The Care Quality Commission (CGC) Is Being Duped by IAPT

IAPT is camouflaging what most of its clients receive and has eskewed a focus on clinically relevant outcomes. But one of the domains that the CQC assesses services against is whether they are Outcomes-focused. The CQC needs to conduct an inquiry into IAPT.

Guided Self-Help (GSH) has been the diet of 71% of IAPT’s clients, but therapists have now been advised not to mention GSH, because it may be off-putting! But rather to refer instead to ‘low intensity telephone CBT’ . Notwithstanding that NICE has justified its’ support for low intensity CBT on the basis of studies that were termed ‘GSH’. There is a transparency about offering GSH, clients have a right to know what they are letting themselves in for. Informed consent cannot be meaningfully given to a term like ‘low intensity telephone CBT’.

The matter of informed consent is compounded further by IAPT by their failure to inform clients of what clinically relevant outcome he/she can expect. In particular what minimally important difference the client can expect and clearly see as meaningful. Changes on a psychometric test do not qualify as a clinically relevant outcome by contrast a client can clearly understand say an expectation to be back to their usual self.

IAPT’s ‘low intensity telephone CBT’ itself rests on a fault line, studies that found statistical significance between groups e.g computer assisted CBT vs waiting list, but without a) any discussion of the clinical relevance of the findings and b) blind independent assessment of outcome. Dissemination of the low intensity interventions has been promoted on the back of statistical significance rather than clinical relevance. This makes it imperative that the CQC becomes outcomes focused in a transparent way and is not sucked in by IAPT’s self serving surrogates.

Dr Mike Scott

IAPT’s Eventual Implosion

there are no limits to IAPT’s ambitions, making failure inevitable. IAPT’s target in practice is, “whatever the client complains of” and treatment is operationalised as “whatever its’ therapists do”, Both focii are so loose that it cannot fulfill it’s promise, like a totalitarian revolution that runs out of steam.

The IAPT Manual published a year ago leaves both targets and treatment ‘fuzzy’, whilst proclaiming a commitment to NICE Guidelines. A target of ‘client complaints’ makes no distinction between ‘ disorder’ and everyday unhappiness/stresses. Yet the treatments advocated by NICE are quite specific to disorders.

At most IAPT staff ask about some symptoms of a disorder, but without coverage of all the symptoms of a disorder. But they are not taught to ask whether a symptom is present at a clinically significant level, i.e whether it is making a real world difference to a client’s life. Only clinically significant symptoms count in DSM. As a result IAPT client’s are typically treated for disorders they don ‘t have, without any fidelity check on compliance with a protocol.

There is tremendous vested interest, financially, emotionally and intellectually in IAPT continuing as it is, marking its’ own homework with applause from BABCP and the BPS.

Dr Mike Scott

Group CBT – Forward Leap or Backward Somersault?

day workshop September 20th, Liverpool. Details from BABCP website are below:

GROUP CBT SPECIAL INTEREST GROUP

Group CBT – Forward Leap or Backward Somersault?

Led by Dr Mike Scott
Friday 20 September 2019
Times: 9.30am to 3.30pm (Registration from 9.00am)
Venue: 54 St James Street, Liverpool, L1 0AB

About the workshop:
Groups are a way of addressing the commonalities amongst peoples’ difficulties/disorders [Scott (2011)]. They also offer the enticing prospect of a wider dissemination of services. This workshop addresses the question of when is group CBT effective and when is it a pawn in a numbers game?
Jo Clifford will present the NICE recommendations on group CBT. Attendees will take part in a simulated stress management group (SMG), to experience the trials and tribulations of being a leader, co-leader and group member. A framework for understanding and managing interactions will be described. The criteria for judging a group as effective will be considered and participants will be asked to deliver a verdict on an SMG group. This then serves as a methodological template for evaluating other group interventions.
The therapeutic relationship is a key element of both individual and group CBT but takes a slightly different form in the latter [Whitfield and Scott (2019)]. These differences will be explicated in the workshop. Participants are invited to reflect on their own experiences of groupwork: in this connection Nicola Walker will give a presentation on the side effects of group therapy.
Finally, participants will be encouraged to reflect on the scope for implementing group CBT where they are.

Scott, M.J (2011) Simply Effective Group Cognitive Behaviour Therapy London: Routledge
Whitfield, G and Scott, M (2019) CBT Delivered in Groups in ‘The Therapeutic Relationship in Cognitive Behavioural Therapy Edited by S Moorey and A Lavender London: Sage publications.

Registration and General Information
BABCP Member fee: £50
Non-Member fee: £70
BABCP Member Student: £40
Non-Member Student: £60
Lunch and refreshments will be provided.
A CPD certificate for 6 hours will be issued – 50/50 skills and theory
Closing date for registrations is Friday 13 September 2019
For any event or booking queries please contact BABCP head office on 0330 320 0851 or email workshops@babcp.com
For venue enquiries please see website –
http://www.thewomensorganisation.org.uk/54stjamesstreet

Timetable
9.00am Registration
9.30am Mike Scott Psychoeducation strengths and limits
9.50am Jo Clifford NICE Recommendations for Group CBT
10.10am Mike Scott Group CBT in practice
10.30am Coffee
10.50am Mike Scott Simulated Group Session of Stress Management.
Reflections of participants, leader and co-leader
11.30am Mike Scott Framework for evaluating group skills and organisational context. But do skills relate to outcome?
12.30pm Lunch
1.15pm Nicola Walker Side effects of Group Therapy
1.45pm Nicola Walker Participants’ experiences and views on best practice for group CBT
Discussion
2.30pm Coffee
2.50pm Putting it together where I am
3.30pm Close

CBT’s House of Cards?

applying the acid tests of the Cochrane Collaboration Tool and the GRADE Handbook for the quality of randomised controlled trials, studies of low intensity CBT fail to clear the methodological bar. Whilst only high intensity studies for depression and the anxiety disorders make a successful jump. This calls into question IAPT’s penchant for disseminating CBT for everything, with an imprimatur from BABCP, paying travel expenses of upto £100 for special interest group members to attend a pre-conference workshop Revolution in Mental Health Service Delivery: The Evolution of Low Intensity CBT on Tuesday 3rd September.

One of the seven domains highlighted by the Cochrane Collaboration tool for assessing bias is the blinding of outcome assessment. I have been unable to locate one outcome study of low intensity CBT that fulfills this criteria whilst there are a significant minority of studies of high intensity interventions for depression and the anxiety disorders that do.

The GRADE handbook for assessing the quality of trials comments in section 3.4 ‘not infrequently, outcomes most important to patients remain unexplored’, with regards to psychological interventions clients are rarely asked by someone independent of the study whether and if for how long they are back to their usual selves since treatment. Instead most commonly reliance is placed on a surrogate measure a client completed questionnaire, as opposed to an independent clinicians assessment using a standardised diagnostic interview to determine whether there has been a loss diagnostic status.

These concerns are crystallised in a study of CBT for Health Anxiety conducted by Cooper et al (2017), Behavioural and Cognitive Psychotherapy, 2017, 45, 110–123 doi:10.1017/S1352465816000527

whilst 10 of the 13 studies in a meta analysis used the DSM or ICD-10 to determine whether people should be admitted to the meta analysis, in no study was meeting these criteria used as an outcome measure. To be no longer suffering from the identified health anxiety at end of treatment/follow up would have been a client important outcome. Instead the self-report Health Anxiety Questionnaire was used as surrogate. Cooper et al (2017) attempted to rate studies using the Cochrane Collaboration tool using a summary score for the seven domains, but this bore no relation to outcome and as the authors admitted was a questionable procedure. Despite this CBT was claimed to be an effective treatment for health anxiety.

I am afraid I can’t join in the jamboree for IAPT services that takes place at the BABCP annual conference. I doubt that the ‘House of Cards’ will be discussed and it would likely be seen as banned literature on IAPT training courses.

Cochrane https://www.dropbox.com/s/bmr98o8z8fcfuzv/paths%20to%20mh%20Cochrane%20Risk%20of%20bias%20assessment%20tool.pdf?dl=0

GRADE handbook

https://www.dropbox.com/s/wudv2eu2oxw7qsr/GRADE%20handbook.html?dl=0

Dr Mike Scott

The Gagging of Clients as Storytellers

‘don’t listen to the story treat the symptom’ that is the advise to be given to IAPT’s PWP’s attending a 3 hour workshop on November 28th 2019 on groupwork. It reflects similar advise given to IAPT clients attending a 6 week course on ‘Understanding PTSD’ in which clients are instructed not to talk about their trauma rather to reflect on what they have found helpful so far. This gagging of IAPT clients is consistant with the Organisation’s 30 minute telephone assessment. But it is inconsistant with the need to help client’s overcome cognitive avoidance e.g in PTSD avoiding talking about their trauma.

In Simply Effective Cognitive Behaviour Therapy, Routledge (2009)

I suggested that clients need treatment simultanously for all the disorders from which they are suffering. This is to look at the totality of the clients story, not to elevate one part of it (e.g the disorder that is most impairing) and just treat that. Interestingly Barlow et al 2017 see link below compared focussing just on the main disorder from which a person was suffering (from amongst panic disorder, GAD, social anxiety disorder and GAD, even though most people had more than one disorder) with a protocol that could be adapted for any of these disorders ( termed a Unified Protocol) and retention of clients was better with the latter. This suggests that addressing the whole story is best as well as being more respectful.

Care has to be taken however with Barlow’s transdiagnostic approach, in that the term denotes just those suffering from an anxiety disorder excluding PTSD. Over half of clients had a degree. All treatments were developed by Barlow and his colleagues, there has been no independent replication. Treatment was individual, no evidence that it works in groups. The treating clinicians were highly qualified/trained and did both treatments, as the UP was the new kid in the block and their ‘kid brother’ that may explain the slightly better results with UP.

Barlow et al (2017) https://www.dropbox.com/s/22qz932flxroas3/The%20Unified%20Protocol%20for%20Transdiagnostic%20Treatment%20of%20Emotional%20Disorders%20Compared%20With%20Diagnosis-Specific%20Protocols%20for%20Anxiety%20Disorders.html?dl=0

Dr Mike Scott

IAPT Misses The Boat Using a Train Timetable

IAPT couldn’t find enough cases of generalised anxiety disorder that a randomised controlled trial comparing CBT with the antidepressant sertraline collapsed, Buszewicz et al (2017) see link below. The metric IAPT uses, problem description is clearly useless as GAD cases are ubiquitous, effecting 4.7% of the population, more common than depression,

Similarly adjustment disorders are ubiquitous but IAPT doesn’t use such a label and engages in treating them then discovers its mistake, what a waste of resources. Dana was distressed by the criminal behaviour of her ex and her children’s exposure to him, she had 4 treatment sessions which she described as helpful, but the service advised that treatment should be suspended and the outcome was ‘mixed’.

  PHQ9 GAD7
Pre 7 13
Post 6 12

:

Yvonne had a long history of anxiety but no problems in the months before she tripped, injured herself and this initially precluded her use of her main coping mechanism of exercise. She was given treatment for ‘anxiety’ in IAPT, which she described as helpful, but she only had fear of falling a specific phobia this was not addressed at all in treatment. Yvonne had not been asked what would constitute her being back to her usual self i.e what would be a clinically relevant difference post treatment, instead IAPT goes blindly on with its own idiosyncratic metric and claims success on the basis of the changes in scores below:

  PHQ9 GAD7
Pre 19 18
Post 6 7

For speed IAPT weds itself to problem specification, but it doesn’t take clients to their destination of a clinically relevant outcome.

Dr Mike Scott

Buszewicz et al 2017 https://www.dropbox.com/s/1wxuws089tj74er/IAPT%20none%20recognition%20of%20GAD%20lead%20to%20collapse%20of%20trial%202017.pdf?dl=0

Only The Client Knows Whether Psychological Treatment Has Made a Clinically Relevant Difference

trouble is nobody asks them! When was the last time you remember a client being asked ‘are you back to your usual self with the treatment you have had’? Organisations, such as IAPT have their own metric, a decrease on a psychometric test and in secondary care psychiatrists will opine ‘seems a bit brighter to day, increase…’. These ‘metrics’ ensure the survival of the Organisation, but have no demonstrated relationship to loss of diagnostic status as assessed by a clinician independent of the service provider.

In a study by Stegenga et al (2012) see link below depressed patients were followed up over 3 years whether there depression took a chronic (17%), fluctuating (40%) or remitting course (43%) course they all showed decreases in PHQ9 scores throughout the study and without any psychological intervention. The only exception was a worsening of PHQ9 score at 6 months for the chronic subgroup. Similarly a 12 year study of anxious patients Bruce et al (2005) showed they were only suffering from their anxiety disorder 80% of the time. Thus finding a decreased psychometric test score per se does not mean anything.

Bruce et al (2005) linkhttps://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0

Stegenga et al (2012) linkhttps://www.dropbox.com/s/k0x2fm0ds01no0k/natural%20course%20of%20depression%20stegenga%202012.pdf?dl=0

Organisations and Clinical Commissioning Groups much prefer to talk about operational matters, numbers and waiting lists and show no interest or expertise in reliably assessing clinically relevant outcomes. But it is not just these bodies, the leading journals have for the past decade predominantly published papers on the efficacy of psychological interventions with no insistence that there should have been blind independent assessment. Instead self-report measures have ruled with little awareness that their completion is subject to demand effects and the measures often bear no obvious relationship to the construct under examination.

It is difficult to escape the conclusion that clients are largely fodder for the Organisations. A problem that will not be resolved by increased funding for mental health services albeit that this is clearly needed or by atypical clients as tokens on mental health bodies. The fundamental problem is a lack of respect/reverence for clients.

Dr Mike Scott