Transcript Document

Psychological
Therapies in the
Modern Era
Centre for Psychological
Therapies
May 19th 2009
May you live in interesting
times
Historical Developments
Regulation and Training
Practice
Research
1. Historical Developments
A Developing Profession
Roots in Hindu, Buddhist and Islamic
Psychology from 8th Century A.D
 Moral Therapy 18th Century A.D
 Phrenology the study of the shape of the
skull
 Physiognomy—the study of the shape of
the face
 Mesmerism, use of magnets

A Developing Profession








Psychology 1879 Wilhelm Wundt the first laboratory
psychological research in Leipzig
Group therapy for the poor who could not afford 1 to
1 1908
Freud “Talking Cure” 1900s
Clinical psychology in 1917
Counselling Carl Rogers 1940s
Counseling Psychology 1954
CBT 1960s
Now over 400 varieties (Corsini and Wedding, 2008).
Medicalisation of unhappiness or
deviancy



For millennia, masturbation, homosexuality etc were
considered grievous sins and punished accordingly.
End of the 19th C with the onset of modern psychiatry
they started becoming "mental" diseases.
Raised to the level of a psychiatric art form by Baron
Richard von Krafft-Ebing (1840-1902). "Psychopathia
Sexualis” Sexology became an integral part of medicine - renaming sexual sins "cerebral neuroses“.

ECT

Drapetomania

Kleptomania
Medicalisation of unhappiness or
deviancy
Sigmund Freud extended Krafft-Ebing's
psychopathologising to everyday
behaviour.
 In "The Psychopathology of Everyday Life"
(1901), he converted Shakespeare's
interpretation of conflict as an integral
part of life into a manifestation of
psychopathology.

So in the 21st century is unhappiness a
mental illness which can be diagnosed
and treated medically….. Or is it part of
the experience of life?
2. Regulation and Training
HMG
 Health Professions Council
 British Association for Counselling &
Psychotherapy
 United Kingdom Council for Psychotherapy
 Alliance for Counselling and Psychotherapy

HMG Strategy
Skills for Health
 NICE National Institute for Clinical
Excellence
 IAPT Improving Access to Psychological
Therapies
 Health Professions Council

Timeline
HPC Professional Liaison Group: 2 more
meetings
 Public consultation summer/autumn
 HPC report to Government in December
this year
 Legislation 2010
 Act of Parliament 2011

British Association for Counselling
& Psychotherapy
50k therapists
 No controls
 Psychological Professions Council
 The need to protect the public.


Manning signs up as race and
sex counsellor

Monday, 26 February 1996

“To highlight the lack of
regulation for counsellors, the
BBC programme Watchdog
asked Mr Manning to attempt
to join the organisation. He
listed his occupation as
performer and performance
counsellor and for specialities
he put down sexual matters
and racial awareness. He also
claimed to hold an imaginary
diploma in counselling and
sent off the pounds 50 joining
fee. A few days later he was
welcomed into the
organisation, became entitled
to vote at general meetings
and could be listed in its
directories. “
UKCP
Radio 4 Interview 30th May







Recognizes the need to regulate, selfregulation, preferred
Needs to be attuned to relationship paradigm...
not medical competencies etc
Not medical model
Art not science
HPC regulation not in keeping
Different values & Philosophical model
Creative and sometimes spiritual dimension.....
How can that be subjected to regulation ?
HPC Professional Liaison Group
Standards of Proficiency (SoP)
Differentiation between psychotherapists
and counsellors.
 Protected Titles.
 Grandparenting.


http://www.hpcuk.org/aboutus/professionalliaisongroups/psychotherapistscounsellors/
Health Professions Council Public Liaison
Group
29 April 2009
That psychotherapists work with more
complex clients than counsellors.
 That only psychotherapists "critically
evaluate" and counsellors do not.
 That psychotherapists have a more
advanced understanding and use of
research.


http://www.bacp.co.uk/regulation/
HPC & Training
Counselling Honours Degree (and PG)
 Psychotherapy Postgraduate

Current courses to be visited by HPC
 Consideration of non-HE courses

HPC & Training

‘Standards of proficiency’ (SOPs) as
opposed to 'training standards‘
Not Modality based
 Requirements for therapy, hours of
practice, hours of training will not be fixed
by HPC
 Courses to demonstrate how SOPs are
met.

Alliance FOR Counselling and
Psychotherapy Against State Regulation
Medicalisation
 Reducing access to relational therapies
 Reducing client choice
 Protecting the Public Myth
 Human science versus natural science
 Art not Science

Alliance FOR Counselling and
Psychotherapy Against State Regulation
Therapy is not about healthcare. (Approx
33%)
 All current bodies have codes of ethics and
practice, disciplinary procedures etc.

Alliance FOR Counselling and
Psychotherapy Against State Regulation
Brian Thorne:
“To subject therapists to statutory regulation
has about the same incongruity as putting
ballet dancers under the direction of a
regimental sergeant major ….are likely to
emerge at best as stilted robotic puppets
or at worst as crippled casualties with
snapped tendons, their vocational
aspirations in tatters”
Alliance FOR Counselling and
Psychotherapy Against State Regulation
We are involved in a battle which is about
power, freedom , transformational love
and the evolution of the human spirit.
Politics
3. Practice
Improving
Access to Psychological Therapies
(IAPT)
The Improving Access to Psychological
Therapies (IAPT) programme is based
upon the commitments the Government
made in their General Election manifesto
2005. The programme was launched in
May 2007
Improving
Access to Psychological Therapies
(IAPT)
Counselling and psychotherapy more cost-effective way of
relieving anxiety and depression than medication, but
only one type of therapy –CBT – has proved its
effectiveness in Randomised Controlled Trials.
This has divided the profession as modalities such as
psychoanalysis and person-centred counselling – many
of whom work in the NHS – have felt excluded.
IAPT’s choice of modalities is informed by research collated
by the National Institute for Health and Clinical
Excellence (NICE).
Therapy is cheaper
than medication.
 But will one washing
powder suit all ?


Treatment Choice
in Psychological
Therapies and
Counselling




Evidence Based
Clinical Practice Guidelines


depression, including
suicidal behaviour,
anxiety, panic disorder,
social anxiety, phobias,
post traumatic disorders,
eating disorders,
obsessive compulsive
disorders,
personality disorders,
including repetitive self
harm
some somatic complaints
Recommendations

“Effectiveness depends on forming a good
working relationship.

Age, sex, social class or ethnic group should not
determine access to therapy.

Therapies of fewer than eight sessions are
unlikely to be effective. Often 16 sessions are
required for symptomatic relief, and more for
lasting change.”
Recommendations
Severe and complex mental health problems or
personality disorders or co-existing personality
disorders
Patient preference and treatment choice
Interest in self-exploration and capacity to tolerate
frustration in relationships important for success
in psychodynamic therapies.
Recommendations

Psychological therapy should be routinely
considered.

Patients who are adjusting to life events,
illnesses, disabilities or losses.

Post traumatic stress symptoms may be
helped, with most evidence for CBT
Recommendations

Depression

Anxiety disorders

Somatic complaints
Recommendations

Eating disorders

Anorexia

Longer-term treatment of personality
disorders
Evidence

Psychological therapy better than no treatment.

Counselling effectiveness in mixed
anxiety/depression.

CBT has been found helpful. Evidence of efficacy
has been shown for other forms of psychological
therapy.
Evidence

Efficacy of CBT and IPT in bulimia has been
established. Various therapies have shown
benefit in anorexia, with little to distinguish
types. Early onset of anorexia may indicate
family therapy, and later onset, broadly based
individual therapy.

A number of approaches have shown some
success with personality disorders, including
dialectical behaviour therapy, psychoanalytic day
hospital programme and therapeutic
communities.

http://www.dh.gov.uk/en/Publicationsands
tatistics/Publications/PublicationsPolicyAnd
Guidance/DH_4007323
Rebuttals

Mollon, P (2009) The NICE guidelines are
misleading, unscientific, and potentially
impede good psychological care and help.
Psychodynamic Practice,15:1, 9-24.
Improving Access to
 Psychological Therapies

Implementation Plan: National
 guidelines for regional delivery


http://www.dh.gov.uk/en/Publicationsands
tatistics/Publications/PublicationsPolicyAnd
Guidance/DH_083150
Teams of therapists

40 trained therapists per population of
250,000

Therapists as part of a single team, led by
senior therapists.

Team members will need to be qualified in the
therapy they are delivering – anything less
involves risks, since inappropriate therapy can
do harm.
Low-intensity treatment

For depression, a system of stepped care
is recommended. This is described as
low-intensity treatment. This may take
the form of guided self-help (which can be
delivered over the telephone) or brief
face-to-face psychological interventions
(up to seven sessions). It can also include
guided use of computerised CBT
High-intensity treatment

“A person who is severely depressed or
does not respond to low-intensity
treatment needs high-intensity
treatment involving up to 20 therapy
sessions, normally on a face-to-face
basis.”
High-intensity
treatment

“For some anxiety conditions, such as
PTSD, phobia or OCD , patients normally
go straight to high-intensity treatment ( 7
to 14 sessions) Recommended for other
persistent anxiety disorders but guided
self-help (e.g computerised CBT) has been
shown to be effective for some
individuals.”

“Present shortage of therapists is in CBT,
which will be the most widely used
therapy in the new service. Initially,
therefore, IAPT training will focus on CBT.
The focus will broaden as the deficit is
addressed and the NICE guidelines are
reviewed.”
IAPT TRAINING

“Trainees in high-intensity therapy are likely to
be drawn from clinical psychology and
psychotherapy, as well as people with
experience of mental health, such as nurses,
counsellors and other professional groups.

They will need a one year course involving up to
two days a week (equivalent) off-the-job training
in a training institution, with the rest of the week
working in an IAPT service providing therapy
under supervision.”
IAPT TRAINING

“The trainee low-intensity therapists will need a
one-year course involving one day a week
(equivalent) off-site, together with supervised
work handling cases in IAPT services.

It is recommended that people with relevant life
and work experience, as well as psychology
graduates, be encouraged to apply for these
roles.”
Jobs and training

http://www.iapt.nhs.uk/workforce/

Advertisements and recruitment will
begin April 2009 in every Strategic Health
Authority area . Search the latest
vacancies www.jobs.nhs.uk Keyword IAPT
4. Research
Evidence-Based Practice

1999 establishment of the National Institute for
Clinical Excellence (NICE).

To manage NHS expenditure

To provide a rational basis for deciding which
treatments to fund (e.g. which medications to
prescribe).
Randomised Controlled Trials

The ‘gold standard’ of evidence

Based on scientific techniques applied to
treatment and research in medicine

“experimental procedures designed to exclude
the possibility that other variables are
responsible for the observed findings.”

Bower, P. & King, M. (2000). ‘Randomised controlled trials and the evaluation of psychological
therapy,’ in Rowland & Goss, op. cit., p. 80
The fundamental problem with
RCTs:

The requirement to standardise treatments
means trials use manualised treatments. These
have limited applicability to everyday practice.

Treatments are for single diagnoses; they cannot
research co-morbidity, i.e. clients displaying
more than one diagnosis.

Reliability of diagnoses is poor.
The fundamental problem with
RCTs:

The more rigorous a trial is scientifically, the less
generalisable are its findings to real-world
settings.

This is known as the gap, or trade-off, between
internal and external validity, or between
efficacy and effectiveness.
The fundamental problem with
RCTs:
“The type of patient most likely to be
screened out of the RCT is the patient
seen by the typical practicing therapist.”
Persons, J. & Silberschatz, G. (1998). Are Results of Randomized Controlled
Trials Useful for Psychotherapists? Journal of Consulting and Clinical
Psychology, 66 (1), p.129
Problems with RCTs
One Size fits all?
Problems with RCTs
UPDATE: Which model is best?



Major British study carried out in the NHS compared
the outcomes of CBT, person-centred therapy (PCT)
and psychodynamic therapy (PDT). Researchers
compared outcomes of six groups: three treated with
CBT, PCT or PDT only, and three treated with one of
these, plus one additional approach.
All six groups averaged marked improvement.
The results indicate these three treatment approaches,
practised in NHS, were consistent with previous
findings that different approaches have similar
outcomes.
Stiles,WB et al. Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as
practised in UK National Health Service settings. Psychological Medicine. 2006 (36), 555-566.
All are winners and all shall
have prizes
What works in therapy?

In one of a number of major reviews, Wampold
identifies the following factors that affect outcomes:

General effects - common factors that underlie all
psychotherapies: 70 per cent

Specific effects – that is particular aspects linked to a
specific model: 8 per cent.

Unexplained variability – most likely linked to client
differences: 22 per cent.

In other words, the model practised counts for only
8% towards positive outcome in therapy.

Wampold BE. The great psychotherapy debate. New Jersey: Lawrence Erlbaum; 2001.
I will say it again

In other words, the model practised
counts for only 8% towards positive
outcome in therapy.
It isn’t what we SAY we do..

Studies suggest that there is significant
therapist variability within any model.

Even a highly manualised approach, (e.g. forms of
cognitive therapy) is undertaken according to the
inner belief systems of the therapist.

Some practitioners of cognitive therapy could not even
be distinguished from psychodynamic or experiential
therapists.

Malik ML et al. Are all cognitive therapies alike? A comparison of cognitive and non-cognitive therapy process and
implications for the application of empirically supported treatments (ESTs). Journal of Consulting and Clinical
Psychology. 2003; 71, 150–158.
So what works?


“The relationship is the most significant
in-therapy factor as related to positive
outcomes.”
Paul, S and Haugh S (2008) The Relationship not the Therapy? In S Haugh and S
Paul, The Therapeutic Relationship: Perspectives and Themes Ross-on-Wye: PCCS
Books.
"It's the most intimate relationship you'll
ever have with another human being. The
therapist knows their patients better than
anybody else in their lives.“
Caroline Garland Tavistock Clinic, London
Summary
1.
2.
3.
4.
History and Development
Regulation and Training
Practice and IAPT
Research
The professions of counselling and
psychotherapy and the psychological therapies
are indeed at a crossroads in this modern era.
Let us hope indeed that in the years ahead
those looking back on these times will not be
seeing back on rupture and disarray but a time
of transformation and new growth.
We live in interesting times.