Month: September 2019

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PWP’s Floundering – Problem Descriptors Are Unreliable

whilst they may describe to a greater or lesser extent the psycho-social context in which the client is operating, different therapist would disagree about the relative importance of the psychosocial stressors and have a different collection of them.  One may emphasise the clients current relationship another a harsh/ ? abusive childhood another poverty. 

At a recent workshop I gave a PWP (Psychological Wellbewing Practitioner)defended reliance on the use of problem descriptors on the basis that they could be complemented by the therapists intuition. But this was precisely the therapeutic task centred approach adopted by social work in the 1970’s, it failed to demonstrate effectiveness  and by the 1990’s social work had become confined to largely a policing role, replete to this day with meaningless checklists. I speak as a former social worker, consumer of social services for over three decades and as a psychologist.

With my psychologist hat on I am very aware of the the work of Daniel Kahneman on the use of rules of thumb (heuristics) in decision making, for example the use of the availability heuristic – the vividness of a description giving a mistaken impression of its’ likelihood, so that a therapist hearing the horrific details of a trauma assumes it must be PTSD. Loretta whom I saw recently simply had a specific phobia about driving/travelling as a passenger in a car as a result of very serious rta. Nevertheless the PWP directed her to a 6 week stabilisation group that did nothing at all for her  difficulties. But the stepping up procedure offered no protection, she attended 3 individual sessions in which she was asked to talk about and write about the trauma, she dropped out because she found the procedure too toxic.   Loretta’s difficulties in driving and travelling as a passenger were not addressed at all. I broke the good news that her problems could be simply addressed.

The PWPs were totally unaware that Beck’s first paper was on the unreliability of the standard interview. This led to the inclusion of standardised diagnostic interviews in CBT outcome studies. In my view the PWP training however quick and simple is not fit for purpose.

 

Dr Mike Scott

Ps Do listen to Radio 4 on Tuesday Sept 24th at 8.0pm  for its’ investigation into ‘The Therapy Business’

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BBC Investigates ‘The Therapy Business’

 with recordings  from an IAPT (Improving Access to Psychological Treatment) client, IAPT therapist, myself and the British Medical Association.  The 37 minute programme will be broadcast on Radio 4 on Tuesday, September 24th at 8.0pm and repeated on Sunday, September 29th at 5.0pm.

hopefully this will be a springboard for the expression of the views of those most effected by IAPT, and will lead to a transformation of the Service.

Dr Mike Scott

 

 

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When You Do Nothing, Repeated Testing Will Likely Indicate ‘Recovery’ or ‘Remission’ At Some Point

IAPT shouts eureka at this point, discharges the client and claims the improvement is due to the therapists efforts.  It is like declaring  that a person who is terminally ill is cured because they have had a good refreshing day gardening. In effect IAPT has gone fishing for flashes in the pan – I make  similar points in a forthcoming BBC Radio 4 investigation into IAPT. 

But studies of depression and the anxiety disorders  e.g Bruce et al (2005) require a 2 month period of symptoms not significantly impairing functioning (see also DSM-5 criteria for recurrence of depression). Bruce et al (2005) point out that anxiety sufferers naturally only have symptoms 80% of the time. With regards to depression Stegenga et al (2012) point out that for 40% of depression sufferers their depression naturally takes a variable course.  Without independent assessment of the period for which the person is without significant symptoms talk of remission/ recovery is meaningless. IAPT’s clients have not been assessed using this metric. 

Bruce et al (2005) https://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0

 

Stegenga et al (2012) https://www.dropbox.com/s/k0x2fm0ds01no0k/natural%20course%20of%20depression%20stegenga%202012.pdf?dl=0

 

Dr Mike Scott

 

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IAPT’s Below Intensity CBT Revolution

IAPT’s low intensity CBT should be re-branded ‘below intensity CBT’, as all the methodologically rigorous CBT outcome studies were conducted  on full dose CBT.  Guided self-help (GSH) interventions were first recommended by a NICE committee in 2007 and 2009 for depression and the anxiety disorders. In its’ wake IAPT enthusiastically adopted GSH such that by 2018, 70% of clients were being given it. But recently therapists have been told not to use the term ‘GSH’ but talk to clients instead of ‘low intensity CBT’. This re-labelling appears to have occurred because of the difficulties of engaging the public in this more obviously cheap option (see previous post).

But NICE did not conduct a systematic review of the outcome literature, rather its’ recommendations were simply the advice of its’ committee. It failed to acknowledge that there were no studies of ‘guided self-help (GSH)’ with a hard outcome measure i.e studies involving an independent blind assessor using a standardised diagnostic interview. Thus there was no evidence that the man/woman in the street would recognise that the GSH had returned them to normal functioning. However the recommendation of NICE was that the low intensity interventions had to be matched to the particular depression or anxiety disorder. But IAPT took what it wanted from the NICE guidance, jettisoned making a diagnosis and proclaimed that appropriate treatment could follow a problem descriptor, without any empirical evidence for the latter.  The upshot is that for a decade IAPT clients have largely been subjected to ‘below intensity cbt’.

There has been a decade of ‘the below intensity CBT’ revolution and it has failed. This is not to say that there may not be cheaper effective options for service delivery such as group CBT, but the scope for such interventions is limited to depression and some anxiety disorders and much more methodologically rigorous outcome studies are necessary to confirm its place.

Dr Mike Scott 

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IAPT’s Failure To Engage

the IAPT Annual Report (2018)/2019] see link below, reveals that a third (31.2%) of new referrals drop out before treatment and approximately two thirds (61.1%) do not complete a course of treatment (using IAPT’s liberal definition of treatment as attending 2 or more session) with almost a third (29.54 %)  attending only one treatment session.

https://www.dropbox.com/s/hwn9ncuuyds8qfa/IAPT%20Annual%20Report%202018-2019.pdf?dl=0

IAPT’s disengagement is illustrated by Jock’s records which revealed that at age 6 he had behaviour problems and threatened to stab himself.  By age 14 he was diagnosed with oppositional defiance disorder and was short tempered. At age 19  he was diagnosed as having an anxiety state low mood drinking 10 units in a binge once or twice a fortnight  and cannabis 2-3 times a week. Despite his extensive history he was assessed by IAPT and assigned to a step 2 (low intensity) workshop, unsurprisingly he DNA’d. Two years later he is referred to them again for depression and unsurprisinly he does not respond to their opt in letter. Five years later the GP notes that he is struggling with an online CBT course has had to enlist his father to help because he is not computer literate. Then after a major negative life event he develops a depressive psychosis. Had IAPT bothered to listen this troubled soul of longstanding, the results could have been very different.

Institutional Disengagement

Engagement difficulties are built into the fabric of IAPT. Daniel consulted his GP 2 years after a major trauma and was found to have PTSD and depression and was promised a referral to IAPT. 4 weeks later he was prescribed an increase in medication and a different GP gave him IAPT’s telephone number to ring. Daniel was furious, he felt that he had explained that his mood was very up and down and that he could not be relied on to ring them. His interpretation of the organisational setup was that no one was really interested. This perception was likely to be compounded if and when he underwent a telephone assessment as had already had lots of acrimonious telephone conversations with the housing Dept and DWP since his trauma.   

It is surely time f or the Care Quality Commission and the National Audit Office to take note of the near universal disengagement of clients, voting with their feet, and institute an independent review of IAPT to determine what if any real world difference it makes. There is considerable media interest in these failings.

Dr Mike Scott