Casualties of Foolhardiness

The more I listen to, read about and consider the progress (or lack of it) of the project that is called Improving Access to Psychological Therapies (IAPT) the more thoughts of the actions of the generals in World War One spring to mind. Haig was a classic study in the unwavering belief of cavalry even in the face of machine guns, he had no idea of the conditions his troops were fighting in, he believed that numbers would win out, just like MacNamara fifty years later in Vietnam.Both believed in numbers, sheer volume would win the war for them.

Image result for mental health casualties

Clark, and his side kick Lord Layard, like his ignominious predecessors, consider that sheer volume of numbers will be sufficient to defeat the epidemic that is mental illness. While Clark and Layard’s numbers are statistics, people are still dying as a result, those sent to fight the war are still being burned out by sheer effort of trying to help others in impossible conditions. For example, 50% of professionals working in front line mental health services are suffering psychological distress, the conditions are intolerable yet most are too frightened to say so. The pressure to achieve a “50% success rate” means that statistics are skewed or even changed to achieved the necessary figure. Professionals are sent for retraining if they don’t achieve and then sent back into the frontline. In the First World War, many soldiers had their wounds stitched up and were then sent back into the front line. As I type this it reminds me of the horses ridden by the toreadors in bull fights; if the horses were gored by the bull they were taken out of the ring stitched up and sent back into ring immediately – amazing cruelty. The same is happening to frontline staff in IAPT.

Yet the politicians are being fed an amazing story of success, in exactly the same way that Haig and others in the First World War sent back messages that told the politicians how well they were doing.

This quote from Historynet really sums it up:
“Haig waged the ensuing political battle with customary remorselessness and prevailed in the bureaucratic trenches. He got everything he wanted in the way of men and materiel for what became known as Third Ypres or Passchendaele, a battle remembered for, among other things, terrain so wet the entire world seemed to consist of nothing but mud and shell holes filled with vile water. Indeed, in no land battle in history did so many men die by drowning.”

Image result for casualties of mental health

So many people are drowning as a result of the disaster that is the Project called Improving Access to Psychological Therapies, clients and professionals alike; yet the politicians remain enamoured of the project’s ability to blame the individual for their failure. It matters not whether it be client or professional, the failure lies within the individual, this is the overbearing ideology of the current government and those who seek to prove the model that is supposed to be Improving Access to Psychological Therapies.

Like Haig, Clark seeks to prove his model by asking for more troops (which, like Haig, will be refused; the worst of all worlds) rather than look at the overwhelming evidence that it is not working. For example, of all those who are referred to the service only 16% make some kind of recovery based upon the analysis of psychometric tools. From a service point of view this is a disaster. No company would continue to function on that basis. Yet the government continues to prop up the project on the basis that it is making a difference. What makes it worse is that IAPT continues to mark its own homework – it is time for an independent review.

There has been no measurable difference to the well being of the country as a whole, and only a few lucky people have benefitted as individuals. With regard to the overall well being of the country we are slipping behind that of other nations and if austerity continues the environment will only continue to get worse. As I have said so many times before, a toxic environment cannot be combatted by providing a leaky gas mask. Therapy and resilience training are no match for a cruel and heartless environment created by cruel and heartless politicians.

References:
http://www.historynet.com/field-marshal-sir-douglas-haig-world-war-is-worst-general.htm

Steve Flatt

The Silencing of Dissent and IAPT

 

This month’s Behavior Research and Therapy features a paper by Ali et al in which IAPT data on relapse after low intensity (Li) interventions is reviewed, and it is concluded that further attention to relapse prevention may be needed. I submitted a rejoinder essentially saying that Li-interventions have been a false economy and complaining that it had not been declared that Ali headed the Northern IAPT Research network, but it was rejected.

The editor began her letter of explanation with ‘Each of the reviewers is a highly experienced researcher in the area of low-intensity treatments for depression anxiety’.  But that is precisely the problem, researchers in low intensity see no pressing need for independent assessment using a ‘gold standard’ diagnostic interview (unlike their forbearers who conducted the bench-marking studies that gave CBT its’ credibility), although they pay lip service to it.

In practice, low intensity researchers find it ‘reasonable’ to conduct research on outcome solely on the basis of changes in a psychometric test. This strategy enables research to be done on the cheap, produce lots of papers and get brownie points in academia. There is a mutually beneficial groupthink amongst low intensity researchers and the IAPT hierarchy. Low intensity interventions fail an evidence based assessment test with a shameful lowering of the bar of methodological rigour. I will return in future blogs to editors/reviewers scant regard for criterion related validity and the misuse of Jacobsen’s Reliable and Clinically Significant Change Index, an abuse that is rampant in IAPT.

Dr Mike Scott

Mental Health Sinkhole Appears – Untold Casualties

 

 

Mental Health Trusts today announced that three quarters of extra monies promised for mental health services are not getting through. A mental health sinkhole has appeared, the depth of which is measured by under-funding and the width by poor quality services. Casualties include an estimated 694,000 people who were treatment failures in the Government funded IAPT service in 2014/2015, 85% of those treated. A further one third of those referred to IAPT did not enter treatment.

I reviewed the trajectories of 65 people who went through IAPT Services in the North West of England using a ‘gold standard’ diagnostic interview just 15% recovered from their disorder. [ Scott (2017) Towards a Mental Health System that Works London: Routledge].  I am wholly independent of IAPT and I made the analysis on the basis of data available to me as an Expert Witness to the Court. Applying this recovery rate to the national picture suggests a massive casualty rate.

Just this past week I picked up a ‘casualty’ who had had 6 sessions with IAPT, she had had a fall 2 years ago, become effectively housebound, though able to walk for 10-15 mins. She was referred to IAPT and had 6 sessions of CBT for depression, to no avail and she was very frustrated by the therapist who had said ‘do you think you might have OCD?’ one week then the next week ‘what about body dysmorphic disorder?’.  No further treatment was offered. I  found she was depressed  but what had not been identified or addressed was that she had a phobia about falling and sustaining further injury. It was this phobia that was driving the depression and needed to be the therapeutic focus.

Dr Mike Scott

Bias in CBT Journals

When the organs of communication are controlled by a single ideology we are on a short road to hell. Recently I protested to the Editor of Behavior Research and Therapy (BRAT), that no conflict of interest had been declared in a paper authored by Ali et al published in this month’s issue of the Journal, focusing on IAPT data on relapse after low intensity interventions. I pointed out that the lead author headed the Northern IAPT research network, not only did the editor ignore the conflict of interest but so to did the two reviewers, of a rejoinder to the paper that I wrote. But it is not just BRAT, IAPT sponsored papers regularly appear in Behavioural and Cognitive Psychotherapy without declarations of conflicts of interest.  I have protested to the editor about this, but again to no avail. Unfortunately it is not just a matter of what Editors of CBT Journals allow through the ‘Nothing to Declare’ aisle but also their blocking of objections to the current zeitgeist that is a cause for concern. More about this anon.

Dr Mike Scott

Evidence Based CBT Joins the ‘Endangered Species’ List

‘The good news is we have successfully amputated your right leg, the bad news is we operated on the wrong leg’.  The moral is that there can be no evidence based CBT treatment without an evidence based assessment (EBA). But EBA’s are increasingly absent in order to ease the research burden, ‘just rely on a psychometric test’, and reduce ‘treatment’ costs.

Emergency medicine operates on the 7 P’s, ‘Proper Pre-planning Prevents Piss-Poor Performance’. Is it seriously proper-pre-planning to operate as IAPT do, with a  typically 15-20 minute telephone conversation, conducted by the most junior member of staff, to be then placed on waiting list of upto 6 months for a treatment of indeterminate appropriateness? The reliability of this ‘pre-planning’ has never been assessed by anyone independent of IAPT. But this has not stopped Clinical Commissioning Groups often ring fencing IAPT monies at the expense of other mental health service providers.   The CCG’s need to be reminded that they ought to be working in an evidence based framework were the results of randomised controlled trials with independent assessment of outcomes hold sway (the top of the pyramid below). 60% of IAPT clients receive low intensity treatment, this is way down at the bottom of the evidence pyramid below, with a high potential for bias, reflected in powerful marketing.

It is time that CCG’s told IAPT that their pre-planning is simply unacceptable, there has to be an evidence based assessment. It is time the National Audit Office asked why are we continuing to fund a Service that has not been independently evaluated using ‘gold standard’, diagnostic assessment procedure. But most of all it is time to listen to those subjected to an inhospitable and unhelpful service. MP’s have to insist they are listened to.

Dr Mike Scott

A Screen for Mental Health – The First Step Questionnaire Revised

Clients often do not improve, not because of a lack of therapeutic skill, but because of something else  going on that they never thought to ask about. Screening clients for all common disorders is a protection against missing an important therapeutic target. The First Step Questionnaire published in Towards a Mental Health System that Works Scott (2017) London: Routledge, is such a screen, covering all the common disorders and importantly asking clients whether or not they want help with a particular difficulty, but also with a ‘don’t know’ option, so that ambivalence can be recognised from the outset. There is also an interview version the 7 Minute Interview. [ The validity studies on the Questionnaire/Interview are considered  in the Simply Effective trilogy Scott (2009), (2011) and (2013).]  I have now revised the Questionnaire/ Interview to take into account the changed diagnostic criteria for PTSD in DSM-5 and added a screen for borderline personality disorder (BPD)

The symptom questions of the PTSD screen are from the Primary Care PTSD Checklist for DSM-5,   from the US National Centre for PTSD, a positive response to 3 or more symptom questions is a positive screen for PTSD.  The  BPD screen is based on a paper by Zimmerman et al (2017) Clinically useful screen for borderline personality disorder in psychiatric outpatients, British Journal of Psychiatry, 210, 165-166. Of those with BPD over 90% endosed the affective instability question in item 11 below, but only 38% of those with affective instability had BPD i.e most of those with affective instability don’t have BPD. This illustrates that screening questions are only ever a starting point, if you don’t ask further clarifying questions in terms of the full DSM-5 criteria they can be very misleading. [Adding the anger item, see item 11 to the BPD screen meant that 97% of those with BPD answered ‘yes’ two both symptom questions according to Zimmerman et al (2017)].  It remains to be seen how much the question about wanting help adds to diagnostic accuracy, it is known that it does so for the depression screen.

 

Name:                                                                                      Date:

 

D.o.b:

 

The First Step Questionnaire – Revised

This questionnaire is a first step in identifying what you might be suffering from and pointing you in the right direction. In answering each question just make your best guess; don’t think about your response too much, there are no right or wrong answers.

 

1. Yes No Don’t know
During the past month have you often been bothered by feeling, depressed or hopeless?
During the past month have you often been bothered by little interest or pleasure in doing things?
Is this something with which you would like help?

 

 

2. Yes No Don’t know
Do you have unexpected panic attacks, a sudden rush of intense fear or anxiety?
Do you avoid situations in which the panic attacks might occur?
Is this something with which you would like help?

 

 

3.

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you

Yes No Don’t know
i. Have had nightmares about it or thought about it when you did not want to?
ii. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
iii. Were constantly on guard, watchful, or easily startled?
iv. Felt numb or detached from others, activities, or your surroundings?
v.  Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
Is this something with which you would like help?

 

4. Yes No Don’t know
Are you a worrier?
Do you worry about everything?
Has the worrying been excessive (more days than not) or uncontrollable in the last 6 months?
Is this something with which you would like help?

 

 

5. Yes No Don’t know
When you are or might be in the spotlight say in a group of people or eating/writing in front of others do you immediately get anxious or nervous
Do you avoid social situations out of a fear of embarrassing or humiliating yourself?
Is this something with which you would like help?

 

 

6. Obsessive Compulsive Disorder Yes No Don’t know
Do you wash or clean a lot?
Do you check things a lot
Is there any thought that keeps bothering you that you would like to get rid of but can’t?
Do your daily activities take a long time to finish?
Are you concerned about orderliness or symmetry?
Is this something with which you would like help?

 

7. Yes No Don’t know
Do you go on binges were you eat very large amounts of food in a short period?
Do you do anything special, such as vomitting, go on a strict diet to prevent gaining weight from the binge?
Is this something with which you would like help?

 

 

8. Yes No Don’t know
Have you felt you should cut down on your alcohol/drug?
Have people got annoyed with you about your drinking/drug taking?
Have you felt guilty about your drinking/drug use?
Do you drink/use drugs before midday?
Is this something with which you would like help?

 

9. Yes No Don’t know
Do you ever hear things other people don’t hear, or see things they don’t see?
Do you ever feel like someone is spying on you or plotting to hurt you?
Do you have any ideas that you don’t like to talk about because you are afraid other people will think you are crazy?
Is this something with which you would like help?

 

 

10. Yes No Don’t know
Have there been times, lasting at least a few days when you were unusually high, talking a lot, sleeping little?
Did others notice that there was something different about you?

If you answered ‘yes’, what did they say?

 

Is this something with which you would like help?

 

11. Yes No Don’t know
Do you have a lot of sudden changes of mood, usually lasting for no more than a few hours?
Do you often have temper outbursts or get so angry you lose control?
Is this something with which you would like help?

 

‘How Do I Deliver Effective CBT Where I am?’

The contexts in which CBT Practitioners work vary enormously, from independent practice to secondary care, from low intensity IAPT to a specialised trauma unit.  For the most part we are Engineers struggling to work within the organisational constraints we are given.  Drawing on our knowledge and skills, working with a diverse population, trying to make a real world, socially significant difference in client’s lives.  The pressing question is how can I deliver effective CBT where I am?

A practitioner working in secondary care in Ireland,  told me he faces the challenge of cases come to him via psychiatrists, there is a preliminary assessment within 4 weeks of referral, a maximum of 12 sessions of CBT are offered.  There is a progress review about the 6th session and a decision is made as to whether another 6 sessions would be beneficial. He asks is this best practice? The managerial edict he believes is to throughput as many clients as possible.

Another practitioner, from IAPT High Intensity told me that she had taken up her post on the understanding that the 6 session maximum was flexible and clients could be quickly re-referred back in for more sessions, but this has proved to be very rarely the case. What should she do?

 

Dr Mike Scott

Saving Normal, Candidates for CBT and Sean Bean

 

Tonight I am planning to watch another episode of the TV drama  ‘Broken’ starring Sean Bean as the central character. He plays Fr Michael who was sexually abused as a child by a priest and had a destructive late adolescence/early adulthood. Fr Michael has uncued flashbacks of the abuse, at times like consecrating the Eucharist. In the last episode he angrily confronted his abuser. But since becoming a priest Fr Michael has nobly served the severely disadvantaged. It was filmed at St Vincent’s, Church, Liverpool directly opposite where I work.  Should I nip across and offer EMDR /CBT?

Set for ‘Broken’

This fictional example echoes a real life conundrum for clinicians – a colleague of mine recently brought to my attention the case of a lady who had intrusive flashbacks of the aftermath of ECT and wondered whether she needed EMDR. By coincidence I had assessed the lady and knew that she was suffering neither from depression or PTSD and had functioned well for many years. She came to my colleagues attention because of some inherently stressful life events. My response was in the words of Allen Frances’ seminal work ‘Saving Normal’ published in 2013 by William Morrow we must not pathologise every uncomfortable memory, the acid test is whether it is directly causing significant functional impairment now.

In a similar vein I remember seeing a lady some time ago who had undergone prolonged sexual abuse as a child, she had been referred to a number of therapists over the years and they had all wanted to focus on the abuse. She protested that the abuse did not get in the way she was simply anxious about everything. When I saw her I found she was just suffering from generalised anxiety disorder, nothing more nothing less. I treated her with a standard protocol for GAD and she recovered.

I think the answer to all of this is “If it is not ‘Broken’ don’t fix it”, I’m off to watch the TV.

Dr Mike Scott

Grenfell Tower Fire and IAPT Trauma Services

In The Wake of the Grenfell Tower Fire, Mrs May Has Announced Additional Monies for Mental Health Services – BBC News 10.0pm June 18th 2017.

But the devil will be in the detail, what ‘treatment’ will be funded for which victim?, delivered by whom? when?.  The UK track record on treating trauma victims is not good. I independently reviewed 65 cases of trauma victims who had gone through the Government funded Improving Access to Psychological Therapies (IAPT) Service [Scott (2017] and found overall a 15% recovery rate, one half the sample had PTSD and again the recovery rate was 15%. There was no difference in recovery rates between those treated before and those treated after a personal injury.    But the difficulties are not confined to IAPT, recently I saw a victim of the 1989 Hillsborough Football Disaster who had since shortly afterwards been attending a weekly support group for victims, run by a Charity, though grateful for its ministrations, he had never been offered evidence based psychological treatment and continued to suffer from severe PTSD, with his marriage in tatters.

The breathtaking hospitality shown to victims of the Fire by the general public, has contrasted sharply with the acknowledged dilatoriness of the Governmental response. If that hospitality is reflected in the behaviour of friends and family towards the victim this will be an enormous benefit as perceived social support is the biggest single predictor of recovery from PTSD [ see Scott (2013)] and as a consequence I have advocated inclusion of partners in treatment if appropriate. Partners and clients can both benefit from my self-help book Moving on After Trauma [Scott (2008)].

One of the biggest roadblocks to delivering Trauma Focussed CBT (TFCBT), is that therapists or clients curtail treatment because the latter cannot face repeatedly going over the details of the trauma. Yet TFCBT is effective if clients can stomach it. I have suggested that a way around this is to teach coping skills for managing the memories, even if this proves insufficient to manage the intrusions, it can become a stepping stone towards a preparedness to engage in TCBT [Scott (2013)]. In a paper currently under review with Behavioural and Cognitive Psychotherapy, titled ‘PTSD Re-imagined’, I have presented a new reconceptualization of PTSD that is user friendly and goes beyond existing forms of treatment.

Dr Mike Scott

References

Scott, M.J (2017) Towards a Mental Health System that Works London: Routledge

Scott, M.J (2013) CBT for Common Trauma Responses London: Sage Publications

Scott, M.J (2008) Moving On After Trauma London: Routledge

CBT on the Cheap – IAPT’s Failed Experiment With Low Intensity CBT

If you are anxious or depressed and wish to seek psychological help on the NHS you are most likely to be offered low intensity CBT (LICBT) via the Government funded Improving Access to Psychological Therapies (IAPT) service. But don’t expect it to make a real world, socially significant difference to your life.  Two just published studies, one focussing on Adults [Ali et al (2017)] and the other on children [ Cresswell et al (2017)], highlight the paucity of evidence in support of this cost-cutting approach.

Ali et al (2017) looked at low intensity IAPT clients who had remitted by the end of treatment and found that half had relapsed within 12 months. Far from suggesting that this sounds like a ‘failed experiment’ the authors suggest that the programme should be simply amended to include relapse prevention despite stating earlier in the paper that relapse prevention was part of the protocol! Some weeks ago I wrote a Rejoinder to the paper which is currently being considered for publication in Behavior Research and Therapy.  Interestingly the Research Digest of the Psychologist for June 13th 2017 headlines its’critique of the Ali et al (2017) paper ‘False Economy?’

Father, Son, Bloom, Spring, Child

Cresswell et al (2017) looked at the effectiveness of parent guided CBT self-help  vs parent guided solution focussed self-help in children aged 5-12 with an anxiety disorder and concluded that they were equally effective but the latter was  more costly. In an accompanying commentary Stallard (2017) heralds the study as marking the way forward for children’s IAPT.  But there is no comment by him that a) the outcome measure used, the Clinical Global Impressions of Improvement was designed for use with regards to the trajectory of specific disorders, it was not intended as an across the board measure and is of doubtful validity in this study, b) there was no waiting list control group – children’s debility is likely to be particularly transitory c) that the study did not include any children with OCD or PTSD and in the CBT arm 50% had generalised anxiety disorder and 25% a specific phobia – generalising from this study to children with anxiety disorders is therefore problematic or d) that 40% of parents in the CBT arm had higher education, this is unlikely to be the case in many areas.

There are conflict of interest concerns with both papers Shehzad Ali heads the Northern IAPT Practice Research Network and Paul Stallard is joining Cathy Cresswell in running a randomised controlled trial. Demand of MPs, GPs and Clinical Commissioning Groups that psychological therapy services make a socially significant difference and are independently rigorously evaluated. Remind them there is good news: fully implemented CBT protocols result in over 50% of clients with depression and anxiety disorders no longer meeting diagnostic criteria for the condition by the end of treatment.[Scott (2017)].

Dr Mike Scott

References

Ali et al (2017) How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study Behaviour Research and Therapy 94 (2017) 1-8

Cresswell, C et al (2017) Clinical outcomes and cost-effectiveness of brieg guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial. Lancet Psychiatry published online May 17th 2017

Scott M.J (2017)} ‘Towards a Mental Health System that Works’ London: Routledge

Stallard, P (2017) Low-intensity interventions for anxiety disorders. Lancet Psychiatry published online May 17th 2017