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REGISTRATION AND ETHICS IN PSYCHOTHERAPY
An
idea to establish the qualification of ‘Chartered Director’ has
recently been floated in the business community. It would comprise coursework and examination, and would appeal to
people with substantial experience in business, who wanted the recognition
that a charter would offer. It
set me thinking about the difference between such a charter and the
registration of psychotherapists. Directors
work in a competitive market, and a charter would give them an entree. What about psychotherapists? To
put it bluntly, do we want anything other than security in a tight job
market?[i]
Most
people supporting registration would say we do want something else: a
service that is respected and trusted. In my view, we aim for an ethical service, and our discussions of
registration should be governed by that aim. But we run into trouble right away, trying to define the nature of
our practice as psychoanalytic psychotherapists. Adopting Freud’s formulation of the state of mind of the analyst
(Freud 1912, pp. 111 – 12), we could say that we offer an
‘evenly-suspended attention’ to the transference, guaranteed by
minimizing distortion from personal complexes. That is it: we don’t offer a product or even a service. Instead, this form of attentiveness respects the patient and
provides a model of an uncompelled, free relationship. It is not a salable commodity, and there could be undesirable
consequences of complying with any pressure to make it one.[ii]
I
want to clarify these points though an exploration of three concepts:
contract, rules and ethics.
articulates
an agreement, and it refers both to the explicit level of agreement and to
implied agreement (the legal concept of implied contract). Thus, we explicitly agree a time, place and fee for
psychotherapy; but what happens in the psychotherapy is probably never
agreed: more often, it has been modeled in a preliminary interview, which
has the explicit function of assessment and the implicit function of
demonstrating the psychotherapeutic method.
Rules:
refer
to codes of practice: to appropriate behaviour, such as seeking competent
help when it is needed; or to inappropriate behaviour, such as
exploitation in financial, sexual or other forms. The implied contract with the patient implies that the therapist
adheres to a code of practice. The
aim of the code is compliance, so that non-compliance can be actionable.
refers
to an aspiration towards an ideal that has been internalized and is not
rule-bound. Instead, it attracts confidence and trust, precisely because
it is not rule-bound, is not based on compliance and cannot therefore be
turned against the patient as a demand for compliance. Openness to discovery, internal consistency, objectivity are
ethical standpoints.
In
most fields, including the directorship of a company, we expect honourable
behaviour but do not rely on its ethical dimension; instead, we extend the
law of contract, and as the field gains autonomy and recognition for its
own qualifications, we expect a code of practice. But in psychotherapy, we expect an ethical attitude as the very
mode of the practice. When
Freud says:
I cannot advise my colleagues too urgently to model themselves
during psycho-analytic
treatment on the surgeon, who puts aside all his feelings, even his human sympathy, and concentrates his mental forces on the
single aim of performing the operation as skilfully as possible. (Freud
1912, p. 115)
he
refers not just to a procedure but to a frame of mind. The ‘putting aside all his own feelings’ has become a major
area of research into counter-transference.
Implicit
Functions of Registration
Registration
of psychotherapists should mainly express this ethical orientation of a
profession, with its emphasis on its implicit or internal significance,
and secondarily the practical function of regulation. In order to make this case, I want first to deal with
psychotherapy as a practice, like any other, in the process of
professionalization.
Psychotherapists
want to draw together to establish an occupational niche, to differentiate
themselves from social workers, clinical psychologists, psychiatric
nurses, psychiatrists or counsellors. In some other countries, such as the United States, this
occupational niche is occupied by clinical social workers, and is
controlled by their statutory authority. In Britain there is a large public sector, including the National
Health Service and Social Services, but it does not provide a career
structure for psychotherapy. There
are no designated posts in the NHS, despite many posts in other
psychological therapies, such as art therapy, drama therapy, psychiatric
nursing and clinical psychology. Insurance will pay for psychotherapy offered by a doctor or a
chartered clinical psychologist, but rarely for psychotherapy offered by a
psychotherapist unless he or she is also a doctor or chartered clinical
psychologist or is supported by one. The ‘core professions’ are usually seen to be the best routes
into psychotherapy training, and it often seems to be a specialism within
them. There is no profession
of adult psychotherapy.
Psychotherapy
is therefore marginalized, except as an adjunct or specialism in a core
profession. In the public
sector, practitioners work within a line-management structure rather than
a professional structure, and are regulated as employees rather than as
professionals. Outside the
public sector, they work as individual entrepreneurs.
As
individuals, they are likely to be treated as private contractors, subject
to the laws that apply to small businesses. To establish the United Kingdom Council for Psychotherapy (UKCP)
and the British Confederation of Psychotherapists (BCP) and their
registers represents a bold move to make a profession. It is bold because there is little public support; and because it
implies a restraint of practice without any public authority, a control of
training without legitimization from educational institutions, and an
enforcement of complaints procedures without any statutory power.
Professionalization
Registration,
therefore, is an aspect of professionalization in a climate that is not
very supportive. In the
classical sociology of professions, the key feature of a profession is self-regulation.[iii] In effect, a profession is ‘allowed’ (by implicit social
consent) to regulate itself in exchange for an ideology of service, as
opposed to self-interest. In
its orientation towards service, it offers the public a code of ethics and
procedures for complaints and disciplinary action, which replace the
ordinary legal channels of redress.
A
professional service differs from any other service because it is offered
by practitioners who belong to, and are identified with, a professional
organization. Through their
membership, they seek to manage the way they are perceived. They want to be trusted for their honourable attitude, not just for
their capacity to provide a service. They want to restrict the provision of their service to their own
group, yet be – and be seen to be – motivated by honourable aims and
not self-interest.[iv]
I
think there is an honourable dimension to professionalization, and that it
lies in the internalization
of an ideal. Even contracts,
when they first became important in support of mercantile investment in
the 15th century, rested on an ideal, primarily on a merchant’s
reputation, his trustworthiness in paying a debt. (Poovey 1998) We now have elaborate contract law, including legal redress; now
the defining feature of a profession moves further into an area not
covered by contract. Instead
of an ideology of service, whose social recognition could be found in the
right of self regulation, the main feature of professionalism for
psychotherapy is the internalization of an ideal.
Consequences
of professionalism
We
need to distinguish between a code of practice and a code of ethics. A code of practice should articulate procedures, for example, how
to initiate a complaint. A code of ethics should aim to articulate the ethical
attitude of the professional and the ethical structure and processes of
the profession. The ethics
that the code articulates refers to an internal situation, whether of the
individual or the organization, of unforced,
undeceived, undeceiving agency: the actuality of being a psychotherapist. It is not as vague as it sounds. It means, for example, to be in a situation – internally, in
relation to the patient, in relation to the profession and its
representatives – to understand and accurately to interpret the
transference.
This
latter point suggests the difference between a code of practice and a code
of ethics. A code of practice
demands compliance. It
instructs from the outside, and is opposed to autonomy or an unforced
agency. It would be possible
to act in accordance with a code of practice and yet unethically
(Hinshelwood 1997, pp. 101 – 6; Levine 1999); in fact, a code of ethics is self-contradictory. In clinical practice, an interpretation that is seen to be correct,
perhaps by teachers or peers, could be unethical if it were based on an
unexamined counter-transference or on extra-analytical criteria. In the profession, the behaviour of one organization with
respect to another, or of registering bodies towards member organizations,
could enforce compliance in the guise of supporting a more psychoanalytic
attitude. They would thereby
be exacting compliance in the explicit interest of the profession, but
actually be undercutting its ethical nature. In my view, the BCP ruling that organizations cannot be members of
both the BCP and UKCP is of this nature; and it has had the knock-on
effect of forcing individual members to act opportunistically, in joining
other organizations and in forming new organizations, such as the
Federation of Independent Psychotherapists and the Confederation of
Analytical Psychologists.
The
ethical aspect of psychotherapy
is that the therapist should act in accordance with the ideal that is
implicit in the situation. The
reason why it is an ethical moment is that the parties cannot include the
analytical process in their contract because there is no way to consent to
it. It cannot be explained
ahead of time, and therefore cannot be agreed to. It might even lie beyond an implied aspect of the contract, and as
such, it must be included in an ethical attitude: that both parties are
acting in good faith, which, for the practitioner, means acting accordance
with the ideals of the practice by virtue of having internalized them. [v]
Neither
patient nor therapist could hold to the contract, even if it could be made
explicit. The impossibility
of consent is implicit, for the patient, in the resistance; and, for the
therapist, in the counter-transference; both of which are unconscious. But these breaches of the contract push the therapy along. Their resultant is the situation recommended by Freud. The equivalent to the surgical operation is the interpretation of
the transference, which is only there in the moment, and cannot be taken
away, used and returned if it is faulty. It is everything that has been discovered to contribute to the
concentration that Freud recommended.
This
is an ethical situation in two ways: first, it rests on the trust that an
ideal of human relationship will be instantiated in the treatment; second,
it rests on the belief that the therapist aspires to an internal ideal of
unforced thinking and agency. It
is a state well described by Money-Kyrle (1956): that of a well-poised
balance between introjection and projection of the patient by the analyst. The patient distorts the analyst’s internal world, but does not
dominate it; in the process of assimilating and understanding, the analyst
restores his or her internal world by projecting, but not by denigrating
or dominating, the patient. Such a moment cannot be bought and sold; the fee does not buy
it, and no contract or consumer protection legislation can cover it.
What
of the ethics of organizations? I
think they should aspire to the same principles. There are three important conditions under which registration is
taking place: 1) large public sector psychological services; 2) the
formation of the BCP, which I call an identity group, from within the
major umbrella organization, the UKCP; 3) the affiliation with
universities. Each of these conditions challenges the ethical orientation
of psychotherapy. Let me
briefly address each of them.
1. The public sector establishes career structures for psychological
services, and the marginality of psychotherapy among these services
creates a pressure to compete with them or be assimilated to them. To compete with them means to produce outcome measures, that is, to
appraise psychotherapy in terms of product-like
measures of performance. This
approach is in line with the idea of clinical audit and of occupation
mapping exercises, both of which break the therapeutic process into
observable units and seek indicators of the effective teaching and
implementation of these units of therapeutic performance. They become a set of rules; and, in terms of the distinction
between ethics and practices, they are practices external to the
practitioner.
2. The sequestering from within an overall regulatory body (UKCP) of a
separate organization (BCP) has led to an emphasis on its identity at the
expense of the regulatory function and clear service ideology of a
professional body. Withdrawing,
as this group did, on grounds of seniority, gave substance to an
appearance of a common identity inside the separating group, even though
the organizations that formed the nucleus were diverse in theory and
practice. Paradoxically,
these organizations cohered on grounds of rules; while still members of
UKCP, for example, they built their common identity on the arbitrary
requirement that they were members of international associations.
The
separation gave added weight to the sense of there being an agency, in
Freud’s meaning, which could be thought of as an ego-ideal, where
previously there could have been a shared ideal. It also hightened the sense of its dictating standards to UKCP, in
the form of imposed rules, rather than embodying values that, in their
internalization, expressed the essence of the therapeutic process. The ‘single membership rule’ – the requirement that member
organizations choose either UKCP or BCP – has added to an atmosphere of
coercion, and in promoting the ego-ideal status of the BCP, it will add to
the confusion in the minds of trainees, between being a patient and being
an acolyte.
If
one thinks of UKCP and BCP together as a psychodynamic system that is
internalized by individual members, then the internal world of the
individual member has become more coercive, more rule-bound, and less
ethical than before. It is
difficult to assess the impact on the whole field of psychotherapy, but in
relation to at least the Psychoanalytic and Psychodynamic Psychotherapy
section of UKCP, it has consolidated an ego-ideal in institutional
psychodynamics and has depleted its identity. Whether this ego-ideal will become a persecutory object that
attracts revenge or an object of aspiration is for the future.
3. The affiliation with universities offers a pathway to de facto
statutory status and equivalence to psychotherapy in Europe. It is a convenient moment for these alliances, because the lack of
statutory recognition of psychotherapy meets the economic hardship of
universities: just as psychotherapy organizations are looking for the
stability and status that universities can offer, the universities are
looking for new areas of expansion. There
could be degree-inflation as a new range of Masters programmes and
practitioner doctorates are devised; and practitioner doctorates could
become the qualification for trainers. Universities will be drawn away from their commitment to
fundamental research and the pursuit of open-ended exploration, and into
the validation of training.
All
these points are challenges to the ethics of psychotherapy, pressures that
could push it away from an essentially ethical core, which is to act in
accordance with openness to the psychoanalytic moment and with a range of
psychoanalytic ideas of the aim of psychotherapy. A number of cautions might help to define the function of a
register, which would be consistent with this view:
Cautious
Thinking About Registration
1.
It would be better to detach registration from training organizations, and
to substitute membership of a College of Psychotherapy for membership of
training organizations.
Before
there was a register, psychotherapists who identified themselves with a
group of similar practitioners expressed their collective identity through
being members of their training organization, which reinforced a
compliance between trainee and training organization.[vi] The registers have brought only a minor modification of this
structure, because they are produced from the memberships of the training
organizations. One function
of a register, as the list of members of a profession, could be to reduce
the effects of guaranteeing membership through training organizations.
2. It would be better for BCP to be part of UKCP
The
cleavage inside UKCP, leading to the formation of the BCP while the UKCP
was still embryonic, has led to – or perhaps has expressed – a lack of
clarity about the functions of a professional
organization. UKCP is
public-orientated, organized from the point of view of lay people seeking
competent psychological help; and politically orientated, organized from
the point of view of mutual recognition and a democratic objection to
restrictive practice. It is
also a regulatory body, which seeks to hold together forms of
psychological therapy without regard to their definition of themselves. The BCP is primarily an identity grouping, organized from the point
of view of identification among its members. Both the UKCP and the BCP functions are important, but they would
be better in the same organization; indeed the section-based structure of
UKCP aimed to include both.
3. It would be better, in thinking of an alternative to BCP returning
to UKCP, for UKCP to disaggregate and for the sections, including BCP to
reaggregate to elect various committees and to form a College of
Psychotherapy.
4. It might be better to
have a single college and register of psychotherapies that are based on
the use of the relationship as a research and therapeutic instrument. The register could be subdivided into identity groupings.
5. It would be better to avoid skills and outcome-based evaluations
until they can be generated from inside an established profession. The College of Psychotherapy could establish research posts in
universities for this function.
6. It would be better to consider carefully why trainings might
affiliate with universities.
The
future of training lies in the universities, and there is a clear movement
throughout the field to affiliate with them and to offer degrees as part
of training. There seem to be
two aspects to it: 1) to
achieve the status of a statutory body in the absence of statutory
registration, through the accreditation of trainings; 2) to consolidate
the idea of a body of theory and its growth through research. The former deforms both institutions; the latter enhances them.
7. It would be better to compose a statement of ethics, and to derive
from it a code of practice and procedures for complaints that are
consistent with it.
Such
a structure would be similar to a constitution, which states the founding
principles on which constitutional law depends. We should study case law applied to psychotherapy, to see how our
practice is appropriated by contract-based thinking, and be wary of making
or implying contracts that are inconsistent with our work.
Conclusion
What
I am sketching is the boot-strapping of a practice into a profession, in
an environment that has been indifferent to it. Registration is part of that process. It is inevitable and must eventually be backed by statute. We need to explore the ramifications of professionalization to
ensure that registration does not deform the practice that it is meant to
protect.
Address
for correspondence: k.figlio@essex.ac.uk
[1] This paper was presented to the conference, Registration
– For and Against, organized by the British Confederation of
Psychotherapists, London, 12 June 1999. It will be published in the British
Journal of Psychotherapy, vol. 16(3), Spring 2000. For letters to the editor or articles, contact
BJP@jarundale.demon.co.uk; to subscribe, contact
101364.2334@compuserve.com.
[i] Although I refer to psychotherapists, I am limiting my limiting
my argument to the situation for psychoanalytic psychotherapists. I hope that psychotherapists with other orientations will
nonetheless find it useful and will compare their own thinking with
it.
[ii] Good practice is a process that furthers the process, as defined by the
theories and the aims of the field. In Balint’s analysis, the psychoanalytic process should
always allow the patient to discover his or her own ‘way to the
world of objects – and not be shown the “right” way by some
profound or correct interpretation’ (Balint 1968, p. 180). ‘The
real problem is not about gratifying or frustrating the regressed
patient but about how the analyst’s response to the regression will
influence the patient-analyst relationship and by it the further
course of the treatment’ (1968, p. 168). Good practice carries itself on; it is permissive. Bad practice
disrupts, interferes.
Hinshelwood (1997) distinguishes between
ethical practice and abuse on the basis of the aim of (re)integration
of the mind, divided by splitting and projection. Ethical practice aims at integration, even if the therapeutic
process temporarily seems to foster disintegration; abuse – torture,
in the extreme – aims for disintegration as an end-point, in the
service of domination and compliance.
We have to be able to define bad practice, and
for the public to be able to press a charge of bad practice. So far, our definitions are very limited: that the patient must
not be exploited sexually, financially or in any other way. I would say that our main area of concern should be ‘in any
other way’, because the other two should be features of any
professional practice, not specifically psychoanalytic or more broadly
psychotherapeutic.
[iii] The classic text on the ideology of a profession, which takes
medicine as the epitome of a profession, is Talcott Parsons (1951, ch.
10).
[iv] The reluctance of successive governments to give statutory authority to a register lies partly in not wanting to be party to restrictive practices.
[v] On the issue of beginning, which, in my formulation, is when
the implied contract is ‘agreed’, Freud says
Lengthy
preliminary discussions before the beginning of the analytic
treatment [has] special disadvantageous consequences for which one must
be prepared. [It] result[s] in the patient’s meeting the doctor with a
transference which is already established and which the doctor must first slowly
uncover instead of having the opportunity to observe the growth and development of
the transference from the outset. In this way the patient gains a temporary start upon us which we do not willingly grant him in the treatment.
(Freud 1913, p. 125)
Hinshelwood (1997, pp. 97 – 106) argues that consent is not possible – at least in psychoanalytic psychotherapy – either at the outset or in the course of treatment, because of the unavoidable presence of transference and resistance, which are also the foundation of the therapeutic process.
[vi] Joseph Stelzer (1986) refers to a ‘deformation of identity’; see also, Britton, 1998.
References
Balint, M. (1968) The Basic Fault: Therapeutic Aspects of Regression. London/NY:
Tavistock.
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_______ (1913) On beginning the treatment
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Copyright: The Author
Address for correspondence: k.figlio@essex.ac.uk