Outcome In Talking Therapies – Calling a Spade a Spade

when did you last hear of a therapist asking a client ‘do those close to you think you are back to your old self now?’, ‘do you think you are back to your old self? ‘how long do you feel that you have been back to your normal?  Yet these questions reflect the implicit dominant concerns of clients. It is at a minimum, neglect not to ask such questions and we may come to see this failure at some future point as abuse.

But Improving Access to Psychological Therapies (IAPT) therapists typically concentrate on whether there has been an improvement of 6 points on the PHQ9, with no attention to how long the improvement has persisted and they are then ejected from treatment.  Client’s are not asked whether the said change on the psychometric test constitutes a minimally clinically significant improvement in their condition.  Nor is there any evidence that the chosen psychometric test is pertinent to the primary disorder for which they were seeking treatment. The typically administered PHQ9 and GAD7 are highly correlated and may not even represent separate constructs i.e depression and generalised anxiety, and by themselves are dubious vectors for directing treatment. 

It is a sleight of hand to claim that the 6 point improvement on the PHQ9 or indeed scoring below 10 at post treatment say anything meaningful about the client’s real world if the test is used outside the context of a standardised diagnostic interview that identified depression as the primary disorder. Using the psychometric tests out of such contexts has more to do with income than outcome. For the unwary such changes seem ‘significant’ but the same change is observed in clients followed up without psychological therapy [see Gilbody (2015)]. Unfortunately it has proven all to easy to dupe Public Health England and Clinical Commissioning Groups. At present it seems it is too embarrassing for them to admit they have allowed themselves to be hoodwinked for years.

 

Dr Mike Scott

‘Are You Back To Your Usual Self?’

at a workshop I gave in Liverpool last Friday, there was much interest in this metric for evaluating the effectiveness of a psychological service. The workshop was titled ‘Group CBT…Yes…But’ (and was also the innaugral meeting of the BABCP Group CBT Special Interest Group), and I reflected that none of the studies of classes, such as ‘Stress Control’ or the ‘Five Areas Approach’ had independent assessors asking people whether as a result of the intervention they were back to their old self, much less whether they remained as their old self for say at least 8 weeks. Yet they are promoted as the first line of treatment in services such as IAPT. Further were groups (as opposed to classes) are run they are often for targets such as ‘low self-esteem’ or ‘destabilisation groups’ with for which there is no evidence at all of real world outcomes. I think a key feature of the workshop for many people was making a sharp distinction between the evidence base for classes as opposed to groups, for depression and the anxiety disorders. The powerpoint presentation for the workshop can be accessed below:

https://www.dropbox.com/s/ikei2478wvnwu15/Group%20CBT%20SIg%20Feb%2022nd%202019.pptx?dl=0

I also suggested that the case for transdiagnostic approaches is, at the very least, not proven. Nevertheless I fear managers will attempt to play a numbers game with regards to groups blurring the distinction between them and classes. With, as suggested in a role play we did, a therapist trying to sell a ‘stress class’ to a client over the telephone, the latter could have had depression, PTSD, body dysmorphic disorder (or some combination there of) or even an adjustment disorder. The therapist herself with insufficient time to make a formulation becoming a candidate for a stress class in her own right!

Dr Mike Scott