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British Psychoanalytic Council:
A position statement on statutory regulation and related issues
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A position statement on:
• statutory regulation and the Health Professions Council
• Skills for Health’s National Occupational Standards
• evidence-based treatment and NICE guidelines
• Improving Access to Psychological Therapies (IAPT)
• New Ways of Working for Psychological Therapists
• the nations and regions
The British Psychoanalytic Council (BPC) is issuing this position statement on a number of important issues that all broadly have in common our relationship with Government and its various agencies.
It has been occasioned, in part, by recent media coverage of the views of a number of psychotherapists, including some psychoanalytic psychotherapists. These views seem to share an underlying theme that an active engagement with Government and its agencies is somehow incompatible with the psychotherapeutic endeavour.
By contrast, the BPC is actively and constructively engaging with the Department of Health, the NHS and a range of government agencies around a cluster of policies and initiatives, including but not limited to statutory regulation. This statement explains our position on these interventions.
The environment within which psychotherapy is offered to members of the public is changing fast. Many of these shifting contours are linked to wider movements in society, e.g. the ‘consumer revolution’ and changing attitudes to professionals. Within the health sector there is a growing requirement for evidence that treatments are effective, together with an emphasis on patient protection and service user involvement.
A number of specific changes currently underway stem from Government. They are all a function of the increasing recognition within Government and the National Health Service that psychological therapies can play a hugely important role in contemporary mental health provision. In giving that endorsement to psychological therapies, Government and its agencies will inevitably expect that they will adhere to the norms and standards of publicly-funded health treatment.
Many therapists will be anxious about this transition. And there will be some who will not wish to engage with the public sector and prefer instead to work wholly within the framework of private practice. That is, of course, an individual choice. The BPC will continue to be a home for psychotherapists working exclusively within private practice who are committed to working within the BPC’s rigorous fitness to practice standards and, with the introduction of statutory regulation, within the reasonable safeguards of the Health Profession Council.
A number of individual therapists and some organisations – not in the BPC – are actively campaigning against these changes, arguing that they will, in some way, compromise the psychotherapeutic process. Whilst we respect the views of such individuals, we believe that this argument has little to offer to the ambition of providing the very best quality of treatment and care to those suffering from mental distress. The BPC continues to believe that psychoanalytic psychotherapy and its applications have an important and continuing contribution to make to the NHS in general and to psychological therapies in particular.
Freud issued a now famous call in 1918 for mental health provision to be put on a par with physical medicine [1]. He claimed that this would only be possible through the intervention of the state, and foresaw that psychoanalytic psychotherapists would be on the front line of this service. As a result many psychoanalysts went on to form free clinics in the 1920s throughout Europe and the psychoanalytic community has ever since made a monumental contribution to public mental health. The BPC is committed to honouring and continuing that innovative and progressive tradition of engagement with the public sector.
Statutory regulation and the Health Professions Council
The British Psychoanalytic Council (BPC) actively supports the statutory regulation of psychotherapists and counsellors as being in the interests of public protection. The BPC exists to maintain and promote the highest possible standards and quality of care for the practice of psychoanalytic psychotherapy, and welcomes statutory regulation as an underpinning to those standards.
The BPC accepts that the Health Professions Council (HPC) will be the regulator for our profession, and has done so since the publication of the Foster review in June 2006. We are actively working with the HPC to ensure we achieve the best possible standards of proficiency and standards of education and training for the profession. To this end, we have formed a working partnership with the other relevant professional bodies as the Psychological Professions’ Alliance Group (PPAG) [2]. We look forward to presenting our views to the HPC’s Professional Liaison Group who will be making decisions on a range of issues central to the regulation of our profession over the coming months.
Skills for Health’s National Occupational Standards
The BPC welcomes the work that Skills for Health (SfH) are undertaking in drawing up National Occupational Standards for psychotherapy. The setting out in an explicit and systematic way the sorts of skills and knowledge that are used by psychotherapists will carry significant benefits for our profession. We welcome the fact that SfH has taken a modality-based approach to this exercise that recognises the specific and distinct approaches of different types of psychotherapeutic approach. We consider that the approach taken to the modality of psychodynamic psychotherapy has been rigorous and sensitive to the fine grain of the psychoanalytic/dynamic modality.
The National Occupational Standards, when completed, will be of enormous value to training providers in the future as they think about curriculum development. They will also provide a basis for more informed commissioning. The BPC is currently working with all its member institutions, addressing the sorts of changes that will need to be made to the structure and content of our clinical training programmes to be fit for purpose in the next few decades.
Evidence-based treatment and NICE guidelines
The BPC wholly supports the idea of evidence-based treatment, and considers that all publicly funded psychological therapies should be evidence-based. One of the classic statements of this principle is from the American Institute of Medicine (2001):
‘Evidence-based practice is the integration of best research evidence with clinical expertise and patient values’ .
We consider that the establishment of the National Institute of Clinical and Health Excellence (NICE) that carefully weighs the evidence for the effectiveness (and cost effectiveness) of treatments in the UK is an immense social gain.
However, we have deep concerns, shared by many in the research community, that the approach taken to the hierarchy of evidence within the more complex area of psychosocial interventions is not the most appropriate. Specifically, there is an issue around whether an overwhelming and over-simplistic primacy has been given to randomised controlled trials (RCTs) at the expense of other forms of evidence, e.g. qualitative research, systematic case studies, single case designs, public health and ethnographic studies, and process-outcome research. Others have raised the question about whether the huge amount of data contained in what has been called ‘practice-based evidence’ has been sufficiently taken into account.
This approach has resulted in what many consider to be a significant over promotion of cognitive behaviour therapy (CBT) as opposed to other forms of therapy within NICE guidelines, which the cumulative weight of broad-based evidence does not support.
Psychoanalytic psychotherapy is cited as a treatment option within certain NICE guidelines, e.g. the guidelines for depression state that ‘psychodynamic psychotherapy may be considered for the treatment of the complex comorbidities that may be present along with depression’.
The BPC supports the growth of further development and evaluation of psychological therapies to make the UK a world leader in this field. We will play our part in supporting and encouraging outcome research across a range of methodologies on the efficacy of psychodynamic psychotherapies.
Improving Access to Psychological Therapies (IAPT)
The BPC supports the objectives of the Improving Access to Psychological Therapies (IAPT) programme and we are playing an active part in the work to make it a success. We welcome the Government’s support for the programme represented by the new funding announced in early 2008 that will build up to a total of £173 million per year in 2010/11 – roughly a doubling of resources for talking therapies.
We have played a central part in the bringing together of the New Savoy Declaration and Partnership which now has some twenty five signatories from across the professional bodies and mental health charities in support of the programme.
As active partners in the programme, we have been clear about a number of issues in the programme’s implementation that we consider are serious risk factors to its overall success. The first is that the new funding, whilst welcome as genuinely additional to existing funding, may not be sufficient to adequately resource the new expansion of services that are envisaged. There is a danger that strategic health authorities and primary care trusts may be encouraged to disinvest in existing services to fund this expansion. There is emerging anecdotal evidence that underlines this concern with the result that many of the most complex cases may find it increasingly difficult to access a service suitable for their complex and long term needs.
Secondly, the whole emphasis of this first phase of implementation is on the provision of cognitive behaviour therapy (CBT), both in terms of training and service provision. There is certainly a genuine concern that CBT is under provided currently, and we can accept the need to make up that deficiency within the service. However, it is essential that IAPT does not become by default a single-modality service. This would risk not only losing the support of the professions but ultimately would impact adversely on the quality of care. The imperatives of quality, diversity and patient choice can only be met through the provision of a range of evidence-based therapies.
New Ways of Working for Psychological Therapists
The New Ways of Working (NWW) project for psychological therapists is now underway. NWW is a part of the National Institute for Mental Health in England (NIHME)’s National Workforce programme and has a close relationship to the IAPT programme, especially around work force issues.
NWW have produced reports on both psychiatry and applied psychology, and is now beginning to look at psychological therapy. This will be looking at a number of areas:
• a career framework, based on an integrated national competency, job responsibility and pay framework, across all professional groups
• how a broad range of evidence based interventions and their underpinning competences can be addressed through the skill mix of psychological therapy services
• how psychological therapists can work collaboratively in multidisciplinary teams
• describe the size and nature of the Psychological Therapy workforce market and associated trainings, public and private, and put in place mechanisms for ongoing provision of accurate workforce data to inform policy development and commissioning.
The BPC is actively supporting this initiative and is playing a key role in the programme of work over the next year.
The nations and regions
The BPC is aware that a number of initiatives referred to above do not extend across the whole of the UK in the same way. The devolved governments of Scotland, Wales and Northern Ireland each have their own arrangements in terms of mental health provision. We are not, as yet, engaged as fully as we would wish to be with the relevant policy developments in these three countries. Whilst we have active member institutions based in Scotland and Northern Ireland, their membership is relatively small.
Equally, as an organisation we are not engaged in the various initiatives as effectively as we would wish to be across the nine English regions. We do have a number of member institutions based in the regions, and these play a central role in key centres, especially in the North East and South West regions.
We are currently working on active strategies for the development of psychoanalytic psychotherapy across the whole of the UK.
Endnotes
1. Freud’s address to the 5th International Psycho-Analytical Congress at Budapest, September 1918, Lines of Advance In Psycho-Analytic Therapy, Standard Edition, 17, 159.
2. Comprising British Psychological Society, British Association of Counselling and Psychotherapy, British Psychoanalytic Council, United Kingdom Council for Psychotherapy, British Association for Behavioural and Cognitive Psychotherapies