Now it is more generally acknowledged that most mental illness is caused by difficulty coping with the demands of everyday living rather than by abnormal brain chemistry, the demand for psychotherapy (sometimes known as ‘counselling’) instead of medical treatment is increasing. Distinct from medicine, psychotherapy is a process that promotes self-help and enables people to learn more about themselves and their relationship to the world, thus increasing the opportunities for improved mental health.
Unfortunately, the nature of psychotherapy is such that it is open to subtle forms of abuse by incompetent or unscrupulous practicians; and when our minds are in turmoil we are particularly vulnerable. Being enticed to take part in physical intimacy is probably the most widely known form of abuse, but there are others less obvious. One example consists of persuading clients that their condition is more serious than they thought and offering them unrealistic assurances of recovery if they agree to accept no other kind of help – and thus become emotionally dependent on the practician. There are even instances of clients being persuaded to ‘remember’ the traumata of being sexually molested in childhood even though it never took place. Another aspect of this emotional blackmail is to hint that what the client has disclosed in confidence could be passed on to others, or that the practician could withdraw support. It is hardly surprising that psychotherapy is sometimes compared to a perverted religious cult.
Legally, anyone can practise psychotherapy. This has prompted many practicians to form professional associations that claim to simplify the task of choosing a practician, because all their members are fully trained and qualified. On the face of it, this reduces the possibility of abuse; but such claims are specious at best because, just as anyone can legally practise psychotherapy, so any group of practicians can form a professional association and claim to speak with authority.
Such claims seem to rely on a common assumption that psychotherapy is a quasi-scientific treatment comprising specific, efficacious techniques. It seems, however, from extensive reviews of thousands of cases, that these techniques, although mostly effective in modifying behaviour, are of relatively little value to someone whose mental health is frail. In fact, the efficacy of psychotherapy largely depends on clients’ own inherent ability to enhance the quality of their mental lives with the help of a dedicated and disinterested practician. The process itself depends mainly on the quality of the ‘therapeutic alliance’, or ‘working relationship’, forged between client and therapist during their structured conversations; and this in turn is related to the practician’s interpersonal, or ‘people’, skills: the ability, for example, to see things as the client sees them (without necessarily being in agreement) and employing a flexible approach that welcomes dissent.
Can such skills be taught? More importantly, how can they be properly assessed? How much credence should be given to claims that stress the importance of what the associations call training, qualifications and, in some cases, supervision?
Although interpersonal skills can certainly be improved by structured seminars, particularly if they include role-playing and critique, these are but a refinement – not a substitute for acquiring, perhaps over a long period of time, skills that can best be learned from close involvement with people from diverse backgrounds in real life situations – much as we acquire the skills, say, of being a parent. Learning what ought to be done in a contrived situation does not ensure that it will be the appropriate response in all similar situations; and, because everyone is unique, every situation that clients ‘bring’ to psychotherapy is unique. Consequently, what really matters is the practician’s open-mindedness and readiness to learn more from clients than from theory – flying, as it were, ‘by the seat of their pants’.
Unfortunately, the criteria many of the professional associations use for their accreditation procedures can neither ensure proficiency nor eradicate covetousness and concupiscence. If anything, such accreditation is likely to encourage arrogance and neglect of the genuine humility that is the attribute most conducive to safe and effective practice. There is much truth in the adage that ‘only the wounded physician heals’. The portrayal of psychotherapy as a recondite undertaking, properly performed only by an association-accredited élite merely beguiles unwary clients into a false sense of security. Although most associations are prepared to expel from membership anyone who does not abide by the normal ethics of interpersonal activity, actual abuse is difficult to prove.
How, then, can we reliably judge that someone will prove a trustworthy and competent practician? Clearly there is no objective criterion, and the only valid accreditation is that which is carried out by the clients, not by other professionals. The surest protection against fraudulent practice is the ancient legal injunction of caveat emptor (that ‘the client should be wary’), although the right of recourse to civil law may also serve to deter abusive practice. Perhaps what little protection clients have could best be increased by a non-discriminatory system of licensing administered by a suitably disinterested body. Current Government proposals to augment the power of the professionals can only make matters worse.
[The writer is a human relations consultant]