Download Reality Checking Psychological Services

Dr Michael J Scott
Psychological Therapies Unit, Liverpool,
United Kingdom
[email protected]
The Promise of Research
For depression and the anxiety disorders at least 50%
recover by the end of CBT treatment
The Reality In Routine Practice - the tip of the
iceberg (15%) have been found to recover, when assessed
independently, using a standardised diagnostic interview.
Sample, n=65, consecutive cases treated by UK IAPT
Service, Either Before or After A Personal Injury
Before injury (n=14)
After Injury(n=51)
No Difference In Recovery Rates
Little Difference In Recovery By Disorder (n=65)
Disorder
Recovery Rate
PTSD (n=33)
15.1% (5)
Depression (n=32)
21.9% (7)
Other (n=26) [ panic disorder 6,
7.7% (2)
specific phobia 12, GAD 1, OCD 2, social
phobia 1, body dysmorphic disorder 1,
excoriation disorder 1, chronic
adjustment disorder 12, and alcohol
abuse 1]
Sample had a mean of 1.6 disorders, assessed using SCID diagnostic interview,
review of records and use of a Malingering Screen. See Scott, M.J (In Press)
‘Towards A Mental Health System That Works’ London: Routledge
Reports of IAPT Service Userslargely negative, two examples
 Ms K described her treatment by a Psychological
Wellbeing Practitioner as ‘hopeless’, and said she had
been asked to put ‘smiley’ faces on activities she had
completed, she dropped out after 3 sessions, however
her PHQ9 score reduced from 23 to 14 and GAD7 from 21 to
10, but despite this my diagnostic interview suggested no
change in her diagnostic status in that she was still
suffering from depression.
 Mr L attended two appointments, according to the IAPT
documentation he had ‘mild PTSD’, was introduced to
EMDR psychoeducation, he declined the offer of further
appointments and in fact he only had a travel phobia
according to SCID interview
Reports Of Psychological Therapists
N=1300
Depression
46%
‘A failure’
49.5%
Long term chronic condition 25%
Job stressful
70%
Source: British Psychological Society February 3rd 2016 ‘ the
overall picture is one of burnout, low morale and worrying
levels of stress and depression….the majority of respondents
made negative comments….10% were more positive’
What’s Gone Wrong?
 Failure to appreciate the complexity of randomised
controlled trials (rcts), resulting in a fundamentalist
translation of them into routine practice
 Failure to appreciate the complexity of measuring
fidelity, leading to the inappropriate use of a single
measure
 Failure to distinguish levels of evidence between low
and high intensity interventions
What Is Being Missed About RCTs?
 CBT treatments are diagnosis specific
 Great care is taken in rct’s to establish a reliable diagnosis and comorbidity
 When cbt is conducted without a reliable diagnosis the outcome is at best sub-optimal and
confusing
Johnsen and Friborg (2015) conducted a meta-analysis of 70 cognitive behaviour therapy (CBT)
studies for depression and concluded that CBT did not seem to be helping reduce depression
symptoms as much now as it did when it was first pioneered in the 1970’s. But inspection of Table
1 of this study showed that from 1977 up to and including the millennium, 85% of studies were
randomised controlled trials (RCT’s) but from 2001 to 2014 the comparable figure was 65%. One
of the hallmarks of an RCT is blind assessment, using a standardised interview. Thus there was no
certainty that treated populations post the millennium were comparable to those before.
The Need For A Multi-Dimensional Model Of Fidelity
(adherence + competence)
The Competence Engine – Simply Effective CBT
Supervision, London: Routledge 2015
Stage Specific
Competences
Diagnosis
Specific
Competences
Generic Competences
References
1.
Scott, M.J (In Press) Towards a Mental Health System That
Works: A Guide for Practitioners London: Routledge
2.
Johnsen, T. J., & Friborg, O. (2015). The Effects of Cognitive
Behavioral Therapy as an Anti-Depressive Treatment is Falling:
A Meta-Analysis. Psychological Bulletin, 141, 747-768, Advance
online publication. http://dx.doi.org/10.1037/bul0000015
3.
Scott, M.J (2015) Simply Effective CBT Supervision: A Guide for
Practitioners London: Routledge
4.
Waltman, S.H., Creed, T.A and Beck, A.T (2016) Are the Effects
of Cognitive Behavior Therapy for Depression Falling? Review
and Critique of the Evidence. Clinical Psychology Science and
Practice, 23, 113-122