The Association for Lacanian Psychoanalysis in the United Kingdom
Response to Department of Health Consultation Foster Review of the Regulation of the Non-Medical Healthcare Professions
1.1.1. The Association for Lacanian Psychoanalysis in the United Kingdom acknowledges the aims underlying these proposals, the intention to provide greater protection and assurance to the users of psychological treatments and the so-called ‘talking therapies’.
1.1.2. However, our Association cannot support the measures proposed to achieve these aims.
1.1.3. We are of the opinion that the application of these proposals to the regulation of psychoanalytic practice would be based on misguided assumptions about both the nature of that practice and the source of the risks involved.
1.1.4. We have concerns that the implementation of these proposals would give rise in the case of the talking therapies to a range of unintended consequences that would ultimately lead to poorer protection of the public they set out to serve.
2.1.1. The proposals contained in the Foster Review would have profound consequences for the psychological professions in this country.
2.1.2. It is remarkable that this Review contains no reference to the implication of these proposals for those professions.
2.1.3. This makes it difficult to comment specifically on these proposals, as we are forced to extrapolate on their implications for our own profession.
2.1.4. The fact that there has been no attempt to consider these implications is one of the clearest indications that this Review cannot be deemed to have given due consideration to the issues at stake in the regulation of the talking therapies in this country.
2.2.1. We understand that the regulation of the psychological professions and the talking therapies would entail the expansion of the remit of the Health Professions Council to a sector numerically greater than the total membership of all the professions currently regulated by the HPC.
2.2.2. This Review apparently fails to consider the implications not just for the structure of the HPC but also for the practical operation of the procedures and processes of regulation itself.
2.2.3. How then can the members of the public and profession be assured that the implications of these proposals and their effect on the provision of psychological therapies has been adequately considered?
2.3.1. While neglecting to consider the implications of these proposals for the psychological professions this Review also fails to take account of the specific differences between these professions and the other professions currently regulated by the HPC.
2.3.2. It is this failure to consider the specific nature of the psychological professions and the ways in which they differ from the other professions currently regulated by the HPC that lies at the root of many of our concerns.
2.3.3. It is also one source of the various unintended consequences that it is possible to extrapolate from these proposals in the case of the talking therapies, consequences that all the stakeholders in this process should have a common interest in seeking to avoid.
3.1.1. The Foster Review lays out proposals for a form of regulation that is explicitly both health-based and employer-led.
3.1.2. These proposals set out from the supposedly neglected fact that ‘most health professionals are now employees’.
3.1.3. The applicability of these proposals to the psychological professions is immediately limited by the fact that in the case of the talking therapies these assumptions are questionable at the least.
3.2.1. The recent Mapping Project of the counselling and psychotherapy professions carried out by the BACP and the UKCP on behalf of the Department of Health indicates that up to 70% of these professionals work outside the public sector, most of these in private practice.
3.2.2. Few of these practitioners would consider that their role or their practice could adequately be captured by a definition as Health Professionals.
3.2.3. How can these practitioners be expected to have confidence in a system of regulation that considers them solely as actual or potential employees of the Health Service?
3.3.1. The main thrust of the proposals contained in the Foster Review appears to involve an attempt to align the requirements of regulation with the requirements of the employer, in this case the NHS.
3.3.2. The proposals for revalidation, in particular, appear to be based almost exclusively on the assumption that the regulated professional is to be considered an employee of the NHS.
3.3.3. While this may be the case for the professions currently regulated by the HPC, on the whole this is not the case for the talking therapies.
3.4.1. The application of these proposals to the case of practitioners working in the private sphere is not considered apart from the suggestion that for this group of practitioners the regulatory body will need to develop direct revalidation arrangements.
3.4.2. There is no indication that adequate consideration has been given to the feasibility of applying procedures of revalidation established within an NHS framework to the regulation of private practitioners, or to the scale of operation involved.
3.4.3. There is apparently no consideration given to the possibility that this will involve a disproportionate burden on the private practitioner in meeting the requirements of this system of revalidation.
3.5.1. The table of risk factors for deciding the intensiveness of revalidation contained in Chapter 3 of the Foster Review suggests that private practitioners will in fact fall into the highest risk band.
3.5.2. It is difficult to avoid the conclusion that private practitioners will then carry the burden of a more intensive application of a system of regulation and revalidation inappropriate to their sphere of practice.
3.5.3. This can only lead to disproportionate outcomes at odds with the criteria of good regulation laid out by the Council for Healthcare Regulatory Excellence.
4.1.1. The failure of the Foster Review to consider the implications of these proposals for the structure of training in the psychological professions and talking therapies is at the root of our other major reservations about these proposals.
4.1.2. The Review itself states that it is ‘largely from their pre-registration education that members of professions derive their professional standards, attitudes and behaviours which normally protect patients effectively’.
4.1.3. It appears that in a number of areas, most obviously in the case of standards of entry to the register, regulation of the psychological professions according to the generic criteria of the HPC will in fact entail a lowering of professional standards.
4.1.4. It is difficult to see how lowering of standards of entry to the professional register can fail to have consequences for standards of training and practice across the profession.
4.2.1. The question of training is of particular importance in the case of psychoanalysis, as it serves to highlight important differences in relation not only to the professions currently regulated by the HPC but also to the psychological professions in general.
4.2.2. These differences concern not simply the duration and intensity of a psychoanalytic training, but more particularly the specific nature of a training that cannot be dissociated from the central role of the training analysis in that process.
4.2.3. It is a perhaps overlooked fact that there is no psychoanalyst currently practising who has not themselves been a user of psychoanalytic services. This is a factor built into the structure of psychoanalytic training and an essential element of the professional context elaborated around it.
4.2.4. A psychoanalytic training cannot be reduced to an academic model of education, nor understood in terms of the simple transmission of knowledge, skills and techniques. On the contrary, a training analysis involves a profound questioning of our assumptions about knowledge, character and competence.
4.2.5. Our Association would therefore have difficulty accepting the pre-defined notions of good character, adequate knowledge and desirable outcomes that these proposals seek to place at the heart of the system of regulation. This attempt would be directly at odds with the principles at stake in an effective psychoanalytic training.
4.3.1. These brief remarks about some of the distinguishing features of psychoanalytic training would also allow us to begin to characterise the specific nature of psychoanalytic practice and indicate some of the ways in which this practice differs from that of the psychological professions and other talking therapies.
4.3.2. Psychoanalytic practice cannot be reduced to a simple application of knowledge, competencies and techniques to the removal of symptoms. Any therapeutic effects that psychoanalysis may offer are rather the product of a personal experience of questioning, uncertainty and growth freely chosen by the analysand.
4.3.3. Lacanian psychoanalysis seeks to place questions of subjective choice and responsibility at the heart of the therapeutic process. This commitment to the particularity of each subject’s choices is one of the fundamental ethical principles that safeguards the analysand within the therapeutic relationship and serves to guide the psychoanalytic process to its resolution.
5.1.1. Our Association would therefore be unable to support any generic form of health professional regulation based on questionable assumptions about the employment context, therapeutic goals and technical base of psychoanalytic practice.
5.1.2. We respectfully submit that any application of the Foster proposals to the regulation of the talking therapies, and of psychoanalysis in particular, would involve a misunderstanding about the nature of the practice concerned.
5.1.3. The assumption that the practice is of the same order as that of the other professions regulated by the HPC would entail a further assumption that the source of the risks involved in these professions is also of the same nature.
5.1.4. In our opinion it would be necessary to examine the assumption that the risks posed to the public by poor practice of the talking therapies are of the same nature as those involved in the predominantly technical professions regulated by the HPC.
5.1.5. This would be the necessary precondition for ensuring that any measures put in place to address those risks were of an appropriate order.
5.2.1. Our concern is that failure to attend to these distinctions would lead to the misguided application to our profession of a system of regulation that might have the dual effect of undermining the form of protection already provided by the professional organisations while failing to put more effective procedures in place.
5.2.2. The implementation of a system of regulation manifestly unsuited to the type of professional practice it seeks to regulate would give rise to a range of inappropriate and unintended consequences, leading ultimately to lower standards of practice and weaker safeguards for the public they are intended to protect.
5.2.3. None of these are difficulties that could not be addressed with an appropriate spirit of partnership and consultation between the Department of Health and the professional organisations representing the talking therapies.
5.2.4. This would require a commitment on the part of the professional organisations to address the concerns that give rise to these proposals in the first place.
5.2.5. It will also require a commitment from the Department to act to address legitimate concerns raised by the professional organisations about the effectiveness of these proposals as they stand.
5.2.6. We therefore ask you to accept these comments in the spirit of constructive criticism with which they are drafted.
Association for Lacanian Psychoanalysis in the United Kingdom
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