A modern approach to mental healthBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1322 (Published 23 February 2012) Cite this as: BMJ 2012;344:e1322
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Fiona Godlee’s editorial is at risk of taking the supposed rational technical modernity of the mental health industry at face value.(1) Firstly, psychiatry is a speciality with shallow epistemological foundations. There is no concensus on either essence or aetiology of any ‘mental disorder’ bar those associated with physical disease. ‘Depression’, for example, is not a biologically validated entity, merely a symptom cluster –clustered by us, not by nature. The Lester and Gilbody editorial on anti-depressants she cites approvingly carries the bullishness typical of the industry. (2) Indeed they start with the mantra that “depression is a major cause of disability worldwide”. This claim falls at the first hurdle, since there is no such thing as depression as a unitary, pathological entity present across cultures worldwide, whether those cultures know it or not. What evidence is there that the pandemic of anti-depressant prescribing- 35 million prescriptions last year in UK, a fourfold increase in little more than a decade- has improved well-being across society?(3) These trends trade on the self-aggrandising claims of the mental health industry and their pharmaceutical partners. This medicalisation of everyday life is societally self-defeating and depleting.
Godlee cites Salkovskis and Wolpert who claim “real improvements in mental healthcare”, but this is to confound activity with outcomes. (doi:10.1136/bmj.e1188). The largest increases in NHS funding has been on mental health- up from £148 per head in 2003/4 to £200 in 2008/9- yet the industry continues to claim massive unmet need: this is where prevalence figures for mental disorder like 1 in 4 come in. When Godlee says “the evidence in fact suggests a higher figure” she is perhaps thinking of a US National Institute of Mental Health survey in 2001/3 which found that 46% met American Psychiatric Association criteria for a mental disorder (and often more than one) over a lifetime. This is a false positive epidemic. How many BMJ readers believe figures that insult our common sense and everyday social experience: if 1 in 2 or 4 citizens truly had a ‘mental disorder’ worthy of the name society would begin to collapse. Perhaps the BMJ should conduct a poll.
A 1997 Australian study claimed similar rates of mental disorder with low rates of treatment. Since then treatment availability has greatly increased but there is little evidence that the nation's mental health has improved. (4)
1. Godlee F. A Modern approach to mental health. BMJ 2012;344.e1322.
2. Lester H, Gilbody S. Choosing a second generation anti-depressant for treatment of major depressive disorder BMJ 2012;344:1014.
3. Summerfield D. Depression: epidemic or pseudo-epidemic? JRSM 2006; 99: 1-2.
4. Jorm A. The population impact of improvements in mental health services:the case of Australia. Brit J Psychiatry 2011;199:443-4.
Competing interests: No competing interests
With reference to “Psychoanalysis: does it have a valuable place in modern mental health services?” (“Head to Head” BMJ 25 Feb 2012) it is ironic that the “NO” lobby argues that psychoanalysis is unscientific, incorrectly stating that it has “no evidence base”, and reads like an ideological polemic in comparison to the more scientific, pluralistic and inclusive arguments of the “YES” lobby.
In their article, Professors Paul Salkovskis and Lewis Wolpert appear to have omitted any mention of the enormous body of work that is the post-Freudian psychoanalytic development, such as Attachment Theory and Object Relations Theory. Their argument that even more recent developments in psychoanalysis such as the work on mentalisation are “successors to psychoanalysis, rather than a continuation” are used to support a view that psychoanalysis is a relic of history cut off without a future, as distinct from the reality that it is a lively and continuously developing work in progress that flourishes outside of the necessary constraints of public health funding.
There appears to be an almost complete lack of recognition that the development of cognitive behaviour therapy (CBT), for example, was as a progressive offshoot of psychoanalysis, which is instead seen as a result of a “paradigm shift”. This smacks of the very tribalism of which psychoanalysis stands accused by them.
It is a further irony that CBT theory in its own developmental history, has itself apparently independently rediscovered more of its own discarded and forgotten psychoanalytic roots in, for example, schema-focused CBT approaches, which are highly congruent with psychoanalytic object relations theory as well as with the hitherto discarded psychoanalytic notion of a developmental paradigm in understanding mental suffering. In turn, interpersonal schemas in CBT are now apparently leading to the rediscovery of something very like transference.
It is obvious that CBT research has contributed massively to the empirical basis of psychological approaches to the treatment of mental disorders, where its more transparent , collaborative (with the patient) and systematised approaches have been shown to be effective. This is somewhat less so in the treatment of personality disorders, where, arguably, psychoanalysis has more to offer, notwithstanding that CBT may develop more efficient approaches through its development of an understanding of interpersonal schemas, for example.
There is much more that could be said along these lines but I hope I have suggested enough examples to support the point I wish to make which is that whilst new developments need room to flourish, they could sometimes benefit by doing this collaboratively rather than by distancing, especially when there is already evidence as in the case of CBT versus psychoanalysis, that what has been discarded is often so treated because its relevance has not been understood by its detractors. And it can be argued that there is a lot more in psychoanalytic theory that has yet to be given an empirical basis.
The use in Professors Salkovskis and Wolpert’s article of simplistic, mocking metaphors such as equating psychoanalysis to the “flat earth society” or to “a metaphorical appendix” or to outmoded theories in cardiology or oncology, is misleading in the extreme. Un-evidenced or arguably incorrect statements such as that psychoanalysis is “perverse” or consists of “dogmas” (as distinct from theories), or that it “stagnated” and “failed to advance the care of people with mental health problems” or that it “opposes the use of treatments that deal with crippling symptoms such as anxiety or depression”, or that it “rejects outcome measures”, add nothing of value to the debate, are misleading, and should not go unchallenged, lest those that contribute to making NHS policy should be unduly influenced by such views, and use them, wittingly or unwittingly, to exclude psychoanalysis from modern mental health service planning.
Competing interests: No competing interests
Fiona Godlee would do well to think twice before placing her money based on Salkovskis and Wolpert’s caricature of psychoanalysis. Particularly as Salkovskis and Wolpert’s intemperate rhetoric reveals a startling disregard of the scientific understanding of psychotherapy process.
Claims for the effectiveness of specific techniques in trials have been largely explained by strong investigator allegiance biases (Luborsky, 1999). Different bona fide short-term psychotherapies, be they psychoanalytic, behavioural, cognitive, humanistic, or integrative have globally comparable outcomes across a range of conditions with effect sizes in the region of 0.85. This is referred to as the equivalence paradox (Cuijpers et al, 2008) and has been confirmed naturalistically in NHS psychotherapy settings (Stiles et al., 2006)
NICE itself identified ‘no clinically important differences’ between CBT, interpersonal psychotherapy (IPT), short-term psychodynamic psychotherapy and brief supportive counselling, behavioural activation or GP treatment as usual when it compared the evidence for psychotherapeutic treatments of depression (NICE 2010, p234-235).
In this issue of the BMJ ‘brands’ of psychotherapy are taken at face value as having construct validity. However the literature on psychotherapy process research demonstrates that psychotherapy is a very complex intervention, and that ‘brand’ of psychotherapy has a limited relationship to what takes place within psychotherapy or what the effective ingredients of successful psychotherapy might be. The branding of different modalities of psychotherapy belies fundamental overlap in psychotherapeutic processes, for instance in the US National Institute of Mental Health's 1985 Treatment of Depression Collaborative Research Program IPT was found to correlate more strongly with the CBT prototype than the IPT prototype (Ablon & Jones, 2002). Psychoanalytic psychotherapy often contains significant CBT elements, and change-promoting processes in CBT can be psychoanalytic (Ablon & Jones, 1998). Convergence between modalities is greater when conducted by master therapists (Goldfried et al 1998). Rigid adherence to a particular model can be negatively associated with outcome (Castonguay et al, 1996; Hayes et al 1996) and effective therapists adjust their use of techniques to the individual patient (Jones et al 1988). This has lead to calls for a move away from what ‘brand’ is best, to what techniques or interpersonal processes achieve what ends with which kinds of patients (Robinson 1990).
CBT also have its own golden calves. A review of studies of component analysis studies of CBT concluded that there is ‘…little evidence that specific cognitive interventions significantly increase the effectiveness of the therapy’ (Longmore and Worrell 2007).
If specific techniques account for little of the variance in outcome, then what are the change promoting ingredients? In psychotherapy, as in psychiatry generally, the interpersonal relationship is often said to be the basic vehicle for producing improvement. The US National Institute of Mental Health's 1985 Treatment of Depression Collaborative Research Program showed that the contribution of the therapeutic alliance outweighs the modality of treatment, whether CBT, IPT, imipramine or placebo (Krupnick et al 1996). Even with pharmacotherapy individual psychiatrist effects accounted for more variance in outcome than did medication over placebo (9.1% vs. 3.4% of variance in Becks Depression Inventory score) (McKay et al 2006)
Rightly increasing emphasis is placed on patient values, individual difference and recovery. Patient preferences strongly influence take-up and completion rates in mental health treatments (Raue et al 2009). Some personality characteristics such as perfectionism predict poorer response to brief treatments (Blatt et al 1998), and different personality types respond differentially to exploratory versus supportive treatments, and to short-term versus long-term treatments (Blatt 2006).
Our patients, and BMJ readers, will be better served by a more measured and evidenced approach to the problems of providing effective treatments to people in distress.
Ablon, JS, & Jones EE. How expert clinicians prototypes of an ideal treatment correlate with outcome in psychodynamic and cognitive-behavioral therapy. Psychotherapy Research, 1998; 8 : 71-83
Ablon, J.S. & Jones, E.E. (2002) Validity of controlled clinical trials of psychotherapy: findings from the NIMH Treatment of Depression Collaborative Research Program. American Journal of Psychiatry , 159; 775 -783.
Blatt SJ. A Fundamental Polarity in Psychoanalysis: Implications for Personality Development, Psychopathology, and the Therapeutic Process. Psychoanal. Inq., 2006; 26 :494-520.
Blatt SJ, Zuroff DC, Bondi CM, Sanislow CA, Pilkonis PA. When and how perfectionism impedes the brief treatment of depression: further analyses of the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting & Clinical Psychology. 1998; 66 (2): 423-428.
Castonguay LG, Goldfried MR, Wiser S, Raue PJ, Hayes AM. Predicting the effect of cognitive therapy for depression: a study of unique and common factors. Journal of Consulting and Clinical Psychology, 1996; 6 : 7–18
Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: A metaanalysis of comparative outcome studies. Journal of Consulting and Clinical Psychology. 2008; 76 (6); 909-922.
Goldfried M, Raue PJ, Castonguay LG: The therapeutic focus in significant sessions of master therapists: a comparison of cognitive-behavioral and psychodynamic-interpersonal interventions. J Consult Clin Psychol 1998; 66 : 803–810
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Longmore RJ, Worrell M. Do we need to challenge thoughts in cognitive behaviour therapy? Clinical Psychology Review 2007: 27: 173-87.
McKay KM, Imel ZE, Wampold BE. Psychiatrist effects in the psychopharmacological treatment of depression. Journal of Affective Disorders , Jun 2006; 92 ; 287-90.
NICE. CG90 Depression in adults: full guidance - updated edition 2010. http://guidance.nice.org.uk/CG90/Guidance/pdf/English (accessed 4/3/12).
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Competing interests: No competing interests
The editor uses her ‘Editor’s choice’ not only to highlight that week’s ‘Head to Head’ debate on the place, if any, of psychoanalysis in modern medicine; but also to tell us that she is swayed by the case against. It’s a pity, then, Dr Godlee didn’t also bring to our attention Iona Heath’s glowing review in the same issue of Ballatt and Campling’s book ‘Intelligent Kindness’ when the central plank of Heath’s review is: “the text is suffused with fascinating psychoanalytical insight”.
1 Godlee, F A modern approach to mental health. ‘BMJ’ 2012;344:e1322. (23 February.)
2 Heath, I Kindness in healthcare: what goes around. ‘BMJ’ 2012;344:e1171. (22 February.)
Competing interests: No competing interests
At best, a polarized debate (Head to Head 25th Feb) sharpens the thinking and promotes intellectual play. It has little place in the uphill struggle to provide effective psychiatric care to a population increasingly burdened by mental health problems. Good doctors recognise the uncertain outcomes in this field and apply their skills to weighing up the biological, the psychological, and the social, then tailoring their interventions to each individual. Within the field of psychological therapies, professionals trained in different modalities increasingly see their skills as complementary with medical psychotherapists (trained in psychodynamic, CBT and systemic approaches but specializing in one) playing an important part in building constructive and mutually respectful work relationships. NICE guidelines too have recognised the difficulties involved in providing a narrowly defined evidence base to an extremely complex population and increasingly recommend a diversity of models, including psychodynamic therapies. It is these, psychoanalytically based, therapies, that are increasingly vulnerable in the NHS, not the ‘psychoanalysis’ caricatured in your debate. Used appropriately, and for the right patients, such methods are effective and far from expensive.
It is particularly disappointing to see the BMJ set up a debate that does not compare like with like and where the two sides do not play by the same rules. So, whilst Fonagy and Lemma give a thoughtful, cautious, ‘evidence-based’ account of how a psychoanalytic approach contributes to a modern health service, Sakovskis and Wolperts’ colourful rhetoric argues against ‘psychoanalysis’ as defined over a hundred years ago. That rhetoric has little connection to the arguments of Fonagy and Lemma and little relevance to the decommissioning of today’s psychodynamic psychotherapy services, although I suspect they will be quoted as supporting such cuts. No-one would dream of bringing electric shock aversion therapy or the zealous attitudes and sometimes fraudulent research of early behaviourists, both part of the developmental history of CBT, into a debate about its uses in the modern NHS!
As Fonagy and Lemma point out, psychodynamic therapy services are being drastically cut at the present time. This is partly to do with diverting resources into primary care IAPT services - although commissioners are not supposed to admit this - and partly that small services (typically with one medical consultant with no crucial technology) are vulnerable targets in the present economic climate. Where a proper consultation process has been followed, including an objective analysis of the evidence base, a rationale for closure has proved hard to sustain. Too often the damage has already been done.
In this context, in a field where staff redundancies and reducing much needed services to some of our most disturbed patients are the reality, I suggest the BMJ could have taken more care about the way it set up the debate. It was particularly concerning that in the Editor’s Choice section, Fiona Godlee reinforced a simplistic argument and risked making it even more difficult for a vulnerable specialty to get the thoughtful consideration it deserves.
Competing interests: No competing interests