Last month I asked the newly appointed UK Health Minister, Dr Coffey, seven questions about whether our mental health services are credible. On October 12th 2022, I received a response, from one of her aides, that began by informing me that NHS England would be best placed to respond to my queries! Only two of the seven questions (reproduced at the end of the blog) are refenced in the reply, with only one question answered.
With regards to the answered question, I had asked that given that the government is introducing Community Diagnostic Centres for physical conditions, were they going to follow suit for mental health? The response was that “there would be significant challenges to making this approach work for mental health conditions. Diagnosis for mental health is less straightforward…would require a significant expansion in numbers of mental health staff… no plans at present to replicate this model for mental health.” So unbridled clinical judgements will continue to reign.
Is it any wonder that in the real world, the output from mental health therapists amounts to so little? My own independent examination of 90 cases passing through the UK Improving Access to Psychological Therapies (IAPT) Service revealed that only the tip of the iceberg recover, in the sense of losing their diagnostic status.
The judges might agree on features of the fare, e.g., presentation, but without tasting the produce, the judgements are meaningless. The ultimate metric is whether psychological treatment makes a real-world difference to client’s lives. But the data proffered by official agencies cannot answer this key question. Their claims are like those of a totalitarian state in which the populace/consumers are not seriously considered.
In the UK, the National Institute of Health and Care Excellence (NICE) guidelines are the ultimate arbiter of physical and mental health care. Failure to comply with them leaves a clinician open to possible legal action. Clinical commissioning groups operate with the belief that the services they fund are NICE compliant; service providers assiduously assert that they are indeed NICE compliant. But it can be argued that, at least as far as mental health is concerned, the NICE guidelines function as a revered cookbook with no evidence of fidelity to the recipes at the coal-face. The guidelines are a committee’s take on good recipes; they represent the committee’s distillation of evidence-based studies. The influence of NICE is, at best, distal.
The Trickling Down of Good Mental Health Provision?
Ultimately, politicians determine what is spent where. But they have no unique body of knowledge with regard to mental health, and are therefore particularly vulnerable to the effects of lobbyists. A politician who takes a particular interest in mental health is likely to appear particularly credible, “one of our own,” even more so if they recruit an eminent, eloquent mental health expert. The politician will likely opine that it’s not necessary to demonstrate to colleagues that a certain mental health modus operandi is evidence-based, simply that it is “plausible” e.g., “investment in psychoeducation in schools (or drop-in centres) will reduce levels of anxiety and depression in adults,” for success.
Whilst politicians in collaboration with charismatic mental health professionals have brought about mental health policy changes, they have shied away from independent mental health audit.
Politicians and professional bodies may also look to government-funded bodies (e.g., the Department of Health in the UK, or National Institute of Mental Health in the US), to take the lead on implementation and monitoring of evidence-based treatments. But they are likely to take action only if prompted. For example, in the UK following the NICE guidelines on chronic fatigue syndrome (2021), the Department of Health began a consultation with a range of professional bodies with at least some stake in mental health, not all of which decided to participate.
Distilling a joint statement in such a context is a monumental task, and important issues can easily be kicked into the long grass. The inclusion of persons with lived experience of mental health problems (including professionals affected by the particular mental health problem) in the deliberations has borne no obvious fruit to date; rather it has become an article of faith that this is the way forward.
The evidence that politicians and professional bodies have aided in the translation of positive results from randomised controlled trials into practice is lacking. One can only guess at why, in the UK, the National Audit Office (NAO) discontinued its investigation into the Government funded Improving Access to Psychological Therapies service. The NAO’s brief is to help Parliament hold the government to account and improve public services.
Determinants of Quality Control
There are five proximal influences on the quality control of therapeutic output: a) the courses accredited, b) external examiners, c) supervision, d) service providers, and e) professional bodies. Individuals often exert their influence simultaneously via a number of routes. But the prime movers across these sources of influence belong to a managerial class. They may micro-manage what happens at the coal-face but they are not visible there. Importantly, they do not assess and treat clients with the limitations of the “coal-miner.” Further, the managers are not involved in research and development on the product.
Considering the proximal influences in turn:
Accreditation of Courses
Most mental health courses are founded on an alliance of stakeholders. Often there is a prime mover in a university department, where the academic part of the course is located. But service providers also have an input, providing placements and would-be therapists with opportunities to hone their skills. Representatives of “lead” organisations also have a say in the accreditation of courses. Thus, the establishment of a mental health course is usually the product of a working alliance of stakeholders, together with a co-opted member of the public with “lived experience” of mental health difficulties.
But the stakeholders have different agendas. The university has a prime concern with the monies the course can generate. The service providers are concerned with reputation management by links with the university, which in turn enhances their ability to secure funding from commissioning bodies (in the UK, Clinical Commissioning Groups). Representatives of lead organisations can enhance their CVs by involvement in the accreditation process. If asked, most of those involved in the accreditation process would probably say they are simply trying to make a difference and, although this is undoubtedly true, it is likely to be only a partial explanation of their behaviour.
The working alliance will likely fracture if one or more of those involved in the accreditation process asks, “what is the level of evidence that this course makes a real-world difference to those on the receiving end of the ‘trained’ therapists?.” If an academic clinician voices such a question he/she may well find themselves deprived of the service providers data; research has to be done within the metrics defined by the latter. Thus, the accreditation process is not a guarantor that the public’s mental health needs will be met.
External examiners are often headhunted by course leaders at professional conferences. Following the old maxim that people only appoint those like themselves, the possibility of disagreements is minimised. The university rests content with a statement from the external examiner that the said course is of the same standard as comparable courses in other academic institutions. Course leaders provide external examiners with a sample of course work to be evaluated with the approved metrics of a professional body. The system is designed to ensure both conformity and uniformity. At best an external examiner may be able to nudge a course in a slightly different direction. I know of no data on the proportion of external examiners who resign before their tenure is completed.
What is the primary purpose of supervision? The response of most professional and would-be professional therapists is “to promote professional development/ growth.” But development and growth to what? Almost a decade ago I suggested the primary purpose of supervision was to act as a conduit for evidence-based treatment. This has been met with a deafening silence. Workshops on supervision have become a rarity: just one at this year’s 50th Anniversary celebration of the British Association for Behavioural and Cognitive Psychotherapies (BABCP). The most common mode of supervision in low-intensity IAPT involves two to three minutes of case discussion per case and is, in effect, managerial rather than clinical supervision.
There are a plethora of service providers, from government backed agencies such as IAPT to charities such as Mind. But the latter ape the former to secure funding. Independent private practitioners engage in a similar form of imitation, in the UK, to ensure funding from insurance agencies like Bupa. They all utilise a meaningless, self-serving measuring tape that has two key features: a) test scores invariably get lower with the passage of time, and b) clients do not wish to be discourteous to their largely well-meaning therapists and oblige by endorsing improvement. Service providers thereby maintain the fiction of recovery.
Bodies such as the British Psychological Society (BPS) validate courses such as IAPT’s low-intensity course. But this was done without any review of empirical evidence, simply at the behest of BPS members who had volunteered themselves for a validating committee. BABCP accredits 60 courses including CBT courses, IAPT trainings, and clinical psychology doctorates, with members invited to join the Course Accreditation Committee. As the self-proclaimed lead organisation for CBT, it dictates how therapists should be assessed with the cognitive therapy rating scale revised for depression, despite therapists not being taught to reliably identify which disorder the person is suffering from. It further runs approved supervision training courses. All this despite a paucity of evidence that clearing the hurdles of BPS or BABCP makes any real-world difference to clients’ lives.
Saying more than is known. This looks very much like an exercise in power.
This analysis gives raise to major questions:
- How do therapists fare at the coal-face? In the UK, 42% of GPs wish to retire in the next five years, which will bring the NHS to a state of near collapse. I do not get the impression matters are any better in the government IAPT service, with most complaining of burnout.
- Is diagnosis the least worst metric for measuring outcome? If, after psychological treatment, a person cannot report, to an independent assessor, that they are either back to their old selves or their best and have been for what they regard as a significant period, it is difficult to see how the intervention can be judged effective. But the answers to these questions would lack credibility if the person had not also lost their diagnostic status according to a standardised semi-structured interview. Without the foundation of the diagnostic interview, it is possible that the reported improvement is simply a reflection of their need to feel that they (and their therapist) have not wasted all their time in going through therapy. So it is not that diagnosis is the least worst metric; it merely enhances the credibility of claims of a real-world gain.
- Should we be using a quality control metaphor? For some, the use of a quality control metaphor regarding psychological therapy is anathema. But there is also a certain poetic licence about metaphor to make a point rather than to be taken literally. It is not at all meant to imply that clients are units of production. My underlying philosophical position is that we are not defined by information processing, but that it is consciousness that makes us human, and bestows our sense of self, purpose, meaning, values, and appreciation of beauty and love. Although these aspects of consciousness have correlates in the brain, they are not synonymous with them. In short, there is mind, not just brain. It is from the mind, rather than the brain, that the two crucial elements of therapy—reverence and honesty—are derived. There is no physical mechanism to generate these.
- Are self-report measures an impression management strategy? We are involved in impression management all the time (e.g., my wearing a tie for an interview when I don’t normally wear one). It is important to bear in mind that self-report measures are an impression management strategy that clients may use not only for others but also for their own sake.
- How well-grounded are alternatives, such as computer algorithms, transdiagnostic conceptualisations, and research domain criteria? It has been suggested that a combination of computer algorithms and key features from a person’s past will better predict who will benefit most from therapy. But, to date, this has not been established. However, it may be that our real interest should be in those who would likely benefit least: the poor, the disabled, etc. Transdiagnostic therapies have only been evaluated by those who have developed them and the field awaits independent replication. Similarly, there is a dearth of evidence that looking at research domains is any more fruitful than utilising diagnostic categories.
- How do we move forward? Psychological therapy needs to get back to basics by listening to clients’ narratives with a sense of reverence before helping them to consider reframing and reimagining their future. But all this must be done with a sense of honesty about the real-world limitations of the client’s actions, and the therapist’s limitations in bringing about system change.
The starting point has to be that clinicians need to engage in mental time travel and recall what made most of them move in the direction of a mental health career in the first place. Most will, I think, answer that it was to make a real-world difference to client’s lives. Then to ask, “in all honesty, am I delivering on this?” If the answer is “no,” there has to be a major rethink—the sense of self is lost by simply escaping into a role.
The rethink needs to include a critique of whether the system within which they are operating is facilitating an encounter with the client in which the needs of the latter are paramount. So that the delivery of therapy is not solely a top-down process determined by powerholders, but also a bottom-up process involving a human encounter. The powerholders may have a unique body of knowledge (for example, about the strengths and limitations of a proposed intervention), but the message of the last decade or so is that they have prescribed beyond their knowledge.
We need to rediscover walking with the client, essentially a pilgrimage in which we are not waylaid by the powerholders. But for any real change to take place, the managerial class have to stop distancing themselves from where the action is and experience what it is like trying to treat people with limited training, performing the administrative tasks deemed necessary, and managing the uncertainty of being sanctioned if targets are not met. Unfortunately, I see no sign of managers getting their hands dirty anytime soon.
A letter in the October issue of The Psychologist rightly draws attention to unacknowledged and pernicious managerialism. The managers need to taste the fare.
Questions to the Health Minister from Dr Scott
[Explanatory note: In the UK, IAPT is the main provider of psychological therapy services in primary care and is free to the public. But there are other providers, such as the charity Anxiety UK, who charge, but on a sliding scale. Whilst they adopt the same assessment/outcome measures, the PHQ-9 and GAD-7, they do not operate a stepped care approach of usually low-intensity therapy first and then, if unsuccessful, high intensity. Most recently, Anxiety UK appears to have outperformed IAPT.]
- The Government Improving Access to Psychological Therapies (IAPT) Service is experimenting with public, direct access to a Psychological Wellbeing Practitioner. But PWPs are not trained in diagnostics, nor are they qualified therapists. Why then are they being given this gatekeeping role?
- The IAPT service has cost billions of pounds since its inception in 2008. Why then has there been no independent audit of the service?
- With regards to physical health, the Government is funding Community Diagnostic Centres; with regards to mental health, why is there no facility for reliable
diagnosis in IAPT?
- With regards to mental health, there is no evidence that those availing themselves of IAPT fare any better than those attending the Citizens Advice Bureaux. What then is the added value of funding IAPT?
- How is the experiment of making PWPs gatekeepers being evaluated and who decided on the criteria?
- IAPT’s claimed recovery rate of 50% has not been independently verified. The independent evidence of an Expert Witness to the Court suggests that, in fact, only the tip of the iceberg recover. Is this not grounds for a publicly funded independent audit?
- How do we know IAPT is value for money?
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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