The questionable evidence base of SCoPEd

David Murphy, Associate Professor at the University of Nottingham, interrogates the claim that the SCoPEd framework is ‘evidence-based’.


 

A cornerstone of the SCoPEd approach to generating their competences is to arrive at their findings having drawn from an ‘evidence base’. This is apparent in two separate claims made in the opening two paragraphs. Here the SCoPEd projects’ members say, “The aim of the SCoPEd project is to agree a shared, evidence-based generic competence framework to inform the training requirements, competences and practice standards for counsellors and psychotherapists working with adults.” And they go on in the next paragraph to say that, “The draft framework has utilised an evidence-based process of mapping existing competence frameworks, professional standards and practice standards to identify areas of overlap and areas of difference between counselling and psychotherapy.”

In this blog, the first of two tackling the issue of an ‘evidence-base’, I shall point to the fact that any reference to the use of evidence is questionable and more likely not, and therefore lacks integrity. First, let’s look at one of these statements again in more detail, “The aim of the SCoPEd project is to agree a shared, evidence-based generic competence framework to inform the training requirements, competences and practice standards for counsellors and psychotherapists working with adults”. Here the aim clearly suggests that the differentiated competences between the role of counsellor and psychotherapist will be grounded in evidence. But what do the SCoPEd team mean by evidence? And what might be an example of ‘evidence based competence’ that could be differentiable and identify clear evidence for a difference between the activities carried out under these two adjectival titles?

To first address the issue what evidence is being used, it seems that the list of sources used to arrive at the differentiated competence framework have been taken from existing lists of competences used, or even sponsored, by the same institutions that are trying to the find the evidence for the claimed differences between these titles. One of the issues with this process is that the documents tend to identify something that isn’t real. They are a fiction in regards to what people actually ‘do’. This is a well-known problem with the development of competences designed for a ‘labour market’ and they fail to adequately identify both the specifics and idiosyncrasies of actual praxis. What would be better, and would provide real evidence, is to look closely at what people actually ‘do’ in their work under these different titles.

Doing this would, I am sure, show something quite different from what is presented in the framework and might even show some new or unexpected findings. But the chance of discovering something new through this process has been closed off right from the outset because the aim is really not as it appears on the surface. The idea that counsellors are not doing the same work as psychotherapists flies in the face of all the evidence one can find from spending even just a little time listening to counsellors talking about their work. The chance to find this out has been forgone because a decision was made, at the outset, to look for the evidence in the data that already tells the SCoPEd team what they wanted to know.

‘But what does the actual evidence say?’

Let us look at just one example of a differentiation offered in the SCoPEd report. That is, Competency 3.10 under Theme 3 – Relationship, and refers specifically to the idea of ‘alliance ruptures and repairs’ (competence 3.10, 3.10b, 3.10c). In the SCoPEd document it is suggested that where there is a lack of ‘empirical evidence’, ‘grey literature’ has been used. It is difficult to know what evidence or grey literature has been used for the differentiation of this particular competence; not least because the research on therapeutic alliance, including the more specific topic of alliance rupture and repair, is one the largest bodies of empirical research in the entire psychotherapy process-outcome literature. Yet there is no citation to the empirical evidence that has been consulted. However, as this area of the psychotherapy literature is so extensive we probably should assume that the SCoPEd team will have consulted a recent meta-analysis of alliance rupture repair and outcome studies.

Looking at the differentiated competences (3.10, 3.10b, 3.10c) it seems that the SCoPEd project claim that psychotherapists are more skilled in dealing with alliance ruptures and repairs than are counsellors. But what does the actual evidence say about such a claim? Well let’s take a quick look. In a recent meta-analysis published in the American Psychological Association journal Psychotherapy (not a lightweight publication by any means) the very issue of alliance rupture and repair was considered as was its association to the improvement or progress that clients might make. Let me just say that whether or not one is against or for the quantitative paradigm, given that SCoPEd is an advocate for evidence it is probably worth noting the findings of this type of research because that is the premise on which it claims to be able to differentiate competence.

Esteemed alliance researchers Eubanks, Muran and Safran (2018) examined the association between alliance rupture repair and outcome in 11 studies involving 1,314 clients. Overall the effect size for rupture resolution and positive outcome was pretty impressive (d = .62 for those interested). Clearly good news for those theoretical approaches that regard the alliance as an integral feature of their practice (mainly psychodynamic but also CBT and some integrative therapies). A number of the studies included in this meta-analysis included ‘trainee therapists’ (so not even ‘qualified’ counsellors). The researchers tested the data to see if there were differences between the trainees and qualified/experienced therapists in this association between repairing ruptures and outcome. This was a test of moderation to see if this can account for the variance in the effects. The findings showed those studies that included primarily trainees do not differ significantly from those studies of more experienced qualified therapists in showing an association between rupture repair and outcome. This finding cannot provide evidence for supporting the claim that the more qualified/experienced a therapist is the more likely they will show an association between rupture repair and outcome.

‘the competences drawn up by SCoPEd have been deduced rather than induced from the close observations and recording of what therapists actually do’

So, the evidence from this most recent, up-to-date, and rigorous meta-analysis is overwhelmingly in favour of there being no difference between experienced/more trained therapists and the unqualified/trainee therapists in the associations they show between alliance rupture repair and outcome. But wait, the psychotherapists will say, obviously we refute this claim. Psychotherapists will work with ‘more complex and more distressed clients’ so there would be a difference if you looked at that, wouldn’t there? Well it seems the answer to that might also be available in the ‘evidence’ provided by this cutting edge meta-analysis. The evidence is as follows. Eubanks, Muran and Safran (2018) addressed the issue that more complex client work (such as that with clients given a diagnosis of a personality disorder) might mean that there would be less chance of a positive association between rupture repair and outcome. Again this was not found to alter the effects, meaning that whether or not a study included a majority of clients with a diagnosed personality disorder or not, the association between rupture repair and outcome did not differ significantly from those studies where this was not the case. So the ‘evidence’ suggests that even if psychotherapists claim to work with more distressed cases it seems this cannot be used as evidence to suggest they require more skills in working with alliance ruptures.

But wait, surely psychotherapists would be ‘trained specifically to deal with ruptures and repair’ and that is why their training is at a higher level. So now the question is what effects does having specific training in managing alliance ruptures have on the association of alliance rupture repair with outcome? Well, the same researchers completed a second meta-analysis comprising six separate studies and 276 therapists that had undergone such specific training. The findings again point to some interesting ‘evidence’. Once more, status as a trainee or qualified therapist undergoing this specific rupture repair training did not moderate the association between rupture repairs and outcome, suggesting that the finding is not affected by level of qualification. However, interestingly those training in CBT had a much stronger association between rupture repair and outcome than did the psychodynamically oriented rupture repair training. In fact, for psychodynamically trained therapists, the association was in a negative direction – suggesting the less effective they were in rupture repair, the better were client outcomes!

So what are we to make of this? Well it seems that if we are to look at the empirical evidence, that drawn from the very latest and most up-to-date evidence from meta-analysis, it appears to be suggesting that there’s little difference in association of outcome and rupture repairs in terms of the level of training a therapist has had. Of course, if we look to the ‘grey literature’ it is highly likely that we will find such differences; not least because those differences are simply statements of intent and not reality of practice. The issue here is that the competences drawn up by SCoPEd have been deduced rather than induced from the close observations and recording of what therapists, regardless of their level of qualification, actually ‘do’.

But let’s be honest, the ‘aim’ of SCoPEd is, at best, to determine what the differences are between ‘counselling’ and ‘psychotherapy’ in order to protect the various financial interests of those involved in the accrediting the training of counsellors and psychotherapists. At worst the aim is about laying the groundwork for the next attempt at protecting these titles under statute by pursuing the Statutory Regulation of counselling and psychotherapy. Referring to an ‘evidence-base’ is merely an attempt to give this project legitimacy in the eyes of the membership, who are kept in the dark about the real agendas playing out. This is an attempt to try and convince the members of BACP, UKCP and BCP – run down into the ground by the lack of employment opportunities after training – that they will be better off having these titles first differentiated and then protected. But in truth this will do nothing to protect or enhance the employment opportunities for the tens of thousands of under-employed counsellors/psychotherapists already trained and looking for work, and will do nothing to protect the public from rogue practitioners.

 

Reference

Eubanks, C. F., Muran, J. C., & Safran, S. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55, 508-519.


 

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SCoPEd: Denial, Distortion & Deception

The British Association for Counselling & Psychotherapy (BACP), the British Psychoanalytic Council (BPC) and the United Kingdom Council for Psychotherapy (UKCP) – collaborating under the banner of the SCoPEd (Scope of Practice & Education) project – recently published a draft ‘competence framework’, which attempts to differentiate counselling and psychotherapy.

Andy Rogers (BACP member and counselling service coordinator in further and higher education for two decades) submitted the following response to BACP’s consultation survey.


 

It is astonishing that the SCoPEd project claims this document will improve clarity for clients, employers, trainers and other stakeholders. I can only assume the competence framework exists for other political purposes, because there is certainly no clarity here, which might be forgivable if the document was at least more truthful.

But, as one of a number examples of the confused (unintentional?) deceptions in this framework, it is completely erroneous to identify 3.5.c (Ability to negotiate issues of power and authority experienced in the inner and outer world of the client or patient as part of the therapeutic process) as a ‘psychotherapist’ competency (one therefore presumably not held by mere ‘counsellors’), when for any person-centred counsellor worth their salt, this would be a central principle of everything they do! The same could be said of another ‘psychotherapist’ competency, 5.1.c. (Ability to evidence reflexivity, self-awareness and the therapeutic use of self to work at depth in the therapeutic relationship and the therapeutic process).

These examples demonstrate how formal differentiation between the adopted titles often means the imposition of something (i.e. simplistic, hierarchical separation and compartmentalisation) that isn’t actually there in practice among the human beings entering into therapy as practitioners and clients. In reality, there is much fluidity and complexity, which the framework attempts to iron out by positioning psychotherapists as doing the really deep stuff, counsellors as merely dabbling, and then a mysterious in-between group that does more than the basic counsellors but isn’t quite at the psychotherapist level.

“it is not the practitioner’s title that determines what happens in the therapy relationship.”

As most of us know, these levels – assumed in the document to be clear-cut enough to be separated into columns and boxes – are manufactured. At best they are only partially truthful, some of the time, in some situations, for some individuals. They certainly do not accurately represent the field, within which many practitioners who identify as counsellors will see their day-to-day work in the ‘psychotherapist’ column; while there will be plenty of ‘psychotherapists’ who have not yet developed the depth of practice (if we describe it that way) of some ‘counsellors’. After all, it is not the practitioner’s title that determines what happens in the therapy relationship.

That we end up working under one label and not the other is subject to all sorts of choices, influences, values, historical precedents and contextual factors, and often says little to nothing about what the experience of therapy will be like for clients, which could be vastly different between any two ‘psychotherapists’ or any two ‘counsellors’. For a whole swathe of the field, such as the humanistic section – and particularly in person-centred therapy – there is no distinction at all made between ‘counselling’ and ‘psychotherapy’ in terms of the actual work (which this framework purports to articulate); the different titles merely refer to the traditions and histories of various training programmes, professional organisations/groupings and work contexts (and the job titles therein).

“When did therapists become so uncritically disengaged from the roles of history and power in the narratives we hold about ourselves?”

The therapy field is a diverse and complex ecology, which, rather than celebrate, the framework appears to want to eliminate by reasserting hierarchies that are well past their use-by date. A historical aside here is that counselling as an alternative word for psychotherapy has roots in Carl Rogers’ mid-twentieth century tactical switch from the latter to the former at the University of Chicago, which was necessitated by a law that ‘psychotherapy’ could only be practiced by medical professionals. From the very beginning of ‘counselling’, then, the different words were not functional descriptors of differing activities, roles or levels of ‘competence’, depth, ability, skill or experience but were value-laden, politically charged and subject to the operation of power and professional (self-)interest. This is no less true today, but the SCoPEd project is in complete denial about it. When did therapists become so uncritically disengaged from the roles of history and power in the narratives we hold about ourselves?!

It’s notable in sections of the framework that ‘psychotherapist’ is apparently equated with greater alignment with psychoanalytic theory. Is the field not done yet with this power struggle, with the idea that psychoanalytic theory sits at the top of a hierarchy? The ‘note on terminology’ almost acknowledges this tension but concludes, absurdly, “Where terminology has been used that could be interpreted as being modality-specific, this is not the intention.” Oh, that’s okay then – it’s the thought that counts, eh? Being ‘expert’ therapists, I thought the Expert Reference Group (ERG) might have a bit more to say about the importance of language and the power that runs through it, looking beyond stated intentions towards the deeper meanings and influences when we choose one way of saying something over another (especially in a potentially influential document such as this). No?

I was also wondering how this apparent pro-psychoanalytic bias – with its implicit discrediting and delegitimising of humanistic/existential/person-centred counselling/psychotherapy (and their associated values, not least around language) – came about. Then I noticed the ERG was made up of 12 practitioners, 7 of whom were identified as psychoanalytic, whereas only 1 was clearly identified as humanistic (and even then, only as part of an ‘integrative’ model) (see pp.72-73 of the SCoPEd Methodology document). How can the framework produce an accurate picture of the field, when the ERG does not represent the diversity within it?

But the whole project is also skewed by other assumptions and value systems around therapy, which are perhaps even more important for the future of our professions. The Roth/Pilling UCL methodology used here was developed originally by manualised CBT proponents for the CBT competence framework, which was commissioned by the Department of Health as part of IAPT’s development. As this history suggests, breaking down the relational art of therapeutic work into lists of discrete ‘competences’ is not a neutral or objective activity (however ‘evidence-based’ it disingenuously claims to be); it is a technocratic pursuit that clearly derives from the NHS-appeasing assumption that therapy can be manualised into specific skills that, if applied in accordance with the manual, provide ‘effective’ ‘treatment’ for specific ‘disorders’. In other words, the project inevitably – via its very form – aligns therapy with an instrumental and medicalised healthcare model, again potentially delegitimising approaches that see therapy as, say, a meaning-making dialogical encounter or principled way of being.

That none of these biases or agendas, and the political expediency from which they spring, are acknowledged in the framework, highlights its failure to take a therapeutically informed, self-reflective, critical thinking approach to its own motivations, intentions, guiding principles, methodology or articulation. Presumably none of this matters much if your goal is to air-brush the imperfect, fallible, human complexity of relational therapeutic work, in order to prepare for the distribution of power that statutory regulation would involve for the organisations that have composed this empty but highly potent document.

andyrogerscounselling.com

@AndyCounsellor

 


 

 

‘Psychoanalytic coup’ – Andrew Samuels on the SCoPEd Competence Framework

Sent to the Chairs and CEOs of BACP, UKCP and BPC

January 24th 2019

From Professor Andrew Samuels


You have every right to ignore this.

I was in the room as chair of UKCP when the HPC Professional Liaison group in 2010 were told by Prof Peter Fonagy that counselling was inferior to psychotherapy. BACP (Sally Aldridge) were apoplectic. But now, when I look at the lists of competences, I feel sure that many counsellors meet those ascribed to psychotherapy. I’ve trained some of them.

(Incidentally, didn’t the abject failure of the Skills for Health competency based project stick in anyone’s memories?)

Moreover, the interests of Jungian analysis, body psychotherapy, arts psychotherapies and transpersonal psychotherapy have been downplayed. I am not sure how a humanistic and integrative psychotherapist might react, to be honest. Not well, I surmise.

What has happened is that psychoanalysis and psychoanalytic psychotherapy have pulled off a major coup. Their values and approaches have triumphed. I am sure that this will be widely recognised by anyone who reads the documents. It reflects the dynamism and skill of their top people, in my view, so hats off to them in a way!

I have returned the survey to BPC and UKCP. In the free section, I have expressed astonishment that the discredited work done by Roth and Pilling in different contexts has been utilised in this one. Those academics are gung-ho for NICE, IAPT and statutory regulation. They are not friends of the work that we do.

The whole thing strikes me as an example of fiddling while Rome burns. Actually, it is worse than that. We’ve spent decades making sure that, for example, job adverts ask for BACP or UKCP or BPC membership where once the BPS held sway. I’ve been proud to be a part of that. We even managed to reduce the stress on modality in most adverts, except those where the consultant doctors were psychoanalysts. We have begun to get the Professional Standards Authority on the map.

Now three utterly bizarre neologisms are being put forward. And this is going to make getting jobs easier? Or help applicants? ‘Qualified counsellor’, ‘advanced qualified counsellor’, ‘psychotherapist’.

Even if the old terms are restored once the survey has run its course, the discrepant crunch between the two indicative languages will be so confusing.

And what is the point of saying that these terms are ‘loosely described’? They are not loosely described at all; they are clearly differentiated (albeit on shaky grounds) and formed into a tendentious hierarchy.

Sorry for the passionate way in which I write. I am hoping that there will be massive opposition to these proposals but am realistic: the supine memberships mostly won’t bother about it at all – a few will support, a few will oppose, and we shall lumber on, promoting the demise of depth, relational work – what I still call (semi-seriously) ‘real psychotherapy’.

Finally, I will comment on page 72 of the main document where the membership of your Expert Reference Group is given. There are 12 in total, 7 of which are psychoanalytic, 2 integrative (unspecified combination), 1 hypno-psychotherapy, 1 pluralistic (unspecified combination) and 1 humanistic-integrative. Add in the chair and information analyst and I believe it comes to 8 psychoanalytic and 6 others (of which only two are explicitly humanistic in orientation).

How is this a balanced group of experts??