Month: April 2024

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NHS Talking Therapies Makes No Difference

Improvements on the PHQ-9 and GAD-7 are the metrics that the Service uses to justify its’ effectiveness. But data from a study by Graham et al (2020),  shown below, reveal the changes in both these measures on a waiting list i.e simply with the passage of time:

Time PHQ-9  GAD-7
Baseline 13.6(5.2)) 11.2(4.7)
Week 4 11.9(5.6) 10.7(5.2)
Week 8 11.4(6.6) 9.8(5.5)
Week 12 8.0(5.9) 7.0(4.5)
Week 16 7.0(5.4) 6.0(4.8)

Inspection of NHS Talking Therapies Data for 2022-2023  

reveals the following changes on the PHQ-9 and GAD-7 from the beginning to end of treatment (for those initially at a casenness level):

  PHQ-9 GAD-7  
Beginning treatment 15.4(5.5) 14(4.5)  
End treatment 9.4(6.4) 8.4(5.7)  

These results are not discernibly different to those on Graham et al’s 2020) waiting list! No added value for ‘psychological treatment’ has been demonstrated. Importantly there is no evidence that NHS Talking Therapies ministrations make an enduring difference to client’s lives.

According to the IAPT (NHS Talking Therapies predecessor) Manual – a reduction of 6 or more on the PHQ-9 and a reduction of 4 or more on the GAD-7 is taken as clinically meaningful improvement. If the person has reduced to below 10 on the PHQ-9 and below 8 on the GAD-7 they are deemed to have recovered. Thus judged by NHS Talking Therapies  yardstick those on Graham et al’s 2020) waiting list are an unbridled success! There is clearly something very misleading about the Service’s use of the                PHQ-9/GAD-7 metric.

 Why then is the UK Government spending £2billion a year on Adult and Child NHS Talking Therapies.

Dr Mike Scott

 

 

 

 

 

 

 

     
     
     
     
     
     
     
   
     
     
     
     
     
     

 

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The Lived Experience of Psychological Treatment

On June 28th 2022 Mad in America published my piece ‘The UK’s IAPT Service Is An Abject Failure’. Unsurprisingly the Service was re-branded NHS Talking Therapies in  January 2023.  I’ve just discovered that on March 16th 2023, Ewan Beck reported his lived experience of the Service thus:

‘I went through IAPT, and a lot of what you’ve said here resonates with me. 

I was going through a particularly low period at the time, which tends to happen to me every now and then, but this was the first time in years that I was experiencing suicidal thoughts and urges to self-harm, so I decided to finally try and get help. I saw a mental health advisor at work who referred me to IAPT, and following a short assessment over the phone, I was short-tracked (because of the suicidal thoughts I guess) and given weekly over the phone appointments. 

My therapist was nice enough, but the sessions were highly impersonal, stilted, and even patronising at times. In the first session I explained that I had issues with anxiety, that I’d read up about mindfulness etc. but had never been able to make anything work. My therapist then proceeded to explain what anxiety was, the fight or flight response and it’s supposed origins in our hunter-gatherer past. Things I’d read a gazillion times already, as he might have known if he’d asked, or even guessed from what I’d already said. Worse than that, every week I had to remind him of the details of our previous conversations, and he would often repeat things we’d already gone over.

His advise was never personally catered to me or what I was saying. Once we reached the 6th session (I think) he told me that I was going to be discharged because my scores showed I’d improved. I was a baffled, I didn’t even realise I had given higher scores, and I didn’t feel as though I’d really made any progress. As you allude to in this article, I’ll hit a low and then come somewhere closer to normal after a few weeks. That doesn’t mean I’m cured or have progressed mentally in any fundamental way. When I said to him that I didn’t feel like I was done, he said that because of my test scores, unless there was some specific issue I needed help with, his “boss” would tell him to discharge me. So I said that actually I was still feeling worried about bumping into an ex-friend I’d had to cut-off recently (whom we’d talked about in previous sessions). He was pretty dismissive of that, he made me feel like I was making a big deal out of nothing, saying something along the lines of “you know eventually it might happen and it will be fine when it does”. 

I thought that maybe I’d just been unlucky with it, and could give it another go if I got bad again. But over the next few months I found out a few of my friends had also been through the service, and they’d all had very similar experiences. None of them had found it helpful, all 3 mentioned it feeling awkward and that they felt their therapist was patronising them (which is more likely just a byproduct of the impersonal process than the fault of the therapists themselves).

To give some credit, when I did my initial assessment I had mentioned that I wasn’t happy in my work, and that I found filling out application forms really brought out feelings of self-loathing, so they also put me onto a job coach, who was much, much more helpful than IAPT. She actually listened to me, remembered the things I would say, and catered her approach to me personally. She was great, and I actually managed to change jobs with her help. Thinking about it now, if my scores did improve, it was certainly more thanks to her than the IAPT.

 To give some credit, when I did my initial assessment I had mentioned that I wasn’t happy in my work, and that I found filling out application forms really brought out feelings of self-loathing, so they also put me onto a job coach, who was much, much more helpful than IAPT. She actually listened to me, remembered the things I would say, and catered her approach to me personally. She was great, and I actually managed to change jobs with her help. Thinking about it now, if my scores did improve, it was certainly more thanks to her than the IAPT.

Updating to today, NHS Talking Therapies forthcoming conferences are sponsored by a) Limbic an artificial intelligence company and b) Silver Cloud, an online CBT self-help platform. The claims of neither have been independently verified. Small wonder that the robots are taking over.

Dr Mike Scott

 

 

 

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NHS Talking Therapies has been given uncritical acclaim in an international declaration

on the future of psychological treatments, but closer inspection of the authors of the paper, in the Clinical Psychology Review, reveals that one is the lead psychologist of the Service, another his partner and another a former researcher in their Department. No mention is made of any study that casts doubt on the evidence for the effectiveness of the Service. If this is not allegiance bias, I do not know what is, yet the matter is not even raised.

The mantra of a 50% recovery rate is quoted as gospel, with no dissenting voices from the great and the good. It appears to matter little to the international luminaries, that NHS Talking Therapies (and its predecessor the Improving. Access to Psychological Therapies Service):

  1. has never been subject to independent evaluation, using a ‘gold standard diagnostic interview
  2. there has been no fidelity checks to see that practitioners deliver what they say they deliver
  3. the best evidence suggests a tip of the iceberg recovery rate Scott (2018)
  4. only 40% of clients compete 2 or more treatment sessions

How NHS Talking Therapies Has Got Away With It

The paper reveals that they told the UK Government it can get people back to work, thereby paying for itself. But it did this without referring to its own data,  but by quoting a) an apparent Norwegian study that included the British lead psychologist, but is not found in the references at the end of the paper and I have not been able to locate it  and b) citing a Spanish study, of their IAPT, which bizarrely makes no claim that it got people back to work.

‘Recently helped secure UK government funding to expand further the English iapt workforce so that 344,000 more people can have a course of treatments in the next five years (UK Government Back to Work Plan 2023)’ it states.

Dr Mike Scott

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No Evidence of CQC Monitoring NHS Talking Therapies and It Is Not Going To Happen Anytime Soon

The Service has talked its’ way into unaccountability for the £2billion cost each year of child and adult mental health services in primary care.  We would never know, but I bet even, MI5 and MI6 have not achieved this feat! Perhaps they might give a webinar to other Government Departments?

On April 5th I received the following e-mail from the CQC:

‘Dear Dr Scott

Thank you for your further email of 22 March and apologies for the delay responding.

Having co-ordinated a search with colleagues I can confirm that CQC does not hold information which you have requested as it is not currently within our remit.  All our inspection reports of services are publicly available on our website.

As previously stated we are working with DHSC, trade associations and other key stakeholders to identify and understand how we may assess and rate psychological therapies in the future and to make sure our legislative powers cover all which needs to be covered, which may include NHS Talking Therapies for Anxiety and Depression previously known as IAPT services.

To assist you with information requests, I would be grateful if you could direct future queries to enquiries@cqc.org.uk to ensure your request for information is directed to the relevant department within CQC.

Many thanks

Mat’

Where does one go from here?

 

Dr Mike Scott

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The Centrality Accorded to an Anxiety Label Determines The Level of Avoidance

 according to a study by Ahuvia et al 2024 [Ahuvia, I., Eberle, J. W., Schleider, J. L., & Teachman, B. (2024, March 21). Anxiety Identity Centrality Is Associated With Avoidant Coping in Anxious Adults. https://doi.org/10.31234/osf.io/5wgnc (Link)]. To assess centrality, members of the public scoring highly on a measure of trait anxiety were asked to consider 2 circles, one labelled ‘me’ and the other labelled ‘anxiety’. Then to consider the extent of overlap between the two circles, on a 1-5 point scale, were a one would mean no overlap at all (minimal centrality), to a 5 which would denote total overlap (maximal centrality) and that anxiety was central to their identity.  Their findings applied whether the focus was on situational anxiety or on emotional avoidance. The results stood up when differences in the severity of initial anxiety was taken into account. 

People commonly bestow a mental health label before they first see a mental health professional e.g ‘I have always been a worrier’, without any evidence they are worse in this regard, than anyone else.  Or ‘my father developed dementia, my concentration has become poor, I will probably follow in his footsteps’. On the one hand the label confers a sense of identity but on the other as Ahuvia et al 2024 have suggested, it may result in avoidance of anxiety evoking situations e.g a busy shop, or emotional avoidance e.g non-attendance at a funeral, ‘don’t want to get upset’. The anxiety is thereby perpetuated. 

In principle a psychological therapist could help reduce the overlap of the 2 circles. But centrality has not been a focus in CBT, except in my works on trauma [ I have addressed the Centrality issue with regards to trauma extensively in the clinician handbook ‘ Personalising Trauma Treatment : Reframing and Reimagining’ Routledge (2022) and in the 2nd edition of the self-help book ‘Moving On After Trauma’ to be published in June, by Routledge]. The Centrality framework is also clearly pertinent beyond trauma.

NHS Talking Therapies the main provider of UK primary care mental health services, staff do not make diagnoses. GPs mental health diagnoses are usually vague e.g ‘mixed anxiety and depressive disorder’, but can be more specific, though no more reliable, in the wake of an extreme trauma when PTSD may be opined. It seems likely that most people use largely publicly available information on disorders to explain their difficulties.

In the anti-psychiatry movement psychiatrists are often branded as the villains of the piece for making diagnoses. But their domain is largely restricted to those with moderate-severe impairments, who are at the top of a pyramid of prevalence with the great majority of sufferers being at the base of the pyramid. It is arguably the insidious effects of self-diagnosis that is the bigger problem numerically than those effected by severe mental illness. Most people with a recognised psychiatric disorder are likely to be mildly affected with comparatively few at the moderate-severe end. Judgements at the mild end/difficulties are likely to be the most unsound and it is in this area that self-diagnosis is likely to be most in evidence. In the real-world, self-diagnosis is likely to be far more prevalent than diagnoses made by usually psychiatrists on those with moderate to severe disorder.

A mental health professional can be alert to the sabotaging behavioural and emotional avoidance consequences, highlighted by Ahuvia et al (2024] that can arise from over-identification with a diagnostic label, ‘this is who I am’ and strive to separate difficulties to be addressed from the person. A process akin to stopping a person with a physical disability defining themselves in terms of it. But the lay person who has self-diagnosed is likely less equipped to address the centrality issue.

 

Dr Mike Scott