The document entitled Consultation on the development of National Occupational Standards for Psychological Therapies was published by The Sector Skills Council for Health and may be accessed from the Skills For Health website.

The following document is from The College of Psychoanalysts to Skills for Health in response to the above consultation document, to which it refers:

Psychological Therapies Consultation
Response of The College of Psychoanalysts - UK

General Comments:
The development of National Occupational Standards for psychological therapies represents a commendable attempt to place them in a structure which will define competencies in as flexible a manner as possible. However, this task involves the negotiation of certain basic ideas that are philosophically opposed to pragmatic definition and the framework as it currently stands.

In this response, we will make some general comments about the nature of psychoanalysis or psychoanalytic psychotherapy, and then address specific points.Psyhoanalytic therapy or psychoanalysis entails the establishment of a particular relationship between therapist and patient, particular both in the sense of its difference from other types of relationship and in its uniqueness to each therapeutic dyad. This relationship is based not only on communication which is conscious, but more prevalently on the search for unconscious communication. There is a fundamental assumption that what the patient wants may not be - often indeed is not - what the patient might need in order to work through his or her difficulties.

From this central assumption it becomes clear that:

• the relationship cannot be exhaustively defined, either by positive or negative description. This would limit the flexibility and potential for uniqueness.
• interventions cannot be prescribed which will be appropriate for all cases - or indeed for any one case.
• the nature of the work is not to address symptoms but their unconscious roots, so outcome cannot be measured by the alleviation of symptoms - or even of distress - in the short term.
• unconscious attitudes and conflicts will be played out in the relationship with the analyst, which will affect the patient's perception of what is happening.
• the unique nature of each relationship rules out any foreknowledge of process, direction, or the outcome of the therapy.

Given the above points, the notions of contract, negotiation and transparency of process become ambiguous and complex. They are indeed part of the work but difficult to define in any standardised way.

Specific Comments:

Preparation - starting the therapy
Most of these points are problematic for psychoanalysis. There is an assumption that what is being said consciously is to be taken at face value; and this is in direct contradiction to the assumptions of psychoanalysis. As noted above, transparency cannot be taken for granted. Further to this, any notion of "success" in psychoanalysis is predicated precisely upon the breakdown of ordinary communication, which allows unconscious conflicts and attitudes to come into play. If we add to this the problems with predicting outcome, there is little chance of agreeing anything with the patient other than a very simple contract to meet regularly at agreed times for an agreed fee. Nothing more can be promised or guaranteed.

The therapeutic work and the working alliance
Point 2.1 is workable for psychoanalytic psychotherapy, on the understanding that psychoanalysis entails challenge and at times discomfort for the patient. On the face of it, most of the other points are eminently reasonable expectations of any therapist. However, we would argue that to try to capture the process of analysis in this way, together with the positivistic and rather specific language used, is to limit and concretise the potential of the therapeutic relationship. The analyst is constantly assessing and responding to the patient. This cannot be defined in terms of evaluation or measurement as in behavioural approaches; it is woven into the fabric of the interaction.

Given the lack of transparency between conscious and unconscious thoughts and desires, point 2.3 would be impossible.

The need for supervision seems to be taken for granted. Psychoanalytic psychotherapy assumes the opposite: that, once qualified, the therapist is free to choose when and whether to enter supervision but, in general, is deemed able to practise without it.
The notion of helping a patient to do anything is problematic because anything worthwhile, so to speak, has to be done by the patient him or herself. The analyst is there to facilitate the emergence of unconscious material.

Ending the therapy
Again, although seemingly sensible, many of these points are not applicable to psychoanalytic psychotherapy. Generally speaking, as the patient is doing most of the work, he/she will be the one to identify when the end is coming and would probably not need "help" to conclude. That is not to say that the analyst is not involved in working toward the end. Patients and analysts frequently disagree about when the time is right to end. The friction and conflict this generates may introduce unconscious currents that were not apparent until that moment in the analysis. This painful moment in an analysis may result in powerful though unpredictable change.
Follow-up and planning to prevent a relapse are both relevant considerations for behavioural forms of psychotherapy, such as CBT, but not for psychoanalytic clinical practice.
To return to the question of process: the skills entailed in psychoanalytic psychotherapy are developed practically, as a praxis, embedded in individual experience, rather than as a process which can be formulated in terms of an exhaustive definition. As noted above, there is no blueprint of technique but, rather, a unique responsiveness to human suffering. Thus, although the skills outlined in the document make common sense, most of them are not applicable to the psychoanalytic work.

14th February 2007

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