Disseminating Group CBT – What You Need To Know

Clients often have similar stories, so it is a no-brainer to treat those with the same story in a group. But groups can go badly wrong – a colleague of mine was unavailable to lead a group because of illness, one of the group ‘stepped-in’ and ran the group at his flat, suggesting that he would be a much better group leader!

On September 6th I am giving a 1 Day Workshop on Delivering Group CBT to Bedford IAPT, one of many I have delivered to BABCP local Groups and IAPT. In 2013 when I gave the workshop in Copenhagen I discovered that  there Group CBT is the usual mode of service provision and therapists have to justify individual therapy, they found it surprising that in the UK we  did not operate that way. There are free group materials for depression, anxiety disorders and PTSD if you click the Resources button on this site, from Simply Effective Group Cognitive Behaviour Therapy (2011) London: Routledge. The Workshops have raised a whole host of questions that might be worth discussions in your locality and/or on this forum:

 

 

The learning objectives for the Delivering Group CBT workshop are for attendees to be able to answer most of the following questions by the end of the day:

  1. How do we ensure that we don’t play a numbers game with regards to groups?
  2. Why not admit all-comers?
  3. Aren’t classes a better use of resources than groups?
  4. How do we select the right people?
  5. Is group CBT really an answer to a Manager’s prayer?
  6. How do you identify and circumvent special problems in marketing group CBT?
  7. How can you integrate individual and group cbt?
  8. What is the structure of a session?
  9. What might the session by session content look like for depression and the anxiety disorders?
  10. How do you capitalise on group members assembling and/or departing?
  11. Do you have to specify groundrules?
  12. How do I handle clients with more than one disorder/difficulty in a group?
  13. How do you handle the difficult client?
  14. How do I know if the group is making a socially significant, real world difference?
  15. Which groups are best to start with?
  16. How do I manage group processes?
  17. How can I know whether I am managing group processes well?
  18. How does group cbt compare to individual cbt in terms of effectiveness?
  19. What if you are expected to run a group alone?
  20. How do you divide up the work between leader and co-leader?
  21. How should leader and co-leader debrief each other?
  22. Can you really do Socratic dialogue in a group?
  23. Are there advantages to a story telling/narrative approach in groups?
  24. What are useful materials?
  25. What can you do if your supervisor has no experience of group CBT?                                                    Dr Mike Scott

IAPT Performance Investigation – National Audit Office Request

‘The National Audit Office is currently carrying out an investigation into the performance data of IAPT services. The investigation is focussing on waiting times, but also refers to the reported 50% recovery rates and can accept information about the collection and measurement of data across IAPT outcomes.  

This is a genuine opportunity for us to challenge the data on which mental health service targets are being set.

Many of you have important experience of what is happening in IAPT services that is crucial for the NAO in building an accurate picture of what is going on.

Please submit your evidence to Jenny George Jenny.George@nao.gsi.gov.uk and David Rarity David.Raraty@nao.gsi.gov.uk  who will be writing the report during August. It’s a tight deadline so please submit what you can as soon as possible.

The NAO website is HERE and below is the information provided about the inquiry.

Improving Access to Psychological Therapies performance data

The ‘Improving Access to Psychological Therapies’ (IAPT) programme increases access to National Institute for Health and Care Excellence approved treatment for depression and anxiety disorders. In October 2014, the Department of Health and NHS England jointly published Achieving Better Access to Mental Health Services by 2020. This set new standards for the time people should wait for mental health treatment and the care they should be able to access. In the case of IAPT services, the standards are that 75% of people referred should be treated within six weeks, and 95% within 18 weeks of referral, and that 50% of those who complete treatment will recover. NHS Digital publishes monthly statistics that report performance against these standards. This investigation will establish the facts around how the national statistics are prepared.

This is a really significant opportunity for us to share our experiences of what is going wrong in performance management of services. Please, take the time to contribute to the report’. 

 Thanks to Steve Flatt for alerting me to the above from the ‘Surviving Work’ website
Dr Mike Scott

 

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NHS Psychological Therapy Services In Tatters – Lifting the Veil, Press Release

NHS Psychological Therapists feel so threatened by their employer that Consultant Psychologist,           Dr Michael Scott has set up an independent online support group for them at cbtwatch.com. A Therapist from the Government funded, Improving Access to Psychological Therapy (IAPT) Service, in the South of England, wrote to the forum:

 

I am leaving… .. while many patients have a very positive experience of IAPT, a significant number have had a far more negative, even sometimes damaging experience:

  • I have spoken to people who have I have spoken to people who have told me their 30 minute telephone assessment left them distressed and confused, having talked about highly sensitive topics without the time to process the emotional aftermath.
  • I have spoken to people who dropped out of treatment and decided CBT was a waste of time, after being misdiagnosed and offered unsuitable guided self-help.
  • I have come across people with deep seated trauma being offered six sessions of telephone therapy, and feeling that this left them ultimately worse off.
  • I have also spoken to people dismayed and angry because they unavoidably missed one appointment and subsequently received a letter telling them they had been discharged and would need to re-refer, and go back on the waiting list’.

Dr Scott commented  that ‘it speaks volumes that I have to use a pseuodonym, Zara, to express the therapist’s voice’.  He is author of ‘Towards a Mental Health System That Works’ published by Routledge earlier this year and said ‘I had to set up a safe harbour for therapists like ‘Zara’ at cbtwatch.com. My own research, conducted without any conflict of interest, across services across Merseyside suggests that the recovery rate from a diagnosed disorder in IAPT is just 15%’.   ‘Zara’ added ‘I won’t miss the lost sleep worrying that I may be put on performance management measures if I fail to maintain a 50% recovery rate, and I certainly won’t miss witnessing, and indeed experiencing, some of the management bullying tactics I have seen in IAPT’.  Dr Scott commented       ‘ IAPT have always marked their own homework, there has never been an independent audit, using a ‘gold standard’ diagnostic interview. Not only is it likely that taxpayer’s money is being wasted but the average therapist and patient far from being helped, is stressed by the experience, MPs, Clinical Commissioning Groups and the National Audit Office need to take up this issue’.

Dr James Davies, Reader in Social Anthropology and Mental Health at the University of Roehampton, author of the forthcoming  book ‘Mental Health and Neo-liberalism’ comments ‘an impartial observer looking at the IAPT data, could not help but conclude that the Service haemorrhages clients, and that the criteria it uses for success are very suspicious’.

 

Dr Mike Scott

‘Psychometric Tests, Administered In Isolation, Are Not Footprints of Anything’ – IAPT’s Big Mistake

IAPT uses psychometric tests to identify ‘cases’ and changes in test score to gauge effectiveness.  This is not an evidence based assessment and without it there can be no evidence based treatment.

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A psychometric test can’t exist in a vacuum it has to refer to something tangible i.e it must have criterion related validity. For example in last month’s British Journal of Psychiatry, Quinlivan et al [‘Predictive accuracy of risk scales following self-harm’] assessed the ability of risk scales to predict whether a person will make a further suicide attempt  (the criterion). It was found that the much used scales, did not in fact predict self-harm, i.e they lacked criterion validity. Thus when psychometric tests such as the PHQ-9 (an intended measure of depression) and GAD-7 (an intended measure of generalised anxiety disorder) are used, individual test results are only meaningful if they are actually the ‘footprint’ of the construct under examination. Imagine seeing a footprint in the snow:

 

 

does it relate to the abominable snowman, a polar bear, a human being or the great yeti? Without a specification of what it refers to changes in the footprint found are meaningless.  Thus when IAPT use the PHQ-9 and GAD-7 in isolation it is not known to what they refer, as no reliable diagnostic interview has been performed. Is the person simply stressed, depressed, worried well or what? The myriad possibilities likely have very different trajectories e.g the stressed improving as the stressor passes. Lumping them altogether, creates confusion, prevents any evidence based assessment, which is the foundation for evidence based treatment. Clients cannot be reliably signposted to anything, resulting in the wrong tools being used:

Worryingly, I wrote a rejoinder to a paper by Ali et al in this month’s  Behavior Research and Therapy, on relapse after IAPT low intensity intervention, making the point that they had abused psychometric test results in just this way, it was rejected, the reviewers pointed out that I hadn’t included a reference supporting criterion related validity!  I despair. The reviewers tried to justify the approach of Ali et al on the grounds that the PHQ-9 is a reliable instrument, identifying 80% of those who are depressed (sensitivity) and 80% of those who are not depressed (specificity), which is true. But this provides no basis on which to judge whether Mr X who scored say 25 on the PHQ-9 should a) be regarded as a ‘case’ of depression and relatedly b) whether his progress should be charted with this measure, a) and b) can only be determined by a reliable standardised diagnostic interview, which is absent from the IAPT assessment protocol. If you found your electrician was measuring current with a voltmeter you would, forgive the pun be ‘shocked’, we need to create a similar state of alarm about the quality of audit in IAPT. There is a pressing need for independent rigorous assessment.

Dr Mike Scott

The Silencing of Dissent and IAPT

 

This month’s Behavior Research and Therapy features a paper by Ali et al in which IAPT data on relapse after low intensity (Li) interventions is reviewed, and it is concluded that further attention to relapse prevention may be needed. I submitted a rejoinder essentially saying that Li-interventions have been a false economy and complaining that it had not been declared that Ali headed the Northern IAPT Research network, but it was rejected.

The editor began her letter of explanation with ‘Each of the reviewers is a highly experienced researcher in the area of low-intensity treatments for depression anxiety’.  But that is precisely the problem, researchers in low intensity see no pressing need for independent assessment using a ‘gold standard’ diagnostic interview (unlike their forbearers who conducted the bench-marking studies that gave CBT its’ credibility), although they pay lip service to it.

In practice, low intensity researchers find it ‘reasonable’ to conduct research on outcome solely on the basis of changes in a psychometric test. This strategy enables research to be done on the cheap, produce lots of papers and get brownie points in academia. There is a mutually beneficial groupthink amongst low intensity researchers and the IAPT hierarchy. Low intensity interventions fail an evidence based assessment test with a shameful lowering of the bar of methodological rigour. I will return in future blogs to editors/reviewers scant regard for criterion related validity and the misuse of Jacobsen’s Reliable and Clinically Significant Change Index, an abuse that is rampant in IAPT.

Dr Mike Scott

Bias in CBT Journals

When the organs of communication are controlled by a single ideology we are on a short road to hell. Recently I protested to the Editor of Behavior Research and Therapy (BRAT), that no conflict of interest had been declared in a paper authored by Ali et al published in this month’s issue of the Journal, focusing on IAPT data on relapse after low intensity interventions. I pointed out that the lead author headed the Northern IAPT research network, not only did the editor ignore the conflict of interest but so to did the two reviewers, of a rejoinder to the paper that I wrote. But it is not just BRAT, IAPT sponsored papers regularly appear in Behavioural and Cognitive Psychotherapy without declarations of conflicts of interest.  I have protested to the editor about this, but again to no avail. Unfortunately it is not just a matter of what Editors of CBT Journals allow through the ‘Nothing to Declare’ aisle but also their blocking of objections to the current zeitgeist that is a cause for concern. More about this anon.

Dr Mike Scott

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?

 

‘How Do I Deliver Effective CBT Where I am?’

The contexts in which CBT Practitioners work vary enormously, from independent practice to secondary care, from low intensity IAPT to a specialised trauma unit.  For the most part we are Engineers struggling to work within the organisational constraints we are given.  Drawing on our knowledge and skills, working with a diverse population, trying to make a real world, socially significant difference in client’s lives.  The pressing question is how can I deliver effective CBT where I am?

A practitioner working in secondary care in Ireland,  told me he faces the challenge of cases come to him via psychiatrists, there is a preliminary assessment within 4 weeks of referral, a maximum of 12 sessions of CBT are offered.  There is a progress review about the 6th session and a decision is made as to whether another 6 sessions would be beneficial. He asks is this best practice? The managerial edict he believes is to throughput as many clients as possible.

Another practitioner, from IAPT High Intensity told me that she had taken up her post on the understanding that the 6 session maximum was flexible and clients could be quickly re-referred back in for more sessions, but this has proved to be very rarely the case. What should she do?

 

Dr Mike Scott