Peter Pearce and Ros Sewell Metanoia Institute. Peter Pearce and Ros Sewell

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1 Peter Pearce and Ros Sewell Metanoia Institute

2 We decided to take these two issues as our conference topic as they are the two most frequently asked questions from people who have undertaken CfD training. We hope you will find this information helps equip you to dialogue effectively with colleagues from the range of other evidencebased modalities. We will look at two different sets of research on the effectiveness of PCE the evidence reviewed by the Guideline development group in constructing the NICE guidelines for depression and Robert Elliott et al s 2013 meta-analysis of humanistic therapy

3 Five studies met the criteria for inclusion in the evidence review:- Greenberg et al (1998) and Goldman et al 2006 RCTs from Canada with n=38 and n=34 all with major depression both compared two different types of PCE :- client-centred therapy with emotionfocused therapy(eft) Both studies found each approach to be effective, in the reduction of self-reported depression scores Greenberg et al found that there was no significant difference between interventions and Goldman et al report larger improvements for the EFT group

4 Caution in the interpretation of these findings because sample sizes were relatively small and there was no none treatment control group

5 Bedi et al (2000) an RCT n=103 compared the effectiveness of 6 sessions of counselling versus anti-depressants No significant differences were found between each intervention but at 12 months follow up clinician reported depression scores were significantly lower for the anti-depressant group compared to counselling

6 The study was viewed as inconclusive and the introduction of a patient preference element led to significant differences in baseline severity measures between the two study groups

7 Simpson et al (2003) a UK RCT n=145 which compared psychodynamic counselling plus GP care with usual GP care The study found no clinical benefit for therapy plus GP care compared with usual GP care Watson et al (2003) an RCT from Canada n= 93 all with major depression compared EFT with CBT

8 The GDG criticised this study on the basis of its sample size, and concluded the evidence from it was insufficient to reach any definite conclusion about the relative effectiveness of the two interventions

9 Ward et al (2000) a UK RCT n=464, 62% diagnosed with depression compared 6-12 weeks of non-directive counselling (based on Rogers) with CBT and with usual GP care

10 The GDG initially excluded this study as only 62% met the diagnoses for depression and the study wasn t completely randomised

11 A sub-group analysis focusing on this 62% was re-submitted. This study showed a significant (medium-sized) impact on depression scores at 4months but no significant effect at 12 month follow-up

12 This sub-set analysis was included But was excluded from the analysis in the 2009 update

13 Several studies reviewed were rejected as not meeting the inclusion criteria:- Marriott and Kellett (2009) compared counselling, cognitive analytic therapy and CBT in everyday UK NHS practice settings No randomisation or non-treatment control group

14 Excluded as the sample size was too small to reach any definitive conclusions and only 34% of the sample had a depression diagnosis

15 Stiles et al (2006) and (2008) in UK GP practice settings n =1309 and n=5613 compared CBT, psychodynamic and person-centred therapy in routine NHS settings using CORE All were shown to be effective and about as effective as each other with the same intake of severity, chronicity etc. No randomisation or non-treatment control group

16 Excluded as not all participants met the criteria for depression and other diagnoses were included in the sample, so the GDG felt it was difficult to draw conclusions about the effectiveness with depression

17 Evidence was seen as limited by the small sample sizes so the studies were seen as relatively low power and not all participants met the criteria for depression Participants in the studies reviewed were viewed as predominantly from the mild-to moderate range of depression (though for two studies all participants had major depression measured by DSMIV) and two studies included people with minor depression

18 Evidence supported the effectiveness of counselling for mild-to-moderate depression but not for severe depression

19 The official description of CfD within the IAPT programme is as follows: Counselling for depression is a manualised form of psychological therapy as recommended by NICE (NICE, 2009) for the treatment of depression. It is based on a person-centred, experiential model and is particularly appropriate for people with persistent sub-threshold depressive symptoms or mild to moderate depression. Clinical trials have shown this type of counselling to be effective when 6-10 sessions are offered. However, it is recognised that in more complex cases which show benefit in the initial sessions, further improvement may be observed with additional sessions up to the maximum number suggested for other NICE recommended therapies such as CBT, that is, 20 sessions.

20 Meta-analysis reviewing 200 studies of the outcome of PCE therapies (humanistic-experiential psychotherapies) covering, depression, chronic medical problems (eg. HIV), self-damaging behaviours( substance misuse and eating disorders) relationship problems and psychosis. Studies of depression were the most frequent, at 27 studies, comprising a total of 1287 clients The 27 studies included those that measure pre and post therapy distress with (n=8) and without a control or comparison group.

21 The effect size across all the studies was large though somewhat smaller (though still statistically relevant) in the controlled trials

22 23 studies compared PCE with other types of therapy The outcomes were found to be broadly equivalent For comparison within the family of PCE therapies there was some preliminary support that process-guiding approaches may have some superiority over approaches that do not use these methods with depressed clients

23 Holden, Sagovsky & Cox (1989), Morrell et al (2009), Wickberg & Hweng (1996) all RCTs of person-centred therapy for perinatal depression with medium to large sample sizes Verdict The studies all found therapy to be more effective than usual treatment alone

24 Cooper, Murray, Wilson & Romaniuk (2003) an RCT comparison of Person-Centred with CBT for perinatal depression and with short term psychodynamic therapy (Cooper et al (2003); Morell et al (2009) Verdict Person-centred therapy showed no difference in comparison with the other therapies

25 Mohr, Boudewyn, Goodkin, Bostrom & Epstein (2001); Mohr et al (2005) compared outcomes for individual CBT, supportive-expressive group therapy and sertraline for the treatment of depression in multiple sclerosis and Stice, Rohde, Gau & Wade (2010) (a study where adolescents with mild to moderate depression were randomised to either:- supportive group therapy vs. CBT group therapy vs. CBT bibliotherapy vs. controls.)

26 In both studies those who received supportive therapy showed comparable benefits to those in CBT. In the Stice et al study these were sustained at 2 year follow ups and were much better than the control group

27 In summary this more comprehensive review of research on the effectiveness of PCE therapies with depression suggests they have significant positive effect with some preliminary support for approaches which include process-guiding

28 Increasingly, it is recognised that depressive symptoms below the DSMIV and ICD10 threshold criteria can be distressing and disabling if persistent. Therefore this updated guideline covers 'sub-threshold depressive symptoms', which fall below the criteria for major depression, and are defined as at least one key symptom of depression but with insufficient other symptoms and/or functional impairment to meet the criteria for full diagnosis

29 NHS psychological services are organised around the principle of a stepped care model which should deliver the, least intrusive, effective response AND clients should be able to have some choice over the therapy they are offered So minimal interventions such as GP watchful waiting (for around 2 weeks) followed by a limited number of guided self-help sessions from a PWP are offered for less severe presentations and if the person experiences sufficient recovery then no further help is needed. If there is not sufficient response or severity is clear at initial assessment then one of the NICE approved, high-intensity, face to face talking therapies is offered for sessions

30 CBT tends to be the recommended frontline high intensity therapy for most problems However, each of the following NICE approved, additional modalities are also recommended for depression:- CfD (Counselling for Depression) IPT (Interpersonal psychotherapy) DIT (Dynamic Interpersonal Therapy) BCT (Behavioural Couples Therapy)

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33 Not all therapies are effective for everyone as some people suit some approaches better than others and some approaches can be better at helping at certain times than other times. All five therapies in this booklet are recommended by NICE for treating mild to moderate depression in adults.

34 Thinking and doing therapy, CBT aims to help people change patterns of thinking and behaviour that are causing problems Changing how you think and behave also changes how you feel CBT is a structured approach you agree goals with your therapist and try things out between sessions It is recommended as the first line treatment for : - Panic Agoraphobia Social phobia Depression mild to severe Health anxiety Anger management Specific phobias Generalised anxiety disorder Obsessive compulsive disorder Post traumatic stress disorder Severe habits Chronic fatigue

35 How does it work? the way we feel is affected by our thoughts, beliefs and by how we behave People become depressed for many different reasons (stress, relationships, set-backs, etc) Once depressed, people tend to have negative thoughts (e.g. I m a failure, Things are hopeless, It s all my fault ) This makes them more depressed and can lead to negative behaviour (such as stopping doing things that used to be pleasurable) Changing how you think when depressed, and what you do as a result, also changes how you feel

36 Main focus - the present Involves doing and talking planning practical exercises and experiments with your therapist Carrying these out together and as homework between sessions

37 A time-limited and structured psychotherapy Psychological symptoms can be understood as a response to current difficulties in relationships Depressed mood can also affect the quality of relationships Therapy focus - identifying how the person is feeling and behaving in relationships IPT typically focuses on the following relationship difficulties :- Conflict with another person Life changes that affect how you feel about yourself and others Grief and loss Difficulty in starting or keeping relationships going

38 a form of brief psychodynamic psychotherapy developed for treating depression difficult experiences in the past can continue to affect the way people feel and behave in the present and this can cause problems in relationships which in turn can be linked to depression If a person s difficulties go back to earlier in life they may not notice for themselves the impact this can have on how they are behaving or responding to others because it becomes second nature the way things are By drawing attention to some key aspects, the DIT therapist tries to help them make sense of how they are in their present relationships more clearly

39 Exploration of current and past relationships DIT uses what happens in the relationship between you and your therapist to help think about the problems in your life In each session your therapist will typically help you identify and focus on a recurrent pattern in your relationships that helps you understand your discussion and make progress towards what you want out of the therapy Your therapist may remain silent, waiting for you to speak as they want to hear what is on your mind and get a sense of how your emotions and thoughts are interacting or give a pause for reflection when powerful feelings are stirred up This may feel a bit uncomfortable in which case, your therapist will try to help talk about this so you can both explore things freely again

40 Can help both people in a relationship with the emotional difficulties Pressures from work, money, children, family tensions and ill health can all contribute to creating problems and these problems can lead to depression and other difficulties for one or both partners Sometimes couples can t talk to each other and meeting with a couple therapist can open the way to better communication which seems to be a key part of improving relationships Mostly, the therapist will help the two of you have a conversation so that you can find your own ways to understand and resolve the problems you are having Occasionally this may involve some homework

41 Tends to see depression as primarily an emotional problem Being overly critical of ourselves, feeling we are worthless and being left with unresolved feelings from difficult relationships can make us feel low and depressed Counselling aims to help people get in touch with the feelings underlying their depression, to express these, make sense of them and develop new ways of looking at themselves and the world around them This is achieved by counsellors focusing on how you feel and understanding your situation from your point of view The counsellor is not there to tell you what to do but to help you to explore what you wish to talk about in a thoughtful and understanding manner

42 Counselling believes that two things make this process of recovery more likely: - a) the development of a trusting relationship between the counsellor and client because without this it is very difficult for clients to get in touch with how they think and feel without this trusting relationship, change is unlikely to happen b) rather than focusing on symptoms counselling sees the client as a whole person and tries to understand their world from their point of view

43 Everyone s counselling will be tailored to suit their problems Many people find it difficult to speak about their problems with someone they do not know, and it is important that your counsellor makes you feel that they are to be trusted, and helps you manage if you talk about things which upset you or about which you feel embarrassed Your counsellor will try to help you make sense of any worries you may have about starting counselling

44 What approach might you recommend for the following presentations? Jill is very depressed. She explains how this leads to constant conflict with her partner who came with her to both the GP appointment that led to her IAPT referral and her first session here. Jill s partner was also very keen to speak to the assessor. She feels she has lost her Jill and just wants for them to find their way back together.

45 Ahmed describes lacking energy, being sleepless and feeling he is a failure to himself and his family. In his first session he describes to the therapist how he wants to learn skills to manage himself better and understand and overcome his problems. He keeps looking to the therapist to lead, asks repeatedly for the therapist s advice and perspective and at the end asks if there are things he should/ could be doing at home to work on his problem ahead of the next session.

46 Ciara describes between sobs how low she often feels and how this leads to arguments with her partner who doesn t understand, is just like dad and who just takes off out whenever they row, which seems to be all the time now. Ciara worries she has, done it again and tells you about an ex who treated her badly and had a string of affairs whilst with her. What s wrong with me she asks?

47 Some pointers CfD requires the client to :- contact and reflect upon emotional experience work relationally make use of the therapeutic conditions this may be overwhelming for some clients

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49 Peter Pearce and Ros Sewell Metanoia Institute