Counselling and Psychotherapy in Contemporary Private Practice

Adrian Hemmings, Rosalind Field, Adrian Hemmings, Rosalind Field

• Publisher: Routledge
• Year: 2007
• Print ISBN: 9781583912454
• eBook ISBN: 9781135452841
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

What are the dilemmas faced by counsellors and psychotherapists in contemporary private practice and how do these impact on the therapeutic relationship?

Working as a counsellor or psychotherapist in contemporary private practice presents a number of clinical, ethical and philosophical dilemmas that impact on the therapeutic relationship. Counselling and Psychotherapy in Contemporary Private Practice brings together experienced contributors to explore these dilemmas, with insightful and illuminating results.

This book distinguishes itself as it does not simply offer practical ideas. It also presents the reader with issues that arise from the specific context of working in independent practice and explores how these affect what takes place in the therapeutic relationship.

Counselling and Psychotherapy in Contemporary Private Practice will provide essential reading for students of counselling and psychotherapy, qualified and experienced practitioners contemplating setting up in private practice. It will also be of interest to those already working in private practice, who wish to reflect upon the dilemmas that arise in this working environment.

Chapter 1
Introduction

Rosalind Field and Adrian Hemmings

Up until the mid-1990s starting an independent practice was a comparatively uncomplicated undertaking. It was not unusual to complete a counselling or psychotherapy training and immediately set up in independent practice. Currently, however, with the gradual professionalization of counselling and psychotherapy there are an increasing number of jobs available in the voluntary sector as well as within the NHS. These may be either salaried or unpaid positions, and practitioners may prefer to gain experience within the potentially more supportive environment of an organization before setting up on their own. Indeed, many counselling and psychotherapy training organizations insist that their graduates do not set up in independent practice until they have gained considerable experience working within one of these organizations. The British Association of Counselling and Psychotherapy (BACP) suggests that ‘ideally, a counsellor in independent practice should have substantial training and experience’. Therefore this book is as much for experienced practitioners of counselling and psychotherapy as it is for trainee and newly qualified therapists contemplating setting up as an independent practitioner in the future.

The future role of the independent counsellor or psychotherapist is particularly pertinent in a period of NHS deficits, financial cuts and the world of financial ‘turnaround teams’. Currently, there appears to be a shift in the focus of primary care counselling from clients with mild to moderate difficulties to those with moderate to severe. This means that patients with mild to moderate difficulties and those who do not fit into an obvious diagnostic category are likely to fall through the net and may be told by their GP to seek independent counselling practitioners or psychotherapists. This could have a profound effect on contemporary independent practice.

While this book does offer some practical ideas, this is not its main focus. There are several books of this kind already on the market (McMahon 1994; Syme 1994; Thistle 1998; Clarke 2002; Feltham and Horton 2006). Instead we present the reader with issues that arise from the specific context of working in independent practice and explore how these affect what takes place in the therapeutic relationship.

The contributors to the book are all experienced practitioners who work or have worked independently as well as within the public sector. They have drawn on their own experience to illustrate their ideas and to engage the reader in thinking creatively about the issues. While most of the contributors use a psychodynamic paradigm with which to illustrate their ideas, the issues examined are highly relevant to practitioners using other theoretical models.

Counselling is a relatively new profession and as such is developing its identity. In the light of this Dr Glyn Hudson-Allez sets the scene of the book with her chapter on the history of counselling in independent practice. She describes the increasing availability of paid positions for counsellors in primary care and explores the impact of this on the independent practitioner. She moves on to discuss current developments in counselling in general such as practice-based commissioning (PBC) and in independent practice specifically.

Chapter 3 by Lawrence Suss introduces the thorny question of where one finds clients once we have decided to set up in independent practice. Until recently, advertising was frowned upon by many professions including medicine and the allied professions such as counselling and psychotherapy. In the last decade there has been a radical change in the culture that, combined with recent advances in information technology, has made advertising not only possible but almost a necessity. The topics covered in this chapter range from the ethics to the merits of advertising. Different forms of advertising are discussed from a simple leaflet to more complex media such as Yellow Pages and the internet. Advertising affects client expectations of counselling and the impact of this on practice is also explored.

Once we have attracted our client, how do we progress when we have none of the usual procedures imposed by working in an organization? Chapter 4 by Melanie Withers on assessment addresses this. While she highlights the need for assessment, she also introduces the notion that in independent practice the client has purchasing power. He or she may shop around for the therapist that suits them and therefore has more choice. Assessment becomes a two-way process.

In Chapter 5 on working with other professionals, Adrian Hemmings explores the issue of working with the background presence of GPs, social workers and other practitioners, and the dangers of splitting both by the client and the professionals concerned. He also discusses the concept of the ‘other’s’ presence in the therapeutic work where there is no direct contact between the ‘other’ and the therapist. While the term ‘other’ mainly refers to other professionals, it may also fall into the category of a substance such as a drug (therapeutic or illegal). The ‘other’ may also be a ‘significant other’, that is, a family member who is metaphorically brought into the room by the client but who nevertheless has an impact on the work. The subsequent chapters move on to examine the issues that arise when working within specific environments.

In choosing to work in independent practice counsellors and psychotherapists are faced with the decision of whether to work from home or whether to rent a consulting room in a clinic. Some clinics are run along the lines of a group counselling practice offering practitioners a dedicated environment in which to set up their work. In Chapter 6 Jeremy Christey and Andrea Halewood describe how, by choosing to work in a group practice, the independent therapist steps into the world of organizational dynamics. Using Bion’s theory of ‘basic assumptions’, they explore the issues involved in working within this context. Using examples from their own experience they explore the dynamics within the team of practitioners that can be mirrored in the work with their clients to positive or negative effect.

Increasingly practitioners choose to work in a complementary health clinic where the environment is not dedicated specifically to counselling or psychotherapy. Robert Withers is a Jungian analyst but also trained and worked as a homeopath and an acupuncturist. In Chapter 7 he examines the dynamics of working with other complementary health workers. He discusses the notion of professional territoriality, confounding the assumption that complementary health suggests a group of practitioners who are willing to collaborate with other practitioners in an integrated health care setting. Difficult obstacles are presented to the practitioner working in this context such as competition in the marketplace, professional rivalry and differing and conflicting models of symptom causation and cure. The danger of being invited into a mind/ body split is particularly potent when working in this environment.

In Chapter 8 Rosalind Field discusses the advantages and disadvantages when the practitioner opts to work from home. She explores the notion that working in this context creates specific boundary issues that affect both the therapeutic work and other family members who share the therapist’s home. She makes particular reference to how envy plays a part in these relationships and explores the dilemmas that this creates. Using composite clinical vignettes, she describes her own attempts to address this.

Peculiar to working independently the practitioner is confronted with the matter of money. The way in which client and therapist relate to money and how this may be played out in the work are areas discussed in Chapter 9 by Adrian Hemmings and Rosalind Field. They also examine the significance of the way in which the client actually pays the therapist and how this might offer information to the therapist as to what is happening within the therapeutic relationship. Also explored is the fact that the act of payment becomes part of the therapeutic frame setting.

Fittingly, the final chapter of the book by Rosalind Field is on endings. Inevitably the therapeutic relationship comes to an end, whatever the working context. However, Chapter 10 examines the nature of ending itself and how this may create particular tensions if working in independent practice. One such tension is the potential for fiscal dependence by the therapist on the client. This may affect the therapist’s professional judgement as to whether or not it is appropriate for the client to leave the therapy. She introduces the idea of ‘forced endings’, particularly focusing on the situation where the therapist becomes pregnant. When this occurs the therapist’s personal needs interrupt the therapeutic frame. However, this powerful metaphor creates profound dynamics of its own. Other situations such as taking holidays, therapist’s illness and the necessity for interim cover are also examined in this chapter.

The issues discussed in this book are those that have emerged from the authors’ own experiences and they propose a series of dilemmas for which they do not purport to have the answers. Where they give examples, they endeavour to describe how they have handled each situation, and in doing this invite the reader to become mindful of these issues and to accommodate the paradoxes that may arise.

References

Clarke, J. (2002) Freelance Counselling and Psychotherapy: Competition and Collaboration, Hove: Brunner-Routledge.

Feltham, C. and Horton, I. (2006) The Sage Handbook of Counselling and Psychotherapy, 2nd edn, London: Sage.

McMahon, G. (1994) Setting Up Your Own Private Practice in Counselling and Psychotherapy, Cambridge: NEC.

Syme, G. (1994) Counselling in Independent Practice, Maidenhead: Open University Press.

Thistle, R. (1998) Counselling and Psychotherapy in Private Practice: Professional Skills for Counsellors, London: Sage.

Chapter 2
The changing status of counselling and its impact on private practice

Glyn Hudson-Allez

Introduction

When I first undertook training as a counsellor in the early 1980s, counselling in the UK was very different from what it is today. A new way of thinking about counselling and psychotherapy was emerging at that time. There were few formal courses. Most therapists learning their skills through reading, dialogue with peers, seminars or being members of analytical societies. The British Association for Counselling (now BACP) was a small interest group. There was no United Kingdom Council for Psychotherapy (UKCP), no British Confederation of Psychotherapists (BCP) no Counsellors and Psychotherapists in Primary Care (CPC). While there was a special interest group in psychotherapy, the counselling division of the British Psychological Society (BPS) did not exist, nor did appropriate guidelines or codes of ethics. The whole concept of psychotherapy was considered rather alternative and typically American, and was regarded sceptically by the medical profession. Many private therapists worked on a basis of a preferred theoretical model with no formal qualifications as there were few awarding bodies to provide them.

The Foster Report of 1971 was the first published government initiative toward regulating the profession and restricting its implementation only to those who had appropriate training. This chapter will focus on the emerging profession of counselling and psychotherapy since that time, and discuss how that transformation now affects counsellors and psychotherapists who work in private practice. I will use the term ‘therapist’ as a generic term to apply to any counsellor, psychologist or psychotherapist working in a clinical setting providing therapy. I will also use the terms ‘patient’ for users of the NHS system and ‘client’ for those attending a private practitioner.

The move towards regulation

Regulation of the profession is not a new idea. It has been ubiquitously discussed in various reports over the last 30 years. As already mentioned, it started with the Foster Report as a consequence of fears about the rapid spread of Scientology, and was followed by the Seighart Report in 1978, which proposed the establishment of a Psychotherapy Council. However, the government of the day was of a mind to let the psychotherapists regulate themselves. Three years after this report, a Private Member’s Bill to regulate psychotherapy and counselling failed in its second reading and it was this that led to the opportunity of establishing the UKCP. The subsequent development of moves to self-regulate in order to protect both the public and the profession by means of professional registers swung into place. Further attempts to regulate psychotherapy came with a Private Member’s Bill proposed by Lord Alderdice in 2000-2002, but again did not make it past the Committee stage in the Lords. The government per se has been reluctant to become involved in the process when there is such a division with the professions of counselling, psychotherapy and psychoanalysis as to appropriate standards on qualifications, training and professional standards. These peaks and troughs in attempts to regulate the profession have probably provided the most influential swing of change, whilst at the same time being the most fiercely debated process of development to the current form of counselling used by the private practitioner (Mowbray 1995; Baron 1996; Frankland 1997).

Regulation per se brings together groups of therapists to form cohesive groups that metamorphose into professional bodies. These organizations position themselves between the membership and the state, providing a professional identity for the former, and recognition and legitimacy in its dealings with the latter, whose aim is to protect the user. The USA, as always, was ahead of the UK on this. They already have statutory regulation by means of a licence, which is only issued if certain qualifications are met. It also regulates the use of the title of ‘psychotherapist’, thus prohibiting anyone using the title unless they have got the appropriate qualifications and licence. However, the US regulatory licences are not without their critics, particularly with the problems of being portable between one state and another. The UK may experience similar difficulties if Scotland, Wales, Northern Ireland and England all choose to adopt their own methods of credentialing.

Movement into primary care settings

The next big change within the profession came as pressure was applied from those involved in preventative healthcare to move counselling and psychotherapy into medical contexts to work alongside medical professionals. Again this was following the initiative in the United States, but there the defining factor of any psychotherapeutic help offered to patients was financial, not clinical. Health maintenance organizations (HMOs), developed by the health insurance industry, have been progressively withdrawing the funding of psychotherapeutic interventions that are not evidence based and refuse to employ counsellors or psychotherapists who have no formal qualifications. What happens in the USA tends to follow on in the UK within five years or so. In the UK the move started in the early 1980s and was reinforced when the Counselling in Medical Settings section of the BACP (now FHPC) was established in 1985.

By the time I published my first paper on the issue in 1988, counselling within primary care was emerging, but still a minority occupation (Hudson 1988), and still meeting with a lot of resistance from health authorities. The medical profession, interestingly though, was becoming much more open to introducing counsellors into primary care, as a result of a psychotherapist who ran GP work groups (Balint 1974). GPs started using innovative methods to sidestep family practitioner rules for employing non-medical staff by using the ancillary staff budget as a means to bring therapists into the practice. However, once GPs were given their own fundholding budget, there was a positive mushrooming of therapists moving into primary care settings, until today it is considered that 81 per cent of GP surgeries now have access to a primary care counselling service (Wilkin et al. 1999).

Of course, this is not happening in every area throughout the UK. Some counties are providing a comprehensive primary care counselling service with a therapist in every GP practice, while in other areas there is no service at all. Thus the much-heralded government concept of removing fundholding from GPs in order to provide equity of provision throughout the country has not resulted in this aim being achieved as yet. Counselling in primary care is still a benefit of postal code, but the expansion in primary care has had a ripple effect on to employment assistance programmes (EAPs) and private practice as the public demand for talking cures increases. Thus, there is a direct correlation between access to NHS-supported counselling and the growth demand for counselling in the private sector.

Practice-based commissioning

Practice-based commissioning (PBC) is a recent government initiative whereby GP practices or groups of practices can commission services that are not part of the NHS but part of nonprofit making independent organizations (Department of Health 2004). While the current focus in the NHS is on more physical problems, mental health will have to be addressed in the not too distant future. But here it appears that we have come full circle. Much of the professionalization of counselling is attributable to therapists in independent practice offering their services to GPs who paid them through a variety of creative funding streams, for example through the auxiliary workers’ budgets. Many of these therapists subsequently left private work to become part of managed teams in primary care...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Chapter 1 Introduction
• Chapter 2 The changing status of counselling and its impact on private practice
• Chapter 3 Advertising
• Chapter 4 Assessment
• Chapter 5 Other professionals – support or intrusion?
• Chapter 6 The individual therapist working in an independent group practice
• Chapter 7 Psychodynamic counselling and complementary therapy
• Chapter 8 Working from home in independent practice
• Chapter 9 The role of money in the therapeutic exchange
• Chapter 10 Breaks and endings in independent practice