Getting the right therapy?!

A while ago I attended a session to discuss the idea of therapy, it was laid on by the therapist in my local area as I was on the waiting list, along with quite a few others and they got us all to gether obstenibly to talk about what going into therapy could mean.

At some point in their presentation they asked some questions of the audience including how many different types of therapy we thought were available and to name some and then having established that most people actually knew pretty much nothing asked us what we thought was the best type of therapy and threw it open to discussion.

I replied ‘the one that works for me’

They laughed and the therapists smiled and I sat there trying to work out if the therapists thought I had been joking. I still have no idea but it kind of struck me that people assumed I was joking when in fact I hadn’t been. 

There are over 300 defined different types of therapy and yet so few are being practised which suggests that some are in fact better than others however that doesn’t detract from the fact that actually not all therapies will work for you.

For instance I recently saw this article in Pych Central that clearly and concisely puts over why the approach to some problems is all important and that even the experts don’t always get it right. It also shows an incorrect approach in therapy can make people worse not better.

So are you getting the right kind of therapy? How can you tell?

It’s an interesting question and one that is hard to answer. I have done two different types of therapy neither was easy and neither made me feel particularly good/ positive or better and yet in my opinion they were bother successes.  But then you might not want or need to go down the road of having therapy. It’s been suggested in this newspaper report that providing people with self-help books is better  than doing talking therapy. For a start I find these reports interesting because self-help books are often thought to not help but also because in this study as with others, they have also brought the person into contact with a trained professional; in this case for 3 or 4 meetings lasting up to 2 hours in total and used work book to stimulate participation. The full report can be found here and it does make clear that people who had problems with concentration or motivation were excluded from the study and they report that using the BDI-II scores to access the patients response they saw a 50% reduction in score (ie 50% better score than their original BDI-II score for depression)

At 4 months 43/101 (42.6%) participants in the GSH-CBT arm (self help book plus session) achieved this reduction compared to 25/102 (24.5%) at 4 months (odds ratio 2.28, 1.25 to 4.17, p = 0.008) in TAU. Recovery at 12 months was 31/62 (50.0%) for GSH-CBT, and 20/55 (36.4%) for TAU (odds ratio 1.75, 0.83 to 3.70, p = 0.14

Which is pretty good however if you look at the does related section which looks at how the take up of the sessions affected the overall change in wellness score you see

Overall, 3/16 (18.8%) recovered when they attended one or fewer self-help support consultations, compared with 40/85 (47.1%) in those attending 2 or more consultations (odds ratio 3.85 (95%CI 1.01–14.7 p<0.049)).

Which just goes to show that being in touch with someone alters how well you may recover but what it doesn’t explain is why? For instance less motivated people may not turn up to appointments and therefore would equally not do the exercises so get the help but you can’t be sure of that from the data.

However this kind of intervention driven by GP’s surgeries could help a lot of people if only some time could be found to go through it, or maybe just a good friend to talk it through with.

But what about those of us who aren’t suitable for this is the system here in the UK actually helping the problem? Are people recovering?

Well I periodically look at this kind of stuff and it seems that in the first years report found here. This table shows recovery rates were each diagnosis was given it’s appropriate therapy for diagnosis (so not all the same type of treatment)

Diagnosis Recovery	Rate
Depressive Episode	40.4%
Mixed Anxity and depressive disorder MADD	38.9%
Generalised Anxietydisorder GAD	51.9%
Recurrent Depression	35.5%
All Phobias	48.6%
Obsessive Compulsive Disorder OCD	43.0%
Post-Traumatic Stress Disorder PTSD	45.2%
Family Loss	39.0%
Other	41.0%

The biggest problem here is of course that you can’t compare this data with the study above because it uses a very different metric. In this case this is recovery rate and not a reduction in depressive score. All this data refers to people who were considered to need help on a clinical level changing to be not considered to have a clinical problem. Having read most of the report but particularly the section on the data reliability I would say it’s a guideline at best but it does have some uses. However it also points out that there is a lot of variation between the different facilities.

 The median recovery rate ranged from 27% to 58% across the 123 different facilities with median of 42%. However the biggest problem I find with the data is that is so unreliable and they aren’t even sure if some of the different parts are over estimates or underestimates. Hopefully in the coming years this will iron itself out, despite this it did show that

·         the higher scoring patients were less likely to make a full recovery although often cold be seen to have a big change in their overall score from start to finish. Diagnosis was also found to have been an important factor in patients’ likelihood of recovery, with patients diagnosed with a depressive episode, MADD, GAD, or PTSD having a greater likelihood for recovery than if they were diagnosed with another disorder.

·         The more sessions taken by the more experienced staff the better the chance of recovery (As denoted with staff banding on AFC band 7 or above)

·          The number of patients treated at a site was found to be an important predicting factor in patients’ recovery. The greater the number of patients treated at the site, the more likely it was that patients treated at the site would recover (however whether this correlates to the staff banding and experience is not noted)

·         For low intensity treatment, the higher the average dose (median number of sessions) that a site gave, the more likely it was that patients treated at that site would recover. The greater the median number of sessions that patients who were stepped up at a site received, the more likely it was that patients at the site would recover.

However I personally feel all these conclusions to be obvious and I certainly would have expected them.

It is quite disheartening to see the recovery rate so low but the one thing that wasn’t done that maybe should have been was to grade the patients by severity of illness and the improvement in terms of reducing score because in real terms accessing if a treatment is workings is about the improvement seen over time.

 Are they getting better?

I just hope that people start to see that going for therapy if you have a severe problem isn’t about the short term or one course and quick fixes really only happen for those with less severe problems.  More time will need to be taken if people are to become well and so it seems getting the right therapy might be just as important as getting enough. Certainly there is good reason to suggest that increasing the number of sessions a patient attends increases their chances of a full recovery but how do you motivate the powers that be to fund such a thing when the waiting lists are not any smaller.