29 JULY 1972, Page 31


What is psychotherapy?

Jef Smith

"Psychotherapy? Down there on the right," said the man at the door. It isn't of course quite as simple as that and my destination was merely a meeting covened to explore the place of psychotherapy within social work. It is nver easy to sum up a range of fairly unrelated contributions to such a gathering especially one chaired like this with the permissiveness of a true therapist. But there are some undesirable generalisation that can be made about the selection of social workers who turned out to discuss their links with or allegiances to psychotherapy. For a start nine tenths were female, a much higher proportion than for social work practitioners as a whole. Very nearly as significant, when it was proposed that a follow-up group should meet during the annual conference of the British Association of Social Workers in October only two or three were planning to be there; an interest in psychotherapy one concludes corelates negatively with involvement in social work politics.

The preoccupying question, however, concerns the future of psychotherapy as practised by those not medically qualified. Many social workers reasonably claim to have more training in the handling of inter-personal relationships than most doctors, and though medical education is broadening to include a stronger emphasis on behaviour sciences, it is still possible to qualify as a psychiatrist with only the sketchiest of of introductions to dynamic psychology. While the terminology used remains basically that of medicine it will be difficult to divorce the practise of psychotherapy from the concepts of health, sickness and cure, though the medical model is clearly quite inappropriate for describing many of the fields to which psychoanalytic theory is applied.

Current tren-ds within the health service are likely to lessen still further the possibility that many patients will receive psychotherapy in the light of the speed, convenience and superficial effectiveness of physical treatments. The closure of psychiatric hospitals and the transfer of work to district general hospitals, it is argued, will strengthen the links with physical medicine, will increasingly incorporate into psychiatry the concept of a quick bed turn-over, and will halt progress towards a deeper understanding of the therapeutic elements present in the very ' sick ' and need 'treatment' is a daudable environment and regime of a hospital. To stress that the mentally disturbed are attempt to kill the stigma of psychiatric disorder, but in terms of understanding What is happening to patients under personal stress and what can be done to help them it could be very much less than helpful. Given this situation it can be argued that most mentally disturbed people stand a better chance of getting a personal inter pretative discussion of their problems from a social worker than from a psychiatrist in a mental hospital or a general practitioner, (the former will probably, the latter almost certainly, prescribe drugs).

One other constraint inhibits the wholehearted development of psychotherapeutic techniques by social workers — the simple pressure of work under which most social services departments operate. Here the psychotherapy lobby has itself to blame for stressing too often that a full psychoanalysis, which can require as much as a daily hour of treatment for five years, is the ideal. Such prolonged work is out of the question for all except a tiny minority of patients who must necessarily be highly motivated, very articulate, and as things stand at present rather rich. The emphasis on length of contact, however, is misleading. Recent American research has demonstrated that some clients are helped by brief rather than extended casework and it is widely recognised that emergency help to a client at a point of acute crisis may well be better received than a prolonged relationship through a fairly unstressful period. The logic of this thinking has not been widely followed through into practise in this country. Social workers still feel guilty about seeing a client only once with the result that a first office interview frequently tails off tamely with a pointless offer of a home visit, and emergency work continues to be spoken of as merely an unfortunate bye-product of the present highly pressured situation. There is too a widespread yearning for a situation in which it would be possible to do long term casework or be involved with situations at a much earlier stage, but this is far from how the client sees the service. There is real evidence that people seek professional help from psychiatrists and social workers only when the stress has become intollerable and when they have exhausted all other channels. Having gained immediate relief very few wish to preserve the contact through a long period of therapy.

Of what then does psychotherapy consist? Definitions vary from the very conservative who argue that those who have had an analysis themselves should be allowed to practise, though a moderate view insisting on proper qualified cover for lay or training practitioners, to the very liberal position that identifies psychotherapy as an element in the work of a whole range of professionals not least social workers. The debate is full of painful hair-splitting. Where does casework end and counselling begin? Can the use of psychotherapeutic skills fall short of actual psychotherapy? Is there such a thing as supportive psychotherapy, or is the term to be reserved for deeper interpretative work? Between the different school of analytic thought tension is sometimts as acute, and as seemingly pointless to an outsider, as theological debate.

The implications of this situation go far beyond the social services. Sir Keith Joseph has recently written to a number of organisations including BASW asking for their views on defining the limits of what may properly be called and practised as psychotherapy. His concern springs from Sir John Foster's report on scientology which recommended a statutory system of registration for practitioners; the idea sounds attractive but would be impossible to administer while the boundaries of what was being registered are so uncertain. A list of psychotherapists could exclude only those who sought to use the term, but there are of course plenty of alternative descriptions, such as counselling, casework, personal advice and any number of permutations on therapy — group, encounter, individual, dynamic, analytic, and so on.