Response to the Skills for Health consultation:
Consultation on the Draft National Occupational Standards for Psychodynamic and
Psychoanalytic Therapy
The British Psychological Society thanks Skills for Health for the opportunity to respond to
this consultation.
The British Psychological Society (“the Society”) is the learned and professional body,
incorporated by Royal Charter, for psychologists in the United Kingdom. The Society is a
registered charity with a total membership of almost 50,000. Under its Royal Charter, the
key objective of the Society is "to promote the advancement and diffusion of the
knowledge of psychology pure and applied and especially to promote the efficiency and
usefulness of members by setting up a high standard of professional education and
knowledge".
The Society maintains the Register of Chartered Psychologists and has a code of conduct
and investigatory and disciplinary systems in place to consider complaints of professional
misconduct relating to its members. The Society is an examining body granting certificates
and diplomas in specialist areas of professional applied psychology.
We are content for our response, as well as our name and address, to be made public.
We are also content for Skills for Health to contact us in the future in relation to this
consultation response. Please direct all queries to:Policy Support Unit, The British Psychological Society,
48 Princess Road East, Leicester, LE1 7DR.
Email: psu@bps.org.uk
Tel: (0116) 252 9926/9577
Fax: 0116 227 1314
This response was prepared on behalf of the Society by Professor Andrew Gumley,
CPsychol, AFBPsS, member of the Division of Clinical Psychology (DCP) and of the
DCP’s Faculty of Psychosis and Complex Mental Health, and Rosemary Rizq, CPsychol,
AFBPsS, member of the Division of Counselling Psychology (DCoP) and Senior
Practitioner on the Society’s Register of Psychologists Specialising in Psychotherapy
(RoPSiP), with contributions from: Dr Debora Diamond, CPsychol; Dr Anne Douglas,
CPsychol, member of the DCP; Dr Emma Ducklin, CPsychol, member of the DCP; Dr
Susan Hingley, CPsychol, member of the DCP; Dr Martin Milton, CPsychol, AFBPsS,
CSci, member and Past Chair of the DCoP and Specialist Practitioner on RoPSiP; and Dr
Thomas Schroder, CPsychol, AFBPsS, member of both the DCP and the DCoP. We
hope you find our comments useful.
Dr C M Crawshaw, CPsychol, AFBPsS
Chair, Professional Practice Board
NOS for Psychodynamic & Psychoanalytic Therapy
British Psychological Society response, April 2009
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Response
Introduction
The development of National Occupational Standards (NOS) for psychoanalytic/
psychodynamic therapy is both welcome and timely. Competency models are of potential
value to psychologists, professional training institutions and the public, and the Society is
pleased to contribute to this consultation. However, we have identified several
substantive problems with the draft NOS for psychoanalytic/psychodynamic
psychotherapy as they currently stand. Accordingly, our response addresses these wider
issues, rather than offering a detailed commentary on each competency.
Our concerns relate to the following areas:
1.
2.
3.
4.
5.
6.
1.
The relationship between the psychoanalytic/psychodynamic psychotherapy
competence framework and the NOS;
The context of the NOS;
The evidence base used to support the NOS;
The healthcare focus of the NOS;
Lack of clarity about the levels of competency required for differing disciplines
working in a psychoanalytic/psychodynamic modality;
Further issues.
The Relationship Between the Psychoanalytic/psychodynamic Competence
Framework and the NOS
The Society notes that the draft NOS are derived from the work of Lemma, Roth and
Pilling (2008) who were commissioned by Skills for Health to identify the
competences associated with the delivery of high quality
psychoanalytic/psychodynamic therapy. Their report, overseen by the Expert
Reference Group, offers a substantial, carefully considered framework within which
to consider, contextualise and carry out psychotherapeutic work in a
psychoanalytic/psychodynamic modality. We would like to acknowledge the value
of the work undertaken by Lemma et al. and concur that this is potentially a useful
step towards clarifying and articulating the variety and complexity of skills and
competences required in this field of clinical practice.
However, we note that, in their current form, the NOS appear to constitute only a
small part of the above inter-related framework, which in its entirety includes:
•
•
•
•
•
generic competences;
basic psychoanalytic/psychodynamic competences;
specific psychoanalytic/psychodynamic competences;
problem-specific psychoanalytic/psychodynamic skills; and
metacompetences.
The draft NOS include only the basic psychoanalytic/psychodynamic competences,
and appear to offer an extremely lengthy, ‘stand alone’ list of performance criteria,
knowledge and skills. The Lemma et al. report makes it clear that effective delivery
of psychoanalytic therapy depends on blending a range of generic, basic, specific,
NOS for Psychodynamic & Psychoanalytic Therapy
British Psychological Society response, April 2009
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problem-specific and metacompetences, according to the client, the presenting
problem and the clinical judgement of the practitioner:
‘Delivering effective therapy involves the application of parallel sets of
knowledge and skills, and any temptation to reduce it to a collection of
disaggregated activities should be avoided. Therapists of all persuasions
need to operate using clinical judgment in combination with their
technical skills, interweaving technique with a consistent regard for the
relationship between themselves and their clients’ (Lemma et al., p.27).
As currently drafted, the NOS appear to have reduced this complex framework of
interrelated skills to a single, lengthy list of competences supplemented by yet a
further catalogue of skills. This leaves the competences lacking in both application
and context, and runs the risk of psychoanalytic/psychodynamic psychotherapy
being delivered by practitioners - and taught by trainers - in a ‘cook book’ fashion.
It is the Society’s view that all therapists offering safe and effective
psychoanalytic/psychodynamic psychotherapy should be able to offer skills in
generic, basic, specific and metacompetences. When working with specific clinical
problems, such as borderline personality disorder, additional skills may be required as suggested by the problem-specific psychoanalytic/psychodynamic competences.
In our view, considerably more work is needed on defining a clear and consistent
relationship between the competency framework of Lemma et al., and the NOS.
Without this link, such an exhaustive and repetitive list of competences is
unworkable in practice and therefore unlikely to be fit for purpose either by
practitioners or by trainers.
2.
The Context of the NOS
As currently drafted, the NOS fail to reflect the professional context within which
they will be applied. The Lemma et al. report makes it clear that the competency
framework may be deployed in commissioning, clinical governance and health
service organisation of psychoanalytic/psychodynamic therapy and may inform
supervision, training, statutory registration and research within this modality.
The Society considers it important to explain the way in which the NOS are to be
used within psychological training and clinical practice. In particular, it should be
clearly and unambiguously stated whether the NOS are to be used as a guide only,
or whether they are to be used prescriptively. In view of the imminent statutory
regulation of psychologists by the Health Professions Council (HPC), the anticipated
relationship between the NOS for psychoanalytic/psychodynamic therapy and the
HPC Standards of Proficiency (SoPs) should be clarified and articulated.
3.
The Evidence Base Used to Support the NOS
The Society supports the effort to ensure that the competences underpinning the
NOS are evidence-based. We note that the draft NOS are derived from evidence
abstracted from manualised treatments and randomised controlled trials (RCTs) of
psychoanalytic/psychodynamic psychotherapy.
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British Psychological Society response, April 2009
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However, we recognise that there are well rehearsed problems with RCTs (Westen,
Novotny & Thompson-Brenner, 2004). In particular, patient samples included in
RCTs are carefully selected to ensure homogeneity, and cannot be considered
representative of the more complex clinical populations that ordinary practitioners
deal with in real-life clinical situations. Given that these competences appear to be
designed specifically for use in healthcare/NHS contexts, where psychologists
routinely work with multiple problems and complex co-morbidities, the utility and
validity of competences derived mainly from treatment manuals could reasonably be
questioned.
Whilst acknowledging the position of Lemma et al., we are aware of the wider frame
of reference with regard to establishing evidence-based practice that is endorsed by
many in the clinical and research community. We note the stance adopted by the
American Psychological Association’s Task Force on Evidence-Based Practice
(American Psychological Association, 2006), which effectively re-defines evidencebased practice as: ‘the integration of the best available research with clinical
expertise in the context of patient characteristics, culture, and preferences’ (p.273).
The modality-specific evidence base privileged by the NOS fails to take empirical
evidence relating to naturalistic effectiveness studies into consideration
(Leichsenring, 2009). These studies tend to focus on the therapeutic relationship
and therapist variables, rather than diagnostic categories; they emphasise
therapeutic process rather than manualised procedures; and they examine clinical
techniques that are aligned with patient choice and clinical judgement rather than
those designed to ensure standardisation. Such studies are empirically wellsupported and may have considerably more external validity – and clinical utility –
than some studies included in RCTs.
The Society values a pluralistic approach to establishing an evidence base for
psychoanalytic/psychodynamic psychotherapy, including evidence derived from, for
example, qualitative research, systematic case studies, single case designs, public
health and ethnographic studies, process-outcome research and practice-based
evidence. As currently drafted, the evidence base from which the
psychoanalytic/psychodynamic NOS have been derived does not appear to reflect
this wider frame of reference.
4.
The Healthcare Focus of the NOS
The Society notes a clear healthcare/NHS focus to this set of competences and to
the language used to describe them. Psychologists work across a variety of
occupations, setting and contexts – for example, children, adolescents, disability
services, voluntary services, educational settings, pastoral, workplace and
independent sectors. Psychoanalytic/psychodynamic competences that are
appropriate for healthcare settings may not be appropriate for other settings,
particularly where clients enter into therapy for developmental or personal growth
reasons. It is our view that competences should reflect skills required for all
contexts within which psychoanalytic/psychodynamic psychotherapy is offered.
This is particularly important if, as seems likely, the NOS will be used to inform
standards of proficiency for psychologists regulated by the HPC. Statutory
regulation will include psychologists who undertake therapeutic work within all the
above occupational settings.
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British Psychological Society response, April 2009
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5.
Lack of Clarity about Level of Competency Required for Differing Disciplines
Working in a Psychoanalytic/psychodynamic Modality
There is a lack of clarity about what constitutes an appropriate level of competency
required to deliver psychoanalytic/psychodynamic psychotherapy. The NOS make
repeated reference to ‘working knowledge’ or ‘in depth knowledge’. However, it is
not clear if or how these terms map on to those already benchmarked by the Quality
Assurance Agency’s (QAA) Framework for Higher Education (Quality Assurance
Agency, 2001). The QAA descriptors include ‘critical understanding’, a level that we
would consider appropriate to psychologists training and working within a
psychoanalytic/psychodynamic modality.
The Society also notes that, despite the emphasis on the necessity for an evidence
base to the NOS, and the claim that a competency framework can contribute to the
field of psychological research, there is no mention in the draft NOS of knowledge of
the relevant research literature nor of a critical awareness of the application of
research findings to psychoanalytic/psychodynamic psychotherapy.
Along with clinical and scientific training, theoretical understanding and ongoing selfreflection, we consider the evaluation and use of research evidence to be a
distinctive component of the training and practice of psychologists working in a
psychoanalytic/psychodynamic modality. Indeed, evidence-based practice requires
that psychologists recognise the strengths and limitations of evidence derived from
widely differing types of research. Since individual patients may require decisions
not always directly addressed by the available research evidence, this is an issue
that is heavily dependent on the capacity of the individual practitioner to consider the
evidence, and adapt and individualise psychoanalytic/psychodynamic interventions
to suit clinical need, cultural context and patient acceptability.
This in turn relates to the need for a clearer definition of metacompetences in the
NOS, including the capacity to select the most appropriate analytic/dynamic
intervention. Differing professions using psychoanalytic/psychodynamic
interventions will be trained in, and employ, differing metacompetences, and not all
will have the same training and expertise in psychological science and research as
psychologists. In our view, the NOS must include:
•
•
6.
an unambiguous definition about the level of competence considered essential
for all therapists working in a psychoanalytic/psychodynamic modality; AND
a clear definition of competences and metacompetences that are considered
additional and specific to particular disciplines in the field.
Further Issues
The Society notes three further areas of concern emerging from the draft NOS:
a.
b.
There appears to be an overemphasis on risk as something to be avoided in
therapeutic work. Risk is something that cannot be eliminated entirely when
undertaking clinical work. The NOS should include more detail about how to
engage with risk in a thoughtful way during psychoanalytic/psychodynamic
therapy rather than how to forestall or stop it.
There is insufficient emphasis on issues of ethnic, cultural and sexual
difference, and lack of explicit detail about how to address areas of difference in
psychoanalytic/psychodynamic psychotherapy.
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British Psychological Society response, April 2009
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c.
There is insufficient attention paid to the importance of practitioners engaging
with their own psychoanalytic psychotherapy as a prerequisite for undertaking
safe and effective clinical practice. Research has suggested that therapists
undertaking their own therapy may be an important factor in safeguarding public
confidence (Mace, 2001). In our view, an experience of personal
psychotherapy is central to the training and practice of psychologists working
psychoanalytically or psychodynamically. This should be specified in the NOS:
for example, as an analytic-specific metacompetence as outlined in the Lemma
et al. report.
References
American Psychological Association (2006). Presidential Task Force Report on EvidenceBased Practice. American Psychologist, 61(4), 271-285.
Leichsenring, F. (2009). Psychodynamic Psychotherapy: A review of efficacy and
effectiveness studies. In R. Levy & S. Ablon. (Eds.) Handbook of Evidence Based
Psychodynamic Psychotherapy: Bridging the gap between science and practice (Chapter
1). Totowa, New Jersey: Humana Press.
Lemma, A., Roth, A., & Pilling, S. (2008). The Competences Required to Deliver Effective
Psychoanalytic/psychodynamic Therapy. London: Research Department of Clinical,
Educational and Health Psychology, University College London.
Available for download from: http://www.ucl.ac.uk/clinicalpsychology/CORE/Psychodynamic_Competences/Background_Paper.pdf
Mace, C. (2001). Personal Therapy in Psychiatric Training. Psychiatric Bulletin, 25, 3-4.
Quality Assurance Agency (2001). The Framework for Higher Education Qualifications in
England, Wales and Northern Ireland. Gloucester: Quality Assurance Agency. Available
for download from: http://www.qaa.ac.uk/academicinfrastructure/fheq/EWNI/default.asp
Westen, D., Novotny, C.M. & Thompson-Brenner, H. (2004). The Empirical Status of
Empirically Supported Psychotherapies: Assumptions, findings, and reporting in controlled
clinical trials. Psychotherapy Bulletin, 130, 631-663.
End.
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British Psychological Society response, April 2009
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