Tuesday, December 01, 2009

Third New Savoy Conference on Psychological Therapies in the NHS

Two years ago, I attended the first New Savoy Conference on Psychological Therapies in the NHS, engineered by Jeremy Clarke in the wake of the Improving Access to the Psychological Therapies initiative, which had appropriated 172 million pounds to a scheme to move people off of the unemployment and disability rolls by offering them CBT for anxiety and depression. In a blog entry I wrote at the time, I discussed the tension and bad feelings that were rife at this earlier conference; this so struck me that, along with M., I started a dialogue with Tony Roth and Steve Pilling, which resulted in our involvement in the Humanistic Competence Expert Reference Group (also documented extensively in this blog). I didn’t go last year, from sheer overwork and because I wasn’t invited to speak, but Michael Barkham invited me to be part of a panel, so I was happy to come along this time.

What a difference two years can make! The mood of this conference was very different: While not always amicable, it was much less confrontational. Resentments and concerns remain, and bubbled to the surface from time to time, but there was a real sense of movement openness and dialogue. Here is my personal list of emerging trends and highlights: (I’ll discuss the greater focus on wellbeing separately in a later entry.)

1. Opening IAPT for nonCBT therapies? I think the biggest news is that the parties running IAPT (the Improving Access to Psychological Therapies initiative) are now promising to include a wider range of therapies including Interpersonal Psychotherapy, Brief Dynamic Therapy, Couples therapy, and Counselling. Andrew Burnham, Secretary of State for Health (=Health Minister) said this to us in his speech on Thursday, also noting that all therapies listed in the NICE guidelines would be included. This introduced some ambiguity into the government’s position, because brief dynamic therapy and counselling are only included in the revised guidelines (published last month) as a last resort therapy for clients who decline CBT or IPT, and then only with a health warning about the lack of evidence. But I guess this means that Counselling (still not defined) is being considered as inside the fence, which puts it in a better position that EFT, still ignored in spite of RCTs. Similarly, we took it as a good sign that Andy Burnham also referred to “getting the most out of experienced workforces of counsellors and psychotherapists”, many of whom lost their jobs when they were supplanted by IAPT CBT workers. Indications are that in many places, these workers were subsequently hired back in IAPT programs, often after brief top-up CBT training.

2. Update on the IAPT evaluation. Back at the beginning of the IAPT initiative, Glenys Parry, Michael Barkham, Gillian Hardy and their team at Sheffield landed the contract to do the independent evaluation of the IAPT pilot sites in Doncaster and Newham (an area of London). Glenys presented an update on their progress on Thursday, apologizing for the lack of outcome data, which due to various circumstances are still being analyzed. In addition, they are still collecting data from their matched control cohorts. She did present some fascinating audit, qualitative and organizational data. It is already clear, for example, that the program has succeeded in delivering services to a significantly larger population of clients; in other words, the IAPT program has in fact Improved Access to Psychological Treatments, as advertised. Glenys went on to describe qualitative data on helpful (many) and hindering (relatively few) aspects of the program. She also pointed to the crucial role of good IT systems for managing both treatment and data analyses. The outcome data are expected to be available in 6 months or so and should be worth the wait.

3. Life span view: Delivery of services was described in various sessions for children/young people, in the workplace (adults), and older people. This yielded a much more balanced coverage of the range of client populations that is generally present at an SPR conference, and so very informative presentations.

4. Acceptance of the importance of research and measurement of therapy outcome: A huge shift here compared to two years ago. The issue now is not whether but how, and what should be done in addition to quantitative outcome monitoring. Michael Lambert, Wolfgang Lutz and Dave Richards did a useful session: Mike Lambert reported that there have now been two successful RCTs on the usefulness of providing feedback together with a set of clinical support tools, that is, further assessment instruments to evaluate the cause of a therapy being off track (these include therapeutic alliance, social support, motivation for change).

In addition, Dave Richards reported an emerging critique of the Stiles et al (2006 & 2007 studies), in the form of intent-to-treat analyses of these data, which show much smaller effect sizes than the completer analyses. Intent-to-treat analyses deal with missing posttherapy scores by carrying forward the last available data point and using it to replace the missing data, even if this is the pre-therapy score. This method is used in RCTs to deal with the internal (i.e., causal) validity threat of selective attrition, that is, distortions in outcome results due to clients in different treatment conditions differentially dropping out. This is the first time I’ve heard of intent-to-treat analyses being used for nonrandomized pre-post designs. Like intent-to-treat analyses more generally, this one only addresses the effects of assigning clients to therapy, not the effects of therapy itself.

5. Anti-stigma initiative. The New Savoy Declaration, the constituting document for these conferences, was modified to add anti-stigma language, and the issue of stigma and what to do about it was a recurring theme. At a reception on Thursday night, mental health user advocates previewed a sophisticated new advertising campaign, which seems to me to have a greater potential for success than previous campaigns have had to date.

6. Continuing role and voice of service users. One of the best things about the New Savoy conferences is the strong role played by mental health service users. This is far different from any of the other conferences that I go to and makes a refreshing change. One of the high points of the conference occurred on the panel of mental health issues in older adults: A service user named Bill Davidson, a very articulate retired former head teacher, was speaking when the panel chair passed him a note saying that his time was up. He took the note, looked at it, set it down, and said to the audience, “I’m a service user -- that means I can talk as long as I want!” The audience applauded.

7. The voluntary sector. Another thing I noticed this year was that more attention was being given to the voluntary sector, that is, mental health charities or nonprofit counselling and advocacy services, recognizing the vital role these counselling services and advocacy organizations play in the mental health sector.

8. Continuing dialogue with CBT therapists. As was the case two years ago, the conference again provided an opportunity to talk with various CBT types. I think that we tend to get quite insular in the PCE approach, only talking among ourselves. So I welcomed the chance to talk further with Tony Roth, Shirley Reynolds, and Roz Shafran, and look forward to continuing these conversations.

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