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August 20th 2004

Goldbeck-Wood and Fonagy’s thoughtful contribution on the future of NHS psychotherapy (BMJ 2004; 329, 245-6) raises some interesting questions which cannot be properly considered in isolation from the professionalisation process more generally. Over many years a number of colleagues, ourselves included, have written at great length in the field’s professional journals about the manifold dangers of the institutional professionalisation of psychotherapy and counselling.1 One of our core concerns has been that any institutional regulatory arrangements must needs be consistent, in terms of power dynamics, with the fundamental nature of the therapy experience itself; and concomitantly, that to the extent that there is any incongruity between regulatory structures and therapy practice, the quality of the latter will inevitably suffer, to the detriment of patients and clients.2

It would be wrong to assume that those who are sceptical about the institutional professionalisation of psychotherapy are ‘against’ any kind of accountability whatsoever; rather, we are in favour of accountability with heart, accountability that works, and accountability that is consistent with the core philosophy of the therapeutic work we do. In Britain, the Independent Practitioners Network (IPN),3 founded in 1994, is a national network of practitioners which offers an accreditation or competency route based on continuing peer assessment. Practitioners participating in the IPN come from a wide variety of therapeutic and educational backgrounds, and the Network is independent of training and accrediting bodies. IPN is altogether a remarkable piece of leading-edge social innovation that reverses the top-down power dynamic of conventional accountability structures, in favour of devolving responsibility for competence and ethical conduct to localised, continuing, face-to-face contact. By its existence IPN is very challenging of the mainstream approaches to accountability, since it represents the kind of social creativity that is in danger of being eliminated or severely restricted by statutory regulation.

A further concern is that, for many practitioners, the very idea of psychotherapy being a medicalised practice is fundamentally incoherent and inappropriate – not least because the totem of human potential development to which most practising therapists aspire and adhere is, in a paradigmatic sense, quite incommensurable with the “deficit”, psychopathological approach that the medical model routinely embraces.4 This is not to argue, we hasten to add, that psychotherapy and counselling therefore have no place in conventional medical settings. Indeed and on the contrary, one of the strengths of the NHS’s embracing of an intervention – psychotherapy - that eschews a medical-model conceptualisation of distress and ill-health is that it paradoxically reveals conventional medicine’s maturity in being able to acknowledge the value of diverse and different approaches to human health. A strong, undefensive medical service might even be favourably influenced by the kinds of “post-medical model” values that psychotherapy and counselling at their best represent.

The evidence-based (some might say manic) “accountability culture” that has recently swamped the public services in general, and the NHS in particular, has received devastating criticism from a whole range of sources,5 and there is a danger in Goldbeck-Wood and Fonagy’s contribution of uncritically buying into a politically correct, culturally ephemeral fashion which many believe to be perpetrating untold damage in modern public culture.6 And what if the values and associated practices of the accountability culture are antithetical to, and incapable of authentically measuring7 even in accordance with their own favoured metric, the healing value or otherwise of psychotherapy? – a proposition obliquely hinted at by Goldbeck-Wood and Fonagy. This, again, is where we observe a fundamental clash of paradigms or worldviews8 – where one approach prizes the criterion of quantitatively measurable efficacy and “cost effectiveness” above all others, while the other questions the hegemony of such symptom-based evaluation criteria, preferring instead to embrace hermeneutic values of meaning-making and human potential development.

For many years now, we have seen the burgeoning growth of General Practice counselling within the NHS, and there is overwhelming evidence of very high levels of patient satisfaction with this widely used service. Certainly, this is in stark contrast to the shocking number of deaths due to iatrogenic mainstream medical practice, as recently widely reported,9 with an estimated 10,000 premature deaths occurring per annum due to bad reactions to medication. It is indeed a sad reflection of the times we currently live in that a service that is so highly valued by patients and which leads to little if any iatrogenic effects – GP counselling – should be subject to such constant threat to its very existence, while conventional medicine is beset with demonstrable levels of literally fatal iatrogenicity. Indeed, given the way in which both rigidly professionalised medicine and professionalised psychotherapy can be harmful to patients/clients, perhaps we should be grateful that, as Goldbeck-Wood and Fonagy disapprovingly point out, there currently exists “piecemeal and ad hoc” provision of psychotherapy services within the NHS!

It is also important to be extremely careful when approvingly repeating the fashionable shibboleth about Cognitive Behaviour Therapy (CBT) being one of the few empirically validated treatment modalities, for the CBT approach entails a “philosophy of the person” which is squarely rooted in the ideology of modernity10 - so it is hardly surprising that it “passes” an empirical assessment whose methodology is mechanistically positivistic in conception and execution.

Goldbeck-Wood and Fonagy are entirely correct in asserting that “factors related to the individual practitioner and patient are probably at least as important a part of the ‘active ingredient’ as the modality of therapy”. And it is for precisely this reason – among others – that the kind of evidence-based empiricism routinely applied to conventional medical treatments is singularly inappropriate in any attempt to evaluate psychotherapeutic interventions.

Far from seeing it as a problem, we positively celebrate the fact that “Britain has no legal definition of psychotherapy”! And the internecine warfare between psychotherapy and medicine bemoaned by the authors is not some random event, but rather, a revealing symptom of the epistemological chasm that rightly exists between what are arguably two incommensurable worldviews about human health and well-being. We passionately believe that therapeutic practice will only continue to evolve and progress if the field is left unfettered by rigid professionalising imperatives, with the freedom to encourage leading-edge innovation and diversity,11 free of the deadening encumbrances of institutionally professionalised “Regimes of Truth”.12 In this sense, we welcome rather than seek prematurely and inappropriately to legislate away the contested terrain of psychotherapy within the NHS – for in the visionary words of William Blake, “Without contraries is no progression”.


1 House R, The professionalization of counselling: a coherent case against? Couns Psych Quart 1996;9: 343-358; Postle D, Gold into lead: the annexation of psychotherapy in the UK. Int J Psychoth 1998;3: 53-83.

2 Hogan DB, The regulation of psychotherapists, 4 vols. Cambridge, Mass.: Ballinger, 1979.

3 A full briefing document on the IPN is available at http://ipnosis.postle.net

4 Totton N, Inputs and outcomes: the medical model and professionalisation. In House R and Totton (eds), Implausible Professions: Arguments for Pluralism and Autonomy in Psychotherapy and Counselling (pp. 109-116). Ross-on-Wye: PCCS Books, 1997.

5 Cooper M, The state of mind we’re in: social anxiety, governance and the audit society. Psychoanal Stud 2001;3: 349-362.

6 Power M, The audit society: rituals of verification. Oxford: Oxford University Press, 1997.

7 House R, Audit-mindedness in counselling: some underlying dynamics. Brit J Guid Couns 1996;24: 277-283.

8 House R, General practice counselling: a plea for ideological engagement. Couns 1996;7: 40-44.

9 BBC News Online report, Medicines ‘killing 10,000 people’. Friday 2 July 2004, http://news.bbc.co.uk/1/hi/health/3856289.stm

10 Woolfolk RL, Richardson FC, Behavior therapy and the ideology of modernity. Am Psychol 1984;39: 777-786.

11 Bates Y, House R (eds) Ethically Challenged Professions: Enabling Innovation and Diversity in Psychotherapy and Counselling. Ross-on-Wye: PCCS Books, 2003.

12 House R, Limits to professional therapy: deconstructing a professional ideology. Brit J Guid Couns 1999;27: 377-392.


Richard House MA (Oxon), Ph,D. is a General Practice counsellor and a Steiner (Waldorf) early years teacher living in Norwich, UK. With seven years training in counselling and body-oriented psychotherapy, he has been a practising therapist since 1990, and has published very widely in the psychotherapy, counselling and education literatures, with over 250 publications to date. His latest book, Therapy Beyond Modernity, was published by Karnac Books in 2003; and he has co-edited two widely acclaimed critical anthologies – Implausible Professions: Arguments for Pluralism and Autonomy in Psychotherapy and Counselling (with Nick Totton, 1997), and Ethically Challenged Professions: Enabling Innovation and Diversity in Psychotherapy and Counselling (with Yvonne Bates, 2003, both published by PCCS Books, Ross-on-Wye).

Address for correspondence: richardahouse@hotmail.com

NHS psychotherapy and its discontents: finding creativity amidst the conflict

Richard House
Magdalen Medical Practice, Lawson Road, Norwich NR3 4LF, UK

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