Outcome In Talking Therapies – Calling a Spade a Spade

when did you last hear of a therapist asking a client ‘do those close to you think you are back to your old self now?’, ‘do you think you are back to your old self? ‘how long do you feel that you have been back to your normal?  Yet these questions reflect the implicit dominant concerns of clients. It is at a minimum, neglect not to ask such questions and we may come to see this failure at some future point as abuse.

But Improving Access to Psychological Therapies (IAPT) therapists typically concentrate on whether there has been an improvement of 6 points on the PHQ9, with no attention to how long the improvement has persisted and they are then ejected from treatment.  Client’s are not asked whether the said change on the psychometric test constitutes a minimally clinically significant improvement in their condition.  Nor is there any evidence that the chosen psychometric test is pertinent to the primary disorder for which they were seeking treatment. The typically administered PHQ9 and GAD7 are highly correlated and may not even represent separate constructs i.e depression and generalised anxiety, and by themselves are dubious vectors for directing treatment. 

It is a sleight of hand to claim that the 6 point improvement on the PHQ9 or indeed scoring below 10 at post treatment say anything meaningful about the client’s real world if the test is used outside the context of a standardised diagnostic interview that identified depression as the primary disorder. Using the psychometric tests out of such contexts has more to do with income than outcome. For the unwary such changes seem ‘significant’ but the same change is observed in clients followed up without psychological therapy [see Gilbody (2015)]. Unfortunately it has proven all to easy to dupe Public Health England and Clinical Commissioning Groups. At present it seems it is too embarrassing for them to admit they have allowed themselves to be hoodwinked for years.

 

Dr Mike Scott

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