4 November 2014

Regulation - a client and therapist friendly way forward?

by Amanda Williamson

[Please note that this post was edited on 17th August 2015 due to the change of name of the Professional Standards Authority's registers from Accredited Voluntary Registers (AVRs) to Accredited Registers (ARs]

I am pro-regulation of my profession. In fact, as I have said previously,  in my opinion counselling and psychotherapy are currently more of a free for all than a profession. What other profession exists, where such a position of immense trust is involved, where a professional who is proven to abuse or exploit that position of trust can carry on his/her practice unimpeded? 

As a counsellor, every time I hear of another therapists' disgraceful behaviour I ask myself; what am I part of? 

The good news is, there have been improvements in the industry and we now have voluntary regulation. More on that below.

Sadly, the real world = rotten apples in EVERY profession

Sticking our fingers in our ears and singing ourselves a pretty tune will not change the fact that therapist abuse occurs and the fact that the impact can be retraumatising and devastating for a client on the receiving end of abuse or exploitation by a therapist.

I want clients to be protected from sociopathic and narcissistic therapists as far as possible. I also want them to be protected from incompetent therapists. But it also important to me that I feel that the profession I am in has integrity and self-awareness. With no regulation and scant research we are operating in the dark. How can we foster self-awareness and integrity in our clients or even in ourselves if our profession chooses to stumble around unchallenged?

Who cares what I want? Who's opinion REALLY matters?

More important than what I, or indeed other therapists want, what do our clients want? I am an advocate of Mick Cooper and John McLeod's Pluralistic Approach to counselling and psychotherapy which I see as a research based and intelligent progression of the concept of person-centredness. So instead of assuming that I know what's best for clients I asked them. My findings can be found here where I discovered that 92% of people asked were for regulation, most of whom were strongly for. What is compelling is that I then found a poll held in Ireland which gave very similar results, with over 80% of people asked thinking that the profession should be regulated.

Then recently Phil Dore aka Zarathustra (more on him later) sent me this research done by Mind (EDIT Link no longer exists as of Jan 2024); Findings from a service user survey on the regulation of counselling and psychotherapy. Again, findings that mirror my own in respect of public/service user opinion. Some of the comments from service users regarding incompetent/unethical behaviour from therapists will make your toes curl. 

EVERYBODY, regardless on their stance on regulation would do well to read all of these, particularly the Mind article to increase their awareness of what this is really about. 

Since being vocal about my wish to shine light on the shadow side of our profession I have been approached by clients and by fellow professionals from all over the country sharing snippets (or more) of their experience of abuse by a therapist. Of course, you only have my word for that. But I am not alone. Many of these people felt powerless in the complaints process and like me, some of them have sometimes wondered if there is any point in a complaints process when serious or gross misconduct does not stop a practitioner from carrying on regardless.

Do we need regulation?

This is a very emotive question. There are people vehemently lodged on each side. As I have said before, I have tried to look outside of my restrictive, personal agenda and look at the bigger picture. 

First of all, somebody who I think has a very important perspective on this is Dawn Devereux, (formerly) the Director of Public Support for the Clinic for Boundaries Studies. This clinic specialises in professional boundaries and boundary violations. Dawn featured in a Guardian article in 2009 saying pretty much what I am saying today, that regulation is needed. Dawn too learnt experientially of the need for regulation, by being abused by her therapist as a trainee. I have to say that some of the people who have contacted me regarding therapist abuse were trainee therapists at the time. If you have any ambivalence or cynicism regarding this I highly recommend Peter Rutter's Sex in the Forbidden Zone which articulates the power dynamics and abuse of position of trust most compellingly.

On the clinic's website they state the following:

"We believe that some practitioners who have violated boundaries will never be safe enough to work with the public in a professional role; we also believe that some have the capacity to be successfully rehabilitated, alongside their professional accountabilities.
We recognise that anyone can become a victim of professional abuse, just as anyone can become a perpetrator." 
So, I told Dawn that I was writing this post on regulation and she offered the following:

"About 20% of the calls we get are from people who have seen a psychotherapist or counsellor who turns out not to be registered with a professional body.  Sometimes these people are actually qualified and have chosen not to register, but many have no recognised qualification at all.  This means that unless the actions of the 'professional' constitute a criminal offence there is usually nothing the person can do to seek redress.  The only way to remedy this is to have statutory regulation that protects the title of 'counsellor' and 'psychotherapist' .  The idea that professionals will simply call themselves something else sounds reasonable in theory but in practice this doesn't seem to be a problem for others professions with protected titles such as doctors.  I have never come across a case of someone pretending to be a doctor by calling themselves something similar".

So back to Phil Dore aka Zarathustra who authors a blog called The Not So Big Society. I have got to know Phil over the last couple of years, orginally making contact with him via his blog posts on abusive therapists. I was researching the therapist Derek Gale who was struck off the HPC and UKCP for abusive practice. 

It turns out that Phil has become a bit of a port of call for people who have been abused by their therapist. His blog/s come up on Google and he writes extensively about the topic. I am aware that he has been contacted by many people, some of whom are desperate for support or advice. I asked Phil to comment, given his vantage point:

"A few years ago I wrote a blog post saying I thought counselling and psychotherapy should be regulated. Since then I've received a steady stream of first-hand accounts from people who've been emotionally or sexually abused while in a therapeutic relationship. Such cases are enormously traumatising, and sadly often happen to already-vulnerable people. I've been shocked not only by the nature of the cases, but also by the way the perpetrators either don't get struck off, or do get struck off and just carry on practising. One of my readers did a survey of people who'd been removed from the BACP register, and found that 22% of them were still advertising themselves as counsellors or psychotherapists."

Opposition to regulation from within the industry

A couple of weeks after the Palace Gate/Phoenix Counselling story was in the papers I was discussing regulation on Twitter. Somebody expressed dissatisfaction at the HCPC (formerly HPC) model. The Labour government were going to introduce statutory regulation of therapy via the HPC but the plans were abolished by the coalition. I appreciate that there were a number of therapists who were opposed to this route and indeed, the Alliance for Counselling and Psychotherapy formed in order to oppose this planned state regulation. This fellow Tweep emailed me with his concerns at regulation, two issues being the bureaucracy and the requirement for homogeneity of therapies. It struck me at that moment that with the existing voluntary register scheme that we already have something in place that could be built upon.

The Accredited Registers (ARs)

So at the moment, we have voluntary regulation and it is the Professional Standards Authority who oversee different ARs. There are currently five ARs listed for psychotherapy and six listed for counselling. So if a practitioner says that they are on an approved AR you can check each register online for their individual registration. For example, you can check my entry on the BACP register here. Being on this register means that I have a minimum level of qualifications and have insurance. It also means that if a client were to make a complaint about unethical behaviour then I could be sanctioned or struck off. In theory, I would not be able to join any of the other ARs because there is supposed to be system in place whereby the ARs communicate regarding struck off therapists. How this actually happens in practice and how it ensures that practitioners don't slip through the net I really don't know at this point.

So it makes sense to me that there exists a system that could be adapted. Essentially, take the voluntary aspect out of the Accredited Register scheme. Make it illegal for somebody to practice as a therapist without being part of the one of the several ARs available.

Could this work as a way forward? Can we give the public what they want in terms of statutory regulation (and many assume already exists) AND keep therapists happy? What about the associated professional bodies? 

I wrote to various AR [or AVR as they were known at the time] holders and was pleased to receive responses in answer to the following question: 

I am writing a blog post on the regulation of counselling and psychotherapy and specifically on the premise of it being via the existing PSA AVR route, effectively taking the "V" out of AVR. 

I am very much pro-regulation but do appreciate that there is sizable opposition within the industry regarding the HCPC route. Whilst I am sympathetic to the concerns I am not personally totally opposed to regulation via the HCPC route. That said, I do believe that statutory regulation that builds on the existing PSA AVR scheme would be favourable overall, perhaps for the government in terms of expenditure and, I would imagine, for those within the industry that have fears around the HCPC route.

I am asking various stakeholders their opinion on statutory regulation through the PSA led accredited register and would very much appreciate comment from the _____ on this matter.

The first response was from Liz McElligot the CEO of the NCS who replied thus:

The NCS supports the current AVR scheme as the best way of regulating counselling and related professions.

 Should a statutory scheme be able to be developed, the NCS would support this being an adaptation of the current AVR scheme.   Building statutory regulation around professional associations would ensure that the profession is always at the heart of regulation, rather than having it imposed.  It would protect counsellors, counselling modalities, access to training and the volunteer sector. 

In addition, our experience of the Professional Standards Authority is that they have been very willing to engage with professional associations across a number of therapies and do so in a highly productive manner.  We would support them as our regulator of choice should statutory regulation be progressed.

I also heard back from Ruth Clowes, the media and communications manager at the BACP:

As you’re aware, we have for some time been working, and continue to work, within the current Government's preferred regulatory framework for the counselling and psychotherapy professions, the Accredited Voluntary Register scheme. Statutory regulation through the Health and Care Professions Council (HCPC) was proposed by previous administrations and historically was indicated as the path the profession would follow – as such we were keen to work with the proposed regulators to ensure the best regulation for the profession. Subsequently, this route changed to voluntary regulation and we made a commitment to work within this new form of public protection.

Crucially, we’re committed to working within any regulatory framework that will deliver the high professional standards and a level of public protection across the whole counselling and psychotherapy professions that is expected of our members through the Ethical Framework for Good Practice in Counselling and Psychotherapy.

After chasing them up, I received a response from the UKCP via their communications manager, Sandra Scott:

To answer your question about regulation, we are in favour of regulation.  We are the voluntary regulator of psychotherapists. There is no proposal for state regulation on the table for us to comment on.  But our voluntary register has been accredited by the PSA, an agency of the state.

I find it interesting that the UKCP refer to themselves as the regulator of psychotherapists as it is my understanding that the BACP also regulate psychotherapists. I also would argue that "voluntary regulation" isn't actually regulation, the two words in the phrase being paradoxical. I suppose that's an issue of semantics.

The Professional Standards Authority provided a prompt and informative response:

Making it compulsory to join an accredited register and creating protected titles would in effect recreate statutory regulation. In this case, whether compulsory registers were held by the HCPC or accredited by the Professional Standards Authority, they would restrict individuals’ right to work. This would require the government to satisfy various legal requirements, including compliance with the Human Rights Act. It is for Parliament to decide whether that would be appropriate. 

The Authority’s view is that Right-touch regulation requires us to first look at the existing system. We must consider whether the scheme is providing the right level of protection and work to develop it wherever there is scope to do so.

Accreditation is not regulation. It is a different form of assurance. It does have one limitation: it cannot bar practitioners from working, although accredited registers are required to recognise each other’s decisions – to strike someone off the register for poor practice such as financial dishonesty or abusive behaviour. If a complaint is brought to an accredited register about the conduct of one of its registrants it may – following consideration under its complaints procedures – strike the person off its register. If this were to happen, the other accredited registers would not permit that person to join them. This means that the public and NHS employers can avoid poor practice by only using people who are on an accredited register.  

The Authority believes that there is scope for improvement, for example through the disclosure and barring scheme, which can be used to prevent unsuitable people from working in health and care. Making this work effectively will achieve a similar result in removing unsuitable people from health and care occupations. The Authority will continue to advocate this approach with the Department of Health.

Accredited registers, however, can and should provide the public with appropriate protection and improve quality in counselling and psychotherapy, as well as the other occupations covered by the scheme. As it stands, the Authority has accredited four registers of counsellors and psychotherapists, all of which provide the public with good levels of protection. Our challenge is to harness the benefits of choice. 
Counsellors and psychotherapists may choose to belong to accredited registers. In doing so, each makes a personal commitment to high standards and to quality. We expect that any practitioner with a commitment to professionalism and compassion for the people who use their services will choose to belong to an accredited register. 

Wherever possible, members of the public should always choose a practitioner from an accredited register. We and the accredited registers are using every opportunity we can to educate the public about the registers and how they protect people looking for health and care services. Anyone using the NHS to access counselling and psychotherapy should be referred to a therapist on an accredited register. This scheme is recognised by key stakeholders including NHS Employers, NHS England and the Care Quality Commission.

As more and more people choose practitioners from accredited registers and increasing numbers of practitioners choose to belong to one, it will become very difficult to work as a counsellor or psychotherapist without belonging to an accredited register. Belonging to an accredited register will be mandatory in practice, if not by law. 

The Authority does recognise that there is some way to go to reach this goal. To arrive there, we need the support of counsellors and psychotherapists, as well as other practitioners covered by accredited registers. We hope that you, your readers and everyone who cares about counselling and psychotherapy will help us to spread the word about accredited registers.

What about other stakeholders? Well, given the very vocal opposition to the HPC/HCPC route by the Alliance for Counselling and Psychotherapy I sent them the same question. I received two responses. The first was from a member to whom my email had been forwarded:

One aspect I have a personal investment in is the area of multidisciplinary therapists. Therapists registered in one psychological therapy under AVR can practice in other areas (subject obviously to competence) without duplication of regulation. Thus professional bodies like NACHP, NCP, SSM, and other bodies with trained therapists providing a range of psychological therapies (usually counselling, psychotherapy, psychoanalysis, hypnotherapy, coaching) can be providing several and be avr registered under the umbrella of CNHC (voluntary regulator and AVR) under the hypnotherapy category.  

Likewise several colleagues of mine are BACP or UKCP avr registered and provide coaching or hypnotherapy. Some are HCPC psychologists providing other therapies etc
The danger of AR might be that suddenly false divides occur where people on one register, say CNHC, are suddenly unable to practice parts of their skill set because of a simple rule change. 

I would be fairly happy with AR if there was an acceptance that a primary psychological therapy needs to be covered, but with that in place other therapies can also be provided if competent and insured. 

Hmmn. Very reasonable and open I thought.

Then a few days later I recieved this email from "The Alliance":

Thank you for your interest in the Alliance’s views on making Assured Voluntary Regulation statutory by removing the voluntary element. The Alliance has consistently opposed the statutory regulation of counselling and psychotherapy. We cautiously welcomed the PSA voluntary registers scheme and are interested in dialogue on the future of the field, so can you say why you think this new form of regulation should be scrapped so soon after its inception? What do you hope would be achieved? How would the statutory system you propose improve the experiences of clients seeking, undertaking and/or having difficulties within therapy?

Well first of all, I don't think it should be scrapped, rather, built upon. What I hope to be achieved is the protection of clients from therapists who have been found to be abusive or exploitative as there is currently nothing to stop them from practising. I think I have already made this point in the first part of this article.

Where I'm at for now…

As a professional...

There isn't ever going to be any such thing as the perfect regulation for our profession. However, I strongly believe that regulation is necessary for the overall good of our clients and the profession. I do find the PSA are approachable and willing to listen, which is a good start.

I have also done a lot of thinking about the individual organisational body that I am a member of. The BACP have received criticism for allegedly "empire building".   I became a member of the BACP because I did a BACP accredited course and it was mandatory. They do also happen to be the largest body, membership wise.  Since qualifying I have learned more about each body, read the various criticisms of each and have given great consideration as to which organisation I should be with. I conclude that the BACP are the best fit for me. 

As a counsellor, being fully appreciative of the potential for damage to clients of getting it wrong, I welcome the opportunity for my practice to be scrutinised if somebody believes that my practice has had an adverse effect on them. It would be stressful and incredibly difficult but if somebody truly feels that my work has harmed then what sort of therapist would I be if I tried to shut that person down, with no mediation, no recourse and no accountability whatsoever on my part. 

I would also say that having been through the accreditation process for the BACP I am aware of how rigorous it is. It is my understanding that they set the highest standards for their individual members which gives me the confidence that on balance, this is an organisation I choose to be a part of.

As a client…

As a complainant in a BACP professional conduct hearing I am satisfied that the panel were aware enough to look at the complaint objectively and professionally (although it seemed unfair sometimes, because they were being so fair!). The only disappointment I felt acutely was the fact that the BACP findings effectively remain hidden from potential future clients of this therapist. But that is not the responsibility of the BACP in a profession without regulation. 

My hope is that all the ARs under the PSA have robust enough complaints procedures but only time will tell. At least there is now a port of call for complainants (against AR therapists) who feel that they have been treated unfairly during a complaints process.

I keep on hoping for the regulation of the profession, and I will keep on talking about it as long as I am receiving emails from all over the country from those abused by a therapist who can carry on regardless.

If my horrible experience of an abusive therapist can make a change for the benefit of this profession then it will have alchemised what was a horrendous 2 years into something tangibly productive for talking therapies which I passionately believe can be wonderful and transformative for clients. We just need to shine a light on the shadow of our profession.

More posts on regulation:

Guest Blogger Patrick Killeen - Accredited Registers vs Protected Titles (July 2015)

If I had the power to regulate counselling (April 2015)

A new name for the PSA's registers for counselling and psychotherapy (February 2015)

The problems with a voluntary regulatory scheme (Sept 2014)

Spreading the word on AVRs - the Professional Standards Authority responds (Sept 2014)

The Regulation of Counselling and Psychotherapy - What the Public Want (June 2013)


Anonymous said...

BACP's response is surprisingly open to - or at least non-critical of - a statutory (not voluntary) regulatory system, given that the current BACP Chair, Amanda Hawkins, wrote in Therapy Today that she was 'confident' that ‘statutory regulation won’t be happening on my patch [sic]’! ('From the Chair' vol.22, issue 9; accessible for BACP members here: http://www.therapytoday.net/article/show/2773/ ). Note that she wasn't just talking about H(C)PC, but 'statutory regulation' itself.

Patick Killeen said...

The idea that professionals will simply call themselves something else sounds reasonable in theory but in practice this doesn't seem to be a problem for others professions with protected titles such as doctors. I have never come across a case of someone pretending to be a doctor by calling themselves something similar".

The problem is not people pretending to be a doctor by calling themselves something else, the problem is people offering medical consultations and avoiding regulations by pretending not to be a doctor by calling themselves something else. One example would be unqualified individuals offering complementary health services. To quote the NHS website:

Unregulated complementary and alternative medicines

In the UK, there is currently no statutory professional regulation of any other complementary and alternative medicine practitioners.

This means, for example, that anyone in the UK can legally call themselves a homeopath and practise homeopathy on patients, even if they have no training or experience. These practitioners are not legally required to adhere to any standards of practice. If you have a complaint about treatment you have received from a homeopath, you have no special legal rights beyond normal civil and criminal law.


Other professions also have similar problems, e.g. unqualified "legal advisors" not being regulated as Lawyers. On their own protected titles protect professionals from being tainted by the same brush as these individuals by distancing themselves from them, but they don't protect the public from incompetent and unethical individuals offering these services.

It's also significant that it's not just doctors' titles that are protected but some of the functions that a doctor carries out are protected as well, such as prescribing drugs. So if a doctor is struck off and sets himself up as a “Health Consultant” he wouldn’t be able to carry on his practice as he had done because there would be things (such as prescribing drugs) that he could no longer do.

This wouldn’t be the case for psychotherapists and counsellors if their titles were protected, if a counsellor struck off the counsellor’s’ register set himself up as a “Talk Therapist” he could offer exactly the same services just so long he didn’t use the word “counsellor”.

A well-publicised and widely understood system of statutorily accredited voluntary registers offers exactly the same level and type of protection to both professionals and the public as a well-publicised and widely understood system of statutorily protected titles.

The AVR system has the potential to be a robust and effective form of regulation, just so long as the general public learns to look for the AVR logo when choosing therapeutic services and organisations recognise it and demand that the professionals they engage with are covered by it. (Exactly the same could be said about protected titles.)

Anonymous said...

You seem to be a counsellor who is well aware of the dangers of bad therapy and therapeutic malpractice but I notice, with deep concern, that you have allied yourself with the controversial organisation Positive Outcomes for Dissociative Survivors (PODS).

I am astonished and dismayed by this and wondered whether you have done this because you have failed to read any of the sceptical, rationalist, evidence based material relating to DID? Is it because you have met one or more people who identify as having DID and you have taken an unquestioning stance?

I am genuinely interested to know as a former client of an abusive therapist who had convinced her clients that they had DID after recovering memories of incest and satanic ritual abuse.

Have you ever read, for example Making Monsters by Richard Ofshe? Have you ever read any of the very informative threads on the International Skeptics Forum?

Serious questions, please do reply

Amanda Williamson (She/her) said...

Thank you for your message, Anonymous. Yes I am supportive of the work that PODS do in terms of raising awareness of the full spectrum of working with trauma in therapy. I have not come across anything that would indicate that they are controversial or causing harm. If I came across something of substance to that effect then I would certainly review that information.

I would agree that a therapist insisting that a client has DID when this is not the client’s lived experience is reckless, dangerous and abusive. I am also aware of the skepticism around DID. This is not enough for me to outright deny the reality of some of the people I know who’s lived experience is that they very much identify with DID. It is my opinion that in the context of a therapeutic relationship to do so might also be abusive.

I am very sorry that you have experienced therapy that has been harmful to you.

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