An Independent View of Mental Health Services

‘Independence Day

IPSIG should have its’ own Independence Day, in early July before the Annual conference, celebrating its’ independent view of Government funded Mental Health Services. State funded agencies such as IAPT have only ever marked their own homework and judging by their marketing they have been remarkable, independent practitioners may well beg to differ. IPSIG is a considered refuge for private CBT therapists wishing to escape the often toxic NHS and is in a position to comment on the state of the ‘refugees’. However it has had a very small voice at Conference and within BABCP, both dominated by those charged with running Government Services and academia with a fast lane motorway connecting the two

On Independence Day there could be a celebration of independently minded assessment. In his first published work Beck [Beck et al 1962) Reliability of psychiatric diagnoses. A study of consistency of clinical judgements and ratings. American Journal of Psychiatry, 119, (351-357) laid out the framework for independent assessment – clinicians would ask questions of each symptom in a diagnostic set, sometimes asking supplementary clarifying questions and then make a judgement whether on the bases of the examples furnished that symptom was present at a clinically significant level. Depending on the number of symptoms present an individual would or would not be considered as having the disorder. A psychometric test was only valid if the diagnostic interview revealed first of all that the person had the disorder the test referred to.

By contrast asking clients to complete a psychometric test in front of the clinician for an unidentified disorder, is not independent, clients are likely to respond to please the therapist. I would hope that on Independence Day there would be a call for evidence based assessment (EBA) which though being the foundation for evidence based treatment has been sorely neglected, resulting in EBT rarely coming to pass in routine practice.

Independent practice offers the opportunity to take a critical stance with regards to current mental health practice, without having to look over your shoulder and worry that your career may not be advanced, you might not be able to pay the mortgage or your working life made such a misery that you just want to leave. Next year will be my Silver Jubilee of working independently, and I have always had medico-legal work as part of my portfolio, together with a focus on trauma [see for example CBT for Common Trauma Responses (2013) London: Sage]. As an Expert Witness, one is independent of instructing solicitors and the primary responsibility is to the Court. It has afforded me a superb opportunity to see how people have fared in the mental services and this has informed my recommendations to the Court as to treatment. People resort to litigation whenever they feel they have been wrongly harmed from the physical/psychological consequences of a slip on a wet floor to the Hillsborough Football Disaster.

In the medico-legal context it is necessary to review all records, GP notes, psychological treatment notes and ask about their history, so that any pre and post trauma debility and its time frame is very clearly delineated. I have reviewed 65 cases that have gone through the IAPT service, some had done so before the incident that initiated the compensation claim others had had a post trauma involvement. The results have just been published in my book ‘Towards a Mental Health System that Works’ (2017) London: Routledge. Whether or not people were treated before or after the event that triggered their compensation claim, their recovery rate, assessed using a standardised diagnostic interview, was just 15% far short of the claimed IAPT recovery rate of approaching 50%. The experiences of these people has been overwhelmingly negative.

Though the intent of IAPT, to increase access to psychological therapies is laudable it is in need of reform, but as Chris Williams, President of BABCP says in his comment on the books jacket there are within my book ‘many nudges to small as well as large service redesign….readers will find a robust challenge to the status quo’. I would have been delighted to be able to recommend to the Court the IAPT Service, it would make life much easier for me rather than seek out a competent private practitioner but unfortunately I cannot.

It is very difficult for private CBT therapists and indeed any practitioners who are not academic clinicians to collect and publish data and this calls into question the notion of being a scientist practitioner. In Simply Effective CBT Supervision (2013) I argued that we are more like engineers at the coal face trying to adapt the findings of randomised controlled to our particular context. Though scientists were the prime movers in the development of the computer it was engineers who reconstructed it in such a way that it could be as widely disseminated as the personal computer that I am writing this on.

IPSIG members alongside other clinical practitioners are part of an engineering rather than a scientific challenge. As such we have an ethical and clinical duty to consider and chronicle IAPT’s limitations together with its reported adverse psychological effects. Failure to do so harms us all.

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