Waft, Y., 2011. Is CAT in danger of being squeezed out of the NHS?. Reformulation, Summer, pp.18-21.
At the time of writing, there is considerable change taking place within the United Kingdom’s National Health Service (NHS) and there are moves afoot which may threaten the freedom of psychological therapists to use the full range of therapeutic approaches that have been available in the past. With the move towards healthcare Trusts taking on Foundation Trust (FT) status, healthcare commissioning is becoming increasingly based on business models and cost/benefit analysis. I work in a secondary care Adult Psychological Therapies Service (APTS) in the North of England and I am just in the process of completing my CAT Practitioner training. In my own Trust and in others locally, I have recently been hearing client groups referred to as “product lines” and services as “business development units”. Whilst this business model might make some sense in some areas of healthcare, it is harder to apply to psychological therapy where we are working with very distressed people who often do not sit neatly within any particular diagnostic criterion. This article will argue that the current model for evaluating and recommending treatment, based on the NICE guidelines, is not well suited to mental health, over-values one particular model of therapy above others, and could, if left unchecked, restrict the development and use of other models of therapy, such as Cognitive Analytic Therapy (CAT). I will use some reflections from my own experience of how CAT fits in to the service I work in, and will consider ways of ensuring that CAT has a future in the NHS.
My department is physically based within the local mental health hospital but really there are few links between us and other parts of local mental health services. Certainly at the level of day to day therapy work, we are very much working in isolation. We have limited contact with local Community Mental Health Teams (CMHTs). Organisational changes have been on the table for years now and for various reasons have been repeatedly put on hold. This has resulted in a lack of clarity about roles and a lack of communication between departments. There is a strong sense of teams marking out and protecting their territory, rather than working together in the best interests of service users. However, in some ways, the stagnant and territorial context works in our favour. While we are mopping up the clients no-one else will accept and keeping our heads down, getting on with therapy as best we can, no-one is scrutinising our work too closely or querying our therapeutic approaches. Lots of people are getting therapy and many of them are happy with it and make clinical gains and at the present time that seems to be enough for our commissioners and managers. CORE forms coming back post-discharge seem to show good enough improvements and good enough satisfaction. Despite our frustrations with the organisational inertia and the difficulties of doing therapy in isolation, we are in quite a privileged position. We are able to offer a range of therapeutic models including approximately one psychodynamic therapist, one gestalt psychotherapist, two integrative therapists and myself as a nearly qualified CAT practitioner in addition to having approximately 2.5 people working in a predominantly CBT way. We are able to use our clinical judgement and case discussion meetings to assess who will benefit most from which type of therapy, using the NICE guidelines as just what they are, “guidelines”. This gives me the freedom, for now at least, to use CAT as and when it seems appropriate with individual clients. Within my service all approaches are valued and my CAT training was supported as a way to increase the diversity of what we can offer.
However, how long this status quo can be maintained is an anxiety on everyone’s mind. With the coalition Government wanting to make its mark and reduce costs, and with Foundation Trust status now in place and new roles being created within the Trust to implement the new business model, anxiety continues to build in my service about the future of psychological therapy services locally.
The NHS has always been cost-conscious: there is always more that could be done, more that could be offered to people. As healthcare has developed since the birth of the NHS 60 years or so ago, costs have spiralled as newer more expensive treatments and technologies become available and more conditions become treatable thanks to research and innovation. The result is that the question of how to manage healthcare costs has increasingly become a major political issue, a vote winner or loser, and overall a political hot potato. The general move towards Foundation Trust (FT) status forces healthcare Trusts into working in competition with each other and with private enterprises, striving to meet targets and win patients over from other Trusts and organisations. The targets we are faced with are informed more by political than by clinical motivations. In psychological therapy services we are often working with some of the most distressed, most difficult to help people in the healthcare system. These people’s difficulties do not lend themselves well to meeting Government targets because the small gains they may make in therapy are hard to achieve and hard to quantify, creating a danger that Trusts will focus their efforts, and indeed their resources, in areas where greater returns can be demonstrated. This could leave vital services under-resourced and some of the most vulnerable people in society without the support they need.
The increasingly “market” orientated health service in the UK has seen whole services being put out to tender in the private sector, not just housekeeping services and catering, but actual clinical services. It remains to be seen how successful this approach to healthcare delivery is, but anecdotally I have heard of more than one instance of unacceptable shortcomings in the services delivered by private providers that did not live up to the promises of their original tenders. Whatever the shortcomings of the market model of healthcare delivery, one impact it has had has been the drive for clearly evidenced, quantifiable, package-able care that is simply not suited to most types of psychological therapy (Feltham, 2005). A medicalised model of diagnosable conditions, treatable by measured doses of therapy, with clearly quantifiable outcomes is a far cry from the reality of secondary care adult mental health work, where people present with complex, co-morbid conditions and varying degrees of capacity to engage in therapy and benefit from it. It is overly simplistic to imagine that psychological therapy can be reduced to a set of measurable techniques in this way (Dyer, 2008). Certainly, in the service where I work, we would rarely see a client with a “straightforward” diagnosis where we could determine at assessment how many sessions and what sort of therapy to prescribe with any degree of confidence.
This medicalisation of psychological therapy is also evident in the way the Government is trying to manage quality in healthcare through the NICE guidelines. Feltham (2005) argues that the field of mental health and psychological therapy is too varied and complex to be amenable to medicalised methods of diagnosis, treatment and evaluation. NICE guidelines are based on a hierarchy of types of evidence, with the best evidence being from meta-analysis of randomised controlled trials (RCTs), then individual RCTs all the way down to individual case studies. Traditionally it has been difficult to carry out the kind of research that NICE value in the field of mental health and psychological therapy due to the complex, pluralistic nature of the field (Feltham, 2005). Mental health is not as easily defined as physical health, and therapy contains many factors that are difficult to control for (Dyer, 2008). Some types of therapy have been more amenable to this model of research than others and this has led to an over-representation of Cognitive Behavioural Therapy (CBT) in the NICE Guidelines at the expense of other models which have also been shown to work but not through the extensive use of RCTs (Russell, 2009). At present the NICE Guidelines do seem to be being treated mainly as guidelines and not as governmental prescription in the UK, but Feltham (2005) fears that we could soon see a move towards more prescription as has happened in the USA. We are already seeing this move in the way primary care mental health services are being delivered through the “Improving Access to Psychological Therapies” initiative (IAPT). Substantial amounts of funding have been poured into developing IAPT services across the country offering strictly prescribed therapies based on NICE guidelines for common mental health problems. Those of us working in secondary care services may view this as the tip of the iceberg and fear that if guidelines were to become more prescriptive across the board it would allow commissioners of our services to dictate much more specifically what treatments they are willing to fund and thus limit innovation and clinical judgement in the provision of therapy more generally (Dyer, 2008). This would ultimately have the effect of stopping the use, development and evaluation of any therapy that had not already been approved and would be highly detrimental to both clinicians and service users (Adams, 2008). In this context, CAT could indeed be under threat along with any therapy that cannot easily ally itself to the CBT model.
A careful reading of the NICE Guidelines for most adult mental illnesses (as defined by NICE) shows that after psychotropic medication, CBT is the main recommendation for most conditions. Pharmacological treatments and CBT are the only recommendations for anxiety, depression, bi-polar disorder and obsessive compulsive disorder (OCD), although the guideline for bi-polar disorder does also mention that family interventions can be helpful. The guideline for OCD explicitly states that if a client requests an alternative therapy “they should be informed that there is as yet no convincing evidence for a clinically important effect of these treatments” (p234 of the on-line document). This could place clinicians in a difficult situation if they offered an alternative such as CAT and the client later made a complaint about the therapy. Where CAT is specifically mentioned in the NICE Guidelines it is in the context of a number of therapies having been considered and there being a “weak” evidence base for any of them. For example, CAT is mentioned as a possible therapy in the guidelines for Anorexia Nervosa and Borderline Personality Disorder but is not strongly recommended for either as the evidence does not come up to the standard that NICE requires. So overall CAT is poorly represented in the NICE Guidelines and there is a lot of work to be done if CAT is to compete with CBT in terms of gaining recognition in this context.
Adams (2008) argues that NICE Guidelines are in fact misleading, as therapies are not necessarily very easy to classify or identify. For example, CBT means many different things to many different practitioners, and what is delivered in any particular clinic may be very different from the treatment studied for a particular piece of research which is reported in the NICE Guidelines. It is likely, therefore, that of the many pieces of research studied for the NICE Guidelines all of the ones reporting on “CBT” may have, in fact, been using quite distinctly different models within a CBT framework, so may not be as clearly comparable as would at first appear. This calls into question the fundamental validity of the evidence base.
The current preoccupation with CBT is very much based on a medicalised model of mental health, which locates disorder within individuals and ignores the context in which their difficulties have emerged (Coles, Diamond and Keenan, 2009). This is a significant weakness of CBT and, where there are complex contextual factors maintaining a person’s difficulties, CBT may not be the most appropriate therapy to offer. Whilst in a research trial it is possible, and indeed preferable, to carefully select participants whose circumstances are less complex, in a secondary care adult mental health service this is not remotely possible and the majority of clients will have far more complex difficulties than the majority of research participants in the trials that appear to have shown CBT to be such a wonderful panacea. It is vital that those writing policy at Department of Health and NICE have some awareness of the realities of delivering mental health services in real life, rather than relying on artificially created research situations that do not reflect the realities clinicians are faced with (Harrison and McGoran, 2008).
I have heard of services where there is a growing requirement to use ICD-10 diagnoses to categorise clients and deliver the recommended therapy as per NICE Guidelines. In secondary care adult mental health we see a large number of people with some degree of personality disorder, most commonly Narcissistic or Borderline PD. ICD-10 does not even include Narcissistic PD, so clients presenting with features of that diagnosis are at a disadvantage in accessing the appropriate care, they may be categorised simply as “dysthymic” and be referred for CBT, which is not an evidence based treatment for Narcissistic PD, so may at best be unhelpful for them. They may then be referred on internally to the CAT team as “the sort of tricky client CAT seems to work with”, but with no resources following them as they do not have a “valid” diagnosis and as such there is no clearly evidence based treatment for them. So from a service point of view it is clear that CAT is needed and useful, but from a commissioning point of view it is rather invisible whilst, on the other hand, CBT is seen as the evidence based treatment for everything, without properly defining what sort of CBT. So for example, people with Borderline PD type presentations have been shown to do well with Schema Focused CBT, which is a very specific model of CBT with its own particular requirements. However, in some areas this has been translated by commissioners as straightforward CBT for Borderline PD. This means that CBT therapists end up being expected to provide a service beyond what they were trained for with clients who are unlikely to do well with the brand of therapy they are receiving and then they are referred on for CAT, again without the resources following them.
Clinicians working within a CAT model would argue that CAT is far better at addressing the complexities of clients’ real life difficulties and the contexts in which they occur than CBT is. There is now a growing evidence base that is beginning to bear this out. Quraishi (2009) sums up the evidence and provides a brief critique of it, identifying a handful of RCTs (Treasure et al, 1995; Dare et al, 2001; Chanen et al, 2008; and Fosbury et al, 1997); a couple of comparative studies (Brockman et al, 1987; Marriott and Kellett, 2009; and Bell 1996); a couple of evaluations of the effectiveness of CAT (Ryle and Golynkina, 2000; and Dunn et al, 1997) and several smaller case studies. The evidence is encouraging: it shows us that CAT works and some of it shows us why and how it works and even that it sometimes works better than other types of therapy. The problem is that it is not enough. To demonstrate effectiveness in a way that meets the criteria for inclusion in the NICE Guidelines, there need to be far more high quality RCTs with large numbers of participants. This largely discounts the majority of the research that has been done and makes an almost impossible demand on the small number of CAT practitioners working in the field to carry out complex research. However, there is a further dilemma here: for example if one were to try to carry out a randomised controlled trial of CAT for OCD, according to the NICE Guidelines as they stand, the participants would have to be told that the CAT has no evidence to suggest it might work. This would hardly help to engender hope or belief in the model and might lead to poorer engagement in the therapy, thus skewing the results. So not only is it difficult to carry out research in the first place, the way research is being directed by the demands of NICE Guidelines creates additional difficulties and limitations on the research that can be done.
CAT was devised by Tony Ryle in the 1980s to provide a time-limited, collaborative therapy that would be ideally suited to NHS practice in the UK (see e.g. Ryle, 1991). Done well, it should provide a more cost effective therapy and allow larger numbers of people to be treated for psychological distress than many of the longer term therapy models would allow. Also, by paying close attention to the dynamics of the therapeutic relationship, CAT may be more successful with clients who have interpersonal difficulties than models of therapy that focus solely on cognitive and behavioural symptoms. For all these reasons CAT appears to make good economic sense in a healthcare climate driven by costs and targets.
As Adams (2008) points out, NICE was designed to evaluate medical interventions, such as drug treatments, which require large scale RCTs to ensure efficacy and safety, whilst psychological therapies tend to be developed through innovation in practice and practice based evidence without the aid of millions of pounds of drug company funding. In this context it is nigh on impossible to get innovative therapies recognised and NICE needs to develop a way to formalise innovation so that therapies with less of an evidence base are not wrongly discredited. It is important to get the message across to policy-makers that weak evidence is not evidence of weakness but of ill-fitting research instruments; and that evaluating psychological therapy requires a different set of processes to evaluating medical interventions.
In the rather threatening context of NICE Guidelines and the potential stunting of any development in therapeutic endeavour we could be pulled into a number of reciprocal role procedures that may or may not help our cause. I have drawn on an article by Jones and Childs (2007) to think about how this may affect us. We may feel ignored and unvalued by “the powers that be” (Managers, Trust Boards, Commissioners, Policy Makers) making us feel it is pointless to bother trying to be heard, so we do not speak out and continue to be ignored, confirming our sense of being ignored and unvalued. Feeling controlled by “the powers that be” we may feel torn between the roles of compliant underling or rebellious voice in the wilderness, neither of which position affords us the assertive voice we need to make a difference to the process of change. Alternatively, feeling threatened and defensive about our position, we may strive to prove our worth by engaging in a process of trying to create the evidence base that will prove our value, but the difficulties of trying to conform to a model of evidence that does not really fit what we do makes this endeavour too hard for many of us, so we give up and remain feeling threatened and defensive. This begins to feel like a hopeless cause, a set of target problem procedures with no easy exits, but as Jones and Childs (2007) argue, there is an exit to be discovered and it involves dialogue. There are two possible ways forward here - dialogue with like-minded colleagues and special interest groups can help us to feel supported in our struggles and give weight to the arguments we wish to make; whilst dialogue with “the powers that be”, through taking part in debate and consultation at all levels may just get our voice heard more clearly (Jones and Childs, 2007).
In addition to creating and engaging in dialogue, we can also use CAT to demonstrate its own usefulness at local levels. For example, using CAT as a tool for consultation to support colleagues in inpatient, community or primary care settings can be a powerful way to gain allies, as colleagues who feel helped and supported will ask for more. Last year I attended a training day on using CAT in consultation, presented by Angela Carradice and Dawn Bennett. It was an inspiring course and particularly helped me to see that even though there is very little CAT happening in my Trust at the moment, there are still ways that I could start to encourage interest in CAT. I hope that by drawing on their model I might be able to develop more support for CAT and carve out more of a niche for myself within the Trust as a provider of CAT.
CAT was specifically designed to be a therapy that met the needs of a financially stretched NHS in the UK. It has grown and developed over a period of 30 or so years to be a well respected model, with a substantial following of therapists trained in the model and practising it in their daily work. Research has been done which shows CAT to be a useful therapeutic model, in particular helping with some of the most “hard to help” clients, such as those with Borderline or Narcissistic Personality Disorders. However, the difficulties of carrying out research into any psychotherapy, combined with the relatively small number of potential CAT research therapists, means that the evidence base is not vast and much of it consists of small scale, or single case studies, which carry little weight in the context of the NICE Guidelines. Conversely, the evidence for CBT seems incontrovertible if the NICE Guidelines are to be read uncritically. CBT as a therapy lends itself more readily to manualisation and evaluation. Consequently, the evidence base for CBT has come to dominate the field, giving a false impression of the efficacy of CBT and leading to its adoption as the treatment of choice for most mental illness according to the NICE Guidelines. As Tony Ryle points out, “Turning statistical associations into prescriptions and policies is definitely not NICE!” (Ryle 2002). If CAT is to survive in the current, market-driven NHS and in the context of CBT being promulgated as a panacea for all ills, a number of strategies need to be employed. Work does need to continue in building an evidence base for CAT, but we need to be wary of reacting to the pressure of this demand and striving to prove our model at all costs. Our first priority should always be the best interests of our clients, and carrying out research may not necessarily be the best way for some of us to meet these conflicting demands. We also need to be careful of getting pulled into reciprocal roles of feeling “controlled” or “ignored and devalued” by “the powers that be”; rather we should be getting involved in dialogue with like-minded colleagues and developing networks of support. At the same time we should be engaging in dialogue with managers, commissioners and policy makers at all levels to advocate for CAT; to point out the shortcomings of the “healthcare economy” approach to commissioning in mental health; and to point out the limitations of the medical model of evaluation being applied uncritically to psychological therapies via the NICE Guidelines.
There is a danger that if left unchecked and unchallenged, the move towards a prescriptive NHS culture based on a flawed interpretation of the evidence base could well squeeze out not only CAT but a number of other therapies that offer our clients far more than CBT alone can offer them. Where that would leave CAT, only time will tell.
Yvonne Waft is a clinical psychologist working in an NHS secondary care adult psychological therapy service, where she has been for about 4.5 years. She has completed CAT training and is currently still working through her supervised cases. She can be contacted via email: firstname.lastname@example.org
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NICE Guidelines downloaded on 23rd March 2010 from the following webpages:-
http://www.nice.org.uk/nicemedia/pdf/cg022fullguideline.pdf - Anxiety
http://www.nice.org.uk/nicemedia/pdf/cg022fullguideline.pdf - Antisocial PD
http://www.nice.org.uk/nicemedia/pdf/CG38fullguideline.pdf - Bi-polar disorder
http://www.nice.org.uk/nicemedia/pdf/Borderline%20personality%20disorder%20full%20guideline-published.pdf – Borderline PD
http://www.nice.org.uk/nicemedia/pdf/Depression_Update_FULL_GUIDELINE.pdf - Depression
http://www.nice.org.uk/nicemedia/pdf/CG9FullGuideline.pdf - Eating disorders
http://www.nice.org.uk/nicemedia/pdf/cg031fullguideline.pdf - OCD & BDD
http://www.nice.org.uk/nicemedia/pdf/CG026fullguideline.pdf - PTSD
http://www.nice.org.uk/nicemedia/pdf/CG82FullGuideline.pdf - Schizophrenia
http://www.nice.org.uk/nicemedia/pdf/CG16FullGuideline.pdf - Self-harm
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