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NHS Talking Therapies Black Hole

Data is only publicly available on the 1 in 2 people who undergo treatment, those who have had just one assessment/treatment session have disappeared down a black hole for the past 16 years. This is hardly the transparent and comprehensive monitoring of outcome claimed in the NHS Talking Therapies updated Manual.

But following a Freedom of Information request (FOI) I have obtained data on those attending only 1 session. But the diagnostic status of almost a third (29.1%) was unknown, making the Services claim to follow NICE approved diagnostic specific protocols meaningless. 

 


The Manual 5.1.3  recommends ‘systematic screening for all the conditions that NHS Talking Therapy treats’.  But there are 11 conditions that the Service treats.There is no evidence that at assessment its’ clinicians employ a standardised screen for the spectrum of disorders that they claim are within their remit to treat. Nor that they use a screen to rule out the disorders that they do not treat: personality disorder, psychosis, bipolar disorder and eating disorder. In the foreword to the Manual it states that those who do not go on to treatment are given ‘advice and signposting (if appropriate)’. But there is no clarity about the content of this ‘advice’ nor of its’ evidence base.  Signposting it seems may not occur, but this could plausibly be because the assessing clinician (usually the most junior member of staff- a Psychological Wellbeing Practitioner) simply doesn’t know the way.  One has a strong suspicion that those who have simply an ‘assessment’ disappear down a black hole, only to possibly re-emerge in desperation, when their difficulties have not resolved.

NHS Talking Therapies published data is at best consistent with passing improvement, for disorders that largely wax and wane anyway. 

Dr Mike Scott

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Something Is Very Amiss In Routine Care – There Is No Evidence of Translation From The Evidence-Based Psychological Treatments Of Randomised Controlled Trials

according to a meta-analysis in the Journal of Affective Disorders. This echoes my own finding of only a significant minority recovering in NHS Talking Therapies Scott (2018). The results are a far cry from the 50% recovery rate claimed by NHS Talking Therapies.

“It makes little sense to conduct hundreds of randomized trials on psychological treatments when they do not lead to better routine practice.” For those in care as usual only 1 in 6 or 7 recovered.When care as usual is persistently failing, the punters are clearly not being listened to.  It is like Stalinist Russia proclaiming another successful 5 year plan, when in reality the peasants are starving .

Where did it all go wrong?

Dr Mike Scott

 

 

 

 

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NHS Talking Therapies Totally Fails The Traumatised – But There Is A New Way of Moving On

On June 5th, 2024 under a Freedom of Information Request (FOI),  NHS Talking Therapies informed me that in the year 2022-2023, 23,069  people with post-traumatic stress disorder had just one assessment/ treatment session with the Service. 

 

The FOI data reveal that for those attending just one session, those with PTSD have higher mean scores on both the PHQ-9 (17.9) and GAD-7 (15.6)  than any other diagnostic group. Further these mean scores are higher than those who start treatment  mean PHQ-9  of  15.5 and GAD-7 14.1. It thus appears that those who have only one session are likely more traumatised than those who go on to have treatment. 

It appears that there is something radically wrong with the traditional trauma-focussed approach to trauma adopted by NHS Talking Therapies. My new self-help book, Moving On After Trauma (2nd edition) published by London: Routledge on June 13th 2024, takes a radically different, more user-friendly approach. Instead of positing that the primary difficulty lies with arrested information processing at the time of the trauma and the consequent need to re-live it therapeutically, I suggest that what is pivotal is the centrality accorded to the trauma for today and that there is no need for a re-traumatisation of the client. My clinical handbook ‘Personalising Trauma Treatment: Reframing and Reimagining’ published in 2022 by Routledge, spells out the specifics of this approach for clinicians.

Accordingly I am adding a ‘Moving On After Trauma’ page to this website for clinicians, those who have been traumatised and those travelling the road with them. Here are my 12 rules for Moving On:

  1. Begin building a bridge between yourself now and the person you were before the trauma. Start by doing a little of what you did before. Constucting gradually as wide a ranging an investment portfolio as you can manage.
  2. Expected that building the bridge, like all forms of construction, will be steps forward and one backwards. It will need daily commitment.
  3. Don’t block the memories of the trauma, the harder you push them away the more they spring back.
  4. Put the traumatic memories in their place by questioning their relevance to today’s plans.
  5. Don’t get hooked by what could have happened. That is just a horror video which spoils today, with dark imaginings.
  6. Expect that the traumatic memory will knock at the door of your mind daily. But it is only asking about its’ relevance to today. Calmly answer this visitor.
  7. Go by what you would bet £5 on happening today, not by how vivid the traumatic memory is and how upsetting you find it.
  8. Remember that guilt is about deliberately doing something wrong. Trauma related guilt is bogus, it arises from either believing you should have looked into your crystal ball before the trauma or that you actually had the time to have done something differently. Feeling guilty and being guilty are not the same.
  9. Refuse to see flashbacks/nightmares as credible forecasts of what is going to happen today. Being constantly on the edge of your seat is about the past not the future.
  10. Give people the time of day. Expect to feel disconnected from others as you are looking at your world through war-zone glasses. Try on the pre-trauma glasses, they are more reliable. The view through them is based on a lifetimes experience rather than on a single drama.
  11. Refuse to take your alarm going off as evidence of danger- it’s just a ‘dodgy alarm’. Tripped easily by anything not exactly as you would want it, reminders or any unusual but not abnormal bodily sensation/s.
  12. Refuse to look at yourself and your personal world through the window of the trauma. Don’t make the trauma, pain or disability central.

 

 

Dr Mike Scott

 

 

 

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Minimalist Approach To Depression Doesn’t Deliver

A just published study in Lancet Psychiatry shows that just screening people for depression  using a PHQ-9 score of 10 or more, doesn’t help the patient, whether or not they and/or their GP are informed. A month after baseline, PHQ9 scores in all groups reduced by 4 points  and remained at this level in follow-up. 

Based on a diagnostic interview only a third of the sample met DSM diagnostic criteria at follow up. But in NHS Talking Therapies, a PHQ-9  score of 10 or more would usher people along a depression treatment pathway. This study indicates that two out of three people would have been directed along the wrong path. Watchful waiting is called for, oftentimes there is just a passing crisis in a person’s life.   Clients need comprehensive assessment, monitoring and treatment. NHS Talking Therapies’ simple dichotomy of low and high intensity interventions is not fit for purpose.

A screen by itself is simply a ‘scream’

Interestingly in the feedback to GPs ( the study took place in Germany) they were told  that ‘a diagnosis cannot be made on the basis of the screening score alone’ and there was a ‘recommendation for further assessment and treatment for any depressive disorders that might be present’. NHS Talking Therapies clinicians are not informed of the need for a thorough going assessment.  There is no diagnosis-informed care. The Service expects clinicians to  continue to work in the dark. Only a quarter of the sample received psychotherapy or an antidepressant.

Dr Mike Scott

 

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‘The UK NHS Talking Therapies Fantasy’

was published on May 23rd 2024 by the Spanish Society for Clinical Psychology   in its’ inaugural journal, Psicología Clínica – it is my updated critique of  the Service. My hope is that it will make countries think twice about adopting the UK model. It was a focus of a 1000 strong gathering of the Society in Cadiz. My thanks to the Editor and staff of the Journal, I wish them well in their new endeavour.

 

In this paper I refute the following myths:

Myth 1 It’s a World Beater

Myth 2 50% Recovery Rate

Myth 3 Real World Lasting Changes

Myth 4 Appropriate for All-Comers

Myth 5 It Delivers Evidence-based Psychological Therapy

Myth 6 Low Intensity Interventions Are Effective

Myth 7 Monitoring Is at the Heart of NHS Talking Therapies

Myth 8 Formulation Is Sufficient, No Need for Diagnosis

Myth 9 It Works Having the Least Qualified Practitioners as Gatekeepers

Myth 10 Talking Therapy Is the Same as Psychological Therapy

Myth 11 It’s Fine that NHS Talking Therapies Has Only Ever Marked Its’Homework

Myth 12 It’s Better Than What Existed Before and Better Than Support – It’s Value for Money

 

Dr Mike Scott

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A Decade of Digital CBT- Questionable Effectiveness and Advertising Standards Concerned

yet it is at the heart of NHS Talking Therapies, with 635,759 sessions of internet enabled therapy taking place in 2022-23.  Recently an Editorial in the American Journal of Psychiatry bemoaned the dirth of quality evidence in support of Digital Mental Health (DGMH). Nevertheless one of the sponsors of NHS Talking Therapies networking events, Silver Cloud is still proclaiming that its’ computerised CBT has ‘up to a 70% recovery rate’. It is registered in Ireland and The Irish Advertising Standards Authority told me on May 14th 2024 that they ‘have ongoing concerns that the recovery rate statistic continues to change’ and need to investigate and will revert back to me when the investigations are concluded.

 

A particular concern raised in the American Journal of Psychiatry is that a randomised controlled trial of a digital version of dialectical behaviour therapy (DBT) for suicidal clients vs waiting list found that those who underwent DBT did worse in terms of harming themselves or completed suicide. The Journal suggests that the best evidence for DGMH  comes from a randomised controlled trial of depressed and anxious patients in primary care, assigned to 16 weeks of CBT or treatment as usual. It was indeed the case that at the 4 and 8 week marker those in CBT were outperforming those on the waiting list but by the 12 and 16 week markers there was no difference in PHQ-9 and GAD-7 scores. These authors have engaged in spin to assert that there must be something beneficial about low intensity CBT. The spin is even more in evidence when the authors fail to mention that the comparison for CBT was a waiting list (people don’t expect to improve on a waiting list) rather than a credible attention control condition. It is a striking example of poor methodology. Even these authors appear to operate with a heuristic that ‘there must be something good about low intensity CBT’.

Dr Mike Scott 

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NHS Talking Therapies Claim To Parity Of Effectiveness With Clinical Trials – Fantastic Marketing, But Totally Bogus

The Service has never been evaluated with the rigour, comparable to that employed in randomised controlled trials i.e using blind independent assessors. NHS Talking Therapies has only ever marked its’ own homework. To compound matters further it has only taken a PHQ-9/ GAD-7 snapshot of  the person at their last contact with the Service. With nothing to indicate the duration of any gain or whether the change on these measures is clinically meaningful. 

Despite this the Service’s Manual cautions:

‘most referrals to NHS talking therapies will have elevated scores on the PHQ-9 nine and GAD-7. But this does not necessarily mean that they are suffering from clinical depression or generalised anxiety disorder. Unless the assessment process for all the NHS talking therapy relevant conditions, there is a risk that people will be started on the wrong treatment”

But the Manual also states that the Service treats 11 conditions and excludes 4 from its remit. Thus we are invited to believe that its clinicians screen for 15 conditions, but is silent on the mechanism by which this is achieved!  The assessors are for the most part by the least qualified (Psychological Wellbeing Practitioners). It is simply not credible that they have wherewithal to conduct such a comprehensive assessment and conduct it on the telephone, in the at most 1 hour assessment. 

The Service digs a deeper whole for itself when the Manual states ‘Focused supervision that starts by looking at the patient questionnaire scores and any changes on these’. The Tests are completed at every session. Clinicians can be called to task for not reaching a 50% recovery ate on the measures. Clearly the two questionnaires are expected to be central to the sessions leaving  little space for the alleged comprehensive screening. The authors of the Manual clearly suspect that things are going badly awry with treatments but their response is akin to that of the Post Office hierarchy with regard to sub-postmasters.

Dr Mike Scott

 

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The NHS Talking Therapies Pathway – ridden with potholes

 

The latest data from the Service shows that in 2022-23, of those at the start of the pathway, 1.76 million, a third (31%) decided that this route was not for them and they did not move beyond an initial contact. Of the 1.22 million who had an assessment, half (44.9%) did not go beyond this one session. Thus, the first two potholes are of a comparable size (i.e the proportion defaulting).

Treatment (defined by the Service as people attending two or more sessions), follows a stepped care model, so that after the 1st two potholes you come to a fork, with 3 possible paths, shown in  Table 1 below, whichever one is taken the majority do not finish treatment

Table 1 Casualties in Stepped Care

 

Referrals finishing treatment

Percentage  referrals finishing

Mean number of sessions

Low intensity only

241,200

35.9

5.5

Both low and Hi intensity

262,063

39.0

10.3

Hi intensity therapy only

141.137

21.0

8.7

 

The potholes following the fork (i.e the proportion of people who default) are thus deeper than those before.

The pathway needs to be closed for repair and a diversion e.g attendance at a Citizens Advice Bureaux or local Charity,  needs to be put in place. There is no evidence travellers would be worse off. It would certainly cost a lot less than the £1 billion a year spent on Adult Mental Health Services in Primary Care.

 

Dr Mike Scott

 

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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