Corona Virus Response and Pathologising Normality

at a 1 day workshop I delivered on March 4th (‘Getting Back To Me Post Trauma’ ) I included the following slides, which with hindsight seem particularly relevant:

  1. Listen to The Story

    ‘ I’ve been back to Hong Kong a couple of times since the unrest began last Summer. A family member was terminally ill and  died recently, his affairs are still in a mess. It was terrible there, I was frightened to go out because of gangs and you just don’t know who will be listening. I am worried about my family still living there, could be effected by the Corona virus’

    Imagine this person has presented for a mental health assessment. How do you proceed? 

  2.  

    You could…
    •Administer the PHQ9 and with his score of greater than or equal to 10 conclude he had probable depression
    •Administer the PCL-5 and with his score of greater than 31-33 conclude he had probable PTSD
    •Consider that he has  adjustment difficulties or is suffering from an adjustment  disorder
  3. Are We in Danger of Pathologising Normality?

decided to write a book Traumatised as a project in my relative isolation (71)

Best wishes

 

Mike Scott

IAPT Behind Closed Doors – Falsifying Quality Control Data

My experience is that at least one person was found to have massaged the figures to reflect a greater recovery rate and consequent discharge.  This was only discovered following a particularly high level of re-referrals for ex-patients and subsequent complaints.

With regard to the PHQ 9 and GAD 7 scoring system, I feel that this could be open to abuse.  This may be because workers are under great pressure to perform and elicit results.  I believe this to have taken place as a consequence of almost overwhelming pressure to discharge referrals.  With more discharges came more referrals and there was never any acknowledgement of best practice or learning lessons appropriately.  I understood also that PHQ 9 and GAD 7 only had pertinence for those suffering from mild to moderate mental health conditions.  I had to use other tests for those persons who had suffered past trauma and more severe mental illness which I myself as a practitioner “filtered out” as a consequence of them being incorrectly referred to step 2 services.

Anonymity protected – Dr Mike Scott

The Need To Tailor Group CBT To Make A Socially Significant Difference

Given the scarcity of therapeutic resources Group CBT is an attractive option.  But to make a real world, socially significant difference in a client’s life a group intervention has to be tailored to each individual. The resources section of this forum contain free content materials for depression and the anxiety groups. Client’s want a real world change, to be free of whatever disorder/problem led them into treatment, not a change on a psychometric test.

Over the past year I’ve given about half a dozen Workshops titled ‘Delivering Group CBT’ to IAPT ( really enjoyed the last one on September 6th to North East Essex IAPT, great group!) and non-IAPT audiences, two points struck me a) most of the audience have been involved in groupwork, for a wide range of problems from low self-esteem to OCD, though most have been for anxiety and depression and b)  the groups that have been run have been more like classes than groups, in that there has been no tailoring of homework assignments in the way one would in individual therapy.  Without such tailoring it is unlikely that there will be any transfer of learning from the ‘group’ setting to the  client’s social context. Clients may express satisfaction with attending a ‘class’ with comments like ‘interesting’ and ‘useful’ but there is no independent evidence that they make a lasting real world difference. I have found it interesting how many therapists are harking for real world observable change in client’s lives and are unhappy with the psychometric test yardstick.

The need to tailor homework places a limit on the number of people that can be treated in a group, as opposed to the number of people that can be ‘taught in a ‘group’. I will return to the issue of tailoring in groups in a later post.

Dr Mike Scott

Discussion With National Audit Office Re: IAPT

On Monday I received a thoughtful, considered and detailed response from the National Audit Office with regards to my submission re: the IAPT investigation. I’ve just penned the following response:

  1. In 2011 the Secretary for State for Health, Andrew Lansley MP and the Minister of State for Care Services, Paul Burstow, MP said stated ‘we are clear that building services around the outcomes which matter to people is the very essence of personalisation’, [Transparency in outcomes a framework for quality in adult social care (2011) Department of Health] so it cannot be for IAPT to choose the yardstick by which it evaluates itself. People seek physical/ psychological treatment in the hope that they will no longer be suffering from an identified disorder by the end of treatment, this is not a matter of clinical judgement, the yardstick is primarily patient driven. If an agency supplies data that does not allow a determination of whether this transparent yardstick is met, then they are remiss. In this connection IAPT ought to be brought to task by the National Audit Office.
  1. Psychometric tests of themselves do not point to any particular NICE approved treatment, if they had this power NICE would have said so, and they did not. Tests are like road signs blowing in the wind, they can only give direction if anchored in a reliable diagnosis. Inappropriate treatment including a failure to treat ( false positives and false negatives) is inevitably ubiquitous when treatment is not moored to diagnosis. Whilst it is the case that some cut offs are better than others at identifying a ‘case’ of disorder, the  cut offs themselves vary from sample to sample depending on the prevalence of the disorder and are at best relevant to one disorder – in practise people usually have more than one disorder. IAPT essentially has two instruments the PHQ-9 and GAD-7 which they purport measure anything of significance, no medical/scientific professional would claim such powers for just two instruments.
  1. I am unsure whether the National Audit Office are aware of the paper by Griffith’s and Steen (2013) [Improving Access to Psychological Therapies (IAPT) Programme: Scrutinising IAPT Cost Estimates To Support Effective Commissioning, The Journal of Psychological Therapies in Primary Care, 2, 142-156]. that suggest that the cost of IAPT therapy sessions is 3 times more than the Department of Health Impact Assessment estimates and this may lead to very different conclusions about the cost-effectiveness of IAPT. For ease of reference I attach a copy of this paper.
  2. How has the IAPT data set demonstrated that it offers added value over a) services as they existed before IAPT b) non-IAPT services in Wales, Scotland and Northern Ireland? In the absence of such a demonstration it can be questioned whether IAPT overs value for money.
  1. It may be that one part of IAPT say high intensity therapy, is value for money but say low intensity (the most common modality) is not but no such analysis has been proferred. Why?

 

Dr Mike Scott