by Peter Morrell
We can define a profession as an occupation which has gained certain important and characteristic features. These are that it has developed its own body of theoretical knowledge and expertise; established associations to identify and clarify, secure and represent its members’ interests; opened training schools to provide standardised education, training and qualifications; gained state recognition for its claim to professional status; adopted strategies to gain occupational and market control of its skills, services and personnel; established demarcation or closure from competing or adjacent occupations; gained independence, a form of autonomy (self-control), and obtained security in its line of work. Professions may be self-controlled, seek control from the State, or end up with a mixture of both.
‘...the normative dimension covers the service orientation of professionals, and their distinctive ethics, which justify the privilege of self-regulation granted them by society; the evaluative dimension implicitly compares professionals to other occupations, underscoring the professions’ singular characteristics of autonomy and prestige.’ [Larson, 1977, x]
In the study of professions, Freidson focused mainly upon exploring the methods professions adopt to achieve occupational autonomy and freedom from restrictive intervention [Spero, pp.283-5], while Johnson, among others, has described some of the economic and political aspects of professional power [Spero, pp.286 & 292; Johnson, 1972].
It is important to remember that all professions, like Law, Medicine, Dentistry, Pharmacy, etc. started out as unregulated occupations which gradually, often turbulently, went through a similar process. Lay homeopathy today is merely going through a process that medicine itself went through in the 1840-60 period. There is no occupation that automatically or naturally has conferred upon it the high status of a profession. It must work at it and go through the professionalisation process in order for it to become so elevated.
To distinguish it from a mere occupation, a profession tends to contain certain features which were largely absent from medicine until 1858 in England. These features include:
* high status;
* unified teaching facilities, qualifications and registration procedures which contrive to restrict entry to the profession
* challenging entry requirements;
* a code of ethics which regulates members’ conduct;
* ‘occupational closure’: systems which bar entry to the unqualified.
* self-regulation or autonomy;
* highly rewarding and technical skilled work;
* a generally high income;
* membership, licentiateship, associateship of or registration with prestigious professional bodies which regulate the profession.
However, the 2 key features of a profession which seem to stand out from all the rest, at least to me, are exclusive entry only through holding the correct qualifications and self-regulation. It is this exclusivity and self-regulation that seem to demarcate a true or fully-fledged profession from a mere occupation. The occupation now becomes closed to all except the suitably qualified, there is no longer any place within it for the unqualified amateur. Self-regulation means that the people within the profession control their own boards of ethics and education. Boards of control are composed of members of the profession itself. This applies to established professions like dentistry, opticians, pharmacy, medicine, accountancy, etc. All professions are regulated in this way.
In exchange for these privileges, members of a profession must abide by certain rules, regulations and codes of conduct, all of which tend to legally restrict the members. Some of these rules may be legally binding and are therefore mandatory, while others are merely voluntary. Failure to comply with such regulations leads to stigmatisation [ostracisation] by other members of the profession or even disciplinary action by the professional body which can, ultimately, lead to expulsion, perhaps permanently, from the profession and thus inability to practice ever again. This particularly applies to doctors, dentists, solicitors, accountants and architects where the privileged status of their job opens them to the temptation of some forms of abuse of their position, through misdemeanours like improper conduct, financial gain, abuse and exploitation of clients, etc.
The Professionalisation Process
Based upon the above definition of profession, professionalisation can be defined as the process whereby occupations become professions.
'Professionalisation has been described as an historical process in industrialising countries, whereby one professional group organises itself as an autonomous body, especially with a standardised training which it controls itself and often with a certain group consciousness including professional interests. Its aim is to distinguish itself from other groups and to keep non-professionals socially at a distance.' [Dinges, in Juette Risse and Woodward, 1998, p.173]
As implied earlier, the process tends towards greater and greater reliance upon qualifications, training and the setting up of statutory bodies to oversee and regulate the profession. Such bodies preside over a wide range of issues pertinent to the profession and make decisions about standards and educational aspects of training, registration procedures, codes of conduct for members, dismissal of members for misconduct, etc. An occupation becomes a profession by this process of demarcation which separates the registered and legitimate members [a credentialised elite] from the unregistered and unqualified proletariat.
‘..the distinction between an occupation and a profession is not something that simply and naturally ‘occurs’. The process...is usually contentious...a profession is a group with control over its members and a degree of autonomy in determining its own modes of training and criteria for membership, it claims a certain kind of power and that power may not be accorded easily.’ [Sharma, 1992, p.116]
The professionalisation process seems to be largely 'market-driven' in the sense that it is through competition between providers within the occupational market-place that a 'natural sorting' of providers into 'good' and 'poor', in terms of the service they offer to clients, i.e. their competence, begins to emerge. This in turn creates a need for some kind of professional body through which the client can judge the relative skill and value of a potential provider. Membership of the professional body thus confers upon the provider a kudos and status that is easily perceived by the client and thus the client, being reassured by this, chooses the services of a 'qualified' provider rather than an unqualified one [i.e. a non-member of the professional body].
‘Professions lay claim not only to a special ethical orientation but to a special expertise. In doing so they run the risk that a gap may open between what the professional claims and what it can actually deliver.’ [Sharma, 1992, p.115]
We can identify four phases of this process. Professionalisation begins with a laissez-faire situation in which no-one within the occupation is necessarily superior to anyone else and work proceeds based mainly upon recommendations between clients. This is a ‘level playingfield' situation in which all providers appear to their clients as homogeneous in quality and worth. The client is unable to discern the good from the bad, or maybe the need for this sort of discernment has not arisen.
In the second phase, controlling bodies arise on meritocratic grounds, in order to sort the good from the bad providers, in order for clients to identify the good providers so that the client can judge, without prior payment, which providers are better than others, regardless of fee. Professional regulation or ‘control' does not begin as the sole function of a controlling body, it also arises as a device by which the client can appraise the worth of a provider among many who are offering their services within the same market-place. In effect it is a labelling method which strives to identify those ‘better' providers from the less worthy unqualified ones.
‘The non-registered and unqualified [dentists] therefore formed their own associations, thereby creating an additional division in the profession.’ [Spero, 1985, p.272]
The need for a controlling body also arises from the market-place situation, as it is from the volume of work in an expanding market-place that differences in quality of service between providers first emerge. This in turn elicits greater discernment on the part of the clients. In this phase the more numerous ‘unqualified’ are tolerated and only appear as slightly subordinate to the qualified. Registration with professional bodies in this phase, is thus entirely optional.
‘American dentists still do not have the equivalent of a self-regulating body as have the dentists in England and France.’ [Spero, 1985, p.275]
The regulating ‘feedback’ influence of ‘client power’ in the development of a profession is also discussed in Johnson [1972, pp.77-86]. It is an important moulding force, which subtly fine-tunes the profession by reminding them of the interests of their clients. Ultimately, members of a profession must please their clientele or pretty soon they will have none. This blunt truth feeds back to temper the arrogant and monopolistic tendencies of all professions.
However, once a controlling body has emerged, it rapidly acquires considerable power of its own. This power derives chiefly from its ability to differentiate the good from the poor providers, from the viewpoint of the clients. Those providers who pass examinations, gain certificates and letters after their name are considered by clients to be superior to those who cannot [or will not] or those who have not passed such examinations, gained certificates, etc. Thus membership of the controlling body takes on a status of great importance for the clients, but also for the providers.
‘Professions have little control over the demand for their services, but they can assay control over the supply side through restricting access [to the profession]. Raising the level of educational qualification necessary for entry into training or prolonging the training itself are strategies which have the added advantage of enhancing the credibility of the group’s claims to esteem and expertise...’ [Sharma, 1992, p.117]
Prolonging the training period also has the added advantage of allowing sufficient time to thoroughly inculcate the ‘occupational norms’ of the profession [Johnson, 1972, p.55] This has the effect of creating cohesion of identity and roles amongst its members [Johnson, 1972, p.56] as well as being connected to the size of the eventual financial rewards conferred [ibid., p.59].
Thus a situation soon develops in which the market becomes dominated by the qualified, and the unqualified diminish numerically and become marginalised. All providers then wish to become qualified in order to get work, make a living and serve their clients. Without the qualification they appear to the clients [and to their own kind] of being unqualified, lower status, unworthy and inferior amateurs. Thus those practitioners who possess qualifications tend to take over any further control or development of the profession, while the unqualified largely relinquish any right of consultation about its future.
‘...non-medically qualified dentists were excluded from holding teaching posts in the hospitals and universities...the dental profession remained open until 1921.’ [Spero, 1985, p.271]
In this third phase of the process there is a large gap opening up between the qualified and the unqualified. The latter are more marginalised and stigmatised than tolerated [as they were in phase 2] and are certainly of secondary importance to the registered.
‘...the layperson does not share the specialised knowledge used by the professional. Most modern societies tend to treat professional interpretations as vastly superior to lay understandings. Medical professionals tend to demean lay conceptions, often labelling them as superstition, ignorance, foolishness...’ [Freund and McGuire, 1995, p.170]
The last phase of the process is marked by occupational closure, i.e. the emergence of a profession entirely dominated by the qualified and regulated by a controlling body derived therefrom. This phase goes further than just marginalising the unqualified, they become outlawed altogether. Membership of the professional body, which becomes a statutory prerequisite for entry to the profession, is allowed only upon production of the appropriate qualifications [or apprenticeship] from an approved or designated institution and thus the total control of entry to the profession becomes effected. The right to practice becomes enshrined in law and the non-qualified are disbarred from entry to the profession. At this point also, regulation of the profession is conducted, in whole or in part, or at least overseen by the State.
'Prior to 1942 the French dental profession was like all other professions, controlled by the state...from the evidence it appears that the profession never wanted it to be otherwise. It seemed appropriate for the state to control the professions in order to inhibit and contain any tendencies to monopoly power.' [Spero, 1985, p.293]
The controlling body also takes on the important function of policing disputes between providers or between provider and client. The issue of good and bad service, ethical control of the profession and the implementation of a code of practice for members also become urgent aspects of the professional body. The professional body acts to identify and protect all the interests of its members, and thus to regulate the profession generally, deal with dissemination of information and act in a consultative capacity both with the public and with government bodies or ministers.
Professionalisation in Medicine
Medicine is frequently held up as a classical example of a profession and of the professionalisation process. This is because it was one of the earliest to undergo this process.
‘The orthodox medical profession took time to grow from an association of several professions, each formerly having its own separate institutions and interests...[it may not be]...realistic to expect the non-orthodox professions to achieve the same degree of unity in a shorter space of time...’ [Sharma, 1992, p.215]
Throughout the 1840s and 1850s due to long-standing disputes, the different professional bodies for surgeons and physicians were jockeying for position, due in large part to entrenched mutual encroachment and poorly-defined roles and identities. These conflicts were eventually resolved in the 1858 Medical Act, which ‘created a high degree of unity in the profession.’ [Wallis and Morley, 1976, p.12].
‘The pivotal 1858 Medical Registration Act sealed the process of professional closure and set up a single register of legally recognised practitioners with self-regulatory powers and a monopoly over not only the title of ‘doctor’, but also state medical employment.’ [Saks, 1992, p.5]
The true regulation of the profession stems from that date.
‘Although allopathy is only one approach to doctoring...its has attained a virtual monopoly of medical education, licensing, and practice in the United States and Canada. It is also the dominant form of medicine practiced in most of Europe, although some non-allopathic approaches have greater legitimacy and freedom there than in north America.’ [Freund and McGuire, 1995, p.181]
‘...this legislation for the first time formally defined, in a consolidated manner, the scope of alternative as well as orthodox medicine on a national basis.’ [Saks, 1992, p.5]
Professionalisation in Alternative Medicine
Saks makes the good point that defining what is alternative can be problematicv, especially in the last century:
‘...it was therefore difficult at this time to talk about a distinct medical orthodoxy and hence to define what constituted alternative medicine, particularly in an era in which a greater emphasis seems to have been placed on self-help...’ [Saks, 1992, p.5]
But in modern times, the distinction between ‘alternative’ and ‘orthodox’ is much clearer. Until recently nearly all alternative therapies were in early phases, in which anyone could set up in practice. This was not true of herbalists and osteopaths, who had professional bodies [National Institute of Medical Herbalists [NIMH] and the British Osteopathic Association [BOA], formerly the British Naturopathic and Osteopathic Association [BNOA] which were set up in the first half of this century.
Acupuncture was one of the earlier natural therapies to set up a series of professional bodies, training schools and qualifications and to regulate itself as a profession [see Inglis, 1964, pp.123-30]. In the 1930s Osteopaths attempted to gain accreditation through Parliament, but this was blocked by the medical profession [Sharma, 1982, p.181; Inglis, 1964, pp.94-122; also Quen, 1975, pp.151-3; and Saks, 1995, pp.121-3]. Herbalists also established themselves as a ‘quasi-profession’ around the same time with the formation in 1927 of a Society of Herbalists [Griggs, 1981, p.271; Inglis, 1964, pp.66-73].
At present, lay homeopathy and reflexology show distinct signs of the professionalisation process [Sharma, 1992, pp.187-9]. Likewise Bach Flower Therapy, whose centre in Oxfordshire now run a very popular training course and have set up a register of approved practitioners.
‘...from about the later 1970s...there was suddenly a proliferation of ‘lay’ practitioners and colleges providing training for people without medical qualifications.’ [Sharma, 1992, p.184]
This fits in with my own impressions, but Saks places this revival much earlier:
‘...there can be no doubt about the dramatic expansion of interest in alternative approaches to health care in Britain since the early 1960s.’ [Saks, 1992, p.8]
‘...there was a proliferation of practitioners with no medical background from whom, on the whole, medical homeopaths tended to distance themselves. Lay homeopaths on the other hand stressed their right to practise...’ [Sharma, 1992, p.184]
One of the chief reasons for alternative therapies undergoing professionalisation is that some people may feel they are being exploited or overcharged by therapists of dubious knowledge or ability. This suspicion comes not only from the public but also from the ranks of conventional medicine, some of whom accuse alternative medicine of becoming a 'bandwagon' upon which anyone can climb. It is thus widely regarded as an unregulated free-for-all within which 'anything goes'.
One of the chief aims of and justifications for professionalisation within alternative medicine, therefore, would be to 'clean it up' and regulate it, purge it of any 'cowboy element'. Thus there is currently a rush within all these therapies to get qualified, to register, to enrol at a college, complete a course, get letters after your name, and likewise there is a rush by therapists to set up codes of practice, professional bodies, setting up colleges, setting and unifying teaching curricula, etc.
‘Contemporary versions of naturopathy as well as homeopathy appear to be increasingly used in the United States and Britain, perhaps as a result of dissatisfaction with the dominant, allopathic medical system (Sharma, 1992; Taylor, 1984).’ [Freund and McGuire, 1995, p.182]
Osteopaths and Acupuncturists have more recently received legal status in the Osteopaths Act of 1993 and the Chiropractors Act of 1994. It is widely expected that lay homeopaths will eventually take the same route.
Professionalisation within Homeopathy
The question has often been asked why someone should train in allopathy first before they can become a homeopath:
‘The other alternative would be to let the perquisites of respectability go; establish independent training colleges, like the osteopaths'; and start again at the bottom of the social ladder. A homeopathic medical school would not require a wholly new curriculum...to some extent the allopathic case needs to be mastered even by those students who are going to reject it; but this is not the same as insisting that a student who wants to become a homeopath must first complete the full allopathic course. To compel him to do so is as illogical as it would be to compel a judo trainee to complete a full professional training as a boxer before he can begin to learn judo. The homeopath needs to know quite a lot about allopathy, but he should not be required actually to qualify in a method with which he is fundamentally in disagreement.' [my emphasis, from Brian Inglis, 1964, p.93]
Since 1985 a process has been ongoing within British homeopathy for it to attain a form of professional status and recognition within medicine generally. This has taken the form of trying to gain accreditation for the colleges and the courses of training which they offer and also to obtain degree status for the courses [see Sharma, 1992, p.186]. There has also been a push to gain parity status between homeopathic practitioners [professional homeopaths, as they prefer to be known] and medical doctors who practise homeopathy. Those have been the main lines of development along this front.
There is much talk currently within homeopathy about the words 'profession' and 'professional' as opposed to 'lay' or 'non-medically qualified practitioner' [NMQP]. There is a good deal of confusion about the meaning of these terms. It is true that lay and NMQP appear to many as pejorative terms in the sense that they imply an underlying amateurness and lack of qualification for the job. But the terms profession and professional are also less than clear. There is as yet only limited restriction of entry [see Sharma, 1992, p.117].
Copyright © Peter Morrell 2000