It’s 1:45pm on a Tuesday afternoon, and I’m sitting in a West End theatre. The house lights are on, and the audience is slowly trickling in; a few people have come in pairs, but most people have, like me, come alone. In the time-honoured manner of London strangers, everyone sits so that there is a least one empty seat between them and the next person. A steward asks us to fill up the theatre from the front, so I go and sit in the middle of the front row. The stage is also lit, but there is no scenery, just the black-painted structure of the stage itself, a piano, a table holding glasses of water, and four chairs. It’s quiet, other than snatches of a very distinctive American voice from the back of the hall.
I’m waiting for the start of one a series of free mental health forums. Attached to Ruby Wax and Judith Owen’s successful Losing It, now at the Duchess Theatre, the forums are run in partnership with the mental health charity SANE and part of their Black Dog campaign. I’m there on impulse, having heard about the forums from other service users, and prompted by a tweet from SANE inviting people to come along. The forums are free, and there is no need to pre-register or book – the intention is that anyone who needs them can just turn up if they are able.
Ruby and Judith come up onto the stage, flanking an elegantly dressed woman and a smiling man. There’s a bit of fiddling about with chairs and microphones. There is no sense of performance, and certainly no slick corporate edge; we might be looking at four people on stage, but it’s not a not play, or a conference, or quite like anything else I’ve ever attended. Ruby introduces the forum by explaining that as she and Judith developed Losing It and took the show to hospitals around the country, they began to wonder about where the social support was for people with mental health problems. If those with alcohol problems had Alcoholics Anonymouus, where was the recovery-focussed peer group for people who were mentally unwell? Who was organising meetings where a depressed person could turn up, meet other depressed people, and share their experiences in a supportive environment?
These mental health forums, Ruby continues, are in part an attempt to create something like a peer support group for those with depression and other mental health conditions, but are also an opportunity to share information and ideas which might be useful or interesting to that group. Each forum, therefore, has a guest speaker (checking my flier, I am annoyed to see that last week I missed Kids’ Company’s Camila Batmanghelidjh) and after the speaker and questions, “we will serve you cookies!” beams Ruby.
Sharing the platform today with Ruby, Judith and Marjorie Wallace (SANE’s chief executive) is Professor Peter Fonagy, Head of Research at the Department of Clinical, Educational and Health Psychology at UCL, who is here to share his specialist knowledge of the different types of psychotherapy and what works – or not – for particular conditions. The house lights stay on throughout, because this is not an “expert” talking at “service users”, but a man who appears to care deeply about his work and to want to share a little of his knowledge with people who really need it. Any barriers between “them” on the stage and “us” in the audience are further broken down when Professor Fonagy share with us his personal experience of major depression and suicidal thoughts in the past.
Professor Fonagy begins by saying that there are literally hundreds of types of therapy, and that the number is increasing all the time, yet all have key ingredients in common. He likens it to the washing powder aisle in the supermarket: new products are released; existing household names continually insist that they are “new” and “improved”; brands try to outdo each other with fancy packaging; but when you come down to it, “they’re all pretty much just soap”. Similarly, says Professor Fonagy, the apparently vast range of talking therapies can be reduced down to a few broad types, or therapeutic schools, and research has something useful to tell us about which of those works for whom. There is a caveat: no treatment, whether pharmacalogical or psychological, is a magic bullet and even the “right” therapy applied to the “right” condition will probably only be successful 50-60% of the time. This might not seem like much of a success rate, Professor Fonagy acknowledges, but it’s the best we can do for now.
Firstly, Professor Fonagy turns his attention to cognitive behavioural therapy. Much promoted in recent years, CBT does appear to have some real therapeutic value, especially for conditions where the patient/client has a very specific issue to be addressed. Professor Fonagy gives the example of person with Obsessive Compulsive Disorder, or someone who wants to tackle a phobia, where the goals of therapy are quite clear; for Generalised Anxiety Disorder, CBT is not quite as effective. It can be an effective treatment for depression, but Professor Fonagy emphasises that it is probably more effective as a means of delaying episodes and giving longer periods of remission, than a “cure”. Sitting in the audience, I realise that in the years before my bipolar diagnosis, when I was treated for major depression, no-one ever told me this. Yet it’s incredibly important for service users and carers to know. Otherwise, there may be an expectation by families, and indeed clinicians, that if we’ve “had the therapy”, we should know how to cope better with situations and if we become depressed again, then it’s our fault for not applying the lessons of therapy well enough. The research, however, suggests that the depression was likely to return eventually anyway.
Next on Professor Fonagy’s list is interpersonal therapy. Less well known in the UK than in the US, IPT is effective not only for people with major depression, but also for people with emotional regulation difficulties such as those diagnosed with Borderline Personality Disorder (for whom, says Professor Fonagy, the evidence suggests CBT is actually counter-productive). He moves on to discuss systemic therapy, which is an effective way of working with couples or families. For people (especially women) with relationship problems, systemic therapy as a couple is as, or more, effective than CBT for one partner alone. Professor Fonagy tells us that it is also very useful for families in which a very young person within the family system has an eating disorder, particularly anorexia; far less so with other patients or those with bulimia.
Professor Fonagy himself is of the psychodynamic school, and works at the Anna Freud Centre. There is good evidence, he says, of the efficacy of psychodynamic psychotherapy, but probably more for people with complex or chronic issues (such as long term depression or personality issues) than those with more clearly defined problems (such as OCD or phobias). Psychodynamic approaches are as effective as CBT for major depression, but take longer (a simple fact which explains the dominance of CBT in a cost-conscious NHS).
Finally, Professor Fonagy discusses eclectic/integrative approaches. Hos view – which causes upset to an integrative therapist at the back of the auditorium – is that there is no good evidence to recommend these approaches, unless the integration is a very clear melding of elements of one school with elements of another (for example, the marriage of a psychodynamic approach with cognitive behavioural techniques in Cognitive Analytic Therapy). What is not useful is a kind of “a little bit of this, a little bit of that” method where there is no coherent underlying approach.
During the question and answer segment of the forum, the issue of mindfulness and mentalisation approaches is raised. Professor Fonagy is generally positive about meditation/mindfulness therapies such as Mindfulness Based Cognitive Therapy, and encourages people to seek this out if possible, but cautions again that it might be more a case of extending periods of remission/delaying the onset of the next episode. Mentalisation, which Professor Fonagy was involved in developing, involves helping patients/clients have a better understanding of how to interpret their own behaviour and that of others on the basis of examining inner desires/thoughts/feelings, and their own inferences about others’ inner mental states. Mentalisation appears to have good results with people with personality disorder, including those with Antisocial Personality Disorder, a group often considered “untreatable” and viewed as a criminal justice problem, rather than having a mental health need.
Even once you have established which clinical approach is likely to be of benefit for you, finding a therapist can still be a minefield. Addressing a question on the licensing/registration of therapists, Professor Fonagy expresses regret that this Government has shied away from moves made by the previous administration towards compulsory registration of psychotherapists. While most people involved in delivering mental healthcare – doctors, nurses, social workers, etc – are required to have formal professional registration, there is no such requirement for counsellors and psychotherapists. This means there is little protection for the consumer from unscrupulous, or even abusive, practitioners. Membership of one of the voluntary bodies such as the British Association for Counselling and Psychotherapy or UK Council for Psychotherapy offers some level of reassurance, but is nowhere near the level of robust scrutiny of the General Medical Council or the General Social Care Council.
Professor Fonagy has some closing thoughts for us. Firstly, that probably of more importance overall that the theoretical stance of the therapist is the relationship between therapist and the client. If you and your therapist are not a good fit, therapy is unlikely to be successful. Secondly, if you as the client feel that the therapy you are engaged in is making you worse, you should stop it. Therapy is supposed to be a support and help make you feel better, not cause you to suffer. As Professor Fonagy suggests to a concerned questioner, we should try not to ask the question, “how long am I going to need therapy?” (or, indeed, “how long am I going to need medication?”). Our brains, he says, are marvellous and complex, but in their very complexity they become fragile. Sometimes, he tells the questioner, “our brains just go wrong!” Sometimes our kidneys go wrong, but we don’t berate ourselves for “still” needing treatment to maintain renal function and feel we should “move on”.
Professor Fonagy is clearly passionate about his subject, and both he and the audience could go on and on with questions from the floor. But Ruby is firm: it’s time for tea and, more importantly, a chance for anyone who needs help to speak to one of the many volunteers in the building, easily identified by their SANE sashes. There is specific support on hand for family members in the Carers’ Corner, and printed material on common mental health conditions is available to take away. Hot drinks and rather nice biscuits are served in the bar, free of charge but with donations towards SANE’s work very welcome. I meet a SANE employee with whom I have exchanged messages via the @CharitySANE Twitter feed, and when the conversation ends I realise the noise level has been steadily rising. People are chatting animatedly in twos and threes, sharing their thoughts about the forum and making connections. Not bad for a theatre full of silent strangers.
The next mental health forums are on Tuesday 20th September (guest speaker: Dr Mark Collins, Consultant Psychiatrist, The Priory Hospital Roehampton) and Monday 26th September (guest speaker: Professor Mark Williams, Director of the Oxford Mindfulness Centre) both at the Duchess Theatre, Catherine Street, London WC2B 5LA between 2 and 4pm.