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 [https://thepsychologist.bps.org.uk/volume-24/edition-5 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

4 thoughts to “Talking Therapies Con”

  1. Another post I simply agree with.

    I remember thinking this a while back and I started my training. I was thinking that our job at best, sells hope and at worst, sells the “siff upper lip” mentality that comes with resilience training (we aren’t in the Blitz or one of the world wars. So, why does IAPT ration it’s counselling budget? Politics?). Also, the fact that we are glofied coaches indeed gives us all the responsibility with none of the power. It is amusing, and sad, that there has been so much money thrown at coaches instead of counsellors or similar. Unfortunately, it is all about bare bones treatment, uncessary need to cut costs and not improving anything long-term. The job is definitely a mix of telemarketing, sales and call centres. It is not a job that I would associate with the betterment of mental health to be honest.

    I just hope that I have the strength left in me to exit this job and take a leap of faith (change caeers). Once I have done the three years at my current job (this way it will be easy to get a reference that covers the full three years), I have to leave this job. Calling myself a “clinician” is embarrassing and a disrespect to actual clinicians.

    Having said that, I do try to impart wisedom to the clients I have to see. Otherwise, it would feel like reading a badly written screenplay, in a Groundhog Day fashion: doing the same thing over and over (by reading the “script”), and expecting different results is the definition of insanity.

    Thank you
    Nathan

  2. I totally sympathise Nathan, I think life is about chipping in your pennyworth as best you can with people u meet along the way. But sometimes as in the case of IAPT there are horrific constraints, and keeping going is a real challenge.
    Take really good care of you
    Mike

    1. Thank you so much Michael, I’ve just read the full paper you referred to, it is an absolute total indictment of IAPT’s assessment process. The total disregard for the client’s story leaves me speechless. The cavalier approach to risk assessment creates a disaster waiting to happen. Will return to this paper. Thanks once again Michael
      mike

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