. All were admitted to a hospital.
After admission they stopped feigning their experiences. All but one was given
a diagnosis of schizophrenia – the other was diagnosed as manic-depressive.
When they became asymptomatic, they were considered to be in remission. Once
admitted, they were not able to obtain release until they agreed with the
diagnosis of the psychiatrists and took antipsychotic medication. Since the
reaction of the psychiatric establishment was disbelief, Rosenhan followed this
up by informing the staff of a teaching hospital, where it had been claimed
that such misdiagnosis could not happen, that over the next three months one or
more pseudo-patients would attempt to be admitted. No such attempt was made –
but out of 193 patients, 41 were considered by staff to be pseudo-patients and
a further 42 were suspected of being. Therefore Rosenhan concluded that
psychiatric diagnosis is subjective rather than reflecting inherent disease
characteristics. Spitzer, heading the DSM-III task group had been one of the
main critics of the Rosenhan study. He sought to establish clear rules for
diagnosis – thus focusing on reliability but ignoring the point that validity of psychiatric diagnosis was in
question.
Trauma specialist Dr. Colin
Ross, drawing on his experience of serving on DSM committees has written of the
ad hoc and non-scientific way in which psychiatric diagnostic categories are
developed. Speaking at the Cardinal
Clinic trauma conference last year, Dr. Ross pointed out that patients often
display a range of psychiatric conditions – for example, a person may have a
personality disorder, OCD, phobias, PTSD, somatic disorders, and depression
(and other possibly other conditions). This co-morbidity is so common that it
seems statistically highly unlikely that the various psychiatric conditions are
truly independent categories of disease. Many of them would at one time have
been collectively described as ‘hysteria’. Dr. Ross argued that most
psychiatric symptoms can be understood as different forms of dissociation,
showing either intrusion or withdrawal. Thus traumatic flashbacks,
hallucinations, OCD, thought insertion etc. are all forms of intrusion.
Amnesia, numbing, thought withdrawal, negative symptoms of schizophrenia etc.
are all forms of withdrawal. The content and type of intrusion or withdrawal
determines the disorder category. One recurrent observation was that when a
person with DID achieves integration, their previous OCD disappears. Linked to
this, he pointed out that when a person is in the grip of OCD, he or she is not
in an adult state of mind but is like a child in an overwhelmed ego state,
engaging in magical thinking as a means of controlling anxiety. He suggested
that SSRIs function to increase dissociation (and referred to research
indicating that the purported serotonin reuptake inhibition explanation is
spurious). Elaborating on his theme, he concluded that patients collectively
would have a good legal case for class action for malpractice against the
psychiatry profession on the grounds of the non-scientific and often harmful
nature of its procedures.
Some forms of mental
disturbance do have illness qualities. One of the toxic effects of NICE is to
encourage an assumption that we understand all forms of mental illness and know
how to treat them. This is not the case. Whilst some states of distress do
respond well to various approaches, I have worked in psychiatric settings long
enough to know there are many people whose disturbance is profound, complex,
and intractable. These seem to involve malformations of the psyche – horrendous
and replicating – analogous to physical forms of cancer – but we cannot just
remove the tumours. There is no question that such people are mentally or
personally ill – yet, as with physical cancer, the cause may be unknown and
many factors may be involved. They do not easily fit conventional diagnostic
categories. We are far from being able to understand or treat such conditions. We
may have to wait for the emergence of some, as yet entirely unknown, new
paradigm. Admitting our ignorance at least enables us to be open to new
observations and perspectives.
When reading accounts of
rcts, it is easy to slip into assuming that statistically significant change
means that people actually resolved their psychological difficulties. Whilst
for some people this fortunate result may have occurred, it is not the case for
most participants in psychotherapy trials. The sobering truth is stated by
Westen et al (2004), as follows:
“…
the existing data support a more nuanced and, we believe, empirically balanced
view of treatment efficacy than implied by widespread use of terms such as
empirically supported, empirically validated, or treatment of choice …
With
the exception of CBT for panic, the majority of patients receiving treatments
for all the disorders we reviewed did not recover. They remained symptomatic
even if they showed substantial reductions in their symptoms or fell below
diagnostic thresholds for caseness; or they relapsed at some point within 1 to
2 years after receiving ESTs conducted by clinicians who were expert in
delivery of the treatment, well supervised, and highly committed to the success
of their treatment of choice” [p615]
Commenting on the huge NIMH
Collaborative Research Program, comparing CBT, IPT, medication, and placebo,
they conclude:
“Despite
a promising initial response, by 18 months posttreatment, the outcome of brief
psychotherapy was indistinguishable from a well-constructed placebo” [p599]
Similarly, Hollon et al.
(2002) conclude:
“Despite
real progress over the past 50 years, many depressed patients still do not
respond fully to treatment. Only about half of all patients responded to any
given intervention, and only about a third eventually meet the criteria for
remission. Moreover, most patients will not stay well once they get better
unless they receive ongoing treatment.”
[p70]
For the most part, our
mainstream psychological therapies, including CBT, are not clinically effective, in the sense of reliably and
predictably eliminating all the manifestations of psychological dysfunction.
One of the problems with the
narcissistic state of mind – detectable by signs of complacent and
unquestioning satisfaction with one’s state of knowledge – is that it does not
tolerate the sense of ignorance. The narcissistic stance assumes it has the
truth – or identifies with some group or organisation that it assumes has the
truth. It then wishes to impose this truth on others. As a character trait, and
if combined with a certain intellectual aptitude, this stance lends itself well
to attaining positions of power and influence within the ‘establishment’. The
result is a powerful block against genuine enquiry, creativity, and depth – and
indeed against full empathy with other’s distress and tolerance of ambiguity –
all factors that are necessary for the effective psychotherapist. I perceive many
of the trends I am speaking of to be expressions of this.
NICE regards states of
distress as ‘specific diseases’ for which it recommends evidence-based
‘treatments’. Yet one of the most consistent findings in several decades of
psychotherapy research is the so-called ‘equivalence paradox’ – that when bona fide
therapies are compared with each other, in randomised controlled trials, they
are more or less equally effective.
Similarly, when naturalistic therapies are compared, there is little difference
between them – e.g. the Stiles et al. 2006 study of 1309 patients at 58 NHS
sites, comparing Person-Centred, CBT, and Psychodynamic therapies. There is no
substantial evidence that CBT is more effective than other forms of therapy. However,
there is substantial evidence that
some therapists are more effective than others – this effect size is greater
than that between therapies.
I think there is one clinically
obvious ingredient that does seem important for effective therapy: where there are
anxiety and/or traumatic stress reactions, maintained by avoidance, these need
to be desensitised through exposure (whether in vivo or in imagination or
through accessing memories). Ordinary CBT seems to do this the hard and least
effective way; EMDR often does it quicker; and the mind-body energy psychology
methods are often even quicker and also gentler. Note that in the Foa study of
CBT for PTSD, the manual for the comparison supportive therapy instructed the
therapist that if the patient began to talk about the trauma, he or she should
be guided to talk of everyday activities – thus ensuring that this crucial active
ingredient was removed from the control. All the other common ingredients are
found in all effective therapies: taking an interest in the client; enquiring
holistically about his or her life, loves, hopes and fears; providing empathy;
discussing problems; exploring thoughts and emotions; enabling shame-laden
thoughts and feelings to be talked of in a non-judgemental atmosphere; considering
alternative perspectives – and so forth. It would be surprising if a person did
not experience some benefit from such experiences and activities. A visit to a
chiropractor would also provide much of this. The now routine ritual of filling
out a CORE questionnaire or similar is also experienced by some clients as
reassuring – and as providing a helpful external calibration of their state of
well-being.
I sometimes enjoy showing
people a DVD
of Aaron Beck conducting cognitive therapy – and asking them who they think it
is. Some think he might be Carl Rogers. Rarely do people assume it is Aaron
Beck (unless they have seen images of him). CBT therapists think he is not
doing CBT. He listens carefully, does not particularly structure the session,
makes simple enquiries about the client’s life and experience, occasional
empathic comments, explores the client’s thoughts, and invites the client to
consider small manageable goals and to agree on what she might do before the
next session. When he first asks her what she wishes to address she says her
marriage. He tells her this is too big a topic and asks her to think of a
smaller issue to work on – they eventually agree she might explore going
bowling. In another recording – of Beck interviewing a patient with anxiety –
he enquires about the details of her fears (of being attacked and rendered
helpless), identifies also her fears of envious attacks and criticisms by
others (her fears had intensified as she became more successful in her work as
an artist), elicits her beliefs that she must be perfect in order to be loved,
and explores the childhood origins of these in her efforts to cope with having
an alcoholic mother and the unrealistic demands of her father. Both of these
examples demonstrate skill and subtlety in Beck’s approach – but much of what
is displayed can be found in other approaches. The ‘branding’ and marketing of
psychological therapies, whilst understandable (especially within the US capitalist health care system), is scandalous –
particularly where it is done so in a disguised way within the UK. Marketing, and the pursuit of public funds, are the
prime motives, but these are hidden behind pseudo-scientific discourse. People
are making money out of NICE.
Consider the following
comment by Isaac Marks:
“Even the most tightly
researched psychotherapies … have a tangled thicket of components. Take ‘CBT’
for panic. Its components differ hugely from one therapist to another, with
varying mixtures of: relevant exposure (diverse forms of which have over 65
labels); interoceptive exposure (stress immunisation); cognitive restructuring;
slow, deep breathing; relaxation; diary keeping; particular homework; family
work; reward for progress; getting a treatment rationale; and expecting to
improve. One therapist may use a bit of this, a lot of that and none at all of
a third component from the list. Another might give none or all of those three
components in equal proportion. Yet all therapists call their method CBT.”
[Marks 2002 p 200]
And consider Beck himself:
“A comparison of
psychoanalysis with cognitive therapy indicates a substantial area of overlap.
In both therapies the patient is asked to make introspective observations
regarding his thoughts, feelings, and wishes, and to report them … both forms
of therapy are insight therapies… The therapist attempts to delineate basic
patterns that may account for a diversity of emotional reactions and
maladaptive overt behaviours. Both cognitive and psychoanalytic therapy are
concerned with uncovering the meanings people attach to their environment, to
other people, and to internal experiences.” [Beck, A. 1976. Cognitive Therapy
and the Emotional Disorders. Penguin 1989]
And again:
“The concepts of
transference and early childhood experiences turned out to be crucial in
understanding the personality disorders.” [Beck, A. 2005 p 955]
And
at last year’s annual conference of the American Psychological Association,
Beck emphasised the role of empathy, saying that some of his past students who
lacked empathy had been unable to become effective therapists – they had been
‘duds’, he said – although they could be effective researchers.
In
the light of such comments, by such eminent exponents of CBT, what sense does
it make to think in terms of rigidly demarcated approaches? Is not
‘integrative’ the only sane position?
It is rather as if a paint
manufacturer decided to test whether their green paint actually succeeded in
creating a surface perceived as green – and so they prepared their paint,
commissioned a specific paint roller, prepared a manual on how to apply the
paint, the direction of strokes, amount of paint on the roller, how many coats
to apply and how frequently etc – trained their research team in the method –
specified the kind of wall that was to be used in the study - used two control
conditions, one in which a wall was simply left unpainted and another in which
the precise same procedure was followed but instead of paint the applicators
used water. Then a large sample of randomised subjects was asked to rate,
before and after the intervention, whether the walls appeared green. Having
established that their painting system – Liquid Base Coating [TM] – did succeed
in creating an increase in perception of green amongst their respondents
significantly greater than in the two other conditions, the manufacturer seeks
to persuade the government that the whole area of professional painting is a
mess – many different manufacturers producing paints, using different
ingredients, with a wide variation in price, applied by diverse practitioners,
some well trained and some minimally so – and that a review of the
evidence-base for painting is required, particularly when the paint is to be
applied in public buildings [and it had increasingly been noted that many
public buildings were in need of painting]. A new agency – the National
Institute for Painting Excellence [NIPE] is set up. On reviewing the data, they
find that only the system called Liquid Base Coating has been demonstrated, in
properly designed studies, to be effective. Accordingly they state in their
guidelines that LBC is to be used when walls show a deficit in green –
practitioners must use the protocol that was demonstrated in the study to be
effective, with the specially designed roller and the guidelines for how the
paint is applied. With the combination
of NIPE and clever marketing, people soon begin to believe there is something
special and unique about the LBC system. The company begins to train people to
use its system – then licenses trainers to train others. Gradually the old
craftsman painters went out of business, unless they paid to undertake the
special trainings in LBC and became accredited by the British Association of
Base Coating Professionals [BABCP]. Of course different studies and trainings
were required for all the different colours. In response to these pressures,
the other paint manufacturers felt obliged to create their own trademarked
systems and to subject these to the same rigorous testing in well designed
randomised double blind studies. Gradually NIPE began to recognise a range of
approved systems – with the advantage to manufacturers that they could
advertise their products as NIPE-approved. In this way the provision of
painting was advanced beyond it’s more primitive ‘craft’ stage, with great
variation in quality and style, to that of an industrialised and standardised
procedure. Of course there were some painters and decorators of the old school,
who had learned their skills prior to the development of the new scientifically
validated systems, often partly in an apprenticeship mode, but these were
increasingly regarded as simply behind the times. [recall my behaviourally
oriented supervisor]
The branding and marketing
of psychological therapies is driven by commercial motives, not by science. It
seems to me obvious that the different therapeutic approaches – including
cognitive, behavioural (with its classical and operant conditioning), psychodynamic,
systemic, neurobiological, and the body-mind interface therapies, and so on –
all capture and address important aspects of a complex whole. We need as many
perspectives as we can … because what we do is not yet good enough!
What of more positive
developments? There have been a number. In the 1980s we began to understand
trauma – and by the early 90s we were gaining some awareness of the
neurobiology of trauma. Allan Schore suddenly emerged from nowhere, with his
astonishing synthesis of neurobiology and attachment perspectives, showing how
the developing brain is shaped by interpersonal experience – and since then the
Bowlby perspective has gone from strength to strength. In the late 80s, EMDR
was developed – arguable the first effective treatment for trauma. From EMDR we
learned how traumatic experience is networked and layered through the
psychosomatic system. We began to appreciate the hitherto neglected realm of
the body – not only through having the client engage in active bodily
stimulation but also by routinely incorporating questions such as ‘where do you
feel it in your body?’ For decades, psychologists and psychotherapists had
operated with the implicit delusion that the mind could be separated from the
body – and would attempt to engage the client in a purely mental discourse – as
if oblivious to the obvious fact that emotions are, in large part, bodily
events. Of course the cerebral nature of many psychologists helped sustain this
illusion. In recent years, the embodied brain and psyche are much more in
evidence in theorising and in psychotherapeutic practice. Many forms of
body-mind therapies have evolved, including sensori-motor therapy – and the
broad genre of energy psychology,
this latter being a field that I have been passionately immersed in for nearly
ten years. In the energy psychology family of approaches – my own contribution
being called Psychoanalytic Energy Psychotherapy –
we engage in all the processes commonly found in cognitive, behavioural, and
psychodynamic therapies, but in addition we incorporate guiding the client to
stimulate their body’s energy system where the dysfunctional information is
stored. This allows for rapid, deep, and gentle change. The details are too
complex and subtle to present here – but it is an example of the value of
continuing to explore and integrate. Such therapies have been endorsed by
neuroscientist and trauma specialist Besel van der Kolk, who has long argued
for the need to engage with deeper parts of the brain and body than the verbal
and cerebral.
Whilst psychoanalytic,
humanistic, and cognitive-behavioural traditions have all contributed important
elements that are needed for an effective response to psychological distress,
it is arguably the recognition of the role of trauma in mental life - its
neurobiological and physiological effects - and its possibilities of
healing, that enable psychotherapy to become truly transformative. From PTSD to
'personality disorder', trauma is the key to understanding and healing. Whilst
some therapeutic modalities facilitate the tracking and healing of trauma,
there are others (such as mentalisation-based psychotherapy) that explicitly
advocate against attempting to address childhood trauma directly. Here we have
a recurrent tension - between those who aim to help the processing and
healing of trauma, and those who seek to help the client acquire new
behavioural and mental skills.
Returning to the lawsuit
between the American Psychological Association and the American Psychoanalytic
Association, Richard Simons, president of the Psychoanalytic Ass at that time,
provided some interesting comments that may have relevance to all of us in the
psychotherapeutic professions. Writing of the tendency for analysts to idealise
their theories, techniques, and organisations – a weakness that other
psychological groups may also display – he comments:
“I
think at least some of us may have forgotten what we analysts have in common
with other human beings. We all have night dreams every night. We all have day
dreams every day. We all defecate and urinate every day, and some of us
(pregnant women and older men) urinate at night as well. We all experience
heartache and loss throughout our lives, as well as recurrent, unfulfilled
masturbatory fantasies and other highly organised unconscious fantasies that
form the core of many or our night dreams and day dreams. And on one of those
days or nights, each one of us is going to die. … What a shock it is when we
discover that all of us are really in the same boat, taking the same existential
journey, working our way rapidly or more slowly to the same end … Ideals can
help us immeasurably along the way, but idealisations are ultimately never very
trustworthy in enabling us to give up our grand illusions of perfectibility and
immortality”. [Simons 2003 p270]
It is common for both
clients and therapists unconsciously to view psychological therapies as
providing solutions, or alternatives, to the pains and uncertainties of life,
and a sense of truth and meaning to counter our ignorance and bewilderment. At
one time psychoanalysis was seen as the answer – then Watson’s behaviourism,
along with Skinner’s operant conditioning and his Walden Two vision – and
currently it is CBT, along with rcts and certain kinds of statistical methods.
Along the way we had Orwell’s nightmare vision of a mind-controlled society in
his novel 1984, as well as the experiments with communism, National Socialism,
and monetarism. Our idealisations become narcissistic prisons – restricting our
capacity to enquire and explore. We should see psychological therapies as culturally
shaped attempts at providing some modest alleviation of human distress, with
some limited sphere of application, perhaps helping to release us, as Freud put
it, from ‘hysterical misery to ordinary unhappiness’ [1895 p 305]. And we must
keep searching for better, more effective, and faster ways of doing so.
References
Beck, A.T. 1976. Cognitive Therapy and the Emotional
Disorders. Penguin. 1996.
Beck,
A.T. 2005. The current state of
cognitive therapy. A 40 year retrospective. Archives of General Psychiatry. 62.
9. 953-959
Bentall,
R.P. 2003. Madness Explained. Penguin. London.
Cooper,
M. 2008. Essential Research Findings in Counselling and Psychotherapy: The
Facts are Friendly. Sage. London.
Eysenck, H. 1952. The
effects of psychotherapy: an evaluation. Journal
of Consulting Psychology. 16. 319-324
Eysenck, H. 1949. Training
in Clinical Psychology: An English point of view. American Psychologist. 4. 173-177
Freud, S. 1926. The question
of lay analysis. Standard Edition of the
Complete Psychological Works of Sigmund Freud. XX. Hogarth. London.
Hollon, S.D. Thase, M.E. & Markowitz, J.C. 2002. Treatment and prevention
of depression. Psychological Science in
the Public Interest. 3. 39-77
Kernberg, O. 1975. Borderline Conditions and Pathological
Narcissism. Aronson. New York.
Marks,
I. 2002. The maturing of
therapy. British Journal of Psychiatry. 180. 200-204
Mollon,
P. EMDR and the Energy Therapies. Karnac. London.
Mollon, P. Psychoanalytic Energy Psychotherapy.
Karnac. London.
Mollon, P. 2009. The NICE
guidelines are misleading, unscientific, and potentially impede good
psychological care and help. Psychodynamic
Practice. 15. [1] February. 9-24
Rosenhan, D.L. On being sane
in insane places. Science. 179 [70]
250-8
Ross, C., & Pam, A.
1996. Pseudoscience in Biological
Psychiatry. Wiley. Chichester.
Ross, C. A. 2008. The Great Psychiatry Scam. Manitou
Communications.
Ross, C. A. & Pam, A.
1995. Pseudoscience in Biological
Psychiatry. Blaming the Body. Wiley. New York.
Simons, R.C. 2003. The lawsuit revisited. Journal of the American Psychoanalytic Association. 51 S 247-271
Stiles, W.B., Barkham. M.,
Twigg, E., Mellor-Clark, J., & Cooper, M. 2006. Effectiveness of cognitive
behavioural, person-centred, and psychodynamic therapies as practiced in UK
National Health Service settings. Psychological
Medicine. 36. 555-566
Totton, N. 2008. Editorial. Psychotherapy and Politics International.
6 [3]
1-2.
Westen, D., Novotny, C.M.,
& Thompson-Brenner, H. 2004. The empirical status of empirically supported
psychotherapies. APA Psychological Bulletin, 130(4) 63.
See
Beck’s account in his 1976 book Cognitive Therapy and the Emotional Disorders,
pages 29-35, in which he describes the moment when he became aware of a more
hidden stream of thought behind the client’s reported free-associations.
[Penguin Edition 1991]
Ross and
Pam, in their book Pseudoscience in
Biological Psychiatry [Wiley 1995] comment:
“Many women who exhibit intense emotions (especially
anger), mistrust authority, and have difficulties with relationships, receive
the diagnosis borderline personality disorder, and a great deal of medication
that doesn’t help, when their symptoms are caused by childhood trauma. These
women become more powerless and silent as a reaction to invalidation, blaming,
and the victimization they encounter within biological psychiatry.” P 223.
The medical model attitude often remains the same when
a seemingly psychological perspective is offered. A ‘prognosis’ is made and
psychological therapy of some NICE-approved variety is ‘prescribed’.
NICE purports to offer clinical guidelines
concerning: “The appropriate treatment and care of people with specific
diseases and conditions within the NHS”.
This somewhat hidden statement is found on the ‘What we do’ section of
the NICE website www.nice.org.uk, where
it explains their three ‘centres of excellence’. The Centre for Clinical
Practice produces the guidelines: “The Centre for Clinical Practice
develops clinical
guidelines. These are recommendations, based on the best available
evidence, on the appropriate treatment and care of people with specific
diseases and conditions”.
The best
general account of psychotherapy research findings is Cooper 2008
A great
deal of valuable information regarding psychotherapy research along these lines
can be found at www.talkingcure.com
Cognitive Therapy of Anxiety and Panic Disorders: First Interview Techniques.
Beck Institute. 1985
www.energypsych.org
Cognitive Therapy of Depression: Hopelessness (patient interview). Beck
Institute. 1979
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