Tag: NHS Talking Therapies

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Implementing and Monitoring Adherence to NICE Guidelines for Depression and the Anxiety Disorders

The evidence on the translation of the Guidelines  to routine practice is conspicuous by its’ absence. Claims to be NICE compliant are used by mental health service providers to secure funding, but without credible evidence of the Guidelines influencing routine practice. But some individual practitioners within providers such as NHS Talking therapies and Anxiety UK may be compliant. As may some independent practitioners.

There is no agreed audit tool, despite spending £2 billion a year on NHS Talking Therapies

NICE guidelines are diagnosis specific, but NHS Talking Therapies’ practitioners do not make diagnoses, making compliance impossible.  Instead its’ clinicians assign an ICD-10 diagnostic code, to what they see as the main presenting problem.  But there is no evidence that this is a reliable surrogate for a standardised diagnostic interview. The randomised controlled trials on which the Guidelines are based, begin with a reliable diagnosis and a matching treatment protocol.  In NHS Talking Therapies there is ‘no key and lock’.

Rather treatments are random, with alleged CBT programmes for disorders such as ‘mixed anxiety and depressive disorder’, that are not in the NICE lexicon. Yet, we are invited to believe that the recovery rate for this, protocol-free disorder, of over 50%,   is on a par with the general recovery rate! 

In my book Simply Effective Cognitive Behaviour Therapy (2009) London: Routledge, using the idea of a Sat Nav, I identified the treatment targets for each disorder and the matching treatment protocol. Making it possible for clinicians to get to their destination.  But in years since the inception of IAPT, out of the 100’s of treatment records I have reviewed, there has been scarce evidence of compliance to any treatment protocol (fidelity) and in the rare instances where it has occurred, there has been no flexibility e.g  persistence with a trauma focussed approach, which was clearly not working, leading the client to default. Flexibility within fidelity has not materialised.

Dr Mike Scott

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NHS Talking Therapies Proceeds by Copying

but as anyone knows who has copied a fellow pupil’s homework, this can end in tears! The Service believes, it disseminates ‘best practice’ by networking clinicians together. But there is no evidence that this is the case.Those most vocal or most eminent are likely to hold sway. Ensuring the dominance of eminence not evidence-based treatment. This runs the risk of creating a totalitarian culture in which it is not possible to express a dissenting opinion. The power-holders then control what is published in journals/publications. But like the Russian regime of the 1980’s they would vigorously protest that they are engaged in Glasnost (0penness).

The use of artificial intelligence in mental health is an exemplar, ‘par  excellence’ of copying. The authors of IESO claim that its interactive text messaging service for clients, is based on the careful selection and analysis of client-therapist exchanges and that they have determined what works. If indeed this were the case it would make the provision of mental heath services much cheaper for the NHS (as well as making a nice profit for IESO). But no such reliable database with real-world outcomes e.g being free of a disorder as assessed by an independent observer for at least 8 weeks, has been determined.There are no published papers to substantiate a real-world effect. Without fidelity checks there can be no assurance of the translation of an evidence-based treatment to routine practice.

I recently read James Davies’s book Sedated: How Capitalism Has Created the Mental Health Crisis, (2021) Atlantic Books, without necessarily buying into his thesis that Capitalism is the arch-enemy, it is certainly the case that financial factors ( NHS Talking Therapies cost the taxpayer £ 2 billion a year), coupled with the opportunity to exercise unbridled power has produced a dysfunctional mental health system. But the problems are not confined to primary care, I recently saw a client who has had 4 years of secondary care treatment in relation to child abuse, the records revealed no objective audit. This echoes the National Audit Offices failure to provide any credible independent assessment of mental health services. There is an inherent believe that the mental health services must be all too the good because the clinicians are well-intentioned. But if they had stopped long enough to listen to my client he would have told them ‘I need a new approach, I have plateaued’. In reality there is no Glasnost. Let’s no be copy-cats.

 

Dr Mike Scott

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NHS Talking Therapies the Victory of ‘Satisficing’ Over What Clients Really Want 

 

Satisficing is a term used by economists to denote a decision-making strategy or cognitive heuristic that involves searching through alternatives until an option is considered to clear an acceptability threshold. The Labour Party Economist, Lord Layard considered that with the help of psychologist, Professor David Clark, they could make a sufficiently plausible case to Government to fund the Improving Access to Psychological Therapy (IAPT) service [now rebranded NHS Talking Therapies for anxiety and depression]. In this they were successful [‘Thrive’ Layard and Clark (2014)]. The new Labour Government shows no sign of wanting to review its’ received mantra, despite a cost £2 billion a year for Adult and Child mental health services. But the voice of mental health sufferers has been nowhere in evidence. There was no evidence that the proposed mode of service delivery would result in recovery, in a way that was intelligible to sufferers, such as no longer suffering from a disorder for a significant period of time.

In the 2011 book by Psychologist, Martin Seligman ‘Flourish’, Layard chides him  “You, like most academic types, have a superstition about the relation of public policy to evidence. You probably think that Parliament adopts a program when the scientific evidence mounts and mounts, up to a point that it is compelling, irresistible. In my whole political life, I have never seen a single example of this. Science makes it into public policy when the evidence is sufficient and the political will is present”.

But what if there are vested interests in determining what is ‘sufficient evidence’ ? For sixteen years the Service has continued to proclaim its’ 50% recovery rate, despite no independent evidence using a ‘gold standard’ diagnostic interview.

 

Heuristics have the advantage of speed, getting things done, but not necessarily well enough from the point of view of the consumer. ‘Satisficing’ is a powerholders judgement, imposing its’ will, blind to cient’s satisfaction but very attractive to other powerholders. With a ‘satisficing’ rationale Layard also announced his intention to bring ‘positive education’ to schools. There has been a psychopathologising of the young with diagnoses of ADHD or ASD seen as the gateway to services and a sought after explanation of difficulties. With little attention to alternative and often more credible explanations of difficulties. This is not to deny that there are those few who truly have ASD in the traditional sense of the term. In practice, there is a de facto absence of specialist reliable assessment for these conditions. The upshot is that a great many people are treated ‘as if’ they have these conditions and may self-diagnose these conditions. 

 

Seligman, Martin E. P.. Flourish . Nicholas Brealey Publishing. Kindle Edition. 2011

 

Dr Mike Scott

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NHS Talking Therapies Black Hole

Data is only publicly available on the 1 in 2 people who undergo treatment, those who have had just one assessment/treatment session have disappeared down a black hole for the past 16 years. This is hardly the transparent and comprehensive monitoring of outcome claimed in the NHS Talking Therapies updated Manual.

But following a Freedom of Information request (FOI) I have obtained data on those attending only 1 session. But the diagnostic status of almost a third (29.1%) was unknown, making the Services claim to follow NICE approved diagnostic specific protocols meaningless. 

 


The Manual 5.1.3  recommends ‘systematic screening for all the conditions that NHS Talking Therapy treats’.  But there are 11 conditions that the Service treats.There is no evidence that at assessment its’ clinicians employ a standardised screen for the spectrum of disorders that they claim are within their remit to treat. Nor that they use a screen to rule out the disorders that they do not treat: personality disorder, psychosis, bipolar disorder and eating disorder. In the foreword to the Manual it states that those who do not go on to treatment are given ‘advice and signposting (if appropriate)’. But there is no clarity about the content of this ‘advice’ nor of its’ evidence base.  Signposting it seems may not occur, but this could plausibly be because the assessing clinician (usually the most junior member of staff- a Psychological Wellbeing Practitioner) simply doesn’t know the way.  One has a strong suspicion that those who have simply an ‘assessment’ disappear down a black hole, only to possibly re-emerge in desperation, when their difficulties have not resolved.

NHS Talking Therapies published data is at best consistent with passing improvement, for disorders that largely wax and wane anyway. 

Dr Mike Scott

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The Care Quality Commission and NHS Talking Therapies

I have today received the following response from the CQC, after seeking clarification from them of the position between the two. (Thanks to Michael Brazendale for raising the matter with me, in my previous blog).  

Dear Dr Scott,

 

Thank you for your email. I’ve liaised with our policy colleagues and the current position is set out below.

 

  • Psychological therapies are a critical part of mental health services and CQC has a role to ensure that people receive safe, effective, compassionate, high-quality care.
  • The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 schedule 1 defines what ‘regulated activities’ are and ‘Treatment of disease, disorder or injury’ (TDDI) is a regulated activity defined in schedule 1(4)
  • TDDI requires the activity to be provided by or under the supervision of a health care professional or social worker – whether psychological therapies is a regulated activity will depend on the person providing it or supervising it
  • CQC therefore regulates psychological therapies that are provided by or under the direct supervision of a doctor, nurse (‘health care professionals’ defined in the Regulations) or a social worker.

 

Does CQC regulate IAPT services?

  • In the IAPT services model, supervision is most likely led by senior therapists (not medical staff), so this would probably not include a nurse, medical practitioner or social worker therefore, CQC would not be able to regulate psychological therapies in IAPT services as they are usually led and supervised by therapists and not a nurse, medical practitioner or social worker.

 

What does future regulation of psychological therapies look like?

  • We are working with DHSC, trade associations and other key stakeholders to identify and understand how we may inspect and rate psychological therapies going forward and to make sure our legislative powers cover all which needs to be covered, which may include IAPT services.

 

I hope this response is helpful.

 

Many thanks

 

Mat

 

Matthew Hughes

Senior Parliamentary and Stakeholder Engagement Adviser

07384 525677

 

For information about CQC, including contact details, information about how we use and protect personal data, and how to request information from us, go to https://www.cqc.org.uk/contact-us

He responded very quickly to my e-mail and in depth, for which I  have thanked him. I would be very interested in any comments on this missive which I could take forward.

Regards

 

Dr Mike Scott

I responded today March 22nd as follows;

Hi Mat

Following on from your email of yesterday I note that the CQC believes that:

‘Psychological therapies are a critical part of mental health services and CQC has a role to ensure that people receive safe, effective, compassionate, high-quality care’.

I gather from your e-mail that the CQC role is restricted to coverage of agencies, in which a Doctor, Nurse or Social Worker heads the Service Providing agency. How many Service Providers of Psychological Therapies has the CQC inspected? Are there publicly available reports on the inspections? What proportion of NHS Talking Therapies Providers fall under the orbit of the CQC?

It appears that the scope of the CQC has been limited by the ’The Health and Social Care Act 2008 (Regulated Activities)’ and there is no mention of psychologists. This may be because NHS Talking Therapies in the shape of IAPT did not come into being until 2008 and the Service has slipped under the radar of the CQC. In my experience it is usually a psychologist who is at the head of a local NHS Talking Therapies Service.

If the CQC is to discharge its’ role, it is difficult to see how this can be done without broadening its terms of reference. In terms of the protection of Service Users there can be no justification for the de facto exemption of the great majority of NHS Talking Therapy sites, from CQC inspection. I appreciate that at present the inspection framework has yet to be decided  but this is a separate matter from establishing the legitimacy of CQC inspection across all psychological therapies Service providers.

I would be grateful for your response to these matters.

Dr Mike Scott

 

 

 

 

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What Mediates Treatment Outcome in NHS Talking Therapies?

 

 


A treatment must directly impinge on a mediator, and the change in the mediator must result in a change in outcome. The mediator and the outcome must be distinct. Thus for example, in the treatment of panic disorder, anxiety sensitivity (the belief that physical and emotional arousal is dangerous) is a mediator of outcome. The treatment, interoceptive exposure (deliberate induction of uncomfortable sensations) dovetails with anxiety sensitivity to affect outcome, the absence of panic attacks. But in                                   NHS Talking Therapies one searches in vain for a mediator – it is all CBT talk, without any substance.

In attempting to apply mediational analysis to NHS Talking Therapies one enters a minefield:

  1. There is no clarity about which disorder/ difficulty is the focus. It could be panic disorder/attacks but there is no reliable mechanism for ruling out disorders beyond the scope of NHS Talking Therapies, such as personality disorders.
  2. Potential mediators are legion, and might include variously post-traumatic cognitions, dysfunctional attitudes and anxiety sensitivity.
  3. There is no evidence that NHS Talking Therapies clinicians have targeted any specific mediator.
  4. In reality NHS Talking Therapy clinicians operate a ‘black box’. Those who have been allowed to penetrate its’ contents Drew et al’s (2021) and Faija et al (2022) have discovered a machine-like process were priority is given to client’s completion of psychometric tests, which do not inform treatment. There is no evidence of the application of mediational analysis.
  5. Outcome is not assessed in NHS Talking Therapies with any hard outcome measure, assessed independently.
  6. All that can be said of NHS Talking Therapies is that time (number of sessions) mediates outcome, but this could be said equally in any possible control group. Time as such is not a relevant theoretical mediator.

 

NHS Talking Therapies claim to provide cognitive behaviour therapy (CBT) is preposterous, as the hallmark of CBT is the highlighting of disorder specific mechanisms of change and corresponding treatment interventions. It is difficult to escape the conclusion that alleging the provision of CBT is simply a good marketing ploy, enhanced by claims to be able to treat over a million people a year.

 

Dr Mike Scott

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‘No Direct Evidence of The Effectiveness of NHS Talking Therapies’

If you disagree, please supply the evidence. The justification for NHS Talking Therapies rests solely on indirect evidence. Primarily the randomised controlled trials cited by the National Institute for Health and Care Excellence (NICE) for depression and anxiety disorders. But there is no assurance (fidelity checks) that these protocols have been accurately translated into routine practice. NHS Talking Therapies legitimate themselves by claiming NICE compliance. Whilst this might be excellent marketing, there is no evidence to substantiate it. Further the randomised controlled trials are themselves of variable quality. In a minority of trials there has been blind independent assessment. In principle the high-intensity NHS Talking Therapy Service could have the capacity to deliver these evidence-based treatments. But there is no evidence that this has actually happened – a gap between theory and practice. By comparison the low intensity NHS Talking Therapy Service has the reference base of relatively poor quality studies. Not only is there the problem of a dirth of evidence of compliance with a NICE approved protocol, but the foundations of the low intensity protocols are weak.

All manner of interventions can be made to appear great in theory. But the acid test is what happens in the real-world. Disinterest in this, paves the way for vested interests, whether they be Organisations or charlatans marketing their wares. Organisations readily adopt a volume approach, operational matters: numbers seen, waiting times, become the key performance indicators, with a blind eye turned to value. NHS Talking Therapies acts it seems in its’ own interest and the client does not get a look in. One might ask how matters have reach such an impasse? Professional bodies such as British Association for Behavioural and Cognitive Psychotherapy (BABCP) and the British Psychological Society (BPS) have advanced NHS Talking Therapies mission at every turn.They have totally failed to critically appraise NHS Talking Therapies.

 

Dr Mike Scott

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NHS Talking Therapies Both Judge and Jury On Recovery

Would you invest in a company simply on the basis of its proclaimed profits? But that is exactly what successive governments have done every year, for the past fifteen years. At a cost of £752 million in the year 2021 for adult Mental Health Services, £922 million on child and adolescent mental health (excluding funding for eating disorders £73 million). Making a grand total of £1.75 billion [Figures from the National Audit Office (NAO ) Report of February 2023] for 2021-2022. The NAO  re-iterates, uncritically, IAPT’s claim of a 50% recovery rate for the Adult mental health service, neglecting to say that there has been no independent verification of this. Further there is not even a claim to the effectiveness of Child and Adolescent Mental Health services!

The NAO  is unphazed by the haemorrhaging of clients from the NHS Talking therapies for Adults. It notes, without comment, that  46% of its clientele drop out before treatment, were treatment is  defined as attending 2 or more treatment sessions. So that the much vaunted 50% recovery rate, applies only to those who complete treatment! 

My own work Scott (2018) on 90 clients going through NHS Talking Therapies predecessor IAPT, was that only the tip of the iceberg recovered.

Dr Mike Scott

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Does NHS Talking Therapies Alter The Course of Mental Health Symptoms?

After 15 years of the Service and £10 billion spent on it, we still do not know! If ever there was a matter for Health Ministers, the Office of Budget Responsibility and the Nation al Audit Office, this is it. To date NHS Talking Therapies have only ever taken their own snapshots of clients, discharging them as soon as their scores fall below ‘casenness’ on a psychometric test. But the natural course of anxiety and depression is a waxing and waning. A photo at any one point is next to meaningless, particularly if it is taken by a party with a vested interest in declaring recovery.

In a 2 year naturalistic study, of depressed, anxious and depressed plus anxious patients in the Netherlands,  Penninx et al (2011)  the criteria of recovery was at least 3 months free of symptoms as assessed by a diagnostic interview. This metric ensured that they were looking at how long it took to what could be taken as a real-world change. [A far cry NHS Talking Therapies studies]. With half of depressed patients recovering within 6 months. Half the anxious group recovered by 16 months and half the combined group by 24 months. Of those who remitted a quarter relapsed. Approximately half the population had psychological treatment and they fared no better than those who didn’t. There is no evidence that NHS Talking Therapies clients fare any better than those in the Netherlands or than those attending the Citizens Advice Bureaux.

In my capacity as an Expert Witness to the Court I reviewed 90 cases Scott (2018), some of whom had NHS Talking Therapies treatment before a personal injury and others who were treated afterwards, whichever was the case only the tip of the iceberg recovered. I called for a a publicly funded independent assessment of the Service, 5 years on, nothing, just a rebranding of IAPT earlier this year. 

 

Dr Mike Scott

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NHS Talking Therapies Under a Cloud

SilverCloud is a computerised CBT programme, which according to the manufacturers supports ‘80%’ of the NHS services. A year ago, I complained to the Advertising Standards Authority (ASA) over its’ claim of, ‘up to 70% clinical recovery rates’, citing my independent evidence, Scott (2018), that only the tip of the iceberg recover.  The matter was passed to the Irish ASAI, under whose jurisdiction it actually falls, and they informed me  (April 27th 2023 ) that the advertised claim has since changed from “up to 70% clinical recovery” to “up to 65% users achieve clinically significant improvement”. For whatever reason there has been a watering down of SilverCloud’s claim. They no longer want to talk about recovery, a concept that most people can easily understand. The ASAI are continuing to address the matter. Unfortunately NHS Talking Therapies, are it seems answerable to no one and there is no indication that they are abandoning their absurd claim of a 50% recovery rate.

The claim that 65% achieve clinically significant improvement, has a scientific aura about it for a member of the public, but with no idea as to what it means in real world terms. They might consider that as ‘77% of volunteers agreed that volunteering improved their mental health and wellbeing’, National Council for Voluntary Organisations survey 2019, this was actually a better investment.  The implication of SilverCloud’s claim is that it is the use of their product that has brought about the ‘significant improvement’ but this has not been demonstrated. The said improvement could represent regression to the mean, patients presenting at their worst and becoming a bit better with time. Equally it could represent the client’s wish to please the therapist and/or to feel that they have not wasted their time. The claim of ‘significant improvement’ because of usage of the product is not evidence-based and is simply a marketing ploy.

NHS Talking Therapies have produced no evidence that its’ therapists using SilverCloud make any added difference to their clients over and above that of those who didn’t use it. see SilverClouds Space for Depression programme   NICE Guidance ‘Space from depression for treating adults with depression’ Medtech innovation briefing published May 7th 2020. Strangely the NICE IAPT Expert Panel concluded that the case for adoption is ‘partially supported’ despite in the body of report noting lower depression scores, at the end of treatment for the clients of therapists who did not use the computer assisted CBT. An example of spin and conflict of interest.

Dr Mike Scott