IAPT’s Class Answer to Improving Access

Use classes. Forget about disorders just call it ‘stress’. Offer something CBT flavoured and capitalise on time and the placebo effect to demonstrate an effect, label the package ‘good practice’. Encourage IAPT providers to write about it in the Cognitive Behaviour Therapist (the online BABCP Journal) special issue to be devoted to IAPT, introduced by the lead clinician in IAPT.

The Stress Control (SC) programme of White et al. (1995) is more of a public health intervention than a psychotherapeutic group. It is run as a night school class, and though there are questions and answers between attendees and presenters, personal problems are not discussed.

IAPT’s Implementation

In an IAPT implementation of the programme, at Step 2, Burns et al. (2015) had a mean group size of seventy-four and a range from twenty-three to 106, with six weekly, two-hour sessions. The programme consisted of week 1, introduction to psychoeducation and the cognitive behavioural model; week 2, management of physiology; week 3, management of mental events; week 4, management of behaviour; week 5, management of panic attacks and sleep; and week 6, self-care. At the end of each session, material for the next session was distributed containing homework exercises. At the final session, relapse prevention materials were distributed.

Outcome

Three quarters of the 1,062 clinical cases [PHQ-9 greater than or equal to 10 and/ or GAD-7 greater than or equal to 8] attended three or more sessions. Of those attending pure stress control alone 37% ‘moved to recovery’, defined as an improvement of 6 points on the PHQ-9 and 4 points on the GAD-7. With mean PHQ-9 scores for the clinical case sample reducing from 15.50 to 11.58.  Burns et al. (2015) claim that ‘SC appears comparatively clinically equivalent to other IAPT interventions’. However Gilbody et al. (2015) looked at how GP patients with a PHQ-9 score of greater than 10 fare with usual treatment, over a four-month period; their mean PHQ-9 score reduced from 16 to 9. It is thus not at all evident that the SC programme is of social significance.

The Case For Classes Is Built on Sand And A Distraction From Providing CBT That Makes a Real World Difference

The methodological quality of the SC studies are poor when assessed by the Foa and Meadows (1997) criteria, in that there are no clearly defined target symptoms, no diagnostic interview was conducted to establish which if any disorder the person was suffering from and the proportion ‘cured’ by the end of the intervention. Further there is no independent evidence that six or fewer sessions constitute an adequate dose of psychotherapeutic intervention.

Burns, P., Kellett, S. and Donohoe, G. (2015) “Stress Control” as a large group psychoeducational intervention at Step 2 of IAPT services: Acceptability of the approach and moderators of effectiveness. Behavioural and Cognitive Psychotherapy, 44, 431– 443. http:// dx.doi.org/ 10.1017/ S1352465815000491

Foa, E.B. and Meadows, E.A. (1997) Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449– 480.

Gilbody, S., Littlewood, E. and Hewit, G. (2015) Computerised cognitive behaviour therapy (CCBT) as treatment for depression in primary care (REEACT) trial: Large scale pragmatic randomised controlled trial, BMJ, 351, h5627. DOI: 10.1136/ bmj.h5627

Scott, Michael J. Towards a Mental Health System that Works: A professional guide to getting psychological help (p. 116). Taylor and Francis. Kindle Edition.

White, J., Keenan, M. and Brooks, N. (1992) Stress control: A controlled comparative investigation of large group therapy for generalised anxiety disorder. Behavioural Psychotherapy, 20, 97– 114.

White, J., Keenan, M. and Brooks, N. (1995) Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural Psychotherapy, 20, 97– 114.

Williams, C., Wilson, P. and Morrison, J. (2013) Guided self-help cognitive behavioural therapy for depression in primary care: A Randomised controlled trial. PLoS ONE, 8( 1), e52735. DOI: 10.1371/ journal.pone. 0052735

Dr Mike Scott

‘Are You Back To Your Usual Self?’

at a workshop I gave in Liverpool last Friday, there was much interest in this metric for evaluating the effectiveness of a psychological service. The workshop was titled ‘Group CBT…Yes…But’ (and was also the innaugral meeting of the BABCP Group CBT Special Interest Group), and I reflected that none of the studies of classes, such as ‘Stress Control’ or the ‘Five Areas Approach’ had independent assessors asking people whether as a result of the intervention they were back to their old self, much less whether they remained as their old self for say at least 8 weeks. Yet they are promoted as the first line of treatment in services such as IAPT. Further were groups (as opposed to classes) are run they are often for targets such as ‘low self-esteem’ or ‘destabilisation groups’ with for which there is no evidence at all of real world outcomes. I think a key feature of the workshop for many people was making a sharp distinction between the evidence base for classes as opposed to groups, for depression and the anxiety disorders. The powerpoint presentation for the workshop can be accessed below:

https://www.dropbox.com/s/ikei2478wvnwu15/Group%20CBT%20SIg%20Feb%2022nd%202019.pptx?dl=0

I also suggested that the case for transdiagnostic approaches is, at the very least, not proven. Nevertheless I fear managers will attempt to play a numbers game with regards to groups blurring the distinction between them and classes. With, as suggested in a role play we did, a therapist trying to sell a ‘stress class’ to a client over the telephone, the latter could have had depression, PTSD, body dysmorphic disorder (or some combination there of) or even an adjustment disorder. The therapist herself with insufficient time to make a formulation becoming a candidate for a stress class in her own right!

Dr Mike Scott

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