Statuatory Registration of Psychotherapists and Counsellors
April 25, 2009 by Vauna Beauvais · Leave a Comment
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The Registration Idea
The Health Professions council (HPC) is opening a register for psychotherapy and counselling, with a view for having it in place by about 2011.
Originally, the UKCP (United Kingdom Council for Psychotherapy) was keen on state registration. They believed that registration would distinguish practitioners with the right training and experience, from anyone who did not have it, and that distinction would help the public to select bonafide psychotherapists and give them reassurance that they were safe with an ethical and professional therapist.
Good idea!
Problems with the preparation of the register
But, in practice, as this program is evolving and various bodies have gotten involved, it seems that not only the UKCP, but also the organisations that train counsellors and psychotherapists, and the individual practitioners themselves, have a sense of disapointment and frustration, in place of the optimisim that was there before in respect of this register.
As is usual for a big project such as this one, huge complexity has to be dealt with. In practice, it has turned from a good idea of making a register of suitable professionals, into something that is defining, not only who is credible, but most importantly, who is effective. It is this last little word that is causing a lot of fuss.
In the process of creating this register, the problems are briefly as follows (and possibly not limited to this list)
- Who should be on the register (depending on what model of therapy you use, which organisations you belong to, and other things)
- What everyone on the register can be called (e.g. which titles count as valid and which do not).
- What can be done about the Health Professions council having a code of practice that are not compatible with the values of a lot of psychotherapists
- What is ‘good’ therapy? It has been decided to be defined by research. However, not all research is being counted as valid, therefore are all therapies being counted as valid therapies?
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Sticking Points
From what I have heard, points 1 and 2 have now just about been resolved, or will be with discussions ongoing. For example, The term’psychotherapy’ is used to cover the full range of psychological interventions. Although there is much more detail of those debates here.
Point 3, it seems to me, has a chance of evolving into an adequate solution, provided that the stakeholders in this project continue to work together throughout the process of regulation, and long after regulation , in order to put forward information to shape the values that will underpin the code of practice criteria.
(The UKCP and a lot of other bodies are doing a lot of work and a lot of talking, and always have done since the idea began).
The big-one
Point 4 is the current hot topic (of contention). The fact that the validity of a therapeutic model, or approach, is defined by the type of research done.
It is the NICE guidelines that are defining acceptable research. OK, after having a quick look at their website, you might think, “whats wrong with that? - It’s got the NHS logo in the top corner”. NICE, however, is an independent organisation and NICE guidance is developed by a number of independent advisory groups made up of health professionals, those working in the NHS, patients, their carers and the public. So, it isn’t the NHS and it isn’t the government.
The research that NICE (currently) says is the only one that can be counted is something called RCT, Randomised Controlled Trails. And the HPC (remember it is the HPC that is making this register) is taking the NICE guidelines about research as the ones to follow. Therefore, in effect, NICE guidelines restricts the validity of research into ‘measures of how and whether therapy works’ to one particular type of research, the RCT’s.
Apparently, there are a couple of things wrong with the idea that Randomised Control Trials can define the efficacy of therapy.
- Therapy is not a branch of medicine - it doesn’t focus exculsively on the relief of symptoms. The goal of therapy is an improvement in the quality of life, in particular areas that the client has presented to the therapist. This is achieved by creating and using the therapeutic relationship (possibly sprinkled with “how-to’s”, sometimes, if appropriate within the context of, and not contra to, the aims of the therapeutic experience).
- In an attempt to find the change-active ingredient of psychotherapy, using the drug trial model for testing is fraught with problems. If you are comparing people who have the benefit of psychotherapy against people who do not, then data is surely subjective and qualitative. Where does one start to gather this data, and how can it be measured accurately?
- The funding for RCTs (or a broader range of research methodologies) has never been in place for the full range of modalities so this is not a level playing field.
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And furthermore…
In addition to the RCT thing, there is another gripe coming from the psychotherapists - the way that the group of people put in charge of creating this register have been selected, and the way that they are doing things to allegedly service their own interests.
The groups are:
These are all projects sponsored by the Department of Health and the complaints are around the ways that these bodies benefit from their interactions, and how transparent all of that is to stakeholders in the registration project.
The UKCP (one of the stakeholders in the project) is concerned that NICE guidelines appear to negate all forms of psychological therapies other than CBT and interpersonal therapy. If you are intereted in this debate you can check out the document here.
My Opinion
I agree with forging ahead to make the register, and I am one of the (probably) very few therapists that is still in favour of regulation.
Having trained as a trainer, a manager and team leader, myself, I am aware of how other individuals have to work within a set of national occupational standards and I don’t see why counselling and therapy should be an exception. Especially if, as I am, we are really concerned with protecting the public (and ultimately the intergrity of our profession and it’s standards).
I do believe that, both the scientific, and the artful nature of the service (counselling / psychotherapy) can be taken in to account when setting measurable standards - although of course this will take a lot of research and processing of data to come to such conclusions.
Things to consider when making an awareness of occupational standards would be at least these three points:
- We therapists do employ a series of actions that we call ‘therapeutic interventions’ and this is done within the context of a relationship (i.e. the relationship is analysed by the therapist, as well as the content and structure of the therapy sessions).
- Each client does present unique issues and demands to the therapist, as indeed does each session.
- The therapeutic field is a complex ecology built up of many different approaches.
And even though these points are in evidence I do still believe that standards can be set.
A helping hand for holding the discussions needed
The UKCP is setting up a new Psychotherapy Council (source: UKCP newsletter, April 2009).
And this will be a deliberative and advisory body to consider the contours/identity of the profession, the profession’s relationship with government, media, and other professions, and other external stakeholders.
Great!
My view is that we, in the UK, do need proper standards of process and outcome for the services of psychotherapy and counselling.
- I believe that therapists may be very skilled and effective with some issues, and some types of clients, but not others.
- Additionally, I believe that some therapists are generally more skilled and effective than some other individual therapists, and I believe that this variation carries across, and includes therapists in all of the wide array of therapuetic models (Some therapists are trained in only one model).
- It is my belief that psychotherapists are responsible in terms of intending to offer an effective service that meets the needs of the individual client presented to them at any one time. However, this is judged by the therapist at that time. There is the added benefit of whether the therapist is being effective with this particular client, by client and supervisor looking at it in clinical supervision (if that therapist decides to present that particular case in supervision, that is).
Are clients really getting the best possible?
The therapuetic results that a prospective individual client might expect is too hit-and-miss, for my liking.
- I do not think that consumers (the clients) of the psychological services (in prvate practice expecially) can possibly make an informed decision about which therapist to choose (i.e. they have no reliable way of measuring depth and quality and effectiveness of service offered, and so cannot make a proper informed choice about investing their money and time).
- I do not think that clients have an adequate way of measuring the effectiveness of their therapy (so that they can choose whether to stay in therapy, or stay with this particular therapist)
You know, in my private practice clients often say that they have selected me as their therapist because I “looked like I had a kind face” or they “liked my photo” or “I sounded like someone they could trust” - or they chose me because of location, or because they liked the website.
All of these reasons are very flattering, and I am delighted to take on these clients, of course, but wouldn’t it be better if I were being selected because these people were able to analayse some data, and after doing so, realised I was a good therapist?
I also have many clients say that they chose me because of my qualifications, or through recomendation of a previous client of mine that they know was helped by me. That’s a start, but its not really good enough for clients, in my opinion. I would like them to be able to make a choice based on standards set that I have obviously met, and then have them tell me that they chose me because of that.
Easier reading on this topic…
If you would like to have a look at a couple of more readable articles on this topic, try this Times Newspaper article, and these guardian letters , and there is also this little piece from a medical news blog
Experimental designs on therapy
February 19, 2009 by Vauna Beauvais · Leave a Comment
The NHS, as we know, are committed to providing health provision free at the point of delivery to all people who need it - but it must also provide a cost-effective health provision.
National Institute for Health and Clinical Excellence
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The National Institute for Health and Clinical Excellence (NICE) is responsible for guiding the NHS and it does this by recommending treatments that are cost effective and those that minimise the burden for the client. The guidelines it produces are based upon the current best evidence available.
Improving access to psychological therapies
The government funds an initiative called IAPT (improving access to psychological therapies). This program is not only about improving access to therapies, but also it is about improving the quality of therapy (as well as ensuring that they meet the NICE guidelines).
The processes for finding evidence that a particular kind of therapy has a high quality is slow as it requires a lot of research over a number of years.
Cognitive Behavioural therapists have always used evidence-based research
Cognitive Behavioural therapists have always used evidence-based research as part of their therapy model, and so there are already many years worth of empirical data to support the effectiveness of CBT (and this is widely promoted by people who use CBT with clients - including me!).
CBT has always been research-based
The therapists that work in other models of therapy (including me, again) now know that they have to provide evidence of effectiveness of their models of therapy, too (otherwise, people can say that CBT is the only therapy that can be evidenced to be effective - and some therapists actually imply that means that the other types of therapy are not effective! Tut, tut, very naughty!)
So, for other models of therapy to be able to prove that they meet the NICE guidelines evidence needs to be provided. And to get the evidence, research has to be done. And research takes a long time.
Further Research
Some of the areas that I would like to see be researched are the presuppositions:
- ‘It is the therapeutic relationship that heals, not the particular model of therapy’
- ‘All therapies have an equal effect’
- ‘Outcomes largely depend on the therapist’
Berne Institute to fund University research on TA
The Berne Institute, in Kegworth at junction 24 of the M1, is a training centre for psychotherapy. They are funding a research study on Transactional Analysis therapy to be carried out in the University of Nottingham.
Professor Patrick Callaghan, is experienced in examining various approaches to psychotherapy and counselling. His research into TA therapy will include questions such as
- What makes TA work?
- With what client groups?
- What systematic evidence is there on which to judge TA’s effectiveness?
Research is now all part of it
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The people who make up the bodies that influence governments and make decisions about public policy believe that empirical data proves that therapies are effective. Hence research now has to become part of the whole system of the therapy model (research, training, practicing, clinical supervision) if a model of psychotherapy is to survive. This is good, though, in terms of clients having confidence that the particular model of therapy is proven to work.
IAPT can have long waiting lists
The IAPT initiative has promted a new wave of thought regarding evidence-based decisions about what is effective. When NHS patients are given the choice they commonly prefer psychological therapy over medication. Due to long NHS waiting lists, many people are not benefiting because they are not getting referred or because they have ‘patched over’ the problem by the time their therapy sessions become available.
Private Practitioners can see clients immediately
A lot of people look for a therapist in private practice, where they can be seen immediately. Sometimes, as a therapist in private practice, I see clients who are on NHS waiting lists, and they tell me that they want therapy or counselling just for while they are waiting to be seen. I am happy to do that, if it is made clear from the start of our time together. Sometimes I see clients who have had their allocated amount of sessions via NHS or IAPT, and that has started them on a journey to a better life, and then they wish to continue, and pay for that themselves. That is very encouraging, and I am happy to see clients in those situations, also.
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