by Aidan Maloney
This policy review investigates and reports on the current state of National Health Service (NHS) psychotherapy services in England. Improving the mental health of the population is one of the key policy priorities for the NHS. The report states that explicit targets have been set for improvements without saying exactly what the targets are. The objective of the review itself is to achieve psychotherapy services that are:
Comprehensive Co-ordinated User-friendly Safe Clinically effective and Cost effective.
There are two main approaches to the treatment of mental health problems in the NHS, physical treatments such as medication and ECT and “talking treatments” or psychological therapies. This review describes the psychological therapies used to treat mental health problems in adults and children in primary, secondary and tertiary care in the NHS. It presents conclusions about the effectiveness of such treatments.
The term psychotherapy within the NHS refers to three different approaches to psychological intervention.
Type A: Psychological treatment as an integral component of mental health care.
In this context the psychotherapy is part of a care programme offered by a team or service and is not offered separately. For example a client while receiving, medical treatment (pharmacological, hospitalisation etc.) may also receive some form of counselling or psychotherapy in conjunction with medical treatment.
Type B: Eclectic psychological therapy and counselling.
This classifies a complete treatment intervention offered in a series of set sessions following an assessment that generates a therapeutic plan. It includes both non- directive counselling and psychotherapeutic work that uses a range of techniques to address different facets of a patient’s problem.
Type C: Formal psychotherapies
This is a complete treatment offered within a specific psychotherapy model with its own theory and protocols of practice e.g. psychoanalytic, cognitive-behavioural, systemic.
The number of treatments a patient receives varies from single session treatments to indefinite treatments. There is a trend towards briefer, time limited treatments but only 4% of Health Authorities reported specifying lengths of treatment. Patterns of delivery include very brief intervention (one to three sessions), focal time limited therapies (between 8 and 25 sessions or up to six months treatment), intermediate therapies (up to 18 months) and longer term therapies (up to two years or more).
Demand for all types of therapy outstrips supply and while some services see some patients quickly, waiting times can be very long. Two years was the maximum reported wait between referral and assessment but the wait between referral and treatment could be much longer with the maximum delay of nearly three years.
Nearly half the Health Authorities reported purchasing some form of therapy from non-NHS agencies but the practice varied in different areas.
The steady growth in counselling in the last twenty years has arisen partly from the need for GPs to get help for patients who could not be seen as a priority by the psychiatric service and who cannot be treated in the standard medical consultation format. Many GPs employ a counsellor, psychologist or psychotherapist within their practice to overcome the difficulty of getting psychological care for their patients.
I had the impression that psychotherapies have been less studied than more traditional forms of medicine. It is surprising to learn that psychotherapies have been more studied than many other health interventions and their evaluation has brought new techniques into health technology assessment.
“Despite this, which forms of therapy are provided and the ways patients are allocated to treatments at present owe very little to research evidence on effectiveness and far more to the personal allegiances of therapists to different schools of therapy.”
According to the report there is considerable body of evidence that properly delivered psychological therapies are effective in relieving symptoms of mental ill health and in improving functioning. Four large research trials have demonstrated the value of structured therapies for depression, particularly interpersonal therapy and cognitive behaviour therapy, and in a more preliminary way, brief psychodynamic therapy.”
Treatments for panic disorder and obsessive-compulsive disorder show behavioural techniques of exposure and response prevention to be beneficial, with probable benefit of additional cognitive techniques. Patients with schizophrenia show high residual levels of dysfunction even with adequate medication; family intervention programmes reduce the incidence of relapse and a range of cognitive behavioural techniques for the management of delusions and hallucinations are of demonstrable benefit to patients.”
The report has an implicit vision that once we have all the research done we will know precisely how to manage mental and emotional health. It stresses the importance of outcome research into psychotherapy interventions.
“There is evidence that patients receiving more psychotherapy benefit more than those receiving less … but that this dose-response relationship is progressively weaker with increasing number of sessions, so that for example in out-patients, 52 weekly sessions were reported as the maximum effective dose for uncomplicated depression and anxiety without borderline personality disorder or comorbid conditions…. Where these were present, however, the dose response relationship was attenuated, requiring longer treatments.. ‘
For those who have private practices 52 weekly sessions for uncomplicated depression sounds most generous and we would not argue with such a finding except that our clients seem to get better much earlier than 52 sessions.
Outcomes can be evaluated from the perspective of:
– the individual patient, – society and – the mental health professional.
Four main users of the outcomes are envisaged:
– evaluation of care for individual patients. – audit of services far specific groups of patients, – feedback for Health Authorities and GP fundholders and – research.
Outcomes can be measured in three principal domains:
– general symptomatology and well-being – how patients feel in general, – focus of therapy – what the patient is being treated for and – social functioning and quality of life e.g. interpersonal, occupational, financial, family, personal interests.
“Finally for all outcomes, ideally both patient and therapist rating should be obtained and in some cases, a third party perspective (e.g. family member or school).”
Of course we now have to manage the information;
“This will include a key person who oversees and co-ordinates the system, time for the coordinator to run the system and for clinical staff to obtain the information computer hardware and software for storage, analysis and printing of the data”.
One can enthusiastically support more research into therapies and their effects but the vision that therapies can be administered in standard doses ignores the fact that therapy may be closer to art than to practical science. Can one measure paintings by counting brushstrokes? What would the answer signify if one could say that someone produced a painting with 1200 brushstrokes and three colours? Is it a useful question or just a trivial pursuit?
While heart operations and hip replacements can be standardised it is not entirely clear that mental and emotional problems are equally amenable to such treatment. Even if such a model can be applied to the emotional health of the nation is it the best approach?
This is a strategy document that treats psychotherapy provision as an instrument of centralised planning for improving the health of the population. The NHS is one of the monuments of the British system and is much admired. Providing for the physical health of the population through such a system involves a centralised planning system with estimates of need and treatments to meet those needs. It presumes that it is possible to measure the health or illness of the population and that the treatments physical or mental can be delivered like surgical operations or pharmacological doses for standardised ailments. While the Government has decentralized the NHS somewhat it still operates on the premise that either a Health Authority, a Trust or a GP plans and purchases treatments for patients which have been prescribed by medical experts.
The problem facing a bureaucracy trying to administer such a system is how does one find out what is needed, what treatments are effective and who should deliver them. If you start from a premise that those who need the service are not competent to decide what they need, then you require a feedback system to guide decision- making. For example, if we decided that people were not competent to decide what to eat, we could envisage a system where one could determine the dietary needs of the population and then purchase and provide meals to feed them. Meals would be provided in large mess halls in standard portions like holiday camp or army dining facilities. However, if you think it is better to let people choose their own food, and where they want to eat, because it is a much more efficient way of operating and anyway personal choice is a critical part of the experience, then you would give people the income to feed themselves.
One of the simplest ways of providing a client centred approach to counselling and psychotherapy is to let the client choose the most appropriate therapy. If, as the report states, that most of the variance in outcome in therapeutic intervention depends amongst other things on rapport (therapeutic alliance) between client and therapist and not on the therapeutic procedure or the diagnosis, it seems contradictory and pointless to devise sophisticated planning systems to match client and therapy when it may be more important to match client and therapist. These sophisticated systems are designed to replace individual choice and decision-making, and by their nature at least to minimise the possibilities for rapport or even militate against it happening by disempowering the client from exercising choice and judgement. When people are hungry what is the best meal? It’s the one they choose, cooked in the cuisine and style they like and eaten in the context and circumstances they enjoy and that varies from individual to individual. This strategic policy document is not strategic enough. It fails to examine the problem of psychotherapy provision at the level of the NHS model itself. This would mean the authors would have to doubt their own occupational and ideological security and apply the vocabulary and concepts of efficiency, effectiveness etc. to their own roles.
How to be a psychotherapist?
The final part of the review deals with training and standards in psychotherapy. The review recognises that therapy wrongly applied can cause harm and that the NHS has a responsibility to ensure that those offering those treatments are properly trained. It discusses the skill areas where psychotherapy practitioners emerge from, clinical psychology, psychiatry, mental health nurses and other mental health professionals, social workers, art, drama and music therapists and the emergence of psychotherapy as a profession in its own right through various training schools. It mentions the difficulty in establishing or getting agreement about the core competencies for psychotherapy with some schools very sceptical about the possibility of such an approach. However the Mental Health Foundation has commissioned research in this area and the National Council for Vocational Qualifications is attempting to develop national standards for qualifications, to map psychotherapy competencies, identifying shared and unique skills and knowledge between different fields of psychotherapy.