Month: March 2020

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Test Those With Symptoms – A Message From The Pandemic To IAPT

Without such testing for NHS staff we would be on the road to chaos. But the Government’s Improving Access to Psychological Treatment (IAPT) service  makes no diagnosis of clients,  directing them to whatever service the therapist deems fit. There is likely to be a myriad different IAPT responses to client’s presenting variously, anxious about developing the Corona virus, saddened that they could not properly say goodbye to a loved one who died of the virus (?PTSD) or distressed that they cannot visit a loved one. In jettisoning diagnosis IAPT has ceased to operate within the bounds of evidence based treatment (EBT). EBT is based on the belief that it is known  that certain treatments work for certain conditions under certain circumstances. This applies certainly to the common mental disorders and is reflected in the NICE Guidelines.

NHS England have failed to meaningfully document the personal consequences of IAPT’s ministrations. IAPT have engaged in a high risk operation of providing therapy on the cheap using largely low intensity interventions. This has understandably attracted a great deal of funds – it’s the answer to a power holders prayer. But there is no accountability if things go wrong, as they have. It’s like a repeat of the banking crisis, morally reprehensible. Unfortunately and understandably the NHS is pre-occupied with COVID-19 and I don’t see them addressing the issue in the forseeable future.

Dr Mike Scott

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If Outside and Under 70 And No Underlying Condition Skip

this injunction isn’t from a Government Health Minister, but could bring a smile from others and those watching from windows. About a year ago I was walking a chronically depressed client to the lift and we saw on the other side of the street, a man about 50, skipping along the pavement opposite the building towards Liverpool City Centre, we both fell apart.

Maybe life is about celebrating the little things

 

Dr Mike Scott 

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Corona Virus Response and Pathologising Normality

at a 1 day workshop I delivered on March 4th (‘Getting Back To Me Post Trauma’ ) I included the following slides, which with hindsight seem particularly relevant:

  1. Listen to The Story

    ‘ I’ve been back to Hong Kong a couple of times since the unrest began last Summer. A family member was terminally ill and  died recently, his affairs are still in a mess. It was terrible there, I was frightened to go out because of gangs and you just don’t know who will be listening. I am worried about my family still living there, could be effected by the Corona virus’

    Imagine this person has presented for a mental health assessment. How do you proceed? 

  2.  

    You could…
    •Administer the PHQ9 and with his score of greater than or equal to 10 conclude he had probable depression
    •Administer the PCL-5 and with his score of greater than 31-33 conclude he had probable PTSD
    •Consider that he has  adjustment difficulties or is suffering from an adjustment  disorder
  3. Are We in Danger of Pathologising Normality?

decided to write a book Traumatised as a project in my relative isolation (71)

Best wishes

 

Mike Scott

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IAPT 10 NICE Guidance 0

a study by Barkham and Stone https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-018-1899-0 of over 33,000 IAPT cases has revealed high intensity counselling as being the most cost effective, requiring on average just 6 sessions compared to the 9 sessions for high intensity CBT, to achieve the same result. But the NICE Guidance  recommends CBT as the first line treatment not only for depression http://www.nice.org.uk/guidance/cg90 but also the common anxiety disorders. In the 2 years since the published study, IAPT appears not to have considered that there is likely something wrong with its’ data set when it provokes a conclusion at variance with the NICE Guidance. However it is IAPT that has muscle at the coal face, not NICE. The juggernaut of IAPT carries on, paying lip service to NICE Guidelines to placate NHS England and local Clinical Commissioning Groups.

The Barkham and Stone study also suggests that whatever of the 4 trajectories clients take in IAPT: 1. high intensity counselling (9%) 2. high intensity cbt (18%) 3. low intensity cbt followed by high intensity counselling (20%) 4. low intensity cut followed by high intensity cut (53%) there is no difference in outcome, all improve by 6 points on the PHQ9 each starting off at a score of 15. This would suggest that there are no meaningful distinctions between the categories and that the stepped care approach bears no fruit. Yet IAPT continues with stepped care. IAPT fails on quality control, it can provide no meaningful data with regard to treatment integrity i.e a guarantee that an evidence based protocol has been followed for a reliably identified disorder. Nor can it provide any evidence that the observed changes of score would not have happened with the passage of time and attention (an active placebo).

Regrettably IAPT, markets itself superbly with Ontario in Canada being the latest to be conned by the IAPT model, when will people wake up and smell the coffee.

 

Dr Mike Scott

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Getting Back To Me Post Trauma

this was the title of a one day workshop that I gave on Wednesday        March 4th 2020  to the Chester and North Wales Branch of BABCP. My video commentary on the day can be accessed here

https://vimeo.com/user94707142/download/397657814/67ae027afe

and the Powerpoint presentation can be accessed here 

Getting-Back-To-Me-Post-Trauma-2Download

The theoretical background to this new approach to a 1st line treatment for PTSD is described in my paper PTSD An Alternative Paradigm ptsd an alternative paradigm.

any comments gratefully received.

 

Dr Mike Scott

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Problem Descriptors – A Confusing IAPT Signpost Leading to Crashes

‘ I think it is social anxiety disorder, from my problem description my manager thinks its’ generalised anxiety disorder’  should treatment be determined by the power holder or should they just spin a coin with a ?50% chance of the client getting the right treatment. Such is the soap opera acted out in IAPT.

IAPT uses problem descriptors to determine what treatment to give to whom. But problem descriptors are a rule of thumb to determine treatment. In randomised controlled trials treatment was based on a reliable diagnosis, which would typically take an hour or more to determine. IAPT has come up with a problem descriptor shortcut of undetermined reliability and which it seeks to legitimate by asking therapist to provide an ICD-10 code.

The IAPT Manual considers it best practice if a service provides an ICD-10 code for at least 80% of cases. Can it be acceptable for up to 1 in 5 people to have rudderless treatment? When clients are assigned an ICD-10 code it is usually a single code and a Manager may advise that a another code is appropriate rather than the one the clinician selects.  Whilst the IAPT Manual advises that more than one code can be appropriate, it also advises that treatment should be dictated by the principle problem, this likely has the effect of making for single awards of ICD-10 codes.

The IAPT Manual claims that ICD-10 codes are the basis of the NICE recommended treatments, but they are not. Most of the mental health trials considered by NICE are based on the more reliable and stricter DSM criteria. Notwithstanding this ICD-10 provide diagnostic criteria for each disorder, but IAPT also contends that it does not make diagnosis. It is therefore difficult to escape the conclusion that IAPT pays lip service to ICD-10 codes for its’ own credibility.  Despite this the IAPT Manual insists that the treatment protocol should follow the identified problem but the protocols have never been matched to problems but to disorders!

Dr Mike Scott

 

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‘We Are Not Going To Give You The Tools To Do The Job’ – IAPT Becomes INEPT

this summarises the blog https://notaguru.blog/2020/02/16/resilience-its-time-to-change-the-conversation/  from Low intensity Therapist,  James Spiers.

Yesterday I gave a one day workshop on ‘Getting Back to Me Post Trauma’, arranged by the Chester, Wirral and North Wales Branch of BABCP at Chester Rugby Club with over 65 attendees. It went down very well,  what was very striking was the level of demoralisation of IAPT staff, complaints of the numbers of contacts to be made, being hauled over the coals about recovery rates, the meaninglessness of the questionnaires completed and the powerlessness of staff to get their employer to listen. Will do a blog on the Workshop shortly.

 

Dr Mike Scott

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IAPT’s Dominance of The Mental Health Agenda

interesting blog on this https://novaramedia.com/2020/02/17/marketising-the-mental-health-crisis-how-the-cbt-empire-builders-colonised-the-nhs/

I have written a and submitted a rejoinder article to the fulsome praise of IAPT in the February issue of CBT Today, I await its’ fate with interest

Dr Mike Scott