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Proposals for massive expansion of psychological therapies would be counterproductive across society

  • Derek Summerfield (a1) and David Veale (a2)

Summary

In 2007 the UK Government announced a substantial expansion of funding for psychological therapies in England to provide better support for people with conditions such as anxiety and depression. Will these services result in the medicalisation of normal distress? Or are they simply an evidenced-based solution for a previously unmet need? In this debate Derek Summerfield and David Veale discuss the issues raised by these controversial proposals.

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References

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11 Singleton, N, Bumpstead, R, O'Brien, M, Lee, A, Meltzer, H. Psychiatric Morbidity among Adults Living in Private Households, 2000. Office for National Statistics, 2000 (http://www.statistics.gov.uk/downloads/theme_health/psychmorb.pdf).
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14 Adam, S, Emmerson, C, Frayne, C, Goodman, A. Early Quantitative Evidence on the Impact of the Pathways to Work Pilots. Research Report No 354. TSO (The Stationery Office), 2006 (http://www.dwp.gov.uk/asd/asd5/rports2005-2006/rrep354.pdf).
15 Gillespie, K, Duffy, M, Hackmann, A, Clark, DM. Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb. Behav Res Ther 2002; 40: 345–57.
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Proposals for massive expansion of psychological therapies would be counterproductive across society

  • Derek Summerfield (a1) and David Veale (a2)
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eLetters

Layard�s IAPT. Evaluation of 2 pilot sites shows no benefit and increased costs

derek a summerfield, consultant psychiatrist/hon sen lect
30 March 2011

In 2008 in a BJP Debate Dr David Veale and I discussed Layard’s proposals for a massive expansion of psychological therapies (IAPT). Dr Veale was strongly supportive whereas I argued that IAPT would not work and would be counter-productive across society.(1) At the time Professor Glenys Parry was undertaking a £480,000 study of 2 pilot programmes- in Doncaster and Newham. A BMJ report has just reprised her findings, which seem at odds with continued governmental support for IAPT at a time of widespread cuts in NHS budgets. (2) Indeed the Department of Health’s supporting documents carry 90 references but strangely omit the Parry study.

Parry found little difference between the IAPT sites and the comparator PCT services. What differences there were in outcomes were not significant 4 months after treatment and had disappeared at 8 months. IAPT treatments cost more, not less, than those provided in neighbouring boroughs. So the service cost more and failed to deliver significant improvements, the opposite of what Layard and his proponents were claiming.

A study in 2010 by the North East Public Health Observatory showed that in the first 32 IAPT sites only about half all referrals even had an initial assessment, and more than one third of those taken on only attended one session. Only 1.4% of the supposedly serious cases met NICE guidelines of 16-20 sessions. This also begs questions about the economic calculations behind IAPT, since these are based on 80% of patients completing treatment.

IAPT also trumpeted the impact it would have in getting people back to work. These figures alone make this claim seem vainglorious.

Discussion about the future shape of NHS mental health services is highly topical. As a continuation of the BJP Debate I and others would appreciate a response to these findings from Dr Veale, or from Professor David Clark of the Institute of Psychiatry, the main proponent of IAPT within the mental health field.



1. Summerfield D, Veale D. Proposals for massive expansion of psychological therapies would be counter-productive across society. Br J Psych 2008; 192: 326-30.

2. Hawkes N. Talking therapies: can the centre hold? BMJ 2011; 342: 578.

Derek Summerfield Consultant Psychiatrist and Honorary Senior Lecturer, Maudsley Hospital and Institute of Psychiatry, King’s College London, UK. Email:Derek.summerfield@slam.nhs.uk
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Conflict of interest: None Declared

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Clinical Psychology Training

Jenny Taylor, Clinical Psychologist
14 July 2008

Dear Sir/Madam,

I read with interest the 'In Debate' article in June's edition of theBJP 'Proposals for massive expansion of psychological therapies would be counterproductive across society'. An important debate and some interesting points made on either side.

I would however like to make one point of clarification. David Vealemakes the comment 'Qualification as a clinical psychologist is not adequate [for CBT delivery] as CBT is a postgraduate qualification', which appears to imply that Clinical Psychology training is not a postgraduate qualification. Of course it is a postgraduate (doctoral) qualification, and in addition it is a requirement of clinical training that on qualification clinical psychologists be competent in at least two forms of evidence-based therapy, one of which is currently required to be CBT.

I would therefore humbly suggest that David Veale's quality control question might have been better phrased as: Are the therapists delivering CBT either Chartered Clinical Psychologists or accredited (or accreditable) by the British Association of Behavioural and Cognitive Psychotherapies as reaching a minimum standardfortraining?

It is of course important that the public are clear about the qualifications of mental health professionals, and that other professionals are not confused regarding one another's qualifications.

Yours faithfully,

Jenny Taylor,Chair of the Division of Clinical Psychology, British Psychological Society.
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Re: Response by author-Cultural Adaptation of CBT

Shanaya Rathod, Consultant Psychiatrist
02 July 2008

Dear SirWe agree with Dr Summerfield’s concerns that mere adaptation of manuals based on Western psychiatric templates will have questionable validity. Cognitive behaviour therapy uses a pragmatic approach and to be successfulneeds to be individualized to a client's value system. Our projects aim toadapt CBT so that therapists understand the individual’s psychopathology in light of cultural influences and background, develop culturally based explanations for advice and CBT work. The process may require theoretical adaptation and modification to make it culturally appropriate. It may alsoneed to incorporate themes from culturally acceptable practices of healing.The other option would be to continue providing cognitive therapy to ethnic minority clients in its current format using western concepts.References:Summerfield D, Response by author- Derek. Summerfield/ David Veale. Proposals for massive expansion of Psychological therapies would be counterproductive across society: BJP 2008, 192, 326-330.Rathod S, Naeem F, Phiri P, Kingdon D. Cultural Adaptation of Cognitive Behaviour Therapy. e letter 28 May 2008 ... More

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Response by author

derek a summerfield, consultant psychiatrist
11 June 2008

Mushtaq shares my concern about inappropriate medicalisation, but sees short term interventions like CBT as something apart (1). I must disagree: talk therapies delivered in the NHS by mental health professionals are part and parcel of what profession and public understands by 'medical'.

In working to produce "culturally sensitive CBT" for depression in Pakistan, Rathod et al hope that mere adaptation of standard practices andmanuals, and good translations, will do the trick (2). I'm afraid I challenge the assumption that Western psychiatric templates can generate auniversally valid knowledge base (3). Methodologies routinely fail the core test of scientific validity, which relates to the "nature of reality"for the subjects under study.

Globalising Western psychiatric approaches is not value free. A telling example of the moral and political shifts to which I alluded in the debate is provided by the invasion of Latvia by the diagnosis of depression (4). This was prompted by the translation of ICD into Latvian, and by conferences organised by pharmaceutical companies to educate psychiatrists and GPs about this new diagnostic category (who in turn educated their patients). This was a radical departure from the traditional language of (largely somatic) distress- notably nervi- shared by doctors and lay public. To present nervi was to invite a life story, which could include a critical commentary on disorder or dysfunction outside the self, in wider society and politics. The doctor-mediated shiftfrom nervi to depression is a shift away from the lived contexts that nervi embodied, the focus now inwards to the individual person. With thiscomes the internalisation of a heightened sense of personal accountabilityfor life circumstances. But at the same time post-Soviet Latvian society has lost much of its former sense of stability and security, and most people have in fact less control over their lives. The narrative structureof these new accounts of distress indicates that Latvians have internalised the values of capitalist enterprise culture and the responsibility for personal failure that goes with it. It is this shaping of a different kind of citizen that is evoked in the globalisation of depression.

1 Mushtaq S. Expansion of psychological therapies is long due. e letter 28 May 2008.

2 Rathod S, Naeem F, Phiri P, Kingdon D. Cultural Adaptation of Cognitive Behaviour Therapy. e letter 28 May 2008

3. Summerfield D. How scientifically valid is the knowledge base ofglobal mental health?BMJ 2008; 336: 992-4.

4. Skultans V. From damaged nerves to masked depression: inevitability and hope in Latvian psychiatric narratives. Soc Sci Med 2003; 56: 2421-31.

Declaration of Interest: none
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CBT: something (evidenced-based) is better than nothing.

Rais I Ahmed, Speciality Registrar
11 June 2008

It was an interesting debate but what intrigued me most was Derek Summerfield’s perspective of CBT and its role in modern psychiatric practice. He very aptly highlighted the shortcomings of the psychiatric diagnostic systems and criticised the inadequacies of psychiatric therapeutics. These issues are well known but then he goes on to draw someconclusions, which are not warranted by those assertions and possibly defythe very logic of his argument. Lack of a universally valid and reliable diagnostic scheme does not imply that our patients do not suffer from psychiatric ailments. Neither it is advisable to do nothing until a “perfectly clean” treatment is discovered. Any credible evidence does not support DS’s contention that political expediency is responsible for expansion of CBT services. Psychological interventions in general and CBT in particular strives to provide individuals a guided discovery of their natural resilience. Obviously, Psychological interventions do not spontaneously change the objective realities of life. However, they enable individuals to learn and practice better coping techniques. Well-adapted people would not simply moan about their deprivations but they are more likely to take some practical measures to challenge those socio-political inequalities. Therefore, CBT cannot be blamed by any stretch of imagination for “relocating distress ordysfunction from socio-political space, a public and collective problem, to mental space, a private and individual problem”. I like to draw reader’s attention towards the executive summary of Lord Layard’s original report (1). He found six reasons for action: - there is massive distress - such suffering is a major form of deprivation - much ofit goes untreated - this involves huge economic costs - treatments exist that can relieve the distress, and that pay for themselves - NICE Guidelines(2) should be implemented. He also the described key elements of a solution - ten thousand more therapists - working in teams - according to a 7-year plan, centrally funded and commissioned No one is trying to sell CBT as a panacea; like all other intervention, CBT is liable to some nuisances. However, when DS advocates active participation of clients in a durable change process, he actually presentsa case for CBT itself. There are some legitimate concerns regarding effective implementation of these guidelines in prescribes timescale. Nevertheless, an easy access to CBT is not going to produce or reinforce dependence, institutionalization and loss of motivation by any means. If anything, it is one of the evidence-based solutions (3) for those problems though not a perfect solution. A thirteen-century Chinese scholar said, “Should my book be perfect, it would never be complete”. Reference: 1:http://cep.lse.ac.uk/textonly/research/mentalhealth/DEPRESSION_REPORT_LAYARD.pdf2: http://www.nice.org.uk/nicemedia/pdf/CG23quickrefguideamended.pdf

3:http://londoncognitivebehaviouralpsychotherapy.co.uk/PDF/treatment%20choice%20brief%20version.pdf
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Both are right

Paul Hutton, Trainee Clinical Psychologist
28 May 2008

Dear Sir

Summerfield is right to express anxiety over the pathologising of normal experience. One of the architects of DSM, Robert Spitzer, has himself expressed similar fears in an interview in Adam Curtis's BBC documentary "The Trap: What Happened to Our Dream of Freedom?" (2007). Summerfield is also right to express concern that suffering in response tosocial inequality may risk being treated as a psychological phenomenon.

On the other hand, Veale is correct to query the idea that this is actually the case. His compelling description of a woman trying to cope with the trauma of being sexually assaulted brings home the point that, when such people ask for help, it would be morally wrong to refuse.

Veale also discusses how the CBT approach has its roots in Buddhist and Enlightenment thought. This appears to be particularly applicable to recent mindfulness approaches. The Stoic philosopher Epictetus is also often cited by cognitive therapists, in particular his assertion:

“Men are disturbed not by things, but by the view which they take of them.”

Of course there is a danger this approach can be insulting when applied too liberally or literally and can lead to a person being robbed of their reality. That’s not to deny that people still have some choices in how to view things, however we need to acknowledge this is highly limited for many, by virtue of their situation. Veale's other point that CBT aims to help a person achieve their goals in life seems fair enough but it is also the case that these will often be subject to some level of evaluative judgement by the therapist, implicitly or explicitly.

I think there is a compromise position between Veale and Sumemrfield,which perhaps they both take already. That is that the provision of psychological input should be available for people who need it now, but that it should never be seen as a solution to the actual problem. Summerfield notes that much of the problem is sociopolitical and King in his commentary draws our attention to the need for people to have purpose and meaning, perhaps through religion.

So perhaps the longer term solution to mental ill-health should be part sociopolitical and part philosophical? I'm no idealist though, and the challenge for those who wish to address the social origins of mental ill-health must be to come up with a political and social theory which minimises inequality but at the same time does not encroach upon liberty.

As Nick Tarrier (2002) concludes:

"Much of mental distress no doubt has its roots in, or is at least exacerbated by, social deprivation and inequality and their psychological consequences. A good dose of social justice and redistribution of wealth would do the world's health a lot of good. In the meantime, any psychological treatment can only be a sticking plaster over the wound of such inequality, but, as far as evidence goes, cognitive behaviour therapyis the best plaster available."

Yours sincerely

Paul Hutton

Curtis, A. & Lambert, S. (2007). The Trap: Whatever Happened to Our Dreams of Freedom? BBC documentary first shown on 11/03/2007.

King, M. (2008). Invited commentary on... Proposals for massive expansion of psychological therapies would be counterproductive across society. The British Journal of Psychiatry, 192, 331-332.

Summerfield, D., & Veale, D. (2008). Proposals for massive expansion of psychological therapies would be counterproductive across society. The British Journal of Psychiatry, 192, 326-330.

Tarrier, N. (2002). Yes, cognitive behaviour therapy may well be all you need. British Medical Journal, 324, 288-294.
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Expansion of psychological therapies is long due

Dr Salman A Mushtaq, Psychiatrist
28 May 2008

I read with great interest the debate by Summerfield .D/ Veale. D (1), regarding the expansion of psychological therapies, which most certainly merits a wider discussion.

Working as a Psychiatrist in CR/HT, where over 20% of our patients fall within the category of population discussed in this debate, I would like to express my opinion. Over 20% patients with Depression, Anxiety andrelated disorder is a significant percentage, however not a surprise, as this is similar to the percentage reported by Office for National Statistics (2).

Summerfield’s concerns about ‘medicalising the problems of living’, ‘contribution of mental disorder to sickness absence’ and the economic cost of disability benefits, are indeed justified and alarming. However these are associated and complicating factors, rather than the core issue of this debate.

The main issue is the expansion of psychological therapies, mainly CBT, which is the recommended first line treatment for mild to moderate depression, anxiety and related disorders. In fact one of the first key messages in the NICE guidance for anxiety and related disorders is ‘ If left untreated, they are costly to both individual and society’ (3), and any psychiatrist working in the community cannot deny this fact.

While I agree with Summerfield that ‘normal stress’ and problems of living should not be medicalised and people should not be given ‘mental disorder card’ to claim sick leave and unjustified benefits, hence promoting the culture of ‘sick role’, equally care should be taken not to underestimate the need for short term interventions which can prevent longterm disability. To me the key would be in balancing between, non-medicalising and providing meaningful interventions where necessary.

Providing short-term psychological therapies, such as CBT, which is backed by evidence, seems to be a very useful way of providing necessary interventions, without medicalising or encouraging the ‘sick role’ culture.To me medicalising would be the use of medications and hospital admissions, rather than the use of CBT, which aims to provide positive change in thinking and behaviour and giving the responsibility back to thepatient, thus preventing people from becoming ‘cases’ in the long term.

Working in the community in the Crisis resolution/Home treatment team, we get a huge number of referrals from primary care, which are not suitable for specialist services yet not manageable with in the primary care. Lot of these patients are most suitable for short-term psychologicaltherapy, however due to lack of quick access to such services and with waiting lists of 1 year, the risk of them becoming ‘cases’ and medicalisation increases.

In fact the very reasons Summerfield has mentioned in his debate, areenough to suggest that the expansion of psychological therapies is essential, rather than unnecessary.

On the other hand, Veale’s comment on the quality of psychological services is also very significant. The emphasis should not only be on expanding the services and increasing the access but also on improving andmonitoring the services provided. Truly, qualification as a clinical psychologist is not adequate to practice CBT, as CBT is a postgraduate qualification. At present most services indeed, have shortage of properly qualified CBT therapists.

References:

1.Derek. Summerfield/ David Veale. Proposals for massive expansion of Psychological therapies would be counterproductive across society: BJP 2008, 192, 326-330.

2.Psychiatric morbidity among adults living in private household, 2000: Office for National Statistics. (www.statistics.gov.uk/downloads/theme_health/psychmorb.pdf)

3.NICE Guidelines on Anxiety, 2004: www.nice.org.uk
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Cultural Adaptation of Cognitive Behaviour Therapy

Shanaya Rathod, Consultant Psychiatrist
28 May 2008

Dear Sir,In his criticism of the expansion of psychological therapies, Summerfield1contends quite reasonably that 'talking therapies are grounded in an ineffably Western version of a person'. Sociodemographic factors and cultural background influence perception of symptoms of mental illness andhence, engagement with services. As David Veale1 rightly points out, CBT does not ignore the social context of the illness but cultural adaptationsand understanding of ethnic, cultural and religious interpretations is an area which currently remains underdeveloped. We are seeking to address this by developing a qualitative methodology which can be used to produce culturally-sensitive CBT for diverse ethnic groups. Two projects are underway: In Pakistan, we are assessing whether CBT for depression is compatible with local beliefs and values and if so, what adaptation to manuals, training and practice is needed. In the UK, a similar project is tackling CBT for psychosis in black and minority ethnic populations. Bothprojects involve interviewing lay groups, patients who have and have not had CBT, mental health professionals from the relevant ethnic groups and CBT therapists. Analysis of transcripts from the Pakistan project does endorse the use of CBT but has already indicated, for example, that presentation of depression is frequently somatic and CBT has to directly address this. Literal translation into Urdu of terms used in CBT may not be possible or can be misleading. Adaptation and accessibility is necessary to literacy levels. Family members tend to accompany patients and are essential to successful work. Often there is better engagement with local faith healers and religious leaders. Similarly, African and African Caribbean people have traditionally consulted their traditional healers for help. Often within similar African cultures, concept of mentalillness differs considerably2. Piloting of an adapted manual has begun andfurther evaluation of culturally-sensitive CBT in Pakistan and the UK is planned. These measures are essential to the success of the CBT programme in a multicultural society.

1.Summerfield, D and Veale, D. Proposals for massive expansion of psychological therapies would be counterproductive across society. The British Journal of Psychiatry. 2008; 192: 326-3302.Edgerton, R. Conceptions of psychosis in four East African societies. American Anthropologist. 1966; 68: 408-25
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Individual solutions to political problems?

James A Rodger, Specialty Registrar - AOT
28 May 2008

Summerfield makes a profound and far-reaching point when he highlights the political advantages of relocating distress or dysfunction "from socio-political space, a public and collective problem, to mental space, a private and individual problem." This need not imply conspiracy (although it might), but simply the blind workings of Foucauldian power.

We know only too well that both physical and psychiatric morbidity are over-represented in disfranchised populations, and by locating the problem within individuals we obscure the socio-economic and political determinants of ill health (Taussig 1980).

However here in lies a moral quandary. Cigarette smoking causes lung cancer, and a major determinant of the likelihood to smoke is social class. Should we therefore let people die and suffer more visibly – and indoing so attempt to reframe lung cancer as a socio-political problem - so that the government will take more urgent action against tobacco companies, and in tackling economic and social inequality. Obviously not -although treatment providers could, simultaneously, "politicise" the problem, and further encourage their patients to do so. And so with psychotherapy.

In this light, CBT might be less individualistic than it first appears. For as Veale points out - people might acquire better problem solving skills to tackle social problems, and may even, in fact, be helpedto grow Summerfield's "thicker skin".

Taussig, M. 1980: Reification and the consciousness of the patient. Social Science and Medicine, 14: 3-13.
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