THE EMERGENCE OF ‘STATE-ENDORSED THERAPY’…? a keynote presentation to the Universities Psychotherapy and Counselling Association Conference on 22nd November 2014

 

Over the course of the next 20 minutes or so I want to talk about what is happening within the British Association for Counselling and Psychotherapy. I want to put it to you that what is going there represents a shift towards “state endorsed therapy”.

 

I use the phrase “state endorsed” to draw attention to the fact that these proposals are designed not by government, or by one of its arm’s length agencies, but by one of our own professional associations. I want to make a separation between this and “state approved therapy”, a term that has been applied to the delivery of therapy under the banner of IAPT (Improving Access to Psychological Therapy). There the format and structure are, to all intents and purposes, laid down by the state itself.

 

BACP is in transition –

  • In February 2013 its register of counsellors and psychotherapists was endorsed by the Professional Standards Authority for Health and Social Care.
  • In December 2013 the BACP Board of Governors decided to align its membership structure to the BACP Register. By April 2016 all members will either be registered or en route to becoming so.
  • In April 2014 BACP began a consultation with its members on professional ethics. This consultation will close in just under a week’s time on 28th November and its revised Ethical Framework will come into force in January 2016.

 

Until this summer BACP had not undertaken a thorough review of its ethics since the late 1990s. In April, May and July this year it ran three 2½ hour webinar seminars on Saturday mornings.

To give you an idea of what this involved…  On each of these Saturday mornings there were two half hour presentations by Professor Tim Bond. Emeritus Professor of Professional Ethics (University of Bristol). There were questions from the live audience and there were panel discussions before and after each presentation. The presentations themselves were accompanied by a split screen Powerpoint display so you could read as well as listen to what was going on.

The impetus for changing the Ethical Framework comes from a variety of sources. There have been those developments in theory, in research and in the law that one might expect – and there has also been a quantum leap in computerisation. The most important changes though are connected to the abuse of trust. There have been a whole string of celebrities who have been exposed – Jimmy Savile, Rolf Harris and the rest; there’s been the Winterbourne View care home scandal where residents were physically abused by staff; and there’s the Mid Staffordshire hospitals scandal where perhaps 300 or more people died unnecessarily.

Most importantly there have been the two Francis Reports. One published in 2010 was some 2,000 pages long and dealt with what went wrong in Mid Staffordshire. The other, published in 2013, is half that length and is about how to prevent it happening again.

Robert Francis QC wanted a change of culture in the NHS, but his proposals have been taken up not just by Government but by local authorities, trades unions and professional associations. His Reports are changing the whole landscape of health and social care.

In brief Francis is demanding that, when things go wrong, managers must be much more active in setting about remedying matters. They can no longer receive a complaint, set up an enquiry and then sit back and wait for it to report. The impact of the Francis Reports was most apparent in the second of these webinar seminars which proposed major changes to line management and supervision – and these changes need to be understood in the context of two notions which had been previously floated in the webinar presentations (a) that therapy can be conceptualised as a product and (b) that supervision can be thought of as part of a quality assurance system.

Not surprisingly, I was more than a little taken aback when I heard these comments.

To the specific proposals and their implications –

  1. All clients to be informed by their therapist of the name of their supervisor.
  2. The jobs of both therapist and supervisor to be defined as operating in the “best interests” of the client.
  3. Supervisors to be required to keep records to show that they have acted in this way.
  4. These records to demonstrate that each client of each of supervisee has been spoken about at each supervision session and that the supervisor has, in each case, acted in the client’s best interests.

The focus in this webinar seminar was squarely on the position of those in employment in the health and social care sector. The argument was that, as austerity bites and managers, like everyone else, are expected to do more with less and to new “post Francis” standards, the position of employed supervisors will be in danger of being marginalised unless supervision can be demonstrated to have a direct impact on client outcomes.

But for me, as a self-employed supervisor working from home, the nightmare scenario was that, if my name is given to all my supervisees’ clients, because of the ease with which contact details can be identified via the internet, I will have to be prepared for the possibility of dissatisfied “customers” contacting me at any time of the day or night demanding that I intervene on their behalf to remedy whatever they happen to be concerned about. The pressure to “do something” will be inescapable and I am almost certainly going to get caught up in enacting something that properly belongs within the therapy itself.

But the situation is worse than this. If BACP is to lay down that there is to be a this direct link between supervision and client outcome and I’m required to keep records on all the supervision I do, I need to be mindful that anything I write may be trawled over by a lawyer in order to detect whether a case can be made out that, at some point, I have failed to act in the “best interests” of his or her client.

 

What’s the likely outcome? Three things, I think –

  • In the first place there’s the danger of supervisors slipping into defensive practice
  • Secondly, the knock on consequence is that a surface level understanding of reflective practice will be further entrenched – instead of a reflective attitude lying at the heart of good supervision it becomes a kind of “add on”.
  • Another way of putting this is to say that something will be taken away from the quality of attention I believe a supervisor needs to cultivate, who then acts a role model for each supervisee. Let me give some examples. For Freud the ideal state of mind for a therapist is one in which attention is “evenly hovering” or “evenly suspended”. Drawing on a very different body of theory, Carl Rogers identified six necessary and sufficient conditions for therapeutic change. In both cases there’s a focus that requires full attention – and, if this focus is absent or diluted, something is lost in the quality and depth of the work.

Taken altogether, then, what we have here is an impoverishment of supervision and therefore a constraint on supervisees’ learning about good practice. This is bound to lead, I would argue, to a narrower understanding of what in depth therapy is.

Moreover in these webinar seminars BACP drew explicitly on an understanding of therapy that highlights its role in the alleviation of distress without any acknowledgement that any such understanding needs to be embedded within a contextual understanding concerned with meaning‑making. This is contrary to the research evidence, as Bruce Wampold showed in the meta-analysis he undertook for his book ‘The Great Psychotherapy Debate’, where he carefully examines the results of thousands of outcome studies.

What puzzled me deeply about these proposals for change is that they appeared to run counter to BACP’s traditional stance, which is to position itself as a broad church and so maximise its chances of dominating the field. So, I suppose, it’s not surprising that, when BACP circulated a revised draft early last month it had made changes.

The emphasis on for supervisors keeping records of each supervision session was limited to a general obligation to keep records appropriate to the service being provided.

And the duty to tell each client the name of your supervisor has been dropped completely.

 

But what, you may say, are we to make of all this? Should we be pleased that BACP is responsive to feedback?

Or should we be alarmed at the extent to which, under the rubric of revising its ethics, BACP is apparently willing to accommodate its definition of good practice in counselling and psychotherapy to a shift in government policy?

 

At a BACP meeting I attended in September it was claimed that the original proposals were simply possibilities that were being floated rather than serious options. Shades here of Nigel Farage’s recent backtracking from a firm commitment to privatise the NHS (“We never really meant it anyway” “It was just an idea we were floating”).

But I think what we can say is that, in the course of these webinar seminars, we got some insight into what BACP would be willing to countenance.

 

So what is there in the latest draft of BACP’s Ethical Framework that still gives rise to concern? And to what extent is it still legitimate to be worried about a movement towards “state endorsed therapy”?

I think there is a good deal to be concerned about, but first we need to look more closely at the wider context and the kind of organisation that BACP is in the process of becoming.

 

BACP’s mission includes wanting to be the leading body for counselling and psychotherapy in the UK.

BACP was originally founded in 1977 as an educational charity open to anyone with an interest in counselling. Charitable status confers a patina of respectability and, under English law, all BACP’s activities must be charitable and wholly in the public interest so that any personal benefit accruing to members has to be “incidental”.

Yet at the same time BACP operates a trade association – in other words, it is a group, one of whose primary purposes is to attempt to influence public policy in a direction favourable to its members.

BACP’s membership has expanded rapidly in recent years. When I joined in 1992 it had 6,000 odd members. It now claims it has over 41,000. I think it’s pretty self-evident that people join BACP because they think it is an important step in advancing their careers. Is that, then, an “incidental” benefit? So how can BACP continue to be a charity? I have to hold my hands up here and admit I am completely bemused by what looks to me, a mere cottage industrialist, to be a mismatch between the theory and practice of how charity law works. But what do I know? Eton, after all, remains a charity.

BACP’s Register is endorsed by the Professional Standards Authority for Health and Social Care. By endorsing Registers such as BACP’s the PSA has said it hopes to establish a gold standard for voluntary regulation in the area of health and social care – and thus obviate the need for statutory regulation.

BACP has decided to align its membership structure to the BACP Register. By April 2016 its membership will consist of registered therapists or those on their way to becoming so.

 

This series of steps links membership of BACP back to the state and, I suggest, leaves individual BACP members more anxious than ever that they will need to comply with any requirements laid down by the organisation if their careers are to thrive…

 

One thing I think we can say is that, whereas in the past statements about ethics issued by BACP could be viewed as the distillation of a consensus about good practice that was derived from the field, matters are now more complex.

 

In the October 2014 draft of its Ethical Framework BACP is in some respects more prescriptive. Sometimes the requirement is straightforwardly normative – for instance, formally reviewing knowledge and skills in supervision – but elsewhere standardisation is embedded in the very fabric of the document. The argument seems to be that introducing standardised practices is a good thing because it makes matters more explicit and a greater degree of explicitness is the route to establishing greater trust between therapist and client. This is evident in the overarching structure of the commitment to clients, which frames everything that follows –

“We recognise that our clients must be able to trust their practitioners with their well-being and sensitive personal information. Therefore we have agreed…that we will…”

The detail then follows – for instance in paragraph 26 in the section on ‘Good Practice’ there are the new requirements about written contracts between therapist and client. In this way the building of trust is reduced to a standardised procedure.

The relationship between line managers and clinical supervisors is also specified in terms of procedures that have to be adhered to and reviews that have to be undertaken at least once a year in particular ways – again a standardised procedure. Here are some
examples –

  • Where supervision is taking place alongside line management we will consider how responsibility for the different supervision tasks is distributed and will review how the allocation of these tasks is allocated at least once annually.
  • We will review the application of this Ethical Framework to the services being provided at least once annually.
  • We will clarify who holds specific responsibilities to our clients between the practitioner, supervisor and any line managers and review how well these responsibilities are working in practice. This review will take place in supervision as required and at least once annually.

Members are even required to be activists outside the therapy room –

  • We recommend supervision to anyone providing therapeutically‑based services, regularly giving or receiving emotionally challenging communications or engaging in relationally complex or challenging roles.
  • We will challenge colleagues or others involved in delivering related services whose views appear to be discriminatory…

In other words – it’s not all bad!!

 

Elsewhere in this document BACP is deliberately using vaguer language…

Some of this is both badly phrased and, I want to say, provocative – for example

“we have agreed…that we will demonstrate accountability and candour by being accountable to you for the …effectiveness of services provided”

What on earth does this mean? Statements of this kind could prove a hostage to fortune, for instance when working with people who adopt a wholly passive attitude to therapy and expect their therapist to fix their problems for them without ever themselves really engaging in the therapeutic endeavour. I don’t think it would be hard for such an individual to use this paragraph in order to make a complaint.

BACP has been here before. In the mid 1990s the BBC’s ‘Watchdog’ programme took what was then just the BAC (the British Association for Counselling) to task for not taking effective action against the comedian Bernard Manning who had joined BAC and then fixed a brass plaque to his wall announcing that he was a counsellor. BAC claimed this attack was unfair as they had no power to stop him and make him take it down – all they could do was expel him from membership. After that BAC redoubled its effort to gain statutory powers.

In offering to be accountable in this way is BACP setting things up for another media furore that will allow them to press Government for more powers?

I wonder.

 

But there’s another even more significant matter, which is that BACP has deliberately put at the core of the 2014 Ethical Framework the notion that therapists will work in clients’ “best interests”.

Who defines “best interests” and from whose point of view? This is a notoriously slippery concept in law and here, I would argue, BACP is quite deliberately leaving it to the courts to decide what good practice is, I would say in line with what good practice is in the health and social care sector – after all BACP’s Register is accredited by the Professional Standards Authority for Health and Social Care (as opposed to asserting what is special and different about therapy). A statement asserting what is different about the professions of counselling and psychotherapy is something the courts could have reference to if they needed to consider whether therapists, and especially those in private practice, have different obligations in law from those in the state sector – they certainly do under the Children Act and for good reasons. Here BACP is emphasising the similarity between therapy and health and social care rather than highlighting the difference –

Commitment
We recognise that our clients must be able to trust their practitioner with their well-being and sensitive information. Therefore, we have agreed as members or registrants of BACP that we will….
Put our clients first by making you our first and most important concern during our work together

Putting clients first
4. We will make each client’s well-being and best interests our priority whilst working together.

Working to professional standards
12. We will collaborate with colleagues to serve the best interests of clients.

In short, is BACP in this draft of its Ethical Framework, abdicating its responsibility to assert what it believes is distinct about good practice in counselling and psychotherapy in favour of inviting the courts to determine how counselling and psychotherapy sit within the overall thrust of state health and social care policy?

 

Looking into what’s going on in this kind of detail reveals the underlying thrust of the present revision of BACP’s Ethical Framework. If you want further evidence, look no further than the new title – ‘BACP Ethical Framework for the Counselling Professions’.

So there we have it – an organisation, whose mission includes being the lead body for counselling and psychotherapy, is subsuming both coaching and psychotherapy under such a heading – and is thereby marginalising both psychotherapy and in depth counselling whilst, at the same time, privileging a narrow definition of counselling that is actively not supported by the research evidence.

Not only that, BACP is preparing to redefine coaching, psychotherapy and counselling as subsets of health and social care.

And, whilst claiming that this is a review of ethics, BACP is overtly (as was quite clear in the webinar seminars) redrafting those ethics in order to seek to protect members’ jobs – and, I would argue, promote itself and curry favour with Government.

 

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The British Association for Counselling’s 2014 Consultation on Ethics

Early April

The date of the first BACP webinar seminar is approaching. If I want to watch it I need to make sure I register and that my tired old computer is up to the job….

Late April

This is easier than I thought. I’ve watched Tim Bond’s short introductory video and I’ve downloaded some background documents. What I now need to do is gear myself up to spending a Saturday morning in front of my computer. These webinar seminars are 2½ hours long and my previous experience of this format is mixed – I really don’t like being talked at for even an hour at a time. All too often I ponder what’s been said so that my attention wanders and I’m in danger of missing something important. I’m going to take notes so as to help me stay focused.

I’ve download the two versions of the draft of duties that will become the top page on this part of the website. I’m already concerned about the wording of one of them. It reads –

“We have committed ourselves to…being accountable to you for the safety and effectiveness of services provided”

Only this week one of my supervisees brought a client who sat back and expected his therapist to fix his problems for him. Nothing she said was good enough. It’s absurd if he can base a complaint on a promise of this kind.

Saturday 26th April

I watched these seminars and I was gripped. I’m impressed by the way BACP has structured the two and half hours. It was exhausting but my attention scarcely wavered.

I do email in a question based on my recent experience in supervision, but my brain is buzzing as I try to take in the implications of what I’m hearing. I don’t want to be distracted from giving the webinar seminar my full attention.

Saturday 10th May

It’s time to post something alerting colleagues to these proposals –

From the viewpoint of counselling and psychotherapy this is a thoroughly negative move. In my view it emphasises the technique‑oriented, fixing‑people‑and‑their‑problems version of therapy at the expense of the more contextual meaning-making version (ie this move can be seen as positive if your focus is on raising BACP’s profile, enhancing the status of BACP’s members and positioning BACP in the social welfare mainstream as an organisation able to help meet government targets).

The proposal is to insert a list of ‘duties’ into the working alliance negotiated between therapist and client …. In its language this is a softer version of the list of 30 or so ‘musts’ that the HCPC imposes on its registrants.

One way of describing the proposed changes is that, whereas the old version of BACP’s Ethical Guidelines is a document designed to be a point of reference for therapists, the new one is inserted directly in between therapist and client.

This move is predicated on the notion that trust is engendered when matters are made explicit and are put into writing.  BACP, therefore, in its patronising fashion, is going the extra mile to make its members trustworthy. It says that because of recent events (mid Staffs hospital deaths, Winterbourne View, Jimmy Savile, gay conversion therapy and so on) and especially the two Francis Reports (2000pp) therapists can no longer be regarded as stand alone individuals but must be thought of as people-in-systems.

Mind-bogglingly, BACP seems to think such an awareness can be engendered in somewhere around 40,000 members by gaining their consent to a new document of this nature.

But what BACP is undertaking is in some ways quite an impressive consultation exercise. It has set up three well structured and presented two and a half hour webinar seminars that members are entitled to participate in –

ie in real time you click on to a link and then watch a lecture in real time on a split screen with a powerpoint presentation alongside it. Tim Bond, who has been the main author of the different versions of BACP’s ethical guidance since the mid 1980s, delivers two 30 minute presentations to a small invited audience who then ask questions. After each of these 30 minute slots there’s a discussion in a separate room involving Amanda Hawkins (BACP Chair) and AN Other and two ‘practitioners’. You can email questions and these are themed and fed into the discussion. At the end TB joins the small discussion group and responds. This was all quite intense but it kept my attention throughout.

The first of these three webinar seminars took place two weeks ago. Another – on supervision and line management – will be held on 24th May and the final one in July. These are only open to BACP members, but all members can register and take part…

The one on supervision is the most interesting one. I fear supervisors will be made into the enforcers of this list of duties and the role of supervision will be redefined at its very core.

I think this change could well prove a disaster for BACP. I think it will precipitate a division in BACP’s membership and hasten the kind of split we’ve discussed in this email group for many years now – between on the one hand “real” therapy and one the other a simplified bastardised version of it which prioritises conscious mind activity and the “medical model”, but lobs in an additional chunk of managerial policing. Interestingly, throughout his presentation Tim Bond referred to “counselling, coaching and psychotherapy” and no longer simply to “counselling and psychotherapy”.

BACP values “inclusivity”. I can’t see how it can have this whilst promoting changes of this kind. Such a development is bound to undermine the cultivation of ‘evenly suspended’ or ‘free floating’ attention that Freud recommended and so it will alienate anyone involved in serious counselling or psychotherapy. I think it will also undermine the development of critical reflective practice, since practitioners will have to look over their shoulder at the multiple ways these ‘duties’ might understood and used as a peg on which to launch complaints. Above all it will lead to more defensive practice.

Tim Bond implied that, if these changes are to go ahead, it must be with the consent of the membership and at the close of his presentation he flagged up explicitly that the advantages must outweigh the drawbacks.

There’s plenty for me to get my teeth into here… I am responding to BACP’s consultation in general terms at this stage, but will be paying close attention to the webinar seminar on supervision and line management where I sense the core of what’s wrong will emerge most clearly.

There’s a much more to say about all this but this redraft of the Ethical Framework can be seen either as a preparation for statutory regulation or as an effort at pre-empting what BACP believes will otherwise be imposed.

Friday 16th May

I’ve sent off a response to Tim Bond. This is some of what I wrote in my letter –

I was struck by the criticism you made of the existing Ethical Framework … that its weakness is that it’s directed inwards towards practitioners rather than outwards towards the public and the users of our services. This certainly made me stop and think. It’s clearly an important difference if we’re no longer dealing with a document written as a resource for practitioners, but with one that will, so to speak, be inserted directly into the working alliance and every relationship between practitioner and client.

You say that what’s now needed is something that communicates, as far as possible in ordinary language, with others outside the world of counselling, coaching and psychotherapy. It is important, you insist, to be more explicit but without being so behaviourally prescriptive that BACP loses the virtue of inclusivity. You argue it’s important to develop a fuller discourse across professional boundaries. The case you make is not for a break from the past, but for evolution within a changed world.

These are ambitious goals. You point out that it may not be possible to realise them in their entirety, but in closing you acknowledge that potential gains must be weighed up against potential losses. It’s on this that I want to concentrate. I am concerned that, in an effort to accommodate to discussion and debate taking place within the wider culture, critical aspects of the core work of in depth counselling and psychotherapy are being devalued. I want to highlight four issues:

The importance of “evenly suspended attention”

The danger of slipping into defensive practice in the face of these new duties

Further entrenching a surface level understanding of reflective practice

Trust

I will deal with each in turn.

‘Evenly suspended attention’

For Freud the ideal state of mind for a therapist was one in which attention is “evenly hovering” or “evenly suspended”. Drawing on a very different body of theory, Carl Rogers identified six necessary and sufficient conditions for therapeutic change. In each case there’s a focus that requires full attention – and, if this focus is absent, something is lost in the quality and depth of the therapy.

If a set of explicit duties is to be inserted I think the clarity of the therapeutic alliance will be contaminated by outside expectations. Practitioners’ attention is bound to be skewed away from the focus of the work. There seems to be an assumption in these proposals that being explicit is automatically and necessarily a good thing. The counter argument is that by emphasising what can be laid out in words undue emphasis will be laid on conscious mind activity at the expense of what is embodied and harder to verbalise.

Defensive practice

If duties are spelt out in detail documentation becomes cumbersome. If they are not, those bound by them will be somewhat uncertain exactly where they stand – not least because it is accepted that interpretation is context specific and no therapist can be wholly confident that their own interpretation will be shared by others sitting in judgement over them, for example in the event of a complaint being made. This is bound to lead to defensive practice.

Publishing a list of duties makes it possible for a certain kind of client to focus defensively on their own interpretation of any such public document. Take, for example, the notion that registrants are accountable for the effectiveness of services provided. Statements of this kind could prove a hostage to fortune, for instance when working with people who adopt a wholly passive attitude to therapy and expect their therapist to fix their problems for them without ever themselves really engaging in the therapeutic endeavour.

Critical reflection

Based on my experience as a supervisor and as a core tutor on a counselling diploma course, I notice it is becoming increasingly hard for new practitioners to develop the capacity for critical reflection as the expectations laid on therapists grow. These expectations include the anti-scientific overemphasis on RCTs by NICE and the growing complexity of IAPT+ as well as the increased pressure to acquire qualifications designed to secure a competitive advantage in the market place. When they do not find what is required of them to be intelligible, trainees start to regard both qualifying and their professional development as an extended process of jumping through hoops. Another way of putting this is to say that, as the external loci of evaluation become ever more complex and varied (as well as confused and confusing), strengthening and supporting the emergence of an internal locus becomes all the more crucial. I fear these proposals will take us away focusing on this.

This is a dynamic situation. In a sense you acknowledge this when you argue that the practitioner can no longer be seen as an individual functioning in isolation but must be viewed within a systems perspective. But I don’t think you deal with the absence of a systems perspective by developing more sophisticated “to do” lists. Look, for instance, at the successive editions of Gerard Egan’s ‘The Skilled Helper’. Egan has always been an advocate of a people‑in‑systems approach and has constantly sought, over many decades, to deal with what’s problematic by extensive re-writing. Not everyone would agree he has succeeded.

This problem is that much more acute for therapists seeking to work in therapeutic depth. They need to be flexible and to have the ability to step outside conventional frames of reference since it is these, as often as not, which inhibit creativity and effectiveness.

There’s a paradox at the heart of rewriting the Ethical Framework in terms of duties. By drafting something in the language of current social norms what is emphasised is the capacity to inhabit these norms, whereas the meaning-making aspect of therapy needs therapists to develop the ability to do just the opposite. This raises complex questions, but the risk is that therapists will be pulled towards meeting laid down requirements at the expense of extending their ability to work in depth.

Trust

I agree with what you said in your introductory video about trust between therapist and client lying at the heart of what you are trying to do. But trust isn’t best developed by having a professional body insert a list of expectations into a relationship. Trust doesn’t work like this.

Let’s look at how trust is established experientially. Usually in the first few moments of meeting face to face with somebody new we have a felt sense as to whether or not we trust them. Typically, we make a judgement quite quickly and at a fairly instinctive level. We then check this out. Different people do this in different ways. Some people prefer to tie things down in detailed contracting, while others tend to take relationships on trust until something causes them to question matters.

I recall one client whom I subsequently saw for many years. She contacted me by phone and was clearly struggling to make up her mind whether to proceed to a first appointment. I offered her a half hour session, for which I wouldn’t charge, to help her make up her mind, but almost as soon as she arrived she wanted to start counselling. I could see she was quite congruent about this and so we went ahead, even though I remained somewhat bemused.

Later on she explained. Because she had been diagnosed with a terminal illness she said she needed to know whether I looked after myself, because if I didn’t I wouldn’t be able to look after her. She decided this on the basis of one look at me. As she put it, “I could see that you were not overweight and that meant you looked after yourself.” I felt the basis for working in depth was there from that moment, although, as she later told me, I also said something part way through that first session that strongly confirmed her in her judgement about my trustworthiness.

This example highlights how the process of developing trust can go on largely out of conscious awareness. I certainly didn’t take her words at face value but I was willing to accept that, in saying what she did, she was in touch with something deep within herself.  I suspect everyone has their own idiosyncratic way of testing others out when establishing trust and, even though I recognise the validity of Freud’s aphorism “where id is there shall ego be”, I think it confuses matters to attempt either to standardise this process or to attempt to hurry it along by – in this case – inserting a list of duties in between counsellor and client. The best that can be said is that, while with some people it may help, with others it will detract from spontaneity and add in a layer of awkwardness that then has to be negotiated.

Inclusivity or division?

Isn’t this revision of the Ethical Framework, therefore, in too much danger of proving divisive rather than inclusive? Won’t it skew our work in favour of

short term counselling at the expense of longer term or in depth counselling and psychotherapy?

work that focuses on explicit goal setting and on technique at the expense of process?

work where an expert treats the client rather than, for instance, works collaboratively?

work that emphasises what can be put into words rather than work that is based upon embodied approaches?

In short, doesn’t it represent a betrayal of the core of good therapy?

In the fortnight or so it took me to complete this letter I spoke to a number of people. None had watched these seminars. This fires me up and plays on my tendency to get more deeply involved when I feel something needs to be said and I don’t see anyone else saying it.

Saturday 24th May

The second seminar. I’m quite keyed up. Most of my practice is as a supervisor and the changes that have been hinted at could really affect me and my work.

After a few minutes the screen freezes in front of my eyes. None of my efforts to retrieve things work. Eventually I decide to go round to my partner’s house and eventually I re‑connect using her computer, but I’ve lost 30 minutes. This leaves me feeling somewhat detached from the whole exercise as I wonder what key bits I’ve missed.

It’s very frustrating. The edited version of the seminar won’t be available online until Tuesday. It’s a bank holiday and we’re about to go away on holiday.

 

Thursday 3rd July

I’ve been sitting on my second response to the consultation for some weeks. I really can’t understand why BACP seems to be proposing something that cuts so deeply against their business model which has always been one of operating as broad church. I fear I have missed something. This is what I eventually send –

BACP Webinar Consultation: supervision and line management

At the end of your second webinar seminar you pose a challenge for BACP –

“Can supervision be positioned positively in the new professional governance requirements or will it be subsumed in the line management responsibilities – perhaps only surviving for private practice practitioners working outside any agency setting?”

Put like this, the review of the Ethical Framework sounds less like a gradual evolution than a conscious decision to redefine supervision. Furthermore, irrespective of what supervision might be in private practice, this redefinition arises directly out of a desire to accommodate to changes in the health and care system. Supervision is conceptualised as part of a quality assurance mechanism, while therapy itself is regarded as a product. From this perspective supervisors are treated as a frontline resource for delivering consumer protection.

Can this be accomplished without betraying the integrity of professional practice? I don’t think it can. In my earlier letter dated 12th May I attempted to show how these proposals are likely to seriously affect the longer term future of in depth counselling and psychotherapy. I argued that they will result in, amongst other things, more defensive practice. It was disappointing to hear such reservations dismissed in this second seminar as “paranoid fears”. The proposed changes are problematic, not simply because they involve an additional burden of responsibility for therapists and their supervisors, but because these roles will lose their focus. The core issue here is to do with role clarity, to borrow a concept from the field of group relations, and these changes actively promote role complexity and role confusion. In what follows I hope I can adequately convey why I think this is the case and why I think this is such an important matter.

At the heart of this confusion lies your question as to who is the focus of supervision, which you pose as though it is a binary choice. I can see why it might be attractive to conceptualise matters in this fashion when considering major changes in governance, but I think it is profoundly unhelpful. There have been a number of asides during these webinar seminars about vested interests, but it is clear that, in advocating these changes, BACP is glossing over any detailed examination of the complexities of supervision. There’s no doubt either that these complexities exist (they were highlighted in panel discussions in this webinar seminar) or that theory about supervision is underdeveloped (if compared, for example with the sophistication of the discourse about therapy).

When in role as a supervisor it’s not a question of choosing between the best interests of the supervisee and the best interests of the client. The focus is the work of supervision and the supervisor approaches it primarily through the lens of the supervisee’s view of that work. At present, when doing so, supervisors can be encouraged to give their undivided attention to supporting the supervisee in doing the best work they possibly can.

It will confuse this focus if BACP is to promote a public relations document insisting that the therapist’s and the supervisor’s “most important concern” is “the best interests of the client”. There are several reasons for this confusion, but one arises straightforwardly out of what we mean when we say something is our “most important concern”. Do we mean we give it most of our time and attention? Or, as I think you do, that – in the ultimate analysis – if there’s a choice to be made, the client’s needs take priority over the supervisee’s? As you point out, in most instances this need not alter practice, since the best way of supporting the client is usually to do so by working through the supervisee. Moreover, when the supervision is good, potential problems are likely to be identified early on and nipped in the bud. In fact good supervision has always treated the impact of the supervisee on the client as a litmus test of good practice.

But when BACP rewrites the Ethical Framework so that it becomes a set of promises about what a client can expect when in therapy – in other words when it is deemed to be a part of each and every working alliance – the phrase “best interests” acquires additional weight and the ambiguity in its meaning is brought into the heart of the work. The interpretation of this phrase is further complicated where, as well as the kind of ordinary everyday ambiguity highlighted in the previous paragraph, there is a lack of clarity about its meaning within society at large, including within the legal system.

As a result supervisors will be required to split their attention between two points of focus. One, which is perfectly manageable at present, is a deep concentration on facilitating the supervisee’s development as a therapist (I say this bearing the restorative, formative and normative functions of supervision fully in mind). The other is on a mix of possible legal interpretations of “best interests” and whether or not anything that the supervisor might do to intervene would involve “acting out” some element of the therapeutic dynamic. If supervisors are to be held to account by BACP for what their supervisees do to the point where they are not only identifiable and contactable but can be expected by clients to intervene on their behalf, this leaves private practice sole traders intolerably exposed.

Having to pay attention to the two points of focus identified in the last paragraph and being required to give priority to the second of them is bound change, quite fundamentally, what takes place within supervision sessions. This will be all the more so if supervisors are required to keep notes that can be trawled over, in extreme instances by lawyers, to detect whether a plausible case can be made out that the supervisor hasn’t acted in the “best interests” of their client. Supervisors will have to alter what they do so that they can always be confident they can demonstrate the appearance of good practice – in other words that they can show they have complied with the quality assurance system.

There is a further important point that needs mentioning. Whatever changes are made to the Ethical Framework in the short term as a result of this review, you have indicated a longer term objective of embedding definitions of therapy and supervision within a discourse about quality assurance within the health and care system. But, it can reasonably be asked, does therapy sit comfortably within such a discourse? You deploy a definition of it that highlights its role in the alleviation of distress without acknowledging that this needs to be held within a broader understanding to do with collaborative and contextual meaning‑making. Wampold has shown that the research data is unequivocal in supporting this wider definition[1].

This distinction is important because, if therapy is to be restricted to the goal of distress alleviation it can readily be encompassed within the aims and objectives of organisational programmes designed to alleviate different kinds of distress – for instance, that which arises as a result of addiction, eating difficulties, any form of abuse and so on. Therapy can then come to be viewed, not as a discrete area of professional expertise, but as one way of helping amongst many – for example, peer support, support groups, one to one listening support and so forth. It’s not hard to see how therapy might no longer be considered to be in “the best interests” of clients, if that means limited resources can be spread more thinly and more people can be helped.

On the other hand, if the definition of therapy rightly embraces its collaborative and meaning‑making dimensions, it becomes much more obvious that there must be a sharp distinction between the role of the supervisor and that of the line manager. I don’t see why the problems you have identified can’t be addressed in a relatively low key manner. Why can’t guidelines be written for supervisors under the umbrella of the existing Ethical Framework so as to take account of managers’ new responsibilities following the Francis Report? This won’t lead to the ambitious changes on which you pin your hopes, but it won’t result in a potentially disastrous split within the profession either.

Once supervision is securely embedded within an intergroup (ie public) discourse in the way you advocate, it is likely that the intragroup (ie professional) discussion about the complexities of good practice in supervision (or indeed in counselling or psychotherapy) will be permanently marginalised and, to use your word, subsumed in a broader debate shaped by the preoccupations of the dominant culture. Even the intragroup discussion is likely to be predominately determined by the perspective of therapists operating within organisational settings who are regarded, and regard themselves, as part of the health and care system, since the security of their careers may hinge on the extent to which discussion can accommodate itself to the agenda and terminology of the mainstream discourse. This is a toxic environment for intelligent debate about the subtleties of ethics and good practice.

In the first of these seminars you pointed to a weakness in the 2001 Ethical Framework in that it privileges the therapeutic dyad and pays too little attention to the systemic context within which it operates – as though it were possible detach oneself reliably from the cultural setting within we are all embedded. I want to suggest that the “post Francis environment” may itself be a culturally encapsulated perspective that prioritises certain values over others and is riddled with contradictions of its own. In saying this I don’t wish to belittle the Francis Report as a step forward for health and social care, but I do wonder whether it is over optimistic to hold that, by adopting a pragmatic stance and redrafting its Ethical Framework, BACP can have a significant positive impact on the practice of line management and supervision throughout the public sector (you suggest that your target is wider than the health and social care system). Might there, just possibly, be a touch of grandiosity in this aspiration?…

To summarise – these proposed changes to BACP’s Ethical Framework are unsatisfactory in a number of respects:

They introduce too much complexity for the role of the supervisor to remain clear, which will mean that the practice of in depth counselling and psychotherapy will be seriously compromised[2].

They promote the interests of those working in the public sector at the expense of those working in private practice.

They therefore should be regarded as a political agenda rather than as an evolution of ethical guidance. Currently BACP’s ethical guidance has a straightforward purpose – it serves as a summary for practitioners of the accumulated wisdom gleaned from decades of practice. This would no longer be the case.

The underlying definition of counselling and psychotherapy, on which this revision to the Ethical Framework is based, is unduly restrictive and cuts against the research evidence. It is unethical to use a misleading definition of therapy in order to achieve a political goal.

These proposals are divisive.

They represent a further step towards defining state approved therapy as a different animal from counselling and psychotherapy, as traditionally understood and practised.

There is a strong probability they will polarise the field.

Given all this, it is something of a misnomer for BACP to describe this consultation as a revision of its Ethical Framework. It is much more than this, for it encompasses not simply a redefinition of supervision, but a redefinition of therapy itself in which core aspects of in depth work are to be marginalised so as to accommodate the contemporary – and, I would argue, rather confused – conventional wisdom about the nature of good practice in the delivery of public services. This is a dangerous direction in which to go and I hope that, as a result of this consultation, BACP will take stock and think again.

 

Late July

After sharing my concerns informally with others I’ve been asked to write something for the autumn edition of ‘Self and Society’. This isn’t easy as anything I do write is likely to be out of date by the time it is published – BACP has promised to circulate a draft of its revised Ethical Framework to its members in early October. Not only that, but the material to which I’ve been responding will have been taken down from the BACP website – that is to say, the three 2½ hour webinar seminars, which could only be accessed by BACP members anyway.

I’ve decided that the best way of dealing with this problem is to put something together in a diary format showing how my thinking has evolved over time. As I’m starting to do this I’m asked to consider presenting this material to a conference in November. This is what I wrote to the conference organisers –

There’s a sense in which, now that the BACP system of self regulation has been kite marked by the Professional Standards Authority, BACP is in a position to exercise significantly more control over its membership. In his recent webinar seminars Professor Tim Bond viewed supervision as part of a quality assurance mechanism, while regarding therapy as a product and the client as the consumer. From this perspective supervisors are a frontline resource for delivering consumer protection. He gave examples of how this might work in practice with counselling supervision perhaps needing to take on some aspects of line management in what he calls “the post Francis environment”. One might soon therefore need to refer to PSA kite marked BACP therapy as ” state endorsed therapy” (in contrast to labelling IAPT+ therapy as “state approved therapy”, given its unscientific over reliance on NICE guidelines and RCTs).

It is, of course, hard to tell what exactly will result from BACP’s consultation on its Ethical Guidelines and things may well have moved on considerably by the time of your Conference in November. Not only that but I come at this material from the perspective of someone working wholly in private practice and am therefore largely free from anxiety about managerial edicts (I can quite easily relinquish supervision work if I am unhappy with the way an organisation operates).

I see these BACP proposals as driving a wedge between in depth counselling and psychotherapy, on the one hand, which I think will be pretty much free to continue as they are in private practice and, on the other, “state endorsed therapy” which looks as though it could evolve in a different direction. “State endorsed therapy”, it seems, will have supervisors who take on aspects of line management. They will, under these new arrangements, be held to account by BACP for what their supervisees do to the point where they will not only identifiable and contactable but can be expected by clients in extremis to intervene on their behalf. One option is that supervisors will be required to keep notes that can be trawled over, including by lawyers, to detect whether a plausible case can be made out that the supervisor hasn’t acted in the “best interests” of their client. If these changes to BACP’s Ethical Framework are agreed, supervisors will have to alter what they do so that they can always be confident they can demonstrate the appearance of good practice – in other words that they can show they have complied with the quality assurance system.

BACP may back off installing such tight control – for the time being. However by, in effect, inserting a list of duties (that will be visible on the BACP website) into each and every “state endorsed” working alliance, it will have prepared the ground for some kind of quality assurance system eventually. Once enough practitioners are sufficiently conditioned to defer to the authority of BACP (rather than develop their confidence as critically reflective therapists), it will no doubt be relatively easy to modify the requirement for continuing BACP membership (ie by making changes to the ethical guidelines) and thereby amend the definition of state endorsed therapy.

What is so remarkable is that all this is framed within a discussion about professional ethics.

I’ve no idea whether you’ve been following this discussion within BACP but I hope my outline of what I think is going on is going on is reasonably intelligible. There’s obviously a lot of detail behind all this – I’ve had to sit through seven and a half hours of webinar seminars and I’ve struggled to make this much sense of it. What’s going on is hard to credit, not least because BACP seems to be about to destroy the “broad church” that has been such an important foundation for its current domination of the field (apparently it now has approaching 40,000 members). Very odd.

 

 Friday 5th September

BACP runs a day for members in Bristol which I attend. Tim Bond has a slot at which he alerts those who haven’t seen the webinar seminars to the consultation exercise BACP is conducting and gives an indication as to what has changed as a result of the feedback received to date.

The requirement that BACP members must give each of their clients the name of their supervisor has been dropped, as has the requirement that supervisors must keep notes of all their work. There will not, therefore, be quite the pressure on supervisors to act defensively that I initially feared. But something has nonetheless shifted. Now that BACP has had its regulatory framework endorsed by the Professional Standards Agency, it is no longer, as in the past, to be seen as simply summarising good practice based on the diversity of counsellors’ and psychotherapists’ experience of doing their work, but is increasingly in a position to shape that practice with a view to meeting social policy objectives set by Government. In these webinar seminars we have perhaps had a foretaste of BACP flexing its muscles in this regard. We should not assume that such muscle-flexing is automatically in the interests of good practice in counselling and psychotherapy.

[1] Bruce E Wampold (2001) ‘The Great Psychotherapy Debate’ (London: Lawrence Erlbaum Associates). “(i)t would be difficult to imagine how a scientist could examine these data and come to a different conclusion” (p xiii).  At the end of the book on pp 227/229 Wampold makes policy recommendations based on his findings. Although his discussion is based on the US experience, the options described there are, in important respects, analogous to those faced by BACP at present. A second edition of this book is due out in the Spring of 2015.

[2] See my earlier letter dated 16th May where I discussed how the proposed changes to the BACP Ethical Framework are likely to affect in depth counselling and psychotherapy.