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BABCP Response - NICE Consultation January 2022

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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BABCP Response - NICE Consultation January 2022

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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BABCP Response - NICE Consultation January 2022

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

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BABCP Response - NICE Consultation January 2022

Self-Diagnosis Rules – Should It?

The main provider of psychological treatment, NHS Talking Therapies,  says that  its’ clinicians are not trained to diagnose [IAPT Manual 2018)]. But the full name of the Service is ‘NHS Talking Therapies for anxiety and depression’ so how can they possibly not diagnose! Alice, in Alice in Wonderland thought words could mean whatever you wanted them to mean, a view apparently shared by NHS Talking Therapies. 

 

Many CBT practitioners see diagnosis as anathema. Sufferers are left to make sense of their difficulties themselves. In this vacuum people often affix a diagnostic label themselves, conferring a sense of identity and they hope direction. 

Recently I met a 17 year old, in a social context, who told me he was autistic and also had ADHD. He was being helped with interview skills and how to apply for jobs. We chatted amiably for 20 mins and I thought it was not impossible he had the self-identified disorders but it seemed unlikely. He had not enjoyed secondary school, skitted for his religious beliefs and thought animals were a better bet job-wise than humans. I was not wearing a professional hat at the time and followed my usual dictum of not revealing my professional identity because of its capacity to sabotage all social occasions. [This can have a downside, once told a taxi-driver that I worked in banking, unfortunately he was very interested in banking and asked searching questions. I was so relieved when the journey came to an end!]. Locally the waiting list for an autism/ADHD diagnosis is as long as a piece of string and for the foreseeable future he was likely to operate with the said ‘diagnoses’. 

Many professionals do not see the above as problematic, it is simply about accepting neurodiversity.  A way of people coping with their ‘lived experience’. They might add that mental health diagnosis is meaningless anyway, so people can choose their diagnostic label just as NHS Talking Therapies can choose any diagnostic code ( problem descriptor) based on the presenting problem.  It is open season for diagnostic labels for the public and routine psychological therapists. 

But there is no way in which the above 17-year old could come up with an alternative hypothesis about his difficulties e.g that he was by nature  introvert, part of an out-group, had difficulties concentrating at school because the academic subject matter did not interest him. Most plausibly he had adjustment difficulties and this was likely a better explanation than autism/ADHD. Self-diagnosis carries with it an inability to generate and the means to falsify an alternative hypothesis, as such it is inherently unscientific. The danger is the self-diagnosers and their fellow travellers operate unknowingly with a confirmation bias, only seeking information that confirms their hypothesis. 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

The Care Quality Commission and NHS Talking Therapies

I have today received the following response from the CQC, after seeking clarification from them of the position between the two. (Thanks to Michael Brazendale for raising the matter with me, in my previous blog).  

Dear Dr Scott,

 

Thank you for your email. I’ve liaised with our policy colleagues and the current position is set out below.

 

  • Psychological therapies are a critical part of mental health services and CQC has a role to ensure that people receive safe, effective, compassionate, high-quality care.
  • The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 schedule 1 defines what ‘regulated activities’ are and ‘Treatment of disease, disorder or injury’ (TDDI) is a regulated activity defined in schedule 1(4)
  • TDDI requires the activity to be provided by or under the supervision of a health care professional or social worker – whether psychological therapies is a regulated activity will depend on the person providing it or supervising it
  • CQC therefore regulates psychological therapies that are provided by or under the direct supervision of a doctor, nurse (‘health care professionals’ defined in the Regulations) or a social worker.

 

Does CQC regulate IAPT services?

  • In the IAPT services model, supervision is most likely led by senior therapists (not medical staff), so this would probably not include a nurse, medical practitioner or social worker therefore, CQC would not be able to regulate psychological therapies in IAPT services as they are usually led and supervised by therapists and not a nurse, medical practitioner or social worker.

 

What does future regulation of psychological therapies look like?

  • We are working with DHSC, trade associations and other key stakeholders to identify and understand how we may inspect and rate psychological therapies going forward and to make sure our legislative powers cover all which needs to be covered, which may include IAPT services.

 

I hope this response is helpful.

 

Many thanks

 

Mat

 

Matthew Hughes

Senior Parliamentary and Stakeholder Engagement Adviser

07384 525677

 

For information about CQC, including contact details, information about how we use and protect personal data, and how to request information from us, go to https://www.cqc.org.uk/contact-us

He responded very quickly to my e-mail and in depth, for which I  have thanked him. I would be very interested in any comments on this missive which I could take forward.

Regards

 

Dr Mike Scott

I responded today March 22nd as follows;

Hi Mat

Following on from your email of yesterday I note that the CQC believes that:

‘Psychological therapies are a critical part of mental health services and CQC has a role to ensure that people receive safe, effective, compassionate, high-quality care’.

I gather from your e-mail that the CQC role is restricted to coverage of agencies, in which a Doctor, Nurse or Social Worker heads the Service Providing agency. How many Service Providers of Psychological Therapies has the CQC inspected? Are there publicly available reports on the inspections? What proportion of NHS Talking Therapies Providers fall under the orbit of the CQC?

It appears that the scope of the CQC has been limited by the ’The Health and Social Care Act 2008 (Regulated Activities)and there is no mention of psychologists. This may be because NHS Talking Therapies in the shape of IAPT did not come into being until 2008 and the Service has slipped under the radar of the CQC. In my experience it is usually a psychologist who is at the head of a local NHS Talking Therapies Service.

If the CQC is to discharge its’ role, it is difficult to see how this can be done without broadening its terms of reference. In terms of the protection of Service Users there can be no justification for the de facto exemption of the great majority of NHS Talking Therapy sites, from CQC inspection. I appreciate that at present the inspection framework has yet to be decided  but this is a separate matter from establishing the legitimacy of CQC inspection across all psychological therapies Service providers.

I would be grateful for your response to these matters.

Dr Mike Scott

 

 

 

 

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BABCP Response - NICE Consultation January 2022

How Do NHS Talking Therapies Clients’ Fare Downriver?

The Improving Access to Psychological Therapies River began flowing 15 years ago, rebranded NHS Talking Therapies last year. Yet we still don’t know how clients fare, downstream long-term. Quite why we don’t know is an interesting question. One doesn’t have to be a conspiracy theorist to suggest that there may be an unholy alliance of Service Providers and politicians/media at work. The former fearing independent public audit, the latter wanting to be seen championing the side of the ‘good’.

Clients invariably enter the river destabilised. Some may quickly regain their balance and be part of the 40% of people who do not go on to engage in treatment (defined by the service as engaging in 2 or more treatment sessions). But what proportion of those who have had treatment go on to return to how they were before entering the river? Or to put it another way, what proportion reach the promised land? What proportion  continue to thrash about at sea? Despite the much vaunted and extensive NHS Talking Therapies database it is impossible to answer these simple questions. There is clearly something amiss here. The answer cannot be to spend £2billion a year on child and adult services in NHS Talking Therapies. Just throwing money at a problem cannot be an answer to anything. 

The best guess from an independent review [Scott (2018)] is that only the tip of iceberg recover. The burden of proof is on those who would claim otherwise, simply reiterating NHS Talking Therapies mantra of a 50% recovery rate is not evidence.  

The NHS has proposed that interventions are evaluated using the mnemonic PICOTS. P requires a specification of the population being addressed and presupposes a reliable diagnosis. But NHS Talking Therapies therapists are not trained to make diagnoses. The Service therefore fails at the first hurdle. I stands for intervention and requires the specification of the intervention used so that it could be replicated and evaluated by other clinicians. But there have been no fidelity checks to establish whether a particular protocol has been followed. Rather there is a cacophony of voices claiming to deliver ‘CBT’. The service falls at the 2nd hurdle. C pits the service against a control condition, but there has been no such evaluation of NHS Talking Therapies. There is no reason to believe that its clients fare any better than if they had attended the Citizen’s Advice Bureaux. O refers to outcome, but there has never been a blind independent assessment of NHS Talking Therapies Clients instead there has been entire reliance on self-report measures which are subject to both demand characteristics (wanting to please the therapist and not think you have wasted your time) and regression to the mean (people invariably come at their worst and there is some improvement with time whatever. Finally there is T, which is about the duration of gains (time),  never has there been a real world assessment of recovery e.g lasting at least 8 weeks. NHS Talking Therapies fails all the NHS hurdles.

Dr mike Scott 

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BABCP Response - NICE Consultation January 2022

The Scandal of ME/CFS Treatment – A Portent of What Is To Come?

A Guardian staff writer has produced a brilliant critique of the treatment of ME/CFS. Thanks to Tom Hepburn for alerting me to this. Tom makes the point that it would be great if there were a similar lucid analysis of routine mental health services. Communicating in such a way as to give people a ‘light bulb moment’ is no easy task. 

 

Perhaps he might consider that Child and Adolescent Mental Health Services are like pirates capturing despairing parents and their children.

A teenager, X, I recently assessed was captured at the age of 12. She had a very supportive Mum. It was apparent that X had developed an eating disorder. But they failed to identify that she also suffered from generalised anxiety disorder and social anxiety disorder.  Treatment was entirely focussed on her anorexia. She was hospitalised but X received no personalised treatment, rather she was tasked with helping other patients eat. X did undergo Dialectical Behaviour Therapy but found it too upsetting. She said what she needed to say, to get out of hospital. Regular CAMHS sessions continued for years. Therapists insisted that her estranged, transgender father was a major factor in her debility, despite her assertion to the contrary. Four years on her BMI was 21, (a BMI less than 17 usually indicates moderate/severe thinness), Mum considered that she had done very well with regards to the anorexia. Inspection of her records revealed that there were no signs of the GAD or SAD being identified, much less treated. X considered that these were at least as important as her eating disorder.

CAMHS appears a monumental failure, there ought to at least be independent audit of child and adult services. Spending £2billion a year on services without accountability is scandalous. 

Dr Mike Scott

 

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BABCP Response - NICE Consultation January 2022

Excercise Better Than CBT For Depression

according to a network meta analysis by Noetel et al (2024) published in the BMJ. These authors suggested  ‘those delivering psychotherapy may want to direct some time towards tackling cognitive and behavioural barriers to exercise’. But I suspect that a goodly proportion of CBT therapists already do this routinely as part of Activity Scheduling or Behavioural Activation. It would likely be atypical CBT to have no mention of excercise. This would make the CBT v exercise comparison in the study problematic.

The study reveals an effect size for Excercise about 0.5, but a little higher  for dance. This means that of those in excercise/dance arm the average person did better than about  69% of those who had CBT.  This equates to patients in both arms scoring  say 28 on the BDI initially and an added reduction of 4 points in the excercise/dance compared to the CBT. Is this really meaningful?

I searched in vain to find what proportion of people in each modality recovered from their depression and remained in remission (more than 8 weeks) . The real world significance of the Noetel et al (2024) findings are in doubt. Nevertheless there is a danger that exercise is seized on and promoted as a cheap alternative to CBT.

Outcome in this meta analysis was based on self-report measures and not the ‘gold standard blind diagnostic interview’, suggesting caution in interpreting the results. Further the studies reviewed included those were entry was gained by scoring over 13 on the 2nd version of the Beck Depression Inventory. I have just seen a client who suffered from a DSM-5 defined adjustment disorder with depressed mood for 6 months, who would almost certainly have scored high on the BDI in this period, but never met criteria for primary major depressive disorder.  There was a clear psychosocial stressor that would have been upsetting to most people. The good news is that he was not referred for CBT and his symptoms were not pathologised.

Dr Mike Scott

 

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BABCP Response - NICE Consultation January 2022

Ejection From NHS Talking Therapies

occurs whenever a persons scores below cut-offs on two psychometric tests. Just how ludicrous, this is, was brought home to me recently when I was called to assess a lady who had been trapped in her car, by a fallen tree. After 12 sessions of trauma focused CBT, she was scoring below cut-offs on the PHQ-9 (a measure of the severity of depression) and on the GAD-7 (a measure of the severity of generalised anxiety disorder). But she still felt unable to return to her, much-loved job as a bookkeeper, despite every support from her employer. For six months after the incident, she met the DSM-5 diagnostic criteria for post-traumatic stress disorder, currently, she had a sub-syndromal level of PTSD (meeting 3 of the necessary 4 symptoms clusters for PTSD). But she had never met criteria for depression or generalised anxiety disorder, the two tests administered were therefore entirely inappropriate. [ Details have been changed  to protect confidentiality.]

Common sense would dictate that this lady is not back to her usual self. But NHS Talking Therapies staff seize on the lightest sign of improvement, make it central and abandon the client. There is no evidence that its’ staff appreciate the meaning of the psychometric tests they administer. Wilfully or not they are not listening to the client’s story – ‘just keep the production line rolling‘ is the mantra.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Case Conceptualisation Rules – Should It?

Most clinicians match clients to their prototypes of disorders. But how much information should you collect before matching ? ‘Since Persons (1980) and Judith Beck (1996) ‘Case Conceptualisation’  rules. But there has been no demonstrated added value of ‘case conceptualisation’ .

Prior to these authors there was simply ‘case formulation’ [see www.psychologytools.com for examples of formulations of most disorders] which was the way in which a person was an exemplar of a particular disorder e.g a person with panic disorder might say that in their 1st panic attack they t0ok their palpitations as evidence that they were having a heart attack, but though nothing untoward physically happened they became hypervigilant over bodily sensations and avoided provoking  any such symptoms. Applying Clark’s cognitive model of panic disorder the key dysfunction is catastrophising  and avoidance of opportunities to disconfirm the catastrophic cognitions. A case formulation requires 1st of all a reliable diagnosis, what they are a ‘case of’  and an example of the mechanism by which this disorder is brought about. As such there are clear limits of the range of information that is pertinent to a ‘case formulation’. Making it usually a manageable task for the clinician at 1st interview  and  to set a pertinent homework exercise. Contrast this efficient use of time, with a real-world impact, with what happens when the focus is on ‘case conceptualisation’.

With case conceptualisation  there is no control of information variance, the therapist likely assembles information under a number of headings,  but this information does not speak for itself

 

page7image813689392

Case conceptualization Kuyken 2009

The therapist arbitrarily selects a piece/s of information and  claims it/they are pivotal  e.g their father was alcoholic, they were involved in a life threatening incident. The descriptive information of itself is not prescriptive of a mechanism. One could assemble information under the above headings ‘until the cows come home’ it would make no difference, it is arbitrary to stop at any particular point. In this context clinicians easily succumb to ‘formulation nausea’ a condition arising from a bewildering array of arrows. Presented with such a picture clients can easily feel a victim and or blameworthy and disempowered. They are unlikely to have any success experience any time soon, homework is delayed. Therapy becomes an exercise in the acquisition of meaningless data, with the client likely to default. In fairness Judith Beck ( Centre for Cognitive Therapy 2018) does retain diagnosis in her case conceptualisation but this appears to be lost in translation, at least in UK CBT courses. 

It is 15 years since Kuyken et al produced their seminal work on Case Conceptualisation, recognising the evidence base for it was lacking but expressing confidence that this would be repaired. But no such further evidence has been forthcoming [Easden and Kazantis (2018)] and state that ‘the efficacy of case conceptualisation in CBT has yet to be demonstrated’.What has actually happened is that the framework of Case Conceptualisation, minus the diagnosis component, has been passed on to training courses and taken as gospel. Thus whilst there is a consensus about the importance of case conceptualisation there is a conspicuous lack of evidence, at least about what is customarily put into practice. Better returning to simply effective CBT [Scott (2009)]

The Kuyken model of case conceptualisation, suggests that the latter is an emergent property of a ‘soup’ , into which everything is thrown in,  genetic predisposition, precipitants of episodes etc. But this is reminiscent of the claim that life emerged from a ‘primordial soup’, there is no specificity of mechanism.  It is claimed that case conceptualisation is at another level of abstraction to case  formulation. This may well be the case, but there is no evidence that the former helps the latter. Contrast this with the multidimensional description of patients difficulties in DSM IV axis 1 disorders e.g depression, PTSD axis 2 disorders personality disorders, axis 3 physical disorders, axis 4 psychosocial stressors and  axis 5 judgement of overall functioning .   Applying this framework to a person in Gaza with likely PTSD symptoms would greatly change the therapeutic approach. It might well be concluded that the ‘toxic environment’ precludes psychological treatment at this point in time 

Dr Mike Scott