Shifting The Focus To The Client Being Well

Conferences, government agencies such as IAPT and recent research papers, gloss over the proportion of clients who are well at the end of CBT (remission), preferring instead to talk of the number of people who have responded (response) to an intervention (proportion of people whose score reduced by greater than x%). Springer et al (2018) call for a shift in focus to the real world outcome of remission ‘remission should be the ultimate goal of treatment’. Chasteningly they point out  that the remission rate for CBT across the anxiety  disorders is just 50%.

Interestingly the results of Springer et al’s meta-analysis showed that the remission results were poorer when there was no blind evaluator. This may be important in evaluating IAPT’s performance because they have had no independent evaluator! Further the results in the Springer analysis were poorer still when there was comorbid conditions such as depression and/or subtance use disorder, suggesting that all a client’s disorders need tackling not just the primary anxiety disorder. GAD and PTSD did better than OCD and SAD with panic disorder in between.

Clients want to be well again not just reduce their score on a psychometric test that some clinician deems acceptable for their own reasons. Losing their diagnostic status should be a necessary condition  for assessing outcome, albeit that arguably it also ought to be complimented with reduction below a certain cut-off on a psychometric test.

 

Springer, K.S., Levy, H.C and Tolin, D.F (2018) Remission in CBT for adult anxiety disorders. A meta-analysis. Clinical Psychology Review, published online ahead of print

Please cite this article as: Springer, K.S., Clinical Psychology Review (2018), https://doi.org/10.1016/j.cpr.2018.03.002

Dr Mike Scott

IAPT Problem Descriptors Lead To Treatment Chaos

IAPT base treatment on problem descriptors not standardised diagnosis, resulting in a gross failure to identify appropriate treatment targets. A recent study by Thomlison et al (2017) indicated 4 out of 5 PTSD cases were missed.    There is no evidence that identification of other disorders is any more reliable Scott (2018) see earlier post (link below)

In the Thomlinson et al study (2017) three quarters of IAPT clients were in low intensity groups, conducted without reference to any explicit evidence based protocol. This looks like playing a numbers game with groups.

Thomlinson et al (2017) Comorbidity between PTSD and anxiety and depression: Implications for IAPT Services. Archives of Depression and Anxiety

Scott, M.J (2018) IAPT – The Need for Radical Reform Journal of Health Psychology https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/.

 

 

 

Dr Mike Scott

IAPT at Sea On Risk Assessment

A study just published by Na et al (2018)  in the Journal of Affective Disorders*  suggests that item 9 of the PHQ-9 is an insufficient assessment tool for suicide risk and suicide ideation, creating large numbers of false positives. Yet within IAPT, GP’s may be informed that either there are no risk issues on the basis of a ‘not at all’ response to  item 9, ‘thoughts that you would be better off dead or of hurting yourself’ or that there are risk issues on the basis that they have been bothered by these thoughts for at least several days in the last 2 weeks. The message is usually communicated to the GP following a telephone assessment conducted by the most junior members of staff a Psychological Wellbeing Practitioner. The GP then feels obliged to call the patient in for an assessment which turns out to be invariably pointless, not good for the patient or for the GP who may be seeing 40 patients that day!

A (2012) paper on IAPT by Vail et al ** stated ‘that IAPT clinicians did not have set procedures or questions for assessing mental health risk, and were  flexible in the approaches they adopted. They often relied upon their own clinical judgement and experience about how to approach the topic of mental health risk’. This chimes with what I found in an analysis of 90 cases going through IAPT, Scott (2018) in only three cases was there mention of risk in the documentation. Inspection of item 9 on the PHQ-9 shows that it confounds passive suicidal ideation with active planning making it unclear what the frequency response refers to, creating many false positives.

More direct questionning based on the C-SSRS * is probably more appropriate:

Have you started to work out or worked out details of how to kill yourself? Do you intend to carry out this plan ?

Have you made a suicide attempt- purposely tried to harm yourself with at least some intention to end your life?

Have you  taken any steps to prepare to kill yourself or actually started to do something to end your life or were stopped before you actually did anything?

A none response to either of the 3 questions would indicate no suicide risk.

* Na, P.J et al (2018) The PHQ-9 item 9 based screening f or suicide risk: a validation study of the Patient Health Questionnaire (PHQ) – 9 item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS) Journal of Affective Disorders, 232, 34-40.

** Vail, L (2012) Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRIST. Mental Health in Family Medicine, 9, 57-67

 

Dr Mike Scott

PTSD and Winnie-the-Pooh

Winnie-the-Pooh’s 100 Acre Wood has taken on a whole new meaning, after watching on DVD ‘Goodbye Christopher Robin’. The ‘Wood’ is arguably A.A Milne’s construction of a new personal world for his son (Christopher Robin), an alternative to the war zone map he appears to have operated on  since  his involvement in the Battle of the Somme in 2016, his illustrator had been involved in the Battle of Paschendale in 2017. The DVD  sees the playwright A.A Milne returning to London after his war experiences, needing to retreat to the country, startled and debilitated by unexpected noises, unhappy to make people just laugh dismayed at his son going off to another war.

 

It seems that the quest post-trauma is to seek a better map, oftentimes returning to the pre-trauma map but perhaps sometimes creating an altogether better map. Perhaps some clients are a little like Eye-ore because of their experiences!

 

Dr Mike Scott

 

Is Aggressive Management Endemic in the Mental Health Field?

This week the demise of the construction Company, Carillion was laid at the door of aggressive management – hiding the true nature of performance. Isn’t this what IAPT have done with claims of a 50% recovery rate, when the actual recovery rate was 10% [ Jounal of Health Psychology, ‘IAPT- The Need for Radical Reform ‘http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264  http://journals.sagepub.com/doi/full/10.1177/1359105318755264.  With two thirds of IAPT low intensity workers suffering burnout, as well as half of those in high intensity it looks suspicious.

 

 

My experience yesterday  giving a talk ‘From Disaster to Functioning’ [ slides here https://www.dropbox.com/s/0jgvhhz0bva81s2/From%20Disaster%20to%20Functioning.pptx?dl=0 and http://www.cbtwatch.com/from-disaster-to-functioning/ ] at the Health and Wellbieng Conference held at the NEC, Birmingham suggests that misrepresentation is not confined to IAPT, I heard of mental health wares such as suicide prevention packages and the Critical incident Stress Debriefing  variant TRIM, being promoted despite a dirth of evidence supporting them. I began writing this blog on the train yesterday coming home from the Conference, as I was getting off the attendant announced “if you see anything suspicious see it, report it sort it”,  it  may be an important dictum for the whole mental health  field.

 

Dr Mike Scott

What If Information Processing Models of PTSD are Wrong?

Consider that only a small minority of those experiencing an extreme trauma experience PTSD, consider also that most people experiencing such an event try not to think/talk about it, is it really plausible that PTSD arises from arrested information processing? If not why are we subjecting clients and therapists to a painful procedure, trauma focussed CBT/EMDR,  that they are likely to default from?

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It is true that with trauma focussed CBT or EMDR about 50% of those undergoing these treatments in randomised controlled trials fully recover from PTSD, nevertheless compliance in routine practise appears much less . But it is possible that to the extent that these treatments do work they do so for reasons other than achieving ‘full processing of the traumatic memory’. More plausibly as a side effect of these interventions they learn experientially that the ‘war zone’ map of their personal world that they have employed since the trauma, leads nowhere and they revert to a pre-trauma map. Oftentimes the prime concern of a victim is not what did happen but what could/should have happened i.e it is not the trauma per se.

Dr Mike Scott

From Disaster to Functioning

Talk at Health and Wellbeing at Work Conference, NEC, Birmingham March 6th 2018. My key themes are:

  • ‘Saving Normal’ and watchful waiting in the immediate aftermath of a disaster.
  • Critical Incident Stress Debriefing is unproven and may be harmful.
  • The dangers of trauma focussed CBT/EMDR when a person does not actually have PTSD
  • Daring people to gradually do what they did before – resetting the alarm (amygdala)
  • Poor recovery rate in IAPT for treating trauma responses 10%
  • Ubiquity of rules of thumb for treating trauma victims probably leads to an almost universal low recovery rate
  • Dr Mike Scott