Missing The Boat With A Focus on Pressing Concerns

As a matter of respect clinicians necessarily focus on a client’s pressing concerns, but the time constraints imposed by routine services, such as IAPT, means that this becomes the sole focus. The upshot is that initially the client’s focus is say on their depression but at the next appointment on disturbing flashbacks/nightmares of child abuse and at the next appointment they may mention occasional excessive use of alcohol causing arguments at home. The clinician doesn’t know where they are working is this depression? PTSD? relationship problems/ alcohol dependence? or some combination thereof. This means the clinician is unable to help the client navigate through the fog of their difficulties, changing tack with every gust of wind.

Alternatively the clinician might simply pursue the first disorder ‘identified’ because the client doesn’t mention any other, discharging the client at the first signs of an improvement on some psychometric test or when progress has been made on that disorder. Despite the client actually suffering from a number of other disorders, making any gains in the ‘successful’ domain likely short lived. The client’s then go thru a revolving door. It seems that clients are rarely asked ‘are you back to your usual self following this treatment? and importantly ‘how long have you been back to your usual self for? [ anything less than 8 weeks is likely nothing more than the waxing and waning of the natural course of a client’s symptoms].

One of the ways of getting the bigger picture is to first use an open ended interview that contains the screen below, the dropbox link for this

APPENDIX A. SCIP screening questions
Codes: 0=absent, 1=present, 8=unsure, 9=missing data, unless otherwise
specified in the question
Questions apply to the present episode, typically the past month, unless otherwise
specified by the interviewer.
HAVE YOU:

  1. Felt very anxious and afraid out of proportion to the situation (with or
    without physical symptoms) for more than one month?
  2. Had panic attacks, when you suddenly felt anxious and frightened and
    developed physical symptoms, such as fast heart beat, shaking, or
    sweating?
  3. Been afraid of going out of the house alone, traveling alone, being alone,
    being in crowds?
  4. Been afraid and anxious doing things in front of people, such as eating in
    public, speaking in public?
  5. Had unpleasant and unwanted thoughts or images coming into your mind
    over and over even if you try to get rid of them? Examples: Contamination
    or aggressive, sexual, or religious thoughts.
  6. Had the urge to do things over and over and could not resist doing them
    (such as washing your hands even if they are clean, checking doors,
    counting up to certain numbers, reciting phrases)?
  7. Witnessed or experienced a traumatic event that involved actual or
    threatened death or serious injury to you or someone else (e.g., physical or
    sexual abuse, terrorist attack, natural disaster, war)? Did you feel intense
    fear and helplessness?
  8. Re-experience the traumatic event in the last month in a distressing way
    (flashback, nightmare)?
  9. Had physical symptoms or physical illness for which doctors did all
    necessary work up and could not find medical explanation?
  10. Had pain and your doctor did all necessary work up and could not really
    explain?
  11. Worried about gaining weight to the point that you self-induced vomiting,
    or used diet pills, laxatives, or heavy exercise?
  12. Eaten a large amount of food within an hour or so, that is binge eating?
  13. Felt or described your mood as sad, downcast, gloomy, low in spirits, or
    depressed?
  14. Been unable to enjoy things like walking, working at your hobbies, or
    socializing with friends as usual?
  15. Had thoughts about harming yourself or even made an attempt at suicide
    (Include whether thought was due to depression or not)?
  16. Felt very happy, elated without reason, or very irritable without reason?
  17. Had mood swings: periods of depression and elation or irritability?
  18. Felt that people are spying on you, follow you around, talk about you?
    Felt that there is a plot or conspiracy against you?
  19. Felt that people are trying to harm you or poison your food?
  20. Had experiences of hearing voices or noises that other people cannot hear?
  21. Had experiences of seeing things (images, flashes, shadows, objects,
    people, whole scene) that other people cannot see?
  22. Been violent in the past (with or without the influence of alcohol or drugs)?
  23. I would like to ask you questions on alcohol use over the past year:
    A. On days when you drank, did you drink >5 alcohol drinks per day
    (sometimes)?
    B. Did you have any problems resulting from drinking alcohol?
  24. I would like to ask you questions on illicit drug use (e.g. marijuana) over
    the past year:
    A. Did you use the illicit drug >10 times per month?
    B. Did you have any problems resulting from using the illicit drug?

is also below:

https://www.dropbox.com/s/j5rfmy6hthp6142/Reliability%20of%20Diagnoses%20SCIP.pdf?dl=0

then when you have an idea of possible diagnoses you can make systematic enquiry about all the symptoms of that disorder using the diagnostic questions in Simply Effective CBT Scott (2009).

In my view the poor results for therapy in routine practice is often because the therapist doesn’t know what they are dealing with rather than therapeutic competence per se.

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Dr Mike Scott

Shifting The Focus To The Client Being Well

Conferences, government agencies such as IAPT and recent research papers, gloss over the proportion of clients who are well at the end of CBT (remission), preferring instead to talk of the number of people who have responded (response) to an intervention (proportion of people whose score reduced by greater than x%). Springer et al (2018) call for a shift in focus to the real world outcome of remission ‘remission should be the ultimate goal of treatment’. Chasteningly they point out  that the remission rate for CBT across the anxiety  disorders is just 50%.

Interestingly the results of Springer et al’s meta-analysis showed that the remission results were poorer when there was no blind evaluator. This may be important in evaluating IAPT’s performance because they have had no independent evaluator! Further the results in the Springer analysis were poorer still when there was comorbid conditions such as depression and/or subtance use disorder, suggesting that all a client’s disorders need tackling not just the primary anxiety disorder. GAD and PTSD did better than OCD and SAD with panic disorder in between.

Clients want to be well again not just reduce their score on a psychometric test that some clinician deems acceptable for their own reasons. Losing their diagnostic status should be a necessary condition  for assessing outcome, albeit that arguably it also ought to be complimented with reduction below a certain cut-off on a psychometric test.

 

Springer, K.S., Levy, H.C and Tolin, D.F (2018) Remission in CBT for adult anxiety disorders. A meta-analysis. Clinical Psychology Review, published online ahead of print

Please cite this article as: Springer, K.S., Clinical Psychology Review (2018), https://doi.org/10.1016/j.cpr.2018.03.002

Dr Mike Scott

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