What happens when an experienced therapist, in order to secure their employment in the NHS, undertakes training that may be at odds with their core model and values? Can they have the same allegiance to a new model as to their existing one? What happens to their practice and outcomes when they can’t? A study of Counselling for Depression training raises these very questions.
Therapist allegiance refers to the degree to which the therapist delivering a treatment believes that treatment to have efficacy. It is understood to be one of the essential components that contribute to the variation in therapy outcomes.
Allegiance is of research interest because of its impact on studies comparing the outcomes of two or more different therapies. Quite simply, there has been strong tendency for researchers to find results that support their own beliefs, expectations or preferences. [i] In other words, to find in favour of their preferred model of therapy.
A number of factors may produce allegiance effects in comparative studies of therapies. They include:
The alternative treatments used as comparison against the experimental treatment may not be bona fide therapies – in other words they are not therapies that are designed to be therapeutic in the same sense e.g. supportive ‘counselling’.
Both experimental and comparative treatments may be delivered by practitioners whose primary allegiance is to the experimental treatment, and who may not have been effectively trained in delivery of the comparative treatment. Given that the therapist’s belief in the efficacy of the therapy being delivered is a critical component in its actual efficacy, it is hardly surprising in these conditions if the comparative treatment produces inferior outcomes.
Within many research designs there has been a failure to control for factors that may inflate the apparent effectiveness of the experimental treatment – for example, using measures that may be particularly sensitive to changes in cognitive processes, or failure to consider therapist performance as a variable that impacts on outcomes.
Routine practice is surely different, however? We believe in what we do, we can articulate a rationale for it, and we deliver it. After all, we wouldn’t dream of doing anything else, would we? After reading a recent study of the experiences of counsellors that undertook training in Counselling for Depression (CfD), [ii] however, I’m beginning to wonder.
For the most part, practicing therapists choose the approach to psychotherapy that is compatible with their understanding and conceptualization of psychological distress and health, the process of change, and the nature of the client and his or her problem. Consequently, clients can rest assured that their therapist is committed to and believes in the therapy being delivered.Bruce Wampold
IAPT and other stories
The landscape of NHS primary care mental health is unrecognisable from that of ten or twelve years ago. As the delivery of CBT and manualised therapies has taken centre stage, counselling and counsellors have struggled to maintain both position and respect. Being able to ‘do our own thing’ behind the therapy room door is now seldom an option.
The establishment of IAPT has been transformational rather than developmental, and counsellors have had to adapt to this new environment. I’ve heard many examples of those who have made a radical shift from their core model and retrained in CBT.
When Bruce Wampold wrote the words above, [iii] I don’t think he had IAPT in mind. In IAPT settings, they may be applicable to practitioners whose core training is CBT or who trained within the IAPT framework. They may not ring true for counsellors from different modalities or outside IAPT. To survive, or remain employed, many have had to compromise. For some, the underlying message has been ‘shape up, or ship out.’
But how far can we compromise before the integrity of our work is undermined? And at what point does being required to work differently undermine our allegiance to a new model, as well as our effectiveness?
Practitioners experiences of CfD training and implementation
The paper I referred to earlier [iv] aimed to investigate counselling practitioners’ experiences of learning the CfD model and implementing it in practice settings. Participants were recruited to the study (which involved an online survey, followed by semi-structured interviews) from BACP’s CfD Practice Research Network (PRN). Further details are shown in the adjacent panel.
A total of 18 participants completed the online survey, which asked for their experience of CfD training, as well as its impact on their practice, sense of professional competence and skill set. Further details are shown in the panel below.
Findings from the online survey
Of the 18 participants who completed the online survey (see panel below for further details), most reported either a very positive or positive experience of the CfD training. Sixteen stated that the training had an impact on their practice, though no further detail is given about whether that impact was experienced positively or negatively.
Participants were recruited from BACP’s CfD PRN
A mixed-methods design including online survey and semi-structured interviews
18 participants completed the online survey, of whom 12 indicated willingness to be followed up
Six further participated in semi-structured interviews
Core professional training was predominantly humanistic (n=14)
Average post-training experience was 12.6 years (range 4 – 25 years)
Main job roles: NHS IAPT high-intensity counsellor (n=11) or IAPT high intensity counsellor not employed by NHS (n=5)
An increase in skill set was reported by all but two practitioners, though this should hardly be surprising given that this was a practically focused professional development course.
Online survey (completed by 18 participants), with 24 items using Likert-scale questions, including:
‘How would you describe your experience of training to become a CfD practitioner?’
(five-point scale from ‘very negative’ to ‘very positive’)
‘How challenging was the experience of training in CfD?’
(three-point scale from ‘not challenging at all’ to ‘very challenging’
‘How far has training in CfD changed the way you practise?’
(three-point scale from ‘not changed at all’ to ‘changed significantly’
‘To what extent has training in CfD affected your sense of self as a professional therapist?’
(five-point scale from ‘made me feel far less confident’ to ‘made me feel far more confident’)
To what extent has training in CfD impacted on your set of skills as a professional therapist?’
(four-point scale from ‘did not change skill set’ to ‘greatly increased skill set’)
Additional demographic data were sought including: professional qualification, theoretical orientation, counselling experience, CfD training information, motivating factor for undertaking the course and current job role.
Two points in particular seem relevant to the question of allegiance: participants’ motivation for undertaking the CfD training and the degree of perceived fit between the CfD model and their own philosophy, values and practice.
Motivation for undertaking CfD training
The main motivating factor for undertaking the CfD training was to remain employed by the NHS (n=9). One other respondent indicated that it was a mandatory requirement. Only seven (39%) cited developing professional and personal practice.
Degree of fit between the CfD model, and current philosophy, values and practice
13 participants stated that ‘the CfD model fits very well with my philosophy, values and the way I work with clients’. Three indicated that ‘the CfD model restricts the range of skills and approaches I would normally use with clients’. A further two indicated that both statements applied, suggesting that their experience might be situation dependent.
For more than a quarter of participants, then, full congruence between the CfD model and their own ways of working seems either absent or equivocal.
The experience of interviewees
The six participants interviewed were drawn from 12 of the 18 participants that completed the online survey and indicated a willingness to be interviewed. For balance, they included:
Two that selected the online survey statement ‘The CfD model fits very well with my philosophy, values and the way I work with clients’.
Two that selected the statement ‘I find the CfD model restricts the range of skills and approaches I would normally use with clients’.
Two that stated that neither statement reflected their experience of using the CfD model.
An outline of the interview schedule is shown in the panel below.
Eight questions encompassing six areas of experience of CfD in training and use in implementing it in service settings:
General experience of CfD training
Degree and types of challenges experienced
Experience of being assessed
Impact of training on work with clients
Experience of managerial and clinical supervision
Practising CfD in a service setting.
Participants’ responses provide a mixed picture of more and less positive experiences. Reconnecting with a core theoretical approach, supportive teaching and feedback, the acquisition of additional skills and having a non-CBT approach which was manualised and had IAPT recognition were all seen as positive.
Less positive experiences included service constraints and regulations which impeded effective use of newly acquired skills, and mixed levels of course, managerial and clinical supervision and support. For some, adapting to a new model of practice was a particular challenge. In the words of one:
‘My core model is [model specified] so obviously I had to set that to one side and that was quite a challenge, you know to stop thinking in those terms.’
Another participant described this challenge as like learning a new intervention ‘with one hand tied behind my back’.
Compromise at what cost?
In a review of 29 studies comparing psychotherapies, Luborsky et al (1999) estimated that the allegiance of the researchers accounted for over two-thirds of the variance in outcomes between therapies. Reviewing the literature Wampold (2001) comes to a similar conclusion i.e. that allegiance effects have generally been found in meta-analyses investigating the phenomenon, with an upper effect size of d=0.65 (a significant and medium sized effect in research terms). He concludes by saying:
“That the effects due to allegiance account for dramatically more of the variance in outcomes than does the particular type of treatment implies that therapist attitudes towards therapy is a critical component of effective therapy…”
The participants in the CfD study had an average of 12.6 years post training experience. It’s hard to imagine that before their CfD experience they had not developed a way of working which already suited their philosophy and values.
Over half (55%) cited their main motivating factor for undertaking the CfD training as remaining employed by the NHS or being mandated. Irrespective of what they may have gained, what level of real choice did they feel themselves to have?
Adapting to a new model was clearly a struggle for at least two of the six participants whose words are quoted above. They felt compromised and I truly feel for them.
The study is based on a relatively small sample. As such, we cannot know whether its findings and conclusions generalise to the wider body of practitioners who have undergone CfD training. As the study authors point out, however, given that this sample was drawn from BACP’s CfD Practice Research Network:
“…the findings from this research are likely to be representative of a more positive, enthusiastic cohort that may not be an accurate representation of training in CfD as a whole.”
It is clear that therapist allegiance to the therapy being delivered is critical to its outcomes. What is unknown is the extent to which participants in the CfD training feel the same allegiance to the CfD model as they did to their pre-CfD way of working. We also don’t know whether the outcomes of those who do not feel the same allegiance have been compromised as a result. For their sake, however, and the sake of their clients, we need to know. As researchers are usually given to saying….”more research in this area is needed.”
Whatever struggles some of the CfD training participants may have in adapting to a new way of working, and whatever difficulties they experience in gaining proper recognition, the good news is that CfD is more than holding its own in outcome terms. A recent study shows the recovery rates of clients receiving counselling and CBT over three years to be virtually identical, while those receiving counselling utilised fewer sessions. You can find details in my recent blog on the subject.
[i] Cooper M. (2008). Essential research findings in counselling and psychotherapy: the facts are friendly. Sage, London
[ii] Alongside CBT, Interpersonal Therapy (IPT), and Brief Dynamic Behaviour Therapy (DIT), Counselling for Depression (CfD) is one of the treatments approved by NICE for the treatment of mild to moderate depression. It is a manualised form of person-centred experiential therapy. While there has been an increased in practitioners delivering CfD over time since its introduction in 2012, they are thought to account (at 2016) for just 6% of the high intensity therapist workforce.
[iii] Wampold B E. (2015). The great psychotherapy debate: The Evidence for What Makes Psychotherapy Work. Routledge.
[iv] Drewitt L et al. (2018). Practitioners’ experiences of learning and implementing Counselling for Depression (CfD) in routine practice settings. Counselling and Psychotherapy Research. March 2018
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