by Jay Beichman
Evidence-based medicine can be conceptualised as a three-legged stool in which ‘the use of evidence (first leg) is to be balanced with the expertise of the clinician (second leg) and characteristics and context of the patient (third leg)’ (Wampold & Imel, 2015, p. 11). It has been further described as making ‘use of individual patients’… preferences in making clinical decisions about their care’ (Sackett et al., 1996, p. 71). Sackett et al. (1996) warn that ‘without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient’ (p. 72). It is important to note that in these conceptualisations of evidence-based medicine, which are mostly sympathetic to and uncritical of it, evidence is not seen as superior to ‘clinical expertise’, and it is also not seen as superior to patient choice. Yet arguably, in the practical application of evidence-based medicine, it seems as if two legs of the stool have been taken away, with just the first leg (that of evidence) being considered, with the wishes of clinicians and patients being demoted if not forgotten. This was how some practitioners viewed the impact of evidence-based medicine in the USA, and it is also how many practitioners began to view it in the UK, especially since the establishment of the National Institute for Clinical Excellence (NICE) in 1999 (its title was later changed to the National Institute for Health and Care Excellence, but it uses the same abbreviation).
NICE states that their aim was ‘to ensure that the most clinically and cost effective drugs and treatments were made available widely on the NHS in England and Wales’ (NICE, 2016, online) and to ‘speed up the pace at which good value treatments were used’ (ibid.). They also claim that they ‘established a worldwide reputation for producing authoritative, evidence-based advice and guidelines’ (ibid.). In this self-appraisal it is worth noting the casual use of the phrase ‘evidence-based’, which has fully seeped into everyday discourse and is used, without any need of explanation or critique, throughout the media. Everyone knows, or thinks they know, what it means. It is also worth noting the managed-care implications of ‘good value treatments’ putting the cost of treatments as a central concern. NICE is, unsurprisingly, supportive of the medical model, and this necessarily has implications for the provision of therapy. Therapy was perceived by NICE as a medical treatment like any other, and it seemed as if therapeutic practices were shoehorned into the medical model, without any consideration that they might not be as straightforwardly understood in the same way as drug treatments or medical devices.
This is partly due to NICE’s privileging of RCT evidence over any other kind (see, for example, NICE, 2014/2017, p. 103 cited in Barkham et al., 2017). The BACP in its response (BACP, 2017a) to the NICE draft guideline for depression note that RCTs are seen as superior to even the ‘very large… IAPT dataset’ (ibid., comment 8) and therefore does not even follow ‘NICE’s own procedural manual’ (ibid.). As Loewenthal puts it: ‘whilst [NICE] recognises many of the issues concerning its methodology, it ends up acting as if they don’t exist’ (Loewenthal, 2016, p.18). Loewenthal (2016) suggests that therapy’s historical and contemporary practices of supervision, writing and presenting papers provide a functional way of monitoring and evaluating practice which is superior to RCTs which he asserts are ‘against the very nature of what for many is the therapeutic enterprise’ (p. 14). He perceives the emphasis on RCTs, and similar forms of privileged quantitative research, shaping practice detrimentally, and mourns ‘[t]heoretical explorations’ not being seen as research at all. He cites the APA’s encouragement of a pluralistic approach to research methodologies to suggest a way forward for NICE and IAPT, whose over-adherence to a medicalised symptom-based model constructs versions of therapy, and ways of researching therapy, which can only be useful for therapists and clients if they are in agreement that the latter’s problems fit neatly into diagnostic labels. Real consequences of the monistic, quantitative and scientistic approach to approving therapies are that choices for NHS patients are, self-evidently, limited to the approaches that have been approved, and therapists, some with decades of clinical practice and experience, who have not trained in these approved practices, are perceived as having nothing to offer. This issue has been highlighted by research undertaken by the BACP (Perfect et al., 2016) in their document Choice of Therapies in IAPT: An overview of the availability and client profile of step 3 therapies. Barkham et al. (2017) also make the point that ‘improving patient treatment choice improves therapy outcomes’ (ibid., p. 264), so reducing choice is counter-productive. Additionally, despite the success of Counselling for Depression (CfD) in RCTs leading to it being nominated by NICE as an ‘evidence-based’ therapy, CfD practitioners only make up ‘6% of the high-intensity therapist workforce’ (Drewitt et al., 2018). In other words, even providing the required evidence does not seem to have made much impact in improving choice of different therapies for clients.
The biggest change affecting the provision of therapy in the UK was the formation of IAPT. This has been dated to 2003 when Lord Layard met Professor David M. Clark at a British Academy tea party (Evans, 2013). From a symbolic interactionist perspective it is notable that perhaps the most important development in the provision of therapy in the UK this century occurs in a microsocial context.
On one level, the introduction of IAPT, when it came, was a giant leap for the provision of therapy in Britain, as ‘[b]efore IAPT, the NHS spent just 3% of its mental health budget on talking therapy’ and ‘IAPT… tripled that budget’ (ibid.). However, with the publication of the NICE guidelines for depression in 2004, it was disappointing for therapy professionals that only two types of therapy were recommended – namely, CBT and a time-limited, structured therapy called interpersonal therapy (IPT). All other approaches were not recommended for depression because, according to NICE’s definition of evidence, all other approaches did not have enough to gain the status of ‘evidence-based’. Even accepting that therapeutic approaches should be seen as targeting specific disorders, and prove their effectiveness at targeting them, the guidelines were problematic, as the evidence was clearer for ‘severe’ as opposed to ‘mild’ or ‘moderate’ depression. Therefore a potential danger, recognised by medical professionals themselves, was that clinicians/patients might take on a more serious ‘depression’ diagnosis in order to obtain treatment that would not be available with a less serious or non-medicalised complaint. However, the evidence of what worked for mild or moderate depression was not as robust so, ultimately, there was not sufficient evidence that people with mild or moderate depression were actually getting evidence-based treatment (Middleton et al., 2005).
In January 2005, Layard and Clark presented their recommendations at 10 Downing Street, and proposals for IAPT went into the Labour Party’s manifesto for the 2005 general election (Evans, 2013; Cohen, 2008). One major reason that Layard and Clark were able to get the Labour government to commit to an IAPT programme was because ‘CBT had built up a big evidence base to show it worked’ (Evans, 2013, online; see also Research Excellence Framework, 2014) – although the superiority of CBT to counselling and other psychological therapies is easily disputed (e.g. Barkham et al., 2017). When what has come to be known as Layard’s ‘Depression Report’ came out in 2006, CBT was recommended as a therapeutic approach that would not just be effective, but also inexpensive and efficient (CEPMHP, 2006). In the report CBT was described as the ‘most developed of [the evidence-based psychological therapies]’ (p. 1). Of the 10,000 new therapists that they proposed should be trained in delivering CBT, they suggested that half of them should be ‘clinical psychologists’, and the other half trained from the existing workforce of ‘nurses, social workers, occupational therapists and counsellors’ (p. 7). It is interesting to note that counsellors are enumerated last in that list, and their expertise in delivering therapy only acknowledged as equivalent to the other professions that precede their mention. Psychotherapists receive no mention at all. This powerful document, whose effects are still reverberating around the provision of therapy in the NHS, effectively discounted the expertise of therapists (both psychotherapists and counsellors) already working in the NHS, and the models they had trained in, as insufficient for the task of ‘improving access’ to psychological therapies. Documents like this came to create a cultural ground in which CBT became privileged as the best therapeutic approach at the expense of others. Perhaps the only ‘winners’, in terms of increased employment opportunities and power, were psychologists associated with CBT: recent figures (IAPT’s own) state that 42 per cent of the IAPT workforce are CBT practitioners (Drewitt et al., 2018).
Therefore, in the sociohistorical developments of the therapy profession in the UK, a trajectory can be traced from competing interests within the profession itself, leading to an emphasis on research which then leads to an emphasis on the RCT. In response to the context of a developing audit culture and that culture’s need for evidence and efficiency, CBT, with its evidence base and perceived efficiency, then comes to dominate the provision of therapy, and other approaches lose their status and are marginalised, if not erased, from public providers. The private sector, EAPs, insurance companies and the third sector continued to provide employment opportunities for other approaches but, within the NHS, CBT, to a great extent, began to monopolise therapy provision.
The dominance of CBT and the marginalisation of other types of counselling and psychotherapy is one of the biggest, most frustrating problems facing current practitioners and of course, clients, who cannot access what these therapists provide even if they know it is what they want. You could say CBT has been the flavour of the past decade in the NHS and beyond. In terms of public relations it has made great achievements in influencing the media, usually uncritically, to accept it as the only evidence-based therapeutic approach for a wide array of ‘disorders’. Simultaneously it has come under attack from therapists who do not follow the approach, perhaps with some rationality, but also with emotional defensiveness (e.g. Leader, 2008). For therapists who do not follow the approach, and have belief in the efficacy of their own non-CBT approaches, it can seem like watching helplessly as one pupil gets all the prizes.
A common critique of CBT, articulated in different ways, is that it reflects a wider neoliberal agenda in which teaching ‘“technologies of the self” to the CBT patient echo Foucault’s notion of “disciplinary power”… where the state uses subtle power to mould its subjects into acquiescence’ (Watts, 2016, p. 89). Unsurprisingly, CBT practitioners and their proponents rebuff these kinds of criticisms as a caricature (e.g. Veale, in Samuels & Veale, 2009).
In 2008, adding to the plurality of psychological practitioners, the DH produced an implementation plan for the training of ‘low-intensity therapies workers’ who would facilitate the use of CBT via ‘guided self-help and computerised CBT’ (Department of Health, 2008, p. 3). These workers would come to be known as ‘Psychological Wellbeing Practitioners’ (PWPs) who would be perceived as fit to practise after 45 days training (ibid.). One advantage, in terms of cost, is that these practitioners could expect a maximum pay rate less than even a trainee psychotherapist. Therefore therapists in the NHS were not only coming under pressure in terms of their approaches being devalued, but also in terms of their professional opportunities being ‘undercut’ by the creation of jobs/titles purportedly needing less expertise and a ‘proletarianisation’ of therapeutic practice.
It is against this background of an audit culture which based its decisions about therapy provision on narrow definitions of evidence that led to the monistic hegemony of CBT in the NHS and the pushing away of counsellors and psychotherapists into other sectors.
BACP (2017a). BACP response to NICE: Depression in Adults: Recognition and Management consultation on draft guideline. Accessed at https://www.bacp.co.uk/media/2275/bacp-response-nice-guidance-depression-in-adults.pdf on 6 March 2018.
Barkham, M., Moller, N.P. & Pybis, J. (2017). How should we evaluate research on counselling and the treatment of depression? A case study on how the National Institute for Health and Care Excellence’s draft 2018 guideline for depression considered what counts as best evidence. Counselling & Psychotherapy Research, 17(4). 253–268.
CEPMHP (The Centre for Economic Performance’s Mental Health Policy Group). (2006). The Depression Report: A New Deal for Depression and Anxiety Disorders. Centre for Economic Performance, London School of Economics. Accessed at eprints.lse.ac.uk/818 on 15 November 2017.
Cohen, A. (2008). IAPT: A brief history. Healthcare Counselling & Psychotherapy Journal, April. 8–11.
Department of Health. (2008). Improving Access to Psychological Therapies: Implementation Plan: Curriculum of Low-Intensity Therapies Workers. London: Department of Health.
Drewitt, L., Pybis, J., Murphy, D. & Barkham, M. (2018). Practitioners’ experiences of learning and implementing Counselling for Depression (CfD) in routine practice settings. Counselling & Psychotherapy Research, 18(1). 3–13.
Evans, J. (2013). A brief history of IAPT: The mass provision of CBT in the NHS. Accessed at https://emotionsblog.history.qmul.ac.uk/2013/05/a-brief-history-of-iapt-the-mass-provision-of-cbt-in-the-nhs/on 11 November 2016 (originally posted 30 May 2013).
Leader, D. (2008). A quick fix for the soul? Guardian, 9 September. Accessed at https://www.theguardian.com/science/2008/sep/09/psychology.humanbehaviour
Loewenthal, D. (2016). Therapy as cultural, politically influenced practice. In J. Lees (Ed.), The Future of Psychological Therapy: From Managed Care to Transformational Practice. Abingdon: Routledge.
Middleton, H., Shaw, I., Hull, S. & Feder, G. (2005). NICE guidelines for the management of depression: Are clear for severe depression, but uncertain for mild or moderate depression. British Medical Journal, 350. 267.
NICE. (2016). History of NICE. Accessed at https://www.nice.org.uk/about /who-we-are/history-of-nice on 11 November 2016.
NICE. (2014 / updated 2017). Developing NICE guidelines: the manual: process and methods. Accessed athttps://www.nice.org.uk/process/pmg20/chapter/introduction-and-overview on 4 July 2018.
Perfect, D., Jackson, C., Pybis, J. & Hill, A. (2016). Choice of therapies in IAPT: An overview of the availability and client profile of step 3 Therapies. Lutterworth: British Association for Counselling & Psychotherapy.
Research Excellence Framework. (2014). Improving policy and practice to promote better mental health. Accessed at http://impact.ref.ac.uk/CaseStudies/CaseStudy.aspx?Id=40639# 6 September 2017.
Sackett, D.L., Rosenberg, W.M., Gray, J.A.M., Haynes, R.B. & Richardson, W.S. (1996). Evidence based medicine: what it is and what it isn’t. British Medical Journal, 312. 71–72.
Samuels, A. & Veale, D. (2009). Improving access to psychological therapies: For and against.Psychodynamic Practice, 15(1). 7–24.
Wampold, B.E. & Imel, Z.E. (2015). The Great Psychotherapy Debate: The Evidence for What Makes Therapy Work, 2nd Edn. Hove: Routledge.
Watts, J. (2016). IAPT and the ideal image. In J. Lees (Ed.), The Future of Psychological Therapy: From Managed Care to Transformational Practice. Abingdon: Routledge.
Jay Beichman is a member of the uACT organising group.