On Regulation for The Psychotherapies in Ireland

I submitted the following comments on the question of regulation for the psychotherapies in Ireland to CORU, the national regulative authority, on Saturday, 14th November 2020. This post contains minor revisions and corrections made to the text on Monday, 23rd November 2020.

Four years ago in the autumn of 2016 the Minister for Health invited submissions from interested parties on the issue of regulation for the profession of psychotherapy. 

In response to this I submitted an outline of some 7,000 words on the factors that in my view needed to be born in mind before we embarked on any regulative program. 

My hope in writing this outline was that it might help to establish the basis for a discussion throughout the profession as a whole, offering practitioners and regulators alike an indication of some of the complexities involved in the task of regulating such a unique and in many ways unusual field as the psychotherapies. 

To this submission, beyond a one-sentence email acknowledging receipt, I received no response of any kind. 

I know, from speaking with colleagues, that mine was not the only submission on this topic at that time that received no response. Some of us at least were left with the fairly clear impression that if your views did not match closely with what the Minister and his advisers already intended to do, they would be brushed aside without comment. 

So far, it would appear that a small number of privileged members of the profession have had their views taken into account and that the rest of us, despite our best efforts to participate in the debate, have been simply cut out of the the process of consultation.  

Hopefully things will improve in the months ahead and a genuine dialogue can be established and a consensus of views can be achieved. 

My submission of 2016 can be found online by following this link: 

https://pangurcottage.blogspot.com/2017/03/submission-to-minister-of-health-on.html

I would still be happy to receive any response to the points I made at that time, and I will gladly discuss the issues I raise there with anyone in CORU, the regulatory authority, who wishes to do so. 

In the interim, CORU has announced that it has set up a regulatory board for the professions of psychotherapy and counselling. This regulatory board will oversee two separate professional registers, one for psychotherapy and one for counselling.

To the best of my knowledge, there has been no public statement from CORU explaining the thinking behind this move. I have seen no account offered of why it was felt necessary to divide the field as a whole between two separate professional registers, rather than leaving it at one (or for that matter setting up three or four); no account of how this particular distinction is expected to raise the standard of treatment for emotional problems more than another might have done; and no account of what alternatives to this particular division, if any, came up for consideration, and why they were rejected. All this remains, to most of us at least, a series of unanswered questions. 

If there had to be two registers for the one profession it is not clear, for instance, why the most obviously relevant division in psychotherapy, that between psychoanalytic therapy and cognitive behavioural therapy, was not adopted. This reflects a real difference in the philosophy of therapy, is of old lineage, and has significant implications for the particular form regulation might take. Yet, as far as I know, it was never considered. 

Had I been asked, I would not have recommended dividing the field between psychotherapy and counselling. Let me try to explain why. 

My intent here is not to gripe about a decision that has now been reached and cannot, at least in the immediate term, be reversed. That would be fruitless. My aim rather is to clarify what I believe are some of the problems that will flow from this decision, so that their impact may be minimised, as far as this is reasonably possible.  

In a nutshell, the root problem with institutionalising such a distinction is this: we do not currently have definitions of “psychotherapy” and “counselling” that enjoy sufficiently wide consensus for us to be able to draw a clear and generally accepted boundary between these two things. 

In the world of the mental therapies the terms “psychotherapy” and “counselling” are used largely interchangeably. It is true that they are used to some extent by different groups: “counselling” tends to be favoured by the general public while “psychotherapy” is a term you are more likely to hear used by professionals in the field. But they refer to the same thing. 

The term “counselling” was first popularised in the context of psychotherapy in the 1940s by the American psychotherapist Carl Rogers (1802-1987). He used it partly because at the time in the US the title of “psychotherapist” could only legally be used by those with a medical qualification, and partly because he wanted to stress that what is valuable in psychotherapy are those things that are not specifically medical about it. (Freud had made the same point in 1926 in his The Question of Lay Analysis.) 

Rogers however did not attach any particular theoretical significance to the term “counselling”. For instance he did not use it to distinguish his own brand of “humanist” or “person-centered” psychotherapy from other psychotherapy, as he might have done. 

In fact, at no time since the inception of modern psychotherapy in the late 19th century up to the present day has the term “counselling” ever had any particular theoretical or procedural significance within the field. 

Rogers himself writes in the opening pages of his Counselling and Psychotherapy (1942): “These terms will be used more or less interchangeably in these chapters, and will be so used because they all seem to refer to the same basic method – a series of direct contacts with the individual which aims to offer him assistance in changing his attitudes and behaviour. There has been a tendency to use the term counselling for more casual and superficial interviews, and to reserve the term psychotherapy for more intensive and long-continued contacts directed towards deeper reorganisation of the personality. While there may be some reason for this distinction, it is also plain that the most intensive and successful counselling is indistinguishable from intensive and successful psychotherapy. Consequently, both terms will be employed, as they are in common use by workers in the field.” (Chapter 1, page 4, my emphasis)

Over the years the word “counselling” has developed into a broad and slightly vague term, now used widely among the general public to refer to what specialists have traditionally called “psychotherapy”. 

The preference for the term “counselling” among the general public is without a doubt because it does not carry so directly the connotation of “mental illness”, which is inevitably attached to the “therapy” part of “psychotherapy”. Most people feel more comfortable saying they are attending a “counsellor” than they do saying they are attending a “psychotherapist”. And most people who have been working with a psychotherapist intensively even for several years will nevertheless still refer automatically to their therapist as their “counsellor”. 

The distinction between “counselling” and “psychotherapy” then has no reality within the actual practice and theory of the psychotherapy field. There is no “school of counselling” or “school of psychotherapy”. No such things exist. 

However, because the term “counselling” has become such a popular term with the general public the distinction has come to have an important reality within the market for the psychotherapies. 

In general, the more knowledgeable a prospective client for therapy is about the different schools that exist in the field of therapy, the more likely is he or she to look specifically for a service called “psychotherapy”. 

For instance, prospective clients often contact me looking for “psychotherapy” because they know I am a psychoanalytic therapist and they want this kind of psychotherapy specifically. Such clients will very likely be interested in therapy as a means to developing better their self-knowledge; they may also intend to become therapists themselves and want to learn more about psychoanalytic therapy in particular. In short, they will be interested in therapy in the first instance as an educative process, but an educative process that is also a means to improving the quality of their life and their ability to handle its vicissitudes. 

In contrast, prospective clients who know little about the world of psychotherapy and are not particularly interested in the fact that it consists of many different schools and philosophies are much more likely to come to me looking for a service called “counselling”. Such clients are likely to be focused on the curative aspects of therapy, rather than its educative aspects, and they are likely to be looking for help with specific problems, such as anxiety, depression, relationships, sex, the aftermath of sexual abuse or other trauma, and so on. These clients have no preconceptions about the kind of therapy they want. Although this may well change as the therapy develops, they are at the outset interested in the result of therapy, not in the process itself.  

At the moment, roughly half of my clients come to me because they are looking explicitly for “psychotherapy” and about half because they are looking explicitly for “counselling” services. 

Does this mean half my clients receive one kind of therapy, called “psychotherapy”, and the other half receive a different kind of therapy, called “counselling”? 

No. 

Each of my clients receives the unique treatment that I judge he or she most needs. This is because each client is unique, with a unique history and circumstances, a unique personality, and unique needs, and, in addition to this, every therapist-client relationship is unique and will develop in its own way. 

With each client, a skilled therapist is judging all the time just how much explicit psychological analysis and theory, how much overt support and encouragement, how much advice and suggestion, how much humour and small talk, how much silence, how much self-revelation on the part of the therapist, will be of benefit to the client. Because with each client the optimum mix of these things will be different. Knowing how to combine and balance these things well and effectively, along with many others, is the art of therapy, and it takes many years of practice and experience to acquire this. 

We need to consider the consequences of the decision to set up separate registers for psychotherapy and counselling from two points of view. 

First, we need to think about the consequences for the general public trying to find help with emotional problems. 

Second, we need to think about the consequences for the professionals within the field trying to provide help with emotional problems. 

From the point of the view of the general public, the presence of two registers within the field of psychotherapy as a whole will create a greater degree of confusion about the nature of therapy than exists already. Furthermore, it will be those members of the public who are least informed about the world of psychotherapy and most in need of helpful clarification who will be most confused.

For the first time, those members of the public who would normally be content with looking for a “counsellor” will find themselves induced to ask an entirely new, and entirely redundant, question: “Do I need counselling, or do I need psychotherapy?” And no one will be able to answer this question for them, because no answer exists to this question. The question has no content, because it arises purely from a misapprehension about the meaning of words. 

From the point of view of practitioners in the field, the existence of these two registers will make it harder for them to explain to a newly confused public what service exactly it is they provide. If a prospective client asks a therapist, “Do you provide counselling or psychotherapy?”, and a therapist replies, “They are the same thing,” then the client would be entirely justified in asking, “So why has the government set up a separate register for each?”, to which the therapist’s likely inability to find a response might well make the client doubt his professional abilities more broadly. 

This distinction between “psychotherapy” and “counselling”, unless it is carefully handled, also has the potential to generate significant problems for therapists in reaching the market of people who are looking for their help. 

Let me try to explain. 

Some therapists will experience no trouble as a consequence of registering themselves purely as “counsellors”. This is particularly true for those therapists who work mainly or exclusively for the HSE. Their customer base will be largely unaffected by such an exclusive registration, because most of their clients will have been looking for, and will (subject to the qualification I have just mentioned about increased public confusion) be happy to receive, a service that is called “counselling”.

Equally, there will be some therapists who will experience little or no trouble as a consequence of registering themselves purely as “psychotherapists”. For instance, some therapists in private practice in central Dublin will probably be serving a catchment area where there will always be a sufficiently large number of potential clients who are specifically seeking the services of a “psychotherapist” for them to be able to make an independent living using this nomenclature alone. 

There will however be a large number of therapists who fall into neither of these two categories and who, if they are required to give up either the title of “psychotherapist” or that of “counsellor” are likely to find their practice adversely affected in a significant degree. 

Therapists in this third category are likely to be those working in private practice, but located outside the greater Dublin area. 

I myself fall into this third category; I work in private practice and I am based in Cork city.

Those of us in this third category now regularly describe ourselves, on our websites and our business cards, as “Psychotherapist and Counsellor”. This combination of terms is now used as a standard, widely recognised professional description. 

Therapists in this third category cannot confine themselves to one term or the other, because their customer base consists of large numbers of potential clients who are equally likely to be looking for either a “counsellor” or a “psychotherapist”. 

It is therefore imperative that all practitioners in the field be permitted, should they wish it, to register both as a “psychotherapist” and as a “counsellor”. Any restrictions in this regard will damage the therapeutic work that many of us are doing throughout the country. 

In conclusion, there is one central general point in the context of regulating the field of psychotherapy that cannot be sufficiently emphasised.  

It cannot be stressed often enough that psychotherapy is not like a field that applies the physical sciences, as do most of the other disciplines that come under the remit of CORU. It is not for example like physiotherapy, or radiology, or nursing. 

In disciplines based on physical science treatment processes can be regulated easily because we can easily reach consensus beforehand on the range within which acceptable outcomes of such processes must fall. Also, this range invariably will be amenable to mathematical measurement. 

In psychotherapy this is not possible, because it belongs to the broad field of the humanities and the human sciences, not to the physical sciences. Debate and discussion about what are the range of desirable and acceptable outcomes is not peripheral to the practice of psychotherapy, it is of the very essence of the procedure itself. 

Consider a comparative example. No one would suggest that the correct procedure for a cardiologist is to engage in extended and repeated discussion with his patient as to what is the meaning of desirable heart health. Such a suggestion is nonsensical. Yet this is exactly what the daily work of the psychotherapist, or counsellor, involves. It is a continuous, ongoing exploration of what spiritual and emotional health might mean for each unique individual client. 

And this is why psychotherapy, or counselling, is nothing like anything else in the field of medicine. And this in turn is why genuine regulation of the process of psychotherapy, or counselling, insofar as such a thing is possible at all, will bear no resemblance to regulation in any other field of health. 

Writing of psychoanalysis, which is a root discipline of all the modern psychotherapies, and for most of them the principal root, Freud remarked in 1925 that it occupies a “middle position between medicine and philosophy” (The Resistances Against Psychoanalysis). 

More precisely, psychotherapy occupies a middle position between the traditions of the doctor-patient relationship (which is not the same thing as contemporary medicine, with its overwhelming reliance on physical science and its increasing neglect of the doctor-patient relationship) and the tradition of ethics and moral philosophy. It is immersed, that is to say, in the ancient question of how a human being should live, what values matter in life, and what the goal of a human life ought to be. 

Now in a democratic, liberal society such as ours there is a presumption that this is a question that each adult individual, provided he or she abides by the laws of the land, should be free to decide for him- or herself. This is not a question, in such a society as ours, that the government or its agencies undertake to answer for the individuals within society. 

As an adult citizen of such a society I have the essential right to consult in private with whomever I choose on the personal issues of my life, on the aims of my life, on the values of my life. This is not a matter on which any third party in the State has the right to be informed or in which it has the right to interfere in any way without my consent. 

CORU has not yet told us how it plans to address this crucial problem of undertaking to regulate psychotherapy without compromising this essential right of every citizen to resolve the meaning of his or her own life in private, in consultation with whomever he or she wishes, without outside interference.  

This is not a marginal, merely abstract problem that can safely be ignored in the hope that it will somehow resolve itself. It is of central practical consequence for the whole future practice of the psychotherapies in this country. 

Because it is of the essence of psychotherapy not to result in a consensus on outcome, in fact continually to question consensus on outcome, it has throughout its history had a marked tendency towards factionalism. Over the years the number of different schools and traditions that have been generated in the broad field of psychotherapy is legion. 

This looks messy, but so long as no particular school enjoys a privileged position before the law it is by and large a healthy state of affairs because it encourages debate and diversity of views and it maximises the choice of therapy available to the public. 

The greatest danger for CORU is that, because, as a matter of fact, it is impossible to regulate psychotherapy in the way one can regulate a discipline based on physical science, it will opt instead for the politically expedient alternative of a “false regulation”. In other words, the danger is that CORU will simply choose, in effect, to endow certain prominent factions within psychotherapy with authority over the others. This will look, to the layman, like regulation, but it won’t be regulation. It will simply mean that CORU has itself become, de facto, the instrument of the most powerful and politically savvy groups within the profession. 

The overriding aim of CORU must therefore be to find a way to transcend the factionalism and politicisation that are, and always will be, endemic to the field of psychotherapy, and to ensure that all voices and viewpoints within it are legitimised.

If CORU manages this task well everything else will run smoothly and both the public and the professionals will be happy. If CORU gets this wrong its future in the field of psychotherapy will be one of trying to explain away failure.

I do urge CORU therefore most carefully to consider this and the other points I have made in this short submission.  

Marcus Bowman PhD

Author: Marcus Bowman PhD

I am a psychoanalytic therapist working in Cork.

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