Does the NHS offers anything other than CBT and if so what criteria do you have to meet in order to be referred?

Roughly 3 year wait to see a psychiatrist in Essex then assessment for psychotherapy then if you get
accepted 2 year wait for it

You misread me. It wasn’t in the slightest bit snarky. I meant that it IS really nice that some places do have those services. I am sincerely glad that they do. I did not know it was possible. We have nothing like that where I am. I am also a frontline worker who has lived experience and tries their best to help people in tough situations every day. The inverse care law is a recognised thing. In most cases the best services are not in the places with most need but I am very glad if that is not so where you are.

”Very nice”. Did you mean that to sound snarky? Are you misplacing your frustration at the system to me - a lone parent frontline NHS worker who works day in day out with the most severely unwell in society? I have a severe mental illness (disability) myself, as stated up-thread, which means I have to take 7 medications per day and nearly cost me my life last year.

So it’s worth remembering there’s a real life human at the end of snarky off-hand texts.

ps: you’re wrong that it’s not in places with the most need. The patch I cover is the most deprived council estate in the UK. I work every day to improve the mental health of those with 3 generations of unemployment, intergenerational trauma, sexual abuse, war torture, and endless suicide attempts / drug addiction / alcoholism. Last week I assessed a woman who experiences psychosis rooted in the trauma of having been gang-raped whilst watching militia soldiers decapitate her patents. And then went straight into an session with a woman who the night before tried to throw herself from a motorway bridge (this also being the method by which my partner ended his life, so quite challenging for me).

But thanks for the lesson on where help is “needed most”.

Very nice. Not the case in most places sadly and certainly not in places with the most need (inverse care law)

In my area we have a tier of provision to plug that gap between IAPT and CMHT. It’s a large city-wide service. I am a Band 7 clinician working in it, and there are scores of other Band 7 or Band 8’s in it.

We comprise senior mental health nurses, specialist occupational therapists, senior psychotherapists, associate psychologists, specialist MH pharmacists, wellbeing practitioners, employment coaches, social prescribers, medics etc. It’s a great service.

When I said level 7 I was talking about training level of the therapist, sorry it wasn't clear. And then yes band 7/8 employment level.

I think it would be preventative of all sorts of things tbh but I can understand the funding issue you raise. Difficult one!

Band 7 is a very expensive staff member. I doubt that IAPT therapists are on more than a band 5. To employ a whole army of extra expensive staff at primary care level something else would have to be defunded and what would that be? There is zero additional investment all MH Trusts are in the red. I absolutely agree there is a gap that ideally would be filled but it will not happen any time soon unless the country someone gets rich and decides to spend on MH which is so unlikely.

Ir wouldn’t save on admissions either. Everyone always argues that new innovations will save admissions but it’s not credible. No one is getting admitted anyway these days. The vast majority of people admitted to an acute ward have psychotic illnesses for which the mainstay of treatment is medication. Very few people with the kinds of conditions that can be helped by therapy will be admitted precisely because it’s unlikely to help them as there will be no therapy available as an inpatient.

There is a gap in provision with the people who are deemed too risky for IAPT and not risky enough for Secondary Care CMHTs.

Some areas have secondary care psychotherapy departments that are not CBT - they are not open ended, but longer term, 20 sessions to say, 90 sessions. I think the NHS could use funds more effectively to employ therapists, perhaps at level 7 and above, from all the voluntary organisations - BACP, UKCP etc. Psychodynamic, Integrative, Trauma etc.

Some people that end up being admitted to psychiatric hospitals for example, at extraordinary cost incidentally, would have probably not needed an admission were they to have been seen on a longer term basis.

And then also those who carry on and don't have a crisis, but are miserable, perhaps suicidal, therefore screened out of IAPT, also I think could do with this kind of provision.

The CBT techniques are useful for some people, and I’d used them for years to successfully manage my mental health. That’s partly why I was so angry at being sent on another CBT course when circumstances beyond my control sent me into depression.

The point is effective triage to find out where people are, what is going on and what they’ve already done. Rather than just putting everyone into CBT.

And more joined up thinking. If there was more support with housing, employment and other social issues then that would go a long way to resolving problems that can’t be dealt with using CBT.

But how the hell would the NHS be able to afford long term 1:1 therapy for everyone who would benefit and/ or thinks they would benefit/ wants that? It’s just impossible. There are not the army of trained therapists that this would require.
There is an obvious reason why a publically funded service cannot do lots of open ended long term 1:1 therapy and cost is that reason. It can do short term 1:1 or it can do groups as that is what is affordable.
The alternative to lots of short term CBT courses was what we had before IAPT which was nothing at all. Years long waiting lists for everyone. At least the CBT helps some people and in fact quite a lot of people. Prior to IAPT what we had was just a very very long waiting list.

Yes, I have difficulty with the term “evidence led”. Quite a lot of patients will say they feel better immediately after a short course of CBT with a competent clinician. Not all change will be lasting, though, yet the NHS has their evidence.

NHS is dominated by CBT and short term therapies because the focus is on symptom reduction - this is what can be measured. NICE likes RCTs and blinded studies as evidence. Understandably on one level - NHS uses tax payers money and treatment needs to be proven as it were to be effective. The medical model is also based on symptom treatment. Bish bash bosh you're sorted. Like fixing a broken leg. Counselling and psychotherapy don't really fit into that model. The NHS has struggled with this.

There are studies that suggest that longer term psychotherapy does better at a longer term follow up, but these don't seem to be taken into account so much, although this is dependent on area. And staff. If you've got a department dominated by clinical psychologists say, the pathways will probably be geared towards clinical psychology.

Also, risk. The NHS gets very scared, again understandably on one level, about suicidality. It literally can't handle the anxiety. So it responds in a very particular way. Manage, medicate, do coping skills. A psychotherapist would ask the question - why? explore, unpick, try to understand. The work can be slow. But effective. This isn't efficient enough for the NHS. And it's scary - don't open the box, you don't know what's inside!

Extraordinary really.

Yes, past v current circumstances are highly relevant.

A severe and specific anxiety in the a form of a phobia- bitten by a dog in the past, you going to be currently anxious around dogs.

Knowing your past experiences and how these may affect your currently is important as you can now make that distinction then and now as a basis to adapt.

In the past anxiety was present due to real events occurring and now it maybe present due to a hypothetical worry about that past real events reoccurring- as that is what you learned back then. Both real and hypothetical can lead to anxiety - which is just debilitating and enough to negatively impact people

Not everyone is able to step outside their stream of thoughts and gain insight. Some people just do not have the capacity. Most do then will acknowledge their biases/default thinking then return to….but - hang on to that if you will and you will get what you always got with that. It sounds harsh but it is true.

Spot on

If your anxiety arises from a real ongoing situation such as housing or an abusive relationships then CBT will not help other than manage surface level coping as the source of your anxiety is real and present.

CBT is effective when anxiety arose from unhelpful thinking styles that have no current factual basis.

That is not what I am saying:-

Anxiety is real

The source of the anxiety can be real or hypothetical hence the examples.

In my experience, ALL anxiety stems from a problematic life experience, some more obvious than others.

I have to say that I find that incredibly offensive.
Firstly, that’s not how the system works. No one gets ‘special treatment’, whether working in the system or not.
Secondly, you know nothing about the treatment I’ve either had, struggled to get, or been denied. To assume I’ve had it easy is very hurtful. I nearly lost my life last year, partly due to failings in the system. There is a CQC enquiry into the failings in my care under the NHS Trust in question. This was in secondary care, and my condition is very much more complex and severe than the part of the system I work in and that I was advising the OP on in a bid to clarify and assist with information.

I get that you’ve had a bad experience but please don’t be dismissive to me, with unfair and untrue assumptions. I’ve remembered why MN is not the place it used to be.

Oh and the one I’m with also offered employment support within Talking Therapies but when I enquired it turned out this was help writing a CV with an assumption people weren’t working.

There was no support for keeping people already in work, at work, if that makes sense? Which would surely make more sense in terms of paying tax, as well as better mental health.

I do get the impression that if you know the system, ie are a practitioner or know how the complaints process works and are prepared to use it, then you can get
support from Talking Therapies/IAPT.

Sadly, there must be countless people really struggling and unable to access this as they don’t know how, don’t have the skills to complain or their mental condition means they don’t have the ability to do so in terms of being assertive, following up etc.

It’s a shocking thing that only a few are able to get the help they need and everyone else is getting fobbed off with poor quality CBT courses (the one I was put on initially wouldn’t have met the criteria for NICE recommended CBT!)

Yes but not via the gp in my experience you need need to be referred to secondary psychiatric services which means it needs to be more serious. Most people i know pay privately if they have talking therapy. The problem with mental health is it’s very subjective so far harder to quantify whether x or y therapy works

The Talking Therapies website included Counselling for Depression (CfD) as one of the treatments they offered at stage (level?) 3. CBT appeared on both stage 2 and 3 lists. EMDR was also listed.

If you’re a clinican then I imagine that your treatment experience would be quite different from that of ‘ordinary’ service users. Primary and secondary care will be aware you know the pathways and what should happen, you know how to make a complaint etc. That will make a difference in how you’re treated.

We’re probably in different parts of the country, but this is the case in the area I live and work in. It’s not a fantasy - why would I make it up? I’m giving advice based on the mental health service I work within (a senior clinician). I can only comment on my own knowledge and experience though. Sorry if you want to call it ‘a fantasy’. I also happen to be disabled, living with a very severe SMI (severe mental illness) so am a user of secondary care MH services too myself. So see things from both sides of the fence so to speak.