Could therapists, their supervisors and their professional bodies do more to protect the public?

Introduction

To be more specific, this editorial ventures, somewhat audaciously, to consider whether psychotherapists, counsellors, psychoanalysts, arts and play therapists, psychologists, their supervisors, their trainers/educators and their professional bodies could do more to protect the public.

When I started my psychotherapy training, many other trainees appeared to have already been there for around 10 years. I, whilst having already successfully completed a 3-year diploma in counselling, was to take much longer. Now I would agree that I was probably a more difficult ‘case’ than most, but would I currently be shown that – given therapeutic training today, or would I ‘get away with it’ to both my clients’ and my detriment?

In the case of the UK, it is now possible to advertise as a psychotherapist on the main sites that the public uses to access therapy after 1-year full-time training or 2-year part-time training, appearing to be fully qualified. Furthermore, an increasing number of even 4-year part-time trainings do not require the trainee to go to the expense, time, and potential emotional furore, of having personal therapy. Let alone the questions of how many times a week and whether such personal therapy is at least throughout the training.

The potential client is faced with the confusing complexity of professional labels, for example, MBACP (registered) and MBACP (accredited), psychotherapist, psychotherapeutic counsellor, psychoanalytic psychotherapist, psychodynamic psychotherapist, psychoanalyst, practitioner psychologist, clinical psychologist, counselling psychologist, and so on. There seems little in the way of help provided, particularly by referral websites, for somebody who is likely to be in distress in the first place to understand all these different titles and labels (let alone to then go into looking at choosing a modality). Furthermore , this lack of clarity over therapeutic professional labels is not just a problem for potential clients, for in my experience most health service professionals, who might advise the client, are also unlikely to be clear. I previously ran CPD programmes for general practitioners who seem to have little clue about these differences – so what chance has the general public?

SCoPeD

An attempt for a solution to this very problem in the UK might be seen in the creation of ‘SCoPeD’ (ACC et al, 2022). Here, the main professional bodies involved with counselling and psychotherapy (but not psychoanalysis and psychology; and, does the public, let alone many of the professionals involved, really know the differences) have come together and agreed a classification whereby the therapies are divided into three categories: the A group (1-year full-time or 2-year part-time training and/or experience) includes ‘MBACP registered’, the B group (3 years of minimum part-time training and/or experience) includes ‘MBACP accredited’ and UKCP ‘psychotherapeutic counselling’, BPC’s ‘psychodynamic counsellor’. The C group (4-year part-time training and/or experience) includes all UKCP & BPC’s psychotherapists but not their psychoanalysts or the counselling, clinical/practitioner psychologists of the British Psychological Society (BPS) or the Association of Child Psychotherapists (ACP). Furthermore psychiatrists’ psychotherapeutic training requirements are not included. We might also ask what is meant by ‘and/or experience’ (not a phrase normally stated by most professional bodies). However, can this very difficult to achieve SCoPeD venture be seen as a first step in helping the general public (and the professional bodies) in being clearer as to what is being offered?

To explain further, the SCoPeD partners, who each hold Professional Standards Authority accredited registers, are:

• Association of Christians in Counselling and Linked Professions (ACC)

• British Association for Counselling and Psychotherapy (BACP)

• British Psychoanalytic Council (BPC)

• Human Givens Institute (HGI)

• National Counselling and Psychotherapy Society (NCPS)

• UK Council for Psychotherapy (UKCP)

Not everyone is enamoured with SCoPeD. Concerns expressed include it being ‘hierarchical and paternalistic, and infantilises counsellors whilst denying their autonomy’ (Egeli, 2019) and ‘politically motivated, misaligned with therapeutic values and methodologically flawed’ (Stevens, 2019). (Personally, when I write of ‘psychotherapy’ in general, I take it to include ‘counselling’ and ‘psychoanalysis’. However, I do regard the length of trainings important as well as the extent of the practice and one-to-one personal therapy unless the modality can clearly show that these elements are not essential.)

We now await how each member organisation of SCoPeD implements the review as well as the results of an impact assessment. In the meantime, this editorial first provides a different analysis and then offers some different solutions to safeguarding the public.

It is argued that there have been several important external political, economic, social and technical (the latter to be covered in a forthcoming European Journal of Psychotherapy and Counselling issue) changes that have implications for the provision of psychotherapy and counselling. These include taking the form of state intervention, regulation, managerialism and increasingly anxious times.

State intervention, ‘safeguarding’ and ‘prevent’

With regard to protecting the public, another important debate is to what extent, if any, should the state be involved in protecting the public. A necessity for many, yet for some the state’s involvement is more an excuse for ideological control (Parker & Revelli, 2019). Two important state interventions in the UK have been the introduction of ‘safeguarding’ (HM Government, 2012) and ‘prevent’ (HM Government, 2011). However, without underestimating, the need to safeguard young people and vulnerable adults, or everyone from terrorism, such state intervention can also be seen to threaten the raison d’être of psychotherapy (Donner et al., 2008; Rizq, 2017) and not just for those who see its essential character as subversive (Trotter, 2019).

Yet, hopefully most therapists would agree that our prime purpose is to enable clients/patients to talk therapeutically about what cannot be talked about elsewhere (which can be seen as enabling them to work through what is constricting them). Indeed, is there a single human being who has not had a disturbing thought or dream that might worry them too much to say to another? Yet, aren’t clients also sometimes increasingly at inappropriate risk to themselves and those around them if they were to share such thoughts with a therapist? For is there the potentially catastrophic, avoidable, trauma for them and those around them for wrongly being referred through ‘safeguarding’ or ‘prevent’? Furthermore, would therapists with 1 or 2 years of training, let alone those with relatively little, if any, in the way of personal therapy, enable them to be clear as to when they are saying something for themselves rather than the client, and thus be able to judge what is appropriate?

Regulation & counsellors and psychotherapists as ‘semi-professionals’?

Unfortunately, ‘safeguarding’ and ‘prevent’ systems can also be seen to be tilted such that it is far less risky for the counsellor/psychotherapist, as opposed to the client and those around the client, to refer to safeguarding. Clients may then see social workers, or clinical psychologists et al. who, along with their supervisors, it could be argued are less likely to have interpersonal psychotherapy training and are not required to have personal therapy.

Yet the clinical psychologist will have had 6-year full-time training plus work experience and will have at least learnt what it is to be a professional. This is in stark contrast to psychotherapists and counsellors and particularly those who are advertising their services after a 1-year full-time or 2-year part-time training.

After Shipman (Smith, 2005), there was a change whereby professions were no longer fully trusted to self-regulate. Yet this ability to self-regulate, together with the right to prescribe, had been previously regarded as an essential characteristic of being a professional (Freidson, 1970). There was much consternation among all the therapeutic professions bodies with the BPS finally deciding to be externally regulated by the Health and Care Professions Council (HCPC) who ‘protect the public by regulating 15 health and care professions in the U.K’. (https://www.hcpc-uk.org). Whereas the others decided to self-regulate through the aforementioned Professional Standards Authority (PSA) who ‘set standards for organisations holding voluntary registers for people working in unregulated health and care’ (https://www.professionalstandards.org.uk/home). One outcome of this was that many of the various groupings of modalities within counselling and psychotherapy could become less independent of their central professional body and less able to defend who used their modality titles. This has the advantage of the psychotherapy professional body’s ‘centre’ having more say on core standards but the disadvantage being that there could be less checks and balances on what modality titles therapists can use. This can make it more difficult for members of the public to be assured that what is on the label is in the tin. There was also another important external cultural change:

The move from administration to management

We have seen a move particularly pronounced in public services whereby rather than administrators working on behalf of professionals, administrators are replaced by managers who manage the professionals. Therapeutic organisations, as with universities, public hospitals and government, are run more along the lines of New Public Management (Ferlie et al., 1996) with its audit culture (King & Moutsou, 2010). Here, we have growing central systems and costs in an increasingly competitive managerial labour market with a resulting need to generate more ‘bums on seats’ income and the ever-present danger of a ‘rush to the bottom’ dilution of training standards. The checks and balances brought in to safeguard the public from the potential abuses of ‘professionals’ can also potentially lead to the loss of that often tacit difficult/impossible to describe professional knowledge that can also safeguard standards.

Social mobility

Then again, perhaps on a lighter note, there is the argument that counselling, psychotherapy and psychoanalysis reflect the British working, middle and upper-class system. Hence, rumblings also started to happen when some of the working-class wanted to be more middle-class (counsellors calling themselves ‘psychotherapists’) and some of the middle-class want to be more upper-class (‘psychotherapists’ calling themselves ‘psychoanalysts’)!

The demand for therapy: War in Ukraine and climate change

There was a recent time when a senior member of a therapy training organisation said that most psychotherapists were lucky to have two unwashed clients! But that has changed, the demand for therapy in our increasingly anxious times with the first major European war for over 70 years, and current unrelenting global warming/famine/starvation/migration, etc., have produced an almost exponential demand for therapy. As a result, therapists with minimal training appear more likely to find work (and sometimes with little, if any, in the way of price differential compared with longer trained therapists).

What if anything can be done to protect the public?

How can potential clients, who are more often in an anxious state, decide which therapist is best for them?

How can they decide on which of our different cultural practices to choose: Whether they should focus on feelings or behaviour or experience or an unconscious or family systems, etc., or whether they should primarily consider their goals or needs or drives or desires, etc.? In order to help, could we all as therapists both be clearer to ourselves as to how we describe ourselves and then provide not too little and not too much information for members of the public to be able to decide what is best for them?

In attempting to answer this question, my thoughts, above and below, are not intended to be exhaustive and certainly do not necessarily represent the views of any professional body or training organisation. The following are therefore just tentative possibilities. I am sure there will be good arguments as to their inappropriateness and hopefully far better suggestions will emerge (in both cases article submissions to this journal would be very welcome!).

Further suggestions the professional bodies (collectively and individually) might consider to protect the public

Shouldn't all professional psychotherapy bodies state clearly for each of their professional titles the minimum training requirements, including number of years, training hours and hours of personal therapy? Further, in the case of personal therapy they should not allow just ‘or equivalent’ but state why certain modalities do not require this and specifically what they require instead.

How come some modalities regard trainees’ personal therapy as the most important aspect of the training (transcending such notions as part-time versus full-time); whereas others regard something more often described as self-development as ‘equivalent’?

There is the related question of ‘What if any evidence is there for the effectiveness of personal therapy for trainees?’. But does this again raise questions about the nature of therapeutic knowledge with its vital tacit dimension (including what can only be imparted and acquired rather than taught and learned) and what is culturally fashionable as evidence? Surely, though, whatever, the public could at least know whether or not, the therapist has had personal therapy, what the minimum required hours are, and why many consider it of vital importance (for example, minimising the therapist unknowingly leading the client down the therapist’s own unexplored mine/mind fields).

Further consideration might also be given by the professional bodies to ensure that their registrants do not make claims on their personal websites and elsewhere to have professional training in modalities without approved certification. For example, claiming they can do individual therapy when they have only been trained in group therapy and vice versa.

A further area of ethical concern is whether if the professional body strikes a therapist off its register, whether the individual can still claim to be a psychotherapist/counsellor within, and through belonging to a member organisation of the professional body. Finally, before turning to specific organisations, it is recommended that professional bodies each standardise exactly what letters a registered therapist can put after their name and have sufficient teeth to deregister the therapist and training organisation if they were to use questionable awards and postnominals.

For the BACP in their current planned deliberations to make a clear distinction between ‘MBACP registered’ and ‘MBACP accredited’ in a way the public can understand or drop ‘MBACP registered’.

For UKCP to make clear the distinction between ‘psychotherapeutic counselling’ and ‘psychotherapy’ in a way, the public can understand or drop ‘psychotherapeutic counselling’. (This is not the only place where I have to admit some responsibility for adding to the confusion for the public and other professions: I initiated ‘psychotherapeutic counselling’, then with a view that the training could be at undergraduate as well as postgraduate level, and that the focus would be primarily on short-term work. However, it evolved, with good intentions, otherwise.)

Additionally, it can be difficult for professional bodies to ensure where there are core training elements that these are carried out by all member organisations. (Particularly in those cases where existing member organisations may not be required for up to 5 years to have reviewed changes to an existing or new training qualification). It can also be useful to know (for the potential client and other professionals) where the therapist has been trained (as with a university) and this is not always available.

For the BPC to make clearer to prospective clients the difference in the training requirements of their psychoanalysts, psychoanalytic psychotherapists, psychodynamic psychotherapists and psychodynamic counsellors; particularly both regarding how many times they have therapy a week and why they regard such differences important.

For the British Psychological Society to distinguish between ‘practitioner psychologists’ (which is their only HCPC regulatory category) who are ‘clinical psychologists’ (and most likely to primarily have CBT type training that does not entail personal therapy) and ‘counselling psychologists’ and other psychologists including ‘research psychologists’ in a way that is clear to the public. In so doing to ensure that clinical psychologists cannot advertise themselves for example as a ‘psychodynamic’ or ‘integrative’ psychotherapist if they have not had such a training. Also, that research psychologists cannot call themselves ‘psychologists’ or use for example their qualifications as ‘CPsychol’, ‘Associate Fellow of the British Psychological Society’ as an apparent licence and prime means of advertising as a psychotherapist or counsellor. The public could also be confused by where the BPS’s ‘Register of Psychologists Specialising in Psychotherapy’ fits into the above.

For the Royal College of Psychiatrists, to make clear what psychotherapy training psychiatrists are required to have and where this has changed over time for their current members. This could further safeguard members of the public who may wrongly assume that all psychiatrists can also practice as psychotherapists. Further to ensure that those psychiatrists who have psychotherapy training they state the extent and modality.

Supervision: ‘The greatest resistance is in the supervisor’

I have recently been involved in co-leading a 1-year supervision training programme. Tutors and trainees were all in full agreement that the greatest resistance to successful psychotherapy lays not so much within restrictions of the supervisee let alone the client. Rather, the greatest resistance derived from the therapeutic blind spots in the supervisor and not from any lack of knowledge of a particular model of supervision.

It can be difficult for a supervisor (besides being often also paid by the supervisee) to suggest, strongly or otherwise, that the supervisee might take an issue that has arisen to therapy when the supervisee is already registered as a psychotherapist or counsellor (perhaps the more so when it is peer supervision). However, it is assumed that it can be at least equally difficult for supervisors themselves to return to, let alone for the first time initiate having, personal therapy.

Additionally, consideration could be given to training organisations and supervisors ensuring that the supervisors chosen have the appropriate basic training that matches the trainees requirements. There are various trainings where trainees are assigned to placements and do not have to pay for their placement supervisors. However, sometimes insufficient attention may be paid as to whether the supervisor’s qualifications are commensurate with the modality and level of the trainee’s course. It is suggested that professional body and training organisation should insist that the correct supervisor is used and, if necessary this requiring payment by the trainee.

For referral agencies

To recheck the validity of advertisers’ claimed therapeutic qualifications, including for example university degrees that do not meet professional body standards.

To make clear to the public the nature of all therapeutic qualifications claimed by advertisers perhaps by using the ScoPeD framework, and ensure that this has to be consistent with what therapeutic advertisers state on their linked websites.

To also enable those who do not believe in professional therapeutic qualifications to advertise so long as this is made clear.

For therapist training organisations

(developed from Loewenthal, 2015 and The Critical Psychotherapy Network https://criticalpsychotherapy.wordpress.com)

To focus on education, as well as training, to include sociology, philosophy, anthropology, the arts and political economy.

To develop trainees’ skills to observe and deconstruct ideologies particularly of their own training.

To learn how to inform and challenge public policy and discourse

To lengthen counselling and psychotherapy trainings so that they are at least 3 if not 4 years of full-time training (or equivalent).

For psychotherapists, counsellors, psychoanalysts and psychologists

(developed from https://criticalpsychotherapy.wordpress.com and Loewenthal, 2015)

To resist threats to providing a therapeutic, confidential space.

To not be just seduced by methodologies that simply do not fit with what we do, but instead to find new ways of providing testimonial to ourselves, our colleagues and the public.

To be wary of state interventions and psychiatric nosology which threaten pluralism and the clients’ right to create a therapeutic space that works for them.

To be able to work with our own and others sexuality and violence.

To recognise the cult of individualism can create suffering and overshadow the common good.

To work actively around and outside the consulting room to inform and challenge public policy and discourse.

To continue to know how to learn about how our values and blind spots as therapist can limit our therapeutic effectiveness.

Traditionally this last point has been done through individual and group therapies. (I find it difficult to see how this can usually be done through self-development without a therapeutic relationship with another, preferably though admittedly again debatably, at least weekly throughout the training – unless the modality clearly does not involve a therapeutic relationship.)

To be aware that there will be blind spots in our training therapist and supervisor and partly through this in ourselves.

For the potential client

Where possible to first get a recommendation for a therapist from someone they trust. Also, if their distress allows it, to read the professional bodies websites which are likely to be more reliable than those of the referral agencies and sometimes of the individual therapist. Here check on choosing a therapist as to the type of therapy being offered, the therapist’s minimum length of training and what they write about their personal therapy.

Hopefully at least some of the aspects, regard- less of whether, or how ScoPeD is implemented, that have also been tentatively mentioned here will further safeguard the quality of future client’s therapeutic experience.

Before next introducing the papers, I very much want to thank the following for their invaluable assistance in developing this issue of the European Journal of Psychotherapy and Counselling: Gauri Chauhan, Georgaca Eugenie, Jasper Feyaerts, Kathleen Galvin, William Horsnell, Anthony McSherry, Peter Nevins, Sally Parsloe, Gillian Proctor, Daniel Rubinstein, Michael Scott and Patricia Talens. I would also like to again thank our translators: Nicole Fisher (German), Trish Talens (Spanish), Ayres Marques Pinto (Italian), Lea Misen (French) and Anna Mylona & Christina Lagogianni (Greek).

I would also like to welcome to our new book review editors: Ioannis Papadopoulos (North Hellenic Psychoanalytic Society, Greece) and Emmanouil Manakas (University of Thessaly, Greece). Further, to take this opportunity to give my particular thanks to Evrinomy Avdi (Aristotle University, Greece), who for numerous years has not only been our excellent Book Reviews Editor but has also inspirationally helped the journal in so many ways from Guest Editing, to reviewing papers, to bringing her knowledge and engaging presence to our editors meetings. We very much hope she will still find a little time to make some further contributions to the journal.

My thanks also to the book reviewers for this issue, namely, Di Adderley for reviewing The Marion Milner method: Psychoanalysis, autobiography, creativity by Alison Vaspe, Antonios Poulios for reviewing Sexuality Beyond Consent. Risk, Race, Traumatophilia by Avgi Saketopoulou, and Anthimos Tzikos for reviewing Disalienation: Politics, Philosophy, and Radical Psychiatry in Postwar France by Camille Robcis.

Finally, my further thanks, of course, to the authors of the following papers of this issue. Our first paper is Exploring themes of racialization in ‘The Vanishing Half’: Is the term ‘white passing’ a useful way for psychotherapists, counsellors and psychological therapists to conceptualise racial identity? Here the author, Olivia Mohtady draws on themes from The Vanishing Half and intersectionality theory to evaluate the usefulness of the term ‘white passing’ for psychological therapists, counsellors and psychotherapists exploring racial identity phenomena in their practice.

Reviewers comments include:

‘This is a well-written, articulate and scholarly manuscript that discusses the term “white-passing” within the broad field of crossectionality’.

‘I think this is a valuable contribution to the conversation about race and racialisation’.

Our next paper is:

‘Blurred facilitation stand’ - The hidden factor when working with LGBTQ: Diagnosis and addressing an unspoken effect of internalized homophobia. The author Eliezer Sharon has created the term ‘blurred facilitation stand” to underscore a unique effect that can surface in an encounter between a heterosexual or non-heterosexual therapist and a non-heterosexual client. The author argues that this effect may undermine the potency of a therapeutic alliance, which theoreticians and researchers affirm has unique dimensions in working with LBGTQ clients. Factors are discussed that lead to the ‘blurred facilitation stand’ and steps are proposed in the therapeutic process to reduce its effect.

Reviewers comments include:

Firstly, I would like to say that the paper is touching on something very important which can easily go unnoticed. The paper raises some very interesting ideas and brings with it debates about self-disclosure around sexuality within the therapeutic alliance.

‘Thank you for this article on an important subject. It is a good review of the literature and the complexities of therapist and client identities and disclosure of LGBTQ+ status’.

Our third paper is A return to Sartre. An existential approach to the therapeutic relationship with young people with anorexia nervosa: clinical examples from an inpatient eating disorder service. Here, the authors Kevin Ball and Lucia Giombini question the recommendation of the NICE guidelines for the psychological treatment of anorexia nervosa in young people of family-based therapy, cognitive behaviour therapy or psychodynamic therapy. They argue that with all of these approaches, externalisation is embedded as a therapeutic tool. In contrast, they explore Sartre’s phenomenological ontology as it does not presuppose the separation of the person from the illness, which can be seen as the basic premise of externalisation. (Again, papers arguing differently – very much welcomed.)

Reviewers comments include:

This was an interesting piece to read. It is clear that the authors have experientially gained insights into the significance of subjectivity/objectivity/intersubjectivity in the treatment of people with anorexia. It says some really useful things about why and how parents can be led to be so unhelpful to the young person, and how this might be mitigated. Also, how treatment options can be humanised for the families concerned.

Our next paper is:

An exploration of victim blaming in ‘medically unexplained symptoms’: Neoliberalism and the need to justify the self and the system by Joanne Hunt. The author argues that narratives within mainstream psy disciplines around ‘medically unexplained symptoms’ (MUS), as constructed through (bio)psychosocial theorising, have been charged with promoting victim blaming. Practitioner psychology is explored through a critical lens, locating this within a context of organisational and biopolitical influences which likely reinforce mainstream theory and practice. It is argued that (bio)psychosocial constructions of MUS satisfy society’s need to create and ascribe to a shared reality, dominated by a belief in a just, meaningful and relatively predictable world that justifies the self and broader social systems. Critical reflexivity is emphasised as a starting point for transforming practice.

Reviewers comments include:

‘The article brings to light a broad range of social and political factors at play within MUS. A very relevant and well written account of critical theory and implications towards practice’.

‘The authors ask what societal factors lead to the labelling of a person as suffering from MUS? They make use of psychodynamic explanations ‘splitting’, ‘defence’, ‘unconscious processes … ’.

Our final paper is Complementary perspectives in subclinical psychosis: from clinical high-risk and personality organisation to ordinary psychosis. In this paper, the author, George Mitropoulos, attempts to bring the Lacanian psychoanalytic concept of ‘ordinary psychosis’ into dialogue with the prevailing paradigms in psychiatry and psychodynamic theory regarding subclinical psychosis: respectively, the model of clinical-high-risk for psychosis and that of personality organisation/disorder. It offers insights into the communication between the medical and the psychodynamic models.

Reviewers comments include:

‘You have covered a wealth of knowledge across paradigms succinctly and helpfully for the reader. Thank you for writing this article. I think it will appeal to many clinicians and provoke wider reading and engagement with the practise of psychotherapy for unusual people.’

‘This is a very interesting paper, attempting to bring in dialogue psychiatric and psychoanalytic perspectives on subclinical psychosis, and mainly to offer the post-Lacanian concept of ordinary psychosis as a preferable solution to understanding and treating people with psychotic levels of functioning without overt psychotic manifestations. For a Lacanian inspired paper, it is commendable – and exceptional – that it engages with other perspectives, which are presented in a fair and accurate way’.

In conclusion, as with this last reviewer’s comments, it is very much hoped that we at the European Journal of Psychotherapy and Counselling will be presenting papers from you that also engage with other perspectives ‘in a fair and accurate way’.