The future of psychotherapy

This week I co-wrote a 1,700 word feature for the Observer. Find it on the Guardian website here, or full text is below.

Sex scandals, rows and mavericks: is it time to regulate psychotherapy?

Long-overdue efforts to bring discipline to the profession and end malpractice by a number of rogue operators are causing tempers to fray

The plot comes straight from a campus novel: splenetic academics; a government hell-bent on reforming their discipline; sexual impropriety, whispering campaigns and litigation threats. The narrative practically writes itself. But this is not a David Lodge tour de force; this is the bitter, increasingly public, war ripping through the UK’s “talking therapies”. If psychotherapy were on the couch right now, it would not be short of issues.

Like all wars, the origins of this one can be traced back decades. In the 1970s various psychotherapy bodies – alarmed that rogue mental health practitioners such as the maverick Church of Scientology could damage their burgeoning industry’s reputation – lobbied for greater regulation. The charlatans, the abusers of power and the wackier practitioners should be rooted out once and for all.

In the end, nothing was done. But the push for regulation, in an effort to root out malpractice, has returned with a vengeance in the past few years. The Harold Shipman murders turned the spotlight on the relationships between all health professionals and their patients, and a reforming New Labour government was keen to flex its muscles. Psychotherapy came into its sights, especially given the intense relationship between patient and therapist.

“Like any profession, there are occasions when bad practice and abuse takes place,” said Colin Walker, policy and campaigns manager at the mental health charity Mind. “This is of particular concern in psychotherapy or counselling as patients are often in a vulnerable state. The consequences of abuse are more severe.”

One recent high-profile scandal has become totemic for the psychotherapy industry. Psychotherapist and art therapist Derek Gale was accused of multiple cases of inappropriate sexual contact, falling asleep in sessions and offering his patients illegal drugs.

A hearing of the Health Professions Council (HPC), the government-appointed body that regulates most health professionals, also heard allegations that Gale regularly went on holiday with patients, asked them to act out scenes of sexual abuse and on one occasion advised a patient to take advantage of “unlimited sex”.

Yet it was only last year, when Gale was struck off by the HPC, that the UK Council for Psychotherapy (UKCP), a self-regulatory body that has some 7,000 members, also revoked his membership, although it had suspended him on its register since 2006.

Critics of psychotherapy – and they are particularly vocal in cyberspace – suggested that the Gale case illustrated why the various professional bodies could no longer be relied upon to keep their own houses in order. Hence the plans to give the HPC powers to regulate the UK’s estimated 50,000-plus counsellors and psychotherapists, outlined in a government white paper in 2007, and now the subject of an almighty row.

Under the proposals, the HPC would become the profession’s sole regulator and registrar, determining those who could call themselves therapists, what qualifications they would need and the code of conduct they must follow.

The idea appeared reasonable and not before time. “There is no independent complaints procedure,” Walker said. “There are a plethora of organisations with their own procedures, and no minimum trading standards for the industry. Some people have waited years for their complaints to be processed, and the end sanctions can be minimal. What’s more, those registers are voluntary, and you can continue to practise.”

Jonathan Coe, chief executive of Witness, an organisation that provides “professional boundary training” for therapists, said the sanctions handed down by their professional bodies often did not reflect the severity of the transgression.

“There are cases where professionals have behaved in an incompetent and unboundaried way and have been allowed to continue to practise,” Coe said. “There are therapists who have had sexual contact with clients and have been given supervision, or simply been asked to write an essay on their behaviour as a punishment. Or therapists who talk too much about themselves during sessions and have been told to undergo psychoanalysis themselves.”

But some therapists are furious at the proposals that threaten to further splinter an already fragmented profession.

A bemused public might be forgiven for thinking the row is not its concern. But one in five people receive some form of counselling and a nation on the couch cannot afford to have its therapists so divided on such a key issue.

Leading the vanguard of malcontents is the UKPC, whose chair, Professor Andrew Samuels, is scathing about the idea that the HPC should regulate therapists. “The HPC is poorly led and not able to deal with the complexities of our profession; it is inflexible and dogmatic,” Samuels said. “Imagine a friend of yours is in therapy with me and I make a pass at her. At the moment she can complain in confidence and we believe she will get a fair hearing [in private]. But in the future she would face enormous difficulties. Her complaint would be trampled over by committees, and she runs the risk that everything I know about her will end up in the newspapers. We feel that, in public protection terms, it’s a crappy system.”

Samuels fears the regulatory regime will open therapists to litigation. “Armed with a piece of paper saying their complaint was valid, a person will go to court and claim for damages,” he said. “But how do you quantify the damage?”

Given his robust views, Samuels has become a target for those who believe their lives have been wrecked by rogue psychotherapists. He has even been portrayed as a supporter of Gale after letters were published showing he agreed to supervise him after the HPC launched its investigation. But it is normal practice for professionals facing regulatory hearings to be supervised. “It is a wholly respectable, normal thing for a professional to do – something lots of people at my level do,” Samuels said. “It does not imply I support Gale; I clearly don’t.”

More difficult to counter are concerns about tensions within the UKCP. Documents have been leaked and at least one person has resigned from one of its committees. All of this has provided ammunition for critics and those keen to attack psychotherapy. “It is true there are people out there who are getting a lot of attention that is damaging the profession and the profession is finding it difficult to respond to that,” Samuels conceded.

He predicted that, if the HPC does end up regulating the industry, many therapists will simply opt out, ditch the psychotherapy title, rebrand themselves and regroup under a new regulatory body.

“Thousands won’t register,” Samuels said. “They don’t believe it will work or is properly thought through. They are prepared to enter a state of alternative professional regulation – it would be voluntary, but not in the loose way as things are organised now.” It is not an empty threat. Some 3,000 professionals have signed an open letter registering their opposition to the HPC regulation plan.

“To call them dissidents or refuseniks is to insult them,” Samuels said. “They have decided what is on offer is no good. Nobody believes psychotherapists should proceed as they are. There has got to be regulation, but whether it is by the HPC or by extremely good voluntary regulation remains to be seen.”

However, not all therapy bodies are as opposed to HPC regulation as Samuels. “There are upsides to regulation, not just downsides,” said Laurie Clarke, chief executive of the British Association for Counselling and Psychotherapy (BACP), Europe’s largest organisation of professionals working in the field. “The protest alliance is numerically small compared to the rest of the profession.”

Phillip Hodson, the BACP’s spokesman, said: “It remains a desirable goal to apply legal force to sanctions against malpractice across the entire therapy field – because BACP can only regulate its own membership.”

Samuels gives short shrift to groups open to HPC regulation. “There is an unseemly, greedy struggle for power, money, influence and status going on among various elements in psychotherapy and counselling,” he said. “There is an awful lot going on around the HPC that is monetarily driven – there are a lot of people who want to support it because they see it as their pot of gold.”

In the face of the growing backlash, the HPC has admitted it is examining alternative regulatory models. Any regulatory framework is unlikely to become law until 2012 at the earliest, a prospect that dismays psychotherapy’s critics.

Complicating matters is the prospect of a judicial review that could force a future government to start a new consultation on its proposals for regulation.

Masterminded by Darian Leader, president of the College of Psychoanalysts UK, the legal action could further delay regulation. But Leader is unrepentant. “The incredible spin being put on this row is that anyone against HPC regulation is an anti-regulation anarchist,” Leader said. “Our point is that the HPC is for regulating health professionals, but is not suitable for therapists.”

Health professionals such as doctors, he argues, take a “positivist” view – one based on empirical, quantifiable notions like improving a nation’s health or its happiness levels. But trying to increase happiness levels of a nation is the goal of politicians, not therapists, for whom such notions are deeply simplistic. “Psychotherapy must operate in an independent state, not according to generic standards,” said Leader. “Psychotherapy offers a non-judgmental space, there are lots of complexities and turbulence.”

Ultimately, the battle within psychotherapy may not be so much about regulation but about its very sense of self.

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