Diaguessnosis and Agnosis

Diaguessnosis is a condition that often afflicts psychiatrists, whilst agnosis is commonly found amongst psychological therapists, but sometimes they coexist. They have in common that the person doesn’t know who or what they are dealing with. It is debateable whether they are in fact different conditions, and a transdiagnostic approach might suggest the common feature is a deficit in understanding the contribution of a standardised reliable diagnosis.

I first heard the term diagussnosis used a few weeks ago by Stephen Fry on Radio 4 when he was interviewing a comedienne and fellow mental health sufferer. She said that she had been given so many labels for her ?bipolar disorder that  she thought that professionals engaged in diaguessnosis rather than diagnosis.

Shortly afterwards I saw a lady, Ms A who was injured and scarred at work, she had a telephone IAPT interview and was told she needed CBT. But when a face to face appointment came to pass it was decided she needed counselling. Ms A had 4 counselling sessions, missed a session and could not be bothered to ring to make the missed appointment, she was frustrated that the focus had been on different family members reactions to her scarring.  Further she was offered no diagnosis. This illustrated to me that generally the psychological practitioners maintain a rigid agnosticism about diagnosis with occasional forays into diaguessnosis.

I concluded that she met DSM-5 criteria for a chronic adjustment disorder, this led to a profitable discussion of the better and worse ways of playing her difficulties.

Dr Mike Scott

IAPT Behind Closed Doors – Supervision

As I mentioned in my first post last week I was working in IAPT in Bury in 2015. Clinical Supervision was delivered in the group setting and was not compulsory to attend.  Often the supervision had to be postponed for several weeks if the supervisor was either not available or was on holiday or had casework at a higher step which took precedence over the needs of the group.  Personal supervision was a similarly structured affair, with pressure and time constraints eating into very short sessions.

 

It was incumbent upon the supervisee to ensure that “risky cases” were discussed in a timely manner, since it was the supervisee’s responsibility to “raise the alarm”.  In many cases, the supervisee was not aware that any alarm needed to be raised, since they were inexperienced with either the identification or managing of risk with regard to mental health patients.  Please do not take this as a criticism of my colleagues; it is a criticism of the system’s failure to provide them with the knowledge they needed to understand the risks.

Anonymity protected Dr Mike Scott

 

National Audit Office Listening Over Critique of IAPT

On September 21st I received an e-mail response from the National Audit Office which said: ‘The clarification you have provided regarding the usefulness of the tests used to assess patients, and the fact that, in IAPT, a link is not consistently being made between diagnosis and treatment, is very useful in helping us to understand more about the points you previously raised with us about recovery rates’

See earlier post on National Audit Office, extract below:

  1. In 2011 the Secretary for State for Health, Andrew Lansley MP and the Minister of State for Care Services, Paul Burstow, MP said stated ‘we are clear that building services around the outcomes which matter to people is the very essence of personalisation’, [Transparency in outcomes a framework for quality in adult social care (2011) Department of Health] so it cannot be for IAPT to choose the yardstick by which it evaluates itself. People seek physical/ psychological treatment in the hope that they will no longer be suffering from an identified disorder by the end of treatment, this is not a matter of clinical judgement, the yardstick is primarily patient driven. If an agency supplies data that does not allow a determination of whether this transparent yardstick is met, then they are remiss. In this connection IAPT ought to be brought to task by the National Audit Office.
  1. Psychometric tests of themselves do not point to any particular NICE approved treatment, if they had this power NICE would have said so, and they did not. Tests are like road signs blowing in the wind, they can only give direction if anchored in a reliable diagnosis. Inappropriate treatment including a failure to treat ( false positives and false negatives) is inevitably ubiquitous when treatment is not moored to diagnosis. Whilst it is the case that some cut offs are better than others at identifying a ‘case’ of disorder, the  cut offs themselves vary from sample to sample depending on the prevalence of the disorder and are at best relevant to one disorder – in practise people usually have more than one disorder. IAPT essentially has two instruments the PHQ-9 and GAD-7 which they purport measure anything of significance, no medical/scientific professional would claim such powers for just two instruments.

It will be very interesting to see the final report of National Audit Office.

 

Dr Mike Scott

The Scientist Practitioner Delusion?

‘Surviving this week as a therapist, trumps being a scientist practitioner’, there were gasps of surprise and murmurs of agreement, as I said this at a recent IAPT Workshop I was giving. I mused out loud about who had the space to collect data on a client, write it up and present it for publication. No contrary voices were raised despite the scientist practitioner model being an article of faith on CBT training courses.  Students should be invited to write an essay on ‘The Scientist Practitioner Delusion?’

The engineering narrative is a better descriptor for the overwhelming majority of CBT practitoners, rather than being invited to ape academic clinicians, for whom the scientist practitioner model is probably the best descriptor. But the concerns of the true ‘scientist practitioners’ are very different to the engineers, yet they dominate service provision, conferences etc. I remember Paul Salkovskis, Current President of BABCP, once saying to me that the membership speaks with a small voice, but this isn’t surprising, if most are powerless, stressed engineers. I debated with Paul at an Annual Conference a few years ago but he didn’t see a problem with scientist practitioner as a universal descriptor and was dismissive of the idea of engineers.

But whilst it was scientists who developed the first computers, vis a vis Alan Turing at Bletchley Park in the war years (The Imitation Game is a brilliant watch!), it was engineers who developed the personal computer that we all know. Dissemination needs a creative dialogue between scientists (scientist practitioners) and engineers.

Dr Mike Scott

 

IAPT Behind Closed Doors – Like Jumping Into a Cold Plunge!

Throughout my time in IAPT in Lancashire (I had 2 separate occasions working there) I was employed as a PWP and was taken on to “get the waiting list down” in terms of the volume of cases which had been referred, predominantly by GPs.  I am an Agency Nurse who has worked in many roles across the country, but this was my first role as a PWP.  The first thing that occurred to me was how little awareness the PWPs had about mental health and how people were allocated to various parts of the Service.  There seemed to be an emphasis on “clearing the lists” because lengthy lists would not be favourably looked upon by the commissioners and may affect the funding already provided for the Service, but also future funding.

My PWP colleagues were very new in practice and many of them had only recently qualified and as I have previously outlined, they had little or no experience around mental health.  I was initially asked to “look after them”, since it was very common when working over the telephone to find a suicidal patient on the other end and have a colleague not know what to do.  I was often asked to sit in the room with my colleague and to support through the assessment, as I was in a position to know when to call an ambulance or to get further assistance, where often they did not.  Many patients who were referred to IAPT services, especially at step 2, were referred wholly inappropriately.  My colleagues were subjected to a degree of unnecessary distress and pressure by these inappropriate referrals, as they knew that they were inappropriate, but were expected to treat them in any case.  In cases of face to face referrals, the situation was often worse, since inexperienced colleagues very often were asked to give 6 or 8 sessions to someone who had been referred who was actively psychotic, but whom the PWP did not recognise as being psychotic.  The result of this at best, was that the patient never got better and at worst, may have harmed either themselves or another person.  There were also safety issues in terms of lone working in buildings which were vacated at 5 pm but in which it was expected that workers would have to receive patients because the Service was open until 7 pm.

Anonymity protected – Dr Mike Scott

Stressed Because You Are Asked To Do What Is Not Possible?

‘I am not IAPT’s employee of the month’, ‘For all to view, I am nowhere near the top of the league table for recovery rates’ – just two of the voices of stressed therapists that I have heard in recent months. Unfortunately challenging the Organisational zeitgeist that generates such demoralisation is likely to be seen as a further sign of ‘inadequacy’.

But the American Psychological Association, Clinical Psychology Division, have refined the criteria for an evidence based treatment in such a way, that it could add ‘grist to the mill’ of those who wish to take issue with what they are being asked to do. The new criteria contain the added requirement that there must be evidence of effectiveness in at least one study, in a nonresearch setting using non-academic therapists and also evidence of effectiveness on functional impairment and not just symptom improvement. [The new requirement is based on the Tolin et al (2015) paper Empirically supported treatment: recommendations for a new model. Clinical Psychology Science and Practice, 22, 317-338]. With this added criteria many of the CBT treatments for health anxiety, psychosis and long term physical health problems and computerised cbt would not clear the raised bar for evidence based treatment. Even an accepted treatment such as exposure and response prevention for OCD has just one routine practice study and this was without a control condition, Tolin still strongly recommended the treatment but suggested that there did need to be further evidence.

Pencil in ‘and CBT’ next to ‘antibiotics’ in the poster below and display in Staff and ? Waiting Rooms for the coming Winter

 

Often times a client has considerable comorbidity, I have just seen a person with ptsd, depression, binge eating disorder, panic disorder with mild agoraphobic avoidance and ?body dysmorphic disorder following an rta 4 years ago. No randomised controlled trial has ever been conducted on a population with such extensive comorbidity. There has to be proper acknowledgement of the challenges such a client presents for a therapist, it is insufficient to label a client simply as ‘complex’ because this can easily be seen by the powers that be as a ‘cop out’, the only true defence is a comprehensive reliable assessment.

The bottom line may be to challenge, where you can, whether there is evidence of effectiveness for this specific type of client in the routine context in which you are working – a reality check.

 

Dr Mike Scott

The Need To Tailor Group CBT To Make A Socially Significant Difference

Given the scarcity of therapeutic resources Group CBT is an attractive option.  But to make a real world, socially significant difference in a client’s life a group intervention has to be tailored to each individual. The resources section of this forum contain free content materials for depression and the anxiety groups. Client’s want a real world change, to be free of whatever disorder/problem led them into treatment, not a change on a psychometric test.

Over the past year I’ve given about half a dozen Workshops titled ‘Delivering Group CBT’ to IAPT ( really enjoyed the last one on September 6th to North East Essex IAPT, great group!) and non-IAPT audiences, two points struck me a) most of the audience have been involved in groupwork, for a wide range of problems from low self-esteem to OCD, though most have been for anxiety and depression and b)  the groups that have been run have been more like classes than groups, in that there has been no tailoring of homework assignments in the way one would in individual therapy.  Without such tailoring it is unlikely that there will be any transfer of learning from the ‘group’ setting to the  client’s social context. Clients may express satisfaction with attending a ‘class’ with comments like ‘interesting’ and ‘useful’ but there is no independent evidence that they make a lasting real world difference. I have found it interesting how many therapists are harking for real world observable change in client’s lives and are unhappy with the psychometric test yardstick.

The need to tailor homework places a limit on the number of people that can be treated in a group, as opposed to the number of people that can be ‘taught in a ‘group’. I will return to the issue of tailoring in groups in a later post.

Dr Mike Scott

Fatal Consequences of Missed Disorder

On Tuesday last BBC News at Ten reported a Serious case review of the murder of 2 year old Ayeeshia-Jayne Smith at the hands of her mother, which concluded that social workers failure to identify significant psychological disorder played a pivotal role in the child’s death. Would CBT practitioners have been any better at identifying such disorder? It is not an academic question, the mother or her then partner could have come a CBT practitioners way as a referral from Social Services because of ‘issues with anger’.

The social workers had focussed largely on the supposedly supportive relationship between the mother and child, but there were concerns, a Risk Assessment meeting was held the day before the murder! But had they screened the parents for say borderline personality disorder and if positive done a more detailed examination, using reliable diagnostic criteria, their approach would have arguably been more balanced, resulting in earlier action. The diffiiculty is that for social workers and CBT practitioners staying in their comfort/ ideological zone of relationships is easier.

Existing risk assessment procedures, represent an expert consensus and to my knowledge there is no empirical evidence that they predict outcome. Agencies promote them but it is more a matter of them covering their back.

The 7 Minute Interview contains the following Screen for BPD and its’ psychometric prpoerties were discussed in an earlier post.

11. Yes No Don’t know
Do you have a lot of sudden changes of mood, usually lasting for no more than a few hours?
Do you often have temper outbursts or get so angry you lose control?
Is this something with which you would like help?

Do You Suffer From Formulation Nausea?

Formulation Nausea (FN) is induced by a bewildering array of arrows, resulting in disorientation. It is maintained by exaggerating the idiosyncracy of a client’s difficulties. Training courses may serve as vulnerability factors with Organisational factors e.g supervision acting as an immediate preciptant. Sufferers from FN are often stressed in silence, to reveal it to course leaders, supervisors may be taken as a sign of ‘weakness’.

The antidote is ‘case formulation’ as opposed to ‘formulation’. A case formulation is a specific example of the cognitive model of the disorder. Without  reliably defining what the person is a ‘case/s’ of the 5 P’s above lead nowhere and is likely to generate a 6th P! To overcome FN regular usage of ‘case’ formulation for at least 3 months is necessary for full recovery

 

Brief Assessments Are The Norm And Invariably Wrong

Work on the assumption that the assessments of others are wrong because they have probably operated on some idiosyncratic  rule of thumb to save time. My cynicism about the assessments of colleagues was heightened recently, two years ago I saw a lady who had a phobia about driving and travelling as a passenger in a car and needed CBT. I’ve just discovered that her GP has decided she has PTSD and she is consequently, about to undergo 12 sessions of CBT.

In a previous post I talked about the importance of ‘Watching and Waiting’ but if this is done without the appropriate measuring instrument, a standardised reliable diagnostic interview all is in vain. My suspicion is that the GP, like many clinicians has in mind a ‘cardinal symptom’ of PTSD such as flashbacks and/or nightmares and uses this rule of thumb (heuristic) to determine treatment. The advantage of heuristics is that they are quick, the disadvantage is that they are usually wrong

see Daniel Kahneman’s book, resulting in a waste of resources and the client likely defaulting from CBT

Dr Mike Scott.