this is the original, full length version of an article
based on a talk given at the British Confederation of Psychotherapists Conference 'Statutory Regulation - for or against', June 1999. It appears in shortened and revised form in the British Journal of Psychotherapy, Spring 2000
Read short version
view talk with slides
The BCP billing for the talk that forms the basis of this article described me as an 'independent psychotherapist'. This phrase merits brief attention, since in a political debate of this kind, the context from which an article is written matters a lot. |
For the last fifteen years I have been in independent private practice in West London as a 'facilitator', 'psychotherapist', 'coach', 'counsellor', one of the hundreds, maybe thousands, of psycho-practitioners in the UK with very diverse training and experience who developed outside the dominant training psychotherapy cultures. I work with people using a diverse mix of skills and orientations through which I attempt to find a close match for clients' needs. However, 'independence' doesn't mean isolation. During all of this time I have been in one or another form of accountability structure, all of them based on self and peer assessment. For the last ten years I have been in open-ended personal therapy and since 1995 I've been a founder-participant in the Independent Practitioner Network [IPN] (Totton 1995) to which I return below.
From this perspective I see the professionalisation and statutory regulation of psychotherapy in the UK as the annexation, or colonisation, the theft
.of a piece of the territory of psycho-practice (Postle 1998). For that reason this article is primarily about power.
The statutory regulation of psychotherapy means engaging the power of the state to endorse the values, practices and worldview of the organisations that seek it. As Ann Casement, the current Chair of the UKCP, Ann Casement recently put it in a radio broadcast
Casement: At the moment, we're a voluntary register but we are now in the process of moving to registration by law, to statutory registration, we're actually in the process of doing that.
Interviewer: You would then be the professional body and without qualifications from you, people would not be able to practise?
Casement: Exactly So. We're seeking to protect the title of 'psychotherapist', so anybody after that, once we've registered by law anyone who calls themselves a 'psychotherapist' will have us to deal with. (Casement 1999)
The rather parental tone of the last sentence, more so in the original, is a further reminder that in choosing to accept, resist or ignore the statutory regulation of psychotherapy, it is vitally important, in our occupation of psychotherapy, to be vigilant about 'power', its varieties or qualities and who is exercising it on behalf of which constituencies.
In this article, as in the talk on which it is based, I offer a series of propositions about the way power has been deployed in the field of UK psycho-practice. I extend some of the assertions and add support for them in ways that were impracticable in a short talk and draw conclusions about the value of statutory regulation of psychotherapy.
I begin by outlining my notion of 'positional power'. The power of the proprietor, the occupier, the owner, inherited privilege, or the licensed professional. Positional power is often arguably legitimate, as in the case of elected public officials, whether it constitutes a bulwark against disorder, a form of imprisonment, a refuge, or an enduring and valued form of social enhancement depends on how it is deployed. However, to suppose that accumulated positional power confers some intrinsic virtue would be naïve. The reverse seems to be the case with the rush to professionalisation, which often seems to be a form of licensing for incongruence. (Postle 1998) The above radio phone-in provides one cogent example of this in the first sentence, where the chair of the UKCP claims
At the UK Council we run the national register for psychotherapists
Elsewhere, UKCP ex-chair Digby Tantam provides another recently published example.
There already exists a professional association for all generally accepted psychotherapy organisations in the UK - The United Kingdom Council for Psychotherapy.(Tantam 1999)
As anyone who has followed the debate about psychotherapy professionalisation knows these statements are simply untrue. The UKCP is one of the national registers for, or that includes, psychotherapists; the BCP has one and in its own style, and so does IPN, and there is also the BPS and the UKRC.
In the next breath Ann Casement goes on to assure her listeners that UKCP registered practitioners are:
..qualified. They have to fulfil entry, training and ethical requirements.
Yet here are two supposedly 'fully trained', 'qualified' and 'ethical' practitioners making public statements that are factually untrue and very misleading for present or potential clients.
This is positional power in action and I believe it signals a deep, fundamental incongruence in the psychotherapy professionalisation project, and thus regulation, whether statutory or not.
The proprietors of UK psychotherapy training schools have been accumulating positional power for a couple of decades by forming what I regard as trade associations, the UKCP, more recently the BCP, and also the BPS, trade association for the more scientifically inclined.
In the last ten years, the psycho-practice training market has seen an explosive growth in counselling training. Is it coincidence that it is exactly this period during which the UK psychotherapy trade associations have worked hardest to consolidate their positional power? - notably through attempting to inflate their trade association status to that of a 'profession'. As though this body of psychotherapists had no historical or political sense of the tendency of such bodies to gravitate towards the self-serving clubs (Kendel 1998). Plentiful evidence of this evolutionary tendency of professions is all around us, from medicine (Boseley 1999), law (Dyer 1998,1999), psychiatry (Kendel 1998, Cassidy 1999), and biomedical research (Boseley 1999).
Trade associations, whether of psychotherapy trainers or cement manufacturers, have intrinsic legitimacy. However for the former to inflate an understandable business agenda into the ring-fencing of a sector of the psycho-practice prairie seems to me unforgivable. Both on ethical grounds, because, as I show here it is contrary to the interest of clients; it arbitrarily imposes oppressive and indefensible conditions on the occupation of psychotherapy that I and others practice, without either representation or consultation; and lastly because, for the registrants who have chosen to be herded into the 'professional' enclosure, it will constitute a form of imprisonment.
What often seems to disappear from sight in this debate is the range, extent and value of psycho-practice as a whole. There seems to be little awareness of how much of it there is e.g. counselling in its rich diversity, (career, stress, trauma, bereavement) assertiveness training, coaching, stress management, the Alexander method, Tai Chi, massage, co-counselling, voice-work, bodywork etc. As the Department of Health has acknowledged, (Anne Richardson 1997) much of this mirrors, or comprehensively overlaps with psychotherapy. Many of these modalities are locally just as effective and/or more economic than some varieties of psychotherapy and may often more accurately match some client's needs:
Another thing that militates against [statutory regulation] is the increasing evidence of the effectiveness of a variety of approaches which some people wouldn't call psychotherapy. Some sorts of stress management you might not call it psychotherapy, some forms of psycho-educational approaches you might not call psychotherapy but others would and do. And there is good evidence for the effectiveness of some of these approaches with mental illness groups. So if you were to regulate or legislate you might stop that, prevent that diversity and that would be unwelcome.
She outlined her department's conclusions at that time, June 1997.
There are no plans to regulate what, after all we have to call, an 'activity', rather than a 'title'. I mean psychotherapy is something that people do. It's something doctors, psychologists, nurses, social workers, lay psychotherapists, do. Lots of different people practise this activity. Many, most
.some with training some without training, with different kinds of training. Psychotherapy is an activity not a job title.
Its important to say it would be extremely difficult to regulate by statute something which is an activity like that. Could you imagine trying to write a law? It would be impossible.
So far as we take account of the strength, diversity and richness of UK psycho-practice as a whole, trade associations such as the UKCP, BCP and BPS and their professional ambitions amount to formidable concentrations of un-elected, un-accountable positional power.
How these organisations deploy this positional power and especially, how they deal with dissent points to the ideology around power that they have adopted. And there has been considerable dissent during (at least) the last ten years as UK psychotherapy professionalisation and the prospect of statutory regulation have emerged. Since many practitioners seem not to be aware of the extent and depth of this dissent, here are a few items from it, the tip of an iceberg.
First and certainly the most influential, is The Case Against Psychotherapy Registration: A Conservation Issue for the Human Potential Movement by Richard Mowbray. (Mowbray 1995)This is a substantial, thoroughly researched book, well supported by evidence from a wide variety of sources, with an eighteen page bibliography. I am going to quote at some length from a review of the text by Richard House (House 1995) one of the more articulate dissenting voices.
[Mowbray] criticises UKCP for being dominated by training organisations with a vested interest in monopolising the market in training provision, with procedures which make it extremely difficult if not impossible for new entrants to establish themselves in the training market (55-6). He quotes the psychiatrist Peter Breggin, who has written that 'Overall, licensure laws enable groups of professionals to monopolise the psychotherapy market by locking out unlicensed competitors while guaranteeing a steady flow of clients and high fees for themselves' (142).
In a time of occupational uproar such as we have in psychotherapy at the moment
'prospective trainees may avoid organizations which are not approved. Thus both training organizations and prospective trainees are under pressure to board the bandwagon whatever its merits' (55). With training effectively 'frozen' in the hands of established members and innovation effectively stifled, 'UKCP is essentially an exclusive club for the psychotherapy training business' (57). Perhaps more damning still is the criticism that within the UKCP 'there is little involvement of the public interest, the consumer interest, the client interest, the trainee interest, or the non-trainer practitioner interest in the core institutions of UKCP' (ibid.).
Market regulation protects vulnerable clients, so runs the populist litany of professionalisation
Yet a close study of the experience of licensing in the USA reveals that 'disciplinary action is extremely ineffective as a means of protecting the public' (81); and Mowbray quotes J. Pfeffer who concluded that 'It is difficult to find a single empirical study of regulatory effects that does not [conclude that the outcome is frequently not in the interests of consumers or general public'] (85).
Not only can it be shown that licensing has harmful side-effects in terms of restricting the supply of practitioners, inflating the costs of services, stifling innovation and discriminating against minorities by raising market entry requirements (86), but Mowbray goes on to show at length that none of the preconditions which should be fulfilled to justify the introduction of licensing (89-91) are in fact present in the counselling and therapy fields. Thus, psychotherapy does not have a clearly defined scope of practice capable of clear legal definition (92-3); it is not a unified field, there being no consensus as to values, goals and means (96-7); simpler and less restrictive methods that could accomplish the same purposes as licensing and regulation are available within existing laws (205, 215-16); there is no evidence of there being potential for significant harm from incompetent or unethical practitioners (10, 101, 103, 106, 148); it is not possible to demonstrate that practitioner incompetence is the source of harm to clients (106-8, 111); licensing laws do not necessarily prevent harm to clients (112-14, 116, 118, 124); and overall, it is very difficult not to conclude that the negative side-effects of licensing more than outweigh the positive benefits (86, 214). (House 1995)
Mowbray asks 'Is psychotherapy a suitable case for statutory treatment?' His book responds with a resounding 'No!'
One of the justifications for psychotherapy professionalisation and statutory regulation is that "This is the best of all possible worlds and everything in it is a necessary evil.' The 'inevitability' argument. But is the institutional infrastructure that supports and drives it forward 'inevitable'? A necessary evil? Might it not signal a failure of awareness of group dynamics? A failure of creativity? A narrowness of institutional vision?
These topics, beginning with a critique of the current psycho-politics and moving towards worked-through alternatives to the 'necessary evils', feature in another substantial textImplausible Professions: Arguments for Pluralism and Autonomy in Psychotherapy and Counselling edited by Nick Totton and Richard House. Twenty four authors, many of them well-known in the field, examine the dynamics of professionalisation from a variety of different points of view and in some detail. The challenge to the whole basis of professionalisation is comprehensive and sweeping. Can psychotherapy and counselling be reduced to a set of objective expert skills? Is a core theoretical model necessary or possible? What model of accountability is truly congruent with the values of therapeutic work? Are there viable practical alternatives to current models of professionalisation?
House and Totton assemble several chapters of critique that look at UKCP, BCP, BPS and BAC.
In their different ways and with various degrees of co-operation and rivalry, these organisations all promulgate the idea that psychotherapy is a profession: that this profession needs regulation; and that they are the people to do it- preferably with the help of government.
In our view, and that of many other practitioners and supporters, this would be a disaster.
Several authors then take up the theme of 're-foundation', which seek to re-establish some values that have always been at the centre of the craft of psychotherapy. These chapters point to
the 'normalisation' of psychotherapy and counselling which we aim to throw into question, returning to the clear perception of many of its founders that what they had created was 'wild', extraordinary and unsuitable for domestication.
The book concludes with several chapters which build on the notion of re-foundation and arguing that it points to new foundation, alternative ways forward.
What is new, we feel, is the argument that there is an inherent relationship between psychotherapy and counselling on the one hand and pluralism and autonomy on the other.
This implies, they argue:
ways of thinking and organising which we have referred to in our subtitle 'pluralism and autonomy'. Many other terms are relevant here- 'self-regulation'; 'horizontal organisation'; 'networking'; even 'mutual aid'.
I continue this miniaturised survey of the articulated dissent to psychotherapy professionalisation with a mention of another text that will emerge around the time this article sees the light of day. In his forthcoming book, Limits to Professionalised Therapy, Dr Richard House uses a de-construction strategy to generate a long and scholarly critique of psychotherapy professionalisation. He identifies what he calls
the culturally legitimated 'Professionalised Therapy Form' (hereafter, PTF), which, I will argue, can routinely not only of itself be intrinsically abusive, but which actively sets up a milieu in which abuse (be it emotional, sexual or professional/financial) may be a typical by-product, irrespective of the conscious intentions of the therapist.
But isn't the therapist among other things, an agent for the resolution of abuse?
therapeutic abuse may occur because an artificial infantilising framework (the PTF) is created in whose thrall clients or patients end up being unable to take responsibility for their own choices or behaviour. 'Abuse', then, may be uniquely attributable to, and enabled by, the PTF with its (sometimes deliberate) precipitation of power imbalances, transference dependencies and infantilisation experiences. In addition, 'abusive therapists' could be seen as being just as much subject to the 'regime of truth' that is artificially set up by the PTF ideology as are 'abused clients' - albeit, of course, in a different way.
He moves on to show how therapy, in its modern professionalised form:
increasingly functions as a 'regime of truth' whose discourse actively creates identity and subjectivity (and most centrally, the identities of 'therapist' and 'client'), and whose accompanying practices self-fulfillingly construct an ideological framework which then reinforces and guarantees the conditions of its own existence. More specifically, the very way in which such therapy is structured (or 'framed') continually encourages and threatens to produce client infantilisation and dependency through the deep unconscious dynamics triggered within the PTF, and by the assumptive framework typically (and often uncritically) embraced by the therapist. (House, in press)
Reading the chapters of this book interleaved between clients sessions, as I happened to do, was initially a shocking, and then a highly rewarding experience.
My own contributions to the professionalisation debate began with Stealing the Flame (Postle and Anderson 1989) followed by The Glacier Reaches Town (Postle 1994) and How does your Garden Grow (Postle 1997) The titles of these papers and the present one, reflects my view of the value of metaphor in enquiries of this kind.
the main task of research is to find images and metaphors which arrest the flow of automatic thoughts and actions and make taken for granted metaphors more obvious. (Riikonen and Smith 1999)
More recently, The Alchemists Nightmare: Gold into Leadthe annexation of psychotherapy in the UK, employs a metaphor that conveys my settled perspective that psychotherapy professionalisation in the UK constitutes a form of theft and the article contains a series of arguments that support and extend this perspective.
I begin with the Argument from Equivalence - if statutory regulation of psychotherapy is on the way, what other activities might similarly be regulated? I follow that with the Argument from Human Nature - ideas about what is human and natural often provide hidden foundations beneath the institutional and legal brickwork of psycho-practice institutions.
The Argument from Incongruity points to a mismatch between practitioner and organisational power relations in the UKCP. The Argument from Ecology raises concerns about the threat that psychotherapy registration poses to psycho-practice diversity and innovation.
The Argument from Creative Style lends further support, from a broader perspective, to the notion that the UKCP's annexation of psychotherapy represents a consolidation of vested interests and the marginalising of dissent.(Postle 1998)
I was surprised and pleased that a major journal in the field was prepared to air these contentions especially since the editors of Implausible Professions found that several obvious mainstream publishers were unable or unwilling to take that text
we offered the book to every major publisher we could find with a serious psychotherapy and counselling list. Many were encouraging; none were prepared to publish
an editor for one of the leading firms in the field wrote
I am sure your book will be an interesting and thought provoking collection. I'm afraid, though that______ would not be able to pursue the idea to publication. We
have close links with the UKCP and BAC and other regulatory bodies who are co-publishing or planning to co-publish with us and it would not therefore be appropriate for us to take on this title. (Totton and House 1998)
By way of side-stepping this institutional collusion and to broaden the base of the debate about psychotherapy professionalisation and statutory regulation, some of the dissent has found a home on the Internet. The G.O.R.I.L.L.A. Internet site that I edit, motto 'facilitate the power of love, confront the love of power' (Postle 1996-) contains a large and growing archive of critical articles on professionalisation that might otherwise sink from view. The thousands of visitors to the site in the last year appear to demonstrate that these issues resonate with psycho-practitioners in other countries than the UK.
I will conclude this catalogue of dissent by introducing very briefly one of the concrete outcomes of it, the Independent Practitioners Network [IPN] which currently has several hundred participants fairly evenly spread across the UK. Founded in 1995, IPN is the indirect descendant of two conferences about professionalisation organised by the Norwich Collective, a grouping of psycho-practitioners in and around that city, in 1991 and 1992.
Since the initial proposal was first published, the structure has been confirmed as a network of autonomous member groups, each linked to other groups; with no central administration; with no individual membership but accessible in principle to any psycho-practitioner who can meet the network criteria. The defining task of an IPN group is to get to know each other well enough personally and professionally to be able to stand by each other's work. This entails a lengthy process of support, inquiry and challenge,
Refinement has led to, among other things, two mandatory requirements. One, that to be able to declare itself a Member, each group must have active links to at least two other IPN groups that are prepared to validate the process through which the group reached their agreement to stand by each other's work. And secondly, that member groups publish to the network the names of their members plus a statement of their ethical commitment.
IPN has evolved with numerous centres of influence but no centre of control. In its pursuit of 'power-from-within' for ourselves and our clients it continues to sustain itself exclusively via 'power with' social relations, with varying levels of elegance and certainty.
I will return to these notions of 'power with' and 'power-from-within' shortly.
This accumulated critique of psychotherapy professionalisation/statutory regulation amounts to a formidable body of research/inquiry/practice. Almost all of it expresses disapproval, yet this dissent has met with a very clear response from the register-builders and promoters of statutory regulation
. as Nick Totton has pointed out
. a special form of silence that Germans call Totschweigen, ignoring something to death.
What is it that the promoters of professionalisation and statutory regulation don't want to hear? Principally that the move towards professionalisation/Statutory Regulation of psychotherapy is driven by considerations of economics, status, and territory. Notice that I don't include clients' interests.
I am convinced that one of the fundamental economic drivers of professionalisation/statutory regulation has been the explosive growth in counselling training, up from 76 training organisations in 1990 to 545 in 1997 (Independent 9 December 1997). This means that increasingly, psychotherapy is part of a saturated psycho-practice market. Seen from this perspective several of the key features of professionalisation make good economic/business sense.
Raising the threshold of entry to psychotherapy training, ie to graduates-only, (UKCP 1993) along with academically aligned, theoretical course extensions, contributes to the added-value that psychotherapy might be supposed to embody compared with say, counselling, despite there being little or no evidence that either this academic threshold or the longer courses contribute to better client outcomes.
a great number of outcome studies have shown that the results of therapies mostly correlate with the quality of the interpersonal relationship (measured by factors like 'warmth of the therapist', 'trust', 'hopefulness', 'a constructive nature of conversation', 'feeling understood', etc) not with factors like the methods used, or the length of the training of the professionals involved. (Riikonen and Vataja 1999)
While promoting practitioner registration may enhance training school product differentiation vis a vis other supposedly less valuable modes of engagement with clients, it is also likely to stifle innovation (Postle 1998), through imprisoning practitioners who sign up in professionalised therapy forms that, along with the accreditation structures, glaciate psychotherapy practice (Postle 1998). Plus, as I have seen at first hand, psychotherapy registration forces training schools either, to get into the register system, regardless of the profound values incongruence this can entail, or go out of business.
Lastly, professionalisation requires weed/charlatan creation, a chronic tendency of some of the professorial inhabitants of the UK psychotherapy universe that I have gone to some trouble to confront (Postle 1997, 1998)
The public needs... to be protected from charlatans by the existence of adequate training standards codes of practice and complaints procedures... we were also disadvantaged by the fact that anybody could set up as a therapist and in some case practise erratically and irresponsibly, tarnishing our reputation. (Van Deurzen 1996)
It is easy to see why this makes good business sense. If non-registered psychotherapists can be made to seem unethical, unsound or dangerous then this underlines the supposed virtues of the expensively trained cultivars.
when a garden has been very fertile and has been left to itself for a long period of time it is overgrown. Sprawling plants obscure each other's light and deprive each other of nutrients. It is then necessary to cut the plants back, quite drastically and carefully select the ones that one wishes to encourage and make room for, at the same time as uprooting those plants considered to be weeds. (Van Deurzen 1996)
Such as perspective, devoid of an ecological awareness of the importance of diversity, (Slunecko 1999) coupled with the presumption of a psycho-practice 'gardener' whose values remain out of sight, plus the failure to notice that the notion of a psychotherapy 'weed' is a highly contestable social category, does not support confidence in its cultivar proponents. It may make business sense but it doesn't make ethical or ecological sense.
Psychotherapy professionalisation/statutory regulation is also, it seems to me, about status. In response to earlier articles, I have been reminded by several people, that for some sectors of the UK psychotherapy training world, the status of psychotherapy within the NHS is a prime consideration and thus shapes and energises professionalisation/registration, statutory or otherwise . If you are training people, who, after spending say, £15-20K on their training/therapy, are denied access to work that, for example, less able psychiatrists control, then clearly the status of psychotherapy is a major business consideration. I was also told that, in looking at what drives psychotherapy professionalisation, 'don't under-estimate the importance of envy and jealousy of psychoanalytic 'seniority'/patronage in the NHS' (Coulson, personal communication)
I suppose it is a matter of taste and/or orientation as to whether this understandable desire for parity with psychiatry and clinical psychology in the NHS will eventually constitute a debasement of the psychotherapy currency. In my experience, few UK practitioners know much about the managed 'care situation' in the US (O'Hara 19xx) Were they to be better informed, they might realise that even in the more public service UK environment, the result of these concerns with status will very likely be a compromised, 'tamed', 'domesticated' and probably 'manualised', form of practice that drives out 'wildness' and with it, innovation.
Chaos combines order and irregularity in a subtle way
.Too much order is bad for you!
Living on the edge of chaos is the best place to be if you want to live a creative life (Goodwin 1997)
Satisfying the status concerns I have touched on above tends to require that there be a 'unified profession', so that psychotherapists are able to 'speak with one voice' to government and the other professions, as doctors, psychiatrists and lawyers do, on matters close to their hearts. As readers can hardly have failed to notice, who gets to be the psychotherapy umbrella organisation results in a tremendous struggle for control.
In the fight for this contested territory, one of the groups in danger of being marginalised, the BCP, issued an 'us' or 'them' ultimatum on dual membership which expired earlier this year. Elsewhere in the psycho-practice landscape, UKCP enthusiasts are busy trying to create/lead/manage/control a 'European psychotherapy profession' with 'science' as a badge of merit.
Psychotherapy is an independent scientific discipline
Training takes place at an advanced, qualified and scientific level (EAP 1997)
As though the notion of 'science' in this context had not been thoroughly and comprehensively discredited.
Today even the most rigid scientific orthodoxy is ready to recognize the adverse effects of its own achievement, admitting as unintended consequences the evidence announced by movements in culture and society (Melucci 1989,1996b)
Stephan Chorover, one of the two authors of this and the following statement, has long held tenure at the Massachusetts Institute of Technology [MIT] a fountainhead of technocratic expertise. Yet he is profoundly sceptical of the notion that science has universal efficacy.
these adverse effects are an inevitable result of our uncritical acceptance of the paradigm guiding their creation (Chorover and Melucci 1997)
The EAP's use of 'science' as a form of up-market decoration seemed familiar, I realised that it resembles very closely the way the transcendental meditation [TM] movement used 'scientific research' in the 70's to legitimise their meditation routine.
The more I have studied psychotherapy professionalisation and the desire for statutory regulation, the more it has seemed to be driven by these kinds of market-dominance business agendas. And of course I can appreciate that along with the proprietors of training schools, people in, or seeking to work in this sector, may even applaud this elbow work. But what about the benefits to clients that it are supposed to be the prime focus of professionalisation?
Market protection initiatives such as those I have touched on here need sound-bite style rallying calls, to gain and consolidate support. 'Protecting clients' continues to be the slogan of choice of the regulationists. This, despite the weight of evidence that client abuse is endemic in professions (Pokorny 1998) that licensing doesn't reduce abuse (Mowbray 1995); and that professionalised therapy may be intrinsically abusive. (House in press). I expand on this below. In addition, the populist quality of the 'client protection' argument contributes one component to the arguably authoritarian equation some inhabitants seem to ascribe to parts of the UK professionalisation social relations (Wilkinson 1999). More on that below.
Clients' interests as a way of justifying professionalisation of psychotherapy have become separated from actual benefits to clients of either professionalisation or the proposed statutory regulation.
Are there going to be any benefits for clients?
As a result of psychotherapy professionalisation and statutory regulation, clients seem certain to be faced with increased costs, someone will have to pay for the increased levels of training, supervision and administration. Who else but clients?
There will be reduced choice for clients. The already strident insistence that only registered psychotherapists are any good, and above all 'safe', relies on the spurious definition of 'psychotherapy' in this market as being only what the training schools say it is.
To the extent that professional interests control or influence both the setting and enforcing of licensing standards, there is a risk that the standards will be set too high in order to restrict entry unduly and drive up the incomes of existing practitioners (thus shielding them from the competition of new entrants). The emphasis placed by most professional cultures on technical excellence over other issues of service quality and over issues of cost and access is likely to increase this risk (Trebilcock,1982:98-9 in Mowbray 1995)
This tendency to self-definition by training businesses also denies and avoids the untidy reality that many other modes of delivery of personal development overlap or mirror what the psychotherapy training schools teach. And more important:
...'psychotherapy' in a very real sense is not in need of deconstruction - because there has never really existed any definable activity deserving that name. There are so many schools of therapy and so many varieties of activities calling themselves 'psychotherapy' that it is not easy to even start to look at their differences and similarities....
...The situation is made even more complex when we observe that many of these activities can hardly be separated from what people do continuously in their everyday lives. (Riikonen and Vataja 1999)
Perhaps because of the near certainty that no defensible definition of psychotherapy is possible, the UKCP appears to have decided, rather than confront this inconvenient obstacle, to ignore it.
'we're seeking to protect the title of psychotherapist'. [my emphasis]
There will be no increase in safety. Ex-UKCP chair Michael Pokorny, flying in the face of the notion that his organisation is devoted to client protection, claims that
There is now a huge amount of research showing that about 10% of all professionals abuse their clients sexually. This has been shown for all professions and in many countries
.... The only constant index of the likelihood of a psychotherapist abusing a client sexually is to have been sexually abused during training by one of the training staff. (Pokorny 1999)
Pokorny's view is supported by Jeffrey Masson
something like 15% of all male therapists in America self-admit that they have sex with a client whom they were seeing in therapy (the real figure must be higher since there must have been some who would not admit it to themselves or to a questionnaire no matter how assured of anonymity they were). (Masson 1994)
So far as I can tell the UKCP and other registration strategies intend to deal with this abuse mainly by detecting and dealing with this 10% when someone complains, i.e. the quality control inspector, unpaid, is the client. Might not such a client ask why an institution that claims such privileged, indeed 'expert' knowledge, about the human psyche has not revised its trainings to eliminate this abuse? And if they can't eliminate it, how 'ethically sound' are their 'qualifications'?
This evidence of sexual abuse also leaves out the other kinds of misconduct by other licensed professionals that are coming to the surface, for example
The editors of some of Britain's medical journals yesterday called for an independent body to be set up to counter fraud, plagiarism and other misconduct committed by doctors and scientists in their eagerness for academic status.
Richard Smith editor of the British Medical Journal......said he was haunted by papers from 15 years ago which he had rejected rather than exposing. There was a GP who had a general idea that ECT (electro-convulsive therapy) was effective for almost anything - from arthritis to the menopause. He sent us a paper where he described how he had used this treatment on dozens and dozens of patients.
Guardian Thursday Sept 9 1999 p8
The editors appear to be asking for a regulatory body that is independent of a profession that has for several generations been regulated by statute.
I hope I have given some sense of the flavours and extent of the critique that has been mounted of psychotherapy professionalisation in general and the statutory regulation of psychotherapy in particular. Yet as I have pointed out, in the face of this critique there has been almost total silence from the psychotherapy trade associations. What does this refusal to engage with dissent tell us about their approach to power?
My notion of positional power accounts for much of it. If dissent is experienced as peas bouncing off the battlements rather than as the valid and even vital expression of difference, then it can be ignored. Not a minor matter, because this is not the manufacture of cement but psychotherapy, in which sophistication about power in human relations might be supposed to be a feature. Many of those promoting psychotherapy professionalisation seem deaf, or blind to, or ignorant of the value of dissent.
What other notions of power are there that might help us with this silence or deafness?
Here are Bachrach, and Baratz, whose typology of power
...embraces coercion, influence, authority, force and manipulation. Coercion, as we have seen exists where A secures B's compliance by the threat of deprivation where there is 'a conflict over values or course of action between A and B' Influence exists where A, 'without resorting to either a tacit or an overt threat of severe deprivation, causes [B] to change his course of action'. In a situation involving authority, 'B complies because he recognise that [A's] command is reasonable in terms of his own values'- either because its content is legitimate and reasonable or because it has been arrived at through a legitimate and reasonable procedure. In the case of force, A achieves his objectives in the face of B's noncompliance by stripping him of the choice between compliance and noncompliance. And manipulation is, thus, an 'aspect' or sub-concept of force and distinct from coeercion, power influence and authority since here 'compliance is forthcoming in the absence of recognition on the complier's part either of the source or the exact nature of the demand upon him'
(Bachrach, P. and Baratz, in Lukes 1970)
Pursuit of psychotherapy professionalisation has by these definitions involved 'coercion', 'influence' and 'manipulation', statutory regulation extends the list through adding 'force'. It is perhaps noteworthy that because of this, for those of us outside the trainer's clubs, 'authority' as defined here, has required the creation of a dissenting form of accountabilityIPN.
And yet why the silence in the face of dissent? Not only from the professionalisation institutions but also apparently from their registrants? Is it because, for many people, 'power' and thus dissent, are strongly associated with 'conflict' so that many of us, because of our distaste, or our lack of skill around conflict, don't want to touch it or be touched by it? And indeed, might the power relations of psychotherapy be one of the strategies that we deploy to avoid conflict?
At this point, it may be relevant to make the reminder that observable conflict is not a pre-condition for or, an indicator of, the exercise of power
the crucial point is that the most effective and insidious use of power is to prevent .....conflict from arising in the first place. (Lukes 1976)
And Lukes claims that this is particularly true if organisations give a lot of value to pluralism in their ways of constituting themselves.
...'A polity, .....'that is pluralistic in its decision-making can be unified in its non-decision-making' (Lukes 1976)
In these days of 'spin', if power is being exercised within the system to limit decision-making to acceptable issues:
Individuals and elites may act separately in making acceptable decisions but they may act in concert - or even fail to act at all - in such a way as to keep unacceptable issues out of politics... (Lukes 1976)
Following this we might even ask, is the 'umbrella' of psychotherapy regulation really grounded in the personal preferences of the individual registrants? Or is it an example of what Lukes calls the supreme and most insidious exercise of power'
...to prevent people, to whatever degree, from having grievances by shaping their perceptions, cognitions and preferences in such a way that they accept their role in the existing order of things, either because they can see or imagine no alternative to it, or because they see it as natural and unchangeable, or because they value it as divinely ordained and beneficial
. To assume that the absence of grievance equals genuine consensus is simply to rule out the possibility of false or manipulated consensus by definitional fiat. (Lukes 1976)
If this brief discussion of power comes as a surprise, or seems disagreeable, or in poor taste, that may be because as a topic it is under-represented-to-invisible in psychotherapy journals
with a few notable exceptions Guggenbuhl-Craig, 1971 Embleton Tudor and Tudor 1994 and Parker 1999 the issue of power seems hardly ever discussed in the therapy field. (House 1999)
...there is vast literature on the topic of power but interestingly most of it is to be found within disciplines such as sociology, politics or philosophy and very little within psychology, psychotherapy and counselling;....Clarkson(1997) describes the lack of literature on power in counselling psychology as a blind spot. .........
'the discipline as a whole is deeply implicated in the maintenance and reproduction of power relations which it persistently refuses to make explicit - indeed actively obscures...'(Kitzinger 1991:111) (Hart 1999)
This being so, as psychotherapists we may be somewhat disabled when a major issue entailing the exercise of state power arises such as the Statutory Regulation of psychotherapy. However, the inconvenience or distaste may be unavoidable.
..until psychotherapists address the issue of the abuse of power within their own ranks, they have not given any reassuring evidence that they care about the issue at all.
...Why for example did the evidence of Bruno Bettelheim's abuse of clients have to come from the clients themselves, though analysts in Chicago know about it for years? (Masson 1994)
We should endorse the sentiment expressed by family therapist Lynn Hoffman; 'therapists of all kinds must now investigate how relations of domination and submission are built into the very assumptions on which their practices are based (Hoffman 1999:14 in Hart 1999)
In seeking to follow this injunction I have found American psychotherapist and political activist Starhawk a rich source of nourishment. She offers a model of power that bridges both the personal and the political while honouring the spiritual She proposes three varieties of power, 'power from within', 'power with' and 'power over'. (Starhawk1990)
When working with clients, most psychotherapists seek to evoke, enhance, or awaken, the 'power-from-within' of the client. The 'power-from-within' to survive, to recover, to flourish, to heal, to belong, to love and be loved, to become self-directing, or responsible etc.
In relations with colleagues, family, friends and many clients psychotherapists are likely to adopt 'power with'. 'Power with' refers to co-operation, negotiation, debate, parity, mutuality, consensus-building, power-sharing.
However, in pursuing professionalisation and the statutory regulation of psychotherapy, it seems to me that UKCP, BCP and BPS, and to a lesser extent, BAC, have adopted a 'power over' approach to each other; to their registrants; to dissenting psycho-practitioners; and ultimately to clients.
'Power over' refers to bullying, coercion and domination. The use, or threat, of force/sanctions to ensure compliance, deference, obedience, discrimination, or subjugation.
Here's how Starhawk describes it
'Power-over' comes from the consciousness I have termed estrangement....It is the consciousness modelled on the God who stands outside the world, outside nature, who must be appeased, placated, feared and above all, obeyed.
The language of power-over is the language of law, of rules, of abstract, generalised formulations enforced on the concrete realities of particular circumstances... (Starhawk1990).
Engaging the force of the state through Statutory Regulation, to consolidate the power of a psychotherapy 'profession' is a 'power over' approach to social organisation. It poses a special problem for psychotherapy because
....Power-over motivates through fear. Its systems instil fear and then offer a hope of relief in return for compliance and obedience.
Is this notion that 'power over' characterises the social relations of UKCP BCP and perhaps also BPS and BAC, some irrelevant fantasy on my part? I think not and I offer three strands of evidence.
A semi-official UKCP handbook(Palmer Barnes 1999) attempts to bring order and reasonableness to complaints procedures. The text makes no attempt whatever to be client friendly and I infer from this that it is mainly directed towards the basket-weave of registrants, trainers, trainees and supervisors who remain under the influence of their original training bodies. Between the lines, perhaps unintentionally, the book oozes threat.
Palmer Barnes delineates a huge, cumbersome edifice of complaints committees, adjudication panels, investigations, and appeals boards.
Standardised complaints procedures
based on an adversarial, quasi-legal structure quite inappropriate to the sorts of situations which arise in psychotherapy and counselling Grinding on for month after month, fitting the client to the structure rather than the structure to the client and producing at best a largely irrelevant verdict of 'guilty' or not guilty', complaints procedures are often disastrous for all involved.(Totton 1999)
According to Palmer Barnes, the people who serve on such boards and panels 'need to be people of stature within the organisation'. Why? The answer is that what is being described amounts to a bureaucratically layered, top-down, seniority-driven, 'big stick'. The message to registrants is highly parental, 'be good and everything will be OK, otherwise look what awaits you'. In other words 'power over'. For an account of one such enquiry see (Owen 1999)
Part of my chosen role in the last year or two has been to busy myself opening psycho-practice doors and windows on matters that some people would prefer to be remain un-aired. To let air and light in and occasionally to let out what may have been kept in the dark. This talk/article is one such. The Alchemist's Nightmare: Gold into Lead (Postle 1998) was another. Thirty pages and 17000 words long, it represented a carefully researched inquiry, with extensive peer review from colleagues, into psychotherapy professionalisation in the UK. It sought to confront some of the glaring contradictions and oppressive behaviour to which organisations such as BCP and UKCP seem oblivious. Despite its length and depth, it evoked only a derisory 481 word response (Pokorny 1998) from one of the UKCP ex-chairs. Wearily I responded with a polite but acerbic rebuttal of the inaccuracies and sheer inadequacy of his badly written half page. Here was 'power over' in action dissent can be ignored or derided. However, I mention this here not out of point-scoring but because of the sequel.
Some issues later, the editor, for reasons perhaps also of his own experience, I don't know, devoted almost all of a somewhat elliptical, academically framed eight page editorial (Wilkinson1999) to the constitutional implications of certain aspects of psychotherapy professionalisation in the UK and the rest of Europe. All of it concerns what I have called the 'power over' posture of the promoting organisations and his frame of reference throughout is 'national socialism'.
Is 'professionalization' a mask for anti-constitutionalism?
Wilkinson asks, responding that:
The lack of constitutional ground on which to face our radical power issues and differences, in psychotherapy, leaves a vacuum for power-mongering, and marginalization, paralleling the wider vacuum in our political world as a whole
The fault line which opens the doors to National Socialism is the political equivalent of loss of memory, involving a direct alliance of central leadership (Fuhrer principle) and populist base. This fascist defence against isolation is mirrored in the forms of schizoid concreteness experienced by the marginalized.
After this, as I suppose, indirect reference to my text, he goes on to discuss this assertion, posing a series of questions. Fascists? Surely an absurd and extreme claim? But one less absurd, he argues, when the implications of constitutional history are considered (which I take to be a coded reference to seminal agreements and negotiations within UKCP in particular). If psychotherapists do not engage with constitutional history, if we avoid these questions
Are we democratic psychotherapy organizations destined.... to end up as mere bureaucracies, more or less united or disunited? Is the current catchword slogan of 'professionalization' a mere mask for anti-constitutional, anti-democratic, centralism and autocracy?
Moreover, fundamental values are at risk for registrants
As we engage in the processes of acquiring power as a Profession, we are inevitably caught up with all the issues of the practice of power, including the most questionable. In the institutional context, our naivete' and ignorance, our tendencies to deal with issues of power simply by control, our quietistic tendency to bury our heads, politically, ostrich-like, in the sand, our failure adequately to inform and consult, and our consequent tendencies to take constitutional short-cuts, are all trends which alienate us from the roots of our values.
The on-going dialogue in response to Denis Postle's paper, arguing the hegemonic style of United Kingdom Council for Psychotherapy in particular, and by implication the national and international umbrella organizations in general, carries within it a cry from the depths, a cry of protest at elements of fascistic modes of marginalization for instance, Totschweigen, the German, as Denis Postle notes in this issue, for 'deathly silence', an active, lethal form of silence, ignoring something to death (Totton, 1999)-which elements, the cry says, have even entered the pages of this Journal.
Wilkinson observes that all this might helpfully remind us of the significance of Adolf Hitler.
The most powerful forms of political counter-movement of this century have indeed been those whose essence has been the direct annihilation of constitutionality, but upon a direct alliance of central leadership (Fuhrer principle) and a populist base, offering the apparent short-cut to political identity which by-passes the laborious process of creating or maintaining constitutionality.
By this I understand Wilkinson to mean that UKCP registrants, trainees and students need to be in possession of the constitutional means with which to supersede its present hierarchy and that this is currently not secured.It would be unfair and inaccurate to suggest that Wilkinson is equating UKCP and BCP with national socialism in a one-to-one way but that the discourse should be chosen at all strongly supports my contention that, notwithstanding their federal internal structure, a 'power over' style of social relations is the norm in these organisations.
Lastly in support of this view, I want to ask, is it not curious that in its attempt to dominate psycho-practice in this way, professionalised psychotherapy so willingly embraces the 'power-over' domination that is threaded through the society around us. A recent study of bullying in the UK found that
Children expect bullying to be a regular feature of school life with eight out of ten having suffered at least one sustained attack.
Just over 85% of those who had been bullied said it happened at least twice a week with more than 51 per cent saying that they had suffered both physical and verbal abuse. (Chaudhary 1998)/
Power in Britain is firmly regal in character as befits a country where the monarch remains head of state; it is centralised, undevolved and top-down (Hutton 1998)
Look for instance at the 'power over' language of the 1999 Health Bill which opens the legislative door for professions such as psychotherapy to become regulated by the state.
.'Her majesty' may by order in council make provision
.regulating any other profession which appears to her to be concerned wholly or partly with the physical or mental health of individuals and to require regulation in pursuance of this section (Health Bill 1999)
This is the 'power over' embrace that the statutory regulation of psychotherapy seeks.
At the time of writing, September 1999, a private members bill is being prepared to regulate psychotherapy; it is presently out for 'consultation' to BCP and UKCP and probably BPS and BAC. As a significant feature of the psychotherapy accountability landscape, IPN voices sought to be included in this consultation process. Access was denied.
Who is the progenitor of this bill? And what is its provenance? Its promoter declares his 'interests' as British Medical Association, he's a Doctor; the Royal College of Psychiatrists, he's a Psychiatrist; and a psychoanalytic psychotherapist, though unregistered so far as I can discover. Lord Alderdice is also a member of the House of Lords. If origins matter, a value I would suppose many psychotherapists share, here again is the unaware assumption that the existing 'power over' constitutional status quo, even the House of Lords, is a tolerable, or even the only way, to structure the working life of thousands of psycho-practitioners whether or not they have chosen to assent to the process, and many of us, probably the majority, have not.
Again, 'power over'.
How could what I outline somehow pass without notice as involving dominance and subordination? My presumption is that perhaps, because as practitioners, psychotherapists are one-on-one orientated, there is a tendency for power/political social relations to be out of awareness, so that when choosing a constitutional form there was never any consideration of alternatives to the 'power over' status quo.
While it could be argued that these are unimportant local shenanigans, they have value because of the way the 'micro' is often an indicator of the 'macro'. Nevertheless I don't want to get lost in them, because there is a deeper form of bad news in all this. Especially for clients.
Why does this ubiquity of 'power over' matter? It matters because domination and the long list of 'power over' correlates, threat, coercion, subjection, subjugation, victimisation, discrimination, exploitation, manipulation, bullying, deference, exclusion, dependency, normalisation, obedience and collusion, is the fundamental factor in most client abuse.
As Jeffrey Masson asks
what lies at the heart of child sexual abuse? Sexual pleasure in dominating a weaker person. Sexual pleasure in being on top. Sexual pleasure in the unequal distribution of power. (Masson 1994)
Many, if not most clients, seek to survive or recover from some form of 'power over' social relations; grown-up children whose parents manipulate/control them through giving/withholding family wealth; women who seek to survive the dual violence of being beaten by partners and being threatened with worse if they leave; employees whose employer removes out of office lunch breaks and hints that to object would be interpreted as 'lack of commitment'; employees promised bonuses in return for unpaid overtime who find the offer withdrawn later for trivial reasons; women terrorised by casual acquaintances who repeatedly make heavy-breathing phone calls.
All are struggling with how power, both personal and institutional, is deployed in their lives. If the psychotherapist they hire, whether willingly or not, and my guess is it is often very unwillingly, structures his/her 'professional' life around, or tolerates a 'power over' form of constitutionality as is exemplified by BCP, UKCP, BPS) how can the practitioner fail to remain uncontaminated by this incongruence? Worse, if they are asleep to this issue, how can they fail, as House points out (House forthcoming) to perpetuate some form of 'power over abuse' in the therapy through its 'regimes of truth'?
That proponents of psychotherapy professionalisation deny, avoid, side-step, absorb, ignore but do not generally engage with the body of argument against their project that I have outlined here, eloquently delineates the approach to power that they have chosen. And this 'ignoring to death' has increasingly reinforced my settled sense that there are two over-arching arguments against the statutory regulation of psychotherapy, either of which should be enough to ensure that it is dropped.
One, there is a massive incongruity between 'power from within'/'power with' practitioner/client relations and 'power over' occupational politics. This generates a lot of fear in practitioners that will inevitably contaminate work with clients, if it hasn't already done so.
As Wilkinson asks
if the power structures of psychotherapy are totalitarian, how can our practice fail to be contaminated in significant measure by them? (Wilkinson 1999)
Two, statutory regulation is intrinsically a 'power over' constitutional form. Installing it at the heart of psychotherapy will cement in place the very factor common to both the presenting experience of many clients and the abuse by practitioners that it claims to minimise or eliminate the societal norm that dominance is OK.
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