Month: February 2024

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Ejection From NHS Talking Therapies

occurs whenever a persons scores below cut-offs on two psychometric tests. Just how ludicrous, this is, was brought home to me recently when I was called to assess a lady who had been trapped in her car, by a fallen tree. After 12 sessions of trauma focused CBT, she was scoring below cut-offs on the PHQ-9 (a measure of the severity of depression) and on the GAD-7 (a measure of the severity of generalised anxiety disorder). But she still felt unable to return to her, much-loved job as a bookkeeper, despite every support from her employer. For six months after the incident, she met the DSM-5 diagnostic criteria for post-traumatic stress disorder, currently, she had a sub-syndromal level of PTSD (meeting 3 of the necessary 4 symptoms clusters for PTSD). But she had never met criteria for depression or generalised anxiety disorder, the two tests administered were therefore entirely inappropriate. [ Details have been changed  to protect confidentiality.]

Common sense would dictate that this lady is not back to her usual self. But NHS Talking Therapies staff seize on the lightest sign of improvement, make it central and abandon the client. There is no evidence that its’ staff appreciate the meaning of the psychometric tests they administer. Wilfully or not they are not listening to the client’s story – ‘just keep the production line rolling‘ is the mantra.

Dr Mike Scott

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Case Conceptualisation Rules – Should It?

Most clinicians match clients to their prototypes of disorders. But how much information should you collect before matching ? ‘Since Persons (1980) and Judith Beck (1996) ‘Case Conceptualisation’  rules. But there has been no demonstrated added value of ‘case conceptualisation’ .

Prior to these authors there was simply ‘case formulation’ [see www.psychologytools.com for examples of formulations of most disorders] which was the way in which a person was an exemplar of a particular disorder e.g a person with panic disorder might say that in their 1st panic attack they t0ok their palpitations as evidence that they were having a heart attack, but though nothing untoward physically happened they became hypervigilant over bodily sensations and avoided provoking  any such symptoms. Applying Clark’s cognitive model of panic disorder the key dysfunction is catastrophising  and avoidance of opportunities to disconfirm the catastrophic cognitions. A case formulation requires 1st of all a reliable diagnosis, what they are a ‘case of’  and an example of the mechanism by which this disorder is brought about. As such there are clear limits of the range of information that is pertinent to a ‘case formulation’. Making it usually a manageable task for the clinician at 1st interview  and  to set a pertinent homework exercise. Contrast this efficient use of time, with a real-world impact, with what happens when the focus is on ‘case conceptualisation’.

With case conceptualisation  there is no control of information variance, the therapist likely assembles information under a number of headings,  but this information does not speak for itself

 

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Case conceptualization Kuyken 2009

The therapist arbitrarily selects a piece/s of information and  claims it/they are pivotal  e.g their father was alcoholic, they were involved in a life threatening incident. The descriptive information of itself is not prescriptive of a mechanism. One could assemble information under the above headings ‘until the cows come home’ it would make no difference, it is arbitrary to stop at any particular point. In this context clinicians easily succumb to ‘formulation nausea’ a condition arising from a bewildering array of arrows. Presented with such a picture clients can easily feel a victim and or blameworthy and disempowered. They are unlikely to have any success experience any time soon, homework is delayed. Therapy becomes an exercise in the acquisition of meaningless data, with the client likely to default. In fairness Judith Beck ( Centre for Cognitive Therapy 2018) does retain diagnosis in her case conceptualisation but this appears to be lost in translation, at least in UK CBT courses. 

It is 15 years since Kuyken et al produced their seminal work on Case Conceptualisation, recognising the evidence base for it was lacking but expressing confidence that this would be repaired. But no such further evidence has been forthcoming [Easden and Kazantis (2018)] and state that ‘the efficacy of case conceptualisation in CBT has yet to be demonstrated’.What has actually happened is that the framework of Case Conceptualisation, minus the diagnosis component, has been passed on to training courses and taken as gospel. Thus whilst there is a consensus about the importance of case conceptualisation there is a conspicuous lack of evidence, at least about what is customarily put into practice. Better returning to simply effective CBT [Scott (2009)]

The Kuyken model of case conceptualisation, suggests that the latter is an emergent property of a ‘soup’ , into which everything is thrown in,  genetic predisposition, precipitants of episodes etc. But this is reminiscent of the claim that life emerged from a ‘primordial soup’, there is no specificity of mechanism.  It is claimed that case conceptualisation is at another level of abstraction to case  formulation. This may well be the case, but there is no evidence that the former helps the latter. Contrast this with the multidimensional description of patients difficulties in DSM IV axis 1 disorders e.g depression, PTSD axis 2 disorders personality disorders, axis 3 physical disorders, axis 4 psychosocial stressors and  axis 5 judgement of overall functioning .   Applying this framework to a person in Gaza with likely PTSD symptoms would greatly change the therapeutic approach. It might well be concluded that the ‘toxic environment’ precludes psychological treatment at this point in time 

Dr Mike Scott

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All Therapies Are Equal and Must Have Prizes?

A just published paper in the Journal of Clinical Psychology by Smith and Hewit (2024) proclaims the equivalence of psychodynamic and cognitive behavioural therapy for depressive disorder in adults. At face value it supports the Dodo verdict – that all psychotherapies are equal and it is the common factors between them that makes a difference. But the authors appear to be operating in a parallel universe:

  1. It is impossible to discern from the 10 studies considered what proportion of people in each condition were recovered in the sense that they considered themselves back to their old selves and the duration of such a return.
  2. Only 4 of the 10 studies used independent blind-raters.
  3. Patients had 22-25 treatment sessions, this impossible to provide in routine practice, but this is not even mentioned
  4. Only the results on completers could be furnished, no intention to treat analysis.
  5. Only 4 of the 10 studies assessed treatment adherence.
  6. The authors observe ‘ The HRSD was the most commonly used measure of depressive symptoms across included studies. However, research suggests that the HRSD’s total score is multidimensional, that its factor structure is not invariant across different populations, and that its conceptualization of depression is several decades out of date (see Bagby et al., 2004 for review). Hence, future research would likely profit from using a more psychometrically sound assessor‐rated measure of depression’
  7. 75% of the population was female, no report of social class. 4 studies did not report ethnicity.

Real-world avoidance is it seems ripe

 

Dr Mike Scott

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IT’s A NICE Fiction That Mental Health Guidelines Are Implemented

It is a working assumption of NICE that its’ mental health  clinical practice guidelines (CPGs) will be implemented. If they are not what is the point? NHS Talking Therapies has fostered the myth of compliance without providing any evidence, to secure Government funding.

 To take an example in 2022 NICE published its’ Depression Guidelines advocating group CBT as the gateway to treatment. But this has never happened. BABCP is currently providing webinars on ‘CBT Informed Groupwork’ despite the lack of evaluation in randomised controlled trials and inattention to reliable diagnosis. The evidence-based protocols for group CBT are diagnosis specific [see my book Simply Effective Group CBT published by Routledge in 2013.. NHS Talking Therapies will undoubtedly embrace ‘groupwork’, as part of its mission to increase accessibility turning a blind eye to the issue of effectiveness  and reliable diagnosis. 

The problem with Clinical Practice Guidelines is however not confined to UK. A recent review of CPG ‘s for PTSD [PTSD Research Quarterly vol 35]  by the US National Center for PTSD Jessica.Hamblen@va.gov subject found that most clinicians a) didn’t know about the CPGs and b) of those that did most chose to ignore, largely because of their belief that their client was somehow ‘special’ and was not appropriate for an evidence-based protocol (EBP).

There needs to be a debate about fidelity, it seems likely that what the public are served is  poor fare. But the Service Providers and their fellow travellers including government  will not countenance such a notion and studiously avoid, not only open debate but any support for an independent evaluation. 

Dr Mike Scott