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On Deconstructing and Humanising the Regulatory Impulse: Directions for Mobilisation
Richard House and Denis Postle, Independent Practioners Network, UK
It is our intention that this text closely reflect the live dialogue of our joint presentation to the conference, with the following section headings faithfully reflecting the content of our presentation. We begin by saying something about what brings us to this conference, following which we catalogue the downside, as we see it, of current proposals for statutory regulation (hereafter referred to as SR). We then move on at greater length to introduce the Independent Practitioners Network (IPN), a major positive response to the culture of professionalisation of the British psychopractice field. We end with a perspective on the likely next steps that will be necessary if present plans for SR are to be effectively challenged and successfully interrupted.
Why Are We Here?
We are two therapy practitioners who come from a broadly humanistic, human-potential background (though we are deeply influenced by a range of therapeutic approaches and perspectives, including psychoanalysis), and together we share approaching four decades of consistent therapy practice of diverse kinds and in a range of different settings. We have both published extensively in the literature on the professionalisation of psychotherapy and counselling (see ‘Further Reading’ section, and, for example: ipnosis - a journal for the Independent Practitioners Network [IPN]; and, before that, g.o.r.i.l.l.a., now an archive of the many attempts to confront the professionalisation of psychopractice in the last 17 years, during which time we have been at the forefront of the British challenge to the statutory regulation of psychopractice in this country).
The early stages of the professionalisation of counselling and psychotherapy looked and felt like colonisation, with ‘turf wars’ between rival factions, and with the United Kingdom Council for Psychotherapy (UKCP) behaving variously like a trainers’ club and a trade association, talking the rhetoric of ‘client protection’ but, seen up close, being predominantly driven by the need to capture and sustain therapy trainings. Denis Postle (DP) began taking the colonisation seriously when the then chair of the UKCP started talking about overgrown gardens and getting rid of the ‘weeds’ of which, according to her criteria, he was clearly one.
A second wake-up call was the bizarre episode of the Alderdice Psychotherapy Bill, which sought to capture the high ground for the psychoanalytic community. A text in which everyone mentioned is male, and which didn’t survive first contact with the (then) British Association for Counselling, who were understandably furious to have been sidelined and ignored in the Bill’s development.
Richard House (RH) had a lot to say about the damaging march of professionalisation, including editing and contributing to two books and writing a third (see ‘Further Reading’). The corrupting effects of the drive for professionalisation was soon confirmed by the extraordinary experience of a mainstream therapy publisher turning down the House and Totton text Implausible Professions, on the grounds that they didn’t want to upset the UKCP, who also published with them! (By the year 2000, there had to that date been at least 15 published reviews of Implausible Professions in the therapy literature, all of which have almost without exception been unreservedly positive, and the book continues to sell steadily today, some 9 years later.) DP’s resistance took a different route, using family resources to build and maintain several web sites devoted to writing for and building archives of essential texts (see the web addresses at the end of this text).
Our overall experience has been that what there is substantively to say about the damage that SR will cause has been said, much of it several or many times over. Our experience, as Nick Totton has remarked, has been of Totsweigen - or being ignored to death. We have yet to find a substantial text that argues cogently, and with adequate evidence, in favour of SR.
Both of us were freshly energised by Richard Mowbray's eagerly-awaited and long trailed book, The Case Against Psychotherapy Registration: A Conservation Issue for the Human Potential Movement, which proved to be well worth the wait when it eventually appeared in 1995. The Case (as it soon became colloquially christened) very quickly became the ‘bible’ for practitioners in the field who had severe doubts about the whole direction in which the British psycho-landscape seemed to be headed. RH remembers with great clarity and pleasure the effect that The Case had on him when he first read it - like one of those very rare and profoundly integrating ‘a-ha’ experiences where previously disparate ideas and feelings suddenly cohere into an integral ‘whole’. Here, for the first time in Britain, was an immaculately documented and thoroughly compelling rationale for all the unease he had felt since he first encountered the professionalisation/accreditation issue some five years earlier. Certainly, for anyone wishing to acquaint themselves with the history and advisability of therapy regulation, Mowbray's Case is surely the indispensable starting-point.
For those sufficiently open and ideologically unencumbered to see it, there seemed to us to exist a growing undercurrent of deep unease about the form and direction of therapy professionalization in Britain; and the book Implausible Professions, which RH co-edited with Nick Totton, sought to give a coherent form to those previously ‘unintegrated’ and disparate voices. Implausible Professions seemed to be a natural sequel to, and extension of, Mowbray's scholarly analysis in The Case. In 2003 it was followed by Ethically Challenged Professions: Enabling Innovation and Diversity in Psychotherapy and Counselling, which RH co-edited with Yvonne Bates, and RH’s Therapy Beyond Modernity: Deconstructing and Transcending Profession-Centred Therapy (in which RH took the challenges about self-serving professionalisation to the very heart of therapy procedure and praxis itself). Destined, like Implausible Professions, to receive many favourable reviews in the literature, Ethically Challenged Professions gave due prominence to the substantive contributions that had been made to what, since the mid-1990s, had become a growing critical literature; and between them, Implausible and Ethically Challenged Professions showcased a formidable array of prominent therapy authorities who have grave and manifold concerns about the uncritical and inappropriate professionalisation of the field - among them, Professors Arthur C. Bohart, Petruska Clarkson, Daniel B. Hogan, Arnold Lazarus, Ian Parker, Nikolas Rose, Andrew Samuels, Ernesto Spinelli, Brian Thorne; and David Brazier, Colin Feltham, John Heron, John Kaye, Peter Lomas, Robin Shohet, David Smail, and Nick Totton - to name just some of those books’ many and diverse contributors.
A third element of concern for us has been the extent to which regulation proposals look very much like yet another branch of the UK’s bureaucratically disabling ‘surveillance culture’ (Cooper, 2001), which sees the regulation of psychotherapy and counselling in terms of targets, measurement and ‘evidence-based’ practice. As if this ‘audit culture’ were not only too obviously a form of attempted domestication of the unavoidable unpredictability, wildness and uncertainties of working with the hurts, humiliations and unhelpful happenstances with which clients come to us (Henderson, 2003).
The Downside of Statutory Regulation
Across our decade-and-a-half of resistance to SR, we have been diligent to point to the accumulated research and inquiry of other people who have broadly shared our concerns. Hogan (e.g. 1979, 2003) and Mowbray (e.g. 1995) persuasively demonstrate how SR will restrict the supply of practitioners; inflate the costs of services; stifle innovation in education and training; discriminate unnecessarily; and lead to ‘defensive’ practice. All the major psychopractice organisations have openly used fear of being left out, and/or fear of not being able to work, as blunt instruments for shepherding - or herding, perhaps - their generally deferential flocks in the direction of signing up to whatever is the current regulatory fashion.
And as problematic, in its own way, is the tolerance or ignorance of the substantial incongruence between ‘power over’ mechanisms - a top-down command-and-control system in the accountability structures that administer SR - and ‘power with’ behaviour in the working alliance with clients. We have consistently asked whether others are aware of this glaring incongruence between the accountability structures to which we are subject (whether through self- or state-surveillance), and the values and tacit belief systems we take into our work with clients - consciously or otherwise. In short, such incongruence arguably does grave damage to the client interest in general, and to the very way in which we work with clients in particular. After all, as David Smail and others have consistently argued, do not many/most clients who find their way to therapy come with issues about authority, deference, exploitation and victimisation? As Richard Mowbray and Juliana Brown memorably wrote in the early 1990s, ‘Where there is a genuine need for structures, we should develop structures that foster our values rather than betray them’.
We have also become aware of the widely shared sense that SR rides on several fallacies that have been vigorously contradicted by a variety of critics. One of these is that advanced/extended training and further education lead to (increased) therapeutic effectiveness. There are also compelling arguments and associated research evidence suggesting that newly qualified or lightly trained paraprofessionals in the field do therapy work which is at least as effective as highly trained practitioners (RH sets out some plausible reasons to account for such an important counterintuitive finding – see House 2001; see also Henderson, 2003).
An equally important fallacy is the uncritical assumption that the advent of SR will have any beneficial effect whatsoever on the level of client safety. Not only is there no evidence that trained practitioners are less abusive than less or lightly trained ones, but there are compelling arguments suggesting that therapists trained into a comparatively rigid therapeutic ‘regime of truth’ might actually practise in a way that is routinely abusive (House, 2003). Moreover, we tend to see training schools’ embracing of SR as an open admission that their trainings are unable to provide adequate ongoing quality control protocols in trainees. Curiously, this level of educational inadequacy is somehow regarded as acceptable, even inevitable.
It appears that the overriding reason for the Government’s intended introduction of statutory or state regulation is to provide a means of protecting the public from practitioners who are deemed unfit to practise and who could cause harm to those who seek their services. Given that this is indeed the central raison d’être underpinning regulation, the first and most obvious question is: What is the evidence that statutory regulation, compared with a ‘no regulation’ counterfactual comparison or scenario, would actually succeed in protecting the public by reducing the net level of abuse in the system?
We take it, first, that those arguing for statutory regulation would need to demonstrate that there currently exists a level of abuse that is greater than the level that would plausibly obtain under a statutorily regulated therapy field. In turn, this requires detailed information about the level of abuse that currently exists within the therapy field. Now of course no one would seriously deny that abuse exists – after all, it exists everywhere in life; the crucial issue here concerns the scale of existing levels of abuse. Nowhere have we or our colleagues seen any empirical evidence about the current level of abuse within the British occupational field. Has any serious systematic research been carried out into this issue, and if so, why have its findings not been made public?
Of course there are pressure groups representing ‘users’ and clients (some possibly with axes to grind) who are calling for regulation; but this of itself does not make anything approaching a sufficient case for the appropriateness of statutory regulation, without the accompanying research on the current scale of abuse and dissatisfaction having been carried out. In short, we maintain that in any rational world it is not justifiable that dramatic and wide-ranging changes be made to our occupational field (and potentiality harmful ones at that – see above) simply on the basis of a comparatively small number of high-profile, emotionally charged and anecdotal complaints or representations by user-groups, without comprehensive independent research first having been carried out.
In the literature referred to earlier, there is lengthy ‘chapter and verse’ on just why the ‘public protection’ argument does not hold water – or is at the very least highly questionable. As the American authority on psychotherapy regulation, Professor Daniel B. Hogan, has written, ‘...a similar array of horror stories could easily be assembled about highly credentialed psychiatrists and psychologists, all of them licensed’. In other words, client and patient abuse occurs in professions that are already licensed and have specific sanctions against abuse and malpractice; and there is no clear empirical evidence in the literature to suggest that its incidence differs between licensed and unlicensed settings.
Moreover, and as Richard Mowbray has pointed out, the various cases of abuse discussed by Jeffrey Masson in his well-known book Against Therapy were mainly perpetrated by involved practitioners who were already licensed professionals (i.e. medical doctors, clinical psychologists etc.), and their registered professional status within the community if anything made it harder to challenge their abusive behaviour. Mowbray again: ‘If protection of the public from harm has not been a proven consequence of [licensing] systems in general, there is little prospect that such a system would protect the public in a field as indefinite as this one.’
Another compelling challenge to the ‘public protection’ rationale is that, as we all know, potentially abusive practitioners who are determined to abuse will simply find another way of doing it – e.g. either by calling themselves something else that isn’t regulated, or else by finding another arena/forum in which they can perpetrate abuse relatively unhindered. So on this view, perhaps the most one can say is that the statutory regulation of psychotherapy and counselling might merely redistribute abuse within society as a whole rather than removing it – thus invalidating the ‘abuse reduction’ argument for statutorily regulating the occupational field.
It might be countered that it is public perception that matters most, and that it is important for the Government to be seen to be responding to concerns about abuse, whether those concerns have wide-ranging substance or not. In our view this would amount to expediency of the worst kind, where appearance (‘spin’) matters more than substance and authenticity. Many cultural critics maintain that the increasingly routine triumph of appearance over substance constitutes one of the most harmful trends in modern cultural and political life, and one which it would be potentially disastrous for the therapy field uncritically and incongruously to embrace and collude with. It would also surely constitute dishonesty of the most damaging kind for either our occupational institutions, or for Government itself, wittingly to generate substantially exaggerated fears and anxieties about the dangers of abuse in our field in order to justify the need for legislation, when in reality the empirical evidence which would be needed to substantiate a rational case for regulation simply does not exist.
So, What Is To Be Done?
We believe, first, that there is an urgent necessity for the personal/institutional naturalisation of dominance that lies at the centre of institutional professionalisation to be challenged and transformed, and a more enlightened ‘power with’ approach to accountability be adopted which is more congruent with the widely accepted therapeutic aim of clients’ responsible empowerment. Specifically, we envisage the building of accountability institutions at macro and micro levels that embody 'power with' rather than 'power over’ principles of organisational and human relationship.
The Independent Practitioners Network, in which we have both been full participants for about 12 years, offers one approach to addressing these important questions of the building of mature and congruent accountability structures. What would be the criteria for adequate client/service user accountability? Rather than regulation, accountability is a better and more widely acceptable way of framing ethically sound client/practitioner working alliances.
Over a decade’s worth of IPN theory and practice has identified several key elements of effective accountability:
• Ongoing, long-term, face-to-face contact with a settled group of peers that demonstrates a practitioner’s capacity to form working alliances based on respect, negotiation, mutuality and rapport.
• Declaration by each participant to the peer group of their training, competencies, special area of expertise if any, the client population for whom they are competent, their client workload, their continuing personal/professional development commitment, and their supervision arrangements.
• Mutual disclosure in the peer group of challenges, deficits, difficulties, achievements and significant developments in their practitioner work, coupled with disclosure of any developments in their personal life that might affect their fitness to practise.
• Agreement between the practitioner group members about how disputes with clients should be handled.
Self and peer accreditation in such a group institutionalises practitioner/client accountability in a way that greatly increases the likelihood of client satisfaction, and reduces to close to zero the chances of abusive or exploitative practitioner behaviour.
Some people have objected that the close personal contact of this process invites collusion. In the IPN model, when such a group has formed, they contract with other similar groups to establish external validation of their accreditation/dispute resolution process and possible collusive agendas. There is also a vested interest carried by every group member that their group colleagues’ practice is sound and ethical (not least because if it is not, then that will reflect unfavourably upon their own judgement and practice). Moreover, this approach to accountability also draws fully upon what is commonly a very well developed intuitive and perceptive sense in therapists and counsellors, such that our ‘peers-in-relationship’ are best placed by far to ‘pick up’ concerns about any given practitioner’s fitness to do this demanding work.
As IPN demonstrates, such a framing of psychopractice accountability can be orchestrated in innumerably different ways.
If a regulation process lacks this mix of autonomy and external validation, how can it avoid being perceived by practitioners as coercive and stressful, and an unwarranted imposition? Will it not prove to be lacking in credibility, resulting in low compliance and effectiveness in protecting clients, should the latter indeed prove to be a significant, evidence-based requirement?
Incorporating the key elements of a self and peer accreditation approach into Department of Health (DoH) policy recommendations (to be implemented in a variety of ways by all the diverse organisations presently in the psychopractice field) could ensure that quality assurance of practitioner/client relationships would be intrinsic, i.e. eliminating abuse through continuous monitoring, not as the DoH Next Steps seems to indicate, extrinsic, via the detection, investigation and adjudication of complaints. In so far as quality assurance is intrinsic, the state regulation of psychopractice would be redundant.
Next, we advocate the building of political alliances that bridge cultural divides - on the assumption that in the broad field of ‘therapy’ or psychopractice (i.e. psychoanalysis, psychotherapy, counselling, counselling psychology…), what unites us in regard to SR is greater than what divides us. This very conference has, to our knowledge, been the first time outside of the humanistic and human potential movement that major concerns about the state regulation of psychopractice have been raised in a systematic and concerted way. We are delighted that within the field of psychoanalysis, at least some practitioners are at last waking up to the realities of mooted regulation, and the deleterious effects it could well have on the freedom to practise in way that is informed by the singularity and particularity of each unique helping relationship, rather than by power-infused institutional and bureaucratic imperatives.
A related, if apparently paradoxical, strategic imperative is, wherever possible, to contradict the desire on the part of organisations that favor SR to present UK psychopractice as united and homogenous when this is manifestly not the case. The less-than-conscious drift of the therapy institutions seems to be towards the formation of a spurious psychological monoculture that seeks to hide their shaky foundations behind rubber-stamping endorsement via the power of the state.
Finally, ‘non credentialled registration’ is an attempt to think ‘out of the box’ around accountability, to create a way of institutionalising accountability that would be congruent with clients’ needs and practitioner values. One of us (DP) has drawn up one such carefully specified alternative approach to regulation – viz. his Practitioner Full Disclosure List proposal, which is a variant on the non-credentialled registration approach to regulation. This model avoids many of the worst features of statutory regulation; in it, practitioners opt into a national practitioner database in which their listing is endorsed and dependent on the support of identified practitioners who are publicly prepared to stand by their fitness to practise, their competence and ethical stance, and an outline of how they will resolve disputes. On the basis of such practitioner self-description, available via the internet with local printed supplements, clients would be able to make a much better informed choice about who to select to form a working alliance, than are offered by current registers of names and modalities. This of course may be difficult for psychoanalytic practitioners, for whom personal disclosure might be anathema; but leaving that aspect of the non-credentialled approach aside, the assembling of a group of colleagues who know you and your work well enough personally, publicly to endorse it on an ongoing basis, seems reasonable and eminently achievable. If, we provocatively ask, a practitioner wasn’t able or prepared to engage in such a process, are there not grave questions as to whether they should be working with clients/patients…?
Lastly, the Full Disclosure List, while not an instrument of state control, would ideally be state administered, in the sense that the financing and resourcing of the database, and management of the IT structure, would be contracted out from the DoH.
In Conclusion
What has become clear as a result of this conference is that there exists an unexpected common interest and shared understanding between the position of the College of Psychoanalysts and that of the IPN; and our strong hunch is that this commonality of purpose and perception in relation to regulation is shared by a large (but unknown) number of other therapy practitioners in the many other organizations and modalities. There is surely ample scope for expanding the informal links between like minds that have already begun to be forged through this important conference.
Further Reading
Bates, Y. and House, R. (eds) (2003) Ethically Challenged Professions: Enabling Innovation and Diversity in Psychotherapy and Counselling, PCCS Books, Ross-on-Wye
Cooper, A. (2001) ‘The state of mind we’re in: social anxiety, governance and the audit society’, Psychoanalytic Studies, 3 (3-4): 349-62
Henderson, D. (2003) ‘Colonising shame: shame and the regulatory project’, in L. King and R. Randall (eds), The Future of Psychoanalytic Psychotherapy, Whurr Publications, London
Heron, J. (1990) ‘The politics of transference’, Self and Society, 18 (1); reprinted in R. House and N. Totton (eds), Implausible Professions: Arguments for Pluralism and Autonomy in Psychotherapy and Counselling, PCCS Books, Ross-on-Wye, pp. 11-18
Hogan, D. (1979) The Regulation of Psychotherapists, 4 volumes, Ballinger, Cambridge, Mass.
Hogan, D. (2003) ‘Professional regulation as facilitation, not control: implications for an open system of registration versus restrictive licensure’, in Y. Bates and R. House (eds), Ethically Challenged Professions: Enabling Innovation and Diversity in Psychotherapy and Counselling, PCCS Books, Ross-on-Wye, pp. 172-8
House, R. (2001) ‘The statutory regulation of psychotherapy: still time to think again…’, The Psychotherapist, 17 (Autumn): 12-17
House, R. (2003) Therapy Beyond Modernity: Deconstructing and Transcending Profession-Centred Therapy, Karnac Books, London
House, R. (2005) ‘The state regulation of counselling and psychotherapy: sometime, never…?’, Journal of Critical Psychology, Counselling and Psychotherapy, 5 (4): 176-89
House, R, and Totton, N. (eds) (1997) Implausible Professions: Arguments for Pluralism and Autonomy in Psychotherapy and Counselling, PCCS Books, Ross-on-Wye
Mowbray, R. (1995) The Case Against Psychotherapy Registration: A Conservation Issue for the Human Potential Movement, Trans Marginal Press, London
Postle, D. (1998) ‘The alchemist’s nightmare: gold into lead - the annexation of psychotherapy in the UK’, International Journal of Psychotherapy, 3: 53-83
Postle, D. (2000) ‘Statutory regulation: shrink-wrapping psychotherapy’, British Journal of Psychotherapy, 16 (3): 335-46
Postle, D. (2003) ‘Psychopractice accountability: a practitioner “full-disclosure” list’, in Y. Bates and R. House (eds), Ethically Challenged Professions: Enabling Innovation and Diversity in Psychotherapy and Counselling, PCCS Books, Ross-on-Wye, pp. 172-8
Web sites
IPN: http://i-p-n.org
G.o.r.i.l.l.a. archive: http://g.o.r.i.l.l.a.postle.net/confrontUKPP/carppp.htm
Ipnosis - a journal for the Independent Practitioners Network: http://ipnosis.postle.net
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