by Richard Reeves and Phil Mollon
Note: This paper was first published in Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, Vol. 3, March 2009
Might psychotherapists and psychoanalysts be sleep walking to disaster in their collusion with the rapid progress towards State regulation? Powerful structures and processes have been set in motion that could reduce psychotherapy (including psychoanalysis) to a set of prescribed manualised procedures. Sanctions may be applied to practitioners whose practice does not conform to these ‘National Occupational Standards’ set by the State appointed Health Professions Council (HPC). Furthermore, any practitioner using the State protected title psychotherapist may be the subject of legal action if they are not registered with HPC. This state control would replace the regulation that has been developed by the professional organisations themselves.
The State action proposed, involving surveillance and control, should correctly be referred to, not as statutory regulation, but as State regulation. Statutory regulation may be viewed as a more general self-organising principle by the field in question, often involving a protected title registered with the government authority (Hogan, 2003; Parker and Revelli, 2008). The British government has decided that the statutory model should be rejected as they consider it is biased towards the practitioner grouping (Leader, 2008).
At this crucial time for psychoanalytic practice, we believe that an ethical stance requires all practitioners carefully to consider and assess the evidence base for, and likely implications of, State Regulation of psychotherapy based on a medical ‘health care’ model. Whilst fully respecting the democratic processes within the psychotherapy member organisations, we believe this process can be enhanced by highlighting a range of concerns that have been expressed regarding the potential hazards of State Regulation.
Background history to regulation
In the 1970s, the Foster Report on scientology suggested regulation of all therapies due to the “dangers of transference”. Similarly, the Sighart Report in 1978 campaigned for psychotherapy regulation. Around this time, psychotherapies of all modalities sought to self-regulate through organisations such as UKCP (H. Oakley, 2008).
In 1996, following the Bernard Manning ‘affair’ (Manning was a comedian renowned for offensive jokes of a racial and sexual nature, who became a member of the British Association for Counselling using bogus qualifications), a UKCP representative stated:
“One of the things that is difficult for us is that we are a council, not a trade association. We are here to protect the public, not promote psychotherapy….One of the main criticisms we face at the moment is that people say ‘Oh, anyone can call themselves a psychotherapist or a counsellor’ and this is quite true. Statutory regulations would solve the problem – we can’t control the title without a statute to regulate entry into the profession. There is nothing to stop you or me calling ourselves a medical doctor, but it’s against the law, and we’d be picked up very quickly. For my profession that law doesn’t exist.” (Lacey, 1996).
Following a meeting with UKCP in 1999, and subsequent gatherings which included seven other psychotherapy organisations, Lord Alderdice brought a Private Member’s Bill before Parliament for statutory regulation of psychotherapy. Alderdice proposed a General Psychotherapy Council to oversee and regulate the field, a Register of Psychotherapists, a Code of Practice and Health and Professional Conduct Committees for compliance matters (Casement, 2000). However, the exclusion of the British Association for Counselling and Psychotherapy (BACP) from this cabal effectively ensured that this route to regulation and protected titles would end in failure (House and Postle, 2008).
Following the trial of the serial killer GP, Dr. Harold Shipman, the subsequent inquiry, chaired by Dame Janet Smith, outlined over 100 recommendations in a move to impose greater regulation over the General Medical Council (GMC), who were held to account for not protecting the public. The Shipman Inquiry Report highlighted areas of protection and fitness to practice and the required regulation of the GMC (now undertaken under the Council for Healthcare and Regulatory Excellence). One of the suggested consequences of Shipman was a loss of confidence and trust in the traditional doctor/patient relationship, which opened the door to government intervention, external monitoring and a movement away from responsibility to accountability (Litten, 2008).
The current proposal for State regulation was outlined seven years ago. Article 3 (17) of the Health Professions Order 2001 states that HPC “may make recommendations to the Secretary of State concerning any professions which in its opinion should be regulated pursuant to section 60(1)(b) of the Health Act 1999”. In February 2007, the government published a White Paper titled, ‘Trust, Assurance and Safety – The Regulation of Health Professionals in the 21st Century’, in which it was proposed that “….psychotherapists and counsellors will be regulated by the Health Professions Council, following the Council’s rigorous process of assessing their regulatory needs and ensuring that its system is capable of accommodating them” (Health Professions Council, 2008a).
Once HPC have completed their ‘project’ of ‘regulatory capture’ involving psychotherapy, they will then seek legislative approval from government.
HPC and NHS
The HPC website states that it currently regulates 13 professions: “Arts therapists, Biomedical scientists, Chiropodists/podiatrists, Clinical scientists, Dietitians (sic), Occupational therapists, Operating department practitioners, Orthoptists, Paramedics, Physiotherapists, Prosthetists/orthotists, Radiographers, Speech and language therapists.” It is apparent that HPC are currently involved with overseeing mainly medical and scientific professions.
HPC views itself as an organisation independent of government, psychoanalytic organisations and any other pressure groups. In 2009, the HPC Council will be reduced from 27 to 20 members (some professions currently regulated by HPC will therefore not be represented on this body), with the Council Chair appointed rather than elected. It is questionable whether HPC is ‘independent’ since these changes in structure (to all regulatory organisations) have been imposed by government (Independent Practitioners Network, 2008). Source: http://www.hpc-uk.org/
It is clear that HPC intends to regulate psychotherapy through an authoritarian top-down jurisdiction. This regulatory approach is in many ways based on the outmoded 1960s Quality Assurance model – production output inspection and reject disposal (Independent Practitioners Network, 2008).
HPC’s raison d’être is clearly stated on their website: “When we say that a health professional is ‘fit to practise’ we mean that he or she has the health and character, as well as the necessary skills and knowledge to do their job safely and effectively….Our main responsibility is to protect the public, maintaining public confidence in the professions and professionals we regulate.” Source: http://www.hpc-uk.org/
There are three areas towards which State regulation are directed: protection of the public; competent/ethical practice; scientific development of psychoanalytic approaches involving evidence-based models. HPC will therefore hold authority over a number of areas concerning – fitness to practice; standards for and withdrawal of registration; vetting, evaluating and accrediting training courses and qualifications, including selection criteria (Litten, 2008).
In 2003, the Department of Health (DoH) outlined their thoughts concerning the requirement for regulation of psychotherapy (Richardson, 2001:1). This document expresses the view that statutory regulation does not go far enough (a national register of practitioners) and that an NHS model, including the National Institute of Clinical Excellence (NICE) guidelines relating to evidence-based treatment, is now required for those seeing patients privately in order to provide “for the delivery of effective services”. Furthermore, that governance includes inter alia new training and education initiatives and CPD which would improve knowledge, competence and ethical practice.
Public protection is highlighted in the 2003 DoH document: “Although abuse of clients is a relatively rare event, nevertheless it does occur” (Richardson, 2001:2). It is suggested that “research” exists which provides a greater understanding surrounding “unethical practice”. It is significant that the exact nature of this research is not mentioned. This document also suggests that training organisations do not explicitly address areas of unethical practice and that it is “uncommon” for trainers to focus on issues such as erotic countertransference both in the consulting room and between trainers and trainees. It is also stated that “registration will not be imposed upon a resistant majority….”. Citing POPAN, the charity and pressure group (now called WITNESS), the DoH suggests that complaints against psychotherapists have not been dealt with appropriately. [We have contacted WITNESS requesting statistics of all instances where they have been involved representing clients who have complained about the conduct of their psychotherapist but to date have not received a reply.]
The position of self-regulatory organisations
The major self-regulatory organisations, the United Kingdom Council for Psychotherapy (UKCP), the British Psychoanalytic Council (BPC, formerly BCP) and the British Association for Counselling and Psychotherapy (BACP, formerly BAC) are active participants in State regulation. Chris Oakley observes that there has been a “contagion of collaboration” between these self-regulatory organisations and HPC (C. Oakley, 2008:40). While the reasons surrounding this are complex, factional rivalry, self-interest involving a desire to be generally seen as the ‘primary institution’ by attempting to anticipate the State regulators through implementing new structures, are suggested as being factors (Parker and Revelli, 2008; H. Oakley, 2008). The internecine rivalry between these organisations has principally centred on the effort to “capture and sustain the ‘training industry’” (House and Postle, 2008:192).
Richard House and Denis Postle observe that: “All of the major psychopractice organisations have openly used fear of being left out, fear of not being able to work, the ‘trance inductions’ of the ‘inevitability’ of statutory regulation, together with the unresearched assertions of the need for ‘client protection’, as crass instruments with which to shepherd (or scare) their generally deferential flocks in the direction of signing up to whatever might be the current form of regulation” (2008:194).
The proposal for State regulation involving evaluation and audit is clearly founded on the implementation of standards of practice to counteract the risk posed by unqualified and incompetent practitioners (Litten, 2008). The surge to adopt State regulation, in spite of ever-increasingly complex codes of ethics, codes of practice and continuing professional development, can only be viewed as a tacit admission by the self-regulatory organisations that there has been no effective means to protect the public from practitioners who are unfit to conduct their work (House and Postle, 2008). In part, these revamped codes of ethics were perhaps an attempt to out-regulate the regulators (HPC) in the hope that statutory regulation could still remain on the agenda. However, it became clear that regulation would be solely on those terms devised by the government agencies.
BPC have stated that they are involved in on-going discussions with HPC and a broad range of government agencies “including but not limited to statutory regulation” (British Psychoanalytic Council, 2008). They suggest the need for change within psychotherapy is linked to factors involving “movements in society” relating to the “consumer revolution”. Roger Litten questions this notion when he states: “…the customer charter notion of the therapeutic contract, as filtered through contemporary discourse of codes of practice, not only involves a complete misunderstanding of the subjective ethics of the transferential relation but also entails a subtle but profound abdication of responsibility for the psychoanalytic position in favour of an external guarantee of false accountability” (Litten, 2008:17).
BPC also identify a need for evidence-based treatment, whilst acknowledging the complexities of this when applied to the psychoanalytic approach. However, they suggest that psychoanalytic practice in the future will involve adherence “to the norms and standards of publicly-funded health treatment” (British Psychoanalytic Council, 2008). This appears to indicate that BPC view private practice developing alongside the NHS medical model and empirically grounded protocols of NICE. The authors suggest that this approach fundamentally ignores a pervading malaise in the NHS of “….prescriptive certainty – often distinctly cavalier in its disregard for clinical difficulty and complexity” (Mollon, in press).
There has been little meaningful debate as to whether or not State regulation will enhance or detract from psychoanalytic psychotherapy in the future. Organisations have made an assumption that members favour State regulation but thus far none have put it to the test of a vote (Thorne, 2003).
National Occupational Standards
The National Occupational Standards (NOS) drawn up by Skills for Health (SfH) were commissioned by the Department of Health. SfH is a separate government agency to HPC. NOS are to be viewed as putting “good practice into words…They are designed to express what research and clinical practice have been shown to be effective in a practitioner’s work with an individual or group”. NOS set out aspects of work “that all practitioners and aspiring practitioners should take note of if they seek to improve their practice and continue learning”. NOS are “benchmarks” to improve performance, together with “informing best practice working” (Skills for Health, 2008).
SfH provide an example of the NOS process for cognitive behaviour therapy which will be applied to all other modalities such as “psychoanalytic/dynamic psychotherapy”. This extract is from The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety (IAPT, September 2007): ‘Identifying competences by looking at the evidence of what works: This project began by identifying those therapeutic approaches with the strongest claims for evidence of efficacy, based on the outcome of therapies in clinical controlled trials.’ ‘Almost invariably, the therapy delivered in these trials is based on a manual which describes the treatment model and associated treatment techniques. In this sense, the manual represents best practice for the fully competent therapist – the things that a therapist should be doing in order to demonstrate adherence to the model and to achieve the best outcomes for the client” (Skills for Health, 2008).
There is considerable concern within the psychoanalytic field as to how the concept of these standards will be applied to the psychoanalytic approaches of understanding the human mind and psychological distress (At the time of writing, Skills for Health have published a draft outline of National Occupational Standards for psychodynamic psychotherapy (including psychoanalysis). This lists 593 skills, areas of knowledge, and principles of practice – some of which do appear quite prescriptive. These can be found at www.skillsforhealth.org.uk – click on ‘competencies’). Whilst the client may seek help for a specific problem, therapy often reveals the unconscious wish for it to remain left alone. Philip Bromberg formulates this as follows: clients enter therapy with the same ‘illogical’ wish, “to stay the same while changing” (Bromberg, 2006:53). What the client hopes for and what is therapeutically offered are often contradictory (Leader, 2008).
The paradigm underpinning NOS will inevitably tend to reduce psychoanalytic work to a simplistic and reductionist formula of procedural rules. In a recent issue of The Psychotherapist, Carmen Joanna Ablack, the Chair of the UKCP Standards Board (who sits on the HPC ‘Psychological Therapies Reference Group) expressed her concern at the “few-sizes-fits-all” approach of NOS (Ablack, 2008:22). Bernard Burgoyne (2008) questions whether the very nature of the exercise in compiling NOS renders them a set of rules and techniques that are applied to the client. He wonders whether this is a replacement of the therapist’s proficiency through a set of rules compiled by the State. Rules are therefore established to quantify competence, personal ability and training. Roger Litten (2008) also notes the potential for a shift from personal responsibility to one involving external accountability.
In a recent an article on State regulation appearing in The Times newspaper Billen (2008) suggested NOS could potentially restrict the way in which the psychoanalytic psychotherapist practices. A subsequent letter published in this newspaper on behalf of BPC clearly stated that NOS were only a framework for training and had nothing to do with the individual practitioner in their consulting room. However, SfH and HPC (personal communications) confirmed that this statement was incorrect – NOS were ‘good practice’ but could be used as reference of competence in any HPC disciplinary procedure.
The psychoanalytic approach is unified by one concept alone – the conscious and unconscious; forces which are most often opposed (Leader, 2008). It is an unsustainable proposition to suggest that the psychoanalytic traditions stemming from theoreticians as diverse as Freud, Kohut, Lacan, Klein, Winnicott, Fairbairn, Sullivan, Bowlby, Fonagy, Bromberg and Stephen A. Mitchell form a unified body of theory and homogenous grouping. Indeed what is viewed as desirable and a requirement in the practice and attitude by one group is sometimes anathema to another (Miller, 2008).
A further complication is how we as individual practitioners internalise theory. The authors of this paper both use their unique training and clinical experiences to formulate an understanding of the human mind. This inevitably manifests itself in entirely different ways during therapy, especially when one includes the unique nature of any therapeutic relationship. Our work is based upon clinical judgement with a particular client at any given moment in time. This may not only involve differing theoretical thoughts but may also include aspects of other modalities such as CBT or EMDR. Viewed from this perspective NOS, as standards of good practice could appear a meaningless and reductionist construction.
Some psychoanalytically derived approaches, such as mentalization-based psychotherapy, lend themselves relatively easily to manualisation along NOS lines. Thus, psychoanalysts Anthony Bateman and Peter Fonagy (2004) have written a text on this evidence-based approach for people with borderline personality disorder, which actually contains such a manual, along the lines of ‘if the patient does X, the therapist should do Y’. This manual includes comments clearly distancing itself from important aspects of the psychoanalytic tradition (certainly in relation to this particular client group). For example, they outline what they call their ‘modern view’ which “sees transference not so much as the inexorable manifestation of unconscious mental forces, but rather as the emergence of latent meanings and beliefs, organised around and evoked by the intensity of the therapeutic relationship…. the dynamic is in the present, often only remotely influenced by an infantile constellation from the past.” (2004:207) Such a position may be widely held amongst a broad spectrum of psychoanalysts, but there are some who do not agree with what may be seen as an excessive ‘here-and-now’ focus, and consider it could at times be unhelpful or even harmful (e.g. Bollas, 2007). Professor Fonagy gives one example of a potential future for psychoanalysis in a paper he wrote for the Psychiatric Bulletin, in which he stated: “The structured, manualised psychotherapy techniques of the future will be designed to specifically address empirically established developmental dysfunctions.Future psychotherapy trials will be increasingly seen as the only viable experimental tests of rival psychosocial aetiological models of personality”. (Fonagy, 2004:357). Whilst such an approach has merit in certain contexts, and represents a scientific approach to the study of both psychotherapy and aetiology, it is at odds with the open-ended and free-associative enquiry that is still valued by some psychoanalysts. Perhaps the exclusion of historical transference (in the original Freudian sense) results in a more distilled form of psychoanalysis, better suited to manualisation and ‘industrialisation’ (A term used by Professor Glenys Parry in referring to the move from an original ‘craftsman’ model of psychotherapy to its ‘mass production’ under the impetus of the government’s ‘Improving Access to Psychological Therapies’ programme [Psychological Therapies in the NHS conference, 27-28 Nov. 2008. Savoy Place. London) – but it is a long departure from Freud.
If the NOS for psychodynamic therapy are accepted, it is suggested that within a short time, the field of psychotherapy will inevitably shape itself to the SfH definitions of education and practice standards. As Darian Leader suggests: “…..there is every danger that these changes, together with the emphasis on sanitisation, will produce a new ‘adapted’ psychoanalysis” (Leader, 2008:215).
During the past decade, psychoanalytic psychotherapy training organisations have substantially increased standards of training. Courses have become longer, more complex, with academic standards spiralling to the point where it is now suggested that future (basic) psychotherapy training under HPC would be at doctorate level. Clearly standards of training are of importance but we wonder whether some institutions have lost sight of the fundamental point which is to promote and facilitate in the trainee/candidate the ability to become therapeutic. No amount of academic rigour, or raising of standards as proposed by HPC and NOS will enable this. Furthermore, research has not provided a positive correlation between longer and more complex trainings, often involving higher academic standards, with therapeutic efficacy (Hogan, 2003; Thorne, 2003).
Is psychotherapy a ‘health profession’?
Whilst some psychotherapists and analysts do work within the National Health Service, and thus can legitimately be considered to be providing a component of health care, most do not. Not all clients or analysands can be considered to be psychiatrically ill. Some may be involved in what might more appropriately be called a personal journey of exploration, of life, emotions and thoughts – an exploration of the human condition.
The argument of protecting the public
The principal justification cited by the DoH, HPC and self-regulatory organisations, for State regulation is to protect the public from the unscrupulous and incompetent practitioner (China, 2008). The Government website (www.number10.gov.uk) has recently stated the priority for regulation of psychotherapists (who are referred to as “staff”, perhaps indicating absorption into the NHS model) as being the “significant potential risk to patients and the public”. Likewise HPC emphasise that they “were set up to protect the public” (HPC website).
It is clearly implied by HPC, in spite of the proliferation of codes of ethics, codes of practice and enhanced complaints procedures brought in by organisations such as UKCP and BPC during the past 15 years, that clients have not been adequately protected from psychoanalytic practitioners. This appears to ignore the fact that if grievance recourse through existing self-regulatory organisations failed to provide a satisfactory outcome, the client could seek recourse under English Law (China, 2008).
No ethical or competent practitioner would disagree that psychotherapy is onerous work which carries great responsibility. Furthermore, it cannot be denied that there are instances where psychotherapists have fallen below the standards of competency expected, and miscreants who have abused clients, either emotionally, sexually or financially. How many practitioners fall into this category? Research referred to by the DoH should be published in order that we are all aware of the scale of the problem. This would conclusively prove the justification for State intervention in the psychoanalytic field and would categorically demonstrate that organisations such as UKCP, BPC and BACP have been unable effectively to manage and keep their registrants under any semblance of control.
It is estimated that, excluding supervision and continuing professional development, there are 20 million contact hours with clients in UK psychopractice (House and Postle, 2008). Repeated attempts to obtain statistical evidence from the DoH “have constantly met with vague anecdotal assertions that ‘we know substantial abuse exists’ – but nothing more” (2008:196). It is ironic that this most unsatisfactory situation is compounded when one considers that part of the HPC/DoH ethos is for psychoanalytic psychotherapy is to be a so-called evidence-based approach.
Similarly perplexing is the position on public safety adopted by the self-regulatory organisations. For example, Ablack states that within UKCP “….there remains a commitment to legislation being established that will seek to bring to an end the practicing of psychological therapies by those who do not meet enforceable training, practice and ethical standards….I want the public protected from rogue and unsafe therapists….” (Ablack, 2008:22). BPC and BACP also strenuously state their commitment to protecting the public from as yet unknown numbers of rogue practitioners.
In the United States where regulation of psychotherapy and counselling has proliferated during the past 50 years, Hogan notes that: “Whenever professional associations have gone to individual State legislatures to argue the case for licensing, it has been in the name of protecting the public. It is plain, however, that self-protection and the desire for economic well-being are also at work” (Hogan, 2003:162).
In a recent media campaign on London Underground, an HPC poster portrayed alarming creatures represented by unregulated, that is to say non-HPC regulated practitioners, where the strap-line read: “There is no need to fear any longer such monsters and charlatans” (Bernard Burgoyne, 2008:8). Burgoyne observes: “Needless to say, until this advertisement appeared no one had categorized these practitioners as monsters and wolves”. HPC registrants are asked to circulate leaflets with logos such as “Health Professionals must be registered so you can be sure….your health professional is genuine” and urging service users to check on-line and search that their health professional is HPC registered, or to ask for HPC certificates and identity cards. Even car window stickers are available: “You’re in safe hands; I’m regulated by the HPC.” It is as though HPC need to foster a fantasy of the predatory, unprincipled and inept therapist preying on the vulnerable general public.
It is clear that no external agency imposed through State regulation, can provide an absolute quality assurance to the public regarding the conduct of practitioners (Leader, 2008). As Dame Janet Smith stated after publication of the Shipman Inquiry report: “”I cannot guarantee that, if all my recommendations are implemented, it will be impossible for a doctor who is determined to kill a patient to do so without detection” (British Broadcasting Corporation, 2004). If no amount of regulation can stop an individual who is determined to cause harm, it seems logical to conclude that State regulation of psychotherapy can only result in these unknown numbers of miscreants ‘flying under the authorities radar’ through using a different work title.
Dr Daniel Hogan, with over 20 years experience in studying the impact and effectiveness of regulation, conducted research at Harvard in to US licensing laws of therapists. Hogan published his research findings in a landmark 4-volume series The Regulation of Psychotherapists (Hogan, 1979). He concluded that where there has been State intervention it has “probably caused more harm than good” (Hogan, 2003:160). Hogan also proposes that: “Where special dangers are identified in the psychotherapeutic process and where traditional avenues of dealing with them are ineffective, special laws should be enacted. Existing fraud and sexual harassment laws should be strengthened and used to prevent some of the abuses that currently occur in professional practice. This alone would obviate much of the need for licensing” (Ibid:166).
Toxic effects on psychotherapy
The march towards State regulation has proceeded with only a limited number of dissenting voices from outside the main self-regulatory organisations voicing their concerns at the absence of reflection at the damage that the HPC route may cause. Their experience has been “of Totsweigen, being ignored to death” (House and Postle, 2008:193).
Little or no research, including investigation of regulation in other countries, has been undertaken to ascertain whether the suggested benefits of State regulation – primarily based on public protection – will be eclipsed by unintended and toxic side-effects. “That such an investigative process has apparently not even been considered strongly suggests that the regulatory process has more to do with ideology (modernity) and economic self-interest than it does with either client protection in particular or rational argument more generally “ (House and Postle, 2008:194).
The possibility that state regulation of the private discourse of the consulting room might compromise the integrity of psychoanalytic work seems neither remote nor trifling. We surely cannot assume that government is always benign. It behoves us not to betray future generations by failing to consider and debate these matters as widely as possible.
Decisions for practitioners
At this critical juncture in the history of psychoanalysis, practitioners find themselves in the position of having to make informed decisions as to whether regulation as outlined is right or wrong.
Might some issues be distorted by feelings of insecurity – perhaps resulting from an infantalisation during training, and as practitioners the sense of being ‘less than’ – which are factors in seeking ‘authentication’ from an organisation such as HPC? Do some of us require a Cartesian style affirmation – “I register therefore I am” (C. Oakley, 2008:41) – a sense that credibility will only be achieved through finally being classified as ‘health professionals’? Is State regulation a means through which we can feel legitimate (H. Oakley, 2008:21)?
If this is the case, what will be the cost to psychotherapy and to us as practitioners? In our work we are aware of the tendency of traumatised clients constantly to surrender to unconscious/dissociative punitive states of mind, in thrall to authority. Could our sense of identity as practitioners be so fragile that as Haya Oakley observes: “….the less there is of our ability to articulate what we are about, the more absurd the rules we seek to fix and define us; rules that put an edifice of a solid existence where fluidity, flexibility, and freedom should be” (H. Oakley, 2008:26)? Will the price for State regulation be a fear of the regulators with their fitness to practice rules and third party complaints, which will then extend to “our students and our patients and, very soon, of one another” (2008:26)?
Impact on transference and countertransference
The wording and terms used by HPC, SfH and the DoH indicates that many of the principle tenets of psychoanalytic thinking will be fundamentally changed through State regulation. How will regulation impact on the practitioner? There will undoubtedly be a movement away from the practitioner primarily taking personal responsibility for the work they do, to one of accountability to the external regulator (Litten, 2008). A wish to ‘please’ the client, in order to reduce the danger of complaints, is likely to eclipse a concern to speak the perceived truth. If a complaint is made, will government functionaries be capable of understanding the complexities of transference, and indeed their own transferences, especially towards psychotherapy and psychoanalysis? Similarly, references to the ‘consumer revolution’, a redundant concept with the current global financial crisis, could have profound implications for transference. As Roger Litten points out: “The reduction of the relation between practitioner and patient to a commercial contract between service provider and consumer can only involve a profound misrecognition of the ethical basis of the transferential relationship on which all psychotherapeutic practice is founded” (Litten, 2008:17).
Is psychoanalysis compatible with manualisation?
Psychoanalytic enquiry is about discovering the unknown within the individual, a process of allowing the unconscious to speak. Since the focus is upon the unknown within the individual, it follows also that a manual is fundamentally incompatible with psychoanalysis. As Darian Leader succinctly observes, “To speak of good practice automatically introduces the technology of inspection and evaluation. Although talking therapies should never be shy about scrutinizing their results and suppositions, today’s popular evaluative apparatuses always set norms against which individual paths and practices can be measured. Measurement otherwise has little sense in these frameworks. Yet psychoanalysis, as an exploration of unconscious structure, has results that vary from one individual to another. Each subject is deemed unique, and no standardized result of analytic treatment is sought, a point emphasized by Freud, Lacan, and Winnicott” (Leader, 2008:209).
Evidence-based demands and standardisation sought through State regulation and the NHS approach are contradictory to the psychoanalytic view of the uniqueness of the individual. What may prove therapeutic for one client may be totally inappropriate and ineffective with another. Psychotherapy is not a technique to be learnt and universally applied but is an exploring of human subjective history and experience. It cannot be ‘forced to happen’ and certainly cannot be guaranteed in the form of an ‘offer’ (Leader, 2008).
We have outlined in this paper substantial grounds for questioning whether the HPC process for State regulation is likely to be detrimental to psychoanalytic psychotherapy. A viable and empowering alternative to State regulation has been proposed by the Independent Practitioners Network (IPN) (House and Postle, 2008). This would involve the “building of mature and congruent accountability institutions” at “macro and micro level” that embody “‘power with’ rather than ‘power over’ principles of organizational and human relationship” (2008:198).
IPN have outlined their proposals for statutory regulation:
1. Ongoing, long-term, face-to-face contact with a settled group of peers that demonstrates a practitioner’s capacity to form working alliances based on respect, negotiation, mutuality, and rapport.
2. Declaration by each participant to the peer group of their training, competences, special area of expertise, if any, the client population for whom they are competent, their work-load, their continuing personal-professional development commitment, and their supervision arrangements.
3. Mutual disclosure in the peer group of challenges, deficits, difficulties, achievements, and significant developments in their practitioner work, coupled with disclosure of any developments in their personal life that might affect their fitness to practice.
4. Agreement between the practitioner group members about how disputes with clients should be handled.
5. Self and peer accreditation in such a group institutionalizes practitioner-client accountability in a way that greatly increases the likelihood of client satisfaction, and, we maintain reduces closer to zero than any conceivable alternative the chances of abusive or exploitative practitioner behaviour (2008:198-9).
To counter objections that may be raised concerning collusion between group members it is suggested that: “….when such a group has formed, they contract with other similar groups to establish external validation of their accreditation / dispute resolution process and possible collusive agendas. There is also a vested interest carried by every group member that their group colleagues’ practice is sound and ethical (not least because if it is not, then that will reflect unfavourably upon their own judgement and practice). Moreover, this approach to accountability also draws upon what is commonly a very well developed intuitive and perceptive sense in therapists and counsellors, such that our ‘peers-in-relationship’ are best placed by far to ‘pick up’ concerns about any given practitioner’s fitness to do this demanding work” (2008:199) .
Practitioners would opt into “a national practitioner database where their listing is endorsed and dependent on the support of identified practitioners who are publicly prepared to stand by their fitness to practise, competence, and ethical stance, and an outline of how they resolve disputes….If a practitioner was unwilling to it would be questionable whether they are fit to work as a psychotherapist” (2008:201).
This is just one credible alternative to State regulation which has been proposed by Professor Daniel Hogan and successfully implemented in the United States. A comprehensive report commissioned by the State Government in Victoria in 2004 was undertaken by Psychotherapy and Counselling Federation of Australia (PACFA) into regulation throughout developed countries (including the HPC regulatory model). This 205 page report concluded inter alia that:
- Counselling and psychotherapy are fundamentally different from most other health professions
- The key feature of ‘talking therapy’ is the relationship and process of therapy, rather than performance of certain definable procedures (manualisation)
- It is difficult to define competencies (NOS) and scopes of practice in a narrow legalistic framework
- Diversity of training and theoretical approaches requires a regulatory model that respects multiplicity while maintaining clear standards
- The Profession would be best managed within a self-regulatory model based on professional colleges, who will provide clear standards for training and ethical practice of professionals.
Society is constantly evolving and changing its system of values and beliefs. The advent of ‘consumerism’ 20 years ago is a point in case, which no doubt will be the subject of variation as a result of the current global financial crisis. Paul Verhaeghe (2007) notes a prevailing change in society during past the 40 years. In the 1960s the individual adopted a stance of personal responsibility, mea culpa; the present day ethos being diametrically the opposite: “Guilt has become an obscene word, and if something goes wrong, the cause has to be looked for in some external agency” (Verhaeghe 2007:6). State regulation of psychotherapy epitomizes this societal change. The client may think, ‘the changes I want in my life are not happening through therapy – who can I blame’? HPC has readily provided an answer.
Hogan’s extensive research into regulation paints a grim picture: “The future of counselling and psychotherapy in the United Kingdom would appear to be at a critical juncture today. If restrictive licensing is adopted, then I fear that the field will be crippled for years to come” (Hogan, 2003:169). An even bleaker Orwellian outlook is satirised by Nick Totton as follows:
“It was in 2023 that ‘traditional’ therapy and counselling finally became illegal under the new Social Fraud Act, leaving New Therapy in command of the field. Looking back, this had probably been inevitable since the state regulation of psychotherapy and counselling…. once the state took on the job of policing therapy, its definition of what was acceptable was bound to become increasingly draconian, as therapy was adjusted to fit concepts and standards which the civil service could comprehend and administer…. What happened to the discredited traditional therapists? Some of them had been more or less underground since the later 2010s, changing their name to ‘psychological helper’, ‘emotional supporter’, or some other dubious term, before this option was removed by the Act of 2023. A very few served prison terms for illegal use of protected titles, or later for illegal practice of discredited techniques. But the great majority either silently retired or adapted to New Therapy – demonstrating, as the state saw it, the feebleness and fraudulence of their practice: if they were not even prepared to stand up for the value of their own work, then why should anyone else take them seriously?..In 2025, of course, the Revolution began…. (Totton, 2008:1).”
The 2007 White Paper states that: “….the Government believes that all professionals undertaking the same activity should be subject to the same standards of training and practice so that those who use their services can be assured that there is no difference in quality” (HMG, 2007:85). It is on this basis that HPC will regulate psychotherapy and we do not believe it alarmist to suggest that this will ultimately result in the introduction of ‘New Therapy’. Darian Leader recognises this when he states: “Psychoanalysis and the psychotherapies are expected to replace their antiquated speculative systems and outdated therapeutic aims with new standardized evidence-based models” (Leader, 2008:205).
The authors hope that this paper will stimulate public debate in order that practitioners may fully understand and assess the consequences of State regulation as outlined by HPC. However, if doubts remain as to whether the public safety justification for State regulation is no more than governmental propaganda as part of the so-called ‘Nanny State culture’, which existing self-regulatory organisations have appropriated for their own advantage, then a call for a radical rethink might be the most ethical stance (In this connection, it is significant that HPC recently reported: “A number of respondents [to the HPC ‘Call for Ideas’] commented that some professionals who feel that regulation through the HPC is not appropriate for psychotherapy or counselling would adopt an approach of ‘principled non-compliance’ if regulation was introduced” (Health Professions Council, 2008b, p.10)).
Addendum [added 14.12.08]
The Centre for Outcomes Research and Evaluation at University College London, commissioned by Skills for Health, has now published the official competences for psychoanalytic psychotherapy, which clinicians may be expected to demonstrate in their work. They can be found at:
These contain two documents, one for clinicians and commissioners, and another for ‘service users’, and also a ‘map’ of the competences.
- The documents are written by three UCL clinical psychologists, one of whom is a psychoanalyst, whilst the other two were also the authors of the CBT competences.
- The work is based on studies of forms of psychoanalytic therapy, based on manuals that have been found to be evidence-based in clinical trials. It was overseen by an Expert Reference Group, “comprised of national experts in psychoanalytic therapy, selected for their expertise in the development of novel psychoanalytic treatments, the evaluation of psychoanalytic therapy in formal trials, and the development and delivery of supervision and training models in psychoanalytic therapy” (2008:4).
- There are indications of the specific psychoanalytic competences required for work with specific diagnostic categories.
- Amongst their varied applications, these guidelines will be used to provide “a clear set of competencies which can guide and refine the structure and curriculum of training programmes (including pre and post-qualification professional trainings as well as the trainings offered by independent organisations)” (2008:270). They will also be used in connection with the registration of psychotherapists.
- The concluding section comments: “This report describes a model which identifies the activities which characterise effective psychoanalytic therapy interventions and locates them in a ‘map’ of competences” and refers to its use “as an aid to curriculum development, training, supervision, quality monitoring, or commissioning” (2008:26-7).
Detailed descriptions of the competences can be downloaded as pdf files from the website of the Centre for Outcomes Research and Evaluation: www.ucl.ac.uk/CORE by clicking on the map of competences.
The views expressed in this paper are those of the authors
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This paper was first published in Attachment: New Directions in Psychotherapy and Relational Psychoanalysis, Vol. 3, March 2009
Richard Reeves is a member of the Forum for Independent Psychotherapists and The College of Psychoanalysts – UK. Correspondence email: firstname.lastname@example.org
Phil Mollon is a clinical psychologist, psychotherapist and psychoanalyst working within the NHS