Sex positive parenting: a new collaborative blog

This is a brief check-in from me to draw attention to a new collaborative blog I’m involved with. It’s called Sex Positive Parenting. In a dramatic act of doing exactly what it says on the tin, the aim of the blog is to pull together bloggers who are parents trying to bring up their children in a sex positive way. Consequently, the writing so far has managed to be both amusing and provocative in a contactful way.

My first contribution to the project is “what are you having? A baby (boom, boom)…”, in which I start to explore the importance that gets placed on whether an unborn child is male or female.

I’m excited about the long-term possibilities for blogging with Sex Positive Parenting. I find blogging incredibly supportive for my development as a practitioner because the process of writing helps me focus otherwise quite fleeting thoughts into something solid and clear. I’ve been wanting to do something similar around my thoughts and feelings on parenting but don’t want le chat d’argent to become a parenting blog.

So Sex Positive Parenting will be a great focus for some of the trickier parenting stuff, at the same time as being a chance to experiment with a different writing tone. There will undoubtedly be overlap between what comes up for me there, and my work as a therapist, so I expect some of those thoughts will take a gestalt form here.

In the meantime, I recommend the blog not just for people with kids but for anyone wanting to cultivate a more sex positive attitude generally. For twitter updates, follow @SexPosParent.

Fact check: does IAPT have a recovery rate of only 15%?

Recently, the Centre for Social Justice published the report “Commissioning Effective Talking Therapies” (pdf).

I find this interesting politically, as the CSJ was started by Iain Duncan-Smith, and so is broadly aligned with the Department for Work and Pensions. As the commissioning of talking therapies is the business of the Department of Health, this is an interesting intervention, about which I will have more to say in a future post.

The central message is fairly simple: to commission effective talking therapies, the service should be opened up to the private sector. Now, there’s not much in the way of hard stats on why that should be the case, which makes the report’s one key statistic a bit of a silver bullet to the head of the Improving Access to Psychological Therapies (IAPT) service.

Frankly, when what looks like a hatchet job in the name of free market economics rests its case on pretty much one damning statistic taken from one quarter of key performance indicators, I smell an undead gerbil. And so, inspired by the many, many smack downs delivered to the makers of suspect claims by Cathy Newman’s Fact Check blog, I thought I’d have a go at Fact Checking this core statistic for myself.

The claim:

“The Government has committed to spend an additional £400 million over the next four years on a limited range of National Institute for Health and Clinical Excellence (NICE) approved talking therapies, despite a recovery rate of only around 15% of all referrals” (p4)

The authors are unequivocal about this key fact: the IAPT service has a recovery rate of only around 15% of all referrals. Not only that, but the NHS is actually engaging in statistical skullduggery to disguise this alarmingly low figure:

“In the case of IAPT, it cites ‘recovery rates’ as a proportion of patients treated and also above ‘caseness’, rather than as a proportion of the baseline (patients referred), thus improving the outcome percentage. As described in more detail below, IAPT figures claim recovery as over 40 per cent… but from the point of view of commissioners and referring GPs, 86 per cent are not being helped by the IAPT service” (p37)

The background:

With the passing of the Health and Social Care Act 2012, NHS services are rapidly being opened up to tender by any qualified provider (AQP). The Act specifically opens up NHS services to tender from the private sector; de facto privatisation.

One of the areas open to AQP is adult psychological therapies. Currently, the vast majority of this service is delivered through IAPT. In order to prevent commissioning clusters from effectively defining AQP as an IAPT equivalent service, the CSJ’s report aims to demonstrate that IAPT is failing its users.

The analysis:

First, let’s get our terms clear. The IAPT service uses a peculiar language that aims to do what the majority of therapists tend to claim is not doable; quantify human suffering in statistically measurable terms. When someone is referred to IAPT, they are assessed for ‘caseness’. If someone has caseness, it means they meet the clinical definition for anxiety and/or depression as measured by a specific statistical tool. At the end of someone’s period of therapy, there is a final assessment; if the person’s scores have dropped below ‘caseness’ then they are deemed to have achieved recovery.

The report authors cite the IAPT key performance indicators for Quarter 1 2011/12 (April to June 2011). These figures claim a recovery rate (in England) of 42.5%. Step by step, we get there by:

Step 1. Taking the number of people who a) completed treatment in the quarter, and b) are moving to recovery (this is KPI 6a, and the number is 28,470)

Step 2. Taking the number of people who have completed treatment in the quarter (this is KPI 5, and the number is 75,697)

Step 3. Taking the number of people who a) completed recovery in the quarter, and b) were not at caseness at the start of treatment (this is KPI 6b, and the number is 8,725)

Step 4. Remove the people who didn’t have caseness to start with (step 3) from the total completed cases in the quarter (step 2) to get the number of people who a) completed recovery in the quarter, and b) had caseness at the start of treatment (the number is 66,972)

Step 5. Work out Step 1 as a proportion of Step 4 to get the percentage 42.5%

Phew! At least the stats add up in the way they’re supposed to; so far so gravy, though frankly, a 42.5% recovery rate is not exactly inspiring. But where has this 86% failure rate come from?

Well, the report authors’ claim is based on different stats. They work things out by:

Step 1. Taking the number of people who a) completed treatment in the quarter, and b) are moving to recovery (this is KPI 6a, and the number is 28,470)

Step 2. Taking the number of people who have been referred for psychological therapies in the quarter (this is KPI 3a, and the number is 206,918)

Step 3. Work out Step 1 as a proportion of Step 2 to get the percentage 13.8%

Now, pop-quiz, have you spotted the two sleights of hand that qualify the report authors’ calculations as bad science? Watch carefully:

Sleight of hand 1. The report authors use a suspicious tone of voice whilst pointing out that the NHS are using a smaller subset of the total available stats. This allows them to remove KPI 4 from view, an indicator that gives the number of people who have actually entered psychological therapies during the quarter. This is 123,792, meaning only 59.8% of referrals actually enter therapy. How can someone reach recovery when they’ve never even entered therapy? As a bonus, by the way, these figures contain a clear footnote stating that the number of people referred in a quarter don’t necessarily complete therapy in that same quarter; this is a totally unreliable figure to use as a baseline.

Sleight of hand 2. This one is the smarter move, and takes advantage of the ridiculous language IAPT is using. The very word ‘caseness’ presses the jargon button of all who hear it, making it a great primer for anti-IAPT sentiment from the outset. And so, because we all think we know what recovery means, but have only a vague idea of what caseness means, we are invited to stick with what we know and ignore a vital piece of causation: without caseness, there is no such thing as recovery. By definition, recovery means going from caseness to non-caseness; how can someone reach recovery when they didn’t have caseness in the first place?

The verdict:

It is incorrect to assert that IAPT has a recovery rate of only around 15%. Out of the total number of people referred into the IAPT service in the quarter examined, only 59.8% received therapy. Furthermore, people entering therapy in the quarter didn’t necessarily finish therapy in that quarter, making the figure unreliable for calculating recovery. Besides which, recovery in IAPT terminology means going from caseness to non-caseness using a specific measure. The inclusion of people who started therapy below the threshold for caseness invalidates the recovery rate because these people have nothing to recover from!

Let’s be frank, even if we’re convinced that recovery can be statistically measured (and whilst that’s an a priori assumption of the NHS, it is by no means a consensus in the wider professional field), a recovery rate of 42.5% is not inspiring. It’s enough to criticise IAPT using its own stats; the use of smoke and mirrors to make it look like a failing service is disingenuous at best, dishonest at worst.

Vote yes and help me find an inspirational bristol mayor

I have just finished my first week of paternity leave from therapy practice. Baby is due today and, so far, is declining to make an appearance. What does this have to do with May 3rd’s city wide referendum on whether or not Bristol should have a directly elected mayor? Pretty much everything.

As I started exploring in psychotherapy in a time of political crisis, I am already alive to the overlap between therapy and politics, and to therapy as a distinctly political activity in its own right. Now, it is a gestalt axiom that need organises the organism/environment field, the dynamic interplay between self and situation.

Accordingly, as I start to feel the physical reality of becoming a parent, I become increasingly aware of the social world into which my child will be emerging. The challenge this throws me is simple, difficult, and powerful. I look around me at my situation, and I tune in very quickly to the political domain. I feel urges towards action rise within me and… I explain them away. I’m a therapist, not a politician. There’s no point, I should focus my action in a better direction. Many of the self-same justifications for inaction that I support people in working through in therapy so that they can more fully be who they really are, not who they have been moulded to be.

My experience of starting to become a parent is of suddenly experiencing a need to take action that is stronger than my need to refrain from taking action. It’s not quite that I feel responsible for the world into which my child is being born in a way that I didn’t before, though that is a factor. It’s more that the projection of how my child might see me has revealed to me more starkly how, out of awareness, I am viewing myself. That is, I am fully in contact with the consequences for me of not acting on my political needs. Realising that I owe it to my child to be as fully myself as I can is a bridge to realising that I owe the same to myself. As a therapist, I am constantly re-learning this.

On 3rd May 2012, there will be a city wide referendum on whether Bristol should have a directly elected mayor. There is a yes lobby. There is a no lobby.

The key arguments in favour involve the direct accountability of the mayor vs a current leader who is elected by Council; the transfer of more powers and money (of an as yet undescribed nature) from Westminster to Bristol if we vote yes; and to shake up a tired political system.

The key arguments against involve the belief that the cost of implementing the mayor model will be too high; that the election will descend into a Ken vs Boris style personality contest; that the mayor will not be accountable to Council in the way the current Leader is; and that the candidates will be uninspiring.

In the midst of making up my own mind, I saw Salma Yaqoob‘s article ‘Yes’ to a Mayor who says ‘No’ to Austerity and realised what I want. I want to switch to the directly elected mayor system, and actively seek out the kind of candidate I want to vote for, instead of passively waiting for existing interests to make their offers. In parallel, I’m also seeking to form a political party with a mission to forge a politics of compassion grounded in core therapeutic principles.

I am unlikely to pull off such a feat on my own, so this is my call for support. Here is the kind of Mayoral candidate I am looking for:

A Mayor who opposes austerity: the austerity drive has failed and continues to fail. Britain is not only in a double-dip recession, but in a depression that is now more prolonged than the Great Depression of the 1930s. I want a Bristol Mayor who will actively oppose austerity.

A Mayor who will devolve power: one of the dangers of an elected mayor is that power becomes more centralised. I would like to see Bristol become a functioning e-democracy in which any Bristol citizen with an interest can be part of the decision making process. I want a Bristol Mayor who would seek to make that a reality.

A Mayor who is a woman: the mayor debating panels have been dominated by the usual white, middle-aged men, and the candidates so far proposed belong to this demographic. According to the 2001 Census Bristol’s population was 51.2% female. Austerity measures disproportionately affect women, who, absurdly, form the majority of the population but hold a minority of political posts. I want a woman for Bristol Mayor.

A Mayor who places humanity above economy: we are living through a time of atrocity in the name of balancing a national budget sinking under the weight, not of excessive public spending, but of bailing out the banks. Welfare is under attack, and the NHS is being thrown to the wolves. This is not unique to the Coalition; all three main parties are part of a neoliberal consensus that equates human activity with economic activity. This then justifies the most ruthless of decisions, as economy and humanity are one. I want a Bristol Mayor who will place humanity above the economy.

You might not want what I want, and that’s fine (and if I’ve inspired you to do the same thing as me but for a different kind of candidate, then even better!). Possibly I will get no further with this than the warm glow I get after publishing a new blog post. And if Bristol votes no on 3rd May, it’ll all be fairly academic anyway.

But suppose you want the same thing as me. And suppose Bristol votes yes on 3rd May. Then maybe you can take your own step towards action, and instead of waiting for the usual suspects to offer us up a selection of the same old faces, lend me your support.

Let’s get together, and find a candidate worth voting for.

Get Stable: The future of NHS adult psychological therapy in Bristol?

It was with much conflict that I attended an information evening for therapists by a social enterprise called Get Stable on Tuesday.

On the one hand, here is a company whose aim is to widen people’s access to psychological therapies beyond the CBT hegemony currently held in place by NICE guidelines. Adult Psychological Therapies is an area of the NHS being opened up to delivery by ‘any qualified provider’ (AQP). Get Stables’s main objective is to make it possible for people seeking therapy to be referred to private practitioners by their GP. As a therapist in private practice, my attraction to this idea is clear.

On the other hand, the legislation that has made this possible is the much-maligned Health and Social Care Act 2010-12; a bill so steeped in Fecklessness and Lose that Health Secretary Andrew Lansley defied FOI legislation to prevent publication of its risk register during its passage through Parliament. An early draft of the Health Bill risk register has now been leaked, confirming pretty much every argument against a Bill opposed by the majority of the medical profession. It’s probably clear where I stand on this issue.

So you can imagine the conflict; here is a company, aiming to deliver the kind of access to therapy I think people need to have, made possible by legislation I have actively campaigned against. Never had it been any clearer: I am a private psychotherapist; I am a private sector interest!

I remain opposed to the opening up of the NHS to ‘external markets’, and consider the term ‘any qualified provider’ to be an act of misdirection. It is clearly intended to play on most people’s assumption that ‘qualified’ means ‘good’, while in fact, ‘qualified’ simply means ‘meets the criteria’. As the manager of a small charity pointed out to me a few weeks ago, one of the qualifying criteria in tendering for service delivery is often that the organisation demonstrates a minimum annual turnover, or minimum level of reserve capital. So there are ways of ensuring that the ‘any’ qualified provider criteria are skewed towards, say, organisations that have paid your political party lots of money, or on whose Boards you can expect to sit.

That said, the starting point in gestalt therapy is to make contact with the actual situation and respond accordingly. The Health Bill has passed, ‘the markets’ are mobilising, and I find myself living in interesting times. So…

Who is Get Stable?

Although I asked at the end, I’m still unclear on the governance arrangements of Get Stable. Which doesn’t sound like an interesting thing to be concerned with but is, I think, very important.

The language of Get Stable is one of therapists as partners. The problem with that language is that, to me, partnership implies a more or less equal power relationship. However, Get Stable is a limited company, not a co-operative or collective, so while therapists may be referred to as partners, that doesn’t empower anyone to make organisational decisions; the Board will retain that authority.

That said, Get Stable isn’t (or at least doesn’t seem to be) a shadowy corporation moving in to snaffle up NHS goodies. Benjamin Fry, Get Stable’s founder, gave a very warm and personal account of his motivation for setting the company up, grounded in his own experience of trying to get therapeutic support through the NHS. If Get Stable is successful in its bid, I would like to see it move to a co-operative set up with charitable status.

Scene setting

The following is my understanding of what’s happening, so I’d appreciate it if any factual errors or mis-interpretations could be pointed out in comments.

Delivery of adult psychological therapies will be opened up to tender on 4th April. Any organisation that meets the AQP requirements will be able to put in a bid, with the bidding process closing 24th April. This is Get Stable’s initial window of opportunity.

PCTs are being dissolved, and their place taken by larger clusters, aligned to Local Authority boundaries. Get Stable is bidding in relation to the Bristol, North Somerset, and South Gloucestershire (BNSSG) cluster. This made some of the presentation confusing for me, as Ben mostly referred to how ‘Bristol’ would be doing things; I’m assuming that he was using Bristol as shorthand for the BNSSG cluster.

The BNSSG cluster appears to be the first in the country to be interested in commissioning an adult psychological therapies service that isn’t simply IAPT v2. Rather, the cluster is apparently open to the possibility of tapping into modalities beyond the prescription of NICE guidelines.

The referral process

In Benjamin Fry’s ideal world, Get Stable has successfully been awarded the tender for delivering adult psychological therapies in the BNSSG cluster. The journey from suffering to recovery goes something like this:

You go to your GP. You might have already self-assessed using Get Stable’s website, or you might not know what’s wrong. Your GP agrees or assesses that you need therapy. You then use Get Stable’s website to choose a therapist, using therapist profiles to decide who is right for you. Your GP refers you to that therapist, you make contact to arrange an initial meeting, and off you go.

Essentially, the process is pretty much the same as finding a private therapist, but with your GP as gatekeeper (s/he will hold the money), and Get Stable providing the background administration and quality assurance (only qualified and accredited practitioners can sign up).

This maximises choice on the part of the person seeking therapy in a way that is designed to reassure commissioners that what Get Stable will make available meets the same standards as what is already available in the NHS. It means that therapists who have chosen not to accredit, or who have sought alternative accreditation paths (such as the peer-review system of the Independent Practitioners Network) are unlikely to benefit from this system.

If this model is successful, then I would expect to see organisations like BACP and UKCP grow in strength, especially if this model spread to other clusters. Further, I would expect some degree of ‘therapist immigration’ as therapists outside the cluster area travel into the area, specifically to tap into this referral process. Especially if neighbouring clusters are commissioning services that essentially replicate the current IAPT provision.

I experience a lot of excitement as I make initial contact with these possibilities because it certainly looks like the kind of access to therapy I would like everyone to have. As a private practitioner, I hold a conflict between wanting to support people on the one hand, and needing to make a living on the other. Consequently, I have to acknowledge that my fees are beyond the reach of a large number of people.

Clearly, the Get Stable vision is one in which people can get, through their GP, the same access to therapy that only people with the means to pay can currently enjoy.

Money money money

At one point, I wondered to myself whether we were all going to be asked to pay some money into some kind of pyramid scheme-esque therapy racket. Amusingly, that thought was followed by Ben drawing a pyramid on the flipchart as a visual aid. He was explaining the logic behind Get Stable’s funding model, so far as it exists (the pyramid didn’t detail the funding by the way, it detailed the hierarchy from IAPT (top) down to self-certified therapists (bottom) from the commissioning perspective).

The understanding I’ve come away with is this:

Each person referred by a GP would have an amount of money associated with them. That money is only released to Get Stable when a successful outcome is achieved. A successful outcome in Get Stable’s model is achieving ‘recovery’ as defined by CORE (regular readers will be remembering my post on the Gestalt CORE project at this point). CORE is a way of measuring the impact of therapy in order to allow quantitative assessment of service provision.

This is a murky area of the model for many reasons, and is the main dampening factor on my excitement.

Ben’s argument is that, in order to meet the needs of the commissioners that will be deciding which bids are successful, Get Stable need to minimise the financial risk to the cluster. The NHS already uses CORE to measure the strength of a wide range of services (hence the logic behind the Gestalt CORE Project). Nothing reduces financial risk more than ‘no win, no fee’, so if ‘win’ is defined in terms the NHS already considers definitive, a major hurdle is, theoretically, overcome.

Further, by applying existing NHS standards as sign up requirements for therapists, Get Stable can argue that they are safe in the same way that NHS services were safe. Qualified and accredited therapists provide therapy in the NHS already, so Get Stable isn’t exposing people to anything they wouldn’t already be able to find in the NHS nationally.

The rub for me as a therapist comes in a number of places.

First, CORE methodology consists of a long list of measures at the start and end of therapy, and a shorter list of measures in every other session. So some therapy time must be given over to filling in CORE forms.

Second, it remains unclear to me what happens in terms of payment in the instances where: the person referred doesn’t show up; the person referred comes for assessment and we end up not working together; the person referred disengages from therapy before the agreed end date. My current reasoning is that, in these cases, no money will come from the cluster to Get Stable because there is no ‘win’ (recovery, in CORE language).

Third, suppose I’m seeing two people and see both through to an agreed ending; the CORE scores for one indicates recovery, the scores for the other indicate non-recovery (either no movement in scores or not enough). My current reasoning is that Get Stable receives money for the person with recovery scores but no money for the person with non-recovery scores.

Get Stable has asserted that it will take money centrally from commissioners and re-distribute to partner therapists so that everyone gets paid for their time. If I’ve understood correctly, and money only comes to Get Stable when a recovery score is achieved, then a bizarre economy is created in which the money gained through people with recovery scores subsidises the people without recovery scores. I find it hard to see how that could average out at a decent level of fee for each individual therapist (though a caveat here would be that the money available per person isn’t known yet so no one can crunch any numbers!).

Fourth, I’m unclear on this but assume that the money allocated per referral is a fixed amount, creating an environment that is better suited to brief therapy. If the money per person is fixed, then the money:session ration clearly reduces with every session, creating an incentive to take as few sessions as possible.

While this appears to be a good thing (and Fritz Perls was very opposed to the idea of spending years in therapy), it fails to take into account that people need to move at their own speed. In the case of depression, for example, a depression that is highly situational is more likely to pass more quickly than a depression that is rooted in long-standing problems.

So a further nuance to the therapeutic economy becomes people with simpler therapeutic situations subsidise people with more complex therapeutic situations.

If the money available per person is flexible subject to assessment of complexity and time needed; and/or if there is a ‘basic + commission’ model where Get Stable get a standard payment at the start, and an additional, recovery-linked payment at the end, then much (though not all) of that bizarre economy will be mitigated.

Overall impact on therapy provision

From the perspective of someone seeking therapy through their GP, this model provides a wider choice than currently exists, and I think that is a good thing. Having received my own therapy purely through the private sector, I would have a very hard time being allocated to someone by my GP

From the perspective of the commissioning group, this model clearly transfers all the financial risk away from the commissioners and onto the practitioner. At the same time, it ensures that only private practitioners who meet the current NHS standards for therapy provision are available for referral. I’m not a commissioner, but the no win no fee & NHS standard equivalency logic seems to me to stand a good chance of being appealing.

From my perspective as a practitioner… I don’t particularly like the risk of not getting paid for my time. Get Stable seem to be wanting to use the bizarre economy I’ve described to ensure that everyone gets paid for their time. In which case, I suspect the bigger risk is that the average therapeutic fee will fall below what practitioners currently get privately. Get Stable quoted an expected average fee of £45; given that no numbers are available, I’m assuming that to be an air-plucked number meant to attract an initial wave of therapists to sign up.

Overall, I see the impact as being largely determined by how much money is available for each person referred, and what proportion of that money is dependent on hitting the win of recovery scores.

In the worst case, therapists adapt to a therapeutic economy that is skewed towards people who are more ‘responsive to treatment’ and have ‘simpler presentations’ because these are the most ideal conditions for a speedy journey towards statistical recovery.

In the best case, therapists have the freedom to give each person the time they need, and the discipline of CORE assessment supports practitioners in developing a more sophisticated ability to assess likely therapeutic timeframes.

I suspect there’s a bell curve in this, with ‘available funding’ along the x axis, and ‘therapeutic efficiency’ along the y axis. Whilst it’s obvious that too little money leads to poor conditions for therapy, I do also think that too much money does the same.

That said, I doubt we have to worry about too much money being made available!

In closing, I’m aware that there are many nuances and aspects to this that I haven’t discussed, not least of which being whether the very idea of quantifying a ‘no win no fee’ approach with CORE is good, bad, or meh.

What I’ve stuck to for this post is an immediate remembrance of and response to Tuesday’s meeting; it’s my hope that some discussion will take place in the comments, especially among people who attended the meeting.

My current position is that I think Get Stable is basically a good idea in need of the numbers necessary for financial modelling. I can’t see any real loss involved for a therapist wanting to give this a try by experimenting with making three or four slots available on a one year trial basis to assess whether it works.

I wish Ben Fry and his team the best of luck with the bidding process!

Towards an evidence base for gestalt therapy: the gestalt CORE project

The latest issue of The British Gestalt Journal features an article writing up the findings of the gestalt CORE project (hereafter Stevens et al). In their own words:

This is the account of a three-year research project within the Gestalt therapy community in the UK. It is an example of clinically-based, mostly quantitative research carried out in a methodical and rigorous way, using voluntary effort and minimum funding. The results can be compared with national databases of similar UK studies and show that Gestalt psychotherapists are as effective as therapists trained in other modalities working in the NHS and in primary care (p22).

The issue of evidence-based therapy is a thorny one in the UK, and one which places Stevens et al’s research into an interesting political category. I have a mixed reaction to these research findings, so offer that reaction here. I’ll conclude with congratulations to the people who put this research together because (and I apologise for this in advance) it was clearly a hardCORE effort.

NICE

Let’s start with NICE guidance, because it’s not always all that nice. NICE (or The National Institute for Health and Clinical Excellence to its friends) is a laudable organisation with laudable aims.

From its what we do page: “we develop evidence-based guidelines on the most effective ways to diagnose, treat and prevent disease and ill health”.

From its who we are page: “the National Institute for Health and Clinical Excellence (NICE) was set up in 1999 to reduce variation in the availability and quality of NHS treatments and care – the so called ‘postcode lottery’”.

So, NICE exists in order to ensure that someone in BS6 gets the same quality of treatment as someone in S13. This is basically a Good Thing; no one really wants to die or experience extended pain and suffering because their doctor didn’t get the memo. Which of course leads us to how we decide what is effective in any given case, which in turn leads us to evidence-based care. If I’m going to be prescribed medication, I want it to be the most demonstrably effective medication for my condition, not the only one my doctor knows about (or worse, the one whose company was more effective at marketing to my doctor).

This is all classic medical model stuff. The human body is this really cool machine, and when it breaks or malfunctions, you just identify the faulty part(s) and fix it/them. Since the introduction of that model, infant mortality rates have dropped, diseases that used to be deadly are now fairly routine, and heart transplants are possible. I don’t think anyone really wants to throw out this particular baby.

The bath water, however, is another story. While the medical model allows for miracles when applied to physical conditions, it frequently stalls when applied to issues generally related to the experience of being human. The very idea of mental illness is itself a logical fallacy that presupposes a genuine separation between mind and body. And that leads us into problems because, having presupposed the existence of a distinct ‘part’ called the mind, the medical model then attempts to identify the part of the mind that is malfunctioning in order to fix it. Hence the rise of psychopharmacology and the fallacy of the chemical imbalance model of mental illness.

The conclusion of all this is that, when presented with people whose suffering has more to do with the experience of being human rather than their human machinery, NICE continues to assume it is essentially dealing with a machine and seeks standardisation. And that standardisation requires an evidence-base that strips away the humanity of the individual in order to discover the essential underlying problem. Which simply isn’t possible when there is no essential underlying problem; the so-called malfunction is itself an expression of the humanity of the individual.

And this leaves a major problem for gestalt, because the NHS is the main provider of ‘mental health’ services, and its IAPT (improving access to psychological therapies) programme follows NICE guidance. And NICE guidance strongly favours CBT for treating mental health problems because, as Stevens et al acknowledge, it has a bigger evidence base:

CBT has had the most exposure to clinical trials since it uses set protocols which enable standardised collection of quantifiable data (p22).

Given why NICE has been established, this is understandable. From the perspective of the medical model, clinical trials establish efficacy of method, and set protocols allow for standardisation. Try establishing a protocol for ‘sitting with the uncertainty’ or ‘intuiting my client’s desensitisation on the basis of changes in my own bodily experience’. Quite.

So that’s my meander into NICE and evidence-based therapy. What I’m establishing here is the political ground against which Stevens et al’s research needs to be taken: the therapeutic hegemony of CBT.

Research findings, self-validation, and the equivalence paradox

The key finding of this research is that gestalt psychotherapists are shown to be as effective as other types of psychotherapist according to CORE data. Stevens et al used three other studies with which to compare results. I’m not entirely clear why these three particular studies were used or which other studies were passed over for inclusion, so I think the article would have benefited from a literature review. The result of the comparison is that two studies with large datasets provide benchmarking material, whilst the third study focused on minimally trained mental health counsellors.

My response to these results has been interesting. I was angry at first, in the ‘well tell me something I don’t know and this is just political maneuvering not real research’ vein that is the clearest sign one of my buttons has been pressed; the animal anger of being prodded somewhere sore. A bit of licking later and I realise I am relieved. As a therapist, I sit with a great deal of doubt. I doubt that I’m effective. I doubt that gestalt is effective. I doubt that psychotherapy is effective. After all, if it’s all essentially placebo, then I’ve spent a lot of money, time and energy training in the interpersonal equivalent of prescribing sugar pills. My anger was masking a more fundamental feeling of ‘thank fuck for that!’. There is something vindicating about seeing quantitative research with headline numbers that appear to prove what I do is effective.

Now, pursuing that need for external validation appears highly antithetical to the gestalt therapy that Perls et al originally set down, and I think that will make this research controversial within the gestalt community. On the one hand, I practice a therapy that emphasises organismic self-regulation and the importance of self-validation over living up to externally imposed standards. On the other hand, the rise of CBT as the NICE approved therapy of choice is a genuine social challenge that I want to make contact with, not avoid. As Stevens et al point out:

If as Gestalt therapists we do not take seriously the challenge to articulate and evaluate our therapeutic claims we may be left talking only amongst ourselves and limited to working only with those clients who can afford to pay privately (p26).

I have introjected gestalt therapy if I use the ‘but Perls said I should discern things for myself and not be concerned with empirical validation’ line of defence to block contact with a genuine social challenge. If need organises the organism/environment field, then the fact that standardisation and evidence-based practice is organising the field of psychotherapy provision demonstrates the operation of powerful needs. Furthermore, if many gestalt therapists are, like me, not trained in quantitative research methods and don’t have backgrounds in academic psychology, then we are in danger of not contacting the woods for our own projected trees.

All of which serves to focus me on the CORE methodology and what Stevens et al identify as the equivalence paradox: “treatments that have different and incompatible theoretical backgrounds, philosophies and techniques tend to have the same degree of success as measured by CORE” (p24). In addition, the study focusing on minimally trained practitioners showed what I would have hypothesised; that minimally trained practitioners were less effective than professional practitioners.

This equivalence paradox speaks to an intuition in me that for all our different approaches to doing therapy, as practitioners we are all essentially undertaking the same journey only with different preferred routes and ways of travel. Psychotherapy theory seems to have more to do with the preferences of the therapist than it does the effectiveness of the therapy itself. Which is incredibly ironic because it means that, in the arena of working with the human experience, diversity of method actually leads to standardisation of efficacy!

On the other hand, maybe the equivalence paradox is actually an inherent flaw in CORE methodology itself. Perhaps the statistics are simply recording client expectation of what should be the case rather than effectively measuring what actually is the case. A key question there would be whether the clients in the minimally trained practitioner study knew that their therapists were minimally trained and adapted their expectations accordingly.

Politics and dialogue

Where I seem to end up with all this is a sense that Stevens et al have provided gestalt practitioners in the UK with a valuable opportunity to take part in a national conversation. That makes this research political as it has more to do with positioning gestalt in the professional field than it does developing gestalt practice. Both are valid reasons for research.

Ultimately, politics is an opportunity for dialogue about how key collective issues are to be addressed. And dialogue, as I am keenly aware as a gestalt practitioner, necessitates a willingness to open to contact with an other in such a way that risks being forever changed by the process.

And by definition that works both ways. Stevens et al used the CORE methodology not because it is finely attuned to the needs of gestalt practitioners; the writers acknowledge that there is no gestalt therapy box on the forms that need to be filled in (p23) and that filling out forms every session is quite alien to gestalt’s relational approach (p26).

Rather, the CORE methodology was used because it is a well-established outcome measure that allows for comparison with many other studies, including CBT (p22). In therapeutic terms, Stevens et al decided to learn and use the language of the people they are trying to reach rather than impose their own. Once gestalt therapy as a profession is part of that ongoing conversation, we can then also deconstruct introjections about what should count as an evidence-base and better dispel projections about gestalt therapy as an approach.

Finally, what this also highlights for me is the politics of research as an activity in itself. Having conducted my own, qualitative research, I’ve needed to address the issue of researcher bias and the various political and philosophical assumptions that underlie research as an activity. Basically, who asks what questions and why?

With respect to the gestalt CORE project, the GPTI (Gestalt Psychotherapy and Training Institute) discussion list was the birth place of the CORE project, growing out of “gestalt therapists’ concern to find a way to research the effectiveness of their work” (p22). GPTI also funded costs associated with CORE software and training for the first year to get the project started. Gestalt therapists volunteered to take part in data collection, and The British Gestalt Journal hosted a recruitment page with information about the project and downloadable forms.

One way of looking at this research, then, is this: a group of gestalt therapists, with funding from a gestalt therapy organisation and assistance from a gestalt therapy journal, have conducted research whose findings claim gestalt therapy is as effective as other therapies. This appears to justify one of Babette Rothschild’s favourite phrases: outcome focused research is some of the most biased research there is.

I think this bias is real and would hopefully be recognised by Stevens et al. However, I don’t think that recognition of vested interests damages the research. Rather, I think it opens up nicely the same question of vested interests for outcome focused research in general, and CORE studies in particular. After all, “the CORE measurement is primarily designed to provide managers and practitioners with evidence of service quality and effectiveness” (p23). The whole point is to demonstrate the level of effectiveness, not falsify.

Consequently, the inevitable criticism that can be levied at Stevens et al (ie your research is biased by the vested interests of those concerned) applies equally to other studies and only serves to demonstrate the impossibility of the neutral researcher; the motivation to research has to come from somewhere.

Congratulatory note

What I hope this post portrays is my attempt to reconcile my own thoughts and feelings about the possibility of evidence-based therapeutic practice with my recognition that this is an important piece of research for gestalt therapy.

My congratulations go out to Christine Stevens, Jane Stringfellow, Katy Wakelin, and Judith Waring for putting together this research. This was research conducted by volunteers, outside of academia, and with minimal funding. That is in contrast to CBT as an approach, which has an easier time gathering an evidence-base precisely because there is a greater abundance of resource aimed at producing that evidence-base.

In conclusion, I think those involved can consider this to be three years well spent, and I’ve enjoyed the challenge of chewing over this research.

Article reference:

Stevens et al (2011) The UK Gestalt psychotherapy CORE research project: the findings; The British Gestalt Journal, Vol. 20 (2), pp22-27 (online ref)

My reflection on The People’s Bristol 2050

I look around the room at the couple of dozen people making a rough circle; some sitting, some getting coffee or tea, a couple of groups chatting. It’s coming up for the scheduled 2pm start, so I decide I’ll use the toilet then come back and call everyone together to get started. Off I go.

Returning about five minutes later, the circle has expanded and a steady flow of people is coming into the room. Before I know it, a couple of dozen people has become more like sixty or seventy, and I’m wondering what the hell I’ve got myself into. As it happens, I don’t have enough time to give that question full consideration; there’s an Open Space meeting to start…

That’s pretty much how the first event of The People’s Bristol 2050 got going. This is a response to another Bristol 2050, a business vision of what Bristol should look like in 2050. Co-ordinated by Business West, it “provides a clear statement about jobs, housing and infrastructure requirements to meet the needs of the area and to continue to develop and grow as the economic powerhouse of the South West”. As usual, these are the needs of the area according to business leaders; after all, business leaders have been doing so well in addressing society’s needs lately.

Whether historical coincidence or zeitgeist we may never know, but at about this time, Occupy Bristol had developed into two branches; one that wanted to move on from College Green, and one that wanted to resist eviction. The question of what happens to Occupy Bristol as a movement is one that will be addressed in a public meeting on Saturday 4th February, 2pm to 4pm, location to be announced (the facebook page for this is here).

Among the people who wanted to move on, the idea of developing a People’s Bristol 2050 to rival the business vision offered a new direction in which to aim some of the raw energy of Occupy. What these events demonstrate is that the Occupy Movement as a whole is a crucible from which many different things have the potential to emerge; it all depends on who directs their energy into the mix.

In more gestalt terms, the open space event on Saturday created a fertile ground with the potential to mobilise a wide variety of social actions. There is a buzz that I’ve noticed in every open space event I’ve been involved with, and I can only describe it as being plugged into a circuit of human power, rich with potential.

The downside to many open space events is that, as stand alone events, that buzz inevitably fades, leaving people with a sense of potential unachieved. This makes the People’s Bristol 2050 extra fascinating to me because the next event is already being planned for roughly four weeks time, with the intention being for a series of these meetings to take that buzz and develop it.

Except that there is no one centrally to develop it into anything; the idea is to support a process that challenges the people who turn up to take action for themselves. The idea is to move from a sense of “someone should really…”, to “I am going to…”. Instead of handing over power to someone else, the spirit of open space is to take a group of people and give them the minimum structure necessary to support self-regulation.

And to me, that sounds like gestalt therapy in action as a progressive social force.

Occupy Bristol II: A call for volunteers

I’m going to be facilitating a planning event for a group of people intending to run discussion events for something called Bristol 2050. This is a development of the Occupy Bristol movement by people who are interested in ‘what happens next’, ie how best can Occupy Bristol evolve. The aim is to use the Open Spaces methodology to explore the kind of society people want to live in by 2050.

The planning event will itself be an Open Spaces event as that is the only meaningful way to learn an approach to group discussion that I will wax lyrical about another time. For now, what is needed are people who are interested in getting involved at this stage. The focus of the planning event is making Bristol 2050 as open to as wide a range of voices as possible, and how to make sure events run smoothly. An interest in evolving participatory democracy in a manner that is accessible for a wide range of people is pretty much the only pre-requisite; Open Spaces is very easy to get to grips with and is designed to be empowering.

If you’re free Saturday 21st January, then the training event will take place in the upstairs hall at The Trinity Centre in Lawrence Hill, 2pm to 4pm. Apparently there will be an indoor picnic in the downstairs hall all day and we’ll be welcome to drop into that.

Email me (simon@silvercatpsychotherapy.co.uk) if you’re interested. If you’re interested in getting involved and can’t make the 21st, then still email me, your support is bound to be helpful at some point!

I’ll elaborate on this in another post, as I see a large overlap between this process and the spirit of gestalt therapy. For the time being though, this is the call to arms, and I’d appreciate it if you could spread word to any Bristol-based people who might be interested.