Future of psychotherapy in the NHS

Editor—In discussing the future of psychotherapy, Goldbeck-Wood and Fonagy comment on the difficulties in providing meaningful evidence about efficacy.¹ However, they do not explain that the specific problem is about the adequacy of control groups.²

Comparison of active with control treatment in psychotherapy cannot be conducted double blind as subjects inevitably know to which group they have been allocated. Drug trials may seem to have an advantage over psychotherapy trials in claims for scientific legitimacy because they can be conducted double blind by using placebo drugs. However, the degree of bias remaining in apparently double blind trials should not be underestimated.³,⁴

Goldbeck-Wood and Fonagy may have focused too much on evidence as factual without acknowledging the importance of interpretation and have therefore not spelt out the role of ideology in assessing efficacy. Evaluation of psychotherapy is controversial. Psychotherapy may be in conflict with biomedical psychiatry in its conceptualisation of mental illness. Moreover, statutory responsibilities under the Mental Health Act take precedence within mental health services over psychotherapy, which is a voluntary activity. Psychotherapy therefore struggles against the hegemony of biological psychiatry.

For reasons such as this, psychotherapy has established itself primarily outside the state sector, as Goldbeck-Wood and Fonagy note. Their solution is for the NHS to create a proper career structure for psychotherapists. Politically this may be less likely to be successful than taking advantage of the government policy for choice in the NHS.⁵ Primary care trusts need to look for alternative providers to meet the public demand for psychological therapies. Psychotherapists could organise themselves into provider organisations. These alternative providers should meet standards of training approved by such bodies as the UK Council for Psychotherapy and the British Confederation of Psychotherapists.