Time-conscious Psychological Therapy

Jenifer Elton Wilson

• Publisher: Routledge
• Year: 2003
• eBook ISBN: 9781134822676
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Counselors and psychotherapists are divided about the morality and efficacy of short-term psychotherapy and counseling. The model of therapy described Time-Conscious Psychological Therapy is based on flexible adjustment to the life pattern of the individual client's development, showing how a carefully structured, stage-based series of therapeutic relationships can be rewarding for both client and therapist. Illustrated throughout by case examples, this is a book for practitioners of all psychological therapies who are looking for a rigorous but flexible approach to empowering their clients.

Chapter 1
Why this book?

The ‘talking/listening cure’ is considered by the public and many health professionals as an imprecise, expensive, self-indulgent and slow route to psychological health and welfare. Counsellors and psychotherapists are divided about the morality and the efficacy of short-term psychotherapy and counselling. The critics of psychotherapy and counselling increase as the issues of abuse of power, crude and subtle, are debated: ‘Therapists have put us on the couch for long enough; it’s time we put them in the dock’ (Madeleine Bunting in the Guardian, 24 Feb. 1994).

This book offers a way through the controversy by giving the central position back to the consumers of psychotherapy. Although still a minority, some of the most vivid and popular descriptions of the psychotherapeutic experience are the first-hand accounts written by clients. These accounts are valuable and enlightening, whether written in grateful praise (Cardinale 1984) or in more critical scrutiny (Dinnage 1989), and go some way towards redirecting attention away from the therapy hour and towards the client’s life. Nevertheless, as Peter Lomas (France 1988: back cover) has commented in his recommendation of Anne France’s description of her experience as a consumer of psychotherapy, the preponderance of accounts are given from the point of view of the practitioner. Almost without exception, approaches to psychotherapy or counselling place the practitioner in the principal role. Therapeutic models are offered to the expert professional with the implicit message that it is their responsibility to provide the client with a life-changing experience. Even person-centred models fall into this error by placing the onus of change on the practitioner’s ability to provide ‘core conditions’ for growth of ‘unconditional positive regard’, ‘congruence’ and ‘empathic understanding’ (Mearns and Thorne 1988:14–15).

Instead, this book views individual practitioners as secondary to the life pattern of an individual client’s psychological development. To achieve psychological transformation, one client may use the services of a variety of professional helpers, as well as drawing upon the support of external resources and facing the common existential challenge of needing to ‘cope constructively with the business of being human’ (Gilmore 1973). Many practitioners will agree with this view, yet all are prey to the subtle and seductive notion of being the unique healer, wounded or not, whose singular knowledge, hard-won training and experience is enabling their clients to achieve the changes they seek.

The recommended approach is clear and yet rigorous, based on flexible adjustment to the client’s development through a series of therapeutic relationships, each of which can be negotiated and accommodated by offering a stage-related professional service. At each stage, the client is invited into a clearly stated two-way commitment with an established focus related to the type of relationship operating between client and therapist. Length of time and breadth of focus are related and the process is likely to involve a series of therapeutic encounters with different counsellors and psychotherapists.

This is a book for practitioners of all the psychological therapies, whether they call themselves psychotherapists, counsellors, clinical or counselling psychologists. All these professional roles involve the use of some form of psychological knowledge to inform the practitioner’s interactions with people who are experiencing mental and emotional discomfort which blocks their developmental progress. The approach offered is not linked to any one psychotherapeutic orientation. To an extent, it may be described as a collection of concepts concerning the four overarching professional issues of assessment, contractual commitment, personal development and the therapeutic relationship.

In addition, clients experiencing or contemplating psychological therapy may find some of these ideas interesting. The fictional case scenarios used throughout the book focus on the way in which clients experience and respond to practitioners. Their stories, and their psychological journeys, are the vivid reasons for providing psychological therapy. All the theoretical and technical preoccupations so much prized by practitioners are always peripheral to these central concerns.

THE CRITICS OF PSYCHOTHERAPY

I have already mentioned some of the criticisms which are levelled at the practice of psychological therapy. In Britain, a pragmatic and empiricist scientific establishment continues to influence general attitudes to any form of assisted psychological metamorphosis. This has been compounded and confused by a linked tendency towards an over-determined, if slightly mocking, respect for psychoanalysis as the expensive limousine in which the client with money to spend may, possibly, be carried through the mysteries of psychological transformation. Otherwise, psychological treatments are often considered to be the last resort for unfortunate individuals unable to cope with life’s vicissitudes, and suffering from mental breakdown.

One result of these avoidant and hostile attitudes is that British practition ers have tended to polarise in their loyalties. There are those who seek the elite designation of psychotherapist, with its emphasis on protracted training and self-development in order to conduct an equally prolonged therapeutic engagement. In contrast the professional counsellor has tended to offer a friendly alliance between equals, in which one party offers a more skills-based and practical approach to psychological therapy.

Counselling may be concerned with developmental issues, addressing and resolving specific problems, making decisions, coping with crisis, developing personal insight 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 which respect the client’s values, personal resources and capacity for self-determination.

(British Association for Counselling 1992:3.1)

The popularity of counselling in Britain may well be in the implicit message that this could resemble good old professional advice, similar to that provided by lawyers, accountants and plumbers, and therefore need not be linked with the stigma of mental disorder. The psychological therapies offered by the ‘free at the point of delivery’ (Beveridge 1942) National Health Service (NHS) are in much demand, although seen by most clients as a final admission of their failure to cope, somewhat dignified by diagnosis of mental ill-health. This increased pressure on mental health clinics has encouraged a broader and more pragmatic role for the (NHS) psychotherapy practitioner, who is now likely to employ a wide variety of techniques and to experiment with brief and more focused psychotherapy. A centre of influence has been the careful work of a team of practitioner-researchers based at Sheffield University (Barkham and Shapiro 1989, Culverwell et al. 1994). Nevertheless, a belief in the superiority and desirability of a psychoanalytic training remains entrenched in many medical settings.

In the United States, and in Europe, the use of the psychological therapies seems to be generally more accepted, and less stigmatised. It is argued by Vidaver, Archer and Peake (1988:182) that one of the reasons for the American public’s willing embrace of psychotherapy in its more accessible forms since the 1950s, is that: ‘an emancipation of American thinking, in the form of literature from William Faulkner, Eugene O’Neill and Tennessee Williams, generated an intellectual ferment that placed high value on self-discovery, personal growth and understanding of behavior’ (Peake, Borduin and Archer 1988:182). It is probable that this intellectual interest in psychotherapy was itself imported by emigrants from mainland Europe. Somehow, the British social and medical institutions missed out on this earlier ‘explosion on the scene’ (Vidaver, Archer and Peake 1988) of the psychological therapies as a treatment of choice for a population in search of self-improvement.

Perhaps it needed the dogma of individualistic self-empowerment, endorsed by the Thatcherite 1980s, to encourage the rapid growth of counselling as a recognised British profession. I have already suggested some reasons for the increased acceptability of psychological intervention when this is offered in the form of facilitative counselling skills intended to increase an individual’s mastery of problematic life events. This has led to the rapid development and expansion of the British Association for Counselling (BAC) as an umbrella organisation which offers membership and a code of ethics to a wide variety of people who have some interest in practising as a counsellor. Only a minority have sought BAC professional accreditation. Similarly, there has been a rapid growth, within the British Psychological Society, of psychologists with a special interest in counselling psychology, leading to a professional qualification. Again this is at present held only by a relatively small group of chartered counselling psychologists.

Interestingly, British models of counselling have rapidly adopted the role of junior partners within the major psychotherapeutic orientations, rather than following the American example of establishing a specialised and separate profession with expertise within the more instructional domains of education, health and other areas linked to benevolent social control. This specialisation has been validated by the creation, in the United States, of highly professional training courses in counselling, with mandatory and extensive practice placements. These stringent training standards are shaped and validated by the licence to practice required in every state.

To some extent, the alliances established between models of counselling and psychotherapeutic schools in the United Kingdom have confused the British public’s perception of counselling as a new profession, and encouraged a homespun lay-person approach which sits uneasily with the complex theories of meaning developed by the major psychotherapeutic schools.

The recent development of the United Kingdom Council for Psychotherapy (UKCP) has gone some way towards formalising psychotherapy as a profession. However, the pressure to include a broad range of training institutions, each with their own variety of qualifications, usually linked to theoretical orientation, may not be helpful to the average UK citizen seeking a standard model of psychotherapy which can be trusted. There is, in any case, no empirical support for any generic superiority in efficacy being attached to a theoretical orientation. The development of a British criterion for competence, knowledge and experience which transcends theoretical orientation has been addressed, to some extent, by the qualifications required for accreditation as a BAC counsellor or as a chartered counselling psychologist.

During the same period, there has been a general groundswell, on both sides of the Atlantic, of a renewed critical appraisal, verging on condemnation, of the manner in which the psychological therapies have been employed. The three major criticisms levelled at the profession are that it has abused its power, ignored social injustice and exploited human distress for financial gain. Jeffrey Masson (1985) has spearheaded this onslaught, with particular emphasis on the self-protective theorising which enabled generations of Freud’s descendants to ignore the painful issues of childhood sexual abuse, and to marginalise issues of gender. This indictment has been superseded since the 1970s (Dahlberg 1970, Pope, Sonne and Holroyd 1993) by the evidence of even greater betrayals in the form of sexual usage of clients, usually female, by therapists, usually male. Such unethical betrayals of trust have crudely demonstrated the dangerous asymmetric nature of power (Rutter 1990) within the therapeutic engagement. This imbalance, and its cavalier exploitation within a profession which was traditionally male-dominated, has been explored more extensively by feminist critics and is now an area for open discussion between therapists. The view promoted by this book is that, while practitioners cannot avoid the responsibility of power within the therapeutic engagement, they can refrain from the subtle grandiosities which such power can induce. One method would be to adopt the more straightforward and explicit role of a tradesperson, engaged to offer a service, and to work with and for their clients. This pragmatic attitude has been recommended since the seminal work of Alexander and French (1946) but is still rarely voiced in training programmes or in mainstream psychotherapy literature.

Alice Miller (1985, 1987) has argued that there has been a more general disempowerment of many psychotherapy clients. Their childhood experiences are liable to be discounted within the ‘poisonous pedagogy’ of repressive parenthood imposed through mainstream psychoanalysis and within society at large. David Pilgrim (1992) has consistently and coolly provided a professional psychologist’s critique of the abandonment of collective responsibility and potential risk of victim blaming within the rapidly increasing field of private practice. His arguments dovetail with the more vivid denunciations of the novels of Fay Weldon (see, e.g., 1993), whose anti-therapy statements gain media publicity. The more gentle critiques of David Smail (1987) and Miller Mair (1989) underline the tendency of practitioners to conduct a one-sided dialogue rather than a meaningful discourse with their clients.

In all these critiques, the insidious professional narcissism induced by the intensity of the therapy session is to be discerned. The psychological therapist can be blinkered by an espoused and painfully acquired theoretical training, seduced by the expert role and confined by the setting within which he or she is reimbursed. Practitioners often work within what can seem to the client a closed system. Their reliance on their own theories, regarding the usefulness of transference insights, the prevalence of faulty cognitive schemas or the lack of enough unconditional positive regard tends to supersede the client’s own experience in the external world. Above all, the picture is distorted by the prevalent belief of most practitioners that one particular therapeutic engagement is the central influence on a client’s life.

As I have reiterated throughout this book, the psychotherapeutic situation is unique. Patients may look back upon it as the only time in their lives during which they feel themselves to have been understood and fully accepted by another human being.

(Storr 1979:157)

This book aims to provide a creative response to critics by outlining an approach respectful of a client’s ownership of their personal psychological development.

A fundamental and longstanding doubt about psychological therapy, particularly in its more psychoanalytic guise, is with regard to its efficacy. The doubts and disputes initiated by Eysenck in 1952 are still unresolved, especially in Britain, where the lengthy process of validation engaged in by American therapists during the 1970s (Meltzoff and Kornreich 1970; Luborsky, Singer and Luborsky 1975) is not generally known. Nor will this book attempt to engage with this thorny debate, except to acknowledge the impossibility of engaging in value-free outcome research, the futility of attempts to prove a superior theoretical orientation and the powerful influence of relationship and systemic issues within the therapeutic journey. The growing interest amongst practitioners in developing the evaluative approach of the ‘practitioner-scientist’ (Elton Wilson and Barkham 1994) to their professional activities is a hopeful development which may increase a more realistic understanding of process and outcome of the therapeutic engagement.

THE DEMAND FOR AN ACCESSIBLE AND EFFECTIVE APPROACH

Whatever the criticisms and divisions operating in the field of psychological therapy, there is a continuing demand for the ‘talking cure’ (Breuer and Freud 1955) and a growing acknowledgement of the need for more effective psychotherapy and counselling to be made available to more clients within a climate of limited resources in time and funding. The usual response to this issue is to presume that short-term or brief psychological therapy is indicated. This suggestion is seen by many practitioners as a meagre and cheese-paring solution which puts the cost-effective solution above considerations of quality. Even among those who extol the qualities of the brief psychotherapies there can be discerned an uneasy defensiveness, especially with regard to the appropriateness of short-term approaches for many client groups. The implication is that in the best of all possible worlds, longer-term psychotherapy would be the response of choice. Decades ago, Alexander and French (1946:v) described the prevalence, ‘among psychoanalysts’ of ‘an almost superstitious belief that quick therapeutic results cannot be genuine’. The most recent handbook about psychotherapy demonstrates that little may have changed for psychoanalysis in the 1990s: ‘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’ (Clarkson 1994:5). While humanistic approaches to psychotherapy are critical of many aspects of psychoanalysis, the notion of the length of psychotherapeutic engagement as somehow indicative of its depth is not usually challenged. Indeed it is an aspect of psychoanalysis that is held in somewhat reluctant awe. This emphasis on quantity rather than quality, as the means to deliver conditions for true psychological change, has to be questioned and challenged by practitioners themselves if the profession is to withstand accusations of financial motivation and uncritical elitism.

The model offered in this book, of ongoing assessment, flexible commitment policies and areas of focus respectful of the client’s life process, is not limited to brief psychotherapeutic engagements. It is offered to practitioners, especially those critical of short-term work, as an invitation to use a range of considered options, to design, in consultation with their clients, an appropriate and practical package of focused psychological change. This design would need to take into account and use the external realities of clients’ lives, including considerations of available time and funding. The approach delineated in this book is intended to extend beyond the shortterm versus long-term psychotherapy debate, through an emphasis on the client’s own search for meaning within the materiality of their existence. All practitioners are invited to consider, at point of entry, a series of alternatives to any automatic offer of continuing long-term psychological therapy. The dialectic would then shift to questions of timing, motivation, and readiness for change, and wou...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• LIST OF TABLES
• ACKNOWLEDGEMENTS
• CHAPTER 1: WHY THIS BOOK?
• CHAPTER 2: A FLOW-CHART FOR TIME-CONSCIOUS AND FOCUSED CONTRACTUAL COMMITMENT
• CHAPTER 3: STAGES TO GO THROUGH: USING THE THERAPEUTIC RELATIONSHIP TO DISCERN THE ENTRY POINT WITHIN A LIFE PROCESS OF PSYCHOLOGICAL EVOLUTION
• CHAPTER 4: ASSESSMENT AND REVIEW: A TWO-WAY PROCESS
• CHAPTER 5: THE MINI-COMMITMENT: CONTACT, COMMITMENT AND CLARIFICATION
• CHAPTER 6: THE TIME-FOCUSED COMMITMENT: USING TIME AS A TOOL
• CHAPTER 7: THE TIME-EXTENDED COMMITMENT: MAINTAINING THE MOTIVATION
• CHAPTER 8: THE TIME-EXPANDED COMMITMENT: ‘A DIRECTION, NOT A DESTINATION’
• CHAPTER 9: NINE CLIENTS IN SEARCH OF PSYCHOLOGICAL EVOLUTION: OVERARCHING ISSUES FOR PRACTITIONERS USING A TIME-CONSCIOUS APPROACH
• BIBLIOGRAPHY