Peter Fonagy on psychoanalysis and IAPT

Peter Fonagy is is Freud Memorial Professor of Psychoanalysis and head of the department of Clinical, Educational and Health Psychology at University College London. He has been instrumental in bringing in a new form of psychoanalytic therapy called Dynamic Interpersonal Therapy (DIT) into the NHS’ Improving Access for Psychological Therapies (IAPT) programme, and expanding IAPT into Children and Adolescent Mental Health Services (CAMHS). We interviewed him about the place of psychoanalysis in IAPT.

How did you get interested in psychoanalysis?

I was quite severely depressed as an adolescent. I was sent by my family in Hungary to live and study in England, I didn’t speak any English, I didn’t have any friends. I became majorly depressed. I went into psychoanalysis at the Hampstead clinic. I went for three years and had wonderful analysis from a woman there named Anne Hurry. It was literally a life-saving experience.

Why was it so helpful?

I think it was very well suited to me – intellectually very challenging. Also she was very sensitive, kind, generous, genuine. Lots of the issues I had were to do with having come from a very intellectual family and having to survive in a different context. It helped move from being stuck in the past to bonding with the present day and the here-and-now.

What did Freud get right and wrong?

Freud got his model of the mind spot-on. He identified the importance of sexuality and aggression in human nature. No one has credibly challenged those assumptions. If they do, just look at the internet sites that get the most hits. He also understood the mechanisms of the mind – defenses, unconscious motivations. It’s a very sophisticated model of the mind, which is 60-70% true, which is pretty good going these days.

What he didn’t get right is his model of treatment. He wrote 23 volumes, 22 on models of the mind, and just one on technique. The technique volume is poor – it jumps from here to there, it’s not consistent. But that particular way of practicing got locked down after his death.

It became dogma.

Exactly. And it’s a joke. The idea of long-term deep introspection, of really studying your own mind, might be good for the training of therapists. Is it helpful for people with mental health problems? I think it probably does harm. People assume if one session a week is not enough, you need two. If two is not enough, you need three or four. The idea is flawed. So psychoanalysis got in a lot of trouble. The model of the mind became more and more complicated, but the treatment bit only improved in a patchy and incomplete way.

Some of his ideas seem so Gothic and unlikely to me – the death complex, for example. When I had depression, that idea depressed me even more!

Sure. I’m talking about his core ideas. But he was right about the inherent human capacity to destroy things we feel we can’t control.

Regarding Improving Access for Psychological Therapies (IAPT – which is the expansion of talking therapies within the NHS that’s happened since 2009), how unique is it? Do other countries have IAPT-type services?

A lot of countries have versions of it, and have for years. It’s just in this country the NHS didn’t have any psychological therapy to speak of. Only the occasional secondary care psychotherapy service, which maybe saw five people out of 100,000. Or we had counseling services in some GPs. We had no specially-trained psychotherapists in the NHS. We were totally lagging behind places like Germany, Switzerland and the Scandinavian countries. I would say we have caught up in some areas, and exceeded in some areas. In other areas we have not quite reached the right level – we need to develop longer-term treatments at the primary care level.

Why is the expansion of IAPT not more celebrated in our society in the way the NHS as a whole is celebrated?

Show me any aspect of mental health care that is celebrated. The only one is helping depressed mums take care of their babies. The stigma even for kids with mental health problems is massive. And once you’re adult, forget it. In this country, mental health services as a whole are stigmatized along with the stigma for mental health patients.

Is it better now than when you started as a psychoanalyst?

When I started, I worked in a mental health hospital with long corridors smelling of urine, with patients who had forgotten their names, there were some old women in there who had been admitted in the 1920s for having an illegitimate child, and they’d been there ever since. It wasn’t good. So in that sense there’s been improvement.

The idea of going for therapy seems to have become more mainstream.

Yes, somewhat. If you say ‘coaching’ rather than ‘therapy’, it sounds a lot better. So counselling is done by coaches, people who are not qualified, who have no idea of mental health. That’s a booming business, largely dealing with people with diagnosable mental health problems, who would never in a thousand years go to a therapist.

There is some suspicion of IAPT among some psychotherapists.

That’s an understatement. There is hatred.

Why is that?

It’s a multi-layered thing. It’s something really to be regretted. I’m in the middle of it. I’m one of those people who believe in evidence-based treatment, and I believe that NICE [the National Institute for Clinical Excellence, a body which makes evidence-based recommendations for the NHS] is one of the great gifts that this country has given the world, next to the NHS. I’ve been very involved with NICE in low-level capacities. There is no doubt in my mind that psychological therapies, whatever their label, can do a great deal of harm. For me, evidence-based treatments with an outcome focus, monitored and delivered in a collaborate manner with the patient, are the minimum to justify psychological therapy being delivered. Remove any of those key elements, and there is potential for psychological therapy to do harm.

Some therapists say CBT has a monopoly within IAPT.

It’s not true. It’s about 66% CBT, the remainder is four things – couples counselling, counselling, Dynamic Interpersonal Therapy (DIT), and Interpersonal Therapy. Of that 33%, 80% is counselling. Very little goes to the other two. That’s an imbalance. Part of the problem is that some things are more difficult to train in. If you set the bar very low, or the training is cheap, you’ll get more people providing the therapy. The other modalities have to look at that – how to change their model so that they can train more people more efficiently. Pissing and moaning about it isn’t going to deliver the goods.

I’ve no interest in modalities. They’re guilds. In the 19th century, guilds specialized in making apprenticeships so difficult that they’d always be a scarce resource. That’s not the way to run a free-at-source health service. We should make it as open as possible to people needing therapy. And we should be training treatment people in multiple modalities to give them the maximum chance of treating people in the most effective way possible. That involves radically looking at some of the modalities.

Why and where is a psychoanalytic approach better than CBT?

I can tell you my intuition and then I can tell you the research programme we have to test it. My intuition is that Dynamoc Interpersonal Therapy works better if you have an individual who is reasonably psychologically-minded but actually crippled and traumatized, in the sense of not being able to take some aspects of CBT seriously enough, not because it doesn’t work but because they are cognitively unsuited to it – too paranoid, suspicious.

A lack of ‘epistemic trust’…

Yes, thank you. In that instance, you need a therapist who is going to step more readily and see the world from their point of view, and not work so closely from the perspective of a modality. So mentalization-based treatment is more suitable. That’s my intuition. We’re now finishing a randomised trial of CBT versus DIT for depression, to see the results. I’d like to do a larger study, where we see if DIT can treat people faster than CBT if they have a certain level of trauma.

How is DIT different to CBT?

Insight is very helpful. Insight into relationships, into your own role in a relationship, into how you got into that role. Is it important to discover what you’re thinking non-consciously? Yes. I would say to the person, we can do it two ways – I can equip you with skills that will help you deal with symptoms. Or we can try and think more deeply about the nature of the mess you’re in, and how you got into it, and maybe that will help lever you out of the mess.

Is DIT something new in the history of psychoanalysis, in the sense of being a shorter-term and evidence-based form of psychoanalysis?

Nothing is completely new. But yes – it’s 16 sessions, which is more than the NHS wants to fund. But it can probably achieve something that’s reasonable in that time. It’s structured. It’s focused on particular personal or interpersonal problems, which psychoanalysis is not.

You’ve been very involved in the introduction of Children and Young People’s IAPT (CYPI) and the improvement of Child and Adolescent Mental Health Services (CAMHS) in England and Wales. How is that going?

I think it’s the thing I’ve done that I’m most proud of. The service was not fit for purpose. In many parts it may still not be. In a situation where CAMHS suffered a financial penalty greater than at any time in its history, it has not collapsed but regrouped around a very simple set of IAPT principles. First, work in partnership with young people and parents. Second, be outcome-focused and work towards shared goals that are set collaboratively with young people. Third, restrict treatments to those that are supported by randomised controlled trials, and ensure people are trained, supervised and managed in the best way to deliver them. And finally, ensure that the system is transparent, that results are monitored and reflected on in supervision. That way, if a treatment goes off-piste it’s noticed quickly.

These principles got taken up more quickly by CAMHS because it was seen as a way to get more money from the system. But once the principles were adopted, people liked working within them.

How is the money situation?

People like me have worked tirelessly to provide figures to politicians to try and get more money. First of all we got £30 million set aside to help young people with eating disorders. Then in the last budget of this government, £1.25 billion was set aside for children’s mental health – £250 million a year over the next five years. That’s getting back to the level it was at before the cuts began. If we couple that with the principles I mentioned, we have a chance to improve life for young people and their parents.

What still needs to be done?

CYPI needs to be rolled out 100% across CAMHS. At the moment it’s at around 60%. A lot of the people we’ve trained have been lost to the system because of cuts. So we need to bring some people back into the system. There is some repair to do. We also need to get to a situation quickly where CYPI principles are seen as principles for the entire children’s service – for education, health, youth justice. It should be brought together as an integrated service with the same principles.

If you enjoyed this, check out this interview with leading CBT researcher and chief-architect of IAPT David M. Clark about his vision for talking therapies in the NHS