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I should emphasise that nothing that I have said about concern for patient welfare and anxiety about rogue therapists should be taken to suggest that the professional standards developed by the various professional bodies in these fields are not excellent. Indeed, another reason for their antipathy towards the HPC is that it is perceived to have a lower threshold than the majority of voluntary codes. The concern is that these do not have a statutory basis and anyone can practise without membership of a professional body or reference to their professional codes.
The Minister’s responses to the amendments in Committee in 2001 indicated that he realised this, when he said that HMG might be prepared to consider new arrangements enabling psychotherapy, psychology and counselling to be managed together in a new council set up under the Health Act 1999. Sadly, however, the Government were not willing to amend or widen the terms of that Bill; nor were they willing to proceed with their own version based on the Minister's response.
There have been discussions with stakeholders, although I sense that these attempts have strayed back into trying to define skills and techniques rather than appreciating that, in this field, professionals, their work and relationships with clients are not susceptible to such definitions and protocols. The process of achieving statutory registration in these fields has proved long term, painful and frustrating. The alternative is to do nothing, until eventually the Government are bounced by scandals and public demand into something being done which may be on a less considered and appropriate foundation.
Do Her Majesty’s Government recognise that professional bodies in this field support regulation but are unhappy about the Health Professions Council as an appropriate instrument? How do the Government intend to address those concerns and will they give consideration to a new regulatory council for psychological professions within the framework of the 1999 Act?
In my closing comments during the Second Reading debate in 2001, I noted that in respect of Northern Ireland, Her Majesty's Government had decided that 30 years was long enough and had set their mind to addressing those complex problems—with which I am also somewhat familiar. It would appear that in the intervening six years even the historic problems of Ireland have made more progress towards resolution than the problems of the statutory regulation of psychology, psychotherapy and counselling. I hope that, now the Minister has returned to the Department of Health and again shouldered responsibility for better regulation, he will encourage us by preparing to build on the thoughtful proposition that he made in Committee on my Bill all those years ago, by establishing a body that will bring together into one body what he described as the talking therapies. As he said, that could be done by an
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7.47 pm
Baroness Pitkeathley: My Lords, I thank the noble Lord, Lord Alderdice, for giving us the opportunity to debate this important topic tonight. As I understand that a White Paper is due very shortly I am not sure that I can entirely congratulate him on the timing.
I begin with my declarations of interest. I am a social worker, trained as a counsellor, and I have lost count of the number of times I have recommended these types of therapies to friends, clients and colleagues as a means of sorting themselves out. On more than one occasion in my life, I have been grateful for the help I myself have received to get me through a difficult and distressing period. It has always been helpful, life-enhancing and indeed, on one occasion, life-saving. Therefore, I make no bones about the fact that I am a fan and a believer in the talking therapies. It is because I am a fan and a believer that I very much welcome the Government’s intention to regulate the profession.
I and others use the word “profession” but that is in itself a misnomer. Profession implies a recognised qualification, proper standards, registration, monitoring and, in extremes, striking off. But nothing like that exists for many of the people who practise talking therapies. The British Association of Counselling and Psychotherapy and other bodies do their best. As the noble Lord, Lord Alderdice, reminded us, some of their standards are higher than those that might be imposed by legislation. However, there is no necessity for anyone to register with them. As we have heard many times, anyone can put up a brass plate and practise as a psychotherapist. While we can say to a potential client or patient, “Always be sure that the person you are seeing is approved”, how many people would even begin to know what that was? The plain fact is that we begin to think about seeing such a therapist only when we are in some kind of distress; for example, in bereavement, when our marriage ends or when our most intimate relationships are going wrong. That is when we are at our most vulnerable, most suggestible and when we are least able to make rational judgments.
Sadly, that makes us prey to practitioners who are incompetent or even malevolent. We have all heard of therapists sexually or financially abusing clients. I believe that these cases are rare, but even one is too many. But still too many people find—by chance, by recommendation or through desperation—a therapist who exploits them in some way or who does not help them to cope with the problem they are presented with. This exploitation takes many forms: for example, people may be kept hooked for too long in a therapeutic cycle; people may be caused financial distress because therapy is not cheap and is rarely available on the NHS; or, perhaps worse, therapy does not help them to become strong enough to deal with their own life for themselves.
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Your Lordships may be familiar with that old Woody Allen joke: “I have been seeing my shrink twice a week for seven years now and don’t feel any better. I am going to give him one more year and then I’m going to go to Lourdes”. It may be amusing, but to see people spend their life savings on 10 years of therapy and never move on, or even begin to come to terms with their difficulties, certainly is not. Of course, some problems are so difficult and so deep seated that they may take 10 years, but most people can be helped to find a means of operating which enables them to grow and not be kept in thrall to therapists. Surely, that says more about the therapists than the client.
As Dr Chris Allen said in yesterday’s Observer:
“The government plans are overdue; outside the framework of the NHS too many therapists operate in isolation and without adequate supervision, offer therapies of unproven effectiveness and can end up meeting their own needs for power”.
That is why most reputable therapists, as we have heard from the noble Lord, Lord Alderdice, welcome the idea of more regulation and that it should be statutory. I believe that it should also be necessary to ensure that therapists are in therapy or some kind of continuing counselling relationship.
I know that there is controversy about how regulation will operate. The noble Lord, Lord Alderdice, has shared his reservations about that. No doubt other noble Lords will have received, as I have, briefings about the reservations of the psychological professions and the alternative proposals that have been put forward. No doubt these proposals and others will be extensively debated as we work on the legislation which I hope will follow the White Paper. For my part, I am just glad that the Government are willing to tackle this thorny problem. It is overdue, as I am sure we can all agree.
We also have to acknowledge that it will not be easy to regulate such therapies. By definition, they are carried out on a one-to-one basis where a relationship of trust is established between the professional and the client. But there is no doubt that effective training, assessment and supervision of people in such professions will certainly go some way towards identifying those most likely to abuse power.
The other reason that I applaud the Government’s intention to regulate is the publicity which I believe will result. One of the great problems of talking therapies is that people know nothing about them or know about them only in a mysterious way. I believe that this publicity will be very important in getting away from talking therapies being shrouded in mystery and ignorance. In my view, referral to a therapist should be as ordinary as referral to have an X-ray. Taking the mystery out and putting the regulation in will benefit not just those who avail themselves of the services but the whole of our society. It will help us to understand better our mental and emotional health and needs, as we have begun in recent years to understand our physical needs.
7.54 pm
Baroness Bottomley of Nettlestone: My Lords, I am delighted to follow the noble Baroness, who I have known and admired for 20 years or more. The House
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I have been involved in this debate for many years, originally working in association with the Maudsley hospital and with child guidance clinics in Brixton and Peckham. I was chairman of the juvenile court in Lambeth for many years. One could see those troubled, disturbed young people and believe that the answer for them was a physical, pharmaceutical, medical response. They needed support, encouragement and education, but they and their families also needed talking therapies. As Health Minister, I certainly did not make the progress that I hope future generations of health Ministers will make. We had the Professions Supplementary to Medicine. We have moved on to the Health Professions Council. But I am very much with those who believe that the talking therapies need a different structure.
Since I last visited the subject, the progress has been great. I was brought in again in 2000-01 by a wonderful man, Peter Hildebrand, who had been on the Sieghart committee. He was in charge of adult therapy at the Tavistock. In his last year of life, he called and said, “I will not see the year out, but before the year is through I want progress to be made on the statutory regulation of talking therapies”. I spoke to his widow today and said, “There has been further progress, but we still haven’t got there yet”.
I believe that we have a real opportunity but we must not allow simplicity to cloud the complexity of introducing statutory backing that is sensitive to these therapies. The crucial element is that for many people with mental health problems it is the medical model that they most dislike. They do not want to use a pharmaceutical approach. They find hospitals and the medical culture alien. For them, there is a great demand for talking therapies. I spoke today to Barbara Herts who runs YoungMinds, which has a campaign to mainstream mental health issues for young people—in schools and youth clubs—and be a voice for children and young people. It wants talking therapies. It does not want to go on a pharmaceutical route unless it really has to. Of course, if people have a psychotic condition, that may be the best option. But there is a real demand for talking therapies.
What do these young people want? They want robust regulation, transparency and to know about outcomes. They want less jargon and more openness, and regulation with an independent element. Of course, all the talking therapies have received a great boost from that wonderful report, The Depression Report, by the noble Lord, Lord Layard, which I am sure was greatly inspired by the noble Baroness, Lady Meacher, and all her work at the Mental Health
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I also want to pay tribute to my noble friend Lord Howe. He and my colleague in another place, Tim Loughton, have made a great effort to meet many of those involved in these professions. We all share in the exasperation of being completely unable to follow what one particular group wants, what another group does not want, and how it is all to work together. In that state of exasperation, it is easy to fail to understand the key point made so clearly by the noble Lord, Lord Alderdice: these are therapies of a different kind. The tool is the relationship. We need to understand that there is no prescriptive list of actions, treatments and interventions. The noble Baroness, Lady Pitkeathley, put it only too well.
I should like to cite another example, that of the Immigration Counselling and Psychotherapy Service. This is a remarkable charity employing 300 psychotherapists. It cares for the damaged children of the industrial schools in Ireland and provides support and care for many Irish migrants to this country, a group that is often overlooked and misunderstood. Many of them faced great personal distress during the Troubles and in some of the incidents in this country. The charity’s psychotherapists are regulated by the British Association for Counselling and Psychotherapy and the UK Council for Psychotherapy. It applies high standards with good supervision; indeed, many of its standards are higher than could be expected of a statutory body. Along with all the others involved in practice, it is anxious about the damage that could be done if the Government take what may seem like the simplest and shortest-term option rather than look at the complexity of the position.
I am grateful to Professor Jennifer Brown, head of the Department of Psychology at Surrey University, where I am a Pro-Chancellor. Along with the
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“The HPC procedures are designed to encompass a very broad range of health and allied professions, and as such are neither rigorous enough nor are their standards sufficient to regulate the professional practice of psychology effectively”.
Some 60 per cent of psychologists do not work in the NHS, but in other settings. Some work for charities such as those I have mentioned. I have talked about Young Minds and ICAP. They work with Cruse, Relate, the Samaritans, and on helplines. It is not appropriate to regulate these people in that way. What is more, the perverse aspect of this is that in many cases there is a degree of co-payment, so if the Minister effectively nationalises all these therapists, with that he will pick up a considerable hidden cost. Regrettable as it may be, many charities work through contributions made by patients. That is a further argument. Many work in education and the Prison Service, which is much debated in this House. For them, the sensitivities required in their field of engagement are extremely important.
I hope that the Minister, having returned with a new lease of life, will revisit this subject. There is no doubt that it would be a tragedy to miss this opportunity, given that there has been such a convergence among the relevant bodies, and to go down a blinkered route. Many of us greatly admire the noble Baroness, Lady O’Neill of Bengarve. In her wonderful book, A Question of Trust, she wrote:
“The efforts to prevent the abuse of trust are gigantic, relentless and expensive. The results are always less than perfect”.
Few hope for perfection, but I hope that the Minister can persuade his colleagues of the validity of the profound and very persistent points being made on this subject. If he can do that and prevail, the result of this convergence will be much nearer to perfection.
8.04 pm
Baroness Barker: My Lords, I congratulate my noble friend on securing this debate. The title may be slightly wrong and perhaps we ought rather to look at the progress he has made towards the goal of regulation of these professions. As many noble Lords have said, some 35 years have passed since people first recognised the need to ensure quality and safety for patients, and it is six years since my noble friend made one of the best attempts ever at trying to bring together very disparate and sometimes conflicting groups of people. Like the noble Baroness, Lady Pitkeathley, during my preparation I found my mind wandering off to consider Woody Allen as well. In a slightly different vein, I wondered how many Woody Allen films have been made since people started to address this issue, and how many will there be before it is resolved.
Looking back to the debates in 2001 on my noble friend’s Bill, what he managed to do then was to crystallise the main issues. I would say that the only difference between then and now is that the demand for talking therapies has increased dramatically. Thirty-five years ago, no one had heard of chronic
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A key issue of the time was whether the inclusion of counselling in a regulatory body was desirable. Counselling is now recognised as one of the most cost-effective low level interventions in health, but it is one which people often do not seek for themselves. They are frequently referred by, for example, their GP, and innovative GP practices now provide counselling services. People take counselling on trust and at one remove, and so have no way of establishing the quality of the service for themselves. Another issue was how to include the different modalities of psychological and psychotherapeutic intervention.
A further issue was how to regulate most effectively a range of people working either privately or within the NHS with a myriad of job titles, and some of whom may be subject to different and separate regulation. For example, GPs are already subject to regulation by the GMC, but may provide some form of psychological or psychotherapeutic service although that is not their primary role. Questions were asked about how to establish the most effective and efficient regulatory framework. Back in those days Ministers argued for therapists to be included in a health professionals’ council under the Health Act 1999 while others pursued the route of a stand-alone body, a form of psychological professions’ council as outlined by my noble friend. Six years on, I suggest that it is a good time to look at where we are and where we need to be.
One of the things my noble friend deserves most credit for is bringing about a degree of consensus among the professions, which was not the case back in 2001. I do not say that there is now complete unanimity, but there is a far greater degree of agreement than was the case then. For example, the inclusion of counselling and psychology is now by and large agreed. That is no mean achievement given the range and strength of views held. An additional key issue was the agreement that it is not right to include psychological and talking therapy professions in with other health professionals. It simply does not make sense either to patients, users or the professionals themselves to be lumped in with those treating physical illnesses because they simply do not have a sufficient commonality of approach. My noble friend Lord Alderdice set out the reasons for that extremely clearly.
That mirrors something which is going on in another area of the health field: the proposal by the Government to merge CSCI with the Healthcare Commission and the Mental Health Act Commission. There are similar reservations on the part of mental health professionals who feel that putting these bodies into the same inspectorate framework is misguided. I know we are going to have other discussions about mental health in this House—indeed, we are in the middle of them—but it is important to make the point that when the professions themselves are talking in that way about regulation, the Government ought to listen. The question is whether
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I wish to pick up the point about the composition of any regulatory body, about which there was a big discussion during consideration of my noble friend’s Bill. At that time the Government talked about the need to have lay involvement. No one these days would suggest that not having some degree of user involvement on a regulatory body was anything but acceptable, but the Government were talking then about something in the order of 50 per cent lay people. When one considers the range of disciplines within the fields of psychology, psychotherapy and counselling that have to be included, one is talking about quite an extensive body. I wonder, when the Government get around to discussing the nature of the body with us, whether they might consider that matter.
Finally, back in 2001 the Government made an argument about the need to avoid as far as possible dual regulation of people who are already regulated because they have another medical profession; for example, GPs being regulated by the GMC. It is fair to say that it is not that unusual, within the health service alone, for people to be subject to different forms of regulation. There is a general level of patient care that one would expect in any of the caring professions; that is a given. If someone were to present themselves to a patient as having a degree of expertise above and beyond that—I am thinking, for example, of a nurse who becomes a specialist bereavement counsellor—we would expect them to have that qualification, and I think they would expect that too.
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