CBT for Addictions – As Likely As Winning At Roulette

There has been an outbreak of smashing fruit machines in Liverpool: this week a man was given a 12 month suspended sentence for wrecking a well known Bookmakers machines, he protested that they were not helping him overcome his addiction! This followed hot on the heels of the brilliant fictional TV series ‘Broken’ (filmed in Liverpool) which showed identical behaviour in the wake of the suicide of a gambling addict.

A person I saw recently Mr X ,with a lifelong gambling addiction told me that the longest period he had been without gambling was when he bet a fellow gambler who would last longest, he lasted 2 weeks. Sadly his experience of IAPT was woeful he was introduced to the discredited stop technique to distract himself when he had the urge to gamble.  He said that he had a few sessions with the therapist but the therapist left and he was given a new therapist.  Mr X said that a questionnaire was then administered and because he got below certain thresholds it was deemed that he did not need counselling and the therapy was terminated.  He said that he was alarmed at this because he felt suicidal and he wrote a letter of complaint and was then offered further sessions but declined them because he had lost trust in the enterprise.

Addiction services have been managed by local authorities since 2012 , but with typical cuts of 30% many services struggle. People can fall between services as a tender is often times switched after 3 years.

CBT for Severe Mental Illness – Does It Reach the Parts That Matter?

Is IAPT overeaching itself by straying into the Severe Mental Illness arena? ‘Ian’ had a life long history of psychosis, he had a great deal of support/treatment over the years from Richard Bentall, author of the brilliant book ‘Madness Explained’, for which the family were most appreciative.  Unfortunately Ian had his benefit withdrawn on the grounds that he was ‘fit for work’ and I was asked to help. Within  two minutes of my seeing  Ian it was abundantly obvious to anyone that he could not work, he was so agitated,  his visits to coffee shops often curtailed by his paranoia.  In the event I produced a report, which alongside a letter from Richard resulted in his benefit being reinstated, his parents were delighted. I did offer Ian the opportunity to look at better ways of handling his paranoia etc but he declined.  I felt desperately sorry for him and reflected that even if he had taken up my offer I doubt that I would have made a real world difference, at best he would have been thankful for my efforts. I wonder whether CBT for psychosis has been oversold.

In using the term ‘severe mental  illness’ I toyed between this term and psychosis, I was trying to use a common language with the reader and in writing my report to the DWP I said that Ian met the DSM diagnostic criteria for schiziophrenia. Labels can be problematic and indeed might not have a biological basis but they give a direction for treatment and influence eligibility for benefits. Richard Bentall et al wrote an Expert review ‘Drop the language of disorder’ in Evidence Based Mental Health, February 2013 and recommended a ‘problem definition, formulation’ approach rather than a ‘diagnosis treatment’ approach, but in my view it is not a matter of ‘either or’ but a matter of both.  Notwithstanding our differences neither of us were able to make a real world difference in what I would see for want of a better term is Ian’s schizophrenia.

IAPT has a demonstration site for Severe Mental Illness for people with psychosis, bipolar disorder and personality disorder, before disseminating such a service there needs to be independent verification using clinician-rated measures (PSYRATS for hallucinations and delusions, SCID for personality disorders) that such a such service would add anything over and above support in the community, otherwise it is just extending an empire.

Dr Mike Scott

Casualties of Foolhardiness

The more I listen to, read about and consider the progress (or lack of it) of the project that is called Improving Access to Psychological Therapies (IAPT) the more thoughts of the actions of the generals in World War One spring to mind. Haig was a classic study in the unwavering belief of cavalry even in the face of machine guns, he had no idea of the conditions his troops were fighting in, he believed that numbers would win out, just like MacNamara fifty years later in Vietnam.Both believed in numbers, sheer volume would win the war for them.

Image result for mental health casualties

Clark, and his side kick Lord Layard, like his ignominious predecessors, consider that sheer volume of numbers will be sufficient to defeat the epidemic that is mental illness. While Clark and Layard’s numbers are statistics, people are still dying as a result, those sent to fight the war are still being burned out by sheer effort of trying to help others in impossible conditions. For example, 50% of professionals working in front line mental health services are suffering psychological distress, the conditions are intolerable yet most are too frightened to say so. The pressure to achieve a “50% success rate” means that statistics are skewed or even changed to achieved the necessary figure. Professionals are sent for retraining if they don’t achieve and then sent back into the frontline. In the First World War, many soldiers had their wounds stitched up and were then sent back into the front line. As I type this it reminds me of the horses ridden by the toreadors in bull fights; if the horses were gored by the bull they were taken out of the ring stitched up and sent back into ring immediately – amazing cruelty. The same is happening to frontline staff in IAPT.

Yet the politicians are being fed an amazing story of success, in exactly the same way that Haig and others in the First World War sent back messages that told the politicians how well they were doing.

This quote from Historynet really sums it up:
“Haig waged the ensuing political battle with customary remorselessness and prevailed in the bureaucratic trenches. He got everything he wanted in the way of men and materiel for what became known as Third Ypres or Passchendaele, a battle remembered for, among other things, terrain so wet the entire world seemed to consist of nothing but mud and shell holes filled with vile water. Indeed, in no land battle in history did so many men die by drowning.”

Image result for casualties of mental health

So many people are drowning as a result of the disaster that is the Project called Improving Access to Psychological Therapies, clients and professionals alike; yet the politicians remain enamoured of the project’s ability to blame the individual for their failure. It matters not whether it be client or professional, the failure lies within the individual, this is the overbearing ideology of the current government and those who seek to prove the model that is supposed to be Improving Access to Psychological Therapies.

Like Haig, Clark seeks to prove his model by asking for more troops (which, like Haig, will be refused; the worst of all worlds) rather than look at the overwhelming evidence that it is not working. For example, of all those who are referred to the service only 16% make some kind of recovery based upon the analysis of psychometric tools. From a service point of view this is a disaster. No company would continue to function on that basis. Yet the government continues to prop up the project on the basis that it is making a difference. What makes it worse is that IAPT continues to mark its own homework – it is time for an independent review.

There has been no measurable difference to the well being of the country as a whole, and only a few lucky people have benefitted as individuals. With regard to the overall well being of the country we are slipping behind that of other nations and if austerity continues the environment will only continue to get worse. As I have said so many times before, a toxic environment cannot be combatted by providing a leaky gas mask. Therapy and resilience training are no match for a cruel and heartless environment created by cruel and heartless politicians.

References:
http://www.historynet.com/field-marshal-sir-douglas-haig-world-war-is-worst-general.htm

Steve Flatt

Mental Health Sinkhole Appears – Untold Casualties

 

 

Mental Health Trusts today announced that three quarters of extra monies promised for mental health services are not getting through. A mental health sinkhole has appeared, the depth of which is measured by under-funding and the width by poor quality services. Casualties include an estimated 694,000 people who were treatment failures in the Government funded IAPT service in 2014/2015, 85% of those treated. A further one third of those referred to IAPT did not enter treatment.

I reviewed the trajectories of 65 people who went through IAPT Services in the North West of England using a ‘gold standard’ diagnostic interview just 15% recovered from their disorder. [ Scott (2017) Towards a Mental Health System that Works London: Routledge].  I am wholly independent of IAPT and I made the analysis on the basis of data available to me as an Expert Witness to the Court. Applying this recovery rate to the national picture suggests a massive casualty rate.

Just this past week I picked up a ‘casualty’ who had had 6 sessions with IAPT, she had had a fall 2 years ago, become effectively housebound, though able to walk for 10-15 mins. She was referred to IAPT and had 6 sessions of CBT for depression, to no avail and she was very frustrated by the therapist who had said ‘do you think you might have OCD?’ one week then the next week ‘what about body dysmorphic disorder?’.  No further treatment was offered. I  found she was depressed  but what had not been identified or addressed was that she had a phobia about falling and sustaining further injury. It was this phobia that was driving the depression and needed to be the therapeutic focus.

Dr Mike Scott

Evidence Based CBT Joins the ‘Endangered Species’ List

‘The good news is we have successfully amputated your right leg, the bad news is we operated on the wrong leg’.  The moral is that there can be no evidence based CBT treatment without an evidence based assessment (EBA). But EBA’s are increasingly absent in order to ease the research burden, ‘just rely on a psychometric test’, and reduce ‘treatment’ costs.

Emergency medicine operates on the 7 P’s, ‘Proper Pre-planning Prevents Piss-Poor Performance’. Is it seriously proper-pre-planning to operate as IAPT do, with a  typically 15-20 minute telephone conversation, conducted by the most junior member of staff, to be then placed on waiting list of upto 6 months for a treatment of indeterminate appropriateness? The reliability of this ‘pre-planning’ has never been assessed by anyone independent of IAPT. But this has not stopped Clinical Commissioning Groups often ring fencing IAPT monies at the expense of other mental health service providers.   The CCG’s need to be reminded that they ought to be working in an evidence based framework were the results of randomised controlled trials with independent assessment of outcomes hold sway (the top of the pyramid below). 60% of IAPT clients receive low intensity treatment, this is way down at the bottom of the evidence pyramid below, with a high potential for bias, reflected in powerful marketing.

It is time that CCG’s told IAPT that their pre-planning is simply unacceptable, there has to be an evidence based assessment. It is time the National Audit Office asked why are we continuing to fund a Service that has not been independently evaluated using ‘gold standard’, diagnostic assessment procedure. But most of all it is time to listen to those subjected to an inhospitable and unhelpful service. MP’s have to insist they are listened to.

Dr Mike Scott

Saving Normal, Candidates for CBT and Sean Bean

 

Tonight I am planning to watch another episode of the TV drama  ‘Broken’ starring Sean Bean as the central character. He plays Fr Michael who was sexually abused as a child by a priest and had a destructive late adolescence/early adulthood. Fr Michael has uncued flashbacks of the abuse, at times like consecrating the Eucharist. In the last episode he angrily confronted his abuser. But since becoming a priest Fr Michael has nobly served the severely disadvantaged. It was filmed at St Vincent’s, Church, Liverpool directly opposite where I work.  Should I nip across and offer EMDR /CBT?

Set for ‘Broken’

This fictional example echoes a real life conundrum for clinicians – a colleague of mine recently brought to my attention the case of a lady who had intrusive flashbacks of the aftermath of ECT and wondered whether she needed EMDR. By coincidence I had assessed the lady and knew that she was suffering neither from depression or PTSD and had functioned well for many years. She came to my colleagues attention because of some inherently stressful life events. My response was in the words of Allen Frances’ seminal work ‘Saving Normal’ published in 2013 by William Morrow we must not pathologise every uncomfortable memory, the acid test is whether it is directly causing significant functional impairment now.

In a similar vein I remember seeing a lady some time ago who had undergone prolonged sexual abuse as a child, she had been referred to a number of therapists over the years and they had all wanted to focus on the abuse. She protested that the abuse did not get in the way she was simply anxious about everything. When I saw her I found she was just suffering from generalised anxiety disorder, nothing more nothing less. I treated her with a standard protocol for GAD and she recovered.

I think the answer to all of this is “If it is not ‘Broken’ don’t fix it”, I’m off to watch the TV.

Dr Mike Scott

Grenfell Tower Fire and IAPT Trauma Services

In The Wake of the Grenfell Tower Fire, Mrs May Has Announced Additional Monies for Mental Health Services – BBC News 10.0pm June 18th 2017.

But the devil will be in the detail, what ‘treatment’ will be funded for which victim?, delivered by whom? when?.  The UK track record on treating trauma victims is not good. I independently reviewed 65 cases of trauma victims who had gone through the Government funded Improving Access to Psychological Therapies (IAPT) Service [Scott (2017] and found overall a 15% recovery rate, one half the sample had PTSD and again the recovery rate was 15%. There was no difference in recovery rates between those treated before and those treated after a personal injury.    But the difficulties are not confined to IAPT, recently I saw a victim of the 1989 Hillsborough Football Disaster who had since shortly afterwards been attending a weekly support group for victims, run by a Charity, though grateful for its ministrations, he had never been offered evidence based psychological treatment and continued to suffer from severe PTSD, with his marriage in tatters.

The breathtaking hospitality shown to victims of the Fire by the general public, has contrasted sharply with the acknowledged dilatoriness of the Governmental response. If that hospitality is reflected in the behaviour of friends and family towards the victim this will be an enormous benefit as perceived social support is the biggest single predictor of recovery from PTSD [ see Scott (2013)] and as a consequence I have advocated inclusion of partners in treatment if appropriate. Partners and clients can both benefit from my self-help book Moving on After Trauma [Scott (2008)].

One of the biggest roadblocks to delivering Trauma Focussed CBT (TFCBT), is that therapists or clients curtail treatment because the latter cannot face repeatedly going over the details of the trauma. Yet TFCBT is effective if clients can stomach it. I have suggested that a way around this is to teach coping skills for managing the memories, even if this proves insufficient to manage the intrusions, it can become a stepping stone towards a preparedness to engage in TCBT [Scott (2013)]. In a paper currently under review with Behavioural and Cognitive Psychotherapy, titled ‘PTSD Re-imagined’, I have presented a new reconceptualization of PTSD that is user friendly and goes beyond existing forms of treatment.

Dr Mike Scott

References

Scott, M.J (2017) Towards a Mental Health System that Works London: Routledge

Scott, M.J (2013) CBT for Common Trauma Responses London: Sage Publications

Scott, M.J (2008) Moving On After Trauma London: Routledge

CBT on the Cheap – IAPT’s Failed Experiment With Low Intensity CBT

If you are anxious or depressed and wish to seek psychological help on the NHS you are most likely to be offered low intensity CBT (LICBT) via the Government funded Improving Access to Psychological Therapies (IAPT) service. But don’t expect it to make a real world, socially significant difference to your life.  Two just published studies, one focussing on Adults [Ali et al (2017)] and the other on children [ Cresswell et al (2017)], highlight the paucity of evidence in support of this cost-cutting approach.

Ali et al (2017) looked at low intensity IAPT clients who had remitted by the end of treatment and found that half had relapsed within 12 months. Far from suggesting that this sounds like a ‘failed experiment’ the authors suggest that the programme should be simply amended to include relapse prevention despite stating earlier in the paper that relapse prevention was part of the protocol! Some weeks ago I wrote a Rejoinder to the paper which is currently being considered for publication in Behavior Research and Therapy.  Interestingly the Research Digest of the Psychologist for June 13th 2017 headlines its’critique of the Ali et al (2017) paper ‘False Economy?’

Father, Son, Bloom, Spring, Child

Cresswell et al (2017) looked at the effectiveness of parent guided CBT self-help  vs parent guided solution focussed self-help in children aged 5-12 with an anxiety disorder and concluded that they were equally effective but the latter was  more costly. In an accompanying commentary Stallard (2017) heralds the study as marking the way forward for children’s IAPT.  But there is no comment by him that a) the outcome measure used, the Clinical Global Impressions of Improvement was designed for use with regards to the trajectory of specific disorders, it was not intended as an across the board measure and is of doubtful validity in this study, b) there was no waiting list control group – children’s debility is likely to be particularly transitory c) that the study did not include any children with OCD or PTSD and in the CBT arm 50% had generalised anxiety disorder and 25% a specific phobia – generalising from this study to children with anxiety disorders is therefore problematic or d) that 40% of parents in the CBT arm had higher education, this is unlikely to be the case in many areas.

There are conflict of interest concerns with both papers Shehzad Ali heads the Northern IAPT Practice Research Network and Paul Stallard is joining Cathy Cresswell in running a randomised controlled trial. Demand of MPs, GPs and Clinical Commissioning Groups that psychological therapy services make a socially significant difference and are independently rigorously evaluated. Remind them there is good news: fully implemented CBT protocols result in over 50% of clients with depression and anxiety disorders no longer meeting diagnostic criteria for the condition by the end of treatment.[Scott (2017)].

Dr Mike Scott

References

Ali et al (2017) How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study Behaviour Research and Therapy 94 (2017) 1-8

Cresswell, C et al (2017) Clinical outcomes and cost-effectiveness of brieg guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial. Lancet Psychiatry published online May 17th 2017

Scott M.J (2017)} ‘Towards a Mental Health System that Works’ London: Routledge

Stallard, P (2017) Low-intensity interventions for anxiety disorders. Lancet Psychiatry published online May 17th 2017

Warning Bell for Psychological Therapy?

If we continue as we are then psychology will diminish as a reputable science and could very well disappear’ so wrote Chris Chambers in his just published book The Seven Deadly Sins of Psychology: A Manifesto for Reforming the Culture of Scientific Practice (p. ix). Princeton University Press.

The problem is the widespread failure to replicate original positive findings, and the aversion of psychologists to independent direct replication, preferring instead the enthusiastic marketing of any novel positive finding. This is unfortunately also true of the clinical field where there are few independent direct replications.

Medicine and science are largely self- correcting. Until  the paper by Topiwala et al in this week’s (June 10th 2017)  British Medical Journal , 430-431 it was considered that studies suggested that a little drinking of alcohol was good for you  but it has been discovered that even moderate drinkers (up to 21 units for men) were three times as likely as abstainers to have hippocampal atrophy. Chambers (2017) cites a similar example of self-correction from the field of physics, were in 2012 a study was published that suggested a sub-atomic particle a neutrino was  found to have travelled faster than the speed of light, thereby upstaging Einstein’s theory. Within a few years there were 3 independent replications of the same study all with opposing findings. The original experimenter went back to the drawing board and found he had a faulty fibre-optic cable in the initial experiment. Unfortunately to ask for independent direct replication of bench-marking studies in psychological treatment is regarded as being negative and a fudge of conceptual replication is offered in which another study is conducted  with a key feature absent e.g a blind assessor using a standardised diagnostic interview.

Mrs May, today threatens those like ‘Angela’ below who would take action against the unfounded Draconian actions of Social Services

 Family, Mother, Children, Boy

A client ‘Angela’ that I successfully treated with CBT for depression had her 3 children removed after a psychiatrist diagnosed her as having an emotionally unstable personality disorder (EUPD). I protested that this diagnosis was without foundation (she turned up for every therapy session and did all homeworks) but Social Services refused to consider my report, viewing her behavior through the lens of the EUPD, and she was mandated to attend a 10 session mentalisation treatment. In the event the Court appointed an independent psychiatrist who agreed with me that she did not have an emotionally unstable personality disorder. Despite this she was moved simply from supervised to unsupervised access, an ongoing denial of her right to a family life and the mandated attendance at treatment rescinded. Misdiagnosis destroyed family life. The case is ongoing, more about this anon.

Dr Mike Scott