The Myth of CBT In Routine Practice

search as you might, CBT is a scarce commodity in routine practice. In Coleridge’s poem ‘The Ancient Mariner’, the sailor bemoans that there is ‘water, water everywhere/ Nor a drop to drink’ because it is salt water. The CBT prevalent in routine practice is just this, ‘salt water’. The myth is that this ‘salt water’ can make a real world difference – return the psychologically dehydrated to their usual selves. Dear Clinical Commissioning Group the CBT that you see is salt water.


The reality is that services are populated by terrified therapists, clutching their papers, glancing hurriedly from the PHQ9 to the clock, which will soon announce the arrival of the next test of their exhausted therapeutic skills. The client departs with a promise of intervention strategies that never materialise, because of repeated derailments. The IAPT therapist has the added threat of being shamed in front of colleagues over their poor recovery rates.

But the story from IAPT and BABCP is that therapists are ‘scientist-practitioners’, carefully reflecting on the effectiveness of homeworks set and distilling with the client new, specific challenges.

Nothing will change until we challenge this stereotype of CBT therapists at the coal face.


CAMHS and secondary care are unikely to be the promised land for either clients or CBT therapists. In CAMHS there is a penchant for declaring that everyone is in need of family therapy, even if you are the victim of the Manchester arena bombing! In secondary care the cbt therapist is often a token gesture in a service dominated by a consultant psychiatrist. In private practice it is the ‘Wild West’ with almost anything on offer, from alleged cbt to the real thing.

Dr Mike Scott

Clinical Commissioning Groups, IAPT’s Fairy Godmother

bestowing their munificence without any audit by GPs of local benefit, at a cost nationally of billions of pounds. Yet it should be a simple matter for any GP to interrogate the practice database of IAPT ‘beneficiaries’ and ask the patient the basic question ‘are you back to your usual self since seeing IAPT’? and to further determine whether recovery is stable and reliable by asking ‘for how long have you been back to your usual self?’ Then to integrate the responses with any recent record of functioning in the record of Consultations. Such data can then be presented to the local GP reps on the CCG’s to decide whether the local IAPT is value for money.

CCG’s need to move beyond simple operational matters of numbers of patients seen and waiting times, to a determination of the percentage of people recovering. The randomised controlled trials of cognitive behaviour therapy for depression and the anxiety disorders have suggested a 50% recovery rate when there has been blind assesment of patients. This was the original justification for IAPT. The suspicion is from my independent analysis of 90 IAPT cases that in routine practice the recovery rate is about 10% see link below

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

However when IAPT marks its’ own homework it miraculously comes up with a 50% recovery rate and has seduced CCGs with its own data. The response of most GPs to this is ‘give us a break, but I am nevertheless grateful for a respite from the patient if they are seeing someone else, so I can get on with my core tasks’. We need to move on to a point where GPs are to a degree advocates for their patients, if they don’t do it no one else will. Without such advocacy mental health patients become not just Cinderellas compared to patients with physical problems but confined to their own personal asylum.

Image result for clinical commissioning groups

It is perfectly possible transform IAPT so that it properly translates the findings of rcts into routine practice, see my trio of Simply Effective Cognitive Behaviour Therapy books published by Routledge and my last book Towards a Mental Health System that Works (2017) London; Routledge. But we need to wake up and smell the coffee.

Dr Mike Scott

IAPT’s Ignorance Trap

IAPT acts with impunity, as there is no feedback to IAPT as to how clients have fared in the medium to long term. Clients are  discharged as soon as their PHQ-9 dips below 10, whatever the diagnosis. IAPT continues in blissful ignorance, likely mistaking a short term placebo effect for true recovery. The problem is systemic, the abscence of a feedback sanction, making IAPT incapable of learning from mistakes.

‘For any system to function efficiently, it needs to know the outcomes of specific actions in a consistent, reliable, and expeditious way’. Pat Croskerry (2000) The Feedback Sanction see link below:

https://www.dropbox.com/s/uai9nx79vio9enw/The%20Feedback%20Sanction.pdf?dl=0

GPs could put to patients initially referred to IAPT the question ‘Since IAPT are you back to your usual self? For how long have you been back to your usual self? An 8 week period of back to usual self would be indicative of recovery, shorter than this it is likely to be the natural variation in symptoms observed by Bruce et al (2005)] see link below:

https://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0

For those with a negative response the following clarifying question could be asked:

“Compared to how you felt prior to IAPT treatment, how would you rate the symptoms for which you sought treatment during the past week?

1= substantially worse,

2 = moderately worse,

3 = slightly worse,

4 = no change,

5 = slightly improved,

6 = moderately improved,

7 =  substantially improved)”.

The GP’s response endorsement of a response would be based on the totality of their understanding of the patient’s functioning not just the client’s verbal report. Perhaps classifying patients whose symptoms were rated as “substantially improved” or “moderately improved” as treatment responders. This would be independent assessment of IAPT’s performance and one that could be fed back to the service. A GP conducting such an audit on IAPT clients could present it as part of their professional appraisal. But a GP could similarly audit secondary mental health care.

GP’s are the nearest to advocates for their patients, unless they perform this function with mental health services, patients will be like 17th Century defendants in the legal system without representation, pawns in an overwhelming system. It is time to move on from this to representation in a  21st century health service.

Dr Mike Scott

IAPT – Improving Access to Placebo Therapies

There is no evidence that IAPT’s psychological interventions are better than placebo and the organisation ought to be renamed Improving Access to Placebo Therapies. This calls into question the unswerving devotion of Clinical Commissioning Groups (CCG’s) and the British Association of Behavioural and Cognitive Psychotherapy (BABCP) towards IAPT.

Expectations exert a powerful influence on any psychological therapy, yet in no IAPT study or analysis of its’ own data, has there been a comparison of the IAPT intervention, with that of a group who expected to get better with a particular intervention. There is no reason to believe that IAPT’s results exceed that of a placebo.

IAPT claims to follow NICE Guidelines in delivering evidence-based treatments (ebts) for psychological disorders. But as it takes no steps to reliably identify disorder/s thus there can be no certainty that an ebt is being used that matches the debility.

GPs’ Cognitive Dispositions To Respond Promotes IAPT

Seeing a GP is a common first step along the IAPT pathway, this of itself is likely to increase expectations that something can be done about the presenting problem. The patient then invests time and energy in the said IAPT intervention, at the end of that period he/she does not want to think they have wasted their efforts. Particularly so if the therapist has been ‘nice’, there is a desire to please him/her but this does not mean that they have met criteria for recovery as defined by NICE, i.e they would no longer be eligible to enter a randomised controlled trial for the disorder from which they were originally suffering.

GP’s might be glad of the placebo effect in that it gives them a brief respite from the patient. But because a placebo does not address the mechanism involved in the generation of a disorder, difficulties are ongoing.

It is easy for GP’s to convince themselves that the IAPT interventions are making a difference because in fact, at least for the anxiety disorders, patients naturally only suffer from a condition for 80% of the time.

Thus a GP can doubtless see a post IAPT client in a good state, the vividnes of this experience (availability heuristic) then gives a mistaken impression of how likely this sequence of events is likely to be and the improvement is attributed to IAPT’s efforts (mis-attribution bias), unfortunately the next time a post IAPT patient is encountered in a good state this is seen as confirmation of their believe (confirmatory bias) in the value of the service. Such GPs may unfortunately play a major part in the CCG’s leading to the perpetuation of a failed service.

Resources

  1. Placebo response, Boot et al (2013) click link below: https://www.dropbox.com/s/fnmuv4t6imdcsug/Placebos%20Boot%20et%20al%202013.pdf?dl=0
  2. Not always got a disorder Bruce et al (2005) click link below

https://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0

3. Information processing biases see link below

https://www.dropbox.com/sh/66o4qo8ru8sairz/AABxU_IeXeEcaNOqeEYBgGNOa?dl=0

Dr Mike Scott

The Ongoing Gagging of Discussion About IAPT Following ‘Has IAPT Become A Bit Like Frankenstein’s Monster?’

Ongoing discussion of this matter in CBT Today would have reached an audience of the 12,000 BABCP members. The Editor agreed with the President that the appropriate Forum was not the magazine but the online CBT Cafe. On March 12th I protested about this with a post on the CBT Cafe, there was just one response 8 days later by the BABCP President, Paul Salkovskis. Nearly a month since there has been no further post from anyone on the CBT Cafe! Whatever the intent of the President and the Editor of CBT Today, discussion has been clearly sidelined and the matter of Editorial freedom in CBT Today has not been addressed at all.

Jason Roscoes’ critique of IAPT in CBT Today, can be accessed below

https://www.dropbox.com/s/myz53dyn8zqhj13/Has%20IAPT%20become%20a%20bit%20like%20Frankenstein.docx?dl=0

BABCP is undoubtedly very powerful and well connected but its’ credibility as the ‘lead organisation’ for CBT must be in doubt, given its’ unswerving support for IAPT.

Dr Mike Scott

IAPT’s Sojourn Into The Quagmire

Putting patients with medically unexplained symptoms, such as CFS (chronic fatigue sundrome) and IBS (irritable bowel syndrone) on a mental health pathway, is a fraught endeavour, can there be any certainty that physical investigations of their difficulty will continue? Who will provide that certainty, surely not IAPT( Improving Access to Psychological Therapies) workers? Perhaps GP’s or gastroenterologists – doubtful?

 IAPT’s focus is on psychological interventions, most patients with long term physical conditions will find it incongruous to be offered a mental health intervention, unless there is a clear additional problem such as panic disorder. There is a danger that those with LTC’s will feel the normal emotional distress associated with their long standing problem is being psycho-pathologised.  

Whilst some with LTC’s may wish to avail themselves of psychological help, many will do so at the behest of a GP or gastronetrologist, believing that they would not be suggesting it, if it were not evidence based. Yet there is in fact a weak evidence base for CBT for these conditions compared to that which obtains for the anxiety disorders and depression.

Psychological interventions in the LTC area serve to distract from improving the poor quality services in areas in which CBT could make a real world difference. Rather they have a novelty value and attract funding/empire building.

Dr Mike Scott

Action Line Needed For Those Failed By Mental Health Services

It is 2 years since the Manchester Arena bombing, Cheryl has been absent from school since, despite 5 sessions of counselling at a well known Children’s Hospital. She and her Aunt (also a victim of the bombing) were invited to consider variously that Cheryl may be autistic, her difficulties may be a product of her mum’s childhood stressors, she may have PTSD and they need family therapy. All of which I found to be total rubbish.

The limited counselling she had only occurred because the Manchester Hub (set up to simply signpost people in the aftermath of the bombing) made regular contact with the Hospital. In fact all she was suffering from was panic disorder with agoraphobic avoidance and illness anxiety disorder. Within 2 sessions she has already made rapid progress.

Her aunt has had twelve sessions with an IAPT service followed by group therapy which she dropped out of. She was never offered any diagnosis. Two years on she is still struggling. Neither Cheryl or her Aunt have had anywhere significant to turn to to protest (the Hospital has made a half apology about being short staffed). But for both children and adults it is not just a question of money, the quality of service is woeful.

There is a pressing need for an action line for those failed by Mental Health Services.

Two years ago I wrote the book ‘Towards a Mental Health System That Works’ London, Routledge, the system is no better, just that some agencies are highly skilled at self-promotion and thereby expansion, MPs have been taken in by this and like to be seen to be on the side of mental health.

Dr Mike Scott

IAPT’s Clients – Vulnerable Adults With No Protection

Neither NHS England, Clinical Commissioning Groups or BABCP have taken any steps to ensure that there is independent monitoring of the welfare of IAPT’s clients. Such clients suffer a double whammy, not only do they experience the sense of helplessness often accompanying psychological debility, but they are also powerless to say anything about their experience.

The CONSORT guidelines ( see link below) state that randomised controlled trials should address outcomes that are meaningful to the patient. The same should apply to services delivered in routine practice. Changes in psychometric tests scores are not meaningful to clients, whereas no longer suffering from the disorder they were suffering from at the start of treatment is. But IAPT obfuscates its’ true performance by sleight of hand with psychometric test results. Clients are fodder for providing psychometric test data at each session, no matter that there is no certainty that the test is pertinent to what they are suffering, that repeated administration means that they can remember their last score and will want to convince themselves that they are getting better and that the results are interpreted by their therapist, creating a demand effect.

A major feature of the CONSORT guidelines is that treatment should be evaluated by those independent of service provision. There is no opportunity to protest about incompetence or the arbitrary number of session limit. IAPT violates this and every aspect of the guidelines that might be pertinent to routine practice.

Unfortunately Editors of Journals such as Behavioural and Cognitive Psychotherapy, Behaviour Research and Therapy and the Lancet often ignore the CONSORT guidelines or any translation of them into routine practice. Consequently the evidence base for expansion of IAPT into areas such as psychosis in secondary care, is much less than understood by its’ workers.

https://www.dropbox.com/s/vj2hp1q43hz4lh8/CONSORT%202010%20Explanation%20and%20Elaboration%20Document-BMJ.pdf?dl=0

Dr Mike Scott