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:

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.

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.

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.

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:

An outline of the interview schedule is shown in the panel below.

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.

References

[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