Saturday, September 20, 2008

HPCE Expert Reference Group, Part 5

Entry for 19 September

1. Heisenberg’s Uncertainty Principle Applied to Blogged ERG Proceedings. Possibly the most closely followed of my blog entries has been the series of pieces I’ve written on the Skills for Health project Mick and I have been involved in since last January. The Humanistic-Person-Centred-Experiential Expert Reference Group (HPCE-ERG), as it has come to be called, has been controversial from the beginning. I have documented some of this, and of course in my early entries I have been fairly critical of the methods being used, and in particular the excessive reliance on RCTs as the ultimate arbiter of what would be included or not. Although I still have some misgivings, I’ve been impressed over time by the quality of the discussions and the opportunity for dialog, as well as what is beginning to emerge from the process.

The amusing thing is that it turns out that Tony Roth and Steve Pilling have been following these blog entries, so that the process of blog-observing the HPCE ERG meetings has altered them. At one point at the meeting this past Monday, Tony turned to Steve and told him to put down his chainsaw, a reference to a metaphor I used in my pieces on the March and June meetings. And at the end of the meeting, Tony said he was looking forward to hearing about the meeting in the blogosphere. So here I am, called back from my Blog Block by colleagues whom I’d criticized earlier, and I am left not wanting to disappoint them.

2. Steady progress on the competency framework. Thanks to Alison and Andy’s efforts, the HPCE competence framework is continuing to shape up. The overall, top-level framework, a one-page summary overview chart, looks to me to be in good shape, and the detailed list underneath it is progressing. We spent most of our time going over sections of the latter, trying to flesh it out more concretely, paying particular attention to theory-knowledge competence, which required spelling out what the essential elements of the theory are, and elements of the relational competence. For example, how do you describe what the therapist does to foster “collaborative contact”? Should “presence” be developed as a competence beyond or in addition to the three facilitative conditions? These discussions have been stimulating, fun, collaborative and illuminating.

3. Continued Scoping: Steve and I reported back to the group the results of our continued attempts to scope out data that might warrant including Gestalt and Psychodrama. Back in July, I made another attempt to pull something out of the Gestalt and Psychodrama literatures, which was the basis for a teleconference among Tony, Steve and I. Alas, our efforts were in vain; we are unable to find more than a single decent RCT for one client group for either of these approaches, and for now Gestalt and Psychodrama will continue to languish in the margins of the competence process, as what I am going to refer to below as Ghost Entries.

4. UKCP’s Dilemma: A Modest Proposal. Because of my aversion to flying within the UK, I again arrived 90 minutes into our latest meeting. I had missed a difficult discussion between Vanja Orlans, who again had been saddled with the thankless task of conveying to the group a Bill of Complaint from UKCP. Representatives of the latter had had another meeting with Lord Alderdice and Peter Fonagy, from my point of view trying to accomplish with lobbying what they didn’t have the data to support. By the time I got there, the difficult discussion was done and it was almost time for lunch. I felt somewhat guilty for having missed the experience, but also relieved. However, I did not entirely escape the controversy: Tony gave me a summary, and at the end of the day Vanja stayed on for a bit after, and she, Tony and I went over some of the arguments again. Vanja was frustrated with me for not having been there in the morning to support her position, but the problem was that I had by now gone over to the Dark Side and was prepared offer qualified support for the HPCE ERG project, warts and all.

I have very mixed feelings about the series of complaints that UKCP has lodged against the HPCE ERG process since it began. My very first impression was that they had been caught trying to pull a fast one at the very beginning, having persuaded the Skills for Health folks that Humanistic and Integrative Psychotherapy was a meaningful, conceptually coherent theoretical orientation on the same order as CBT or Psychodynamic psychotherapy. This struck me then and continues to strike me today as an attempt to dress up, in nice scientific and professional clothing, a political compromise by which a collection of humanistic and various other therapists banded together to increase their clout.

Historically, as I now understand it, a body of training, practice and philosophy has by now grown up around this compromise, and I have been impressed by the position that Vanja has put forward. Nevertheless, there are several problems with integrative psychotherapy as a basis for a competency framework: (1) The list of therapies involved is a long and variegated one (which includes Process-Experiential/Emotion-Focused Therapy as well as Cognitive Analytic Therapy), with little in common except that they don’t fit anywhere else. (2) The research basis for this group of therapies is fairly poor, so that it provides little grist for the ERG process Steve and Tony have set up. Even if Steve and Tony’s inclusion rules were relaxed somewhat, there still wouldn’t be much. (3) Unlike PE-EFT, this approach to integrative therapy runs beyond the confines of humanistic therapy, to psychodynamic approaches in particular; so it really cuts across theoretical modalities, creating an inherent difficulty for a modality-based competency approach, and threatening to break the process even if it were to be tried.

But where does this leave us? As I have come to understand it, what Vanja and her colleagues at Metanoia are trying to do with their formulation of a personalized integration approach is admirable, makes sense, and is a Good Thing. I did the same thing at the University of Toledo, but certainly without as much intellectual rigor: The idea is that each student should, through a careful, self-reflective process, develop their own personal integration, building on systematic exposure to multiple theoretical modalities. However, this doesn’t make sense to me as a basis for a competency framework; in fact, given the assumptions of the approach, it should be impossible, or at least seriously unwise, to do so.

Instead, if you are going to integrate humanistic with other therapies, the thing to do is to use multiple competence frameworks from which to draw one’s personal integration. When they are completed, the various competence frameworks now being developed will provide a valuable tool for this process. The ERG competence process is the not the enemy of Humanistic and Integrative Psychotherapy (HIPS), but its helpmate. In fact, this appears to be exactly what Lord Alderdice and Peter Fonagy have recommended to them. Let UKCP’s HIPS section proclaim superiority by owning all the frameworks!

5. Ghost Entries: More Modest Proposals. As noted, Focusing, Pre-therapy, Gestalt and Psychodrama all fall within the HPCE camp, but because of their lack of RCTs (or even, I would say, RCT-equivalents) and therapy manuals, they remain the equivalent of Brown Dwarfs in the evidence-based therapy firmament, their Dark Matter exerting a strong gravitational force, without the visibility they desire. In the emerging HPCE competence framework, they are the Ghost Entries in the Specific HPCE Adaptations column: their proper place is alongside PE-EFT, currently the sole visible inhabitant of that region of the framework.

Given that the Ghost Entries belong in the framework but currently lack the evidence base to qualify formally, what should they do? I have two suggestions:
(1) Jump-starting research. First, they need to start doing systematic, well-designed, focused research on key client populations. Below, I use Pre-therapy as an example of what I’m talking about. It is important to recognize the possibility that some of the ghost therapies are not going to turn out to be as effective for particular client groups as they might have hoped. The psychotherapy field of full of treatments that people swore worked but turned out not to really be effective, at least not without significant further adaptation.
(2) Open-Sourcing the ERG Process. Second, rather than bemoaning their exclusion from the competence framework, they should go ahead and actually create their own Ghost Entries for the framework (or if you prefer a more political metaphor, they should create shadow cabinets). That is, they should use the methods that Alison and Andy are using to generate the Specific HPCE Adaptation competences for Process-Experiential Therapy. Actually, these haven’t been done yet, but they will be in the next couple of months, but once they are drafted, they will provide a template for other specific adaptations, like Psychodrama, Gestalt, etc, to use. These Ghost or Shadow Competence HPCE Adaptation modules can be offered as a supplement to the official HPCE framework, and can also be used to support research, as in my first suggestion.
6. How to get Pre-Therapy on the Map. Every meeting, Catherine Clarke, our caregiver member, makes an impassioned plea for the inclusion of Pre-therapy. Pre-therapy, developed by Gary Prouty for work with clients who are out of contact because of a psychotic process, is another of our highly-promising Ghost Entries and one whose practice is spreading rapidly in the UK, but is presently excluded because it lacks a strong research base. Catherine has seen how effective Pre-therapy was for her son, and also how ineffective other approaches have been; she is also aware of the harm being done by over-medicating people living with psychotic processes, so she takes the omission of Pre-therapy personally. Every meeting we listen to her, and I say that the Pre-therapy folks need to start doing more research, but somehow this isn’t enough. At this week’s meeting, it was clear that she was feeling fairly discouraged, and so I said that I would offer some suggestions for a strategy forward. So here is what I am proposing to the Pre-therapy Network:
(1) Pretherapy practitioners need to form a Practitioner Research Network (PRN) to develop controlled collaborative research using a shared research protocol. No one is going to do this research for you; you will have to do it yourselves! Wendy Traynor has just spent the past year developing such a research protocol, and is willing to act as a consultant for the project. The Pre-therapy Network already exists and provides an existing basis for this kind of collaboration; it is exactly the kind of organizational structure that is needed to support a PRN.

(2) Study 1: After getting ethics approval (Wendy is about to submit her protocol to NHS Ethics) involves as many members of the network as possible to track one new client through a psychotic process using Pre-therapy, measuring process and outcome following Wendy’s protocol, using the HSCED method to analyze whether the client changed and whether therapy was responsible for the changes. Keep track of client outcome over the course of therapy, but evaluate intensively during episodes of psychotic process, so that Pre-therapy phases of therapy can be evaluated inside the longer course of therapy.

(3) This needs to be done from at least 5 – 10 clients, making a clinical case series of systematic case studies. Until you do this, you don’t have a clear sense of the generalizability of the results of the case study in Step 2 or of the older studies reviewed by Dekeyser et al. (2008)

(4) Study 2 is a controlled outcome study against Treatment as Usual, with randomization. This is can done using a cluster design: randomize pairs of clients in relevant agencies, one to receive treatment as usual, the other Pre-therapy.

(5) Study 3: A different group of pre-therapy researchers then replicates this study. Alternatively, you can use the infrastructure from the first set of studies to compare Pre-therapy to a different therapy, like CBT.
A similar stagewise process can be used for other therapies not currently included, but its important for them to focus on a key client group, such as depression or generalized anxiety, rather than doing scattershot studies that don’t cumulate.

The HPCE Expert Reference Group will continue to meet, for at least more meeting in November, and I'm looking forward to it already!

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