The United Kingdom Council for Psychotherapy (UKCP) shows sudden signs of pulling back from the brink it has been staggering towards for the last while. A final stagger might still result in catastrophe, but there has been a kind of positive mood swing.

Following a recent election, Prof. Andrew Samuels will become chairman of the UKCP from 2010. Samuels is a founder member of the Alliance for Counselling and Psychotherapy Against State Regulation, and a determined opponent of state-controlled psychotherapy.

The catastrophe that might yet be avoided is domination of psychotherapy by government-appointed bureaucrats, leading to criminalization of any kind of therapy that government does not approve, and extensive use of therapy techniques to enforce government social policy.

A video message

In a powerful public response to personal attacks on him by Marc Seale, Chief Executive of the government’s Health Professions Council (HPC) quango, Samuels has published a video message. In it, he notes that the HPC’s:

…standards for registration are scandalously low…

‘Regulation’ by the HPC will certainly not protect the public.

Furthermore, he sees the HPC’s proposals as in effect redefining the meaning of the word ‘psychotherapy’, so that it no longer refers to the work that Samuels engages in with clients. Therefore, he argues, it would make no sense for him to register as a psychotherapist according to this altered definition, and he does not plan to do so.

Here’s the video message, (only about 3½ minutes long):

CBT

The present government’s flagship (but increasingly troubled) Improving Access to Psychological Therapies (IAPT) programme is another of Samuels’ targets. As IAPT’s main focus is on what it calls CBT, Samuels tends to take a dim view of CBT generally. However, he’s far from completely daft, and he seems to have some kind of lurking intuition that CBT is not all bad.

There is a sound recording of a rambling lecture in which he touches on the subject. Unfortunately the sound quality is poor, and the content difficult to interpret. At one point he quotes someone on the subject of CBT, expressing some agreement with the point of view, but I was not able to identify the author or the book (26:12):

…in an amazing piece of polemical writing, [he] tries to nail the distortions of a typical CBT relationship as mechanical, controlling of the client, therapist-led and hence abusive of power, normative, and so on and so forth…

Here’s the lecture:

What’s wrong with CBT?

Criticisms

There are really only two closely related criticisms in that quote, both of them criticisms of what I have called ‘fake CBT’. A mechanical approach is certainly favoured by some trainers and therefore by some practitioners, and I suspect it is particularly favoured within IAPT. It goes hand-in-hand with a therapist-led approach, which aims to control and normalize clients by using the therapist’s power over them, and that could be considered abuse.

Real CBT, in contrast, is personal and collaborative. It puts patients back in charge of their own emotions and inner lives, freeing them to pursue their own goals.

In 2007 Samuels clashed with the then president of the BABCP, Prof. David Veale. In the lecture he refers to this clash (19:33):

I think the president of the [BABCP] might have had his tongue in his cheek when he told me in our published written disputation that, quote, “The only reason why the NHS plans to expand the delivery of CBT is because it is empirically grounded. This is what keeps us in good stead.”

And he goes on without a blush I’m sure being [?] ironic, quote, “Being empirically grounded guides us in deciding which approach will help our clients function and return to their roles as a parent, partner, worker, and full member of the community.“

Samuels seems to understand well that to be a sane person is not simply the same as functioning in a social role determined by government, and also to understand the severe limitations of research evidence in mental health as a way of grounding anything. These are signs of hope for the UKCP.

On the other hand, he seems to find it difficult to articulate his understanding with clarity, preferring to make vague and somewhat emotionally loaded statements instead. For example, it’s pretty clear to everyone who has encountered David Veale that he does not make statements like that tongue-in-cheek or ironically — he really does have an uncritical and simplified view of the world and of CBT (as anyone can easily verify by reading the descriptions of CBT on his website). Any lack of clarity by Samuels, and any tendency to evade unpleasant truths, are signs of danger for the UKCP.

A subtle political problem

There’s a subtle political problem for anyone who wants to provide leadership in the psychotherapy world. It’s that the great political divide in UK psychotherapy is unreal. The divide between CBT and all the rest does not make sense in terms of outcomes for patients.

In both camps there are competent therapists who have the skills to help mentally ill people, but in both camps there are also incompetents, and some of the incompetents are well-organized. So Samuels needs to colour the political map of psychotherapy in a different way, if he’s to make a significant difference to the political outcome.

He needs to get real CBT therapists strongly aligned with him, on the basis that CBT is one of many therapeutic orientations that are effective ways to improve patients’ lives. I think he would be amazed how many BABCP members would support him in this, if he were to articulate it clearly.

But at the same time he needs to distance himself from so-called therapists whose methods and goals are anti-therapeutic. This is easy in the case of IAPT form-fillers whose goals are to support government social policy, but it is challenging in the case of those who profess other orientations within the UKCP and whose goals are, for example, the pursuit of personal power.

It’s unlikely I’ll agree with everything Samuels does in his term of office, but nevertheless I wish him luck unconditionally. He’s a man who thinks deeply and speaks his mind. Psychotherapists deserve such leaders as him, not to be the puppets of nameless quangocrats.

There’s a way of doing psychotherapy that’s known as integrative, because it is supposed to integrate other ways of doing psychotherapy. You get the best of them all that way…or do you?

The various different approaches to psychotherapy are known as orientations, an innocent-sounding word that makes it seem they are just different ways of looking at the same thing, different points of view. When you look deeper, though, there are deep and irreconcilable differences between the various orientations.

The orientations

While different orientations do have some elements in common, it’s because of their irreconcilable elements that they have separate bands of followers and separate jargon. The key question is whether the common elements alone are sufficient to deliver effective psychotherapy. If the common elements are sufficient, then an integrative approach would work. But if the irreconcilable elements are essential to effective psychotherapy, then an integrative approach cannot work.

It’s difficult to know which orientations to consider, because there are so many, so I’ll use a loose interpretation of the list of talking therapies provided by SANEline: Talking Treatments

The SANEline list is not really a list of orientations, though. It starts with Counselling, which I’ll reinterpret as person-centred therapy. Towards the end of the list you’ll see Group therapy, Relationship counselling and family therapy, Support Groups and Self-help groups, but these are not orientations at all because they do not have their own separate views of how therapy works.

So, together with person-centred, that leaves CBT, mindfulness and psychodynamic approaches to consider. Four orientations — can they be integrated?

Common elements

The common elements of the orientations are mostly trivial. For example, the therapist generally sits on a chair. Therapy involves a lot of talking, and strong emotions can be expressed. Therapy happens in regular planned sessions that have a time limit. It’s private and confidential. I could go on listing things like this, but none of them gets to the heart of what psychotherapy really is.

A little closer to the heart of the matter, there are three qualities of psychotherapy commonly known as the ‘core conditions’. They are derived from the work of Carl Rogers, whom I mentioned recently in The list.

The third of the core conditions is briefly summarized as ‘empathy’. Here’s how Rogers described it in On Becoming a Person, Chapter 4:

When the therapist is sensing the feelings and personal meanings which the client is experiencing in each moment, when he can perceive these from “inside,” as they seem to the client, and when he can successfully communicate something of that understanding to his client, then the third condition is fulfilled.

But the other two core conditions are more problematic, because some orientations rule them out.

Person centred

The person-centred or humanistic orientations are the most directly related to the work of Carl Rogers, so all three of the core conditions generally apply. The other two conditions are briefly summarized as ‘genuineness’ and ‘warmth’.

Rogers describes genuineness as (original emphasis):

…when the psychotherapist is what he is, when in the relationship with his client he is genuine and without “front” or façade, openly being the feelings and attitudes which at that moment are flowing in him.

And warmth:

It means that the therapist cares for the client, in a non-possessive way. It means that he prizes the client in a total rather than a conditional way… It means an outgoing positive feeling without reservations, without evaluations.

Person-centred theory is based on the observation that when a patient becomes aware of these three qualities in the therapist, an inner change starts to take place in the patient. The change is not directed by the therapist (which gives rise to the description ‘non-directive’ for this kind of technique), but instead is self-directed by the patient.

I’m going to take this kind of psychotherapy as the baseline and examine how well other therapies integrate with it. It’s an arbitrary choice of baseline.

CBT

CBT is very closely related to person-centred therapy, but with one tiny difference. The difference lies in the last two words of the quotation above: “without evaluations”

Suppose a therapist incorporates all three core conditions in his relationship with patients, including unconditional non-possessive warmth, but he ignores those last two words. Evaluations become possible. However, with the therapist making evaluations, the therapy ceases to be non-directive. The patient’s progress in therapy is no longer completely self-directed, but instead is directed in collaboration with the therapist.

Aaron T. Beck, the principal originator of CBT, described the collaboration like this in Cognitive Therapy and the Emotional Disorders, Chapter 9:

It is useful to conceive of the patient-therapist relationship as a joint effort. It is not the therapist’s function to try to reform the patient; rather, his role is working with the patient against “it,” the patient’s problem… Investigators…have found that if the therapist shows the following characteristics, a successful outcome is facilitated: genuine warmth, acceptance, and accurate empathy.

So CBT is fundamentally irreconcilable with the person-centred approach, even though they have a huge amount in common. A therapist must decide in advance whether the patient directs the course of therapy or it’s a joint effort. There’s no in-between. It’s one or the other. Integration is not possible.

Psychodynamic orientations

Several orientations are known as psychodynamic because they are based more or less on Sigmund Freud’s theories about psychological energy. (‘Dynamic’ originally meant having to do with energy, although in modern everyday usage it tends to have a different meaning.) There are many variations on how to go about doing therapy using these theories, and thus there are many psychodynamic orientations.

In order to adapt Freud’s theories for use as therapy, psychodynamic therapists create a very unusual environment for their patients. The intention is that the therapist observes the patient’s use of psychological energy, and helps the patient to interpret it. The patient gains a deep understanding and insight into their own thoughts, feelings and unconscious drives, and uses that insight to resolve any problems that they have.

To make this work, the therapist must not interfere by interacting in ways that would distort flow of the patient’s psychological energy. For example, a psychodynamic therapist is frequently silent, expressionless and unresponsive to the patient, forcing the patient to conduct the session as if alone (even though the therapist is physically present in the room).

That’s why I wrote, above, that the therapist sitting on a chair is a common feature of psychotherapies. The patient sitting on a chair is not — in classical psychoanalysis, one of the psychodynamic orientations, the patient lies on a couch so that the therapist can abstain from human interaction.

Integration with other orientations is a problem, because the therapist’s withdrawal from being a fully-interacting person in the therapy sessions conflicts directly with Rogers’ first two core conditions, the ones I summarized briefly as ‘genuineness’ and ‘warmth’.

Being warm and genuine towards a patient destroys any possibility of psychodynamic work. Failing to be warm and genuine towards a patient destroys any possibility of using any other orientation. This makes psychodynamic orientations impossible to integrate with other orientations. There is an irreconcilable conflict.

Mindfulness

Mindfulness summarizes a wide range of what are known as ‘third-wave’ behavioural approaches to psychotherapy. They include DBT (‘dialectical behaviour therapy’), MCBT (mindfulness-based cognitive behaviour therapy), and many others.

The ‘first wave’ of behavioural approaches focussed on observable behaviours. It was based on the idea that if you can change someone’s behaviour, then their mind will look after itself. In other words, if you can simply ‘act normal’, then your thoughts and emotions will fall into line. My phrase ‘act normal’ belittles behaviour therapy unfairly — there’s a huge quantity of technique and theory available to behaviour therapists. Nevertheless, there is a sense in which it is not psychotherapy at all, because it does not work with the mind directly, so there is some justification for its omission from the SANEline list.

The ’second wave’ of behavioural approaches is what I tend to call ‘fake CBT’ in this blog. It’s not worth serious consideration.

The ‘third wave’ employs a behavioural approach to the mind. That is, it teaches patients to control their own minds in the same kind of way that they control their own behaviours. What really happens is that patients learn to split their consciousness into two parts. One part, the mentally ill part, remains mentally ill in the background. The other part, the mentally well part, becomes the dominant part in the patient’s consciousness.

The patient’s split-off mentally well consciousness observes the mentally ill consciousness with a kind of detachment. This detached observing of oneself is known as ‘mindfulness’.

In these third-wave approaches, and indeed in all the behavioural ‘waves’ the therapist is really a trainer. Like CBT, behavioural approaches discard the non-directive quality of person-centred approaches. But they go further than CBT, because the therapist/trainer has an evaluative role that is not collaborative.

The goal is to teach the patient certain mental techniques. The therapist/trainer evaluates how well the patient is learning the techniques, even if this conflicts with the patient’s own evaluation. Integration with person-centred or CBT approaches is made impossible by this requirement.

Integration?

The conclusion has to be that integrative psychotherapy is a fake. The different orientations are different orientations for good reason, not just for fun. There are irreconcilable differences between them that it is not possible to fudge.

That’s not to say that any orientation must be in some way kept pure. Elements of theory certainly enrich the practice of psychotherapy and (I would say) make it more effective. I would never hesitate to incorporate theoretical elements of other therapies into CBT. For example, I might readily draw on the ideas of Freud, Jung, Perls (Gestalt), Berne (transactional analysis), and many others.

However, elements of theory are not any kind of integration. They are different ways of conceptualizing human experience that can be useful in working towards a CBT formulation in collaboration with a patient. They are definitely not a distraction from the methodology of CBT.

The risk with any so-called integrative approach is that it’s just a huge pile of theoretical fragments that don’t come together in any meaningful way, that don’t have any structure or purpose. Patients who are offered integrative psychotherapy should be very skeptical, and are entitled to wonder whether their therapist is Jack of all trades but Master of none.

Gremlins have attacked my computer. Normal service will be resumed as soon as possible.

There has been some discussion recently amongst BABCP members in private about whether or not it is desirable to record therapy sessions, either just the sound, or on video. Whatever your views on the subject, I’m sure you’ll agree that it’s good to know that professionals discuss these matters amongst themselves and learn from each other in the process.

There are arguments for and against.

Arguments for

Some of the arguments for the recording of sessions are that it can make supervision of the therapist more effective, and that it can make the therapy more effective for the patient.

The argument that it can make supervision of the therapist more effective is based on the idea that a supervisor needs accurate information about how the therapist does his work. It’s not enough for the therapist to report his own recollection of the sessions — he might be wrong.

For example, a therapist might report to his supervisor that he has an excellent therapeutic alliance with all his patients. On listening to the tapes, however, his supervisor might realise that this is not quite true. The therapist might be imagining a good alliance that does not really exist, or he might have some fault that he is not aware of.

The argument that it can make therapy more effective for the patient is based on the realization that patients do not always remember everything that is said to them in their therapy sessions. If everything is on tape, and they can take the tape home and listen to it, it will help them to remember things that they would otherwise have forgotten.

These seem to be tempting arguments for making recordings…but they are only tempting if you’re not a thoughtful and competent therapist.

Protecting congruence

If you are a thoughtful and competent therapist, you will understand that a vitally important quality that you bring to therapy is what’s called congruence — a quality of being genuinely yourself. How does supervision fit with that?

A supervisor has to be able to work with a therapist as-is, without creating conflicts for the therapist. That’s not to say that supervision cannot cause change. Supervision very often causes significant change. But any change that it causes must be completely absorbed, accepted, integrated by the therapist.

If the supervisor instead creates conflicts for the therapist, and if the therapist brings those conflicts to the next session with the patient, it means that the patient now has a therapist who is no longer congruent, no longer genuinely himself because part of him is trying to act the part his supervisor wants him to play.

A recording either confirms everything the therapist remembers of the session (in which case the recording is useless), or it conflicts with the way the therapist remembers the session. If it conflicts, it can create a serious problem for the next session.

You might think that checking the observable facts is the most important thing in supervision, but you’d be wrong. In psychotherapy, perceptions and relationships are far more important than observable facts.

Supervisors who jeopardize a therapist’s congruence are not taking their supervisory role seriously enough. It’s vital for effective supervision that supervisors work with therapists’ perceptions in a focussed and empathic way, avoiding the risk of conflicting material that could damage the therapist’s relationship with his client.

So supervisors who use recordings are barking up entirely the wrong tree. The best that can be hoped for is that the recordings make little or no difference.

Promoting growth

If you are a thoughtful and competent therapist, you will also understand that an important part of what happens in therapy happens between sessions. Patients do not attend a session simply to memorize the advice that is given to them. They attend in order to create starting points for personal growth. But their personal growth does not take place in the sessions. It takes place in the space between the sessions.

When you make recordings of sessions for a patient’s use, you focus therapy too much on the content of the sessions themselves. Instead of moving forward and growing between sessions, the patient listens to the tape and is dragged backwards to the context of the last session.

An insidious side-effect of this dragging-backwards is that the patient comes to the next session in much the same state of mind as the therapist remembers him at the end of the last session. So for the therapist there is an apparently comforting feeling of continuity between sessions. Each session seems to start well because it is a seamless continuation of the last. But while this makes life seem easy for the therapist, it is at the patient’s expense.

The practice of recoding sessions for patients to listen to turns therapy into mere advice-giving, and turns the therapist into some kind of guru whose every word is to be treasured. Good therapy explores many ideas that are then discarded. The ones that survive in the patient’s mind survive by a form of natural selection. The patient is in charge. The patient decides what to build on and what to ignore. Therapists who use recordings stifle this process, and stifle their patients’ growth.

Evidence

The current fashion for ‘evidence based’ medicine makes it seem natural to ask what research evidence there is for or against the use of recordings. Little evidence for it seems to have emerged so far.

As usual in discussions like these, some of the research quoted does not bear close scrutiny. For example, a study was conducted to try to assess whether supervisors’ feedback on audio taped sessions helped therapists to become more competent in a specific technique. The study was a randomized controlled trial. It is described in an online abstract, Strengthening Motivational Interviewing, and you can also see the slides of a symposium presentation about it.

Unfortunately the participants in the trial, both the therapists and the clients, were selected in advance so as to exclude those who did not want their conversations taped. This meant that the people taking part in the trial already felt more positive than average about the value of taping, before the trial even started. A positive outcome for taping was virtually inevitable because of this selection bias in the research design.

The therapists who taped their sessions had worksheets and extra telephone supervision that the control group did not have. It is impossible to say whether the use of tapes was a significant factor in the outcome, because the study entangled three separate factors without adequate controls. Again, this was because the research was inadequately designed.

It is even impossible to say whether the feedback itself was significant, because although the control group had agreed to be taped they were not actually taped. This makes it impossible to disentangle the effect of the feedback from the effect of taping itself. It could be that the very fact of having a tape recorder running changed therapists’ or clients’ behaviour, perhaps without their being aware of it, but the design of this study deliberately obscured all that information too.

The study took place in a training scenario. The aim was to increase the therapist’s general level of skill in a very specific technique, not to facilitate the therapist’s treatment of individual patients, which is the proper aim of clinical supervision. Even if the study had been designed competently, the relevance of any results obtained in a training context to supervision in clinical practice is very questionable.

Finally, the study did not even measure the outcome using real patients, but instead used actors. The level of therapists’ skill was not measured in terms of outcomes for patients, but only in terms of subjective ratings by observers of role-playing exercises.

All in all, the design of the study was a shambles from start to finish. Despite this, the magic words “randomized controlled trial” seem to make some people, people susceptible to magical thinking, imagine that the study provides useful information about the value of taping.

Discussion

Still, it’s good to know, isn’t it, that therapists do discuss subjects like this amongst themselves. The only trouble is, the discussion is taking place after the BABCP’s ruling élite of academics, representing the training industry’s interests, have decided the matter amongst themselves.

Audio or video taping of sessions, or the actual presence of a supervisor in the sessions, is already compulsory for accredited BABCP therapists. Having the discussion now is completely pointless.

Lack of evidence in support of recording does not matter any more. The harm it may do to patients does not matter any more. All that matters is that some trainers thought it would be a good idea (and it possibly is a good idea in training), so it was made compulsory for everyone in clinical practice.

By the way, my own solution is that no recording ever takes place. All therapy sessions are off the record. A supervisor is actually present to observe a proportion of interactions with patients. However, patients do not know (unless they were to press the point) that the extra person present is a supervisor. The patient’s perceptions of what the word ’supervisor’ means might distort the relationship between patient and therapist. This fudge complies with the BABCP’s foolish and irresponsible requirement while minimising harm to patients.

Market saturation is when the producers of a product or service are producing just enough to satisfy demand, but no more. It’s much easier if businesses can control demand to match their production capacity, and this is what sophisticated marketing aims to do. Sophisticated marketing of this kind dominates CBT in the UK, but you probably don’t notice it.

To learn how to see this marketing in action, there are three steps. First, follow the money.

Money

CBT in the UK is overwhelmingly paid for by the NHS. You might not think that if you have been fighting your GP for five years to get on to a two-year waiting list for treatment, but it is nevertheless true.

The gradual roll-out of IAPT (“Improving Access to Psychological Therapies”) by the government had led to extra funding for CBT in the NHS, increasing the already large market share that the NHS accounts for. The NHS is where the money is.

Influence

Second, think about what marketing does. An easy question — it influences purchasing decisions. So this invisible marketing must be influencing the NHS’s purchasing decisions.

CBT is not like nurses’ uniforms or floor polish, though. The NHS’s purchasing decisions for CBT are not made by bureaucrats in procurement departments. CBT is a treatment. The NHS’s purchasing decisions for treatments are made by bureaucrats in NICE (the National Institute for Clinical Excellence).

Evidence

Third, think about how NICE works. It works by considering scientific evidence. The only way to influence NICE is to submit scientific evidence to it.

Scientific evidence comes from research. The scientists who do research are not marketing agencies, they don’t work for business, do they?

Well, yes they do. They work for the same organizations that provide CBT training — universities. The training industry and the scientists are the same folks.

The invisible marketing that drives CBT in the UK is the training industry’s output of research. The research influences NICE. NICE influences the NHS. The NHS buys the end product of the training. Woot!

Depression

Gordon Brown’s official website had to remove the word ‘depression’ at the weekend, replacing it with ‘downturn’, according to a news report, presumably because the original headline might have reminded people about the rumour the Prime Minister is taking antidepressants to help him cope. Whether you call the government’s economic disaster a depression or a downturn, it’s bad for businesses, and very very bad for businesses that rely on government money. That means it’s bad for the CBT training industry.

There are already reports that IAPT funding is being stealthily diverted for other things. The market for CBT training will shrink. Marketing, in the form of research evidence, will not prevent the shrinkage. A different business strategy is called for.

Diversification

When production capacity exceeds demand, one way for the business to adapt is to divert production into other products whose markets are not yet saturated. Applying this logic to the CBT training industry, you would expect to see its marketing machine promoting related products.

But what products are related? How can the NHS be persuaded to buy the product of some other kind of training related to CBT? What other training is there?

What there is, and what you will increasingly see being marketed to the NHS, is additional training in relation to IAPT. This will not just be the training that’s needed so that IAPT workers can do their jobs. It will be additional, unnecessary training to help absorb excess capacity in the training industry as primary sources of funding go into decline.

The initial reasons given to persuade the NHS that this training has to be purchased will be a pick’n'mix of the usual blather that everyone is used to from politicians — to protect the public, to save the planet, for the sake of children everywhere, to help those least able to help themselves etc. etc. — known in the US as “motherhood and apple pie” reasons. The blather will soon be followed up by “research evidence”.

For starters

Kicking off this marketing drive, the NHS employees formerly known as ‘low intensity’ workers, who provide minimal support and self-help materials to patients with the very mildest of anxiety and depression, have been rebranded ‘psychological wellbeing practitioners’ (PWPs).

The BABCP has put in place what it calls an ‘accreditation process’ for them:

PWPs are essential to the success of the IAPT programme and we are proud of the way new training courses following a National Curriculum have been established. It is essential that the unique PWP role is properly recognised and protected with an accreditation process.

You can read more on the front page of the BABCP’s in-house magazine CBT Today (if it ever appears online, that is — at the time of writing the current issue has not been made public).

The article begins:

As Psychological Wellbeing Practitioners (PWPs) make a significant impact upon the nation’s mental health…

This despite the fact that PWPs don’t actually treat anyone.

As you read this self-congratulatory drivel, you can count off the training industry folk it names — academics from the universities of (in order of appearance): Exeter, Nottingham, Sheffield, York, King’s College London and Sheffield (again). Only one other person is named in the article — a bureaucrat employed by central government via a quango.

At least, in five years’ time, if you are still fighting your GP to get on to a two-year waiting list for genuine psychotherapy, you will know where all the money went.

Ever since I started writing here, I have thought of myself as an anonymous blogger. That’s not the case at all, it turns out, as two separate things that happened to me last week revealed. The two experiences illuminated opposite sides of what it means to have an identity, and why identity is important for psychotherapists.

I don’t mean by this that there has been some kind of exposé in which my real name has been revealed, though that could easily happen at any time. Although I have never told anyone explicitly that I write here, there are certainly a few people who now have enough information to work it out, if they chose to take the trouble. Perhaps it is only a matter of time before that happens.

No, what I learned last week was more fundamental than that. It concerns the way all of us, me included, present ourselves to the world as internally consistent people.

Congruence

This sense of being internally consistent and presenting yourself to the world in that way is similar to what Carl Rogers termed ‘congruence’ in a therapist who is (On Becoming a Person, p. 282, original emphasis):

…exactly what he is—not a façade, or a role, or a pretense.

The way it works in practice is not as simple as it seems. For example, if I want to promote CBT (which I do), I have to do that by describing CBT in a consistent way. A large part of what makes me congruent as a writer here is that I use try to language in a consistent way so that readers gradually build up a sense both of me and of what I’m writing about. If I used a term like CBT inconsistently, sometimes to mean one thing and sometimes another, that would make it more difficult for readers to relate to me as a consistent person.

Indeed, a fair amount of what I write here is explicitly to do with the meaning of the term CBT. I often describe things that I think are real CBT, and things that are fake CBT. Anyone who reads what I write about real and fake CBT gets a pretty clear picture, I hope, of what I think about the issue, and at the same time a pretty clear picture of me as a fairly consistent person.

So a side effect of writing here in a way that presents a fairly consistent point of view is that I come across as a person. Congruence creates the identity. It’s not that I’m a person who happens to be congruent. It’s that congruence makes me become a person. And, of course, the identity is not anonymous. The identity, the person, has the name CBTish in the present context, and other names in other contexts.

One of the things that happened to me last week was that I found myself in a situation in which I took the identity CBTish outside the blogosphere — not far outside, but far enough that it felt strange and new. It felt as strange as if the lady in the post office where I get a morning paper had greeted me as CBTish, or by a childhood nickname, instead of by my usual real-world name.

The notion I had previously had, that CBTish is in some way just binary data, some kind of bot that generates articles and comments in the blogosphere, suddenly evaporated as CBTish became a person in the moment, in the here-and-now. It was somewhat surreal but strangely liberating. I never expected to walk up to someone and exclaim, “Charles Bradwell Tish, at your service!”, adding conspiratorially, “But you may call me Charlie”, and that’s not what happened, but suddenly it felt that it could happen.

Terminology

In writing here, one of the factors that helps to maintain identity is consistent use of terminology. I think this is much more important than it often seems, and that is why I feel it is so important to define the term CBT meaningfully.

The second thing that happened last week was that I came across a published but anonymous opinion in a magazine article, an opinion about terminology, about the difference in meaning between the terms ‘psychotherapy’ and ‘counselling’.

The meanings that I assign to those terms are very specific, and they relate to the broad CBT model of mental illness. In the CBT model, people adopt ways of relating to the world that seem to work at the time. They can normally adapt to new circumstances by changing the ways they relate to the world in whatever respect is necessary. But there are times when the connections that provide for normal adaptation get lost somehow. Then the person may be stuck with ways of relating to the world that don’t work any more, and that are resistant to change. That’s mental illness.

CBT, which is a psychotherapy, applies specific techniques to identify and restore those lost connections. These specific techniques lie within what is called the CBT formulation (a.k.a. conceptualization) of the patient’s problems, which gives the patient a conscious, intellectual, common-sense grasp of the ways they relate to the world, and which empowers the patient to change.

Once in possession of that common-sense grasp, the CBT patient is in the position of understanding that some things have to be changed, understanding what they are, and understanding how they got to be that way. It might still be useful for the patient to have some help and support in making the actual changes to themselves. That’s counselling.

Counselling helps people who are not mentally ill, whose connections have not got lost, or have been found again, and who understand the external events that make them feel and behave the way they do. These people just need help and support in the everyday process of adaptation.

Therefore, in my model of psychotherapy and counselling, counselling is for helping people to change themselves and adapt to life; psychotherapy is for helping people to understand what it is about themselves they need to change, and what it is about life that they need to adapt to. The difference between psychotherapy and counselling lies in what they are for, in their purpose.

Orientations

Although I explained what I mean by psychotherapy and counselling with reference to CBT, my view of them translates quite well to other orientations. Orientations are the collections of theories and methods that inform the work of a body of therapists. CBT is an orientation, psychodynamic methods are an orientation, humanistic methods are an orientation. There are many others, and many subdivisions.

No matter what orientation you adopt as a therapist, I think it’s useful to distinguish between clients who know what they need to do and just need help doing it, and clients who don’t realize what it is they need. My definitions of counselling and psychotherapy make exactly that distinction.

But the magazine article I came across takes a different view. It proposes:

Psychotherapy focuses on the [...] as a ‘tool’ of the therapy whereas counselling relies on [...] to focus on a system for change.

I omitted some phrases to make the meaning of this quite clear. It is saying that the difference between psychotherapy and counselling lies in the methodologies that they use.

Differences in methodology, however, already have their own terminology — the terminology of orientations. There is no need to dedicate other terminology for that purpose. Using the terms psychotherapy and counselling to refer to orientations simply makes those terms redundant, because we already have ways to describe orientations.

Also, those orientations that (unlike CBT) include both psychotherapists and counsellors make almost exactly the same distinction between psychotherapy and counselling that I do. Psychotherapy is very generally used to mean the treatment of illness (although definitions of illness vary slightly), while counselling is very generally used to mean help with the challenges of everyday life for people who are mentally well.

Mysteries

It seems to me that the article’s proposal is very poorly thought out, but there is more to the article than that — it contains some mysteries.

One is the use of “We” in several places, implying that the author was some kind of committee, not an individual. (Or, if an individual, one who suffers from a DID-like delusion.)

Another is the phrase:

…those who would control the work we do…

Who is it who would control the work of therapists? The article doesn’t say. Paranoia, perhaps? Is there a conspiracy I don’t know about? Is it just a reference to the recent idiotic collusion (that I have written about several times, for example in Jeopardy) between the UKCP and the HPC? There’s no way to tell.

And another is:

…the way pathology has been used to differentiate titles…

The meaning of this is opaque, but it seems to hint at an anti-pathology standpoint — a view that mental illness does not exist — without sufficient courage to come out and say so.

Then there are some of the words I omitted from my earlier quotation:

…dynamics of the relationship between practitioner and client (patient)…

This is a thinly disguised reference to the psychodynamic orientation. The proposal is really that psychodynamic orientations are proper ‘psychotherapy’ while other orientations are just ‘counselling’.

Finally, there is the extraordinary sentence:

This [attitude] is developed during the training which evolves a state of mind that is congruent with the understandings used in the practice of the profession.

It is reminiscent of the kind of English you get from machine translations like Google Language Tools.

Taken together, these mysterious elements give the article an unreal quality, a feeling that it cannot have been written by someone who is completely in the same world as the rest of us. Significant clues in making sense of this are the way the proposal is in conflict with the general everyday meaning of the terms psychotherapy and counselling, and in the veiled reference to the psychodynamic orientation.

Some detachment from the real world, some paranoia, a delusional feeling of being a ‘we’ rather than an ‘I’, and some loss of the theory of mind that normally enables people to use language with conventional clarity — these are all typical of victims of addictive long-term psychodynamic treatment. A simple defence against the realization that the treatment is causing harm is to come to believe that mental illness does not really exist, that its encroaching symptoms in oneself are a form of insight. Could the article be a cry for help?

A final twist

In a final twist, the article invites comment. This is a classic double bind, a psychological trap of the kind that I explained recently in Cake.

Double binds have three components — two logically conflicting statements, often made simultaneously but in different forms so as to disguise the conflict, and a requirement that prevents resolution of the conflict.

In this case the logically conflicting statements are 1) that the article was not written by anyone (as it has no identified author, not even a pseudonym), and 2) that the article was indeed written by someone (as it does seem to express a point of view of sorts, and even hints at the author’s difficulties with life).

It would be simple for readers to make up their minds one way or the other, to resolve the paradox, but for the third component, which is the invitation to comment. In order to comment, you have to accept the article as a whole, you have to swallow the paradox whole without resolving it.

And then, in a final final twist, the article appears in a magazine whose principal theme is the work of the late R.D. Laing, a psychiatrist who wrote compellingly about double binds and their effect on people (and whose work I mentioned nearly a year ago in Marx). So a final final interpretation of the article is that it is in fact a hoax, an illustration of a double bind inserted in homage to Laing.

You can find the article here (page 35 in print, 37 in PDF): Defining psychotherapy and counselling

Identity

Well, not quite final final either. My own interpretation of the article is that it’s a warning to therapists by being an example of everything not to do.

As a therapist, it seems to me that you have to be fully in the moment as a coherent individual. You have to be able to relate to other people with congruence and consistency, to be open to experience (rather than paranoid), to be self-actualizing (rather than threatened by others’ control), to have a strong theory of mind that enables you to use language with clarity, to be sensitive to meaning, to be able to gauge where difficulty crosses over into illness, and perhaps above all never to create double binds. You have to have an identity, to be a person, and you have to have a name. Any name will do.

A neuroscientist at University College London has explained how CBT works using coloured dots.

That is, his explanation uses coloured dots. CBT doesn’t use coloured dots (though if some wacky ‘third-wave’ therapy based on coloured dots turned up next week heralded as a new form of CBT it would not surprise me one bit).

Actually, Beau Lotto doesn’t mention CBT at all. His work in UCL’s Institute of Ophthalmology concerns vision. But the underlying ways in the the brain processes information are the same no matter what kind of information it is. Vision is just one example:

The light that falls on to your eye — sensory information — is meaningless, because it could mean literally anything. And what’s true for sensory information is true for information generally. There’s no inherent meaning in information. It’s what we do with that information that matters.

The quote is from (04:16) a TED talk that’s embedded below. It uses optical illusions (some of which are similar to the one I used here last month in Socks) to illustrate how our brains process information.

Usefulness

The key idea is that your brain creates meaning out of information, and it does this in ways that it has learned are useful. Here’s an example he gives. Try reading this (04:54):

What are you reading? Half the letters are missing…There’s no a priori reason why h has to go between that w and a, but you put one there. Why? Because in the statistics of your past experience it would have been useful to do so. So you do so again. And yet you don’t put a letter after that [next] t — why? Because it wouldn’t have been useful in the past, so you don’t do it again.

That’s the key idea behind CBT, too. You have learned to process information in a certain way because it is useful, and your brain uses the information to create your perception of reality (11:40):

The senses aren’t fragile. And if they were, we wouldn’t be here. Instead, color tells us something completely different, that the brain didn’t actually evolve to see the world the way it is. We can’t. Instead, the brain evolved to see the world the way it was useful to see in the past. And how we see is by continually redefining normality.

If the way your brain processes information ceases to be useful (causing mental illness), then you can easily learn to process the same information in a different way that’s more useful to you you in the present. Your perception of reality changes, even though the incoming information is the same. Your world seems a different place.

In the video there’s a startling example of how quickly (thirty seconds) your visual processing can change. The changes produced by CBT (weeks or months) in processing thoughts and emotions can be equally startling.

A quote from the very start of the talk could apply to mental illness just as well as to the coloured dots (00:20):

…to win this game, all you have to do is see reality that’s in front of you as it really is…

Formulation

What CBT does is create an actual change in the way your brain processes information. It seems to you that reality has changed, as if the way you thought about things before while you were ill was some kind of illusion.

If you’re a patient and you’re having some kind of therapy that doesn’t do that, it’s not really CBT. Or if you’re a therapist and you’re not doing that for your patients, then whatever it is you’re doing is not really CBT.

The way CBT achieves this change is by uncovering the reasons why you were processing information in a certain way — why it was useful. This component of CBT, this understanding, is known as a formulation or conceptualization. Once you understand why your way of processing information was useful, and why it is no longer useful, you can develop a new way of processing information that’s more useful now.

There is nothing unnatural or artificial about learning to process the same information in new ways. Your brain does this all the time. In the talk, Lotto says (12:04):

So how can we take this incredible capacity of plasticity of the brain and get people to experience their world differently?

It’s that incredible capacity of plasticity of the brain that makes CBT possible.

The talk

Here’s the TED talk, Optical illusions show how we see:

This little gem of a sketch raises interesting questions about imbalance of power in the relationship between therapist and patient, the influence of the therapist’s own fears in informing intuition and advanced empathy, and more…or perhaps less.

If you don’t much care about any of that, it’s also funny:

What do flowers and grapes have to do with mental health? It’s usual, when reviewing a newspaper article, to add some comment, but I think this one speaks for itself…

…since that day I have never, and I mean never, seen a single card – let alone a bunch of flowers – on a psychiatric ward.

Max Pemberton’s Spare a thought for psychiatric patients is in today’s edition of The Daily Telegraph.

The flowers and the grapes can be found on ‘Get well soon’ cards on sale from The Royal College of Psychiatrists.

My recent ranting about fundamental difficulties with the psychodynamic approach to counselling and psychotherapy has one last twist.

Someone told me that they thought my recent posts about psychodynamic counselling, Cake and Hot babes were “going for the jugular”. In the light of my allusion to vampires towards the end of the second piece, I wonder how much I should read into the remark!

Anyway, to reiterate, it’s not that I think psychodynamic theory is necessarily mistaken, or that psychodynamic methods are wrong in themselves. I can see that the theory is a plausible framework for understanding people’s mental lives, but I also see that in practice therapists find it difficult to apply, very often impossibly difficult to apply, with the result that patients do not recover. Furthermore, instead of adapting to these difficulties and resolving them, a common psychodynamic approach seems to be to deny them and to indulge instead in a kind of sham therapy where the therapist, not the client, generates the emotional content of the sessions.

Something similar happens in CBT. There’s a plausible theoretical framework for understanding people’s mental lives, and a practical methodology for applying it. Yet there are therapists who do not understand the methodology, and instead of learning how to do better, they play at ‘CBT techniques’ in a kind of sham CBT.

The crucial difference is that while psychodynamic methods are inherently difficult, so that very few people can acquire the skill to apply them effectively, CBT methods are inherently simple. As a result, effective CBT is pretty common, and effective psychodynamic therapy is pretty rare.

Compulsory therapy

A recent discussion amongst CBT therapists brought out some of these issues. The question raised was: Should it be compulsory for CBT therapists to have therapy themselves as part of their training?

It’s not compulsory at present, and there are no plans for it to be. The basic reason for this is that CBT is designed to treat mental illness. There is no such thing as CBC (‘cognitive behavioural counselling’) for helping mentally well people with the problems of everyday life. The fundamental difficulty with compulsory CBT for trainees that there’s no illness to treat, so it would simply be going through the motions in a limited and pointless way.

Disappointingly, the view was expressed in this discussion that CBT is just a bunch of techniques for living life, and that anyone at all, mentally ill or mentally well, can learn techniques. I think it’s extraordinary that someone with so little understanding of how CBT works should be found piping up in what was meant to be a serious discussion. It’s as I wrote above — even in an orientation as simple as CBT there are therapists who do not understand the methodology.

Another disappointing view was that because there is no hard evidence one way or the other on whether compulsory therapy as part of training makes for better therapists, the idea should be considered to have potential. This is a little like saying that the jury is still out on whether the moon is made of green cheese, until such time as samples from the moon’s central core are obtained and analysed. It’s difficult to imagine how anyone with such a chaotic view of scientific evidence could be effective in helping patients to be rational.

Supervision and mental ill-health

It should be pointed out that what’s called ’supervision’ of therapists is, or should ideally be, a completely different thing from therapy. Therapists use supervision for a variety of reasons (which I discussed recently in Buddy), but it should never be a pointless exercise.

It is probably unwise for a supervisor to provide actual therapy to help the therapist to resolve personal mental health issues, because a supervisor’s goal is to ensure that the therapist provides effective therapy. Having some other goal makes the supervisor’s role very complex and difficult.

Mental ill-health, however, does not in itself prevent someone from being an effective therapist. Past mental ill-health and recovery is probably a big advantage, because it is easier to convey the possibility of recovery to patients if you have experienced it yourself.

Even current mental ill-health is not necessarily a barrier to being an effective therapist, unless it is severe. For example, an effective therapist might be paranoid-schizophrenic, hearing persecutory voices at times of emotional stress, but this need not interfere with work as a therapist, which does not normally cause therapists to experience emotional stress.

Therapy without purpose

Some orientations, particularly the psychodynamic ones, do make it compulsory for trainees to have therapy themselves. They might even make compulsory, or strongly encourage, therapists having continuous therapy themselves after training. What does this achieve?

One thing it achieves is that it legitimises therapy without purpose. Because the therapist has experienced therapy for its own sake, without any overall therapeutic purpose or final goal, it is easier for that therapist to conduct therapy in the same way with clients.

Putting this from a client’s point of view, if you are seeking therapy for some specific reason, then therapists who are themselves having continuous therapy, or who have had compulsory therapy as part of their training, are much less likely to deliver what you hope for. On the contrary, they are much more likely to involve you in a pointless examination of the parts of your life that don’t need any examination, and this is likely to continue without any end ever coming into sight, until you eventually walk away.

Addiction to therapy

In the extreme, it is not unknown for therapy that has no specific goal to create a state like addiction. This is because of the temptation to conjure up emotional intensity between client and therapist so that the therapy seems to have some justification. Psychodynamic theoretical constructs like transference and counter-transference are easily adapted to give conjured-up emotional interactions the appearance of validity.

The problem with this for both client and therapist is that normal relationships can start to seem dull by comparison. Both participants begin to feel that the life they have in therapy sessions is real, and that real life is just an unsatisfactory filler between sessions. This state of mind exactly parallels psychological dependency in substance abuse. It is, alas, quite common.

It seems clear to me that the methods of psychotherapy have real power. It seems equally clear that such power has the potential to cause harm. The most likely scenario for harm is when there is no strong focus on doing good, no specific mental illness to cure.

Therefore compulsory therapy for mentally well trainees only gives them experience of a potentially harmful scenario. Continuous therapy after training does nothing but reinforce it, making addiction to therapy and withdrawal from real life more likely for both therapists and their clients. The twist in the tale of the psychodynamic approach is that it’s theoretical basis can so easily be misapplied to allow this to happen.