For many years I have promoted the idea of thinking critically about the psychological therapies (and more broadly about human distress and the human condition), most recently in my books Critical Thinking in Counselling and Psychotherapy1 and Counselling and Counselling Psychology: A Critical Examination.2
Since the origins of BACP in 1970, we have seen many enthusiasms in the form of new schools of therapy, a great deal of professionalising in the form of ethics documents, training and supervision norms, accreditation procedures and statutory regulation, and a push for research activity. But the field still suffers, in my view, from insufficient critical thinking.
In this short article I want to explore three issues: first, the place of thinking and theorising in counselling; second, the neglect of and suspicions about such thinking, and third, areas in which critical thinking might suggest some priorities for our profession and beyond.
Thinking and theorising
We could begin by asking questions about thinking per se but that would take us into philosophical areas that many readers might believe to be irrelevant and that I lack the expertise to explicate rigorously. Pragmatically, let me begin instead by asking how tutors come to subscribe to and recommend certain theories of psychological therapy and how trainees are taught to evaluate the texts prescribed in course reading lists. It seems doubtful that many tutors of whatever academic or professional background devote years to sifting earnestly through therapy-related texts on theory and research before concluding, ‘Yes, this one ticks all the boxes and can be recommended.’ It is much more likely that the process that Daniel Kahneman refers to as the ‘affect heuristic’ is responsible.3 In other words, those leading the promotion and training of therapy like, or are strongly emotionally influenced by, certain texts and related therapy experiences and, in falling under their sway, become relatively uncritical about them. This phenomenon has been referred to as belief-dependent realism but I think the term ‘personality dependent realism’ is more accurate.4 Choice of and adherence to a therapeutic approach seems to be part of the powerful emotional faith that most counsellors invest in the therapeutic enterprise.
Now, it’s also true that intra-professional promoters, tutors and researchers may commit themselves to developing their chosen approach on the basis of what may look like critical thinking, by adding certain concepts and references to research. But how often do we hear anyone pronouncing, ‘I have rigorously evaluated these claims and, since I find them wanting or defective, I have decided to abandon this approach’? Very rarely indeed, unless we include all those originally wedded to psychoanalytic practice principles who defected or created their own approaches (eg Jung, Perls, Ellis, Beck, Janov et al), having become disaffected with psychoanalysis. But why should early emotional investments in various therapies so rarely change significantly? Well, perhaps we have here not only an emotional path dependency but also a financial one, of sunk costs: unless you are paid to be objective regardless of where your thinking takes you, most cannot afford to abandon livelihood-related theoretical beliefs.
Most training is now academically validated in systems where it has always been an expectation that students will learn to think, discuss and write analytically and critically. Indeed, given the rise of doctoral demands in counselling, counselling psychology and psychotherapy training, we ostensibly expect high levels of rigorous critical thinking. We probably should ask what differences exist between undergraduate level (eg foundation degree) and doctoral level (eg PhD, doctorate in counselling, doctorate in counselling psychology, professional doctorate) training standards and how these impact on practice competency – but we don’t. I am frequently surprised to read doctoral theses that, apart from obligatory discussions of the merits of qualitative methodologies and some Foucauldian or similar jargon, demonstrate somewhat superficial levels of critical thinking. Doctoral candidates mostly remain wedded to their beliefs, make micro-analyses of selected practice issues, and uncover little that is genuinely new.5
Once qualified and in practice, what kind of thinking do we expect from practitioners? Requirements for supervision, accreditation and continuing professional development entail a certain amount of clinical and ethical reflection, theory-into-practice case studies and engagement in self-chosen workshops, conferences and additional training. But there are no real markers of the level or originality of thinking expected: only the amount of activity and sometimes a justification of rationale. This may be due to BACP’s well-intentioned, historical refusal to align training standards with higher academic levels but, even if this were to be mandated, as it is for the British Psychological Society, it would be no guarantee of rigorous, authentic, independent critical thinking*.
Neglect of critical thinking
It is natural to wonder if the faith-oriented, often emotion-loaded ethos of counselling is at odds with critical thinking. It has been argued that trainees need first to be immersed in therapeutic dogma before being encouraged to apply stringent and even radical analytical thinking to it.6 Intellectualisation portrayed as a psychoanalytic defence mechanism may colour our views about the value and importance of thinking over emotional investment. Suspicions may be engendered by the Critical Parent of Transactional Analysis. The emphasis given in training to relational factors, to personal awareness and emotional openness, may discourage too much play being given to critical thinking. The well-known phrases ‘He’s so much in his head’ or ‘I asked you what you feel, not what you think’ may militate against thinking. Even presumably more thinking-oriented CBT courses are likely to severely limit the free rein that could be given to fulsome critical thinking that sceptically challenges the very foundations of all therapeutic theory and outcome claims. And let’s note too that passion and critical thinking are not necessarily mutually exclusive.
Those opposed to statutory regulation who were vocal in their arguments often discovered that the pro-regulation lobby simply refused to engage in the core arguments, as if an attitude of ‘Of course we must have regulation’ were self-evidently true. Try to engender a debate about whether or not supervision, or personal therapy in training, is necessary and you meet the same, or worse, kind of indignation, and an unwillingness to discuss the issue logically. This kind of non-engagement has been called ‘ignoring [one’s opponents] to death’.7 Jeffrey Masson, who dared to rock the psychoanalytic establishment, was not ignored so much as vilified by many therapists, or his accusations that most therapists are abusive were derided or ignored. As a ‘critical friend’ of counselling and psychotherapy since 1992,8 I am quite used to book reviews that offer bland pseudo-appreciation or identify minor faults rather than engaging seriously with the core issues raised. The irresistible picture that emerges is that critical thinking isn’t wanted here, any more than Richard Dawkins is welcome in church. The response, ‘We know therapy works and our traditions are sacred’ may be backed up with predictably confirmatory research but that’s usually the end of the discussion.
For some reason, empirical research has been elevated as the premier mode of analysis of theoretical and practice issues. Hundreds of postgraduate dissertations and theses now routinely investigate nuances of counselling phenomena and researchers confidently proclaim that the effectiveness debate stemming from the 1950s is over; the battle is won; ‘We know therapy works.’ But critics are far from satisfied that the research can ever get at the complex variable experiences of thousands of actual clients. Meanwhile much research tries to establish the most effective therapeutic ingredients, as if new, important practice variables are waiting to be discovered that will significantly improve therapeutic delivery. But who really believes that typical therapy practice will improve a great deal, indefinitely, or indeed that it has improved hugely across the last few decades? Can we even entertain an idea like ‘the cure for depression’ to compare with medical research into a cure for cancer?
Priorities for critical thinking
My hunch is that an article such as this will be regarded as a minor nuisance at best or waved aside with a dismissively humouring ‘There he goes again’ response. I meet relatively few in our field who believe we face serious problems of credibility, particularly since counselling and CBT have been established in the NHS. Therapy’s critics remain a mixture of sociologists, journalists, philosophers, scientists, ex-clients and others who have variable motives and a not always accurate grasp of the field. Internal debates about and schisms around regulation, research, inter-approach wrangling and pluralism continue. But the pressures from critics don’t go away; recent additions include that of the counselling psychologist Paul Moloney.9 What are some of the main objections to therapeutic theories and practice, either perennial or topical, and what might be learned from these?
- The field of the psychological therapies is somewhat detached from the question of, and research into, the deeply intertwined causes of widespread human distress. Therapy is something like a 100-year-old set of touted theories and practices at odds with each other yet all claiming to identify the key (intrapsychic and interpersonal) causes of distress and to bring significant and lasting relief via disciplined listening and talking. Would it be too much to ask for an attempt to produce an interdisciplinary and coherent picture of the probable causes of mental distress, to include genetic, neurological, socioeconomic, individual-developmental and other inputs?
- Is it credible and inevitable that we have hundreds of different and competing therapeutic theories? On top of that we have eclecticism, integrationism, pluralism and unification – that is, different but indeterminate bids to link, blend or rationalise diverse therapies. We could produce a theory of the underlying causes of such multiplicity; we could investigate the problems caused by this fragmentation; we could also philosophically analyse the possible merits of this proliferation. But we don’t. Instead new approaches are constantly invented, unchecked. Why? And what prevents greater co-operation rather than such sprawling creation?
- It suits us to see research conducted into outcomes, usually by insiders of the psychological professions, that always happens to confirm the effectiveness ?of therapy, seemingly regardless of the approach being investigated. Yet much anecdote, the reservations of some psychologists and sociologists, client publications and ex-client websites (eg www.therapyabuse.org; www.trytherapyfree.workpress.com; www.debunkingprimaltherapy.org) suggest that significant levels of dissatisfaction persist. Is it ethical to rest on the laurels of still questionable research?
- If we accept, or put aside, some of the above ‘messiness’ of the field, we are still confronted with a reality of unknown numbers of clients with a variety of personal problems being seen by thousands of practitioners in different settings, each of whom has trained in various, often incompatible theories and associated skills, and who bear different professional titles. Many therapeutic outcomes may be modest or indeterminate rather than wholly successful. We do not ask who make the best therapists (practitioners are self-selecting) but we know the majority of counsellors are women. Are there no significant questions for us here?
- Related closely to the above is the problem of training courses turning out far greater numbers of practitioners annually than there are employment openings, and probably many more than can find enough clients to provide a living in private practice. Many therapists continue to practise into late life, which also reduces work available for younger qualified practitioners. This problem has economic and ethical dimensions (the over-selling of training); it has been raised over the years but has received almost no critical attention or action. I have even heard it said that this is not a topic for serious critical thinking, compared with supposedly more intellectually worthy questions. Who will take this question on?
- Our field has neglected inputs and criticisms from evolutionary, genetic and political analysts of the human condition. This is probably due to a combination of sincere opposition to those proffered aetiologies and also to the urgent, practical orientation of most therapists, whose business is primarily interpersonal and clinical rather than intellectual in nature. Critical psychologists are usually well informed politically and invariably oppose physical treatments but they are often critical of low levels of political engagement among counsellors. Many therapists have humanistic affiliations and spiritual inclinations and oppose medical interventions with people suffering from psychological distress. Is there some sort of unarticulated pro-science vs pro-spiritual vs pro-political dynamic at work here? Contrary to person-centred claims to a ‘quiet revolution’, might not most therapy constitute a rather conservative, indeed collusive, anti-revolutionary quietism?10
- Somewhat in contrast to the above point, we see an emergence of climate change engendered models of ecotherapy. This development seems to show that at least some therapists are seriously engaged with the threat of climate change and the need for a radical psychological change to meet its challenges. But here we have disagreement, many also arguing that the business of therapy must only reflect what the individual client brings, that we are practitioners involved in deep therapeutic relationship work, we are not social activists. Can there be any consensus on these matters?
We could certainly add more critiques. One conclusion we might come to is that the complexity and messiness of the therapy world simply reflects the human condition. No one can know everything or cover all angles; no one is an enlightened saint or fully-functioning person; we’re all just doing our limited best. Marie Adams’ book The Myth of the Untroubled Therapist,11 based on her own doctoral research, shows that therapists are probably no more free of depression, anxiety, relationship problems, illness and physical pain than anyone else, although they presumably retain sufficient skill and discipline to attend meaningfully to others’ distress. But would we equally accept that the entire ‘profession’ of therapy can be described in terms of this myth of the profession that understands and addresses all psychological distress successfully?
James Joyce referred to us as ‘unhappitants of the earth’12 and Samuel Beckett declared, ‘You’re on earth; there’s no cure for that.’13 A growing band of depressive realists argue that life is fairly grim, a struggle that ends in death, and that this view should not be pathologised as merely a projective cognitive distortion of depressed individuals. This is the tragic view about common unhappiness that Freud shared, while humanistic therapists tend to hold a romantic view of inevitable progress and CBT folk hold fast to an ever-upward problem-solving optimism. Could we even see a humanistic-CBT truce soon, as former antagonists agree on a pro-positive psychology agenda? It’s quite possible that counselling and psychotherapy (the enduring dichotomy of these names reveals a central problem) will never achieve a consensus of views, language and practice. Not only do we suffer periodically or incessantly as human beings; we also generate endless social and professional absurdities and impasses, and seem unable to resolve these. Indeed, we seem to have little appetite even to discuss them. Discuss?
Colin Feltham is Emeritus Professor of Critical Counselling Studies, Sheffield Hallam University, and External Associate Professor of Humanistic Psychology, University of Southern Denmark.
* Editor’s note: BACP supported the development of the Quality Assurance Agency’s (QAA) subject benchmarks for counselling and psychotherapy (QAA, 2013) and its professional Education and Development Forum (PEDF) is currently devising training guidance. The QAA benchmarks apply to Level 6 and 7 HE courses but can inform curriculum development across all practitioner training. An interplay between criticality, skills capacity and reflexivity, thereby facilitating trainees to advance a profession in which criticality underpins theory, research, training and practice.
References
1. Feltham C. Critical thinking in counselling and psychotherapy. London: Sage; 2010.
2. Feltham C. Counselling and counselling psychology: a critical examination. Ross-on-Wye: PCCS Books; 2013.
3. Kahneman D. Thinking, fast and slow. London: Allen Lane; 2011.
4. Feltham C. Keeping ourselves in the dark. Charleston, WV: Nine-Banded Books; in press.
5. Brooks O. Methodolatry, irony, apricot cocktails. Self and Society 2013; 41(1): 48–53.
6. Wheeler S. Training in a core theoretical model is essential. In: Feltham C (ed). Controversies in psychotherapy and counselling. London: Sage; 1999.
7. Postle D. Regulating the psychological therapies: from taxonomy to taxidermy. Ross-on-Wye: PCCS Books; 2007.
8. Dryden W, Feltham C (eds). Psychotherapy and its discontents. Maidenhead: Open University Press; 1992.
9. Moloney P. The therapy industry: the irresistible rise of the talking cure, and why it doesn’t work. London: Pluto Press; 2013.
10. Epstein, W. Psychotherapy as religion: the civil divine in America. Reno, NV: University of Nevada Press; 2006.
11. Adams M. The myth of the untroubled therapist. London: Routledge; 2013.
12. Joyce J. Finnegan’s Wake. London: Faber & Faber; 1939.
13. Beckett, S. Endgame (Fin de partie). Paris: Les Éditions de Minuit; 1957.