The Future of CBT In Practice

niNext month is Aaron Beck’s 100th birthday and the journal which he founded ‘Cognitive Therapy and Research’ has a great editorial https://doi.org/10.1007/s10608-021-10232-6, wishing him well and looking at possible developments in CBT for depression, envy, schizophrenia and OCD. But there is a yawning gap between the experiences of the beneficiaries of randomised controlled trials (rcts) of CBT and what UK citizens receive in routine practice. In terms of the model below, going clockwise, there has been a fundamentalist translation of the rcts to determine policy, such that key elements of context such as ensuring reliable diagnosis have been left out, implementation has been determined in a ‘Stalinist’ way e.g the possibility of sanctions if a 50% recovery is not reached, there has been no independent monitoring of the policy, there is a claimed risk reduction, but this is based on responses to the ambiguous suicide item, item 9 on the Patient Health Questionnaire PHQ-9. But there is no evidence that the ‘Science’ is looking at these matters anytime soon. The deliberations of bodies like the British Association for Cognitive and Behavioural Psychotherapy (BABCP) appear to occur in a parallel universe.

Recently Drew et al (2021) https://doi.org/10.1016/j.socscimed.2021.113818 examined transcripts of IAPT (Improving Access too Psychlog ical Therapies)  sessions and the take home message was that clinicians were preoccupied with their own agenda and not really listening. This echoes what  Omylinska-Thurston et al (2019) https://doi.org/10.1002/capr.12249   found when interviewing former IAPT clients:

participants discussed difficulties with the outcome measures they had to fill in each week. Clients said they did not feel comfortable filling them in. Clare said it felt “disheartening… because … it brings it home…just how bad you’ve been feeling”. Clients also said that the scales felt disrespectful to their experience. For some, it was difficult to pinpoint the accurate answer and for others the measures did not reflect the nuances. For example, Jenny said about the self-harm question on PHQ9 “…to harm myself? No, but I know I wasn’t eating …well”. Also Jason said “there’s a difference between wishing you were dead and wanting to die … the question really is: do you think you should kill yourself rather than do you think you’d be better off dead?” Participants also commented that they learnt how to score the measures to get more services or sessions. Jenny said about the self-harm question “If I’ said ‘yes’ then they …‘right, shit’, but because you don’t put that they do ‘OK, see you next week’.” Jenny also worried that “if you put it was only one day this week, does that mean you don’t get any more sessions?” Measures were also reported as focusing on the negative side and did not catch positive change

Difficulties with assessment

Six clients discussed issues they had with the assessment process. Clients said that they were not assessed for the right type of therapy. For example, Adam said “if I had been…assessed better, that therapist doing CBT could have been helping another person”. Clients also said that CBT was not explained to them and Michael commented that he “didn’t know exactly what CBT things were going to entail”. Clients said that assessment involved a lot of paperwork and form filling and did not focus on their needs. Jason commented that he had to fill in a measure first and the score decided that he was depressed rather than a discussion first supported by a measure. Maurice talked a lot about the phone assessment and said it was “uncaring, robotic and intrusive”. He was concerned that people will not engage in therapy following telephone assessments’.

Yet what struck me when I met Beck in 1997 in Canterbury, was how much he genuinely listened. The rcts on CBT continue to generate high expectations but the jury is out on whether they have made or will make a real-world difference.

Dr Mike Scott

Psychological Therapy With Long Term Conditions

Improving Access to Psychological Therapies (IAPT) therapists working with long term conditions (LTC’s) have confidence and organisational, issues Carroll et al (2021) DOI: 10.1111/bjhp.12475. Whilst therapists working in secondary care, with LTC’s, face fewer obstacles to multidisciplinary working, with a focus primarily on the LTC and not on the associated depression/anxiety as in IAPT. Further the metrics for outcome in secondary care are likely to be much broader than in IAPT. LTCs by their very nature, wax and wane with a consequent impact on availability and concentration, creating a need for any therapy to be long term. But IAPT has a major focus on access and waiting times, such that any treatment is usually brief, comprising on average of 6 sessions, thus the service cannot readily accommodate working with LTCs.

The focus in the Carroll et al (2021) is on how the psychological treatment for those with LTC”s can be best integrated into primary and secondary care. They note however that the model they use to identify barriers and facilitating factors to implementation, first requires, evidence that the chosen intervention/s are effective. But they do not address this point. This is crucial, where is the evidence that the psychological therapies for disorders that are comorbid with LTCS make a real world difference?

A case has long been made that it is a matter of basic humanity to offer to accompany a person with an LTC if they so wish. A host of Charities have formalised this. The support may be social, e.g befriending, groups and/or instrumental e.g help with DWP application. The case for profferring ‘support’ is I think uncontestable. But many with LTC’s are wary of being defined by their condition. A dedicated support group may serve as a further reminder of their condition. They may decline involvement in such a group, but this is not necessarily a matter of avoidance, simply that they do not wish to define themselves or their world through the lens of their LTC. If psychological difficulties are grafted on to their LTC they may be even more likely to decline involvement with psychological therapists because it is an LTC type lens (a variant) through which they are being encouraged to view themselves and their personal world with perceived deleterious consequences. Arguably the LTC lens used in secondary care is likely to be less problematic than that used in IAPT. But the issue of centrality has not been systematically addressed with regards to LTCs. In the authors forthcoming work ‘Personalising Trauma Treatment: Reframing and Reimagining’ to be published by Routledge the issue of centrality [ Bernsten and Rubin (2006) (2007)] is addressed in detail with regards to trauma.

There is a distinction between long term physical health conditions and medically unexplained symptoms (MUS), the former are open to objective identification e.g diabetes, the latter are not. In considering the former the therapist feels that they are on solid ground, albeit that it is largely the domain of the medic, with whom there may be fruitful dialogue. But when it comes to MUS the therapist is in a fog, where are the signposts? There is no reference book for translating best practice with LTCs to clients with MUS. Because of this there is likely to be recourse to a powerful body insisting that the way forward is ‘x’ but without any evidence, a recipe for disaster. IAPT”s juxtaposition of LTCs and MUS, smacks more of pragmatism to secure maximum funding, rather than seriously addressing a clinical problem. Where is the therapeutic alliance in addressing MUS symptoms? What is the goal, What are the agreed tasks? Whither the bond, when the therapist covertly believes that the client is somatising and the client believes there physical symptoms are as real as toothache?

Carroll, S., Moss-Morris, R., Hulme, K., & Hudson, J. (2021). Therapists’ perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions. British journal of health psychology26(2), 307–324. https://doi.org/10.1111/bjhp.12475

Berntsen, D., & Rubin, D. C. (2006). Centrality of Event Scale: A measure of integrating a trauma into one’s identity and its relation to post-traumatic stress disorder symptoms. Behaviour Research and Therapy, 44, 219–231. https://doi.org/10.1016/j. brat.2005.01.009

Berntsen, D., & Rubin, D. C. (2007). When a trauma becomes a key to identity: Enhanced integration of trauma memories predicts posttraumatic stress disorder symptoms. Applied Cognitive Psychology, 21, 417–431. https://doi.org/10.1002/acp.1290

Dr Mike Scott

IAPT’s Processes Contribute Towards Death or Injury

transcripts of tape recordings of client’s first contacts with the, UK Government funded, Improving Access to Psychological Therapies (IAPT) service, analysed by Drew et al (2021) https://doi.org/10.1016/j.socscimed.2021.113818 reveal not only steadily increasing access,  but a steadfast refusal to let clients tell the story behind their distress. The double message is ‘come to us, but we don’t want to listen to your troubles’

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’

and 

‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’

Drew et al (2021) give an example of this surrounding risk assessment:

PWP: So just with regards to question nine, okay so we have a duty of care to yourself or others? .hhh.erm (.) > are we okay just to< have a bit of a chat around.hh what those thoughts might be for you at the moment. ‘Cos you’ve scored a one there haven’t you’ Pause 3 secs
 
PWP: Are you having current thoughts of wanting to hurt yourself or end your life? Pause 3.5 secs
 
Pat: No, may. hh Pause for 3.5 secs
 
Pat: It’s – It’s just feels like a really weird (.) week this week because –
(18 lines omitted in which the patient talks about the pressure they are under; only minimal responses and attempts to close from PWP)
 
Pat: I still feel like I – I’m not doing anything and not accompanying anything tearful/tremulous
 
PWP: Mm, mm, okay? .huh
 
Pat: MHHHH HHH [ and it’s tearful/tremulous]
 
PWP: Are you having any thoughts of wanting to be better off dead or off wanting to better off dead or hurting yourself
 
Dangerously The PWP is all at sea  – a disaster waiting to happen, there will be a death. The above exchange shows
 
the therapist unable to move beyond repeating question 9 on the PHQ9, like a broken record, without any reliable
 
exploration of suicide risk. But then the IAPT Manual provides no guidance in this respect, baldly stating risk
 
assessment is part of good assessment.
 
In the exchange above the PWP ignores the client’s story. Assessment and treatment are necessarily built on sand 
 
if the client’s narrative is not first distilled.  Making IAPT’s claim of a 50% recovery rate  beyond belief. [The average
 
session was 44mins for assessment and 33 mins for first treatment]. 

It is bad enough when a friend or relative will not listen to your troubles, but when a Government Agency does it routinely, that is unconscionable. Drew et al (2021) draw attention to the ubiquity of the problem which suggests that it is systemic. However Drew et al (2021) content themselves with recommending that IAPT’s assessors need to ask more open-ended questions at the start of their interviews. The authors claim no conflict of interest, but many of the authors have had previous privileged access to IAPT data, research data may not be so forthcoming if they take a more critical view of IAPT. In this respect they do not question IAPT’s recovery rate or cite data which may disconfirm it Scott (2018) https://doi.org/10.1177%2F1359105318755264.

 

Dr Mike Scott

Talking Therapies Con

the Improving Access to Psychological Therapies (IAPT) assessors are coaches, not trained treating clinicians. Clients and GPs are not made aware of this. The low intensity Psychological Wellbeing Practitioners see their low intensity role  as ‘coaches’ rather than therapists  see [https://thepsychologist.bps.org.uk/volume-24/edition-5 May 2011 Psychologist].  

The working alliance has been found to predict outcome in the treatment of a wide range of psychological disorders [Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy: a meta-analysis. J Couns Psychol. (1991) 38:139–49. doi: 10.1037/0022-0167.38.2.139] and most recently in the treatment of PTSD [Beierl ET, Murray H, Wiedemann M, Warnock-Parkes E, Wild J, Stott R, Grey N, Clark DM and Ehlers A (2021) The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder. Front. Psychiatry 12:602648. doi: 10.3389/fpsyt.2021.60264]. But the measurement of the working alliance requires a determination of the tasks involved, the goals elaborated and the assessment of the therapeutic bond [Tracey TJ, Kokotovic AM. Factor structure of the working alliance inventory. Psychol Assess. (1989) 1:207–10. doi: 10.1037/1040-3590.1.3.207]. Measuring the therapeutic working alliance in low intensity CBT would be a herculean task, in that 42% of those entering treatment only complete one session [Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14]. Further even if the working alliance could be reliably assessed in low intensity IAPT there can be no certainty it would relate to outcome. 

Given the uncertainties surrounding the role of the working alliance in low intensity interventions, doubts arise about the credibility of this intervention. Low intensity interventions do not make a clinically significant difference compared to usual care. BMJ 2013;346:f540 doi: 10.1136/bmj.f540 The situation is analogous to trying to asses the effectiveness of a fraction of a drug, that is demonstrably efficacious in full dose in a highly specified setting.

But the effect size of working alliance has in all studies been found to be in the small to medium range, for example in the Beierl et al study (2021) accounting for 13-28% of outcome depending on whether it was the patients perception of the therapeutic alliance or the therapists.  Thus though consideration of working alliance is of importance it is not of overriding importance and the specifics of the protocol matter.  

Dr Mike Scott