Paranoid, But Judged Recovered If Your Conviction of Threat Falls Below 50%

this is the primary outcome measure used in a just published study of CBT for persecutory delusions https://babcpmail.com/AQ0-7G5L5-2KPHRR-4HXKEC-1/c.aspx. But would the typical person suffering from schizophrenia recognise this metric? What if convictions take a variable course and are mood dependent? What is going on here? Unrestrained by such questions Freeman et al (2021) proclaim in their advertisement for the 5 day online course for the Programme:

‘it is the most effective psychological treatment for persecutory delusions. Half of patients have recovery in their persecutory delusion with the Feeling Safe Programme’

‘Recovery’ here has a meaning far removed from common parlance. ‘When I use a word,’ Humpty Dumpty said, in rather a scornful tone, ‘it means just what I choose it to mean – neither more nor less.’ —LEWIS CARROLL, Through the Looking-Glass, 1871. If my conviction about the likelihood of being flooded fell to less than 50%, I would still be wanting to relocate!

Allegiance Bias

Freeman et al (2021) are evaluating their own Feeling Safe Programme but no mention that therefore their study might be prone to allegiance bias. The same therapists administered the Feeling Safe Programme and the comparison Befriending Programme. Given that the therapists knew that the hypothesis was that the former would prove superior to the latter, they are likely to be more enthusiastic about the CBT. Twenty sessions were to be delivered in 6 months in each modality but in the event more sessions were delivered in the CBT. Thus the possibility of allegiance bias amongst the therapists cannot be ruled out. It is therefore not surprising that a statistically significant difference was found between the two arms of the study. But this does not necessarily demonstrate the added benefit of CBT – a further confounding factor is that  71% of those in befriending were on antidepressants compared to 50% in CBT.

Replication Crisis

Freeman et al (2021) make the common cry of all researchers for more research, but there is no mention of the need for independent replication. This latter is particularly important as previous studies have not demonstrated the added value of CBT for persecutory delusions.

Inappropriate Outcome Measure

Clients in CBT were encouraged to take a 6 session module ( the Feeling Safe Module) targetting threat beliefs, how can the latter then be a credible outcome measure? Broader measures such as functioning as I was before I became paranoid or even as I was when I was least paranoid would have been more credible primary outcome measures.  Further the secondary outcome measures used were all based on self-report measures, there was no standardised diagnostic interview conducted. Whilst diagnostic labels were affixed at entry into the study ( on what basis is not clear), they were ignored with regards to outcome.

Is The Effect Size Found Meaningful?

The effect size for the primary outcome measure was a Cohen’s d of 0.86, Freeman et al (2021). The effect size for total delusions score on PSYRATS was d=1.2 Freeman et al (2021) celebrate this large effect size as comparable to that found in trials of CBT for anxiety disorders. But in terms of the primary outcome measure the average person undergoing CBT improved  by less than one standard deviation compared to the average person who was befriended, this is shown diagrammatically below, does this amount to a real world difference? The economic analysis promised in the pre-trial protocol was not included in the paper, leaving it an open-question as to whether the CBT is worth the added investment. 

 

Eminence-based Rather Than Evidence-based

Advocates of the Feeling Safe Programme, are claiming more than is known, doubtless BABCP and IAPT will seize on it and control how CBT is to be conducted with this population, extending their empire. Well the study was published in Lancet Psychiatry after all? The CBT therapist should be sceptical, but regrettably training courses seem not to equip them for this, I wonder why? Perhaps I am paranoid?

Dr Mike Scott

IAPT’s Hidden Agenda

we can only deal with one problem, because that fits into the 6 sessions of therapy that we start with’, but the Improving Access to Psychological Treatments (IAPT) service makes no  public declaration of this.  Clients want a holistic approach in which all their problems are catered for. It is magical thinking to believe that a) a mental health problem can be resolved in 6 sessions b) the benefits gained from addressing the chosen mental health problem will, by a process of osmosis, resolve the other mental health problems. This represents delusional Organisational thinking, unfortunately I think it would take a lot more than 6 sessions to treat!

Recently I saw Ms X and she related to me her two sojourns through IAPT. I also had access to the IAPT correspondence, for confidentiality reasons, some of the details have been changed:

Five years a ago, Ms X found out that she had been adopted, she felt that she had never fitted in with her adoptive family, though they were kind. She felt that she had always been a ‘worrier’, her adoptive mum had chronic health problems and shortly after learning of her adoption she became concerned over any blemish on her skin. Ms X saw her GP and she advised self-referral to IAPT. She had a telephone assessment with a Psychological Wellbeing Practitioner and was advised that her PHQ-9 score was normal and her GAD-7 score at ‘caseness’. But no diagnosis was given. A letter from IAPT indicated that she ‘agreed to attend a worry management course’ but she said only a group programme was on offer. Ms X dropped out after attending one group session. Her GP had recorded that the treatment had not helped. I assessed her using a standardised diagnostic interview and it was clear that she had been suffering from illness anxiety disorder and general anxiety disorder (GAD) at the time of seeking help form IAPT and her diagnostic status was unchanged by IAPT’s ministrations.

Two years later she was at work, when her hair got caught in machinery at work causing a scalp injury. However the injury was under the hairline and not visible, but she could feel an indentation on her scalp. She developed a phobia about being around machinery leading to poor attendance at work and possible disciplinary action. The accident re-ignited her illness anxiety disorder that had been in remission for about 6 months. I noted that she continued to meet diagnostic criteria for GAD. Her GP advised self-referral to IAPT and she had a telephone assessment with a Trainee Psychological Wellbeing Practitioner, both PHQ-9 and GAD-7 scores were at ‘caseness’.  No diagnosis was given. Ms X was told that they could only treat one of her problems and she chose her health anxiety concerns. She was placed on a 6 week waiting list for the Silver Cloud computerised CBT. During, the course of her cCBT she had 4 interactions with IAPT staff responsible for the smooth functioning of the Silver Cloud programme. They said that she was ‘depressed and anxious’ but gave no diagnosis. During treatment her specific phobia was not addressed at all. The diagnostic interview that I conducted revealed comorbid illness anxiety disorder and GAD but she was not depressed. She understood that there was to be a review of her progress at the end of cCBT to see what if any further help might be appropriate. This never happened. The Silver Cloud programme had no impact on her diagnostic status. IAPT’s treatment was ‘in the Clouds’.

This case raises important questions:

  1. Why was a minimalist intervention repeated when the first such intervention had not worked?
  2. Why are the least well-trained clinicians given the power to direct treatment?
  3. Why are the least well-trained clinicians given the power to re-direct treatment?
  4. Why is IAPT allowed to behave in a way that would not be tolerated in physical care vis a vis a focus on just one problem and continued management by the most junior clinician when treatment fails?
  5. Where is the publicly funded independent audit of IAPT?

Unfortunately, this is not an isolated case, my own review of 90 cases suggests just a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264) . There has been a dereliction of duty by NHS England, Clinical Commissioning Groups and the National Audit Office. The British Psychological Society has rubber stamped whatever IAPT has proposed. The British Association for Behavioural and Cognitive Psychotherapy have become an IAPT mouthpiece, its’ journal CBT Today intolerant of dissent.

 

Dr Mike Scott

 

 

NICE Mental Health Guidance Fails To Address Real World Cost Effectiveness

The National Institute for Health and Clinical Care Excellence (NICE) rightly considers the results of randomised controlled trials in advocating particular psychological therapies, but has not assessed whether, as implemented, they represent an added value compared to previously available therapies. Consider a new drug that is of proven efficacy in randomised controlled trials, NICE would understandably look positively at it, but before recommending it would want to know about side effects and the proportion of people discontinuing use. However NICE seems blissfully unaware that for the psychological treatments that they recommend, when delivered in routine practice, only one half of people tolerate more than one treatment session [Improving Access to Psychological Therapies (IAPT) Annual report 2019-2020 https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf,.  But they do know that there is no independent evidence of greater remission since the inception of IAPT – their silence on this point is deafening. 

 

The NICEimpact mental health document (2019) asserts, p4 ‘The IAPT programme offers NICE-recommended treatments’  for common mental health disorders in adults. No it does not and what is worse still is that NICE have never bothered to check. NICE has been simply the voice of the power holders in mental health and not the consumers.

The usual metric employed by NICE is Quality Adjusted Life Years (QUALY), as a general rule of thumb new interventions are recommended if the cost of one QUALY does not exceed £20,000. But a QUALY can only be assessed against the benchmark of the previous standard drug/service i.e there is a presumption that this is reliably known. However NICE has operated without this data, as such its recommendations on mental health and in particular on depression and the anxiety disorders are blind. Yet organisations such as IAPT (Improving Access to Psychological Therapies)   establish their legitimacy to paymasters (NHS England and Clinical Commissioning Groups) by claiming the NICE seal of approval.  NHS England and CCG’s prefer to nod to this ‘seal’ rather to enquire about IAPT’s claims, much less to set up an independent body to address the veracity of claims. This is not too surprising as there is a semi-permeable membrane between the Department of Health and service providers. Conflicts of interest have not been addressed. 

 

Determining a QUALY with regards to mental health is not easy, but one QUALY could reasonably be interpreted as the cost of achieving the absence  of meeting diagnostic criteria for a recognised psychiatric disorder for a year for a client, following say an IAPT intervention, this would be compared with the typical cost of achieving this goal with the same type of client in pre IAPT services. But no follow up of IAPT clients has been conducted that independently tracks diagnostic status. NICE is saying more than it knows, but at whose behest?

Dr Mike Scott

Half of IAPT Clients Attend Only One Treatment Session

according to the UK Governments Improving Access to Psychological Therapies (IAPT)  annual report for 2019-2020 -https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf,  489,547 people curtailed involvement after having one treatment appointment,  whilst 606,192 had two or more treatment sessions. If half of people never returned to a particular Cafe in their locality it would not be a good advertisement. But the IAPT Cafe is the only affordable one for most people, with a third of its’ clientele returning for further courses of ‘sustenance’, Hepgul et al (2016) https://doi.org/10.1186/s12888-016-0736-6.  Doesn’t sound like this Cafe confers health.

This haemorrhaging of clients is not a feature of the NICE recommended treatments, yet IAPT claims fidelity to such treatments! What then does one make of IAPT’s claim of a 50% recovery rate? This would be a fitting subject for Radio 4’s ‘More or Less’ statistical programme. To set the context, of 1.69 million referrals to IAPT in 2019-2020, 1.17 million left the starting gate, 30.77% (almost 1 in 3) were non-starters. Further only 1 in 3 (36.8%) got around the course (defined curiously by IAPT as attending 2 or more treatment sessions). IAPT’s terrain is much like that of the Grand National horse race. The ‘50% recovery rate’ refers to the significant minority who cross IAPT’s finishing line. Thus even using IAPT’s own yardstick  the true recovery rate is much less than 50%.

With regards to those who cross IAPT’s finishing line, there is no indication that their ‘success’ is lasting. It is not known what proportion of them ever ‘race’ again. Thus, the true recovery rate is likely to be far less than 50%. My own independent study of 90 IAPT clients, Scott (2018) https://doi.org/10.1177%2F1359105318755264  suggests that in fact only the tip of the iceberg, 10% , recover in any real world sense.

It serves all Organisation’s well to be vague about its’ criteria for success, they almost certainly operate with a confirmatory bias, cherry picking data that would justify its’ existence in the eyes of its paymaster. Biases or heuristics do not necessarily operate consciously but are nonetheless powerful and likely to be employed if survival is at stake. See for example Lilienfeld and May’s (2015) https://doi.org/10.1002/9781118625392.wbecp567 critique of reliance on self-report measures, a particular penchant of IAPT. These authors also point out that the only sure way of de-biasing is to have independent review, but IAPT has never been subjected to publicly funded independent review. 

Dr Mike Scott

 

IAPT Out Of Its’ Depth

a just published paper in the British Journal of Clinical Psychology by Martin et al https://doi.org/10.1111/bjc.12314 concludes:

‘Improving Access to Psychological Therapies provision and research at present does not adequately consider the complexity of its clientele in the context of treatment outcomes and service delivery’

The authors suggest that practitioners bear the following in mind:

  • Improving Access to Psychological Therapies (IAPT) has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged.
  • Given the ongoing focus on and investment in IAPT informed developments into long-term conditions and serious mental illness, this review considers whether additional elucidation of the model’s original objectives is required, as a precursor to its expansion into other clinical areas.
  • The review indicates that there is a stark lack of data pertaining to the generalisable, real-world clinical benefits of the IAPT programme as it currently stands.
  • Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.

I did throw IAPT a lifebelt with my paper ‘Ensuring IAPT Does What It Say On The Tin’ published in the BJCP  in
 
March 2021  https://doi.org/10.1111/bjc.12264 but the rebuttal from Kellett et al in the same issue of the Journal
 
DOI:10.1111/bjc.12268 suggests that  my comments fell on deaf ears.
 
 

Dr Mike Scott 

When Mental Health Screening Makes You Want to Scream

assessment in the Improving Access to Psychological Therapies (IAPT) Service takes up 25% of all resources, yet in the NICE approved protocols for depression and the anxiety disorders assessment takes about 8% of resources       (roughly an assessment session for 10-15 treatment sessions). Much of the IAPT assessment consists of telephone completed screening questionnaires by contrast the assessment in the NICE protocols consists largely of a reliable standardised diagnostic interview. But there is no reason to believe that the screening measures in IAPT (PHQ-9 and GAD-7) are pertinent to the client’s problems. Despite this in IAPT, these measures are re-administered every session and often made the focus of discussion, thus the actual total time spent in IAPT on ‘assessment’ is likely much more than 25% of the budget. The added value is? IAPT has a credibility gap. Is it really credible that with such a skewed distribution of resources, that IAPT should claim success comparable to that found in the randomised controlled trials that are the basis for NICE recommendations? IAPT claims fidelity to NICE protocols, so that it is not divorced from its’ paymasters NHS England/Clinical Commissioning Groups, but it is a well known philanderer. It provides no evidence of fidelity, just protestations.

I hear that IAPT is looking at introducing artificial intelligence into the assessment process! Whilst there are attempts to develop an algorithim for suicide risk by looking at records etc, the outcome is likely to be some marrying of this with clinician expertise. But this goal is quite a challenge. A meaningful algorithim for IAPT’s assessments  is likely to be a whole different ballgame. Time would be better spent doing the simple things such as really listening to clients and making a reliable diagnosis to direct treatment, this would be an exercise in intelligence. 

IAPT represents an extreme case of the tail wagging the dog when it comes to screening. A just published editorial in the Journal of the American Medical Association by Mitchell Katz, shows the more general problem of screening:

 
Editor’s Note
June 14, 2021

A Response to Excessive Screening Questions

JAMA Intern Med. Published online June 14, 2021. doi:10.1001/jamainternmed.2021.2925

‘Recently, JAMA Internal Medicine published a firsthand account of a trauma survivor who had disclosed over a series of years on multiple self-administered screenings that she had experienced trauma,1 yet none of her health care clinicians had ever followed up with her or provided any support or resources. In reading her account, I wondered how many of her clinicians had even seen the screening questionnaires she completed.

Standardized screening questionnaires allow primary care clinicians to learn important information about patients, especially in psychosocial areas (eg, depression, anxiety, substance use) that can be difficult to assess in short appointments. Adding to their efficiency, they can be completed in the waiting room. But for them to be useful, they have to be read, and the appropriate resources must be available.

Just as “alarm fatigue” can result in not paying attention to important warnings from electronic health records, use of screening questionnaires performed more often than necessary can deluge clinicians with more information than they can incorporate in a visit, decreasing the efficiency of the visit and leading to cynicism on the part of patients (eg, “Why do they keep asking me if I am depressed, when I keep telling them I am not?”) and on the part of primary care clinicians (eg, “Why are my patients repeatedly given these screeners, when I dealt with this issue on the last visit?”).

In this issue of JAMA Internal Medicine, Simon and colleagues2 estimated the proportion of standardized screenings performed at 24 federally qualified health centers in 2019 that were excessive, defined as performed when not recommended. Six screeners were evaluated (depression, anxiety, smoking status, passive smoke exposure, health literacy, and preferred learning style), all of which were tied to national performance metrics. The authors found that 34.9% of all screenings performed (2 067 152 of 5 917 382) were excessive’.

Dr Mike Scott

 

When Does Psychological Therapy Count As A Success?

always, if you lower the methodological bar low enough. The just published study by Chalder et al (2021), is an exemplar,  focussing on cognitive behaviour therapy for people with persistent physical complaints (PPS) https://doi.org/10.1017/S0033291721001793:

  • that there was no significant difference in outcome on the primary outcome measure, the self-report Work and Social Adjustment Scale
  • the authors of their report were evaluating their own protocol for PPS [hitherto known as Medically Unexplained Symptoms (MUS)]
  • there was no independent clinical assessment of outcome
  • the control group received ‘standard medical care’, there was no control for attention (the treatment group received 8,  1 hour sessions) 
  • there was no evaluation of effectiveness in a non research setting

Tolin et al ( 2015) https://doi.org/10.1111/cpsp.12122 have presented a clearly defined methodological bar as to what constitutes an Empirically Supported Treatment (EST), that has been adopted by  the American Psychological Association. Far from clearing this bar Chalder et al (2021) protocol  failed on each of the 5 criteria above. In addition Chalder et al (2021) fail to mention that total reliance on self-report measures, this makes the study especially prey to demand characteristics, in that those given attention are likely to want to please the therapists and not to feel they have wasted their own time by indicating a better response than otherwise.

Chalder et al (2021) fail to reference any work that challenges the very concept of MUS e.g Geraghty and Scott (2020) https://doi.org/10.1186/s40359-020-0380-2. The theoretical basis for Chalder et al’s CBT (2021) is that ‘Patients with PPS can develop unhelpful cognitions and behaviour which can consequently lead to a reduction in daily functioning, reduced quality of life, and an increased susceptibility towards developing depression and anxiety’. These authors inform the reader that all those in the study met criteria for fibromyalgia, but by Chalder et al’s (2021) rationale all with a persistent physical symptom require psychological therapy, this would just about swallow up all mental health resources in primary and secondary care. 

 In their statement of Conflict of Interest the authors Chalder et al (2021) indicate their background in the training of IAPT staff, unfortunately it is likely that the treatment protocol will find its way into the organisations ministrations, before any independent evaluation, despite the authors call for further research .  

 

References

Chalder T et al (2021). Efficacy of therapist-delivered transdiagnostic CBT for patients with persistent physical symptoms in secondary care: a randomised controlled trial. Psychological Medicine 1–11. https://doi.org/10.1017/S0033291721001793

Geraghty, K., & Scott, M. J. (2020). Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2

Tolin, D. F., Mckay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015). Empirically supported treatment: Recommendations for a new model. Clinical Psychology: Science and Practice, 22(4), 317–338. https://doi.org/10.1111/cpsp.12122

Who Is Monitoring The Quality of Primary Care Mental Health Services?

Nobody, Clinical Commissioning Groups (CCGs) confine themselves to operational matters, number of patients seen, waiting lists.  The Improving Access to Psychological Therapies (IAPT) service has been allowed to self-monitor since its’ inception in 2008.  The National Audit Office abandoned its’ investigation of IAPT because of competing priorities citing the Carillion debacle amongst others in June 2018. Who is listening to the voice of the recipients of the mental health services?  

The mantra appears to be to get everyone to talk about mental health, especially celebrities, get everyone involved in mental health, teachers etc, secure more funding for anything with a mental health flavour on the basis that ‘it must be good’. But frenetic activity does not equal making a real world difference, achieving this has to be carefully monitored.

It goes without saying that we all need a more caring society nationally, for example assisting those who have been self-isolating for over a year to gradually venture out.  From an international perspective we should be giving a £1bn a year to fund the provision of vaccines in poorer countries. The need for compassion is never redundant.  But political correctness about mental health can obscure fully engaging with those in most need. 

Dr Mike Scott

The Future of CBT In Practice

niNext month is Aaron Beck’s 100th birthday and the journal which he founded ‘Cognitive Therapy and Research’ has a great editorial https://doi.org/10.1007/s10608-021-10232-6, wishing him well and looking at possible developments in CBT for depression, envy, schizophrenia and OCD. But there is a yawning gap between the experiences of the beneficiaries of randomised controlled trials (rcts) of CBT and what UK citizens receive in routine practice. In terms of the model below, going clockwise, there has been a fundamentalist translation of the rcts to determine policy, such that key elements of context such as ensuring reliable diagnosis have been left out, implementation has been determined in a ‘Stalinist’ way e.g the possibility of sanctions if a 50% recovery is not reached, there has been no independent monitoring of the policy, there is a claimed risk reduction, but this is based on responses to the ambiguous suicide item, item 9 on the Patient Health Questionnaire PHQ-9. But there is no evidence that the ‘Science’ is looking at these matters anytime soon. The deliberations of bodies like the British Association for Cognitive and Behavioural Psychotherapy (BABCP) appear to occur in a parallel universe.

Recently Drew et al (2021) https://doi.org/10.1016/j.socscimed.2021.113818 examined transcripts of IAPT (Improving Access too Psychlog ical Therapies)  sessions and the take home message was that clinicians were preoccupied with their own agenda and not really listening. This echoes what  Omylinska-Thurston et al (2019) https://doi.org/10.1002/capr.12249   found when interviewing former IAPT clients:

participants discussed difficulties with the outcome measures they had to fill in each week. Clients said they did not feel comfortable filling them in. Clare said it felt “disheartening… because … it brings it home…just how bad you’ve been feeling”. Clients also said that the scales felt disrespectful to their experience. For some, it was difficult to pinpoint the accurate answer and for others the measures did not reflect the nuances. For example, Jenny said about the self-harm question on PHQ9 “…to harm myself? No, but I know I wasn’t eating …well”. Also Jason said “there’s a difference between wishing you were dead and wanting to die … the question really is: do you think you should kill yourself rather than do you think you’d be better off dead?” Participants also commented that they learnt how to score the measures to get more services or sessions. Jenny said about the self-harm question “If I’ said ‘yes’ then they …‘right, shit’, but because you don’t put that they do ‘OK, see you next week’.” Jenny also worried that “if you put it was only one day this week, does that mean you don’t get any more sessions?” Measures were also reported as focusing on the negative side and did not catch positive change

Difficulties with assessment

Six clients discussed issues they had with the assessment process. Clients said that they were not assessed for the right type of therapy. For example, Adam said “if I had been…assessed better, that therapist doing CBT could have been helping another person”. Clients also said that CBT was not explained to them and Michael commented that he “didn’t know exactly what CBT things were going to entail”. Clients said that assessment involved a lot of paperwork and form filling and did not focus on their needs. Jason commented that he had to fill in a measure first and the score decided that he was depressed rather than a discussion first supported by a measure. Maurice talked a lot about the phone assessment and said it was “uncaring, robotic and intrusive”. He was concerned that people will not engage in therapy following telephone assessments’.

Yet what struck me when I met Beck in 1997 in Canterbury, was how much he genuinely listened. The rcts on CBT continue to generate high expectations but the jury is out on whether they have made or will make a real-world difference.

Dr Mike Scott

Psychological Therapy With Long Term Conditions

Improving Access to Psychological Therapies (IAPT) therapists working with long term conditions (LTC’s) have confidence and organisational, issues Carroll et al (2021) DOI: 10.1111/bjhp.12475. Whilst therapists working in secondary care, with LTC’s, face fewer obstacles to multidisciplinary working, with a focus primarily on the LTC and not on the associated depression/anxiety as in IAPT. Further the metrics for outcome in secondary care are likely to be much broader than in IAPT. LTCs by their very nature, wax and wane with a consequent impact on availability and concentration, creating a need for any therapy to be long term. But IAPT has a major focus on access and waiting times, such that any treatment is usually brief, comprising on average of 6 sessions, thus the service cannot readily accommodate working with LTCs.

The focus in the Carroll et al (2021) is on how the psychological treatment for those with LTC”s can be best integrated into primary and secondary care. They note however that the model they use to identify barriers and facilitating factors to implementation, first requires, evidence that the chosen intervention/s are effective. But they do not address this point. This is crucial, where is the evidence that the psychological therapies for disorders that are comorbid with LTCS make a real world difference?

A case has long been made that it is a matter of basic humanity to offer to accompany a person with an LTC if they so wish. A host of Charities have formalised this. The support may be social, e.g befriending, groups and/or instrumental e.g help with DWP application. The case for profferring ‘support’ is I think uncontestable. But many with LTC’s are wary of being defined by their condition. A dedicated support group may serve as a further reminder of their condition. They may decline involvement in such a group, but this is not necessarily a matter of avoidance, simply that they do not wish to define themselves or their world through the lens of their LTC. If psychological difficulties are grafted on to their LTC they may be even more likely to decline involvement with psychological therapists because it is an LTC type lens (a variant) through which they are being encouraged to view themselves and their personal world with perceived deleterious consequences. Arguably the LTC lens used in secondary care is likely to be less problematic than that used in IAPT. But the issue of centrality has not been systematically addressed with regards to LTCs. In the authors forthcoming work ‘Personalising Trauma Treatment: Reframing and Reimagining’ to be published by Routledge the issue of centrality [ Bernsten and Rubin (2006) (2007)] is addressed in detail with regards to trauma.

There is a distinction between long term physical health conditions and medically unexplained symptoms (MUS), the former are open to objective identification e.g diabetes, the latter are not. In considering the former the therapist feels that they are on solid ground, albeit that it is largely the domain of the medic, with whom there may be fruitful dialogue. But when it comes to MUS the therapist is in a fog, where are the signposts? There is no reference book for translating best practice with LTCs to clients with MUS. Because of this there is likely to be recourse to a powerful body insisting that the way forward is ‘x’ but without any evidence, a recipe for disaster. IAPT”s juxtaposition of LTCs and MUS, smacks more of pragmatism to secure maximum funding, rather than seriously addressing a clinical problem. Where is the therapeutic alliance in addressing MUS symptoms? What is the goal, What are the agreed tasks? Whither the bond, when the therapist covertly believes that the client is somatising and the client believes there physical symptoms are as real as toothache?

Carroll, S., Moss-Morris, R., Hulme, K., & Hudson, J. (2021). Therapists’ perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions. British journal of health psychology26(2), 307–324. https://doi.org/10.1111/bjhp.12475

Berntsen, D., & Rubin, D. C. (2006). Centrality of Event Scale: A measure of integrating a trauma into one’s identity and its relation to post-traumatic stress disorder symptoms. Behaviour Research and Therapy, 44, 219–231. https://doi.org/10.1016/j. brat.2005.01.009

Berntsen, D., & Rubin, D. C. (2007). When a trauma becomes a key to identity: Enhanced integration of trauma memories predicts posttraumatic stress disorder symptoms. Applied Cognitive Psychology, 21, 417–431. https://doi.org/10.1002/acp.1290

Dr Mike Scott