If
as seems to be the case with many practitioners, you are sitting with
considerable ambivalence about the value of State Regulation for
clients, for yourself and for the field, what might you need to know?
As I have long argued, there is an over-arching aspect of the HPC's
actions that merits your attention and which should be kept in mind in
reading what follows. As an instrument of the state the HPC's values,
especially their power relations, are of the 'power over' variety,
'power with' consultations and the PLG meetings have consistently
proved to be public relations exercises concerned with ticking the
regulators performance criteria boxes.
HPC personnel are amiable, transparent and accessible, their processes
exude modernity and reasonableness. However this is a culture of
domination and everything that the Professional Liaison Group [PLG] has
recommended in the draft standards of proficiency that we will look at
here has been produced via a process of collaboration under duress and
which can be expected to be enforced by the HPC with matching duress.
Why does this matter? Because as a practitioner I'd be surprised if you
didn't follow a way of working with clients that was as far as possible
free of duress, and that you'd be aware that the abuse that many
clients show up with is in one way and another the result of 'power
over' bullying, excessive or unjustified force, manipulation,
victimization or discrimination, ie duress. Exactly the qualities that
the HPC as a regulator brings to its capture of the psychological
therapies. How can such a culture of coercion as the HPC embodies fail
eventually to contaminate, restrict or skew the work you do?
Does this seem far-fetched? Let's look first at how your professional
representatives have decided that as a practitioner you will be
expected to behave. The Standards of proficiency for psychotherapists
and counsellors' document is here. (link)
An 11pp catalogue of injunctions, it lists 68 items that begin with 'be
able to', 40 that begin with 'understand' 5 that begin with
'recognize', and 3 with 'be aware of'. Not that controversial you might
think until you look at how the document frames these items (more on
that anon).
On page 2 is a headline that applies to everything that follows -
Registrant psychotherapists and counsellors must:
This word 'must' is the key to the whole document. By joining the HPC
register you take on a legal obligation to adhere to these 'abilities',
'understandings', 'recognitions' and 'awarenesses'. And if it still
isn't clear, you buy into a system of coercion and duress that has at
its end point legally binding 'fitness to practice' hearings based on
these standards that are sharply adversarial in style.
Keeping this over-arching culture of coercion in mind, let us look into
the 'consultation draft' of the 'Standards of proficiency for
psychotherapists and counsellors'. I'll add in italics the missing
element of duress: must.
Text in blue, as in the original document applies to psychotherapists
and counsellors, where it is only applicable to counsellors or
psychotherapists I preserve the original red, alongside this I have
tried to keep the original bold formatting.
1a.1
- you must understand the
need to respect, and so far as possible uphold, the rights, dignity,
values and autonomy of every service user including their role in the
diagnostic and therapeutic process and in maintaining health and
wellbeing
Do
you have a 'diagnostic process'? Can you willingly or ethically
undertake to 'uphold the values' of every service user?
- you must be able to recognise and
manage the dynamics of power and authority
Yes…
and might this also include being able to recognize and reject (or at
least discuss) inappropriate regimes of power and authority such as
that entailed by HPC regulation.
1a.2 - you
must be able to practise
in a non-discriminatory manner
Yes
laudable. The HPC requires it but has consistently demonstrated
discrimination against other ways of generating civic accountability in
favour of its pre-existing approach to regulation. See this account of
the first PLG meeting for how this has been done.
1a.4 - you
must understand the
importance of and be able to obtain informed consent
Informed
consent for what? This seems another indicator of a 'power over'
coercive culture in which something is to be done to
a client for which informed consent must be obtained. See later the use
of the word 'apply'.
1a.6 - you must be able to practise as an
autonomous professional, exercising their own professional judgement
you must
be able to assess a situation, determine the nature and severity of the
problem and call upon the required knowledge and experience to deal
with the problem
"Assess a situation?” Many practitioners
would see themselves as exploring perceptions of a
“situation” (including the naming of it as a
“situation”). And then
“problem” is a potentially narrow perception of
experience: it may be that the extent to which a client sees something
as a problem might often interfere with their
ability to develop resources to “deal” with
“it”.
you must
be able to initiate resolution of problems and be able to exercise
personal initiative
Again this
presumes a practitioner 'managing'/'controlling' the relationship with
the client.
- you must know the limits of [your] practice and when
to seek advice or refer to another professional
- you
must recognise that [you] are
personally responsible for and must be able to justify [your] decisions.
Why is it
necessary to include this? As soon as the imjunction 'you must' is
added there is something about these lines that more than hints at a
parent talking to an errant teenager.
This suggests that we might usefully look at the potential 'fitness to
practice' version - if for 'able to, we 'substitute 'failure' :
- you
failed to assess the situation,
determine the nature and severity of the problem and call upon the
required knowledge and experience to deal with the problem
- you
failed to initiate resolution of
the problems and were unable to exercise personal initiative
Very
subtle nuances of the therapeutic alliance are freeze-dried into
'nature and severity' making it an object to which knowhow can be
applied as though definition of 'being able to' somehow disposed of
what 'failed to' might entail in a fitness to practise hearing.
Lets hold this reversal for a moment and use it to look at 1a.7 and
1a.8 which screws down the generic HPC notion of 'fitness to practise'
that as a registrant you would be legally contracted to deliver.
1a.7
- you failed to
recognise the need for effective self-management of workload and
resources and be able to practise accordingly
This seems to imply that if on occasion
you put yourself out in exceptional ways that other practitioners saw
as interfering with their status or employment prospects, this could
count as a failure of self-management. These standards already appear
to have provided a rich field for denunciations based on interpersonal
rivalries in other regulated professions.
1a.8 - you failed to understand the obligation to
maintain fitness to practise
you
failed to understand the need to practise safely and
effectively within your scope of practice
Hmm…
safely and effectively… no vigorous body work or role play
then. And if we go on down this failure road:
-
you failed to understand the need to maintain high standards
of personal conduct
Did you perhaps fail to adopt and live consistently
from the set of cultural values that enable the HPC to present itself
as a benign protector that hides the duress which shapes its actions,
i.e. no exploratory life-style innovation.
-
you failed to understand the importance of maintaining your
own health
Well
yes… except that ill health is relative and often
genetically driven and stressors such as the strong un-negotiated
external demands that the HPC entails contribute, as teachers and
social workers have found, to undermining health and morale.
-
you failed to understand both the need to keep skills and
knowledge up to date and the importance of career-long learning
I.e. you may
have failed to appreciate that deep in the ideological base of the
HPC's approach to regulation is the notion that anything can be reduced
to a set of behavioural descriptors. Psychotherapy and counselling are
no exception. Not understanding the behavioural descriptors is one
thing, not appreciating what is left out, empathy, intuition, nuance,
relationship, lived experience, mêtis, touch and emotionality
is potentially disastrous. As I have said elsewhere, (link) this
amounts to the systematic elimination of love by the HPC.
We might conclude this excursion into failure by noting that could be
tempting for practitioners with a humanistic and transpersonal
worldview to be very even-handed and acknowledge that in its impersonal
detachment this document merely reflects the perceptions of others, an
aspect of the diversity of the psychological therapies. This would be a
mistake since there is a clearly identifiable cluster of institutions
seeking to impose a medical, university psychology, behaviorist
paradigm of coercion and control. This behaviourist fundamentalism goes
to the heart of the fallacy of the HPC concept of therapy as something
external to the client (now patient), to be “done to
them” as part of the 'treatment'.
While this section of generic requirements applies
to all HPC registrants, there is an add-on for Psychotherapists
& Counsellors
they must -
recognise the obligation to maintain fitness to practise including
engagement in their own counselling or psychotherapy based process in a
way consistent with their own theoretical approach
they must - be
able to identify and manage their personal involvement in and
contribution to the processes of therapy, including recognising their
own distress or disturbance and by being able to develop self-care
strategies
What
would a failure to engage in your own 'counselling or psychotherapy
based process' look like? How much supervision would you have had to
miss or ignore? How often and for how long would you have to engage in
personal therapy? Again, consider what would constitute failure?
Even a modest amount of contact with the evolution of the HPC and the
collection of professions that it regulates points to it being
something that the NHS needs, stronger than that, has
to have.
The standards of proficiency are very obviously shaped by an NHS, ie a
thoroughly medical, approach. The medical paradigm of pathology,
diagnosis, and treatment stands behind almost everything that you must
be able to do, to understand, to recognize and be aware of.
And in 1b.1-b4 this NHS context comes out into the open
1b.1 You must
be able to work, where appropriate, in partnership with other
professionals, support staff, service users and their relatives and
carers.
Oh
yes and to go on, even if you are one of the 70% or thereabouts of
practitioners who doesn't work in the NHS:
-
You must understand the need to build and sustain
professional relationships as both an independent practitioner and
collaboratively as a member of a team
And
even if you have actively rejected a medical mental illness approach to
working with clients:
you must understand the need to engage service users and
carers in planning and evaluating diagnostics, treatments and
interventions to meet their needs and goals
They
left out recognizing 'pathologies' here but we'll come to it later.
Remember these are legally binding requirement on registrants who sign
up to them.
Also under 1b.1 there is an add-on for counsellors and psychotherapists
you must -
understand the role of the therapist in the broader social and cultural
context
A very necessary
requirement, not least in divining in a legally binding context what
such a sentence means. Again what would failure look like? Might this
requirement imply deference? For instance to how power is expressed in
and around organizations such as the NHS, the DoH, NICE and the HPC.
Understanding the role of the therapist would appear to require
suppressing any sense that a coercive, duress laden cultural context
might be antipathetic to the commonplace values of psychotherapy and
counselling practice i.e. what you would actually do in the room with
clients.
-
you must be able to demonstrate
sensitivity to organisational dynamics
Again a requirement that perhaps derives from NHS
needs. Might it also imply that deference to existing pecking orders
should be maintained - that clinical psychologists and counselling
psychologists with PhDs who are on salary level 11 should be
acknowledged as privileged in the NHS and other hierarchies over MA/MSC
psychotherapists on level 7, and no-degree counsellors on level 5. This
despite extensive research which shows that para-professionals do as
well with clients as highly degreed professionals; due, it might be
expected, to their capacity for being present as persons rather than
being present as an item of job description.
This NHS multidisciplinary team theme continues in 1.b2 where
'effective and appropriate skills in communication' must be
demonstrated.
At the end of this section there is the anodyne requirement that
Psychotherapists and Counsellors
You
must - be able to build, maintain
and end therapeutic relationships with clients
Missing is the
notion for many practitioners that therapeutic relationship are always
co-created. And how curious that other essential aspects of client work
are missing, remembering to collect your fee, paying into the bank,
keeping records for the IR… and being sure to always change
your socks every day!
In the next section, the medico-scientific ideological position of the
HPC becomes more transparent. Therapy is about 'identification and
assessment of health (ie mental health) and social care needs'.
2a.2 You
must be able to select and use appropriate
assessment techniques
You must - be able to
undertake and record a thorough, sensitive and detailed assessment,
using appropriate techniques and equipment
Counsellor and psychotherapists only:
You must - be
able to devise a strategy and conduct and record the assessment process
that is consistent with the theoretical approach, setting and client
group
You must - be able to observe and record clients'
responses and assess the implication for therapeutic work
2a.3 You must - be
able to undertake or arrange investigations as appropriate
2a.4 You must - be able to
analyse and critically evaluate the information collected
You must - be able to apply a chosen
theoretical approach to assess the clients' needs
You must - be
able to apply a chosen theoretical approach to assess the suitability
of the therapy offered to clients
The problem with this is, as elsewhere, alongside
what this ideological stance demands, as what it leaves out. There is
later window dressing about 'the chosen theoretical approach', no doubt
due to representations from the PLG, but even then, ideological
arrogance (and ignorance) shines through in the 'power over'
supposition that therapy is something that is applied
to clients: A paradigm of entering into a relationship based on
rapport, support and challenge and often the long-term waiting and
listening for the emergence of a hidden client story, is missing. A
Gestalt approach would jointly enquire in a co-created process how the
client creates and dissolves his/her preferences or expectations.
Making an 'assessment' is problematical since it will impose the
therapists preferences or expectations rather than have them be an
ingredient in the inquiries.
On page 7 of the draft standards there is an open embrace of
NHS-manager speak in the service of a medico-scientific approach to
civic accountability.
'Formulation
and delivery of plans and strategies for meeting health and social care
needs'
Again the
medical notion that it is mental health that the standards are talking
about is submerged.
2b.1
You must be able to
use research, reasoning and problem solving skills to determine
appropriate actions
You must - recognise the
value of research to the critical evaluation of practice
You must - be able to engage in
evidence-based practice, evaluate practice systematically, and
participate in audit procedures
You must - be aware of a range of
research methodologies
You must - be able to demonstrate a
logical and systematic approach to problem solving
You must - be able to evaluate
research and other evidence to inform [your] own
practice
The positivist view of research in which a passive
object is acted upon by an alienated enquirer who is subject to random
controlled trial and statistical analysis of data is uncritically
embraced here. As though this pharma-driven evidence-based practise
driven approach to enquiry had not been subject to decades of critical
review and challenge ou of which has arisen the notion that therapy is
itself a valid form of research, the outcome of which is significant if
the client experiences it as significant.
After 2b.2, a list of anodyne specifics for counsellors and
psychotherapists, we hear more of the management paradigm
2b.3 You
must be able to formulate specific and appropriate
management plans including the setting of timescales
“Management plans” is
again NHS-speak, along with the need for
“timescales” irrelevant to self-employed majority
of practitioners. And below in 2b.4, “treatment” is
medical, “done to” stuff.
2b.4 You
must be able to conduct appropriate diagnostic or
monitoring procedures, treatment, therapy or other actions safely and
skilfully
Another
long list of 'musts' for counsellor an psychotherapists follows. No one
seems to have noticed that some tend to be somewhat or very
contradictory of the previous demands, for example:
You
must - be
able to establish an effective, collaborative working relationship with
the client
You must - be
able to initiate and manage first and subsequent
counselling/psychotherapy sessions by developing rapport and trust
Again, from a non-medical humanistic, educational,
gestalt, or transpersonal approach, to name only a few, we don't
“manage” sessions. We might facilitate or introduce
some other more collaborative, consensual approach. We might use words
like “holding” or “being
present” instead. And in 2b.4 there is an assumption that the
practitioner establishes the relationship, ditto “developing
rapport and trust”. The client might have a difficulty with
trusting people or trusting life: so how on earth does the therapist
become responsible for establishing trust with them?
Another couple of
musts:
2b.5
You must be able to maintain records appropriately
You must - be able to keep accurate, legible
records and recognise the need to handle these records and all other
information in accordance with applicable legislation, protocols and
guidelines
You must - understand the need to use only accepted terminology in
making records
No listing of what would be accepted terminology
appears, and acceptable to whom? The mind boggles at the encyclopaedic
extent of what would be required! However, if sadly you should find
yourself up before a 'fitness to practise' hearing, keep in mind, as a
recent case demonstrated, that what might seem to you adequate notes in
terminology which matches the nuances, style, spaces and omissions of
the work you do, could be grounds for sanctions if they aren't in the
legally required (but unspecified) vocabulary.
On page 9 (only two more to go) we get to the HPC's model of quality
assurance.
Critical evaluation of the impact of, or
response to, the registrant's actions
2c.1 you must - be able to monitor and review the
ongoing effectiveness of planned activity and modify it accordingly
you
must - be able to gather information, including qualitative and
quantitative data, that helps to evaluate the responses of service
users to their care
you must -
be able to evaluate intervention plans using recognised outcome
measures and revise the plans as necessary in conjunction with the
service user
you must -
recognise the need to monitor and evaluate the quality of practice and
the value of contributing to the generation of data for quality
assurance and improvement programmes
you must -
be able to make reasoned decisions to initiate, continue, modify or
cease treatment or the use of techniques or procedures, and record the
decisions and reasoning appropriately
This probably all sounds very reasonable
to a mind entranced by a scientised approaches to validity and thus in
a permanent state of genuflection to reason-based medicine and a
positivist version of science. And quite insane to practitioners for
whom assigning this version of rationality to the sidelines of
therapeutic validity has been an developmental task.
Some
years ago being part of a team developing an international
manufacturing quality assurance [QA] programme, plus my experience over
the past 15 years of The Independent Practitioners Network [IPN] has
helped me understand how QA matched to the psychological therapies can
have value. From this wider perspective the HPC's notion of QA seems an
obviously archaic formulation.
The
HPC approach to QA is archaic because it entails an 'inspect and
reject' form of quality assurance that has long been dismissed in
industry as hugely wasteful.
However the HPC don't seem to know this. Probably they have never
visited a factory making video cameras or lenses, or for that matter
thermostats. In such production processes 'inspect and reject' QA was
replaced decades ago by regimes of continuous scrutiny by the personnel
closest to the item being produced. As and if the process goes out of
spec. immediate action can be taken by them to interrupt production
before any faulty item is produced. So far as I am aware IPN is the
only example of this level of scrutiny in the psychological therapies.
No
amount of shape-shifting of verbiage will prevent the QA process that
the HPC embodies from being fundamentally unfit for the purpose of
regulating the transferential subtleties and embodied and spiritual
realities of the psychological therapies.
To
move on, the PLG members appear to have negotiated some caveats local
to different theoretical approaches (why is it always theoretical
differences, don't any of them employ a bit of metis?) These all apply
to checking out the client experience which I suppose is fair enough.
However
at this point the infection of government and half the UK by one or
another form of audit culture begins to take over the document. Keep in
mind it is an 'inspect and reject' regime i.e. action is only taken
when there is a case to answer about misbehaviour. Misbehaviour is not
prevented, it is punished.
2c.2 You
must - be able to audit, reflect on and review practice
You must - understand the principles of quality
control and quality assurance
You must - be aware of the role of audit and review in quality
management, including quality control, quality assurance and the use of
appropriate outcome measures
You must - be able to maintain an effective audit trail and work
towards continual improvement
Expect to see a lucrative line in
trainings emerging for practitioners to learn the 'use of appropriate
outcome measures', how to 'maintain an effective audit trail' and
participate in quality assurance programmes following recent political
fashion.
You must -
participate in quality assurance programmes, where appropriate
But see
above, only the paradigm of 'inspect and reject' QA that the HPC
mistakenly sees as a match for the psychological therapies.
As though none of the above would have any effect on how they practise,
the PLG seem to have managed to get in a couple of line about
supervision, a necessary but very limited notion of what is needed to
sustain the ongoing capabilities of practitioners.
You must - understand
the need for and role of supervision
You must - be
able to make use of supervision, consistent with [your] theoretical
approach
You must - be
able to critically reflect on the use of self in the therapeutic
process and engage in supervision in order to improve practice
'Self' is something to
be 'used', and it is introduced as it had the same commonplace concrete
meaning as 'knife and fork'.
The last section of the HPC draft
standards of proficiency for counsellors and psychotherapists is
devoted to
Knowledge,
understanding and skills
In this
section the HPC sees the psychological therapies through academic
spectacles (they accredit courses at around sixty UK universities)
coupled with the familiar medical, mental illness emphasis seen earlier.
The musts in 3a.1 include, 'Key
concepts', 'bodies of knowledge', 'health', and 'disease ', 'disorder'
and 'dysfunction'.
Registrants:
You must - be aware of the principles and applications of scientific
enquiry, including the evaluation of treatment efficacy and the
research process
There is some presumption that there is
only one paradigm of science, the one that has for the moment made its
home in the DoH conceptual universe.
Registrants:
You must - understand the theoretical basis
of, and the variety of approaches to, assessment and intervention
A paean to intellectual
dominance still with no acknowledgement of the prominent role of metis
in the psychological therapies. The PLG appears to have had a few
things to say about this but they are just as intellectual in their
formulation; seven sentences begin with 'understand', one with 'know
about'.
Even more dubious than this academic bias is the open embrace of
psychiatric, i.e. DSM4 notions of mental health, as though its notions
of 'disorder' were an uncontroversial gold standard of the human
condition and not pharma/psychiatric concoctions serving, in their
country of origin the US, to structure the health insurance industry's
payments and revenue.
Psychotherapists&
Counsellors (3a.1)
You must - be
able to recognise severe mental disorder in clients / or - be able to
recognise disorder of the mind in clients
You must -
understand and be able to work with common / general mental health
problems / or – understand and be able to work with mild /
moderate mental health problems
Psychotherapists only
You
must -
understand typical presentations of severe mental disorder
You must - understand
methods of diagnosis of severe mental disorder appropriate to the
theoretical approach and be able to conduct appropriate diagnostic
procedures
You must -
understand and implement treatment methods to address symptoms and
causes of severe mental disorder
Counsellors appear to be seen as poor relatives who
can't be trusted to get down to the nitty gritty with clients, their
'musts' are less onerous.
Counsellors
only
You
must - understand theories and research on mental health
and well-being and obstacles to wellbeing and be able to use these to
facilitate client development
You must - understand theory and
research concerning specific life problems, issues and transitions that
commonly lead individuals to seek counselling and be able to use these
to inform practice
There is a bottom of the page caveat to the effect
that 'the views of stakeholders should be sought during the
consultation process on alternative forms of wording for these
'standards' in 3a.1., as though it was only a 'wording' rather than a
paradigm problem. Not surprising then that as of the end of July the
BACP chair made a public rejection of the PLG recommendation that
provide for separate titles and thresholds of entry for
'Psychotherapist' and 'Counsellor', plus we should add, different NHS
pay scales.
Lastly the consultation document on standards and proficiency pays lip
service to diversity:
3a.2 You
must - know how professional principles are
expressed and translated into action through a number of different
approaches to practice, and how to select or modify approaches to meet
the needs of an individual, groups or communities
The text goes on to run the HPC version of the
national cultural obsession with 'safety', failing to notice how this
is likely to contribute to a generally risk-averse practice, as if this
were in client's interests.
3a.3 understand the
need to establish and maintain a safe a practice environment
You must - be aware of
applicable health and safety legislation, and any relevant safety
policies and procedures in force in the workplace, such as incident
reporting, and be able to act in accordance with these
You must - be able to work safely,
including being able to select appropriate hazard control and risk
management, reduction or elimination techniques in a safe manner in
accordance with health and safety legislation
You must - be able to select
appropriate protective equipment and use it correctly
You must - be able to establish safe
environments for practice, which minimise risks to service users, those
treating them, and others, including the use of hazard control and
particularly infection control
Here endeth the lesson, a curious form of
employer-led theology that the HPC would have us absorb - that it is
possible to make people moral through the use of threat, coercion and
duress.
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