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Flexibility Within Fidelity

was the title of a great CBT workshop that I attended yesterday, delivered by Prof Philip Kendal. He described how time saving rules of thumb, can short circuit the therapeutic process (described in his book with the same title, published in 2022 by Oxford University Press). One of the attendees, a low intensity practitioner, volunteered one such heuristic, automatically disqualifying a client from the Service (presumably NHS Talking Therapies) if they had had a bereavement. Prof Kendall replied:

‘when the system is screwed up change  the system’  

A totally reasonable response from an objective observer outside the system. In the Webinar didn’t hear further from the therapist, and Prof Kendall did, understandably, not quite appreciate that bringing about such a change is a monumental task for anyone in IAPT’s successor. He did opine that one way of changing a system is to set up a comparison of the current system with the proposed system. But there has been no independent assessment of NHS Talking Therapies. He opined that the most credible randomised controlled trials were those in which there had been a blind, independent assessor. The Service’s  clientele have never been involved in such a trial, much less in a comparison of the Service’s routine practice with the mode of delivery suggested in my 2009, tome Simply Effective CBT, published by Routledge.

Prof Kendal said that in the US a lot of CBT therapists don’t give homework and in this  context clients do no better than in an attention control condition. This side of the pond, in my review of numerous records, for the Court I have never seen the written specification of a homework much less its’ monitoring. It is a myth that CBT is routinely provided, literally it would not stand-up in Court. Nevertheless the UK Government continues to fund adult and child and adolescent mental health to the tune of £2 billion a year. Where else could this happen without independent evaluation?

Prof Kendal insisted that his workshop was not about flexibility with infidelity but that is what routine psychological treatment in the UK amounts to. There is nothing in the UK NHS Talking Therapies approach that prevents therapists using unbridled clinical judgements. Its’ therapists perform what Prof Kendall terms a ‘diagnostician’ role, in that they assign ICD 10 codes to the client’s problems (without making an ICD 10 or DSM-5) diagnosis, but this has not stopped treatment wandering from a recognisable diagnostic pathway.  I felt he ducked the importance of reliable diagnosis. 

Prof Kendall rightly insisted on the importance of personalising treatment and having a therapeutic relationship. both of which Drew et al (2022) found notably absent in NHS Talking Therapies low intensity interventions. In Personalising Trauma Treatment: Reframing and Reimagining Routledge (2022) I give lots of examples as to how this can be done in the trauma field. I agree with him that both personalising treatment and a therapeutic relationship are necessary but not sufficient conditions for effective treatment. The other necessary active ingredient for treatment is that it must address the mechanism that is pivotal in the maintenance of the condition. With regard to trauma I have suggested it is the centrality accorded to the trauma and not arrested information processing.

Thank you Prof Kendall for such a human and illuminating workshop.

 

Dr Mike Scott

 

 

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Simply Too Complex CBT!

abandon ‘what treatment works for what’ and you end up with a free for all of imagined complexity.

What Works for Whom?: A Critical Review of Psychotherapy Research

With stressed clinicians lost in a fog, arguing interminably about possible landmarks (formulations) for treatment. Not surprisingly the issue of ‘complexity’ now figures highly on IAPT’s list of workshops. Paradoxically formal IAPT training eskews trainees working with ‘complex cases’. IAPT specifies the importance of following the NICE guidelines but without a reliable procedure for determining what cases they do and importantly do not apply to.

The IAPT Courtroom

An obvious defence for IAPT workers failing to consistently obtain the 50% recovery rate is to contend that they were dealing with complex cases.

In rebuttal the Organisation can contend that complex cases are: ‘namely primary or comorbid psychosis, personality disorder, autism spectrum disorder, substance dependence, severe and/or treatment-relevant physical health conditions, and severe psychosocial difficulties Liness et al (2019) see link’ https://link.springer.com/article/10.1007/s10608-018-9987-5 and that the clinicians case falls outside this definition. But in areas of high deprivation it is relatively easy to claim that a particular client falls within this definition of complexity e.g ongoing pain from an injury or associated with a condition such as MS, having to use a Foodbank.

Flexibility Within Fidelity As A Defence

Flexibility has to be constrained by fidelity, if it is not then arguments between clinicians and line managers/supervisors have no arbiter. The clinician will lose out simply because the line manager/ supervisor has more power, at its’ worst ‘my way or no way’.


If fidelity is safeguarded, then there are agreed issues/concerns that need to be addressed with a particular client. It also sets limits on the range of interventions (flexibility) that are permissible for those particular issues/ concerns. Without a twin focii on fidelity and flexibility the clinician is up a creek without a paddle. But a hostile work environment can nevertheless ignore or more commonly pay lip service to fidelity and flexibility – they need to be admitted to the IAPT courtroom for the sake of both clinicians and clients.

Clinicians and Constructive Dismissal

Nevertheless there is a vagueness about the debate of simplicity vs complexity, that could mean that an IAPT therapist is hounded from office, without the case being put to anything like a jury, with no procedures in place to ensure any transparency and accountability.

The Need To Rediscover A Biopsychosocial Model

But actually matters are nowhere as simple as this simple/complex distinction. Steve Stadling (1990) and I https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/group-cognitive-therapy-for-depression-produces-clinically-significant-reliable-change-in-communitybased-settings/ADFC2B6A2D2BBCCC37CD41820DFD5287

were involved in a randomised controlled trial of individual and group CBT for depression in Toxteth, Liverpool, and managed to make important lasting differences using Beck’s protocol for depression. But because we were using a biopsychosocial model I saw it as much a part of my work to say write a letter to a Housing Association for a client as conduct the CBT. Similarly many patients were prescribed antidepressants, again in keeping with a biopsychosocial model. This holistic approach to client’s problems appears to have been lost in IAPT’s fundamentalist translation of the randomised controlled trials. An alternative perspective is presented my trilogy of Simply Effective CBT books


Dr Mike Scott