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Flexibility Within Fidelity

was the title of a great CBT workshop that I attended yesterday, delivered by Prof Philip Kendal. He described how time saving rules of thumb, can short circuit the therapeutic process (described in his book with the same title, published in 2022 by Oxford University Press). One of the attendees, a low intensity practitioner, volunteered one such heuristic, automatically disqualifying a client from the Service (presumably NHS Talking Therapies) if they had had a bereavement. Prof Kendall replied:

‘when the system is screwed up change  the system’  

A totally reasonable response from an objective observer outside the system. In the Webinar didn’t hear further from the therapist, and Prof Kendall did, understandably, not quite appreciate that bringing about such a change is a monumental task for anyone in IAPT’s successor. He did opine that one way of changing a system is to set up a comparison of the current system with the proposed system. But there has been no independent assessment of NHS Talking Therapies. He opined that the most credible randomised controlled trials were those in which there had been a blind, independent assessor. The Service’s  clientele have never been involved in such a trial, much less in a comparison of the Service’s routine practice with the mode of delivery suggested in my 2009, tome Simply Effective CBT, published by Routledge.

Prof Kendal said that in the US a lot of CBT therapists don’t give homework and in this  context clients do no better than in an attention control condition. This side of the pond, in my review of numerous records, for the Court I have never seen the written specification of a homework much less its’ monitoring. It is a myth that CBT is routinely provided, literally it would not stand-up in Court. Nevertheless the UK Government continues to fund adult and child and adolescent mental health to the tune of £2 billion a year. Where else could this happen without independent evaluation?

Prof Kendal insisted that his workshop was not about flexibility with infidelity but that is what routine psychological treatment in the UK amounts to. There is nothing in the UK NHS Talking Therapies approach that prevents therapists using unbridled clinical judgements. Its’ therapists perform what Prof Kendall terms a ‘diagnostician’ role, in that they assign ICD 10 codes to the client’s problems (without making an ICD 10 or DSM-5) diagnosis, but this has not stopped treatment wandering from a recognisable diagnostic pathway.  I felt he ducked the importance of reliable diagnosis. 

Prof Kendall rightly insisted on the importance of personalising treatment and having a therapeutic relationship. both of which Drew et al (2022) found notably absent in NHS Talking Therapies low intensity interventions. In Personalising Trauma Treatment: Reframing and Reimagining Routledge (2022) I give lots of examples as to how this can be done in the trauma field. I agree with him that both personalising treatment and a therapeutic relationship are necessary but not sufficient conditions for effective treatment. The other necessary active ingredient for treatment is that it must address the mechanism that is pivotal in the maintenance of the condition. With regard to trauma I have suggested it is the centrality accorded to the trauma and not arrested information processing.

Thank you Prof Kendall for such a human and illuminating workshop.

 

Dr Mike Scott

 

 

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