Psychotherapy has a long and chequered history from Freud to CBT (cognitive behavioural therapy) and beyond. There are hundred of different therapies each claiming efficacy – some through analysis, some through interpretation, some through formulation, and some through diagnosis.
Virtually, all psychotherapies begin with some sort of assessment which is based upon the interpretation and expertise of the therapist. There is an assumption that all therapists have this skill to divine what is happening inside the skull of their clients (note the paternalistic tones in the wording; so often psychiatrists and therapists are incredibly territorial about ‘their’ clients).
Many therapists would say that they have a collaborative relationship with their clients, that they have built a ‘therapeutic relationship‘ with their clients, again the language is interesting; the idea that this relationship has been constructed by the skill of the therapist. Yet we don’t build relationships with any other professional person in our lives; so why is there an assumption that it is necessary in psychotherapy and that it is some special skill that only psychiatrists or therapists have? It seems to me that the ‘therapeutic relationship’ is a construct necessary to bolster the special nature of the therapist rather than anything to do with the purpose of the work that a person and their therapist do together.
In reality, any relationship is built on three things: trust, hope, and imagination. Trust in each other (or more if it is a group or a team), hope that something can be achieved and sufficient imagination to be able to work out a common goal. In the case of psychotherapy, this is the goal that the person seeking help desires. Too often therapy is based upon the goals of the therapist or their service; a good formulation or diagnosis, a reduction in some metric (the absence of symptoms), x number of sessions (regardless of outcome).
The reality is that a person comes seeking help from a therapist and has an objective in mind, in every other walk of life the person is the arbiter of what is wanted, in therapy the straightforward question, ‘If we have been successful what will you have achieved and how will we know?’ is rarely asked. Sadly, therapy is always looking for that secret ingredient that makes the work therapists do special and unfathomable to the layperson. Well, let me tell you what is special in my work – the people I work with – they are amazing. My outcomes are not good because I have a special skill, though I like to think that I do have some ability, but because the people I work with are all wanting to change themselves in some way and we spend time finding out what that change would look like when they have achieved it.
Once they have engaged their imagination, dumped the idea that the past is significant (though there may be good bits to hang on to) and got on with the process of change, in the here and now and in the direction that they want to travel, we are off and running and the client is in the lead; I’m merely following-up by asking more questions about: ‘How did you do that?’ – usually with awe in my voice.
Most therapies assume that the past is a problem to be dealt with or overcome before the person can move into their preferred future. Again, in no other aspect of our lives do we do that. Imagine taking your car to the garage and the mechanic trying to take a full history of where you have been in the car before they repair it! You don’t analyse your past grocery lists to determine what you want to eat in the future. It is as mundane as that! The special qualities ascribed to psychotherapy are all for the benefit of the therapist and have little or nothing to do with the wishes of the person.
The history and diagnosis or formulation is a product of the history of psychology and medicine; not a requirement for change by the person. The persistence of these arcane activities is a product of the needs of the therapist, the service that employs them (or sometimes insurance companies) to enable them to have some kind of fig leaf that denotes their professional credentials – it is not necessary for good practice in helping people in distress. After all, diagnosis is a fiction created by (mostly) men in suits in a committee room, there is no scientific basis for psychiatric diagnosis.
Assessments are just a way of creating the fiction of science and adhering, illogically, to the medical model. It is time to review our practice in the round and begin to really study what is effective and that it is the forward-focused questions that give hope and develop the imagination of the person the therapist is working with who then creates their own future and we, as therapists, need never know what that is. There is a different way.
Steve Flatt is the director of the Psychological Therapies Unit which provides psychological services to private citizens, solicitors, commercial organisations, and third sector organisations.
