In routine practice the treatment of PTSD is often ineffective, IAPT’s recovery rate with this disorder is around 16%. But the operation of certain rules of thumb sabotage treatment across the board. Which, if any, of the following saboteurs do you operate on:
It is probably PTSD because it was an awful incident
It is probably PTSD because there arte flashbacks and nightmares
It is probably PTSD because of a high score on the Impact of Event Scale
Whatever it actually is trauma focused CBT/EMDR offers the best way of resolving it
Formulation rules anyway
You can’t treat more than one disorder at a time
Issues need to be resolved first
In January 2018 I was due to make a presentation at an Improving Access to Psychological Therapies (IAPT) Conference, titled ‘Approaching Patients With Trauma – Can IAPT help patients with trauma?, but was overtaken by my own trauma of falling down the stairs at home! Here is the link to the presentation:
The good news is that I was able to specify how IAPT might change its’ practice, but unfortunately the chances of this happening anytime soon are remote, openness to debate with those outside of IAPT is conspicuous by its’ abscence.
Alexandra Painter was for 2 years a Psychological Wellbeing Practitioner, in her doctoral thesis *, she reviews her experience and that of other PWP’s. She notes that in the so called ‘Case Management Supervision’ that PWP’s are subjected to, a core component of supervision, the opportunity to reflect on practice and talk about how you feel about cases is routinely absent. Alexandra calculates that approximately 2.5 minutes is allowed to discuss each case! It seems that the PWPs, who are the most numerous of IAPT workers, are at the ‘front line’, most commonly they have been health care assistants in the past, unlike the high intensity therapist’s in the rear with often clinical or counselling psychology backgrounds. In this war against mental ill health it is more likely that the troops at the front will bear the brunt.
Leaving the troops fearful of going over the top and disobeying commands from on high. The PWP’s plight resembles resembles the Charge of the Life Brigade, in that the powers that be refuse to accept that they are not on solid ground intent on reaching their target at all costs. There are no evidence based techniques, only evidence based treatments and all the so called EBT’s in low intensity treatment fail to meet criteria for evidence based treatment [ Scott (2017) Towards a Mental Health System that Works London Routledge].
At least two randomised controlled trials, on a clearly specified population, with independent assessment by a blind rater using a standardised interview
At least one of the rcts conducted by researchers independent of the developers of the treatment
Replication in routine practice using non-expert clinicians
How long will it be before there is a national outcry about such waste. Unfortunately the National Audit Office is still undecided about whether to publish its’ investigation into IAPT. People including myself and BACP made a submission to the NAO fully expecting the latter’s findings would be made public, if they and I knew that this was not necessarily the case, we would have wondered whether it was worth the effort! At the moment they appear to be countenancing a letter to NHS England, inspection of their website shows the latter’s wholesale support for and funding of IAPT! The NAO, to date, seems no better than Carillion’s Auditors!
Dr Mike Scott
* Painter, A. (2018) Processing people! The purpose and pitfalls of case
management supervision provided for psychological wellbeing practitioners,
working within Improving Access to Psychological Therapies
(IAPT) Services: A thematic analysis. DCounsPsych, University of
theWest of England. Available from: http://eprints.uwe.ac.uk/33351
With a 10% recovery rate in IAPT https://doi.org/10.1177/1359105318755264, serious questions have to be asked about the quality of supervision. But it could be that Supervisors in IAPT feel that their role is constricted or the use of practitioner league tables sabotages their endeavours. Clearly something is going badly wrong. However it could also be that current supervision practices whether or not they take place in IAPT are not fit for purpose, they are eminence rather than evidence based.
‘Its’ about monitoring, personal development – a bit like treating a client, has to be tailored to the supervisee’ this seemed to be the consensus at a BABCP Supervision Workshop I attended with about 40 others in Liverpool last week. The presenter Jason Roscoe, asked the 40 attendees what model of supervision they followed, there was a deafening silence. He then presented the Roth and Pilling competencies for supervision, I opined that just looking at the rows and columns gave me ‘mental indigestion’. Given the outbursts of laughter I think that this was a widely shared view. I had a sense that people feel rudderless with regards to supervision, and there was no enthusiasm about becoming a BABCP accredited supervisor.
I suggested that the prime function of supervision is to act as a conduit for evidence based treatment. Since the Workshop I have reflected that no alternative definitions of the prime function were offered rather the Bennett-Levy model of supervision involving 3 different types of knowledge declarative, procedural and reflective was recommended. The implication was that one might need to do more or less on any one of these forms of knowledge with any particular supervisee. Hmm I thought, this is no different to what one would do with a client in treatment. The offering at the Workshop was I found typical of what passes for evidence in BABCP with regards to supervision, but there is sparse evidence such supervision makes a real world difference to client’s lives. What is known is that supervision has been an integral part of randomised controlled trials and that type of supervision can be considered evidence based. It follows that to the extent that this type of supervision is adopted, with its’ emphasis on reliable diagnosis and fidelity checks for adherence and competence one is still in the ball park of evidence based supervision ( see Simply Effective CBT Supervision London: Routledge).
Department of Health and Social Care Chronic Fatigue Syndrome
To ask Her Majesty’s Government what are the recovery rates of patients with myalgic encephalomyelitis who have received treatment under the Improving Access to Psychological Therapies programme.
This is the title of James Binnie’s commentary on my paper, he adds that my findings of a 10% recovery rate in IAPT are ‘quite shocking’. His paper and mine are available by clicking the following links:
Commentaries and my commentary on the commentaries will be available in a Special Issue
of the Journal of Health Psychology this Summer. It’s great to get some public debate, it has been difficult because many are not in a position to voice their concerns openly.
We have not yet made a firm decision about whether or not we will publish a short report on IAPT in due course…We may choose to simply write a management report’, my communication received from the NAO today. I have made a Freedom of Information request re: the decision making and communications, which legally I should have in the next 10 days.
Given that £1bn has been spent on IAPT not to have an independent audit/assessment seems scandalous. Claims of competing pressures is not terribly convincing.
This is the title of a Commentary on my paper ‘IAPT – The Need for Radical Reform https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/ published in the Journal of Health Psychology, by Sami Timimi the link is: Article first published online: March 30, 2018
Two further commentaries are in the pipeline, with my commentary on the commentaries to be published in the Summer, in a Special issue of the Journal. Timimi’s comments/data on Childrens and Young Persons IAPT are particularly interesting.
Special thanks to Donna Botomley for all the help she has given in the construction and maintenance of this site and she is retiring from this role. As many of you might know technology, particularly social media is not my forte, any comments always welcome.