Friday, December 26, 2008

Scottish Matrix Slights Person-Centred-Experiential Psychotherapies

Entry for 26 December 2008:

After some delay, the new template that is supposed to guide the delivery of psychological therapies for Scotland has been released, just in time for Christmas. The document is entitled, Mental Health in Scotland: A Guide to delivering evidence-based Psychological Therapies in Scotland: “The Matrix”, and was produced by NHS Education for Scotland (NES), drawing on inputs from experts. (I drafted the section on Social Anxiety/Social Phobia, which appears with some later additions by others.)

1. What is The Matrix?
To begin with, the stated purpose of the the Matrix document is, “to help NHS Boards:
• Deliver the range, volume and quality of Psychological Therapy required for the effective treatment of common mental health problems, and the achievement of ICP accreditation;
• Provide evidence-based psychological interventions in other key government priority areas; and
• Work towards reducing waiting times for Psychological Therapies in anticipation of future ‘referral to treatment’ targets,”
It does this by, among other things, ‘Summarising the most up-to-date advice on evidence-based interventions.’ In addition, there is the following qualitified disclaimer: “The Guidance is not intended to be prescriptive, but does offer guidance to local groups involved in the strategic planning and delivery of Psychological Therapies.”

The bulk of the document is a set of tables of recommended therapies organized into different common client presenting problems, for both adult and child populations.

2. How was The Matrix document constructed?
NHS Education Scotland assembled a collection of experts on different client presenting problems. I was asked to review the literature on social anxiety, presumably because there aren’t too many people working on it in Scotland. We were given a relatively short amount of time, less than 2 months, and encouraged where possible to rely on the NICE and SIGN guidelines, which are respectively the English and Scottish official summaries of research evidence and clinical recommendations for Evidence based practice. Since there are no published NICE or SIGN guidelines for Social Anxiety, I was on my own. Reviewing the literature on outcome for therapies for Social Anxiety/Social Phobia turned out to be interesting and useful for me, in spite of the lack of evidence for PCE therapies and the preponderance of CBT research. Interpolating from existing general effectiveness data and clinical reports, as well as our early outcome data from our Social Anxiety Protocol, I was able to return a level C rating for Psychodynamic and Humanistic-Person-Centred-Experiential therapies, that is, “No evidence to date but opinion suggests that this therapy might be helpful”. However, interesting as the experience was, it did confirm the misgivings that Steve Pilling had expressed to me about the Scottish equivalents of NICE being under-funded.

3. How does PCE therapy generally fare in The Matrix?
Given the approach of the Matrix (organizing guidelines by client present problems), the political climate (dominated by CBT), and current state of the scientific literature on PCE therapies (fairly scattered and focused on different research questions), it is not really surprising that Person-Centred therapy is mentioned exactly twice in the document, once one page 10, in a list of therapies commonly-practiced in Scotland, and again on page 40 in the Guideline for Social Anxiety/Social Phobia that I drafted, referred to above.

In other words, PCE therapies are virtually invisible. If NHS Boards follow the advice in the Matrix, they will not commission PCE therapists to provide services for any common group of clients.

There are many problems with the verdict of The Matrix document on PCE therapies: philosophical, political, scientific, practical etc. However, I want to focus on just one of these and just one client presenting problem:

4. The Matrix document fails to fairly summarize the existing scientific evidence on therapies for depression.
Mild-to-moderate is arguably to most common client presenting problem in practice settings. Actually, a mixture of depression and anxiety accompanied by various other issues is probably the most common, but Depression has become a kind of flagship diagnosis, an entry-point for new therapies vying for broader recognition.

This past September, SIGN (the Scottish Intercollegiate Guidelines Network, i.e., the Scottish equivalent of NICE) released its revised treatment guidelines for depression, on which The Matrix section on Depression appears to have been largely but not entirely based. Building on earlier work I’d done for the HPCE competence Expert Reference Group, I took the meta-analytic data that Beth Freire and I had collected and pulled out the depression studies, looking for patterns. As a result, I was able to derive the following recommendations that were missing from the draft SIGN Depression guidelines:
(1) Person-Centred/Experiential therapies in general for Mild to Moderate Depression: Evidence Level A: Highly Recommended
(2) Person-Centred Therapy for Mild to Moderate Depression: Level B: Recommended
(3) Process-Experiential/Emotion-Focused Therapy (PE-EFT) for Depression: Level A: Highly Recommended
(4) Person-Centred Therapy for Perinatal Depression: Level A: Highly Recommended
These recommendations are documented with citations to published RCT and meta-analytic data (the defining criteria for the different evidence levels) in a summary document. I sent my evidence document off to the SIGN folks, who thanked me for my input; I have heard nothing since then. For some reason, I never got around to posting this evidence document on this blog, so I remedying the situation by doing so now.

Meanwhile, the Depression section of The Matrix appears to have been added after the rest of the Matrix was developed, between the September and November draft versions, limiting the time for feedback on it. Moreover, in the November draft, it was clear that there were significant omissions, even when compared to the draft SIGN Guidelines. These omissions didn’t just involve PCE therapies: Psychodynamic therapy, Problem-solving therapy (for elderly depression clients), and generic Counselling had also been left out, as was much of the documentation for the recommendations. Accordingly, I sent off a proposed revision of the Depression Matrix recommendation to The Matrix folks. Unfortunately, this input and the associated scientific evidence are not reflected in the published version of The Matrix Depression recommendations, although the documentation has been added.

5. What should we do?
As a teenager, I remember reading in Arthur Koestler’s The Ghost in the Machine, something that has become one of my favorite quotations: “When in danger or in doubt, run in circles, scream and shout.” But is The Matrix verdict the End of the World As We Know It? The fight for recognition of PCE therapies is worldwide and involves scientific, political, educational and practical elements. One that we have learned over the past 15 years is that a single set-back isn’t the end. It’s damaging, as we have seen in Germany, where Person-Centred therapists have been fighting a rear-guard action against the government and the insurance industry for at least 10 years. These kinds of set-backs are bad for morale and can have serious negative consequences for practitioners working in an approach, such as losing their jobs.

However, conceding defeat would be worse and is not necessary; instead it is vital that HPCE therapists persevere and continue meet the challenges, using a variety of tactics. Here are some suggestions:

First, as noted, it is important not to give up, and not to take no for an answer. We can take heart from the fact that The Matrix Depression recommendations are already out of date, because they do not include the recent research evidence, which has so far been ignored by the relevant bodies. There is room for more negotiation.

Second, it seems to me that a useful next step is going to be political: Those of us who can vote (I can’t since I’m neither a British nor an EU citizen) need to contact their MSPs and to express concern about the scientific data left out of published version The Matrix. To do this, you will need to be in possession of the facts about the research (see accompanying summary of the depression research literature. The point here is that we don’t even have to attack The Matrix’s depression review on the basis of its standards, even though these aren’t particularly fair: By its own standards, HPCE therapies should be included in The Matrix at Level B or A (depending on the speicific knowledge claim you want to defend).

Third, we need to move ahead with more research on the use of HPCE therapies for depression, especially more RCTs. It appears that Michael King’s 2000) ground-breaking RCT comparing, Person-Centred, CBT and GP clinical management is now being discredited because Beck Depression Inventory scores were used rather than formal diagnostic interviews. We need to keep doing more and better research.

Fourth, it’s important for us to be in dialogue with our CBT brothers and sisters rather than attacking them. Most CBT folks that I’ve met are genuinely concerned first and foremost for client welfare and believe that scientific data can help us learn how to help our clients more effectively. We can make common cause with our CBT colleagues in helping government bodies more fairly evaluate the available research evidence.

Fifth, HPCE therapists need to make common cause with one another instead of fighting for their particular brand of HPCE therapy against the others. In Germany, Systemic therapy has recently been recognized by the government, on the basis of a broad, inclusive approach to the research data, while Person-Centred, Gestalt therapies, and Psychodrama languish because they refuse to cooperate with one another. We can no longer sustain this kind of divisive approach.


megha said...

well i am suffering from this anxiety.

Social Anxiety

Robert Elliott said...

I'm allowing the above comment to appear on here in the interests of free speech. However, I have serious doubts about its legitimacy, because it is a link to a commercial site that is selling a "miracle" cure for all kinds of anxiety. The site is filled with testimonials claiming to be from satisfied customers, but no systematic outcome research is cited. I encourage the author of this commercial product to do the appropriate outcome research to see if his treatment really does work. In the meantime, as the Romans used to say, Caveat emptor! Let the buyer beware! -Robert