Talking Therapies Con

the Improving Access to Psychological Therapies (IAPT) assessors are coaches, not trained treating clinicians. Clients and GPs are not made aware of this. The low intensity Psychological Wellbeing Practitioners see their low intensity role  as ‘coaches’ rather than therapists  see [ May 2011 Psychologist].  

The working alliance has been found to predict outcome in the treatment of a wide range of psychological disorders [Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy: a meta-analysis. J Couns Psychol. (1991) 38:139–49. doi: 10.1037/0022-0167.38.2.139] and most recently in the treatment of PTSD [Beierl ET, Murray H, Wiedemann M, Warnock-Parkes E, Wild J, Stott R, Grey N, Clark DM and Ehlers A (2021) The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder. Front. Psychiatry 12:602648. doi: 10.3389/fpsyt.2021.60264]. But the measurement of the working alliance requires a determination of the tasks involved, the goals elaborated and the assessment of the therapeutic bond [Tracey TJ, Kokotovic AM. Factor structure of the working alliance inventory. Psychol Assess. (1989) 1:207–10. doi: 10.1037/1040-3590.1.3.207]. Measuring the therapeutic working alliance in low intensity CBT would be a herculean task, in that 42% of those entering treatment only complete one session [Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14]. Further even if the working alliance could be reliably assessed in low intensity IAPT there can be no certainty it would relate to outcome. 

Given the uncertainties surrounding the role of the working alliance in low intensity interventions, doubts arise about the credibility of this intervention. Low intensity interventions do not make a clinically significant difference compared to usual care. BMJ 2013;346:f540 doi: 10.1136/bmj.f540 The situation is analogous to trying to asses the effectiveness of a fraction of a drug, that is demonstrably efficacious in full dose in a highly specified setting.

But the effect size of working alliance has in all studies been found to be in the small to medium range, for example in the Beierl et al study (2021) accounting for 13-28% of outcome depending on whether it was the patients perception of the therapeutic alliance or the therapists.  Thus though consideration of working alliance is of importance it is not of overriding importance and the specifics of the protocol matter.  

Dr Mike Scott