Tuesday, December 6, 2022

Comments by Michael Scott

Showing 17 of 17 comments.

  • I am with you Steve. The problem is that people often pay lip service to diagnosis, creating chaos, instead of only using it in mental health with a standardised diagnostic interview. The consequences of this are shown in the November issue of the British journal of Clinical Psychology were clinicians have used a rule of thumb ‘cant be PTSD because its a child in care, must be a developmental problem’ rather than engage in a standardised diagnostic interview. Without a standardised diagnostic interview, heuristics, (peoples idiosyncratic mental shortcuts) abound and there is no agreed treatment for the fuzzy label e.g ‘developmental problem’. Diagnosis is like nuclear energy used properly it is great contribution to addressing Climate change, used badly the results are unthinkable. The problem s not with nuclear energy or diagnosis per se.

  • Without using a standardised diagnostic interview I would not have been able to demonstrate that that the UK IAPT service was failing clients, the solution focussed colleagues with whom I was working at the time and had a great relationship with could not demonstrate this. The utility of an intervention is gauged by the proportion of clients who can report that they are back to their old selves with the treatment and remain so.

  • Ah a further update, I’ve had a further communication from NHS England, would you believe it, they suggest I contact the Department of Health! But it was they who 1st said that NHS England would be better placed to answer my questions. I have therefore asked them to make a considered response to my questions, but I’m not holding my breath on this.
    But just a point Nick, the cavalier use of diagnosis in mental health is commonplace and wreaks havoc, but that is totally different to using a gold standard diagnostic interview to make a diagnosis and help chart direction. I have seen no ill effects from the use of a gold standard. Mental heath diagnoses have no biological markers and are therefore judged by their utility or lack of it.

  • You’re absolutely right Steve, the only person in a position to evaluate the outcome of an intervention that they receive is the person receiving it. But the context in which their opinion is elicited can make a huge difference. If asked on a self-report measure that they remember having completed at the start of therapy, to give themselves a sense of hope, they can indicate a lower score and avoid the sense of having wasted their time. In addition they are aware their therapist will see their completed questionnaire, as most think their therapist has done their best and they don’t want to appear ungrateful , these demand characteristtics can result in a lowered score. It is crucial that the primary outcome measure focussed on has real world meaning to the client e.g ‘are you back to your old self now?’, if yes for about how long would you say you have been back to your old self? and/or since therapy started ‘do you feel the same, a little worse, little better, much worse, much better?.But even this may not be thought sufficient to determine the truth of he matter, and the credibility of the positive gain can be enhanced or otherwise if the person has lost their diagnostic status according to a reliable standardised diagnostic interview.
    Any publicly funded service/charity has to be independently evaluated because the agencies have a vested interest in their promotion. It is not at all that the independent assessor is making a judgement of the client about how well they are, he/she is trying to impartially assess whether the agencies intervention has made a real world difference for this client.
    In the UK it is a scandal that the biggest provider IAPT has not been subject to publicly funded independent assessment and my data suggests a total mess. It has got away with its own idiosyncratic outcome measure ( a change on a self report measure) taking credit for any improvement, ignoring regression to the mean and the beneficial effects of mere attention. Agencies like IAPT have had have a field day with Nick’s simple and broad measures, they claimed their interventions got people back to work. But there was no specification of the mechanism by which this happened, what was it in their intervention that helped clients persist with a task? pace themselves? manage the hassles of the workplace? Without a specified mechanism there can be no effect. Such agencies go on a fishing expedition to claim causation when all that exists is a correlation, people present at their worst, get a bit better with time enough to return to work and hey presto it was the ear lobe therapy that has returned those with mental ill health to productivity!

  • Ah Nick, you are caricaturing me, I am vehemently against ‘scientism’, the view that science explains everything. Because there is nothing within science that can prove it is the explanation of everything. I have a great interest in philosophy/religion as the solution focussed colleagues I worked with just before the pandemic would testify, together with a commitment to reverence and honesty (not science products).
    I simply believe that we should have outcome measures that are meaningful to the client such as ‘back to old self’ that are gauged by independent assessors, people generally don’t want to seem unappreciative of a therapists usually well meaning efforts. Diagnostic interviews should only be a part of a conversation with the client, and in 30+ years of using them it has never been a problem with a client. They have just better illuminated the landscape for us to both traverse on a pilgrimage of equals.

  • Since I wrote my blog NHS England have replied, or rather not replied, suggesting that I put the questions to my local Integrated Care Board (ICB’s are the recent replacement for Clinical Commissioning Groups). But my questions obviously relate to national policy and not local difficulties! NHS England has chosen to duck the issues, taking a leaf out of the Health Minister’s book. I have now asked them for a considered response to my questions, but I’m not going to hold my breath waiting for an answer.
    Nick is absolutely right, when a diagnostic label is used with no agreed meaning, as in the case of ADHD, chaos is bound to ensue. Some ‘diagnoses’ have been based on self-report measures, some are based on clinical interviews plus or minus neuropsychological tests and plus or minus information from informants. The plethora of assessment modes leads to an ill-defined population. The worse outcome for diagnosed children likely reflects arbitrary assessments. There is a need to more carefully define, what it is that is being measured. The lack of standardisation of assessment opens the pathway for the use of heuristics e.g ‘ADHD is mainly a boy thing’, such that 90% of identified ADHD sufferers are boys, but the ratio of boys to girls is actually only 3 to 1! But not all mental health diagnoses are too fuzzy for use, for example with the CAPS/SCID interviews for PTSD agreements are of the order of 80-90% and carry clear implications for treatment.
    What would effective treatment with brief solution focussed therapy (BSFT) look like? To be credible it would have to be demonstrated that a) a significant proportion of those treated with BSFT return to being their old selves or at least almost their old selves with treatment b) this proportion was significantly greater than in a comparison attention placebo group c) the return to old self lasted for a period that was clinically meaningful to the person d) the assessors were independent of the treatment providers and did not have an allegiance bias e) the study was such that the findings could be independently replicated, this would require a detailed specification of the population studied (in the absence of diagnosis it is difficult to see how this would be achieved). It is not so much that BSFT is outlawed, as that it outlaws itself to bodies like NICE because of a failure to meet criteria a to e. BSFT has no inbuilt protection against the unbridled clinical judgements of its clinicians with regards to assessment and outcome. For example a BSFT practitioner declaring that treatment was a success because the client was now driving, when the reality was that the person was still suffering from PTSD, depression and binge eating disorder, with no systematic identification or treatment of either.
    I must look into Bessie, your right Service providers do not want independent assessment

  • Hi Topher
    for over 30 years I have seamlessly woven a standardised semi-structured interview into my conversations with clients, none have ever voiced concerns over my assessment. The results of the assessment have highlighted particular treatment directions, in the style of my recent book Personalising Trauma Treatment. No one has ever said it is in anyway robotic and its a million miles away from IAPT’s fundamentalist translation of CBT.Try it as per my recent offering and see how it goes.
    I really do sympathise with your having to endure IAPT, have a look at the recent blog of a PWP on cbtwatch.com it is truly ghsastly
    Regards
    Mike

  • I think that the researchers have missed an angle, the personal history of the Journalist. In one instance the ‘external watchdog’ was a Journalist who believed he had benefitted from the IAPT service, the whole radio presentation was skewed to the power holders in IAPT, national key luminaries at Oxford University. No matter that my own research showed only the tip of the iceberg recovered. The other instance was a TV Journalist who advocated antidepressants on the basis of his experience. Using the Elaboration Likelihood Model of Persuasion in Social Psychology these are examples of peripheral processing, short-circuiting effortful processing of data by an appeal to the vividness of personal experience. Central processing involves detailed exploration of the claims. The two examples highlight the operation of the availability heuristic and an appeal to eminence based medicine rather than evidence based. An awareness of the possible information processing biases of ‘expert watchdogs’ can in principle be a means of challenging the latter, but it is no easy matter as the ‘challenger’ is in danger of vexing the ‘watch-dog’ – possible growls or bites.

  • Sorry A.M, only just noticed your blog. Getting heard in the UK is extremely difficult, there is no open discussion about IAPT, people fear for their jobs if they criticise it. Hence this blog. To see how I have become persona non grata in the UK have a look at todays blog on cbtwatch.com. I think the way forward is to approach CBT along the lines I described in my Simply Effective trilogy of books, the 1st of which was written a year after the inception of IAPT. The process has been updated in the just published Personalising Trauma treatment. But basically it all starts with really listening to clients, giving them the time they need, not speeding through checklists. It is not rocket science and comes down to respect.

  • Hi Steve, I’m not suggesting that the way I use ‘diagnosis’ in the mental health arena tells us everything about the person or anything like it. It is just a part of a bigger picture including the social stressors, physical difficulties, values that the person has – their story. In Personalising Trauma Treatment I am very much looking at what the person takes their trauma/s to mean about today, how they do their mental time travel. I just noted that the most debilitated of trauma sufferers seem to be in a state of ‘terrified surprise’ coupled with having lost their sense of being me, treatment focuses on the restoration of their old self or in some cases a rebuild, what I term rcbt.

  • If you go back to the 1960s, research on psychological treatment was impossible because one persons case of x was another persons case of y. A common language is necessary to conduct any research, so that we are not talking at cross purposes. There are no biological markers for. any psychological ‘disorders’ so that the description of them as disorders is problematic. So the ‘disorders’ are constructs which may be more or less useful. How then does one begin to try and make sense of the plethora of emotional problems people experience? What would be the most useful ways of carving up the joint? Some problems seem more threat related, future oriented and for want of a better term, could be subsumed under an anxiety umbrella. Others problems are more to do with a negative view of self and have a sadness/melancholy hue and we might be regarded as being in the depression domain. In some people you get a state of ‘terrified surprise’, a combination of exaggerated startle response and hypervigilance, which I have argued is a hallmark of PTSD.
    To make sure we are all singing from the same hymn sheet, we have looked at particular constellations of symptoms that seem to go together e.g there are 9 symptoms in DSM for depression, so all the symptoms within a constellation have to be enquired about (technically controlling for information variance) but a symptom is only endorsed if the person judges that symptom as significantly impairing their functioning (technically criterion variance is controlled for) clearly those with more symptoms are more impaired, and somewhat arbitrary cut offs are used to try and distinguish what could be regarded as normal functioning to functioning that is problematic for many. With this type of procedure using a standardised semi-structured diagnostic interview you can get independent raters coming to the same conclusion around 80% of time, without such an interview the chances of agreement are no graeater than chance. The high inter rater reliability makes research possible and its proven possible to distinguish disorders by their different cognitive content and to establish that different’ disorders’ respond to different foci. e.g those with panic attacks often benefit from having 2nd thoughts about their catastrophic cognitions about bodily sensations. The most common scenario is that people have a number of ‘disorders’ and need to be treated holistically for all as they experience them as a whole entity they are not just a collection of all the disorders, see Personalising Trauma Treatment, there is no substitute for really listening it is the starting point for everything and IAPT fails miserably on this.
    It is possible to have an a priori belief that anything to do with diagnosis is unscientific, but there is nothing within science that proves that this is the case. Rather than pre judge the issue it is important to follow the data were it leads, we have had some limited success in treating some of the commonest disorders with cbt but exporting that to routine practice is not easy and it is extremely unlikely that cbt contains the whole truth, it just lightens the pathway a bit. CBT may only be a candle and I would happily use a torch if available but Ive not been able to find one.
    I should add that I think there is much more to life than psychological therapy, social problems, philosophy, religion are massively important. I do not believe that psychology has a monopoly on truth.

  • In many ways I totally agree, people are mysterious, deserving of great reverence. They are ill-served by IAPTs reductionism of therapy, which has an irreducible complexity, with the whole being much greater than the sum of its parts. But without recourse to diagnosis I would not have been able to demonstrate that IAPT’s claimed recovery rate is absurd. Diagnosis, reliably made, can act as a check on self-serving claims, it can also indicate which ball park might be fruitful. But it all has to be personalised and I have tried to explain how I do this recently in my book Personalising Trauma Treatment.

  • I totally agree that the way diagnoses are made in the UK i.e using wholly open-ended interviews is no help to clients at all. IAPT’s use of diagnosis is totally cavalier. The levels of reliability of such interviews is so poor as to make them useless. But it is possible to use a standardised semi-structured diagnostic interview that also gives full scope to assessing social problems. In our trial of CBT for depression in Toxteth, Liverpool (the scene of the 1981 riots) I addressed the social problems as well. It is useful to clients and therapists to know what sort of strategies can deliver with what sort of problems, without at all minimising real-world constraints. For depression and some anxiety disorders there is credible evidence that CBT is a reasonable starting point, in that about half of sufferers appear to recover in the randomised controlled trials Cuijpers et al 2016 https://doi.org/10.1002/wps.20346. But great care has to be taken in the translation of this finding: it applies to a limited number of disorders (depression, generalised anxiety disorder, panic disorder and social anxiety disorder), there has to be certainty that the person before you is suffering from one of those disorders and that is the main problem, not something else. Further there has to be fidelity to a treatment protocol in that targets and strategies must match but there also has to be the flexibility of a human encounter. In addition there has to be certainty that the person before you could be regarded as member of the population e.g age, education that was involved in the trial. So it is important not to exaggerate the importance of CBT and minimise the difficulties in translation. To echo Cuijper et als claim (2016) ‘We conclude that CBT is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still uncertain and should be considered with caution’. But what IAPT does bears no relationship at all to what was done in any trial.

  • I don’t doubt that IAPT is better than nothing. But people did not always get nothing before the advent of IAPT in 2008. The pre-IAPT studies of counselling showed changes on psychometric tests of the same magnitude as IAPT. This means that IAPT has demonstrated no added value. Further the changes in psychometric test scores in IAPT are comparable to those in patients followed up by GPs without any psychological intervention. Thus, to a very limited degree time is a healer. All this raises the question of why fund an IAPT like service?
    Matters have today taken a further turn for the worse in the UK, as the National Institute for Health and Care Excellence (NICE) has recommended that the PWPs who assess people, should market the following to depressed clients, in order of least costly first, guided self-help, group CBT (8 sessions), group behavioural activation and onwards to the 11th item short-term psychodynamic therapy. It is the PWPs, who are not trained therapists, who provide the cheapest options. But there is no empirical evidence that 8 sessions of the least costly interventions delivered by PWPS makes a real-world difference to clients lives as assessed by a blind assessor.
    It is possible to see everyone as a totally unique individual and formulate a treatment for them. To a degree this is what I have done in my most recent book ‘Personalising Trauma treatment: Reframing and Reimagining’. But it is difficult to provide guidance without saying ‘this sort of thing works with that type of problem’. Diagnosis is just a convenient, imperfect taxonomy of problems, if there had been proven to be a better categorisation, that would be great and I would use it. But at the moment it is the ‘least-worst’ and as I say in my book one has to go ever so carefully with it. The bizarre thing in the UK is that PWPs are tasked with treating depression, yet their Organisations Manual says they don’t make diagnosis. Yet many PWPs use diagnostic terms in passing. But this is regarded as wholly unreliable in a UK Court, anyone can have an elevated score on a PHQ 9 for a myriad of reasons.