From the Meaning of Madness to the Madness of Meaning:
A History of Ideas in Counselling and Psychotherapy
Last updated 3 November 2026
Introduction to the Second Edition
A paper I published on this site in 2004, From the Meaning of Madness to the Madness of Meaning: A History of Ideas in Counselling and Psychotherapy, is still being linked to more than twenty years later. So rather than simply put the old paper back up, I have corrected a few errors, tightened the references and added the main developments since 2004, both in the professions it describes and in the research that informs them. Otherwise, this second edition is essentially the paper I wrote then.
If I were writing it today, I would go much further with its “madness of meaning” theme. The paper argues that theory in counselling and psychotherapy is incoherent, and that which theory a therapist follows makes little difference to outcomes. I would now add that our commitment to the scientific method, or at least to the positivist version of it that the therapies adopted, is what keeps this “epistemological anarchy” (Laungani, 1999) from being resolved. That would be a much bigger project. If you’d like a sense of where it leads, follow my new project, Belief is the Battlefield.
The full second edition runs to well over 10,000 words, and you’ll find it as a PDF at the end of this article. What follows here is a selection of highlights.
At the heart of all theories of counselling and psychotherapy is the belief that a conversation between the client and the therapist may in some way relieve the client’s subjective distress. Different therapeutic movements have tried to account for the therapeutic character of conversation, and have developed theories to help structure the complex social situation of therapist-client talk. The three main approaches to therapy, psychodynamic, cognitive-behavioural, and humanistic, all developed at different times and within different social and organisational contexts throughout the twentieth century. My aim in this paper is to follow the history of the main ideas in therapy, and to link these with the development of the social arrangements for therapeutic practice, training and accreditation.
Freud, Psychoanalysis and the Profession of Psychotherapy
With the intellectual revolution of the Enlightenment, demon possession as the cause of mental health problems was being replaced by more ‘rational’ and ‘scientific’ thinking. One of the first people to try to use scientific thinking to help people with mental difficulties was Franz Anton Mesmer (1734-1815). Mesmer was impressed by the discovery of electricity and hypothesised that illness was due to a problem with the patient’s ‘animal magnetism’.
… By the time ‘animal magnetism’ had reached Freud via Charcot, the techniques had undergone a century of intellectual refinement and had become (almost) respectable (Stone, 1998). …
It seems then that the ‘art’ of psychoanalysis owes much to the intellectual climate in which Freud worked. Freud, like Mesmer before him, had tried to wrestle with the ‘demon’ of madness, and bring it firmly under rational scrutiny (and control). …
Despite this analysis of Freud’s methods, he had great aspirations for the theory his methods were to generate.
“Neither speculative philosophy, nor descriptive psychology, nor what is called experimental psychology … are in a position to tell you anything serviceable of the relation between body and mind or to provide you with the key to understanding of possible disturbances of the mental functions. … This is the gap which psychoanalysis seeks to fill.”
(Freud, 1917, p. 45)
“Nothing takes place in a psychoanalytic treatment but the interchange of words between the patient and the analyst.”
(Freud, 1917, p. 41)
At one and the same time Freud wants us to believe that he has solved the Cartesian problem of ‘the duality of mind and body’, and that he has done so simply by having a conversation with his patients. It is true that, by working within Cartesian duality, Freud has made the most compelling and exhaustive attempt at ‘filling the gap’. … Psychoanalysis is, if anything, a theory of mind.
… Perhaps Freud’s greatest contribution was the idea that patients’ despair, anxieties, obsessions, headaches, and ‘irrational’ fears, thoughts and dreams had a ‘sense’, and could be seen, after analysis, to be ‘sensible’ adjustments to the patients’ world. …
Although the ‘political’ implications of not wanting to be seen to be placing the First World War veterans under the care of psychiatrists led to a boost in the fortunes of psychoanalysis within the British health care system, the main impetus for the spread of psychoanalytic thought world-wide can be attributed to the rise to power in the 1930s of the National Socialist Party in Germany, and the anti-Semitism of Adolf Hitler. … Freud, as a Jew, and Freudian ideas themselves, became under increasing threat from the National Socialist state machinery, with the result that many of the leading thinkers in psychoanalytic thought fled from its persecution, mainly to New York or London (Pilgrim, 1990).
The Move to Registration
With the post war adoption of psychoanalysis into medicine, there appeared a much more settled institutional base for psychoanalytic treatment. There was an almost exponential growth in training institutes for psychotherapists. … Indeed, it took a branch of psychotherapy known as ‘Dianetics’, and its location within the ‘cult’ of Scientology, that finally galvanised the ‘respectable’ psychotherapy institutes into action (Pilgrim, 1990). There was much public concern about Scientology and its ‘brain washing’ techniques during the 1970s (e.g. see Foster, 1971), yet the ‘Rugby’ conference of psychotherapy training institutes did not first meet until 1982, over ten years later, to work towards self-regulation. … The Rugby Conference eventually became the United Kingdom Council for Psychotherapy (UKCP), and became the main validating body for psychotherapists in the UK. …
Behaviourism, Cognitivism and the Profession of Psychology
The development of psychoanalysis can be clearly traced to the work of one man. Although the behavioural and cognitive approaches to therapy developed in direct opposition to psychoanalytic thought, and particularly its conceptualisation of ‘unconscious’ mental processes, no one single person could be said to have been influential above all others. … What such approaches have in common is that they attempt to change problem behaviours, feelings and thoughts directly, without recourse to the notion of the unconscious.
The Emergence of Clinical Psychology
… With the development of behavioural models of neurosis, psychologists were now in a position to challenge the orthodoxies of psychodynamic psychotherapy on the one hand, and traditional nosological psychiatry on the other (Pilgrim, 1990). One man was in the forefront of this challenge, Hans Eysenck. One aspect of Eysenck’s strategy for the development of a ‘clinical psychology’ was to challenge directly the other major psychological model operating within the health service, psychoanalysis (Eysenck, 1952).
As Pilgrim (1990) argues, “[T]he denigration of psychoanalysis and its psychotherapeutic derivatives went hand-in-glove with clinical psychology differentiating itself from medicine and marking out an area of separate epistemological validity” (p. 7). …
The Modern Applied Psychologist
The organisation of psychology as a professional activity started in 1901 with the formation of the British Psychological Society (BPS). …
The social legitimacy of the BPS gained a huge boost in 1965 when it was granted its Royal Charter. … The Royal Charter reflects (if anything) the aspirations, determination and connections of its protagonists to legitimise their activities within the British establishment. Indeed, it also reflects a willingness of the British establishment to facilitate this, something it clearly lacked with respect to the development of the psychotherapy profession. …
… Modern clinical psychology can be considered nothing other than eclectic. In any event, in 1977 The Trethowan Report (DHSS, 1977), a report into the role of clinical psychology within the NHS, had recommended structural autonomy of clinical psychology from medicine. The need of the 1950s for sharp epistemological boundaries between medicine and clinical psychology was now redundant. …
Humanism, Carl Rogers and the Profession of Counselling
Carl Rogers (1902-87) is perhaps the most radical and influential theorist since Freud himself. …
… Rogers’ career also had a broader social impact. In particular Rogers was often at loggerheads with the psychiatric profession as to whether he should be allowed (as a psychologist) to practise psychotherapy at all. On one occasion, a psychiatrist at the University of Chicago tried to have the centre Rogers was working at shut down because it was practising psychotherapy, and therefore medicine.
Furthermore
“The word ‘counselling’ was originally used by Rogers as another cheeky strategy to silence psychiatrists who were objecting to psychologists practising psychotherapy. By simply changing the name of the activity he enabled practitioners to continue their work without any change in their situation and without any detriment to their clients.”
(Thorne, 1992, p. 60)
Rogers on the Core Conditions
Rogers (1990) wrote, “I have long held that it is not the technical skill or training of the therapist that determines his success . . . [but] I believe it is the presence of certain attitudes in the therapist, which are communicated to, and perceived by, his client, that effect success in psychotherapy” (p. 10). …
Rogers repeatedly stated his belief that these three core conditions, empathy, unconditional positive regard and congruence, were both necessary and sufficient conditions for therapeutic personality change. The most fundamental observation of these conditions is that they focus upon the quality of the relationship between therapist and client. In other words, it is the relationship itself which is seen as therapeutic, rather than any techniques or interventions per se.
The Significance of Professional Knowledge
“That the symptom has meaning, if it is neurotic, is Freud’s basic discovery, the basic insight which opened up the way to an understanding of functional illness and the principles of psychoanalytic treatment. … In discovering that the symptom has meaning and basing treatment on this hypothesis, Freud took psychoanalytic study of neurosis out of the world of science into the world of the humanities, because a meaning is not the product of causes but the creation of a subject.”
(Home, 1966, p. 42)
By the end of the 19th century, the science and practice of medicine had come to monopolise the understanding and treatment of madness. … Since pathological biological processes cannot be said to be ‘meaningful’ (other than in biological terms), medicine rescued the insane from the moral responsibility for their own condition implied by religion. …
As I documented earlier, the 20th century witnessed a further revolution in the understanding of madness. … It is ironic that by the time Freud (1917) was able to put forward his first comprehensive account of the meaning of symptoms, psychoanalysis had already become a deeply fragmented discipline. Freud split with two hitherto close collaborators, Alfred Adler (1870-1937) in 1911 and Carl Gustav Jung (1875-1961) in 1913. The splits were to be irreconcilable.
The Meaningful Symptom
What is perhaps of most interest about the split with Adler and Jung is that what was at issue was the meaning of symptoms themselves. … The fundamental principle of Freud’s talking therapy, that the symptom had meaning, was not challenged by either man. What was challenged was that the meaning of symptoms was to be found only in childhood sexual development. The transition of psychoanalysis into social science was most evident by these moves. Moreover the rest of the history of counselling theory can be seen as a continuation of just this debate: what do symptoms mean? For no other reason this puts Freud at the apex of modern therapeutic thought.
As I showed earlier, as psychoanalysis itself continued to fragment after Freud’s death, the meaning of symptoms was also strongly challenged from another source: academic psychology and the reactionary epistemologies of behaviourism, cognitivism and humanism. What the psychoanalysts and psychologists all sought was the elusive: to explain and account for patients’ suffering in psychological terms. Freud’s basic insight, that symptoms had meaning, was the fundamental orienting ideology that drove all the new theoretical movements. The paradox of therapy theory building since Adler’s and Jung’s splits with Freud is that, given therapy is centrally concerned with helping clients make sense of their suffering, what patients’ suffering means is the central axis around which therapists continue to disagree.
The Ideology of the Scientific Method
… With respect to the three main traditions of therapy outlined above, however, what is clear is their respective commitment to different kinds of epistemological positivism. They all ‘believed’ their epistemology was ‘scientific’, and then pursued their ‘scientific’ aspirations in their unique but disparate ways. … Each of the three main traditions of therapy, however, conceived of their scientific obligations differently. I will consider each in turn.
For psychoanalysis, the methods of scientific investigation and the methods of therapeutic intervention are the same thing. The ‘scientific’ methods of revealing the unconscious mind of the patient through free association, dream interpretation, analysis of the transference, etc., provides the raw material for the development of psychoanalytic theory itself. The product of the deliberations of psychoanalytic thought is a grand theory of mind, one that attempts to elucidate the structure of the mind, together with an understanding of its development, disturbance and cure.
Behaviourism and, indeed, cognitivism in its wake, conceived of their ‘scientific’ project in quite different terms. In this tradition, research is taken from experimental psychology and used to generate models of human problems. … The products of cognitive behavioural thought are numerous theories of discrete kinds of problems and a collection of empirically tested strategies for their treatment.
For both psychoanalysis and cognitive behaviour therapy, the ‘scientific method’ is used to generate models of human problems that are tested in the consulting room. Although person centred therapy does have a model of psychological disturbance, it is a generic model, applicable to all client groups. Indeed, person centred theory of clients’ problems might better be conceived of as a philosophy of the kinds of problems people have, something that is intrinsically incapable of empirical refutation. …
Technical Rationality
My concern here is not so much to highlight the divergence in thinking in the conceptualisation and execution of the different research agendas of the different therapeutic traditions, but rather to highlight a particular kind of convergence which the commitment to the ‘ideology of the scientific method’ has had. What I wish to draw attention to is that in following the doctrines of positivism, a new literature, or body of knowledge, has emerged. … In this sense, the commitment to positivism in therapy has created a ‘knowledge rich’ class of academics (Schön, 1983) whose job it is to pass this knowledge down to the practitioners of the various therapies who, in turn, are required to apply this knowledge in their clinical practice.
The difficulty for Schön (1983) with the development of the knowledge based professions is that the theory as handed down from the academy is usually insufficient to account for all the problems of routine everyday professional practice. The knowledge we need to perform our professional duties is often not represented in the theory as stated. … Perhaps this is nowhere more true than in the field of counselling and psychotherapy. The theory as handed down from the academy, on its own, in no way prepares anyone for the practice of therapy. Reading Freud would not tell us how to respond to someone overwhelmed with grief. The cognitive behavioural literature would not instruct us in how to cope with our feelings when a client is bent on taking their own life. Furthermore, person centred theory would not be in a position to help us cope with a client who was threatening to hit us. In other words, the routine and everyday experience of ‘doing’ therapy is not captured in the espoused ‘rational’ schemes of therapeutic thought as handed down to practitioners. There is a theory-practice gap (Schön, 1983). In this sense, the commitment in therapy to the ideology of the scientific method has also unwittingly created a commitment to the same kind of ‘technical rationality’ shared by every other knowledge based profession. The result is a range of epistemologies of therapy unable to describe what is done in their name.
The Equivalence of Outcomes
Despite this titanic inability to agree about how people who are suffering should be best helped, the business of therapy continues unabated. Ultimately unresolved questions of epistemology and theory have not hindered therapists’ ability to practise. It is my concern now briefly to ask the question if any one approach to therapy has been shown to be more effective or useful than any other. Are psychodynamic therapists any better than either cognitive behavioural therapists or humanistic therapists?
… Wampold et al. (1997) selected studies published between 1970 and 1995 comparing two or more bona fide psychotherapies and concluded that all bona fide therapies have similar effectiveness. Later reviews have broadly supported this conclusion (Wampold and Imel, 2015). Although there is a perennial debate about what constitutes a good therapy outcome research protocol, it appears that therapy, on the whole, does ‘work’. It is also a clear and ongoing finding that, generally speaking, whatever it is that makes therapy effective, the choice of therapeutic theory the therapist has trained in is not an important factor. Indeed, as early as the 1950s evidence started to gather which seemed to demonstrate that the therapeutic qualities of counselling relationships are, in fact, qualities of the counsellors themselves, and unrelated to the trappings of counselling technology, such as theoretical frameworks, technical terms, and techniques with which professionals surround themselves (Fiedler, 1950a,b; Seeman, 1954; Parloff, 1961; and Rogers, 1962). Research also seems to suggest that in certain circumstances trained therapists differ in effectiveness from amateur helpers to no significant degree (e.g. Berman and Norton, 1985). More recent research on ‘therapist effects’ continues to suggest that who the therapist is makes a real difference to outcomes, more so than theoretical training (Wampold and Imel, 2015; Johns et al., 2019).
The conclusion that any theory will do, and not having a theory at all may even be preferable, has been available for some time. It has long been known as the “Dodo” verdict (Rosenzweig, 1936; Luborsky et al., 1975; Holmes and Lindley, 1989), named after the bird in ‘Alice in Wonderland’ which proclaimed, “Everybody has won, and all must have prizes.”
The 3 x 3 March of Contemporary Therapeutics
What my earlier analysis of the history of therapy shows, however, is that the epistemological boundaries between the differing therapies were also the battle lines as the different professions vied with each other (and medicine) for the right to practise and receive status, etc. What is of more interest is that as the 20th century moved into its later decades, and the therapeutic professions became more established, the need for the maintenance of sharp epistemological boundaries started to disappear. Now all three main therapy organisations [the UKCP, the BACP and the BPS] accredit practitioners of all three approaches to counselling. … This I would characterise as the 3 x 3 march of contemporary therapeutics: three professional bodies each validating practitioners of the three main therapeutic traditions. Consequently, there is no meaningful sense anymore in which the theory of therapy is seen as being ‘owned’ by any one particular therapeutic profession. This convergence has since been formalised: the SCoPEd framework, published in 2022 and since adopted by the BACP, UKCP, British Psychoanalytic Council and three other professional bodies, sets out a shared set of competences for counsellors and psychotherapists (SCoPEd Partnership, 2022).
At the turn of the 21st century, therapists are more willing than ever to learn from each other to the point that ideas concerning the integration and the eclectic sampling of theory have formed the predominant theoretical debate (e.g. see Clarkson, 1996 and Palmer and Woolfe, 1999). Of course, there are insurmountable philosophical problems in trying to sample eclectically or integrate theoretical positions developed from the great, but diametrically opposed, social philosophies of the 20th century. Indeed Laungani (1999) has characterised the state of theory in the therapeutic professions as “epistemological anarchy” (p. 125). It is difficult not to draw the conclusion that therapeutic theory building has today become like a horse designed by committee, that is to say, a camel.
Conclusion
In this paper I have charted the rise of the main three approaches to counselling and psychotherapy. What becomes clear from this analysis is that espoused epistemology has had as much to do with inter-professional rivalry as with the detached pursuit of truth. What is perhaps reassuring about this is that the choice of espoused theory appears to matter little in helping clients make sense of their suffering. Any theory seems to do. The challenge for the industry is to account for why this might be the case.
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References
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