On Psychodynamic Therapy & Its Relation with Medicine - Part One (of Four)

There are creative manners, there are creative actions, & creative words; manners, actions, words, that is, indicative of no custom or authority, but springing spontaneous from the mind’s own sense of good & fair.

– Emerson

In 1893, in the very early years of psychoanalysis, Freud remarked that hysterical symptoms behave as if the nervous system did not exist.[i] In pointing this out he was on the way to changing not just the treatment of mental illness but our entire framework for thinking about it. And he was doing so in a way that was more radical than most doctors at the time or later realized.

Psychiatrists in the first few generations after Freud mainly did not see that this new discipline of psychoanalysis took the treatment of mental illness outside the bounds of medicine as these had been conceived up to that point. Psychoanalysis represented a dilemma for psychiatrists, but one they were reluctant to acknowledge. If they were properly to practice psychoanalysis they would have to re-think what it meant to be a doctor of mental illness. They would have to re-examine the meaning of mental illness, & they would have to re-evaluate what it meant to cure mental illness. Many psychiatrists were attracted by the possibilities of psychoanalysis but they were not prepared for this reassessment of their own professional role. So for several decades the incompatibility of psychoanalysis with the wider assumptions underpinning the profession of medicine was fudged.

In the longer term the fault lines between psychoanalysis & the rest of medicine became increasingly difficult to ignore. As the years went by psychiatrists to a large extent gave up on psychoanalysis. In the end, faced with the choice between taking a psychoanalytic approach to things & retaining their self-identification as medical doctors, psychiatrists chose the latter.

To continue to take a psychoanalytic approach meant for psychiatrists having to abandon important assumptions learned in their medical education about the nature of illness. Unwilling to do this, they tried to rationalize their decision to abandon psychoanalysis on the grounds that a psychoanalytic approach was an unscientific approach. This, they hoped, would justify unlearning the interesting things psychoanalysis had taught them about their patients. Accordingly, they gave up thinking in a psychoanalytic way about their patients. Or at least they tried very hard to give up thinking in this way.

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Freud began his medical career in neurology & made important contributions to this field before beginning his own private medical practice in the mid-1880s. In this, he specialized in treating patients suffering various kinds of mental illness which at the time, by & large, were assumed to be caused by malfunctions in the nervous system. Throughout his working life he maintained close connections with the medical world in which he had been trained. Most of the early psychoanalysts were medical doctors. But Freud was consistent in holding the view that psychoanalysis should be independent of medicine & should not be subordinated to it. He emphasised that a medical education, as such, was not a particularly good preparation for psychoanalytic work. And he encouraged many people who were not trained as medical doctors but whose background was in the humanities to become psychoanalysts.

In the generations immediately after Freud psychoanalysts without a medical background, like Anna Freud & Melanie Klein, had a prominent place. Nevertheless up until perhaps about 1980 or thereabouts probably most people practicing psychoanalysis or some form of psychodynamic therapy were medically trained. They qualified in medicine & then trained as psychiatrists by becoming specialists in nervous diseases, & only then did they undertake training in psychoanalysis.

And in important respects most psychiatrists who became psychoanalysts continued to see themselves as doctors in a traditional sense. They behaved as if psychoanalysis was not essentially incompatible with the rest of medical science; they did little to discourage the view that they could cure people of mental illness in the same way that their colleagues in the rest of medicine cured their patients of physical disease; & they claimed for themselves the professional rewards of income & status that went with being doctors.

Eventually however, the attempt to keep psychoanalysis largely under the control of the medical profession & to treat it as just another branch of medicine broke down. Over the last forty years or so fewer & fewer psychiatrists have undertaken training in psychoanalysis. And the position now in the second decade of the 21^st century is that the great majority of people who practice some form of psychoanalytic therapy have not been trained as medical doctors.

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What can we learn about the nature of psychoanalysis & psychodynamic therapy from these events? Why did the enthusiasm for psychoanalysis that psychiatrists at one time showed turn into such an unequivocal rejection of it? And is it more realistic to see these events as psychiatry giving up on psychoanalysis, or as psychoanalysis giving up on psychiatry?

The expectations that psychiatrists had in the first half of the 20^th century that they could adopt psychoanalysis without a fundamental re-assessment of their own place in the broader profession of medicine were misplaced.

Why were they misplaced?

The underlying problem here is that psychoanalysis approaches the questions of illness & health in a different way from physical medicine. Psychoanalytic therapy treats these issues as problematic; it subjects them to critical examination. That is why it is called psychoanalysis. It assumes that in the case of each patient who undergoes a course of therapy, illness, health & cure will turn out to mean something unique, they will have no exact parallels in the life of any other individual.

The first task of psychodynamic therapy therefore is to figure out in each particular case what these things might mean. It specifically rejects the suggestion that knowing what is healthy for one individual will give you knowledge of what is healthy for someone else.

Physical medicine does not proceed in this way. A doctor of physical disease who went about his work with such an attitude would be negligent. In physical medicine the distress of the patient & the malfunctioning of his body are treated as things to be rectified as quickly & as completely as possible, given the existing state of medical knowledge & its technical capacities. It is not the task of the doctor of physical illness to inquire whether it is desirable to cure a patient of a fractured arm, or high blood pressure, or cancer. His task is only ever to inquire whether it is technically possible to do so, & to do so without harming the patient in some other more serious way.

In psychoanalytic therapy however this is not what happens.

In psychodynamic therapy, in the first instance, we approach the distress of the patient & his presenting symptoms & the unhappy aspects of his life as things to learn from. They are trying to say something to us & our first objective is to understand something of what they are trying to say to us. We want to discover from these things as much as we can about the patient & his life & his circumstances. We take them as signs & symbols of conflict within the patient & we use them to try to understand as well as we can what is in conflict within the patient.

It is not just the fact that the patient is emotionally divided that is causing his distress. Mainly, his distress is caused by the fact that he is divided in a unique way that no one else can properly understand, indeed often in a way so unique that no else can even recognize it. Because of this, he cannot communicate its dimensions to other people, he cannot even articulate them to himself. The language to describe these divisions does not yet exist; that is why the patient is forced to fall back on the language of his symptoms. And it is this isolating aspect of mental illness, this resistance to communication, that makes it so painful. The patient does not wish to know what forces are fighting inside him because he is running so hard from the isolation that such knowledge entails. And those around him do not wish to know either, because they fear this isolation too.

Our physical illnesses reflect our similarities with everyone else, they reflect the fact we are subject to the same physical vulnerabilities & frailties as them. But our emotional crises & distress reflect the fact that we are unlike anyone else. When we are born we are autonomous individuals only potentially. It takes many years to mature into a healthy individuality, much longer than it takes to become mature physically. And we have to fight to achieve this. We have to struggle to sort out in what ways we are like those nearest to us & from whom we acquire our first perspectives on things, & in what ways their perspectives are not beneficial for us.

Mental illnesses are the emotional injuries we sustain in the course of this long fight for independence & autonomy. Some people achieve a happy maturity without great emotional turmoil, though often their understanding of life can be relatively superficial because of this. At the other extreme some people succumb to their injuries & never overcome them & become bitter & destructive. Some of the most destructive men in history have been of this type. In his great geniuses of envy, like Iago & Edmund, Shakespeare loved to portray them. And many people lose their nerve in this struggle for autonomy & more or less successfully suffocate their individuality.  They become the pillars of whatever is regarded as proper & correct in the age. But some people come through the fight, overcome their injuries, & eventually achieve a fruitful & happy level of emotional freedom characterized neither by anxious conformity nor by envy & resentment.

The war within the patient will be between some tendencies that are good & healthy & which it is desirable for him to develop in his life, & some tendencies that are inhibiting & which it is desirable for him to let go. Another way of thinking of this division is that between the past, which is an essential part of the patient’s identity but is in some way holding him back, & the future which the patient must move towards if he is to go on living in the world but which may have distressing or destructive things within it.

In psychodynamic therapy the symptoms that the patient presents are treated as the expression of the struggle between these things. There are good things that we want to cultivate & bad things that we want to allow to atrophy.

At the outset of the analytic process however we cannot know exactly which aspects of the patient’s life & habits are the good things & which are the bad things. Again, this is because they will be unique to each patient, who is living out a life story no one has lived before & no one will live again. Only when we have acquired quite a detailed knowledge of the history & circumstances of the patient will we begin to get some idea of which trends are desirable & which are undesirable in his life.

Psychodynamic therapy is often caricatured as an endless re-working of the remotest years in the patient’s past in an effort to dredge up his most distant memories. Such a procedure is not psychodynamic. The exploration of memories, on the assumption that repressed memories are the cause of the illness, is the characteristic of what was once called the cathartic cure. The cathartic cure, as the name indicates, aimed to dissipate emotions provoked by past events that the patient supposedly had not been able to express at the time of those events. The memories associated with the emotions were thought of as locked in the unconscious. The aim of the therapy was to get the patient to remember these events & allow the emotions into consciousness. The belief was that the patient would be cured of his symptoms simply by experiencing the emotions. If the symptoms persisted it was assumed this was because the emotions associated with the memories had not yet been experienced deeply or fully enough.

Historically, the cathartic cure preceded psychoanalysis, although variants of it are still widely practiced today. It regarded the memories themselves, & the question of whether they were unconscious or conscious, as the causal factor in mental illness. The purpose of cathartic therapy was to break through to the unconscious memories & release the emotions associated with them.

Initially Freud worked with this theory too. But right from the beginning, in his Studies On Hysteria, he was in the process of replacing this early theory of mental illness with a much more sophisticated framework. Freud’s innovation was to regard neurotic symptoms not as the outcome of repressed memories & emotions but as the result of conflict between two different tendencies in the mind. On this view, distortions of memory, so far from being the causal agency of neurotic illnesses, are merely another symptom of them. In the psychodynamic theory of the mind that Freud went on to develop the causal mechanism in mental illness is viewed as the presently existing conflicting trends within the patient. The aim of therapy is not to make memories as such conscious but to help the patient be more aware & less afraid of the emotions at war inside him. This involves both intellectual & emotional development, but it does not aim, as such, for the kind of display of affect that is associated with catharsis. In the psychodynamic framework, being able to remember things well & being open to the emotions associated with the past can be important indicators of strength. But by themselves they won’t be enough to get you well.

All memory is subjective. Psychodynamic therapy emphasises that memory is always uncertain, always distorted, & always partial & limited by perspective. The memories that recur to the patient in the course of the therapy simply furnish us with another set of symbols & symptoms from which to make sense of the forces & drives the patient is struggling with here & now, today. The focus of psychodynamic therapy is not on memory as an end in itself but only insofar as the critical examination of memory assists us in the articulation & resolution of present internal divisions. This is where the patient’s fears lie & this is where the illness must be resolved if it is to be resolved.

The whole art of psychodynamic therapy is that of distinguishing what within the patient is most likely to be helpful for the future from what is most likely to be sterile. This is very difficult. And this is where most of the mistakes in psychodynamic therapy are made. It cannot be reduced to a formula. When it is successful it is the outcome of a happy interaction between the therapist & the patient. Some of the time it involves discovering things that have been there already. And some of the time it involves cultivating things that have only existed in an inchoate form. It is immersed in uncertainty & ambiguity. You can never be sure it has been done in the best possible way. It will always have an indeterminate outcome.

The skill of the psychoanalytic therapist is being able to draw out what is unique in the divisions the patient is suffering, being able to explore & discuss these with him in a way that reduces his fear of them, & being able to interact with the patient at a personal level in such a way that what is valuable & healthy within him is encouraged to take greater strength in its fight with what is destructive & repetitive.

The primary requirement of such a psychotherapist therefore is that he should be sufficiently aware & in control of his own conflicts & with what makes them unique that he is not frightened of what makes those of his patient unique. It is well established that the crucial factor in the success of psychotherapy is the capacity of the therapist to establish a personal relation with his patient. But to be able to do this the therapist must have achieved a good relation with himself.

Every good therapist works in a way that reflects his own personality & experience. He is sufficiently at ease with what is novel in his own make-up that he is not frightened of what makes his patient isolated. The relationship between patient & therapist will contain within it metaphors of other relationships in the patient’s life. The therapist needs to be aware of this because it can be an important source of understanding. But to be able to do this the therapist must first be sufficiently at ease with his own individuality to allow a personal relation to develop with his patient while at the same time remaining sufficiently detached to be able to observe it in a critical & objective manner. None of this is easy.

The therapist who is less at ease with his own individuality will generally seek to reduce the process of therapy to a formula of some kind. In effect, he will be looking outside the therapeutic process itself for sanction & authorization. The easiest way to identify a poor or inexperienced therapist is by the over-emphasis he gives to the school of thought he adheres to or by the fact that he puts so much stress on the formalities of treatment that a personal relation with the patient never properly develops. The better therapist does not take flight to theoretical formulas but brings himself & the experience of his own development to the process. If the autonomy of the therapist is not sufficiently developed he will be unable to establish a relationship with the patient that is personal & real but at the same time is contained by critical reflection, & the therapy will fail. And the therapy will fail also if the therapist’s own experience & imagination are too remote from those of his patient.

The first task of psychoanalytic therapy then is not to try to remove as quickly as possible the symptoms of the patient but rather to understand what things are fighting with each other & finding expression in the symptoms.

Psychodynamic therapy is the only form of psychotherapy that emphasises that we cannot know in any final sense what mental health is. We will always debate it & we will always have to return again to figure out what it means for us here & now. This is not so as to give sanction to the lazy attitude that madness & sanity are the same thing or that there is no such thing as mental health. Quite the contrary, it is to recognize that making these distinctions in a responsible way requires difficult, sustained, rigorous intellectual work that is never finished. If we could define mental health in a final sense none of this would be necessary.

And it is to recognize also that the assessment of mental health always requires us to take the responsibility for making an ethical judgement, though always of course a provisional one, on how life should be lived. It is this ethical aspect in the assessment of mental illness that is the most difficult for us to accept. We live in a world that has become frightened of ethical puzzles because it feels it no longer has a confident basis for solving them. This is why so much of modern intellectual life is devoted to attempts to evade the ethical. Such attempts include our excessive reverence for the idea of science, our excessive devotion to trying to regulate the minutiae of social life, & our excessive faith that majority or consensus views are the most reliable guides to action.

And it is this discomfort with ethical problems, essentially, that is the reason the attempt to keep psychoanalysis within the sphere of medicine eventually broke down. Medical doctors are not taught to be sceptical about what they understand by health. They are taught that their professional status depends upon appearing to know what health is. A good psychotherapist of course knows a lot more about health than does his patient, & it is often his responsibility to reassure an anxious patient that this is the case. Nevertheless, he uses this reassurance not as a basis for instructing the patient on what he should do to get better but rather to open a discussion with his patient as to what health might mean now for him. A doctor treating physical illness does not proceed in this way.

Psychodynamic therapy is always asking, what is health? What is healthy, not for all time, but for this person, here & now & in the future? It introduces into the treatment of mental illness attitudes & questions formerly associated with philosophy & ethics. Medical science as it is currently understood cannot contain within it a discipline that proceeds in this way. This, fundamentally, is why medicine & psychoanalysis parted company.

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[i] In a paper of 1893 Freud wrote: “The lesion in hysterical paralyses must be completely independent of the anatomy of the nervous system, since in its paralyses & other manifestations hysteria behaves as though anatomy did not exist or as though it had no knowledge of it. … Hysteria is ignorant of the distribution of the nerves.” Standard Edition, I, p. 169.

On the Training & Registering of Psychotherapists

In The Irish Times last month Dr Paul O’Donoghue emphasized the importance of training in the practice of the psychological therapies & looked forward to a day when all psychological therapists would be registered on the basis of training. (13^th December 2012, Training is a requirement for being a psychologist)

Dr O’Donoghue suggests that when deciding which therapists to register the choice we face is a simple one between carefully backed scientific psychology, represented by psychologists like himself, & the kind of therapy he illustrates with the example of a little known school called “Energy Psychology”, which he reports has six practitioners in Ireland & apparently is based on an unorthodox application of Einstein’s equation between matter & energy.

In fact, it is not entirely clear exactly what Dr O’Donoghue would like to see done here. If he is proposing only that we should deny groups like the Energy Psychologists official registration it is difficult to see what practical difference this would make, since being unofficial is presumably a quality that they & their clientele value. On the other hand, if his proposal is that groups like this should be outlawed from offering their services to the public at all it is hard to see how this could be reconciled with the democratic right of citizens to consult with whomever they wish.

Nevertheless, the fundamental problem with Dr O’Donoghue’s position is not his call for registration as such but rather the way he uses Energy Psychology as a cypher for all therapy that is not undertaken by clinical psychologists like himself.  In effect, he portrays the field of psychotherapy as falling neatly into two schools: the school of Sense – his own one – & the school of Nonsense – all the others.

The reality of contemporary psychotherapy is much more complicated than Dr O’Donoghue is willing to acknowledge. His endorsement of “scientific” psychology & his implicit rejection of any therapy that does not qualify as science raise many central questions he chooses to ignore. So far from being widely accepted, the idea of a scientific psychology is one of the most contentious & fiercely argued over in modern thought. For over half a century now there has been an extensive & often very technical debate as to whether psychotherapy is, or can be, or should be, a science, &, if so, then what kind of science we are talking about. As yet no consensus has been reached on these matters.

The truth is that the area of therapy confronts us with a host of technical & moral questions to which there are no easy answers. The nature, status & aims of therapy are all subject to debate.

Certainly, it is true that there is no good therapy that is not based, in part, on science. But there is no agreement on exactly how therapy should be based on science. And there is no good therapy that is based on science alone.

In recent years there have been rumblings about legislation for psychotherapy in Ireland. But a debate on what therapy is, what role it should play in society, & what it is we hope & expect legislation to do, we have not yet begun. We cannot regulate something if we don’t know what it is. The problem is that most people not involved in therapy understand little about it, while each faction within therapy strives to present itself to the public as better than all the others. The result is a state of general confusion.

From the point of view of legislation there are two essentially distinct categories of therapy & it is necessary to separate these out from the beginning.

First, there are those therapists who work in private practice, with adult patients, & who engage in a private contract with their patients.

Second, there are therapists working for third parties. These further subdivide into two major sub-groups. There are those who are employed by either governmental or non-governmental agencies to work with patients on their behalf. And there are therapists employed by parents or guardians to work with children & minors.

The first category of therapy is therapy in its primary form. Here, the client, the person who pays for the therapy, & the patient, the person who attends the therapist, are one & the same person. Both parties, therapist & patient, are working to maximize the personal autonomy of the patient.

The second category is therapy in a more derivative form because client & patient are not one & the same person. As a result there are implicit limits on the degree of autonomy of the patient that the therapy is aiming to achieve. Therapy of this type will cease at any point that the client, whether this means the parent or guardian of a child patient, or the employing agency in the case of an adult patient, judges that it has run its course or feels dissatisfied with its progress.

Therapy of this secondary or derivative type does not present any issues of principle in regard to registration & licensing. Therapists working with children should be registered in any event.  And if the client paying for the therapy is an agency of some kind, whether it be governmental or semi-governmental or a wholly private enterprise, it is in any case free to stipulate any criteria & credentials it wishes for the therapists in its employ. This is the case as it stands now & no likely kind of registration or licensing would make any essential difference to this.

Registration & licensing only become problematic in the case of primary therapy, that is, therapy with adults, in the self-employed sector. Furthermore they only become problematic here to the extent that they attempt to restrict who may enter the market as a therapist. Here, therapist & client are engaged in a purely private arrangement in which, provided the law is being obeyed, no third party has any right to interfere. 

Put simply, a registration or licensing system that does not recognize the basic right of adults in a democratic society to discuss their private concerns with whomever they choose will be rendered irrelevant. If I choose to discuss my personal life with Mrs Murphy down the road because I find her sensible & helpful, even though she has no more formal qualification than a Leaving Cert, that is no business of anyone apart from her & me. If we arrange to meet once a week & I agree to pay her for her time, this again is a matter purely for us alone. The government has no legitimate role in it.

But of course, as Dr O’Donoghue stresses, there is a generally held assumption that some kind of formal training is necessary to make an effective therapist. Like many important generalizations in therapy this is difficult to demonstrate & one can always find exceptions. But there is little doubt that most of the time, in general terms, it is true.

The main benefit training confers is a sense of security & confidence in the trainee by providing her with a support network within which to work & an intellectual framework that helps make some sense of the often very confusing data one encounters when working with disturbed & unhappy people. As she becomes more experienced the therapist may well discard both of these supports, but they are undoubtedly very helpful at the start of one’s career.

However two things need to be stressed about training for psychological therapy.

First, we have not been able to show clearly exactly what kind of training is required to produce good & effective therapists. In the absence of such clear demonstration, of course, everyone has their own opinion. This is why there are so many divergent schools within psychotherapy. But no one particular course of training has been shown to be clearly better at producing effective therapists than any other. Nor for that matter has any particular course been clearly shown never to produce effective therapists.

Second, every kind of training that we currently have places into the system every year a significant number of therapists (impossible to say how many) who probably should not have been qualified. The most significant shortcoming of all our current training programs, including the most prestigious, is that they do not systematically eliminate candidates who turn out to be not all that happy in the work of therapy & consequently not all that good at it.

But we must remember nevertheless that the worst therapists probably save some lives, just as the best & most experienced therapists sometimes fail. Therapists like to tell the public that the profession divides into the experts & the amateurs, but this is a distortion. Every therapist, except the very worst, is in part an expert & in part an amateur. The good ones are those who have the self-knowledge to recognize this, the bad ones are those who do not.

Almost everyone (with the possible exception of those who have the most fanatical faith in strict “scientific” method, whatever they conceive this to be) agrees that the most important factor in the making of a good therapist is temperament & character. Every good therapist is unique, of course. That is why she is good. Nevertheless every good therapist has a high degree of self-control, is good at thinking critically about her own motives, is able to tolerate conflicting feelings within herself, & has a sufficiently firm grasp of her own preferences & values not to need to have these confirmed by others, i.e. by her patients. She must in addition have a lively imagination & be able to put herself in the position of others who may be very different from herself. She must in sum be strong enough in her own individuality to be able to connect deeply in imagination with others without fearing to lose herself in them.

Can training impart any of these vital qualities?

My own view, & I don’t believe I am in a minority here, is that an individual who is largely lacking in these qualities at the outset is unlikely to acquire them as a result of training. Training helps the trainee become familiar with the “mechanics” of therapy – how people generally behave in therapy, the kind of responses they make, the questions they are likely to ask, the problems that most often crop up, & so forth. And it helps the trainee acquire the professional habits for dealing with the typical therapeutic situations one encounters. If a trainee already possesses the vital temperamental qualities of a good therapist then training helps her to become more practiced & self-confident in exercising them. But that is all. If the essential therapeutic temperament is not present from before the training commences, it won’t be acquired as a result of training.

The crucial problem we face however is that we don’t have any objective test for who may possess these essential temperamental qualities, or who may lack them.

 

In selecting candidates for training therefore we perforce fall back on proxies for such a test.

 

Acceptance for training depends on a subjective judgment made by the senior members of the school to which a candidate applies. This judgment is based on things like academic qualifications & work experience, but above all on whether the school members feel comfortable with the candidate, feel in other words that her perspective is reasonably close to theirs or can be made reasonably close to theirs.

 

For instance, a candidate who expresses an admiration for Freud is unlikely to be accepted by a school that is strongly Christian in outlook; or indeed one that believes Freud was essentially unscientific. Equally, a candidate who expresses a faith in the healing power of the Holy Spirit is unlikely to be accepted by a school of orthodox psychoanalysts.

 

The problem here is that acceptance for training is not decided by the patients of therapy. It is determined rather by existing therapists who view the candidate from their point of view, i.e. as a potential pupil, a potential adherent of the school & a potential source of income for it, & ultimately as a potential professional colleague &, it may be, as a potential professional rival. None of these things has anything to do with how good a therapist the candidate will one day be.

 

Success as a therapist depends upon personal temperament & upon the possession of a knack, upon a capacity to connect with those in emotional turmoil. At the early stages of a therapist’s career this knack is difficult to identify, because everyone who genuinely possesses it goes on to develop it in a way that is unique to themselves. In candidates who initially seem doubtful it can sometimes flower in unexpected ways. Equally, those who initially seem full of promise can sometimes flounder & never seem really comfortable in the work.

 

But those therapists involved in training other therapists are usually reluctant to reject candidates if it emerges in the course of training that they seem unsuited to the work. There are several reasons for this.

 

First, such a judgment is always subject to error & uncertainty in the first years of a candidate’s career & supervisors don’t like to hurt the feelings of candidates who may have already invested a lot of time, & a lot of money, in becoming trained.

 

Second, no one likes having to admit to themselves they may have made a mistake in taking a candidate on in the first instance.

 

And third, the income & professional prestige of supervisors generally depends upon the number of candidates they have for training.

 

The upshot of all this is that training is of no practical help as a system for screening out unsuitable candidates.

 

So right here we have a major problem for any scheme that proposes to make training the basis of registration or of the right to practice. Training can give a general indication of a therapist’s theoretical orientation. But, as such, it tells us nothing about the effective skill of a therapist.

 

Those who are keen to see licensing of therapists introduced gloss over this. Instead, they try to support their argument by suggesting parallels between psychotherapy & the profession of medicine, which of course does have a licensing system.

 

Psychotherapy however is not like medicine. Psychotherapy has become an important presence in Irish society not as the result of any innovation in medical science. On the contrary, it has become important because of the decline in power of the Catholic Church & the advent of a secular society. As a consequence of these cultural changes people are looking for ways of making sense of the suffering of life & of coping with it, outside of a religious framework. This is what people look to psychotherapy to provide.

 

To become a little more technical for a moment, psychotherapy is one of the ethical sciences, rather than one of the physical sciences. It is a science, that is, in the sense, for instance, that economics, or history, or anthropology are sciences. It is not however a science in the way that cardiology is a science.

 

Like these other human disciplines it requires a good solid background knowledge & mastery of the intellectual tools involved to be practiced properly. But, like them, it also requires unorthodox views, critical assessment & freedom of expression. Without these things, like them, it quickly stagnates into a sterile orthodoxy wherein no one dares to challenge the conventional wisdom.

 

The catch, however, is that psychotherapy is able to pretend not to be one of these ethical sciences, because its history enables it to masquerade as an off-shoot of medicine. The grand illusion that governs the field of psychotherapy in general, & is much the greatest danger to it because it is so widely shared, is not that the various fringe therapies around it are scientific (generally speaking they aren’t), but that the field itself somehow can be made a part of the medical sciences. This is the classical error in discussions about psychotherapy.

 

Of course, psychotherapy is connected with medicine. Therapists generally work closely with doctors. Some therapists are doctors, though this is less often true now than it was in the past. But this is not because therapy is a sub-discipline of medicine. It is because psychotherapy picks up just at the point where medicine leaves off. The problems of therapy begin where the solutions of medicine end. Therapy & medicine are like two adjoining countries with a common border. But they are separate countries, with different laws, customs, traditions & values.

 

Sometimes, therapists cure their patients of their presenting symptoms. But when they achieve this it is essentially incidental to their principal object. Their principal object is to help their patients come to terms with the pain, the loss, the tragedy of their circumstances &, with time, turn these experiences from being something negating of life into something affirming of it. This is no small achievement. But it is not what you go to any kind of medical doctor for.

 

As I have said, the success of therapy depends primarily upon the personal rapport between therapist & client. Licensing therapists on the basis of training would therefore not improve the quality of therapy available overall. Nor, as such, would it be any help to the public in finding a therapist. Members of the public seeking effective therapy would still have to rely on recommendations by friends & GPs, & simple trial & error. There is no other way you can find a therapist that is right for you.

 

What restrictive licensing would do, however, is increase the cost of therapy to the public overall (possibly bringing insurance companies into the market too), make therapists who train others wealthier, & make those holding unfashionable & dissenting viewpoints a little more reluctant to speak out. A vocal minority within the profession who enjoy dabbling in politics would, liaising with government agencies, determine the accepted line on such things as the family, sexuality, religion & moral questions generally. Anyone who diverged from the officially sanctioned line would potentially risk having her license revoked.

 

If then licensing – licensing that is designed to restrict entry into the market – is clearly such a bad idea for psychotherapy, where is the suggestion coming from? What is behind the calls for licensing?

 

In part of course it is simply a commercial response to the growth in competition we have seen in the therapy sector over the last twenty years. No doubt, there are some practitioners who would like to control further entry into it, & secure an income from those who do enter it. Inevitably, these are the therapists who are most eager to persuade the public that their brand of therapy is rigorously scientific & ethically pure & that everyone else is just messing around, representing a potential menace to public health.

 

But in fact most therapists are not mercenary & I do not believe that, within the profession, this is the most important source of the current push for registration & licensing. That is to be found, in my view, at a deeper & more interesting level, in the anxiety & guilt that is an inherent part of being a therapist.

 

Working as a therapist involves very particular emotional demands, & these are not always easy to meet.

 

The psychotherapist has to confront in a very direct & uncompromising way the essential moral uncertainty & ambiguity of our age. The only categorical imperative the therapist should recognize is the autonomy of her patient. She works all the time to uncover the layers of unconscious consensus that have accreted to the instincts of her patient, entrapping & suffocating the true identity beneath. But to obey that imperative, the therapist must not be intimidated by moral consensus herself. She must be able to suspend her own moral preferences if, & to the extent that, she perceives it to be in the interests of her patient to do so.

 

Let no one pretend this is easy. It requires a great autonomous strength on the part of the therapist which, inevitably, sometimes she can summon up & sometimes she cannot. As I have said, the best & most experienced therapists sometimes do poor therapy.

 

But, because she is being asked to suspend her own moral preferences, the work always involves for the therapist in some measure moral anxiety, shame, the fear of alienation, & guilt. These are primeval reactions to questioning consensus views & values, bred into all of us over millennia of prehistory when diverging from consensus was the only sin, & we all have less control over these reactions than we like to imagine.

 

Every therapist deals with these feelings by trying to hold on to something that feels secure & congenial. For some therapists, including myself, this is Freud & his general perspective. For some of a more religious temperament it is faith in God. For others it may be something more abstract, like the Correct Scientific Method. But every therapist has her preferred fallback position, the intellectual & emotional position she retreats to, in the face of the inherent moral uncertainty of the work she does.

 

All therapists hanker after tangible symbols of belonging to something that feels authoritative & protective. We are all drawn to symbols that reassure us we will not face attack by the community in spite of the essentially subversive work we do, which always involves questioning the assumptions of the community.

 

For, as therapists, we need to remember that we are not here to serve the community, as such. That is not our vocation. Our starting premise, as therapists, is that we do not know enough about human nature to be sure what the interest of the community is. Our assumption is that all human beings lie to themselves & that what the community takes to be in its interest contains much that is mistaken. Working on that assumption, we are here to serve, as best we can, the interest of the individual. Our faith is that what strengthens the individual will, ultimately, strengthen the community. At any rate, we hope so. But don’t ask us to prove or demonstrate this, because we cannot do so.

 

And in the interim, much that we learn about the patients we work with will inevitably be in conflict with conventional values. Our patients are ill because, in their fear of conventional & community values, they will not let themselves face certain vital truths about themselves.

 

We must remember how much of what we now take for granted about mental health was regarded only a few years ago as sinful & heretical. And this was so nowhere more than in Ireland which as a society can still be surprisingly intolerant of minority views. The conventional view of what is good in the emotional life always lags behind what we as therapists are discovering. To do our work properly we must have the courage of our own insights & not be intimidated by consensus.

 

But it is in the emotional pressure of maintaining this independent stance, I believe, that we find the root of the wish for a public licensing system. We therapists feel that if we were licensed, if, in other words, we could point to something that reassured us we were legitimized by an authority to do what we do, then the guilt & anxiety of our work would be lessened. An essential part of that legitimation, of course, would be to see our sibling rivals (the Energy Psychologists, perhaps?) denied societal approval. The good can only ever be defined in contradistinction to the bad. It would be reassuring, we feel, to have a bit of paper that certified that we are truly scientific, while they are merely crackpots.

 

The contrary is the truth: every good therapist is scientific enough to be at ease with the crackpot in herself. Rather than running away from it by projecting it onto others she uses the crazy part of herself to deepen her understanding of life.

 

A licensing system would, in essence, externalize the professional neurosis from which all therapists, in greater or lesser measure, suffer. Like all neurotic responses it would at best be an irrelevant waste of resources & at worst be destructive of diversity & alternative viewpoints.

 

What then is the practical alternative to restrictive licensing?

 

I have proposed a straightforward register of therapists, which it would be obligatory for anyone who practices as a therapist to join, & which would give the general public background information on education, training, memberships & general theoretical orientation for each therapist. This would bring much needed transparency for the public & make the market for therapy more efficient.

 

Everyone on this register would be bound by a basic code of ethics.  This code would also include basic standards for advertising, in particular precluding anything that could reasonably be expected to mislead the public about training, expertise, or likely therapeutic outcomes.

 

A system of sanctions should be provided in the event of infringement of the code. In cases of serious offences such sanctions should include removal from the register & thereby disbarment from the right to practice.

 

Such a system would be straightforward & inexpensive to administer, & it would solve all the outstanding problems a restrictive licensing system has been proposed to address, without any of the inevitable problems such a system would bring with it. Its underlying assumption is that as far as possible it is best to leave it to the public to decide whom they wish to attend for therapeutic help, rather than trying to decide this for them.

 

Good psychotherapy depends, ultimately, upon a willingness to confront the complexity of the truths that make up our human condition. In the investigation of these truths we do not need to fear viewpoints that diverge from our own. If they are of no value they will fade as a result of their own sterility. If they have something useful to say, we should listen to them. At the very least, we should welcome diversity & competition in the marketplace of therapeutic ideas.

 

People who challenge our assumptions are good for all of us. They are especially good for us therapists, for whom dogmatic slumbers, induced by fear of uncertainty, are always a danger. We should think carefully before we decide to outlaw them.

 

November Morning

La Serenissima

Aristotle: thought for the day

Neither in moral nor in mathematical science is the knowledge of first principles reached by logical means: it is virtue, whether natural or acquired by habituation, that enables us to think rightly about the first principle. - Aristotle, Nicomachean Ethics, Bk VII.

Tramore - August 2012

A Few Studies in Black & White