Friday, 4 April 2014

CBTp, Psychiatry and the "facts on the ground": Thoughts on the latest Maudsley Debate

Though it is rarely framed this way, the folk who critique CBT for psychosis and the folk who defend it have an important piece of common ground it seems worth talking about. Both are concerned about the way the “facts on the ground” can be at odds with an evidence base. 

"Facts on the ground” are what powerful people change without recourse to the necessary forms of law or reason. Putin changed the facts on the ground by annexing Crimea and stationing 10,000 troops on the border of Ukraine. This change was important precisely because the international community did not want to respond in kind; Putin changed the question from “how can we negotiate a diplomatic solution to Ukrainian unrest?” to “how can we negotiate a diplomatic solution to an invasion?” 

Vladmir Putin riding to a psychotherapy session.

“Facts on the ground” is usually a military term used to highlight a contrast with efforts at governance. In mental health, what actually happens to people are the facts on the ground, while the evidence base is our governance.

Those who propose (qua the Maudsley debate from 2nd April) that CBT for psychosis has been “oversold” see facts on the ground about CBTp that are at odds with the provision of evidence-based care. NICE (along with many mental health professionals) is promoting a therapy which, according to the highest quality available meta-analyses, appears to offer virtually no benefit.

Among those who opposed the motion, we hear much talk of the actually-existing alternatives; lifelong neuroleptic medications, forced restraint; traumatic and chaotic sectioning procedures. These too are facts on the ground, at odds not only with the evidence base (prescribing practices are frequently out of line with evidence) but with our sense of how it’s decent to treat people.

I have spent a lot of my career in mental health, some of it in a CBTp milieu, and I have come to feel wary of the team-affiliations and self-protection that allow for therapeutic orientations to flourish and self-promote un-troubled by the voice of skeptics from outside. Perhaps this constitutes its own form of bias (the zeal of the apostate?), but I can’t help but be persuaded by the meta-analyses that show CBTp to have miniscule treatment effects. I am also persuaded by my own experiences trying (often rather ineffectually it seemed to me) to change people’s thoughts about experiences which seemed to powerfully disruptive of their thinking. Show me anecdotally positive cases if you like, but if you follow the “I know someone who found it helped” research methodology, there is virtually no imaginable treatment that doesn’t make the grade.

Where do we go from here?

This seems to be where most discussions of this topic leave off, but that is a highly unsatisfactory state of affairs. There is only so much interest to be gleaned from me telling you that, as things stand, I see little that is active or helpful in CBTp. What role should psychology have in psychosis?

We hear so often that being detained, locked up, forcibly medicated and released with no aftercare is traumatic and unhelpful. This ought to come as no surprise. Some people see psychiatry and psychology as by their very nature set up to create this kind of experience. I am more optimistic. What both professions ought to have in spades is ideas about how they could be different, and the research understanding to discover how.

It is surely structural changes that hold the most hope. With imagination we can structure services so people are checked in on more often, professionals are better supported and transitions from the community to hospital can be calmer and better planned. The Open Dialogue approach, which seeks to involve entire families in the early stages of a psychotic crisis is one way to re-imagine the point of entry. It is getting a tentative start here in New York, and from what I understand it is principally concerned with giving genuine respite in a time of crisis and bolstering the support given to people going through crisis.

Such structural changes are promising even if you are agnostic about the nature of psychosis. “Brain disease” or “trauma reaction”; both sorts of problem should respond to well structured well integrated care. Whether we decide CBTp has been “oversold” or not seems less relevant than the question of whether we can do something better than what is currently available. You’d have to be quite a pessimist to think that the answer to that is no.

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