The British Association for Counselling and Psychotherapy (BACP) would like to submit the following response to the Consultation on the statutory regulation of psychotherapists and counsellors.

BACP is the leading professional body for counselling and psychotherapy in the UK, with a membership of over 32,000 practitioners and 1200 organisations across the UK, drawn from the various professional disciplines in the field of counselling and psychotherapy and based in a range of settings from frontline NHS Services to voluntary agencies. BACP is the largest counselling and psychotherapy organisation in each of the four home countries of the United Kingdom.

BACP has not sought entry to the Health Professions Council and has opposed the HPC as a suitable regulator; preferring a newly-constituted, Psychological Professions Council. Following the Government's decision to regulate counselling and psychotherapy in the HPC in the 2007 White Paper "Trust Assurance and Safety", BACP has participated in the exploratory work undertaken by the Professional Liaison group on the regulation of counselling and psychotherapy.

We have to report that many of BACP's 32,000 members have questioned the integrity of the process and it is difficult to refute the charge that the Chair of the PLG, as a registered Art Psychotherapist and UKCP registrant, has an interest in an outcome that privileges psychotherapists. There appears to be an underlying assumption of difference and hierarchy in the HPC and the PLG.

We wish to emphasise that we have consulted widely by means of regional meetings, personal letters, emails, e-bulletins and on our website in order to inform our response and represent the views of our 32,000 individual members and 1200 organisational members on the HPC's proposals. The 4 500 responses received are representative of the membership in terms of membership category, age, gender and geographical location. Our comments are based on both the feedback received and the evidence base for the proposals. 87% of members who responded opposed the proposed differentiation between counsellors and psychotherapists.

Counsellors, both BACP members and non-members, make up approximately two thirds of the occupational field of counsellors and psychotherapists in the United Kingdom. It is self-evident that the proposals should have the support of the majority of this population if regulation is to be effective and inclusive.

Introduction

BACP supports the principle of statutory regulation for counsellors and psychotherapists and supports the key tenets of Professional Regulation - namely acting in the interest of the public (individuals or as a group) maintaining professional standards and maintaining the reputation of the profession. BACP also hopes that the HPC will keep in mind the five key principles of regulation, that is should be proportionate, accountable, consistent, transparent and targeted (The Better Regulation Task Force Principles of Good Regulation 2000).

The Association does not support the specific proposals to differentiate between counselling and psychotherapy and the consequent differentiation within the Standards of Proficiency and threshold entry levels to the register. This introduction contains a summary of BACP's rationale for the rejection of the specific proposals. Detailed responses are given in the body of the consultation response and in answer to Question 18 on the potential impact of the implementation of the proposals.

BACP notes that the HPC proposals have resulted in an increased number of its members moving to the position of opposing statutory regulation and joining the Alliance for Counselling and Psychotherapy Against State Regulation. We see this as an unfortunate consequence of the proposals.

"..I think the key issue is the lack of understanding of the modern mental health context demonstrated by the HPC. It brings to my mind Maslow's saying - ‘to the man who only has a hammer in the toolkit, every problem looks like a nail'."Learning and Development Consultant

"This ill-conceived attempt to create a hierarchy in the psychological therapies does not bear scrutiny from a critical analysis. It is demeaning to the intelligence and integrity of the many therapists who are familiar with other domains of knowledge, particularly sociology, social psychology, epistemology and philosophy. The attempt at professional closure by interested groups is abundantly clear. The sequestration of concepts such as wellbeing, mental disorder, and diagnostic procedures is a lamentable attempt to create a divisive and indefensible hierarchy...."Counsellor / Psychotherapist

"My sincere longing is that the BACP will now actively demonstrate its opposition to the HPC's involvement in the State regulation of counselling and psychotherapy and seek to renegotiate an outcome that will protect and enhance the practice of counselling/psychotherapy. If the BACP does not, I see little choice for practitioners, other than to take up a position of principled non-compliance."Bereavement Services Manager

The proposal to differentiate between counselling and psychotherapy is out of step with research and other developments in the field of the psychological therapies for example New Ways of Working and IAPT. The work undertaken by Skills for Health to develop National Occupational Standards for the Psychological Therapies does not differentiate between counselling and psychotherapy There are an increasing number of training courses that title themselves ‘counselling and psychotherapy' for example, Bridgewater College - Advanced Diploma in counselling and Psychotherapy, Liverpool John Moore's University - MA in counselling and psychotherapy and Chrysalis - Diploma in counselling and psychotherapy.

BACP is strongly of the opinion that to separate two professions on the basis of five uninformed, non-evidence based standards is unacceptable and flies in the face of common sense. There are 52 Standards of Proficiency for counsellors and psychotherapists of which 49 are common to both counsellors and psychotherapists with only three different standards for psychotherapists and two different standards for counsellors.

BACP's rejection of some of the proposals is based on the following issues and concerns.

1. The risk to members of the public implicit in the proposed Standards of Proficiency for psychotherapists only.

2. The medical model that is both explicit and implicit in the HPC's generic and proposed psychotherapy Standards of Proficiency.

3. The lack of any evidence to support the differentiated Standards of Proficiency.

4. The HPC's anomalous position with regard to setting academic threshold levels.

5. The reduction of opportunities for career progression for counsellors and psychotherapists.

6. The lack of any consideration of the impact on the delivery of services.

7. The impact of the short grandparenting period on counsellors and psychotherapists in training.

"The HPC proposed standards will create a very different profession than the one that currently exists - to the detriment of clients." Visiting Professor, Director Non Profit Educational Trust and Chartered Psychologist

"I am not opposed to the regulation of our profession, and indeed welcome this development. However, when the accepted main professional body that represents our profession, and the vast majority of its members feel that the current proposal is not fit for purpose, it should be of great concern to the HPC." Acting Manager, Young Persons Drug and Alcohol Treatment Service

"I can find absolutely NO evidence that the criteria the HPC is proposing to distinguish between them has any correlation with the ‘real' world practice of psychotherapy and counselling and was horrified when I read of these distinctions in last month's Therapy Today." Counsellor/Therapist (private practice); School Counsellor (educational setting)

1. Risk to the public

BACP is concerned that the proposed Standards of Proficiency for psychotherapists only, would place members of the public at risk by indicating a level of competence that is currently not required or delivered in training. These proposed Standards of Proficiency are almost identical to two of the three competences required of an "approved responsible clinician" in the 2007 Mental Health Act. A role previously restricted to medical practitioners and now restricted to experienced members of five professions. It would clearly be inappropriate for someone who is not qualified to diagnose to undertake any diagnosing.

2. The medical model

The medical model used in and by the HPC and expressed in this consultation in the Standards of Proficiency is questioned and rejected by BACP on behalf of its members. There is evidence from our members that many who work as psychotherapists eschew the medical model and adopt the approach implicit in the proposed two SoPs for counsellors. This is a principled approach attempting to move away from the stigmatising of mental illness, not a matter of higher or lower levels of training or competence. If one philosophical stance is given higher status than another, it could set back developments in the field of mental health seen as desirable by user organisations.

Several members commented that there seemed to be an implicit assumption that most psychotherapists worked in mental health and within a medical model. The joint 2005 Interim Report to the DH on the Mapping Project for Psychotherapy and Counselling by BACP and UKCP found that a minority of psychotherapists worked in mental health.

"These standards are in danger of defining both a hierarchy and a polarity between medical and humanistic models.........

The only further thing I would add is that there seems to be a serious possible risk that counselling will be seen as therapy for the "sane" and psychotherapy will be seen as therapy for the "insane." Counsellor / Psychotherapist

3. The lack of an evidence base for the proposed Standards of Proficiency

Given the HPC requirement for practice to ‘cover a discrete area of activity' and for practice to be ‘based on efficacy'; the Association questions the acceptance of the lack of evidence in or for the proposed Standards of Proficiency. In particular, BACP is concerned with the dismissal of evidence in the PLG that many psychotherapists are not trained to meet the separate proposed Standards of Proficiency for psychotherapists. The current situation is that standards of training are so variable that existing titles are no reliable guide to the skills and competence of the practitioner. (BACP recognises that it is this situation that Regulation seeks to address and supports the overall aim.)

"To my knowledge most psychotherapy training programmes do not focus on the detailed treatment of severe mental illness including both psychological and pharmacological approaches. To my knowledge there is no theoretical, practical or research rationale for distinguishing between counsellors and psychotherapists." Professor of Psychological Medicine & Medical Psychotherapy

4. The HPC's anomalous position with regard to setting academic threshold levels

It is clear to the Association that the HPC is not a qualification awarding body and the Standards of Proficiency cannot be used against the NQF to set levels of qualification. Therefore the HPC must approve any course that meets the HPC Standards of Proficiency and Standards of Education and Training for a specific profession, regardless of the academic award of the course. This appears to make nonsense of Questions 16 and 17. We have however answered them. This is addressed in detail in Question 16 and 17. We draw HPC's attention to the attached letter from the Institute of Education (see attachment below)

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5. The reduction of career opportunities for counsellors and psychotherapists

The current structure of the HPC register is such that after the grandparenting period the only means of entry to the protected titles of counsellor and psychotherapist and therefore to these sections of the register will be by undertaking an approved qualification in either counselling or psychotherapy. Counsellors and psychotherapists wishing to use the other protected title will be required to undertake an approved qualification in order to meet two or three out of 52 Standards of Proficiency. This does not make practical sense, either for practitioners or for employers, who will wish to recruit from the widest possible field of skilled practitioners. Additionally, there is currently a geographical divide, for example, there are few if any psychotherapy courses in Northern Ireland and very few outside of London, (BACP training map of psychological therapy training courses 2008).

6. The lack of any consideration of the impact on the delivery of services

BACP is surprised that this subject was seen as irrelevant to the work of the PLG. As indicated below, in two of the six guiding principles of HPC regulation, the potential impact on delivery services must be considered as an integral and crucial part of the process.

"Communication and responsiveness" - the HPC will develop meaningful accountability to the public and the health service.

"Providing a high quality service" - the HPC will ensure that the needs of its customers are met, namely the public, patients, health professionals and the health service.

http://www.hpc-uk.org/aboutus/aimsandvision/principles/index.asp

7. The impact of the short grandparenting period on counsellors and psychotherapists in training.

Training in counselling and psychotherapy normally takes between three and four years. There are a significant number of training courses that are not approved by any professional association and offer no formal award. Students starting on these courses after the register opens will have no access to the statutory register if the grandparenting period is two years. HPC will need to take into account the position of such courses and their students.

Summary

In summary, the proposals aim to create a division in the therapeutic field that does not exist in the workplace. BACP acknowledges that the current situation is far from ideal, with highly variable standards in training and practice and applauds the principle of public protection. However, the current proposals do not reflect or improve upon the workplace provision of therapeutic services as it exists, but try to create an artificial distinction between counselling and psychotherapy.

If the task were to be to create a future profession and lay down appropriate standards, then BACP would happily contribute to this effort. Furthermore, if this were to be the case, BACP believes it unlikely that there would be an operational need to create two distinct roles with different titles. As evidence for this - at the risk of repetition - there are 49 common SoPs and only 2 / 3 differentiators.

There have been many attempts in the past to differentiate between counselling and psychotherapy and in a past world, where people were believed either to be mentally ill (in which case they were removed from the community or heavily medicated) or ‘normal', there might have been some need. However, the world that we are moving toward seeks to help people to function in the best way they can within our communities. Pragmatically, a practitioner in a workplace, college or GP surgery will have clients across the range, including those who might actually or potentially be diagnosed as having a DSM defined mental illness. This is why the nature of counselling training courses has changed dramatically over the last 20 years - in response to the demands of the workplace

Therefore it is BACP's contention that the proposals as they stand are a retrograde step, harking back to an era when the mentally ill were segregated and stigmatised. Our view is that we should be looking forward as a profession and seeking to reinforce the highest standards of competence for all practitioners in this field.

BACP's response to the consultation questions are below:

Question 1: Do you agree that the Register should be structured to differentiate between psychotherapists and counsellors? If not, why not?

BACP does not agree that the Register should be structured to separate counsellors and psychotherapists. Over 87% of responses from members did not support a differentiation between counsellors and psychotherapists. There should be one register with two titles within it - ‘counsellor' and ‘psychotherapist'. 13% of members responding supported a difference between counsellors and psychotherapists. Some of these members believed that there should be a difference as the psychotherapy training they had undertaken was longer and required more personal therapy. Some also found the psychotherapy training more in depth and demanding than counselling training. This view was contradicted by some members who commented on the depth and demanding nature of their counselling training. The members who identified themselves as psychotherapists did not support the differentiation contained in the draft Standards of Proficiency.

I DO strongly believe that there is a difference between Counselling and Psychotherapy and therefore strongly disagree with the BACP stance. However I do not agree with, or accept, the medicalised "Mental Disorder" differentiation as set out by the HPC. Psychotherapist

BACP takes an evidence-based position that there is no difference between counselling and psychotherapy. This is based on research undertaken by BACP's independent research committee, which comprises international scholars of counselling and psychotherapy, from psychiatry, psychology and counselling and psychotherapy professions (see attachment below)

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A search of the literature reinforces this position. In terms of role, value and effectiveness, we thus posit that each occupational area has equal value.

Several members commented that the proposal for differentiation seems to arise from a discourse of status and power rather than having regard for the actualities of practice.

"There is very little from a research perspective that would provide any evidence for separating counsellors and psychotherapists along the lines suggested by the HPC." Professor of Psychological Medicine & Medical Psychotherapy

"I have a diploma in counselling and a diploma and an MSc in Integrative psychotherapy and call myself a ‘counsellor and psychotherapist' on those occasions when I am required to state my title. I am also a GP...and I would not make a distinction when discussing a possible referral with a patient." Counsellor / Psychotherapist and retired GP

"I find this division insulting. I can only speak for myself but I am sure that this will resonate with many people. I have been a Counselling practitioner for the same amount of time as I have been working in the mental health field. So I have experience, which would not be recognised." Young Person's Mental Health Project Co-ordinator

The terms are used interchangeably in the workplace, with many of our members using different titles depending on the environment in which they are working. The separation will have a negative impact on counsellors and psychotherapists in employment with regard to remuneration and grade level and the expectation of the nature of clients with whom they will be able to work. This could have serious funding implications for some workplace settings in particular. It will also cause problems for those commissioning services.

Although the HPC may be able to take CPD into account when considering counsellor competence in mental health, risk-averse employers will look for the title that indicates mental health competence for the many arenas where this is part of the client presentation. This would matter less if client presentation were clearly demarcated along mental health lines, but as we demonstrate elsewhere, it is not.

In 2005 the DH commissioned BACP and UKCP to carry out research into counselling and psychotherapy training and practice in the United Kingdom. 20% of members of 29 professional associations were surveyed and over 50% responded. The data shows that 70% of respondents did short term work - defined as less than 20 sessions. The client issues worked with did not vary greatly between counsellors and psychotherapists. The full report to the DH can be found at http://www.bacp.co.uk/admin/structure/files/doc/651_DoH_interim-rep_jun05.doc. The evidence from the workplace suggests that counsellors and psychotherapists are working with similar clients.

"I have just completed a 2 year PGDip. in Psychodynamic Counselling and am embarking on a research project to upgrade my qualification to an M.A. in Psychodynamic Counselling. My professional training has entailed a clinical placement of 120 hours and I have worked in this capacity in an NHS Adult Psychology/Psychotherapy Department in an unpaid position of 'Psychotherapist in Training'. I am continuing at this placement under the role of 'Psychotherapist'. The proposed changes pertaining to 'Protected Titles' mean I would not be able to apply for the job I currently do for free should funding become available, although this would be open to people with a DipHE in CBT" 3^rd Year MA Psychodynamic Counselling Student and Psychotherapist in Training

"I work in an FE college with two other counsellors (at least that is our title). One of the other counsellors and she is a counsellor not a psychotherapist works often with students who have the more severe mental health issues including borderlines, suicidal ideation etc. She attends case conference meetings with the CAMHS teams etc whereas the less disturbed clients often come to me and the third counsellor and we are both psychotherapists with mental health training. This has to do with the hours we work and the college system. It just happens that way. The college pays us all as counsellors not psychotherapists..." Head of Counselling Service, Supervisor, Psychotherapist

Question 2: Do you agree that the Register should not differentiate between different modalities? If not, why not?

BACP agrees that the Register should not differentiate between different modalities, on four grounds.

1. This would be confusing to members of the public. There are reported to be between 400 and 600 approaches to therapy, all of which might have a claim to a protected title. If there were to be two parts to the Register this would have to be doubled to provide modality title for both counsellors and psychotherapists. How many registered titles might one individual hold and what would happen to integrative therapists?

2. The effect would be to restrict the development of new approaches. Regulation by modality would reduce creativeness and development within the field, by preventing new modalities from becoming recognised. It is difficult to see how the discipline could legally develop new effective approaches? Criteria for the acceptance of a modality title would be needed and the HPC lacks the independent expertise to make such judgements.

3. BACP questions the contribution to public protection of regulation by modality. Presumably counsellors and psychotherapists could practise using non- regulated modality titles as the stem titles of ‘counsellor' and ‘psychotherapist' would not be protected titles.

4. It is doubtful that titles that distinguish particular theoretical approaches or ‘modalities' are of as great significance to the public as they are to practitioners of the different branches of therapy.

Question 3: Do you think that the Register should differentiate between practitioners qualified to work with children and young people and those qualified to work with adults? If yes, why? If not, why not?

BACP does not support the differentiation between practitioners qualified to work with children and young people and those qualified to work with adults. A small number of BACP members do support separate registration. There are currently many professional routes for people to specialise in working with children and/or young people. There are a small number of initial specialist training courses in counselling and psychotherapy and specialist training which can be undertaken through continuing professional development, after earning an existing qualification. There is no evidence that any one route into this specialisation is more effective than any other.

BACP considers that the responsibility for ensuring competence to work with any identified group of clients or in any specific context rests with the employer and the registrant. It may be that the HPC decides to revisit this issue in the future, in which case this should include all its registered professions that work with children and young people. In the meantime a post registration annotation on the register(s) might offer a way forward if the Council is so minded.

This proposal lacks any definition of ‘children' or ‘young people'. Such a definition would be essential before any serious consideration could be given to the issue. There are a number of different definitions in different statutes. These can be found in the following attachment.

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To differentiate at the threshold stage of entry to the statutory register would lead to a significantly reduced workforce, leaving this sector without enough trained counsellors and psychotherapists to deal with the existing let alone growing needs of young people in the UK. There appear to be no specialist counselling or psychotherapy training courses in working with children and young people in Northern Ireland and Wales and only one in Scotland. The Welsh Assembly Government is currently rolling out a programme for a counsellor in every school, which would be impossible to implement with such differentiation.

Question 4: Do you agree that ‘psychotherapist' should become a protected title? If not, why not?

BACP agrees that ‘psychotherapist' should become a protected title.

Question 5: Do you agree that ‘counsellor' should become a protected title? If not, why not?

BACP agrees that ‘counsellor' should become a protected title.

Question 6: Do you agree with the approach to dual registration outlined in the report? If not, why not?

BACP recognises that the regulation of counsellors/psychotherapists means that some professionals who are already registered in other professions, for example psychologists, nurses, may be required to become dual registered. However our position is that if a professional is working in both professions, and using protected titles, they should be required to register again. In particular psychiatrists, nurses and psychologists delivering psychotherapy should be required to register. The Kerr and Haslam cases provide evidence and clear recommendations that this dual registration is necessary.

Question 7: How appropriate are the draft criteria for voluntary register transfers?

The draft criteria may be adequate, but there is no indication in the criteria of the process or nature or the assessment of evidence. BACP would suggest that the HPC has little experience of assessing voluntary registers of the range and variability that exists in the field of counselling and psychotherapy. For example, some training courses keep graduates in a post qualification body for continuing professional development purposes and ‘register' these graduates.

It would be advisable for HPC to establish some criteria for eligibility for assessment.

Question 8: Do you have any comments on the outline process for identifying which transfers should transfer?

The current entry standards for BACP's register the United Kingdom Register of Counsellors / Psychotherapists (UKRCP) are much higher than those proposed by the HPC as they require training, experience and CPD. They therefore do not match the minimum threshold model for entry to the register that the HPC would adopt.

Hypothetically, if BACP decided to support the final proposals for the regulation of counsellors and psychotherapists, BACP would need to consider how the Association might meet the low entry standards required for an eligible register.

Question 9: What evidence might an organisation holding a voluntary register provide in order to support their submission?

• The number of registrants
• The processes in place for assessing entry to the register.
• The ethical and practice frameworks registrants are required to follow.
• The supervision and continuing professional development requirements of registrants
• The fitness to practice processes and evidence that these have been used.
• Information on the persons involved in hearing and adjudicating fitness to practice cases

Question 10: Do you agree that the grandparenting period for psychotherapists and counsellors should be set at two years in length?

BACP holds to its original view that the grandparenting period should be for three years. The grandparenting period must be long enough to enable students who begin training as the register opens to complete that training. The HPC does not seem to have taken into account the large number of training courses that will not be eligible for ‘grandparenting' acceptance as approved qualifications, and the position of students embarking on these three to four year courses.

Question 11: Do you think that the standards support the recommendation to differentiate between psychotherapists and counsellors?

BACP considers that the standards do not support the recommendation to differentiate between psychotherapists and counsellors

BACP's opposition is fourfold.

1. The overwhelming commonality of standards - 49 / 52

2. There is a lack of clarity and definition in the proposed differentiated Standards of Proficiency and this could have implications on defining the scope of practice

3. The aspirational nature of the psychotherapy Standards of Proficiency and the risk to the public

4. The rejection by the PLG of workplace evidence that counsellors and psychotherapists are doing the same work and that the two titles are used interchangeably.

The impact of the proposals if accepted is addressed in Question 18.

1. The overwhelming commonality of standards

BACP is strongly of the opinion that to separate two professions on the basis of five uninformed non-evidence based standards is unacceptable. The proposed Standards of Proficiency are not supported by research and are contradicted in practice. The proposals accept that the vast majority of standards (49) are common to both counsellors and psychotherapists with just three applicable specifically to psychotherapists and a further two relevant only to counsellors. It is difficult to see how anyone could see this as supporting a valid differentiation.

"... surely the figures speak for themselves 49 points the same out of 54 that's over 90% the same how can we be divided up? any job description that had so much in common with another would warrant the same pay scale again interference by those who know nothing about the 'counselling' process." Family Centre Worker / Counsellor

2. The lack of clarity and definition and the implications of this

The differentiated standards for psychotherapy lack any definition, for example, what is meant by ‘severe mental disorder'? The Diagnostic and Statistical Manual of Mental Disorders (DSM) does not provide grading definitions of mild, moderate and severe for the conditions it identifies. The term ‘mental disorder' was introduced to cover the range of mental illness in the 2007 Mental Health Act replacing earlier differentiated descriptions. It is difficult to see how such undefined standards could be used to inform Fitness to Practice investigations. There is a further problem in that philosophically a significant number of counsellors and psychotherapists do not work within the paradigm of mental disorder.

Several members raise the issue of the developmental nature of the therapeutic relationship and the ethical issues that may be involved in meeting the proposed Standards of Proficiency. It appears that they had interpreted the Standards of Proficiency as meaning that a registered counsellor might have to stop working with a client who as a result of the development of an effective therapeutic alliance work disclosed a mental disorder.

".. clients often only raise their serious mental health concerns once they are already engaged in their counselling and it would be unethical to stop their sessions merely because counsellors are disabled from working with serious mental health difficulties. Likewise if a ‘psychotherapist' is working with a client who raises focused life events that are supposed to be only the remit of counsellors." Association for University and College Counselling (AUCC)

3. The aspirational nature of the psychotherapy Standards of Proficiency

BACP challenges the assertion that all psychotherapists are trained and equipped at the point of registration to diagnose and treat severe and enduring mental health problems. The evidence of current training courses demonstrates that this is not the case. (This area of competence is not required in the UKCP Training Standards.) Some do, as do some counsellor training courses, however, this is not standard.

" .... the rule of thumb is that no self respecting psychotherapist works with someone AS psychotherapist unless that person can negotiate and keep a contract. How mentally disordered is someone who can?" Counsellor / Psychotherapist

"I wish to also express my disagreement on the issue of 'Standards of Proficiency'. All of the differentiated criteria pertaining to 'Psychotherapy' are daily features of my clinical work, yet by dint of being known as 'counsellor' I am somehow not trusted to work with these themes, despite having significant training by leading figures? ... Again, evidence needs to be produced here and a stronger rationale is required." 3^rd Year MA Psychodynamic Counselling Student and Psychotherapist in Training

4. The rejection by the PLG of workplace evidence that counsellors and psychotherapists are doing the same work and that the two titles are used inter changeably.

Responses received from BACP's organisational members from a wide range of workplace contexts[1] provide evidence that the counsellors and psychotherapists do the same work in the services.

"Since qualifying as a counsellor I have worked in a student counselling service and a primary school. In these I have mostly done short-term work, though in some cases I have worked with clients for 1-2 years, in others for much shorter periods. I have also been working with a charity which provides therapeutic treatment for refugees and have worked there with young people aged between 16 and 21. The work I have done there has been longer-term, and I have worked with several clients for nearly 4 years. When I look at the work that I have done with these young people, I am at a loss to say how this differs from psychotherapy either in regard to the length of the work or its depth". School Counsellor / Student Counsellor

"In the FE and HE context, many counsellors work with students with moderate and severe mental health problems, and many practitioners who trained as psychotherapists work with transitional issues and life events. It is a totally ludicrous differentiation." Association for University and College Counselling (AUCC)

"The HPC seem to be suggesting that the differences between counsellors and psychotherapists lie in the understanding of the nature and treatment of severe mental disorder. This doesn't make any sense whatsoever. Psychotherapists and counsellors who work in the NHS or in private practice should have some understanding of severe mental disorder. This would especially apply to counsellors working in primary care." Professor of Psychological Medicine & Medical Psychotherapy

"I regard the differentiation between counsellors and psychotherapists in terms of level of severity of client problem/issue as a fabrication in that it does not reflect reality which is that people do not assess the problems they bring to the talking therapies in the terms specified by PLG. This results in both counsellors and psychotherapists working with a client caseload which includes individuals with issues of wellbeing and also individuals with severe mental health issues." Senior Curriculum Leader, Counselling programme, FE sector, and accredited counsellor

Question 12: Do you think the standards are set at the threshold level for safe and effective practice? If not, why not?

BACP believes that the proposed Standards of Proficiency for psychotherapists will put clients/patients at risk and reiterates that it will be difficult to use the standards to inform fitness to practise procedures in any consistent way.

There is evidence (UKCP Training Standards) that many current psychotherapy training courses do not cover the diagnosis and treatment of people with severe and enduring mental health problems. Therefore regulating the title with this Standard of Proficiency and transferring voluntary psychotherapy registers is irresponsible and will put the public at risk. There will be an assumption by service users and employers that a registered psychotherapist is trained and competent to diagnose and work with severe mental health problems in a first job. It appears to BACP that the desire for status by psychotherapy organisations will put the public in potential danger. (See Question 11)

As previously mentioned the 2007 Mental Health Act introduced the roles of Approved Mental Health Practitioner and Responsible and Approved Clinician. It is clear from the regulations that these roles are filled by post qualification staff experienced in mental health work.

These roles are restricted to five professions - registered medical practitioners, registered psychologists, occupational therapists, social workers and first level nurses whose practice is in mental health or learning disability.

It is expected that only experienced senior professionals will be able to demonstrate that they meet these competences

• Identifying the presence of a mental disorder
• The severity of that disorder
• Determining whether the disorder is of a kind or degree warranting compulsory confinement." (2007 Mental Health Act 5.2.4)

The proposed Standards of Proficiency for psychotherapists are very similar to the competences outlined for Responsible and Approved Clinician and Approved Mental Health Practitioners. To propose these Standards of Proficiency for newly qualified psychotherapists in their first job, is irresponsible and in contradiction to the level of public and patient protection sought in the 2007 Mental Health Act.

A point made by many respondents and shared by BACP is that the Standards of Proficiency for psychotherapists claim competences in diagnosis and treatment of severe mental health problems that fit within the remit of psychiatrists. These are competencies not uniformly taught on all psychotherapy courses.

"I wonder how the PLG thinks people normally get suspected (of course there is also the occasional client who announces seriously at once that he is mad) of being seriously mentally ill, and what happens next, and who other than medically trained professionals can "conduct appropriate diagnostic procedures"-is anyone other than a psychiatrist likely to be permitted to make a diagnosis which has treatment consequences, like hospitalization, e.g.?--GPs will normally want the opinion of a psychiatrist, though they will be able to give repeat medication once the patient has been seen and diagnosed. And, in the practice I was in (and no doubt others), to offer occasional time with their "practice counsellor.

Are there many, or any, people whose only professional designation is psychotherapist who can actually "diagnose" severe mental disorder and then "implement treatment methods," or even have access to the means of doing these things, if an apparently severely mentally ill patient should turn up in their consulting room." Psychotherapist

"Lastly, I believe that it is a psychiatrist's remit to "conduct appropriate diagnostic procedures" and to "implement treatment methods to address symptoms and causes of severe mental disorder" rather than a Psychotherapist, some of whom might have more experience and training in Psychiatry than others. Of course, Psychotherapists must be able to identify possible conditions but then work with Psychiatrists for an official diagnosis and treatment, part of which might well be Psychotherapy" Psychotherapist

"I wonder too if the HPC, when identifying three differentiated criteria for psychotherapy, were confusing in some way psychotherapy, a talking therapy where we meet with our clients on a relational level, with psychiatry, a medical and diagnostic model of treatment?" Counsellor

The Standards of Proficiency for psychotherapy reflect a particular view of client presenting issues based on a medical and psychoanalytic model. BACP, in partnership with many of its members, believes this is unacceptable and out of step with the experience of many psychotherapists and practitioners of other theoretical approaches.

"As an Existential Psychotherapist, I could not put my name to any of the 'three differentiated criteria for psychotherapy' ... I like the second guideline for counsellors, as this reflects more accurately how I work:" Existential Psychotherapist and Lecturer

Question 13: Are the draft standards applicable across modalities and applicable to work with different client groups?

BACP agrees that the common standards for counsellors and psychotherapy are suitable across modalities and client groups. BACP notes the considerable feedback received on the inappropriateness of the HPC's medical model for counselling and psychotherapy.

Question 14: Do you think there are any standards which should be added, amended or removed?

The standards differentiating counselling and psychotherapy should be removed - in particular those relating to psychotherapists and their ability to diagnose and treat severe and enduring mental health problems.

In addition, there should be the following Standards of Proficiency for both counsellors and psychotherapists.

• The recognition and assessment of the full range of mental health disorders and mental health problems.
• Knowledge of the research evidence of the effectiveness of therapeutic approaches to such problems.
• Work with such issues within their scope of competence.

If the HPC remains committed to differentiation we urge it to use a transparent evidence-based process.

Question 15: Do you agree that the level of English language proficiency should be set at level 7.0 of the International English Language Testing System (IELTS) with no element below 6.5 or equivalent?

BACP accepts the recommendation.

Question 16: Do you agree that the threshold educational level for entry to the Register for counsellors should be set at level 5 on the National Qualifications Framework? If not, why not?

BACP has already noted its challenge to the HPC's Standard of Education One (SET 1). BACP disagrees with the differentiation between counselling and psychotherapy. Therefore there must be a common threshold educational level. The Association affirms that the entry standard should be level 6 on the NQF for both counsellors and psychotherapists.

BACP challenges the proposal that there is a differential of two levels on the NQF based on three Standards of Proficiency which contain within them nothing related to NQF Level 7 Learning outcomes.

BACP challenges the HPC's requirements for a threshold educational level on the NQF based on the profession specific Standards of Proficiency. BACP is aware that this issue has been the subject of discussion at the HPC Education and Training Committee. BACP has sought independent advice and has consulted with the Institute of Education (see Appendix 1). This report raised two main and related issues. The first issue is that the draft standards have not been formulated in a language that facilitates their comparison with existing, qualification frameworks: the National Qualifications Framework (NQF); the Qualifications and Credit Framework (QCF); and the Framework for Higher Education Qualification (FHEQ). This means that the draft standards cannot easily be located within existing statements of academic and professional ‘levels'.

The Association understands that if a course meets the SoPs and SETs the HPC will approve it as a qualification whatever the academic level of the course. It asks what the HPC will do with Level 6 and Level 5 courses in psychotherapy?

There are a large number of post graduate counselling courses (40+) whose graduates would be discriminated against in employment by this threshold as the proposed differentiation Standards of Proficiency have no connection with Level 7 learning outcomes.

"That the HPC is thinking of regulating on the basis of level 5 for counsellors and level 7 for psychotherapists flies in the face of the kinds of training which have long been available. I have been involved for many years in the delivery of the Postgraduate Diploma, now the MA Counselling, in Goldsmiths College - a training which qualifies as a level 7 programme. Other university settings such as Birkbeck College, The University of Greenwich, UEL and Roehampton provide similar trainings. What does the HPC propose to do about them?" Academic Coordinator, Department of Professional and Community Education

"My understanding is that there are equal numbers of counselling and psychotherapy courses at level 7 at the present time," Senior Lecturer, Courses Director

Question 17: Do you agree that the threshold educational level for entry to the Register for psychotherapists should be set at level 7 on the National Qualifications Framework? If not, why not?

Given the generic Standards of Proficiency required for counselling and psychotherapy are identical, BACP does not believe that the title of psychotherapist supports the case for a higher level of qualification. For that reason we believe that level 6 should be the entry level for psychotherapists.

It should be noted that, approximately 60% of current psychotherapy courses offer no academic award whatsoever. They are not at level 7 on the NQF. Many are approved by the professional associations UKCP and BPC, which are not qualification awarding bodies.

"Indeed my own experience as an external examiner and validation officer for the university gave me the experience of seeing how much staff at privately run psychotherapy training courses struggled with the expectations of the academic world, since they were invariably outside these structures, had few library facilities and no day to day interaction with those deep in differing research fields. I suspect that the HPC requirement that psychotherapy courses to teach at level 7 will create enormous problems for course providers and staff, let alone the course members. For example, I cannot be the only external who had to insist to private psychotherapy course tutors, that the course members should present their work following accepted Harvard referencing rules in order to properly reflect argument and evidence." Senior Lecturer, Courses Director

"I am doing an MA on top of my Diploma and working towards accreditation but I don't think this should be entry level for psychotherapists. I know plenty of fine psychotherapists who are working in a long term deep way without an MA. Also, MAs tend to add small, incremental benefits to the whole profession and research rather than making the individual a much better therapist." NHS Programme Specialist: Population Mental Health and Private Psychotherapist

Question 18: Do you have any comments about the potential impact of the PLG's recommendations and the potential impact of statutory regulation?

It is unfortunate that this issue was not seen as relevant to the PLG's discussions as it will be relevant to the DH's impact assessment exercise. BACP and its members believe that regulation based on these proposals will have a series of negative impacts on the delivery of counselling and psychotherapy in the United Kingdom. There is evidence that this is already happening:-

"An interesting situation has occurred twice over the last month in response to how I am being treated as a counsellor. The first occurred in my personal therapy where out of the blue, my position as a counsellor was raised. My psychotherapist bought up the subject of me being a counsellor which I was a little concerned about and asked him why the subject was being raised.

He said it was asked in light of the current debate between counselling and psychotherapy which I felt was strange as it was no concern of mine, but all of a sudden it seems to be. A distinction was being made in the room which left me feeling uncomfortable. I concluded that the therapist was trying to work it out for himself.

However, yesterday I attended supervision by my psychoanalyst supervisor. I raised a client who was in a deep anxiety state and his need to come twice weekly for therapy. My supervisor raised a concern about working at this depth with a client as a counsellor. I asked how she had arrived at such a position and she said it was a training issue, I had not received this as part of my training, yet in reality it was an assumption which was not true.

I was quick to point out she was making a distinction between the two professions which I was very unhappy about. As my training was actually taught by psychotherapists and counsellors, supervision and personal therapists were psychoanalysts, then my training and practice has been informed by many trainers. My personal thought is the psychoanalytical model fits comfortably with the psychodynamic model, yet a distinction after many years of practice suddenly has become an issue.

Actually, I work long term and short term with clients, which actually many of my counsellors and psychotherapist friends share. Why are the psychotherapists suddenly trying to pigeonhole counsellors? Who will gain from these recommendations, will the client?" Counsellor

Negative Impacts

Workplace

The terms are used interchangeably in the workplace depending on the context and issues of access and stigma. This would cease if the proposals are accepted.

Impact of contracts of employment

The separation will have a negative impact on counsellors and psychotherapists in employment. Psychotherapists who transfer to a psychotherapy register and who are employed as counsellors will be required use the grandparenting scheme to be able to continue on their employment as counsellors. The same will apply to counsellors working under the title ‘psychotherapist'.

Access and stigma

The proposals have the effect of reducing access and increasing stigma. Research evidence suggests that the public see counselling as more accessible and carrying less stigma than psychotherapy. Ref Brainchild project 2006? Therefore, a consequence of obliging services to include the term ‘psychotherapy' is likely to reduce access. (Future Foundation Projects (2004) The Age of Therapy - Exploring attitudes and acceptance of counselling and psychotherapy in modern Britain The Future Foundation: London.)

"The AUCC also believes that the differentiation will confuse the public, and the students and staff in FE and HE institutions may baulk at attending a psychotherapy service which is geared towards more serious mental health difficulties. This may have a stigma that AUCC services have worked so hard - and successfully- to challenge." Association for University and College Counselling (AUCC)

Impact on Services

Services

Services that currently employ psychotherapists as counsellors will have to change their staff or amend contracts of employment. If they choose to keep employing those using the title ‘psychotherapist', they will have to change their advertising and publicity at substantial cost to the service. Some third sector services may have to change their constitutions and negotiate such changes with the Charity Commission. A service that employs psychotherapists as counsellors may have to change its way of working to the detriment of service users. Many counselling service users perceive stigma in being seen or diagnosed as having a mental health problem and shy away from anything that suggests this, such as "psych" in a professional title. (Future Foundation Projects (2004) The Age of Therapy - Exploring attitudes and acceptance of counselling and psychotherapy in modern Britain The Future Foundation: London)

"The ... Centre chooses to call itself a counselling service because for many women, including many of those with more complex and severe mental health problems, "counselling" feels less stigmatising and potentially intimidating than "psychotherapy". Many clients are fearful and suspicious of anything whose name begins with "psych". Working with hard to reach groups in the community means we have to reduce the stigma and barriers as much as we can. The differentiated standards would require us to call ourselves a counselling and psychotherapy service, which has potential impact on our vulnerable and hard to reach clients." Counselling Manager, Well Women Centre

Services that currently allocate clients to counsellors and psychotherapists on the basis of informed professional judgement would be unable to do so and this would result in longer waiting lists. Also, some clients are likely to be returned to the waiting list as their needs move beyond the remit of their current practitioner due to these competency restrictions. This will have a knock-on effect of preventing a practitioner from continuing to work with a client with whom they could have continued therapy prior to regulation.

Services which focus on the reduction of the stigma associated with mental illness would no longer employ psychotherapists if they had to advertise this.

"I work full-time for a local authority service which offers counselling in schools across Hertfordshire. In many cases, the young people I work with are referred to our service as they cannot access CAMHS due to waiting lists, or because CAMHS will only see the individual when accompanied by their parents/family. Naturally, the work can break down due to these constraints, and in many cases does. I feel that we offer a vital service to young people who may not be able to access an alternative. I work with young people in both the short and long term. In one case, I have been working with a young girl for almost two years and feel that I have offered her a vital service at a crucial point in her life." School Counsellor

Restriction of career progression for counsellors

The HPC's structures and registers will restrict career progression for counsellors and thus have the effect of limiting their employment opportunities. It will discriminate against less well off counsellors and psychotherapists who cannot afford lengthy post graduate training required to qualify for the alternative register. It will discriminate against counsellors in Northern Ireland, Scotland and Wales where there are few psychotherapy training courses. (32 out of 50 UKCP approved courses are based in London)

Counsellors who develop additional competences in working with severe mental health will be unable to register in the psychotherapy register without undertaking a complete new training in order to meet three additional Standards of Proficiency. The same will be true for psychotherapists in order to meet two additional Standards of Proficiency for counsellors.

"Nor does the HPC (presumably, because of advice from the PLG) appear to have taken into account that, as a counsellor's experience grows, caseloads often include individuals who, according to psychiatric criteria, are 'mentally ill'. Indeed, such organisations as Mind regularly employ counsellors.

As regards the three differentiated criteria for psychotherapy, in the student counselling service where I work the university concerned has prioritised widening participation in higher education, and this means that understanding and assessment of mental disorder, sometimes severe, is a prominent feature of my work there. Among various factors, the Disability Discrimination Act means that universities have to take far more care in enabling students with quite serious mental illnesses to stay at university. Counsellors in the service work in conjunction with a psychiatrist who consults to the service, as well as with the clients' GPs and Community Mental Health Teams.

My own experience seems to bear out the conclusions that the HPC criteria are arbitrary and not fit for purpose and need to be vigorously challenged, which I hope the BACP will do on behalf of the profession." School counsellor / Student counsellor

Employment opportunities

If differentiated levels of training are approved, service providers may choose to replace existing psychotherapists with counsellors, who are likely to be cheaper to employ but will do the same work as those titled psychotherapists. Counsellors with a lower threshold entry will be paid less with a possible reduction in the number of jobs for more expensive psychotherapists.

In addition counsellors with post graduate qualifications are discriminated against in these proposals

Ethical implications

Mental health problems often emerge during the therapeutic process. This leads BACP to ask is a counsellor who is competent in working with such issue obliged to stop working with the client because of their registered title. The impact of this will be to increase the stigma related to mental illness and damage the therapeutic relationship.

Clinical Placement provision

The proposals will reduce placement opportunities. Currently placement providers take both counselling and psychotherapy students and do not discriminate in the allocation of clients on the basis of title. These proposals will mean that psychotherapy students may not be able to take placements in counselling services and vice versa. Services that do take students from both will have to allocate clients by perceived problem; this will result in longer waiting lists.

Question 19: Do you have any comments about the potential implications of this work on the future regulation of other groups delivering psychological therapies?

BACP considers that the future regulation of many other groups has been addressed in the report, Extending Professional and Occupational Regulation: The Report of the Working Group on Extending Professional Regulation.

The involvement of several BACP staff in the IAPT programme leads the Association to a serious concern for public protection. There appears to be a desire to use statutory regulation in the HPC as a form of occupational/job registration rather than professional regulation. BACP is concerned that IAPT High Intensity workers may be able to register as psychotherapists after undertaking a one year post graduate diploma with no previous training or experience in the delivery of counselling or psychotherapy. The IAPT High Intensity training curriculum teaches students to deliver manualised treatments for mild to moderate depression and specific anxiety conditions. It is not a full training in counselling and psychotherapy. HPC registration is not a job specific licence but general registration for practice in a profession. We consider that approving the High Intensity IAPT courses as HPC Approved psychotherapy or counselling qualifications would compromise public protection and the HPC's independence.

We hope these comments will be of some interest and value. Please do contact me if you would like to discuss further any of the points our comments may have raised.

As all public consultation submissions made by BACP are available from its public-access website at http://www.bacp.co.uk/consultation/previous_consultations.php we do not require anonymity.

Yours sincerely

Sally Aldridge

Director of Regulatory Policy

sally.aldridge@bacp.co.uk

[1] The range of contexts included Universities, Colleges, Employee Assistance Programmes, Schools, Third Sector, Young People and specialist services.