according to the BABCP’s submission BABCP response – NICE consultation draft to the National Institute for Health and Clinical Excellence (NICE ). Implementation of the latter’s proposed guidance would mark the end of the Improving Access to Psychological Therapies (IAPT) service.
Interestingly BABCP recommend that assessment should begin with a reliable diagnostic interview and acknowledges that IAPT’s Psychological Wellbeing Practitioners (PWPs) are not equipped to do this. Further BABCP recommend that outcomes should be assessed from the client’s perspective but do not specify how. Ironically some of BABCP’s own recommendations undermine the functioning of its over-induIged prodigy, IAPT. BABCP are alarmed that the proposed guidance would, in their view, herald the end of stepped-care.
BABCP are aghast that NICE have not included studies by IAPT related personnel in determining the way forward. In defence of IAPT, BABCP cite the Wakefield et al(2021) https://doi.org/10.1111/bjc.12259 study published in the British Journal of Clinical Psychology but fail to mention my rebuttal paper Scott(2021) https://doi.org/10.1111/bjc.12264 published in the same issue of the Journal. Quite simply NICE does not consider studies that are based on agencies marking their own homework as having any credence. This is thoroughly reasonable.
The BABCP have rightly pointed out to NICE that in recommending group interventions as the starting point for offering clients help, they have not properly looked at the context of the group studies. As I pointed out in my submission to NICE COMMENTS ON PROPOSED GUIDANCE (and simultaneously submitting via BABCP as a stakeholder), there are considerable hurdles in engaging clients in group therapy, see Scott and Stradling (1990)Group cognitive therapy for depression produces clinically significant reliable change in community-based settings Behavioural Psychotherapy, 18: 1-19 and Simply Effective Group Cognitive Behaviour Therapy Scott (2011) https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiph5Hlvbb1AhWKX8AKHRSJDZ0QFnoECAUQAQ&url=https%3A%2F%2Fwww.amazon.co.uk%2FSimply-Effective-Cognitive-Behaviour-Therapy%2Fdp%2F0415573424&usg=AOvVaw0nam02gszlQ0HqCktSCB0s.
In fairness, I think Prof Shirley Reynolds from BABCP has done a great job in reviewing the extensive documentation provided by NICE and collating the individual submissions, all within a very brief period of time. I understand from her that these matters will feature in the next issue of CBT Today and whilst I was happy to have my name noted as having submitted, there are important aspects of the submission on which I wish to dissent.
NICE make its’ formal recommendations in May, interesting times
excludes consideration of assessment https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0725/consultation/html-content-3, in it’s’ update of the 2009 Guidance [CG90], despite advocating different pathways for ‘less’ and ‘more severe’ depression, advocating a cut-off of 16 on the PHQ-9.! De facto the authors rubber-stamp the widely held practice, reflected in the Improving Access to Psychological Therapies (IAPT) Service, of routing high scorers on a depression psychometric test (e.g PHQ-9 score 10 or greater) to treatment for this condition. But patients with a wide range of disorders including, panic disorder, PTSD, obsessive compulsive disorders and adjustment disorder have elevated depression scores. Nevertheless NICE signals a diversion along a depression pathway with one fork for ‘less severe’ and another for the ‘more severe’. Clinicians and clients are likely to be equally bemused by the ‘road signs’. The upshot is likely to be misguided treatment.
In assessing the outcome studies NICE do not take seriously the concept of minimally important difference (MID) i.e what change would a a patient see as the minimum requirement necessary for them to say treatment has made a real world difference. There is no evidence that they would regard a change of score on a psychometric test as conferring a real world difference. But they would recognise being back to their old self or best functioning and possibly no longer suffering from the disorder, so that loss of diagnostic status would be a reasonable proxy for a MID. However only a minority of studies furnish this data with the use of blind assessors. Inferences can therefore only be properly drawn from this sub-population of studies, which exclude the low intensity studies.
Under the proposed Guidance client’s preferences are paramount. If the client is judged as having ‘less severe’ depression and volunteers no treatment preference, they are to be taken through a menu of options in a set order starting with first group cognitive behavioural therapy, second group behaviour activation, third individual CBT and on to the 11th option short-term psychodynamic therapy. For ‘more severe’ depression top of the league is individual CBT plus antidepressants, in 2nd place individual CBT, and in 3rd place individual behavioural activation and in last and 10th place is group excercise. The ‘more severe’ route is more labour intensive and there is likely to be congestion as approximately half those entering IAPT have mean scores of 15 or more on the PHQ-9 [Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173]. Unwittingly the Guidance spells the end of low intensity interventions because none of the top of the league options are low intensity! But 70% of clients entering the IAPT service are given a low intensity intervention first. However there is nothing to prevent a Service Provider declaring that ‘unfortunately none of the top of the league options are currently available’ and recourse has to be made to options in danger of relegation. So much for NICE Compliance and patient choice.
The NICE guidance assumes that psychometric test results speak for themselves but they are only meaningful when described in context. To my knowledge there is no study of the reliability of the PHQ-9 in UK routine mental health services compared to a ‘gold standard’ diagnostic interview. Rather data on the PHQ-9 has been extrapolated from from US studies of psychiatric outpatients, in a population with a high prevalence of depression, but not using a ‘gold standard’ diagnostic interview [The Prime MD was used instead, with insufficient distinction between this interview and the questions on the PHQ-9]. It is the author’s experience that in the UK the PHQ-9 gives a large number of false positives compared to a reliable diagnostic interview, such as the SCID.
NICE has a ‘blind spot’ about context. In its’ analysis of outcome studies it lumps together ‘depression studies’ that were wholly reliant on self-report measures with those that included the results of a diagnostic interview as an outcome measure. Outcome is assessed in terms of statistical differences between either different modes of service delivery e.g stepped v non-stepped or between different treatments e.g CBT v waiting list. There was no attempt to try and discern what proportion of clients in each arm of a study would have regarded themselves as back to their normal selves or best functioning post treatment [ or in lieu of this, lost their diagnostic status] and the duration of those gains. Rather than patients being asked to cite preferences over treatments they largely have no knowledge of, they would be very interested as to the likelihood of treatment making a real world difference to their lives.
NICE’s failure to look at context is highlighted in the top league place it gives to group CBT for less severe depression. No mention that in our study [Scott and Stradling (1990)https://doi.org/10.1017/S014134730001795X ] of individual and group CBT for depression in Toxteth, Liverpool the invitation to group CBT went down like a ‘lead balloon’ and we had to change the protocol to include up to 3 individual sessions in the ‘group’ arm. Entry was determined by independent diagnostic interview, but mean entry Beck Depression scores were around 27, so the population was likely ‘more severe’ in NICE terms. NICE also fails to critically appraise the Group Behavioural Activation studies, having previously called for BA studies to include observer rated assessments. They may have also added the need for credible attention control comparisons. NICE is content with statistical sweeps at large data sets rather trying to discern what is happening at the coal face.
NICE puts group interventions as top of the league for less severe depression, but ignores the context of the pandemic, realistically how possible will it be two get 2 therapists together with 8 clients for 90 minutes a week for 8 weeks, all face to face. The logistics and effectiveness of conducting it online is a venture into the unknown. NICE appears to operate without contextualisation of findings.
NICE are open to commentary on the proposals upto January 12th 2022. Will send the above, but I don’t think I will receive a return Christmas Card any time soon. Nevertheless a Happy Christmas to everyone.
As the pandemic recedes and concerns about scarcity of individual therapy continues, there are likely to be increased calls for group interventions, whether psychoeducational or psychotherapeutic. But the vexed question has to be asked, does the particular group intervention envisaged make a real world difference to client’s life? Is the group intervention more to do with appearing to have done something?
There are 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:
But I have a number of concerns about the utilisation of group interventions in the IAPT-ification of psychological therapy services. There is a danger of spin with regards to group CBT. This can happen easily by taking the abstracts of studies at face value, when many of the authors have developed the protocols that they are evaluating – allegiance bias. I doubt whether, despite the best efforts of any training institution, there will be a monitoring of fidelity to evidence-based protocols and a meaningful assessment of outcome. In practice clients may be short-changed by Group CBT and may then be put off further therapy. Whilst the group interventions may be intended as part of a stepped care package, clients are least likely to attend the appointment that marks the start of the new dawn [ Davis et al (2020)https://doi.org/10.1136/ebmental-2019-300133]. The following critique of group studies may be useful:
Group psychoeducation interventions have an appeal that belies evidence of their effectiveness. I can find no study in which there has been independent assessment of effectiveness using a standardised diagnostic interview. Thus it is not known what proportion of sufferers with a particular disorder would lose their diagnostic status as a result of treatment, much less how enduring recovery would be. ‘No longer suffering from a disorder’ is a metric that a member of the public can readily understand, but to be told that you no longer require treatment because you are now below ‘caseness’ on a psychometric test is likely to produce a puzzlement, that the client is too polite or disadvantaged to challenge.
It may be to the advantage of Managers and Academic institutions to promote psychoeducational groups but to the pay-off for the client is what? The experience of group involvement may not be adverse, they may have even enjoyed the sense of belonging that has come from group attendance, but if at the end of the day it has not made a real world difference to the client’s life, was it worthwhile? The issue of group psychoeducation has to be approached from a bottom-up perspective not top-down. Ost (2008) Outcome studies Quality Ost 2008 has published a 22 item measure of the reliability of psychotherapy outcome studies, each item is rated 0-2, so that a score of 44 is possible. Applying this measure to the most popularly delivered psychoeducation group Stress Control, I found yielded a score of 9, but the mean score in CBT outcome studies was 28 and Ost suggested that studies with scores of 19 or below could not be considered empirically supported treatments. Failings of the recent SC studies (the original White et al study fared slightly better because it specified a particular diagnosis, GAD) included amongst others the following domains: reliability of the diagnosis, specificity of outcome measure, blind evaluation, assessor training, design, assessment points, controlling for concomitant treatment, and assessment of clinical significance.
3. In a paper titled “Are individual and group treatments equally effective in the treatment of depression in adults? Cuijpers et al answered with a cautious ‘yes’. They drew upon my own study [ Scott and Stradling (1990)https://doi.org/10.1017/S014134730001795X ] comparing individual and group CBT with a waiting list, but did not mention that in order to get the group CBT to be a viable entity, we had to offer up to 3 individual sessions concurrently, though interestingly few took up all three. Selling the group CBT was a challenge, however both modalities were equally effective and I think Cuijpers et al’s conclusion is appropriate.
4. In 2018 carpenter et al published https://doi.org/10.1002/da.22728 a study of the efficacy of CBT for anxiety disorders. They considered only studies in which the comparison condition was a psychological placebo e.g supportive counselling i.e one in which there is a credible rationale, this controls for common factors such as the therapeutic alliance. Carpenter et al found only 7 studies comparing individual and group CBT with these provisos, and for only 2 disorders social anxiety disorder and PTSD was their sufficient data to reach conclusions and in both instances individual CBT was superior to group CBT.
But in 2020 Barkowski et al Group CBT for anxety dsorders 2020 published a meta analyses of group psychotherapy and claimed that group psychotherapy for anxiety disorders is more effective than active treatment controls. They cite a Hedges g effect size of 0.29. But these authors fail to point that this effect size is small. A Hedges g of 0.2 would mean that the average person in the largely CBT groups would have done better than 58% of those in the control condition. Whether these differences are clinically significant is a matter of debate. Further only 3 anxiety disorders were considered GAD, panic disorder and social anxiety disorder, the results do not apply to OCD or PTSD (which historically was placed in the anxiety disorders but now no longer is). The authors proclaim that mixed-diagnoses groups are equally effective as diagnostic specific groups. But this is misleading, the most recently published group trans diagnostic study by Roberge et al (2020) Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clini had approx half of clients (52.8%) suffering from generalised anxiety disorder and approx a third (29.4%) suffering from social anxiety disorder, thus over 80% of the clients are suffering primarily from either one or the other of just 2 disorders, more accurately it should be termed limited transdiagnostic therapy. Further clients were recruited via newspaper advertisements, 86% of the clients were women and 42% had a University Diploma, only half of clients were completers i.e attended 8 or more of the treatment sessions, and only half lost their principal diagnosis. Making generalising from these studies problematic.
The danger is that group devotees look simply at the abstracts of the group studies, without realising that the authors were the developers of the protocols and their findings need taking with a great deal of caution. My worry is that IAPT in particular will seize on groups as a way forward in a numbers game and clients will be short changed.
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: