Yesterday Pulse published its’ investigation of IAPT, it was the effigy on the bonfire despite NHS England’s protestations, see link below:
It follows close on the heels of the BBC investigation., see link http://www.bbc.co.uk/news/health-45895541
What is still not properly recognised is that despite over £1billion being spent on IAPT there has been no independent assessment and my work suggests just a 15% recovery, it is a scandal.
Dr Mike Scott
If the stigma of having a mental health problem was abolished overnight, it wouldn’t make a real world difference to the daily life’s of any of the enormous numbers of sufferers that I know. Being against stigma is like being against war, desirable, but no guarantor of functioning. Politicians and Prince’s rightly clamour to be against the stigma surrounding mental health problems but it is delusional to think this has or could determine recovery from any recognised disorder. The clamour is often associated with the promise of more monies for mental health. This is given a cautious welcome by providers of mental heath services, but with a muttering of ‘yes but it is not enough, we need (an unspecified sum) to expand’. There is a steadfast refusal to acknowledge that even those currently treated are ill-served.
In my recent BBC TV interview (October 19th) I made the point that there is only a 15% recovery in the IAPT service, a total abscence of independent assessment despite spending over £1billion on the service, initial assessments by telephone by the least qualified clinicians, resulting in treatment built on sand. IAPT declined to be interviewed and simply re-iterated its’ party line, with no attempt to critique my findings. This has been followed by a deafening silence, what does this betoken?
Dr Mike Scott
Cochrane reviews are often used as a ‘gold standard’ for establishing whether a treatment can be regarded as efficacious. They are independent of practitioners/researchers. But they don’t always get it right, for example on the appropriateness of graded exercise for chronic fatigue syndrome (CFS). Nevertheless there is a re-consideration of conclusions in the the light of the critique of others and they are for example going to post a qualifying note about their original conclusions on CFS. Whilst others including myself would wish that their original report was withdrawn, nevertheless one feels that there is an openness and objectivity. By contrast when it comes to evaluating whether treatments are effective in routine practice, as in IAPT, there is no such ‘Cochrane’, it feels much more like voicing dissent in some totalitarian regime. Those in power dominate the media, refuse to directly and openly debate and the juggernaut roles on, until one day it will implode and people will wonder why the writing on the wall was not heeded earlier!
Dr Mike Scott
On Friday the BBC TV broadcast an interview with me in which I said IAPT’s recovery rate was just 15%, this contrasts with IAPT’s claim of a 50% recovery rate, arrived at by marking their own homework. Further I noted that using IAPT’s own data there is a threefold difference in recovery rate by geographic area, if there were such differences in outcome with heart bypass surgery it would be thought that something was seriously amiss. It is great that the subject of IAPT has finally come under public scrutiny but Clinical Commissioning Groups, MPs, and professional bodies have to put IAPT in the dock and question whether the £1bn expenditure on it has been justified. That there has been no funded independent assessment is an ongoing scandal.
The BBC Investigation can be accessed using the following link
interestingly IAPT focussed the BBC’s attention on the 1 in 7 geographic areas that fail to reach its’ 50% yardstick, rather than that only 1 in 7 of its’ clients overall recover.
Dr Mike Scott
The final straw for a friend working in High Intensity ‘I’ve just been told that in the 1st session , I must tell the client that in our service and nationally most people manage with 6 sessions in Step 3’. He’s had enough, sorting out his mortgage, then leaving for private practice! We agreed that IAPT management seem to have never heard of the importance of rapport.
A study just published by Sara Antunes-Alves et all of 43 clients undergoing CBT for depression found that the only predictor of outcome was rapport, examples of this included exchanges where the therapist and client were joking , laughing together. In the study rapport was observer rated none of the competence skills predicted outcome, however the study was small, technically underpowered and they may have been predictors with a bigger sample. Nevertheless the study is a salutary reminder of the importance of humanity. Antune-Alves et al (2018) Therapist interventions and patient outcome: addressing the common versus specific factor debate. Archives of Psychiatry and Psychotherapy 3, 7-35. Interestingly clients had at least 12 therapy sessions with a maximum of 20, this is the number of sessions that quality research has found necessary for real world change. The ‘norming’ of 6 sessions in IAPT is an insult to clients and a betrayal of trust – a sub-therapeutic dose of treatment.
Dr Mike Scott
Mr Matt Hancock has just announced on BBC Radio 4 that ‘our (mental health) services are better than almost any other services in the world’. But how can he possibly know this – there has never been an independent assessment of the Government funded Improving Access to Psychological Therapies Service (IAPT), the latter have only ever marked their own homework. The Secretary of State might ask the National Audit Office why it has never published the results of its’ investigation into IAPT. My own study published in the Journal of Health Psychology in February of this year
suggests the recovery rate in Adult Services is just 15% far short of the Government target and IAPT’s claim of a 50% recovery.
Dr Mike Scott
‘Very interesting and lots of new ideas for approaching what can be a complicated mind field’. Delighted Christine Roberts twittered this response, thanks. It was a full house at the Lakeside Centre, Crosby, Liverpool, super day except for a microphone that had a life of its’ own!
But there was unanimous agreement from the 80 participants that generally therapists are a) stressed out b) daren’t publicly voice there discontent with IAPT. One person voiced that the customary IAPT 6 sessions is like putting a sticking plaster on a wound and all you get is a revolving door of clients. We need to stop the bleeding.
The voices of dissent are not in evidence at Nationally Organised BABCP Events, indeed I did not go to the Annual Conference because it looked like a further feast of uncritical acclaim of IAPT, reflected in the current issue of CBT Today.
The great thing at the Workshop is that we were able to address participants concerns e.g comorbid PTSD and OCD in a 15 year old. But we were all at a loss as to how to break out of the current mode of IAPT delivery, it seemed to resonate with being a citizen of some totalitarian state.
Dr Mike Scott
Psychological therapists in the UK and beyond almost universally believe that they are equipped to personalise treatment and jealously guard their autonomy. Services feed the quest for autonomy by taking no steps to ensure clinicians make reliable diagnosis. This, despite the fact that the NICE approved psychological treatments are almost all diagnosis specific. As therapists are promoted the system perpetuates itself.
Not too long ago it was believed that physical and mental disorders arose from an imbalance of the four humours – blood, yellow bile, black bile and phlegm. A person with disordered blood would obviously improve with bloodletting. Years of experience of people recovering after thoughtful personalised bloodletting were confirmation of efficacy.
Evidence based psychological treatment (EBT) still requires a clinical judgment as to whether a particular person could be matched to the population of a particular randomized controlled trial. But EBT’s prevent the unbridled use of clinical judgement .
Moving towards reliable assessment will need nothing short of a revolution because it runs counter to the current expert consensus. This consensus does not accept that current provision simply does not work, a 9.2% recovery rate, when assessed independently Scott (2018) https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0 and calls for replication studies have fallen on deaf ears amongst the power holders and the media [ Marks (2018) https://www.dropbox.com/s/uw47oh03k9uvpo0/Marks%20IAPT.pdf?dl=0 There is an understandable concern about an increased cost of assessment but this will be offset by a treatment that might actually work. There is a massive vested interest in the status quo that extends to courses and politicians. The latter want to be seen to be on the side of mental health, happy to be seen opening mental health facilities or advocating more mental health personnel in schools but they run shy of considering independent assessment of outcome, it is of no short term political advantage. Politicians have let the National Audit Office get away with not publishing the results of its investigation into Improving Access to Psychological Therapies ( IAPT) .
Scott, M.J (2018) IAPT – The Need for Radical Reform, Journal of Health Psychology, 23, 1136-1147.
Marks, D.F (2018) IAPT Under the Microscope, Journal of Health Psychology, 23, 1131-1135.
Dr Mike Scott