A pre-publication copy of the paper follows to introduce the website.
Malcolm McFadyen shares a critical reflection of clinical psychology’s relationship with CBT, and the evidence behind national guidelines in Scotland.
DCP-Scotland – what we stand for, together. Really?
For the past few years the Division of Clinical Psychology-Scotland Review has opened with the headline DCP-Scotland – what we stand for, together.
Apart from the usual platitudes of the ‘those who need services should get them’ variety, we apparently stand for Cognitive Behavioural Therapy (CBT) for all, with the boring stuff passed on to others. Not any old CBT, but manualised CBT along the lines of the Oxford Group (Clark and Fairburn, 1997) so that there are no deviations. For this to be achieved we will need lots more clinical psychologists to train, and monitor the ‘others’, not to mention the ‘leadership’ role to advise everybody on everything psychological. It is all in the Wells Report on applied psychologists and psychology in the NHS (Scottish Government, 2011), and The Matrix (2015) a guide to delivering evidence based psychological therapies in Scotland (Scottish Government, 2015). The package is very similar to the Improved Access to Psychological Therapies (IAPT)/NICE recommendations in England (2011).
Having retired over twenty years ago I thought I could look forward to this view being challenged by the next generation. In the rest of the UK there was a healthy level of opposition to the similar bias in the IAPT/NICE recommendations. Ten years ago Marzillier and Hall (2009) questioned the economic analysis of the Layard initiative and noted the weakness of the evidence behind the associated IAPT/ NICE promotion of Cognitive Behaviour Therapy (CBT) to be delivered by para-therapists. McPherson (2018) raises similar issues with a focus on NICE guidelines for depression. Holmes (2002) asks if the prominent position of CBT may be more a matter of marketing than evidence.
Surprisingly, DCP-Scotland does not feel the need to examine the validity of the assumptions in its mission statement.
Clinical psychology has apparently ‘progressed’ to the point where we only need to consult The Matrix, select the right psychological therapy for the presenting condition, (first on the list, Panic Disorder), and follow the manual, knowing that what we are doing is evidence-based, delivered according to a ‘matched stepped care model’ (no evidence required here – it’s obvious isn’t it?). Much of the time all that will be required is a self-help booklet, or for more difficult cases an online computer CBT program. You could even provide five two hour group sessions of CBT. If all that fails, you could give some instructions on exposure (but keep it brief!). For cases serious enough to be labelled as mild then you should add minimal contact CBT (4-6 hours) plus bibliotherapy, and more internet delivered CBT. For moderately severe cases there is therapist-supported CBT (6-12 hours) augmented by CBT self-help a) Bibliotherapy, b) Computer-Assisted CBT c) Internet-delivered CBT with therapist contact (up to six hours) d) Group CBT (8-18 hours). We can certainly expect that to bring down waiting times!
Conveniently enough when we consult The Matrix to find out what to do about other common adult mental health problems we are presented with slightly varying combinations of the same ‘matched steps’, involving the same self-help CBT, computer delivered CBT, and Therapist delivered CBT (up to 20 sessions). Provision is made for Interpersonal Therapy, Psychodynamic Therapy, Humanistic, Person-Centred-Experiential Therapy amongst others, but CBT in some form or other is the psychological therapy of choice for virtually all adult mental health conditions.
If we look at the strategy for service delivery and development most associated with the CBT movement, the pattern over many years has been to try to deal with the ‘excess demand’ by adding more and more para-therapists, real or digital, the most recent cohort in Scotland being graduates from the Stirling/Dundee one year MSc in Psychological Therapy in Primary Care, and yes you guessed it, the ‘therapy’ is CBT.
To deliver these grand plans we are going to need an army of para-therapists trained to varying skill levels according to which level of service they operate in. Some, like the Clinical Associate in Applied Psychology in Scotland, will be newly created, and others will be NHS and other workers with time on their hands. Perhaps we could put the Matrix manuals on neural implants to be inserted into the brains of para-therapists until para-thera-bots can be developed. This will leave us to get on with the important stuff of creating more digital therapy manuals and adding more ‘evidence’ for the universal superiority of CBT.
It appears that we have transformed clinical psychology into a myriad of more or less (actually less and even less) evidence-based psychological therapies, manualised(sic), computerised and, sometimes, passed fit for human consumption by a committee who have applied another manualised technique of evaluation of available research. Someone is already working to remove humans from the service delivery process by digital transformation. NHS England (2019). Job done!
There are obvious dangers in this vision of ‘progress’ where we can anticipate a last man standing competition to decide which psychological therapy will be funded for which condition. More worrying is that the race started years ago and betting has already closed on the front runner, despite the fading cries of “unfair, everyone has won and all must have prizes”. Even more worrying is that NICE has considered making some of its recommendations mandatory. Morriss, R.,(2015) . Perhaps we need a new competition, with a prize for anyone who can spot a condition for which CBT does not claim to be cheapest and best. Yes, it would be funny if it wasn’t so serious.
A recent statement from the Scottish Association for Mental Health, based on data provided by the Information Services Division of the NHS Scotland, states “Scotland was the first country in the world to set waiting time targets for psychological therapies, but the 18-week target is still not being met by all NHS boards, eight years after it was first introduced. This quarter, we saw no change in the percentage of people being seen within 18 weeks, and just one NHS board met the target” (SAMH 2019). An update on 4 June 2020 noted that this quarter, for the first time ever, no health board met the 18-week target on psychological therapies. So much for improving access to psychological therapies.
The Science of the Cognitive Model
Rachman (1997), acknowledges the essential conceptual flaw in the cognitive model that depression and anxiety symptoms are due to ‘faulty thinking’, in that this view suffers from “the prickly questions of causality”. Logically, and psychologically, there is no necessary causal connection, and any ‘faulty thinking’ could equally be caused by depression and anxiety. He also notes the failure of studies to prove the superiority of cognitive therapy in practice, and the “elusiveness of evidence to support the claim that there are exclusive connections between specific cognitive changes and reduction in depression”. Despite this Rachman goes on to say; “Importantly, the cognitive explanation for the results of cognitive therapy in treating panic is the best supported at present. Indeed, there is no plausible alternative explanation for the effects of cognitive therapy at present” (Rachman’s italics). I beg to differ, (McFadyen, 1989).
I use these Rachman quotes to demonstrate that strong commitment to a model is not necessarily ‘evidence-based’. It demonstrates the normality of getting it wrong. If one of the (rightly) most revered psychologists of his, and my, generation can get it wrong, why would we have to assume that patients who think a panic attack could be dangerous are ‘catastrophising’?
Another giant of Behaviour and Cognitive Behaviour Therapy, Michael Gelder, 1997, in a chapter called The scientific foundations of Cognitive Behaviour Therapy, discussed the ‘evidence’ for spending the largest part of treatment time in modifying catastrophic cognitions on the grounds that change in these cognitions is the essential step in therapy (Clark,1989). He described how “abnormal thinking can be illustrated by the example of panic disorder”. The illustrations listed are various clinical and research accounts of how panic disorder patients describe fears that one or more of the panic symptoms will lead to a medical emergency, and that panic patients endorsed more fears of anxiety symptoms. These are taken to demonstrate “that this pattern of thinking (catastrophising) is present in all panic disorder patients and distinguishes them from other anxious patients”. This is used as support for the “focused approach” of Clark and the Cognitive Model underlying it. The fact that panic disorder patients fear that a panic attack is dangerous does not of course illustrate that the thinking causes the panic. A more obvious and parsimonious interpretation is that the panic attacks cause the thinking, and is more in tune with clinical observations.
The Practice of Cognitive Behaviour Therapy
In one sense it does not matter that the Cognitive Model, supposedly underpinning CBT, is flawed logically and psychologically. If the cognitive therapy component of CBT is effective then we have the opportunity to refine it through both clinical experience and empirical research. The difficulty arises when, after 40 plus years, clinical practice is still largely being directed by the original flawed model, (Beck, 1976; Clark, 1989) rather than by clinical experience and evidence.
There is no convincing evidence that direct cognitive modification of ‘catastrophic thinking’ is indeed essential in the treatment of panic and anxiety disorders. Once it is accepted that thinking in anxiety disorders is readily understood in terms of normal rather than abnormal processes, we are largely freed from the need for a cognitive modification component separate from the exposure component. Modification of the appraisal of panic as dangerous will naturally follow successful behavioural experiments (exposure). The very considerable time taken up by unnecessary ‘modification of catastrophic thinking’, and the training of others to do so, becomes available for more productive therapeutic activities.
Service Delivery; Matched-stepped Care Model
What is the cost of The Matrix matched stepped care model in financial terms, clinical time, and patient outcome? Despite a thorough literature search the ‘evidence’ is little more than anecdotal and conjectural (NHS Education for Scotland, January 2010). The matched-stepped care model nevertheless became pivotal in The Matrix. Evidence based?
Undoubtedly there is a value in improving awareness and understanding of common mental health problems, for healthcare staff and sufferers . Again the time saved by replacing manualised Matrix CBT training with information on the normality of sufferers’ experiences of panic attacks would allow both patients and healthcare staff to appreciate that there is a natural, normal way to overcome the fear of panic attacks (McFadyen, (1989, 1998 a,b,c); Baker, (2011); This could offer a rare opportunity for effective mental health promotion, since information is easier (and cheaper) to communicate than unnecessary self-help therapy techniques.
The evidence for “evidence-based therapies delivered according to a matched-stepped care model?”
Stripped of hype, The Matrix grand plan for mental health, and its NHS England IAPT/NICE counterpart, is a particular pseudo-medical brand of Cognitive Behavioural Therapy, an all-purpose psychological pill for every ill, based on a model which is conceptually flawed, which is associated with a therapy for which there is no evidence of superiority of effectiveness over other psychological therapies, and which has spectacularly failed to deliver improved access to psychological therapies. Maybe not so grand. More unfit for purpose. And no excuse for not seeing it coming (Marzillier and Hall, 2009).
Where from here?
Wampold (2001), based on a broad and detailed analysis of the absolute and relative effects of psychological therapies states, “Therapists need to realize that the specific ingredients are necessary but active only in the sense that they are a component of the healing context”. The point Wampold makes is that the Matrix/IAPT promotion of CBT ignores the evidence about the many interacting factors that make psychological therapy work.
We need to take Wampold’s (2001) advice for therapists (and therapy researchers) “to have a healthy sense of humility with regard to the techniques they use”. Most psychotherapy models will have some insight to offer, even when the model is not supported by the evidence, as in the case of exposure for panic disorder and thought modification in depression. We need a continuing interplay between theory, practice and research. What happened to the scientist-practitioner model of clinical psychology? There can be no practice without theory and no research without practice.
Until the weaknesses in the current process for assessing evidence of effectiveness of psychological therapy, and its delivery, can be remedied, our first choice source of evidence must surely be practice-based.
My experience post-retirement, working as a locum in a number of different services, was that some very clearly provided a much better service than others both in quicker access and in outcome. The two were not unrelated. That would seem to be the obvious starting point for looking for evidence of good (and bad) practice. Academic research should complement clinical practice rather than be an alternative to it (Barkham and Mellor-Clark, 2003).
Practically, we could stop wasting time persuading patients that their thinking is ‘disordered’ when there is no clinical evidence of disordered thinking (sometimes there is). At the same time we could stop trying to persuade trainees, para-therapists, NHS managers, and everyone else, that patients all have disordered thinking. Now that could bring down waiting times.
We could put more time into increasing our understanding of the role of ‘exposure’ in CBT, given that it is the one component which has been found to be effective regardless of the theoretical orientation of the therapist. We could even restore ‘affect’ to the mix (Rachman, S. (1980); Baker, R (2007
More than anything, perhaps, we need to better protect the public, and the profession, from the dangers of promoting the transformation of clinical psychology into a plethora of ‘psychotherapies’ each with different beliefs (models), associations, journals, and their ‘specialist’ training, all competing for professional territory, and now for NHS contracts.
Scientists are people too, as Kelly (1955) might have said. We are all subject to bias, prejudice, and simply getting it wrong. Surely time for a new mission statement DCP-Scotland, one that promotes genuine inquiry into the helping process, with adequate safeguards to ensure that apparently sensible ideas are not extended to the absurd by apparently sensible people. As Wampold (2001) says, “Slavish adherence to a theoretical protocol and maniacal promotion of a single theoretical approach are utterly in opposition to science” (my italics).
Baker, R. (2007). Emotional Processing; Healing through feeling. Oxford: Lion Hudson
Clark, D. M. (1989). Anxiety states; panic and generalized anxiety. In K Hawton, P.M., Salkovskis, J Kirk, & D. M. Clark (Eds) Cognitive behaviour therapy for psychiatric problems ((pp97-128). Oxford: Oxford University Press
Clark, D. M. & Fairburn, C. G. (Eds) (1997). Science and Practice of Cognitive Behaviour Therapy. Oxford: Oxford University Press
Gelder, M. (1997). The scientific foundations of cognitive behaviour therapy. In Clark, D. M. & Fairburn, C. G. (Eds) Science and Practice of Cognitive Behaviour Therapy. Oxford: Oxford University Press
Holmes, J. (2002). All you need is cognitive behaviour therapy? British Medical Journal,2; 324(7332): 288–294.
Kelly, G.(1955). The psychology of personal constructs. New York: W. W. Norton & Company
McFadyen, M. (1989). Cognitive invalidation and panic disorder. In B. Baker (Ed.) Panic Disorder Theory Research and Therapy. Wiley. Available from the author’s website, http://www.ClinicalPsychologyMatters.net/
McFadyen, M. (1998 a) Understanding Stress. Available from the author’s website, http://www.ClinicalPsychologyMatters.net/
McFadyen, M. (1998 b). Understanding panic attacks, panic disorder and agoraphobia. Available from the author’s website, http://www.ClinicalPsychologyMatters.net/
McFadyen, M. (1998 c). “Understanding Stress”, guidelines for use. Available from the author’s website, http://www.ClinicalPsychologyMatters.net/
McPherson, S. (2018). Guidelines for depression: more gourmet nights from NICE. Clinical Psychology Forum, 304
Marzillier, J. & Hall J. (2009). The challenge of the Layard initiative. The Psychologist, 17, 392 -395.
Morriss, R (2015) Mandatory Implementation of NICE Guidelines for the care of bipolar disorder and other conditions in England and Wales. BMC Medicine ,13 (1)
NHS Education for Scotland, (2010), A review and discussion of psychological therapies and interventions delivered within stepped care service models. Retrieved from https://www.nes.scot.nhs.uk/media/228092/literature_search_final_full_report_section_1_13_jan.pdf on 05 January 2020
NICE (2011). NICE Guidelines Common mental health problems: identification and pathways to care. Retrieved from https://www.nice.org.uk/guidance/cg123/resources/common-mental-health-disorders-full-guideline , 4 January, 2020
NHS (England) Mental Health Implementation Plan 2019/20 – 2023/24 (2019), page 47. Retrieved from https://www.longtermplan.nhs.uk/wp-content/uploads/2019/07/nhs-mental-healh-implementation=plan-2019-20=2023=24.pdf 04 January 2020
Rachman, S. (1997). The evolution of cognitive behaviour therapy. In Clark, D. M. & Fairburn, C. G. (Eds) (1997). Science and Practice of Cognitive Behaviour Therapy. Oxford: Oxford University Press
Rachman, S. (1980). Emotional Processing. Behaviour Research and Therapy, 18, pp 51-60
Scottish Government, (2011). Wells report on applied psychologists and psychology in the NHS retrieved from https://www.sehd.scot.nhs.uk/mels/cel2011_10.pdf 16April 2019
The Matrix (2015) A Guide to Delivering Evidence-Based Psychological Therapies in Scotland. Retrieved from https://www.nes.scot.nhs.uk/education-and-training/by-discipline/psychology/the-matrix-(2015)-a-guide-to-delivering-evidence-based-psychological-therapies-in-scotland.aspx 16 April 2019
SAMH (2019). Statement on psychological therapies waiting times. Retrieved from https://www.samh.org.uk/about-us/news-and-blogs/samh-comment-on-psychological-therapies-waiting-times 16 April 2019 and 4 June 2020.
Wampold, B. E. (2001). The Great Psychotherapy Debate: Models, Methods, and Findings. New Jersey: Lawrence Erlbaum Associates, Inc