How do you distinguish an adaptive reaction to Covid from a maladaptive one? Without answering this fundamental question NHS England has offered guidance….https://www.yourcovidrecovery.nhs.uk/managing-the-effects/effects-on-your-mind/managing-fear-and-anxiety/. on how psychological debility associated with having Covid might be managed. They offer a range of cognitive behavioural strategies commonly employed in the management of anxiety and depression. In addition they invite the public to complete a quiz, https://www.nhs.uk/conditions/stress-anxiety-depression/mood-self-assessment/ that actually comprises the questions in the PHQ-9 (that measures the severity of depression) and the GAD-7 (that measures the severity of generalised anxiety disorder), together with a question on the extent to which they feel impaired by these difficulties.
If the person scores highly on the quiz they are advised to see their GP and/or refer themselves to IAPT, as a diagnosis can only be made by professionals. But the IAPT Manual states IAPT therapists don’t make diagnosis, further they have no expertise with regards to a physical disorder.What then would an IAPT therapist be treating?
How meaningfully can a GP determine whether the fatigue associated with Covid should count towards a diagnosis of depression? Should the low mood associated with being ill count as a depressive symptom? Many Covid patients have breathing difficulties that can disturb sleep, should this insomnia count as a depression symptom? Loss of appetite is a common symptom of being ill, should it count as a symptom of depression? Should the worries of a Covid patient about the trajectory of their illness and occupational/financial impairment count as a symptom of anxiety? With the exception of helping patients with Covid who are suicidal, psychologising Covid patients symptoms looks like an exercise in empire building.
Whilst NHS England’s offering of the CBT strategies to members of the public might not be unreasonable, there is no evidence that these strategies taken out of the context in which they were developed make a real-world difference to those with a long term condition. Equally there is no evidence that such strategies delivered by IAPT practitoners makes a real world difference, the service has a recovery rate of 10% Scott (2018) https://doi.org/10.1177/1359105318755264
Are we to assume that those most debilitated by Covid, the likely most stressed, are the most in need of psychological intervention?
What body of knowledge do psychological therapists have that would make a real-world difference to the outcome of Covid in a particular instance?
Dr Mike Scott
9 replies on “Questions NHS England and IAPT Have Ignored Over Covid”
The difficulties around representing fatigue as an inherently psychological symptom that may respond to CBT is compounded by the (until recently influential) CBT model of ME/CFS (which resembles many of the experiences of people with ‘long’ covid). Many clinicians, including some GPs as suggested here, have unfortunately come to frame fatigue not in terms of an unnerlying pathology or the residual effects of one, but rather as the result of maladaptive thinking patterns that lead to dysfunctional behavioural patterns. While this may have siome relevance to dpression, our experiences in our family of Covid 19 (me) and ME (my daughter) suggest that fatigue and exercise intolerance are part of a phsyical condition. By the way Dr Scott if you haven’t already done so (i’m a newcomer to your interesting blog) then do have a look at NICE’s recent rejection of the discredited CBT based PACE trial for ME. Amongst many other problems with the CBT approach is an insistence on referring to this condition not as ME but as ‘chronic fatigue’ – in elevating the fatigue above other symptoms which are harder to frame as ‘psychological’, this also serves to give added legitimacy to interventions that target this.
Hi Mike Thought you might find this interesting. This blogger Politics and Insights @SueJonesSays has written a great deal this is from 2017 I share your articles often with your tag on twitter but it seems you don’t see them I always add your tag and tag others who are interested. Anyway, hope you find this interesting
IAPT is value-laden, non-prefigurative, non-dialogic, antidemocratic and reflects a political agenda https://politicsandinsights.org/2017/03/07/iapt-is-value-laden-non-prefigurative-non-dialogic-and-antidemocratic/
Hi Mike I wasn’t able to find another way to contact you with this article which was retweeted to me in response to one of your articles I posted thought it might be of interest
“Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified
Keith Geraghty & Michael J. Scott
BMC Psychology https://link.springer.com/article/10.1186/s40359-020-0380-2
Thanks Richard, I’m in full agreement. Thanks Liz, I hadn’t seen the material from Politics and Insight, I’m afraid I have never acquired social media skills beyond tweeting a blog!
Have a good Christmas
Hi Mike, maybe I could help you with that? Your work is invaluable and although some subscribe and share it’s barely being seen I’ve shared some of your work today and its gained some traction regarding ‘Long Covid and CBT but not nearly enough even if you visited your twitter feed and commented and rt’d it would make a huge difference to who see’s your work anyway, the offer is there
Some research here.
” It also showed that CBT, just like treatment with a placebo or doxycycline, does not lead to objective improvement of activity or improvement in self-reported disability.”
“What is particularly important now is that muddled thinking is not used to justify ‘rehabilitation’ of people with persistent unexplained symptoms after Covid-19 infection. We have no reason to think that post-viral syndromes are likely to benefit from anything other than time and not trying to do too much. There is no valid analogy with stroke or trauma.”
Daily Mail article
Thanks Michael, really interesting article. There appears to be a new kid on the block ‘Crazy Biopsychosocial Treatment’ it masquerades as CBT, its’ key assumptions are 1. negative thoughts are Public Enemy Number One 2. negative thoughts are responsible for any condition for which a physical explanation cannot be found 3. if strategies that have worked in one context bu do not work in another context it is because of negative thoughts 4. minimal doses of CBT (six or less sessions) are sufficient to ensure most people recover from a diagnosable disorder 5. a screening test can determine the most appropriate course of treatment.
The treatments delivered in randomised controlled trials of cognitive behaviour therapy, with blind assessors can be properly termed CBT. But if a therapist had attempted to provide a ‘Crazy Biopsychosocial Treatment’ for example providing only 6 sessions within these rcts then this would be regarded as infidelity to the treatment protocol. The ‘Crazy Biopsychosocial Treatments’ are actually exemplars of ‘infidelity’, the fruits of which are…..