Stressed Because You Are Asked To Do What Is Not Possible?

‘I am not IAPT’s employee of the month’, ‘For all to view, I am nowhere near the top of the league table for recovery rates’ – just two of the voices of stressed therapists that I have heard in recent months. Unfortunately challenging the Organisational zeitgeist that generates such demoralisation is likely to be seen as a further sign of ‘inadequacy’.

But the American Psychological Association, Clinical Psychology Division, have refined the criteria for an evidence based treatment in such a way, that it could add ‘grist to the mill’ of those who wish to take issue with what they are being asked to do. The new criteria contain the added requirement that there must be evidence of effectiveness in at least one study, in a nonresearch setting using non-academic therapists and also evidence of effectiveness on functional impairment and not just symptom improvement. [The new requirement is based on the Tolin et al (2015) paper Empirically supported treatment: recommendations for a new model. Clinical Psychology Science and Practice, 22, 317-338]. With this added criteria many of the CBT treatments for health anxiety, psychosis and long term physical health problems and computerised cbt would not clear the raised bar for evidence based treatment. Even an accepted treatment such as exposure and response prevention for OCD has just one routine practice study and this was without a control condition, Tolin still strongly recommended the treatment but suggested that there did need to be further evidence.

Pencil in ‘and CBT’ next to ‘antibiotics’ in the poster below and display in Staff and ? Waiting Rooms for the coming Winter

 

Often times a client has considerable comorbidity, I have just seen a person with ptsd, depression, binge eating disorder, panic disorder with mild agoraphobic avoidance and ?body dysmorphic disorder following an rta 4 years ago. No randomised controlled trial has ever been conducted on a population with such extensive comorbidity. There has to be proper acknowledgement of the challenges such a client presents for a therapist, it is insufficient to label a client simply as ‘complex’ because this can easily be seen by the powers that be as a ‘cop out’, the only true defence is a comprehensive reliable assessment.

The bottom line may be to challenge, where you can, whether there is evidence of effectiveness for this specific type of client in the routine context in which you are working – a reality check.

 

Dr Mike Scott

The Need To Tailor Group CBT To Make A Socially Significant Difference

Given the scarcity of therapeutic resources Group CBT is an attractive option.  But to make a real world, socially significant difference in a client’s life a group intervention has to be tailored to each individual. The resources section of this forum contain free content materials for depression and the anxiety groups. Client’s want a real world change, to be free of whatever disorder/problem led them into treatment, not a change on a psychometric test.

Over the past year I’ve given about half a dozen Workshops titled ‘Delivering Group CBT’ to IAPT ( really enjoyed the last one on September 6th to North East Essex IAPT, great group!) and non-IAPT audiences, two points struck me a) most of the audience have been involved in groupwork, for a wide range of problems from low self-esteem to OCD, though most have been for anxiety and depression and b)  the groups that have been run have been more like classes than groups, in that there has been no tailoring of homework assignments in the way one would in individual therapy.  Without such tailoring it is unlikely that there will be any transfer of learning from the ‘group’ setting to the  client’s social context. Clients may express satisfaction with attending a ‘class’ with comments like ‘interesting’ and ‘useful’ but there is no independent evidence that they make a lasting real world difference. I have found it interesting how many therapists are harking for real world observable change in client’s lives and are unhappy with the psychometric test yardstick.

The need to tailor homework places a limit on the number of people that can be treated in a group, as opposed to the number of people that can be ‘taught in a ‘group’. I will return to the issue of tailoring in groups in a later post.

Dr Mike Scott

Fatal Consequences of Missed Disorder

On Tuesday last BBC News at Ten reported a Serious case review of the murder of 2 year old Ayeeshia-Jayne Smith at the hands of her mother, which concluded that social workers failure to identify significant psychological disorder played a pivotal role in the child’s death. Would CBT practitioners have been any better at identifying such disorder? It is not an academic question, the mother or her then partner could have come a CBT practitioners way as a referral from Social Services because of ‘issues with anger’.

The social workers had focussed largely on the supposedly supportive relationship between the mother and child, but there were concerns, a Risk Assessment meeting was held the day before the murder! But had they screened the parents for say borderline personality disorder and if positive done a more detailed examination, using reliable diagnostic criteria, their approach would have arguably been more balanced, resulting in earlier action. The diffiiculty is that for social workers and CBT practitioners staying in their comfort/ ideological zone of relationships is easier.

Existing risk assessment procedures, represent an expert consensus and to my knowledge there is no empirical evidence that they predict outcome. Agencies promote them but it is more a matter of them covering their back.

The 7 Minute Interview contains the following Screen for BPD and its’ psychometric prpoerties were discussed in an earlier post.

11. Yes No Don’t know
Do you have a lot of sudden changes of mood, usually lasting for no more than a few hours?
Do you often have temper outbursts or get so angry you lose control?
Is this something with which you would like help?

Do You Suffer From Formulation Nausea?

Formulation Nausea (FN) is induced by a bewildering array of arrows, resulting in disorientation. It is maintained by exaggerating the idiosyncracy of a client’s difficulties. Training courses may serve as vulnerability factors with Organisational factors e.g supervision acting as an immediate preciptant. Sufferers from FN are often stressed in silence, to reveal it to course leaders, supervisors may be taken as a sign of ‘weakness’.

The antidote is ‘case formulation’ as opposed to ‘formulation’. A case formulation is a specific example of the cognitive model of the disorder. Without  reliably defining what the person is a ‘case/s’ of the 5 P’s above lead nowhere and is likely to generate a 6th P! To overcome FN regular usage of ‘case’ formulation for at least 3 months is necessary for full recovery

 

Brief Assessments Are The Norm And Invariably Wrong

Work on the assumption that the assessments of others are wrong because they have probably operated on some idiosyncratic  rule of thumb to save time. My cynicism about the assessments of colleagues was heightened recently, two years ago I saw a lady who had a phobia about driving and travelling as a passenger in a car and needed CBT. I’ve just discovered that her GP has decided she has PTSD and she is consequently, about to undergo 12 sessions of CBT.

In a previous post I talked about the importance of ‘Watching and Waiting’ but if this is done without the appropriate measuring instrument, a standardised reliable diagnostic interview all is in vain. My suspicion is that the GP, like many clinicians has in mind a ‘cardinal symptom’ of PTSD such as flashbacks and/or nightmares and uses this rule of thumb (heuristic) to determine treatment. The advantage of heuristics is that they are quick, the disadvantage is that they are usually wrong

see Daniel Kahneman’s book, resulting in a waste of resources and the client likely defaulting from CBT

Dr Mike Scott.

 

Failure to ‘Watch and Wait’ Results In Unnecessary Treatment

I doubt that ‘watchful waiting’ has been applied as a policy post the Grenfell Fire, as it is not usually operative in the aftermath of more everyday trauma.  Distressing emotions in the aftermath are oftentimes ‘pathologised’ instead of being seen as part of normal healing process.

A client of mine was involved in a bad car accident, saw her GP who identified whiplash and was concerned that she was troubled by memories of the incident and referred her to IAPT. At IAPT she was offered a choice between a 10 week waiting list for face to face treatment or immediate treatment via telephone counselling. She wanted face to face counselling  and so instead took up her employer’s offer to provide counselling. The two sessions did not help and did not involve cbt.  All this took place within weeks of the accident.

There is a pressing need for GP’s, IAPT and counsellors to be seen to do something, but in all this haste, in the aftermath of a destabilising incident there had been no reliable definition of the problem. Further there was no recognition that typically those destabilised generally find that their own resources are, given time, sufficient to help them regain their balance.
In the event when I saw her 4 months post incident she simply needed CBT for a phobia about driving and travelling as a passenger.
Operating a Watch and Wait over the first 3 months would have resulted not only in a far better use of resources but also the development of a necessary therapeutic alliance. It also advances ‘Saving Normal’ the title of an excellent book by Allen Francis.

Watchful waiting is nothing to do with administering a PHQ-9 every month for 3 months and then concluding ‘something’ must be done if a high score is maintained or the score worsens. Rather it involves the careful tracking of a reliably identified disorder/difficulty.

IAPT and Health Service Are Failing Suicidal Clients

Please tell me why a telephone assessment is deemed appropriate for a suicidal client? How many people have commited suicide because of IAPT’s ‘Opt In’ policy? Why is it beyond the remit of NHS Psychiatric Hospitals to offer a ‘One Stop Shop’, including CBT, for suicidal patients?

These pressing issues occurred to me recently when I came across a person who had in recent weeks stepped in front of a car to kill himself and narrowly escaped death on a railway line, because of the care of a passer-by. After attending the Emergency Department of the local NHS Hospital, within days he was assessed by a Mental Health Practitioner and he referred him to IAPT.
The latter wrote to him asking that he ring them to book a telephone assessment, which he did not do and so IAPT discharged him. Inspection of his Hospital records should have alerted the Hospital of this likely sequence of events as he had dropped out of the first session of counselling treatment at a psychiatric Unit a few years ago.

Dr Mike Scott

Dire Consequences Of Unchallenged Diagnostic Labels

‘Angela’ lost access to her 3 children, because a psychiatrist said she had an ‘Emotionally Unstable Personality Disorder’. When challenged he claimed 4 other clinicians had said the same! It is a classic example of the dire consequences of ‘sticky labels’, the passing on of a diagnosis without rigorous critical appraisal.

In submission to the Court I challenged the psychiatrist’s diagnosis thus ‘he seems unaware of the operation of ‘Diagnosis momentum: once diagnostic labels are attached to patients they tend to become stickier and stickier. Through intermediaries (patients, paramedics, nurses, physicians), what might have started as a possibility gathers increasing momentum until it becomes definite, and all other possibilities are excluded’ [ Crosskerry, P (2003) The importance of cognitive errors in diagnosis and strategies to minimize them. Academic Medicine, 78, 775-780]. Further the category of Emotionally Unstable Personality Disorder, Borderline Type is never used for research purposes, because to my knowledge there are no studies of its’ reliability [i.e the level of agreement (kappa) amongst a group of clinicians independently viewing the assessment of the same person] instead use is made of the comparable Borderline Personality Disorder in DSM-5 which has very explicit diagnostic criteria and requires assessment of each symptom in a criteria set, in my book Towards a Mental Health System That Works (2017) London Routledge I reviewed evidence that the kappa for DSM defined Borderline Personality Disorder is 0.54 making it a reliable set of symptoms, further when I assessed ‘Angela’ using the DSM criteria for Borderline Personality Disorder she did not meet the criteria’.
In the event the Expert Witness appointed by the Court agreed with me that the psychiatrist had got it wrong, and neither he or his like-minded clinicians had utilised agreed criteria. But all this did not happen until Social Services looked at ‘Angela’s’ behaviour entirely through the lens of Emotionally Unstable Personality Disorder depriving her of a family life.

Dr Mike Scott

Gross Abuse of Power – Misdirection of Therapy A Bigger Scandal Than The Misselling of PPI’s

I mentioned in an earlier post that a former client of mine, ‘Angela’, lost contact with her children because a psychiatrist diagnosed her as having an ’emotionally unstable personality disorder’.

The case has now been partially heard in Court and an Expert Witness agreed with me that the diagnosis was unfounded, as there had been no adherence to the agreed diagnostic criteria for the disorder. In the interim, despite my protestations, Social Services  were insistent she attend Group Mentalisation Therapy, a treatment targetted at people with a personality disorder. Social Services refused to respond to my two reports. To date ‘Angela’ has increased access and the legal case against the local authority is ongoing, I and ‘Angela’ are therefore limited in what we can say at this stage. But cavalier diagnosis and misdirected therapy are a national scandal. ‘Angela’ is happy to write on this Forum at the conclusion of the case. The horrors she has endured are unspeakable and a consequence of a systemic abuse of power in Health and Social Services.

Dr Mike Scott

Discussion With National Audit Office Re: IAPT

On Monday I received a thoughtful, considered and detailed response from the National Audit Office with regards to my submission re: the IAPT investigation. I’ve just penned the following response:

  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.
  1. I am unsure whether the National Audit Office are aware of the paper by Griffith’s and Steen (2013) [Improving Access to Psychological Therapies (IAPT) Programme: Scrutinising IAPT Cost Estimates To Support Effective Commissioning, The Journal of Psychological Therapies in Primary Care, 2, 142-156]. that suggest that the cost of IAPT therapy sessions is 3 times more than the Department of Health Impact Assessment estimates and this may lead to very different conclusions about the cost-effectiveness of IAPT. For ease of reference I attach a copy of this paper.
  2. How has the IAPT data set demonstrated that it offers added value over a) services as they existed before IAPT b) non-IAPT services in Wales, Scotland and Northern Ireland? In the absence of such a demonstration it can be questioned whether IAPT overs value for money.
  1. It may be that one part of IAPT say high intensity therapy, is value for money but say low intensity (the most common modality) is not but no such analysis has been proferred. Why?

 

Dr Mike Scott