Beyond the Stigma of Mental Health

If the stigma of having a mental health problem was abolished overnight, it wouldn’t make a real world difference to the daily life’s of any of the enormous  numbers of sufferers that I know. Being against stigma is like being against war, desirable, but no guarantor of functioning. Politicians and Prince’s rightly clamour to be against the stigma surrounding mental health problems but it is delusional to think this has or could determine recovery from any recognised disorder. The clamour is often associated with the promise of more monies for mental health.  This is  given a cautious welcome by providers of mental heath services, but with a muttering  of ‘yes but it is not enough, we need (an unspecified sum)  to expand’. There is a steadfast refusal to acknowledge that even those currently treated are ill-served.

In my recent BBC TV interview (October 19th) I made the point that there is only a 15% recovery in the IAPT service, a total abscence of independent assessment despite spending over £1billion on the service, initial assessments by telephone by the least qualified clinicians, resulting in treatment built on sand. IAPT declined to be interviewed and simply re-iterated its’ party line, with no attempt to critique my findings.   This has been followed by a deafening silence, what does this betoken?

 

Dr Mike Scott

‘I Have a Right to Know Whether Treatment Has Made A Real World Difference’

From a client’s point of view if they were considered ‘bad enough’, on the basis of a standardised diagnostic interview, to enter a controlled trial, the latter should also be the yardstick for judging whether their treatment was a success i.e they are ‘good enough’ not to be included in a further trial. Perhaps the researchers would like to explain to clients why there is an asymmetry between the assessment (standardised diagnostic interview) and outcome processes (the latter relying on self-report measures).  Arguably consent to treatment should only be given once the client feels this asymmetry has been properly explained! This is I think a matter for the National Institute of Health Research to consider when reviewing applicants for research funds, as a reviewer I have sometimes found submissions lacking this ‘real world’ feel.

 

Cuijpers et al meta analysis in 2016, [World Psychiatry, 15, 245-258 How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence] of 144 rcts for depression, panic disorder, generalised anxiety disorder and social anxiety disorder was restricted to studies that had used a standardised diagnostic interview for initial assessment, but the potency of the interventions were assessed only using psychometric tests. A standardised diagnostic interview is an independent reliable assessment, it is curious that outcome on this was not established and contrasted with the self-report data. It is not clear what proportion of the studies reviewed by Cuijpers reported on a re-administration of the standardised diagnostic interview. If a standardised diagnostic interview is the ‘gold standard’ for entry into an rct why is it relegated when it comes to assessing outcome. Is it that such an independent interview would be too high a bar for purported efficacious cbt treatments to clear or perhaps it is just cheaper to rely on self-report.

 

But the right to know whether treatment has made a real world difference  is not just a right to be exercised in the context of rcts, the right surely exists in routine practice. This right helps to ensure that the client is not just fodder for some numbers game. The realisation of this right forces a consideration about whether the customary sole self-report assessment and outcome measures are fit for purpose.

Dr Mike Scott

Without A Written Aid To Remembering Session Content Little Chance Of Real World Change

Most client’s are highly anxious, the chances of them remembering session content accurately, much less applying it, are therefore slim. But review of therapy records usually provides no evidence of session summary or detailed specification of homework. At most therapists may write ‘activity scheduling’, ‘thought records’ or ‘continue exposure’. Compare this vaguenness with the specificity of a medical prescription “take ‘x’ 3 times a day after meals’.  I remember a client with Multiple Sclerosis who was in agony with his symptoms for a couple of weeks before it was discovered he had inadvertently been prescribed a sub-therapeutic dose of medication. The lack of specificity about CBT homework means that it cannot be easily corrected and in essence there is no accountability as there is in medicine. Below replace ‘students’ with ‘clients’:

If CBT is primarily educational then we have to teach properly. But training does not equip therapists to teach, even worse therapeutic interventions are often not modelled by tutors first!

Despite therapists endeavours clients lose out because of poor therapist training, psychological therapists often come off CBT courses less confident than when they began.

Dr Mike Scott