 Felly, ychydig i'n ddweud i fynd i ddweud i'r gyfnodd yma, ond mae'n gweithio'r cyfnodd, yn ysgrifennu'n gweithio. Felly, ddweud i'n gweithio, yn gyffredinol, ac mae'n gweithio'n gweld, mae'n fydd ymgylch gysylltu'r cyffredinol, ac mae'r psychotheraeth yn y ddweud i'r gwirionedd. Mae'r cyffredinol hwyl hwn yw'r psychotheraeth yn y 80s yn y 90s. Mae'r cyffredinol yn y ddweud i'r cyfrifol Llyfrin, rydw i mwy o'r Llyfrin, yn peraigliannol gyda'r CVT corpus yma a'r Llyfrin i IPT Scotland, Rhywpopol Llyfrin, ac rwy'n dwi'n credu paleol yn gydydd i glamor, i'r Llyfrin i'r ffordd Siwyd Dragons, ac mae'r gyllido'r gyllid Cymru yn enllunol a'r Llyfrin i'merydd yn cael mynd. Rydaw i'n gweithio i'r Llyfrin i'r Llyfrin i'r Llyfrin i'r Llyfrin i'r dysgol? A dyne sydd wedi ni fyddwch doedd y dwy am beamol yn bwysigрabledd a chyfyddoedd yn ddysgwysgysgu'r cyllidau mewn rhywadol. Ac mae'r haf yn ymgyrch wedi'i chael gwneud eu cyffredinol o dweud o ymddyddol yn eu bwysigr Python â eu ddweud o'ch mynd. Rwyf wedi bod i'r gwaith yn ein mynedd o'r bydeg yn ddysigr групodau, rwyf am y椅wyr, rydyn ni'n angen, yw'r seidio, rydyn ni'n angen, stryd ni'n grannol, gyda'r mwyaf bach ac ar hyn o'r ceisio. A wedyn y gweithio, rydyn ni'n gwneud o'r cyfrifioedau yma, a rydyn ni'n ddwych o gweithio'r cyfrifioedau bod oedd yn gyfnodydd ymgyrch. Yn hynny, mae'r gweithio'r gweithio'r meddwl yn wych, ma'n ymdweud o'r cyfrifioedau sydd yn gyfnod ymgyrch yn gweithio'r mewn. A oedd ymgyrch yn gweithio ddysgu'r cyfrifioedau. because I don't want any of his colleagues offers psychotherapy in the state hospital at car stairs and other stairs, Forest who is still in his twenties works with prisoners. I'm taking some trouble to tell you who I am in case any of you google me before signing up for tonight. I'm sorry to disappoint you, I'm not the pre-reformant news umarrogly moroes. Ac rydyn ni'n rydyn ni'n gweithio y cyfnod ac rydyn ni'n gweithio Gwnggrarsbyr Fyll. A dyfodd yn mynd i'w amser y gallu ymddiannod yng nghymru i'w eu bod yn ymddiannod a'r Fyginnod Fysiotheraeth. Ond rydyn ni'n gweithio'r gweithio'r ddeud yng Nghymru, oedd yn ymgyrch yn ei ddweud i'r cyfnod o'i gweithio'r gweithio'r cyfnod, ac mae oeddech chi'n dwi'n dylun i'r gyffredinol arferwain yn psycho. Felly mae hoddodd yn cael y cerdddwyd i chi'n gweithio arweithio, mae wedi cael ei wneud i'r cyllid i'r IQ yn y mylion. Mae'r cychwyn ddiddordeb sydd wedi ddod yn ddiddordeb yn cyfnodol. Mae'n ddiddordeb sydd wedi ddiddordeb sydd wedi'u ddiddordeb sydd wedi'u ddiddordeb? Ond yw'r gwaith sydd y gallwch chi yn gwybod. Mae'n cyffredinol yn gallu gwahod o gyllideb yn frym. Ac mae hefyd yn gallu duties ond maen nhw'n gynghwyl gyntaf o arferwydig am gwybod sydd gyntaf cyfjeir Lord, a mae'n rhai gweithio cyffredinol ac maen nhw unrhyw llyfr yn gyllideb yn ygafodd. felly, dwy'n mynd i gyfnogi'r synghau cyfnogi, dwy'n mynd i'r cyfnogi'r cyfnogi, dwy'n mynd i'ch eu ddweud o ddwyllion. Yn ymgyrchu, mae yn ymgyrchu'r cyfnogi'r cyfnogi yn ymgyrchu'r cyfnogi'r cyfnogi, ymgyrchu'r cyfnogi'r cyfnogi'r cyfnogi. Mae'r gweithio ar unrhyw deilig yw'r cyfnogi sy'n ei ddim yn ei ddweud yw'r cyfnogi'r cyfnogi o'r ddweud o'r cyfnogi, Of course, like everyone here, even Glasgow Phil himself, I am a potential patient as well as a professional, and in fact I have been a psychotherapy patient on two occasions. Many years ago I received a course of CBT. I was an NHS patient but also part of a clinical trial, which provided the most excellent service. Some years later, in contrast, I had private, psychodynamically-informed art therapy, and those who know me agreed that on both occasions therapy really helped me to function better as a person. I remember what hard work it was for me as a patient. At the time I didn't even notice that the therapist was working too. But the memories that still stand out were their gestures of real human kindness that seemed to transcend many manuals, protocols or trainings that they had. Now after years of training and experience, when it comes to pure psychotherapies, I still feel like a muggle in a group of wizards. I would find it really hard to declare any exclusive allegiance to one modality of psychotherapy. And this means that whatever I say tonight about psychotherapy in Scotland may displease some people. I'm not in the business of newly pleasing you, of course, but I'm so grateful to be given a voice tonight to discuss whatever I care about deeply. Of course I don't want to attract destructiveness to any of the psychotherapists or to found the flames of self-sabotage. But I believe that intelligent people need to consider the role of psychotherapy in our country explicitly and constructively if we're to make the most of it. Psychotherapy is certainly alive in Scotland today, but I'm not sure that it's kicking. At a recent psychotherapy conference, one delegate remarked that we were all being quite unnaturally nice to each other, and he really yearned for the good old days when there was robust dispute. And then after the cutting thrust, people ended up in the bar drinking together late into the night. But my own memory of those days is that actually the cutting thrust could be so vicious. Even those who could still face each other in the evenings had to drink gallons of whiskey to survive the ordeal. Certainly psychotherapy, like philosophy, is not for winters. It's a high-risk profession. It carries a risk of potential side effects for patients, and perhaps an even higher risk for the therapists themselves. They should get dangerous. Does anybody recognise this now? It's Socrates, the news of cognitive behavioural therapy, and the origin of the technique of so-called Socratic question. In 499 BC, he was condemned to death for asking provocative questions and inciting the young people of Athens to think for themselves. Now, John has promised that there will be time later this evening for discussion and drinks. I only hope my room won't be hemlock. If we don't have enough time left for all your questions and comments, however robust, I would be very pleased to have your emails and further feedback so that we can continue the dialogue. First of all tonight, I want to emphasise three crucial elements of effective psychotherapists, all of them backed by research. They are the therapeutic relationship, the need for emotion regulation, and the benefits of supervision. Now, I've just predicted that some of us might fall out this evening, that our relationship might break down. This is actually a technique that I've been using for 20 years now, ever since I read this book by Safran and Siegel. The blurb on the cover boasts the following. The authors integrate findings from cognitive psychology, infant developmental research, emotion theory and relational therapy to show how change takes place in the interpersonal context of the therapeutic relationship. I could probably go home because equally that would be on the cover of my talk this evening. Safran and Siegel have a fabulous chapter on the alliance rupture and how to manage it. Their main point is this, that it's helpful for patients and therapists to begin by anticipating how their relationship might well break down during the therapy. They can then make it one of the main goals of treatment, simply to learn how to repair the relationship when that happens. So I remember vividly working with a woman called Jo, obviously that wasn't her name, who had severe borderline personality disorder. And whenever she felt hurt, she would lash out and try and inflict a lot of hurt and return. In the past, she'd always ditched her boyfriends the moment this started to happen, and she'd also sacked her previous therapist. Now during her sessions, there did indeed come an occasion when somebody had badly hurt her feelings. She began to tell me contemptuously how useless I was and how coming to appointments with me were pointless. She said it would be much better if she took an overdose or cut herself as she had used to do in the past. And then she suddenly stopped herself and she said, you know, I warned you about this. I could tell that you'd end up irritating me, but I did promise you I'd give you a second chance, so I will. And that was my first experience of suffering in Siegel's alliance rupture actually at work. Of course I hope that this audience will be as generous as Jo was. Now obviously it's crucial to invest in the therapeutic relationship. There can be no therapy without it. You might say well some people do terribly well with self-help materials, either as books or online. But I would reply that there's always a relationship, even one with an invisible author. And the best self-help materials seem to speak to us in a humane and kindly voice. But a live therapist can take account of the patient's individual attachment style. We've learned from the work of John Bowie and Gwilacott and their followers that ordinary people, and in particular mothers, generally have the capacity to make these good enough relationships. So why actually might we need professions at all? Well a study that was hotly debated in my youth was one published in 1979 by Strachan Hadley. Some of you may know this. They selected two groups of similarly anxious and depressed students. And one group was treated by highly experienced trained psychotherapists. The others were treated by their college professors. These were American professors, so they were lecturers and directors of studies rather than people as eminent as jam. And these professors have been chosen for their ability to form understanding and genial relations. And guess what? There was no difference in the outcomes. The professors appealed to do as well as the professionals. However, the professionals lived to fight another day, whereas the experience was emotionally exhausting for the academics. And I've had quite a lot of experience of this sort of situation. One of my roles is to supply supervision to the university mental health mentors over their yonder in the Athens of the North. The demand for the support for these mentors has actually grown exponentially over the century. The government funds mental health mentoring for any student with a self-declared mental illness. And those mentors are provided with training and supervision. The students directors of studies are very grateful for the extra support, but many of them have also told me they're nostalgic for the days when they have time and support to provide pastoral care themselves. I'm interested in what you think. Would it be a reasonable alternative to provide the academics with the extra supervision and support rather than separate out students' mental health needs from their educational development? As psychotherapy moves into the 21st century, I do see a need for it to remember it's more systematic and systemic rather than purely individual role, particularly if it is to bring benefits to the increasingly large numbers of people in need. So let's move on to examine the practice of supervision. I'll just describe what I mean by this. We're talking about the regular practice of therapists meeting individually as a group, often with a senior practitioner, to discuss their cases and to get some guidance and support. Some supervisors will actively teach therapy skills and techniques and may insist that the therapist is true to the spirit of a certain model of therapy. They may even review audio or video recordings of the therapy. Other supervisors will use a more socratic approach to get the therapist to notice and criticise their own practice. For decades we've all behaved as if there was no question but that supervision for mental health practitioners is a jolly good and necessary thing. Now every therapeutic modality at least pays lip service to it and questioning its benefit might seem heretical. Now obviously some of the benefit of supervision is a rather cynical insurance policy against gross malpractice. But until recently I'd never come across any research to demonstrate that it had clear benefits for patients. For that matter I don't remember seeing hard evidence that it reduces malpractice. My own personal experience is that I learn and teach useful therapeutic skills in the course of supervising and being supervised. I look forward to supervision and I tend to come out feeling clearer if not always more cheerful. So I was delighted to find that in 2007 Bambling and Lambert had decided to find out where the clinician's supervision actually improved patients recovery. So this was a group of patients with major depressive disorder and the results did show significant benefits for them. If their therapists have been in a supervision group, one of two supervision groups in fact, the patient rated their therapeutic relationship as better if the therapist was not supervised, the patients were more likely to actually turn up to their therapy sessions and their symptoms improved more. And it didn't seem to matter which particular style of supervision was being offered. I actually would like to see more research into the power of supervision and not only whether but how it works its magic. So my third crucial common factor across all types of therapy is helping the patient to identify and manage their feelings. And Sloan and colleagues published a review of this only last year. And their work demonstrated that emotion regulation is a key construct across most diagnoses and most therapists. They found that regardless of the intervention or the disorder, what successfully treated patients showed was an experience of less dysregulation in their emotions and the use of fewer maladaptive strategies to manage those feelings. And this was true whether the patient suffered from anxiety, depression, substance misuse, eating disorders or personality disorders. All psychotherapies teach the art of emotion regulation whether explicitly or not, simply in the act of sitting together in the presence of those feelings. The therapy to be any use, it has to conjure up emotion in manageable doses and help the person generate better ways of responding. Often this simply means tolerating those feelings. And sometimes the mere fact that a trusted therapist is sitting there too is comfort enough. Other times the patient may have to learn specific skills to manage the discomfort without doing things that are self-sabotaging. Dialectical behaviour therapy is a therapy that involves actually attending classes on emotion regulation and distress tolerance. Mentalisation-based therapy helps patients to access their own feelings and also to imagine and take account of other people's feelings too. The key spirit of interpersonal therapy is to invoke and tolerate emotion rather than to try and fix it in some way. And perhaps surprisingly research into CBT suggests that the benefits don't really come about from logically arguing away negative thoughts. It's more likely that the sheer experience of confronting and examining those thoughts and feelings is the healthy factor. And whilst in the past behavioural therapy has had a very bad name, in fact it's one of the most highly emotional treatments of all. Edna Fawr is a great American behaviourist who's been working since the mid-80s to develop emotional processing therapy. And her basic principle is exposure and response prevention. The patient learns that being in touch with what we fear does indeed trigger a huge wave of terror. But if you can learn ways to emotionally surf that wave, you can actually ride it down health until it fades. And subsequent waves will seem easier and easier. But on the other hand, if you bail out when the wave is still rising, you just teach yourself that the terror grows and grows. And Fawr's paper has described brilliantly how such therapists have to work. It's like being an orchestral conductor to moderate the dynamic and temperature and intensities of feeling in a room. The feeling has to be powerful enough to drive useful learning but not so intense that the patient tunes out altogether. The therapist needs to be sensitive and alert and at the same time strong and well-balanced personality. And I've noticed that these skills are the hallmark of all good therapists in all modalities. In fact, this may well be the key skill set that's developed when therapists undertake baby observation as part of their training. And perhaps it's much the same skill that good parents draw upon in helping their children to grow and develop. But during baby observation, the training has to observe another and baby together in a disciplined way without disturbing the dynamic or interfering. Even when the temptation to help out and fix the difficulties is immense. And interestingly, the feedback from the mothers who were observed is that somehow the presence of the positively focused observer is remarkably helpful and supportive. Perhaps one of the main differences between models of therapy is the degree to which therapists do actively teach or advise or intervene. But in all therapy, the essential is that the patient has to learn and all good teachers and good therapists seem to me to have a lot in common. I know from my family and often from observing them brilliantly in practice in their classrooms that teachers as well as therapists have to orchestrate an atmosphere in the classroom that is both stimulating enough to prompt learning but also calm enough not to distract the pupils and students by a sense of threat. And Anthony Ryall, pictured here, who created cognitive analytic therapy was particularly fascinated by this notion that the necessary sense of security for learning could be provided by a relationship and attachment. He drew on the work of Bobby and the other attachment theorists and he was also particularly interested in the work of the Russian educational psychologist Vygotsky who observed that the teacher or therapist creates a reassuring secure learning zone. They then introduce a task that is difficult but no longer impossible because they go to tackle it together. I'd like to tell you a bit more about couch cognitive analytic therapy. It's built on the notion of reciprocal relationships. Ryall says that we all have a repertoire of these potential relationship patterns available to us and the more variety and flexibility of potential relationships that we have in our repertoire, the better we can function. When we find ourselves stuck in mental disorders we often find that we've got stuck in particular repetitive relationship patterns. For instance, we may start to feel that the whole dynamic between us and others is gone of power. The situation can become one where one person is always the top dog and the other person is the underdog and whatever we do just feels as if we're simply trying to get into the top dog position. Now obviously this can be a successful strategy in some circumstances but you can imagine what happens if such a person needs help. They may avoid going to the doctor because they can't bear to feel like the underdog in that relationship. They may not risk learning a new skill or they may not even have been able to gain a basic education because teachers and other authorities make them feel like an underdog but in cat they can work to try out other potential reciprocal roles such as perhaps carer and cared for or teacher and student for instance. And this is what happened for Jo, the lady I spoke about earlier. Jo felt hurt and pals when her friends criticised her and even telling me about it put her in that horrible touch with her sense of helplessness and my sympathy came across as intolerably condescending and irritating in her mind I might just as well have been jeering at her but she decided to forgive me. Now one way of looking at that might be well she was just putting herself onto the moral high ground she was deciding to be top dog but she might also have been moving us across into another reciprocal role relationship altogether. She was actually behaving in a way that took account of my own feelings and I could interpret it as a caring response and I did and as time went on she learnt to tolerate the feeling of being cared for as well as putting herself into the world of carer. So these two diagrams have illustrated a cognitive analytic therapy formulation of Jo's difficulties and now that we've thought about the three big powers I mentioned that make psychotherapy effective I'd like to move on to talk about the concept of formulation How many of you are already familiar with the idea of formulation of your therapists or not? Well it's a hallmark of the psychotherapies to explicitly formulate difficulties but it's not unique to the psychotherapies it's just a theoretical model of how symptoms and signs can be driven and how they can continue to drive the way that the person functions. It's not something fixed it refers to this hypothetical model of either a small or a large part of the person's functioning either in health or in disorder or both at once whether in the past or in the here and now and sometimes both. And a formulation can incorporate a diagnosis and expand usefully upon it or it can replace the notion of diagnosis altogether when diagnostic categories are unsuitable or unavailable and we find it particularly helpful as a team as an integrating concept particularly when a person's disorder attracts many different diagnostic labels and ideas and we use this very basic diagram to guide us as to how each individual patient might be functioning in terms of all these different roles and behaviors. We don't like diagnosis very much in my team because it can tend to cause a major treatment reaction so for instance the diagnosis major depression automatically implies prescribed antidepressant drugs but a formulation is different it's a sort of working machine and it ties you to fiddle with different bits of the engine you might want to whirl the cogs or unblock the filter as well as maybe topping up the fuel tank. So excuse the mixed metaphors by the way but we find that a lot of psychotherapy involves trying out a lot of different metaphors to see which ones suggest useful ways forward. Freud was a master of metaphor he used archaeological metaphors to describe levels of consciousness but best of all I absolutely love his metaphor of the ego the self as a rider on the horse that is the id so the little self seems to be struggling to control and master the primitive animal drives and instincts that are dynamic assault. The CBT also thrives on formulation and the classic CBT model uses a diagram that's a bit like a hot cross bum and it draws out the interactions between our thoughts, feelings, actions and physiology and here's one that might actually be relevant to Glasgow Phil so let's imagine that Phil's client gen has a big athletics competition coming up in a fortnight's time she's feeling terribly anxious and panicky and she's actually stopped showing up for her training sessions now for an athlete that's dysfunctional and it's discourageous to Phil but even worse her friends are worried about her she's behaving in a socially withdrawn way when Phil calls her and she says oh I'm not ready for this what if I lose she's giving voice to her negative automatic thoughts and they demonstrate the common habit of catastrophising when you feel anxious physically Jen is shaky and junky and she feels nauseated so she's not eating properly now by using this sort of diagram you can see that Jen has a choice of approaches it's not as simple as one thing leading to another there's a whole interacting series of vicious circles wheels within wheels but the great thing is that oiling any of the wheels or several of them could be helpful in its own right so a behavioural route might be to support her to come out to the training sessions she could at least socialise even if she can't manage to full workout yes it would be anxiety provoking but if she can bear to surf that wave of anxiety a few times then it will gradually become easier and of course physically both exercise and company have proven benefits on mood a more directly physical approach might be to improve her diet and she could cut out caffeine in case that is mimicking anxiety symptoms she might even consider medication if this goes on whereas a more cognitive approach would involve helping her to recognise that this style of thinking is catastrophising and then use one of a variety of techniques to challenge those automatic thoughts so for instance she could ask Phil for feedback on her recent performance times to give a realistic perspective on her chances of winning and losing now CBT is absolutely not about replacing negative thoughts with positive ones if the feedback is that she's pretty certain to lose all her races particularly since she stopped coming to training it would be rash and discourteous to just encourage her to look on the bright side it has to be faced but she could then manage that in a much more confident and constructive manner she might decide to take charge and pull out of this competition but continue training for the next perhaps meanwhile enjoying a bit more leisure time so this is an example of the sort of CBT that was developed by Tim Beck, now a very old man back in the 1970s and 80s in Philadelphia and we call that diagram a top level formulation because it deals with the here and now rather than delving back into the narrative of Jen's life story and in the 1990s the cognitive psychologist Howard Jacobson showed that in most cases of therapy this top level of formulation gives results that are just as good in terms of well-being and symptom relief as if the therapist formulates at a more historic level with the patient but he also found that both patients and therapists greatly prefer the experience of considering the whole life story this is probably why modern CBT tends to add a back story to the hot cross band and to consider how both nature and nurture bring about an individual set of schemers, deeply held beliefs or rules for living these are known as schemers the rules for living and schema based therapy can either be incorporated into classic CBT or now offered as a specific therapy in itself so to stay with the case of Jen perhaps she's the child of highly successful striving parents and has got perfectionist genes and maybe she's also attended a prestigious sports academy or her childhood so these might predispose her to develop core beliefs that as she is a potentially very strong person other people expect her to strive and compete and that the world is a highly judgmental place and she may also have developed more conditional schemers that are rules for living your life by such as unless I'm the best then I'm worthless and it will be those schemers that inform the way that her automatic thoughts, both positive and negative come into her mind now Paul Gilbert has developed Compassion Focus Therapy and this is an example of a formulation that can shift the course of Compassion Focus Therapy but is also I think compatible with other therapies and some of us like to use this diagram even in IPT or CBT as well as for those patients who are undertaking a specific course of Compassion Focus Treatment and it's a useful shorthand to remind us that different parts of the human mind serve different functions and have actually evolved to do so without having to think about it consciously and I've just annotated this to show there may even be some overlap for its ideas of id and ego and superego and we could perhaps use this diagram to show Jen that while she can normally use her competitiveness the blue circle and drive to excel in competitions without trouble at the moment she hasn't got the balance for this to work out well so she's actually picked up a sense of being under threat and this is in the yellow circle this represents the primitive part of her brain which is making her responders if other people might be enemies rather than allies and adrenaline is getting her ready for fight or flight or to freeze and she hasn't got enough balancing sense of nurture represented by the pink circle to help her feel that competing is still nevertheless playful and fulfilling now Glasgow Phil can help her reconnect with that sense of security and support if we're using IPT into personal therapy we might also focus on that pink circle by zooming in on her interpersonal network and working out how she might best use that to get her needs met now and also in the future IPT grew up about the same time as CBT in the US and Canada led by the sociologist Myrna Weissman it's a lot less famous than CBT but it's demonstrated similar effectiveness in many areas and Scotland was a pioneer in offering IPT both to patients and as trainers in fact ten years ago we had more IPT therapists per head of population than any other country in the world so this is an IPT diagram of Jen's closeness circles Jen is the big J in the middle and she's put the closest people to her in the immediate circle Phil, her trainer and her parents and she's divided the circles into slices showing whether people fall into the areas of family or the athletics community or friends from other walks of life like her best friend Lynn Phil has already encouraged her to come back to the club where she will get the opportunity to be supported by him and her friends there but she will also be wise to socialise with family and with other friends and when the therapist asks about these other friends that's when Jen becomes very tearful and if he manages that she's been struggling with some nasty online conversations between them IPT treats emotions as signals to be respected and tolerated they're not necessarily acted on without consideration and reflection one of the focus areas which IPT offers would be a disputes or conflicts focus and this would be appropriate here for Jen's situation she could be encouraged to roleplay some of the difficult situations the therapist would take the role of a friend and then they could replay them differently perhaps also exchanging roles so Jen could get an idea of how it felt to be in the friend's role this might prepare her for managing such interpersonal situations more confidently that's an absolute whistle-top tour of some of the skills and formulation techniques in some of the newer models of therapy and you can see how much they like to draw diagrams our patients go out of the room clutching lots of pieces of paper but not prescriptions for drugs but imaginary maps and family trees and sketches and sometimes letters that we have written to each other I find that sharing diagrams is a really useful way of stepping back from a highly charged situation without bailing out you can get a broader perspective on the balance that's needed it's especially helpful for patients who prefer visual ways to learn especially younger patients and for people who are more comfortable in the realm of the concrete than the purely metaphorical and verbal and it can be a way to spare patients the uncomfortable burden of eye contact often it ends up feeling very playful particularly when the patient picks up the coloured pens and starts drawing things in for themselves and I do particularly like the CFT diagram because of the way that it integrates therapy with some of our newer ideas about how the brain works so we can demonstrate to our patient how not only with therapy but with medication too we're trying to support particular balances I believe it's time for departments of psychotherapies of neurosciences to collaborate rather than approach each other As old adversarial stance is now as stale as asking whether it's nature or nurture that dictates our behaviour I think we can afford now to explore questions of interaction and particularity and maybe develop better models and statistical designs for that exploration Besides I think many of us professionals have had the experience that a patient simply can't manage the work of psychotherapy until they have started to benefit from some medication or in contrast that there are some patients who need months of therapy before they can build up the trust to start taking medication that could help them So I've moved away now from looking at the big three common elements and started to discuss some of the specific characteristics of different models of some of the newer therapies and I do respect those differences between different schools and models of psychotherapy I think there's a subtle but important difference between acceptable borrowings and practising a sort of sloppy eclecticism on the other hand Perhaps it's a bit like communicating in different languages or playing different musical instruments When I worked at the Cullen Centre Maggie Gray refused to take me into the CAT supervision group for a whole year until I thoroughly practised CBT She said it was important to thoroughly exploit all the resources of a certain way of working before jumping ship and moving into different structures and she was absolutely right But of course this leaves the question for us as patients as practitioners and as politicians which therapies should be offered? How do we know what works for who? For the past quarter century most of our professions have welcomed the evidence-based medicine movement but I know that many of my colleagues are deeply concerned about the way in which the principles of evidence-based medicine are applied to the psychological therapies The experimental design paradigms that we would hope to use when assessing medicines are not necessarily applicable I might be quite happy to take a drug for my acid reflux if a trial conducted in 2017 showed that it was clearly effective in hundreds of thousands of people across the world and that is indeed the sort of trust I might often be faced with I'd be far less happy to be treated for a mental disorder using a psychotherapy that had helped fewer than 100 American patients back in a study that was not published till the 1990s Well obviously we have much more than numbers in the psychotherapy trials and we also need to remember that psychotherapy has to be culture sensitive in a manner that doesn't necessarily apply to more physiological treatments and the majority of psychotherapy studies do come from the US where people have very different social and political backgrounds and most participants in research trials there are individuals who would have to pay for therapy if they weren't in a study and I'm writing that this sense of privilege could affect psychological outcomes even more than physical ones In 1989 Stiles and Shapiro strongly criticised this drug metaphor The metaphor suggests that psychotherapy consists of active ingredients purely supplied by the therapist it overlooks the context, the role of the patient and the validity of outcome measures which are usually self-completing paper questionnaire and since then many wise critics have continued to raise similar questions If you have time and interest I'd recommend some of the most up-to-date quantities of Professor Peter Fonachey He has many wise balanced and even controversial reflections about the uses and misuses of research design and interpretation and some useful ideas on ways we might go forward He recommends abandoning the strategy of making comparisons of various families of therapies for diagnostic groups that are heterogeneous He suggests that we move on to use the opportunities provided by the neurosciences and other biosciences and by computational methods of psychology to creatively explore and assess treatments He particularly suggests that we dissect out specific components of the therapy as I was trying to do early on and then deliberately recombine them to address the key problems of individual patients as revealed by their formulation Now one way we can address more numbers is to use meta-analyses so you can pull results from multiple studies but these are potentially misleading if the participants in different studies are not very similar So the honourable exceptions to poor research are often very disappointing For instance, Christine Steiner's recent meta-analysis rigorously showed that dynamic therapy is not inferior to CBT-based therapies in most trials but sadly in order to achieve this rigor the authors had to confine themselves to studies that use short-term manualised dynamic psychotherapies with very similar diagnostic and outcome measures and this rules out most of psychotherapy as it's practised in the real world However an alternative approach is to use quantitative research that takes us back to the joys of old fashioned individual case studies and case series but now subjecting them to sophisticated new analyses and I feel that a small country like Scotland might well prioritise this so-called idiographic investigation and meanwhile what do we do in the presence of only an incomplete range of not particularly reliable or informative research Well the current reality is that most patients do receive empirically untested combinations South of the border, Lord Layard and Professor David Clark have introduced indeed mandated something called IAPT improving access to psychological therapies and the aim was to improve the effectiveness and efficiency by insisting that people are provided with treatments that have the best possible evidence best using for instance the nice guidelines Now obviously this does risk censoring treatments that haven't yet established a research record however the reporting from IAPT suggests that the commonest treatment that patients get is other that is not CBT not psychodynamic therapy, not family therapy none of the models of therapy which nice specifies have an evidence base in the field IAPT has also used a lot of the jargon of happiness and positive thinking which makes many others rather suspicious and it's been strongly criticised for delivering low level very rationed brief therapies which can seem unduly goal directed and some of those goals are explicitly overtly political goals such as getting people back to work So what is the political background to psychological therapies in this country Well Scotland is blessed to be free from IAPT just as it is theoretically free from the nice guidelines or rather for us they're optional guidelines rather than binding laws We do have signed guidelines but they're not legally mandated in the same way as nice Unfortunately not many of the side guidelines address mental health conditions so far The Scottish NHS and Government have instead opted to provide psychotherapies at the discretion of different health boards The government introduced a HEAT target designed to improve access to talking treatments but rather strangely it initially framed this in terms of reducing the prescribing of antidepressant medication rather than actually increasing access to therapy Now HEAT targets have been replaced now by LDPs or local delivery plan standards but most of these are in fact the old HEAT targets under a new name and the Scottish Government has since December 2014 set a target for the NHS in Scotland that 90% of patients should access psychological therapies within 18 weeks of referral As of June 2017 only 72% do so and some waiting lists are many years long Meanwhile training for practitioners in the NHS in Scotland is provided and controlled by a body called NESS NHS Education for Scotland and this uses yet another guide to the body of evidence for psychological therapies called The Matrix This appears to have been constructed at some point by invited Scottish therapists and I wasn't able to discover its clear status although health boards often voted in service design It was last updated in 2014 and most of the evidence quoted is older than that For instance in my own field of eating disorders I could find nothing that has been published in the last 10 years I also noticed that the evidence in the field of schizophrenia was somewhat sparse and some of the studies have been tested on Chinese patients I think I should warn you that I've now come to the low point of my talk When John first invited me to speak tonight I thought it would be an opportunity to cry woe to bemoan the loss of psychotherapeutic excellence in a once enlightened country I believe that there was a crisis in the recruitment and training of young psychotherapists In fact Aberdeen Medical School recruits more psychiatrists than any other and I've noticed that they're very keen to participate in psychotherapy supervision We have psychotherapy supervision groups to help trainees learn all the important factors of psychotherapy I'd like to quote a young doctor who just computed his first psychotherapy case He told us, it's amazing he's actually recovered I've only ever seen patients get better with EC2 before This was a compliment to the supervision group but perhaps not a happier reflection on the status of Scottish psychiatry Perhaps the success of his psychotherapeutic import is particularly laudable When you consider that the population of patients we now see in hospital clinics in specialist psychiatry and psychotherapy is very, very severe People who attend the NHS now only get psychotherapy if they have very, very high severity and complexity of illness In other words patients who would be excluded from all clinical research and whilst I welcome the blossoming interest in helping people with complex personality disorders and other conditions where psychotherapy can help in ways that medication cannot I'm also worried that people with less severe disorders are not getting the investment of group therapy and instead for them there has been a potential cheapening and dilution of the psychotherapeutic process People now rely on their own couches in their own rooms and download mobile phone apps on how not to think negative thoughts and how to be mindful and I don't wish to knock this but I don't think it's always helpful and it could actually provide an illusion of psychotherapy without including those important drivers of therapeutic change the attachment, the emotional arousal and regulation and the overseeing power of some therapists supervision and sadly many of the institutions that maintain Thai standards and fostered intelligent discussion and inquiry have shrunk or even closed down altogether We no longer have such a powerful, thriving Scottish Institute of Human Relations That used to be the Scottish equivalent of the Tavistock and was renowned for disseminating psychotherapeutic enlightenment in the late 20th century and Scotland's rival CBT courses are also much reduced You can still train in CBT here in Glasgow but Dundee University's CBT course the only Scottish course fully accredited with BABCP is closed to further intake and Scottish child and adolescent CBT course has banished IPT Scotland lost its charitable status and the adolescent has ceased to award its own accreditation or to offer regular 5-day training courses Medical psychotherapy is as popular as ever with young psychiatrists but so many of their elders have taken early retirement In nursing and LA professions we've seen a reduction in therapy posts and even a downgrading particularly for those following any model that is not CBT I don't think it helps that at meds all psychotherapy resource has to fall under the titles of either medicine or psychology but as I came to put together this talk I started to feel that maybe all this world is telling us something useful It's time to regroup and I agree with Peter Fongy that we have to be brave enough to take things apart and put them together again differently One way to do that might be under the banner of the chief medical officer's realistic medicine programme Catherine Calderwood is campaigning under six banner principles of what she has called realistic medicine and so in conclusion I wonder if we might consider how to apply those to the field of psychotherapy What might realistic psychotherapy look like? Well psychotherapy is renowned for putting the person receiving the health and care at the centre of the decision making Formulation encourages a personalised approach to their care I think we should reduce harm and waste very carefully not by rationing people 100 people to have one hour each of psychotherapy but making sure that where psychotherapy is given it is given completely and in full I think we could probably reduce harm and waste also by a more creative and intelligent use of modern technologies For instance in the north of Scotland very good use is made of high quality video conferencing for therapies and certainly for supervision What about tackling unwarranted variation? Well I think in the psychotherapies we also have a problem to tackle unwarranted sameness and care and it's very important until we know which therapies might have something to offer that we don't close down experimentation and send people down rigid pathways or protocols We need to manage risk partly by acknowledging that there really is risk in psychotherapy and that some of these computerised open programmes of psychotherapy or some of these forums that people join unless they're properly moderated and accredited could do more harm than good Talking can be extremely powerful for ill as well as for good and we also need the older people to become active on social media so that we can turn that into a therapeutic and health-bringing place instead of just a general affair and as for innovating to improve I think we're now at the best possible stage in the development of the psychotherapy to expressualities to engage in auditing and exploring the variation I'd like to propose a new Scottish alliance of psychotherapies across the age range across the whole of the country I believe it should be disciplinary, transprofessional, informed by the rigorous and self-critical principles of science but also by the creativity and playfulness of the odds and it should be imbued with the spirit of a new Scottish enlightenment So what about you Glasgow Phil? What's your agenda for psychotherapy in Scotland today? Very much so!