Guest Post by Bruce Scott on the PLG meeting 12th May 2010

The professional liaison group meeting for the proposed regulation of psychotherapists and counsellors on the 12th May 2010: An example of how not to dwell in un-knowing.

Bruce Scott, Philadelphia Association, London.


Introduction

The philosopher Ludwig Wittgenstein [1] subscribed to the idea that it is important to attend to the language one uses; the words that we habitually use and the contexts we use them in. Wittgenstein also recognised the inevitable coming up against the ineffability/ungraspability (in words) of our experience of life and language and famously wrote:

“What we cannot speak about we must pass over in silence.” [1, p 74]


Heaton [2] argues that the psychotherapist should do what Wittgenstein says the philosopher should do. The therapist must set limits between what can and cannot be said and thought by working out from what can be said (or thought). Thus the therapist lets the patient say and think everything he possibly can. This process thus hopefully helps the patient find the limits of thought and language. It is crucial that the patient (and therapist) experiences the limits of language as nobody can point this out to him. Only by wrestling with his own problems can he see the dissolving of his problems when he reaches his limits of his language (e.g., the futility of working out how can get happiness). The result of this is that he can never say how his problems were dissolved or how he was cured. This is why as Heaton argues, it is no good telling a patient when he comes to therapy that his problems will be solved when he reaches the limits of thought and language. This is because the limits cannot be put into words; they can only be reached through words and thoughts. Heaton admits that this formulation may sound mystical but this is a common facet of everyday experience. In other words, many people enjoy themselves, laugh, love etc but they cannot tell themselves or other people how to do these things (not even experts in CBT can do this). However, it was Wittgenstein’s intention to emphasis the mystical, to highlight it as a phenomenon and not to ignore it as some of his critiques have argued, because it cannot be put into words. There is a lesson here to be learned for the members of the PLG trying to work out how to go about implementing the regulation of psychotherapists and counsellors. It was a lesson the members of the PLG could have done to have been taught before the 12th May 2010. Maybe they don’t have to panic, create definitions of counselling and psychotherapy, set standards, get overly worried about public safety, pin down what psychotherapy is all about and regulate it (in the way they think it should be regulated). There could be another way. But this way has been forgotten and/or ignored by the PLG group and the HPC.

But let us go slowly. It may seem odd (to some members of the PLG) not to panic (and rest in silence) at the thought of non-HPC regulated therapists and counsellors at large in the country, but let me explain that in actuality, the panic should be put in its proper place; in the fact that panic is being deployed by the HPC and PLG, this is taking them further away from what is more important: Keats’ [3] notion of negative capability which Wittgenstein would have been proud to see them use. The poet Keats in a letter to his brother in 1817 wrote:

“I had not a dispute but a disquisition with Dilke, on various subjects; several things dovetailed in my mind, and at once it struck me, what quality went to form a man of achievement especially in literature and which Shakespeare possessed so enormously- I mean Negative Capability, that is when man is capable of being in uncertainties, Mysteries, doubts, without any irritable reaching after fact and reason…” [3, p40-41]

The lack of negative capability was shown in the panic, frustration and activity that were being utilized at the PLG meeting on the 12th May. The battle lines were being drawn, tactics were being assessed, and words were being used as weapons all in the fight to colonise the non-HPC regulated psychotherapists and counsellors in this country.

What I am trying to articulate by the wonderful philosophical insight of Wittgenstein [1] and Keats [3] is that the very act of the PLG group irritably and in a state of panic trying to find the words, concepts, and plans to regulate psychotherapists and counsellors is ignoring a fundamental mode of experience, that is both fundamental to psychotherapy, but also to how to live a good and happy life for those not necessarily in therapy. This mode of experience is not set out or recognised in the HPC’s standards of proficiency and conduct. Therefore, the PLG/HPC are ignoring their own dis-eased dialectic and use of words, which if attended to, as Wittgenstein advocated we should do, they would realise that they were ignoring the limits of what can and cannot be said but also what was right under their noses; their violent unconscious (or conscious?) intentions on those who don’t agree with HPC regulation and their own maltreatment of their own and others psyches by their refusal to dwell within the realm of unknowability and ungraspability (of their project to regulate the psychotherapies) that their dialectic in continually bringing them back to face.

The thing is, the PLG and HPC were trying (and it was painful to watch) to put a full-stop at the end of the psychotherapy and counselling debate and its regulation. But can psychotherapy or counselling be led to the full stop? To my mind no, and how can it be, for it would then no longer be what I and many others regard psychotherapy and counselling to be. The HPC want to bring us (those opposed to HPC regulation) into line and wipe out any uncertainty that rightfully has its place in a true psychotherapy; anything after the full stop wont exist (under HPC law) and will be regarded as chaos, criminal, quackery and all the rest of the bad names they can muster up in their defence of putting in the full stop in their text of what psychotherapy and counselling should be.

However, let me outline some of the narratives that occurred on the 12th May at the PLG meeting. It may serve us well and take Derrida’s [4] hint to do a close reading and listening to what went on during this meeting. I will outline what was said by some members of the PLG group accompanied by some of my thoughts from my field notes that I made during and after the PLG meeting (in italics).

The PLG meeting

Fiona Ballantine Dykes, in being invited to share her thoughts at the start of the meeting, questioned if the process (of trying to regulate psychotherapists) was really worthwhile, and questioned the nature of what being a regulator meant in the domain of psychotherapy and counselling. She also wanted a discussion of how the HPC regulation would be accepted by the field.

Jonathon Coe commented that energies were being sapped and that we (the HPC/PLG) had to attend to that.

One person mentioned (and echoed several times during the meeting by Anna van der Gaag, Chair of the HPC) that we had done a lot of good work and had made a lot of progress.

To my mind the futility and/or impossibility of the regulation and the “demand” to put a full stop on this whole regulation issue is apparent. Moral is low in the PLG. Their energy is low, and some of the PLG group are questioning the whole idea. Anna van der Gaag is the encouraging General, being positive in the shadow of a very difficult if not impossible task. The PLG/HPC are recognising the limits of language, but refusing to bow to these limits. They obviously see their goal as conquering and domination over the unregulated bad lands of psychotherapy and counselling.

One gentleman (perhaps Brian McGee, or maybe Peter Bell) was concerned about the regulation of volunteer counsellors and finding a way of least pain (yes pain) for them to be regulated.

Are the HPC trying to force a procedure upon people but trying to find a way to sooth them into a false sense of security so they just lie down and accept it? Like the promise of a lolly by the dentist to a child scared of going under the drill.

Sally Aldridge commented that we have to convince those who have opposition to HPC regulation that it is the best thing to do.

Why do those against the HPC regulation of psychotherapists and counsellors have to be convinced? Is it the best thing to do, to be regulated by the standards/format proposed by the HPC? Are there not other ways to address this whole issue? Many respectable people, including therapists, politicians, artists, and activists for example can see the dangers of HPC regulation not just for the practice of psychotherapy, but the effects this would have on human freedom and free creative space where individuals can express themselves [5].

Peter Fonagy said that one of the crucial bits of deal sold to the British Psychological Society to get the psychologists HPC regulated was that we agreed that the deal they (the psychologists) got would be open for review if they were unhappy with it. He also mentioned that the competence of the HPC has been questioned.

My mind goes back here to the well publicised HPC hearing of psychologist Dr Malcolm Cross, who to my mind was a prime example of mis-management and misconduct by the HPC themselves [6].

Fonagy also mentioned that a substantial sub-group of psychotherapists and counsellors have made it clear that they will never sign up for HPC regulation. Fonagy finds this problematic.

Why does he see it as problematic? Is diversity not applauded in this day and age? Surly diversity of psychotherapists and counsellors should be encouraged? If psychotherapists and counsellors were all the same, saying the same things, and acting in the same way, what kind of world would we live in? Diversity of people in life is what makes life interesting and fulfilling. It would be problematic if all psychotherapists and counsellors were the same and signed up to a regulatory system if they did not agree with it. Perhaps objection should be celebrated, and not condemned. It seems that freely objecting is frowned upon by the PLG/HPC. I find that worrying.

Carmen Ablack echoed Fonagy’s thoughts and said that there was an elephant on the table that is never talked about; the opposition to the HPC.

Well perhaps you should listen to them then. The opposition are quite contactable. But are they opposition? Are they not just different? See my comments directly above.

Anna van der Gaag, chipped in at this point (almost like rallying the demoralised troops) and said the “our” strongest weapon is dialogue and that the narratives going on externally (to the HPC/PLG) must not distract us from our job in hand; regulating the psychotherapists and counsellors. She continued. “Our” commitment must remain strong and I am sure we will get a good outcome.

This seems like military speak. Why must the narratives going on outside not distract you? Surely the narratives going on in the outside world are important. Perhaps the job in hand is to listen and acknowledge that other narratives exist that do not fit into the HPC narrative. To ignore them, or even silence them (what regulation is intent on doing) is barbaric. What would be the outcome of ignoring the external narratives? Victory over the opposition against HPC regulation? Would that be good? Good for whom?

Later, Mick Cooper talked about getting the views of user groups (or service users) to ask what they wanted from psychotherapy and counselling.

This might on the surface seem very logical, but is there not a potential (unsolvable) problem asking people what they want from therapy? Someone might say I want to be happier and be cured. This person goes to a therapist, does not get happier, is not cured, and blames the therapist. The person complains to the HPC, and the therapist may be suspended through a hearing, and/or re-educated in the ways of making people happier and curing them. He may even be struck off. Often a patient’s “demands” are the “problem”, as are their ideas/language of what is happiness and what is mental distress (e.g., depression). In other words it is just as valid to assert that there is no self, happiness is illusory, and there is no mental disease as such (in comparison to organic disease), to cure. To believe that you have a depression to be cured for example may be the problem; the belief and faith in a disease entity that causes depression that one has to get rid of.

Jonathon Coe asked the group what is the nature of protection and how do we protect. Peter Fonagy stated that the HPC has to protect people against human frailty.

Surely we do not need protected from human frailty, but recognise that we (human beings) are frail. To be protected from our frailty would be to take away what it is to be human; what educates us, what guides us, what makes us love and care for others. To feel depressed or to feel the angst of life may be life affirming. It may be a necessary political move to feel frail or feel like hell. The recent IAPT initiative of putting poorly trained psychology graduates in job centres to dish out CBT (note to HPC: which they are not really qualified to do) to get the jobless back to work smacks of ignoring human frailty. I am sure many jobless would want a job rather than some IAPT worker telling (patronising) them that the evidence for their negative beliefs are false. Government policies at times do not recognise human frailty, and act in full knowledge that people will be affected and hurt by them.

Sally Aldridge said that we should do research and the get the views of potential clients or patient and see what they want from psychotherapists and counsellors.

Again, well yes I can see the logic in this, but what if the patient’s “demands” are the problem? See comments above. But isn’t this the process of analysis itself; getting to grips with one’s destructive demands? Is psychotherapy not a conversation about a patient’s demands and why they come to see a therapist and pay for it.

One of the more thoughtful comments by the PLG group was by a woman called Linda Matthews. She asked the group, is regulation appropriate for psychotherapists and counsellors and is it Ok not to be regulated.

Is there doubt among the PLG troops?

Then there was whole debate about the differentiation of psychotherapy and counselling. I will not go into the details of this, suffice to say many people had different views about it, there was much disagreement, and an awful lot of confusion and grasping for ideas. Anna van der Gaag intervened and said that this discussion has opened a can of worms and now perhaps it is time to shut it. She did question how the problem affects the process of the regulation of psychotherapy and counselling.

I think it is important here to recognise the realm the PLG is now in; the land of ambiguity and uncertainty. But is this not one of the important things about psychotherapy; being committed to ambiguity and uncertainty? This reminds me of the late Peter Lomas’ [7] book, “Committed to uncertainty”. Perhaps uncertainty (which is certainly part of psychotherapy) should be laid on the table at the PLG and held up as “a reality” that will never go away. Perhaps the can of worms that is the difficulty of distinguishing psychotherapy and counselling should never be shut, it does not need to be shut, it is healthy that it remains forever open.

The topic of getting service user input was again brought up by Mick Cooper who enquired if there was any research money available for finding out about service user’s perspectives. There was some talk that this was possible. Anna van der Gaag asked it there was general agreement in the group that research into service users’ perspective should be sought. It generally was.

It looks like lots of other people’s money is now going to spent on research. Who will design the research study, what measures will they If this research is done in-house so to speak, how “scientific” and unbiased will the research be? Perhaps, Mick Cooper and Peter Fonagy will be enlisted to do this research? The big question is, why has these research proposals not been talked about already? This PLG group has been running for nearly two years and only now they come up with the idea of service user input; very worrying. It really felt the PLG group were desperately clutching at straws here.

Later on Brian Magee voiced his opinion that he thought we should find out how psychotherapy and counselling has been regulated, or not, overseas. Sally Aldridge replied that there is a lot of information readily available of how other countries “do it”. Fiona Ballantine Dykes replied, and opened that can of worms that earlier Anna van der Gaag asked to be shut, and said that all “these” other countries (I don’t know which countries she was referring to) differentiate between psychotherapists counsellors and if we did not do the same we would be doing something that was out of line.

But why would we (I take it with we she means the HPC/PLG or the UK) be out of line? If the HPC did not differentiate we would make another line, and other countries would be out of “our” line. Perhaps these other countries have got it wrong and need to join their (the HPC) or our countries potential regulatory policy?

There was then a whole lot of talk about setting educational standards for psychotherapists and counsellors. The response was to talk to education experts, get their opinion of what educational standards we should set. Fiona Ballantine Dykes responded to this with some degree of alarm. She said that psychotherapy is relational, and things get lost when you get stuck on just setting educational standards. Anna van der Gaag retorted that even with words things still get lost.

We are again getting back to the idea of uncertainty. The HPC don’t like this realm. It does not seem to want to go away. A bit like what psychotherapy is like, then. However, Anna van der Gaag is highlighting the limits of language that Wittgenstein [1] was on about. But as always, they (the HPC/PLG) shy away from this terrain.

Annie Turner continuing this theme asserted that the whole is greater than its parts; the therapist and the constituent parts of the therapist (i.e., training, personality, and school of thought). She argued that it was impossible to capture the nature of therapists on the basis of looking at the individual constituent parts. She insisted that getting caught up with entry levels and educational standards of psychotherapists and counsellors was a red herring.

Mmmm…getting back again to the realm of uncertainty.

Anna van der Gaag agreed that today we are not going to agree on educational standards for psychotherapists and counsellors.

Maybe there will never be agreement.

A little later, Sally Aldridge commented that we have never looked at the curriculum of psychotherapists and counsellors and that this might be a way forward.

Looks like that red herring that was mentioned before.

Julian Lousada said that we are going to get lost in too much information here and we should just battle out the key issues.

Did he mean getting lost in the fact there is no information to grasp onto? Does this
frighten the members of the PLG? Why can’t they withstand being lost? Surly they must recognise the need for potential lost-ness in the issue(s) they are talking about, that certainty can never be assured. Is not one of the key issues the uncertainty or the lost-ness inherent in the psychotherapeutic endeavour, and why should one battle with this?

The argument seemed to go back to the issue of opposition to HPC regulation and one gentleman said we must listen to our opponents. Fiona Ballantine Dykes replied to this and said that we should not ask what they object to, but how would they like it (regulation). Mick Cooper retorted and asked what is the point in that. Linda Matthews joined in and said that it is not “our” place to have a forum for opposition. Peter Fonagy said that we have to hear the objections. Fiona Ballantine Dykes had concerns that stakeholders views had been noted in the past but nothing had been done with them.

There is obviously a lot going on here. A mess … Chaos ... Struggle… Confusion.

At the close of the meeting, where nothing much had been agreed apart from getting service user input (costly research proposed) and getting an international perspective of how other countries regulate (or not) psychotherapists and counsellors (costly research proposed).

As a member of the public I resent money being spent at this late stage on research as a result of the grasping ramblings of a PLG group that frankly does not give me much confidence in the process they are painfully trying to conduct.

Anna van der Gaag sent her troops away and left her PLG troops with this message: Keep in radio contact.

The military metaphor, keep in radio contact is fitting. The PLG group and HPC see the issue of regulation as a colonisation of an invading army, forcing the frontline ever forward, ignoring the cries of mercy from the natives (psychotherapist and counsellors), believing they are correct, justified, and protecting the public. Sounds familiar? This was the cry from the righteous war-mongering governments of George Bush and Tony Blair when they tried to convince the world that they were protecting the West from terrorists and weapons of mass destruction. They also said they were protecting the people of the countries the US and UK armies invaded. Some protection!

In praise and honour of the paradox

The PLG group were, as I hope to illustrate, dipping in and out of what Kierkegaard [8] called the Paradox of Reason (or the impossibility of reason explaining away all uncertainty). Well let me correct myself, the PLG group were not so much dipping into the Paradox, they were often scrambling to get out of it. This is an important point, but it is never acknowledged by the PLG group. “It” is there, but it is not talked about. It lurks in the shadows but this paradox must play a part in the issue of the HPC regulatory issue of psychotherapists and counsellors. One example of this as discussed above, is the frantic issue of trying to pin down service users’ needs and expectations of what therapy can and should be like. A more obvious example of PLG/HPC anxiety and their running from the paradox is evident in their discussions of “capturing” the opposition to HPC regulation as if they are “right” and the opposition is wrong and misguided. Thus it seems the HPC/PLG think they have the monopoly on surety, reason, and correct judgment (or if they don’t are fighting to get it). Perhaps they could take a lesson from Kierkegaard.

Kierkegaard, in his chapter called “The absolute paradox: a metaphysical crochet” from his book “Philosophical Fragments”, says:

“The thinker without a paradox is like a lover without feeling: a paltry mediocrity.” [8, p46]

In other words, to live a human life without the mystery as described by Wittgenstein, this almost mystical unknown that the limits of language (and reason) brings us to, a mediocrity of existence. I realise that some highly educated intellectual fools in some ivory tower somewhere might baulk at this statement. However, Kierkegaard goes to on to describe how reason in actual fact seeks a collision (a realisation of the limits of reason). This is the supreme paradox; that all thought is the attempt to discover something that thought cannot think. What is this unknown that reason collides with? Kierkegaard called it the God, others call it the unconscious or the Real-we can never fully understand this. But Kierkegaard puts it like this; how should reason be able to understand what is absolutely different from itself. Reason mongers of the HPC and PLG have not grasped this, but taking Keats’ line, perhaps they should not even grasp.

Put another way, reason desires its own downfall because reason can never pin down everything, especially when it comes down to problems of the human soul, psyche, or how to live a good life. Kierkegaard called this the consciousness of sin, when one realises the paradox, that reason cannot solve everything. It is self-love, or vanity that thinks reason can be called upon to dominate the world. This self-love shrinks from the paradox; it is offended, because it perceives itself as passive. Self love is intent on concealing passivity. The offended consciousness or self love, Kierkegaard argues, can be taken as proof of the validity of the paradox. One truly learns when one is faced with the paradox, self-love dies, the absurdity of many things in life is realised, and one can move on from the stuck-ness that the vicious circle of reasoning has got one into. Many patients and psychotherapists know this place or experience (if one can call it a place or even experience). These are the moments of movement in psychotherapy, the Zen moments of realisation when one realises that the panic over the abyss of uncertainty is nothing really to worry about (but if there really is something to worry about, that is OK too, but one may not stop the forces of nature by thinking one’s way out of it). It is truly other, new, becoming (not pre-determined), playful, and cannot be scripted before hand. One has to take risks in getting there. As Laing [9] rightly said, one has to take one’s chances with the other in the consulting room; the therapist with the patient, the patient with the therapist, and also with oneself.

But as the HPC and PLG seem incapable of seeing, taking one’s chances with “another” human being and oneself is what is needed in therapy; but they want to erase all chance or risk taking. Offended consciousness in Kierkegaardian terms will occur in psychotherapy and counselling; with the therapist, with the patient, and between them. Not only that, the patient will be offended by the realisation of his offended consciousness, and may be offended that the therapist can do nothing about it. It may be the most natural thing, and helpful thing to let this offence play itself out in a natural therapeutic unfolding. It may mot be comfortable for both parties, but this is something that has to be realised (that can happen in therapy and everyday discourse) and play itself out. This is the basic fact of the impossibility of totalization through reason; there will always be a space or “in-between” that intersects our being in the world. The HPC want to erase this kind of experience from psychotherapy.

This last point leads me to Plato [10], who outlines, as I and many others believe, where mainstream thinking in relation to mental distress has gone wrong, and where the PLG and HPC are going astray in their thinking.

Chora is a philosophical term described by Plato in the Timaeus as a receptacle, a space or an interval. It is neither being nor non-being but an interval between in which the “forms” were originally held. Chora gives space; a very important idea in relation to psychotherapy and everyday living. Jacques Derrida [4] uses the concept of chora from Plato to name a radical otherness that gives a place for being. Derrida argues that chora defies attempts at naming an either/or logic. In other words, the chora is fully other, defies totalization, and I believe epitomizes what it is to be human; that logic cannot fully encompass this domain, and this is where “scientistic” thinking fails in relation to the human sciences and proliferation of theoretical abstractions of “mental health” and “treatment” fall foul. There is no getting away from chora, but you cannot get it either.

Derrida’s reading of Plato is like many commentators believe a correct reading of Plato, in comparison to the “logocentric” use/reading of Plato’s philosophy [11]. That is, readings of Plato which pick out the demonstrably true or false claims, making these the centre of the argument, while sending everything off to the periphery as mere rhetoric or ornamentation; letting logic lead the letter. Derrida argues that the result of a logocentric hegemony of Plato’s philosophy and logocentric scientistic viewing of the world is that any text (oral, written) is neutralized, numbed, inhibited, even though the these heterogeneous forces continue to stir in their inhibited form. The result is that a sanitised version of “reality” is constructed through the logocentric viewpoint, but something lies still stirring that defies the logocentricism. This is radical stuff, but a radicalism that is in great need of being acknowledged; the sanitized version of reality being constructed by the HPC and PLG with regards psychotherapy and counselling is being constructed by a logocentric reading of mental distress and psychotherapy and counselling. As Feyerabrand states:

“Proliferation of theories is beneficial for science, while uniformity impairs its critical power. Uniformity also endangers the free development of the individual.” [12, p24]

The above statement, like the visceral feeling of reading one of Plato’s dialogues is that of the sensation of the opening of the proverbial can of worms. One can feel the de-centering of the logocentric viewpoint. It also shows how uniformity, however well intentioned, banishes autonomy and critical thinking; there is no one truth, or even there is “no truth”. However, the person must dare to speak it, but he must question his truth-making as truth is no-thing; truthfulness is a way of being but always an unfinished business. We arrive here at a very interesting point, a point which is crucial to the idea of psychotherapy; if a prevailing logocentralism prevails the consulting room, what room for a different reading of the text is allowed. More importantly, if the “law” is handed down from say the Government or HPC via the PLG, of what one should do with people in mental distress, how many readings of “truth” are banished? This is a very serious question and is applicable to all parts of human living, not just with regards the practice of psychotherapy or the “treatment” of those deemed mentally ill.

The Chora of doing no good or doing harm: The statistical impossibility of doing away with risk in psychotherapy and counselling

Over lunch, at the PLG meeting, I listened to Peter Fonagy talk about the serious risk that unregulated therapists pose for society. He related the findings of a research study that found that 5% of psychotherapists do no good (patients do not get any benefit) or that they do harm of some kind (e.g., the patient gets worse or is traumatized by the therapist). Now, this might seem a statistic worthy of attention, but let me highlight something very thought provoking. Take a sample of 100 HPC regulated psychologists and the treatment they have administered (say CBT for depression) and also take 100 antidepressant treatments for depression and subject them to statistical analysis for efficacy and harm. In the distributions from the two samples (Psychologists’ CBT treatment and antidepressant treatments), there will always be some small percentage in both tails of scores (e.g., of efficacy) in the sample’s distribution where the treatment will show to have done nothing and/or done harm [13]. This is because the laws of probability and distributions in statistical analysis will always show small percentages (scores) in both tails of a distribution.

But, I hear a pro-HPC person say, psychologists are regulated and antidepressant drugs are regulated (for their use in depression). So if they are regulated, and they have done harm or have done nothing, they can (the psychologist or the drug) can be dealt with (the psychologist suspended, the drug taken off the shelves etc). However, it is not so simple. Before I explain why, SSRI antidepressant drugs have been shown to do harm for many years [14], but they are still used as treatment; obviously the risk attached to the use of them is deemed acceptable by those in power who sanction the drugs for the treatment of depression. If they do not sanction harm, why are these drugs still used? Those who advocate the use of the drugs may say that the small risk is worth it, but they still know someone will definitely be harmed.

But getting back to doing harm or no good, no matter how much regulation you apply to practitioners in the psychotherapies, and no matter how many therapists adhere to the standards of proficiency set by the HPC, every single research study conducted on efficacy and harm by therapists will show that some do nothing and some do harm. In other words you will always find that some percentage of therapists have either done nothing in regards treatment efficacy or even done what is regarded by some as harm (upset the patient, made them madder or made them worse, or offended them etc). No amount of regulation will ever change this. Some patients will just never get anything out of psychotherapy, and some patients will always feel that a therapist has traumatized them; the result of the pitfalls of therapy and transference. Moreover, sample distributions, as I have already said (in both tails of) will always yield a result where statistically a small percentage of therapists will still do either harm or no good. All you can do to ensure no risk or harm is outlaw all psychotherapy and psychology and while your at it, ban all drug treatment for depression, and all medical treatment for heart conditions (and many other conditions), because they all carry a statistical risk (via the laws of probability) of doing harm or no good [13].

So I put it to the HPC and PLG, if the banishment of risk and harm is not possible ever, what is the reasoning behind the proposed regulation of the psychotherapists and counsellors? Perhaps the HPC and PLG are coming up against the Paradox as Kierkegaard [8] talked about, are in the presence of Chora, and are offended, frightened and/or frustrated. Or perhaps there is a more sinister ploy; to attain a scientistic uniformity, which outlaws any other way of thinking. This would have benefits for those on the side of uniformity for sure (economic, status, power) , but would certainly be a terrible blow for freedom in a supposedly democratic country which values free speech. Free speech and free development would be repressed under an HPC led psychotherapy world; not only in its therapists but also its patients too. To witness the goings on at the PLG meeting on the 12th May 2010, was frightening. Do they not realise what they are doing to freedom? Perhaps they do, and are thinking of the benefits of that for themselves.

Coda into Chora

The dialectic of the PLG and HPC drips down notions and concepts into the hungry mouths of its members. Their irritability for the need to know, label and regulate is that they feel this approach will satisfy them. But there really is no real end to the irritability; there will always be another notion, idea, issue and problem to regulate; it will never be perfect. Why is it so difficult to get beyond this regulatory treadmill? What lies beyond this domain, beyond the irritable regulatory mind? The paradox is that the more you scratch or irritate this mind, the worse the irritability or itch gets.

The tragedy of HPC and similar “regulatory or classificatory systems” (i.e., DSM, NICE, IAPT, Skills for Health, CBT,) is that their “treatments” serve the itch or irritability they purport to get rid of. They start out on the root of uncertainty, celebrate their constructed certainty, re-create error (of false certainty), multiply error, reward error, and then realise that they cannot get rid of uncertainty. They then say things are getting worse; we need better treatments, more therapists, more research, and more funding; this is a capitalist obsession with production. And we all know about the problems of over-production as a result of capitalism. Capitalist time, as described by Deleuze and Guattari [15], has deemed productivity to be applicable to all domains of life, not just to economy and political sphere. Sleeping, eating, dieting, love-making and our mental health are all under this domain and are affected by its threat. There is always a “new” treatment to be followed, another media psychologist to tell us how to get better, slimmer, more productive, happier etc. It is this that makes life pathological and certainly not enjoyable or natural. The production of more and more information takes us away from the paradox, and attempts to hide the chora.

The sadness of our love-making, our love to each other, and of our experience is pent up also with the idea that if we don’t itch our itch or try to erase the irritability we will land in boredom. We do not want boredom I hear you yell! Yes for most people a world where there is no irritability to fix or an itch to scratch is a land of boredom. However, the pity is that we have not been properly educated as to what proper boredom is or what it feels like. Indeed, it might not even exist if one really looked into this problem. One might not need any external stimulation/action to deal with the painful irritability we like to scratch. But even so this alternative is not something that can be attached to a formulaic way of thinking-it can’t be. It would be a disaster if it was. This is because if we followed this way of dealing with our itch or irritability, of following a plan wilfully, piously, or stubbornly, we may tragically experience the itch-less path not how it is meant to be experienced. This is the world the HPC want to construct for psychotherapists, counsellors and patients.


Footnote

i Certain groups of therapists who join the HPC will have greater access to a livelihood of working as a therapist. Non-HPC regulated psychologists can no longer get work in the NHS for example. There is no room (or it was not taken up as an option) for principled non-compliance with HPC regulation.


References
1. Wittgenstein, L. (1961). Tractatus Logico-Philosophicus. Translated by G.E.M. Anscombe & B.F. McGuiness. London, Routledge and Kegan Paul.

2. Heaton, J.M. (1972). Symposium on saying and showing in Heidegger and Wittgenstein. Journal of the British Society for Phenomenology, Vol. 3, No1.

3. Keats, J. (1966). Selected Poems and Letters of Keats. Edited by R. Gittings. London, Heinmann Educational Books Ltd.

4. Derrida, J. (1997). Deconstruction in a nutshell: A conversation with Jacques Derrida. Edited by J.D. Caputo. New York, Forham University Press.

5. The Coalition Against Over-Regulation of Psychotherapy, www.coregp.org

6. Scott, B. (2010). A case of dialectical disease: A tale of a Health Professions Council hearing of a psychologist. Retrieved from www.hpcwatchdog.blogspot.com

7. Lomas, P. (1999). Committed to uncertainty: Essays in honour of Peter Lomas. Edited by L. King. London, Whurr Publishers Ltd.

8. Kierkegaard, S. (1985). Philosophical fragments/Johannes Climacus: Kirkegaard’s writings. Vol. 17. Edited by H.V & E.H. Hong. Princeton New Jersey, Princeton University Press.

9. Laing, R.D. (1972). Asylum. A film by Peter Robinson. Kino Video.

10. Plato: The Complete works. (1997) Edited by J.M. Cooper. Indianapolis, Hackett Publishing Company Inc.

11. Heidegger, M. (2001). Zollikon Seminars. Protocols-conversations-letters. M. Boss (Ed.). Translated by F. Mayer & R. Askay. USA: Northwestern University Press.

12. Feyerabrand, P. (1975). Against method. London, Verso.

13. Howell, D.C. (1995). Fundamental statistics for the behavioural sciences. Third Edition. Belmont California, Wadsworth Publishing Company.

14. Healy, D. (1997). The antidepressant era. Cambridge , MA, Harvard University Press

15. Deleuze, G., & Guattari, F. (2004). Anti-Oedipus: Capitalism and schizophrenia. London, Continuum.

A new template letter you can use to send to your MP

with thanks to the author, here is a helpful outline you can use to write to your new MP.

Dear ---

I am writing to you regarding the proposed regulation of the talking therapies by the Health Professions Council. At the time that the HPC was suggested as a potential regulator by the previous government, nearly all of the psychotherapeutic training organisations in the UK protested that the remit of HPC was too narrow to accommodate the breadth and diversity of the talking therapies. Detailed arguments were set out which explained why the talking therapies could not be reduced to health professions, yet the government at the time overruled these without any real process of consultation. We hope that now, with a new government in place, the time has come to recognize the shortcomings of the HPC model and to explore the best regulatory model for the field.



The consultation process itself has been highly controversial: representatives of training organisations and user groups initially included in draft lists of committee membership were excluded, and the original Department of Health requirement to include representation from the wide spectrum of professional groups was not followed. Instead a small number of people with their own highly specific political agenda gained control of the process and tried to force the talking therapies into a mould which quite simply won't fit. This is the mould of the medical health professional: that what a therapist does is to correct pathology.



Although there are certainly some therapists who use the medical model as a metaphor of their work the majority do not. For them, therapy is a conversation with the unconscious, an enquiry into an individual's history, a spiritual journey, an exploration of the human condition and the many other forms of enquiry which could be described under the heading: a life examined.



In the HPC's brief, following the 2001 Health Professions Order, it is stated that "The occupation [proposed for regulation] must cover a discrete area of activity displaying some homogeneity". With the talking therapies this is simply not the case: some therapies aim to remove people's symptoms, some do not; some involve the application of predetermined procedures, some do not; some offer a set outcome, some do not; some focus on an individual's history, some do not. The list goes on, but the key is the absolute heterogeneity of the field, a fact which those who have gained control of the consultation and regulatory process seek to obscure.



Regulatory consultations in many other countries have recognised this diversity of conceptions of therapy and appropriate regulation has then been proposed. This has happened in Australia and many parts of Canada and the US. The most robust model involves the statutory requirement that all therapists are registered with a list, administered by an independent professional body, giving full disclosure of training and qualifications, together with a public education programme to inform the public about the different varieties of therapy available.



Under HPC, the public will no longer have the freedom to choose the therapist they wish to consult. Therapists will have to fit the restricted definition of what therapy is set by HPC. Innovation in the field will be severely limited likewise by the parameters set by HPC on what constitutes best practice, a concept in itself rejected by many traditions in the therapy world. The richness and diversity of the field will be dramatically affected, with therapy trainings forced to satisfy requirements which are antithetical to their basic philosophies.



The issue of public protection is the main card HPC has played, yet the key point for thousands of therapists is not this, which everyone agrees is crucial, but rather the whole package that comes with it: therapy will become something different, shoe-horned into a vision of human life and relations that many traditions reject, offering instead critiques of received notions of ‘happiness’, ‘wellbeing’ and ‘health’.



It is understandable that HPC is lobbying harder than ever to become the regulator of the therapies, as its budgets are spiralling, with massive increases predicted for next year. Regulating therapists would provide the single largest cash injection the HPC has ever had. Yet alternative models of regulation, such as the Psychotherapy Bill proposed by Lord Alderdice or the models used in other countries, are far less expensive, and are for the most part entirely funded by registrants. Further detailed information on the regulation debate can be found in The Maresfield Report (www.maresfieldreport.com).



I hope that you will give these matters your consideration, and recognise the diversity of the field of the talking therapies and the risks involved in hasty regulation under HPC. I also hope that you will advocate an alternative model which does not reduce the therapies to outcome-based healthcare procedures but gives space for those many enquiries into the human condition which have flourished for the last 100 years.



Yours sincerely





Facts and Spin in the Regulation Debate

1) Current spin is that anyone opposed to HPC is opposed to regulation. In fact, everyone campaigning against HPC is in favour of regulation, just the appropriate kind. Therapy organizations have been in dialogue with government to seek appropriate regulation for nearly 40 years now.

2) When the Department of Health proposed HPC as regulator in 2006, nearly all groups in the field objected. Since then some groups have come to support HPC, less in terms of approving of its framework than of not wanting to ‘miss the boat’. It is believed by some that if HPC regulation happens, some individuals will become ‘Partners’, thus increasing their power and influence.

3) It is sometimes said that only a minority of practitioners object to HPC. In fact, in the only poll conduced to date, 48% were firmly opposed and only 22% in favour. The main organizations have refused to poll their members, and most therapists in the UK simply haven’t been given all the information about the process.

4) Public protection is the main card played by HPC. If a therapist abuses a patient they can, according to HPC, continue to practice under current arrangements. But in fact the HPC model allows precisely this. The practitioner can simply change their title, re-branding themselves as a ‘coach’ or any other kind of ‘therapist’. Regulatory schemes in other countries close this loophole.

5) HPC complaints procedures are public, formal and adversarial, and do not include mediation as a first step. HPC also deem more than 70% of complaints from members of the public ‘no case to answer’. In contrast, the main therapy organizations deem only around 10% of complaints ‘no case to answer’. In the field, more than 60% of complaints are successfully dealt with via mediation. HPC would thus discourage or disallow complaints, especially those which deal with sensitive issues requiring confidentiality.

6) The very rare cases of abuse that have come to light have nearly always involved a breach of current laws of the land. Little additional legislation would be required to prevent those convicted from practising again.

HPC and the torture of language

The new government hopes to roll back the database state, but do they understand what generates it, or their own role in it?

I would point them to the problem of language and prescribe a dose of Lewis Carroll.

HPC agents often use language to mean whatever they want at any particular time. I have reported many examples from Di Waller’s chairing of the PLG for C&P. The HPC video on CPD is another great treasure trove of examples. But Chair Anna van der Gaag is also quite skilled at this game. She recently wrote an introduction to a new scoping report on existing research on complaints mechanisms commissioned by the HPC and called it a monograph. And this is odd, because, you know, the word has hitherto referred to a scholarly and original piece of work that contributes to a field of intellectual study and thus to the overall enlightenment of society – the Longman Dictionary defines it as ‘a learned treatise on a small area of learning, a written account of a single thing’. The report, no matter how well executed is not a monograph. The stuff in it, no matter how elegantly writ, hardly constitutes the ‘evidence base’ on whose back van der Gaag wishes to advance her expansionist cause.

Who benefits from finding out how to get more people to complain? The report is quite clear in its conclusions. People seem to complain for some unspecific reason that has more to do with standing up for a little bit of truth. Very few people actually want compensation, or to cause trouble, or to break trust. They seem simply to want to be heard.

Will these people be helped if the HPC makes it easier for them to complain? No. The complaint may well trigger a process, but this is an HPC ‘fitness to practice’ process applied to the standardised conduct of a specific individual. The scoping document gave no reason to believe that the information from existing complainants had much to do with this. Secondly, the vast majority of complaints received by HPC are received from employers or other professionals, not from members of the public.

‘I weep for you, the Walrus said, I deeply sympathise, through sobs and tears he sorted out those of the largest size, holding his pocket-handkerchief before his streaming eyes.’

The beneficiaries of this peculiar FTP process are the HPC which turn cases into statistics to prove to Privy Council that they are doing a job; the barristers who receive the fee for pushing the case through to its administrative conclusion; and employers, who avoid having to deal with the problems that arise in their own back yard. None of this has anything to do with increasing the country’s intellectual capital or adding to its programme of enlightenment.

I’m reminded of the monetisation mania preached by Mrs Thatcher and her minions.

Anyway, the report is not a monograph. It is, as it says on the cover, a scoping document that scopes a possible field of colonisation for the HPC. It is commissioned as a kind of market research. Come on.

The HPC newsletter ‘In Focus’ has been pinging into my mailbox for nearly two years now and is dull as ditchwater. It used to list the FTP cases and often provided a little case study of how practitioners were messing up. Since October 2009 however, (Issue 25), the FTP cases have disappeared, and since June (issue 23) the In Focus front page has been given over to the problem of cajoling people into making their renewal on time. Every single issue from 23 to the current issue (29) exhorts registrants to renew their membership on time. How interesting. Supplementary news items tend to report the rate of renewal achieved, and suggest that you encourage your colleagues to renew and put posters up in your consulting room. There is also a regular little line or two thanking the personnel managers and union reps that have helped to round up the registrants and corral them into the pen. Great stuff.

Also regularly featured over the last year are the ‘listening exercises’. Like me, you probably imagine that a listening exercise is where the HPC listen to the views of its various constituents – a kind of corrective to the lack of democratic procedures associated with this kind of organisation. WRONG! These events are for YOU to listen to the HPC. They are undertaken in order to tell you what you need to do to comply with their CPD and FTP procedures. It should come as no surprise that lots of people attend these events (all hopping through the frothy waves, and scrambling to the shore), for if they do not comply they will surely lose their livelihood.

For all its literary faults, the current issue of In Focus does, however, give another wonderful example of the insidious spread of the database state.

On 1 July this year the contentious vetting and barring scheme comes into force. This caused quite a splash when Philip Pullman and other authors objected to being treated as potential paedophiles. The objections were heard, but no one grasped that the scheme itself was where the problem lay. Politicians unwilling to admit they might be wrong simply reduced the volume surrounding the idea but didn’t change the record.

The vetting and barring scheme is designed ‘to ensure that everyone working or volunteering to work with children or vulnerable adults is suitable to do so by being checked and registered’. This law defines a vulnerable adult as any adult receiving healthcare. Health care. This word has been subject to so many twists and turns over the last year or so as the Health Professions Council seeks to define just about everything as health in order to incorporate it within its remit that we can see how the logic of this silly discourse will press everyone to sign up to this pernicious system. Instead of seeing the flaw in the system (a replication of agencies all trying to save the public from itself), the HPC views the VBS database as a potential competitor for the services it provides itself! I quote:

‘…the majority of HPC registrants will need to be registered with the V&B Scheme. … However registration with the VBS will not be a requirement of registration with HPC… Registration with the VBS does not replace HPC registration… The HPC will continue to set the standards for practising in one of the professions it regulates and you will still need to be registered with the HPC if you use one of the titles we protect.’

As the government continues to broadcast scare stories about how little money the country has, and how awful things are going to be, I suppose we cannot expect those employed to administer these various databases regimes to willingly acknowledge that the work they are doing is worse than a waste of time. The money they waste is not raised by direct taxation, but by a kind of stealth tax levied directly on their registrants (who have no right to vote on the way this money is then used). The accompanying discourse of security assumes the population is probably guilty, and punishes it by making it pay for the computers and offices and administrators in these little database states. Is this the kind of thing that politicians would ask seven maids with seven mops to spend half a year sweeping clear?

I doubt it, said the Carpenter, and shed a bitter tear.

Andrew Lansley replied to Esther Hague, the physiotherapist caught in the CPD trap. Basically he told her that the HPC is independent from the professions it regulates and from Government in order to function fairly and effectively, and he is therefore afraid that it is not possible for the Department of Health to intervene in this matter. He also said:

“Section 28 of the NHS Reform and Health Care Professions Act 2002 gives me as Secretary of State the power to make provisions in regulations for the Council for Healthcare Regulatory Excellence (CHRE) to investigate complaints about the way the nine health professions regulatory bodies have exercised any of their functions. However, Section 28 has not yet been enacted and the CHRE does not, therefore, currently have any statutory power to take action on the complaints it receives.

“The purpose of the CHRE is to promote good practice in regulation and consistency across the nine healthcare regulatory bodies. In the absence of formal powers under Section 28, the CHRE can work with the regulatory bodies only informally and consensually on the complaints they receive."

So, there you have it, says Esther. The powers of the HPC are totally unchecked. With regards to her concern about the linking of CPD with re-registration or a refusal to re-register if the arbitrary standards of the HPC are not met, Nick Clegg (her MP) has written to the CHRE to raise the concerns with the Chief Executive.

“So”, she says, “we go round in circles.” But she hopes that Nick Clegg is beginning to recognise the unchecked powers of the HPC and says she is determined to take it further with him “to get this culture of mistrust and excessive regulatory powers of the HPC brought out in the open and hope that the new government will see the negative effect this has on health professionals”. Way to go, Esther.

The union now known as Unite has set up a National Occupational Advisory Committee for counselling and psychotherapy. Meeting Wednesday, 29th September 2010. Vacancies still exist for: Wales region, North East/Yorkshire and the Humber, Ireland, Eastern, East Midlands. You can email me for more info.