Psychological Therapy With Long Term Conditions

Improving Access to Psychological Therapies (IAPT) therapists working with long term conditions (LTC’s) have confidence and organisational, issues Carroll et al (2021) DOI: 10.1111/bjhp.12475. Whilst therapists working in secondary care, with LTC’s, face fewer obstacles to multidisciplinary working, with a focus primarily on the LTC and not on the associated depression/anxiety as in IAPT. Further the metrics for outcome in secondary care are likely to be much broader than in IAPT. LTCs by their very nature, wax and wane with a consequent impact on availability and concentration, creating a need for any therapy to be long term. But IAPT has a major focus on access and waiting times, such that any treatment is usually brief, comprising on average of 6 sessions, thus the service cannot readily accommodate working with LTCs.

The focus in the Carroll et al (2021) is on how the psychological treatment for those with LTC”s can be best integrated into primary and secondary care. They note however that the model they use to identify barriers and facilitating factors to implementation, first requires, evidence that the chosen intervention/s are effective. But they do not address this point. This is crucial, where is the evidence that the psychological therapies for disorders that are comorbid with LTCS make a real world difference?

A case has long been made that it is a matter of basic humanity to offer to accompany a person with an LTC if they so wish. A host of Charities have formalised this. The support may be social, e.g befriending, groups and/or instrumental e.g help with DWP application. The case for profferring ‘support’ is I think uncontestable. But many with LTC’s are wary of being defined by their condition. A dedicated support group may serve as a further reminder of their condition. They may decline involvement in such a group, but this is not necessarily a matter of avoidance, simply that they do not wish to define themselves or their world through the lens of their LTC. If psychological difficulties are grafted on to their LTC they may be even more likely to decline involvement with psychological therapists because it is an LTC type lens (a variant) through which they are being encouraged to view themselves and their personal world with perceived deleterious consequences. Arguably the LTC lens used in secondary care is likely to be less problematic than that used in IAPT. But the issue of centrality has not been systematically addressed with regards to LTCs. In the authors forthcoming work ‘Personalising Trauma Treatment: Reframing and Reimagining’ to be published by Routledge the issue of centrality [ Bernsten and Rubin (2006) (2007)] is addressed in detail with regards to trauma.

There is a distinction between long term physical health conditions and medically unexplained symptoms (MUS), the former are open to objective identification e.g diabetes, the latter are not. In considering the former the therapist feels that they are on solid ground, albeit that it is largely the domain of the medic, with whom there may be fruitful dialogue. But when it comes to MUS the therapist is in a fog, where are the signposts? There is no reference book for translating best practice with LTCs to clients with MUS. Because of this there is likely to be recourse to a powerful body insisting that the way forward is ‘x’ but without any evidence, a recipe for disaster. IAPT”s juxtaposition of LTCs and MUS, smacks more of pragmatism to secure maximum funding, rather than seriously addressing a clinical problem. Where is the therapeutic alliance in addressing MUS symptoms? What is the goal, What are the agreed tasks? Whither the bond, when the therapist covertly believes that the client is somatising and the client believes there physical symptoms are as real as toothache?

Carroll, S., Moss-Morris, R., Hulme, K., & Hudson, J. (2021). Therapists’ perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions. British journal of health psychology26(2), 307–324. https://doi.org/10.1111/bjhp.12475

Berntsen, D., & Rubin, D. C. (2006). Centrality of Event Scale: A measure of integrating a trauma into one’s identity and its relation to post-traumatic stress disorder symptoms. Behaviour Research and Therapy, 44, 219–231. https://doi.org/10.1016/j. brat.2005.01.009

Berntsen, D., & Rubin, D. C. (2007). When a trauma becomes a key to identity: Enhanced integration of trauma memories predicts posttraumatic stress disorder symptoms. Applied Cognitive Psychology, 21, 417–431. https://doi.org/10.1002/acp.1290

Dr Mike Scott

‘Intensive Care PTSD’

this was the banner  headline on the BBC News today, January 13th 2021. It followed the announcement of a study by Prof Neil Greenberg, which revealed that staff had been ‘traumatised’ by the first wave of the pandemic. This in turn led for Paul Farmer Chief executive of MIND to call for ‘the right support at the right time’ on BBC radio 4 today. The Government has promised an extra £15 million so that extra support can be given.  But what sort of support?

In the press release accompanying publication of his study in the journal Occupational Medicine, Professor Greenberg notes ‘Further work is needed to better understand the real level of clinical need amongst ICU staff as self-report questionnaires can overestimate the rate of clinically relevant mental health symptoms’. His study was based on a web survey of ICU staff about half of whom responded, about half whom met the ‘threshold’ for PTSD, severe anxiety or problem drinking. There is a clear need to go beyond self-report measures.

I am currently writing a book ‘Personalising Trauma Treatment: reframing and reimagining’ to be published by Routledge. In this work I suggest that the initial conversation with trauma victims   should include ‘Gateway Diagnostic Interview Questions’ , with regard to Covid an appropriate subset would be:

Depression (evidence that at least one of the answers to the following questions is in the affirmative)

1. During the past month have you often been bothered by feeling, depressed or hopeless?

2. During the past month have you often been bothered by little interest or pleasure in doing things?

 

Panic Disorder

1. Do you have unexpected panic attacks, a sudden rush of intense fear or anxiety?

2. Do you avoid situations in which the panic attacks might occur?

 

Post-traumatic Stress Disorder

In your life, have you ever had any experience that was so frightening, horrible or upsetting that, in the past month, you

1. Have had nightmares about it or thought about it when you did not want to?

2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

5. Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the events may have caused?

Evidence that at least three of the answers to the symptom questions above are in the affirmative

Alcohol Dependence (evidence is that the response to the first three of the following questions is in the affirmative)

1. Have you felt you should cut down on your alcohol/drug?

2. Have people got annoyed with you about your drinking/drug taking?

3. Have you felt guilty about your drinking/drug use?

4. Do you drink/use drugs before midday?

Asking GDIQ questions encourages the person to furnish possible examples of the impact of the symptom on their life, so that they feel listened to. Reference can then be made to other  diagnostic symptoms for the particular disorder, to tease out whether there are sufficient impairing symptoms for that disorder, to merit that diagnostic label.  Use of GDIQ’s is part of a conversation, it is not a rapid fire interrogation or checklist. As a supplement to the GDIQ people can be asked whether this is something that they want help with, as they might not want to verbalise that they want to sort the problem out themselves, but are too polite to express this. 

The NICE recommended treatments are diagnosis specific, thus there is a recommendation of trauma focussed CBT for PTSD. But those traumatised by Covid are likely to find it toxic to be pushed to describe in graphic detail the horrors encountered. In my book I argue that this is unnecessary, rather that what is of key importance is to assess what the person takes their memory of being in ICU means about today. It is not the event that causes PTSD but the mental time travel to the worse period and the significance given to it  for today. This approach  is much less challenging for whoever is  accompanying the effected medical staff and family/friends who have seen horrors.

 

Dr Mike Scott