Should the medical establishment regulate psychotherapy?

When someone with a serious mental illness – schizophrenia, bipolar disorder — takes pharmaceutical drugs for their condition, we’re obviously talking about medicine and the medical profession. Drugs affect the physiology of the body, and drug use needs to be monitored by someone who’s been to medical school. But what if you see a talk therapist because you’re unhappy with your relationship or feeling low after losing your job? Should that be under the control of the medical establishment?

This issue – should psychotherapy be treated as a health profession and regulated by the government — is currently under debate in the UK. Advocates on both sides of the argument are talking past each other. Their reasoning appeals to their constituencies, but the two sides are unwilling or unable to consider a compromise.

The Health Professions Council: New rules for therapists

The Health Professions Council (HPC) is a UK regulatory agency set up to “protect the public.” If a “health professional” does not meet certain standards, HPC can put them out of practice. Currently the HPC regulates 13 professions, including podiatrists, physical therapists, and radiographers.

Last summer HPC announced its intention to regulate psychotherapists and counselors. This comes at a time when there is a high demand in the UK for psychotherapy. The economic recession has increased the number of individuals seeking help. Both doctors and patients regard therapy as safer and more effective than antidepressants and tranquillizers when it comes to anxiety and depression. The National Health Service is training an additional 3,600 therapists at a cost of $261 million a year.

Draft legislation of the HPC proposal was presented to Parliament this spring. The new regulations include 451 rules for the therapeutic session. For example, there’s a rule that requires identifying the client’s response to a therapist’s use of silence. There’s another one that requires getting feedback from a client about whether a therapist’s interpretation has been helpful.

Therapists find this objectionable. It’s not just the specific rules they dislike. They object to government interference in what they feel should be a private conversation. In the country that gave us 1984, therapists see shades of Big Brother in the proposed legislation.

Therapist objections

Therapists and counselors have formed the Alliance for Counselling and Psychotherapy Against State Regulation to fight the proposed regulations.

Among their objections:

• The regulations are supposed to protect clients and decrease abuse, but there’s no evidence that regulation makes any difference. “[D]octors, for example, have been so regulated for many years, but shocking cases still occur regularly.”

• Therapy and counseling are not branches of medicine. Therapy is an exploration and creation of a relationship. The goal, if there is one, is to improve the quality of the client’s life, not to relieve a symptom. Applying the values and criteria of medicine -rapidly and efficiently eliminating the presenting symptoms — is contrary to the objectives of therapy and counseling.

• The proposed rules list the “competencies” expected of a therapist. This is nothing more than a parody of what happens in therapeutic practice. “Many practitioners see their work as more an art than a science: a series of skilled improvisations in a relational context, where each client, and indeed each session, offers unique issues and demands unique responses.” Requiring practitioners to abide by a predetermined set of rules not only stifles creativity, but forces the practitioner to disregard the individuality of the client. “This is ethically unacceptable for the practitioner as well as therapeutically ineffective for the client.

• Therapy is a venue for resisting what’s wrong with modern society. “The initiative to regulate psychotherapy and counselling is itself a symptom of our tick-box [checklist] society: of an obsession with ‘safety’, a compulsion to monitor every activity, an illusory belief that everything can be brought under control. In many ways, psychotherapy and counselling inherently expose this illusion: they support us in tolerating uncertainty, difference, risk, and the unknown.” If you can’t use therapy to explore and subvert the status quo, or at least your own personal status quo, what’s left?

• Therapy is inherently “risky” and cannot be forced to conform to a safety-first culture. Regulations would only strengthen the medical trend towards practicing defensively. They are designed to reduce complaints about practitioners and to prevent lawsuits. Clients seek personal growth and self-understanding through therapy rather than the safest experience possible. On this count therapists must be braver than doctors, for they are dealing with the meaning of a client’s life.

Some of these arguments against the medical model could not have been used a mere 50 to 100 years ago: Medicine, like therapy, was once more art than science. Doctors knew and treated their patients as unique individuals, and the doctor/patient relationship was part of the healing process. That’s not how medicine is practiced today.

Client objections

Therapists aren’t the only ones who object to the proposed regulations.

A group of artists and performers have drafted an international petition to oppose state regulation of psychotherapy. The petition, published in The Guardian, was signed by Peter Gabriel (of Genesis fame), sociologist and novelist Richard Sennett, Susie Orbach (Fat is a feminist issue), novelist Will Self, sculptors Anish Kapoor and Antony Gormley, and 42 others. Their objections to HPC regulation echo the themes of the therapists:

• There is a freedom of speech issue here. What transpires between a therapist and a client is a private conversation between adults.

• Therapy is about the relationship, not about the use of particular procedures with predictable outcomes. What ultimately happens in such an open-ended relationship may not have been anticipated. “The proposed regulation leaves no room for the unknown, as if the solution to each person’s problems were known in advance.”

• HPC regulation forces therapists into the role of medical health professional with the goal of correcting pathology. This is not the model followed by the majority of practitioners, for whom “therapy is a conversation with the unconscious, an enquiry into an individual’s history, a spiritual journey, an exploration of the human condition and the many other forms of enquiry which could be described under the heading: a life examined.”

• The HPC proposal is a “market-led vision of therapy and normality. … part of a wider move today to regulate not simply behaviour but human thought itself: beyond the official policies to respect diversity and difference, there is an ever growing intolerance of belief systems that do not fit a business framework. Human relationships are seen as transactions, and a patient’s wish to pursue a particular therapy that does not offer any set outcome will no longer be taken seriously. Instead, they must be protected from their own beliefs, and consult only someone chosen by the State.”

This last point should resonate with consumers of health care in America, where medicine has become a business and the doctor/patient relationship has been reduced to a transaction. Why would anyone want more of that?

The medical profession supports the legislation

Once this debate went public, the British medical publication The Lancet ran an editorial on the subject. It states unequivocally that therapy must be part of the medical establishment and must abide by its rules.

• “The idea that psychotherapy has no health dimension is ludicrous.”

• “Regulating the training and practice of psychotherapy should be a non-controversial positive step towards strengthening the important place that psychotherapy services have in modern health systems today.”

The letter from artists and performers is quoted with barely contained ridicule and distain.

The Lancet does not represent doctors in the way The Journal of the American Medical Association does in the U.S., but when the editorial board of a leading British medical journal agrees to publish this unsigned editorial, it certainly suggests that the opinion represents the British medical profession.

Apples and oranges

The medical profession, at least as represented by The Lancet, obviously has no sympathy for the objections raised by therapists and their clients. On the other hand, therapists and clients at least recognize that some of their practitioners do indeed choose to follow a medical model. Their objection is that this should not translate into requiring all therapists to conform to that model.

Marital counseling and schizophrenia may not be as different as an apple and an orange, but it should be possible to acknowledge that some difference exists. Surely reasonable and intelligent adults can agree to draw a line somewhere between the two that satisfies the interests and concerns of all parties.

Update 12/9/10:
Therapy shows us life is not neat or safe. So why judge it by those criteria? (Guardian)

Great essay by Darian Leader on Health Professions Council attempt to regulate talk therapy.

Therapy occupies a unique space in the modern world. In a culture obsessed with surface and statistics, it allows the detail and narrative of a human life to be explored. Where society tells us what to be, therapy allows us to reflect critically on the imperatives that shape us. Challenging received notions of wellbeing and happiness, we can try to find out what is really important to us, often with life-changing consequences. It offers a system of values freed from the moral judgments of social authorities.

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