Is the NHS the best home for CBT? A sceptic's view
I'm increasingly aware of two things: firstly, I can be a bit of a tub-thumping evangelist for Cognitive Behavioural Therapy (CBT), as it worked for me; and secondly, the Improved Access for Psychotherapies (IAPT) government programme is far from perfect, and we need to look at how to improve it. So in the spirit of open rational debate, I'm going to publish some alternate views to my own, from people working in and around mental health services. Firstly, here is a piece by Robert Jenkins, a counsellor, transactional analyst and cognitive therapist from Yorkshire. Robert is pretty sceptical of the marriage of CBT and the NHS, and argues for a more de-centralised approach. Tell me what you think of the piece. Robert is helping to organise a rally and conference on the future of psychotherapy in north London on Sunday December 2nd. Details here. So, without further ado, over to Robert.
Is NHS primary care really the best place to get therapy? Or could offering it more widely in the community broaden its appeal, relevance and ultimately its effectiveness?
I share Jules Evans’ enthusiasm for making CBT and other therapies more widely available. Not just because I am a psychotherapist, not just because, like Jules, I myself have benefitted from it, but because I believe that the complexity, unpredictability and absurdity of modern life make it at times indispensible for all but the most resilient and resourceful amongst us.
Currently what is limiting the availability of therapy is not so much the expense [the relative cost of privately sourced therapy has never been lower] but the government’s insistence that it should be provided to a uniform standard across the whole of NHS primary care.
In a recent blog, Jules bemoans some therapists’ criticisms of CBT [increasingly the ‘uniform standard’ aimed at under the NHS’s IAPT programme] as “shallow, simplistic and mechanistic”. He suggests that they resent not being awarded any public money for their own types of therapy and reminds them that they can’t expect to get public funding for ways of working that have no convincing evidence-base.
I can assure Jules that most therapists, whether working in the NHS or privately, are acutely aware of the NICE Guidelines on the appropriateness of therapy for common ‘mental health conditions’ and of how they have been arrived at. They don’t question the need for an evidence base, but they are increasingly questioning the validity of the evidence base for CBT, which relies predominantly on the kind of randomised-controlled trials utilised in the testing of drugs, i.e. those prescribed for a precisely defined condition to effect relief of objectively defined symptoms, etc. while completely ignoring a much larger evidence base for the efficacy of other therapies on the grounds that the relevant research studies do not rest exclusively on the objectification of psychological distress.
Quite apart from its blatant disregard for the subjective experience of humans and the complex adaptivity of their relationships, a number of other problems ensue from the top-down approach to therapy exemplified by IAPT.
The most significant of these is the assumption, derived largely from the medical setting in which it is offered [or ‘prescribed’, if you will] that therapy is actually another form of medication to be ‘tried’, that there is therefore something ‘wrong’ with the patient. Her thoughts and/or feelings are ‘negative’, and being ‘seen’ by a therapist [or increasingly these days a Psychological Wellbeing Practitioner] skilled in a set of manualised techniques will somehow over the course of a six-session ‘treatment’ modify them, thereby enabling her to go back to work. This form of ‘therapy’, like everything non-urgent in the NHS, has to be rigorously titrated within a framework of so-called ‘stepped care’. The reality of CBT ‘delivered’ in such a setting is a million miles from its foundation in Stoic philosophical principles. The philosophy on which IAPT is based is distinctly utilitarian – and the impact of therapy offered under it is as a result more paternalistic than therapeutic.
Another is the attitude to ‘mental health’ that pre-supposes we should all aspire, if not conform, to certain ‘happiness’ standards. The ‘positive’ psychologists, in rejecting notions of pathology in favour of ‘what works’, have merely exchanged one set of instruments for another. They are not so much ‘positive’ as normative. And many governments, not just our own, have jumped on this bandwagon, and are now rolling out National Wellbeing Policies. But I’d better not get too miserable about this. Who knows where it might lead?!
A third consequence of IAPT is the abrupt closure by the NHS of hospital psychotherapy departments on cost grounds. From a utilitarian standpoint, filleting out layers of Band 8B consultant and principle psychotherapists in secondary care and bringing into primary care a raft of Band 3 PWPs whose training has barely reached NVQ Level 3 seems a great idea. Part of me wonders how a hospital like St George’s in London could once employ twelve psychotherapists at Band 8b [average salary £70k] while a hospital serving a similar demographic in Bradford can manage on two and half practitioners at that grade. However, I don’t think levelling the playing field by retiring such a huge wealth of knowledge and expertise makes any sense in the long term. True, more people will have more access to more therapy. But this is just another way of saying more boxes will be ticked on PHQ9-forms in more places and more “evidence” collected and entered into System One in support of the said top-down decision to hamburgerise wellbeing delivery.
I don’t doubt the good intentions underlying the current changes in therapy provision. I appreciate the need of successive governments to demonstrate that they are doing something, especially after raising so many voters’ expectations of shorter waiting times and more effective outcomes. And it’s good that the governments take anxiety and depression seriously. But there is something deeply disquieting about the degree to which naturally occurring reactions (“negative” thoughts and feelings) to unmanageable life conditions (poverty and austerity) are constantly medicalised and pathologised these days. Anxiety and depression are in 95% of cases emphatically not illnesses, and I seriously question whether the NHS should be tasked with “treating” them at all. Of course, there are medical conditions which can accompany or give rise to them and these need to be checked out. And psychological practitioners would be foolish to work completely apart from medical practitioners. But they don’t need to be regarded by the DoH, GPs and patients alike as part of the medical establishment, still less regulated according to the same criteria.
My own experience of working in the NHS, and that of many of my colleagues, has convinced me that it cannot provide the sort of secure base on which safe and effective psychological services can be built. From its inception, the NHS has been a political football constantly held hostage to electoral priorities. IAPT is but the latest in a long line of policy swings and roundabouts. Ask anyone working with it and they will tell you that its introduction has been immensely disruptive of time, personnel and facilities. To bring everyone “up to speed”, many therapists had to be taken out of service [sending waiting lists sky high] to go on CBT courses, which offered them very little they didn’t know or weren’t doing already, only to find a year down the line that they would be asked to continue in their original modality, since PWPs would be recruited to carry out the ‘basic stuff’.
Therapists do not criticise the notion of ‘increasing access’. They are concerned about increasing caseloads, increasing paperwork, and increasing stress – their own, not the patients’. Eavesdrop on their internet bulletin postings, listen to them in clinical supervision (as I have) and you will understand why there is so little to celebrate about IAPT. Practitioners (of whatever modality) are not complaining about the provision of CBT, or its supposed lack of rigour or depth. They are unhappy about the political and economic context in which the decision to implement it has been arrived at. It is the setting, which their guts tell them is fundamentally inimical to the provision of therapy, that is the problem.
Therapy has been around in some form or another throughout human history. The evidence base has its roots in antiquity, and not just in the West. It was only in the late 19th century that tracts of it were corralled by a rapidly rising medical elite, from which it has both benefitted and suffered to varying degrees. From the mid 20th century psychotherapy has largely shaken off the yolk of medicine, but even in the 21st it has still some way to go. Psychiatry is in the process of reforming if not disestablishing itself, and yet in much of the public imagination it is still synonymous with psychotherapy. It is certainly a good time to reacquaint the public with psychotherapy’s philosophical basis, and perhaps to remind them also that the ‘great learnings’ distilled over millennia by various peculiar intellects were once elemental pieces of folk wisdom. Yes, once we were all in it together.
There is no reason why therapy and other forms of wise and insightful support could not be more widely shared once again, why they shouldn’t be de-nationalised, de-centralised, de-standardised so as to appeal to the widely diverging needs of individual humans, each with their unique ideas about what happiness is for them. Good therapy does this already of course, and there are plenty of therapists working in the NHS to standards that are way above those expected by Layard. Many of them would prefer, as I once did before I left, to work in the service of their clients, rather than of a nationalised industry. Many of them succeed in spite of restrictive agendas to find the right balance of professionalism and compassion that constitute the best therapy. But the cost to them is, ironically, their own well-being.
I am for expansion of psychological services but not in IAPT and not in the NHS. I would re-brand IAPT as BAPT, where the B stands for Broadening and the name Be-Apt means what it says: adapted to and working within the real conditions in which people’s psychological inflexibilities first arise – family, school, neighbourhood, workplace, community. I would transfer it lock stock and barrel into the voluntary and private sectors where there are any number of settings equipped to provide a wider range and depth of psychological services to individuals and groups. These include anything and everything you like, from Sure-Start to Philosophy Clubs.
I invite readers to come along to a rally and conference of the Alliance for Counselling and Psychotherapy on Sunday 2nd December at the Selby Centre in Tottenham, North London on precisely these themes. It is entitled “The Future of Counselling & Psychotherapy” and features contributions from Andrew Samuels (Essex U), Rosie Rizq (Roehampton U), Phil Thomas (Critical Psychiatry Network, author of ‘Postpsychiatry’), David Pink (Chair of UKCP), Ian Simpson (former head of S London & Maudsley Psychotherapy Service) among others. It is a Pay On The Door event [minimum £20] but it helps if you let the organisers know you’re coming and whether you would like lunch [£6].
Here’s a link: http://www.allianceforcandp.org/page7a.html