Tuesday, February 13, 2007

Interpreting the Research Evidence: Further Comments on the Draft Report on Occupational Standards for Psychotherapy

Entry for 13 February 2007:

A government body called Skills for Health is planning to develop National Occupational Standards (NOS) for the practice of Psychological Therapies in 2007. This development will complement standards in other areas of healthcare in the public, private and voluntary (nonprofit) sectors. They have now produced a draft document for comment, which lays out the proposed framework and a basic model of psychotherapeutic skills. Many of us in the Counselling Unit are concerned by an apparent cognitive-behavioral tilt to the draft document. In addition, the document includes a listing of four types therapy: CBT, Psychodynamic therapy, Family systems therapy, and humanistic therapy and counselling. Perhaps we are being too sensitive, but we noticed that “humanistic therapy and counselling” was the only one (a) not capitalized and (b) listed as “therapy and counselling” and not just as “therapy.” At the end of January, we had a large, vocal and productive meeting that included both full time and part time Counselling Unit staff, which led to the drafting of a response/commentary on the National Occupational Standard draft, which we submitted last week.

However, Mick then talked to a contact at BACP (the British Association for Counselling and Psychoherapy), who gave us information that we interpreted as indicating that the division of psychotherapy and counselling into the four main types may be part of a strategy setting the stage for excluding humanistic/person-centred/ experiential approaches, as has been done in Germany. Last Thursday, after a quick consultation with Tracey and me, Mick drafted a further response, which I then extensively edited. In doing so, I came up with a formulation of the research evidence’s main conclusions, which I quite liked. Here, with Mick’s permission (since it is a joint effort), is the formulation:

While we believe that it is a useful heuristic, particularly for training purposes, to talk of different forms of psychological therapy, we think it is essential to emphasise that the scientific evidence from multiple lines of research overwhelmingly points to four overall findings:
(1) The different major approaches to therapy are all generally equivalent in their effectiveness (Lambert, 1992; Wampold, 2001). Indeed, in the largest comparative effectiveness study to date, Stiles, Barkham, Twigg, Mellor-Clark, & Cooper (2006), using the functional equivalent of a randomized controlled trial, found that cognitive-behavioral, person-centred, and psychodynamic therapies were virtually identical in their effectiveness for clients in primary and secondary care settings.

(2) The strongest, most consistent factors associated with improvement in the psychological therapies - such as the quality of the therapeutic relationship (Norcross, 2002) and clients' levels of engagement (Gonzales, 2002) - are common to all the major therapy approaches.

(3) There is very little evidence to indicate that any one approach is more effective or efficacious with any particular psychological difficulties than any other. (However, there are one or two exceptions to this, such as behavioural modification techniques for sexual difficulties; Anderson, & Lunnen, 1999).

(4) By far the strongest predictor of the results of comparative outcome trials is not type therapy but researcher allegiance (Luborsky et al., 1999).
On the basis of these and other lines of evidence, there is thus no basis for using the division of the talking therapies into the four approaches stated, in order to limit the therapies that can be accessed by particular groups of clients. While cognitive-behavioural researchers have conducted a larger number of studies demonstrating the efficacy of their therapies, this is largely a result of their history of greater access to research funding and overrepresentation in academic positions. It is a logical error to interpret differences in amount of evidence as evidence for differential effectiveness. That is, having more studies showing effectiveness does not equal greater effectiveness.

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