How do we know what we need: differentiating evidence based treatments for the public

I am interested in making a website to help direct people at the right kind of sources of support when they are hitting a block or feeling unhappy with their lives. So I started to look at what was out there. I found lots of small silos full of professional jargon that would help people to identify a counsellor, psychotherapist or psychologist if they knew that was what they needed. But I also found lots of sites that point people at all kinds of snake oil that has no evidence of efficacy at all. For example, Findatherapy.org lists the following categories as “therapies”:

Abdominal-Sacral Massage
Acupressure
Acupuncture
Alexander Technique
Allergy Therapy
Aromatherapy
Arts Therapy
Autogenic Training
Ayurveda
Biofeedback
Bioresonance Therapy
Body Stress Release
Bowen Technique
Chiropody
Chiropractic Treatment
Clinical Pilates
Cognitive Behavioural Therapy
Colon Hydrotherapy
Colour Therapy
Counselling
Craniosacral Therapy
Crystal Therapy
EMDR
Emmett Technique
Emotional Freedom Technique
Energy Medicine
Flower Essences Therapy
Foot Health
Havening Techniques
Healing
Herbal Medicine
Homeopathy
Homotoxicology
Hydrotherapy
Hydrotherm Massage
Hypnotherapy
Indian Head Massage
Kinesiology
Life Coaching
Manual Lymphatic Drainage
Massage Therapy
Matrix Reimprinting
Maya Abdominal Therapy
Meditation
Microsuction
Mindfulness
Myofascial Release
Naturopathy
NLP
Nutritional Therapy
Osteopathy
Physiotherapy
Pilates
Psych-K
Psychotherapy
Reflexology
Regression Therapy
Reiki
Relationship Therapy
Rolfing
Sex Therapy
Shiatsu
Speech Therapy
Sports Therapy
Structural Integration
Tension and Trauma Releasing
Thai Massage
Thought Field Therapy
Yoga Therapy
Zero Balancing

That’s a list of 70 “therapies” of which at least 40 are obvious quackery, and very few could be said to have any form of persuasive evidence base for efficacy*. But the practitioners of each are persuasive, and the websites use pseudoscientific rationales that might fool those who are not as cynical or conversant with the scientific method as we are. So how do the public know what kind of help to seek out? How does someone who is feeling miserable, has a job they hate, financial difficulties and problems in their relationship know whether to get financial advice, careers advice, life coaching or therapy? And if they pick “therapy” how do they know whether to get CBT, psychoanalysis, art-therapy or non-directive counselling? And how do they know whether to get it from a therapist or a psychologist or a counsellor or a mental health specialist or any of a hundred other job titles? And within psychology, how do they know when to seek a clinical psychologist, a health psychologist, a counselling psychologist or any of the job titles that the HCPC don’t register?

I think apart from word of mouth and google, they don’t. Most people ask their GP or their friends for recommendations, and then go with something available locally within their price range. They don’t read the NICE guidance or understand the various professional bodies or regulatory systems. They trust that they’ll get a gut feeling as to whether it is going to help or not from the first session, and most of that “gut feel” is probably based on personality and charisma, and whether or not they feel listened to. The decision then rests on whether the therapist wants to work with them and has the capacity to take them on, and the price they ask for (assuming the service is in the private domain rather than the NHS).

Even the NHS itself isn’t very consistent about evidence based practise. For example, the NHS still funds some homeopathy – possibly wasting up to £5million per year on this placebo treatment that is entirely without evidence or credible rationale. Likewise I’ve seen NHS therapists who have done training in models of therapy that are implausible and without evidence (eg ‘energy therapies’ like EFT). Perhaps this is why the majority of clients doubt the efficacy of talking therapies. Yet, despite this scepticism, most would prefer to try therapy than medication yet the use of psychotropic medications has risen much more rapidly than the use of psychological therapies.

So where do we draw the line? If we only deliver fully evaluated treatments and those where we understand exactly how they work, then the amount the NHS can do when it comes to therapy will be much more limited. Lots of therapeutic interventions in practise are derived from other models or by combining aspects of various models. This allows individualisation of care. Similarly, there are many therapies which are being developed that have promising methodologies and are tightly rooted in scientific knowledge, but have not themselves been subjected to RCTs that prove efficacy yet (eg DDP). And many RCTs seem far removed from actual clinical practise where clients have a variety of overlapping conditions and clinicians deviate substantially from the treatment manuals.

The other confounding factor is that when it comes to talk therapy, it turns out that the modality or adherence to the manual matters very little compared to the relationship between the therapist and client. It seems the key ingredients are listening to the client, genuinely caring about them, giving them hope that things could be different, and giving them the confidence to try doing things slightly differently. Whether we have years of training and follow the manual diligently or whether we are newly qualified and muddling through seems to make much less difference than we think. In fact, therapist variables are much more powerful in influencing outcomes than modality, and even than the difference between treatment and placebo. That is no surprise to me as I’ve personally benefited from physiotherapy that included acupuncture – despite having read studies that show it to be no more effective than ‘sham acupuncture’ where random locations are pricked with a cocktail stick!

In the paper I’ve linked above, Scott Miller argues persuasively that we don’t need to focus on understanding how therapy works, or in using the medical model to work out what works for whom with endless RCTs. He shows evidence that experts are defined by having deep domain-specific knowledge, earned by a process of gathering feedback and focusing on improvement. So he argues that in the same way, expert therapists are those who collect and learn from client feedback. So his answer to the issue of evidence-based practise is for us each to collect our own outcome data to show whether our work is effective according to our clients (and by comparison to other options), and to see if we can improve this by using simple ratings within each session that check we are working on the right stuff and that the client feels we understand them, and that the working relationship is good.

So what does this mean for the proliferation of made up therapies? Does it mean that we should leave the public to buy a placebo treatment if they so wish? Or does it mean we need to focus on the modality and evidence base after all? The ideal would obviously be better regulation of anyone purporting to provide therapy of any form, but given the HCPC remit doesn’t even include counselling and psychotherapy, I think we are far from this being the case. To my mind it throws down a gauntlet to those of us providing what we believe are effective and evidence based treatments to collect the outcome measures that demonstrate this is the case. If we are sure that what we offer is better than someone having an imaginary conversation with an imaginary ‘inner physician’ by feeling imaginary differences in the imaginary rhythm of an imaginary fluid on our scalps then surely we ought to be able to prove that?

And what does that mean for my idea of making a website to point people at helpful places to start a self-improvement journey? To me, it shows there is a clear need for simple and accessible ways to identify what might be useful and to allow the public to differentiate between sources of support that have evidence of efficacy, professional regulation, a credible rationale for what they do, reputable professional bodies and/or personal recommendations. Maybe such a website can be one contribution to the conversation, although I’ll need both allies and funding to get it to happen.

 

 

*I’d say EMDR, physiotherapy, speech therapy, CBT and some types of psychotherapy and counselling probably reach that bar. Mindfulness is probably getting there. Art therapy probably suits some people with some issues. Yoga, sports massage, pilates, osteopathy, meditation, life coaching and (controversially) even acupuncture probably have their place even though the evidence for them as therapy modalities is limited. Most of the rest are quackery.

How to recruit (and what to do with my therapy company)

My working life has been increasingly focused on improving outcomes for Looked After Children. I deliver training and consultancy to care providers such as residential care companies and fostering agencies, as well as to health, social care, education and legal sector professionals. I have also developed a suite of online tools to help commissioners and providers to assess needs, track progress and evaluate outcomes for Looked After Children, including www.BERRI.org.uk  I think the introduction of clinical governance processes to the social care sector is long overdue, and I’m hoping that I can contribute to a culture change that drives up standards for Looked After Children. Signs are good, in that Jonathan Stanley chair of the Independent Children’s Homes Association (ICHA) said “you have set the gold standard for care providers” and Sir Martin Narey said “this is the missing link” when it comes to residential care. So I am trying to make this my business.

I’d like to find someone to help me take that forward, who has the kind of financial/business/admin skills that will complement my clinical skills and ensure we run efficiently as a company. Perhaps a business graduate with lots of energy, or an experienced admin who wants a new challenge. Ideally able to come to meetings in Derbyshire at least once a week. I’ve been inundated with demand, which is great, but it means I need help to keep organised and on top of all the competing demands in my new line of work. And that means that I need to give up, hand over or sell on other things I have been involved in.

With that in mind, I am wanting to make a plan for what to do with my existing therapy and court work business in Milton Keynes when I move out of area in a month from now. It’s a profitable business, and meets the needs of a client group who fall between health and social care. We offer edge of care assessments, psychological therapy and support to prevent kids coming into care, to support placements, enable rehabilitation to family, or for children and families who want help with parenting or a mental health issue. We also do court expert witness work for the family courts, and provide consultation into two sets of children’s homes.  However, the only other qualified CP involved is going on maternity leave soon and there is nobody else to provide cover. If I was staying in the area and/or had the time and mental capacity to continue running it myself, I would. But given I can’t, I want to make a good landing for it. And that means either recruiting a temporary or permanent clinical psychologist, or selling the business on to somebody who has the capacity to build on it.

I also need to recruit to provide cover for the services that I supervise within Keys group whilst various staff are on maternity leave, as well as to new vacancies within Keys. But despite the enormous importance of the work, and the fact it is highly valued, and as part of a well-equipped team without many of the niggles of the NHS (for example, we provide tea and coffee, you get your own desk and computer, and the caseload is manageable) recruitment pathways are not as easy when you are outside of the NHS and the first point people look at when seeking work is NHS jobs. We’ve tried BPS appointments memorandum and various recruitment agencies and websites, but so far nobody suitable has applied. So what now?

If anyone has any ideas, the company information is below:

1) My company in Milton Keynes

Lifepsychol/Evolving Families offer therapy to about 10 families, some court expert witness work, and consultation at a day rate into Keys in south Bucks and Peterborough. The qualified CP is going on maternity leave and I am moving out of area. We therefore either need to:
a) sell the business as a going concern to somebody or a company who can pick up the clinical provision (this could potentially include the evolving families business name, bank account, social media, website and email address, with ongoing referrals and enquiries – to run either as a traditional company or as a social enterprise)
b) recruit a member of staff to pick up this work and be an ongoing employee
c) recruit sessional cover of 2 days per week for 6 months to cover the maternity leave

2) To help run my BERRI project

A business graduate or experienced admin who can turn their hands to all kinds of tasks to make a small business work effectively, from responding to email and telephone messages, to keeping on top of the finances, client account management, customer support and converting enquiries into subscribers. Basic salary, plus bonus related to success of company, and the chance to grow with us and earn ‘sweat equity’ in year three. We are flexible and family-friendly. May be able to work some hours from home, but must be able to meet in Derbyshire at least once per week. It may be possible to start part-time and build up, if you are returning to work after a career break.

I would welcome enquiries about any of the above options to lifepsychol@gmail.com

2) Within Keys we have several vacancies to deliver consultation as part of our psychology pathway, and to supervise the APs doing assessments. There may also be scope for some direct therapy. We would either be able to offer permanent contracts for full or part time work, or sessional work which would be contracted for six months initially and then potentially extended.

Vacancies include:
– Full time or part-time posts to cover Warrington/Manchester
– Full or part-time post to cover Shrewsbury area
– Full or part-time post based at Sheffield/Chesterfield/Peterborough
– Full or part-time post to cover Taunton and/or South Wales (we have about 2 days work in each location, but can top this up to full-time with input into another project)

With all of the above, hours, location and salary are negotiable dependent on experience. Email lifepsychol@gmail.com and/or juliehamilton@bettercare.co.uk

Also, if anyone has any contacts to circulate the same around the clinical courses, we would be interested in prospective applications for trainees due to qualify this year.

Gaining Influence

Quite a long time ago, I identified that it gives me most satisfaction when work gives me the opportunity to have 5 I’s: Intellectual challenge, Independence, Innovation, Income and Influence. This month I have really been working on the last of those, and trying to connect with the right people to make change within the Looked After Children sector as a whole, rather than individual by individual or company by company.

It transpires that over time I have accidentally built up a wide professional network, and a credible platform from which to connect with higher level influencers. It seems that all the time I’ve invested into unpaid stuff helps when it comes to connecting with new people and looking like I know what I’m talking about. This is helpful for me to hold in mind as committee work can all too often feeling like a drain on my time that is almost invisible to anyone else and may have little that is tangible as an outcome for what can be quite an onerous process. Logically I know that this type of activity is rewarded by the innate satisfaction of contributing to important work that needs doing, but this is something I find easier to recognise at the start of the process when I first put up my hand to volunteer and after the end of all the graft than whilst in the middle of it.

Being chair of CPLAAC, on the national CYPF committee for the BPS, part of the NICE guidance development group and the BPS/FJC standards group have let me contribute to various publications that will hopefully reach wider audiences and influence practice. Whether that is in terms of the support and interventions offered for children with attachment problems or the standards that should be expected of psychologists who act as experts to the family courts or the chapter on best practise for psychological services for children and families with high social care needs in What good looks like in psychological services for children, young people and their families, the paper I wrote about Social Enterprises as a vehicle for delivering psychological services or the CFCPR issue I edited on good clinical practise around attachment difficulties, I feel like I have been part of some good work that establishes professional standards and reference points.

And with those things on my CV and a network of allies who share my goals about improving outcomes for Looked After Children, I have been able to meet with various decision makers and influencers about my ideas. The first important contact I made was with Jonathan Stanley, the chair of the Independent Children’s Homes Association. He has been fantastic at promoting my work to residential care providers and helping me to gain a seat at the table. I then met Almudena Lara at the DfE, although she was very new to the role of being LAC lead, and moved on before she was able to pick up our discussion again. I have also met with Social Finance. More recently I was able to meet with Sir Martin Narey, the government advisor (and ex-chair of Barnardos) conducting a review of children’s homes in the UK, and a representative of the DfE. And latterly I had the opportunity to meet Lord Listowel at a recent conference and hope to speak with him further soon.

In all of these meetings, I have been promoting the value of clinical governance in the social care sector. That is, the importance of being able to evidence clinical outcomes and substantiate that you are doing what you claim to do – in this case, that placement providers are improving outcomes for children and young people in their care. My wider goal is to allow commissioners, social workers and Ofsted to be able to see what kind of placement a child needs, whether a placement is making positive change for a child and who can provide the most suitable and effective placement. I’m also keen that the idea of “therapeutic care” is better defined, and that therapists working within care organisations need to be qualified, supervised, regulated by a professional body and practice within their areas of competence. But my main goal is to stop the situation in which placements are paid to provide care for the most complex and vulnerable young people in society, and do so by providing accommodation, food and transport to education but do nothing to address their emotional, behavioural, mental health, developmental/learning needs, risk to self and others, or ability to form healthy relationships with others. I think the tools I have been developing, like http://www.BERRI.org.uk, and the training I provide for staff/carers can help with that, but my goal is nothing less than to change the culture of care in the UK.

Evidence has shown that money invested in the most complex children during their childhood is repaid tenfold in savings to the public purse in reductions in use of mental health, social care and criminal justice services over their lifetime. So why is it that the placements for the most complex children and young people are primarily provided by carers with very low levels of qualification and training? The first steps to improving standards are to ensure that all carers in the foster and residential sector get training about managing the impact of trauma and disrupted attachments, and that all children in public care are regularly monitored on outcome measurements. But these need to be meaningful, and linked into practice, rather than done as hoops to jump that are disconnected from daily care.

I can think of nothing more worthwhile to do with my professional life than to improve care for Looked After Children in the UK, and I hope that I can achieve enough reach and influence to make a genuine difference.