It is good to know that the Government has pledged increased funding for its Improving Access to Psychological Therapies programme (IAPT); mental health provision in the UK has been woefully underfunded for more than a decade. I am not quite so heartened, however, when reading the small print.

The NHS is committed to providing health provision ‘free at the point of delivery to all people who need it’, but it must also provide cost-effective health provision. Richard Layard’s plan, to use NHS staff trained in brief therapy (CBT), would therefore appear a win-win situation, particularly in the area of ‘mild to moderate depression and anxiety’. But who precisely falls into this category? My understanding is that the mental health issues the Government wishes to address are those that prevent people working and thereby becoming a financial drain on the State. Layard’s plan, by using brief therapy, with its ‘evidence-based outcomes’ is nicely ‘accountable’: budgetary targets are kept in line, people are happily back to work within two months, all is well with the world.

Or is it? Your article quotes Professor Layard as saying: ‘Clients would be referred by GPs, job centres or self-referred, and outcomes would be monitored by asking clients to complete forms at the beginning and end of each session.’ So much in this statement concerns me. The ‘rigorous research’ alluded to in Sarah Browne’s editorial, with its tick-box culture, runs counter to many therapeutic modalities. How does this scientific approach sit with non-hierarchy or systemic therapy, for example?

I have lived in both urban and rural communities and worked in both the state and private sectors. I have trained as a counsellor with independently funded students and attended NHS-funded courses. The vast majority of BACP members practise outside the NHS in what I would describe as the ‘real’ world – inhabited by our clients – with unpredictability of finances, the solitary nature of decision making, and the need to take individual responsibility for our actions. The State would have us ‘comply’ with a central belief system that is easier to manage but human beings are, by their very nature, difficult to ‘manage’. As David Crepaz-Keay is quoted in your article: ‘Clinicians need to remember that users don’t want to become normal like the clinician, they want to become normal like themselves.’

Science, as Peter Fonagy points out, is very humbling, but psychotherapy is about more than science and I am intrigued by the ‘superb scientific presentations on the effectiveness of CBT for anxiety disorders’ mentioned again by Sarah Browne in reference to the recent NHS conference. I am assuming these were properly validated, evidence-based research papers that showed a positive outcome for the majority of CBT participants. I wonder how such research papers accommodate variables such as new friendships, changes in geographic environment, parallel drug therapy, improved physical health, systemic (ie family and work) impacts, bereavement, self selection, drop-out rates, etc. But, of course, if therapy lasts for such a brief period, none of the above can be monitored over time. So how is a ‘successful outcome’ defined? Are we speaking of mild anxieties with no systemic complications? Then I fear we are talking about a miniscule section of society.

Another concern in your article was Louis Appleby’s assertion: ‘CBT therapists who would be employed by these services would inevitably integrate other forms of therapies as needed.’ What exactly does that mean? I am a person-centred/ integrative counsellor but if I consider a client would benefit from systemic therapy or couple counselling or CBT or joining a dance group, I refer on to people with greater experience than myself. There is too much spin and not enough factual evidence or knowledge in these comments and I am reminded of Gerry Robinson’s recent TV programme on the NHS. ‘It is clear’ he said, ‘…that the NHS is constantly making policy decisions and assuming that, once announced, these policies will be put into practice. There is no proper process in place for achieving them.’

Peter Fonagy believes we need ‘a new intellectual framework for psychotherapy’. I disagree. What we need is less scientific intellectualising. This Government is too quick to control every facet of our lives: we are told what to eat, how to think, how to behave, how to parent. In therapy, this would be seen as obsessive, overcontrolling and somewhat dysfunctional.

It is now impossible for us to be non-political in this important debate, particularly for those of us outside the NHS. If, as I suspect, the Layard scheme provides a service appropriate only for the ‘mildly anxious’, then the majority of clients will be left feeling even more inadequate when the CBT doesn’t ‘work’ and too poor to pay for private sessions. What is needed is a ‘third way’ within the ‘third sector’ – a privately funded social enterprise agency that refers clients in an appropriate manner to the right person at the right time.

Above all we must never lose sight of the power of relationships and, as Susie Orbach and Peter Hobson put it: ‘…the need to understand the complexities of clients’ problems, the importance of maintaining a thoughtful approach and keeping central the transformational power of interpersonal engagement.’

Carol Jones
Counsellor