Posts Tagged ‘bristol therapist’

Recently, a number of things have come together, and I feel myself undergoing a developmental leap in my practice and professional identity. I am manifesting that change through two decisions: leasing my own therapy room, and rebranding my practice.

It is unlikely to be a coincidence that Generation Rent is a political topic of the day. The transience and rootlessness of renting therapy rooms by the hour is something I have begun to find unbearable. The experience is interesting. Renting a space means more than just renting a space that belongs to someone else. After all, I haven’t bought my own building; my new therapy room is still on a lease. But there is a substantial difference between hiring a space, and a hire-space.

My new room is in The Ethical Property Company‘s centre on Colston Street. It is “my” space in so much that I contract with Ethical Property for use of that space to be exclusively mine for the period of the lease. Importantly, this means that the shaping of that space is down to me. I am free to create, not simply a therapy space, but my therapy space. Every decision about shaping this therapy space becomes a consideration of how this space can express the possibilities of my practice.

Contrast that with the nature of a hire-space, a room whose function is to be hired. The decoration may range from magnolia boxes, to beautifully themed rooms. But the spirit of the room, its very structure, is one of transience. The room is hired by many therapists, but belongs to none. It is no one’s “home room”. I tend to feel this as a sense of emptiness in the room; it is missing the many, tiny, background cues that suggest there is one specific person using this space on a regular basis.

In terms of figure/ground formation, the ground doesn’t support the figure of a tangible therapist. On the one hand, this means that it supports a kind of everytherapist, which certainly maximises the utility of the room as a hire-space. But this invites the therapist using the room into an everytherapist role. Just as any therapist could be using that room, so too could the clients who come to the room be seeing any therapist. The effect for me now is similar to every town having an identical high street; the unique element of soul that arises from place goes missing.

This has been ok so far. Gestalt therapy can be practised anywhere, with the only requirement being that the environment in which the therapy is situated be explicitly included in the therapy. There isn’t a correct set-up for the therapy, there is only the co-created experience of the therapy session, in awareness. If the therapy takes place in a soul-less box, then the experience of being in a soul-less box can be invited into the foreground for exploration. It is simply that my needs have changed, and now I feel constrained by hire-space in a way that I haven’t before.

Consequently, I am in the process of setting up my new room, and will practice from there as of the beginning of September.

A second need that arose as I made the decision to lease a room, was the need to attend to my professional identity. I feel like I have outgrown Silver Cat Psychotherapy, that this particular image no longer represents my practice. So, over the next few weeks, I will be transforming into the bristol therapist, a practice name that is more rooted in place, and reflects my sense of gestalt therapy as a particularly Bristol-ish approach. If psychotherapy was the UK, gestalt would definitely be Bristol!

And just to make that transformation process suitably challenging, I’ll be moving this blog to a new website, the very definition of growing pains!

I feel a mixture of excitement and trepidation. I wonder if my room will fulfil my expectations, or if I’ll discover that it’s no different to hire-space when it comes right down to it. I notice how applicable the cycle of gestalt formation and destruction is to specific projects like setting up a new therapy room and rebranding a practice.

Expect some updates. In the meantime, here is a work in progress shot of a painted corner of the room (first coat!):

therapy room work in progress


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Today’s blog post is brought to you by Freddy Weaver. By way of context, Freddy and I are involved in forming an IPN Group (future blog post on IPN/therapist accreditation pending) so I’m finding this an interesting way for me to see more of his professional influences.

Last week Focus Counselling hosted Brian Thorne’s “last public speaking event on the circuit” at St. Michael’s Church on Broad Street, Bath.

I was excited. I had “discovered” Brian Thorne, the much-admired torch-holder of the Person-centred tradition in the UK, two years ago when my new supervisor pointed me towards his work. The clarity, courage and heart in his writing spoke to me of an approach to counselling that I had hitherto been unable to find, yet felt called to employ. I was grappling with the division between my experience of working in fairly directive environments (addiction rehabilitation centres) and my yearning to bring a softer, more permissive, yet more authentic aspect to the therapeutic encounter. Here, it seemed, was a man who was willing to throw caution – and perhaps the security of specific techniques or targets – to the wind: to uncompromisingly meet his clients’ relational needs. Using Carl Rogers’ triumvirate of core conditions as his watchword he shone light upon a legitimate way forwards in my ideological impasse! I admired, too, his willingness to fly in the face of convention, take risks and challenge a discipline in which it is easy to allow caution to overwhelm creative clinical integrity.

Thorne began with the impact Rogers has had on psychotherapy. He spoke with conviction about the Rogerian approach in which “what mattered was the kind of relationship he offered his clients – nothing less, nothing more.” He touched on the actualizing tendency – the underpinning assumption of his approach -, which espouses that, if met with the right conditions, people will grow, develop and realize their full potential. He praised Rogers’ refusal to assert power within the therapeutic relationship, and noted that this commitment followed through into his work as an international peacemaker towards the end of his life.

He spoke of Rogers as “The Quiet Revolutionary”. In many ways Rogers’ impact on western society is so great that it is invisible: his ideas about the value of listening, of the transformative power of self-expression in safe conditions has become almost ubiquitous. Our society’s narcissism has, of course, taken this individualizing impulse to an extreme in which many foster a self-centredness, expressed by the need to share intimate details to all and sundry in the form of reality television, social media etc. (The irony of my posting this critique on a blog is not lost on me!). However, the cultural shift from a position of excessive emotional containment to one of increasingly widespread emotional tolerance remains a sign of progress towards a more balanced way of being.

Thorne touched on the core conditions of Unconditional Positive Regard (acceptance), Empathy (understanding) and Congruence (authenticity), which have been so influential in the development of counselling. I would have loved to hear more of his thinking around these admittedly widely discussed attitudes. But Thorne was on polemic form and seemed more interested to address some of the more contentious and portentous issues on his mind!

Thorne chose to focus on Rogers’ final book A Way of Being (1980), which came to acknowledge the transcendent, the mysterious, and the spiritual in the therapeutic encounter. In the world of psychology this unquantifiable language, let alone concept, was not welcome. Indeed, Thorne was saying that many within the person-centred tradition had actively avoided and ignored the implications of Rogers’ later writings, preferring to focus on the more accessible aspects of his early philosophy. Thorne seemed to be admirably supporting a more transparent acknowledgement of these elements within psychotherapy, and was at pains to communicate the failure of contemporary psychotherapy and society to integrate spirituality into its value systems. He did not address the issue of how this might be embodied on a practical level within counselling, or how to prevent therapists imposing, however subtly, their own belief systems on clients.

Thorne spoke as if a lone voice in the wilderness. But is he really so unusual in championing the transparency of the spiritual in therapy? Did not Jung turn to alchemy, mystery schools and eastern esoterica in his penetrating search for meaning? What about Transpersonal Psychotherapy – a whole psychological tradition that acknowledges the presence and importance of the soul life? More recently, with the fruitful incorporation of mindfulness and eastern awareness traditions into mainstream psychology, there seems to be increasing tolerance for the dogma-free techniques and tools of contemplative religion in therapeutic systems. Moreover, there are numerous openly Buddhist psychotherapists in practice and broadly held esteem. To my mind the position that Thorne was taking was aimed more at policy-makers than practicing therapists.

It was Thorne’s contention that the current climate of service provision, with its focus on outcomes and interventions, rather than the quality of human relationship, sanitizes and stultifies therapy. The current system encourages us to become “psychological technicians that tinker around with the psychological mechanisms of the human mind”. He felt that this represents more than the simple mistake of overemphasizing form over substance. For him it is evidence of the field of psychotherapy becoming infected by the shadow aspects of our society – namely an obsession with achievement over experience, productivity over provision, and consumption over everything. The increasingly litigious environment, he feels, is contributing to the crushing of therapeutic creativity – and thus we therapists are losing the ability to model a creative, spirited self to our clients for fear of judgement and condemnation. His concern was communicated with an oppressive solemnity and extended out from the therapeutic world to the challenges facing humanity in general, from continued human atrocities to global warming.

Many of his concerns I emphatically share. I’d consider myself a poor therapist indeed if my observations of societal ills did not extend into the restrictions and challenges of the context in which our clients are living. I was somewhat baffled, then, by his focus on these woes because my very being a therapist is born from a keen awareness of these massive challenges, and the instinctive desire to therefore facilitate meaningful individual and collective change. I admire his willingness to take on denial and break our seeming indifference towards the challenges we face. But in this case he was preaching to the converted, and rather than offering constructive insight, dwelt on hopelessness, whereas I see progress in many areas of human development.

He did observe that, while support for the traditional faiths of the world is dwindling in this country, the contemplative orders are flourishing and that an authentic individual search for spiritual connection is flowering. He also noted that the quality of relationship, although not yet at the centre of psychological policy in the UK, is becoming increasingly recognized. But he didn’t seem to join the dots of these significant shifts towards a brighter future. To me the growth in partisan spirituality is evidence of a cultural development that seems to embody the person-centred ethos of allowing organic, rather than imposed, evolution to take hold.

During question and answer time at the end he softened. Having sounded the clarion call of doom he was perhaps ready to acknowledge hope! Interesting questions were raised which prompted the observation that in order for things to change a crisis often needs to be reached – a scenario I’m sure many of us are familiar with in our personal and professional lives.

Near the beginning of the talk Thorne threw down the person-centred gauntlet: “I am challenged to trust my client as a person designed for wholeness and possessed of the inner resources to achieve wholeness.” I am endeavouring to extend this trust to humanity as a whole, as well as my clients. My challenge to Brian Thorne is to do the same.

As I observe clients grow I see the changes they make radiate out across the constellations of their relationships, like ripples in a pond. So, as each of us progresses along our own growth towards our potential I believe we make a microscopic, yet meaningful, contribution to the evolution of the systems to which we belong. For anyone who feels discouraged by the task ahead, be it in response to a personal or the global situation, I offer you these illuminatingly paradoxical words from Gandhi, “Whatever you do will be insignificant, but it is very important that you do it.”

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Today I have passed a new blogging milestone: my first guest post on someone else’s blog!

It’s actually something I put together on Storify, a site that encourages the telling of social (media) stories by pulling in twitter posts, facebook statuses etc into a blog post. I see lots of tweets that spark off gestalty thoughts in me, so this was a first attempt at putting those thoughts into writing.

So without further ado, I suggest you all make your way over to Reversal experiments: @suey2y vs the seasick as hosted on Diary of a Benefit Scrounger.

@suey2y is the twitter account of Sue Marsh, a campaigner for disabled rights who recently led multiple smackdowns on the Government by beating them over the head with the Spartacus Report.

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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.

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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.

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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.

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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!

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