Reality Checking Psychological Services Dr Michael J Scott Psychological Therapies Unit, Liverpool, United Kingdom michaeljscott1@virginmedia.com

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) Recovery Rate PTSD (n=33) 15.1% (5) Depression (n=32) 21.9% (7) Other (n=26) [ panic disorder 6, 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] 7.7% (2) 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 Users- largely 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 Generic Competences Diagnosis Specific Competences Stage Specific Competences

References Scott, M.J (In Press) Towards a Mental Health System That Works: A Guide for Practitioners London: Routledge 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 Scott, M.J (2015) Simply Effective CBT Supervision: A Guide for Practitioners London: Routledge 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