Crystallising The Role of Practitioners

Dr Michael J Scott

michaeljscott1@virginmedia.com

A Top Down Account of Evidence-Based Provision

Clinician Providers of CBT

Clients

CBT Training CoursesManagers Supervisors

Academic CliniciansRandomised Controlled Trials Scientist Practitioner Model

A Blend of Top Down and Bottom Up Accounts of EB Provision

Clinician Providers of CBT

Clients

CBT Training CoursesManagers Supervisors

Academic Clinicians

The Limited Applicability of the S-P Model to Practitioners Becomes

Apparent By A Consideration of:

• Utility

• Authority

• Validity

What Then are the CBT Practitioner’s ‘Scientific’ Credentials

• He/she is primarily an ‘Engineer’, tasked with providing something useful at the coalface

• He/she is a critical consumer of the offerings of academic clinicians, knowledgeable about whether an intervention has in fact been demonstrated to work

• Dissemination is a key function of the ‘Engineer’ - the Industrial Revolution occurred because of Engineers not Scientists

• The ‘Engineer’ is just as much an empiricist as the ‘Scientist’

The Gap Between RCT’s and Routine Practise

• Shafran et al (2009) have highlighted a considerable gap between recommended treatments and what clinicians do in practice, BRAT, 47, 902-909.

An example: Prolonged exposure therapy is an evidence based treatment for PTSD but practitioners rarely implement it. Scott and Stradling (1997) pointed out that in routine practice only just over a half of clients listened to an audio recording of their trauma in any way that vaguely resembled the injunctions of the academic clinicians Foa et al.

Despite this the Foa et al ( 2013) message continues to travel down a ‘motorway’ uninfluenced by the ‘non-viability’ message transmitted along a ‘back road’

A Blend of Top Down and Bottom Up Accounts of EB Provision

Clinician Providers of CBT e.g Scott and Stradling

Clients

CBT Training CoursesManagers Supervisors

Academic Clinicians e.g Foa et alProlonged exposure

Have the scientists-practitioners divorced?

If they have separated, what does this mean for the S-P model?

The Practitioner as Engineer Can Critically Appraise The External Validity of Studies

Example: The Ehlers et al (2013) BRAT, concluded that TF-CBT works in routine practice, but as an Engineer one might observe:

a) ‘fuzzy’ outcome measure ‘57% clinically significant change’b) all therapists had weekly supervision - unlikely to happen in routine

practice (except for IAPT)c) 91% of therapists were clinical psychologists (qualified or in training) or

trainee psychiatrists - an educational background very different to most practitioners

d) Social problems were a predictor of poor outcome, is this going to be particularly problematic in my context

The Engineer may have serious doubts about transferability

The Practitioner As Engineer Can Critically Appraise Dissemination Efforts

IAPTS goal is to reach 15% of those with mental health problems, Fairburn and Patel (2014) believe that that the training of therapists of the type employed by IAPT is not scalable they recommend:1. Using less highly trained people2. Web based stand alone training3. Recruitment of more therapistsAnd the evidence for this public health policy is?

The Practitioner Is Necessarily Conducting Applied CBT

• To the extent that the practitioner is a scientist at all he/she is an applied scientist, more akin to an Engineer

• There has to be dialogue between the scientists and applied scientists on an equal footing

Converting Back Roads to Motorways

1. Create Mental Health Architects who are the first contact with a client asking what would you like me to build for you so that you can function? He/she would be aware of construction possibilities (rct’s) and the local terrain and oversee the construction process

2. The Architect would be aware of the different competences Scott (2013), would liase with engineers on site.

3. The Architect would review treatment notes to ensure fidelity (adherence plus competence) of construction.

Collect Your Hard Hats As You Go Out Let Your Voices Be Heard