Head of Regulatory Policy
15 St John's Business Park
Competencies Consultation Response
There are a number of points I'd like to make in relation to the article 'The Future of Counselling and Psychotherapy' in the February 2007 edition of Therapy Today.
1. Do these domains units and elements accurately summarise the elements of competent counselling/psychotherapy practice?
Having been actively involved in the development of NVQs for Advice, Guidance, Counselling and Psychotherapy a decade and more ago, I am now more sceptical than I was about the practicality of applying functional analysis to this field. I note that the article in Therapy Today states, presumably in reference to NVQs -
"Previous work on mapping competencies and standards failed to do justice to the complexity of the profession…"
I find that rather odd, given the complexity of what did emerge. Take Sue Wheeler's comment about just one of these NVQ units - Unit B.7 'Develop the counselling relationship' - on p 119 of her book 'Training counsellors: the assessment of competence' (London, Cassell: 1996), where she writes -
"Under ideal circumstances, over a period of several years in a busy counselling practice, it might be possible, through regular individual clinical supervision, to be sure that a candidate for assessment had met all the requirements…"
It would appear from this that, far from being too lacking in complexity, what emerged was over complex. But I don't want to get distracted. What's crucial is whether there are fundamental problems with the approach as a whole in relation to this field of activity. I suspect there are. In particular I'm not convinced anyone has succeeded in developing satisfactory criteria for determining whether or not any given therapeutic relationship is satisfactory.
Since NVQs were drafted the significance of this failing has become more apparent. Research by Bruce E. Wampould has clarified the extent of the difficulty - see 'The Great Psychotherapy Debate: models, methods and findings' (London, Lawrence Erlbaum: 2001). Duncan et al summarise a key finding of Wampould's on p 36 of 'The Heroic Client: a revolutionary way to improve effectiveness through client directed, outcome informed therapy' (San Francisco, Jossey-Bass: 2004) in this way -
"The amount of change attributable to the alliance is about seven times that of the amount attributable to a specific model or technique"
The question that this begs, then, is whether a competency based approach can give enough weight to a finding of this magnitude (as opposed to its significance getting lost amidst a lengthy list of relatively much less important competency statements). The practitioner's involvement in developing the therapeutic alliance is particularly difficult to measure, given the part that clients also play (see Arthur C. Bohart and Karen Tallman "How Clients Make therapy Work: the process of active self healing" (Washington, American Psychological Association: 1999)). If BACP is determined to regulate entry to the profession of counselling and psychotherapy through the drafting of national occupational standards of one kind or another a means of doing this will be essential.
One alternative, of course, is to stop looking in the wrong place for a solution and, instead, listen to the advice that Professor Daniel B Hogan has been offering for decades. His view is that the key is to pay attention to outputs rather than inputs - see his curiously neglected (by BACP) but nonetheless seminal study 'The Regulation of Psychotherapists' (Cambridge Massachusetts, Ballinger: 1979) and his more recent updates, Professional Regulation as Facilitation, Not Control: implications for an open system of registration versus restrictive licensure in Bates, Y. and House, R. 'Ethically Challenged Professions: enabling innovation and diversity in psychotherapy and counselling' Ross-on-Wye, PCSS Books: 2003 and Control, not Regulation in Greenberg, S 'Therapy on the Couch: a shrinking future? (London, Camden Press: 1999).
I am deeply disturbed by BACP's apparent position - namely that, while as practitioners we should pay close attention to research findings, as members of a trade association it is perfectly fine to ignore them. BACP's stance would be much strengthened if it could show that Professor Hogan is mistaken, given the importance of his study, which is by far the most extensive ever written.
There is a further problem with the list of domains, units and elements that I do not see how a competency based approach can resolve. If there's one ability that lies at the heart of good counselling and psychotherapy it's the skill of being able to put into words what needs saying but isn't being acknowledged. This skill is exceptionally difficult to measure objectively - not least because each intervention takes place within the context of a therapeutic relationship that has been developed jointly by (a minimum of) two separate individuals.
As Bruce E. Wampould has shown the evidence "convincingly corroborates the contextual model and disconfirms the prevailing medical model" (op cit: summary on back cover). For the purposes of his argument in 'The Great Psychotherapy Debate' the contextual model is the one proposed by Jerome Frank in the various editions of his seminal book, 'Persuasion and Healing' (see Frank, Jerome D. and Frank Julia B. (1991) 'Persuasion and Healing: a comparative study of psychotherapy' London: John Hopkins University Press).
Once we look closely at the central elements of good counselling and psychotherapy the problems with a functional analysis approach begin to multiply -
- " I have already touched on diametrically opposed views over the issue of complexity.
- " There is also the tricky question of "mistakes". An expert practitioner will be flexible enough to make appropriate adjustments and what appears to be a mistake can turn out to be a turning point in the therapy - because of the way in which the "wrong" intervention is nested within a good enough therapeutic alliance. Patrick Casement has written a series of books exploring this theme.
- " One major problem lies in the judgement about what constitutes sufficient evidence of competence. There is considerable scope for erratic interpretation of competency statements with too much depending on the background understanding and subjective experience of the individual making the assessment, especially in relation to judging - for example - the quality of the therapeutic relationship or, as mentioned above, the ability to put into words what needs saying but isn't being acknowledged.
- " It gets worse. In my experience competency statements can actively promote poor practice as soon as the assessor - as is, unfortunately, too often the case - starts to behave defensively, when faced with practitioners willing to make full use of complaints procedures. Appeals procedures in my observation tend to focus on legalistic rulings.
The difficulty is partly that there is always a subjective element involved in assessing something such as the strength of a therapeutic relationship, but I believe there is a more fundamental problem. To go back to Professor Daniel Hogan's point, once you start to make judgments about inputs (ie entry to a profession) not only do you run the risk of excluding competent practitioners by developing criteria that aren't justified by the evidence, but you generate a further difficulty when you endorse other practitioners and label them "competent". If the criteria for assessing competence can't be defined precisely enough, there is the danger of conveying a false sense of safety, both to the public and to practitioners themselves. A powerful case can be made that, once labelled as "competent", practitioners tend to rest on their laurels and regard supervision and CPD requirements differently. I don't think this happens in quite the same way when counsellors and psychotherapists are under effective ongoing peer scrutiny.
We have to face the possibility that problems of regulating entry to the field of counselling and psychotherapy using a set of competency-based statements may prove intractable. It can be argued that no counsellor or psychotherapist is ever able to work well with anything more than a relatively restricted range of clients - and that the only respectful attitude to others and the diversity of their needs is always to be seeking to extend the range of their competence. There are too many barriers of language, culture, class, life experience and so on - quite apart from, for example, the range of mental health difficulties or spiritual experience of which no one can claim to have a comprehensive understanding. Many have argued - and this fits well with the Frank and Frank's broad based comparative study - that counsellors and psychotherapist need to be constantly developing their ability to step outside conventional points of view and take a critical look at what is too often taken for granted. From this viewpoint competence is only ever provisional, since it demands that each practitioner stay within the limits of their abilities, which - in turn - requires ongoing monitoring.
It is possible, as Professor Daniel Hogan has argued, that the most useful way of addressing this problem is to look not at inputs, but at outputs. Counsellors and psychotherapists are only as good as the results they achieve. I find it interesting that, by and large, my colleagues choose their own therapists on the basis of reputation - that is to say "outputs". Why, then, is BACP so preoccupied with inputs? Should there really be different rules for our clients from the ones we apply to ourselves?
I think within BACP not given enough time and attention has been given to the exploration of these fundamental issues. For years BACP has been too blinkered in its approach and in its reluctance to look at evidence that doesn't fit its own preconceptions. The interesting and creative explorations have, by and large, taken place outside the organisation. Accountability structures such as one developed by the Independent Practitioners' Network over the last decade or so avoid some of the pitfalls described above and deserve further consideration. But the essential difficulty with defining core competencies is that we don't know enough about what makes therapy work to be able to do this properly.
2. Should BACP endorse the proposal in the report that counselling and psychotherapy become a graduate and postgraduate profession, and work towards this end?
BACP is an educational charity and should base its policy on a balanced understanding of evidence. On p 37 of her 'Report on Effective Psychotherapy: legislative testimony' (Lake Placid, NY Hillgarth Press: 1981/1994) Roberta Russell wrote -
"The studies all indicate that long years of academic study are not a prerequisite for competence."
More recently Arthur C Bohart and Karen Tallman concluded (op cit, p. 33) -
"What we find impressive is that trying to find evidence of differences in effectiveness as a function of training and experience is similar to trying to find evidence of differences among therapies. It is so hard to find evidence of anything more than very small differences."
The short answer to the question, then, is a resounding "No!" Without convincing evidence that academic qualifications make counsellors and psychotherapists more effective practitioners there is absolutely no justification for such a policy change - especially in view of the negative consequences involved.
3. What are the potential positive and negative consequences of going down this route?
In the first place it runs the risk of contravening charity law. BACP is an education charity. As such it must present a balanced case for any change it seeks in government policy.
Secondly, it is unethical for an educational charity whose purposes must be entirely to do with serving the public interest to press for a policy change simply because this is in the interests of (some) BACP members. There is an important conflict of interest here. As I have long argued, BACP's existing structure makes it vulnerable to the claim that all too often it acts as a trade association whilst masquerading as "the voice of counselling". This is all the more serious because of the high emphasis counselling and psychotherapy traditionally place on ethical behaviour. Indeed some practitioners see their whole work as an expression of practical ethics - for example, the dust jacket of Paul Gordon's book "Face to Face: therapy as ethics" (London, Constable: 1999) reads -
"In this book, Paul Gordon argues that psychotherapy is fundamentally an ethical endeavour in which the therapist is called upon to take up a stance of responsibility and openness to the other. Such openness requires the abandonment of a great many preconceptions and a critical examination of what is too often taken for granted…"
It is disingenuous for BACP to try to seek a mandate from its members (who in this case could be reasonably be suspected of acting out of self interest) to enable it to ignore its educational charity obligations and press a partisan view that is quite demonstrably in conflict with the existing research.
Thirdly, as Professor Daniel B. Hogan and others have persistently pointed out, there are serious equal opportunities issues involved in making this policy shift. It will unnecessarily restrict the supply of practitioners. It will unnecessarily inflate costs, both of training and of services. It will make it more difficult for volunteers to perform effectively. It will discriminate against minorities by unnecessarily raising entry requirements in terms of time and cost.
We already know that BACP membership is very far from being representative of the population as a whole and this shift will further favour the already privileged. This proposal therefore ought to be totally unacceptable to BACP, given its recent declarations of a commitment to good equal opportunities practice. What is particularly obnoxious is the supposed "new…recognition of equality and diversity issues, social and political contexts…and research" (Therapy Today February 2007, p.48) espoused in the very competencies that are the subject of this consultation.
In the face of all this it is hard to see what positive consequences "of going down this route" there could be above and beyond than acquisition of more power, status and money for those counsellors and psychotherapists remaining within the profession.