A lot of my working day is spent doing psychological therapies. Despite the image of child psychiatry as Ritalin-obsessed drug pushers, CAMHS probably makes more use of talking treatments than any other branch of NHS mental health services. Hence I take a keen interest in news about psychotherapy.
We, the undersigned providers and/or users of counselling and psychotherapy, call upon the Department of Health to instigate an urgent independent investigation into the National Institute for Health and Clinical Excellence (NICE) guidelines for the use of psychological therapies in the NHS. These guidelines currently display unwarranted and well documented bias in favour of cognitive behaviour therapy (CBT). Their formulation involved inadequate representation of and consultation with the counselling and psychotherapy field, and relied upon a very narrow range of research methodologies which fail to do justice to clients’ subjective experience and the complexity of human interaction.
I think before commenting I need to admit to a little bit of bias. I don’t like the ACP. They were formed to campaign against statutory regulation of psychotherapy, which would have brought in robust codes of conduct and a fair complaints process to protect vulnerable people. Horrific cases of abuse by psychotherapists such as Derek Gale (who was able to carry on practising as a psychotherapist even after being struck off as an arts therapist) show how the under-regulated psychotherapy industry is putting people at risk.
I regard the ACP’s anti-regulation campaign as at best misguided and at worst self-serving. Their spokesman Darian Leader claimed that regulation would subject psychotherapy to “a market-led vision of human life”. But you only have to look at the complaints procedures of the College of Psychoanalysts UK (of which Leader is the President) to see what self-regulation looks like. A complaint to the CPUK has to meet the criminal burden of proof (beyond reasonable doubt) rather than the civil burden (on the balance probabilities) which is more usual for a complaints procedure. Oh, and if the complaint isn’t proved beyond reasonable doubt, the complainant may have to pay the costs of the investigation! Most people would probably just not complain.
Even so, I’ll try to put my dislike of the ACP to one side and have a think about what kinds of psychotherapy ought to be on offer from the NHS.
In my personal practice, the two mains strands of therapy that influenced my day-to-day clinical work are cognitive-behaviour therapy and systemic and family therapy. I’ve recently started using some mindfulness-based techniques (part of the so-called “third wave” of CBT) though it’s something that’s new to my practice. I’m also of the view that it’s important not to neglect your basic Carl Rogers person-centred counselling skills. It may be regarded as the easy-peasy-lemon-squeezey of talking therapies, but my experience is that a bit of Uncle Carl can go a long way.
Within our service we have a mixed bag of clinicians – not just doctors, nurses and psychologists but also family therapists and the occasional psychoanalytic psychotherapist. Some of our staff have developed skills and training in certain types of therapies – for example, CBT-E or Eye Movement Desensitisation and Reprocessing. All in all, I think we’ve got a fairly mixed set of therapeutic tools in our toolbox.
I’d agree with the ACP that while CBT can be useful to a lot of people, it’s not a cure-all panacea, and it’s not suitable for everybody. There’s a lot of kids I wouldn’t be able to help if I just sat there doing CBT with them and didn’t do any systemic work to try to improve the family dynamics. Working alongside psychoanalytic therapists has converted me from my previous cynicism about psychoanalysis, although these colleagues seem to base their work on John Bowlby and attachment theory rather than any Freudian ideas about wanting to kill Daddy and have sex with Mummy.
I’d also agree that while there tends to be more of an evidence base for CBT, often that’s because there’s more of a culture of doing research among cognitive-behaviour therapists compared to some of the other modalities. Some would also say that its format is one that’s more disposed to being measured.
Where I’d disagree with the ACP is the suggestion that the threat of a narrowing of focus to CBT is coming from NICE. For one thing, although NICE does often tend to recommend CBT for various conditions, it’s not the only therapy they ever recommend. For example, here’s a list of the conditions that family therapy is recommended for.
Personally, I suspect the real threat to therapeutic eclecticism is not from NICE but…yes, you’ve guessed it, the cuts. I’ve previously commented on the way is which CAMHS seems to be losing more of the family therapists, psychoanalytic therapists, play therapists, arts therapists…more of them are being laid off, and there’s less offers to train new ones. Without these highly specialist practitioners with their often-rigorous training, we’re falling back more and more onto a core of doctors, nurses and psychologists. It’s simple financial pressures that are likely to degrade CAMHS into a crude CBT-and-Ritalin service, rather than NICE.
Actually I suspect that the practitioners that the ACP think should have a slice of the NHS pie are not necessarily the modalities I’ve previously mentioned. In the ACP there’s Darian Leader, a Lacanian, also Andrew Samuels, a Jungian. The ACP also tends to attract quite a few people from the Independent Practitioners Network, which includes some people who strike me as surprisingly innovative practitioners (“whack jobs” would be putting it more bluntly). There are almost as many models of psychotherapy as there are psychotherapists. Some of those models are a bit kooky.
Ultimately, I’d agree that the NHS shouldn’t just be offering CBT. That said, it can’t be a free-for-all and there does need to be some quality control. If the ACP genuinely wants to see more varieties of psychotherapy available to the public, maybe they should stop whining about the NICE Guidelines, and go out and publish some research which might then make it into those guidelines.