Letters, July 2008

Evidential issues

Recent correspondence about 'evidence-based practice' by the Midlands Psychology Group (Letters, April 2008) and Roz Shafran and Craig Steel of the Charles Weller Institute of Evidence-Based Psychological Treatment (Letters, June 2008) provokes me to make the following observations.

Like most people in 'the developed world' I am constantly exhorted to purchase all sorts of products and services that, I am informed by the advertisers, are desirable or essential for my health, comfort and happiness, my appearance, my personal effectiveness, the proper maintenance of my possessions, and every other aspect of my daily existence. I accept that all of this is an inevitable consequence of economic progress in a democratic society, even though I am aware that much of what is on offer is of marginal utility or of complete irrelevance to any of the aforementioned.

It is much the same in my role as a clinical psychologist. I am regularly confronted by advertisements for an ever-expanding range of psychological tests, which are promoted as 'essential tools' in the conduct of my work. Likewise I am overwhelmed by the sheer number of books that are deemed to be 'essential reading'. The same goes for journals, more of which seem to be on the market every year. Most bewildering of all is the number of different therapies in which I am invited to train and the plethora of courses and workshops that offer to equip me with 'powerful, and effective techniques' for disposing of all manner of problems.

How much of this is really necessary or beneficial and for whom? More importantly, how much of this industry really makes a difference to the people who ask us to help them? And how much, in the market place of psychological therapies, is the term 'evidence-based' merely sales talk for promoting the product on offer, just as 'natural' and 'holistic' are used by the alternative medicine industry to promote its products: impressive sounding, yet sufficiently elastic to include most of what is on offer, and hence devoid of any real meaning?
Michael Heap
Rotherham

Roz Shafran and Craig Steel (Letters, June 2008) would have been more accurate to write that: 'people with mental health problems are entitled to be treated with interventions that have been shown to work' sometimes (my italics). This is not a trivial point as the evidence base shows a significant non-response rate for CBT, which can be as high as 50 per cent in some groups for common mental health problems (e.g. older people for anxiety disorders). One would hope those running the Charlie Waller Institute go about their work with their blinkers off, recognising that people who don't respond to CBT deserve alternatives, and that some of those alternatives may not be congruent with the espoused theory underlying CBT.
Michael Church
Coventry & Warwickshire Partnership Trust
 

Truth and bullshit
In response to Rudolph Steiner's (1924) reported assertion ('On vines and minds', May 2008) that filling a horn with cow's manure and burying it until the spring solstice (sic) will ensure good viticulture, Miles Thomas writes that 'Many psychologists would find such an approach contrary to scientific understanding…'. I wonder what those psychologists' understanding of the discipline is?

Science in general, and psychology in particular, is comparatively poor at explaining how things work, but, given a sufficient error margin, is somewhat better at explaining whether things work.

Presumably the people who undertook the burying of manure-filled cow's horns had some, at least anecdotal, evidence of the practice's efficacy. As I am unaware of any double-blind scientific studies on the subject, I suggest that in asserting that the practice is unscientific a value judgement is being made, in that a scientist cannot see how it could work, ergo it does not. This is of course deeply ironic as value judgements by individual scientists are themselves unscientific.

The last argument often made in this regard is that 'exceptional claims require exceptional proofs' and that it is not down to the observer to prove that the thing is not true, rather it is down to the person who makes such a claim to prove its veracity; as with the flying spaghetti monster and Bertrand Russell's teapot orbiting the earth. In general I agree, but I wonder who decides that these claims are exceptional? (And on what scientific basis?) There must be a fuzzy band within which the sceptical scientist will 'recognise the importance of such phenomena' and will be prepared, here in the literal sense, to get their hands dirty and uncover the truth of, if not how, at least whether the claim is actually false.

Or perhaps as we are scientists we should say: 'The individuals who inter excreta-retaining bovine bucera…' – then fewer people will understand us and we can claim our specialty (and our paycheques).
Christina Richards
West London Mental Health NHS Trust


Remind the Gap
We read with interest the 'Working lives' article on intermediate psychological services ('Mind the gap!', May 2008) as the new service described has similarities with the service we have been providing for some years in South Birmingham. We apologise for missing the request for information in The Psychologist, and are disappointed that the trawl for information did not reveal our service.

In 1983 a comprehensive psychology service was commissioned for the people of South Birmingham. This was for all ages, and for people with physical health, mental health and learning difficulties with a contractual component for 'Direct Access' including direct GP and self-referral.

In 1995 with the advent of 'a primary care led NHS' the Direct Access contract was coordinated as the 'Primary Care Psychology and Family Service', and reorganisation meant a catchment with a 400,000 population. The service was based in and provided from a house in the suburbs, and within GP surgeries. We evolve as required by service configurations and changes in demand. For example, our service has recentralised following the addition in 2001of primary care mental health practitioners into GP surgeries, and we respond to increasingly complex psychological issues.

In the current NHS IAPT climate, GPs know us as a service where they can gain rapid (but non-urgent) access to highly qualified clinical and counselling psychologists who will work with people (16+) on their own, as couples or in families. People can engage in a range of services offering evidence-based therapies suitable for a wide range of difficulties. We are a small team (7.0 w.t.e.) with significant provision of supervision, training, management, and research, as well as client work, but our therapeutic approach enables us to respond to around 1000 referrals each year. Most clients are seen within a few weeks of referral, 100 per cent within the 18 weeks to treatment target (although as
a primary care service this does not strictly apply).

Like Redbridge, we have taken pressure off secondary services, by seeing people otherwise unnecessarily absorbed into those services when a multidisciplinary approach is not required, and any risk can be managed in a primary care setting. As an essentially unidisciplinary team, we shift our resources as required by clients, rather than shift clients from one set of skills to another. Our clinical outcome measures and service use surveys demonstrate good clinical efficacy and high levels of satisfaction, even though our service maintains an average of only four contacts per client. This makes such a service highly cost-efficient.

Various factors enable us to provide this service, including a paradigm shift (social constructionist) that repositions us as providers, combined with an overarching therapeutic approach (systemic) that facilitates constructive brief contact, and ease of access that paradoxically encourages ease of disengagement. More detail of these aspects of the service are given in Roper-Hall & Hatton (2004), but we would be pleased to have contact from other interested service providers.Also we would be interested in joining with others to develop a nationally applicable cost-efficient 'intermediate' psychological service model that could be adapted, building on existing services and according to local configurations.
Alison Roper-Hall
Jo Everill
Sam White
Primary Care Psychology and Family Services
Kings Norton, Birmingham

Reference
Roper-Hall, A. & Hatton, T. (2004). How to provide a service for 400,000 people? Context, 72, 17–20.


Statutory regulation – get it right
I was dismayed to see the brief summary of the Society's response to the Department of Health in the June edition of The Psychologist (also published on the Society's website). This summary does not represent the views of the whole Society and contains a number of inaccuracies. It reflects the Society's failure to grasp the external realities concerning this issue.

The view of those representing the Division of Clinical Psychology is that the Society's position is misguided. They recognise that there are a number of matters where the Department's plans and HPC's terminology need to be revised but have taken the view that the best way to achieve these goals is to work constructively and collaboratively with those bodies in order to influence them effectively. These points, and many detailed differences from the Society draft responses, have been communicated on a number of occasions, are noted (not necessarily appropriately) in the full Society response, but are not referred to at all in what purports to be a 'summary'. This is disingenuous at best.

The first inaccuracy is in the first bullet point. There is a profession regulated by HPC that has more than one protected title – arts therapists. This profession is not as complex as applied psychology – three titles as opposed to seven (although eight required) – but one would expect the Society as a learned body to be able to get things like this right. A further inaccuracy is over the requirement for psychology managers to be regulated. The consultation document refers to those 'who as practitioners…are wholly or partly engaged…in managing psychologists', not all managers of psychologists. It is true that this wording has not been properly incorporated into the draft section 60 order, but a number of us have pointed this out and it is a simple matter of rewording rather than a significant point of principle. In addition HPC have indicated that the use of alternative titles such as 'school psychologist' would lead to prosecution as an attempt to mislead the public. Incidentally, the wording about managers also applies to those who teach trainee applied psychologists and so, when properly implemented, will meet the concerns of your correspondent Sandie Hobley in the same issue. People in this position will not need to be registered with HPC but will be able to teach applied trainees and recognised as psychologists.

Finally, we need to remind ourselves that the Department published a White Paper in February 2007. There was not a green stripe in sight. In other words this is a settled and determined view of how the government plans to proceed, i.e. that applied psychologists should be regulated by HPC. This is the external context in which we need to be having discussions about statutory regulation. The consultation exercises are about how this should be done best, not about whether it should be done in this way and through this organisation.
Malcolm Adams
University of East Anglia

Society President Liz Campbell replies: The Trustees and Representative Council are well aware of the position of the representatives of the Division of Clinical Psychology, which is at odds with the positions agreed at several meetings of Council and encompassing the views of all sectors of the Society. I can assure Professor Adams that the Society is currently engaging in constructive and collaborative discussions with the Department of Health (DH), the Health Professions Council (HPC) and the Scottish Executive in an attempt to achieve what we are all signed up to – the effective statutory regulation of practitioner psychologists.
The point concerning protected titles in our summary is actually a point concerning the fact that every other profession regulated by the HPC has their specific title protected by law, e.g. one of the protected titles for arts therapy is 'arts therapist', whereas 'psychologist' is not the suggested title for the profession of psychology. The DH say that protecting the title 'psychologist' would be illegal, but I am still waiting a copy of the legal opinion from the DH – it has been promised since February. It is also worth noting that in Europe the protected title in nearly all countries is 'psychologist'.
Professor Adams is right that the issue is about the 'how' of regulation, but the devil is in the detail and that is what I, the rest of the Trustees, and Representative Council will ensure is as correct as we can make it.