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

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

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

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

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