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How do we make sense of social organizations such as the HPC and the mainstream accrediting and training bodies of UK psychopractice that, full of good intentions, deny contradictory evidence, suppress or ignore dissent, (less so lately) and seek to create closed communities of believers who must sign up to their tenets of faith, with serious consequences for non membership? I have come to see them as analogous to religions. The HPC resembles a religion insofar as it is based on a technocratic belief in 'positivist science', 'evidence-based practice' and especially 'protection of the public', which many people would see as contested articles of faith, rather than established features of the landscape.
To continue the metaphor further, (perhaps even to extinction!) DoH frustration with disputatious and warring psychopractice cults—400+ creeds and multiple sets of commandments or none—government damage limitation following the Shipman and other medical disasters—plus the decision that there be only one regulator for the UK psyche world—have substantially raised the profile of the HPC.
Along with its rationality, reasonableness and good intentions, key features of technocracy, and perhaps because of them, it resembles an 'established' religion, i.e. one that has reached an accommodation with the state, and has been installed as the dominant sect or cult by government. Following which has been given the power to insist on its re-engineering of the doctrines and commandments of behaviour of the mainstream UK psychopractice accrediting and training cults.
The 'established technocratic religion' status of the HPC has a curious resemblance to the Roman Church, where following the take over of the Jesus cult by the Emperor Constantine, a bundle of very disparate religious practices were homogenized and brought under the control of the state. Innovation was controlled via the device of insider religious orders through which dissenting movements that broke away from orthodoxy could be contained, while Rome retained the power to insist on its core standards, at least in the priesthood, and strikeoff any holdouts who disagreed. This is something like the future we are heading towards in psychopractice.
I suggest that this is a helpful context for making sense of the HPC as it presents itself in the following documents. And if what follows seems lengthy or even tediously picky, then keep in mind that the future does not usually present itself in such detail as happens with the HPC
What I’m going to do is scan the documents for significant detail. And gather conclusions on the way and at the end.
HPC Annual Report Fitness to Practice 2006
In some ways this is the most contradictory of the three documents. Mirroring the way the NHS misrepresents itself as a 'Health' Service when more accurately it is an 'illness' service, so the HPC facade of Fitness to Practice reflected in this HPC document would be much more accurately described as a report from the Complaints Service. But Fitness to Practice sounds better doesn't it?
Perhaps as an indication of this mismatch the HPC document Strategic Intent - The Health Professions Council – The next three years published March 2006 notes that,
if implemented, the potential recommendations of the Foster & Donaldson reviews may fundamentally change the role & responsibilities of the HPC including removing some or all of the Investigating &/or Fitness to Practise process from regulators.
The Foreword of Fitness to Practise raises a intriguing issue. Even though the registrants of the 13 registered professions all come from HPC approved trainings or have satisfied the entry criteria:
There has been a substantial increase in the number of allegations made about registrants in 2005-2006 For the first time we received in excess of 300 cases over the one year period. (Foreword)
The number of allegations received by the HPC has more than doubled since our first year of operating under our new rules and procedures. This figure has in fact quadrupled since the last year of operating under the rules of our predecessor, the Council for Professions Supplementary to Medicine (CPSM) p5
The highest number of allegations are about registrants who have an approved qualification.p8
We are invited to take this as evidence of HPC's regulatory virtue but is it not equally pertinent to note that the HPC's input approach to accountability had 300+ holes in it? I.e. that its confidence in the input 'threshold' qualifications and training hoop that registrants jump through is significantly flawed?
Another item in FtP 2006 mentions Article 22(6) of the Health Professions Order 2001
When the HPC becomes aware of a concern about a registrant's fitness to practice (this may be through an anonymous allegation or a newspaper report) the Council may make an investigation in the Fitness to practice of the person concerned. […] We have used this power extensively in 2005-2006 p6
Note that this instance of our UK surveillance cultures could also be held to be an indicator of a dysfunctional, not fit for purpose, accountability protocols, where instead of continuing mutual scrutiny, there is a reliance on anonymous tipoffs, newspaper reports, and not least the bad experiences of members of the public, in order, post hoc, to cull alleged perpetrators of harmful practice. It will obviously work to eliminate some obvious malefactors, such as paramedics selling defibrillators on eBay but that apart, what a generator of paranoia, and nourishment for interpersonal harassment.
In the same vein, on p8 there is an announcement that:
The professions regulated by the HPC are on the Home Office Circular for Notifiable Occupations. This means that we should automatically be informed when a registrant is cautioned or convicted of an offence […] professions regulated by the HPC are exempt for the Rehabilitation of Offenders Act. This means that convictions are never regarded as 'spent' and can be considered in relation to a registrant's character.p8
So far as I can tell, a 'conviction' or 'accepting a caution' for political dissent, say non-violent direct action deemed unlawful, would carry the same finality with the HPC as one for stealing cars. Though perhaps the Investigation Committee is more adept at handling ambiguity and respectful of honest error than this quotation suggests.
The Investigating Committee appears to consist of panels of subcontractor 'partners', experts from the occupation of the registrant in question. They are presently acquired by HPC as a result of advertising short-listing and interview but though this mix is apparently due to be changed soon through the addition of appointed professionals who will complement an appointed council.
The role of the panels of the Investigating Committee is to investigate any allegation referred to the latter and consider whether, there is a 'case to answer'.
The case to answer stage is a paper based exercise at which the registrant does not appear. The function of this preliminary procedure is to help ensure that a registrant is not required to answer an allegation at a full public hearing.
This seems curious in several ways. The use of the word 'exercise' suggests that an unconscious agenda here is taking the heat out of complaints, and note the absence of face to face contact in either the registrant or client/complainant direction. There is a presumption that the member of the public raising a concern will be able to write well enough to establish the often very convoluted subtleties of a legitimate complaint and the first task of the investigating committee, as here presented, is to protect the registrant.
If the Council establishes a prima facie case against a registrant, he or she will have answer that allegation at a full public hearing.
If the panel decides that there is a case to answer, it is at this point that we are obliged to publicise referrals. This means that we have to inform the four UK Departments of Health and we place the name of the registrant, their registration number and the allegation on our website.
The further assumption being, it would appear, that everyone who matters these days has web access. But in practice the HPC, I suspect is here relating to its NHS managerial constituencies and its commissioning structures that are on the way to being implemented, not the general public. A point to keep in mind as we go on through this material.
The HPC investigation process takes pride in being speedy. The 'Investigation Committee' mentioned a few lines earlier has an individual person as a channel for information and insight.
On receipt of an allegation against a registrant, the case will be allocated to a 'case manager' who will have responsibility for investigating the complaint.
Registrants have 28 days in which to respond. And they would do well to remember that:
HPC do have powers to demand information if it is relevant to the investigation of a Fitness to Practise issue. We use this power to demand information for example, the police and from employers.
Of the cases that reached final hearing in the year 2005-2006 it has taken an average of 52 weeks from receipt of allegation to final hearing.
A very long time for a member of the public who is being protected to sustain confidence, attention and resources without, so far as I can see, any face to face contact and thus the sense of being heard that (psychopractice) complainants appear to value most highly.
I found it noteworthy that of 369 complaints about the misuse of a protected title In the 2005-2006 period, only 53 were from members of the public, while 225 arose from fellow professionals.
The HPC is funded entirely by registrant fees with no financial support of any sort from government. This has virtues but also raises questions about how they will be able to handle the massive increases in the numbers of registrants that the capture of Psychotherapy, Psychology and Counselling would entail, around 100,000 according to a press release from the British Psychological Society at the end of 2006. With such an intake, HPC looks to be vulnerable to a potentially very unstable mismatch between income and essential tasks. This strongly suggests that capture will be highly selective, first the Applied Psychologists, then the rest of the Psychologists, then the Psychotherapists, and last Counselling. Even if this turns out to be idle speculation, HPC Registrants would seem to have no redress against spiraling fees except to quit.
The budget for the Fitness to Practise Department was £2.4 million in 2005-2006 - this was approximately 20% of the entire HPC budget.
This supports my contention that the HPC's Fitness to Practise Department is a misnomer. Its name massages reality, it does not promote Fitness to Practice it investigates and adjudicates complaints and since it is undoubtedly (if inadvisedly) devoted to a statutory framing of justice for complaints and registrants, it would be better for it be called something that better reflects its judicial standing, such as a 'Complaints Court'.
Almost the last paragraph of the 2006 report gives details of 'how to make a complaint', p23. Nowhere in this report there any hint of ways of framing difficulties between practitioner and clients other than as complaints. The convoluted disputes, disagreements, misunderstandings, and differences of opinion that can arise in psychopractice and that are often fairly directly resolvable face to face by an apology, or (perhaps with the help of mediation), an exploration of the divergence of perspective that has arisen, seem missing from this account.
HPC Fitness to Practise Department. Ipnosis adjudication: not fit for purpose!
Another generic and revealing HPC document is the:
Application form for Regulation of a New Profession by the Health professions Council.
This document, familiar no doubt to the mainstream accrediting and training bodies, but new to Ipnosis, provides another intriguing window into the possible futures of psychopractice. At the top of the document we find a curious oscillation that repeats throughout many of the 15 sections—between the notion of 'occupation' which Ipnosis applauds, and 'profession'—an often questionable framework for service delivery. The implication seems to be that an 'occupation' that succeeds in being regulated by the HPC will thereby be magically anointed with 'professional' status.
Even more puzzling—how this process of accepting an application from the plurality of some 'occupation' with ambitions for, as it would seem, privileged professional status—sits with registrants' direct, independent relationship with the HPC?
The HPC's understandable preoccupation with boundaries (they are tasked with policing them!) tends to ensure that the application document favours narrow categorical enquiries.
Section 4 declares that:
The occupation must cover a discrete area of activity displaying some homogeneity
While radiographers working in the NHS or private sector undoubtedly have a discrete area of activity that is homogeneous, would it be acceptable to describe the 'discreteness' of say psychotherapy as 'a series of appointments'?
Please define the applicant occupation's scope of practice in terms of activities practised. P2
And to respond to this succeeding question would it be acceptable to add to 'a series of appointments' – 'to meet someone to explore their current delights and difficulties within the human condition'?
In Section 5 the application form steps up a notch or two, ambitiously reaching out towards an actual category error by inviting definition of the indefinable.
The occupation must apply a defined body of knowledge
p2 Please attach evidence of applicant occupation's body of knowledge
If yes, please provide evidence showing how the applicant occupation's body of knowledge is distinct.
Unless I am very much mistaken, to regulate an occupation such as psychotherapy without an acceptable definition of the body of knowledge, would be contrary to human rights legislation but here is a request for evidence of the cogency and distinctness of the occupation's body of knowledge that assumes such a description is feasible. And here again we are taking about an 'occupation' not an 'activity', a further extension of the confusion between occupation, profession and activity. Each being shuffled apparently randomly in this document.
The implicit HPC presumption that the knowledge involved in the activity of psychotherapy can be grasped and distilled into categories continues in the next section of the application form. As though mêtis, the embodied experiential knowledge that for example infuses intuition, rapport and love, was a poor or inconsequential relative of academicized knowledge, (how curious that all Arts Therapists trainings are university-based), or that love was not the dimension of the human condition that is probably the most fundamental to well-being.
SECTION 6 The occupation must practise based on evidence of efficacy
Please provide evidence of research into the efficacy of the applicant occupation's practice.
You are encouraged to attach copies of articles published in journals accepted as learned by the health sciences community.
Please provide evidence demonstrating the scientific and measurable basis for measuring practice outcomes. You are encouraged to provide evidence demonstrating the scientific basis for the applicant occupation's body of knowledge and other aspects of its practice as well, if possible.
Please attach any additional evidence that demonstrates that the applicant occupation subscribes to the ethos of evidence-based practice. You are encouraged to provide examples of how treatment strategies have changed in the light of evidence.p4
Here we meet stark naked, the emperor without clothes. This is a requirement for a affirmation of faith. The occupation must believe in and practice the hegemony of science to be acceptable. Reading this I understood why, in a submission to the DoH the UKCP used the word science 40 times in 75 pages, a blatant piece of window dressing that bore next to relation to their registrants' worldview, or what they actually do (see the Ipnosis review article Science as a Form of Decoration). The extent to which science is unawarely placed here at centre stage in the regulatory theatre is what triggered my sense the HPC is yet another instance of a technocratic civil religion, a hegemony that mixes scientism, technical expertise and faith.
It is no part of my intention to blame people engaged in the HPC for this myopia, they, like so many other occupations, not least education, have gradually succumbed to the over-determined needs for efficiency, efficacy and security we live in and through. What falls out of sight in this embrace is that technocracy has no place for love. Indeed as I have said elsewhere, (Ipnosis video, not yet)) the full out technocracy of current regulatory proposals involves the extraction and disposal of love from the psychological therapies, as though it was a waste product.
Section 7 The Occupation must have at least one established professional body which accounts for a significant proportion of that occupational group.
Please provide documentary evidence of established professional bodies for the applicant occupation.
[…]
If there is more than one established professional body or representative organisation for the applicant occupation, please attach evidence that all bodies are involved in and support this application. You are encouraged to provide evidence of a steering group or similar structure, and to provide evidence of its work.
Here again the triple confusion of 'individual registrants' signed up to the HPC as though to the Inland Revenue, 'occupation', and now 'profession'. And don't we and the HPC in this Section 7 come face to face with the nitty gritty of the HPC's task? To anyone employed in the field there is extensive overlap between Counselling and Psychotherapy (having denied it for years, the UKCP instituted a Psychotherapeutic Counselling section last year) but in the categorical world of HPC the titles seem headed for an imposed distinctiveness.
Section 7 of the Application form is followed by two queries and a request that may not have received as wide a circulation outside the walled gardens of the UKCP, BCP, BPS and BACP as they deserve.
Are there any professional bodies or other representative organisations for the applicant occupation that have not been informed of this application?
If there are practitioners who have not followed the defined routes of entry to the profession, please discuss potential grandparenting requirements and implication. (Ipnosis emphasis)
[…]
Finally, please provide evidence indicating how many practitioners of the applicant occupation are not on any of the voluntary registers for which you have provided details above. (Ipnosis emphasis)
p6
The latter task might be a difficult one! Since who would know whether the definition of Psychotherapy Counselling, or for that matter Psychoanalysis, is drawn so as to exclude or include them?
To end this review of the application form for 'Regulation of a New Profession', I'll briefly assemble a little more evidence from it of the HPC's laudable devotion to the notion of occupation which raises the question of who it is talking about when it speaks of profession.
SECTION 9 The occupation must have defined routes of entry to the profession
please provide […]
Information about the applicant occupation's QAA Subject Benchmark or equivalent. If none yet exists, please provide evidence
demonstrating an intent to work towards a benchmark.
SECTION 10 The occupation must have independently assessed entry qualifications
Please provide details of qualifications recognised as being a necessity for entry to the applicant occupation, including details of the provider bodies and system of monitoring. p8
SECTION 12 The occupation must have disciplinary procedures to enforce
those standards
Please attach evidence demonstrating the system used for disciplining practitioners. Please also attach descriptions of the procedures used to administer the system, along with at least three anonymised case reports. […]p10
SECTION 13 The occupation must require commitment to Continuous
Professional Development (CPD)
Please provide evidence demonstrating that the profession is committed to the principles of CPD. You are encouraged to provide details of any planned or existing CPD schemes.
SECTION 15 Impact on Council's ability to carry out its functions effectively
Regulation by the Council is, to a large extent, dependent on participation by members of the regulated profession in a number of roles. The inability or limited ability of an applicant occupation to provide this input will never, of itself, be a reason for the Council to recommend that the application should be turned down. However, the Council will discuss this in its report to the Secretary of State accompanying its recommendation for an application. If the applicant occupation wishes, it can provide information or comment on this issue here:
The third HPC document I thought worthy of close attention is one of several Marc Seale gave me at our May meeting.
Standards of Conduct, performance and ethics. Your duties as a registrant (April 2004)
Because they are so compelled to control rather than cooperate, technocratic, often implicitly, if veiled, authoritarian institutions, tend to have leaky boundaries. I felt that through its copious repetition of 'must'—84 times in 8 pages—this booklet demonstrated how over-determined the HPC's coercive agenda is.
Standards of Conduct introduces registrants to their duties. On the first page, immediately counterposing carrot and stick, it lists:
…the standards of conduct, performance and ethics that registrants and prospective registrants (health professionals) must keep to […] It also gives health professionals an idea of the kind of behaviour that is likely to lead us to take disciplinary action against them.
On page two the headline 'Inquiries into allegations against registrants' introduces an outline that indicates how the HPC's disciplinary preoccupation—control and compliance—runs far ahead of any agenda about how standards of ethics, performance and conduct might promote occupational flourishing.
…three practice committees […] look into allegations against registrants – the Investigating committee, the Conduct and Competence Committee and the Health Committee.
If we find that a case against a health professional is well founded, we can take action against them if necessary.
We have no power to act against prospective registrants. However if you do not meet our standards of conduct, performance and ethics and you apply to be registered with us, we will take this into account when we decide whether to accept your application.
This lightly veiled tone of threat continues on the more detailed pages dealing with conduct, performance and ethics.
Some items, such as injunctions to 'act in the best interests of patient clients and users', and 'confidentiality', are uncontroversial but others contribute to the mix of coercive bonding and surveillance that the HPC provides:
You must not do anything that may affect someone's treatment by, or confidence in you p4
We will always look at any conviction or caution that we learn of, and we have arrangements in place to be told about cautions and convictions involving registrants.
On standards of performance:
You must be capable of meeting our standards of proficiency that relate to clinical practice. You have to meet these standards […] it is important to recognize that the standards of proficiency are minimum standards of clinical practice. p5
'Must' is a not only a coercive word used throughout this booklet, but also one that is empty of content about how the injunction is to be satisfied. Further down the page:
We cannot and will not test all registrants to check that they are still meeting the standards of proficiency. However we can and will test you if we have reason to believe that you might not meet the standards of proficiency any more. p5
Here would appear to be an admission that the size of the 'HPC safety net', as Marc Seale described it, has holes at least as big as the present voluntary regulation arrangements.
The HPC does fairly clearly rest on what I have elsewhere described as a 'power over' approach to working with the human condition, a feature of technocratic governance.
You must get informed consent to give treatment p6 (Ipnosis emphasis)
You must explain to the patient, client or user the treatment you are planning on carrying out, the risks involved and any other treatments possible. (Ipnosis emphasis)
This document revolves around a medicalized, 'I do to you' mode, of working relationship. The practitioner is seen throughout this text as acting on the client rather than with the client. This is a fundamental philosophical and practical issue that isn't going to go away, and it seems to Ipnosis another limitation that renders HPC in its present manifestation as not fit for purpose as a regulator of the psychological therapies.
You must make a record of the person's treatment decisions and pass this on to all members of the health or social care team involved in their care p6
Making and keeping records is an essential part of care and you must keep records for everyone you treat or who asks for professional advice or services. All records must be complete and legible, and you should write sign and date all entries. (Ipnosis emphasis)
While I'd acknowledge that keeping notes on sessions with clients may be useful, the injunction that they be complete records seems to betray an ignorance of the high subjectivity of anything other than numerical record keeping. When applied to psychopractice, the technocratic presumption that the lived moment can be (must be) reduced to a fully communicable record, disqualifies this approach to civic accountability from both effectiveness and being theoretically up to date.
You must always keep high standards of ethics
(13.) You must always carry out your duties in a professional and ethical way p8
'Professional' as I point out earlier in connection with the FtP 2006 report is a very loose category in the HPC universe and here it is undefined. The same is true of 'ethical'. What if, as a practitioner, I see the HPC as epitomizing in its coercive stance the kind of organizational entity that reproduces many of the chronic patterns of governance of corporate and political life—that it sees power only into terms of force, dominance, threat, coercion and 'acting on'—a style of relating that generates exactly the sort of experience, not infrequently of victimization, that many clients bring to therapy? This is more than an ethical dilemma, it more than likely means that via this hidden authoritarian structural bias the HPC will be a net contributor to client abuse rather than an effective agent in minimizing it.
Another loose but potentially oppressive injunction to registrants the HPC insists that:
14. You must behave with integrity and honesty
You must make sure that you behave with integrity and honesty and keep to high standards of personal and professional conduct at all times. P8
Not many practitioners would have an issue with 'honesty' but isn't integrity a higher order values statement? For instance if, as I would argue, the HPC reproduces in its structural predisposition what I and many other people regard as chronic social patterns of dominance and victimization, doesn't 'integrity' mean refusing to collude with, or 'bystand' this? And for HPC not to recognize this issue means that its theoretical/philosophical base is not up to date.
Lastly from this document:
16. You must make sure that your behaviour does not damage your professions' reputation.
You must not get involved in any behaviour or activity which is likely to damage your profession's reputation or undermine public confidence in your profession. p8
What? Even if you see the psychological therapies' institutions as ethically challenged? As a long time critic of professionalisation itself I'm already out of here! (and again, what happened to occupation in these sentences).
One of the ways of 'diagnosing' the 'health' of institutions such as the HPC is to look at how they deal with dissent. While I applaud the openness of Marc Seale and Rachel Tripp in letting me get close to the HPC, their transparency and directness seems contradicted by this injunction to protect the profession's reputation. To invite registrants to actively challenge institutional collusion, contradictions, or incongruence, as a way of enhancing standards of quality assurance, would surely be a more appropriate injunction.
Conclusion
Before my recent contact with HPC it was a somewhat distant and indistinct feature of the psychopractice landscape. I fancy that anyone who had shared my experience of closer contact would have no hesitation in accepting the directness, openness and precision of how it conducts its affairs but sadly, while acknowledging that, I'm inclined to conclude: integrity, Yes, credibility, No.
As a practitioner looking to protect my clients experience and as someone who has not been entranced by the notion that state regulation is inevitable, I find myself at least for the moment standing aligned with the mainstream accrediting and training bodies that have declared HPC not fit for the purpose of regulating the psychological professions.
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