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Rapid Responses: Rapid Responses published:
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The future of psychotherapy: it takes more than evidence based services for psychotherapists to be recognized as professionals
- Samuel Y Wong (30 July 2004)
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The Future of Psychotherapy in the NHS
- James Baxter (1 August 2004)
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Choosing the future of psychotherapy in the NHS
- DB Double (1 August 2004)
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Biopsychosocial model and the need of psychotherapy.
- Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS (1 August 2004)
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NHS psychotherapy and its discontents: finding creativity amidst the conflict
- Richard A House (3 August 2004)
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Samuel Y Wong, Assistant Professor 4/F, School of Public Health, Prince of Wales Hospital, Shatin, New Territories
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Goldbeck-Wood et al1 stated that one of the key obstacles for psychotherapy has been a conflict of cultures. In fact, I believe that differences in the training of psychotherapists also play a key role in hindering the recognition of psychotherapy as an independent profession. Besides the various modality of psychotherapy that includes cognitive behavioral therapy, interpersonal therapy, family therapy, psychodynamic therapy that often make people wonders the exact meaning of the word “psychotherapy”, the huge variation of psychotherapist’s training background also makes the word “psychotherapist” too broad for anyone to understand what psychotherapists do. A psychotherapist can be a counselor, a social worker, a general practitioner, a clinical psychologist or a psychiatrist. As there is often no mandatory training or regulatory bodies for psychotherapists in general, and the term is often loosely used, anyone with little training can call themselves psychotherapists. Moreover, who practices what kind of psychotherapy is also influenced by social and political factors. For example, although not very often practiced nowadays, psychiatrists used to practice more psychotherapy2. In fact, the founders of both well known types of psychotherapies, cognitive behavioral and psychodynamic therapies were psychiatrists. However, the practice of psychotherapy has gradually been replaced by other non- psychiatric mental health professionals such as clinical psychologists due to the cost and time involvement for psychiatrist to conduct psychotherapy2. On the other hand, other form of psychotherapy such as family therapy is often conducted by social workers and other counselors who have training in counseling and family therapy3. Indeed, the involvement of health professionals from various disciplines in conducting psychotherapy has created confusion for both patients and health care workers when the word “psychotherapist” is referred. As a result, it will make a better claim for public resources to be allocated to psychotherapy if individual claim is made to specific kind of psychotherapy and therapist, rather than using a general term “psychotherapy” or “psychotherapist”. For example, in Canada, family physicians can get reimbursement from the government for the practice of GP psychotherapy4. Although there has been much debate in the past of what GP psychotherapy constitutes, it has now been accepted as a legitimate and important health services provided by the public health system in Canada. Similarly, in Australia, a recent initiative has given5 incentives for general practitioners to engage in psychosocial counseling and brief psychotherapy strategies for patients, and publications and courses were offered to practitioners who are interested to become “GP psychotherapists”. In the US, with the influence of Health Management Organization to control costs, much psychotherapy now is conducted either by clinical psychologists or social workers2 as a measure to reduce the cost involved. The reasons that psychotherapy is not recognized as an independent profession are multiple and include factors other than its lack of therapeutic evidence. It is also due to the generalness of the term “psychotherapy”, and it may be better for us to speak of the effectiveness of individual therapy in treating specific disorders, at the same time taking into consideration the training of the professionals who conduct such therapy. I believe it is only through this way that government in any country will allow health care money to be spent on such treatments. Reference 1. Goldbeck-Wood S. The future of psychotherapy in the NHS: More evidence based services are taking shape to meet growing demand. Brit Med J 2004; 329: 245-246. 2. Gabbard G, Kay J. The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist? Am J Psychiat 2001; 158: 1956-1963. 3. Lieberman F. Psychotherapy and the clinical social worker. Am J Psychiat 1987; 41: 369-83. 4. Trent B. GP psychotherapy: its popularity is growing among patients and MDs. Can Med Assoc J 1990; 143: 320-323. 5. Hickie I, Groom G. Primary care led mental health service reform: An outline of the Better Outcomes in Mental Health Care Initiative. Australas Psychiat 2002; 10: 376-382. Competing interests: None declared |
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James Baxter, Freelance consultant Gables Farm, Higham, Alfreton DE55 6EH
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'... the internecine warfare between the culture of medicine and psychotherapy' [Goldbeck-Wood and Fonagy] (and no less between psychotherapy professionals) will not stop until society as a whole makes up its mind whether functional mental illness is a healthy response to an indifferent, and sometimes hostile, social environment or a symptom of weakness in the sufferer. Competing interests: Psychotherapy practician |
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DB Double, Consultant Psychiatrist Norfolk and Waveney Mental Health Partnership NHS Trust
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In discussing the future of psychotherapy, Goldbeck-Wood & Fonagy comment on the difficulties in providing meaningful evidence about efficacy.1 However, they do not explain that the specific problem is about the adequacy of control groups.2 Comparison of active with control treatment in psychotherapy cannot be conducted double-blind as subjects inevitably know to which group they have been allocated. Drug trials may appear to have an advantage over psychotherapy trials in claims for scientific legitimacy because they can be conducted double-blind by using placebo medication. However, the degree of bias remaining in apparently double-blind trials should not be underestimated.3,4 Goldbeck-Wood & Fonagy may have focused too much on evidence as factual without acknowledging the importance of interpretation and, therefore, have not spelt out the role of ideology in the assessment of efficacy. Evaluation of psychotherapy is controversial. Psychotherapy may be in conflict with biomedical psychiatry in its conceptualisation of mental illness. Moreover, statutory responsibilities under the Mental Health Act take precedence within mental health services over psychotherapy, which is a voluntary activity. Psychotherapy, therefore, struggles against the hegemony of biological psychiatry. For reasons such as this, psychotherapy has established itself primarily outside the state sector, as Goldbeck-Wood & Fonagy note. Their solution is for the NHS to create a proper career structure for psychotherapists. Politically this may be less likely to be successful than taking advantage of the government policy for choice in the NHS.5 Primary care trusts need to look for alternative providers to meet the public demand for psychological therapies. Psychotherapists could organise themselves into provider organisations. These alternative providers should meet standards of training approved by such bodies as the UK Council for Psychotherapy (UKCP) and the British Confederation of Psychotherapists (BCP).
1. Goldbeck-Wood S & Fonagy P. The future of psychotherapy in the NHS: More evidence based services are taking shape to meet growing demand. BMJ 2004; 329: 245-246 (published 31 July 2004) [Full text] 2. Bergin AE, Garfield S. Handbook of psychotherapy and behaviour change (Fourth edition). New York: John Wiley, 1994 3. Fergusson D, Glass KC, Waring D, Shapiro S. Turning a blind eye: the success of blinding reported in a random sample of randomised, placebo controlled trials. BMJ, doi:10.1136/bmj.37952.631667.EE [Full text] 4. Moncrieff J & Double DB. Double blind random bluff. Mental Health Today 2003; Nov: 24-26 5. Department of Health. Building on the best. Choice responsiveness and equity in the NHS. December 2003.
Competing interests: None declared |
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Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS, Medical Director [A], Director, CME&R Buraidah Mental Health Hospital, Postcode.2292, Saudi Arabia
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Sir: Clinical wisdom suggests robustly that the treatment interventions-drug or nondrug-in any disease-psychiatric or nonpsychiatric are more often based on etiological theories rather than symptom-based mechanisms, which may be purely speculative or otherwise. Moreover, there is a converging sound evidence towards diseases including mental disorders being caused by biological, meaningful psychological, social and cultural factors. Notably, treatment models encompassing drugs may well improve the biological diathesis of a disease but at the same time may leave patients with psychosocial diathesis. Furthermore, it is not always necessary that improvement in biological dysfunctioning will also bring about improvement in psychosocial impairment. Likewise, psychosocial therapies, by and large very effective treatment modalities in all types of diseases though relatively lack controlled trials as compared to drug trials, which is one of the yardsticks of evidence-based data, may improve psychological and social functioning of the patients without effectively impacting disturbed biological matrix of the disease. However, there are reported reciprocal therapeutic relationships between biological and nonbiological factors underlying a disease. So what are the therapeutic implications of these formulations? Like drug interventions, psychotherapy is an effective means of treating a variety of patients with mental and/or medical disorders. A combined approach that addresses therapeutically both etiological components of a disease probably would be more effective. Both placebo effect and relapse are common denominators of drug as well as nondrug treatment interventions. To collect evidence-based data, psychotherapy only needs more randomized controlled trials. Finally, the future of psychotherapy [1] is bright in the NHS because it is an essential component of overall management of a disease whether it is a cancer or panic. Reference: 1.Sandy Goldbeck-Wood and Peter Fonagy. The future of psychotherapy in the NHS. BMJ 2004; 329: 245-246 Competing interests: None declared |
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Richard A House, Practice Counsellor Magdalen Medical Practice, Lawson Road, Norwich NR3 4LF, UK
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RAPID RESPONSE: NHS psychotherapy and its discontents: finding creativity amidst the conflict Richard House Magdalen Medical Practice, Lawson Road, Norwich NR3 4LF, UK Goldbeck-Wood and Fonagy’s thoughtful contribution on the future of NHS psychotherapy (BMJ 2004; 329, 245-6) raises some interesting questions which cannot be properly considered in isolation from the professionalisation process more generally. Over many years a number of colleagues, ourselves included, have written at great length in the field’s professional journals about the manifold dangers of the institutional professionalisation of psychotherapy and counselling.1 One of our core concerns has been that any institutional regulatory arrangements must needs be consistent, in terms of power dynamics, with the fundamental nature of the therapy experience itself; and concomitantly, that to the extent that there is any incongruity between regulatory structures and therapy practice, the quality of the latter will inevitably suffer, to the detriment of patients and clients.2 It would be wrong to assume that those who are sceptical about the institutional professionalisation of psychotherapy are ‘against’ any kind of accountability whatsoever; rather, we are in favour of accountability with heart, accountability that works, and accountability that is consistent with the core philosophy of the therapeutic work we do. In Britain, the Independent Practitioners Network (IPN),3 founded in 1994, is a national network of practitioners which offers an accreditation or competency route based on continuing peer assessment. Practitioners participating in the IPN come from a wide variety of therapeutic and educational backgrounds, and the Network is independent of training and accrediting bodies. IPN is altogether a remarkable piece of leading-edge social innovation that reverses the top-down power dynamic of conventional accountability structures, in favour of devolving responsibility for competence and ethical conduct to localised, continuing, face-to-face contact. By its existence IPN is very challenging of the mainstream approaches to accountability, since it represents the kind of social creativity that is in danger of being eliminated or severely restricted by statutory regulation. A further concern is that, for many practitioners, the very idea of psychotherapy being a medicalised practice is fundamentally incoherent and inappropriate – not least because the totem of human potential development to which most practising therapists aspire and adhere is, in a paradigmatic sense, quite incommensurable with the “deficit”, psychopathological approach that the medical model routinely embraces.4 This is not to argue, we hasten to add, that psychotherapy and counselling therefore have no place in conventional medical settings. Indeed and on the contrary, one of the strengths of the NHS’s embracing of an intervention – psychotherapy - that eschews a medical-model conceptualisation of distress and ill-health is that it paradoxically reveals conventional medicine’s maturity in being able to acknowledge the value of diverse and different approaches to human health. A strong, undefensive medical service might even be favourably influenced by the kinds of “post-medical model” values that psychotherapy and counselling at their best represent. The evidence-based (some might say manic) “accountability culture” that has recently swamped the public services in general, and the NHS in particular, has received devastating criticism from a whole range of sources,5 and there is a danger in Goldbeck-Wood and Fonagy’s contribution of uncritically buying into a politically correct, culturally ephemeral fashion which many believe to be perpetrating untold damage in modern public culture.6 And what if the values and associated practices of the accountability culture are antithetical to, and incapable of authentically measuring7 even in accordance with their own favoured metric, the healing value or otherwise of psychotherapy? – a proposition obliquely hinted at by Goldbeck-Wood and Fonagy. This, again, is where we observe a fundamental clash of paradigms or worldviews8 – where one approach prizes the criterion of quantitatively measurable efficacy and “cost effectiveness” above all others, while the other questions the hegemony of such symptom-based evaluation criteria, preferring instead to embrace hermeneutic values of meaning-making and human potential development. For many years now, we have seen the burgeoning growth of General Practice counselling within the NHS, and there is overwhelming evidence of very high levels of patient satisfaction with this widely used service. Certainly, this is in stark contrast to the shocking number of deaths due to iatrogenic mainstream medical practice, as recently widely reported,9 with an estimated 10,000 premature deaths occurring per annum due to bad reactions to medication. It is indeed a sad reflection of the times we currently live in that a service that is so highly valued by patients and which leads to little if any iatrogenic effects – GP counselling – should be subject to such constant threat to its very existence, while conventional medicine is beset with demonstrable levels of literally fatal iatrogenicity. Indeed, given the way in which both rigidly professionalised medicine and professionalised psychotherapy can be harmful to patients/clients, perhaps we should be grateful that, as Goldbeck-Wood and Fonagy disapprovingly point out, there currently exists “piecemeal and ad hoc” provision of psychotherapy services within the NHS! It is also important to be extremely careful when approvingly repeating the fashionable shibboleth about Cognitive Behaviour Therapy (CBT) being one of the few empirically validated treatment modalities, for the CBT approach entails a “philosophy of the person” which is squarely rooted in the ideology of modernity10 - so it is hardly surprising that it “passes” an empirical assessment whose methodology is mechanistically positivistic in conception and execution. Goldbeck-Wood and Fonagy are entirely correct in asserting that “factors related to the individual practitioner and patient are probably at least as important a part of the ‘active ingredient’ as the modality of therapy”. And it is for precisely this reason – among others – that the kind of evidence-based empiricism routinely applied to conventional medical treatments is singularly inappropriate in any attempt to evaluate psychotherapeutic interventions. Far from seeing it as a problem, we positively celebrate the fact that “Britain has no legal definition of psychotherapy”! And the internecine warfare between psychotherapy and medicine bemoaned by the authors is not some random event, but rather, a revealing symptom of the epistemological chasm that rightly exists between what are arguably two incommensurable worldviews about human health and well-being. We passionately believe that therapeutic practice will only continue to evolve and progress if the field is left unfettered by rigid professionalising imperatives, with the freedom to encourage leading-edge innovation and diversity,11 free of the deadening encumbrances of institutionally professionalised “Regimes of Truth”.12 In this sense, we welcome rather than seek prematurely and inappropriately to legislate away the contested terrain of psychotherapy within the NHS – for in the visionary words of William Blake, “Without contraries is no progression”. References 1 House R, The professionalization of counselling: a coherent case against? Couns Psych Quart 1996;9: 343-358; Postle D, Gold into lead: the annexation of psychotherapy in the UK. Int J Psychoth 1998;3: 53-83. 2 Hogan DB, The regulation of psychotherapists, 4 vols. Cambridge, Mass.: Ballinger, 1979. 3 A full briefing document on the IPN is available at http://ipnosis.postle.net 4 Totton N, Inputs and outcomes: the medical model and professionalisation. In House R and Totton (eds), Implausible Professions: Arguments for Pluralism and Autonomy in Psychotherapy and Counselling (pp. 109-116). Ross-on-Wye: PCCS Books, 1997. 5 Cooper M, The state of mind we’re in: social anxiety, governance and the audit society. Psychoanal Stud 2001;3: 349-362. 5 Power M, The audit society: rituals of verification. Oxford: Oxford University Press, 1997. 6 House R, Audit-mindedness in counselling: some underlying dynamics. Brit J Guid Couns 1996;24: 277-283. 7 House R, General practice counselling: a plea for ideological engagement. Couns 1996;7: 40-44. 8 BBC News Online report, Medicines ‘killing 10,000 people’. Friday 2 July 2004, http://news.bbc.co.uk/1/hi/health/3856289.stm 9 Woolfolk RL, Richardson FC, Behavior therapy and the ideology of modernity. Am Psychol 1984;39: 777-786. 10 Bates Y, House R (eds) Ethically Challenged Professions: Enabling Innovation and Diversity in Psychotherapy and Counselling. Ross-on-Wye: PCCS Books, 2003. 11 House R, Limits to professional therapy: deconstructing a professional ideology. Brit J Guid Couns 1999;27: 377-392. ABOUT THE AUTHOR: RICHARD HOUSE MA (Oxon), Ph,D. is a General Practice counsellor and a Steiner (Waldorf) early years teacher living in Norwich, UK. With seven years training in counselling and body-oriented psychotherapy, he has been a practising therapist since 1990, and has published very widely in the psychotherapy, counselling and education literatures, with over 250 publications to date. His latest book, Therapy Beyond Modernity, was published by Karnac Books in 2003; and he has co-edited two widely acclaimed critical anthologies – Implausible Professions: Arguments for Pluralism and Autonomy in Psychotherapy and Counselling (with Nick Totton, 1997), and Ethically Challenged Professions: Enabling Innovation and Diversity in Psychotherapy and Counselling (with Yvonne Bates, 2003, both published by PCCS Books, Ross-on-Wye). Address for correspondence: richardahouse@hotmail.com Competing interests: None declared |
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