Psychotherapy and the NHS: time for a rethink?

In the early 2000s I spent three years working as an honorary psychoanalytic psychotherapist in an NHS mental health trust as part of my analytic training. Back then, this was the time-honoured route to becoming a psychotherapist. What was particularly interesting about this experience was that I saw my first patient for three years and the second one for two.

Nowadays this would be unheard of! Instead, anyone being referred for ‘talking therapy’ on the NHS is likely to be seen for six sessions or so. I know this not only from the data1 but also because, in 2010, I was involved in helping to set up a psychological therapy service in the south-east of England as part of the Improving Access to Psychological Therapies (IAPT) programme.2 I also became very familiar with the idea of the six month (or more) waiting time for those six sessions (although to be fair things have improved on that front), and the fact that what had once been a very intimate relationship between two people had now become a mechanistic and bureaucratic process – and on an industrial scale.

However, my real point is not to criticise IAPT per se, but rather to suggest that the price that has been paid for this service is the steady decline of long-term psychotherapy in the public sector. By ‘long-term psychotherapy’ I’m referring to approaches that place the dynamics of the therapist-patient relationship at the heart of the work and which focus on working with a patient’s symptoms rather than trying to remove them. And in case anyone thinks this idea is so (early) twentieth century and that things have ‘moved on’ to the brave new world of cognitive-behavioural therapy (CBT), I suggest they take a look at Oliver Burkeman’s article on psychoanalysis and CBT.3 It seems that perhaps Freud was on the right side of history after all.

But why ‘long-term’? Surely, if someone can be ‘cured’ in half a dozen or so sessions, so much the better, especially if it’s tax payer’s money that’s funding it? The problem, however, is that, in the long-term, such ‘quick fixes’ simply don’t work. As Burkeman points out in his article, although CBT (which is still by far the predominant therapy offered in IAPT) can produce good results in the short-term, over a longer period it’s the more exploratory approaches, such as psychoanalytical psychotherapy, that have lasting effects. To put it rather crudely, the more time and effort one invests in therapy the more one gets out of it.

This brings me to another irony: although it is becoming increasingly difficult to receive the kind of long-term therapy on the NHS that I’ve just described, there are plenty of people who can offer it. In fact, there are over 50,000 therapists who are registered with one or more of the three main professional psychotherapy bodies: the UKCP, the BACP and the BPC. However, there is just one small problem: most of these practitioners work privately, and therefore money starts to become an issue, especially if we are looking at months or even years in therapy.

I say ‘problem’, but according to some research carried out by the UKCP and BCP an increasing number of patients are voting with their feet and going private.4 The same research also highlights the steady decline of NHS-funded long-term psychotherapy. However, by ‘private’ we are not talking about the Virgin Care’s of this world, who are too busy providing IAPT services on behalf of the NHS (the supreme irony, I know), but predominately single-handed practitioners who work from home or hire a room in a local health or therapy centre. However, these are all trained, qualified and often very experienced therapists who receive regular clinical supervision and work to a strict code of ethics.

Bearing in mind that approximately one in four people in the UK are likely to experience some kind of mental health difficulty in the coming year,5 and that in spite of its most valiant efforts IAPT is still only scratching the surface with regards this problem, perhaps it’s time to start seriously thinking about how this army of 50,000 could play a much more active role in the mental health of the nation.

Of course, there are a number of practical and, perhaps more significantly, ideological hurdles to overcome.  Is it a question of the NHS sub-contracting private therapists (as they currently do with GPs6)?  If so, this then raises all sorts of questions regarding accountability, power and control.  Or is it more about raising public awareness that there is an alternative to long waiting lists for brief therapy?  Of course, this then raises the spectre of the private sector becoming involved in the provision of mental health care.  The irony here, of course, is that many of the determinants of good mental and physical health and wellbeing are effectively linked to the ability to pay, i.e. good housing in a pleasant environment, membership of good fitness or sports club, a good diet, a good education, etc, etc.

And as I mentioned earlier, we are not talking here (in most cases at least) about large corporate providers, but rather dedicated, well qualified and experienced individuals who want to do the best for their clients.  The tragedy is, as highlighted in the UKCP/BPC report, many practitioners now feel they are unable to provide this kind of service within the NHS.

  1. http://digital.nhs.uk/catalogue/PUB20519 []
  2. http://www.iapt.nhs.uk/ []
  3. https://www.theguardian.com/science/2016/jan/07/therapy-wars-revenge-of-freud-cognitive-behavioural-therapy []
  4. https://www.bpc.org.uk/sites/psychoanalytic-council.org/files/PublicPsychotherapyProvision-FINAL-WEB.pdf []
  5. https://www.mentalhealth.org.uk/publications/fundamental-facts-about-mental-health-2015 []
  6. I’m not sure if many people realise that a large number of GPs in the UK are essentially in private practice []