Who should deliver therapy? When up to 1 in 4 people worldwide have a mental health issue – not necessarily a diagnosis – delegates strongly believed that there was no place for elitism in the scaling of mental health services. Therefore, and from an Australian perspective, diploma-trained counsellors matter greatly to the future of our profession and should be encouraged. It is they, more than their degree-trained colleagues, who will likely find themselves working with particularly vulnerable people, or within specific communities.

What is the purpose of therapy? Although no single answer exists, presenters recognised two schools of thought. If we consider mental health issues to be a worldwide pandemic, and the scaling of mental health services to be a priority, then symptom reduction becomes an important way to improve individual functioning, family dynamics, and community strength. Yet a number of European psychiatrists, often trained psychodynamically, pushed back. From a human rights perspective they argued that therapy was not deficit-based but, instead, aimed at producing human flourishing. Most interesting, however, was now the language describing counselling shifted. Gone was client risk, case conceptualisation, and symptom outcomes being replaced with identity, relationships, and even unconditional love. As one French professor stated, “[I] don’t seek to make my clients happy!”. A bold pronouncement, but one which encapsulated thoughtful resistance to simplistic consumer-led models of therapy.

Is it valid to hold self-evident truths in counselling? Two counter-intuitive examples illustrate how culture influences the creation of knowledge and how we can naively become susceptible to a dominant culture’s monocular perspective:

An eminent Moroccan psychiatrist noted how his people experience war, famine, or pestilence about every 30 years. He then went on to question our Western perception of trauma. In fact, he demonstrated with a wide variety of evidence that trauma is an environmental pressure which may improve “fitness” at both biological and psychological levels To him, trauma was to be engaged with positively. In fact, he even said that a person who hadn’t experienced trauma was probably “more fragile”.

Another eminent professor, specialising in ADHD, then used her lived experience of Black American culture to recast this “disorder”. Might a child’s disruptive behaviours actually be meaningful play? Further, might the cause of ADHD lie not in individual psychopathology but in collective social conditions? And she was not referring to intergenerational trauma or poverty, but a collective desire to over-parent children for fear that they would be labelled “vulnerable” or bring shame on the community. The implication being that fidgeting and disruptive behaviour may be the child’s story of oppression uniquely expressed.

How do we think about our clients? Our standard interpretation of the bio-psycho-social model, which underpins all case conceptualisation, is inherently medical. Biology precedes sociology. Therefore, it was refreshing to find a group of Italian psychiatrists willing to reinterpret the bio-psycho-social model. Using a subtle argument pertaining to the limits of heritability they were then freed to ask what social conditions influence individual functioning. This rich reinterpretation not only recast good mental health as a collective responsibility, but also led to the definitive statement that “all children are born equal and normal”! These same highly qualified delegates then went on to discuss the value of ongoing low-cost community-based “collective analysis” and delightful interventions for children such as painting together in a park on a warm summer day.

What do we target in therapy? Interestingly, BPD and moral injury – and by implication PTSD – were recast by other delegates in terms of a fractured identity. While managing risk and limiting distress are useful they are not necessarily the focus of therapeutic work. So rather than a masterclass on using manualised therapy we were, instead, asked to consider the client’s identity. To this end we were presented with case examples, discussed the importance of a coherent self-narrative, learnt about restoring values congruency, and building character strengths through indigenous Asian virtues (e.g., ren or katatagan).

What constitutes good therapy? CBT is emblematic of doing therapy well, being often considered the “gold standard” treatment. Given that CBT works with cognitions, influences emotion, and seeks behaviour change, what more could we want? Yet according to members of the Italian contingent mentioned above, the WHO declared CBT to be the gold standard for reasons in addition to therapeutic effectiveness, specifically its high return on investment (i.e., speed vs. cost), and its ease of manualisation. In fact, thinking about the many sessions I took part in therapy could be many things – I even learnt about “horticultural therapy”. But what hung all these practices together were simple realisations about people needing people, the importance of meeting the need put before you, accepting imperfection, … and yes, one last thing – having hope.