Organisations Bias Diagnosis and Treatment Pathways

Organisations find the diagnosis they were set up for, creating a label that is passed on without critical re-appraisal – ‘sticky labels’. Resulting oftentimes in inappropriate treatment. Culprits are not only the obviously dedicated services such as those  for Autism Spectrum Disorders (ASD) but missionaries of monopoly training bodies such as EMDR and IAPT. The danger is that the Organisations do not seriously consider a contradictory diagnosis.

 

Recently I saw a 14 year old, two years ago a panel decided that he met criteria for ASD. No individual clinician in the ASD pathway had been definitive about an ASD diagnosis, and the possibility had only been raised when he was aged 11. His social communication was in fact good, interrupting mum appropriately in the Consultation. He clearly had behavioural problems, but there had been no consideration of a possible alternative DSM-5 diagnosis of ‘conduct  disorder with limited prosocial emotions’, instead the Panel concluded ‘will need to be taught social skills methods which suit his ASD needs’ but this has never happened in the intervening 2 years. When Panel decisions are made there is a need to be wary as they make riskier decisions (groupthink). His GP has now suggested that he be guided to a general counselling service for adolescence. No chance it seems of CBT appropriate to his and/or his mum’s needs!

In similar fashion EMDR therapists find PTSD everywhere and IAPT finds a mix of anxiety and depression ubiquitous resulting in poorly targetted treatment.

Dr Mike Scott

Institutional Bias Against Independent Monitoring of Mental Health Outcomes

There is no parity between the ongoing assessment of physical and mental health problems, there is an institutionalised bias against the latter. Patients increasingly refer themselves to IAPT (a 100% in Blackpool) , the GP simply hands them the telephone number and only sends in a report in unusual circumstances e.g a patient too frightened to ring and book the standard telephone assessment.

 

Whilst the GP’s are increasingly freed from this administrative burden, it removes a baseline against which to independently measure a patients progress through IAPT. The latter continues to mark its’ own homework, claiming a 50% recovery, but Scott’s study (2018) suggests the true figure is just 10% https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0.

 

Dr Mike Scott

Delivering Group CBT – A Special Interest Group

For many years I have been running a ‘Delivering Group CBT’, Workshop following the June 15th Workshop in Manchester, there were 25 signatories for a BABCP Special Interest Group. An application for a SIG has now been made. Anyone interested in joining this merry band would be appreciated, just e-mail me at michaeljscott1@virginmedia.com.

 

The following is a link to the Powerpoint for my recent workshop https://www.dropbox.com/s/6sq5mvrhyvtnz1q/Delivering%20Group%20CBT%20Manchester%20June%2015th%202018.pptx?dl=0. A key feature is that it avoids the dichotomy either individual or group CBT.

 

Dr Mike Scott

IAPT Is a Car Crash – Transforming IAPT

IAPT (Improving Access to Psychological Therapies) is a car crash, funded by the taxpayer to the tune of £1bn, but without any insurance for the public. Staff are stressed out and there is a 10% recovery rate for clients. The National Audit Office (NAO) recently investigated IAPT but have chosen not to make its’ findings  public. I pursued a Freedom of Information Request but the NAO’s response has shed no light on their decision making. These findings are contained in my just published paper ‘Transforming IAPT’ in the Journal of Health Psychology:

 

 

the abstract reads:

The three commentaries on my paper ‘IAPT – The Need for Radical Reform’ are agreed that Improving Access to Psychological Therapies cannot be regarded as the ‘gold standard’ for the delivery of psychological therapy services. Furthermore, they agreed that Improving Access to Psychological Therapies should not continue to mark its ‘own homework’ and should be subjected to rigorous independent evaluation scrutiny. It is a matter for a public enquiry to ascertain why £1 billion has been spent on Improving Access to Psychological Therapies without any such an independent evaluation. What is interesting is that no commentary has been forthcoming from the UK Improving Access to Psychological Therapies service nor have they shared a platform to discuss these issues. It is regrettable that the UK Government’s National Audit Office has chosen, to date, not to publish its own investigation into the integrity of Improving Access to Psychological Therapies data. Openness would be an excellent starting point for the necessary transformation of Improving Access to Psychological Therapies.

 

Dr Mike Scott

Preserve Us From Specialist Units – The Need for Proper Audit

 ‘Complex’ clients tend to gravitate to Specialist Units, but their focus is overwhelmingly on the disorder that they were set up for, recommending anything else outside its’ remit is dealt with elsewhere. The problem is it doesn’t actually work! I recently saw a client with a 10 year history of bulimia, alcohol abuse/dependence. The file was enormous as the Specialist Units had each made their contributions as the client went at greater speed through the revolving door.

 

In fairness there was one letter from the alcohol Unit that suggested that the ‘underlying cause’ for these problems should be sought, now there is a novel idea! But neither of the Specialist Units took this responsibility. IAPT sent  a letter asking the client to telephone to arrange an assessment which was not acted upon and promptly discharged the client. When I saw the client I found that the underlying problem was social anxiety disorder, which pre-dated all the other problems. The records did mention in passing that the client was anxious in social situations, but this had never been a therapeutic focus. The client readily appreciated that there had to be a comprehensive/holistic treatment approach and not the piece-meal approach followed by the agencies. Changing their modus operandi is a monumental task, as there are so many vested interests. But a starting points is to insist on independent audit of recovery rates along the lines that I have pursued re: IAPT.

Dr Mike Scott

Rules of Thumb That Can Sabotage The Treatment of PTSD

In routine practice the treatment of PTSD is often ineffective, IAPT’s recovery rate with this disorder is around 16%. But the operation of certain rules of thumb sabotage treatment across the board. Which, if any,  of the following saboteurs do you operate on:

  1. It is probably PTSD because it was an awful incident
  2. It is probably PTSD because there arte flashbacks and nightmares
  3. It is probably PTSD because of a high score on the Impact of Event Scale
  4. Whatever it actually is trauma focused CBT/EMDR offers the best way of resolving it
  5. Formulation rules anyway
  6. You can’t treat more than one disorder at a time
  7. Issues need to be resolved first

 

In January 2018 I was due to make a presentation at an Improving Access to Psychological Therapies (IAPT) Conference, titled ‘Approaching Patients With Trauma – Can IAPT help patients with trauma?, but was overtaken by my own trauma of falling down the stairs at home! Here is the link to the presentation:

https://www.dropbox.com/s/21ye8ewczvmfamn/IAPT-January-23rd-2018-Birmingham-City-Football-Ground.pdf?dl=0

The good news is that I was able to specify how IAPT might change its’ practice, but unfortunately the chances of this happening anytime soon are remote, openness to debate with those outside of IAPT is conspicuous by its’ abscence.

Dr Mike Scott

Supervision Of Most IAPT Workers Is Not Supervision – Monumental Waste

Alexandra Painter was for 2 years a Psychological Wellbeing Practitioner, in her doctoral thesis *, she reviews her experience and that of other PWP’s.  She notes that in the so called ‘Case Management Supervision’ that PWP’s are subjected to, a core component of supervision, the opportunity to reflect on practice and talk about how you feel about cases is routinely absent. Alexandra calculates that approximately 2.5 minutes is allowed to discuss each case! It seems that the PWPs, who are the most numerous of IAPT workers, are at the ‘front line’, most commonly they have been health care assistants in the past,   unlike the high intensity therapist’s in the rear with often clinical or counselling psychology backgrounds. In this war against mental ill health it is more likely that the troops at the front will bear the brunt.

Leaving the troops fearful of going over the top and disobeying commands from on high. The PWP’s plight resembles resembles the Charge of the Life Brigade, in that the powers that be refuse to accept that they are not on solid ground intent on reaching their target at all costs. There are no evidence based techniques, only evidence based treatments and all the so called EBT’s in low intensity treatment fail to meet criteria for evidence based treatment [ Scott (2017) Towards a Mental Health System that Works London Routledge].

  • At least two randomised controlled trials, on a clearly specified population, with independent assessment by a blind rater using a standardised interview
  • At least one of the rcts conducted by researchers independent of the developers of the treatment
  • Replication in routine practice using non-expert clinicians

How long will it be before there is a national outcry about such waste. Unfortunately the National Audit Office is still undecided about whether to publish its’ investigation into IAPT. People including myself and BACP made a submission to the NAO fully expecting the latter’s findings would be made public, if they and I knew that this was not necessarily the case, we would have wondered whether it was worth the effort! At the moment they appear to be countenancing a letter to NHS England, inspection of their website shows the latter’s wholesale support for and funding of IAPT! The NAO, to date, seems no better than Carillion’s Auditors!

Dr Mike Scott

* Painter, A. (2018) Processing people! The purpose and pitfalls of case
management supervision provided for psychological wellbeing practitioners,
working within Improving Access to Psychological Therapies
(IAPT) Services: A thematic analysis. DCounsPsych, University of
theWest of England. Available from: http://eprints.uwe.ac.uk/33351

Current Supervision Practices Have Not Prevented the Poor Outcomes In IAPT

 

With a 10% recovery rate in IAPT https://doi.org/10.1177/1359105318755264, serious questions have to be asked about the quality of supervision.  But it could be that Supervisors in IAPT feel that their role is constricted or the use of practitioner league tables sabotages their endeavours. Clearly something is going badly wrong. However it could also be that current supervision practices whether or not they take place in IAPT are not fit for purpose, they are eminence rather than evidence based.

 

‘Its’ about monitoring, personal development – a bit like treating a client, has to be tailored to the supervisee’ this seemed to be the consensus at a BABCP Supervision Workshop I attended with about 40 others in Liverpool last week.  The presenter Jason Roscoe, asked the 40 attendees what model of supervision they followed, there was a deafening silence. He then presented the Roth and Pilling competencies for supervision, I opined that just looking at the rows and columns gave me ‘mental  indigestion’.  Given the outbursts of laughter I think that this was a widely shared view.  I had a sense that people feel rudderless with regards to supervision, and there was no enthusiasm about becoming a BABCP accredited supervisor.

I suggested that the prime function of supervision is to act as a conduit for evidence based treatment. Since the Workshop I have reflected that no alternative definitions of the prime  function were offered rather the Bennett-Levy model of supervision involving 3 different types of knowledge declarative, procedural and reflective was recommended. The implication was that one might need to do more or less on any one of these forms of knowledge with any particular supervisee. Hmm I thought, this is no different to what one would do with a client in treatment. The offering at the Workshop was I found typical of what passes for evidence in BABCP with regards to supervision, but there is sparse evidence such supervision makes a real world difference to client’s lives. What is known is that supervision has been an integral part of randomised controlled trials and that type of supervision can be considered evidence based. It follows that to the extent that this type of supervision is adopted, with its’ emphasis on reliable diagnosis and fidelity checks for adherence and competence one is still in the ball park of evidence based supervision ( see Simply Effective CBT Supervision London: Routledge).

Dr Mike Scott

House of Lords – Expansion of IAPT into ME Despite Not Knowing How Such Clients Have Already Fared In The Service!

Chronic Fatigue Syndrome: Written question – HL7468

Asked by The Countess of Mar
Asked on: 01 May 2018

Department of Health and Social Care
Chronic Fatigue Syndrome

HL7468
To ask Her Majesty’s Government what are the recovery rates of patients with myalgic encephalomyelitis who have received treatment under the Improving Access to Psychological Therapies programme.

Answered by: Lord O’Shaughnessy
Answered on: 15 May 2018

This information is not available

 

 

Whatever happened to evidence based CBT?

 

Dr Mike Scott

Medical approaches to suffering are limited, so why critique Improving Access to Psychological Therapies from the same ideology

This is the title of James Binnie’s commentary on my paper, he adds that my findings of a 10% recovery rate in IAPT are ‘quite shocking’. His paper and mine are available by clicking the following links:

https://doi.org/10.1177/1359105318769323

https://doi.org/10.1177/1359105318755264

Commentaries and my commentary on the commentaries will be available in a Special Issue

of the Journal of Health Psychology this Summer. It’s great to get some public debate, it has been difficult because many are not in a position to voice their concerns openly.

 

Dr Mike Scott