Accountability for client/practitioner relationships in UK psychopractice
Document submitted to Department of Health Foster Review of non-medical regulation, 2005
Client protection examined.
Psychopractice trade associations have been promoting Statutory Regulation [SR] for around 20 years. During this time their training needs, especially those of sustaining and consolidating trainee streams, i.e. of keeping courses in business, have been the overwhelming but unavowed, tacit need driving their desire for SR. SR would add incomparable added value to training products.
A second related dynamic has been the desire on the part of some practitioners, particularly those connected to the NHS, for the enhanced status and career/pay structures that a state regulated profession is believed to convey.
Client protection has been a convenient smokescreen behind which these economic and status factors could be hidden. (When recently, I asked the BACP/UKCP registered participants of an IPN group what the benefits of registration were, their unanimous response was ‘You get more work’).
Discussions about psychopractice regulation often invoke the need for ‘evidence-based practice’. Yet the need for client protection still appears to be based on hearsay and anecdotal evidence. If we presume 37,000 UK psychopractitioners, each with say, 10 or 12 clients, this amounts to approaching half a million working alliances; then multiply this by the number of client hours, say 40 per client per year and we have a figure of getting on for 2 million contact hours, year after year, which is also probably a very conservative figure. Considering the scale of this, the number of disputes, let alone the instances of actual abuse in psychopractice, appears to be quite insignificant or even negligible.
But are they insignificant? Ros Mead appeared to maintain, at the recent meeting to hear the results of the BACP/UKCP mapping research that they are significant but where is the evidence for this? If the DoH has evidence, why has it not been disclosed? If the DoH doesn’t have research evidence from across the client population to demonstrate that client abuse is significant, why is it planning to spend public money and tie up already scarce resources on measures to regulate psychopractice based on a need for client protection?
Here it appears, is a gaping hole in the proposals for psychopractice regulation, one that requires research to establish, through independent inquiry across the client population, that psychopractitioner abuse is significant. Such research could establish how many clients/service users feel they have been abused, (and in what way) how many have had disputes, and how many have been generally/well pleased with the practitioners they have worked with. Without such research, regulation of any kind seems likely to lack credibility other than as support for trade association control of a market for services. (There is of course a sense in which any abuse is significant for the abused, but we are not yet such a risk-averse society such that every conceivable instance of abuse is necessarily assumed to require legislative intervention.)
Developing regulation without an evidence-base of the actual scale of client abuse is one thing. Using what is likely to be seen as a ‘combine harvester’ approach of the external application of the categorising techniques of NVQ, QAA and Skills for Health to reap and thresh psychopractice competencies, standards, and training seems highly likely to be seen as anathema by many practitioners (and training institutions). Taken together, these two seem certain to result in low compliance with any resulting legislation/regulation, and a flight by practitioners to other, unregulated titles, of which there are many, leaving the official mainstream occupied by practitioners asleep to the down-side of professionalisation. It is difficult to imagine how this could conceivably be of net overall benefit to the client/service user population.
Criteria for adequate client/service user accountability.
Rather than regulation, accountability is a better and more widely acceptable way of framing ethically sound client/practitioner working alliances.
Over a decade of IPN theory and practice has identified several key elements of effective accountability.
• On going, long term, face to face contact with a settled group of peers that demonstrates a practitioner’s capacity to form working alliances based on respect, negotiation, mutuality and rapport.
• Declaration by each participant to the peer group of their training, competencies, special area of expertise if any, the client population for whom they are competent, their client workload, their continuing personal/professional development commitment, and their supervision arrangements.
• Mutual disclosure in the peer group of challenges, deficits, difficulties, achievements, and significant developments in their practitioner work, coupled with disclosure of any developments in their personal life that might affect their fitness to practice.
• Agreement between the practitioner group members about how disputes with clients should be handled.
Self and peer accreditation in such a group institutionalises practitioner/client accountability in a way that greatly increases the likelihood of client satisfaction, and reduces to close to zero the chances of abusive or exploitative practitioner behaviour.
Some people have objected that the close personal contact of this process invites collusion. In the IPN model, when such a group has formed, they contract with other similar groups to establish external validation of their accreditation/dispute resolution process and possible collusive agendas. There is also a vested interest carried by every group member that their group colleagues’ practice is sound and ethical (not least because if it is not, then that will reflect unfavourably upon their own judgement and practice). Moreover, this approach to accountability also draws fully upon what is commonly a very well developed intuitive and perceptive sense in therapists and counsellors, such that our ‘peers-in-relationship’ are best placed by far to ‘pick up’ concerns about any given practitioner’s fitness to do this demanding work.
As IPN demonstrates, such a framing of psychopractice accountability can be orchestrated in innumerably different ways.
If a regulation process lacks this mix of autonomy and external validation how can it avoid being perceived by practitioners as coercive and stressful, and an unwarranted imposition? Will it not prove to be lacking in credibility, resulting in low compliance, and effectiveness in protecting clients, should the latter indeed prove to be a significant, evidence-based requirement?
Incorporating the key elements of a self and peer accreditation approach into DoH policy recommendations (to be implemented in a variety of ways by all the diverse organisations presently in the psychopractice field) could ensure that quality assurance of practitioner/client relationships would be intrinsic, i.e. eliminating abuse through continuous monitoring, not as the Department of Health Next Steps proposals seems to indicate, extrinsic, via the detection, investigation and adjudication of complaints. In so far as quality assurance is intrinsic, state regulation of psychopractice would be redundant.
Such an outcome would be strongly supported by what is a missing ingredient in the whole discussion of psychopractice regulation, education.
Education the missing ingredient
In the recently outlined plans for taking forward SR, the DoH seems to be adopting a dominance and subordination approach to institutional power that mirrors the difficulties many clients bring to practitioners. I accept that it may not feel like bullying to the DoH but that is the underlying posture of the ‘Next Steps’ to those of us with a professional training in and around power relations in groups.
External control as the paradigm for professional regulation is an archaic take on quality assurance whose lack of efficacy has, in recent years, been demonstrated only too well in the medical world. Industrial quality management long ago moved away from external quality control, where production is monitored for rejects that are then scrapped (the present psychomedical institutional model) to designing accountability processes that minimize the possibility of producing rejects. IPN is an example of this well-established industrial paradigm.
A less expensive and much more effective approach to addressing the concerns that may be politically important around supposed client abuse, is to commit major resources to educating the UK population on the benefits and limitations of psychopractice; making available through publications, help lines, web sites and publications, why, when, and for whom, psychotherapy, counselling or other modalities are relevant, and what are reasonable expectations as regards outcomes and practitioner behaviour.
In addition, I believe there would need to be a comprehensive, publicly available, listing of all psychopractitioners whatever their accreditation, who are prepared to declare in some detail their training, experience, orientation, capability, terms, complaints procedures and accreditation status, I have published a detailed proposal for how this can be implemented in my proposal for a Practitioner Full Disclosure List.
There are two other reasons why regulation of psychopractice should not take legislative form and why it will continue both to meet with determined resistance and low compliance. They deserve greater space than I have time for here but are likely to exert a vital influence on the shape of any psychopractice-wide accountability settlement.
Defining human nature
Though many psychopractitioners appear unaware of it, all psychopractice involves the constant renegotiation of what is ‘human’ and ‘natural’, an ongoing task that many people see as being a core element of all acceptable political settlements. For a very diverse grouping such as psychopractitioners, but only perhaps 50,000 in number, to be licensed by the state as the people who know about human nature, who are implicitly experts in the definition of human nature, and for other, unlicensed practitioners who conduct such negotiations with clients to be criminalised, is politically unacceptable. This perception, though not often clearly articulated, is I believe at the root of the deep disquiet and continuing resistance of many psychopractitioners to SR.
There is considerable informal evidence that across the last decade, the ‘getting ready for regulation’ components in the accreditation of psychopractice training courses, have resulted in the inhibition of psychotherapeutic creativity and a corresponding shift towards a ‘pasteurised’, risk-averse practice. Two examples will illustrate this. Discussing touch in US therapy, Babette Rothschild (Rothschild 2000) says ‘many malpractice insurance policies will not cover treatment methods that use touch and the licensing boards of most U.S. states forbid it. (my emphasis). Describing the end of his long training, a psychotherapist I work with said recently that, ‘it wasn’t an inquiry; it was a regulation framework I was being pushed into’. That this process will be dramatically accelerated by a state licensure that requires the definition of ‘roles’, ‘standards’ and ‘discipline’ seems overwhelmingly likely. If this is the price to be paid for ‘client protection’, is it not far too high, both for the field of psychopractice and for clients?
Independent Practitioners Network
Denis Postle is an Independent Practitioners Network participant, a member of the ‘Leonard Piper’ IPN practitioner group (founded in 1995), and a founder-participant of the organisation. He has been in private practice as a psychotherapist, counsellor, coach, supervisor and groupwork facilitator since 1985.
Books: Fabric of the Universe, Macmillan 1978. Catastrophe Theory, Fontana 1980. The Mind Gymnasium, Gaia Books 1989. Letting the Heart Sing - An Introduction to Personal and Professional Development CDROM WLR 2003
The following internet material includes original articles and extracts from journals that support and extend the assertions in this briefing document.
British Medical Journal, Editorial: The future of psychotherapy in the NHS 2004;329:245-246 (31 July)
Colorado Association of (unlicensed) Psychotherapists
Heron, J., The Politics of Transference: an essay of the AHPP
Hogan, Daniel, B., Protection not control
House, R., The state regulation of counselling and psychotherapy: sometime, never…?
House, R., The statutory regulation of psychotherapy: still time to think again
Gross, S. J., Professional Licensure and Quality: The Evidence
Hernderson, D.,Colonising the Heart: shame and the regulatory project
Kalisch, D., Professionalisation: A Rebel View
Postle, D., The Professionalisation of Psychotherapy and Statutory Regulation
Postle, D., and Anderson, J., Stealing the Flame
Postle, D., The Glacier Reaches Town
Postle, D., How Does The Garden Grow?
Postle, D., The Alchemists Nightmare: Gold into Lead, the annexation of psychotherapy in the UK
Postle, D., Shrink-wrapping Psychotherapy
Postle, D., Practitioner Full-Disclosure List
Postle, D., House, R., et al, IPN Briefing Documents
Postle, D., Ipnosis editorial: An Established Church of False Promises
Rothschild,B., The Body Remembers The Psychophysiology of Trauma and Trauma Treatments. W.W. Norton New York 2000
Wasdell, D., In the Shadow of Accreditation
Whan, M., Registering psychotherapy as an institutional neurosis: or, compounding the estrangement between soul and world.