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about use of terminology

Sunday, October 19th, 2008 @ 6:26 pm
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I read this article below from March 2004 Issue of Therapy today Journal by the BACP, in relation to the use of terms ‘counselling’ and ‘pscyhotherapy’ (also available on http://www.therapytoday.net/archive/mar2004/cover_feature2.htm )

Counselling and Psychotherapy: is there a difference?

Are counselling and psychotherapy the same or are they different? And how much does it matter? This question lies at the heart of a debate, heated up by the prospect of professional regulation. By Clare Pointon

Rachel, 39: ‘I went into psychotherapy in my 20s. The trigger for seeking help was the end of a relationship; at the time I felt that I couldn’t cope with life at all. I had an initial assessment with a woman who spoke to me at length about why I was interested in having psychotherapy and what the issues were I wanted to deal with. At the end of the assessment she said that she thought I would be a suitable candidate for psychotherapy. She said that it would be a longterm commitment – perhaps several years. She also took quite a bit of trouble matching me up with the right person, paying particular attention to whether I wanted to see a man or a woman; it felt like a lot of thought went into that whole process. There was a male therapist she thought would suit me and I waited for several months until a vacancy with him came up. I then saw him for five years.

In psychotherapy I felt that there was no limit to what I could explore. I went through some very difficult times, but having the opportunity to do that felt very important. The therapy wasn’t perfect; it ended quite inconclusively and I have spent much time criticising aspects of what happened. Yet I look back on it as a life-changing experience – one which affected me as much, if not more, than having children…Years later I had counselling – in three different contexts. The last one followed my separation from my husband. We contracted for eight sessions (this was a counsellor I saw privately, not through an agency) but I ended up going for six months. At that time all I felt I needed was some support. I didn’t expect it to be deep work, but what I found difficult, having done the deep work in psychotherapy, was the concept of a time limit from the outset. For me that completely changed the way I could be with that person.

With the counsellor, we had clear goals, we worked towards them and it was helpful in many ways. It allowed me to sound off about my anger about the way my relationship had ended and to look at a number of work issues. But I never felt invited to explore the places I had been to in my psychotherapy; it didn’t feel like a context in which I could. I felt instinctively that I had to protect the counsellor from parts of myself; that I might be too much…’

The view that psychotherapy is likely to involve a deeper meeting between two people than counselling is not new. But to what extent does this stereotype the work of the two professions? Is it even correct to make such a sharp distinction between them? These questions lie at the heart of a live debate, heated up by the prospect of professional regulation, a process which before long will put the onus on those of us in the field to explain to the Government who we are and what we do.

When we examine our professional roots, it’s clear that counselling and psychotherapy have been historically distinct, that each has brought with it a different legacy. Psychotherapy emerged via psychoanalysis in Europe in the 19th century and was always at some level associated with medicine – later with academia and psychology. Counselling evolved in America in the 20th century as part of the Mental Hygiene movement and when it came to Britain was closely linked to education and the church, with practitioners offering advice and guidance (Rowan, 2001).1

Today these professions have certainly cross-fertilised; the thinking of Sigmund Freud and the early psychoanalysts can be tracked in the work of many psychodynamically-oriented counsellors, just as Carl Rogers’ influence has permeated psychotherapy, inspiring many in the humanistic field and beyond it. However, with regulation on the horizon, the stakes have risen in the debate about the relationship between the two. This is no longer a purely intellectual issue. It will impact on the very practical way in which counsellors and psychotherapists are evaluated, hired and paid in the future. And the professional accrediting bodies are well aware of what they and their members stand to lose or gain. So what are the arguments put forward on either side – and what may be at stake for our clients?

The value of training

Psychoanalytic psychotherapist Lesley Murdin, a co-director of WPF, argues that, if we believe in the value of training, we must differentiate between practitioners who have undergone trainings of different lengths and intensities. At WPF a postgraduate diploma in psychodynamic counselling usually takes four years if done part-time. Those who want to train as psychotherapists have to do this before either adding onto it a series of extra modules to qualify as psychodynamic psychotherapists or taking a longer route – an extra three years – to become psychoananalytic psychotherapists.

‘We differentiate in our training on the basis of the practical work that people are asked to carry out,’ she says. ‘The counselling training limits to some extent the degree to which regression is encouraged and the amount of pathology that people are expected to work with. The preparation for this work is then also different.’

Qualified counsellors going on to train as psychotherapists are required to take the additional modules in skills such as carrying out assessments, they receive further academic seminars, undergo a psychiatric placement, have individual as well as group supervision and spend extra time in their own personal therapy, including a period of twice-weekly sessions. For Lesley Murdin, the end result, hopefully, is a professional who can work autonomously: ‘I think a psychotherapist should be able to be an independent practitioner who can relate to other mental health practitioners on an equal footing in the field, someone who has had a long postgraduate training and who has a degree of self-awareness, but is at least well aware of the ways we can all be subverted by the unconscious. They would be able to assess helpfully and constructively and to take on a fairly difficult caseload, but they would also know their own limitations. Counsellors, on the whole, need to go on learning and they have the tools to do this. I would hope that they would get help with assessments – in fact many of them are likely to be working in agencies where this is done for them.’

However, not all trainings today uphold these kind of distinctions; some would even argue that to do so is divisive. Lesley Murdin acknowledges the risks of professional segregation – and makes the point that some who go on to further training may be motivated by the narcissistic rewards it offers.

In theory, she says she wouldn’t be opposed to the abolition of the different titles, but stresses that, if this were to happen, she would want to see all practitioners undergo a minimum four-year generic training, with the opportunity for those who wanted to study beyond this to add on individual specialisations. In practice, she believes that bridging the worlds of counselling and psychotherapy is not straightforward:

‘There’s a lot of investment that individuals have made in their training and I think it would involve a tremendous amount of generosity on the part of someone who’s spent seven or eight years on a psychotherapy training with twice or three times a week personal therapy to say that that’s the same as a counselling training which might have been two or three years with once weekly therapy.’ But she argues that, with regulation in the wind, dialogue and compromise between practitioners will be important if they are to put a coherent case to the Government.

All ‘process work’

Outside the realm of psychoanalysis, acceptance of this compromise is widespread – particularly in the work of experienced professionals. In his practice, writer and integrative psychotherapist/counsellor John Rowan – who operates variously under both titles – makes no distinction between the two. For him, ‘it’s all process work’, the only difference being the route that a client comes to him – someone may be seeking ‘a couple’s counsellor,’ another ‘a transpersonal psychotherapist’. And in his view, a client suffering from entrenched problems could just as well be seen by an experienced counsellor as by a psychotherapist. However, out there in the world, he argues that differences do remain – some of them emanating from the very earliest days of the two professions. ‘Counselling can be incredibly optimistic,’ he says. ‘I think a lot of counsellors believe that anything that’s wrong can be counselled away which I don’t think is true. That’s a kind of American optimism – and I believe there’s still a lot of it about. I also think that, because of its links with the church, counsellors are much more embarrassed about money than psychotherapists. It’s the idea of doing good in some way, the view that things connected to the church and education should not be commercial.’

Psychotherapists, he argues, rarely have such qualms. They come – with all the pessimism inherent in the visions of Freud and the existentialists – from a bleaker European tradition where they see themselves as practising something halfway between an art and a science. Within this, they regard themselves as ‘exercising talents’ for which they have a right to be rewarded. (Humanistic and behavioural therapists, however, do not come from this psychoanalytic tradition).

Structurally, John Rowan points out, society organises counselling and psychotherapy provision differently. Counselling tends to be carried out within organisations, with more immediate access than psychotherapy, which is likely to be an independent activity and involve more of a wait:

‘In the eyes of most people, counselling is more ordinary and accessible than psychotherapy which is seen as more to do with serious and long-standing problems and therefore to carry more stigma and more commitment,’ he says. ‘The consumers are different, too, with the poorer ones going to counsellors and the richer ones going to psychotherapists.’

Perhaps more controversially, John Rowan posits the view that psychotherapists are generally likely to have a wider range of ‘therapeutic tools’. He argues that whilst a counsellor may need to have more knowledge on topics such as access to legal advice or referral routes to specialised agencies, a psychotherapist will probably have a bigger repertoire of interpersonal interventions. And s/he may at certain points be more likely to confront and put pressure on a client. He offers a research tool designed to identify a practitioner’s professional range consisting of a grid of seven ‘octaves’ for this purpose. It moves from low to high pressure on the client, ranging from summarising through interpreting, touching, confronting and exposing transference and countertransference to suggesting topics, limited directing and urging (Rowan, 1998).2

Rogers’ generic term – therapy

Such distinctions are hotly disputed amongst person-centred practitioners who have traditionally regarded the terms counselling and psychotherapy as interchangeable. Roger Casemore, Director of Counselling and Psychotherapy Courses at Warwick University, says he has never been attached to one or other of these titles, rather preferring Rogers’ generic ‘therapy’.

However, in recent years he has begun to question the rather loose use of this term as he has come to identify a clear difference between two types of work – one that involves real ‘psychological contact’ and one that does not.

In the second – for which he uses Prouty’s terms ‘psychological support’ or ‘pre-therapy’, a practitioner may be offering support, information, giving advice or even telling the client what to do. In the second, there is the kind of contact which allows for deeper psychological work (Prouty, 1994).3 What concerns him is where the two are confused: ‘There are times when I see in supervision or from videos of practice that what I understand to be the process of therapy doesn’t seem to be taking place,’ he says. ‘Rogers makes clear in all his writings that the pre-requisite is psychological contact with the client.’

Roger Casemore acknowledges the very heavy toll which work at a deep psychological level can take on a therapist. He believes it is not work which everyone can do with every client all the time, that there is enormous value in offering periods of psychological support. It is here, he says, faced with the question of how to distinguish between the exacting work with someone suffering from a personality disorder and other, as he puts it, ‘less intensive’ work, that he could be tempted to distinguish between psychotherapy and counselling. But it’s a temptation he says he chooses to resist:

‘As a person-centred therapist with a strong existential philosophy, I have a belief in paradoxes; they have to be lived with. I don’t think this is really a dilemma about whether we should be called counsellors or psychotherapists. I think it’s a dilemma about there being a number of different and similar functions being carried out by people with different titles.’ What’s most important, in this, he says, is that a practitioner knows how to give potential clients clear and practical information about what s/he does, how s/he does it and what it will be like for them if they do decide to engage.

Where does BACP stand?

This is the climate which has been exercising the BACP in recent years. Its Chair, psychodynamic counsellor Val Potter, is well aware of the potential risks to counsellors if they are governed separately from psychotherapists: ‘When regulation comes, some people will have registered titles and will be able to do certain kinds of work in certain areas like the NHS and some won’t. If you get this hierarchical definition – that one is more skilled than the other – then there is a danger that the senior jobs will go to the psychotherapists and the junior ones to counsellors. I feel very strongly that counsellors should have due respect for the work that they do. They may work in ways that are different, but they shouldn’t be seen as the junior profession.’

Val Potter argues that all attempts to clarify a concrete difference between the professions ultimately break down. Whilst psychodynamic approaches do distinguish trainee counsellors from trainee psychotherapists, she points out that some courses allow students who qualify to choose their own professional title. And, although it is generally believed that a counsellor works mainly short-term and a psychotherapist mainly long-term, she says this is not necessarily the case. Neither, she argues are psychotherapists always more experienced practitioners who have done more personal therapy; the nature of personal therapy she points out is more likely to depend on the training’s theoretical model.

‘These distinctions are political and social ones, not functional ones,’ she says. ‘They are often defined by groups with a particular interest in the definition, one of protecting their own area of interest. In my more cynical moments, I feel that the whole counselling and psychotherapy debate is reminiscent of the old British class debate – the gentlemen and the players. Counsellors do the practical work, but psychotherapists do the intellectual stuff!’

So if attempts to maintain the distinctions come down to political self-interest on one side, what about moves to blur them on the other? Could the step in 1999 by the then BAC to add the ‘P’ to its title and deal with psychotherapist and counsellor members on the same terms not in itself be seen as a political move ahead of regulation, one focussed on empowering counsellors and their main accrediting body? Val Potter stresses that this decision came in response to a request from its own psychotherapist members and says the move was aimed at supporting the people it represents.

‘It’s our responsibility to put BACP members in the best position for their professional wellbeing, so we do see it as our job to represent them politically. And it’s true that if we took on both counselling and psychotherapy we had more chance of speaking on both and that, we felt, was important for people who use our services as well as our members.’

Meanwhile, she is keen to point out that BACP’s main concern is to do what it can to ensure that someone seeking therapy is able to find competent and appropriately trained practitioners who are self-aware and experienced, working within a robust ethical framework and answerable to a complaints system. When regulation comes, she argues, it must be based on these aims. ‘If you measure practitioners against these requirements you could come up with a set of standards that would give everyone a basic qualification to which they could add specialisms. After all, all doctors begin with the same training and qualification. They all work to the same ethical code etc. This does not stop them specialising in neurology, psychiatry, General Practice. They gain their specialist training and experience post-qualification.’

Other views

James Pollard, chair of the United Kingdom Council of Psychotherapists (UKCP), says he is also concerned that stringent professional standards are upheld. In his view, the addition of the ‘P’ to the former BAC title has had a significant impact on the debate about the relationship between counselling and psychotherapy – not one, however, that he believes, has been productive.

‘While there are undoubtedly psychotherapists who are members of the BACP,’ he says ‘the change of name has risked giving the impression that there is no significant distinction to be made or that how the distinction is made is of no importance. This is not the case and the impression has been unhelpful.’

Like Val Potter, James Pollard calls for dialogue between the different professional bodies, but unlike her, he believes that clarifying distinctions between counselling and psychotherapy is important. In his view these centre on the two practices’ historically independent traditions, different levels of training and a greater emphasis in counselling on problem-solving and shorter-term work. And he argues that explaining these to the public gives potential clients the possibility to understand something of what they might expect from a treatment or course of action.

‘The public is likely to expect a lower key and more pragmatic solution-focussed approach from a counsellor,’ he says. ‘There is still widespread apprehension about anything which has “psyche” in its name.’

Against this background, James Pollard acknowledges the ‘considerable overlap’ which the UKCP sees between the two professions. And he points to a recent move by his organisation – one that followed BACP’s official incorporation of psychotherapists into its title – to establish a section for ‘psychotherapeutic counsellors’, a group he describes as ‘counsellors who recognise an affinity between counselling the psychotherapy’.

The picture is anything but clear

The invitation to define who we are professionally and how we are distinct from and similar to each other is clearly a task that can trigger powerful personal and political response. But, amidst the emotion, where do we find the criteria we need? On our various training courses? In our conflicting accrediting bodies? Perhaps in our theoretical orientations?

The picture is anything but clear. Once regulation comes, it may – or may not – be a whole different story. At least, if we do ever manage to agree about if and how we are different, it should then be laid down in black and white in British law.

References

1. Rowan J. Counselling and Psychotherapy, Different and the Same, CPJ August 2001
2. Rowan J. Therapeutic Interventions, Journal of Psychotherapy Integration 8/4 231-248; 1998
3. Prouty G. ‘Theoretical Evolutions in Person-Centred/Experiential Therapy – Applications to Schizophrenic and retarded Psychoses,’ Westport Connecticut, Praeger; 1994

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