Colin Feltham talks to Lysanne Sizoo about her battle to introduce some form of self-regulation for counsellors in Sweden, and the barriers she has faced within and outside the profession
Colin: From what I know, counselling is at different stages of development and has somewhat different identities in different countries. Germany’s beratung, for example, took time to leave its social work connotations behind and get closer to psychotherapy; BACP took over 40 years to get where it is today. Is Sweden’s counselling (or samtals-therapy) similarly subject to temporal growth and public acceptance?
Lysanne: The concept of counselling is what is new and will take time to become ingrained, with its attending standards and regulations, but of course the samtals-therapy sector in Sweden is not new. One or other form of the latter has been around for many years in social work, career guidance, church settings, but mainly in private practice. And more recently, in the past 10 years, those trained by overseas training organisations were quite happy to limit their professional identity to their theoretical modality: ie being a Swedish Gestalt samtals-therapist, or a Swedish psychosynthesis guide.
What is new is the suggestion that we can be stronger and gain more recognition for the profession, as well as make it more reliable and transparent to the general public, if those who hold a certain level of training and make certain professional commitments to supervision and CPD come together under the same professional umbrella title of counsellor, which also happens to be an internationally recognised profession with accompanying standards and regulations.
Finally, the first Swedish book that has the word ‘counselling’ in its title has been written by two social workers who propose that the activity of ‘counselling’ describes the tasks of social workers and specifically kurators in Sweden. Of course this raises again some boundary issues about a social worker/counsellor wearing two hats, and this is something they quite rightly address in their book.
So, on the one hand samtals-therapy has been around for over 20 years but on the other it is disorganised, with a varying degree of professional standards, and unrecognised by the government and state sanctioned psychological professions. And at present there is no demand on any of them, including the regulated professions, to have any kind of supervision after their training, or further CPD, liability insurance, tax registration etc.
Colin: It seems you’ve put an enormous amount into the Register for Accredited Counsellors in Sweden (RACS) yourself. Have you had much support? In a country with a population of only nine million, is there inevitably a proportionately smaller pool of pioneers and counsellors (compared with the UK’s 62 million and with BACP’s well-over 30,000 members, for example)?
Lysanne: Indeed, and it has very much been a labour of love. I have sometimes compared myself to a surrogate mother who was asked and agreed to carry the RACS baby and bring it into the world. The benefit of being a European nomad is that you can take a good idea from one country and share it with another. However, I am not a Swede, and it will take Swedish leadership and vision to bring RACS out into society and take ownership of it. This goes well beyond language and custom, and to the very heart of ownership of a new construct.
My driving force has always been the right of the general public in Sweden to have some clarity in the confusion of titles, methodologies and approaches, as mentioned above. The support and the encouragement have come mainly from the training organisations that qualify for accreditation and my counselling colleagues. However, it is also fair to say that this same surrogate mother is deeply concerned that the very people who, throughout the ‘pregnancy’, continued to express their desire for this baby and now shy away from the hard work of taking care of it.
Colin: If you’re saying that RACS requires 850 hours of taught theory, this is well above BACP’s requirement, and BACP has no specified personal therapy requirement as such. Can you say how these demanding figures were arrived at by RACS, and with what reasoning? (I also wonder how many people can meet the European Certificate of Psychotherapy’s – presumably highly expensive – demand of 3,200 hours of training?).
Lysanne: In the years leading up to the formal constitution of RACS I had several discussions with four training organisations who I knew had a high standard of training and some measure of international vision regarding standards and regulations. These were the Scandinavian Gestalt Institute, the Psychosynthesis Academy in Stockholm, the Psychosynthesis Institute in Gothenburg and the transactional analysts, whose representative Lasse Ahnby had tried some 15 years ago to start a Swedish counselling association.
These training organisations offer around 1,200–1,500 theoretical hours and so fall between the general counselling and the psychotherapy standards of training, using European Association of Counselling (EAC) and European Association of Psychotherapists (EAP) guidelines. While this is not the place to get into the debate about the (perceived) difference between counselling and psychotherapy, it was most definitely part of the discussions. And also, psychotherapy is a protected profession in Sweden, and access to psychotherapy training is limited both through entry level requirements and accepted theoretical modalities. Yet the schools also expressed concern that, if we set standards at 450 hours training (EAC comparable), we would somehow devalue the training that people received. These were important and valuable discussions to have, and I was often reminded of the expression that in the land of the blind, one eye is king.
The options were to continue being nothing in the eyes of the Swedish establishment, to opt to collect under the professional title of ‘counsellor’ through self-regulation and adopt international standards, and maybe undersell ourselves, or to get into trouble for using the word ‘psychotherapist’, which is protected and often unattainable at EAP level. It was therefore decided to go the first route, but set Swedish counselling training standards at the higher level of 850 hours. In the end, the Gestalt Institute decided against opting for RACS as it felt it wanted to uphold the MA in psychotherapy validation that it had attained through a link up with a UK university, despite the fact that students are not allowed to use the title in Sweden.
Colin: What you say about the problems of expatriates, new mothers, and those exposed to and used to adapting to cold, dark, northerly conditions is very interesting. Alongside these factors you have a significantly multicultural and multi-linguistic community. Do you think these call for a kind of training that is less Anglo-American in its theory-dependency and more sensitive to the Swedish context?
Lysanne: No, I don’t think that holds true. In fact, the Swedes are just like any other nation in the respect that they believe they do things the best way possible, because otherwise they would be doing them differently. In fact, from the very start, the desire within the training organisations that were originally set up by overseas training institutes was to focus the training on the needs of the Swedish students and, by extension, Swedish clients. In addition, there are a great number of other training organisations that have been set up by Swedes for Swedes, and their training hours range from anything between 150 hours over a series of weekends to 600 hours as a so-called steg 1 training.
The very reason Turning Point fulfills such an important function is that there is a lack of adequate mental health care for the growing international and multicultural population groups in Sweden. For example, a number of times our clients have first visited a Swedish mental health provider. As with most Swedes, the mental health providers’ dinner table English will have been excellent. However, these clients felt unheard and unseen because these otherwise excellent professionals lacked the language skills for a deep and trusting therapeutic relationship. As I mention in the article, this is supported by research from the US and from Australia. And I am sure there are exceptions to this too.
A common observation from internationals living in Sweden, and perhaps something that creeps into the counselling dynamic with a local therapist, is that once you’ve got your personal number (without which you can’t even borrow a library book), and pay your taxes, from a Swedish point of view it ought to be your desire to become as Swedish as possible, as quickly as possible. I am well aware that this is probably true for most countries that welcome immigrants but, as a global nomad myself, I think most of us will – as Emmy van Deurzen so beautifully describes in Existential Counselling and Psychotherapy in Practice – eventually embrace an identity of non-belonging. A challenging and provocative thought, yet one that leads to an international cohort of people that have outgrown the nationalistic ‘My way or the highway’ thinking, and can meet on a far more level playing field. I see the next generation already far more geared up to this than my own.
Colin: One outsider’s image of Sweden is a country with very high taxes but good equality and excellent welfare; one that is friendlier to immigrants than most countries, and with many ‘deep’ Bergmanesque characters and sexually liberated people and, overall, like other Scandinavian countries, with high levels of happiness among its citizens. Is this a mistaken or anachronistic caricature, or if accurate could it partly account for the sluggish development of counselling?
Lysanne: Continuing in that vein, the Dutch (about whom I dare to speak with impunity since I am one of the tribe) are seen as liberal, drug smoking, prostitute visiting characters, with an ‘get the job done’ attitude. Yet, I was raised in a conservative Calvinistic family, where the Bible was read every night after dinner, and where Sundays were kept for quiet activities. The magic of Holland is that these extremes live very happily alongside each other, and if I were to summarise the Dutch attitude to life, it would be, ‘Be who you are, as long as you don’t harm others in doing so.’
But you asked about the Swedes and foreign stereotypes. Internationals that come here often have exactly the expectations that you describe and, indeed, when you go swimming in Sweden you will only find common (male and female) changing rooms. On my first visit to Sweden with my future husband, we first attended a church wedding in top hat and tails, followed by a midsummer night’s party a week later where the entire party ended up squeezed stark naked into a tiny sauna at the edge of a lake. Where in Holland these opposites often end up living together in relative pragmatic harmony, in Sweden they are, at least to foreigners, more paradoxical.
In my view, Sweden has no better or worse medical, educational or social structures than the rest of Europe, and the high taxes don’t always translate into better services. A now slightly dated study from the EU1 shows that 13 per cent of the Swedish population sought help for psychological problems during 2004. This was similar to the rest of the EU, although I believe it might hide a ‘grey’ number of people seeking help from the unregulated sector.
Size doesn’t matter, but quality does. We will never match the multitudes of accredited counsellors that the BACP represents and our current potential number of accredited members is no higher than about 350. But I would still rather shine a light on 350 well-qualified, serious professionals than leave the Swedish public to sort their way through the hundreds of non-regulated mental health providers that currently characterise a very grey and chaotic sector.
Colin: Your points in your article about the domination of the medical model and Swedes being used to being told what to do are interesting. Just how much of an obstacle to the promotion of samtals-therapy do you think this is?
Lysanne: I think it is the major obstacle. As I said in the article, the idea of self-regulation is really quite alien and if you look at the ‘new’ professions that have managed to get themselves noticed (naprapaths and osteopaths), you see that the driving people behind that were also foreigners who said, ‘Look how well this works in other countries, let’s try it here’.
I believed for a long time that the term ‘counsellor’ could become synonymous with ‘a professionally trained and reliable samtals-therapist’, and that the foreignness would soon wear off in favour of having a title that was ‘fresh from the shelf’ and integrated internationally. However, I now see that even that was a barrier for some colleagues, who continued to want to put their theoretical orientation before their professional identification and so we have considered reverting back to the ingrained Swedish title for now.
Interestingly, the title of coach seems to have no such problems and leapt into the forefront of the public’s imagination very swiftly. Therefore some colleagues, with the training level of a samtals-therapist, prefer to call themselves coaches, as it sounds more robust and clearer than the not-yet established professional title of counsellor.
The situation with RACS now is that the search is on for a strong board to take over from the pioneers and the hope is that the faith of the training organisations and the first colleagues that have sought RACS accreditation will be answered by a strong Swedish response in taking the surrogate baby to their hearts and helping it grow into a strong and healthy Swedish citizen.
Colin: The importance of native language use suggests that ideally future Swedish counsellors will be home-grown Swedish people, and I wonder how attractive or otherwise counselling training will be, and counselling will become, as a career choice among Swedes?
Lysanne: I would say 96 per cent of those that are trained in Sweden at a level that we would call counselling are home-grown. As far as the Swedish colleagues are concerned, samtals-therapy is an entirely Swedish profession and the idea that it ‘fits’ with an international professional identity that we call counselling is, as I said, perhaps a greater barrier than the idea of self-regulation. For so long my well-trained and professional colleagues have been working under the radar, without having to make themselves ‘seen’ in terms of their professionalism and dedication to maintaining standards, and perhaps the effort involved in doing so is what makes some of them remain sceptical.
Colin: I understand that the Swedish government this year ‘demoted’ CBT, following a long-term evaluation of it that turned out very negatively (see www.scottmiller.com on 13 May 2012) and declares the importance of clients having choice. Does this accord with your local knowledge?
Lysanne: Yes, that was quite a turn around, although it didn’t receive half as much press as had been hoped and so the trickle-down effect will take time. Now that so many of the established mental health providers have trained and embraced CBT therapists, it is still widely seen as a natural choice. For there to be true choice, there has to be equal access to both. And from what I see in my practice, the people that come into contact with the Swedish Social Insurance Agency through burnout at work or stress-related conditions are immediately given CBT as a first option. And again, many clients wouldn’t know to ask for anything else either, beginning to equate the very word CBT with ‘therapy’.
Colin: Although your own position is strongly pro-regulation, the UK has seen many practitioners opposed to state regulation and some opposed to all regulation, leading to serious divisions and delays in an agreed way forward. Can Sweden avoid such divisions?
Lysanne: It has been very interesting to follow the developments in the UK and I would say I am pro self-regulation, and remain a little wary of government regulation, especially if, as was the case in the UK, we end up regulated in a way that does not respect the needs of the profession. At the same time, if government regulation had become a fact in the UK, I would have had a stronger case with the regulators of the psychotherapy profession to have my UKCP accreditation converted to a Swedish psychotherapist licence. As it is, transpersonal therapy is not considered an appropriate theoretical approach, and so there would still be that hurdle to cross.
So from day one, the aim with RACS has been self-regulation rather than government regulation. In addition, the intention has been to shine the light on a particular set of well trained, professional samtals-therapists, to create greater clarity both for the general public and for the other, regulated mental health professionals. It is a necessary first step anyway, and it will be entirely up to those who take over to decide to what extent they will lobby the government to, for example, be included on the register for complementary health services, which may, or may not, be voted into law in 2013.
Colin: Thank you very much for an informative dialogue and good luck with developments in Sweden.
1. TNS Opinion. Eurobarometer 63: public opinion in the European Union. Luxembourg: European Commission, 2005. http://ec.europa.eu/public_opinion/archives/eb/eb63/eb63_en.htm [accessed October 2012].