The Handbook of Psychotherapy

Petruska Clarkson, Michael Pokorny, Petruska Clarkson, Michael Pokorny

• Publisher: Routledge
• Year: 2013
• Print ISBN:
  9780415077231
• eBook ISBN:
  9781317762010
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Psychotherapy is a fast-growing profession and The Handbook of Psychotherapy offers a unique and comprehensive overview of its many aspects. The editors and contributors are all highly experienced practitioners who articulate, singularly or jointly, a particular viewpoint, approach or opinion to produce an overall perspective on psychotherapy today. Each brings a different emphasis to the relevant issues and the creative tension of this dialogue contributes to a lively and well-informed picture of theory and practice. Presented under five main headings - the nature of psychotherapy and its research, its culture, modalities, settings and issues - the book offers a rich source of information and reference. It has been written for all health professionals, including nurses and general practitioners; for social workers; for psychotherapists in training; for anyone considering psychotherapy as a career or seeking psychotherapy; for voluntary organizations; in short, for all those who need or wish to know more about psychotherapy. Petruska Clarkson is a consultant clinical psychologist, Head of School and Founder Director of both the metanoia Psychotherapy Training Institute and of metanoia Organisations International. Michael Pokorny is a psychoanalyst and psychoanalytic psychotherapist, past Chair of the UK Council for Psychotherapy and currently Chair of the Registration Board.

Part I

Introduction

Chapter 1

The nature and range of psychotherapy*

Petrūska Clarkson

A chapter of this length cannot fully do justice to the ongoing debate about the nature and range of psychotherapy. It is a subject which continues to exercise some of the finest minds active in psychotherapy today, as witness both the mainstay texts in any training course in counselling and psychotherapy, and the current debate in specialist journals.

In the first instance, definitions of psychotherapy will be briefly reviewed. This will be followed by an attempted differentiation between the major professions engaged in counselling and psychotherapy, following closely the conventions of the main professional bodies involved. The third section will concern a review of the major traditions in psychology which have given rise to different approaches, and briefly review the significance of research in this field. Lastly, there is a diagram for differentiating between different modalities or arenas for counselling and for psychotherapy.

Definitions

Definitions of psychotherapy are legion, and none is entirely comprehensive nor entirely satisfactory.

Legislators and courts of law have found it almost impossible to define ‘psychotherapy’ in such a way as to include, by universal agreement among therapists, that which is psychotherapy and to exclude that which is not psychotherapy.

(Watkins 1965:1142)

In their textbook of psychiatry, Henderson and Gillespie (1956) regard psychotherapy as any therapy of the mind, appearing to include talking treatment alongside insulin coma in their fifth edition of 1940 but, by their eighth edition of 1956, psychotherapy has become specific to psychoanalysis and its derivatives. Mayer-Gross et al. (1954) do not offer a general definition of psychotherapy but use the term to cover a variety of talking treatments. They seem to distinguish it from psychoanalysis as well as from behaviour therapy. They regard all forms of physical treatments as quite separate and different. Merskey and Tonge (1965) clearly regard psychotherapy as talking treatment.

Holmes and Lindley offer a definition: ‘The systematic use of a relationship between therapist and patient – as opposed to pharmacological or social methods – to produce changes in cognition, feelings and behaviour’ (1989: 3). Notice that the use has to be systematic. Holmes and Lindley go on to consider forms of psychotherapy under the headings of structure, space and relationship. Another idea is that psychotherapy is the treatment of psychological conflicts no matter what the presenting symptoms are.

All these definitions rely on the idea of bringing about changes in the personality and manner of a person’s relating by the use of essentially psychological techniques. If we are to cover all forms of psychotherapy, that seems to be about as definite as we can get. As soon as we try to be more specific, we begin to exclude some therapies. Of course we may wish to exclude some therapies. There is no agreement on the exact boundaries of psychotherapy. One result of this is that the political definition of psychotherapy has given rise to great argument and considerable tensions within the profession. I refer to the process by which the United Kingdom Council for Psychotherapy (UKCP) has come into being from the original Rugby Psychotherapy Conferences, via the intermediate stage of the UK Standing Conference for Psychotherapy. It is possible to define psychotherapy as all those therapies that are recognised by the UKCP. That is a simple way of reaching some sort of agreement. The trouble is that there are always some who claim that some psychotherapy is excluded from the Council. This is merely another way of having the argument of what is, and what is not, psychotherapy. On the other hand we can recognise that other professions also have ill-defined borders, and we can stop worrying so much about our general definition or our political solution by recognising that the borders of psychotherapy are not fixed.

The time-span within which psychotherapy operates ranges from one interview to many years of treatment. The rise of brief psychotherapy (as discussed in Chapter 11) has shown that not only can important changes be made very quickly, such as in ten or fifteen sessions, but can also occur within just one interview. The time boundaries of group psychotherapy have proved to be very varied. From a start of once-weekly group meetings lasting one-and-a-half or one-and-a-quarter hours, groups have become marathon, intermittent, more than once a week; the variations that have been tried out seem endless. Once the psychotherapy is exported to the home setting, as can happen in some family therapy clinics, the time frame changes altogether, lasting until something is achieved, or the team has to leave. Even in the psychoanalytic sphere there has been change. In some places analysis takes place five times per week, in others four or three times weekly. Even more radical, the revolutionary French psychoanalyst Lacan would end the session when some significant moment had been experienced. Thus sessions could last for ten minutes or two hours.

In many psychotherapies a contract for time and fees is made at the start, although it may have to be modified later. Even where the contract appears not to have been made overtly, as in psychoanalysis, in reality the contract is for as long as it takes, even if that is many years. Of course in a therapeutic community the time involved is twenty-four hours a day for many weeks, months or years.

The range of clients that are offered psychotherapy has varied from time to time and from place to place. There seems to be general agreement that neurotic symptoms are amenable to psychotherapy, and there is so far no clear evidence that the form of the psychotherapy makes a material difference to the outcome. Other diagnostic categories, or the psychotherapy from which they draw, produce very different reactions from different psychotherapists. There are therapeutic communities that specialise in treating psychosis, such as the Arbours Association and the Philadelphia Association, both being descendants of the original work of Laing. Some psychotherapy schools seem to specialise in certain types of client, so that, for instance, specific phobias have become largely the province of behaviour therapy, especially the implosion treatment for phobia of spiders (arachnophobia). Others have specialised in the treatment of psychopathy, especially the Henderson Hospital, and yet others in the treatment of offenders, such as the Portman Clinic for sexual offenders and Grendon Underwood prison which has an excellent record in the rehabilitation of recidivist criminals using a combination of community and group methods, including psychodrama. The validation of results, psychotherapy studies or outcome (as discussed in Chapter 3) is another matter of great concern to us all. It is hoped that the new moves towards psychotherapy audit will help on this front.

Allied Disciplines

This section considers some of the factors involved in differentiating counselling, psychotherapy, psychology, psychiatry and several allied fields. It is written for several reasons. One is to help establish for counsellors, psychotherapists and counselling psychologists separate and valuable professional identities which have a place and domain of their own. Such an attempt can provide helpful guidelines for referral agencies, professionals and members of the public to distinguish between different kinds of service provision, so that needs and resources can be more accurately aligned. Ignorance and confusion in themselves further perpetuate difficulties endemic to the most complex task of providing the best and most cost-effective help for individuals in emotional trouble, with the least long-term detrimental effects, and hopefully of most benefit in terms of improved psychological health. Secondly, the ability to know where helping modalities overlap and where they differ can be a tremendous help to professionals themselves. It can establish boundaries, acknowledge strengths and limitations and afford a working relationship between them that fosters mutual respect rather than distrust. Professionalisation, accreditation and ethical sanctions can go some way towards reducing potential damage: they can also provide the first step towards professional identity and the ability to relate to other professionals from similar and different helping backgrounds.

According to Carroll (1991, 1992b), there are three main approaches to considering the relationship between counselling, psychotherapy, psychology and psychiatry.

First, there are those who ‘lump them together’ and refuse to acknowledge any differences. They point dramatically to the client groups dealt with by each profession and hail the fact that counsellors see clients, psychotherapists see clients (but they may call them patients) and counselling psychologists see clients (they call them both clients and patients) and that these clients do not differ substantially from one another. Domains held sacred by one profession are invaded without apology by another. Psychotherapists see clients in long-term therapy, some of whom are very disturbed and difficult people who may even have psychiatric histories and they may work with transference and the unconscious. Such very disturbed clients traditionally have been the work of the psychiatrist, the clinical psychologist, or the psychotherapist. The counsellor, on the other hand, sometimes works in a college of higher education, can average six sessions a client and deals with crisis and developmental issues. The counselling psychologist (a new breed on the British scene) works in hospitals, organisations, mental health centres and all those areas once claimed by counsellors, psychotherapists and clinical psychologists. Why try to fabricate differences if all three approaches do much the same thing?

According to Carroll, a second group ‘split’ the groups and refuse to acknowledge many similarities. Counsellors, they claim, are low on theory, have no requirement for personal therapy in their training, work in the short term and with developmental issues. Counselling psychologists are psychologists who use counselling in their work, are high on theory and research and as yet seem unsure about where they will end up or in what client groups they will specialise. Psychotherapists concentrate on personal psychotherapy, use supervised client work, spend a long time as apprentices, and have deeply disturbed and long-term clients. However you view it, these are three different approaches to helping people and proponents of this view believe they must be kept separate. Some view the differences in terms of specialisation, others in terms of training. It is also true that issues of power, ideology, money, status, employability and snobbery play a significant part in such territorial anxieties.

A third group talk about ‘overlap’ between the three: areas of similarity and areas of difference. Duffy (1990: 11) recognises the areas in common and sees differences coming from ‘intentionality’; that is, not what is done but how practitioners think of their work. This contribution of Carroll is supplemented here by a diagram (Figure 1.1), which I developed to illustrate the discussion. Figure 1.1 is offered as a potentially helpful tool in guiding and demarcating the discussion areas between the overlapping fields of counselling, psychology and psychotherapy and will form the basis for the discussion in the rest of this section.

Figure 1.1 Venn diagram representing the three primary arenas of counselling, psychology and psychotherapy

Figure 1.1 shows each area as distinct in itself, but relating to each of the other two areas, and indicates the interrelationship between all three. The overlap area between counselling and psychotherapy represents the work of counselling professionals with advanced practice qualifications or the psychotherapist using counselling skills. The overlap area between psychotherapy and psychology represents psychotherapists with a psychology qualification or psychologists trained as psychotherapists. The overlap area between counselling and psychology represents counselling psychologists – that is, psychology graduates with counselling qualifications, but no special training in psychotherapy. ‘X’ marks the area of work which involves the work of psychology graduates who have training and experience in both counselling and psychotherapy. This may be the appropriate area for the profession of counselling psychology.

We will look in detail at each of the above – namely, the counsellor, the psychotherapist and the counselling psychologist – and then note four areas where dialogue can take place between the three approaches. For each profession, people can be self-referred, or come via their general practitioners, friends or contacts.

Counsellor

The British Association for Counselling, founded in 1977, defines counselling as follows:

Counselling is the skilled and principled use of relationship to facilitate self-knowledge, emotional acceptance and growth, and the optimal development of personal resources. The overall aim is to provide an opportunity to work towards living more satisfyingly and resourcefully. Counselling relationships will vary according to need but may be concerned with developmental issues, addressing and resolving specific problems, making decisions, coping with crisis, developing personal insights and knowledge, working through feelings of inner conflict or improving relationships with others.

The counsellor’s role is to facilitate the client’s work in ways that respect the client’s values, personal resources and capacity for self determination.

(BAC 1989:1)

Counsellors may bring special training, experience and expertise to the counselling relationship, to enable people to further their own growth and enhance their personal functioning. In this way, counsellors are enablers and facilitators, helping a client with a specific problem and focusing on evolutionary change. Counselling is largely a general field, but it can also be quite specific; for example, redundancy counselling, marital or sexual counselling, debt counselling, HIV, retirement and health counselling, or bereavement counselling.

The British Association of Counselling publishes a directory of counsellors throughout the United Kingdom. This body also has a Code of Ethics and Practice for Counsellors, whose ...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Contents
• List of illustrations
• Contributors
• Preface
• Acknowledgements
• Part I Introduction
• Part II Culture
• Part III Modalities
• Part IV Settings
• Part V Issues
• Appendix A Structure of the United Kingdom Council for Psychotherapy and list of its member organisations
• Appendix B The United Kingdom Council for Psychotherapy Ethical guidelines
• Name index
• Subject index