Research in Group Analysis: Commissioning the Systematic Review

Introduction

Group analysts, particularly those in public health services like the National Health Service (NHS), are at an interesting and challenging time, alongside our psychoanalytic colleagues as providers of psychological therapies. In a climate of preferential commissioning of evidence-based treatments and dwindling resources it is prudent to look beyond our established and familiar referrers and friendly colleagues to understand the changing commissioning landscape, and to marshal and present the case for continuing, and even expanding group psychotherapy services.

The case for cognitive behavioural therapy (CBT) has been very clearly made. It has a strong evidence base; it has used research to refine what works, enabling it to provide effective short-term therapies. It has also tailored its provision for different psychiatric disorders, e.g. depressive disorders, anxiety disorders or obsessive compulsive disorder, which is appealing for referrers and commissioners, as well as patients. It has also been successful in presenting its evidence, and engaging powerful champions like Lord Layard from the London School of Economics who made a case that treatment would enable those who were unemployed and currently suffering from depression being able to come off benefits, and return to the work place in a way that was accepted within the Department of Health. This secured significant funding and a new therapeutic programme, Improving Access to Psychological Therapies (IAPT).

This programme involved establishing new treatment centres, whose results would be tested and published. Then the programme was rolled out from demonstration sites at Doncaster and Newham to 10 pathfinder sites. Phase three of the programme has increased the funding to £173 million, establishing a further 32 IAPT sites. Phase four has begun, with the aim of a ‘full roll out’ for patients with depression or anxiety disorder being able to receive universal equitable access, through establishing ‘IAPT services in every locality of every Primary Care Trust (PCT) area equally available to all’ (National Mental Health Development Unit/IAPT Programme, 2010), with completion in 2011/12 and beyond. The impact of the change in government, and current economic climate will have on this programme is not known at this point.

Psychodynamic psychotherapists have, in this context, been actively advocating the contribution that we can make to the provision of psychological therapies. Our professional bodies, and key organizations have come together with charities and service providers to form the New Savoy Partnership, which describes itself as a group of organizations working together to bring psychological therapies to the NHS and improve access for all who need them. Thus we have had representation on the work-streams drawing up policies for the ‘New Ways of Working’ for psychological therapists, which is linked with implementing IAPT. The recommendations from ‘New Ways of working’ are constrained by a framework that prioritizes evidence-based treatments.

CBT researchers have conducted a number of randomized controlled clinical trials (RCTs), regarded as the gold standard of evidence on efficacy, measuring outcomes in recognized conditions within the ICD classification. Their positive outcomes have provided evidence sufficiently compelling for CBT to be the main treatment recommended by the National Institute for Clinical Excellence (NICE) for the treatment of anxiety and depression. This has serious long-term consequences as NICE produces the guidelines advising which treatments should be preferentially commissioned within the NHS.

Other forms of gathering evidence, although not as methodologically rigorous as randomized controlled trials, do have a role to play in research and contribute a greater understanding of therapeutic mechanisms and process: outcome studies that are not randomized or controlled; qualitative studies of process; and studies of users’ views. For instance, qualitative studies are often helpful in understanding complex processes that often cannot be determined from necessarily simpler quantitative trial designs. Users’ views can be a powerful source of advocacy for therapies and can help refine the provision of treatment approaches.

Our European colleagues are not yet in the position of having a body equivalent to NICE advising on the state commissioning of treatments, but do also report being aware of the increasing expectation to provide an evidence base for treatments. However, it is interestingly within Europe that more of the research into group therapy is being carried out, as will be evident from the systematic review reported later in this journal. In his Foulkes lecture of May 2011 (Karterud, 2011), Karterud provides an example of research assessing which type of group works best for whom; the outcomes for the borderline and more complex patients in his study seem better with mentalization-based therapy groups than group analysis in this type of patient.

There has not been a centre providing a body of research into dynamic group therapy within the UK. The Institute of Group Analysis has clearly viewed this with concern, and David Kennard has written an article for Contexts (Kennard, 2010) which sets out the history of the Institute of Group Analysis’ joint research committee which was set up in the 1970s and continued until the 1990s with the same group analysts who had an interest in research, and investigating group analysis. Kennard describes the task that the group set themselves was:

to describe what characterizes group analysis in practice by asking the simple but elusive question, ‘What do group analysts actually say and do in their groups?’ The results of this study were published in Garland et al. (1984) and Kennard et al (1990). (Kennard, 2010)

They also edited a special section on research in group analysis in 1992 and, in 1993, Kennard et al. produced the most lasting outcome of the committee’s efforts, A Workbook of Group-Analytic Interventions (1993).

This was a very helpful contribution, and yet defining what group analysis is, and what group analysts do remains elusive. There are recognized processes in groups that characterize group analytic therapy, but we have not yet distilled down what defines our practice.

The Systematic Review

The Institute of Group Analysis’ Board of Trustees has again recently considered the best way to take up the research and audit agenda for the IGA, and I was asked to take up a leadership role on Research and Audit in 2006, having joined the Board of Trustees the previous year. I drew up a list of options, which I brought to the board, having consulted with research minded colleagues, especially Chris Evans. From the options considered we decided to commission a systematic review, which would present the current state of the evidence for the effectiveness of psychodynamic group therapy and group analysis. A key aim was to see if there was evidence, in particular randomized controlled trials, which would mean that group therapies could be included in the National Institute for Clinical Excellence (NICE) guidelines as to which treatments should be preferentially commissioned within the NHS. The NICE depression guidelines were being revised at the time, which meant we could pass on any relevant studies directly for inclusion.

We did expect from our understanding of the field that we were not likely to find many studies meeting these exacting criteria, but it was important to look. We also asked the reviewers to look at a range of outcome studies as we wanted to know who was being offered group therapy, and for whom was it most effective, in terms of type of condition and what characterized the patients who did do well; as well as identifying those who did not do well. Inevitably it is challenging to be prepared to look at how group psychotherapy and group analysis fares in a research trial when compared with other treatments, under the conditions of short treatment times favoured by both researchers and commissioners and when outcomes are often difficult to operationalize in research measurable terms.

Research treatments were conducted in homogenous groups, often for six months, in comparison with clinical practice of heterogeneous groups being conducted between one to three years, generally in slow open groups. Research that also looked at the difference made by longer treatment times, which is our usual clinical practice were thus also very important. The review planned to include qualitative studies, although only one of this type of study was found.

We were supported by the Executive Committee of the Group Analytic Society’s (GAS) decision to join us. We had representatives from GAS in the commissioning group, which has overseen the project, alongside IGA members, and GAS provided a third of the funding for the review. This was an important investment for the IGA and GAS, while being a modest figure relative to the usual costs for a review. Members of the commissioning group were Marcus Page, Kevin Power, Earl Hopper and myself.

We drew up a tender for the project, with the help of Chris Mace, and advertised widely to encourage applicants. I chaired the appointment panel with colleagues, ably assisted by Earl Hopper, Mark Ashworth, Morris Nitsun and Chris Mace. We were pleased with the calibre of the four applicants for the tender, and from our short list we appointed a team from the Centre for Psychological Services Research, at the University of Sheffield, part of the School of Health and Related Research (ScHaRR).

Chris Blackmore was the principal investigator working closely with Claire Beecroft, an information specialist. Professor Glenys Parry and Andrew Booth oversaw the project, with input from Professor Digby Tantam and Eleni Chambers (service user). Their brief was to produce a credible, thorough and independent view on the current state of the evidence for the effectiveness of psychodynamic group therapy and group analysis. Our contract with ScHaRR included as deliverables the systematic review report, an article for the International Journal of Group Analysis, and another peer reviewed article, as well as two presentations.

As specified in the tender we also advertised for, and appointed, an expert panel, which had the role of meeting on three or four occasions with the reviewers to discuss the terms and progress of the review and offering comments and advice, as necessary. Final members of the expert panel were: Paul Calaminus (NHS manager to provide a commissioners perspective); Alison Faulkner (service user); David Kennard (group analytic expert); Steinar Lorentzen (researcher and group analyst); Steve Pilling (NICE expert); David Taylor (conducting an RCT at the Tavistock Clinic). I chaired the expert panel meetings, in my role as project manager for the systematic review.

The conference of the 29th January 2010 was the first of the two presentations of the findings of the systematic review. The first half of the conference focussed on the review and responses to the review.

The papers from the conference are presented in this edition of Group Analysis.

There was clearly a great deal of interest in the conference in view of the topicality of the theme, which we had not previously come together to discuss. Chris Mace had been appointed as guest editor for this edition of Group Analysis, and his untimely illness and death meant this was not possible. This edition honours the contribution of Chris Mace to supporting research in group analysis; he freely gave his knowledge, support and involvement, despite a very busy life with many commitments.

Glenys Parry and Chris Blackmore started the presentations with a summary of the systematic review; whose conclusions were that there was broad and consistent evidence for the effectiveness of group therapy across a range of conditions, but insufficient evidence to distinguish between the group therapies, and insufficient randomized controlled trials.

This puts us in the position of not being able to make a case for inclusion in NICE guidelines apart from in a combined treatment with individual therapy for personality disorder.

The aim of commissioning the review, and presenting it at the conference was also to inform, stimulate and facilitate the dialogue necessary to bring research into a more central role in the thinking of our members and our organization.

In our workplaces most of us are expected (in my experience) to be aware of the need for research, and to be informed and educated consumers of research. However, this has not been a very significant part of group therapy training, and I suspect many of us feel ill equipped and uncertain about how to take this up, preferring, and indeed needing to allocate all our time to keep up with our clinical commitments!

Within our training we are steeped in accounts; reading many articles and chapters relevant to therapy in groups, to help us develop an understanding and a facility with the narrative necessary to become effective group therapists, and deal with the complexities of treating patients, the figures within the complexity of the ground of the group.

It is not news that psychotherapists struggle with doing research, which often involves a whole new language and training, although those who do use their psychotherapeutic knowledge to frame research investigation have produced very interesting work: John Bowlby, Tirril Harris (who worked with George Brown), Peter Fonagy and Mary Target come to mind.

Many have written on the complexities of research into the psychoanalytic therapies, and others on the reasons why research should not be attempted, or why a descriptive, qualitative frame of study should be maintained. Beyond pragmatic considerations of survival, which may be impelling us towards taking research more seriously and helping us to face the task of doing our service evaluation and outcome research, I think we do have an imperative to value, and support those interested in doing research into group therapy. This is to do with the need to put our clinical responsibility to our patients above all other considerations. Thus it follows that we should foster research that will test what works best, find out how to improve our practice, and listen to what is valued and what can be destructive.

In her lecture Islands of the Blest Group analysts and their Groups (2010) Jane Campbell emphasized that Foulkes distanced himself from the medical model based on ‘normality, illness and cure’. Instead he offered a setting within which the creative function of the therapist would enable group members ‘to become themselves, to lead a fuller life, to make use of happiness and to avoid adding too much further suffering to their miseries’ (Foulkes, 1990: 270).

In the context of the current emphasis on task-focussed, evidence-based, time-limited, treatment-oriented, closely monitored psychological therapies, she argued that group analysis, shaped as it is by humanitarian principles at the heart of European culture, has never been as meaningful and relevant as it is today. Campbell showcased the foundation of our discipline and the value of the skills we have developed thus far.

However, I am taking up the opposing position: that research is an essential component of further healthy development of the knowledge, understanding and the therapeutic skills of our members, which our organization requires. For all the problems of randomized controlled trials, they provide what is regarded as the clearest objective evidence for the effectiveness and usefulness of treatments. Our own experience, as patients and therapists, is personally compelling, but we are a highly selected group, with strong personal and professional allegiances, and a vested interest. I believe it is essential that sufficient of us step forward to take up the challenge to put group analysis on a sufficiently firm basis in research terms to secure its future. We can be encouraged (or not) by Glenys Parry’s comment that research funding will sustain only about 5% of a professional group, and the majority of us will be consumers of research.

How to respond to the need to provide evidence for the effectiveness of our treatments is preoccupying many of our colleagues within all the aspects of dynamic therapies, and I think it is instructive to look at what they are making of this issue.

This was a key topic at the Psychoanalytic Psychotherapy Now! Conference in June 2009, with key articles published in Psychoanalytic Psychotherapy (24 (1): 2010). I liked the metaphor Michael Brearley (President of the British Psychoanalytical Council) used in his article Rendering unto Caesar the things which are Caesar’s, and unto God the things which are God’s (2010). He suggests that

. . . we need to show Caesar (the socio-political world) that we help people, and have not exploited them: we have to state criteria and be judged on the basis of ordinary and understandable terms. We are not exempt from the requirement to show the value of our work. We have to convince others that what we do is not esoteric or purely subjective. We have to protect the patient and be seen to do so. At the same time, we have to function according to the spirit of our work. (Brearley, 2010: 5)

Matthew Patrick (2010), (Chief executive of the Tavistock and Portman NHS Foundation Trust), comments that although we rightly perceive that we are under attack, and that these are hard times for our professional community, his view is that psychoanalysis is a robust animal and anything but fragile. ‘I think that its strength lies not only in the intellectual quality of its theories and of their expression in clinical practice, but in its fit with human experience (2010: 10).’ He speaks to the experience familiar to us in our own therapy experience, and in making contact with the patient in an assessment and in our group practice where there is an experience of understanding and profound recognition ‘its speaks to our inner self, to unconscious wishes, impulses and fears, and as such it holds tremendous power (2010: 10)’.

Group therapy offers an experience of being understood in the round that gives a profound sense of belonging and integration within a group that allows us to fit better into our networks of relationships: personal, work and social, and feel more whole ourselves. My own clinical experience as the referrals manager of a busy NHS Psychotherapy Department shows that this is recognized by our referrers, including our local IAPT service. Our referrals have increased by more than a third; those patients who evidently have suffered developmental traumas and abuse being referred directly to us. Thus I am very much in agreement that with Patrick’s view that psychoanalytic therapies contribute an essential developmental perspective to the public mental health agenda.

Similarly I agree that

Now is not the time to batten down the hatches, however. Rather, we should be confident in the strength of our contribution and throw open the doors and windows, to welcome in what is outside, to engage with it and to learn from it. (Patrick, 2010: 11)

He argues for the ‘value of an intellectual multi-culturalism of the best sort, as a contrast to a defenceless sectarianism which so easily arises when there is anxiety, uncertainty and threat, as indeed there is now (2010: 12)’.

Research Priorities

Our organizations and members face challenges in promoting and providing appropriate research. How can we move forward on this? I have suggestions to make to contribute to a discussion and debate.

The IGA will be greatly assisted by having a research committee, probably, jointly with GAS. This could set up and develop research networks for those members interested in research, with connections to those outside with the appropriate expertise. A system of mentoring for those beginning with research will be helpful to enable them to do research that accomplishes what they seek to achieve. In view of the current focus on research within the psychodynamic therapies we would benefit from establishing links and networks with our colleagues e.g. those within the New Savoy Partnership.

As indicated by the review we need a clear definition of what constitutes group analysis, which can be used in research. A clearer definition will facilitate our communication with the general public, relevant external bodies, commissioners, and potential patients; and also support our teaching and training commitments and in thinking about our clinical work. An interesting option to assist this would be to commission a narrative synthesis of a number of key papers, and opinions, perhaps from questionnaire responses of our members.

The significant priority to my mind is commission a pilot for an RCT. The systematic review demonstrates how acutely this is needed, particularly in the current NHS climate.

As a result of being the project leader for the systematic review I was invited on the evidence-based workstream for ‘New Ways of Working’ for Psychological Therapists. Hearing at close hand the process of updating the NICE depression guidelines showed that within the committee they were becoming stricter with evidence criteria for recommending treatments, rather than more relaxed. A group RCT would involve studying a homogenous group, with one identified condition, with patients randomized to the treatment and control group. There does seem the possibility of a design with a fit for the work we do. This would involve placing research patients into heterogeneous slow open mature groups—very consistent with the way we practice; and it will be interesting to see if this can be developed, and funding found for using this model. If possible combining an RCT with a qualitative study on a subsample of patients allows for the possibility of gaining interesting detail, and an understanding of process. The qualitative study (MacDonald) included in the review was completed as part of a PhD, and was regarded by the author as a manageable piece of work. It would be worthwhile to repeat this, for heterogeneous groups, perhaps comparing homogenous and heterogeneous groups.

User Feedback

Graham Thornicroft’s (Dean of Research at the Institute of Psychiatry) view is that commissioners are taking service user’s feedback as seriously as the opinions of experts, and the NICE guidelines.

Users can give feedback directly in meetings with commissioners on their views of the treatment they have received, and their view of the services that they support for funding. This process is however time consuming and demanding and Thornicroft (personal communication) recommends that we videotape service user’s feedback from a semi-structured interview, developing a ‘bank’ of such feedback to contribute to information that commissioners can consider in designing services.

User forums offer service users the opportunity to give feedback directly to local services, which encourages users to have a say in shaping services. Service users regularly sit on appointment panels, and are beginning to have more involvement in the planning of research.

Final Thoughts

I am interested in the relevance of a talk I attended given by Ian McGilchrist promoting his recently published book The Master and his Emissary (2009). He argues in his book that the division of the brain into two hemispheres is essential to human existence, making it possible to deal with incompatible versions of the world, with quite different priorities and values.

This book argues that the differences between the cerebral hemispheres lie not, as has been supposed, in the ‘what’—which skills each hemisphere possesses, as all skills are subserved by both hemispheres—but in the ‘how’, the way in which each uses them, and to what end. He describes the left brain as being responsible for the getting hold of what is in our environment that is important and useful for us, while the right brain looks at more of the overall picture.

This differentiation occurs in many species, beginning early in evolution, and is a way of being able to do two things at once. For example, for a bird seeking out food to peck can at the same time keep the other ‘eye’ on danger in the environment around. This differentiation is much more highly developed in man. I found the focus of the talk interesting because the value it places on the tension between figure and ground, as being able to shift between the two is very central to group analytic theory and thinking.

McGilchrist points out that, like the brain itself, the relationship between the hemispheres is not symmetrical. He suggests that the left hemisphere is designed to exploit the world effectively, but is narrow in focus and prizes theory over experience. It prefers mechanisms to living things, ignores whatever is not explicit, lacks empathy, and is unreasonably certain of itself. By contrast the right hemisphere has a much broader, more generous understanding of the world, but it lacks the certainty to counter this onslaught, because what it knows is more subtle and many faceted.

It is essential that the two hemispheres work together, but in western culture there is evidence of a power struggle, with the left hemisphere becoming increasingly dominant. The result is a dehumanized society, where a rigid and bureaucratic mentality, obsessed with structure and mechanism holds sway, at huge cost to human happiness and the world around us.

The left hemisphere, though unaware of its dependence, could be thought of as an ‘emissary’ of the right hemisphere, valuable for taking on a role that the right hemisphere—the ‘Master’—cannot itself afford to undertake. However it turns out that the emissary has his own will, and secretly believes himself to be superior to the Master. And he has the means to betray him. What he does not realize is that in doing so he will also betray himself. (McGilchrist, 2009: 428)

The process of marginalization of dynamic therapies does seem to me to carry the hallmark of being part of this process of the increased dominance of the left hemisphere. Group therapy in common with other dynamic therapies seems allied with right hemisphere functioning, helping to develop meaning and understanding. However, I think its power also comes from aspects of integration between the two hemispheres, in dealing with the challenges of living in the world in a way that makes relationships more satisfying.

Some of the aversion to research amongst colleagues seems related to a sense of avoiding giving in to the ‘threatened dominance of the left hemisphere’ (McGilchrist, 2009: 428 – 429); and this should be considered seriously.

However, I think that if we fashion research in a way that is consistent with our values we can benefit from the challenge of making an integration of past and present, allowing more of the objective into our by now subjective experience, and by exploring the many new ways we have of listening to our patients that research offers.