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BABCP Response - NICE Consultation January 2022

When the ‘Psychosis Service’ Becomes Psychotic

I was just talking to a colleague in a Psychosis Service, where he is the only CBT therapist. He is tasked with doing ‘relapse prevention’, trouble is that none of his clients have recovered from their psychosis, making relapse prevention meaningless (psychotic)! Further none of the clients have had any CBT treatment, he is restricted to providing a diagnosis, a formulation and relapse prevention. I am at a loss to understand the evidence base for such an approach.

 

 

When I was told also of a client who is visited at home and is required to take his antipsychotic medication in view of the Nurses and there is discussion of ECT, I began to wonder whether we have moved beyond the asylums of old.

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

‘Nobody In Their Right Mind Wants to Talk of Horrible Things’

But  trauma therapist are  going to make you at the drop of a hat. Surprise, surprise lots of people drop out. The problem is that therapists are poor at making the distinction between cognitive avoidance and saving normal.

Ms X was on a works training course , but got upset when discussion got around to the Manchester bombing and she left the room. She had escorted her 2 children from the arena. Ms X was referred to Occupational Health     and seen by a therapist who said that she was not suitable for learning to manage workplace trauma. Ms X’s reaction was arguably a normal reaction to an abnormal situation , it had not been ascertained whether she was suffering from PTSD or any other recognised disorder.

 The therapist had not appreciated  that traumatic memories have to be handled with ‘kid gloves’ , there is a normal aversion reaction to such encounters. Recognising and accepting Ms X’s response is acknowledgement of the need to ‘save normal’ . This is not to say that on occassion , there is not a need to learn a better way of handling an intrusive memory when it is significantly impairing functioning (e.g in PTSD) or to reconstruct the memory so that it is a better template for predicting everyday life. But the burden of proof is with the therapist to demonstrate that this is necessary.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Rules of Thumb That Sabotage Treatment Post Trauma

IAPT January 23rd 2018 Birmingham City Football Ground Were you thinking this heading referred to post-traumatic stress disorder (PTSD) teatment? If you did, you may have been using a particular rule of thumb relating to an exalted status for PTSD. The following may be a common set of saboteurs:

  1. It is probably PTSD because it was an awful incident
  2. It is probably PTSD because there are flashbacks and nightmares
  3. It is probably PTSD because of a high score on the IES
  4. It is probably mixed anxiety and depression because of high scores on PHQ9 and GAD7
  5. Whatever it actually is trauma focussed CBT/EMDR offers the best bet for resolving it
  6. Formulation rules anyway
  7. You can’t treat more than one disorder at a time
  8. Issues need to be resolved first

I was due to present these Saboteurs next Tuesday during an IAPT Workshop at Birmingham City Football Ground, unfortunately 2 days after Christmas I fell down the stairs, presentation of the saboteurs has been sabotaged! The Power Point Presentation is available above.  The effects of the rules of thumb are I believe devastating leading to a recovery rate of 10% in IAPT.

my paper IAPT- The Need For Radical Reform will appear in the Journal of Health Psychology shortly.

Dr Mike Scott

 

 

 

 

 

 

 

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BABCP Response - NICE Consultation January 2022

‘Just Give Us The Resources To Treat Personality Disorders’ and then what?

There has been a great clamour this week from mental health bodies, including the Royal College of Psychiatrists (RCP) for more monies  to address the grave problems of clients with personality disorders (PDs). But they have neglected to add that there are few randomised controlled trials of psychological treatments for PDs and those that have been conducted have had very different outcome measures. It is important that clients with personality disorder are given realistic expectations of treatment and are protected from commonplace misdiagnosis.

One of my clients lost access to her children in part because a psychiatrist claimed she had an emotional unstable personality disorder (EUPD), fortunately legal action is being taken against the local authority for their part in this debacle. The latter were insistent she attend a mentalisation group, my protest that she did not have a personality disorder and therefore did not have to  attend went unheard! The stresses of taking the legal action have been colossal. Maybe the energies of the RCP might be better spent making sure its’ members make reliable diagnosis.  As part of the legal proceedings in this case a Psychiatric Expert Witness rejected the opinion of the treating psychiatrist but not before a great deal of distress had already been caused to her and her 3 children.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022 Current Psychological Therapy Issues IAPT

Prestigous Journals Have Stopped Looking at Real World Mental Health Outcomes

Papers in Journals such as The Lancet, Behaviour Research and Therapy and Behavioural and Cognitive Psychotherapy have in recent years relied entirely on psychometric tests completed by clients, with no independent assessment by an outside body using a ‘gold standard’ diagnostic interview. The sole use of psychometric tests is great for academic clinicians, research papers can be produced at  pace and at little cost, securing places in academia. Conferences are dominated by their offerings but actually nothing is changing in the real world of clients.

 

 

The Lancet paper on the PACE trial on CBT  for chronic fatigue syndrome [Sharpe et al (2015) Rehabilitative treatments for chronic fatigue syndrome Lancet Psychiatry, 2, 1067-1074] provides a great example of how to ‘muddy the waters’. The authors presented CBT as making a major contribution to the treatment of CFS. But Bakanuria (2017) [ Chronic fatigue syndrome prevalence is grossly overestimated using Oxford criteria compared to Centers for Disease Control (Fukuda) criteria in a U.S population study. Fatigue: Biomedicine, Health and Behavior, ps 1-15] has pointed out that the authors used the very loose Oxford criteria for CFS, requiring mild fatigue, but the incidence of CFS is ten times less if the Center for Disease Control (CDC) rigorous criteria are used. Thus Sharpe et al had not demonstrated the efficacy of CBT in a population who truly had CFS. In December last the Lancet published a paper by Clark et al on predictors of outcome in IAPT but again the dependent variable is of  doubtful validity, changes on PHQ9 and GAD7 in a population whose  diagnostic status is unknown. In fairness in the discussion Clark et al (2017) do note that it is a limitation of their study that they have relied on self-report measures but there is no acknowledgement that their findings are actually unreliable. Doubtless their conclusion that organisational factors effect delivery of an efficacious treatment is true, but this is stating the obvious, if a treatment is found to be efficacious in a randomised controlled trial, unless there is a careful mapping of key elements in the rct e.g reliable diagnosis, ‘gold standard’ assessment, fidelity measures, there will be an inadequate translation from research into routine practice.

My hope for the New Year is objective measures of outcome so that we can truly begin serving clients, now there is a novel idea.

Dr Mike Scott

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IAPT

A Country called IAPT

Imagine you lived in a country where there was a pharmacy and a GP in every town but few hospitals. The pharmacy and GP’s services were widely advertised, encouraging all the unwell, or those who had not really thought of their symptoms before as illnesses to come in, get checked out and get treatment. The government set targets that a certain percentage of the population must be treated by the pharmacy and GP each year – if that target was not met the commissioners would be castigated by NHS England and an expensive tender process would be instigated, to bring “healthy competition“ to the market.

What if a GP and pharmacy were successful in advertising for all the patients and people turned up in their hundreds per month? You realise that you have not got enough supplies and enough staff to treat them all, so you “innovate” new methods, such as getting 12 patients at a time into the room and talking to them about what might be wrong rather than having time to check their individual symptoms. People with symptoms of diabetes were taught about diabetes, if the symptoms were there for another reason and didn’t resolve– what then? Maybe send them on another course and see if that sorted them out, maybe some internet self-help on diet or lifestyle would do – or, maybe they need to be checked out at hospital…..oh….there is no hospital, there was no money to concurrently expand the hospital, in fact, commissioners had saved money on the quiet by closing the hospital because there are no government targets for treating those outside of the GP and pharmacy. There are just a few hospitals further away with not enough capacity to see any more people whose piles may actually be bowel cancer or whose aches and pains are actually a degenerative rheumatoid arthritis.

As a patient who needed more than the GP and pharmacy can offer, you are confused and sad and angry -the GP and pharmacy advertised all over town saying – come and see us if you have these symptoms, but then you are told that there is nowhere to go if physio doesn’t fix that carpal tunnel and you need an operation, nowhere to go for the intravenous antibiotics for your severe infection where the standard course is not enough.

Imagine being a staff member at the pharmacy or GP – wanting to care for people and help them but having no time, having to break the bad news that, yes, there are recognised treatments for what you have but only at hospitals and we don’t have one of them, there is a private one but if you can’t pay you will go unwell and untreated. Might it seem to you that you need more staff to at least try and better help with the supplies that you do have? Oh, you discover that, although the government set guidelines for numbers to be seen, wait list times and recovery rates they set no guidelines for staff numbers and experience. So the commissioners have no basis to give you more budget for more staff and tell you rather to get on with the job or you will lose the service to another provider who magically can get the job done. Might you become stressed, depressed and less able to do your job?

This country is IAPT country. The country that demanded that its services for mild to moderate mental health conditions be built, with high targets to meet, with no proper staffing guidelines. The country that forgot to consider that expanding a mild to moderate service would attract the full spectrum of mental ill health. The country that once did the maths for how many therapists would be needed on the back of an envelope and then lost the envelope.

The country that forgot that not expanding but actually cutting your services for the more unwell would breed the cruelty of unattainable promises to the unwell, staff exhaustion and a desperation that leads to cooking the books to show that targets are met rather than standing up and saying that the Emperor of this country who proclaims that IAPT data is sound and targets are met has no clothes on.

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BABCP Response - NICE Consultation January 2022

A New Year Resolution – Take a First Step to Evidence Based Assessment

It is likely that for most agencies 80% of the work is in relation to a few disorders, (Pareto’s Law of the ‘Vital Few’) so developing an expertise  at identifying these accurately represents a good investment of time and effort.        First of all it is necessary to accurately audit what is coming in through you agency, this could involve using a screen for the 10 most common disorders, the First Step Questionnaire Revised ( available freely on this blog) and then  ask the further diagnostic questions in Simply Effective CBT  [ Scott (2009)] for any positive screen.  Knowing say the 4 commonest disorders dealt with by your agency it would be comparitively easy to cascade training for the accurate identification of these to front line staff, who have perhaps little training.   At a later date training can be given in say the next 4 most common disorders  and  so on so ultimately there is a comprehensive assessment.  Such rigorous assessment is also the best way of monitoring outcome.

Questionnaires completed by the client are subject to demand characteristics, clients wanting to please the therapist or convince themselves that they haven’t wasted time in attending therapy. Administration of weekly psychometric tests are particularly suspect, as clients can remember their scoring and show reductions which can be mistaken for real world differences.

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Gifting Evidence Based Assessment

Evidence based assessment (EBA) is like unwrapping a Christmas present, the first layer is ‘What are we dealing  with (prediction)?, the next what are the options for use, ‘what can we do about it (prescription)? the core is whether the present has made a real world difference ‘ how will we know if we are accomplishing our goals (process)?

 

The three phase approach to EBA, prediction, prescription and process is described (minus the Christmas present!) in December’s Clinical Psychology Science and Practice by Youngstrom et al with an accompanying commentary (including the questions above) by Steven D Hollon.   Youngstrom et al suggest screening for the 10 disorders that most likely comprise 80% of your workload. This can be achieved using the First Step questionnaire from Simply Effective CBT, Scott (2009) London: Routledge an updated free version for 10 disorders is on this blog. Then using a standardised semi-structured interview for positive screens to reliably identify disorders.  Knowing the disorder/s it is possible to predict what is likely to be the best treatment, and prescribe appropriate treatment targets and matching strategies.  Assessment is not just a front end process, assessing whether there has been appropriate process can only be gauged at the end when the assessment is repeated to determine whether the client has got their life back.

 

 

 

In practice many therapists paddle their own canoe, if they stop long enough to really listen they would find that despite the client’s politeness, oftentimes scoring a psychometric test low to please the therapist (weekly administrations have also been found to artificially lower scores), there has not been the real world change.

A very Happy Christmas to Everyone

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Heading Towards the Iceberg – The Mental Health Service’s Response to The Grenfell Fire

‘Three quarters of those living closest to the Grenfell Tower are suffering from PTSD, with 40% suffering in buildings a little further away’ (BBC Radio 4 December 14th 2017). But these figures from Grenfell Health and Wellbeing are highly improbable, numerous studies of responses to natural disasters show the incidence of PTSD is 30-40% amongst direct victims of disaster  and 5-10% in the general population [ Galea et al (2005)]. The rampant overdiagnosis of PTSD opens up the prospect of swathes people enduring trauma focussed CBT (or EMDR) quite unnecessarily. The spectre of inappropriate help rivals the sight of the Tower.

This gross overdiagnosis has come about because counsellors have gone door to door, ‘if they thought it appropriate’ the questions on a PTSD screening questionnaire  were asked and using a cut off a diagnosis of PTSD was made. This method on its’ own is highly unreliable, a screen has to be followed by a reliable standardised diagnostic interview  to establish true prevalence.

The interviewed clinician claimed that their approach was a ‘first’, but actually it is reminiscent oF IAPT’s approach to assessment, resulting in a treatment, that by my independent assessment, has a 10% recovery rate -‘the tip of the iceberg respond’.

 

 

The mental health services are it seems like the like the Titanic heading towards the iceberg, hopefully unlike the crew they will heed warnings and take a new direction.

 Galea et al (2005) ‘The Epidemiology of PTSD After Disasters’ in Epidemiological Reviews

 

Dr Mike Scott

 

 

 

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BABCP Response - NICE Consultation January 2022 Current Psychological Therapy Issues

Grenfell Fire – A Cunning Plan?

Yesterday a Counsellor from the Children and Adolescents Mental Health Services (CAMHS) announced on the BBC News, that staff are going to go door to door asking whether the occupants want professional help. Is this really the best use of resources 6 months after the tragedy? The days news also contained an item on a parent averting the gaze of her children from the Grenfell Fire Tower Block as she took her children to school.

Without health staff having a clear understanding of what in effect constitutes the ‘bruising/ tissue damage’ from  the Tragedy as opposed to that which constitutes ‘disorder’ scarce resources are likely to be squandered. There is clearly a role for a preventative/ 1st Aid input, information about not blocking intrusions, the normality of a period of increased irritability, anxiety about rehousing but there also has to be a reliable assessment of dysfuntion so that an evidence based treatment can be highlighted.

Dr Mike Scott

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