Categories
BABCP Response - NICE Consultation January 2022

NHS Talking Therapies – A Black Hole For Psychological Wellbeing Practitioners?

On January 23rd 2023 NHS mental health director, Claire Murdoch, announced that:

‘Despite the disruption caused by the pandemic the NHS is on track to deliver its Long Term Plan commitment to boost mental health spending by £2.3 billion a year, enabling around 4.5 million adults and over 700,000 young people to access mental health services’.

All this without independent evidence of effectiveness. The best evidence available Scott (2018) suggests that for adults only the tip of the iceberg recover.

Australia [Allison et al (2023)] has just completed an inspection of its similar service and concluded:

‘In conclusion, this most recent Better Access evaluation reminds policymakers that psychotherapies are generally developed for clinical cohorts with more severe conditions. The mass rollout of brief psychotherapies for milder conditions does not appear to reduce population distress or suicide rates, and a considerable proportion of these patients experience deterioration [20-40%] Offering treatment for milder symptoms might undermine personal coping abilities and social support networks.Deterioration was less likely for patients with severe symptoms, and they also experienced more improvement.Based on these findings, severity could be used as a criterion for priority setting and resource allocation. Instead of the mass rollout of brief psychotherapies for milder conditions, prioritising longer courses of psychotherapy for more severe conditions may minimise risk and maximise the potential benefits of the Better Access initiative’.

The Better Access initiative was introduced into Australia in 2006 and by 2021 1 in 20 Australians had one or more sessions of psychotherapy at a cost 1.2 billion AUD.  But with no improvement in population mental health.

Alisson et al (2023) comment further:

‘In translating psychotherapies to the real world, CBT may have re- duced effectiveness unless treatment is carefully targeted, expertly delivered, and of adequate duration. In 2021, the average number of psychotherapy sessions per patient in Better Access (5.4) was lower than most research trials of CBT’

If the Australian findings were taken seriously, it should surely mean the end of low intensity NHS Talking Therapies. But about 70% of their clients are recipients of this dosage of therapy. Psychological Wellbeing Practitioners are threatened with extinction, in the unlikely event of the  UK Government becoming more concerned about wasting money than appearing to be politically correct.

But in neither Australia or the UK has there been publicly funded independent assessors of routine outcome, using a metric of lasting recovery from a disorder. This radical apathy, suggests a real-world indifference to the plight of those with mental health problems, despite political overtures.

Dr Mike Scott

Categories
BABCP Response - NICE Consultation January 2022

Formulation Nausea Revisited

Six years ago I blogged about Formulation Nausea, which is induced by a bewildering array of arrows, resulting in disorientation. A just published paper by Owen (2023) in Psychological Medicine notes the demise of Formulation amongst Psychiatrists. But it is still a staple of CBT training courses, based around the 4P’s of predisposing, precipitating, persisting and protective factors. This despite any evidence of its’ systematic usage in routine practice or effect on outcome. Yet it was meant to explain the client’s functioning. It is surely time for a re-formulation. 

The problem is that the 4P’s are in suspended animation with no specification of what kind of thing they are trying to explain. As Owen (2023) points out there is a need for a diagnostic anchor when it comes to formulation. Diagnosis is descriptive, with reliable agreement only occurring in the context of ‘gold standard’ diagnostic interviews. Without such an anchor Formulation is adrift on the high seas, clinicians suffer nausea and clients doubt their survival. Shorn of its’ moorings, Formulation becomes an exaggeration of the idiosyncracy of a client’s difficulties. There are evidence-based CBT protocols for depression and the anxiety disorders but their usage is dependent on ‘case-formulation’ not formulation.

Re-formulation needs to be added to re-framing and re-imagination

Matters have been compounded by psychological imperialism, assuming that there is only one axis needed to explain a clients functioning and subsuming  the social and biological under the first of the  4P’s, Kuyken et al (2009). A 3-D representation of a clients functioning, should arguably be represented by 3 axes at right angles to each other, psychological, social and biological with no primacy attached to the psychological per se. Each person has a score along each axis and their functioning represented by x, y, z coordinates. With this multi-axial classification (akin to DSM IV and not its successor DSM-5-TR) it is perfectly possible to ‘score’ much more highly on a non-psychological axis, making that the more relevant ‘intervention’ dimension. For example a client I saw recently was clearly depressed, with no previous psychological problems, but found himself living in terrible housing conditions that was seriously effecting the health of his children and all attempts to remedy this problem to date had failed. The social axis was clearly more pertinent in his case, but the presenting problem, as far as the way the local mental health services operate would be depression, albeit that moving in an intrapsychic direction flies in the face of common sense. Kuyken et al (2009) smuggle in an extra ‘P’ presenting problem to make 5P’s, but presenting problem is not part of an explanation, each of the 3 axes  has a predisposing, precipitating, persistence and protective explanatory framework, inclusion of ‘presenting problem’ is a category error. To take another example a patient may be judged non-compliant with physio after an operation, but a previous unrelated and unrecognised neurological condition was actually operating, resulting in a demoralised patient and frustrated physio’s. The appropriate axis here is a biological one not ‘stress management’ for the patient or physio. The failure to have a multi-axial approach means that psychological therapists take on everything, and their core skills get crowded out. Kuyken et al (2009) and CBT trainers and supervisors have unwittingly abandoned a biopsychosocial model adding to the stressors of would be clinicians. The failure to use a multi-axial system can be seen in NHS Talking Therapies practitioner’s struggle to provide therapy for those with long term physical conditions, carrying a sign ‘don’t ask me how far along the biological axis is this person located, because it is a mirage’, they are consigned to wander around the desert. Sufferers from FN are often stressed in silence, to reveal it to course leaders, supervisors may be taken as a sign of ‘weakness’. What is needed is a re-formulation.

Dr Mike Scott

 

 

 

 

 

Categories
BABCP Response - NICE Consultation January 2022

NHS Talking Therapies – A Sacred Cow

NHS Talking Therapies is the only NHS service that it is not independently assessed. Costing £2 billion a year for adult and child services, it has escaped the scrutiny of both the National Audit Office and the Care Quality Commission. It is also, it seems, the only NHS service were staff are not in a public pay dispute.  What is going on?

It deftly keeps below the radar, so that ‘value for money’ questions  are not asked. The other string to its’ bow is ‘gas-lighting’, the repeated repetition of a claim, absorbed by its familiarity. Its’ much vaunted ‘50% recovery rate’, has warmed the cockles of the hearts of politicians,  Integrated Care Boards and the media, who have all readily and willingly accepted the lie [see Scott (2018)] in the name of political correctness – to be seen to be on the side of mental health.  In Mental Awareness Week the powerholders need educating that functioning does not equal working. The Annual reports of IAPT (NHS Talking Therapies previous embodiment) portrays its functioning: numbers seen, waiting times and self-determined targets met. But with no evidence that it is working – no independent assessment of the proportion of clients who are back to their old self and remain so post treatment. There is no credible listening to the client by a Red Cross-like body.

The Citizens Advice Bureaux are a nationally recognised and valued body. Many of their clientele have mental health problems, but there is no evidence that they are any the less served than if they had attended NHS Talking Therapies.  The added value of this NHS service has not been demonstrated. Perhaps NHS Talking Therapies staff dare not consider strike action because they are afraid nobody would miss them. GPs may miss the brief respite that may come with off-loading to NHS Talking Therapies, some perhaps even believing or at least wanting to believe NHS Talking Therapies fairy tale. They may be complicit in marketing the tale to patients.

Dr Mike Scott

Categories
BABCP Response - NICE Consultation January 2022

CBT V’s Production Line

CBT is in principle, user and client friendly. But in practice over two thirds of CBT practitioner’s experience burnout [Westwood et al (2017) see previous blog]. Recent evidence Kat Wheatley (2023) suggests no improvement, since the identification of the problem. Practitioners returning to work today, after the Coronation weekend, could be depicted as Lowry-like figures.What is going on?

 

I think that is is probably a combination of proximal and distal factors. The distal factor may be the commodification of psychological treatment, in which therapists are no longer regarded as people, but as individuals that are instrumental in achieving  targets: such as number of clients seen, waiting times and delivering on the Organisations metric of recovery.

The proximal factor may be a failure on CBT courses and the delivery of workshops, to ever mention the ‘irreducible complexity’ of therapy. Rather it has been implicitly accepted that it is possible to deliver CBT by selecting components of it to deliver vis a vis low intensity therapy.  But the studies of the efficacy of low intensity are of such poor quality e.g no independent assessment, that they offer no firm foundation for the delivery of effective treatment. In CBT the whole is greater than the sum of its’ parts.

Arguably it is the therapist as a human being interacting with another human being, utilising appropriate CBT strategies, that explains the potency of the therapeutic enterprise. Assembling components of CBT at various points on a production line, is unproductive. The idea of receiving a better component down the line, the much vaunted stepped-care approach, just does not work. Rather it is the synergistic interaction of two human beings in a context in which there are specific strategies available for the different disorders, that makes for the ‘living cell’ that is therapy. Just as a living cell cannot be constructed from inanimate parts (pace macro evolutionists). There is an ‘irreducible complexity’. The popular selling of individual parts of CBT, in self-help books is unlikely to make a real-world difference to the readers life,  unless the material is somehow personalised.

Dr Mike Scott 

Categories
BABCP Response - NICE Consultation January 2022

NHS Talking Therapies On The Brink?

Six years ago the prevalence of burnout in the predecessor of NHS Talking Therapies (the Improving Access to Psychological Therapies  Service) was reckoned to be as high as 67% (Westwood 2017). Writing in this month’s Psychologist, Kat Wheatley, a Psychological Wellbeing Practitioner writes the following, anonymised to protect the service and the individuals involved:

“In early February 2022, we received a mass email from service leaders stating that we were not on track to meet the monthly target for triage assessments. They stated this was due to too many staff taking leave over half term and being on sick leave. The email went on to tell us we would be required to offer 1-2 additional triage assessments per week throughout the month to ensure the services’ targets were met, and to discuss any concerns with our Line Managers.

Later that day, an informal discussion with my PWP colleagues highlighted the email had provoked shared feelings of stress, frustration, and dread. One of my colleagues became tearful, sharing she was already too overwhelmed by the current workplans. Someone else stated they were going to ignore the request entirely and expressed anger towards managers for not acknowledging the pressure we were already under. Another simply said they were too drained to think about it today. Over the next few weeks, the stress and low morale was tangible, with more colleagues taking sickness leave throughout the month. And while we should have felt relieved when the month was up, instead we all shared a sense of defeat that this would happen all over again at Easter.”

It does not sound as if burnout has reduced in the past six years. There is no sign of an improvement anytime soon. The author opines that is possible to mitigate the deleterious effects of burnout  by shifting ‘towards a culture of compassion within leadership’. This is at best an untested hypothesis. Nevertheless it could serve to keep hope alive amongst staff, to make going into work at least tolerable. But what would likely be the level of ‘mitigation’ achieved? Is it to be seriously suggested that it would have a major impact,  or more realistically, at best a minor impact? Would one have seriously suggested  that developing a ‘culture of compassion within the leadership’ of the Metropolitan Police would have prevented the debacle that we have seen since the murder of Stephen Lawrence, 30 years ago? More plausibly, NHS Talking Therapies has ‘Institutional’ problems that need to be addressed by a publicly funded independent review. This is not to say that individual leaders within NHS Talking Therapies cannot behave better, regarding staff as persons rather than individuals instrumental to a goal.  Similar considerations would doubtless apply to the Confederation of British Industry.

Dr Mike Scott

Westwood, S., Morison, L., Allt, J. & Holmes, N. (2017). Predictors of emotional exhaustion, disengagement and burnout among improving access to psychological therapies (IAPT) practitioners. Journal of Mental Health, 26(2), 172-9. 

 

Categories
BABCP Response - NICE Consultation January 2022

The Scientific Credibility Of NHS Talking Therapies

Taxonomy is at the heart of the scientific enterprise, different  treatments, for different phenomenon. But NHS Talking Therapies applies no reliable categorisation of patient difficulties. The Service thus lacks scientific credibility. 

But where is the public accountability? We rightly insist that schools are independently evaluated (Ofsted) so that parents know what they can expect from their child’s attendance at a particular school.We are concerned at any possible failings in the inspection body, with a recent recommendation that it ought to be complemented with another body the Care Quality Commission (CQC). However for the biggest provider of psychological treatment, NHS Talking therapies there is no independent inspection at all. Are those seeking help with mental health difficulties less important than children?

 

There is at least a case to answer with NHS Talking Therapies. Drew et al (2021 ) have demonstrated the factory-like quality of NHS Talking Therapies.De facto the therapists on the production line are given carte blanche to do what they want, provided the necessary paperwork, PH-9, GAD-7 and ICD-10 codes are completed. Should we as a Society be buying these wares at a cost of £750 million per year?

 

Most of what makes us human: consciousness, morals, values, meaning is outside the cause and effect world of science. Without an infusion from this level, psychological therapy is reduced to a production line. This applies not only to the ministrations of the therapists but also to those with responsibility for the Service, ultimately the NHS and politicians. Lip service is paid to a duty of care.

 

Dr Mike Scott

Categories
BABCP Response - NICE Consultation January 2022

Diagnostic Stewardship’s Abscence from NHS Talking Therapies

Diagnostic error occurs when a diagnosis is missed, inaccurate, imprecise, or incomplete.1 Diagnostic stewardship reduces diagnostic error primarily by reducing misdiagnosis. NHS Talking Therapies use problem descriptors, as a surrogate for diagnosis, and on this basis choose an ICD-10 code, but nowhere else in the NHS operates like this. Neither the validity or reliability of ICD-10 codes, established by these means, has been established. It is no more reliable than establishing a code based on the way the wind is blowing. The purpose of such a charade is to give NHS Talking Therapies a spurious scientific legitimacy. It is akin to a candidate for a post over-selling themselves at interview. It is tempting in such circumstance to blame the ‘candidate’, but the real problem is the interviewing panel ( Integrated Care Boards, politicians) all with their own agendas. These include being seen to do something that is immediately credible to the public, such as increase access, shorten waiting times. Achieving these goals maintains their position.

NHS Talking Therapies engages in further posing when it claims its’ therapists intervention are NICE compliant. Given that the services clinicians do not make diagnosis and that the treatments recommended by NICE are largely diagnosis specific, this is logically impossible. But by clever marketing and a strenuous avoidance of independent evaluation, NHS Talking Therapies perpetuates the myth. This is coupled with a phobic avoidance of discussion in the public domain. Preference is given to internal networking meetings of ‘best practice’ in which the agenda is set by the power holders in NHS Talking Therapies. Lessons in this are on offer from all totalitarian states, the only ones that pay are the subjects/clients.

The totalitarians are unwittingly helped by those who totally eskew diagnosis. The latter ‘free spirits’ have no metric with which to invalidate the claims of the totalitarians. It becomes a free for all of assertion and counter assertion, with no methodology that might lead to agreement. The primacy given to an individual therapists subjective formulation of a client’s difficulties can be easily dismissed on the grounds that it is idiosyncratic. In such circumstances the therapist’s bottom line amounts to ‘I want my autonomy at all costs, any infringement is coercion, deserving of my righteous wrath’ and an ignoring of the bigger picture.

Dr Mike Scott

Dr Mike Scott

Dr Mike Scott

1. Balogh  E, Miller  BT, Ball  J; Institute of Medicine.  Improving Diagnosis in Health Care. National Academies Press; 2015.

Categories
BABCP Response - NICE Consultation January 2022

Piracy in NHS Talking Therapies

The initial press-ganging of patients is conducted by a Psychological Wellbeing Practitioner (PWP). He/she is the least qualified member of staff. Nevertheless, the PWP determines the ‘vessel’ on which the patient is put. At best, the patient can vote with their feet. There is no indication of the ‘soundness’ of the vessel for them.

Here is an extract from a letter to the GP following an initial assessment by a PWP:

‘The difficulties as described at assessment appear consistent with PTSD although this is a description of symptoms and should not be considered a diagnosis’

Nevertheless, the PWP specifies an ICD-10 code for PTSD. Following the 40-minute telephone assessment this patient has 3 sessions of low intensity group treatment. The trauma in this case was a physically threatening altercation at work. But inspection of the DSM-5-TR stressor criteria for PTSD states that only an extreme trauma is the gateway to PTSD and that it is ‘extreme’ in that it is sudden and catastrophic Noorholm et al 2021. The PWP’s idiosyncratic use of diagnostic criteria is precisely what is condemned in DSM-5-TR (2022) P23 ‘lack of familiarity with DSM-5 or excessive, flexible and idiosyncratic application of DSM-5 criteria substantially reduces its utility as a common language for communication’. Noorholm et al 2021 also point out that the DSM-5 stressor criteria should be established using a standardised diagnostic interview and not be based on a self -report measure alone.  The PWP used a PTSD self-report measure on most occasions, and followed NHS Talking Therapies customary practice of routinely using the PHQ-9 and GAD-7.

Notwithstanding the above considerations there is no evidence that 3 sessions of group therapy makes a real-world difference to a person with PTSD. It is not an appropriate vessel for them to be put on. There is no evidence that the PWP or patient was aware of this. The patient is a victim of traffickers/organisational dictate. Informed consent is notable by its’ absence.

The patient is then switched ‘vessel’, with group sessions followed by 5 individual high intensity sessions of CBT. But there is no evidence that this dose of CBT makes a real-world difference to patients with PTSD – journeying once again on an ‘unsound vessel’. Unsurprisingly the high intensity therapists decides to switch the patient again to another ‘vessel’, EMDR. The patient then has 13 sessions of this, involving re-living of the altercation. But EMDR is only a NICE approved treatment for PTSD. The patient has had extensive inappropriate treatment. At the final session the female patient reports that the ‘memories …. don’t bother me much anymore’. But the avowed purpose of EMDR is to achieve such a response, the patient would feel that they were failing the therapist and themselves not to report such an improvement – the demand characteristics of therapy. Similarly changes on the PHQ-9 and GAD-7 could also reflect the demand characteristics and/or simply the passage of time.

A more plausible explanation of the patient’s difficulties was that they suffered a chronic adjustment disorder that would be in place until the employer ensured the safety of the patient. The extensive treatment has involved a psychopathologizing of the patient’s difficulties. It has also been a massive waste of psychological therapy resources. Assuming the high intensity therapy was costed at £100 per session the cost would be £1800. Assuming the group sessions cost £70 each the total cost would be £210 and the individual assessment by the PWP at say £80. The total cost of therapy would be £2000+.

The patient has been taken on an unnecessary and costly journey that could have been avoided with careful assessment, followed by watchful waiting. It is the public purse and patients that are the victims of this piracy.

Dr Mike Scott

Categories
BABCP Response - NICE Consultation January 2022

BMJ Mental Health and Bias

It is regrettable that BMJ Mental Health marks its transition from the Journal  Evidence-based Mental Health with the publication of a paper by O’Driscoll et al (2023) that obscures allegiance bias, by the authors simply declaring what grants they receive.  The authors work either for NHS trusts or IAPT, the former operate the latter. They use an IAPT dataset and uncritically utilise the services self-serving metric of recovery. These authors have not considered the Cochrane Risk of  Bias tool against which the study would have been judged as at high risk of bias. There is no acknowledgement of works that cast serious doubts on the Services claimed 50% recovery rate, Capobianco et al (2023), Scott (2018). 

 The O’Driscoll et al (2023) paper claims that CBT may be preferred  to counselling for clients who have anxiety symptoms comorbid with depression. But the conclusions are built on sand in that:

  1. there can be no certainty that the subjects studied were depressed as there was no ‘gold standard’ diagnostic interview conducted. Instead reliance was placed on a psychometric test, PHQ-9
  2.  there can be no certainty about comorbidity because of the absence of a diagnostic interview
  3. no fidelity checks were carried out to establish whether therapists were conducting CBT or counselling. Reliance was instead placed on therapists claims.
  4.  no blind-raters were used to assess outcome
  5. there can be no certainty that the observed changes would not have happened anyway because of the absence of a credible attention control condition
  6. there can be no certainty that the observed changes were clinically meaningful or that changes endured. A 6 point improvement in the CBT group and a 5 point improvement in the counselling for depression group on the PHQ-9.
  7. the study was restricted to patients who attended 5 or more treatment sessions, but these are unrepresentative of IAPT clients. Only half of clients have 2 or more treatment sessions (defined by IAPT as ‘treatment’). The mean number of IAPT treatment sessions is 7 but the mean number of treatment sessions in the O’Driscoll et al (2023) study was 10 in counselling for depression and 11 in CBT. Further the third of IAPT clients who undergo low intensity intervention alone were excluded. Generalisation from this study is fraught with difficulties

Does the emergence of BMJ Mental Health signal the demise of evidence-based mental health? I hope not.

Capobianco, L., Verbist, I., Heal, C., Huey, D., & Wells, A. (2023). Improving access to psychological therapies: Analysis of effects associated with remote provision during COVID-19. The British journal of clinical psychology, 62(1), 312–324. https://doi.org/10.1111/bjc.12410

 

 

O’Driscoll C, Buckman JEJ, Saunders R, et al Symptom-specific effects of counselling for depression compared to cognitive–behavioural therapy BMJ Ment Health 2023;26:e300621.

 

Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology, 23(9), 1136–1147. https://doi.org/10.1177/1359105318755264

 

Categories
BABCP Response - NICE Consultation January 2022

The National Audit Office Confers With Mental Health Powerholders and Not Patients


Unsurprisingly the surveyed integrated care board (ICB) mental health leads and mental health trusts tell the NAO what a great job they are doing.  The NAO also interviewed mental health stakeholder organisations such as the BPS and BMA. On this basis, the NAO [“Progress in improving mental health services in England”] declared last month, that ‘the government has achieved value for money’. The yardstick used by the NAO was whether the surveyed bodies ‘met ambitions to increase access, capacity, workforce and funding for mental health services’. No attempt to access the voice of the people. 

Interestingly the NAO did not even attempt to make the claim of the prime movers in IAPT Layard and Clark (2015) that the Service costs nothing, due to savings on welfare benefits and physical healthcare costs!  The response of the great and the good in mental health (the NHS Confederation, SANE and Mind) has been, that the report highlights the need for increased funding, to recruit and retain more staff. No awareness that more of the same is unlikely to make any difference to patients.

 

The report reveals that £752 million was spent on NHS Talking Therapies predecessor, IAPT, in 2021-22. But when the NHS acquired IAPT earlier this year no audit of the latter was conducted. No business would behave in this way. Yet the NAO report re-iterates the target of ‘at least 50% achieve recovery across the adult age group’. No mention that there is no independent evidence that this has ever been achieved. With the best evidence Scott (2018) suggesting that only the tip of the iceberg recover. What sort of auditors are the NAO? Under their watch acquisitions can be made without credible scrutiny.

In 2018 the NAO jettisoned an enquiry into the Improving Access to Psychological Therapies (IAPT) Programme. In response to a Freedom of Information request, the NAO responded on February 17th 2020 ‘We commenced work on the IAPT programme in 2017-18. However, the work on this programme was curtailed in June 2018 by the Comptroller and Auditor General (C&AG) of the time in response to changing priorities. The alterations to the work programme were made so that the C&AG could respond quickly on important topical issues, such as work on the UK’s exit from the European Union, the government’s handling of the collapse of Carillion, and on significant NHS spending increases in 2017- 18 on generic medicines in primary care’.

Dr Mike Scott

%d bloggers like this: