Twist

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.