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Since the introduction of the Improving Access to Psychological Therapies (IAPT) programme in NHS England, psychological therapy has gained traction as 'evidence-based' and 'effective' in both clinical and economic terms. In the process, psychotherapeutic care has been reconstituted as highly manualised, standardised, and quantifiable. Drawing on anthropological fieldwork with mental health practitioners, this paper examines some common tensions that practitioners experience in their daily work where psychotherapy is sought within the framework of evidence-based medicine (EBM). For therapists working within IAPT, extensive monitoring and practices of accountability have come to undermine psychotherapeutic efforts to care for patients as 'people'. As a result, many practitioners now feel that they are working in a 'factory of therapy' whereby psychological treatment is recast in the service of outcome measures, and by which critique of the IAPT service, as well as caring relations within it, have been precluded. [ABSTRACT FROM AUTHOR]

The City and Hackney Primary Care Psychotherapy Consultation Service is an innovative, public sector service designed to support GPs in meeting the needs of patients with complex psychological/physical health issues throughout the London Boroughs of Hackney and the City. This paper provides an account of how this new model for the National Health Service (NHS) developed in the context of psychotherapy provision within the NHS, within the national and local context in the UK and gives an overview of some the service's key features and how it differs from other services operating in primary and secondary care. A linked paper, in this journal, explores the reality within which the service functions and describes clinical outcomes, health economic data, the modifications to the original model and prospects for the future. [ABSTRACT FROM PUBLISHER]

Purpose: Evidence-based psychological therapies are available for severe and enduring mental health problems, but resources and access to these are limited within England. Practitioners in community mental health teams (CMHTs) can act as gatekeepers for access to psychological therapies for those in secondary care, but little is known about how they make referral decisions. This paper aims to understand how CMHT practitioners make decisions about who to refer or not, to secondary care psychological therapy services (PTS). Design/methodology/approach: A total of 11 CMHT practitioners were interviewed to understand the decision making processes underpinning their referrals or otherwise, to a PTS within NHS England. The data were analysed qualitatively using thematic analysis. Findings: Thematic analysis resulted in 11 sub-themes under three main themes of the self, the organisation and wider structure and the service user. Results indicated that some participants were referred automatically for psychological therapy if a service user asked or if there was external pressure to refer, while others' decisions were informed by contextual information such as the service user's ability to engage or change, risk status and limited organisational resources. Originality/value: This study explores the decision making of multi-disciplinary professionals referring to PTS. The findings have important implications for understanding some of the factors that can influence patient access to psychological treatment in secondary care. [ABSTRACT FROM AUTHOR]

Whilst an earlier paper (Part 1) in this journal describes the historical, political and economic drivers behind the creation of the City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), this paper (Part 2) focuses on exploring the context within which the service functions. The paper provides an overview of its operational model and is organised into 10 sections. The first section outlines the service's clinical practice, whilst the second addresses the value of GP consultations as a core part of the PCPCS's provision. The third section addresses how the service, as departure from a more ‘pure’ psychoanalytic tradition of providing longer-term therapy, has managed its provision of brief treatments. There is a description of how the service manages its team of multi-disciplinary clinicians and their work in a variety of micro-cultures, conveying some of the challenges faced by the service and the team since its inception. Thereafter, the quantitative and qualitative evidence for the service's clinical and cost effectiveness is assessed, including outcome results and findings from a health economic evaluation. To illustrate some of the service's work in practice, some disguised clinical vignettes are presented. The paper also summarises the service's recent clinical innovations, as well as its contribution to the field of research, audit and training. Finally, the way forward for the service is considered in the context of current and emerging trends in psychological provision in primary care. [ABSTRACT FROM PUBLISHER]

Purpose – The IAPT programme has been rolled out across England in the last ten years. Although undoubtedly many people have benefited from having greater access to psychological therapy there are several issues with the practicalities of Improving Access to Psychological Therapies (IAPT) and also with its ideology. The paper aims to discuss these issues. Design/methodology/approach – This is a personal reflection of working within the IAPT system for several years. Significant statements heard or interpretations of what has been said are presented alongside an analysis of the implications. Findings – A number of important concerns are presented. The overarching concept of the “McDonaldization” process is discussed as a way of encapsulating the IAPT experience; with its theoretical reliance on the medical model and the real world impact of tendering for services in the modern NHS. The impact of IAPT on cognitive behavioural psychotherapy is also highlighted. Originality/value – A lot has been written in the press and online about IAPT. Many of the criticisms seem to derive from people outside of the IAPT system, many of whom have their own personal or professional agenda for attacking IAPT and Cognitive Behavioural Therapy (CBT); often the criticisms are uninformed. This paper is a reflection of working within the IAPT system and not just an uninformed critique of CBT. Several concerns are raised that without remedy may seriously hold back the progress that psychological therapy has made in recent years. [ABSTRACT FROM AUTHOR]

Purpose – The mental health experience of people from ethnic minorities differs from that of the majority, including differential access to services and treatments. The 2014 National Health Service (NHS) Community Mental Health survey gathered data from 13,787 individuals in 57 NHS trusts in England, providing one means of monitoring such experience. The purpose of this paper is to analyse survey variables describing treatments offered to respondents for evidence of differential access or treatment experiences associated with ethnicity. Design/methodology/approach – Secondary analysis of survey data. Proportions for target variables were modelled using multilevel logit models. Ethnic background, age and gender were entered as independent variables. Findings – Respondents in most minority groups were more likely to be on the care programme approach (CPA) to provision than white British respondents and less likely to report receiving psychological treatments. Unmet need for psychological treatment was relatively high in certain Asian groups. Medication use was consistently high across respondents, but differences by ethnic background were evident. Research limitations/implications – The study was dependent on existing survey data of a relatively limited nature, and potentially subject to non-response bias. The survey excludes users of certain types of service, giving an incomplete cross-section. Originality/value – This represents a novel use of the data from the Community Mental Health survey, and complements evidence from a range of other sources. The findings mostly concur with other evidence but provide important new data in relation to medication, unmet needs in psychotherapy and use of the CPA. They remain suggestive of the complex nature of discrimination and/or unequal access and treatment in mental health services. [ABSTRACT FROM AUTHOR]

In this paper I will attempt to describe the treatment of a seriously ill patient in a National Health Service (NHS) clinic who suffered from recurrent depressive disorder with co-morbidity, repeated breakdowns and was at risk of suicide. The purpose of writing a clinical case study is to illustrate the vital importance of a psychoanalytically-informed approach in the treatment of a very ill patient in the public sector. At a time when there is a decrease in the provision of long-term psychoanalytic psychotherapy my aim is to illustrate its value in the understanding and treatment of complex disorders, a perspective that seems to be under constant threat from internal and external pressures and at risk of being sidelined as a non-evidence-based form of treatment. I will try to describe the different stages in the treatment; from referral through to the beginning of treatment, its interruption, the patient's breakdown and admission, and finally his return to treatment upon discharge. The ending will be discussed with a view to highlighting some of the patient's internal movements enabled by the work undertaken. [ABSTRACT FROM AUTHOR]

Low‐intensity interventions for common mental disorders (CMD) address issues such as clinician shortages and barriers to accessing care. However, there is a lack of research into their comparative effectiveness in routine care. We aimed to compare treatment effects of three such interventions, utilizing four years' worth of routine clinical data. Users completing a course of guided self‐help bibliotherapy (GSH), internet‐delivered cognitive behavioural therapy (iCBT) or psychoeducational group therapy (PGT) from a stepped‐care service within the NHS in England were included. Propensity score models (stratification and weighting) were used to control for allocation bias and determine average treatment effect (ATE) between the interventions. 21,215 users comprised the study sample (GSH = 12,896, iCBT = 6862, PGT = 1457). Adherence‐to‐treatment rates were higher in iCBT. All interventions showed significant improvements in depression (PHQ‐9), anxiety (GAD‐7) and functioning (WSAS) scores, with largest effect sizes for iCBT. Both propensity score models showed a significant ATE in favour of iCBT versus GSH and PGT, and in favour of GSH versus PGT. Discernible differences in effectiveness were seen for iCBT in comparison with GSH and PGT. Given variance in delivery mode and human resources between different low‐intensity interventions, building on these findings would be valuable for future service provision and policy decision making. [ABSTRACT FROM AUTHOR]

A strong association exists between the quality of nurse‐service user therapeutic relationship and care outcomes on acute mental health inpatient wards. Despite evidence that service users desire improved therapeutic engagement, and registered mental health nurses recognize the benefits of therapeutic relationships, such interactions remain sub‐optimal. There is a dearth of evidence on factors influencing implementation of interventions to support and encourage therapeutic engagement. This study aimed to understand the barriers and enablers to implementation of the Therapeutic Engagement Questionnaire (TEQ), across fifteen acute inpatient wards in seven English mental health organizations. Qualitative methods were used in which data were collected from ethnographic field notes and documentary review, coded, and analysed using thematic analysis. Theoretical framing supported data analysis and interpretation. Reporting adheres to the Standards for Reporting Qualitative Research. The TEQ as an evidence‐based intervention co‐produced with service users and nurses was valued and welcomed by many nurse directors, senior clinicians, and ward managers. However, a range of practical and perceptual factors impeded implementation. Furthermore, many existing contextual challenges for intervention implementation in acute inpatient wards were magnified by the COVID‐19 pandemic. Suitable facilitation to address these barriers can help support implementation of the TEQ, with some transferability to implementation of other interventions in these settings. Our study suggests several facilitation methods, brought together in a conceptual model, including encouragement of reflective, facilitative discussion meetings among stakeholders and researchers, effort put into winning nurse 'buy‐in' and identifying and supporting ward‐level agents of change. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the clinical perspectives and experiences of therapists when engaging in direct dialogue with auditory hallucinations. Method: Therapist accounts were explored via a qualitative study nested within a pilot randomized controlled trial of a novel intervention for supporting distressed voice‐hearers (Talking with Voices). Five therapists were involved, none of whom had substantive previous experience of the technique. All agreed to take part in two semi‐structured, in‐depth interviews which were arranged prior to delivering therapy and again after therapists had experience of conducting dialogues. Data were analysed using inductive thematic analysis. Results: Participants described their impressions of seeking to improve the relationship between voice(s) and voice‐hearer using dialogue. The findings are organized within three main themes and associated subthemes: (1) Commitment to delivery (professional values, mentorship, professional growth); (2) Communication and collaboration (therapeutic alliance, relationships with voices, managing clinical perceptions); and (3) Challenges of delivery (client/voice engagement, impact of trauma, systemic issues). A series of recommendations are derived from the findings to support implementation and guide the practice of therapists undertaking dialogue work with clients who hear voices. Conclusion: Despite clinical challenges, therapists also identified professional gains from conducting their work. Their accounts demonstrate that it is possible for practitioners with no previous formal experience to engage in direct communication with voices within a context of appropriate training and supervision. Practitioner points: Therapists with no previous experience of dialogue work can be trained and supported to verbally engage with the voices heard by people experiencing psychosis.Therapeutic alliance and therapist values are important components of successful therapy.Confidence for dialoguing with voices can be increased through drawing on therapist's existing transferable clinical skills.The emotional and practical needs of therapists undertaking such work should be addressed through training and regular group supervision. [ABSTRACT FROM AUTHOR]

A new diagnosis of Complex Post-traumatic Stress Disorder, CPTSD, is included in ICD-11 which was adopted in May 2019 by the World Health Organisation, WHO. In addition to the symptoms of PTSD, CPTSD includes emotional dysregulation, negative self-concept, and disturbances in relationships. It may be a helpful diagnosis for trauma survivors with experiences of human mistreatment such as torture and abuse. This study explores the views of patients in the community on psychotherapy for the diagnosis of CPTSD, taking a qualitative, participatory approach. Twenty-four former patients from an NHS secondary mental health service in London interviewed each other about their treatment. Participants also collaborated in data analysis. All had a diagnosis of PTSD, with additional symptoms of CPTSD identified at assessment. The key factor in recovery was rebuilding relationships, beginning with the therapist. Groupwork was helpful in promoting relationships with others, as it may result in shame reduction. Involvement in the wider community through peer support groups was also valuable. The rebuilding of relationships based on trust was an active mechanism of change and recovery from CPTSD. Participants felt that sufficient time, at least one year of psychotherapy with weekly sessions, was needed. [ABSTRACT FROM AUTHOR]

Objectives: To assess progress towards improving the administering of electroconvulsive therapy (ECT) in England since an audit covering 2011, 2013, and 2015. The same information was gathered, for 2019, on usage, demographics, consent, and adherence to national guidelines and the Mental Health Act. Design and Methods: Freedom of Information Act requests were sent to 56 National Health Service Trusts. Results: Thirty‐seven trusts (66%) provided data. The gradual decline in the use of ECT in England has levelled off at about 2,500 people per year. There was a 47‐fold difference between the Trusts with the highest and lowest rates per capita. Most recipients are still women (67%) and over 60 (58%). Only one Trust could report how many people received psychological therapy prior to ECT, as required by government (NICE) guidelines. More than a third of ECT (37%) is still given without consent, with 18% of Trusts non‐compliant with legislation concerning second opinions. There were slight declines, compared to a previous audit, in the use of standardized depression scales, down to 30%, and standardized measures of cognitive dysfunction, down to 24%. Only six Trusts provided any data for positive outcomes and seven for adverse effects. None provided data on efficacy or adverse effects beyond the end of treatment. Twelve Trusts used identical sentences to each other, verbatim, in response to one or more questions. Conclusions: Given the apparent failure of current monitoring and accrediting of ECT clinics in England, by the Royal College of Psychiatrists' ECT Accreditation Service (ECTAS), an independent government sponsored review is urgently needed. Practitioner points: Psychologists and other mental health staff should ensure that people are offered evidence‐based psychological treatments before being offered E.C.T.All staff should ensure that patients are fully informed of the high risk of memory loss and the smaller risk of cardiovascular failure and mortality.Individuals receiving ECT should be closely monitored for adverse cognitive effects, and treatment immediately terminated if these become apparent.Because of increased risk of memory loss for women and older people, the use of ECT should be kept to a minimum and avoided where possible, with these two groups. [ABSTRACT FROM AUTHOR]

This qualitative study explores the experiences of five primary care counsellors working in the NHS with clients identified as diagnosable with borderline personality disorder (BPD). Participants completed a semi-structured interview about their experiences of clinical work with BPD clients. Interview transcripts were analysed via Interpretative Phenomenological Analysis (IPA) and three master-themes were identified: recognition and implications; managing feelings of inadequacy; and managing dilemmas in the primary care context. Despite struggling to manage feelings of failure evoked by these clients, counsellors described feeling a sense of ethical responsibility, and adapted the traditional short-term model of counselling to ensure clients received ongoing, supportive work. Whilst NHS guidelines propose that BPD is best managed and treated in secondary care and specialist services, this study found that counsellors are working with this complex group of clients in primary care and require specialist supervision and support in managing unconscious process issues emerging from the work. [ABSTRACT FROM AUTHOR]