Last month I gave a days workshop ‘Better Together’ at the Maudsley Hospital for an IAPT Service, I did think it was going into the lion’s den but the hospitality was superb. The link to my presentation is below:
I presented for the first time the DAGger for groups, a questionnaire containing the dysfuntional attitudes that will often have to be circumnavigated to successfully engage someone in a group. I also spelt out how to engage in a debate about the ‘DAG’s using the vectors of validity, utility and authority. But such dialogues are not easily possible with IAPT’s standard triage, there is a need for reform to make groups properly viable. One of the problems with groups is that those most likely to benefit from groups are those least likely to agree to attend!
Groups are not the same as classes and I was struck at the Workshop by the lack of understanding that there is a strong evidence base for the former for depression and most anxiety disorders but the evidence base for the latter is extremely weak by comparison. There was also near universal acceptance that a stepped care model was intrinsically better and that not having an extended face to face conversation with a client initially was in any way problematic. Near the end I did mention my findings of a 10% recovery rate in IAPT see link below:
whilst they may describe to a greater or lesser extent the psycho-social context in which the client is operating, different therapist would disagree about the relative importance of the psychosocial stressors and have a different collection of them. One may emphasise the clients current relationship another a harsh/ ? abusive childhood another poverty.
At a recent workshop I gave a PWP (Psychological Wellbewing Practitioner)defended reliance on the use of problem descriptors on the basis that they could be complemented by the therapists intuition. But this was precisely the therapeutic task centred approach adopted by social work in the 1970’s, it failed to demonstrate effectiveness and by the 1990’s social work had become confined to largely a policing role, replete to this day with meaningless checklists. I speak as a former social worker, consumer of social services for over three decades and as a psychologist.
With my psychologist hat on I am very aware of the the work of Daniel Kahneman on the use of rules of thumb (heuristics) in decision making, for example the use of the availability heuristic – the vividness of a description giving a mistaken impression of its’ likelihood, so that a therapist hearing the horrific details of a trauma assumes it must be PTSD. Loretta whom I saw recently simply had a specific phobia about driving/travelling as a passenger in a car as a result of very serious rta. Nevertheless the PWP directed her to a 6 week stabilisation group that did nothing at all for her difficulties. But the stepping up procedure offered no protection, she attended 3 individual sessions in which she was asked to talk about and write about the trauma, she dropped out because she found the procedure too toxic. Loretta’s difficulties in driving and travelling as a passenger were not addressed at all. I broke the good news that her problems could be simply addressed.
The PWPs were totally unaware that Beck’s first paper was on the unreliability of the standard interview. This led to the inclusion of standardised diagnostic interviews in CBT outcome studies. In my view the PWP training however quick and simple is not fit for purpose.
Dr Mike Scott
Ps Do listen to Radio 4 on Tuesday Sept 24th at 8.0pm for its’ investigation into ‘The Therapy Business’
CBT luminaries are spinning the plates furiously this conference season, a paper in next months Behavior Therapy, 50 (2019) 864–885 by clinicians from the University of Sheffield, has an abstract that advocates Group Behavioral Activation for depression as a front line treatment. The abstract also claims a moderate to large effect on depressive symptoms. Most people are unlikely to read further than the abstract, but closer inspection reveals the conclusions are deeply flawed.
In passing the abstract mentions that the standardized mean difference (SMD) between group BA and waiting list was 0.72. This would cause few people to question the findings, but actually it means the results are of doubtful clinical relevance, as it actually means there is less than one standard deviation in outcome between the treated group and the waiting list. Your eyes may already be glazing over at the thought that some stats are on the way, but bear with me. If a group of depressed patients had a mean Beck Depression Inventory Score of 28 at the start of treatment, [assuming that the spread of the results was 7, the standard deviation – taken from the Scott and Stradling (1990) study Behavioural Psychotherapy, 18, 1-19 ] a mean score of 23 at the end of treatment would produce an SMD of 0.71, i.e about the same as in the University of Sheffield analysis. Thus the average person experiencing this change of score is unlikely to feel that they are back to their normal selves, and are likely to view it as part of the normal cycling of mood, influenced by positive events e.g the company/support of fellow sufferers for a time in a group. In none of the Group BA studies was there an independent assessor determining whether clients were still depressed or the permanence of any change. Unsurprisingly the authors found that the Group BA was no better than any other active treatment (i.e controlling for attention and expectation), and make an implicit plea for the Dodo verdict ‘ all therapies are equal and must have prizes’.
In the body of the paper the authors acknowledge that the Group BA studies are of low quality, save one and that analyses were on treatment completers as opposed to the more rigorous intention to treat. But there is no indication anywhere as to what proportion of people recover from depression with any permanence. Yet this did not stop the spin in the abstract! Unfortunately it will likely be music to the ears of IAPT and one can expect Group BA to be soon advocated, particularly as it is contended that BA is easier for therapists to learn than CBT.
In 1990 Steve Stradling and I had published [Behavioural Psychotherapy, 18, 1-19] a study of depressed clients comparing, group CBT, individual CBT and a waiting list condition. For Group CBT the initial mean BDI was 29.0 and end of treatment score was 6.2 whilst for individual treatment the comparable scores were 28.21 and 11.53. However those on the waiting list also improved from 25.89 initially to 20.26 at the end of waiting list. Thus, it is far from clear that the results from the University of Sheffield analysis on Group BA are actually better than those of putting people on a waiting list.
In the August 2015 issue of the Psychologist I wrote:
“In the July issue of the Psychologist you referred to a meta-analysis of 70 CBT studies for depression conducted by Johnsen and Friborg (2015) and opined ‘CBT doesn’t seem to be helping reduce depression symptoms as much today as it used to when it was first developed in the 1970s’. But this conclusion may be premature, inspection of Table One of Johnsen and Friborg’s study shows that from 1977 up to and including the millennium 85% of studies were randomised controlled trials (RCT’s) but from 2001-2014 the comparable figure was 65%. One of the hallmarks of an RCT is blind assessment, using a standardised diagnostic interview. Thus there can be no certainty that populations treated post the millennium are comparable to those before. Johnsen, T. J., & Friborg, O. (2015, May 11). The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment is Falling: A Meta-Analysis. Psychological Bulletin. Advance online publication. http://dx.doi.org/10.1037/bul0000015″ Reliance on weak evidence has become a post-millenium phenomenon.
But spin is not confined to recent CBT studies, Jellison et al (2019) have examined spin in leading journals of psychiatry and in the journal Psychological Medicine, of 116 randomised controlled trials spin was identified in 56% of them, with 21% in the abstract results section and 49.1% in the abstract conclusions section. See link below:
day workshop September 20th, Liverpool. Details from BABCP website are below:
GROUP CBT SPECIAL INTEREST GROUP
Group CBT – Forward Leap or Backward Somersault?
Led by Dr Mike Scott Friday 20 September 2019 Times: 9.30am to 3.30pm (Registration from 9.00am) Venue: 54 St James Street, Liverpool, L1 0AB
About the workshop: Groups are a way of addressing the commonalities amongst peoples’ difficulties/disorders [Scott (2011)]. They also offer the enticing prospect of a wider dissemination of services. This workshop addresses the question of when is group CBT effective and when is it a pawn in a numbers game? Jo Clifford will present the NICE recommendations on group CBT. Attendees will take part in a simulated stress management group (SMG), to experience the trials and tribulations of being a leader, co-leader and group member. A framework for understanding and managing interactions will be described. The criteria for judging a group as effective will be considered and participants will be asked to deliver a verdict on an SMG group. This then serves as a methodological template for evaluating other group interventions. The therapeutic relationship is a key element of both individual and group CBT but takes a slightly different form in the latter [Whitfield and Scott (2019)]. These differences will be explicated in the workshop. Participants are invited to reflect on their own experiences of groupwork: in this connection Nicola Walker will give a presentation on the side effects of group therapy. Finally, participants will be encouraged to reflect on the scope for implementing group CBT where they are.
Scott, M.J (2011) Simply Effective Group Cognitive Behaviour Therapy London: Routledge Whitfield, G and Scott, M (2019) CBT Delivered in Groups in ‘The Therapeutic Relationship in Cognitive Behavioural Therapy Edited by S Moorey and A Lavender London: Sage publications.
Registration and General Information BABCP Member fee: £50 Non-Member fee: £70 BABCP Member Student: £40 Non-Member Student: £60 Lunch and refreshments will be provided. A CPD certificate for 6 hours will be issued – 50/50 skills and theory Closing date for registrations is Friday 13 September 2019 For any event or booking queries please contact BABCP head office on 0330 320 0851 or email firstname.lastname@example.org For venue enquiries please see website – http://www.thewomensorganisation.org.uk/54stjamesstreet
Timetable 9.00am Registration 9.30am Mike Scott Psychoeducation strengths and limits 9.50am Jo Clifford NICE Recommendations for Group CBT 10.10am Mike Scott Group CBT in practice 10.30am Coffee 10.50am Mike Scott Simulated Group Session of Stress Management. Reflections of participants, leader and co-leader 11.30am Mike Scott Framework for evaluating group skills and organisational context. But do skills relate to outcome? 12.30pm Lunch 1.15pm Nicola Walker Side effects of Group Therapy 1.45pm Nicola Walker Participants’ experiences and views on best practice for group CBT Discussion 2.30pm Coffee 2.50pm Putting it together where I am 3.30pm Close
‘don’t listen to the story treat the symptom’ that is the advise to be given to IAPT’s PWP’s attending a 3 hour workshop on November 28th 2019 on groupwork. It reflects similar advise given to IAPT clients attending a 6 week course on ‘Understanding PTSD’ in which clients are instructed not to talk about their trauma rather to reflect on what they have found helpful so far. This gagging of IAPT clients is consistant with the Organisation’s 30 minute telephone assessment. But it is inconsistant with the need to help client’s overcome cognitive avoidance e.g in PTSD avoiding talking about their trauma.
In Simply Effective Cognitive Behaviour Therapy, Routledge (2009)
I suggested that clients need treatment simultanously for all the disorders from which they are suffering. This is to look at the totality of the clients story, not to elevate one part of it (e.g the disorder that is most impairing) and just treat that. Interestingly Barlow et al 2017 see link below compared focussing just on the main disorder from which a person was suffering (from amongst panic disorder, GAD, social anxiety disorder and GAD, even though most people had more than one disorder) with a protocol that could be adapted for any of these disorders ( termed a Unified Protocol) and retention of clients was better with the latter. This suggests that addressing the whole story is best as well as being more respectful.
Care has to be taken however with Barlow’s transdiagnostic approach, in that the term denotes just those suffering from an anxiety disorder excluding PTSD. Over half of clients had a degree. All treatments were developed by Barlow and his colleagues, there has been no independent replication. Treatment was individual, no evidence that it works in groups. The treating clinicians were highly qualified/trained and did both treatments, as the UP was the new kid in the block and their ‘kid brother’ that may explain the slightly better results with UP.
Barlow et al (2017) https://www.dropbox.com/s/22qz932flxroas3/The%20Unified%20Protocol%20for%20Transdiagnostic%20Treatment%20of%20Emotional%20Disorders%20Compared%20With%20Diagnosis-Specific%20Protocols%20for%20Anxiety%20Disorders.html?dl=0
Bernard felt ‘ten times worse’ after his first session of IAPT, Group CBT. He didn’t return for further sessions. IAPT advised him to seek individual therapy via his GP, which he did but none was ever forthcoming. When I saw him it was three years after his industrial accident that rendered him unable to work, his depression had continued unabated. The GP records simply recorded that he did not attend 3 sessions and so was discharged, the implication was that he was at fault!
What had actually happened is that following an IAPT telephone assessment he was invited to therapy at a local centre. On arrival he and others were given a questionnaire to complete. He and about 15 others were then ushered into a room, but there were not enough chairs so some stood. The group leader began asking each of them in turn what their problem was. Bernard protested ‘ I can’t tell my problems in front of all these’, he said that he could see that the young men in the group were agitated and one ‘girl’ on the verge of tears. ‘it was more like a lecture with flipchart and screen’.
The IAPT treatment bears no relationship at all to the group CBT detailed, in my book ‘Simply Effective Group CBT’ published a decade ago by London: Routledge or to what I am trying to promote as Co-chair of the BABCP Group CBT Special Interest Group. A year ago the IAPT Manual was published but none of it confers any protection for a client suffering the same fate. The worry is that in the interest of a numbers game more people will suffer Bernard’s fate.How long is the cover up going to go on!
Group CBT treatments for PTSD leave 70% of participants still suffering from the condition and it appears less effective than individual PTSD. Further, other active group treatments appear as effective as group CBT for PTSD, but are slightly better able to retain people, probably because they are not trauma focussed, see link below to the Sloan et al (2018) study:
Groups/classes are a great attraction for Organisations pre-occupied with numbers and waiting lists, reflecting the prime concerns of Clinical Commissioning Groups. IAPT has a penchant for running groups/classes without an evidence base for effectiveness. For example, it offers trauma victims a Stabilisation Group, here is how two participants fared:
Mr X had two accidents within weeks of each other and attended a 6 week course. My independent assessment found the course had no effect on his mild PTSD and mild depression and he was then put on a waiting list for individual CBT. The group sessions began with 12-15 participants and went down to 4 people. Topics covered included calming down after nightmares, mindfulness and deep breathing. Nevertheless he described the course as ‘helpful’ but was given no diagnosis at any point either in the telephone assessment or on the course.
Mr Y attended a 6 week course with initially 8-10 people and 3-4 dropping out before the end he also found the course ‘helpful’, albeit that he felt that he was not back to his usual self after the course. My independent assessment revealed that he was still suffering from PTSD after the course and he received a letter stating ‘ have now success fully completed the Stabilisation Symptom Management Course … .. you have opted to complete therapy at this time discharged you from the service’ but IAPT made no attempt at reliable diagnostic assessment before or after the course, patronisingly ‘success’ is now defined as completing an IAPT course!
Background to Stabilisation Groups
The impetus for the IAPT stabilisation groups probably derives from the Institute of Psychiatry 10 week programme teaching coping strategies for dealing with symptoms of PTSD, but in which trauma histories are not discussed . The programme uses cbt, mindfulness and relaxation techniques. But with no published study on effectiveness. IAPT has run a cut down version of this, just 6 sessions. Robertson et al at the Traumatic Stress Clinic offer 5-8 weeks of 2 hour group sessions for up to 10 people for refugees with a focus on managing hyper-arousal, anxiety, re-experiencing and dissociation but again there are no outcome studies. Like in IAPT it is intended as part of a phased treatment model but there is no evidence that it in any way adds to established treatments for PTSD.
Evidence Based Delivery of Group CBT
The Trauma Groups run in the UK bear no resemblance to those described in the Sloan et al (2018) study. The latter involved 14 2hr sessions and an adequate dose of treatment was regarded as attendance at 10 or more sessions. Though only a minority of study participants recovered from their PTSD there were high levels of satisfaction with both the trauma focused CBT intervention and with the non-trauma focused intervention. The trauma focused intervention involved writing about their trauma in 2 sessions and at home for homework. Further the trauma focussed group treatment was based on a group programme developed originally for victims of road traffic accidents. Interestingly both the trauma focused group CBT programme and the comparison Present Centred Therapy had bigger effects on coexisting generalised anxiety disorder and depression than on PTSD, the main target!
There are evidence based group protocols for depression and the anxiety disorders described in my book Simply Effective Group CBT (2011) London: Routledge.
The content for the group sessions I detailed in the book can be downloaded by clicking the link below:
at a workshop I gave in Liverpool last Friday, there was much interest in this metric for evaluating the effectiveness of a psychological service. The workshop was titled ‘Group CBT…Yes…But’ (and was also the innaugral meeting of the BABCP Group CBT Special Interest Group), and I reflected that none of the studies of classes, such as ‘Stress Control’ or the ‘Five Areas Approach’ had independent assessors asking people whether as a result of the intervention they were back to their old self, much less whether they remained as their old self for say at least 8 weeks. Yet they are promoted as the first line of treatment in services such as IAPT. Further were groups (as opposed to classes) are run they are often for targets such as ‘low self-esteem’ or ‘destabilisation groups’ with for which there is no evidence at all of real world outcomes. I think a key feature of the workshop for many people was making a sharp distinction between the evidence base for classes as opposed to groups, for depression and the anxiety disorders. The powerpoint presentation for the workshop can be accessed below:
I also suggested that the case for transdiagnostic approaches is, at the very least, not proven. Nevertheless I fear managers will attempt to play a numbers game with regards to groups blurring the distinction between them and classes. With, as suggested in a role play we did, a therapist trying to sell a ‘stress class’ to a client over the telephone, the latter could have had depression, PTSD, body dysmorphic disorder (or some combination there of) or even an adjustment disorder. The therapist herself with insufficient time to make a formulation becoming a candidate for a stress class in her own right!
this is the title of a Workshop I’m delivering on Feb 22nd in Liverpool, it is also the inaugral meeting the BABCP Group CBT Special Interest Group. Whilst the workshop is full you can join in the discussion on Group CBT simply by posting a reply to this post. There are also other posts on group CBT on this blog just type in ‘group CBT’ in the search box.
Manuals for depression and the anxiety disorders, assessment protocols etc from Simply Effective Group Cognitive Behaviour Therapy (2009) London: Routledge are freely available by clicking the link below:
The questions to be addressed at the workshop include:
are a rarity compared to individual therapy, despite the fact that barely more
than the tip of the iceberg of clients are likely to be offered therapy in the
forseeable future, Why is this? Is changing attitudes to the running of
groups likely to be sufficient to ensure wider dissemination of group therapy?
you believe you have got the skills necessary for running a group? What are
they and how do you know if you have got them? How can you get the skills?
you believe running a group would make a worthwhile difference? What outcomes
constitute a real world difference? How
would I know if marketing is outstripping evidence?
group treatment works for whom? What
about transdiagnostic groups? How transdiagnostic can you go? What is the
minimum dose of group CBT? What happens if you don’t ensure full recovery?
What are the organisational obstacles and plusses?’
Do join the SIG by contacting Nicola, email@example.com
The therapeutic relationship has withered under the blistering sun of IAPT. The latest IAPT annual report (2018) shows that 40% of clients attend only one treatment session, with the average client attending just 6 sessions. The therapeutic relationship needs the space of at least 10 sessions to flower according to NICE guidelines. For assessed only referrals 43% were deemed suitable but declined treatment , 23% were deemed not suitable and only 9% discharged by mutual agreement (IAPT 2018).
I’ve just edited the proofs of my contribution to ‘The Therapeutic Relationship In Cognitive Behavioural Therapy’ by Stirling Moorey and Anna Lavender to be published by Sage. The contributors cover all the disorders and contexts (my own chapter is ‘CBT Delivered in Groups’ written with Graeme Whitfield). Most of the authors are well known and agree on the importance of the therapeutic relationship. The approach taken in the book contrasts sharply with the practices in IAPT.