Grenfell Fire – A Cunning Plan?

Yesterday a Counsellor from the Children and Adolescents Mental Health Services (CAMHS) announced on the BBC News, that staff are going to go door to door asking whether the occupants want professional help. Is this really the best use of resources 6 months after the tragedy? The days news also contained an item on a parent averting the gaze of her children from the Grenfell Fire Tower Block as she took her children to school.

Without health staff having a clear understanding of what in effect constitutes the ‘bruising/ tissue damage’ from  the Tragedy as opposed to that which constitutes ‘disorder’ scarce resources are likely to be squandered. There is clearly a role for a preventative/ 1st Aid input, information about not blocking intrusions, the normality of a period of increased irritability, anxiety about rehousing but there also has to be a reliable assessment of dysfuntion so that an evidence based treatment can be highlighted.

Dr Mike Scott

I’ve Had 10 Diagnoses, Got This Disorder For Life

A teenager Bex’s despair at our mental health system . Twice she has been refused Hospital admission when suicidal. ( Radio 4 today full transcript on Newsbeat ‘Me and My Mind’ available on i-player.  Jeremy Hunt Health Secretary responded ‘only had Crisis Teams 3 years ..it takes time, help isn’t happening everywhere’, he might have added nor does it look like happening anytime soon.

Bex complains that she has OCD, repeatedly checks windows etc, her thoughts sometimes make her too fearful to leave home ‘all thoughts going over, no off switch, tight, chest. It is extremely unlikely that she actually has 10 disorders, but as comorbidity is the norm doubtless she has a couple of disorders. It is inecusable that these  disorders have not be reliably identified and treatment pathways for each illuminated. Making treatment available doubtless requires increased funding but just as importantly the monitoring of fidelity to evidence based treatment protocols for the identified disorders.

I’d like to think of Bex’s case as exceptional, but she reminds me of a former client of mine who unquestionably had a primary diagnoses of borderline personality disorder (BPD). I discovered yesterday that she dropped out of treatment at the behest of a drug taking boyfriend. Since she has done the rounds of local mental health services who have labelled her as having bipolar disorder and she is taking Lithium and having therapy in secondary care. To her family’s dismay she continues to create chaos, her mum has to look after her baby etc. Once again a failure to address the key problem.

 

Dr Mike Scott

The Failure To Deliver Quality Child Mental Health Services

Children and adolescents are failed not only by an underfunding of services  ( see The Guardian, Sunday  December 3rd) but by an aping of models based on IAPT for adults.

I have just seen a 10 year old who had 8 counselling sessions, completed a wide range of psychometric tests, mum was allowed to attend the first ‘assessment’ session. At the end of treatment the agency declared that he had made ‘excellent progress’ and the child thought treatment was ‘fine’. But the reality is that the only disorder he was suffering from before counselling was separation anxiety disorder, when I re-examined him with his mum after treatment there had been no significant change in his diagnostic status. He was happy to chat about anything other than being separated from mum. Inspection of the counselling notes  mentioned working on self-esteem, work with play dough and breathing techniques. Mum had felt excluded from treatment and reported his recent ‘melt down’ when she briefly lost him coming out of a cafe.

Unfortunately neither a diagnostic competence nor ensuring fidelity to an evidence based protocol figure anywhere in IAPT and when agencies ape it, it is no surprise that the results are very poor. Appointing a counsellor in every school sounds good in that the child does not have to go to a mental health establishment and teachers could act as reality checks that ‘treatment’ is making a difference.  But the ‘caseload’ and training remain to be determined. In principle working in a school gives the opportunity  for the counsellor to engage in preventative work, but we have no hard evidence that this works. Nobody it seems has yet addressed the question of the right balance between preventative work and treatment. I can foresee a situation in which the counsellor becomes overwhelmed by the volume of work and redefines their role in a Citizen’s Advice Bureau manner acting primarily as a signpost, doubtless labelled Step 2 making no real world difference

Dr Mike Scott

Evidence Base for CBT Depends On How You Focus The Camera

What NICE says about the efficacy of CBT has been taken as gospel, but Moriana et al (2017) have pointed out that what other similar bodies say is significantly different. The actions of practitioners are micro-managed by august bodies such as NICE (via IAPT), Division 12 (Clinical Psychology American Psychological Association, Cochrane and the Australian Psychological Society, an essentially top down process is in operation.  But which, if any should be the determinant?

Rather than arguing about which body has produced the best synthesis of outcome studies the focus should shift to bottom up, asking how does cbt fare in routine practice?

Tolin et al (2015) have suggested that a treatment should only be regarded as effective if there has been a randomised controlled trial of the intervention in routine practice using non-specialist therapists, further the researchers should be independent of those who originally developed the treatment.  This has been adopted by the American Psychological Association. An additional requirement should be that the ‘gold standard’ entry requirement for the trial, admission by a standardised diagnostic interview, should also be the primary outcome measure as assessed by independent blind assessors.  Only in this way can it be known whether the treatment makes a real world difference i.e it will be known that x% no longer suffer from the disorder at the end of treatment compared to y% in the control condition. Without these diagnostic strictures one ends up with the highly questionable conclusion of Pybis et al (2017) that cbt and counselling are equally effective. Tolin et al (2015) have suggested the external validity criteria have been fulfilled in the case of CBT for OCD, but when we look at other disorders such as trauma focussed cbt for PTSD it is doubtful that it clears such a high methodological bar, for example the supposed replication of Ehers et al  CBT for PTSD (2005) by Gillespie et al in Northern Ireland did not involve a standardised diagnostic interview as the primary outcome measure, further there were no independent assessors.

It may be that the struggles of practitioners to achieve performance targets are not so much to do with their deficiencies as inherent in the context within which they are working. Singling out ‘poor performers’ may be unjust in extremis. Pybis et al (2017) concluded that ‘half of all patients (IAPT clients) regardless of type of intervention (counselling or CBT) , did not show reliable improvement’, leaving aside whether the IAPT self-report mesasures they review are at all meaningful, are half the therapists going to be put in the dock?

Ehlers, A et al (2005) Cognitive therapy for PTSD development and evaluation. Behaviour Research and Therapy, 43, 413-431.

Gillespie, K et al (2002) Community based cognitive therapy in the treatment of PTSD following the Omagh bomb. Behaviour Research and Therapy, 40, 345-357.

Moriana, J.A et al (2017) Psychological treatments for mental disorders in adults: A review of the evidence of leading international organizations. Clinical Psychology Review, 54, 29-34

Pybis, J et al (2017) The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evdence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 17:215

Tolin, D.F et al (2015) Empirically supported treatment: recommendations for a new model. Clinical Psychology Science and Practice, 22, 317-338.

Dr Mike Scott

 

‘I Have a Right to Know Whether Treatment Has Made A Real World Difference’

From a client’s point of view if they were considered ‘bad enough’, on the basis of a standardised diagnostic interview, to enter a controlled trial, the latter should also be the yardstick for judging whether their treatment was a success i.e they are ‘good enough’ not to be included in a further trial. Perhaps the researchers would like to explain to clients why there is an asymmetry between the assessment (standardised diagnostic interview) and outcome processes (the latter relying on self-report measures).  Arguably consent to treatment should only be given once the client feels this asymmetry has been properly explained! This is I think a matter for the National Institute of Health Research to consider when reviewing applicants for research funds, as a reviewer I have sometimes found submissions lacking this ‘real world’ feel.

 

Cuijpers et al meta analysis in 2016, [World Psychiatry, 15, 245-258 How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence] of 144 rcts for depression, panic disorder, generalised anxiety disorder and social anxiety disorder was restricted to studies that had used a standardised diagnostic interview for initial assessment, but the potency of the interventions were assessed only using psychometric tests. A standardised diagnostic interview is an independent reliable assessment, it is curious that outcome on this was not established and contrasted with the self-report data. It is not clear what proportion of the studies reviewed by Cuijpers reported on a re-administration of the standardised diagnostic interview. If a standardised diagnostic interview is the ‘gold standard’ for entry into an rct why is it relegated when it comes to assessing outcome. Is it that such an independent interview would be too high a bar for purported efficacious cbt treatments to clear or perhaps it is just cheaper to rely on self-report.

 

But the right to know whether treatment has made a real world difference  is not just a right to be exercised in the context of rcts, the right surely exists in routine practice. This right helps to ensure that the client is not just fodder for some numbers game. The realisation of this right forces a consideration about whether the customary sole self-report assessment and outcome measures are fit for purpose.

Dr Mike Scott

CBT Researchers Have Abandoned Independent Blind Assesment – Beware of Findings

I have been looking in vain for the last time CBT researchers assessed outcome on the basis of independent blind assessment, which was a cornerstone of the initial randomised controlled trials of CBT.  Current CBT research is more about academic clinicians marketing their wares. Journals such as Behaviour Research and Therapy and Behavioural and Cognitive Psychotherapy and organisations such as BABCP and BPS are happily complicit in this. The message is give a subject a self-report measure to complete, it is less costly than expensive highly trained independent interviewers blinded to treatment, forget about the demand characteristics of a self-report measure ( a wish to please those who have provided a service) and don’t worry if the measure does not accurately reflect the construct under question. My psychiatric colleagues might be forgiven for saying that at least the trials of antidepressants have usually been double blinded, if since the millennium CBT studies have rarely managed to be single blinded, is it time the CBT-centric era ended? But purveyors of other psychotherapies have even more rarely bought into the importance of independent blind assessment.

The overall impact of inattention to independent blind assessment is that the case for pushing CBT is actually not as powerful as the prime movers in the field would have us believe, this may actually be a relief to struggling practitioners. For example Zhu et al (2014) [Shangai Arch Psychiatry, 26, 319-331 examined 12 randomised controlled trials of CBT for generalised anxiety disorder in which there was supposedly independent blind assessment  but in 6 of the 12 studies the main outcome measure was based on the results of a self-reported scale completed by the client (i.e outcome was not actually assessed by the blinded assessor) and concluded that the quality of the evidence supporting the conclusion that CBT was effective for GAD was poor. A meta-analysis of outcome studies  conducted by Cuijpers (2016) World Psychiatry, 15, 245-258 found that using criteria of the Cochrane risk of bias tool only 17% (24 of 144) rct’s of CBT for anxiety and depressive disorders were of high quality. Cuijper et al concluded that CBT ‘is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still
uncertain and should be considered with caution’. Only half the studies had blind assessors and it is not clear whether they were the determinants of outcome or a client completed self-report measure, the study needs further analysis. My impression is that the weakest of studies are those examining guided self-help, computer assisted CBT, (the step 2 interventions in IAPT) yet these interventions are most commonly offered.

Dr Mike Scott

CBT’s Dominance Arose From A Medical Model Paradoxically Most Practitioners Disown It

CBT is heralded as the treatment of choice by NICE,  because it is based on randomised controlled trials of ‘effective’ disorder specific protocols, but most CBT practitioners have paroxsyms at the mere mention of a medical model! This makes it inevitable that there is  going to be a yawning gulf between treatment in the rct’s and in routine practice. In this context it simply is not credible that the generally positive  findings from research will be effectively translated. There is a pressing need to build a bridge between practitioners and those who were involved in high quality rct’s:

A way forward is to acknowledge that there is more than one Medical Model, Dominic Murphy [ The Medical Model and the Philosophy of Science  (2013) in The Oxford Handbook of Philosophy and Psychiatry] recommended the minimalist version of the model which asserts that  ‘…. mental illnesses are regularly co-occurring clusters of signs and symptoms that doubtless depend on physical processes but are not defined or classified in terms of those physical processes’. It is this version of the model that largely underpins the DSM criteria. The minimalist version is in fact quite different to the strong version of the model and rejection of this is not synonymous with rejection of the medical model – the strong version is in many ways a caricature. But caricatures are good for uniting people in what they are against and avoids the difficult question of what they are  for.

Dr Mike Scott

Without A Written Aid To Remembering Session Content Little Chance Of Real World Change

Most client’s are highly anxious, the chances of them remembering session content accurately, much less applying it, are therefore slim. But review of therapy records usually provides no evidence of session summary or detailed specification of homework. At most therapists may write ‘activity scheduling’, ‘thought records’ or ‘continue exposure’. Compare this vaguenness with the specificity of a medical prescription “take ‘x’ 3 times a day after meals’.  I remember a client with Multiple Sclerosis who was in agony with his symptoms for a couple of weeks before it was discovered he had inadvertently been prescribed a sub-therapeutic dose of medication. The lack of specificity about CBT homework means that it cannot be easily corrected and in essence there is no accountability as there is in medicine. Below replace ‘students’ with ‘clients’:

If CBT is primarily educational then we have to teach properly. But training does not equip therapists to teach, even worse therapeutic interventions are often not modelled by tutors first!

Despite therapists endeavours clients lose out because of poor therapist training, psychological therapists often come off CBT courses less confident than when they began.

Dr Mike Scott

IAPT and The Absence of Treatment Markers

IAPT purportedly offers NICE –indicated treatments for depression and anxiety at Steps 1-3.  But the NICE guidelines do not offer guidance on the treatment of specific phobias or adjustment disorder.   So that in practice Psychological Therapists fail to adequately distinguish between these excluded categories and the included ones such as PTSD, OCD etc.  The result is that there is a serious mismatch between disorder and treatment, for example I’ve just seen a person treated with 10 sessions of trauma focussed CBT, I knew him to have simply a specific phobia about driving and travelling as a passenger in a car and he was still suffering from just this after IAPT treatment. The treatment records referred to ‘likely PTSD’,   such statements are not only unreliable but dangerous. There is a need for a

In practice IAPT treatment is determined by therapists rules of thumb, such as ‘if the trauma was extreme and there are disturbing intrusions go for PTSD treatment’, ‘if there was prolonged abuse go for complex PTSD’, ‘ a high score on the Impact of Events Scale means PTSD is likely’,  but there is no scientific basis for such rules.  The NICE guidance makes no mention of treatment being determined by the therapists ‘formulation’, but many therapists are perfectly happy with this supposed magical insight into the way forward, which they see as a product of their clinical experience and acumen.  In practice lip service is paid to the NICE guidelines, for the most part therapists do their own thing, with perhaps a psychometric test such as the IES thrown in to appease management and a concern to use keywords like habituation, trauma focussed CBT and exposure. Training courses do not it seems help students critique the validity of the IAPT treatment approach.

Wither true accountability?

Dr Mike Scott

Which Guide To Mental Health

‘Did the mental  health service that you used, give you the lifestyle that you wanted?’ , answers in a new ‘Which’ guide. At present consumers are entirely at the mercy of the manufacturer’s advertising.

The views of employer’s and GP’s have potentially a greater objectivity than that of the mental health service providers. The danger is that employers can by pass serious consideration of the matter, by reminding themselves that their primary objective is profit/productivity and that provided that they can be seen as making some gesture to health and wellbeing, ‘look no  further’. In a similar way GP’s can bypass central processing of objective outcomes with a rationale that they are fully extended performing their primary function of looking after the physical health of patients, ‘so long as I can off-load mental health patients at least for a time so much the better’.

There is a pressing need to ask questions nobody wants to hear. According to George Orwell, liberty is the freedom to ask such questions. How much liberty is there really in the mental health/medical sphere?

 

Dr Mike Scott