Month: May 2023

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NHS Talking Therapies – A Black Hole For Psychological Wellbeing Practitioners?

On January 23rd 2023 NHS mental health director, Claire Murdoch, announced that:

‘Despite the disruption caused by the pandemic the NHS is on track to deliver its Long Term Plan commitment to boost mental health spending by £2.3 billion a year, enabling around 4.5 million adults and over 700,000 young people to access mental health services’.

All this without independent evidence of effectiveness. The best evidence available Scott (2018) suggests that for adults only the tip of the iceberg recover.

Australia [Allison et al (2023)] has just completed an inspection of its similar service and concluded:

‘In conclusion, this most recent Better Access evaluation reminds policymakers that psychotherapies are generally developed for clinical cohorts with more severe conditions. The mass rollout of brief psychotherapies for milder conditions does not appear to reduce population distress or suicide rates, and a considerable proportion of these patients experience deterioration [20-40%] Offering treatment for milder symptoms might undermine personal coping abilities and social support networks.Deterioration was less likely for patients with severe symptoms, and they also experienced more improvement.Based on these findings, severity could be used as a criterion for priority setting and resource allocation. Instead of the mass rollout of brief psychotherapies for milder conditions, prioritising longer courses of psychotherapy for more severe conditions may minimise risk and maximise the potential benefits of the Better Access initiative’.

The Better Access initiative was introduced into Australia in 2006 and by 2021 1 in 20 Australians had one or more sessions of psychotherapy at a cost 1.2 billion AUD.  But with no improvement in population mental health.

Alisson et al (2023) comment further:

‘In translating psychotherapies to the real world, CBT may have re- duced effectiveness unless treatment is carefully targeted, expertly delivered, and of adequate duration. In 2021, the average number of psychotherapy sessions per patient in Better Access (5.4) was lower than most research trials of CBT’

If the Australian findings were taken seriously, it should surely mean the end of low intensity NHS Talking Therapies. But about 70% of their clients are recipients of this dosage of therapy. Psychological Wellbeing Practitioners are threatened with extinction, in the unlikely event of the  UK Government becoming more concerned about wasting money than appearing to be politically correct.

But in neither Australia or the UK has there been publicly funded independent assessors of routine outcome, using a metric of lasting recovery from a disorder. This radical apathy, suggests a real-world indifference to the plight of those with mental health problems, despite political overtures.

Dr Mike Scott

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Formulation Nausea Revisited

Six years ago I blogged about Formulation Nausea, which is induced by a bewildering array of arrows, resulting in disorientation. A just published paper by Owen (2023) in Psychological Medicine notes the demise of Formulation amongst Psychiatrists. But it is still a staple of CBT training courses, based around the 4P’s of predisposing, precipitating, persisting and protective factors. This despite any evidence of its’ systematic usage in routine practice or effect on outcome. Yet it was meant to explain the client’s functioning. It is surely time for a re-formulation. 

The problem is that the 4P’s are in suspended animation with no specification of what kind of thing they are trying to explain. As Owen (2023) points out there is a need for a diagnostic anchor when it comes to formulation. Diagnosis is descriptive, with reliable agreement only occurring in the context of ‘gold standard’ diagnostic interviews. Without such an anchor Formulation is adrift on the high seas, clinicians suffer nausea and clients doubt their survival. Shorn of its’ moorings, Formulation becomes an exaggeration of the idiosyncracy of a client’s difficulties. There are evidence-based CBT protocols for depression and the anxiety disorders but their usage is dependent on ‘case-formulation’ not formulation.

Re-formulation needs to be added to re-framing and re-imagination

Matters have been compounded by psychological imperialism, assuming that there is only one axis needed to explain a clients functioning and subsuming  the social and biological under the first of the  4P’s, Kuyken et al (2009). A 3-D representation of a clients functioning, should arguably be represented by 3 axes at right angles to each other, psychological, social and biological with no primacy attached to the psychological per se. Each person has a score along each axis and their functioning represented by x, y, z coordinates. With this multi-axial classification (akin to DSM IV and not its successor DSM-5-TR) it is perfectly possible to ‘score’ much more highly on a non-psychological axis, making that the more relevant ‘intervention’ dimension. For example a client I saw recently was clearly depressed, with no previous psychological problems, but found himself living in terrible housing conditions that was seriously effecting the health of his children and all attempts to remedy this problem to date had failed. The social axis was clearly more pertinent in his case, but the presenting problem, as far as the way the local mental health services operate would be depression, albeit that moving in an intrapsychic direction flies in the face of common sense. Kuyken et al (2009) smuggle in an extra ‘P’ presenting problem to make 5P’s, but presenting problem is not part of an explanation, each of the 3 axes  has a predisposing, precipitating, persistence and protective explanatory framework, inclusion of ‘presenting problem’ is a category error. To take another example a patient may be judged non-compliant with physio after an operation, but a previous unrelated and unrecognised neurological condition was actually operating, resulting in a demoralised patient and frustrated physio’s. The appropriate axis here is a biological one not ‘stress management’ for the patient or physio. The failure to have a multi-axial approach means that psychological therapists take on everything, and their core skills get crowded out. Kuyken et al (2009) and CBT trainers and supervisors have unwittingly abandoned a biopsychosocial model adding to the stressors of would be clinicians. The failure to use a multi-axial system can be seen in NHS Talking Therapies practitioner’s struggle to provide therapy for those with long term physical conditions, carrying a sign ‘don’t ask me how far along the biological axis is this person located, because it is a mirage’, they are consigned to wander around the desert. Sufferers from FN are often stressed in silence, to reveal it to course leaders, supervisors may be taken as a sign of ‘weakness’. What is needed is a re-formulation.

Dr Mike Scott

 

 

 

 

 

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NHS Talking Therapies – A Sacred Cow

NHS Talking Therapies is the only NHS service that it is not independently assessed. Costing £2 billion a year for adult and child services, it has escaped the scrutiny of both the National Audit Office and the Care Quality Commission. It is also, it seems, the only NHS service were staff are not in a public pay dispute.  What is going on?

It deftly keeps below the radar, so that ‘value for money’ questions  are not asked. The other string to its’ bow is ‘gas-lighting’, the repeated repetition of a claim, absorbed by its familiarity. Its’ much vaunted ‘50% recovery rate’, has warmed the cockles of the hearts of politicians,  Integrated Care Boards and the media, who have all readily and willingly accepted the lie [see Scott (2018)] in the name of political correctness – to be seen to be on the side of mental health.  In Mental Awareness Week the powerholders need educating that functioning does not equal working. The Annual reports of IAPT (NHS Talking Therapies previous embodiment) portrays its functioning: numbers seen, waiting times and self-determined targets met. But with no evidence that it is working – no independent assessment of the proportion of clients who are back to their old self and remain so post treatment. There is no credible listening to the client by a Red Cross-like body.

The Citizens Advice Bureaux are a nationally recognised and valued body. Many of their clientele have mental health problems, but there is no evidence that they are any the less served than if they had attended NHS Talking Therapies.  The added value of this NHS service has not been demonstrated. Perhaps NHS Talking Therapies staff dare not consider strike action because they are afraid nobody would miss them. GPs may miss the brief respite that may come with off-loading to NHS Talking Therapies, some perhaps even believing or at least wanting to believe NHS Talking Therapies fairy tale. They may be complicit in marketing the tale to patients.

Dr Mike Scott

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CBT V’s Production Line

CBT is in principle, user and client friendly. But in practice over two thirds of CBT practitioner’s experience burnout [Westwood et al (2017) see previous blog]. Recent evidence Kat Wheatley (2023) suggests no improvement, since the identification of the problem. Practitioners returning to work today, after the Coronation weekend, could be depicted as Lowry-like figures.What is going on?

 

I think that is is probably a combination of proximal and distal factors. The distal factor may be the commodification of psychological treatment, in which therapists are no longer regarded as people, but as individuals that are instrumental in achieving  targets: such as number of clients seen, waiting times and delivering on the Organisations metric of recovery.

The proximal factor may be a failure on CBT courses and the delivery of workshops, to ever mention the ‘irreducible complexity’ of therapy. Rather it has been implicitly accepted that it is possible to deliver CBT by selecting components of it to deliver vis a vis low intensity therapy.  But the studies of the efficacy of low intensity are of such poor quality e.g no independent assessment, that they offer no firm foundation for the delivery of effective treatment. In CBT the whole is greater than the sum of its’ parts.

Arguably it is the therapist as a human being interacting with another human being, utilising appropriate CBT strategies, that explains the potency of the therapeutic enterprise. Assembling components of CBT at various points on a production line, is unproductive. The idea of receiving a better component down the line, the much vaunted stepped-care approach, just does not work. Rather it is the synergistic interaction of two human beings in a context in which there are specific strategies available for the different disorders, that makes for the ‘living cell’ that is therapy. Just as a living cell cannot be constructed from inanimate parts (pace macro evolutionists). There is an ‘irreducible complexity’. The popular selling of individual parts of CBT, in self-help books is unlikely to make a real-world difference to the readers life,  unless the material is somehow personalised.

Dr Mike Scott 

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NHS Talking Therapies On The Brink?

Six years ago the prevalence of burnout in the predecessor of NHS Talking Therapies (the Improving Access to Psychological Therapies  Service) was reckoned to be as high as 67% (Westwood 2017). Writing in this month’s Psychologist, Kat Wheatley, a Psychological Wellbeing Practitioner writes the following, anonymised to protect the service and the individuals involved:

“In early February 2022, we received a mass email from service leaders stating that we were not on track to meet the monthly target for triage assessments. They stated this was due to too many staff taking leave over half term and being on sick leave. The email went on to tell us we would be required to offer 1-2 additional triage assessments per week throughout the month to ensure the services’ targets were met, and to discuss any concerns with our Line Managers.

Later that day, an informal discussion with my PWP colleagues highlighted the email had provoked shared feelings of stress, frustration, and dread. One of my colleagues became tearful, sharing she was already too overwhelmed by the current workplans. Someone else stated they were going to ignore the request entirely and expressed anger towards managers for not acknowledging the pressure we were already under. Another simply said they were too drained to think about it today. Over the next few weeks, the stress and low morale was tangible, with more colleagues taking sickness leave throughout the month. And while we should have felt relieved when the month was up, instead we all shared a sense of defeat that this would happen all over again at Easter.”

It does not sound as if burnout has reduced in the past six years. There is no sign of an improvement anytime soon. The author opines that is possible to mitigate the deleterious effects of burnout  by shifting ‘towards a culture of compassion within leadership’. This is at best an untested hypothesis. Nevertheless it could serve to keep hope alive amongst staff, to make going into work at least tolerable. But what would likely be the level of ‘mitigation’ achieved? Is it to be seriously suggested that it would have a major impact,  or more realistically, at best a minor impact? Would one have seriously suggested  that developing a ‘culture of compassion within the leadership’ of the Metropolitan Police would have prevented the debacle that we have seen since the murder of Stephen Lawrence, 30 years ago? More plausibly, NHS Talking Therapies has ‘Institutional’ problems that need to be addressed by a publicly funded independent review. This is not to say that individual leaders within NHS Talking Therapies cannot behave better, regarding staff as persons rather than individuals instrumental to a goal.  Similar considerations would doubtless apply to the Confederation of British Industry.

Dr Mike Scott

Westwood, S., Morison, L., Allt, J. & Holmes, N. (2017). Predictors of emotional exhaustion, disengagement and burnout among improving access to psychological therapies (IAPT) practitioners. Journal of Mental Health, 26(2), 172-9.