Darian Leader calls for a waaaahmbulance

Thanks to Writing in the Margins of My Mind for pointing out this Guardian article by the Lacanian psychoanalyst Darian Leader, albeit one in which Darian Leader really seems to need some cheese to go with his whine.

Darian Leader is annoyed because the government has decided to regulate psychotherapists – you know, the way doctors, nurses, OTs and so forth are regulated. Just so they don’t, like, kill you or something. The proposal is that psychotherapists come under the Health Professions Council which currently regulates occupational therapists, physiotherapists, paramedics, art therapists and other professions.

Fair enough, I’d say. If the HPC is already successfully regulating art therapy, then there’s no reason not to extend it to the rest of psychotherapy. Darian Leader, on the other hand, responds with the kind of defensive hostility one might expect of somebody who’s probably had to spend a fair few dinner parties being told that Lacanian psychoanalysis is a load of pretentious, pseudo-intellectual, vacuous drivel.

Leader’s claim is that psychotherapy can’t be regulated by the HPC because psychotherapy doesn’t fit the “market-led vision of therapy the HPC presupposes”.

What drives and sustains the therapy is the relationship between the two parties, and not the application of any sort of therapeutic instrument.

This is where the problems really start. In a culture driven by the market, what shelf should the talking therapies go on? Surely, they must be made to conform to the familiar frameworks of business and sales. And if everything is so uncertain and unknown, what would stop the unscrupulous therapist from exploiting their patients – sexually, financially and morally?

Rather than working with a person holistically, some therapies have bought into an atomisation of individual symptoms that they claim to treat. Therapy becomes reduced to a series of localised interventions, targeting specific cognitive “errors”. The therapeutic relationship becomes a transaction, and human attributes become commodities. Not surprisingly, this is the kind of therapy the government understands and NHS managers smile on.

What’s market-led about being professionally regulated? I work alongside OTs, dietitians and art therapists in my eating disorders unit. None of them seem compelled to operate in a particularly “market-led” kind of way due to their HPC registration. As with the NMC for nurses, the HPC is only there if they breach confidentiality, go outside their professional competence, or grope the patient. It doesn’t dictate the kind of approach they use.

In the above quotation Leader seems to be referring to the increasing vogue for presenting CBT as a one-size-fits-all model of therapy., mainly because it’s cheap and easily broken down into manageable chunks that look attractive to policy-makers and service providers. This is a valid issue, but not really one that affects professional regulation. The arts therapists on my unit all work psychodynamically. If there’s any pressure on them to switch to a CBT approach (and as far as I can tell, there isn’t) then it’s far more likely to come from funding sources and managers rather than the HPC.

This isn’t all about free-marketeering, it’s about state intervention. The sort of thing nasty socialists do rather than nasty Thatcherites. You picked the wrong bogeyman to invoke, Darian!

Darian Leader also doesn’t seem to understand what it means to be professionally accountable to a regulator.

HPC hearings are also highly adversarial. If you are accused of misconduct, you are named and shamed on its website before your hearing, which may take place several months later. If you are found to be innocent, your reputation and livelihood may already be gravely damaged.

Well, sorry Darian, but Fitness to Practice hearings are public hearings, not private events behind closed doors. That’s equally true if a nurse is hauled up before the NMC or if a doctor goes before the GMC. That’s simply the price of being accountable to the public.

Allegations, interestingly, hardly ever come from patients but mostly from NHS employers or colleagues.

Well, yes, Darian, that’s because most patients haven’t heard of the Health Professions Council, and usually make complains in the first instance to somebody’s employer. That said, any patient can make a complaint to the HPC.

Anyway, Darian Leader continues,

The HPC has set itself up as a super-moral agency, suspending or striking off practitioners for failures of “personal conduct” that a normal court of law would not necessarily judge in the same way.

That’s because a registered pratctitioner is subject to a higher standard of conduct than members of the public. That’s why you get those fancy letters after your name. That’s why you’re put in a position of trust with vulnerable people.

However, in the HPC’s information leaflet Making a Complaint About a Healthcare Professional (PDF file) they’re pretty clear about what sort of conduct they’re interested in.

We only consider complaints about fitness to practise. The types
of complaints we can consider are those that question whether a
registrant’s fitness to practise is ‘impaired’ (negatively affected) by:
– misconduct;
– a lack of competence (not having the necessary skills
and knowledge);
– a caution or conviction for an offence in the United Kingdom (or
somewhere else for an offence that would be a crime if it was
committed in England and Wales);
– their physical or mental health; or
– a determination (a decision) made by another regulator
responsible for health care.

This is not the same thing as applying a Mary Whitehouse standard of conduct to somebody’s private life.

Leader’s next objection is, my view, just as spurious.

The final feather in the HPC’s cap is its ability to strike you off its register. Yet anyone struck off can simply set up a new practice with a different title. If you are struck off as an arts therapist, there is nothing to stop you setting up as a life coach.

True, but you wouldn’t get a job in the NHS as a “life coach”. I also suspect that a lot of people who would be willing to pay privately for psychotherapy wouldn’t do so for “life coaching”.

All this matters because. so far, “therapist” has been allowed to become a vague, nebulous title that sounds grand but means nothing. In my previous CAMHS post, I was designated a “nurse therapist”. The “nurse” part had required me to complete three years training and register with the NMC. If I hadn’t done so, I’d be committing a criminal offence that could land me in prison. On the other hand, the “therapist” part meant nothing. I hadn’t done any extra training, or registered with any professional bodies to gain this title. It had just been tacked on.

Despite this, whenever I mentioned my job title to people, they would say, “Oh, you’re a nurse therapist?” apparently unaware that it was the former part of my job title that I had worked hard for, and not the latter.

Anyone can call themselves a therapist. You can be a psychotherapist, a “journey” therapist, a sit-under-this-pyramid-and-connect-with-your-inner-dolphin therapist. This isn’t safe, and it needs professional regulation to protect the public from quacks, charlatans and the downright dodgy.

In all fairness, Darian Leader isn’t suggesting that psychotherapy be left unregulated. He does want it regulated, but only by his kind of people.

The most robust model of regulation would limit government intervention to the requirement that all therapists join a national register, to be administered by a body made up of therapists and lay people who know what therapy is about. This would give full details of each therapist’s training and orientation, as well as details of complaints procedures. The public could then check up on the person they were considering and make their own choice, rather than have an unsuited government agency limit their decisions for them.

Yes, Darian, you’d like that, wouldn’t you?

The trouble is, self-regulation has a tendency to wind up becoming toothless, even complicit. Take a look at the Press Complaints Commission, doing the square root of bugger all to address inaccuracies and invasions of privacy by scumbag journalists. This isn’t the model of regulation that psychotherapy needs.

Don’t forget that psychotherapy has instances of misconduct going right back to its historical foundations. There’s Freud’s development of seduction theory concocted in order to dismiss accounts of sexual abuse as mere fantasies. Or Carl Jung, who’s alleged to have slept with at least one of patients, Sabina Spielrein. Also don’t forget that psychotherapists, particularly psychoanalysts, have at times had a reputation for cliquey, even slightly cultish behaviour – a good read of Jeffrey Masson’s Final Analysis provides some shocking illustrations of this.

Psychotherapy needs proper regulation, not fig-leaf regulation by a self-serving clique. The Darian Leaders of the world will piss and whinge and whine and object to it, but if it goes ahead, I’m sure they’ll discover soon afterward that it really isn’t the end of the world for psychotherapy, and will add some much-needed protection for patients.