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NHS Talking Therapies – Wasting Access to Psychological Therapy

by reliance on two screening instruments. Coupled with a failure to conduct an interview that would reliably confirm or reject the impression given by the tests. The effect is that  many are treated needlessly, as most score above the designated cut-offs on the tests [IAPT Manual 2018)]. Further, diagnostic possibilities are constricted by the scope of the 2 instruments, depression (PHQ-9) and generalised anxiety disorder (GAD-7). The message from this Government service is:

 

Usage of the 2 screening tests would not rule out that a person had say an adjustment disorder triggered by job loss, marriage breakdown, serious illness, bereavement or an accident.  But such difficulties are not the domain of the disorders that are the focus of the randomised controlled trials of cbt for depression and the anxiety disorders. Yet such difficulties are the common currency of primary care. Thus the application of the cbt protocols for these disorders to those with these difficulties is not evidence-based and is a waste of resources. It is likely a matter of pathologising normality.

 

One third of those attending NHS Talking therapies have a low intensity intervention alone, i.e they are not treated by a psychological therapist, but by a Psychological Wellbeing Practitioner (PWP) [IAPT Manual (2018)].  But the PWPs do not know the diagnosis of any patient, as they, like all NHS Talking Therapies clinicians are not trained to diagnose. The allegation is that they deliver CBT, but for what?

The evidence-base for low intensity interventions is weak, in that, there is an absence of attention control conditions and independent blind assessment. The evidence that PWPs implement the low intensity interventions from the weak trials is weaker still. There have been no fidelity checks on PWPs ministrations i.e independent assessments of treatment targets and matching treatment strategies. 

Almost half of those entering NHS Talking therapies never progress to treatment defined by the Service as attending 2 or more treatment sessions. This is likely a ‘thanks, but no thanks’ response on behalf of patients. There is a monumental waste of scarce resources. Unsurprisingly I found that only the tip of the iceberg recover.  

The trajectory of patients in NHS Talking Therapies is rather like that of horses entering the Grand National. There were 1.69 million referrals to IAPT in 2019-2020, 1.17 million left the starting gate, 30.77% (almost 1 in 3) were non-starters. Further only 1 in 3 (36.8%) got around the course (defined curiously by IAPT as attending 2 or more treatment sessions). The much vaunted ‘50% recovery rate’ that this Governmental service boasts about, refers to the significant minority who cross IAPT’s finishing line. Thus even using IAPT’s own yardstick  the true recovery rate is much less than 50%.

With regards to those who cross IAPT’s finishing line, there is no indication that their ‘success’ is lasting. It is not known what proportion of them ever ‘race’ again. 

The NHS Talking Therapies is an exemplar of what happens when there is an unaccountable Service. In which a therapist’s unfettered judgement, on how to treat a patient, is allowed to rule. Opinion-based treatment withers on the vine.

 

Dr Mike Scott

10 replies on “NHS Talking Therapies – Wasting Access to Psychological Therapy”

please read William M Epstein’s three key books – The Illusion of Psychotherapy, Psychotherapy as Religion and Psychotherapy and the social clinic in the united states soothing fictions and Paul Maloney’s The Therapy Industry along with all of David Smails books – there are many others to pick from – what we see from these careful researchers is that no psychotherapy has any robust evidence supporting it and they can and do cause harm to people.

The books that you mention are not based, as you claim, on careful research, they are essentially polemical. These authors fail to address the question of what works with whom?. They do so by failing to a) offer fidelity checks that would meaningfully distinguish treatments b) failing to operationalise what would constitute working and c) failing to specify the population addressed. These deficiencies are covered up by tilting at the windmill of psychotherapy, which allegedly suffers from the twin evils of being individualist and religion-like. But I am not interested in psychotherapy per se, just whether the CBT I have described in my books can make a real-world difference. I have never doubted that social factors are important or that values and meaning are critical. If it is considered that there are resonances with religion, I don’t find that at all problematic. I am not individualist nor do I subscribe to ‘scientism’.
To be more specific critical shortcomings in these books include:

1. A failure to acknowledge that in the randomised control trials of CBT for depression and the anxiety disorders the recovery rate is on average 50%. Further, some of these studies have involved independent assessor’s of recovery and attention control conditions.
2. In routine practise only the tip of the iceberg recover. No fidelity checks have been conducted, to see if clients actually get the treatment they are allegedly getting. Thus, in the recent IAPT study in BMJ Mental Health comparing supposedly CBT for depression and Counselling for depression, there was no fidelity check and no reliable diagnosis of depression. All this in a new Journal that replaces the Journal Evidence-based Mental Health. The authors of the study have clear IAPT allegiances.
3. In routine practise therapists do their own thing, this is entirely consistent with the view that all therapies are equal and must have prices – the Dodo verdict in Alice in Wonderland. Current practice is a laboratory in which this hypothesis has been tested out and the results are an abysmal failure.
4. Reliance on diagnosis is not perfect, the interrater reliability findings (kappa) are a source of concern in DSM-5. But the Perfect must not become the enemy of the good. Diagnosis is the least-worst option with regards to depression and the anxiety disorders. The burden of proof is on those who jettison diagnosis to come up with a better way forward. The authors of these books have totally failed to chart a way forward.
5. Disorders are distinguished by their different cognitive contents e.g PTSD by items on the Post-traumatic Cognitions Inventory which are predictive of PTSD symptoms, depression by the Dysfuntional Attitude Scale, panic disorder by the panic cognitions questionnaire. This confers some legitimacy to diagnosis for at least a limited range of disorders, with protocols that match the cognitive content. So that whilst treatment is tailored to the individual ( see Personalising Trauma Treatment) it is not arbitrary or idiosyncratic like treatment in routine practice.

regards

Mike

Epstein’s books are not trying to look at what works for whom. Those three books are a careful analysis of the research base for the main approaches including CBT. He dismantles the best of the research on methodological grounds and shows there is no robust evidence for any of it. Claims of 50% recovery are illusory because the research is riddled with problems, bias, attrition, self report, inconsistent measures, no proper placebo, and on and on He is also interested in looking at Psychotherapy in its cultural position and what role it plays within culture. Smail also looks at therapy from a more cultural/power perspective and is also critical of the evidence base.

In Smails own words: ‘It is, I believe, a profoundly ironic paradox that modern psychology has done more than anything else to divert us from an understanding and appreciation of the subjective experience of self. Instead of a delicate, modest, tentative, respectful consideration of the unfathomably chaotic, sometimes extraordinarily beautiful, sometimes horrifically frightening, always wildly idiosyncratic interior which is to be found within each one of us, psychology has tried to unpick us with a kind of fastidious distaste that has nothing to do with respect or love and everything to do with discipline. At least in part because of the success of the psychological enterprise, we are as individuals largely unable to celebrate and rejoice in the experience of self; but rather, when we have to, turn our gaze inward with deep apprehension for what we may find there. What we find, certainly, is a person like no other – and that is one of the principal causes of our misery. For psychology has imposed on our subjectivity an entirely inappropriate normativeness, a narrow set of moral and aesthetic prescriptions which turns each one of us into a kind of self-diagnosing psychiatric inquisitor, ready to infer from the recognition of each new feeling pathological deviance from an ideal we think we see embodied in everyone else. I can think of no mainstream approach to psychological therapy which doesn’t harbour at its core a humourless authoritarianism, a moralistic urge to control, that has the ultimate effect of causing infinitely more pain than it could ever conceivably hope to cure’. (Smail, 2007)

The books that you mention are not a ‘careful analysis of the research base of …cbt’. No criteria are evinced for distinguishing studies with a high risk of bias from this with a low risk . Nor is there any careful weighing of the evidence for cbt for a particular disorder such as PTSD. For example there can be no doubt of the methodological soundness of the Ehlers et al (2014) study discussed at length in my recent bool Personalising Trauma Treatment and the general conclusion of a 50% recovery rate across those studies with a low risk of bias. Smail’s branding of psychotherapy as ‘humourless authoritarianism’ is a sweeping generalisation and certainly not found in the pages of anything I have written, but I am not a defender of psychotherapy per se. He also claims that psychotherapists have a ‘moralistic urge to control’ , this sounds like an arbitrary inference, I do not at all recognise this in the CBT that I conduct. Doubtless if I protest too loudly that I don’t do this, this will be taken as evidence that I do – pace.

I am beginning to wonder if we have read the same books – chapter two in his last book 2019’s Psychotherapy and the Social Clinic, soothing fictions is titled ‘Psychotherapy for Post-traumatic Stress Disorder’ https://link.springer.com/chapter/10.1007/978-3-030-32750-7_3 HIs books encompass CBT but are not just about CBT but psychotherapy in general and its cultural position.

For something more specific to CBT try The CBT Tsunami by Farhad Dalal. The Therapy Industry by Paul Maloney is also useful there are many others. Smail isn’t talking about individual therapists who are often well meaning, good intentioned people but the way in which therapy essentially serves to maintain the status quo, by internalising what are often cultural disorders and turning the world inside out, obfuscating and loading each person with responsibility to adjust to cultural level disorders, most jobs, schools, political and economic ideologies that drive so much distress. This is a crude few lines, reading him is best, he was a therapist in the NHS for years so has important experience to share.

I think you mentioned in a recent blog how IAPT is pathologising more and more normal human behaviour – i’d say whatever is happening for the person is normal when we fully place person in historical context and current cultural disorders. The world is not fine and its not a matter of faulty perceptions but the culture we must seek to change – working in mental health across primary and secondary care is seriously bad for your wellbeing but we’re meant to be teaching clients to ‘be their own therapists’ as if therapists are any more able to withstand cultural disorders when we meet them – of course the middle class have more access to resources and given resources are the biggest factor in any positive outcome then its easy to delude ourselves its just a matter of sifting the data and making rational decisions.

I wonder why aren’t the critics of the research or the industry more generally taught on training courses – how can it be settled in any way given we are always dealing with the subjective.

The abstract to Epstein’s chapter on PTSD reads ‘The best of the PTSD outcome research is deeply flawed’. This is simply not true, see p45-48 of my book Personalising Trauma Treatment. There are exemplary studies such as Ehler et al’s (2014) and Carpenters review of 14 studies, which would meet criterion for a low risk of bias in the Cochrane Assessment of Risk of Bias. Epstein fails to consider Ehlers (2014) study or Carpenter’s (2018) review. Epstein continues his condemnation thus ‘researcher and institutional biases, lack of blinding, large attrition, questionable patient self-report, and others’. But these criticisms do not apply to the aforementioned studies there is no ‘large attrition’, there are studies were there has been blinding. There are studies funded by the VA, but this does not invalidate them, veterans have in fact been to have a lower recovery rate than civilians. Epstein offers me absolutely nothing that I can use to assist my traumatised clients. The Tsunami book I found equally useless. I have never thought of myself as ‘teaching clients to be their own therapist’ , just as someone meeting clients along the road and chipping in what I have to offer that may be of use. Sometimes I am lost for words it is just a sharing, they may have a terminal illness or depression from appalling housing conditions and I might liase respectively with a cleric and a solicitor.

For me the books are best read together as they layer each other and Smail’s critique is far broader than a comment on a post. Smail was a professor of psychology who worked as a therapist for years in the NHS and he is generally speaking about systems rather than individuals. Both of these authors consider human to human support useful and necessary, it just does not require a professional therapist to off such support, especially in light of the obvious issues mentioned in our discussion, your excellent blog and the ongoing issues with diagnosis or the misapplication of the medical model to ‘mental health’.

As if mind (whatever and wherever that is) can be separated from body and both from the unfathomable complexity of culture, history, bias, heuristics, unresolved issues around free will or not and our general ignorance and blindness as a species about what is going on here.

Epstein makes the point time and again that those deeply embedded within the industry, such as therapists are not best placed to conduct research because of the bias and blinding it brings. He demonstrates throughout his books how even obvious issues within research is spun into a positive result – This is also well documented and remains a huge issue in the field of psychology more generally highlighted by the ongoing replication crisis.

Even the concepts being studied such as ‘ptsd’ are also highly contested with no objective tests to determine diagnosis – The outcome of this is clear to see because just about anyone and everyone is either self labelling or being labelled with pstd, ‘autism’ ‘gad’ ‘depression’ etc. its almost as if we are losing the ability to understand ourselves and our rich emotional reactions outside of medicalised terms.

I didn’t mean to suggest that you personally are trying to teach your clients to be their own therapists, but this is a common idea sold to training course participants and in discussions between therapists in IAPT etc.

The mental ill health industry has been and continues to be more about fads and fashions and whatever rises to the top in todays world does so because it is useful to vested and self interests – these are, it seems, key elements of value system disorders driving the bus.

Keep up the excellent work with the blog – I agree with so much of it, but I do find it concerning that a solution for you seems to be more medical model not less.

Hi Topher
There is so much of what you say that I am in agreement with, but your requirement of an ‘objective test’ for a diagnosis would gravely disadvantage many people. Let me give you an example.I was in Court recently as Expert Witness for a claimant. The latter was a shadow of his former self since a near death incident. The prosecuting barrister tore the poor guy apart. I was then cross examined for 2 hours along the lines of there is no ‘objective’ evidence he had PTSD. If this ‘objective’ standard had been accepted compensation would not have been awarded by the judge, nor would the failures of all treatments to date have been recognised or the improbability of further treatments being successful. I argued that he had ongoing PTSD and panic disorder and there was a need for support not treatment. Time and time again I see examples of the casual application of diagnostic labels to people that results in unnecessary or inappropriate treatments. But if one uses the type of standard diagnostic interview involved in Ehler et al’s PTSD study kappas are of the order of 0.9, a very high rate of interrater agreement, giving some certainty that if using such an instrument one is talking about the same phenomenon. I totally agree that mental health issues and pain are ultimately subjective but this does not mean that you cannot use an evidence-based approach legally and clinically
Take good care
Mike

Hi Mike,

I think the court case you mention highlights why the misapplied medical model for human wellbeing persists and is hard to stop.

As you say without the label this man might not have received compensation. The DSM mindset is so thoroughly embedded in the culture that its hard to operate without it and a new way of thinking and doing needs to break through.

Its akin to the idea of free will being tied to our judicial systems when free will is likely an illusion – Robert Sapolsky’s forthcoming book should tackle this.

The DSM mindset is umbilically tied to tangible benefits or scraps from the table, so now people covet a disorder in order to receive some scraps. People are now shopping for a disorder as one might shop for a brand of footwear – ah this one feels right and I’ve engaged with enough online echo chambers so it must be the correct diagnosis. Not to mention the professionals happy to label and rarely if ever explain any of the issues with diagnosis meaning informed consent is out of the question – and try and remove a label once applied, some of them are sticky buggers.

Whether its the mental health professional battered by targets, complex lives and limited sessions, stressed out, bullied, harangued by managers and commissioners -producing empty data based on lies and manipulation and thoroughly impoverished ideas about ‘recovery’ Perhaps a label for the professional of ‘depressed’ or ‘GAD’ or ‘CFS’ might provide a brief reduction in the relentless case load or some ‘reasonable adjustments’ SCRAPS. Obfuscating the real causes of out suffering, internalising and depoliticising it all in the process.

Whether its the school teacher in similar position

Whether its the pupil or student

Or anyone working today – large scale surveys tell us most people hate or are disengaged from their work. Something we do day in day out for the best years of our lives.

YET it is the suffering individual that is sent for therapy, to have our disordered, dysfunctional, or irrational thoughts and behaviours corrected.

In the news today (who knows if its true, post truth, mistruth, confusing world hey) today we hear Sunak paid privately to upgrade his local electricity grid in order for his pool to be heated.

Meanwhile – just look at the incredible carnage and disgusting mess our culture is in, food banks appear to be experiencing the largest growth in the G7, people are hanging by ever thinning threads, working harder to stand still and go backwards

The WHO state
More than 700 000 people die due to suicide every year.
For every suicide there are many more people who attempt suicide. A prior suicide attempt is the single most important risk factor for suicide in the general population.
Suicide is the fourth leading cause of death among 15-29 year-olds.
77% of global suicides occur in low- and middle-income countries.
Ingestion of pesticide, hanging and firearms are among the most common methods of suicide globally

I’m sure you are away of all of this and know I could go on about the many, varied and growing cultural disorders – how does/can therapy reduce the world to a ‘trigger’ and the fault be some internal cognitive/behavioural malefaction, dysfunction or disorder that is changeable with a few hours of therapy? – our core beliefs, assumptions and thoughts are marinated in our embodied selves in this world/culture/chaos over lifetimes- a smattering and splattering of causality and chaos – we don’t even know what or where a mind is.

For those somewhat protected or ignorant of the chaos, the middle class the well resourced etc its easy to assume its all a matter of sifting the data and making rational choices. Then we see contemporary researchers and scientists centralising the role of emotion in the human being – after years of subjugation and denial it seems we are more emotional than rational – the elephant is in control the rider is their to spin a yarn about what the elephant is doing, to butcher Jonathan Haidt’s work.

I won’t prattle on but for me we need to be there for each other – this might be best served by de-professionalising and democratising care and compassion and as Smail and Epstein suggest, getting together to make the world a place fit for human and planetary thriving not this mad and unnecessary struggle for survival.

The problem about denying free will Topher, is that I could dismiss what you said because it was just the expression of a compulsion, no choice involved. It gets even more problematic when you see free will as an ‘illusion’, this looks very like pathologising most people’s experience of what they deem their experiential reality. You are in danger of doing exactly the reductionism that both you and I find dehumanising when people are defined solely as information processing devices.
Very best wishes
mike

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