..and I ask myself- how did we get here?

Person-Centred Experiential Counselling for Depression

– and I ask myself- how did we get here?

To carry on with the specific subject of my first blog entry, I am sharing another piece originally drafted a few years ago, and updated this month.

 This blog describes the development and delivery of Person-Centred Experiential Counselling for Depression (PCE-CfD). It is an evidence based and accredited approach that has been accepted for counsellors working for Increasing Access to Psychological Therapy (IAPT) services in the English National Health Service (NHS).

(With thanks to Gillian Proctor and Stephen Joseph for their initial input)

Person-centred therapists have long seen themselves as offering a way of helping that challenges what they see as the unnecessary and harmful medicalisation of distress.  Brian Thorne, one of the leading figures in the person-centred community, said:

I believe we are involved in a battle which is concerned with power, with freedom, with transformational love, with the evolution of the human spirit. Put that alongside symptom reduction, treatment plans, empirically validated procedures, best practice, and NICE guidelines, and you begin to see the collision of worlds (Thorne, p 22, 2009).

Is it a lost battle, to continue with Thorne’s metaphor, now that the person-centred approach struggles to sustain public funding in an increasingly barren landscape, as the grip of austerity has squeezed the voluntary sector to such an extent, that the only option left is to somehow gasp for a place within the NHS IAPT service?

For the past three decades cognitive-behavioural therapies, have become embedded into health services.  CBT therapies are consistent with the dominant medical model.  In the early years, cognitive-behavioural approaches were developed to help people with depression but have since been adapted and extended to treat people experiencing a wide range of diagnosed ‘psychological’ disorders.  It is an approach whose practitioners on the whole do not question a need for specific treatments for specific disorders.  Thus whilst cognitive-behavioural therapists have been developing their approach in such a way as to fit the needs of a medicalized health service, person-centred practitioners for ideological reasons have not. 

In fact, person-centred practitioners, writers, educators and academics argue for principled opposition to the medicalization of distress.  In short, we should have nothing to do with it. Over ten years ago Sanders quotes Shlien who wrote:

‘There is no advantage in cooperating with the dominant clique. The lion and the lamb may lie down together, but if it’s in the lion’s den, the lion is probably quite relaxed, looking forward to breakfast in bed’ (2005 p. 35).

The lamb in this metaphor is the person-centred approach which will not fare well if it compromises its principles and aligns itself with the medicalization of distress. Looking into the future ten years ago, one would be surprised to discover that one of the leading developments is that the lamb has walked  directly into the lion’s den. As yet, the Lion hasn’t really noticed, but psychotherapists, counsellors and those concerned with social sciences and education have.

Long long ago..

Across England in the 1980’s  the provision of counselling had been reliant on Primary Care Trusts (PCT) decisions as to whether  counselling was to be accessed through charities or centrally through the NHS. During the era of GP fundholding in the 1990’s, many counsellors were employed, or registered as self-employed, and engaged by GP’s who were particularly interested in mental health. This resulted in the provision of counselling services across England being inconsistent and many areas of the country had no free counselling services offered by employed therapists at all.

In the era of New Labour (1997-2010), a focus on mental health arose due to mental illness being seen as a big reason for the high sickness benefits bill. The London School of Economics identified that the main cause of claims for sickness benefit was depression (2006). The economist, Layard, argued that by investing into psychological therapies this cost would be minimized.   Initial pilots of services offering very short-term Cognitive Behaviour Therapy (CBT) demonstrated some success and a massive investment into psychological treatment were announced in 2008. As Rogers states (2019):

IAPT has been driven by an unambiguous ideological agenda. Its goal is to reduce the welfare bill by rolling out ‘cost-effective’ (cheap, fast), NHS-based talking therapy in order to get depressed and anxious benefits claimants back to work ‘

IAPT services were set up with a clear focus on short-term work. New posts were funded for therapists to train in CBT and many aspiring CBT therapists were recruited with no requirement for a prior qualification in therapy. Experienced counsellors already offering talking therapies within the NHS were not considered to be offering evidence based treatment and many counsellor contracts were discontinued.

The investment into IAPT has been replicated by each subsequent administration especially by the 2011-2015 coalition government. The Health Minister, Norman Lamb strongly advocated the case for psychological therapy throughout his term in office. In 2016 Jeremy Hunt was quiet about IAPT but announced ‘massive investment ‘into mental health.

Friedli and  Stearn (2019)  highlight and question the motivation for government funding of psychology in order to implement  their wish to reduce the unemployment bill:

‘There has been little debate about the recruitment of  psychology –and, by implication, psychologists – into monitoring, modifying and punishing people who claim social security benefits (Friedli & Stearn, 2013; Cromby & Willis, 2014) or research into the impact of mandatory positive affect on an expanding range of ‘unproductive’ or failing citizens

(Howell & Voronka, 2012): those who are out of work, not working enough,not earning enough and/or failing to seek work with sufficient application.

In 2008, on the same day the investment into psychological therapies was announced, Robert Elliott and Elisabeth Friere shared the results of their meta-analysis into all the research carried out into person-centred related therapy.  They concluded that ‘Person-Centred/Experiential (PCE) Therapies are highly Effective’ and this was announced at the World Association for Person Centered & Experiential Psychotherapy & Counselling Conference at the University of East Anglia (Elliot and Friere, 2008). This evidence offered the person-centred community potential legitimacy within the specific demands of publicly funded evidence based treatments. That very same day as already mentioned,   the press statement supporting the principle of the investment of money in talking therapies within IAPT  was specifically and only for , in their view, the sole existing  evidence based treatment.  IAPT was in fact to be a CBT service and nothing else. At that point ‘talking therapies’, for IAPT  was CBT.

In response, the  head of research for the British Association for Counselling and Psychotherapy (BACP), Andy Hill, was determined to ensure that thousands of BACP members did not lose their place in the NHS, and that clients could still access free on delivery counselling. The need to include counselling as an option within NHS talking therapies became seen as a battle to prevent the end of person-centred counselling across the country.

As a result of determination and hard work by numerous international researchers and practitioners, this challenge became an opportunity for counselling and psychotherapy, resulting in the creation of the curriculum for Counselling for Depression a person-centred and experiential approach. (CfD) (Hill, 2011; Sanders and Hill, 2014).

            (PCE)-CfD ( the title changed in 2018) was developed using theory and research from person-centred and emotion-focused therapy.  As such it is grounded in the theoretical stance established by Rogers (1959) that each individual has an inherent potential for growth, and that this potential will be released under the right relational attitudes characterized by the six necessary and sufficient conditions for therapeutic change.

            The authors of (PCE)-CfD articulated how person-centred and emotional focused theories could account for  experiences described and labelled by the DSM as  depression. An example from person-centred theory, shows a depressed experience  results from discrepancies within the self, i.e. between the person we believe ourselves to be, the person we  believe we should be, and the person we think others see and experience. The intensity of that discrepancy will vary from person-to person, and resulting life experiences  range from  finding it impossible to move from  a bed or a chair, to those who find no reason to exist in life and  just go through the motions  of a life half lived.

            Understanding how person-centred theory accounts for  specific conditions can be a means of empowering the therapist who may otherwise come to believe that to work with a particular client group they need other forms of training or knowledge. The therapist can enter into dialogue about how the person-centred approach can be helpful. For anyone employed by IAPT, PCE-CfD has become the required qualification for  person-centred counsellors. The course attendance is becoming increasingly  mandatory, however the places are funded by health Education England, or the specific trust.

Since the coalition, and the subsequent conservative government, the huge focus on Brexit has dominated  parliament and government. During this three years of stalemate, we hear alarming incidents of benefit related suicides, loss of  funding for children’s centers, the demise of the voluntary sector,  people being detained in mental health silos run by private companies, police being the front facing force dealing with suicidal and psychotic breakdown, yet somehow the Government deny this is related to austerity, and argue there is more access to benefits, to therapy and to services than ever before. The picture is distorted and muddled, yet the suffering goes on.

Penelope Campling (2019)  highlights:

Despite government claims that NHS spending has been protected from the cuts that other government departments faced, when the increasing percentage of elderly patients and the known extra-inflationary costs of health spending are taken into account, there is clear evidence that healthcare spending has been proportionally lower than at any time since the 1970s, and markedly lower than other countries such as France, Germany, Sweden and the Netherlands (Office for National Statistics, 2016).

For some, PCE-CfD represents a necessary compromise that has led to the re introduction of person-centred ways of working in the NHS, albeit at a cost of being perceived as colluding with  diagnostic procedures and an illness ideology  where  specific conditions  require specific treatments. Without proper representation throughout this project, even if the actual approach isn’t compromised, the general perception offered by critics and campaigning groups, unequivocally argue PCE-CfD is inherently aligned to the medical model.  Even the language of ‘dosing’ is applied in IAPT . It aligns the idea of counselling as a ‘treatment’ that has a certain amount of ‘doses’, as if only  language that mimics  medicine is comprehensible to commissioners  who fund the services.  It seems there is serious work to be done in order to inform and educate those who hold the power and the money. Being human is not an illness in itself and emotional distress is best responded to ,not by medical ideology but by a humane and proven attitudinal stance which engages in the specific context of the person seeking counselling, offered by person-centred experiential counsellors who hold values that are aligned with a growth approach to distress,  in all its manifestations.

Many hundreds of delegates across the United Kingdom have now trained in PCE-CfD, which involves an intensive week of experiential learning to top up their previous trainings. The previous blog offered some insight into that. PCE-CfD is establishing itself along with other NICE mandated alternatives to CBT. These include IPT (Interpersonal Psychotherapy) and DIT (Dynamic Interpersonal Therapy). To date, PCE-CfD has the highest number of trained counsellors next to CBT practitioners in IAPT. However according to the Iapt 2014 workforce audit (unfortunately the public access link has disappeared since 2016), they still represent a tiny percentage of the IAPT workforce (9% of the entire workforce are trained in a non CBT approach and nearly half of these are PCE-CfD trained)  

Steen (2019) referring to research carried out by Barkham et al (2017) states  :

.. there was a 35% decrease in the number of qualified counsellors working as high-intensity therapists between 2012 and 2015, despite the total IAPT workforce growing by up to 18%.

PCE-CfD may seem like a compromise too far.As already noted, the language used in mental health services indicates how little progress there has been from a person-centred perspective. For example, Rogers’ use of the term ‘client’ was considered revolutionary in the 1950’s. More than a semantic distinction, the idea behind this shift in terminology was not so much about what word the therapist actually uses but how they think about what they are doing.  The term client connotes a departure from the medical model of illness. The term emphasizes that a person seeking help should be not treated as a dependent patient but as a responsible person. Yet, mental health services still refer to ‘patients‘. IAPT services expect all their staff to cluster their ‘patients’ in their first appointment. This expectation for a PCE-CfD therapist goes against all the principles of the approach, by requiring therapists to put their client into a category rather than understand and accept them as a unique person. Having gone through a cluster training myself when I worked for a charity funded by IAPT, I tried to pose the arguments for the position I was specifically in as a person-centred therapist. At this stage I also held the PCE-CfD license and was training people at the University I still work for. I thought they may be interested in my view. Not only was I asked to leave the training for  asking too many questions, I was also ridiculed by the trainer in front of everyone (if she doesn’t get off my tits, I’m going to tell her to leave’.) When I lodged a complaint, my employer took the side of IAPT. My union stated I had no case to make as alternative training was being provided to ‘upskill’ me. I had no option other than to resign.

However

Is it right that practitioners  have to continue to argue their case individually  in order for their non-medical stance  to be recognised,  valued and supported?  PCE-CfD therapists need to demand they are in receipt of PCE-CfD supervision. PCE-CfD counsellors should  not be expected to cluster ‘clients’. PCE-CfD Supervisors have clinical governance over case management issues. Targets cannot be  prioritized over process. From this stance, services could grow  and move in a direction where  not only clients can flourish, but also  their therapists. Yet the relatively newly formed Psychotherapy and Counsellors Union (PCU) takes a very clear anti- IAPT stance, for many important and commendable reasons. This means though that PCU are not going to attract membership from PCE-CfD practitioners employed by IAPT, who potentially need their support. Anyone with any knowledge of PCU will see clearly that PCE-CfD and all IAPT therapists are perceived and characterized as pariahs. PCE-CfD therapists need the support of a specialized Union, such as PCU to demand their rights to access theory consistent supervision. They need to argue for employment rights, as many are employed on zero hours contracts. They need to ensure their approach is captured through  theoretical consistent data collection rather than just tied to the minimum data set(MDS).

Having been present when IAPT started to impact on charity run counselling services, I recall the arguments that went back and forth, and indeed made them about sessional collection of MDS. The final argument being- you want funding, you do this. I had to be re interviewed for my post as a result of the fuss I made. On this occasion my union could support me as I agreed to comply. So, ‘we did this’.

Eight years on, the evidence (TT 2016 p 45),  from the MDS showing that PCE-CfD was more effective than CBT in a shorter period of time,  was ignored  by ’NICE’. The cards seem stacked continuously against anything associated with a growth approach to change.

 Was the development of PCE-CfD worthwhile despite all of this?  Has it resulted in the further commodification of counselling, unwittingly creating a medicalised version that renders at its heart a hollow replica of the original philosophy? The description of PCE-CfD being ‘manualised’ is a big disservice in my view. As my previous blog shows, those who engage in the intensive PCE-CfD week do not experience the week as an introduction to a manual.

The question I am left with is, who is championing PCE-CfD to, or in the NHS? Critics abound and their arguments are valid and strong. The idea of IAPT being driven by a neo liberal agenda is indisputable. As a government funded body it seems inevitable in these times. Everything has a price, cheap is best, quality is to be ignored. What is not known however, is that the lower paid PCE-CfD counsellors are delivering quality, as the numerous in practice recordings that come through the institute I work for, testify. This is despite, for many, a working environment that neither recognizes nor supports their practice once the qualification is gained.

The research carried out by Proctor and Brown (in press) describes a familiar and dissatisfactory snapshot of therapist’s experiences of working in IAPT. Inevitably the research can only speak of those 15 therapists who participated. Many others engaged in IAPT services have different experiences and enjoy a better work culture- however, as was the case for Gillian, this view can only be offered as ‘anecdotal’ and so loses credibility.

For me, there is a permanent and almost numbing dilemma. On the one hand, the NHS Mental health lead refused to participate in the 2019 IAPT ‘New Savoy’ conference because she did not wish to have the ‘world’ class IAPT service criticized, indicating an undemocratic and  uncritical position, seemingly fearful of being challenged. On the other hand BACP are cosying up to all things IAPT, seemingly driven by an anxiety to represent their membership, as without a seat, the entire profession could disappear. In the process of doing this they appear unaware of the dangers that lurk which will compromise not only  PCE-CfD therapists, but all who describe themselves as counsellors and psychotherapists from any approach. Those who challenge BACP and ask them to be more vocal and more critical are viewed with hostility and as problematic. It seems those in control of BACP lack the knowledge and insight to understand the arguments, or are so intent on sustaining a piece of the IAPT pie and keep their members trapped within their professional body, they don’t actually care. Or is it simply they do not have enough thinking or reflection time to really consider it all properly. The fact is BACP, its members and all the other associations are less than a lamb being sent to the lion’s den, more like a flea on the end of the Lion’s tale. We are insignificant.

Thorne pointed out at the start of this essay,

…we are involved in a battle which is concerned with power, with freedom, with transformational love, with the evolution of the human spirit. Put that alongside symptom reduction, treatment plans, empirically validated procedures, best practice, and NICE guidelines, and you begin to see the collision of worlds (Thorne, p 22, 2009).

Perhaps that was the moment we should have said ‘no’ we won’t comply. The lost counselling jobs would not have been replaced with IAPT posts, and counselling trainings would once again be in the domain of those who could afford to engage in a pursuit for the wealthy, or offered by the wealthy. Counselling would once more reside for those who could afford to pay or offered by those who could afford to not be paid.

The NHS itself is under threat . The so called jewel in our democratic crown is more at risk now of being sold than at any other time in its 71 year history. We all wish to ‘save the NHS’. Neo liberal IAPT,’s  incalcitrant child, PCE-CfD’s, attempt to preserve the beauty, delicacy and unique nature of a psychotherapeutic relationship, where a person can feel free to be who they are with no fear of being summed up or measured, may not thrive .

Nevertheless we have hundreds of PCE-CfD therapists employed throughout England who offer Person-Centered Experiential counselling free for up to 20 sessions. There is no specific body or individual who  is holding the line for PCE-CfD, demanding appropriate supervision for the  therapists, explaining why ‘clustering’ does not match the ethics of the approach,  maintaining the ‘up to 20 sessions’ growth approach, and arguing for therapy consistent measures for more accurate data. Those of us involved in offering the week long experiential cpd and subsequent  license, achieved over a year, will do our best to support our delegates during and post qualification to support them to argue for themselves,  for their clients, and its seems, for the integrity of the person-centred approach.

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