For some people that might not mean a great deal, for others, it might carry a certain level of prestige. But for others still, it’s something I should probably be embarrassed about.
There’s no doubt that some people passionately believe psychotherapy helps them. At the same time, reading the comments sections of any number of Mad in America articles, there’s also no doubt that many have been harmed. Many of those people believing that the whole profession should be abandoned, that people like me should have a good look at ourselves and go and do something else.
Add to that what James Davies has argued in his work, Cracked and Sedated: that despite the proliferation of services, the overall picture is far more mixed than often assumed, with little clear evidence of sustained improvement and some indications of worsening outcomes.
So, what I want to do here is not necessarily defend psychotherapy, but to think about the lens, or the ‘conceptual framework’, through which psychotherapy operates, and consider how psychotherapy as a field, or what are now commonly called ‘mental health services’, have come to understand human distress.
I want to consider how the very phrase ‘mental health’ says something about this lens, and the suggestion that our emotional life is organised along a continuum of health and illness, much like physical disease. And that what follows from there are words like patient, symptom, diagnosis, treatment that have become part of our established cultural language and have shaped the very nature of our emotional discourse.
For psychotherapy, this has had implications not only for the people psychotherapy is ostensibly here to help, but also for research, for how professionals see themselves, and for how, more broadly, we come to understand ourselves and our emotional lives.
I write this as someone working within psychotherapy, aware that I am not outside the very framework I am describing.
So, with that in mind, I want to ask one question.
What if the problem isn’t only the practices of the field of psychotherapy, but the lens through which it sees and operates?
When Words Carry Different Worlds
When it comes to many of the words involved in psychotherapy; therapist, patient, treatment, and so on, they seem so familiar they are almost taken to be neutral, as if they simply ‘are what they are’.
But, on reflection, it seems clear that these words are anything but neutral. In fact, they’re loaded. They carry with them any number of reference relationships and assumptions. Think of the word ‘patient’ for a moment. What comes to mind? Illness, hospital, doctor, disease, cure? Now keep thinking about that word, really ‘go there’. What comes to mind now? Ward, IV drips, suffering, healing, hope, fear, helplessness, death? It’s hardly neutral, is it?
However, this is how conceptual frameworks work, and this is what happens when the language of that framework, in this case medicalised language, becomes established. These terms can come to feel so straightforward as to be a given, not a matter for reflection or questioning at all.
In this sense, what also feel like a given, is that a psychotherapist is a clinician. And what a clinician does is treat a patient who is suffering.
In terms of the established parlance, it follows. It makes sense. How would it be otherwise?
The role of the clinician is to identify the problem and to intervene with the appropriate technical expertise to bring about positive change. If you look to define what a therapist does, this is it. If you look to define what a therapist is, it’s in the ‘what they do’.
But historically, the word therapy carries a rather different meaning, and in that sense offers up a different lens. The word therapy is often traced to the Greek therapeia, understood as ‘to stand beside’ or ‘to attend’, where the role of the psychotherapist is not primarily to fix or correct, but to stay with ‘a fellow traveller’s’ experience and to attend to it. It is a matter of being-with rather than doing-to.
Through one lens, psychotherapy is understood to be an intervention designed to treat a psychological condition. In another, it is seen as a practice in which another person’s experience is attended to and gradually understood within the context of that person’s life.
Two different lenses, exactly the same phenomena.
When the Framework Shapes the Interpretation
Conceptual frameworks are strange in the sense that they are not something we choose. We do not select a framework to fit the job. What they tend to do is reveal themselves in what feels like the almost invisible assumptions of everyday life.
In terms of psychotherapy, this framework is revealed in everyday practice; in the way behaviour is thought about and interpreted, and in what explanations about that behaviour then tend to follow.
A really good example is the now very familiar language of resistance or non-compliance in psychotherapy. We can see that within a treatment conceptual framework these terms appear entirely logical. If therapy is understood as an intervention designed to address a condition, then resistance or reluctance to engage can easily be interpreted as non-compliance.
But, at the same time, if the encounter is understood relationally, the same situation can appear very different.
A person who hesitates might not be resisting ‘treatment’ at all. They may be cautious about trusting another human being. They may feel misunderstood. They may feel damaged by a cruel and unforgiving world and be wary of someone they do not yet know. Or they might simply feel no real sense of connection, no sense of chemistry with the person sitting opposite them.
In everyday human relationships, this is something we recognise easily. When two people fail to connect, what we tend to say is that the chemistry is just not there. What we do not do is suggest that one of them has a problem with compliance.
Again, the same behaviour carries very different meanings depending upon the lens through which it is viewed. Within a treatment conceptual framework, reluctance becomes resistance or non-compliance, with the issue largely located within the person sitting opposite. Within a relational framework, the same phenomenon says something about the encounter itself.
The nature of the phenomenon has not changed. Only the way of interpreting it has.
Before Moving On
It might be tempting at this stage to assume that this distinction maps neatly onto different schools of therapy, that some approaches operate within a treatment framework while others reject it. But the reality is far less clear-cut. Opposing schools of psychotherapy debate their differences, often passionately so, and yet continue to speak the same language of patient, treatment, and intervention, even where the intent is described in more humanistic or relational terms.
The treatment framework, it seems, holds, despite the differences.
When the Evidence Points in a Different Direction
However, if psychotherapy were best understood as a form of treatment, then we might expect the research literature to align with that. We would expect clear differences between therapeutic models, that different problems would require different specific techniques, and that those techniques would produce better outcomes than those not specifically fitted to the particular condition, much like in medicine, much like with physical disease.
What we know, however, is that the psychotherapy outcome literature is more complicated than that. Across decades of research, several patterns repeatedly emerge. Outcomes vary significantly between therapists. Some therapists appear to be consistently more effective than others . The quality of the relationship between two people consistently predicts how things tend to unfold, and the differences between therapeutic models are consistently so small that the phenomenon has been termed the ‘dodo bird effect’.
Within the current framework, much of the evidence base for psychotherapeutic approaches is organised around what are called protocolised approaches for conditions such as ‘post-traumatic stress disorder’, ‘anxiety disorders’, ‘major depressive disorder’, and so forth. The evidence for these structured interventions is based on randomised controlled trials that are used to determine that these interventions produce positive effects for these specifically defined conditions.
This way of thinking about ‘evidence-based practice’ is another way in which the assumptions of a treatment framework are revealed, in the sense that positive change is understood to follow from the correct application of these specific protocolised techniques. Within this framework, it is therefore entirely natural that research focuses on the technical aspects of the intervention, measurable change, and the importance of staying true to the protocol.
But at the same time, these methods tell us very little about what unfolds between two people in a room, even when what we now know from those same decades of research, is that what happens between two people in a room is absolutely central to the broader psychotherapy evidence base.
That is not to say that structured or protocolised approaches never help people. They can, and they do. Many people will attest, from both sides of the room, that lives have been transformed via these approaches. However, what is being argued is that the broader findings of psychotherapy research remain difficult to reconcile with a purely technical understanding of how change occurs.
Which then raises the question, if change is primarily understood in terms of protocol fidelity and the correct application of specific techniques, why does the relationship matter so much? And why do differences between therapists remain so clearly pronounced?
Seen through a relational lens, however, the existing evidence becomes easier to understand.
Through a relational framework, the relationship moves from a vehicle for protocols to the centre, while techniques take a secondary place.
In practice, clinicians often find themselves balancing what is described as therapist drift. Practitioners frequently move away from strict manualised adherence so that they can respond more flexibly, more authentically, to the person and to the emotional encounter itself. Within a treatment framework, this can be seen as a tension between protocol fidelity and responsiveness. Seen relationally, no such tension exists.
Projects such as Loren Mosher’s Soteria House emphasise interpersonal presence and relational understanding, with a compassionate but medically untrained staff and very minimal pharmaceutical intervention. Their outcomes were striking at the time and remain difficult to explain within a strictly medicalised framework.
Seen through a relational lens, the pieces begin to fall into place.
When the Lens Changes
In the history of science, progress does not always occur simply by the collection of more data. Sometimes it occurs when the frameworks through which that data is interpreted begin to feel incomplete.
These are the findings of the philosopher of science, Thomas S. Kuhn. Kuhn describes these frameworks as paradigms, frameworks that organise both knowledge and understanding by shaping what counts as evidence and what questions are asked, and in so doing what aspects of a phenomenon are made visible and what remain obscured.
Kuhn also recognised that for long periods, a field may operate unmoved within a particular paradigm, but that occasionally, over time, findings begin to appear that do not sit easily within the existing framework. And, that when those tensions grow large enough, progress sometimes occurs not through the accumulation of new data, but through a shift in the conceptual lens itself.
When Language Narrows Experience
Culturally, the treatment paradigm and the language of ‘mental health’ have moved well beyond professional services and are now so embedded that they have become an integral yet rarely questioned part of how we understand ourselves and each other.
Depression has become a condition, anxiety has become something someone has, trauma has become a disorder, and mental illness and mental health are understood as a continuum along which we are all assumed to sit.
Emotional experiences that would test the breadth and depth of our shared language are now increasingly translated into diagnostic or disease-model terms.
That is not to say that such shorthand is always experienced as a bad thing. Diagnostic language can sometimes provide a felt sense of recognition or validation. It can also serve to underpin or substantiate a sense of identity.
However, for many people, this same language is experienced not as something that describes emotional life, but as something imposed upon it. Some have described lived experience as being taken, even ripped, out of the context of a life within which it finds its meaning, and recontextualised in medical terms, often with far reaching consequences.
Listening to the Critics
The fact that survivor and service user movements exist says something about how these encounters can feel from the other side of the consulting room.
Accounts of being pathologised for human responses to the travails of life are not new. Many describe being pushed towards interpretations of their experience, or having interpretations imposed upon them that did not align with their lives. Others describe these encounters as re-traumatising, or as experiences that have been so damaging that they have led them to lose trust in helping relationships altogether. It is also nothing new that the harm people describe is often explained away.
It is true that many people describe encounters in psychotherapy that have been deeply valuable and are passionate in the view that therapy has been transformative, even lifesaving.
But this does not resolve the tension.
The question is not whether psychotherapy can or does help, but how these experiences are understood, and how easily accounts of harm can be explained away within a particular framework.
Reluctance or disagreement can be interpreted as resistance, non-compliance, or lack of insight, with the issue largely seen as located within the person.
Within a relational understanding, the same situation may look very different.
Seen in this way, some of the tensions described by survivors may not simply arise from individual failures in practice, but from a deeper mismatch between a relational human encounter and a conceptual framework designed for ‘a patient in treatment’.
A Different Stance
Seen through a different conceptual lens, the role of the psychotherapist begins to look rather different from the one implied by medical language.
What if the task of the therapist is not primarily to correct, to intervene, or to resolve, but instead to attend to another person’s experience and to understand that experience within the world in which it takes shape?
What if distress is first and foremost understood as part of the complexity of human life?
The task that follows is not primarily to fix, but to listen carefully enough that another person’s experience can appear in its own way, on its own terms, and be understood within the life to which it belongs. This does not mean there is no room for techniques or technical approaches. It means they are moved from the centre to the periphery; offered as invitations rather than assumed.
This does not mean that change does not occur. The difference lies in how that change is understood. Within a treatment framework, psychotherapy sees itself as the instigator of change, where value is determined by the ‘positive change’ it brings about.
Within a relational framework, psychotherapy becomes a space in which the issues of a person’s life can be clarified, where perspectives can be explored, and where a person may come to accept, reassess, or act upon the possibilities for change that gradually come into view.
Many therapists would passionately attest that the relational is the most important aspect of their work. However, this reveals an uneasy tension. Training pathways, our professional identities, and models of practice remain organised primarily around techniques and adherence, often strict adherence, to specific approaches.
This tension is also visible in how people describe what mattered to them in their therapy experience. What people rarely speak about are the technical aspects, the techniques, or even the cleverness of the therapist. What they do speak about, overwhelmingly so, is being understood, or feeling met, or being in the presence of someone responsive, someone human, someone that was genuinely interested, someone that was able to be with them in their pain and distress in an open and accepting way.
These are not technical qualities. They are relational ones.
Conceptual frameworks rarely shift easily. Paradigms do much of their work invisibly, and once established, their assumptions can become so familiar that they operate largely unchecked and unexamined. Even the most relational practitioner will find themselves speaking the language of treatment, patients, and intervention, simply because that language has become so ingrained.
And yet, the evidence discussed here invites a different possibility. What follows is not the abandonment of psychotherapy, but a reconsideration of what it is understood to be: less as the application of treatments to psychological conditions, and more as a relational encounter in which human experience is attended to and gradually understood.
Seen in this light, a shift in paradigm brings our understanding of emotional distress closer to both the phenomena itself and the evidence that surrounds it.
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Mad in the UK hosts blogs by a diverse group of writers. The opinions expressed are the writers’ own.
