Rapport vs 6 Sessions In High Intensity IAPT

The final straw for a friend working in High Intensity ‘I’ve just been told that in the 1st session , I must tell the client that in our service and nationally most people manage with 6 sessions in Step 3’. He’s had enough, sorting out his mortgage, then leaving for private practice!  We agreed that IAPT management seem to have never heard of the importance of rapport.

 

A study just published by Sara Antunes-Alves et all of 43 clients undergoing CBT for depression found that the only predictor of outcome was rapport, examples of this included exchanges where the therapist and client were joking , laughing together. In the study rapport was observer rated none of the competence skills predicted outcome, however the  study was small, technically underpowered and they may have been predictors with a bigger sample. Nevertheless the study is a salutary reminder of the importance of humanity. Antune-Alves et al (2018) Therapist interventions and patient outcome: addressing the common versus specific factor debate. Archives of Psychiatry and Psychotherapy 3, 7-35.  Interestingly clients had at least 12 therapy sessions with a maximum of 20, this is the number of sessions that quality research has found necessary for real world change. The ‘norming’ of 6 sessions in IAPT is an insult to clients and a betrayal of trust – a sub-therapeutic dose of treatment.

 

Dr Mike Scott

Deluded Secretary of State for Health and Social Care

Mr Matt Hancock has just announced on BBC Radio 4 that ‘our (mental health) services are better than almost any other services in the world’.  But how can he possibly know this – there has never been an independent assessment of the Government funded Improving Access to Psychological Therapies Service (IAPT), the latter have only ever marked their own homework. The Secretary of State might ask the National Audit Office why it has never published the results of its’ investigation into IAPT. My own study published in the Journal of Health Psychology in February of this year

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

suggests the recovery rate in Adult Services is just 15% far short of the Government target and IAPT’s claim of a 50% recovery.

 

Dr Mike Scott

Yesterday’s CBT for PTSD and Beyond ‘A really great workshop it was too’ –

‘Very interesting and lots of new ideas for approaching what can be a complicated mind field’. Delighted Christine Roberts twittered this response, thanks. It was a full house at the Lakeside Centre, Crosby, Liverpool, super day except for a microphone that had a life of its’ own!

 

But there was unanimous agreement from the 80 participants that generally therapists are a) stressed out b) daren’t publicly voice there discontent with IAPT. One person voiced that the customary IAPT 6 sessions is like putting a sticking plaster on a wound and all you get is a revolving door of clients. We need to stop the bleeding.

The voices of dissent are not in evidence at Nationally Organised BABCP Events, indeed I did not go to the Annual Conference because it looked like a further feast of uncritical acclaim of IAPT, reflected in the current issue of CBT Today.

The great thing at the Workshop is that we were able to address participants concerns e.g comorbid PTSD and OCD in a 15 year old. But we were all at a loss as to how to break out of the current mode of IAPT delivery, it seemed to resonate with being a citizen of some totalitarian state.

Dr Mike Scott

Clients Cast Adrift By Individualised Treatment Without An Anchor

Psychological therapists in the UK and beyond almost universally believe that they are equipped to personalise treatment and jealously guard their autonomy. Services feed the quest for autonomy by taking no steps to ensure clinicians make reliable diagnosis. This, despite the fact that the NICE approved psychological treatments are almost all diagnosis specific. As therapists are promoted the system perpetuates itself.

Not too long ago it was believed that physical and mental disorders arose from an imbalance of the four humours – blood, yellow bile, black bile and phlegm. A person with disordered blood would obviously improve with bloodletting. Years of experience of people recovering after thoughtful personalised bloodletting were confirmation of efficacy.

 

Evidence based psychological treatment (EBT) still requires a clinical judgment as to whether a particular person could be matched to the population of a particular randomized controlled trial. But EBT’s prevent the unbridled use of clinical judgement .

Moving towards reliable assessment will need nothing short of a revolution because it runs counter to the current expert consensus. This consensus does not accept that current provision simply does not work, a 9.2% recovery rate, when assessed independently Scott (2018) https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0 and calls for replication studies have fallen on deaf ears amongst the power holders and the media [ Marks (2018) https://www.dropbox.com/s/uw47oh03k9uvpo0/Marks%20IAPT.pdf?dl=0 There is an understandable concern about an increased cost of assessment but this will be offset by a treatment that might actually work. There is a massive vested interest in the status quo that extends to courses and politicians. The latter want to be seen to be on the side of mental health, happy to be seen opening mental health facilities or advocating more mental health personnel in schools but they run shy of considering independent assessment of outcome, it is of no short term political advantage. Politicians have let the National Audit Office get away with not publishing the results of its investigation into Improving Access to Psychological Therapies  ( IAPT) .

Scott, M.J (2018) IAPT – The Need for Radical Reform, Journal of Health Psychology, 23, 1136-1147.

Marks, D.F (2018) IAPT Under the Microscope, Journal of Health Psychology, 23, 1131-1135.

 

Dr Mike Scott

Who Arrested Information Processing?

Was it Freud, Horowitz, Foa, Resick, Shapiro, Brewin or Ehlers? Arrested information processing has long been held as pivotal in the development of PTSD, but in my Workshop, ‘CBT for PTSD and Beyond’ to be delivered at the Lakeside Centre, Crosby, Liverpool on October 4th 2018 under the auspices of Merseyside BABCP I question this.

 

There is also a paper ‘PTSD An Alternative Paradigm’ in submission.

Dr Mike Scott

Psychiatrists and Social Workers Acting With Impunity

A client of mine LC, see news item link , lost access to her 3 children for 5 months because a psychiatrist declared she had an emotional unstable personality disorder. I protested to the Court that this was wholly unfounded, having treated LC succesfully myself with CBT for depression. The appointed Expert Witness agreed with me that LC did not have an emotionally unstable personality disorder. The social workers refused to distribute my report to the agencies involved and were insistent that she attend a non-evidenced based treatment targetted at personality disorder. LC was mandated to attend regular meetings with social workers and other agencies. After legal action against Cumbria County Council they have apologised simply on the basis that there were no grounds for insisting that access had to be supervised.  The link to the News item is below:

http://www.newsandstar.co.uk/news/Cumbria-County-Council-sorry-after-mums-five-month-hell-0b215a18-055c-43e3-8b03-69ff77b5a05e-ds

But there is absolutely nothing to prevent this psychiatrist or any other, from making a diagnosis without careful reference to diagnostic criteria, routinely psychiatrists use criteria in a cavalier manner. There is no systematic enquiry about each of the symptoms that constitute a diagnostic set and no use of published thresholds to determine whether a symptom is present at a clinically significant level. This is no academic matter, the abject misery caused to my client LC for those 5 months was absolutely horrendous. To my knowledge there have been no sanctions against the social workers, they simply took a view of LC, taking their lead from the psychiatrist and refused to consider information that might contradict their conclusions. They showed no understanding of the concept of a personality disorder nor of what constituted evidence-based treatment. These professionals have been left to carry on and wreak havoc wherever, doubtless in good faith.

These matters should be a serious concern for the Royal College of Psychiatrists and the British Association of Social Workers but I have no confidence that these matters will be addressed because they are endemic within those professions.

Legal proceedings are still continuing for human Rights Violations by Cumbria County Council in respect of 2 of the children.

 

Dr Mike Scott

My black cloud, revolving door and IAPT

‘I found Silvercloud ineffective, generic and not tailored to my personal situation. It wasn’t engaging or helpful and as such I didn’t engage with the website very much. Consequently, the following weekly call with the IAPT therapist  were sometimes made difficult by the fact I hadn’t completed the same questionnaire as the week before or read through articles. I wanted to talk about my situation, my feelings and find out why I was feeling the way I was, but I felt I was just being led back to using the online Silvercloud resource.

‘It was in 2017 that my doctor suggested I try Silvercloud online CBT with telephone support and in September 2017, I started speaking to another IAPT counsellor. He seemed to be a very nice man. After a few weekly calls, he stated that he didn’t believe I was depressed and so he changed the original Silvercloud course I had started and reset it back to a new series of 6 sessions. The weekly calls lasted between 20 minutes to an hour depending on what we discussed, but always concluded with him asking me to log onto Silvercloud and work my way through the programme before our next call. After the requisite 6 sessions finished in February 2018, that was it! No answers, no tools to help me cope, just signed off, discharged, but told I had 12 month access to SilverCloud. I haven’t used the resource since.

I had a very poor experience of counselling through IAPT around 2013. I had been scheduled 6 sessions, these hour long sessions were so ineffective and pointless I can hardly recall anything that was discussed. I may have missed a couple of sessions due to work, but once the 6 sessions expired, I was discharged even though I may have only seen the counsellor 4 times. All I can recall is going over the initial questionnaire about my mood over the previous week which I had been told to monitor through photocopied pictures and graphs which I was told to keep in a file and bring to each appointment’.

 

 

The above is the anonymous report of a depressed client of mine, who is responding very well to my cbt treatment. Not only is she scathing about her IAPT treatment but also about her treatment from her GP:

‘At its height, I was being prescribed 200mg sertraline, 80mg of propranolol. I went to see my doctor for something routine, when she commented on my ‘low mood’ and suggested increasing my antidepressants. I told her I was already taking the maximum dosage and said I didn’t want to take more prescription medicine. I was already taking 200mg of setraline and 80mg of propranolol at that time. My prescriptions had been increased over a period of time without much investigation. In a short 5-10 minute appointment, my ‘low mood’ was usually commented upon and an increase in antidepressant and/or beta blocker was almost automatically prescribed.
In early 2018, I went to see my doctor and insisted that we work together to reduce my medication as I felt so unwell and was sure that the amount of medication I was taking was actually making me feel worse rather than better’.

There is no substitute for really listening.

Dr Mike Scott

IAPT – A Crumbling Edifice and The Law

A friend has recently got a post as a Hi-Intensity therapist in IAPT, he is restricted to providing just 6 sessions, but can go up to 10 for PTSD and OCD.  He is expected to make 24 contacts a week, each session to be no more than 45 minutes. If he doesn’t reach the 50% recovery rate for 6 consecutive months he will have to attend a meeting.  Perhaps I should book him in for a reliable assessment in 6 months time, conducted not by telephone but with hospitality. I wouldn’t consider stipulating the number of sessions in advance. But I would be mindful not to pathologise his likely stress reaction – ‘saving normal’.

I might advise that he consider whether his employer has breached a duty of care in that it is known that 6 sessions is not an evidence based dose of treatment for any psychological disorder and it is reasonably forseeable, that a therapist charged with delivering this is likely to be stressed. It would then be a matter for the Health and Safety Executive and Personal Injury Lawyers. But there are also issues of informed consent, in that clients are not informed that they are to receive a sub-therapeutic dose of treatment – they could become litigants. Clinical Commissioning Groups have done absolutely nothing to ensure that clients receive a therapeutic dose of treatment and are open to a charge of medical negligence.

Will IAPT reform itself before it is too late? There is a glimmer of hope, in that I did not meet with open hostility recently when I suggested that it needs reconfiguring to ensure reliable assessment.  But the economic argument for IAPT will be in tatters after a new paper is likely published in the coming months, which will show what the National Audit Office has signally failed to make public – a matter for the House of Commons Public Accounts Committee.

Dr Mike Scott

‘What We Need Is Good Quality Talking Therapies’

Says Will Self talking on Radio 4 this morning, a must listen on BBC i-player. He was  distressed at his friend who had been sectioned, his visit to her on a locked ward resembled still, ‘One Who  Flew Over the Cuckoo’s Nest’. When she questioned the appropriateness and mechanism of action of the drugs prescribed for her bipolar disorder the psychiatrist became defensive. After  discharge no therapy was on offer.

 

 

He is absolutely right we do need good quality talking therapies but we have not got them, rather we have a 10% recovery rate for those undergoing treatment with IAPT http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264.  I very much doubt that IAPT or anyone has an evidence based psychological treatment for a person with bipolar disorder and it would be disingenuous to pretend we have. Nevertheless IAPT has trespassed into providing treatment for medically unexplained symptoms, which is an unfortunate precedent for claiming more than we can deliver.

Will Self makes the excellent point that we need small communities to support people like his friend. But it is very difficult to create them for people who are isolated, charities, churches etc do what they can but it is a tough road to make a real world difference

 

Dr Mike Scott