Therapy: State of Play in the UK 2022 – A Personal View

In the following blog, ‘therapy’ is used as a term to describe both ‘counselling’ and ‘psychotherapy’ and the term ‘therapist’ is used to describe both ‘counsellors’ and ‘psychotherapists’ . I do not recognise any substantial differences in the meanings of the two terms or the two titles. Of course, this has implications for my views on and around the ‘politics of therapy’ as they have evolved up to this point in April 2022, in the UK context. I also need to acknowledge the influence of the online launch of the universal Access to Counselling and psychoTherapy (uACT) on Saturday January 29 2022 which has inspired me to clarify – at least somewhat – where I stand on some of the issues concerning therapists in the current climate.

Counselling, Psychotherapy, CBT, SCoPEd and Regulation

There is a lack of clarity around substantial differences between ‘counselling’ and ‘psychotherapy’ because, in my view, there aren’t any. Similarly cognitive behavioural therapy (CBT) has positioned itself as something superior and different to therapy even though it is just one of many therapeutic approaches. One argument, with regard to perceived differences between ‘counselling’ and ‘psychotherapy’, is that because the ‘core training’ — as the Scope of Practice and Education (SCoPEd) describes it — for psychotherapy is usually longer than for counselling it deserves and its practitioners deserve to be recognised as superior and different to counselling and counsellors. The core training is the training which leads to educational qualifications and SCoPEd, thus far, places less emphasis on pre- and post-qualification trainings. Qualified therapists are likely to undertake the latter as part of their continuing professional development (CPD) throughout their careers. Although a longer initial training costs more money it is extremely arguable if it really produces better therapists in the long run. There might be some justification for recognising and valuing longer trainings at the point of qualification but most therapeutic skills are gained via practice post-qualification. This practice is also enhanced by continuing professional development (CPD) and supervision.

It is important to highlight that my thoughts about therapy mostly apply to the UK. Although there are similarities between the politics of therapy here with other places, such as the USA or Europe, there are not enough to comprehensively generalise. For instance, in the USA, therapy practitioners calling themselves both ‘counsellors’ and ‘psychotherapists’ often train as part of a social work qualification which is unheard of in the UK. Many concerns we have in the profession about the provision of therapy are specific to our locality.

The on-going discussion about SCoPEd is the most visible change in what some call the ‘therapeutic landscape’. According to the British Association for Counselling and Psychotherapy (BACP) this framework will clarify the ‘training, practice and competence requirements’ for therapists ‘working with adults’ (https://www.bacp.co.uk/about-us/advancing-the-profession/scoped).

The latest version of the SCoPEd framework was published in January 2022. Initially a project started by three bodies, the BACP, the United Kingdom Council for Psychotherapy (UKCP) and the British Psychoanalytical Council (BPC) it has more recently included, in its discussions, a few more professional bodies who are also accredited by the Professional Standards Authority (PSA).

According to the BACP: ‘it is an important step as part of our wider work to deliver a number of our members’ priorities – to set standards for the profession, protect clients from unsafe or unethical practice and provide members with the resources and support needed to practice’. Further, the BACP also believes that SCoPEd will prove effective in ‘demonstrat[ing] the value of counselling and psychotherapy to employers, commissioners and government’.

The driving force behind all this activity seems to be an uncritical assumption that the therapy profession, over a hundred years since a ‘patient’ lay on Freud’s couch, are not sufficiently ‘credible, diverse and thriving’ or ‘understood, valued and trusted’.

It seems to me that the BACP, in particular – since the motivations of the UKCP and BPC are much more comprehensible (of which more later) – are suffering from a kind of institutional ‘imposter syndrome’. If they do not consider themselves to be ‘good enough’ then it is not too much of a stretch to think their members are not good enough either.

Overall, I do not share their gloomy view. It seems to me that therapy is currently extremely credible. It is being represented in film, TV, radio and old-fashioned newspapers more than ever. And, although it is sometimes the butt of satire, it is mostly represented with respect and varying degrees of realism.

In terms of diversity, it is undeniable that there is a lack of access to being able to qualify as a therapist for a variety of disadvantaged people. However, there are convincing arguments that SCoPEd is likely to increase this exclusion. In addition, if SCoPEd does come into play, an expensive and time-consuming accreditation process might become a necessity rather than a voluntary addition to a therapist’s CV. If this becomes the case then it would seem to mostly be advantageous to the BACP’s income rather than therapists or clients per se (each application costs £115 to £230). When I applied for accreditation in the late 1990s-early 2000s I don’t remember it being so expensive or having the same level of ‘audit’ as it seems to have now. Various professions have post-qualifying accreditation processes so I am not against accreditation but it must be fairly accessible to all qualified therapists and not used as an excuse to keep perfectly employable therapists stuck in voluntary or low-paid roles.

As well as diversity of ‘backgrounds’ the BACP also refers to the diversity of ‘approaches, philosophies and professional training’ and assure us that SCoPEd will ‘enhance and embed that diversity’. Some bemoan the abundance of different approaches and yearn for an integrative therapy based on common principles of therapeutic change. To my mind, this abundance is more reflective of a creative and fertile culture. As therapists and clients we are struggling with nothing less than the meaning of life (or sometimes lack of meaning) – with such a remit, why wouldn’t we expect different people to be coming up with new and different therapeutic ideas all the time? The expectation that therapy should somehow let itself be fixed into something static and objective profoundly misses the point. The BACP says it is supporting a diversity of approaches and trainings, yet the more it tries to own what the standards and competencies of therapy should be the less it empowers others to consolidate, innovate and evolve different ways of teaching and training. It also dismisses educational levels, with their own external assessors, as having credible meaning. In other words, if the already established hierarchies of Certificates, Diplomas, Degrees, Masters and Doctorates – and numbered educational levels — have credible meaning then why is there any need at all for the BACP to establish alternative hierarchies?

The last time the government attempted to regulate therapy was in 2009 – it caused a lot of problems then, much like SCoPEd is doing now. With a change of government the plans were dropped and eventually we ended up with the PSA which accredits the registers of membership bodies like the BACP. The PSA seems to be enacting a reasonable compromise between self-regulation and statutory regulation (SR) yet a surprising number of therapists, perhaps a majority, are still in favour of SR.

Despite protestations that SCoPEd is all about extra clarity for therapists, clients and providers, it could actually be – and I hesitate to state this as a fact — about the institutionalisation of ‘psychotherapy’ as something better and different to ‘counselling’. I don’t mind this being a goal of the UKCP and the BPC – after all, they are representing their members – but the BACP — whose very name suggests that counselling and psychotherapy inhabit the same professional world — rather than getting behind SCoPEd’s hierarchical emphasis would be better off suggesting a common entry point for both counsellors and psychotherapists, with additional ‘badges’ available to those who either want or need them. As it stands, it seems likely to fail on the same grounds it did last time, in 2009: therapists cannot agree on what the differences between counselling and psychotherapy are and many (both ‘counsellors’ and ‘psychotherapists’) do not recognise that substantial differences exist in the first place. This debate will run and run, and although it would be beneficial to get beyond it, SCoPEd fires up the debate rather than extinguishing it.

More people need the chance to become therapists. A bar needs to be set but it shouldn’t be a bar to keep people out. I can agree with a major aim of SCoPEd – to attempt some kind of clarification – but I am against it because it confuses rather than clarifies and manages both to over-simplify and over-complicate at the same time. The columns need to go and be replaced with a framework which allows everyone to achieve perceived competencies.

The ‘psychoanalysts’, as represented by the BPC, despite being part of the SCoPEd project, seem to exist outside its parameters. CBT therapists, similarly, do not have anything to do with SCoPEd and trust their membership bodies – the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and British Psychological Society (BPS) – to access employment opportunities, at all pay levels, by ensuring CBT remains the top choice for therapy in the NHS. The CBT lobby have successfully gained and held power in the Increasing Access to Psychological Therapies (IAPT) organisation and in NICE’s ‘guidelines’ for various mental ‘disorders’. There has been a long, brutal turf war and therapists (particularly those who belong to psychodynamic, humanistic and transpersonal orientations) have lost out.

Our membership bodies are helping the therapy profession to a certain extent. For instance, good work has been done within the BACP on the new NICE depression guidelines. But therapists, as a whole, continue to be marginalised. Besides the controversial SCoPEd project – which the BACP asserts is supportive of therapists’ interests – the BACP does not seem to have many other ideas or hold the same kind of influence and power as the BPS and the BABCP.

This is the status quo and this is what needs to be challenged.

Challenging the Status Quo

‘Without Contraries is no progression’ wrote William Blake and in a much needed counterpoint to mainstream attitudes to therapy as exemplified by organisations such as the NHS, IAPT, NICE, BACP, UKCP and BPC (those presently holding overt political power) there are also organisations springing up which attempt to articulate and promote different views about therapy and what it means to people (both therapists and clients). These organisations wield at least some influence for thousands of therapists whose voices are marginalised and whose talents are underestimated by systems getting lost in ‘audit culture’. The organisations therapists can join which offer critical counter-narratives include: Partners for Counselling and Psychotherapy (PCP), Drop the Disorder! (DtD), Psychotherapy and Counselling Union (PCU), Radical Therapist Network (RTN), Disabled People Against Cuts (DPAC), Counsellors Together UK (CTUK) and more recently uACT. Support for more therapy in institutions such as the NHS might also come from critical psychiatrists.

Increasingly, therapists have no option but to work privately as their trainings – of whatever level, up to and including doctoral — are being shunned by the NHS. We are in the middle of a political battle in which therapy, as most people know and understand it, is losing out to more powerful ‘psychology’ lobbies and so-called ‘evidence-based’ therapies.

Politicians, on the whole, think that what’s on offer is enough. The IAPT service has a lot of funding but unfortunately and paradoxically does not provide many different types of therapies/therapists so people don’t end up getting who or what they want. Consequently they are unable to explore, understand and change their lives in ways that resonate with them. Unsurprisingly, there is a high drop-out rate: the idea of ‘personalising’ therapy (Norcross & Cooper, 2021) is nowhere to be seen in an NHS dedicated to their own in-house ‘evidence-based’ therapies. It is also reported that IAPT is pushing out smaller providers, who have the skills and knowledge to direct people to appropriate therapies/therapists, in favour of larger providers who are not in touch with the communities they serve.

Our mental suffering cannot be separated out from our environments and the demands of those environments. This has become even more apparent in the post-COVID world in which our everyday assumptions about education, work, home life and childcare have all been challenged. Some, such as James Davies in his book Sedated (Davies, 2021), suggest contemporary mental health crises have been created more by capitalism as a system than by individuals not having enough ‘resilience’ (for example).

CBT has done a good job as promoting itself as the ‘answer’. And there are some who are anti-CBT. I don’t think CBT is the answer or the problem. And a lot of CBT therapists would agree. CBT is not different to or above therapy – it is, in fact, just one type of therapy, useful for some people some of the time and completely alienating for some people some of the time. ‘Personalizing’ therapy rather than idealising or demonising certain approaches would be more beneficial for clients (Norcross & Cooper, 2021). And it is useful to remember that even some CBT therapists do not recognise IAPT-CBT as proper CBT. I do not object to ‘IAPT therapy’ per se – what I object to is ‘therapy therapy’ not being on the menu. For instance, Counselling for Depression (CfD) is not the same — at least, theoretically – as person-centred therapy (PCT). But, undoubtedly, there are therapists doing work in the NHS and even IAPT who are sneaking in ‘therapy therapy’ even if, on paper, it is called CBT, CfD or interpersonal psychotherapy (IPT).

Schools are offering pseudo-therapy via ‘pastoral support’ and it would be preferable if there were therapists in every school. This is a symptom of the wider encroachment of therapy by other professionals/paraprofessionals with new and different titles. The message that therapists are actually the most suitable practitioners to be delivering therapy needs to be loud and clear.

The public know what they want even if policy makers and commissioners don’t. That is why those who can afford it go private and give up on the possibility of free provision. So many people have had positive experiences of therapy. Somehow we need to get their voices heard and their support for others to get what they have had. We need to bring about a situation in which everyone can access what is already available in the private sector (and to a limited extent via EAPs and insurance). The public need to make it clear that they want alternatives to medication and medicalised responses.

The IAPT/NICE/NHS conglomerate is central to problems in the provision of therapy. The battle with that conglomerate is worth fighting but there are other fronts e.g. in communities, the third sector, and social services rather than health services. It always strikes me as a slightly difficult challenge to convince a medical service they should not be conforming to a medical model… maybe the NHS isn’t the right place for therapy?

IAPT is a ‘failing service’. Waiting lists for CfD in some districts are over a year. This is not universal access and it is not taking the problems of those requesting therapy seriously. For the time being, whilst IAPT holds such hegemonic power within the NHS we do need to work ‘with as well as against’ IAPT in the hope that different kinds of therapists and therapies might be added to what is already there. There are good practitioners within IAPT and it is not so much about being against what is already provided (although there are many valid critiques) but for the provision of therapy as most people, therapists and the public alike, understand it. There needs to be more client input and more client choice. There is no reason why clients should not be able to choose how they access therapy, for instance via video, phone or in person. They could collaborate with therapists on how many sessions they want and they could make choices about how relational or how instrumental they want their therapeutic experience to be. Some clients might also want to venture into transpersonal approaches which are completely unavailable in the NHS (notwithstanding ‘mindfulness’ getting in the back door on the back of ‘CBT’). If the NHS does not respond to the demand that therapy (as it is understood by most people) be available in its services then the only place where therapists can work according to what clients actually want, rather than what other people say is good for them, is in the private sector. Everyone should be able to access that – either as it is via subsidisation – or if that is not possible via the public and third sectors (with fair pay and conditions).

Davies, J. (2021). Sedated: How Modern Capitalism Created Our Mental Health Crisis. London: Atlantic Books.
Norcross, J.C & Cooper, M. (2021). Personalizing Psychotherapy: Assessing and Accomodating Patient Preferences. Washington: American Psychological Association.

Evidence-based medicine, evidence-based practice, NICE, IAPT and CBT: A short history

Evidence-based medicine can be conceptualised as a three-legged stool in which ‘the use of evidence (first leg) is to be balanced with the expertise of the clinician (second leg) and characteristics and context of the patient (third leg)’ (Wampold & Imel, 2015, p. 11). It has been further described as making ‘use of individual patients’… preferences in making clinical decisions about their care’ (Sackett et al., 1996, p. 71). Sackett et al. (1996) warn that ‘without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient’ (p. 72). It is important to note that in these conceptualisations of evidence-based medicine, which are mostly sympathetic to and uncritical of it, evidence is not seen as superior to ‘clinical expertise’, and it is also not seen as superior to patient choice. Yet arguably, in the practical application of evidence-based medicine, it seems as if two legs of the stool have been taken away, with just the first leg (that of evidence) being considered, with the wishes of clinicians and patients being demoted if not forgotten. This was how some practitioners viewed the impact of evidence-based medicine in the USA, and it is also how many practitioners began to view it in the UK, especially since the establishment of the National Institute for Clinical Excellence (NICE) in 1999 (its title was later changed to the National Institute for Health and Care Excellence, but it uses the same abbreviation).

NICE states that their aim was ‘to ensure that the most clinically and cost effective drugs and treatments were made available widely on the NHS in England and Wales’ (NICE, 2016, online) and to ‘speed up the pace at which good value treatments were used’ (ibid.). They also claim that they ‘established a worldwide reputation for producing authoritative, evidence-based advice and guidelines’ (ibid.). In this self-appraisal it is worth noting the casual use of the phrase ‘evidence-based’, which has fully seeped into everyday discourse and is used, without any need of explanation or critique, throughout the media. Everyone knows, or thinks they know, what it means. It is also worth noting the managed-care implications of ‘good value treatments’ putting the cost of treatments as a central concern. NICE is, unsurprisingly, supportive of the medical model, and this necessarily has implications for the provision of therapy. Therapy was perceived by NICE as a medical treatment like any other, and it seemed as if therapeutic practices were shoehorned into the medical model, without any consideration that they might not be as straightforwardly understood in the same way as drug treatments or medical devices.

This is partly due to NICE’s privileging of RCT evidence over any other kind (see, for example, NICE, 2014/2017, p. 103 cited in Barkham et al., 2017). The BACP in its response (BACP, 2017a) to the NICE draft guideline for depression note that RCTs are seen as superior to even the ‘very large… IAPT dataset’ (ibid., comment 8) and therefore does not even follow ‘NICE’s own procedural manual’ (ibid.). As Loewenthal puts it: ‘whilst [NICE] recognises many of the issues concerning its methodology, it ends up acting as if they don’t exist’ (Loewenthal, 2016, p.18). Loewenthal (2016) suggests that therapy’s historical and contemporary practices of supervision, writing and presenting papers provide a functional way of monitoring and evaluating practice which is superior to RCTs which he asserts are ‘against the very nature of what for many is the therapeutic enterprise’ (p. 14). He perceives the emphasis on RCTs, and similar forms of privileged quantitative research, shaping practice detrimentally, and mourns ‘[t]heoretical explorations’ not being seen as research at all. He cites the APA’s encouragement of a pluralistic approach to research methodologies to suggest a way forward for NICE and IAPT, whose over-adherence to a medicalised symptom-based model constructs versions of therapy, and ways of researching therapy, which can only be useful for therapists and clients if they are in agreement that the latter’s problems fit neatly into diagnostic labels. Real consequences of the monistic, quantitative and scientistic approach to approving therapies are that choices for NHS patients are, self-evidently, limited to the approaches that have been approved, and therapists, some with decades of clinical practice and experience, who have not trained in these approved practices, are perceived as having nothing to offer. This issue has been highlighted by research undertaken by the BACP (Perfect et al., 2016) in their document Choice of Therapies in IAPT: An overview of the availability and client profile of step 3 therapies. Barkham et al. (2017) also make the point that ‘improving patient treatment choice improves therapy outcomes’ (ibid., p. 264), so reducing choice is counter-productive. Additionally, despite the success of Counselling for Depression (CfD) in RCTs leading to it being nominated by NICE as an ‘evidence-based’ therapy, CfD practitioners only make up ‘6% of the high-intensity therapist workforce’ (Drewitt et al., 2018). In other words, even providing the required evidence does not seem to have made much impact in improving choice of different therapies for clients.

The biggest change affecting the provision of therapy in the UK was the formation of IAPT. This has been dated to 2003 when Lord Layard met Professor David M. Clark at a British Academy tea party (Evans, 2013). From a symbolic interactionist perspective it is notable that perhaps the most important development in the provision of therapy in the UK this century occurs in a microsocial context.

On one level, the introduction of IAPT, when it came, was a giant leap for the provision of therapy in Britain, as ‘[b]efore IAPT, the NHS spent just 3% of its mental health budget on talking therapy’ and ‘IAPT… tripled that budget’ (ibid.). However, with the publication of the NICE guidelines for depression in 2004, it was disappointing for therapy professionals that only two types of therapy were recommended – namely, CBT and a time-limited, structured therapy called interpersonal therapy (IPT). All other approaches were not recommended for depression because, according to NICE’s definition of evidence, all other approaches did not have enough to gain the status of ‘evidence-based’. Even accepting that therapeutic approaches should be seen as targeting specific disorders, and prove their effectiveness at targeting them, the guidelines were problematic, as the evidence was clearer for ‘severe’ as opposed to ‘mild’ or ‘moderate’ depression. Therefore a potential danger, recognised by medical professionals themselves, was that clinicians/patients might take on a more serious ‘depression’ diagnosis in order to obtain treatment that would not be available with a less serious or non-medicalised complaint. However, the evidence of what worked for mild or moderate depression was not as robust so, ultimately, there was not sufficient evidence that people with mild or moderate depression were actually getting evidence-based treatment (Middleton et al., 2005).

In January 2005, Layard and Clark presented their recommendations at 10 Downing Street, and proposals for IAPT went into the Labour Party’s manifesto for the 2005 general election (Evans, 2013; Cohen, 2008). One major reason that Layard and Clark were able to get the Labour government to commit to an IAPT programme was because ‘CBT had built up a big evidence base to show it worked’ (Evans, 2013, online; see also Research Excellence Framework, 2014) – although the superiority of CBT to counselling and other psychological therapies is easily disputed (e.g. Barkham et al., 2017). 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).

Therefore, in the sociohistorical developments of the therapy profession in the UK, a trajectory can be traced from competing interests within the profession itself, leading to an emphasis on research which then leads to an emphasis on the RCT. In response to the context of a developing audit culture and that culture’s need for evidence and efficiency, CBT, with its evidence base and perceived efficiency, then comes to dominate the provision of therapy, and other approaches lose their status and are marginalised, if not erased, from public providers. The private sector, EAPs, insurance companies and the third sector continued to provide employment opportunities for other approaches but, within the NHS, CBT, to a great extent, began to monopolise therapy provision.

The dominance of CBT and the marginalisation of other types of counselling and psychotherapy is one of the biggest, most frustrating problems facing current practitioners and of course, clients, who cannot access what these therapists provide even if they know it is what they want. You could say CBT has been the flavour of the past decade in the NHS and beyond. In terms of public relations it has made great achievements in influencing the media, usually uncritically, to accept it as the only evidence-based therapeutic approach for a wide array of ‘disorders’. Simultaneously it has come under attack from therapists who do not follow the approach, perhaps with some rationality, but also with emotional defensiveness (e.g. Leader, 2008). For therapists who do not follow the approach, and have belief in the efficacy of their own non-CBT approaches, it can seem like watching helplessly as one pupil gets all the prizes.

A common critique of CBT, articulated in different ways, is that it reflects a wider neoliberal agenda in which teaching ‘“technologies of the self” to the CBT patient echo Foucault’s notion of “disciplinary power”… where the state uses subtle power to mould its subjects into acquiescence’ (Watts, 2016, p. 89). Unsurprisingly, CBT practitioners and their proponents rebuff these kinds of criticisms as a caricature (e.g. Veale, in Samuels & Veale, 2009).

In 2008, adding to the plurality of psychological practitioners, the DH produced an implementation plan for the training of ‘low-intensity therapies workers’ who would facilitate the use of CBT via ‘guided self-help and computerised CBT’ (Department of Health, 2008, p. 3). These workers would come to be known as ‘Psychological Wellbeing Practitioners’ (PWPs) who would be perceived as fit to practise after 45 days training (ibid.). One advantage, in terms of cost, is that these practitioners could expect a maximum pay rate less than even a trainee psychotherapist. Therefore therapists in the NHS were not only coming under pressure in terms of their approaches being devalued, but also in terms of their professional opportunities being ‘undercut’ by the creation of jobs/titles purportedly needing less expertise and a ‘proletarianisation’ of therapeutic practice.

It is against this background of an audit culture which based its decisions about therapy provision on narrow definitions of evidence that led to the monistic hegemony of CBT in the NHS and the pushing away of counsellors and psychotherapists into other sectors.

References

BACP (2017a). BACP response to NICE: Depression in Adults: Recognition and Management consultation on draft guideline. Accessed at https://www.bacp.co.uk/media/2275/bacp-response-nice-guidance-depression-in-adults.pdf on 6 March 2018.


Barkham, M., Moller, N.P. & Pybis, J. (2017). How should we evaluate research on counselling and the treatment of depression? A case study on how the National Institute for Health and Care Excellence’s draft 2018 guideline for depression considered what counts as best evidence. Counselling & Psychotherapy Research, 17(4). 253–268.

CEPMHP (The Centre for Economic Performance’s Mental Health Policy Group). (2006). The Depression Report: A New Deal for Depression and Anxiety Disorders. Centre for Economic Performance, London School of Economics. Accessed at eprints.lse.ac.uk/818 on 15 November 2017.

Cohen, A. (2008). IAPT: A brief history. Healthcare Counselling & Psychotherapy Journal, April. 8–11.

Department of Health. (2008). Improving Access to Psychological Therapies: Implementation Plan: Curriculum of Low-Intensity Therapies Workers. London: Department of Health.

Drewitt, L., Pybis, J., Murphy, D. & Barkham, M. (2018). Practitioners’ experiences of learning and implementing Counselling for Depression (CfD) in routine practice settings. Counselling & Psychotherapy Research, 18(1). 3–13.

Evans, J. (2013). A brief history of IAPT: The mass provision of CBT in the NHS. Accessed at https://emotionsblog.history.qmul.ac.uk/2013/05/a-brief-history-of-iapt-the-mass-provision-of-cbt-in-the-nhs/ on 11 November 2016 (originally posted 30 May 2013).

Leader, D. (2008). A quick fix for the soul? Guardian, 9 September. Accessed at https://www.theguardian.com/science/2008/sep/09/psychology.humanbehaviour

Loewenthal, D. (2016). Therapy as cultural, politically influenced practice. In J. Lees (Ed.), The Future of Psychological Therapy: From Managed Care to Transformational Practice. Abingdon: Routledge.

Middleton, H., Shaw, I., Hull, S. & Feder, G. (2005). NICE guidelines for the management of depression: Are clear for severe depression, but uncertain for mild or moderate depression. British Medical Journal, 350. 267.

NICE. (2016). History of NICE. Accessed at https://www.nice.org.uk/about /who-we-are/history-of-nice on 11 November 2016.

NICE. (2014 / updated 2017). Developing NICE guidelines: the manual: process and methods. Accessed at https://www.nice.org.uk/process/pmg20/chapter/introduction-and-overview on 4 July 2018.

Perfect, D., Jackson, C., Pybis, J. & Hill, A. (2016). Choice of therapies in IAPT: An overview of the availability and client profile of step 3 Therapies. Lutterworth: British Association for Counselling & Psychotherapy.

Research Excellence Framework. (2014). Improving policy and practice to promote better mental health. Accessed at http://impact.ref.ac.uk/CaseStudies/CaseStudy.aspx?Id=40639# 6 September 2017.

Sackett, D.L., Rosenberg, W.M., Gray, J.A.M., Haynes, R.B. & Richardson, W.S. (1996). Evidence based medicine: what it is and what it isn’t. British Medical Journal, 312. 71–72.

Samuels, A. & Veale, D. (2009). Improving access to psychological therapies: For and against. Psychodynamic Practice, 15(1). 7–24.

Wampold, B.E. & Imel, Z.E. (2015). The Great Psychotherapy Debate: The Evidence for What Makes Therapy Work, 2nd Edn. Hove: Routledge.

Watts, J. (2016). IAPT and the ideal image. In J. Lees (Ed.), The Future of Psychological Therapy: From Managed Care to Transformational Practice. Abingdon: Routledge.

The Future of Counselling and Psychotherapy (Notes in the Margins)

Recently I presented at the Sussex Counselling and Psychotherapy AGM about the future of counselling and psychotherapy as I see it. Very kindly, SCAP, as well as putting up the video on their own members’ resource page have allowed me to post it here as well. Please share if you think others might be interested. It should mostly appeal to therapists. Although if people more generally are wondering why it’s a bit of a struggle to access counselling and psychotherapy via the NHS there is info here you might find illuminating. https://sussex-counselling.co.uk/images/video/Future21.mp4

Counselling and Psychotherapy: What’s the Difference?

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.

Abbott, P. & Wallace, C. (Eds). (1990). The Sociology of the Caring Professions. Bristol: Falmer Press.

Alderdice, J. (2009). Interview. In S. Aldridge, Counselling – An Insecure Profession? A Sociological and Historical Analysis. Ph.D. thesis, University of Leicester.

Aldridge, S. (2011). Counselling – An Insecure Profession? A Sociological and Historical Analysis. Ph.D. thesis, University of Leicester. Accessed at https://lra.le.ac.uk/handle/2381/10261 on 13 January 2017.

BACP (2010). BACP: Student pages: FAQs: What is the difference between counselling and psychotherapy? Accessed at https://www.bacp.co.uk/student/faq.php on 22 November 2016.

Balfour, F. (1995). The British Confederation of Psychotherapists: The background to its establishment and character. Accessed at https://www.bpc.org.uk/resources/history-british-confederation-psychotherapists on 18 November 2016.

BPS. (2009). History of the British Psychological Society Timeline 1901 to 2009. Accessed at http://www.bps.org.uk/system/files/Public%20files/HOPC/bps_timeline.pdf on 30 August 2017.

CEPMHP (The Centre for Economic Performance’s Mental Health Policy Group). (2006). The Depression Report: A New Deal for Depression and Anxiety Disorders. Centre for Economic Performance, London School of Economics. Accessed at eprints.lse.ac.uk/818 on 15 November 2017.

Cooper, M. (2008). Essential Research Findings in Counselling and Psychotherapy: The Facts Are Friendly. London: Sage

de Swaan, A. (1990). The Management of Normality. London: Routledge.

Drewitt, L., Pybis, J., Murphy, D. & Barkham, M. (2018). Practitioners’ experiences of learning and implementing Counselling for Depression (CfD) in routine practice settings. Counselling & Psychotherapy Research, 18(1). 3–13.

Dunnet, A., Cooper, M., Wheeler, S., Balamoutsou, S., Wilson, C., Hill, A. et al. (2007). Towards Regulation: The Standards, Benchmarks and Training Requirements for Counselling and Psychotherapy. Rugby: BACP.

Ellis, A. (1955). New approaches to psychotherapy techniques, Journal of Clinical Psychology Monograph Supplement, 11. 1–53.

Foster, J.G. (1971). Enquiry into the Practice and Effects of Scientology. London: HMSO.

Hearn, J. (1982). Notes on patriarchy, professionalization and the semi-professions. Sociology, 16(2). 184–202.

HPC. (2009). The statutory regulation of psychotherapists and counsellors: Report of the Psychotherapists and Counsellors Professional Liaison Group (PLG) incorporating recommendations to the HPC Council. London: HPC.

Hugman, R. (1991). Power in the Caring Professions. Basingstoke: Macmillan.

Larson, M.S. (1977). The Rise of Professionalism: A Sociological Analysis. London: University of California Press.

Macdonald, K.M. (1995). The Sociology of the Professions. London: Sage.

McLeod, J. (2013). An Introduction to Counselling (5th Edn.). Maidenhead: Open University Press.

McLeod, J., Smith, K. & Thurston, M. (2016). Training in pluralistic counselling and psychotherapy. In M.Cooper and W. Dryden (Eds), The Handbook of Pluralistic Counselling and Psychotherapy. London: Sage.

May, R. (2011/1992). Abbreviated foreword to the first edition. In J.C. Norcross, G.E. VanderBos & D.K. Freedheim, History of Psychotherapy: Continuity and Change, 2nd Edn. Washington, D.C.: American Psychological Association.

Mowbray, R. (1995). The Case against Psychotherapy Registration: A Conservation Issue for the Human Potential Movement. London: Trans Marginal Press.

Norcross, J.C., VanderBos, G.E. & Freedheim, D.K. (2011). History of Psychotherapy: Continuity and Change, 2nd Edn. Washington, D.C.: American Psychological Association.

Parry, G. & Richardson, A. (1996). NHS Psychotherapy Services in England: Review of Strategic Policy. NHSE.

Polkinghorne, D.E. (1992). Postmodern epistemology of practice. In S. Kvale (Ed.), Psychology and Postmodernism. London: Sage.

Rice, I.N. & Greenberg, L.S. (1992). Humanistic approaches to psychotherapy. In D.K. Freedheim (Ed.), History of Psychotherapy: A Century of Change. Washington, D.C.: American Psychological Association.

Rogers, C.R. (1942). Counseling and Psychotherapy. New York: Houghton Mifflin.

Rowan, J. (2016). The Reality Game: A Guide to Humanistic Counselling and Psychotherapy, 3rd Edn. Abingdon: Routledge.

Sieghart, P. (1978). Statutory Registration of Psychotherapists: A Report of a Professions Joint Working Party. Cambridge: E.E. Plumridge.

Skinner, B.F. (1953). Science and Human Behavior. New York: The Free Press.

Walker, C., Hanna, P. & Hart, A. (2015). Psychology without psy professionals: Exploring an Unemployed Centre Families Project as a mental health resource. Journal of Community & Applied Social Psychology 25(1). 502–512.

Wampold, B.E. & Imel, Z.E. (2015). The Great Psychotherapy Debate: The Evidence for What Makes Therapy Work, 2nd Edn. Hove: Routledge.

Witz, A. (1992). Professions and Patriarchy. London: Routledge.

Wolpe, J. (1958). Psychotherapy by Reciprocal Inhibition. Stanford: Stanford University Press.

Yalom, I.D. (2015). Creatures of a Day: And Other Tales of Psychotherapy. New York: Basic Books.

First thoughts on SCoPEd 2

As at the time of SCoPEd 1 a year ago I am confused by the need for SCoPEd (The Scope of Practice and Education for counselling and psychotherapy). Minimum standards are already required to be a member of the BACP Register. If these minimum standards are viewed as not high enough, then it is these standards that should be raised for the whole membership. What is the point of a brand new ‘evidence-based’ framework that is not working for a unified membership but seems to have as its aim to split it into three distinct groups?

There is an assumption that everyone, especially employers, are confused by ‘counselling’ and ‘psychotherapy’ [hereafter ‘therapy’ and ‘therapists’]. That’s not my impression. The awareness of therapy as a route to explore self, others and the world for various reasons and desired outcomes is embedded in our culture perhaps more now than ever before. Most people know what it is or have an idea of what it is or at least seen passable representations of it in films and on television. I am more confused as to what counselling and psychotherapy are, after reading the SCoPEd framework.

The implicit assumption of the SCoPEd project seems to be that if only the NHS/IAPT/NICE understood how well trained we are then there will be a huge expansion of employment opportunities. In my view that does not explain the latter’s enthusiasm to employ their own in house paraprofessionals such as ‘PWPs’ and ‘mental health workers’ who tend to work with exactly the same groups of people counsellors and psychotherapists used to before the IAPT ‘juggernaut’. The higher our training standards the higher a salary we will rightfully demand so, from an economic perspective, it is better to hand the work to workers with less training who will accept lower wages. In this context it is the BACP’s job to challenge the marginalisation of therapists at a political level. Buying into the myth that nobody knows what we do and if only we explain ourselves better than all will be well is a defensive move. The BACP should be proud of their ‘kitemark’ and proudly recommend BACP members as providers of quality therapy (versus faster, cheaper versions of ‘mental health’ interventions) and challenge the NHS’s choice to provide its own qualification and accreditation process in therapy provision.

The hierarchical nature of titles seems to have been fudged by just re-naming three supposedly different types of therapist A, B and C with the intention of re-instating titles at a later date. I think the fuss over supposed differences between counselling and psychotherapy has to go and any differentiations of training and experience can be distinguished by already existing academic standards such as BA, BSc, PGDip, MA and PhD. Or all the different numerical levels. This is a framework that already exists. There can also be post-qualification recognition of specialisms and continuing professional development over a therapist’s career. Since BACP represents both ‘counsellors’ and ‘psychotherapists’ presumably they see the two professions as having enough in common to be able to belong to one body. I am confused by where the BACP stands on this issue now, but in 2009 they did not recognise a difference. If they have changed their mind on that I would suggest changing it back quickly. I would also suggest their role is to value counsellors and psychotherapists equally. I understand some psychotherapists would not go along with this view and would like to be perceived as different and/or better by virtue of being a ‘psychotherapist’ — they still have the UKCP to further their interests.

Part of the underlying structural problem is that the therapy ‘industry’ has over time taken on aspects of a ‘pyramid scheme’ in which the newer entrants are finding it more and more difficult to get returns on their investments and those nearer the top have a tendency to stake out their territory with more stringent demands. I think there is an aspect of this problem in the SCoPEd project. Psychotherapists and psychoanalysts have an interest in ensuring they are seen in a superior light to counsellors and need to stake out and claim their territories.

The main qualitative difference in training (I accept the initial quantitative difference) between counsellors and psychotherapists — as far as I can make out — is that most psychotherapists will do a 30 hour ‘mental health placement’ or failing that ‘familiarisation’ via other means. Having worked in mental health for over 5 years I do not see how this 30 hour placement has gained such perceived kudos. The perception that people with ‘chronic and enduring mental health conditions’ are so challenging — whilst sometimes true — for the most part is an unhelpful view which simultaneously idealises practitioners who work with this group as having special skills whilst denigrating the patients/clients as overwhelmingly difficult. For the most part these clients/patients just need the basics of a respectful relationship. In any case, if it is perceived that practitioners lack something because they have not worked in a mental health placement this is a very easy ‘top up’ that seems, according to SCoPEd, to need about a week in practice plus a bit of reading/writing.

This piece is a reflection of my first thoughts and is purposefully blunt. I might well reconsider some of my views and I welcome being challenged. But in sum, despite the reassurance that the views of some BACP members would be seriously reflected in this second iteration, I cannot help but sense that the whole purpose is to privilege psychotherapists and psychoanalysts over counsellors. I totally accept that as the purpose and remit of the UKCP and BPC. But the BACP, in my view, are meant to represent both counsellors and psychotherapists. This means that they need to stand by the assertion that there are no substantial differences between counselling and psychotherapy. Differentiations between practitioners need to be based on actual qualifications and actual pre- and post-qualification experience rather than titles.