In 325 AD, the Emperor Constantine convened the First Ecumenical Council at Nicaea in Bithynia (present day Iznik in Turkey).  It brought together a remarkable array of charismatic bishops and priests, each representing a different interpretation of the Christian scriptures.  There were the three patriarchs, Alexander of Alexandria, Eustathius of Antioch, and Macarius of Jerusalem, the confessors, Paphnutius of Thebes, Potamon of Heraclea and Paul of Neocaesarea, who came to the council with the marks of persecution on their faces.  Other remarkable attendees were Aristakes of Armenia (son of Saint Gregory the Illuminator);a former hermit, Hypatius of Gangra; and Spyridion of Trimythous, who, while a bishop, still made his living as a shepherd.  There were bishops from as far away as Persia, Egrisi in the Caucasus, the Gothic lands to the north, Dijon in Gaul, Cordoba in Hispania, Carthage in North Africa, and the provinces of the Danube.  They had all travelled to come to resolve certain fundamental differences in the belief and  practice of Christianity, in particular whether Jesus was God or just similar to God and the date on which to celebrate the resurrection.  While they were there, they also established twenty new canons or laws, which included the prohibition of self castration, the setting of a minimum time of instruction before baptism, the prohibition of the presence of a young woman in the house of a cleric, the provision of provincial synods, rules concerning ordination of bishops, prohibiting usury among the clergy and kneeling during the liturgy.  This was the first time that an attempt had been made to establish concensus among the diverse beliefs and practices which constituted the broad church of Christianity.  Seventeen centuries and scores more councils later, divisions still exist but they are not as serious or as profound as they were and for the most part there is a peaceful coexistance among Christian beliefs.      

 

Psychotherapy is also a broad church.  There are psychoanalytical psychotherapists,  cognitive behaviour therapists, Gestalt therapists, humanists, existentialists, couple therapists and family therapists.  And within the psychoanalytical subdivision, there are Freudians, Jungians, Kleinians and even Rogerians.  In the past, too much effort has been spent in arguing which is the true path to understanding and salvation.  Psychotherapists, experts in helping others resolve their personal conflicts, have themselves been split, even splintered, by their extraordinary capacity for internecine warfare, for division and entrenched non communication. 

 

The organizations that represent them, as many as the early Christian sects, are now in crisis as they struggle to hold the tension between the interests of public and private practitioners, between cognitive behavioural and psychoanalytic modalities, between psychodynamic and psychoanalytic practice and  between Jungian and Freudian.  Although diversity is professed to be the strength of psychotherapy, and eclecticism a virtue, unless the profession can attain a clear concensus of core values and practice,  it is in risk of being shunted into the sidings of everlasting analysis.

 

 

It doesn’t. The goals of therapy can appear too abstract, the principles of practice as diverse as complementary therapies, the profession fragmented, the public confused and the government frustrated.  With depression the most common illness in the UK and antidepressants not really the answer, psychotherapy should be accessible, brief and effective.

 

In order to establish consistency of practice and improve accessibility to psychotherapy, the British Government has proposed that regulation of the psychotherapies should be  removed from the professions concerned and placed in the hands of public servants who are unfamiliar with the nature of the clinical work. The Health Professions Council (HPC) has been given the task of regulating talking therapies through the establishment of clear criteria for accreditation, approved training courses and strict codes of ethics. Skills for Health (S4H) has been charged with developing National Occupational Standards for psychotherapy.  More than 450 rules have been listed for psychodynamic and psychoanalytic therapy. They dictate every aspect of how therapists should organise their sessions, how they should ‘monitor’ themselves and how they should carry out their work. They go into minute detail about the timing of interventions, the setting of the therapy, its aims – and even the expression of appropriate ‘feelings’.

 

Psychotherapy is therefore in danger of being forced into the current culture of outcomes, where everything can be predicted in advance, and evaluated in relation to the expected results.  It will increasingly become an intervention to be applied to patients, rather than the long and painstaking change achieved by patients under the guidance of the therapist. Only those professionals who practice (or appear to practice) an approved form of intervention will be allowed to remain in business.      

 

But what is likely to be the approved intervention?  The government’s watchdog on medical treatments,  The National Institute of Clinical Excellence (NICE) recommends cognitive behavioural therapy (CBT) as the approved treatment for most mental illnesses.  CBT works on the principle that people get ill because of the way they think about things.  Thus, if they can be instructed to change they way they think, they will return rapidly to health. 

 

CBT has a clear protocol and programme, which can be conducted over a few weeks.  The required change in thinking and behaviour can be clearly defined and what’s more importance for an evidence based culture, the achievement of those goals can be assessed by questionnaire. But response to questionnaires is subjective, people often provide the answers they have been trained to provide and make responses that will please the therapist.  It is hardly surprising that CBT gets the results it intends, the relief of specific symptoms.  But critics point out that although it conforms to a medical model and, as such, is just what the doctors and their employers order, it does not achieve a lasting change in attitude nor even a return to health. 

 

If CBT is adopted as the true religion, then more psychoanalytical sects will need to adapt and conform or risk excommunication.  

 

 

Psychoanalytical psychotherapies in the UK are cuirrently regulated by two main bodies, the United Kingdom Council for Psychotherapy (UKCP) and the British Psychoanalytical Congress (BPC). Practitioners belong  to a variety of member organizations, some geographically based, some modality based.  Each has strict codes of ethics, practice and complaints procedures, and is inspected periodically by the regulatory body. The new developments threaten to render the existing regulatory structures obsolete.

 

It is not surprising therefore that psychoanalytically based psychotherapists feel under pressure to get their house in order, to clear out the box room of ancient couches and dusty books and to convert the basement into a new purpose built mental health centre. 

 

The Alliance for Counselling and Psychotherapy, which represents the views of many psychonalytically oriented psychotherapists, is opposed to state regulation.  In a recent statement,  they point out that most forms of psychotherapy do not focus exclusively on the relief of symptoms.  ‘The goal is more an improvement in general quality of life.  Moreover, psychotherapy is a contract between responsible adults, not a health intervention regulated by the state.  The client should have freedom of choice for the kind of therapy they need.  Many practitioners see their work as an art rather than a science,  a series of skilled improvisations within the context of a relationship where each client offers unique issues and demands unique responses.  Such activity cannot be captured by a list of competencies. Diversity and flexibility are important.  By privileging cognitive behavioural therapy because it appears to be evidence based, the proposal for state regulation will reduce access to long-term, rationally-oriented therapies, to reduce client choice and to medicalise the field, to rigidify training and inflate its cost and hence the cost of therapy, making access more difficult to the disadvantaged.’ 

 

Thousands of therapists have been writing to MPs and politicians, seeking a recognition of the fact that analytic work cannot be reduced to a set of rules to be mechanistically applied to a patient with predictable outcomes, but involves an exploration of the meaning of an individual’s history.

 

To head off the threat of statutory regulation, the UKCP has organised numerous meetings on how it might restructure itself to satisfy the regulatory zeal of the state without losing its psychoanalytic soul.  This exercise is known as SHAPES and might be compared, by the cynical, to arranging the next day’s onboard activities on the Titanic.  The latest creation, SHAPE 6, proposes a Psychotherapy Council that includes representatives from each of the major divisions as well as from regional member organisations.  The Council would advise the Board of Trustees, which under the by laws of its charitable status, oversees the work of the executive.  The next tier of organisation would include new colleges for the major modalities of practice.   It would be the colleges that would organise their own trainings, criteria for accreditation and models of  ethical and clinical practice, but under guidelines and supervision and approval of the Board of Trustees of the UKCP.  Overlapping with the colleges would be the faculties, multidisciplinary groups, that support an integrated form of practice for special interests, such as eating disorders, trauma and mind-body illness.  The diverse collection of regional and modality based member organisations would align themselves with the faculties and colleges according to their specific practices and interests. 

 

James Antrican, the current Chair of UKCP, has asserted that the member organisations   are the life blood of the profession.  If the member organisations withdrew their support,  then the UKCP, a charity totally funded by subscriptions and a few donations, would not exist and many psychotherapists would lose any influence they might have on government policy.  The hope is that although psychotherapists would need to register with HPC in order to practice, registration would be subject to controls and criteria set out by the professional organisations working as agencies for the HPC.  But the UKCP are needs confidence and support of government if it is to function as its agent for regulation of the psychotherapies.  This fear is that this might mean that it would restrict support for psychoanalytical psychotherapists. 

 

Since the colleges have not yet formed, psychoanalytical psychotherapists are organised under a section of the UKCP, known as the Council for Psychoanalysis and Jungian Analysis (CPJA).  The panic felt by UKCP has been passed down to CPJA, who are rapidly attempting to rebrand themselves with mission statements and clear descriptions in order to be appear less abstract and more accessible. 

 

But why are the professions not talking directly with HPC?  I have an impression of HPC smiling benignly and just allowing the psychoanalytical professions to demonstrate that they cannot organise themselves and the money is better placed elsewhere.   

 

It probably doesn’t help to be defensive.  Change is going to happen.  It is easier for government to work with professions than against them so it will listen if the message is clear and sensible.

 

Indeed, what is happening is the evolution of psychoanalysis.  Initially a dangerous doctrine with a certain cult status, it grew throughout the thirties, forties and fifties to be the dominant force in medicine.  Many professors of medicine in the nineteen fifties were psychoanalytically trained.  Then disillusion set in.  There were some spectacular failures, important diagnoses were missed, the treatments were too long, too expensive, the method too abstract and erudite,  Freudian philosophy was seen as antithetical to feminism.  Psychoanalysis became restricted to private practice available largely to those rich enough to afford it. 

 

In the meantime however, the philosophy of psychoanalysis had invaded the culture.  Film, plays, poetry and novels took up the baton and the precepts of psychoanalysis became an accepted part of human discourse. 

 

So instead of seeing state regulation as a threat and cognitive behavioural therapy as the enemy, I wonder if there is sufficient scope and enthusiasm for adaptation and flexibility.  Cognitive analytic therapy (CAT) and ‘mentalisation therapies’ are hybrids that enrich the strain of CBT with a psychoanalytical culture of meaning while maintaining treatment goals. 

 

    

Like the early religions, psychoanalysis is not an immutable dogma but more a process.  It will not disappear but it will change and merge with other methods to become more relevant to the requirements of a changing culture.  It seems that instead of mounting a defensive rearguard action against change, we should be seeking ways of working with the powers enforcing change to ensure that optimal understanding and help for the ever increasing numbers of people suffering from unexplained mental and physical illness. 

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