Background

1. Background This project arose out of my experience of working in the NHS as an existential-phenomenological therapist. And it is with the support of my trainees and supervisees that this has been maintained for 16 years so far. So I am grateful for all of the hard work of these students and qualified clinicians without whom I would not have been able to develop this way of working.

2. So this primary care project is known as Existential Experimentation and is designed to focus on three principle issues: 1. It is effective (by which I mean useful to clients) I will speak about how we use measures and collaborate regarding goals later in the presentation 2. and rigorous (by which I mean is able to stand alongside NHS dominant therapies) 3. and authentic (by which I mean true to the principles of existential-phenomenological thinking applied to practice.

3. This project is based on my belief in the original mission statement of the NHS made by Nye Bevan that was to provide equity of access to all people in need, not to discriminate based upon diagnosis age or location. Existential experimentation is a form of therapeutic process that considers the concerns of the client in an existential manner, employing a phenomenological form of enquiry and accepting that all therapy involves change even if this is a change in understanding rather than behaviour for example. The aims are: 1. to provide a focus on recovery and well-being rather than pathology or illness, 2. deliver interventions in a timely fashion, 3. and at GP surgeries to improve attendance by reducing stigma associated with mental health facilities.

4. The landscape of need identified by Department of Health The key paper that drives the architecture and landscape of need for mental health service provision is known as ‘No Health without Mental Health’ and this is what sets out the government’s agenda for mental health services’ aims.

5. Half the adult population at some point The government state that at some point in their lives about half the population will experience diagnosable depression or anxiety The landscape of need identified by Department of Health

6. Half the adult population at some point The government state that at some point in their lives about half the population will experience diagnosable depression or anxiety • More than £105 billion p.a = approximate total NHS budget! The landscape of need identified by Department of Health This represents the need to spend more than £105 billion to treat these concerns which includes £21 billion in health and social care costs and £29 billion in losses to business (Centre for Mental Health, 2010). This represents approximately the total NHS budget!

7. Half the adult population at some point The government state that at some point in their lives about half the population will experience diagnosable depression or anxiety • More than £105 billion p.a = approximate total NHS budget! The landscape of need identified by Department of Health This represents the need to spend more than £105 billion to treat these concerns which includes £21 billion in health and social care costs and £29 billion in losses to business (Centre for Mental Health, 2010). This represents approximately the total NHS budget! • 1 million people on incapacity benefits This need is reflected in the number of people that are estimated at over 1 million on incapacity benefits

8. Half the adult population at some point The government state that at some point in their lives about half the population will experience diagnosable depression or anxiety • More than £105 billion p.a = approximate total NHS budget! The landscape of need identified by Department of Health This represents the need to spend more than £105 billion to treat these concerns which includes £21 billion in health and social care costs and £29 billion in losses to business (Centre for Mental Health, 2010). This represents approximately the total NHS budget! • 1 million people on incapacity benefits This need is reflected in the number of people that are estimated at over 1 million on incapacity benefits • One third of all GP consultations Furthermore, within the NHS, mental health concerns are now occupying one third of all GP consultations

9. So what is the current position of mental health services? Current Mental Health Service Positions

10. So what is the current position of mental health services? Current Mental Health Service Positions IAPT - Good Idea! Improving Access to Psychological Therapies is a government stand-alone initiative conceived of in 2004 by Lord Richard Layard, emeritus professor of economics, LSE. Implemented in 2008, this has dramatically raised the awareness of people suffering with, and the need to recognise, the scope of mental health problems. It is an essentially good idea, but one that is grounded in economics and politics. In other words, to fund mental health services we need to accurately identify the scope of the problem, thus we need a structure for diagnosing severity, chronicity and need, and of course we need a ‘measurable’ system of treatment so we know what this will cost. So far so good!

11. So what is the current position of mental health services? Current Mental Health Service Positions Figures and Problems with Figures But there are problems with the figures. First of all, existential thinking takes a critical view of the notion of anxiety and depression that is espoused by the IAPT programme. Using the formulaic manner of defining depression and anxiety causes the irreconcilable problem of simultaneously producing an enormous number of ‘ill’ people and not having the funds or the resources to treat them! Full roll-out of IAPT by 2015 will cost £400 million and will endeavour to treat 15% of people eligible for the service under these definitions!

12. Human Difficulties- Existential Concerns - However, if we consider the situation from a different or ‘existential’ perspective, we first challenge the notion of anxiety (and other ‘symptoms’) as being necessary to be eradicated and then the treatment offered centres upon understanding two simple, yet elusive from the government’s adopted position, ideas:

13. Human Difficulties- Existential Concerns - • Disability or distress • 1. Existential experimentation reconstrues the notion of illness and prefers to consider the idea of distress rather than disability, thus challenging the very premise upon which these pathologising labels are built.Therefore, the therapeutic endeavour goes beyond the content of the person’s difficulties and focuses upon understanding the CONTEXT in which the client experiences these concerns.

14. Human Difficulties- Existential Concerns - • Illness or problems of living? • 2. This process of therapy then considers the meaning of the experience that the client attributes to their difficulties. In other words, this process of therapy takes up the CBT position of understanding the problems and then goes beyond this to ask in what way is the experience of difficulty an expression of their relationship to themselves, others and the world. Figures suggest that while people referred for anxiety and depression are individually greater than for other concerns, that all other concerns such as loss, relationship difficulties etc add up to more people collectively. Therefore, it makes more sense to, first of all, understand anxiety as the expression of the client’s position in the world and second, to address it as one of but not the most prevalent problem, if indeed a problem at all once we de-constructed the notion of anxiety.

15. Human Difficulties- Existential Concerns - • Isn’t all therapy existential? Having thought about the problems in defining distress or living problems in terms of illness categories, it is our assertion that the therapy then becomes about learning to live with and manage and tolerate life’s inevitable difficulties and to consider the position that one takes in respect of these experiences.

16. The Elephant In The Room The elephant in the room – this is a glaringly obvious yet unspoken about issue. If the government insists on promoting IAPT and IAPT endeavours to treat 15 of every 100 people entitled to treatment, what do the other 85 in every hundred people do? Existential experimentation aims to address this problem by linking training to practice and research by bringing training therapists into GP surgeries to provide therapy according to the principles outlined above and below, and developing practice-applicable research to compliment rather than compete with existing or incumbent models. We challenge the implementation of RCT evidence based therapies as outcomes achieved through manualised treatments are less effective in naturalistic settings than in the trials.

17. Cost Effectiveness Paramount concern in delivering mental health interventions in the public sector At the heart of service commissioning is the need to focus on cost effective therapies.

18. Early Intervention

19. Early Intervention Key to successful outcomes Intervening early in the life-cycle of human distress is central to achieving better outcomes.

20. A Relational Approach That Is Existentially Informed Therefore, we arrive at the practical aspect of the process of this therapy that takes a relational approach as indicated above.

21. A Relational Approach That Is Existentially Informed • Seeking to elicit values, attitudes and assumptions that expose the position a person adopts and thus can own The phenomenological inquiry attempts to elucidate the world-view of the client by an active enquiry, since this is a short-term 6 session model. Thus, the initial session seeks to elucidate the living concerns of the client and the values, attitudes and assumptions that the client holds about their concerns. Moving from the content to the process further elicits the assumptions about the therapy and the role and person of the therapist.

22. A Relational Approach That Is Existentially Informed • Is experience meaningless if painful or how else could it be understood? This short-term existential model proposes that all experience is potentially meaningful and challenges the cognitive notions of meaninglessness. In other words, whereas some therapies may understand painful experience as the result of maladaptive thinking or dysfunctional attitudes and therefore meaningless and in need of eradication, this process places emphasis on the meaningfulness of all experience as positioning the person in relation to themselves, others and the world. Thus, painful or distressing experience is understood in terms of the position the person adopts in relation to their experience so promoting a position of ownership and agency.

23. A Relational Approach That Is Existentially Informed • Collaboration or compliance This model questions CBT notions of collaboration – if the person’s interpretation of experience leads to maladaptive thoughts and behaviour and requires the therapist to provide a disconfirming view and an adaptive process towards solution, we would consider this process as one the client has to comply with in order to ‘recover’. Alternatively, existential experimentation proposes that the entire endeavour commences and proceeds from the establishment with the client about what concerns are present and how the client would wish to engage with their concerns. In other words, a truly collaborative exercise to attempt to identify and achieve client-directed goals for therapy.

24. Monitoring Of Progress And Outcomes First of all – in today’s therapy marketplace, the notion of monitoring progress and outcomes is not going away.

25. Monitoring Of Progress And Outcomes • Why not join in? Therefore, we decided to join in and have initially addressed the idea that ‘all therapies are equally effective’ by using the language and measures of services like IAPT - so we can see from later slides that we are as effective and sometimes more effective than these services by utilising CORE 5-OM session by session monitoring, GAD-7 and PHQ-9 scales

26. Monitoring Of Progress And Outcomes • Why not join in? • Challenging the meaning of monitoring of therapy – a critical view However, we believe that these measures are not effective because they accurately reflect the quantity or quality of distress but we utilise them as clients who collaborate in their therapeutic journey demonstrate two things: first, that they are committed and motivated which correlates positively with outcomes; second, the Hawthorne/Pygmalion effects of expectation suggest that monitoring represents the possibility of roughly a 15% better improvement in terms of outcome.

27. Monitoring Of Progress And Outcomes • Equivalence or no difference Therapies have for a number of years tried to compete or outdo each other to prove that some are better than others or for specific problems some are more appropriate. The Dodo Bird effect suggests equivalence but does not prove equivalence but rather proposes no difference which is not the same thing. We can devise ways of proving equivalence but why bother? This therapy aims to fundamentally address concerns indicated at the outset by asking the client to articulate their own defined goals and then asks them to quantify and qualify if or to what extent some or all of these have been achieved. Finally, clients that are committed to therapy and motivated, that attend at GP surgeries at an early stage in their distress improve according to routine outcome measures as the graphs demonstrate. This is not magic or even the wonder of existential therapy. It is a common-sense, compassionate, timely and engaged manner of doing therapy that promotes a self-reflective stance towards experience. It is the understanding of the self-construct and the position that the person has adopted that defines their difficulty and therefore, the experimentation aspect of this therapy centres upon moving to trying to discover meaning in the experience and creating meaning by experimenting with a temporary sense of self that is the self that the person would want to be.

28. Monitoring Of Progress And Outcomes We need to recognise that without joining in the dialectical process of change that has seen paradigm shifts in ways of working in the NHS in the last decade, that we would rapidly move from being vaguely tolerated to possibly being ostracised. Therefore, we closely monitor progress and outcomes to ascertain the qualitative and quantitative effectiveness of this approach.

31. Summary In summary, there are several simple and yet fundamental assumptions that underpin this approach. • 1. All clients that optionally come to therapy in the NHS want to change – it is incumbent upon us as existential therapists to establish what that might be for these people. • 2. To seek to address clients’ concerns from the position of the client – rather than from the position assumed to be valid i.e. as proven by RCT types studies or empirically supported or evidence based treatment – I am a big believer in evidence but I think we need to establish what we mean by this • 3. To challenge the incumbent medicalisation of human concerns – the technological/pseudo-scientific symptom focused position of diagnosis/pathologisation – and then to go beyond these position • 4. To try and discover whether an existentially informed practice could achieve similar or better outcomes than dominant/prescribed models of treatment • 5. To attempt to do this in in a timely and cost effective manner

32. Questions ?

33. Thank you