Analysis
and Critique of
the
Consultation Document
Psychological
Therapies Specification Draft 0.9 July 2011
Presented by UNITE on behalf of the Specialist Psychodynamic
Psychotherapy Service
17/10/2011
ANALYSIS AND CRITIQUE OF THE CONSULTATION DOCUMENT ‘Psychological Therapies Specification’
Draft Version 0.9
This paper offers an analysis and
critique of proposals contained in the Consultation Document 'Psychological
Therapies Specification Version 0.9 (Draft)' produced by Derbyshire PCT Commissioners
in July 2011.
It is presented by UNITE on
behalf of Clinicians who work as Specialist Psychodynamic Psychotherapists
within the Derbyshire Healthcare NHS Foundation Trust.
We address concerns about the processes
by which these proposals were arrived at and presented for
consultation, and their content.
We address our concerns to all
stakeholders: the Commissioners, Derbyshire Healthcare NHS Foundation Trust,
G.P.s, service users and their representatives, and the Overview and Scrutiny
Commissions for Derby
City and County Councils
who have authority for holding Commissioners accountable for their decisions.
We describe who we are, provide
an initial executive summary of our response and then speak in more depth to
these issues.
The Specialist Psychodynamic
Psychotherapy Service.
For over thirty years, we have
provided a tertiary service within Derbyshire Healthcare NHS Foundation Trust
treating adults with severe and complex psychological disorders. These are
vulnerable adults, often presenting with lifelong histories of mental
ill-health and multiple use of local services. Staff have a core professional
training in mental health, and a post-qualification specialist training in
psychodynamic psychotherapy of four or more years. Some staff have Doctorate or
PhD qualifications in addition to their clinical qualifications.
Treatment within the service
takes the form of individual, group or couple therapy, with an average
attendance time of 18 months to 2 years. The service aims not just to
ameliorate symptoms, but to produce lasting change and a number of outcome
measures are used to demonstrate this. The Psychodynamic Psychotherapy Service
is provided from the Department base in Derby City,
and from locality Recovery Team bases in the South of the County.
Summary of
Response.
The draft Service Specification fails to
provide a context within which to understand what is being proposed. It does
not make clear which clinical services are included and what the implications
are for service users.
The opportunity
has been missed for a review of the whole range of psychological therapies
within Adult Mental Health services in Derbyshire, and the Specialist
Psychodynamic Psychotherapy service appears to have been singled out
to bear the brunt of the need for savings in the general mental health
budget.
Commissioners
did not consult with clinicians to ensure they understood the needs and
vulnerability of service users currently engaged in Psychodynamic
Psychotherapy, and the adverse effect the proposals would have on them.
The draft
Service Specification was developed without necessary dialogue with all
relevant stakeholders, and this has serious consequences for the clinical
viability of the proposals.
Through these
proposals, the choice of therapy for service users will be restricted to
cognitive and behavioural approaches. Commissioners do not appear to
have appreciated the important part that service user choice is known to play
in the success or failure of a therapy.
The proposal to
de-commission the Psychodynamic Psychotherapy Service is based on a flawed
analysis of the evidence base as, contrary to the assertion of Commissioners, there
is clear and objective evidence in support of psychodynamic psychotherapy for
the treatment of severe and complex disorders. Furthermore, Department
of Health guidance repeatedly asserts that clinically indicated psychodynamic
psychotherapies of appropriate length should be provided as part of Specialist
Mental Health Service provision.
Either there has been an exclusion
of step 5 service users from this proposal or a relegation of
their clinical needs to step 4 levels of treatment. The struggle to appreciate
the severity and complexity of difficulties, and the intensity of highly
skilled treatment required is evident throughout the draft Service
Specification document.
At a time when there is increased funding
available through the Improving Access to Psychological Therapies (IAPT)
programme for those with mild to moderate difficulties, an appreciation of the needs of
those in greatest difficulty has become lost and they appear to have
become a lesser priority.
The failure to
recognise the costs of these proposals to service users, their families and
wider society, as well as the provision of mental healthcare in Derbyshire is a
major omission.
Contents.
1.
Relevant background.
1.1
The cost of Tier 4 Psychological Therapy Services.
1.2
How Psychological Therapy Services are commissioned.
1.3
How clinical opinion has informed the draft Service Specification.
2.
Problems with the process of proposal development and subsequent consultation.
2.1 Poor quality
of information, obscuring the fact of significant cuts in service provision to
those in greatest need.
2.2
Failure to consult with clinicians.
3.
Problems with the content of the draft Service Specification.
3.1
Failure to adequately appraise the clinical evidence.
3.2
Failure to ensure service users have a choice of psychological therapies.
3.3 The struggle
to appreciate the severity and complexity of difficulties, and the intensity of
highly skilled treatment required.
3.4 Failure to
recognise the false economy of cutting skilled Specialist Psychodynamic
Psychotherapy.
4.
Concern about the future experience of service users in therapy.
5.
Commissioner critique of the Psychodynamic Psychotherapy Service.
6.
Conclusions.
Appendix 1: detailed appraisals
of the evidence base for Psychodynamic Psychotherapy and critique of the
Commissioners' use of research data.
Appendix 2: a precis of the way
in which service user care has been adversely affected by these proposals and
the way they have been communicated.
Appendix 3: a glossary of terms
to aid the reader.
1.
Relevant background.
The draft Service Specification
fails to provide a context within which what is being proposed can be
realistically considered and understood. It is unclear to whom this proposal
applies and the terminology used to describe services is confusing. We refer
the reader to Appendix 3 where we have attempted to clarify terms as far as we
are able to do so.
1.1
The cost of Tier 4 Psychological Therapy Services.
The majority of psychological
therapy at tier 4 of Mental Health Services in Derbyshire is provided by
Clinical Psychologists in Recovery Teams and Specialist Services, and by
smaller teams of Specialist Psychotherapists providing Cognitive-Behavioural
(CBT) and Psychodynamic Psychotherapies. These psychological therapy services
are commissioned and funded within different budget streams.
It is unclear to whom this draft
Service Specification relates: is it all tier 4 psychological
therapy services, including Clinical Psychology, and the total
budget allocated to this service provision? Or does it apply to Specialist
Psychotherapy Service provision alone?
The answer to this question is
important to the Consultation in order that the cost and distribution of
funding for psychological therapy services, and the true scale
and clinical impact of what is being proposed can be understood.
1.2
How Psychological Therapy Services are commissioned.
This draft Psychological
Therapies Service Specification has been developed in conjunction with NHS
Nottinghamshire, updating the Nottinghamshire Specification with figures from
Derbyshire. Unlike this Derbyshire specification, the Nottinghamshire
Specification clearly considers Clinical Psychology and Specialist
Psychotherapy Service provision together, along with the clinical research
evidence base, and arrives at different recommendations as follows: psychodynamic,
cognitive-behavioural and systemic therapies will be provided as
frontline therapy services, and dialectical behavioural therapy (DBT) as an
adjunctive service according to service user need and available therapist
skills.
In failing to be clear about
which services are included in the Derbyshire specification, it is
impossible to see how comprehensive local psychological therapy services will
be provided and integrated with specialist service provision, and what
other options there may be for gaps and savings to be equitably met.
1.3
How clinical opinion has informed the proposal.
We understand that the clinicians
consulted in developing these proposals in Derbyshire were mainly Clinical
Psychologists with clinical and research interests in the development of
Cognitive Behaviour Therapy (CBT) and Dialectical Behaviour Therapy (DBT), and
a Psychotherapist with a similar special interest in Short Term Dynamic
Psychotherapy (STDP). It is not perhaps surprising then, that these are the
treatment modalities recommended in this draft Service Specification document.
However, neither frontline
clinicians within mainstream Specialist Psychotherapy Services, nor referrers
or service users have been involved or consulted with in the development of these proposals. As a
result, the Commissioners are proposing in this document to reduce and
ultimately decommission a Specialist Psychotherapy Service about which they
have not taken adequate clinical advice nor educated themselves sufficiently.
This is contrary
to Department of Health guidance (2008) and the recommendations of the
NHS Chief Executive, David Nicholson, when he says:
'It is vital that the NHS
continues to modernise and improve, and to meet the challenges of QIPP, but
this must go hand in hand with an NHS where improvements are driven by local
clinicians, service users and their representatives from the ground up'.
(Nicholson, 2010; authors' emphasis).
2.
Problems with the process of proposal development and subsequent consultation.
In falling short of meeting the
requirements of Department of Health guidance regarding service
reconfiguration, Derbyshire PCT have failed to consider, consult, assess
and then communicate the implications of their proposals for people
with severe and complex difficulties requiring Specialist Psychotherapy.
2.1
Poor quality of information, obscuring the fact of significant cuts in service
provision to those in greatest need.
The Service Specification makes
no mention of what is at the heart of these proposals - the decommissioning of
Specialist Psychodynamic Psychotherapy Services in order to achieve financial
savings within the general Mental Health budget. This is clarified to some
extent in a supplementary document where a phased £750,000 saving is described.
However, because of the lack of
clarity about what exactly is being proposed, the current level of
psychological therapy service provision and how expected new service levels
will look, the reader is still left unclear about the implications of these
proposals for the availability of psychological therapies in future.
It is proposed
that access to Specialist Psychodynamic Psychotherapy Services for people with
complex and severe difficulties will be cut.
In the context of increased
funding being available through the Improving Access to Psychological Therapies
(IAPT) programme for those with mild to moderate difficulties, a sense of
perspective and an appreciation of the needs of those in greatest
difficulty appear to have become lost.
2.2
Failure to consult with clinicians.
The pre-consultation on which
these proposals were based was unacceptably selective and limited.
This has had serious consequences for the clinical viability of the
Commissioners' proposals. What will happen to those service users with severe
and complex difficulties for whom psychodynamic psychotherapy is indicated, who
would not choose to receive the therapies proposed for commissioning, or have
not responded to these therapeutic approaches in the past?
Furthermore, in failing to
consider, consult and assess the impact of these proposals, the consultation is
having an adverse effect on the care of current psychodynamic
psychotherapy service users (see Appendix 2).
3.
Problems with the content of the draft Service Specification.
In the Service Specification
Commissioners fail to appraise objectively all available research evidence.
They do not ensure real service user choice of treatment nor do they recognise
the importance of this choice to a positive outcome to therapy for the service
user. Commissioners appear to struggle to appreciate the severity and
complexity of problems that are skilfully treated by Specialist Psychodynamic
Psychotherapists. The considerable costs of these proposals to service users,
their families, to wider society and to the provision of mental health care
services is not acknowledged.
3.1
Failure to adequately appraise the clinical evidence.
The Commissioners have asserted
that their reason for their proposal to decommission Psychodynamic
Psychotherapy (unstated in this document) is that there is insufficient
research evidence for it to be further commissioned. This assertion is incorrect as it
does not do justice to the research evidence.
The selective evidence that
Commissioners have put forward undermines the recommendations within NICE
guidance which are in support of psychodynamic psychotherapy. There is no
acknowledgement of the limitations NICE itself recognises in its guidance. The
evidence cited is not inclusive of the most up-to-date empirical research and
unjustified inferences are drawn from poorly analysed data to the detriment of
the case for psychodynamic psychotherapy. There is a robust and developing evidence base which is comparable to
that of other therapies, including CBT, for these tier 4 service users
with complex and severe difficulties. It is unfair therefore, to demand a
higher standard of psychodynamic psychotherapy research than that applied to
other therapies, and to decommission it as a result.
Given the importance of this
issue, we have submitted in a separate document detailed and
careful appraisals of the evidence, and a critique of the Commissioners' use of
guidance and research data (see Appendix 1).
3.2
Failure to 'ensure real service user choice' (Royal College
of Psychiatrists, 2008).
The proposal describes how
service users will be offered ‘a choice of evidence based and relevant
therapies'. In reality, choice will be restricted to cognitive and
behavioural approaches to therapy as frontline treatments. Other
modalities 'may' be provided, dependent on emerging evidence, available
clinical skills and identified need in the population. Whilst the need for
treatments other than cognitive and behavioural therapies is acknowledged in
the Service Specification there is however, no assurance of funding to provide
them.
Locally, it is recognised that a
significant proportion of service users would not choose or have not responded
to these cognitive and behavioural approaches in the past. Some are labelled as
'treatment resistant', which means that their experiences have led them to a
profound distrust of others that makes the establishment of a therapeutic
relationship hugely challenging on both sides. The removal of Psychodynamic
Psychotherapists, who specialise in reaching people whose ability to
trust has become severely compromised, will leave these people without
hope of appropriate therapeutic help.
A further important point that
the proposal loses sight of is that service user choice plays a crucial
part in the success or failure of a therapy. The Royal College of
Psychiatrists (2008) assert that individuals with the same condition do not
respond equally to a given intervention, while an active preference by
individuals for the method used is associated with better outcomes.
3.3
The struggle to appreciate the severity and complexity of difficulties, and the
intensity of highly skilled treatment required.
The Service Specification relates
to Tier (Step) 4 services within the Stepped Care Model for Mental Health.
Within Derbyshire Healthcare Foundation Trust, Specialist Psychotherapy
Services are delivered as part of Tier 4 service provision. However, the
current service user population fits more accurately within the Royal College
of Psychiatrists' (2008) description of Step 5 disorders, in terms of
the level of intensity of treatment required. Step 5 is described as 'Treatment
for complex disorders; for example, psychodynamic/milieu approaches for
personality disorders/compound trauma, comorbid problems, and consultation
around individuals not responding to treatment'.
Is the draft
proposal excluding these Step 5 service users or, if included, are they to be
offered the recommended therapies which are more suited to the 'treatment of
severe disorders' at Step 4?
This is a significant group of
highly vulnerable service users, whose histories of abuse, trauma and neglect
have led to forms of major psychological disturbance that have a profound
impact upon themselves, their children and their families. They are likely to
have had substantial previous contact with Mental Health and other services,
and have often tried a variety of therapeutic approaches before being referred
for Specialist Psychodynamic Psychotherapy. Service users arrive via a
carefully considered primary and secondary care screening and assessment
process. Psychotherapists then assess suitability for treatment and if
clinically indicated, decisions are made for service users to progress on to
individual or group psychotherapy.
Guidance for the development of
services for people with personality disorder (Department of Health, 2002)
identifies effective therapy as relatively long term, with treatment being
experienced in a well-constructed and coherent interpersonal endeavour such as
that found in psychodynamic psychotherapy. Further guidance (Department of
Health, 2007) states that for Specialist Mental Health Services, a
comprehensive local service would include access to most forms of psychological
therapies including psychodynamic/psychoanalytic psychotherapies, cognitive
behavioural therapies and systemic therapies. It also informs us that the
length of time in therapy will depend on the severity, depth (age and
developmental stage when the trauma occurred), and extensive character of the
psychological disturbance.
Department of
Health guidance repeatedly asserts that clinically indicated psychodynamic
psychotherapies of appropriate length should be provided as part of Specialist
Mental Health Service provision.
3.4
Failure to recognise the false economy of cutting Specialist Psychodynamic
Psychotherapy.
The development of trust needed
for in-depth work can take time, and an average of 18 months to 2 years of
therapy is often required. At any one time, an average of 270 to 300 service
users are actively engaged in the psychotherapeutic work of assessment and treatment.
When it is considered how many years (sometimes decades) service users have
already spent in Mental Health Services then the cost of therapy becomes
a worthwhile investment, and the cutting of Specialist Psychotherapy
Services becomes a false economy.
The skill and experience of the
Specialist Psychodynamic Psychotherapist also needs to be taken into account.
Department of Health (2001) guidance states that it is safer practice for
people in severe and complex difficulties and with greater risk of self harm to
be treated by therapists who are more skilful. The therapists in this
Specialist Service are a highly experienced group of clinicians who have an
excellent record of helping service users manage and reduce risk to themselves
during therapy. They provide consultation which facilitates movement within
care pathways in ways that minimise treatment failure. They also provide vital
training and supervision which enables other staff to also undertake this
highly demanding work.
This proposal would effectively remove
a highly skilled and experienced group of Specialist clinicians, and
once gone it will be difficult and costly to re-establish such a hard-earned
level of expertise.
4.
Concerns about the future experience of service users in therapy
It appears from what is proposed
that therapy will in future be based around techniques and time limited up to
30 sessions of CBT (or up to 100 sessions of
DBT). Service user need will be fitted into diagnostic categories, with
work designed to help stabilise the service user and prevent deterioration
being regarded as insufficient. Service user progress and symptomatic
improvements will also be intensively measured.
All of these have their place in
a service vision. However, caution is needed to avoid losing other
valuable perspectives.
As well as helpful techniques,
service users at this level of complexity and severity need a therapeutic relationship.
Whilst it is important that therapies last no longer than is needed, treatment
length needs to be clinically appropriate. Service users may need
help at times to contain their difficulties and maintain their level of
functioning to prevent serious deterioration of their mental health, and for
this to be valued as a shared therapeutic task. And whilst
objective evidence of improvement is important, the quality of
this needs to be captured. Measurement of change can have a negative impact if
service users feel the measures used are pressurising or intrusive to
their therapy.
5.
Commissioner critique of the Psychodynamic Psychotherapy Service.
As the consultation has proceeded
it has become apparent that the Commissioners have made assumptions that inform
a critique of how the current service operates. Comments made in different
settings provide some small indications of what these might be. They have
however, developed these proposals without making explicit and testing out,
through discussion with clinicians, their critical assumptions about the
service they are seeking to reconfigure. This leaves their proposals at risk
of being based on a misunderstanding of the service, and those who use it.
6.
Conclusions.
The manner in which this service
specification was developed lacked an adequate engagement with key
stakeholders, not least the therapists who understand and provide the service.
This has had serious consequences for its clinical viability and
appropriateness.
The initial presentation of this Service
Specification was not been helped by being rushed and unnecessarily
adversarial.
Furthermore, the service specification
is founded on a major inaccuracy, namely that Psychodynamic Psychotherapy lacks
an evidence base and cannot be recommended as a treatment of choice in
NICE guidelines nor in policy on Best Practice from the Department of Health.
This has been detrimental to the clinical viability of the Service
Specification proposals and thus to the consultation process as a whole. It
will result in a delay in the development of more viable proposals that address
the whole range of psychological therapies within the adult mental health
services in Derbyshire.
There are significant service
delivery issues in the proposal that will gain significantly from careful
discussion with clinicians, in an open and transparent manner, to agree how
services can be shaped and modernised for the future. A limited financial
envelope inevitably means that resources are limited, and these resources need
to be deployed equitably in terms of location, range of presenting difficulty
and service user choice.
Psychodynamic psychotherapy
'fits' as a crucial element in the success of other parts of mental health
services: in providing specialist expertise through consultation and
supervision, in the support and development of psychodynamically informed
practitioners, in the core teaching and training of psychologists and
psychiatrists, and in the provision of highly skilled interventions to those
who have not benefited from local treatment. It provides a vital option for
service user choice.
In 2005 a wide ranging and well received
review of Psychological Therapy Services in the County (‘the Shapiro Report’)
was commissioned by the PCT and involved all stakeholders. It would form a very
appropriate basis for further consultation. The place of the Specialist
Psychodynamic Service in treating people with more severe and complex
difficulties was never questioned in this review.
In 2010 a further review of
Specialist Psychological Therapy Services was conducted by clinicians and
managers within DHFT. They produced a draft service specification with a vision
of a Complex Trauma and Personality Disorder Service. This specification
maintained a choice of models, addressed the issue of treatment length and also
the need to make efficiency savings of 30% over five years.
A way forward now would be to
organise wider discussions involving the full range of stakeholders in order to
develop more viable proposals. The 2010 review could then be further developed
and integrated with other services to support a modern, comprehensive and high
quality model of psychological therapy service provision for the people of
Derbyshire.
References
Department of Health (2001) Treatment choice in psychological therapies
and counselling: Evidence based clinical practice guideline
Department of Health
(2002) Personality Disorder: no longer a diagnosis of exclusion
Department of Health (2007) Specialised Services National Definition, Set
22: Specialised Mental Health
Department of Health (2007)
Commissioning a Brighter Future: Improving Access to Psychological Therapies
Department of Health (2008) High Quality Care for
All
Department of Health (2009) Recognising complexity: Commissioning guidance for personality disorder
services
Department of Health
(2010) David Nicholson: Service reconfiguration
NICE (2009) Borderline
personality disorder: treatment and management. National
Royal College of Psychiatrists
(2008) Psychological Therapies in Psychiatry and Primary Care
Appendices.
Appendix 1 refers to two
documents appraising the evidence base for Psychodynamic Psychotherapy which
can be found in full (along with other documents) on the internet at
savednhspp.blogspot.com
The first document provides a detailed
critique of the evidence that the PCT has posted on its website as background
to the consultation around its plans to cut long-term psychodynamic
psychotherapy services.
It shows how the PCT
has failed to properly reflect guidance from the National Institute for
Clinical Excellence (NICE), has failed to take notice of recently published
research in the field of psychodynamic psychotherapy and has failed to draw
sound conclusions from the data that it has produced.
The document then
describes recent research publications and systematic reviews which do
demonstrate very clearly that long-term psychodynamic psychotherapy has a
strong supporting evidence base. The
treatment works and works well.
Finally, the document
discusses the implications of these points in relation to local psychotherapy
services for the people of Derby and Derbyshire.
The author of the
document is Dr David Smith, Retired Consultant Psychiatrist, M.B.,B.S.
M.R.C.Psych.
The second document provides a detailed appraisal of the evidence base
for Psychodynamic Psychotherapy with Borderline Personality Disorder.
Its author is John Fletcher,
Psychodynamic Psychotherapist, Department of Psychotherapy, 63 Duffield Road,
Derby DE22 1AA.
Appendix 2 outlines concerns about the care of current service users.
Appendix 3 provides a glossary of terms used in the Service Specification document.
Appendix 2
Concerns about the care of
current service users.
Serious concerns have been
expressed about the adverse effect on therapies currently being experienced by
Psychodynamic Psychotherapy service users. Commissioners did not first consult
with clinicians in order to ensure they understood who was attending for
Psychodynamic Psychotherapy, what their complex needs were and what might be
the effects and risks attached to ending their therapies. The Commissioners
appeared therefore to be unprepared for the clinical concerns raised about the
impact of their proposals on current service users.
The proposals have already
created a serious level of uncertainty for service users engaged in a
therapeutic process which requires safety and trust. This has caused
significant distress and insecurity leading some service users to consider
withdrawing from therapy, and others to limit the necessary depth of their
therapy to protect themselves from further emotional pain. For their part, therapists
are still reluctant to put service users at potential risk by opening up highly
sensitive issues in assessment or in therapy while there is the possibility
that the agreed therapeutic contract will not be available or will be changed. It appears that Commissioners did not
anticipate that their proposals would have this effect on service users. It was
perhaps the result of Commissioners underestimating the level of vulnerability
and the degree of disturbance experienced by our service users.
Commissioners have moved during
the consultation period to a position where they have now given an undertaking
not to remove from existing service users a clinically required therapy. However Commissioners have yet to clarify who
will determine this clinical need or how on-going therapy for these service
users will be protected if the service is indeed de-commissioned. Uncertainty
remains for service users and this uncertainty continues to seriously affect
their experience of therapy and their well-being.
How concerns arose.
Psychodynamic Psychotherapists
were advised on 20th July 2011 that PCT Commissioners intended to
de-commission Psychodynamic Psychotherapy and they were served with redundancy
notices. They were led to believe that therapies would have to be completed by
20th October 2011, and no prospect was held out at that time of
therapies continuing beyond this point. It was clear that de-commissioning was
being described as a ‘proposal’ whilst actually being put into immediate
effect.
Concerns were raised that service
user care and safety would be compromised by this timetable. There would also
be inadequate time to prepare service users for an ending of therapy and to
find alternative supports. Concerns were formally raised by therapists under
the ‘Raising Concerns at Work (“Whistle Blowing”) Policy’ that the timetable and plans were
detrimental to service user care and were “clinically unsafe”.
In response, concerns were
acknowledged and it was explained that the situation would be monitored and the
timescale might need reviewing. However therapist redundancy notices continued
and were not “deferred” until 5th September 2011.
The Derby City Council Overview
and Scrutiny Committee recommended at their meeting on 25th July
2011 that a full consultation needed to be carried out. On 10th
August, therapists were advised that a PCT Commissioner-led Consultation had
begun on 1st August and would run until 30th October 2011.
Therapists were told it would be ‘business as usual’ for the service such that
new referrals could be accepted and assessed, and new service users could begin
therapies whilst the consultation took place.
Uncertainty for service users
continued in August 2011. In a press release in the Derby Evening Telegraph on
23rd August 2011, PCT Commissioners were reported to have said that “service
users currently receiving treatment would no longer be able to get that type
[psychodynamic] of therapy…..those service users would be reviewed to see which
alternative treatments would be suitable for them”. Then, in a generally
distributed email dated 30th August 2011, the PCT Commissioner,
David Gardner, stated “we would like to make it clear that the PCT has given an
undertaking that people already in receipt of psychodynamic psychotherapy, and
who have been assessed as needing to continue with their therapy will not have
it stopped. The PCT will support whatever is in the service user’s best
interests.” In a subsequent e mail, Commissioners stated that “those [service
users] who have a clinical need to continue with psychodynamic psychotherapy
will do so. The PCT will support whatever is in the service user’s best
interest. The intention is for a "phased reduction in psychodynamic
psychotherapy….”.
Whilst the commitment made is
very welcome, Commissioners have yet to clarify who will determine this
clinical need or how on-going therapy for these service users will be protected
if the service is indeed de-commissioned. Uncertainty remains for service users
and this uncertainty continues to seriously affect their experience of therapy
and their well-being.
Appendix 3
Glossary of terms.
Psychodynamic Psychotherapy (PP): Psychodynamic Psychotherapy is a treatment
approach that works with feelings, thoughts and behaviour. It is an intensive
therapy which uses the therapeutic relationship as a major agent of change. At
the heart of psychodynamic psychotherapy is the understanding that traumatic
experiences, emotional deprivation or invalidation early in life impact
significantly on the forming and maintaining of healthy relationships, and also
lead to the development of psychological symptoms. The psychodynamic approach
both explores the origins of psychological difficulties but also works in the
here and now, to develop healthier patterns of relating. Treatment length
varies from an average 18 months to 2 years, and forms of therapy include
individual, couple, group and family. Adaptations of PP include Transference Focused Psychotherapy (TFP), Short
Term Psychodynamic Psychotherapy (STDP), Mentalisation Based Treatment (MBT)
and Cognitive Analytic Psychotherapy (CAT).
Cognitive Behavioural Therapy (CBT): Cognitive
Behavioural Therapy aims to solve problems associated with dysfunctional
thoughts and behaviours through a practical focus in the present. Treatment
tends to be time limited, drawing on a wide range of specific techniques, and
can be accessed in a number of ways: self-help, bibliography and computerised
programmes of help, individual, couple and group therapies. Treatment lengths
vary from short (6-12 sessions) to longer term (30-60 sessions). Adaptations include Eye Movement
Desensitisation and Reprocessing (EMDR), Mindfulness and Compassionate Mind
therapies.
Dialectical Behaviour Therapy (DBT): Dialectical
Behaviour Therapy is based on a bio-social theory of borderline personality
disorder designed for the treatment of emotionally vulnerable adults who have
experienced abuse and the invalidation of their emotional experience early in
life. Treatment is focused on the regulation of emotion and the reduction of
acting out. Treatment length tends to be longer term (40-80 sessions) and is
delivered individually and in groups.
Psychological Therapies:
This term is used in this critique of the draft Service Specification to refer
to the total provision of psychological therapy to the adult population of Derby City
and Derbyshire County. This includes a variety of
approaches, provided by a variety of professions, within which there is some
specialist provision.
Specialist Psychotherapy Services: This
term is used in this critique to refer to the Specialist Cognitive Behavioural
and Psychodynamic Psychotherapy Services.
Specialist Psychological Therapies:
This term may be used to refer to the above but it is not made clear.
Specialist Services: This
is a generic term used in this critique to refer to specialist services for
specific client groups such as those with eating disorders.
For further information, the interested
reader might like to look at the MIND website.
