I was just talking to a colleague in a Psychosis Service, where he is the only CBT therapist. He is tasked with doing ‘relapse prevention’, trouble is that none of his clients have recovered from their psychosis, making relapse prevention meaningless (psychotic)! Further none of the clients have had any CBT treatment, he is restricted to providing a diagnosis, a formulation and relapse prevention. I am at a loss to understand the evidence base for such an approach.
When I was told also of a client who is visited at home and is required to take his antipsychotic medication in view of the Nurses and there is discussion of ECT, I began to wonder whether we have moved beyond the asylums of old.
But trauma therapist are going to make you at the drop of a hat. Surprise, surprise lots of people drop out. The problem is that therapists are poor at making the distinction between cognitive avoidance and saving normal.
Ms X was on a works training course , but got upset when discussion got around to the Manchester bombing and she left the room. She had escorted her 2 children from the arena. Ms X was referred to Occupational Health and seen by a therapist who said that she was not suitable for learning to manage workplace trauma. Ms X’s reaction was arguably a normal reaction to an abnormal situation , it had not been ascertained whether she was suffering from PTSD or any other recognised disorder.
The therapist had not appreciated that traumatic memories have to be handled with ‘kid gloves’ , there is a normal aversion reaction to such encounters. Recognising and accepting Ms X’s response is acknowledgement of the need to ‘save normal’ . This is not to say that on occassion , there is not a need to learn a better way of handling an intrusive memory when it is significantly impairing functioning (e.g in PTSD) or to reconstruct the memory so that it is a better template for predicting everyday life. But the burden of proof is with the therapist to demonstrate that this is necessary.
IAPT January 23rd 2018 Birmingham City Football Ground Were you thinking this heading referred to post-traumatic stress disorder (PTSD) teatment? If you did, you may have been using a particular rule of thumb relating to an exalted status for PTSD. The following may be a common set of saboteurs:
It is probably PTSD because it was an awful incident
It is probably PTSD because there are flashbacks and nightmares
It is probably PTSD because of a high score on the IES
It is probably mixed anxiety and depression because of high scores on PHQ9 and GAD7
Whatever it actually is trauma focussed CBT/EMDR offers the best bet for resolving it
Formulation rules anyway
You can’t treat more than one disorder at a time
Issues need to be resolved first
I was due to present these Saboteurs next Tuesday during an IAPT Workshop at Birmingham City Football Ground, unfortunately 2 days after Christmas I fell down the stairs, presentation of the saboteurs has been sabotaged! The Power Point Presentation is available above. The effects of the rules of thumb are I believe devastating leading to a recovery rate of 10% in IAPT.
my paper IAPT- The Need For Radical Reform will appear in the Journal of Health Psychology shortly.
There has been a great clamour this week from mental health bodies, including the Royal College of Psychiatrists (RCP) for more monies to address the grave problems of clients with personality disorders (PDs). But they have neglected to add that there are few randomised controlled trials of psychological treatments for PDs and those that have been conducted have had very different outcome measures. It is important that clients with personality disorder are given realistic expectations of treatment and are protected from commonplace misdiagnosis.
One of my clients lost access to her children in part because a psychiatrist claimed she had an emotional unstable personality disorder (EUPD), fortunately legal action is being taken against the local authority for their part in this debacle. The latter were insistent she attend a mentalisation group, my protest that she did not have a personality disorder and therefore did not have to attend went unheard! The stresses of taking the legal action have been colossal. Maybe the energies of the RCP might be better spent making sure its’ members make reliable diagnosis. As part of the legal proceedings in this case a Psychiatric Expert Witness rejected the opinion of the treating psychiatrist but not before a great deal of distress had already been caused to her and her 3 children.
Papers in Journals such as The Lancet, Behaviour Research and Therapy and Behavioural and Cognitive Psychotherapy have in recent years relied entirely on psychometric tests completed by clients, with no independent assessment by an outside body using a ‘gold standard’ diagnostic interview. The sole use of psychometric tests is great for academic clinicians, research papers can be produced at pace and at little cost, securing places in academia. Conferences are dominated by their offerings but actually nothing is changing in the real world of clients.
The Lancet paper on the PACE trial on CBT for chronic fatigue syndrome [Sharpe et al (2015) Rehabilitative treatments for chronic fatigue syndrome Lancet Psychiatry, 2, 1067-1074] provides a great example of how to ‘muddy the waters’. The authors presented CBT as making a major contribution to the treatment of CFS. But Bakanuria (2017) [ Chronic fatigue syndrome prevalence is grossly overestimated using Oxford criteria compared to Centers for Disease Control (Fukuda) criteria in a U.S population study. Fatigue: Biomedicine, Health and Behavior, ps 1-15] has pointed out that the authors used the very loose Oxford criteria for CFS, requiring mild fatigue, but the incidence of CFS is ten times less if the Center for Disease Control (CDC) rigorous criteria are used. Thus Sharpe et al had not demonstrated the efficacy of CBT in a population who truly had CFS. In December last the Lancet published a paper by Clark et al on predictors of outcome in IAPT but again the dependent variable is of doubtful validity, changes on PHQ9 and GAD7 in a population whose diagnostic status is unknown. In fairness in the discussion Clark et al (2017) do note that it is a limitation of their study that they have relied on self-report measures but there is no acknowledgement that their findings are actually unreliable. Doubtless their conclusion that organisational factors effect delivery of an efficacious treatment is true, but this is stating the obvious, if a treatment is found to be efficacious in a randomised controlled trial, unless there is a careful mapping of key elements in the rct e.g reliable diagnosis, ‘gold standard’ assessment, fidelity measures, there will be an inadequate translation from research into routine practice.
My hope for the New Year is objective measures of outcome so that we can truly begin serving clients, now there is a novel idea.