A Country called IAPT

Imagine you lived in a country where there was a pharmacy and a GP in every town but few hospitals. The pharmacy and GP’s services were widely advertised, encouraging all the unwell, or those who had not really thought of their symptoms before as illnesses to come in, get checked out and get treatment. The government set targets that a certain percentage of the population must be treated by the pharmacy and GP each year – if that target was not met the commissioners would be castigated by NHS England and an expensive tender process would be instigated, to bring “healthy competition“ to the market.

What if a GP and pharmacy were successful in advertising for all the patients and people turned up in their hundreds per month? You realise that you have not got enough supplies and enough staff to treat them all, so you “innovate” new methods, such as getting 12 patients at a time into the room and talking to them about what might be wrong rather than having time to check their individual symptoms. People with symptoms of diabetes were taught about diabetes, if the symptoms were there for another reason and didn’t resolve– what then? Maybe send them on another course and see if that sorted them out, maybe some internet self-help on diet or lifestyle would do – or, maybe they need to be checked out at hospital…..oh….there is no hospital, there was no money to concurrently expand the hospital, in fact, commissioners had saved money on the quiet by closing the hospital because there are no government targets for treating those outside of the GP and pharmacy. There are just a few hospitals further away with not enough capacity to see any more people whose piles may actually be bowel cancer or whose aches and pains are actually a degenerative rheumatoid arthritis.

As a patient who needed more than the GP and pharmacy can offer, you are confused and sad and angry -the GP and pharmacy advertised all over town saying – come and see us if you have these symptoms, but then you are told that there is nowhere to go if physio doesn’t fix that carpal tunnel and you need an operation, nowhere to go for the intravenous antibiotics for your severe infection where the standard course is not enough.

Imagine being a staff member at the pharmacy or GP – wanting to care for people and help them but having no time, having to break the bad news that, yes, there are recognised treatments for what you have but only at hospitals and we don’t have one of them, there is a private one but if you can’t pay you will go unwell and untreated. Might it seem to you that you need more staff to at least try and better help with the supplies that you do have? Oh, you discover that, although the government set guidelines for numbers to be seen, wait list times and recovery rates they set no guidelines for staff numbers and experience. So the commissioners have no basis to give you more budget for more staff and tell you rather to get on with the job or you will lose the service to another provider who magically can get the job done. Might you become stressed, depressed and less able to do your job?

This country is IAPT country. The country that demanded that its services for mild to moderate mental health conditions be built, with high targets to meet, with no proper staffing guidelines. The country that forgot to consider that expanding a mild to moderate service would attract the full spectrum of mental ill health. The country that once did the maths for how many therapists would be needed on the back of an envelope and then lost the envelope.

The country that forgot that not expanding but actually cutting your services for the more unwell would breed the cruelty of unattainable promises to the unwell, staff exhaustion and a desperation that leads to cooking the books to show that targets are met rather than standing up and saying that the Emperor of this country who proclaims that IAPT data is sound and targets are met has no clothes on.

A New Year Resolution – Take a First Step to Evidence Based Assessment

It is likely that for most agencies 80% of the work is in relation to a few disorders, (Pareto’s Law of the ‘Vital Few’) so developing an expertise  at identifying these accurately represents a good investment of time and effort.        First of all it is necessary to accurately audit what is coming in through you agency, this could involve using a screen for the 10 most common disorders, the First Step Questionnaire Revised ( available freely on this blog) and then  ask the further diagnostic questions in Simply Effective CBT  [ Scott (2009)] for any positive screen.  Knowing say the 4 commonest disorders dealt with by your agency it would be comparitively easy to cascade training for the accurate identification of these to front line staff, who have perhaps little training.   At a later date training can be given in say the next 4 most common disorders  and  so on so ultimately there is a comprehensive assessment.  Such rigorous assessment is also the best way of monitoring outcome.

Questionnaires completed by the client are subject to demand characteristics, clients wanting to please the therapist or convince themselves that they haven’t wasted time in attending therapy. Administration of weekly psychometric tests are particularly suspect, as clients can remember their scoring and show reductions which can be mistaken for real world differences.

 

Dr Mike Scott

Gifting Evidence Based Assessment

Evidence based assessment (EBA) is like unwrapping a Christmas present, the first layer is ‘What are we dealing  with (prediction)?, the next what are the options for use, ‘what can we do about it (prescription)? the core is whether the present has made a real world difference ‘ how will we know if we are accomplishing our goals (process)?

 

The three phase approach to EBA, prediction, prescription and process is described (minus the Christmas present!) in December’s Clinical Psychology Science and Practice by Youngstrom et al with an accompanying commentary (including the questions above) by Steven D Hollon.   Youngstrom et al suggest screening for the 10 disorders that most likely comprise 80% of your workload. This can be achieved using the First Step questionnaire from Simply Effective CBT, Scott (2009) London: Routledge an updated free version for 10 disorders is on this blog. Then using a standardised semi-structured interview for positive screens to reliably identify disorders.  Knowing the disorder/s it is possible to predict what is likely to be the best treatment, and prescribe appropriate treatment targets and matching strategies.  Assessment is not just a front end process, assessing whether there has been appropriate process can only be gauged at the end when the assessment is repeated to determine whether the client has got their life back.

 

 

 

In practice many therapists paddle their own canoe, if they stop long enough to really listen they would find that despite the client’s politeness, oftentimes scoring a psychometric test low to please the therapist (weekly administrations have also been found to artificially lower scores), there has not been the real world change.

A very Happy Christmas to Everyone

 

Dr Mike Scott

Heading Towards the Iceberg – The Mental Health Service’s Response to The Grenfell Fire

‘Three quarters of those living closest to the Grenfell Tower are suffering from PTSD, with 40% suffering in buildings a little further away’ (BBC Radio 4 December 14th 2017). But these figures from Grenfell Health and Wellbeing are highly improbable, numerous studies of responses to natural disasters show the incidence of PTSD is 30-40% amongst direct victims of disaster  and 5-10% in the general population [ Galea et al (2005)]. The rampant overdiagnosis of PTSD opens up the prospect of swathes people enduring trauma focussed CBT (or EMDR) quite unnecessarily. The spectre of inappropriate help rivals the sight of the Tower.

This gross overdiagnosis has come about because counsellors have gone door to door, ‘if they thought it appropriate’ the questions on a PTSD screening questionnaire  were asked and using a cut off a diagnosis of PTSD was made. This method on its’ own is highly unreliable, a screen has to be followed by a reliable standardised diagnostic interview  to establish true prevalence.

The interviewed clinician claimed that their approach was a ‘first’, but actually it is reminiscent oF IAPT’s approach to assessment, resulting in a treatment, that by my independent assessment, has a 10% recovery rate -‘the tip of the iceberg respond’.

 

 

The mental health services are it seems like the like the Titanic heading towards the iceberg, hopefully unlike the crew they will heed warnings and take a new direction.

 Galea et al (2005) ‘The Epidemiology of PTSD After Disasters’ in Epidemiological Reviews

 

Dr Mike Scott

 

 

 

Grenfell Fire – A Cunning Plan?

Yesterday a Counsellor from the Children and Adolescents Mental Health Services (CAMHS) announced on the BBC News, that staff are going to go door to door asking whether the occupants want professional help. Is this really the best use of resources 6 months after the tragedy? The days news also contained an item on a parent averting the gaze of her children from the Grenfell Fire Tower Block as she took her children to school.

Without health staff having a clear understanding of what in effect constitutes the ‘bruising/ tissue damage’ from  the Tragedy as opposed to that which constitutes ‘disorder’ scarce resources are likely to be squandered. There is clearly a role for a preventative/ 1st Aid input, information about not blocking intrusions, the normality of a period of increased irritability, anxiety about rehousing but there also has to be a reliable assessment of dysfuntion so that an evidence based treatment can be highlighted.

Dr Mike Scott

I’ve Had 10 Diagnoses, Got This Disorder For Life

A teenager Bex’s despair at our mental health system . Twice she has been refused Hospital admission when suicidal. ( Radio 4 today full transcript on Newsbeat ‘Me and My Mind’ available on i-player.  Jeremy Hunt Health Secretary responded ‘only had Crisis Teams 3 years ..it takes time, help isn’t happening everywhere’, he might have added nor does it look like happening anytime soon.

Bex complains that she has OCD, repeatedly checks windows etc, her thoughts sometimes make her too fearful to leave home ‘all thoughts going over, no off switch, tight, chest. It is extremely unlikely that she actually has 10 disorders, but as comorbidity is the norm doubtless she has a couple of disorders. It is inecusable that these  disorders have not be reliably identified and treatment pathways for each illuminated. Making treatment available doubtless requires increased funding but just as importantly the monitoring of fidelity to evidence based treatment protocols for the identified disorders.

I’d like to think of Bex’s case as exceptional, but she reminds me of a former client of mine who unquestionably had a primary diagnoses of borderline personality disorder (BPD). I discovered yesterday that she dropped out of treatment at the behest of a drug taking boyfriend. Since she has done the rounds of local mental health services who have labelled her as having bipolar disorder and she is taking Lithium and having therapy in secondary care. To her family’s dismay she continues to create chaos, her mum has to look after her baby etc. Once again a failure to address the key problem.

 

Dr Mike Scott

The Failure To Deliver Quality Child Mental Health Services

Children and adolescents are failed not only by an underfunding of services  ( see The Guardian, Sunday  December 3rd) but by an aping of models based on IAPT for adults.

I have just seen a 10 year old who had 8 counselling sessions, completed a wide range of psychometric tests, mum was allowed to attend the first ‘assessment’ session. At the end of treatment the agency declared that he had made ‘excellent progress’ and the child thought treatment was ‘fine’. But the reality is that the only disorder he was suffering from before counselling was separation anxiety disorder, when I re-examined him with his mum after treatment there had been no significant change in his diagnostic status. He was happy to chat about anything other than being separated from mum. Inspection of the counselling notes  mentioned working on self-esteem, work with play dough and breathing techniques. Mum had felt excluded from treatment and reported his recent ‘melt down’ when she briefly lost him coming out of a cafe.

Unfortunately neither a diagnostic competence nor ensuring fidelity to an evidence based protocol figure anywhere in IAPT and when agencies ape it, it is no surprise that the results are very poor. Appointing a counsellor in every school sounds good in that the child does not have to go to a mental health establishment and teachers could act as reality checks that ‘treatment’ is making a difference.  But the ‘caseload’ and training remain to be determined. In principle working in a school gives the opportunity  for the counsellor to engage in preventative work, but we have no hard evidence that this works. Nobody it seems has yet addressed the question of the right balance between preventative work and treatment. I can foresee a situation in which the counsellor becomes overwhelmed by the volume of work and redefines their role in a Citizen’s Advice Bureau manner acting primarily as a signpost, doubtless labelled Step 2 making no real world difference

Dr Mike Scott