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BABCP Response - NICE Consultation January 2022

Routine Psychological Treatment Is Like A Car Being Revved Stuck in Mud

Marija has had OCD for 30 years since adolescence, her treatment included exposure and response prevention at the Institute of Psychiatry, many years ago. Her most recent therapist has suggested she try this again. But closer examination of her notes reveal that she simply felt better for some months after exposure and response prevention. When I asked her did she return to her usual self after exposure and response prevention she said ‘no’, but was 80% better for a while. Whilst exposure and response prevention is a NICE recommended treatment, at most only 50% recover. The NICE guidance can as applied to routine practice create a tunnel vision. She is a classic example of how clinicians stop at the first identified disorder. Whilst she clearly has severe OCD, there is no mention at all in the voluminous records that she has also been suffering from panic disorder, depression and illness anxiety disorder, all of which have gone untreated. Her son commented ‘I always knew there was more than just OCD’.

Marija was relieved that there was some new potentially beneficial therapeutic targets and that a ‘light touch’ with her OCD rather than ‘battling with my thoughts’ might be useful. She entered a different mode when I suggested a) that she had performed an experiment by not completing her rituals when she was asleep and found she came to no more harm than when awake and b) would not ring the local radio station to tell them that everybody must perform her rituals to stop harm coming to their loved ones c) she had performed rituals for a year as a 8 year old but when she gave them up nothing happened.

Marija has gone through a revolving door of mental health clinicians, which could have been stopped by a careful reassessment and history taking using a standardised diagnostic interview.

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Evidence Base for CBT Depends On How You Focus The Camera

What NICE says about the efficacy of CBT has been taken as gospel, but Moriana et al (2017) have pointed out that what other similar bodies say is significantly different. The actions of practitioners are micro-managed by august bodies such as NICE (via IAPT), Division 12 (Clinical Psychology American Psychological Association, Cochrane and the Australian Psychological Society, an essentially top down process is in operation.  But which, if any should be the determinant?

Rather than arguing about which body has produced the best synthesis of outcome studies the focus should shift to bottom up, asking how does cbt fare in routine practice?

Tolin et al (2015) have suggested that a treatment should only be regarded as effective if there has been a randomised controlled trial of the intervention in routine practice using non-specialist therapists, further the researchers should be independent of those who originally developed the treatment.  This has been adopted by the American Psychological Association. An additional requirement should be that the ‘gold standard’ entry requirement for the trial, admission by a standardised diagnostic interview, should also be the primary outcome measure as assessed by independent blind assessors.  Only in this way can it be known whether the treatment makes a real world difference i.e it will be known that x% no longer suffer from the disorder at the end of treatment compared to y% in the control condition. Without these diagnostic strictures one ends up with the highly questionable conclusion of Pybis et al (2017) that cbt and counselling are equally effective. Tolin et al (2015) have suggested the external validity criteria have been fulfilled in the case of CBT for OCD, but when we look at other disorders such as trauma focussed cbt for PTSD it is doubtful that it clears such a high methodological bar, for example the supposed replication of Ehers et al  CBT for PTSD (2005) by Gillespie et al in Northern Ireland did not involve a standardised diagnostic interview as the primary outcome measure, further there were no independent assessors.

It may be that the struggles of practitioners to achieve performance targets are not so much to do with their deficiencies as inherent in the context within which they are working. Singling out ‘poor performers’ may be unjust in extremis. Pybis et al (2017) concluded that ‘half of all patients (IAPT clients) regardless of type of intervention (counselling or CBT) , did not show reliable improvement’, leaving aside whether the IAPT self-report mesasures they review are at all meaningful, are half the therapists going to be put in the dock?

Ehlers, A et al (2005) Cognitive therapy for PTSD development and evaluation. Behaviour Research and Therapy, 43, 413-431.

Gillespie, K et al (2002) Community based cognitive therapy in the treatment of PTSD following the Omagh bomb. Behaviour Research and Therapy, 40, 345-357.

Moriana, J.A et al (2017) Psychological treatments for mental disorders in adults: A review of the evidence of leading international organizations. Clinical Psychology Review, 54, 29-34

Pybis, J et al (2017) The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evdence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 17:215

Tolin, D.F et al (2015) Empirically supported treatment: recommendations for a new model. Clinical Psychology Science and Practice, 22, 317-338.

Dr Mike Scott

 

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BABCP Response - NICE Consultation January 2022

‘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