Tuesday, 31 May 2011

Professionalism Does Not Equal Care or Good Practice.

‘The urge toward professionalism builds up a rigid bureaucracy… Bureaucratic rules become a substitute for sound judgment… the bureaucrat is beginning to dominate the scene.’
Rogers C. A way of being. Boston: Houghton Mifflin; 1980.

Back in the last century when I trained as a nurse we worked full time on the wards as students with 2-week blocks in college. I bloody hated it, it was horrific hard graft, I spent a great deal of my first 6 months confused and at 18 part of me felt mildly outraged that I was mopping floors. I was deeply concerned about my status – me, with excellent A levels, washing old ladies: wasn’t I better than this? It took me some years to learn how important that intimate, thorough, routine act of care was; how vital it was to my understanding of the overall wellbeing of the patient; how it could be a tender and meaningful opportunity to touch and be touched in a world where touch usually involves pain.

When I qualified 3 years later and met some student nurses at the end of their first year I thought they were joking when they told me I’d need to show them how to take a blood pressure.

What had happened was Project 2000, a scheme to professionalise nursing.

The knock-on effect was enormous: care assistants, untrained or semi-trained people who are paid a pittance, took over the bulk of patient care, nurses changed from people intimately involved in and minutely informed about patient wellbeing to university trained academic professionals. There are never ending court cases and a growing debate about patients being neglected, positive cruelty and, if it didn’t happen in a hospital, manslaughter.

My daughter is moving into the world of work and wants to train as a midwife. In a haze of middle-aged nostalgia I got out my first wage packet from 1983 when I earned £65 for 3 weeks work after rent for my room in the nurses home was taken out. My girl is supposed to feel grateful that she doesn’t have to pay in order to become a member of a profession that serves the country, and she’ll have to get a paid job at the same time as training and living at home. But she’ll be a professional.

What’s all this got to do with counselling?

The discourse around the professionalization of counselling in modern times has been going on for at least 20 years and I note that so many of the names cited in this article – Anderson, House, Heron, Pilgrim, Thorne - have inevitably become older and distanced from the shaping of counselling. I note also, and with no satisfaction whatsoever, that everything that this article foresaw has come to pass other than the predicted ‘closed ranks’ of counsellors: instead we’ve atomised into individuals who work in fear of being featured on the back pages of Therapy Today, scrabbling about for a paid job.

There is an ebb and flow in all philosophy and the talking therapies over time have moved from elite private practices to institutionalised medical models, from a deep concern about the humanity of the individual to an objectification of the client as an ‘opportunity’ (as an illustration of the problem, this article which used to be free is now not available while the fee gathering service is being set up. You can find the reference to the independent research on a decades worth of counselling complaints here.)

For me, this is a central issue:

“The client will have access only to privileged, affluent and academically gifted counsellors. Not all clients would choose a counsellor with that general background. The cost of training and the tilting of the balance towards demand exceeding supply will drive counselling prices up - the client will have to pay more for counselling and it will become even less accessible to those on low incomes (House, 1995). The increase in counselling fees will be reflected in increased supervision fees and the combined effect of these increases may be cumulative in successive generations of practice.”

After all these years of debate my 18 year old can still legally set herself up as a counsellor tomorrow. After all the years of hoop jumping and box ticking, status-anxiety and portentous intoning about ‘protecting the public’, we still ignore the fact that clients make hardly any complaints that accreditation was quickly taken up by many counsellors most likely to be abusive and speaks volumes about our delusions of grandeur and fear of our own legitimate power – Protecting The Public From The Omnipotent, Dangerous Counsellor (that’s you, by the way.) Clients aren’t stupid and particularly vulnerable people are cared for by systems that are already massively regulated, and which still continue to fail, depressingly often.

The dynamic between status and money has always been complex. I’d go so far as to propose that in the absence of money, the desire for status becomes acute and we know that counsellors seldom make money from counselling. We are naïve if we don’t see the link between money and care at the most fundamental levels. The US, where the connections between money and care are brutally demonstrated, is now experiencing the extraordinary situation of pioneering practice and research running alongside a system that is moving steadily back into the medieval, as one in five hospitals is run by the very wealthy Catholic church.

Why? Because the system wants to save and to make money and will take it from the highest bidder, no matter their philosophy. In business hard cash comes before life or choice so relatedness and connection come way down the list of prioroties. Our NHS, schools and other public services are inexorably being groomed into this mindset. What would you chose for yourself? Have you made the same choice for the ‘profession’ of counselling?

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