One problem, inherent in debates about therapy, is the use of the different terms ‘counselling’, ‘psychotherapy’ and ‘therapy’. There are some ‘counsellors’ and some ‘psychotherapists’ who insist that there are real differences in their practices. However, it is arguable whether there are any essential differences between ‘counselling’ and ‘psychotherapy’. Dunnet et al. (2007) assert that there is a ‘lack of any reliable evidence indicating a difference between the practices of “counselling” and “psychotherapy”’ (quoted in Cooper, 2008, p. 9).
Another confusion concerning the meanings of ‘counselling’, ‘psychotherapy’ and ‘therapy’ is that these terms can refer to the people who practise such activities, organisations who engage with these activities, as well as the practice itself, in a similar way to how the words ‘medicine’ and ‘law’ are used (Aldridge, 2011).
From a historical perspective, therapy evolved in the ‘modern’ era (e.g. McLeod, 2013), and struggles to find a ‘legitimate’ place for itself in a ‘postmodern’ age (e.g. Polkinghorne, 1992). Indeed, perhaps one major difference in the profession is between those who wish to claim legitimacy for therapeutic practices as, for example, ‘scientific’ and ‘evidence-based’, and those who see such achievements, or even attempts to claim them, as spurious or irrelevant to the unpredictable dialogical encounters between human beings taking on identities as ‘therapists’ and ‘clients’/ ‘patients’ (e.g. Polkinghorne, 1992; Yalom, 2015).
In 1942 Carl Rogers published Counseling and Psychotherapy (Rogers, 1942). This work laid down the basic tenets of a non-directive therapy, at that time referred to as ‘client-centred’, which would come to take a prominent place in the array of humanistic therapies. A further split, evident in the title of Rogers’s (1942) book, was the ongoing development of another profession — ‘counselling’. In the UK, counselling had also begun to take root — in organisations such as the Western Electric manufacturing company, which set up an in-house ‘employee counselling scheme’ in 1936, and two years later, in 1938, the National Marriage Council developed to eventually be formally established as the Marriage Guidance Council (now RELATE) in 1942 (McLeod, 2013). In the USA the APA (American Psychological Association) founded a division in Counselling Psychology not too much later, in 1945 — although a ‘counselling psychologist’ might be argued to be something different to a ‘counsellor’ in the developing plurality of professional titles. The former title was, perhaps, a way for psychologists to claim an activity as their own that, it might be claimed, comes from social movements focussed on particular areas and issues, rather than a psychological model focussed on the individual (McLeod, 2013). In the UK, the British Psychological Society (BPS) laid claim to both counselling and psychotherapy with the formation of a counselling psychology section in 1982 and establishment of a register for psychologists specialising in psychotherapy in 2004 (BPS, 2009). However, McLeod suggests that counselling should be seen as coming from education and voluntary organisations, in sharp contrast to the more scientifically and medically inclined psychotherapists and psychologists (McLeod, 2013).
In the 1940s psychotherapy ‘was the province of medicine’ (Wampold & Imel, 2015, p. 20) so Rogers, who was a psychologist and not a doctor, was not allowed to use the title ‘psychotherapist’. In the UK, although there were no regulations to prevent non-medical practitioners from using the title, in effect psychotherapy was seen as a medical practice until the end of the 1960s (e.g. see Balfour, 1995). So borrowing the title ‘counsellor’, which had previously been associated with careers guidance and education, to enable practice by non-medical practitioners, might be seen as a completely pragmatic move intended to enable non-medical practitioners to practise; however, this division of practitioners into ‘counsellors’ and ‘psychotherapists’ has become another unresolved area of dispute and controversy in the field. Some practitioners are supportive of this distinction (e.g. McLeod, 2013) and others are not (e.g. BACP, 2010) [this page accessed in 2016 does not seem to exist anymore and at this point (September 2020) I am not sure where the British Association for Counselling and Psychotherapy (BACP) stands in relation to this issue — perhaps they don’t have a position whilst their Scope of Practice and Education (SCoPEd) project continues?]. Although ‘psychotherapy’ could eventually be practised by non-medical practitioners, the wish to hold on to a perceived difference and/or superiority continued, adding another dimension to the steady increase of divisions within the practice of therapy. This development in the profession illustrates conflicts that continued to manifest around medicine/science/expert models of therapy versus philosophy/art/facilitator models, with the latter being more associated with humanistic therapies.
In 1952 the American Personnel and Guidance Association, later to become the American Counseling Association, was founded (McLeod, 2013) — the same year the Diagnostic and Statistical Manual of Mental Disorders (DSM) was first published. Retrospectively it is possible to see the birth of movements, with different philosophical assumptions and opposing ideas about how best to practise, that would eventually develop into therapy cultures destined to be at odds with each other. The DSM created a common resource for the diagnosis of disorders that gives the impression of a scientific-medical certainty about human experience that would build upon the predominantly medicalised approach of psychotherapy in this period. The model was of patients consulting experts who could diagnose and then offer treatments which were preferably validated by some kind of scientifically-based research. This approach contrasts significantly with the humanistic and person-centred approaches being developed during the same period. The former might be seen as more valuing of an ‘instrumental’ approach, whilst the latter humanistic and person-centred approaches might be seen as more ‘relational’ (Rowan, 2016), although those terms had not yet been formulated.
Behavioural therapy fitted well with the medicalised, scientifically-informed approach to therapy, and throughout the 1950s behaviourism made further progress in developing therapeutic approaches. The most important contributions were made by B. F. Skinner (1953); Albert Ellis (1955) acknowledging the importance of thoughts and feelings as well as behaviour in his aptly-named Rational Emotive Behavior Therapy (REBT); and Wolpe’s ‘reciprocal inhibition’ (1958). It was also ‘about the same time the medical barrier was lowered and psychologists began to practice psychotherapy more prevalently’ (Wampold & Imel, 2015, p. 20) – although in New York State, it was a close call, as the American Medical Association (AMA), in 1955 and 1956 (what Rollo May called the ‘dangerous years’), attempted to legally ‘make all psychotherapy a branch of medicine’, which would have ‘outlawed’ psychologists from practising psychotherapy (May, 2011/1992, p. xxiii).
Although those initially trained or educated in psychology are represented in all therapeutic approaches, the particular emphasis on a more scientific sense of psychology is particularly associated with behaviourism and its associated therapeutic approaches, later to be most commonly practised as cognitive behavioural therapy (CBT). It could be argued that these kinds of therapies have, as at least part of their agenda, the wish to promote psychotherapies closely aligned with the discipline of psychology (as opposed to philosophy, for instance). This reflects another aspect of the professional splitting and divisions around the practice of therapy, and disputed boundaries around who is – and who is not – thought fit to practise.
As counsellors and psychotherapists began to professionalise themselves and organise associations (e.g. the Standing Council for the Advancement of Counselling in 1971, which became the British Association for Counselling (BAC) in 1976), humanistic approaches began increasingly to fall outside of the mainstream (Rice & Greenberg, 1992). Although therapy as a whole was gaining popularity, the BAC only had a membership of about 1000 in 1977, so it was not nearly as strong in influence or numbers as it is today. The professionalisation of psychotherapists in the UK could be viewed as not so much a proactive choice but a reactive one, namely to their fear of being seen in the same category as Scientologists, who claimed to be practising psychotherapy, and whose practices had led to the publishing of the Foster Report (1971).
McLeod (2013) asserts that ‘[a]ttempts to fuse counselling and psychotherapy into a single psychological therapy will never be successful’ (p. 53, emphasis in original) because, he argues, the influence of multiple disciplines on therapy is too important for its practices to be only located within psychology. However, because from an academic point of view singular disciplines are more powerful, and the discipline of psychology is particularly powerful, there has been a tendency for trainings to locate therapy within it. These trainings – ‘counselling’ or ‘psychotherapy’ at graduate, postgraduate, masters or doctoral levels – are merely introductions into a practice which relies mostly on experience and continuous, open-ended learning (McLeod et al., 2016). This may go against instrumental notions which demand that a trainee knows everything they need to know before they can be seen as ‘qualified’, but it is probably a more realistic view of what actually happens in practice.
McLeod (2013) argues that psychotherapists base their practice on one approach whereas counsellors draw on different approaches depending on ‘their relevance to a particular client or group’ (p. 58). He seems to be making the case for counselling as pluralistic in nature. I would suggest that this attempt to distinguish counselling and psychotherapy by arguing the former to be more pluralistic is arguably a disingenuous, misguided attempt to find a unique jurisdiction for ‘counselling’ that is unnecessary and undermines the personal and professional potential of all therapists including ‘counsellors’.
Macdonald (1995) states that ‘[n]o monopoly can be obtained and guaranteed… without the active cooperation of the state… the state is the omnipresent external feature of the professional project’ (p. xiii). Therefore, it might be argued that it was just a matter of time before bodies representing counsellors and psychotherapists would begin to want the state to sanction its activities.
Counselling and psychotherapy can be viewed as being in the midst of a ‘professional project’ (e.g. Larson, 1977), which in the UK, particularly, has been beset by problems. Pressure groups, such as the Alliance for Counselling and Psychotherapy (originally called the Alliance for Counselling and Psychotherapy Against State Regulation), actively campaigned against statutory regulation (SR), resisting the furtherance of the project, which was simultaneously supported more keenly (although still with some ambiguity) by therapy’s professional or ‘occupational’ associations such as the BACP and the UKCP. Macdonald suggests that a ‘feature of the professional project is the internecine strife that occurs in the early stages, as different occupational strands or professional philosophies contend for power’ (Macdonald, 1995, p. 138). Professionalisation and regulation is common to occupations who are engaged in a professional project to achieve social closure, market control, status and respectability (e.g. Macdonald, 1995).
Macdonald (1995) asserts that in the ‘[state/profession relationship]… conflicts tend to get resolved in the long run’ (p. 119). Whether this turns out to be the case for counselling, psychotherapy and whatever other names might be applied to therapeutic activities, remains to be seen. The intangible nature of the meaning of ‘therapy’, and the multiple divisions of opinion about its meaning, might have produced a knot too difficult to untangle. This is in addition to the issue of differentiating counsellors, psychotherapists, clinical psychologists, mental health nurses and other allied professionals who practise therapy. There are many professionals who claim they can, and indeed do, practise therapy, who do not bear the titles of either ‘counsellor’ or ‘psychotherapist’. Macdonald (1995) refers to the ‘Marxian sociology of the professions’ (p. 22) which, as well as highlighting the relationship of professionalisation to the state, also observes the ‘proletarianization of professional occupations’ (ibid.), especially, one might add, when they have not achieved social closure. The practice of therapy by allied professionals such as nurses, and the newly titled ‘Psychological Wellbeing Practitioners’ (PWPs), exemplify a profession that has failed to accomplish ‘social closure’ (e.g. de Swaan, 1990). Similarly, a weakness in the professionalisation of CBT is the perception of it as a collection of techniques (which, therefore, might not need a specific kind of professional to deliver them), as opposed to a highly skilled activity because ‘association of technique with knowledge is one of the potential weak points in the professional armour, for if the technique can be separated from knowledge then the door is opened for other occupations to encroach’ (Macdonald, 1995, p. 184).
In relation to the conflict between ‘counselling’ and ‘psychotherapy’ it has failed to achieve ‘dual closure’ which is when ‘occupations… having been successfully excluded by an occupation, strive to carve out their own occupational field, distinguishing it from that of other, probably dominant groups but establishing at the same time their own exclusionary practices’ (ibid., p. 133). This is problematic in the counselling/psychotherapy divide because some psychotherapists, especially in the private sector, would be disadvantaged by being unable to offer ‘counselling’, and it is arguable that counsellors do not offer ‘psychotherapy’ – so jurisdiction of both activities (if, in fact, they do differ) is often claimed by counsellors and psychotherapists.
In the sociology of the professions it is recognised that ‘problems… confront many occupations pursuing their professional project’ (Macdonald, 1995, p. 140) because it is difficult to ‘[define] themselves, their work, their jurisdiction and their market in a way that will satisfy all interested parties’ (ibid.); and further, ‘professional unity is necessary if a professional body is to be sufficiently impressive to obtain state recognition’ (ibid., p. 199). These insights foreshadow the problems, which attempts to professionalise therapy have encountered.
Aldridge (2011) identifies counselling and psychotherapy as ‘caring profession[s]’ like ‘nursing, midwifery and social work’ (p. 102). Whilst this categorisation of therapy is contestable, that is often how it is perceived, and caring professions are typically associated with predominantly female workforces engaged in ‘“female” work’ (Aldridge, 2011, p. 103).
Counselling and psychotherapy, as caring professions, are therefore entangled with issues around gender and patriarchy (e.g. Witz, 1992). The wish to gain professional status supports ‘masculinisation’ of the caring profession seeking such status (e.g. Aldridge, 2011; Hearn, 1982; Hugman, 1991). This masculinisation of would-be professions occurs in the context of a patriarchal society which devalues occupations associated with predominantly female workforces. Thus professionalisation can be seen as a process in which practitioners disempower themselves in order to gain status by mirroring and conforming to a patriarchal system (e.g. Abbott and Wallace, 1990; Aldridge, 2011). Whilst there are strong arguments for suggesting therapists need to be recognised as professionals, and need such legitimisation to work in the public sector, there are different types and levels of professionalisation (e.g. Aldridge, 2011), some of which may be more suitable for therapists than others. Some have argued that professionalisation does not suit therapy at all (e.g. Mowbray, 1995).
There have been attempts to regulate psychotherapy since the 1970s (Aldridge, 2011). In 1971, Sir John Foster compiled a report on Scientology which concluded that psychotherapy should be regulated (Foster, 1971). In response, a working group was set up by several therapy-related associations who, in their own report (Sieghart, 1978), stated that they had ‘serious doubts whether psychotherapy as a function could be defined precisely enough by statutory language to prevent evasion’ – a problem that arguably remains unresolved. They suggested that this might be avoided by regulation of title rather than practice. However, similar problems occur with trying to regulate titles because unscrupulous (or principled non-complying) practitioners can easily invent unregulated titles. Eventually, in 1981, notwithstanding these problems, a private members bill to regulate psychotherapy was brought to the House of Commons but it was not passed.
The difficulty in defining ‘counselling’ and ‘psychotherapy’ – and in identifying the extent to which there are any substantial differences between them — is a major obstacle for attempts at regulation. For instance, the National Health Service (NHS) attempted to define ‘counselling’ as ‘eclectic or a-theoretical in comparison to psychotherapy’ (Aldridge, 2011; Parry & Richardson, 1996). This can be true, but ‘counsellors’ can adhere just as rigidly to a single theoretical model as any ‘psychotherapist’. In addition, many person-centred counsellors shun eclecticism because they believe that their effectiveness is based on consistently delivering the ‘core conditions’. This example of Britain’s NHS making basic errors about the differences between counselling and psychotherapy illustrates the challenge of differentiating the two activities, even if an assumption is made that they are, in fact, different.
In 1999, Lord John Alderdice brought together stakeholder groups in order to statutorily regulate ‘psychotherapy’ but not ‘counselling’. The BAC (as it was then) was unhappy about being excluded, and Alderdice remembered saying: ‘I’m not talking about regulating what you are describing and if there are any of your people who are psychotherapists of course they would be able to be regulated’ (Alderdice, 2009 in Aldridge, 2011). This statement demonstrates a surprising lack of knowledge and confusion from someone nominally directing the regulation of psychological therapies. Even if the only point of consensus is that both psychotherapists and counsellors talk to people in confidence, if one profession was felt to be in need of regulation then that would imply regulation of the other, as a major stated aim of regulation is to ‘protect’ the public. If psychotherapists alone were regulated, then unscrupulous or regulation-averse practitioners would merely have to change their title from ‘psychotherapist’ to ‘counsellor’ to enter an unregulated profession. This confusion about ‘counselling’ and ‘psychotherapy’, and whether one is more ‘professional’ (and therefore more worthy of being regulated), again remains unresolved. As Aldridge wittily put it in her research journal: ‘It seems that there is now a direct confrontation facing us between the evidence that finds no difference between counselling and psychotherapy and the political view, that there is a difference even if we don’t know what it is’ (Aldridge, 2011, p. 390). In any case Alderdice’s private members bill attempting to regulate psychotherapy was rejected by the government in 2001.
The Health Professions Council (HPC) published its report ‘Consultation on the statutory regulation of psychotherapists and counsellors’ in 2009 (HPC, 2009). The most controversial aspect of the report was how the Professional Liaison Group (PLG) wanted to differentiate between counsellors and psychotherapists. There are various complaints in the BACP response to the HPC report but it mostly elaborates on their insistence that there should be no differentiation between counselling and psychotherapy, and therefore no differentiation between counsellors and psychotherapists, although they do agree with both professions’ titles being protected. The argument that there is no distinction between counselling and psychotherapy, yet agreement that there should be two separate and different titles for practitioners of the same activity (rather than one title such as ‘psychological therapist’), seems contradictory.
Although the BACP does not recognise any difference between counselling and psychotherapy [this was true at least up to 2016 — as stated before, if, when and how the BACP changed their mind I don’t know] some practitioners do perceive differences. Some counsellors would like to claim jurisdiction over some practices, such as basing themselves in community-based projects rather than health centres (e.g. McLeod, 2013), and some psychotherapists would like to claim jurisdiction over other practices, such as working at a ‘deeper… level… over a longer period, usually with more disturbed clients’ (ibid., p. 11). Both claims are extremely arguable, and even McLeod, who favours making distinctions, suggests that these differences, amongst several he identifies, be seen as a ‘direction of travel’ rather than a ‘fixed map’ (ibid., p. 13).
When what has come to be known as Layard’s ‘Depression Report’ came out in 2006, CBT was recommended as a therapeutic approach that would not just be effective, but also inexpensive and efficient (CEPMHP, 2006). In the report CBT was described as the ‘most developed of [the evidence-based psychological therapies]’ (p. 1). Of the 10,000 new therapists that they proposed should be trained in delivering CBT, they suggested that half of them should be ‘clinical psychologists’, and the other half trained from the existing workforce of ‘nurses, social workers, occupational therapists and counsellors’ (p. 7). It is interesting to note that counsellors are enumerated last in that list, and their expertise in delivering therapy only acknowledged as equivalent to the other professions that precede their mention. Psychotherapists receive no mention at all. This powerful document, whose effects are still reverberating around the provision of therapy in the NHS, effectively discounted the expertise of therapists (both psychotherapists and counsellors) already working in the NHS, and the models they had trained in, as insufficient for the task of ‘improving access’ to psychological therapies. Documents like this came to create a cultural ground in which CBT became privileged as the best therapeutic approach at the expense of others. Perhaps the only ‘winners’, in terms of increased employment opportunities and power, were psychologists associated with CBT: recent figures (IAPT’s own) state that 42 per cent of the IAPT workforce are CBT practitioners (Drewitt et al., 2018).
In the UK, the notion of counsellors and psychotherapists as differentiated professions with different skill-sets to psychologists and other ‘psy professionals’ (e.g. Walker et al., 2015) has been established more successfully than differences between them. In the USA, from the literature (e.g. Norcross et al., 2011) it often seems that psychotherapy is viewed as a practice that belongs to an array of practitioners, from social workers to psychiatrists, but especially psychologists; whereas in the UK the idea that psychotherapy belongs to psychotherapists and counselling belongs to counsellors, seems relatively more embedded. This is not to say, however, that other professions laying claim to both counselling and psychotherapy is not also problematic in the UK, as mentioned previously. The structures of training cannot help but change the way practitioners practise; and, arguably, the ways in which ‘counselling’ and ‘psychotherapy’ are conceptualised by practitioners and clients in the USA and the UK are very different. These different cultural interpretations — before you even get to Europe and the rest of the world — of what counselling and psychotherapy mean severly problematises the assertion of anyone who wants to insist that differences between ‘counselling’ and ‘psychotherapy’ are real and incontrovertible.
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