Posts Tagged ‘cbt’

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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There is currently a petition running to “reform the NICE guidelines and end the bias towards Cognitive Behaviour Therapy (CBT) in the IAPT programme”.

I am supporting this because, metaphorically speaking, 1% of the UK’s Counselling and Psychotherapy profession is in danger of enjoying more influence over the delivery of mental health services than the remaining 99% combined. I have no official figures to back that up with, but you have to admit it sounds good!

Ok, so that’s mostly artistic licence; however, I’m not making the comparison lightly. Nor do I really have much beef with CBT in itself; gestalt integrated cognitive and behavioural approaches to therapy back in 1951 (see Perls, Hefferline and Goodman‘s Gestalt Therapy on working through introjects cognitively (pp189-210) and behavioural experimentation (pp14-17). Maybe I’ll write more on this at some point, but in essence, I think that good gestalt therapy already encompasses much CBT).

My objection, along with the authors and co-signatories to this petition, and the people involved in the Occupy movement, is the concentration of power into a small minority. And that is what is currently happening with respect to the provision of officially sanctioned therapy services in the UK, as CBT is promoted as the evidence-based therapy of choice. And this despite the relevance of the measures underpinning that evidence-base being questionable, and a lack of longitudinal and follow-up studies. As well as the inherent logical flaw in claiming that any form of therapy has an evidence-base for efficacy in treating conditions such as depression, when there isn’t really any solid professional consensus about what depression actually is.

I support the need for evidence-based therapy and for research into counselling and psychotherapy generally. If we are to avoid a bizarre therapeutic turf war between Great Houses (my theory’s harder than your theory!) then counselling and psychotherapy as a profession needs to live up to its own values and support the part that research plays in developing reflexive practice. But that means developing a research tradition that is appropriate to the area under research. Which must include philosophical exploration into what can realistically count as a measure by which efficacy can be assessed, if indeed such a thing is possible. Remember, all information is potentially evidence; the term ‘evidence-base’ merely means an amassed body of information used to argue for a specific position. It does not constitute a proof.

In my experience, there is no such thing as the cure-all magic pill when it comes to the human condition. There is great danger in pinning so much hope on CBT, and it is the same danger that applies in any idealisation of another. Sooner or later, the idealised other will fail to meet the impossible ideal of perfection and fall from grace. At which point, the idealised other becomes demonised. That is the inevitable fate of any therapy that is pointed to as the answer to every individual’s problem. If gestalt therapy were being lauded in place of CBT, I’d be arguing the same thing; probably more passionately, as on top of my general feeling that therapeutic efficacy has more to do with the relationship than the theory involved, I’d also see the risk to myself as a practitioner of an idealised theory.

Consider my argument to be one in favour of biodiversity in the therapeutic field and you’ve probably got it in a nutshell. I won’t demand that you agree with me. Rather, I present you with my opinion, a petition, and an invitation to consider your own position on the issue.

You’ll find the petition here.

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I’ve been blogging away for about six months now, and have decided that it’s high time I named a principle after myself as my enduring contribution to psychotherapy. I’m not entirely sure how I arrived at what I arrived at (which, as you’ll see, is a rather neat case in point) but it was fun getting there.

I was thinking about the seemingly diametrically opposed focuses of process and outcome in psychotherapy. I think of therapies like CBT as being essentially outcome focused, the logic being ‘so you suffer from panic attacks? Right then, we’ll find a way of stopping those damn panic attacks!’. A process focused therapist might well scoff at this attitude. I think of therapies like humanistic person-centred as being essentially process focused, the logic here being ‘so you suffer from panic attacks? *therapist looks warmly at client whilst embodying the core conditions*’.

The two approaches are, of course, focusing on two completely different things. The CB Therapist (btw, please can everyone stop saying CBT Therapist? What you’re saying is Cognitive Behavioural Therapy Therapist; my brain automatically expands the acronym and it causes me physical pain! Thank you) wants to solve the problem (outcome), the HPC therapist wants to explore the problem (process).

In HPC, the idea is that the panic attacks are something the person needs to experience in some way. Roughly speaking, the person, driven by their actualising principle to develop and grow, encounters some deep-rooted obstacle to that growth, resulting in panic attacks. By supporting exploration of the problem, the HPC therapist is supporting the person’s growth with the belief that the actualising principle will eventually win out, with the person spontaneously discovering their panic attacks to be meaningful expressions of their humanity. This may or may not result in release from panic attacks, but will certainly lead to an expanded consciousness.

By contrast, in CBT, the idea is that panic attacks are an undesired consequence of the person’s thinking and behaviour. This person wants and needs to change their thought and behaviour patterns in order to gain release from the suffering of panic attacks. The goal is to stop the panic attacks, and this is achieved by identifying the problematic thought and behaviour patterns and changing them to non-problematic thought and behaviour patterns. Successful CBT ends the panic attacks, unsuccessful CBT doesn’t end the panic attacks; expanded consciousness is beside the point.

If you’re HPC or CBT trained and are currently frothing at the mouth at how badly I’ve misrepresented your field, please do correct me; I reserve the right to disagree with your interpretation of your own area of practice for entertainment purposes.

Gestaltists will most readily ally themselves with the process focus but to be honest I think gestalt actually moves between the two, with the majority of the time spent with a process focus. The fact that I engage in creative experimentation in my practice places at least some of what I do in the CB camp. Experiments, by their nature, are a behaviourist approach to therapy. And sometimes, they have an outcome focus.

If I was working with panic attacks, for example, an experiment might be to re-create a low-level panic attack situation in the therapy room (like reading a passage from a book to an imagined audience). The point of this in gestalt is to gain direct access to the feelings involved in a safe environment instead of being two steps removed from the issue by talking about what happened last week (and of course, I wouldn’t do this with someone if I felt they weren’t going to be able to re-stabilise afterwards). This can be process focused; the experiment brings powerful feelings into awareness and we see where those feelings take us. Or this can be outcome focused; the experiment serves as a training ground for building tolerance for the panic-attack situation (it becomes exposure therapy really).

‘Yes yes, but what about this principle you’ve invented?’, thanks for the reminder…

Heisenberg’s uncertainty principle postulates that:

“The more precisely the POSITION is determined, the less precisely the MOMENTUM is known”

Roughly speaking, determining the position of a particle in space is difficult because all things are in motion relative to each other. So the momentum of a particle is a function of its spatial relationship to other particles (note here the similarity to gestalt’s field theory where behaviour is a function of a person’s environmental/situational relationships).

Consider the earth orbiting the sun. We know the speed with which the Earth orbits the sun because we take the sun to be a fixed point. But of course, the sun is also hurtling through space; it is only a fixed point relative to the planets that orbit it. The moon orbits the earth at the same time as the earth orbits the sun, so how fast is the moon travelling and in which direction? It’s ok, my mind just melted too.

My argument is that the same uncertainty applies to process and outcome in psychotherapy, hence The Staff-Tow Uncertainty Principle:

“The more precisely the OUTCOME is determined, the less precisely the PROCESS is known”

As a guy I once knew used to say, ‘you can have yan or t’other but ye anae avin’ baeth’.

This doesn’t mean that one factor is better than the other, only that you can’t have a full and vibrant awareness of both at the same time. And that’s because the sheer scope of possible outcomes for any given process is huge. In order to arrive with any kind of probability at a pre-determined outcome, the process has to be geared towards that outcome, meaning that the possibility of all other outcomes is closed off as much as possible.

On the other hand, focusing on process, on what is happening right now, opens up progressively more outcomes that themselves become part of the process until there is only process and no outcomes at all. Again, this is relative; in order to define something as an outcome, we have to create a fixed state, and the illusion of an outcome as a final state of affairs.

Strictly speaking, stopping panic attacks only counts as an outcome if we arrive at a point where the person never has a panic attack again. Hence, the outcome is relative to the process of a person’s entire lifetime. And there is one very good reason why, as unpleasant as a panic attack is, the removal of panic attacks is an undesirable outcome; survival. I would quite like to have a panic attack in a life threatening situation if that panic attack mobilised me into running away and surviving.

We can become more precise about our outcome: no more panic attacks in such and such a situation. In which case, we become less precise about the process of being human of which those panic attacks are an expression. We can also become more precise about the process: panicking is a fear reaction to certain environmental factors that were real once but are now largely internalised and projected onto similar situations in the present and actually have as many pros to the individual as cons. In which case, we become less precise about the outcome we’re aiming at.

In gestalt theory, this would be an example of need configuring the field. A desired outcome is our need, so we arrange our perception of our current situation around that need; hence, we are most aware of aspects of our situation that will bring us closer to our desired outcome, and lose awareness of other aspects of our situation. This is a good thing, by the way, because if we were fully aware, moment to moment, of every aspect of our immediate situation, we would quickly lose ourselves in an overhwelmed state in which we would be unable to selectively block out environmental stimuli.

Just like position and momentum, outcome and process are two ends of the same continuum. I think of this as having an outcome/process dial. A CB therapist most likely has that dial way in the outcome direction, whilst the HPC therapist will be way in the process direction. My personal preference as a gestalt therapist is to change my dial’s position depending on the therapeutic situation. Generally speaking, I enjoy being more on the process side than the outcome side. But just try having a traumatic flashback in my therapy room and see how quickly I turn that dial to outcome!

Outcome and process are two ways of focusing the same experiential lens; awareness. Awareness is often likened metaphorically to light (which is apt bearing in mind that light can be considered a particle or a wave depending on the situation). If we use the outcome/process dial to change the focus of the light of awareness, then maximum outcome is going to be highly focused like a laser beam and maximum process something more diffuse like twilight.

Try out this metaphor for yourself. Imagine a dial that goes from (maximum process) 0 to 100 (maximum outcome) with an exact halfway point at 50. What is your dial turned to right now? Where do you habitually keep your dial? What range of settings feels possible/impossible for you? Where’s your comfort zone?

For me, the ideal isn’t to find the right setting on the dial. The ideal is to be able to change the setting from situation to situation by choice; and that is organismic self-regulation.

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