The Dodo Verdict
I’ve been working for a Local Authority Educational Psychology and Specialist Support (EPSS) service for 16 years. I’m called an Advisory Support Teacher. In written documentation it is stated that the service we provide is based on sound psychological principles. In the last few years we have been trying to tighten up the interventions we offer to support children who are struggling in school for a wide range of reasons. With no specialist training offered by my employers I was employed as a Behaviour Support teacher doing outreach for mainstream and special schools and a Pupil Referral Unit science teacher for children permanently excluded from secondary school. I started my Ph.D. at the same time, intending to research the history and practrice of thePRU. I assumed there would be a great documentary archive to explore for my research data, building my thesis as a natural scientist. However when I started looking there was no documentary record, as the place had metamorphosed form one from of provision to another all documents had been destroyed, or moved out to other services where they were unavailable.
In the course of my work I came across solution focused brief therapy as an approach to children with a range of difficulties. I undertook some training at BRIEF in London, which I arranged and got funding for from an outside source. I asked my employers to pay but they refused my request. A few years in to my job I was accidentally recategorised as a Learning Support Teacher, again with no specific training. My Authority separated ‘behaviour’ from ‘learning’ and still does for no apparent reason. At about this time I accepted a secondment to work in part-time in the local Child and Adolescent Mental Health Clinic. When I started there I met a mental health nurse practitioner who had trained in solution focused brief therapy and used the approach routinely. He told me that when he started the job with the NHS he was asked what specific training he needed. He said he wanted to go to Milwaukee to train with Steve de Shazar and Insoo Kim Berg, the key people in the solution focused world. The NHS had to follow NICE guidelines in commissioning interventions and SFBT is included amongst the unspecified group of ‘non-directive’ therapies, with weak evidence quoted for its effectiveness. Cognitive Behaviour Therapy is promoted by NICE despite the evidence for its effectiveness also being weak.
My role with CAMHS was unclear and not set out by my management. I decided to review what had gone before and write a proposal for my work which was accepted by my manager. The previous Advisory Teacher from the EPSS had used a small room in the clinic to provide a very limited programme of education for children and young people who were missing school because of their mental health difficulties. I felt that there were already far better facilities in schools and my role would be to act as an intermediary between the CAMHS professionals and school staff to ensure that children and young people maintained access to their entitlement education. I was having good success with the solution focused approach in my direct work with children at the PRU and in mainstream schools and offered to contribute my approach to CAMHS provision. A mental health professional was always the case holder.
At the clinic I worked with a 14 year old girl who was experiencing serious anxiety problems and related physical effects that resulted in her being unable to leave her home. I was asked by a clinical psychologist who had started CBT with her and was making no progress, if I could join a meeting to offer solution focused support. The psychologist knew about sfbt because of its presence at the clinic and felt that maybe this approach could do something useful where CBT had not been effective. The psychologist had explained the principles of sfbt to the girl and her parents and asked them if they would like to meet me, to try this different approach and they readily agreed.
When I first met this girl in May, with her mother and the clinical psychologist, I used the usual sf framework. I asked her about her best hope for school and she said to be in school fulltime in September in the same year. I asked her to scale her current position, where 1 was when things had been at their most difficult for her and 10 being in school full time in September. She said she was at 3. I asked her if the meeting had been useful to her and she said it had been and she said she’d like to meet me again. I asked her this question; if we were to meet in two weeks, as was usual at the CAMHS clinic, where did she hope she might be on the scale. Did she hope things might change a bit or did she hope to keep going at 3? She said her best hope was to keep at 3, to ‘stay at the same place’. I asked her to look out for things that would tell her she was keeping at 3, and said I would ask her about what was telling her that she was ‘staying in the same place’ when we met next time. I complimented her about a strength she had shown in the meeting and asked her parents and the psychologist to compliment her. I asked her to compliment herself which she did.
When we met two weeks later I asked her about ‘staying in the same place’ as we had agreed. She said that she thought she might have gone up a bit. I said that was good to hear and we would talk about that later, after she we’d talked about her keeping going at 3, if that was ok with her. Then we talked about the change she’d noticed. She said she thought she was at 4 this time. I asked her to tell me her best hope for the next two weeks and she said ‘stay in the same place’ at 4.
We met fortnightly over the summer term. Her best hope remained the same – to be in school full time in September. Each time she said she hoped to stay in the same place and each time she’d made progress. Each time I asked her the ‘staying in the same place’ question before we got onto what had changed. During the course of our meetings she experienced several very diffucult events, affecting her general health and particularly her level of anxiety, yet never moved down the scale and she maintained her steady progress.
We didn’t meet over the summer holiday period. In early September I returned to the clinic for a prearranged meeting with her and her mother. Just inside the main entrance is the waiting area. She was sitting with her mother. She smiled when she saw me and I said ‘Good morning’ and walked past her and into the clinic. She was wearing her full school uniform.
I discussed what had happened with the clinical psychologist, who had attended every meeting and addressed the medical needs and coordinated our work with the psychiatrist who was managing the girl’s case. What was the difference that had made a difference? CBT is problem-focused, the therapist directs the work and anticipates week by week changes taking place; it’s directional and directed. For a patient to be taken on for CBT it’s a requirement that they demonstrate their motivation to make changes. My clinical psychologist colleague felt that for this highly anxious girl, the pressure applied to her by the CBT process was too great and she could not respond because it made her more anxious. My question to her, about whether she hoped to stay in the same place on the 1-10 scale or to make changes was the key. All she had to do was keep going as she was, nothing new, no pressure, by her choice. What she did was to make continuous changes, even when unexpected outside factors put her under considerable additional pressure.
CBT of SFBT? Both the clinical psychologist and I did our best, with work which had sufficient but limited conventional positivist scientific evidence to be approved by NICE. We both intended to do something useful and in this case the solution focused approach was right for this particular young individual.
So how come sfbt is relatively little known approach and CBT is growing and expanding nationally?
Have a look at this from the University of East Anglia in 2007
“CBT superiority is a myth
The idea that Cognitive-Behavioural Therapy (CBT) is more effective than other types of therapy is a myth, according to leading psychotherapy experts attending a major conference at the University of East Anglia (UEA) today.
The US and UK researchers will present data and critical analyses that debunk the widespread belief in the superior effectiveness of CBT.
The major international conference will be hosted from July 6-10 by UEA’s Centre for Counselling Studies. Organised on behalf of the World Association for Person- Centered and Experiential Psychotherapy and Counselling, it is the first time the conference has been held in England and 400 delegates are attending from across the world. Professors Mick Cooper and Robert Elliott (both University of Strathclyde), William B Stiles (Miami University) and Art Bohart (Saybrook Graduate School) will issue the following joint statement today:
“The government, the public and even many health officials have been sold a version of the scientific evidence that is not based in fact, but is instead based on a logical error. This is how it works: 1) More academic researchers subscribe to a CBT approach than any other. 2) These researchers get more research grants and publish more studies on the effectiveness of CBT. 3) This greater number of studies is used to imply that CBT is more effective. This is a classic example of the logical fallacy known as ‘argument from ignorance’ ie the absence of evidence is taken as evidence of absence. Although CBT advocates rarely make this claim so boldly, their continual emphasis on the amount of evidence is misunderstood by the public, other health care workers, and government officials, a misunderstanding that they allow to stand without correction. The result is a widespread belief that no one takes responsibility for. In other words, a myth.
“This situation has direct negative consequences for other well-developed psychotherapies, such as person-centred and psychodynamic, which have smaller evidence bases than CBT. These approaches are themselves supported by substantial, although smaller, bodies of research. The accumulated scientific evidence clearly points to three facts: 1) People show large changes over the course of psychotherapy, changes that are generally maintained after the end of therapy. 2) People who get therapy show substantially more change than people who don’t get therapy, regardless of the type of therapy they get. 3) When established therapies are compared to one another in scientifically valid studies, the most common result is that both therapies are equally effective. A case in point is person-centred and related therapies (PCTs): In a meta-analysis of more than 80 studies to be presented by Robert Elliott and Beth Freire at the Norwich conference, PCTs were shown to be as effective as other forms of psychotherapy, including CBT.
“In view of these and other data, it is scientifically irresponsible to continue to imply and act as though CBTs are more effective, as has been done in justifying the expenditure of £173m to train CBT therapists throughout England. Such claims harm the public by restricting patient choice and discourage some psychologically distressed people from seeking treatment. We urge our CBT colleagues and government officials to refrain from acting on this harmful myth and to broaden the scope of the Improving Access to Psychological Treatments (IAPT) project to include other effective forms of psychotherapy and counselling.”
Beyond this joint statement, Prof Cooper, in his lecture to the Norwich conference, will say: “The research consistently suggests that the kind of therapy that a practitioner delivers makes little difference to outcomes. More important is the client’s level of motivation, how much they get involved with the therapeutic process, and how able they are to think about themselves in a psychological way. After that, the key ingredient seems to be the quality of the therapeutic relationship, with warm, understanding, trustworthy therapists having the best results.”
Last year Health Secretary Alan Johnson announced that by 2010, £173m a year would be spent on CBT as part of the UK Government’s Improving Access to Psychological Therapies programme. The increased funding will allow 900,000 more people to be treated using psychological therapies. Prof Cooper added: “The Government’s decision to spend £173 million on CBT can only be applauded, but not all clients will benefit from that approach. There is clear evidence that some clients will do better with other forms of therapy. It all depends on who the client is, and what kind of treatment they can most make use of.”
Art Bohart, a world-leading psychotherapy theorist and researcher, will say: “There is evidence that some clients prefer an approach to counselling where the focus is on helping you explore and understand yourself. The outcome of this approach is that you make choices that move your life in new, more meaningful and personally satisfying directions. The counselor’s expertise lies in his or her ability to create a relationship where you have companionship and support on your journey to understanding. Client-centered and psychodynamic counseling are examples. In contrast, other clients prefer an approach where the therapist takes the lead in teaching you particular cognitive and behavioural skills, such as how to think. Since both work about equally well it is important that both be available to the public.”
In the world of psychotherapy research, the finding that different therapies are about equal in their effectiveness is known as the ‘Dodo verdict’, after the Dodo in Alice in Wonderland who, on judging a race, declared ‘everybody has won and all must have prizes’. This conclusion continues to be hotly contested by some CBT advocates, but the four researchers presenting at the Norwich conference are unanimous in calling for a more balanced, scientifically accurate reading of the available evidence.
Also speaking at the conference will be Pamela J Burry, whose mother ‘Gloria’ was a patient of Carl Rogers, one of the founding fathers of psychotherapy, and featured in the celebrated 1960s educational films, Three Approaches to Psychotherapy, more popularly known as ‘The Gloria Films’.
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You could apply this thinking to current claims currently being made about the absolute superiority of direct instruction over other teaching approaches, logical error and the ‘Dodo verdict’ notwithstanding.
Today’s question: where else can you see ‘the logical error’ operating in your world?
If you’re interested in children’s behaviour in school, have a look at the sources of evidence that informed the 1989 Elton Report on discipline in schools, what type of recommendations the report made and what’s happened as a result since 1989. See if you can spot the logical error.
I’ll come back to the matter of direct instruction later.
Thanks for reading this far.