The field of counselling and psychotherapy in the UK is rich and diverse, with several hundred different schools and orientations. Approaches to therapy differ enormously: some therapies focus on symptom-relief, some specifically avoid this; some aim at insight into unconscious phantasies, some reject the very notion of an unconscious; some try to bolster a patient’s belief-system, some to undermine it; some encourage physical warmth, some proscribe this; some aim to get patients back to work, some do not. The range of practices is extraordinarily wide, and the public benefits from a choice as to this range of different approaches.

Since the early 1970s, the field has organized itself into a small number of umbrella organisations - UKCP, BACP, BPC - which have worked progressively on codes of ethics, practice and complaints procedures. There have been various attempts over the years to add a statutory framework to the field’s own set of procedures, yet these have been consistently ignored or rejected by government. Nearly every practitioner currently working in the UK belongs to a professional association with codes of ethics, practice and complaints procedures, which is inspected periodically by its umbrella organisation. These codes were found by the UKCP-BACP mapping project, funded by the Department of Health, to fulfil or exceed HPC requirements.

This situation has not been especially controversial, yet calls for statutory regulation have been made by some therapists and lay people for the following reasons: there is nothing to stop any untrained person setting up a brass plate calling themselves a therapist; if a therapist is expelled from their professional organisation, there is nothing to stop them continuing to practise elsewhere; there are a small number of therapists who do not belong to any organisation and so are not subject to any agreed codes of ethics, practice and complaints procedures. These three factors are deemed to represent a significant
risk to the public, which is the main reason given for statutory regulation.

The scare stories circulated to the media by HPC and by Witness, an advocacy group that the HPC works closely with and that has received significant funding from the DoH, serve to inflate the risks involved and confuse the relevant issues. No therapy organisation in the UK to date has shown any opposition to regulation. The question for them is whether HPC regulation is the best way to deal with these issues of protection of the public. HPC regulates professional titles, so if it regulated the title ‘psychotherapist’, it would be illegal for anyone to use this title without being HPC-registered. Likewise, being struck off the HPC register would make it illegal for someone to continue to offer their services as a psychotherapist. This seems to solve the issue of public protection, yet HPC regulation in fact fails to do so since the practitioner may simply set up shop using another title not regulated by HPC: life coach, therapist, life skills advisor, mentor etc. It thus fails to deal with the brass plate argument or the practising after expulsion issue.

Even if it were to close these loopholes by regulating functions and not simply titles, HPC regulation poses a number of very serious problems to the field of the talking therapies. It subscribes to outcome-based notions of health and wellbeing which are rejected by many schools of therapy, as well as redefining the actual concept of therapy itself. Therapy is defined as the correction or ‘treatment’ of developmental and psychological dysfunction via the application of a set of techniques to the patient. Yet many schools of therapy see their work as totally opposed to this model based on the health/illness framework. For
them, therapy is a joint creative work, a collaborative effort to explore human life, with no manifest aims to ‘correct’ dysfunction or promote health.

The very notions of health, wellbeing, normality and dysfunction are rejected by many schools of therapy. These schools of therapy have a tradition of social critique, and distance themselves from the contemporary industry of ‘wellbeing’. Terms like ‘health’ and ‘wellbeing’, they argue, often carry a political agenda in any given society, and the work of therapy has to go beyond them. Psychoanalysis, for example, has always aimed to subvert received forms of knowledge, and hence the current objection from most of the UK’s psychoanalytic groups to subsume analysis into a framework which is based on received forms of knowledge and concepts which it has always rejected historically.

Given that the notions of health, wellbeing and illness run through HPC regulations, and influence its requirements regarding education and training, conduct, performance and the hearing of complaints, they naturally see HPC as unsuited to regulate their work. To construe therapy as a set of techniques to be applied to a patient, rather than as a relationship, an ongoing work between two people which can have no predictable outcomes or set goals, is to misunderstand its basic principles and ethics. HPC has redefined therapy though a medical lens which is not appropriate to the relationshipbased paradigm of analysis and most forms of therapy.

HPC uses a model of health professions as service industries: a client pays an expert for a service, which they deliver. But for many schools of therapy, the service is actually provided by the patient. Like an artist’s studio, the therapist provides a space where the patient can create something, following their own rhythm and logic. Therapy is thus not about the performance of any procedure. No outcome can be predicted in advance and so, contrary to the service industries, it is not self-evident which product the patient is paying for. This inherently risky work is clearly not served by pretending that its results and procedures are clear, predictable and transparent.

The most recent HPC Standards of Proficiency for Counselling and Psychotherapy testify to this misunderstanding of the therapeutic process. Therapists will have to:

- know how to operate equipment and minimise the risk of infection.
- know how to select appropriate hazard control and risk management, reduction or elimination techniques.
- have a knowledge of health, disease, disorder and dysfunction.
- be able to evaluate and implement intervention plans using recognised outcome measures.
- know when to use protective equipment.
- know how to formulate and deliver plans and strategies for meeting health and social care needs.
- understand the principles of quality control and quality assurance and conduct audits correspondingly.
- maintain an effective audit trail, participate in audit procedures and work towards continued improvement.
- be able to formulate specific and appropriate management plans including the setting of timescales.
- demonstrate a logical and systematic approach to problem solving and be able to initiate problem solving techniques.
- observe and record client’s responses.
- be able to demonstrate effective and appropriate skills in communicating information, advice and instruction.
- understand the need to engage service users and carers in planning and evaluating the diagnostics, treatment and interventions to meet their needs and goals.
- understand the importance of maintaining their own health.
- know how to meet the needs of the client.

Where other European projects to regulate psychotherapy have specifically avoided imposing a set view of what therapy should consist of - emphasising instead registration and complaints procedures - HPC’s framework is unique in Europe in actually prescribing rules and guidelines for the content of therapy sessions. The Standards have already provoked astonishment abroad, and a petition largely from German and French doctors and psychiatrists has been established (See Bibliography for details).

The HPC Standards of Proficiency may be suitable for some health professions, but will change radically the framework of current psychotherapy practice. Many therapists do not see their work as involving set outcomes, or data gathering, or problem solving, or drafting management plans for the health of their patients, or applying possibly unacceptable systems of classification of ‘disease’ or ‘dysfunction’ (See the detailed critique of these standards in Appendix 3).

Where medical interventions may involve set outcomes which the patient could complain about if not achieved, many therapies are about the open-ended work done not by the therapist but by the patient him or herself. One could visit a therapist’s office for years and not actually be doing a therapy, in the sense of being authentically engaged in an activity of self-exploration. Therapy, for many schools, is about what the patient manages to invent and construct in their encounters with the therapist, who does not apply the kind of protocol-based procedure envisaged by HPC.

Likewise, some schools of analysis and therapy hold that patterns of thought and behaviour that produce suffering in the patient derive from childhood responses to what is unknown and unpredictable in their caregivers. The compulsion to please others, for example, may have its roots in interactions with an erratic and unpredictable parent.

Therapy will play out this situation, so that the therapist may behave in an erratic and unpredictable way, allowing an access to the process by which the patient’s patterns of response were established. HPC’s emphasis on clarity of communication and behaviour may fit a small group of therapies, but cannot subsume this latter model.

Many clinicians who do not subscribe to the healthcare model see their work as an exploration of the human condition, a journey in the same sense that becoming a Buddhist monk involves a long process of questioning one’s life, ideals and expectations. Like a Buddhist training, this long process of psychotherapy cannot be identified with a set of techniques or procedures to be applied to a human being, but forms rather a strange kind of relationship which operates in unpredictable and unexpected ways. One cannot know what will happen in advance, and change often takes place through surprise, bafflement, shock and disappointment. HPC regulates professions within a framework which explicitly aims to remove these variables, and so it cannot accommodate those therapies which give a valued and central place to risk, shock and disappointment, seen as tools of growth and development.

A further and critical reason for the unsuitability of HPC as regulator lies in the field of ethics. Psychotherapy has, for the last 100 years, offered the patient a system of values freed from the moral judgments of social authorities. This has indisputably been the central characteristic of psychotherapy and what set it aside from the mental hygiene movement and from techniques of social engineering. Therapy provides a space for challenging received wisdom, social imperatives and norms of all kinds. Yet HPC regulation, for many schools of therapy, would involve the wholesale application of such norms to the therapeutic encounter. The therapist would have to become a ‘health professional’, whose practice must adhere to a moralistic and normative framework.
Failing this, the practitioner would be struck off.

This tension between psychotherapeutic ethics and social morals is a crucial issue, yet it must not be misunderstood to suggest that therapists see their work as somehow beyond the law. All therapy organisations agree that rigorous codes of ethics and conduct must be in place, as well as complaints procedures. In the event of any instance of sexual assault or financial fraud, the criminal justice system should be appealed to. In line with international practice, in other cases, mediation and informal resolution of complaints are the first step, rather than automatic escalation of a complaint to the level of litigation.

For some critics of traditional models of regulation, mediation and informal resolution are a profession’s way of avoiding responsibility for mistakes and misconduct. Yet escalation to the level of litigation and formal complaint may constitute barriers to real resolution of issues for those working within a non-healthcare model. For those therapies that are relationship-based, the parallel is less with HPC-regulated disciplines such as radiology or physiotherapy than with the introduction, encouraged by government, of mediation procedures as a first step when the divorce of a married couple is considered. Although this might seem surprising, it reflects more accurately the kind of problems some patients may experience in therapy - which, for many schools, is about re-living problematic relationships from the past – than the model of a failed medical intervention.

All of the above points have been made repeatedly to HPC by stakeholder groups, yet there has been no serious response to the issues raised. Rational debate is almost wholly absent, and the question of HPC regulation has been spun by HPC to give a picture of those therapists who oppose it as opposing any regulation of psychotherapy. As we have pointed out, this is by no means the case: the question is not ‘no regulation’ but ‘the appropriate regulation’, yet HPC has been unwilling to recognize this fact.

For these reasons, therapists and counsellors have been critical of the proposed HPC regulation of the field of the talking therapies. As well as criticism from many of the established groups, newly created organisations have been formed, brought together by serious concerns about HPC: The Alliance for Counselling and Psychotherapy and The Coalition Against Over-Regulation of Psychotherapy are two of the most vocal and active of these networks, and most of the UK’s best-known therapists have added their names to the petitions that these groups have created. One of the results of the work of these groups has been to show that most practitioners in the UK are not aware of the detail of the current proposals. This report aims, in part, to make this information available to practitioners, as well as to patients, prospective patients and anyone concerned with the practice of psychotherapy in the UK.