We know it’s not the #psychotherapy model or #therapeutic techniques that matter – it’s the #human #being

For a number of years, debates have been rampantly widespread about the way we do therapy, what it is about therapy that works.  Since Rosenzweig in 1936 first raised this issue, psychoanalysts debated through clinical case studies what was effective and first coined the now famous dodo bird verdict.  This, some years later led to the issues raised first in 1975 by Luborsky in his paper with the famous Alice in Wonderland quote.  More recently, it has become commonplace to re-augment the scientific approach to establishing effectiveness through randomised control trials.  Clearly, there is good reasoning for this as these trials have to be conducted in environments that can exclude many variables and rely on delivering a therapy from a manual in order to try to deliver conformity.  However, we know that these types of therapy are less effective in naturalistic settings.  However, it remains important to try to know what it is that we are doing….but we still do not really know what part of what we are doing is the effective part.  Common factors approaches tried to establish what are those aspects of therapy that are common to all therapies that are effective.  Yet the war rages on.

This post comments on the graphical representation of aspects of therapy demonstrated by Lambert’s Pie.  What this shows is that only a small proportion of effectiveness is due to technique, another small proportion is due to expectation and placebo.  The two largest segments of the pie are due to relational factors and the most significant slice relates to what are known as client-attributable or context-related factors.

Miller and Hubble wrote an important contribution called the Heart and Soul of Change and Schneider provided an erudite treatment in his two editions of Existential Humanistic Therapy.  Only Ernesto Spinelli has in recent years provided a framework for the delivery of existential therapy.  The profession however as well pointed out by Jeffery Smith continues to do battle over modality, professional status and diagnosis as a number of books by prominent psychiatrists try to dissemble the vast array of confusing labels.

Our form of existential-phenomenological humanistic therapy recognises the need to measure whether some type of therapy is effective and tries to manage the tension in allowing for creativity, flexibility and individuality in therapy while retaining an element of operationalization of the process in order that we can assert with a degree of assurance that the interventions that we are delivering are measurable and contain elements that are effective.

Therefore, we have designed and tested a form of therapy that focuses primarily upon the qualities of the therapeutic relationship and empowering the client, in order that those factors in the pie are ignited and that the therapy may be more successful, whilst being measurable and informed by existential attitudes, a phenomenological method and humanistic principles, in order to address the breadth of human experience, challenge the medical model and stigma associated with psychological difficulties.

Integrating physical and mental healthcare

EASE (Engaging Activity Supporting Existence) is a Community Interest Company set up to provide an integration of physical and mental healthcare services. Specifically, EASE clinicians work alongside and collaboratively with medics who treat people with a range of physical healthcare needs that have psychological components or ramifications. For example, there is clear evidence about how untreated conditions lead to premature mortality in people who have mental health concerns and do not routinely address physical healthcare needs. However, more importantly, many physical conditions lead to psychological and emotional distress which not only inhibits the person further but may exacerbate the physical conditions as well as lead to compound pharmacological interventions that are complicated to manage and often conceal the co-morbid or multi-morbitity of the difficulties. Most clearly, it is apparent when people are diagnosed with cancer or other potentially life-threatening or limiting conditions where the initial diagnosis is a shock, the treatment is lengthy and requires psychological resilience, the outcome is unclear so hope is called into question, meaning of life issues arise as well as a host of other concerns. Further examples such as asthma, ME,fibromyalgia and other conditions are difficult to treat simply from a somatic stance and it is known that approximately 30% of all GP consultations involve psychological presentations

Recovery

Mental health services should aim to achieve what medicine has achieved in many areas.  Treatment that produces recovery!

However, psychological or psychotherapeutic treatments are not the same as medical treatments.

Medical treatment can reliably rest upon the identification of symptoms of or manifestations of illness, whether it be a virus, infection, lesion or other physiological dysfunction, disease or malady.  Contemporary medical science is reasonably able to accurately identify, diagnose, treat and cure most physical or somatic complaints.

Psychology is not!  Why not? Because the ability to accurately identify emotional, psychological or existential malaise relies upon observation and interpretation which is not sufficient to adequately state with reasonable accuracy what is wrong and, thus, what would resolve the difficulty.  This is because of the centrality of the person in the role of the client in the field of psychology.  in this field, what the person says about their experience of difficulty or distress is as important, if not more important, than what a clinical expert is able to interpret, far less able even to observe with any degree of reliability.

Therefore, recovery is a complicated notion in this arena of mental health treatments.  Keeping aside political persuasion and economic arguments, recovery is possible if one of two possible positions are adopted in relation to the treatment of the person who expresses emotional or psychological or existential distress or difficulty.

First, recovery is possible if what is wrong is subjected to a different system of taxonomy than physical illness.  in other words, the language of illness needs to be re-construed in order that the notion of recovery is not recovering from something but recovering  one’s life or recovering for….

Second, recovery is possible as long as you do not define recovery in terms of the reduction of pathology or symptomatology but rather the creation of a manner of viewing the world in terms of embracing the inevitable difficulties that have to be faced in life in order for it to be understood by the person and experienced as meaningful.

Either of these two positions make recovery a possible and plausible reality for people and they further raise questions about the role of the clinician or practitioner invested in the work of providing treatments that aim for recovery that will be addressed shortly.