Therapy Today on Dangers of Regulation
Dare we do away with professionalism?
The institutionalisation of therapy through statutory regulation, Andy Rogers argues, poses great dangers for the profession as a whole and specifically for those working in the person-centred approach
‘I state sorrowfully: there are as many certified charlatans and exploiters of people as there are uncertified.’
Carl Rogers1 As Rogers’ famous statement reminds us, the person-centred approach has a long tradition of vigorously questioning professional developments in counselling and psychotherapy. More recently, considerable disquiet about the proposed state regulation of the psychological therapies through the Health Professions Council (HPC) has been reported anecdotally among person-centred therapists.2 Many in the community feel uncomfortable with the regulatory agenda and are concerned for the philosophical and therapeutic integrity of their practice under the proposed regime. Here I unearth some possible roots of that discomfort in the theory and philosophy of the person-centred tradition, in the hope that it will help
practitioners reflect on their experience of the political changes afoot and channel their concerns into positive collective action. This is not a definitive account of the case against regulation, which you can find elsewhere3, 4 but a snapshot of the most conspicuous issues for person-centred therapists.
Theory and values
A central proposition in Rogers’ theory of personality change and therapeutic process5, 6 is that, given the right interpersonal conditions, an individual will gain ‘a dawning realisation that the evidence upon which he can base a value judgment is supplied by his own senses, his own experience’,6 minimally corrupted by judgments originating in the ‘personal cultural environment’.6 Known in the theory as ‘internalising’ the ‘locus of evaluation’, this shift in the person’s valuing process is, in Mearns and Thorne’s view, ‘an expected consequence of person-centred counselling’.7
In the context of such genuine, empathic, accepting relationships, it is argued, we free ourselves from ‘conditions of worth’; that is, we become liberated from the oppressive or ambivalent judgments of others, judgments we have absorbed – or ‘introjected’ – to the detriment of self-esteem. As Dave Mearns writes, ‘Helping another person to internalize his locus of evaluation is not achieved by exercising power over him… but by creating a relationship in which the client may take responsibility for himself.’8
So at the level of values, the theory tells us that the person-centred approach is committed to self-authority, self-responsibility and the right to selfdetermination, not just for clients but for therapists too. This is clearly in opposition to the values of regulation, as currently proposed, which suggest that people in therapeutic relationships should be subject to a greater degree of external authority. It is apparently not sufficient for us to practise within self-regulating systems of civic accountability9 and existing laws governing human behaviour and transactions, which if necessary could be tweaked to tackle the worst exploitation in therapy.10, 11 Instead, it will be the state – rather than ourselves, our peers and clients – deciding who is fit to counsel and how they should be doing so.
The prospective client under this new regulatory framework, who in personcentred terms could be struggling to trust their internal, ‘organismic’ valuing process, will enter a helping system that is considered ‘safe’ and ‘effective’ – and therefore trustworthy – only when judgment is deferred to a set of external structures and processes. Regulation, in this scenario, becomes a network of oppressive conditions of worth for counsellors to negotiate, all the harder not to internalise and transmit to clients because they carry the power of the law, the fear of criminalisation and professional humiliation and the economic threat to destroy careers. The locus of evaluation of therapy itself thus becomes externalised, leaving the person-centred values that counsellors hope to embody with their clients entirely at odds with the values of the proposed professional
working environment.
Values incongruence: an ethical dilemma
It seems that counselling and psychotherapy – that is, people and relationships – cannot be trusted. The public, we are told, need protecting from potentially dangerous therapists who will be deemed trustworthy only if registered with the designated authorities (HPC) and trained in approved schemes, despite the fact that this flies in the face of research findings which consistently fail to demonstrate that training, experience or professional accreditation are important in determining either positive therapeutic outcome or reduced incidence of malpractice. As Brian Thorne has argued, there is even evidence to the contrary, that the status of the licensed professional ‘attracts precisely the person who succumbs to the allurement of power, and who is therefore more likely to abuse it.’12 Indeed, independent research into cases of BACP’s own professional conduct procedure spanning almost 10 years found that accredited members were overrepresented in complaints.13
Person-centred practitioners, then, who attempt to provide the appropriate facilitative conditions for clients to free themselves from the oppression of external judgment, face a formidable ethical dilemma here – they can work under this proposed system only if they defer assessment of their practice to externally imposed expectations and processes, which will be rooted in an institutionalised therapeutic ideology, as discussed below. And in its evidence free assertion that we need the proposed legal controls to minimise harm, state regulation promotes a lack of trust in therapeutic relationships that explicitly contradicts Rogers’ and his followers’ consistent faith in the universal human tendency towards growth, constructive relationships and the fulfilment of potential, known in person-centred circles of course as the ‘actualising tendency’, a concept which underpins much of what I have said above. Instead, state regulation communicates a worst-case scenario, infantilising belief in the tendency for therapists to be destructive if allowed too much freedom. Ironically, the regulatory machinery then uses this fear to justify removing the very conditions – accepting, open, genuine and nondirective – which would have been most likely to facilitate and support practitioners in offering constructive, growth promoting or agenda free therapeutic spaces rather than disempowering or abusive ones. This situation creates a devastating incongruence between therapeutic and professional/administrative values. And as person-centred counsellors will atest, therapist incongruence outside the therapeutic relationship invariably manifests within the therapeutic relationship, potentially undermining the work in the most damaging of ways. If this were not challenging enough, the conditions provided by a postregulation environment will most likely limit freedom and creativity in the profession. Contemporary writers from a range of approaches have argued this point14 but it is also made explicit in person-centred theory. An internalized locus of evaluation is an ‘inner condition of constructive creativity’,15
Rogers proposed, without which truly creative acts would not be possible. The person must be free enough from external evaluation to give voice to new ideas, to work idiosyncratically and challenge accepted practice, a freedom that will be inhibited by a highly externalised evaluative regime such as state regulation through the HPC. Clearly Rogers carried this creativity hypothesis into his own analysis of professionalisation when he wrote, ‘I have slowly come to the conclusion that if we did away with “the expert”, “the certified professional”, “the licensed psychologist”, we might open our profession to a breeze of fresh air, a surge of creativity.’1 The conditions imposed by registration, certification and licensing systems were, in Rogers’ mind, at best
unhelpful and at worst oppressive because they elevate the status, expertise and power of the therapist – which will always be at the expense of the client’s empowerment – while simultaneously creating an environment in which therapists themselves are restricted and subordinated by the very framework conferring that status and authority. As such, the construction of a system as will soon be upon us, in which therapists can work only once they are approved by the Government and its chosen organisations, is incongruent with an approach that, as Rogers claimed, ‘is politically centred in the client’16 and involves ‘a conscious renunciation and avoidance by the therapist of all control over, or decision-making for, the client.’16 Why? Because the person-centred practitioner’s trust in the client will face a smothering fear of the punitive professional measures that might arise from anything that steps outside the prescriptive norms of an increasingly standardised therapy.
Anti-person-centred therapy
I will now highlight four other key ways in which person-centred – if not all – therapists need to be concerned about the shape of therapy as it is likely to emerge under state regulation through the HPC, which we might preface with Rogers’ remarks that, ‘the urge toward professionalism builds up a rigid bureaucracy… Bureaucratic rules become a substitute for sound judgment… the bureaucrat is beginning to dominate the scene.’1 First, the traditional person-centred emphasis on therapeutic attitudes and idiosyncratic expressions of the personcentred ‘way of being’ will be threatened by increasingly standardised trainings and legally enshrined descriptions of ‘best practice’ in each modality, which find ‘skills and competences’ much easier to grasp than relationship qualities like, say, intimacy or mutuality. Evidence for this ‘manualisation’ of counselling and psychotherapy can be found in the work of the Skills for Health (SfH) organisation, particularly its National Occupational Standards (NOS) and ‘competences in development’ for the psychological therapies.17 Interestingly, it is psychoanalysts who have had most to say about how this attempt to pin down procedure does a disservice to the subtle relationship issues of therapy.18 Second, therapeutic practice will become increasingly dominated by the healthcare model. As the HPC reveals in its name, therapy will be ordained as one of the ‘health professions’. To many in the person-centred approach this is not an appropriate umbrella for the work, which concentrates on human potential rather than deficiency19 and the offering of facilitative conditions rather than medical style instrumental intervention with predictable outcomes. Indeed, some client-centred therapists have argued recently for ‘principled and strategic opposition to the medicalisation of distress and all of its apparatus.’20 But, sadly, a medicalised
paradigm in government initiatives around therapy is already evident in the state funded Improving Access to Psychological Therapies (IAPT) scheme and its financial and ideological honouring of the modality claiming most loudly a medical style ‘scientific’ evidence base, cognitive behavioural therapy (CBT). Needless to say, the person-centred approach, with its non-medical model(s) of human distress and its differing research methodologies, has not been blessed with the IAPT coffers. Third, and linked to the expectations of this health model, many therapy professionals are already focusing attention on the evidence provided by outcome research. The difficulty with this trend lies in the question of what constitutes acceptable research and evidence and the demands placed on the therapist to demonstrate consistent outcomes using the approved methods, such as those favoured by and favouring approaches like CBT. Leaving aside the fact that outcome research of this kind is incongruent with the client-centred idea of ‘principled’ rather than instrumental work21 and is irrelevant to an ‘ethics alone’ approach,22 more generally it will jar with the personcentred commitment to the uniqueness of each client, the idiosyncratic nature of each therapeutic relationship and the innumerable range of diverse outcomes that might arise from such encounters and still be considered by the participants to be ‘successful’, with or without structural endorsement. Crucially, the use of such evaluation tools potentially corrupts the personcentred therapist’s efforts to meet the client as a person and an equal rather than as an expert assessor of their difficulties, however much practitioners find superficially pragmatic workarounds. Last but not least, we would do well to remember that the person-centred approach has, since the 1960s, been closely allied to social critique and political radicalism – it is even fond of describing itself as ‘revolutionary’.16, 23 Historically significant in that Rogers was evermore concerned with social and political matters as his career progressed, there was for some time a lull in this area of person-centred activity. Recently, however, it has gained a new lease of life.24 How, might we ask, will such an important dimension of the person-centred worldview flourish when therapists require government sanction to practise? We should not underestimate the cultural, ideological and economic pressure towards conservatism and political acquiescence that could be exerted upon a therapy when it is coerced into a binding professional relationship with the state. At worst, market forces operating within the tight boundaries of regulatory policy might threaten an approach with extinction if it does not toe the party line. Simply, you will not be employed to work or funded to train others in a non-compliant modality. And once the approach is chased into the private sphere and training courses dry up, it will be ever harder for counsellors to justify their practices to the regulatory body that decides who can work legally in the newly institutionalised profession. Again it is clear: the person-centred approach is practically, theoretically, politically and ethically at odds with current regulatory proposals.
The future: institutionalised therapy?
A decade ago, Mearns and Thorne warned person-centred therapists about capitulation ‘to the seemingly dominant Zeitgeist… a cautious, carefully circumscribed form of therapy where the key criteria are the achievement of prescribed goals, proven cost-effectiveness and predictable therapist behaviour as laid down in manuals of practice… a profession where the creeping forces of institutionalisation and regulatory dogmatism are insidiously advancing.’19 They claimed the emerging culture threatened to destroy the heart of person-centred therapy in ways prefiguring my account here and asked if counselling and psychotherapy generally was ‘losing its humanity’. At the turn of the century, then, the institutionalization of therapy posed great dangers for the profession as a whole and specifically for those working in the person-centred approach. But these warnings from the year 2000 were not, it seems, heeded. Make no mistake, the analysis is as pertinent now as ever, particularly for person-centred practitioners who wish to stay true to the historical, philosophical and therapeutic tradition created by Rogers. If anything has dated in the last 10 years, it is Mearns and Thorne’s diplomatic commitment to tread a middle path with regard to how the person-centred approach should respond to these changes, retaining hope, as they did, that the worst excesses of professionalisation might yet be restrained by something other than outright opposition. Of course, that was probably a reasonable position then. But things have moved on. We are only a few meetings away from the drafting of legislation.25 If ever the person-centred approach needed to think critically, attend to its collective power, find a voice and safeguard its future integrity and values congruence, it is now.
Andy Rogers has been a counsellor in further education for nearly 10 years.
‘State regulation explicitly contradicts Rogers’ consistent faith in the universal human tendency towards growth, constructive relationships and the fulfilment of potential’
References
1. Rogers C. A way of being.
Boston: Houghton Mifflin; 1980.
2. Sanders P. Personal
communication; 2009.
3. Mowbray R. The case against
psychotherapy registration: a
conservation issue for the human
potential movement.
Trans Marginal Press; 1995.
4. Postle D. Regulating the
psychological therapies: from
taxonomy to taxidermy.
Ross-on-Wye: PCCS Books; 2007.
5. Rogers C. A theory of therapy,
personality and interpersonal
relationships as developed in the
client-centred framework. In Koch S
(ed) Psychology: a study of science
vol. 3: formulations of the person
and the social context.
New York: McGraw Hill; 1959.
6. Rogers C. Client-centred therapy.
Boston: Houghton Mifflin; 1951.
7. Mearns D, Thorne B. Personcentred
counselling in action, 2nd
ed. London: Sage; 1999.
8. Mearns D. Developing personcentred
counselling. London: Sage;
1994.
9. Postle D. Protecting the client
experience: a catastrophe map
of civic accountability in the
psychological therapies. 2008.
http://ipnosis.postle.net/PDFS/
SRCTMapFINAL.pdf
10. Karian P, Musgrave A. Prophet
in the wilderness: Previn Karian
interviews Arthur Musgrave. Ipnosis
33; 2008.
11. Hogan D. The regulation of
psychotherapists. Ballinger; 1979.
12. Thorne B. Guest editorial:
Regulation – a treacherous path.
CPJ. 2002; 13(2):5.
13. Khele S, Symons C, Wheeler S.
An analysis of complaints to the
British Association for Counselling
& Psychotherapy, 1996-2006.
Counselling & psychotherapy
research (CPR). 2008; 8(2):127.
14. House R, Totton N. Implausible
professions: arguments for pluralism
and autonomy in psychotherapy and
counselling. Ross-on-Wye: PCCS
Books; 1997.
15. Rogers C. On becoming a person.
Boston: Houghton Mifflin; 1961.
16. Rogers. C. On personal power:
inner strength and its revolutionary
impact. London: Constable; 1978.
17. See www.skillsforhealth.org.uk/
page/competences/competencesin-
development/psychologicaltherapies#
18. For example http://ipnosis.postle.
net/pages/DLCritiqueofPPNOS.htm
19. Mearns D, Thorne B. Personcentred
therapy today: new frontiers
in theory and practice. London:
Sage; 2000.
20. Sanders P. Principled and
strategic opposition to the
medicalisation of distress and all of
its apparatus. In Joseph S, Worsley
R. Person-centred psychopathology:
a positive psychology of mental
health. Ross-on-Wye: PCCS Books;
2005.
21. Grant B. Principled and
instrumental nondirectiveness in
person-centred and client-centred
therapy. Person-Centred Review.
1990; 5(1):77-88.
22. Grant B. The imperative
of ethical justification in
psychotherapy: the special
case of client-centred therapy.
Person-Centred & Experiential
Psychotherapies (PCEP). London:
PCCS Books. 2004; 3(1):152-165.
23. Bozarth J. Person-centred
therapy: a revolutionary paradigm.
Ross-on-Wye: PCCS Books; 1998.
24. Proctor G, Cooper M, Sanders
P, Malcolm B (eds). Politicizing the
person-centred approach: an agenda
for social change. Ross-on-Wye:
PCCS Books; 2006.
25. Follow progress at http://
hpcwatchdog.blogspot.com/ and
oppose state regulation at www.
allianceforcandp.org/pages/