Information, news and debate about psychoanalytic and psychodynamic psychotherapies
1. Do you agree that the Register should be structured to differentiate between psychotherapists and counsellors? If not, why not?
Yes.
There seems to be little question that these two professions have a separate provenance, development, training base and positioning as perceived by the professions themselves, the wider health and social care sector (e.g., within Agenda for Change) and the public. We accept that this distinction is not absolute and there is considerable cross-over. Nevertheless, most counsellors seem to have a meaningful self-identity as counsellors, and similarly with psychotherapists. This is illustrated by the fact that the counselling community has been debating the appropriate threshold entry level for training within the range of NQF Level 4 – 6. By contrast, there is a clear consensus amongst all the main bodies historically representing psychotherapy (BPC, UKCP, BABCP) that the entry level for psychotherapy should be NQF Level 7 / FHEQ M Level. Our perception is that an attempt to artificially conflate these two traditions would not only damage the professions involved but would significantly diminish professional buy-in.
In broad terms, psychotherapists engage more actively and deliberately with the psychological processes that go awry in psychological disorders. For this reason their training includes a more thorough study of these mechanisms regardless of orientation. Their interventions are focused on the processes identified by particular models as central to the disturbance. This would include, for example, the specific nature of the dysfunctions of cognitive processes in CBT interventions or the exploration of unconscious determinants of the interpersonal relationship with the therapist in psychodynamic psychotherapy.
By contrast, counselling prototypically seeks to identify problematic issues of concern to an individual and their social context and aims to maximize psychological and social adaptation. It is less focused on psychological processes that function pathologically and more on optimizing normal processes of adaptation. It may indeed use, for example, CBT or psychodynamic techniques in interventions but these are not normally formulated in terms of addressing specific malfunctioning psychological processes.
2. Do you agree that the Register should not differentiate between different modalities? If not, why not?
In our submission to the Call for Ideas the BPC argued the case for considering a small number of modality-specific titles as being in the interests of public protection. However, we were aware of some of the difficulties associated with this proposal (especially, the large number of different schools of psychotherapy and counselling). We accept therefore that the task of defining and promoting standards for specific modalities is more appropriately left to the relevant professional bodies.
However, we continue to contend that giving members of the public greater information enhances patient protection. One possible approach would be to encourage registrants to use an adjectival title and, at the same time, give very strong guidance on the conditions under which such adjectival titles could be justified. Thus, for example, if someone wishes to use the title ‘cognitive behavioural therapist’, the guidance might stipulate that unless the person had completed an approved course in CBT or an equivalent training then they would be guilty of misleading the public, and thus contravening sections 6 and 14 of the Standards of conduct, performance and ethics. Approval in this context could mean both accreditation by HPC as a psychotherapy training course and accreditation by an appropriate professional body as a modality-specific training (e.g., BABCP).
3. Do you think that the Register should differentiate between practitioners qualified to work with children and young people and those qualified to work with adults? If yes, why? If not, why not?
Yes.
The BPC supports the development of a separate title of Child Psychotherapist with distinct standards of proficiency. Almost all psychotherapy trainings are specific to either adult or child clients and we believe that there are distinct competencies that are required for safe and effective practice with children.
We consider that the safeguarding of children is best achieved by ensuring that the system of dedicated training programmes for child psychotherapy is upheld.
4. Do you agree that ‘psychotherapist’ should become a protected title? If not, why not?
Yes.
5. Do you agree that ‘counsellor’ should become a protected title? If not, why not?
Yes.
6. Do you agree with the approach to dual registration outlined in the report? If not, why not?
Yes.
7. How appropriate are the draft criteria for voluntary register transfers?
We remain extremely concerned generally at the looseness of the proposed criteria and specifically at the absence of any linkage of these draft criteria to the draft standards of proficiency and HPC’s own standards of educations and training.
We understand that there are legal reasons, in particular legislation around human rights and restriction of trade that may militate against overly exacting criteria in this area. However, we are concerned that these criteria may set the bar so low as to provide recognition and effectively endorsement to many thousands of practitioners whose competency to practice may be very questionable. We consider that there is a serious risk of this diminishing rather than strengthening patient protection.
It would be helpful to understand more precisely the legal constraints that operate in this area.
8. Do you have any comments on the outline process for identifying which transfers should transfer?
No, apart from the points made under Q7.
9. What evidence might an organisation holding a voluntary register provide in order to support their submission?
• Register – including a statement of what fitness to practice standards are implied for those registered
• Documents which articulate:
o Accreditation of training programme standards
o Accreditation of training programme procedures
o Examples of records of specific accreditation decisions
o Codes of professional conduct and ethics
o Complaints procedures
o Examples of specific findings under a complaints procedure, including records of determinations, reasons, sanctions
o Policies on Continuing Professional Development (CPD)
o Procedures for monitoring CPD compliance, including sample audits.
10. Do you agree that the grand-parenting period for psychotherapists and counsellors should be set at two years in length?
Yes.
11. Do you think that the standards support the recommendation to
differentiate between psychotherapists and counsellors?
The only SoP in the Draft that support the distinction currently are in section 3a.1. The differentiation could and should probably be reflected in other sections of the standards. We do not have specific proposals for these at this stage (apart from those mentioned for 2b.2 in Q14), but would welcome the opportunity of making a further submission in this respect before the next meeting of the PLG.
12. Do you think the standards are set at the threshold level for safe effective practice? If not, why not?
Yes, subject to the various qualifications and proposals made throughout the replies.
Also, the standards will invariably be tested in practice over the coming months and years. We assume that there will be an opportunity to review and evaluate them after a period of time, and would propose that some sort of evaluative framework is put in place as soon after registration as possible to ensure that there is appropriate data to form the basis of an evaluation.
13. Are the draft standards applicable across modalities and applicable to work with different client groups?
The standards appear to be generally applicable across modalities (though see response to Q11), though additional standards are required in relation to work with children – see response to Q3.
14. Do you think there are any standards which should be added, amended or removed?
1b1
Psychotherapists & Counsellors
- understand the limits of the therapist’s own knowledge and expertise in relation to mental and physical disorders and to know when it is necessary or appropriate to refer to another specialist professional
2a and 2b
There is a general problem for psychotherapy practice in respect of the overarching structure and descriptions used in sections 2a and 2b, as well as in the specific competencies proposed.
The model used entails an overly rigid sequence:
• Assessment/diagnosis of problem
• Formulation of treatment plan
• Delivery of treatment plan.
The reality is that few psychological (or, arguably, medical) problems lend themselves to such a neat schema. Particularly in the course of long term treatments, we commonly find that clients may present themselves with a set of ‘symptoms’ but this is often the starting point for a process which gradually uncovers what may be a complex, multi-faceted set of psychological difficulties. Some of these may be captured, to some extent, by the nosological categories of DSM-IV or ICD-10, but many are likely to be multifactorial, entailing idiosyncratic social, relational and personal aspects not readily categorized within nomothetic systems. The current tone of the narrative does not pay sufficient attention to this aspect of the work of psychotherapists. In any case, the process of diagnosis, assessment and formulation is likely to be an iterative, open-ended and provisional process that extends throughout the period of the treatment.
To address this properly may mean looking at the structure and generic descriptions of these sections, which we realize is not within the remit of the PLG. However, given that the psychological professions will soon represent a very significant proportion of the professions which the HPC will regulate, it will be critically important to ensure that the structure and language of the generic competencies is more compatible with psychological realities and processes than is currently the case in a generic template based on physical illness.
There may be specific profession-specific competencies that could capture this dimension, but they would fit awkwardly with the overall logic of these sections. Unless this issue is adequately addressed and the roots of HPC regulations in physical healthcare are sufficiently adjusted, the call for a regulatory body with a specific focus on psychological therapies will inevitably grow louder.
There are some extra specific competencies we would wish to propose at this stage.
2b.2
Psychotherapists only
- be able to assess the impact of intensity/frequency of treatment and make a judgment about the appropriateness of time-limited or open-ended work
- to provide an appropriate psychotherapeutic setting for a client enabling them to feel safe enough to explore disturbing thoughts and feelings as they emerge during the therapeutic process
- to be able to bear their own experience of disturbance when exploring troubling areas with the client and to be able to use this experience of disturbance to help a client address their difficulties
3a.1
Perhaps the assumption that psychotherapists will be working with severe mental illness may be overly prescriptive (a point that BPS makes). For example, IAPT’s high-level therapists, who have a good standard of training, work with people with mild to moderate anxiety disorders or depression.
We propose therefore:
• To delete the last two (blue) proposed standards for Psychotherapists and Counsellors
• To revise the red standards as follows:
Psychotherapists only:
- understand how mental disorders of varying degrees of severity typically present
- understand and be able to conduct methods of diagnosis of mental health problems appropriate to the psychotherapist’s theoretical approach
- understand and be able to apply in psychotherapy psychological models of mental disturbance appropriate to the diagnosis arrived at above
- understand and be able to implement methods of psychotherapy based on the psychotherapist’s theoretical approach, their understanding of the underlying psychological causes of the disorder and typical barriers to implementing effective treatment
Counsellors only:
- understand theories and research on well-being and obstacles to well-being and be able to use these to facilitate client development
- understand theory and research concerning normal development and factors entailed in determining individual reactions to specific life problems, issues and life transitions which often lead individuals to seek counselling and be able to use these to inform practice
- understand and be able to work with common, mild mental health problems
In addition, we would broadly support the additional competencies proposed for Child Psychotherapists by the Association of Child Psychotherapists.
15. Do you agree that the level of English language proficiency should set at level 7.0 of the International English Language Testing System (IELTS) with no element below 6.5 or equivalent? (Standard 1b.3)
We broadly agree with the position of the British Psychological Society that the level of English language proficiency equivalent to IELTS level 8 with no element below 7.5 is required for safe and effective practice, with the qualification that this applies where someone is practicing in English. If someone is practicing within a different language working with people speaking that language, then this requirement would and should not apply.
In general, the BPC is concerned about the relationship of language ability to questions of accessibility and cultural diversity. We would welcome a profession-wide project to look in depth at these issues.
16. Do you agree that the threshold educational level for entry to the Register for counsellors should be set at level 5 on the National Qualifications Framework? If not, why not?
We are generally persuaded by the arguments that have been made around the desirability of ensuring the broad accessibility of counselling and training in counselling. In these terms, NQF level 5 seems be a sensible threshold standard.
Nevertheless, we are open to the argument that counselling should be a graduate entry profession (NQF Level 6) – though not if this is attached to the argument that the distinct professions of counselling and psychotherapy are the same (as there is a clear consensus within the psychotherapy profession that the entry level for psychotherapy should be at Masters level or equivalent).
17. Do you agree that the threshold educational level for entry to the Register for psychotherapists should be set at level 7 on the National Qualifications Framework? If not, why not?
Yes.
18. Do you have any comments about the potential impact of the PLG’s recommendations and the potential impact of statutory regulation?
The BPC has consistently argued in favour of statutory regulation and believes that overall it will enhance patient protection and the quality of care, as well as bring benefits to the profession.
We understand that there is a vocal section of the professional community that is opposing regulation by the HPC, although we are unclear how widespread support is for this position. However, there is a far larger and more significant group that is not intrinsically opposed either to statutory regulation or even to regulation by the HPC but is uncertain and anxious about the implications of regulation on their practice (see also Q20).
We have found HPC to be an organisation that values a partnership approach with professional bodies and we welcome this. We are certain that HPC will wish to work with all the professional bodies over the coming months to ensure that the benefits of regulation are fully explained to the profession and to do all that we can jointly to allay the fears and uncertainties that many are experiencing.
19. Do you have any comments about the potential implications of this work on the future regulation of other groups delivering psychological therapies?
There is a question about the status of IAPT’s low-intensity workers. We understand there will be a submission from IAPT and look forward to considering their proposals.
20. Do you have any further comment?
We fully appreciate that the remit of the PLG does not extend to examining HPC’s generic Standards of Conduct, Performance and Ethics or the procedures for dealing with complaints. Nevertheless, many of the anxieties and uncertainties that our own registrants are expressing relate to these areas as well as the draft standards of proficiency. We hope that a review of all relevant aspects of HPC’s policies and procedures will be undertaken to ensure the effective regulation of the psychological professions while maintaining its effectiveness in respect of its currently regulated professional groups.
We would recommend the convening of a forum as a matter of urgency for the professions to engage with these questions. This will go some way to secure greater professional support for this process.