Some comments on proposed regulation for the therapy professions

by Marcus Bowman

Editorial note: At the invitation of the Editorial Board, Marcus has shared the text of a speech he presented at the conference chaired by Dr. Finian Fallon on ‘What is the future for counselling and psychotherapy in Ireland?’, City Colleges, Dublin, March 25th, 2018.

Introduction
I am going to make just a few brief comments on the question of regulation for the therapy professions. This is a very complicated subject that needs to be given a lot of thought, but I will keep my remarks short and hopefully to the point.

I know that my remarks may seem surprising to some people, but I want to stress that my intention in making them is not to cause upset or to shock anyone. My hope here only is to make a few points that can be used as an opening for discussion. My concern is that we have not up to the present had a proper debate about regulation and given the potentially significant and long-term consequences of legislation, we need to remedy this lack.

Some clarifications and qualifications
I want to preface my remarks by saying that I am using the terms therapist and therapy here purely in a generic sense to refer to anyone who uses talk therapy as a way of assisting people with emotional problems, whether they call themselves counsellors or psychotherapists or anything else. I am not here concerned to draw any distinctions within the field of the talk therapies in general.

Also, I need to stress that I am speaking here only of therapy with adults. I have nothing to say about therapy with children, who obviously need special safeguards. Adult therapy involves a dyadic relation between two people, either of whom is free to end the therapy at any time. Child therapy in contrast involves a triadic relationship, because a parent or guardian is always included, and consequently the dynamics of the process are quite different.

Indeed, my essential objection to the current proposals for regulation of the therapy profession is that they would turn adult therapy into a variant of child therapy, by establishing an external authority to oversee the patient-therapist relation. In my view this is incompatible with the practice of therapy in a secular democracy.

The first regulation option
The first thing we need to understand is that in designing legislation for any profession we confront two fundamentally distinct options.

Our first option is to erect entry barriers into that profession. This approach starts from the assumption that a candidate for entry into the profession is not competent to practice that profession until he or she has proven otherwise. This proof of competence is provided by the candidate passing certain prescribed tests and examinations.

This is how, for example, medicine is regulated, and also its ancillary professions, like nursing and physiotherapy, and so on.

By and large this approach to regulation is the one adopted in the case of any profession that is based on the practice of the physical sciences. Alongside medicine we could mention professions like engineering and architecture, and also trades that have traditionally required apprenticeships, like that of the plumber or the electrician.

The reason this approach of setting up entry barriers is taken in professions like this is that it is easy to establish tests in the physical sciences that are objective and that will give rise to results that command a high degree of consensus. There is doubtless an element of luck in being admitted to any profession, but in general you won’t become a hospital consultant unless you have been able, over many years, to demonstrate a high degree of technical skill in your specialty.

The second regulation option
Now, our second option in regulation is to start from the opposite assumption, namely to assume de facto that all candidates – or virtually all candidates – for entry are competent to practice, unless they clearly prove themselves unfit to do so.

This is the approach that is taken to most of the professions based on the human sciences, that is to say, the non-physical sciences. It is taken here because with these sciences it is not possible to establish objective tests of competence that will command broad consensus.

This is why anyone is free to practice as, for example, an historian, or an economist, or a social scientist, or a journalist, and to describe themselves professionally in such terms.

This family of professions based on the human sciences have certain characteristics in common. For instance, forms of employment within them tend to be quite diverse. Some practitioners work in education, some work for government agencies, some are employed in industry, and some are self-employed. Those who are employed by formal organisations will of course have to meet the particular requirements stipulated by those employing organisations. But entry into the profession as such is open to anyone, irrespective of their formal qualifications.

Another characteristic of these professions, based on the human sciences, is that they tend to form within themselves informal schools of thought, reflecting the fact that influences and approaches are diverse. There is, in other words, not a high degree of agreement on what standards, or priorities, or approaches are crucial for inclusion in the profession as a whole. This again reflects the fact that in the human sciences, unlike the physical sciences, it is not possible to set up tests of competence or ability that will give results that command wide consensus.

Therapy belongs to the human sciences
My contention is that, with certain qualifications, it is to this latter family of humanities that our profession belongs, and not to the former family of professions based on the physical sciences like medicine.

Like the other professions based on the human sciences, our field is fragmented into multiple schools. This reflects the fact that there is not broad agreement on many significant aspects of the philosophy underlying the work we do, and therefore on what particular values and aims we should prioritise.

I contend therefore, that an attempt to treat the talking therapies as if they belonged to the former group rather than to the latter will not work. What is being made here is what the philosopher Gilbert Ryle long ago called a “category-mistake” (Ryle, 1980: 17ff. et passim).

The current proposals mistakenly treat therapy as a medical discipline
The current proposals for legislation for therapy are explicitly formulated in the first way, not in the second. They expressly treat therapy as an ancillary discipline to medicine and propose to provide a legislative framework based on that assumption.

In other words, the assumption is being made that we have an objective basis for establishing within the profession a system of hierarchy and authority that will be able to command general consensus, when in fact this crucial element for the successful functioning of such a system is absent.

The likely consequences of the current proposals
If we legislate as if we have the basis for a consensus on such matters, even though we don’t have this, I suggest that certain undesirable consequences will inevitably ensue.

First of all, the arena will be set for an intense power struggle between the various associations, groups and factions that constitute the therapy profession as a whole as each one fights to acquire authority in the hierarchy that the law will create.

Since we have no objective measure of who is qualified to exercise authority in our field, this will be decided by the groups which are most effective and ruthless at political lobbying on behalf of their own members. In the absence of an objective test of the right to exercise authority, such as we have in medicine for instance, there is no other way the matter can be settled.

Second, and following on from this, an arbitrary line will be drawn through everyone who now, and in the future, is practising as a therapist. Those who are lucky enough to fall on the right side of this line, who have membership of the groups that successfully seize power, will be legalised. Those who happen to fall on the wrong side of this line will be criminalised, or at the very least strongly disadvantaged in their work as therapists. This line won’t make any distinction between good therapists and bad therapists. On both sides of the line there will be some therapists doing good work, and some doing mediocre work.

Thirdly, under the proposed system, some therapists will become wealthy at the expense of others. Privileged groups within the profession will become enriched, because they will be granted effective monopolies in the most lucrative aspect of therapy, which is the training of other therapists. Those dependent on these privileged groups for legitimation and accreditation will be impoverished at their expense.

What our aims should be in this field
I suggest therefore, that the problem of the design of legislation for our profession needs to be thought through very carefully – something that clearly did not happen before the current proposals were first made, over 10 years ago, and so far as I can see, has not happened since.

The aim of legislation in this area should not be arbitrarily to empower certain groups at the expense of others within the profession, but rather to empower the general public vis-à-vis the profession as a whole.

The aim should be to make the market for therapy as efficient and transparent as possible, by providing as much information to the public as we can about therapists and the profession of therapy.

In my view, we should not place major restrictions on any adult person who wishes to work as a therapist. Possibly the minimum qualification of holding a degree and having spent a couple of years as a client in therapy would be sufficient. I think a minimum age of perhaps 30 or 35 for registering as a therapist would not be inappropriate. I don’t know. These are things that need to be mulled over and discussed by all of us and not just by a self-appointed minority.

I suggest that anyone who chooses to enter the profession should be required to appear on a register of therapists, which should be available to the public. On this register each therapist would be free to outline their education and qualifications, membership of organisations, if any, general background and experience, general philosophy of therapy, and any other information they wish to give about themselves.

Everyone on the register would be bound by a general code of ethics. Any therapist found to have infringed that code would be subject to suspension from the register, either temporarily or permanently, and the reasons for this suspension would be noted.

Each member of the public would thus have access to all relevant information about any therapist he or she chose to attend, and it would be up to each client to decide whether he or she wished to attend that therapist.

In addition, there should be a concerted attempt to educate the public in general about what therapy is, what it can realistically achieve, what it cannot realistically achieve, and what a member of the public should expect if they choose to enter therapy.

Such a system would not be perfect. No system of legislation for such a complex field as ours can be perfect. But it would reflect the reality of the world of therapy as it actually exists now and as it will continue to exist in the future.

Conclusion: Therapists need to be more honest about their own motives in seeking regulation
It needs to be acknowledged that there are many personal stresses that are unique to the profession of therapy. We all have to deal with these as best we can, and I think if we are honest we all manifest symptoms of these stresses to some degree.

For people of a certain temperament, however, this stress manifests itself in the form of a wish to try to control the work of other therapists and to deny them full legitimacy. From the inception of our profession a century ago – in Vienna – this exclusionary neurosis, if I may call it that, has been the main blight on it. It is rooted, I suggest, in unconscious fantasies of sibling rivalry and a sense of insecurity about parental love and approval.

Our focus, I suggest, should be on developing institutional structures that minimise the scope for this kind of symptomatic behaviour. My concern is that the current proposals, which were not designed with any reference at all to the very unusual characteristics of our profession, will have exactly the opposite effect. It will cause us to hand on to the next generation of therapists a damaged profession, lacking in honesty about its own motives and distorted by its own anxieties.

Thank you for your attention.