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NHS Talking Therapies Tangled Web

The Service claims recovery from mixed anxiety and depressive disorder (MAD), without a treatment protocol. But at the same time insists that it is National Institute for Health and Care Excellence (NICE) compliant. NICE specifies the disorders for which there is an evidence-based treatment, but MAD is absent from the list. It therefore not possible for the Service to be protocol driven in this domain. Yet it boasts a recovery rate for MAD comparable to that for the recognised anxiety disorders  and depression. For tennis afficionados this may well evoke the John McEnroe response of ‘you cannot be serious!’

How MAD clients of the Service apparently fare, throws up an interesting conundrum: given that their recovery is on a par with other disorders (without the use of any evidence-based treatment), could it be that these other ‘successes’ are nothing to do with the alleged use of specific protocols, but are just what happen if you give anybody attention, time and present a credible rationale for treatment?. The burden of proof is on NHS Talking Therapies to demonstrate that its’ ministrations have an effect, over and above, that which would obtain from say the Citizens Advice Bureaux helping its’ distressed clients with difficulties. The Service has shown no inclination to recognise or address this credibility problem, perhaps suspecting it would be like turkeys voting for Christmas. 

But the NHS Talking Therapies debacle over MAD is even more extensive. The author of the Service’s Manual dissuades clinicians from using the MAD label because it might lead to missing clients who truly have PTSD. But omits to mention that there is no way the Service can identify those who do or do not have PTSD, because its clinicians do not make diagnoses! We are at least on the border of MADness and dishonesty.

Dr Mike Scott

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NHS Talking Therapies Undue Deference to Two Psychometric Tests Stymies Listening and Treatment

 

Two psychometric tests, the PHQ-9 for depression and the GAD-7 for generalised anxiety disorder, are the twin pillars used by NHS Talking Therapies [formerly Improving Access to Psychological Therapies (IAPT)] service to direct therapy and evaluate outcome. The pillars form a gate through which the client is expected to pass, at every treatment session. Thus, making less time for listening to and treating clients.  

NHS Talking Therapies clinicians are not trained to make diagnoses, so the tests are the sole arbiter of the services effectiveness. I made a freedom of Information Request to NHS England requesting  details of the experience of clinicians and cost of the Service, bizarrely they said that they  did not have this information. Drawing on data from the rest of mental health services, it seems likely that most practitioners are less than 3 years in post, over 80% are female and most age 40 or below.   It stretches credibility to believe that these practitioners are sufficiently competent or diverse for the public they serve.

 

 Unfortunately, other agencies such as the Charity, Anxiety UK have felt compelled to adopt IAPT’s metrics. The result is chaos, when viewed through the lens of the recent Negeri et al (2021) meta-analysis of the accuracy of the PHQ-9 to assess for depression. A chaos which is compounded by looking through the other lens, of the accuracy of the GAD-7 in different settings.

The Misuse of the PHQ-9

Negeri et al (2021) provide a tool to indicate the likely consequences of use of the PHQ-9 by itself. The first step is to enter the likely prevalence of depression in the target population (in primary care they suggest it is likely to be 5-10% and in specialty care settings or those with chronic health conditions it is likely to be 10 to 20%). Entering a prevalence of 10% for the level of depression in those presenting to IAPT (using the standard cut-off of a score of 10+) 22% of client i.e 22 out of 100  would screen positive. Of the 22 9 (39%) would meet diagnostic criteria for major depression (true positives) 13 (61%) would not meet diagnostic croiteria for major depression ( false postives). Thus inappropriate treatment would be given to more than 1 out of 2 clients. Alternatively inputting a prevalence of 15% ( perhaps more accurate if the population included those with long term conditions) would give a prevalence rate of 26% i.e 26 out of 100.. Of the 26 13 (50%) would meet diagnostic criteria for major depression (true positives) but 13 (50%) would not meet diagnostic criteria for major depression (false positives). Thus, one out of two clients would be treated for depression when they did not need to be.

Using the PHQ-9, as often as not, IAPT’s clinicians are treating the wrong disorder. How then can the results ( a claimed 50% recovery rate) be comparable to that in the randomised controlled trials for depression where all the clients were known (on the basis of a ‘gold standard interview’) to be suffering from depression?

The Use of the GAD-7 By Agencies in Addition to the PHQ-9, Adds To the Misdirection and Makes Their Claims of Effectiveness Even Less Credible

Rutter and Brown (2016) concluded that the GAD-7 is ‘a dimensional indicator of GAD severity rather than a screening tool for the presence or absence of the disorder in outpatients with anxiety and mood disorders’ and the GAD-7 did not provide sufficient specific information to indicate the presence of a GAD diagnosis’, At a cut-off of 10 the sensitivity was 79.5% and specificity 44.7%. Using a cut off of 8 the sensitivity was 86.5% but the specificity was 34.8%. But In the validation study of the GAD-7 by Spitzer et al (2006) the optimal cut off was a score of 10 or more, 89% with GAD had GAD-7 scores of 10 or greater (sensitivity ), whereas most patients 82% without GAD had scores less than 10 (specificity). The psychometric properties of the GAD-7 have also been examined in a heterogeneous sample of different diagnoses. Beard and Björgvinsson (2014) found poor specificity and a high false positive rate for specific anxiety disorders and the proposed cutoff by Spitzer et al. (2006) of ≥10 was only partly supported with a sensitivity of 74% and specificity of 54%. Kroenke et al. (2007) found that the GAD-7 performed well as a screener for GAD, post-traumatic stress disorder (PTSD), social anxiety disorder (SAD), and panic disorder (PD) in primary care patients and proposed a score of 8 as a cutoff score with a positive likelihood ratio above 3. It appears that it is only the authors of the GAD-7 that claim its value.

 

Getting Real

The most plausible explanation is that IAPT has engaged in self-promotion. Realistically, only the tip of the iceberg of IAPT clients recover Scott (2018).

But it is not only IAPT who are making false claims so to are other service providers. There is pressing need for independent audit using ‘gold standard’ assessments of the trajectory of clients lives after treatment.

 

Beard, C., and Björgvinsson, T. (2014). Beyond generalized anxiety disorder: psychometric properties of the GAD-7 in a heterogeneous psychiatric sample. J. Anxiety Disord. 28, 547–552. doi: 10.1016/j.janxdis.2014.06.002

Kroenke, K., Spitzer, R. L., Williams, J. B. W., Monahan, P. O., and Löwe, B. (2007). Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann. Intern. Med. 146, 317–325. doi: 10.7326/0003-4819-146-5- 200703060- 00004

Rutter, L. A., and Brown, T. A. (2017). Psychometric properties of the generalized  anxiety disorder scale-7 (GAD-7) in outpatients with anxiety and mood disorders. J. Psychopathol. Behav. Assess. 39, 140–146. doi: 10.1007/s10862-016- 9571- 9

 

Spitzer, R. L., Kroenke, K., Williams, J. B. W., and Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder the GAD-7. Arch. Intern. Med. 166, 1092–1097. doi: 10.1001/archinte.166.10.1092

 

 

Dr Mike Scott

 

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NHS Talking Therapies the Victory of ‘Satisficing’ Over What Clients Really Want 

 

Satisficing is a term used by economists to denote a decision-making strategy or cognitive heuristic that involves searching through alternatives until an option is considered to clear an acceptability threshold. The Labour Party Economist, Lord Layard considered that with the help of psychologist, Professor David Clark, they could make a sufficiently plausible case to Government to fund the Improving Access to Psychological Therapy (IAPT) service [now rebranded NHS Talking Therapies for anxiety and depression]. In this they were successful [‘Thrive’ Layard and Clark (2014)]. The new Labour Government shows no sign of wanting to review its’ received mantra, despite a cost £2 billion a year for Adult and Child mental health services. But the voice of mental health sufferers has been nowhere in evidence. There was no evidence that the proposed mode of service delivery would result in recovery, in a way that was intelligible to sufferers, such as no longer suffering from a disorder for a significant period of time.

In the 2011 book by Psychologist, Martin Seligman ‘Flourish’, Layard chides him  “You, like most academic types, have a superstition about the relation of public policy to evidence. You probably think that Parliament adopts a program when the scientific evidence mounts and mounts, up to a point that it is compelling, irresistible. In my whole political life, I have never seen a single example of this. Science makes it into public policy when the evidence is sufficient and the political will is present”.

But what if there are vested interests in determining what is ‘sufficient evidence’ ? For sixteen years the Service has continued to proclaim its’ 50% recovery rate, despite no independent evidence using a ‘gold standard’ diagnostic interview.

 

Heuristics have the advantage of speed, getting things done, but not necessarily well enough from the point of view of the consumer. ‘Satisficing’ is a powerholders judgement, imposing its’ will, blind to cient’s satisfaction but very attractive to other powerholders. With a ‘satisficing’ rationale Layard also announced his intention to bring ‘positive education’ to schools. There has been a psychopathologising of the young with diagnoses of ADHD or ASD seen as the gateway to services and a sought after explanation of difficulties. With little attention to alternative and often more credible explanations of difficulties. This is not to deny that there are those few who truly have ASD in the traditional sense of the term. In practice, there is a de facto absence of specialist reliable assessment for these conditions. The upshot is that a great many people are treated ‘as if’ they have these conditions and may self-diagnose these conditions. 

 

Seligman, Martin E. P.. Flourish . Nicholas Brealey Publishing. Kindle Edition. 2011

 

Dr Mike Scott

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NHS Talking Therapies Black Hole

Data is only publicly available on the 1 in 2 people who undergo treatment, those who have had just one assessment/treatment session have disappeared down a black hole for the past 16 years. This is hardly the transparent and comprehensive monitoring of outcome claimed in the NHS Talking Therapies updated Manual.

But following a Freedom of Information request (FOI) I have obtained data on those attending only 1 session. But the diagnostic status of almost a third (29.1%) was unknown, making the Services claim to follow NICE approved diagnostic specific protocols meaningless. 

 


The Manual 5.1.3  recommends ‘systematic screening for all the conditions that NHS Talking Therapy treats’.  But there are 11 conditions that the Service treats.There is no evidence that at assessment its’ clinicians employ a standardised screen for the spectrum of disorders that they claim are within their remit to treat. Nor that they use a screen to rule out the disorders that they do not treat: personality disorder, psychosis, bipolar disorder and eating disorder. In the foreword to the Manual it states that those who do not go on to treatment are given ‘advice and signposting (if appropriate)’. But there is no clarity about the content of this ‘advice’ nor of its’ evidence base.  Signposting it seems may not occur, but this could plausibly be because the assessing clinician (usually the most junior member of staff- a Psychological Wellbeing Practitioner) simply doesn’t know the way.  One has a strong suspicion that those who have simply an ‘assessment’ disappear down a black hole, only to possibly re-emerge in desperation, when their difficulties have not resolved.

NHS Talking Therapies published data is at best consistent with passing improvement, for disorders that largely wax and wane anyway. 

Dr Mike Scott

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Something Is Very Amiss In Routine Care – There Is No Evidence of Translation From The Evidence-Based Psychological Treatments Of Randomised Controlled Trials

according to a meta-analysis in the Journal of Affective Disorders. This echoes my own finding of only a significant minority recovering in NHS Talking Therapies Scott (2018). The results are a far cry from the 50% recovery rate claimed by NHS Talking Therapies.

“It makes little sense to conduct hundreds of randomized trials on psychological treatments when they do not lead to better routine practice.” For those in care as usual only 1 in 6 or 7 recovered.When care as usual is persistently failing, the punters are clearly not being listened to.  It is like Stalinist Russia proclaiming another successful 5 year plan, when in reality the peasants are starving .

Where did it all go wrong?

Dr Mike Scott

 

 

 

 

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NHS Talking Therapies Totally Fails The Traumatised – But There Is A New Way of Moving On

On June 5th, 2024 under a Freedom of Information Request (FOI),  NHS Talking Therapies informed me that in the year 2022-2023, 23,069  people with post-traumatic stress disorder had just one assessment/ treatment session with the Service. 

 

The FOI data reveal that for those attending just one session, those with PTSD have higher mean scores on both the PHQ-9 (17.9) and GAD-7 (15.6)  than any other diagnostic group. Further these mean scores are higher than those who start treatment  mean PHQ-9  of  15.5 and GAD-7 14.1. It thus appears that those who have only one session are likely more traumatised than those who go on to have treatment. 

It appears that there is something radically wrong with the traditional trauma-focussed approach to trauma adopted by NHS Talking Therapies. My new self-help book, Moving On After Trauma (2nd edition) published by London: Routledge on June 13th 2024, takes a radically different, more user-friendly approach. Instead of positing that the primary difficulty lies with arrested information processing at the time of the trauma and the consequent need to re-live it therapeutically, I suggest that what is pivotal is the centrality accorded to the trauma for today and that there is no need for a re-traumatisation of the client. My clinical handbook ‘Personalising Trauma Treatment: Reframing and Reimagining’ published in 2022 by Routledge, spells out the specifics of this approach for clinicians.

Accordingly I am adding a ‘Moving On After Trauma’ page to this website for clinicians, those who have been traumatised and those travelling the road with them. Here are my 12 rules for Moving On:

  1. Begin building a bridge between yourself now and the person you were before the trauma. Start by doing a little of what you did before. Constucting gradually as wide a ranging an investment portfolio as you can manage.
  2. Expected that building the bridge, like all forms of construction, will be steps forward and one backwards. It will need daily commitment.
  3. Don’t block the memories of the trauma, the harder you push them away the more they spring back.
  4. Put the traumatic memories in their place by questioning their relevance to today’s plans.
  5. Don’t get hooked by what could have happened. That is just a horror video which spoils today, with dark imaginings.
  6. Expect that the traumatic memory will knock at the door of your mind daily. But it is only asking about its’ relevance to today. Calmly answer this visitor.
  7. Go by what you would bet £5 on happening today, not by how vivid the traumatic memory is and how upsetting you find it.
  8. Remember that guilt is about deliberately doing something wrong. Trauma related guilt is bogus, it arises from either believing you should have looked into your crystal ball before the trauma or that you actually had the time to have done something differently. Feeling guilty and being guilty are not the same.
  9. Refuse to see flashbacks/nightmares as credible forecasts of what is going to happen today. Being constantly on the edge of your seat is about the past not the future.
  10. Give people the time of day. Expect to feel disconnected from others as you are looking at your world through war-zone glasses. Try on the pre-trauma glasses, they are more reliable. The view through them is based on a lifetimes experience rather than on a single drama.
  11. Refuse to take your alarm going off as evidence of danger- it’s just a ‘dodgy alarm’. Tripped easily by anything not exactly as you would want it, reminders or any unusual but not abnormal bodily sensation/s.
  12. Refuse to look at yourself and your personal world through the window of the trauma. Don’t make the trauma, pain or disability central.

 

 

Dr Mike Scott

 

 

 

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Minimalist Approach To Depression Doesn’t Deliver

A just published study in Lancet Psychiatry shows that just screening people for depression  using a PHQ-9 score of 10 or more, doesn’t help the patient, whether or not they and/or their GP are informed. A month after baseline, PHQ9 scores in all groups reduced by 4 points  and remained at this level in follow-up. 

Based on a diagnostic interview only a third of the sample met DSM diagnostic criteria at follow up. But in NHS Talking Therapies, a PHQ-9  score of 10 or more would usher people along a depression treatment pathway. This study indicates that two out of three people would have been directed along the wrong path. Watchful waiting is called for, oftentimes there is just a passing crisis in a person’s life.   Clients need comprehensive assessment, monitoring and treatment. NHS Talking Therapies’ simple dichotomy of low and high intensity interventions is not fit for purpose.

A screen by itself is simply a ‘scream’

Interestingly in the feedback to GPs ( the study took place in Germany) they were told  that ‘a diagnosis cannot be made on the basis of the screening score alone’ and there was a ‘recommendation for further assessment and treatment for any depressive disorders that might be present’. NHS Talking Therapies clinicians are not informed of the need for a thorough going assessment.  There is no diagnosis-informed care. The Service expects clinicians to  continue to work in the dark. Only a quarter of the sample received psychotherapy or an antidepressant.

Dr Mike Scott

 

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‘The UK NHS Talking Therapies Fantasy’

was published on May 23rd 2024 by the Spanish Society for Clinical Psychology   in its’ inaugural journal, Psicología Clínica – it is my updated critique of  the Service. My hope is that it will make countries think twice about adopting the UK model. It was a focus of a 1000 strong gathering of the Society in Cadiz. My thanks to the Editor and staff of the Journal, I wish them well in their new endeavour.

 

In this paper I refute the following myths:

Myth 1 It’s a World Beater

Myth 2 50% Recovery Rate

Myth 3 Real World Lasting Changes

Myth 4 Appropriate for All-Comers

Myth 5 It Delivers Evidence-based Psychological Therapy

Myth 6 Low Intensity Interventions Are Effective

Myth 7 Monitoring Is at the Heart of NHS Talking Therapies

Myth 8 Formulation Is Sufficient, No Need for Diagnosis

Myth 9 It Works Having the Least Qualified Practitioners as Gatekeepers

Myth 10 Talking Therapy Is the Same as Psychological Therapy

Myth 11 It’s Fine that NHS Talking Therapies Has Only Ever Marked Its’Homework

Myth 12 It’s Better Than What Existed Before and Better Than Support – It’s Value for Money

 

Dr Mike Scott

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A Decade of Digital CBT- Questionable Effectiveness and Advertising Standards Concerned

yet it is at the heart of NHS Talking Therapies, with 635,759 sessions of internet enabled therapy taking place in 2022-23.  Recently an Editorial in the American Journal of Psychiatry bemoaned the dirth of quality evidence in support of Digital Mental Health (DGMH). Nevertheless one of the sponsors of NHS Talking Therapies networking events, Silver Cloud is still proclaiming that its’ computerised CBT has ‘up to a 70% recovery rate’. It is registered in Ireland and The Irish Advertising Standards Authority told me on May 14th 2024 that they ‘have ongoing concerns that the recovery rate statistic continues to change’ and need to investigate and will revert back to me when the investigations are concluded.

 

A particular concern raised in the American Journal of Psychiatry is that a randomised controlled trial of a digital version of dialectical behaviour therapy (DBT) for suicidal clients vs waiting list found that those who underwent DBT did worse in terms of harming themselves or completed suicide. The Journal suggests that the best evidence for DGMH  comes from a randomised controlled trial of depressed and anxious patients in primary care, assigned to 16 weeks of CBT or treatment as usual. It was indeed the case that at the 4 and 8 week marker those in CBT were outperforming those on the waiting list but by the 12 and 16 week markers there was no difference in PHQ-9 and GAD-7 scores. These authors have engaged in spin to assert that there must be something beneficial about low intensity CBT. The spin is even more in evidence when the authors fail to mention that the comparison for CBT was a waiting list (people don’t expect to improve on a waiting list) rather than a credible attention control condition. It is a striking example of poor methodology. Even these authors appear to operate with a heuristic that ‘there must be something good about low intensity CBT’.

Dr Mike Scott 

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NHS Talking Therapies Claim To Parity Of Effectiveness With Clinical Trials – Fantastic Marketing, But Totally Bogus

The Service has never been evaluated with the rigour, comparable to that employed in randomised controlled trials i.e using blind independent assessors. NHS Talking Therapies has only ever marked its’ own homework. To compound matters further it has only taken a PHQ-9/ GAD-7 snapshot of  the person at their last contact with the Service. With nothing to indicate the duration of any gain or whether the change on these measures is clinically meaningful. 

Despite this the Service’s Manual cautions:

‘most referrals to NHS talking therapies will have elevated scores on the PHQ-9 nine and GAD-7. But this does not necessarily mean that they are suffering from clinical depression or generalised anxiety disorder. Unless the assessment process for all the NHS talking therapy relevant conditions, there is a risk that people will be started on the wrong treatment”

But the Manual also states that the Service treats 11 conditions and excludes 4 from its remit. Thus we are invited to believe that its clinicians screen for 15 conditions, but is silent on the mechanism by which this is achieved!  The assessors are for the most part by the least qualified (Psychological Wellbeing Practitioners). It is simply not credible that they have wherewithal to conduct such a comprehensive assessment and conduct it on the telephone, in the at most 1 hour assessment. 

The Service digs a deeper whole for itself when the Manual states ‘Focused supervision that starts by looking at the patient questionnaire scores and any changes on these’. The Tests are completed at every session. Clinicians can be called to task for not reaching a 50% recovery ate on the measures. Clearly the two questionnaires are expected to be central to the sessions leaving  little space for the alleged comprehensive screening. The authors of the Manual clearly suspect that things are going badly awry with treatments but their response is akin to that of the Post Office hierarchy with regard to sub-postmasters.

Dr Mike Scott