Ryle, A., 2002. CAT and the NHS. Reformulation, ACAT News Spring, p.x.
In 1950, national servicemen returning to civilian life received a demob suit and the following letter about the NHS:
Alas, this was never entirely true and was least of all true about mental health and within that least of all true about psychological treatments. But there have been many developments and many more are on the way.
In reviewing today’s topic I can to some extent draw on my own experience of the past 50 years to provide the historical context. The need for the NHS had been established by the gross pre-war inadequacies and by wartime experience of absenteeism and military casualties due to physical and psychological causes. After the war, the importance of psychological factors was highlighted by the psychological consequences of social disruption due to rehousing - the so-called "new-town neurosis" – and by the fact that the GP lists now included whole populations and provided a basis for prevalence studies, one of which I carried out.
In co-operation with a psychiatrist and a social worker, I conducted a survey of 112 families with primary school aged children on my GP list in Kentish Town. This provided evidence for high rates of emotional disturbance in the parents and their children; these were not formally mental illnesses but represented complex problems of living and longstanding personality and relationship difficulties. Parents’ adverse childhoods, their current symptoms and poor marital relationships were all associated with disturbance in children. The conclusions of the study were that the damage caused by adverse childhoods was potentially preventable and reparable but it was clear that resources would never be enough to provide individual therapy for all in need. We proposed that therapy might be best focused on young adults, with a family casework service located in GP treating children and couples. We suggested that the therapeutic role of psychiatrists (there were virtually no psychotherapists in the NHS at the time) should involve spreading psychological understanding to other professions, adding "Before the psychiatrist can accept this role, he himself may have to lose some of his own preoccupations … for the roots of psychiatry in medicine make situations other than the structured doctor-patient pair unfamiliar and at times threatening."
During the first 25 years of the NHS there was a slow growth of resources for psychological treatments, although much was still concentrated in London and a few other centres. Psychoanalysis remained largely confined to the private sector but psychodynamic psychotherapy, Group Analysis and therapeutic communities became available in more places and behavioural treatments entered the field and offered an expanding and transformed role for clinical psychologists. The main preoccupations of psychiatry were organic, however, with pre-frontal leucotomies and ECT being used widely and often unreflectively. The "chemical revolution" generating a tide of tranquilisers, anti-psychotics and new antidepressants, meant that emotional problems were largely given symptomatic diagnoses and were often treated with minor tranquillisers (and often converted to substance dependencies) but it also contributed to the emptying of the traditional mental hospitals. The anti-therapy stance of British Psychiatry was largely maintained or reinforced by these successes and in this situation the proper role of psychotherapy needed to be clearly established if it was to survive. By 1976 Eysenck’s provocations and psychoanalytic complacency had combined to generate my interest in psychotherapy outcome research (evidence based practice), from the practice of which CAT emerged.
Twenty-five years later what works for whom is still poorly defined and the absence of a common theoretical framework means that psychotherapy remains in disarray and vulnerable. But, despite this and despite resource starvation and widespread prejudice, psychological treatments are much more widely available. With the NHS, CBT has established itself as a main model, circumventing old prejudices against dynamic therapies and establishing a research base – although one largely based on the treatment of less severe disorders. Counselling trainings have multiplied. And CAT has arrived as more or less the only integrated model. The Royal College of Psychiatrists now requires exposure to therapy during training and a number of dynamic and some more eclectic trainings now exist outside London. South of Potters Bar, however, psychoanalysis is still a dominant influence, taught on a model derived from long term, intensive, unvalidated, (private) practice. It is still very slow to develop NHS-relevant models and is still largely under-researched and largely unready for the now emphatic requirement for evidence based practice.
Comparing the current situation with the proposals made on the basis of my GP survey in the 1950’s, it is clear that the general level of therapy provision has increased and that the move to locate psychological treatment in primary care is under way. Traditional child guidance has been replaced by family approaches based either on systems theory or psychodynamic models, but social work resources have largely been absorbed by issues concerned with the physical and sexual abuse of children which were hardly recognised 50 years ago. The popular acceptance of counselling and therapy has greatly increased. General psychiatrists, however, are still largely hostile or uncomprehending, in part because they are preoccupied with managing patients with severe illness with scant resources, in part because neither psychoanalysis nor CBT provide accessible psychological understandings on the basis of which case management and staff supervision might be based. I believe that CAT has a major contribution to make here.
Recent changes in organisation and policy are beginning to have an impact and we need to consider how CAT will fare. The transfer of responsibility for therapy to Primary care settings is now under way and could be a constructive development. In general practice, however, the number of sessions available and the quality of counselling is often inadequate. In Community Mental Health Centres the present guidelines specify priority for "severe mental illness" which in practice means too little or no therapy for milder cases and a refusal or inability to treat borderline patients. The current Guy’s CAT randomised controlled trial for borderline personality disorder has revealed that the "business as usual" control condition represents virtually nothing in most cases.
The present emphasis on evidence based practice is to be welcomed but there is a Catch 22 situation, illustrated by the fact that, in the recent past, two applications for research funding were well reviewed and not costly studies of CAT were (after very long delays) turned down. We need also to be aware of the possible misuses of research, especially in fields such as psychotherapy where different concepts and values operate. Turning statistical associations into prescriptions and policies is definitely not NICE.
We do not need research to demonstrate that the distribution of psychotherapy resources by geography and social class is still very uneven, in part like all NHS resources, in part reflecting the historical location of PsA training. Over half of all PsA trained practitioners work in London, mostly in north and west postal districts. CBT is far more evenly spread and for this reason is in a dominant position in the NHS. One of the strengths of CAT is our expanding development of trainings in many different locations.
Psychotherapy continues to be under-resourced, under-researched and undervalued. The likely impact of current developments may be summarised as follows:
The effect of this is potentially good but combined with major under-resourcing it could be bad because it makes GPs responsible for rationing and hides government responsibility for underfunding. Psychotherapy is vulnerable to ignorance and prejudice, even though public demand is there.
The effect of this could be good but the level of training of GP counsellors is uneven and the time available is often inadequate and because the staff of CMHCs are preoccupied with maintaining psychotic patients with medical treatments and often operate with minimal psychological understandings.
The effect of this could be good but there is almost no resource for collecting the evidence which is bad. In this context I believe that CAT can play a crucial role, for the following reasons:
—— 1 ——
We offer a highly developed general psychotherapy theory, not just another bag of tricks. We have grown over the past 25 years, despite having no firm academic base and receiving very little attention in the professional press, because CAT was conceived to be NHS relevant and because it makes sense to clinicians and has attracted many workers from a variety of backgrounds who have contributed to its development. It offers therapy based on intellectual and ethical foundations; the Vygotskian transformation of object relations theory generates a non-reductive understanding of people at the level of the self and the relation to others. This informs our methods and provides the basis of our respecting, collaborative methods of working with patients, allowing therapy in our model to provide an intense experience within time limits. What CAT can offer was summarised by a patient at follow-up recently in these words:
—— 2 ——
We have some evidence base. Not good enough, but no other model has better evidence than CAT in respect of the most disturbed patients we treat. We need to become even more emphatically a research-based culture, while remembering
(a) CAT grew out of research into outcome and process in the form of small scale trials which were supportive and clarifying of practice.
(b) RCTs have demonstrated its value in improving the self-care in diabetic subjects and asthmatic subjects – both to be heard of today
(c) The Maudsley eating disorders unit showed CAT as compared to other interventions to be as effective, quicker and preferred by patients with anorexia nervosa.
(d) Our Guys naturalistic study of CAT for BPD showed that 50% were no longer borderline at 6 months and that improvement continued in the next year.
(e) Despite no funding we continue to struggle with our RCT for BPD at Guys.
(f) Research into process by Dawn Bennett has shown that reformulation in BPD does identify the key themes, that good CAT practice involving basic therapy methods plus specific CAT linking of transference themes to diagrams is associated with short term resolution and with overall outcome. The "delivery" of CAT is better with more trained therapists and improves with supervision. So we should not be inappropriately modest. BUT we need a better and larger evidence base. A great deal of innovative work is going on but not much is disseminated. Case studies and uncontrolled trial and work with new populations are all contributory.
The research committee should be more pro-active and supportive and maybe it is time to have an in-house journal.
For reactive and milder problems any form of counselling will help. For chronic/intermittent anxious, depressed and somatising patients CAT is probably better, as suggested by Rachel Reidy’s demonstration of reduced consulting and prescribing after 12-16 sessions. GP-based CAT therapists need to collect experience and publish. Should we involve trainees more systematically in primary care placements?
At present these largely offer medical model interventions or basic CBT. CAT trained CPNs, clinical psychologists and psychiatrists can introduce CAT reformulation in terms of RRPs and diagrams. Ian Kerr and Clare Tanner at the Cawley Centre, Mary Dunn in Hull and others have shown that CATspeak is comprehensible and empowering to staff and patients.
Most institutional settings are humanly damaging because of an absence of an adequate model of the power of relationships and the common provision of collusive or mechanical responses. Work in these contexts could be our single most important contribution to mental health services. We need to develop some form of postgraduate training in this role and we need published reports.
Within the NHS, judging by recent Guys experience, the caseload is increasingly made up of patients with BPD – which nobody outside CAT seems to want to treat. In a sensible service CAT would provide outpatient therapy which would be integrated with other resources such as therapeutic communities (where CAT also has a potential contribution to make by offering a model of collaborative development of understandings).
The experience of treating these more disturbed patients is a basis for work in many settings eg. substance abuse, where Tim Leighton reports a growing percentage of personality disordered patients, in liaison psychiatry, where patients who fail to get better are often personality disordered, in forensic work, as Philip Pollock has demonstrated and in early dementia as Laura Sutton has described. We need to hear about and write about such applications.
In the current climate of Blairite Thatcherism we cannot be quietly hopeful. All forms of mental health care and especially therapy are potentially under threat. However, in their language, there are many gaps in the market and we have a very good product to sell.
We need to be clear about and proud about the scope and human breadth of CAT. We offer a non-reductive focus on essential human issues in a collaborative relationship – working with, not being with or doing to. And our morale is high. BUT we are competing with other models, some with firm hands on the policy tiller, and good wine may need a bush.
We are still small, lacking supportive academic base, scattered and running to keep up with ourselves. We are still ignored in professional press and are probably seen as a threat by CBT and dynamic colleagues. Or am I paranoid?
To flourish I suggest that we need:
Evidence submitted by the British Association for Counselling and Psychotherapy (NICE 92)
Rowland, N., 2007. Evidence submitted by the British Association for Counselling and Psychotherapy (NICE 92). Reformulation, Winter, p.20.
What's it like to have Cognitive Analytic Therapy?
Sloper, J., 2002. What's it like to have Cognitive Analytic Therapy?. Reformulation, ACAT News Spring, p.x.
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