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State Regulation of Psychotherapy: Protecting the Public or ‘Professionalising’ Psychotherapy at the Expense of Therapeutic Integrity, Creativity and Diversity?

Pollard, R., 2009. State Regulation of Psychotherapy: Protecting the Public or ‘Professionalising’ Psychotherapy at the Expense of Therapeutic Integrity, Creativity and Diversity?. Reformulation, Summer, pp.29-31.

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In common with many other therapists I have recently woken up to the implications of impending state regulation of our ‘profession’. On 5th April I attended the inaugural conference of the Alliance for Counselling and Psychotherapy, an inspiring cross modality occasion in which over 300 therapists; counsellors, psychoanalysts, psychologists and psychotherapists from a broad range of theoretical persuasions came together to express their common concerns about registration with the Health Professions Council and the related roles of other governmental bodies such as NICE, IAPT, Skills for Health and National Occupational Standards that between them will regulate and control the activities of therapists. I went to the meeting out of concern and a desire to learn more and came away feeling profoundly alarmed and resolving to contribute towards the political fight back against state regulation.

The registration of psychologists, psychotherapists and counsellors has never been debated in parliament but is the result of delegated legislation from the 1999 Health Act. If registration goes ahead, counsellors and psychotherapists will be subject to the legal jurisdiction of the HPC, trainings will be subject to inspections, registrants will be subject to CPD spot checks and employers will have to notify the HPC of any disciplinary actions taken against registrants.

An equally important concern is the reduced range of therapies that would be available in the NHS leading to a further impoverishment of mental health provision. Initially this would exacerbate the two tier system in which the majority of people with mental health problems are offered drugs or languish on waiting lists before being offered a few sessions of CBT, if they are lucky, while those that can afford it pay for therapy in the private sector. Subsequently the choice of therapies and therapists in community and voluntary organisations as well as in private practice will diminish as training courses not approved by the state will find it difficult to fill their places.

Most therapy organisations including the BACP and the UKCP and its member organisations have seen it as their role, despite unease about many aspects of the legislation, to comply with registration and protect the interests of their members by trying to negotiate as beneficial an outcome as possible. Representatives from ACAT have been working hard on this for some time and the recent letter from the Chair suggested that getting sufficient recognition for CAT is an uphill struggle as different therapy organisations are forced into competition with each other for a slice of the post registration cake and as there is a lack of transparency about how members of the HPC are selected. Since many members of ACAT work in the NHS and feel strongly about protecting and expanding the role of CAT in NHS provision, the organisation understandably feels that the best course of action is to comply with registration both to protect the membership who might otherwise be legislated out of their jobs and safeguard the future of CAT. In these circumstances there is a very real tension between the continuance (through state endorsement) of ACAT, CAT therapists, the diverse profession of psychotherapy as a whole, and provision of quality and choice of therapies that will be on offer to the public in the future.

The registration agenda has created sharp divisions in the field between those who see state regulation as enhancing their professional standing and giving greater protection to the public and those who see it as a profound threat to independence of thought and practice in psychotherapy. It is politicising the profession and turning people away from internal debates into a political engagement with the government and its agencies whether they agree with or oppose the legislation.

An Attack on Therapists’ Integrity

The seductive argument that registration will protect the public is being used to mould public and parliamentary opinion but there is no evidence to support it1. Nor is there any evidence that abuse by therapists is a widespread phenomenon. The main therapy organisations already set standards for training and qualification that require their members to adhere to detailed and highly considered codes of ethics. They also investigate complaints and discipline/strike off therapists found to be in breach of these codes. The HPC seems unqualified to either investigate or adjudicate complaints against psychotherapists and proposes to replace the principle of ethical practice, the complex interrelation of theory, philosophy and practice that is at the heart of psychotherapy with a crude notion of ‘fitness to practice’. To quote from the Alliance press release:

Many complaints against psychotherapists and counsellors are not about clear cut matters such as sexual or financial exploitation or false claims to qualification. All therapists agree that exploitation and deception are utterly unacceptable….Because of the nature of this work, many complaints are best resolved via conciliation, negotiation and, where appropriate, apology and a change of approach on the part of the therapist. However, true to its understanding of a ‘health profession’ the HPC’s approach to ethics and discipline is bureaucratic, adversarial, utterly devoid of the emphasis on conciliation, mediation and mutual understanding that characterizes the best contemporary approaches to ethics and discipline in the therapy field. In this and in other ways, far from raising standards the HPC has embarked on lowering them.

Far from protecting the interests of the public, the HPC could lead to defensive practice in which therapists are less willing to take risks and be creative in their work. Just as the restrictions on teachers and social workers, because of fears of accusations of abuse, have lead to vulnerable children being starved of affection and physical contact with adults, this legislation is an attack on the central importance of the relationship in psychotherapy.

Historically, psychotherapy and counselling have been conducted in a private, confidential space, free of externally defined institutional agendas, in which clients can take matters of deep personal concern for discussion and reflection. I believe that the therapeutic space is one of society’s last surviving bastions against, and refuges from, narrowly stultifying mechanistic thinking, and from the abusive compliance experiences that, in various forms, bring many or even most clients to therapy in the first place. The State’s regulatory moves constitute a gross intrusion into this precious private space, and can only compromise it if subjected to a governmental control-oriented compliance agenda3

An Attack on Knowledge

The HPC’s understanding of psychotherapy is constrained by its adherence to a medical model of mental ill health that relies on Newtonian-Cartesian assumptions about human beings4 in which human behaviour is determined and predictable. This denies what for many therapists is the ethical principle of the irreducibility of each human individual and the unique nature of each therapeutic relationship. The two main categories of individual psychotherapy approved are CBT and psychoanalytic therapy both of which are characterised by clearly delineated schools of thought and practice, leaving no room for integrative and eclectic therapies that allow for greater uncertainty and in which theory is subordinated to the particularities of each encounter. The processes of therapy and its effects on the participants are not amenable to statistical categorisation and measurement nor is it possible to link particular causes to particular effects. The ‘evidence base’ so often appealed to in the HPC is an abstraction in which human subjectivity, the core material of psychotherapy, has been stripped away.

The restricted choice of therapies approved by the HPC will lead to a standardisation of training and prescribed forms of knowledge and competencies. I find this aspect particularly frightening as the diversity of theories and practice in psychotherapy are in part a reflection of the diversity of human experience, history and culture. There is no one body of knowledge that encompasses all the complexity of human subjectivity and interrelatedness. That is what makes the work we do so demanding and so interesting. Are we in future to be subject to government prescribed CPD programmes? Can we not be trusted to identify and endeavour to meet our own training needs? To approve only certain models of therapy is equivalent to prescribing a particular version of personhood and mental health ideologically biased in favour of the dominant forms of subjectivity. Standardisation would therefore be discriminatory, marginalising many people because of their class, gender, ethnic origin, sexuality, religion and so forth. It is absolutely desirable that mental health services reflect the diversity of the communities they serve.

The drive towards the state registration of psychotherapy is a continuation of the Thatcherite/Blairite agenda in which giving free reign to business, the financial markets and the banking system is accompanied by increasing subordination of the professions to regulation by government. Under Thatcher, ‘management became the highest calling of all’5 . This was essentially an attack on knowledge as managers were not required to know anything except how to ‘manage’.

This split between managerial and professional knowledge that has been increasingly characteristic of public sector organisations since the 1980s, is particularly painful in organisations whose collective purpose is to care for other people6 From a psychodynamic perspective knowledge which the other possesses and we do not understand is experienced as a threat and has to be denied; ignorance then becomes an institutional defence of management. The result of this is that front line workers are progressively undermined by management who are determined ‘not to know’ what the people they manage know leaving workers feeling vulnerable and demoralised. This process has been going on in teaching and social work for many years, (with disastrous results in the recent tragic and preventable death of Baby P) where bureaucratic controls and a tick box approach to ensuring that ‘targets’ have been met has left teachers and social workers floundering under mountains of useless paper work or tied to computer screens rather than doing the work they entered the profession to do. It is no accident that Richard Layard drafted in to devise the IAPT ‘happiness’ agenda is an economist rather than a professional in the field of mental health and psychotherapy. The knowledge of workers in the field is not only detached from management but is subordinated to its economic demands7 The HPC is continuing this grand tradition of not knowing by making a virtue of not understanding the practices they are charged with regulating.

An Attack on Diversity

While politicians and business people have been left free to pursue their activities unfettered by government regulations with disastrous results for the global economy and the global environment, the rest of us as citizens, professionals and workers are deemed not sufficiently trustworthy to live and work without constant monitoring ,surveillance and regulation. State regulation of psychotherapy and counselling is yet another extension of this insidious process which is an attack on freedom, knowledge and diversity.

Psychotherapy and counselling currently allow for a variety of flexible relationships that individuals choose to enter for a variety of purposes, including the alleviation of mental distress, personal development and self exploration in which the social and political dimensions of subjective mental states can be thought about alongside the particular aspects of each person’s history and experience. State regulation threatens to replace this diversity with an instrumental notion of ‘therapy’ in which patients are taught how to manage their symptoms so as to better comply with the social and economic demands of ‘responsible citizenship’.

Diversity of thought and practice is the lifeblood of psychotherapy. Theories and practices develop in response to other theories and practices, borrowing some ideas, whilst rejecting or modifying others with each new idea having the potential to provoke further new ideas. No theory arises in a vacuum and all are mutually interdependent. From this perspective the plurality of thought and practice in psychotherapy is a rich resource from which we all benefit8 Cognitive Analytic Therapy has developed as a response to and as a development of other theories and continues to evolve through its interaction with other schools of thought in the therapy field and beyond. There may be short term gains for CAT and CAT therapists if we are granted government approval but state regulation will inevitably lead to far greater losses for the activities of counselling and psychotherapy as a whole.

References:

1 Samuels, A. (2009), Alliance for psychotherapy and counselling – against state regulation, The Psychotherapist, Spring, (44)
2 www.allianceforcandp.org
3 House, R. (2009), Still time to stop the regulatory juggernaut, Ipnosis magazine, Spring, (33)
4 Mowbray, R. (1995), The Case against Psychotherapy registration, London, T.M.P
5 Slater, J. (1993) Macho managers are killing my profession, The Independent 4th August
6 Pollard, R. (1999), Managing conflict: a psychodynamic approach to understanding court welfare practice, Journal of Social Work Practice, (13), (1) 19-28
7 Smail, D. (1993) The origins of unhappiness: a new understanding of personal distress, London, Harper Collins.
8 Pollard, R. (2009), Negotiating difference and acknowledging interdependency: A dialogical perspective on some of ethical implications of theoretical diversity in psychotherapy (forthcoming).

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Pollard, R., 2009. State Regulation of Psychotherapy: Protecting the Public or ‘Professionalising’ Psychotherapy at the Expense of Therapeutic Integrity, Creativity and Diversity?. Reformulation, Summer, pp.29-31.

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