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BABCP Response - NICE Consultation January 2022

No Real-World Feel To CBT In Routine Practise

Two features of CBT give it a ‘real-world feel’ a) relapse prevention conducted towards the end of therapy and b) homework set after each session with review at the next session. Without these two elements CBT is, at best, just a chat. But NHS Talking Therapies (and its’ predecessor IAPT) have never furnished any documentary evidence that relapse prevention strategies and homework are a part of routine practise. As a consequence there is a ‘revolving door’ in mental health Menzies et al (2024) with most people having more than one episode of disorder. These authors call for an extension of relapse prevention. 

Relapse Prevention

Relapse prevention is important as at the end of therapy clients have to anticipate the likely hurdles post-therapy and come up with a protocol for handling them. This is usually fine-tuned in the final sessions. Without such attention to the client’s real-world they are likely to fall as difficulties arise.

Homework 

Homework is a summation of key learning points in a session and their planned application in the real-world, with review and if necessary refinement at the next session. This provides continuity between sessions and stops them descending into a purely abstract/academic discussion of issues.

CBT – An Endangered Species

CBT is dying in routine practice for lack of homework and relapse prevention strategies. In the 100’s of NHS Talking Therapies/IAPT communications I have examined for the Courts I have not found one case where there has been a clear delineation of relapse prevention strategies and the setting and review of homework. So much for accountability. Courses advocate the Cognitive Therapy Scale  to help decide who is a competent therapist [ Branson, Shafran and Myles (2015)] but their findings did not demonstrate a relationship between competence and outcome. Homework and relapse prevention strategies are a simple, litmus test, for adherence to a CBT protocol, albeit that it does not directly address the issue of competence. But without adherence there can be no competence, adherence is necessary but not sufficient. 

The Neglect of the Added Value of CBT

The selling point of CBT over medication was that it had  half the relapse rate after discontinuation. With a failure to distil relapse prevention strategies in routine practise, can it be seriously claimed that CBT is being delivered?

 Despite the dissemination of NHS Talking Therapies to over a million clients a year, there is no documentary evidence of either the provision of relapse prevention or of the routine setting of homework ( a hallmark of CBT). Taken together there is a paucity of evidence as to fidelity to any evidence-based treatment.  NHS Talking Therapies has signally failed to measure treatment integrity.

NHS Talking Therapies Is In the Mire Over Relapse Prevention

NHS Talking Therapies has one hand tied behind its back when it comes to relapse prevention, as the latter can only be measured if the person has had a meaningful period of recovery, usually taken as 8 weeks (the period used to distinguish one episode of a disorder from another). But NHS Talking Therapies has never evaluated clients in such a follow up, so it cannot boast that it delivers on relapse prevention. To compound matters NHS Talking Therapies has never utilised independent observers using a standardised diagnostic interview to evaluate outcome, so its’ very notion of ‘recovery’ is highly problematic. 

NHS Talking Therapies Problems With Relapse Prevention Are Even More Acute When It Comes To Low Intensity Interventions

NHS Talking Therapies ignore the fact that there is no evidence that relapse prevention strategies have a place in low intensity interventions. Rather it is assumed that they must be relevant because they were a feature in the randomised controlled trials that are better mirrored by high intensity interventions. 

Workshops – a Corrective?

Attending CBT Workshops recently, the great and the good are totally silent about what is happening in routine practice. This may simply be a lack of awareness. But they seem to have little appreciation that there are any problems in the translation of their fare (which can indeed work ) to the coal face. However I don’t doubt the tremendous efforts that have been put into the materials for these workshops but I have concerns about the engagement power of the suggested modus operandi for most clients. 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Flexibility With Infidelity – The Demise of Low Intensity Interventions In Practise

There has been no independent investigation of the effectiveness of NHS Talking Therapies low intensity interventions (the services most common form of delivery). But a review by Fleming (2023) of how employers cater for staff’s emotional wellbeing, including: coaching resilience training, Employee Assistance Programmes, mindfulness, counselling, stress management programmes has shown that they conferred no added value. There is no reason to believe NHS Talking Therapies low intensity interventions would fare any better.

It could be argued that the workplace interventions are about changing the worker not the workplace. There was no evidence that participants in individual-level mental health well-being interventions at work had higher well-being than those who did not. The only exception was volunteering.

Fleming (2023) concludes his paper thus ‘By evaluating these types of initiatives out of research context, implemented in the messy realities of organisational life, any benefits appear to be smaller. Such discrepancies emphasise the need for policy recommendations to evaluate evidence of workplace well‐being initiatives in situ as well as ‘in vitro’. Fleming observes that whilst there is evidence in the abstract(rcts) for the effectiveness of some of the strategies these dissipate in the real-world .Exactly the same could be said about NHS Talking Therapies low intensity interventions. 

The above findings also send a warning that the Labour Party’s (Wes Street) proposal to recruit 8.5K staff to provide mental health services in every school may be doomed  if they simply follow the public mantra on resilience training and mindfulness. The latter appear to have made no difference in the occupational context why should they fare any better in an educational? 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Who is responsible for the delivery of CBT?

This question was prompted by by Prof Kendall’s response to my previous post ‘flexibility within fidelity’, he writes: 

THANKS…I agreesometimes I say change the system when, in reality, it takes time and may not be possible in some places‘.

This is the time of year when many of us look at workshops we might attend to boost our CPD .   There are many good ones at CBTReach and bespokemental health  that focus on the delivery of an empirically supported treatment. But by and large they are by clinicians who do not have the constraints to which clinicians in routine practice are subjected e.g number of sessions, meaningless outcome measures, sanctions for not achieving targets.    BABCP run workshops by clinicians working in low intensity interventions but they lack the evidence base of randomised controlled trials with independent assessment.  

It may be that clinicians in routine practise are rather like the 1000 + sub-postmasters prosecuted  by the Post Office. Their voice has also  not been heard over the past 15 years and they have struggled to implement a flawed system, one which has not been subjected to independent evaluation. Is NHS Talking Therapies any better than the Post Office/Fuijitsu.?

Dr Mike Scott

 

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BABCP Response - NICE Consultation January 2022

Flexibility Within Fidelity

was the title of a great CBT workshop that I attended yesterday, delivered by Prof Philip Kendal. He described how time saving rules of thumb, can short circuit the therapeutic process (described in his book with the same title, published in 2022 by Oxford University Press). One of the attendees, a low intensity practitioner, volunteered one such heuristic, automatically disqualifying a client from the Service (presumably NHS Talking Therapies) if they had had a bereavement. Prof Kendall replied:

‘when the system is screwed up change  the system’  

A totally reasonable response from an objective observer outside the system. In the Webinar didn’t hear further from the therapist, and Prof Kendall did, understandably, not quite appreciate that bringing about such a change is a monumental task for anyone in IAPT’s successor. He did opine that one way of changing a system is to set up a comparison of the current system with the proposed system. But there has been no independent assessment of NHS Talking Therapies. He opined that the most credible randomised controlled trials were those in which there had been a blind, independent assessor. The Service’s  clientele have never been involved in such a trial, much less in a comparison of the Service’s routine practice with the mode of delivery suggested in my 2009, tome Simply Effective CBT, published by Routledge.

Prof Kendal said that in the US a lot of CBT therapists don’t give homework and in this  context clients do no better than in an attention control condition. This side of the pond, in my review of numerous records, for the Court I have never seen the written specification of a homework much less its’ monitoring. It is a myth that CBT is routinely provided, literally it would not stand-up in Court. Nevertheless the UK Government continues to fund adult and child and adolescent mental health to the tune of £2 billion a year. Where else could this happen without independent evaluation?

Prof Kendal insisted that his workshop was not about flexibility with infidelity but that is what routine psychological treatment in the UK amounts to. There is nothing in the UK NHS Talking Therapies approach that prevents therapists using unbridled clinical judgements. Its’ therapists perform what Prof Kendall terms a ‘diagnostician’ role, in that they assign ICD 10 codes to the client’s problems (without making an ICD 10 or DSM-5) diagnosis, but this has not stopped treatment wandering from a recognisable diagnostic pathway.  I felt he ducked the importance of reliable diagnosis. 

Prof Kendall rightly insisted on the importance of personalising treatment and having a therapeutic relationship. both of which Drew et al (2022) found notably absent in NHS Talking Therapies low intensity interventions. In Personalising Trauma Treatment: Reframing and Reimagining Routledge (2022) I give lots of examples as to how this can be done in the trauma field. I agree with him that both personalising treatment and a therapeutic relationship are necessary but not sufficient conditions for effective treatment. The other necessary active ingredient for treatment is that it must address the mechanism that is pivotal in the maintenance of the condition. With regard to trauma I have suggested it is the centrality accorded to the trauma and not arrested information processing.

Thank you Prof Kendall for such a human and illuminating workshop.

 

Dr Mike Scott

 

 

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BABCP Response - NICE Consultation January 2022

Long Covid and CBT

CBT is commonly recommended for those with Long COVID, despite a sparse evidence base. There has been no randomised control trial comparing CBT for long COVID with a credible attention control condition. Rather a study of CBT for severe fatigue [Kuut et al 2023] has been pressed into service as a proxy, for a gold-standard study. This lacks credibility as:

  1. There are objective measures of recovery from Long Covid such as return to work and distance walked compared to pre-infection. By contrast, studies of severe fatigue rely on a subjective measure of the person’s self-report of fatigue. As such Kuut et al, like studies cannot be judged as being in the same category as a gold-standard study.
  2. The Kuut et al (2023) study has all the methodological limitations that Vink et al described in their 2020 paper.

What we have is the ongoing spin of CBT.  But does it matter? It does, because sufferers from Long Covid are pushed in the direction of a treatment in which ‘unhelpful cognitions and behaviours’ are believed by the therapist as pivotal in the maintenance of symptoms. Therapists have varying degrees of transparency about this. The Long Covid sufferer is likely distressed by their symptoms, with the prospect of redundancy and the strain on relationships. They are very vulnerable, they do not need it implied, however nicely phrased, that they are responsible for their condition with unhelpful beliefs and behaviours.

 

Professionals can compound matters by muddying the waters  on aetiology and diagnosis. In instances were no Covid test was done and the diagnosis of Long Covid is a best guess on the evidence available, it can be suggested that the Long Covid morphed into Chronic Fatigue Syndrome . Thus, the Long Covid sufferer can find themselves ushered down a CFS treatment pathway. But as Vink et al (2020) argue that if objective measures of outcome are used there is no evidence that CBT works for CFS.

Long Covid sufferes are stressed but that does not automatically mean that the difficulties they are experience equate to a psychological disorder. At best assessment of anxiety and depression in Long Covid suffers is based on self-report measures, which are notorious for yielding false positives. I have yet to come across a case were the prescence of anxiety and depression was assessed using a gold-standard standardised diagnostic interview.

Looking at a Long Covid Sufferer through an anxiety/depression window requires a rigorous justification, in general the burden of proof is lacking.  The client’s view, if allowed to be heard is that the better window to look through is of having a chronic physical condition that is inherently frustrating. Some may or may not find a support group of similarly effected individuals helpful. But there should be no pretence that this will resolve their disability or return them to pre Covid functioning.

What window is NHS Talking Therapies looking through?

 

Dr Mike Scott