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

Survival Manuals for Depression, Anxiety Disorders and PTSD – Free

Simply Effective Group CBT All Appendices

Separate Manuals for each disorder/s together with screening instruments from, ‘Simply Effective Group Cognitive Behaviour Therapy: A Guide for Practitioners’ (2011) Scott, M.J London: Routledge

They can be used as the basis for individual or group CBT and in a self-help context.

The included pocketbook contains diagnostic questions for each disorder and ‘Sat Navs’ detailing treatment targets and matching treatment strategies.

 

Here is a copy of ‘Simply Effective Group CBT Therapy, free to download:

 Simply Effective Group CBT All Appendices

Warning Bell for Psychological Therapy?

If we continue as we are then psychology will diminish as a reputable science and could very well disappear’ so wrote Chris Chambers in his just published book The Seven Deadly Sins of Psychology: A Manifesto for Reforming the Culture of Scientific Practice (p. ix). Princeton University Press.

The problem is the widespread failure to replicate original positive findings, and the aversion of psychologists to independent direct replication, preferring instead the enthusiastic marketing of any novel positive finding. This is unfortunately also true of the clinical field where there are few independent direct replications.

Medicine and science are largely self- correcting. Until  the paper by Topiwala et al in this week’s (June 10th 2017)  British Medical Journal , 430-431 it was considered that studies suggested that a little drinking of alcohol was good for you  but it has been discovered that even moderate drinkers (up to 21 units for men) were three times as likely as abstainers to have hippocampal atrophy. Chambers (2017) cites a similar example of self-correction from the field of physics, were in 2012 a study was published that suggested a sub-atomic particle a neutrino was  found to have travelled faster than the speed of light, thereby upstaging Einstein’s theory. Within a few years there were 3 independent replications of the same study all with opposing findings. The original experimenter went back to the drawing board and found he had a faulty fibre-optic cable in the initial experiment. Unfortunately to ask for independent direct replication of bench-marking studies in psychological treatment is regarded as being negative and a fudge of conceptual replication is offered in which another study is conducted  with a key feature absent e.g a blind assessor using a standardised diagnostic interview.

Mrs May, today threatens those like ‘Angela’ below who would take action against the unfounded Draconian actions of Social Services

 Family, Mother, Children, Boy

A client ‘Angela’ that I successfully treated with CBT for depression had her 3 children removed after a psychiatrist diagnosed her as having an emotionally unstable personality disorder (EUPD). I protested that this diagnosis was without foundation (she turned up for every therapy session and did all homeworks) but Social Services refused to consider my report, viewing her behavior through the lens of the EUPD, and she was mandated to attend a 10 session mentalisation treatment. In the event the Court appointed an independent psychiatrist who agreed with me that she did not have an emotionally unstable personality disorder. Despite this she was moved simply from supervised to unsupervised access, an ongoing denial of her right to a family life and the mandated attendance at treatment rescinded. Misdiagnosis destroyed family life. The case is ongoing, more about this anon.

Dr Mike Scott

What Chance Effective Psychological Treatment?

“If You Have Heart Problems and Depression You Are Four Times More Likely To Die In The Next Year or Two Than Those With Cardiac Problems Minus Depression”

– All In The Mind, Radio 4 May 3rd 2017.

 But scarcely more than the ‘tip of the iceberg’ of those with mental health problems receive psychological help

Iceberg, Water, Blue, Ocean, Ice

Here are two examples of people that I have seen recently who have been drowning in the ‘frozen waters’

‘Sarah’ was made redundant and had a fall 3.5 years ago. She has suffered from depression since and the only help she has been offered is antidepressants by her GP. Psychological therapy which is the NICE approved first line treatment for depression has not been discussed.

‘Ivan’ recently had a serious road traffic accident two years ago, and was referred by his GP to his local IAPT Service. He said that had a few face to face conversations with the staff but they did not offer him a diagnosis and said that they did not have the funding to treat him. Ivan was referred back to his GP with a recommendation he be referred to secondary care. On examination I found that he was suffering from PTSD complicated by the back pain he had suffered in the incident. The Secondary Care Unit provided no diagnosis but suggested a group programme could cater for his needs but he was not keen on this.

Dr Mike Scott

 

Moving Forward

Perhaps this diagram may help us in how we can move forward from this:-

 

Ultimately we want to make a socially significant to client’s lives, a real world difference, [See Scott (2017) Towards a Mental Health System that Works: a guide for practitioners. London: Routledge], not just a questionable change on some psychometric test.

Wounded Healers

“Two thirds (68.6%) of workers in low intensity CBT (PWP’s) are suffering from burnout and so are half of workers in high intensity.”

(Journal of Mental Health, published online January 13th 2017 “Predictors of emotional exhaustion, disengagement and burnout among improving access to psychological therapies (IAPT) practitioners” Westwood et al).

 

The position is no better than a year ago.  On February 3, 2016, The British Psychological Society reported on a 2015 survey of over 1,300 psychological therapists working in the NHS. The survey found that 46% reported depression, with half (49.5%) feeling they are a failure. One quarter considered that they now have a long-term chronic condition, and 70% said that they find their jobs stressful. Reported stress at work was up 12% in 2014: ‘The overall picture is one of burnout, low morale and worrying levels of stress and depression . . . the majority of respondents made negative comments about their work environment, 10% of comments were more positive’,

Should working in IAPT carry a government health warning? One educator said to me recently ‘I wouldn’t work in low intensity for a ‘gold clock’!

Hospitality

This new website is intended to be a safe-harbour for cbt clinicians – many will be the ‘wounded healers’ described below. Hopefully, it will help clinicians chart new directions and empower them to advocate change, not least via the Discussion Forum and the careful monitoring of service provision.

Hospitality’ has to begin with welcoming clients, as we would a friend/relative in difficulty. MP’s and GP’s insist on face to face contact with those whom they serve in the first instance, but curiously those with mental health difficulties are expected to book a telephone assessment with the least qualified mental health clinician, is this a perpetuation of stigma?  Head over to the forum and have your say.

Welcome to the website, invite others

Dr Mike Scott