Psychological therapies (e.g. counselling, cognitive behavioural therapy and psychoanalytic psychotherapies) are an important part of the mosaic of mental health services. They are provided within both primary care and specialist mental health services.
The DoH review of NHS psychotherapy services (1996)1 reported that these were widely practised in the NHS and recommended an evidence-based approach to improving safety and clinical effectiveness. More recently, the National Service Framework for Mental Health (Standard 2)2 requires access to safe and effective psychological therapies.
A new research-based guideline from the DoH, Treatment Choice in Psychological Therapies and Counselling,3 has just become available to GPs and others to support clinical decisions on which form of psychological therapy is likely to be of most benefit for a given problem and what factors to consider when making referrals.
Why are guidelines needed?
Psychological therapies are a complex field. While there is plenty of research evidence, there are also gaps in the evidence, and the application of research to practice is not straightforward.
Whereas guidelines exist on the medical treatment of depression, anxiety and other common mental health problems, GPs and other non-specialists are often unclear as to whether or not a psychological therapy is indicated. In these circumstances, GPs sometimes refer patients to local mental health specialists for 'brokerage assessment'.
This guideline has been designed to be of value not only to GPs, but also to primary care counsellors, psychiatrists, and other health professionals undertaking assessment in local mental health teams and NHS departments of psychology and psychotherapy.
The primary purpose of the guideline is to reduce inappropriate referrals, leading to more effective care and fewer wasted resources, in a situation where demand exceeds supply and waiting lists are long.
The development of guidelines in this field may have other, broader benefits:
- Clear public statements of optimal treatment give mental health service users more information and hence more scope to influence the quality of the service they receive.
- In professional training and education, guidelines relate research evidence to practice and supplement traditional learning resources such as textbooks.
- Guidelines raise the profile of research in the minds of both practitioners and the public, create a valuable debate on the validity of different types of evidence, and force research to become more relevant to practice.
The guideline was funded by the DoH and the National Institute for Clinical Excellence, and developed under the auspices of the British Psychological Society Centre for Outcomes Research and Evaluation at University College, London.
Collaborating organisations included:
- The Royal College of General Practitioners
- The Royal College of Psychiatrists
- The British Association for Counselling and Psychotherapy
- The UK Council for Psychotherapy
- The British Confederation of Psychotherapists.
The guideline took 2 years to develop, is based on best evidence from research and expert clinical consensus, has been subject to independent peer review and has been formally appraised against criteria for guideline quality.
The scope of the guideline is broad, potentially including:
- Cognitive and behavioural therapies
- Humanistic and client-centred therapies
- Systemic therapies
- Psychodynamic therapies
- Integrative therapies
- Eclectic or pragmatic therapies.
It focuses on common mental health problems in adults:
- Social anxiety and phobias
- Post-traumatic disorders
- Eating disorders
- Obsessive-compulsive disorders
- Personality disorders.
It also includes common psychosomatic conditions that GPs rate as most important for considering psychological treatment:
- Chronic pain
- Chronic fatigue
- Gastrointestinal disorders
- Gynaecological problems.
The guideline excludes a number of other disorders for which psychological therapies may be helpful:
- Mental health problems in childhood and adolescence
- Psychoses including schizophrenia, mania and bipolar disorder
- Alcohol and other drug addictions
- Sexual dysfunction and paraphilias
- Organic brain syndromes.
Evidence underpinning the guidelines
The guideline development group commissioned an extensive research review from the Psychological Therapies Research Centre at the University of Leeds, which worked closely with the Cochrane Collaboration on the neuroses.
The reviewers appraised systematic reviews of psychological therapies for common mental health problems in adults against eight quality criteria,4 and found 42 reviews that met all eight criteria and a further 43 that met six or seven criteria.
The guideline development group also used structured consensus methods to outline best practice in areas where research was weak. Each of the participating organisations nominated expert therapists from a wide range of approaches,and experienced GPs with knowledge of mental health issues.
This was the first time that psychological therapists from different therapy 'schools' had been asked to develop a consensus on treatment choice decisions, and the fact that such a consensus was attainable was in itself an interesting finding.
A service user panel was convened in a parallel process with professional consensus development. Service users commented on early drafts of both the brief and the full versions of the guideline.
A further, user-led process is now in progress, based on the guideline development findings, to produce an evidence-based user guide to psychological therapies.
The evidence suggests that although there are many different forms of psychological therapy, only a small part of the difference in outcomes (usually measured in terms of symptoms of mental ill health and level of functioning) can be attributed to the specific effects of the type of treatment.
Therefore, although the guideline presents the best available evidence for specific presenting problems and therapy types, it also sets out a range of general principles to consider when making referrals.
The strength of the evidence for each recommendation is graded from A (a consistent finding in a majority of studies in high quality systematic reviews or evidence from more than one high quality study) to D (based on evidence from structured expert consensus).
The recommendations of the guideline are summarised in Table 1 (below).
|Table 1: Recommendations of the guideline Treatment Choice in Psychological Therapies and Counselling3|
Psychological therapy should be routinely considered as an option when assessing mental health problems. (B)
In considering psychological therapies, more severe or complex mental health problems should receive secondary, specialist assessment. (D)
Effectiveness of all types of therapy depends on the patient and the therapist forming a good working relationship. (B)
The patient's age, sex, social class or ethnic group should not determine access to therapy. (C)
Therapies of fewer than eight sessions are unlikely to be optimally effective for most moderate to severe mental health problems. Often 16 sessions are required for symptomatic relief, and more for lasting change. (C)
Counselling is not recommended as the main intervention for severe and complex mental health problems or personality disorders. (D)
A coexisting personality disorder may make treatment of most disorders more difficult and possibly less effective; indications of personality disorder include forensic history, severe relationship difficulties, and recurrent complex problems. (D)
Patient preference should inform treatment choice, particularly where the research evidence does not indicate a clear choice of therapy. (D)
Interest in self-exploration and capacity to tolerate frustration in gelationships may be particularly important for success in psychoanalytic and psychodynamic therapies. (C)
The skill and experience of the therapist should also be taken into account. More complex problems, and those where patients are poorly motivated, require the more skilful therapist. (D)
Patients who are adjusting to life events, illnesses, disabilities or losses may benefit from brief therapies such as counselling. (B)
Post-traumatic stress symptoms may be helped by psychological therapy, Hith most evidence for cognitive behavioural methods. Routine debriefing following traumatic events is not recommended. (A)
Depression may be treated effectively with cognitive therapy or interpersonalxtherapy. A number of other brief structured therapies for depression may be of benefit, such as psychodynamic therapy. (A)
Anxiety disorders with marked symptomatic anxiety (panic disorder, agoraphobia, social phobia, obsessive compulsive disorders, generalised anxiety disorders) are likely to benefit from cognitive behaviour therapy. (A)
Psychological intervention should be considered for somatic complaints with a psychological component, with most evidence for cognitive behaviour therapy in the treatment of chronic pain and chronic fatigue. (C)
Eating disorders can be treated with psychological therapy. Best evidence in bulimia nervosa is for cognitive behaviour therapy, interpersonal therapyçand family therapy for teenagers. Treatment usually includes psycho-educational methods. There is little strong evidence on the best therapy type for anorexia. (B)
Structured psychological therapies delivered by skilled practitioners can contribute to the longer-term treatment of personality disorders. (C)
Using the guideline to promote good practice
The contribution of research-based guidelines in psychological therapies is controversial, and they must be used judiciously if they are to promote good practice.
The new DoH guideline is only one part of a strategy to achieve high quality psychological therapies. Other components of the strategy include:
- Developing new techniques and theory (i.e. evidence-based practice must not stifle innovation)
- A range of research methods, including qualitative process research, formal randomised controlled trials of psychotherapy outcomes and large field trials of outcomes in routine provision
- Application of research to professional training and education
- Locally based standards of service delivery and outcomes
- Audit of local standards and outcomes benchmarking for common mental health problems
- Training programmes targeted at skill gaps within the NHS workforce.
In particular, there has been concern that the guideline will be used inappropriately and simplistically as a basis for service commissioning rather than as a support for clinical decision-making.
Certainly, it is hoped that the guideline will be used locally to inform and systematise agreed referral procedures between primary and secondary care, and to stimulate transparency and clarity in information about the range of therapies available locally.
Where a recommended therapy is not available locally, the guidelines may help in assessing local need for such services and in making decisions on priorities for investment.
However, in line with NHS Executive advice,1 such decisions should not be made solely on the basis of the evidence reviewed in this guideline, but also by attention to evidence of clinical effectiveness of the services delivered in localities.
The full guideline can be downloaded from the Department of Health website at www.doh.gov.uk/mentalhealth/treatmentguideline or free copies of the full or brief versions of the guideline can be obtained from: Department of Health Publications, PO Box 777, London SE1 6XH. Fax: 01623 724524; e-mail firstname.lastname@example.org. Please quote reference number 23044 when ordering.
- Department of Health. A Review of Strategic Policy on NHS Psychotherapy Services in England. London: NHS Executive, 1996.
- National Service Framework for Mental Health. London: DoH, 1999.
- Treatment Choice in Psychological Therapies and Counselling: Evidence based clinical practice guideline. London: DoH, 2001.
- Oxman AD, Guyatt GH. Guidelines for reading review articles. Can Med Assoc J 1988; 138: 697-703.