Posts Tagged ‘therapy’

egg timerWe’re often admonished to, “think before you speak!”, and most people, most of the time, would probably agree there is wisdom to that statement. This gives rise to the problem of thinking for too long, and never speaking as a result. It also gives rise to the problem of waiting for one’s turn to speak at the sacrifice of listening. Dialogue can disappear.

One of the main ways trainee therapists prepare for practice is by practising on each other in small groups. A trio of trainees take turns to swap the roles Therapist, Client, and Observer. I remember being client in one skills practice session, and discussing the problem of thinking so much about what I wanted to say that I never got to say it. The person being therapist suggested an experiment: for the rest of the duration of the experiment, I could only take a maximum of 3 seconds to think before responding. They would hold the time boundary and demand I respond if it got to 3 seconds.

This was a very uncomfortable experiment for me, bringing me into contact with shame and anxiety. It also became very energising and liberating. Most importantly, it was an effective learning experience because it generated emotionally charged insights. This is gestalt at its most here and now, when the current moment is itself the power source driving the therapy session.

The lesson here isn’t that 3 second thinking is preferable. An experiment I’ve tried with people who talk a great deal to avoid uncomfortable silences is to sit in silence together until the discomfort starts to feel too great. This kind of experimentation has its roots in behavioural therapy, and usually has the aim of increasing the versatility of a person’s behavioural range. But even this isn’t the lesson for a gestalt therapist.

In gestalt therapy, the aim is awareness. What happens if? Where a behavioural therapy would say, “you are unable to respond in less than 3 seconds, so here’s an exercise for getting better at that”, gestalt therapy says, “you are unable to respond in less than 3 seconds, isn’t that curious? Let’s experiment with that and see what’s going on”.

It’s up to the client to create meaning out of what the experiment turns up. And that awareness is a powerful thing, because once I’m aware of something, I’m responsible for what I do with that awareness. I gain response-ability, and even if I shrug and let that awareness slip away again, that’s a choice I have made. Generally speaking, I find it to be good practice to spend some time contemplating what I need to do with what comes into my awareness; some discoveries come before their time and need to be let go.

Some people need more 3 second thinking. Some people need less 3 second thinking. In both cases, awareness is key.

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Image credit: http://www.aliexpress.com/promotion/promotion_60-second-egg-timer-promotion.html

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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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One of the things that epitomises the character of the gestalt approach for me is the therapeutic use of experimentation. Before entering training, the word experiment for me held connotations of scientists in white coats getting rats to run around mazes for their general amusement (and benefit of mankind of course). This is, I think, a common image association in Western culture; we’re used to experiments being what scientists do. Consequently, when I explain gestalt to interested acquaintances, the ‘and I’ll often invite clients to try an experiment’ part can invoke some interesting looks.

An experiment is nothing more than trying something to see what happens. For the scientist, the purpose of an experiment is to test some hypothesis; if I carry out process x, I would expect to get result y. Plato thought experimentation was un-necessary, and that thinkers could discover the laws of nature through logical thought. Western science disagrees; a hypothesis describes what we think is the case, and the scientific experiment is the means by which we test the hypothesis.

Gestalt is less concerned with testing hypotheses. The purpose for an experiment in gestalt therapy is to move from talking about something to experiencing something. Think of the last time someone told you about how annoyed they are with someone else. A classic gestalt experiment would be, ‘imagine that person is sitting in that chair over there and say all this to them’. The purpose of the experiment is to move from telling me about anger to expressing anger. Telling me about anger involves being one or two steps removed from the emotion itself. By contrast, it isn’t possible to express anger to someone, real or imagined, without being angry.

The aim is to attempt to make contact with those angry feelings and see what happens. A whole host of things can happen at this point. Angry feelings might be too overwhelming, so the person shuts down or cries. The experiment might collapse because the person becomes self-conscious, or feels silly talking to an empty chair. Reading about this example, you might exclaim ‘but it’s not real, there’s no one there!’ which is perfectly true. Then again, when someone tells me about how angry at so and so they are, it strikes me that so and so isn’t there in that example either. Which is another point of the experiment; the original, external target of that person’s anger isn’t available to receive it, so they create a substitute. I’m not willing to be that substitute, so I offer an alternative, equally non-existent alternative; the imaginary person in the empty chair.

The gestalt therapist doesn’t know what is going to happen when they suggest an experiment. All they know is that they’ve had an idea for a way of exploring the material at hand more directly. The experiment is also a novel situation, ie a situation that is new and therefore hasn’t been adapted to. That means we get the chance to witness, first hand, the process of creative adjustment; we get to see the process of adapting to one’s life situation taking place right in front of our eyes. And because that process is now in awareness, rather than taking place automatically in the background without us noticing, we learn something important about how we tick.

Fritz Perls called this the ‘safe emergency’; we feel a state of emergency because we’re doing something that pushes us out of our comfort zone, but it’s safe because we are supported by a compassionate therapist who doesn’t need us to fail or succeed. Gestalt therapists adopt an attitude of creative indifference. When I suggest an experiment, I’m just putting an idea out there; my client can choose to give it a go or not. And because the purpose of the experiment is to see what happens, I’m not concerned with the experiment succeeding or failing. It can’t succeed or fail, it can only be whatever it is. An experiment that seems to fall flat on its face is providing just as much information as one that seems to fly.

When Perls, Hefferline and Goodman first published ‘Gestalt therapy: excitement and growth in the human personality’, the first half of the book was a series of experiments any reader could use to explore the ideas and claims of gestalt for themselves. Self-verification is very important to gestalt therapists. This runs against the grain of our contemporary scientific culture in which validity is associated with being able to demonstrate an evidence base.

There is probably a future blog post in this topic, but for the time being my main point is that an evidence base represents what other people tell you is the case, whereas self-verification is what you have experienced to be the case. The scientists who carried out the experiment they then write a paper about have self-verified; they actually did the experiment. The person who cites their paper as part of an evidence base for such and such a claim hasn’t self-verified. The evidence base is nothing more than a series of claims used by someone to lend weight to an argument or proposition.

Gestalt therapy emphasises self-verification because it is a more vigorous process to try something for oneself than to take someone else’s word for it. A vigorous scientist replicates the experiment they’ve read about to satisfy themselves that the methodology is appropriate and that the process works. Consequently, in the tradition of Perls and co, I will include suggestions for experiments that will help make what I write about in this blog more directly accessible. You are then welcome to try out what I suggest or not. If you’d like to feed back your experience of any experiments then feel free to comment on the post, anonymously or otherwise.

And remember to exercise some self-care in relation to any experiment; the idea is to move from a general talking about something to a direct experiencing of something, so it’s hard to predict who might have strong responses to what. If you feel uneasy about an experiment, just remember that it’s your choice what you do; you don’t have to do an experiment just because I suggest it. And I’m not your therapist, so I won’t be available to support you in exploring whatever comes up. That said, I’m happy to point you in the direction of a gestalt therapist, wherever you happen to be, if something comes up and you feel you need that kind of support; just email me.

Gestalt experimentation is a kind of permission to get back some of that child-like inquisitiveness that too often gets drummed out of people as they adjust to the demands of their life situation. I personally believe that the more outcome-focused a culture becomes, the more inhibited its people become because of the pressure to ‘get results’ ie results judged to be valuable.

For me, being is valuable in and of itself, and that makes life the greatest experiment of all.

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Welcome to 2011. The noughties, a term that has caused me irritation for an entire decade, is over, and the serious business of working out what to call its successor comes to the fore. My money is on ‘the tweenies’.

For me, New Year invariably brings up the context of beginnings and fresh starts. Some years, I have rejected the idea of resolutions, curtly observing that any day can provide a fresh start to anyone in need of one, it’s just a matter of will. Other years, I have appreciated the contextual springboard, and made and broken well meaning aspirations with the best of them.

This year feels like another springboard year. In the midst of my habits and time commitments, many a creative or well intentioned seed has failed to be planted, watered, and grown. What I enjoy about New Year is that it’s a point in the year where my wider social context is geared towards the idea of planting just those seeds that have been hitherto neglected.

The seed currently in question is this blog. For a while now, I’ve been holding ‘psychotherapy’ and ‘blogging’ in my thoughts, feeling something spark between them, and wanting to unleash it upon an unsuspecting world. However, like many, I am at times afflicted with the common vice of thinking too much about a thing and so not getting stuck in and doing it.

In gestalt terms, this blocking process is down to two modifications to contact called egotism and retroflection.

The gestalt concept of contact is ultimately about connection; with other people, the world around us, ourselves. To check what you’re in contact with right now, answer this question: what are you aware of right now? As you read this blog entry, do you stay focused on and interested in what you’re reading? Or have you started scratching an itch, daydreaming about something else entirely, or noticed how hungry you are? As you experience each of these things, you make contact with them; contact is an active process and you do it every second of every day.

Modifying contact is about exerting a degree of control over what we make contact with. This can be a healthy process. Sometimes, I feel like visiting violence upon my laptop when it crashes at an inopportune moment. However, I choose to modify how much contact I make with that destructive urge in order to save myself having to buy a new laptop and potentially losing useful data.

Modifying contact can also be a very limiting process. What happens is that a naturally arising impulse is unable to reach fulfilment. Consequently, the extent to which a person modifies their contact making determines the extent to which that person limits their fulfilment. Back to my egotism and retroflection for a worked example:

Egotism means to think about doing something rather than experience doing something. For example, do I really need to think to myself ‘this orange juice is really tasty’ to enjoy how tasty the orange juice I’m drinking is? No. What I do in that moment is make contact with the thought, which necessitates breaking contact with experiencing the tasty orange juice.

Healthy egotism is taking time to reflect in order to better consider the wider implications of an action. I had good reason to think about my blog instead of starting one on impulse; what about the ethical considerations? What if a client of mine started reading my blog? What if someone read my blog for a while and then contacted me for therapy? What are my motivations for starting a blog? These were valuable questions to chew over. Eventually, however, egotism exhausts the energy of the original impulse (which is, of course, the whole point of the modification) and the end result is… no action.

One of the things therapy has helped me learn about myself is that if I think about something too much, I’ll start imagining doing it instead of actually doing it, and be unlikely to do it at all. Imagining doing something instead of actually doing it is a form of retroflection, the process of doing to yourself what you want to do to the environment.

We visited healthy retroflection earlier when I chose not to attack my crashing laptop. Instead of throwing the laptop out of the window, running into the street, and jumping up and down on it repeatedly Basil Fawlty style, I imagined doing that instead. Just like with egotism, far less satisfying than fully going into and experiencing the original impulse, but in this case saving me from further frustration and incurred expense. Eventually, however, retroflection also exhausts the energy of the original impulse (equally the whole point of the modification) and the end result is… no action.

Imagine living a life in which most of your energy goes into contemplating the issues surrounding what you’re interested in doing, and then only ever daydreaming about what it would be like to do it. This is what I mean by saying the extent to which a person modifies their contact making determines the extent to which that person limits their fulfilment.

So I’m taking the opportunity of New Year to springboard my blog out of contemplation and daydreams, and into full and vibrant action.

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