When is a therapy?

I have used this blog before to beef on about therapies being branded and packaged and commodified and marketed like drugs – but a couple of days in Verona (which I seem to be coming to more often than any rational reason would suggest) have given me another layer of it to think about. I suppose it is how to ‘monetise’ the therapeutic alliance.

Aldo translates for Renee

My line is always that the ‘nature of the therapeutic relationship’ is always, absolutely always, more important than the type of therapy. And that is backed up by the research going back to the Dodo-Bird verdict, the statistical analyses that show that only 15% of the variance comes from the type of therapy, the PD pilot project showing the crucial role of engagement – and agreement about it with every therapist I have ever talked to (though I don’t talk to pure CBT therapists very often). And it’s at the root of the ‘quintessence’ too: the attachment and containment need to be securely in place before you can get on with the routine bits of therapy, and they’re mostly unconscious anyway.

Yet the ridiculous horse race between the alphabetti spaghetti therapies continues, and more and more horses are bred - and trained, and put through their paces in the RCT hurdle steeplechase. They have to keep entering more races, of course, to keep their form. When everybody knows it doesn’t really matter who wins.

…Except that we have a competitive international research system, run by sharp, smart and competitive research staff. This system demands absolute certainty (well, as much as RCTs can give), a marketised system where celebrity academics and a few others can make a fortune out of it, and a lot of other pedantic and arcane reasons for ultimately stripping the humanity and agency out of the decisions when the needy person actually meets the human representative of the machine.

So I was a bit wary of going to Verona to share a platform with my old friend Aldo (who spoke with dazzlingly animated slides of neurobiology and sociotherapy) and an infrequent acquaintance Renee Harvey (who presented the STEPPS model and her creative Sussex adaptations of it). My worry was that STEPPS is one of the alphabetti spaghetti therapies I have been so rude about in the past, and I didn’t want to fall out with Renee as I do respect the way she works.

Indeed, it shone through how she works – in close partnership with service users, in a very relational way, attending to engagement, using the manual as flexibly as needed, in conflict with the powers that be (about their anti-therapeutic demands), wanting to make partnerships with the third sector, making full use of positive group dynamics, and seeing it as much as a framework for therapy as a definitive intervention. In other words, a therapeutic environment. With that lot in place, it felt quite close to what we do, for example, in the Slough micro/macro TC.

But one tiny thing she said set me on edge: when describing the room, she showed us a picture including ‘the cupboard where we keep all the materials’. As if everything you needed could be bundled up and put in a cupboard – and those materials, I assume, are like lesson plans and detailed handouts for the highly structured sessions. So even though it’s a fairly well-guaranteed way of establishing and maintaining the therapeutic culture where the quality of relationships is paramount, it’s commodified and packaged and marketed. I fear it’s the way of the world – inexorable and inevitable – though I still don’t think it’s a price worth paying. It’s the corporate way, and it moves authentic therapy closer to prostitution…

The vibrant Verona gang!