The task of drafting psychodynamic/psychoanalytic competencies was given by Skills for Health to Tony Roth and Steve Pilling, employees in the UCL Sub_Department of Clinical Health Psychology run by Peter Fonagy. Fonagy chairs the Executive Group and the Strategy Group of the SfH project and also sits on the Reference Group. These researchers, aside from having the link to Fonagy, are known for their work on CBT, a set of therapies which are totally at odds with psychoanalysis. It is extraordinary that the work was given to them rather than to one of the many university departments of psychoanalysis in the UK. It raises the question of how the UCL department managed to secure this contract.
This bias is continued in the composition of the project Expert Reference Group and the Modality Working Group, both of which are chaired by Anthony Bateman. Bateman is a colleague of Fonagy and the two have co-authored a treatment manual for a form of therapy (MBT) which they endeavour to promote within the NHS. Fonagy is Director of the Anna Freud Centre, which holds courses on MBT in conjunction with the UCL Sub-Department of Clinical Health Psychology. These courses are held for those working in the NHS and generate revenue for the institution concerned. There is thus a clear line of economic benefit here. It is no accident that the competencies produced for psychodynamic/psychoanalytic therapy fit MBT remarkably well, but not psychoanalytic work.
The composition of the Expert Reference Group and the Modality Working Group is biased quite radically in favour of Fonagy and Bateman’s orientation, with nearly all of the members coming from their grouping, the British Psychoanalytic Council (BPC). We believe that some BPC groups failed to inform their members of developments in the consultation process, with a handful of those on the relevant committees making claims for their membership without proper consultation. It is remarkable how nearly everyone involved in the SfH working groups either comes from BPC or the Fonagy UCL Department.
In September 2007 the UCL department apparently sent out a letter inviting participation in the expert reference group for psychodynamic therapy, yet this letter was not received by any psychotherapy organisation that we aware of. It stated that the general framework would be that used for CBT, a fact which would have caused a great deal of protest in the profession had it been known.
The methodology of the work is stated as “identifying manuals published in the UK, the US and elsewhere and building the framework from these sources”. This would also have caused a great deal of protest in the field for the simple reason that there are no manuals of psychoanalysis, a fact which Fonagy himself points out in a minuted SfH meeting of 11/4/08. On 5/2/08, Roth and Pilling claim to have sourced “the psychoanalytic treatment manuals” for the criteria they have formulated, yet in the list supplied by them in May there are no psychoanalytic texts at all.
The documents supplied by SfH under the Freedom of Information Act, and others, indicate the effort to push through a political agenda without fair or proper representation for the interest groups in the field. This fact was pointed out to SfH several times, yet with practically no real action taken, apart from going back to Fonagy, Bateman and one of their colleagues. On a number of occasions, SfH promised action which did not subsequently take place. Information supplied by Fonagy seems to have been taken as unquestionable, a fact which caused serious problems when the information was false, as was the case regarding the College of Psychoanalysts, and potentially bringing the profession into disrepute, as was the case regarding his comments on Lacan.
When the College asked for further documents from SfH regarding exclusions from the consultation process re psychoanalytic work, SfH eventually sent a bundle of almost totally irrelevant documents regarding the constitution of the groups dealing with Cognitive Behavioural Therapy. They then claimed that they had spent the budget that requests under the Freedom of Information Act allows for. In the bundle, more than 100 pages were duplicates of the same irrelevant emails. This is a clear example of bad faith, and we believe that one letter sent by SfH was falsified. It would have been the only letter they ever sent just by post (never arriving) when all correspondence is also received in email form, and subsequent correspondence would have clearly contradicted the contents of this letter, had it existed.
The reliability and truthfulness of SfH is seriously put in question by their response to Steven Richards, Chair of the British Society for Clinical Psychophysiology, who contacted SfH on 18.10.07 requesting involvement in the cognitive and psychodynamic work groups. Linda Hardy of SfH writes to Rod Holland on 25.10.07, that “We need not have him on the group if you are not happy I’ll rely on your superior knowledge of the therapies here!”. This illustrates SfH’s failure to do their work properly, leaving the process open to political maneouvering. Holland writes that Richard’s school of therapy “is at variance with most concepts of CBT”, yet SfH do not assess this claim or even object to the exclusion of a diverse practice. Hardy’s reliance on others is shown again in her email to Marc Lyall of 19.10.07, where she writes re Fonagy “I sort of feel I don’t want to ask him everything”. Regarding Richards, Hardy writes to him on 29.10.07, “I contacted the chair of the group with your information and he feels that at this stage, with numbers on the group nearing capacity we really need to give the remaining few places to NHS employed practitioners as they are really underrepresented on the groups”. In fact, it is because, as she writes to Marc Lyall two hours earlier on the same day, “Rod does not want this guy on the group…However I’m not sure what to say back to him it’s difficult when we invite people to show an interest and then tell them they can’t join a group…I could say we are now seeking more NHS employed practitioners as they are under represented on the groups? [sic]”. A further and similar exchange follows re his involvement in another group.
This is typical of the SfH process. Consultation is supposed to respect and recognise diversity, yet in the end is controlled by a small number of people with their own agendas. There follows some further examples of problems with the consultation process.
On 1/10/07 Marc Lyall from SfH writes to Anthony Bateman asking him if he will chair the ‘Psychodynamic Reference Group’ when he has already been made chair in September by the UCL team of Roth-Piling. It appears that the Roth-Pilling decisions are just implemented by Lyall.
On 10/10/07 Marc Lyall emails Bateman, Fonagy and Alderdice the list of group members of the Psychodynamic Modality Group for them to review. Then on 16/10/07 the membership list is established. The list is of 11 people, all of whom come from the one and the same political grouping! (Institute of Psychoanalysis/BPC).
On 9/1/08 Marc Lyall of SfH writes to Bateman that “I am finding out which of the names…were nominated by UKCP and BACP..”. yet how could he not have known if he was in charge of this part of the process? It suggests that he just left it to Bateman, Fonagy and their team.
UKCP write to Lyall on 20/1/08 questioning the composition of the working groups, yet this letter is not included in the documents SfH supply, nor is the response to this and the other relevant correspondence regarding the response. They point out the bias and political interest grouping that has taken over the project despite initial assurances of equality and transparency, and request further representation and democratic procedure. These documents just disappear.
On 23/1/08 Lyall writes to Julia Carne that he has asked UKCP for nominations. He states that “Any list that you have seen..will be a list of nominations and does not represent the final membership of the group”. Yet already in November 2007, we can read in SfH documents: “Here is the membership list for the group”.
On 25/1/08 Lyall writes to Darian Leader; “I am of course aware that the list circulated is not representative of the organisations present within the field, something that we are looking to address”. It is crucial, he writes, that the modality group “represents a cross section of the field” and that the list “has not been through the appropriate membership approval procedures”.
25/1/08 Julia Carne’s name is now on the list of the psychodynamic psychotherapy working group. Of the 20 people in the group listed here, 15 are from the same political grouping. Julia Carne’s name then vanishes.
On 17/2/08 Lyall emails Fonagy to query the involvement of the College of Psychoanalysts and the Psychoanalytic Consortium. He wants to run the group list by Fonagy. Fonagy replies that the College “is a largely Lacanian organisation (French psychoanalyst Lacan interllectual superhero but clinical and ethical problem, ultimately dismissed from the rank of the international psychoanalytic movement) with a mixture of other sub-groups and about 200 members belonging to the UKCP. It has to be represented because they are very vocal”. He then states that Lyall has already “appointed 2 members of the College of Psychoanalysts to the Working group (Atkinson and Barratt) it [sic] think this is more than enough. The Psychoanalytic Consortium and Jason Wright are the same group under a different name…They are deeply opposed to and concerned about regulation. They do not have the same training standards as the British Psychoanalytic Council but would require regulation. …They are very much against evidence based practice and might try to sabotage the process”.
In fact, Fonagy could hardly have been unaware that Atkinson and Barratt were UKCP reps and not College reps. Lyall was also aware of this, as noted in a UKCP letter to him of 20/1/08, not included in the documents supplied by SfH. Re the Consortium, The Consortium is a separate grouping to the College. Fonagy says that the list “goes slightly too far in the direction of UKCP”. However, in the list circulated a few days later, there are 2 UKCP reps out of 16 people, with 11 from BPC! UKCP, moreover, had pointed out to Lyall in Jan 08 that it represented the majority of psychoanalytic practitioners in the UK.
On 22/2/08 Lyall writes to the College of Psychoanalysts that SfH have not chosen a “democratic” path, yet that the College will have 2 places in the working group. The College does not receive an invitation to the subsequent meetings of the working group.
19/3/08 Julia Carne and Darian Leader from the College meet with Marc Lyall and Nadine Singh. They explain the politics of the analytic world, the distribution of analysts and emphasise yet again that the Fonagy-UCL group is not representative of the different analytic groups and orientations in the UK and that it does not speak for the majority of practitioners. They explain the debates around the question of evidence in psychotherapy, and send copies of articles and a bibliography requested by Lyall. They give him information about university departments and the BIOS centre at LSE where work critical of the UCL grouping takes place. The notes from this meeting are written up by Lyall and he confirms here and in a letter of 20/3/08 that representatives of the College will be invited to join the Modality Working Group and that “these will be formally addressed by the Project Strategy Group at its next meeting”.
Lyall asks in this letter; “Could you confirm what, if any, further action is reasonable for the Strategy Group to consider to remove the element of bias in the project…”, yet then no further action is taken. The College is excluded from meetings. On 3/4/08 Lyall writes to the College; “...I will get back to [sic] as soon as possible on the points you have made and the information you have provided.” Yet no further correspondence ensues.
The membership of the Psychoanalytic/Psychodynamic Expert Reference Group was set by 9/10/07 and, after all the apparent debate and assurances to achieve fair representation, it had exactly the same members in May 08!
Steve Richards of the BSCP is mentioned in the above documents, and adjacent to this eIpnosis had been in touch with him for a couple of years about the downside of state regulation. His organization found itself excluded from the UKCP and later from the SfH NOS process and a FIA disclosure request revealed the following SfH decision process re his application. Steve Richards follows it with some comments on the SfH NOS process:
Taken from an e-mail from Linda Hardy to Marc Lyall: sent on 29.10.07
"Rod does not want this guy on the group saying that he has checked the background and he doesn't seem to understand CBT!
However I'm not sure what to say back to him - it's difficult when we invite people to show an interest and then tell them they can't joina group! Should I say something like the group's (he wants to join two -the psychodynamic too however Rod says that he probably wants to promote himself more than anything else as he has set himself up. I could say that we are now seeking more NHS employed practitioners as they are underrepresented on the groups?"
This judgement about my wanting to promote myself more than anything else, is deeply offensive and wholly untrue. It comes from people who have never met me, or even spoken to me on the phone. As for self-promotion, given that I've been in the wilderness for years as far as the likes of UKCP et al are concerned, and that I do not make my living from psychotherapy, that simply doesn't hold any credibility at all. I work as an author and publisher under a pen name.
The cover story re the NHS is laughable as I worked front line in the NHS for over ten years, and applied my school of therapy there. I have also trained healthcare profssionals who continue to practice with my approach. I was a pioneer in applying clinical respiratory psychophysiology to psychological 'conditions' presenting in primary care and presented a paper on this at XIIth International Symposium on Respiratory Psychophysiology at the Wellcome Centre in London in September 1993 detailing the use of this method with 500 NHS patients.
As for not understanding CBT that's almost as amusing as it is insulting. I was 'trained' in CBT techniques in 1990-1991 by a member organisation of UKCP who were pushing its application in hypnotherapy.There is nothing at all intellectually challenging about cognitivism -hence its utility in a setting like the NHS. On my website I make my position very clear about it, which is perhaps why Holland reacts the way that he does. Rather than, the problem is that I most likely understand it (CBT) 'too well.' I mention CBT's positive applications on the website, but I do also point out some of the historical background within the analytic traditions that could have made the development of CBT unnecessary - particularly Jung's theory ofassociative learning and 'complexes' - as organised, potentially independently functioning psychological systems, held together by a common affect charge. I maintain and would in person to Rob Holland,that CBT is psycho-reductive, and that it lacks Jung's appreciation of physiology - which he himself was at pains to point out, going even so far as to say that complexes have a (dissociated) physiology of their own. His use of word association tests with GSR, pneumographs etc was groundbreaking, and we have continued that by introducing the application of respiratory psychophysiology - using a clinical capnograph - a mass spectrometer to monitor changes in end-tidal partial pressure of CO2 in response to cognitive and imagery challenges. CO2 dis-regulation is widely recognised as either a concomittant of physical symptoms such as hypertension, asthma, irritable bowel and coronary arterial spasm etc or even as a directly precipitating cause. Its role in acute psychotic episodes was identified in 1968 by Allen and Agus in the USA and its also well known in panic attacks, phobia's and, now, as an indicator both of neurosis and even of 'defence mechanisms'.
The reducing dose-effect curve noted in CBT is due simply to it being based wholly upon suggestion. Any suggestion based therapy will have the same short-term efficacy - and it may be enough, but often it is not. This has been true since even before the proto 'cognitive therapist' Paul Dubois (1904) and his 'Rational-Therapy'. CBT's main weakness here is that it is suggestion without a trance state - in contrast to hypnotherapy, which in my NHS experience is far superior to CBT as a 'technique.'
Holland et all seem to be proprietorial about a 'brand' (CBT) rather than a function - clinically efficaious short-term cost-effective focal therapy. I've maintained and still do that a psychoanalytic/psychodynamic approach based on Jung's complex theory coupled with psychophysiology will clinically out perform CBT in an NHS setting. That perhaps is my 'sin'?
SfH’s credibility might be thought to be dependent on whether or not you have time for taxonomies that attempt to centralize knowledge and practice in ways that support centralized audit and control. Yes we know this is in pursuit of an ‘evidence base’ of ‘effectiveness’ but relative to the fields of human experience and despite their global, pharma-driven brandings, research such as rcts and meta analyses derived exclusively from research on people (and as we see below, textual reviews of others’ texts), is bound to be narrow and local. Its discourse is technical, category-obsessed, expertise-heavy, and literally dis-‘embodied’.
The quality of life, the lived values that go into the making of such taxonomies as the NOS for psychotherapy and counselling can be a better indicator of their credibility and worth. Unusually, a very detailed account of several of the phases of the development of current instances of NOS has come available in the blog written by Professor of Counselling, Robert Elliot of the Counselling Unit at the University of Strathclyde, Glasgow, Scotland. As an essential part of this review, eIpnosis excerpts three sections from Professor Elliot’s blog. Values congruence does not seem to a high, or indeed any priority, for this or other key participants in Skills for Health counselling and psychotherapy NOS development.
29 January 2008
Tony began to brief us on the whole project and the methods that he and Steve have adopted for carrying it out.
Their method is an interesting one from the perspective of psychotherapy research, and basically one that would never fly as a change process research method in the Society for Psychotherapy Research or its journal Psychotherapy Research: They collect examples of the therapy they are studying based on a set of criteria (the last of which Steve claimed to have invented on the spot today): (a) the approach has one or more Randomized Clinical Trials associated with it; (b) it has a written treatment manual; and (c) it is based on a coherent theory. Based on this list, they then collect the associated treatment manuals, often by getting the developer to recommend or provide them. After that, they pay someone to plow through a large pile of therapy manuals for 6 or more months, collecting descriptions of treatment competencies. The intersting thing is that this is really what most North American therapy researchers are now calling change principles (cf. Castonguay & Beutler, 2005). So in SPR terms this is change principle research on therapy manuals, which isn't the same as actual change process research.
The questionable part of this is that simple presence of a competency/principle in the treatment manual of therapy supported by RCT evidence is taken as prima facia evidence of its effectiveness (i.e., an inference is made that it is a change process). What is really annoying and goes against 50 years of psychotherapy research science -- is that no direct evidence of the effectiveness of a therapeutic element (such as process-outcome correlations or helpful factors research) is given this status as a starting point. (I can almost hear Hans Strupp turning over in his grave.) We went around on this point for at least half an hour, with Steve invoking a metaphor of frogs vs. bicycles. That is, you can take a part a bicycle and put it back together again without harming it (actually a questionable assumption if you were my brother Willy as a kid), but you can’t do this to the poor frog (at some point Steve indicated that he was speaking from experience). It’s a bit difficult to know how to respond when CBT folks start invoking holism… what is the poor humanist to do, launch into a defense of atomism?
In any case, it soon became clear that they had the money and were in love with the rules of the game they had invented. For all we could say, they were still going to pay the piper to play “We will rock you” if that’s what they wanted.
Eventually, when this had gone on long enough, I remarked that we were going in circles. I proposed that since the treatment manual criterion was going to let in all sorts of things that weren’t necessarily justified, it nevertheless would make for a good starting point, simply because it is so broad. Then, I said, we could use the other evidence, process-outcome, helpful factors to modify the RCT-manual-based competencies. That way all the evidence would come in along the way. There was a moment of stunned silence, then all agreed and we went on to the next issue without further discussion.
Actually, the trickiest thing we had to handle today was finding the proper name for what the review was going to encompass. Fortunately, “Humanistic and Integrative had already gone out the window at the National Reference Group meeting last week, in favour of “Humanistic with a focus on Client-Centred.” We all agreed that sticking with humanistic was going to let us in for a load of trouble with a lot of different special interest groups, so gradually over the course of the discussion, Mick and I persuaded the others to go with “Person-Centred/Experiential”. Mick came up with a really helpful concentric circles formulation: Person-centred in the middle; then person-centred/experiential (including Process-experiential); then the broader humanistic including bioenergetics, transpersonal, psychodrama etc. We agreed that person-centred by itself is too narrow, while humanistic is too much to take on; however, following the Goldilocks principle, Person-Centred/Experiential is just right for the exercise. The issue of whether Gestalt would be in or out was left open for now, in part depending on some initial scoping. Given our initial fears, this felt like a major accomplishment, and left me feeling deeply grateful for all the hard work the World Association had done in formulating its scope.
Now, we have a job of work to do: (a) nominating additional individuals to make up the Expert Reference Group for PCE therapies; (b) proposing exemplars of PCE therapies that meet their criteria; (c) identifying therapy manuals for these; (d) identifying a knowledgeable, skilled person to do the extracting of competencies/principles from the manuals. And mainly hanging in with the process as it goes forward, and doing our best to keep it on the tracks.
Expert Reference Group on HPCEs, Meeting, 9 June 2008
When last we met, the Expert Reference Group (ERG) on Humanistic-Person-Centred- Experiential (HPCE) therapy competencies, it was to pass judgement on the scoping document that Beth Freire and I had put together from our in-progress-but-we-hope-soon-to- be-completed meta-analysis of PCE outcome research. As I wrote in my blog entry about that meeting (see entry 30 March 2008, posted in early April), I found this to be a somewhat painful experience, but ended up feeling relieved that anything had survived the cutting process. In any event, it was enough to provide Andy Hill and Alison Brettle a basis for beginning the process of reading therapy manuals and extracting competencies (or what others would call “therapy change principles”).
Move the clock forward 2 months to today, and you would have found our intrepid E[xpert]R[eference]G[roup] sitting around the rectangle of tables in room 544 of the Sub-department of Clinical Psychology, right next to my old friends Chris and Nancy’s office. You would have heard us nit-picking (or if you prefer, “fine-tooth combing”) Andy and Alison’s (A&A’s) draft framework for the competencies they are identifying. Now it was their turn to feel they were under the knife for some unwanted surgery, as the rest of us worked through their framework (really an outline), one node at a time.
I was more than 90 minutes late, owing to a signal failure at Nuneaton.) I slipped in next to Mick, and was immediately confronted with another document from the HIPS (Humanistic and Integrative Psychotherapies Section) of the UKCP (UK Council of Psychotherapies), this time asking that we Cease and Desist in order to give them time to marshal evidence that might persuade us to include wider range of therapies in our remit. […].
The next order of business was the overall headline summary competence, what we call the core category in qualitative research. For example, the CBT framework has, “Ability to implement CBT using a collaborative approach”, and the Psychodynamic one offers, "Ability to maintain an analytic attitude". Alison and Andy had proposed, “Ability to facilitate experiential processing”. This was essentially a quote from Greenberg, Rice & Elliott (1993), so I knew it would never fly.
Like the CBT […] and psychodynamic frameworks, the HPCE one has five columns:
I. Generic Therapeutic Competencies: These are shared with the other frameworks, but are languaged somewhat differently. Thus, “ability to deal with emotional content of sessions” (CBT) became “ability to work therapeutically with the emotional content of sessions” (HPCE).
II. Basic HPCE Competencies: After further discussion, these ended up being divided into two main sections: (1) Knowledge of the principles underlying HPCE therapy; (2) Initiate, develop and conclude the therapeutic relationship. These two sections have further subheadings. The therapeutic relationship section has two kinds of subheadings: (a) ability to draw on who one is as a person in order to facilitate therapy; and (b) ability to facilitate the relationship in various ways.
III. Specific HPCE Methods: We had a very interesting discussion about what to call the specific ways in which therapists carry out the basic HPCE competencies. Tony seemed to feel that we were being hypocritical in refusing to call these “techniques”, but we insisted that “techniques” was too mechanistic and would get us all kinds of grief. I pointed out the technically correct term (from a linguistic point of view) is "speech acts", but this didn't help. Finally, Tony asked us to think of a synonym (I think he meant euphemism) for “technique”. Oh, that’s easy, we said, and rattled off several, with “method” being the odds-on favourite. This section is still a bit of a mess and will need A&A’s wordsmithing, but we did manage to get in some generic versions of PE-EFT tasks, like “Ability to appropriately use therapeutic enactments”. This latter is code for chair work and related Gestalt/psychodrama kinds of things; Tony, who is understandably somewhat allergic to our jargon (as we are to his), put scare quotes around “therapeutic enactments.”
IV. Specific HPCE Adaptations: This is where PE-EFT ended up, after it was shoved out of column III, in a little black hole of its own. Right now, PE-EFT is the only thing in this column. (Don’t blame me; the chainsaw did it…) We will just have to do our best to hold the space open until more folks come along with the requisite combination of evidence and theory around specific approaches or client problems. At the moment, there is a pretty good view down the valley…
V. Meta-competencies: Competencies about the use and application of competencies, some generic, others specific to HPCE. This is where the framework brings in the “integrative” that the “humanistic and integrative” folks are worried about losing. Look: You have your own column!
This took us most of the afternoon, but Tony did save some time at the end for discussing the latest UKCP petition, hoping that all present would have seen for themselves by that point that the whole process, however many scientific and political warts, was capable of producing a pretty decent frog, with the specific competency of hopping over the various objections, both large and small, principled and paranoid. It was a pretty good argument, actually, because the emerging framework does look like an excellent next step.
However, some of us (including me) were not totally convinced by this means-justifies- the-ends argument, and the discussion will go on. Vanja spoke calmly and in a matter-of-fact manner of the unhappiness, anger and fear of some of her colleagues in UKCP, and their concerns about lack of transparency in the HPCE ERG process. Several things will in fact come from their intervention, all of them potentially useful:
1. UKCP are being encouraged to take their philosophy of science concerns to the scientific steering committee for the competencies project, which is the correct venue for many of the issues raised.
2. In addition, they have now assembled a list of RCT studies, working off the references for Beth and my meta-analysis, and adding their own. I will take these back to Beth, and we will see how many of the additional studies we are missing; we will then explore whether and how it might be feasible to incorporate these into our meta-analysis.
3. In the meantime, Tony and Steve and I will meet to look again at the research evidence. Gestalt therapy and psychodrama are still missing in action, along with EFT for trauma/emotional injury, in spite of substantial bodies of research, theory and clinical practice. It would be a crying shame to miss them out, and I think the whole project would suffer both scientifically and politically. The biggest problem with much of the research literatures on these approaches is that they are such as mish-mash of different client populations and different kinds of evidence that it is difficult to conclude anything from them without doing a meta-analysis, which is beyond the scope of the present project. However, with a little help form our friends in UKCP-HIPS and FEPTO (the psychodrama trainers organization with whom I’ve become involved), we may be able pull something out of the swamp, perhaps even a couple of bull frogs.
2. Steady progress on the competency framework. Thanks to Alison and Andy’s efforts, the HPCE competence framework is continuing to shape up. The overall, top-level framework, a one-page summary overview chart, looks to me to be in good shape, and the detailed list underneath it is progressing. We spent most of our time going over sections of the latter, trying to flesh it out more concretely, paying particular attention to theory-knowledge competence, which required spelling out what the essential elements of the theory are, and elements of the relational competence. For example, how do you describe what the therapist does to foster “collaborative contact”? Should “presence” be developed as a competence beyond or in addition to the three facilitative conditions? These discussions have been stimulating, fun, collaborative and illuminating.
3. Continued Scoping: Steve and I reported back to the group the results of our continued attempts to scope out data that might warrant including Gestalt and Psychodrama. Back in July, I made another attempt to pull something out of the Gestalt and Psychodrama literatures, which was the basis for a teleconference among Tony, Steve and I. Alas, our efforts were in vain; we are unable to find more than a single decent RCT for one client group for either of these approaches, and for now Gestalt and Psychodrama will continue to languish in the margins of the competence process, as what I am going to refer to below as Ghost Entries.
4. UKCP’s Dilemma: A Modest Proposal. Because of my aversion to flying within the UK, I again arrived 90 minutes into our latest meeting. I had missed a difficult discussion between Vanja Orlans, who again had been saddled with the thankless task of conveying to the group a Bill of Complaint from UKCP. Representatives of the latter had had another meeting with Lord Alderdice and Peter Fonagy, from my point of view trying to accomplish with lobbying what they didn’t have the data to support. By the time I got there, the difficult discussion was done and it was almost time for lunch. I felt somewhat guilty for having missed the experience, but also relieved. However, I did not entirely escape the controversy: Tony gave me a summary, and at the end of the day Vanja stayed on for a bit after, and she, Tony and I went over some of the arguments again. Vanja was frustrated with me for not having been there in the morning to support her position, but the problem was that I had by now gone over to the Dark Side and was prepared offer qualified support for the HPCE ERG project, warts and all.
I have very mixed feelings about the series of complaints that UKCP has lodged against the HPCE ERG process since it began. My very first impression was that they had been caught trying to pull a fast one at the very beginning, having persuaded the Skills for Health folks that Humanistic and Integrative Psychotherapy was a meaningful, conceptually coherent theoretical orientation on the same order as CBT or Psychodynamic psychotherapy. This struck me then and continues to strike me today as an attempt to dress up, in nice scientific and professional clothing, a political compromise by which a collection of humanistic and various other therapists banded together to increase their clout.
Historically, as I now understand it, a body of training, practice and philosophy has by now grown up around this compromise, and I have been impressed by the position that Vanja has put forward. Nevertheless, there are several problems with integrative psychotherapy as a basis for a competency framework: (1) The list of therapies involved is a long and variegated one (which includes Process-Experiential/Emotion-Focused Therapy as well as Cognitive Analytic Therapy), with little in common except that they don’t fit anywhere else. (2) The research basis for this group of therapies is fairly poor, so that it provides little grist for the ERG process Steve and Tony have set up. Even if Steve and Tony’s inclusion rules were relaxed somewhat, there still wouldn’t be much. (3) Unlike PE-EFT, this approach to integrative therapy runs beyond the confines of humanistic therapy, to psychodynamic approaches in particular; so it really cuts across theoretical modalities, creating an inherent difficulty for a modality-based competency approach, and threatening to break the process even if it were to be tried.
But where does this leave us? As I have come to understand it, what Vanja and her colleagues at Metanoia are trying to do with their formulation of a personalized integration approach is admirable, makes sense, and is a Good Thing. I did the same thing at the University of Toledo, but certainly without as much intellectual rigor: The idea is that each student should, through a careful, self-reflective process, develop their own personal integration, building on systematic exposure to multiple theoretical modalities. However, this doesn’t make sense to me as a basis for a competency framework; in fact, given the assumptions of the approach, it should be impossible, or at least seriously unwise, to do so.
Instead, if you are going to integrate humanistic with other therapies, the thing to do is to use multiple competence frameworks from which to draw one’s personal integration. When they are completed, the various competence frameworks now being developed will provide a valuable tool for this process. The ERG competence process is the not the enemy of Humanistic and Integrative Psychotherapy (HIPS), but its helpmate. In fact, this appears to be exactly what Lord Alderdice and Peter Fonagy have recommended to them. Let UKCP’s HIPS section proclaim superiority by owning all the frameworks!
5. Ghost Entries: More Modest Proposals. As noted, Focusing, Pre-therapy, Gestalt and Psychodrama all fall within the HPCE camp, but because of their lack of RCTs (or even, I would say, RCT-equivalents) and therapy manuals, they remain the equivalent of Brown Dwarfs in the evidence-based therapy firmament, their Dark Matter exerting a strong gravitational force, without the visibility they desire. In the emerging HPCE competence framework, they are the Ghost Entries in the Specific HPCE Adaptations column: their proper place is alongside PE-EFT, currently the sole visible inhabitant of that region of the framework.
Given that the Ghost Entries belong in the framework but currently lack the evidence base to qualify formally, what should they do? I have two suggestions:
(1) Jump-starting research. First, they need to start doing systematic, well-designed, focused research on key client populations. Below, I use Pre-therapy as an example of what I’m talking about. It is important to recognize the possibility that some of the ghost therapies are not going to turn out to be as effective for particular client groups as they might have hoped. The psychotherapy field of full of treatments that people swore worked but turned out not to really be effective, at least not without significant further adaptation.
(2) Open-Sourcing the ERG Process. Second, rather than bemoaning their exclusion from the competence framework, they should go ahead and actually create their own Ghost Entries for the framework (or if you prefer a more political metaphor, they should create shadow cabinets). That is, they should use the methods that Alison and Andy are using to generate the Specific HPCE Adaptation competences for Process-Experiential Therapy. Actually, these haven’t been done yet, but they will be in the next couple of months, but once they are drafted, they will provide a template for other specific adaptations, like Psychodrama, Gestalt, etc, to use. These Ghost or Shadow Competence HPCE Adaptation modules can be offered as a supplement to the official HPCE framework, and can also be used to support research, as in my first suggestion.
6. How to get Pre-Therapy on the Map. Every meeting, Catherine Clarke, our caregiver member, makes an impassioned plea for the inclusion of Pre-therapy. Pre-therapy, developed by Gary Prouty for work with clients who are out of contact because of a psychotic process, is another of our highly-promising Ghost Entries and one whose practice is spreading rapidly in the UK, but is presently excluded because it lacks a strong research base. Catherine has seen how effective Pre-therapy was for her son, and also how ineffective other approaches have been; she is also aware of the harm being done by over-medicating people living with psychotic processes, so she takes the omission of Pre-therapy personally. Every meeting we listen to her, and I say that the Pre-therapy folks need to start doing more research, but somehow this isn’t enough. […]
Robert Elliot a professor of Counselling Theory and an unelected member of the Expert Reference Group for the production of NOS for counselling and psychotherapy, and author of this blog is also it would seem, a High Master of values incongruence.
Complacent? Arrogant? Self-satisfied...? Anything else?
These extracts from his blog demonstrate how the Skills For Health NOS taxonomists under contract to the DoH and housed in the NHS Trust in Bristol handle the psychological therapies. They display an astonishing picture of raw positional power, as though they were colonial powers dividing up Africa. I include them here at length partly for reasons of historical record and partly as evidence of the style of discourse used in the combine-harvesting of the psychological therapies.
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Messages from Taxonomist Heaven
Ethical distortion and values incongruence in the Skills for Health National Occupational Standards for Counselling and Psychotherapy Development Process