How Can You Know Best Practise When You See It?

 

Best practise networking is in vogue. It is a central plank in the Improving Access to Psychological Therapies (IAPT) Service  professional development programme. But who decides what should be marketed as best practice? Is it the powerholders within the Service in conjunction with those who are happy to eloquently re-iterate the party line? What assurance can there be that it is not a matter of the blind leading the blind? The dissemination of ‘best practice’ in psychological therapy rests primarily on a consensus. In Britain, the self-proclaimed lead organisation for cognitive behaviour therapy (CBT), the British Association of Behavioural and Cognitive Psychotherapy (BABCP) sees itself as the custodian of ‘best practice’ and has bestowed an imprimatur on IAPT.

But the British Medical Journal has a very different notion of what constitutes ‘best practice’. For each of the common mental disorders, it identifies screening psychometric tests complemented by standardised diagnostic interviews to identify the particular disorder. Then a treatment algorithm for each disorder. However IAPT clinicians are not trained to make diagnoses so that their ‘best practise’ must diverge from the BMJ’s. Who is right and on what basis?

The gulf between evidence-based practise and IAPT’s ministrations is shown in sharp relief if we focus on the latter’s low intensity guided self-help (LIGSH). I could find no study of LIGSH in which there was a blind assessor of the treatment and comparison with an active placebo. Thus any effects of LIGSH could be attributed to simply attention. By contrast over half (58.7%) of randomised controlled trials of CBT have employed blind assessors.  

The behaviour of IAPT clinicians is highly prescribed. In a study of LIGSH transcripts of tape recordings of client’s first contacts with the Service analysed by Drew et al (2021) there is a steadfast refusal to let clients tell the story behind their distress. The double message is ‘come to us, but we don’t want to listen to your troubles’

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’

and 

‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’.

But not only does the IAPT Service refuse to listen to its clients, it refuses to listen to outside criticism. There has been no change in its’ modus operandi in over a decade as it pursues expansionism.  But it is an expansionism to areas were there has been no demonstrated efficacy and evidence is at best circumstantial. Operating on the dubious premis that ‘it just might be the answer to the world’s problems’. 

The networking of IAPT clinicians, whose operation is validated by BABCP, is an ‘In Group’ that talks amongst themselves, reinforcing their world view and refuses to engage in effortful processing of external criticism.

Dr Mike Scott

 

The Juries “Give Us a Break” Response to IAPT Claims

The afternoon session begins with my cross examination by the Defence barrister, ‘isn’t it the case that those who wrote the IAPT Manual and proclaim a 50% recovery rate are emminent in their field?’. I reply in the affirmative. The Defence barrister continues ‘Have IAPT’s findings been publicly questioned  by bodies such as NHS England? To which I replied ‘no’. He continues ‘so you set yourself up against the acknowledged Experts? My response is ‘I am not setting myself up against anyone, this is not a gladiatorial combat. I am simply insisting that the psychological therapy provided by IAPT should be evidence-based and not eminence-based. The credibility of any service is called into question when it does not rely on the data of an independent assessment. The Expert’s you cite, authors of the Manual, NHS England all have a vested interest in proclaiming the merits of the IAPT Service’. The Defence barrister retorts ‘NHS England is responsible for the health of the nation, are you seriously suggesting that there has been a derogation of duty? I respond ‘yes, for over a decade it has unquestionably accepted IAPT’s claims, with staff holding posts in both Organisations. Recently at the behest of the Department of Health I asked NHS England seven questions with regards to IAPT, they simply told me to go and ask the questions of the Department of Health’. 

I continued ‘With  breathtaking skill, IAPT engages in eminence-based medicine, vehemence-based medicine and eloquence-based medicine. It also engages in ‘it won’t hurt to try’, for example running groups for those traumatised despite a paucity of evidence as too efficacy and under waiting list pressures assigning a clear PTSD case to a trainee’. My own findings of 90 litigants  who went through IAPT whether or not before or after personal injury was that only the tip of the iceberg recover’. The defence barrister continues ‘this is using your own idiosyncratic view of recovery not that used by IAPT, is that not the case?. My response was ‘No, I was using the criteria that is used in Court in personal injury litigation, is the person still suffering from the disorder acquired as a result of the personal injury, it is very straightforward’. The defence barrister continues ‘IAPT uses a drop in score on a psychometric test as evidence of recovery, is this not more reliable?’ My response is if it were, such a metric would be in routine use in Personal Injury litigation, it has had no such status over my 30 years of medico-legal work. The danger of a psychometric test administered at the end of a treatment session is that the recipient of the services does not wish to appear ungrateful and makes an exaggeratedly positive response’.  

Jury members are most likely to use a credible metric in determining whether a Service has failed to deliver and whether or not it has made exaggerated claims for its’ own ends.  Expert Witnesses may protest their independence, but the possibility of bias cannot be excluded as they appear either for the Defence or Prosecution. Additionally they may have an academic bias, re-iterating current mainstream opinions, with scant regard for alternative views.

Dr Mike Scott

 

I co

‘IAPT Is Not Curative’

this could be the opening gambit in the prosecutions case against the Improving Access to Psychological Therapies Service. The indictment is that IAPT has misled GP’s and the public into believing that 50% of its clients recover. Further it is on this basis that IAPT has wrongfully acquired Government funding of £2 billion a year covering adult and children’s services.

IAPT IS ON TRIAL

IAPT is being tried in absentia, because in the 6 years of cbtwatch.com the Service has steadfastly refused to engage in any public debate. In principle, IAPT could call defence witnesses, the British Association for Behavioural and Cognitive Behaviour Therapy (BABCP), the progenitors of IAPT Professor David Clark and Lord Layard, Dr Adrian Whittington the Clinical Lead for Psychological Professions at NHS England and Health Education England, and the IAPT National Clinical Advisor. There is an open invitation to them to attend the trial but there is no Court Order mandating their attendance. Given their track record to date the likelihood is that they will treat the proceedings with contempt and a deafening silence will ensue.

The prosecuting barrister’s role is to present to a Judge and jury in ordinary language the truth of the matter. Operating on the maxim “KISS’ keep it simple stupid, he/she would utilise an everyday notion of recovery, explaining to the jury that in everyday parlance, it means being back to your old self and staying that way. In this way the Judge and jury are invited to consider the evidence that 50% of IAPTs clientele are back to their old selves with treatment and stay that way. But the Judge smells a rat when he/she learns that there has been no independent corroboration of IAPT’s claim. In the circumstances the Judge feels obliged to advise the jury of the distinction between direct evidence and circumstantial evidence and that IAPT’s case, at best, rests on circumstantial evidence. Reminding the jury that at an interview we would all say that we are the best possible person for the job. The claim might possibly be right, but it could not be relied  upon, because of the likelihood of bias. The prosecuting barrister has thereby placed a seed of doubt in the mind of the Judge and jury.

The prosecuting barrister puts the latest IAPT Manual in the dock, under cross examination it is revealed that 50% of IAPT clientele drop out before they have had 2 treatment sessions. When asked ‘is it likely that they are happy bunnies?’, a deafening silence reverberates around the Courtroom. The Judge intervenes ‘please answer the question that Counsel has asked?’ but this is met with a stony silence, and the Judge muses whether this constitutes contempt of Court. The prosecuting barrister wades in ‘I put it to you, that on the balance of probability, their disengagement signifies disenchantment’ or ‘are you seriously asking us to believe that in one therapy session or after just an assessment, the lifes of half or more disengagers has been transformed and permanently so?.   The Manual protests that the claim of a 50% recovery rate only applies to those who attend two or more treatment sessions. The Judge intervenes and addresses the Manual ‘let me be clear on this, looking at all who attend IAPT we have 50% who do not have treatment as you define it, and even if it were the case that 50% of the remainder recover, the overall recovery rate would be just 25%, have I got that right?’, the Manual mutters ‘I suppose so’ . The prosecuting barrister continues that the Manual states that IAPT’s therapists are not trained to make diagnoses, how then can they possibly know  whether a person has recovered or indeed what the recovery rate is for the Service? To speak of recovery without diagnosis is nonsense, recovery from what?

The prosecuting  barrister then calls myself to the witness stand and I explain  that in the context of my role as an Expert Witness to the Court, I assessed 90 litigants who went through IAPT, whether before or after their personal injury and which ever was the case, only the tip of the iceberg recovered see previous blog. The barrister  asks ‘so your primary duty was to the Court, and not to anyone instructing you?’ and I reply in the affirmative. The cross-examination continues ‘is there a possibility of your having a bias over IAPT’, I reply no and that it was not until about 2015 that it was becoming apparent that the Service simply was not working. In my book of 2009 Simply Effective CBT I was neither for or against IAPT considering it a worthwhile experiment that may or may not work.

At this point the Judge declares this would be good time to break for lunch, with the defence barrister cross-examining Dr Scott afterwards. The Judge asks the defence barrister ‘is it the case that you are not calling any Expert Witnesses for your own side?’ The defence barrister confirms this and the Judge can be overheard muttering beneath his breath ‘strange’.

Dr. Mike Scott 

 

 

‘CBT Today’ An Apologist for IAPT Expansionism

CBT Today is the Official Magazine of the British Association of Behavioural and Cognitive Therapy, the supposed lead organisation for CBT. But today it is a vendor for cheap and easy solutions to human difficulties. This sits comfortably with its’ friends in high places, politicians and the media. The funds flow, almost £2billion a year for IAPT  adult, children and young people services. With £988.0m the projected spend on children and young people in 2022/23. But no independent valuation of whether either service is value for money. This would beggar belief at any time, but in these days of financial stringency it has to be insanity, corruption or some combination thereof.

In the December issue of CBT Today Dr Adrian Whittington the new Clinical Lead for Psychological Professions at NHS England and Health Education England, states the IAPT services ‘have lived up to the assumptions that showed they would save money overall for the public purse’ p 10. But the article fails to state that he is also the IAPT National Clinical Advisor: Education clearly vested interests are at work. The null hypothesis for any service, including IAPT, is that it costs something. A null hypothesis, is assumed to be true, unless contradictory evidence is provided. But Dr Whittington and the IAPT powerholders have provided no refutation of the null hypothesis. My own findings confirm the null hypothesis, see previous blog .

Dr Whittington (2022) continues ‘we need to  support a a psychological approach as the norm  for major health conditions. We know that these developments can support people to adjust and manage long term conditions more effectively, reducing unwarranted medical consultations’.  A further null hypothesis is that psychological therapy makes no difference to the management of these conditions. Again the burden of proof is with those who would  rebut the null hypothesis. Who is it that judges that there are ‘unwarranted medical consultations’? What is the world view of a person who sees many consultations for long term conditions as unwarranted?

Dr Whittington (2022) lauds it that the expansion of the Adult IAPT service is being mirrored in the provision of services for children and young people in the form of Mental Health Support Teams in school and colleges.. But there has been no audit of the Service for children and young people at all.The smoke and mirrors continue. 

In the same issue of CBT today Dr Claire Willis declares ‘a small to moderate effect’ for a transdiagnostic approach to persistent physical symptoms in a trial in which she was a therapist. She enjoins that the same approach should be used with Long Covid. No matter that the protocol was evaluated by those who developed the protocols. These authors engaged in a fishing expedition to find any positive findings, administer enough measures something will urn up positive by chance. The spurious claims for the study Dr Willis were rebutted in an earlier blog  of mine.

 

Dr Mike Scott

 

The Myth That IAPT Costs Nothing – it takes money away from where there is real need 

 

The leading lights in the development of the Improving Access to Psychological Therapies service Layard and Clark (2015) have claimed that it costs nothing, due to savings on welfare benefits and physical healthcare costs. But there has been no independent verification of this claim.

Last year the amount spent on IAPT for 47 providers was £547.2 million according to Government figures with 4 million appointments. But only 5% of IAPT clients are on long term sickness benefit and in the last year, by the end of treatment, only 5%  of these were no longer on benefit, amounting to 1783 clients. Using the figure of £650 furnished by Layard and Clark (2015) as the amount the State saves in a month by getting a person off benefit, the total saving that would accrue from IAPTs ministration in getting the 1783 clients off benefits would be £1.16million. This doesn’t even begin to compare with the totality  of IAPT’s cost. Even were one to assume these clients were all off benefit for a year, a saving of approx £15million, the impact on the total cost of IAPT is miniscule, there is no way that IAPT pays for itself!

I could find no published data that compares the proportion of people IAPT gets off benefits with the proportion of people who would have come off benefits before the inception of IAPT. One can imagine that if one tracked a population of Citizens Advice Bureaux attendees a proportion of them would move off benefits, but would this be any more or less than those going through IAPT?

There is a lack of clarity on the specifics and unique way in which IAPT gets clients off benefits.

There is no independent evidence of the effectiveness of IAPT with depression and anxiety disorders in the context of an established physical disorder. Layard and Clark (2015) appeal to CBT studies conducted in in this population, but there is no evidence that IAPT staff have followed such protocols. IAPT does not employ measures of treatment integrity. Nor is there any documented evidence of savings in physical healthcare costs as a result of IAPT’s ministrations.

The National Audit Office has perpetuated the IAPT myth by steadfastly failing to investigate the Services claims. Friends in high places. But each IAPT appointment costs £136, last year, if at each appointment the client was given this sum for their heating/ living expenses it would I believe make a much greater contribution to the common good. I have just seen on TV a single mum with 3 young children from the North East, as she attends a foodbank, in tears as she battles with heating and food costs.

 

Dr Mike Scott

 

 

 

IAPT’s Capitalisation on Time Is A Great Healer

The natural recovery rate for depression is 50% within 6 months. The Improving Access to Psychological Therapies (IAPT) claim a 50% recovery  rate for its clients. It is therefore not at all obvious that psychological treatment has conferred any benefit. The rate of natural recovery from depression is about 2% per week. Looking at natural recovery in generalised anxiety disorder (GAD), of those who had ever suffered GAD, 72% had not had it in the past year. Whilst recovery rate from depression and anxiety disorders at 2 year follow up was 41.7%. These high rates of natural recovery offer Service providers, such as IAPT, a golden opportunity to claim that they have played a pivotal role in client’s recovery. 

Many, many years ago I had a Summer job working part of the time in a Mortuary, the day I began was a glorious Summer’s day and the most Senior pathologist remarked that  ‘you’ve brought the good weather with you’. Much as I had a tendency to take credit when things went well, and to blame others when it didn’t, I did feel that even I couldn’t take credit for the good weather. But Service provider’s it seems have no such inhibitions. They operate with a self-serving heuristic in which the exact mechanisms by which they bring about change are left unattended and they invite others to believe their eminent representatives. In this way effortful processing of data is by-passed, by an appeal to ‘credible sources of persuasion’ as it is termed in the Elaboration Likelihood Model of Persuasion.

Within this ‘Capitalisation’ it easy to smuggle in other purported benefits of psychological therapy such as getting people back to work, improving their physical health without actually demonstrating either, see Layard and Clark (2015) by simply saying ‘it is likely’. All to the glee of politicians, Clinical Commissioning Groups and media. Thus the band wagon continues in a race to the bottom.

 

Dr Mike Scott

IAPT – The Rogue Santa

If Santa lost half his deliveries before reaching the 2nd home on his itinerary, he would be viewed with suspicion. But last year the Improving Access to Psychological Therapies Service (IAPT) lost 46% of clients before their 2nd treatment session. What’s going on?

The Service would prefer to deftly switch attention to treatment completers, defined as those who complete at least two treatment sessions. But no Oncology or Physiotherapy service would define completion of treatment in such a minimalist way. This looks like sleight of hand. Nevertheless for ‘completers’, IAPT offers the defence of effectiveness  across a range of disorders as evidenced by the effect sizes in the Table below:

 

IAPT’s Defence By Disorder

 IAPT’s 2021-2022 Annual Report

Within Subject Effect Size using PHQ9 (for all cases initially at caseness) and only for those who completed two or more treatment sessions.  The ES is pre-treatment mean minus the post-treatment mean/pooled standard deviation 

Depression

1.5

Agoraphobia

0.8

Body Dysmorphic Disorder

1.2

Generalised anxiety disorder

1.0

Hypochondriacal disorders

0.9

Mixed anxiety and depressive disorder

1.2

Obsessive-compulsive disorder

0.9

Other anxiety or stress related disorder

1.2

Panic disorder [episodic paroxysmal anxiety]

0.9

Post-traumatic stress disorder

1.1

Social phobias

0.9

Specific (isolated) phobias

0.8

The mean ES in the above table is 1, this means that at the end of treatment the average client is better than 84% of those at the start. But it is not known how long this change lasts or what proportion of clients would consider themselves back to their old self. No independent person has asked them. The results are based on questionnaire responses made in the presence of the Santa like therapist. Who wants to displease Santa?

Science Has Progressed By Categorisation but IAPT Feigns This

The IAPT Manual states  that its’ staff do not make diagnoses. How then are the IAPT staff supposed to know which label to attach to whom? It can be contended that the diagnostic labels don’t matter, but that is not what NICE says, they recommend specific protocols for particular disorders. IAPT has been dishonest since its’ inception, in claiming NICE compliance. It should publicly admit that its staff excercise unbridled clinical judgement in choosing a ‘diagnostic’ label. As a consequence the treatment it serves up is necessarily idiosyncratic. There is know knowing what this Santa will deliver!

IAPT squeezes its clients into 12 categories, one of which mixed anxiety and depressive disorder is still used despite the advice in the 2019 Manual. No room at the inn for those with an adjustment disorder, personality disorder, bulimia, substance dependence, bipolar or psychosis. The injunction from the Service is to treat the principal disorder, but comorbidity is the rule rather than the exception. The implication is that comorbidity is best ignored. Clients are made to fit the Service and not the other way round.  

The Demise of The Supposed Medical Model and The Rise of Autocracy

There are many who see the ‘medical model’ as totally anathema and who should therefore be rejoicing at the de facto ignoring of diagnosis in IAPT. But they do so under their breath, as the prime movers in the development of the IAPT service, based their reputations on the efficacy of specific protocols for particular disorders e.g panic disorder.

 

The IAPT service is actually an experiment in determining what happens to clients if clinicians have free reign to treat clients as they see fit. The results of this clinician autocracy (or oligarchy if those who hold sway in IAPT/BABCP are considered) is that clients do not improve by any more than would be expected with the passage of time and attention.

The successors to Clinical Commissioning Groups make decisions locally as to how much money to invest in IAPT. But none have been prepared to open the ‘can of worms’ and insist that there is an independent assessor who at a minimum asks clients ‘compared to when you first went to IAPT are you the same, a little better, a little worse, much better, much worse? How long have you been the way you are now?

The Blatant Ignoring of Published Guidelines by IAPT

IAPT’s behaviour is in glaring contrast to that espoused in an Editorial in the most recent issue of the British Journal of Psychiatry who recommended observance of both NICE and Australian/New Zealand Guidelines for the treatment of depression  with ‘robust diagnosis and re-evaluation’ at the start of treatment and at 4-6 weeks, to check that the diagnosis is correct and redirect treatment if no response. They re-iterate that the Guidelines also state that if a person is unresponsive after 4-6 weeks there is ‘a need to address problems that may not seem to be directly pertinent to depression, such as personal, social or environmental factors, and advises that other illnesses (especially personality dysfunction) should also be considered as potential contributors to depression’. No such detailed re-evaluation ever takes place in IAPT, by their own admission they do not diagnose and certainly not personality disorders.

Dr Mike Scott

 

Dr Mike Scott

 

Children In Care Go Down A Rabbit Hole When It Comes to Diagnosis and Treatment

Their world becomes Alice In Wonderland like. A recently published study by McGuire et al (2022) gave one of two alternative vignettes to 270 mental health professionals. The only difference in the narratives was that in one the child was described as being in care and in the other as living with their mother. For the sample in which the child was described as living with their mother, the rate of diagnosis of PTSD was more than double (31.0% vs 14.5%). According to NICE, children with PTSD should follow a particular treatment pathway, trauma focussed CBT. Thus for every child in care placed on the  correct NICE pathway, another would be misdirected. Matters were even worse than this, as only one half of those who diagnosed PTSD recommended a NICE approved treatment (trauma Focussed CBT or EMDR).

Overall the most popular diagnosis was developmental trauma (57.3%)  followed by attachment problems (22.1%) and PTSD (14.5%). But these clinicians seemed unphased, that there is no evidence-based protocol for either developmental trauma or attachment problems. The use of such diagnostic labels is an exercise in unbridled clinical judgement that serves the interests of neither the children in care  nor the troubled child not in care.

Unfortunately the use of idiosyncratic rules of thumb (heuristics) is commonplace, 9 out of 10 of those diagnosed with ADHD are boys, but boys are only 3 times as likely to have ADHD as girls, Bruchmuller et al (2012) the representativeness heuristic operates, in that boys are seen as prototypical. Heuristics short circuit decision making, sacrificing accuracy for speed. But they are not the exclusive preserve of clinicians working with children, their usage is ubiquitous  amongst mental health professionals. It is an article of faith amongst aspiring mental health clinicians that the ‘medical model’ must be derided at every turn, diagnosis is anathema to be replaced by the autocracy of the clinicians judgement. But it is unfettered clinical judgement, imagine what would happen if Judges engaged in this with regards to sentencing! Diagnosis is built on explicit criteria and another clinician can challenge whether there is sufficient evidence that those criteria are/were met. We can even distil more reliable diagnostic criteria. There is no appeal against the autocracy of unbridled clinical judgement, it is an exercise in power without responsibility. We are back to the era that pre-dated the randomised controlled trials of psychological interventions in the 1970’s. It was like being at the Mad Hatter’s Tea Party, I remember having the timidity to ask on a social work course ‘does this social casework, work?’ and arriving late for a T Group, to be told this was a manifestation of ‘resistance’, my remonstration that I had missed the bus counted for nought.  The social casework totally failed, with failures to protect children abounding and idiosyncratic decision making, supplemented with box ticking.

 

Dr Mike Scott

Spurious Claims For The Impact of Transdiagnostic CBT on Persistent Physical Symptoms 

 

In a just published study James et al (2022) extol the virtues of their transdiagnostic CBT therapy (plus standard medical care) for Persistent Physical Symptoms.
s. In an earlier study  these authors found no difference in outcome at 52 weeks follow up on the Work and Social Adjustment Scale (WSAS: the declared primary outcome measure) between those undergoing the transdiagnostic CBT plus standard medical care and those having the latter alone. Not to be outdone they have gone on a fishing expedition in their latest paper  James et al (2022) and focus on two secondary outcome measures, WSAS score at the end of active treatment  and the PHQ-15 score at 52 weeks, claiming that there was a significant difference between the transdiagnostic CBT  and standard medical care using both these secondary measures.

 This looks a little fishy as they are the originators of the treatment. No mention of the need for independent replication of their findings. Further the comparison group was standard medical care, but this design does not control for attention or the presentation of a credible treatment rationale. Scepticism seems in order. This intensifies when the outcome measures used are considered.

The WSAS (Mundt et al 2002) was designed to assess the impact of mental health on functioning in 5 domains work, home management, social leisure activities, private leisure activities and close relationships. As such there is clear separation between the causal agent (mental health) and effect (functioning). In the initial validation study the WSAS was administered to a sample of depressed patients and a sample of OCD patients, the WSAS scores correlated with the severity of each disorder.  

Mental Health can affect one’s ability to do certain day-to-day tasks in their lives. Please read each item below and respond based on how much your mental health impairs your ability to carry out the activity. 

Table

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If however the term ‘mental health’ in the above table is replaced with “Persistent Physical Symptoms’ the distinction between causal agent and effect is lost. Consider, a person who is terminally ill with cancer or a progressive neurological disorder, they would likely score high in each domain. But it would not be anticipated that any psychological intervention is going to attenuate their physical symptoms, because there is a fusion of physical symptoms and impairment. [In the original validation study the term ‘disorder’ was used because they were known to have either depression or OCD].

The burden of proof is on those who would reword the WSAS so that it related to PPS to demonstrate a meaningful distinction between say fibromyalgia and impairment in functioning or irritable bowel syndrome and functioning or between chronic fatigue syndrome and functioning. The WSAS was not validated for PPS  but that has not stopped James et al (2022) using it as their primary outcome measure in their study of transdiagnotic CBT for PPS compared to standard medical care.

 

The PHQ-15 is a measure of symptom severity and is rated on a 3- point Likert scale. This brief validated measure looks at a range of symptoms and asks patients to report to what extent their symptoms bothered them in the past four weeks. The PHQ-15 contains 15 items and the total score can range from 0 to 30 where a higher score indicates greater symptom severity (Kroenke et al., 2010). The items include several related to pain, (stomach pain, back pain, pain in arms and legs or other joints, headaches, chest pain), fatigue, as well as other symp- toms related to the different systems of the body i.e. shortness of breath, dizziness, bowel symptoms.

But there is no clear mechanism by which a psychological intervention impacts such an array of symptoms. The authors considered 9 possible mediating variables (7 of which were cognitive), but only 2, catastrophising and symptom focusing appeared operative (Type 2 error). Suggesting that the supposed mediating variables may be chance findings. One of the suggested variables related to depression (PHQ-9) and the other anxiety (GAD-7) but for the supposed cognitive mediation model evinced by James et al (2022), they cannot be mediators, depression is known to covary with WSAS as such it cannot be an explanatory variable.

Assessment in the study is entirely by self-report measures but the authors totally ignore that they are subject to demand characteristics e.g wanting to please the therapist by reporting improvement or to convince oneself that time has not been wasted. It would have been more meaningful for an independent assessor to ask since ‘x’ have you felt the same, a little better, a little worse, much better, much worse.  

James et al (2022) justify their transdiagnostic therapy on the basis that ‘people with different PPS share some cognitive and behavioural responses to symptoms, including catastrophising, symptom focusing, fear avoidance beliefs, avoidance behaviour and lack of acceptance (Deary, Chalder, & Sharpe, 2007)’. This is a sweeping statement certainly catastrophising and avoidance behaviour have been implicated in the development of chronic pain, but this is not to say that they are germane to the category of PPS (MUS). The use of the term ‘some’ makes the Deary, Chalder, & Sharpe, 2007 model incapable of falsification.

 

The  term PPS as used byJames et al (2022), is a smokescreen for the construct Medically Unexplained Symptoms whose validity Keith Geraghty and I have challenged.

Dr Mike Scott

 

Mis-Guided Self Help In IAPT

A just published study by Duhne et al (2022)found that almost a third (29%) of those assessed by the Improving Access to Psychological Therapies Service (IAPT) and referred to Guided self-help (either face to face or computer assisted CBT) did not attend any treatment sessions. Whilst of those who attended treatment over half (54%) dropped out, defined as attending three or less treatment sessions. These figures are much higher than the 20% Swift and Greenberg (2012) of clients who typically dropout of psychotherapy.

 

Curiously the authors miss the obvious implication that GSH is misguided. Instead they recommend further investigating an algorithim for better matching those who would do better in cCBT or better in face to face! Why is this? The authors declare no conflict of interest, but the Department from which it emanates at Sheffield University has a long list of IAPT teachers. There is a complete absence of critical appraisal of IAPT’s metrics suggesting that the Sheffield researchers don’t want to bite the hand of a service that gives them a ready-made data set, it eases the research burden. The Journal in which it was published Behaviour Research and Therapy characteristically ignores any criticism of IAPT.

 

Concluding anything  about the relative merits of cCBT and face to face GSH is problematic, in the Duhne et al (2022) study as the mean initial PHQ9 scores  were respectively 12.32 and 15.01, which is statistically significant p < 0.0001, when the sample sizes and standard deviations  are input into a the MedCalc comparison of means calculator.  This suggests some systematic bias in the allocation of people to these modalities. 95,088 patients accessed diverse low-intensity interventions: GSH (n = 84,503; 88.4%), psychoeducation groups (n = 8671; 9.1%), cCBT (1611; 1.7%), and other interventions (n = 753; 0.8%). 

Dr Mike Scott