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Response to the Research Committee's Position Paper

Sheard, T., 2000. Response to the Research Committee's Position Paper. Reformulation, ACAT News Spring, p.x.

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I was invited to oppose the motion to accept the position paper at last March’s conference alongside Rachel Pollard who presented her viewpoint in the last newsletter. The conclusion of the debate was that the paper be modified and then presented to the council. I offer my thoughts as a contribution to that process.

The position paper addresses two distinct issues:

1. ACAT’s overall policy on the position of research
2. How CAT therapists may be educated in research theory and methods

Clarification of the first principles is essential before embarking on the details of implementation. The paper suggests that "Cognitive Analytic Therapy ... does have an explicit commitment to research and evidence-based psychotherapy". Unfortunately this is not so. We have not, as an organisation, argued and formalised a policy or ‘vision statement’ on research. It is my view that clarification of this fundamental question is the current priority, and that details of its implementation, including the teaching of research in CAT training, will follow on from this. I think that the research position paper has been of great help to us in opening this question. However the bulk of the position paper is about implementation while it was striking that the bulk of the conference debate was about philosophy, politics and the resulting differences in priorities.

The main criticisms of the position paper from debaters and floor alike were about the assumptions implicit in it rather that about logistics and details of implementation. There seemed to be a shared assumption that it should be in our core values as an organisation to seek to evaluate our work and for it to be open to evaluation by others, and as individuals to be reflective practitioners. I doubt that many in ACAT would disagree with this overall principle, but there seems to be a rich diversity of views on what this could, or should mean in practice.

I now offer an outline of what I think the ‘big’ questions or issues might be which an ACAT policy would need to address, and how they might be framed. I think Rachel Pollard’s paper is particularly helpful in describing some of these.

Philosophy

I suggest that ACAT explicitly acknowledges that psychotherapy occupies an unusual position as a bridge between science, the arts and the existential/spiritual. This poses both a massive challenge and an opportunity for creative approaches. On a theoretical level this breadth and diversity of dimensions demands a reasonably sophisticated philosophical position which can embrace rather split them. This diversity certainly suggests that no one approach or ‘methodology’ should be allowed either to achieve hegemony or be excluded or devalued.

Politics

Psychotherapy practice and research has important, often unacknowledged social and political dimensions. Research within some traditions is often presented as if it is value free and as if the power relations of the research activity (funders to funded, employers to employees, researchers to subjects and peer pressures) do not skew or distort findings. I am particularly thinking of the more positivistic and quantitative traditions as being very guilty of this. I would hope that ACAT, which has quite a radical political element to its make up, could explicitly embrace these difficulties and begin to define its position in relation to them.

Rachel Pollard identified that an important question in psychotherapy research is the position of the ‘patient’, or ‘client’, the ‘subjects’ of research who are usually included as objects. What is ACAT’s position on collaboration in research? Do we wish to include subjects of co-researchers, would we like a voice on the research committee representing their interests?

A crucial political dimension is the power vested in the NHS and research funding bodies. Clearly such bodies have to be worked with rather than ignored. The political reality in the NHS is a move towards evidence based practice. The randomised control trial (RCT) is seen as the gold standard for evidence of effectiveness. Faith in the RCT as useful in psychotherapy research may be debatable both in theory and in terms of evidence from research synthesis but right now it is a political necessity for the continued deployment and development of therapy models in the NHS. The evidence base for CAT in terms of RCT’s is almost non-existent and this needs to rectified urgently if we wish CAT to have much hope of playing a significant role in future NHS services.

In saying this I am assuming that RCT’s will demonstrate that CAT works and is of comparable effectiveness to other ‘validated’ therapies like CBT. This is the usual outcome of trials of psychotherapy (the so-called ‘Dodo verdict’ from Alice in Wonderland: "everyone has won and all shall have prizes"). Integrating different psychotherapy research trials using meta-analysis has indicated that (a) psychotherapy in general results in what is taken to be clinically significant change and (b) it is hard to find convincing evidence that any one therapy is better than another. There are many arguments as to how the ‘equivalence paradox’: this apparent parity of therapies comes about (including the procedural sequence model). However, whatever the reasons the NHS seems to think that randomised control trials of psychotherapy are de rigeur: there is a strong demand for evidence of efficacy from purchasers and providers. Whether or not one sees RCT’s as useful in evaluating psychotherapy the political reality is that such trials need to be done.

The place of research in relation to ACAT core values

This has not been formulated and is clearly a central issue. Is research a sideline that a few admired, envied, feared, pitied or despised people do? Or is it an essential part of one’s development as a practitioner and maintenance of professional standards? I vote for the latter and I imagine ACAT would too. I would argue that ‘research’ is an activity that can span from something that supports the development of the practitioner and maintenance of her individual professional standards to something that can speak to wider issues of effectiveness and more universal meanings.

It is generally acknowledged that CAT was formally born out of Tony Ryle’s research with repertory grids; it would seem odd indeed if we chose to sever ourselves from our origins.

It has been repeatedly identified that psychotherapy as a culture suffers from a split between research and clinical practice. I would like to see an ACAT policy that addresses how we as CAT practitioners are seeking to bridge rather that reproduce the same old split.

The impact of research on a psychotherapy organisation

This issue came home to me in the two days of rapid preparation for the debate. Why had no one else come forward to oppose? In composing my debating position I found myself subject to what I can best describe as narcissistic splitting pressures. At times I found myself mentally rubbishing the position paper and what I saw, when in that ‘self state’ as an excessively quantitative and complacent position, while feeling superior about my philosophical/political sophistication………

or I’d do a ‘state shift’, switch camps and feel dismissive of those who might oppose the position paper as ignorant of quantitative research methods and whom I felt to be either arrogant or fearfully hiding their heads in the sand. I found it hard to find an ‘exit’ in what felt a more balanced position which embraced head and heart.

In my experience a lot of informal debate by psychotherapists around psychotherapy research is riven by such idealisation and denigration. Perhaps it is not surprising that research probes our narcissistic wounds. Research implies some sort of critical scrutiny of one’s practice by oneself and or others. Scrutiny of professional practice is likely to excite hopes of admiration and fears of denigration in most professional contexts, but perhaps even more so in psychotherapy in which we inevitably deploy our personal selves and emotional sensitivity (and at times lack of it) as part of the process. I think it is therefore important that in setting up a research policy that ACAT:

1. Explicitly recognises (names) the likelihood or indeed inevitability of narcissistic splitting within the organisation around research issues and
2. Proposes ways to constructively address this issue.

(A suggestion: that we have at least one member of the ACAT research committee who is not a researcher and can hold a different voice).

Appendix:

Notes on some issues of implementation arising from the position paper:

Once the policy framework is clearer then implementation and accreditation requirements can be focused up.

1. A clear distinction must be made between requirements for practitioner and advanced level training. My experience of the former was in Bristol, the formal teaching input was not considerable and I don’t see how there would be much room for teaching research issues within that framework. Maybe it’s different in London or CAT North. I think the practitioner course would have to be expanded to include much at all in the way of research, and also very careful thought given to what could be realistically learned by trainees with backgrounds which have not provided some of the basic academic building blocks underpinning research methods. (Or that a requirement is made that they take an extra ‘module’ to bring them up to speed). One problem might be finding people to teach research on the CAT trainings, many trainers might not feel (or b judged) qualified to do this, do we have enough?
2. The position paper as it stands does seem to lean excessively towards the quantitative paradigm. I think it is essential, as outlined above that trainees are introduced to a wider and more sophisticated view of psychotherapy research, the strengths, weaknesses and problems of different approaches. Once this is done then even for the advanced training I think it would be impossible to give trainees an adequate grounding in different methods to the level of detail suggested in the position paper. I think trainees would have to choose to explore and get to know one particular method in detail and present an assignment or project based on this.
3. I think there would be a good opportunity here for trainees to teach each other about their own areas of ‘special interest’. I think that involving students in this way would encourage the growth of a ‘research culture’ and a sense that research is not something alien but a part of everyday practice. Lawrence Welch illustrated one teaching problem very well when he opened the conference debate. He said he’d learned about statistics on three different occasions (I think it was three!) but he still kept forgetting it. I suspect this is to do with abstract learning versus using knowledge on a regular basis.
4. So the training in research should in my view be offered in such a way that it encourages the practitioner to continue to engage with it as part of their professional practice; i.e. it might seem laudable to teach statistics to all trainees but (a) many will either never understand or quickly forget it and (b) the amount of statistical knowledge required in order to be able to competently evaluate a quantitative psychotherapy paper is really quite considerable, to gain this would require a great swathe of teaching time. In short I am saying that I see the "two essential skills" as suggested in the position paper as being generally unattainable even for advanced trainees. I am proposing instead an overview input and an in-depth project and students sharing their learning.
5. The ACAT research committee would need at the very least to ‘support’ trainers in teaching research skills. Would we like to see a requirement for trainers to be able to teach research issues, or probably more feasible, that certain individuals are recognised as having reached training level in research and offer inputs on ACAT courses? Either way we must have mechanisms for ensuring that research inputs are given and supervised by people who have the necessary competencies and experience.
6. I would suggest that training include an input reviewing what we have learned so far about CAT from research done on it do date.
7. I suggest that a directory be drawn up of research projects done by trainees and that their dissertations are made available. I think the current position of dissertations being lost in a filing cabinet in London encourages the old split between research and practice. It is as if an assumption is being made that the wider CAT community has nothing to learn from all that hard work.

Tim Sheard

Full Reference

Sheard, T., 2000. Response to the Research Committee's Position Paper. Reformulation, ACAT News Spring, p.x.

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