IAPT Training – ‘jump through our hoops and make no difference to client outcome’

that’s the take home message from a study conducted by Liness et al (2019). IAPT trainees were evaluated using the Cognitive Therapy Rating Scale Revised (CTRSR) and client outcome assessed, mainly with the PHQ9 and GAD7, and no relationship was found, either at the end of training or 12 months later, see link below:

https://www.dropbox.com/s/e26n191ie09sngs/Competence%20and%20Outcome%20IAPT%20no%20relation%202019.pdf?dl=0

Instead of the author’s concluding that something is seriously amiss if there is no relationship between competence and outcome, the authors celebrate that they could keep the newly trained therapists scoring highly on the CTRS!

Curiouser and Curiouser


It is a truly bizarre paper, on the one hand the authors acknowledge that it is important to assess adherence, competence and outcome but proceed only to analyse the relationship between competence and outcome. Treatment fidelity involves a combination of adherence (highlighting the appropriate disorders/difficulties and matching treatment strategies) and competence (how skillfully treatment is delivered). Thus the assessment of a surgeon’s key hole skills (competence) would make no sense at all if he/she were not using them in an appropriate context , e.g this week it was reported that a 26 week old unborn child with spina bifida was operated on with key hole surgery in the womb to help ensure some mobility after birth. By contrast key hole surgery, no matter how competently delivered, for say a person with simply diabetes would make no sense at all, it would be a matter of infidelity.

Inept IAPT

IAPT’s procedures make it impossible to ensure adherence. In order to guarantee adherence an open ended interview needs to be conducted to let the client tell their story. This is then the springboard for a reliable diagnostic interview, designed to elicit the prescence of disorder/s. Such a two-fold procedure protects against the use of misleading rules of thumb e.g ‘nightmares of extreme trauma, must be PTSD’. There can be no appropriate matching of protocols to reliably identified disorders without taking the time to get a comprehensive client story [see Scott (2009) Simply Effective Cognitive Behaviour Therapy London: Routledge]. Taking shortcuts means that the individual receives a hotchpotch of generic CBT for which there is no evidence base.

Trying to determine competence within IAPT’s structures is a will o’ the wisp exercise.

The Mis-Selling of the CTRS

On October 2017 I wrote a blog on this topic. Liness et al (2019) maintain that the CTRS addresses the issue of adherence, but it does not, whilst there is an agenda item on the CTRS, keeping to the agenda does not at all mean that an appropriate agenda has been identified!

The authors note that the CTRS has become the ‘gold standard’ on courses, but their is a weak evidence base for it’s predictive power for depression (see earlier blog ), an even weaker power for anxiety disorders and none outside this range. I have suggested that what should be employed are fidelity measures that incorporate both adherence and competence. Scott (2015) Simply Effective Supervision, London: Routledge.

Re-focussing on Real World Outcomes With Routine Clinicians In Customary Contexts

It appears not to have occured to Liness et al (2019) that changes on the PHQ9 and GAD7 may not be actually measuring outcome. Rather they are most likely measuring a) improvements with the passage in time as people inevitably enter therapy at their worst point and b) a placebo response because the therapists in the study (42% of the IAPT therapists were clinical or counselling psychologists) created an expectation the alleged CBT would make a difference and they gave clients attention (an average of 11-12 session).

Clients were not assessed by someone independent of IAPT using a standardised diagnostic interview to determine whether they had got back to their usual self with treatment and the results were not contrasted with an attention placebo. It is thus impossible to actually determine whether the alleged CBT made a real world, socially significant difference. Nevertheless the IAPT luminaries in the study will doubtless use the ‘findings’ to promote their brand in the UK and beyond!

The study also lacks ecological validity: where else are there such a high proportion of qualified clinicians, where else are IAPT staff routinely providing 11-12 sessions, where else are there clients without severe psychosocial problems and staff given weekly group and 1.5 hr long individual supervision. Further the therapists in the study chose sessions to be rated on.

The Hi-jacking of Supervision

Within IAPT training supervisors are expected to attend courses run at Universities at which there supervisees are being trained. But there is no evidence that this form of supervision results in better client outcome. It is possible to operate with a wholly different model of supervision in which its’ major function is to act as a conduit for evidence based treatment.

The New Totalitarians

Disturbingly IAPT is like a totalitarian state determining, mental health job opportunities and the way in which assessment, treatment and supervision are conducted. Further it controls journals such as Behavioural and Cognitive Psychotherapy, Behaviour Research and Therapy and even it seems Cognitive Therapy and Research in which the Liness et al (2019) paper appeared (this was the journal to first publish Beck’s seminal study on the efficacy of CBT for depression). It is extremely difficult to get an airing if one sees IAPT in practice as deeply flawed

Dr Mike Scott

‘ A Strong Therapeutic Alliance Is an Essential Element of (CBT) Treatment’

so writes Judith Beck, President of the Beck Institute for CBT (2019 Moorey and Lavender) in a book to be published next week, echoing what her father Aaron Beck wrote in 1979 in his seminal work Cognitive Therapy for Depression. But IAPT have made their own fundamentalist translation of Beck’s work, indoctrinating its’ footsoldiers, Psychological Wellbeing Practitioners (PWPs), one of whom from Liverpool (2019 p214 Jackson and Rizq) has written:

‘The PWP role is high volume low intensity, just churn them out… young PWPs straight from universities, who are naively prepared to do as required by the service…There’s a big gap between the data and the reality of what we’re trying to do’.

It is disturbing that the most vociferous critics of IAPT are also fierce critics of CBT, [ see Jackson and Rizq (2019)] creating a caricature of the latter as mechanistic and uninterested in the the therapeutic relationship. But I have just contributed a chapter the Moorey and Lavender (2019) edited volume. Anyone reading my chapter on Group CBT in this work can be in no doubt about the importance I attach to the alliance/ cohesion in a group.

I am still reading the Jackson and Rizq (2019) book and it contains many perfectly valid criticisms of IAPT. But it does engage in unnecessarily distracting polemics about the medical model and diagnosis.

The contributors to the Jackson and Rizq (2019) work seem blissfully unaware that no medic or psychologist has ever espoused anything other than a biopsychosocial model, it is only the mouthpieces for drug companies that have ever voiced purely biological explanations. To say that biology will be involved in psychological reactions isn’t at all to say that the former determines the latter or its course.

Breathtakingly Jackson and Rizq (2019) are profoundly mistaken when they assert that IAPT believes in diagnosis, they do not at all, they pay lip service to it to secure funds!. IAPT never ever perform a standardised diagnostic interview such as the SCID which is the ‘gold standard’ for establishing whether a person has a recognised psychiatric disorder. The first part of the SCID begins with an open ended interview in which clients are given the space to tell their story, only then is their systematic enquiry about each of the symptoms in a diagnostic set and a clinical assessment of which symptoms are significantly interfering with real world functioning. If IAPT started to use the SCID it would stop the production line referred to by the PWP above. There has to be space created for any relationship. But in my personal communication with David Clark, IAPT’s progenitor he baulked at the cost involved, but did not criticise my proposal per se.

Diagnosis provides a common language and it is the least worst way of communicating, try trying to talk about say ‘power threat meaning ‘ in a medico-legal case! Its’ usage does not at all depend on believing in a particular biological pathology rather it is pragmatic and subject to revision.

Jackson and Rizq (2019) reiterate the ‘Dodo verdict’ that all therapies are equal and must have prizes citing Wampold’s work, but Tolin’s findings

https://www.dropbox.com/s/r3bja27takbicnc/Tolin%202015%20Dodo.pdf?dl=0

are very different. But notwithstanding this, in routine practice one does not find evidence of fidelity to any psychotherapeutic protocol, I have yet to see any written evidence in treatment notes of fidelity that would satisfy anyone from any of the psychotherapeutic schools. Manuals are seen as anathema, with a total ignorance that flexibility is an integral part of all such published manuals. Unfortunately the manuals have never been tested out by the Jackson and Rizq (2019) advocates, nor has the viability of using a standardised diagnostic interview, instead theirs is a fundamentalist view that they and their client will somehow find the right way. In their own way they are as ideological as IAPT.

References

Moorey, S and Lavender, A eds (2019) The therapeutic relationship in cognitive behavioural therapy. London: Sage Publications

Jackson, C and Rizq, R (2019) The industrialisation of care counselling, psychotherapy and the impact of IAPT. PCCS books

Dr Mike Scott

CBT Is Overeaching Itself – Clients and Therapists Are The Likely Casualties

A re-examination of the evidence base for CBT, using published guidelines for the evaluation of randomised controlled trials [ Guidi et al (2018)], suggests that low intensity interventions and interventions for ME, long term physical conditions and psychosis are not evidence based. Such studies lack credibility either because of the abscence of blind outcome assessment or when blind assessment has been conducted the results have been negative. Further the number of blind credible trials supporting the efficacy of CBT for depression and anxiety disorders is about half the number of studies usually considered as evidence. Dissemination of CBT beyond the boundaries of an evidence base hampers finding real world solutions to a clients difficulties and will likely result in demoralisation of the latter and therapists. This casts doubt not only on the wisdom of IAPT’s expansion beyond depression and the anxiety disorders but the ethics of its’ treatment of staff.

An international team of Experts [Guidi et al (2018) see link below] have developed evaluation guidelines stipulating the need for blind independent assessment of psychological interventions, particularly when psychometric tests are the outcome measure.

https://www.dropbox.com/s/hizta38yqm4lfh3/Methodological%20Recommendations%20for%20Trials%20of%20Psychological%20Interventions.pdf?dl=0

The PACE trial for chronic fatigue syndrome was heavily criticised [ Edwards (2017)] because it relied on self-report measures of outcome without blind assessment, a methodology that is unacceptable in medicine and in the evaluation of pharmacological products see https://journals.sagepub.com/doi/full/10.1177/1359105317700886

To my knowledge there are no blinded assessment of outcomes for any low intensity interventions. Efficacy has a way of disappearing when there is blinded assessment, for example Morrison et al (2018) conducted a blinded outcome assessment of CBT for schizophrenia and found no clinically meaningful difference, see link below:

https://www.dropbox.com/s/2jqwurf2z9ydyb7/Schizophrenia%20CBT%202018.pdf?dl=0

One other stipulation of the Guidi et al (2018) guidelines is that studies of an intervention should involve an active placebo, in order to ensure that any impact of treatment is not just due to raised expectations and attention. But more than 80% of trials in the anxiety disorders have used waiting list control groups [Cuijpers (2016)] as opposed to active placebos .

https://www.dropbox.com/s/d2tu2ymzp9it7v5/CBT%202016%20Cuijpers.pdf?dl=0

Carpenter et al’s (2018) , study of anxiety disorders see link below found that there were only 41 studies using an active placebo and in only two thirds of them was there a low risk of bias because outcome assessment was blinded. Thus though CBT was still regarded as efficacious, this number of studies spread across all the anxiety disorders does not make the case for CBT being irrefutable.

https://www.dropbox.com/s/js2bljurdwijxkf/Carpenter_et_al-2018-Depression_and_Anxiety%20%281%29.pdf?dl=0

As Zhu et al (2014), see link below, put it with regard to generalised anxiety disorder, the evidence for CBT is ‘strong but not definitive’. They point out that although the 12 randomised controlled trials they reviewed all had blind assessors, in 6 of them outcome was not based on the assessors assessment but on a self-report measure.

https://www.dropbox.com/s/cng09hehty9qo02/GAD%20Meta-analysis.pdf?dl=0

Of the 144 studies of depression, generalised anxiety disorder, panic disorder and social anxiety disorder reviewed by Cuijpers et al (2016) only half (48.6%) had a blind outcome assessment,

https://www.dropbox.com/s/d2tu2ymzp9it7v5/CBT%202016%20Cuijpers.pdf?dl=0

Further Cuijpers et al (2016) found that the effects of CBT are small to moderate when the comparison condition is usual care or active placebo compared to a large effect size when the comparison is a waiting list control condition.

In view of Guidi et al’s (2018) strictures around the evaluation of randomised controlled trials, it is wholly inappropriate for IAPT to admonish its therapists for ‘poor performance’ based solely on a psychometric test. There are surely grounds here for a therapist to claim constructive dismissal.

Dr Mike Scott

Groups and Trauma

Group CBT treatments for PTSD leave 70% of participants still suffering from the condition and it appears less effective than individual PTSD. Further, other active group treatments appear as effective as group CBT for PTSD, but are slightly better able to retain people, probably because they are not trauma focussed, see link below to the Sloan et al (2018) study:

https://www.dropbox.com/s/qoly0wkquhzu44x/Simply%20Effective%20Group%20CBT%20All%20Appendices.pdf?dl=0

Stabilisation Groups


Groups/classes are a great attraction for Organisations pre-occupied with numbers and waiting lists, reflecting the prime concerns of Clinical Commissioning Groups. IAPT has a penchant for running groups/classes without an evidence base for effectiveness. For example, it offers trauma victims a Stabilisation Group, here is how two participants fared:

Mr X had two accidents within weeks of each other and attended a 6 week course. My independent assessment found the course had no effect on his mild PTSD and mild depression and he was then put on a waiting list for individual CBT. The group sessions began with 12-15 participants and went down to 4 people. Topics covered included calming down after nightmares, mindfulness and deep breathing. Nevertheless he described the course as ‘helpful’ but was given no diagnosis at any point either in the telephone assessment or on the course.

Mr Y attended a 6 week course with initially 8-10 people and 3-4 dropping out before the end he also found the course ‘helpful’, albeit that he felt that he was not back to his usual self after the course. My independent assessment revealed that he was still suffering from PTSD after the course and he received a letter stating ‘ have now success fully completed the Stabilisation Symptom Management Course … .. you have opted to complete therapy at this time  discharged you from the service’ but IAPT made no attempt at reliable diagnostic assessment before or after the course, patronisingly ‘success’ is now defined as completing an IAPT course!

Background to Stabilisation Groups

The impetus for the IAPT stabilisation groups probably derives from the Institute of Psychiatry 10 week programme teaching coping strategies for dealing with symptoms of PTSD, but in which trauma histories are not discussed . The programme uses cbt, mindfulness and relaxation techniques. But with no published study on effectiveness. IAPT has run a cut down version of this, just 6 sessions. Robertson et al at the Traumatic Stress Clinic offer 5-8 weeks of 2 hour group sessions for up to 10 people for refugees with a focus on managing hyper-arousal, anxiety, re-experiencing and dissociation but again there are no outcome studies. Like in IAPT it is intended as part of a phased treatment model but there is no evidence that it in any way adds to established treatments for PTSD.

Evidence Based Delivery of Group CBT

The Trauma Groups run in the UK bear no resemblance to those described in the Sloan et al (2018) study. The latter involved 14 2hr sessions and an adequate dose of treatment was regarded as attendance at 10 or more sessions. Though only a minority of study participants recovered from their PTSD there were high levels of satisfaction with both the trauma focused CBT intervention and with the non-trauma focused intervention. The trauma focused intervention involved writing about their trauma in 2 sessions and at home for homework. Further the trauma focussed group treatment was based on a group programme developed originally for victims of road traffic accidents. Interestingly both the trauma focused group CBT programme and the comparison Present Centred Therapy had bigger effects on coexisting generalised anxiety disorder and depression than on PTSD, the main target!

There are evidence based group protocols for depression and the anxiety disorders described in my book Simply Effective Group CBT (2011) London: Routledge.

The content for the group sessions I detailed in the book can be downloaded by clicking the link below:

https://www.dropbox.com/s/ys0ogfo3k93qmwb/Ptsd%20Group%20treatments%202018.pdf?dl=0

I will be circulating this blog to the BABCP, Group CBT Special Interest Group, anyone interested in joining can contact Nicola at nicoladrurywalker@fastmail.com

Dr Mike Scott

We Rejoice In Reliable Cancer Screens But Accept The Incompetence Of Mental Health Screens – Time To Sue

Nobody would accept unreliable cancer screens, but mental health screens are conducted in IAPT (Improving Access to Psychological Therapies) by Psychological Wellbeing Practitioners (PWPs), the least well qualified practitioners and conducted over the telephone in a 20-30 minute ‘assessment’.


Tell me this is ok:

  1. Ms B underwent a telephone assessment after which her GP was informed that she had a PHQ9 score over 10 and GAD7 score over 8 and was being placed on a waiting list f or a psychoeducational group at step 3. No indication of what she apparently screened positive for, nor what evidence based treatment was proposed for the said condition/s.
  2. 5 months later the GP writes in her notes that Ms B did not attend IAPT and is worrying about everything and added ‘tried counselling doesn’t feel useful’
  3. 15 months after her initial telephone assessment she has another IAPT telephone assessment, by a PWP from the Screening Team and the GP is informed that her PHQ9 is 19 and GAD7 is 9. Further she has suicidal thoughts but no plans and the GP is reminded that she took an overdose years ago. The PWP added that they were going to put her on a waiting list for a face to face assessment and had given her the phone number of the Samaritans.

If a patient had telephone consultations with a GP over an unexplained lump, with no face to face assessment or treatment conducted in 15 months, there would be outrage. A Personal Injury claim would likely be mounted, yet this is accepted without a raised eyebrow in the mental health sphere. I don’t think anything will change until someone sues IAPT.

Dr Mike Scott