Therapeutic Competence

I  am happy to report that I recently passed the BACP competency test. But because the test has a pass rate of around 93%  my achievement can hardly be called exceptional. Still,  it is noteworthy in that it helps to secure my status as a member of the largest body of counsellors and psychotherapists in the UK.  I have actually been a BACP member ever since I began training as a counsellor and therapist and perhaps like most people who have joined, I see membership as a useful credential in plying my trade.  But I also believe in the BACP's mission to uphold ethical standards for our profession. For counselling and psychotherapy depend on the therapist's ethical commitment to the psychological welfare of clients; any practitioner who violates that trust by exploiting the vulnerability of clients for his own personal gratification should not be practising at all.  But the BACP does more than try to uphold ethical standards for the profession. It also attempts to inculcate methods of good practice for which the competency test serves as a standard.  There are some essential tasks such as record keeping, therapeutic contracts, and above all, client confidentiality, which all  practitioners should understand and manage responsibly and the BACP is right to insist on their importance. But beyond these things, I wonder what constitutes good practice and wonder even more how it can be tested.  I don't doubt the possibility of learning to be a good therapist. Indeed, learning to be a therapist is a necessity, though I believe it can only be learned through experience, not by didactic teaching methods that are more likely to inhibit the intuitiveness and spontaneity which I believe are essential for therapy. But if these essential skills can only be learned and not really taught, how can they be tested?

A good friend of mine who has been a trainer and psychotherapist for years, tells me that my concern is pointless. "Everybody knows you can't test these things, " she agreed. "But the BACP need to have something in place to show their concern about the competence of therapists. Basically, you just need to tell them what they want to hear." Indeed, this is what everyone seems to believe, even, I suspect, the good people of the BACP. But what nobody seems to want to admit is that pre-scripting the therapeutic encounter as the competency test does, actually  blunts the fine edge of discrimination that every therapist should always be striving to hone. The problem begins with the typical  case studies that the test uses. It is not that these case studies are unrealistic; it is that they are all too typical. For in order for therapy to be truly effective the therapist has to see beyond the signs and symptoms of any given condition and find the human subject, the actual person with his/her unique life experiences who is suffering from it.  Although the BACP advice is generally sound, it often has the effect of freezing the therapist's deeper, more intuitive responses that make such a discovery possible. When, for example, a severely depressed person comes in complaining of a feeling of hopelessness, the BACP advises a risk assessment for suicide. People do, of course, contemplate suicide in the depths of severe depression and a responsible therapist will always be alert to that danger. But how exactly should such an assessment be conducted? Direct questioning would work well for some clients, but others would respond better to a less overt approach. Although it might be comforting  to believe that there are right and wrong ways of doing something as important as a risk assessment, the truth is it all depends on the characteristics and needs of the client. 

In fact, the competence of the therapist goes far beyond making an accurate risk assessment of the client, as even the BACP test recognises. But it also goes beyond following a check list of do's and don't's of therapeutic practice, which the test does seem to encourage.  For what psychotherapy involves is a unique form of communication of personal experience that remains bravely open to the mystery of being.  I have quoted R.D. Laing  before about this, but it bears repeating here: "Psychotherapy must be an obstinate attempt by two people to recover the wholeness of being human through the relationship between them." It begins then, with the self experience of both parties, but the primary concern must be for the client.  And as it progresses, therapy develops ever deepening levels of trust which become manifest through the close and sympathetic attention of the therapist. Even so, it is somewhat mysterious how a successful therapeutic relationship develops. I have heard some therapists say that unconditional love is the hidden factor behind all successful therapy, but I don't agree. If anything, it is the highly conditional nature of therapy that gives it a certain potent urgency which helps to bring about positive change in the client. For it is within the limits and conditions of the therapeutic encounter that the client may not only confront painful truths, but also might discover better possibilities for himself. But there is no way of knowing what will happen in advance of the fact.  

Perhaps more than ever, therapy is under pressure to justify itself as an effective form of treatment which is why so much emphasis is placed on the presentation of evidence that will confirm its value. Thus we hear so much about "evidence based therapy" as kind of a guarantee of therapeutic effectiveness. Yet, though research into the effectiveness of therapy is a valid and necessary undertaking,, there can be no guaranteed outcome for any individual case. Still, what research does reveal is that it is the strength of the therapeutic relationship that is the best indicator of successful therapy. But establishing a strong therapeutic relationship is more of an art than a science and depends crucially on the awareness, intuition and communication skills of the therapist.. Focussing on the world experience of the client, a good therapist will be able to establish a bond of trust which makes  a deeper exploration of the client's experience possible. But given the infinite possibilities of individual experience, we must always ask how this can be done.

In my experience, it is listening that counts as the single most important skill that a therapist can possess. Although this might seem to be nothing more than the therapist keeping his mouth shut, listening in therapy is actually much more dynamic than it might appear . This is not to suggest that the therapist should ever be trying to prompt the client's responses by employing a cunning strategy of silence. On the contrary, it means that the client's speech should be met with keen attention that is both open to surprises, as well as alert to inconsistencies. For the client.  knowing that the therapist is listening sympathetically can feel like being held and supported in the loneliness of self consciousness. Still, a client usually needs some indication that he is actually being heard, which means the therapist's responses, both verbal and gestural, must be well timed and skilfully expressed. But this does not mean that it will always  be "appropriate" according to the protocols laid down by some code of therapy. I once attended a workshop conducted by a psychotherapist I regard as a master, in which he shocked some members of the audience by saying that sometimes it is necessary to be extremely blunt with a client in terms will be readily understood. "Quit fucking about, mate, you're wasting my time and yours," he recalled once saying to a client who was avoiding the issue at hand. This was, to be sure, a daring gambit and any therapist who would employ such bluntness carelessly would certainly be erring grievously. But another friend of mine made an excellent point about how to judge the matter. "Within some very fundamental ethical boundaries, it basically comes down to connecting with the client in a way that feels natural to them. And then, anything goes." This requires more than competence; it requires  attentiveness and compassion. And it can only be tested in each therapeutic situation.