Master Signifers, Aggression, and Truth.

Developments in linguistics and in anthropology brought this idea into use in the early parts of the last century. I shall not lecture you on it but invite you to cut to the chase.

There are words or phrases frequently uttered that have great power but very little meaning - they appear unattached to other elements either in a sentence or in the world. They point to nothing. The vagueness of this can raise anxiety, especially when uttered by people occupying positions of institutional and legal power. Lets call them 'master signifiers' - they have power 'because I or We say so'.

I should add that they are not always necessarily bad. They are a part of language and life and can be extremely useful and put to the good with care. They are a necessary feature of language, in fact, because when we speak we are usually trying to speak about something beyond speech, something that our speech aims to invoke. I think this might be particularly difficult for native English speakers to grasp, because we are so seldom required to face the foreigness of our mother tongue. If we forget this nature of language, however, we can easily forget how important it is to attend to the invention and deployment of master signifiers. Lets keep this practical.

Three of the major master signifiers that organise the discourse around the hpc are: Evidence, Public Protection, and Regulation. I have been trying to turn Public Protection into a meaningful phrase by attaching it to specific examples and paying particular attention to its use (which section of the public is being protected, from what particular harm, and on which specific occasion?). In this way the signifier is introduced to other signifiers with which it is revealed to have an otherwise hidden relation. The concealed relations leave them unquestionable, and we have seen in the case studies particularly, that this can be seriously unhelpful.

When the relations are left in the dark, the phrase can get wielded rather aggressively - intentionally or not - by someone who happens to be occupying a position of power. If used by someone not in any kind of position of power you can safely ignore them as a babbling fool. Unfortunately, these phrases are very often heard coming out of the mouths of people in positions of power - journalists, politicians, members of panels, committee members, for example. To call these people babbling fools might be true in that particular moment, and there have been times in this country when it has been perfectly acceptable to say so, even if you are no-one in particular yourself. But - and its a big but, and one that needs to be acknowledged and understood - at the moment because these people are supported by society and given positions of power, calling them such without great tact seems likely to provoke much more than their own personal wrath. It is as if the whole edifice will crumble away with them, as if they personally are the power. To speak out seems to risk bringing the power of the institution right down on your head.

So, master signifiers are instruments of power: they are cut off from meaning and draw attention to the power of the person that speaks; and they are used to cut off meaning in other conversations, to disempower other speakers - this is a double whammy.

Law

The bloke who runs the local heel bar in West Norwood used also to run a dry cleaning service out the back. He had to shut it down because some distant law or other now declares his machines to be dangerous. He might shut down his shop, leaving yet another empty space in this benighted high street.

In the ten years that Tony Blair took up the PM post the UK government passed more laws than at any other time ever. The Magna Carta is in shreds. So many laws were passed that the people in the House couldn't actually read them all. Eventually someone had the idea to turn Acts into Orders which reduced the amount of time officially needed to scrutinise them.

Instead of a god shaped hole in our social fabric, we've stuffed it full of laws laws laws. Good for no-one except, well, no, not even for lawyers.

But does this help to explain the existence of the hpc? I look, I search, I want to know what has happened to this country that it brings a thing like this into being. Answers on a postcard, please.

Right now a piece of legislation is waiting in the wings to be tabled in the House of Lords. It goes under the name of a statutory instrument - a Health Care and Associated Professions (Miscellaneous Amendments) (no 2) Order 2008. It is laid before parliament under Section 62(10) of the Health Care Act 1999 for approval of each house and of Scottish Parliament. If passed it will transfer a set of psychologists into the domain of the HPC. It is done under the familiar phrase 'in order to protect the public'.

The administrators at the HPC will receive a huge list of names to write onto their register. The HPC will then become the administrators of applications to join this register, remain on this register, or be removed from this register. In order to know how best to exercise this centralised power, they will have to grapple with the problem of knowledge, never mind the infinite variety of practice. Here we are again in Popper's Nightmare (see previous blogs and side panel for succint explanation).

The folly that produced the hpc would have us believe that it is because they know nothing about a practice that they are the best people to manage those practices. Grasping the real truth of this point is akin to grasping the idea of zero. There is all the difference in the world between zero and nothing.

Do you remember when Gordon Brown took up the PM post - shortly after this he was out and about consulting Citizen's Councils. The idea was that the political machinery would gather together groups to advise politicians, and the qualification to be a member of the group was to have no idea at all about the subject in question. The implicit belief behind this is that everyone has the potential to say something sensible, be useful, be a valuable citizen. But alongside this another kind of implicit belief is at play - that those who had achieved positions of power and status on particular topics were not to be trusted with the truth. That they would be more interested in maintaining their position than of applying the truth that had led them there. There is a little bit of truth in both positions, an no-one needs me to tell them.

So what is it that leaves us in such a lurch as we are in? One hypothesis that I have been advancing is that Popper's Nightmare has been long time in the making, and this has gradually weakened the knowledge base across the country at grass roots level. This is one strand. Another hypothesis comes from Max Weber, whose discourse on institutional power has been helpful in reminding me that these questions are not new but have always to be grappled with. A third strand relates to the way that we are dominated by empty phrases which get weilded as aggressive objects rather than as parts of a meaningful discourse between subjects. It is this that I shall now try to talk about using a word from linguistics: signifiers.

FTP or management failing?

Today's case at the HPC is that of a physiotherapist. It is another case where the management structure of the NHS has clearly failed to take timely action on a minor question, and which has allowed the machinery of the HPC to blunder in. It is difficult to justify this as a serious misdemeanour from which the public needs protecting. It is more easily understood as petty malice on someone's behalf. Copied below is the allegation as printed on the HPC website. In the next financial year. The FTP budget for next financial year is estimated in the region £5.6million.

Your fitness to practise as a registered health professional is impaired by reason of your misconduct and/or lack of competence in that:

1. At all material times you were employed as a Physiotherapist by East Elmbridge and Mid Surrey Primary Care Trust.

2. On 1st August 2005 you took unauthorised absence from work whilst on duty.

3. On 6th February 2006 you took unauthorised absence from work whilst on duty.

4. Between March 2005 and February 2006 whilst on duty:
(a) you made excessive personal telephone calls on the Trust’s telephone and;
(b) this was contrary to Trust policy.

5. Following an audit of your patient treatment notes it was found that:
(a) there were discrepancies between the activity recorded on your statistics sheets and the activity documented in your patient notes;
(b) you failed to keep adequate patient notes.

6. During your employment at the Trust:
(a) on 6th March 2006 you did not assess a patient, Mr A pre-operatively.

Redefining 'Professional' & Frightening the Public: more on Mr R

From the transcript of the case of Mr R. [I have used the name Freddy in place of his real name, to reflect the familiar diminutive that was used at the hearing.]

Ms B, the witness said: "A family member, the father, said that this was the work that Freddy had given his son to do privately. When I questioned him and said "was it the case that Freddy also saw your son privately?" the answer was "Yes". The family felt very anxious and asked me whether I was in touch with Freddy. I explained that I had never met Mr R and that it was not good practice or approved practice to work with somebody privately whilst on their NHS case load. The family were anxious. They really liked Freddy and they had built up a very good rapport."

When Ms B was asked to explain why it was not good practice for someone to work in private with someone also on the NHS case load, she replied:

Ms B: "Firstly it is in our professional guidelines that we are not allowed to manage a case where we are already seeing that particular individual on an NHS case load. Also for me, personally, it is unethical to be seeing somebody and then at another time to be taking money from them."

Is it just about money? Ms B said Mr V should also belong to the association for private practice. Then she mentioned note taking and liaison with other professionals involved. This allowed HPC Council to ask the purpose of note taking, which brought forth this revealing answer:

HPC Q: Why would you be taking clinical Notes?
Ms B: Just as a record really otherwise you will be leaving yourself open to be vulnerable.

When questioned by Council for Mr R, Ms B explained more clearly: 'it is recommended to protect you from suspicion.'

Ms B had not made her allegation against Mr R because his professional work was in question, but because she thought he was open to suspicion. What kind of suspicion, and from who? This brings us back to defining the idea of 'protection of the public'.

Protection of the Public. Who represents the public in this case? The family is implicitly ruled out as the case unfolds - they are described in ways that throw them into question, and which excludes their point of view. They become the group that tempt the professional off the straight and narrow. The public that is being protected here seems to be one that might be shocked to hear that someone employed by the NHS is not completely under control, and this would imply that they are being protected from that shock. This is clearly irrational, and cannot be the intention of anyone involved, but the accumulation of evidence does seem to point to this interpretation.

Ms B is not throwing doubt on the professional practice of her colleague. The family is pleased with the work, the young man in question is happy with the work. In fact Ms B went on to say "I think Mr R did a really good job".

When Ms B was questioned by the Panel, the lay member, Ms Lesley Hawksworth, brought her back to the point of how she interpreted the rules.

Ms Hawksworth: "You have already been referred to the guidelines on page 34. In paragraph 4 it says: "Therapists who have any current health service involvement may not normally undertake private therapy with that client." It does not say must never. "
Ms B: "Can you say that again?"
Ms H: "The sentence does not say 'must never' undertake private practice'
Ms B: I would have to clarify that with the independent practice to clarify exactly what that means.
There then followed a confusion between the panel members which brought to light two different versions of rules. Mr Duckworth (the panel member representing the Speech and Language Therapy profession) had a more recent version:

Mr D: "The statement from the Communicating Quality latest edition, would seem, from the text here that I have just read out, that the suggestion is, if you are treating the NHS client, you may not undertake private management of that case. Is that your understanding?
Ms B: "Yes, it is".

Mr D has re-established Ms B as a sensible woman, but only if you don't ask any questions about the validity of the text itself. There followed a brief confusion about the dates of the different versions of this text, as well as the authority which published them. It is published after the date Mr R's practice was called into question. It seems likely that the rule is written as a diplomatic matter between the Royal College and the Independent Practitioner bodies that each try to represent the Speech and Language therapists. Fair enough, they are carving out their respective territory of jurisdiction; but should this not be taken into account when interpreting the text? The lay member is right to pose her question here on the side of sense and reason rather than of management and trade. But she seems to have been side-lined quite quickly.

more to follow shortly,

Investigating Committee, Feb 09

There are 555 food days arising from Fitness to Practise activity.
And £300,000 is spent each year on hiring the shorthand writers.

I am now attending various committee meetings at the HPC to find out what is talked about at strategic level.

Most people have not really thought about the implications 0f the HPC - why would they, when there are so many other things to do in life? Those people who are forced to think about the HPC tend to leave it in the abstract realm of a TLA and at most associate it with the figure of the CE, Marc Seale. Well, the HPC in practice is a very different thing. I know of people who make appointments to visit Marc Seale in the belief that they will speak to a man and persuade him with reason. None have yet succeeded. There is little reason to think that they would. First of all Mr Seale is placed in a highly particular position. This organisation did not come into existence through the desire of a man, not the demand of the market nor of local people, nor from the exigencies of practice - it came into existence through a highly particular, and alarmingly flawed, political will. Discussing things with this CE is not going to work, because, in effect, he has been set up in a highly constrained position and given the power, in effect, to print money.

There is a second thread to take into account: the organisation is large, has a history, and is stitched into the fabric of life in many different ways. There are sandwich makers and stenographers makers who depend upon it for their living, for example.

By going along and observing I have two different aims. One is to allow readers to realise that this organisation supports the living and the careers of a lot of real people (and won't disappear overnight, nor give up its wish to make money). Second is to gradually reveal what the day to day business of the place really is. I have been an ethnographer in my time, and it is this that is giving me an orientation.

In the meeting there were some familiar faces around the committee table, and a nod of recognition from Anna van der Gaag. I sat behind another familiar figure - Diane Waller, chair of the C&P PLG - and was surprised that she said nothing at all throughout the whole of this meeting. I recognised the new Secretary, and was pleased to see Kelly Johnson, head of FTP, who I had read about at the Tribunal. I was surprised at how young and inexperienced she looked.

The committee meeting itself is, of course, based on a large number of documents which are numbered more than named, eg: 100026AC20090205Investigating-enclosure7-complaintsliterature, and 100026AA20090205Investigating-enclosure5-workplan2009-10. Teams of people are employed full time to compile and take care of these documents. Panel members are probably paid a fee to read them and to come to London to discuss them. Little by little, I shall find a way through too, and try to reveal something which renders them accessible and perhaps gives a fresh view.

Where to begin? I'll take two points of humour.

There's an HPC CPD DVD, and will be an HPC FTP DVD, several people laughed quietly at this, perhaps enjoying the poetry in the letters.

The second thing that made members laugh was the idea that the figure for costs invoked by a High Court Appeal had been increased, which means that someone failing to win an appeal against an HPC decision would be obliged to give up several thousand pounds. One panel member punched the air with joy and Kelly Johnson giggled.

A little less funny is the fact that by the end of the month the Kent Police will have delivered their special 'escalation procedure' training programme which is aimed to help the FTP employees in their business of conflict management.

So let's turn to something more comforting. Sylvia works on reception, and has done so for more than 13 years. She has seen many refurbishments in her time, as well as the re-naming of the organisation and changes in its relation to the public. She told me that her desk has been moved around the building. First she sat in the basement, then in the heart of the building, now she sits at this nice little number in a double locked chamber right next to the glass front door. Before, visitors and public were trusted to come in and find their way through the corridors. Now they are forced to obey magnetic locks, wear large name tags, and wait to be escorted wherever they want to go.

There are other important things to say about the meeting, and relate to the planning, forecasting, and expansion that formed a bulky and central document. I'll have leave it here for the moment, and return to the task later on.

The actual HPC Council meeting, Feb 2009

The 30 minute meeting was extraordinary for the lack of debate and discussion. Not all of the papers had been ready before the meeting and a couple of them were handed out, one in particular was presented to the group and 5 minutes were designated for reading. This paper had been written by the Department of Health who are apparently all of a frenzy these days, and hadn't got there act together. The Council Members duly bent their heads to consider this important document. A lacklustre attempt to comment followed, and was met by a robust rebuttal from the resident lawyer.

This lawyer turns out to be none other than Jonathan Bracken, a partner at Bircham Dyson Bell. This is the man credited with writing the documents that brought the HPC to life (see blog below headed 'The Information Commissioner'): the Father of the organisation. He was in fine form, probably the only member of the meeting who hadn't just spent 5 hours in brainstorming future strategy and expansion. His joke related to another new short document, on which the increases in fees were written. This must pass through parliament. He informed the meeting that altho the document was just being handed round, in fact nothing on it had changed since their view of its draft. This of course was good, he quipped, except he might have liked to have seen the figures increase. He laughed "hahaha".

HPC Council meeting, Feb 2009

Yesterday I went to observe the full Council meeting at the HPC. I had set aside the whole day for the occasion, but as most of the day was given over to a strategy work shop and an expansion work shop, the actual business of the group was restricted to 30 minutes at the end of the afternoon. This was the 30 minutes to which the public were admitted. There was one other public obliged to wait in the reception area until the Council were ready to display themselves and we had a few minutes conversation before we were ushered into the only two empty chairs in a very full room, where once more I discovered myself crammed into the corner looking at the back of a row of heads. I was luckier than my colleague - his seat had been soaked by a leak in the air conditioning...

This other member of the public was a young man - an Oxford graduate. Why on earth was he there? I had asked. He works for the CHRE - the official watchdog of the HPC. As part of their remit they like to drop in on the various regulatory bodies under their auspice to see how they are getting on. He asked me why I was there - I had to concede that I was the unofficial watchdog, and as he didn't immediately laugh out loud I launched my manifesto.

I told him I was very worried about the unintended consequences of such a strange invention as the HPC, and indeed the CHRE, come to mention it. He looked amazed. I talked about the centralisation of power and the centralisation of knowledge and the catastrophic consequences this has on the local practice of any profession. He let me continue. I spoke of the collapse of the banking system and pointed to the system of regulation they had been subject to. I drew the comparisons and predicted a similar collapse in the professions subject to it here, due to the inevitable destruction of local knowledge that such a move sets in train. He seemed to be interested, so I risked Popper's Nightmare. Of course he had heard of Karl Popper, but he had not studied his nightmare, so I referred him to the you-tube clip of Richard Gombrich, which is linked to the side-bar of this blog. I seemed to be on firm ground, so I followed it up with encouragement towards Marilyn Strathern and Michael Power, then pressed my advantage by mentioning Mark Neocleous.

Here he rallied and began putting counter arguments.
- Professionals must be regulated - the public think they are already.
- They are, I quickly replied.
- Self regulation? He countered, with a rye smile.
- Yes, of course, said I.
- But that is hardly reliable, the professionals only look after themselves.
- But such a cynical argument also applies to yourself.
- How so?
- The HPC, the CHRE must also look after themselves, attend to their public persona, safeguard their jobs and their future employment, this is just part of life.
- But surely standards of knowledge and performance are necessary to protect the public.
- Yes but how are they produced and policed - we are back at Popper's Nightmare.
- But people need these rules for practice
- Which rules? There are rules generated in the process of practice and discussion within the communities that work on these things, and then there are rules made by centralised committees and constructed by political processes. Then there are rules for practice, questions of ethics, and rules of law. The context is complex, but not so complex that those who work and practice can't attend to them. It is more difficult for people who don't work in the practice to come up with a good set of rules. This question touches on science and politics. Which rules do you mean?

Enter Colin Bendall whose job it is to usher us into the performance.

IPN women's delegation to Marc Seale, CE, HPC

This letter is brought to my attention:

Marc Seale
Chief Executive and Registrar
Health Professions Council

8 February 2009

An Open Letter to Marc Seale:
First of all we really appreciate your taking the time to meet with us on 27th January and would like to thank you for that. We should say though that we were rather surprised to also meet with Diane Waller, as that had not been part of our agreement. However, the meeting was instructive as it helped to clarify our thoughts and feelings about statutory regulation, although probably not quite in the way you intended.

As you may remember, your invitation came about as a result of your meeting with Denis Postle, when you said you would like to meet with other members of the Independent Practitioners Net-work. We trusted therefore you would be interested in our views on the proposed statutory regula-tion of the psychological therapies. Perhaps naively we assumed that you would first want to hear our reasons for not welcoming this proposal and then, having listened to us, counter our arguments point by point. This might have allowed for an interesting debate, but sadly this was not what hap-pened.

You did agree with our suggestion that we could perhaps all take a few minutes to expand on who we were, what had brought us to the table, what we would like from the meeting and perhaps even what we felt passionate about. After that, however, instead of listening to our views, in which you ap-peared to have no interest, you did your best to dominate the meeting with your views. You then said ‘I don’t understand your argument!’, which surprised us, as we had not had a chance to inform you of what our argument might be! It was hard for us to break into your or Diane’s monologues and when we tried, we ended up feeling talked over. At the end of the meeting you did not ask what it had been like for us, but told us that it had been ‘useful’. Really? We left your office feeling disap-pointed and very frustrated with a clear sense that you really did not want to hear anything that might be anti regulation.

You left us with only one hope: that if not enough counsellors and psychotherapists wish to find a safe home ‘under your tent’, then, by your own admission, being regulated by the HPC would not work. If we may be so bold as to make that assumption, where would you and everyone else go from there?

To conclude, did you happen to see the article in the education section of the Guardian of 27th
January, 2009, the date of our meeting, regarding Universities and red tape entitled “Regulation, regulation, regulation”? Steven Egan, HEFCE’s deputy chief executive is quoted as saying:

“…Our sector is still over-regulated proportionate to the risks that arise from it. As a general proposition, the country will gain more value from us if we devote our resources to doing rather than measuring?”

Could this not also apply to the psychological therapies?

Yours Sincerely,


Irene Galant, Barbara Hacking, Jenny Nicholson, Els van Ooijen

Jucial Review, appealing against the HPC decisions

Someone had been advised by the HPC that the only means of redress open to them after a decision had been made by the HPC was via a judicial review. They duly set one in process, and hired a solicitor. Only then did they discover that they were not in a position to put such a process into play.

This case involved an NHS manager who had been sacked. The HPC tend to trawl these cases and bring them into their own net to re-play the scene and ring out the surplus value. The upshot of this is that the HPC then becomes the complainant in the HPC Process. People who had been involved in the original case might be forgiven for thinking that they still had a part in this second playing of the scene, but in fact they don't. The HPC take over the show - in this way they act on behalf of an imaginary public and take a local sacking into a national misdemeanour.

There are two threads - one is the way a local event is passed to a central court (local difficulties acquire national status), the other is the question of self interest. The original professions were attacked on the grounds that they couldn't be trusted to keep their house in order as they were likely to be biased in their own favour. This inconvenient truth, however, also applies to any new body set up to keep order, it is part of life and must be dealt with by each of us as we act. The idea was that the HPC would always be objective because it has no interest in the professions it manages. However, this completely ignores the interest it has in maintaining itself - it is a naive, puerile view. The HPC is left with no other purpose than to maintain a register and police it - it is administrator, law enforcer, law interpreter, law maker. In the case of the original professions they were also interested in the work itself, and the knowledge pertaining to the work. In fact they were more interested in the work itself for without it they would cease to exist. In the case of the HPC their work - their trade, their profession so to speak - is administrative and legal. They are not interested in the actual work of the people over whom they have such far reaching legal powers. Their business is collecting names onto registers (and money associated), arranging the lists, creating sets of abstract standards of character and practise at a distance, and of enforcing these standards. That's it. It is a false profession, based on nothing. They are under the jurisdiction of another such body (the CHRE) and each of these is under the jurisdiction of the Privy Council, as far as I can see.

My contention is that the HPC is an artificial creation based on a false assumption. This is very shaky ground which sets up a need for a strong policing in order to make it work - an artificial force takes the place of any possible natural order. This sets up an absolute system and places far too much power in the hands of a small set of people. It is a very tricky situation, and one which is out of balance with the requirements of the situation.

It has been very common to explain the creation of the HPC and the CHRE through reference to Harold Shipman. The fear that is created by this move is two fold. There is the fear invoked through reference to a serial killer, and there is fear invoked by the irrationality of the reference to the subject in question. That is, there is no rational link between this murderer, and the creation of a large list, a centralised knowledge base, and an aggressive police force. The link has more in common with a paranoid idea than it does with reason, experience, and rationality.

The Information Commissioner & HPC's FTP

You can go to www.informationtribunal.gov.uk and get copies of cases, I have one whose decision was promulgated on 14 March 2008. According to my dictionary of word origins, promulgate is linked to the idea 'to milk', that is to cause to emerge. This promulgation was set in motion by a series of events which culminated in a Freedom of Information (FOI) request by Ms Z who had referred a case to the HPC. The HPC refused to give the information which led to the Information Commissioner being called onto the scene. He then issued an Information notice requesting sight of the disputed information and the HPC appealed this notice under section 57(2) of the FOI Act.

Are you following all this?

I'm new to all this too, but little by little I intend to try to discover something about the particularity of the time we live in, the institutions we invent, the context in which bits of our lives get lived.

From the promulgated decision I learn things that I already knew: "The HPC is established under the Health Professions Order 2001 (the 2001 Order)" and subtle differences from things that I thought I knew: ... "It's main functions are set out at article 3(2) of the 2001 Order as "...to establish from time to time [my emphasis] standards of education, training, conduct, and performance for members of the relevant professions and to ensure the maintenance of those standards." The main objective in exercising its functions is "to safeguard the health and well being of persons using the services of registrants." This is written in The Order. But there is room for interpretation in practise and it is this that is in question at the Tribunal Service.

"The HPC's functions include the maintenance of a register of health professionals and a mechanism, called the Fitness to Practise process (the Process) whereby the conduct and performance of registrants may be investigated and called to account. An adverse adjudication on a registrant's fitness to practise may lead to, amongst other things, a registrant being removed from the register (such that they could not work in their chosen profession) or conditions being attached to the performance of their profession. Members of the public, employers etc, may make allegations to the HPC with regard to the fitness to practise of particular registrants. Such cases are investigated by the HPC and as a preliminary step in the Process a decision will be taken by a Panel of the Investigating Committee whether there is a case to answer. [If not, the Process ends. If so, a new Committee is called for a full hearing." (Quoted from the Tribunal's introduction.)

In the case in question the initial Committee decided there was no case, so Ms Z made her FOIA request to see on what basis this decision had been made. This was refused by the HPC on the grounds that certain exemptions applied, namely sections 30, 40, and 41... So Ms Z made an application under section 50 of the FOIA for a decision by the Information commissioner as to whether her request had been dealt with in accordance with law. After a lot of argy bargy the HPC filed a Notification of Appeal against the Information Commissioner's Information Notice and so triggered this appeal to tribunal.

It's quite Dickensian - we are in the field of law, very particular human relations, and, by the by, a professional practise.

The Tribunal heard evidence from Mr Jonathan Bracken from Bircham Dysen Bell, who were solicitors for the HPC. Mr Bracken had been involved in the setting up of the HPC and had advised on many of its processes, he had drafted most of its rules. He explained to the Tribunal that the HPC had 'moved away' from a punitive disciplinary scheme, and had put in its place the Fitness to Practise regime. It is a process in two stages. These stages were put into question at the Tribunal and Mr Bracken was revealed as lacking (he had to admit that some of his documents 'perhaps were not as well worded as might be') .

The next in the dock was Ms Kelly Johnson, the HPC's Director of Fitness to Practise. She was obliged to say that 'the practise and procedure guidance were living documents and in certain respects in need of revision'. In the course of her evidence she revealed that the information gained in the Process at the early stage could be shared with the competent authorities of the other European Union states, and in addition, circumstances could arise in which the HPC gave the police a registrant's information prior to a 'no case to answer' determination. Registrants are not warned of these possible disclosures.

To cut a long story short, the Tribunal concluded that 'registrants were unaware of the fact that HPC on occasion made disclosures in the public interest... The reality was that the 'aura' of confidence (as Counsel for the HPC had put it) attached to the information provided by registrants, was not as clear or as bright as contended." [my emphasis] Furthermore, the Tribunal added "this case came nowhere near the mark". Their decision in favour of the Information Commissioner had indeed been unanimous.

A public point of view: Paola

Paola commented recently that: From where I am standing, the HPC has been protecting the professional against ACCOUNTABILITY. This has not helped her either: learning of the dire consequences of her many misguided actions and inappropriate interferences would have given her valuable feedback and helped her in her professional development and in her personal growth: the HPC has failed her too...

She continues:

"I always felt that there would be much more value for us in an apology and in a constructive use of the damage done to my son and myself as an opportunity for education and training, awareness and growth. The HPC does not do these things. In fact, and with reference to my previous post, the HPC does not do apologies either. The HPC does not do feelings and emotions and real people full stop..."

Paola's experience reveals more of the nature of this particular bureaucracy. It has been set up not as a pre-packaged or natural object without history, values, or character. It is a kind of living thing that can be assessed as a creature in its own right. In a previous blog I reported that Mr Williamson (one of the FTP panel chairmen) had pointed out that the HPC was similar to the GMC and that had inherited something from its predecessor (housed in the same building, and perhaps employing some of the same administrators and support staff) the Council for Professions Supplementary to Medicine. There is every reason to procede with an enquiry into the nature of this new thing, and not to assume that an organisation has no character nor that such is irrelevant. It is a necessary discipline to consider the character of the HPC and its conduct and to ask if it is fit for purpose.

There are also the unintended consequences. Paola raises this other point. "It seems to me that there may well be another worrying outcome of HPC regulation, a danger inherent in their structure and procedures: that the academic and professional standing of registrants under investigation will have a bearing on the outcome. In other words, that there will be a hierarchy of vulnerability to sanctions ..."

From my random attendance of FTP hearings I could not help but be struck by the absence of genuine cases raised by bona fide patients. So far there has been an angry and aggressive man shouting at an ambulance driver, a frightened colleague wishing to avoid another hearing about his own conduct, a training manager who thought he would be held responsible for an amblance drivers decisions, and a new recruit anxious not to be contaminated by any kind of accusation that she rules had not been obeyed.

The HPC has a particular nature, which has an effect on those it brings within its domain.

HPC PLG C&P day 2, pm

Towards the end of the HPC PLG for C&P last week the group started thinking about their next meetings. According to the work plan written down by Mr Guthrie, most of these meetings will be taken up with the question of Education and Training/standards of proficiency.

As the group approached this they revived something that Diane Waller had mentioned and parked a bit earlier. It was the question of 'life coaches' and people using other titles but doing similar work. Mr Guthrie had reminded the group that the process was about Protecting Titles, not function. This left the difficult question of figuring out how the HPC could guarantee anyone on its register without recourse to training and validation of practise. There is also the question of what they would do if people simply invented a new title for their work.

This is the way the nightmare works. Having invented a name, they now have to invent a new practise that fits the name and that they can police, otherwise they have no power whatsoever. It is a where the twist in the law is most obvious. The mistake Ian Kennedy and his followers made was to imagine a group of people who were the exception to the rule. The rule was that professionals were not to be trusted, the exception to this rule could alone solve this problem. The exception to this rule is the HPC. When Ian Kennedy said so casually 'why should they [the medics] have the power over life and death' he implicitly also said 'it should be us, who are better'. Which is, of course, nonsense.

What follows is a compact and incomplete account of some of the discussion. I've given it like this as an antidote to the anodyne minutes which reduce all the differences in the group to a single unanimous voice. I have also included their names so that anyone reading this blog might decide to engage in a conversation with any of these people (simple to figure out how through google) on some of the points that they make.

Jonathan Coe (Witness CE) said "The need for standards in professional training is what will protect the public."

Graham Smith (HPC Panel, Physio) linked this to the 'intention to deceive'.

Karen Ablack (UKCP standing in for Kathi Murphy) remarked that 'if people are not doing it [therapy] well enough and they are using my professional title then ...' she left it to her body language to indicate what she would do (flush them down the loo, I guess, she seemed to
indicate poo).

Mary Clark Glass (HPC Panel lay member) said 'we'll get them on it - if you go beyond your skills and competence, you will be called to account'.

Someone said "Prevention is the better protection of the public"

Finally Julian Lousada (BCP) remarked 'we've parked a difficult issue' to which

Diane Waller (chair) replied 'we can be seen to have done justice to the question'.

Sally Aldridge (BACP) then offered to exhume a dead and buried report done by the big 5 some years ago [UKCP, BACP, BPS, BCP, BABCP I think] which had tried and failed to synthesise competencies across the board. Someone else offered another similar dead and buried document, and Peter Fonagy (SfH) offered his NOS. All were eagerly accepted as fodder for the next few meetings.

In this way the work done in these other places by these other people for those other purposes are going to emerge into this tight schedule and could easily be taken up for want of the time to make something more suitable. This is how bad laws get made, and its other people who are going to suffer the consequences without any idea how it happened to them. That's why I'm writing this blog.

Max Weber on Structures of Power

"All political structures use force, but they differ in the manner in which and the extent to which they use or threaten to use it against other political organisations." This is the opening sentence of an essay first published in 1921 but written between 1910 and 1914. He is careful to distinguish the differences in the ways different states make use of their structures of power, as he goes on "Not all political structures are equally 'expansive'. They do not all strive for an outward expansion of their power". He speaks of the jealousy of neighbouring states, of the vulnerability of those in possession of colonies to that jealousy, and of the way that proximity and shape might expose some states to invasion from their neighbours. In the opening paragraph he sketches the usual way a structure might acquire domination over another: "by incorporating [others] or making them dependent."

All this can be read in the collection by HH Gerth and C Wright Mills that I have borrowed from my local Lambeth Library, and which I note (not without interest) was first published in 1948.

He goes on to sketch two broad attitudes that political structures tend to have towards those outside their immediate control. They can be more 'isolationist' or they can be more 'expansive', and of course they can change their mind about this along the way. 'On the basis of this power the members may pretend to a special 'prestige' and their pretensions may influence the external conduct of the structure.. Experience teaches us that claims to prestige have always played into the origins of war... Feudal lords, like modern officers or bureaucrats, are the natural and primary exponents of this desire for power-oriented prestige... power for the political community means power for themselves as well as prestige based upon this power."

"For the bureaucrat and the officer, an expansion of power, however, means more office positions, more sinecures, and better opportunities for promotion (even in a lost war)."

After a short excursion into some moments in history describing states favouring isolationist policies (including Roman, Britian, and Spartan) he returns to the question of fear. "The Spartan aristocrats, so far as they were able, quite deliberately limited their political expansion for the sake of isolation. They restricted themselves to the smashing of all other political strucures than endangered their power and prestige. They favoured the particularism of city states. Usually, in such cases, and in many similar ones, the ruling groups of notables (the Roman nobility of office, the English and other liberal notables, the Spartan overlords) harbor more or less distinct fears lest an Imperator, that is, a charismatic war lord, emerge. A tendency towards centralisation of power goes very readily with a chronically conquering 'imperialism' and the war lord might gain the ascendancy at the expense of the power of the ruling notables."

Weber concludes this opening section by returning to the question of money: "Like the Romans, the British, after a short time, were forced out of their policy of self-restraint and pressed into political expansion. This occured, in part, through capitalist interests in expansion."

In order to try to understand the nature of the hpc it is necessary to understand the context which brought it into existence. I've gone back to Weber as a kind of touch stone. I particularly like the way that he sets off without forgetting that human beings are subject to fear, jealousy, aggressivity, and greed. He doesn't emphasise this unduly, he doesn't do it like Ian Kennedy, and he doesn't pretend it isn't part of the scene. It is the sensibility of a novelist in the service of a sort of science, not the raging of a beautiful soul against the sins of the others.

Local practise, central rhetoric.

The issue that continues to get lost in all this public protection and regulation type talk is the real local problem of the difficulty that people get into when they try to work together. What can be done when someone disagrees strongly with the way their practitioner is operating, or if they think they have been harmed by it in some way? On a comment to a previous blog Paola has talked of the change in relation between her and her son when he began working with a music therapist. The music therapist is registered with the HPC so Paola took her complaint there. Judging from her comments she found the process very unsatisfactory, and instead of reducing her disquiet it has given her more to complain about. From her point of view the HPC is protecting the practitioner against her right to complain.

Jonathan Coe is the chief executive of Witness, a charity set up to help people give voice to their complaints against practitioners. He is on the PLG for C&P at the HPC. At the last meeting (Jan 09) he said that the evidence base was clear that there is harm done by practitioners in the field of counselling and psychotherapy and that something must be done about it. He was particularly concerned to know how to stop someone practising after it had been decided they should be struck off the register. But what, Jonathan, what shall be done? I can see  no good reason to believe that the HPC will make things any better, with it's huge computerised list of names, its random spot checks on Continuing  Professional Development, and the centralised policing of educational standards across the hundreds and hundreds of colleges up and down the country. I can see plenty of reason to believe that it will make things worse.

When it comes down to it, the problem is  how to create conditions for safe practise, for informed and thoughtful practitioners and publics, and for safe and productive forums of debate and disputation. 

At the recent Rally of Impossible Professions, in London (September 2008) a university counsellor gave a little example in the morning of the way that safe spaces were being eroded by the encroaching audit culture. Where once there was a group of practitioners who created a space in which it was possible to discuss the issues and deal with the anxiety arising from some of the work, now the manager closes down difficult topics and imposes brute control.

In an afternoon session at the Rally, Mark Neocleous outlined  the steady rise in the discourse of security and shows how, paradoxically, it creates the conditions conducive to hostility. The repetition of empty phrases like 'we must protect the public', or 'regulation is the only way', or '5% of practitioners are a danger to society' contribute to a rising unease because there is no way to understand what they mean.

It is this that is the crux of the problem. The PLG at the HPC are happy to keep repeating the phrase 'we must protect the public', but are less interested to hear that they are perpetrating a problem that is producing a very real danger for a much bigger public by obliterating the conditions for safe practise and genuine enquiry.  The HPC is part of a very large and long process of centralisation in this country that is steadily tearing knowledge away from practise. Michael Power's ongoing work into the rise of the audit culture leaves the reader in little doubt as to the way that this is happening. Read the beginning of the argument  here and follow it up in his other books, they are very well written, cogently argued, and give an unbiased account of the nitty gritty  way that these things are happening. And they are happening here in the UK.

Centralisation

On this morning's Today programme a piece of news announced that Government Minister's were interested by Denmark's Social Workers' approach to looking after children. Government Ministers, mind.

Five years ago I was at a conference in Birmingham at which a few hundred people (medics, managers, policy makers) were discussing European Health Management issues. I think it may have been a man from Denmark who said with emphasis (that seemed to stun even him) that the British System was so very much more centralised than in all the rest of Europe.

Twenty five years ago, as a freshly minted business studies graduate, I was engaged on a project on the question of Centralisation at British Telecom. This was in the year of its privatisation. It was the first of the nationalised industries to come onto this new scene, and was Mrs Thatcher's innovative entry into creative accounting. At that time the rhetoric was all about decentralisation as the most effective business strategy, and it was used very much as a rationale for flogging the national asset and for dismantling the organisation. Everything was put into question as 'centralisation' was linked to the 'old ways of doing things' (and thus put into the moral bad box) and decentralisation was linked with the cut and thrust of commerce (hence morally good).

I am not interested here in the rights and wrongs of nationalisation and privatisation, but I am (and was) very interested that a centralist decision was being rolled out under the rhetoric of decentralisation and that there was a twist in the idea that seemed impossible to resist. A few years later I fetched up at Thames Water to do an ethnographic study of computer systems design. Here I was amazed to discover that privatisation was in preparation under the signifier centralisation! Thames Water, in virtue of the nature of its business, was very much tied to the ground. It's operations (water works, sewage treatment works) were very much linked to particular localities and had a strong association with people and their bodies. In spite of the obvious reasons for this, 'decentralisation' soon became associated with nationalisation, and hence part of the moral bad ground, and Centralisation became the name of the new strategy, associated with all that was good.

This new strategy at Thames Water was brought in at huge expense from Anderson Consulting. This was one of the Big Five consultancies who enjoyed great success around the world, and who employed the elite of the graduate crop each year. This organisation now goes under the name of Accenture - the name change came shortly after the Enron debacle, I'm sure you will recall. The bulk of the work that I witnessed at Thames Water was to do with the creation of a call centre in Swindon (one of the first of this new idea) which was to be supported by the creation of an immense set of computerised information systems. A significant, yet implicit, part of this new ideology was the belief that it was better to remove knowledge from local human beings, and place it in machines.

I think it would be easy to read this as an attempt to lay blame and seek retribution. I'm sure I am susceptible to that, at least as much as anyone else. But actually I think that this is precisely the problem. It is only just dawning on me, after all these years of study, analysis and consideration, that we as a country (at least) are well on the way to Popper's Nightmare in so far as a certain process of centralisation has been steadily ongoing in so many different areas of our life for at least 25 years - and is accompanied by the rise of a rather ridiculous morality .

The creation of the HPC is very much part of this process, and even with the best will in the world and the greatest minds in the Kingdom, it would be difficult for anyone to overcome the pressure that has been building up over decades which aims to produce intelligent centralised systems based on a pernicious idea, and at the expense of decentralised, real, local, loyal (at least they used to be) human subjects.

Small wonder it is Government Minister's who are so interested in Denmark's Social Workers, or that this counts at mainstream morning national news.

Snow

The last time there was snow like this was 1991. A huge cloud of snow on its way to Moscow dumped itself prematurely on south east England. I remember it well. The roof to our block of flats was removed in readiness for a new set of slates. Perfect timing. But more memorable was the fact that I was off to Moscow for the 33rd Annual Conference for the Young Historians and Philosophers of Science. Much excitement as everyone was saying it was colder in London than in Moscow. I had been offered the chance to go to this conference by Steve Woolgar, who was then the head of a research centre at Brunel University that hosted a number of projects looking at innovation, culture, and technology. I was engaged on an ethnographic study of computer systems designers at in a water company just before privatisation. It was this research that formed the basis of the paper I was to give to the young historians and philosophers in Moscow.

I count myself very lucky to have had the chance to go. There was one MacDonalds in the main square, a single bright blob of colour in a grey landscape with a huge long queue snaking out the door and down the road. Queues were not unusual, of course, and not particular to MacDonalds, they were a part of city life. Other bits of life were also open to me. I was given a room in an appartment of a lovely young woman and her husband for the duration of my stay. Their fridge and cupboards were stocked to the gills with merchandise of one form or another. Their phone rang almost constantly when we were at home, and this was the mechanism that triggered the exchange of money and goods for this family and their friends.

I also remember my amazement when standing at a bus stop with Natasha waiting to get home. We were there for just a few minutes when a car pulled up and we jumped inside. She explained that this was normal - she didn't know the driver, but in return for taciturn grunts she handed him a few coins when we got out. It was not a pleasant social experience, but it was extremely helpful on a cold winter's night.

I had intended to go to the HPC today to observe the Education and Training Committee Panel meeting, but apparently all the buses in London have been suspended, and I'm certainly not chancing my bike. Can you imagine our society developing a private taxi service along the lines that sprung up in Moscow? I wonder what we would do should it ever become necessary to innovate.

Little Dorrit - nobody's fault, everyone's in it

The recent serialisation of Dicken's Little Dorrit was remarkably well timed on the question of unexpected wealth followed by unexpected crash. In an earlier film version of the book, however, the subtitle is added to remind us of the subtle point that Dickens was making throughout the story: Nobody's Fault. This refrain runs through each of the intricate threads of the book and is especially interesting in relation to Arthur Clennam recently returned from 20 years in China. He imagined that his family must be responsible for Mr Dorrit's extended stay in the Marshalsea debtors' prison, and tried to assuage what he felt sure was his guilt in this other family's story, and in doing so unwittingly set up the conditions in which a greater tragedy was to play out.

In the meantime, Mr Merdle, man of the age, was held captive in his position of money maker. Few wanted the trouble of working out how to make their own money increase in value, rather they clamoured to press their cash into his bank in the irrational belief that Merdle could make it increase in value.

A third theme includes the Circumlocution Office where legal documentation and process are entirely submerged in arcane process and bureaucratic nightmare coupled with men who, robbed of any access to worthwhile work of their own, barely rise above the pettiness of obstruction and snobbery.

In the telling of the tale Dickens draws out the characters, and allows this to be the motor of the story. The overall 'fault' is the accumulation of faults of the players.

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

PLG: structure of the register - the call for ideas

The call for ideas - what is it? Part of the process of HPC-ification is to convene a Professional Liaison Group, who will discuss the issues and come up with a proposal. However, in order to avoid accusations of partisanship, there is a big effort to show how open to other ideas they are. The Call for Ideas is one way of presenting the image of openness. Another way is to hold the meeting in public. A third way is to hold a Stakeholders meeting to feed back to a wider group and even to take more comments (scheduled for March in Manchester). It reminds me of 'iteration' carried out by information system designers that I studied in the early 90s. High level policy makers made the decision to centralise knowledge and computerise processes, and engaged Anderson Consulting to help them to do it. A set of people called systems designers went out to discover how the work was being done, came back to the office to encode it into programmes, then sent the change management guys out to take the flak and find out what kinds of problems would need to be overcome when rolling out the new system.

Calling for ideas is a wonderful way of discovering the opposition. It is also a wonderful way of saying that you've consulted widely and listened carefully. But it is not a good way to conduct research, to make an analysis of the situation, and to think through unintended consequences.

The government has already decided that psychotherapists and counsellors constitute a threat to the public, but has not troubled to say how. It has already announced that they shall come under the regulation of the hpc. The government has also stipulated the structure and nature of the hpc in so far as it is able. It is a top down political decision that is enmeshed in a process of law. It is not an enquiry in the scientific spirit of enlightenment - it has no real interest in discovering how best to set things up so that the practice, the patient, the punter, the practitioner are operating in the best of conditions.

Right at the beginning of the meeting the Strathclyde Professor asked the sensible question: what is our role, what are we trying to do? The chair responded: to look at the arguments, to debate, to think, to say what we believe for reasons of public protection, to sketch things out, not hard and fast, but to give three main proposals for the structure. The HPC panel member representing physiotherapists added: it is not necessary to come up with a definitive decision, and the chair reiterated, 'yes, keep it vague, come up with a sketch'. Another HPC panel member, this one a lay member, added 'we aim to favour a model, but we know that it may change'. In the first meeting of the group it had been made plain that the role of the PLG was to recommend something to the HPC council who would propose it to the DH who have a team of writers to turn the proposition into law, should the government agree.

PLG: Day 1 structure of the register, protection of title

Wednesday 28 January 2009, Thought for the Day on Radio 4 was with the Right Reverend Tom Butler, Bishop of Southwark. As part of his job he is obliged to take up a seat in the House of Lords. His thought for the day was provoked by a 'cash for questions' allegation but led him to speak about the mundane details of the tedious work of a Lord: many hours of rather tedious examination of a bill, line by line. This, he went on, is 'the main contribution of the Lords to our democracy, not dramatic speeches to the gallery but meticulous revising of proposed legislation'.

Put this alongside the fact, now more and more openly acknowledged, that since 1997 the government has passed more laws than at any other time ever, and that many of those laws have been in the form of statutory instruments (which limit the possibility of debate severely), and it is perhaps not suprising that some Lords might be trying to regulate their work flow in the time honoured way of invoking an economic sanction.

No, it's not right and the individuals concerned should certainly be put into question. But there is also another way of looking at it, to wonder how the overall scenery could be contributing to a rash of unusual symptoms.

Tom Butler's thought ended with the words 'I see a House with mostly pretty dedicated and impressive characters working long and hard for the common good'. This was almost exactly the way a fellow member of the public gallery described what she saw at the HPC PLG for C&P later in the same day.

The first meeting of this group had been an unpleasant experience to observe. This was not all due to the inconvenient layout of the seats for sure (which had miraculously been rearranged in spite of letters to the contrary the day before). It was mostly about the implicit force with which the machinery was being applied with the result that debate, discussion, dispute were stifled. Today that was not so much the case.

Nevertheless, the thorny issue of centralised power imposing a state of affairs without a rational debate still has a part to play. But this is a part that has to remain concealed in order for the state to save face. And it is in everyone's interest, apparently, to maintain the mask in place.

There is the substance and there is the structure, and somehow the structure has been bent out of shape, which poisons the stuff of the substance. So, both of these things need to be addressed.

The business of the day took its lead from Michael Guthrie's summary of responses to a section of the call for ideas. But here again, it is impossible to go forward without first attending to the detail of the process. It will be the subject of the next blog.

Innocence or objectivity

There is an impossibility at the heart of the hpc. The impossibility is the assumption of innocence and the relation this has to the supposed position of objectivity. It is not a natural impossibility, like death, in the face of which one can labour heroically, but an unnatural impossibility which can render us at best foolish, at worse pernicious.

Ian Kennedy's Reith Lectures, delivered in 1980, led to a book which he gave the title: The Unmasking of Medicine (London George Allen & Unwin). In it he mounts a polemic against the profession of medicine, accusing medical practitioners of wielding the power over life and death. Kennedy ultimately wanted to know why it should be doctors who have that power, and why it couldn't be 'us' instead. He never elaborated what he meant be 'us', but Ian Kennedy was at that time an academic lawyer - a lecturer at the LSE. It never occurred to him that the profession of medicine ipso facto forced the practitioner into a position which ultimately must tangle itself up with death. In short, Kennedy's fallacy is that medics are inherently unsuitable to practise medicine, and 'we' would do it better, if only, like Austen's Lady Catherine, we had devoted ourselves to the practice. "If I had ever learnt I should have been a great proficient".

The assumption here, to spell it out, is that people fall into different categories. Them, and us: we are good, they are morally stained. It is the myth of the 'beautiful soul'. For surely, had Ian Kennedy chosen medicine, he would be confronted by the impossibilities of the practise himself.

When the Bristol Royal Infirmary row blew up in the national arena, the controversial labour peer Lord Levy phoned Ian Kennedy to invite him to chair the Inquiry. It is in the report of this inquiry that the explicit recommendations are made that the CHRE (see side panel for link) and the HPC be set up on the general principle that objectivity means knowing nothing about the practise. There is an assumption that objectivity can be achieved by obeying a set of rules, and limiting the subjective elements of life to the point of non-existence. It is a naive idea of objectivity, and open to abuse. It also flies in the face of recommendations by Dame Janet Smith, and written by the Right Hon Patricia Hewitt that the preservation of trust (that we have in people in general, including professionals in the medical field) has to be the starting point - that rules should not be written on the evidence of exceptions.

The recommendations of Kennedy's inquiry were taken up in the Health Professions Order 2001, and gave the basis upon which to create the CRHP (which now goes under the name CHRE) and the HPC. The HPO2001 was passed into law through Privy Council, thus making it one of very many pieces of legislation brought into existence without the usual full debate in the houses of parliament.

Laws, even well made laws, have to have careful attention when applying them in practice. And for this a whole other profession has grown up through the custom and practice of centuries: law. There is a common theme: how is the written rule brought to life in particular situations and applied to the life of a real human being. There are examples of bad application of law, with tragic consequences. There are examples of heroic bravery, sometimes also ending in tragedy. There is the letter of the law, and the spirit of the law. But the fact remains that some things, even tho written in books, still have to be carefully interpreted and weighed against the reality of the situation. Following the rules is not an adequate defense. No matter which way you look at it someone has to step in and bear the burden of reality. The rest of us can endeavour to create a society that won't scape-goat them, much less build an edifice upon that scape-goating, if hindsight gives a better solution.

We are back in the province of religion.

Conscientious Objection

Please bear in mind that these notes are written without recourse to a tape recorder and seated in place from which not everyone is visible. This was a particularly turbulent part of the meeting with some comments delivered in arch, barbed manner provoking several members to say 'we should not ridicule these people'. They are not strictly verbatim and the list is incomplete.

There was a part of the meeting today that focussed on Conscientious Objection, or Principled Non Compliance, p 37 of circulated document prepared by Michael Guthrie, Head of Policy and Standards.

The Strathclyde Prof asked HPC Head of Policy and Standards if the PNC suggestion was a practical option in his opinion. Guthrie replied that he could not foresee the government being able to accommodate it. [he spoke v quietly and quickly but this was the gist]

One lay member from the HPC said she had looked carefully at the arguments and chose one to dispute with here. The argument that the practise is entered into by consenting adults could not be supported because, as with dentists or estate agents, great harm could be done. She said 'it flies against the move'.

The HPC member representing Occ Therapy said You can't have your cake and eat it (you can't be on a register to be unregistered).

The User representative said 'What is the purpose of regulation - without statutory regulation people who are known to be harmful will continue to practise. People need to be prevented from practising. Either its the regulator or the law - and you can't have one law for one person and another for another.

Skills for Health quipped: they could always be taken [struck] off the non-register
another voice added "or sent off to Vermont"

The User representative continued: The evidence base [unsubstantiated] is clear that there is harm, the best outcome of these processes is that the vast majority will continue to practise in the way they've done before. Good practitioners will already be doing this. We have to come back again, and again, and again, to Public Protection. We are in the New World now, professional led self regulation is dead. The Health and Social Care Bill last year saw to that. There must now be equal numbers of lay people to professionals in the [regulation of the profession]

SfH said: Totally agree, these people constitute a harm. We must take a very firm view. Compared to other professions Psychotherapy is definitely harmful, potentially, 5% of practitioners cause harm [unsubstantiated]. The public is ill served by ineffective treatments with adverse effects. We hope it [the practise] will become more evidence based, with a little bit more notice of what is known, a general improvement in client care can happen. ...

BABCP said: We must not mock or ridicule these people, but the public needs protecting. The professionals need protection too. I think it [HPC] is a good move for the profession.

BPC: said We are the victim of our own rhetoric. Public Protection - we are part of the public too. We need protection, the clinical community needs protecting. Care providers are vulnerable. The public is at risk from us, but we are vulnerable to them.

HPC Physiotherapist said. Other aspirant groups have had this problem

The Chair: we have all been lobbied, the letter is philosophical. But they point to the confusion of State and Statutory Regulation, the question of totalitarianism. I've lived [or known someone who has lived] in [eastern bloc] for many years, I know what totalitarianism is, this is not that. It might look like it from the outside, but it doesn't feel like it inside the HPC. Also they talk of the medical model ...

CPCAB said The Petition had 1600 names at the beginning of the week, many of those are names of people I know and respect. I am not willingly a part of this but when I saw it couldn't be stopped I decided I had to join in to try to influence it.

HPC speaker said Public Protection also protects the registrant, it helps credibility, they have nothing to do but pay their fee, and gain status and credibility.

HPC Lay member said: HPC upholds public confidence in the profession, its a matter of pride to have been recognised by the HPC - its an external validation.

Amidst all this the COSCA member said: we might consider that there could be a number of registers springing up alongside the HPC one.

The chair suggested a ten minute break, and this discussion spilled into the adjacent room for coffee. On return they talked about the title Psychological Therapist. Then it was over as the HPC Lay member said 'if we think its right we'll do it, and ignore what goes on elsewhere.'

Being dragged willingly: experience of regulation by the state

During today's meeting of the PLG for C&P one of the group said that she had not wanted to be part of this process, but could see it was happening anyway and thought it was better to join in and to try to influence it, rather than be dragged unwillingly along.

Another member said there was no argument to avoid this process: times had changed, 'that' was history, 'this' is now, it is time for something new. This is new. That's all.

The HPC line is to reduce things to a shorthand: Professionals on the HPC register are safe, it is the others who are not. Then someone will say that professionals were a danger to the public before, and are only being brought under control by the introduction of lay people into their dominion. There is a lot to say here, a lot. But not much is being said in today's climate. There is a caste iron supposition that professionals are dangerous to society, and that lay people on boards and panels are the antidote to that. The force of this argument is quite frightening - it is used as a full stop to any further discussion. It has become a kind of magic bullet. This is the point on which I am focussed. How to uncover the process and mechanism that produces this kind of non-sensical thought. There is no magic bullet. I am more interested in the question: what needs to be done to allow ideas to be discussed and tested so that people can better understand the risks they are asking themselves or other people to take as a consequence.

The difficulty we are now faced with is how to minimise the damage that this twisted logic will cause. Only if we engage in thinking - and think not constrained by fear, nor compelled by brute force - can we hope to get out of this mess.

Names and naming

The PLG for C&P has been thinking about names that describe or label a practise, and I've been wondering about names that designate a person. I have been quite alarmed by the HPC habit of naming people as potentially unfit for practise before their case is heard. In effect this means that someone has their name exposed in some way for more than a year, and this is obviously a harm. I have wondered whether the HPC should apologise when the FTP panel decides there is no case to answer. When writing about these cases I have deliberately not used the registrant's name. The more cases I went to, tho, the more I began to wonder about the anonymity of the other people engaged in the process. To begin with it never occurred to me to include these people's names. But the more I observed, the more I thought about the meaning of a person's name and how that related to the professional nature of their work.

Being a professional, if you take it etymologically, can mean standing by what you say in public. There are other things to say here, but for now this is what I want to think about. The Fitness to Practise hearings are public spectacles. Board meetings are held in public. The PLG is held in public. The Fitness to Practise hearings are written down by a court stenographer who types up the notes and they become a testament to the process. People's names are used in these documents, and the HPC will send them to you if you request them. They are in the public domain. The people are named, and take responsibility for what they say. They are professionals. The lay members are professional in this respect too. Everyone is willing to act in their own name. No-one is 'just following orders'.

The professional liaison group is populated by people who are willing to speak, but some of these are speaking in their own name, others are speaking on behalf of organisations or associations of others. Should they be named in the notes? How should they be named in the notes? How should their contributions be attributed, and what is the responsibility of a blogger in this respect?

Well, I take responsibility for what I write, and I remind you that you can comment on it - this is the nature of a blog. You can also email me easily enough, and I can change what is written if necessary. The new technologies that have sprung up over the last few years give us new pause for thought. Join me in figuring out how to make this work in the spirit of long term public good. You are welcome.