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Talking Therapies – ‘What Works For Whom?’

this is the title of a book by Roth and Fonagy (2005) published by Guilford Press. The authors answer this question with a focus on disorders. Their conclusions inform the NICE Guidelines.


By contrast the contributors to ‘Drop the Disorder!’ edited by Jo Watson (2019) recommend jettisoning disorder in favour of formulation. However there has been no determination of ‘what works for whom?’  where the focus is formulation. Indeed it is impossible to do this as formulations are inherently unique/idiosyncratic theories about an individual. It is an attempt to personalise treatment without first acknowledging that the person is likely a member of some category or categories. Ironically it is personalised medicine without first getting into the right ball-park.  For the past decade the IAPT (Improving Access to Psychological Treatments) service has been an undercover exemplar of this, paying lip service to the NICE Guidelines. If IAPT had truly done ‘what it says on the tin’, it would have ‘improved’ upon on Roth and Fonagy’s work. But it has signally failed to make any contribution to the question they raised. . 

Dalgleish et al (2020) in their just published paper a Transdiagnostic. Approach to Mental Health Problems advocate a ‘hard transdiagnostic’ approach, similarly wishing to totally jettison the diagnostic nomenclature of DSM-5. But this hard trans diagnostic approach is so bewildering in its’ complexity, it would serve only to totally muddle practitioners. There is no evidence that trans diagnostic approaches add value. To date studies have only been conducted by the developers of the trans diagnostic approaches, leading to likely allegiance bias.  There are no effectiveness studies in real world settings with independent evaluators.

Dr Mike Scott

‘Drop the Disorder!’ – IAPT Have Already Done This and It Hasn’t Worked

‘Drop the Disorder!’ is a just published book edited by Jo Watson published by PCCS, but the contributors totally avoid any mention of the Improving Access to Psychological Treatments (IAPT) service. The latter assert that they do not make a diagnosis.  My independent assessment of IAPT has shown that only the tip of the iceberg recover

What is interesting in this book is that none of the contributors have come up with a framework that has allowed them to evaluate the IAPT service. Their frameworks are so nebulous, choose between Power, Threat, Meaning  or an exaggerated importance being given to formulation, that there is no risk of application to any service any time soon. Clients are the casualties of this approach.

I was just trying to imagine an Expert Witness arguing for the reliability of the application of one of these frameworks to that of a person he had to assess, the Expert Witness for the other side would have a field day, with legal reps putting their head in their hands. 

When the notion of ‘disorder’ is dropped, so too is loss of diagnostic status as an outcome measure. Without a person no longer being an instance of a disorder how can one approach determining whether the person is back to their old selves/best functioning?

This is not to say that every diagnostic label is meaningful, there is an excellent chapter in the book on schizophrenia by John Read and he cogently argues that this is not a reliable diagnostic entity. He suggests that we are better served by terms such as hallucinations and delusions. Similarly there are doubts as to whether chronic fatigue syndrome/ME are meaningful diagnostic entities. But across depression and the anxiety disorders (including PTSD) the diagnostic criteria have served us well leading to different protocols for different disorders.

Unfortunately in routine practise diagnostic criteria are not applied with rigour using standardised diagnostic interviews, which also allow for the identification of comorbid disorders (that will usually also need to be treated.)  

The authors suggest that in their communications clinicians should always put diagnostic entities like OCD in quotation marks. I can see this becoming the new political correctness. I will comment on any such missive that the quotation marks simply indicate unreliable assessment.

Dr Mike Scott

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