Psychological warfare: What's the best way to treat mental health problems?

You are probably unaware that a revolution is occurring in the way in which you will receive psychological therapy if, unfortunately, you become one of the many people who will suffer from anxiety or depression this year in the UK. This revolution is not of the velvet variety, with everyone in agreement that "things must change" to meet the exponential demand placed on psychological services. Instead, it is exciting passions, anger and schisms among mental-health professionals across the country.

Traditionally, a GP with a patient suffering from emotional distress would offer medication or, if available, a referral to a psychologist for a talking therapy. For many people, the clichéd image of psychoanalytic psychotherapy is that of a patient lying on a couch being encouraged to talk about their mother. In the 1980s, talking therapies took a different turn as scientific trials - as rigorous as those used for new medications - indicated that shorter-term treatment could be as effective as conventional analysis. Instead of dwelling on the past, patients were encouraged to find more balanced perspectives from which to view their negative and self-limiting thinking. They were also offered support in structuring activities in order to become more active and participate in life more fully. This combination therapy was called cognitive (thinking) behavioural (action) therapy, also known as CBT. Despite the marked differences between analytic and cognitive therapy, meeting with your therapist weekly was expected and uncontroversial, until now.

Today, however, when you visit your GP suffering from anxiety or depression, you might not get to see a therapist at all. A new development in psychological treatment potentially removes the need for one-to-one sessions in a process called "stepped care". This simply means that you enter treatment at the level appropriate to the severity of your problems. If, for example, you are feeling low but have few debilitating symptoms, you might be offered a "book referral scheme", whereby appropriate self-help literature is recommended. You might also be offered "guided self-help", where someone with a brief training in CBT can help you identify goals and direct you to source material and activities that can help you recover more quickly than if left to your own devices. You could also be offered a six-week computerised CBT package, often in your local library or health centre. But - in none of these initial interventions - would you see a trained psychologist at all.

If, and only if, your problems are complex enough to warrant it, will you receive a talking therapy from a mental-health professional. Again, the aim is to keep treatment in the community, so you are likely to see a psychologist or counsellor attached to a GP practice for an average of six sessions. Training psychologists is expensive and there are not enough of them to meet the public's reasonable expectation of receiving psychological help when they need it most, which is when they ask for it. Additionally, NHS budget restraints mean that many psychology posts are frozen or have disappeared altogether. (You may well suspect that this is why we now have new therapies that don't require a therapist.) All of which means that, even with the "stepped care" approach, there is still far more demand for talking therapy than the NHS has the capacity to provide.

David Richards, Professor of Mental Health at the University of York, describes current mental-health provision as "obscene". He says that, of the 164 people in every 1,000 who will face a mental-health problem this year, only 40 will receive any sort of treatment at all, 15 of whom will "get some form of probably ineffective talking treatment" and only two of whom will receive evidence-based CBT. "Obscene" because there are treatments that are available and proven to work which could reach thousands of people, rather than just a handful. He proposes, and is trialling, a radical and innovative CBT treatment that delivers immediate support within 24 hours of requesting help, with community-based case managers working collaboratively with their clients, with 75 per cent of contact being made via telephone.

Instead of the exclusive patient/therapist relationship, costly in both time and money, Richards asks us to "imagine a call centre, where 20 workers can make contact with 300 people a week, spending 30 minutes with each, accessing an informative database. People with mental-health problems say they want help at the moment they pluck up the courage to admit their needs. His system would end, he argues, "the long waiting times, inequality of access to therapy and the corresponding despair of those left unassisted". Richards cites evidence from more than 30 clinical trials to support his concept, which would utilise CBT as a foundation. It would be a mistake to assume, however, that CBT has wide acceptance in the mental-health community.

You don't have to be particularly aware of the levels of psychological support available in the UK to have noticed the current debate concerning CBT. The economist and philanthropist Lord Layard has encouraged Labour to take the nation's mental health seriously and to provide CBT to enable people to get over their emotional problems and get on with their lives. His laudable intentions have often been aggressively misrepresented as a form of psycho-fascism by psychotherapists who do not practise CBT, as was witnessed at the recent "Politics of Well-Being" debate in the House of Commons last month.

Darian Leader, a Lacanian analyst, claimed in the Guardian that CBT is no better than "taking a pill or injection" and is "merely a quick fix designed to get people back to work". More sinisterly, he writes that it was used by the Maoists to brainwash Chinese citizens during the Cultural Revolution - such is the ill-will directed at this scientifically tried and tested talking therapy. (Incidentally, a Lacanian session can last anywhere from five minutes to 90 depending on the "interpretation" given by the analyst, which would make scheduling it as a mainstream NHS therapy somewhat problematic.) Oliver James also claims that CBT is not a "real" therapy, bizarrely likening it to having "a Peter Mandelson spin doctor in your head".

Why is it then that a versatile therapy, effective in verbal, computerised and written form, and scientifically shown to help many people recover from depression and anxiety ends up being vilified, dismissed and attacked by many psychotherapists who all, presumably, want their patients to get better?

The answer may lie in part in the investment that analysts have to make to become trained in what is often felt by other psychological therapists to be a doctrine rather than a model of therapy. Psychoanalytic training demands that trainee therapists receive three to five sessions of psychoanalysis weekly, for eight months of the year, for up to six years, with each session costing approximately £50. Therapists have to invest heavily, both emotionally and financially, and in turn often have an expectation that their patients "should" be in therapy for a minimum of a year and often longer. Clearly, then, this is a therapy that is both practiced and received by the well-off, as there is very little provision for it in the NHS. The harsh reality is that talking therapies are expensive and time-consuming, and the most expensive and time-consuming of them all is psychoanalytic therapy.

It seems obvious that more people need access to therapy, and therapy should be community-based, therefore the way in which it is delivered needs a radical review. Professor Richards goes a long way in promoting his community-based model as a challenge to what could be argued as being an elitist, ethnocentric, middle-class psychotherapy clique, clinging like fundamentalists to the religion of analysis, while attacking other psychological methods as not being "real" despite the evidence to the contrary.

There is growing concern among therapists that the schisms that are polarising the therapeutic community are damaging to all, not least to the patients who look to us for help in their worst moments. It seems odd that professional colleagues, skilled in negotiating difficult subjects, find it hard to converse on this key issue to forge a future for talking therapies that is both viable and sustainable. The Campaign for Therapy (www.campaign fortherapy.org), to be launched this autumn, aims to put aside the arguments as to which therapy is best and highlight instead the common factors that ensure therapy is effective, whatever model is being used.

Just as we expect choice in many areas of our life, just as the Government promotes choice in medical treatment, choice should also be part of the mental-health provision in the UK. Not all psychological therapies suit all people. Some will be appalled by a computerised CBT package, others will find it helpful and life-changing. Some will want to see a therapist for many weeks, working analytically, others will want only a few, focused sessions, while still more will want telephone contact to help them manage their emotional difficulties.

You might not have been aware at the start of this article about the revolution occurring in mental health provision in this country, but you are now, so join the revolution and have your say by contacting the Campaign for Therapy. What sort of mental health service do you want? What would you be looking for in therapy? What sort of therapy would appeal to you and what issues would you want help with? Your voice matters. Join the revolution and let the psychological therapy "experts" hear what you have to say, before they decide it for you. s

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