The need for a fair deal
It is increasingly recognised that
psychological therapies are effective in the treatment of a range
of mental disorders1–8 and they are favoured by many
service users.9 However, in both primary and secondary
care services, psychological therapies are lacking and they are
rarely provided in a timely fashion. Waiting times of over 12
months for people in crisis (unacceptable for physical health
problems) are reportedly commonplace.9
We welcome the fact that governments
within the UK are taking steps to address this. Certain groups,
such as older people, hospital in-patients, individuals from
minority ethnic backgrounds, asylum
seekers, prisoners and people with learning disabilities have a
high level of unmet need and the new government initiatives
(including the IAPT (Improving Access to Psychological Therapies)
programme may not reach them. A distinct strategic plan is needed
for these disadvantaged groups and for those with other
mental disorders.
What we are calling for
- Strategic planning to ensure that service
users in secondary care, older people, people with severe and
enduring mental illnesses, those with dual diagnoses, learning
disabilities or in custody and people from Black and minority
ethnic communities, can gain timely access to effective
treatments.
- Organisations providing psychological
therapies should promote the development of psychological
mindedness and therapeutic skills among all staff, preferably through the
appointment of a champion at a high level within the
organisation.
- The training of all general practitioners
to include delivering effective therapeutic and supportive
interventions and shared training with trainee psychiatrists where
possible.
- Support for research into frequently used
and promising psychological interventions is required.
Examples of what the College will do
The College will ensure that psychiatric
training confers psychotherapeutic understanding and skills
appropriate to each psychiatric specialty.
We will ensure a clearer and more defined
role for psychiatrists in actively monitoring the availability of
psychological therapies and assisting with the training and
supervision of others.
We will seek a well-thought-out
collaboration with stakeholders, including colleagues in
psychology, primary care and the voluntary sector in the
development and provision of psychological therapies.
We will audit programmes to document practice
and progress within the provision of psychological therapies and
seek research funding to address promising psychological
interventions.
Psychological therapy: availability and accessibility
There is considerable evidence in support
of the effectiveness of psychological therapies across a range of
presenting problems, therapeutic modalities and settings.
Psychological therapies are recommended by the National Institute
of Health and Clinical Excellence (NICE) for mild and moderate
depression and anxiety, obsessive–compulsive disorder, bipolar
disorder, post-traumatic stress disorder, eating disorders and
schizophrenia.1–8 They encompass a broad range of
treatments, including talking therapies of different models (e.g.
cognitive–behavioural, psychodynamic and systemic models) and
different forms of delivery (e.g. individual, family and group).
The most appropriate treatment may vary according to the person’s
age, situation, diagnosis and personal preference.
Case study
1
Deborah Hart, Carer
My daughter had been self-harming for
several years. One day, aged 17, having drunk heavily, she had a
terrible argument with her boyfriend and ended up in the middle of
the night at accident and emergency having cut a major vein in her
wrist. She was told to go to see her general practitioner for a
referral to a child and adolescent psychiatrist. The general
practitioner sent a referral letter to the local child and
adolescent team and in the meantime prescribed her some
antidepressants which she refused to take. A few days later we were
contacted by the team to say that there was a waiting list of
between 6 and 9 months in order to get any psychological help. I
eventually found someone privately who helped her through this very
difficult period in her adolescence. I was very lucky that as a
working mother I could afford this, although it created a lot of
personal hardship.
Not only can psychological therapies reduce
symptoms, they can also help a person to cope with adversity and
make lasting changes to their behaviour and personality. The
Department of Health provides evidence-based guidelines9
for practitioners to make informed assessments about the potential
effectiveness of treatment options for common mental disorders and
some somatic syndromes The Cochrane Collaboration
(www.cochrane.org/) provides a more extensive review of the
evidence for and against psychological therapies in physical and
mental health. These therapies can be part of a holistic care
package that together promotes recovery. Although people with
mental health problems repeatedly report that better access to
psychological therapies is a priority, waiting times of well over a
year are not uncommon.10 There is considerable unmet
need for treatment with psychological therapies of different
modalities, in all patient populations, for various mental
conditions, in both primary and secondary healthcare.
Northern Irish Division,
I
’Like most
general adult psychiatrists, I am deeply frustrated, and at times
highly embarrassed, that owing to a lack of psychotherapists I am
unable to offer patients the evidence-based treatments which many
would prefer to receive. Too often all I can offer is an
antidepressant and supportive psychotherapy.’
Case study
2
College Research
and Training Unit
The Royal College of
Psychiatrists’ Centre for Quality Improvement has been awarded
funding by the Healthcare Commission to run a national audit of
psychological therapies services. The audit will run for 3 years
and will centre on the care being delivered to people with
depression or anxiety disorders. This will complement other
national initiatives, including the new Public Service Agreement indicator for
psychological therapy services, and the English Department of
Health’s Improving Access to Psychological Therapies programme.
In England, Scotland and Wales,
government surveys indicate that of
individuals experiencing common mental health problems (one in six
of the UK population) only 9% received any counselling or
therapy.11 In prisons only half of all prisoners were
found to have access to supportive discussions with
staff.9 Lord Layard’s 2004 report stated that untreated
depression and anxiety had significant costs for individuals and
for the economy (in terms of unemployment), but access to treatment
was severely restricted.12
Psychiatrists report particular
difficulties in accessing psychological therapies for older people
(individuals with dementia being an additional priority) and for
children and adolescents (especially those aged 15–18 years, in the
transition to adulthood). Family therapy is particularly needed for
these groups. People with learning disabilities have frequently
been denied access to psychological therapies despite a growing
body of evidence suggesting that therapeutic models and processes
can be adapted to work with people with a range of learning
disabilities.13 There is also an unmet need for
treatment for conditions such as resistant depression, chronic
psychosis, eating disorders and severe personality
disorders.14
Policy responses
The Scottish government has made a
commitment to ‘increase the availability of evidence-based
psychological therapies for all age groups in a range of settings
and through a range of providers’.15 This will deliver
therapies through primary care to adults with anxiety and
depression. The Scottish Division of the College accordingly
favours the introduction of a target waiting time of 18 weeks from
assessment to treatment. In Wales, local health boards have been
tasked to improve access to psychological services within primary
care and to collaborate with voluntary and specialist
services.16
Northern Irish Division,
II
‘NICE guidelines recommend psychotherapy
for moderate and severe depression and schizophrenia, as well a
range of other conditions. Despite this, no NHS trust in Northern
Ireland is able to offer therapy for the large bulk of patients who
would benefit. If the treatment was a drug recommended by NICE, it
is unimaginable that so little would be done to make it
available.’
In Northern Ireland, the Department of
Health is establishing a mental health service framework and
performance targets that include the expansion of psychological
therapies.17 In England, a £170m 3 year programme has
been launched to increase the number of trained psychological therapists, concentrating on
cognitive–behavioural therapy, to help cope with anxiety and
depression.9 These are very welcome but should not
happen at the expense of other forms and modes of psychotherapeutic
provision for other service users’ groups. The waiting times for
physical and mental health treatment should be comparable.
Case study
3
Cognitive–Behavioural Therapy: Structured
Self-Help
Each year the College Education
and Training Centre delivers a series of workshops with Dr Chris
Williams (Glasgow). They are designed to support staff in the use
of structured self-help cognitive–behavioural materials to help
patients who are suffering from depression, anxiety, long-term
physical illness and medically unexplained symptoms.
Roles for psychiatrists
Psychiatrists need to monitor the
availability of psychological therapies on behalf of service users,
drawing attention to any gaps in services. They need to give
well-informed advice on appropriate therapies and supervise
colleagues providing supportive interventions. Their role should
include collaborating with colleagues in the primary and voluntary
care sectors, especially where service users require high-intensity
psychological treatment but fall between primary care and
specialist services.
Further, all general practitioners and
psychiatrists should have mutual experience of each other’s work,
with opportunities for a placement in different settings
across the two specialties during
training. Appropriate training in psychotherapeutic understanding
and skills should be available throughout the postgraduate training
of all psychiatrists.
Needs for services for substance misuse are
even greater than the experience of these services suggests, as
approximately 40% of in-patients in general adult facilities have
substance misuse problems. There is also a lack of provision of
therapies for those with complex and often serious emotional
problems who require high-intensity psychological treatment but
fall into the gap between primary care and specialist services
Establishing a therapeutic culture
Although not everyone will be offered
therapy, all patients and staff benefit from a service which
understands psychotherapeutic principles and provides opportunities
for containment and reflection, where the fears of the patients and
also of the staff who care for them are recognised.
Psychotherapeutic techniques can be valuable in the general
clinical work of mental health professionals. The skills include
those associated with communication, the ability to listen, to
empathise, showing an openness to patients’ emotions, making sense
of patients’ experience and using personal emotional response as a
source of understanding. Training is also needed for professionals
to raise their knowledge of emotional problems and the potential
role of psychological interventions.
Psychological mindedness is key to
therapeutic relationships. It can motivate clinicians who, having
little previous training, take an interest in psychological
therapies. Good psychological therapies require therapists working
in psychologically oriented organisations. Progress will depend
upon acknowledging psychological mindedness as a common value that
all parties can adopt. Historically, attitudes have been as large
an obstacle to the use of psychological therapies as have a lack of
resources. These attitudes have included the stigma against people
who seek therapy, unjustified skepticism about its effectiveness
and the failure of different groups of clinicians and therapists to
respect one another’s work. In each case changes in attitude have
been necessary for services to improve
Case study
4
Typical
Scenario
At a ward review to discuss the care of
Mrs Green, admitted with a moderate depressive illness, staff from
different disciplines seemed annoyed. They considered that Mrs
Green should be discharged as she had turned down all attempts to
help her. The consultant tended to agree. However, after taking a
more extensive history, it appeared that the staff may be
re-enacting rejection Mrs Green had experienced in her early life.
Once they understood this, staff became more patient with her. In
her turn she started to accept suggestions offered to her as part
of a slow but steady recovery. As a result she was discharged at a
time that was right for her health.
Knowledge for action: audit and research
Research is needed into frequently used and
promising psychological interventions. Psychological treatments
need to better reflect effectiveness rather than simply the amount
and quality of research undertaken. There need to be investigations
which will evaluate the acceptability and availability of
psychological therapies. Information on services and patient
experiences should be audited and assessed in order to increase the
range of choices of treatments.
References
1 National Institute for
Clinical Excellence (2002) Schizophrenia. Core Interventions in the
Treatment and Management of Schizophrenia in Primary and Secondary
Care. NICE.
2 National Institute for Clinical Excellence (2004)
Depression. Management of Depression in Primary and Secondary Care.
NICE.
3 National Institute for Clinical Excellence (2004)
Management of Anxiety in Adults in Primary, Secondary and Community
Care. NICE.
4 National Institute for Clinical Excellence (2004)
Self-Harm. The Short-Term Physical and Psychological Management and
Secondary Prevention of Self-Harm in Primary and Secondary Care.
NICE.
5 National Institute for Clinical Excellence (2004)
Eating Disorders. Core Interventions in the Treatment and
Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating
Disorders. NICE.
6 National Institute for Clinical Excellence (2005)
Obsessive–Compulsive Disorder. Core Interventions in the Treatment
of Obsessive–Compulsive Disorder and Body Dysmorphic Disorder.
NICE.
7 National Institute for Clinical Excellence (2005)
Post-Traumatic Stress Disorder. The Management of PTSD in Adults
and Children in Primary and Secondary Care. NICE.
8 National Institute for Clinical Excellence (2006)
Bipolar Disorder. The Management of Bipolar Disorder in Adults,
Children and Adolescents in Primary and Secondary Care. NICE.
9 Department of Health (2001) Treatment Choice in
Psychological Therapies and Counselling. Department of
Health.
10 Mental Health Foundation (2006) We Need to Talk. The
Case for Psychological Therapy on the NHS. Mental Health
Foundation.
11 Singleton, N., Bumpstead, R., O’Brien, M., et al
(2001) Psychiatric Morbidity Among Adults Living in Private
Households, 2000. TSO (The Stationery Office).
12 Layard, R. (2005) Mental Health: Britain's Biggest
Social Problem? Department of Health.
13 Royal College of Psychiatrists (2004) Psychotherapy
and Learning Disability. Council Report CR116. Royal College of
Psychiatrists.
14 Royal College of Psychiatrists & Royal College
of General Practitioners (2008) Psychological Therapies in
Psychiatry and Primary Care. Royal College of Psychiatrists.
15 Scottish Executive (2006) Delivering for Mental
Health. Scottish Executive.
16 Adult Mental Health Services (2005) Raising the
Standard. The Revised Adult Mental Health National Service
Framework in Wales. Welsh Assembly Government.
17 Department of Health, Social Services and Public
Safety (2007) The Bamford Review of Mental Health and Learning
Disability (Northern Ireland). DHSSPS.