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Mis-selling of the Cognitive Therapy Rating Scale

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

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

 

Dr Mike Scott

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‘We’ll Spin the IAPT Wheel To See What You Need’

Maybe the IAPT wheel will stop at counselling, or perhaps low intensity CBT or maybe  high intensity CBT! I have just  had a client who was within 6 weeks of a road traffic accident given an IAPT telephone assessment and deemed in need of low intensity CBT, but didn’t attend the scheduled treatment appointment and therefore discharged. 14 weeks post rta  he underwent a further telephone assessment and was now deemed in need of high intensity CBT, unsurprisingly he DNA’d the first treatment appointment.      The GP was provided with no explanation of the rationale followed by IAPT nor was he furnished with any psychometric test data. Accountability?

It is difficult to see the logic of IAPT’s position, other than to be seen to offer a speedy service,  it could be argued that some distress post rta is normal and in the interests of ‘saving normal’ (and resources) waiting and seeing a little longer would have been helpful . Perhaps a case for counselling could be made but on what basis?

 

Dr Mike Scott

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IAPT Behind Closed Doors – Falsifying Quality Control Data

My experience is that at least one person was found to have massaged the figures to reflect a greater recovery rate and consequent discharge.  This was only discovered following a particularly high level of re-referrals for ex-patients and subsequent complaints.

With regard to the PHQ 9 and GAD 7 scoring system, I feel that this could be open to abuse.  This may be because workers are under great pressure to perform and elicit results.  I believe this to have taken place as a consequence of almost overwhelming pressure to discharge referrals.  With more discharges came more referrals and there was never any acknowledgement of best practice or learning lessons appropriately.  I understood also that PHQ 9 and GAD 7 only had pertinence for those suffering from mild to moderate mental health conditions.  I had to use other tests for those persons who had suffered past trauma and more severe mental illness which I myself as a practitioner “filtered out” as a consequence of them being incorrectly referred to step 2 services.

Anonymity protected – Dr Mike Scott

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Post Trauma Mapping – circumventing difficulties with trauma focussed cbt

From an evolutionary perspective the problem with PTSD is not so much the traumatic memory but that the latter furnishes a maladaptive map, as if the sufferer is operating in a ‘war zone’.  This suggests a different treatment focus to the often resisted trauma focussed CBT.  The goal of treatment is to construct an adaptive map, this involves ‘scouting’ to ascertain where if anywhere the ‘real and present dangers’ are.  PTSD sufferers are often operating like Tony Blair on the ‘dodgy dossier’, if the weapons of mass destruction are not found in one place there is a rush to somewhere else thinking ‘they must be here’.

For clients resistant to trauma focussed CBT (TFCBT), post trauma mapping readily enhances the therapeutic alliance. Alliance problems are a bigger problem in delivering trauma focussed cbt in routine practice than have ever been acknowledged in randomised controlled trials, resulting in therapists feeling deskilled. Steve Stradling and I found that in routine practice only just over half of clients comply, even loosely defined, with a trauma focussed CBT [ Journal of Traumatic Stress (1997)].  There is a gap between what the scientist practitioners in the randomised controlled trials find and what the routine clinician/ ‘engineer’ finds in routine practice. Such mapping can be insufficient to resolve the PTSD but in passing the person becomes so acquainted with talking about the trauma that shifting from the ‘shallow end’ to exercising in the ‘deep end’, trauma focussed CBT is seemless.

From an evolutionary perspective the only function of memory is to to help us better anticipate future events, there is no value in memory per se. It may transpire that trauma focussed CBT is not actually essential for recovery from PTSD, certainly we do know that TFCBT is not necessary and is often experienced as ‘toxic’ for those traumatised but not suffering from PTSD e.g simple phobia, depression. Making it very important to carefully delineate the psychological sequelae of trauma.

Dr Mike Scott

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Telephone First Consultations Fail

IAPT is synonymous with telephone first consultations, but the first independent study of this intended cost saving device, with GP’s, has shown it fails to deliver. An editorial in this week’s British Medical Journal on the Newbould et al study* (2017) states:

‘ Telephone first systems alone will not solve the perennial problem of ensuring timely, safe, and equitable access….It is also yet another reminder of the importance of independent evaluation of initiatives before investment in widespread implementation’

Instead of piloting and having an independent evaluation, IAPT has ploughed on regardless. Accountability is a major issue for IAPT, it positions itself between primary  and secondary care but is accountable to neither. It claims comprehensive data collection on almost all its clients. Yet in the authors examination of 90 cases (In preparation) that went through IAPT, for clients having two or more treatment sessions, before and end of treatment psychometric test data was given to GPs in less than half of cases. One quarter of cases did not clear the first hurdle of either ringing IAPT for a telephone assessment or IAPT being unable to contact the person. Whilst 13.3% ‘attended’ only the initial assessment. Thus IAPT is failing to engage just less than 4 out of 10 clients.

 

In GP practices with telephone first consultation the proportion of patients who would recommend their practice to friends fell. There was also a reported increase in emergency admissions associated with telephone first systems.

Clinical Commissioning Groups should insist on IAPT reforming itself, by dropping telephone first consultations.

* Newbould et al (2017 Evaluation of telephone first approach to demand management in English general practice: observational study. BMJ: 358:j4187

Dr Mike Scott

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IAPT Behind Closed Doors – ‘Group CBT’

I have had some interesting experiences with regard to group work.  Groups were divided into either Anxiety or Depression groups and it was often a difficult task to understand or to divide those suffering predominantly from anxiety and those suffering mostly from depression.  Added to this, groups were designed to deliver the most information to as many people as possible and were not tailored to individual need.  It was a “scattergun” approach, designed to keep the commissioners happy in terms of figures.  I think the worst example of this, was when a “Welcome Group” was planned which gave “due consideration in terms of numbers of people who could drop out” and asked 15 people to attend.  The room’s capacity in terms of seating was only 12, but in fact, 45 people attended and this would have been more if inclement weather had not prevented others from attending.  This was put down to a mistake with the figures and in the following week, only 3 attended the course.

Courses routinely had the obligatory people who presented with alcohol or drug problems and it was a regular occurrence that either one or the other would disrupt a group.  I once had a complaint made against me by a member of a group who felt that I had not been supportive to her situation and had been tearful and had had to go to the Ladies’ to recover.  I asked my colleague to accompany her.  I was rounded upon by the drunk in the room, who jeered and berated me for “making her cry” and that I should be ashamed of myself.  I told this inebriated person that he may not attend the next session and for this I was abused verbally.  I felt quite threatened, but was asked to explain my actions at a later date, when the complaint came in.  The situation was seen to be “one of those things” but my efforts to point out that anyone with either drug or alcohol problems should not have any place in a depression group, were largely ignored.  I had argued that anyone who had not made some kind of recovery from either drug or alcohol issues should not be permitted to attend a step 2 group, because they would not benefit and could possibly disrupt a group.

Anonymity protected – Dr Mike Scott

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Developing Groupwork – An Exercise in Storytelling

Shifting the therapeutic focus from ‘classes’ to a shared narrative has greatly resonated with attendees at my ‘Delivering Group CBT’ workshops this year. My message has been if you are running a group make sure participants have the same story.

 

Social groups are formed by people having the same story e.g Labour Party supporters or Church groups. Therapeutic groups with diverging narratives are likely to run into difficulties.  Consider an anxiety group which includes a person with OCD, another group member with say generalised anxiety disorder , might well consider the OCD person as ‘weird’, become fearful that they will ‘catch’ the same disorder and drop out of treatment.  The therapists leading the group might well find that they are stretched too far in having to cater sufficiently for the person with OCD, yet simultanously keep other group members involved throughout.

Diagnosis is simply a way of ensuring people share the same story i.e the cognitive model of the particular disorder. There are free ‘storybooks’ for depression, the anxiety disorders and PTSD in the ‘Resources’ section of this site, which can form the content of group sessions.

Thus all members of a panic disorder group would be taught not to be ‘bullied’ by the panic attacks, but to gradually ‘dare’ go to places that they have historically avoided both within and outside the group session. The story-telling rationale ‘chunky CBT’ lends itself more to the use of  metaphor e.g ‘being bullied’, rather than talking class room style about say ‘the fight and flight response’.

Dr Mike Scott

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Diaguessnosis and Agnosis

Diaguessnosis is a condition that often afflicts psychiatrists, whilst agnosis is commonly found amongst psychological therapists, but sometimes they coexist. They have in common that the person doesn’t know who or what they are dealing with. It is debateable whether they are in fact different conditions, and a transdiagnostic approach might suggest the common feature is a deficit in understanding the contribution of a standardised reliable diagnosis.

I first heard the term diagussnosis used a few weeks ago by Stephen Fry on Radio 4 when he was interviewing a comedienne and fellow mental health sufferer. She said that she had been given so many labels for her ?bipolar disorder that  she thought that professionals engaged in diaguessnosis rather than diagnosis.

Shortly afterwards I saw a lady, Ms A who was injured and scarred at work, she had a telephone IAPT interview and was told she needed CBT. But when a face to face appointment came to pass it was decided she needed counselling. Ms A had 4 counselling sessions, missed a session and could not be bothered to ring to make the missed appointment, she was frustrated that the focus had been on different family members reactions to her scarring.  Further she was offered no diagnosis. This illustrated to me that generally the psychological practitioners maintain a rigid agnosticism about diagnosis with occasional forays into diaguessnosis.

I concluded that she met DSM-5 criteria for a chronic adjustment disorder, this led to a profitable discussion of the better and worse ways of playing her difficulties.

Dr Mike Scott

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IAPT Behind Closed Doors – Supervision

As I mentioned in my first post last week I was working in IAPT in Bury in 2015. Clinical Supervision was delivered in the group setting and was not compulsory to attend.  Often the supervision had to be postponed for several weeks if the supervisor was either not available or was on holiday or had casework at a higher step which took precedence over the needs of the group.  Personal supervision was a similarly structured affair, with pressure and time constraints eating into very short sessions.

 

It was incumbent upon the supervisee to ensure that “risky cases” were discussed in a timely manner, since it was the supervisee’s responsibility to “raise the alarm”.  In many cases, the supervisee was not aware that any alarm needed to be raised, since they were inexperienced with either the identification or managing of risk with regard to mental health patients.  Please do not take this as a criticism of my colleagues; it is a criticism of the system’s failure to provide them with the knowledge they needed to understand the risks.

Anonymity protected Dr Mike Scott

 

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National Audit Office Listening Over Critique of IAPT

On September 21st I received an e-mail response from the National Audit Office which said: ‘The clarification you have provided regarding the usefulness of the tests used to assess patients, and the fact that, in IAPT, a link is not consistently being made between diagnosis and treatment, is very useful in helping us to understand more about the points you previously raised with us about recovery rates’

See earlier post on National Audit Office, extract below:

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  1. In 2011 the Secretary for State for Health, Andrew Lansley MP and the Minister of State for Care Services, Paul Burstow, MP said stated ‘we are clear that building services around the outcomes which matter to people is the very essence of personalisation’, [Transparency in outcomes a framework for quality in adult social care (2011) Department of Health] so it cannot be for IAPT to choose the yardstick by which it evaluates itself. People seek physical/ psychological treatment in the hope that they will no longer be suffering from an identified disorder by the end of treatment, this is not a matter of clinical judgement, the yardstick is primarily patient driven. If an agency supplies data that does not allow a determination of whether this transparent yardstick is met, then they are remiss. In this connection IAPT ought to be brought to task by the National Audit Office.
  1. Psychometric tests of themselves do not point to any particular NICE approved treatment, if they had this power NICE would have said so, and they did not. Tests are like road signs blowing in the wind, they can only give direction if anchored in a reliable diagnosis. Inappropriate treatment including a failure to treat ( false positives and false negatives) is inevitably ubiquitous when treatment is not moored to diagnosis. Whilst it is the case that some cut offs are better than others at identifying a ‘case’ of disorder, the  cut offs themselves vary from sample to sample depending on the prevalence of the disorder and are at best relevant to one disorder – in practise people usually have more than one disorder. IAPT essentially has two instruments the PHQ-9 and GAD-7 which they purport measure anything of significance, no medical/scientific professional would claim such powers for just two instruments.

It will be very interesting to see the final report of National Audit Office.

 

Dr Mike Scott