Month: November 2023

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Is Psychological Therapy for Young People Value for Money?

 

 In 2023, 1 in 5, 8 to 25 year olds had a probable mental disorder, with 700,000 young people given psychological help, according to NHS England. Heralding these findings, this morning (November 21st 2023), on BBC TV, the athlete, Jessica Ennis-Hill, led a call for all to listen more to children and for greater investment in the mental health services. The case for the first is beyond dispute but the case for the latter is ‘not proven’. It is an attractive notion that if we invest more in the young it will prevent adult mental health problems. The idea does give a sense of control, and the sense of powerlessness we get when we see the dire state of distressed youth, can be assuaged perhaps a little by it. But as presently constituted the evidence that we can deliver on this ‘promise’ is lacking. But it does not behove the Service providers, or their likely employer, NHS England to proclaim this publicly. To do so may dispirit well-meaning staff.

 The Children and Young Persons Improving Access to Psychological Therapies (CYP-IAPT) has never been audited despite costing almost a £1billion a year. Ludlow et al (2020) have warned of the importance of not repeating the same mistakes as in the Adult IAPT Service, with low recovery rates. The natural recovery rate for young people with depression and/or anxiety is 54% within a year, Roach et al (2023). This can be reliably used as a benchmark for effectiveness of interventions. Does anyone seriously believe that existing psychological services for young people would clear this threshold? If not, why is there not a major rethink? A case can be made that ‘watching and waiting’ may often be the best policy, perhaps circumventing the pathologising of youth. It is more likely than not that the practise of identifying disorder on the basis of self-report measures, though extremely convenient for researchers , leads to the over-identification of ‘cases’, particularly as the time frame for DSM disorders e.g 6 months for GAD is ignored. But the more prevalent you can claim a disorder the greater ease of attracting funding, Service providers will quietly rejoice in NHS England’s ‘findings’.

 

Dr Mike Scott

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Misdiagnosis Equals Mistreatment – Why Then Does NHS Talking Therapies Eskew Diagnosis?

The NHS Talking Therapies Manual (2023), p24 indicates that reliable diagnosis is not part of a ‘good assessment’. Yet paradoxically, it states that clients with PTSD or social anxiety disorder should not be offered low intensity interventions first. This begs the question, of how a clinician would know, which level of stepped-care was appropriate without making a reliable diagnosis. Its’ clinicians apparently have magical insight, in that they can determine from the ‘presenting mental health problems’, the appropriate National Institute for Health and Care Excellence (NICE) protocol.  But NICE clearly states that its’ recommendations are predicated on a reliable diagnosis. NHS Talking Therapies attempt to force a square peg into a round hole is risible.

To give a further example of the Services misdiagnosis consider the following.The Service rejects referrals with a psychosis label. It does not stop long enough to carefully consider whether the label is misplaced. Mr X was a casualty of this –  a series of mental health professionals, over a period of 7 years, declared that he was a paranoid schizophrenic, each uncritically accepting the label applied by their contemporaries. NHS talking therapies declined to treat him. Finally, he was seen by a clinician who expressed his total bewilderment at the historical diagnosis, and concluded that he was suffering from obsessive-compulsive disorder, obsessive type. He successfully treated Mr X for the OCD using a standard protocol for obsessions. The Service engages in a game of ‘pass the bomb’ when it comes to certain labels.

NHS Talking Therapies has nothing in place to protect a person against the ‘slings and arrows’ of outrageous diagnoses. The de facto missive of the British Association for Behavioural and Cognitive Therapies (BABCP the CBT Lead Organisation) is to ‘suffer’ these ‘slings and arrows’, reliable diagnosis is not part of any of its approved training courses. There is no sense of ‘taking up arms’ against misdiagnosis, even though its’ former Presidents are well aware of the importance of diagnosis. Their overriding concern, is it appears, the wider dissemination of services. Which is perfectly laudable in itself. But any good has to be contextualised, it was perfectly right in the early twentieth century to seek to redistribute wealth, but not as in Stalinist Russia, at the expense of reverence for the individual and honesty. It is difficult to escape the view that BABCP and for that matter, the British Psychological Society (BPS), are on a ‘mission’, that needs contextualising.

Dr Mike Scott

 

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What Mediates Treatment Outcome in NHS Talking Therapies?

 

 


A treatment must directly impinge on a mediator, and the change in the mediator must result in a change in outcome. The mediator and the outcome must be distinct. Thus for example, in the treatment of panic disorder, anxiety sensitivity (the belief that physical and emotional arousal is dangerous) is a mediator of outcome. The treatment, interoceptive exposure (deliberate induction of uncomfortable sensations) dovetails with anxiety sensitivity to affect outcome, the absence of panic attacks. But in                                   NHS Talking Therapies one searches in vain for a mediator – it is all CBT talk, without any substance.

In attempting to apply mediational analysis to NHS Talking Therapies one enters a minefield:

  1. There is no clarity about which disorder/ difficulty is the focus. It could be panic disorder/attacks but there is no reliable mechanism for ruling out disorders beyond the scope of NHS Talking Therapies, such as personality disorders.
  2. Potential mediators are legion, and might include variously post-traumatic cognitions, dysfunctional attitudes and anxiety sensitivity.
  3. There is no evidence that NHS Talking Therapies clinicians have targeted any specific mediator.
  4. In reality NHS Talking Therapy clinicians operate a ‘black box’. Those who have been allowed to penetrate its’ contents Drew et al’s (2021) and Faija et al (2022) have discovered a machine-like process were priority is given to client’s completion of psychometric tests, which do not inform treatment. There is no evidence of the application of mediational analysis.
  5. Outcome is not assessed in NHS Talking Therapies with any hard outcome measure, assessed independently.
  6. All that can be said of NHS Talking Therapies is that time (number of sessions) mediates outcome, but this could be said equally in any possible control group. Time as such is not a relevant theoretical mediator.

 

NHS Talking Therapies claim to provide cognitive behaviour therapy (CBT) is preposterous, as the hallmark of CBT is the highlighting of disorder specific mechanisms of change and corresponding treatment interventions. It is difficult to escape the conclusion that alleging the provision of CBT is simply a good marketing ploy, enhanced by claims to be able to treat over a million people a year.

 

Dr Mike Scott

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‘No Direct Evidence of The Effectiveness of NHS Talking Therapies’

If you disagree, please supply the evidence. The justification for NHS Talking Therapies rests solely on indirect evidence. Primarily the randomised controlled trials cited by the National Institute for Health and Care Excellence (NICE) for depression and anxiety disorders. But there is no assurance (fidelity checks) that these protocols have been accurately translated into routine practice. NHS Talking Therapies legitimate themselves by claiming NICE compliance. Whilst this might be excellent marketing, there is no evidence to substantiate it. Further the randomised controlled trials are themselves of variable quality. In a minority of trials there has been blind independent assessment. In principle the high-intensity NHS Talking Therapy Service could have the capacity to deliver these evidence-based treatments. But there is no evidence that this has actually happened – a gap between theory and practice. By comparison the low intensity NHS Talking Therapy Service has the reference base of relatively poor quality studies. Not only is there the problem of a dirth of evidence of compliance with a NICE approved protocol, but the foundations of the low intensity protocols are weak.

All manner of interventions can be made to appear great in theory. But the acid test is what happens in the real-world. Disinterest in this, paves the way for vested interests, whether they be Organisations or charlatans marketing their wares. Organisations readily adopt a volume approach, operational matters: numbers seen, waiting times, become the key performance indicators, with a blind eye turned to value. NHS Talking Therapies acts it seems in its’ own interest and the client does not get a look in. One might ask how matters have reach such an impasse? Professional bodies such as British Association for Behavioural and Cognitive Psychotherapy (BABCP) and the British Psychological Society (BPS) have advanced NHS Talking Therapies mission at every turn.They have totally failed to critically appraise NHS Talking Therapies.

 

Dr Mike Scott