When all therapies are equal, why are some more equal than others?
The NICE draft guideline for the treatment of depression is out for consultation. The evidence from IAPT’s own data shows CBT and counselling to be broadly equivalent in outcome. So, why is CBT being offered as a first line treatment while counselling is made to sit in the corner like an embarrassing relative?
Read why, and how you can have your say in the consultation. Let’s make some noise.
It was Mark Twain who said that truth is stranger than fiction, and the last couple of weeks in the world of evidence and guideline development in therapy have borne out the truth of that statement.
In rapid succession, we have seen:
Publication of a paper comparing CBT and counselling in the treatment of depression showing that, across 103 IAPT sites, the type of therapy was not a predictor of outcome
- Another paper showing that patients who expressed a stronger preference for a treatment achieved better outcomes in that treatment compared with the alternative
- A call to action from BACP fearing that counselling would be excluded from the forthcoming draft NICE guideline for the treatment of depression in adults.
- Publication of the draft NICE guideline that does include counselling, but not, unlike CBT, as a first line treatment.
We know from meta-analysis, from practice based evidence, even from IAPT’s own data, that there is equivalence across the therapies for common mental health problems. The Dodo bird principle applies. All have won so all must have prizes.
NICE does not give the same weight to data from routine practice as it does to that from RCT’s, however. Because of the way that NICE prioritises evidence, some therapies (notably CBT) are effectively more equal than others. All have won, but CBT gets the top prizes.
What does the evidence say on equivalence?
From Smith and Glass’s landmark meta-analysis of therapy outcome in 1977, [i] to the present day, research has highlighted the broad equivalence of bona fide therapy models. If you’re interested in the detail I don’t know of a better analysis of the key points and findings from this history than Bruce Wampold and Zac Imel’s The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work. [ii]
June 2017 saw the publication of a study comparing the relative effectiveness of CBT and counselling in the treatment of depression. [iii] Drawing on data from over 33,000 patients from 103 IAPT sites, the study found ‘…the outcomes of CBT and generic counselling to be comparable and that the model of therapy did not predict outcome.’
It further found that ‘…..CBT only had significantly better outcomes than counselling for patients attending 18 and 20 sessions, which only accounted for 3.2% of the patients who attended up to the 20 sessions.’ It concludes that ‘Given that the majority of patients in IAPT are being treated in fewer than ten sessions, this finding is of some significance and warrants further investigation as it could be argued that counselling is more efficient than CBT in treating depression.’
What’s the evidence on the link between choice and outcomes?
The evidence of a link between client expressed preference of therapy model and outcomes also seems clear. Of note is a meta-analysis by Swift and Callaghan, [iv] which compared differences in treatment outcomes between clients matched to a preferred treatment and those not matched. It found that matched clients had a 58% chance of showing greater improvement, and were about half as likely to drop-out of treatment when compared with clients not receiving a preferred treatment.
Further evidence of the power of client preferences is provided by the study by Cooper et al published in June 2017. [v] In a trial of person-centred counselling versus low-intensity cognitive behavioural therapy for persistent sub-threshold and mild depression, clients who showed a stronger preference for a treatment achieved better outcomes in that treatment compared with the alternative.
What’s in the draft NICE guidelines for the treatment of depression in adults?
Despite BACP’s fears that counselling would be excluded from the draft guidelines (now out for consultation), it does appear as a recommended treatment. Its inclusion is hardly a ringing endorsement, however. It is listed under higher intensity psychological interventions for less severe depression for people ‘…….who would like help for significant psychosocial, relationship or employment problems……’ and have either received or declined other treatments that include CBT and Behavioural Activation. (p19) In every case counselling should be based on a model developed specifically for depression, and consist of up to 16 individual sessions over 12 – 16 weeks.
Similar guidance applies to the consideration of short-term psychodynamic therapy for people with less severe depression who want help for emotional and developmental difficulties in relationships.
How you can make your voice heard
We have a state of affairs where counselling remains relegated to a second line treatment in the draft NICE guidelines, despite some powerful evidence:
- Evidence for the equivalence of therapy models for common mental health problems.
- IAPT’s own data, which shows that when comparing CBT and counselling in the treatment of depression, type of therapy is not a predictor of outcome and that counselling may even be a more efficient intervention.
- That clients achieve better outcomes in their preferred treatment.
If you’re as unhappy with this state of affairs as I am, you can easily make your voice heard. Anyone can comment directly to NICE (see below) or BACP members can support the BACP campaign by sending comments to BACP where they can be considered as part of an organisational response. You can do both, but be aware the deadline is 12 September 2017.
Please do consider sending comments to NICE and/or BACP. It may make little difference to the outcome, but I’m reminded of Edmund Blake’s stark warning about what happens when good men (sic) do nothing.
Here’s where to start:
- Check out BACP’s NICE campaign messages and how to respond to the NICE consultation pages
- Download the NICE comments form from the Add your comments section here
- Insert your comments (feel free to draw on my example above) and return to the email address on the form.
- Alternatively, send your comments to BACP to be considered as part of BACP’s organisational response.
- The NICE guideline short version can be found here
Go make some noise and make your voice heard!
Do leave a post with your thoughts.
[i] ML Smith & GV Glass. Meta-Analysis of Psychotherapy Outcome Studies. American Psychologist 32(9):752-60 · October 1977
[ii] B Wampold and Z Imel. 2015. The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work. Routledge, New York
[iii] J Pybis, M Barkham et al. 2017. The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: Evidence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry 17(1):215 · June 2017
[iv] J Swift and J Callaghan. 2009. The Impact of Client Treatment Preferences on Outcome: A Meta-Analysis. Journal of Clinical Psychology · April 2009
[v] M Cooper et al. 2017. Patient preference as a predictor of outcomes in a pilot trial of person-centred counselling versus low-intensity cognitive behavioural therapy for persistent sub-threshold and mild depression. Counselling Psychology Quarterly · June 2017