Month: January 2023

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The Hijacking of Fatigue by CBT To Foster Expansionism

 

A just published paper by Picariello et al 2023 singles out fatigue across 5  disorders, suggesting that certain cognitions and behaviours  play a pivotal role in the worsening or maintaining  of this symptom. In addition it is suggested that targeting such cognitions and behaviours would   make a clinically significant difference to associated low mood and anxiety. The cognitions and behaviours are enshrined in the authors Cognitive and Behavioural  response to Symptoms Questionnaire  (CBRSQ-SF) short form.  The authors posit that the scale could be a therapeutic aid, indicating treatment targets. Further they suggest  that it may facilitate the development of a low intensity treatment for these conditions.

 

But the data Picariello et al 2023  present is all correlational, it does not establish causation. To establish causation it would be necessary to demonstrate that amongst those who had remitted from the conditions a high score on the CBRQ-SF was predictive of fatigue score, controlling first for the effect of mood. [Dysfuntional attitudes are known to be correlated with mood].  The partial correlation analysis would then need to be repeated with low mood and anxiety as the dependent variables. The danger is that the CBRQ-SF is promoted on the basis of its face validity and used to justify the expansion of psychological therapy into the Long Term Conditions Arena. Given that 43% the  population of England have at least one LTC there is the prospect of rich pickings for service providers, such as the Improving Access to Psychological Therapies Service. One of the authors of the Picariello et al 2023 Trudie Chalder is a regular presenter to IAPT staff on the treatment of LTC’s.

Unfortunately it is unlikely that IAPT and its fellow travellers will take note of the study by Serfaty et al  (2020) on the efficacy of CBT for the treatment of depression in patients with advanced cancer, which used  IAPT therapists and revealed no difference to treatment as usual. Claims for the efficacy of CBT with LTCs rest on studies using self-report measures and without blind assessment. 

Returning to the Picariello et al (2023) study  although 5 populations are considered (chronic fatigue syndrome, multiple sclerosis, hemodialysis, irritable bowel disease and chronic dizziness) the focus was on a particular aspect of these disorders, fatigue. Thus, at best, targeting the dysfunctional attitudes and behaviours enshrined in the instrument would at most have a circumscribed impact on these disorders. With the possible exception of CFS sufferers, it is unlikely that most people with these disorders/difficulties would see fatigue as their primary issue.   It could equally plausibly be suggested that irritability and low mood are accompaniments of these disorders and also of Long Covid. But there is no evidence to suggest that targeting CBRQ-SF items would have a clinically significant impact on this diffuse array of symptoms across a wide range of long term conditions, despite the intimation of Picariello et al 2023.  Arguably the fatigue, low mood, anxiety and irritability are an epiphenomenon of these conditions. The elevation of fatigue to the status of a cardinal symptom of long-term conditions is without  foundation. It is a heuristic designed to short circuit  the assessment of multi-faceted disorders, accuracy is sacrificed for speed.                                  

A pinch of salt is required for the claim of Picariello et al 2023that it is a ‘transdiagnostic measure of cognitive interpretations of symptoms, and related behaviours which are associated with the experience of more severe and disabling symptoms, low mood and anxiety’ and from a treatment perspective ‘the focus and content of therapeutic techniques may vary depending on the coping procedures employed by a client (avoidance/resting versus all-or-nothing behaviour); or developing lower-intensity interventions while retaining key therapeutic techniques in line with stepped-care treatment models’.  

My thanks to Joan Crawford for help with this blog .

Dr Mike Scott 

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How Can You Know Best Practise When You See It?

 

Best practise networking is in vogue. It is a central plank in the Improving Access to Psychological Therapies (IAPT) Service  professional development programme. But who decides what should be marketed as best practice? Is it the powerholders within the Service in conjunction with those who are happy to eloquently re-iterate the party line? What assurance can there be that it is not a matter of the blind leading the blind? The dissemination of ‘best practice’ in psychological therapy rests primarily on a consensus. In Britain, the self-proclaimed lead organisation for cognitive behaviour therapy (CBT), the British Association of Behavioural and Cognitive Psychotherapy (BABCP) sees itself as the custodian of ‘best practice’ and has bestowed an imprimatur on IAPT.

But the British Medical Journal has a very different notion of what constitutes ‘best practice’. For each of the common mental disorders, it identifies screening psychometric tests complemented by standardised diagnostic interviews to identify the particular disorder. Then a treatment algorithm for each disorder. However IAPT clinicians are not trained to make diagnoses so that their ‘best practise’ must diverge from the BMJ’s. Who is right and on what basis?

The gulf between evidence-based practise and IAPT’s ministrations is shown in sharp relief if we focus on the latter’s low intensity guided self-help (LIGSH). I could find no study of LIGSH in which there was a blind assessor of the treatment and comparison with an active placebo. Thus any effects of LIGSH could be attributed to simply attention. By contrast over half (58.7%) of randomised controlled trials of CBT have employed blind assessors.  

The behaviour of IAPT clinicians is highly prescribed. In a study of LIGSH transcripts of tape recordings of client’s first contacts with the Service analysed by Drew et al (2021) there is 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’.

But not only does the IAPT Service refuse to listen to its clients, it refuses to listen to outside criticism. There has been no change in its’ modus operandi in over a decade as it pursues expansionism.  But it is an expansionism to areas were there has been no demonstrated efficacy and evidence is at best circumstantial. Operating on the dubious premis that ‘it just might be the answer to the world’s problems’. 

The networking of IAPT clinicians, whose operation is validated by BABCP, is an ‘In Group’ that talks amongst themselves, reinforcing their world view and refuses to engage in effortful processing of external criticism.

Dr Mike Scott

 

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The Juries “Give Us a Break” Response to IAPT Claims

The afternoon session begins with my cross examination by the Defence barrister, ‘isn’t it the case that those who wrote the IAPT Manual and proclaim a 50% recovery rate are emminent in their field?’. I reply in the affirmative. The Defence barrister continues ‘Have IAPT’s findings been publicly questioned  by bodies such as NHS England? To which I replied ‘no’. He continues ‘so you set yourself up against the acknowledged Experts? My response is ‘I am not setting myself up against anyone, this is not a gladiatorial combat. I am simply insisting that the psychological therapy provided by IAPT should be evidence-based and not eminence-based. The credibility of any service is called into question when it does not rely on the data of an independent assessment. The Expert’s you cite, authors of the Manual, NHS England all have a vested interest in proclaiming the merits of the IAPT Service’. The Defence barrister retorts ‘NHS England is responsible for the health of the nation, are you seriously suggesting that there has been a derogation of duty? I respond ‘yes, for over a decade it has unquestionably accepted IAPT’s claims, with staff holding posts in both Organisations. Recently at the behest of the Department of Health I asked NHS England seven questions with regards to IAPT, they simply told me to go and ask the questions of the Department of Health’. 

I continued ‘With  breathtaking skill, IAPT engages in eminence-based medicine, vehemence-based medicine and eloquence-based medicine. It also engages in ‘it won’t hurt to try’, for example running groups for those traumatised despite a paucity of evidence as too efficacy and under waiting list pressures assigning a clear PTSD case to a trainee’. My own findings of 90 litigants  who went through IAPT whether or not before or after personal injury was that only the tip of the iceberg recover’. The defence barrister continues ‘this is using your own idiosyncratic view of recovery not that used by IAPT, is that not the case?. My response was ‘No, I was using the criteria that is used in Court in personal injury litigation, is the person still suffering from the disorder acquired as a result of the personal injury, it is very straightforward’. The defence barrister continues ‘IAPT uses a drop in score on a psychometric test as evidence of recovery, is this not more reliable?’ My response is if it were, such a metric would be in routine use in Personal Injury litigation, it has had no such status over my 30 years of medico-legal work. The danger of a psychometric test administered at the end of a treatment session is that the recipient of the services does not wish to appear ungrateful and makes an exaggeratedly positive response’.  

Jury members are most likely to use a credible metric in determining whether a Service has failed to deliver and whether or not it has made exaggerated claims for its’ own ends.  Expert Witnesses may protest their independence, but the possibility of bias cannot be excluded as they appear either for the Defence or Prosecution. Additionally they may have an academic bias, re-iterating current mainstream opinions, with scant regard for alternative views.

Dr Mike Scott

 

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‘IAPT Is Not Curative’

this could be the opening gambit in the prosecutions case against the Improving Access to Psychological Therapies Service. The indictment is that IAPT has misled GP’s and the public into believing that 50% of its clients recover. Further it is on this basis that IAPT has wrongfully acquired Government funding of £2 billion a year covering adult and children’s services.

IAPT IS ON TRIAL

IAPT is being tried in absentia, because in the 6 years of cbtwatch.com the Service has steadfastly refused to engage in any public debate. In principle, IAPT could call defence witnesses, the British Association for Behavioural and Cognitive Behaviour Therapy (BABCP), the progenitors of IAPT Professor David Clark and Lord Layard, Dr Adrian Whittington the Clinical Lead for Psychological Professions at NHS England and Health Education England, and the IAPT National Clinical Advisor. There is an open invitation to them to attend the trial but there is no Court Order mandating their attendance. Given their track record to date the likelihood is that they will treat the proceedings with contempt and a deafening silence will ensue.

The prosecuting barrister’s role is to present to a Judge and jury in ordinary language the truth of the matter. Operating on the maxim “KISS’ keep it simple stupid, he/she would utilise an everyday notion of recovery, explaining to the jury that in everyday parlance, it means being back to your old self and staying that way. In this way the Judge and jury are invited to consider the evidence that 50% of IAPTs clientele are back to their old selves with treatment and stay that way. But the Judge smells a rat when he/she learns that there has been no independent corroboration of IAPT’s claim. In the circumstances the Judge feels obliged to advise the jury of the distinction between direct evidence and circumstantial evidence and that IAPT’s case, at best, rests on circumstantial evidence. Reminding the jury that at an interview we would all say that we are the best possible person for the job. The claim might possibly be right, but it could not be relied  upon, because of the likelihood of bias. The prosecuting barrister has thereby placed a seed of doubt in the mind of the Judge and jury.

The prosecuting barrister puts the latest IAPT Manual in the dock, under cross examination it is revealed that 50% of IAPT clientele drop out before they have had 2 treatment sessions. When asked ‘is it likely that they are happy bunnies?’, a deafening silence reverberates around the Courtroom. The Judge intervenes ‘please answer the question that Counsel has asked?’ but this is met with a stony silence, and the Judge muses whether this constitutes contempt of Court. The prosecuting barrister wades in ‘I put it to you, that on the balance of probability, their disengagement signifies disenchantment’ or ‘are you seriously asking us to believe that in one therapy session or after just an assessment, the lifes of half or more disengagers has been transformed and permanently so?.   The Manual protests that the claim of a 50% recovery rate only applies to those who attend two or more treatment sessions. The Judge intervenes and addresses the Manual ‘let me be clear on this, looking at all who attend IAPT we have 50% who do not have treatment as you define it, and even if it were the case that 50% of the remainder recover, the overall recovery rate would be just 25%, have I got that right?’, the Manual mutters ‘I suppose so’ . The prosecuting barrister continues that the Manual states that IAPT’s therapists are not trained to make diagnoses, how then can they possibly know  whether a person has recovered or indeed what the recovery rate is for the Service? To speak of recovery without diagnosis is nonsense, recovery from what?

The prosecuting  barrister then calls myself to the witness stand and I explain  that in the context of my role as an Expert Witness to the Court, I assessed 90 litigants who went through IAPT, whether before or after their personal injury and which ever was the case, only the tip of the iceberg recovered see previous blog. The barrister  asks ‘so your primary duty was to the Court, and not to anyone instructing you?’ and I reply in the affirmative. The cross-examination continues ‘is there a possibility of your having a bias over IAPT’, I reply no and that it was not until about 2015 that it was becoming apparent that the Service simply was not working. In my book of 2009 Simply Effective CBT I was neither for or against IAPT considering it a worthwhile experiment that may or may not work.

At this point the Judge declares this would be good time to break for lunch, with the defence barrister cross-examining Dr Scott afterwards. The Judge asks the defence barrister ‘is it the case that you are not calling any Expert Witnesses for your own side?’ The defence barrister confirms this and the Judge can be overheard muttering beneath his breath ‘strange’.

Dr. Mike Scott 

 

 

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‘CBT Today’ An Apologist for IAPT Expansionism

CBT Today is the Official Magazine of the British Association of Behavioural and Cognitive Therapy, the supposed lead organisation for CBT. But today it is a vendor for cheap and easy solutions to human difficulties. This sits comfortably with its’ friends in high places, politicians and the media. The funds flow, almost £2billion a year for IAPT  adult, children and young people services. With £988.0m the projected spend on children and young people in 2022/23. But no independent valuation of whether either service is value for money. This would beggar belief at any time, but in these days of financial stringency it has to be insanity, corruption or some combination thereof.

In the December issue of CBT Today Dr Adrian Whittington the new Clinical Lead for Psychological Professions at NHS England and Health Education England, states the IAPT services ‘have lived up to the assumptions that showed they would save money overall for the public purse’ p 10. But the article fails to state that he is also the IAPT National Clinical Advisor: Education clearly vested interests are at work. The null hypothesis for any service, including IAPT, is that it costs something. A null hypothesis, is assumed to be true, unless contradictory evidence is provided. But Dr Whittington and the IAPT powerholders have provided no refutation of the null hypothesis. My own findings confirm the null hypothesis, see previous blog .

Dr Whittington (2022) continues ‘we need to  support a a psychological approach as the norm  for major health conditions. We know that these developments can support people to adjust and manage long term conditions more effectively, reducing unwarranted medical consultations’.  A further null hypothesis is that psychological therapy makes no difference to the management of these conditions. Again the burden of proof is with those who would  rebut the null hypothesis. Who is it that judges that there are ‘unwarranted medical consultations’? What is the world view of a person who sees many consultations for long term conditions as unwarranted?

Dr Whittington (2022) lauds it that the expansion of the Adult IAPT service is being mirrored in the provision of services for children and young people in the form of Mental Health Support Teams in school and colleges.. But there has been no audit of the Service for children and young people at all.The smoke and mirrors continue. 

In the same issue of CBT today Dr Claire Willis declares ‘a small to moderate effect’ for a transdiagnostic approach to persistent physical symptoms in a trial in which she was a therapist. She enjoins that the same approach should be used with Long Covid. No matter that the protocol was evaluated by those who developed the protocols. These authors engaged in a fishing expedition to find any positive findings, administer enough measures something will urn up positive by chance. The spurious claims for the study Dr Willis were rebutted in an earlier blog  of mine.

 

Dr Mike Scott