Association for Lacanian Psychoanalysis in the United Kingdom
Response to Skills for Health
Draft Psychodynamic/Psychoanalytic National Occupational Standards
I am submitting this response to the Skills for Health Draft of the Psychodynamic/Psychoanalytic National Occupational Standards on behalf of the Association for Lacanian Psychoanalysis in the United Kingdom.
Our organisation has reservations not just about the formulation of the standards themselves but also about the way in which they have been arrived at. We do not see how these standards can claim to be representative of best practice in this field. At best they represent a very particular and limited view of psychodynamic work with no apparent appreciation of the full range and diversity of psychoanalytic schools and approaches. They certainly demonstrate no awareness of the work being carried out by perhaps the largest body of psychoanalytic practitioners in the world, those practising psychoanalysis in the Lacanian orientation under the umbrella of the World Association of Psychoanalysis.
This astonishing oversight is simply one indication of the failure of the work of the so-called Expert Reference Group to provide a representative overview of work in this field. This is demonstrated not just in the composition of the group itself, the material on which it appears to have based its work, its procedures of consultation and inclusion, but also in the formulation of the performance standards themselves. Hence we question the claims of this group to be representative of a field of practice characterised above all by its long history and diversity of approaches. On what basis does this group claim to reduce one hundred years of psychoanalytic history to a list of arbitrary, incoherent and ultimately contradictory technical principles on the basis of a handful of meetings? From where do they draw their competence to dictate to others technical principles intended to apply to all?
We wish to lodge our protest not just about the way in which these standards have been arrived at but also the way in which they have been made available for consultation. This has happened without notification even of those who were involved in the initial consultation on this project, let alone with what might be considered reasonable time for the organisations involved to prepare and submit detailed responses. This means that we find ourselves having to submit a provisional and less comprehensive response to this document than we would have wished. I will accordingly focus on more general concerns about the procedures on which this process appears to have been based rather than on a detailed rebuttal of the technical points contained in this document, which in the appropriate context would have to be refuted almost one by one.
I will also point out that this process directly contradicts the pledges contained in the Skills for Health response to the initial consultation. This report spoke of the development project being ‘open and accessible in all its stages’, resting on principles of ‘partnership and engagement with the community of practitioners’ in a way that would render the outcomes ‘credible within the community of psychological therapy practitioners’. The manner in which the Expert Group has proceeded until now and the way in which it has been prepared to make its work available for scrutiny leaves us with serious doubts not just about the willingness of this Group to take into account positions other than their own but also about the integrity of the process of consultation as a whole. How inclusive can this process claim to be in giving voice to the full range of practitioners and stakeholders who might have an interest in the future of the profession?
We thus question in what way the work of the Expert Group is supposed to be considered as representative of the field of psychoanalysis and psychodynamic psychotherapy in general. Can the process of composition of this group be shown to be either democratic, representative or transparent? On what basis do they claim to draw up standards of best practice to which the entire field is expected to conform? On what basis can this list of competences claim to capture a representative range of psychoanalytic approaches given the narrow basis from which they start? If these standards are to determine best practice within the field, should not more careful consideration be given to their drafting and possible impact on the future of our profession than is currently being demonstrated? Who will ultimately own these standards? Will they remain the property of Skills for Health? Will Skills for Health retain commercial rights to sell access to them?
Our concerns about the composition of the Expert Group extend to the list of references provided as the basis for this Group’s work. The ‘context information’ disclaimer takes great pains to prioritise the values of ‘evidence and efficacy’ in justifying their reliance on a handful of manuals of ‘dynamic therapy’ that have been ‘used in research trials and which have shown to be effective when applied’. Can the Expert Group demonstrate in what ways the resulting competencies are related to the evidence of these trials? Can they explain the rationale for the choice of these texts as references and not others? In what way are these manuals to be considered an adequate or representative basis for determining best practice for psychoanalysis across the board? This appears to be a random and ill-assorted list with no claims to representative sampling. Almost a quarter are unpublished and therefore not available for public consumption. The others seem remarkably biased either towards very specific treatment modalities that are perhaps not most representative of broader practice (for example, 3 out of 13 concern the treatment of Borderline Personality Disorder) or towards generically ambiguous notions such as ‘interpersonal’, ‘interpretative’ or ‘dynamic’ therapies.
Even the NICE guidelines make room for alternative sources of reference when primary sources of research evidence are not available. Where is the evidence that the Expert Group has considered an adequate and representative range of material when drawing up these guidelines? Simply mouthing the words ‘evidence and efficacy’ is not sufficient grounds for limiting your field of reference so drastically and arbitrarily, above all in a field of practice that is so diverse and contested. Is there any acknowledgement of the broad reservations and concerns about the quality and relevance of research trials on psychoanalytic therapy, given the methodological complexity and relatively undeveloped state of this field? Is there any evidence of balanced recourse to a range of available theoretical or technical manuals that present a diverse array of accepted psychoanalytic approaches? Then on what grounds can the Expert Group justify arriving at these particular performance criteria and excluding others that may be equally valid?
It is disturbing that those who seek to establish standards of best practice for psychoanalysis and psychoanalytic therapy in this country should show such a limited awareness of the range of principles, concepts and approaches at stake in psychoanalytic practice. It is even more alarming that they should seek to impose on others such a partial grasp of the field they claim to represent. One obvious symptom of these difficulties lies in the absence of any explicit distinction between ‘psychoanalysis’ and ‘psychodynamic therapy’. We now find these competences being presented as ‘Psychodynamic/Psychoanalytic National Occupational Standards’. It thus appears that they are intended to define best practice in the field of psychoanalysis as well as psychodynamic psychotherapy. In fact it becomes very difficult to see where the distinction might any longer be introduced within this register of ‘performance criteria’. The work of the Expert Group thus merely carries to its completion the tendency of a very particular strand of English psychoanalysis, one that seeks to reduce the field of psychoanalysis to some kind of garbled version of ‘evidence-based’ psychodynamic principles that threaten to erase the basis of any possible psychoanalytic efficacy whatsoever.
These concerns can be followed through at every stage in the Expert Group’s formulation of the ‘performance criteria’ being proposed for our field of practice. In each instance we see a constant tendency to reduce the stakes of the psychoanalytic process to the concrete, pragmatic and presumably measurable aspects of the ‘two-person’ relationship. Yet it is this very preoccupation with the effects of the setting, the measuring of boundaries and the contractual agreement of goals that excludes any meaningful psychoanalytic notion of either transference or the unconscious, hence eliminating any possible basis for authentic psychoanalytic work. In its place we find an incoherent array of dogmatic, universalising and normalising prescriptions, linked together only by the insistent refrain ‘You must…’. We could have no more telling demonstration of the way in which the attempt to codify the principles of psychoanalytic action in a set of universal prescriptions runs the danger of contradicting itself in its very utterance. This is why the most eminent theoreticians of psychoanalytic practice, starting with Freud, have always approached this question with far more caution than is currently being demonstrated by the work of the Expert Group.
The majority of the resulting performance standards can then be shown to be either arbitrary, redundant, self-contradictory, or at least consistently contestable on both technical and ethical grounds. The Group’s work thus further demonstrates the dangers of attempting to combine technical and ethical prescriptions in the form of normalising prescriptions. If this process is followed through you very quickly end up with a technique that is no longer effective and at the same time is without any discernible ethical orientation whatsoever. No amount of moralising about boundaries and evidence is then likely to be able to retrieve either the sense, the rationale or the sources of effectiveness of a practice that has been cut adrift from its ethical moorings. If a set of standardised competences in this form were in fact to be unleashed on the field of practice, let alone imposed on the organisation of recognised psychotherapeutic and psychoanalytic trainings, we would very quickly be faced with the loss of a century of creative psychoanalytic work within a generation.
It is in the light of these concerns that we demand the right and the opportunity to take up our reservations about this project and its current results in a point by point engagement with this array of technical prescriptions being proposed as standardised criteria for best practice in our field. For the current effort demonstrates just how important it is that this ill thought out process of bureaucratic standardisation is not launched on our field of practice without adequate consideration of the consequences and without legitimate and inclusive consultation with all those who might have an interest not just in the present but also in the future of our profession. We call on those who are currently engaged on this project, to the extent that they might have any sincere interest in the profession they claim to represent, to engage in an open, ethical and considered discussion of the issues at stake here.
Dr. Roger Litten