|Fitness to Practise What?
The Destruction of Psychotherapy in 21st Century Britain
Contribution to the conference of The College of Psychoanalysts-UK ‘Are you fit to practise? From ethical framework to model of good behaviour’- London, 6 June 2009
Is psychotherapy or psychoanalysis a health care profession?
In his highly relevant monograph The Question of Lay Analysis , 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. Our friends among the protestant clergy, and more recently among the catholic clergy as well, are often able to relieve their parishioners of the inhibitions of their daily life by confirming their faith – after having first offered them a little analytic information about the nature of their conflicts. Our opponents, the Adlerian ‘individual psychologists’, endeavour to produce a similar result in people who have become unstable and inefficient by arousing their interest in the social community – having first thrown some light upon a single corner of their mental life and shown them the part played in their illness by their egoistic and distrustful impulses. Both of these procedures, which derive their power from being based on analysis, have their place in psychotherapy. We who are analysts set before us as our aim the most complete analysis and profoundest possible analysis of whoever may be our patient. We do not seek to bring him relief by receiving him into the catholic, protestant or socialist community. We seek rather to enrich him from his own internal sources, by putting at the disposal of his ego those energies which, owing to repression, are inaccessibly confined in his unconscious, as well as those which his ego is obliged to squander in the fruitless task of maintaining these repressions. Such activity as this is pastoral work in the best sense of the words.” [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. As the afflicted person talked, under the particular invitation to talk freely of whatever came to mind, his or her underlying distress would become apparent. The analyst is a skilled listener. Whilst it is true that the analyst will, from time to time, provide interpretive comments designed to help the analysand become more aware of what is hidden in his or her discourse, the essential skill is that of listening.
Freud does acknowledge some mental conditions that are of a medical nature:
“I also share the view that all those problems which relate to the connection between psychical phenomena and their organic, anatomical and chemical foundations can be approached only by those who have studied both, that is by medical analysts.” [p 257]
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. However, this 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.
The inclusion of psychological therapy as a ‘health profession’ might be appropriate in those instances where the practitioner claims to offer ‘treatments’ for people with a diagnosed mental health condition. Would this be the case with Jungian analysts, Lacanian psychoanalysts, existential psychotherapists? Do such people consider they are operating as a health profession and providing treatment for ICD10 diagnostic conditions? Are they instead more concerned with assisting people in a personal exploration of the mind, life, and its meaning? Is the exploration of archetypes, the collective unconscious, and the social unconscious, an aspect of ‘health care’? Was Erich Fromm a health care practitioner?
I would like to re-instate an old-fashioned but apt term – ‘depth psychology’ – originally used to refer to those approaches that explored the deeper and less conscious parts of the psyche. Whilst differing in many ways, Freud and Jung and the traditions they spawned, were both to do with enquiry into deeper, hidden realms of mind and soul, beneath the social surface. They were inherently subversive – questioning and undermining the official discourse of conscious mind, establishment culture, and medical model. By contrast, what we find promoted at present is very much a surface psychology – a technology of thought reform woven within a medical model – promulgated as a treatment for diagnosed mental diseases, such as depression and anxiety.
Back in the 1950s, Hans Eysenck, one of the first clinical psychologists in Britain, launched an attack on psychoanalysis – 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.]
He 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.
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. They are, after all, by their own 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’ or ‘munchausen’s by proxy’ 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.
When I began preparing this presentation I thought about the clients I had seen that day. My first client was a psychotherapy trainee. She talked of various experiences in her training. I made some reflective comments. These seemed to deepen her awareness of what she was feeling and thinking. Nothing remotely resembling a medical model was relevant to her presentation. Then I saw a man who talked nonstop in a slow relentless discourse that was difficult to follow and seemed to require no comment from me – he alluded to strange experiences that I could not understand and displayed volatile emotions, of both elation and despair, that were also essentially incomprehensible to me. I had the impression that his mind was very ill – and that whatever I might say would simply be absorbed by this illness. I felt overwhelmed and disturbed by the experience of listening to him for an hour – and worried about him. Next I saw a woman who told me that the depression she had experienced for years had been completely alleviated by having a hysterectomy – suggesting that her previous dysphoric states of mind had been essentially driven by a hormonal disturbance. My next client was a woman who had been depressed following the death of her beloved husband – she told me the stress relief methods I had used with her had enabled her to be left with happy memories of her husband rather than the traumatic memories of his death that had haunted her previously. Then I saw a young woman who was suffering from the effects of being sexually abused for a couple of years during her childhood – we used natural stress relief methods to address the traumatic aspects, as well as her complex feelings of guilt, shame, and rage. She was followed by a man who talked of his struggles to find a viable occupation having lost his previous job after developing severe RSI. My next client was a woman who has suffered with severe and disabling anxieties, about leaving the house and being on her own, since being abandoned by her fiancé some years ago.
Are any of these people suffering from ‘specific diseases’ – the term used by NICE to describe their remit? In some cases the medical model may have some relevance – for example, if hormonal disturbances were indeed causing a woman’s chronic depression. Some states of mind may be abnormal enough to merit the term ‘ill’ – perhaps ones which are beyond the scope of psychotherapy. Mostly 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.
Of course, the fact that some states of stress and misery are relieved or modified by psychiatric medication does not indicate that these are diseases. A state of unhappiness may be modified by cocaine or heroin, but this does not mean the person is suffering from a cocaine-deficit syndrome.
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 therapies are compared with each other they are more or less equally effective. By contrast the variation in effectiveness between therapists is considerable. Sometimes the absurdity is amusing. Consider Interpersonal Psychotherapy. IPT began as a plausible placebo, a manualisation of supportive psychotherapy – by Gerald Klerman – in studying whether antidepressants combined with supportive psychotherapy was better than antidepressants alone for combating depression. When it was later compared with cognitive therapy it was found to be similarly effective. NICE therefore recommends CBT or IPT in treatments for depression – as if it had been simply serendipity that both psychological treatments that were compared in this trial turned out to be helpful. The ‘equivalence paradox’ is scandalously ignored within NICE guidelines [Mollon 2009].
In contributions to the Cardinal Clinic trauma conference last year, and also in his 1995 book Pseudoscience in Biological Psychiatry (Wiley), Dr Colin Ross explains the ad hoc, somewhat arbitrary, and non-scientific way in which psychiatric diagnostic categories are established, based on his experience of working on DSM committees. One example he gave was of the category of acute stress disorder. Apparently this was originally proposed as ‘brief reactive dissociative disorder’ – but that term would have implied it belonged within the dissociative disorders, whereas its link to PTSD (to which the diagnosis would switch after one month) might place it within the anxiety disorders.
“…there were only two possible solutions to the problem: [a] move PTSD to the dissociative disorders or [b] move brief reactive dissociative disorder to the anxiety disorders. The decision to move brief reactive dissociative disorder to the anxiety disorders was based solely on the greater political power of the anxiety disorders group compared to the dissociative disorders group. One the switch was made, it was necessary to change the name of the disorder, because one cannot have an anxiety disorder called brief reactive dissociative disorder” [p 124]
Despite its eventual name of acute stress disorder, and its inclusion within the anxiety disorders, all the symptoms within this diagnosis are of dissociation.
Exploring psychiatric nosology more generally, 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 (at the Cardinal Clinic conference), 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. [Please note that he is a psychiatrist!]
The medical model, and the assimilation of psychotherapy to a ‘health care profession’ involve a category error. A ‘medical’ person can be expected to ‘diagnose’ and ‘treat’ specific ‘diseases’, and to be able to provide predictive ‘prognosis’ of that disease, as well as prescribe the correct medicine and dosage. The NICE guidelines, IAPT, stepped care models, HPC, the provision of expert opinion in court, and so forth, all rest on such assumptions. The psychological ‘health care professional’ will provide therapeutic services according to empirically validated protocols, just as NICE prescribes. Freud’s secular pastoral work was not of this kind. Psychoanalytic truth indicates that we cannot genuinely ‘diagnose’ psychological distress – we can only be open to what is gradually communicated as our client becomes willing to do so. When I had a consultation with my first analyst, as a young man of 23, I asked her what she thought was wrong with me – she replied: “I haven’t a clue what’s wrong with you – it will take an analysis to find out!”.
The medical model leads to a prescription of ‘approved treatments’ for specific diseases, with diagnostic codes, ‘validated protocols’ and checks for compliance with these ‘manualised treatments’. This is what currently happens within the NHS – and increasingly it will contaminate private practice. Our clients read NICE guidelines, and are at liberty to complain if they consider they are not receiving an approved ‘treatment’ for their condition. Adherence to the authority of NICE and its validated protocols – truly an emperor with flimsy clothes – takes the place of the psychotherapist’s inner integrity. Of course, none of this works in practice. Real clients tend to be complex, idiosyncratic, and often stubbornly defy diagnostic categories. One has to work to understand them and to find a way of helping, making use of all available knowledge and skill. The external authority of NICE is of limited assistance. Indeed any assumption that we know and understand our client is an obstacle to real exploration. To my perception, the authority that can often be given most weight is that of the client’s unconscious mind, expressed as an unconscious commentary upon the psychotherapeutic process – a phenomenon particularly explored by Robert Langs in the USA and Patrick Casement in Britain.
Freud’s vision of the ‘secular pastoral worker’ explicitly alludes to the role of priest. Perhaps there is a similar ‘calling’. No-one becomes a psychoanalyst or psychoanalytic psychotherapist because they think it is a good profession. The training, and the work itself, are too difficult and personally demanding. Similarly, psychotherapy is not for everyone. With the new IAPT trainings in CBT I think there probably are some who view these forms of psychological technology, now promoted as being as effective as antidepressants, as being attractive career options. There is scarcely any point of contact between these two professions.
Ethics are at the heart of the psychotherapeutic encounter. There is surely nothing more important in psychotherapy than the integrity of the ethical stance of the practitioner. But this is not a matter of a checklist of do’s and don’ts.
I will quote from an excellent book by Dorothea Hover-Kramer [Creating Right Relationships]
“Highly ethical behaviour means acting with integrity. Another word for integrity is wholeness meaning the therapist’s behaviour is congruent with his values, knowledge, intuition, and feelings. It also indicates there is harmonious, consensual dialogue between the practitioner’s inner process resulting in external behaviour that is consistent and ethical. In other words we act in accordance with our own personal Sacred Contract as well as honouring the covenant with our clients.” [p 137]
There is always the potential for predatory or deluded practitioners to cause harm. Psychotherapy is not always helpful. It can sometimes be useless, or worse. This danger is not alleviated by framing psychotherapy as a ‘health care profession’. Of greater importance, it seems to me, is to nurture within the novice practitioner the ethical core – of respect, care, thought, sensitivity to boundaries, and refraining from presuming to know.
Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders, Penguin 1996
Casement, P. (1985) Learning from the Patient, Routledge London
Eysenck, H. (1952) The effects of psychotherapy: an evaluation, in Journal of Consulting Psychology, 16. 319-324
Freud, S. (1926) The question of lay analysis, in Standard Edition of the Complete Psychological Works of Sigmund Freud. XX, Hogarth London
Hover-Kramer, D. (2006) Creating Right Relationships. A Practical Guide to Ethics in Energy Therapies, Behavioral Health Consultants, Cave Junction OR
Mollon, P. (2009) The NICE guidelines are misleading, unscientific, and potentially impede good psychological care and help, in Psychodynamic Practice, 15.  February. 9-24
Ross, C., & Pam, A. (1996) Pseudoscience in Biological Psychiatry, Wiley Chichester.
 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”.
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