![]()
1
Introduction
Introduction
Locating client and therapist within the world of social and cultural contexts, psychotherapy takes as its focus the intra- and inter-subjective world of client and therapist and the meanings they attribute to experience as fundamental to the process of therapeutic change. By contrast, psychopathology examines the nature of the problem or diagnosis attributed to clientsâ experiences. It analyses how this problem evidences itself across people, in patterns often described as conditions, as for example depression, anorexia nervosa or borderline personality disorder. Current psychological services are largely framed by the latter psychopathological, or condition-focused, culture. Consequently, clients tend to be signposted towards, or excluded from, services based on whether they meet the criteria for a particular diagnosis or condition. The apparent tension between these two world views is regularly experienced by applied psychologists, psychotherapists and counsellors. Such experience reveals the profound importance of analysing how this tension manifests itself in work with clients, yet to date there has been little exploration of these tensions or how they translate into practice and might be addressed in the best interests of clients. The contemporary relevance of this book is therefore significant for practitioners in the development of their work with clients.
By examining the relationship between psychotherapeutic practice and the presenting issues experienced by clients this book aims to meet a fundamental need of trainees and qualified practitioners. Its central argument is that tensions between competing world views of humanistic and medical models characterise the learning, development and practice of many applied psychology trainees, psychotherapists and counsellors. Indeed, this may also be the experience of qualified practitioners, as they work towards finding an integration of their values with a developing understanding and knowledge of theory, practice and research evidence. It concludes that this tension must be addressed head-on in the interests of best practice.
The book is made up of nine chapters: this introduction defines the scope of the book and the nature of the topic and addresses its tensions and debates. Seven subsequent chapters then focus on a specifically labelled area of experienced psychological distress or difficulty that is regularly seen within services. It is almost a paradox that the labels themselves form the proposed chapter headings. These include anxiety, depression, trauma and post trauma stress, bipolar, psychosis, borderline personality and eating disorders. The ninth and final chapter draws together the bookâs themes.
Each chapter addresses a specific named workplace/context and interweaves the historical context, theory, research, casework and inherent tensions in the work with clients. The topics included have been chosen because they represent the more frequent presenting problems encountered by trainee therapists and practitioners in their work with clients. Areas of practice which are perceived as more specialised, for example working with clients with a diagnosis of antisocial personality disorder, are excluded for pragmatic reasons of book size and on the basis that these provide less developmental potential for the wider readership within applied psychology, psychotherapy and counselling. We would acknowledge however that similar themes to those addressed in the included sections are likely to be of relevance to these other areas of practice.
For the purposes of this book we have chosen to use the phrase âpsychotherapeutic practiceâ to encompass those therapeutic relationships with clients with whom a range of professions engage. This includes counselling psychologists, clinical psychologists and counsellors as well as psychotherapists. Note also that the term âpsychologistâ may refer to either clinical or counselling psychologists who are working psychotherapeutically, and the term âcounsellorâ will refer to those who have undergone counselling training (they are also sometimes referred to as âtherapistsâ). Finally, the term âpsychotherapistâ may refer to those who are trained as such, but also that the termâs use in practice can be assumed by counsellors and psychologists. The authors suggest that this difference in naming has its origins in the historical context of psychotherapy: for example, the British Psychological Societyâs formation of a register of psychologists specialising in psychotherapy aims to collate those psychologists who are working in this way across the applied psychologies. In recent years, the British Association of Counselling has extended its description to become the British Association of Counselling and Psychotherapy.
Part 1: Exploring the Historical Context of Psychotherapy (Barbara Douglas)
The contexts within which psychotherapy is practised are both time and place contextual. It would be naĂŻve, for example, to consider that such âfounding fathersâ of psychotherapy as Sigmund Freud, Carl Jung or Carl Rogers emerged independent of their historical contexts.
The early nineteenth-century Quaker development of Moral Therapy (Tuke, 2010 [1813]) could in many senses be considered the precursor of the practice of psychotherapy with the term âmoralâ having a different meaning from our current understanding â one that held a broader sense of the psychological. The development of psychotherapy within the nineteenth century can be viewed as a drive to search for a more optimistic view of the human condition than that of the pervading and profound despair of social Darwinism with its concepts of tainted heredity and degeneration, propounded so influentially in England by Henry Maudsley and in France by Benedict Morel (Dowbiggin, 1985). Before Freudâs major works appeared, discourses of European psychiatry and neurology were already evolving an embryonic language of dynamic psychiatry that included notions about hypnotism, hysteria and the power of the unconscious (Ellenberger, 1981).
With the work of Freud came the powerful theoretical development of psychoanalysis. While Freudâs theories changed over time he has become known as the founder of a view of psychological problems that emphasises the evolving, developmental dynamic structures of the psyche. The early emergence of psychoanalysis was jealously contained within the medical profession but also influenced by social geography. The clearest example of this was the 1930sâ interweaving of its various schools of thought that was brought about by the persecution of Jewish analysts in Europe and their migration to England and America. The Viennese, Berlin and London schools were forcibly brought together during the late 1920s and 30s, each having to engage (uncomfortably) with the conceptual and practice emphases of the others.
While the early emergence of psychoanalysis was contained within the medical profession, the wider growth of psychotherapy was subsequently â and profoundly â influenced by the growing discipline of psychology. By the 1930s this had rejected introspection in favour of the study of observable behaviour. The resulting emergent behaviourist tradition lent itself to a very different form of âpsychotherapyâ, one which emphasised behaviour change through various programmes of conditioning and modification. These first took root in practice through the development of training programmes for children, psychiatric patients, and those contemporaneously referred to as âmental defectivesâ. Increasingly, however, frustrations emerged at the limitations imposed by such rigidity. As the twentieth century progressed the focus shifted increasingly towards a concern with meaning and subjective experience, with resulting psychological and psychotherapeutic challenges to the behaviourist movement.
The development of concepts such as learned helplessness (Seligman, 1975) furthered a need to consider the subjective world of the individual, and as such cognitive behaviour therapy (CBT), with its emphasis on the role of cognitions, arose out of behaviourism. More recently, with the shift towards a postmodern constructionist ethos (across disciplines), CBT is also shifting its approach, placing increased emphasis on the construction of meaning as the link between thought processes and emotion, and acknowledgement of the importance of the therapeutic alliance and the breakdown of CBT concepts into devolved subsystems of thinking in psychotherapeutic practice (for example, in the current development of mindfulness as a practice for depression: see Kabat-Zinn et al., 2002).
In the mid-twentieth century a challenge came also from Carl Rogers and a developing humanistic ethos. While the conditions of empathy, congruence and acceptance were conceived within a positivist framework of psychological research and experimentation, they were fundamentally challenging the limitations of such an approach by emphasising the importance of hearing and understanding the subjective experience of the individual. Towards the end of his life Rogers took this further, grappling with a concept of âpresenceâ in which the inner spirit of the therapist would touch that of the client (Kirschenbaum and Henderson, 1990).
There emerged therefore a broad movement towards a relational, shared meaning place within the therapeutic relationship that evolved as part of a narrative development in the theory of knowledge, both within psychology and across other disciplines within the social sciences and humanities. The more recent emergence of narrative therapy with its ideas of shared meanings, re-storying and co-creating understanding within psychotherapy further exemplifies this shift.
Historically the locations of psychotherapeutic practice have also changed. While there was previously little place for psychotherapy within the financially constrained and bureaucratic world of institutional psychiatry, in recent years statutory and voluntary services have increasingly embraced forms of psychotherapy. Psychological services in these broad frameworks are all now considered stakeholders in the development of psychotherapeutic practice. Thus while changing theoretical models of the person have influenced the development and practice of psychotherapy, so shifting contextual factors â including issues surrounding the classification of psychological distress, and the need to provide services for much larger numbers of people â have played their parts as well.
The classification of mental disorders took a powerful turn at the beginning of the twentieth century with the work of German psychiatrist Emil Kraepelin (2011 [1904]). Much of our current classification of mental disorders, for which psychological therapies are being offered, is premised on Kraepelinâs influential nosology of psychiatric illness. Underpinned by a medical model, this classificatory system stressed aetiology and disease process and was based upon Kraepelinâs longitudinal research evidence for his proposed twin underlying axes of all mental illness i.e. manic depression and dementia praecox (Greene, 2007).
But while current versions of the Diagnostic and Statistical Manual (DSM) embrace a medical approach to the classification of psychological distress that reflects Kraepelinâs work, early versions were influenced by psychoanalytic concepts of the unconscious and by the psychiatrist Adolf Meyer (1866â1950). Initially immersed in Kraepelinian psychiatry, Meyer later argued for â and led the development of â a more socially-based view of mental illness, in which individual experiences were described as reactions, or responses to, individual circumstances, rather than biologically-based disease entities. It was this framework of individual response, continuum of experience and behaviours as manifestations of unconscious conflict that underpinned the original DSM-I (APA, 1952) and its successor DSM-II (APA, 1968).
Only with the DSM-III (APA, 1980) and its subsequent revisions was there a paradigmatic shift towards a categorical, and debatably descriptive, classification of psychological distress reframed as disorder (sometimes referred to as the rise of the second biological psychiatry: see Shorter, 1997: 239).
Much psychological distress, framed by the DSM as disorder, now has an associated treatment of choice psychological therapy approaches, and so medical model frameworks have increasingly become the framework within which psychologists, psychotherapists, counsellors and psychological therapists are being required to work (and sometimes resulting in tensions that are further discussed in Part 2 below). It could be argued that the development of manualised and prescribed therapy, introduced as an attempt to provide a service to all at the point of need, threatens the retention of an individual emphasis. The ideals of cost effective therapy for all who may benefit from it are to be applauded, but these also raise tensions that echo the very same dilemma experienced by institutional psychiatry in late-nineteenth and early-twentieth century psychiatry, when burgeoning numbers of patients resulted in the standardisation â and ultimately dilution â of the earlier aims of moral therapy.
Charles Mercier, a leading psychiatrist of the late nineteenth century, expressed the hope that âmanagement of patients by the gross will give way to management of the individualâ (Mercier, 2011 [1894]: viii). Has this occurred or are we sometimes in danger of regarding science as linearly progressive towards ever greater knowledge and improved practice? Joan Busfield (1986: 18) expresses the view that âpsychiatryâs history is viewed as basically linear and progressive, albeit at times halting (or even occasionally regressive), in which science and progress are seen as synonymousâ. Foucault (1988) in his work on madness reframed the study of psychiatry within a much more critical analysis of madness, psychiatry and mental illness â their meanings within, and relationships to, contemporaneous society. Part 1 of each chapter in this book examines the history of each of the presenting issues with this in mind, inviting the reader to consider the interrelationships between practice and historical, social and political contexts.
While the above is a bald outline of the historical contextual development of psychotherapy, it serves to demonstrate that time and context sit side by side with theorists and practitioners as co-creators of any model of psychotherapeutic endeavour. It is to a discussion of the nature of current dilemmas in the practice of psychotherapy that this chapter now turns.
Part 2: Exploring Dilemmas, Evidence and Practice (Pam James)
In each chapter, dilemmas are discussed arising from the tensions and differences in professional opinion that can occur in psychiatry, psychology and psychotherapy. Such dilemmas may be considered as places where there is more than one way of understanding an issue â where there are different views about the impact of situational and personal factors associated with mental health and the appropriate therapeutic response. The reader is asked to pause in this uncertain place, sometimes evaluating the evidence, sometimes appreciating that there is no one absolute truth.
Those compiling the National Institute for Health and Care Excellence (NICE) Guidelines will review and grade evidence supporting particular therapeutic approaches, and a hierarchy of types of evidence exists where randomised controlled trials will have priority. This has resulted in a lack of emphasis on information collected by qualitative methods which are seen as a less preferred way for finding out about clientsâ experience, whereas Corrie (2010) takes a more inclusive view as to what constitutes evidence, suggesting that a consideration of the widest appreciation of what is happening for the client (and therapist) at the therapeutic interface is acceptable, and that research is only one part of the enquiry process.
In the UK the field of mental health could be perceived as a stage on which there are many players. Currently these include psychiatrists, general practitioners, clinical and counselling psychologists, psychotherapists, counsellors, psychiatric social workers, psychological wellbeing practitioners, high intensity workers and mental health nurses. The people who make up this multi-professional group do not all share the same understanding and explanation of the concept of mental health. Indeed it is only in the last ten years that the field itself has been so described, preferring for many years the term âmental illnessâ. Psychiatrists may also have a varying emphasis on a biological or psycho-social focus. They are licensed to prescribe medication â symptoms are seen as identifiable markers that provide a basis for categorisation and the treatment response. Over the years, iterations of the DSM have aimed to group the similar, giving a framework at the descriptive level, and providing a pathway though the complexity of human experiences. This is one area where dilemmas and tensions may arise resulting from the impact, effect and perception of the DSM by clients and non-psychiatrists.
Amongst psychologists and psychotherapists working at the boundary with psychiatrists, differences of opinion that are reflected in practice will occur related to the use of diagnosis. The emphasis on symptoms â their measurement, reduction and management, maintenance and perpetuation â is not consistent. A prescriptive approach matches type o...
