‘Too Complex for IAPT’ – Dumping on Secondary Care?

I work in secondary care as a band 7 CBT therapist within a CMHT. Often I will have referrals sent directly from IAPT who describe the patient as being too ‘complex’. Indeed this seems to have become an actual care pathway (not that we have too many of those). As far as i can tell at this stage  the patient may have not had a face to face assessment, rather has been deemed too complex simply because of the stated diagnosis e.g if they have a so  called personality disorder. I have also been told that if someone scores a above a certain score on the HADS scale (I don’t understand why this particular measure is being used as the ‘cut off’)  they too are apparently ‘too complex’. I am also told that  the outcome measures used by IAPT apparently mean that the ‘too complex clients’ would impact on these performance scales which in turn  could mean further funding for the service is jeopardized.

This concerns me on two fronts. Firstly in principle… this seems to completely  go against the ethos  of  the IAPT envisioned by Layard & Clark (although how workable or realistic this ever actually was in another thread) and another example of how it  seems management  are ‘cooking the books’ . Secondly on a more  personal level  I am employed in same Trust as a band 7 cbt therapist , i have no support from care coordinators and supposedly have the same amount of sessions to offer patients so how can possibly i offer anything different to IAPT? I suspect management know I can’t , but i ( and my colleague) serve as  i convenient sponge to soak up all the pts that may threaten the outcome measures…

 

I wonder has anyone else working in secondary care had  similar experiences  or is this an isolated thing ?

A Screen for Mental Health – The First Step Questionnaire Revised

Clients often do not improve, not because of a lack of therapeutic skill, but because of something else  going on that they never thought to ask about. Screening clients for all common disorders is a protection against missing an important therapeutic target. The First Step Questionnaire published in Towards a Mental Health System that Works Scott (2017) London: Routledge, is such a screen, covering all the common disorders and importantly asking clients whether or not they want help with a particular difficulty, but also with a ‘don’t know’ option, so that ambivalence can be recognised from the outset. There is also an interview version the 7 Minute Interview. [ The validity studies on the Questionnaire/Interview are considered  in the Simply Effective trilogy Scott (2009), (2011) and (2013).]  I have now revised the Questionnaire/ Interview to take into account the changed diagnostic criteria for PTSD in DSM-5 and added a screen for borderline personality disorder (BPD)

The symptom questions of the PTSD screen are from the Primary Care PTSD Checklist for DSM-5,   from the US National Centre for PTSD, a positive response to 3 or more symptom questions is a positive screen for PTSD.  The  BPD screen is based on a paper by Zimmerman et al (2017) Clinically useful screen for borderline personality disorder in psychiatric outpatients, British Journal of Psychiatry, 210, 165-166. Of those with BPD over 90% endosed the affective instability question in item 11 below, but only 38% of those with affective instability had BPD i.e most of those with affective instability don’t have BPD. This illustrates that screening questions are only ever a starting point, if you don’t ask further clarifying questions in terms of the full DSM-5 criteria they can be very misleading. [Adding the anger item, see item 11 to the BPD screen meant that 97% of those with BPD answered ‘yes’ two both symptom questions according to Zimmerman et al (2017)].  It remains to be seen how much the question about wanting help adds to diagnostic accuracy, it is known that it does so for the depression screen.

 

Name:                                                                                      Date:

 

D.o.b:

 

The First Step Questionnaire – Revised

This questionnaire is a first step in identifying what you might be suffering from and pointing you in the right direction. In answering each question just make your best guess; don’t think about your response too much, there are no right or wrong answers.

 

1. Yes No Don’t know
During the past month have you often been bothered by feeling, depressed or hopeless?
During the past month have you often been bothered by little interest or pleasure in doing things?
Is this something with which you would like help?

 

 

2. Yes No Don’t know
Do you have unexpected panic attacks, a sudden rush of intense fear or anxiety?
Do you avoid situations in which the panic attacks might occur?
Is this something with which you would like help?

 

 

3.

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you

Yes No Don’t know
i. Have had nightmares about it or thought about it when you did not want to?
ii. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
iii. Were constantly on guard, watchful, or easily startled?
iv. Felt numb or detached from others, activities, or your surroundings?
v.  Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
Is this something with which you would like help?

 

4. Yes No Don’t know
Are you a worrier?
Do you worry about everything?
Has the worrying been excessive (more days than not) or uncontrollable in the last 6 months?
Is this something with which you would like help?

 

 

5. Yes No Don’t know
When you are or might be in the spotlight say in a group of people or eating/writing in front of others do you immediately get anxious or nervous
Do you avoid social situations out of a fear of embarrassing or humiliating yourself?
Is this something with which you would like help?

 

 

6. Obsessive Compulsive Disorder Yes No Don’t know
Do you wash or clean a lot?
Do you check things a lot
Is there any thought that keeps bothering you that you would like to get rid of but can’t?
Do your daily activities take a long time to finish?
Are you concerned about orderliness or symmetry?
Is this something with which you would like help?

 

7. Yes No Don’t know
Do you go on binges were you eat very large amounts of food in a short period?
Do you do anything special, such as vomitting, go on a strict diet to prevent gaining weight from the binge?
Is this something with which you would like help?

 

 

8. Yes No Don’t know
Have you felt you should cut down on your alcohol/drug?
Have people got annoyed with you about your drinking/drug taking?
Have you felt guilty about your drinking/drug use?
Do you drink/use drugs before midday?
Is this something with which you would like help?

 

9. Yes No Don’t know
Do you ever hear things other people don’t hear, or see things they don’t see?
Do you ever feel like someone is spying on you or plotting to hurt you?
Do you have any ideas that you don’t like to talk about because you are afraid other people will think you are crazy?
Is this something with which you would like help?

 

 

10. Yes No Don’t know
Have there been times, lasting at least a few days when you were unusually high, talking a lot, sleeping little?
Did others notice that there was something different about you?

If you answered ‘yes’, what did they say?

 

Is this something with which you would like help?

 

11. Yes No Don’t know
Do you have a lot of sudden changes of mood, usually lasting for no more than a few hours?
Do you often have temper outbursts or get so angry you lose control?
Is this something with which you would like help?

 

Survival Manuals for Depression, Anxiety Disorders and PTSD – Free

Simply Effective Group CBT All Appendices

Separate Manuals for each disorder/s together with screening instruments from, ‘Simply Effective Group Cognitive Behaviour Therapy: A Guide for Practitioners’ (2011) Scott, M.J London: Routledge

They can be used as the basis for individual or group CBT and in a self-help context.

The included pocketbook contains diagnostic questions for each disorder and ‘Sat Navs’ detailing treatment targets and matching treatment strategies.

 

Here is a copy of ‘Simply Effective Group CBT Therapy, free to download:

 Simply Effective Group CBT All Appendices