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REGISTRATION AND ETHICS IN PSYCHOTHERAPY

by

Karl Figlio[1]     

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. 

 A contract:

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.

 Ethics:

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.

 

 



Notes

 

[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.

 

Britton, R. (1998) Publication anxiety. In Belief and Imagination: Explorations in  

     Psychoanalysis. London: Routledge.

 

Freud, S. (1912) Recommendations to physicians practising psycho-analysis. In The 

     Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 12.

     London: Hogarth/Institute of Psycho-Analysis, pp.109 – 20.

 

_______ (1913) On beginning the treatment (further recommendations on the

     technique of psycho-analysis, I). In SE, vol. 12, pp. 121 – 44.

 

Hinshelwood, R. (1997) Therapy or Coercion? Does Psychoanalysis Differ From

     Brainwashing. London: Karnac.

 

Levine, D.  (1999) The capacity for ethical conduct. In Psychoanalytic Studies 1:

     73 – 85.

 

Money-Kyrle, R. (1956) Normal counter-transference and some of its deviations. In 

     Melanie Klein Today: Developments in Theory and Practice (Ed. E. Spillius),

     vol. 2, Mainly Practice. London: Routledge.

 

Parsons, T. (1951) The Social System. London: Routledge & Kegan Paul.

 

Poovey, M. (1998) A History of the Modern Fact: Problems in Knowledge in the  

     Sciences of Wealth and Society. Chicago and London: University of Chicago 

     Press.

 

Stelzer, J. (1986) The formation and deformation of identity during psychoanalytic

     training. In Free Associations 7: 59 – 74.

                                               

Copyright: The Author

Address for  correspondence:  k.figlio@essex.ac.uk


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