Sham Psychological Therapy Rules

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!

Dr Mike Scott

Groups and Trauma

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:

https://www.dropbox.com/s/qoly0wkquhzu44x/Simply%20Effective%20Group%20CBT%20All%20Appendices.pdf?dl=0

Stabilisation Groups


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:

https://www.dropbox.com/s/ys0ogfo3k93qmwb/Ptsd%20Group%20treatments%202018.pdf?dl=0

I will be circulating this blog to the BABCP, Group CBT Special Interest Group, anyone interested in joining can contact Nicola at nicoladrurywalker@fastmail.com

Dr Mike Scott

‘Are You Back To Your Usual Self?’

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:

https://www.dropbox.com/s/ikei2478wvnwu15/Group%20CBT%20SIg%20Feb%2022nd%202019.pptx?dl=0

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!

Dr Mike Scott

‘Group CBT….Yes….But’

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:

https://www.dropbox.com/s/yv51kiieskubaww/Simply%20Effective%20Group%20CBT%20All%20Appendices%20-%20Copy.pdf?dl=0

The questions to be addressed at the workshop include:

‘Groups 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?

Do 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?

Do 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?

What 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, nicoladrurywalker@fastmail.com

Dr Mike Scott

The Annihilation of The Therapeutic Relationship

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.

 

Dr Mike Scott

Delivering Group CBT – A Special Interest Group

For many years I have been running a ‘Delivering Group CBT’, Workshop following the June 15th Workshop in Manchester, there were 25 signatories for a BABCP Special Interest Group. An application for a SIG has now been made. Anyone interested in joining this merry band would be appreciated, just e-mail me at michaeljscott1@virginmedia.com.

 

The following is a link to the Powerpoint for my recent workshop https://www.dropbox.com/s/6sq5mvrhyvtnz1q/Delivering%20Group%20CBT%20Manchester%20June%2015th%202018.pptx?dl=0. A key feature is that it avoids the dichotomy either individual or group CBT.

 

Dr Mike Scott

IAPT Behind Closed Doors – ‘Group CBT’

I have had some interesting experiences with regard to group work.  Groups were divided into either Anxiety or Depression groups and it was often a difficult task to understand or to divide those suffering predominantly from anxiety and those suffering mostly from depression.  Added to this, groups were designed to deliver the most information to as many people as possible and were not tailored to individual need.  It was a “scattergun” approach, designed to keep the commissioners happy in terms of figures.  I think the worst example of this, was when a “Welcome Group” was planned which gave “due consideration in terms of numbers of people who could drop out” and asked 15 people to attend.  The room’s capacity in terms of seating was only 12, but in fact, 45 people attended and this would have been more if inclement weather had not prevented others from attending.  This was put down to a mistake with the figures and in the following week, only 3 attended the course.

Courses routinely had the obligatory people who presented with alcohol or drug problems and it was a regular occurrence that either one or the other would disrupt a group.  I once had a complaint made against me by a member of a group who felt that I had not been supportive to her situation and had been tearful and had had to go to the Ladies’ to recover.  I asked my colleague to accompany her.  I was rounded upon by the drunk in the room, who jeered and berated me for “making her cry” and that I should be ashamed of myself.  I told this inebriated person that he may not attend the next session and for this I was abused verbally.  I felt quite threatened, but was asked to explain my actions at a later date, when the complaint came in.  The situation was seen to be “one of those things” but my efforts to point out that anyone with either drug or alcohol problems should not have any place in a depression group, were largely ignored.  I had argued that anyone who had not made some kind of recovery from either drug or alcohol issues should not be permitted to attend a step 2 group, because they would not benefit and could possibly disrupt a group.

Anonymity protected – Dr Mike Scott

Developing Groupwork – An Exercise in Storytelling

Shifting the therapeutic focus from ‘classes’ to a shared narrative has greatly resonated with attendees at my ‘Delivering Group CBT’ workshops this year. My message has been if you are running a group make sure participants have the same story.

 

Social groups are formed by people having the same story e.g Labour Party supporters or Church groups. Therapeutic groups with diverging narratives are likely to run into difficulties.  Consider an anxiety group which includes a person with OCD, another group member with say generalised anxiety disorder , might well consider the OCD person as ‘weird’, become fearful that they will ‘catch’ the same disorder and drop out of treatment.  The therapists leading the group might well find that they are stretched too far in having to cater sufficiently for the person with OCD, yet simultanously keep other group members involved throughout.

Diagnosis is simply a way of ensuring people share the same story i.e the cognitive model of the particular disorder. There are free ‘storybooks’ for depression, the anxiety disorders and PTSD in the ‘Resources’ section of this site, which can form the content of group sessions.

Thus all members of a panic disorder group would be taught not to be ‘bullied’ by the panic attacks, but to gradually ‘dare’ go to places that they have historically avoided both within and outside the group session. The story-telling rationale ‘chunky CBT’ lends itself more to the use of  metaphor e.g ‘being bullied’, rather than talking class room style about say ‘the fight and flight response’.

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

Disseminating Group CBT – What You Need To Know

Clients often have similar stories, so it is a no-brainer to treat those with the same story in a group. But groups can go badly wrong – a colleague of mine was unavailable to lead a group because of illness, one of the group ‘stepped-in’ and ran the group at his flat, suggesting that he would be a much better group leader!

On September 6th I am giving a 1 Day Workshop on Delivering Group CBT to Bedford IAPT, one of many I have delivered to BABCP local Groups and IAPT. In 2013 when I gave the workshop in Copenhagen I discovered that  there Group CBT is the usual mode of service provision and therapists have to justify individual therapy, they found it surprising that in the UK we  did not operate that way. There are free group materials for depression, anxiety disorders and PTSD if you click the Resources button on this site, from Simply Effective Group Cognitive Behaviour Therapy (2011) London: Routledge. The Workshops have raised a whole host of questions that might be worth discussions in your locality and/or on this forum:

 

 

The learning objectives for the Delivering Group CBT workshop are for attendees to be able to answer most of the following questions by the end of the day:

  1. How do we ensure that we don’t play a numbers game with regards to groups?
  2. Why not admit all-comers?
  3. Aren’t classes a better use of resources than groups?
  4. How do we select the right people?
  5. Is group CBT really an answer to a Manager’s prayer?
  6. How do you identify and circumvent special problems in marketing group CBT?
  7. How can you integrate individual and group cbt?
  8. What is the structure of a session?
  9. What might the session by session content look like for depression and the anxiety disorders?
  10. How do you capitalise on group members assembling and/or departing?
  11. Do you have to specify groundrules?
  12. How do I handle clients with more than one disorder/difficulty in a group?
  13. How do you handle the difficult client?
  14. How do I know if the group is making a socially significant, real world difference?
  15. Which groups are best to start with?
  16. How do I manage group processes?
  17. How can I know whether I am managing group processes well?
  18. How does group cbt compare to individual cbt in terms of effectiveness?
  19. What if you are expected to run a group alone?
  20. How do you divide up the work between leader and co-leader?
  21. How should leader and co-leader debrief each other?
  22. Can you really do Socratic dialogue in a group?
  23. Are there advantages to a story telling/narrative approach in groups?
  24. What are useful materials?
  25. What can you do if your supervisor has no experience of group CBT?                                                    Dr Mike Scott