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8.59 pm
Baroness Meacher: My Lords, I welcome this debate initiated by the noble Baroness, Lady Tonge, but I begin by applauding the Government on the considerable progress that they have made so far in extending the availability of CBT across many parts of the country. Improved Access to Psychological Therapies is bringing CBT and other NICE-recommended treatments to millions of depressed people and people suffering from anxiety, most of whom have never had access to any psychological therapy in the past. That is an important point, because a number of NICE-recommended treatments are included within the programme. As others have commented, this is the most significant development in mental health since the inception of the NHS. It is pretty powerful stuff. The IAPT programme is placing this country in a leadership role internationally in the delivery of psychological therapies.
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My noble kinsman Lord Layard, as I think I have to refer to him, spoke about CBT itself, and I want to limit my remarks to the computerised version of that programme. Before doing that, I should briefly mention that I have an interest in this as chair of the East London NHS Foundation Trust. We happen to have one of the two pilots in the CBT programme and it was very moving to listen to a number of users talk about having direct access to this programme. They did not have to wait 18 months; they could walk in, self-refer and have access to CBT. They talked about how much better they felt and the fact that they now had jobs. Things really are happening on the ground which we can be very pleased about.
I want to be clear that when referring to computerised CBT I am referring to all the versions of it. I was a little distressed that the noble Baroness, Lady Tonge, mentioned only one such version, and I fear that she may have been at the receiving end of some pretty effective marketing on behalf of a commercial company, because there are a number of computerised versions. The commercial product is called Beating the Blues, which was recommended by NICE in 2005. More recently other programmes have been reviewed and encouraged by NICE, which regards them as comparable to and as good as Beating the Blues. The dramatic difference between Beating the Blues and the other computerised programmes is that these others are free of charge, whereas the licence fee for Beating the Blues is £30,000—not an inconsiderable sum.
These programmes can be used for primary treatment; alternatively, they can be used to add value to a therapist-delivered programme where the therapist’s work is the core treatment. The research evidence quoted by NICE suggests that the computerised programmes can be helpful in either situation, given a professional therapeutic environment.
The only really important point that I want to make is that computerised CBT can only be effective if it is delivered in a therapeutic environment and is supported by about three sessions of face-to-face CBT. These programmes should not, therefore, be delivered without that support, nor only with the support of a Beating the Blues member of staff, who are not actually trained to Department of Health standards. This is fundamental. The best way to ensure benefit to the user is for the patient to access a computerised CBT programme at a recognised IAPT site where they can be sure that the support therapists are properly and appropriately trained. The only cost per patient using a free programme is between £17 and £36 for two or three hours of a low-intensity worker at band 4 or 5.
The significant impact of input by trained therapists was well illustrated by a recent study of the computerised treatment of social phobia. Only 33 per cent of patients completed a course of stand-alone treatment without any therapist input, whereas 77 per cent of those receiving clinician support as well as the computer programme completed the treatment. The conclusion of the research was that the clinician-supported programme was a success and the non-supported programme was not in any significant way.
Why am I so concerned to ensure the availability of therapeutic support from a properly qualified person if a patient is using computerised CBT? It is common
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Baroness Tonge: My Lords, I am extremely interested in, and overwhelmed by, the noble Baroness’s knowledge of this subject. However, I have seen the reverse situation apply, which is why I was so enthusiastic about the computer system. Many patients see a behavioural therapist and do not get on with them: the therapy does no good, or they do not like having to go and see somebody or to take time off work. They are greatly advantaged by the computerised system.
Baroness Meacher: My Lords, one interesting aspect of the two pilots of the new IAPT system was the use of the telephone in the Doncaster pilot. We have all learned a lot from that experience. Some people do not want face-to-face therapy. However, having a professional therapist working with you over the phone is very different from working with a computer, on your own and unsupported, feeling depressed and trying to manage. Having lost my speech on my flipping computer this evening, I say with great feeling that the frustrations caused by a computer can be considerable.
These are complex matters, but the evidence suggests that it is very important to have a well trained professional with you at the beginning of your treatment, so that when you start using your computer, the therapist can check that you are getting along okay, are happy with it and making progress. We do not want people buying a very expensive product and starting the programme without the necessary support. Not all of us are computer-literate. I like to think that I am half-computer-literate, but many people are not even that. Workbooks can be given to people, in which the treatment is the same as the computerised CBT, but the words are on paper instead of on a screen. All the options can be weighed up by a professional therapist who understands the different treatments available, and can judge what will suit each patient.
That is what we need to work towards. What we must be careful about is something that does more harm than good. There is no question that a stand-alone computer programme can do more harm than good to many people, by blocking them from a treatment that could be much more effective.
I look forward to hearing what the Minister has to say. I hope that she will assure the House that, for the treatment of depression, every PCT will be encouraged to make available computerised CBT—ideally the free version, but certainly some sort—along with the face-to-face and group treatments involving CBT techniques.
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9.09 pm
Lord Rea: My Lords, I thank the noble Baroness, Lady Tonge, for asking this very interesting Question. I am sorry that her noble friend Lord Alderdice was not able to stay on the speakers list, because I should have been very interested to hear how he, as a consultant psychotherapist, viewed this subject.
I am also delighted to have heard the double act that we have just experienced. Both noble Baronesses and the noble Lord, Lord Layard, are singing from the same hymn sheet—at least, they are in harmony—but, in comparison, I shall strike a slightly discordant and rather more cautious note. As noble Lords might expect, I shall speak from the perspective of a former GP.
Large numbers of studies testify to the very high proportion of consultations in primary care that are due to psychological problems. Some estimates are that they account for up to 50 per cent of a GP’s work. Although only about 10 to 15 per cent of the population on a GP’s list may have a long-term identifiable psychiatric illness, those people consult much more frequently than the average. At any one time, a similar proportion of the psychologically “normal” members of a GP’s list have transient problems in reaction to a particular life stress: bereavement, relationship breakdown and now, as all noble Lords have said, job loss, possibly repossession of a house or bankruptcy. Often, psychological distress is expressed indirectly in physical symptoms or in consultations for self-limiting afflictions which more robust people would shrug off. Sometimes anxiety about physical symptoms without demonstrable cause can be allayed only by a hospital referral. Thus, many specialist out-patient clinics also contain a high proportion of anxious or depressed patients. Often, a negative X-ray or blood test, for example, is needed before the patient, and sometimes the doctor, can accept that the problem is psychological or emotional rather than physical.
However, part of the reason for the apparent increase in stress-related disorders is that it is now more socially acceptable to speak about them and to seek help. It is also now recognised that more physical symptoms may have a psychological explanation than was previously thought to be the case. However, while some of these symptoms can be relieved by suitable medical drugs, the patients are likely to relapse when the treatment stops if the problem is long term. There are also unpleasant side-effects, and dependence is common, especially with the benzodiazepines.
Medication is of course a tempting option when consultation times are short and psychological treatments are rare, but the benefit is temporary unless psychological or talking therapy is also given by either the doctor or another person. Medication does not touch the root of the problem—it has been described as “sweeping the dirt under the carpet”—but it can often be useful at the beginning of a course of psychological treatment. For example, if a client is too depressed to engage with the therapist, he or she may need a small pharmacological boost to begin with. However, I think that all noble Lords here accept that there is a real need for psychological therapy in both primary and secondary care. As all noble Lords have said, it is good that the Government
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CBT, as we now always call it, has gained in importance partly because it lends itself to assessment much more readily than other therapies. It is of limited duration and predictable structure. A large number of case control studies have been carried out on CBT which have shown its usefulness and, in some cases, its cost effectiveness compared with medication. The methodology of some of these studies has been criticised. However, NICE, which has a reputation for insisting on sound research, has recommended CBT including CCBT, as other noble Lords have described, in that programme, Beating the Blues for depression in children and for a number of adult conditions. However its effectiveness compared with other forms of psychotherapy is not so well documented—at least according to my rather limited search when preparing this speech.
A comparable and more ambitious form of brief psychotherapy is CAT—cognitive analytic therapy—developed by Dr Anthony Ryle which consists of, rather similarly to CCBT, 16 sessions and aims at reformulation of a person’s relationships with the important people in their life history, thus increasing understanding as well as altering behaviour. Both clients and therapists in that treatment have to work harder than in CBT, which is popular with clients and therapists alike partly because it has a readily understandable structure and does not probe too deeply into uncomfortable areas. It helps clients to devise coping strategies for their symptoms and maladaptive behaviour, but it does not attempt to help them to understand fully the origins of their difficulties.
One problem with behavioural therapy—cognitive or otherwise—is that while it is often very effective in eliminating symptoms or compulsive behaviour, for instance, other problems tend to crop up later because the underlying problems have not been addressed. Psychiatrists have suggested to me that while it can be useful in itself, it is a good non-threatening introductory route into more in-depth psychotherapy for those who need it. Others have been less kind and describe it as a quick fix—possibly pushing the dirt aside rather than, as drugs do, sweeping it under the carpet, but nevertheless not clearing it away. That task is of course sometimes not attainable with any form of therapy. Some, who are even less kind, have let off broadsides against it. Professor David Richards, professor of mental health at New York University and a one-time proponent of CBT, said in a recent paper:
“It is an unproven contention that it is possible to take the results of experiments conducted by charismatic product champions, in highly controlled environments and implement them in the widespread manner suggested by Layard".
Sometimes I am thankful not to be in the stimulating atmosphere of the academic world.
Lord Layard: My Lords, there have been field trials, including the two in Doncaster and Newham, that have found exactly the same results as those in the more rarefied clinical trials to which the American professor referred.
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Lord Rea: My Lords, I thank my noble friend for that explanation. CBT is popular at the moment, but I am sure that my noble friend will agree that the Government should not put all their eggs in one basket. The Royal College of Psychiatrists and Royal College of General Practitioners last year produced an excellent joint report on Psychological Therapies in Psychiatry and Primary Care in which all forms of psychological therapy are considered. One recommendation which I like is that all organisations providing psychological help should “promote psychological mindedness”. This certainly prevailed in the health centre in which I worked to the benefit of both patients and staff. The Government would be well advised, if they have not already done so—it is likely that they have—to take full note of this report and act on its recommendations.
9.20 pm
The Countess of Mar: My Lords, from my point of view it is wholly appropriate that this subject should be debated at this time and I am grateful to the noble Baroness, Lady Tonge, for her introduction. I declare my interest as chairman of Forward-ME and as patron of several ME charities.
While I recognise that there are some patients with a variety of conditions apart from mental illness—cancer, for example—who might benefit from cognitive behaviour therapy, or CBT, as it is known, I would like to introduce another note of caution. The noble Lord, Lord Rea, has already introduced his. CBT is not the cure for all ills that it is sometimes held up to be. Indeed, it is not, strictly speaking, a treatment at all, since its purpose is to support patients in recognising and managing their symptoms. However, there is a group of chronic illnesses where overwhelming post-exertional fatigue is a major factor, causation is poorly understood, and for which there is no single or comprehensive treatment—CFS/ME, fibromyalgia and irritable bowel syndrome, for example—that do not respond positively to CBT. Patients expect doctors to provide answers, and doctors are, naturally, reluctant to admit defeat. Current advice to doctors is that, after routine tests have failed to point to causation, there is no need for further investigations. Some doctors take the easy route by concluding that the illness must be psychological and that CBT will provide the answer. However, many clinical tests listed in the Canadian criteria do show disease/disorder dysfunction in many bodily systems.
I will deal only with the 240,000-odd CFS/ME sufferers this evening. This is an illness that, according to some researchers, has had several different names in the past; neurasthenia and hysteria are examples. Other researchers have believed since 1934 that it is caused by viruses, other micro-organisms or toxins. Even more confusing is the incidence and severity of symptoms reported by patients. It is not surprising that almost everyone concerned with this illness, be they patient, carer or medical practitioner, is, to some degree, bewildered.
In the face of this bewilderment, in 2004, the Secretary of State for Health and the Welsh Assembly asked NICE to prepare,
- “guidance on the assessment, diagnosis, management of adjustment and coping, symptom management, and the use of rehabilitation
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In August 2007, the guideline was published amid a barrage of criticism from the ME community. Why was it criticised? It was because the only “treatments” recommended by NICE on the basis of very limited and strongly criticised scientific evidence were CBT and its twin sister, graded exercise therapy or GET. The quick reference guide to the 300-plus pages of the full guidelines described CBT as:
“An evidence-based psychological therapy that is a collaborative treatment approach. When it is used for CFS/ME, the aim of CBT is to reduce symptoms, disability and distress associated with the condition. The use of CBT does not assume that the symptoms are psychological or ‘made up’”.
Unfortunately, in the view of a number of professional organisations and researchers working in this field, the evidence-base is not as clear as NICE would have us believe. A statement from ME Research UK asserts that:
“The evidence base consists of only five trials which have a validity score of less than 10. We note that the most recently published RCT on CBT (O'Dowd 2006) states: ‘there was, however, no evidence that the treatment restored normal levels of function for the majority of patients’”.
The Association for Psychoanalytic Psychotherapy in the NHS states,
- “it is highly misleading to state that CBT is the therapy of first choice, since the only relative efficacy RCT quoted in the Guideline (Risdale et al 2001) shows that counselling has better outcomes than CBT”.
“This recommendation seriously conflicts with the recommendation that patient choice and preference need to be uppermost in the collaborative approach to care, and the finding that 45% of patients report either being made worse or not helped at all by CBT and, elsewhere, only 7% of patients surveyed report being helped”.
“Why is a misleading recommendation being made?".
There is no mention in the NICE guidance of the analysis report in 2004 by the 25% ME Group for Severe Sufferers that was submitted to the GDG of NICE that reported that 93 per cent of respondents found CBT unhelpful.
I could cite a great many more criticisms of the recommendation by NICE for CBT. The recent judicial review did not test the scientific validity of NICE's recommendation for CBT and GET. The statement issued by Professor Littlejohns, NICE clinical and public health director, that the decision,
People with ME already bear a great burden of disbelief about the reality of their illness from their closest relatives, their friends, the medical profession and other care professionals they encounter, as well as the community at large. There has been a preponderance of articles on “yuppie flu” in the press and broadcast media; research funding, other than that provided by the ME charities, has been exclusively weighted in favour of the psychosocial as opposed to the biomedical aspects of the illness; and ME patients seem to have to
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I have a quotation from Health Insurance News UK dated 22 February 2009. Under the heading,
it gives a condensed description of ME. It then states:
“This sounds like a physical problem, doesn’t it? However, the NICE guidelines suggest that it is a psychiatric condition rather than a physical one.”.
- “Because of the NICE guidelines private health insurance companies are within their right to refuse cover if an applicant’s policy does not include psychiatric cover”.
I cannot find any confirmation for the extraordinary suggestion that ME is a psychiatric condition in the NICE guidelines. Will the Minister ensure that this misinformation is rapidly withdrawn?
Young people with ME get very little understanding of their predicament from educationalists and social workers. Far too frequently their parents are accused of “perpetuating the child’s illness behaviour”. This often results in the child being put on the at-risk register, forcibly removed from the family and given medical treatment, including CBT and GET, that commonly does not work. The child is then blamed for the failure. It can then take years for the child to regain any semblance of a normal life. Too many children remain isolated and ignored and living in a twilight world.
I have been dealing with ME sufferers for 17 years and I have never encountered a group of patients who are so maligned. The last straw for them is the requirement that they undertake a course of CBT and/or GET in order to qualify for benefits and private insurance payments. I accept that, in some cases, CBT alone may be beneficial. I suspect that in the old days it would have been called “grin and bear it”. However, CBT is rarely offered without GET and ME patients know only too well—and their views are supported by some 4,000 papers on scientific and clinical research—that GET makes their symptoms worse.
The NICE guidelines lay great stress on the importance of shared decision making, working in partnership with the patient and the need for specialist expertise. Unfortunately, because this is a “Cinderella” condition, there are few specialists. Indeed, some of the specialist centres set up following the CMO report in 2002 have had to close because of a lack of funding and expertise. For this reason, “referral out of area” and “choose and book” should be available to all sufferers.
The Department of Health and the World Health Organisation acknowledge that this is not a psychiatric condition. What action is the Minister’s department taking to ensure that people with ME are as respected as people with other medical conditions and that they are not forced to accept, as a condition for receipt of benefits and social care, “treatments” such as CBT and GET that, at best, provide no beneficial effects and, at worst, are positively harmful?
I remind the Minister that NICE guidelines state:
- “Healthcare professionals should be aware that—like all people receiving care in the NHS—people with CFS/ME have the right to refuse or withdraw from any component of their care without this affecting other aspects of their care, or future choices about care”.
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