Sunday, December 06, 2009

Emotion-Focused Therapy Classified as Counselling by NICE

Entry for 5 December 2009:

In my comments at the New Savoy Conference on Psychological Therapies in the NHS, I gave a version of my rant about the new Revised NICE Guidelines for Treatment of Depression, which had been thoughtfully placed in all delegate packs. What I said was:

(a) there is a need to relook at NICE’s weighing of the evidence, such that it gave infinite weight to RCT’s and zero weight to everything else; and (b) NICE wasn’t even following its own evidence guidelines, as witnessed by their not even looking for studies on Person-Centred or Emotion-focused therapy in their computer-based search strategy, and then ignoring perfectly good RCTs on Emotion-Focused Therapy even after these had been brought to their attention.

I based my comments on having revised the summary recommendation document. The final published version of the recommendations on Counselling has been reformatted (mainly by lumping it together with brief psychodynamic psychotherapy) but is unaltered from the draft version distributed earlier this year for comment. It reads as follows: For people with depression who decline an antidepressant, CBT, IPT,

behavioural activation and behavioural couples therapy, consider:

counselling for people with persistent subthreshold depressive

symptoms or mild to moderate depression

short-term psychodynamic psychotherapy for people with mild to

moderate depression.

Discuss with the person the uncertainty of the effectiveness of

counselling and psychodynamic psychotherapy in treating depression.

Based on this, I mistakenly assumed that the NICE reviewers had totally ignored the vigorous commentary from BACP, which included the evidence on EFT for depression that I had provided.

A few days ago, however, I received an email from Les Greenberg about a request for more information about these recommendations from Klaus Pederson, a Danish psychologist involved in setting policy for that country on treatment of depression. He wanted to know why EFT was lumped with counselling in the new NICE guidelines. That can’t possibly be true!, I thought, and went and downloaded the complete guideline from the NICE site.

Much to my surprise, I found the following in their review of the evidence for Counselling:

Page 219:

Three new studies (GREENBERG1998, GOLDMAN2006 and WATSON2003) that met the inclusion criteria were found in the update search. … Two studies, GREENBER1998 and GOLDMAN2006, are not listed in Table 52 given that these compare two different types of counselling.

Page 222-23:

The comparison of counselling versus CBT was included in one study (WATSON2003). There is insufficient evidence (only one small-sized study with wide CIs [=Confidence Intervals]) to reach any certain conclusion about the relative effectiveness of these two treatments (for BDI [=Beck Depression Inventory] scores post-treatment: SMD [=Standardized Mean Difference] 0.04; 95% CI -0.38, 0.47)…

Two studies, GREENBERG1998 and GOLDMAN2006, compared two different types of counselling (therefore are not included in the tables above). GREENBERG1998 examined the effectiveness of client-centered counselling versus process-experiential counselling. The evidence indicates that there was no significant difference between treatments in reduction of self-reported depression scores (SMD 0.13; 95% CI, -0.57, 0.82). GOLDMAN2006 compared client-centered counselling with emotion-focused counselling. The results favoured emotioned-focused therapy (BDI scores: SMD 0.64; 95% CI -0.02, 1.29). These two studies are small in size and therefore results should be interpreted with caution.

In addition to the limited data available for counselling interpretation of the results is complicated by the different models of counselling adopted in the studies. For example, Bedi2000 and Ward2000 follow a Rogerian client-centred model of counselling, Simpson2003 a psychodynamic model whereas the studies by WATSON2003, GREENBERG1998 and GOLDMAN2006 adopt a process-experiential/emotion-focused model which is compared in the latter two trials to the client-centred model of Rogers.

It is difficult to know what to say about this dismissal of the evidence for EFT with depression. The three RCTs were certainly enough to get EFT added to the list of empirically supported therapies in the United States, but here in the UK the NICE review committee has written it off as a form of generic counselling! The criticism of the different models of counselling in the last paragraph is particularly annoying because of course the NICE reviewers created the problem by lumping these therapies together in the first place.

I wrote the following back to Les:

I commented on an earlier version of this draft and supplied information on three RCTs on EFT for depression. I note that this revision appears to have been done hastily by throwing EFT in with a miscellaneous collection of studies of counselling. No other therapy for depression appears to have suffered this sort of indiscriminate treatment; the EFT RCTs are dismissed as involving small samples, even though this criticism has not been lodged against comparable CBT studies. … Having spoken with various people associated with the NICE work on this guideline, I can verify that it [the revised NICE Depression Guideline] is conceptually and empirically sloppy; [therefore,] the Danish Reference Program should not follow this. For example, they [NICE] do not distinguish different kinds of counselling and even include psychodynamic counselling along with EFT under the same heading. It is clear that the committee that did this work was dominated by CBT and psychopharmacology supporters, who do not really care to understand what humanistic therapy is or the nuances between different forms of either counselling or humanistic therapy.

I have two further comments at this point:

1. The Mental Health Providers Forum, a consortium of 60 mental health charities (including both counselling services and service user advocacy groups), has set in motion a process to investigate the process by which these and other NICE guidelines have been constructed and to develop alternatives. I have been invited onto the Scientific Committee of the Mental Health Providers Forum, a task force of psychotherapy and mental health services researchers led by Michael Barkham. We had our first meeting 10 days ago, the day before the New Savoy conference, and will be looking at the science end of things. But it’s now clear that science isn’t going to be enough here: The cavalier treatment of the EFT evidence makes it clear that the NICE review committee is perfectly capable of changing the rules on the evidence to suit the conclusions that they have already decided on. Scientific evidence is critical here, but so is political action!

2. Ironically, the end result of this biased review process is that counselling -- now explicitly including Person-Centred counselling and Emotion-focused Therapy – is nevertheless “in the NICE guidelines”. For example, in his speech at the New Savoy conference the Health Minister simply referred to treatment “recommended by NICE” without specifying what the level of the recommendation was, then referred to counselling as one of the treatments that now need more emphasis. Doubly ironically, UKCP’s Humanistic and Integrative Psychotherapy brand, which they have gone to great pains to distinguish from counselling, is not included.

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