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What kind of regulatory framework do we really want to work in? A personal response to compulsory state regulation.

Andrew Cook MSc RCST IPN
Andrew Cook is a Craniosacral Therapist in Norwich, and has been practicing complementary therapies since 1987.

In July 2006, the Department of Health (DoH) circulated a letter to various umbrella organisations asking for feedback on their proposals to state-regulate psychotherapy, counselling and psychoanalysis through the Health Professions Council1 (HPC). They essentially have threatened compulsory state regulation (rather than voluntary self-regulation) of psychotherapy, counselling and psychoanalysis, under the auspices of the HPC and the training framework of Skills for Health2 and ENTO3. This proposal is based on the Foster Report4. Although the DoH may not have any allocated budget to carry this out, it is a serious threat not just to psychotherapists, but to complementary therapists as a whole. Furthermore, this very political maneuver is just the visible end of a rather large iceberg of public policy, legislation and regulation which has been moving for over two decades. Remarkably, I only recently heard about this by means of the Independent Practitioners Network5 (IPN) email discussion group6.

Trying to force a herd of cats into a box

Compulsory state regulation of the psychological professions would in effect drive a wedge between this functional part of complementary therapies and the rest of therapeutic practice. Because it is compulsory regulation by Act of Parliament, it would define that divide, not by the title of its practitioners, but by the kind of intervention they provide. There has been a large debate over the past years as to the distinction between a “food” and a “medicine” for nutritional supplements. The dilemma of “when does a food substance become classifiable as a medicine” is at the core of this DoH proposal. Where is the cutoff line between a friend giving advice, a doctor or nurse giving advice reassurance and psychological support to a patient, and psychotherapy/counselling? A physiotherapist might talk to a client during a session as part of their professional service - most people like to talk a bit about themselves. So when does this become psychotherapy? Any definition of counselling based on an intervention/ outcome (rather than on its professional title) would place many people in an invidious position.

The DoH also seems to want to classify psychotherapy so that training and qualifications can be standardised and fitted into a recognisable structure. This is the purpose of the National Occupational Standards (NOS). it’s statement of assisting ‘workplace flexibility’ is really about categorising each task to allow flexible deployment of human resources in a largely inflexible industrial environment. The fact that this leviathan of an industrial training policy has been rolling out over the past 20 years to cover every possible job that anyone can do in the UK is a statement in how the external form of work tasks has been mistaken for the real thing. I read recently that I can now obtain an NVQ level 3 in Taiji. As someone who has practiced Taiji for something like 15 years, I cannot convey adequately the utter ridiculousness of this “qualification”. As someone who practices a subtle form of therapeutic bodywork which is largely based on variations of intention rather than on its external form, I am appalled at the prospect of an NOS in Craniosacral Therapy or any other Complementary Therapy. it gives me nightmarish visions of newly trained well intentioned people pretending to do something which they have no significant grasp of.

The DoH also wants to be able to calculate. ‘we do X at cost P and have result Y at value Q, giving a net benefit of Q – P’. Essentially this is an attempt to fit all services which it might use into the same model as that used to classify medicines. In practice there are a vast array of different trainings and even of paradigms in psychotherapy. Hence the failure of the various professional bodies to reach agreement over a common syllabus core or training structure over the past few years; and hence the DoH stepping in, threatening to take over and run the profession themselves.

The sheer diversity and rate of development and change of these disciplines places them outside the ability of the ‘Skills for Health’ and ENTO programmes to classify and box them. This is NOT a good reason to force them into a box. In fact it is an indication that whilst this formal kind of classification may be desirable for NHS administration, it is not a reflection of reality. The DoH/NHS is a large and powerful enough institution to be able to attempt to change realities which it finds inconvenient - I am really not convinced that it should be allowed to do so. If the NHS wishes to define the training standards which it imposes on its employees, then it can easily do so by internal policy decision - there is absolutely no need to impose this arrangement on everyone else by Act of Parliament.

Actually, I can see one possible reason why the DoH would want to impose a universal training format on healthcare workers. This would be possibly necessary if the NHS were to be privatised and everyone issued with healthcare coupons for the purchase of services. The biggest problems this will create will not be in the current generation of practitioners, who have a large word of mouth patient referral rate - but when we retire, there would be no means to replace us. New people would either come up through the State system, or not at all. Below, I briefly outline just a few of the implications.

If any complementary therapists are in doubt as to the DoH.s intentions, the recent developments with Pharmacists are instructive. Pharmacists are currently overseen by a body (RSPGB7) which has a dual role of promoting the members professional (not financial) interests and regulating the profession. The government has said that (a) better regulation is needed (the RSPGB complied and set up stricter regulations), and (b) Oh, now we think it isn't a good idea to have dual roles, so the HPC is likely to take over the regulatory function. The result seems to be that the RSPGB, which was responsible for regulation - and therefore had compulsory membership - would no longer have that function. This has led to something akin to panic in the Society HQ, as the new role would be less defined, and certainly carry no statutory compulsion8. Similarly an entry into the Federal structure proposed by the Princes Trust would have exactly the same effect by different means - professional organisations would be reduced to little more than printing magazines and designing T shirts.

Political fashion ignores long-term needs
In many ways, the political adoption of Cognitive Behavioural Therapy (CBT) from about 2005 has muddied the waters. CBT is a ‘think positive’ approach which has many positive things going for it. However, it just doesn’t go deep enough into the subconscious to make a lasting impression in many cases. The relapse rate one year after treatment is about 90% - which fact seems to have been forgotten in all the hype about how effective it is in the short term. The 10% long-term success might be worth its political sponsorship, but there should still be something left to catch the 90% who don’t make it!

CBT fits the current fashion for telling people to pull their socks up and then abandoning them if they cannot do so. If someone has had a mental health condition for 20 or 30 years, telling them what to do and then pushing them out of the door is not really going to heal them, or help them. In my more cynical moments, I suspect that some of them will eventually succumb to cold whilst living on the streets, or will take an overdose whilst isolated in their back into the community flats.

Playing with Mr Potato Head
Huge advances in neurophysiology have been made over the past 50 years. The fundamental principles of many body therapies and psychotherapies are now converging onto a recognisable model of bodymind interactions - and how to work with them therapeutically.

Psychotherapists and counsellors approach the mind-body phenomenon from the direction of the psyche. There are many bodywork techniques which approach it from the body/ physiology/ motor systems. The two approaches naturally meet in the middle, because that is where the complete human being is situated. There is actually no division between mind and body except for the artificial one we have taken on culturally. If I breathe shallow and quickly I feel panicky. If I think of a lemon, my mouth salivates. If I get frightened or angry, then my metabolism mobilises and certain muscles tighten. If I consciously tighten those muscles while relaxed, I become more Sympathetic-aroused and alert. If I sit with head drooped, I feel depressed, and if I pull myself vertical, my mood lifts. If I talk about a stressful situation, even for a few seconds, my blood pressure rises. If I touch an old scar tissue or a particular place on the body, or take up a particular posture, memories are evoked. So where does psychotherapy end and physiology begin? Cutting edge research such as the brain activity research of Ellert Nijenhuis9 in the Netherlands and PTSD work of Eli Somer10 in Israel, along with work by Babette Rothschild11 and Pat Ogden12 are just a few of many demonstrations of the deep interplay between soma and psyche, and show that the body and mind work as a unified whole at the level of personality and the subconscious.

The DoH seems determined to legislatively cut the human being off at the head - just as the psychotherapy professions themselves are starting to join the head back onto the body. My personal practice sits exactly in the middle of all this. I have a main practice of Cranio sacral Therapy which is supposedly "bodywork", and I talk to my clients to resource them and to assist the mental part of the body processing. Furthermore, I have a large proportion of clients who have received psychotherapy for years, and who come for the bodywork I offer because it helps them mentally - once they have hit their limits of talking, they can get more progress by approaching themselves through their tissues and muscles.

Vulnerability vs Victimhood
The vulnerability of clients who come for counselling, psychotherapy, or other 'complementary' therapy is already fully recognised by the various professional bodies and codes of conduct already in place. Overemphasising a client’s vulnerability is usually counter-productive and unhelpful. In psychotherapy there is a well known relationship between the co-dependent13 roles of Rescuer, Victim and Persecutor. If one person is given a Victim role, the helper becomes the Rescuer/Persecutor (there is psychologically very easy slippage from the role of Rescuer into Persecutor). Similarly, if a person or an organisation takes up a Persecutor or Rescuer role, the third party takes up a Victim role. State-sponsored healthcare always teeters dangerously on the edge of a ‘Rescuer’ role, creating ‘victims’ by default, and always at risk of falling into a Persecutor role. I’m not saying this doesn’t also happen in the private sector, but the power of the roles (and helplessness of a defined victim) is far greater in a state-sponsored system. There is a grievous error being made in over-protecting sectors of the public14, because they begin to take on the role in this co-dependent triangle they have been given by default. Once someone is subconsciously acting as a Victim, they naturally attract Rescuers - and Persecutors.

The NHS is the envy of many countries worldwide, and provides a fantastic service to people in the UK. However, this public health insurance through universal taxation has some downsides. One serious problem created by a National Health care system is that the State promises to care for the health of its citizens, and over the years most of us have lost interest in maintaining our bodies in any real sense of the word because the State will pick up the pieces (and the tab) when something goes wrong. Doctors do not provide a way out of this dilemma because they are trained to think in terms of illness instead of the promotion of health. As a complementary health practitioner, I sometimes am left overawed at the degree to which we have become separate from our bodies, and the degree to which any sensed connection with them as self-repairing organisms has been given up as ‘flights of fantasy’. In fact, Health is the greatest gift we have in life, and it is freely available to anyone who cares to focus on health rather being hypnotised by the cultural statements of the inevitability of illness. The separation from the realities of nature culminate in our attitude towards death - when after 65 years of leaving the responsibility for health of our bodies to someone else, we ask them to postpone death indefinitely. And when death is welcome, Doctors are averse to letting it happen easily just in case they are accused of euthanasia.

Treating the Private Sector as if it is Public Sector: Confrontation vs Mediation
Historically, people have talked with each other and helped each other - counselling is a professionalisation of a very old art. Somewhere in between plain human-to-human talking and NHS psychiatrists who deal with suicide cases and acute schizophrenia, there is a soft, grey middle ground. This is populated by tens of thousands of mainly private sector professionals, not by NHS professionals. People do not go to these private professionals and give themselves body-and-soul unconditionally, trusting that the treatment is OK because it has been provided by the benevolent state. Instead, the clients are largely self-regulating and can largely tell if they are receiving valuable help, or not. If not, most of them are perfectly capable of leaving, and do so.

It is a fundamental mistake to attempt to regulate the private sector as if it is part of the public sector. Because the NHS appears to dominate the health ‘market’, the DoH appears to have a rather limited view of the importance and high quality work being provided in this grey middle ground by the private sector. The HPC is a highly aggressive regulator which places on its website the names of people who are subject to complaints investigations even before any evidence has been heard. This ‘name and shame’ policy is pretty close to assuming guilt first, until proved innocent and is as abusive as the situations it is supposed to prevent. If you were accused of professional misconduct, I really wonder which procedure you would prefer - the HPC model, or a mediation process? For NHS sector employees who are within a large (hopefully) supportive organisation, are salaried (and therefore will be paid regardless of whether they work or not), who are often members of a union, and who are also often members of very large professional associations; there is some buffering, protection and support available. Self-employed private sector therapists are not so lucky.

Furthermore, it does not help patients/clients to be given a confrontational complaints procedure as first choice when there are already excellent models for mediation procedures already in practice in the complementary therapy world - procedures which are based on models applied in industry and at international level15,16. Mediation-driven complaints procedures are far more able to distinguish between the vulnerable abused client and the would-be stalker who is persecuting the therapist, and to respond appropriately and in a timely manner; partly because they deal with small numbers of complaints for a small number of therapists. Compare this to the 2 year waiting list (December 2006) for complaints procedures for the nursing profession

Confrontation (or lack of compassionate mediation) just ups the insurance premiums and makes people work to ‘jobsworths’ rather than to the best interest of clients. Why risk following an obviously productive route when it is a ‘non-standard’ procedure, and so might not be supported by a governing professional body which wants to protect its own public image, and is so large that sacrificing one or two of its members is not particularly problematic? Worryingly for complementary therapies as a whole, the main alternative to the HPC at the moment is the Princes Trust17. Reading between the lines of the ‘consultation’ document they produced, they are following the fashion for aggressive control, and also appear to favour a punitive (rather than mediatory) complaints procedure to ‘protect the public’.

This will lead to expensive professionalisation of Complementary Therapies, which may look good from the top down as a way of controlling public safety. From the bottom up, it looks not so good. Complementary therapists (CTs) are fairly expensive to someone on a minimum wage, but are nevertheless just about affordable. At the moment, if the conventional medical services available through the NHS come to a limit of what they can achieve, many people turn to CTs. Professionalisation (in the direction being proposed by the NPC and Princes Trust) will mean more expensive training, more expensive insurance, more expensive professional upkeep, and higher professional fees. Where will people then go?

I typically see about 200 individual patients a year and perform about 1000 treatments, at an average cost to each person of about £180. Something like 90% of them find relief from the various kinds of pain or physical dysfunction they came with. Most of them have already gone through the NHS system and found little or no relief. If this is a typical complementary practice, the financial contribution in reduced prescriptions, reduced hospital and GP visits, increased work availability must be enormous. Even more importantly is the enhanced quality of life, reducing the stress and improving long-term health of both themselves and their family and work colleagues.

The path to inhuman control is paved with good intentions
The slippage into a jobsworth culture is the spiritual death of every profession in which it happens, and has been accelerated by a gradual diffusion of the philosophy of the Health and Safety Act (1974) into every corner of working life. As an ex-mining engineer who applied this Act every day in dangerous situations, I have no difficulty accepting its importance. However, its attempts to prevent (and blame someone for allowing) every possible act of human stupidity or malice in every sphere of human activity is becoming stifling. Following the H&S Act to its logical final conclusion - as we seem to be doing, one small regulatory step at a time - could make any inspired or non-standard response a statutory offence. One part of a professional’s job is to balance the risks against the possible gains, and to decide accordingly. As a society we are becoming so risk-averse that professionalism is becoming defined in some sectors by how well someone can stick to a rather limited rulebook. Occasional stories of councils permanently closing children’s playgrounds for health and safety reasons are just one aspect of this sorry slippage into a society which protects its own backside at any cost.

A second working code which I am familiar with is ISO 9000, the Quality Assurance guidelines, which are being used to write those limited rulebooks. These paperwork-heavy systems were originally devised to control critical processes in military and nuclear manufacturing. They quickly became a manufacturing ‘golden standard’ in the 1980.s, and then continued to diffuse into almost every corner of life in the UK; and most insidiously into education. A system originally devised to prevent any possible human error is now being used to define teaching methods. My strong opinion is that ISO 9000 and its offspring, the NVQ (National Vocational Qualifications) system (e.g. ENTO for counselling training), is now driving teaching practice (and many other human activities) rather than being a tool which assists it. At its best, the ISO 9000/ NVQ system gets rid of sloppy, vague and woolly teaching and replaces it with a well structured course. At its worst, it provides an exercise in box-ticking, which, because of its meeting official standards, is far harder to identify as ‘poor’. What has really been gained? I wonder whether it is truly possible to evaluate this?

The H&S Act and ISO 9000 provide fantastic models for the workplace, as tools for management ‘but are not a good basis for defining all of human activity. When applied inappropriately they cost a lot – in administration overheads (which almost always reduce supportive person-to-person interactions in favour of paperwork), in restricting human adaptability, and in alienation and stress. The cart has moved itself in front of the horse, and needs to be stopped and put back in its place.

Post-Shipman (etc) and institutional fear of psychopaths
Finally, there is also a Post-Shipman fear about possible abuse of patients by psychopaths, and of children by child molesters. Just as in the supplements debate, another aspect of the above dilemma is the apparent inability of administrators (and legislators) to draw a line between publicly supplied and endorsed high impact, high risk interventions vs privately provided low risk interventions. Shipman as a psychopath was a danger because a) he was a trusted institutional authority figure and b) because he had access to highly dangerous substances which most people cannot obtain. Applying legislation aimed at someone like Shipman to people who have no official public position, and who do not have access to life-threatening substances is applying a rather large sledgehammer to a very small nut. It is widely acknowledged that real psychopaths know how to manipulate the system. Placing loops and hurdles to make a public display of ‘doing the right thing’ does not prevent them getting in and doing damage, but it makes life a lot less pleasant for everyone else. Once inside a supposedly safe institutional framework, they become more dangerous because of the supposed safety of that framework. If there is a punitive complaints procedure (rather than a fair mediation process which uses teeth only when necessary), colleagues are in fact far less likely to report ‘suspicions’ to a regulatory body.

More insidious is the tendency to treat everyone as if they might be a paedophile or a psychopath. Instead of assuming that everyone is motivated by a sense of wanting to help fellow humans (admittedly hopelessly optimistic, but if you expect something from someone, they are far more likely to give it) - we assume they are fundamentally bad and flawed. This is a modern secular version of the mediaeval view of man as being unremittingly sinful. Do we really want to live in a society which has this unspoken assumption at its core? The more this kind of expectation is applied, the more rotten the apple will get, because there is no real moral call to be upstanding. Statements about ‘good citizenship’ hold absolutely no weight when accompanied by actions which imply that all citizens are potentially bad.

Maastricht and beyond
It would be a serious omission not to mention the Maastricht Treaty, which the UK signed in 2000. Much legislation since that date has been aimed at fulfilling the promises made by the UK government to unify its regulatory framework with Europe. This carries a significant cultural cost, so far largely invisible, due to the deep-rooted incompatibility between English Common Law and the European Code Napoleon. Common Law contains a list of things which are not allowed, and allows anything which is not on that list. It allows traditional practices to continue, amended by laws over time, but with relatively little external intervention. In contrast, the Code Napoleon provides a list of what is allowed, and anything not on that list is illegal. The CODEX for nutritional supplements is one of the first branches of complementary therapy to be affected by this - with a list of exact chemical substances having been drawn up. This list can only be added to if something passes the current medical standard for proof of efficacy and safety - the double blind placebo trial. At first sight there is little wrong with this. However, remember this is being applied to supplements which are already essentially, by their nature, safe - they are not fundamentally of the same nature as the dangerous pharmaceuticals which the system was set up to regulate - the prescription of which is rightly restricted to doctors with 4 or 5 years intensive medical training. What this CODEX does do is hand over manufacture of all new nutritional supplements to the small number of multinational pharmaceutical companies, and rather than protecting public safety it is a political and financial coup for big business.

So the application of Code Napoleon to other areas of working life in the UK looks like it will begin in the health sector. In many ways the NVQ and NOS systems already pave the way for this. Perhaps an extreme view that I hold is that there is a fundamental danger in state control of the healing professions - particularly the psychotherapeutic ones. One of the first legislative acts of the Nazi regime was to pass the Healing Practitioner Law - which forbade anyone to perform any type of therapeutic intervention whatsoever on anyone unless they possessed medical qualifications. In another example of State control, the mental health system was notorious in the USSR as a tool for disposing of dissidents. The zeitgeist of the 21st Century is uncertainty, resulting in fear, resulting in a demand for increasing control. These are ideal conditions for gradual slippage into a police state, particularly as the media are unaware of this and mostly scream for more control. Politicians seem to prefer to ride on its wave and increase its momentum rather than stand as statesmen and provide the steady presence which would reverse this dangerous trend of public hysteria.

Back to Complementary therapies
In summary, a lot of legislative and regulatory measures are being taken out of fear for public safety, an increasing blame culture, and a subsequent need to control augmented by a need to structure the NHS. Many of these measures are already creating long-lasting impacts which are highly negative.

Complementary therapists, including counsellors and psychotherapists, are a highly useful group of largely self-employed, private sector workers who are being affected by all this. We are probably split into two main factions - those who see their future in the NHS (which group is not strongly opposed to the current regulatory moves, mainly I suspect because they haven’t read between the lines); and those who would prefer to remain in the private sector, like myself. The former are actively lobbying for regulation, thinking that professionalisation will lead to lucrative NHS contracts, and more status. However, my opinion is that there is an overwhelming majority who do not wish to see the HPC, or anything like it, regulate this profession. I can see no positive long-term benefit to the general public’s health and safety from this kind of regulation, but rather can see it having a serious negative impact. As a small part of a much bigger social trend, it bodes no good for democracy in the UK and Europe.

1 http://www.hpc-uk.org/

2 http://www.skillsforhealth.org.uk /

3 http://www.ento.co.uk/

4 The Foster Report can be found at http://www.dh.gov.uk/assetRoot/04/13/72/95/04137295.pdf

5 http://i-p-n.org/

6 A rough summary of the opinions voiced are found at http://ipnosis.postle.net/pages/TaxonomyandTaxidermy.htm and linked webpages

7 http://www.rpsgb.org.uk/

8 Email from Tyagi, IPNlist Digest 47, Issue 2

9 The Haunted Self by Onno Van Der Hart, Ellert R. S. Nijenhuis & Kathy Steele. Publ WW Norton 2006 ISBN 0-393-70454-8

10 http://www.issd.org/Conference2006/Plenary2006.htm#eli

11 http://home.webuniverse.net/babette/

12 Trauma And The Body by Pat Ogden, Kekuni Minton & Clare Pain. Publ WW Norton 2006 ISBN 0-393-70457-2

13 Co-Dependency is a maladaptive relationship pattern which most people fall into at some time or other. It usually plays out subconsciously, so the various parties who have taken up the roles are usually unaware of what they are doing.

14 The ‘Safeguarding Vulnerable Groups Act 2006’ came into effect on 8th November, centralising the vetting system for people who work with children and vulnerable adults. Under the proposed new law employers will be committing an offence and will face penalties if they employ people to work with children and vulnerable adults that they know are barred. In the most serious cases they could face penalties of up to five years in prison. Failure to make a background check could also result in fines of up to £5,000. What does this imply for clinics? Are they employers?

15 Mediation means giving all parties a fair say, and providing an opportunity for them to come to an agreement - it does not mean a soft option for anyone who has really abused their client, but is designed so that all parties as far as possible recognise that justice has been done.

16 As an example, BACP publish names and details of complaints received in their journal, in the interests of transparent process, but only after the complaint has been considered and sanctions decided upon. It does publish complaints which have been found to unfounded, and therefore dismissed and no sanctions applied. Plus - later - details of whether any sanctions have carried out and the complaint has been lifted or not. The IAHP and IPN use processes even more in line with international peace/negotiation protocols.

17 http://www.princes-trust.org.uk/

Ipnosis is edited, maintained and © Denis Postle 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006
January 23 2006
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