Forum, June 2009

Speaking up for IAPT

The Improving Access to Psychological Therapies (IAPT) initiative and its place in the development of the full range of psychological therapies have been caricatured by John Marzillier and John Hall's two 'Opinion' pieces (May 2009). Readers who wish to understand the initiative, rather than their caricature of it, are referred to www.iapt.nhs.uk where they will find the Implementation Plan, the Commissioning Toolkit (including a description of the service framework), the curricula for training therapists, the Outcomes Toolkit, Commissioning for the Whole Community, Supervision Guidance, a Supervision Competencies Framework, the Equality and Diversity Toolkit, an Equality Impact Assessment, the LSE's evaluation of the two demonstration sites, plus other useful documents. Sadly, these are not referenced and are hardly mentioned by Marzillier and Hall.

In the short space available for a letter, it is impossible to itemise all the misleading statements in Marzillier and Hall's seven pages of opinion. However, it is important to mention that many of the 'Alternative Ways of Working' advocated by them are already part of IAPT. These include: -    training in, and respect for, the role of the therapeutic relationship (see the curriculum for high-intensity therapists);
-    a broad-based, person-centred assessment that goes well beyond simply establishing a diagnosis (see Commissioning Toolkit, chapter 5);
-    a decision tree that recognises that assessment and formulation can lead to either no-treatment, sign-posting to social and community support, psychological intervention, or help by another profession (see LSE Evaluation of Two Demonstration Sites);
-    provision of a range of evidence-based therapies (see the Statement of Intent, plus the forthcoming details of a training programme in interpersonal psychotherapy and support for the importance of counselling);
-    recognition of diversity (all IAPT services carefully monitor access by ethnic minorities and have been opened up to self-referral because this has been shown to be particularly helpful for equitable access; see Outcomes Toolkit, Equality Impact Assessment, the BME Positive Practice Guide, and the LSE Evaluation); and
-    recognition that poverty and other social factors substantially contribute to depression and anxiety (hence the inclusion of employment advisers, debt counselling, and other social assistance in the IAPT services: see Implementation Plan and Commissioning Toolkit).

We should also mention that Marzillier and Hall's purported critique of the assumptions behind the Layard Report contains a number of errors. For example, IAPT low-intensity treatment is not defined as 'four sessions' but rather is characterised by a particular type of intervention (for example, guided self-help) that is typically delivered for 4–8 sessions but with flexibility to go beyond that. Similarly, it is not correct to say that CBT has been shown to be most effective for people who are only mildly or moderately anxious or depressed. On the contrary, many of the trials in anxiety disorders that find CBT superior to a psychological control condition (e.g. Clark et al., 1994, 2006) explicitly excluded cases that were mild or of short duration. The same applies to Hollon, DeRubeis and colleagues' recent trials of CBT versus medication in severe depression (DeRubeis et al., 2005; Hollon et al., 2005). Moreover, it is not correct to say that 'levels of uncompleted treatment in both research and practice settings' were not taken into account. The Layard Report uses 'intention-to-treat' rather than 'completer' analyses, and the IAPT programme itself has taken steps to assure that data is available for incomplete interventions by developing a new session-by-session outcome monitoring system. This means that even when patients drop out of therapy there is still data on their progress. This system is operating well, and the data from the demonstration sites has already shown its advantage over more traditional, less frequent, outcome monitoring, where missing data leads to overestimation of the value of a service (see LSE Evaluation). Marzillier and Hall's critique also seriously misrepresents the NICE guidelines on which much of the IAPT programme is based, for example to state that NICE 'privileges randomised controlled trials (RCTs) and minimises the value of meta-analytic studies' is simply not correct; NICE recommendations are predominantly based on meta-analyses of high-quality evidence.

The IAPT programme has already made a substantial contribution to improving the mental health of those suffering from a range of common mental disorders. Everyone involved in developing the IAPT programme believes that it is simply the beginning – not the whole story. Of course, changes will be made in the light of experience and the rigorous approach to outcome monitoring adopted by IAPT should facilitate that process. The efforts of applied psychologists (and the pages of The Psychologist) would be, we suggest, better focused on debating such developments rather than on misinformation. Such an approach will best serve the interest both of those suffering from anxiety disorders and depression and of the many psychologists involved in developing and providing IAPT services.

David M. Clark,1 Peter Fonagy2,3, Graham Turpin4,5, Steve Pilling6,7, Malcolm Adams5,8, Miriam Burke9, John Cape9,10, Tim Cate5,11, Anke Ehlers12, Philippa Garety10, Rod Holland10,11, Judy Liebowitz9, Kay MacDonald9, Tony Roth2,7, and Roz Shafran8

Key: 1IAPT National Clinical Advisor. 2Author of What Works for Whom?. 3Freud Memorial Professor of Psychoanalysis, UCL. 4IAPT National Education and Training Advisor. 5Ex-Chair of DCP. 6Director, CORE, UCL. 7Author of DH Competencies Framework for Psychological Therapies and Supervision. 8IAPT Training Provider. 9IAPT Service Lead. 10Head of Psychology, NHS Mental Health Trust. 11IAPT Regional Clinical Advisor. 12Co-Chair of NICE PTSD Guideline.

References
Clark, D.M., Ehlers, A., Hackmann et al. (2006). Cognitive therapy and exposure plus applied relaxation in social phobia: A randomised controlled trial. Journal of Consulting and Clinical Psychology, 74, 568–578.
Clark, D.M., Salkovskis, P.M., Hackmann et al. (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164, 759–769.
Hollon, S.D., DeRubeis, R.J., Shelton, R.C. et al. (2005). Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Archives of General Psychiatry, 62(4), 417–422.
DeRubeis, R.J., Hollon, S.D., Amsterdam, J.D. et al. (2005). Cognitive therapy vs medications in the treatment of moderate to severe depression. Archives of General Psychiatry, 62(4), 409–416.

Correction
Last month's article by John Marziller and John Hall was missing a reference: Mollon, P. (2009). The NICE guidelines are misleading, unscientific, and potentially impede good psychological care and help. Psychodynamic Practice, 15(1), 9–24.

 
IAPT – more pertinent questions
It is useful to see deeper consideration of the Layard proposals and the Improving Access to Psychological Therapies (IAPT) initiative (Marzillier and Hall, May 2009). The simplistic generalisations offered by Layard have clearly been very attractive to politicians committed to making sure they provide the 'best' without getting into the annoying intricacies of what that might actually mean. However, it is important to recognise that many of the limitations of IAPT have grown out of the policy structure in which health services currently operate. At present, NHS treatment developments primarily come from a central push to raise quality through the application of evidence, as recognised in the National Institute for Health and Clinical Excellence (NICE) guidelines. These guidelines undeniably have many benefits, but there is a danger that the result is a rigid emphasis on particular treatment models rather than on addressing differing individual needs.

The central question posed by Layard – how to help people on incapacity benefit – is an important one. It is also a subject that (as Marzillier and Hall point out), requires a response of far greater complexity than IAPT has thus far been able to offer. From community work to a mix of therapies there is clearly ongoing research and practice in many relevant areas. NICE, for all its strengths, does not necessarily offer a system capable of capturing this range, nor of providing strategies to deal with thorny social issues. Given this, perhaps the primary lessons of Layard are twofold. Firstly, as IAPT eloquently demonstrates, the NICE guidelines can lead to unhelpfully limited answers to complex problems. Secondly, in the face of such problems, a central challenge for psychologists at the present time is to think about how to develop systems that will foster more innovative, creative and above all appropriately sophisticated solutions.
John McGowan
Year 1 Director and Academic Director of
the Clinical Psychology Training Scheme
Canterbury Christchurch University

 

Paul Gilbert ('Moving beyond cognitive behavioural therapy', May 2009) poses the pertinent question as to whether we should be working with individuals at all or with communities. Intuitively, the latter would make more sense to me. And yet, in my experience, many clinical psychologists are working only or mainly with individual clients, irrespective of their predominant approach (e.g. CBT, psychodynamic, CAT, EMDR, IPT).

Although clinical psychology places central importance on social relationships (as Gilbert reminds us), in their day-to-day clinical practice, many clinical psychologists seem to focus exclusively on dyadic relationships. When working with adults, individual therapy tends to be prioritised over family, group or community work. Alas, the new IAPT movement, with its focus on one-to-one CBT sessions, is no exception. Considering that the developmental process occurs within a socio-economic/political milieu, which inevitably permeates the psychology of the individual, therapies that focus on the individual and treat her/him separately from her/his social contexts, seem naively reductivist. However, this kind of thinking, which conceptualises individuals in some way as separate from their social contexts, is dominant in Western societies. It privileges the individual over the group and values rationality, autonomy and, by implication, choice.

Choice is commonly predicated on a construction of the individual, who engages in rational decision making, and considers and compares the costs and benefits of his/her actions. Considering the privileged position of both individualism and rationality in Western societies, it is perhaps not surprising that CBT has emerged as a dominant model of psychotherapy. Yet choice is also premised on our values (and beliefs, which, at times, can be irrational). The decision to offer more individual therapy (in this case CBT) at the expense of group and community work seems more like a value-based rather than an evidence-based choice (which ironically is also predicated on values). Whether such approach will be cost-effective and alleviate human misery remains debatable.
Susanne Iqbal
Fulbourn Hospital
Cambridge
 

Being adult about humour
The recent debate about gender and teaching (Forum, April and May 2009) has been instructive in revealing how hard it is to have an intelligent and mature debate about these issues. On the one hand, the raising of legitimate concerns is viewed by Sallie Baxendale as an 'attack' (Forum, May 2009).

On the other hand, the headlines chosen by The Psychologist suggest a difficulty in addressing these issues without resorting to ill-advised humour. For example, 'Not amused' is the headline accompanying Mary Boyle and Pippa Dell's letter (Forum, April 2009) about Andy Field's article ('Can humour make students love statistics?', March 2009) – presumably implying some reference to Queen Victoria's oft-quoted 'We are not amused' [Editor's note: I can assure you this was not intended]. It is ironic that Boyle and Dell anticipated this reaction in the first line of their letter when they noted that women could be seen as prudish or humourless when raising such concerns. This compounds the problem noted by Boyle and Dell in the choice of heading for the box in Field's article: 'Bringing lap dancers to the lecture theatre'.

Interestingly, in the original article, Andy Field discussed the possible effect of gender stereotypes on how students might perceive the use of humour by tutors. Moreover, in the conclusion to his article he suggests avoiding sexual themes in teaching. It is a shame, then, that the lap dancing study was given such prominence in his article. It is also a shame that, in his response (Forum, May 2009), he argues that Boyle and Dell's focus on gender obscures the need to create a good teaching environment. Surely these aren't incompatible objectives?

Andy Field notes that the intended target of his humour was the idea of the researchers obtaining grant funding for their study. However, one presumes that students would probably also laugh at the introduction of the topic of lap dancing, whether that was intended or not. Humour can be quite tricky for this reason. Indeed, advertisers are increasingly using humour to undermine potential criticisms of sexist imagery (Gill, 2009).

Given the fact that sexual discrimination still exists in many areas of life (e.g. consider the small percentage of heterosexual rape cases reported by women and successfully prosecuted) perhaps psychologists should try to use material that subverts stereotypes rather than inadvertently reinforcing them. A more socially relevant and engaged approach to teaching might also be of more interest to students. Moreover, surely, one of the lessons of the last 30 years of stand-up comedy is that it is possible to be funny without reinforcing gender stereotypes? Perhaps readers of The Psychologist could suggest humorous examples of research that does just that.
Dave Harper
School of Psychology
University of East London

Reference
Gill, R. (2009). Supersexualise me! Advertising and the midriffs. In F. Attwood & R. Cere (Eds.) Mainstreaming sex: The sexualisation of culture. London: IB Tauris.

Andy Field reports (Forum, May 2009) that he received many messages of support for his article 'Can humour make students love statistics?' (March 2009); the article included a box on the use of an evolutionary psychology study of men's responses to lap dancers in Field's statistics teaching. But we also received many messages of support for our criticism of this section (Forum, April 2009). 

Contrary to Field's assertion, we certainly would not argue that 'as a man, he is incapable of understanding the power dynamics' in this particular issue. We did, however, point out that his account in The Psychologist showed no awareness of them. But perhaps our argument could have been spelled out more clearly. If psychologists are to incorporate popular culture in their teaching, and Field is surely right that they should, we need openly to acknowledge that some aspects of popular culture are strongly contested. The lap-dancing industry is a particularly good example; it is contested partly because of its attempts to make heterosexual men's purchase of sexual services a 'normal' part of mainstream culture and local communities. It is in topics like these that humour is likely to function, in complex social and psychological ways, to avoid or deflect discussion of more serious and threatening issues (and we don't mean methodological ones) or to allow discussion only in a disguised form. Perhaps some of the student contributions that Field described as 'entertaining' were of this sort. Given this, it is particularly important to ask who has the power publicly to define a topic as involving humour and to recognise that the experience of presenting such topics, and the reception they receive, is very likely to be influenced not only by the group membership (age, ethnicity, sex, sexuality, etc) of the lecturer and their audience but by the relation of this membership to the topic under discussion.

Finally, and again contrary to Field's assertion, we agree with him that The Psychologist should publish articles that encourage reflection and debate about good teaching practice. It was the lack of reflection in Field's original piece on issues we see as crucial in teaching that led us to write in the first place.
Mary Boyle
Pippa Dell
School of Psychology
University of East London

 

Climate change – answering the sceptics
We are heartened by the many positive responses received to our article 'Climate change – psychology's contribution' (February 2009). However the letter by Stephen Murgatroyd (April 2009) argues that (a) we show uncritical, unscientific thinking to draw the conclusion that the anthropogenic causes of global warming are undisputed within the scientific community, (b) that there is a large body of scientists (over 650 according to Murgatroyd) who have 'signed up' to being sceptical about the dominant climate change thesis, and (c) that a properly scientific approach should seek to 'go beyond media reporting of this issue (especially in the UK)'. Of course, we can fully agree that media reporting is the last thing one should base a scientific opinion on. While psychologists by training, all three of us have spent proportions of our time working on environmental issues with natural scientists and engineers. As the interview with Patrick Devine-Wright (February 2009) clearly illustrates, the challenges of climate change do not respect traditional disciplinary boundaries. One of us (Pidgeon) held a Chair at the School of Environmental Sciences at the University of East Anglia, home to some of the UK and the world's best climate science as well as the UK Research Councils' Tyndall Centre for Climate Change Research. Our paper therefore draws upon a collective and ongoing interaction with leading climate scientists, learning from and debating the issues with them, as well as our reading of the contemporary peer-reviewed scientific literature on the topic. We would argue that it is engagement with the latter that marks out a genuinely critical scientific approach.

While there is always room for doubt with any proposition, scientific or otherwise, the IPCC framework assessments are clear and authoritative in their synthesis of the now extensive peer-reviewed evidence about climate change and the anthropogenic contribution to this. The most recent IPCC in 2007 involved 2500 expert reviewers, 800 contributing authors, and 450 lead authors from more than 130 countries who confirmed, in the words of Dr Rajendra Pachauri, the Chair of the IPCC, that 'Today, the time for doubt has passed. The IPCC has unequivocally affirmed the warming of our climate system, and linked it directly to human activity.'

Regarding the 650 'climate sceptics', we presume this refers to the recent US Senate Committee on Environment and Public Works publication, a minority committee report that presents a series of quotes from individuals with little context, conventional scientific evidence, or supporting peer reviewed references. This report should of course be interpreted against the highly partisan nature of contemporary climate politics in the USA (see Dunlap & McCright, 2008).

We reiterate our judgement that climate change is serious, real and a threat that we all need to face up to. Shortly after the publication of our article in The Psychologist over 2500 academics, from both the natural and social sciences, met at a major climate conference in Copenhagen. A recurrent theme was that behaviour and behavioural sciences were urgently needed in the fight against climate change, and that if anything the current interpretations of the established science underestimate the risks that we all face. We do firmly believe that our article and its conclusions will withstand the march of time, while those of any remaining climate sceptics by contrast will not.
Nick Pidgeon
Alexa Spence
Cardiff University
David Uzzell
University of Surrey

Reference
Dunlap, R.E. & McCright, A.M. (2008). A widening gap: Republican and Democratic views on climate change. Environment, V50(5), 26–35.
 

Statutory regulation – where next…?

The Society's campaigns to prevent registration by the Health Professions Council (HPC) and to protect the title 'psychologist' have been ineffective. The HPC is expected to open its register on 1 July. The HPC has already over-ruled the Society's advice about the level of language proficiency required for registration as a practitioner psychologist. It may next overrule the basic rules about training and qualifications on which chartering has been based.

So this is a good time to start unpacking what HPC registration will mean for individual psychologists. From the beginning of July, HPC will control two generic and umbrella titles and seven adjectival titles but not any other titles, including 'psychologist'. It will determine what constitutes competence to practise in those seven domains of the profession through approving programmes of education and training and will only register psychologists competent in one or more of those domains.

The intended relationship between the HPC and practitioners who are legitimately not registered is not clear. For example, neuropsychologists are a special case. Those not eligible for one of the protected titles will still be able to call themselves 'neuropsychologists' precisely because it is not protected. Chartered psychologists with no adjectival title are another special case. The Minister, speaking at the House of Commons committee, said:

'If the BPS is unable to allow those people to use the titles associated with full membership in its divisions it is difficult to give them automatic right to do so without further consideration by the HPC.' So, for three years, they will have the option of applying for one of the seven protected title via the HPC's grandparenting procedures. Does that mean they are obliged to seek HPC registration? What happens if they do not? The Society has expressed the view that disbarring these psychologists from professional practice except by registering under one of the protected titles is a 'restraint of trade'. Could they, like neuropsychologists, continue practising under a non-protected title of their choice?

How many employers will feel confident that the HPC is the right body to regulate the training and conduct of their staff and will impose HPC registration as a condition of employment? How much of the work of professional psychologists will, by legislation, require a 'registered psychologist' as opposed to a 'psychologist'? And how many psychologists will decide that HPC registration offers them no personal benefit and they can practise without it? For example, will chartered psychologists without adjectival titles work to fit the Procrustean bed of the seven protected titles in order to gain registration or will the HPC act as an environmental pressure for evolution outside itself? Counselling psychology, health psychology, and sport and exercise psychology have all evolved during my professional lifetime, only seeking and achieving formal recognition within the Society after the evolutionary process, not before it.

Bearing in mind the Society's remit 'to promote the advancement and diffusion of a knowledge of psychology pure and applied' but the ineffectiveness of its registration campaigns, we, its members, need a significant change in its culture and two urgent actions. Firstly, we need assertive promotion of psychological services provided by psychologists.

We must provide leadership concerning the roles and responsibilities that can be undertaken by newly qualified professional psychologists, and we need to be able to advise those who are entering the professional psychology training about the career pathways open to them. Secondly, as a consequence of the title 'psychologist' not being protected, we need reliable guidance concerning the legitimate practice of psychology and provision of psychological services outside the seven domains. How can the profession ensure that psychologists' creativity is not inadvertently stifled by the statutory roles and functions of the HPC?Bernard Kat
Jesmond, Newcastle upon Tyne

When statutory regulation was first up for consultation, I remember the huge effort and collaboration that occurred. I really valued the fact that psychologists of all varieties came together in great numbers to argue the problems inherent in the HPC project. Unfortunately it appears we gave up when we realised that the government 'consultations' were by and large cosmetic, thanking us for our input but leaving the framework pretty much unaffected by the key concerns we voiced.

Although as a discipline our membership of the HPC may be a foregone conclusion, there are still issues for individual members to ponder. What do we think of the project? Does it seem ethical? If it does, we will be grandparented onto the register no problem, but what about those concerned about the project?

While client protection is cited as the main grounds for regulation, this argument has never been shown to be a valid one. Some argue that this position is in effect a fear-based fallacy that has been drawn on to pressure certain responses from us (a bit like 'weapons of mass destruction' in the run up to the Iraq war). It is based on the ever-growing premise of 'guilty until proven innocent' that seems to pervade British political life. There is also a 'safety first' feeling to it all, a culture that has embedded itself in many contexts and has already interfered with good practice. Ticking boxes and monitoring all activities has come to be an acceptable part of practice, yet it is based on the illusory belief that we can control everything. The frameworks as they stand demonise the unknown and expect it to be eradicated. Is this not a delusional belief to foist upon our clients?

The regulation framework also risks ironing out the rich diversity within our field so that we conform to a limited view of what constitutes 'best practice' rather than develop our own unique style of work and the ability to tailor this to the needs of individuals. While attractive, the act of applying a predetermined set of principles to a particular client overrides their individuality and the assessment of what will work for them. 'Best practice' has overwhelmingly becoming a macro-economic label rather than an ethical or therapeutic one.

As ethically minded individuals, how do we discuss the issues so that we can act on our conscience? How do we come together to discuss this before we simply allow ourselves to be sucked up into a system that may well offer limited and dubious benefits but potentially cause profound damage to therapeutic psychology, facilitating defensive practice primarily concerned with protecting the practitioner from complaint. What do individual practitioners do in relation to concerns such as these? I for one am certainly unclear on our professional body's degree of support for those who might want to take a stance of ethical non-compliance. Will 'the BPS' work with insurance companies so that they recognise that it would be inappropriate for them to write statements such as 'protection as long as practising from manual A, B or C with clients diagnosed with X, Y and Z' into our insurance cover? While our professional body's immediate future may be clear, I suspect that many individuals are left feeling very unclear.
Martin Milton
Department of Psychology
University of Surrey

Noticeboard

Are you looking for part-time voluntary work to gain experience relevant to progressing your career in clinical or health psychology? I can offer a variety of work (research and clinical) for interested and enthusiastic graduate psychologists at MEND (www.mendcentral.org), an organisation specialising in the management of child obesity with links to the Institute of Child Health, UCL. Please send me a recent CV and letter of interest.
Paul Chadwick
[email protected]

I am a member of the BPS and part of an international group of artists looking to artistically record interpretations of human emotion from differing cultural perspectives. (see www.artreview.com/group/
humanemotionproject2009). If you have an interest in showing the works, please contact me.
Bill Millett
[email protected]

For my final-year clinical psychology doctorate thesis, I am undertaking research that explores the experiences of clinical psychologists in relation to strains and ruptures in the therapeutic relationship. Please contact me if you are a clinical psychologist trained within the UK, currently working in the adult mental health NHS clinical practice at least part time, two years post qualification, London area.
Reetta Leinonen
University of East London
[email protected]

The founder of scientific psychology in the Netherlands, Gerardus Heymans (1857–1930), participated in 1892 at the International Congress of Experimental Psychology, in London, with a paper about his research related to Weber's law (and Fechner's law). I cannot trace or reconstruct the calculations he performed on the raw data. Does anyone know of an archive where written material related to the 1892 congress is kept?
Kars Dekker
Groningen, The Netherlands
[email protected]