Summary of the impact

Work by Fonagy and Roth at UCL to establish a firm evidence base for psychological therapies has had a profound impact on the delivery of services across the UK. This evidence was used to establish the Improving Access to Psychological Therapies programme. Building on the original research, Roth and Pilling developed a series of competence frameworks which have been used to train thousands of additional therapists to deliver the programme. More than a million patients have now benefitted from the programme, which, along with the clear impacts on individual wellbeing, has also been recognised as having significant economic gains, in terms of NHS savings, reduced welfare spending, and increased return to the workforce.

Underpinning research

The book What works for whom? A critical review of psychotherapy research (WWFW), co-authored by Anthony Roth (Professor of Clinical Psychology, UCL) and Peter Fonagy (Professor of Psychoanalysis, UCL) is now a cornerstone for policy and practice in psychological therapy in the UK and around the world.

In 1993-4, Fonagy and Roth were commissioned by the Department of Health to conduct a review of the efficacy of psychological therapies as the evidential base for their policy review, "Strategic Review of Psychological Therapies." The aim was to assess psychological therapies across a broad spectrum of mental health disorders, and on this basis to recommend which ones should be part of standard provision in NHS mental health services, alongside pharmacological interventions. This review was published in 1996 [1].

Developing this work further, Fonagy and Roth wrote the now-seminal book, What works for whom? A critical review of psychotherapy research. The first edition, published in 1996, was closely modelled on the earlier report [2]. A second edition was published in 2005. The book represented the first systematic and comprehensive review of all extant quantitative studies of the efficacy of psychological therapy in relation to the major diagnostic categories of mental health disorder. Its unique feature is the concise review and balanced evaluation of approximately 2,000 clinical studies in the first edition, and 2,500 in the second, accompanied by explication of the clinical implications of this literature. It was the first definitive evaluation of psychological therapy studies, with a powerful and profound impact on treatment selection for the current generation of therapists, service managers, commissioners of services and (increasingly) patients.

Some examples of conditions covered include: depression where the research found that there was clear evidence of the efficacy of Cognitive Behaviour Therapy (CBT) approaches and interpersonal psychotherapy, with limited evidence of efficacy for short-term structured psychodynamic psychotherapy; dysthymia, where the evidence suggested medication is the treatment of choice with little advantage conferred by the addition of psychological therapy; generalised anxiety disorder, where the review found strong evidence for the efficacy of CBT and Applied Relaxation; panic disorder, where three evidence-supported interventions were identified, Exposure Therapy, CBT and Panic Control Therapy; PTSD, where the review found trauma-specific CBT and Eye Movement Desensitisation and Reprocessing (EMDR) to be effective, along with emerging evidence to support the use of individual psychodynamic psychotherapy.

Growing out of this work, Fonagy went on to develop What works for whom? A critical review of treatments for children and adolescents which was published in 2002 [3]. This evaluated the evidence for the full range of widely used child and adolescent mental health treatments, organised around the major presenting problems in child and adolescent practice.

A major outgrowth from WWFW has been the acceptance that competence has to be linked to the evidence-base, and that this is best achieved by systematically disaggregating the content of manuals employed in research trials to guide therapists employed in demonstrating efficacy. A series of competence frameworks (described further in section 4) were commissioned from Roth and Professor Stephen Pilling (Professor of Clinical Psychology & Clinical Effectiveness), funded by the English Department of Health or (in one case) NHS Education for Scotland.

References to the research

Grant awarded to fund the review of psychological therapies: 1993-4. Research on the efficacy and effectiveness of psychological therapies. Department of Health. £16,000

Grants awarded to fund the development of the competence frameworks: In all cases grants awarded jointly to Anthony Roth and Stephen Pilling. Between 2007 and 2013, the Department of Health awarded £181,000 to develop five competence frameworks. They were also awarded £28,000 by NHS Education for Scotland, between 2009 and 2011, to develop a competence framework for child and adolescent mental health services.

Peer review: The frameworks were subject to a process of systematic intensive peer review by:

a) An Expert Reference Group convened to oversee each framework, and composed of 10-15 national and internationally recognised researchers in the relevant field;

b) Invited peer review by the primary researchers whose work is represented in the framework.

Details of the impact

What works for whom? is a standard reference and teaching text for teaching in the area of psychological therapy, for postgraduate training programmes and academic courses, and for a broad range of professional groups both in the UK, North America, Australasia and increasingly in Europe. Beyond its direct teaching impact it has had a significant influence on clinical practice.

In October 2008, the government launched a new programme, Improving Access to Psychological Therapies (IAPT) [a]. This was designed to ensure speedy access to evidence-based psychological therapies for depression and anxiety in adults (presentations which, taken together, represent the largest proportion of significant mental health problems in the UK population). The initiative to drive this project through government was led by Lord Layard, who specifically employed the evidence contained in WWFW to underpin his argument [b].

In order to deliver the IAPT programme, it was necessary to train a large number of additional therapists capable of delivering evidence-based interventions to the same standard as had been practised by the research teams who had demonstrated their efficacy. Roth and Pilling were commissioned to develop a series of competence frameworks and National Occupational Standards for psychological therapies which would enable the workforce to be expanded in the necessary manner. They developed a methodology for anchoring the frameworks closely to the research base set out in WWFW, linking it to clinical skills for seven modalities of psychological therapy, as well as for psychological interventions in work with children and adolescents:

• CBT for depression and anxiety [c]
• Psychoanalytic/Psychodynamic therapy [d]
• Systemic therapy [e]
• Humanistic psychological therapies [f]
• Interpersonal Psychotherapy [g]
• Child and adolescent mental health services [h]
• Psychological interventions for people with psychosis and bipolar disorder [i]
• Psychological interventions for people with personality disorder [i]

These frameworks have been used to develop national training curricula, making a critical contribution to closing the gap between the therapeutic technologies employed in research contexts and those implemented in `routine' NHS settings (`bench to bedside'). The National Occupational Standards for psychological therapies were published in 2010. These cover four modalities (cognitive and behavioural therapy, psychoanalytic/psychodynamic therapy, family and systemic therapy, and humanistic therapy). The competence frameworks constituted the `statements of evidence' on which the standards rested [j].

By espousing and comprehensively explicating the principles of evidence-based practice as applied to the psychological therapies, WWFW acted as a driver of change, such that a commitment to evidence-based practice is now accepted as an organising principle of almost all professional training in psychological therapy in the UK. In the UK, this specifically includes training overseen by the British Psychological Society, the Royal College of Psychiatrists, and that accredited by the British Association of Counselling and Psychotherapy (BACP) and the United Kingdom Council for Psychotherapy (UKCP) [k].

The IAPT programme represented a major strategic development within the NHS, and resulted in an increase in funding for services, availability of therapists, and the numbers of patients treated.

Funding for services: During the period 2008-13, NHS funding for psychological therapies increased significantly, from £161M in 2007/08 to £389M in 2011/12. When expressed as a percentage of the total NHS adult mental health spend, this is a rise from 4.0% to 6.6% [a, p.38].

Availability of therapists: Between 2008 and 2012 (the last date for which reliable figures are available), the IAPT programme trained, or was training, almost 4,000 therapists, the vast majority in specific techniques for which there is clear evidence of efficacy, with further expansion in training planned. Since training packages were developed in 2010, more than 400 high-intensity therapists have been trained in the new modalities of therapy that have been approved to treat depression. A further 400 trainees were expected to be trained over the course of the present academic year (2012/13) [a, p17].

Number of patients treated: After its first three full years, more than 1 million people used the new services, recovery rates were in excess of 45% and 45,000 people had moved off benefits. Norman Lamb, the minister of state for care services, noted: "There are strong indications that the IAPT initiative is beginning to not only make a difference to individuals and their families but also to realise economic gains in terms of anticipated savings to the NHS and welfare system alongside increased tax contributions." [a, p3]

In 2011, IAPT expanded its remit to include interventions for children and adolescents with an £8m/year investment for four years. Fonagy is the National Clinical Lead on this work. In February 2012, ministers agreed significant additional investment for 3 years [l]. The research led to the decision in July 2013 to extend the programme to 24 new sites, with services covering 54% of 0-19 year olds in England by the end of the year [m].

Sources to corroborate the impact

[a] Department of Health. IAPT three-year report: the first million patients. November 2012.
http://www.iapt.nhs.uk/silo/files/iapt-3-year-report.pdf

[b] Layard R. Mental Health: Britain's Biggest Social Problem. January 2005. References WWFW on p.9: http://eprints.lse.ac.uk/47428/; in an interview with the Guardian in 2008, Layard explained how this paper was presented directly to the No.10 Strategy Unit in 2005:
http://gu.com/p/xzxz3/

[c] Roth AD, Pilling S. The competences required to deliver effective cognitive and behavioural therapy for people with depression and with anxiety disorders. London: Department of Health; 2008.
http://webarchive.nationalarchives.gov.uk/20130107105354/ http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_078535.pdf

[d] Lemma A, Roth AD, Pilling, S. The competences required to deliver effective Psychoanalytic/Psychodynamic therapy. London: Department of Health; 2008. Copy available.

[e] Roth AD, Pilling S. The competences required to deliver effective systemic therapy. London: Department of Health; 2009 http://www.ucl.ac.uk/clinical-psychology/CORE/Systemic_Competences/competences_required_for_effective_systemic_therapies.pdf

[f] Roth AD, Hill A, Pilling S. The competences required to deliver effective humanistic psychological therapies. London: Department of Health; 2010. Copy available.

[g] Lemma A, Roth AD, Pilling S. The competences required to deliver effective Interpersonal Psychotherapy London: Department of Health; 2010.
http://www.iapt.nhs.uk/silo/files/interpersonal-psychotherapy-for-depression-ipt-competency-framework.pdf

[h] Roth AD, Calder F, Pilling S. A competence framework for child and adolescent mental health services. Edinburgh: NHS Education for Scotland; 2011. http://www.ucl.ac.uk/clinical-psychology/CORE/child-adolescent-competences/CAMHS%20Competences%20Framework_V1%20(2).pdf

[i] Available from the Centre for Outcomes Research & Effectiveness:
http://www.ucl.ac.uk/clinical-psychology/CORE/competence_mentalillness.html

[j] Digest of National Occupational Standards for Psychological Therapies, Skills for Health, March 2010, http://www.skillsforhealth.org.uk/about-us/resource-library/doc_download/174-digest-of-nos-for-psychological-therapies.html

[k] The principle of evidence-based practice for the RCPSYCH Core Psychiatry Training (p.63)
http://www.rcpsych.ac.uk/pdf/CORE_CURRICULUM_2010_Mar_2012_update.pdf; in training accreditation criteria, BACP (pp.7-8)
http://www.bacp.co.uk/admin/structure/files/pdf/11914_atc_scheme09_v2012.pdf; BPS Clinical Psychology accreditation standards: http://dcp.bps.org.uk/dcp/the_dcp/news/consultation-on-new-accreditation-standards-for-doctoral-programmes-in-clinical-psychology.cfm

[l] IAPT Children and Young People's Programme, Key Facts Briefing, July 2013,
http://www.iapt.nhs.uk/silo/files/cyp-iapt-key-facts-july-2013-.pdf

[m] "New sites to join Children and Young People's IAPT programme", NHS press release, 26 July 2013, http://www.iapt.nhs.uk/silo/files/cyp-iapt-new-sites-press-release-july-13-.doc