The Handbook of Individual Therapy

Windy Dryden, Andrew Reeves, Windy Dryden, Andrew Reeves

• Publisher: SAGE Publications Ltd
• Year: 2013
• Print ISBN: 9781446201374, 9781446201367
• eBook ISBN: 9781446293560
• Edition: 6
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

?[This] is essential reading for all who aspire to professional practice to ensure that knowledge and skills are up to date in order to best serve their clients.?
Professor Sue Wheeler, University of Leicester

?[It] continues to be the book that one turns to when looking for a clear introduction to the broad range of therapies that are offered in the UK today.?
Dr Nick Midgley, Anna Freud Centre

This classic text has helped over 50,000 students wishing to understand the key counselling and psychotherapy approaches. This sixth edition is the most comprehensive update since it was first published in 1984, with 15 newly contributed chapters and 8 updated chapters. Each approach now includes a new Research section summarising the research findings, an in-depth Case Study illustrating how that approach works in practice, and an extended Practice section. Also covered:

· historical context and development

· main theoretical assumptions

· which clients will benefit most

· strengths and limitations.

New chapters include Compassion-Focussed Therapy, Interpersonal Therapy, Mindfulness in Individual Therapy, Pluralistic Therapy and The Transpersonal in Individual Therapy.

This is an ideal one-stop shop for trainees of counselling, psychotherapy, counselling psychology, psychology and other allied professions wanting to learn about the most commonly practised therapies today.

Windy Dryden has worked in the fields of counselling and psychotherapy since 1975. He is author/editor of over 200 books.

Andrew Reeves is a BACP Senior Accredited Counsellor/Psychotherapist at the Univeristy of Liverpool and a freelance writer, trainer and supervisor.  He is former Editor of the Counselling and Psychotherapy Research journal.

1

The Cultural Context of British Psychotherapy

Colin Feltham

Psychotherapy and counselling¹ happen most commonly between two individuals, in private. Not only is therapy private when it happens but is also confidential later, so that relatively little of the actual phenomena of therapy, in spite of some consumers’ write-ups, disguised case studies, transcribed tape-recordings and conversational analyses, find their way into publications. This book presents the theories of various mainstream therapies structured according to certain historical, conceptual, professional and clinical frameworks, along with case studies. A focus on research, training and supervision is provided in later chapters. In order to provide some wider and integrating balance, this introductory chapter looks at a number of transtheoretical areas to contextualise this most private of activities.

1 THE NATURE OF HUMAN SUFFERING AND PSYCHOLOGICAL NEED

Some of the literature on therapy sustains the impression that it arrived a little over a century ago with Freud and perhaps his immediate predecessors and contemporaries, and that not much of interest or relevance existed or is worth talking about from before that time. But clearly human beings have suffered and have had emotional or spiritual needs and aspirations for millennia, even if these have manifested in very different ways. During that time many remedies or solutions have been practised (Ellenberger, 1970). Today’s needy or help-seeking client and trained therapist did not appear in a vacuum and we deceive ourselves if we imagine they did.

There are several reasons for including this brief overview. First, while therapeutic theorists are asked to consider their ‘image of the person’ and human nature, this area of theory is arguably one of the weakest in many models of therapy, probably due to therapists’ background lying in psychology rather than philosophy or historically grounded disciplines, and to their naturally prioritising urgent, practical, clinical concerns. Messer (1992) discusses therapists’ ‘belief structures’ and ‘visions of reality’ and the very language used betrays a certain subjective tenor. Secondly, this weakness is not merely an intellectual inelegance but arguably a potential pitfall for the advance of theory and clinical understanding and for the status of therapy. Thirdly, since the development of evolutionary psychology and psychotherapy, relatively few writers from the ranks of different therapeutic models have kept pace with this trend (exceptions including Burns, 2007; Stevens and Price, 2000). Fourthly, another weakness in most theories of therapy has been in their definitions of the scope of what they can do in relation to what clients need; in other words, a failure to define ‘suffering’ or deficit or, if this terminology is disliked, then an alternative nomenclature and set of explanations. Fifthly, it is doubtful whether progress can be made towards the integration of therapeutic models without a better philosophical and scientific focus on what it means to be human and to have psychological needs, if indeed any consensus can be achieved in our so-called postmodern era.

There is considerable agreement that we have existed for about 100 000 to 150 000 years in our homo sapiens sapiens form. Our ancestors’ upright gait probably came about some 4 million years ago, notable increases in brain size took place about 2.5 million years ago, coinciding with significant meat-eating. Some writers have speculated on such distant events and our modern problems with birth difficulties – long, dependent and vulnerable childhoods, over-cognitivisation and environmental rapaciousness. Even now, in our contemporary theoretical models of therapy, we are sometimes obliged to make judgements as to whether cognition or emotion is the primary mode of human functioning, the latter being more evident earlier in our evolution and probably having some female bias, the former arguably having connotations of emotion-suppression, control and detachment – some models urge us to think more rationally, others to feel more deeply.

Our original ancestors, probably from Africa, were hunter-gatherers who lived cooperatively in quite small groups. Suggestively, however, use of alcohol is recorded from 7000 years ago and opium 5000 years ago. There is ample evidence of violence and, alongside geographical expansion and technological progress, common anxieties about death. A drastic decline in the nomadic, hunter-gatherer lifestyle occurred about 4000 years ago, coinciding roughly with the advent of the Abrahamic religions. In short, there is a recognisable human story comprising both progressive and destructive, and myth-making and knowledge-seeking elements. We have become increasingly technologised, urbanised and overpopulated (projected to rise towards 8 billion by 2020) and we have not overcome our warring tendencies, although many live in conditions of relative peace and prosperity.

All religions offer accounts of human beings losing deep contact with spiritual identity, suffering as a consequence, and needing guidance or succour. Whether certain individuals hanker pathologically for a bygone age or for lost intrauterine bliss (Freud’s ‘oceanic feeling’) when they present for therapy is a moot point. In roughly the last 200 years, the dominance of industry and capitalism with their attendant effects on working lives is extremely significant. Those forms of unhappy servitude, or what Marx termed ‘immiseration’, associated with capitalist growth, may or may not be compensated for by the advantages provided by medicine and technology, such as disease reduction and prevention, higher rates of successful births and greater longevity. While some argue that we now live in and need to adjust to a ‘post-emotional society’, others are alarmed at the loss of emotional intelligence and humanness, qualities that are of course the bread and butter of most forms of therapy.

Many now argue that there is no universal human nature at all, that we cannot speak meaningfully of a human nature but only of different theoretical versions, different cultures and individuals. Others argue that we have an all too obvious set of determined characteristics – many of them, like aggression, jealousy, greed and deception, highly negative – which parallel a range of freedoms (Pinker, 2003). Today’s debates echo the unresolved nature–nurture debates of past decades. But we can say with confidence that it is in our common nature to be dependent when young, to grow, to couple, to age and die, and along the way most of us struggle and experience non-physical suffering to some extent. If, therefore, we have any human condition shared by all 7 billion of us, it is this – that we must negotiate our way across the lifespan with whatever resources we possess, and most of us are driven to avoid suffering and maximise pleasure, as Freud wrote. Even then, none of us can avoid ageing and physical death and many have far more than their share of loss and sorrow, depending on genetic inheritance, formative experiences, life events, luck, exercise of choices, cultural and idiosyncratic factors. Kleinian and existentialist therapies take some such realities on board more obviously than most other models of therapy. It is also the case that most of us define ourselves and are closely supported by families and communities; and that insufficiencies in care, abuse, shame, loss and rupture in the social domain explain the formation of many of our psychological problems.

Insofar as distinct images of human nature, or pertinent aspects of it, can be identified in the approaches outlined in this book, we might select the following: self-deception, struggle, dualism, trustworthiness, existential becoming, experiencing, OK-ness, cognitive processing, hedonism, storytelling, solution-building, attachment-oriented and evolved. Some approaches have no single clear view of human nature and many regard us as complex biosociopsychological beings. Key questions for exponents of different models of therapy include the following: To what extent is there an agreement on any essence of human nature and its problematic aspects? To what extent does each model either address this and explain how it is incorporated, or dismiss it as irrelevant, and why? Where does each model lie on the spectrum from conceiving human beings as being ‘wholly determined’ to ‘wholly free’? To what extent is each model optimistic or pessimistic in its outlook? To what extent does each model remain open to new information from scientific or other disciplines? Significant differences in answers to these (and one would expect humanistic approaches to be somewhat more optimistic than psychoanalytic approaches, for example) indicate their implicit philosophies of human nature and potential.

2 ROOTS OF THE PSYCHOLOGICAL THERAPIES

Ellenberger (1970) traces the rise of therapy from the ‘primitive psychotherapy’ of the Guyanan medicine man and the use of drugs, ointments, massage and diet. He also acknowledges therapeutic work with loss of the soul, spirit intrusion, breach of taboo and sorcery across many cultures. Possession and exorcism are phenomena associated with the Christian church as well as many non-Western cultures, Ellenberger making links with the ‘hysterical neurosis’ and attempted cures of late nineteenth century Europe. Ellenberger also lists confession, gratification of frustrated wishes, ceremonial healing, incubation, hypnosis and magical healing, and temple healing and philosophical psychotherapy as forerunners to contemporary scientific psychotherapy. Hence, we can see the seeds of today’s methods in distant history – we can also see, in certain epochs, rivalry between schools of therapy or healing, as in early Greek schools of healing. Albert Ellis’s repeated tribute to the Stoic philosopher Epictetus (55–135 CE) demonstrates a clear link across almost 2000 years between original Stoicism and the modern, psychological, clinical therapy of rational emotive behaviour therapy and cognitive-behavioural therapy (CBT) generally. (See also Nussbaum, 2009.) Many similar ideas are found in the teachings of the Buddha more than 500 years before Epictetus. Let us recall too that Frank’s (1974) anthropologically informed study of psychotherapy acknowledged such sources as well as contemporary transcultural likenesses, arguing that certain common factors could be found universally. The superiority of Western, talking therapy is easily assumed but this is being questioned by some, such as Moodley and West (2005), and arguments put forward for an integration of psychological with traditional healing methods.

Physical, medical or biological models of therapy have early roots and include herbal remedies, blood-letting, emetics, trepanning, acupuncture, neurosurgery, electroconvulsive therapy (ECT) and psychopharmacology among others. Even homeopathy must be considered a form of physical intervention. In the west, psychiatry developed as the extension of medical analysis and treatment into the domain of severe psychological or emotional problems. Psychiatric abuses and failures – unwarranted incarceration, indiscriminate and damaging use of ECT, drugs used as a ‘chemical cosh’ with highly negative side-effects, and crude, botched lobotomies – created much vociferous opposition from patients and formed part of the drive against the ‘biomedical model’ (Bentall, 2010). Today, psychopharmacological treatment for schizophrenia and bipolar disorder, for example, is partly accepted but also strongly objected to by some groups. While a great deal of therapy has been criticised for targeting the self-indulgent ‘worried well’, psychological therapy has been increasingly appropriated and boosted by those suffering from depression, anxiety and similar conditions wanting to talk in an exploratory, cathartic and social learning manner rather than (or as well as) ingesting medication. There is growing research evidence in support of the use of certain medications alongside psychological therapies and in some cases a demonstrated superiority of talking therapy over medication.

The prefix psyche comes from the Greek for breath, soul or life. The psychological therapies clearly did not properly begin with Freud in 1896, who regarded himself as a neurologist and his discovery, psychoanalysis (the ‘talking cure’), as his own creation. Many regard psychoanalysis as having its conceptual and inspirational origins in religious and romantic aspects of the Judeo-Christian tradition. Many of the founders of contemporary mainstream psychotherapies themselves have Judeo-Christian origins. The term psychotherapy appeared in 1853 but did not refer to an applied discipline necessarily drawing from psychology. Psychology itself appeared as a technical term in 1748 and even then had overtones associating it with ‘soul’. Psychology has of course had its internal battles over identity and has moved significantly from its early insistence that it should scientifically exclude subjectivity. What we generally mean by ‘psychological therapy’ is an essentially talking-and-listening form of help that does not primarily utilise medical or physical means. While this could broadly include any spiritual or philosophical concepts and techniques (these are, after all, not medical or physical), it tends not to. Since psychology is promoted as a scientific discipline, clinical psychology, and latterly counselling psychology, have been advanced as applied scientific professions, in turn suggesting a superiority over earlier religious and philosophical traditions of helping people with their problems in living.

3 CURRENT SOCIOCULTURAL CONTEXTS OF THERAPY IN BRITAIN

Cushman’s (1995) seminal text on the historical development of psychotherapy within the American context remains highly instructive but no directly comparable British text exists. Cushman’s analysis problematises the rise of the peculiarly Western sense of self and Rose’s (1989) analysis of British trends in the rise of psychology and its influences on our sense of a private self has some resonances (see also Wright (2011) for an Australian-based but widely applicable view). Significantly, in spite of a decades-long tradition of couple counselling and group therapy, individual therapy remains by far the preferred choice. We were told by the authors of one piece of (market) research (BACP/FF, 2004) that 21 per cent of the British population had had some form of counselling or psychotherapy and that up to 82 per cent of people would willingly have therapy if they thought they needed it. Previous estimates of the numbers experiencing therapy had been around 5 per cent at most and there may be reasons to doubt a figure as high as 21 per cent. Nevertheless, since the struggling 1970s, when counsellors and psychotherapists encountered a great deal of public and media resistance, acceptance has continued to grow. The visibility and accessibility of counsellors in many GP practices and Improving Access to Psychological Therapies (IAPT) schemes means that therapy is no longer perceived as an elitist, unaffordable or dubious activity but as potentially available and beneficial to the entire adult population. Availability has been buttressed by the presence of free counselling in many colleges and universities, employee assistance programmes and voluntary organisations such as Relate, Cruse and Mind.

Twentieth-century therapeutic provision was driven by a combination of factors: early psychoanalytic pioneers promoting their ideas via medical training, by the personnel of voluntary agencies and others exploiting American therapeutic practices and by a general enthusiasm for theories focusing on the inner life of individuals and its improvement. Britain became home to several eminent psychoanalysts, the Tavistock Clinic and Institute of Psychiatry were very influential in the dissemination of therapeutic theory and practices. Attachment theory and object relations therapy, driven by Klein, Winnicott, Bowlby, Fairbairn and others, owe much to the British empirical tradition of infant observation; and key figures like R.D. Laing promulgated original views on the limits of psychiatric treatment and the promise of talking therapy.

The sociologist Halmos is well known for his thesis that counselling and therapy came into their own around the 1950s as formal religion and politics were often perceived as not meeting individual needs: ‘at least to some extent, the counsellors have been responsible for a revival of interest in the rehabilitation of the individual, and a loss of interest in the rehabilitation of society’ (Halmos, 1978: 7). Perhaps the 1960s, 1970s and early 1980s were characterised by a certain secularism, hedonism and optimism (which paralleled the humanistic psychology movement), and respect for formal politics declined markedly in the 1990s and early 2000s alongside a steady turn against left-leaning politics and towards acquisitiveness. But at the same time the growing impact of feminist freedoms, the rise of multiculturalism and gradual acceptance of homosexuality made for an openly diverse society in which consumer demands and health reforms have combined to favour certain forms of counselling and psychotherapy, as well as witnessing a growth of interest in spirituality and transpersonal therapies.

Can it be said that the contemporary social and psychological problems of the British have a character distinct from those of other nations? In some surveys of self-assessed happiness the UK rates relatively highly. Yet some commentators have assessed Britain as a society populated by somewhat depressed citizens who cannot keep pace with the heavy expectations placed on them and who sense that ever greater acquisition and pleasure-seeking do not result in satisfaction but in compromised mental health. Obesity too has become a marked problem for the British. Layard (2003) cites a figure of about 35 per cent for British happiness across the past 40 years but points out that we deserve to be much happier given our level of affluence compared with eastern European nationals. Marked depression and anxiety as national characteristics paint a gloomy picture and one that inexplicably contradicts the more optimistic happiness survey cited above. Trite though the conclusion is, we must assume that UK citizens are pulled between a kind of stoicism and frank demoralisation. George Cheyne’s The English Malady, published in 1733, celebrated for its portrayal of depression as a very common characteristic, shows that this is nothing new.

The UK has been a major importer of American therapy models, as of most other American commodities. In turn, Britain has provided inspiration for many other countries in developing their own therapy services and professions, as well as a certain positive energy devoted to professionalised therapy and links with social justice. Psychotherapists and Counsellors for Social Responsibility was formed in 1995 to promote the political dimension of therapy, to challenge oppression and to champion better and fairer provision of therapy. Decades ago Reich sought to integrate psychoanalytic with Marxist concepts. Adler, Horney, Fromm and others attempted to bring social conditions into the aetiological equation. In the heyday of humanistic therapy, Re-evaluation co-counselling had begun to promote the discharge of social as well as individual distress. Groups like Red Therapy sought to combine radical individual and group therapy...

Table of contents

• Cover Page
• Halftitle
• Advertisement
• Title
• Copyright
• Dedication
• Contents
• List of Figures
• List of Tables
• About the Editors and Contributors
• Preface
• Acknowledgements
• 1 The Cultural Context of British Psychotherapy
• Part I The Psychodynamic Tradition
• Part II The Humanistic-Existential Tradition
• Part III The Cognitive-Behavioural Tradition
• Part IV Other Specific Approaches
• Part V Broader Developments in Individual Therapy
• Part VI Professional Issues
• Appendix 1
• Index