In England there’s an independent health advisory body that provides guidelines to clinicians working in the NHS, to make sure that wherever patients are in the country, they receive the best possible evidence-backed care. The National Institute for Health and Care Excellence (NICE) was set up in 1999 and many of its guidelines pertain to mental health, and they often promote psychological approaches – for example, the guidelines for depression state that talking therapies should be the first-line of treatment for all but the most severely affected patients. While clinical and counselling psychologists have been involved in producing these guidelines, many of their colleagues – especially those in practice – are highly critical of them. Why? A series of interviews with 11 clinical psychologists, published in Clinical Psychology and Psychotherapy, sheds new light on the scepticism and concern felt towards NICE guidelines, and why some psychologists are even deliberately ignoring them.
Alex Court at the Salomons Centre for Applied Psychology interviewed 11 clinical psychologists “in routine practice in the NHS” for roughly an hour each. Court’s approach was open-ended and he began each interview by simply asking each psychologist to share their thoughts on the NICE guidelines. Court subsequently transcribed the interviews and together with his colleagues he set about looking for emerging themes in their answers. He kept a diary throughout, in part to reflect on how his own opinions might be influencing his interpretation of the findings.
The psychologists valued the NICE guidelines for the way that they provide a useful roundup of the latest evidence relevant to a particular condition or social issue, and also for the fact they often promoted psychological approaches. However, many of the psychologists were also very concerned about the premise of the guidelines, especially their grounding in a medical perspective on psychological distress, and the implication that the evidence is “neat” and that there is a correct approach across the board. The psychologists felt this curtailed their freedom to use their judgment and tailor their approach to individual patients. In particular there was a feeling that the guidelines are biased toward Cognitive Behavioural Therapy (CBT), and that they could influence NHS commissioners and managers to favour cost-saving approaches, to the potential detriment of individual patients.
Given these concerns, some of the interviewees said they sometimes gave managers the impression that they were delivering NICE-approved treatments, even when they weren’t:
“I would probably say I’m doing CBT, even if I’m not doing, you know, even if it’s a bit fudgy around the edges,” said Jenny (the study doesn’t use the psychologists’ real names).
“I use approaches that aren’t in the NICE guidelines at all. Er I do what I see to be effective,” said Morgan.
“Well I, well I certainly wouldn’t advertise what I do to the managers,” said Amy.
“For me, they’re guidelines, rather than somebody telling me what to do,” said Kim.
Part of what’s driving these psychologists’ concerns is that the influence of NICE guidelines has seen the emergence of single-approach therapists, such as CBT-therapists, who are cheaper for the NHS to employ but who arguably aren’t able to offer patients multifaceted, individually tailored care in the way that psychologists can:
“… [A]s a clinical psychologist I will be bringing in lots of different therapy kind of techniques and models and formulations from different erm models of psychological therapies, so I don’t think it’s as purist as maybe NICE guidelines might encourage people to think,” said Amy.
“[Integration is] seen as weak or criticism, and actually I think that’s our biggest strength, and that’s what I mean by we’re shooting ourselves in the foot. As psychologists it would be nice if we actually worked to maintain our identity and what we have that’s special to offer,” said Jan .
Reflecting on the interviews, Court and his colleagues said that there seemed to be a “perverse incentive” within the NHS for clinical psychologists “to claim to be doing protocol-driven, single-model therapy whilst actually conducting much more sophisticated interventions, drawing on a range of psychological theory and based on an individualised, formulation co-constructed with the service user.” The researchers also argued that their results highlight the need for NHS managers to allow clinical psychologists (and other skilled clinicians) flexibility in choosing the care they offer to service users, rather than being overly prescriptive. However, to play devil’s advocate, I would suggest the guidelines can help correct for the difficulty clinicians can have in judging whether their favoured approach is effective or not.
It’s difficult to know how representative these findings are of clinical psychologists more generally, and how much the research authors’ own feelings influenced the interviews and how they were interpreted. Court and his colleagues acknowledged the subjectivity in their research – “this study makes no claims that the findings are objective,” they wrote. It’s perhaps worth noting too that there was nothing random about the recruitment process – four of the interviewees were already known to Court (though they weren’t colleagues), and he chose others based on a pre-interview screening process to try to reflect a mix of opinions. Also, Court’s supervisor and co-author Anne Cook has written publicly about the adverse effects of treatment time limits and targets on clinical psychologists, and it seems at least plausible that her own concerns about NICE guidelines may have influenced the tone of the paper.
That said, this research provides an important and rare insight into what some NHS clinical psychologists think of the official guidelines that are meant to be guiding how they work.
—They’re NICE and Neat, but Are They Useful? A Grounded Theory of Clinical Psychologists’ Beliefs About and Use of NICE Guidelines (full-text available for free download via Academia.edu).
–Alex Court’s reflective diary and other related materials can be found in his thesis (pdf) which formed the basis of this research.