What does a prospective psychotherapy/counselling client need and deserve from a process of practitioner accountability? Revising my last book, The Mind Gymnasium (Postle, 1988, 2003) for re-publication has repeatedly put me in the position of adopting a client perspectivewhat do people seeking help with the human condition need to know when hiring a psychopractitioner? They need to know a lot more than they are likely to at the moment.
Many practitioners and employers, and consequently we might expect, most clients/service users, still see accountability through the narrow, professionalised lens of hoop-jumping'qualification' and 'training'. Two other lenses are likely to be more relevanteffectiveness and as practitioners how we maintain our capability.
First effectiveness. Psychotherapy and counseling don't generally subscribe to the practice, commonplace in management and technical training; consultancy; and language interpretation, of eliciting client feedback after events. Asking for feedback on our presumed effectiveness and paying attention to what we hear makes it more likely that clients will benefit from their time with us. This is not to argue that psychopractice is free of feedback on effectiveness, only to note that it is usually informal. For example I, and I imagine other practitioners, invite clients to take time at the end of the year or end of quarter to review progress or development.
Recent enquiries based on more formal approachesthat in effect asked 'Did it work?', 'Did I get the help I needed?' (Duncan, Sparks 2002, Lambert, M.J., Whipple, J.L., Smart, D.W., Vermeersch, D.S., Nielsen, S.L., & Hawkins, E.J. (2001)) point to a handful of effectiveness factors that challenge the sacred cows of professionalised psychotherapy. For example the value of academic and technical competencecredentialingin terms of ‘qualifications’, training and Continuing Professional Development [CPD] is seen as contributing as little as 15% to client outcomes. Placebo effectshope and expectations are held to be at least as important. The quality of the rapport between the partners in the therapeutic or, as I prefer, educational alliance, count for as much as these two together and furthermore, what the client brings in the way of support, resourcefulness, education, and lived experience of survival and problem-solving, account for getting on for half the outcome.
So if the resourcefulness of the client makes a very high contribution to therapy outcomes how can this be facilitated or enhanced? Apart from underlining the importance of a facilitative/client-centred approach, client education seems one obvious answer, an option that is almost entirely neglected by the bodies such as the UKCP, BACP, BPS and BCP that seek to dominate accountability in the UK.
When they seek a practitioner, the vast spread of self help books, magazine articles, radio programmes and web sites that refer to psychological matters are likely to mean that clients may be well informed, if haphazardly, about the territories of counselling and psychotherapy. They are not likely to be knowledgeable about what to expect, how to choose someone fitted to their needs, or what is involved in hiring a practitioner. Personal recommendation aside, clients finding a practitioner through medical referral, the yellow pages, or checking out one of the psychotherapy organization directories in the public library, are likely to know little or nothing about the person they are starting to work with. A recipe for a poor match between what the client needs and what the practitioner offers. After all, the psychotherapy/counselling relationship may affect how the whole of the rest of their life plays out. As I see it, the issue from a client’s perspective is not getting it absolutely right or eliminating risk but increasing the chances of a fruitful match.
Alongside effectiveness there is the question of how to sustain practitioner competence. How can practitioners be helped to navigate life's swamps and precipices and still be present for the clients that bring their lives to us? I borrow from industrial quality assurance the notion of capabilityif we become, through a mix of education and experience, capable of delivering effective psychopractice, how do we stay capable? Supervision, the on-going discussion of current concerns and declaration of potential risks; plus some form of CPD certainly helps us stay capable. However I want to argue that both CPD and supervision are limited in their support of capability because disclosure of where a practitioner is as a person tends to be optional or absent.
To summarise, present forms of psychotherapy /counselling accountability rely too much on input ‘qualifications’, and training, and on CPD events plus supervision to support and sustain practitioner capability, while neglecting client education and information. How could they be replaced by, or become transformed into, a new kind of accountability structure, one more congruent with what is now known about outcomes and client/practitioner power relations and consequently more attuned to client’s interests?
I am convinced that the missing element in present approaches to accountability is disclosure. Full disclosure to peers of information about where the practitioner is in their life as well as how their practice is going; and disclosure of relevant information to clients about available practitioners.
The Independent Practitioners Network [IPN] (ipnosis 1999-) has pioneered Continuing Self and Peer-Assessment and Scrutiny [CSPA & S] (House, Totton 1997) as an ongoing process of quality assurance that in my experience wonderfully supports and maintains practitioner capability. CPA&S requires continuing (eye) contact with practitioners, not only as a people who deploy models, skills and experiencebut also with the practitioner as a person with a lifeso that contingencies that might skew, distort, or undermine the quality of alliances with clients can be surfaced, supported or confronted. CSPA & S itself depends on practitioners getting to know each other very well in a safe enough and confidential enough forum for non-disclosure or resistance to disclosure to become a focus for attention. For example a practitioner who, not for the first time, casually says they are so tired they could scream, might be disclosing something about their current life that is likely to affect the quality of their work with clients and that merits confrontation by peers.
Secondly, and the main but related focus of this chapter, how can disclosure of information about practitioners be extended and deepened so as to better support consumer choice. I propose that this requires development and installation of an innovative accountability process through which practitioners publish, in some detail, who they are, how they got to be practitioners, what their life experience and working orientation is, and doing this on a scale sufficient that a client can make some kind of informed guess that this is someone who they could work with.
On the following pages I outline a proposal for such a psychotherapy/counselling accountability process. It requires, I believe, a switch of gestalt from the present secretiveness/reticence of professionalised psychopractice to what has been called a ‘full disclosure’ model. Mowbray lists Will Schutz , Dan Hogan, Roberta Russell and S.J, Gross as advocating full disclosure as a basis for accountability (Mowbray, 1995 p205-9) Since such shifts of paradigm are often hard to grasp in the abstract, I will describe my proposal for a full disclosure accountability structure as if it existed. By the time this text is in print I hope there will be a web site that demonstrates the potential of the scheme.
A practitioner ‘full disclosure’ list [PFDlist]
What would be the key elements of disclosure?
Participation in the PFDlist requires a statement in each of the following categories.
N.B. practitioners may choose to make minimal or detailed statements.
Life experience: work, jobs, roles, responsibilities; relationships: single, married, divorced, separated, partnered; children, grandchildren, adopted children, step-children; sexual orientation. A recent photograph.
Practitioner development: education, training, relevant life experience/skills transfer, competency process (qualification, accreditation, Self and Peer Assessment etc)
Practitioner style: approaches/orientation(s) statement; ethical statement; terms and conditions including charges; weekly client load, specialties and preferences, who they wouldn’t work with, confidentiality, note-keeping, supervision.
Practitioner competence: supervision, continuing practitioner development, client feedback.
Practitioner ‘referees’ statements: documents from three peers who attest:
1. to the accuracy and integrity of the claims to competence of the practitioner in the statements made in the disclosure.
2. a brief account of the process through which they keep this information up-to-date.
Practitioner confidentiality: note keeping, supervision.
Practitioner/client disputes: details of practitioner’s conflict resolution process and details of who to contact.
Practitioner trade activities: publications, journal contributions, research, books, interviews, trade association roles.
What form should this information take? What would be mandatory?
The categories of disclosure should be mandatory but practitioners need to be free to say as much as they like (but not nothing) in response to the each of the categories. Similarly the style of presentation is also entirely a matter for the practitioner. Styles seem likely to range from the purely factual to more discursive, or narrative. The openness to, and ease of change of entries by practitioners (see below) is intended to encourage a ‘disclosure culture’ that is both self-sustaining and self-correcting through it’s appeal to clients and service purchasers.
How would the PFDlist be implemented as an institution?
The PFDlist information would be held in a government funded computer database accessible through any standard web browser. Access to this database would be free to users and, because the task of preparing and updating an entry is considerable, to practitioners also.
Since the PFDlist entries would be in the public domain, local initiatives to publish paper directories for the IT-challenged would be likely and desirable.
A sector of the PFDlist would make available a moderated user forum where users and practitioners could exchange information and experiences.
The PFDlist would by managed by a small secretariat charged with the maintenance of the List and its functions. They would not be responsible for conflict resolution but would maintain (see below) a mediation/advocacy resource, which might from time to time be drawn on for disputes that could not be locally resolved.
How could we ensure that clients experience it as user-friendly?
The user-friendliness of the whole system would be a commonplace IT design task. The ‘friendliness’ or otherwise of the entries would be entirely a matter of practitioner capacity and choice. Easily accessible, though password-protected access to the PFDlist would mean that practitioners could edit, add to, and develop, their entry as the need or occasion demands. Non-IT practitioners would be able to mail additions or amendments to the PFDlist manager.
How would it be administered/financed?
The PFDlist is a service enhancement for psychopractice users that needs to be free at the point of access. To enable this, Government funding would be essential. However this should be taken to imply government participation/support/facilitation rather than control. The database function is a commonplace IT function for which tenders could be invited. The layer of necessary management could be sub-contracted to an existing contractor responsible, adjacent to, the DofH. The PFDL, List manager and staff would be charged with maintaining the database, promoting it and taking action on abuses or deficiencies in List entries (see below)
Does PFDL amount to statutory regulation by another name?
The PFDlist applies to the task of accountability what we know about the uses and abuses of power both interpersonal and institutional, while at the same time respecting the lack of agreement on, what constitutes competent or effective psychopractice. Out of that, it seeks to make available the widest range of psychopractice offerings while at the same time giving users adequate information about who/what may, or may not, meet their needs, and how to complain and seek redress if they experience an abuse of power and trust. Government supported, but not government controlled.
Which practitioners would be included/excluded from PDFlist?
Any person offering services in the psychopractice area would be entitled to an entry on the PFDlist. Non-registration should be tolerated but not encouraged.
How would practitioner statements be verified?
Practitioner statements have to be verified by the referees who are named and posted with the entry. If the accuracy of the statements is significantly challenged the PFDlist manager in the first instance would invite the referees to check out the challenge/objection. Their response may lead to the PFDlist manager requiring that the entry be edited or withdrawn. However the intention of the PFDlist is to display carefully framed statements by practitioners that have been peer-assessed sufficiently well for accuracy before posting as to generally eliminate significant challenges. Indeed such a challenge would indicate a failure of the refereeing process.
What sanctions might there be for inaccurate or misleading statements?
The aim of the PFDlist is not to eliminate risk but to honour users needs for personal safety and value for money, without eliminating the ‘wildness’ and unpredictability implicit in effective psychopractice. If disputes arise the PFDlist will seek to enable all parties to reach some resolution through mediation and advocacy rather than adjudication of guilt and blame. I.e. ‘Sadder and wiser’ being more important than ‘right/wrong’.
The PFDlist management would not be responsible for resolving disputes but they would develop and maintain access to legal and advocacy/mediation resources to enable clients and practitioners to progress disputes. The costs of such facilities could be contained through an insurance charge on PFDlist participants.
Disputes about misleading or inaccurate statements or allegations of fraud or abusive practice, should be explored and resolved by the practitioner’s designated dispute process and his/her referees. If they are unresolved, then they should be referred to the PFDlist managers’ layer of advocacy and mediation services. Persisting with misleading, fraudulent or inaccurate statements should lead to removal from the PFDlist.
The List management would maintain pages on the PFDlist web domain for posting apologies, explanations, notices of agreement, settlement, or failure to agree.
What sanctions might there be for abusive behaviour?
Complaints or allegations of abusive or other behaviour by a practitioner in contravention of her/his stated practice description should in the first instance be pursued via the practitioner's stated dispute process. If redress or satisfaction is not reached through these means then the management can be asked to invoke mediation/advocacy services. If the dispute/complaint is resolved as an instance of abuse i.e. behaviour that the practitioner's referees cannot support, this would result in removal of the practitioner from the PFDlist.
Re-instatement in the list would require the re-establishment of the initial criteria including the support of the same referees.
What would be the PFDlist’s relations to other 'lists' such as those maintained by the IPN, BPS, UKCP, BPS, UKRC and BAC (P)?
Multiple lists of practitioner offerings appear to be in client’s interests since they maximize choice. A single government sponsored listing that is inclusive of the wide range and variety of psychopractice offerings would go a long way to securing a free market in these services.
The PFDlist is intentionally inclusive, for instance, practitioners would be free to specify dispute procedures that lead to existing accountability bodies such as IPN, BPS, UKCP, BPS, UKRC and BAC (P). The PFDlist is intended to promote benign co-existence between these and the dozens possibly hundreds of other institutions whose members might be participants.
How would the PDFlist resolve the range and divergence between the styles of psychopractice that are currently available?
Client education would be an essential feature of the PFDlist. The list would publish and maintain user-oriented information about how to hire a practitioner, what to expect, and guidance on how to negotiate with them. Several divergent, even contradictory guides might be expected to co-exist side-by side in reflection of the comprehensive disagreement in the field about routes to competency and the kinds of contracting that psychopractice entails. In addition organizations and individuals would be free to take web space to present the claimed virtues of their particular way of working with clients. The intention of this would be informative/educational and a role of PFDlist management would be limited to discouraging, and if need be removing, organizational statements that amounted to advertising or promotion, while encouraging the display of articles, research, personal experiences etc.
Drafts of this proposal have produced mixed reactions. Some people missed the point of the integration of practitioner accountability and client choice and saw the PFDlist as a form of advertising; others warned that psychodynamically inclined practitioners wouldn’t want to disclose anything at all because it ‘would distort the transference’, as though a client’s ignorance of what they were getting into didn’t also distort (or generate) transference; two people were concerned that this amount of disclosure 'would provide clients with ammunition'; there were understandable anxieties that any government involvement would amount to a takeover and that the internet format would exclude too many clients. An objection that I feel has validity but which is also a reminder of the purist reaches of psychotherapy, is that in helping clients find someone who was a good match for their needs the PFDlist would promote collusion through eliminating or reducing the chances that clients benignly meet a practitioner whom they wouldn’t consciously choose. The trouble with the present randomness is that it too often seems to lead to unhelpful mismatching, ineffectiveness, and clients struggling to adapt to the practitioner’s style.
My aims in devising the PFDlist have sought to satisfy two criteriaone, to further confront the creative inadequacy of the DOH and the UK trade associations UKCP, BCP, BPS and BACP. Their notions of hierarchically structured accountability, based on archaic and discredited input forms of quality assurance, without ongoing face-to-face contact, mimic existing, deeply flawed, medical-style accountability (I don’t need to quote any evidence do I?). Like the GMC and the medical Royal Colleges, the psychotherapy trade associations are intrinsically exclusive and imperious in their relation to both registered practitioners and clients. Contrary to their assertions about client safety, through their claims of privileged, superior knowledge, they harm clients’ interest by undermining the credibility of the very broad reach of personal and professional development work of which they are only a small part. As outcomes research seems to show and as others have argued (Mowbray 1995) this supposed virtue and it’s false promise of client safety is an ‘emperor’s new clothes’ assertion.
Secondly, after more than a decade of resistance to, and confrontation of the professionalisation of psycho-practice, I have sought to answer a personal questionmight there be government-sponsored form of accountability for counselling and psychotherapy and their relatives in the field of personal development that I could sign up to? And if so, what form would it take? I feel that the PDFlist would be good enough.
Duncan, B., Sparks, J. Heroic Clients Heroic Agencies: Partners for change Nova Southeastern University
Full Disclosure List demo: http://www.mind-gymnasium.com/
Gross, S.J. Professional Disclosure: alternative to licensing The Personal Guidance Journal Vol.55 (1977) pp586-588
Hogan, Daniel B., The Regulation of Psychotherapists Cambridge Massa chusetts: Ballinger 1979use, House, R.R.Totton, N.Implausible Professions PCCS Books 1997
Lambert, Michael J. The Effectiveness of Psychotherapy: What has a Century of Research Taught Us About the Effects of Treatment?
Lambert, M.J. Whipple, J.L., Smart, D.W. Vermeersch, D.S. Nielsen, S.L. & Hawkins, E.J.Handbook of Psychotherapy and Behavior Change (5th ed.). New York: Wiley (2001)
Mowbray, R. The Case Against Psychotherapy Registration Trans Marginal Press 1995
Postle, D. The Mind Gymnasium Macmillan London 1988
Postle, D. The Mind Gymnasium: CD-ROM edition WLR London 2003
Independent Practitioners Network: Principles and Procedures, ipnosis a journal for the Independent Practitioners Network 1999- http://ipnosis.postle.net
Russell, R. Report on Effective Psychotherapy: legislative Testimony New York Hilgarth Press 1981
Shutz,W. Profound Simplicity Joy Press USA 1979