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COMMENTS ON HEALTH CARE AND ASSOCIATED PROFESSIONS
(MISCELLANEOUS AMENDMENTS) NO 2 ORDER 2008
Statutory Consultation regarding state regulation of the British Psychological Society applied psychology members
Guy Gladstone The Open Centre
For the attention of
The Health Professions Order No 2 Consultation
Room 2N12, Quarry House
Quarry Hill, Leeds
Rt Hon Alan Johnson MP, Secretary of State for Health
House of Commons
Rt Hon Jeremy Corbyn MP House of Commons
From Guy Gladstone, Psychotherapist
The Open Centre
While I am not an applied pyschologist I have been practising as a psychotherapist for the last 24 years and understand that this order is the template for "your turn next" with the HPC. Very little can be said within the terms of this consultation document and its associated questionnaire because it is structured, whether intentionally or not, to mostly exclude consideration of the very issues to which I would like to draw your attention. These issues are meta issues that define the entire context of the debate on state regulation of psychological therapies, a debate that has been consistently avoided. The answers cant be put in boxes. Accordingly I am listing 7 considerations for your attention and would welcome your responses. In summary I believe state regulation of psychological therapies to be a HUGE MISTAKE for the following reasons:
1) MISUSE OF AUDIT AND SURVEILLANCE
It is not the proper business of the state to be busying itself with the subjective life or inner worlds of its citizens. For the state to arrogate to itself or its agents a managerial capacity in this respect is to jeopardise the neutrality of the practitioner and to erode the psychic space of the client. The intrusion of the state into this deeply private place is also dangerously close to creating an established church without the freedom of conscience for which a civil war was fought in 17th century England. Significant civil liberties are at stake. Currently the Muslim community in Britain would understand this rather better than the mainstream.
2) MISAPPLICATION OF A MEDICAL MODEL
It is an error to extend the medical model of the NHS so as to cover all forms of independent/private practice. Since the state would appear to have no other model available to it with which to establish hegemony this move is crudely politic but seriously incoherent. Thousands of psychological practitioners do not identify their work as within it and even more to the point neither do their clients. Nor is it acceptable to revamp the medical model by dressing it up in the slimy corporate ideology of Wellness or Wellbeing. Presumption of a medical or wellbeing model violates the public's right to choose practitioners who do not define them as patients or consumers of health care products and services but offer a variety of other frames for the resolution of ordinary human difficulties, tragedies and personal development issues. That said , so long as the state is paying salaries to psychological therapists who work within a public sector NHS, it is entirely legitimate for it to regulate those practitioners as part of their conditions of employment. However in this regard please note 6).
3) STANDARDISATION AS A SUBSTITUTE FOR ETHICS
A bureaucratic mania for standardisation in the name of standards when extended into the domain of the psychological is profoundly unethical and inherently disrespectful of difference and diversity. The diverse, local and intuitively responsive ecology of the current field as it has developed over the last eighty years is preferable to a centralised monoculture of psychological practice within a limited choice of brands administered by a tickbox bureaucracy. Creativity in developing new forms of practice will be paralysed and research will be artificially restricted.
4) MISCONCEPTIONS REGARDING THE ROLE OF TRAINING
The drive for state regulation partly derives from a fallacy concerning the power of input regulation (the control of entry into psychological practice by training institutes) to protect the public better than output regulation (the fostering of integrity at the point of contact between therapist and client). In the competition to survive in the training market institutes able to claim their state validation as an exclusive passport into practice can cover reliance on the capacity of trainees to pay ever higher training costs as the key criterion for acceptance as candidates. However there is both more efficacy and integrity firstly in practitioners being supported or even required to monitor themselves in their work by means of ongoing peer review (as demonstrated by IPN - The Independent Practitioner Network) and discussion of ethics, regular supervision arrangements with a senior colleague and at times being in personal therapy themselves (do as you would be done by); and secondly in the public being supported to become discriminating through education in what to reasonably expect from psychotherapists and counsellors,- notwithstanding a degree of therapisation of daily life the public remains remarkably in the dark. Would the government sponsor a full disclosure list for psychotherapists as has been done by the state government of Vermont (U.S.A.)? Such a negotiable light touch piece of voluntary registration is respectful of the needs of both practitioners and public and shortcircuits the powerplays of the umbrella organisations which have been the curse of the psy field in the U.K. for the last 15 years.
5) MISALLOCATION OF RISK AND REDRESS
There is insufficient publicly available evidence (if it exists it has yet to be produced) of psychotherapists and counsellors abusing clients on a scale that warrants the costs (financial, political,psychological and cultural) of state intervention in the form of the HPC. Does not the HPC's advertising for reports of abuse suggest post hoc justification? Furthermore charlatan myths are a notoriously convenient form of projection,- "its not us, its them, those ones over there!" Long ago it was remarked by Carl Rogers, originator of Person Centered Therapy, that there are as least as many licenced charlatans as unlicensed ones and that the licensed ones are actually more dangerous. The regulatory style embedded in the HPC has already provided examples of this. Have members of the HPC in their wisdom paid any attention at all to the definitive magnum opus, the four volumes by Daniel B.Hogan "The Regulation of Psychotherapists" (1979 Cambridge Massachusetts) the Harvard professor whose research into the efficacy of licensing systems in the psy field comes to measured but very uncomfortable conclusions. This should be required reading for all policy makers concerned with regulating psychological therapies.
The dominant medical model confuses what is essentially a co-created relationship-based enquiry between two generally responsible enough for themselves adults (the vast majority of therapies even allowing for necessary regressive phases) with the exceptional events that appear to have pushed the government to be seen to be doing something, anything, ahaa, there on the shelf the HPC solution! The predations of the murderous Dr Harold Shipman and Drs Kerr and Haslam, sexually abusing psychiatrists, were not pre-empted because they were not in any proper sense peer-monitored,- see 4). They would not be in the least pre-empted by from-above regulatory regimes such as the HPC or, as we know, the General Medical Council. Psychological therapists are being bundled in with offenders from outside their profession. Running through all of this is the entirely unproven assumption that state intervention can actually pre-empt and prevent abuse for which there is no evidence (see Hogan). The government thus falls here into its increasingly ubiquitous and dangerous promotion of the illusion that through further controls it can remove risk from its citizens lives. Step by step a slide into the benign totalitarian. Once in place the same levers are available for the less well-meaning to get hold of as history amply shows. It needs to be more openly acknowledged that psychological therapists are themselves increasingly at risk today. The burgeoning of a litigious complaints industry is now providing a dubious but impelling motivation for therapists to retreat from independent practice and run for state shelter. However a closer look at the HPC's procedures is already provoking second thoughts in many therapists.
I incline to the view that the existent voluntary registers and channels for legal redress while not perfect are about as good as the public and practitioners will get short of implementing the control from below measures suggested in 4). If matters are left as they are there may be a case for creating a fallback instrument of legal deterrence as proposed by The Counselling Society, that is a new category of criminal offence, which would require criminal standards of proof, termed Professional Abuse which would be applicable only in cases of financial or sexual abuse or physical assault by a professional acting in a trust-based caring capacity (psychological therapists would obviously be among a number of professions where this charge could apply).
If or when the HPC presides over the psychological therapies there is a likely negative knock-on effect within the psy field. The current local ear-to-the-ground network of ethics committees and panels for complaints procedures will wither, the requirements of ownership and the sense of responsibilities that go with self-management will atrophy. Arse covering and cynicism will be on the up. STASI-style demands and rewards will begin to appear as the fear levels rise. Shop that colleague before she shops you. The HPC has already signalled that it will not tolerate any rival complaints procedures. The One court rules O.K. Thus proceeds the government's attack on the professions.
Beyond the question of how the relatively rare ethical breaches are best handled lies a huge grey area, the morass known as Competencies which the HPC will encourage the public to conflate with ethical matters, as without annexing governance of Standards its workload will be too light and its budget cut. Enter Skills for Health, a quango subject to the overarching Skills for Business, which will dictate the dessicated fodder that psychological therapists will be licensed to provide. Even with collaborators recruited from within the psy field these agencies will be dismally inadequate to adjudicate in this area. Subjective experience and relationship-based work just don't equate with radiography, plumbing and financial services. Targets, audit and the performance principle are irrelevant, time-wasting gumbage.. The HPC is quite simply the wrong regulatory mode. There is a wisdom that pertains to knowing when to leave well alone.
6) AN IMPENDING MISAPPROPRIATION
There is a further problem ahead for the integrity of the psychological therapies in the event of the imposition of state regulation. State regulation will put in place mechanisms of administration which will excite the same interest in takeover and the same designs upon the field as is currently evident in Virgin, Asda and Tesco interest in the NHS. Here 'choice' and 'change' become buzzwords that echo but don't actually refer to the process of therapy itself, cheatwords that seem to be offering the public something but are actually signposts for the deregulated corporate drive to incorporate and open up new profit sectors. Good morning sir, have you tried our new product, Virgin Therapy? Hello miss, here's our latest special offer, KwikFix, from Prudential Counselling, U 2 can trust the PRU! Current networks of gratis and beneficent referral safeguard the public from such incentivised insults. A captured therapeutic service might itself be a loss leader but its transferential potentials will not be lost by its proprietor who will proceed to sell train tickets, hi-fi, mortgages and holidays off the back of it. This further shadow side of state regulation deserves serious discussion. State regulation of psychological therapies will facilitate its deregulated incorporation and the fetish of the market will be appeased. The door will be open for far more subtle, extensive and diabolic forms of abuse of trust than anything currently identified. Once up and running this market will buy up trainings, perhaps via academies, and with brands of therapy profitable to shareholders, would successfully resist all attempts to exercise influence over it, whether by the state, the profession or the public. The scenario outlined here would truly be the end of all worthwhile psychological therapy. In fact state regulation would finally not present a problem at all because there would be nothing left worth not regulating.
7) THE CONJOINT FORECLOSURE OF PROPER DEBATE
In the last 10 years at least 3 full length books (for which I will provide references on request ) and numerous articles, amongst them my own most recent in the journal "Psychotherapy and Politics International Vol 5 No 1 2007 , have been published that argue the case against state regulation of the psychological therapies. A comparable 'case for' has never been articulated. The case against has simply been ignored as if some just wished it would go away.Which it hasn't and if anything it has become more cogent than ever. The 'case for' really hasn't got much further than "state regulation is a good thing so repeat that after me". This phenomenon should alert observers from outside the psy field to the fact that something is being avoided, a debate is being refused because one side can't muster an argument or can't come clean or some mixture of the two. Why is it that this can pass so unremarked within of all places the psy field, a field which likes to pride itself on its self-reflexive capacities? Until the failure of the drive by the training organisations that constitute the UKCP to secure the holy grail of Statutory Registration of an independent profession of psychotherapy with title protection via a freestanding Act of Parliament (Lord Alderdice's failed Bill of 2001) the only drivers were the UKCP and its psychoanalytic breakaway the then BCP.The government rightly recognised this as a problematic manoeuvre of professional self aggrandisement that excluded a massive majority of the psy field. Since then it would appear that the government has developed its own agenda for wanting to settle this matter, one less to do with the aspirations of the psy field itself and more to do with the management of public perceptions (that at least chimes with the UKCP's favourite phrase 'to be seen to be'), the diversion of attention away from more material and intractable social risks and the co-option of psychological therapists to serve Lord Layard's formula for economic and population management (Too many people out of work linked to anxiety and depression, cognitive behavioral therapy will clear that up, roll out a programme off government sponsored therapy = IAPT). The point here is that post -Alderdice and post- Layard the government has moved to close off the question of whether regulation of the psychological therapies is appropriate just when the profession itself might finally be waking up to what is at stake.
I would ask you not to make the mistake of assuming that opposition to state regulation of the psychological therapies either before, during or after its imposition will just go away. Significantly the HPC has already anticipated its resistance in terms that only do discredit to itself and really miss the mark. There will of course be widespread false compliance (with a corrosive effect on practice), particularly within the NHS from the perception that that is necessary to preserve one's livelihood. There will also be psychotherapists and counsellors taking up a position of principled non-compliance, the reasons for which I have outlined above and which I am here serving you notice of. The ethical gaze of the latter will remain firmly upon the government and its advisers and the critique that will emerge will not be in the government's best interest or do it any favours. There is still time to think again and pull back from a policy of folly.
COMMENTS ON HEALTH CARE AND ASSOCIATED PROFESSIONS
(MISCELLANEOUS AMENDMENTS) NO 2 ORDER 2008