Podcast – Does therapy do you good?

The audio for this podcast can be found here.

Hello my name is John McGowan and welcome to Discussions in Tunbridge Wells, the Salomons podcast.  I am joined by what I hope will be our regular panel, Anne Cooke, Angela Gilchrist and Rachel Terry.  And today we are also joined by our colleague, Fergal Jones, also a Clinical Psychologist and a reader in research at the Salomons Centre.

Some of you know we are based in Kent in the UK and some of the core business of our centre is training clinical psychologists and cognitive behavioural therapists.  We also do a lot of work in health settings.  It’s clear that we are very concerned not only with psychological thinking and theories but also with psychological therapies.  What we are going to discuss today really is: are these things any good, are they of any value?  I suppose that’s my first question to the panel, does Psychotherapy, the talking cure, as Freud referred to it, does it do you any good?

Anne speaking:

Well I guess the question for me is who judges that and there is all this kind of therapy outcome research which seems to imply that there is somehow some kind of way to measure how useful it is but I think that begs a lot of questions and it also positions therapy as very much akin to a pill, something that you can say, ok it is this, we are going to deliver this and we are going to see whether it’s effective in reducing this and that symptom and of course under that is a whole load of assumptions, whereas to me essentially therapy is a conversation between two people. One person is there with the purpose of helping the other person and that person is the one who is in the best position to know whether that conversation is helping them, what they want out of the conversation, how it needs to be changed if it isn’t being very helpful. So it’s very different to a pill.

Angela speaking:

I think one of the biggest problems really is assessing psychotherapy outcome in medical terms. Outcome seems to be primarily interested in reduction of so-called symptoms and that’s only one possible outcome of psychotherapy and until we can get it out of that mode I think a lot of the evidence base is built on sand really. 

Rachel speaking:

But we were coming from a starting point where there was a very limited evidence base and I think that was a problem because we need to be as therapists offering things that we know have been helpful to people in the past so we do need to be looking to some sort of outcomes but I think we also need to be more aware of how sometimes simplistic the evidence base is and how problematic it is.  At the same point we don’t want to discount evidence because we do want to be trying to offer interventions that can be helpful based on some knowledge.

Angela speaking:

Absolutely, I think evidence is very important but I think it’s how we gather and think about that evidence that we need to put under more scrutiny.  I think we are far too focused on looking at therapy by brand as well, when we say for example that cognitive behavioural therapy is effective for depression what do we really mean by that because cognitive behavioural therapy consists of many different strings; it’s cognitive re-structuring, it’s all the different ingredients that make up so-called CBT and I think we need to be looking more at what are the change processes that help people rather than looking at therapy in specific brands.

Anne speaking:

Yes because it lumps it all together. A brand is a whole load of things put together.

Fergal speaking:

Probably more of us would agree that there are limitations from the outcome research but perhaps I feel more positively about the work that for example NICE collates because I do think it makes a powerful difference to people’s lives, that’s not to say it’s not limited but NICE guidance about what helps on average in relation to depression or various anxiety conditions or PTSD has led those sort of talking therapies to be more available to people in distress and I think there’s reasonable evidence that it has helped people’s lives. So I am cautious about knocking the value of that too much and I would agree there are a lot of assumptions and limitations to it. It is often about the groups and on average we can say that something is different to something else but often we can’t say what it is about a particular therapy that makes a difference, it may well be different things for different people and I think there’s also questions about how does therapy that’s done in trials generalise or not what we offer in clinical practice.  Nevertheless I still think that body of research is useful. 

John speaking:

Could you say something more about that Fergal, just the notion that what we are actually looking at within a trial, why that might or might not be applicable to a wider population.

Fergal speaking:

I guess one of the issues is the circumstances in which a trial is conducted compared with the circumstances in which therapy is offered and I guess it comes back a bit to what Anne was saying about it being different from a pill so with a drugs trial with a pill you can I guess be more sure that the pill that’s offered in the trial is the same or very similar to what’s offered in clinic, in the NHS or wherever.  With psychotherapy of course that’s different, we have therapists who are offering it to them and one of the critiques of trials that is sometimes made is that the people, the participants in the trials may have lesser severity and less comorbidity in the randomised control trials than in clinical practice.  There is some actual debate about that and I’m not sure how true that is because in the United States for example I think some people who are not on health insurance or who have limited access to psychological therapy seek that through trials so actually sometimes the complexity may be greater in trials but I think when there is a problem is that often the training the therapists have, the number of sessions they can offer, the amount of supervision that they have is probably in general not as good in clinical practice as in the trials.  So even if we accept all the assumptions that they’re based on, aspects can always be critiqued.

 

 

Anne speaking:

Do you think there’s a problem with how evidence is used in practice, the idea of evidence, because I’ve certainly had people come to me who’ve said that they have been told that when they felt that what they needed was a particular thing, a particular kind of conversation, they’d been told, no, that’s not evidence-based and I think what people forget is that evidence does tell us something, it tells us about what works on average for people, it doesn’t actually tell us anything about what’s going to work for that person and I think sometimes it can lead us not to be sufficiently humble as therapists, we think we know that because there’s this thing called evidence we think we know what will help that person and of course we don’t.  We just know what on average has helped other people.  All we can do is offer things and if people think it might possibly help then we can try it out with them but that’s not sometimes how evidence is used in practice and of course evidence is used to inform what money is spent on various services and some things just aren’t available because there are no NICE guidelines.

John speaking:

Surely we have to be humble in front of that kind of evidence, you know, I’ve got a particular therapy and I want to say this is good, I want it to be in NICE guidelines, I feel it’s good, I feel I’m doing good work but I do a trial on it and it turns out it’s no better than nothing. Surely I have to be humble in front of that kind of evidence.

Anne speaking:

Yes, you mean so the trial has shown that on average people did as well with nothing as with your therapy?

John speaking:

Yes, no matter how great I feel about my therapy I have to, you know..…

Angela speaking:

I think we do have to be humble, we do have to be concerned with evidence, because otherwise any of us could say that anything is going to be okay, for example, eat more bananas and that will fix your depression or whatever.  So I think we do need to be humble in the face of evidence but I think we also need to bear in mind that there is a large body of work now which suggests that something like 40% of the variants in psychotherapy outcome can be attributed to extra therapeutic factors.  So that’s not techniques, not what the therapist is bringing but all the extras, the unknown quotient of the relationship, things like hope, things like what the client expects, their motivation, things that happen outside of the room but happen to impinge on the process.

John speaking:

I think that’s a really interesting point because in many ways the way therapies get traction and get ahead is by being branded. So you have, you know, cognitive behaviour therapy is obviously the most popular therapy at the moment and probably the dominant model.  Now, we can find research that suggests that on average that does a lot better than nothing for a range of presentations but this is a question that’s often in my mind, how do we know what bits of it are doing good, how do we know it’s actually CBT, how do we know it’s not the tone of our voice or something like that, how do we know whether it’s a challenge to the evidence for your belief?  Randomised control trials are brilliant ways of answering certain sorts of questions but it seems to me that it’s more cumbersome; I’m thinking, partly, how do we tease out which is the bit that is having the effect?

Fergal speaking:

I think it’s hard but you can use research design sometimes if there’s a substantial bit that you can remove from a therapy and look at that independently but even that is complicated and often I think the difficulty is probably different components interact and it will be tracked differently for different people so I would tend to agree that an RCT is probably not going to provide you with all the answers in relation to that and I guess for me the most convincing evidence is when we have convergent evidence from different types of research, when you have experience of working with people and it seems to be helped when the people you are working with, that it’s making a difference to their lives.  I think where the difficulty comes is when there’s some kind of disagreement and I guess everything has its limitations so I agree with the idea of respecting what the people you work with seem to be finding helpful but also I have some experiences in relation to randomised control trials where there seems to be something that people are saying stuff that the therapists feel is helping but at the end of it when you look at the dates and measuring the things that people think made a difference they are no different to the control group.

Rachel speaking:

But that might mean we aren’t measuring the right things.  As we said before, measures tend to be symptom specific whereas perhaps they should be more about, are people’s goals being met? Are the goals that people came in with being met, because the goals might not always be symptom specific or they may not be one disorder specific whereas the outcomes might be.

Fergal speaking:

For sure and I think in the examples I was thinking of, though, it was in relation to the specific problem so our individual perceptions of what might be most helpful for us or as therapists again are limited so I think ideally it’s about how to converge bits of evidence and at least where that tends to agree then I guess we can draw stronger conclusions.

Angela speaking:

I think it is important for the public to know or to think about the idea that anything that can potentially help can also potentially harm and the public on the whole does seem to think that therapy is a very benign process, that you just go and talk to somebody and no harm can possibly come from that and we know actually that this isn’t necessarily true, that some people report getting worse as a result of therapy and we are not always sure why that is.  We are also not altogether sure how to define getting worse because we know that some people’s symptoms are going to escalate during the course of therapy as they come more into touch with feelings, more into touch with suppressed emotions and so on, but I do worry a bit when people have a very casual approach to therapy, let’s try it, you know, it can’t do any harm, that isn’t always true and there are some people who perhaps shouldn’t be referred for therapy in certain instances.  I know that’s going to be a controversial statement but I’m thinking if only six sessions are available and somebody has very complex trauma, say, you could do far more harm by opening it up as opposed to just giving somebody social support if you haven’t got enough sessions to do a really good job with that person.

Anne speaking:

But aren’t you arguing against having restrictions on the type of conversation that you can have and how long you can have those conversations for rather than arguing against the possibility of a set of conversations being helpful to that person at all.

Angela speaking:

I’m arguing for caution. We can’t categorically say that therapy is going to be helpful in every case.

Anne speaking:

No, absolutely, but isn’t that the converse of saying we have to watch about being harmful because both of them depend on suspension of judgement, you know, because one person is seen as an expert we as the public think well they ought to know what they are doing and that as a client the danger is I’d go to a therapist and I’d think well it’s making me feel worse but she’s an expert, she knows what she’s doing and I suspend my normal judgement that I would have, well, when I talk to that person it doesn’t make me feel better so perhaps you need to have a different conversation or I need to talk to somebody else.

John speaking:

Well this is something that I wanted to bring up.  There are a couple of things to it and I think you raised a very important point Angela.  And you also pick up on something about it Anne which is about length of time. What about the way we offer these things, do we offer for example people long enough engagements to be effective within the NHS?  The issue I was thinking of is that around the time that the increasing access to psychological therapies initiative came along, there was a review that was much cited by somebody called Drew Western and colleagues and they said, well actually all our evidence suggests that based around a 16 to 20 session model of therapies, no matter what your model, actually that’s not enough for a gain and actually in the NHS we regularly offer considerably less than that.  Now, it’s not enough for a sustained gain, you’re getting a gain but it’s not enough for a sustained gain on however adequate or otherwise you think that the outcome measures are.  I suppose the other issue that’s floating around in my mind is about harm, you know, about negative effects with therapy, not just it not being enough but you raised the issue of how do we know when there is potential for harm and maybe that’s not something we think about enough.  We talk about it plenty when drugs are involved.

Angela speaking:

Yes, I think that’s true, we don’t talk enough about the potential harms really.  My mind goes back to critical incident debriefing prior to some research which suggested that it shouldn’t be offered unless people began to show frank systems of PTSD and that was very controversial when I worked in South Africa a lot where there’s a huge amount of trauma and critical incident debriefing was used a lot and this research caused enormous controversy.  People couldn’t believe it actually, why shouldn’t we offer this, and despite the research some people still wanted to offer it, saying it definitely would help. It’s interesting how people can get very invested in a certain mode of being and in offering certain things despite what the research says. Now that can be very dicey I think.

Fergal speaking:

I agree and I read some of the NICE guidance in relation to PTSD before this podcast and it’s one of the things that’s in there that it’s not recommended as a general form of provision, some kind of immediate debriefing in the first few days after a trauma and I guess maybe moving away slightly from this specific point, but this is where some of the value for me is in that sort of randomised control trial and then reviews by NICE, is that it gives us at least some kind of overall sense of things that may or may not be more or less helpful and where to best resource this but I think a key thing in NICE guidance and in other things is there’s a sense of this is not the final answer, this is something to inform judgements that we make and also I think clients should make as well.  Now, I’d agree as well that I don’t think we look enough at the possibility of harm but I think it’s very difficult to know what’s caused that because there could be many things that cause that and if someone deteriorates in the course of therapy then they may have deteriorated as a result of the therapy or perhaps less than would otherwise have been the case if they hadn’t had it.

Anne speaking:

In terms of harm caused by therapy there’s also the wider issue of potential harm caused by the ubiquity of therapy in society so there’s huge horrible things going on everywhere and yet the answer that gets trotted out is let’s send people off to IAPT for six sessions of CBT or whatever as if that addressed the problem and the danger is that that takes our eye off the ball in the sense that we just look at life as a series of individual casualties to be fixed by some kind of technical fix rather than looking at the very real suffering that things like austerity for example cause.

Rachel speaking:

One of our trainees here has just done her research about service users that deteriorate on outcome measures through therapy and one of the things that she found is that sometimes that’s because things are happening in their life outside of the therapy that are making it very hard for them and very distressing and therefore it is hard to make progress or improve, if you want to use that expression in therapy, when they are living in poverty or they have got housing situations so I think that very much is a reality out there, it’s hard for people to have therapy in those kinds of   circumstances.

John speaking:

It’s tricky, isn’t it? I was interested in that, and again we have online versions of that that we can link to if people are interested, but I was struck by that just to the extent which actually theories of how therapy has a negative effect, research isn’t terribly well evolved in that area and at some level I was thinking there was more on that and this idea that you are not necessarily offering therapy in adverse circumstances is kind of a tricky one because societally that’s when we offer therapy to people or we seek therapy ourselves, if our circumstances are adverse, though of course it may not necessarily change some very concrete realities.

 

Rachel speaking:

It’s interesting the comparison with drug treatments again because if one medication doesn’t work we try another and that’s fine but I think with therapy, if one therapy doesn’t work someone’s more likely to write off therapy rather than trying a different therapist or a different approach.

Fergal speaking:

Also it feels like there’s a difference between something not working and something actively causing harm and I guess I think from my point of view I want to say as well, to give some kind of balance, I think, at least the evidence suggests and in my experience in clinical services, therapy can for a lot of people be helpful too so it’s not to say that at times it can’t be unhelpful but I wouldn’t want people listening to this who didn’t know much about therapy going away and actually feeling some significant anxiety around this being quite a risky thing to take part in.

Angela speaking:

I think the evidence has shown quite clearly that it probably helps most people and they have a lot of evidence as well that most of the work is often done within the first eight sessions which is interesting.

Anne speaking:

And the other thing is we don’t have to take it on trust. I think if you go into therapy with the idea that this is something that I’m going to do with the therapist and together we’re going to try to tease apart what might have caused my problems, what might be keeping them going, what maybe I could try and do about it and it’s good to have somebody to talk to and then judge yourself whether that’s happening, that’s very different from taking it on trust, a bit like you have to do with a pill or indeed a pile of bananas or something else that somebody tells you this will be good for you and I think if we go into it with that attitude it’s very different, taking the whole expert thing out of it. 

John speaking:

Yes, much of it does seem to rest on what people can bring to it and their own readiness and it does make me wonder sometimes about the degree to which consent can genuinely be informed for the endeavour that you’re about to embark on and where it can take you, and how there are degrees of meaningful consent but you don’t really know where you’re going.

Rachel speaking:

I would say one of the strengths of clinical psychology as a profession is that we try to draw on ideas from a range of different models and theories and work with the service user to think about what would be the best approach for them but I guess the downside of that is that there’s therefore not necessarily a clear evidence base for the individual work with that individual client when you are drawing on a range of ideas.

 

 

Anne speaking:

Yes, we don’t market what we do as a brand of ‘this thing that we do to people’ and the downside of that is it’s then very difficult to demonstrate how helpful we are but I suppose I would agree with you that that’s what we can bring and it’s very very important to bring a range of resources that we can use that are ideas that are helpful, we don’t have to provide to somebody the package but we can draw on them as we go on as and when they’re helpful.

John speaking:

Well that of course is relatively contentious as well, as some would argue. I am thinking of Lord Layard I suppose there, the economist at the London School of Economics, who was partly responsible for an influx of funding I think into psychological therapies, that we should actually be offering things in a consistent model-specific way and not just flying by the seat of our pants, or clinical judgement as we might say it less pejoratively.

Anne speaking:

It’s not quite by the seat of our pants, it’s offering individualised collaboratively drawn up intervention.

John speaking:

That’s your version of it.

Anne speaking:

It is my version of it and I’m sticking to it!

Fergal speaking:

Even a manualized treatment is individualised and collaborative so I think it is probably a question of degree and I think that the question that Angela alluded to earlier is a really interesting one about what’s important.  So there’s this body of evidence about common factors, like the therapeutic relationship, and there’s another body of evidence that looks at things in a different way about specific approaches for specific conditions and they both have evidence behind them and there’s, I guess, some disagreement here that some of the CBT literature suggests that changes in therapeutic relationship follow changes in symptoms and I think one of the challenges is that these are complex human and social behaviours so it may well be this complex interaction that we need some kind of special level of therapeutic relationship for something to work with but then beyond that changes in therapeutic relationships follow changes in outcome for example.

Anne speaking:

It’s a complex interactive dance!

Fergal speaking:

It is and the other thing is the large scale experimental studies are very expensive to do so actually there could be lots of interesting studies that we might want to do to look at some of these questions but to run a randomised control trial costs hundreds of thousands of pounds and resources are very limited so one of the challenges, while evidence can be helpful, is we are always not going to have as much evidence as we’d like.

Angela speaking:

Surely RCT’s aren’t always the best way of thinking about therapy, they’ll tell us that there has been an effect but surely we need more experiential phenomenal logical research as well which tells us about people’s experiences of therapy, what they found helpful and what they didn’t because it is after all a human interaction, it’s not a pill that we’re talking about.

Fergal speaking:

Absolutely, I’d agree and I think it’s whether you have that convergence of evidence when it’s most convincing. RCT is just one strand of that. I guess for me I wouldn’t want to dump the RCT because I think that some of the different forms of evidence offset the limitations that they each have so I was saying earlier that while in many ways our experience can be a good guide it’s not infallible. It could be something that we might be thinking helps us and not actually the things that help but at the same time we wouldn’t want to ignore people’s experiences. It’s when we have differences between the evidence I think that’s more challenging to try and understand that.

John speaking:

The point that you raised about a complex human interaction got me thinking about a piece we published on our blog a few months ago by Leigh Emery who’s an old trainee here and Hugh Green, who some of you have encountered who I think was a qualified clinical psychologist now living in America, and they were wanting to have a look at what happens when, well the peg they hung it on was a mindfulness colouring book and was this in some way representative of a dilution of ideas so we just assume that a certain aspect of CBT or mindfulness is just going to work even if we disentangle it from that human interaction and in some way they were pointing to evidence of decreasing effectiveness for things associated with CBT and wondering in some ways why we weren’t calling that out a little bit more like the way some people working in neuropsychology do, where it’s a real point of honour to call out dilutions or diminutions or things of this sort and things that distort evidence and perhaps sometimes purveyors of psychological therapies aren’t actually gutsy enough to do that, they are too keen to just have it accepted, up there with medication or whatever, rather than calling BS on it, you know dilutions of it, the mindfulness colouring book became symbolic of that, I think.

Rachel speaking:

I am quite concerned about the weakening of CBT. I think these days what is called CBT can have massively huge variation and the training of CBT therapists can have massive variation as well so a member of the public can go to an Increasing Access to Psychological Therapy service for example and believe that they are getting CBT when actually they’re getting some support and intervention but from somebody that has had very limited training but that might be perceived in the same way as having CBT therapy with a therapist that has done lots and lots of in depth training and it’s a very different intervention that they’re receiving and I’m quite concerned about the reputation of CBT moving forward when lots of different things are being blanketed under the CBT umbrella when actually it’s very different interventions that are being offered.

John speaking:

A real person might be better than an interactive CD or something

Anne speaking:

Or a mindfulness colouring book!

John speaking:

Or a mindfulness colouring book.  Well, that’s possibly symbolic of what can go wrong with the endeavour of psychotherapy.  I think we will draw to a close there. 

The best way to follow the podcast is to subscribe. You can do that on iTunes, by searching for Discussions in Tunbridge Wells. Also you can find links to some of the things that we’ve talked about on our blog, Discursive of Tunbridge Wells.  As well as that you can follow us on Twitter at CCCUapppsy or on Facebook if you look for Canterbury Christchurch University Applied Psychology and we’ll be putting links to some of the things we’ve talked about, and the Twitter accounts of some of our panel in the show notes.

So thank you very much and I hope you’ll tune in again.