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BABCP Response - NICE Consultation January 2022

IAPT and The Absence of Treatment Markers

IAPT purportedly offers NICE –indicated treatments for depression and anxiety at Steps 1-3.  But the NICE guidelines do not offer guidance on the treatment of specific phobias or adjustment disorder.   So that in practice Psychological Therapists fail to adequately distinguish between these excluded categories and the included ones such as PTSD, OCD etc.  The result is that there is a serious mismatch between disorder and treatment, for example I’ve just seen a person treated with 10 sessions of trauma focussed CBT, I knew him to have simply a specific phobia about driving and travelling as a passenger in a car and he was still suffering from just this after IAPT treatment. The treatment records referred to ‘likely PTSD’,   such statements are not only unreliable but dangerous. There is a need for a

In practice IAPT treatment is determined by therapists rules of thumb, such as ‘if the trauma was extreme and there are disturbing intrusions go for PTSD treatment’, ‘if there was prolonged abuse go for complex PTSD’, ‘ a high score on the Impact of Events Scale means PTSD is likely’,  but there is no scientific basis for such rules.  The NICE guidance makes no mention of treatment being determined by the therapists ‘formulation’, but many therapists are perfectly happy with this supposed magical insight into the way forward, which they see as a product of their clinical experience and acumen.  In practice lip service is paid to the NICE guidelines, for the most part therapists do their own thing, with perhaps a psychometric test such as the IES thrown in to appease management and a concern to use keywords like habituation, trauma focussed CBT and exposure. Training courses do not it seems help students critique the validity of the IAPT treatment approach.

Wither true accountability?

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Which Guide To Mental Health

‘Did the mental  health service that you used, give you the lifestyle that you wanted?’ , answers in a new ‘Which’ guide. At present consumers are entirely at the mercy of the manufacturer’s advertising.

The views of employer’s and GP’s have potentially a greater objectivity than that of the mental health service providers. The danger is that employers can by pass serious consideration of the matter, by reminding themselves that their primary objective is profit/productivity and that provided that they can be seen as making some gesture to health and wellbeing, ‘look no  further’. In a similar way GP’s can bypass central processing of objective outcomes with a rationale that they are fully extended performing their primary function of looking after the physical health of patients, ‘so long as I can off-load mental health patients at least for a time so much the better’.

There is a pressing need to ask questions nobody wants to hear. According to George Orwell, liberty is the freedom to ask such questions. How much liberty is there really in the mental health/medical sphere?

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

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

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BABCP Response - NICE Consultation January 2022

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

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BABCP Response - NICE Consultation January 2022

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

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BABCP Response - NICE Consultation January 2022

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

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Current Psychological Therapy Issues IAPT

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

 

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BABCP Response - NICE Consultation January 2022

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

Categories
IAPT

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

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BABCP Response - NICE Consultation January 2022 IAPT

‘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

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