All I have is a voice to undo the folded lie.
W.H. Auden

Skills for Health and National Occupational Standards for Psychodynamic and Psychoanalytic Therapy
Arthur Musgrave

As a humanistic therapist I’m not well placed to comment in detail on National Occupational Standards for Psychodynamic and Psychoanalytic Therapies. I did, however, become quite involved in the drafting of the precursors to NOS, National Vocational Qualifications [NVQs], back in the mid 1990s. There are some useful parallels.

The NVQs concerned were those for Advice, Guidance and Counselling. A paper I’d written about the advice work and counselling was picked up and used to link the underlying value base of these two activities. I attended a number of consultation meetings, partly because of my advice work background and partly because I was, by this time, on the management committee of the (then) British Association for Counselling. I did some redrafting so as to deal with a particular impasse and contributed to discussions on how practitioners might be assessed. Afterwards the consultants invited me to be part of their bid to draft NVQs for Youth Work.

I say this to give an idea of the extent my involvement. I did this out of curiosity. Yet at the end of each meeting I was left with the same unanswered questions –

• how to understand the words on the page?

• what level of competence is required?

• at what point does the gathering of evidence stop?

If these matters were unclear to us as practitioners and workshop participants, surely they would be sources of confusion for others too. Each time we were assured that these difficulties would be addressed later. Eventually we were told we had nothing to be concerned about because assessment would be in the hands of experienced therapists who appreciated and understood the activity from the inside. This may well have been the case, at least as far as obtaining a qualification was concerned, since in principle, had NVQs ever caught on, those seeking one would have been free to choose an assessor from the body of those qualified to act as one. But another way of putting all this is to say that the key to interpretation lies outside the finished document.

In the event NVQs proved to be too onerous and unwieldy¹: they didn’t catch on. When, in December last year, I attended the launch of NOS for Counselling – the successor document to NVQs for Counselling – no one there knew of anyone who had ever gained an NVQ in Counselling.

Yet the virtues of NOS continue to be trumpeted. Not only is it claimed that they offer a route to qualification, but they are deemed to be of value to employers and those designing and running trainings for all the many and varied reasons listed in ‘An ABC of NOS’. This document makes grandiose claims that don’t stand up to even cursory examination. Who in their right mind would use a document of this kind –

• as ‘a structure to review critical activities…confirm the quality of the service provided…identify where improvements can be made?
Benchmarking and critical review (p.1)

• or to help them ‘plan and take action to develop their careers’?
Career development (p.1)

• or to manage their own personal and professional development’?
Continuing personal and professional development (p.2)

• or to help someone else reflect at the time of an exit interview?
Exit interviews (p.2)

And who – except the most naïve – could possibly believe rhetoric like this?

Organisational culture (p.3)

I could go on, but these suggestions are so bizarre that they raise serious doubts about the credibility of the whole SfH exercise.

The fact is that NOS are too cumbersome to be useful in the kinds of ways envisaged. The words they use are wide open to interpretation (eg what exactly is meant in the NOS for Psychodynamic and Psychoanalytic Therapy by the phrase in “a working knowledge”? whose definition will count – the practitioner’s, the manager’s, the employer’s or the patient’s?) and NOS are completely unable to distinguish what is central from what is peripheral. Anyone using them runs the risk of getting hopelessly lost in detail.

The short introductory sheet (‘Introduction for Expert Readers…’) is more modest than either of the other two documents circulated. It limits itself to valuing NOS as a starting point for detailed discussion –

‘You cannot learn dynamic therapy from NOS, but with a fellow practitioner and NOS you can have a more acutely focused discussion of it from which learning follows.’

There’s no doubt that NOS can spark off discussion, but whether this will necessarily be “more acutely focused” is open to doubt. I think it’s just as arguable that NOS offer so much scope for discussion that discussants are as likely to give up from exhaustion as reach agreement.

The words used in NOS are, at root, the product of a consensus - with all the disadvantages that flow from that. Received wisdom is reified and passed on mindlessly; critical reflection is discouraged by the sheer wordiness of the documents; and – if the ABC of NOS is to be taken literally – everyone is expected to refer back to the printed page before doing almost anything. Take, for instance, the following statement from page 6 of the FAQs paper -

‘National Occupational Standards put good practice into words. They are designed to express what research and clinical practice have shown to be effective in a practitioner’s work with an individual or group. They also set out knowledge and understanding that is necessary to met these standards of practice consistently…

‘An experienced practitioner or trainer will have more to say about good practice than NOS can express. But NOS do set out features of work that all practitioners and aspiring practitioners should take note of if they seek to improve practice and continue learning.’

This is highly controversial –

1. It is unsatisfactory – to put it mildly – to seek to define good practice in terms of consensus.
   
2. It is wrong to assume that NOS express what research and clinical practice have shown to be effective. NOS ignore counterintuitive and uncomfortable research findings - see www.talkingcure.com for some examples of these.
   
3. There is a presumption that there is a correlation between psychotherapy outcomes and knowledge and understanding. The research suggests that there isn’t – see www.talkingcure.com
   
4. Research offers a better guide than NOS to what practitioners and aspiring practitioners should aspire to when seeking to improve their practice and continue learning - see www.talkingcure.com
   

What we know from research is that it is that factors that are common to all psychotherapies are more important than the factors specific to particular brands of psychotherapy². Carving up the territory between expert reference groups cuts against decades of research findings to do with common factors. This is a recipe for obfuscation: it exaggerates the importance of factors that aren’t crucial for good outcomes and detracts from those that are. The resulting confusion will then be frozen in time to be used as a standard of ‘good practice’.

There’s currently a great deal of incoherence in central government policy in relation to psychotherapy – from the over emphasis on the value of CBT3 to Patricia Hewitt’s insistence in her Foreword to the White Paper ‘Trust, Assurance and Safety’ that professional regulation should be as much about “sustaining, improving and assuring professional standards…as identifying and addressing bad behaviour”. But above and beyond all this is the refusal to act on the research evidence that shows that the medical model is an unsatisfactory paradigm as far as psychotherapy is concerned⁴.

Government has failed to grasp that there is a huge mismatch between its aspirations for this field and the methodology it has chosen to adopt. There is more to be said, particularly about outcome research, but that would be to stray too far beyond the territory of National Occupational Standards.

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1 Sue Wheeler (1996) ‘Training Counsellors: the assessment of competence’ London, Cassell

“Under ideal circumstances, over a period of several years in a busy counselling practice, it might be possible, through regular individual clinical supervision, to be sure that a candidate for assessment had met all the requirements.” (p 119)

2 Norcross, John C (2002) ‘Psychotherapy Relationships That Work: therapist contributions and responsiveness to patients’ Oxford University Press

3 ‘Researchers claim CBT superiority is a myth’ p. 10, Therapy Today (July 2008) – “Professors Mick Cooper and Robert Elliott of the University of Strathclyde, William B Stiles of Miami University and Art Bohart of Saybrook Graduate School claim the government, the public and have been sold a version of the scientific evidence that is not based in fact, but on a logical error. In a collective statement, they said: ‘This is how it works: 1) More academic researchers subscribe to a CBT approach than any other. 2) These researchers get more research grants and publish more studies on the effectiveness of CBT. 3) This greater number of studies is used to imply that CBT is more effective.’

4 Wampold, Bruce E (2001) ‘The Great Psychotherapy Debate: models, methods and findings’ London, Lawrence Erlbaum Associates –

“I have striven to examine the results of thousands of studies and present them fairly and accurately. As I progressed with this project, the astonishing consistency of the results with the contextual model was surprising. It would be difficult to imagine how a scientist could examine these data and come to a different conclusion.” (p.xiii)