Edinburgh and Bristol, UK. Patients with a history of Harry Benjamin Syndrome (HBS) must undergo therapy if they follow the structured medical protocols most associated with a successful outcome. Going in, you can sure feel bad about yourself. Perhaps you have proceeded through life with a set of flawed assumptions. HBS patients have the singular task of demonstrating their sanity and capability to make mature and informed decisions. After all, HBS is a life and death matter — and surgery is irreversible.

 

One important approach to psychotherapy consists of modifying cognitions, assumptions, beliefs and behaviors, all with the aim of influencing disturbed emotions. Called cognitive behaviour therapy (CBT), it structures therapist-patient interactions to treat various kinds of neurosis and psychopathology, including mood and anxiety disorders.

 

But such psychotherapies are often under-regulated. All it takes to be a therapist in many countries is a keen eye for opportunity and good advertising. Two experts in psychological medicine examined the situation in the United Kingdom (UK) and concluded that therapy should be subject to the same standards of evidence as drugs.

 

Writing in the Journal of Psychopharmacology, they say there is a largely unrecognized potential for serious adverse effects resulting from talking therapies. To them, that means rules should be tightened, particularly in light of public expenditures for psychotherapy services that claim to alleviate depression and anxiety. The expansion of public funding necessarily means more therapists will hang out thir shingles and/or expand existing practices.

 

While the article centers on UK regulations, this issue crosses borders. Few, if any, countries subject psychotherapies to the same efficacy and regulatory standards as drugs, and psychotherapists are often less regulated than physicians and psychiatrists. Indeed, in some countries therapists aren't regulated at all.

 

“While welcoming the increased profile that mental health problems have been given by the Government and the expansion of scientifically validated psychological treatment…we wish to urge a note of caution,” says Professor Michael Sharpe (University of Edinburgh), who co-authored with Professor David Nutt (University of Bristol).

 

“Our concern is about the tendency to consider psychological treatments less critically than pharmacological ones. It is important that both are seen as having a place in treating depression and that both are subject to the same standards of scrutiny and regulation.” 

 

According to Nutt, few psychotherapy trials meet the requirements demanded of drug tests, and even those that do frequently show that psychotherapy performs no better — and often worse — than pharmacological interventions. What is more, he points out, many psychotherapy trials do not even consider the possibility that their treatment could harm. Yet all therapists should be aware that therapy can have adverse effects on some patients and a major part of psychotherapy training is how to deal with issues such as counter-transference that can mediate these negative effects.

 

“We need a much more sophisticated view than ‘psychotherapy good; drug treatment bad’ if we are to effectively and safely improve the mental health of the population,” says Sharpe.

 

Potential adverse effects of psychotherapy include worsening of the patient’s condition, the development of psychological dependency on the therapist, and wastage of patient and therapist time when the treatment is ineffective. In addition, the article cites evidence that a small minority of therapists take advantage of vulnerable patients and exploit them emotionally, financially, and sexually.

 

“Given that psychotherapy is not necessarily always the benign yet efficacious therapy that seems to be generally assumed, patients should be made aware of the risks as well as the benefits especially now we have a government initiative to improve psychotherapy provision on the NHS,” write the authors.

 

They suggest that patients should be able to alert authorities to problems with psychotherapies they receive by use of a similar scheme to the one through which adverse drug events are reported. Sharpe and Nutt suggest it could be administered by the Medicines and Healthcare Regulatory Agency, the body responsible for dealing with drug reports.

 

Nutt and Sharpe urge therapists to ensure patients are aware of the risks as well as the benefits of psychotherapy. In addition, they suggest that therapists should to commit to performance and practise standards and agree to be monitored or audited on their professional records.

 

“Up-scaling the provision of psychological therapy to the degree [proposed by the UK Government] is a major challenge for quality assurance. Bad therapy will not work and may harm. It will be essential therefore that the increase in number of therapists is done incrementally with (a) rigorous monitoring of the quality of the therapy given and (b) professional regulation of therapists to minimise the risk of exploitation of patients,” concludes Sharpe.

 

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Uncritical positive regard? Issues in the efficacy and safety of psychotherapy. Nutt DJ, Sharpe M. Journal of Psychopharmacology 2008; 22:3-6. DOI: 10.1177 / 0269881107086283.

 

Authors' Introduction. The recent review of the selective serotonin reuptake inhibitors (SSRIs) by the Committee on Safety of Medicines (CSM) and the Food and Drug Administration was occasioned by media concerns about the safety of this class of antidepressant. In much of the prior and subsequent reporting of this issue, two assumptions have consistently been aired. The first is that psychotherapy is equally effective as drugs and the second is that since psychotherapy is not a drug, it is necessarily safer than drug treatments. From these two assumptions emerges a common presumption that psychotherapy should be the preferred approach for many if not most cases of depressive and anxiety disorders. But is this true? And if not, what implications does it have for the management of the new therapists that will soon be employed following the UK government’s award of £150 m for psychotherapy services in depression and anxiety?

 

[ Full Text (PDF) ]

 

 

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