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BABCP Response - NICE Consultation January 2022

‘Drop the Disorder!’ – IAPT Have Already Done This and It Hasn’t Worked

‘Drop the Disorder!’ is a just published book edited by Jo Watson published by PCCS, but the contributors totally avoid any mention of the Improving Access to Psychological Treatments (IAPT) service. The latter assert that they do not make a diagnosis.  My independent assessment of IAPT has shown that only the tip of the iceberg recover https://doi.org/10.1177/1359105318755264

What is interesting in this book is that none of the contributors have come up with a framework that has allowed them to evaluate the IAPT service. Their frameworks are so nebulous, choose between Power, Threat, Meaning  or an exaggerated importance being given to formulation, that there is no risk of application to any service any time soon. Clients are the casualties of this approach.

I was just trying to imagine an Expert Witness arguing for the reliability of the application of one of these frameworks to that of a person he had to assess, the Expert Witness for the other side would have a field day, with legal reps putting their head in their hands. 

When the notion of ‘disorder’ is dropped, so too is loss of diagnostic status as an outcome measure. Without a person no longer being an instance of a disorder how can one approach determining whether the person is back to their old selves/best functioning?

This is not to say that every diagnostic label is meaningful, there is an excellent chapter in the book on schizophrenia by John Read and he cogently argues that this is not a reliable diagnostic entity. He suggests that we are better served by terms such as hallucinations and delusions. Similarly there are doubts as to whether chronic fatigue syndrome/ME are meaningful diagnostic entities. But across depression and the anxiety disorders (including PTSD) the diagnostic criteria have served us well leading to different protocols for different disorders.

Unfortunately in routine practise diagnostic criteria are not applied with rigour using standardised diagnostic interviews, which also allow for the identification of comorbid disorders (that will usually also need to be treated.)  

The authors suggest that in their communications clinicians should always put diagnostic entities like OCD in quotation marks. I can see this becoming the new political correctness. I will comment on any such missive that the quotation marks simply indicate unreliable assessment.

Dr Mike Scott

Categories
BABCP Response - NICE Consultation January 2022

Missing The Boat With A Focus on Pressing Concerns

As a matter of respect clinicians necessarily focus on a client’s pressing concerns, but the time constraints imposed by routine services, such as IAPT, means that this becomes the sole focus. The upshot is that initially the client’s focus is say on their depression but at the next appointment on disturbing flashbacks/nightmares of child abuse and at the next appointment they may mention occasional excessive use of alcohol causing arguments at home. The clinician doesn’t know where they are working is this depression? PTSD? relationship problems/ alcohol dependence? or some combination thereof. This means the clinician is unable to help the client navigate through the fog of their difficulties, changing tack with every gust of wind.

Alternatively the clinician might simply pursue the first disorder ‘identified’ because the client doesn’t mention any other, discharging the client at the first signs of an improvement on some psychometric test or when progress has been made on that disorder. Despite the client actually suffering from a number of other disorders, making any gains in the ‘successful’ domain likely short lived. The client’s then go thru a revolving door. It seems that clients are rarely asked ‘are you back to your usual self following this treatment? and importantly ‘how long have you been back to your usual self for? [ anything less than 8 weeks is likely nothing more than the waxing and waning of the natural course of a client’s symptoms].

One of the ways of getting the bigger picture is to first use an open ended interview that contains the screen below, the dropbox link for this

APPENDIX A. SCIP screening questions
Codes: 0=absent, 1=present, 8=unsure, 9=missing data, unless otherwise
specified in the question
Questions apply to the present episode, typically the past month, unless otherwise
specified by the interviewer.
HAVE YOU:

  1. Felt very anxious and afraid out of proportion to the situation (with or
    without physical symptoms) for more than one month?
  2. Had panic attacks, when you suddenly felt anxious and frightened and
    developed physical symptoms, such as fast heart beat, shaking, or
    sweating?
  3. Been afraid of going out of the house alone, traveling alone, being alone,
    being in crowds?
  4. Been afraid and anxious doing things in front of people, such as eating in
    public, speaking in public?
  5. Had unpleasant and unwanted thoughts or images coming into your mind
    over and over even if you try to get rid of them? Examples: Contamination
    or aggressive, sexual, or religious thoughts.
  6. Had the urge to do things over and over and could not resist doing them
    (such as washing your hands even if they are clean, checking doors,
    counting up to certain numbers, reciting phrases)?
  7. Witnessed or experienced a traumatic event that involved actual or
    threatened death or serious injury to you or someone else (e.g., physical or
    sexual abuse, terrorist attack, natural disaster, war)? Did you feel intense
    fear and helplessness?
  8. Re-experience the traumatic event in the last month in a distressing way
    (flashback, nightmare)?
  9. Had physical symptoms or physical illness for which doctors did all
    necessary work up and could not find medical explanation?
  10. Had pain and your doctor did all necessary work up and could not really
    explain?
  11. Worried about gaining weight to the point that you self-induced vomiting,
    or used diet pills, laxatives, or heavy exercise?
  12. Eaten a large amount of food within an hour or so, that is binge eating?
  13. Felt or described your mood as sad, downcast, gloomy, low in spirits, or
    depressed?
  14. Been unable to enjoy things like walking, working at your hobbies, or
    socializing with friends as usual?
  15. Had thoughts about harming yourself or even made an attempt at suicide
    (Include whether thought was due to depression or not)?
  16. Felt very happy, elated without reason, or very irritable without reason?
  17. Had mood swings: periods of depression and elation or irritability?
  18. Felt that people are spying on you, follow you around, talk about you?
    Felt that there is a plot or conspiracy against you?
  19. Felt that people are trying to harm you or poison your food?
  20. Had experiences of hearing voices or noises that other people cannot hear?
  21. Had experiences of seeing things (images, flashes, shadows, objects,
    people, whole scene) that other people cannot see?
  22. Been violent in the past (with or without the influence of alcohol or drugs)?
  23. I would like to ask you questions on alcohol use over the past year:
    A. On days when you drank, did you drink >5 alcohol drinks per day
    (sometimes)?
    B. Did you have any problems resulting from drinking alcohol?
  24. I would like to ask you questions on illicit drug use (e.g. marijuana) over
    the past year:
    A. Did you use the illicit drug >10 times per month?
    B. Did you have any problems resulting from using the illicit drug?

is also below:

https://www.dropbox.com/s/j5rfmy6hthp6142/Reliability%20of%20Diagnoses%20SCIP.pdf?dl=0

then when you have an idea of possible diagnoses you can make systematic enquiry about all the symptoms of that disorder using the diagnostic questions in Simply Effective CBT Scott (2009).

In my view the poor results for therapy in routine practice is often because the therapist doesn’t know what they are dealing with rather than therapeutic competence per se.

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Dr Mike Scott