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‘Overall, How Satisfied Were You With Your Talking Therapy?’

on a scale 0-10, with 0 indicating ‘Not at all satisfied’ and 10 meaning ‘Very satisfied’. GP’s asking such a question of Improving Access To Psychological Treatments (IAPT) clients would be in a position to to advise local Clinical Commissioning Groups of the results of their audit. There could then also be comparison of results across CCGs. The same audit question could also be asked of the clientele of private providers and secondary care. Newspapers and the media could ask the same question of IAPT clients. It could also be a project for  intercalating medical students.

Admittedly this brief audit is not as good as an independent publicly funded inquiry into the proportion of IAPT clients that lose their diagnostic status with treatment. But such an inquiry is extremely unlikely because of vested interests, despite the spending of £4billlion of the taxpayers’s money on IAPT. Support for IAPT is eminence based not evidenced based.

Richard Layard, a prime mover in IAPT illustrates this eminence base in the following extract  from his recent book ‘Can We Be Happier? Evidence and Ethics’ (2020) Penguin:

‘The book I wrote on Happiness (2005) clearly struck a chord and was translated into nineteen other languages. But I wanted to apply it in practice, so I asked Ed Miliband if I could write a paper on mental health for Gordon Brown. Instead it became a paper for the No. 10 Policy Unit. It was written with help from my wife and presented at a Cabinet Office seminar in January 2005. The key figure at that seminar was David Clark. One of the world’s leading clinical psychologists, David is also an incredible persuader and organizer, who since then has devoted his life to creating the Improving Access To Psychological Treatment’ 

and in Towards a Mental =Health System That Works London: Routledge (2017)  I wrote

Seligman (2011) also quotes a conversation with Lord Layard (a House of Lords Peer) in which the latter told him that in order for an enterprise to get government backing it was not necessary to prove unequivocally that something worked (in this instance Positive psychology) for it to be adopted, as this watermark was almost never achieved, but that a combination of sufficient evidence and political will was enough. Seligman reports that he was much encouraged by this advice. However, I will argue later that this lowering of the bar of the burden of proof has led to the UK Government’s continuing endorsement of the Improving Access to Psychological Therapies Programme fuelled by the prime movers behind the inception of IAPT, Layard and Clark (2014).

But ethics involves honesty, where is the honesty in not mandating an independent evaluation of a service that you have been instrumental in?

 

Dr Mike Scott

 

Declining IAPT – Clients Reject The Service

Rejection of the Improving Access to Psychological Treatments (IAPT) service continues to be the norm. Yet it has been funded to the tune of £4 billion without any independent demonstration that it has better recovery rates than its’ predecessors.

Nearly a decade ago, Richards and Borglin https://doi.org/10.1016/j.jad.2011.03.024 examined the pathway of over 7000 Improving access to Psychological Treatments (IAPT) clients – of those referred, 27.3% did not materialise for an assessment. Of those assessed 26.8% did not go further. Of those attending treatment 29.5% completed only one session. Of those initially referred  the rate of non completion of treatment was 62.5%. [Were ‘completion’ was defined by IAPT as attending 2 or more sessions]. This pattern of engagement is identical to that found in my 2018 study   https://doi.org/10.1177/1359105318755264    there are no signs of improvement, see the Table from my paper ‘IAPT – The Need For Radical Reform’

IAPT’s engagement and retention of clients (n=90).

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1. 23.6% of clients either did not initiate contact with IAPT (an opt-in arrangement) or IAPT were unable to contact them to arrange an assessment
2. 13.3% attended only an initial assessment
3. The mean number of treatment sessions attended was 5.5 with a median of 4.0 sessions, with missing data on one client

4. 39.3% attended 2 or less treatment sessions 5. 57.3% attended less than 6 treatment sessions 6. 23.6% attended 6–8 treatment sessions
7. 80.9% attended 8 treatment sessions or less 8. 4.5% attended 20 more treatment sessions

If such rates of ‘decline’ of treatment had been present in the randomised controlled trials  of the efficacy of CBT, then the latter would have been summarily dismissed.  There would have been no NICE guidance advocating CBT for depression and the anxiety disorders. In the IAPT service the average number sessions attended by those who engage in treatment is 6, this would be regarded as a sub-therapeutic dose of treatment in any of the rcts for CBT. No trial of CBT has ever been conducted with the average dosage delivered in IAPT. It strains all credibility to believe IAPT’s claim that it has achieved the 50% recovery rate that is common place in the rcts of CBT.

IAPT ignores the haemorrhaging and deftly switches the public focus to waiting times and numbers seen. The advantage of such key indicators is that it can always be claimed that with more funding waiting times will reduce and numbers seen increase and so the Titanic continues at speed. The crucial question that is avoided is ‘do waiting times matter in a context in which most decline to engage or complete treatment?’.

An unholy alliance between NHS England and IAPT has meant that the latter’s definition of the key indicators of success has been allowed to hold sway. The public are the victims of a failed duty of care.

 

Dr Mike Scott

Talking Therapies – ‘What Works For Whom?’

this is the title of a book by Roth and Fonagy (2005) published by Guilford Press. The authors answer this question with a focus on disorders. Their conclusions inform the NICE Guidelines.

 
 
 
 

By contrast the contributors to ‘Drop the Disorder!’ edited by Jo Watson (2019) recommend jettisoning disorder in favour of formulation. However there has been no determination of ‘what works for whom?’  where the focus is formulation. Indeed it is impossible to do this as formulations are inherently unique/idiosyncratic theories about an individual. It is an attempt to personalise treatment without first acknowledging that the person is likely a member of some category or categories. Ironically it is personalised medicine without first getting into the right ball-park.  For the past decade the IAPT (Improving Access to Psychological Treatments) service has been an undercover exemplar of this, paying lip service to the NICE Guidelines. If IAPT had truly done ‘what it says on the tin’, it would have ‘improved’ upon on Roth and Fonagy’s work. But it has signally failed to make any contribution to the question they raised. . 

Dalgleish et al (2020) in their just published paper a Transdiagnostic. Approach to Mental Health Problems http://dx.doi.org/10.1037/ccp0000482 advocate a ‘hard transdiagnostic’ approach, similarly wishing to totally jettison the diagnostic nomenclature of DSM-5. But this hard trans diagnostic approach is so bewildering in its’ complexity, it would serve only to totally muddle practitioners. There is no evidence that trans diagnostic approaches add value. To date studies have only been conducted by the developers of the trans diagnostic approaches, leading to likely allegiance bias.  There are no effectiveness studies in real world settings with independent evaluators.

Dr Mike Scott

‘Drop the Disorder!’ – IAPT Have Already Done This and It Hasn’t Worked

‘Drop the Disorder!’ is a just published book edited by Jo Watson published by PCCS, but the contributors totally avoid any mention of the Improving Access to Psychological Treatments (IAPT) service. The latter assert that they do not make a diagnosis.  My independent assessment of IAPT has shown that only the tip of the iceberg recover https://doi.org/10.1177/1359105318755264

What is interesting in this book is that none of the contributors have come up with a framework that has allowed them to evaluate the IAPT service. Their frameworks are so nebulous, choose between Power, Threat, Meaning  or an exaggerated importance being given to formulation, that there is no risk of application to any service any time soon. Clients are the casualties of this approach.

I was just trying to imagine an Expert Witness arguing for the reliability of the application of one of these frameworks to that of a person he had to assess, the Expert Witness for the other side would have a field day, with legal reps putting their head in their hands. 

When the notion of ‘disorder’ is dropped, so too is loss of diagnostic status as an outcome measure. Without a person no longer being an instance of a disorder how can one approach determining whether the person is back to their old selves/best functioning?

This is not to say that every diagnostic label is meaningful, there is an excellent chapter in the book on schizophrenia by John Read and he cogently argues that this is not a reliable diagnostic entity. He suggests that we are better served by terms such as hallucinations and delusions. Similarly there are doubts as to whether chronic fatigue syndrome/ME are meaningful diagnostic entities. But across depression and the anxiety disorders (including PTSD) the diagnostic criteria have served us well leading to different protocols for different disorders.

Unfortunately in routine practise diagnostic criteria are not applied with rigour using standardised diagnostic interviews, which also allow for the identification of comorbid disorders (that will usually also need to be treated.)  

The authors suggest that in their communications clinicians should always put diagnostic entities like OCD in quotation marks. I can see this becoming the new political correctness. I will comment on any such missive that the quotation marks simply indicate unreliable assessment.

Dr Mike Scott

Health Anxiety, Covid-19 and Overwhelming Services

great article in the Journal of Anxiety Disorders  by Asmundson and Taylor just published on this https://doi.org/10.1016/j.janxdis.2020.102211. The authors remind us that we can have too little health anxiety, for example leading a person to ignore requests for social ill distancing, but also too much for example panic buying sanitisers. The article reflects that there may be an overall increase in health anxiety as a consequence of the pandemic. This will likely lead to an increase in referrals.  

If everybody with a current health concern were invited to book a telephone assessment with IAPT or ring Mind,  ( I hear that the Government have given £5million to Mind) the services would be overwhelmed. But not only this, what direction would people be signposted to, and on what basis? The DSM-5 uses the term ‘Illness Anxiety Disorder’ , rather than ‘health anxiety’, its criteria help decide on whether a person is a ‘suitable case for treatment’ or a member of the ‘worried well’.  Helpfully it offers signposts, implying a ‘wait and see’ approach in our current situation with its criteria that an illness anxiety disorder’ label should not be applied  unless the ‘illness-related preoccupation has been present for at least 6months’ implying a normality of upsetting responses before this. Another of the criteria  is that ‘there needs to be ‘a preoccupation with a having or acquiring a serious illness’  [in the DIAMOND interview for DSM-5  https://giving.hartfordhospital.org/tolin-diamond-training-video this is operationalised as an hour or more a day as being clinically significant]. A further requirement is that there should be significant functional impairment in domestic or work roles as a consequence of the health preoccupation. The criteria help stop the pathologising of normality and make for a better use of scarce mental health resources.

But though CBT is recommended for health anxiety I could find no study in which clients had been independently evaluated to see if they were no longer suffering from what has been termed variously ‘hypochondriasis’, “health anxiety’ and now ‘illness anxiety disorder’ at the end of treatment, much less at follow up. So some humility is called for when, as is likely, CBT is vociferously advocated as a response to this pandemic. But the prospect of increased funding is likely to be too attractive to agencies.

 

Regards

 

Dr Mike Scott