Three Conversations on the future of the psychotherapy profession and statutory registration in 2016/17
(Published in the Journal ‘Inside Out’ 2013/14)
1 A conversation with Prof Bill Shannon by Edward Boyne
I spoke with Bill Shannon following his participation in the ‘Exploration Through Dialogue’ panel at the first IAHIP conference held in the Royal Marine Hotel on 18 October 2013.
Ed: I wonder if you enjoyed the recent IAHIP conference? It was quite a landmark and ambitious event and it was the first time that IAHIP had organised such a conference.
Bill: I enjoyed the conference very much and was delighted to have been invited. After the panel session to which I contributed, I managed to attend some of the workshops which were very interesting and worthwhile.
Ed: You are originally from County Clare and worked for a long time as a GP in Cork starting in 1969, .
Bill: Yes, following graduation from UCC Medical School in 1965 I set about training to become a GP by completing 3 years in hospital posts prior to spending a final 4th year as a GP registrar at the University of Edinburgh>
Ed: And you have just completed your term of office as President of the Irish College of General Practitioners (ICGP). You were the first Professor of General Practice in Ireland at the Royal College of Surgeons in 1987. In 2008 you were appointed Foundation Director of Education in the new Graduate entry Medical School at the University of Limerick. From the beginning of your career I understand you have advocated non-drug approaches to psychological issues at primary care level. In many ways you were far ahead of your time in Ireland!
Bill: The role of psychotherapy in primary care has been an interest of mine for many years. It was obvious to me as a medical practitioner for almost 40 years that other approaches and skills were needed apart from or in conjunction with the orthodox medical model as early in my practice I realised emotionally distressed patients need and deserve more than a prescription for medication. Unfortunately many GPs don’t have the necessary skills or resources in terms of time to deal properly with complex mental health issues. I have known several cases where psychotherapeutic intervention has made all the difference and enormously improved the quality of life of patients. One story emerged in my own practice when a lady recently engaged to a caring loving man, disclosed to me how terrified she was about any pending sexual intimacy. This was as a result of her history of being sexually abused as a child. I referred her to a psychotherapist and she gradually overcame her fear and proceeded with the marriage.
Ed: I know when you were in charge of General Practice training in the Royal College of Surgeons in the late 1980s you had the opportunity to appoint a new Director of the General Practice Training Course. GP education is vital if we are to see change. Equally important in this are the backgrounds and attitudes of those who are the GP trainers. You chose a psychotherapist and not a doctor for the post. This was unprecedented in Ireland before or since. Did you get into hot water for that decision?
Bill: Initially yes, because up to that time all Course Directors of GP training were themselves fully qualified GPs and members of the Irish or Royal College of General Practitioners. One interesting fall-out from that decision came about a year later when that particular psychotherapist was invited to resource several workshops for his fellow GP trainers from other universities. They wanted to learn more about the world of psychotherapy and how it might help to expand their own consulting skills with their patients!
Ed: At a certain point you decided to undertake training for yourself in psychotherapy. What made you take that path and how was it for you as an experience?
Bill: In 1985 I was introduced to a German psychotherapist, Maria Huss who was then practising in Cork. I invited her to run some introductory sessions on psychotherapy for my GP trainees and was so impressed by her approach that I signed up myself for her training course. I believe I was the only GP to do so but I greatly enjoyed the experience and tried my best to incorporate any ‘lessons’ learned into my medical practice. It certainly helped to make me a better observer and listener in the process of consultation.
Ed: That brings me on to ask you about the whole area of psychotherapy training in Ireland currently. You have recently been appointed as Chair of the Tivoli Institute Academic Council. As a senior member of the medical profession and as a medical educator what are your views about psychotherapy training today?
Bill: I’m new to the field to some extent but there can be an advantage in that I can bring a fresh perspective and honesty. I think one of the key issues for the psychotherapy profession is the question of standards and accreditation of training. The standards need to be high enough and be seen to be high enough in order to command the respect of other professions including my own, the respect of the Government, and especially certain influential senior civil servants etc. And it’s not just about training courses or training colleges. Every practitioner is affected if training standards are such that they let the profession down in the public eye. It could also affect referrals and the business side of psychotherapy practice on every level. The perception of training is important.
Ed: Do you see parallels with your own area of training in medicine?
Bill: I do certainly. For example all medical school graduates must spend a minimum of 4 years in a post-graduate training scheme before being eligible for registration on the GP specialist register of the Medical Council. I see no reason not to expect psychotherapy trainees to spend a similar length of time in post-graduate training before being eligible for registration as a fully-fledged psychotherapist.
It’s obvious to me that there is a major problem for the psychotherapy profession in this area of training standards. This is due to the variability of standards and the confusion surrounding that..
Ed: Do you mean that the profession’s training standards are too low and are seen to be too low?
Bill: That’s exactly how I see it and I’m not alone. It’s important to state at the outset that the Irish Council for Psychotherapy’s standards are quite acceptable, at least for now and the foreseeable future. I know that the ICP includes IAHIP as an organisation that upholds the highest standards. There is also a strong connection with the European Association for Psychotherapy.
I note that the ICP requires that only graduates or their equivalent can enter psychotherapy training. That is very important and it ensures inter alia that only entrants in their mid-twenties start training. I understand that there is a requirement by ICP for a four year programme of specialised post graduate training. That is also very important as is the strong emphasis on personal development and personal process. The recently published QQI standards which I know you were involved in drafting, state that training should take place at Masters level.
Ed: Do you think these standards are well-enough known in the wider community?
Bill: The ICP does not appear to publicise its standards strongly enough. In the absence of having such standards widely circulated in the public domain and regarded as the norm it is no surprise that other health care professionals are sometimes confused when trying to select a therapist for one of their patients or clients..
Ed In relation to what you say around confusion, alongside the ICP as you know there are other professional bodies. For example a larger organisation, the IACP now also lays claim to speak for psychotherapy. Training standards there are certainly different. There is no requirement for graduate entry to courses.. There are training courses recognised by this organisation which are allowed to accept and do accept school-leavers. Eighteen year olds training to become psychotherapists .
Bill: That is not ideal.
Ed: The IACP once had a long-standing rule which precluded those below 23 years of age from entering a recognised psychotherapy training courses, but that rule has recently been dropped. The length of recognised training can be two years which is obviously problematic. There is hardly any personal therapy requirement. The IACP has done some very valuable work over many years. Maybe its standards need updating to remove the confusion you speak of. What would be your advice?
Bill Well as you know, several Irish Medical Schools have set up 4 year graduate entry courses. The ages of students at entry ranges from 23 to 39.which means that many of our students enter medical school with a broad range of life experience in addition to their primary degree. I am convinced this is already producing better and more rounded doctors. On this basis I would urge the leaders of the psychotherapy profession to study this model rather than expecting much younger people, including school-leavers to be ready for a demanding career as a psychotherapist at the age of 19, 20 or 21.
Ed: It’s clear you fear that poor or uneven standards can bring the entire profession into disrepute. Is it not the case that the psychotherapy profession has, from the beginning, not had a great reputation among other professions?
Bill: That is probably so but all the more reason to show concern for a consistently high standard now and to publicise that standard well and properly. The general public need guidance. Other related professions such as medicine are entitled to be challenging and critical. The high standard is already there in regard to ICP and is in operation. It needs to be asserted regularly and clearly.
There are some excellent practitioners and some excellent trainings which operate to a high level. My point is they deserve better support and a proper context in which to operate. At the moment what we have is confusion and a mixed message to say the least.
Ed: How pressing is this in terms of current political and other policy developments in Ireland?
Bill: At the end of the day the failure of the psychotherapy profession to establish itself would mean that the patient or potential client is poorly served. It would result in fewer properly qualified psychotherapists on the ground where they are needed most in primary care and analogous settings.
We may well see a version of Universal Health Insurance in this country before long. It is already Government policy. Tivoli hosted a seminar on the subject in November 2012 to which I contributed. The psychotherapy profession must establish itself enough to be taken seriously in relation to this new system of payment for medical and psychological services. Training standards are going to be crucial in this respect, in terms of being taken seriously and in terms of ceasing to be a kind of ‘Cinderella’ profession. It comes down to vision and leadership and time is short, but it can be done.
Ed: Thank you Bill for those inspiring and challenging comments.
Dr. Gerard O’Neill of the HSE in conversation with Edward Boyne
Gerard, you are currently Director of Counselling with the HSE in the South East and an accredited member of IAHIP. We first met many years ago when we both served on the Executive of one of the professional bodies. Tell me something of your background and what influences brought you into this area of work?
My original background was in psychiatric nursing and I trained in the National Health Service in the UK. As mental health services there moved from an institutional- based model to a community- based model during the 1980’s, I quickly realized that my original training needed to be updated as my role developed and I was seeing clients in GP surgeries and other settings with a wide range of psychological problems. My involvement in counselling and psychotherapy dates back to then.
So you personally went through the process of moving from the hospital setting into more community-based settings and all that involves and demands of the practitioner. I know you have undertaken advanced studies to Doctorate level. What was your research field and how did it tie in to your therapy work?
My Doctoral studies involved two separate projects. The first project involved the development of a short term specialist counselling service for individuals who self- harm or experience suicidal ideation. This service called the SHIP service (Self Harm Intervention Programme) is available across the south east. The second project involved completing a qualitative piece of research and with the help of colleagues, I examined the impact of introducing and using a particular psychometric measure in a counselling service that deals with clients who have experienced abuse in childhood. I grew up in a village in North Kilkenny with a past coal mining heritage so it comes as a natural instinct for me to look beneath the surface. Close examination of this particular clinical area revealed many important learnings, not least of which is the importance for therapists to be aware of the transferential implications of using measures with particular clients.
Currently I think the profession of counselling and psychotherapy is at a very exciting stage of development in terms of what the research is saying about what makes therapy effective. The meta-analytic studies from the late nineties when combined with the emerging consensus across neurobiology and attachment theory in the current decade raises interesting questions about the wisdom of rigid adherence to one particular therapeutic orientation.
I agree that the profession is at a very exciting and important stage in a variety of ways. There are momentous changes in the offing. I have the impression that the HSE is now taking a greater interest in counselling and psychotherapy generally. Is this the case in your view?
Well certainly the mental health strategy document a “Vision for Change” (2006) envisaged a comprehensive range of psychological therapies to be provided at primary, secondary and tertiary level. Provision of access to counselling and psychotherapy was then prioritised in the 2011 Programme for Government and specific funding was provided for Counselling in Primary Care (CIPC) in the 2012 and 2013 HSE Service Plans under the Mental Health in Primary Care Initiative.
My Director colleagues and I are specifically concerned with the National Counselling Service (NCS) which provides counselling to adults who have experienced any form abuse in childhood and CIPC which provides short term counselling to adults with mild to moderate psychological difficulties who have a current medical card. We are setting standards for recruitment for the range of competencies that are required for the specific clinical contexts in both these services and both services are available nationally around the country. CIPC is coordinated by ten counselling coordinators nationally and although it was only launched in July 2013, it is now receiving approximately 1,100 new referrals nationally per month. In the south east as already mentioned, we also have the SHIP counselling service for adults who are experiencing the impulse to self harm or are experiencing suicidal ideation.
That is a very substantial number of referrals to CIPC and indicates the extent of the need for services. It’s interesting that you mention the development of standards. Many of us are aware that we are now in something of a transition phase where statutory registration of psychotherapists and counsellors is concerned. My understanding is that the HSE is now ‘driving’ the process and the timescale. This was not the case until recently. From your personal vantage point, as it were, and bearing in mind the constraints that apply as a member of such a large and accountable organisation as the HSE, is statutory registration likely to be in place soon and if so how soon ?
I don’t know the timeframe for statutory registration but I do agree that we are in very important transition phase. Minister Reilly has indicated his intention to designate Counsellors and Psychotherapists under the Health and Social Care Professionals Act. His Department are consulting with all the relevant stakeholders (professions), before they can progress the Ministers intention to the stage where a designation order is signed and a registration board appointed. Only when the registration board is appointed will CORU be in a position to advise on both the process and the timescales of statutory registration. I would encourage any counsellors or psychotherapists who are interested in the wider process of statutory registration to visit the CORU website www.coru.ie which is very informative.
I understand that it’s difficult to be definitive on the timescale and I won’t press you on it. My own view is that statutory registration will be with us in a substantial way by about 2017., ie three years from now. There are many questions that arise in relation to statutory registration. Clearly under the provisions of the 2005 Act, a new structure will have to be put in place to be called a ‘Statutory Registration Board’. This new Board will be appointed by the Minister for Health and will take over the core accrediting functions of the current professional bodies. It’s definitely not planned under the legislation that the current professional bodies will have any role or function in the new dispensation where accreditation is concerned. It remains to be seen whether practitioners will continue to pay fees to a professional body which no longer offers them accreditation. Legally, it will become an offence to practice, for example under the title ‘psychotherapist’ or ‘counsellor’, unless you are registered with this new Board and paying your annual fee for accreditation. Are these assumptions correct in your opinion?
I don’t have any particular insight into how the professional bodies will work out in the new dispensation as you describe it. I do understand that the new Statutory Registration Board will identify threshold standards of proficiency for entry to the profession and will also set criteria for education and training programmes. The professional accreditation of a training programme is distinct from the academic accreditation of a training programme. Academic accreditation is based on the suitability of a programme for the award of an academic qualification and we all look forward to the publication of the of the QQI document in this regard. Professional accreditation of a programme on the other hand is a judgement as to whether a training programme prepares the graduate for entry into that profession and will involve also monitoring the quality of placements etc. Clearly there are implications here for all of the professional organizations in terms of their role and function.
I believe there is a widespread assumption among therapists that the existing membership registers of accredited therapists from the more than 20 professional bodies in Ireland in the field of counselling and psychotherapy will somehow be automatically ‘grand-parented’ into the new statutory register. My own view is that this is unlikely to be a correct assumption and that the reality will be much more complex. What is your own view?
I do agree with you that the reality is much more complex. Statutory registration is causing all counsellors and psychotherapists to reflect on the future as indeed are the professional organisations as their role and function will also change. I think any statements on grand-parenting arrangements at the current time would be purely speculative.
Probably the most important question for many therapists hoping to be included in the new statutory register is about the qualifying training and post-training standard that is to apply under the new statutory registration regime. If grand-parenting is not automatic, a lot depends on where or how high the bar is set. For example there is now a large disparity between the standard of accreditation for the ICP and related organisations including IAHIP which require a 4 year specialised training post-graduate on the one hand and the standard required by, let’s say other quite large professional bodies in the field which is a good deal lower. The recently published QQI standard for psychotherapy courses is 4 years of training with graduate entry to training. It does seem to me, if there is to be consistency, that the ‘statutory standard’ when it arrives is likely to be closer to the QQI parameter. What is your own view?
I am not sure that anyone yet has the specific answers to the questions you are raising. As I understand it the forthcoming QQI document concerns learning outcomes that are required to entitle persons to educational qualifications up to Level 9 - they do not prescribe the duration of the programmes leading to such qualifications. Minimum programme duration depends on the standard of learning required for entry as well as on the nature, pace and breadth of the programme. I am aware of the wider debate between the professional organizations but I think that this also reflects the underlying lack of synchronicity between the academic infrastructure and professional infrastructure in counselling and psychotherapy. Progress will need to be made on this as part of the journey towards statutory registration.
I think you will agree that these critical decisions will have to be taken by someone or some entity and probably very soon. There appear to be few certainties and a difficult balance to be struck between trying to be inclusive on the one hand and holding to a sufficiently high standard which will be credible and rigorous on the other. There was a useful position paper from the Psychological Therapies Forum in 2007 which stated that we should have two statutory registers, one for counselling and one for psychotherapy. This idea seems to have been abandoned in the wake of the recent IACP policy document which claims that counselling and psychotherapy are one and the same thing. It’s scarcely possible to argue for two registers now. However, accommodating the range of practitioners and standards from the counselling/psychotherapy spectrum into one single statutory and legally enforceable register will not be an easy task.
I agree there are some difficult challenges ahead and I think practitioners should make the effort to inform themselves and stay in touch with developments as they unfold.
Many thanks Gerard for agreeing to help open up this discussion and for sharing your ideas and views.
Edward Boyne in conversation with Dr Gerry Mulhern, Managing Director of the Psychological Society of Ireland (PSI).
Gerry, you were Director of Professional Development of the PSI for several years and have been Managing Director since June 2014. You are also a former President of the British Psychological Society. The PSI has been engaged very closely with issues to do with statutory registration in recent years. Psychology was designated in the first tranche of professions to be regulated under the Health and Social Care Professions Act 2005. My questions for you today are connected with the PSI experience of statutory registration to date. As you know the profession of psychotherapy has recently (Mar 2014) been designated by the Minister for Health for statutory registration.
Yes that’s true, I’m aware of the designation of psychotherapy which has been a long time coming and is very welcome. Interestingly, to date the model of regulation in Ireland had followed the UK model closely, Regulation of psychotherapy in the way now envisaged is something of a departure from the process in the UK where there are no longer any plans to establish a register of psychotherapists.
The current situation in relation to the PSI has become clearer in recent weeks following some uncertainty over the timeline for registration. The most up to date information I have is that psychology will be among the remaining health and social care professions awaiting registration to begin the process of statutory registration in the first half of 2015.
Edward: What is your understanding of how the statutory registration process works when it is up and running?
The 2005 Act sets out the processes that have to be enacted before full registration is up and running. For psychotherapists the first step will be the appointment by the Minister for Health of a Psychotherapists Registration Board (PRB). This Board will have 13 members and will consist of a mixture of six psychotherapists and seven non-psychotherapists, that is ‘lay’ members. This key Board will be responsible for establishing and maintaining the Register of Psychotherapists, assessing and validating qualifications in psychotherapy obtained outside the State, setting the qualifying standard for entry to the profession, approving and monitoring all education and training programmes relevant for entry to the Register, setting the Code of Professional Conduct for Psychotherapists, and setting requirements for continuing professional development for psychotherapists. While it would be expected that the Board would wish to take into account the views of the existing professional bodies, it is not required to follow those views and will decide for itself about all of the requirements for registration. At this stage it is difficult to know what the PRB will do about the various matters I have listed. It’s fair to speculate that there will be some pressure politically for standards of education, training, conduct and CPD at least comparable with the other registered professions.
Approximately nine months following the appointment of the PRB, a ‘transitional’ Register will be established which will allow existing practitioners to be inducted onto the Register on the basis of transitional criteria. This is a very important element of statutory registration which is intended to cater for the likely significant diversity in qualifications and background among existing psychotherapists and to ensure that no-one currently earning a living lawfully through the practice of psychotherapy would risk being disenfranchised by the move to registration. I am not sure that the current provisions of the 2005 Act would be able to accommodate the grandparenting of psychotherapists, so I would expect that this would require a change in primary legislation. In any case, the requirements would almost certainly be a relevant degree or equivalent and the ability to demonstrate two year’s safe practice in the five years leading up to the opening of the Register.
The transitional Register will be open for exactly two years and existing practitioners are encouraged to join during this period, but are not required to do so. Anyone with ‘non-standard’ qualifications or other unorthodox circumstances would be strongly advised to join the Register comfortably ahead of the closing of the transitional period. Following the ending of the transitional period all eligible psychotherapists will be required to be on the Register. Following the transitional period, it will be illegal for any unregistered person to use the term ‘psychotherapist’.
I think we are all wondering what the transition requirements will be. It sounds like the new Registration Board will hold a lot of statutory power. You mentioned that many of its members will be ‘lay people’ or non-psychotherapists. What is the Government thinking behind appointing such people as opposed to say appointing a Board consisting of elected members of psychotherapy professional bodies or indeed their staff or advisers? After all, they have the experience of operating a form of self-regulation to date. Surely the job of statutory regulation can safely be left to those with such experience?
It’s interesting you should say that Edward, because this is the most commonly held view among practitioners undergoing regulation. However, the view that ‘professions know best’ and ‘we’ve always done it this way’ are the last things that the Regulator (CORU) wants to hear. From the outset, the Government has been absolutely clear that the central focus of statutory registration is the protection and confidence of the public and in order to achieve this, Government has deemed that the process must be driven by the public and be independent of the professions being regulated. In operating the legislation CORU has been very clear about this imperative and has kept a healthy distance between itself and the relevant professional bodies. While acknowledging that it has much to learn from these bodies, CORU has sought to do so on its own terms, ensuring that professions do not overstep the mark. This also explains why the principle of a lay majority on the registration boards, and incidentally on CORU Council itself, is a central plank of the process.
So it sounds like the current leaders of the psychotherapy profession, elected or otherwise, as with other professions such as psychologists will be expected to more or less stand aside and allow a ‘neutral’ entity, i.e. the Registration Board, to take complete control. I imagine this has been and will be difficult for some of those hard-working leaders to take on board. It’s also the prospect of fairly dramatic change and a substantial drop in income as the accreditation function in all its aspects (including financial) is taken over by a statutory body.
How do you see the future for professional bodies? What about your own body, the PSI? What will be their role, if any, in the medium term?
You are absolutely right Edward. All professions undergoing regulation have had sleepless nights about the risk of an implosion in their membership numbers and I have a hunch that one or two professional bodies may not survive in the long run. Within PSI many of our members have asked why they should remain members after statutory registration. The answer for all professional bodies is to be clear about what they do on behalf of their membership and to seek to enhance and expand services to members.
In PSI, we have considered various scenarios around the impact on member recruitment and retention and I think we have developed an approach which will ensure that we remain relevant. Part of the answer is to focus on respective roles of the Regulator (CORU) and the professional body and to remind members that the former focuses solely on public safety and on minimum standards to ensure public protection. Professional bodies on the other hand are concerned with enhancing professional esteem and identity, the highest standards of professional practice and services to members. The challenge for the professional body is to demonstrate this in practice rather than merely asserting that this is ‘what we do’.
We hear a lot about ‘fitness to practice’ issues under statutory registration. Can you comment on this?
One of the first tasks of the PRB following its appointment will be to take CORU’s generic Framework Code of Conduct and Ethics and adapt it for the profession of psychotherapy. The resulting document, likely named the Code of Professional Ethics and Conduct for Psychotherapists, will consist of the generic standards as well as those developed for the profession as a whole and others that apply to specific specialisms. The fitness to practice of any registered psychotherapist will be judged in terms of their compliance with the Code as well as their maintenance of CPD as required by CORU.
Part 6 of the 2005 Act deals with fitness to practice. For psychotherapists, as for other professionals, this will cover complaints from any member of the public, employer, colleague or anyone else who is unhappy with the service provided by a registered psychotherapist. CORU is obliged to investigate all such complaints through a tiered process involving preliminary screening through to professional conduct hearings where deemed appropriate.
The other issue many practitioners raise is in relation to the ‘assessment of professional practice’. In cases where practitioners don’t meet the educational/training standards for statutory registration they must undergo an ‘assessment of professional practice’ by the Registration Board. Can you shed any light on what this assessment might involve?
The methodology for assessment of professional practice will be a matter entirely for the Registration Board and would be likely to involve paper based assessment of knowledge and practical assessment of skills, whether through interview or observation. Such assessment is intended to judge the extent to which an individual’s knowledge and skills are comparable to those embodied in current approved education and training. In many cases there is unlikely to be a need for assessment during the transitional phase of the Register, hence my earlier advice that existing practitioners should ensure that they seek to join the Register during this period. I would also reassure practitioners that the ethos of regulation is not to disenfranchise safe and effective practitioners who have been lawfully earning their living as psychotherapists. But it is intended to weed out unsafe and unqualified practitioners, which I’m sure all would agree is a good thing.
At the present time, professional training courses in psychotherapy are enrolling new students. The trainers don’t and can’t possibly know what the standards for training are to be or even what courses will be accepted by the new statutory registration regime. Given the powers of the Registration Board, recognition by a professional body of a training course might be seen as of somewhat limited value. New students today cannot count on any form of grandparenting or transitional arrangements from a ‘professional body register’ to a statutory register. As someone closely involved in psychotherapy training I am acutely aware of the ethical obligations we have to new students in terms of advising and guiding them for their future careers. Do you have any words of wisdom to offer on these ‘transitional’ problems?
In spite of my earlier comments about the desire of the Regulator to keep a healthy distance from professional bodies, I believe that the new Psychotherapists Registration Board will want to draw upon currently accepted standards of education and training in the profession. Despite the lay majority on the PRB, there will also be a healthy number of psychotherapists, at least two of whom must be involved in psychotherapy education. They will undoubtedly be influential in setting the standards of approved qualifications for entry to the profession and those standards should reflect current good practice. The PRB’s future criteria should reflect those elements of best educational provision that currently exist when they set about doing their work. I would reassure all who are concerned that the intention of regulation is not to wrong-foot or undermine those engaged in current good practice, whether as educators or practitioners - rather, the intention is to embed these high standards into Statute.
Many thanks for agreeing to this conversation Gerry and for your helpful remarks.