Becoming a better therapist: Messages from research

1. Becoming a better therapist: Messages from research Peter Stratton Professor of Family Therapy Leeds Family Therapy and Research Centre Inst. of Health Sciences, Leeds University, UK Hello my name is Helen Pote, I am a clinical psychologist with a special interest in working with children and families using ideas and interventions taken from systemic family therapy. I am lecturer for the department of psychology, RHBNC. Today I am going to talk about a research project I undertook whilst based at Leeds. It was an MRC project carried out at the Leeds Family Therapy & Research Centre, which is part of the psychology department there. The project was one year study which aimed to produce a manual for systemic family therapy which could be used as a research tool to standardise systemic therapy interventions in clinical outcome trials of therapy efficacy. We feel we have achieved this and I want to report the process by which we went about this, some of the findings which were of particular interest, and familiarise you with the manual and its clinical applications. The research team for the project consisted of myself and Peter Stratton, Paula Boston & David Cottrell, 3 experienced family therapists all of whom are actively involved in practising and teaching family therapy. Also in the team was David Shapiro who brought extensive research experience in the area of manualised therapies and outcome research. Hello my name is Helen Pote, I am a clinical psychologist with a special interest in working with children and families using ideas and interventions taken from systemic family therapy. I am lecturer for the department of psychology, RHBNC. Today I am going to talk about a research project I undertook whilst based at Leeds. It was an MRC project carried out at the Leeds Family Therapy & Research Centre, which is part of the psychology department there. The project was one year study which aimed to produce a manual for systemic family therapy which could be used as a research tool to standardise systemic therapy interventions in clinical outcome trials of therapy efficacy. We feel we have achieved this and I want to report the process by which we went about this, some of the findings which were of particular interest, and familiarise you with the manual and its clinical applications. The research team for the project consisted of myself and Peter Stratton, Paula Boston & David Cottrell, 3 experienced family therapists all of whom are actively involved in practising and teaching family therapy. Also in the team was David Shapiro who brought extensive research experience in the area of manualised therapies and outcome research.

2. Issues in making therapy effective To retain the diversity of psychotherapies both for the benefit of clients and so psychotherapy can develop. We need to present decision makers with convincing indicators of effectiveness. We need to know what we are doing and why. Then we can give a convincing account of why family therapy is an obvious choice How can we make political use of the fact that therapy is research?

3. Aims and objectives To review some of the significant issues in psychotherapy research, and the benefits of practitioner research Give you extra perspectives on how using research findings can help your practice

4. USPs of SFT 1 Our focus on family strengths Research evidence for the functional family.

5. If families are dysfunctional People who are unhappy should be taken out of their families to a different context, and cured . But research tells a different story: About families as a powerful resource for positive change

6. Think of an adolescent growing up in extremely adverse conditions Coping with poverty, social stigma, physical limitations, ethnic discrimination, and poor academic performance What do you think will be the priorities in their lives? What might they want from their carers

7. Michael Ungar, Family Process, 2004 43 high-risk adolescents’ seek close relationships with adults to negotiate self-constructions as resilient. High-risk teens say they want the adults in their lives to serve as an audience for their identities. This pattern was evident even among youth who presented as being more peer-than family-oriented.  Is this a surprise?

8. David Campbell et al, Family therapy for childhood depression JFT (2003)417-435. From a qualitative study of childhood depression, concluded that depression is often derived from children’s sense of failure to care for their depressed parents. And therapy is successful once it is recognised that the depression is relational.

9. Meanwhile Fiona Williams In “Rethinking Families” (2004) concludes that the major value across a whole variety of family forms is an ethic of care.

10. Why do we see the whole family when a child is referred? Such findings point to the extent to which children value relationships, especially family relationships, above other concerns.

11. USPs of SFT 2:Acceptability to clients For example the highly regarded family intervention in psychosis service of Burbach and Stanbridge, integrating systemic and family management approaches had high levels of acceptance (Stanbridge et al, JFT 2003). BUT we should be researching client satisfaction much more extensively.

12. Happy Families Intrinsic compatibility with The happiness and positive psychology movements. IAPT and Lord Layard We should use images of functional families What is your image of a lone-parent family with limited resources?

13. “effective quality” Please think, for one minute about a successful piece of therapy, and which of your competences were relevant. Discuss with a neighbour how many kinds of competence might have been relevant. Please make a note of the competences to see how they compare with those I will discuss.

14. Forms of family therapy research Four overarching research areas: (1) does it work? (outcome studies) (2) how does it work? (process studies) (3) subjective experiences and aspects of family living significant for family therapy, (4) the further development of research methodologies for systemic research. Charlotte Burck. (JFT 2005)

15. What did process research do for us? Orlinsky reviews 1978, 1986, 1994 and 2004 Process outcome research finds consistent differences. Clients relate outcome to 24 process variable of which 13 relate to the therapeutic bond. Therapists use 28 variables of which 18 relate to those of the clients.

16. Therapy processes rated differently CLIENTS Paradox Client’s emotional involvement Credible therapist Confrontation and interpretation Stage of therapy THERAPISTS Agreed goals Client suitability Change strategies Client self-exploration Therapist’s empathy and self-congruence

17. Issues Research is expected to be based on specialist clinics using clear diagnostic categories using a manualised prescribed treatment But most psychotherapists, while wanting to make use of the evidence, see a wide variety of clients with confusing combinations of problems.

18. One answer: naturalistic research CORE (UK) and two comparable studies in the USA “The picture we see in the CORE NRD  across 35,000 patients seen by 600 therapists is that each therapist will generally use a combination of two or even three modalities in treating each individual patient” (R. Evans, 2007)

19. The political dimension Insurance companies and health agencies wish they could prescribe empirically supported practice. In the UK, the Increased Access to Psychological Therapies initiative: 10000 extra psychotherapists Which is becoming: everyone must have low-grade CBT. And RCTs consistently fail to find differences between different models of therapy, leading to the hypothesis that all therapies work through the same common factors.

20. An early version of common factorsFrank (1973) Persuasion & Healing Emotionally charged confiding relationship Healing setting The arousal of hope Encourage changed behaviour outside the session Encourage new ways of understanding oneself Conceptual scheme or myth to explain symptoms A ritual to help resolve symptoms Were any of the list you made at the start not included here? Do any of these not apply to your therapy?Do any of these not apply to your therapy?

21. Listings of therapy skills There are many lists but few that have been well researched AAMFT 120 Core Competencies 2004 Only 6 were actual therapeutic skills In couples and marital therapy. I thought I should work through all of them and fortunately 114 of the 120 actual therapeutic interventions.In couples and marital therapy. I thought I should work through all of them and fortunately 114 of the 120 actual therapeutic interventions.

22. Norcross & Lambert 2006 Estimates based on meta-analyses: Patient variables including severity 25-30% Therapy relationship 10% The therapist 8% Treatment method 5-8%

23. But seriously Research has consistently shown that the therapeutic relationship, or alliance, is a major factor. Other factors are a shared belief between therapist and client that the approach will work. And there is clear evidence that therapists differ in effectiveness Elaborate the finalElaborate the final

24. Family therapists always did work through relationships But research is pushing SFT to work most directly on the relationship between the therapist and the family members. Blow and Sprenkle (2001) identified the following therapist factors as common to the major models of family therapy:

25. Empathy Acceptance Respect Support Caring Warmth self-awareness authenticity.

26. The Leeds SFT Manual Designed for use to standardise therapy for research, but has been mainly used as a training tool. Qualitative and quantitative research (Pote et al, 2003) of what therapists did and how they thought this would produce change. So this Manual is a research report of therapist’s theories in practice The full Manual available on web. A couple of examples:

27. Developing Solutions In the analysis of the video observations of therapy sessions it was interesting that the % of the session taken up by focussing on solutions and successes that the family had achieved increased from just over 4% in the first session to nearly 15% by the final session of therapy. Although we were still surprised that only 15% of final sessions were taken up focussing on strengths and successes, we did recognise that this increased focus on successes and solutions from the first session did mirror how we thought about our practice and our systemic ideas. By contrast the focus on the difficulties with which the family were struggling remained fairly constant across the therapy - though this analysis does not address the nature in which the difficulties were discussed, for example they could be discussing contingency planning around difficulties arising in the future in end sessions. The rest of the session was spent focussing on family, wider system, relationships, life events, therapy process etc.. In the analysis of the video observations of therapy sessions it was interesting that the % of the session taken up by focussing on solutions and successes that the family had achieved increased from just over 4% in the first session to nearly 15% by the final session of therapy. Although we were still surprised that only 15% of final sessions were taken up focussing on strengths and successes, we did recognise that this increased focus on successes and solutions from the first session did mirror how we thought about our practice and our systemic ideas. By contrast the focus on the difficulties with which the family were struggling remained fairly constant across the therapy - though this analysis does not address the nature in which the difficulties were discussed, for example they could be discussing contingency planning around difficulties arising in the future in end sessions. The rest of the session was spent focussing on family, wider system, relationships, life events, therapy process etc..

28. Item from the Adherence Manual1.6 Was the therapist taking a self-reflexive stance? the therapist was able to apply systemic thinking to themselves and thus reject any thinking about families and their processes that does not also apply to therapists and therapy. Self-reflexivity focuses especially on the effect of the therapy process on the therapist and the way that this is a source of (resource for) change in the family. … Therapists should be rated at or above sufficient adherence level if they label the origins of ideas they are sharing with the family, and share with the family some of the reasoning behind their ideas or questioning.

29. Factor 2: shared belief that the approach will work. LSFT Manual Goals during initial sessions: 1. Outline Therapy Boundaries & Structure 2. Engage and Involve all family members 3. Gather and Clarify Information 4. Establish Goals and Objectives of Therapy We consistently challenge trainees to be able to explain to supervisors and family why their way of working will create change. Using M. White’s repeated checking “is this helpful” and Cecchin’s “is this useful”

30. Factor 3: therapists differ in effectiveness Differential effectiveness is invisible in most outcome research because it is treated as error variance. Since it matters, what do we do about it? Routinely assess outcomes More training, but training in what? A systemic circle to coordinate the ideas so far.

32. Leeds trainee ratings of competences: confidence ranked in order of perceived need First 8First 8

33. Family therapy is one therapy whose skills match the factors that research has shown produce change. But in many countries there is a determination to only use RCTs applied to modules of therapy. And to take the fact that most research has involved CBT as proof that CBT is most effective. In fact it is proof that psychologists have been effective in doing research and other psychotherapies have not.

34. The research-practice gap We need research that carries conviction: In a format developed in consultation with service users Conducted by practitioners in real-life clinical settings Substantial data, but cheap. Therefore , Practitioner Research Networks

35. The politics of randomised controlled trials ‘The system’ has, perhaps rather lazily, applied a research methodology designed for other purposes to psychotherapy. The therapy that looks most like a drug treatment for a diagnosed illness, CBT, has acquired reasonable evidence within this paradigm. There is a danger that all other therapies will be excluded from the NHS.

36. Randomised Controlled Trials (RCT) These tell us how different therapies compete in standardised situations. There are many ways in which they are unhelpful to psychotherapy. “If we were just starting to evaluate psychotherapy we probably would not choose a method developed in agriculture and adapted for use in physical medicine”

37. Let’s discuss If you feel you have had a successful session or therapy, what kind of thing will have happened? Would a family in therapy have a different view? How about a manager deciding whether to employ a family therapist?,

38. Some issues for constructionist family therapy What does it mean to say SFT worked? How can our belief that it works translate into reportable measures? Dilemma: We have an ethical responsibility to be effective. But we do not find it easy to specify what change is required.

39. Issues Research wants to make the practice as consistent as possible. ? focus on the treatment Psychotherapy wants it to be a flexibly responsive as possible. ? focus on the (complex interpersonal and cultural) context. And anything that depends on measurement runs foul of Nash’s Law of Inconsequentiality

40. Conditions with effectiveness evidence Adult depression and bipolar affective disorder Childhood depression Anxiety disorders Substance abuse, especially Adolescent drug addiction Delinquency and conduct disorder Eating disorders, especially under 21 yrs. Schizophrenia Marital conflict and distress Child and adolescent difficulties

41. But: There is surprisingly little good-quality evidence for the effectiveness of family systemic interventions with child and adolescent depression given the prevalence of depression and the demonstrated association with a range of family factors. ……. What research there is evaluates older structural models of therapy: there is a real need for more evaluation of newer models of practice. David Cottrell (2003) Journal of Family Therapy Volume 25 Page 406 

42. Review of IAPT and AFT political moves. Following Lord Layard’s proposals for 10000 new therapists, the pilots in Newham and Doncaster are only testing CBT. AFT has sent the review of evidence for SFT to many politicians and others, with some success.

43. The Newham Pilot Only CBT has a sound evidence base CBT is the only psychotherapy supported by NICE Government will only understand a simple message.

44. Implications We need research that carries conviction: In a format developed in consultation with service users Conducted by practitioners in real-life clinical settings Substantial data, but cheap. Therefore , Practitioner Research Networks (PRNs)

45. Solutions in generating evidence for everyday practice The CORE (Clinical Outcomes in Routine Evaluation) system has worked well to gather data from practitioners in individual psychotherapy. So how about a systemic version of CORE?

46. 2. Qualitative PRN Three therapists each interviewed three experienced therapists about SCORE, pooled the data and ran a collaborative analysis of the 9 interviews via email. Thematic analysis of therapeutic judgements. Article in Australian & New Zealand Journal of Family Therapy 2006.

47. Making available or giving away? Lots of people work with families and relational systems. AFT is considering how training in systemic work with families can be offered to a wide range of relevant professions: the medium-level training So why is it important to have properly trained family therapists?

48. What can only fully qualified family therapists do? Discuss for a minute, then call out suggestions

49. The need for properly trained family therapists supervise; train; input to multidisciplinary therapeutic team work; input to organisations; provide consultation. And do therapy cost-effectively with a wide range of issues, and take over the most difficult cases

50. But also: to develop the therapies; And to create a better understanding of how relationships work (and sometimes don’t) both within and outside families. EFTA’s Training Standards Committee is establishing standards, equivalent to the UK qualifying level, to apply across Europe

51. reasons to ensure and expand provision of Family Therapy include: It has proven effectiveness where researched supportive evidence of effectiveness from research and clinical experience. Trained family therapists draw on a good range of approaches with clear theoretical rationales therapy for families in the UK needs to develop through practice in the UK. Properly trained family therapists have transferable skills (team work etc) Family therapists can support other professionals in their work with families.

52. What do we need for the health and development of family therapy? 1: A commitment of the profession to research so that systemic family therapy will become seen as research-based Practitioner research networks

53. Limitations of EBP shown by: the relative failure to incorporate research into training – either as a basis for what is taught, or as an inspiration that will carry past the end of the course into having practitioners committed to research. Weissman, M.M. & Sanderson, W.C. (2002).  

54. What we need 2:Better family therapy Better theories that make sense to clients, managers and politicians More appreciation of our past Overt examination of what we do that works.

55. Conclusion All trainers are researchers All trainees are being trained in research methods. But the connections from therapy need to be explicit, and the dialogues need to lead to a self definition as a competent researcher.

56. What we need 3:Political influence AFT: Media Lords and Ladies Contributing to NICE guidelines and other discussions. So we need trainers and practitioners to register their specialist interest. Please write yours down with your email and give to Peter at the end. Academic and Research Committee EFTA, the EU, and the common platform

57. We do need: A mental health system that recognises that there is an enormous amount still to learn about psychotherapy and about fostering better relationships. This means supporting research that will release the benefit of what has been learned in the full range of relevant therapeutic practice, and service provision that maintains the variety of promising therapies.

58. Further Information Association for Family Therapy and Systemic Practice in the UK www.aft.org.uk Especially my ‘Academic and Research’ pages for updates on the evidence base. And Visit Peter’s work-in-progress website:www.psyc.leeds.ac.uk/staff/p.m.stratton/