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If You Contact NHS Talking Therapies Can You Tell If You Are Interacting With A Human Being?

A just published paper in The International Journal of Social Psychiatry, by Arundell et al (2024) reports the experience of 12 clients:

  1. A long wait was often the first thing participants reported when asked about challenges with accessing NHSTT treatment:

. . .there was a huge delay from the time the referral was done back in May till I got my first session in November. . .So the GP referred, and I didn’t hear back until November. [P.12]

Another challenge was the limited support offered whilst waiting to begin therapy. While people did reference offers of self-help information or group sessions, this was either seen as insufficient:

. . .if you’re struggling, there’s like these videos online. . . on their website or something, they were useless. . . it was too general. . . so the information I can find from anywhere. . .. [P.5]

The amount of time given per session was often seen as insufficient and as such, this posed a challenge for service users:
. . .only having like half an hour session. . .I think with the treatment that I had because it was half an hour, she had to follow a very rigid structure. . .And that just felt like it took up a lot of time [P.3]
 
It was often the case that service users felt they needed more sessions or that they had not managed to work through everything they had wanted to:
. . .I guess it’s not, you know, a longer process. . .it’s not a program that’s meant to continue along with you. So, I guess there’s very much like goals that you intend to complete throughout the- the end of the program, but you know, obviously mental health issues like, continue. [P.10]

Service users appreciated when they were given the option of longer or additional sessions

We were supposed to stop at six [sessions], but I wasn’t feeling very mentally well, so we extended to seven. . . [P.8]

Disquiet at forced revisiting of painful memories
Some of the most common challenges expressed by service users related to their own personal challenges of therapy, such as the fact that talking about their mental health problems was difficult in itself:
In terms of the help for me it’s been OK, the only thing I would say that could be negative is just that the actual program itself like there are some parts that become difficult because of the nature of what is being spoken about. . . I think it’s more like revisiting memories I didn’t really want to revisit. That was the hardest part of it. [P.4]
 
Arundell et al (2024) concluded ‘Service users should be made to feel comfortable and confident in requesting additional support where they feel it is needed so that this can be considered as part of their treatment package’. 
 
At each session two psychometric tests are administered, the results determine the nature of treatment. Arguably NHS Talking Therapies has become de facto an Artificial Intelligence operative but the Arundell et al (2024) paper also cited the comments of some clients about the warmth of some therapists. The clients were all female and from ethnic minorities but felt no cultural adaptations to their treatment had been  necessary. But no data is provided on outcome.

Dr Mike Scott

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NHS Talking Therapies Glaring Failures, Are Highlighted By A Focus On One of The Long-Term Conditions It Targets

CBT is hailed as effective treatment for long-term conditions (LTCs) such as Irritable Bowel Syndrome (IBS). The latter is posited as being maintained by excessively negative cognitions. NHS Talking Therapies, purportedly, provides access to effective treatment for this condition. But this is yet another NHS Talking Therapies myth.

Minimal Access

The prevalence of IBS is between 5 and 20%, and given an adult population of 30 million in England, one would expect (at 10%) 30 X 105 sufferers annually. Thus 3 million is the potential pool of IBS sufferers that could present at NHS Talking Therapies. The service receives approximately 1 million referrals a year and therefore one could expect 100,000 sufferers from IBS to present to NHS Talking Therapies a year, But the latest data from NHS Digital and a response to a Freedom of Information Request (FOI) that I received in June 2024. suggest that approx. 200 present each year, so that it is seeing just 1 in 500 of IBS sufferers. Thus, it cannot be said to be meaningfully provide access to IBS sufferers.

Disengagement

Further, for every 2 people having one assessment/treatment session, only 1 person has 2 or more treatment sessions. The Service is having a serious engagement problem with IBS sufferers.

No Evidence of Recovery

Yet for those who have 2 or more sessions it claims a 50% recovery rate, but this is based on using the PHQ-9, a self-report depression questionnaire as an outcome measure. It can scarcely be taken to measure the severity of IBS. 

Dubious Non-Friendly Model

CBT treatment for long-term conditions (LTCs) is predicated on the assumption that difficulties are maintained by excessively negative cognitions. Little wonder that IBS sufferers have a ‘thanks, but no thanks’ response to engaging with NHS Talking Therapies.

Dr Mike Scott

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How Not To Be A CBT Therapist?

‘CBT, CBT everywhere and not a drop to drink’. It has become common currency, but how often do you see it making a real-world difference to a person’s life? Therapists are likely to keep in mind, a ‘case’ were it has worked, recalling it in great detail to keep motivated. They may via the National Networking Forum, share ‘best practice’ with other CBT therapists, exchanging details of their hallmark case. Thereby, fostering the illusion that it is routinely effective.

But even the randomised controlled trials (rcts) of CBT for depression and the anxiety disorders, whose protocols are recommended by the National Institute for Health and Clinical Excellence (NICE), depict the results in terms of differences in average scores between those who have CBT and those who do not. It is not at all clear from the rcts, what proportion of people have a lasting recovery with CBT. However, the NHS Talking Therapies Manual takes the rcts as demonstrating a 50% recovery rate. This has been the basis on which the Service for adults and children has been funded to the tune of £2 billion a year. But there is no empirical evidence of a translation of the results of the rcts to routine practice. There has been no publicly funded independent assessment of NHS Talking Therapies.

As an Expert Witness to the Court I assessed 90 people who had been treated by NHS Talking Therapies, Scott (2018) and found that only the tip of the iceberg recovered. The results were the same whether they were treated before or after a personal injury. My assessment was based on the use of a ‘gold standard’ diagnostic interview, the most reliable metric in a Court of law. By contrast NHS Talking Therapies own claims are based on changes on two psychometric tests (PHQ-9 and GAD-7) over time. If this data was presented in Court, the Barrister would likely ask “is it not the case that people come to you at their worse, so that there will be some change, ‘time heals’?”, with a follow-up ” like members of the jury I do not doubt that people are pleased with your attention and that you offer hope, but there is no evidence that the Service is responsible, for the alleged recovery?” and “can you please explain, to the Court, why this level of funding is necessary?”.

Such cross-examination of the data does not take place either within the lead organisation for CBT, The British Association for Cognitive and Behavioural Therapy (BABCP) or within NHS Talking Therapies sponsored events. The British Psychological Society (BPS) has been happy to validate courses for low intensity CBT, in a rush to extend the empire of psychological therapy, without the methodologically sound database that high intensity programmes were based on, see Scott (2009) Simply Effective Cognitive Behaviour Therapy, London: Routledge.

Dr Mike Scott

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NHS Talking Therapies Tangled Web

The Service claims recovery from mixed anxiety and depressive disorder (MAD), without a treatment protocol. But at the same time insists that it is National Institute for Health and Care Excellence (NICE) compliant. NICE specifies the disorders for which there is an evidence-based treatment, but MAD is absent from the list. It therefore not possible for the Service to be protocol driven in this domain. Yet it boasts a recovery rate for MAD comparable to that for the recognised anxiety disorders  and depression. For tennis afficionados this may well evoke the John McEnroe response of ‘you cannot be serious!’

How MAD clients of the Service apparently fare, throws up an interesting conundrum: given that their recovery is on a par with other disorders (without the use of any evidence-based treatment), could it be that these other ‘successes’ are nothing to do with the alleged use of specific protocols, but are just what happen if you give anybody attention, time and present a credible rationale for treatment?. The burden of proof is on NHS Talking Therapies to demonstrate that its’ ministrations have an effect, over and above, that which would obtain from say the Citizens Advice Bureaux helping its’ distressed clients with difficulties. The Service has shown no inclination to recognise or address this credibility problem, perhaps suspecting it would be like turkeys voting for Christmas. 

But the NHS Talking Therapies debacle over MAD is even more extensive. The author of the Service’s Manual dissuades clinicians from using the MAD label because it might lead to missing clients who truly have PTSD. But omits to mention that there is no way the Service can identify those who do or do not have PTSD, because its clinicians do not make diagnoses! We are at least on the border of MADness and dishonesty.

Dr Mike Scott

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NHS Talking Therapies Undue Deference to Two Psychometric Tests Stymies Listening and Treatment

 

Two psychometric tests, the PHQ-9 for depression and the GAD-7 for generalised anxiety disorder, are the twin pillars used by NHS Talking Therapies [formerly Improving Access to Psychological Therapies (IAPT)] service to direct therapy and evaluate outcome. The pillars form a gate through which the client is expected to pass, at every treatment session. Thus, making less time for listening to and treating clients.  

NHS Talking Therapies clinicians are not trained to make diagnoses, so the tests are the sole arbiter of the services effectiveness. I made a freedom of Information Request to NHS England requesting  details of the experience of clinicians and cost of the Service, bizarrely they said that they  did not have this information. Drawing on data from the rest of mental health services, it seems likely that most practitioners are less than 3 years in post, over 80% are female and most age 40 or below.   It stretches credibility to believe that these practitioners are sufficiently competent or diverse for the public they serve.

 

 Unfortunately, other agencies such as the Charity, Anxiety UK have felt compelled to adopt IAPT’s metrics. The result is chaos, when viewed through the lens of the recent Negeri et al (2021) meta-analysis of the accuracy of the PHQ-9 to assess for depression. A chaos which is compounded by looking through the other lens, of the accuracy of the GAD-7 in different settings.

The Misuse of the PHQ-9

Negeri et al (2021) provide a tool to indicate the likely consequences of use of the PHQ-9 by itself. The first step is to enter the likely prevalence of depression in the target population (in primary care they suggest it is likely to be 5-10% and in specialty care settings or those with chronic health conditions it is likely to be 10 to 20%). Entering a prevalence of 10% for the level of depression in those presenting to IAPT (using the standard cut-off of a score of 10+) 22% of client i.e 22 out of 100  would screen positive. Of the 22 9 (39%) would meet diagnostic criteria for major depression (true positives) 13 (61%) would not meet diagnostic croiteria for major depression ( false postives). Thus inappropriate treatment would be given to more than 1 out of 2 clients. Alternatively inputting a prevalence of 15% ( perhaps more accurate if the population included those with long term conditions) would give a prevalence rate of 26% i.e 26 out of 100.. Of the 26 13 (50%) would meet diagnostic criteria for major depression (true positives) but 13 (50%) would not meet diagnostic criteria for major depression (false positives). Thus, one out of two clients would be treated for depression when they did not need to be.

Using the PHQ-9, as often as not, IAPT’s clinicians are treating the wrong disorder. How then can the results ( a claimed 50% recovery rate) be comparable to that in the randomised controlled trials for depression where all the clients were known (on the basis of a ‘gold standard interview’) to be suffering from depression?

The Use of the GAD-7 By Agencies in Addition to the PHQ-9, Adds To the Misdirection and Makes Their Claims of Effectiveness Even Less Credible

Rutter and Brown (2016) concluded that the GAD-7 is ‘a dimensional indicator of GAD severity rather than a screening tool for the presence or absence of the disorder in outpatients with anxiety and mood disorders’ and the GAD-7 did not provide sufficient specific information to indicate the presence of a GAD diagnosis’, At a cut-off of 10 the sensitivity was 79.5% and specificity 44.7%. Using a cut off of 8 the sensitivity was 86.5% but the specificity was 34.8%. But In the validation study of the GAD-7 by Spitzer et al (2006) the optimal cut off was a score of 10 or more, 89% with GAD had GAD-7 scores of 10 or greater (sensitivity ), whereas most patients 82% without GAD had scores less than 10 (specificity). The psychometric properties of the GAD-7 have also been examined in a heterogeneous sample of different diagnoses. Beard and Björgvinsson (2014) found poor specificity and a high false positive rate for specific anxiety disorders and the proposed cutoff by Spitzer et al. (2006) of ≥10 was only partly supported with a sensitivity of 74% and specificity of 54%. Kroenke et al. (2007) found that the GAD-7 performed well as a screener for GAD, post-traumatic stress disorder (PTSD), social anxiety disorder (SAD), and panic disorder (PD) in primary care patients and proposed a score of 8 as a cutoff score with a positive likelihood ratio above 3. It appears that it is only the authors of the GAD-7 that claim its value.

 

Getting Real

The most plausible explanation is that IAPT has engaged in self-promotion. Realistically, only the tip of the iceberg of IAPT clients recover Scott (2018).

But it is not only IAPT who are making false claims so to are other service providers. There is pressing need for independent audit using ‘gold standard’ assessments of the trajectory of clients lives after treatment.

 

Beard, C., and Björgvinsson, T. (2014). Beyond generalized anxiety disorder: psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. J. Anxiety Disord. 28, 547–552. doi: 10.1016/j.janxdis.2014.06.002

Kroenke, K., Spitzer, R. L., Williams, J. B. W., Monahan, P. O., and Löwe, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann. Intern. Med. 146, 317–325. doi: 10.7326/0003-4819-146-5- 200703060- 00004

Rutter, L. A., and Brown, T. A. (2017). Psychometric properties of the generalized  anxiety disorder scale-7 (GAD-7) in outpatients with anxiety and mood disorders. J. Psychopathol. Behav. Assess. 39, 140–146. doi: 10.1007/s10862-016- 9571- 9

 

Spitzer, R. L., Kroenke, K., Williams, J. B. W., and Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder the GAD-7. Arch. Intern. Med. 166, 1092–1097. doi: 10.1001/archinte.166.10.1092

 

 

Dr Mike Scott

 

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NHS Talking Therapies the Victory of ‘Satisficing’ Over What Clients Really Want 

 

Satisficing is a term used by economists to denote a decision-making strategy or cognitive heuristic that involves searching through alternatives until an option is considered to clear an acceptability threshold. The Labour Party Economist, Lord Layard considered that with the help of psychologist, Professor David Clark, they could make a sufficiently plausible case to Government to fund the Improving Access to Psychological Therapy (IAPT) service [now rebranded NHS Talking Therapies for anxiety and depression]. In this they were successful [‘Thrive’ Layard and Clark (2014)]. The new Labour Government shows no sign of wanting to review its’ received mantra, despite a cost £2 billion a year for Adult and Child mental health services. But the voice of mental health sufferers has been nowhere in evidence. There was no evidence that the proposed mode of service delivery would result in recovery, in a way that was intelligible to sufferers, such as no longer suffering from a disorder for a significant period of time.

In the 2011 book by Psychologist, Martin Seligman ‘Flourish’, Layard chides him  “You, like most academic types, have a superstition about the relation of public policy to evidence. You probably think that Parliament adopts a program when the scientific evidence mounts and mounts, up to a point that it is compelling, irresistible. In my whole political life, I have never seen a single example of this. Science makes it into public policy when the evidence is sufficient and the political will is present”.

But what if there are vested interests in determining what is ‘sufficient evidence’ ? For sixteen years the Service has continued to proclaim its’ 50% recovery rate, despite no independent evidence using a ‘gold standard’ diagnostic interview.

 

Heuristics have the advantage of speed, getting things done, but not necessarily well enough from the point of view of the consumer. ‘Satisficing’ is a powerholders judgement, imposing its’ will, blind to cient’s satisfaction but very attractive to other powerholders. With a ‘satisficing’ rationale Layard also announced his intention to bring ‘positive education’ to schools. There has been a psychopathologising of the young with diagnoses of ADHD or ASD seen as the gateway to services and a sought after explanation of difficulties. With little attention to alternative and often more credible explanations of difficulties. This is not to deny that there are those few who truly have ASD in the traditional sense of the term. In practice, there is a de facto absence of specialist reliable assessment for these conditions. The upshot is that a great many people are treated ‘as if’ they have these conditions and may self-diagnose these conditions. 

 

Seligman, Martin E. P.. Flourish . Nicholas Brealey Publishing. Kindle Edition. 2011

 

Dr Mike Scott

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NHS Talking Therapies Black Hole

Data is only publicly available on the 1 in 2 people who undergo treatment, those who have had just one assessment/treatment session have disappeared down a black hole for the past 16 years. This is hardly the transparent and comprehensive monitoring of outcome claimed in the NHS Talking Therapies updated Manual.

But following a Freedom of Information request (FOI) I have obtained data on those attending only 1 session. But the diagnostic status of almost a third (29.1%) was unknown, making the Services claim to follow NICE approved diagnostic specific protocols meaningless. 

 


The Manual 5.1.3  recommends ‘systematic screening for all the conditions that NHS Talking Therapy treats’.  But there are 11 conditions that the Service treats.There is no evidence that at assessment its’ clinicians employ a standardised screen for the spectrum of disorders that they claim are within their remit to treat. Nor that they use a screen to rule out the disorders that they do not treat: personality disorder, psychosis, bipolar disorder and eating disorder. In the foreword to the Manual it states that those who do not go on to treatment are given ‘advice and signposting (if appropriate)’. But there is no clarity about the content of this ‘advice’ nor of its’ evidence base.  Signposting it seems may not occur, but this could plausibly be because the assessing clinician (usually the most junior member of staff- a Psychological Wellbeing Practitioner) simply doesn’t know the way.  One has a strong suspicion that those who have simply an ‘assessment’ disappear down a black hole, only to possibly re-emerge in desperation, when their difficulties have not resolved.

NHS Talking Therapies published data is at best consistent with passing improvement, for disorders that largely wax and wane anyway. 

Dr Mike Scott

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Something Is Very Amiss In Routine Care – There Is No Evidence of Translation From The Evidence-Based Psychological Treatments Of Randomised Controlled Trials

according to a meta-analysis in the Journal of Affective Disorders. This echoes my own finding of only a significant minority recovering in NHS Talking Therapies Scott (2018). The results are a far cry from the 50% recovery rate claimed by NHS Talking Therapies.

“It makes little sense to conduct hundreds of randomized trials on psychological treatments when they do not lead to better routine practice.” For those in care as usual only 1 in 6 or 7 recovered.When care as usual is persistently failing, the punters are clearly not being listened to.  It is like Stalinist Russia proclaiming another successful 5 year plan, when in reality the peasants are starving .

Where did it all go wrong?

Dr Mike Scott

 

 

 

 

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NHS Talking Therapies Totally Fails The Traumatised – But There Is A New Way of Moving On

On June 5th, 2024 under a Freedom of Information Request (FOI),  NHS Talking Therapies informed me that in the year 2022-2023, 23,069  people with post-traumatic stress disorder had just one assessment/ treatment session with the Service. 

 

The FOI data reveal that for those attending just one session, those with PTSD have higher mean scores on both the PHQ-9 (17.9) and GAD-7 (15.6)  than any other diagnostic group. Further these mean scores are higher than those who start treatment  mean PHQ-9  of  15.5 and GAD-7 14.1. It thus appears that those who have only one session are likely more traumatised than those who go on to have treatment. 

It appears that there is something radically wrong with the traditional trauma-focussed approach to trauma adopted by NHS Talking Therapies. My new self-help book, Moving On After Trauma (2nd edition) published by London: Routledge on June 13th 2024, takes a radically different, more user-friendly approach. Instead of positing that the primary difficulty lies with arrested information processing at the time of the trauma and the consequent need to re-live it therapeutically, I suggest that what is pivotal is the centrality accorded to the trauma for today and that there is no need for a re-traumatisation of the client. My clinical handbook ‘Personalising Trauma Treatment: Reframing and Reimagining’ published in 2022 by Routledge, spells out the specifics of this approach for clinicians.

Accordingly I am adding a ‘Moving On After Trauma’ page to this website for clinicians, those who have been traumatised and those travelling the road with them. Here are my 12 rules for Moving On:

  1. Begin building a bridge between yourself now and the person you were before the trauma. Start by doing a little of what you did before. Constucting gradually as wide a ranging an investment portfolio as you can manage.
  2. Expected that building the bridge, like all forms of construction, will be steps forward and one backwards. It will need daily commitment.
  3. Don’t block the memories of the trauma, the harder you push them away the more they spring back.
  4. Put the traumatic memories in their place by questioning their relevance to today’s plans.
  5. Don’t get hooked by what could have happened. That is just a horror video which spoils today, with dark imaginings.
  6. Expect that the traumatic memory will knock at the door of your mind daily. But it is only asking about its’ relevance to today. Calmly answer this visitor.
  7. Go by what you would bet £5 on happening today, not by how vivid the traumatic memory is and how upsetting you find it.
  8. Remember that guilt is about deliberately doing something wrong. Trauma related guilt is bogus, it arises from either believing you should have looked into your crystal ball before the trauma or that you actually had the time to have done something differently. Feeling guilty and being guilty are not the same.
  9. Refuse to see flashbacks/nightmares as credible forecasts of what is going to happen today. Being constantly on the edge of your seat is about the past not the future.
  10. Give people the time of day. Expect to feel disconnected from others as you are looking at your world through war-zone glasses. Try on the pre-trauma glasses, they are more reliable. The view through them is based on a lifetimes experience rather than on a single drama.
  11. Refuse to take your alarm going off as evidence of danger- it’s just a ‘dodgy alarm’. Tripped easily by anything not exactly as you would want it, reminders or any unusual but not abnormal bodily sensation/s.
  12. Refuse to look at yourself and your personal world through the window of the trauma. Don’t make the trauma, pain or disability central.

 

 

Dr Mike Scott

 

 

 

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Minimalist Approach To Depression Doesn’t Deliver

A just published study in Lancet Psychiatry shows that just screening people for depression  using a PHQ-9 score of 10 or more, doesn’t help the patient, whether or not they and/or their GP are informed. A month after baseline, PHQ9 scores in all groups reduced by 4 points  and remained at this level in follow-up. 

Based on a diagnostic interview only a third of the sample met DSM diagnostic criteria at follow up. But in NHS Talking Therapies, a PHQ-9  score of 10 or more would usher people along a depression treatment pathway. This study indicates that two out of three people would have been directed along the wrong path. Watchful waiting is called for, oftentimes there is just a passing crisis in a person’s life.   Clients need comprehensive assessment, monitoring and treatment. NHS Talking Therapies’ simple dichotomy of low and high intensity interventions is not fit for purpose.

A screen by itself is simply a ‘scream’

Interestingly in the feedback to GPs ( the study took place in Germany) they were told  that ‘a diagnosis cannot be made on the basis of the screening score alone’ and there was a ‘recommendation for further assessment and treatment for any depressive disorders that might be present’. NHS Talking Therapies clinicians are not informed of the need for a thorough going assessment.  There is no diagnosis-informed care. The Service expects clinicians to  continue to work in the dark. Only a quarter of the sample received psychotherapy or an antidepressant.

Dr Mike Scott