Blogs 5 December

A Thousand Ways to Therapy

Therapy is constantly evolving. It has blossomed far beyond the four walls of a psychotherapy consulting room, embracing new ways to access support, new approaches, and developing new strands of integrative therapeutic interventions.

With this array of therapies delivered in person, over the phone, online or via email, surely there’s a high chance of finding a personalised approach to suit most of us, when in need.

It concerns me that this is not the case.

In an effort to provide therapies with the requisite evidence-base, we risk stifling the choice therapists have worked so hard to create. Today only those therapies which lend themselves more readily to empirical study satisfy the criteria required.

While I understand the need for evidence-based practice (using evidence derived from laboratory style research, for example randomised control trials or RCTs), I would argue that practice-based evidence (so called ‘real-world’ research) has a vital role in determining recommended therapeutic approaches. Rigorous research designs collecting high quality and systematic feedback from experienced practitioners and from their clients are a vital indicator of effectiveness and can provide valuable insight.

Saying this, it is worth thinking of the words of sociologist William Bruce Cameron: “Not everything that can be counted counts and not everything that counts can be counted.”

Some therapies have already generated the standard of evidence required to earn a high billing in NICE guidelines. Cognitive behavioural therapies (CBT), for example, have amassed numerous RCTs. This level of evidence is valued highly by Government decision-makers today, who are tasked with providing proven treatments and who are keen that talking therapies for mental health are as robustly tested as medicines prescribed for other ailments.

And while it might be up to the therapeutic community to develop similar kinds of data across all therapies, this will take some years to create, and will diminish choice in the meantime for those who may not opt for or respond well to a limited list of recommended approaches.

It is because we prize a specific brand of quantitative evidence that we may be unwittingly enabling a prescriptive and singular approach to mental health support, directly contravening the principle of choice we know is so important.

The field is moving so quickly, with new, innovative approaches and modalities developing apace. To wait years building a top-down evidence base risks blocking the availability of such treatments to those who could benefit today.

I am not arguing against rigour or evidence, just against a therapeutic monoculture based on too high a bar. We should be open to finding new ways to demonstrate impact and deploying different methodologies than we are used to.

But it’s not just this change that’s needed. We also need to reframe the concept of therapy itself, to include those we are familiar with, but also to incorporate therapeutic activities we also know are effective. We know that there are a thousand ways to therapy and we know that because we are all different, we must offer access to a myriad of services and types of support to meet an individual’s need.

As Dr Terry Hanley, Programme Director of the Doctorate in Counselling Psychology at the Manchester Institute of Education, put it: “That idea that ‘one size does not fit all’ should be at the heart of any therapeutic approach, because you never quite know what someone’s going to talk to you about when they come through the door.”

Importantly, when they do come through the door, they may not necessarily be in a position to select a therapeutic approach. So the principle of choice for the therapist is a challenging one. This challenge holds more broadly too, not only for the reasons already described.

We know addressing mental health issues isn’t about sending an individual home with the same blue pill or with a prescription for a universal evidence-based six-session counselling course. It’s about understanding an individual’s pain and working with them in an attempt to help them feel better.

This might mean trying several approaches to see which resonate. And it is worth putting the work in here as so often we see people returning to the system they first came to for help, having not quite found a way to recovery.

Dr Hanley, as well as applying different face-to-face therapeutic approaches, believes in offering creative therapies which hold a different appeal. He volunteers for Freedom from Torture in Manchester, where football is offered as a form of group therapy for torture survivors. Terry’s role is to listen to any problems that arise and to support any men who might be having difficulties during the session. This might happen on the pitch, when they are travelling or using the changing rooms. Offering support informally, outside the therapy room is vital for this group of men.

Dr Hanley: “This is all part of an idea that at times it’s necessary to work in more creative ways to engage with people…the football project I work on is about developing relationships and trust with the people we work with…[to]…feed into other parts of support.”

Counsellor Dan Mills-Da’Bell, clinical lead at XenZone, also takes a creative approach. Having studied a number of different therapies, from person-centred and psychodynamic, to relational depth, CBT and Dyadic Developmental Psychotherapy, he also regularly uses drama, music and art therapy as a way of exploring issues without putting pressure on a client to sit and talk through their problems.

Dan works a lot with young boys, many of whom find it hard to trust or open up; they can also struggle to find the right emotional vocabulary. He has found being able to offer a choice of approaches critical: “For me, what’s been useful is having all these different approaches in the toolbox, to be able to pull out and use when needed. And these can change over the course of a session or multiple sessions with a client.”

Putting this choice in the hands of the client and enabling them to make decisions about which type of therapy they would like is perhaps a logical next step when we consider that clients do better in therapy when their preferences are taken into account. Therapeutic pluralism, the framework for this approach to counselling, is a way of thinking about therapy that tries to be valuing of all the different therapeutic approaches.

Pluralism offers a lot of freedom in finding the ‘right’ approach. It recognises that there are different ingredients to therapy. You have goals, tasks and methods, but fundamentally behind all that you’ve got the therapeutic alliance. This is the bond that is critical for therapy to work.

According to Mick Cooper, Professor of Counselling Psychology at the University of Roehampton, who co-developed the framework, “Pluralism starts from the assumption that there are lots of different ways that people can be helped, whether through a CBT, person-centred, or a psychodynamic approach. Lots of different approaches can be helpful as people are likely to need different things at different points in time.”

This is an interesting point: often we see a progression in need as issues change, link to past events or move on to require a different, perhaps solutions-orientated approach. As our mental health is rarely linear, clients themselves can become adept at recognising waves of depression or anxiety and developing their own therapeutic ways of coping.

This idea of therapeutic activity is one which particularly interests Miranda Wolpert, Professor in Evidence Based Practice and Research at UCL. She believes the challenge for mental health professionals is to consider every therapeutic option: “I think we need to really question and think about what choices are available and to think much wider than we have to date. So, not just choices within therapy but choices beyond therapy and for people’s lives more generally.”

Consideration for what may lie outside our standard notion of therapy is central to expanding its definition and offering choice. I was in a meeting recently when someone asked me whether an online peer-to-peer support community was really therapy. I realised that the real question was whether it was ‘therapeutic’. The important point was whether or not the young person found the experience helpful, not whether it fitted into a formal definition.

In deciding to go online and join an online community discussing self-harm, for example, a young person may not have needed one-to-one counselling, but may have been looking for the therapeutic comfort of being with a group of young people with similar experiences.

Equally, a person may find talking to friends, going for a walk or playing football therapeutic. It may be that they need to write about their feelings, express themselves through art or listen to music. The list is endless. And it shows that the need for support doesn’t always warrant a formal or medical response.

In fact, Tim Tod, founder of Red 22, an organisation working with schools and organisations to support children and young people, believes that presenting formal or medical routes to support is likely to put a young person off getting help or sharing their feelings. He maintains that young people need to feel able to have a ‘first conversation’ about mental health without feeling judged or railroaded down a particular path.

According to Tim, “Helping young people and supporting their mental health isn’t just the preserve of the therapist. There are trusted adults who are not therapists but who can work therapeutically with young people – and regularly do. Medical professionals, foster carers, teachers and others all have an important part to play.”

That being said, counselling can be vital and is often life-changing. Giving someone the opportunity to reveal themselves emotionally in a safe space, without being judged, can be critical in aiding recovery. This does not, however, have to be anyone’s first brush with therapy.

If we believe in the value of choice, then therapy and therapists must be flexible. The process should not be prescriptive. Therapy is not done to people; it is a powerful and collaborative process that puts the client at its heart.

This choice and flexibility is of course reliant on therapists. To get away from a purist approach means that from a core model of therapy, a counsellor expands his or her knowledge base to experience what else is out there, building on their framework of understanding. Therapists should have a good grounding in, for example, attachment or the impact of trauma. Equally they need to be able to take a different solutions-based approach for someone who has something niggling away at them.

As a therapist, you’re treating different parts of a being. When someone has a complex need they also need some simple solutions. Often with clients presenting with a range of issues, therapists will address them in layers, helping clients achieve day to day tasks and goals, to function and get through the week. When basic needs are addressed, the more complex issues can then be approached.

We know that we need to work harder to reach people in the way that they need it. Of course, this includes models of therapy, but also to the way in which therapy is experienced, whether that be online or face-to-face, through supported peer-to-peer work, guided self-help or any other approach.

We need to work hard to push for rigorous practice-based evidence to be an acceptable level of proof to enable innovative practice to be accessible to all.

The reality is, without choice, therapy would become unpopular and redundant. So while it has come a long way, it cannot stand still.

Therapy needs to grow and prove its worth, but above all it needs to show how choice is at the heart of anyone’s opportunity of recovery.

Watch our video interviews with experts discussing therapeutic choice and register to receive a full ‘A Thousand Ways to Therapy’ Transcript Report with a forward from Dr Lynne Green.

Aaron Sefi

MA Couns

Research and Evaluation Director, XenZone