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Letters I find myself realising that under no circumstances whatsoever would I refer a fellow member (and their clients) to such an ordeal, short of being convinced that membership should be immediately withdrawn. In fact I would agree with Kearns 1 that the current policy of publically naming those who have been judged to need merely an improving sanction, brings BACP perilously close to breaching its own Ethical Framework (in respect of malfeasance, justice and self-respect). David Solomon MA; MBACP (Accred) reference: 1. Kearns A. The mirror crack’d: when good enough therapy goes wrong and other cautionary tales. Karnac; 2007. Understanding IAPT’s progress I am trying to make sense of IAPT’s own review of its progress. 1 The detailed analysis of the effects of the implementation of the IAPT programme (Glover et al, 2010) concludes that: ‘...the collection of such a large outcome dataset is in itself a remarkable achievement for the services’ (p40). However, to my untrained eye, it does little to establish the effectiveness or otherwise of the treatments offered to patients. The treatment offered to patients at the 32 sites varied greatly: ‘Of the 18,308 patients with finished episodes receiving some high intensity therapy, 57.8 per cent received CBT and 50.1 per cent counselling, with 1.3 per cent and 0.6 per cent receiving IPT and couple therapy respectively’ (p21). Efficacy of the high level interventions (of which CBT and counselling were the main offerings) varied greatly and the data reported seem (to me at least) very confusing. This seems to be backed by the authors: ‘It is important to stress that this cannot be seen as a test of the comparative efficacy of the different treatment approaches, as patients were not assigned randomly, but to the approach which appeared most suitable in the light of initial assessment and locally available resources. The table makes it clear that the different approaches were used selectively for different problems. As the programmes included a substantial element of training for CBT therapists, it is also likely that a substantial proportion of the staff providing CBT were inexperienced or trainees, whilst those employed to provide counselling were probably mainly already trained and experienced’ (p30). I have also failed to find a meaningful definition of counselling in the document, which seems to me to be a glaring omission. Whilst I cannot fault the review conclusions about the tremendous success in gathering (and indeed its ability to process) data, the study does little to support the theory that CBT is the best option for the treatment of a whole host of mental illnesses and that counselling is less efficacious; this theory is actually based on other randomised clinical trials which have been previously reported on CBT in a highly controlled and scientific manner (counselling being less well evidenced; not less efficacious!). Therefore, IAPT evidence does not (yet) support the theory that ‘CBT is best’ in vivo! I am now wondering if it is possible that the data that IAPT has made available could be re-evaluated by BACP, such that people like myself might be able to make better sense of the real role counselling has played in the IAPT programme so far. Mark Smith MBACP reference: 1. Glover G, Webb M, Evison F. Improving access to psychological therapies: a review of the progress made by sites in the first rollout year. July 2010. http://www.iapt. nhs.uk/wp-content/uploads/iaptyear-one-sites-data-review-finalreport.pdf Supervision intervention It is interesting that the dilemma (‘Managing boundaries’, October 2010, Therapy Today) is presented in the second person. This perspective forces the responder to make a choice. One option is to discuss the shortcomings of the supervisor as if they were one’s own; the other is to reply in the third person and disown the supervisor’s work. Naturally I would prefer to take the latter stand: the supervisor isn’t me; I hope I would never work this way with a supervisee. But in the interests of trying on this supervisor’s person I will accept the invitation to reply in the first person. While I have noted that I have ‘challenged’ Jason on the succession of issues I am concerned about, there is a glaring absence of information in this scenario about how I have been addressing the apparently increasing unprofessionalism of his work. This suggests that I may not have carefully planned out or implemented a method of effectively helping Jason address these issues or indeed to see them as problematic in the way that I do. Jason’s defence structure is such that he does not react to ‘challenging’, so another style of intervention should now be attempted. I don’t seem to be experienced in dealing with supervisees who break the rules, which may suit Jason perfectly if he is genuinely unwilling to undertake further training. It would appear that in fact it is I who may need further training, particularly in how to deliver appropriate feedback to enable ethical practice. It is good news that I have been taking my concerns about Jason’s work to my peer supervision group, but it is worrying that of all the feedback given by the group, the suggestions to either dump or report Jason are the ones I am considering. Both of these courses of action sidestep my responsibility to provide Jason with a suitably robust supervisory approach. Additionally, both are unnecessarily punitive, humiliating and potentially damaging to Jason under the circumstances. After all, it was I who said ‘none [of the issues of concern] have warranted immediate action’. Am I harbouring an unacknowledged wish to be rid of Jason, or worse, to punish him for not being a well-behaved and easy supervisee? Caroline Vermes MEd, MBACP (Accred) 36 Therapy Today/www.therapytoday.net/November 2010
Reviews Evidence for the economic value of therapy Psychotherapy is worth it: a comprehensive review of its cost-effectiveness Susan G Lazar (ed) American Psychiatric Publishing 2010, £40 ISBN 978-0873182457 Reviewed by Colin Feltham This is an important, authoritative and persuasive contribution to the explication and promotion of psychotherapy. British readers who are counsellors and psychotherapists will note that it is decidedly psychiatric and American in style and orientation. It opens with considerations of mental illnesses, their costs to society and the contributions of psychotherapy. Its chapters examine clinical outcomes and cost-effectiveness relating to schizophrenia, borderline personality disorder, PTSD, anxiety disorders, depression, substance abuse, ‘medical conditions’, and children and adolescents. It concludes with a favourable examination of long-term intensive (psychodynamic) psychotherapy. The book sets ‘mental illness’ (standard psychiatric terminology is used throughout) in a global context as the leading cause of disability but most of its examples and statistics are associated with the US experience. Looked at starkly, the incidence of all kinds of psychological distress and their costs to society proves both interesting and ‘useful’ as a base from which to argue for the benefits, indeed necessity, of psychotherapy. Contributing authors review all relevant literature for their topics and a major strength of the book is its scholarly thoroughness. It seeks to provide (presumably to fund-holding sceptics) almost irrefutable evidence of clinical effectiveness and the economic wisdom of utilising psychotherapy. Tables of published evidence are supplied, case studies vividly demonstrate effectiveness and authors fairly critique the various research methodologies underpinning the evidence presented in each domain, although the ‘gold standard double-blind randomized control study’ still appears to have the edge here. There is a mass of comparative research and data that should to some extent be generalisable in the UK context. One of the disappointing (but not surprising) aspects of the book, to my mind, is its emphasis on CBT and psychoanalytic therapies. Curiously, it actually asserts that ‘there are several [my emphasis] theoretical approaches to psychotherapy, chief among them cognitivebehavioural and psychodynamic’ (p9). Cognitive analytic therapy (CAT) and dialectic behaviour therapy (DBT) do appear but humanistic therapies do not. ‘Counselling’ is mentioned in the context of alcoholism and depression and there is a very brief review of ‘non-directive counselling’ compared (with uncertain results) with GP care. Some European examples have been given but no links are made with, say, Layard’s work on the economic benefits of CBT in the UK. The book certainly offers no critique of American society vis-â-vis the aetiology of mental distress but it does in places include relevant culturally specific data. This book champions psychotherapy as a clinically productive and probably costeffective intervention. In spite of its presumably unintended biases and limitations, it is a welcome addition to the debate in the UK about the economic value of therapy. Colin Feltham is Emeritus Professor of Critical Counselling Studies at Sheffield Hallam University Risks of group interaction Difficult topics in group psychotherapy: my journey from shame to courage Jerome S Gans Karnac 2010, £22.99 ISBN 978-1855757691 Reviewed by Chris Rose This is a collection of articles first published in the International Journal of Group Psychotherapy, dating from 1989 to 2008, introduced with some personal reflection upon each topic. Jerome S Gans is a Distinguished Fellow of various American institutions, with many years’ experience of working with groups privately and within the American medical system. Both patients and therapists take the journey he describes from ‘shame to courage’. Shame refers to a global sense of inadequacy, of being ‘no good’, which, according to Gans, we defend against in myriad ways, including indifference, depression, perfectionism and compulsive caretaking. He talks of an internalised ideal therapist who is wise, compassionate, and able to make a positive impact. The constant failure to realise this ideal in the real word of helplessness, incompetence and sometimes hatred can generate feelings of shame, which distort our practice and prevent us from looking clearly at various issues. In a similar way, the patient’s profound sense of November 2010/www.therapytoday.net/Therapy Today 37
Page 1 and 2: Therapy Today November 2010, Vol. 2
Page 3 and 4: Contents Sarah Browne Editor For se
Page 5 and 6: Mental health groups praise governm
Page 7 and 8: In practice Words and labels Kevin
Page 9 and 10: In training Walking the line Alex E
Page 11 and 12: Increasingly, counsellors and psych
Page 13 and 14: defined as the assumption that diff
Page 15: Questionnaire Jeremy Clarke A natio
Page 18 and 19: Viewpoint References 1. Wampold BE.
Page 20: Training Becoming a counsellor Surp
Page 23 and 24: ‘Trainees were primarily concerne
Page 25 and 26: © hans neleman/the image bank/gett
Page 27 and 28: my work. This is not because I am o
Page 29 and 30: November 2010/www.therapytoday.net/
Page 31 and 32: Dilemmas The counselling-coaching i
Page 33 and 34: Kate Cunnion (counsellor, superviso
Page 35: female client and was seeking suppo
Page 39 and 40: Co-creating therapeutic conversatio
Page 41 and 42: News From the Chair How are develop
Page 43 and 44: Could you write an information shee
Page 45 and 46: Case Study Research in Counselling
Page 47 and 48: skills and attitudes as a tutor to

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