For anyone new to the mysteries of current events in the regulation of counselling and psychotherapy I’ll begin this report on yesterday's HPC Professional Liaison Group meeting with a sentence or two about the group's formation.
The PLG is an appointed group. Applications were invited and the HPC, or some persons in the HPC, chose a group and gave it the task of recommending how counselling and psychotherapy could be brought into state regulation.
Two of the seventeen PLG members look after the interests of the 36,000 BACP counsellors, along with the largest of the accrediting organizations for counselling trainings. Three people speak for psychotherapy, two of them manifestly from the psychoanalytic approach, and the other the UKCP, around eighty organizations, some of whom behave like a trade association. Five people on the PLG including the chair, double as HPC council members. As I have observed in previous reports, they can be relied on to act as ballast; if the ship looks like it might become unstable, they steady it with reassurance.
Hold in mind that what follows is an account of a meeting which is massively unrepresentative of the field. It is a group appointed to rule, that has chosen to pick up and run with the HPC’s authority to rule. What unites this group is that these people are meeting with each other to insist on bringing into existence state regulation of the psychological therapies.
Is the PLG only about ‘counselling’ and ‘psychotherapy’? Those of us on the margins of these activities, those of us who have had a different beginning and a different trajectory through this field, see it as the enclosure, or capture and privileging of a quite narrow seam of working with the human condition. Try thinking of the PLG as a group seeking to capture the ‘mineral rights’ to the ‘territory’ of the psychological therapies, rights which if they are granted by the state, amount to a monopoly to mine for profit the psychological seams that have been identified. Am I unhappy about this? Are the many practitioners who have become aware of what is afoot unhappy about this? You bet. So if the tone of this piece seems unduly sceptical, critical, dismissive, then that's because it comes at the end, or at an inflection point in a process of capture that demeans and disgusts.
The February 2nd PLG meeting lasted around for four and a half hours. It was an historic moment, no doubt about that. I took eight pages of notes. For the first time the public gallery was full. Indeed there were people disappointed at not being able to attend. As the meeting began it had the expectant quality of a full house at a new theatrical production. A feeling shaped also by the fact that this was apparently the final PLG meeting.
Like previous PLG meetings, it was a tedious event, and as it progressed, the veneer of civility was increasingly revealed to be covering a knot of fundamental disagreement. I intend sieving my notes to give you hints, impressions and intuitions, with the aim of conveying something of the dynamic at the heart of this farrago.
Dr van der Gaag, chair of the HPC, was present and though not a member of the PLG, spoke up throughout the day, something of an anomaly, it might be thought. Her introduction touched on the recent Health and Social Care Bill, and noted that there was to be a White Paper in mid-February that would define for the period of this parliament the policy areas which the Bill was intended to facilitate, i.e. the Department of Health will set out its decision about whether, how, by whom, but probably not why, counselling and psychotherapy will be regulated.
In, as it seems to eIpnosis, the first of several mentions of a future for the PLG, or more likely a future for HPC regulation of counselling and psychotherapy, she said that, ‘while this might be the last PLG meeting’, ‘there was a lot of momentum here’, ‘the process was not at an end’, that ‘pending a decision on the future’ ‘they ‘would continue to work on standards. And then, with a hint of leakage, she concluded, ‘more than that I can't really say’.
Dr van der Gaag went on to touch on the emergence of the CHRE in its new guise. Ever aware of taxonomic differentiation, of pecking orders, she outlined how the HPC was about holding a professional register, whereas CHRE would be engaged in administering somebody else's register. However, as she emphasized, 'these were early stages'.
A very large part of the morning was taken up with discussion of whether the ‘child psychotherapy profession’ merited a separate title, a discussion that could be construed as surreptitious lobbying in favour of the primacy of psychotherapy. The Association of Child Psychotherapists [ACP] had presented at a previous PLG meeting and eIpnosis recalls that ACP qualification was only at doctoral level and that this seemed overvalued. Since when did a doctorate guarantee, or even support the quality of empathic divining that working with distressed children, indeed any children might require?
The difficulty of deciding whether child psychotherapy is distinct from other forms of psychotherapy was not the only reminder in this meeting that taxonomy is difficult. Especially where it's inappropriate, unhelpful, and likely to have damaging unintended consequences.
For some present, having a separate register for child psychotherapists was held ‘to be divisive’. Professor Lucas, also an HPC council member (did qualification as a lay member of the PLG require being a professor and an HPC council member?) he wanted the register to be ‘simple and minimalist’ and later on in the same topic of child psychotherapy title, he wanted ‘a (regulatory) future that looks tidy and sensible’ for him this discussion was ‘too concerned with tidying up the past’.
Yes taxonomy is difficult.
At times during the morning we seemed to be being showered with regulatory language: ‘title at statutory level’, ‘the package of being a psychotherapist’, ‘commonalities’, ‘distinctions’, ‘generic standards’, ‘standards of proficiency’, ‘sops’, ‘competencies’, ‘complexity’, ‘differentiation’, ‘frameworks’, ‘distinct competencies’, ‘threshold entry levels’, 𠆎ntry point thresholds’, ‘frameworks’, ‘disorders’, ‘normative levels’, ‘definitional issues needed to be clear and distinct’, and ‘mapping’.
A technocratic confetti, the language of taxonomy, the language of technical solutions, the language of scientism.
If this feels too strong, or exaggerated, consider the image that Malcolm Allen introduced in pursuit of a child psychotherapy title: the notion that counsellors and psychotherapists were like elephants and hippopotamuses built of Lego, made from the same yellow building blocks. ‘ But an elephant is not a hippopotamus with a different head’, ‘they are each differently configured’, ‘one is not the same as the other with a bit added’. Dr Van der Gaag later continued the theme, asking whether perhaps there were other animals in that box, made of the same bits of Lego. How different, she wondered, were the animals in the box? A telling image and one which matches the powerfact wishdream of counselling and psychotherapy practice being successfully re-engineered from interlocking components - standards of proficiency or SOPs - as the meeting repeatedly called them.
But let’s cut to the chase because this was, as you are perhaps discovering, a very tedious meeting. Returning to child psychotherapy and the impasse of whether it merited a separate statutory title… a suggestion emerged… the PLG should recommend that since there was no agreement in the PLG they should let Council, the HPC Council, make the decision. Professor Fonagy thought it was OK to delegate such a decision to Council, Carmen Ablack of the UKCP objected, ‘do we protect title here or not? There was considerable regret that they could not get this agreed.
After the lunch break there was further discussion about how to fit people into title boxes and how many boxes were needed. Two or four? This seemed to be the issue. At this point an innovation emerged, voting, which seem to surprise some of those present, voting on whether this was an issue to be passed to the Council. Four voted for a separate title for Child Psychotherapists, three were against, and there were three abstentions. (the PLG Council members remembered not to vote).
The meeting then moved on to discuss ‘level of entry to the register’ for counsellors. Entry was proposed to be at level 5. This despite objections that many counsellors working in agencies are at level 4 and a further objection that for practitioners to move up a level, i.e. from 4 to 5, would mean at least an extra year's study, so that the cost of being a practitioner would increase.
The innovation of voting was again invoked, should level of entry for counselling to the register be at level 5, yes or no? There were 14 votes for, and one abstention.
The actual elephant in the room, ‘Differentiation’, now climbed onto the table. Are counselling and psychotherapy the same? ‘Or are they intrinsically different? There had been long and presumably onerous offstage discussions about this between the PLG meetings. They had failed to find a resolution, the two cultures taxonomically title-boxed by the HPC as ‘counselling’ and ‘psychotherapy’ were not in agreement. The counselling culture asserted that Counselling was the same as psychotherapy; the psychotherapy culture asserted that Psychotherapy was intrinsically different to counselling. This was held ‘to be a shame’, ‘surely a sensible middle ground could be found?’ Other voices re-iterated that the current standards of proficiency were inadequate as descriptions of counselling and psychotherapy. At this point the room did seem to fill with regret, regret that, despite long meetings outside the PLG discussing differentiation there was no agreement on this issue, and regret too we might suspect, that the cross cultural desire for statutory regulation was perhaps blocked.
Professor Fonagy expressed his strongly felt view that ‘this was an issue of principle and public protection’ and that the definitional issues about counselling and psychotherapy were clear and distinct and that psychotherapy was intrinsically different. He quoted, not for the first time in the meeting, the European Association of Psychotherapy’s definition of psychotherapy and invited the counselling culture to bring out their definition. A blatant attempt at domination by definition, eIpnosis felt. It's worth quoting the definition of psychotherapy that Professor Fonagy thinks is so excellent.
(1) The practice of psychotherapy is the comprehensive, conscious and planned treatment of psychosocial, psychosomatic and behavioural disturbances or states of suffering with scientific psychotherapeutic methods, through an interaction between one or more persons being treated, and one or more psychotherapists, with the aim of relieving disturbing attitudes to change, and to promote the maturation, development and health of the treated person. It requires both a general and a specific training/education.
(2) The independent practice of psychotherapy consists of autonomous, responsible enactment of the capacities described in paragraph 1; independent of whether the activity is in free practice or institutional work:
Professor Turner said that ‘if there is a difference, it has to be quantifiable’ this was supported by another voice who agreed, ‘we can't be vague’.
After lunch, the chair, Professor Waller, introduced the afternoon session by saying that this might be the last PLG, but it was not the end and that the HPC would support continuation of the work.
The discussion of differentiation between counselling and psychotherapy continued. The BACP position appeared to be that counsellors did the same work and had the same jobs as psychotherapists. Malcolm Allen said ‘that for 50,000 practitioners four boxes ain’t bad’ and went on to emphasize that for psychotherapists, language was ‘like the scalpel and forceps of a surgeon’ ‘that language is the basis of their interventions’, ‘that language is what practitioners do, it is the material stuff of interventions’. This was supported by Professor Fonagy: ‘clinical’, ‘psychopathology’, ‘mental illness’ and ‘treatment’, all this language was intrinsic to psychotherapy, he insisted.
eIpnosis increasingly felt that what was going on in the room at this point was a replay of the Alderdice Bill of 10 years ago in which the psychoanalytic culture attempted to reinforce its professional identity through attempting state regulation of psychotherapy. It was a definitions contest. Professor Fonagy, notionally representing Skills for Health, argued that psychotherapy was ‘philosophically and historically sound and clear’, and to say that it was the same as counselling would be to obliterate psychotherapy. It would be a challenge to its identity.
Other voices, alarmed perhaps by the implied seniority of this assertion spoke up, ‘for state regulation to work there is a need to bring everyone with us’. ‘We need to find a pragmatic way forward’. ‘Public protection is what matters’. ‘BACP has 36 thousand practitioners who say there is no difference between psychotherapy and counselling’. Professor Fonagy returned with the notion of Cicero’s qui bono, 'Who wins? Who loses?' 'A four box model was OK but with a two box model a huge amount was lost'. It became very clear that, at least for him, a loss of identity was involved, professional identity. Again, Professor Turner called time on the dispute, ‘the group can’t make this decision. It could put the arguments but it would need an outside body to make the decision’, ‘there is too much talk of winners and losers here’.
The PLG again moved to a vote. Is counselling different from psychotherapy, or the same as psychotherapy? Six people said yes, they were different, two voted against and a decision on the truth value of this disagreement was delegated to the membership of the Council of the Health Professions Council.
Shortly afterwards, chair Professor Waller reached for, and pulled up the duvet of positivity. She knew that not everybody was happy but that the meetings of the PLG had achieved a lot for the professions and that we should continue to do this work. Yet again it appeared that the statutory regulation of counselling and psychotherapy had a future.
That this meeting was held at all, that it passed impossible decisions to the Council, coupled with multiple hints of continued forward movement, fed the eIpnosis intuition that the HPC does expect to be given title ownership of counselling and psychotherapy.
If so what outcomes might there be?
1. Willingly or unwillingly many practitioners would opt for HPC capture, especially those in jobs with the NHS or its commissioning service providers which are overwhelmingly likely to require HPC's title protection for counsellors and psychotherapists.
2. Where would that leave CHRE in its new mode? If we put aside counsellors for a moment, psychotherapists in the UKCP who couldn’t stomach the HPC offer of professional identity enhancement might well fancy putting themselves under the administrative umbrella of CHRE. Along with voluntary registers of say, aromatherapists, mentors, mediators, humanistic psychologists, coaches, reflexologists, and human givens.
However, if HPC have ownership of counselling and psychotherapy titles, HPC-averse practitioners would not be able to use either title. This promises to consign the CHRE to secondary status in the field. Not because what they could do would be inferior, but because through state regulation of these two titles the government will have labelled counselling and psychotherapy intrinsically superior.
3. A third option for practitioners could be to follow neither of these two options and become, or stay independent, free to explore alternative practitioner accountability and new, post-professional ways of working with the human condition based on the power of love rather than the love of power.
If HPC regulation of counseling and psychotherapy is implemented, state endorsement of these titles might be expected to result in considerable collateral damage. Following today’s meeting, PLG participants will be able to say ‘don’t look at us; it was the Council that took the decision’. How very convenient.
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PLG - The Final Meeting February 2nd, 2011
Key decisions delegated to HPC Council
The Health Professions Council Counselling and Psychotherapy
Professional Liaison Group [PLG]