UKCP Report on Practice Based
Evidence (PBE)
Research Centre for Therapeutic Education
Roehampton University
November 2006
Issue 1
Rhiannon Thomas, Sue Stephenson, Del Loewenthal – UKCP Research Unit
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Introduction
The purpose of undertaking this work was to produce a report on the findings of a literature search on practice based evidence to
establish what kinds of therapy service users feel works.
Approach and Scope
The work undertaken was as follows:
1.
Literature review of published material relating to practice based evidence for each of the following approaches

Systemic Psychotherapy

Hypno-Psychotherapy

Humanistic and Integrative Psychotherapy

Psychoanalytic Psychotherapy
The published material accessed was as follows:

Psychotherapy databases
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2.

Literature on CORE

Information from mental health user groups.
Identification of the proportion of work undertaken in private practice versus that undertaken in the NHS.
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Practice Based Evidence Research in Psychotherapy and Counselling
Introduction
Within this literature search has been included both research specifically using the term ‘practice based evidence’ and research
which appears essentially practice based in its approach, namely that which is looking specifically at client experience of
psychotherapy, or ‘user-led research’, using both qualitative and quantitative research methods and including research from
organisations such as the Sainsbury’s Centre for Mental Health and the Mental Health Foundation. The percentages of research
undertaken in private practice versus the NHS located by this review are approximately 48% private practice, 42% NHS and 10% not
known. Research from outside of the UK was classified either as private practice or not known, as appropriate.
Due to the time considerations of this initial three month study, the focus was to be on research into the experiences of service
users rather than service providers. The literature search outcomes have been documented as follows:
1. Discussion of the arguments in favour of ‘practice based evidence’ either in place of, or as a complement to, ‘evidencebased practice’ research and literature which defines what is meant by ‘practice based evidence’ in comparison to
‘evidence based practice’.
2. Consideration of practice based evidence which has sought to make direct comparison between the outcomes and/or
effectiveness of different therapeutic modalities.
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3. Review of research literature specifically relating to systemic psychotherapy.
4. Review of research literature specifically relating to hypno-psychotherapy.
5. Review of research literature specifically relating to humanistic and integrative psychotherapy.
6. Review of research literature specifically relating to psychoanalytic psychotherapy.
7. Review of research literature on other practice based evidence research such as issues of outcome and/or effectiveness
generally, including practice based evidence looking at the practitioner/client relationship, at reasons for not taking up
psychotherapy and counselling appointments and at issues such as self-disclosure/non-disclosure and perceived impact on
therapeutic effectiveness. In this last section, the proportion of research focused on process, or ‘process-outcome’– that is
research which assumes a fundamental link between process and outcome - appears to outweigh that focused solely on
outcome.
8. Some issues raised by the literature review.
1.
Arguments in favour of practice based evidence
The concept of practice based evidence is that it gives a voice to practitioners and service users, recognising that they have first
hand knowledge and experience of what works and alternatively both what needs to change, and how it may change (Ryan, P. &
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Morgan, S. 2004). According to Margison et al (2000), of importance to clinicians is ‘the poor success of RCTs in predicting outcome
at the level of the individual case from data summarised at the level of group means’ (averages) in comparison to ‘the best predictor of
outcome(which) is initial therapeutic alliance’(Margison et al 2000:124). John McLeod argues that ‘despite the general
acknowledgement that it is important for counselling and psychotherapy practice to be informed by research, it is clear that in recent
years a widening gap has emerged between research and practice’ (McLeod 2001a:3). According to Aveline (2006:25), a ‘new
paradigm of Practice-based evidence is well established’, his position clarified by citing Margison et al (2000) who defined practicebased evidence as the gathering of ‘good-quality data from routine practice’ (Margison 2000:124). Aveline continues that
‘inferences are drawn from naturalistic unselected client populations. The samples may be large, particularly when
services pool routinely collected data through organised practice-research networks (PTNs)…Routine monitoring of
outcome is an essential component with performance feedback to the clinicians and the service as a whole.’ (Aveline
2006:19)
There are a number of papers which have focused on the need for practice based evidence or arguing in favour of consideration of the
service user’s perspective regarding therapy they have received, including Barkham et al (2001), Foskett (2001) Macran et al (1999)
and Mellor-Clark & Barkham (2003) rather than the tendency to focus on exclusively evidence-based research. This is perhaps not
least because of the ‘significant differences’ (Shepherd et al 1994:6) in perspectives which can exist between, for example, service
users, family carers and professionals (Shepherd et al 1994). An example of this arguably can be seen in Flitton and Buckroyd (2005)
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where interviews with a student/client, teacher and teaching assistant pre and post 26 weeks of humanistic counselling revealed that
the staff were not able to report ‘any significant changes’ yet, the student ‘reported a change in herself and an awareness of the process
in the counselling relationship’ (Flitton & Buckroyd 2005: 131). Similarly, Taylor (2005), in studying the counselling experiences of
bereaved people found that ‘80% of counsellors were not perceived by participants to have worked with them satisfactorily in relation
to their sense of presence of the deceased or in relation to the story of the death itself’ (Taylor 2005: 53). Beeforth et al (1994:1)
suggested that ‘user researchers bring a new and different perspective, which generates new ideas and constructs and enhances the
quality of the whole research process’. However, just as with evidence-based practice, there are many definitions, philosophies, and
research methods associated with the term “practice-based evidence” although what is undoubtedly held in common is the ‘patient
centred’ nature of the research focus.
In these papers listed above such as Barkham et al (2001) and others such as Conway et al (2003), the distinction between
practice based evidence and evidence based practice is clearly outlined. Sackett et al (1997) define evidence based practice as ‘the
conscientious, explicit and judicious use of current best evidence in making decisions about the care of individuals.’ (Sackett et al
1997:2). Simons et al (2003) argues in favour of practice based evidence in terms of the concept of a ‘situated generalisation’, in
reference to the argument that the generalisations made about practice from ‘evidence-based’ research often are not applicable to
individual cases. Whilst practice-based evidence research aims to be no less rigorous that evidence-based practice, the primary
difference between the two approaches appears to be the degree of focus on the experiences of service users and providers in
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comparison to externally set criteria of assessment. Papers such as Lucock et al (2003) discuss how to conduct practice based evidence
specifically using the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) as a complement to the evidence
based practice paradigm. It appears that researchers using the CORE-OM have been the more prolific in applying the principles of
practice based evidence – the gathering of ‘good quality data from routine practice’ (Margison 2000:124 [see above]) - to
psychotherapy outcome studies and in using quantitative data analysis and according to Aveline (2006), CORE is ‘one of the most
promising’ of several ‘reliable, relevant and sensitive psychometric systems for routine use’ which have been developed. Another such
approach is the Psychological Outcome Profiles or ‘PSYCHLOPS’ (Ashworth et al 2004) which argues that ‘focusing on the problems
of greatest priority to the client might prove a sensitive measure of improvement after counselling’ (Ashworth et al 2004: 27). In
contrast to these approaches however, the majority of practice based evidence research, that is, research which is focused on
experiences of therapy from the perspective of the patient or client, appears to be qualitative and focused on process rather than
outcome.
Within this however, it is perhaps also important to note literature which highlights the difficulties in using ‘self-report
questionnaires’ in research into therapeutic change (McLeod 2001b). McLeod focuses specifically on three main problematic aspects,
firstly that ‘questionnaires are completed in a social setting that itself changes as a result of therapy’; secondly that ‘the experience of
psychotherapy changes the way that clients make sense of questionnaire items (the ‘response shift’ phenomenon) and thirdly that ‘the
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conceptualisation of the person implicit in questionnaire design is not compatible with the conceptualisation of persons espoused by
most contemporary therapeutic approaches’ (McLeod 2001b:215)
Some proponents of practice based evidence suggest that qualitative methods are the most appropriate for example Margison et
al (2000) who observe that practice based evidence is particularly well-suited to questions about the quality of interventions, including
the extent to which they are comprehensive, relevant, acceptable, and accessible. Through naturalistic inquiry, practice-based research
has also been used to examine unexpected results, such as early improvement related to hope, therapeutic engagement, or other
common factors across interventions (Stiles et al 2003).
2.
Comparative Practice based evidence
Recently, ‘The Depression Report: A New Deal for Depression and Anxiety Disorders’ (Layard et al 2006) highlighted the
NICE guideline that ‘most people with mental illness should be offered the choice of psychological therapy’ (Layard et al 2006: 2)
and discussing specifically Cognitive Behavioural Therapy in relation to its positive impact on depression, anxiety and schizophrenia,
arguing – from examination of a number of individual research studies - that ‘CBT will on average produce significant improvement’
(Layard et al 2006:7). In relation to practice based evidence research comparing different psychotherapies which has been carried out
into the experiences of service users, Stiles et al (2006) using the CORE-OM, surveyed over 1300 service users of Cognitive
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Behavioural, Person-Centred and Psychodynamic therapies, concluding in agreement ‘with previous findings that theoretically
different approaches tend to have equivalent outcomes’ (Stiles et al 2006: 555). This concurs with the ‘dodo bird’ or ‘equivalent
outcome’ finding which has been the conclusion of many other forms of research into psychotherapy outcomes (Shapiro 1995;
Luborsky & Singer 1975). The different conclusions of Layard et al (2006) and Stiles et al (2006) can perhaps be explained with
reference to the different natures of the research – one an overview of existing research, the other a stand-alone research project.
However, one difference between Cognitive-Behavioural clients and others according to Gershefski et al (1996) was that CBT clients
‘gave responses coded as reflecting aspects that were specific to the treatment they received significantly more often’ than clients of
other therapeutic modalities (Gershefski et al 1996:233).
3.
Systemic Psychotherapy
Regarding systemic psychotherapy, the majority of practice based research appears to be primarily focused on process rather
than specifically on outcome, for example O’Connor et al (1997) who defined several categories of the client’s experience, namely
‘externalizing conversation, developing the alternate story, personal agency, reflecting/consulting teams, building a wider audience,
and the helpful and unhelpful aspects of the therapy’ (O’Connor et al 1997: 479). The ‘notation that families found the therapy to be
very effective’ (O’Connor et al 1997:479) is also included, but outcome in this research is implicitly understood to be consequential of
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process. An exception to this includes Bryan et al (2004) who considered the effects of client and therapist gender/ethnicity and
matches on other variables and compared client perceptions of therapy outcome with therapist views. Similarly, Bowman & Fine
(2000) whose study of client perception of helpful and unhelpful aspects of couple therapy concluded three main influences: Whether
or not they felt they were given choices regarding ideas and ways of working which fit them; whether or not they were working with a
therapist they trusted; whether or not they were developing new ideas about the couple relationship. With implications for outcome,
Vossler (2004) considered, with reference to family counselling in Germany, the participation of children and adolescents, finding that
adolescents feel partly excluded and insufficiently integrated into the counselling process.
4.
Hypno-psychotherapy
In relation to practice-based evidence research specific to hypno-psychotherapy, this literature search did not locate any
relevant papers.
5.
Humanistic and Integrative Psychotherapy
In relation to humanistic and integrative psychotherapy, research which is practice based is dominated by research which has
focused on process rather than outcome, for example Paulson, Everall & Stuart (2001) whose qualitative study firstly considered the
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experiences of eight adult clients by asking what was ‘unhelpful or hindering’ about counselling and ‘what would have made
counselling more helpful? (Paulson et al 2001:53) and then found three ‘core aspects’ of unhelpful therapy, specifically counsellor
behaviours, external or structural barriers and finally client variables. Other research has considered specifically the client
‘experience’, for example Marchant and Payne (2002). In this study, collaboration between the researcher and the participants led to
an identification of two of the six ‘core' conditions identified by Rogers as being of real importance to clients with anorexia:
unconditional positive regard and congruence. According to Marchant and Payne (2002) the context in which counselling is offered
was also of crucial significance to these clients.
6.
Psychoanalytic Psychotherapy
With reference specifically to psychoanalysis, Leuzinger-Bohleber, Stühr, Rüger and Beutel (2003) have conducted ‘multi-
perspectival’ research, mixing practice based evidence with evaluations of the patients’ “analysts, independent psychoanalytic and
non-psychoanalytic experts” (Leuzinger-Bohleber et al 2003: 263). This research found that 70-80% of patients achieved (an average
of 6.5 years after treatment) ‘good and stable psychic changes’. Other papers considering outcome following psychoanalytic treatment
include Midgley, Target and Smith (2006) although in comparison with Leuzinger-Bohleber et al (2003), the focus is specifically on
the experiences of the patient and in this sense could be argued to be more ‘practice based’ evidence. Midgley et al (2006) in
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qualitative analysis of semi-structured interviews with 27 adults who had as children been seen in psychoanalytic treatment at the
Anna Freud centre between 1952 and 1980, found that for some of the interviewees, one of the most important factors in a successful
long term outcome was the ‘development of a self-analytic function’ (Midgley et al 2006:257). In particular with this research, several
specific themes were established which described the different ways in which the research participants felt the experience of
psychoanalytic treatment impacted upon their lives.
Winter et al (2003), exploring the effectiveness of a voluntary sector psychodynamic counselling service using data from two
studies; one using the General Health Questionnaire and Personal Opinion Survey and the second, CORE and WPF questionnaires
CQ01 and CQ02 found ‘clinically as well as statistically significant’ evidence pointing to the ‘effectiveness of the psychodynamic
counselling service provided by WPF and its affiliated counselling centres’ changes that are ‘largely maintained following
counselling’ (Winter et al 2003: 266). WPF was chosen as the focus for the research as it is ‘believed to be the largest voluntary sector
provider of individual psychodynamic counselling in England and which has a client group with comparable psychiatric morbidity to
clients attending National Health Service psychiatric outpatient services’ (Winter et al 2003: 262) and as such it is assumed would
provide results which are representative of those which would be discovered in alternative settings. It is important to note that there
was no obvious researcher allegiance in relation to this study which would have impacted upon the findings (Luborsky et al 2003).
In contrast, the Women’s Therapy Centre research project (Morris 2005) – a primarily qualitative study carried out in 2003 –
2004 - exploring what the clients ‘did or did not gain from the experience’ of psychoanalytic psychotherapy was carried out by
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researchers working for the centre itself and the findings may arguably need to be considered in this light. Using evidence gathered
from 47 service users, the project considered experiences of therapy itself in terms of it’s perceived effectiveness (29 out of the 47
reported a perceived positive outcome), but also aspects of therapy as diverse as the users’ experiences of fitting therapy into their
lives, making contact with the centre, the building and atmosphere, disability access, timing of sessions, payment, interruptions and
travelling to and from the Centre (Morris 2005).
Outside of outcome research, research into process (or perhaps more accurately ‘process-outcome’) in psychoanalytic or
psychodynamic therapy has included such as Arthern & Madill (2002) who have considered clients’ views on how, for example
transitional objects ‘work’. Others include Bowden (2002) who describes a study of patients’ attitudes to group therapy at the time of
referral for psychotherapy, an aspect of patient experience which arguably carries direct implications for outcome.
7.
Other practice based evidence research
Overwhelmingly however, practice based evidence in psychotherapy research has not distinguished between different types of
therapy in terms of the specific connection between therapeutic modality and an apparently positive therapeutic outcome. These
include Gershefski et al (1996) and Miller (2002) whose study of client experiences of an ‘in-house’ police counselling service
highlighted the service users’ general satisfaction, whilst Rennie (2001) again points to the primacy of the patient-therapist
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relationship rather than therapist orientation in perceived outcome of therapy. Similarly, in considering specifically adolescent clients,
Everall and Paulson (2002) highlighted that a ‘strong alliance was found to be necessary in that the perception of the therapist as
accepting, supportive and trustworthy influenced evaluation of the appropriateness of therapeutic tasks and goals’ (Everall & Paulson
2002:78), a conclusion supported by Fitzpatrick et al (2006) who identified positive feelings in relation to the therapist helping to
enhance the exploratory process.
There is a significant amount of research which is looking not at specific modalities of therapy, but at specific client groups,
not least Mair’s (2003) study of gay men’s experiences of therapy, Marchant & Payne’s (2002) research into the experiences of
anorexic clients and Setiawan’s (2006) exploration of counselling in relation to Asian students.
In addition to this, there is also a significant amount of research which although not considering outcome and/or effectiveness
directly, has used practice-based evidence to consider factors which have implications for the effectiveness of therapy; specifically
research into client attitudes to therapy and client experience of the process of therapy, which could be argued to fall into the category
of process-outcome research. These include Snape et al (2003) who considered the reasons given for not taking up counselling
appointments, a significant influence on both counselling process and effectiveness, citing General Practitioner support, receiving
information about the service and realistic expectations of waiting times as most often impacting upon the possibility of ‘feeling
better’ (Snape et al 2003: 239). Also Audet & Everall (2003) who found both hindering and beneficial effects of therapist disclosure
depending on the context in which it occurred and the way in which it was delivered by the counsellor and in a similar area of study
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Hanson (2005) who considered counsellor self-disclosure and non-disclosure in relation to the impact on clients. Hanson argued that
‘disclosures were twice as likely to be experienced as helpful and non-disclosures twice as likely to be unhelpful’ and suggesting ‘that
skill, or lack of it, was the intervening variable that affected the perceptions of both techniques’ (Hanson 2005: 96). Along the same
lines, research by Thomson & Hill (1993) considered client perceptions of therapist competence, finding that facilitative therapists
were most likely to be given a positive rating, whilst those seen as ‘detracting’ were seen negatively.
8.
Some issues raised by the literature review
This review raises questions regarding the nature of evidence, for example, the use of case study as a method which arguably is
an account of both process and outcome and also the importance of smaller scale qualitative studies in informing debates on
effectiveness in comparison to larger projects such as Roy-Byrne et al (2005). The majority of the literature researching non-Cognitive
Behavioural Therapies, with notable exceptions such as research using the CORE-OM, discussed below, has tended to be qualitative
and focused on process rather than explicitly on outcome with any discussion of outcome seen as inextricably linked to process. In
addition, there is a significant proportion of the literature which concentrates on specific client groups without attempting to generalise
about the population at large, or on detailed aspects of the client experience rather than seeking to describe an overall experience.
Within this, the client/therapist relationship is given particular attention. The review of current research also raises the issue of
perception of ‘wellness’ with researchers working outside the medical model arguably looking for other indicators of wellbeing than
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those approaching therapy research from a medicalised perspective. With this in mind, authors such as Robinson (2002), in
consideration of the principles of transparency, accessibility, accountability and protection in relation to measurement and outcomes in
an NHS psychotherapy context, suggest that outcome measurements can in fact impede delivery of good services, risk being essential
to the process of psychotherapy (Robinson 2002: 37).
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