Therapy Through the Looking Glass

Last month (March 2018) the Minister for Health announced that he had acquired approval from the Oireachtas (Ireland's Parliament & Senate) to recognise officially within the field of psychological therapy two professions: that of "psychotherapist" and that of "counsellor". The aim is that everyone working in the field of talk therapy will have to register with the authorities under one or other of these two headings. 

It is not clear in what way the Minister thinks enshrining this distinction in law will help the general public to find assistance for emotional problems or in what way he thinks it will improve the mental health of the nation as a whole. It will in fact do neither of these things.

Every skilled and conscientious therapist who uses talk therapy with her clients modifies continuously the approach she takes, reflecting her perception of the unique needs of each person she works with. She has a hundred kinds of response ready in her therapeutic toolbox, and she knows when to deploy each one.

Sometimes she will listen quietly, sometimes she will speak, sometimes she will make suggestions, sometimes she will give guidance, sometimes she will carefully leave the client to find the solution to a problem himself. Sometimes she will confront her client with hard truths, sometimes she will offer sympathy and support. Sometimes she will laugh at a client’s jokes, sometimes she will suggest how he is using humour to evade issues he finds emotionally difficult. Sometimes she will point out how a client is neglecting his responsibilities to others who depend on him. Sometimes she will draw his attention to how he is using a sense of duty to others as a way of neglecting his responsibilities to himself. Sometimes she will encourage a client to forget immediate daily concerns to take a look more carefully at how his life is shaped by longer term trends that have their roots in the distant past. Sometimes she will tell him to stop dwelling on the past as a pretext for not making as much as he can of his circumstances here and now.

This is a description of the daily work of the psychotherapist.

This is also a description of the daily work of the counsellor.

So how is it then that we have arrived at the point where the Minister for Health is proposing to make two distinct professions that go by these names?

It is a good question, and not easy to answer. The proposal is so manifestly impractical and so obviously divorced from reality that one can only speculate as to how it was derived.

What the Minister has failed to grasp, or perhaps is simply unwilling to acknowledge, is that the terms “psychotherapist” and “counsellor” are conventional rather than substantive. They reflect not practical realities in the therapy world but rather differences in how therapists have traditionally described themselves and the schools with which they identify.

For example, in twenty years working as a therapist I have always felt more comfortable with the label “psychotherapist”. Largely, this is because I have a long-standing interest in psychoanalysis, which is where the talk therapies began over a century ago. I am not a card-carrying member of any psychoanalytic association, however, so I prefer not to call myself a psychoanalyst. But my thinking on therapy has always been informed by psychoanalytic ideas. Traditionally, the term “counsellor” has carried the implication, however vague, of a therapist who is more focused on practical matters in the present and who gives less emphasis to the unconscious roots of problems than one would expect, conventionally, from a psychoanalyst. For this reason, especially when dealing with professional colleagues, I generally do not use the term for myself.

Nevertheless, most of my day-to-day work is indistinguishable from counselling and most of my clients refer to me as their “counsellor”. This is simply because, to the general public, this is the term that is most familiar. For this reason also, on my business cards I, like many of my colleagues, offer “psychotherapy and counselling”.

Most people have a reasonably clear idea of what a “counsellor” does. He, or she, is someone who talks through personal problems in confidence with a client. But this is as much as the term means to people who are not specialists in the therapy field. They would find it much harder to describe what a “psychotherapist” does, or how what she does differs from what a “counsellor” does.

And so would I.

It is true that if I were challenged in an academic argument I could make a distinction between the two terms, but not without recourse to a lot of technical language about unconscious processes that only a handful of specialists with an extensive knowledge of the literature would be able to follow or would have any interest in. Furthermore, the distinction I made would still be conventional, and other specialists might well prefer alternative definitions. The point is that the terms of the distinction are not those upon which specialists are agreed. They are still debated, and they always will be. The distinction here is qualitatively different in kind from that, for example, between a cardiologist and a neurologist, where the lines of demarcation are clear-cut and accepted by everyone in the profession.  

In short, the distinction between “psychotherapist” and “counsellor” is one that could keep a small number of experts innocently entertained for a long time, but as far as the general public is concerned has absolutely no practical reality at all.

However, if the Minister of Health has his way this distinction is one we are all now going to have to make routinely, whether we are therapists trying to explain our work to clients, hard-pressed GPs trying to decide to whom to refer patients in emotional distress, or bewildered members of the general public looking for help.

The result will be confusion throughout the therapy field on a scale we have not seen before. It will be much harder for therapists to explain themselves to the general public and it will be much harder for the public to understand what services therapists have to offer.

It is impossible to say whether the Minister simply does not comprehend this and has been misled by very bad advice, or whether he does comprehend it and is cynically hoping to use the resulting confusion as a way of increasing the bureaucratic grip of the Department on the therapy field in general. After all, the more confusion there is, the more paperwork we need, the more everyone is entangled in red tape, and consequently the bigger the budget the Minister’s Department can demand. And the bigger the budget a minister has at his disposal, the greater becomes his importance vis-à-vis his colleagues in government.

Whatever may be the truth of this matter, the Minister cannot claim that he has not had ample opportunity to acquire an understanding of the consequences of his decision, had he chosen to take it.

In the autumn of 2016 the Department of Health invited suggestions on how best to legislate for the therapy field. At this time, many of us made detailed submissions, pointing out that to think of the therapy professions as simply subordinate branches to medicine is a mistake and leads inevitably to the creation of what are in important respects artificial categories like, for instance, that of “psychotherapist” and “counsellor”.

To these submissions we received no response.

Then in May 2017 the announcement came from the Department that the field was to be split anyway into these two professions.

No explanation was given for how this decision was reached, who had been consulted, or what was the rationale behind it.

It is clear the consultation process was from the outset a fiction. There was a careful exclusion of anyone who had raised an objection to what, evidently, the Minister had already decided to do.

Dividing the profession in this way is either an act of simple ignorance or it is an exercise in raising a political smokescreen. In the latter case, it is designed to bamboozle people, to give the impression that somehow something significant must have been done, when in fact nothing has been done, apart from making the world of therapy even more confusing to the public than it already is.

Imagine the reaction we would have if the Minister for the Arts were to propose licensing artists on the basis of whether they use oil or water colours, or licensing writers on the basis of whether they write novels or short stories. Yet the distinction between psychotherapists and counsellors lacks even this degree of reality. A profession for therapists who wear blue socks and one for therapists who wear yellow socks would be as helpful, indeed probably more so.

This decision is a very bad one, for the public and for those who work in the therapy profession. Its effects will be regressive and damaging. It should be put on ice. 

And while it is on ice we should have what we have not yet had, which is a serious discussion about the complex nature of therapy, its place in modern Irish society, and the best way to ensure that it remains vital and creative in the years to come.