Month: November 2017

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Evidence Base for CBT Depends On How You Focus The Camera

What NICE says about the efficacy of CBT has been taken as gospel, but Moriana et al (2017) have pointed out that what other similar bodies say is significantly different. The actions of practitioners are micro-managed by august bodies such as NICE (via IAPT), Division 12 (Clinical Psychology American Psychological Association, Cochrane and the Australian Psychological Society, an essentially top down process is in operation.  But which, if any should be the determinant?

Rather than arguing about which body has produced the best synthesis of outcome studies the focus should shift to bottom up, asking how does cbt fare in routine practice?

Tolin et al (2015) have suggested that a treatment should only be regarded as effective if there has been a randomised controlled trial of the intervention in routine practice using non-specialist therapists, further the researchers should be independent of those who originally developed the treatment.  This has been adopted by the American Psychological Association. An additional requirement should be that the ‘gold standard’ entry requirement for the trial, admission by a standardised diagnostic interview, should also be the primary outcome measure as assessed by independent blind assessors.  Only in this way can it be known whether the treatment makes a real world difference i.e it will be known that x% no longer suffer from the disorder at the end of treatment compared to y% in the control condition. Without these diagnostic strictures one ends up with the highly questionable conclusion of Pybis et al (2017) that cbt and counselling are equally effective. Tolin et al (2015) have suggested the external validity criteria have been fulfilled in the case of CBT for OCD, but when we look at other disorders such as trauma focussed cbt for PTSD it is doubtful that it clears such a high methodological bar, for example the supposed replication of Ehers et al  CBT for PTSD (2005) by Gillespie et al in Northern Ireland did not involve a standardised diagnostic interview as the primary outcome measure, further there were no independent assessors.

It may be that the struggles of practitioners to achieve performance targets are not so much to do with their deficiencies as inherent in the context within which they are working. Singling out ‘poor performers’ may be unjust in extremis. Pybis et al (2017) concluded that ‘half of all patients (IAPT clients) regardless of type of intervention (counselling or CBT) , did not show reliable improvement’, leaving aside whether the IAPT self-report mesasures they review are at all meaningful, are half the therapists going to be put in the dock?

Ehlers, A et al (2005) Cognitive therapy for PTSD development and evaluation. Behaviour Research and Therapy, 43, 413-431.

Gillespie, K et al (2002) Community based cognitive therapy in the treatment of PTSD following the Omagh bomb. Behaviour Research and Therapy, 40, 345-357.

Moriana, J.A et al (2017) Psychological treatments for mental disorders in adults: A review of the evidence of leading international organizations. Clinical Psychology Review, 54, 29-34

Pybis, J et al (2017) The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evdence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 17:215

Tolin, D.F et al (2015) Empirically supported treatment: recommendations for a new model. Clinical Psychology Science and Practice, 22, 317-338.

Dr Mike Scott

 

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‘I Have a Right to Know Whether Treatment Has Made A Real World Difference’

From a client’s point of view if they were considered ‘bad enough’, on the basis of a standardised diagnostic interview, to enter a controlled trial, the latter should also be the yardstick for judging whether their treatment was a success i.e they are ‘good enough’ not to be included in a further trial. Perhaps the researchers would like to explain to clients why there is an asymmetry between the assessment (standardised diagnostic interview) and outcome processes (the latter relying on self-report measures).  Arguably consent to treatment should only be given once the client feels this asymmetry has been properly explained! This is I think a matter for the National Institute of Health Research to consider when reviewing applicants for research funds, as a reviewer I have sometimes found submissions lacking this ‘real world’ feel.

 

Cuijpers et al meta analysis in 2016, [World Psychiatry, 15, 245-258 How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence] of 144 rcts for depression, panic disorder, generalised anxiety disorder and social anxiety disorder was restricted to studies that had used a standardised diagnostic interview for initial assessment, but the potency of the interventions were assessed only using psychometric tests. A standardised diagnostic interview is an independent reliable assessment, it is curious that outcome on this was not established and contrasted with the self-report data. It is not clear what proportion of the studies reviewed by Cuijpers reported on a re-administration of the standardised diagnostic interview. If a standardised diagnostic interview is the ‘gold standard’ for entry into an rct why is it relegated when it comes to assessing outcome. Is it that such an independent interview would be too high a bar for purported efficacious cbt treatments to clear or perhaps it is just cheaper to rely on self-report.

 

But the right to know whether treatment has made a real world difference  is not just a right to be exercised in the context of rcts, the right surely exists in routine practice. This right helps to ensure that the client is not just fodder for some numbers game. The realisation of this right forces a consideration about whether the customary sole self-report assessment and outcome measures are fit for purpose.

Dr Mike Scott

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CBT Researchers Have Abandoned Independent Blind Assesment – Beware of Findings

I have been looking in vain for the last time CBT researchers assessed outcome on the basis of independent blind assessment, which was a cornerstone of the initial randomised controlled trials of CBT.  Current CBT research is more about academic clinicians marketing their wares. Journals such as Behaviour Research and Therapy and Behavioural and Cognitive Psychotherapy and organisations such as BABCP and BPS are happily complicit in this. The message is give a subject a self-report measure to complete, it is less costly than expensive highly trained independent interviewers blinded to treatment, forget about the demand characteristics of a self-report measure ( a wish to please those who have provided a service) and don’t worry if the measure does not accurately reflect the construct under question. My psychiatric colleagues might be forgiven for saying that at least the trials of antidepressants have usually been double blinded, if since the millennium CBT studies have rarely managed to be single blinded, is it time the CBT-centric era ended? But purveyors of other psychotherapies have even more rarely bought into the importance of independent blind assessment.

The overall impact of inattention to independent blind assessment is that the case for pushing CBT is actually not as powerful as the prime movers in the field would have us believe, this may actually be a relief to struggling practitioners. For example Zhu et al (2014) [Shangai Arch Psychiatry, 26, 319-331 examined 12 randomised controlled trials of CBT for generalised anxiety disorder in which there was supposedly independent blind assessment  but in 6 of the 12 studies the main outcome measure was based on the results of a self-reported scale completed by the client (i.e outcome was not actually assessed by the blinded assessor) and concluded that the quality of the evidence supporting the conclusion that CBT was effective for GAD was poor. A meta-analysis of outcome studies  conducted by Cuijpers (2016) World Psychiatry, 15, 245-258 found that using criteria of the Cochrane risk of bias tool only 17% (24 of 144) rct’s of CBT for anxiety and depressive disorders were of high quality. Cuijper et al concluded that CBT ‘is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still
uncertain and should be considered with caution’. Only half the studies had blind assessors and it is not clear whether they were the determinants of outcome or a client completed self-report measure, the study needs further analysis. My impression is that the weakest of studies are those examining guided self-help, computer assisted CBT, (the step 2 interventions in IAPT) yet these interventions are most commonly offered.

Dr Mike Scott

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CBT’s Dominance Arose From A Medical Model Paradoxically Most Practitioners Disown It

CBT is heralded as the treatment of choice by NICE,  because it is based on randomised controlled trials of ‘effective’ disorder specific protocols, but most CBT practitioners have paroxsyms at the mere mention of a medical model! This makes it inevitable that there is  going to be a yawning gulf between treatment in the rct’s and in routine practice. In this context it simply is not credible that the generally positive  findings from research will be effectively translated. There is a pressing need to build a bridge between practitioners and those who were involved in high quality rct’s:

A way forward is to acknowledge that there is more than one Medical Model, Dominic Murphy [ The Medical Model and the Philosophy of Science  (2013) in The Oxford Handbook of Philosophy and Psychiatry] recommended the minimalist version of the model which asserts that  ‘…. mental illnesses are regularly co-occurring clusters of signs and symptoms that doubtless depend on physical processes but are not defined or classified in terms of those physical processes’. It is this version of the model that largely underpins the DSM criteria. The minimalist version is in fact quite different to the strong version of the model and rejection of this is not synonymous with rejection of the medical model – the strong version is in many ways a caricature. But caricatures are good for uniting people in what they are against and avoids the difficult question of what they are  for.

Dr Mike Scott

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Without A Written Aid To Remembering Session Content Little Chance Of Real World Change

Most client’s are highly anxious, the chances of them remembering session content accurately, much less applying it, are therefore slim. But review of therapy records usually provides no evidence of session summary or detailed specification of homework. At most therapists may write ‘activity scheduling’, ‘thought records’ or ‘continue exposure’. Compare this vaguenness with the specificity of a medical prescription “take ‘x’ 3 times a day after meals’.  I remember a client with Multiple Sclerosis who was in agony with his symptoms for a couple of weeks before it was discovered he had inadvertently been prescribed a sub-therapeutic dose of medication. The lack of specificity about CBT homework means that it cannot be easily corrected and in essence there is no accountability as there is in medicine. Below replace ‘students’ with ‘clients’:

If CBT is primarily educational then we have to teach properly. But training does not equip therapists to teach, even worse therapeutic interventions are often not modelled by tutors first!

Despite therapists endeavours clients lose out because of poor therapist training, psychological therapists often come off CBT courses less confident than when they began.

Dr Mike Scott

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IAPT and The Absence of Treatment Markers

IAPT purportedly offers NICE –indicated treatments for depression and anxiety at Steps 1-3.  But the NICE guidelines do not offer guidance on the treatment of specific phobias or adjustment disorder.   So that in practice Psychological Therapists fail to adequately distinguish between these excluded categories and the included ones such as PTSD, OCD etc.  The result is that there is a serious mismatch between disorder and treatment, for example I’ve just seen a person treated with 10 sessions of trauma focussed CBT, I knew him to have simply a specific phobia about driving and travelling as a passenger in a car and he was still suffering from just this after IAPT treatment. The treatment records referred to ‘likely PTSD’,   such statements are not only unreliable but dangerous. There is a need for a

In practice IAPT treatment is determined by therapists rules of thumb, such as ‘if the trauma was extreme and there are disturbing intrusions go for PTSD treatment’, ‘if there was prolonged abuse go for complex PTSD’, ‘ a high score on the Impact of Events Scale means PTSD is likely’,  but there is no scientific basis for such rules.  The NICE guidance makes no mention of treatment being determined by the therapists ‘formulation’, but many therapists are perfectly happy with this supposed magical insight into the way forward, which they see as a product of their clinical experience and acumen.  In practice lip service is paid to the NICE guidelines, for the most part therapists do their own thing, with perhaps a psychometric test such as the IES thrown in to appease management and a concern to use keywords like habituation, trauma focussed CBT and exposure. Training courses do not it seems help students critique the validity of the IAPT treatment approach.

Wither true accountability?

Dr Mike Scott

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Which Guide To Mental Health

‘Did the mental  health service that you used, give you the lifestyle that you wanted?’ , answers in a new ‘Which’ guide. At present consumers are entirely at the mercy of the manufacturer’s advertising.

The views of employer’s and GP’s have potentially a greater objectivity than that of the mental health service providers. The danger is that employers can by pass serious consideration of the matter, by reminding themselves that their primary objective is profit/productivity and that provided that they can be seen as making some gesture to health and wellbeing, ‘look no  further’. In a similar way GP’s can bypass central processing of objective outcomes with a rationale that they are fully extended performing their primary function of looking after the physical health of patients, ‘so long as I can off-load mental health patients at least for a time so much the better’.

There is a pressing need to ask questions nobody wants to hear. According to George Orwell, liberty is the freedom to ask such questions. How much liberty is there really in the mental health/medical sphere?

 

Dr Mike Scott

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Victims of Bombings Receive Face To Face Help, But Not For Mental Health

Can there be a more glaring illustration of the disparity between physical and mental health, when a victim of the Manchester bombing is subjected to a series of telephone conversations (IAPT) about her distress and it takes 6 months for a face to face consultation to take place. The public are rightly alarmed at the hours it took some of the Emergency services to be able to offer medical help, but it is as nothing compared to the time taken to address the person’s mental health. But there is no outcry about this from either GP’s, MP’s or mental health staff, there is tacit approval of the disparity.

Recently it was the centenary of the 3rd Battle of Ypres, in which my grandfather was killed on    October 28th 22017. To my knowledge nobody ever  suggested that the ‘shell shocked’ from the conflict should be catered for by telephone.

Rather there were dedicated Hospitals like Craiglockhart in Edinburgh and Moss Side in Liverpool and such Hospitals continued functioning after the 2nd World War. Being face to face with victims is surely the least we can offer.

A thought for Remembrance Sunday ‘A century on, are we really any more respectful?’

Dr Mike Scott

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Psychological First Aid for Business, GP’s and others

Psychological First Aid https://files.acrobat.com/a/preview/e63fef15-64b0-4ccd-9766-64ae469ba067 mirrors CBT evidence based treatment protocols for specific disorders and the ultimate target is recovery from that disorder. It went down well when I introduced it to GP’s  on Merseyside in meetings spanning 18 months just after the millenium. I also introduced similar materials to ICI (now Ineos) managers in day long training sessions over a couple of years. Given that GP’s are often the first port of call with mental health problems and  and that mental health sees 300,000 people leave their job each year [‘Thriving at Work’ (2017) report by Paul Farmer], the material seems particularly opportune.

Here is an example from the panic disorder section:

  1. First assess.
  2. Conceptualise: a) panic attacks fuelled by catastrophic interpretation of unusual but not abnormal bodily sensations. View panic attacks as a ‘Big Dipper Ride’, ascending the symptoms get worse, tempting to get off near the top, but if you don’t do anything comes down the other side within ten minutes. b) use of ‘safety behaviours’ that prevent learning that nothing terrible would happen if they did nothing at all in the panic situation.
  3. Treatment: a) review of last bad panic attack. Identification of characteristic misinterpretations e.g. ‘I am going to faint…have a heart attack….make a show of myself’ b) challenging misinterpretations e.g almost impossible to faint with increase in blood pressure c) giving up the ‘safety behaviours’ e.g. escape, deep breaths, sitting down d) in session hyperventilation challenge (provided no heart problems) to help patient ‘know with their guts not just their head’ that panic symptoms are not dangerous e) daring to gradually expose to avoided situations

Psychological First Aid needs updating for the DSM-5 criteria, I developed it in the DSM IV era.

Mental Health First Aid targets ‘stress’ or ‘mental wellbeing’. This ‘disorder’ without boundaries approach, makes the outcomes of intervention always ‘fuzzy’ [ see Towards a Mental Health System that Works Scott (2017) London: Routledge]. But unfortunately ‘stress’/ mental wellbeing’ and their supposed antidotes are a more marketable commodity. Much supposed psychological first aid should be more appropriately labelled mental health first aid because of its’ fuzzy focus. Nevertheless Businesses and Pastoral Workers in Churches can feel more comfortable with Mental Health First Aid because the ‘stress/mental wellbeing’ emphasis means they are not straying  out of their comfort zone into what is perceived as more medical. By contrast psychological first aid has a clear recovery from disorder focus. Pragmatically Mental Health First Aid can be a good starting point but it is unlikely to lead very far.

Coming Soon ‘Improving Mental health via GP’s and Business’ will be the topic of a further post.

Dr Mike Scott

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Soothing, Improvement and Recovery – vested interests in muddying the waters

The list of those with a vested interest in consciously or non-consciously muddying the waters of mental health outcomes (fake news) is staggering and include Charities, IAPT and Independent Practitioners. Consumers, Businesses and Clinical Commissioning Groups beware!

Most client’s of mental health services are glad of the help proferred, they find them ‘soothing’ but this is a far cry from recovery from identifiable disorder. I’ve just put ‘Voltarol’ on my sprained ankle it is soothing, less of a burning sensation, but it doesn’t actually speed up the rate of recovery or increase gait velocity (improvement). Recovery would be back to what I was before I crumpled getting out of the taxi. Blurring the distinction between soothing, improvement and recovery is good for the marketing of a product, analgesic/wares of a mental health service provider, but the ‘injured’ are not well served and ill equipped to protest. As a consequence the juggernaut of existing services continues. There is a pressing need to go beyond expressions of client satisfaction.

 

E-cigarettes look like a good way of helping people giving up smoking cigarettes, but the long term effects are unknown, a Parliamentary Committee has just been appointed to look at the matter. There is an understandable wariness about wide dissemination in the abscence of evidence.  But there is no such critical awareness when it comes to mental health.

 

Dr Mike Scott