Psychological Therapies in the Modern Era

1. Psychological Therapies in the Modern Era Centre for Psychological Therapies May 19th 2009

2. May you live in interesting times

3. Historical Developments Regulation and Training Practice Research

4. 1. Historical Developments

5. A Developing Profession • Roots in Hindu, Buddhist and Islamic Psychology from 8th Century A.D • Moral Therapy 18th Century A.D • Phrenology the study of the shape of the skull • Physiognomy—the study of the shape of the face • Mesmerism, use of magnets

7. A Developing Profession • Psychology 1879 Wilhelm Wundt the first laboratory psychological research in Leipzig • Group therapy for the poor who could not afford 1 to 1 1908 • Freud “Talking Cure” 1900s • Clinical psychology in 1917 • Counselling Carl Rogers 1940s • Counseling Psychology 1954 • CBT 1960s • Now over 400 varieties (Corsini and Wedding, 2008).

8. Medicalisation of unhappiness or deviancy • For millennia, masturbation, homosexuality etc were considered grievous sins and punished accordingly. • End of the 19th C with the onset of modern psychiatry they started becoming "mental" diseases. • Raised to the level of a psychiatric art form by Baron Richard von Krafft-Ebing (1840-1902). "Psychopathia Sexualis” Sexology became an integral part of medicine - - renaming sexual sins "cerebral neuroses“. • ECT • Drapetomania • Kleptomania

9. Medicalisation of unhappiness or deviancy • Sigmund Freud extended Krafft-Ebing's psychopathologising to everyday behaviour. • In "The Psychopathology of Everyday Life" (1901), he converted Shakespeare's interpretation of conflict as an integral part of life into a manifestation of psychopathology.

11. So in the 21st century is unhappiness a mental illness which can be diagnosed and treated medically….. Or is it part of the experience of life?

12. 2. Regulation and Training

13. HMG • Health Professions Council • British Association for Counselling & Psychotherapy • United Kingdom Council for Psychotherapy • Alliance for Counselling and Psychotherapy

14. HMG Strategy • Skills for Health • NICE National Institute for Clinical Excellence • IAPT Improving Access to Psychological Therapies • Health Professions Council

15. Timeline • HPC Professional Liaison Group: 2 more meetings • Public consultation summer/autumn • HPC report to Government  in December this year • Legislation 2010 • Act of Parliament 2011

17. British Association for Counselling & Psychotherapy • 50k therapists • No controls • Psychological Professions Council • The need to protect the public.

18. Manning signs up as race and sex counsellor Monday, 26 February 1996 “To highlight the lack of regulation for counsellors, the BBC programme Watchdog asked Mr Manning to attempt to join the organisation. He listed his occupation as performer and performance counsellor and for specialities he put down sexual matters and racial awareness. He also claimed to hold an imaginary diploma in counselling and sent off the pounds 50 joining fee. A few days later he was welcomed into the organisation, became entitled to vote at general meetings and could be listed in its directories. “

19. Recognizes the need to regulate, self-regulation, preferred  Needs to be attuned to relationship  paradigm... not medical competencies etc Not medical model Art  not science HPC regulation not in keeping Different values & Philosophical model Creative and sometimes spiritual dimension..... How can that be subjected to regulation ? UKCPRadio 4 Interview 30th May

20. HPC Professional Liaison Group • Standards of Proficiency (SoP) Differentiation between psychotherapists and counsellors. • Protected Titles. • Grandparenting. • http://www.hpc-uk.org/aboutus/professionalliaisongroups/psychotherapistscounsellors/

21. Health Professions Council Public Liaison Group 29 April 2009 • That psychotherapists work with more complex clients than counsellors. • That only psychotherapists "critically evaluate" and counsellors do not. • That psychotherapists have a more advanced understanding and use of research. • http://www.bacp.co.uk/regulation/

22. HPC & Training • Counselling Honours Degree (and PG) • Psychotherapy Postgraduate • Current courses to be visited by HPC • Consideration of non-HE courses

23. HPC & Training • ‘Standards of proficiency’ (SOPs) as opposed to 'training standards‘ • Not Modality based • Requirements for therapy, hours of practice, hours of training will not be fixed by HPC • Courses to demonstrate how SOPs are met.

24. Alliance FOR Counselling and Psychotherapy Against State Regulation • Medicalisation • Reducing access to relational therapies • Reducing client choice • Protecting the Public Myth • Human science versus natural science • Art not Science

25. Alliance FOR Counselling and Psychotherapy Against State Regulation • Therapy is not about healthcare. (Approx 33%) • All current bodies have codes of ethics and practice, disciplinary procedures etc.

26. Alliance FOR Counselling and Psychotherapy Against State Regulation Brian Thorne: “To subject therapists to statutory regulation has about the same incongruity as putting ballet dancers under the direction of a regimental sergeant major ….are likely to emerge at best as stilted robotic puppets or at worst as crippled casualties with snapped tendons, their vocational aspirations in tatters”

28. Alliance FOR Counselling and Psychotherapy Against State Regulation We are involved in a battle which is about power, freedom , transformational love and the evolution of the human spirit.

29. Politics

30. 3. Practice

31. ImprovingAccess to Psychological Therapies (IAPT) The Improving Access to Psychological Therapies (IAPT) programme is based upon the commitments the Government made in their General Election manifesto 2005. The programme was launched in May 2007

32. ImprovingAccess to Psychological Therapies (IAPT) Counselling and psychotherapy more cost-effective way of relieving anxiety and depression than medication, but only one type of therapy –CBT – has proved its effectiveness in Randomised Controlled Trials. This has divided the profession as modalities such as psychoanalysis and person-centred counselling – many of whom work in the NHS – have felt excluded. IAPT’s choice of modalities is informed by research collated by the National Institute for Health and Clinical Excellence (NICE).

33. Therapy is cheaper than medication. But will one washing powder suit all ?

34. Treatment Choice in Psychological Therapies and Counselling Evidence Based Clinical Practice Guidelines depression, including suicidal behaviour, anxiety, panic disorder, social anxiety, phobias, post traumatic disorders, eating disorders, obsessive compulsive disorders, personality disorders, including repetitive self harm some somatic complaints

35. Recommendations • “Effectiveness depends on forming a good working relationship. • Age, sex, social class or ethnic group should not determine access to therapy. • Therapies of fewer than eight sessions are unlikely to be effective. Often 16 sessions are required for symptomatic relief, and more for lasting change.”

36. Recommendations Severe and complex mental health problems or personality disorders or co-existing personality disorders Patient preference and treatment choice Interest in self-exploration and capacity to tolerate frustration in relationships important for success in psychodynamic therapies.

37. Recommendations • Psychological therapy should be routinely considered. • Patients who are adjusting to life events, illnesses, disabilities or losses. • Post traumatic stress symptoms may be helped, with most evidence for CBT

38. Recommendations • Depression • Anxiety disorders • Somatic complaints

39. Recommendations • Eating disorders • Anorexia • Longer-term treatment of personality disorders

40. Evidence • Psychological therapy better than no treatment. • Counselling effectiveness in mixed anxiety/depression. • CBT has been found helpful. Evidence of efficacy has been shown for other forms of psychological therapy.

41. Evidence • Efficacy of CBT and IPT in bulimia has been established. Various therapies have shown benefit in anorexia, with little to distinguish types. Early onset of anorexia may indicate family therapy, and later onset, broadly based individual therapy. • A number of approaches have shown some success with personality disorders, including dialectical behaviour therapy, psychoanalytic day hospital programme and therapeutic communities.

42. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007323http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4007323

43. Rebuttals • Mollon, P (2009) The NICE guidelines are misleading, unscientific, and potentially impede good psychological care and help. Psychodynamic Practice,15:1, 9-24.

44. Improving Access to • Psychological Therapies • Implementation Plan: National • guidelines for regional delivery • http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083150

45. Teams of therapists • 40 trained therapists per population of 250,000 • Therapists as part of a single team, led by senior therapists. • Team members will need to be qualified in the therapy they are delivering – anything less involves risks, since inappropriate therapy can do harm.

46. Low-intensity treatment • For depression, a system of stepped care is recommended. This is described as low-intensity treatment. This may take the form of guided self-help (which can be delivered over the telephone) or brief face-to-face psychological interventions (up to seven sessions). It can also include guided use of computerised CBT

47. High-intensity treatment • “A person who is severely depressed or does not respond to low-intensity treatment needs high-intensity treatment involving up to 20 therapy sessions, normally on a face-to-face basis.”

48. High-intensitytreatment • “For some anxiety conditions, such as PTSD, phobia or OCD , patients normally go straight to high-intensity treatment ( 7 to 14 sessions) Recommended for other persistent anxiety disorders but guided self-help (e.g computerised CBT) has been shown to be effective for some individuals.”

49. “Present shortage of therapists is in CBT, which will be the most widely used therapy in the new service. Initially, therefore, IAPT training will focus on CBT. The focus will broaden as the deficit is addressed and the NICE guidelines are reviewed.”

50. IAPT TRAINING • “Trainees in high-intensity therapy are likely to be drawn from clinical psychology and psychotherapy, as well as people with experience of mental health, such as nurses, counsellors and other professional groups. • They will need a one year course involving up to two days a week (equivalent) off-the-job training in a training institution, with the rest of the week working in an IAPT service providing therapy under supervision.”