Therapy: The great cultural divide

I’ve always known that pursuing a career in a therapeutic profession posed unique challenges. At slow times I might explain away the lull in enquiries by putting it down to cultural attitudes: “Therapy and coaching are viewed differently in Britain; it’s much more common and accepted to seek help in the US“. Not an entirely untrue statement, if rather defeatist and limiting (I try to catch my own limiting beliefs where I can).

But I don’t think that’s all there is to it. It’s not merely a stiff-upper-lip attitude and access to mental health services at no extra cost through the NHS; Britain and America mean different things when we talk about ‘therapy’ and ‘coaching’, and I think it’s vital to understand what that cultural difference means in real terms.

While there may be a reluctance to ask for help, and a resistance to paying privately for something that is (ideally) accessible for free, the fact is that what people see therapy portrayed as in film and TV from the US is not what they get if they seek a therapist in the UK. This can present a problem when it comes to expectations vs reality.

Of course, no fictional representation of therapy is going to be 100% accurate – things are altered or exaggerated for dramatic or comedic effect. We do need to open our eyes to the huge differences in approach, and how it affects perception and demand.

I recently read this article; while admittedly not the most current take (it’s from 2012), some of the points in it expose the gulf in practices between what the UK and US both call ‘psychotherapy’:

Many patients need an aggressive therapist who prods them to face what they find uncomfortable: change. They need a therapist’s opinion, advice and structured action plans.

This is reiterated and broadened on later:

In graduate school, my classmates and I were taught to serve as guides, whose job it is to help patients reach their own conclusions. This may work, but it can take a long time. I don’t think patients want to take years to feel better. They want to do it in weeks or months.

Despite the litigious culture in the US (far more so than in the UK), there is a willingness – even an expectation – for therapists to play a more active, advice-giving role. Perhaps the prevalence of therapists building thriving careers out of their work is less to do with cultural attitudes and more to do with perceived value for money; clients feel they are getting something more than just time and a listening ear.

With that said, I don’t devalue what counsellors and psychotherapists do here in Britain. I have both seen and experienced firsthand the difference that a non-directive, actively listening counsellor can make in peoples’ lives. There are arguably pros and cons to more and less directive forms of therapy.

The trouble is that there isn’t generally room for that here. In contrast to the article above, the BACP – the largest governing body of counselling and psychotherapy in the UK – clarifies thatCounselling is not about giving advice or opinions, nor is it a friendly chat with a friend. The therapist helps the client to understand themselves better and find their own solutions to resolve or cope with their situation“.

Bit of a big difference there. The efforts that have been made over the past few decades to standardise counselling and psychotherapy have undoubtedly achieved some great things. I maintain that the requirement to have regular supervision was one of the best outcomes of the process – I’d never want to practice without that monthly resource, and I don’t envy therapists overseas who don’t necessarily have that in place. The question, however, is whether the increasing standardisation of therapy in the UK – ostensibly to bring it in line with the medical professions it frequently works within and alongside – actually pulls it further away from what clients want, expect, or find approachable.

Long-term therapy is much more common in the US. It’s frequently used as a prevention, rather than a cure; a space to share your thoughts with a trusted, friendly face, get another person’s take on what’s going on for you, and challenge you to keep growing and looking after yourself. Sessions may be less frequent, acting as more of a ‘check-in’ than intensive work. Here in the UK, if you’re seeing a therapist long-term it is generally because there are lots of complex things to work through that short-term counselling hasn’t been able to untangle. The idea of seeing a counsellor just because it’s probably a good idea to talk about your life and mental health on a regular basis seems ludicrous to many people.

Just talking to others and getting their views, the cultural difference seems to boil down to this: in America, counselors – to respect the US spelling 😉 – are seen as mentors and advocates, with the capacity to work with mental health issues as part of a broader nurturing relationship that may include advice-giving. In the UK, counsellors are perceived as medical practitioners; an expert in emotional issues, who you may see if you reach breaking-point and can no longer cope. Many people don’t know the difference between a psychotherapist and a psychiatrist, despite psychiatry requiring a medical doctorate and having an entirely different perspective and approach to mental health. Perhaps, amidst all the preconceptions and misconceptions, it’s unsurprising that so many clients are somewhat perplexed when they are told that they will not be given advice as part of the process.

The therapeutic profession is still very much in flux; requirements and expectations are ever more stringent, while many definitions remain debatable and ambiguous. Ultimately, though, anyone who considers themselves a talking therapist of any kind has to ask themselves a few probing questions: How do I want to be perceived? How am I perceived? What do I want to give to my clients – and what do they want and need me to give?

One further question, for good measure: why is it that in a country where counsellors are less likely to face lawsuits for professional services they refuse to give advice, while in a culture that carries an incredibly high risk of litigation over the slightest professional mis-step therapists seemingly have a greater willingness to be more directive?

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