Psychoanalytic Practice and State Regulation

Ian Parker, Simona Revelli, Ian Parker, Simona Revelli

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367326357
• eBook ISBN: 9780429917981
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book arises out of an important international conference held in 2006 to discuss how regulation by the state has affected psychoanalysis as a clinical discipline in many different parts of the world. It explores the threat in psychoanalytic practice and draws together arguments against it.

Part I
Contexts

Chapter One

Psychoanalysis and state regulation

Bernard Burgoyne

Where are we now with the professions put forward by the state to be able to govern psychoanalysis and related fields? The days when the state took itself to be an arbitrator, acting on the margins of civil society, are no longer here. Instead there is a more intrusive governance—one that aims to decide on questions of competence, on questions of appropriate training, on questions of personal ability, even on questions of reason. But what are the bona fides of such claims? What are the competencies offered by the agencies of the state?

Self-harming is more prevalent in the young here in the UK than in any other European country. The young people affected need help—more extended and more accessible help than is currently available. What are these young people offered now? They are offered insufficient and inadequately structured services that have not been well enough thought through in terms of what problem they are addressing and attempting to resolve. It is as though the state were averse to thinking; as though there were something in the nature of knowledge that gave it cause for alarm.

Some problems are complex, and best formulated and resolved by professionals, whose training enables them to deal with this complexity. Compared to this, national government is often in a state of relative and often absolute ignorance. Yet still, there is a regular initiative that comes from the state to intervene in such areas, and to replace the proficiency of professionals with rules of the state’s own devising.

Examinations for schoolchildren are being changed: the present system has introduced too much stress, too much worry, too much strain. After subjecting children to this—not before, as you might expect—the state is deciding to replace its own system with another one, a system that, in all likelihood, it will withdraw in similar circumstances in five years’ time. Such changes have been tormenting the working lives of children for many years now. And there has been a further effect. Each such change has also introduced an immense lowering of standards.

Many children in Britain are obese—and the government takes it as its responsibility to intervene. The government here is well into the schedule of the programme that it has devised; it is, in fact, within two years of having to achieve its first round of targets. But it has not yet decided even how to measure obesity, let alone start the implementation of any policy based on this decision. Meanwhile, British children are still waiting for an agency that is capable of adequate response.

Teaching standards are determined by government administrators, nowadays. What this means is that where in the past teachers used to govern a subject, government departments now set indices of quality. Immense amounts of time are now spent by teachers at all levels of education completing paperwork that demonstrates the attainment of targets set by people ignorant of their field. A government quality index is therefore an indicator of the reverse of quality: it is an index of how much time—and we are talking very large amounts of time—has been wasted by professionals who would in other circumstances have been getting on with their work. The government claims that it needs to demonstrate that its interventions have led to increases in quality: but “demonstration” in this context is also something of a joke. The imposed language of outcomes and targets is itself regulated so as to be “unambiguous and clear”, and this means that a wooden language is introduced into the targets so that they can be trivially achieved. You may wonder what kind of target I am talking about: after much deliberation, the Department of Health decided that among the indices in the first round of quality attributes proposed for the ability to work as a psychotherapist was “the ability to sit still for fifty minutes”.

All of these moves towards State regulation and control lead to an enormous decrease in the power and effectiveness of professionals. Rather, the authority to govern a field is given to administrators: junior and senior officials in the civil service, junior ministers, senior ministers, and Secretaries of State.

And what about the achievement of the targets set by the wooden language? Trivialized perhaps, therefore easy? No: you start off with targets, cascaded targets, and quality indices. You then find that you have to write reports on good practice, and on the achievement of targets, cascaded targets, and quality indices. You then have to have training on writing reports on good practice, and so on; and then training on how to do peer reviewing of reports on good practice, and cascaded targets, and so on. And then there is the checking of outcomes and feedback—little boxes and ticks to be added to the reports about wooden language. And then there follow more reviews and assessments, and reorganization, and reformulation of targets, and changed systems, and the need to retrain people concerning the difficulties of the attainment of quality. There is little time left for the real work of professionals; and, in all of this, “quality” means the opposite of quality. And dissent about such things almost always results in loss of government income, and in loss of resource. The government is likely to lower resourcing anyway. And some of these targets are insisted on by government for reasons of political expediency; it is for this reason that hospitals in Britain are losing thousands of staff.

Adult learning and evening classes are currently being cut; the number of classes is being reduced massively, fees doubled: why? Because taxpayer’s money would be better spent improving the skills of others. This is the reply of the government. Who are these others? They are the people that the government has already failed to educate at school. Who is to lose access? The loss will be borne by those who have already demonstrated a real interest in knowledge and learning. Here, as elsewhere, the Government allows guilt about the real standards built into its provision to allow it to destroy achieved standards elsewhere. The Association of Colleges estimates that one million places will be lost in this way. The government claims that this is an appropriate outcome, because it has a “new economic mission”: it wants increasingly specialized tuition in skills that will support courses “valued by employers”. So it compounds its motivation by guilt with an assumption that markets, rather than knowledge, will provide the solution: the government claims that there is a lack in this country of skills necessary for “productive employment”.

It may be worthwhile remembering at this point that what used to be called the Department of Education is now called the Department for Innovation, Universities and Skills. It is clear which of these two terms—education and skills—the government takes as a quality indicator. And what is the result of this? At the moment we achieve rank twenty-four out of twenty-nine developed countries in terms of the proportion of sixteen-year-olds who are in education or training. So, a state whose regulations have produced this dire result now wants to reorganize, in order to put more emphasis on attainable and measurable criteria of its own devising. Colleges that fail to meet these new requirements will be closed—taken over by private companies who will be hired to meet targets and to redress “any failure to meet standards”. What standards represent in such a context is fairly clear: a destruction of national general culture; the removal of a critical climate of opinion; the destruction of a search for knowledge; the destruction of the valuing of knowledge; and the replacement of knowledge by skills.

There used to be a series of ideas—fairly well received in this country—concerning the Socratic functioning of the state. Civil society would best be served, it was claimed, by formulating as the duty of the state the support of a critical climate of opinion, and the support and inducement of shifts to better theories within the body of publicly available knowledge. Last year the two hundredth anniversary of the birth of John Stuart Mill was celebrated by an International Congress in University College London. Mill, together with his friend George Grote—later to be Vice-Chancellor of London University—struggled to give a real Parliamentary voice to such a theory of knowledge. This notion of a Socratic change of opinion was very influential on Freud: the detail of how this gave form to many of his notions of psychoanalytical technique was one of the themes investigated at this bicentennial congress. Questions like this—of opinions and how they can shift—are at the centre of psychoanalysis; so also are questions of the relation between interpretation and transference; the phasing of beginning, middle, and end moments of analysis, the nature of unconscious phantasy, all of which are related to this central question of what effects are brought into being when a person changes some basic elements in their view of the world. How many of these central themes will the government include as markers of quality in the fields of psychoanalysis and psychotherapy? The government’s advisers are unlikely to spend much time on this Mill–Freud question. You can see their preference for unambiguous wooden language, for the trivialization of problems, for published lists of targets, for the permanent reorganization of professionals, and the proliferation of employer-generated skills.

You may think perhaps that this destructive drive to reorganize and master professionals is something new. I have a quote here taken from a Mediterranean country, and from some while ago. It is often attributed to Caius Petronius, Roman Consul in 66 AD:

We trained hard, but it seemed that every time we were beginning to form up in teams, we would be reorganized. I was to learn in later life that we tend to meet any new situation by reorganizing and a wonderful method it can be for creating illusion of progress, while producing confusion, inefficiency and demoralization.

So, then, we are faced with the current situation—a proposal in the UK that the government decide on the proper content of a psychotherapy training, and decide also on what it means for a psychotherapist to be of good character. Previous proposals for legislation in this field had been put forward; the government decided that they were not to their taste, and they abolished them. But these previous proposals were at least being introduced by parliamentary means. The Bill put forward by Lord Alderdice was blocked by government intervention in the House of Lords: the government was in the process of writing its election manifesto, and wanting to include in it details and quality aims other than those found in the Bill. During the progress of this Bill through the Lords, there had been constructive and insightful critical proposals put by a number of Members of the Lords who took these issues affecting the human condition seriously. Here are some of the interventions made by Lord Wedderburn of Charlton:

The Bill cannot succeed except on some basis of professional consensus … there is no point in regulating for the sake of regulation, nor indeed of choosing a form of regulation which loses something which has been built up in the recent past …

Historically, problems which range across the field of psychotherapy have arisen because of various orientations, or modalities, as they have come to be called, which find their interpretation either in different analytical fields … or in more recent analysts than the masters such as Klein, Lacan, or Winnicott …

We must be careful not to lose what is a precious historical oddity; namely the freedom of groups to find new ways to practise and to introduce new concepts in the field … I have always thought that when Sigmund Freud was convinced that he had to leave Vienna, he came to the right place where freedom of enquiry is something which regulation must respect.

But this discussion was stopped. And now what is proposed to replace it is the authority of the Health Professions Council—an Agency of State determined by the government to be an appropriate regulator in this field. The Health Professions Council advertised—a year or so ago—on the tube trains. You may have seen their advert. It was to do with a range of therapies—including, I think, art therapy—taking up their membership of the HPC. Drawings on the tube posters showed alarming creatures meant to represent the unregulated professionals. “There is no need to fear any longer such monsters and charlatans”, said the advertisement, hoping to calm anxieties in the public. Needless to say, until this advertisement appeared, no one had categorized these practitioners as monsters and wolves. But the government was simply trying to establish and implement standards in the field.

Cognitive behavioural therapy is given high-quality rating by the government: it is cheap, and it is quick, and is approved of by government for both financial reasons and for reasons to do with what kind of therapy best keeps people in the workforce. That is, able to work in the sense of “those who have skills to operate in private companies”: skills and finance are usually found at the centre of the government’s programme of regulation. The question of whether or nor China is buying euros or dollars has more to do with the government’s motivation in such matters than have professional concerns in the psychotherapeutic field.

Listen again to the words of Petronius: confusion, inefficiency, demoralization. To them we could add incapacity, ignorance, and hostility to knowledge. This is what the state has laid up in store for a profession to which it seeks to give rules. The state is not a good listener, and does not provide an environment for the good of psychotherapy. The state does not support knowledge—in fact it barely tolerates it. Not itself possessing the knowledge held by professionals, the state seeks to replace it with something of its own devising. The result is the pauperization of the universities, the emiseration of the Health Service, the subordination of professionals to regulation, and the continuation and augmentation of the suffering of ordinary people. Psychotherapy will not benefit from being further subjected to such administrative bureaucracies. As in the case of psychotherapy generally, the natural environment for the governance of psychoanalysis is that of the critical culture of professionals in its field.

Chapter Two

Responsibility and accountability in psychoanalysis

Roger Litten

We are faced with a move towards the state regulation of what are called the talking therapies in this country. The most obvious difficulty for opponents of this move is the apparent self-evidence of the need for regulation—the demand for enforceable standards of practice to counter the risk to the public posed by unqualified or incompetent practitioners.

This makes it difficult even to raise the question of whether in fact we need regulation of these forms of therapy, especially when the call for regulation is supported by the majority of professional bodies themselves. The debate in this country seems already to have moved beyond the question of whether regulation is necessary to a discussion of the pragmatic details of how to be regulated, losing sight of any basis for attempts to oppose the principle of regulation itself.

In order to find ways to oppose regulation, we thus need in the first instance to bring the apparent self-evidence of the demand for regulation back into question. I want to suggest that the most effective way of doing this is to examine the relation between the why and the how of regulation in an attempt to make visible the logic at stake in the current move towards regulation. I hope in this way to be able to identify a possible basis for effective opposition.

I would like to start with a distinction between what we might call the rationale and the logic of regulation. I propose to examine the rationale of the demand for regulation in an attempt to expose an alternative logic at stake.

This approach turns on the articulation between the discourse of regulation and a more complex and insidious discourse of evaluation, accountability, and audit. I would like to suggest that it is this discourse of evaluation and audit that lies behind the government’s push towards state regulation of the talking therapies, and must thus be exposed as the hidden stake of the discourse of regulation.

The rationale for regulation is summed up in the common refrain of the need for public protection and the maintenance of standards of practice. Already here in the two elements of this refrain, which has become so familiar that we no longer question the self-evidence of the association between public protection and maintenance of standards, I suggest we can make out the nuclear articulation between the discourse of regulation and that of evaluation.

I would like to follow through the rationale of this discourse to the point where regulation articulates with the question of evaluation in order to expose the logic at stake and the contradictions entailed. In this way I hope to arrive at the point where not only does regulation not achieve what it claims to set out to achieve— that is, does not do what it says on the tin—but also entails consequences and effects that just happen to be the very opposite of what we start out with.

In other words, we set out from a rationale for regulation elaborated on the basis of a discourse of public protection only to stumble into a system of audit and accountability that at certain points can be seen to provide no protection at all to the very people it claims to serve. By following this trajectory I hope to elaborate a symptomatic and diagnostic reading of the discourse of regulation that will provide the basis for effective opposition to that discourse by elaborating a psychoanalytic critique of the logic at stake.

I have suggested that it is the apparent self-evidence of the rationale for regulation that makes it so difficult to challenge. The difficulty in getting a hearing for the question of why we need regulation does not in the first instance prevent us from introducing questions such as: well, why now, and why like this? The prospect of regulation of the psychotherapies has been on the horizon for decades, yet it is only now that the government seems to have built up a head of steam to push it through.

We will thus start with the question “why now?” in order to return to the question “why at all?”. There are at least two possible answers to the question “why now?”, one extremely localized and the other more complex and diffuse. I will trace a relation between the two in order to provide a framework for discussion of the apparatus of regulation outlined in the current proposals for the regulation of the talking therapies by the Health Professionals Council.

I think it would be a mistake to lose sight of the fact that this programme of regulation is not aimed at psychoanalysis in particular, nor even necessarily at the talking therapies in general. It...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• ABOUT THE EDITORS AND CONTRIBUTORS
• FOREWORD
• INTRODUCTION
• PART I: CONTEXTS
• PART II: RESPONSES
• PART III: INTERNATIONAL CONTEXTS AND RESPONSES
• PART IV: LESSONS AND DIRECTIONS
• INDEX