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• A Statement of Intent from the Government presented at the Psychological Therapies in the NHS conference last month, pledged to tackle the stigma which often stops people with common mental health problems from seeking treatment; to ensure services offer a choice of evidence-based interventions; and to develop services around the needs and wishes of the individual.

  This was good news for those of us who have been concerned about the direction in which the Improving Access to Psychological Therapies (IAPT) programme has developed since it started in 2006. One conference delegate described the programme as a ‘juggernaut’ that was obliterating integrative work and replacing it with CBT. So it was reassuring to hear speaker after speaker, from Richard Layard to Louis Appleby (National Director for Mental Health in England), stress that CBT is not the only thing in the National Institute for Health and Clinical Evidence (NICE) guidelines and we should be offering patients all the evidence-based therapies recommended by NICE (see page 40). ‘When you look at the complexity of people’s lives, how could one therapy be of benefit to all of them?’ said Appleby.

  There was broad recognition from those who have worked within an IAPT service so far that there are patients who don’t want CBT, that cases are not always straightforward, and that an effective service needs to be flexible and creative and incorporate a range of therapies. However, it was sobering to notice that in a debate between Steve Hollon (Professor of Psychiatry and Human Development, Vanderbilt University) and Bruce Wampold (Professor of Counselling Psychology, University of Winsconsin-Madison) – ‘Is it the treatment or the therapist that works?’ – Richard Layard and David Clark, Clinical Advisor to the IAPT programme, were in a minority voting in favour of the treatment.

  Patient choice
  It will be written in the NHS constitution that patients have a right to a choice of NICE approved therapies, said Secretary of State for Health Alan Johnson. This will be a very powerful tool for patients. There was some interesting debate around what patient choice really means in practice. Are we talking about a choice of therapist or therapy? Would some patients want to make a choice around gender, age or race of therapist? One delegate told a moving story of an African man who went to his doctor in great distress and insisted that he needed to see a spiritual healer. Diane Waller, President of the British Association of Art Therapists, pointed out that people often make choices that are bad for them. And asked why, in increasing numbers, do people choose alternative therapies for which there is so little evidence? On the other hand, while a greater range of therapies will be on offer, we have to accept that some patients will choose drug treatment over any psychological therapies.

  One speaker who had suffered from OCD said that choice of treatment was important later on but when you first have a problem you are desperate and not in a fit state to make an informed choice. Results from the 11 IAPT Pathfinder sites show that a third of patients felt that they were not given enough choice and were being asked to make a choice too early. Sir Mark Waller of the Charlie Waller Memorial Trust said that all therapists have their own agenda and patients who are not in a position to make any meaningful choice, need to be better informed. It was also acknowledged that within the IAPT services, staff in charge of allocating clients for different treatments should not be the least experienced people, as has been the case in some services to date.

  NICE guidelines
  Various attempts were made to justify the dominance of CBT within the programme. ‘The NICE guidelines weren’t meant to be restrictive,’ said Appleby. ‘The reason CBT has been at the forefront of IAPT is because it has demonstrated its effectiveness so well.’ It was in CBT that there had been the greatest need, said Head of Adult Mental Health Policy Kathryn Tyson, which is why all the training had initially been focussed on CBT. In the next phase training would be developed for other NICE approved interventions.

  Whether or not clinical guidelines can be credible and useful was hotly debated. Guidelines had originally come into being in the 1990s, said Simon Gilbody, Professor of Psychological Medicine and Health Services Research from the University of York, because of the failure to turn research evidence into clinical practice. This is mainly due to the reductionist process by which they are produced, said Glenys Parry, Professor of Applied Psychological Therapies at the University of Sheffield; guidelines on their own don’t work. Others complained that they are written in a restrictive and dogmatic way, are not inclusive, and could ‘seriously damage your relationship with your commissioner’. But Richard Layard pointed out that the only reason the IAPT programme exists at all is because of the NICE guidelines – its raison d’etre being to deliver what they recommend.

  Mental health stigma
  As Vice President of BACP, Sandi Toksvig, who received the Statement of Intent at an evening reception on behalf of the professional bodies, said: ‘Today’s commitment to broaden choice is about the best news for the health of this nation for a very long time.’ Also speaking in support were Alastair Campbell who read an extract from his new novel All in the Mind, and spoke movingly about his own experience of needing therapy, and Greg Beales, special advisor to Gordon Brown. Because of the economic downturn, said Beales, getting these services up and running and responding quickly to patients is even more important. In the 80s and 90s, he said, we left a whole swathe of people to drift out of the workplace, some of them never to return. He agreed that the vast majority of us have experience either ourselves or in our families of mental health problems, and the campaign to fight stigma was crucial.

  Alan Johnson echoed this by saying that mental health problems needed to be recognised as a normal part of life, and employers needed to get much better at identifying them. Long-term unemployment should carry its own health warning, he said, although this was not about forcing people back into work. Next year the Government will be investing in public awareness campaigns with two groups, Time to Change and Shift, to destigmatise mental illness.

  ‘Our time has come,’ said Paul Farmer of Mind, ‘because people like Alastair, Sandi and others are prepared to stand up and talk about mental illness and because we have an unprecedented level of co-operation in working together.