Refl exive positioning as a tool for organisational change: Systemic approaches to implementing outcome measurement


Rob Whittaker and Chloe Lack Therapists have, in the main, a fairly mixed relationship with outcome measurement, with most practitioners in


statutory services nowadays going along with it because they must – a kind of begrudging pragmatism. It can be a particular challenge for therapists informed by systemic and social constructionist ideas to accept the decontextualised and reductionist ideas and practices outcome-measurement is founded on. In this article, we share some changing contexts that have required us in the Clinical Health Psychology Department


in Bradford to embrace outcome measurement, and the ways in which some systemic ideas have been helpful throughout this process. We have drawn heavily on the ref lexive positioning work of Hornstrup and colleagues in Denmark in our thinking and practice, and we would recommend their re-workings of some familiar systemic ideas to others interested in organisational development (Hornstrup et al., 2008; Hornstrup et al., 2012). We also ref lect on the multiple contexts in which outcome data collection can be useful and the possibilities it has opened up.


Context #1: NICE, Improving Access to Psychological


Therapies (IAPT) and long-term conditions


Systemic theorists draw attention to


the ever-shifting contexts of our work. The year I (Rob) started clinical training, 2002, saw the unveiling of the fi rst NICE clinical guideline on “schizophrenia” (NICE, 2002). A powerfully dominant discourse underpinning this initiative was that some psychotherapies were more eff ective than others, both for particular “disorders” and, by extension, in general. The logical extension of this medical model was IAPT – within which therapy was seen as a technical exercise that did not even require a therapist (i.e. online psycho-education). IAPT, presided over by an economist and a cognitive behavioural therapist, yoked this very reductionist version of therapy to a neoliberal agenda, prioritising the economic productivity of citizens over all other concerns (Cotton, 2017; Jackson & Rizq, 2019). As others have observed (Rose, 2019), this


marriage of neoliberalism and the medical model of mental health has resulted in unemployment being reframed as a purely psychological problem – context and structural inequalities neatly edited out of the narrative. Whatever the politics and clinical ethics of IAPT, however, it


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undeniably represents an outstanding logistical achievement in one particular domain: it is a gargantuan data-generating system – an entity whose existence depends on its production of data that demonstrates its eff ectiveness, to such an extent that both clients and therapists alike report that collection of data can predominate over the clinical work itself (Rizq, 2012; Jackson & Rizq, 2019). IAPT claim that over 50% of their clients


move into recovery and that overall savings to the economy are realised through supporting clients to enter or re-enter work. Despite recent independent research suggesting that the recovery rate is closer to 9% (Marks, 2018), the negligible evidence for the economic case for IAPT (Steen, 2018), and the extremely modest outcomes from studies where IAPT was trialled with people living with chronic physical disease (for example, Coventry et al., 2015), NHS England are proceeding with the national expansion of IAPT into long-term conditions (IAPT-LTC) (NHS England, 2018). This poses a challenge to clinical


health psychology departments who are increasingly required by commissioners to provide equally transparent, comprehensive and easily comprehensible data on clinical eff ectiveness. But how might it be possible to respond to this shift in context without being fl attened by the IAPT juggernaut?


Context #2: Common factors research


Another shift in the wider context, and


one that runs diametrically counter to the medical model, has been occurring in the psychotherapy research world. A very sizeable body of research has signifi cantly debunked many of the foundational truths of the “what works for whom”, medical model project. This has followed from the asking of a very diff erent research question – what is it about therapy that seems to be eff ective? This literature was not available when I (Rob) trained but demonstrates the equivalence of outcome between bona fi de psychotherapies (the “Dodo verdict”) and strongly suggests that the particular psychotherapeutic technique (the aspects of therapeutic models that most distinguish them from one another and to which therapists of all denominations are so emotionally attached) seem to play almost no role at all in predicting therapy outcomes (see Wampold & Imel, 2015). The increasingly infl uential “common


factors” model both undermines the foundations of the IAPT model and, of perhaps greater interest to systemic practitioners, places relational factors back at the very heart of psychotherapy – outcomes hinge on how therapist and client get on together, how they work


Context 170, August 2020


Refl exive positioning as a tool for organisational change: Systemic approaches to implementing outcome measurement


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