When Does Psychological Therapy Count As A Success?

always, if you lower the methodological bar low enough. The just published study by Chalder et al (2021), is an exemplar,  focussing on cognitive behaviour therapy for people with persistent physical complaints (PPS) https://doi.org/10.1017/S0033291721001793:

  • that there was no significant difference in outcome on the primary outcome measure, the self-report Work and Social Adjustment Scale
  • the authors of their report were evaluating their own protocol for PPS [hitherto known as Medically Unexplained Symptoms (MUS)]
  • there was no independent clinical assessment of outcome
  • the control group received ‘standard medical care’, there was no control for attention (the treatment group received 8,  1 hour sessions) 
  • there was no evaluation of effectiveness in a non research setting

Tolin et al ( 2015) https://doi.org/10.1111/cpsp.12122 have presented a clearly defined methodological bar as to what constitutes an Empirically Supported Treatment (EST), that has been adopted by  the American Psychological Association. Far from clearing this bar Chalder et al (2021) protocol  failed on each of the 5 criteria above. In addition Chalder et al (2021) fail to mention that total reliance on self-report measures, this makes the study especially prey to demand characteristics, in that those given attention are likely to want to please the therapists and not to feel they have wasted their own time by indicating a better response than otherwise.

Chalder et al (2021) fail to reference any work that challenges the very concept of MUS e.g Geraghty and Scott (2020) https://doi.org/10.1186/s40359-020-0380-2. The theoretical basis for Chalder et al’s CBT (2021) is that ‘Patients with PPS can develop unhelpful cognitions and behaviour which can consequently lead to a reduction in daily functioning, reduced quality of life, and an increased susceptibility towards developing depression and anxiety’. These authors inform the reader that all those in the study met criteria for fibromyalgia, but by Chalder et al’s (2021) rationale all with a persistent physical symptom require psychological therapy, this would just about swallow up all mental health resources in primary and secondary care. 

 In their statement of Conflict of Interest the authors Chalder et al (2021) indicate their background in the training of IAPT staff, unfortunately it is likely that the treatment protocol will find its way into the organisations ministrations, before any independent evaluation, despite the authors call for further research .  

 

References

Chalder T et al (2021). Efficacy of therapist-delivered transdiagnostic CBT for patients with persistent physical symptoms in secondary care: a randomised controlled trial. Psychological Medicine 1–11. https://doi.org/10.1017/S0033291721001793

Geraghty, K., & Scott, M. J. (2020). Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2

Tolin, D. F., Mckay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015). Empirically supported treatment: Recommendations for a new model. Clinical Psychology: Science and Practice, 22(4), 317–338. https://doi.org/10.1111/cpsp.12122

Is Evidence Based Treatment Possible Without Evidence Based Assessment?

‘no’, this is the take home message from a just published study by Moses et al in the Journal of Anxiety Disorders https://www.sciencedirect.com/science/article/pii/S0887618520300931. An evidence based assessment includes a diagnostic interview, as well as a clinical interview and psychometric tests. Moses et al (2020) summarise the literature that the inclusion of a diagnostic interview improves outcome, by minimising missed diagnosis and misdiagnosis. These authors bemoan their finding that only a small minority of Australian psychologists use a diagnostic interview, but the position is even worse in the UK, as the largest provider of services the Improving Access to Psychological Therapies (IAPT) explicitly excludes the making of diagnosis/diagnostic interviews.   IAPT cannot improve access to evidence based psychological therapies because it does not operate the admission gate of an evidence based assessment.

The absence of an EBA leads to a revolving door, demoralising clients in search of a credible explanation of their difficulties. An EBA is a necessary part of evidence based practice (EBP) in that it highlights candidate evidence supported treatments (ESTs). But clinical judgement is still required to ascertain whether there is a sufficient match between client and the subjects in the EST. Most ESTs have admitted clients to the study with a limited range of comorbid disorders and have not been cognitively impaired, or suffering debilitating pain. Further the clients in the EST have been in a safe environment. 

 

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