Wednesday, January 30, 2008

Expert Reference Group for Person-Centred/Experiential Psychotherapies

Entry for 29 January 2008:

At the Improving Access to Psychological Therapies (IAPT) conference last December, Mick and I realized that the adversarial relationship between the person-centred/experiential therapies and CBT had become counter-productive and that it was now necessary to open a dialogue with CBT types and power players in the IAPT movement. The result of our overtures to Tony Roth was that we were invited to a preliminary meeting with him and Steve Pilling at University College London, on the topic of developing competencies for what was then problematically (from our point of view) titled “Humanistic and Integrative Therapies”. After mastering our anxieties about the whole thing being a trap and with the support of Nancy Rowland, we were able to adopt a conciliatory tone and agreed to attend the meeting on their turf in London. That meeting was today.

Having gotten up at 4am, I met Mick at Glasgow Central in order to catch the 5.55 train to London-Euston. On the way, between napping, we looked over the draft CBT competencies that Sally Aldridge had sent along to us last week, as well as the fuller version Tony and Steve had produced last September, trying to puzzle out the state of play and the relationships among all the numerous organizational entities and people involved.

On arrival at Euston Station, we rendezvous-ed with Sally and Nancy, who provided further briefing and orientation on the plethora of groups in play here, involving at least 3 different sets of guidelines/standards/competencies/skills. For example, the professional therapy/counselling organizations are pursuing a competing parallel process based on regulation of helping professions, while Tony and Steve are working for Skills for Health (SfH), which is working on a rather different model, that of defining National Occupational Standards (NOS) based on skills.

The Psychotherapy/counselling competencies project is itself a highly complex and politically divided thing. When I expressed total confusion to Sally last week, she helpfully provided the following partial explanation (email, 25 Jan 2008):
The NOS project has been set up with several layers. At the top is a Strategy Group with reps from the 4 countries [England, Scotland, Wales, Northern Ireland) departments of health, the QCA, Skills for Health Staff, and maybe some other people.

It is chaired by Peter Fonagy [=prominent colleague of Steve, Tony and my friends Chris and Nancy at University College London]. There is a management group to look after the money I think. Then there is a National Reference group that sees all the modality group draft standards and I think advises on consistency, overlap and it seems from last week is the place where inter professional battles will be fought… Then there are research groups for each modality who draft standards based on research evidence. These draft standards are then sent to a group of modality based practitioners to consider and revise. They then go up to the National Reference Group which comprises people from the professional associations - ACP, BACP, BABCP, BPC, UKCP, RCN, a forensic psychologist, [and] Peter Fonagy. ... Skills for Health then plan to test the draft standards in the workplace... .
In addition, it turns out that Tony and Steve also have their agendas, which appear to be in part to subvert the skills agenda by using research evidence to make the competency lists prescriptive (i.e., guidelines of good practice) rather than descriptive, which amounts to reprofessionalizing the whole thing. (I happen to agree with this goal, personally.)

We collected in Steve’s office, where Tony fed us sandwiches and fruit while we hung out, began to get used to each other, and waited for Steve to finish with another meeting. In addition to Tony, Mick, Sally, Nancy and I, there was a lay representative, Catherine, who introduced herself as a Carer, i.e., a person who cares for a mental health service user (consumer in US parlance), in this case her son, who has a psychotic process. Then Tony began to brief us on the whole project and the methods that he and Steve have adopted for carrying it out.

Their method is an interesting one from the perspective of psychotherapy research, and basically one that would never fly as a change process research method in the Society for Psychotherapy Research or its journal Psychotherapy Research: They collect examples of the therapy they are studying based on a set of criteria (the last of which Steve claimed to have invented on the spot today): (a) the approach has one or more Randomized Clinical Trials associated with it; (b) it has a written treatment manual; and (c) it is based on a coherent theory. Based on this list, they then collect the associated treatment manuals, often by getting the developer to recommend or provide them. After that, they pay someone to plow through a large pile of therapy manuals for 6 or more months, collecting descriptions of treatment competencies. The intersting thing is that this is really what most North American therapy researchers are now calling change principles (cf. Castonguay & Beutler, 2005). So in SPR terms this is change principle research on therapy manuals, which isn't the same as actual change process research.

The questionable part of this is that simple presence of a competency/principle in the treatment manual of therapy supported by RCT evidence is taken as prima facia evidence of its effectiveness (i.e., an inference is made that it is a change process). What is really annoying – and goes against 50 years of psychotherapy research science -- is that no direct evidence of the effectiveness of a therapeutic element (such as process-outcome correlations or helpful factors research) is given this status as a starting point. (I can almost hear Hans Strupp turning over in his grave.) We went around on this point for at least half an hour, with Steve invoking a metaphor of frogs vs. bicycles. That is, you can take a part a bicycle and put it back together again without harming it (actually a questionable assumption if you were my brother Willy as a kid), but you can’t do this to the poor frog (at some point Steve indicated that he was speaking from experience). It’s a bit difficult to know how to respond when CBT folks start invoking holism… what is the poor humanist to do, launch into a defense of atomism?

In any case, it soon became clear that they had the money and were in love with the rules of the game they had invented. For all we could say, they were still going to pay the piper to play “We will rock you” if that’s what they wanted. Nevertheless, I feel duty-bound to say that this strikes me as yet another example of methodological sloppiness on the part of CBT-types, for whom I have often found that an inordinate adulation of the hard science of RCTs so often goes hand-in-hand with a compensating carelessness about other methodological safeguards or scientific logic. It’s almost as if there were some law of the conservation of sloppiness, like the Third Law of Thermodynamics applied to science. Entropy will have its way!

Eventually, when this had gone on long enough, I remarked that we were going in circles. I proposed that since the treatment manual criterion was going to let in all sorts of things that weren’t necessarily justified, it nevertheless would make for a good starting point, simply because it is so broad. Then, I said, we could use the other evidence, process-outcome, helpful factors to modify the RCT-manual-based competencies. That way all the evidence would come in along the way. There was a moment of stunned silence, then all agreed and we went on to the next issue without further discussion.

Actually, the trickiest thing we had to handle today was finding the proper name for what the review was going to encompass. Fortunately, “Humanistic and Integrative had already gone out the window at the National Reference Group meeting last week, in favour of “Humanistic with a focus on Client-Centred.” We all agreed that sticking with humanistic was going to let us in for a load of trouble with a lot of different special interest groups, so gradually over the course of the discussion, Mick and I persuaded the others to go with “Person-Centred/Experiential”. Mick came up with a really helpful concentric circles formulation: Person-centred in the middle; then person-centred/experiential (including Process-experiential); then the broader humanistic including bioenergetics, transpersonal, psychodrama etc. We agreed that person-centred by itself is too narrow, while humanistic is too much to take on; however, following the Goldilocks principle, Person-Centred/Experiential is just right for the exercise. The issue of whether Gestalt would be in or out was left open for now, in part depending on some initial scoping. Given our initial fears, this felt like a major accomplishment, and left me feeling deeply grateful for all the hard work the World Association had done in formulating its scope.

Now, we have a job of work to do: (a) nominating additional individuals to make up the Expert Reference Group for PCE therapies; (b) proposing exemplars of PCE therapies that meet their criteria; (c) identifying therapy manuals for these; (d) identifying a knowledgeable, skilled person to do the extracting of competencies/principles from the manuals. And mainly hanging in with the process as it goes forward, and doing our best to keep it on the tracks.

Castonguay, L., & Beutler, L. (Eds.) (2005). Principles of therapeutic change that work. Oxford, UK: Oxford University Press.

1 comment:

Robert Elliott said...

My friend Jo Hilton asked me to post this comment for her:

Firstly, it sounds like your meeting gave a great boost to the need for person centred and experiential therapies to be taken seriously within the new post-Layard NHS. Whilst I have many reservations about this, it seems important that we are not simply burying out heads in the sand waiting for the next fashion from the organisation that is said to be the third largest in the world, after the Indian Railways and the Chinese Army. As a lifelong Labour supporter, I find this Blairite thinking to be reductive and Stalinist but that's for another day. We have work to do.

I'm not against the need of the NHS to establish that the therapeutic interventions that it supports are cost-effective with appropriate evidence to support them. It is the adherence by NICE to an evidence scale that gives such weight to evidence that gives most support to those that can fund randomised controlled trials for either a drug that will earn back the research and development costs or a therapeutic approach that benefits already from significant funding that troubles me. If only we had collected a royalty for every hour of effective person centred therapy we would have a good research fund!

I've been looking into this area of “Skills for Health” myself, partly because it takes me back to a project that I was involved with about twenty years ago when competency based ways of breaking down working practice was first introduced. My first meeting with someone who told me that she had just “done” hairdressing and was now “doing” the arts and cultural sector was not a pleasant experience. A conference on the “skills” involved in dance, confirmed for me that there is always something that can’t be broken down and that is the part that makes it all worthwhile. My fear is that it leads to "tick the box" behaviourist on-the-job training that loses much of the magic of learning - but I guess I'm just old fashioned!

With the intention of being a little less negative, I see that there are other models around to the ones offered to you for comparison - such as the format used by the National Occupational Standards for Social Work - which comes under Skills for Care I'd be interested to see how the current thinking for counselling differs from this format.

Good luck in collecting your team - I think that we locate ourselves at the intersection of many fields, medicine, science, the arts, philosophy and spirituality. My understanding is that, from Gordon Brown, at least, there is some emphasis being put on the personal as an important factor in health care. I hope that we don't lose this in slicing ourselves up into manualised segments.

Jo Hilton