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 –
- All clients to be informed by their therapist of the name of their supervisor.
- The jobs of both therapist and supervisor to be defined as operating in the “best interests” of the client.
- Supervisors to be required to keep records to show that they have acted in this way.
- 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
- 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?
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 –
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.