This article appeared in THE PSYCHOTHERAPIST, 17, 2001, pp. 12-17
The statutory regulation of psychotherapy: still time to think again…
Independent Practitioners Network participant
‘You cannot make men moral by Act of Parliament.’
I was delighted to be asked to contribute a piece on registration to The Psychotherapist – and impressed that, notwithstanding its pro-statutory registration position, the UKCP’s house-journal is prepared to offer space to a writer who takes a robustly different view on regulation. This coheres with The Psychotherapist’s pluralistic editorial policy of including ‘from time to time… articles of a controversial nature’ (no. 15, 2000, p.2). I imagine that what follows will be seen as falling into the ‘controversial’ category!
An incisive article in the journal by Kidd (2000) pointed out that the Alderdice consultation process ‘focused on concerns broadly of the accrediting and training institutions rather than the likely effect of the Bill on the profession’ (p. 36) - a theme that recurs throughout this article. Kidd illuminates a vital issue which has erstwhile been essentially ignored – viz. the effects of regulation on part-time, non-career practitioners. In 1999 I wrote to the Department for Education and Employment, the Department of Health and the Inland Revenue, seeking to discover how many active therapy practitioners there are in Britain. The replies conclusively indicated that no one remotely knows the answer to this crucial question. For all anyone knows, the category of ‘part-time’ practitioner might easily constitute the majority of practitioners in the field - yet as Kidd points out, a significant number of them are unlikely to be able to afford the likely cost of registration (p. 37). Under statutory registration, then, ‘To Them Who Hath…’ will tend to be the norm - a ‘Robin-Hood-in-reverse’ redistribution of income from poorer to richer, with some smaller practices being forced out of business – in short, a kind of creeping embourgeoisisement of the therapy field.
With part-timers, women and low-fee chargers tending to be ‘forced out’ in such a quasi-Thatcherite ‘market rationalisation’ process, there is a real danger of the field losing practitioners who offer a freshness of energy in the work that full-time therapists cannot naturally offer. Indeed, I believe there are compelling reasons why part-time, non-career practitioners might well, all other things being equal, be more effective therapists than full-time ‘career’ ones – not least because of the greater freshness of energy they bring to their client work and the greater likelihood of their having a healthily ‘grounding’ life outside of the therapy world. If there is any substance to this argument, then a statutorily regulated field which effectively disenfranchises at least some of its most effective practitioners cannot but do significant harm to the client interest as a whole – not least because ‘sources of low cost psychotherapy available to the public may shrink rapidly’ (Kidd: 38). It is surely clear that, at a minimum, substantial research should be conducted into these questions before statutory registration is imposed upon the field.
In a recent paper (House, 2001), I posed three key questions which, I believe, any coherent case in favour of statutory regulation must explicitly address:
I contend that if the answer to any one of these three questions is ‘no’, then the case for statutory regulation unambiguously falls.
Some years ago, I attempted a ‘nut-shell’ summary of the case against statutory regulation. Quoting from that paper (House, 1997a: 32-3): ‘The public interest argument in favour of registration simply doesn’t stand up to scrutiny…. First, can didactic accreditation and registration procedures be shown to create and guarantee practitioners who are more competent and less likely to harm clients than in a non-registration environment? And secondly, if such a guarantee of competence can’t be demonstrated or sustained, then the only remaining rationale favouring registration is that of weeding out and disqualifying abusive or incompetent practitioners’. Yet a wide range of evidence points to the conclusion that, quoting Roberta Russell, ‘therapists who have undergone traditional training are no more effective than those who have not’ (for an authoritative review of relevant literature, see Bohart and Tallman, 1996); and (quoting Alex Howard), it would appear that ‘highly trained counsellors succumb at least as much as less skilled colleagues [to abusing their clients]’ (both quoted in House, 1997a).
Nor should these findings be surprising, as less-trained practitioners will tend to be more tentative and nervous with clients, whereas those with greater ‘status’ and longevity may well be more susceptible to the ‘expert’ counter-therapeutic wielding of power - the level of complaints against (regulated) psychiatrists being a case in point. Just as one cannot ‘make [people] moral by Act of Parliament’, so ‘you cannot legislate against one of the greatest dangers in therapy – that power can "go to the head" of the practitioner, cut him or her off from an intuitive sense of what is right, and encourage arrogance’ (‘Anna Sands’, personal communication). In short, the oft-repeated overriding rationale for statutory registration, that of ‘providing the greatest possible protection… for the public’ (Casement, 2001: 7), may be at best shaky, and at worst erroneous.
It has been routine for many therapists to dismiss such conclusions out of hand – after all, it’s surely just plain common sense that trained practitioners will be more effective and less abusive than their less trained counterparts. To the contrary, I believe there are strong theoretical and empirical reasons to support the counter-intuitive view that, overall, inexperienced and comparatively lightly trained practitioners can commonly be at least as effective as, and no more abusive than, long-standing, experienced ones. Practitioner therapeutic effectiveness is surely a highly complex, empirically unmeasurable and ultimately mysterious process, with a multitude of variables, many or most of them of the ‘intangible’ variety (as Karl Menninger convincingly showed). On this view, the positivist ‘wild goose chase’ of trying reductionistically to isolate therapy’s ‘active ingredients’ is firmly stuck in the ‘old paradigm’ scientistic world-view of modernity. I am increasingly of the (impressionistic, ultimately unverifiable) view that it is the practitioner’s freshness of energy, enthusiasm and associated interest-in-the-other that may well be a far more important, even decisive ‘ingredient’ in therapist effectiveness than has heretofore been recognised.
If there is any substance to this intuition, then it would follow that the longer therapists work in this field, the more likely that these qualities will be progressively diminished in their work – with, all other things being equal, therapists’ effectiveness declining as a result. And such a decline might well more than counteract any increase in effectiveness resulting from greater training and experience. Certainly, such an analysis would account for the empirical finding that relatively inexperienced practitioners commonly obtain outcome results which are at least the equal of more experienced therapists. At the empirical level, for example, and to add to the plethora of previous confirming studies (Bohart and Tallman, 1996), a recent study of effectiveness in a voluntary counselling agency found no difference in client outcome between qualified and trainee counsellors (Archer and Forbes, 2000).
I contend, then, that far from statutory registration being of benefit to the client interest, its net effect may well be profoundly against the client interest. If the foregoing analysis has any validity, then the institutionalising of therapeutic help might well be harmful to the extent that it ossifies in place a large body of full-time ‘career’ practitioners whose registered professional identity, and all that goes with it, will be antithetical to the unhampered freshness of energy and ‘enabling naivity’ that those practitioners unencumbered by therapy’s ‘regime of professional(ised) truth’ enjoy.
Elsewhere I have proposed the term ‘Professionalised Therapy Form’ to denote the constraining ‘regime of truth’ into which ‘clients’ (and ‘therapists’) are discursively inserted when they enter a therapy relationship (for detailed elaborations, see House 1999) (a discourse, incidentally, which also emphasises and institutionalises therapist/client difference rather than our shared common humanity). In her book Falling for Therapy, ‘Anna Sands’ (2000) has elaborated at length on the way in which therapy’s ‘discourse’ can strongly influence clients’ subjective experience, and on the innate precariousness of the therapeutic endeavour. Therapy can, I suggest, routinely become a ‘material-generating’ activity, constructing a ‘regime of truth’ which self-fulfillingly creates a framework that serves to guarantee its own legitimacy, and outside the confines of which it is often exceedingly difficult for clients or therapists to think. More generally, the quasi-legalistic form taken by the institutionalisation of therapeutic help cannot but cement therapy’s ‘professionalised form’ in place, and will do little if anything to encourage greater practitioner openness and non-defensiveness (‘Anna Sands’, personal communication), which are, arguably, absolutely central enabling qualities for any therapist to possess.
Moreover, seen in this light, the routine advocacy of ‘the greatest possible… education of the public’ about psychotherapy (Casement, 2001: 7) might ultimately be far less beneficent than it at first appears. Elsewhere, for example, we find therapy’s ‘regime of truth’ alive and well, with ex-UKCP Chair, Emmy van Deurzen’s extraordinary characterisation of therapy as ‘the professionalisation of motherhood’, and her grandiose assertion that psychotherapy should ‘move to a position where our new knowledge is applied to an increasingly necessary reorganisation of the world’ (1996: 17, 19, my emphasis)! Such a brazenly profession-centred blueprint is a very different animal from the aforementioned innocent-sounding ‘educational’ agenda.
In order to avoid the procedural imposition of a straightjacket of therapeutic orthodoxy, I maintain that therapy, at its best, should be ongoingly and processually deconstructive of its professional ideologies (not least, its medical-model associations), clinical practices, and especially its organisational arrangements, if the kinds of dangers so ably highlighted by ‘Anna Sands’, David Smail and others are to be avoided. Moreover, the momentum towards institutional professionalisation is surely significantly out of step with leading-edge developments in postmodern epistemology, participatory and consensual ‘organisational’ ethics (of which the Independent Practitioners Network is a notable example – Totton, 1997; House, 1997b), and ‘New Paradigm’ thinking more generally.
In sum, if an ongoingly deconstructive approach to therapy as ‘profession’, clinical practice and cultural phenomenon is the most healthy future path for the field (House, 1999), then one sure way to limit this is to cement in place ‘old-paradigm’, legally sanctioned organisational structures that freeze rather than facilitate innovation and creativity. As Carl Rogers so poignantly wrote, ‘In every sphere… certification has tended to freeze and narrow the profession [in question], has tied it to the past, has discouraged innovation… Can psychology find a new and better way?’ (quoted in House and Totton, 1997: 4). One need only glance at the appalling malaise that has overtaken our ‘hyper-modernised’ education system to witness the stultifying, deadening effect that an obsessively regulating, low-trust mentality has on the erstwhile creative art of teaching (House, 2000). Are these pernicious cultural forces (termed ‘the death throes’ of the master-discourse of modernity by Barratt, 1993: xii) really ones with which we wish to collude?
There are other crucial questions which I have had no space to address in this article – for example:
The great spiritual teacher Jiddu Krishnamurti once said, ‘we are addicted to institutions… [they] will never stop what is happening in the world… Organization in the psychological world is destructive’. All my experience of human organisations, and especially therapy ones, leads me to agree with him. Certainly, the important work of Jeffrey Masson and Bob Young points to a very similar conclusion about the ‘dysfunctional dynamics’ of psychotherapy organisations (e.g. Whan, 1999).
I will end with a deliberately provocative question: Can existing or aspiring registrants, in the privacy of their own conscience, with their hand on their heart and beyond all reasonable doubt, sincerely aver that statutory regulation is on balance a beneficent process - rather than one driven by commercial competition and profession-centred self-interest, culturally fashionable, anxiety-driven ‘control-freakery’, and the ‘dysfunctional’ institutional dynamics to which all organisations – and especially psychotherapy ones – seem subject? I would first invite readers to look at whether they are open even to the possibility of their answer being ‘no’. And if your answer is ‘no’, then, surely, personal authenticity demands that you either make your view known vociferously to your relevant institutional officers, or else withdraw, as a matter of principle, from any organisation that is pursuing statutory regulation.
My sincere thanks to a number of colleagues who offered valuable feedback on the first draft of this article, which has led to significant improvements.
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RICHARD HOUSE is an NHS counsellor and a Steiner Waldorf teacher, currently working in both fields. Deliberately unregistered, he is an active participant in the Independent Practitioners Network, and since 1994 he has contributed extensively to both the psychotherapy and education literatures. He co-edited (with Nick Totton) the widely acclaimed anthology Implausible Professions (PCCS Books, 1997), and has recently launched (with Pete Davies) the W.A.S.T.E. (Welfare Action for Surviving Teachers and Ex-teachers) web site (www.wasteedu.org). Particular current interests are early years learning and educational practices in the eras of modernity and ‘trans-modernity’.
Address for correspondence: 13 Denbigh Road, Norwich, Norfolk NR2 3AA; e-mail: email@example.com