As professions that are now firmly entrenched in society, psychotherapy and counselling are relative newcomers. However, wanting to help another in difficulty must surely have ancient roots. Indeed, our success as an evolving species may have been due to our propensity to bond with others and work on shared challenges. We take for granted that it is normal to listen to the problem of a close friend and offer advice or support. For millennia, writers have praised the virtues of friendship, even regarding a person’s friend as their ‘second self’.
My book The Therapy Relationship: A Special Kind of Friendship interprets all forms of counselling and psychotherapy as allied to friendship and as sharing many of its norms and expectations. A person typically turns to therapy when friends are unavailable or not up to the task. This situation can arise when the originating causes of distress are obscure or complex, and a means of changing them is not obvious. Therapists have found a social niche for themselves by offering to analyse a problem in greater depth and to suggest a way of resolving it. The nature of their professed expertise varies greatly – from delving into the hidden consequences of childhood trauma, clarifying the parameters of a problem, remediating a lack of skill, to offering a new personal vision. It is understood that a therapist has more to offer than tea and sympathy, which are rarely seen as sufficient. At the same time, therapy delivered solely as technical expertise lacks the human dimension of a friendship-like relationship. To view therapy as no more than a technical fix would place therapists in the same category as dentists, solicitors, and plumbers. I suggest that this would leave out the reciprocity, trust, liking, and other virtuous qualities that most people look for in a person with whom they can share their vulnerability and darkest secrets. The relationship becomes a very ‘personal’ one, whatever we mean by that phrase. When the causes of a problem have been successfully resolved, the person who has received this help usually experiences an urge to offer a therapist something in return, such as a gift or continued informal contact in which appreciation is shown. Although we may develop a friendly relationship with the technical experts mentioned earlier, the services they render are usually viewed as little more than commercial transactions.
However, for conceptual, political, and professional reasons, the technical aspect of therapy has been emphasised to the neglect of shared humanity as the bedrock of therapy. The therapy relationship itself has been conceived as a set of technical skills, with theory-driven justifications for adopting an ‘effective’ professional attitude. In this respect, therapy joins a trend towards decomposing all personal services (e.g. banking, food outlets, customer complaints) into a set of simple responses that can be delivered by a piece of computer software or by a human being who need not think deeply about what they are doing. If this kind of service delivers a result, at least in terms of outcome criteria that are deemed adequate, it tends to get adopted. There has been a rush to produce therapy manuals that translate any form of help into a set of explicit and definable steps. Codes of professional ethics also stress the importance of drawing a sharp distinction between doing what is taken to be in a client’s ‘best interests’ and acting in an intuitive, spontaneous, or human way, which may be seen as unethical or as having a detrimental effect on the outcome.
How has this rational approach to therapy been rationalised? Its chief ideological support is the myth of mental illness, the idea that lying behind any expression of distress is a disorder of the individual analogous to an illness. Redefine a complex problem into a mental disorder and you reduce the need for its assessment and limit remediation to a relatively small set of possibilities (e.g. medication for depression, desensitisation for anxiety, mindfulness for anything). With the myth of mental illness well-established, governments and charities are given a clear mission – to reduce the mental ill-health of the nation and to remove any obstacles to accessing ‘services’. There is, moreover, a convenient indicator for their success in doing so – the reduction of mental illness as defined operationally in manuals of psychiatric disorders. And if people can be persuaded that common forms of unhappiness are mental disorders, there is no longer any need to examine their complex causes. For instance, distress caused by difficulty in satisfying basic needs or associated with few opportunities to lead a meaningful life get translated into a clinical condition. In fact, each citizen has an implied duty to sort out their ‘mental health issues’ if, say, they are having problems managing their children or finding employment. Given that any impediment to a smooth fulfilment of social roles is likely to incur costs (in the form of lost production, social welfare payments, or dependence on other services) it makes sense for the state to justify the provision of therapy as a way of mitigating those costs. The economic implications of ‘mental ill-health’ and its remediation are simply enormous. Therapy, counselling, and advice in all its various forms amount to a sizeable sector of the economy, not to mention the even greater economic significance of the manufacture and sale of psychotropic drugs.
Therapists themselves are caught between several conflicting pressures. In order to receive funding from the state, health insurance companies, or grant-giving bodies, they must play the game by rules defined by others. For some practitioners it has become a criminal offence to practice without the necessary stamp of approval from a regulatory body. In order to demonstrate marketability and public appeal, each brand of therapy feels obliged to adopt strategies that demonstrate results in terms of illness criteria. Often enough, this means inflating claims for success and denigrating the methods of competitors. There is little incentive to take a non-partisan approach to researching the causes of distress or to break through the conceptual boundaries of the ideology of mental illness. Professional regulation, together with the imposition of ethical codes of practice that presuppose a technical definition of therapy, leave little room for innovation. It is left to organisations in the unregulated and voluntary sector to generate alternative perspectives. These may offer advice, support, or self-help at no cost, and they have sometimes managed to bring about a redefinition (or de-medicalisation) of the ‘disorder’ that concerns them.
My book examines the way in which the main approaches to therapy incorporate, accommodate to, or ignore the values implied by the kind of relationship that differentiates psychotherapy from other professional or technical services. It critically evaluates the research methods used to make claims for effectiveness. While by no means denying that therapists require competence of a technical kind, it reviews research in the field from the standpoint that therapy is founded on a form of friendship. The inferences that have been drawn from the best predictors of a successful therapy outcome (that is, a client’s characteristics and the quality of the therapy relationship) are criticised and the data reinterpreted. The book summarises research on how clients perceive therapy and examines the promise and limitations of self-help. It also considers the arguments put forward by sociologists (and sometimes by therapists themselves) when critiquing the practice of therapy. A re-construal of psychotherapy that emphasises its non-technical and human aspect has implications for what it can legitimately claim to be offering. The final chapter considers ethical regulation and the issues that arise from offering a service that is not merely technical. As a ‘kind of friend’, with conditions attached, the nature of this relationship is bound to be controversial and will become even more so when the mythology of mental illness is eventually abandoned.
Richard Hallam trained as a clinical psychologist and has combined university teaching and research with work in a variety of National Health Service settings. His main areas of interest are adult problems, hearing-related complaints, and case formulation. He has published several books, most recently Virtual Selves, Real Persons (2009) and Individual Case Formulation (2013). He now works as an independent researcher and in private practice. His latest book, The Therapy Relationship: A Special Kind of Friendship, is published this week by Karnac Books.