What's a smile worth?

January 19, 2007

The Government wants to cut welfare costs by improving people's mental health, but academics have questions about the proposed ways and means. Nic Paton reports

A central tenet of the Government's agenda to reform Britain's welfare state is that if a million of the estimated 2.7 million Britons currently claiming incapacity benefit can be returned to work, then £7 billion can be slashed from the £12.5 billion welfare bill.

Coincidentally, a million incapacity benefit claimants are estimated to be off work because of mental illness - notably anxiety and depression. Last June, plans were outlined to tackle the problem with a radical shake-up of mental health services.

In The Depression Report: A New Deal for Depression and Anxiety Disorders , which was published by the Centre for Economic Performance's Mental Health Policy Group, Professor Lord (Richard) Layard suggested a sweeping overhaul to improve access to psychological therapy services. But the proposals are creating divisions among academics with an interest in mental health. The UK Council for Psychotherapy is planning a meeting of academics and mental health groups in the next few weeks to try to address some of the most contentious issues.

Layard envisages creating a "proper" psychological therapy service in every corner of the country by 2013 - a move that would rescue the subject from something of an academic and health backwater and raise it up the financial agenda.

This would consist of 250 new services (with about 40 being created each year over the seven-year time frame) that would require 10,000 new therapists. They would offer access primarily to short bursts of cognitive behavioural therapy (CBT), normally 16 one-to-one weekly sessions. The estimated cost of offering this course of therapy to an individual is £750. Remarkably neatly, this is said to be the same amount that it costs the state to fund a person on incapacity benefit for a month, including lost taxes.

The report foresees a 50 per cent success rate. It says: "One course of CBT is likely to produce 12 extra months free of depression. That means nearly two months more of work. And, if treatment is combined with the extra employment advice that the Government is planning, we can expect a much bigger response in terms of work."

For academics, this neat solution poses a number of challenges: where will all these new therapists come from, who will train them and, more fundamentally, is it right to have such a tight focus on a single therapy?

Layard himself reckons that half the extra 10,000 therapists he envisages "would be clinical psychologists on their way to becoming therapists, and the other half would be people coming in, people such as nurses, counsellors and so on". He estimates that there are some 5,500 clinical psychologists working within the National Health Service, and that 500 to 600 new ones qualify each year after doing postgraduate courses.

Over the seven-year time frame outlined it would be perfectly possible to build up the numbers required, he says. "It will not be something that will be able to be done overnight. The capacity for clinical psychology would need to be expanded."

Some people would, over time, be trained and supervised through the new services via a mix of on and off-the-job training, which he envisages universities delivering.

Graham Turpin, vice-chair of the clinical psychology division of the British Psychological Society and director of the clinical psychology unit at Sheffield University, supports Layard's report because access to psychological therapies is "very patchy at the moment, with very long waiting lists".

He says: "There are many people who should be receiving psychological-based, evidence-based therapies who are not; so any major investment is an extremely valuable proposition."

But he also notes that change cannot be had on the cheap. "This new capacity can be achieved, but it will require new investment both in the infrastructure and in terms of the employment of new clinical staff."

In recent years, the number of training places available has been contracting - last year it shrank by about 5 per cent. Moreover, there is currently no national funding of CBT training at postgraduate level.

Turpin thinks one way round the problem could be for higher education institutions to consider shorter diploma-style courses delivered over, say, 12 to 18 months, to create assistant practitioner positions.

Sheila Hollins, president of the Royal College of Psychiatrists, agrees that shorter university-certified courses in CBT, underwritten by the NHS and supervised by consultant psychiatrists or psychologists, could be the way forward.

From there, people could progress to more complex masters courses. Courses could also be linked to local psychotherapy services.

"There needs to be some systematic setting-up of training. We think the best way would be for university departments to do it within psychiatry or psychology academic departments," Hollins says.

But who would deliver the training? Academic medicine has suffered in recent years, and psychiatry lecturer and senior lecturer positions have been hit particularly hard. Hollins says: "Psychiatry has been one of the worst affected areas; some places have been reduced in size or almost closed down. Research in psychotherapies within academic departments has been diminished, too."

For some academics, their problems with Layard's conclusions are much more fundamental. They question the emphasis on CBT. Psychologist Oliver James thinks it is a simplistic and ineffective therapy that it is being promoted simply because it is relatively cheap, quick and has measurable goals.

Phil Richardson, professor of clinical psychology at Essex University and director of the Psychotherapy Evaluation Research Unit at the Tavistock and Portman NHS Trust in London, believes the therapy will not be effective in the number of sessions being suggested. "A great many of the people I study at the Tavistock are chronically depressed and have been treated in the past with drugs without success. The vast majority of them are on incapacity benefit and a great many have been treated with CBT without success.

"The idea that you can give them 16 sessions of a very specific form of therapy, delivered by people who are not experts, and that that kind of help will get them off incapacity benefit and save the Government millions is completely laughable."

He says his experience shows that 40 to 50 sessions are often needed to get a positive outcome. There is also the issue of how a focus on a single therapy will affect the resourcing of other equally worthy and valuable therapies. When Layard's report was published, one sceptical psychiatrist was moved to describe the emphasis on CBT as being another example of focusing on "the bollocks du jour".

Over the past three months the UKCP has been pushing for the inclusion of other therapies in the Layard mix. Last month it was invited to join the expert reference group that is taking Layard forward after the leader of one of the two pilot studies based on the plans agreed that CBT was "not the only fruit".

Others, though, understand Layard's emphasis on CBT.

"CBTs are the most tried and true procedures," says David H. Barlow, a leading US psychiatrist and keynote speaker at a British Psychological Society conference last month. "To draw the conclusion that we do not administer short-term treatments when they are not effective for some people, but (instead) use a long-term treatment that has no evidence to support it seems very backward. We are now really recognising the ravages of diseases such as depression and the negative impact they have on physical health."

He agrees, though, that part of the reason for the current emphasis on CBT is the historical lack of funding of research into what works in mental health. Some critics argue that the therapy may get more good press than other treatments simply because it is easy to study its effects. CBT is fairly clear about its outcomes, according to Turpin. "Some other forms of treatment talk about bringing new understanding and personal meaning, which are not easily measured on a questionnaire. CBT measures quality of life and wellbeing. The whole purpose is to objectify what the client wants to gain and how they want to change."

Despite differences of opinion over CBT, most psychiatrists are eager to see more funding for mental health provision, which is often dubbed the Cinderella service because it has historically lacked investment. In making the economic case for more therapy, Layard is all too aware that whether his proposals see daylight or end up gathering dust on a shelf in Whitehall depend on whether there is the political stomach to make them a reality.

Anything half-hearted or underfunded will be doomed to failure, he says.

"The whole thing is very heavily dependent on the Comprehensive Spending Review being announced in June. There is tremendous interest and sympathy, but whether the Government will be able to find the money remains to be seen," he says.

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