error. However, in diagnosing metastases with no
known primary, such as liver metastases as a first pres-
entation, consideration should be given to the need for
histological material. Cytology is ideal for confirming
metastasis from a clinically or radiologically suspected
primary site and distinguishing between limited
alternatives such as small cell or non-small cell lung
cancer. However, if there is no indication of a possible
primary site, core biopsy facilitates more thorough
assessment of a tumour’s architecture and immunohis-
tochemical profile, allowing better prediction of origin
and prognosis. The trauma and risks of biopsy are
greater than for fine needle aspiration,
and we need
to consider for each patient which technique is most
suitable and how the result of any invasive test would
Used appropriately FNAC remains a powerful tool
in the diagnosis and management of patients with
malignancy. A realistic approach to what is achievable,
with clear communication between clinician and
cytopathologist, is vital.
Derek E Roskell consultant pathologist
Ian D Buley consultant pathologist
Department of Cellular Pathology, John Radcliffe Hospital, Oxford
Competing interests: None declared.
1 Metcalfe MS, Bridgewater FHG, Mullin EJ, Maddern GJ. Useless and
fine needle aspiration of hepatic colorectal metastases. BMJ
2004;328:507-8. (Also electronic responses at http://
2 Brown LA, Coghill SB. Cost effectiveness of a fine needle aspiration
clinic. Cytopathology 1992;3:275-80.
3 Buley ID, Roskell DE. Fine needle aspiration cytology in tumour diagno-
sis: uses and limitations. Clin Oncol 2000;12:166-71.
4 Powers CN. Complications of fine needle aspiration biopsy: the reality
behind the myths. In Schmidt WA, ed. Cytopathology. Chicago: ASCP
5 Snead DRJ, Vryenhoef P, Pinder SE, Evans A, Wilson ARM, Blamey RW,
et al. Routine audit of breast fine needle aspiration (FNA) cytology speci-
mens and aspirator inadequate rates. Cytopathology 1997;8:236-47.
6 Singh N, Ryan D, Berney D, Calaminici, Sheaff MT, Wells CA. Inadequate
rates are lower when FNAC samples are taken by cytopathologists.
7 Britton PD. Fine needle aspiration or core biopsy. Breast 1999;8:1-4.
8 Castro MR, Gharib H. Thyroid fine-needle aspiration biopsy: progress,
practice and pitfalls. Endocrine Pract 2003;9:128-36.
9 Orell SR, Phillips J, eds. The role of fine needle biopsy in the investigation
of thyroid disease and its diagnostic accuracy. In: The thyroid, fine needle
biopsy and cytological diagnosis of thyroid lesions. Monographs in clinical
cytology. Vol 14. Basel: Karger, 1997:8-16. (Chapter 3.)
10 Gharib H, Goellner JR: Fine-needle aspiration biopsy of the thyroid: an
appraisal. Ann Intern Med 1993;119:282-9.
11 Buscarini L, Fornari F, Bolondi L, Colombo P, Livraghi T, Magnolfi F, et
al. Ultrasound-guided fine needle biopsy of focal liver lesions: techniques,
diagnostic accuracy and complications. A retrospective study on 2091
biopsies. J Hepatol 1990;11:344-8.
The future of psychotherapy in the NHS
More evidence based services are taking shape to meet growing demand
he demand for psychological therapies in Brit-
ain has never been greater,
yet their claim on
scientific legitimacy and therefore on public
resources has never been under greater scrutiny.
At a meeting held by the UK Council for Psycho-
therapy in November 2003 to address the future of
psychotherapy in the NHS, the clearest messages were
that although the taxpaying public
demands increased access to psychological therapies
and the government espouses both patient choice and
user centred services,
the evidence on the efficacy and
cost effectiveness of the many different psychothera-
pies is patchy. Randomised trials cover only a limited
number of treatments, and many treatments remain
unevaluated in relation to many conditions.
rates of 40-70% of presenting patients limit their gen-
eralisability to the treatment seeking population,
dearth of long term data, data on quality of life, non
experimental evidence, user perspectives, and evidence
of the generalisability to NHS practice of studies
carried out in other settings hampers rational purchas-
ing decisions. Little is known about equity of access to
therapy across socioeconomic or ethnic groups, and
with neither a career structure nor a pay scale of its
own, psychotherapy is not even formally recognised as
an independent profession. The result is a lottery for
patients and piecemeal and ad hoc arrangements for
recruitment and supervision of staff.
One of the key obstacles has been a conflict of cul-
tures. The narrative based hermeneutic culture of post-
Freudian psychotherapy and the empirical culture that
dominates medicine have proved reluctant bedfellows.
Theoretical differences are reinforced by longstanding
political antagonisms and resentments. Analytic thera-
pists in particular have been defensive and suspicious
in the f ace of the evidence culture as though the very
idea of objective scrutiny represented a hostile
intrusion into a quasi sacred private world.
behaviour therapy has done much better at embracing
the need for evidence and the requirements of
purchasers. As a result its strong research and dissemi-
nation strategy has found favour with service providers
and research funding bodies lost in a jungle of conflict-
ing claims and vested interests, regardless of whether it
is the most effective for any given indication.
Real difficulties exist in providing meaningful
evidence on psychotherapies.
Although research is
legitimately and necessarily a public activity, much of
what is most important in psychotherapy is legiti-
mately and necessarily private.
As with surgical
research, 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.
Individual, patient related factors such as coping style
may also be influential. A meta-analysis of 16 trials
showed that self reflective and introspective individuals
seem to benefit more from insight oriented therapies
Additional references w1-w13 are on bmj.com
245BMJ VOLUME 329 31 JULY 2004 bmj.com
whereas impulsive and aggressive patients respond
better to symptom focused procedures.
In short, some
of the influences that randomised trials would
normally seek to exclude seem actually to be part of
the active ingredient of psychotherapy. It seems that a
good therapist can achieve results with the right
patient almost irrespective of his or her declared brand
To complicate matters, therapists them-
selves disagree over fundamentals such as relevant
outcome measures, and what constitutes a “therapeutic
dose.” Analytic therapists favour a long term view, in
which short term worsening of presenting symptoms
may be seen to play a necessary part and success is
measured less in terms of symptom relief than of self
understanding. All these represent real barriers to the
pursuit of evidence but barriers which are being
Evidence from randomised controlled trials now
exists for the efficacy of psychotherapy in depression,
panic, generalised anxiety disorder, eating disorder,
and personality disorder. Cognitive behaviour therapy,
family therapy, interpersonal therapy, cognitive ana-
lytic therapy, and some psychodynamic therapy have
variously been shown to reduce life impairing mood
states and behaviours substantially.
But with notable
exceptions, such as the use of cognitive behaviour
therapy for panic disorders, most trials still leave
patients with residual symptoms, and most participants
in trials relapse or seek further treatment within a year
or two of “successful treatment.”
presenting at clinics are polysymptomatic, and
improvement is inversely proportional to the chronic-
ity and complexity of their presenting condition. Dura-
tion of treatment is also highly correlated with
comorbidity and chronicity, and we know that theoreti-
cally based therapies with a coherent theoretical
mechanism of action deliver better results than
interventions, such as simple interpersonal support,
which lack a coherent theoretical model.
But though the overall picture is diffuse, differences
between individual therapies in relation to specific dis-
orders are now emerging. The efficacy of cognitive
behaviour therapy in conditions such as panic
disorder, specific phobias, and obsessive compulsive
disorder is well established, although critics argue that
effect sizes have been overestimated because of
Psychodynamic therapy has
been shown to be effective in severe personality disor-
which responds poorly to cognitive behaviour
Family therapy is effective in anorexia
and structured br ief psychological therapies
are generally effective at least in the
short term, although with no clear evidence of advan-
tage to any particular approach.
Again few trials have
extended follow up, and those that do show a clear ten-
dency for patients to relapse.
Unlike medicine and allied professions, psycho-
therapy has established itself primarily outside the
state sector. From Freud’s fir st analyses of the Viennese
bourgeoisie to modern Britain, private provision still
exceeds state provision. Britain has no legal definition
of psychotherapy, so the British market is richly varied
in type of therapy, training, price, and quality.
Regulation with bodies such as the United Kingdom
Council for Psychotherapy, and the British Association
for Counselling and Psychotherapy, is still purely
voluntary. But if evidence based psychotherapy is to be
more than a private luxury for the wealthy, and if the
NHS is to meet growing demand for mental health
services, the internecine warfare between the cultures
of medicine and psychotherapy must stop. The NHS
needs to recognise psychotherapists as professionals
with proper career and pay structures, rather than
treating them as petitioners at the gate. Psychothera-
pists need to speak coherently and convincingly as a
profession in language that others can understand.
And the joint pursuit of rigorous, theory based, patient
centred, therapist led research into talking therapies
must go on. Only then will patients receive the accessi-
ble, affordable, and effective talking treatments they
need and want.
Sandy Goldbeck-Wood associate editor BMJ
Peter Fonagy Freud Memorial professor of psychoanalysis
Psychoanalysis Unit, University College London, London WC1E 6BT
Competing interests: SG-W has received training in psychody-
namic and humanistic therapies. She is not currently practising
as a therapist.
1 Department of Health. National service framework for mental health: modern
standards and service models. London. DOH, 1999. www.dh.gov.uk/
en?CONTENT_ID = 4009598&chk = jmAMLk (accessed 7 Apr 2004).
2 National Institute for Clinical Excellence. Depression: the management
of depression in primary and secondary care. Second consultation draft,
3 Roth, Fonagy P. What works for whom? A critical review of psychotherapy
research. 2nd ed. New York: Guilford Press (in press).
4 Westen D, Morrison K, Thompson-Brenner H. The empirical status of
empirically supported psychotherapies: assumptions, findings, and
reporting in controlled clinical trials. Psychol Bull (in press).
5 Holmes J. All you need is cognitive behaviour therapy? BMJ
6 Beutler LE, Machado PP, Neufeldt SA. Therapist variables. In: Bergin AE,
Garfield SL, eds. Handbook of psychotherapy and behavior change. New York:
7 Wampold B, Minami T, Baskin T, Callen Tierney S. A meta-(re)analysis of
the effects of cognitive therapy versus “other therapies” for depression. J
Affect Disord 2002;68:159-65.
8 Westen D, Morrison K. A multidimensional meta-analysis of treatments
for depression, panic, and generalized anxiety disorder: An empirical
examination of the status of empirically supported therapies. J Consult
Clin Psychol 2001;69:875-99.
9 Leichsenring F, Leibing E. The effectiveness of psychodynamic therapy
and cognitive behavior therapy in the treatment of personality disorders:
a meta-analysis. Am J Psychiatry 2003;160:1223-32.
10 Dare C, Eisler I, Russell G, Treasure J, Dodge L. Psychological therapies
for adults with anorexia nervosa: randomised controlled trial of
out-patient treatments. Br J Psychiatry 2001;178:216-21.
11 Churchill R, Corney R, Knapp M, McGuire H, Tylee A, Wessely S. A sys-
tematic review of controlled trials of the effectiveness and cost-
effectiveness of brief psychological treatments for depression: Health-
Technology Assessment 2002;5(35).
246 BMJ VOLUME 329 31 JULY 2004 bmj.com