Month: October 2023

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NHS Talking Therapies and the Forgotten Art of Conversation

It is a paradox that NHS Talking Therapies is dominated by psychometric tests and not by conversations with clients. In a study of the telephone exchanges of Psychological Wellbeing Practitioners, Drew et al’s (2021) principal findings were that only rarely were patients asked open questions, early in the interaction, about why they had approached a mental health service for support. PWPs prioritised the routine outcomes measures questionnaires and other proforma question banks. There was evidence of a routinised approach and lack of flexibility in treatment delivery. In similar vein Faija et al (2022) noted that the psychometric tests we’re always administered at the start of a treatment session, and were seen by the PWPs as an encumbrance and the results did not influence the sessions at all. These authors called for a more conversational style but also noted that this would put extra time pressure on the PWP.

The Organisation itself appears to suffer from social anxiety disorder, steadfastly refusing to interact with its critics. Preferring the holy huddle of like-minded zealots in ‘best-practise’ gatherings.It is xenophobic.

 

Dr Mike Scott

 

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NHS Talking Therapies In The Dock

 An NHS Talking Therapies client who had seriously considered suicide the previous year was placed on a waiting list for low intensity CBT. It beggars belief.

The client had 6 sessions of therapy across two therapists without identification or treatment of her OCD. The first therapist she found unhelpful ‘no life experience’ and the 2nd could not satisfactorily negotiate with his Manager flexibility in her arriving for her appointments, because of the need for bus travel and care for her parent. The sessions ended with no plan in place for altering the trajectory of her OCD. The abuse in childhood was not touched upon. Is such treatment, or the lack of it, not an adult abuse? Where is the accountability?

 

Dr Mike Scott

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Mis-Guided NHS Talking Therapies

NHS Talking Therapies [ IAPT Manual (2023)] claim that their Services are guided by National Institutes of Health and Care Excellence (NICE) guidelines. But the evidence for this is conspicuous by its absence. Embarking on a search for Guideline compliance, is like searching for the Holy Grail. The Services interventions are therefore mis-guided.

The hallmark of compliance is [Tolin et al (2015)]:

  1. treatment for an identified disorder
  2. a matching of disorder specific targets  and treatment strategies 
  3. the utilisation of a protocol that is evidence-based, in that it was evaluated in a randomised controlled trial against an attention control condition
  4. the protocol was evaluated by independent blind-raters.

None of the Services low intensity interventions meet the above criteria. It is possible that on occasion an evidence-based treatment might be delivered in high intensity NHS Talking Therapies, there, at least in principle, there is the space to deliver a therapeutic dose of treatment. But the quest is akin to searching for the presence of water on other planets. Just as one has to be wary of claims for extra-terrestrial life, so to with the suggestion that NHS Talking Therapies is the best model for other countries to adopt for the delivery of psychological therapy services. I have suggested a simpler way forward [Scott (2009)].

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NHS Talking Therapies -Blatant Marketing

NHS Talking Therapies use two psychometric tests to monitor outcome, the PHQ-9, a measure of the severity of depression and GAD-7, a measure of the severity of generalised anxiety disorder. But nevertheless proclaim a 50% recovery rate, (IAPT Manual, February 2023 ) across a heterogenuous set of disorders. Depression and GAD are but two of the multitude of disorders that present to the Service. An assessment of clientele by Hepgul et al (2016) using a diagnostic interview, covering 16 disorders, found that just over a third, 37%, fell into the depression or GAD category. Thus the Service has pontificated on outcome for the two thirds of its population that it has not used a disorder specific measure for. Matters are even worse in that specific phobia, body dysmorphic disorder and illness anxiety disorder were not assessed by Hepgul et al (2016). Making the spectrum of disorders even broader. NHS Talking Therapies is telling more than it can possibly know, this is blatant marketing.

But Hepgul et al (2016)  showed how misleading the two tests used in isolation could be. 72% of the sample scored over 10 on the PHQ-9 but only 52% were found to be currently suffering from depression by the diagnostic interview. Sole reliance on the PHQ-9 would mean 1 in 3 people treated unnecessarily for depression.Whilst 78% of the sample scored over 8  on the GAD-7 only 66% were found to have GAD, still an overdiagnosis resulting in overtreatment, albeit not as glaring as for depression.

The fallacies of using a psychometric test in lieu of diagnosis are elaborated in detail in Clinical Psychology Science and Practice ( 2023). Bovin and Marx (2023) highlight that this reification of a psychometric tests leads to both a missing of those with a disorder and the unnecessary treatment of those without a disorder.

Though their focus was on another test, the PCL-5, used with those who have been traumatised, their findings were that cut-offs varied with the particular population addressed and the prevalence of the disorder in the particular community. Without attention to these details, clients will be misdirected.

Listening is the way forward 

Bovin and Marx (2023) suggest that a test should only be used as an adjunct and involve a discussion with the client as to the meaning of each item. But this is highly likely to introduce extra bias in the UK, as clinicians are penalised if they do not achieve 50% of patients falling below caseness. They further point out that an essential part of a diagnostic interview is the assessment of social and occupational impairment, a psychometric test cannot do this. Use of a diagnostic interview involves taking the time to listen to the client, if this does not happen treatment will likely be built on sand. 

A psychometric test takes a photograph of an individuals functioning over typically the last 2 weeks, but most disorders naturally take a fluctuating course. A ‘video’ of how they have been functioning over say the last 8 weeks is likely to be much more informative about their real-world functioning. But the distillation of this video with the client, takes prolonged listening. This has become anathema in the UK & US, targets have become everything with nobody questioning whether they are meaningful. Speed has become everything but without any understanding of where you are heading – headless chickens suggest themselves. The name of the game is apparently to take a photograph of the client as soon as they hit a better patch, claim success and reimbursement and close the case. In the DSM-5-TR the diagnostic criteria specify a 6 month timeframe for GAD, social anxiety disorder and illness anxiety disorder.

Dr Mike Scott

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NHS Talking Therapies-Sham Monitoring

The most recent edition of the IAPT Manual, February 2023   states that over 98% of clients completed two psychometric tests at the beginning and end of treatment. This sounds like pretty impressive monitoring of outcome. But less than half of clients (46%) complete treatment, defined as attending two or more treatment sessions. There is a deafening silence from NHS Talking Therapies about the dropouts. Most plausibly half of clients are voting with their feet before treatment begins.

Therapist use the test results to demonstrate to managers that they have achieved the necessary 50% recovery rate with clients. Failure to achieve this target can result in sanctions.  It is therefore not surprising to find, as Faija et al (2022) did, that there is considerable variation in the way in which clinicians ask the questions on the tests and in the proffered response options. These authors found that the ritual completion of two tests (PHQ-9 and GAD-7)  at the beginning of each session was regarded by clinicians an encumbrance and that it had no bearing on the treatment session. For managers and NHS Talking Therapies the data is nevertheless pressed into service as  propaganda.  This extensive database is meaningless.

 

The questionnaires measure the severity of depression and generalised anxiety disorder. But NHS talking therapies clinicians do not make diagnoses. So that the tests are de facto administered in a vacuum. The data are no more meaningful than same tests completed by attenders attenders at a shopping centre or at a GP surgery. By themselves they betoken nothing at all. It can be expected with repeated completion of the tests, in whatever context, scores will come down as people remember previous scores. Announcing as NHS Talking Therapies does that the improved scores indicate recovery from a disorder, is nonsense. Matters become even more bizarre when the Service implies that its’ ministrations have played a pivotal role in the recovery. 

Monitoring is an expected part any professional activity, whether it be in an operating theatre or on a plane. It is understood that those charged with monitoring will be able to give feedback to the active players if anything is amiss. Whilst there is an authority gradient between the latter and former, this is not allowed to hold sway. But it is very different in NHS talking therapies the clinician has no means of open dialogue with managers or the Organisation. It is despotic rule. The client is a pawn in a game with combatants of different agendas. 

Dr Mike Scott