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A new era of contemporary psychological therapy

A new era of contemporary psychological therapy, delivering robust practice-based research and an integrative intervention in the public sector using digital platforms, on-going monitoring and measurement and a focus on service-user experience, understanding, empowerment and recovery.

As we enter a new year and, hopefully, a new era, are there some aspects of what we do that we would like to bring with us on the landscape of contemporary psychological therapy and some we could usefully leave behind and some that we could draw a line under and start to work above and beyond that line. Forgive the potential allusions to other areas that might be justifiably implicated in the above statements.

EASE Wellbeing CIC continues to deliver a form of existential-phenomenological-humanistic psychological therapy in the #primary care sector of the NHS. We bring with us some of what we know and continue to evolve through #practice-based #research and #client #feedback and outcomes and build upon foundations that are solid.

Can we now bring with us certain ideas such as the knowledge that therapy works better than no therapy? Can we now accept that no therapy has established itself as better than another?

Can we leave behind us professional biases about what is this or that therapy is in favour of articulating clearly what the therapeutic endeavour is aimed to deliver on? Can we leave behind us debates about what recovery means or whether clients want to change?

Can we draw a line that now addresses all human beings’ needs to live a satisfying as possible life within the ontic limitations of such lives, whether they are therapists or people asking for therapy?

Can we now reach for a more adequate exploration and language that embrace human distress and suffering and present a concrete challenge to the medical model that informs dominant taxonomies of disease and is fuelled by corrupt affiliations between stakeholders and pharmaceutical companies?

Everyone encounters difficulties in the course of their lives. At EASE, service providers, called clinicians, and service users, called clients, both have to find the courage to face each other with their concerns to create a truly collaborative endeavour. By this I mean that it takes courage to enter therapy and present oneself as willing and motivated to look at life’s difficulties as a client and we expect clinicians to also have the courage to attend to their own difficulties and have the courage to sit with the pain of the other to be a therapist who is present and able to tune into the world of the therapy encounter.

Thus, we at EASE consider existential ideas in the broadest form of the use of this language to mean addressing the living experience of the client. In this endeavour, we turn to certain aspects of the doing of therapy by drawing on historically acknowledged information about certain common factors as well as developing contemporary and innovative ideas, such as focusing upon client-attributable factors and using creative ways of understanding what it is that a client wants from therapy.

Our struggle has been to embrace the tension identified by Plato in Meno’s Paradox and addressed by Merleau-Ponty. That is the notion that in order to discover something one needs to know what one is looking for versus how can one discover anything new if one already knows what one is looking for? In order to do this, we have published and presented a number of ideas in journals and conferences.

To summarise:

Change is inevitable ontologically and in therapy we have illustrated what this change may look like – ref JHP 2015 results
Understanding is a form of change thus can be considered as valid as previous publications have demonstrated – ref (CORE Blimey)
Evidencing this is clearly possible without challenging the current measurement systems (ref Hermeneutic Circular/JHP/ Grids paper in print and previous)
Our ongoing programme of research now turns to delivering a replicable protocol that allows for personalising the approach of the EASE intervention (JHP 2016) and focusing upon how clients reflect upon their experiences of therapy (ref research in progress ). Initial findings both do what most research does, which proves what it sets out to prove but, more importantly, give rise to what may be useful in future research. Given our commitment to evolving this and that we exist in the health and social care organising system that we live in, means that we have to communicate in language that addresses public sector requirements around adherence. Further, however, this research indicates that there is more interesting work to be done to focus more rigorously on what clients want from therapy and establish potentially optimal length of therapy to manage clients’ expectations.

Given the statements I began with, this opens up much interesting work to be done. Three areas that are on the horizon and being considered currently are: first, delivering different lengths of therapy with ‘similar’ client groups to identify if there are differences and what they might be around length of therapy; second, to review what clients articulated was beneficial about therapy and build upon this; third, if the therapeutic relationship is an important factor in the percentage of positive outcomes of therapy, establishing what the essential qualities in this ‘relationship’ are or might be. Of course, these may have overlaps and be intertwined in certain ways as clinical work and research are also but both and all are aimed at clarifying and re-clarifying in the spirit of the one phenomenological project we may only ever need to do since every person we see in therapy adds to our understanding of human existence and struggles.

We know it’s not the #psychotherapy model or #therapeutic techniques that matter – it’s the #human #being

For a number of years, debates have been rampantly widespread about the way we do therapy, what it is about therapy that works.  Since Rosenzweig in 1936 first raised this issue, psychoanalysts debated through clinical case studies what was effective and first coined the now famous dodo bird verdict.  This, some years later led to the issues raised first in 1975 by Luborsky in his paper with the famous Alice in Wonderland quote.  More recently, it has become commonplace to re-augment the scientific approach to establishing effectiveness through randomised control trials.  Clearly, there is good reasoning for this as these trials have to be conducted in environments that can exclude many variables and rely on delivering a therapy from a manual in order to try to deliver conformity.  However, we know that these types of therapy are less effective in naturalistic settings.  However, it remains important to try to know what it is that we are doing….but we still do not really know what part of what we are doing is the effective part.  Common factors approaches tried to establish what are those aspects of therapy that are common to all therapies that are effective.  Yet the war rages on.

This post comments on the graphical representation of aspects of therapy demonstrated by Lambert’s Pie.  What this shows is that only a small proportion of effectiveness is due to technique, another small proportion is due to expectation and placebo.  The two largest segments of the pie are due to relational factors and the most significant slice relates to what are known as client-attributable or context-related factors.

Miller and Hubble wrote an important contribution called the Heart and Soul of Change and Schneider provided an erudite treatment in his two editions of Existential Humanistic Therapy.  Only Ernesto Spinelli has in recent years provided a framework for the delivery of existential therapy.  The profession however as well pointed out by Jeffery Smith continues to do battle over modality, professional status and diagnosis as a number of books by prominent psychiatrists try to dissemble the vast array of confusing labels.

Our form of existential-phenomenological humanistic therapy recognises the need to measure whether some type of therapy is effective and tries to manage the tension in allowing for creativity, flexibility and individuality in therapy while retaining an element of operationalization of the process in order that we can assert with a degree of assurance that the interventions that we are delivering are measurable and contain elements that are effective.

Therefore, we have designed and tested a form of therapy that focuses primarily upon the qualities of the therapeutic relationship and empowering the client, in order that those factors in the pie are ignited and that the therapy may be more successful, whilst being measurable and informed by existential attitudes, a phenomenological method and humanistic principles, in order to address the breadth of human experience, challenge the medical model and stigma associated with psychological difficulties.

Integrating physical and mental healthcare

EASE (Engaging Activity Supporting Existence) is a Community Interest Company set up to provide an integration of physical and mental healthcare services. Specifically, EASE clinicians work alongside and collaboratively with medics who treat people with a range of physical healthcare needs that have psychological components or ramifications. For example, there is clear evidence about how untreated conditions lead to premature mortality in people who have mental health concerns and do not routinely address physical healthcare needs. However, more importantly, many physical conditions lead to psychological and emotional distress which not only inhibits the person further but may exacerbate the physical conditions as well as lead to compound pharmacological interventions that are complicated to manage and often conceal the co-morbid or multi-morbitity of the difficulties. Most clearly, it is apparent when people are diagnosed with cancer or other potentially life-threatening or limiting conditions where the initial diagnosis is a shock, the treatment is lengthy and requires psychological resilience, the outcome is unclear so hope is called into question, meaning of life issues arise as well as a host of other concerns. Further examples such as asthma, ME,fibromyalgia and other conditions are difficult to treat simply from a somatic stance and it is known that approximately 30% of all GP consultations involve psychological presentations

Recovery

Mental health services should aim to achieve what medicine has achieved in many areas.  Treatment that produces recovery!

However, psychological or psychotherapeutic treatments are not the same as medical treatments.

Medical treatment can reliably rest upon the identification of symptoms of or manifestations of illness, whether it be a virus, infection, lesion or other physiological dysfunction, disease or malady.  Contemporary medical science is reasonably able to accurately identify, diagnose, treat and cure most physical or somatic complaints.

Psychology is not!  Why not? Because the ability to accurately identify emotional, psychological or existential malaise relies upon observation and interpretation which is not sufficient to adequately state with reasonable accuracy what is wrong and, thus, what would resolve the difficulty.  This is because of the centrality of the person in the role of the client in the field of psychology.  in this field, what the person says about their experience of difficulty or distress is as important, if not more important, than what a clinical expert is able to interpret, far less able even to observe with any degree of reliability.

Therefore, recovery is a complicated notion in this arena of mental health treatments.  Keeping aside political persuasion and economic arguments, recovery is possible if one of two possible positions are adopted in relation to the treatment of the person who expresses emotional or psychological or existential distress or difficulty.

First, recovery is possible if what is wrong is subjected to a different system of taxonomy than physical illness.  in other words, the language of illness needs to be re-construed in order that the notion of recovery is not recovering from something but recovering  one’s life or recovering for….

Second, recovery is possible as long as you do not define recovery in terms of the reduction of pathology or symptomatology but rather the creation of a manner of viewing the world in terms of embracing the inevitable difficulties that have to be faced in life in order for it to be understood by the person and experienced as meaningful.

Either of these two positions make recovery a possible and plausible reality for people and they further raise questions about the role of the clinician or practitioner invested in the work of providing treatments that aim for recovery that will be addressed shortly.