Why might Jeremy Corbyn be doing so well? A person-centred view and an authentic politics

Hello, it’s been a while since I wrote an entry to the blog. Pressure of work and the demand of finishing one or two projects have meant I simply haven’t had the time required to keep up with writing for the blog. Apologies to those of you that I never replied to when you emailed and asked what’s been going on and where were the blogs – I’m amazed at the capacity for writing some bloggers seem to have that manage to keep a steady trickle of blogs over a period of years; perhaps I need to learn something from them about pacing my life to fit it all in.

Talking of pace of life…how must Jeremy Corbyn be feeling right now? Exhausted I’m sure! Over the last weeks and months he’s been giving countless talks at rallies and hustings and Q&A sessions. I’ve decided to write this quick blog to share a few thoughts about my take on why he might be doing so well in this election race and is now looking like he will be elected the next Leader of the Labour Party. I went to the rally at Derby Roundhouse last weekend to see him for myself. I was impressed, not so much by the policies, they are after all pretty much standard Labour policies that New Labour abandonned. What  I was more struck by was that he really is just as he seems to be when he’s on the television or on the radio. This had been what I suspected and to be honest had hoped. It made me think that people are not necessarily coming back to Labour because of something mysterious; they are coming back because they can see, in Corbyn, a clear, consistent, transparent message being delivered by someone that ‘believes’ the message himself. What we see in Corbyn is an authentic person living in accord with his beliefs and values. His politics are congruent with his person.

It is clear from Corbyn’s policies that he values the freedom and right to self-determination of the individual; their right to be themselves and to fulfill their potential. No matter what their race, gender, sexuality, age, whether disabled or able bodied each person is an equal. He believes in the power and wisdom of the group, the collective, and that the way to release the potential in the group comes about through the empowerment and liberation of individuals, in the trust they will set to work for the development of the group as a whole. He believes in people and their constructive capabilities, he believes in dialogue as a means to bring about change and he has an unwavering desire to engage with all sides of a conflict, and towards the development of a better society and world.

Now, I guess that many involved in politics would say that they too aspire to these values; so why does Corbyn seem to have garnered the support of the majoirty of party members and the wider public so quickly?  One explanation might be that Corbyn has been able to be himself; he is being authentic in all of the things he is saying. He knows himself and what he believes in. He has a hsitory of being authentic and standing by his values and principles even when it will have been dificult for him to do so. He has defied external control when he has needed to vote by concsience. He knows what he believes in and so far he has been able to act in a way that is consistent with these beliefs. He does not wriggle out of questions needing to avoid saying something that will upset others, he says what he believes and what he believes in seems to be resonanting with hundreds of thousands of people sympathetic to Labour and socialist values. He has clear principles that run through his politics and his person.

There is no doubt challenging times lie ahead for Jeremy Corbyn if he does get elected as leader. However, It seems that the power of authenticity is being released through Corbyn and he really does offer a new hope for an ‘authentic politics’ to emerge.

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Psychotherapy, ontology and therapist positioning: why simplistic integrationist approaches don’t work

In this post I explore some thoughts about the idea of ‘ontology’ and how this affects a therapist’s approach to working with their clients. I think this is an important underlying feature to our therapeutic work. I am going to suggest that all therapists have an ontological position from which they practice. This may be either implicit or explicit to their personal theory and philosophy for practice. It is helpful to try and understand your ontological positioning because as a therapist there are consequences for practice. One reason that I think ontology is becoming increasingly important is the current trend in psychotherapy towards integrationist and pluralist approaches to therapy. It is in some of these that I think the issue of ontology holds particular concern. I will argue that it is not possible to integrate therapeutic approaches at the ontological level. And because of this the approach taken to integration at the theoretical and practice levels have to be very carefully thought through.

So far this year I have examined two doctoral students through viva voce. One was a PhD and the other a PsychD. Both passed with only minor corrections. In each of the viva voce exams I asked the candidate to give an outline account of their ontological position for understanding psychological distress within the thesis. That is, I invited each of them to present in the viva their view on the nature of being a human and the suffering they encounter. This question is one that, I believe, lies at the heart of being a psychotherapist. What we believe about people, their basic nature and make-up, is the foundation upon which psychotherapy theories are based. However, I am not sure that all psychotherapists give this issue much thought and nor do I think that enough psychotherapy training demands students to develop a clearly defined understanding of their ontological position. The consequence of a poorly understood or vaguely defined ontological position as a therapist is that their practice is based on something that is not known to them and therefore the basis of their approach cannot be known to their clients.

So what are some of the different ontological positions that underpin psychotherapy? There are three main schools of psychology that we can easily link to each of the major schools of psychotherapy. First, there is analytic psychology that’s linked to Freud’s psychoanalysis. Next there is behavioural psychology that is linked to behaviour therapy. Third, there is humanistic psychology that is linked to humanistic/experiential psychotherapies. From within each of these there are many variations of how the therapy can be practiced. Therapies linked with a school of psychology naturally share more in common with other therapies from within that school, both in theory and in the way they are practiced, than with those others from other schools. For example, Freudian analysis and attachment therapies both fall under the analytic school and thereby share more in common with each other than either would share with person-centred therapy that comes under humanistic psychology. The reason for these major differences are important and relate to the ontological standpoints that each of the major schools of psychotherapy are based upon.

In the following paragraphs I outline the three ontological perspectives, as I see them, and relate these to each of the different schools of psychology and psychotherapy that have been outlined above. Following this, I point to some of the potential difficulties that arise when therapy is practiced in a way that is inconsistent with the ontological standpoint of the therapist. This is particularly evident when therapists try to ‘mix it up’ in a bid to match therapeutic strategies to their client’s problems, as the therapist sees it, when in fact this creates an incongruence between ontology and theory and practice.

Humanistic ontology
In the 1940s and 50s American psychologist Carl Rogers outlined his view on the basic nature of a human being. Rogers was a humanistic psychologist and together with other significant psychologists of his time, such as Kurt Goldstein and Abraham Maslow, he claimed that human beings are basically (ontologically) prosocial. In addition to this, they suggested that given the right socio-environmental conditions, the intrinsic nature of a person was to grow in a socially constructive direction. The logical conclusion of this viewpoint is that people can be trusted to grow in a constructive direction if the socio-environmental conditions are right. This is the ontological standpoint for what are known as the humanistic-experiential psychotherapies. Consequently, humanistic-experiential therapists trust their clients’ inner resourcefulness and therapy aims to promote clients’ innate tendencies for growth and recovery. They do not assume to know what is best for their clients, or how their clients should think or feel, and neither do they believe that clients need to be controlled or regulated by external forces.

Psychoanalytic ontology
The psychoanalytic position is very different and suggests that people are inherently destructive. If not controlled or regulated, people are believed to be unable to control their instincts and will behave in ways that will cause harm to either themselves or to others. The destructive nature of a person is understood by way of innate drives that need to be controlled through the moderating effect of the personality (ego). The innate destructiveness of a person is unknown to them as their impulses are unconscious. The practice of psychotherapy consistent with this requires that the therapist make the client aware of their unconscious impulses. Only the therapist can help them to do this as traditional psychoanalytic theory claimed that clients cannot make their unconscious known to themselves. Therapists help the client to become more aware through interpreting their psychological and behavioural processes. The therapist is the expert on the client’s unconscious world. To support the therapeutic climate required for psychoanalysis the therapist is neutrally distant and maintains an objectivity about the client in a bid to not contaminate the client’s projections with their own experiences, thoughts or feelings. The ontological position of psychotherapy based on analytic psychology is that the nature of a person is destructive.

Behaviourist ontology
The third ontological standpoint can be associated with that of classical behaviourist psychology. The classical behaviourist view is that people are born into the world as a ‘blank slate’, or ‘tabular rasa’ as it is sometimes known. Here it is thought that a person’s nature is basically neutral, neither socially constructive nor socially destructive; a blank canvas onto which everything is imprinted. In this sense the person is thought to be malleable and shaped to become his person through learning and reinforcement from within the environment. Over time, the therapeutic methods derived from this ontological standpoint have been developed to engage the client in therapeutic tasks. Techniques such as behavioural experimentation and reinforcement regimens, both positive and negative are used to help the client unlearn old and learn new behaviours in the world. The therapist is best thought of as someone that does not get personally or emotionally involved in the therapy. The idea that logically follows this approach is the more closely the therapist follows a strict procedure the more effective the therapeutic strategies will be. In the classical behaviourist approach the therapist directs the client to the tasks of therapy and the outcomes for therapy are typically predetermined by dint of the problem being presented.

What I have provided above might be considered a bit provocative and probably over simplistic overview of the main schools of therapy. I’m not a philosopher after all! However, as the accounts above suggest the standpoints for each ontological position are quite distinct. The fact that each therapy is based on a distinct ontological standpoint means that the ensuing therapeutic methods cannot be integrated at the ontological and philosophical level. In brief, humanistic-experiential therapists go with the client’s direction; psychoanalytic therapists appoint themselves the task to make the unconscious conscious to minimise the inherently destructive nature of a client, and behavioural therapists direct clients through reinforcement schedules to relearn their responses to events to repaint a new person on the blank canvas.

Techniques in PCT and client self-determination

This is the second in a short series of blogs about the use of techniques in Person-Centred Therapy. In the first blog (see here http://wp.me/p36NbZ-3r) I considered whether therapists can use techniques and still be Person-Centred. Agreeing with earlier writers on this (such as Barbara Brodley) I concluded that it is possible under certain conditions. Two examples given were when responding to requests directly from the client and when facilitating the client’s process in a way that supports their self determination. It is this second point that I will explore further in this blog.

To understand the issues surrounding the use of techniques for Person-Centred therapists it is probably worth considering a little bit of the history to the development of the approach. As Rogers developed what is now called PCT he first named it ‘Non-directive Therapy’ and did so largely as a way to distinguish it from the two mainly directive approaches around at that time; namely, psychoanalysis and behaviour therapy. The focus on non-directivity was presented as a primary feature of PCT. Interestingly, during those early years the main emphasis was on ‘reflection of feeling’ as the therapist’s primary task. Reflections on feelings were communicated to the client and were based on the therapist’s empathic understanding of the client’s experience. It could be said that by  concentrating on ‘reflection of feeling’ the role of empathy was situated as a technique within this early form of PCT.

As the approach evolved the idea of non-directivity as a ‘behaviour’ expressed through empathic reflections changed and the emphasis became more towards the therapist having a non-directive ‘attitude’. The non-directive attitude is best understood as a stance that the therapist maintains (en)counter to the client. The attitude is one in which the therapist considers the client to be a distinct other, a unique individual. However, in more recent terms, we can pose this as the client and therapist being in relation to one another and the therapist and client impacting each other. They are the relationship. In PCT the impact of the therapist on the client always aims to support client self determination. As Rogers said, it is the client that knows what hurts and in which direction they need to move to grow.

So my point here is that techniques in PCT are for the purpose of supporting client self determination and thereby are consistent with the non-directive attitude. To make this point clearer it can be helpful to consider the work of Barry Grant, a Client-Centred Therapist from Chicago. Grant (1990) has argued for two types of non-directivity. First he proposed that some therapists will ‘use’ a non-directive approach with the intent for the client to grow. This type of non-directivity is where I think students get stuck in their thinking about techniques; holding back from engaging fully with their client and not bringing their whole self (and therapeutic repertoire), can implicitly cajole a client through the approach. Grant argued that this way of being non-directive is ‘instrumental’ and is actually directive  as it has a goal for the client; that is, the client will grow best if the therapist doesn’t direct them in any way.

The second type of non-directivity Grant refers to is ‘principled’ non-directivity.  This type is much more about the stance of the therapist in relation to the client. This type of non-directivity helps create a therapeutic environment into which the client can self direct. As Grant says, this may or may not end in client growth. Principled non-directivity has no agenda for the client. However, as the client’s self determination is paramount the therapist’s task is to support this and therefore we can see how techniques can be present. To intentionally withhold from the client something that can support their self determination in order to maintain a non-directive stance is actually potentially thwarting the client’s actualising process.

From this line of argument it is possible to see how techniques in PCT are consistent with the non-directive attitude and may be present in support of the client’s self determination. Together with my colleague Stephen Joseph we have written about this and how it features in therapy with traumatised clients. See our forthcoming book for a chapter on this topic (http://www.palgrave.com/products/title.aspx?pid=515014).

Can I use techniques and still be Person-Centred?

It’s been a few months since I’ve created enough time to write a blog. A feeling of there being so much to do and not always enough time to do it is something I can relate to my psychotherapy work and also in everyday life. The pressure to complete therapy in as short a time as possible has long been around. However, perhaps more apparent in my work training therapists is the related pressure, and to some extent confusion over, the use of techniques that facilitate change. This is going to be the first of a short series of blogs on the use of technique in Person-Centred Therapy.

Can I use techniques and still be Person-Centred? This is the one question that creates probably as much, if not more, discussion in the counselling training groups that I teach. This is interesting because within some approaches to psychotherapy this question is not  an issue. Some approaches are largely a collection of techniques. A good example of this is cognitive behaviour therapy (CBT). To some extent in CBT the client is being trained to become their own therapist; through the application of techniques the therapist teaches the client how to think and behave differently and learn the techniques to then apply for themselves.  The use of technique here is the core of the approach.

In Person-Centred Therapy (PCT) the trainee therapist is learning a way of being. Training helps to develop self awareness and the goal is to develop  the congruence between direct and symbolised experience. Additionally, for self acceptance or, unconditional positive self regard, as some may know it are also critical for the developing trainee therapist.  So what’s the difference here between the CBT and PCT approach when it comes to the issue of techniques? Well, I think the answer can be related directly to the goals for the their training. In CBT training the goal is to teach the therapist techniques to support the development of functional thoughts and behaviours in their clients. It is about doing to the other person. In PCT the goal is for the trainee therapist to develop congruence and self acceptance to support a particular way of being in relationship with the client.

As a Person-Centred therapist I place an emphasis on experiencing unconditional positive regard and empathic understanding for the client. Anything that gets in the way of this needs to be confronted by me in my supervision. As a therapist I make empathic reflections based on experience of the client’s frame of reference, that is, how the client feels or thinks. Typically, as the therapist I don’t have a view, or at least do not impose my view, on how the client ‘ought to be’. So if as the therapist I am going to use a technique, I’d have to be clear as to the purpose and intention behind the decision to use it.

One way to consider the use of techniques in PCT is that they are present as a response to a request directly from the client. The client might ask the therapist to provide help and assistance with an issue they may be struggling. An example of this might be to request help in relaxing or calming themselves when anxiety feels as though it is overwhelming. Over the years clients have reported to me how they’ve found that in helping them to breathe more steadily, they regain a sense of control over their immediate experiencing, and their thoughts or feelings about being in the world return to being more acceptable to them. Responding to direct requests from client to help them through a relaxation technique does not detract from being a Person-Centred therapist. The response is consistent with and supports their self determination.

Another example of how techniques might present in PCT is through supporting the experiencing and communication of the therapeutic conditions in relationship with the client. From my own practice an example I can think of might be as a response to the client expressing a difficulty in processing an emotion related to a past experience. Sometimes I’ve found that after a trauma or a relationship that has ended clients have the need to process some of their responses to this. They may say ‘if only I could say to them what I really felt’ and I may say to them ‘so if they were here now what is it you’d really want to say to them’. The client may chose to either follow that by expressing their feeling or they may not; there’s no pressure to follow the invitation as it is typically a spontaneous and unconditional response on my part to sensing their attempt to express/process their feeling. I try not to over analyse such spontaneous responses from me to the client. I think this can lead to paralysing myself in the relationship and is partly what trainees are doing when they consider the question of techniques.

I’m pretty sure there are probably many more ways that techniques can be presented in PCT. I’m also pretty sure that other Person-Centred therapists might disagree with what I’ve said above. Either way these are just a few thoughts on addressing the question that seems to come more frequently than others from trainees in many Person-Centred therapy training groups.

Counselling for Depression

Earlier this month I co-facilitated another Counselling for Depression (CfD) training group with my colleague Kate Hayes. The course is aimed at skilled and experienced therapists working in primary care psychological therapy services. Most people attending worked in Improving Access to Psychological Therapies (IAPT) services. This was the third such training that we’ve provided at the University of Nottingham this year to therapists from within the East Midlands.

Counselling for Depression (CfD) is basically Person-Centred Therapy and is approved by the National Institute for Health and Clinical Excellence (NICE). CfD is offered as an alternative to CBT and is a high intensity therapy for depression in IAPT services. The training manual upon which the course is based was developed by the British Association for Counselling and Psychotherapy (BACP) a couple of years ago.  CfD  is based on Person-Centred Therapy. The approach pays particular attention to the important role of emotion, and  processing for people that experience depression.

Since the launch of CfD there has been a lot of controversy around the training. Understandably, for many therapists they feel disgruntled when asked to attend training in CfD. The training has been made mandatory by many NHS Trusts and now Clinical Commissioning Groups (CCGs). Being told one ‘has’ to do something can feel threatening or as though people’s autonomy has been inhibited. I can appreciate this feeling. Think of this. Therapists, some of who have been working for many years in the NHS are required to undertake training in an approach that, for many, they feel they know very well. The scrutiny and exposure can feel difficult and challenging. For others the course offers a chance to encounter more deeply the Person-Centred Approach. For these trainees the model is experienced as something new in that they have trained in an integrative humanistic model that typically paid little attention to the deeply radical epistemology of the Person-Centred Approach. On the positive side the course is paid for by NHS local education training boards and staff are supported by managers to attend. A real investment in the Person-Centred Approach from the NHS – the first time on this scale ever – has to be something to acknowledge, if not celebrate.

For some trainees, the CfD course can be challenging. The lack of exposure to a person-centred training environment (even if a course claims to be person-centred this is no guarantee that’s what people get) it is not clear to trainees why the course is facilitated in a style that supports the development of individual autonomy. It might be confusing  why the facilitators don’t interpret of diagnose the group dynamic. Similarly, some trainees want to be ‘told’ what to do in CfD. They might have come with an expectation that within Person-Centred Therapy the therapist is going to ‘do’ something ‘to’ the client in order to bring about change. Instead, the radical powerful experience of genuine unconditional positive regard and empathic understanding are offered from the nondirective, ethical stance that respects the client’s right to self determination.

CfD is a political statement. Its presence has enabled Person-Centred Therapy to maintain a place within free at the point of access psychological therapy services in the public sector. It offers a credible alternative to CBT as a high intensity therapy for clients. Training is challenging, rigorous and political. Whatever one thinks about the link to a diagnosis such as depression, CfD has been an incisive and strategic move to protect the presence of Person-Centred Therapy in the NHS.

There are a number of Person-Centred organisations that span around the world. Check out some websites for more information:

Association for the Development of the Person-Centered Approach

British Association for the Person-Centred Approach

Centre for the Studies of the Person

World Association for Person-Centered & Experiential Psychotherapy & Counselling

BAPCA Research Group

BAPCA Practice Research Network – 29 June 2013 – Edge Hill University.

 The next meeting of the BAPCA PRN will take place on Saturday 29 June and will be held for the second time at Edge Hill University, Room H242, in the Faculty of Health and Social Care between 11:00 – 16:30 (refreshments will be available at 10:30).

Robert Elliott will be presenting the following:

Big Data and Little Data: Getting the Most We Can out of the Practice-Based Evidence on Person-Centred-Experiential Psychotherapies.

“I propose to offer a mixture of lecture, discussion and consultation considering the complementary roles of Big Data (large n research) and Little Data (systematic case study research) in the development of an evidence base for PCE therapies.  I will start with one kind of Big Data, offering a closer look at some of the more recent results derived from the 2008 PCE meta-analysis data set developed by Beth Freire and me.  I then propose to move on to a discussion of the BAPCA PRN data set and the various possibilities afforded by it, including systematic case study research of interesting cases (Little Data), focused client subpopulation investigations (Middle-Sized Data), and the large n bench-marking and data mining (Big Data).  It is hoped that a good time will be had by all.”

There will be space to discuss the further development of the PRN. There will also be time for people to discuss new research ideas and for the group to share thoughts and feelings from the day.

Refreshments and lunch will be provided for all. Free car parking will be available on the campus: Edge Hill University, St Helens Road, Ormskirk, Lancashire, L39 4QP. You can find downloadable location maps and full directions to the Edge Hill University campus at:

http://www.edgehill.ac.uk/location

In order to plan the refreshments and catering in advance, I’d be grateful if you could let me know if you are able to attend (and if you have any specific dietary requirements, such as vegan/vegetarian):

graham.westwell@edgehill.ac.uk

Another brick in the wall…

Blogging about professionally political issues can be a risky business for a number of reasons (http://tiny.cc/wjpzvw). So I was relieved when, over recent days and weeks, I received some  encouraging messages from people reading the Psychotherapy and everyday life blog. Project IAPT entries seem to be catching the interest of a modest number so they must be  speaking to something that resonates within our community. These messages of support have arrived totally out of the blue or occasionally off the back of other unrelated conversations. It is so heartening to hear from readers. Thank you. But what might it be and why does project IAPT seem to touch on something so  meaningful for so many in our profession? A clue to my take on this is in the title of this post.

Offering a critical voice on any subject can feel risky and I’ve certainly felt that at times publishing these blogs is a risk. It’s risky because I don’t necessarily want to be or get labelled or pidgin holed as some sort of hostile dissenter. Interestingly, it feels more risky now than when Paul McGahey and I published a critically reflective piece on IAPT back in 2008. Back then we shared concern about what might be lost under IAPT. So much of what we discussed then is sadly now coming to be reality. Being a voice that dissents, someone that stands in opposition to a dominant discourse, or offering an alternative perspective in questioning the way things are is not only risky but challenging and sometimes scary too. Professionally, I wonder what might be the repercussions. However, much like the title for this blog implies, there is a need for people to question authority, challenge attempts at power being used over people and against formalising and standardising psychotherapy and our practice and training. Project IAPT has done all of these things and I think that it is this experience, when pointed out, people unite through a sense of injustice and a sort of responsive dissent.

At a recent conference in Leicester I asked some searching questions of those invited to speak on the successes of IAPT. I ended up feeling as though I was being a bit of a thorn in their side…which probably I was. But there’s something more for me to this feeling. Group responses can be very telling. It’s not uncommon for people to set about marring the character of someone when they voice a counter argument rather than actually addressing the argument. We saw this in action within the psychotherapy profession when there was a movement to oppose the statutory regulation of psychotherapists. Rather than addressing the critiques being voiced it was the personalities of the opposers that were focused on and defamed. It’s an effective tool used by the media too and I guess we see it also in politics. Needless to say at the Leicester event I was so pleased (and relieved) that a number of practitioners came to speak to me during the break for coffee. At lunch I had a lovely discussion with a group of PWPs about their work. The discussion was flowing and they shared how my questions spoke precisely to the issues they were discussing and wrestling with in supervision or in their offices but that felt too risky to voice in a public arena. It was obvious they were worried about speaking out and, when the rhetoric is decorated with such strongly positive sentiment about project IAPTs success, trying to voice a counter argument can be very difficult. These people were literally frightened for their jobs and livelihoods! What kind of culture and work environment is that for providing psychological therapy?

With the exception of the Chair of the event, all but one of the speakers gave me an extremely wide birth (or I am just being paranoid). Not only this but I could see people fidgeting when I raised my hand to ask another question or decided to respond to the speaker providing an answer that bore little connection to an initial question. Of course, my fantasy is they wanted to say something like “SHUT UP” but couldn’t or wouldn’t be publicly so authentic. The seeds of self doubt can easily take hold at these moments. I’m inclined to start thinking, is it just me that thinks IAPT is problematic, am I the only fool seeing things this way? Another part of me is quite satisfied being an irritant. I’ve been accused on more than one occasion of ‘dancing on the head of a pin’. Perhaps it’s the narcissistic bit of me that enjoys the detail, the ‘small’ differences often underlying ‘big issues’. But these differences are rarely small in my view. They are so often the very crux of the issue that competing sides don’t want or can’t bear to be revealed. Sure it’s uncomfortable when difficult questions are raised. But without having to answer for the way we do our work, and here I refer to being accountable and not audited a la King and Moutsou (http://tiny.cc/beqzvw) a kind of ‘groupthink’ can set in. What I experience as being uncomfortable when raising difficult issues might also be something of the discomfort and awkwardness that can be felt when groupthink is revealed.

So where’s all this heading? Well, three people have indicated to me, in personal communications, their growing concerns about the way that psychological therapies are being developed through IAPT. Nothing new there some might say but now I’m being told these stories from people that reach across the entire project. Firstly, just a short time ago I had a communication from someone holding quite a significant and senior role in IAPT that openly  expressed a growing disillusionment and concern. Once a staunch supporter and advocate they now expressed serious concern and were questioning whether IAPT is actually doing what it claims to be doing, i.e. ‘improving’ access. Is the IAPT groupthink starting to dissolve? Are people on the inside, and in positions where they can really influence change, starting to see the situation differently?

Improving access to psychological therapies has become something of a ‘slogan’. And as we know most slogans often are shown to have little by way of substance beneath them or at the very least least they tend to bear little resemblance to actual experience. In a second communication a senior therapist shared experiences of working under the the new AQP system, whereby the organisation they were working for, a new commissioned QP contracted for a specialist service arrangement, were being paid, in line with national guidance, a set fee for completed cases. However, the therapist was not being paid anything when the client did not attend for one of their planned sessions. The new commissioning arrangements mean that providers are paid a set fee based on an assessment plus two further sessions and for up to an agreed amount of sessions (usually around 12 for step 3 services).When a client misses a session you might reasonably now question if you’ll be paid for that session, chances are that you won’t. Yet your employer will. Unlike when therapists in the NHS were paid a salary, now they are working to something more akin a production line!

The final communication came from a new trainee for CYP IAPT. I’ve quoted it pretty much in full as it captures something of the CYP IAPT initiaitve unfolding in much the same way as IAPT for adults did. It shows the groupthink of those involved in developing and training and how any kind of critical voice is squashed. This message came from someone currently being trained in CBT preparing to work in one of the new CYP IAPT partnership service.

“I have been reading your Tweets and blog posts with keen interest. I just wanted to get in touch to say, thank you for being a critical voice ‘out there’! Your writings are truly a breath of fresh air from the rhetoric that my CYP-IAPT peers and I are constantly being asked to swallow without question, and you have articulated some concerns that we can’t seem to find ears for. Please continue critiquing!

I work in a CAMHS service whilst also currently undertaking the CYP-IAPT CBT training. On my CYP-IAPT course it is a shame that I have both witnessed and experienced that to question, is to make yourself incredibly unpopular and labelled a ‘troublemaker’. This is a stark contrast from my previous training, where critical voices were encouraged. Willing for us to be uncritical automatons is causing a lot of difficulties for my peers. I find it disconcerting that in my cohort on my CYP-IAPT training, a number of my training peers left within the first term; others are planning on leaving imminently; and others are currently considering their options (as many have jobs tied to the training, and therefore choosing to leave the course could possibly equate to losing one’s job). I have also witnessed frequent tears from my peers related to both the confused delivery of the course (for many reasons), as well as how we are supposed to operate within our services, especially alongside colleagues who very much wish to reject what we trainees represent (i.e. unpopular service redesign). Therefore, trainees unfortunately end up getting squeezed from both sides, and it is nigh on impossible to find anyone in a position of power who will entertain conversations about this. I don’t feel that the experiences of my cohort are an anomaly in the world of CYP-IAPT training. I know of other peers and supervisors who are linked to a different CYP-IAPT collaborative. Our experiences appear to be very similar, and there is a developing sense of having to resign oneself to a position of passive hopelessness.“

Hey teacher! Leave them kids alone…(you know the rest!)

CYP IAPT: making the same mistakes?

When checking the IAPT website, as I do on a daily basis, details inviting new IAPT partnerships for Children and Young People (CYP) providers had been published. If you’re interested follow the link below and you’ll find a number of documents outlining information on how to sign up to the new CYP IAPT venture (http://www.iapt.nhs.uk/downloads/). In this blog I’m going to highlight just a few issues, as I see them,  concentrating mainly on issues of learning from the experience of IAPT with adults; as this is claimed by the authors of the document to be something the CYP IAPT has done (http://www.iapt.nhs.uk/silo/files/cyp-iapt-2013-offer-for-new-partnerships-apr-13.pdf). We know in the field of psychotherapy training that experiential learning is deeper, lasts longer and better enables the transfer of theory into practice; I’ve read the documents and I’m still interested to know precisely where the learning has taken place.

Prior to unpacking a little of the content on the CYP IAPT website let’s remind ourselves of a few of the errors that arose in IAPT for adults (of working age). One of the major criticisms has been that IAPT tied itself to NICE, too rigidly in my view, and that doing so meant a reduction in or, in some areas, complete absence of  choice. That is, investing too heavily in a small range of therapies resulted in losing the diversity of therapies that were once available in primary care psychological therapies services. Some of these therapies are growth oriented and able to respond to the full range of human functioning and needs and not just deficits.

In contrast to needs based services, people would get access to therapy that had been shown to be ‘effective’ based on evidence from RCTs for medicalised problems; people would not get access to a therapy that was supported to work through non RCT based evidence. Thousands of counsellors lost their jobs or had to retrain in a therapy that was supported in the NICE guidelines for depression and anxiety. CYP IAPT is on the verge of doing exactly the same thing. Why? Because the therapies being supported lend themselves to the hierarchy of evidence (which is in serious need of being revised) and not, as we know from adult IAPT, because they are necessarily more effective in routine practice. We’re now going to invest millions of pounds in training staff to do specific type of therapy (CBT) for CYP with depression or anxiety. The furore that followed the arrival of IAPT and its emphasis on CBT for adults has given way to (re)training therapists in the therapy they had already been trained in but now to deliver a form of that same therapy (DIT, CfD, BCTfD) and for which there isn’t as yet any RCT evidence to support them. Instead they are supported by a ‘pick n mix’ approach to the RCT evidence that leads to integrative practice. Something that resembles what was there before IAPT. PEople doing what their clients informed them that worked. So whatever happened to the NICE hierarchy of evidence here then?

Rant alert! This is not to mention the lower than target completion of therapy, poor recovery rates, and a dissatisfied workforce, that followed – make any sense? Of course not!!! So one would hope that later iterations of the IAPT project, extending as it is into CYP, would have learnt from this and done something different. Have they? Well it’s not obvious if they have so they’ve also failed in creating a successful PR campaign and in getting everyone on board. So let’s have a look at what services will be required to do and what they’ll need staff to focus on developing.

To begin its important to note  the positive. The report outlines that the project has been developed in partnership with young people and parents. This is an important feature of any service design and transformation and whilst it isn’t clear how they were involved, or what influence they have actually had over the type of help they will get, it’s still good to know that they have been consulted. The cynic might be inclined to think that this is simply a case of being seen to do the right thing but I’ll reserve  judgement on that until there’s real evidence that’s the case. So the new CYP IAPT project is inviting Child and Mental Health Services (CAMHS) to form partnerships  with existing collaboratives. There are five regional collaboratives set up in the UK that will act as the central hubs for CAMHS partnerships to coalesce around. The learning seems to have been primarily in the sense of transforming organisations. There seems to be an emphasis on partnerships being formed from cooperatives of statutory and charitable sector organisations. In the report this is emphasised as an important issue for CYP and families. Children and young people, in my experience, generally don’t like receiving services from the NHS. Many say they don’t consider themselves as ‘mentally ill’ and don’t see themselves as needing or getting what they need from CAMHS. School counsellors, when of a good quality, are often preferred by young people.

Under the new CYP IAPT it seems that existing staff will be re-trained in CBT, Behaviour Therapy or parenting support programmes. Financial support is in place for back filling staff positions whilst they are away on training courses. There is money to back fill training positions for therapists, supervisors and managers. Universities are involved as  training providers and a curriculum has been developed (http://www.iapt.nhs.uk/silo/files/cyp-iapt-national-curriculum-v6.pdf). If you follow the link above to the document there are some interesting projected costs for implementing CYP IAPT. Services will, like adult IAPT, have to complete a minimum data set and they will be monitored on their compliance with returning full data for 90% of the clients  they see.

So where’s the problem? For me the problem is that CYP IAPT is being tied in to the medicalisation of children. Once again the medical model language of ‘depression’ and ‘anxiety’ are foremost in the documentation. there’s nothing about growth and development, of a spectrum of functioning, of disentangling human distress from the language and discourse of the medical model. There’s no critique or even a hint of reflective process to raise a question or two about whether there might be alternative ways of working with CYP and their families. It’s depressing for anyone that doesn’t have a medical model leaning in their practice and there’s one thing that worries me more than anything, the lack of emphasis on the therapeutic relationship and social support.

Now this might sound a bit extreme but I did a quick search for terms in the curriculum that sets out the skills and knowledge base for prospective CYP IAPT workers.   Searching for the term ‘therapeutic relationship’ turned up a very disappointing, wait for it, single hit! Yes, afraid so. This document is a 20,000 word document detailing the development of services and training therapists for working with CYP and families. Where’s the relationship? A quick change in the use of terminology to ‘therapeutic alliance’ didn’t fare much better either returning only three matches. So why is this important? Well it might be a simplistic view but one of the fundamental issues underlying much of the distress experienced by CYP can be linked to either poor quality or entirely absent good quality relationships in their life. Relational capacity is essential to wellbeing. The emphasis and balance is clearly tipped to a focus on treatments, diagnosis, medicalising CYP and consequently lacks a spirit of care, compassion and relationship. Just the things the NHS has been criticised of needing to develop.

IAPT Workforce Census

I’ve recently been blogging (http://wp.me/36NbZ) about Improving Access to Psychological Therapies (IAPT) as part of a research study and in this particular blog I’m giving a quick overview of the situation for employed therapists. I thought it might be of interest to those both in or out of IAPT circles, and to look into what the future might hold, especially for those seeking work. Being involved in training therapists I’m interested in the possibilities for employment and future prospects for trainees once  qualified.

Several years ago, when the IAPT initiative was first announced, there was understandable excitement about the prospect of enhanced psychological therapy services in primary care. Trained counsellors and psychotherapists working in primary care could have the opportunity to gain reasonably well paid work whilst remaining faithful to the model in which they initially trained. However, then came news that IAPT would be tied to NICE Guidelines and that CBT was going to be the approach; into which millions of pounds would be invested. Of course CBT has received significant support from randomised control trial (RCT) evidence. But does RCT evidence translate to real world settings or can we questions whether CBT really is any more effective than other bona fide therapies when applied in   routine practice? Probably not; yet the questions that were raised regarding the methodological inappropriateness of RCTs for psychological therapy research were ignored and the project rolled out all the same. The sad thing about this is that, despite the initial promise of increased access,  many people actually lost their jobs and access to therapy was restricted to predominantly to CBT. This was the result not because therapists were doing their job badly, or that what they were doing was ineffective, rather they lost their jobs because their particular therapeutic model was not supported by NICE. However, here we are five years on  and it’s interesting to look at the situation with the knowledge from recent history still in view.

The IAPT website  recently published its workforce census report detailing the state of play as of August 2012. This link will take you to the full document (http://tiny.cc/egbevw). There’s some interesting figures to digest although there’s little by way of surprise. Predictably high intensity CBT workers make up the largest proportion of the 5860 workers employed in IAPT services across England that returned the census. Of this number 3870 are either high intensity therapists or working in psychological wellbeing practitioner (PWP) posts. This works out, when broken down further, to 40% of the entire workforce being CBT high intensity workers whilst 33% PWPs.

One noteworthy figure is a shift in the balance for the ratio of PWPs to high intensity workers. Initially, guidance for services setting up back in the early days of IAPT suggested a 60:40 split receptively; this now appears to be a 50:50 PWP:high intensity CBT ratio. What can we take from this? Perhaps the need for more high intensity therapists has increased in response to the steady increase in the severity of distress that is experienced by people being referred into IAPT. We might even expect this ratio to shift even further towards more high intensity workers. As IAPT continues to expand the range of people seen at the primary care level to include those with long term conditions and medically unexplained symptoms the need for high intensity workers is likely to grow. High intensity therapists are more highly trained that PWPs and posses more specialist skills. Other possible reasons for needing more high intensity workers is to cope the lengthy waiting lists that are often characteristic of IAPT services. Once a client is referred into step 3 PWPs become redundant. With more people being stepped up rather tan stepped down high intensity workers are ultimately more in demand.

But what about those therapists that stayed the course and didn’t retrain in CBT? Do they still have jobs and what are the prospects for those training in non CBT approaches? As many of you will be now aware four further therapies have approved by NICE for use in IAPT for depression. These are Counselling for Depression (CfD) based on Person-Centred Therapy, Dynamic interpersonal Therapy (DiT) based on brief psychodynamic therapy, Behavioural Couples Therapy for Depression (BCTfD) and Interpersonal Therapy (IPT). Well, the figures aren’t great but there is some hope. Of the total workforce in IAPT it was reported that 333 (5.7%) workers were trained in and offering these therapies. In addition to this a further 1110 (19%) therapists are working in services but not yet trained in one of the four other ‘approved’ therapies but are probably offering a version of these therapies. This means that, if all of the remaining non-CBT therapists were trained in one of the four approved therapies, that approximately 25% of IAPT staff would be offering approved alternatives to CBT. That’s more than I’d imagined had survived the  cull when IAPT intially began to roll out. It suggests that counsellors and psychotherapists of all orientations have managed to find ways to protect positions and provide choice for clients. Therapists that have managed to do this really have beaten the odds and thank goodness for them! This is something to be really positive about and we need to recognise these workers for their commitment to staying the course in what has been a really difficult period.

So with this good news in mind what else can we expect to see in the future of IAPT? The report also suggested that CBT will continue to receive the greatest investment for training and new posts. However, the report also offers encouragement for commissioners to find more effective ways of training non CBT therapists in one of the four approved modalities. I Tweeted some time ago something like ‘has the CBT bubble finally burst?’ As I encounter more and more IAPT workers, go to more conferences on IAPT and speak to commissioners and managers alike, I get the feeling that IAPT is finally starting to broaden in its scope for increasing access to a range of therapies. There’s still a long way to go before the IAPT project really delivers on its potential. It’s still too tightly tied in to NICE Guidance and I’m sure there’s probably still too many people involved that have too much face to save by really increasing the access to a range of therapies. Those involved at the start got it badly wrong by investing so heavily in CBT. For sure there was a need for more CBT therapists. But there was also a plethora of richly diverse, creative and passionate, not to forgetting effective(!), therapy available. Standardising IAPT through NICE guidance was and remains a mistake.

I don’t particularly like the feeling I get when I have a thought about the possibility of IAPT being where it is because a bunch of the people involved saw IAPT as a crusade for CBT; an opportunity to build a CBT empire and in their manoeuvring crushing all else that stood in the way. From time  to time I still  do get this feeling, however, as time puts distance between the advent of IAPT and the initial CBT onslaught it feels as though, much like our long overdue spring this year, we’re beginning to see the shoots of something new. One final thought, anyone involved in the CYP IAPT, please learn from the grave errors that have been made in the early stages of the Improving Access to Psychological Therapies for adults of ‘working age’! (Yes, that was the original name of the programme!)

Psychotherapy for wellbeing. Or just a return to zero?

Returning to a zero level of functioning 

Although nowadays a range of psychotherapies are available, only a small number have gained the full support and backing of NICE clinical guidelines. Some have partial support and others are yet to gain any explicit support from NICE whatsoever. For example, cognitive behaviour therapy (CBT), Interpersonal Psychotherapy (IPT), Dynamic Interpersonal Therapy, Behavioural Couples Therapy (BCT) and Counselling for Depression (CfD) have all been supported by NICE for depression (http://tiny.cc/jwkwuw).

A helpful metaphor to think about depression, or other states such as wellbeing, is as a continuum representing human functioning. For example, we might assume that on average the base line level of functioning typically experienced by people is located at zero.When the variation of human functioning is normally  distributed within the population zero is in the middle and functioning can be thought to vary along the continuum. At different times and in response to different circumstances people can fluctuate from, say, minus five to plus five . Within this metaphor, the people seeking help for psychological distress through primary care psychological therapies services, such as IAPT, have got stuck somewhere between zero and minus five. Their functioning has become impaired and gives rise to concomitant distress. It is as a result of the distress they have become aware of that drives them to seek help.

But is focussing solely upon the symptoms of distress, at the neglect of other aspects of functioning, the only approach to providing psychotherapeutic help? If so, does this make psychotherapy solely about helping people move back from a position some way below to a baseline of zero? Certainly, if one looks through the manuals for therapies approved by NICE for depression, this would be a logical conclusion to draw. So where, if at all, does wellbeing fit in? And what can the various therapies supported by NICE for depression offer to people by way of wellbeing? One could also ask whether therapies provided in the NHS even ought to be focussing on enhancing wellbeing or whether we should be content with a return to zero. Perhaps therapies that are focused on wellbeing and psychological growth would be better outside of the NHS and not least because of the close association between the NHS approach to psychological therapies with the medical model. These are difficult question to face. I’ve said before  in a previous blog that people’s jobs are at stake when such issues are raised. However, we have to ask ourselves whether skewing therapies to fit with medical model diagnoses will be helpful in the long run.  Or, more importantly, does it actually thwart the progressive fight against medicalisation of the variation on the minus five to plus five continuum of human functioning?

Shifting the focus

Within the CfD manual (http://www.iapt.nhs.uk/workforce/high-intensity/counselling-for-depression/) depression is conceptualised as arising through a notion of self discrepancies. The CfD approach states, following integration of self experiences as a result of successful emotional and cognitive processing, new and more resilient ways of being can emerge. The approach is based on a philosophy of human functioning consistent with this outcome. People often report that following this type of therapy they experience higher levels of functioning. They may be functioning better than they had prior to becoming stuck or blocked and that led up to them seeking therapy in the first place. What can be observed is more than a reduction of symptoms. Instead, psychological growth is achieved and that leads to enhanced wellbeing.

However, this kind of outcome isn’t currently being considered through the IAPT data set. Measures used in the data set focus on a ‘return to zero’ as being the main target for change. This is unfortunate. However, services can of course add their own measures to data collection systems. But without this being an explicit feature within the IAPT  project the medical model remains at the heart of the initiative. A shift in focus at the centre of IAPT could have huge implications, resulting in positive experiences for clients, and for the delivery of services.

Evidencing wellbeing

Shifting the focus in the measures being used as part of an evidence based practice can shift the whole enterprise of therapy. It will have an effect on what the therapist brings to therapy. Stephen Joseph’s recent blog post on car mechanics and gardeners highlights this superbly (http://tiny.cc/jikwuw). Changing the emphasis from diagnosis would also mean the issue of caseness becomes less important. As an alternative, change can be considered through measures that focus on the integration of self experiences and ask questions about living more authentically.

The emphasis in psychological therapies within the NHS need not solely be on the treatment of symptoms. But what can be done to change things? Perhaps small effective changes can be made that collectively would have a significant impact. An easy place to start would be changing the focus in the measures used within a service. This could inspire a shift within the entire spirit in which IAPT services are provided. Improving access to psychological therapies for psychological wellbeing. If you work in an IAPT service why not ask your service lead why there are no measures focusing on growth and psychological development, or, why the only measures you use are symptom/diagnostically focussed. If you are a commissioner reading this, think about requesting providers to include measures that capture growth and enhanced functioning in their data set and monthly returns. Nowhere is this more important when thinking about children and young people’s services. Sadly, however, I think it might be too late for CYP IAPT, which looks set to follow in the mistaken footsteps of the adult IAPT project in medicalising too many young people before they’ve even had a good run at developing their selves.

So, wouldn’t psychotherapy be better off looking towards the development? Or are we to be content with a ‘return to zero’ as the best we dare to aim for?