In Ireland over the last twenty years psychological therapies have grown rapidly and in a largely uncontrolled manner. No one knows just how many people there currently are describing themselves as counsellors and psychotherapists, but it seems to be in or around five thousand.
A general consensus has arisen that some kind of statutory regulation of the field is required in response to this development. The general public needs greater clarity regarding qualifications of practitioners and the interests of qualified therapists need also to be protected.
To date the favoured solution to this problem has been that outlined in the Health & Social Care Professionals Act of 2005.
This would slot the psychological therapies into legislative position alongside several other professions including social work, with which they have some things in common, and a number of others including physiotherapy, radiography, and chiropody, with which they have rather little.
On these disparate disciplines would be imposed a double-layered regulatory system comprising a registration board for each designated profession, and a supervising council over all. Under current proposals, anyone practicing one of the named professions would be required by law to be registered by the relevant board.
There is general consensus that the minimum conditions required for anyone to be registered as a psychological therapist should include the completion of a primary degree, in addition to having undergone a certain minimum number of hours experience of personal therapy, and of supervised therapy of others.
These are eminently sensible suggestions to which no reasonable person could object. And perhaps they will provide us with the basis for a successful registration scheme.
But I suggest nevertheless that there remain certain fundamental problems with the very concept of issuing certificates to therapists which these criteria leave unresolved and which deserve greater consideration in public debate than they have received to date.
Licensing is an appropriate measure in any field where there is a clearly agreed core body of knowledge of which every competent practitioner must have mastery, and of which the failure to possess mastery unequivocally renders someone incompetent to practice.
This is the case pertaining in the medical profession, in the law, in engineering, and generally in any profession that applies a branch of physical science.
But this case does not pertain in the field of psychological therapy.
What we learn when we learn to practice a psychotherapy is a way of thinking, a style of thinking, but not as such a body of thought. To learn psychotherapy is to learn to listen for nuances, for the subtext beneath what is expressed overtly. We are learning to listen with what Nietzsche famously called the “third” ear.
But because we are learning a technique of thinking, not a list of facts, it means that the field as such is not defined by a particular body of accepted knowledge.
The literature in counselling and psychotherapy is now vast, as any visit to a bookshop can attest. Yet there is not a single text within this literature that one could identify and say with assurance that it had been read and mastered by every competent practitioner in the field.
Not even the works of such a central figure as Freud enjoy this primacy. There are for instance many counsellors of a Christian orientation in Ireland who will have read little or possibly even no Freud. Such therapists look to other texts for their main inspiration and guidance.
In place of an agreed core of knowledge that defines the field what we find in psychological therapy are a number of competing philosophies of therapy, with slightly differing value systems. Schools in this field are numerous and tend to be fissile. There are more than twenty in Ireland at present.
However, the absence of an agreed core of knowledge means that we lack an objective test by which the competence of practitioners can be assessed. There is no academic exam that can test ability in this area.
What we lack therefore is an objective criterion on which the decision to grant certificates to counsellors and psychotherapists can be based.
If the decision is taken to push forward with a registration system based on the 2005 Act, the absence of an objective test of competence will make the task facing a registration board enormously difficult.
Ultimately, the granting of certificates to practice will hinge on how comfortably each candidate is perceived to fit into the particular therapeutic philosophy that happens to be favoured by the members of the registration board, or by the members of the subordinate associations to which the board farms this task of assessment out.
In practice, this is how candidates are selected for membership in any of the many professional associations in psychotherapy worldwide. Minimal educational qualifications and specific experience are of course always important, but the final deciding factor is how teachers and prospective colleagues feel about a candidate. It comes down ultimately to whether they feel at ease with the candidate on a personal level, and whether they feel that the candidate’s philosophy of therapy meshes with their own.
There is nothing to condemn in this. We psychotherapists are taught quite rightly to listen carefully to our feelings about others, irrespective of what the rational part of our mind may be saying, for this is the basis of our work. One of the great contributions of psychotherapy is that it teaches us to be very sensitive to the subjective in life. But it means that we do not as a profession have an objective test of each other’s ability and competence.
However in the absence of such an objective test the question arises whether a registration system, the purpose of which would ultimately be to decide who should be prevented from practicing, could hope to achieve a degree of legitimacy that everyone in the field was willing to recognize and abide by.
The short answer is, I do not know. But I see reasons to doubt it.
How judiciously power to grant certificates was exercised would of course vary from case to case. But there would be opened significant scope for mistakes, and in the worst case scenario for the exercise of personal prejudice. The crucial thing is that everyone involved would be aware of this, and would judge the outcome of the process accordingly.
It is impossible to predict exactly how things would play out in practice but a number of scenarios are possible. It could be the case that over time the registration board would come to be dominated by one group or perhaps a small number of groups within the profession. With over twenty associations in the field, only a minority of these could have representatives on the board. The danger here is that smaller groups could find their candidates were denied certificates and that with time they were squeezed out of the field. The longer term result would be that dissenting views, which have always been the lifeblood of this profession, would be discouraged.
More immediately, if there were significant numbers of rejected candidates for registration, it would be very difficult to escape the perception that prejudice was at work. And rejected candidates would always be able to make the claim that they had been the victims of prejudice, no matter how inadequate their credentials.
Any significant number of rejected candidates for certification would result in a proliferation of appeals and counter-appeals, and over time we would see the development of an unregistered and unregulated sector.
An alternative scenario, at the other extreme, is that the members of the registration board were so sensitive to this danger and to the possible accusation of prejudice that virtually everyone with the slightest claim to be qualified was granted a certificate. But here again the result would be to render registration without any real value.
Now, clearly some kind of regulation is indicated for a profession that has come to play such a significant role in modern Irish society. But I suggest we need to think more carefully than we have done about what is the best framework for this.
In many ways it is unfortunate that the Health & Social Care Professionals Act has coincided with the development of a general consensus on the need to regulate the psychological therapies. The rise of these professions represents a cultural shift in the values of society. To view their proliferation as comparable to the development of a new medical technique is misleading. Ultimately, they reflect a change in our conception of what man is and what is his relation with nature. In particular, they reflect the rise of secularism, and the relative decline of traditional religion. The complexity of the ethical problems they present is of an entirely different order from those associated with the other professions to be regulated by the Act. Their significance goes beyond the normal ambit of the Department of Health, raising difficult philosophical questions about the ends of human life and the nature of truth to which there are no easy answers. To try to wish these complexities away will get us nowhere.
The psychological therapies belong as much under the aegis of the Department of Education as they do under that of Health. Freud stresses that his ideas occupy a “middle position” between medicine and philosophy. Those of us who work in this field have a vocation that combines the therapeutic one of nurturing and preserving health with the Socratic one of questioning and challenging widely held assumptions. By any objective measure at a minimum these professions require special and separate legislation to deal with their unique characteristics. We should not treat them as a variety of nursing and we should not overlook their politicized nature.
However, a narrowly restrictive registration system like that outlined by the 2005 Act is not the only way in which regulation can be achieved within this field.
I suggest that the best and most workable solution would be a national register of all counsellors and psychotherapists, to which it would be compulsory for practitioners to subscribe.
Such a register would contain details of educational qualifications, and current memberships of professional associations. This register would be available on the web and would give clarity to the general public on what is often a confusing field for them.
Everyone on this register would automatically be bound by data protection legislation, and any other legislation that was deemed appropriate.
A grievance board should be established, comprising members nominated by the existing associations within the profession, to deal with complaints from members of the public. This board would have the power to impose sanctions in cases of professional misconduct, including the power to disbar from the right to practice.
Such a system would in effect allow free entry into the profession but would ensure that regulatory standards were applied to everyone who chose to enter it.
The Health Service Executive and other agencies could stipulate membership of particular professional organizations as a condition of employment with them. This would encourage practitioners to belong to one association or another, but would preserve the important right of experienced professionals to be independent should they wish it.
Such a registration system would provide transparency and protection for the general public. It would protect the profession itself against potentially destructive rivalries and it would allow dissenting voices to speak in a constructive manner. It would ensure that a non-regulated field did not develop. And it would be simpler and less expensive to administer than the Byzantine proposals currently on the table.
We should remember that psychological therapy is still a very young field in Ireland. It has come to find a place in Irish culture several generations after becoming established in most other Western countries. We have not yet assimilated it in the way other societies have done. We suffer a shortage, for instance, of experienced practitioners who have accumulated more than a decade or two of work in this area. And there are few professions in which long experience is more vital to the exercise of sound judgement.
In legislating for this new field let us move carefully and thoughtfully, not hastily or impulsively. Let us take care not to force it prematurely into an inappropriately restrictive framework that we may come to regret but rather place it in one that will allow it to grow and flourish in a fruitful manner in the years ahead.
