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A Regional Training Survey of Psychotherapy and Counselling

Michael Göpfert and Patricia A. Hunt

A) Introduction:

What training initiatives are likely to be available for psychotherapy and counselling? This intriguing question prompted us to carry out a local survey which may be of interest to other psychiatrists, because it may act as a pointer for their own fact-finding initiative.

The training survey was carried out on behalf of the Merseyside Psychotherapy in the surrounding region (Hunt, 1995).

B) Background:

The Merseyside Psychotherapy Institute (MPI) is a registered charity whose objective is to further psychotherapy in Merseyside. Psychotherapy is defined as any valid method of psychological therapy and this is reflected in the membership of the Institute.

C) Method:

The survey involved three sources of information:

1) As much printed material as possible relating to counselling and psychotherapy courses from various local training institutions. A more detailed survey of 69 prospectuses relating to courses of more than one year's duration.

2) A questionnaire survey of diploma courses or above which required their students to practice counselling or therapy under regular supervision as part of the training. 28 such courses were identified. The questionnaires elicited detailed information on course content, supervision arrangements, course orientation and procedures used when students did not meet the required standards.

3) Interviews of course directors to elicit their opinions about the future of psychotherapy training. A semi-structured interview schedule was used containing 8 questions. Enquiries addressed the impact of recent changes in the UK NHS and UK Higher Education on psychotherapy and counselling trainings, the likely impact of National Vocational Qualifications (NVQs) and the kind of work courses equipped students to do.

D) Summary of Findings:

1) Survey of printed materials:

Of the 69 courses lasting a year or more, 50 courses were counselling courses. 26 were certificate courses 21 were diploma courses and 3 were MA courses. As far as it was possible to establish, most of these counselling trainings followed a person-centred or related orientation (e.g. Egan), and only three courses appeared to be accredited by BAC.

The remaining 19 courses included 2 clinical psychology trainings in the nearest cities, Liverpool and Manchester; 3 substantial psychotherapy trainings (of 2-4 years duration) and two one-year foundation courses in psychotherapy. These were predominantly psychodynamic and individual in orientation. Three group therapy courses, at various levels; four courses on marital and family therapy (including the Relate training on couple therapy); and two sex therapy trainings, which were predominantly behavioural in orientation. Cognitive-Behavioural Psychotherapy was sparsely represented but there was a proposal for a new course starting in 1995. The courses concerned with the creative therapies and transactional analysis were at pre-qualifying level.

Brochures and leaflets differed widely in the information provided which was patchy in many instances. The survey report makes detailed recommendations about the standard content of printed course materials which will also be published separately (Hunt, in preparation).

2) Questionnaire survey:

28 questionnaires were sent out to diploma level courses which had clinical practice and supervision as an integral part of the course. There were 25 replies. Two notes said their course was not running, leaving 23 questionnaires to be analysed. Our findings were:

Psychopathology and the effects of medication were not taught on 48% of the courses.
Working with older clients (over 55) was not addressed on 53% of the courses.
Working with patients who have been sexually abused was covered by 82% of the courses, although on some it was limited or an option.
Brief therapy, an increasingly sought after skill required in a variety of settings, was not taught on 44% of the courses.
Counselling in a primary care setting, despite its prevalence, did not feature in 52% of the courses.
The increasing phenomenon of EAP (Employee Assistance Provision) counselling, was not addressed on 83% of courses.

In addition to specific knowledge about the settings, both GP practice counselling and EAP counselling normally require counsellors and therapists to work in a brief and focused way. Working with people with physical or learning disabilities is not routinely covered in trainings; even when there is indication that particular aspects are addressed by a training course it is impossible to make any statement about the depth and quality of that coverage.

Responsibility for and organisation of supervision varied widely. 20 courses claimed that they took some responsibility for supervision. 10 courses indicated supervision was a shared responsibility between the course and the student which basically meant that they offered access to a list of supervisors. Supervision was the responsibility of the student on 2 courses and one course did not require supervision. The cost of supervision was included in the course fees of 14 courses, not in eight and not applicable in one.

3) Interviews:

Three issues emerged about the UK NHS changes:

NHS training funds seem to be drying up.
The place of psychotherapy and counselling within the NHS is not certain possibly leading to less job opportunities.
NHS employees are less able to teach on courses and if they do, it usually has cost implications. Either this results in higher fees which confounds the problem of reduced funding for NHS staff to train in psychotherapy, or the quality of training has to be lowered.

The following issues emerged with regard to the changes in the education system:

Productivity in research is now of overriding importance in order to attract funding to universities. The result is an implicit devaluation of teaching, especially of less scientifically productive issues such as psychotherapy.
Qualifications and standards nationally and regionally show considerable disparity.
Concern was expressed that the pressure to respond to interest in counselling training in some instances might have led to the establishment of 'cowboy departments with scantily designed courses'.
Modularisation overall was seen as helpful though there was concern that the value of the participation in an ongoing training process should not be lost.

Interviewees was positive toward NVQs. There was some hope that they might provide a better standard because of the emphasis on what professionals do, rather than what qualifications they had. The worries about some of the negative effects of modularisation would also apply here but one person thought it would be good for psychotherapy to be challenged by the NVQ process. Accreditation by BAC or UKCP were seen as arduous but possibly positive in that there was agreement that high standards of training were important and a register for accredited psychotherapists or counsellors needed to have genuine meaning.

Some interviewees were concerned that there were many inadequately trained people in the field and that development in counselling had been too fast, lacking depth. Similarly it was acknowledged that the expansion of counselling had not been matched in psychotherapy. Concern was expressed about the increasing potential for competition between professions which could lead to a protracted distribution battle rather than promoting collaboration in the interest of those in need of counselling and therapy. Collaboration was seen as positive and potentially useful within the regions and between institutions with overlapping interests.

Finally, in one interviewee's opinion a significant shift in motivation for training in counselling/therapy had occurred: whereas previously counselling would typically attract a number of women volunteers looking for something stimulating and useful to do, trainee counsellors now tended to come from established careers, e.g. in nursing or teaching which they were trying to get away from ('escapees') because of burnout or dissatisfaction.

E) Discussion:

Surprisingly, actual trainings in psychotherapies (including family therapy) had not, or not much, increased in recent years; there is currently an impression that actual numbers of psychotherapy trainees within the established substantial psychotherapy trainings have decreased; this issue was not addressed in the original survey. However, there was a substantial number of counselling trainings of more recent origin which were in larger part person-centred or similar in orientation. Simultaneously there were increasing difficulties for interested trainees to find funding for training which indicated that some of the recent government-inspired changes may have contributed to this as well as an increasing saturation of the market. If these findings are representative for the whole country they could indicate that we are likely to encounter long-term changes with regard to available therapies: There will be a good supply of counsellors trained usually below the standards required for BAC accreditation whereas there might be an increasingly scarce supply of well qualified therapists. Therefore, in order to avoid a shortage of suitably qualified therapists, and hence also trainers, we will need to attend to this situation now. This is particularly important for the therapeutic training within professions such as psychiatry and clinical psychology, since they require their trainees to acquire skills at an intermediate level within a densely packed professional training; this requires high-calibre trainers, and appropriately designed training facilities. The MPI is currently trying to address this locally.

For other therapists, and professional groups like clinical psychologists and psychiatrists it might also be necessary to acknowledge the massive expansion of person-centred counselling. Psychiatric trainees might need to be more substantially informed about the essentials of person-centred approaches and their implications which are manyfold. There is considerable conflict potential between a person-centred attitude and a more traditional stance of clinicians with regard to diagnosis and treatment. Since person-centred counsellors are increasingly likely to cross paths of other mental health professionals as colleagues, or even as purchasers of services, the capacity for communication is increasingly important in order to facilitate appropriate patient care. Also, there is much that the person-centred approach can contribute to the training of mental health professionals.

Conversely, only a small proportion of counselling and psychotherapy trainings teach psychopathology and address medication, which is worrying. This includes some of the more respectable therapy trainings. Overall the impression is that training in counselling and psychological therapies is more oriented toward a market dominated by the wishes and desires of the student therapists/counsellors and that training curricula do not reflect the health needs of the population at large. Established professional organisations in the fields of psychology, psychiatry and psychological therpies might wish their training standards to include adequate knowledge of health psychology, psychiatric disorders and non-psychological treatment methods. Special attention might be given to the issue of combining psychotropic medication and psychotherapy/counselling since this is a common occurrence in practice.

Only a few courses are specific about what they train their students for in terms of available employment and means of earning a living. A small minority actually taught their students how to set up in private practice whereas a larger but still insufficient percentage included at least some teaching on health and employment issues. This is worrying since many qualified counsellors end up working in primary care or in employee assistance programmes (EAPs), often without being adequately prepared for it. Similarly, only a proportion of trainings included some teaching on how to work briefly which is of concern when purchasers and managers are trying to keep treatment needs to an absolute minimum. Courses are also not clear about the standards and even academic degrees of apparently similar levels were widely differing in standards. In one extreme case the graduates from an MA counselling training at one university do not even meet the entry requirements for an intermediate diploma training in psychotherapy at another, local university. Some differentiation seems unavoidable (see also Shoebridge and McCartney, 1995) but better interfaces between respective training levels might be desirable for trainees.

The re-emergence of a conflict of interest between good psychotherapy training and research in academic settings reinforces the risk of deepening the split between high-quality therapy training and academia which has plagued the psychotherapies for so long. This would either lead to a powerful reinforcement of psychotherapy training being undertaken as a mission in the fulfilment of strong beliefs rather than because there are patients who need psychotherapy. Or it would lead to a deterioration of standards as already discussed. Neither is a desirable outcome. It might just be possible that collectively the body of psychotherapy research has accumulated enough of a critical mass to enable the introduction of elements of evidence-based learning which would help to bridge the gap.

Unfortunately, this opens up another structural problem of research and knowledge development in the psychological field. As long as psychotherapies cannot be patented and owned by commercial companies, they will always lose out in the competition with technological and biochemical interventions and with the research funds which will be available. Yet good psychotherapy research is costly and expensive. Research should - as a question of policy - address the comparison of drug therapy with and the combined efficacy with psychological therapies without falling into the trap of treating psychotherapy as the equivalent of just another drug. This would go some way toward balancing spheres of influence in a clinically appropriate way within a market-oriented system.

References

Hunt, P.A. (1995) Regional Training Audit: A Survey of Counselling, Psychotherapy, and Related Trainings within
Merseyside and Adjacent Regions. Merseyside Psychotherapy Institute, Liverpool.

Shoebridge, P. J. & McCartney, M. (1995) Masters courses in psychiatry. Psychiatric Bulletin, 19, 555-558.

Acknowledgements:

We wish to thank all the participants in the survey for the generously donated time and help. We also gratefully
acknowledge the financial support of the Specialist Mersey Regional Training Committee, and the support of
the Postgraduate Dean, Dr. T. Bayley. Jackie Richards assisted with the collection of materials. Bill Barnes and
Julia Nelki provided helpful comments.
The full report can be obtained from: The Administrator, Merseyside Psychotherapy Institute, c/o 26 Barchester Drive,
Liverpool L17 5BZ. Please enclose a cheque of £ 7.80 to cover the costs of printing, binding and p&p.

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