Sunday, April 26, 2009

Diax’s Rake and HCSED

Entry for 26 April 2009:
“Diax’s Rake: A pithy phrase, uttered by Diax on the steps of the Temple of Orithena when he was driving out the fortune-tellers with a gardener’s rake. Its general important is that one should never believe a thing only because one wishes that it were true….” (Neal Stephenson, 2008, Anathem, p. 895. London: Atlantic Books)
In his latest novel, science fiction writer Neal Stephenson posits an alternate world in which there are multiple monastic orders of scientist-philosopher monks. One them, Saunt (short for “savant”) Diax is famous for having driven the fortune tellers out of the Temple of Orithena (equivalent to the Greek goddess Athena), whilst saying “Never believe a thing simply because you want it to be true.”

This invention is characteristic of what Stephenson does throughout the book, alluding to multiple cultural references familiar to us, and blending them together to yield something strange but familiar. Here, he appears to have combined Occam’s Razor (another sharp domestic implement, applied to facilitate logical thinking), Jesus driving the money changers from the Temple in Jerusalem, and a saying of the Greek historian Thucydides (“It is a habit of mankind to entrust to careless hope what they long for, and to use sovereign reason to thrust aside what they do not desire.” See:’s_Rake).

It seems to me that Hermeneutic Single Case Effiacy Design (HSCED) is a version of Diax’s Rake applied to the purpose of inferring causality in single therapy cases. Against the therapist and researcher’s desire to show that a client has changed because of therapy, HSCED brings forth a logical rake consisting of eight tines: four nonchange explanations and four nontherapy alternative explanations that are applied to the case data in order to combat the wish to see one’s therapy as effective.

Stephenson’s apparent allusion to Thucydides is particularly appropriate to HSCED. According to the Wikipedia article, the Greek historian is known as “the father of ‘scientific history’ due to his strict standards of evidence-gathering and analysis in terms of cause and effect without reference to intervention by the gods…”. HSCED is essentially a careful application of methods used by historians to psychotherapy case study research, a systematic method for undoing the natural desire for one’s favoured therapy to be effective.

Since the original development of the method, we have tried to develop it further by separating out two opposing sides, known as affirmative and sceptic. The Affirmative side’s task is look for replicated evidence connecting therapy to client change, while the Sceptic side’s job is to apply Diax’s Rake by looking for other explanations for apparent client change. In other words, HSCED assumes that Diax’s Rake is not enough, but must be balanced by a careful search for supporting evidence, which can then be brought against Diaxian skepticism in a search for the truth whether and how the client has changed. Thus, a fitting response to Diax's Rake might be, "But gardens do not grow by rakes alone!".

In fact, Stephenson’s scientist-philosopher monks would probably agree that the real value of Diax’s Rake is precisely in invoking skepticism as a means to inspire stronger arguments that mere wishful thinking.

Bridge Pastoral Foundation Scottish Conference 2009

Entry for 26 April 2009:

Almost two years ago, Franny and Robert, friends from St Mary’s, invited me to present at the 2009 Scottish Conference of the Bridge Pastoral Foundation (BPF). The BPF, originally known as the Clinical Theology Association, was founded in 1962 by Frank Lake, a Christian psychiatrist who is reported to be one of the pioneers of pastoral counselling in the UK.

On Easter Monday, we drove to St Andrews. For Americans, this is the ancestral home of golf, but for Scots it is the seat of the oldest university in Scotland and according to legend is where the relics of Scotland’s patron saint were brought in the first millennium of the common era. The weather was sunny and warm(ish) when we arrived at St Leonard’s School; however, the rest of the week was apparently more typical for St Andrews: overcast, cold, and very windy. Our room faced the sea, overlooking the ruins of St Andrews Cathedral, built in the 12th and 13th centuries and for several centuries the ecclesiastic capital of Scotland.

I was the main speaker for the four-day conference, doing three 90-minute after dinner presentations and two afternoon workshops of the same length. The theme of my presentations and indeed for the whole conference was: “Working with Emotions: A Path to Spiritual and Psychological Growth”. The conference blurb went like this:
Emotions are an essential part of what makes us human, helping us take in what is important for us in the situations in our lives; offering direction for effective action; and linking body and spirit. However, many of our experiences of our emotions are quite difficult: We often find ourselves stuck in repetitive, painful emotions; or we find ourselves numb and unable to access important feelings when we need them ion our relationships with others; or we get overwhelmed and frightened by emotions that we are not sure we can bear. So emotions have great power for good and ill in our spiritual and psychological lives, making it vitally important that we develop our ability to effectively work with our own and others’ emotions, in our daily lives, relationships and psychological and spiritual development. The theme for this conference is therefore working with emotions as a path for spiritual and psychological growth and accompaniment. In plenary sessions and workshops, Robert Elliott will guide participants through a series of sessions aimed at introducing the basic concepts of contemporary emotion theory, including presentations, small group exercises, and personal sharing.
When we first met to discuss my participation in the conference, Franny and Robert warned me that my talks would be after dinner and that my audience would be a mixture of professionals and lay people and wouldn’t want to sit through a long dense, lecture. The audience would want to get involved in some sort of exercise, they said, preferably involving personal sharing in small groups or twos or threes. Hmm… I’d been thinking of focusing on basic PE-EFT emotion theory, but it was clear that my standard 1-hour overview lecture was going to be too long and dense for this group. I decided to break it up over the three 90-minutes slots. I generally bombard my audience with material, preferring to overwhelm rather than bore people, but thought that it would be instructive to see what happened if I used a different strategy.

In the event, this approach worked brilliantly. Each time, I talked for about half an hour, focusing on a small bit of PE emotion theory: The first night this was the concept of emotion in general and its adaptive functions; the second night, the emotion scheme model and the five aspects of emotion; and the third night, types of emotion response. Each night I played a 5 – 15 minute video clip, offered a small group exercise for 10 – 20 minutes, led discussion, and answered questions after each component. The first night, after I’d talked for half and hour, I offered the audience a choice of whether to see the video before or after the small group work; they startled me by clamoring for small group work. The second night, I decided on the spur of the moment to begin with the video. By the third night, I was confident enough in their process to give them 20 minutes for the small group work.

It was a strange experience for me to watch them working in pairs or triads, going at it intently, while I sat in the front of the room. This sort of small group work, such a central part of the counsellor training culture in the UK, was foreign to me when I arrived here two and a half years ago. I’ve since gotten used to it, but it still doesn’t come naturally. So I found myself feeling a bit bored and jealous of the participants. I played with my computer, which has the capability of displaying one image through the data projector while I looked at a different image on my screen, but couldn’t get out of the Powerpoint file I was displaying. (The third night, this caused my computer to lock up, which was annoying when I tried to go on after the exercise, so in future I’ll have to work on occupying myself more effectively during group exercises.)

At the end of each of these talks, the audience expressed their appreciation by applauding strongly. This inspired me further, so that by the third night, I’d really given it my all: I’d spent all morning making a new flow chart to help people identify the four emotion response types (leaving it up on the screen as a visual aid during the exercise); I’d presented my audience with a challenging exercise and given them plenty of time to do it; I’d answered their questions; and I’d finished with an intense, powerful video clip. Thus, when the third and final presentation was done, the applause went on and on in a way that felt almost overwhelming and I felt the audience’s appreciation wash over me, like a wave, buoying and affirming. Something special had happened here between us, and I felt a moment of genuine happiness and joy.

On Friday’s closing session, we did an exercise. By this time, of course, I’d also done two workshops on emotion regulation (using Clearing a Space and Two Chair Work as examplars of containing and accessing emotion); spent three afternoons wandering around St Andrews exploring the ruined cathedral and the remains of the bleak sea castle (with its creepy underground mine and countermine); and gone to Thursday night’s ceilidh to which I wore a kilt for the first time. I'd been very impressed by the quality of the organization of the conference, with it's multiple layers of supervision and careful attention to boundary issues, and even more by the quality of the people attending and supporting the conference.

For the exercise we were asked to reflect on the three phases of our experience of the conference: as we’d arrived, engaged in it, and now were about to leave. We were encouraged to express this in some way. Most people drew pictures, but I pulled out my trusty Pukka Pad and wrote the following:
What I brought to the conference: Anxiety: Who are these people? What will they want/need? Can I meet them productively? Will the complexity of the relationships be OK and manageable for me? Will it get so messy that this will spoil the experience and make it a grind rather than an adventure?

What has happened for me during the week: I felt welcomed, but somewhat on the outside because I was not in a small group. Although I had to do a lot of presentations, the pace was fairly leisurely and I didn’t feel pressurized (as I usually do at conferences). It didn’t feel like a vacation, but it was a relief from my everyday life. Nevertheless, some part of me longed to be part of the intense processes going on all around me, and felt left out and at times a bit lonely. At the same time, it felt freeing to be able to take my hands off the wheel.

What do I want to take away with me from this experience?
1. A set of new inputs and workshops to apply elsewhere in my work.
2. A sense of being able to blend my research/theory/practice with my spiritual life.
3. A sense of community with a new group of people and respect for the culture of this conference.

Sunday, April 19, 2009

Science Indistinguishable from Magic

For Ann Elliott, on her 80th birthday. This poem references two other poems, written respectively for my mom and dad on their 75th birthdays; these can be found at: The title refers to one of the science fiction writer Arthur C. Clark’s Three Laws. There is a video of me reading the poem at the following link, although it may be necessary to sign up for my brother Joseph’s Kyte video/photo streaming service to view it: .

1. Breaking

Three years ago, the valley filled with white,
Science failed, the great oaks broke,
And with them our hearts, a veil torn in two.

The Shaman passed through that veil;
But your journey took a different path,
A winding way: great pain, many places.

Knees, back, foot: these had to be broken and restored,
These parts of us that must be strong and stand,
But whose real strength is bend and flex.

And you yourself were strong,
And like the willow you willed yourself
To bend and flex in new ways.

2. Rite of Passage

For your rite of passage, you became a pilgrim,
And wound your way among your children’s homes,
Until at last you came to Scotland.

There, you took up the Shaman’s mantle
To heal the Borders, where modern, dark plantations
Cover the land, smother ancient war wounds.

Instead of reiving, we rode from point to point
Of a great triangle, from a hill above Hawick,
To Wauchope Forest and Hermitage Castle.

In each place we made Kaddish, praying
In remembrance, and for healing, laying
A crystal, leaving a sign of the Labyrinth.

3. Reintegration

I Ching knows, all things return:
Polarities shift, your science and his magic;
Old Yin becomes Yang.

You’ve turned another corner on your
Winding way, had your house rebuilt,
Made the Shaman part of you.

In daily dialog with him, you’ve found
Your voice, rebalanced yourself,
And grown to become the Shaman-Crone.

And as you’ve journeyed these last three years,
You’ve found your Science has advanced enough
And is now indistinguishable from his Magic.

-10 April 2009, Good Friday

Monday, April 13, 2009

HPCE ERG Part 9: Dialogue and Understanding

Entry for 9-12 April 2009:

The full moon shone through the clouds as I stepped out of the front door of my flat in Hyndland and walked down the hill to the train station. The Caledonian Sleeper carried me down to London, arriving at 6:15am, a bit earlier than I wanted. I sat at a café in Euston Station for an hour and a half, ate a bit of breakfast and reviewed the materials for the day’s meeting of the Humanistic Person-Centred-Experiential (HPCE) psychotherapy competences Expert Refernce Group (ERG).

This was an extra meeting, beyond the official end of the project’s funding, organized under special dispensation and with a change of venue (because of the Easter holiday). So it was that I found myself getting off the underground at the Finchley Road tube station about quarter to nine on Maundy Thursday, climbing the hill up Trinity Walk, and progressing along the road in search of the Anna Freud Centre. Just as I was beginning to think I’d made a wrong turn, Steve Pilling came walking jauntily down the street from the other direction, equally early for our 10am meeting.

Lead-up. Several things had happened since our previous meeting in late February: Steve and Tony had had another meeting with representatives from UKCP, who were asking for more changes, and in particular for additional representation and for the restoration of psychodynamic language like “transference” and “projective identification”. The issue of the name of the “Fourth Modality” had once again been raised; this had also been discussed at the Modality Working Group (the next stage of the competence development process), and the word on the street was that our ungainly working title (HPCE) was due for an overhaul.

After the previous ERG meeting (see HPCE ERG report 8), I was stricken by the injustice of including psychodynamically-sourced material from the humanistic-integrative approach in the absence of outcome data while failing to include material on Pre-therapy, as advocated by Catherine Clarke, our carer representative. As a result, I subsequently contacted sources to see if we could develop set draft set of Pre-therapy competences. These sources (I’m being deliberately mysterious here) kindly obliged and we had run the draft through 7 revisions by the beginning of the week of the meeting; these had by now been rebranded as psychological contact competences. In the meantime, Steve had phoned me the previous week to discuss the name issue and to try to convince me that Pre-therapy should not be included even though humanistic-integrative had been (with less outcome data). In addition, Tony and Andy had revised and distributed the Process-Experiential Specific Adaption section. Clearly, we had a full plate for the day.

After an hour’s wait, the others arrived, minus M and our BACP representatives Nancy Rowland and Sally Aldridge, who were away. Angela Kotter, whom I knew from previous contacts, joined us as an 11th hour addition of another representative from UKCP (ironic in the absence of both BACP reps); she was there to provide some support and to take some of the pressure off Vanja Orlans in the negotiations.

The core issue. At the heart of what we’ve struggled with all along are the large apparent discrepancies among the different suborientations in theory, practice and language. For example, many aspects of Process-Experiential practice (most outstandingly, the various forms of chair work) are unacceptable to Person-Centred therapists. Similarly, for reasons mysterious to us, many Humanistic-Integrative therapists feel deeply attached to psychodynamic language like “countertransference” and “unconscious communication”, which the Person-Centred and Process-Experiential therapists find beyond the pale, even when talking about the same clinical phenomena and forms of practice, such as when working with clients with chronic severe dysfunction like borderline/fragile process. These discrepancies have continually strained the conceptual and structural intregrity of the competence framework, as well as the patience and tolerance of the ERG members, and at times feelings have been intense and distrust has been rife.

Over the months, however, relationships among ERG members have developed and the group has learned to deal with its conflicts and to hear the similarities amid the differences, some of which are more apparent than real, while others cut deeper. Here’s how the work went:

1. Specific Approaches. We started out by reviewing the overall HPCE Competence map and in particular the structure of the Specific Competences, which had developed into the key venue for the inclusion of additional competence modules, including the psychodynamicly-flavoured relational work, the person-centred nondirectivity, and the proposed psychological contact work competences. How could such diverse and mutually exclusive material be combined within a single framework? To our surprise, Tony and Steve managed to finesse this one by proposing to label the modules in this section as “Approaches”, thus allowing the different suborientations to do their own thing without the requirement of being consistent with each other.

Later in the day, in the process of our general review of the work done so far, we relooked at the structure of this Specific Approaches section and reorganized the working with emotion and working with meaning sections into a single Working with Emotion and Emotional Meanings sections, making a nice sequence of Accessing Emotion => Articulating Emotion => Reflecting on and Developing Emotional Meanings.

2. Lexical allergies and language as identity. Another big item on our agenda was the issue of mutually-objectionable language, exemplified by terms such as “Actualising Tendency” (person-centred) and “Transference” (UKCP). Many years ago, Marv Goldfried described such terms as “X-rated language”, but in today’s permissive culture another metaphor is called for. I’ve been using the metaphor of a kind of lexical allergy, words that evoke a strong negative reaction in some people. In our case, the problem is not semantic, because we agree on the importance of concepts such as the natural tendency of organisms toward growth and adaptation, or key repeating interpersonal patterns. In some cases, some suborientations valorize certain concepts by giving them special names, like “transference” (humanistic-integrative) or “emotion schemes” (process-experiential), while other suborientations recognize the phenomenon but don’t choose to give it a special name; thus, the person-centred therapists choose not to name the phenomenon, even though they are happy to talk about characteristic and repeatedly-experienced elements of their clients’ core self-concept (as my colleague Beth Freire did last week when we compared notes on how we were thinking about our work with some of our Social Anxiety clients).

Instead, some of us reject certain terms because of their connotations. For example, person-centred and process-experiential therapists reject “transference” and “unconscious” because, like Carl Rogers before us, these terms are a Language of Oppression, representing a psychiatric power structure that we rebel against. Similarly, for process-experiential and humanistic-integrative therapists, apparently, “actualizing tendency” might be seen as a dewy-eyed naïve usage, suggesting a specific pre-formed blueprint; we want something more neutral and open, like “growth tendency” or more interactive and rich, like “dialectically constructive process” or "intersubjective multilevel complexity". Thus, the terms in questions are symbols of an identity that we reject.

Conversely, for various of us, specific key terms are signs of an identity that we espouse and embrace as defining who we are. To use another metaphor, as I did on Thursday, these terms are our native tongue; to make us give up these words is like forbidding people in Ireland and the Scottish Highlands from speaking Gaelic. That is, as people often forget, language is culture, and culture is identity.

How is this relevant to the work of the HPCE ERG? Well, the different suborientations that have been sparring with each other over the past year: person-centred, process-experiential, humanistic-integrative and pre-therapy are each a little culture. Each of these has its own language and points with pride to some aspect that makes it big or important: Person-centred to its history and tradition; process-experiential to its research and its process-differentiation; humanistic-integrative to the size of its practitioner base and the complexity of its theory; pre-therapy to social justice issues grounded in the neglect and mistreatment of severely distressed client populations.

This applies to the humanistic-integrative suborientation as much as the others: What UKCP’s Humanistic and Integrative Psychotherapies Section (HIPS), including Ken Evans -- who keeps sending me cranky emails and postings to this blog -- has been saying is that over the past 20-odd years they have developed their own culture of humanistic practice that incorporates key psychoanalytic terms and now have a substantial practitioner base. They say that they have redefined the psychoanalytic terms and cleansed them of their oppressive connotations, and for them I can only assume that this is true.

However, the terms still retain their toxicity for the rest of us. This is not because we are stuck-in-the-mud, but because we practice in a different culture, where those words mean something else.

Thus, we can argue back and forth as we have been doing about just how big the specific base of the humanistic-integrative suborientation is (it’s undoubtedly not as large as HIPS itself, which is made of quite diverse subgroups, including person-centred, gestalt, psychosynthesis etc), whether this is really a humanistic therapy if it uses all that psychoanalytic language, and why it has none of its own, focused outcome research (what is the impact on outcome using all the psychoanalytic language, even if you don’t actually act interpret your clients?). However, it is still its own developed culture, complete with key texts, language and practitioner base… and Steve and Tony have already agreed with The Powers That Be that humanistic-integrative therapy will be included, psychoanalytic language and lack of focused outcome research and all, and there you have it.

The real key is understanding the fact that the language issue was about our different cultures, and once we finally did that on Thursday, we were able to develop a compromise: We agreed to continue to emphasize ordinary language, generally acceptable versions of important concepts, while giving the technical, identity-based terms as examples, in brackets and quotations, such as “the assumption that people are motivated towards self-maintenance, psychological growth and development, and the realisation of their potential (e.g., “actualising tendency”)”.

Thus, much of our time was spent reviewing the existing framework for places where various of us had trouble with particular terms, going right back the Basic Competence section and following through the rest one more time.

3. Psychological contact competences. It appeared that everyone but Tony and Steve liked the idea of adding psychological contact competences, and we argued around in circles for quite a while about this. Steve had two main arguments against it: (a) the potential for controversy over what would be perceived as a claim to have an effective treatment for severe disorders such as schizophrenia and dementia, coupled with (b) the lack of research to back such a claim up. Steve argued on the basis of having had 20 years of experience with psychotic populations in community mental health settings, fearing the risk of falsely raised expectations might threaten the credibility of the whole framework. The discussion became quite heated as Catherine argued passionately for the need for an alternative to what she described as abusive medication policies.

Andy reminded us that we had previously talked about including psychological contact in the Basic Competences and wondered if something like this could go there, perhaps broadened a bit to include a wider spectrum of contact disturbances such as might be encountered short of but also including psychosis; these include being overmedicated, under the influence of alcohol or other substances, or just interpersonally unengaged. Afterall, psychological contact is the first of Carl Rogers’ six facilitative conditions. Finally, Tony proposed that Andy and he work from the draft I’d put forward to produce a new module on psychological contact to go early in the Basic Competence section, and to run it by the rest of the ERG via email. In spite of the difficult discussion, I ended up feeling quite hopeful that something would come of this. Of course, as always the devils are in the details, and some of the fine details about specific types of therapist responses in the draft are unlikely to survive intact, so we will have to see what the revision looks like. Nevertheless, at the very least we should be able to come out with something that addresses an important clinical issue, broadens the relevance of the competence framework, and acts as a pointer to the rapidly emerging area of Pre-therapy and contact work.

4. The Name issue. One of the final things the ERG tackled was what to call the competence framework that we’ve been working on for the past year. UKCP was now complaining that it wasn’t fair the framework should be named after two suborientation brand names (“person-centred” and “experiential”) while their brand name was left out. Of course, the PCE label was developed as an inclusive label by our professional organization (WAPCEPC, talk about an awkward name) 10 years ago, but it wasn’t UKCP's label and they don’t identify with it, so we were once again back to identity politics. On the other hand, no one was seriously proposing to go back the original title “Humanistic and Integrative”, because “Integrative” is just too large an umbrella (it includes Cognitive Analytic Therapy, Multi-modal therapy etc). And everyone agreed that “Person-Centred-Experiential-Humanistic-Integrative” was too long and clumsy. Really, the only viable label we are left with is one that no one really likes: “Humanistic”. This is a kind of lowest common denominator solution, a shoe that fits no one perfectly but one that almost all of us can wear like a kind of one-size-fits-all-of-us-with-mediumish-sized feet. Germain Lietaer did made a final plea against this, because the term is simply not used in Europe and has relatively few practitioners today in North America. He argued that our adopting “Humanistic” would limit the usefulness of the competence framework internationally. In the end, however, the competence framework must first work domestically in the UK, so we agreed to go forward with this spartan label. HPCE has now become H.

Finishing up and summing up. And so our long series of face-to-face meetings devoted to developing a set of humanistic competences finally has finally come to an end. The rest will have to be done by email and possibly teleconference. We didn’t get to the Process-Experiential therapy competences, but Andy, Tony and I will continue working on those over the next few weeks, before we send them out to Les Greenberg, Jeanne Watson, Rhonda Goldman and possibly Sandra Paivio for further review and comment.

Over the past year, the HPCE (now H) ERG evolved over a complicated and sometimes fractious process, and I’m sure that when it’s finally finished the result won’t totally satisfy anyone wholly. Interestingly, it seems to me that the most important thing about it is not the emerging framework itself but the opportunity for dialogue among folks representing the different points of view within the humanistic therapy world and also between us and Tony and Steve. We have come to understand and respect each others’ perspectives. It is clear that differences in practice and language remain and will continue to set us apart from one another; but it is even clearer that we need to continue to try to hear and understand each other in spite of (and also because of) those differences.

Sunday, April 12, 2009

Commentary on NICE Depression Draft Guideline Update

Entry for 12 April 2009:

The NICE (National Institute for Clinical Excellence) guidelines are a set of practice guidelines developed to guide the treatment of medical and psychological problems in the UK. Over the past few years, however, they have become increasingly controversial, and there has been quite a lot of fulmination and even some lawsuits over them. For example, recently by a group of people with ME (Myalgic Encephalomyelitis; the UK term for Chronic Fatigue Syndrome) sued NICE, claiming that the guidelines for ME restricted their treatment to CBT and graded exercise, which they said were ineffective for them (they lost...).

In February, NICE issued its long-awaited revised draft guideline on treatment of depression. Previously, “counselling” had been in the guidelines as a second line treatment if CBT or medication didn’t work. Now, however, this recommendation had been transformed into what amounts to a health warning (p. 197): For people with persistent minor and mild to moderate depression who have declined a low intensity intervention or group CBT, counselling may be considered. However, practitioners should take care to explain the uncertainty about the effectiveness of counselling for people with
depression. Counselling for people with persistent minor and mild to moderate
depression should be:
• based on a non-directive person-centred model
• typically in the range of 6 to 10 sessions over 8 to 12 weeks
In other words, if clients are pig-headed enough to turn down the recommended treatments, they should be permitted to receive counselling, but with a warning that nobody knows if it's effective for depression. The guideline goes on to say that the counselling should be “nondirective person-centred” and generally no more than 10 sessions, after which the person would once again to urged to get themselves to a more effective treatment, possibly with an “I told you so!”.

There are so many things wrong with this recommendation that it is difficult to know where to begin. When I first looked at the document, I felt so scandalized and embarrassed by it that I didn’t know what to say; it seemed so shoddy, really a travesty of science. What is my justification for such a strong reaction?

1. Let’s start with the cited evidence base for the guideline, which consists of three RCTs (Bedi, 2000; Simpson, 2003; Ward et al., 2000). These three studies are a diverse group: Simpson (2003) used psychodynamic counsellors; Ward (2000; a version of the King study) used person-centred counsellors; and the theoretical orientation of Bedi (2000)’s counsellors was given. When Beth Freire and I were collecting studies for our meta-analysis of Person-centred-experiential (PCE) therapy outcome, we looked at the Bedi (2000) study and dropped it because the theoretical orientation of the counsellors wasn’t specified; and we didn't look Simpson (2003) at all because of their focus was on psychodynamic counselling. (The latter should have been included in the short-term psychodynamic therapy section, but apparently was not.)

However, the theoretical orientation of counselling in the draft guideline is described as person-centred. It is a step in the right direction to specify the theoretical orientation of the counsellors (this was not done in the previous depression guideline). However, only one of the cited studies (Ward, 2000) used counsellors with a person-centred orientation (more on this below). So the first problem is that the guideline is not consistent with its evidence base.

2. Nevertheless, on looking more deeply at the documentation for the guideline, it became clear that the real problem is a significantly flawed search strategy: This is described (in the Full Guideline document, section 6.1.5, p. 132) as using the following treatment inclusion criteria:
Behaviour activation
Cognitive behavioural therapies
Computerised cognitive behaviour therapy
Couples-focused therapy
Guided self-help
Interpersonal therapy
Problem solving
Physical activity
Psychodynamic psychotherapy
Rational emotive behaviour therapy
I was startled to note the absence of the following important search terms, all of which have outcome literature:
Person-Centred therapy
Client-Centred therapy
Nondirective therapy
Supportive therapy
Process Experiential therapy
Emotion-Focused therapy
So the second problem is that, by any account, the search strategy used resulted in an under-representation of the existing literature on PCE therapy for depression. When Beth Freire and I (Elliott & Freire, 2008) did our meta-analysis, we identified 17 different comparative outcome studies involving person-centred-experiential (PCE) therapies, 16 of them RCTs. Yet only one of these studies (Ward, 2000) was reviewed in the GL document.

Why weren’t these studies included? Why didn’t the review panel look more carefully for literature? Were they under-resourced? Did they lack expertise on this literature? Or did they just not bother because they didn’t think there was anything there anyway? In any case, this should be, for them, an embarrassing omission.

What studies are missing? In particular, the following RCTs of process-experiential/emotion-focused therapy with clinically depressed clients are not included:
*Goldman, R. N., Greenberg, L. S., & Angus, L. (2006). The effects of adding emotion-focused interventions to the client-centered relationship conditions in the treatment of depression. Psychotherapy Research, 16, 537-549. [Replication of Greenberg & Watson, 1998: Well-designed RCT with clinically depressed clients and medium-sized sample, comparing PE-EFT to Person-Centred therapy; outcomes were strongly and significantly better for PE-EFT.]

*Greenberg, L.S., & Watson, J. (1998). Experiential therapy of depression: Differential effects of client-centered relationship conditions and process experiential interventions. Psychotherapy Research, 8, 210-224. [Well-designed RCT with clinically depressed clients and medium-sized sample, comparing PE-EFT to Person-Centred therapy; outcomes were slightly but not significantly better for PE-EFT.]

*Watson, J.C., Gordon, L.B., Stermac, L., Kalogerakos, F., Steckley, P. (2003). Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 71, 773-781. [Balanced researcher allegiance RCT comparing PE-EFT to CBT in clinically depressed sample; outcomes for PE-EFT were generally at least as good as CBT and on some measures were better.]
In addition, the following studies of person-centred counselling with perinatal depression are also missing:
*Cooper, P. J., Murray, L., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. British Journal of Psychiatry,182, 412-419 . [Well-designed RCT; Person-centred comparable outcome to CBT and Psychodynamic]

*Holden, J.M., Sagovsky, R., & Cox, J.L. (1989). Counselling in a general practice
setting: Controlled study of health visitor intervention in treatment of postnatal depression. British Medical Journal, 298, 223-226. [Medium-sized RCT: Clients in Person-centred therapy had better outcomes than control clients]

*Morrell CJ, Warner R, Slade P, Paley G, Dixon S, Walters SJ, Brugha T, Barkham M, Parry G, Nicholl J. (In Press). Clinical effectiveness of health visitor training in psychological interventions for postnatal women – a pragmatic cluster-randomised trial in primary care. BMJ. [RCT; Person-centred similar outcome to CBT, better than treatment as usual]

*Wickberg, B., & Hwang, C. P. (1996). Counselling of postnatal depression: A controlled study on a population based Swedish sample. Journal of Affective Disorders, 39, 209-216. [RCT; Person-centred much better than treatment as usual]
The Elliott & Freire meta-analysis also includes RCTs by Beutler et al., 1991; Brent et al. 1997; Fleming, 1980; Lerner, 1990; Maynard, 1993; McNamara, 1986; Propst et al, 1992; Shaw, 1977; Stice et al., 2006; Tyson et al, 1987; Wilson et al., 1990.

3. What are the consequences of omitting these studies? Across 33 comparisons between PCE therapies and other therapies (in 22 cases, CBT) in Elliott & Freire’s (2008) data set, the mean comparative effect size was -.07, a statistical equivalence finding (meaning that it is not statistically different from zero but is significantly different from -.4 standard deviation units, a useful cut-off for demarcating small from medium effect sizes). A robust literature supports the proposition that PCE therapies are equivalent in effectiveness to CBT and other therapies. The third problem with the revised draft guideline is that the reading of the evidence base is simply inaccurate.

The implications: The Revised Draft NICE Guideline for Depression is in significant error on its recommendation against offering counselling to depressed clients. The guideline should be revised by deleting the prejudicial language on counselling, cited at the beginning of this entry, and the Treatment options section should at minimum be revised as follows:
6.5.4 Treatment options Discuss the relative merits of different interventions with the person with depression and offer:
• antidepressant drugs (normally SSRIs)
• psychological interventions (normally CBT, interpersonal therapy, or person-centred-experiential [PCE] therapy)
• a combination of antidepressants and CBT.

The choice should be based on patient preference, the likelihood of adherence to the treatment, and the likely side effects.
Furthermore, the next section should also be revised, at minimum, as follows:
6.5.5 Choice of psychological treatment For people with moderate depression who are offered psychological interventions the choice of treatment should include:
• Individual cognitive behavioural therapy
• IPT if the person expresses a preference for it or if, in the view of the healthcare professional, the person with depression may benefit from it.
• PCE therapy if the person expresses a preference for it or if, in the view of the healthcare professional, the person with depression may benefit from it.
I say these guidelines should be revised at least as far as I’ve suggested, because to my mind they still display way too much bias in favour of SSRIs and CBT, but this at least would be less of a travesty of science than the current version.

When the BACP Research Committee examined these draft guidelines last month, we noted various places where evidence was interpreted in favour of CBT and against other therapies, and also how difficult it was to really pin down the evidence base for the conclusions made. I’m sorry that the report isn’t more careful, thorough or balanced, given the amount of time and effort that the review panel obviously put into the review process (there are a couple of thousand pages of documentation). Maybe I'm wrong, but it looks like they just didn’t care what they did with the PCE therapy or counselling evidence base. Not caring might be convenient when it favours your expectations or preferences, but it is neither good science nor good health care policy. When the consequences of this carelessness have real world consequences, risking thousands of counsellors losing their jobs or having to retrain in CBT, and hundreds of thousands of clients having their access to the full range of effective treatments curtailed, then carelessness can begin to take on a moral or even an ethical dimension.