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The future of psychotherapy in the NHS

DOI:10.1136/bmj.329.7460.245
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Sandy Goldbeck-Wood at UiT The Arctic University of Norway
Sandy Goldbeck-Wood
Peter Fonagy at University College London
Peter Fonagy
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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,
11
and we need
to consider for each patient which technique is most
suitable and how the result of any invasive test would
alter management.
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
(derek.roskell@orh.nhs.uk)
Ian D Buley consultant pathologist
Department of Cellular Pathology, John Radcliffe Hospital, Oxford
OX3 9DU
Competing interests: None declared.
1 Metcalfe MS, Bridgewater FHG, Mullin EJ, Maddern GJ. Useless and
dangerous
—
fine needle aspiration of hepatic colorectal metastases. BMJ
2004;328:507-8. (Also electronic responses at http://
bmj.bmjjournals.com/cgi/content/full/328/7438/507)
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
Press, 1996:69-91.
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.
Cytopathology 2003;14:327-31.
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
T
he demand for psychological therapies in Brit-
ain has never been greater,
1
yet their claim on
scientific legitimacy and therefore on public
resources has never been under greater scrutiny.
2 w1-w4
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
conflicting ones
—
that although the taxpaying public
demands increased access to psychological therapies
and the government espouses both patient choice and
user centred services,
1
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.
3
Exclusion
rates of 40-70% of presenting patients limit their gen-
eralisability to the treatment seeking population,
4
and a
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.
w5
Cognitive
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.
5
Real difficulties exist in providing meaningful
evidence on psychotherapies.
w6
Although research is
legitimately and necessarily a public activity, much of
what is most important in psychotherapy is legiti-
mately and necessarily private.
w7
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.
6w8
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
Editorials
BMJ 2004;329:245–6
245BMJ VOLUME 329 31 JULY 2004 bmj.com
whereas impulsive and aggressive patients respond
better to symptom focused procedures.
6
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
of therapy.
6
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
surmounted.
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.
3
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.”
3
Most patients
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.
7
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
inappropriate controls.
8w9
Psychodynamic therapy has
been shown to be effective in severe personality disor-
der,
9
which responds poorly to cognitive behaviour
therapy.
w10-w12
Family therapy is effective in anorexia
nervosa,
10
and structured br ief psychological therapies
in depression
11
are generally effective at least in the
short term, although with no clear evidence of advan-
tage to any particular approach.
7
Again few trials have
extended follow up, and those that do show a clear ten-
dency for patients to relapse.
4 w13
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
(sgoldbeck-wood@bmj.com)
Peter Fonagy Freud Memorial professor of psychoanalysis
Psychoanalysis Unit, University College London, London WC1E 6BT
(p.fonagy@ucl.ac.uk)
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/
PublicationsAndStatistics/Publications/
PublicationsPolicyAndGuidance/
PublicationsPolicyAndGuidanceArticle/fs/
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,
December 2003..
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
2002;324:228-94.
6 Beutler LE, Machado PP, Neufeldt SA. Therapist variables. In: Bergin AE,
Garfield SL, eds. Handbook of psychotherapy and behavior change. New York:
Wiley, 2004.
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).
Editorials
246 BMJ VOLUME 329 31 JULY 2004 bmj.com
... There is no legal requirement for accreditation with any regulatory body and once accredited there is no common standard for ongoing accreditation. 1 This lack of a regulatory framework means that quality ABSTRACT Objectives To evaluate whether effective psychological therapies are being provided in an inner London population and to describe the ethnicity of clients in relation to estimated need in the population. Methods A questionnaire survey was sent to 78 providers of structured psychological therapy in the borough. ...
... 14 There are many problems with assessing the evidence base for psychological therapies. 1 We ensured that we related evidence of effectiveness to each of the common mental illnesses and used the best current evidence of effectiveness based on independent systematic reviews. The effectiveness grid was approved by a multidisciplinary steering group. ...
... There is now sufficient evidence to show that some types of therapy are more effective for different common mental health problems. 1,5,[7][8][9][10][11][12] We have no independent assessment of the effectiveness of therapy provided and have relied solely on therapists' own assessments of the treatment type they usually used for each common mental illness. None appeared to have any problems identifying the type of therapy they provided, and since respondents were not aware of the effectiveness grid there were no incentives to record other than their usual practice. ...
Psychological therapies for common mental illness: How effective and equitable is provision?
Article
  • Mar 2005
Objectives To evaluate whether effective psychological therapies are being provided in an inner London population and to describe the ethnicity of clients in relation to estimated need in the population.Methods A questionnaire survey was sent to 78 providers of structured psychological therapy in the borough.Results Fifty-nine (76%) providers of structured psychological therapy described the types of therapy they use for each of the common mental illnesses. At least one effective or likely to be effective therapy was used by 70% of voluntary sector providers, 61% of the primary care team, 59% of the primary care counselling service and 53% of private therapists. Twenty-five percent of the primary care team, 23% of voluntary sector providers and 5% of private therapists only used a therapy that was unlikely to be effective. A validated outcome measure was used by 100% of the primary care counsellors, 67% of the primary care team, 10% of private therapists and none of the voluntary sector providers. Twenty-three percent of the population of Greenwich are from a black and minority ethnic (BME) group. Only 15% of the client group for the primary care counselling service were from BME groups compared with 47% of clients of the private sector and 40% of voluntary sector clients.Conclusions Levels of use of treatment that is unlikely to be effective are unacceptably high for all provider groups. BME groups are more likely to access voluntary and private sector providers of psychological therapies, and services within the NHS should be developed appropriately to address this inequity of access.
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... Clearly these kinds of anxieties are not exclusive to the discipline of child psychoanalytic psychotherapy, but of particular interest was the lack of a formal evidence base as perceived by the medical establishment. (Goldbeck-Wood and Fonagy, 2004), which may put it at risk of becoming obsolete. Child psychoanalytic psychotherapy is an important part of the history of Child and Adolescent Mental Health Services and, some argue, an important part of the history of child psychiatry. ...
... There is an extensive literature on the history of psychoanalysis and a range of opinion about whether it is a science (Hale, 1995; Rustin, 2003; Strenger, 1991). However, to have a place in the UK NHS in the later part of the twentieth century, it became necessary for a treatment to have a strong evidence base ( Wood and Fonagy, 2004). Therefore, this review looks for signs that child psychoanalytic psychotherapy is positioning itself as a scientifi c discipline, in recognition that this is a necessary prerequisite to establishing an evidence-based practice. ...
Child psychoanalytic psychotherapy in the UK National Health Service: An historical analysis
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  • Dec 2009
This review developed from a discussion with the late Professor Richard Harrington about interventions in Child and Adolescent Mental Health services (CAMHS) that lacked an evidence base. Our aim is to investigate the literature for signs that child psychoanalysis is a declining paradigm within the Child and Adolescent Mental Health Services (CAMHS) in the United Kingdom (UK). We present the literature chronologically since the inception of the UK National Health Service. This study shows that there have been a number of threats to child psychoanalytic psychotherapy, but no significant consistent decline. The profession is beginning to develop the social profile of a scientific discipline. We conclude that child psychoanalytic psychotherapy does not consistently demonstrate features of a declining scientific paradigm.
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... A theory regarded as 'scientific' may eventually receive the legitimate status of a grand narrative. It should be also noted that, in the context of public health of which psychotherapy has become part, the scientific legitimacy of certain therapeutic models is reflected in access to public resources (Goldbeck-Wood and Fonagy, 2004). Therefore, it might be said that the system encourages and justifies seeking explanatory, scientific models that could be established as grand narratives in psychotherapy. ...
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Different modes of psychotherapy can be an effective form of treatment for a range of mental health problems. Psychotherapy provision in the NHS is organised in a variety of ways, with patient entry to various modes of therapy determined by a range of factors including evidence-based guidelines and patient or referrer preference. The methods by which patients arrive at a particular mode of psychotherapy are largely unreported. This paper aims to describe this process in one UK NHS psychotherapy service offering cognitive behavioural and psychoanalytic psychotherapy, and provides data to inform a discussion on the theoretical congruence of these allocation decisions.
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Future of psychotherapy in the NHS - Psychotherapists require more than evidence based services to be recognised as professionals
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Future of psychotherapy in the NHS - Control groups play important part
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Full-text available
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