Controversies in Management Psychotherapy - a luxury the NHS cannot afford? More expensive not to treatBMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6961.1070 (Published 22 October 1994) Cite this as: BMJ 1994;309:1070
Psychotherapy is “the systematic use of a relationship between therapist and patient - as opposed to physical or social methods - to produce changes in cognition, feelings and behaviour.”1 Psychotherapy, or perhaps more usefully “the psychotherapies,” is a generic term covering a spectrum of treatments that can be grouped under four main headings: analytic therapy, cognitive behavioural therapy, systemic (or family) therapy, and creative therapies such as psychodrama and art therapy. Each of these can be brief or long term and delivered to individuals, couples, or families and groups. I shall consider the case for the psychotherapies under three main headings: empirical, economic, and ethical.
Controversy about the empirical evidence for the value of psychotherapy continues, although the debate has moved on considerably since Eysenck's ill fated attempt to discredit it in the 1950s. Meta-analysis has provided overwhelming evidence for the usefulness of psychotherapy, which produces “effect sizes” of around 0.8-1.0.2 This means that the average patient having psychotherapy does better than 85% of control subjects. This kind of outcome is comparable with that found with antidepressant drugs, and far better than those found in some medical trials. For example, in a study of aspirin in the prevention of heart attacks the effect size was 0.32, and trials were discontinued on the basis of this figure, because it was thought unethical to withhold such an effective treatment from control subjects.3
The debate has now moved on from considering psychotherapy's overall effectiveness to questions such as which forms of therapy are suitable for which conditions, what “dose” is likely to produce greatest benefit, and what are the active ingredients and non-specific factors of different psychotherapy treatments? Some of the most robust recent research findings can be summarised as follows. Where emotions run high in the families of schizophrenics, family intervention prevents relapse and readmission to hospital4; patients suffering from depression who discontinue antidepressant drugs relapse on average within five months while those who receive cognitive behavioural or analytic psychotherapy stay well for more than two years5; psychological treatments for anxiety are an effective alternative to drug therapy and result in lower relapse rates once treatments are stopped6; women with chronic refractory irritable bowel syndrome improved physically and psychologically after a course of brief analytically oriented psychotherapy compared with those who were offered supportive “chats,” and this improvement was maintained for at least one year7; in patients with borderline personality disorder, a year of twice weekly individual analytic therapy produced an effect size of around 1.0 on most measures of improvement.8 These studies suggest that in the central areas of psychiatric morbidity psychotherapy can help improve health.
Costs of psychotherapy
Attempts to estimate the annual costs of neurotic disorder in the United Kingdom suggest figures of pounds sterling 600m in direct medical costs, and a staggering pounds sterling 5.6bn in lost production - one third of the total cost of the NHS. If psychotherapy can be shown to diminish only a small fraction of this it will have proved its economic worth. Numerous studies have shown reduced offset costs - reduced use of medical services, drug bills, and social security payments - after psychotherapy.9 Two highly intensive inpatient psychotherapy units - the Henderson and Cassel Hospitals in London - have shown reduced use of health and social services by patients in the three years after discharge, saving sums far greater than the relatively expensive cost of a six month stay in the units.10
Not treating is unethical
Results such as these suggest an ethical dimension to the psychotherapy debate. Medical dilemmas inevitably imply questions of value. In the short term it may save money not to use expensive facilities and to make do without the luxury of effective psychotherapy - to muddle through with a mixture of drug therapy, intermittent support, and a blind eye turned to much human misery. But is such short termism ethical given the evidence which suggests that good treatment produces lasting benefit which, from a medium or long term perspective, would save both money and unhappiness?
A wise therapist looks behind a question to the anxiety that underlies it. The NHS is in a crisis that seems to be based on underfunding - and certainly more money for health is much needed. But is it also a crisis of values, in which the personal aspect of medicine increasingly competes with rather than complements medical technology? Patient dissatisfaction and staff stress both have their roots in this conflict. Psychotherapy is concerned not just with removing distress, important though that is, but with the search for self esteem and a sense of meaning that underlies good health and has much to contribute to the managerial quest for quality and good morale.1 Psychotherapy epitomises the values of the doctor-patient relationship, of healing as opposed to treating, that patients and doctors alike find so elusive in modern medical culture. To see psychotherapy as a luxury is to compound the heartlessness of a medicine whose values are already endangered. A vision of psychotherapy as both a necessary and ordinary part of medical practice offers hope in the bewildering world in which the NHS now finds itself.