The UK’s IAPT Service Is An Abject Failure

 

from ‘Mad In America’ https://www.madinamerica.com/2022/06/uk-iapt-abject-failure/

 

Rescued man in boat looking on shipwreck

Dr Michael J Scott Ph.D

In 2012, an editorial in the prestigious journal Nature claimed that the UK’s IAPT Service is “world-beating”—meaning that the service is the world’s best for treating mental health concerns. Now that 10 years have passed, it’s clear that this was not true. Despite the hype, the IAPT is hardly “world-beating.” In fact, it is a doubtful model for other countries to follow.

The IAPT (“Improving Access to Psychological Therapies”) was created in 2008 and fully funded by the UK government (though restricted to provision only in England). The program claims to provide evidence-based psychological treatment, most commonly in the form of cognitive behavioural therapy. It was initially focused on patients with depression and anxiety disorder diagnoses, but its scope has been gradually expanded to include the psychological treatment of long-term physical conditions such as chronic fatigue syndrome.

Patients either self-refer (at no cost) or are referred to the IAPT by their primary care physician/general practitioner. Clients are initially assessed during a 30-minute telephone conversation by a Psychological Wellbeing Practitioner (PWP) who is not an accredited therapist and is not trained to diagnose. IAPT clients initially receive low-intensity CBT (six hours or less of therapy contact) delivered by a PWP. If they are deemed not to have responded to this, on the basis of a psychometric test, they can be “stepped up” to high-intensity CBT delivered by an accredited psychological therapist.

How Well Is the IAPT Doing?

Proponents of the IAPT cite its outcomes for the clients who complete their treatment sessions—but over half of IAPT clients don’t even attend two sessions. The response of the IAPT to this massive disengagement with the service—clients “voting with their feet,” as it were—is currently to offer training to its staff to “streamline” matters by encouraging them to use a computer algorithm to decide which clients go where. This training, which was held on June 22, 2022, involves expert advice from the CEO of Limbic, an artificial intelligence Company. Thus, not only are IAPT staff to be distracted by clients having to complete psychometric tests at each encounter, but now additionally by the administration of the computer algorithm.

Yet Limbic claims it is “an AI assistant for clinical assessments in IAPT—improving access, reducing costs and freeing up staff time.” Where is the independent evidence for this? What clients really want is to be listened to, but there is little chance of this any time soon. Conquering disengagement in this manner is a forlorn hope. 

IAPT’s 2019 manual states that IAPT staff do not make a diagnosis. However, the treatment recommendations of NICE (the UK’s National Institute for Health and Clinical Excellence) are explicitly tied to a taxonomy of specific treatments for identified disorders (largely, diagnosis-specific variations on CBT). IAPT legitimises itself by a claim to be NICE compliant, but how could they be if they don’t make diagnoses? How can they follow NICE’s specific treatment guidelines without first assessing which condition they are treating?

Whilst the IAPT’s claim to be NICE-compliant might be music to the ears of NHS England and clinical commissioning groups, it is simply not true. No independent fidelity checks have ever have been made on IAPT’s ministrations. IAPT allegedly provides specific CBT protocols for different disorders, but it has provided no evidence that it does this.

In my examination of the physician’s records of 90 IAPT clients, I found no evidence of compliance with CBT protocols.IAPT operates simply as a business with superb marketing.

In no independent audit of IAPT, have clients been asked “are you back to your usual self since this treatment?” This is a goal that is meaningful to the client—with the possible supplementary question, “for how long have you been back to your usual self?” In papers published by IAPT staff, no such real-world outcome measures have ever been used. Instead, reliance has been placed on changes in psychometric test scores. Yet without a control group, it’s impossible to know whether these changes would have occurred with passage of time anyway. After all, people present to psychological treatment at their worst, and at any other time, they are likely to score better. In statistics, this principle is known as regression to the mean, and it is vital to account for this effect.

Further, the client knows his/her therapist sees their completed questionnaire, pushing them to respond more positively. A client may also not want to endorse negative responses on the questionnaire because it would mean acknowledging that they have wasted their time in therapy. These are known issues with self-report measures that are commonly cited as important limitations in research studies.

Finally, the questionnaire results also give no indication of whether any improvement has lasted for a period that the client would regard as meaningful, such as eight weeks or (hopefully) more.

In an era of personalised medicine, it is essential that the voice of the client is heard. It is an almost ubiquitous failure of studies to employ a primary outcome measure that a client can identify with—known as patient-centred outcomes. Perhaps the nearest proxy is loss of diagnostic status (full recovery) determined by an independent assessor. The burden of proof rests on providers of services to demonstrate that their treatments are making an important difference to a client’s life in a way that is clearly recognisable to the client. IAPT has not cleared this evidential bar.

Use of an algorithm is not incompatible with a clinician operating on a knowledge base of what works for whom. But it has to be first demonstrated that the former constitutes added value over the latter. The burden of proof is on AI advocates to demonstrate its relevance in a particular context. This cannot be done by a company with a vested interest in AI.

It is perfectly possible that using two systems, an algorithm and clinical judgement, might create confusion. Should an IAPT client not fare well (for example, if a client dies by suicide) when treated under such a dual system, could IAPT convince a court, on the balance of probability (the UK benchmark in personal injury cases), that its approach was evidence-based? After all, an AI approach is not something that NICE has recommended—so it flies in the face of the guidelines. Traditionally, courts are swayed by eminence-based evidence (such as the word of authority figures like psychiatrists), but they have become more aware (at least in the UK) of the perils of unbridled clinical judgement.

Inadequacies of IAPT’s Chosen Metric

IAPT’s chosen metric is a change in score on two psychometric tests. Clients are deemed to have responded if on the PHQ-9 (a measure of the severity of depression) their test score has gone from above 10 to below 10 with treatment, with a difference of at least 6 points, and if on the GAD 7 (a measure of the severity of generalised anxiety disorder) their score has gone from above 8 to below 8 with treatment, with a difference of at least 4 points. This approach has numerous deficiencies:

  • It is not known whether the completer of these two measures was actually suffering from depression or generalised anxiety disorder, because IAPT clinicians do not make diagnoses. Further, it is not known whether either of these “conditions” was the disorder that was causing most impairment in functioning.
  • When test results are observable by the treating clinician, clients may wish to be polite and relay a lower score, particularly as they do not want to feel that they have wasted their time in therapy.
  • No attention control comparator: Changes in test scores are meaningless unless there is a comparator group who have received the same attention and a credible rationale. It’s unclear whether the therapy resulted in the improvement, or if the client would have improved with a “placebo” therapy (simply receiving professional “attention” without CBT techniques).
  • Regression to the mean: Clients typically present at their worst, so with the mere passage of time they will score more modestly.
  • The vagaries of a minimally important difference (MID) in a score: MIDS are established by statistical comparisons between an “ill” and “well” group, but they do not necessarily indicate clinically important difference. They also fail to address the client’s perception and there is no personalisation of treatment outcome. Clients are given no voice.

Haemorrhaging

Last year about a third of referrals (30.1%) to the IAPT service did not access it. Of those who accessed the service over a third (38%) had just one treatment session. Thus, by the start of the IAPT race over half of people (57%) have not engaged in treatment (as defined by IAPT’s metric of attending two or more sessions). If these results applied to a physiotherapy service it would raise serious doubts about the suitability of the service! Why then does the UK National Audit Office studiously avoid scrutiny of IAPT, which costs the taxpayer over £1 billion a year?

Sub-Therapeutic Dose and Treatment Outcomes

Of those who engaged in IAPT, the average number of sessions was 7.5, which is well below the 12 to 20 sessions that NICE recommends for depression and anxiety disorders (IAPT’s primary targets). Are we to believe that IAPT’s clinicians are so skilled that they can achieve recovery with only half the dosage of therapy as that delivered by therapists in the randomised controlled trials of CBT for depression and the anxiety disorders?

The benchmark set by trials of therapy as a treatment for these conditions is that at least 50% must “recover” (no longer meet criteria for a diagnosis). But there is no evidence that IAPT has achieved this. My own research suggests that only the tip of the iceberg recover.

In my capacity as an Expert Witness to the Court, I examined 90 IAPT clients who had been through the service either before or after the personal injury. Only 9.2% of subjects lost their and diagnostic status, as assessed using the “gold standard” SCID interview. It mattered not whether subjects were assessed before or after their personal injury. (These findings are in need of replication by clinicians independent of IAPT with a non-litigant population.)

Diagnostic Creep

IAPT appears not to so much follow the data, but to follow funding opportunities. It has branched out into territory were angels fear to tread: Medically Unexplained Symptoms (MUS). MUS is an umbrella term embracing conditions as diverse as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. IAPT’s contention is that exaggerated negative beliefs about symptoms, and maladaptive behaviours (e.g., avoidance), play a pivotal role in the maintenance of symptoms in these conditions. The therapeutic task, as they see it, is to then to modify these cognitions and behaviours.

What happens if a client protests that they have valid medical symptoms? Well, IAPT clinicians are taught not to openly disagree and not to say ‘it is all in your mind’. But to nevertheless continue to focuss on the ‘exaggerations in beliefs and avoidance behaviours’, so much for honesty.

Along with Keith Geraghty from the University of Manchester, I have published a critique of this sojourn. We identified a series of seven core problems and failings of the IAPT, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment. We concluded that psychotherapy should not become the default option when patients have “medically unexplained symptoms.”

The term “medically unexplained symptoms” should be written in lowercase to avoid conveying the impression that a meaningful homogenous entity is being described. The term should not enter the taxonomy of disorders. Importantly, even the DSM-5 has shunned recourse to the term. But unfortunately, IAPT only pays lip service to the standard diagnostic criteria.

Big Pharma and IAPT

Whilst some large pharmaceutical companies have greatly served the public good with regard to COVID, their performance with regard to psychotropic drugs is much less impressive. Researchers like Read and Moncrieff pin their hopes on the efficacy of CBT demonstrated in randomised controlled trials, but make no mention that CBT as delivered in routine practice bears little relationship to the protocols utilised in RCTs. Just as the claims of pharmaceutical companies require critical appraisal so too does the UK IAPT service.

 In an article in the British Journal of Clinical Psychology, I explained what the IAPT needs to do to get back on track. I noted that in their published papers, IAPT staff do not declare their allegiances and indeed state that they have no conflict of interest! This dishonesty needs to change. I suggested that there is a need for IAPT to prove their case using the standards of proof that are required in other areas of medicine.  To this effect, they cannot simply claim that they deliver evidence-based treatment—there has to be documented evidence for it that would be persuasive to an independent observer.  The IAPT service has to demonstrate that it provides an added value over someone attending an advice centre or counselling service. Yet the IAPT has yet to demonstrate that it makes an important enough difference to clients’ lives that they would recognise it.

This catalogue of omissions may create a sense of déjà vu for those who have followed the machinations of Big Pharma with regards to mental health. Unfortunately, there has only been a deafening silence from the IAPT regarding my critique.

 

 

 

The IAPT Double Myth of Economic and Clinical Utility

 

The impetus for the Improving Access to Psychological Therapies (IAPT) service was derived from a) economic considerations and b) an assertion that the positive results of randomised controlled trials of, primarily CBT, for depression and the anxiety disorders would be realised in routine practise.

 

 

A Money-Saver?

In 2006 the Centre for Economic Performance stated that “the total loss of output due to depression and chronic anxiety is some £12 billion a year-1% of our total national income ”. The contention was that investment in psychological therapy would pay for itself by a reduction in such costs. But currently IAPT costs over £1 billion a year, where is the evidence of a substantial reduction in the loss of output? Where is the evidence that IAPT constitutes a no-cost talk therapy?

 

Poor Performance at the Coal-Face

In the randomised controlled trials on average 50% of clients lost their diagnostic status as assessed by independent blind assessors. But no such unbiased assessors have ever gauged the impact of IAPT’s ministrations. IAPT has always marked its own homework. Rather than the claimed recovery rate of 50%, the best available evidence suggests that only the tip of the iceberg recover, Scott (2018).

Each myth means that the other is not carefully examined and IAPT advocates can deftly switch the focus from one to the other under critical scrutiny – a politician’s dream.

 

Psychological Therapy – a history of exaggerated claims

T.S Eliot wrote ‘Humankind cannot bear very much reality’ this applies particularly to looking at the effects of mental heath treatment. In 1751 the scientist and Quaker, Benjamin Franklin petitioned the Pennsylvania colonial assembly for funds to build a hospital on the grounds that ‘it has been found , by the experience of many years, that above two thirds of the Mad People received into the Bethlem Hospital in England  and there treated properly , have been perfectly cured’. He was reiterating claims made in published books by English doctors. Fast forward over 260 years, to 2012 and an editorial in the prestigous journal Nature declares IAPT ‘represents a world-beating standard thanks to the scale of its implementation and the validation of its treatments’ (p. 473)’.  A decade later, NHS England echoes this declaring ‘the Improving Access to Psychological Therapies (IAPT) programme began in 2008 and has transformed the treatment of adult anxiety disorders and depression in England. IAPT is widely-recognised as the most ambitious programme of talking therapies in the world and in the past year alone more than one million people accessed IAPT services for help to overcome their depression and anxiety, and better manage their mental health’ and recommends the IAPT Manual (2021). In 2019, Pickersgill examined the proliferation of IAPT by canvassing the views of professionals and professional bodies, noting that IAPT fellow-travellers were in the ascendancy. But in this evangelisation for the in vogue psychological interventions nobody has asked the consumer or considered the operation of vested interests.

The Absence of Open Discussion

Psychological disorders are ubiquitous and can negatively impact the course of coexisting physical conditions. Since the days of Benjamin Franklin, UK data on mental health treatment, has been used to foster the belief that UK treatments are a ‘world beater’. But independent evidence to support this contention is lacking. There is not just a gap between the psychological treatments delivered in randomised controlled trials and what comes to pass in routine psychological services, such as the Improving Access to Psychological Therapies Programme (IAPT) service, but a chasm. Efforts to have a meaningful debate on the issue have been met with a deafening silence. In the silence, the scope of psychological treatments has gradually been expanded, beyond the initial focus of depression and the anxiety disorders to include patients with long term physical conditions – a psychological imperialism. The power-holders definition of the outcome of routine psychological treatment reigns.

 

Dr Mike Scott

Nature (2012) Editorial: Therapy deficit. Nature 489(7417): 473–474.

Pickersgill M. (2019). Access, accountability, and the proliferation of psychological therapy: On the introduction of the IAPT initiative and the transformation of mental healthcare. Social studies of science49(4), 627–650. https://doi.org/10.1177/0306312719834070

 

 

 

 

 

 

Low Intensity CBT, ‘Penny Wise & £ Foolish’

Psychological Wellbeing Practitioners (PWPs) deliver the smallest dose of psychological interventions (low intensity CBT), less than 6 hours of contact per client (Shafran 2021). Making it cheaper than high intensity CBT. But there is little evidence that the PWPs ministrations make a difference the client would recognise. There are no randomised controlled trials of high or moderate quality (Cochrane Grade) that attest to low intensity CBTs efficacy. The PWPs are not psychological therapists, as such, most IAPT clients do not receive psychological therapy. The name IAPT, Improving Access to Psychological Therapies is therefore an example of doublethink. Here we have a classic example of false economy.

Low intensity CBT is intended to be the first step for those suffering from depression and the anxiety disorders, with PTSD and OCD clients going straight to high intensity interventions. Most clients first encounter low intensity CBT, should they not respond they are placed on a waiting list for high intensity CBT. In practice comparatively few, about 10%, are stepped up,  but with wide regional variations.It is not so much stepped care as stopped care.

Implementation of the ‘stepped care’ model costs the taxpayer of over a £1bn a year. But there has been no independent evaluation of the package or its components. IAPT is the first ANGO (an autonomous non- governmental agency) funded by the government, as opposed to the intended and understood QUANGO – a quasi autonomous non-governmental agency. Perhaps the National Audit Office and MPs might care to explain why there has been this failure of governance?

 

Dr Mike Scott

Why Fund The IAPT Business?

 

‘Two thirds of GPs providing specialist mental health support beyond their competence’ this was the headline in Pulse, May 9th 2022. This has been brought about by NHS pressures. With 38% of consultations having a mental health element compared to 25% pre-Covid. But there is no evidence the patients have fared less well than if they had been referred to the Government’s Improving Access to Psychological Therapies (IAPT) business (or secondary care mental health services).   In similar vein there is no evidence that those attending the Citizens Advice Bureau with mental health problems do any less well than those attending IAPT [http://www.cbtwatch.com/no-evidence-that-the-improving-access-to-psychological-therapies-iapt-service-does-any-better-than-contact-with-the-citizens-advice-bureaux-cabx]. It appears that IAPT is no better than an attention placebo.

Ideally IAPT would have been subjected to a randomised controlled trial in which clients were alternately assigned to the services ministrations and to  a credible placebo intervention. With outcome gauged by blind assessors, using a standardised reliable diagnostic interview. But no such study has been forthcoming or seems likely to happen anytime soon. Though less than ideal comparisons can be made with the trajectory of attendees of GPs and Citizens Advice Bureaus.

The burden of proof is on IAPT to demonstrate that its’ staff have a competence beyond that of GP’s and Citizens Advice Bureau Workers, that makes a real world difference to client outcome. My own research [Scott (2018) https://doi.org/10.1177%2F1359105318755264] suggests that only the tip of the iceberg of IAPT clients recover .

GPs acknowledge the limits of their competence, IAPT staff do not, at least publicly. Unfortunately nobody holds them to account, they are a law unto themselves. We continue to throw away over a £1 billion a year on IAPT, with the National Audit Office, NHS England and Clinical Commissioning  Groups showing a radical apathy about the matter.

Dr Mike Scott

 

 

 

Arrested information-processing – an illegitimate justification for toxic treatment

Both of the main treatments for post-traumatic stress disorder, trauma focused cognitive behaviour therapy (T-FCBT) and eye movement desensitisation  reprocessing (EMDR), postulate that arrested information processing lies at the heart of debility post trauma. The therapeutic task is therefore to elaborate the traumatic memory. But does the model stand up to close scrutiny?

  • What does arrested information-processing look like?
  • Is forced engagement with the traumatic memory, the only way forward, given that most people do not want to think about something horrible?
  • Is there evidence beyond reasonable doubt that a noxious treatment for post-trauma debility is necessary?
  • What happens when arrested information-processing is put under the microscope? 

Consider that you have produced a one page  document on your computer. You try to print it out, alas nothing! Various arrested information processing ‘bugs’ may have come  into play. You may have forgotten to refill the paper tray. The cable at the rear of the computer may have become disconnected.  With age the printer might now demand that it be a) unplugged from the mains b) the printer key depressed for 20 seconds with the paper tray out and c) the printer plugged in and the printer key depressed again. There would thus be very clear and demonstrable reasons as to why you have no printout.

 

But when a person is debilitated following an extreme trauma there is no such clarity. It may be asserted the extreme trauma caused the debility, but all that is known is is that debility followed a trauma. The temporal sequence does not necessarily signify causation. A failure by trauma focussed clinicians to specify the mechanisms by which arrested information-processing occurs, casts doubt that it has been operative. The injunction for trauma focused clinicians is to ‘elaborate’ the traumatic memory. Staying with the analogy, no amount of changing the contents of the one page document (elaboration) will result in a printout. Arrested information processing, in the context of trauma, sates intellectual curiosity with abstractions but is bereft of any actual detail. The evidential bar for the concept is set so low that it is possible to walk over it.

Just as the one page document is a creation, so to is the traumatic memory, but it differs in that every time the latter is retrieved it is different. It is rather like Alice in the above observation. 

Any information encoded at the time of the trauma may be properly regarded as syntactic information, i.e information without any meaning – rather like being sent a text message that consisted simply of a number of symbols. A friend may at a later point give a meaning to the symbols but you may nevertheless conclude that it was a meaningless text. Importantly the meaning is subject to negotiation and is not located in a special place in the trauma itself. Plantinga, Oxford University Press (2011) says that it is essentially impossible to see how a material structure or event could have content in the way that a belief does.This takes us to a new and more useful model based on mental time travel [Scott (2022) Personalising Trauma Treatment: reframing and Reimagining. London: Routledge https://www.amazon.co.uk/Personalising-Trauma-Treatment-Reframing-Reimagining/dp/1032013125/ref=sr_1_1 crid=2T4OARM3EH4TB&keywords=personalising+trauma+treatment+paperback&qid=1653757479&sprefix=%2Caps%2C73&sr=8-1 ] and the axiom that it is not the trauma per se that is important but what it is taken to mean for today, that has significance.

The Utility and Effectiveness of Trauma-Focussed Interventions

It is true that with trauma focussed CBT or EMDR about 50% of those undergoing these treatments in randomised controlled trials fully recover from PTSD. However compliance with trauma-focussed  protocols in routine practise is problematic, with only a half of patients loosely compliant with the homework [Scott and Stradling (1997)  Journal of Traumatic Stress. Over 60% of veterans dropping out of trauma focussed interventions [ Maguen et al (2019) https://doi.org/10.1016/j.psychres.2019.02.027]. Not buying into the treatment rationale for trauma focussed work is the biggest predictor of non-completion [ Kehle-Forbes et al (2022)https://doi.org/10.1016/j.brat.2022.104123].

it is possible that to the extent that these treatments do work they do so for reasons other than achieving ‘full processing of the traumatic memory’. More plausibly as a side effect of these interventions they learn experientially that the ‘war zone’ map of their personal world that they have employed since the trauma, leads nowhere and they revert to a pre-trauma map. Oftentimes the prime concern of a victim is not what did happen but what could/should have happened i.e it is not the trauma per se.

Resistance To A Paradigm Shift

Rather than re-examine the trauma-focussed paradigm the likelihood is that the movers and shakers in the CBT/EMDR world will either resolutely ignore this challenge or concentrate their firepower on the inappropriateness of the computer/printer analogy, without suggesting a more appropriate analogy. An essentially fundamentalist approach is taken to the potency of arrested-information processing. Heretics should at best be marginalised.

Dr Mike Scott

An Impotent Approach to Psychological Therapy (IAPT)

there is no evidence that routine psychological therapy, as delivered in the Improving Access to Psychological Therapies (IAPT) programme either, resurrects a person or  returns them to their best functioning. As such IAPT is impotent.

Most of those entering the IAPT programme undergo low intensity cognitive behaviour therapy (LICBT). This latter involves a reduction of the multifaceted protocols from randomised controlled trials to single elements of those protocols eg avoidance or cognitive restructuring, in the belief that this may resolve client’s difficulties. But over a decade on, there is no evidence that this minimalist approach makes a real-world difference.  It is still unknown ‘what, if any, low intensity intervention works with whom?’. 

The problem with reductionism is that it fails to acknowledge that  the whole is more than the sum of its parts. The multifaceted CBT protocols distilled for randomised control trials likely work because of the synergistic interactions of components, delivered by a particular type of agent (therapist). Simply providing ‘an agent’ or ‘a technique’ is not evidence based.

A recent debate in the Journal Psychological Medicine, has focused around a paper by Read and Moncrief (2022)Moncrieff, J., & Read, J. (2022).[ Messing about with the brain: A response to commentaries on ‘Depression: Why electricity and drugs are not the answer’. Psychological Medicine, 1-2. doi:10.1017/S0033291722001088 https://www.cambridge.org/core/journals/psychological-medicine/article/messing-about-with-the-brain-a-response-to-commentaries-on-depression-why-electricity-and-drugs-are-not-the-answer/C93997DBF4D174D9807D0F65BD994999] highlighting the problem of reductionism when applied to antidepressants and ECT. Both treatments are based on the postulate that there is particular dysfunction in the brain largely responsible for depression, which these intervention rectify. However the search for such an organic deficit has been unsuccessful. These authors point that such interventions are no more effective than enhanced placebo for depression.  

Interestingly Read and Moncrief (2022) pin their hopes on psychological therapies by appealing to the results of randomised controlled trials of CBT for depression. However they are over-stepping the mark. The routinely provided CBT by IAPT has none of the hallmarks of CBT in the trials: the dosage of sessions is sub-therapeutic, no fidelity checks have been conducted to check that individuals actually receive appropriate CBT, there have been no independent assessors of outcome.

In their paper Read and Moncrief (2022) were quite specific about the population they were addressing ‘depressed patients’ but there is no such specificity about the populations treated in routine practice. IAPT clinicians do not make reliable diagnoses, (albeit that they have the temerity to ascribe a diagnostic code). Whilst it is comparatively easy to guarantee that an antidepressant or ECT has been administered, guaranteeing that an appropriate CBT protocol has been imparted, requires independent fidelity checks. No such checks have been applied to IAPT’s ministrations. Read and Moncrief (2022) may well be right, that psychological therapy is the best hope, but the way to hell is paved with good intentions. Currently IAPT is impotent.

Dr Mike Scott

Has Routinely Collected Outcome Data Assisted In Answering, ‘What Works For Whom?’

 

Over 50 years ago Paul (1967) asked the fundamental question for psychotherapy “What treatment, by whom, is most effective for this in- dividual with that specific problem, under which set of circumstances” (Paul, 1967, p .111). The proud boast of the Improving Access to Psychological Therapies (IAPT) service is of a million referrals a year, with test results for 90% of treatment sessions [IAPT Manual 2019]. But despite the quantity of data IAPT has amassed over the last 14 years, it has been of no help to clinicians in answering this key question. It has simply been an added stress.

What is the function of the IAPT data? Is it to simply bamboozle paymasters NHS England/Clinical Commissioning Groups (CCGs)? Perhaps it is to improve the practice of IAPT staff? Even if this latter were the case, there is no evidence that this translates into an improved outcome for clients that they would recognise.

The irrelevance of the IAPT data set, can be gauged by inspecting the table below:

Treatment

Clinician

Characteristics of the client

Specificity of the Problem

Specificity of Psychosocial Functioning

There is no treatment typology within the service. Simply a claim that most clients get CBT in varying doses.

The service distinguishes deliverers of low and high intensity. But clinicians training varies enormously from clinical psychologists with Ph.Ds  to recent graduates who have done voluntary work.

Clients are not distinguished in terms of whether they may or not have a personality disorder or a neuro developmental problem.

The service has no typology of problems. It does not make diagnoses so cannot specify disorders, albeit that it allocates a diagnostic codes.

There is no framework within which to specify level of functioning

With IAPT’s data there are fuzzies in every column of Paul’s framework,  leaving its’ clinicians rudderless.

 

Dr Mike Scott

Paul, G. L. (1967). Outcome research in psychotherapy. Journal

of Consulting Psychology, 31, 109–118.

 

A Gentler Approach to Fergal Keane’s Post-Traumatic Stress Disorder

Last night the BBC broadcast the experiences of its’ intrepid reporter, Fergal Keane, in battling with PTSD and alcohol. He has performed an invaluable service in normalising responses to extreme trauma. In the program he described being sometimes wiped out for days after a session of EMDR. Fergal showed great fortitude in continuing with such treatment. But it raises the question the question of how many others would persist? Particularly if they were not attending an exalted Private Hospital. 

Unfortunately the treatment that he had had  is predicated on the assumption that he needs to confront  all the horrors that he experienced in different lands.  Fergal returns to Rwanda and relives the smells and sights of extreme traumas. He feels guilty that he left Rwanda in the first place. Fergal is annoyed with himself that he left a hotspot in Ukraine at the beginning of the current conflict. In the program he is reunited with an adult from Rwanda who as an older child escaped under a blanket hidden by younger children. He is amazed that  she has not suffered his debility. De facto she has not seen her traumatic memory as relevant to her day-to-day functioning in the UK, but works in mental health. The key point I make in ‘Personalising Trauma Treatment: Reframing and Reimagining’ Routledge 2022 is that traumas only need to be confronted in the sense of addressing their relevance for today. Thus this lady might well write to Priti Patel about the obscenity of routing refugees to Rwanda, whilst not letting the traumatic memory be her central window through which she views the world.

In the programme the EMDR therapist is seen trying to replace Fergal’s thought ‘I am going to die’ whilst under a mortar attack in Lebanon, with the installation of a positive thought ‘I survived’. But this replacement is unnecessary, more parsimoniously it could  have been pointed out that he made a negative prediction and was wrong and may have developed a penchant for making negative predictions that turn out to be wrong. He would be advised to have second thoughts when he makes negative predictions or damns himself.  Fergal appears to believe that he has to be successful in his endeavours encountering horrors rather than just do what he can. He berates himself  for returning to war zones but I think he’s simply trying to ensure that horrors don’t have the last word – a noble task if ever there was one!

The programme featured groups for survivors and whilst they are useful, groups to resolve PTSD appear not to be effective. Interestingly one group member highlighted the problem with a sequential approach to PTSD treatment, an insistence that drink problems is sorted 1st before PTSD. People want treatment for all their conditions now. 

 

Dr Mike Scott

Exaggeratedly Negative Beliefs Perpetuate LTCs and MUS?

This is answered resoundingly in the affirmative and prescriptively in a just published book ‘CBT for Long-Term Conditions and Medically Unexplained Symptoms’ by Philip Kinsella and Helen Moya (Routledge 2022). But the book represents a triumph of ideology over evidence. It carefully avoids any consideration of studies that challenge its modus operandi.  The take home message is

With evangelistic fervour these authors proclaim on P16 For the typical cognitive  behavioural therapists it’s not necessary to be fully understanding of the debates around medically unexplained symptoms it’s more helpful to be aware of what the contributing factors are how to recognise and consider them and how to consider whether they are relevant to current problems’.

The reader is not informed of the details of the debate or the range of opinion.

There is no mention of:

  1. The Editorial in the Journal of Health Psychology in 2021 hDttOpsI://1d0o.i1.o1r7g/71/01.13157971/103539210151302318103482042 The ‘medically unexplained symptoms’ syndrome concept and the cognitive-behavioural treatment model’  that I and others wrote. In this paper we explored the validity of the MUS construct and the proposed treatment model.
  2. A 2020 paper in BMC Psychology by Keith Geraghty and I [Geraghty, K., & Scott, M. J. (2020)] Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified]. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2]  in which we identifiedan unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under- reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment.
  3. The study by [ Serfaty et al (2019)] of treating depressed cancer patients. In this study patients were given CBT by IAPT staff in addition to treatment as usual (TAU) and the results compared with TAU alone. Whether the outcome measure was the PHQ9 or Beck Depression inventory there was no difference in outcome. Serfaty et al add ‘our results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness’.

Kinsella and Moya (2022) operate with a confirmatory bias, searching out studies that support their position and ignoring those that do not.

 

When research findings are presented they are not contextualised, for  the Liu et al (2019) meta analysis published in the Journal of Affective Disorders is cited by Kinsella and Moya (2022) and they report their broad conclusion that CBT is effective for somatoform disorders and medically unexplained symptoms. But fail to state that these authors concluded  that          

‘the overall quality of evidence is relatively low due to a high risk of bias with lack of blinding of the participants, therapists, and outcome assessors’. Further 12 of the 15 studies assessed patients using a ‘gold standard’ standardised diagnostic interview these are not used in IAPT making the generalisation from the studies problematic. None of the studies involved an active comparator in which a credible therapy rationale was given, thus there is no evidence that any effect of the CBT is specific to the CBT. Self-report outcome measure scores were used, these are likely to be subject to demand characteristics when people have invested time and energy undergoing treatment. There was no determination of whether the treatment made a real world difference to patients lives nor of how enduring such change was. 

No mention that the RCTs are of patients who find it acceptable to go for psychological treatment of their MUS, the likelihood is that many find it simply unacceptable to take this pathway. Thus the results of the RCTs may not generalise to all patients with MUS.

 A Gross Violation of Transparency

In our 2020 paper [Geraghty, K., & Scott, M. J. (2020). Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2] we wrotepatients should be fully informed of the rationale behind psychotherapy, before agreeing to take part’

Kinsella and Moya take no heed of this and write in Chapter 14 identifying and helping patients who are fearful of recovery

page 180-1 ‘This phenomena is delicate Which may be conscious or out of awareness If there is a lot of resistance and and hostility and the general sense that the patient will be unable to contemplate a formulation that includes fear of recovery then it would be better to hold back…. If the formulation is not shared it can still be used by the therapist to guide their interventions…. Sometimes however one gets a sense of the reinforces for being nil being so strong or the fear of recovery being so powerful that therapeutic progress can’t be made for example if there’s a very attentive spouse a generous pay benefits payment under strong fear of going back into the old situation that triggered the symptoms then there is little of the therapist can do to overcome this a possible step by step approach to this problem is as follows’

Whatever happened to transparency and openness as a pre-condition for CBT?

 

CBT Treatments Bereft of An Evidence Base 

Somatoform Disorders They fail to mention that the DSM-5 dropped the construct of MUS, absenting if from the definition of somatic symptom disorder. None of the CBT studies of somatoform disorders included in the Cochrane review of 2014 https://doi.org/10.1002%2F14651858.CD011142.pub2 involved independent blind assessors and in the only comparison with an active placebo (Progressive Muscle Relaxation) there was no difference  in outcome. Cochrane concluded that the quality of the evidence in the reviewed studies was weak. Whether or not IAPT therapists do not use a standardised diagnostic interview to determine the presence of a somatoform disorder, so there is no sound foundation for the proposed interventions.

Chronic Pain  In 2021 NICE published guidance on the management of chronic pain https://www.nice.org.uk/guidance/ng193 Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain www.nice.org.uk/guidance/ng193. They made a recommendations to consider CBT for chronic pain rather than make a stronger recommendation to offer CBT because the evidence was not of high quality. Most of the evidence showed that CBT for pain improved quality of life for people with chronic primary pain. A consistent benefit was not demonstrated in other outcomes

ME/CFS In 2021 NICE published guidance on the management of this condition https://www.nice.org.uk/guidance/ng206/resources/myalgic-encephalomyelitis-or-encephalopathychronic-fatigue-syndrome-diagnosis-and-management-pdf-66143718094021 ‘The committee wanted to highlight that cognitive behavioural therapy (CBT) has sometimes been assumed to be a cure for ME/CFS. However, it should only be offered to support people who live with ME/CFS to manage their symptoms, improve their functioning and reduce the distress associated with having a chronic illness’. So that clients should be informed at the outset that the scope of CBT is limited. Further NICE adopts a different theoretical base to that of CBT therapists working in this area, it does not assume people have ‘abnormal’ illness beliefs and behaviours as an underlying cause of their ME/CFS, but recognises that thoughts, feelings, behaviours and physiology interact with each other. No mention of this in the said volume. 

ME/CFS Clients May Have a ‘Fear of Recovery’ claim Kinsella and Moya (2021), I am lost for words

Dr Mike Scott

 

 

 

 

Low Intensity CBT Is Devoid of “Intelligent Scaffolding”

As a consequence there are no protocols for Psychological Well-being Practitioners (PWPs) to follow. The scaffolding is on the back of a lorry but nobody knows what to do with it. Restoration or rebuilding is unchecked by any blueprint. There is no typology of PWP treatments. It is made up as you go along.

Consider ‘CBT for long term conditions and medically unexplained symptoms’, a book by that name has just been published [Kinsella and Moya (2022) Routledge], these authors note that their protocol isn’t deliverable within the 6 hours or less of low intensity CBT, so they suggest have just one target, say depression and with subsequent multiple referrals a comprehensive protocol can be covered! But there is no evidence that this piecemeal approach works, no evidence that such brief Behavioural Activation for depression that they recommend (nor that the entirety of the package) makes a real world difference.   

The above considerations makes IAPT’s claim  that 50% of its customers get what they want,  ‘recovery’, incredulous. The true recovery rate in IAPT is around 10% Scott (2018) https://doi.org/10.1177%2F1359105318755264 and is likely to be even less amongst those with long term conditions. Medically unexplained symptoms (MUS) is such a nebulous entity that it was dropped from the DSM. 

 

The randomised control trials of CBT for depression and the anxiety disorders, conducted before the millennium, had fidelity checks built in to ensure that clinicians were doing what they were supposed to be doing.  For each diagnosed disorder, there were specific treatments targets and matching treatment strategies. With adherence, competence and outcome assessed independently. IAPT’s mantra has been that it is compliant with these NICE approved protocols. However no fidelity check  has ever been been applied to either IAPT’s  high-intensity service or its low intensity service. 

If builders behaved in such a cavalier manner they would soon be out of business, ‘never mind about the restoration of your house, we have built you a nice bungalow’. A year ago I had published a paper ‘Ensuring IAPT Does What It Says On The Tin’ https://doi.org/10.1111/bjc.12264 but it has washed off the IAPT teflonocracy. 

Dr Mike Scott