Phil Mollon Ph.D. DCEP
Paper presented to the British Psychological Society: Division of Counselling Psychology Annual Conference. University of Warwick. 11 July 2009
Our Rich Heritage – are we building upon it
or destroying it?
[The views expressed here are the personal opinions of the author. It should not be assumed that any of his colleagues would share his views. Phil Mollon recognises that his own views, although sincerely held, may be mistaken]
A paradox haunts the psychotherapy professions. Whilst talking therapies are ostensibly being promoted within the NHS, Counselling (and Clinical) Psychology are being destroyed. The rich and complex discourse of 120 years of psychotherapy, with its attention to the nuances of individual experience, is collapsed into comparisons of specific protocols for specific diseases. This trend currently finds its zenith in the deeply malign NICE guidelines, which explicitly endorse a medical model. Decades of deconstruction of 'mental illness' and examination of the socio-cultural-political context in which mental distress evolves have been discarded in a vulgar exuberance over favourable comparisons between CBT and SSRIs. That psychologists, and the BPS, have colluded in this betrayal of our professions through an endorsement of the crude medical model of NICE is deeply puzzling - a phenomenon that itself deserves careful study. A further paradox is that behind the tawdry glamour of IAPT and dumbed-down forms of CBT, there are exciting developments that hold out the possibilities of real healing of psychological distress.
Here is a vision of the future, drawn from an editorial by Nick Totton in Psychotherapy and Politics International:
"It was in 2023 that ‘traditional’ therapy and counselling finally became illegal under the new Social Fraud Act, leaving New Therapy in command of the field. Looking back, this had probably been inevitable since the state regulation of psychotherapy and counselling…. once the state took on the job of policing therapy, its definition of what was acceptable was bound to become increasingly draconian, as therapy was adjusted to fit concepts and standards which the civil service could comprehend and administer…. What happened to the discredited traditional therapists? Some of them had been more or less underground since the later 2010s, changing their name to ‘psychological helper’, ‘emotional supporter’, or some other dubious term, before this option was removed by the Act of 2023. A very few served prison terms for illegal use of protected titles, or later for illegal practice of discredited techniques. But the great majority either silently retired or adapted to New Therapy – demonstrating, as the state saw it, the feebleness and fraudulence of their practice: if they were not even prepared to stand up for the value of their own work, then why should anyone else take them seriously?....In 2025, of course, the Revolution began...." (Totton 2008 p 1-2)
When I have read this to colleagues, some have immediately understood and resonated with it, whilst others have appeared puzzled, thinking it just sounded strange and paranoid.
My own original core profession is clinical psychology. I feel counselling psychology is actually in a healthier state and potentially more able to survive some very destructive trends and forces that currently bear down – partly because of the humanistic values that are at its heart, and partly because it is not dominated and owned by the NHS and the government in the way that is the case for clinical psychology.
Those who work within the NHS will know, from tangible daily experience, that a huge agenda of control is currently distorting therapeutic work with clients. It is dictated, in Stalinist fashion, from the top – expressed through a variety of political mechanisms and processes, including Improving Access to Psychological Therapies, current commissioning procedures, but, above all, using the vehicle of NICE. It is my perception that NICE is a most extraordinarily toxic and malign influence upon psychological therapy in Britain. I have no problem with the idea of seeking cost-effectiveness and for the rationing of limited resources – nor is my concern that it recommends only therapies A & B and not C & D. The problem with NICE is deeper and more insidious in its corrupting action – on therapeutic practice and scientific discourse. It is an organ of the state that consumes our psychological discourse, our rich heritage, our multifaceted gems of brilliant theorising and observation around human nature and the human condition, our charismatic and visionary pioneers – such as Rogers, Maslow, Freud, Jung, Beck, Bowlby, Winnicott, Kelly – and homogenises all of this into a bland and emotionally denuded prescription of CBT for everything. Within the NHS we have a marketplace, where different providers compete – but it is not a natural marketplace based on what services people wish to purchase. Instead it is shaped by government targets, strange performance indicators, and psychotherapeutic ‘products’ determined by NICE.
When I was a very young man, back around 1974, training in clinical psychology, my behaviourally oriented supervisor explained that he did not really find the concept of personality very useful. He reasoned that people behave differently in different situations – and that basic principles of learning theory indicate that behaviour is determined by the reinforcement contingencies in the environment. BF Skinner had outlined, in his novel Walden Two, his vision of a utopian society organised on scientific behavioural principles, such that desirable behaviours were reinforced and damaging behaviours extinguished through lack of reinforcement. Today we have our government, through the vision of an influential economist, promoting a different model of behavioural modification, now based on training people to think differently.
My behaviourally oriented supervisor was a friendly guy – a warm smile – he would convey empathy and acceptance – explore people’s thoughts, feelings, and behaviours, suggest they try out new behaviours – above all, he would be encouraging, rewarding his students and clients for their stumbling efforts. He did not give his way of working a fancy name.
However, some of the behavioural thinking of the 60s and 70s seems in retrospect a mixture of the sophisticated and the naive. It was a time when an electric shock box was standard equipment for the clinical psychologist – and I recall being taught to apply this to a lady with a nervous tic (it made her cry) and a young man who sexually exhibited himself to children (I don’t think it helped). The shock box was also used to ‘treat’ homosexuality (the lack of success gradually extinguished these efforts). They could sound very scientific. For example, in the 1969 book Aversion Therapy and Behaviour Disorders [by Rachman and Teasdale], in a chapter on aversion therapy for sexual disorders, I found the following equation used to account for the process:
[where E is excitatory potential; H is habit strength; D is drive; K is incentive motivation].
Before we laugh too much, we might wonder how our colleagues of 50 years in the future might view our present preoccupations and assumptions.
It was also during the 1970s that a Chilean-born psychoanalyst in the US, Otto Kernberg, began to propose a concept of ‘borderline personality disorder. He presented some rather complex theorising, based on Kleinian concepts of constitutionally elevated aggressive drive combined with primitive defences, particularly splitting and projective identification. This originally obscure and somewhat esoteric diagnostic concept, created through an amalgam of South American Kleinian culture and North American psychoanalytic ego psychology, has now become a commonplace cliché (although its psychoanalytic roots are often forgotten). It is startling to reflect on the shift, from the opposition to the notion of personality shown by behavioural psychologists of the 70s to the ubiquitous concepts of personality disorder and diagnostic categories that saturate the constructs of contemporary cognitive-behavioural psychologists.
Now we are all regulated by a body called the Health Professions Council – but are the psychotherapies health care professions? In his 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. [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 – and particularly by talking to one who will listen
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 – and in the 1980s, the American Psychological Association successfully sued the American Psychoanalytic Association for its refusal to train psychologists. However, this medicalisation 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.
It seems to me that human thought processes and attitudes are, to a greater extent than sometimes appreciated, economically determined. The ways people think, and the views they hold, are influenced, not entirely by a rational consideration of the evidence, but by what is rewarding financially. Thus there are economic rewards, for some, in espousing an implicit medical model even if its validity is dubious. Similarly, those who harness their therapeutic products to certain statistical and experimental methods, such as randomised controlled trials, may declare that these are the ‘gold standard’ – an explicitly economic metaphor implying a usurping of the fundamental standard of value against which all other methodological currencies must be compared. This is done despite the otherwise obvious point that one may often learn much more of clinical value from detailed case studies.
Back in the 1950s, Hans Eysenck, one of the first clinical psychologists in Britain, launched an attack on psychotherapy – 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.]
Slightly earlier, in 1949, Eysenck had stated the Maudsley view of training in clinical psychology:
“It is our belief that training in therapy is not, and should not be, an essential part of the clinical psychologist’s training, that clinical psychology demands competence in the fields of diagnosis and/or research, but that therapy is something essentially alien to clinical psychology, and that if it is considered desirable on practical grounds that psychologists perform therapy, a separate discipline of Psychotherapist should be built up to take its place alongside that of Clinical Psychologist.” 
Adding later in the same paper:
“it has been our experience that students who are interested in the therapeutic side are nearly always repelled by the scientific flavour of research training, while conversely, the students who are best suited and most successful on the research side betray little interest in active therapy” 
The editor of a book of Readings in Clinical Psychology [R.D. Savage], published in 1966, wrote of the importance of “well standardised, valid, and reliable tests for diagnosis, sound experimentally based techniques” and then adds “at the same time it must be recognised that the task of the clinical psychologist is a difficult one, because he has to confront patients … The Clinical Psychologist has to be in contact with patients and this unavoidable complication complicates his work”. This is not written in a tone of irony.
By contrast, looking at the special edition of the Counselling Psychology Review of Feb 2006, celebrating the first 10 years of the profession, I find Emmy van Deurzen describing counselling psychology as characterised by a “commitment to an ideal of psychology with a human face” [p 11] and by David Lane and Sarah Corrie as “a value set that favours the personal and the subjective alongside scientific values” [p 14], who also state that “At its core, counselling psychology privileges respect for the personal, subjective experience of the client over and above notions of diagnosis, assessment and treatment, as well as the pursuit of innovative phenomenological methods for understanding human experience.” - adding that “A move towards a more medical model could threaten precisely those attributes that make counselling psychology distinctive” [p 17].
Eysenck 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. Whilst cognitive therapy has a place, it does not help to process emotional pain. I can think of several instances where I have heard of a client being ‘challenged’ out of their emotional pain when their presenting symptoms were obviously an expression of that pain – for example, a young man with panic attacks, that had arisen as a result of his attempts to suppress his grief about his mother’s death, being subject to standard CBT for panic.
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. These are, after all, in the 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’ 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.
Are the clients we see suffering from ‘specific diseases’ – the term used by NICE to describe their remit? In some cases the medical model has some relevance – where we are trying to help people with the emotional aspects of physical illness, or where an underlying biological condition is determining a person’s mental state. Moreover, some states of mind may be abnormal enough to merit the term ‘ill’ – perhaps ones which are beyond the scope of psychotherapy. Mostly, however, 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.
Richard Bentall, in his book Madness Explained demonstrates persuasively that the Kraepelin-based diagnostic system, which is still the basis of psychiatric classification today, has no scientific validity. Whilst people can experience a variety of psychological ‘complaints’, in most instances, there is no underlying ‘disease’ causing these.
In 1980, the DSM-III was produced – a vast increase in size from the earlier DSM-II. The task force was led by Robert Spitzer. He had been particularly concerned about the reliability of psychiatric diagnosis since the famous 1973 study by the sociologist Rosenhan called On being Sane in Insane Places. He had arranged for 8 non-psychotic confederates to get themselves admitted to a psychiatric hospital by claiming to experience a voice saying a single word (either ‘thud’, ‘hollow’, or ‘empty’). This was the only symptom presented. All were admitted to a hospital. After admission they stopped feigning their experiences. All but one was given a diagnosis of schizophrenia – the other was diagnosed as manic-depressive. When they became asymptomatic, they were considered to be in remission. Once admitted, they were not able to obtain release until they agreed with the diagnosis of the psychiatrists and took antipsychotic medication. Since the reaction of the psychiatric establishment was disbelief, Rosenhan followed this up by informing the staff of a teaching hospital, where it had been claimed that such misdiagnosis could not happen, that over the next three months one or more pseudo-patients would attempt to be admitted. No such attempt was made – but out of 193 patients, 41 were considered by staff to be pseudo-patients and a further 42 were suspected of being. Therefore Rosenhan concluded that psychiatric diagnosis is subjective rather than reflecting inherent disease characteristics. Spitzer, heading the DSM-III task group had been one of the main critics of the Rosenhan study. He sought to establish clear rules for diagnosis – thus focusing on reliability but ignoring the point that validity of psychiatric diagnosis was in question.
Trauma specialist Dr. Colin Ross, drawing on his experience of serving on DSM committees has written of the ad hoc and non-scientific way in which psychiatric diagnostic categories are developed. Speaking at the Cardinal Clinic trauma conference last year, 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, 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.
Some forms of mental disturbance do have illness qualities. One of the toxic effects of NICE is to encourage an assumption that we understand all forms of mental illness and know how to treat them. This is not the case. Whilst some states of distress do respond well to various approaches, I have worked in psychiatric settings long enough to know there are many people whose disturbance is profound, complex, and intractable. These seem to involve malformations of the psyche – horrendous and replicating – analogous to physical forms of cancer – but we cannot just remove the tumours. There is no question that such people are mentally or personally ill – yet, as with physical cancer, the cause may be unknown and many factors may be involved. They do not easily fit conventional diagnostic categories. We are far from being able to understand or treat such conditions. We may have to wait for the emergence of some, as yet entirely unknown, new paradigm. Admitting our ignorance at least enables us to be open to new observations and perspectives.
When reading accounts of rcts, it is easy to slip into assuming that statistically significant change means that people actually resolved their psychological difficulties. Whilst for some people this fortunate result may have occurred, it is not the case for most participants in psychotherapy trials. The sobering truth is stated by Westen et al (2004), as follows:
“… the existing data support a more nuanced and, we believe, empirically balanced view of treatment efficacy than implied by widespread use of terms such as empirically supported, empirically validated, or treatment of choice …
With the exception of CBT for panic, the majority of patients receiving treatments for all the disorders we reviewed did not recover. They remained symptomatic even if they showed substantial reductions in their symptoms or fell below diagnostic thresholds for caseness; or they relapsed at some point within 1 to 2 years after receiving ESTs conducted by clinicians who were expert in delivery of the treatment, well supervised, and highly committed to the success of their treatment of choice” [p615]
Commenting on the huge NIMH Collaborative Research Program, comparing CBT, IPT, medication, and placebo, they conclude:
“Despite a promising initial response, by 18 months posttreatment, the outcome of brief psychotherapy was indistinguishable from a well-constructed placebo” [p599]
Similarly, Hollon et al. (2002) conclude:
“Despite real progress over the past 50 years, many depressed patients still do not respond fully to treatment. Only about half of all patients responded to any given intervention, and only about a third eventually meet the criteria for remission. Moreover, most patients will not stay well once they get better unless they receive ongoing treatment.” [p70]
For the most part, our mainstream psychological therapies, including CBT, are not clinically effective, in the sense of reliably and predictably eliminating all the manifestations of psychological dysfunction.
One of the problems with the narcissistic state of mind – detectable by signs of complacent and unquestioning satisfaction with one’s state of knowledge – is that it does not tolerate the sense of ignorance. The narcissistic stance assumes it has the truth – or identifies with some group or organisation that it assumes has the truth. It then wishes to impose this truth on others. As a character trait, and if combined with a certain intellectual aptitude, this stance lends itself well to attaining positions of power and influence within the ‘establishment’. The result is a powerful block against genuine enquiry, creativity, and depth – and indeed against full empathy with other’s distress and tolerance of ambiguity – all factors that are necessary for the effective psychotherapist. I perceive many of the trends I am speaking of to be expressions of this.
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 bona fide therapies are compared with each other, in randomised controlled trials, they are more or less equally effective. Similarly, when naturalistic therapies are compared, there is little difference between them – e.g. the Stiles et al. 2006 study of 1309 patients at 58 NHS sites, comparing Person-Centred, CBT, and Psychodynamic therapies. There is no substantial evidence that CBT is more effective than other forms of therapy. However, there is substantial evidence that some therapists are more effective than others – this effect size is greater than that between therapies.
I think there is one clinically obvious ingredient that does seem important for effective therapy: where there are anxiety and/or traumatic stress reactions, maintained by avoidance, these need to be desensitised through exposure (whether in vivo or in imagination or through accessing memories). Ordinary CBT seems to do this the hard and least effective way; EMDR often does it quicker; and the mind-body energy psychology methods are often even quicker and also gentler. Note that in the Foa study of CBT for PTSD, the manual for the comparison supportive therapy instructed the therapist that if the patient began to talk about the trauma, he or she should be guided to talk of everyday activities – thus ensuring that this crucial active ingredient was removed from the control. All the other common ingredients are found in all effective therapies: taking an interest in the client; enquiring holistically about his or her life, loves, hopes and fears; providing empathy; discussing problems; exploring thoughts and emotions; enabling shame-laden thoughts and feelings to be talked of in a non-judgemental atmosphere; considering alternative perspectives – and so forth. It would be surprising if a person did not experience some benefit from such experiences and activities. A visit to a chiropractor would also provide much of this. The now routine ritual of filling out a CORE questionnaire or similar is also experienced by some clients as reassuring – and as providing a helpful external calibration of their state of well-being.
I sometimes enjoy showing people a DVD of Aaron Beck conducting cognitive therapy – and asking them who they think it is. Some think he might be Carl Rogers. Rarely do people assume it is Aaron Beck (unless they have seen images of him). CBT therapists think he is not doing CBT. He listens carefully, does not particularly structure the session, makes simple enquiries about the client’s life and experience, occasional empathic comments, explores the client’s thoughts, and invites the client to consider small manageable goals and to agree on what she might do before the next session. When he first asks her what she wishes to address she says her marriage. He tells her this is too big a topic and asks her to think of a smaller issue to work on – they eventually agree she might explore going bowling. In another recording – of Beck interviewing a patient with anxiety – he enquires about the details of her fears (of being attacked and rendered helpless), identifies also her fears of envious attacks and criticisms by others (her fears had intensified as she became more successful in her work as an artist), elicits her beliefs that she must be perfect in order to be loved, and explores the childhood origins of these in her efforts to cope with having an alcoholic mother and the unrealistic demands of her father. Both of these examples demonstrate skill and subtlety in Beck’s approach – but much of what is displayed can be found in other approaches. The ‘branding’ and marketing of psychological therapies, whilst understandable (especially within the US capitalist health care system), is scandalous – particularly where it is done so in a disguised way within the UK. Marketing, and the pursuit of public funds, are the prime motives, but these are hidden behind pseudo-scientific discourse. People are making money out of NICE.
Consider the following comment by Isaac Marks:
“Even the most tightly researched psychotherapies … have a tangled thicket of components. Take ‘CBT’ for panic. Its components differ hugely from one therapist to another, with varying mixtures of: relevant exposure (diverse forms of which have over 65 labels); interoceptive exposure (stress immunisation); cognitive restructuring; slow, deep breathing; relaxation; diary keeping; particular homework; family work; reward for progress; getting a treatment rationale; and expecting to improve. One therapist may use a bit of this, a lot of that and none at all of a third component from the list. Another might give none or all of those three components in equal proportion. Yet all therapists call their method CBT.” [Marks 2002 p 200]
And consider Beck himself:
“A comparison of psychoanalysis with cognitive therapy indicates a substantial area of overlap. In both therapies the patient is asked to make introspective observations regarding his thoughts, feelings, and wishes, and to report them … both forms of therapy are insight therapies… The therapist attempts to delineate basic patterns that may account for a diversity of emotional reactions and maladaptive overt behaviours. Both cognitive and psychoanalytic therapy are concerned with uncovering the meanings people attach to their environment, to other people, and to internal experiences.” [Beck, A. 1976. Cognitive Therapy and the Emotional Disorders. Penguin 1989]
“The concepts of transference and early childhood experiences turned out to be crucial in understanding the personality disorders.” [Beck, A. 2005 p 955]
And at last year’s annual conference of the American Psychological Association, Beck emphasised the role of empathy, saying that some of his past students who lacked empathy had been unable to become effective therapists – they had been ‘duds’, he said – although they could be effective researchers.
In the light of such comments, by such eminent exponents of CBT, what sense does it make to think in terms of rigidly demarcated approaches? Is not ‘integrative’ the only sane position?
It is rather as if a paint manufacturer decided to test whether their green paint actually succeeded in creating a surface perceived as green – and so they prepared their paint, commissioned a specific paint roller, prepared a manual on how to apply the paint, the direction of strokes, amount of paint on the roller, how many coats to apply and how frequently etc – trained their research team in the method – specified the kind of wall that was to be used in the study - used two control conditions, one in which a wall was simply left unpainted and another in which the precise same procedure was followed but instead of paint the applicators used water. Then a large sample of randomised subjects was asked to rate, before and after the intervention, whether the walls appeared green. Having established that their painting system – Liquid Base Coating [TM] – did succeed in creating an increase in perception of green amongst their respondents significantly greater than in the two other conditions, the manufacturer seeks to persuade the government that the whole area of professional painting is a mess – many different manufacturers producing paints, using different ingredients, with a wide variation in price, applied by diverse practitioners, some well trained and some minimally so – and that a review of the evidence-base for painting is required, particularly when the paint is to be applied in public buildings [and it had increasingly been noted that many public buildings were in need of painting]. A new agency – the National Institute for Painting Excellence [NIPE] is set up. On reviewing the data, they find that only the system called Liquid Base Coating has been demonstrated, in properly designed studies, to be effective. Accordingly they state in their guidelines that LBC is to be used when walls show a deficit in green – practitioners must use the protocol that was demonstrated in the study to be effective, with the specially designed roller and the guidelines for how the paint is applied. With the combination of NIPE and clever marketing, people soon begin to believe there is something special and unique about the LBC system. The company begins to train people to use its system – then licenses trainers to train others. Gradually the old craftsman painters went out of business, unless they paid to undertake the special trainings in LBC and became accredited by the British Association of Base Coating Professionals [BABCP]. Of course different studies and trainings were required for all the different colours. In response to these pressures, the other paint manufacturers felt obliged to create their own trademarked systems and to subject these to the same rigorous testing in well designed randomised double blind studies. Gradually NIPE began to recognise a range of approved systems – with the advantage to manufacturers that they could advertise their products as NIPE-approved. In this way the provision of painting was advanced beyond it’s more primitive ‘craft’ stage, with great variation in quality and style, to that of an industrialised and standardised procedure. Of course there were some painters and decorators of the old school, who had learned their skills prior to the development of the new scientifically validated systems, often partly in an apprenticeship mode, but these were increasingly regarded as simply behind the times. [recall my behaviourally oriented supervisor]
The branding and marketing of psychological therapies is driven by commercial motives, not by science. It seems to me obvious that the different therapeutic approaches – including cognitive, behavioural (with its classical and operant conditioning), psychodynamic, systemic, neurobiological, and the body-mind interface therapies, and so on – all capture and address important aspects of a complex whole. We need as many perspectives as we can … because what we do is not yet good enough!
What of more positive developments? There have been a number. In the 1980s we began to understand trauma – and by the early 90s we were gaining some awareness of the neurobiology of trauma. Allan Schore suddenly emerged from nowhere, with his astonishing synthesis of neurobiology and attachment perspectives, showing how the developing brain is shaped by interpersonal experience – and since then the Bowlby perspective has gone from strength to strength. In the late 80s, EMDR was developed – arguable the first effective treatment for trauma. From EMDR we learned how traumatic experience is networked and layered through the psychosomatic system. We began to appreciate the hitherto neglected realm of the body – not only through having the client engage in active bodily stimulation but also by routinely incorporating questions such as ‘where do you feel it in your body?’ For decades, psychologists and psychotherapists had operated with the implicit delusion that the mind could be separated from the body – and would attempt to engage the client in a purely mental discourse – as if oblivious to the obvious fact that emotions are, in large part, bodily events. Of course the cerebral nature of many psychologists helped sustain this illusion. In recent years, the embodied brain and psyche are much more in evidence in theorising and in psychotherapeutic practice. Many forms of body-mind therapies have evolved, including sensori-motor therapy – and the broad genre of energy psychology, this latter being a field that I have been passionately immersed in for nearly ten years. In the energy psychology family of approaches – my own contribution being called Psychoanalytic Energy Psychotherapy – we engage in all the processes commonly found in cognitive, behavioural, and psychodynamic therapies, but in addition we incorporate guiding the client to stimulate their body’s energy system where the dysfunctional information is stored. This allows for rapid, deep, and gentle change. The details are too complex and subtle to present here – but it is an example of the value of continuing to explore and integrate. Such therapies have been endorsed by neuroscientist and trauma specialist Besel van der Kolk, who has long argued for the need to engage with deeper parts of the brain and body than the verbal and cerebral.
Whilst psychoanalytic, humanistic, and cognitive-behavioural traditions have all contributed important elements that are needed for an effective response to psychological distress, it is arguably the recognition of the role of trauma in mental life - its neurobiological and physiological effects - and its possibilities of healing, that enable psychotherapy to become truly transformative. From PTSD to 'personality disorder', trauma is the key to understanding and healing. Whilst some therapeutic modalities facilitate the tracking and healing of trauma, there are others (such as mentalisation-based psychotherapy) that explicitly advocate against attempting to address childhood trauma directly. Here we have a recurrent tension - between those who aim to help the processing and healing of trauma, and those who seek to help the client acquire new behavioural and mental skills.
Returning to the lawsuit between the American Psychological Association and the American Psychoanalytic Association, Richard Simons, president of the Psychoanalytic Ass at that time, provided some interesting comments that may have relevance to all of us in the psychotherapeutic professions. Writing of the tendency for analysts to idealise their theories, techniques, and organisations – a weakness that other psychological groups may also display – he comments:
“I think at least some of us may have forgotten what we analysts have in common with other human beings. We all have night dreams every night. We all have day dreams every day. We all defecate and urinate every day, and some of us (pregnant women and older men) urinate at night as well. We all experience heartache and loss throughout our lives, as well as recurrent, unfulfilled masturbatory fantasies and other highly organised unconscious fantasies that form the core of many or our night dreams and day dreams. And on one of those days or nights, each one of us is going to die. … What a shock it is when we discover that all of us are really in the same boat, taking the same existential journey, working our way rapidly or more slowly to the same end … Ideals can help us immeasurably along the way, but idealisations are ultimately never very trustworthy in enabling us to give up our grand illusions of perfectibility and immortality”. [Simons 2003 p270]
It is common for both clients and therapists unconsciously to view psychological therapies as providing solutions, or alternatives, to the pains and uncertainties of life, and a sense of truth and meaning to counter our ignorance and bewilderment. At one time psychoanalysis was seen as the answer – then Watson’s behaviourism, along with Skinner’s operant conditioning and his Walden Two vision – and currently it is CBT, along with rcts and certain kinds of statistical methods. Along the way we had Orwell’s nightmare vision of a mind-controlled society in his novel 1984, as well as the experiments with communism, National Socialism, and monetarism. Our idealisations become narcissistic prisons – restricting our capacity to enquire and explore. We should see psychological therapies as culturally shaped attempts at providing some modest alleviation of human distress, with some limited sphere of application, perhaps helping to release us, as Freud put it, from ‘hysterical misery to ordinary unhappiness’ [1895 p 305]. And we must keep searching for better, more effective, and faster ways of doing so.
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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”. The best general account of psychotherapy research findings is Cooper 2008 A great deal of valuable information regarding psychotherapy research along these lines can be found at www.talkingcure.com Cognitive Therapy of Anxiety and Panic Disorders: First Interview Techniques. Beck Institute. 1985 www.energypsych.org Cognitive Therapy of Depression: Hopelessness (patient interview). Beck Institute. 1979