NICE versus not-nice: A false dichotomy Dr Joël Vos [email protected] Ψ Dept. of Psychology.

NICE versus not-nice:A false dichotomy

Dr Joël [email protected]

Ψ Dept. of Psychology

http://www

Imagine…

You are a cardiologist. The arteries around the heart of your patient are clogged up by fat. You need an urgent solution. You know two options from literature:

1. Widen the arteries with a widening technique described step by step and tested in RCTs in 1000 patients with positive effects on reducing the risk of heart attacks, but unknown effects on the general well- being and interaction with other organs of the patient.

2. Use a bypass technique that is only generally described -as bypass surgery is assumed to be a skill and not a specific step by step technique-; this has been tested in 7 patients, with known positive effects on short term on the patient’s self-perceived well-being, functioning of heart and interactions with other organs.

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Imagine…

False dichotomy…

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Not-nice(nasty)

NICE

Imagine…

False dichotomy…

- The alternative to NICE can also be nasty- NICE can also be nice

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NastyNICE

NICE

Alternative to NICE

nasty nice

NastyNICE

niceNICE

nicealternative

nastyalternative

NICE

NICE: neutral description1. Support consistent decision-making & efficient allocation of money 2. Responsibility lies with NIHR (independent organisation)3. Economic evaluation important role4. Focus on outcome-based, RCT, quantitative 5. Simplification of cases, e.g. no comorbidity

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Nasty

Nasty alternative system1. Let individual counsellor and patient make all decisions, regardless of whether it is effective or not expensive? Quality of care inconsistent, dependent on individual?2. A counsellor can continue giving therapy that ‘feels good’ but does not really help the client not self-critical enough? Not able to transcend the specific situation?3. Unlimited amount of money research indicates that time-limited therapy is more effective4&5. Focus on small qualitative studies which show complexity of the client’s psychological life but which cannot be generalised and used in praxis

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Nasty NICE1. Only NICE-supported interventions get paid, regardless of needs and skills of this individual client2. Assessment by counsellor and client is irrelevant for decision-making; NICE is influenced by (implicit neo-liberal) politics and austerity policy3. Only QALY < 20,000 regardless of subjective meaning of increased well-being4. Narrow-minded linear solving of one problem after another problem5. no attention to the process; simplistic following step-by-step guidelines See other speakers

Nice NICE

Suggestion: nice NICE

How would that look like?

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Nice NICE

Basis = accurate research: • No logical biases, e.g.:

- ‘we know that this works for many similar clients BUT NOT ALL’: (deduction bias) other types of counselling possible

- ‘no evidence’ means ‘no evidence’, not ‘ineffective’ - quantitative effects (reduction in symptom scores) is NOT same as qualitative

effects (subjective experience and satisfaction)- statistical change is NOT the same as clinically reliable and significant change

(Jacobsen & Truax. 1991)• Accurate sample: e.g. inclusion criteria = NOT only ‘most extreme scores’, but ALSO ‘clinically

relevant scores’- ceiling effects explains effectiveness of RCTs in CBT- discuss moderators, outliers, st.dev.

• Control groups consist of the gold standard: - bona fide intervention (Wampold et al, 2008)

- e.g. extent to which the therapists believed in the effectiveness of the control group explains effectiveness of RCTs in CBT (Cuijpers et al,’10)

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Nice NICE

Different methods at different stages of development1. Understand clinical problem

Qualitative 2. Development of therapy & feasibility study

qualitative, some quantitative3. Larger scale pilot study

qualitative and quantitative4. Large RCT

mainly quantitative, qualitative interviews with 5% with largest change, 5% average change, 5% smallest change/deterioration5. Examining new questions qualitative

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Nice NICE

Conceptually sound therapyContext what is the context of the problem?Clinical what is the psychological problem at stake?Aetiological how did the problem develop?Therapeutic which specific techniques and processes could foster change?Findings what are main findings, and what are outliers / st.dev.?Methodological what appropriate methods used to study this? Critical what are weakness and alternative interpretations of findings?Recommendations

e.g. anxiety in general population BT?anxiety in cancer patients existential

therapies?

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Nice NICE

Different therapies have different samples + outcomes

Aim CBT = reduce frequency of negative cognitions and/or influence that negative cognitions have on mood

Sample CBT = general depression, no comorbidity (e.g. cancer)Outcome = frequency of negative cognitions + mood

Aim meaning-centred therapy = improve living a meaningful satisfying lifeSample MCT = individuals with acute questions about

meaning in life, eg cancer, dyingOutcome cancer = improve living a meaningful satisfying life

CBT has small effects in cancer patients MCT has large effects in cancer patients

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Nice NICE

The relationship matters

Outcome ≠ process: - NICE = outcome-oriented

it only tells which types of counselling have which outcomes it cannot lead on and prescribe the therapeutic process

- Include process in research: mediator-research, complex models (SEM), confounders/alternative explanations for the process (e.g. common therapy factors, the relationship)

Limitations:- Research can intervene in therapeutic relationship- Certain aspects cannot be studied, for ethical or organisational reasons

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References

Conclusion

• nice NICE is possible but demands rigorous, unbiased complex research

• existing NICE may be criticised for not being rigorous, unbiased and complex enough

• as long as NICE is not up to standard, NICE should NOT be used as the only gold standard determining which type of therapy/counselling is offered to whom

• we should strive towards a nice NICE, and not try to blow up NICE

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© 2015 Dr Joël Vos

Reader in Counselling PsychologyUniversity of Roehampton, Dept. of Psychology

Room 3022Holybourne Avenue, London, SW15 4JD [email protected]/staff/Joel-Voswww.roehampton.ac.uk/psychology+44 (0)20 8392 3000

Ψ Dept. of Psychology