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Not a NICE situation!

It is sadly the case that the UK mental health sector is paradoxical.

On the one hand, we’ve blazed a trail in evidence-based health & social care since 1999. The National Institute for Clinical Excellence (NICE)* is an international role model for the development of evidence-based clinical guidelines so that mental & physical health care is at the very least, empirically sound. Hurray! Clinical Excellence 1, Unprofessional Standards 0.

On the other hand, these guidelines haven’t actually translated into higher standards or more uniformity of care within the unregulated, inconsistent, multifarious sector that is the UK mental health care system. Clinical Excellence 0, Unprofessional Standards 1.

The reasons why this is the case are essentially simple: the users of the mental health care system don’t read the NICE guidelines and many of the professionals delivering the treatment don’t adhere to them.

The first issue is understandable. Why would distressed people with mental health issues trawl through tedious clinical protocols when they are at their most vulnerable? They are unlikely to know that such guidelines exist.

The second issue is much more complicated. In many ways, mental health care isn’t as evolved as physical health care and consequently, specialism is a rarer occurrence in mental health. Whereas NICE guidelines for clinical excellence are condition or disease specific, mental healthcare tends to be approach specific. In other words, the clinical guideline for the treatment of obsessive-compulsive disorder and body dysmorphic disorder, or Guidance CG31, is condition specific. However, most mental health professionals are delineated according to their approach, e.g., cognitive behaviour therapy (CBT), psychodynamics, systemic, etc. suggesting that the condition must fit the approach. This seems incongruent with clinical excellence where the imperative is to standardise a protocol for a condition. Ultimately, even though NICE is an Executive Non-Departmental Public Body, and Government directed, there isn’t widespread adherence, certainly not in the case of mental health and particularly OCD (I suspect that there is more adherence in the NHS but insufficient resources for it to be meaningful).

Odd, because the guidance isn’t ambiguous. It is explicit; Cognitive Behaviour Therapy (CBT) and Exposure Response Prevention (ERP) with or without medication support, is the only evidence-based treatment for OCD. Furthermore section states:

When adults with OCD request forms of psychological therapy other than cognitive and/or behavioural therapies as a specific treatment for OCD (such as psychoanalysis, transactional analysis, hypnosis, marital/couple therapy) they should be informed that there is as yet no convincing evidence for a clinically important effect of these treatments.**

Nevertheless you don’t have to look far to see general counsellors, hypnotherapists, psychoanalysts or psychodynamic therapists professing to treat OCD. In fact, the vast majority of our clients have seen one of the aforementioned on their journey to us. In the 16 years since this guidance was published, not one of these clients has been informed of the above and we’ve asked them!

How has this situation been able to continue? It is largely because the UK private mental health care sector is largely unregulated. The regulatory bodies that do exist are voluntary and currently anyone can call themselves a therapist in an environment where marketing and online presence isn’t determined by qualifications, reputation or professional ethics. It is determined by Google position and social media followers. Hence you can have OCD therapists with no cognitive behavioural qualifications in Somerset earning tens of thousands per month due to Google position and an Instagram 'recovery' group with no qualifications but thousands of OCD followers earning even more than that. This situation relies heavily upon vulnerable people in need, for whom there is no central, clear source of information.

For OCD, as with other mental health disorders, the solution won’t be simple but it should include the following:

  • Clear, user friendly, accessible Government information on mental health treatment protocols based upon NICE (aimed at the general public not professionals)

  • Distribution and marketing of the above information on and offline (think COVID guidance – we know it can be done!)

  • Compulsory regulation and accreditation of mental health practitioners according to training, qualifications and experience

  • Increased cooperation between NICE and mental health professional regulators

  • Increased mental health specialism based upon training, qualifications and experience

  • Increased focus upon condition rather than approach specific training

  • Stricter controls for those offering mental health advice/treatment via social media

  • Criminalisation of practices that include payment for unregulated & unqualified mental health advice/treatment

It is inspiring that the message ‘It’s good to talk’ is being widely promoted but the professionals, regulators and policy makers aren’t talking to each other nearly enough. For as long as this is the case, clinical excellence, professional standards and those in need are very much the loser. * **

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