Victims of Bombings Receive Face To Face Help, But Not For Mental Health

Can there be a more glaring illustration of the disparity between physical and mental health, when a victim of the Manchester bombing is subjected to a series of telephone conversations (IAPT) about her distress and it takes 6 months for a face to face consultation to take place. The public are rightly alarmed at the hours it took some of the Emergency services to be able to offer medical help, but it is as nothing compared to the time taken to address the person’s mental health. But there is no outcry about this from either GP’s, MP’s or mental health staff, there is tacit approval of the disparity.

Recently it was the centenary of the 3rd Battle of Ypres, in which my grandfather was killed on    October 28th 22017. To my knowledge nobody ever  suggested that the ‘shell shocked’ from the conflict should be catered for by telephone.

Rather there were dedicated Hospitals like Craiglockhart in Edinburgh and Moss Side in Liverpool and such Hospitals continued functioning after the 2nd World War. Being face to face with victims is surely the least we can offer.

A thought for Remembrance Sunday ‘A century on, are we really any more respectful?’

Dr Mike Scott

Psychological First Aid for Business, GP’s and others

Psychological First Aid https://files.acrobat.com/a/preview/e63fef15-64b0-4ccd-9766-64ae469ba067 mirrors CBT evidence based treatment protocols for specific disorders and the ultimate target is recovery from that disorder. It went down well when I introduced it to GP’s  on Merseyside in meetings spanning 18 months just after the millenium. I also introduced similar materials to ICI (now Ineos) managers in day long training sessions over a couple of years. Given that GP’s are often the first port of call with mental health problems and  and that mental health sees 300,000 people leave their job each year [‘Thriving at Work’ (2017) report by Paul Farmer], the material seems particularly opportune.

Here is an example from the panic disorder section:

  1. First assess.
  2. Conceptualise: a) panic attacks fuelled by catastrophic interpretation of unusual but not abnormal bodily sensations. View panic attacks as a ‘Big Dipper Ride’, ascending the symptoms get worse, tempting to get off near the top, but if you don’t do anything comes down the other side within ten minutes. b) use of ‘safety behaviours’ that prevent learning that nothing terrible would happen if they did nothing at all in the panic situation.
  3. Treatment: a) review of last bad panic attack. Identification of characteristic misinterpretations e.g. ‘I am going to faint…have a heart attack….make a show of myself’ b) challenging misinterpretations e.g almost impossible to faint with increase in blood pressure c) giving up the ‘safety behaviours’ e.g. escape, deep breaths, sitting down d) in session hyperventilation challenge (provided no heart problems) to help patient ‘know with their guts not just their head’ that panic symptoms are not dangerous e) daring to gradually expose to avoided situations

Psychological First Aid needs updating for the DSM-5 criteria, I developed it in the DSM IV era.

Mental Health First Aid targets ‘stress’ or ‘mental wellbeing’. This ‘disorder’ without boundaries approach, makes the outcomes of intervention always ‘fuzzy’ [ see Towards a Mental Health System that Works Scott (2017) London: Routledge]. But unfortunately ‘stress’/ mental wellbeing’ and their supposed antidotes are a more marketable commodity. Much supposed psychological first aid should be more appropriately labelled mental health first aid because of its’ fuzzy focus. Nevertheless Businesses and Pastoral Workers in Churches can feel more comfortable with Mental Health First Aid because the ‘stress/mental wellbeing’ emphasis means they are not straying  out of their comfort zone into what is perceived as more medical. By contrast psychological first aid has a clear recovery from disorder focus. Pragmatically Mental Health First Aid can be a good starting point but it is unlikely to lead very far.

Coming Soon ‘Improving Mental health via GP’s and Business’ will be the topic of a further post.

Dr Mike Scott

Soothing, Improvement and Recovery – vested interests in muddying the waters

The list of those with a vested interest in consciously or non-consciously muddying the waters of mental health outcomes (fake news) is staggering and include Charities, IAPT and Independent Practitioners. Consumers, Businesses and Clinical Commissioning Groups beware!

Most client’s of mental health services are glad of the help proferred, they find them ‘soothing’ but this is a far cry from recovery from identifiable disorder. I’ve just put ‘Voltarol’ on my sprained ankle it is soothing, less of a burning sensation, but it doesn’t actually speed up the rate of recovery or increase gait velocity (improvement). Recovery would be back to what I was before I crumpled getting out of the taxi. Blurring the distinction between soothing, improvement and recovery is good for the marketing of a product, analgesic/wares of a mental health service provider, but the ‘injured’ are not well served and ill equipped to protest. As a consequence the juggernaut of existing services continues. There is a pressing need to go beyond expressions of client satisfaction.

 

E-cigarettes look like a good way of helping people giving up smoking cigarettes, but the long term effects are unknown, a Parliamentary Committee has just been appointed to look at the matter. There is an understandable wariness about wide dissemination in the abscence of evidence.  But there is no such critical awareness when it comes to mental health.

 

Dr Mike Scott

Voice of the Powerless

It has taken 28 years for the voice of the Hillsborough victims to be heard, Bishop’s Jones’s report published today is aptly titled ‘The Patronising Disposition of Unaccountable Power’.  In the aftermath I successfully treated a victim of the tragedy for PTSD, we have kept in touch and he was devastated a few years ago to find that his statement to the police had been doctored to make it appear that the police had been helpful, the facts were the total opposite. But the patronising attitude has been pervasive, my client had to see a Consultant Psychiatrist for the Insurers, the latter’s behaviour was so bad that my client came out of the Consulting Room sat down on the kerb outside and wept! I appeared in Court where this Psychiatrist referred to me as a ‘so called counsellor’, fortunately the Judge was not impressed by this! But unfortunately I regularly meet people with a personal injury claim who have been treated in a cold and upsetting manner by the Expert for the Defendant’s. I have little confidence that some of the claimant’s following the Grenfell Fire will not meet a similar experience. Assessments are often both inhuman and unreliable.

The failure to listen to the powerless unfortunately does not end with Hillsborough victims, it is repeated again in the accounts I’ve been given by clients going through the IAPT system.  It was repeated yet again today when I heard a Mental Health Nurse give anonymous testimony as ‘John’ on the Radio 4 You and Yours Programme. He was working for ATOS assessing entitlement to Personal Independence Payments he described a person with PTSD and Psychosis living in a night shelter. John wrote a report saying he needed full benefit the ‘back office/ auditor’ decided support was not needed just ‘prompting’ and he needed to alter his report.  He said that the Organisation discriminates against those without visible impairment.

From tragedy to tragedy, but hopefully people will not walk alone.

Dr Mike Scott

Jeremy Hunt Conned on Mental Health

Today Health Secretary, Jeremy Hunt claimed ‘ we have a world-beating service for depression and the anxiety disorders that other countries are considering adopting, particularly Sweden’ [BBC One Andrew Marr Show]  but  he appears not to know that the IAPT service he cites has never been subjected to independent scrutiny and he is victim to its’ excellent marketing.  From my own work as an Expert Witness to the Court I have found a recovery rate of just 10%, ‘IAPT the Need for Radical Reform’ (In submission) which also contains testimonies of those who have gone through the system, work on a smaller sample (n=65) is summarised in ‘Towards a Mental Health System that Works’ (2017) Routledge.

Tip of Iceberg Recover

 

I presented my findings ‘Reality Checking Psychological Services’, https://files.acrobat.com/a/preview/93ed8696-b12e-44b0-a2bd-3f0646f62052 on the smaller sample at EABCT Conference in Stockholm on  September 1st 2016. Internationally countries have not rushed to adopt the IAPT approach and are much more circumspect about the IAPT results than Mr Hunt. Unfortunately in politics the bar for ‘evidence’ is set low, with evidence outstripped by enthusiasm. On October 10th 2017 Mr Hunt announced £15 million to train 1 million people in Mental Health First Aid with 1 trained member of staff in every secondary school by 2020.  He argued plausibly on You Tube that half of emotional problems are there before age 14 and if there is some early input problems could be prevented. Nice idea, but the evidence on this is lacking, arguably the monies might be better spent on what we know does work, CBT treatment with fidelity to an evidence based protocol.  Whether or not,  he anticipated the training would be online with volunteers who could thereby become less stressed, more ‘resilient’ and help others!

 

Dr Mike Scott

 

Government Commits to Mental Health Yet Has Presided Over Increase In Mental Health Staff Abscences

Today the Prime Minister, Mrs May committed the NHS and Civil Service  to protecting the mental health of its’ staff. But a BBC freedom of information request (September 22nd 2017)  has revealed the number of NHS mental health staff who have had to take long-term leave of a month or more rose by 22% in the past 5 years. On the same day the Department of Health announced ‘we are transforming mental health care for everyone in this country, including NHS employees’.

If this is transformation maybe I should enter a home for the bemused and befuddled.

 

Dr Mike Scott

IAPT Behind Closed Doors – Compulsion and Inadequate Training

There is certainly a high degree of compulsion associated with attending IAPT services, with people being told that if they do not attend IAPT interventions then their benefits may be stopped.  This seems counter to the idea of patients’ voluntary engagement, with the notion of ‘opt in’ being the sole indicator of patient willingness for participation.  My personal opinion is that there is no real choice and no other type of treatment offered if they refuse.  IAPT is a service where clear up target rates appear to be more important than the quality of the treatment and ‘one size’ most certainly does not fit all.

I am of the opinion that my colleagues who are Psychological Wellbeing Practitioners would benefit greatly from having knowledge and experience of mental health since my experience was that most of the higher level CBT Practitioners were and are mental health nurses by discipline.  Whilst I am critical of IAPT, I am also critical of mental health services and for this reason I am currently aiming to change direction and to re-train in the area of Psychology.

Anonymity protected Dr Mike Scott

‘What Proportion of People With This, Recover With This Treatment?’

If you are undergoing a medical procedure this is a pressing question. Curiously, psychological therapists create an aura in which clients are disuaded from asking this question, with responses that amount to ‘we don’t like to use labels, just complete questionnaires to see how you go’, masking a wholesale distrust of the medical model.  Clients are intimidated from voicing their basic concerns, when asked whether they were given a diagnosis usually the response is ‘no’ or  “they said I had ‘x’ symptoms” either way they do not feel on solid ground. Invalidating a person/client’s nascent question whether it be the ‘meaning of life’ or the likelihood of treatment that makes a socially significant difference is direspectful.

IAPT obscures the answering of this question by a sleight of hand, using changes on 2 psychometric tests to indicate recovery, with no blind, independent assessment of outcome and no use of a ‘gold standard’ diagnostic interview. But this obscurantism is not confined to Government funded psychological therapy services, in private practice there is an equal failure of diagnostic accuracy and comprehensive evaluation at both initial assessment and at the end of treatment. However at least in the private sector one can search out a therapist who can deliver, no such option is available within IAPT.

 

Dr Mike Scott

IAPT Behind Closed Doors – The Need for Listening and Flexibility

At Bury I had occasion to treat an older gentleman who lived alone and had no family locally.  He also had received step 3 CBT work on at least 2 occasions previously and he had been re  – referred to me at step 2.  This gentleman had a stammer and a thick Scottish accent and did not speak often, as he was anxious and low in mood since he was embarrassed that people did not understand him.  My brief was to “get him out and mixing with other people”.  I discovered that he did not go out very often and had been interested in computers in the past, going on a Government scheme to learn more, until the funding was stopped.  He showed me his phone, which was his “lifeline” and stated that he had got it a few years ago, but that it was quite expensive to run.  He told me about his female companion, who was unfortunately ill and who used to accompany him to the Library when she had been well, as he did not cope well in public.  I began thinking about his phone and his love of computers

 

Over the first 3 sessions, I understood that he was not a particularly social person, could not afford a computer of his own, but was able to consider that he may get a better phone and a better deal than the one he had.  I did not see this gentleman for 2 weeks, as he sent word that he had a cold, but by the 4th session, he had been on his own to a local branch of Carphone Warehouse and had negotiated a deal on a new phone which had a full screen internet access and which was affordable.  He recovered to the extent that not only was he able to go out alone to places now, he was going to coffee shops and public places accessing the free internet there to talk to his many friends over the internet and was no longer a person who avoided people, because he could now make himself understood.  I remember his words to me at session 5 when I discharged him, telling me, “the world is mine!” and about how his female friend was also recovering with his help.  He explained that she had always had to help him to go shopping and to explain things for him, but that now he had more confidence, he was doing things for her for a change.  The key for him was being understood and improving his life through his talents and his love of computers and gadgetry.  Everything else followed on from this.

One of my better experiences at Bury was with a lady who was referred onto my caseload because she had long – standing issues with physical injury sustained at work and who was in the process of claiming compensation from her employer for her injury.  She was newly married and had become extremely anxious and suffered with co-morbid depression.  She had been seen and treated with CBT at step 3 twice before and was also referred to Mindfulness Relaxation.  She was referred to me at step 2 because she had “failed to be able to use mindfulness to relax and was still anxious and suffering from depression”.  I had 6 sessions with this lady and she missed one because of needing to go to court to represent herself for her case, but this was tagged on the end for review.  I adapted an approach for this lady’s needs which did not include mindfulness and helped her to see her new situation not so much in terms of what she could no longer do, but with an emphasis on new opportunities.

This demonstrated that current IAPT approaches are markedly inflexible and there is little or no notion of adaptation to suit individual needs and also, too much emphasis on “getting the list down”.

 

Anonymity protected Dr Mike Scott

Mis-selling of the Cognitive Therapy Rating Scale

If your performance has been evaluated using the cognitive therapy rating scale (or the revised version) you may have a claim for ‘damages’. Curiously the cognitive therapy rating scale has a shaky foundation:

  1. The CTRS has only been evaluated in a sample of depressed clients undergoing cognitive therapy [Shaw et al (1999)] , therapists scores on this did not  predict outcome on self-report measures the Beck Depression Inventory or the SCL-90 (a more general measure of psychological  distress) however it did predict outcome on the clinician administered Hamilton Depression Scale predicting just 19% of the variance in outcome, but it was the structure parts of the scale (setting of an agenda, pacing, homework) that accounted for this 19% not items measuring socratic dialogue etc. The authors concluded: ‘The results are, however, not as strong or consistent as expected’
  2. There is no evidence that the CTRS is applicable to disorders other than depression. Some aspects of the CTRS such as socratic dialogue may be particularly inappropriate with some clients e.g OCD and PTSD sufferers.
  3. The CTRS does not make it clear that the clinician cannot have set an appropriate agenda without reliably determining what the person is suffering from.
  4. In practice raters appear to pay more attention to the socratic dialogue item as opposed to interpersonal effectivenes (e.g non-verbal behaviour). There is a poor intra class correlation of the order 0.1, ratings of least competent therapists are more in agreement with those of supervisors than the more competent therapists! [McManus et al (2012)]
  5. The Hamilton Scale used in the Shaw et al (1999) study was developed before the development of DSM criteria and it is questionable about whether any correlation would be found between DSM diagnostic status and score on the CTRS for depression or indeed any disorder.

 

Dr Mike Scott