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BABCP Response - NICE Consultation January 2022

Ejection From NHS Talking Therapies

occurs whenever a persons scores below cut-offs on two psychometric tests. Just how ludicrous, this is, was brought home to me recently when I was called to assess a lady who had been trapped in her car, by a fallen tree. After 12 sessions of trauma focused CBT, she was scoring below cut-offs on the PHQ-9 (a measure of the severity of depression) and on the GAD-7 (a measure of the severity of generalised anxiety disorder). But she still felt unable to return to her, much-loved job as a bookkeeper, despite every support from her employer. For six months after the incident, she met the DSM-5 diagnostic criteria for post-traumatic stress disorder, currently, she had a sub-syndromal level of PTSD (meeting 3 of the necessary 4 symptoms clusters for PTSD). But she had never met criteria for depression or generalised anxiety disorder, the two tests administered were therefore entirely inappropriate. [ Details have been changed  to protect confidentiality.]

Common sense would dictate that this lady is not back to her usual self. But NHS Talking Therapies staff seize on the lightest sign of improvement, make it central and abandon the client. There is no evidence that its’ staff appreciate the meaning of the psychometric tests they administer. Wilfully or not they are not listening to the client’s story – ‘just keep the production line rolling‘ is the mantra.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Case Conceptualisation Rules – Should It?

Most clinicians match clients to their prototypes of disorders. But how much information should you collect before matching ? ‘Since Persons (1980) and Judith Beck (1996) ‘Case Conceptualisation’  rules. But there has been no demonstrated added value of ‘case conceptualisation’ .

Prior to these authors there was simply ‘case formulation’ [see www.psychologytools.com for examples of formulations of most disorders] which was the way in which a person was an exemplar of a particular disorder e.g a person with panic disorder might say that in their 1st panic attack they t0ok their palpitations as evidence that they were having a heart attack, but though nothing untoward physically happened they became hypervigilant over bodily sensations and avoided provoking  any such symptoms. Applying Clark’s cognitive model of panic disorder the key dysfunction is catastrophising  and avoidance of opportunities to disconfirm the catastrophic cognitions. A case formulation requires 1st of all a reliable diagnosis, what they are a ‘case of’  and an example of the mechanism by which this disorder is brought about. As such there are clear limits of the range of information that is pertinent to a ‘case formulation’. Making it usually a manageable task for the clinician at 1st interview  and  to set a pertinent homework exercise. Contrast this efficient use of time, with a real-world impact, with what happens when the focus is on ‘case conceptualisation’.

With case conceptualisation  there is no control of information variance, the therapist likely assembles information under a number of headings,  but this information does not speak for itself

 

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Case conceptualization Kuyken 2009

The therapist arbitrarily selects a piece/s of information and  claims it/they are pivotal  e.g their father was alcoholic, they were involved in a life threatening incident. The descriptive information of itself is not prescriptive of a mechanism. One could assemble information under the above headings ‘until the cows come home’ it would make no difference, it is arbitrary to stop at any particular point. In this context clinicians easily succumb to ‘formulation nausea’ a condition arising from a bewildering array of arrows. Presented with such a picture clients can easily feel a victim and or blameworthy and disempowered. They are unlikely to have any success experience any time soon, homework is delayed. Therapy becomes an exercise in the acquisition of meaningless data, with the client likely to default. In fairness Judith Beck ( Centre for Cognitive Therapy 2018) does retain diagnosis in her case conceptualisation but this appears to be lost in translation, at least in UK CBT courses. 

It is 15 years since Kuyken et al produced their seminal work on Case Conceptualisation, recognising the evidence base for it was lacking but expressing confidence that this would be repaired. But no such further evidence has been forthcoming [Easden and Kazantis (2018)] and state that ‘the efficacy of case conceptualisation in CBT has yet to be demonstrated’.What has actually happened is that the framework of Case Conceptualisation, minus the diagnosis component, has been passed on to training courses and taken as gospel. Thus whilst there is a consensus about the importance of case conceptualisation there is a conspicuous lack of evidence, at least about what is customarily put into practice. Better returning to simply effective CBT [Scott (2009)]

The Kuyken model of case conceptualisation, suggests that the latter is an emergent property of a ‘soup’ , into which everything is thrown in,  genetic predisposition, precipitants of episodes etc. But this is reminiscent of the claim that life emerged from a ‘primordial soup’, there is no specificity of mechanism.  It is claimed that case conceptualisation is at another level of abstraction to case  formulation. This may well be the case, but there is no evidence that the former helps the latter. Contrast this with the multidimensional description of patients difficulties in DSM IV axis 1 disorders e.g depression, PTSD axis 2 disorders personality disorders, axis 3 physical disorders, axis 4 psychosocial stressors and  axis 5 judgement of overall functioning .   Applying this framework to a person in Gaza with likely PTSD symptoms would greatly change the therapeutic approach. It might well be concluded that the ‘toxic environment’ precludes psychological treatment at this point in time 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

All Therapies Are Equal and Must Have Prizes?

A just published paper in the Journal of Clinical Psychology by Smith and Hewit (2024) proclaims the equivalence of psychodynamic and cognitive behavioural therapy for depressive disorder in adults. At face value it supports the Dodo verdict – that all psychotherapies are equal and it is the common factors between them that makes a difference. But the authors appear to be operating in a parallel universe:

  1. It is impossible to discern from the 10 studies considered what proportion of people in each condition were recovered in the sense that they considered themselves back to their old selves and the duration of such a return.
  2. Only 4 of the 10 studies used independent blind-raters.
  3. Patients had 22-25 treatment sessions, this impossible to provide in routine practice, but this is not even mentioned
  4. Only the results on completers could be furnished, no intention to treat analysis.
  5. Only 4 of the 10 studies assessed treatment adherence.
  6. The authors observe ‘ The HRSD was the most commonly used measure of depressive symptoms across included studies. However, research suggests that the HRSD’s total score is multidimensional, that its factor structure is not invariant across different populations, and that its conceptualization of depression is several decades out of date (see Bagby et al., 2004 for review). Hence, future research would likely profit from using a more psychometrically sound assessor‐rated measure of depression’
  7. 75% of the population was female, no report of social class. 4 studies did not report ethnicity.

Real-world avoidance is it seems ripe

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

IT’s A NICE Fiction That Mental Health Guidelines Are Implemented

It is a working assumption of NICE that its’ mental health  clinical practice guidelines (CPGs) will be implemented. If they are not what is the point? NHS Talking Therapies has fostered the myth of compliance without providing any evidence, to secure Government funding.

 To take an example in 2022 NICE published its’ Depression Guidelines advocating group CBT as the gateway to treatment. But this has never happened. BABCP is currently providing webinars on ‘CBT Informed Groupwork’ despite the lack of evaluation in randomised controlled trials and inattention to reliable diagnosis. The evidence-based protocols for group CBT are diagnosis specific [see my book Simply Effective Group CBT published by Routledge in 2013.. NHS Talking Therapies will undoubtedly embrace ‘groupwork’, as part of its mission to increase accessibility turning a blind eye to the issue of effectiveness  and reliable diagnosis. 

The problem with Clinical Practice Guidelines is however not confined to UK. A recent review of CPG ‘s for PTSD [PTSD Research Quarterly vol 35]  by the US National Center for PTSD Jessica.Hamblen@va.gov subject found that most clinicians a) didn’t know about the CPGs and b) of those that did most chose to ignore, largely because of their belief that their client was somehow ‘special’ and was not appropriate for an evidence-based protocol (EBP).

There needs to be a debate about fidelity, it seems likely that what the public are served is  poor fare. But the Service Providers and their fellow travellers including government  will not countenance such a notion and studiously avoid, not only open debate but any support for an independent evaluation. 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

No Real-World Feel To CBT In Routine Practise

Two features of CBT give it a ‘real-world feel’ a) relapse prevention conducted towards the end of therapy and b) homework set after each session with review at the next session. Without these two elements CBT is, at best, just a chat. But NHS Talking Therapies (and its’ predecessor IAPT) have never furnished any documentary evidence that relapse prevention strategies and homework are a part of routine practise. As a consequence there is a ‘revolving door’ in mental health Menzies et al (2024) with most people having more than one episode of disorder. These authors call for an extension of relapse prevention. 

Relapse Prevention

Relapse prevention is important as at the end of therapy clients have to anticipate the likely hurdles post-therapy and come up with a protocol for handling them. This is usually fine-tuned in the final sessions. Without such attention to the client’s real-world they are likely to fall as difficulties arise.

Homework 

Homework is a summation of key learning points in a session and their planned application in the real-world, with review and if necessary refinement at the next session. This provides continuity between sessions and stops them descending into a purely abstract/academic discussion of issues.

CBT – An Endangered Species

CBT is dying in routine practice for lack of homework and relapse prevention strategies. In the 100’s of NHS Talking Therapies/IAPT communications I have examined for the Courts I have not found one case where there has been a clear delineation of relapse prevention strategies and the setting and review of homework. So much for accountability. Courses advocate the Cognitive Therapy Scale  to help decide who is a competent therapist [ Branson, Shafran and Myles (2015)] but their findings did not demonstrate a relationship between competence and outcome. Homework and relapse prevention strategies are a simple, litmus test, for adherence to a CBT protocol, albeit that it does not directly address the issue of competence. But without adherence there can be no competence, adherence is necessary but not sufficient. 

The Neglect of the Added Value of CBT

The selling point of CBT over medication was that it had  half the relapse rate after discontinuation. With a failure to distil relapse prevention strategies in routine practise, can it be seriously claimed that CBT is being delivered?

 Despite the dissemination of NHS Talking Therapies to over a million clients a year, there is no documentary evidence of either the provision of relapse prevention or of the routine setting of homework ( a hallmark of CBT). Taken together there is a paucity of evidence as to fidelity to any evidence-based treatment.  NHS Talking Therapies has signally failed to measure treatment integrity.

NHS Talking Therapies Is In the Mire Over Relapse Prevention

NHS Talking Therapies has one hand tied behind its back when it comes to relapse prevention, as the latter can only be measured if the person has had a meaningful period of recovery, usually taken as 8 weeks (the period used to distinguish one episode of a disorder from another). But NHS Talking Therapies has never evaluated clients in such a follow up, so it cannot boast that it delivers on relapse prevention. To compound matters NHS Talking Therapies has never utilised independent observers using a standardised diagnostic interview to evaluate outcome, so its’ very notion of ‘recovery’ is highly problematic. 

NHS Talking Therapies Problems With Relapse Prevention Are Even More Acute When It Comes To Low Intensity Interventions

NHS Talking Therapies ignore the fact that there is no evidence that relapse prevention strategies have a place in low intensity interventions. Rather it is assumed that they must be relevant because they were a feature in the randomised controlled trials that are better mirrored by high intensity interventions. 

Workshops – a Corrective?

Attending CBT Workshops recently, the great and the good are totally silent about what is happening in routine practice. This may simply be a lack of awareness. But they seem to have little appreciation that there are any problems in the translation of their fare (which can indeed work ) to the coal face. However I don’t doubt the tremendous efforts that have been put into the materials for these workshops but I have concerns about the engagement power of the suggested modus operandi for most clients. 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Flexibility With Infidelity – The Demise of Low Intensity Interventions In Practise

There has been no independent investigation of the effectiveness of NHS Talking Therapies low intensity interventions (the services most common form of delivery). But a review by Fleming (2023) of how employers cater for staff’s emotional wellbeing, including: coaching resilience training, Employee Assistance Programmes, mindfulness, counselling, stress management programmes has shown that they conferred no added value. There is no reason to believe NHS Talking Therapies low intensity interventions would fare any better.

It could be argued that the workplace interventions are about changing the worker not the workplace. There was no evidence that participants in individual-level mental health well-being interventions at work had higher well-being than those who did not. The only exception was volunteering.

Fleming (2023) concludes his paper thus ‘By evaluating these types of initiatives out of research context, implemented in the messy realities of organisational life, any benefits appear to be smaller. Such discrepancies emphasise the need for policy recommendations to evaluate evidence of workplace well‐being initiatives in situ as well as ‘in vitro’. Fleming observes that whilst there is evidence in the abstract(rcts) for the effectiveness of some of the strategies these dissipate in the real-world .Exactly the same could be said about NHS Talking Therapies low intensity interventions. 

The above findings also send a warning that the Labour Party’s (Wes Street) proposal to recruit 8.5K staff to provide mental health services in every school may be doomed  if they simply follow the public mantra on resilience training and mindfulness. The latter appear to have made no difference in the occupational context why should they fare any better in an educational? 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Who is responsible for the delivery of CBT?

This question was prompted by by Prof Kendall’s response to my previous post ‘flexibility within fidelity’, he writes: 

THANKS…I agreesometimes I say change the system when, in reality, it takes time and may not be possible in some places‘.

This is the time of year when many of us look at workshops we might attend to boost our CPD .   There are many good ones at CBTReach and bespokemental health  that focus on the delivery of an empirically supported treatment. But by and large they are by clinicians who do not have the constraints to which clinicians in routine practice are subjected e.g number of sessions, meaningless outcome measures, sanctions for not achieving targets.    BABCP run workshops by clinicians working in low intensity interventions but they lack the evidence base of randomised controlled trials with independent assessment.  

It may be that clinicians in routine practise are rather like the 1000 + sub-postmasters prosecuted  by the Post Office. Their voice has also  not been heard over the past 15 years and they have struggled to implement a flawed system, one which has not been subjected to independent evaluation. Is NHS Talking Therapies any better than the Post Office/Fuijitsu.?

Dr Mike Scott

 

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BABCP Response - NICE Consultation January 2022

Flexibility Within Fidelity

was the title of a great CBT workshop that I attended yesterday, delivered by Prof Philip Kendal. He described how time saving rules of thumb, can short circuit the therapeutic process (described in his book with the same title, published in 2022 by Oxford University Press). One of the attendees, a low intensity practitioner, volunteered one such heuristic, automatically disqualifying a client from the Service (presumably NHS Talking Therapies) if they had had a bereavement. Prof Kendall replied:

‘when the system is screwed up change  the system’  

A totally reasonable response from an objective observer outside the system. In the Webinar didn’t hear further from the therapist, and Prof Kendall did, understandably, not quite appreciate that bringing about such a change is a monumental task for anyone in IAPT’s successor. He did opine that one way of changing a system is to set up a comparison of the current system with the proposed system. But there has been no independent assessment of NHS Talking Therapies. He opined that the most credible randomised controlled trials were those in which there had been a blind, independent assessor. The Service’s  clientele have never been involved in such a trial, much less in a comparison of the Service’s routine practice with the mode of delivery suggested in my 2009, tome Simply Effective CBT, published by Routledge.

Prof Kendal said that in the US a lot of CBT therapists don’t give homework and in this  context clients do no better than in an attention control condition. This side of the pond, in my review of numerous records, for the Court I have never seen the written specification of a homework much less its’ monitoring. It is a myth that CBT is routinely provided, literally it would not stand-up in Court. Nevertheless the UK Government continues to fund adult and child and adolescent mental health to the tune of £2 billion a year. Where else could this happen without independent evaluation?

Prof Kendal insisted that his workshop was not about flexibility with infidelity but that is what routine psychological treatment in the UK amounts to. There is nothing in the UK NHS Talking Therapies approach that prevents therapists using unbridled clinical judgements. Its’ therapists perform what Prof Kendall terms a ‘diagnostician’ role, in that they assign ICD 10 codes to the client’s problems (without making an ICD 10 or DSM-5) diagnosis, but this has not stopped treatment wandering from a recognisable diagnostic pathway.  I felt he ducked the importance of reliable diagnosis. 

Prof Kendall rightly insisted on the importance of personalising treatment and having a therapeutic relationship. both of which Drew et al (2022) found notably absent in NHS Talking Therapies low intensity interventions. In Personalising Trauma Treatment: Reframing and Reimagining Routledge (2022) I give lots of examples as to how this can be done in the trauma field. I agree with him that both personalising treatment and a therapeutic relationship are necessary but not sufficient conditions for effective treatment. The other necessary active ingredient for treatment is that it must address the mechanism that is pivotal in the maintenance of the condition. With regard to trauma I have suggested it is the centrality accorded to the trauma and not arrested information processing.

Thank you Prof Kendall for such a human and illuminating workshop.

 

Dr Mike Scott

 

 

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BABCP Response - NICE Consultation January 2022

Long Covid and CBT

CBT is commonly recommended for those with Long COVID, despite a sparse evidence base. There has been no randomised control trial comparing CBT for long COVID with a credible attention control condition. Rather a study of CBT for severe fatigue [Kuut et al 2023] has been pressed into service as a proxy, for a gold-standard study. This lacks credibility as:

  1. There are objective measures of recovery from Long Covid such as return to work and distance walked compared to pre-infection. By contrast, studies of severe fatigue rely on a subjective measure of the person’s self-report of fatigue. As such Kuut et al, like studies cannot be judged as being in the same category as a gold-standard study.
  2. The Kuut et al (2023) study has all the methodological limitations that Vink et al described in their 2020 paper.

What we have is the ongoing spin of CBT.  But does it matter? It does, because sufferers from Long Covid are pushed in the direction of a treatment in which ‘unhelpful cognitions and behaviours’ are believed by the therapist as pivotal in the maintenance of symptoms. Therapists have varying degrees of transparency about this. The Long Covid sufferer is likely distressed by their symptoms, with the prospect of redundancy and the strain on relationships. They are very vulnerable, they do not need it implied, however nicely phrased, that they are responsible for their condition with unhelpful beliefs and behaviours.

 

Professionals can compound matters by muddying the waters  on aetiology and diagnosis. In instances were no Covid test was done and the diagnosis of Long Covid is a best guess on the evidence available, it can be suggested that the Long Covid morphed into Chronic Fatigue Syndrome . Thus, the Long Covid sufferer can find themselves ushered down a CFS treatment pathway. But as Vink et al (2020) argue that if objective measures of outcome are used there is no evidence that CBT works for CFS.

Long Covid sufferes are stressed but that does not automatically mean that the difficulties they are experience equate to a psychological disorder. At best assessment of anxiety and depression in Long Covid suffers is based on self-report measures, which are notorious for yielding false positives. I have yet to come across a case were the prescence of anxiety and depression was assessed using a gold-standard standardised diagnostic interview.

Looking at a Long Covid Sufferer through an anxiety/depression window requires a rigorous justification, in general the burden of proof is lacking.  The client’s view, if allowed to be heard is that the better window to look through is of having a chronic physical condition that is inherently frustrating. Some may or may not find a support group of similarly effected individuals helpful. But there should be no pretence that this will resolve their disability or return them to pre Covid functioning.

What window is NHS Talking Therapies looking through?

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

The Myth That A Positive Psychometric Test Result Means Something

when administered, in the customary fashion, in isolation. It doesn’t, it is likely to be a red herring, about as useful as contending that because a person has a scar on their face they are likely to be a criminal. 

Service providers such as NHS Talking Therapies and Anxiety UK have adopted the routine use of the PHQ-9 and GAD-7 to chart the trajectory of Client’s symptoms. But have done so without first reliably clarifying which population the completer of the test is from. The particular completed questionnaire could have been handed in yesterday by a man in a red suit! There needs to be a fit between the domain of test and an identified disorder. The Service providers do not assess whether the chosen test is ‘fit for purpose’.

Psychometric tests are given credence if they have high sensitivity, (identifying a large proportion, typically 90%, of those with a disorder) and high specificity ( identifying a large proportion, typically, 90% of those without the disorder). But such impressive figures are only relevant if the population being addressed is known, This is quite unlike the routine clinical situation, in which the client has not been reliably categorised. The metric that is really important for a clinician is the positive predictive power of the test Monaghan (2021) positive predictive value reflects the proportion of subjects with a positive test result who truly have the outcome of interest.  But this is usually no better than chance. 

Only a minority of clients are likely to have are likely to have a particular disorder. There are many more people without a disorder than with a disorder. This means that using a test, even with a high specificity, the number of false positives may be several times greater than true positives. Resulting in widespread inappropriate treatment.

Harrison, A. G. & Edwards, M. J. (2023) assessed the the accuracy of 7 psychometric measures of ADHD and found that they were no more accurate than flipping a coin. The ability of self-report methods to accurately diagnose attention deficit hyperactivity disorder: A systematic review. Journal of Attention Disorders, 27(12), 1343-1359. https://doi.org/10.1177/10870547231177470 (Link)

Dr Mike Scott