IAPT Behind Closed Doors – The Need for Listening and Flexibility

At Bury I had occasion to treat an older gentleman who lived alone and had no family locally.  He also had received step 3 CBT work on at least 2 occasions previously and he had been re  – referred to me at step 2.  This gentleman had a stammer and a thick Scottish accent and did not speak often, as he was anxious and low in mood since he was embarrassed that people did not understand him.  My brief was to “get him out and mixing with other people”.  I discovered that he did not go out very often and had been interested in computers in the past, going on a Government scheme to learn more, until the funding was stopped.  He showed me his phone, which was his “lifeline” and stated that he had got it a few years ago, but that it was quite expensive to run.  He told me about his female companion, who was unfortunately ill and who used to accompany him to the Library when she had been well, as he did not cope well in public.  I began thinking about his phone and his love of computers

 

Over the first 3 sessions, I understood that he was not a particularly social person, could not afford a computer of his own, but was able to consider that he may get a better phone and a better deal than the one he had.  I did not see this gentleman for 2 weeks, as he sent word that he had a cold, but by the 4th session, he had been on his own to a local branch of Carphone Warehouse and had negotiated a deal on a new phone which had a full screen internet access and which was affordable.  He recovered to the extent that not only was he able to go out alone to places now, he was going to coffee shops and public places accessing the free internet there to talk to his many friends over the internet and was no longer a person who avoided people, because he could now make himself understood.  I remember his words to me at session 5 when I discharged him, telling me, “the world is mine!” and about how his female friend was also recovering with his help.  He explained that she had always had to help him to go shopping and to explain things for him, but that now he had more confidence, he was doing things for her for a change.  The key for him was being understood and improving his life through his talents and his love of computers and gadgetry.  Everything else followed on from this.

One of my better experiences at Bury was with a lady who was referred onto my caseload because she had long – standing issues with physical injury sustained at work and who was in the process of claiming compensation from her employer for her injury.  She was newly married and had become extremely anxious and suffered with co-morbid depression.  She had been seen and treated with CBT at step 3 twice before and was also referred to Mindfulness Relaxation.  She was referred to me at step 2 because she had “failed to be able to use mindfulness to relax and was still anxious and suffering from depression”.  I had 6 sessions with this lady and she missed one because of needing to go to court to represent herself for her case, but this was tagged on the end for review.  I adapted an approach for this lady’s needs which did not include mindfulness and helped her to see her new situation not so much in terms of what she could no longer do, but with an emphasis on new opportunities.

This demonstrated that current IAPT approaches are markedly inflexible and there is little or no notion of adaptation to suit individual needs and also, too much emphasis on “getting the list down”.

 

Anonymity protected Dr Mike Scott

The Need To Tailor Group CBT To Make A Socially Significant Difference

Given the scarcity of therapeutic resources Group CBT is an attractive option.  But to make a real world, socially significant difference in a client’s life a group intervention has to be tailored to each individual. The resources section of this forum contain free content materials for depression and the anxiety groups. Client’s want a real world change, to be free of whatever disorder/problem led them into treatment, not a change on a psychometric test.

Over the past year I’ve given about half a dozen Workshops titled ‘Delivering Group CBT’ to IAPT ( really enjoyed the last one on September 6th to North East Essex IAPT, great group!) and non-IAPT audiences, two points struck me a) most of the audience have been involved in groupwork, for a wide range of problems from low self-esteem to OCD, though most have been for anxiety and depression and b)  the groups that have been run have been more like classes than groups, in that there has been no tailoring of homework assignments in the way one would in individual therapy.  Without such tailoring it is unlikely that there will be any transfer of learning from the ‘group’ setting to the  client’s social context. Clients may express satisfaction with attending a ‘class’ with comments like ‘interesting’ and ‘useful’ but there is no independent evidence that they make a lasting real world difference. I have found it interesting how many therapists are harking for real world observable change in client’s lives and are unhappy with the psychometric test yardstick.

The need to tailor homework places a limit on the number of people that can be treated in a group, as opposed to the number of people that can be ‘taught in a ‘group’. I will return to the issue of tailoring in groups in a later post.

Dr Mike Scott