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.
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.
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.
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.
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
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.