THE FUTURE OF PSYCHOTHERAPY IN EUROPE

Emmy van Deurzen-Smith

Abstract: What is the future of psychotherapy in Europe and what is the role psychotherapists can play in the next millennium? Multiple social problems have increased the need for psychotherapy and these are in turn based on a number of cultural changes which must redefine the function and duties of our profession. European registration of an independent and accountable profession of psychotherapy is seen as the first step in a process that will open up new avenues for research and that will facilitate the effective use and expansion of available psychotherapeutic resources.

Introduction

A century of psychotherapy and only now are we coming into our stride. At last we are taking ourselves seriously, forming professional associations and setting standards for our training and practice. Why has it taken so long? And where are we going now that we have come this far? What is the future of psychotherapy and what can we expect it to contribute to the world as it is developing for the next millennium? What is the function of psychotherapy? What is the role that we can play in Europe? What is the destiny of our profession?

Rising to the challenge

There are still many psychotherapists who would rather not ask these questions, let alone try to answer them. Psychotherapists are self-selected to be rather inwardly turned, shy creatures, who are generally more at ease in a study or consulting room than on the political scene, or in the public eye. We sort out our clients' and patients' problems and keep quiet about the social implications of it all. But is it right that we should do so and that we should allow our profession to be belittled and dragged through the mud by those who dismiss it as insignificant or as irrelevant to the real world? Surely not. For after all it is in the public interest that we professionalise and create registers. We have realised that the public needs to have access to reliable and responsible services of psychotherapy and that they need to be protected from charlatans by the existence of adequate training standards, codes of practice and complaints procedures. But these measures are merely the external framework of our accountability, within which we can begin to pay much more attention to the duties that come with our new professional status. This is when we realise that psychotherapy has a distinct role to play in our culture and that it is high time for us to define what this is.

The current situation

The current state of psychotherapy is not so different from that of the profession of medicine 150 years ago. It was then often reviled and it was disorganised. People could practice medicine with few or no qualifications. People such as barbers or surgeons often did practice in such a haphazard way. General skepticism for quacks made the profession of medicine seem unattractive and dangerous. It was only after the profession had been organised and proper qualifications had been put into place that it became obvious that it could contribute to society. Once room was made for a regulated profession to deal with physical ailments in a responsible manner, funds became available for more research and this in turn led to the development of the profession. What we now take for granted as the sine qua non of a healthy society had to be generated and established, developed and sustained.

In many ways it is astounding that the equivalent profession for mental and moral well-being has not been more developed at an earlier stage. This may well be the case because often these functions were looked after by religion and then to some extent by medicine, through psychiatry. Psychologists too have made a claim to being able to look after people's mental well-being, but as their profession is based on a positivistic, statistical approach, it has clearly limited itself to dealing with a very restricted area of human concern. The professions of counselling and psychotherapy were specifically developed to connect to the human predicament as it is experienced by ordinary people in their everyday lives. They focus on the relational aspects of being human as well as on the internal emotional dimension.

A genuine need in society

It is hardly surprising that we are now faced with an increasing and pressing demand for psychotherapeutic help from the public. With soaring figures on divorce, suicide, depression, substance abuse, stress, anorexia, bulimia, schizophrenia, post-traumatic stress disorders, and many other forms of emotional and relational problems, there is an overwhelming need for our profession. There are, for example, over 5000 people who kill themselves in the UK alone every year and a further 200,000 who attempt to do so. There are many thousands of people who consult a specialist for a psychological disorder of some kind and research with general practitioners has shown that six out of 10 of their patients have psychological difficulties underlying their presenting symptoms.

Undeniably there is a widespread malaise in our society that medicine alone cannot provide the remedies for, that the police force and the courts cannot stave off, that politics cannot control and that religion can no longer alleviate. Psychotherapy has a role to play in understanding this malaise and in providing the means to preventing and solving some of these problems. For the study of psychotherapy is about understanding human nature in all its complexity. Psychotherapy as a profession is needed more than ever before, as it uniquely studies and addresses the very issues and dilemmas that society is currently incapable of coping with successfully.

Practical applications of psychotherapy

To give an example, there is the issue of community care. In using that laudable term it is all too easy to overlook the fact that such care must attend to people's personal and psychological as well as their physical and social well-being. It is simply not sufficient to give people medication and a place to live. We also need to show them how they can mentally and emotionally put the pieces of their lives together again and make sense of what may otherwise seem like chaos, leaving them passive and at the mercy of further despair, illness and abuse.

Much the same can be said for those who have offended or those who are addicted to any number of substances. They too need more than punishment and re-education: they also need to be allowed to heal their old wounds and find ways of retrieving a more positive self-image out of all their failures and disasters: it is the sine qua non of rehabilitation. Human society, in order to be humane, needs to provide places and times for the sort of healing reflection and discussion that psychotherapy provides. There simply is not enough time and space set aside in our institutions for this. There is not enough counterbalance to the pressures of the modern competitive and consumerist world.

As the balance in our culture has shifted away from the home towards the workplace and as the structure of the family that used to underpin our emotional well-being has become undermined, we need to ensure that this function is looked after elsewhere. It is of course the classic function of mothering, with all its attention to human relations and personal wellbeing, that has become most eroded and that psychotherapists often compensate for. These days with shifting patterns of care people may prefer to think of it as the function of parenting, but that is in itself the consequence of the shifting emphasis. It is clearly the traditional role of motherhood that has been transformed through women's engagement in the workforce outside the home and it is this that has to be compensated for. It is therefore quite justified to depict the rapid development of the professions of psychotherapy and counselling as the professionalisation of motherhood and take this new function of society extremely seriously.

A new vision for psychotherapy

All this raises important and interesting questions for our profession. If we are talking about a profession that is to look after the emotional balance of our culture, we can no longer content ourselves with the task of curing psychopathology or erasing or overcoming distress. We have a responsibility for the prevention of such problems and beyond that a larger duty of understanding and overseeing the complexity of individual emotional need and its relationship to the interactions of a perplexing and chaotic world. Now we can see what professionalisation of motherhood entails: it does not just mean to care for people's emotional well-being on a large scale rather than on the small scale of the family, but to do so in a purposeful and carefully articulated manner. It means that we have to understand human need and interaction well enough to make sense of it and to be able to train people to intervene in this dimension with some amount of purposeful certainty.

The professionalisation of motherhood

We have to transform what used to be a craft or an art based on moral and religious principles into a scientifically based accountable professional expertise. The craft of motherhood used to be based in biological and intuitive functioning, which was picked up through a process of intimate learning in the very families it would serve. These were things women just simply did, because they were mothers and their mothers had done it before them. They tended to any family member, infant, child, adolescent or adult, especially when they were most vulnerable, keeping them emotionally functional and fluid and always reminding them of how they were valued and a part of the wider unit. Women were experts at healing psychological pain and sorrow through the provision of a loving presence and a process of reinsertion into the myth of the family and its role in the community, which could make sense of almost any predicament. Women and their propensity to communicate and make connections held communities safe and held their families together inside them.

When women started to go out into the workplace, they were at first handicapped by having to adjust to the different, male morality that seemed to reign there and which was underpinned by an ethos of production and performance that disrespected and disregarded this constant need for emotional processing (for that was split off and reserved for the home). More recently women have begun to realise that they cannot function without their networks and stories, their gossip and folklore, their attention to the personal and their need to confide in each other and draw the men back into the process of paying attention to the personal dimension as well. While women have become more willing to draw on their intrinsic abilities rather than trying to fit in, men have at the same time become aware of how bereft their organisations have been of the human relations element and what the cost of this has been in material and in human terms. Introducing elements of counselling at work leads to a reappraisal of the way in which businesses and companies function and to a consideration of how society can be made more organically whole through reintroducing the mothering elements of which it has been so sorely deprived for so long and that are now being eroded at home as well. In this way we can observe a slow trend towards an externalisation and generalisation of the mothering function.

But in all this there is a real risk: that the soft end of the spectrum of motherhood might overwhelm society in a counter-productive backlash that could lead to matronisation and unarticulated, uncontrolled emotional matriarchal domination. This is no better alternative to patronisation and a culture of competition and productivity and the other macho-values that have dominated the world in a patriarchal culture. Many people who oppose our profession fear just such a backlash of soft and oozing self-indulgence and psychological pampering and they will keep fighting against the rise of psychotherapy until we can show what our profession can provide that is constructive and essential for a new world.

From craft, through art and religion to science

So how can we transform what was once the craft of motherhood into something that is more like a science and which articulates and meets the overall needs of the human family? How do we move from the intuitive use of skills to an explicit and reasoned process of purposeful understanding of what human relations are all about? We need to gain a clear view of human process and human purpose and the multivaried interventions we can make into it. We do need to study systematically what the effect of our interventions is. When psychotherapy becomes a profession, it is raised to the public level where it needs to be fully accountable for its impact on the individual and on society. We need to move the profession beyond the stage of being an art and articulate precisely what the principles of human connectedness are and how psychotherapists intervene in them. Of course these principles are often related to what was previously known as religion or ethics. Religion, from the Latin religare, signifies that which binds people together and it is what has given people their guidelines for operating on the human dimension for many centuries.

Mothers and women have always been the guardians of religion in the family, transmitting the values that would keep its members safe. The task of translating principles of religion and guidelines for human living into something more explicit, measurable and predictable comes with the new territory of the profession of psychotherapy. We can no longer rely on prescriptive notions of faith, on beliefs or intuitive convictions: those were part of our heritage of family life and motherhood, in a pre-scientific, pre-industrial era. We have now moved to a situation where we need to externalise such principles, describing and scrutinising them, so that we can work with them in a conscious and deliberate manner. We need to make concrete the underlying assumptions and mechanisms of how the human world functions and dysfunctions and draw conclusions that allow us to move to a position where our new knowledge is applied to an increasingly necessary reorganisation of the world.

Need for more information and research

Psychotherapists have to realise what is at stake when they speak of the need for professionalisation and what the wider implications and potentials of their field are. Whilst psychotherapy should not be held out as the miracle cure for all society's ills, it is nevertheless a resource that has been developed to deal with the deep-seated psychological and emotional stresses and distresses that are at the root of so many of our present day troubles and these troubles need to be addressed in a fundamental way. Currently psychotherapy services are often still looked upon with suspicion, because people simply do not know what psychotherapy consists of or what can be achieved by it. Psychotherapy for many is associated exclusively with severe mental illness. The public confuses it with psychiatry and the giving of psychotropic drugs, or with psychology and personality assessment procedures. Psychotherapy for many people gets conflated with traditional views of psychoanalysis and the use of the couch, which in fact is only one of its many modalities.

There is such a lack of adequate information about psychotherapy and still such a dearth of access to good quality psychotherapeutic services in most European societies that it is not surprising that the flippant and critical references to psychotherapists far outstrip the serious and appreciative ones. We have not had a chance yet to show what we can contribute. We have not had the time yet to bring together a substantial body of evidence and widespread research. As one of the youngest professions, having had to cope with the fragmentation of diverse orientations and a lack of public recognition, we were also disadvantaged by the fact that anyone could set up as a therapist and in some cases practice erratically and irresponsibly, tarnishing our reputation.

Concrete steps to take

Having drawn the profession's boundaries, as we are now doing everywhere across Europe, our next step must be to move on towards official recognition of the profession by the European Commission and the European Parliament. This is not lust about securing high standards and establishing free movement for psychotherapists, but also about finding ways to obtain further funding for the profession so that it can begin to make the contribution that it is capable of making whilst doing the necessary research. We need to begin educating people about the ways in which the profession can make a difference to our evolving world, showing how it can counterbalance the alienation of technologisation.

To do this we need funding. Such funding may well be an extremely cost-effective investment on the part of the European Commission. Some studies suggest that a timely referral to a psychotherapist could cut health costs and costs of crime drastically (Holmes & Lindley, 1989). Psychotherapy can make a significant contribution to society and it is ready to do so. What is needed is to expand the scope of psychotherapy research and find out exactly how the profession can make the best contribution to society. To make this possible, psychotherapists themselves have to be willing to work together. When formerly separate factions come together to challenge, to stimulate and cross-fertilise each other, new methods will evolve, old methods will be refined and honed, and ever improved services for the community will result. Although this profession is approximately 100 years old, it has never had the benefit of a public platform and the recognition, resourcing and respectability that accompany it.

New duties of psychotherapists

Although Freud envisaged that psychotherapy would have a societal role to play (Freud, 1919), we have only begun very recently to take this seriously. The crisis of meaning that Europe is currently experiencing now makes it essential for us to do so rapidly. There are a number of situations where psychotherapists are needed and are already making a contribution. One is in relation to refugees from Bosnia and other war-torn parts of the world, in work with groups of people who have suffered torture and other forms of physical and psychological oppression. Psychotherapeutic work, in relation to post-traumatic stress, is absolutely essential in a world that throws up crisis after crisis. But there is also a role for us in relation to the prevention of these crises It has been shown how this can work by applying psychotherapeutic principles to diplomatic negotiations. This is illustrated most clearly by the role played by John Alderdice, psychotherapist and leader of the Alliance Party, in relation to the beginning of peace negotiations in Northern Ireland (Elliott, 1995). There is enormous scope for human relations specialists working with those who are trying to understand the complexity of human conflicts, be it individually, in families or in much larger political or social groups.

This also applicable to the cross-cultural problems that many European countries are now experiencing, and which will require more and more expertise and understanding. A colloquium organised by the Simon Wiesenthal Foundation in Paris on anti-semitism and racism showed the extent of these difficulties and the importance of turning to professionals who are able to draw on their expertise in stopping these processes and reversing them wherever possible. It is extraordinary that it is not more well known that psychotherapeutic resources are well developed to do so.

The same is true in relation to the changes in Europe in political terms, with the new need to integrate East European countries. The shock of the introduction of western standards and habits to the eastern bloc has wrecked havoc with these countries and it has become crucial that some people should address these problems in emotional and relational terms, providing a framework for understanding and careful management of change. Equally politicians, diplomats and military leaders need to be enabled to make changes in their perceptions of what used to be the former enemy, as I have argued elsewhere (van Deurzen-Smith, 1995). Much unnecessary paranoia and animosity can be avoided if people are helped to face up to conflicts and to confront new realities. Psychotherapists need to take a lead in bringing this to the attention of organisations such as the European Commission and the UN. Our services need to be made available not only at the individual level but also at the collective level and we have a long way to go in bridging the gap that still exists between what is available and what is needed.

Conclusion

It is time for us to realise that psychotherapy has many duties to attend to and that we need to begin to see what these are so that we can alert those in power to the psychotherapeutic resources that are available. In last analysis, this means that we have to engage in a public relations exercise to let people know about our profession. This can only be done effectively if we ourselves take notice of our new position in the world and find ways of demonstrating our possible contribution to it through carrying out essential and necessary research. It is time for us to heed our responsibilities and to extend ourselves to those who need us. Cooperation between psychotherapists across Europe is the sine qua non of this project succeeding. The European Association for Psychotherapy is the medium for that cooperation which allows us to underpin our efforts through the protection of an independent and recognised profession across Europe. Extending our networking through the World Council for Psychotherapy is the logical step onwards.

References

ELLIOTT, M. (1995). Personal communication.

FREUD, S. (1919). On the teaching of psychoanalysis in universities S.E. XVII. (Standard ed., Vol. 17).

HOLMES, J. & LINDLEY, R. (1989). The values of psychotherapy. Oxford: Oxford University Press.

VAN DEURZEN-SMITH, E. (1995). Opening NATO to former adversaries: the human dimension. Intemational Minds, 6.

Comments from Michael (initial preparatory comments for a response):

To see the finished response "Collective Mothering and the Medical Model"

To see the longer article on the same theme: "Collective Mothering and the Medical Model"

Emmy van Deurzen-Smith has recently pointed out how counselling and psychotherapy have taken over professionally the kind of tasks and skills which traditionally belonged to the role of mothering.

She hopes that what was once a craft and an art depending on intuition can now - through the process of professionalisation - be turned into an accountable science: the science of effective mothering! I agree with Emmy that we can’t help but be seen and treated as the spearhead of re-matriarchalisation (“But in all this there is a real risk: that the soft end of the spectrum of motherhood might overwhelm society in a counter-productive backlash that could lead to matronisation and unarticulated, uncontrolled emotional matriarchal domination. ... Many people who oppose our profession fear just such a backlash of soft and oozing self-indulgence and psychological pampering and they will keep fighting against the rise of psychotherapy until we can show what our profession can provide that is constructive and essential for a new world”), but that’s precisely why I don’t want to accept ‘mothering’ as a self-definition of my essential task as a therapist. I think therapy has a lot more potential as a discipline when we see it not as representing one polarity in the cosmic battle of the sexes, but - if anything - as facilitators of the war, both externally and internally, helping to embrace the pain of the split

....

But what it did leave me with is a need to clarify my position as a psychotherapist in relation to the medical model. We are confronted with it by our clients (“And how long will it take ?” i.e. to change my character structure against my resistance); and now we are confronted with it by the media. That’s fair enough. But we need to find a position towards it.

The main misunderstanding which runs right across journalists and medical ‘experts’ is that they apply to us the same paradigm which they operate by: the ‘medical model’. And, of course, in terms of the requirements of that model they see us failing left, right and centre. “She was labouring under the common misconception that a counsellor’s job is to counsel [i.e. to advise, direct, recommend ... ].” “There is no coherent theory, and no evidence that it works.” “Full-time counsellors will say they do it because they are interested in people - certainly one rarely feels that they are engaged in a demanding intellectual pursuit.” In the media the field of counselling and psychotherapy is not judged on its own terms. Typically, there is a split between ...

- on the one hand seeing the therapist as all-powerful, omniscient and omnipotent, being able to see through people and exploit their dependency to the point of turning them into clones (e.g. the implication that Susie Orbach used therapy to instill her feminist beliefs in Princess Di and manipulated her into a certain position as demonstrated in the famous Panorama interview), and ...

- on the other hand dismissing the therapist as gullible, plain stupid or lacking in intellectual capacity, woolly, whacky and esoteric and heaping contempt on the whole enterprise as unscientific, unreliable and no better than having a chat with your friend over a pint or a cup of coffee.

It is easy to see in the abstract that what we are talking about here is the shadow side of the medical model, the other side of the benign, benevolent and authoritative father figure which the medical model is built on. This shadow aspect gets projected onto therapy, which means that therapy gets treated as the culturally undervalued mother (you know, the one that does all that yucky feeling stuff). Isn’t the particular quality of this double-whammy accusation (all-powerful manipulative versus stupid, irrational and spineless) reminiscent of everybody’s favourite attack on ‘mother’ - maintaining a dismissive independence against the pull of a deeper attachment and need ?

Last Updated April 5, 2005