Take a look at ‘Personalising Trauma Treatment: Reframing and Reimagining’ here https://doi.org/10.4324/9781003178132. To access the abstracts of each chapter you have to first register with Taylor and Francis Publishers
Evidence-based psychological therapies are near extinction. Their demise began in 2008 with the inception of the Improving Access to Psychological Therapies (IAPT) service. Aided and abetted by the British Psychological Society’s validation of IAPT’s Psychological Well-being Practitioner’s (PWPs) training programmes and the service’s fellow traveller, the British Association for Behavioural and Cognitive Psychotherapy (BABCP). Gone is the welcoming open door and the careful distillation of what ails the client, instead there is a 30 minute+ telephone conversation, with a third of people then not going beyond one treatment appointment.
The public most commonly receive PWP ministrations when they seek NHS psychological help. But the PWP’s do not follow any treatment protocol for any disorder, indeed they do not make diagnoses. How then can they be said to deliver CBT? By the spurious claim that they can select a CBT strategy which is sufficiently potent. But they furnish no evidence of systematically following any strategy, notwithstanding that there is no evidence that CBT strategies delivered as stand alone interventions make any real world difference. The PWP’s deliver the Alice in Wonderland, Dodo verdict on CBT strategies ‘all are equal and must have prizes’. Raising the question ‘is CBT as dead as the Dodo?’
Where else might CBT be found? It is not impossible for it to be delivered in IAPT’s high intensity service, but few of its practitioners conduct a reliable standardised diagnostic interview which is the foundation for delivering CBT. The treatment integrity of high intensity CBT interventions has never been assessed. No steps have ever been taken to ensure clinicians are dovetailing diagnosis appropriate treatment targets with matching treatment strategies. Is CBT to be found in private practice? It is possible, but private organisations have largely sought to ape IAPT in the mistaken belief that this confers credibility. Are the chances of finding CBT in private practice comparable to finding life on Mars?
Is CBT alive and kicking in secondary care? Here we enter the muddy waters of clients who might traditionally be regarded as having personality disorders (PD). But there is an understandable reluctance to use the term PD because of the associated stigma and because historically use of such a term has consigned people to the dustbin. Nevertheless Sperry and Sperry (2016) have produced the 3rd Edition of CBT for DSM-5 Personality Disorders (Routledge) but it is eminence-based rather than evidence-based. It is light on outcome studies. I struggled to find any where there was independent assessment of outcome by blind raters, use of an outcome measure that clients would regard as a minimally important difference and evaluations by those other than the creators of the protocols. It is a free for all with strategies such as ‘thought stopping’ recommended, without specification of any contraindications such as PTSD or OCD. Only eclipsed by recommending solution focussed therapy for anxiety. If clinicians in secondary care operate on this text it is very different to Beck’s own work on CBT for personality disorders. But no typology of what clinicians say they do and what they actually do in secondary care has been produced. Tertiary care seems preoccupied with crisis management and is not guided by any recognisable CBT protocol.
In neither primary or secondary care is there a differentiation of treatments or clients. Thus in the UK it is impossible to answer the question of ‘What Works With Whom?’. This leaves clinicians up a creek without a paddle.
Dinosaurs may have been wiped out by an asteroid hitting the earth 66 million years ago, but life survived, doubtless CBT will survive the impact of IAPT, but it is a close call and it is likely going to be down to individual practitioners doing what they know to be best for their clients.
Dr Mike Scott
Under a heading ‘Long-Covid: interventions not proven’ the May issue of The Psychologist publishes a letter (see below) I wrote with Joan Crawford. The same issue contains an interview with Jo Daniels, the newly appointed Chair of the Scientific Committee of the British Association for Behavioural and Cognitive Psychotherapy (BABCP) outlining her mission to apply CBT to all long-term conditions (LTC). This despite a paucity of evidence that CBT protocols matched to a specific LTC make any unique contribution. She proclaims “It is now commonly accepted that CBT ‘works’ to a greater or lesser extent for most physical health conditions”, this is grist to the mill for the expansionism of the Improving Access to Psychological Therapies (IAPT) service. But contrary voices do not get a hearing in BABCP, echoes of Russia.
‘The underlying message of Dr Siddaway’s article ”We need to talk about Long-Covid” in the March 2022 issue of the Psychologist is that there is or will be an added value from psychological intervention for those affected by Long-Covid i.e Covid of more than 3 months duration. But the Scottish verdict ‘not-proven’ seems appropriate.
There can be no doubt that offering emotional support to people like Grace, cited in the article, is an important resource for anyone suffering from a long-term medical condition. But there is a distinction between the provision of emotional support (travelling alongside) and delivering a psychological intervention (fixing). The latter is inevitably more costly, requiring more highly trained staff and therefore less likely to be available. Is it a proper use of scarce psychological resources to offer psychological treatments to those with Long-Covid?
Clearly if a person with Long-Covid suffers from an additional disorder such as PTSD or depression a case can be readily made for addressing the comorbid disorder. But the effectiveness of this treatment, in such circumstances, remains to be demonstrated. There are no randomised controlled trials of the psychological treatments of Long Covid plus or minus comorbid disorders. Thus, the evidence for the efficacy of treatment must be currently regarded as weak.
Siddaway suggests that it is possible to extrapolate from studies of chronic fatigue syndrome and pain and apply the strategies to Long-Covid. But there are significant problems with this: a) it assumes Long-Covid is in the same domain as CFS and pain, but arguably, there is little evidence that this is a homogenous category b) the evidence base for the efficacy of psychological treatment for CFS Is problematic if objective indices of outcome are insisted upon c) the evidence base for psychological treatments for CFS and pain, such as it is, is for protocols and not for the components of the interventions, such as pacing or distraction. Using strategies out of context is problematic.
Siddaway appeals to a biopsychosocial model to justify psychological intervention for Long- Covid, despite any evidence that mood and coping strategies make a significant difference to the physical symptoms of Long-Covid. The proposed model ” the complexity of Long-Covid” is not capable of falsification, any factor e.g a hostile working environment, could be proposed to be pivotal in the development of Long Covid, but not ruled out. As such it is not a model.
It serves the interests of the powerholders of psychological therapies to transmute the physical disorders into candidates for psychological intervention. An extending of Empires. This is not to say that psychological intervention may not sometimes be helpful in the context of a long-term medical condition but unless the population is clearly specified clients will be failed by inappropriate treatments and services exhausted.
This is a restatement of the question asked by Roth and Fonagy in their seminal work ‘What Works for Whom’ (2005) Guilford Press. This text formed the backbone for the National Institute for Health and Clinical Care Excellence (NICE) recommendations on psychological therapy. The Improving Access to Psychological Therapy (IAPT) service has made a formal commitment to observe the NICE guidelines. PWPs are the most common providers of psychological interventions in IAPT. They have been operational for over a decade, at a cost of £billions, answering this question with regards to this professional group is therefore long overdue.
PWPs Modus Operandi
The BABCP ‘PWP Registration and Renewal Policy’ under a heading ‘Core Principles’ states
‘PWPs are specially trained to work with people who have common mental health problems such as anxiety disorders and depression, to support them in managing their recovery…….are revolutionising our approach to the delivery of psychological therapies in a number of specialist areas…..Have graduated from a British Psychological Society (BPS) Accredited PWP training course/apprenticeship’.
PWPs deliver low intensity CBT, defined by Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803 as offering 6 hours or less client contact. The input can be any self-help material. This is a ‘revolution’ in that it is substantially less dose of therapy to that in the high intensity CBT prescribed in the randomised controlled trials of CBT for depression and the anxiety disorders, with 10-20 sessions being the norm.
IAPT’s Magical Beliefs Include:
‘ Six hours or less clien’t contact makes a real world difference to client’s lives’ and ‘inputting any self-help material will do the job’. But what is the evidence for these beliefs? At the advent of IAPT Lars-Goran Ost (2008) published a set of key questions (see the end of this blog) that researchers had to satisfactorily answer for a treatment to be considered an Empirically Supported Treatment (EST). No judge would declare that these injunctions/criteria have been comprehensively answered in any of the low intensity CBT studies. It follows that low intensity CBT is not an EST.
The Government and IAPT
The Government’s wish to push ahead with low intensity CBT parallels Priti Patel’s insistence that refugees are sent to Rwanda, over the heads of Civil Servants who claim that it should be first demonstrated that this makes economic sense. Once the powerholders decide on a course of action, they are unrestrained by any moral imperatives to show compassion and hospitality. It is immoral to offer a dose of treatment for which there is no evidence that it works and to treat refugees so despicably.
Dr Mike Scott
L.-G. O ̈st / Behaviour Research and Therapy 46 (2008) 296–321
- Do not use WLC as the control condition, since criterion I requires a placebo or another treatment.
- Do not use TAU as the control condition, since the methodological problems described above are so extensive.
- Use an active treatment as comparison, preferably one that has been established as effective for the disorder in question.
- Do a proper power analysis before the start of the study and adjust the cell size for the attrition that may occur.
- Use a representative sample of patients, diagnose them using suitable instruments in the hands of trained interviewers, and test the diagnostic reliability.
- Let an independent researcher or agency use an unobjectionable randomization procedure, and conceal the outcome of it from all persons involved in the study.
- Use reliable and valid outcome measures; both the ones that are specific to the disorder and general ones.
- Use blind assessors and evaluate their blindness regarding treatment condition of the patients they assess.
- Train the assessors properly and measure inter-rater reliability on the data collected throughout the study (not just during training).
- Use three or more properly trained therapists and randomize patients to therapist to enable an analysis of possible therapist effect on the outcome.
- Include at least a 1-year follow-up in the study and assess any nonprotocol treatments that the patients may have obtained during the follow-up period.
- Audio- or videotape all therapy sessions. Randomly select 20% of these and let independent experts rate adherence to treatment manual and therapist competence.
- Insert procedures to control for concomitant treatments that patients in the study may obtain simultaneously as the protocol treatment.
- Describe the attrition, do a drop-out analysis and include all randomized subjects in an intent-to-treat analysis.
- Assess clinical significance of the improvement of the primary measures.
as the magician Tommy Cooper would have said. The Improving Access to Psychological Therapies Service (IAPT) invites its’ paymasters Clinical Commissioning Groups (CCGs)/NHS England to fund a simple and cheap solution to mental health problems. If it sounds too good to be true, it probably is. But this hasn’t stopped IAPT becoming the over a £1bn a year magnet for investment and all without independent assessment.
Here is an extract from a Psychological Wellbeing Practitioner’s (PWP) letter to a GP:
Stress Control Course undertaken outcome was successful evidenced by the first and last questionnaire
The PWP is unaware that a score on a psychometric test is not an evidence-based construct. Such scores are not specific to anything. They cannot be used as a surrogate for a diagnosis. ‘Stress’ is a fuzzy, the terms usage in this context, resembles Alice in Wonderland where words mean whatever you want them to mean. Further, a change in the score is not evidence that the person’s needs have been met.
The mechanism’s of action in the original randomised controlled trials of CBT for depression and the anxiety disorders were clearly stipulated. As were outcomes e.g loss of diagnostic status as assessed by independent clinicians. But in the low intensity interventions there is no specification of an evidence-based mechanism for change. In effect we are invited to believe in the magic, it works just like described in the letter abstract. One can only gasp at the incredulity of CCGs and wonder what agenda they are working on. But the British Association for Behavioural and Cognitive Psychotherapy (BABCP), the ‘Lead’ organisation for CBT practitioners has a special section for PWPs and IAPT rejoices that its’ low intensity CBT courses are validated by the British Psychological Society. They have failed clients abysmally.
Dr Mike Scott
abound.These beliefs are inculcated by initial training and maintained by sharing ‘best practices’. For example, low intensity CBT therapists operate, on beliefs such as ‘if I go into the CBT superstore and choose a strategy it will be potent’, ‘my clinical judgement is sufficient to make the right choices’, and ‘improvements in test scores are sufficient basis for believing the clients needs have been met ‘. But these beliefs are not evidence-based.
For the past 50 years it has been taken as axiomatic that ‘arrested information processing plays a pivotal role in debility post-trauma and should be targetted’. In Personalising Trauma Treatment: Reframing and Reimagining Routledge’ (2022)https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwj2r8v8m_j2AhWxQEEAHQrjAGgQFnoECAUQAQ&url=https%3A%2F%2Fwww.taylorfrancis.com%2Fbooks%2Fmono%2F10.4324%2F9781003178132%2F I examined this issue in detail, dissented and concluded that it is the centrality accorded to the trauma that is the driving force for debility post trauma. To the extent that clients utilise the trauma as their window on themselves and their world they are likely to suffer impairment in functioning, both personally and interpersonally. It is a magical belief that the problem lies with the traumatic memory, rather the issue is what the person takes the memory to mean for today (see youtube video https://youtu.be/3UeJ1Lux4pU) detailing how to help the client back to their old selves post trauma – Restorative CBT (RCBT).
‘All disorders are maintained by a negative belief system, making CBT appropriate’, this belief underpins the extension of CBT to the treatment of long-term conditions. But it would not stand up in Court. It would be suggested that the idea is promulgated to satisfy the acquisition of power by service providers. A relatively newly emergent, magical belief is that ‘if children are taught the elements of CBT model/adaptive coping it prevents the development disorder’ this may or may not be true but dogmatism here has no place.
In the Middle AgesIn it was believed that the earth was the centre of the universe and planets such the sun and moon orbited it in circles. This geocentric view of the universe persisted for a long time after it became evident that the earth was not at the centre and that orbits were elliptical rather than circular. Unfortunately the power of the current Teflonocracy will likely lead to the persistence of these magical beliefs for some time to come.
Dr Mike Scott
a meaningless outcome measure.
The January issue of the American Journal of Psychiatry, contains a paper by Delgadillo et al https://jamanetwork.com/journals/jama/fullarticle/10.1001/jamapsychiatry.2021.3539?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamapsychiatry.2021.3539 claiming that 52.3% of those routed along a stratified treatment pathway showed a reliable and clinically significant improvement (RCSI), compared to 45.1% along the Improving Access to Psychological Therapies (IAPT) usual stepped care pathway. The additional cost of the stratified pathway was £104.5 per patient, representing the additional time devoted to a patient to determine the data needed to put into an algorithim and determine whether low intensity should be first or high intensity first. The authors concluded that for this additional sum there was approximately a 7% increase in the probability of RCSI. But at no point do the authors question the validity of adopting IAPT’s self-report metric for outcome.
There has never been independent assessment of treatment outcome in IAPT. Further there is no evidence that the changes in IAPT self-report measures represent an added value over the comparable changes when counselling was employed pre-IAPT. There are a number of reasons why there would be improvements on self-report measures as treatment progresses that have little to do with therapeutic effectiveness including: A) regression to the mean, as patients tend to present initially at their worst B) the test results are a focus in therapy, creating a demand issue for the patient and C) patients, understandably, do not wish to feel they’ve wasted their time.
IAPT ignores the fact that the context in which a psychometric test is conducted is crucial. Used in isolation, they are a mirage of the client’s real-world concerns. The RCSI is a perfectly reasonable outcome measure if used in a controlled trial in which the diagnostic status of the patient has been assessed with a standardised reliable interview, at the beginning and at a minimum post-treatment. But in the Delgadillio et al (2022) study, as in all IAPT studies, no diagnosis is made using in gold-standard semi-structured interviews. The population addressed lacks specificity, the only boundary for entry into the study was a PHQ9 score greater than 10, making replication highly problematic. The title of the Delgadillio et al (2022) study suggests that focus was on depression but there can be no certainty that this is actually that case.
The Delgadillio et al (2022) study does not address whether a patient would see the apparent difference in outcome between stratified approach and a step approach as a difference that matters. It is impossible to gauge from study what proportion of patients lost their diagnostic status along the differing trajectories. The self-report measures used by refer to functioning in the previous two weeks, patients typically have their treatment’s terminated when their score falls below a threshold of 10 on the PHQ9. But anxious and depressed patients experience waxing and waning of symptoms so that a reliable outcome must specify the duration of recovery, for example eight weeks. The supposed recoveries in IAPT could often be flashes in the pan.
Dr Mike Scott
Delgadillo J, Ali S, Fleck K, et al. Stratified Care vs Stepped Care for Depression: A Cluster Randomized Clinical Trial. JAMA Psychiatry. 2022;79(2):101-108. doi:10.1001/jamapsychiatry.2021.3539
is a new body set up by the Royal College of Psychiatrists https://www.rcpsych.ac.uk/improving-care/public-mental-health-implementation-centre to ‘Provide high-quality evidence, advice and recommendations on public mental health to government and other policy-making bodies at local and national levels’. They add ‘If you think that there is an opportunity for us or would like to explore working with us, please contact us at public.MH@rcpsych.ac.uk.’ The PMHIC ‘are keen to Support collaboration and leadership on public mental health with a broad range of stakeholders’. All very laudable, but stakeholders have a vested interest in the perpetuation of their own service. For over a decade the stakeholders have managed to mark their own homework. They are charming, hidden persuaders, with the ear of the powerful.
A starting point for the PMHIC would be to review the independent evidence on the effectiveness of routine psychological interventions in primary and secondary care. But insisting on the outcome measures that are used in the best randomised controlled trials of psychotropic medication. The PMHIC could then make a judgement on the current quality of the evidence on effectiveness and suggest ways forward to improve the quality. In the 21st Century it should no longer be acceptable that treatment recommendations are based solely on the consensus judgement of ‘experts’, many of whom have conflicts of interest.
Dr Mike Scott
New youtube video https://youtu.be/3UeJ1Lux4pU detailing how to help the client back to their old selves post trauma – Restorative CBT (RCBT). Not only for those who have developed PTSD but also for those who have acquired other disorders, whether singly or in combination. The video is based on my new book ‘Personalising Trauma Treatment: Reframing and Reimagining’, available from amazon https://images-na.ssl-images-amazon.com/images/I/5141wjLVgrL._SX331_BO1,204,203,200_.jpg. and published by Routledge.
RCBT is likened to restoring a dilapidated property but in some instances it may be a rebuild on the same site, for those who feel they have never functioned well. Mental time travel to a trauma/s is inevitable but it is what the person takes it to mean about today that is crucial for possible ongoing psychological debility. It is the centrality accorded to the trauma that is pivotal in the development of disorder. The book is replete with metaphor making for ease of dissemination. For example, PTSD clients are invited to consider that they are wearing a pair of ‘war-zone’ glasses and are invited to practice swapping these for the ‘spectacles’ that they would have worn in the weeks before the trauma.
It is suggested that a) there is no credible evidence that traumatic memories are different in kind to ordinary autobiographical memories and b) traumatic memories do not have unique neural basis. Consequently there is no need for clients to relive their trauma. It is much easier for clinicians and clients to consider the adaptiveness of a memory than to relive it to the point of desensitisation. In randomised control trials, trauma focused interventions result in recovery in about 50% of cases. However in routine practice because of comorbidity and population differences, the proportion is likely to be significantly less. Further to the extent that trauma-focussed interventions work, they may do so simply because the client collects experimental evidence that they are not in a ‘war zone’. There is then ample justification for approaching the psychological sequelae of trauma from an RCBT perspective.
Dr Mike Scott
Restorative CBT(RCBT) focuses on getting the trauma victim back to their old selves, as far as possible. It does not require the client to relive the trauma. The difference between RCBT and trauma focussed CBT (TFCBT) is stark when it comes to considering long-term psychological help for those affected by the war in Ukraine. A theme throughout the book is helping trauma victims forgo the ‘war zone glasses’ through which they may view their current environment. The RCBT approach is likely to be more acceptable and easier to disseminate. The specifics are in my book ‘Personalising Trauma Treatment: Reframing and Reimagining’ https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwi_sby24qz2AhUOa8AKHfyaCFYQFnoECAEQAQ&url=https%3A%2F%2Fwww.taylorfrancis.com%2Fbooks%2Fmono%2F10.4324%2F9781003178132%2Fpersonalising-trauma-treatment-michael-scott&usg=AOvVaw1vevwk6WE3_-ghkv14ZpM2 published by Routledge, March 2022. The accompanying commentary and slides give a taster http://www.cbtwatch.com/wp-content/uploads/2022/03/Forget-Trauma-Focussed-Interventions-1.pptx see also Youtube https://studio.youtube.com/video/FN_ck6iCIpE/edit . Do get back to me if you would like to discuss cases.
In this book, clients are taught to rediscover their sense of self by reframing the trauma. Within this new framework the focus is on the client’s mental time travel from the trauma to today and reimagining their future. The therapeutic targets are the thoughts and images (cognitions) that interfere with day-to-day functioning. It does not assume that arrested information processing lies at the heart of the development of PTSD, with a consequent need for the client to re-live the trauma. For those clients who were abused in childhood, their experiences are viewed through a particular central window, but other ‘windows’ may make for more appropriate engagement with their personal world and a reimagining of their view of themselves. Treatment delivery options from telephone consultation, group work and videoconferencing are discussed. With illustrative examples, the author highlights the pathway to recovery for a wide range of clients with the comorbidity often found in real-world settings.
The book will be essential reading for therapists and other mental health professionals working with trauma survivors.
Dr Mike Scott