Tag: secondary care

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Only The Client Knows Whether Psychological Treatment Has Made a Clinically Relevant Difference

trouble is nobody asks them! When was the last time you remember a client being asked ‘are you back to your usual self with the treatment you have had’? Organisations, such as IAPT have their own metric, a decrease on a psychometric test and in secondary care psychiatrists will opine ‘seems a bit brighter to day, increase…’. These ‘metrics’ ensure the survival of the Organisation, but have no demonstrated relationship to loss of diagnostic status as assessed by a clinician independent of the service provider.

In a study by Stegenga et al (2012) see link below depressed patients were followed up over 3 years whether there depression took a chronic (17%), fluctuating (40%) or remitting course (43%) course they all showed decreases in PHQ9 scores throughout the study and without any psychological intervention. The only exception was a worsening of PHQ9 score at 6 months for the chronic subgroup. Similarly a 12 year study of anxious patients Bruce et al (2005) showed they were only suffering from their anxiety disorder 80% of the time. Thus finding a decreased psychometric test score per se does not mean anything.

Bruce et al (2005) linkhttps://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0

Stegenga et al (2012) linkhttps://www.dropbox.com/s/k0x2fm0ds01no0k/natural%20course%20of%20depression%20stegenga%202012.pdf?dl=0

Organisations and Clinical Commissioning Groups much prefer to talk about operational matters, numbers and waiting lists and show no interest or expertise in reliably assessing clinically relevant outcomes. But it is not just these bodies, the leading journals have for the past decade predominantly published papers on the efficacy of psychological interventions with no insistence that there should have been blind independent assessment. Instead self-report measures have ruled with little awareness that their completion is subject to demand effects and the measures often bear no obvious relationship to the construct under examination.

It is difficult to escape the conclusion that clients are largely fodder for the Organisations. A problem that will not be resolved by increased funding for mental health services albeit that this is clearly needed or by atypical clients as tokens on mental health bodies. The fundamental problem is a lack of respect/reverence for clients.

Dr Mike Scott

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IAPT Resources

‘Too Complex for IAPT’ – Dumping on Secondary Care?

I work in secondary care as a band 7 CBT therapist within a CMHT. Often I will have referrals sent directly from IAPT who describe the patient as being too ‘complex’. Indeed this seems to have become an actual care pathway (not that we have too many of those). As far as i can tell at this stage  the patient may have not had a face to face assessment, rather has been deemed too complex simply because of the stated diagnosis e.g if they have a so  called personality disorder. I have also been told that if someone scores a above a certain score on the HADS scale (I don’t understand why this particular measure is being used as the ‘cut off’)  they too are apparently ‘too complex’. I am also told that  the outcome measures used by IAPT apparently mean that the ‘too complex clients’ would impact on these performance scales which in turn  could mean further funding for the service is jeopardized.

This concerns me on two fronts. Firstly in principle… this seems to completely  go against the ethos  of  the IAPT envisioned by Layard & Clark (although how workable or realistic this ever actually was in another thread) and another example of how it  seems management  are ‘cooking the books’ . Secondly on a more  personal level  I am employed in same Trust as a band 7 cbt therapist , i have no support from care coordinators and supposedly have the same amount of sessions to offer patients so how can possibly i offer anything different to IAPT? I suspect management know I can’t , but i ( and my colleague) serve as  i convenient sponge to soak up all the pts that may threaten the outcome measures…

 

I wonder has anyone else working in secondary care had  similar experiences  or is this an isolated thing ?

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‘How Do I Deliver Effective CBT Where I am?’

The contexts in which CBT Practitioners work vary enormously, from independent practice to secondary care, from low intensity IAPT to a specialised trauma unit.  For the most part we are Engineers struggling to work within the organisational constraints we are given.  Drawing on our knowledge and skills, working with a diverse population, trying to make a real world, socially significant difference in client’s lives.  The pressing question is how can I deliver effective CBT where I am?

A practitioner working in secondary care in Ireland,  told me he faces the challenge of cases come to him via psychiatrists, there is a preliminary assessment within 4 weeks of referral, a maximum of 12 sessions of CBT are offered.  There is a progress review about the 6th session and a decision is made as to whether another 6 sessions would be beneficial. He asks is this best practice? The managerial edict he believes is to throughput as many clients as possible.

Another practitioner, from IAPT High Intensity told me that she had taken up her post on the understanding that the 6 session maximum was flexible and clients could be quickly re-referred back in for more sessions, but this has proved to be very rarely the case. What should she do?

 

Dr Mike Scott