Jeremy Hunt Conned on Mental Health

Today Health Secretary, Jeremy Hunt claimed ‘ we have a world-beating service for depression and the anxiety disorders that other countries are considering adopting, particularly Sweden’ [BBC One Andrew Marr Show]  but  he appears not to know that the IAPT service he cites has never been subjected to independent scrutiny and he is victim to its’ excellent marketing.  From my own work as an Expert Witness to the Court I have found a recovery rate of just 10%, ‘IAPT the Need for Radical Reform’ (In submission) which also contains testimonies of those who have gone through the system, work on a smaller sample (n=65) is summarised in ‘Towards a Mental Health System that Works’ (2017) Routledge.

Tip of Iceberg Recover

 

I presented my findings ‘Reality Checking Psychological Services’, https://files.acrobat.com/a/preview/93ed8696-b12e-44b0-a2bd-3f0646f62052 on the smaller sample at EABCT Conference in Stockholm on  September 1st 2016. Internationally countries have not rushed to adopt the IAPT approach and are much more circumspect about the IAPT results than Mr Hunt. Unfortunately in politics the bar for ‘evidence’ is set low, with evidence outstripped by enthusiasm. On October 10th 2017 Mr Hunt announced £15 million to train 1 million people in Mental Health First Aid with 1 trained member of staff in every secondary school by 2020.  He argued plausibly on You Tube that half of emotional problems are there before age 14 and if there is some early input problems could be prevented. Nice idea, but the evidence on this is lacking, arguably the monies might be better spent on what we know does work, CBT treatment with fidelity to an evidence based protocol.  Whether or not,  he anticipated the training would be online with volunteers who could thereby become less stressed, more ‘resilient’ and help others!

 

Dr Mike Scott

 

Government Commits to Mental Health Yet Has Presided Over Increase In Mental Health Staff Abscences

Today the Prime Minister, Mrs May committed the NHS and Civil Service  to protecting the mental health of its’ staff. But a BBC freedom of information request (September 22nd 2017)  has revealed the number of NHS mental health staff who have had to take long-term leave of a month or more rose by 22% in the past 5 years. On the same day the Department of Health announced ‘we are transforming mental health care for everyone in this country, including NHS employees’.

If this is transformation maybe I should enter a home for the bemused and befuddled.

 

Dr Mike Scott

IAPT Behind Closed Doors – Compulsion and Inadequate Training

There is certainly a high degree of compulsion associated with attending IAPT services, with people being told that if they do not attend IAPT interventions then their benefits may be stopped.  This seems counter to the idea of patients’ voluntary engagement, with the notion of ‘opt in’ being the sole indicator of patient willingness for participation.  My personal opinion is that there is no real choice and no other type of treatment offered if they refuse.  IAPT is a service where clear up target rates appear to be more important than the quality of the treatment and ‘one size’ most certainly does not fit all.

I am of the opinion that my colleagues who are Psychological Wellbeing Practitioners would benefit greatly from having knowledge and experience of mental health since my experience was that most of the higher level CBT Practitioners were and are mental health nurses by discipline.  Whilst I am critical of IAPT, I am also critical of mental health services and for this reason I am currently aiming to change direction and to re-train in the area of Psychology.

Anonymity protected Dr Mike Scott

‘What Proportion of People With This, Recover With This Treatment?’

If you are undergoing a medical procedure this is a pressing question. Curiously, psychological therapists create an aura in which clients are disuaded from asking this question, with responses that amount to ‘we don’t like to use labels, just complete questionnaires to see how you go’, masking a wholesale distrust of the medical model.  Clients are intimidated from voicing their basic concerns, when asked whether they were given a diagnosis usually the response is ‘no’ or  “they said I had ‘x’ symptoms” either way they do not feel on solid ground. Invalidating a person/client’s nascent question whether it be the ‘meaning of life’ or the likelihood of treatment that makes a socially significant difference is direspectful.

IAPT obscures the answering of this question by a sleight of hand, using changes on 2 psychometric tests to indicate recovery, with no blind, independent assessment of outcome and no use of a ‘gold standard’ diagnostic interview. But this obscurantism is not confined to Government funded psychological therapy services, in private practice there is an equal failure of diagnostic accuracy and comprehensive evaluation at both initial assessment and at the end of treatment. However at least in the private sector one can search out a therapist who can deliver, no such option is available within IAPT.

 

Dr Mike Scott

IAPT Behind Closed Doors – The Need for Listening and Flexibility

At Bury I had occasion to treat an older gentleman who lived alone and had no family locally.  He also had received step 3 CBT work on at least 2 occasions previously and he had been re  – referred to me at step 2.  This gentleman had a stammer and a thick Scottish accent and did not speak often, as he was anxious and low in mood since he was embarrassed that people did not understand him.  My brief was to “get him out and mixing with other people”.  I discovered that he did not go out very often and had been interested in computers in the past, going on a Government scheme to learn more, until the funding was stopped.  He showed me his phone, which was his “lifeline” and stated that he had got it a few years ago, but that it was quite expensive to run.  He told me about his female companion, who was unfortunately ill and who used to accompany him to the Library when she had been well, as he did not cope well in public.  I began thinking about his phone and his love of computers

 

Over the first 3 sessions, I understood that he was not a particularly social person, could not afford a computer of his own, but was able to consider that he may get a better phone and a better deal than the one he had.  I did not see this gentleman for 2 weeks, as he sent word that he had a cold, but by the 4th session, he had been on his own to a local branch of Carphone Warehouse and had negotiated a deal on a new phone which had a full screen internet access and which was affordable.  He recovered to the extent that not only was he able to go out alone to places now, he was going to coffee shops and public places accessing the free internet there to talk to his many friends over the internet and was no longer a person who avoided people, because he could now make himself understood.  I remember his words to me at session 5 when I discharged him, telling me, “the world is mine!” and about how his female friend was also recovering with his help.  He explained that she had always had to help him to go shopping and to explain things for him, but that now he had more confidence, he was doing things for her for a change.  The key for him was being understood and improving his life through his talents and his love of computers and gadgetry.  Everything else followed on from this.

One of my better experiences at Bury was with a lady who was referred onto my caseload because she had long – standing issues with physical injury sustained at work and who was in the process of claiming compensation from her employer for her injury.  She was newly married and had become extremely anxious and suffered with co-morbid depression.  She had been seen and treated with CBT at step 3 twice before and was also referred to Mindfulness Relaxation.  She was referred to me at step 2 because she had “failed to be able to use mindfulness to relax and was still anxious and suffering from depression”.  I had 6 sessions with this lady and she missed one because of needing to go to court to represent herself for her case, but this was tagged on the end for review.  I adapted an approach for this lady’s needs which did not include mindfulness and helped her to see her new situation not so much in terms of what she could no longer do, but with an emphasis on new opportunities.

This demonstrated that current IAPT approaches are markedly inflexible and there is little or no notion of adaptation to suit individual needs and also, too much emphasis on “getting the list down”.

 

Anonymity protected Dr Mike Scott

Mis-selling of the Cognitive Therapy Rating Scale

If your performance has been evaluated using the cognitive therapy rating scale (or the revised version) you may have a claim for ‘damages’. Curiously the cognitive therapy rating scale has a shaky foundation:

  1. The CTRS has only been evaluated in a sample of depressed clients undergoing cognitive therapy [Shaw et al (1999)] , therapists scores on this did not  predict outcome on self-report measures the Beck Depression Inventory or the SCL-90 (a more general measure of psychological  distress) however it did predict outcome on the clinician administered Hamilton Depression Scale predicting just 19% of the variance in outcome, but it was the structure parts of the scale (setting of an agenda, pacing, homework) that accounted for this 19% not items measuring socratic dialogue etc. The authors concluded: ‘The results are, however, not as strong or consistent as expected’
  2. There is no evidence that the CTRS is applicable to disorders other than depression. Some aspects of the CTRS such as socratic dialogue may be particularly inappropriate with some clients e.g OCD and PTSD sufferers.
  3. The CTRS does not make it clear that the clinician cannot have set an appropriate agenda without reliably determining what the person is suffering from.
  4. In practice raters appear to pay more attention to the socratic dialogue item as opposed to interpersonal effectivenes (e.g non-verbal behaviour). There is a poor intra class correlation of the order 0.1, ratings of least competent therapists are more in agreement with those of supervisors than the more competent therapists! [McManus et al (2012)]
  5. The Hamilton Scale used in the Shaw et al (1999) study was developed before the development of DSM criteria and it is questionable about whether any correlation would be found between DSM diagnostic status and score on the CTRS for depression or indeed any disorder.

 

Dr Mike Scott

‘We’ll Spin the IAPT Wheel To See What You Need’

Maybe the IAPT wheel will stop at counselling, or perhaps low intensity CBT or maybe  high intensity CBT! I have just  had a client who was within 6 weeks of a road traffic accident given an IAPT telephone assessment and deemed in need of low intensity CBT, but didn’t attend the scheduled treatment appointment and therefore discharged. 14 weeks post rta  he underwent a further telephone assessment and was now deemed in need of high intensity CBT, unsurprisingly he DNA’d the first treatment appointment.      The GP was provided with no explanation of the rationale followed by IAPT nor was he furnished with any psychometric test data. Accountability?

It is difficult to see the logic of IAPT’s position, other than to be seen to offer a speedy service,  it could be argued that some distress post rta is normal and in the interests of ‘saving normal’ (and resources) waiting and seeing a little longer would have been helpful . Perhaps a case for counselling could be made but on what basis?

 

Dr Mike Scott

IAPT Behind Closed Doors – Falsifying Quality Control Data

My experience is that at least one person was found to have massaged the figures to reflect a greater recovery rate and consequent discharge.  This was only discovered following a particularly high level of re-referrals for ex-patients and subsequent complaints.

With regard to the PHQ 9 and GAD 7 scoring system, I feel that this could be open to abuse.  This may be because workers are under great pressure to perform and elicit results.  I believe this to have taken place as a consequence of almost overwhelming pressure to discharge referrals.  With more discharges came more referrals and there was never any acknowledgement of best practice or learning lessons appropriately.  I understood also that PHQ 9 and GAD 7 only had pertinence for those suffering from mild to moderate mental health conditions.  I had to use other tests for those persons who had suffered past trauma and more severe mental illness which I myself as a practitioner “filtered out” as a consequence of them being incorrectly referred to step 2 services.

Anonymity protected – Dr Mike Scott

Post Trauma Mapping – circumventing difficulties with trauma focussed cbt

From an evolutionary perspective the problem with PTSD is not so much the traumatic memory but that the latter furnishes a maladaptive map, as if the sufferer is operating in a ‘war zone’.  This suggests a different treatment focus to the often resisted trauma focussed CBT.  The goal of treatment is to construct an adaptive map, this involves ‘scouting’ to ascertain where if anywhere the ‘real and present dangers’ are.  PTSD sufferers are often operating like Tony Blair on the ‘dodgy dossier’, if the weapons of mass destruction are not found in one place there is a rush to somewhere else thinking ‘they must be here’.

For clients resistant to trauma focussed CBT (TFCBT), post trauma mapping readily enhances the therapeutic alliance. Alliance problems are a bigger problem in delivering trauma focussed cbt in routine practice than have ever been acknowledged in randomised controlled trials, resulting in therapists feeling deskilled. Steve Stradling and I found that in routine practice only just over half of clients comply, even loosely defined, with a trauma focussed CBT [ Journal of Traumatic Stress (1997)].  There is a gap between what the scientist practitioners in the randomised controlled trials find and what the routine clinician/ ‘engineer’ finds in routine practice. Such mapping can be insufficient to resolve the PTSD but in passing the person becomes so acquainted with talking about the trauma that shifting from the ‘shallow end’ to exercising in the ‘deep end’, trauma focussed CBT is seemless.

From an evolutionary perspective the only function of memory is to to help us better anticipate future events, there is no value in memory per se. It may transpire that trauma focussed CBT is not actually essential for recovery from PTSD, certainly we do know that TFCBT is not necessary and is often experienced as ‘toxic’ for those traumatised but not suffering from PTSD e.g simple phobia, depression. Making it very important to carefully delineate the psychological sequelae of trauma.

Dr Mike Scott

Telephone First Consultations Fail

IAPT is synonymous with telephone first consultations, but the first independent study of this intended cost saving device, with GP’s, has shown it fails to deliver. An editorial in this week’s British Medical Journal on the Newbould et al study* (2017) states:

‘ Telephone first systems alone will not solve the perennial problem of ensuring timely, safe, and equitable access….It is also yet another reminder of the importance of independent evaluation of initiatives before investment in widespread implementation’

Instead of piloting and having an independent evaluation, IAPT has ploughed on regardless. Accountability is a major issue for IAPT, it positions itself between primary  and secondary care but is accountable to neither. It claims comprehensive data collection on almost all its clients. Yet in the authors examination of 90 cases (In preparation) that went through IAPT, for clients having two or more treatment sessions, before and end of treatment psychometric test data was given to GPs in less than half of cases. One quarter of cases did not clear the first hurdle of either ringing IAPT for a telephone assessment or IAPT being unable to contact the person. Whilst 13.3% ‘attended’ only the initial assessment. Thus IAPT is failing to engage just less than 4 out of 10 clients.

 

In GP practices with telephone first consultation the proportion of patients who would recommend their practice to friends fell. There was also a reported increase in emergency admissions associated with telephone first systems.

Clinical Commissioning Groups should insist on IAPT reforming itself, by dropping telephone first consultations.

* Newbould et al (2017 Evaluation of telephone first approach to demand management in English general practice: observational study. BMJ: 358:j4187

Dr Mike Scott