David Wasdell is a regression and integration therapist. He was founding director of URCHIN and has been carrying out consultancy research into resistance to change.
The field of accreditation in psychotherapy is fraught with fears, threats and anxieties, some acknowledged, some unconscious. Two distinct trends or patterns of behaviour seem to be emerging. The first is a commitment to the highest possible standards within the profession, the improvement of quality, the upholding of ethics, continued learning and the sustained provision of a high quality service to the whole population. Accurate and widely disseminated information is also needed so that potential clients can make appropriate choices in the continued search for health, wholeness and the realisation of human potential. Opinions may differ sharply as to how best to achieve these ends but the professional integrity behind the conirnitment to common goals cannot be called in question.
There is, however, a second and more shadowy side to the accreditation scene. Here the dynamics and motivation are largely unconscious, dominated by the processes of transference, projection and collusion. This paper is an attempt to probe a little further into the dark side of the force that is driving the complex set of dynamics in play. The analysis is based on a series of conversations and interviews, backed by literature review, a study of the history and emergence of the institutions of professionalism and accreditation within the field and observation of those group and institutional processes which arise in conferences debating the critical issues involved.
Grounds of Accreditation?
The assessment of competence in the area of counselling, psychoanalysis and psychotherapy, is extraordinarily difficult. There is a confusing plethora of schools, beliefs, practices and doctrines - a glittering galaxy of psychoclass fragments gathered collusionally around the memory of charismatic leaders whether dead or alive. Each grouping is more or less convinced that their own way of going about the therapeutic task is correct, while the approaches of all others are wrong and ineffective. In this sense the group norms of the particular fragment to which a therapist belongs carry in their construct the common coding of anxiety defences of that particular group. Denied negativities are duly projected into the environment and focused into the set of out- groups, the corporate carriers of the shadow. Attitudes to accreditation inevitably reflect the splitting, projection, displacement and paranoia already inherent in the complex inter-group and inter-institutional dynamics of the field. Under these conditions no in-group is likely to take kindly to accreditation procedures based on the criteria of other groupings or institutional sectors, let alone staffed, adniinistered or imposed by outsiders, whose competence is called in question by the very fact that they are outsiders. Incestuous processes of in-group mutual-accreditation proliferate, reinforced by self-assessment, peer-assessment, client-feedback and institutional authorisation. Recognition of such sub-group accreditation by other sub-groups and institutions in the field is, however, just as fraught as external accreditation itself. The same arguments and objections apply, raised now to the inter-group and inter-institutional level of dynamic, rather than held at the individual level. If accreditation by the outsider is bedevilled by projection, accreditation by the insider is fraught with collusion. If we turn to client-feedback and outcomes research, we fmd little help. Few clients have the experience to make effective comparisons between a number of therapists, which might be used for the basis of evaluation of one against an-other. Client assessment is also coloured to a profound extent by the inter-personal relationship established between client and therapist. Client-feedback is therefore as much a statement of the current processes of transference and counter-transference, as it is an objective evaluation of the skills, practice and competence of the therapist concerned. A client may terminate a therapeutic engagement in angry protest at what is perceived to be therapeutic incompetence, only to realise years later that the therapist concerned had put their fmger on issues of counter-dependency in an intervention which, with hindsight, had been the creative turning point of the client's life.
Outcome research in the therapeutic world is a mine-field of methodological problems. It involves long term monitoring of the client's condition before, during and after the therapeutic process, followed by some kind of comparison of those 'results' with a control group which does not in fact exist. It is virtually impossible to answer the question, 'What would have happened to those particular clients if they had not been working with this particular therapist, had not been engaged in therapy at all, or had been working with someone from a different school, training or approach?' It is impossible to identify a group of people within the population as a whole who have identical problems proceeding to different outcomes in the absence of therapy. In any case the numbers of clients involved with a potential therapist are small and the time base of longitudinal studies quite out of the question in any procedure of accreditation, particularly in view of the fact that accreditation would normally take place at the start of the person's professional career before they had engaged significantly with many clients in the first place.
So, accreditation procedures tend to be forced back onto the most easily measured parameters, which in this situation are the least significant. Books read, courses attended, training analysis, or number of hours spent under supervision, intellectual understanding of the issues involved - none of these are necessary, let alone sufficient criteria of competence in the therapeutic engagement. One thing that does emerge from outcomes studies is that it is not so much the paradigm, the ideological framework, or the particular skill set involved that makes a difference, but the quality of the inter-personal relationship established between therapist and client. Seen in this light truly the therapist has no clothes and accreditation is an attempt to generate a veritable Emperor's wardrobe of nonsense.
Client Choice
Against this background the task facing a potential client is indeed daunting. There is a bewildering array of therapies and approaches from which to choose, with almost no available criteria of comparison or effectiveness. Even if such criteria did exist, the level of self-awareness m the prospective client would have to be very high indeed if the comparative information were then to be related to the particular needs which motivated the client to seek to employ a therapist. Once a particular approach has been selected, there may be a large number of individual practitioners associated with the particular method chosen. Comparative information which might enable the choice between therapists within a particular school is also unavailable. So the degrees of freedom involved in the choice are extremely high, information is minimal, uncertainty is massive and all at a point in the person's life where anxiety is already great. The capacity for making judgements about the appropriateness or otherwise of any particular therapist from any particular school is likely to be clouded by the very condition which motivated the client to seek a therapist in the first place. A national register of accredited psychotherapists would hopefully solve all such problems, reducing the anomia and anxiety and ensuring that any client who wished to engage a therapist could pick a name from a list in full confidence that the service rendered would be competent, uniform and effective. Tragically any such confidence is misplaced. A register of accreditation would provide a token or symbolic form of arixyolite, while in fact hiding the realities of confusion, uncertainty and unpredictability that underlie the choice making procedure. In this sense the drive toward accreditation that stems from client anxiety is a defensive manoeuvre, colluding with the public desire for a simplified and irresponsible decision making process.
The Bottom Line
There is a very powerful feedback loop involved once the idea of accreditation is raised. Therapists who depend for their livelihood upon the fees paid to them by clients (or the wages given to them by their employers - it all depends on your point of view) become distinctly 'twitchy' once one group parades itself as 'accredited' and clients.begin to stipulate accreditation as part of their choice making process. What begins as a trickle ends in a paranoid stampede to get the appropriate letters after one's name and the papers of accreditation and affiliation firmly established and publicly noted. The risk is a rapid diminution in the client base and eventual starvation. In that sense the drive towards accreditation may stem from the very lowest levels of Maslow's hierarchy of need. It is a bandwagon, to fail to board which is to put at risk the very means of earning a living. Once the movement towards accreditation has passed a certain critical point, therefore, it is the bottom line of economics that drives it towards universal adoption, rather than anything inherently appropriate or professionally significant in the actual process of accreditation itself. The result is one group of therapists who are accredited, who get business and survive, and another group of therapists, who may be equally competent but are not accredited and therefore do not get business and do not survive. The boundary between the two is a false, or pseudo, dichotomy, designating a distinction between the in-group and the out-group that is lacking in meaning, since the quality and lack of uniformity of therapy inside and outside the boundary is unlikely to differ significantly.
Of Rejection and Discreditation
From the therapist's point of view, however, a different range of motives and anxieties presents itself. Leaving aside for the moment the professional adult search for excellence and the open and confident submission of one's practice to examination by one's peers, other more shadowy motives emerge. There is the hysterical desire to belong to a group and the fear of rejection. From these roots springs the complaint that therapists offer to the accrediting procedures precisely those facets of their practice which are deemed to match the criteria of acceptance, whether or not they reflect the practice of the therapist concerned. There is a presentation of a 'false self' and a suppression of potentially damaging information, in an attempt to press through the needle's eye of accreditation. In that coveted space beyond, guarded by the generalised boundaries of the in-group, the newly accredited therapist feels freer to practice in ways which may or may not be coherent with the principles of accreditation employed.
part 2, part 3
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