No Health Without Mental Health

Greetings all!

The Coalition Government has just published its initial plans on mental health - "No Health Without Mental Health": "No Health Without Mental Health"

I don't want to go into the content of the document at present or even raise the question of how mental health can be improved within a context of service cuts.

Instead, I want to draw your attention to and seek your thoughts on a key expressed assumption within the document highlighted by NHS Networks, namely that " THE GOVERNMENT [HAS THE] AIM OF ACHIEVING PARITY OF ESTEEM BETWEEN PHYSICAL AND MENTAL HEALTH". I’ve never come across such a strongly expressed statement of parity between physical and mental health in ANY government policy document before.

Now, of course, this may all be talk and that the reality may be quite different. However, my cynicism isn't quite so marked - not because of my belief in the intrinsic altruism of governments - but rather because of the financial issues currently being grappled with.

Firstly, there is the issue of the welfare budget. Forgive me if I'm teaching you to suck eggs here but for those unaware of the history of incapacity benefits let me give some brief background. Twenty years ago, Invalidity and Sickness Benefit (as it was then called) along with associated housing benefit was significantly short term in nature (six months or less) and primarily claimed by those with industrial injuries and pain problems. By 2010 this situation had radically changed whereby an increasing number of claimants were claiming for more than six months and over 50% of these were claiming for mental health problems. At estimated costs of £16 billion a year all political parties began to look seriously at the question of addressing this cost. IAPT (Increasing Access To Psychological Therapies), introduced by the last government and extended by this government by hundreds of millions of pounds, is the most visible example of how seriously central government now takes mental health. (CBT Training); (Managing Depression)

Secondly, the parity between mental health and physical health has also become apparent as a result of their interconnectedness - again from the perspective of the costs, this time associated with health costs associated with "long term conditions". The latter includes such illnesses as diabetes, cardiovascular problems, respiratory diseases and stroke. They are conditions that are often associated with repeated hospital admissions (which are costly) usually prompted by failure to maintain changes in health behaviour or because of the de-motivating effects of mental health problems such as depression. The thinking is that IF services can address depression or poor motivation in such groups, hospital re-admission rates will fall and costs reduced. (Motivational Interviewing Training); (Psychological Coping Post-Stroke)

Now this is all very understandable and laudable stuff - all industrialised countries at present are trying to contain healthcare costs, but a recognition that mental and physical health are intrinsically interconnected strikes me as a radical new framework in which to start debating this. However, it also raises difficult questions about the priorities that we we establish within this however.

• With limited money, do you agree that Depression and Degenerative Arthritis are of "parity of esteem".
• What about Panic Attacks and Palliative Care or Gall Bladder problems and Generalised Anxiety Disorder? Or do you think that we should recognise that such "parity of esteem" varies according to the type of problem.
• Should Botox continue to be funded on the NHS in certain circumstances when those with a diagnosis of borderline personality disorder still have problems finding ANY service wanting to work with them?
• Should Pancreatitis be seen as having a "parity of esteem" with PTSD or should the latter be seen as a more pressing issue.

These are difficult questions with no easy answers. However the government's express acceptance of "parity of esteem" between physical and mental health opens up this debate.

WHAT DO YOU THINK? ALL VIEWS AND IDEAS ARE GREATLY WELCOMED.

Whats going to happen to CBT after IAPT is cut back ?

Well...the writing is on the wall. IAPT looks like its in the frontline for public spending cuts.

The Observer this month says that the The Iapt Expert Reference Group (that oversees the project) has been informed that IAPT is failing to meet its targets in a big way - both in training the number of therapists needed, and in the number of people who have come off of benefits as a result of interventions made. Many staff are being asked to reapply for their jobs and the remaining £100 million allocated will not be ringfenced but will be incorporated into local NHS Trusts' budgets - to be spent as they wish. This will almost inevitably mean that traditional mental health priorities will re-establish themselves and that those perceived as "the worried well" will be left out.

The interesting question is whatb is going to happen to CBT as a result ? There are undoubtedly many who are secretly happy to see what is going to happen. Whenever someone grabs a large share of the pie ( and nearly £200 million is a VERY large share) it creates powerful reactions - jealousies amongst non-CBTers who feel unjustifiably excluded, fear amongst traditional CBTers - of which I must count some in my own profession - who fear poorer qualified (and cheaper) therapists taking their jobs.

However, I have strong suspicions that the CBT project is not dead in the water and will continue and even thrive - except in a slightly different format. Here are my predictions for CBT for the next 10 years.

(1) CBT will continue to thrive because both governments and insurance companies (the main funders and benchmarkers of therapy) want evidence that what they fund works and has a clear time limited structure to it. Whatever some people think about the application of RCTs and experimental paradigms to therapeutic outcomes,they are a continuing and growing part of the Zeitgeist we are a part of, and at present CBT is really the only show in town.

(2) CBT will fit in well to the developing mixed economy in mental health that will grow with increasing speed. There will be more people wanting to see CBT therapists on a private basis and CBT will infiltrate (even further) organisations interested in behaviour change. The Welfare-to-Work and the Criminal Justice sectors being obvious first past the post candidates.

(3) The concept of Accredited CBT Therapist will continue to be an aspirational gold standard for many, but will lose its exclusive cache. Expect to see "Non-Accredited" CBTers fulfilling important roles and a greater variation in the types and length of training on offer.

At SDS, we have long been convinced of the need for shorter intensive CBT course that are recognised (our Introductory 3 day course is Approved by The British Psychological Society) but which do not place the same heavy demands on trainees that BABCP Accreditation requires. If you are interested in such a course, by the way, details can be found at http://www.skillsdevelopment.co.uk/seminars.php?courseid=69

Equally expect distance learning methods to gain pace from training DVD packs (www.psychotherapydvds.com) to webcam conferences.

(4) Finally, we will see other forms of psychotherapy coming to the fore again. These will be those that have learnt the importance of published outcome work as a marketing tool and who already have some footholds within the establishment. Brief Solution Focused Therapy, Brief Dynamic Psychotherapy and Interpersonal Psyschotherapy seem obvious candidates. Those that fight a rearguard action against registration and regulation (you know who you are) and who totally dismiss the value of empirical research will disappear even further into the shadows

Whatever happens, its likely that even a partially completed IAPT will leave its mark on the landscape. In my opinion, for the better. Which is reassuring really. I'd hate to think that £75 million was spend and its effects disappear without a trace.

Paul Grantham
Consultant Clinical Psychologist