Intensive Short-Term Dynamic Psychotherapy associated with healthcare reductions in patients with functional seizures 2023 Malda-Castillo et al

[Andy]

Abstract

Intensive Short-Term Psychodynamic Therapy (ISTDP) has demonstrated promising evidence for the treatment of Functional Neurological Disorders (FND) including functional seizures.

This paper aimed to further examine the therapeutic effects of a 3-session course of this treatment focusing on its potential to maintain reduced healthcare utility within a group of patients with complex difficulties, across an extended time period, post-therapy.

The original study followed a mixed methods case series design and recruited 18 patients from secondary adult mental health care and specialist neurology services. Seventeen participants completed the intervention and attendance rates were very high (95%). In this follow-up study, which was solely focused on the utilization of healthcare resources, results showed decreases when comparing 12 months prior and 12 months post three sessions of ISTDP.

The results provide further support for the use of ISTDP in this group of participants with complex clinical presentations, specifically, its capacity to reduce healthcare usage over 12 months post-therapy. Further evidence from controlled and randomized studies with larger sample sizes is warranted.

Paywall, https://www.epilepsybehavior.com/article/S1525-5050(23)00065-3/fulltext

 

[rvallee]

Just putting up a sign at the door that says "Don't come back" would be a lot cheaper if that's the only goal. Probably just as effective, it's essentially the same message in a different form anyway.

Or just close the clinic. Zero direct healthcare costs when you do that. If that's the only goal.

Paywalled, for some reason, but when you don't even put any numbers in the abstract, it's because they're really bad and you're only selling a story.

 

[Trish]

The results provide further support for the use of ISTDP in this group of participants with complex clinical presentations, specifically, its capacity to reduce healthcare usage over 12 months post-therapy.

I find that a very concerning outcome measure. What if 'patients with complex difficulties' actually need frequent medical attention? Is the therapy scaring them off - telling them seeking medical help is wrong, or they don't deserve help, or their symptoms aren't serious?

 

[Arnie Pye]

Perhaps ISTDP reduces health costs because patients realise that doctors have nothing to offer them so they stop using the health system.

 

[Hutan]

This paper aimed to further examine the therapeutic effects of a 3-session course of this treatment focusing on its potential to maintain reduced healthcare utility within a group of patients with complex difficulties, across an extended time period, post-therapy.

There is surely a Freudian slip in that abstract. I think they meant to say 'focussing on its potential to maintain reduced healthcare use', rather than 'reduced healthcare utility'.

Definition of utility: the state of being useful

I would say that it is extremely likely that this treatment maintains reduced healthcare utility. To the authors, I would say 'the subconscious mind is indeed powerful' - here yours have managed to convey the truth, even though your conscious minds have tried hard to ignore it.

Ah, it would be funny if it wasn't yet more evidence of people ignorantly and arrogantly messing with the minds of people who deserve practical help.

 

[bobbler]

Just putting up a sign at the door that says "Don't come back" would be a lot cheaper if that's the only goal. Probably just as effective, it's essentially the same message in a different form anyway.

Or just close the clinic. Zero direct healthcare costs when you do that. If that's the only goal.

Paywalled, for some reason, but when you don't even put any numbers in the abstract, it's because they're really bad and you're only selling a story.

Agreed

which was solely focused on the utilization of healthcare resources, results showed decreases when comparing 12 months prior and 12 months post three sessions of ISTDP

Also getting increasingly frustrated with the lack of trust I have in abstracts to not mislead where most who might read it and not be 'in the industry' would have to pay e.g. $31 - was it 'all healthcare resources' in which case how did they be sure of that, or just the mental health and neurology?

Because of course in the 12months prior said people probably had appointments to diagnose them and then tell them they should do this therapy, so whether something 'reduces' is entirely comparative surely to potentially criteria set to participate.

I do find it strange that noone mentioned whether the seizures improved.

And that '95% attendance' was crowed about, but we don't have response rate or details of whether their facts on 'usage' their one measure are complete

 

[Hutan]

Listing the authors here, because I think it's important for anyone potentially visiting these services or seeing these people clinically that they are aware of the underlying priorities.

Javier Malda-Castillo
Psychotherapy and PD Hub, 12 Haigh Road, Psychotherapy Services, Waterloo, L22 3XP Liverpool, UK

Bethany Howell
Personality Disorder & Psychotherapy Hub, Mersey Care NHS Foundation Trust, Merseyside, UK

Leo Russell
Functional Neurological Disorder Service, Devon Partnership NHS Trust, Exeter, UK

Allan Abbass
The Centre for Emotions and Health, Dalhousie University, Halifax, Canada

Guillermo Perez-Algorta
Division of Health Research, Lancaster University, Lancaster, UK

Sophie Valavanis
Personality Disorder & Psychotherapy Hub, Mersey Care NHS Foundation Trust, Merseyside, UK

 

[rvallee]

Perhaps ISTDP reduces health costs because patients realise that doctors have nothing to offer them so they stop using the health system.

Seems to be the whole point. And I do mean all of it, there is no secondary point to this, it's only this one. They are confusing the process with the outcome.

The process of treating sick people is so they don't come back. Because why would they when the problem has been resolved? And we know that "patient didn't come back" is explicitly perceived as "recovered, no longer needs healthcare". So patients not coming back is likely explicitly recorded as having recovered. They get all the credit for doing something, while doing nothing. Perfect scam.

And judging by how effective it has been with us and long haulers, it's clear that they are judging this a rousing success. Most of us have abandoned the idea of even seeing a doctor. They see this as success. They see us being erased from existence as success.

The horrors found in medical history are especially awful, but they really haven't stopped. If it wasn't for higher standards of living, it would be just as awful today. Medicine is just as awful at this as it was a century ago.

 

[Hutan]

On Allan Abbass:

He has a personal website titled http://reachingthroughresistance.com

It seems that ISTDP is an invention of a Canadian; it is claimed to have outperformed CBT:

Intensive short-term dynamic psychotherapy (ISTDP) is a form of psychotherapy developed by Dr. Habib Davanloo of McGill University, taught in training programs worldwide, and actively researched and taught at the Centre for Emotions and Health in Halifax, Canada.

Interruptions and trauma to human attachments cause a cascade of complex emotions that may become blocked and avoided. When later life events stir up these feelings, anxiety and defenses may be activated. This basic finding was derived from a large case series by Davanloo in the 1960-70s.

The treatment approach of ISTDP, as designed by Davanloo, is first to acquaint the patient with these unconscious processes and then to help the patient overcome the emotional blocking processes. This often means focusing on the feelings the patient has in the office during the interview and pointing out the ways the patient blocks off both the emotions and the connection with the therapist in treatment.

This treatment and variants of it have been extensively researched and shown to be effective with depression, anxiety, somatic symptoms, substance abuse, eating disorders, and personality problems. It has outperformed CBT treatment in 3 studies of chronic pain populations.

A CLINICIAN’S GUIDE TO PSYCHOPHYSIOLOGICAL DISORDERS

ALMOST ONE HALF OF PRIMARY CARE PATIENTS have at least one medically unexplained symptom that does not respond to standard care. This leads to unnecessary investigation, referrals, health costs, medications as well as frustration in patients and health professionals alike. The great majority of these patients have psychophysiological disorders (PPD).

USING CUTTING EDGE PSYCHOTHERAPEUTIC and neurophysiologic principles, Hidden From View explains how the brain develops neural pathways that cause symptoms, such as headaches, irritable bowel and bladder syndromes, fibromyalgia, fatigue, insomnia, and neck and back pain. It illustrates powerful emotion focused interviewing techniques to both detect and treat PPD.

REACHING THROUGH RESISTANCE: ADVANCED PSYCHOTHERAPY TECHNIQUES

About half of all psychotherapy clients have little to no response—or can even worsen—in treatment. Why? They unknowingly use treatment-defeating behaviors, or resistances, placing all manner of obstacles to prevent emotional closeness and a successful collaboration with the therapist. It is as if they cannot allow treatment to succeed. This can be frustrating and demoralizing for both the therapist and the client.

How can you and your client detect and handle treatment resistance? How can you reach through to the person beneath this resistance—the person your client was meant to be?

 

[bobbler]

There is surely a Freudian slip in that abstract. I think they meant to say 'focussing on its potential to maintain reduced healthcare use', rather than 'reduced healthcare utility'.



I would say that it is extremely likely that this treatment maintains reduced healthcare utility. To the authors, I would say 'the subconscious mind is indeed powerful' - here yours have managed to convey the truth, even though your conscious minds have tried hard to ignore it.

Ah, it would be funny if it wasn't yet more evidence of people ignorantly and arrogantly messing with the minds of people who deserve practical help.

I just checked to see which country: UK, NHS, Liverpool (lead author)/Merseyside (x2)/Exeter/Lancaster/Canada seems to be where the authors are based. Interesting as it is $ if you want to see beyond the abstract.

Main objective: to reduce visits to: their depts (?) or 'all healthcare' (as they infer?)

3 of these (Merseyside, lead author from Liverpool) are from a personality disorder and psychotherapy hub

these are people with functional seizures, complex issues etc as they've said - I don't understand how even if they meant 'usage' it would be a measure, given surely there must/should be a responsibility to keep an eye on how such patients are actually doing (or is the trick that doesn't 'count' as an appointment?)

 

[Hutan]

Perhaps ISTDP reduces health costs because patients realise that doctors have nothing to offer them so they stop using the health system.

It looks like this study was funded by some NHS Clinical Commissioning Groups, which helps to explain the focus on reduced healthcare usage. (And again I note a Freudian slip - the title talks about 'reduced healthcare', which is surely accurate, while I think they really meant to say 'reduced healthcare service usage'.)

This ISTDP seems to be a pushback by psychotherapy proponents against CBT. It fixes the criticism of psychotherapy being too expensive and too slow - it's 'intensive', just 3 sessions (so more cost-effective than CBT's usual 10 sessions). I think this isn't the last we'll hear of it.

 

[NelliePledge]

I think reduced healthcare and reduced healthcare utility are very apt descriptions of the thinking behind this approach, MUS etc.

 

[Trish]

It occurs to me that a course of just 3 sessions of intensive therapy whose aim is to unblock intense emotions in patients already struggling with complex medical problems will leave them at the end of the 3 sessions with an awful lot to cope with. And the added burden of therapist expectations that unblocking emotions will somehow miraculously cure their neurological symptoms. No wonder they stop utilising health services. They may be left too traumatised and fearful of what horrors will be imposed on them next.

 

[Charles B.]

This guide to recognizing the emotions purportedly leading to these persistent symptoms and unblocking treatment defeating behaviors is honestly one of the most insane things I’ve ever seen. There is no difference between these insipid and platitudinous missives and something you would hear from a medium, faith healer, and strip mall psychic. Effectively, this just gets patients physicians would rather not deal with out of the healthcare system. It’s telegraphed and nobody cares.

 

[Sean]

I do find it strange that noone mentioned whether the seizures improved.

Very.

–––––––––

About half of all psychotherapy clients have little to no response—or can even worsen—in treatment. Why? They unknowingly use treatment-defeating behaviors, or resistances, placing all manner of obstacles to prevent emotional closeness and a successful collaboration with the therapist. It is as if they cannot allow treatment to succeed. This can be frustrating and demoralizing for both the therapist and the client.

How can you and your client detect and handle treatment resistance? How can you reach through to the person beneath this resistance—the person your client was meant to be?

No possibility that the diagnosis and/or therapy are inappropriate, even flat out wrong?

That would be a very good explanation for lack of therapeutic response.

But no, the expert couldn't possibly be wrong. It must be the patient.

 

[Peter T]

Very.

–––––––––


No possibility that the diagnosis and/or therapy are inappropriate, even flat out wrong?

That would be a very good explanation for lack of therapeutic response.

But no, the expert couldn't possibly be wrong. It must be the patient.

Impossible to falsify such beliefs: if it works it is because we are right, if it doesn’t work it is because we are right.

In my early ‘try everything and anything’ phase I saw a homeopath, and he would interpret any subjective change in my symptoms as indication of his treatments working, be it improvement or deterioration. This is not science, as the hypotheses behind it are unfalsifiable.

 

[bobbler]

Seems to be the whole point. And I do mean all of it, there is no secondary point to this, it's only this one. They are confusing the process with the outcome.

The process of treating sick people is so they don't come back. Because why would they when the problem has been resolved? And we know that "patient didn't come back" is explicitly perceived as "recovered, no longer needs healthcare". So patients not coming back is likely explicitly recorded as having recovered. They get all the credit for doing something, while doing nothing. Perfect scam.

And judging by how effective it has been with us and long haulers, it's clear that they are judging this a rousing success. Most of us have abandoned the idea of even seeing a doctor. They see this as success. They see us being erased from existence as success.

The horrors found in medical history are especially awful, but they really haven't stopped. If it wasn't for higher standards of living, it would be just as awful today. Medicine is just as awful at this as it was a century ago.

It's a bit transparent isn't it according to this article: using 'whatever under the label of psychotherapy' (noone has confirmed it is helpful rather than harmful - just because it has been given the name therapy ) effectively as a trapdoor/back door to remove certain people from healthcare.

Sadly it makes you ask directly if it is written for its audience ie as a sales pitch

NHS being about everyone getting access to free healthcare at the point of use seems to miss a caveat it didn't know that it needed when that phrase/cliche was invented.

Very.

–––––––––


No possibility that the diagnosis and/or therapy are inappropriate, even flat out wrong?

That would be a very good explanation for lack of therapeutic response.

But no, the expert couldn't possibly be wrong. It must be the patient.

Disturbing that anyone thinks saying something like that is OK, or I guess at least they are admitting that is how they think and act and it is disturbing that society or regs/oversight are so bad they do write and believe this and aren't under treatment themselves.

It is saying 'unless you give me what I want ergo a good rating, then it is your fault' and there is a power imbalance. Replace their 'therapy' with anything else and any other person in such a vulnerable situation and imagine what you would do. That situation should not be existing.

It also shows a huge lack of their own confidence in their own abilities or 'therapy' that they'd feel the need to do that.

I can't help but note 3 of these individuals work in personality disorder hubs and that these days some seem to be selling as 'up for debate' [as an undertone in some of the literature that comes through from certain schools on here] whether it is the antisocial person and their behaviour towards others that is incorrect, or those impacted by them/who don't think like that who are 'the problem'. ie if only people just didn't get ill from me being horrible to them there would be no issue. The 'normal reaction to inappropriate behaviour' getting simmered down by the person doing the inappropriate behaviour which provokes said only possible stimulus to using that to infer the other person is somehow strange as the behaviour 'unusual' - yet only in the sense most don't weather such situations.

I have huge worries reading statements like this which to me sound like reality-distortion. For incredibly vulnerable people who have almost certainly been through a lot at least with their health. Just because you have the power doesn't mean you get to decide reality in your favour. And that is even more important an underline if you are supposed to be working in an area such as mental health than outside it.

Psych can theoretically in a poorly oversighted world be very much be used for harm, and there are historical well-known lessons of where this has happened which should be being always heeded. Heck read the dystopian literature classics, Margaret Attwood's Testaments being one recent example. Not describing how something would be of any therapeutic help at all vs what someone has whilst focusing on blame and insinuation about the other person in the relationship before they have even done it is... well yes I will say it again disturbing, and not a positive sign of intention.


What seems to also be worrying is the definition of being allowed to use the word 'therapy' as if it infers 'doing good'. Without feeling any need to prove that in terms that matters to those you are doing it to. People who might have little choice about it.

 

[rvallee]

Very.

–––––––––


No possibility that the diagnosis and/or therapy are inappropriate, even flat out wrong?

That would be a very good explanation for lack of therapeutic response.

But no, the expert couldn't possibly be wrong. It must be the patient.

The bastards. They just don't want to get better.

This is far worse than alternative medicine when it happens in healthcare because it has power over people. It has more power than the law, even basic human rights. You have the "right to competent medical care", unless someone looks at you and believes otherwise. This almost ends up worse than charity because it's almost as arbitrary as charity, but the exclusions are formalized and legally enforced. The worst of both systems.

In the end all this BPS stuff has done is give unlimited power to pseudoscience over people who explicitly object. It made all medicine worse, less effective, and essentially did away with basic ethics and professionalism.