What is the 10 year plan for psychoanalytic therapies in the NHS?

9 May 2019

Last night, with others, I addressed the Association of Psychoanalytic Psychotherapy and guests. The topic we were seeking to address was important and timely. It is also one of great significance to the Tavistock and Portman NHS Foundation Trust, as the largest provider of psychodynamic interventions and training in the UK.

There seems to be a sad irony that, at a time when mental health more widely is in the ascendancy, we should be having a debate about a threat to an important part of the armoury of what to offer patients experiencing more complex and challenging needs.

Why might that be? I hope as someone who has led the Tavistock and Portman for 5 years, but who has also campaigned more widely on mental health issues, I might offer some helpful reflections.

The first point I want to make is stating the obvious. There are many more people, adults and young people, who could benefit from psychoanalytically-informed psychotherapy than currently have the chance to do so.  That is a function of policy and of funding but also, perhaps, of our inability to make a convincing case for what long-term therapy has to offer.

There are in my view five things we need to address to change this.

The first is to be much better at communication.

To the lay person psychoanalysis is both a familiar concept but also one which, in reality, can be tremendously remote. Few people, outside the profession, know much about what goes on in the consulting room. We have not made enough effort to promote and explain our work in ways that are accessible to wider audiences. We have allowed ourselves to be stereotyped as old fashioned and elitist.

There is a big need to do better and to tell the human stories (both of clinicians and service users and families) which sit behind the disciplines and modalities we represent. We need to harness the power of psychoanalytic and systemic thinking to provide understanding of some of the problems which most distress society today. This is something I have tried to get our organisation to give focus to, for instance in letting the television cameras in to follow aspects of our work with young people in the documentary series Kids on the Edge. I also applaud the recent work of the Association of Child Psychotherapists in trying to raise the profile of child psychotherapy, highlighting its benefits for some of our most distressed young people.

The second imperative is to work together.

From the outside, the world of psychotherapy can look incredibly disjointed and at times divided. The same used to be true of the world of mental health more generally. It is part of the success, in recent years, of the mental health lobby that it has found ways of working together and presenting a common voice on key issues to Government and other decision-makers.

As champions of psychotherapy we have started to make the right moves in this direction, in particular working together to challenge the narrowness of the draft NICE guidelines proposed for depression in adults. Felicitas Rost, President of the Society for Psychotherapy Research (UK) and a research lead at the Trust, deserves a lot of credit for her leadership on this issue. NICE is doing further thinking, and in the meantime the sector is coming together and finding allies in the political and wider spheres. Building on this I would welcome working with the APP, BPC and others to establish more of a common agenda for the future of long-term therapies within the NHS.

The third challenge is around research and evidence.

Psychoanalysis prides itself in its own traditions around the development and sharing of knowledge. Those are perfectly valid, but the result has been that it has been disadvantaged compared to other traditions such as CBT in being able to demonstrate outcomes, including the economic benefit of interventions. Randomised controlled trials may not be the holy grail they are sometimes made out to be, but there is a real danger that without comparable evidence, long term psychotherapy will be squeezed out in the competition for resources. The Tavistock Adult Depression Study was a major milestone in attempts to address this but there is a need to do a lot more.

My fourth point is to be better at focusing our arguments on the why and not the what.

By this I mean channelling our arguments not on the preservation of particular approaches and modalities for their own sake, but rather on the key difference they can make, uniquely or in tandem with other approaches, to address intractable individual or systemic problems. Successful innovations here include the Family Drug and Alcohol Courts (FDAC), which include psychotherapeutic and systemic approaches. FDAC has achieved its profile by being able to demonstrate effectiveness in addressing the human tragedy of parents losing their children due to unmanageable drug or alcohol misuse issues. In many cases seen by FDAC, these seemingly intractable situations are the result of intergenerational trauma and can only be overcome by often painful exploration and a ‘making sense’ of them. There are many other issues where a similar approach could be taken, for instance school exclusion and knife crime, to name but two.

Linked to this, and as my fifth and final point, is the need to be able to innovate and adapt to meet different opportunities.

This innovation and adaptation may relate to how and where therapy is delivered. It may relate to how we make approaches more accessible to different groups. It may also relate, on occasions, to the duration of treatment offered. Our Primary Care Psychotherapy Service in Hackney and Camden has been a successful example of where we have been able to adapt traditional models of intervention to focus on the specific needs of patients presenting in primary care with medically unexplained symptoms.

I can appreciate that there are some who will be suspicious of attempts, as they might see it, to dilute or 'dumb down' traditional approaches. There must be boundaries, but change is also necessary if the traditions we value are to survive and be relevant to the modern world. As Gustav Mahler said of music, “Tradition is not the worship of ashes but the preservation of fire.”

Crucially this is also necessary in the interest of fairness. If therapies are to continue to be accessed through the NHS, we must seek to make them more widely available than they currently are. As the largest provider of training in this area, I’m acutely aware that our work is also to ensure a wider spread of qualified clinicians in some of the areas where there is the greatest need, as the recent study conducted by the Guardian pointed out.

So, I think there is much to campaign for over the next 10 years. There are plans to expand mental health services and to address the treatment gap for those in mental distress. To do so, a range of approaches will be required including the longer term psychoanalytically informed treatments which can be effective in supporting those with some of the most complex and enduring difficulties, and which also offer powerful insights in how we support the wellbeing of the NHS workforce.

However, to make our argument for investment we will need to work in different ways, facing outward and evidencing not just our right to exist but the contribution we can make to addressing need and solving wider issues facing society. In doing so we will need, as other groups have succeeded in doing, to narrow internal differences and broaden the shared common ground on which we make our case.

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