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14th December 1999 text download this article
The baby and the bathwater:
'professionalisation' in psychotherapy and counselling

by Nick Totton
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The current rush to professionalisation in the field of counselling and psychotherapy, and some of its deleterious effects, are examined. The parallels between this process and the experience of psychoanalysis in the USA in the 1940s and early 1950s are demonstrated, quoting from contemporary critics; and comparisons are drawn with the American phenomenon of managed care. An account is offered of what is happening in terms of the sociology of professions, suggesting that 'expert systems' are being substituted for 'local knowledges '-skills and wisdoms which cannot be fully systematised. The argument that this process is for 'the good of the client' is considered and rejected. Finally, some thoughts are presented about the likely future for counselling and psychotherapy, arguing that the victory of professionalisation and expertise is unlikely to be complete.

'I have slowly come to the conclusion that if we did away with "the expert", "the certified professional", "the licensed psychologist", we might open our profession to a breeze of fresh air, a surge of creativity, such as has not been known for years. In every area - medicine, nursing, teaching, bricklaying, or carpentry - certification has tended to freeze and narrow the profession, has tied it to the past, has discouraged innovation.... The question I am humbly raising, in the face of what I am sure will be great shock and antagonism, is simply this: Can psychology find new and better way?'

The rush to professionalisation

'Good morning , lemmings' (railway graffiti near Paddington station, London).
The unfortunate truth is that the primary response to Car Rogers' question, then and now, is not so much 'shock and antagonism' as a deafening silence. Rogers (who developed the term counselling because he was himself unable to get certified as a psychotherapist is by no means the first significant figure in the field to oppose aspects of professionalisation. For example, Freud (1926/1962) vehemently objected to the medical model of psychoanalysis, which was intimately tied to professionalisation (Jacoby, 1986, p.145); while Jung said of psychotherapy that 'holding lectures, giving instruction, pumping in knowledge, all these ....... procedures are of no use here' (Adler, 1976, p.534).

Many eminent and well-respected contemporary figures have also expressed reactions ranging from horror to despair at what is happening to counselling and psychotherapy, both in the UK and in the USA (e.g. Heron, 1997; Lomas, 1997; O'Hara, 1997; Thorne, 1997). The opponents of headlong professionalisation have largely dominated the argument; but its proponents' strategy of what in German is called Totschweigen (deathly silence), combined with remorseless organisational advance, meets with continued success.

What is 'headlong professionalisation'? This question can readily be answered by scanning the pages of just about any recent issue of a trade journal in the field. For example, the August 1998 issue of Counselling, the journal of the British Association for Counselling (BAC), includes a letter from David Buckingham which says:

'Counsellor training is still expanding. There are ten times as many diploma courses as there were a few years ago. The cart appears to be before the horse. Courses are offered, places are filled, and there is a hope that there will be enough available clients to provide the practice the students require.... How long will it be before placements and clients realise that they are onto a good thing, and begin to charge for the privilege of counselling them?' (Buckingham, 1998, p.175)

There are also several letters both for and against the new BAC accreditation requirement of 40 hours of personal therapy or counselling. Those in favour mainly focus on what Richards et al (1998, p.173) call 'the need for practitioners to be engaged in a constant process of self examination, especially in the way they relate to others'. The arguments against are mainly either that research has not demonstrated the value of personal therapy in training effective practitioners; or simply that personal therapy is too hard, too unpredictable and too expensive! Two other pieces from the same issue stand out as relevant. In the Point of View section, Sally Saunders argues that:

'If counselling trainings are financially directed, they will be consumer-led. The consumers ... may understandably choose a course that does not have the demand for personal therapy because it is cheaper to train.... If counselling training was seen more as an apprenticeship allowing students to develop at their own pace, it might stop the rush for hasty qualification and the pressure to know it all now.... It is surely time to re-evaluate what counselling is and who should be doing it' (Saunders, 1998, pp.179-180)

And in an interview entitled 'Counselling and the abuse of power', Ernesto Spinelli, Academic Dean of the School of Psychotherapy and Counselling at Regent's College, London, questions the introduction of new standards of professionalisation through endless working parties, committees and guidelines:

'All of these things give an illusion of professional bodies. We say: "Look, if we go to all of these meetings, if we have all these standards, if we have these codes of ethics, we must be professionals and we can hide our questions, about what we are professionals of or in, or about, by having all these bodies to protect us' (Spinelli, 1998, p.182)

I am quoting these various viewpoints not in order to make a particular case, but so as to establish the ferment of confusion, doubt and disagreement which currently pervades the field, and through which the professionalisers continue to carve their determined single track. To speak bluntly, counselling and psychotherapy training in the UK is close to being a bubble: a pyramid selling scheme, in which individuals or organisations near the top of the food chain skim off large profits, and those near the bottom starve or eat each other. Far more practitioners are being trained than there are clients available for them; and a series of emergency measures are being used to stave off the collapse of the system by lengthening the food chain further, inserting more roles and jobs. As well as client and therapist, we now have trainer, supervisor, trainer's supervisor, supervisor's trainer, supervisor's trainer’s supervisor. As Spinelli 'sometimes jokingly' says to students and trainees, we’ll eventually reach a point where we'll no longer need clients, because we can just close the circle, we can counsel each other, supervise each other, and train each other ad infinitum' (Spinelli, 1998, p.183).

If only this were the case! But unfortunately a supply of clients must be generated, at approximately 15 or 20 times the rate at which practitioners are being turned out (assuming that a hill practice has 15 or 20 slots). The best hope for achieving this is to colonise the public sphere of free-to-the-client therapy. But as with pyramid schemes, collapse is inevitable—far sooner, usually, than the participants anticipate. Perhaps we should go back to Sally Saunders' questions quoted above: what are counselling and psychotherapy, and who should be doing them?

Deep background

'Slowly but surely psychoanalysis was cleansed of all Freud's achievements. Bringing psychoanalysis into line with the world, which shortly before had threatened to annihilate it, took place inconspicuously at first ... Form eclipsed content; the organisation became more important than its task' (Reich, 1942/1973, p.125).

All this has happened before. In his 1954 paper 'Therapeutic problems in the analysis of the "normal" candidate', the American psychoanalyst Gitelson reports that some analysts 'have begun to despair of the suitability of "normal" candidates for a career in psycho-analysis' (Gitelson, 1954/1989, p.413). He quotes Hans Eissler who, after working with someone who wanted therapy 'only for professional reasons', decided that he 'would never again try the analysis of a "normal" person' (ibid., p.414). Gitelson also quotes the then President of the American Psycho-analytic Association, Robert Knight, on how 'the great increase in numbers of trainees ... and... the more structured training of institutes' had changed the sort of people coming for training. In the 1920s and early 1930s, Knight says,

'... many gifted individuals with definite neuroses or character disorders were trained. They were primarily introspective individuals, inclined to be studious and thoughtful, and tended to be highly individualistic ... read prodigiously and knew the psycho-analytic literature thoroughly.

In contrast, perhaps the majority of students of the past decade or so have been "normal" characters, or perhaps one should say had "normal character disorders". They are not introspective, are inclined to read only the literature that is assigned in institute courses, and wish to get through with the training requirements as rapidly as possible... Their motivation for being analysed is more to get through this requirement of training rather than to... explore introspectively and with curiosity their own inner selves... The partial capitulation of some institutes arising from numbers of students, from their ambitious haste, and from their tendency to be satisfied with a more superficial grasp of theory, has created some of the training problems we now face' (Knight, 1952, quoted in Gitelson, 1953/1989, p.414)

There is an uncanny parallel here with some of the passages from Counselling. The same complaint is being made that people are training for the wrong reasons, coming from the wrong place internally; that they are concerned with the job rather than the work, and with looking into others rather than into themselves; and for the same underlying reasons. Like American psychoanalysis in the 1950s, the occupation of psychotherapy and counselling has shifted to a more central and acceptable cultural position.

The rise of the 'normal' practitioner dovetails very neatly with the remedicalisation of therapy. People have struggled for decades to establish that psychotherapy is, as Freud said of psychoanalysis, 'not a specialised branch of medicine' (Freud, 1926/1962); that those wanting therapy are not sick, since unhappiness or a desire to change are not illnesses. The drive to professionalisation, the enormous expansion of training, demands a huge increase in clients. The only way to get enough therapy and counselling paid for, it appears, is to get the state and other institutions to pay for it. For this to happen, psychotherapy and counselling must present themselves as somehow medical.

In the United States, the dominant issue has been getting therapy paid for by medical insurance. Reasonably enough from their point of view, the insurers have required that the treatment they are paying for is medical treatment: in other words, that the client is defined as ill. A whole profession of 'managed care' has arisen to administer this process demanding that each client is assigned a 'DSM number' a psychiatric definition, based on the Diagnostic and Statistical Manual of the American Psychiatric Association, Fourth Edition, of the supposed disease entity from which they are suffering. The diagnostic categories of DSM IV are a masterpiece of circularity and vacuity for example, '312.9: Disruptive Behavior Disorder'. Each DSM number is allotted a fixed number of authorisable sessions, irrespective of the individual client's needs. Internet users will be familiar with expressions of outrage from American practitioners over the distortions of therapeutic relationship and process entailed (for a print account, see e.g. O'Hara, 1997, pp. 24-28; also Totton, 1997a, pp. 113-114). We in the UK may congratulate ourselves on having escaped. But we have our own mild-mannered version of managed care: the presence of counselling and psychotherapy in the National Health Service, which, although it lets therapy reach large numbers of people who would not otherwise get it (although they may not always want it or be suitable for it), also means that the concept of audited, cost-effective, time-limited therapy and counselling becomes central (House, 1996; Totton, 1 997a). And, of course, the NHS benefits in turn from the training bubble by being able frequently to pay GP practice counsellors a pittance - it is a buyer's market.

Expert systems/local knowledges

'I have felt for some years now like a man who is in danger because he has become imprisoned in the profession of therapy' Thorne, 1997, p.141)

The sociology of professions emphasises two defining features of a profession: the possession of 'expert knowledge' (Giddens, 1991; Stehr, 1994), and the use of political strategies to establish a small elite group in control of its own boundaries. These strategies include 'social closure' (Parkin, 1974), 'occupational imperialism' (Larkin, 1983), state support and market control (Larson, 1977). The medical profession can serve as a template of such processes, and a number of authors have described its use of such strategies to establish a uniquely powerful role for itself (e.g. Cant & Sharma, 1996; Griggs, 1982; Larkin, 1983; Stacey, 1992).

Psychotherapy and counselling - or rather, powerful groups within these occupations - are trying in many ways to repeat the success of medicine. This is partly in resistance to medicine's 'occupational imperialism': one of the powerful forces in the development of the Rugby Conference, which ultimately became the United Kingdom Council for Psychotherapy (UKCP), was the fear that psychiatry would attempt to 'own' the activity of psychotherapy, as it does in many European countries (Heron, 1997; Wasdell, 1997).

Psychotherapy and counselling have responded to the political need for a body of 'expert knowledge' by generating one-radically lengthening and widening trainings, 'technicalising' every aspect of the work, inserting new levels and meta-levels of expertise and qualification. All this in a field where research shows repeatedly that technique and outcome cannot be shown to be connected: that

'there are ... hundreds of different versions of psychotherapy, and many of them seem to work equally well' (Mair, 1992, p.146).

This verdict (backed up by, for instance, Orlinsky & Howard, 1986; Frank, 1973) seems to, but does not, support the notion of generic therapy, which is vital to any notion of expert knowledge: the idea that everyone is in some sense doing the same thing. There are hundreds of different forms of marriage, many of which seem to work equally well; but they are not all the same thing. And what do we mean, anyway, by 'work', in the context of a complex relationship like marriage or therapy? The UKCP, especially, finds itself in the position of gathering together under one roof people whose activities have virtually no point of similarity with one another (Stacey, 1994, p. 110, sees a parallel situation in medicine). The rationale is the creation of a generic profession; but it appears that any non-empty definition of what that profession does leaves out half of its supposed practitioners.

Many people have expressed unease on every level at this process, but it has often been difficult to produce a clear critique of the notion of expertise. A helpful concept here is that of local knowledge (Geertz, 1983): a term developed in anthropology and the new field of science studies to describe the opposite pole from generalised expertise, which is

'... formulated on a global level, that is, within the abstract "synthetic nature" constructed by science. And the terms it is built on are to be highly standardized, quantifiable and not subject to subjective interpretations. It is through such a model, its language and its terms that the necessary control, manipulation and supervision ... is established' (van der Ploeg, 1993, p.219).

Van der Ploeg's seminal paper 'Potatoes and knowledge' (1993) studies the interplay between agrarian science and local farmers in the Andes. It describes how, from the scientists' point of view, it is 'only logical' to model the needs and procedures of agriculture in a standardised way, with so much nitrogen required equalling such and such a dose of chemical fertiliser, and so on. The practical reality of farming, for someone who knows the intricacies of their environment and works by what van der Ploeg calls 'art de la localite, is very different. 'However, the outcome of such methods cannot be exactly predicted. Nor can the necessary methods ... be prescribed in detail... . Local knowledge ... is, under these conditions, rapidly becoming not just a marginal, but more than anything, a superfluous or even a counter-productive element' (pp.219-220).

A closely similar struggle between expert systems and local knowledge is being played out within the field of psychotherapy and counselling. Wynne (1995) characterises local knowledges which are always necessarily plural as

'... interwoven with practices ... highly dynamic systems of knowledge involving continuous negotiation between "mental" and "manual" [for our purposes, practical] labour, and continual interpretation of production expenences ... However because it is so multidimensional and adaptive, experience is rarely expressed in a univocal, clear form. This is frequently mistaken for lack of theoretical content ... [But] there is indeed systematic theory, even though this is in a syntax linked to the local labour process and does not presuppose a universal and impersonal world' (p. 67, my italics).

Is this not an excellent description of the 'knowledge system' of psychotherapy and counselling-'multidimensional and adaptive', 'interwoven with practices'? The concept of local knowledge helps to clarify and support the repeated protests of figures like Lomas (e.g. 1987, 1994) that psychotherapy is a matter of experience, intuition and human sensitivity-wisdom, in fact-rather than of technique and expertise; or Jung's statement that 'any organisation that proposes collective methods seems to me unsuitable, because it would be sawing off the branch on which the psychotherapist sits' (Adler, 1976, p.534). It underlines the crucial role of self-knowledge (the self being a large part of the localite for this particular art), and the real appropriateness of the apprenticeship model.

We can now clarify the quite straightforward socio-politico-economic reasons why counselling and psychotherapy appear to be turning their backs on their own hard-won local knowledges. A profession must have its expertise — which must articulate with the hegemonic expertise of its society. This expertise ....

would have key characteristics: it would be taught in an organized way, most usually in a university (or at least in an institution that collects, transmits and eventually reproduces knowledge); and it would be standardized and accredited and often have scientific anchorage ... Expert knowledge gives some the privilege to speak, to act as arbiters' (Cant & Sharma, 1996, p.6).

It is no accident that the expert systems/local knowledges dichotomy is explicitly linked with themes of colonialism and imperialism. Generic psychotherapy and counselling have used a specious version of expert knowledge to colonise and weld into an empire many diverse local craft knowledges—hence distorting them, much as medical chemistry isolates a supposed 'active ingredient' from a medicinal plant (Griggs, 1982). The political impetus is so strong that it has managed to ignore how 'scientific research' itself-the system's own borrowed expertise-finds repeatedly that, although therapy and counselling seem generally beneficial, neither technique nor training significantly affect the benefits reported. House (1997), Mair (1992) and Mowbray (1995) all offer surveys of relevant research; for a particularly interesting example, see Seligman (1995)). What does make therapy effective is precisely 'local knowledge' - the 'therapeutic bond' and all the imponderables on which it depends.

Another closely related metaphor has been used by Postle (1997, 1998), drawing on Shiva's (1993) concept of 'monocultures of the mind'. Like the multinational companies, generic psychotherapy and counselling extinguish local ecosystems in the interest of economies of uniformity, 'weeding out' the unique and nonconformist. As Postle (1998) points out, 'a register [of acceptable practitioners] creates weeds. Indeed for it to make sense, it has to create weeds, to justify the high cost of the education of cultivars' (p.154).

The close parallel between what is happening in psychotherapy and counselling, and the historical, global effect of Western science and capitalism on local knowledge systems, is made eloquently clear in O'Hara's (1997) account of the current American situation:

'Managed care spokespeople openly describe their revolution as the industrialization of health care and, with unconcealed enthusiasm and frequently contempt, declare that the days of "therapy as a cottage industry" are over. What is happening to therapists in the 1990s is equated with what happened to butchers, bakers and candlestick-makers in the 1800s' (p.24).

The good of the client

'The opinion of the United Kingdom Council for Psychotherapy seems to be that a recognised training is required in order for psychotherapists to be effective. There does not appear to be much evidence to support this opinion' (Mair, 1992, p.150).

Professionalisation has its own self-motivating dynamic: once a group decides to carve out a niche as a profession, it inevitably seeks to make boundaries around itself and to control admission. Perhaps the only way to achieve this is by laying claim to a body of expert knowledge. The fundamental motivation involved is quite simply one of self-interest. However, like many social phenomena (Levi-Strauss, 1967), the drive to professionalisation is not conscious of its own dynamic: it holds false beliefs about its own motivations. The primary conscious belief is that professionalisation is for the good of the client: that it will protect the public from being preyed upon by dangerous, incompetent and unscrupulous quacks.

Unfortunately, there is practically no evidence in support of this belief, and a good deal against it. Mowbray (1995) has extensively documented the practical, philosophical and technical reasons for doubting that registration or licensing protects the client; he draws on a wide range of sources, including Hogan's (1979) magisterial four-volume work. We can conclude the same thing from the everyday evidence of abusive behaviour in the long-regulated medical and legal professions (Stacey, 1992, 1994). What is more, every experienced practitioner knows that practitioner abuse occurs in the most respectable and senior areas of the field, not just on the wild fringes. One well-documented example is the past-president of the American Psychiatric Association and the American Psychoanalytic Association, and honorary life president of the World Association for Social Psychiatry, who was found to have raped patients whom he injected with amytal (Noel & Watterson, 1992).

At least as bad as the false reassurance of expertise, wisdom and unimpeachability is the standardised 'complaints procedure', based upon an adversarial, quasilegal structure quite inappropriate to the sorts of situations which arise in psychotherapy and counselling (Totton, 1997b). Grinding on for month after month, fitting the client to the structure rather than the structure to the client, and finally producing at best a largely irrelevant verdict of 'guilty' or 'not guilty', complaints procedures are often disastrous for all involved. Most differences between practitioner and client are far better suited to a conflict-resolution model than to a legal one. What unhappy clients often want more than anything is an apology, an acknowledgement of hurt; and, of course, this is the one thing that the professionalised complaints procedure prevents them from having. In what Thorne (1997) has called 'this death-dealing culture of accountability and appraisal where the basic assumption is that nobody is really trustworthy' (p.147), few practitioners will dare acknowledge error, for fear of being hung, drawn and quartered pour encourager les autres.

The most striking aspect of all this is the extraordinary way in which practitioners have amputated their own understanding of human psychological processes. We know about the projection of shadow figures; yet we go on talking about all these dangerous abusive therapists 'out there', and setting up ways to hound and expel scapegoats - as if this will somehow resolve our own feelings of resentment and even hatred towards our clients, for stirring us up in so many painful ways (Winnicott, 1947/1987). And accompanying this hatred, there is perhaps a profound fear of our clients and how they may treat us.

The professionalisation process can be understood as one of expulsion. Something is being got rid - for overdetermined motivations, including the formation of boundaries towards 'social closure', and the inculcation of public anxiety about who is a 'safe' therapist. But the motivations also include, it seems, a fantasy that we can get rid of all the messy, dirty, chaotic aspects of therapy and counselling - 'cut back' the weeds, the 'sprawling plants that 'obscure each other's light and deprive each other of nutrients' (van Deurzen, 1996; see Postle, 1998). This powerful and alarming metaphor, in an address by a former chair of UKCP, raises Kleinian spectres of infantile envy and hatred, closely parallel to the suggestion that we may be throwing out the baby with the dirty bathwater which we would so much like to deny. But the dirtiness is intrinsic to the baby; and the baby is what we will, as therapists and counsellors, always be left holding.

'There is no alternative'

'Where, I ask, is the soul in all this? Could it be that all the energy I have devoted over the years to schemes for accreditation and recognition, all the many hours spent in committees and in working parties ... instead of improving the quality of therapy and enhancing the well-being of both therapists and clients has led instead to the creation of an exclusive professionalism and added anxiety, competitiveness and the fear of judgement to the lives of those who were previously lovingly and conscientiously responding to the needs of their clients?' (Thorne, 1997, p.147).

The proponents of professionalisation have so far lost the argument - partly because they have chosen not to join it. Unfortunately, though, arguments are not everything; tremendously powerful forces are involved. At bottom, psychotherapy and counselling are reflecting the values of capitalist society at the end of the 20th century: standardisation, form over content, 'give the customer what they want (and never tell them about other possibilities)'. The one argument to which professionalisers return again and again is a sad but effective one: it is bound to happen. There is no alternative.

This is not wholly the case. Certainly there is and will continue to be 'professionalised' psychotherapy and counselling: hierarchical, consumer-driven and shored up by an easy scientistic posture of expertise. It seems likely, though, that other forms of practice and organisation will in fact survive, and even flourish. As Foucault (1992) tells us, power and resistance are inseparable: every form of control and centralisation immediately creates an uncontrollable margin. Many practitioners from all schools have revolted against professionalisation, because it so directly flouts all their 'local knowledge'-what they have learnt in practice about the interactions which are central to their craft; and because it means organising collectively in a way which actively contradicts their skilled understanding of human nature and human groups. Some are already grouping together to do something else: at least one organisation, the Independent Practitioners Network, is striving to create forms of accreditation and validation which emerge from, rather than flout, therapeutic practice - in this case, based on a network of peer groups (Totton, 1998).

It is inappropriate to take some sort of Luddite stance, mourning the loss of the Good Old Days: they were never that good, in our field or any other. Local knowledges have traditionally been hamstrung by lack of meta-perspective, of the understanding that they are in fact local knowledges; without this awareness, they become dogmas and rituals, preventing the development of new and better ways. The professionalisation debate has, not always intentionally, cast a great deal of light on hitherto 'unconscious' aspects of our work-including aspects, like lack of accountability, that urgently need changing. We cannot go back to the past. The issue is about the future; and the future of psychotherapy and counselling, just like the future of our society in general, is still in contest.


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This article first appeared in the British Journal of Guidance and Counselling Vol 27, No3,1999

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