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NICE recommendations for psychotherapy in depression: Of limited clinical utility
No full textIn 2009/10 NICE partially updated its guidelines on the treatment and management of depression in adults. Due to methodological shortcomings the recommendations for psychotherapy must be treated with caution. Despite recognising the heterogeneous and comorbid nature of depression, and the limitations of depression as a unitary diagnostic category, NICE treats depression as if it were a unitary entity differentiated only by severity. The guidance ignores important aetiological factors such as trauma, loss and maltreatment, personality and interpersonal difficulties. It excludes the largest naturalistic studies on clinical populations treated in the National Health Service on the grounds that they are observational studies conducted in heterogeneous groups with mixed neurotic disorders. It unquestioningly accepts that the "brand" of psychotherapy has construct validity, and ignores psychotherapy process research indicating significant commonalities, and overlap, between treatment modalities and evidence that individual practitioner effects are larger than the differences between treatment modalities. It fails to consider patient differences and preferences, which are known to influence uptake, completion and response. It takes an exclusively short-term perspective on a chronic relapsing disorder. It does not consider the evidence for longer-term treatments. It is of special concern that NICE misrepresents the findings of its own systematic review by implying that CBT and IPT are superior treatments. NICE's systematic review actually found no evidence of superiority between CBT, IPT, psychodynamic psychotherapy, or counselling. Based on the exclusion of much clinically relevant research demonstrating the effectiveness of psychodynamic psychotherapy and counselling many commentators have alleged a bias towards CBT in the guidance. With regard to service delivery NICE proposes the replacement of psychiatric assessment and individualised treatment plans, with an unproven stepped-care model. These clinical and theoretical limitations, perceived bias in the selection of studies, neglect of patient differences, preferences and values, misrepresentation of results of the systematic review, and the proposal for an unproven service delivery model together seriously undermine the validity of the guidance. The guidance, lacking validity is of questionable use, it undermines patient autonomy, professional expertise and, ultimately, patient welfare
Why good placements matter: Pre-placement and placement risk factors associated with mental health disorders in pre-school children in foster care
No full textPre-school children placed in local authority care show elevated rates of mental health disorders when compared to the general population. This study investigated risk factors for mental health disorders relating to the period prior to entering care and while in care. A representative sample of 43 children in care aged 0–72 months in an inner London borough underwent comprehensive multidimensional assessments. Presence of emotional, behavioural, attachment and adaptive disorders was ascertained. Exposure to two pre-placement risk factors and six placement risk factors was compared between children with and without a disorder. A total of 26 children (60.5%) had at least one mental health disorder. The two pre-placement risk factors, multiple types of maltreatment and entry into care after the age of 6 months, were both significantly associated with mental health disorders. The three placement risk factors of sudden placement moves, multiple placement moves and child–carer alienation showed a significant association with mental health disorders. There was a strong correlation between the number of risk factors and the number of co-morbid mental health disorders per child (r = .67, p < .001). In conclusion, this study identified five modifiable risk factors related to the quality of safeguarding and fostering services which showed a significant association with pre-school mental health
The mutism of the mind: Child and family therapists at work with children and families suffering with selective mutism
No full textThe study of selective mutism in children who are well-functioning in all other areas of their lives, has featured very little in the psychoanalytic literature. Yet, more and more children from as young as four up to adolescence are being referred with this symptomatic presentation to our public and private clinics. This paper attempts to bridge this gap by presenting a comprehensive literature review and two case histories of children who chose not to speak outside of their family home. The complex family and intergenerational dysfunctional dynamics around issues of trauma, loss, immigration and dislocation, which contributed to the formation of the symptoms of selective mutism are explored. In the first of these two cases, the individual psychotherapy carried on painstakingly by the child psychotherapist began with parent–child psychotherapy; the second one began with family therapy and was followed by individual child psychotherapy with parallel family therapy. Both children, their ‘silent’ parents and families were helped to give thoughts and words to unthinkable events and emotions, thus achieving a better level of communication
Taking time out of training to shed light on “the dark side”
No full textThe importance of effective management and leadership is increasingly accepted in medicine, moving from “the dark side to centre stage.” However, few trainees are exposed to formal leadership opportunities. On many courses theory predominates over hands-on experience and reflective practice, and trainees are often observers rather than active participants in management decisions.
Some appropriate leadership programmes do exist, however, and increasing numbers of trainees are pursuing these formal learning avenues. One such scheme is the Darzi fellowship, which we completed between 2014 and 2015
Couple and family therapy outcome research in the previous decade: What does the evidence tell us?
No full textMeta-analyses of randomized control trials include only a small proportion of the published outcome research of Couple and Family Therapy. This paper surveys the ranges of published research through a systematic review of the outcome studies of family, couple, and systemic therapies published in English language peer reviewed journals in years 2000 through 2009. After application of criteria of relevance to Couple and Family Therapy and systemic practice, 225 studies were identified, summarized, and coded under 14 broad headings giving 125 potential classifications for each article. Analyses of these codings found consistent conclusions of effectiveness; differential availability and quality of research for different conditions; and quite frequent absence of important methodological information. The findings are interpreted as showing that this body of recent research supports claims of effectiveness. Although the journals included many of good quality there are substantial areas of weakness in reporting. It is concluded that there are significant influences on the body of published research that arise both from funding policies and journal practices as well as perhaps author bias. The consequences are to reduce the value of research to practitioners, to favour randomized control trials with positive evidence of the effectiveness of therapy, and to exclude publication of negative findings
Family therapy for autism spectrum disorders [Cochrane Protocol / Intervention]
Get PDFThis is the protocol for a review and there is no abstract. The objectives are as follows:
To evaluate the clinical effectiveness and acceptability of family therapy as a treatment to enhance communication or coping for individuals with ASD and their family members. If possible, we will also seek to establish the economic costs associated with family therapy for this clinical population
Clinical psychologists' constructions of insight in adult mental health
No full textInsight is a term used in adult mental heath to try to think about and understand how service users’ understand their difficulties. There has been a growth in interest in its potential use in practice. This has led to the development of multiple theories and scales. Research in this area has yielded a vast array of results. Although to date, this enterprise has yielded inconsistent results. While the various insight theories implicate different factors in their models, there is convergence on three recurrent themes: acceptance of mental illness, agreement with treatment, and ability to label experiences as pathological. However, insight in adult mental health is a term that is often used but rarely defined. This research took a social constructionist stance to explore the way insight is deployed by clinical psychologists in practice. It sought to explore the degree to which ideas about insight are used in practice. Conversely it also looked to explore if insight was not used what, if any, analogous psychological theories were deployed in their day-to-day work. The research actively explored a variety of contexts in which clinical psychologists might encounter “insight talk” and how they negotiate these contexts. Nine clinical psychologists working in a variety of adult mental health services within one NHS trust were recruited. Semi-structured interviews were used to explore if, and how, insight is used. The transcripts were analysed using a mixed design of Discursive Psychology and Foucauldian Discourse Analysis. The results suggest that insight and analogous terms are used at different levels of practice. In terms of service user contact (micro-politics) “insight talk” considered insight as psy-model, narrative insight, and formulation. In discussion with colleagues (meso-politics), psychologists constructed their colleagues “insight”. At a system level (macro-politics) psychologists constructed systems as lacking insight and the promotion of a psychologically minded workforce