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

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

‘PTSD – Swap War Zone Glasses For Specs Used A Week Before Trauma’

that’s one of the clinical implications of my just published paper ptsd an alternative paradigm. On March 4th I am giving a One Day Workshop titled ‘Getting Back To Me Post Trauma’, elaborating further  on the clinical implications of this work. The day is organised by Chester and North Wales BABCP at Chester Rugby Club.

My work addresses the problem that with cognitive processing therapy, 42% of people drop out of treatment. Most between sessions 2 and 5. In the traditional CPT protocol homework at sessions 3 and 4 involves clients writing detailed accounts of their trauma, which often does not go down well. I also found that in exposure therapy barely half comply with listening to a trauma tape. I argue that the case for trauma focussed interventions is not proven and there is a more user friendly way of going about things.

 

Dr Mike Scott

  

IAPT’s Mistreatment Of Those With Medically Unexplained Symptoms (MUS)

in our paper published today in BMC Psychology, Keith Geraghty and I write of Improving Access to Psychological Therapies (IAPT) malpractice with MUS clients , see link  https://doi.org/10.1186/s40359-020-0380-2

A series of seven core problems and failings are identified, including:

  1. an unproven treatment rationale
  2. a weak and contested evidence-base
  3. biases in treatment promotion
  4. exaggeration of recovery claims
  5. under-reporting of drop-out rates
  6. a significant risk of misdiagnosis
  7. inappropriate treatment.

We concluded that:

There is a pressing need for independent oversight of this service, specifically evaluation of service performance and methods used to collect and report treatment outcomes. This service offers uniform psycho-behavioural therapy that may not meet the needs of many patients with medically unexplained health complaints. Psychotherapy should not become a default when patients’ physical symptoms remain unexplained, and patients should be fully informed of the rationale behind psychotherapy, before agreeing to take part. Patients who reject psychotherapy or do not meet selection criteria should be offered appropriate medical and psychological support.

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

Missing The Boat With A Focus on Pressing Concerns

As a matter of respect clinicians necessarily focus on a client’s pressing concerns, but the time constraints imposed by routine services, such as IAPT, means that this becomes the sole focus. The upshot is that initially the client’s focus is say on their depression but at the next appointment on disturbing flashbacks/nightmares of child abuse and at the next appointment they may mention occasional excessive use of alcohol causing arguments at home. The clinician doesn’t know where they are working is this depression? PTSD? relationship problems/ alcohol dependence? or some combination thereof. This means the clinician is unable to help the client navigate through the fog of their difficulties, changing tack with every gust of wind.

Alternatively the clinician might simply pursue the first disorder ‘identified’ because the client doesn’t mention any other, discharging the client at the first signs of an improvement on some psychometric test or when progress has been made on that disorder. Despite the client actually suffering from a number of other disorders, making any gains in the ‘successful’ domain likely short lived. The client’s then go thru a revolving door. It seems that clients are rarely asked ‘are you back to your usual self following this treatment? and importantly ‘how long have you been back to your usual self for? [ anything less than 8 weeks is likely nothing more than the waxing and waning of the natural course of a client’s symptoms].

One of the ways of getting the bigger picture is to first use an open ended interview that contains the screen below, the dropbox link for this

APPENDIX A. SCIP screening questions
Codes: 0=absent, 1=present, 8=unsure, 9=missing data, unless otherwise
specified in the question
Questions apply to the present episode, typically the past month, unless otherwise
specified by the interviewer.
HAVE YOU:

  1. Felt very anxious and afraid out of proportion to the situation (with or
    without physical symptoms) for more than one month?
  2. Had panic attacks, when you suddenly felt anxious and frightened and
    developed physical symptoms, such as fast heart beat, shaking, or
    sweating?
  3. Been afraid of going out of the house alone, traveling alone, being alone,
    being in crowds?
  4. Been afraid and anxious doing things in front of people, such as eating in
    public, speaking in public?
  5. Had unpleasant and unwanted thoughts or images coming into your mind
    over and over even if you try to get rid of them? Examples: Contamination
    or aggressive, sexual, or religious thoughts.
  6. Had the urge to do things over and over and could not resist doing them
    (such as washing your hands even if they are clean, checking doors,
    counting up to certain numbers, reciting phrases)?
  7. Witnessed or experienced a traumatic event that involved actual or
    threatened death or serious injury to you or someone else (e.g., physical or
    sexual abuse, terrorist attack, natural disaster, war)? Did you feel intense
    fear and helplessness?
  8. Re-experience the traumatic event in the last month in a distressing way
    (flashback, nightmare)?
  9. Had physical symptoms or physical illness for which doctors did all
    necessary work up and could not find medical explanation?
  10. Had pain and your doctor did all necessary work up and could not really
    explain?
  11. Worried about gaining weight to the point that you self-induced vomiting,
    or used diet pills, laxatives, or heavy exercise?
  12. Eaten a large amount of food within an hour or so, that is binge eating?
  13. Felt or described your mood as sad, downcast, gloomy, low in spirits, or
    depressed?
  14. Been unable to enjoy things like walking, working at your hobbies, or
    socializing with friends as usual?
  15. Had thoughts about harming yourself or even made an attempt at suicide
    (Include whether thought was due to depression or not)?
  16. Felt very happy, elated without reason, or very irritable without reason?
  17. Had mood swings: periods of depression and elation or irritability?
  18. Felt that people are spying on you, follow you around, talk about you?
    Felt that there is a plot or conspiracy against you?
  19. Felt that people are trying to harm you or poison your food?
  20. Had experiences of hearing voices or noises that other people cannot hear?
  21. Had experiences of seeing things (images, flashes, shadows, objects,
    people, whole scene) that other people cannot see?
  22. Been violent in the past (with or without the influence of alcohol or drugs)?
  23. I would like to ask you questions on alcohol use over the past year:
    A. On days when you drank, did you drink >5 alcohol drinks per day
    (sometimes)?
    B. Did you have any problems resulting from drinking alcohol?
  24. I would like to ask you questions on illicit drug use (e.g. marijuana) over
    the past year:
    A. Did you use the illicit drug >10 times per month?
    B. Did you have any problems resulting from using the illicit drug?

is also below:

https://www.dropbox.com/s/j5rfmy6hthp6142/Reliability%20of%20Diagnoses%20SCIP.pdf?dl=0

then when you have an idea of possible diagnoses you can make systematic enquiry about all the symptoms of that disorder using the diagnostic questions in Simply Effective CBT Scott (2009).

In my view the poor results for therapy in routine practice is often because the therapist doesn’t know what they are dealing with rather than therapeutic competence per se.

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Dr Mike Scott

Without IAPT, The Same ‘50%’ Recovery Rate – Why Do CCG’s Fund It?

One of IAPT’s criteria for claiming patient recovery is shifting a patient’s PHQ9 score to less than 10. But in a study by Gilbody et al (2015) [ see link below] involving 179 patients undergoing treatment as usual in primary care with an initial diagnoses of depression and PHQ9 scores of above 10, 101, (56%) of patients recovered within 4 months. [ A study of treatment as usual cases by Moore at al (2012) similarly showed a 47% recovery].  IAPT currently claims a 50% recovery rate, the burden of proof is on IAPT to demonstrate that it produces results significantly different to those treatments engaged in before its’ inception.

Even when the metric is an adequate treatment response the differences between IAPT and treatment as usual (TAU) are not apparent. In the study  by Moore et al (2012) [see link below] of 576 TAU cases of depression who completed the PHQ9 twice (mostly within 3 months)  63% showed an adequate treatment response ( a drop of 5 or more points), this is not  discernibly different to IAPT’s findings.

CCG’s want it seems to be seen to be mindful of mental health, as their masters NHS England dictate, but don’t want to engage in effortful thinking in this domain, bypassing it by talking only of operational matters, numbers, waiting times etc.  It is a new political correctness that also permeates the political parties.

The true metric of recovery is returning a person to their usual self ( a minimum component of which is losing diagnostic status, assessed independently), IAPT has studiously avoided  such a hard outcome measure preferring its’ own surrogate. All this despite that the original randomised controlled trials for anxiety and depression insisting on hard outcome measures.

 

Unfortunately mental health charities are often now dependent on IAPT and private agencies seek to ape IAPTs metrics, the upshot is that for the past decade there has been precious little evidence based psychological treatment of the sort I advocated in Simply Effective CBT London: Routlege (2009).

https://www.dropbox.com/s/awwtpdhv0mxbtht/Treatment%20as%20usual%20recovery%20rate%202015%20Gilbody.pdf?dl=0

https://www.dropbox.com/s/mupj14fq14eba4g/Depression%2050%25%20natural%20recovery%20on%20PHQ9%20within%203%20months%20of%20GP%20diagnosis.pdf?dl=0

Dr Mike Scott

A New First Line Approach To PTSD

On March 4th 2020  I gave a One Day Workshop  Getting Back To Me Post Trauma   detailing the practical implications of my recently published paper ptsd an alternative paradigm. Hope you enjoy the Powerpoint presentation and find the paper interesting. There is a video commentary on the day at cbtwatch.com, please feel free to make your comments and observations there or e-mail me on michaeljscott1@virginmedia.com.

I have just been preparing for a Workshop, I am delivering to the Merseyside Branch of BABCP, on October 4th 2018, titled ‘CBT for PTSD and Beyond’. At this Workshop I shall  unveil my KISS Model of PTSD. KISS for the uninitiated stands for Keep It Simple Stupid. Unlike trauma focussed models of CBT and EMDR, it does not assume a flawed traumatic memory or arrested information processing.

 

 

As part of the presentation I will be saying that therapists should beware of questionnaires as they will overidentify symptoms because:

a) they don’t tease out whether a particular symptom is making a ‘Real World’ Difference e.g a respondent might indicate upsetting dreams, but if they are not woken by the dream and distressed this is not significant functional impairment and so would not count as a symptom that is ‘present’

b) in completing a questionnaire client’s are often not clear about the time frame under consideration, endorsing flashbacks/nightmares when they did have them initially but they are past, and also endorsing symptoms currently present such as poor sleep. For a diagnosis of disorder symptoms have to be simultaneously present and each must make a ‘real world’ difference. Only in an interview can you tease out both and request concrete examples of the extent to which a symptom is impairing functioning

Dr Mike Scott

The Cost of IAPT Is At Least Five Times Greater Than Claimed

The British Medical Journal has just published the following letter of mine online with the above title:

‘Six years ago a News headline in the BMJ proclaimed ‘Increasing access to psychological therapies will cost NHS nothing’ BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4250, citing a report of Lord Layard  of the Mental Health Policy Group of the Centre for Economic Performance http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp, that claimed ‘after an average of 10 sessions half the people with anxiety conditions will recover, most of them permanently, and half the patients with depression will recover’ .  Far from being substantiated an independent assessment by Scott (2018), http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264, using a standardised diagnostic interview, suggest a 10% recovery rate. This represents a five-fold increase of the cost of treatment per cured person.

The progenitors of IAPT, Clark and Layard in their book Thrive (2015) claim that the cost of treatment in IAPT is £650 per person, for people having attended 2 or more treatment sessions.  This leaves out of account the 40% of its clients who attend only one treatment session [IAPT (2018)] and the costs of the initial assessments which totalled £92 million in 2016-2017, with total costs of £367,219,192 in that period.  This means that the true cost of IAPT is at least 5 times greater than alleged, all without any government funded independent audit. Further average session attendance for those ‘treated’ in IAPT is 6.6 [IAPT (2018)] not the average of 10 sessions that Lord Layard deemed necessary, so that the average patient in fact receives a sub-therapeutic  dose of treatment.

In 2012 Lord Layard claimed ‘the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy’. This claim remains unproven and what limited evidence is available points in the opposite direction. How do Clinical Commissioning Groups justify paying such inflated sums? how can they be sure another agency could not achieve the same for less? how do they know that GPs simply tracking clients with depression and anxiety disorders would not achieve the same outcomes? NHS England should surely advise CCG’s to ask searching questions and organise a long overdue government funded independent audit of IAPT focusing on real world outcomes, such as loss of diagnostic status..

BMJ (2012) ;344:e4250 Increasing access to psychological therapies will cost NHS nothing, says report

Clark, D.M and Layard, R (2015) Thrive: The Power of Evidence-Based Psychological Therapies London: Penguin.

IAPT (2018) Psychological Therapies: Annual report on the use of IAPT services England, 2016-17 Data Tables. NHS Digital: Community and Mental Health Team.

Mental  Health Policy Group of the Centre for Economic Performance (2012) How mental health loses out in the NHS.   http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp.

Scott, M.J (2018) IAPT: The Need for Radical Reform. The Journal of Health Psychology, 23, 1136-1147.

 

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