Maresfield Report

Over the last twenty years, a variety of proposals have been made regarding the question of the regulation of counselling and psychotherapy. During this time, organisations such as the UKCP, BACP and BPC have developed rigorous codes of ethics and practice, as well as complaints procedures, designed to ensure maximum protection of the public. Complaints panels must include both professional and lay representation, and are inspected periodically by the umbrella organisation. The most obvious question here is to ask why these structures need be disassembled, after the long process of their elaboration.

There are three main reasons usually cited: to introduce uniformity into the field, so that all procedures are identical; to ensure that bias is not introduced into proceedings by practitioners protecting practitioners; to produce a substantial reduction in the threat of serious harm to the public.

The first of these issues is perhaps the least controversial. All organisations agree on the basic point that in cases of sexual misconduct or financial fraud there should be the involvement of the criminal justice system. Yet such cases are very rare, and most instances of complaint concern friction within organisations, between colleagues or between trainees and training body. Cases of serious violation of professional boundaries are sometimes blamed on lack of regulation, yet in nearly all documented cases the perpetrators broke current laws of the land and hence the appeal to the criminal justice system.

The key question here concerns those cases which are not clear-cut sexual misconduct or fraud, and this introduces the second issue of the possible collusion between practitioners to preserve their reputations. Although such complaints are rare, they must be taken seriously, and this is where the particularity of the talking therapies should be recognised. All forms of talking therapy involve the phenomenon of transference, the mobilisation of thoughts and ideas from our infancy and childhood which have been pushed out of consciousness. Love or hate, for example, are not always easy for us to bear: sexual love for a family member or hatred of a caregiver are unacceptable to us, and so become repressed or radically pushed out of our minds. This, at least, is what 100 years of therapy has agreed. During a therapy, these thoughts and feelings will become real, yet generally without the conscious knowledge of the patient. They will experience them as entirely real and objective in relation to their therapist.

The key issue in the regulation debate has been protection of the public. Therapists accept that their clients need the highest possible form of protection from inadequate and unethical practitioners. No therapy organisation or individual has argued against this principle. Indeed, therapists have consistently been open and active to strengthen the effectiveness of their current systems by all reasonable means. However, there is no research-based evidence suggesting that the client-group here is in the degree of danger that would justify being forced into a type of regulation that, in many respects, is unsuitable and unworkable for current professional practices.

Working this through is the long, difficult and painful work of therapy. The key factor is that it is precisely this working through that the work of therapy consists of, and the therapist must accept to be in the place of a target for all the hostile, negative and amorous projections of the patient. Of course, the therapist will not respond to them in the way that one might in everyday life, and this will in itself create new problems. If a patient falls in love with their therapist and the latter refuses to requite the love, this may generate acute feelings of reproach. By accepting the place of the target of the patient’s projections, the therapist becomes the object of a very serious complaint: indeed, it is highly likely that any trauma or difficulty in the patient’s past will become reactualised in the therapy. If the patient had an abusive parent, it is almost certain that the therapist will be experienced as abusive at some point in the treatment. This is what makes therapy both so difficult and so fruitful, when such transferences are worked through.

Working within a framework that encourages complaint will of course have an impact on what happens to the thoughts and feelings mobilised in a therapy. Every patient will Complaints and the Protection of the Public probably have a complaint in a long-term therapy, yet this will be worked through rather than shifted to a different and legalistic level. The danger of the current proposals is that they fail to recognise the phenomenon of transference, and risk channelling them not into the pathways of working through but into those of adversarial formal complaint. This may well be encouraged by those no win/no fee law firms currently developing the area of ‘emotional harm’ perpetrated by therapists and the well-known fact that insurance companies today prefer to settle complaints in this field out of court.

The mediation procedures currently employed by most therapy organisations help the complainant to consider whether the resolution of the complaint is best settled within or outside the therapeutic space. Lay persons may be involved in this part of the process, and if it should later move to a formal complaint must form part of the panel hearing the complaint. These lay persons ensure against practitioners protecting practitioners, and their own knowledge of the therapeutic process makes them sensitive to the variables relevant to the context of psychotherapy.

Complainants may often be wary of the difficult and stressful bureaucratic process involved in a formal hearing, and see mediation as a better option. Mind service users, for example, have expressed concerns about a ‘paternalistic’ complaints process which would discourage the formulation of complaints. HPC complaints hearings, likewise, may require that the complainant disclose their medicals records, something that no current complaints procedure used by UK therapy organisations requires. HPC hearings are also held in public, unlike any of the current formal hearings that take place in therapy organisations or their umbrella bodies, and it may be traumatising for the complainant to have to discuss intimate details of their therapy in a public space, in front of a gallery that usually includes journalists. HPC hearings may be suited for the investigation of medicalstyle interventions that go wrong, but do not constitute a safe space for the complainant to disclose the personal issues that will usually be at play in a psychotherapy complaint. HPC, unlike therapy organisations and their umbrella bodies, provides no alternative routes to resolve complaints in a fashion sensitive to the complainant’s vulnerabilities.

This situation is made even more difficult by the HPC definition of a ‘service user’ as anyone who is affected by the practice of a registrant: relatives, carers and spouses thus become encompassed within the term ‘service user’. It is well-known that someone doing a therapy may make important changes in their relationships with those close to them, and that such changes are not always welcomed by the other party: distancing, divorce or dispute are not always easily tolerated. HPC’s framework would encourage complaints by those who believe that such changes are somehow the malign influence of the therapist, whatever the view of the patient him or herself. Even if the therapist is exonerated, great damage will be done by the time the complaint is heard.

In those cases where a formal complaint is made and upheld, proponents of HPC regulation argue that only their statutory framework will guarantee that the individual in question cease practising and hence cease to pose a danger to the public. The loophole here is that the individual may simply practise under another title – say, mentor or life coach - as long as they do not use the HPC-protected title of counsellor or psychotherapist. The Practitioner Full Disclosure model discussed below resolves this difficulty, as it involves the statutory requirement that any therapist provide full details of their qualifications and record to the Register. Failure to do so, and providing false information, would be a
criminal offence.

Another significant issue here is the place of complaints within the market of available treatments. To pay money to a therapist you have to know what product you will receive, and hence, if you don’t receive it, be able to complain. This is the position as stated by HPC. Now, a very small percentage of current therapies work within this model of offering a product. Most therapies, on the contrary, do not. For them, therapy is not a product to be applied but a relationship that develops between two people. One can never know what will happen to this relationship, how it will unfold or indeed what risks it may carry.

Most therapies, likewise, do not claim to remove symptoms. Symptoms may disappear during therapy, but this is not the cardinal goal. Rather, therapy involves an exploration of human life, a journey, and as such it cannot be easily shoehorned into the market-based model favoured by HPC.

This situation is rendered more complex by the fact that many therapies – and in particular psychoanalysis – aim specifically at disappointing or frustrating the expectations of the patient. If they expect one thing, the analyst must try to offer something else. The relation is based less on harmony than on discord. Contrary to the HPC requirement that the practitioner ‘must meet the needs of the patient’, psychoanalysis can only work if these needs are not met. According to many schools of psychoanalysis, this frustration will allow access to unconscious material. Through this process, the expectations and ideals of the patient can become clear and may then be challenged and undermined. Most of the time this does not occur through the analyst saying to the patient ‘You expect this’
or ‘You are like this’ but through the actual playing out of frustrations in the treatment. If the patient expects, for example, that the analyst is very moral or perhaps very immoral, the analyst may act in a way that reverses these expectations. Grasping these details of analytic work is crucial for situating potential complaints in their proper context and evaluating them.

The above points, however, should not be taken to support the absurd conclusion that therapists are never at fault. Yet they indicate that any body charged with hearing complaints about the talking therapies must be sensitive to the kind of dynamics involved in treatment, rather than the simplistic medical model of HPC. Faults occur in all human relationships – disappointments, frustrations, insensitivities, mistakes – and often generate strong feelings. Many forms of therapy not only recognise this but see it as an essential part of the therapy itself: the therapist’s mistakes and failings are confronted and explored. Crucially, this takes place within the therapy, allowing the patient to engage with issues of uncertainty, risk and the unknown.

The danger of current HPC regulatory proposals is a movement away from work within the therapy to complaints heard in another space, thus blocking the working through of the therapist’s failings as part of the therapeutic work. It is more logical to increase public information on this question, making it clear to the public what kinds of things may happen in a therapy. They may then engage or not depending on their own informed choice.

The objection might be made here: why this ‘soft’ approach to therapists? Surely if they are guilty of misconduct, they must be punished and struck off, thereby protecting the public. Yet the current system of complaints, with mediation as first step, is not soft in any way on serious issues of misconduct, as is made clear below in the section ‘The Alternative Model’. Therapists do not wish to see dangerous and unscrupulous individuals putting patients at risk and bringing their field into disrepute. The problem is with all the other frameworks that the HPC brings with it.

The risk here is that with HPC regulation, therapists will no longer take on ‘difficult’ patients, those they believe might make a complaint given the culture of encouraging formal complaint. Likewise, in their own practice, they may start to find themselves following a model of ‘defensive practice’, already described by some arts therapist now regulated by HPC and by some medical professionals. The patient is seen first and foremost as a potential complainant, and therapeutic interventions carefully selected so as not to run the risk of displeasing them. The consequences for the patient here are clear: less chance of accessing a therapist and less possibility of therapeutic change due to the restrictive parameters of intervention. Therapy becomes a practice of risk-management where avoidance of complaint or litigation takes priority over authentic work with the patient.

The HPC model also fails to protect the public in another specific way. HPC advertising shows smart professionals holding out their HPC certificates to members of the public, with the message ‘You can trust me, I’m HPC-registered’. Yet in fact, all of HPC complaints hearings concern practitioners who were precisely HPC-registered. There is a certain danger in fostering the illusion that a certificate guarantees trustworthiness, a fact borne out by the actual history of complaints against HPC practitioners. Creating a culture in which trust and expertise are supposed to be guaranteed by a piece of paper will also arguably accentuate the prospective patient’s suggestibility, and hence make them more vulnerable to potential abuse. An attitude of scepticism is far more likely to protect the patient, making them alert to possible boundary violations or, indeed, to the simple fact of poor practice. In contrast, the HPC approach risks fostering a false sense of security and suspension of critical judgement in the public.

An analysis of HPC complaints hearings – detailed in Appendix 2 below – brings out many of the problems discussed as well as indicating the inordinate expenditures involved. In 2008, HPC spent £3.76m on complaints, yet out of 108 allegations made by the public (25% of all allegations), HPC was only able to consider 63 cases in the year, leaving 45 allegations made by the public unconsidered. This builds up a massive backlog, and no doubt puts undue strain and stress on both complainants and those complained against. Only 18 (29%) of the 63 cases from the public that were considered were taken any further, with 45 deemed unfounded. The large part of the £3.76m was thus spent processing allegations from employers, the HPC itself, others within the profession and a small number from the police.

The situation was similar in 2007. £2.9m was spent on complaints, yet out of 78 allegations made by the public, HPC were only able to consider 34. Of these 34, only 12 were found to have a case to answer. 56% of the total allegations made by the public were not considered. Most of the allegations made by the public have not been heard within the year they were made, unlike in the majority of therapy organisations where complaints are dealt with usually within 4 to 5 months of being made. HPC’s bureaucratic and slow handling of complaints generates a growing backlog of complaints. Each year since HPC was established, there have been 30% more allegations made than cases considered. The vast majority of these allegations are made by employers, the HPC itself or from those working within the field. The analysis in Appendix 2 shows that these complaints from employers are clearly prioritsed over complaints from members of the public, yet with registrants paying for hearings rather than employers.

A comparison with the current statistics held by UKCP for the handling of complaints is illuminating. It captures significantly more complaints than HPC. It deals with them more sensitively, using mediation and informal systems of resolution, with nearly 60% dealt with in a satisfactory way by informal processes of mediation. Crucially, it has a higher case to answer rate and a better response rate for complainants. Where HPC finds no case to answer in over 70% of complaints, UKCP found no case to answer in just over 10%. It is also better value for money, with costs nowhere near the HPC figure. See Appendix 2 for further details and comparisons.

These advantages characterise the PFD model for dealing with complaints, detailed below in the section ‘The Alternative Model’. Unless the allegation concerns breach of existing laws, it is heard first of all at a local level, with an emphasis on giving the complainant access to informal systems of resolution. If this is not satisfactory to the complainant, it moves to the level of formal complaint, to be dealt with by the organisation to which the therapist in question belongs. Complaints not resolved at this level - which have to date been quite rare - are then passed on to the PFD complaints panel, which appoints an officer to investigate. Mediation and informal techniques of resolution are favoured as a first stage, although the panel may decide that there are grounds for formal complaint. Sanctions are decided on a case by case basis, and may include exclusion from the PFD register.

	The Maresfield Report

	Complaints and the Protection of the Public

	Over the last twenty years, a variety of proposals have been made regarding the question of the regulation of counselling and psychotherapy. During this time, organisations such as the UKCP, BACP and BPC have developed rigorous codes of ethics and practice, as well as complaints procedures, designed to ensure maximum protection of the public. Complaints panels must include both professional and lay representation, and are inspected periodically by the umbrella organisation. The most obvious question here is to ask why these structures need be disassembled, after the long process of their elaboration. There are three main reasons usually cited: to introduce uniformity into the field, so that all procedures are identical; to ensure that bias is not introduced into proceedings by practitioners protecting practitioners; to produce a substantial reduction in the threat of serious harm to the public. The first of these issues is perhaps the least controversial. All organisations agree on the basic point that in cases of sexual misconduct or financial fraud there should be the involvement of the criminal justice system. Yet such cases are very rare, and most instances of complaint concern friction within organisations, between colleagues or between trainees and training body. Cases of serious violation of professional boundaries are sometimes blamed on lack of regulation, yet in nearly all documented cases the perpetrators broke current laws of the land and hence the appeal to the criminal justice system. The key question here concerns those cases which are not clear-cut sexual misconduct or fraud, and this introduces the second issue of the possible collusion between practitioners to preserve their reputations. Although such complaints are rare, they must be taken seriously, and this is where the particularity of the talking therapies should be recognised. All forms of talking therapy involve the phenomenon of transference, the mobilisation of thoughts and ideas from our infancy and childhood which have been pushed out of consciousness. Love or hate, for example, are not always easy for us to bear: sexual love for a family member or hatred of a caregiver are unacceptable to us, and so become repressed or radically pushed out of our minds. This, at least, is what 100 years of therapy has agreed. During a therapy, these thoughts and feelings will become real, yet generally without the conscious knowledge of the patient. They will experience them as entirely real and objective in relation to their therapist. The key issue in the regulation debate has been protection of the public. Therapists accept that their clients need the highest possible form of protection from inadequate and unethical practitioners. No therapy organisation or individual has argued against this principle. Indeed, therapists have consistently been open and active to strengthen the effectiveness of their current systems by all reasonable means. However, there is no research-based evidence suggesting that the client-group here is in the degree of danger that would justify being forced into a type of regulation that, in many respects, is unsuitable and unworkable for current professional practices. Working this through is the long, difficult and painful work of therapy. The key factor is that it is precisely this working through that the work of therapy consists of, and the therapist must accept to be in the place of a target for all the hostile, negative and amorous projections of the patient. Of course, the therapist will not respond to them in the way that one might in everyday life, and this will in itself create new problems. If a patient falls in love with their therapist and the latter refuses to requite the love, this may generate acute feelings of reproach. By accepting the place of the target of the patient’s projections, the therapist becomes the object of a very serious complaint: indeed, it is highly likely that any trauma or difficulty in the patient’s past will become reactualised in the therapy. If the patient had an abusive parent, it is almost certain that the therapist will be experienced as abusive at some point in the treatment. This is what makes therapy both so difficult and so fruitful, when such transferences are worked through. Working within a framework that encourages complaint will of course have an impact on what happens to the thoughts and feelings mobilised in a therapy. Every patient will Complaints and the Protection of the Public probably have a complaint in a long-term therapy, yet this will be worked through rather than shifted to a different and legalistic level. The danger of the current proposals is that they fail to recognise the phenomenon of transference, and risk channelling them not into the pathways of working through but into those of adversarial formal complaint. This may well be encouraged by those no win/no fee law firms currently developing the area of ‘emotional harm’ perpetrated by therapists and the well-known fact that insurance companies today prefer to settle complaints in this field out of court. The mediation procedures currently employed by most therapy organisations help the complainant to consider whether the resolution of the complaint is best settled within or outside the therapeutic space. Lay persons may be involved in this part of the process, and if it should later move to a formal complaint must form part of the panel hearing the complaint. These lay persons ensure against practitioners protecting practitioners, and their own knowledge of the therapeutic process makes them sensitive to the variables relevant to the context of psychotherapy. Complainants may often be wary of the difficult and stressful bureaucratic process involved in a formal hearing, and see mediation as a better option. Mind service users, for example, have expressed concerns about a ‘paternalistic’ complaints process which would discourage the formulation of complaints. HPC complaints hearings, likewise, may require that the complainant disclose their medicals records, something that no current complaints procedure used by UK therapy organisations requires. HPC hearings are also held in public, unlike any of the current formal hearings that take place in therapy organisations or their umbrella bodies, and it may be traumatising for the complainant to have to discuss intimate details of their therapy in a public space, in front of a gallery that usually includes journalists. HPC hearings may be suited for the investigation of medicalstyle interventions that go wrong, but do not constitute a safe space for the complainant to disclose the personal issues that will usually be at play in a psychotherapy complaint. HPC, unlike therapy organisations and their umbrella bodies, provides no alternative routes to resolve complaints in a fashion sensitive to the complainant’s vulnerabilities. This situation is made even more difficult by the HPC definition of a ‘service user’ as anyone who is affected by the practice of a registrant: relatives, carers and spouses thus become encompassed within the term ‘service user’. It is well-known that someone doing a therapy may make important changes in their relationships with those close to them, and that such changes are not always welcomed by the other party: distancing, divorce or dispute are not always easily tolerated. HPC’s framework would encourage complaints by those who believe that such changes are somehow the malign influence of the therapist, whatever the view of the patient him or herself. Even if the therapist is exonerated, great damage will be done by the time the complaint is heard. In those cases where a formal complaint is made and upheld, proponents of HPC regulation argue that only their statutory framework will guarantee that the individual in question cease practising and hence cease to pose a danger to the public. The loophole here is that the individual may simply practise under another title – say, mentor or life coach - as long as they do not use the HPC-protected title of counsellor or psychotherapist. The Practitioner Full Disclosure model discussed below resolves this difficulty, as it involves the statutory requirement that any therapist provide full details of their qualifications and record to the Register. Failure to do so, and providing false information, would be a criminal offence. Another significant issue here is the place of complaints within the market of available treatments. To pay money to a therapist you have to know what product you will receive, and hence, if you don’t receive it, be able to complain. This is the position as stated by HPC. Now, a very small percentage of current therapies work within this model of offering a product. Most therapies, on the contrary, do not. For them, therapy is not a product to be applied but a relationship that develops between two people. One can never know what will happen to this relationship, how it will unfold or indeed what risks it may carry. Most therapies, likewise, do not claim to remove symptoms. Symptoms may disappear during therapy, but this is not the cardinal goal. Rather, therapy involves an exploration of human life, a journey, and as such it cannot be easily shoehorned into the market-based model favoured by HPC. This situation is rendered more complex by the fact that many therapies – and in particular psychoanalysis – aim specifically at disappointing or frustrating the expectations of the patient. If they expect one thing, the analyst must try to offer something else. The relation is based less on harmony than on discord. Contrary to the HPC requirement that the practitioner ‘must meet the needs of the patient’, psychoanalysis can only work if these needs are not met. According to many schools of psychoanalysis, this frustration will allow access to unconscious material. Through this process, the expectations and ideals of the patient can become clear and may then be challenged and undermined. Most of the time this does not occur through the analyst saying to the patient ‘You expect this’ or ‘You are like this’ but through the actual playing out of frustrations in the treatment. If the patient expects, for example, that the analyst is very moral or perhaps very immoral, the analyst may act in a way that reverses these expectations. Grasping these details of analytic work is crucial for situating potential complaints in their proper context and evaluating them. The above points, however, should not be taken to support the absurd conclusion that therapists are never at fault. Yet they indicate that any body charged with hearing complaints about the talking therapies must be sensitive to the kind of dynamics involved in treatment, rather than the simplistic medical model of HPC. Faults occur in all human relationships – disappointments, frustrations, insensitivities, mistakes – and often generate strong feelings. Many forms of therapy not only recognise this but see it as an essential part of the therapy itself: the therapist’s mistakes and failings are confronted and explored. Crucially, this takes place within the therapy, allowing the patient to engage with issues of uncertainty, risk and the unknown. The danger of current HPC regulatory proposals is a movement away from work within the therapy to complaints heard in another space, thus blocking the working through of the therapist’s failings as part of the therapeutic work. It is more logical to increase public information on this question, making it clear to the public what kinds of things may happen in a therapy. They may then engage or not depending on their own informed choice. The objection might be made here: why this ‘soft’ approach to therapists? Surely if they are guilty of misconduct, they must be punished and struck off, thereby protecting the public. Yet the current system of complaints, with mediation as first step, is not soft in any way on serious issues of misconduct, as is made clear below in the section ‘The Alternative Model’. Therapists do not wish to see dangerous and unscrupulous individuals putting patients at risk and bringing their field into disrepute. The problem is with all the other frameworks that the HPC brings with it. The risk here is that with HPC regulation, therapists will no longer take on ‘difficult’ patients, those they believe might make a complaint given the culture of encouraging formal complaint. Likewise, in their own practice, they may start to find themselves following a model of ‘defensive practice’, already described by some arts therapist now regulated by HPC and by some medical professionals. The patient is seen first and foremost as a potential complainant, and therapeutic interventions carefully selected so as not to run the risk of displeasing them. The consequences for the patient here are clear: less chance of accessing a therapist and less possibility of therapeutic change due to the restrictive parameters of intervention. Therapy becomes a practice of risk-management where avoidance of complaint or litigation takes priority over authentic work with the patient. The HPC model also fails to protect the public in another specific way. HPC advertising shows smart professionals holding out their HPC certificates to members of the public, with the message ‘You can trust me, I’m HPC-registered’. Yet in fact, all of HPC complaints hearings concern practitioners who were precisely HPC-registered. There is a certain danger in fostering the illusion that a certificate guarantees trustworthiness, a fact borne out by the actual history of complaints against HPC practitioners. Creating a culture in which trust and expertise are supposed to be guaranteed by a piece of paper will also arguably accentuate the prospective patient’s suggestibility, and hence make them more vulnerable to potential abuse. An attitude of scepticism is far more likely to protect the patient, making them alert to possible boundary violations or, indeed, to the simple fact of poor practice. In contrast, the HPC approach risks fostering a false sense of security and suspension of critical judgement in the public. An analysis of HPC complaints hearings – detailed in Appendix 2 below – brings out many of the problems discussed as well as indicating the inordinate expenditures involved. In 2008, HPC spent £3.76m on complaints, yet out of 108 allegations made by the public (25% of all allegations), HPC was only able to consider 63 cases in the year, leaving 45 allegations made by the public unconsidered. This builds up a massive backlog, and no doubt puts undue strain and stress on both complainants and those complained against. Only 18 (29%) of the 63 cases from the public that were considered were taken any further, with 45 deemed unfounded. The large part of the £3.76m was thus spent processing allegations from employers, the HPC itself, others within the profession and a small number from the police. The situation was similar in 2007. £2.9m was spent on complaints, yet out of 78 allegations made by the public, HPC were only able to consider 34. Of these 34, only 12 were found to have a case to answer. 56% of the total allegations made by the public were not considered. Most of the allegations made by the public have not been heard within the year they were made, unlike in the majority of therapy organisations where complaints are dealt with usually within 4 to 5 months of being made. HPC’s bureaucratic and slow handling of complaints generates a growing backlog of complaints. Each year since HPC was established, there have been 30% more allegations made than cases considered. The vast majority of these allegations are made by employers, the HPC itself or from those working within the field. The analysis in Appendix 2 shows that these complaints from employers are clearly prioritsed over complaints from members of the public, yet with registrants paying for hearings rather than employers. A comparison with the current statistics held by UKCP for the handling of complaints is illuminating. It captures significantly more complaints than HPC. It deals with them more sensitively, using mediation and informal systems of resolution, with nearly 60% dealt with in a satisfactory way by informal processes of mediation. Crucially, it has a higher case to answer rate and a better response rate for complainants. Where HPC finds no case to answer in over 70% of complaints, UKCP found no case to answer in just over 10%. It is also better value for money, with costs nowhere near the HPC figure. See Appendix 2 for further details and comparisons. These advantages characterise the PFD model for dealing with complaints, detailed below in the section ‘The Alternative Model’. Unless the allegation concerns breach of existing laws, it is heard first of all at a local level, with an emphasis on giving the complainant access to informal systems of resolution. If this is not satisfactory to the complainant, it moves to the level of formal complaint, to be dealt with by the organisation to which the therapist in question belongs. Complaints not resolved at this level - which have to date been quite rare - are then passed on to the PFD complaints panel, which appoints an officer to investigate. Mediation and informal techniques of resolution are favoured as a first stage, although the panel may decide that there are grounds for formal complaint. Sanctions are decided on a case by case basis, and may include exclusion from the PFD register.