The Phobic Avoidance of Attending to Real World Mental Health Outcomes

 

just published  in madinamerica.com/2022/08/phobic-real-world-outcomes/ Michael Scott

When I look at mental health research, I notice a startling avoidance of real-world outcome measures. It seems almost phobic. Yet this type of outcome should be considered the most important. After all, who cares whether some arbitrary measure goes up or down slightly after a week or two? What we care about should be whether people have improved quality of life over the long term. Can they get back to doing the things they used to do? Do they participate in the world, socially, at work? Do they enjoy their hobbies?

So why do researchers avoid asking these questions?

One big reason is that researchers are incentivized to find a positive effect. The motto of academia is “publish or perish,” and everyone knows that null effects are rarely published. But your job may depend on your ability to publish your next study. Even worse, plenty of researchers are funded by the pharmaceutical and device industries—corporations that obviously are hoping you find a nice effect for their drugs and devices.

Even with the best of intentions, though, the people who are testing therapies are often the people who invented the therapy and their disciples—who obviously have at least an unconscious bias, hoping that their personal theory works!

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So, consciously or unconsciously, researchers tend to accept a lower threshold for proof of effectiveness. It’s difficult to actually improve people’s real lives significantly, and it’s a lot easier to use a ton of arbitrary metrics and find at least one “statistically significant” effect over a short time. The upshot is, to paraphrase the Dodo in Alice in Wonderland, “all medications and psychological therapies are winners and all must have prizes.”

And it seems that the media, politicians, and midlevel healthcare bureaucrats similarly have no interest in examining the validity of outcome measures. Instead, they pass on oversimplified understandings and glib slogans as if they encapsulate the nuances of what is actually quite controversial research. Most have the best of intentions to be a “mental health advocate,” and they’re told by establishment figures that any criticism of the existing system would be “stigmatizing” and “stop people from getting treatment”— treatment that we only assume works, again, based on arbitrary statistical outcomes over the short-term, not real-world improvement in the long-term.

In the worst-case scenario, researchers and activists who note the misleading research and conclusions dripping with “spin” in an attempt to improve the system are called “antipsychiatry” and marginalized within their own communities.

One searches in vain for studies that ask, after treatment, “Are you back to your old self?” and, importantly, “for how long?” These are the outcomes that patients really care about. Without such questions it is impossible to chart the trajectory of a person’s functioning. Such questions are at the heart of really listening to the patient. Without that, any therapeutic edifice crumbles. But it is not rocket science, just basic respect!

At best, and rarely, studies will report on the proportion of people who lose their diagnostic status—“recovered”—as assessed by an independent clinician. But these don’t indicate the duration of recovery. Do you lose your diagnostic status after two weeks, but then worsen again by a month?

Symptom Reduction vs Added Value

Finding the right psychological treatment for the right disorder is the window through which CBT researchers have gazed for decades. Likewise, psychiatrists have gazed through a similar window, which van Os and Guloksuz call “finding the right medication for the right brain disease.” Whether therapists or psychiatrists, researchers and clinicians have looked predominantly at symptom reduction, rather than whether treatment has provided added value to the client’s life. And all of this is usually rated by the clinician— rarely do we ask clients what they think about the treatment.

There has however been some limited success in the application of CBT to depression and some anxiety disorders, at least in randomised controlled trials. But even here researchers conclude “CBT is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still uncertain and should be considered with caution.”

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Similarly, other researchers found that CBT had a large effect for treating OCD, and a moderate effect for treating PTSD. But beyond these DSM diagnoses, there is a dearth of credible supportive evidence.

Evolution or Dissolution?

It is the 50th Anniversary of the British Association for Behavioural and Cognitive Psychotherapy, the self-proclaimed lead organisation for CBT in the UK. The recent annual conference included a keynote speech called “On the Evolution of Cognitive Behaviour Therapy: A Four-Decade Retrospective and a Look to the Future.”

But evidence that it has evolved is sparse to non-existent. In 2008, Ost examined the methodology of what were then termed third-wave CBT therapies and concluded that the methodology employed made them significantly less reliable than the early pre-millenium CBT studies. He opined that the third-wave therapies would not qualify as evidence- based, despite yielding evidence of significant effect sizes. The evidence for the small, incremental changes in complexity and greater effectiveness of CBT is simply not there. Rather than evolution, we have evidence of the operation of the 2nd law of thermodynamics, in that therapeutic energies are being made available in less useful ways—dissolution.

Dissolution Under the Microscope

The PICOTS framework is a mnemonic used by the FDA to define evidence-based medicine. The “O” refers to outcomes and the FDA argues that these must be “outcomes that matter to patients and which predict long-term successful results.” Essentially, no cooking the books with small but statistically significant differences in outcome between an intervention and its comparator (the “C” of the mnemonic), ideally an active placebo.

The “P” stands for population, with a prerequisite to specify clearly who received the intervention, so that other researchers can replicate the findings with the same group of people. The “I” stands for intervention and requires a clear elaboration of what the treatment involved. For psychological therapies, this means the publication of a manual. The “T” refers to timeframe: how long have the treatment effects lasted. Finally, “S” refers to the treatment setting (e.g., primary care).

Over the past 40 years, psychological therapy (mainly CBT) studies have increasingly paid lip service to PICOTS. They have progressively looked less like the original pioneering efficacy studies. There has been a drift to reliance on self-report measures to define a population (P), as opposed to defining a population with a “gold standard” diagnostic interview—largely on the grounds of cost and expediency. Outcomes (“O”) have been progressively less likely to be assessed by independent blind raters.

For example, since the millennium there has been the development and evaluation of low-intensity CBT (typically defined as 6 hours or less of therapist contact). In none of these has there been an independent blind rater; outcome has always been assessed by

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self-report and rarely has a diagnostic interview served as the gateway into the study. Yet, in the UK, these low-intensity treatments are the first-line treatments for depression and the anxiety disorders.

Not only has the National Institute of Health and Care Excellence (NICE) endorsed the usage of low-intensity CBT, but they have recently advised that in the first instance therapists should market eight sessions of group CBT for depression.

The lack of any credible evidence on real-world impact and duration of gains troubles them not. It appears an answer to the managerial dream of throughput. Therapies are accessed and patients axed.

CBT and Antidepressants in Practice

There is nothing in the arrangement of routine psychological therapy services that guarantees that a) the “right” disorder will be identified and b) the “right” treatment will be forthcoming. Routine services, such as IAPT in the UK, do not make diagnoses. In a just- reported paper by Clark et al (2022), IAPT clinicians were asked to refer patients to a social anxiety disorder study, but only half the patients referred were found to have the disorder in the study diagnostic assessment.

Thus, left to their own devices, the routine clinicians would have been providing inappropriate treatment to 1 in 2 patients. There can be no certainty that the treatment provided in routine practice is a bona fide treatment, as fidelity checks have never been made. Fidelity checks are disorder specific, with matching treatment targets and interventions. For example, in depression, tackling the loss of the pleasure response (anhedonia) with activity scheduling.

There is a potency of treatment gap between the interventions used in randomized controlled trials and their translation into routine practice. A paper published in the Journal of Psychiatric Research last year showed a 25% response rate for those who had antidepressants and manual-driven psychotherapy (mostly CBT), no better than antidepressants alone. This compares with a 31% response rate in those given a placebo in other studies.

Proper translation of the benefits of treatments identified in randomised controlled trials cannot be done on the cheap. It requires rigorous reliable assessments and a commitment to fidelity. But the latter has to be accompanied by the flexibility of adaptation to the individual. Respect and reverence of patients’ perspectives are paramount. Without funding bodies going beyond operational matters of numbers/waiting times and focussing on real world outcomes, the promise of randomised controlled trials will not be realised. There is a pressing need to return to basics by measuring treatment effects in the real- world.

In practice, there is also unfettered discretion when it comes to a clinician’s choice of which client problems to tackle, in what order and with what evidence-based protocol.

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It is, however, possible for individual therapists to deliver quality therapy. I have outlined the specifics of this in Personalising Trauma Treatment: Reframing and Reimagining. I have termed this “restorative CBT”—returning the person to their old self. In this work, the uniqueness of the individual is recognised (e.g., “what does the trauma mean to you today?”), yet at the same time commonalities are recognised, such as the state of “terrified surprise” (a combination of exaggerated startle response and hypervigilance) experienced by those most debilitated by trauma.

Unfettered Discretion on Outcome Measures

In their important book Noise, published last year, Kahneman et al highlight the poor levels of agreement on matters as diverse as judicial sentencing and psychiatric diagnosis. Such disparities are clearly unfair. But there is also heterogeneity of outcome measures. This makes it possible for authors to claim positive benefits in the absence of any real-world demonstration of effectiveness. Researchers have had a field day with unfettered discretion on outcome measures, facilitating the quest for positive findings and heightening the likelihood of publication.

Clients have a right to expect that primary outcome measures should be meaningful to them. The danger is that because of a power imbalance, clients defer to the conclusions of the professionals on outcome and, in Kahneman et al’s terms, a “respect-expert” heuristic (rule of thumb) comes into play. As a consequence, the client is likely to be continually short-changed.

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The UK’s IAPT Service Is An Abject Failure

 

from ‘Mad In America’ https://www.madinamerica.com/2022/06/uk-iapt-abject-failure/

 

Rescued man in boat looking on shipwreck

Dr Michael J Scott Ph.D

In 2012, an editorial in the prestigious journal Nature claimed that the UK’s IAPT Service is “world-beating”—meaning that the service is the world’s best for treating mental health concerns. Now that 10 years have passed, it’s clear that this was not true. Despite the hype, the IAPT is hardly “world-beating.” In fact, it is a doubtful model for other countries to follow.

The IAPT (“Improving Access to Psychological Therapies”) was created in 2008 and fully funded by the UK government (though restricted to provision only in England). The program claims to provide evidence-based psychological treatment, most commonly in the form of cognitive behavioural therapy. It was initially focused on patients with depression and anxiety disorder diagnoses, but its scope has been gradually expanded to include the psychological treatment of long-term physical conditions such as chronic fatigue syndrome.

Patients either self-refer (at no cost) or are referred to the IAPT by their primary care physician/general practitioner. Clients are initially assessed during a 30-minute telephone conversation by a Psychological Wellbeing Practitioner (PWP) who is not an accredited therapist and is not trained to diagnose. IAPT clients initially receive low-intensity CBT (six hours or less of therapy contact) delivered by a PWP. If they are deemed not to have responded to this, on the basis of a psychometric test, they can be “stepped up” to high-intensity CBT delivered by an accredited psychological therapist.

How Well Is the IAPT Doing?

Proponents of the IAPT cite its outcomes for the clients who complete their treatment sessions—but over half of IAPT clients don’t even attend two sessions. The response of the IAPT to this massive disengagement with the service—clients “voting with their feet,” as it were—is currently to offer training to its staff to “streamline” matters by encouraging them to use a computer algorithm to decide which clients go where. This training, which was held on June 22, 2022, involves expert advice from the CEO of Limbic, an artificial intelligence Company. Thus, not only are IAPT staff to be distracted by clients having to complete psychometric tests at each encounter, but now additionally by the administration of the computer algorithm.

Yet Limbic claims it is “an AI assistant for clinical assessments in IAPT—improving access, reducing costs and freeing up staff time.” Where is the independent evidence for this? What clients really want is to be listened to, but there is little chance of this any time soon. Conquering disengagement in this manner is a forlorn hope. 

IAPT’s 2019 manual states that IAPT staff do not make a diagnosis. However, the treatment recommendations of NICE (the UK’s National Institute for Health and Clinical Excellence) are explicitly tied to a taxonomy of specific treatments for identified disorders (largely, diagnosis-specific variations on CBT). IAPT legitimises itself by a claim to be NICE compliant, but how could they be if they don’t make diagnoses? How can they follow NICE’s specific treatment guidelines without first assessing which condition they are treating?

Whilst the IAPT’s claim to be NICE-compliant might be music to the ears of NHS England and clinical commissioning groups, it is simply not true. No independent fidelity checks have ever have been made on IAPT’s ministrations. IAPT allegedly provides specific CBT protocols for different disorders, but it has provided no evidence that it does this.

In my examination of the physician’s records of 90 IAPT clients, I found no evidence of compliance with CBT protocols.IAPT operates simply as a business with superb marketing.

In no independent audit of IAPT, have clients been asked “are you back to your usual self since this treatment?” This is a goal that is meaningful to the client—with the possible supplementary question, “for how long have you been back to your usual self?” In papers published by IAPT staff, no such real-world outcome measures have ever been used. Instead, reliance has been placed on changes in psychometric test scores. Yet without a control group, it’s impossible to know whether these changes would have occurred with passage of time anyway. After all, people present to psychological treatment at their worst, and at any other time, they are likely to score better. In statistics, this principle is known as regression to the mean, and it is vital to account for this effect.

Further, the client knows his/her therapist sees their completed questionnaire, pushing them to respond more positively. A client may also not want to endorse negative responses on the questionnaire because it would mean acknowledging that they have wasted their time in therapy. These are known issues with self-report measures that are commonly cited as important limitations in research studies.

Finally, the questionnaire results also give no indication of whether any improvement has lasted for a period that the client would regard as meaningful, such as eight weeks or (hopefully) more.

In an era of personalised medicine, it is essential that the voice of the client is heard. It is an almost ubiquitous failure of studies to employ a primary outcome measure that a client can identify with—known as patient-centred outcomes. Perhaps the nearest proxy is loss of diagnostic status (full recovery) determined by an independent assessor. The burden of proof rests on providers of services to demonstrate that their treatments are making an important difference to a client’s life in a way that is clearly recognisable to the client. IAPT has not cleared this evidential bar.

Use of an algorithm is not incompatible with a clinician operating on a knowledge base of what works for whom. But it has to be first demonstrated that the former constitutes added value over the latter. The burden of proof is on AI advocates to demonstrate its relevance in a particular context. This cannot be done by a company with a vested interest in AI.

It is perfectly possible that using two systems, an algorithm and clinical judgement, might create confusion. Should an IAPT client not fare well (for example, if a client dies by suicide) when treated under such a dual system, could IAPT convince a court, on the balance of probability (the UK benchmark in personal injury cases), that its approach was evidence-based? After all, an AI approach is not something that NICE has recommended—so it flies in the face of the guidelines. Traditionally, courts are swayed by eminence-based evidence (such as the word of authority figures like psychiatrists), but they have become more aware (at least in the UK) of the perils of unbridled clinical judgement.

Inadequacies of IAPT’s Chosen Metric

IAPT’s chosen metric is a change in score on two psychometric tests. Clients are deemed to have responded if on the PHQ-9 (a measure of the severity of depression) their test score has gone from above 10 to below 10 with treatment, with a difference of at least 6 points, and if on the GAD 7 (a measure of the severity of generalised anxiety disorder) their score has gone from above 8 to below 8 with treatment, with a difference of at least 4 points. This approach has numerous deficiencies:

  • It is not known whether the completer of these two measures was actually suffering from depression or generalised anxiety disorder, because IAPT clinicians do not make diagnoses. Further, it is not known whether either of these “conditions” was the disorder that was causing most impairment in functioning.
  • When test results are observable by the treating clinician, clients may wish to be polite and relay a lower score, particularly as they do not want to feel that they have wasted their time in therapy.
  • No attention control comparator: Changes in test scores are meaningless unless there is a comparator group who have received the same attention and a credible rationale. It’s unclear whether the therapy resulted in the improvement, or if the client would have improved with a “placebo” therapy (simply receiving professional “attention” without CBT techniques).
  • Regression to the mean: Clients typically present at their worst, so with the mere passage of time they will score more modestly.
  • The vagaries of a minimally important difference (MID) in a score: MIDS are established by statistical comparisons between an “ill” and “well” group, but they do not necessarily indicate clinically important difference. They also fail to address the client’s perception and there is no personalisation of treatment outcome. Clients are given no voice.

Haemorrhaging

Last year about a third of referrals (30.1%) to the IAPT service did not access it. Of those who accessed the service over a third (38%) had just one treatment session. Thus, by the start of the IAPT race over half of people (57%) have not engaged in treatment (as defined by IAPT’s metric of attending two or more sessions). If these results applied to a physiotherapy service it would raise serious doubts about the suitability of the service! Why then does the UK National Audit Office studiously avoid scrutiny of IAPT, which costs the taxpayer over £1 billion a year?

Sub-Therapeutic Dose and Treatment Outcomes

Of those who engaged in IAPT, the average number of sessions was 7.5, which is well below the 12 to 20 sessions that NICE recommends for depression and anxiety disorders (IAPT’s primary targets). Are we to believe that IAPT’s clinicians are so skilled that they can achieve recovery with only half the dosage of therapy as that delivered by therapists in the randomised controlled trials of CBT for depression and the anxiety disorders?

The benchmark set by trials of therapy as a treatment for these conditions is that at least 50% must “recover” (no longer meet criteria for a diagnosis). But there is no evidence that IAPT has achieved this. My own research suggests that only the tip of the iceberg recover.

In my capacity as an Expert Witness to the Court, I examined 90 IAPT clients who had been through the service either before or after the personal injury. Only 9.2% of subjects lost their and diagnostic status, as assessed using the “gold standard” SCID interview. It mattered not whether subjects were assessed before or after their personal injury. (These findings are in need of replication by clinicians independent of IAPT with a non-litigant population.)

Diagnostic Creep

IAPT appears not to so much follow the data, but to follow funding opportunities. It has branched out into territory were angels fear to tread: Medically Unexplained Symptoms (MUS). MUS is an umbrella term embracing conditions as diverse as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. IAPT’s contention is that exaggerated negative beliefs about symptoms, and maladaptive behaviours (e.g., avoidance), play a pivotal role in the maintenance of symptoms in these conditions. The therapeutic task, as they see it, is to then to modify these cognitions and behaviours.

What happens if a client protests that they have valid medical symptoms? Well, IAPT clinicians are taught not to openly disagree and not to say ‘it is all in your mind’. But to nevertheless continue to focuss on the ‘exaggerations in beliefs and avoidance behaviours’, so much for honesty.

Along with Keith Geraghty from the University of Manchester, I have published a critique of this sojourn. We identified a series of seven core problems and failings of the IAPT, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment. We concluded that psychotherapy should not become the default option when patients have “medically unexplained symptoms.”

The term “medically unexplained symptoms” should be written in lowercase to avoid conveying the impression that a meaningful homogenous entity is being described. The term should not enter the taxonomy of disorders. Importantly, even the DSM-5 has shunned recourse to the term. But unfortunately, IAPT only pays lip service to the standard diagnostic criteria.

Big Pharma and IAPT

Whilst some large pharmaceutical companies have greatly served the public good with regard to COVID, their performance with regard to psychotropic drugs is much less impressive. Researchers like Read and Moncrieff pin their hopes on the efficacy of CBT demonstrated in randomised controlled trials, but make no mention that CBT as delivered in routine practice bears little relationship to the protocols utilised in RCTs. Just as the claims of pharmaceutical companies require critical appraisal so too does the UK IAPT service.

 In an article in the British Journal of Clinical Psychology, I explained what the IAPT needs to do to get back on track. I noted that in their published papers, IAPT staff do not declare their allegiances and indeed state that they have no conflict of interest! This dishonesty needs to change. I suggested that there is a need for IAPT to prove their case using the standards of proof that are required in other areas of medicine.  To this effect, they cannot simply claim that they deliver evidence-based treatment—there has to be documented evidence for it that would be persuasive to an independent observer.  The IAPT service has to demonstrate that it provides an added value over someone attending an advice centre or counselling service. Yet the IAPT has yet to demonstrate that it makes an important enough difference to clients’ lives that they would recognise it.

This catalogue of omissions may create a sense of déjà vu for those who have followed the machinations of Big Pharma with regards to mental health. Unfortunately, there has only been a deafening silence from the IAPT regarding my critique.

 

 

 

Arrested information-processing – an illegitimate justification for toxic treatment

Both of the main treatments for post-traumatic stress disorder, trauma focused cognitive behaviour therapy (T-FCBT) and eye movement desensitisation  reprocessing (EMDR), postulate that arrested information processing lies at the heart of debility post trauma. The therapeutic task is therefore to elaborate the traumatic memory. But does the model stand up to close scrutiny?

  • What does arrested information-processing look like?
  • Is forced engagement with the traumatic memory, the only way forward, given that most people do not want to think about something horrible?
  • Is there evidence beyond reasonable doubt that a noxious treatment for post-trauma debility is necessary?
  • What happens when arrested information-processing is put under the microscope? 

Consider that you have produced a one page  document on your computer. You try to print it out, alas nothing! Various arrested information processing ‘bugs’ may have come  into play. You may have forgotten to refill the paper tray. The cable at the rear of the computer may have become disconnected.  With age the printer might now demand that it be a) unplugged from the mains b) the printer key depressed for 20 seconds with the paper tray out and c) the printer plugged in and the printer key depressed again. There would thus be very clear and demonstrable reasons as to why you have no printout.

 

But when a person is debilitated following an extreme trauma there is no such clarity. It may be asserted the extreme trauma caused the debility, but all that is known is is that debility followed a trauma. The temporal sequence does not necessarily signify causation. A failure by trauma focussed clinicians to specify the mechanisms by which arrested information-processing occurs, casts doubt that it has been operative. The injunction for trauma focused clinicians is to ‘elaborate’ the traumatic memory. Staying with the analogy, no amount of changing the contents of the one page document (elaboration) will result in a printout. Arrested information processing, in the context of trauma, sates intellectual curiosity with abstractions but is bereft of any actual detail. The evidential bar for the concept is set so low that it is possible to walk over it.

Just as the one page document is a creation, so to is the traumatic memory, but it differs in that every time the latter is retrieved it is different. It is rather like Alice in the above observation. 

Any information encoded at the time of the trauma may be properly regarded as syntactic information, i.e information without any meaning – rather like being sent a text message that consisted simply of a number of symbols. A friend may at a later point give a meaning to the symbols but you may nevertheless conclude that it was a meaningless text. Importantly the meaning is subject to negotiation and is not located in a special place in the trauma itself. Plantinga, Oxford University Press (2011) says that it is essentially impossible to see how a material structure or event could have content in the way that a belief does.This takes us to a new and more useful model based on mental time travel [Scott (2022) Personalising Trauma Treatment: reframing and Reimagining. London: Routledge https://www.amazon.co.uk/Personalising-Trauma-Treatment-Reframing-Reimagining/dp/1032013125/ref=sr_1_1 crid=2T4OARM3EH4TB&keywords=personalising+trauma+treatment+paperback&qid=1653757479&sprefix=%2Caps%2C73&sr=8-1 ] and the axiom that it is not the trauma per se that is important but what it is taken to mean for today, that has significance.

The Utility and Effectiveness of Trauma-Focussed Interventions

It is true that with trauma focussed CBT or EMDR about 50% of those undergoing these treatments in randomised controlled trials fully recover from PTSD. However compliance with trauma-focussed  protocols in routine practise is problematic, with only a half of patients loosely compliant with the homework [Scott and Stradling (1997)  Journal of Traumatic Stress. Over 60% of veterans dropping out of trauma focussed interventions [ Maguen et al (2019) https://doi.org/10.1016/j.psychres.2019.02.027]. Not buying into the treatment rationale for trauma focussed work is the biggest predictor of non-completion [ Kehle-Forbes et al (2022)https://doi.org/10.1016/j.brat.2022.104123].

it is possible that to the extent that these treatments do work they do so for reasons other than achieving ‘full processing of the traumatic memory’. More plausibly as a side effect of these interventions they learn experientially that the ‘war zone’ map of their personal world that they have employed since the trauma, leads nowhere and they revert to a pre-trauma map. Oftentimes the prime concern of a victim is not what did happen but what could/should have happened i.e it is not the trauma per se.

Resistance To A Paradigm Shift

Rather than re-examine the trauma-focussed paradigm the likelihood is that the movers and shakers in the CBT/EMDR world will either resolutely ignore this challenge or concentrate their firepower on the inappropriateness of the computer/printer analogy, without suggesting a more appropriate analogy. An essentially fundamentalist approach is taken to the potency of arrested-information processing. Heretics should at best be marginalised.

Dr Mike Scott

Low Intensity CBT Is Devoid of “Intelligent Scaffolding”

As a consequence there are no protocols for Psychological Well-being Practitioners (PWPs) to follow. The scaffolding is on the back of a lorry but nobody knows what to do with it. Restoration or rebuilding is unchecked by any blueprint. There is no typology of PWP treatments. It is made up as you go along.

Consider ‘CBT for long term conditions and medically unexplained symptoms’, a book by that name has just been published [Kinsella and Moya (2022) Routledge], these authors note that their protocol isn’t deliverable within the 6 hours or less of low intensity CBT, so they suggest have just one target, say depression and with subsequent multiple referrals a comprehensive protocol can be covered! But there is no evidence that this piecemeal approach works, no evidence that such brief Behavioural Activation for depression that they recommend (nor that the entirety of the package) makes a real world difference.   

The above considerations makes IAPT’s claim  that 50% of its customers get what they want,  ‘recovery’, incredulous. The true recovery rate in IAPT is around 10% Scott (2018) https://doi.org/10.1177%2F1359105318755264 and is likely to be even less amongst those with long term conditions. Medically unexplained symptoms (MUS) is such a nebulous entity that it was dropped from the DSM. 

 

The randomised control trials of CBT for depression and the anxiety disorders, conducted before the millennium, had fidelity checks built in to ensure that clinicians were doing what they were supposed to be doing.  For each diagnosed disorder, there were specific treatments targets and matching treatment strategies. With adherence, competence and outcome assessed independently. IAPT’s mantra has been that it is compliant with these NICE approved protocols. However no fidelity check  has ever been been applied to either IAPT’s  high-intensity service or its low intensity service. 

If builders behaved in such a cavalier manner they would soon be out of business, ‘never mind about the restoration of your house, we have built you a nice bungalow’. A year ago I had published a paper ‘Ensuring IAPT Does What It Says On The Tin’ https://doi.org/10.1111/bjc.12264 but it has washed off the IAPT teflonocracy. 

Dr Mike Scott

An Engaging Trauma Treatment

Take a look at ‘Personalising Trauma Treatment: Reframing and Reimagining’ here https://doi.org/10.4324/9781003178132. To access the abstracts of each chapter you have to first register with Taylor and Francis Publishers

Restorative CBT for Post-traumatic Stress Disorder and Beyond

New youtube video https://youtu.be/3UeJ1Lux4pU detailing how to help the client back to their old selves post trauma – Restorative CBT (RCBT). Not only for those who have developed PTSD but also for those who have acquired other disorders, whether singly or in combination. The video is based on my new book ‘Personalising Trauma Treatment: Reframing and Reimagining’, available from amazon https://images-na.ssl-images-amazon.com/images/I/5141wjLVgrL._SX331_BO1,204,203,200_.jpg. and published by Routledge.

RCBT is likened to restoring a dilapidated property but in some instances it may be a rebuild on the same site, for those who feel they have never functioned well. Mental time travel to a trauma/s is inevitable but it is what the person takes it to mean about today that is crucial for possible ongoing psychological debility. It is the centrality accorded to the trauma that is pivotal in the development of disorder. The book is replete with metaphor making for ease of dissemination. For example, PTSD clients are invited to consider that they are wearing a pair of ‘war-zone’ glasses and are invited to practice swapping these for the ‘spectacles’ that they would have worn in the weeks before the trauma.

It is suggested that a) there is no credible evidence that traumatic memories are  different in kind to ordinary autobiographical memories and b) traumatic memories do not have unique neural basis. Consequently there is no need for clients to relive their trauma. It is much easier for clinicians and clients to consider the adaptiveness of a memory than to relive it to the point of desensitisation. In randomised control trials, trauma focused interventions result in recovery in about 50% of cases. However in routine practice because of comorbidity and population differences, the proportion is likely to be significantly less. Further to the extent that trauma-focussed interventions work, they may do so simply because the client collects experimental evidence that they are not in a ‘war zone’. There is then ample justification for approaching the psychological sequelae of trauma from an RCBT perspective.

 

Dr Mike Scott

 

 

Forget Trauma-Focussed Interventions, Deliver Restorative CBT

Restorative CBT(RCBT) focuses on getting the trauma victim back to their old selves, as far as possible. It does not require the client to relive the trauma. The difference between RCBT and trauma focussed CBT (TFCBT) is stark when it comes to considering long-term psychological help for those affected by the war in Ukraine. A theme throughout the book is helping trauma victims forgo the ‘war zone glasses’ through which  they may view their current environment. The RCBT approach is likely to be more acceptable and easier to disseminate. The specifics are in my book ‘Personalising Trauma Treatment: Reframing and Reimagining’ https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwi_sby24qz2AhUOa8AKHfyaCFYQFnoECAEQAQ&url=https%3A%2F%2Fwww.taylorfrancis.com%2Fbooks%2Fmono%2F10.4324%2F9781003178132%2Fpersonalising-trauma-treatment-michael-scott&usg=AOvVaw1vevwk6WE3_-ghkv14ZpM2 published by Routledge, March 2022. The accompanying commentary and slides give a taster http://www.cbtwatch.com/wp-content/uploads/2022/03/Forget-Trauma-Focussed-Interventions-1.pptx see also Youtube https://studio.youtube.com/video/FN_ck6iCIpE/edit . Do get back to me if you would like to discuss cases. 

 

In this book, clients are taught to rediscover their sense of self by reframing the trauma. Within this new framework the focus is on the client’s mental time travel from the trauma to today and reimagining their future. The therapeutic targets are the thoughts and images (cognitions) that interfere with day-to-day functioning. It does not assume that arrested information processing lies at the heart of the development of PTSD, with a consequent need for the client to re-live the trauma. For those clients who were abused in childhood, their experiences are viewed through a particular central window, but other ‘windows’ may make for more appropriate engagement with their personal world and a reimagining of their view of themselves. Treatment delivery options from telephone consultation, group work and videoconferencing are discussed. With illustrative examples, the author highlights the pathway to recovery for a wide range of clients with the comorbidity often found in real-world settings.

The book will be essential reading for therapists and other mental health professionals working with trauma survivors.

Dr Mike Scott

Another Nail In The Coffin of IAPT

A year ago the British Journal of Clinical Psychology published my paper ‘Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin’  60(1), 38. https://doi.org/10.1111/bjc.12264. This month in the Journal there is a further damning indictment by Martin et al (2022) ‘Improving Access to Psychological Therapies (IAPT) has potential but is not sufficient: How can it better meet the range of primary care mental health needs?’ 61, 157–174, DOI:10.1111/bjc.12314.

Here are the main points from Martin et als’ BJCP paper:

  •  Improving Access to Psychological Therapies(IAPT)has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged.
  •   Given the ongoing focus on and investment in IAPT informed developments into long-term conditions and serious mental illness, this review considers whether additional elucidation of the model’s original objectives is required, as a precursor to its expansion into other clinical areas.

  •   There view indicates that there is a stark lack of data pertaining to the generalisable, real-world clinical benefits of the IAPT programme as it currently stands.

  •   Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.

 

The British Association of Behavioural and Cognitive Psychotherapies (BABCP) ought to look seriously at the promotion of its’ IAPT comic ‘CBT Today’. Interestingly in its’ recent issue it managed to omit that I was one of those who made a submission re: the proposed NICE Guidance on depression. Further, only one of the others who made submissions were given their adjectival title, the leading light in IAPT. The British Psychological Society (BPS) should reconsider its validation of low intensity IAPT courses, in the absence of any credible evidence base on real-world effectiveness.

Dr Mike Scott

Post Trauma, Quality Treatment Shouldn’t Be Traumatic – New Book

Personalising Trauma Treatment is about helping trauma victims back to their old selves and focuses on altering the perception of the centrality of the trauma.

In this book, clients are taught to rediscover their sense of self by reframing the trauma. Within this new framework the focus is on the client’s mental time travel from the trauma to today and reimagining their future. The therapeutic targets are the thoughts and images (cognitions) that interfere with day-to-day functioning. It does not assume that arrested information processing lies at the heart of the development of PTSD, with a consequent need for the client to re-live the trauma. For those clients who were abused in childhood, their experiences are viewed through a particular central window, but other ‘windows’ may make for more appropriate engagement with their personal world and a reimagining of their view of themselves. Treatment delivery options from telephone consultation, group work and videoconferencing are discussed. With illustrative examples, the author highlights the pathway to recovery for a wide range of clients with the comorbidity often found in real-world settings.

The book will be essential reading for therapists and other mental health professionals working with trauma survivors.

Michael Scott identifies the paradox, coolly critiques the evidence, and illustrates and emphasises the collaborative and crucial role of the creative, empathic, and restorative therapist in enabling the client’s natural resilience and preferences for today and tomorrow, without pathologizing normality, imposing supposed processing, and unconstrained by complacent diktat. — Greg Wilkinson Formerly: Editor, The British Journal of Psychiatry and Professor of Liaison Psychiatry, The University of Liverpool; Currently, Consultant Psychiatrist, Liverpool University Dental Hospital and Liverpool University Hospitals NHS Foundation Trust.

Dr Scott offers a unique and refreshing perspective on working with those affected by trauma, particularly when they don’t neatly fit into a PTSD ‘box’ but have nevertheless come to be defined by their experiences. Taking a critical eye to evidence-based practice, and at turns thought-provoking and light-hearted, he combines up-to-date theory and clinical pearls with a robust critique of the modern realities of service delivery. Full of rich clinical examples and dialogue that brings the reader into his therapy room, he takes you step-by-step through his clinical decision making and interventions.Highly recommended! — Sharif El-Leithy, Principal Clinical Psychologist, Traumatic Stress Service  

In Personalising Trauma Treatment: Reframing and Reimagining Dr Scott delivers an approach to treatment grounded in pragmatism and real-world functioning. After considering the pitfalls of poor assessment he guides the reader through the process of detailed and accurate diagnosis questioning whether treatments work for the supposed reasons they give. This book is a must for all IAPT & CBT therapists, counsellors and clinical psychologists involved in the care of individuals suffering with trauma. — Sundeep Sembi, Consultant Clinical Neuropsychologist, Psychology Chambers Ltd

https://www.routledge.com/Personalising-Trauma-Treatment-Reframing-and-Reimagining/Scott/p/book/9781032013121 utm_source=individuals&utm_medium=shared_link&utm_campaign=B021841_ca1_1au_7pp_d875

 

Getting Back To Me Post Trauma

this was the title of a one day workshop that I gave on Wednesday        March 4th 2020  to the Chester and North Wales Branch of BABCP. My video commentary on the day can be accessed here

https://vimeo.com/user94707142/download/397657814/67ae027afe

and the Powerpoint presentation can be accessed here 

The theoretical background to this new approach to a 1st line treatment for PTSD is described in my paper PTSD An Alternative Paradigm ptsd an alternative paradigm.

any comments gratefully received.

 

Dr Mike Scott