..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.

REFERENCES

Campling Penelope,’(2019) The industrialisation and marketisation of healthcare’ in Jackson C  and  Rizq R (eds) 2019 The Industrialisation of Care: counselling, psychotherapy and the impact of IAPT;  Ross –on –Wye : PCCS Books

CORE IMS (2001) [online], available: http://www.coreims.co.uk/About_Core_History.html

HSCIC [2011], available:  http://www.hscic.gov.uk/mhsds

Elliott R., Watson J. C., Goldman R. N., and Greenberg L. S (2004) Learning emotion focused therapy: The process-experiential approach to change. Washington DC: APA

Friere, E. & Elliot, R. (2008) [online],available:https://www.pce-world.org/about-pce/articles/102-person-centredexperiential-therapies-are-highly-effective-summary-of-the-2008-meta-analysis.html

Hill A (2011) Curriculum for Person-Centred Experiential Counselling for Depression [online], available:

IAPT Adult Workforce Report (2014) [online], available: http://www.iapt.nhs.uk/silo/files/2014-adult-iapt-workforce-census-report.pdf

London School of Economics (2006). The Depression Report. A new deal for depression and anxiety disorders. Centre for Economic Performance’s Mental Health Policy Group, LSE.

Proctor, G. (2015) The NHS in 2015. Therapy Today, Nov, pp 19-26.

Proctor G and Brown M (2019) ‘ Industrialising relational therapy: ethical conflicts and

threats for counsellors in IAPT’ in   Jackson C  and  Rizq R (eds) 2019 The Industrialisation of Care: counselling, psychotherapy and the impact of IAPT;  Ross –on –Wye : PCCS Books

Reeves A (2016) From the Chair Therapy Today June, p 45)

Rogers A (2019) Staying afloat: hope and despair in an age of IAPT, in Jackson C  and  Rizq R (eds) 2019 The Industrialisation of Care: counselling, psychotherapy and the impact of IAPT;  Ross –on –Wye : PCCS Books

Rogers, C. R. (1959) A theory of therapy, personality, and interpersonal relationships as developed in the Client-Centered framework. In S. Koch (Ed.), Psychology: A study of a science. Vol. 3: Formulations of the person and the social context New York: McGraw-Hill. pp. 184–256

Sanders P (2005) Principles and strategic opposition to the medicalization of distress and all its apparatus. In: Joseph S, Wolsey R (2005)(ed) Person-centred Psychopathology A Positive Psychology of Mental Health pp 21-42  Ross –on –Wye : PCCS Books.

Sanders P and Hill A (2014) Person-Centred Experiential Counselling for Depression London: Sage.

Steen S (2019) A critical appraisal of the economic model underpinning the Improving Access to Psychological Therapies (IAPT) programme in Jackson C  and  Rizq R (eds) 2019 The Industrialisation of Care: counselling, psychotherapy and the impact of IAPT;  Ross –on –Wye : PCCS Books

The IAPT Data Handbook (2011) [online], available: Version 2 

Click to access the-iapt-data-handbook.pdf

Thorne. B (2009) A collision of Worlds.   Therapy Today, 20, 22-25.

Welcome to My New People Blog

It is hypothesized that there is a formative directional tendency in the universe, which can be traced and observed in stellar space, in crystals, in microorganisms, in organic life, in human beings. This is an evolutionary tendency toward greater order, greater interrelatedness, greater complexity. In humankind it extends from a single cell origin to complex organic functioning, to an awareness and sensing below the level of consciousness, to a conscious awareness of the organism and the external world, to a transcendent awareness of the unity of the cosmic system including people. It seems to me just possible that this hypothesis could be a base upon which we could begin to build a theory for humanistic psychology : Carl Rogers (1978) https://www.centerfortheperson.org/papers/The-Formative-Tendency.php



It is hypothesized that there is a formative directional tendency in the universe, which can be traced and observed in stellar space, in crystals, in microorganisms, in organic life, in human beings. This is an evolutionary tendency toward greater order, greater interrelatedness, greater complexity. In humankind it extends from a single cell origin to complex organic functioning, to an awareness and sensing below the level of consciousness, to a conscious awareness of the organism and the external world, to a transcendent awareness of the unity of the cosmic system including people. It seems to me just possible that this hypothesis could be a base upon which we could begin to build a theory for humanistic psychology : Carl Rogers (1978) https://www.centerfortheperson.org/papers/The-Formative-Tendency.php

A start

I’m Kate, I am fascinated by the depth and complexity of the person-centred approach. This blog is my offer to share things I’ve written, pictures I’ve taken, ideas I wish to experiment with

I’m doing this now because it is now.

The following was written a few years ago. I hope it is of interest.

II

Person-Centred Experiential Counselling for Depression Training

A view from both sides

This article tracks the emergence of Person-Centred Experiential counselling for depression (PCE-CfD)  within ‘Increasing Access to Psychological Therapies’( IAPT) and explores experiences of Person-Centred Experiential counselling for depression training and PCE-CfD in practice.

In 2008 at the World Association for Person Centered & Experiential Psychotherapy & Counselling Conference at the University of East Anglia,  Elliott and Friere shared the results of their meta-analysis, concluding that  Person-Centred/Experiential (PCE) Therapies Are highly Effective 1

This research, funded by the British Association for the Person-Centred Approach, came at a crucial time for those interested in supporting person-centred experiential therapy within the academic mainstream. Research in England,in the last century into  the person-centred approach had dwindled in favour of developing the attitudes that characterized the theoretical stance, and any research that was carried out, focused on qualitative experiential data. No harm in that, however, it’s not the sort of data that is welcome, or even recognised in circles that hold budgets and power.

At the same time as the announcement on the results of the meta analyis, practically on the same day, Lord Layard announced an unprecedented investment   into ‘psychological therapies’, a policy named ‘Increasing Access to Psychological Therapies’ (IAPT)2.

The announcement of this investment into psychological therapies caused shock waves across the country. Investing in mental health had been scarce, however, the bombshell was, counselling was not included in the guidelines.  Consequently many counsellors discovered they no longer had a job. The investment by the NHS was solely focused on training up a new workforce of CBT practitioners.

 In response, and in order to support their membership, BACP created ‘Person-Centred Experiential counselling for depression’ (PCE-CfD). This took great determination and hard work by numerous international researchers and practitioners. Some call the creation of PCE-CfD a desperate fudging in order to meet the agenda for  political game playing. It is not a popular topic in many circles. However PCE-CfD is characterised, without it, the chances that counselling would have diminished as a valid activity supported by the NHS, would be even greater than they are today.

 Person-Centred Experiential counselling for depression is a PCE therapy that incorporates aspects of emotion focused therapy  (EFT)  and has been validated by Skills for Health and NICE (National Institute of Health and Care Excellence)4. This evidence based approach incorporates the theoretical stance established by Carl Rogers (1959)5, that an individual, given the right facilitative conditions, will grow towards health regardless of the nature of the distress.

 In the case of ‘depression’, theory acknowledges the impact of discrepancies that emerge for a person when struggling with their feelings (see Sanders and Hill 2014)6 . These conflicts can flatten or overwhelm an individual and ‘symptoms’ emerge that are considered typical of a person diagnosed with mild to moderate depression. Frequently clients are characterised as feeling ‘stuck’. By enabling an environment that offers the necessary and sufficient conditions for therapeutic change (Rogers 1959),5 the therapist is alongside the  client  as s/he is able to explore all aspects of their life ,frequently resulting in the client  giving expression to  aspects of their experience that have been suppressed, flattened, criticised,  judged, overlooked , ignored or stifled.

EFT, a specific approach to working, and part of person-centred experiential therapies , offers theory around the function of emotions and various focused ways of enabling clients , who typically are ‘stuck’, to sustain  levels of emotional arousal. The evidence from EFT, mainly generated in Scotland, contributed greatly to the validation of PCE-CfD by NICE.

Gaining a secure place for person-centred counselling in the NHS has been a long hard road with a difficult and painful history. Since the introduction of PCE-CfD, new job opportunities for therapists within National Health Service (NHS) funded services are opening up. Numerous concerns exist in regards to the presence of the person-centred approach within the NHS. Is this collaboration with a diagnostic system a compromise too far? Surely existing as an independent service in GP practices was preferable to being incorporated into the NHS wholesale? Catherine Jackson’s Therapy Today article in July 2016 (p 6-9 ) ‘Does counselling make a difference?’ pointed out, the post code lottery- one of the main rationales for IAPT, is still very much in existence five years on from IAPT  being rolled out.

 Measuring Effectiveness

In order to support their investment into developing PCE-CfD, BACP commissioned an RCT (randomised control trial) called: Pragmatic Randomised Controlled Trial assessing the Non Inferiority of Counselling and its Effectiveness For Depression  (PRACtise)10. The results will be announced in 2019

One of the requirements of any IAPT service involves every therapist collecting session by session data using a tool called the Minimum Data Set (MDS)11 . This data is essentially looking at symptoms and was originally devised for use with pharmacological treatments.

Anecdotally, many PCE-CfD clients report relief, are able to become less rigid in and more accepting of their feelings and discover new aspects of themselves that had either been suppressed or forgotten and are able to risk ‘authenticity’ which potentially prior to engaging with therapy was a rare experience or something that held too much risk of not being liked or accepted by others.

‘One day, to his amazement, Peter had made a decision to go and visit a relative

with his wife, a journey he had not made for a very long time. He felt that

as there was not pressure on him he could make a decision to go. He asked

me why I thought that, when he woke up at night, rather than worrying about

everything he felt a deep sense of peace. We explored why that might be and

he decided it was because he had been heard properly and that he no longer

felt any pressure to get better’ (pg 220  Hayes K)7

Presently, there is no way of capturing the nature of that shift Peter describes above using the MDS that PCE-CfD practitioners have to complete for IAPT. This awareness of the limit of MDS is shared with others who are involved in PCE-CfD services. In Jackson’s article (2016) Jessie Emilions states’

‘I support the use of outcome measures in principle, but I prefer CORE, because it includes a more subjective assessment of changes in a client’s experience of their life and their relationships, not just their symptoms.’(2016 p9)

 CORE isn’t used by IAPT and so evidence that more accurately capture the nature of a counselling client experience has no influence on NICE.  Vicky Palmer states:

‘I just keep telling them there is plenty evidence out there that counselling is effective, it’s just not in the form of trials that qualify for the NICE guidelines’(2016  p8)

The amount of evidence that is being collected from ‘counselling’ by the minimum data set, and reported in the 2014/15 HSCIC report shows ‘counselling’ as effective as CBT  in a shorter period of time.

The Therapists View: Training in PCE-CfD

Delegates who attend PCE-CfD courses are experienced and qualified therapists funded to train by their Clinical Commissioning Group  (CCG). The evidence for PCE-CfD is as a brief therapy for up to twenty sessions.

It is arguable that the investment into PCE-CfD by the NHS has had benefits to individual counsellors who up till then had felt previous CPD trainings lacked relevance. The following statements were offered between 2013 and 2015 from different therapists in different cohorts from different regions who attended PCE-CfD training.  

‘I had given up hope of my NHS work providing training and development that had relevance

‘I felt contained, educated and cared for throughout the five days .The delivery of the course has been exceptional from start to finish.  The trainers have facilitated a learning environment that I have treasured’(Debbie 2014)

‘I thoroughly found the course experiential I found the pace and content enjoyable It felt safe to make errors I enjoyed the democratic approach of the tutor. Very refreshing and real’

This does not match  how many perceive PCE-CfD training. ‘Our accredited counsellors see this as teaching them to suck eggs, but because PCE-CfD is recommended by NICE, and humanistic counselling hasn’t been, CCGs’ hands are tied’ (2016 p7)

Regardless of the seeming vortex of complications IAPT evokes, PCE-CfD training seems to be  a great opportunity to reconnect counsellors to the theoretical roots of their practice and encourage further understanding of the process of therapy. It commends the agency or as person-centred therapists would say, the actualising tendency, of the client and consider what that means within a phenomenological counselling relationship. Despite the name –Person-Centred Experiential counselling for depression- it is clear theoretically that the approach is not exclusively for depression and is an approach for many manifestation of distress or ‘incongruence’. It may have more meaning if PCE-CfD became PCE, ‘Person-centred and Experiential Person-Centred Experiential counselling for depression’. That would represent the approach more transparently and be less confusing for Humanistic or Integrative counsellors who may be expecting when they attend PCE-CfD training, something to add to a tool box, and instead encounter an attitudinal approach that is very true to the original principles established by Rogers in  1959.

These quotes are from past delegates who attended training between 2013 -2016.

 All have qualified in PCE-CfD and were from a variety of regions in England and from different versions of IAPT.

 NHS therapists have been expected to complete much training in their roles over the years and often that training had little connection to their initial training as a therapist.

One delegate responded enthusiastically,

 “Are you interested in completing a humanistic evidence-based training, endorsed by the Department of Health, for counsellors who already have grounding in a humanistic modality?”…This is not a question that I hear very often as an NHS counsellor. Hence my eager response of “When do I start?’

A more typical reaction is the one shared by a delegate from a different region: ‘When I was first told that I would need to attend PCE-CFD training, I suddenly felt de-skilled and feared failing, all within a heartbeat.’

PCE-CfD training encourages an experiential person-centred learning environment, so time is available for people to express their concerns and share their anxieties. This sharing has a beneficial impact and can contrast greatly with other approaches to training where people are expected to sit and listen.

‘On the first day, despite my anxiety, I was reassured that I was not the only one with ‘reservations’. This for me was reassuring and the group   started to have a cohesive feel. I felt the desire to learn, rather than my past feelings of dread and frustration’.

One delegate explained

 ‘I describe myself as an integrative counsellor with my roots embedded within the Person- Centred approach, and therefore training within the PCE-CfD model was the one that really appealed to me’

One delegate from the ‘other’ group stated

 ‘I felt the delivery was congruent with the modality. I found the model of person centred (sic) counselling integrated with emotion focused therapy to be very powerful. Also it fitted easily with my existing training’

 

 

PCE-CfD courses will vary, at Nottingham, video work is introduced very quickly so therapists are able to reflect on their practice. We request that participants who are talking as a client  bring real issues rather than  role play something. This adds an additional dimension to the experience and enables the phenomenological stance to be authentic as therapists engage with the process of evaluating their practice with peers.

After feeling more settled the word ‘video’ was mentioned, I did flap (again) but as we were now a group, took comfort in presuming that I would not be the only one, feeling like this.. In my role as Counsellor, it felt real, the video may have been there but what my ‘Client’ brought was more apparent and more meaningful to me, within that ‘session’, than the video running.’

The benefit of having experienced and qualified therapists attend the courses is evident in the capacity for delegates to self-challenge

 ‘My initial enthusiasm was met with the realisation of the challenge that lay ahead. … having worked as a therapist for 15 or so years, I should know what I’m doing and be able to get it right. It was useful at this point to recognise the incongruence-I am not expected to be experienced as the expert in my relationship with clients, it is all about collaboration and so why the expert now?

The end of the PCE-CfD course is marked by submitting a twenty minute video which is marked by the tutors against the Person-Centred Experiential Psychotherapy ( PCEPS) scale9. Each delegate is sent written feedback.

 ‘Having completed a DVD recording during our training, I found the feedback to be detailed, knowledgeable and constructive’

After completing the training, therapists submit up to- six taped recordings of client work, four of which must reach adherence to the PCEPS scale to obtain the PCE-CfD license. These recordings are initially taken to a PCE-CfD supervisor who supports the process beyond the training. The evidence we collected from our data showed that completion time varied from four to eighteen months.  Seventy percent of those who identified as purely person-centred completed between four and six months. None of those who identified as person-centred took over twelve months to complete.

Having noticed this discrepancy in completion time, particularly for those who did not identify as purely person-centred, we implemented ‘refresher’ PCE-CfD days with delegates. One delegate who took six submissions to complete fed back- ‘the refresher course with you in Nottingham was the turning point for me, something just seemed to switch on in my head’

 Feedback from delegates varies and in the same course some feel their needs are met and go far beyond what is expected, and others are less satisfied, seeking more detail about applying PCE-CfD in their work context. This is a challenge and as Catherine Jackson’s July 2016 article demonstrates, the implementation of PCE-CfD is extremely varied.

 ‘In some clinical commissioning groups (CCGs), counselling is available on a 50/50 basis; in some it is an integral part of the IAPT service, alongside CBT, with its own clinical governance structure. In some it has been outsourced to a third sector organisation but is still accessed through a single point of entry. In some it can be offered immediately; in others clients have to go through the stepped care process and have step 2 CBT before they can see a high intensity counsellor; in a very few it isn’t available at all’(2016 p7)

With this as the backdrop, what happens to each delegate once leaving the training environment is inevitably different. All delegates maintain their personal workplace supervision post training and get funded focused specific support for the PCE-CfD qualification from PCE-CfD supervisors. 

 ‘I was used to my own Supervisor and the thought of starting anew, with someone I did not know was challenging for me.’

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Another challenge for PCE-CfD delegates is the prospect of recording clients. I have frequently been told by PCE-CfD delegates that they find this aspect very difficult if not impossible. Others however have different feedback

‘I did not find any difficulty in taping clients. Reviewing the work and reflecting on it in supervision was very helpful. I found reviewing my work in this way gave me new insight and I believe helped me improve as a therapist. I will continue to use recording in my supervision process’.

All the correspondents who qualified shared an overall positive experience of working in this way.

Clearly this is not the case for all delegates who attend PCE-CfD training and for some completing is a necessary ordeal. As the years progress the increasing pressure to complete whilst being prevented from offering over six sessions adds to the mix. Different contracts introduce unexpected elements

and challenges . More and more we meet delegates who are on zero hour contracts, something I suspect is unlikely for those who work as CBT IAPT practitioners. Yet again, the real inequality for counsellors manifests its self in employment terms and conditions.

 

As already mentioned, the IAPT approach includes capturing data through the ‘MDS (Minimum Data Set)10 This data monitors symptom reduction and was developed for drug companies. It suited the initial purposes of IAPT as it was freely available with no cost to implement. It is not so inconsistent with the main model promoted by IAPT of CBT (Cognitive Behavioural Therapy) which usually focuses on symptoms which the MDS measures. However, a symptom focused measure is completely inconsistent with the PCE-CfD model, which is a model of growth. Being able to really engage in the principle of non-directivity has had benefits for therapists and clients it seems.

One delegate shared post qualification:

‘As a Person Centred counsellor I have always stayed with what the client brought, however the training had a new word for me now ‘Nondirectiveness’, enabling a better overview of me in practice. It is my belief that PCE-CFD training has enhanced my work, my focus and improved outcomes for my clients’

The opportunity we have with PCE-CfD is to collect data that is consistent with the growth model. If we have the chance to really connect to therapists as a result of this investment in PCE-CfD, it could be a great opportunity to also encourage meaningful data collection that will support the continuation of counselling in the NHS.

By articulating the emergence of positive aspects of the self in measurements, there is a validation that despite the terrible experiences people encounter throughout life there is always the potential for something different to emerge and offers a positive view of the human struggle. This positive psychology agenda, consistent with the growth model of PCE-CfD, is also compatible with the ‘wellbeing agenda’ promoted in mental health.

In terms of PCE-CfD developing, if we were able to introduce theory consistent data sets, or if clients themselves could identify the sort of change they wish to experience and measure that, we could gather a variety of evidence that is experienced by clients indicating growth, rather than symptoms. There could be a way for Peter, quoted earlier7 to capture the shift he experienced as a result of therapy. Some services have shown in Catherine Jackson’s article that PCE-CfD can be offered in an environment that supports it values in the way CBT is supported. PCE-CfD delegates need not be destined to engage in a confusing and contradictory process Recognising the value of PCE-CfD training and its significance as an investment into a non-medical approach is timely for those involved in managing services and their staff, who could find an experiential approach to client work refreshing and supportive.

Catherine Hayes, University of Nottingham

1 http://www.pce-world.org/images/stories/meta-analysis_effectiveness_of_pce_therapies.pdf

2 Department of Health (2008).Improving Access to Psychological Therapies. Implementation Plan: National guidelines for regional delivery. [pdf] Available at http://www.iapt.nhs.uk/silo/files/implementation-plan-national-guidelines-for-regional-delivery.pdf

3http://www.iapt.nhs.uk/en/workforce/iapt-education-training-and-development/

4 http://www.ncbi.nlm.nih.gov/pubmed/24103190

5Rogers, C. R. (1959) ‘A theory of therapy, personality, and interpersonal relationships

as developed in the client-centered framework’, in S. Koch (ed.),

Psychology: A Study of a Science, vol. 3: Formulations of the Person and the Social

Context. New York: McGraw Hill. pp. 184–256

6Sanders, P. and Hill, A. (2014) Person-Centred Experiential counselling for depression. London: Sage.

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7Hayes.K  (2015) in  S. Palmer  The Beginner’s Guide to Counselling & Psychotherapy London Sage Pg 220   

8 Hayes, Murphy and Proctor  What factors predict successful completion of the Person-Centred Experiential counselling for depression training programme? Unpublished paper presented at BACP Research Conference University of Nottingham May 2015

9Elliott, R. and Westwell[ (2014) in P. Sanders and A. Hill, Person-Centred Experiential counselling for depression. London: Sage. pp. 186–91.

10 (http://www.metanoia.ac.uk/media/1398/thepracticedtrialpptx.pdf),

11 MDS:  http://www.hscic.gov.uk/iapt