Regulation of Psychotherapy and Counselling through the Health Professions Council (HPC) and Integrative Humanistic Psychotherapy

Briefing Paper for Ministers and MPs

Summary of Key Issues

· Integrative Humanistic Psychotherapy (IHP), the market leader in UK psychotherapy training with 29 UKCP accredited master’s level programmes and more than 5000 registered psychotherapists and trainees, is being marginalised and potentially excluded from regulation.

· Two main projects, Increasing Access to Psychological Therapies (IAPT) and Skills for Health (SfH), funded by the Department of Health, are already in place and are setting competence frameworks for Training and National Occupational Standards, which will inform the Health Professions Council’s regulation of psychotherapists and counsellors.

· There has been inequity in the way that the relevant stakeholders have been consulted in this process. IHP as a modality has so far not been included. The terms of reference, the criteria for selection for membership and chairing of the reference groups are also unclear. It is difficult to find out who is making the decisions to exclude IHP, on what basis and where.

· The criteria for a modality to be included in the SfH project are two Randomised Controlled Trials (RCTs) and a manual (or its equivalent). Not all modalities have had access to the funds needed to conduct RCTs, so use of these criteria without taking into account the wider field of research evidence discriminates against them. The view of the profession as a whole and IHP in particular is that while RCTs provide important efficacy evidence, they are of limited usefulness in clinical settings without additional qualitative and quantitative research data.

· It is important that the government intervenes at this stage to ensure that the procedures of State Regulation of psychotherapists are transparent and equitable.

The following outcomes are being sought:

· More education and information about the personnel responsible and the processes informing statutory regulation of Psychotherapy, particularly with reference to the roles of the DH, SfH and the HPC

· Reassurance about the preservation of the diversity of perspective and approaches to psychotherapy

· Equity and transparency in the representation of the different modalities at every stage of the decision-making proceedings. This will be required to mediate the issues related to competition.

The Political Group of the Humanistic and Integrative Section of the United Kingdom Council for Psychotherapy

28th May 2008.

Members of the Political Group of the Humanistic and Integrative Psychotherapy Section (HIPS) of the United Kingdom Council for Psychotherapy (UKCP)

• Heward Wilkinson, hewardwilkinson@googlemail.com, UKCP-Fellow, Chair of HIPS
• Tricia Scott, tricia.scott@btinternet.com, UKCP-Fellow, Co-ordinator Co-operation with Government, HIPS
• Jocyleyne Samuels, jocelynesamuels@aol.com, Co-ordinator Political Group, HIPS
• Ken Evans, ken@euroips.com, Chair of European Association for Gestalt Psychotherapy
• Angela Cotter, acotter@btinernet.com, Chair of Research Committee, HIPS
• Celia Macnab, celiamacnab@onetel.com, Intelligence Officer
• Christine Lister-Ford, christinelister-ford@northernguild.org, UKCP-Fellow

Briefing Paper in Full on State Regulation and Integrative Humanistic Psychotherapy (IHP)

Written for MOs, Registrants and Trainees by the members of the Political Group of the Humanistic and Integrative Section (HIPS) of United Kingdom Council for Psychotherapy (UKCP)

Last year the government announced that it….

..is planning to introduce statutory regulation for applied psychologists, healthcare scientists, psychotherapists and counsellors and other psychological therapists. (HPC Feb 2007)

It was confirmed that regulation would be through a new project within the Health Professions Council (HPC) and that formal consultation would begin in July 2008 with the timescale for completion approximately 2011.

At the UKCP EGM 3rd Nov 2007 the Chair of UKCP reported that the government would recognise three modalities – Cognitive/ Behavioural, Psychoanalytic/Psychodynamic, Family/Systemic – and that Integrative/Humanistic was to be omitted from the proceedings.

28th January 2008 Ken Evans, Chair of the European Association of Gestalt Psychotherapy) wrote to Ros Mead, Project Co-ordinator Statutory Regulation for the Department of Health (DH) asking for clarification.

13th February 2008 a letter from the New Regulations Project Officer in the DH, Kate Horsfield, replying on behalf of Ros Mead to Ken Evans, made it clear that …

We wish to avoid a proliferation of different modalities or types of psychotherapy. All models share some basic functions for which competencies were consulted on by Skills for Health earlier this year. Our view of a comprehensive mental health programme is that it should provide 3 main modalities. These are psychoanalytic/psychodynamic, cognitive behavioural therapy and family/systemic psychotherapy. Most other modalities are variants of these or post-basic specialisms.

21st January 2008. A letter was sent to Ros Mead from the Chair of UKCP requesting an urgent meeting on behalf of the HIP section, which was refused in principle by Ros Mead in her reply.

As a consequence of this an e-petition was drawn up and sent to the government and on 11th March 2008 the Prime Ministers’ Office released a statement confirming the DH’s position as stated above about the three modalities.

Overview of Regulatory Proceedings

It is apparent that even the most informed personnel are unclear about the relationships between the relevant organisations and special interest groups involved in the preparations for regulation. Relevant information is not being made available to all the stakeholders to support a transparent, equitable and accountable process. It seems that the bodies involved include the DH sponsored projects ‘Increasing Access to Psychological Therapies’ (IAPT) and ‘Skills for Health’ (SfH), the DH and the Health Professions Council (HPC). Whilst it is understood that there is an important relationship between these bodies, the exact nature of this relationship, the terms of reference of the various working groups, their membership, the basis for selection for membership and lines of accountability are not evident. It remains unclear how the decision to exclude Integrative/ Humanistic psychotherapy came about.

Notes on Increasing Access to Psychological Therapies (IAPT) and Skills for Health (SfH)

A DH funded project under Skills for Health (SfH) was set up to look at the provision of psychotherapy and counselling. It is led by Dr Anthony Roth and Stephen Pilling of University College London. Their work had initially been commissioned for the Increasing Access to Psychological Therapies (IAPT) project – another DH funded project – to look at the evidence-base for Cognitive Behavioural Therapy (CBT) and to develop a ‘competence framework’ for CBT particularly for use as an intervention in cases of depression and anxiety. This work had then been extended to SfH where they were also tasked with looking at the evidence-base for psychoanalytic/psychodynamic psychotherapy, family /systemic and originally humanistic/integrative. Roth and Pilling decided that ‘humanistic’ should be limited to person-centred/process experiential and that ‘integrative’ should not be included in the frameworks. It is unclear who else was involved in this decision or by whom it was then agreed. There has been some question about whether any of the modalities other than psychoanalytic/psychodynamic are considered as ‘psychotherapies’ as opposed to ‘therapies’ or ‘counselling’. A fifth grouping covering supervision is also included in the project’s remit.

Research Reference Groups (RRG), including Roth and Pilling and chaired by experts in research in the particular modality, were established. These five RRGs had been set up to look at the research evidence and ‘extract competences’ from this evidence to underpin the development of National Occupational Standards (NOS). The work of developing the NOS is to be done by practitioners in those ‘modality groups’ included within the framework established by the project. This has been done in a stepped way and the draft NOS for CBT were released for wider consultation in January 2008. The RRG for the ‘person-centred/ experiential’ modality (referred to as PCE by Dr Roth) is nearing completion with only two meetings left and the project as a whole is due to complete by the Autumn. As yet the modality title integrative/humanistic has not been included.

Selection of Personnel to IAPT and SfH

Marc Lyall was until recently the manager of the SfH project working on behalf of the DH. He is inevitably not a specialist in the field. He may not be aware of the differences between the modalities nor the history of conflict and competition between them. We do not yet know who has replaced him in this role.

It is unclear how widely tenders were sought for the IAPT and SfH projects and if equal opportunities were evidenced in commissioning this work by the DH.

The IAPT and SfH project are accountable to the ‘Strategy Reference Group’, Chaired by Peter Fonagy, also of UCL and a colleague of Roth and Pilling. We would question the fact that vitally important decisions about the future of the whole field of psychotherapy are, it seems, being led by one department, the Department of Clinical Health Psychology of UCL whose special interests are known to be CBT and Psychoanalytic Studies. In particular it is unacceptable in our view that one modality, IHP is excluded when it is a market leader in psychotherapy training programmes and a substantial contender in the clinical field in the public sector as well as the private and voluntary sectors..

A further group, the ‘National Reference Group’, is chaired by Lord Alderdice. As far as we understand it, this group provides a layer of accountability between the RRGs and Modality Groups of SfH and the IAPT projects and the Strategy Reference Group. The Chair of UKCP’s Standards’ Board and Training Standards Committee is our representative on this group.

It is unclear how the membership of any of the working groups has been selected. HIPS has one representative on the PCE RRG but is having to make a case for a second representative in the group. The other members of the group representing the ‘humanistic’ arm of the professional field are almost all members of the BACP. The person-centred counselling approach is heavily represented. It is not possible to adequately consider integrative/humanistic psychotherapy within the narrow definition that has already been decided and in particular there seems to be a limited understanding of the meaning of ‘integrative’. HIPS has made a statement defining IHP and the case for the inclusion of IHP as a modality in the second phase of the project, developing NOS from the competences established in the RRG. It has also submitted a preliminary research report to provide a wider research evidence brief for IHP.

The ‘competence framework’

Roth and Pilling have established a ‘competence framework’ in the SfH project as a basis for inclusion (in effect for work in the NHS). Their criteria are ‘two Randomised Controlled Trials (RCTs) demonstrating efficacy and a manual (or its equivalent). It is a widely held and argued view by professionals from the whole field of psychotherapy, counselling and the psychological therapies generally and IHP particularly that this is a limited framework for the following reasons:

· the funding for RCTs (or a broader range of research methodologies) has never been in place for the full range of modalities so this is not a level playing field.

· RCTs on their own are a very limited research tool for interventions such as psychotherapy. They are designed to measure condition-specific efficacy in tightly controlled conditions for carefully screened patients. This may be quite a different question from what works in psychotherapy practice generally.

· RCTs do not include an in-depth exploration of the client’s subjective experience and satisfaction with the intervention. Client preference and choice is not included.

· There is a great deal of other evidence from research such as practice-based research which experts believe to be at least, if not more relevant to clinical interventions of this kind. This is not being considered

· Manualisation of interventions such as psychotherapy has serious ethical problems. It limits the full use of response in the therapeutic relationship. Research studies have shown the skilful use of this relationship to be one of the major curative factors in psychotherapy.

Relationship between SfH and HPC

It has been confirmed (by various sources) that this SfH work commissioned by DH will ‘inform’ the HPC’s regulation of psychotherapists and counsellors. While the HPC wishes to register the single title of ‘psychotherapist’, the question remains on what basis the title will be awarded. As things stand currently it is clear that the Training Standards that the HPC will use (and with which all MOs will in future have to comply) will be based on – or heavily influenced by – the NOS that are being developed by the SfH project.

There are three areas of concern in this:

· For the psychotherapists themselves and how they are awarded registration and under what title. There are 2,500 psychotherapists currently registered as Integrative Humanistic Psychotherapists and more than 2,000 currently in training.

· For the Member Organisations, Training and Accrediting Institutes and Organisations and on what basis they will be able to seek approval/validation with the HPC and under what title. Integrative Humanistic Psychotherapy has 29 MOs in UK.

· For the development of psychotherapeutic theory and practice on the basis of a wider understanding of how people are and how they learn.

Action so Far

1. 21st January 2008. A letter was sent from the Chair of HIPS via UKCP to Marc Lyall at SfH asking for the inclusion of a wider perspective on the ‘humanistic’ modality than was currently being used in the SfH project. A further letter was sent on the same date to the Chair of UKCP raising concerns and requesting that he seek an urgent meeting with Ros Mead

2. March 15th 2008, HIP section of UKCP elected various members of the section to work politically and strategically to address the situation. A political group was formed to co-ordinate action with government and decide upon strategy.

3. 26th March 2008. In response to Marc Lyall’s reply to HIPS, a report was submitted to him making the case for the inclusion of Integrative Humanistic Psychotherapy (IHP) as a modality within the SfH project. A list of names and CVs was also forwarded to be included in the next stage of the project – the ‘modality group’ developing NOS. There has been confirmation that these were received but it is still unclear whether the IHP modality statement was circulated to the RRG.It appears to be no decision has made to rectify the situation.

4. In 2007, the UKCP had commissioned on behalf of HIPS the Research Unit at Roehampton University to undertake a literature review putting the case for widening the SfH definition of ‘humanistic’ and for the re-instatement of ‘integrative’ in their work. The unit is doing this work in two stages because of its urgency.

5. 22nd April 2008. A preliminary report from Roehampton University’s Research Unit stating the research evidence for IHP as a modality and arguing the case for a wider research framework than RCTs and manualisation was sent to Marc Lyall to be circulated in the RRG and for consideration by the Strategy Reference Group (SRG) that oversees the project.

6. April 2008. A letter campaign was mounted by UKCP with the co-operation of the HIPS Political Group. A guideline letter for registrants to send to their constituency MPs and a covering letter from the Chair of UKCP were circulated to all registrants. Member Organisations (MOs) are currently collating MPs’ responses and returned to the UKCP office – who in collaboration with HIPS’ Political Group will prepare a response.

7. 6th May 2008. A meeting between Professor Diana Waller and HIP section members took place. Professor Waller represents the HPC on the Strategy Reference Group chaired by Peter Fonagy. The meeting was very positive and fruitful. Professor Waller reassured us that the HPC was a transparent and accountable public body that would want to ensure that all the stakeholders were treated equitably. She was able to answer our questions and clarify some areas of concern or confusion. She was supportive in principle of us making our case clear concerning our arguments regarding research. She stated that whilst the HPC will be informed by the DH and SfH, they are also independent.

8. 8th May 2008. A letter requesting a meeting with Alan Johnson, Minister for Health, to include HIPS representation was sent to James Antrican, Chair of UKCP, from the Chair of HIPS.

9. 12th May 2008. Chair of UKCP sent a letter to Alan Johnson requesting an urgent meeting. As of 5th June 2008 there has been no reply.

10. 5th June 2008. This Briefing Paper is passed for circulation to registrants, delegates and MOs. It will be placed on the HIPS website where it will be regularly updated. It may be used in any contact anyone may have with MPs or elsewhere to support them in making their case.

Outcomes to date

2. 7th May 2008 posted on the government website:

Clarifying Statement to the Government's Response of 11 March 2008 to the Psychotherapy E-Petition

The response to the e-petition issued on 11 March 2008 set out the Government's policy position on the regulation of psychotherapists. It stated that the Government's view was that the scope of statutory professional regulation should provide for three main modalities within psychotherapy. We are aware that some people have interpreted this as implying that final decisions about the scope of psychotherapy regulation have now been taken. This is not the case.

We are also aware that there is an ongoing debate about the precise number of modalities which should be included within the scope of regulated practice in future and that there is an argument for more than three modalities to be included. Final decisions about the precise scope of practice to be regulated have yet to be taken. This will be done in consultation with the stakeholders, including the professional bodies.

3. 3rd June 2008

Lord Alderdice and Peter Fonagy are convening a meeting scheduled for early July to include representatives from UKCP and HIPS.

Further Action

Whilst this is a step in the right direction for the government to acknowledge that no final decisions have been made, we need to continue lobbying MPs and the various government agencies at this time.

· Registrants and trainees keep sending letters to MPs. When you receive a response send it to your MO who will pass it to UKCP to collate. Amend the letter to suit your own approach.

· Collect job descriptions of any IHP practitioners working in public settings (NHS, Higher Ed. Community Healthcare etc). Send these to your MO. These will be sent to SfH via UKCP to demonstrate the public sector work already being undertaken.

· Trainees on public sector placements inform MOs of your work and role. This information can be collated anonymously and sent to SfH via UKCP.

· A number of registrants have now received replies from their MPs based on the second government statement dated 7th May 2008. There is still work to be done. There has to date been no confirmed change in the framework set by the Skills for Health project, nor written confirmation of a more diverse understanding of ‘humanistic’ than person-centred/process-oriented/experiential. Integrative Humanistic Psychotherapy is still not mentioned.

The Political Group will continue to seek official confirmation in writing from the government that

· IHP will be included by the DH in a comprehensive mental health system.

· that the DH will not be allowed to discriminate between modalities in the process of setting standards for regulation, prioritise some modalities over others in public mental health services and jeopardise the future employment of psychotherapists in one of the major modalities.