THE LETTER OF CONCERN

Psychiatry and Homosexuality

We write to record our concerns at the decision of the Association for Psychoanalytic Psychotherapy in the NHS (the APP) to invite Professor Charles Socarides to give its Annual Lecture on April 28 1995 with the title 'Advances In the Psychoanalytic Theory and Therapy of Male Patients Who Are Homosexual'.

The signatories to this letter are registered psychotherapists (mainly psychoanalytic psychotherapist) or practitioners who hold or have held posts in the NHS wherein the practice of psychotherapy forms part of their duties.

The letter has been sent for publication to six leading professional journals because of the standing of these journals in the field of psychotherapy and because of the direct or indirect links that exist between the journals and the APP. It should be noted that Full Membership of the APP is restricted to psychoanalytic psychotherapists who have trained with one of the training organisations belonging to the British Confederation of Psychotherapists and who hold a Consultant or equivalent post in the NHS. The journals and organisations in question are:

Psychoanalytic Psychotherapy, which is the journal of the APP itself.

International Journal of Psycho-Analysis, which is published by the Institute of Psycho-Analysis.

Journal of Analytical Psychology, which is published on behalf of the Society of Analytical Psychology, London.

British Journal of Psychotherapy, which is sponsored by a number of psychotherapy organisations including the Lincoln Clinic and Institute for Psychotherapy (a member of the British Confederation of Psychotherapists) which thereby has a representative seat on the editorial board.

Journal of the British Association of Psychotherapists, which is the journal of the British Association of Psychotherapists.

British Journal of Psychiatry, which is published by the Royal College of Psychiatrists. All Consultant Psychotherapists are members of the Royal College.

Professor Socarides is well known for his view that homosexuality is in itself a severe psychopathological condition, warding off the dread of 'castration, fragmentation, separation anxieties and other conflicts' and he is explicit that the task of the analyst is to spoil the perverse gratification' enabling the patient to 'progress along the road to heterosexual functioning'. Professor Socarides also believes that homosexual sexual orientation is associated with severe psychopathologies. He has actively campaigned against moves by psychiatrists to curtail efforts to 'cure' homosexuality.

Our concern is that the APP's Invitation to Professor Socarides to give such a prestigious lecture could be construed as the APP's associating itself with his views or as implying that a consensus exists within the profession of psychotherapy, including psychoanalytic psychotherapy, that is in line with Professor Socarides's views. We believe quite otherwise and one purpose of the letter is openly to invite the APP to make its position clear.

There are public interest dimensions to all of this, given the fact that the APP 'Is concerned to advance the practice of psychoanalytic psychotherapy in the public health sector' (extract from the Register of Psychotherapists published by the British Confederation of Psychotherapists). There is a strong possibility that patients whose sexual orientation is homosexual may consider that they are unlikely to receive appropriate psychotherapeutic treatment on the NHS. They are likely to assume that their relationships will be stigmatized as pathological and their partners devalued.

Hence, a group of potential patients in search of psychotherapy may effectively be disqualified from receiving it. Moreover, given the retrogressive nature of Professor Socarides's views, many patients whose reason for seeking psychotherapy involves a focus on relationships, sexuality and gender, but whose sexual orientation is not homosexual, will consider that they, too, will not receive treatment of the standard that is usually considered to be desirable in the field of psychotherapy.

It should be recalled that the American Psychiatric Association recognised as long ago as 1973 that there is, in fact, no scientific or any other reason for supposing homosexuality to be a mental illness or psychopathology.

A further public interest question concerns the situation with regard to training in psychoanalytic psychotherapy and psychoanalysis in Britain today. Most of such training takes place in private and statutorily unregulated Institutions. However, a situation has developed in which it is advantageous to an individual's chances of promotion to the level of Consultant Psychotherapist in the NHS to have undertaken one of these private trainings. A particular advantage is gained by those who have undertaken the highly prestigious and intensive training offered at the Institute of Psycho-Analysis. In London. for example, over 90% of Consultant Psychotherapists have trained at the Institute of Psycho-Analysis and the figure for Britain as a whole is over 50%.

It has now been clearly documented in newspaper articles and scholarly journals that many of the private psychoanalytic and psychoanalytic psychotherapy training organisations, notably the Institute of Psycho-Analysis, operate a policy of discrimination against potential trainees whose sexual orientation is homosexual. Sometimes, this is absolute discrimination, based on theoretical beliefs that homosexuals can never be sufficiently free from psychopathology to become psychoanalysis or psychoanalytic psychotherapists. Sometimes, there is an effectual discrimination in which, for example, higher standards of mental health and personal behaviour are demanded of lesbians and gay men who apply to train in these lnstitutions. There is a great reluctance on the part of these Institutions to debate their views publicly and lesbians and gay men who do manage to train are often forced to keep their sexual orientation secret: their professional position is thus extremely precarious.

It is clear that a very worrying situation exists in which discrimination against potential candidates for training, arising from Institutional adherence to a set of views about homosexuality, calls into question the adequacy of standards of much present-day NHS psychotherapy.

It is against the backdrop of this situation that APP's decision to invite Professor Socarides should be assessed. A cycle is in operation in which prejudicial (and widely contested) viewpoints concerning homosexuality are being taught in private training institutions where there is little chance of alternative views being expressed or given weight. The candidates who eventually qualify and obtain senior positions in the public health sector will have done so without having sufficiently studied contemporary viewpoints on sexuality and sexual orientation - hetero- as well as homosexual.

Such a situation makes any reasonable discussion of questions of sexual orientation very difficult - not least because, as has been outlined, it is unlikely under the present arrangements that many lesbians or gay men (or, indeed, anyone who contests the general viewpoints of the Institute of Psycho-Analysis concerning sexuality and sexual orientation) will obtain senior appointments in NHS psychotherapy departments. We cannot believe that a similar situation would be tolerated in other areas of NHS provision.

One central implication is that a particular group of taxpayers are unlikely to be getting the best treatment possible from the NHS. Because of this, we have decided to send copies of this letter to the Secretary of State for Health, her various advisers in psychotherapy, the relevant Shadow spokespersons, the Presidents of the Royal College of Psychiatrists and the British Psychological Society, as well as to the Chair of the APP.

We urge these Individuals to look closely into the situation, and to do everything in their power to set right something which has now reached the level of a public scandal.

In particular, we call on the individuals mentioned above, the Editors and editorial boards of the journals listed earlier, all registered psychotherapists of whatever school, and those who work as psychotherapists in the NHS carefully to monitor the APP's responses to this letter and to the various calls for action on the part of the APP which we now make. We call on the APP:

to distance itself publicly from the views of Professor Socarides concerning homosexuality and psychopathology;

to convene a meeting before the end of 1996 at which a wide spread of opinions on these matters can be debated in a proper manner;

to write a letter to each of the organisations, membership of which leads to eligibility for Full Membership of APP, urging them (1) to review their procedures, regulations and habitual practices so as to remove any direct or indirect discrimination against potential candidates for training on grounds of sexual orientation; and (2) to write a letter to those organisations, urging them to make discrimination on grounds of sexual orientation an ethical offence in relation to selection of candidates for training, the ongoing practice of psycho-analysis and psychoanalytic psychotherapy, and the conduct of professional life generally.

REPORT ON 'THE LETTER OF CONCERN' ABOUT PSYCHOTHERAPY AND HOMOSEXUALITY

INTRODUCTION

We wrote to you in April 1995 asking you to sign a letter we had drafted that raised in public important issues that had been bubbling under in the psychotherapy world for some time. These issues - possible discrimination against lesbians and gay men applying to train at the Institute of Psychoanalysis and other psychoanalytic psychotherapy organisations, and favourable treatment given to graduates of the Institute of psychoanalysis in connection with appointments as Senior Registrars and Consultants in Psychotherapy (mainly in London and the South-East) - were highlighted by the invitation to Professor Charles Socarides to give the annual lecture of the Association for Psychoanalytic Psychotherapy in the NHS.

As you may have heard, the response to our initiative was very positive and nearly 200 psychotherapists from all schools, including many working in the NHS. signed the letter which soon became known as the 'Letter of Concern'. This was in fact more than the number of letters sent out.

This document is by way of being a report on what has been happening. We are sorry to have taken so long to communicate with you but we have had to overcome some obstacles along the way and we thought it better to wait until we could give as clear a picture as possible. The report is going to the signatories to the Letter plus those who have applied to see a full copy of it following publication of abbreviated versions. The letter and the list of signatories will appear in the March edition of the British Journal of Psychotherapy (Vol. 12, No. 3). It may be helpful to re-read the Letter in conjunction with reading this report.

Early on we realized that the two of us could not handle the amount of work our letter generated and so we invited some colleagues to join us on a small steering committee. At present the members of the steering committee are: Sally Berry, Chess Denman, Mary Lynne Ellis, Marion Gow, Joanna Ryan,Tom Ryan,and Andrew Samuels.

To anticipate the appeal we make at the end of the report: we have personally had quite substantial expenses connected with the Letter, and we very much hope that you will feel able to make an individual contribution to help cover these.

RESPONSES TO THE LETTER OF CONCERN

A copy of the Letter was sent to the Department of Health and eventually we heard from the NHS Executive and had a highly productive meeting with them. They took out concerns seriously and asked us to look into the question of anti-discrimination arrangements in the organisations belonging to the British Confederation of Psychotherapists. On our own initiative, we decided also to survey the sections of the United Kingdom Council for Psychotherapy. This work is still in progress. We are not getting any responses from BCP organisations, although UKCP sections are responding. We will publish the results of the survey in due course.

In June 1995 the Under Secretary of State for Health (John Bowis) made a speech that we gather was influenced by our campaign. He went out of his way to say he understood the 'concern' expressed at the invitation issued to Professor Socarides. He also praised the contribution of lesbians and gay men to British society and condensed those ■psychiatrists and psychoanalysts' who regard homosexuality as an 'aberration or mental illness'. This speech and its relation to the Letter of Concern was widely reported in the press in accurate terms. (In fact, most of the press reporting of events surrounding our Letter was accurate as well as, broadly speaking, sympathetic.)

A meeting with the Labour front bench spokesperson on mental health issues also produced a positive response and a request that she be kept informed of developments.

Organisations such as the British Psychological Society and the UKCP also expressed their support over what we appeared to be standing for. The favourable remarks by the Chair of UKCP in its Newsletter were especially noteworthy.

As a consciousness raising phenomenon, the Letter has produced striking results. Special meetings have been held in several psychotherapy organisations to discuss questions of homosexuality and training and it s possible that we have in fact succeeded in our aim of persuading a number of organisations which we believe have had discriminatory policies to begin changing them. Equal opportunities statements have been or shortly will be published by the Tavistock clinic and the Institute of Psycho-Analysis. The Society of Analytical psychology has confirmed its position by publishing such a statement. All the statements specifically mention or will mention sexual orientation.

We urge caution in relation to these promising developments. It has not been easy to get anyone to admit that discrimination does take place. Even now, it is possible that grounds will be found to exclude lesbians and gay men or higher standards of 'mental health' may be demanded of them. There is no indication of what arrangements have been made for internal or external monitoring of the situation in any of the organisations that seem to us to be shifting their positions. Crucially, the anomalies that now arise between theories that continue to pathologise homosexuality per se and equal opportunities statements will need careful discussion and debate.

We have received an enormous demand for people connected with the Letter of Concern to speak at conferences, give lectures and offer consultancies.

None of this has been achieved in a pleasant and supportive professional atmosphere. Numerous colleagues told us they were too frightened to sign the Letter, which they supported. We have had to dispel fears that the Letter constituted a breach of the right to free speech (the lecture was cancelled because of ■threats■ received by the APP that had nothing to do with us), and that people connected with the Letter engaged in riotous and disruptive behaviour at another lecture given by Professor Socarides. We have tried to point out that our letter did not call for the lecture by Professor Socarides to be cancelled. In fact, the closing date for signing was after he was due to return home to the United States.

The APP's own record regarding freedom of speech has not been good. The respondent to Professor Socarides was to have been someone whose views are close to his and a further resemblance is that both men have been active campaigners against lesbian and gay rights. Professor Socarides was vocal in protesting against gay men serving in the US armed forces and was to have been the main expert witness supporting the Colorado proposition to remove all homosexual rights legislation. He has also been a public campaigner against what he regards as the threat posed by homosexuality and homosexual rights groups to Western culture. The British respondent had been on television to argue in favour of Clause 28 of the 1988 Local Government Act that made 'promotion' of a 'homosexual lifestyle' an impermissible activity by any local authority.

At the time of the lecture, the APP seemed to realise that their platform was not balanced and, at the last moment, asked one of the steering committee to be an extra respondent. He demurred, suggesting instead a psychoanalytic psychotherapist with a more substantial publication record in the area of sexual orientation. This suggestion was turned down because the writer in question is a lesbian.

We believe that the APP had inadequate information about Professor Socarides■s record and, having learned more, were quite relieved to call the lecture off. But we have found their attitude to our Letter unacceptable. It has been difficult to get a response at all and we have not had anything resembling a proper reply to the various points we have made. We also consider that the constitutional structure of the APP is inappropriate for an organisation concerned with NHS psychotherapy. To be a full member, one has to be, not only a consultant psychotherapist or the equivalent in other core professions, but also a graduate of a training at one of the BCP organisations. There seem to be a few favoured exceptions to this rule but, in general terms, most consultant psychotherapists outside London, and also other workers in NHS psychotherapy, are unable to become full members.

Since we first raised these problems about the APP's constitution and structure, the APP has had to look at them seriously. An announcement to this effect has appeared in their Newsletter and a number of members have started to argue for a more reasonable set-up that would stop the APP from being in the control of one group of psychoanalysts/psychoanalytic psychotherapists. We are glad to have had a hand in these developments. Nevertheless, we must report that we have found it impossible to obtain a list of their members or a copy of their constitution from the APP and no such list appears in the BCP Register even though the APP is a member of the BCP.

We would like to suggest that those of you who are connected with the APP might join your colleagues in raising these questions with the organization.

RESPONSES FROM JOURNALS

You may recall that a key plank of our campaign was to have the Letter published in six leading journals. Here, we must admit to a degree of failure. However, we feel that the reactions and responses from these journals should be widely known within the profession because they indicate a state of affairs that, once recognised, could lead psychotherapists to raise constructive concerns about who controls the journals available to us.

In June 1995 the Editor of the British Journal of Psychotherapy wrote to us following a meeting of the Editorial Board accepting the Letter for publication. About ten days later, we heard from her that she was unilaterally and personally rescinding this decision. She had attended the launch of the BCP Register which had been held in camera so as to avoid the possibility of journalists (allegedly briefed by us) asking questions about discrimination against lesbian and gay men candidates for training and the situation regarding NHS psychotherapy. We had no such plan and the editor now accepts that this is the case.

In view of the sequence of events and having studied the correspondence, our overall perception of the situation at the time was that it was likely that an informal undertaking had been given by the Editor to the BCP that publication of the Letter would be stopped. Subsequently, the Editor has denied that any such undertaking existed. Nevertheless, it is still apparent that we had got caught up in the BCP-UKCP dispute and that fear of offending the British Psycho-Analytical Society was also a significant factor in the decision.

We decided not to accept the rejection of the letter by the BJP. We felt that, if the journal's independence had been undermined and its decisionmaking processes by-passed, there would be a chance of getting the editor's decision reversed by the Editorial Board.

There ensued a protracted and complex negotiation between the steering committee and the BJP Editorial Board. It was clear that, though some members of the Board were dismayed at their Editor's action, and that there had been a substantial majority in favour of publication initially, they would not be powerful enough to prevail and stand by the original decision to publish. The Editor was backed by the proprietor of the BJP and it was claimed that editorial policy lay solely in the hands of the Editor provided that she had the backing of the proprietor. It was stated that a new editorial policy had come into existence whereby letters such as the Letter of Concern would not now be published as they had been in the past. Clearly, this new editorial policy was created specifically for the purpose of preventing publication of our Letter.

The steering committee realized that we would have to make compromises because, as we will detail in a moment, we were also getting refusals to publish from other journals. We therefore proposed that the Letter be published by the BJP as an insert to be placed in every copy of the BJP. This was accepted but as part of the negotiations we realized that it would be essential to make an ex gratia offer to cover the BJP's additional expenses incurred by publishing the letter as an insert. A non-negotiable demand for this had been made by the proprietor. This donation is to amount to no more than £350 and we will not have to pay it until May this year.

At this point we do not know what the individual members of the Editorial Board of the BJP feel about the way the matter has been handled. For a while, they simply did not know what was being said and done on their behalf. So we took to sending copies of the correspondence we received from the BJP to the Board Members and this has helped to get the negotiated compromise.

We think that what has been revealed about the constitutional structure, decision-making processes and lack of independence of the British Journal of Psychotherapy is very worrying indeed. We are relieved that an initiative has been mounted by some members of the Editorial Board to work towards a more appropriate constitutional structure. We are also very pleased that a group of leading psychotherapists has sent a letter to the BJP calling for a far greater say in the formation of editorial policy to be given to the sponsoring organisations upon whose cooperation the BJP depends. (The arrangement is that every sponsoring organisation has agreed to include a BJP subscription in the membership dues of its members.)

It may be relevant that, at present, none of the three most senior people on the BJP have trained at any of the sponsoring organisations. In addition, of a total of around forty members of the Editorial Advisory Board, only 4 or 5 have trained at the sponsoring organisations.

This situation is exacerbated by the current dispute between the proprietor of the BJP and the UKCP over an advertisement placed on his personal authority restricting applications for an NHS post in psychotherapy at the Cassel Hospital (of which he is the C Director) to BCP registrants only. In correspondence that has been widely circulated, the BJP's proprietor has disparaged the training standards of 7 of his 8 sponsoring organisations (all in the UKCP) by comparing them unfavourably to the training standards of the organisations in the BCP. The impression is that the BJP is, to use the vernacular, run by the 'analysts' for the 'therapists'. Its claim to be the 'journal of the psychotherapy profession' is somewhat dubious.

While the BJP situation has been a time-consuming aspect of the committee's work, it is, strictly speaking, a tangential issue for us. We therefore urge those of you who do belong to the sponsoring organisations to contact your representative on the BJP Editorial Board to become more acquainted with the situation. If you belong to an organisation that is not part of the BJP consortium, you may be interested to know that the Editor of the BJP has recently written to the group of leading psychotherapists mentioned above to say that membership of the consortium is in fact open to any psychotherapy organisation of whatever school. All are free to apply, but it is not clear how applications would be processed. Perhaps it is fortunate that it took the Letter of Concern to bring those problems with a privately owned professional journal to light.

The journal Psychoanalytic Psychotherapy turned down the Letter for publication saying that they did not publish letters of such a nature and that they we-re not as closely connected with the APP as might be thought. We replied drawing attention to the masthead statement that the journal is the APP's journal and citing similar and equally controversial letters that had been published in the recent past.

The International Journal of Psycho-Analysis turned down the Letter for publication. Their explanation was that they had a policy of never publishing such letters because, as they were distributed in numerous countries, they could be at risk of so many different legal threats that it was better not to take the chance. We replied saying that we could not follow the reasoning.

The Journal of the British Association of Psychotherapists turned down the letter for publication. Their explanation was that they did not publish such letters, but the letter they sent made it very clear that the editorial committee had consulted with other sections of the BAP which had determined this reply to us. We passed the correspondence to those BAP members who had signed the Letter of Concern.

The Journal of Analytical Psychology turned down the Letter for publication. Their explanation was that the letter was 'political' in nature and that they did not want to be criticising another institution (for example, over its training policy) with whom they had collegial relations. We received information that there was indeed pressure from within the psychoanalytic community not to publish the Letter.

As 50 Jungian analysts had signed the Letter, including a substantial majority of the JAP's editorial Committee, it felt worthwhile exploring the possibility that the Editors of JAP would change their position. 38 of the 50 signed a second letter to this effect, but the answer remained the same.

The British Journal of Psychiatry said that the Letter vastly exceeded their word limits and referred us to the Bulletin of the Royal College of Psychiatrists which goes with the British Journal of Psychiatry to all members of the RCP. The Letter was also too long for the Bulletin, but a 350-word version drawn up by ourselves has now been published.

The Letter has also been published in the Newsletter of the Group of Independent Psycho-Analysts (the 'Middle Group' of the British Psycho-Analytical Society). the Newsletter of the Yorkshire Association for Psychodynamic Psychotherapy, the Journal of the British Association of Drama Therapists, and the UKCP Newsletter. Free Associations asked to publish the letter both as a contribution to an important debate within psychoanalysis and as a matter of historical record. We applaud their action. The Letter has appeared in FA 35.

Correspondence pertaining to the Letter was published without permission in the bulletin of the British Psycho-Analytical Society. In spite of protests by members of BP-AS, letters sent from us in June-July 1995 clarifying our position (which had been misrepresented) and making constructive suggestions regarding the Institute's admissions policy were summarily rejected for publication. Our rejected letter specifically called for the Institute to publish an equal opportunities statement, for its impact to be monitored, and for internal documents setting out criteria for admission to be reviewed for prejudice and bias.

PLANS FOR A CONFERENCE

The steering committee is moving on to plan a conference on homosexuality and psychotherapy. This will be a major international event to be held in Cambridge on Saturday April 26th 1997. We already know that Kenneth Lewes (author of The Psvchoanalytic Theory of Male Homosexuality) and Janine Chasseguet-Smirgel (author of Creativity and Perversion) will be speaking. We intend to make sure that a wide range of views will be represented but have decided on this occasion to limit the range of viewpoints at the conference to those coming from psychoanalysis, psychoanalytic psychotherapy and analytical psychology, as this is where the debates seem most pressing and problematic.

FINANCE

We have had or will have the following expenses:

Typing, photocopying and sending out the Letter: £550 approx,

Ex gratia payment to BJP up to £350

In addition, we would like to have some money in the kitty to cover the start-up expenses of the conference and any possible losses. This is hard to quantify in advance but we would like to have as close to £1000 as possible in hand.

The total we are aiming at is therefore approximately £1900. If everyone who signed gave a one-time contribution of £10 we would achieve this. As this is unlikely, we are asking everyone who is minded to contribute to send a one-time contribution of between £15 and £20. Please make your cheques to 'Psychotherapy and Homosexuality Study Group' and mail them to PHSG, 148 Mercers Road, London N19 4PX.

PERSONAL NOTE

The whole steering committee would like to thank those colleagues whose public and private support has been so important in getting our campaign moving. As we mentioned earlier, there has been a good deal of bad feeling generated, which has made the campaign stressful and it has been heartening to know how much backing we have had within the profession. If you have any questions or suggestions, please contact either of us.

JOANNA RYAN & ANDREW SAMUELS

(March 1996)