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Mental health comment

Getting personal

Stop the therapy brand warfare and recognise it's the personal qualities of a psychological therapist which are more important than the theoretical model, says Martin Seager, a member of a group advising the government on how to improve the therapeutic quality of mental health services

October 31, 2007


Is it really possible to deny any longer the evidence that secure attachments and relationships are the root of mental health and well-being?

It is relationships that make us, maintain us, hurt us and even break us. Relationship is perhaps the most important of several core and universal psychological needs that people have alongside their biological and social needs. This was one of the key conclusions of a national advisory group of distinguished psychological thinkers, clinicians, academics and writers that I convened at the personal request of the then secretary of state for health, Patricia Hewitt.

Our group was put together to reflect a wide range of different psychological approaches (including CBT, systemic, psychoanalytic and Jungian) so that we could move beyond ?brand warfare? and look more deeply at the universal principles underlying all good psychological care and finding something that we struggled to define, but kept coming back to as "psychological mindedness?. Our aim is to find ways to improve the psychological mindedness of our UK mental health and care services.

Our group concluded that whilst there was a welcome increase in recognition by government and society as a whole of the value of psychological therapies and treatment, the big psychological picture was still being missed. For us, there are four key points to this bigger picture.

Firstly, all effective psychological treatment approaches have more commonalities than differences, and it is surely these commonalities that should be the primary focus of the "evidence-base? that informs national guidelines and standards.

Secondly, the evidence shows (eg. Wampold, 2001; Brown & Jones, 2005) that it is easier to tell apart good and bad therapists rather than good and bad therapies. This means that the personal qualities of the therapist are a more universal therapeutic factor than technique or model (although both are important and interact) and yet the national evidence-base emphasises technique and model only.

Thirdly, psychological therapy outcome studies (see Norcross, 2002) also consistently conclude that relationship factors are the single most critical ingredient in effectiveness. But these factors get marginalised as non-specific as opposed to the specific technique or model. It was glaringly obvious to our group that this should be the other way around. In other words, it is technique that is non-specific, whereas the relationship factors are highly specific to the outcome. Relationships are the ?baby not the bathwater? in all care services. This is where future research needs to focus more closely.

Fourthly, psychological therapy research focuses on psychiatric "conditions? (plural) but any effective psychological approach should be relevant to the human condition (singular). A conditions-based approach divides people into ?us and them?, "crazy and normal? whereas a relationship-based approach focussed on the human condition enables us to empathise and connect with people in distress from our own related experience.

Human relationship is, then, the key in psychological therapy, but the even bigger point is that it is also the key in human happiness and well-being. Our group also concluded that all people have basic and universal relationship-based psychological needs. These include: attachment and trust; empathic communication and relationship; identity and belonging; containment, security and discipline; value, meaning and purpose; resilience and self-determination; and satisfaction and pleasure

The less these needs are met the more any one of us will become psychologically distressed. In this context, is it that surprising that the people in our society with the most severe mental health problems would get the lowest scores on the above checklist? Is it that surprising that where users of mental health services report good outcomes this reflects the consistency and continuity of good relationships with professionals? Is it that surprising that where things go wrong in mental health services this usually reflects discontinuity, disruption and breakdown of trust in relationships between users and professionals?

Of all the above needs perhaps ?empathic communication and relationship? is the most important. Our group noted that all the major world religions share the same basic ?golden rule?, namely ?do unto others as you would have them do unto you?.

The psychological need for empathy is then indistinguishable from universal spiritual needs that have long been recognised. However, this wisdom has been forgotten or disconnected when it comes to thinking about mental health and designing mental health services.

Psychological mindedness gets depersonalised as a treatment technique rather than used as a basic service ethos. Attachments are blindly broken on a daily basis as patients (and also sometimes staff) are moved around the system in a ?revolving door?. We still try to prevent suicide physically by removing ligature points rather than supplying meaningful psychological attachments. We expect our frontline staff to be psychologically receptive to services users without themselves being held in mind.

Our national policies and guidelines still, therefore, remain significantly psychologically blind and our mental health services as a result remain psychologically unsafe (Seager, 2006). Where do we go next with these ideas? Our group looks forward to linking up next year with the National Institute for Mental Health, the Care Services Improvement Partnership, the British Psychological Society and other bodies.

* The government's national advisory group on mental health, safety and well-being consists of: Susie Orbach, Andrew Samuels, Valerie Sinason, Lucy Johnstone, Martin
Seager, Glenda Fredman, Ross Hughes, James Antrican, Margaret Wilkinson and Peter Kinderman, assisted
by Tanya Woolf and David Spektor

* Brown, G.S. & Jones, E.R. (2005) Implementation of a Feedback System in a Managed Care Environment; What Are Patients Teaching Us? Journal of Clinical Psychology/In Session, 61(2), 187-198
* Norcross, J.C. (ed.) (2002) Psychotherapy Relationships That Work New York, NY: Oxford University Press
* Seager, M. (2006) The Concept of ?Psychological Safety? ? A Psychoanalytically-Informed Contribution Towards Safe, Sound & Supportive Mental Health Services Psychoanalytic Psychotherapy, Vol. 20, No. 4, 266-280
* Seager, M. et al (2007) National Advisory group on Mental Health, Safety & Well-Being: Towards Proactive Policy: Five Universal Psychological Principles (unpublished paper)
* Wampold, B.E. (2001) The Great Psychotherapy Debate: Models, Methods and Findings Mahwah New Jersey: Lawrence Erlbaum Associates

* Martin Seager is a consultant clinical psychologist and head of psychology at North East London Mental Health Trust


Antidote to endless behavioural therapy evangelism

Comment from: Louise Pembroke, mental health activist, London
Date: November 4, 2007

Thank you Martin - a much needed antidote to the endless behavioural therapy evangelism. I agree that it should be about non-specific techniques which are not diagnosis-led, and that human qualities and relationships are infinitely more crucial than clinical interventions where the evidence base is limited and biased anyhow.



Comment from: Ron Wood, private clinical and counselling psychologist, Plymouth
Date: November 28, 2007

Well done Martin. I hope this wisdom gets listened to by those who influence mental health policy.


Craft, as much as science?

From: Malcolm Davy-Barnes, psychotherapist and team leader, North Essex Partnership NHS Foundation Trust
Date: September 24, 2008

Thank you for providing a voice of sanity in these times. I wholeheartly agree with these views.

I think another factor that gets lost in the discussions is the importance of a theoretical background that has personal meaning for the therapist and sustains the therapist in their work. 'What works for the therapist?', in other words.

Although a scientific approach can inform us in many ways, I do not believe that what I do in my work is science. That mix of technique and imagination could be called a craft perhaps.


Recognise the art of our professions

From: Kim Sherrington, lead clinician/unit manager, day group therapy unit, Avon and Wiltshire Mental Health Partnership NHS Trust
Date: November 27, 2009

Here, here to both Mr Seager and to the comments of Mr Davy-Barnes. The human condition is infinitely bigger than science alone. Many of us do not experience the world in scientific terms yet we are made to fit into one whether a user or staff member.

I agree and long for a recognition of the art and craft of our professions. If we spent more time and money on developing both staff and, therefore, users instead of counting everything perhaps we might have a healthier relationship in general with our masters - the user and taxpayer.

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