Mental Health Sinkhole Appears – Untold Casualties

 

 

Mental Health Trusts today announced that three quarters of extra monies promised for mental health services are not getting through. A mental health sinkhole has appeared, the depth of which is measured by under-funding and the width by poor quality services. Casualties include an estimated 694,000 people who were treatment failures in the Government funded IAPT service in 2014/2015, 85% of those treated. A further one third of those referred to IAPT did not enter treatment.

I reviewed the trajectories of 65 people who went through IAPT Services in the North West of England using a ‘gold standard’ diagnostic interview just 15% recovered from their disorder. [ Scott (2017) Towards a Mental Health System that Works London: Routledge].  I am wholly independent of IAPT and I made the analysis on the basis of data available to me as an Expert Witness to the Court. Applying this recovery rate to the national picture suggests a massive casualty rate.

Just this past week I picked up a ‘casualty’ who had had 6 sessions with IAPT, she had had a fall 2 years ago, become effectively housebound, though able to walk for 10-15 mins. She was referred to IAPT and had 6 sessions of CBT for depression, to no avail and she was very frustrated by the therapist who had said ‘do you think you might have OCD?’ one week then the next week ‘what about body dysmorphic disorder?’.  No further treatment was offered. I  found she was depressed  but what had not been identified or addressed was that she had a phobia about falling and sustaining further injury. It was this phobia that was driving the depression and needed to be the therapeutic focus.

Dr Mike Scott

Evidence Based CBT Joins the ‘Endangered Species’ List

‘The good news is we have successfully amputated your right leg, the bad news is we operated on the wrong leg’.  The moral is that there can be no evidence based CBT treatment without an evidence based assessment (EBA). But EBA’s are increasingly absent in order to ease the research burden, ‘just rely on a psychometric test’, and reduce ‘treatment’ costs.

Emergency medicine operates on the 7 P’s, ‘Proper Pre-planning Prevents Piss-Poor Performance’. Is it seriously proper-pre-planning to operate as IAPT do, with a  typically 15-20 minute telephone conversation, conducted by the most junior member of staff, to be then placed on waiting list of upto 6 months for a treatment of indeterminate appropriateness? The reliability of this ‘pre-planning’ has never been assessed by anyone independent of IAPT. But this has not stopped Clinical Commissioning Groups often ring fencing IAPT monies at the expense of other mental health service providers.   The CCG’s need to be reminded that they ought to be working in an evidence based framework were the results of randomised controlled trials with independent assessment of outcomes hold sway (the top of the pyramid below). 60% of IAPT clients receive low intensity treatment, this is way down at the bottom of the evidence pyramid below, with a high potential for bias, reflected in powerful marketing.

It is time that CCG’s told IAPT that their pre-planning is simply unacceptable, there has to be an evidence based assessment. It is time the National Audit Office asked why are we continuing to fund a Service that has not been independently evaluated using ‘gold standard’, diagnostic assessment procedure. But most of all it is time to listen to those subjected to an inhospitable and unhelpful service. MP’s have to insist they are listened to.

Dr Mike Scott

‘How Do I Deliver Effective CBT Where I am?’

The contexts in which CBT Practitioners work vary enormously, from independent practice to secondary care, from low intensity IAPT to a specialised trauma unit.  For the most part we are Engineers struggling to work within the organisational constraints we are given.  Drawing on our knowledge and skills, working with a diverse population, trying to make a real world, socially significant difference in client’s lives.  The pressing question is how can I deliver effective CBT where I am?

A practitioner working in secondary care in Ireland,  told me he faces the challenge of cases come to him via psychiatrists, there is a preliminary assessment within 4 weeks of referral, a maximum of 12 sessions of CBT are offered.  There is a progress review about the 6th session and a decision is made as to whether another 6 sessions would be beneficial. He asks is this best practice? The managerial edict he believes is to throughput as many clients as possible.

Another practitioner, from IAPT High Intensity told me that she had taken up her post on the understanding that the 6 session maximum was flexible and clients could be quickly re-referred back in for more sessions, but this has proved to be very rarely the case. What should she do?

 

Dr Mike Scott

Grenfell Tower Fire and IAPT Trauma Services

In The Wake of the Grenfell Tower Fire, Mrs May Has Announced Additional Monies for Mental Health Services – BBC News 10.0pm June 18th 2017.

But the devil will be in the detail, what ‘treatment’ will be funded for which victim?, delivered by whom? when?.  The UK track record on treating trauma victims is not good. I independently reviewed 65 cases of trauma victims who had gone through the Government funded Improving Access to Psychological Therapies (IAPT) Service [Scott (2017] and found overall a 15% recovery rate, one half the sample had PTSD and again the recovery rate was 15%. There was no difference in recovery rates between those treated before and those treated after a personal injury.    But the difficulties are not confined to IAPT, recently I saw a victim of the 1989 Hillsborough Football Disaster who had since shortly afterwards been attending a weekly support group for victims, run by a Charity, though grateful for its ministrations, he had never been offered evidence based psychological treatment and continued to suffer from severe PTSD, with his marriage in tatters.

The breathtaking hospitality shown to victims of the Fire by the general public, has contrasted sharply with the acknowledged dilatoriness of the Governmental response. If that hospitality is reflected in the behaviour of friends and family towards the victim this will be an enormous benefit as perceived social support is the biggest single predictor of recovery from PTSD [ see Scott (2013)] and as a consequence I have advocated inclusion of partners in treatment if appropriate. Partners and clients can both benefit from my self-help book Moving on After Trauma [Scott (2008)].

One of the biggest roadblocks to delivering Trauma Focussed CBT (TFCBT), is that therapists or clients curtail treatment because the latter cannot face repeatedly going over the details of the trauma. Yet TFCBT is effective if clients can stomach it. I have suggested that a way around this is to teach coping skills for managing the memories, even if this proves insufficient to manage the intrusions, it can become a stepping stone towards a preparedness to engage in TCBT [Scott (2013)]. In a paper currently under review with Behavioural and Cognitive Psychotherapy, titled ‘PTSD Re-imagined’, I have presented a new reconceptualization of PTSD that is user friendly and goes beyond existing forms of treatment.

Dr Mike Scott

References

Scott, M.J (2017) Towards a Mental Health System that Works London: Routledge

Scott, M.J (2013) CBT for Common Trauma Responses London: Sage Publications

Scott, M.J (2008) Moving On After Trauma London: Routledge

What Chance Effective Psychological Treatment?

“If You Have Heart Problems and Depression You Are Four Times More Likely To Die In The Next Year or Two Than Those With Cardiac Problems Minus Depression”

– All In The Mind, Radio 4 May 3rd 2017.

 But scarcely more than the ‘tip of the iceberg’ of those with mental health problems receive psychological help

Iceberg, Water, Blue, Ocean, Ice

Here are two examples of people that I have seen recently who have been drowning in the ‘frozen waters’

‘Sarah’ was made redundant and had a fall 3.5 years ago. She has suffered from depression since and the only help she has been offered is antidepressants by her GP. Psychological therapy which is the NICE approved first line treatment for depression has not been discussed.

‘Ivan’ recently had a serious road traffic accident two years ago, and was referred by his GP to his local IAPT Service. He said that had a few face to face conversations with the staff but they did not offer him a diagnosis and said that they did not have the funding to treat him. Ivan was referred back to his GP with a recommendation he be referred to secondary care. On examination I found that he was suffering from PTSD complicated by the back pain he had suffered in the incident. The Secondary Care Unit provided no diagnosis but suggested a group programme could cater for his needs but he was not keen on this.

Dr Mike Scott

 

Moving Forward

Perhaps this diagram may help us in how we can move forward from this:-

 

Ultimately we want to make a socially significant to client’s lives, a real world difference, [See Scott (2017) Towards a Mental Health System that Works: a guide for practitioners. London: Routledge], not just a questionable change on some psychometric test.

Wounded Healers

“Two thirds (68.6%) of workers in low intensity CBT (PWP’s) are suffering from burnout and so are half of workers in high intensity.”

(Journal of Mental Health, published online January 13th 2017 “Predictors of emotional exhaustion, disengagement and burnout among improving access to psychological therapies (IAPT) practitioners” Westwood et al).

 

The position is no better than a year ago.  On February 3, 2016, The British Psychological Society reported on a 2015 survey of over 1,300 psychological therapists working in the NHS. The survey found that 46% reported depression, with half (49.5%) feeling they are a failure. One quarter considered that they now have a long-term chronic condition, and 70% said that they find their jobs stressful. Reported stress at work was up 12% in 2014: ‘The overall picture is one of burnout, low morale and worrying levels of stress and depression . . . the majority of respondents made negative comments about their work environment, 10% of comments were more positive’,

Should working in IAPT carry a government health warning? One educator said to me recently ‘I wouldn’t work in low intensity for a ‘gold clock’!