The Lobbed letter: a few home truths

In yesterday's PLG C&P meeting there was a section devoted to the question 'conscientious objection'. This matter had been reduced to 3 lines in Michael Guthrie's report for the group, but it turns out that some members of the PLG had also received a letter from the College of Psychoanalysts UK. Perhaps not everyone had received it, and it wasn't actually mentioned by anyone on the day. But the letter has now been published on the website of the College of Psychoanalysts-UK (click heading for link).

Dear PLG Member,

We are writing to you as a member of the HPC Professional Liaison Group because we believe it is valuable for all those on this important committee to have equal access to information concerning the question of the proposed HPC regulation of talking therapies and the consultation process so far. This process, unfortunately, has failed to remain faithful to the original Department of Health remit to include representation from the breadth of the professional field and to respect the difference and diversity of the stakeholders concerned. Documents recently released under the Freedom of Information Act, which will be detailed below, make this clear and give us serious concern about the parity and transparency of the consultation to date.

There are three main issues here:
. Misunderstandings about the commitment of all psychotherapy groups to appropriate regulation of the profession in the interests of public protection and the vitality of psychotherapy.
. The importance of explicitly reflecting the particular and differing nature of the psychotherapies in the mechanisms of regulation.
. The hijacking of the process by a minority section of the profession to the exclusion of others.

From the first PLG meeting held on 4/12/08 it seemed apparent that the scope for discussion of these difficult issues is likely to be very limited, with the danger that they will be treated as inconveniences to be given an airing and then ignored. We believe it is important that you are aware that they are not minor details and that thousands of clinicians, as well as academics, intellectuals and public figures, across the country are gravely concerned about the high risks involved in a hasty and ill-informed consultation process. A major media campaign will begin later this year which will draw public attention to these problems.

We understand that it is not the HPC's task to assess whether it is fit for the undertaking the Government has given it, yet that it is within the scope of the PLG to comment on the appropriateness of HPC regulation of the talking therapies and to understand and reflect on the relevant arguments. These arguments relate specifically to the issue of the effectiveness of any future register, the protection of the public and the concern that the action of the HPC in carrying out the task of regulation be proportionate to the requirement that the public be protected. 

Commitment to Regulation

We, and all psychotherapy organisations of which we are aware, have been actively committed to regulation for many years. The self-regulatory systems which have been developed over the last 20 years have grown in sophistication and effectiveness and are continuing to do so. When critiques of the proposed HPC regulatory framework are formulated, the response is often that this is because the clinicians in question just don't want regulation. This is a major misunderstanding. The concern is not with regulation, which already exists, but that the proposed process of HPC regulation will narrow the broad practice of psychotherapy, making much of what currently takes place in reputable psychotherapy consulting rooms illegal in the near future. We are also concerned that the Government's insistence that all psychotherapies be subsumed under the Health Professionals' umbrella will inevitably impose on psychotherapies the same framework as fits the health professions but does not translate to a non health-care profession such as ours.

To date, neither HPC nor Skills for Health have published a risk analysis of the field of psychotherapy, nor research into appropriate forms for its regulation. In Australia, the government aimed initially to regulate psychotherapists and counsellors under a healthcare model, yet after a three year consultation period, they accepted that counsellors were best left to self-regulate, and the same result looks set to happen for psychotherapy. The government there has recognised that statutory self-regulation works better for the protection of the public and for the life of the profession itself. The Australian consultation demonstrated that:

. Counselling and psychotherapy are fundamentally different from the majority of health professions.
. The focus of 'talking therapy' is the relationship and the process of therapy, rather than the performance of certain definable procedures.
. It is difficult and even unhelpful to define competences and scopes of practice in a narrow legalistic sense.
. A diversity of training bodies, professional associations, and theoretical approaches is both a strength and a weakness and requires a model that respects diversity while being clear about standards.
. The profession would be best managed within a self-regulatory model based on professional colleges, which will have the necessary expertise to link training standards and practice.

It seems important to us that the question of the regulation of talking therapies which explicitly claim not to be health-related be given proper consideration. Many clinicians see their work as an exploration of the human condition, a journey in the same sense that becoming a Buddhist monk involves a long process of questioning one's life, ideals and expectations. Like a Buddhist training, this long process of psychotherapy cannot be identified with a set of techniques or procedures to be applied to a human being, but forms rather a strange kind of relationship which operates in unpredictable and unexpected ways. One cannot know what will happen in advance, and change often takes place through surprise, bafflement, shock and disappointment. 


The Particularity of the Talking Therapies

The results of the Skills for Health consultation on psychoanalytic/psychodynamic therapy were published recently in draft form. These are the so-called National Occupational Standards (NOS). They list 451 criteria and guidelines for psychodynamic and psychoanalytic therapy. They dictate every aspect of how therapists should organise their sessions, how they should 'monitor' themselves and how they should carry out their work. They go into minute detail about the timing of interventions, the setting of the therapy, its aims - and even the expression of appropriate 'feelings'. Such an application of externally-imposed rules - most of which were expressly contraindicated by Freud, Jung and the analysts who followed, such as Klein, Lacan and Winnicott - removes the very foundation on which such therapies are based, namely the freedom of both parties to work together authentically and creatively.

If these rules were to be accepted, then it would no longer be possible for many clinicians to work in this country. Although the HPC has been keen to point out their independence from Skills For Health (SfH), it has also been made very clear that the work done by SfH on National Occupational Standards will 'inform' the work carried out by HPC. The NOS draft is an extremely controversial document and the process by which it was arrived at has been shown to be highly partisan, an issue we will come to presently. If the HPC has to gain a full understanding of the profession it hopes to regulate, this understanding risks being biased by the influence of the SfH project.

The SfH project has attempted to shoehorn analytic work into the current culture of outcomes, where all variables must be predicted in advance and evaluated in relation to expected results. Analysis, however, and many forms of psychotherapy, involve an open-ended relationship, where results may emerge that were never predicted or even thought of by the person in analysis. The very distinction between conscious and unconscious motivation that lies at the heart of analytic work is ignored by the proposed regulations which encourage a 'false self', a box-ticking clinician, fearful of being watched by the authorities and anxious to please them. If analysis has an aim, it is to help patients free themselves from irrational forms of authority, exactly those that now threaten to constrain their work within the therapy.

According to the government roadmap, HPC will establish a list of reputable practitioners, which will mean effectively those who adopt their particular formulations as to what talking therapy is about. All the documentation published to date by HPC shows a serious misunderstanding of the nature of analytic work, together with a new insistence on 'good character' defined in highly rigid ways. If this goes ahead, then members of the public will no longer have the freedom to choose their analyst, a fact already brought up by user groups. They will have to select a practitioner from a list which only includes those who practise a particular form of therapy. Practitioners who are totally opposed to the idea of their work as 'healthcare' will have to adopt a healthcare model and become 'model citizens', when the whole of the analytic tradition emphasises that the practitioner's human failings are essential for the analysand to recognise and work with.

Nearly all of the professional groups in the field have agreed that HPC is not suitable as a regulator for a variety of reasons, yet one in particular stands out regarding analytic work. In this work, the analyst puts themself in the place of the object of all the projections of the analysand. Powerful feelings of hatred, disappointment and rage that had once been directed to one's caregivers and then repressed or negated may emerge and now be directed to the analyst. These are features of the phenomenon known as 'transference'. The analysand will not be aware that this is happening, and hence a long, difficult and painful period may follow when these feelings are clarified and worked through. At the same time, the analysand may realise that the analyst is no expert but just a fallible and weak human being. The sanitised image of the practitioner aimed at by HPC cannot fit this model, just as the complaints procedures they adopt are not sensitive to the crucial question of transference. Analytic work requires, in a sense, that the analyst should become a scapegoat, and at the same time, act unpredictably or even shockingly. How else, after all, to overcome the defensive system that someone may have spent their whole life constructing? Change in analytic work rarely comes about by the polite communication of some hypothesis ('When you were a child, X must have happened..'), but through interventions that may seem, or indeed may be, totally unacceptable to the analysand. This is how analysis works, and it is unlikely that HPC complaints panels would be well-suited to assess the complexity and often hidden nature of such issues within a culture where complaints against practitioners by their patients are openly encouraged by the regulator. An extensive literature exists on this question, which has been totally absent from all bibliographies published to date during the consultation process.

Hijacking of the Consultation Process

The consultation process initiated by the Department of Health was intended to assess the feasibility and suitability of state regulation through dialogue with all of the professional field. However, Skills for Health allowed their consultation to be monopolised by a very small number of people with both a narrow and restrictive view of psychoanalytic practice and, arguably, a clear agenda to further their own particular brand of therapy which they endeavour to promote within the NHS. The task of drafting psychodynamic/psychoanalytic competences was given by Skills for Health to Tony Roth and Steve Pilling, employees in the UCL Sub-Department of Clinical Health Psychology run by Peter Fonagy. Fonagy, in fact, chaired the Executive Group and the Strategy Group of the SfH project and also sits on the Reference Group. These researchers, aside from having the link to Fonagy, are known for their work on CBT, a set of therapies which are totally at odds with psychoanalysis and most psychodynamic therapies. It is extraordinary that the work was given to them rather than to one of the many university departments of psychoanalysis in the UK. It raises the question of how the UCL department managed to secure this contract.

This bias was continued in the composition of the project Expert Reference Group and the Modality Working Group, both of which were chaired by Anthony Bateman. Bateman is a close colleague of Fonagy and the two have co-authored a treatment manual for a form of therapy (MBT) which they endeavour to promote within the NHS. Fonagy is Director of the Anna Freud Centre, which holds courses on MBT in conjunction with the UCL Sub-Department of Clinical Health Psychology. These courses are held for those working in the NHS and generate revenue for the institution concerned. There is thus a clear line of economic benefit here. It is perhaps no accident that the competences produced for psychodynamic/psychoanalytic therapy fit MBT remarkably well, but not psychoanalytic work.

It is important for the PLG to be aware here of some history. The BPC is a network of organisations centred around the British Psychoanalytical Society, also known as the Institute of Psychoanalysis - of which Fonagy, Bateman and Julian Lousada are members - an organisation which for many years claimed to be the only psychoanalytic training body in this country. They repeatedly published statements that only their own members were psychoanalysts, and even wrote to newspapers claiming that those who pursued other psychoanalytic trainings were deceiving the public. Over the years many other psychoanalytic organisations were established, attracting trainees who were not drawn to the Institute's practices, their theoretical orientations or the ethics of their selection procedures: gay trainees were not accepted until quite recently. As the absurdity of this position became clear, they moderated their claim to a monopoly, yet there is still a real tension between the Institute - and hence the BPC groups - and the other non-BPC psychoanalytic training organisations in the UK. This is a major political factor in the current regulatory landscape.

The composition of the Expert Reference Group and the Modality Working Group is biased quite radically in favour of BPC - Fonagy and Bateman's organisation - with nearly all members coming from there. The list for the Psychodynamic Modality Group established on 16/10/07 consisted off 11 people, all of whom come from the BPC. Another list sent by SfH to Fonagy in January 2008 received the reply that it "goes slightly too far in the direction of UKCP", yet this list of 16 people included 2 from UKCP compared with 11 from BPC. UKCP, moreover, had pointed out to SfH in Jan 08 that it represented the majority of psychoanalytic practitioners in the UK. Documents released under the Freedom of Information Act show how the lists for the work groups were made up almost exclusively of those from BPC and that, when other names of organisations or user groups that had actually been invited to participate were proposed or added to the lists by SfH, they mysteriously vanish. When further information on these disappearances was requested by The College of Psychoanalysts-UK under the Freedom of Information Act, SfH replied by sending hundreds of pages of totally irrelevant documents relating to the CBT groups and then claimed that they could not help further as they were only obliged by the Act to perform a certain number of hours work collating documents.

We also believe that some BPC groups may have failed to inform their members of developments in the consultation process, with a handful of those on the relevant committees making claims for their membership without proper consultation. It is remarkable how nearly everyone involved in the SfH working groups either comes from BPC or the Fonagy UCL Department. In the list of PLG members that HPC have published, Fonagy's institution is listed as Skills for Health, an extraordinary claim given that, as far as we know, he is not an employee of SfH and is in fact associated with the British Psychoanalytic Council, the same organisation as the person preceding him on the PLG list. If Fonagy's affiliation had been stated correctly, it would obviously have shown a bias in the PLG composition. HPC has thus not acted with transparency in this matter.

Fonagy, likewise, has been relied on in a wholly unprecedented way by SfH: in an email of 19.10.07, Linda Hardy of SfH writes re Fonagy "I sort of feel I don't want to ask him everything". The PLG should be aware that Fonagy is a highly controversial figure in the world of psychoanalysis. He has advocated genetic testing as a guide to focus psychotherapy intervention and brain scanning to 'test' the results of psychodynamic work. He has termed the traditional neuroses 'disease processes' or 'weaknesses in brain function', and even encouraged brain scanning of two year old infants to determine whether psychotherapy intervention is necessary (as reported in The Times 12/5/07). For many, probably most psychotherapists, these are extreme views. There are also other questions here: in an email to SfH he states (incorrectly) that The College is a "largely Lacanian organisation" and then follows this with : "French psychoanalyst - Lacan - intellectual superhero but clinical and ethical problem, ultimately dismissed from the rank of the international psychoanalytic movement". Yet the very same Fonagy can refer on the dustjacket of a recent analytic book to "the intellectual sparkle of Lacanian psychoanalytic scholarship" and "the highest quality Lacanian thinking, creating a firm bridge between two forms of psychoanalytic theorisation that have for too long been separated by inadequate understanding". 

In September 2007 the UCL department apparently sent out a letter inviting participation in the expert reference group for psychodynamic therapy, yet this letter was not received by any psychotherapy organisation that we aware of. It stated that the general framework would be that used for CBT, a fact which would have caused a great deal of protest in the profession had it been known. The methodology of the work is stated as "identifying manuals published in the UK, the US and elsewhere and building the framework from these sources". This would also have caused a great deal of protest in the field for the simple reason that there are no manuals of psychoanalysis, a fact which Fonagy himself points out in a minuted SfH meeting of 11/4/08. On 5/2/08, Roth and Pilling claim to have sourced "the psychoanalytic treatment manuals" for the criteria they have formulated, yet in the list supplied by them in May 2008 to accompany the NOS there are no psychoanalytic texts at all!

The result of the dominance of Fonagy and his colleagues in the consultation process has been the exclusion of other voices : professional groups and user groups have been excluded, despite initial inclusion in draft documents, and the Skills for Health team have even conspired to lie directly to an accredited therapist seeking representation in one of the work groups who had been invited to participate. Steven Richards, Chair of the British Society for Clinical Psychophysiology, contacted SfH on 18.10.07 requesting involvement in the cognitive and psychodynamic work groups. Linda Hardy of SfH writes to Rod Holland, who Fonagy had recommended to SfH to chair this group, on 25.10.07, that "We need not have him on the group if you are not happy - I'll rely on your superior knowledge of the therapies here!". This illustrates SfH's failure to do their work properly, leaving the process open to political manoeuvering. Holland writes that Richard's school of therapy "is at variance with most concepts of CBT", yet SfH do not assess this claim or even object to the exclusion of a diverse practice. Hardy then writes to Richards on 29.10.07, "I contacted the chair of the group with your information and he feels that at this stage, with numbers on the group nearing capacity we really need to give the remaining few places to NHS employed practitioners as they are really underrepresented on the groups". In fact, it is because, as she writes to Marc Lyall two hours earlier on the same day, "Rod does not want this guy on the group.However I'm not sure what to say back to him - it's difficult when we invite people to show an interest and then tell them they can't join a group.I could say we are now seeking more NHS employed practitioners as they are under represented on the groups? [sic]".

When a Freedom of Information Act disclosure made these emails available to Richards, and he took them up with SfH, new correspondence was brought forward - strangely not included in the initial disclosure - which it is quite possible and even likely that SfH actually fabricated (further details available on request). The College has also written to SfH regarding an item of correspondence which we believe was falsified in order to cover themselves about another issue.

SfH appear to have failed to conduct the appropriate research for themselves, relying almost exclusively on 'outsourcing' opinion about what is legitimate and what isn't: this means emailing one of a handful of 'experts' to ask if an academic or clinician that SfH had themselves invited to be part of the consultation process should in fact be 'invited'. These distortions to the consultation process have effectively ruled out a rational assessment of the feasibility and suitability of state regulation.

We very much hope that this has been of use to you in laying out some of the detail behind this difficult issue, and to assure you of our good faith in our effort to ensure that you all have full access to the information that is available. The College would be pleased to meet with you to discuss any of these issues further.

Yours sincerely,
Prof. Darian Leader
President, College of Psychoanalysts-UK