Useless and harmful therapy in the horizontal landscape

Beware the therapist whose certificate comes from a summer school, who has a one-size-fits-all programme, and who wants to work in splendid isolation!


Editorial: The horizontal landscape is the place where multiagency and multidisciplinary practitioners meet each other and the service user (or parent or carer) when they agree to integrate their interventions into a whole approach. This horizontal teamwork is the antidote to fragmentation and requires practitioners to step temporarily outside their own organisations and concerns (health, education, probation, drug addiction, homelessness, social care, etc) to work in genuine partnership in a flattened power structure.

This horizontal landscape (which there is all too little of in the UK) will not be a safe place for anyone if we cannot create and maintain competence and high standards within it. Using the field of childhood disability as an example, here is how I see the dangers.

For some years now there has been a gradual blossoming of new treatments, therapies and programmes for children with disabilities and their families provided by the voluntary & community and private sectors. My perception is that this growth is accelerating and my expectation is that public service practitioners will increasingly find themselves being asked to join with these 'new' practitioners in horizontal teamwork.

While good practice requires that team members be competent, there is an increasing danger of new interventions being offered to children and families (and all other categories of service users) by someone without any proper qualifications and in the absence of any evidence base for the effectiveness of the intervention for the particular category of need. The fault here can be that of an individual practitioner or of a whole agency or company.

Without wishing to offend anyone who is genuinely trying to help (as opposed to just making money), I want to echo the thoughts of NHS therapists with whom I have discussed these dangers (see reference 1 below) and assert that there is therapy (and treatment, etc) that is professional and that which is not. This analysis can be a guide for all of us, whether service users, parents, carers or practitioners, who need to know whom to invite into our horizontal landscape – and whom to avoid at all costs.

Professional therapy has an evidence base that relates to the particular need, condition or disability to which it is addressed. The practitioner offering it has a relevant qualification (hopefully to degree level). The practitioner will begin with an assessment, will discuss her findings with the service user or parent, will agree and then deliver a course of action, and will then review progress.

Beware the therapist whose certificate comes from a summer school or evening class, whose treatment has no evidence base for the particular condition in question, who has only one programme to offer and who does not begin with an assessment of the person's individual condition and needs.

Competent practitioners around any service user should feel confident in declining to work with 'therapists' who cannot demonstrate their professionalism and should advise their clients, if asked, that they cannot recommend them.

There is another danger in relation to private therapy and treatment – a danger that I have verified in conversation with some private organisations. While they might be fully qualified and experienced in their field, e.g. paediatric physiotherapy, they might have no intention to ever meet with any other practitioner helping the same child. The result of this attitude, for example, is that the infant who is visually impaired or blind and has cerebral palsy is going to get a fragmented and disjointed approach to positioning, movement, communication, use of hands, etc. – and the parent will be offered no help in integrating her child's sensory and postural-motor development.

While most of us would see some integration of programmes as essential for young children with a multifaceted condition, the private therapist might only make the effort if paid extra – and then might not be trained or competent in horizontal teamwork.

None of this is an argument against private practitioners or private agencies. I very much welcome this opening and expansion of support around children and adults in need and the new thinking and opportunities that can come from both private and voluntary sectors. My plea is for high standards, competence and joint working in the horizontal landscape.

Peter Limbrick, 2012

Your comments welcome. Examples of private therapists who do joint working with people outside their own organisation also welcome.


  1. Three paediatric NHS therapists collectively answered the question, 'So what criteria can we use to distinguish between therapy that is thoroughly professional and that which is not?' for the article - Limbrick, P. with Boulter, L., Wassall, L. & Rimmer S. (2011) 'What do the terms 'therapy' and 'therapist' really mean in early childhood intervention for children who need on-going interventions?' in PMLD-Link, Vol. 23, No. 3, Issue 70
  2. This theme of competence is further developed in Horizontal Teamwork in a Vertical World: Exploring interagency collaboration and people empowerment by Peter Limbrick and published in 2012 by Interconnections. See Chapter 6 'High standards in interagency collaboration'. The book is available on Amazon and direct from Interconnections (order by e-mail please).

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