Month: May 2020

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The IAPT Fiasco – A Failure of Governance Over Talking Therapies

no one is available to answer, why over £4billion has been spent on the Improving Access to Psychological Therapies (IAPT) service without independent evaluation. There should be a call to action when the best available evidence indicates that only the tip of the iceberg of IAPT client’s recover https://doi.org/10.1177/1359105318755264. Which Government Minister is responsible? Does responsibility lie with Public Health England or NHS England? Are Clinical Commissiong Groups (CCG’s) simply acting under orders?

It is not good enough for the architects of the IAPT service to blandly assert it is a ‘world beater’.  There is no transparency with regards to decision making and implementation in IAPT. In the 3 years of cbtwatch no public powerholder has deigned to answer the concerns raised.  Media pressure did however evoke a response by IAPT’s, public advocates, Professors Clark and Salkovskis, who are hardly disinterested commentators, albeit that they are persuaders par excellence. Ministers, Public Health England and NHS England have maintained a deafening silence.

Interestingly the failure in transparency over IAPT resembles that of the handling of the pandemic. It is it seems impossible to discover who postponed testing.  There has been a parallel failure, over the last decade to publicly and independently test out recovery rates in IAPT.  My own findings are that the tip of the iceberg of service users get back to their usual selves.

We seem destined to go from one fiasco to another, but all it needs to avoid this scenario is honesty and care, it is fundamentally an ethical matter. This could start by taking the time to listen to what IAPT client’s are saying and to IAPT front line workers.

Dr Mike Scott

 

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Mental Health Bewareness Week

the deeply unpopular sibling of Mental Health Awareness Week, who can be found muttering in the corner, that only the tip of the iceberg of those who receive routine Talking Therapy  recover, (see link, https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/).   Whilst his sibling proclaims a new dawn awaits us if Society would just provide more funds for the UK Government Improving Access to Psychological Treatment (IAPT) service, secondary care and MIND. This increased funding would she believes help in the colonisation of more and more areas of human suffering from Birth Trauma (see CBT Today May 2020) to long term conditions, with IAPT recovery rates of 50% already for depression and the anxiety disorders.

The focus of this year’s Mental Health Bewareness Week, might well be on the absence of any publicly funded independent evaluation of routine psychological treatment despite over £4billion of the taxpayer’s money being spent on IAPT. In the dire financial circumstances that the UK government finds itself in the questions for this week are:

  1. ‘What is the evidence that this money has been well spent?
  2. ‘If we consider a period before such expenditure, is there convincing evidence that the funding of IAPT for the last decade has constituted an added value?’
  3. ‘Is it appropriate to continue to fund agencies who have only ever marked their own homework?

Unfortunately the devotees of Mental Health Awareness Week are blissfully unaware that there is another story, of clients having been failed for the past decade with little prospect of getting a service that they would consider would return them to their normal (or best functioning).

 

Dr Mike Scott

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Focus On The Chief Psychological Complaint And Miss The Boat

 

Post-traumatic stress disorder (PTSD) is an example of this – only a fifth of those with PTSD present with it as their principal problem, according to a just published paper by Kiefer et al (2020)  in The Journal of Nervous and Mental Disorders. Most commonly PTSD sufferers present with depression, bipolar disorder or borderline personality disorder as the principal diagnoses. These are so likely to absorb a clinicians attention that the PTSD does not get a look in. But it is likely to be one of the elephants in the room that sabotages therapeutic efforts. If working in IAPT the hapless clinician, post the lockdown, is likely to be hauled over the coals for not reaching recovery and/or feels incompetent.  The seeds of the problem is that IAPT clinicians are not trained to make reliable diagnoses. But unreliable diagnosis is not confined to IAPT, it is the norm, bolstered by the dominance of an unthinking anti-psychiatry stance amongst psychological therapists. The banner of ‘Formulation Rules’ is unfurled and brandished but without any evidence that it makes a real world difference to client’s lives. 

Whilst the starting point for all psychological therapies is the client’s chief complaint, in it’s distilling there is no limit to the range of information considered pertinent (no control for information variance), nor of the operational criteria for deciding whether a particular problem is simply a normal reaction to an abnormal situation or something more (no control for criterion variance). Appeal can be made to a clinician’s formulation, but there are likely as many formulations as clinicians. By default the formulation of the local powerholder, whether it be the supervisor, manager or clinician will likely hold sway. The client will rarely have the wherewithal to articulate their definition of the situation and certainly not to make it stick.

Consider a person referred with ?chronic fatigue syndrome, the psychological therapist will certainly find evidence to support this because a) they will rarely be aware of differing criteria for CFS and b) they will find a symptom to support the diagnosis such as fatigue. Here we have the operation of a confirmation bias seeking only information that supports the original hypothesis. Without considering what body of evidence would be needed to refute hypothesis e.g diagnostic entities such as depression that have some symptom overlap with disorders such as CFS and/or an as yet undiscovered entity that might explain the fatigue e.g the development of multiple sclerosis.

Communications to sources of referral are written in the form ‘it was agreed that course x would be best’ but as the client does not understand how course x, differs from courses y and z, much less why one course would be better than another in their circumstances, it is doublespeak for the Agency doing what it wants.

Having elicited what appears to be the chief complaint, almost anything can be deemed appropriate. Today I read a book [ The Well Gardened  Mind by Sue Stuart-Smith a psychiatrist] review on horticultural therapy, in which the reviewer asked  why such a therapy is not a standard treatment for anxiety and depression? Such an approach was regarded as an enlightened response to the plight of  ‘shell shocked’ soldiers returning from the First World War. The short answer to the question is that there is no evidence it returns people to their former selves i.e that it makes for recovery, as opposed to makes them feel better for a time.

How did we reach the point were de facto we have therapy without any boundaries? In my view it is a product of jettisoning the very notion of diagnosis and treatment. There is almost universal support amongst psychological therapists for an anti-psychiatrist stance see ‘Drop The Diagnosis! ‘ by Jo Watson (2019) and Dalgleish’s call http://dx.doi.org/10.1037/ccp0000482 for a hard trans diagnostic approach  and it is used to justify popular offerings such as Solution Focussed Therapy. But we are short of any independent evidence that the talking therapies without reliable diagnosis make a real world difference.

Dr Mike Scott

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Moving The Goalposts So That The Cheapest Talking Therapy Option Always Wins

Managerial goals have been scored for the last decade by putting the focus on numbers, waiting lists and the brevity of therapeutic contact. Couple this with capitalising on:

a) the passage of time – people are likely to present at their worst

b) people’s desire to please the provider of any service face to face

c) people’s need to feel they haven’t wasted their time

This ‘capitalisation’ comes to pass by the client completing a psychometric test, such as the PHQ9, in front of the therapist. Enabling the Improving Access to Psychological Treatment (IAPT) provider to claim effectiveness to its NHS funders the local Clinical Commissioning Group. 

My own CCG, Liverpool, is top of the league in gullibility (should have kept to football). Last Autumn, Talk Liverpool claimed an 87% recovery rate. I protested in writing to the Chief Officer of the Liverpool LCG, that this is a preposterous claim, as it would mean that Liverpool Improving Access to Psychological Treatment  (Talk Liverpool) were well exceeding IAPT’s claimed national average rate of 40-50% and the recovery rates in randomised controlled trials. The Chief Officer of the LCG did not even have the courtesy to acknowledge my letter. The Liverpool Echo asked the CCG about the discrepancy in the recovery rates and their representative told them that it was a 40-50% recovery rate. It is difficult to belief that the LCG had not been influenced by the claimed recovery rate in funding Liverpool IAPT to the tune of £10 million this financial year. It is a fine line between extraordinary claims and fraud.

It is cunningly hidden from CCG’s that most clients are offered a ‘cost’ saving low intensity treatment, such as guided self-help, a group or computer assisted cognitive behaviour therapy, only a minority actually get a psychological therapy. CCG’s seem blissfully unaware that none of the randomised controlled trials (rct’s) of the utilised low intensity interventions go anywhere near meeting the requisites of the CONSORT checklist, in particular there is no blind independent evaluation and the researchers are investigating the effectiveness of their own developed materials.

Dr Mike Scott

 

Moving GoalpostDownload
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In Practice, Off-The Shelf Solutions Silence IAPT Client’s Concerns

the Talking Therapist does the ‘talking’ not the client: 

Noreen was held at knife point in the corner shop in which she worked, she had flashbacks and nightmares of the incident. She was fearful of another armed robbery. Then she was a passenger in a car in which the driver lost control, became fearful of travelling by car and postponed her driving lessons. Noreen completed an Improving Access to Psychological Treatment (IAPT) telephone assessment in which she was scored 8 on the PHQ9 and 11 on the GAD7.  No diagnosis was proferred and the letter from IAPT to her GP said ‘agreed with us to be put on a waiting list for computer assisted CBT’. 3 months later she received a letter from IAPT saying she had been discharged because she had not activated her online therapy accoun.

1. No Listening Ear In IAPT – Noreen had multiple concerns: memories of the robbery, fear of car travel and several bereavements but there was no space for her to vocalise all these in her assessment. Instead she was offered an off the shelf solution computer assisted CBT but with no indication as to how this would remedy her concerns.

2. No Meaningful Agreement to Treatment In IAPT – IAPT makes a play of offering ‘customer choice’ but Noreen did not know what computer assisted CBT involved, much less what the evidence base was on it resolving her presenting complaints and how it compared in efficacy to other treatment options such as face to face CBT. In short IAPT does not offer informed choice, it offers tokenism with regards to customer choice.

3. No Meaningful Assessment in IAPT – Noreen was none the wiser about her difficulties after the telephone assessment and it is not at all surprising that she did not go onto engage in the computer assisted CBT

4. IAPT Blames The Client For Not Engaging In Treatment – the letter from IAPT to Noreen and her GP says ‘sorry you have not activated your…online therapy account….discharged’

5. IAPT Engages In Pseudo- Science  – reporting psychometric test results to GP’s, as if they have a meaning without reliable diagnosis. The social context of the client’s difficulties are deemed not worth reporting.

Low intensity interventions are off-the shelf solutions, their very availability makes them more likely to be deployed, despite their inappropriateness to the task in hand. Even brief attention to Noreen’s difficulties, would suggest a differential diagnoses of PTSD, a specific phobia about travelling by car and depression. If that was as far as the assessor got, and there is no indication that he got even that far, how on earth would this suggest the appropriateness of a course of computerised CBT!

Availability Heuristic The Off-the shelf low intensity interventions have created a new availability heuristic. Traditionally this term is used to describe the way in which the vividness of an experience e.g graphic memories of a serious accident give a mistaken impression of how likely it is [ see Daniel Kahneman Thinking Fast and Slow. Penguin Pres]. It seems that for the Psychological Wellbeing Practitioners who are the usual assessors of clients coming into an IAPT service have a particular familiarity with the low intensity interventions leading them to deploy them inappropriately. Further they may have a graphic memory of one client who did really well in low intensity CBT, oblivious that such a case is very much the exception. This use of the availability heuristic is heightened by the IAPT organisation declaring that low intensity interventions are to be the bread and butter of PWP’s.  Possible shortcomings of low intensity interventions are often glossed over by PWP’s on the grounds that if they don’t work the client can always be stepped up to high intensity, but such stepping up is rare about 10%.  There is a failure to acknowledge that a) if the first intervention does not work a client can become demoralised and dropout  and b) there is no independent evidence that a significant proportion of low intensity clients lose their diagnostic status as a result of this minimalist approach.

Noreen is yet another example of how IAPT fails clients and the problems are systemic, not confined to some PWP’s not adhering to best practice.

 

Dr Mike Scott

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Businesses Could Break IAPT’s Monopoly Stranglehold

Business can make the case to the Conservative Government, that IAPT’s monopoly of the organisation of primary care mental health services (Talking Therapies) is not in the public interest.  Adding that independent assessment of performance is crucial to the delivery of any service, but IAPT has operated for a decade without such accountability – at a cost of £4billion to the taxpayer. 

A businesses could:

A. Ensure that Talking Therapies make a real world difference to clients lives, one that they could recognise. By insisting on i) the independent monitoring of services, on a sampling basis, that assesses client satisfaction and ii) the assessment of the proportion of clients who are returned to their old selves post treatment i.e how many loose their diagnostic status. 

B. Inform Government ministers that it could make an administrative cost saving  by removing the need for therapists to spend time administering psychometric tests at each appointment.

C. Simplify training needs by abolishing the distinction between low and high intensity therapists.

The Businesses could also make the point to Government that their mental health advisers in Public Health England are essentially paid civil servants, who can only speak out with the permission of Government and whose dealings with IAPT are not open to public scrutiny.  There is a pressing need for a wholly independent transparent body charged with assessing the added value of all organisations that deliver Talking Therapies with Government funds. Such a body must go beyond operational matters of numbers and waiting lists and assess the clinical impact of services in a way that is scientifically credible.

With regards to assessing satisfaction, the Business could claim that they intend to ask an independent body to monitor satisfaction with their service by asking:

  1. Overall, How Satisfied Were You With Your Talking Therapy? on a scale 0-10, were a score of 0 is ‘not at all satisfied’ and 10 ‘very satisfied’

My nephew Greg, a Businessman, suggested two very useful supplementary prompts:

       2. Please explain your score

       3. What would need to have been done for you to have given a higher       score?

The data collected can highlight individuals who really were pleased (they
 
are called promoters – scoring 9 or 10). It will also show those who were
 
ambivalent (passives scoring 7 or 8), and those who were not happy at all
 
(the detractors, scoring 6 or less). Understanding why the promoters are
 
happy is key as the lessons learned here could be applied to the other
 
groups. Equally, the feedback from passives and detractors can point to
 
issues that need to be addressed.
 
[ Greg, also suggested that this framework can also be used in a practitioner
 
centric way to help  determine  if a practitioner him/herself is ‘performing’
 
well – you calculate a score by subtracting the percentage volume of
 
detractors from the percentage volume of promoters. The resultant number is
 
called the net promoter score.  But my thought is that it  would need to be
 
complemented by some agreed measure of complexity of caseload. It  could be
 
easy to satisfy clients on your caseload if you only take  on easy cases. The
 
problem of complexity can be circumvented by ensuring therapists make
 
reliable diagnoses, including the assessment of comorbidity. So that the chief
 
outcome measure is loss of diagnostic status, but satisfaction is a 
 
complementary measure].

Businesses could make a real world difference to mental health provision

and the lives of clients. They are well equipped for negotiation at the

highest level and many have pockets, deep enough to surmount any

teething problems. Businesses could also greatly reduce the high stress

levels that are endemic in IAPT’s modus operandi. 

 

Dr Mike Scott

 

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Duplicity In IAPT On MUS

my colleague Joan Crawford wrote the following letter to the Journal of Psychosomatic Research, it highlights that IAPT advises its’ clinicians not to use the term Medically Unexplained Symptoms (MUS). Her letter was rejected. But Prof Chalder, Improving Access to Psychological Treatments (IAPT) adviser on MUS and LTC’s (long term conditions) , regularly holds workshops using the MUS descriptor (see webcast for BABCP sponsored Workshop on June 8th 2020). Joan’s letter reads;

 
 

‘The systematic review into the use of language and relational issues during the patient-doctor interaction where there is medical uncertainty is welcome [1]. However, there are flaws in the methodology and underlying assumptions within this paper that require closer examination.

Medically unexplained symptoms (MUS) were not clearly defined. A broad, assumptive approach was used which included: chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome, without justification or criticism. These are all separately listed World Health Organisation medical conditions [2]. Using MUS gives an illusion of medical respectability, which is ambiguous if not misleading. At no point was there recognition of controversy of the MUS approach or any engagement with extensive alternative literatures. While many routine tests may fail to find a specific underlying disease, it is misleading to assume; therefore, that no objective abnormalities can be identified.

In the UK, chronic pain (explained or unexplained by routine assessment), including fibromyalgia, is managed within the NHS via pain management programmes. This is under the rubric of The British Pain Society guidelines [3]. Such an approach teaches patients the central sensitisation and dysregulation model of chronic pain. This science-based model encourages patients to pace, plan and prioritise tasks to maximise activity; set appropriate goals; minimise flare ups and to live well despite being in pain. At no point does the evidence suggest that their pain is medically unexplained, quite the opposite. Patients adapt well to this model. They improve their self-efficacy, reduce distress along with decreasing presentation at their GPs unnecessarily as they have the confidence to decide how to best manage themselves.

Taking the MUS approach has the potential to de-validate patients’ symptoms as described in this paper [1]. Patients can erroneously be given the impression during the medical encounter, consciously or otherwise, that their symptoms and suffering are not of worth; that they are derived

from within themselves via a self-generated, autopoietic mechanism [4], which they have the power to overcome. For example, “MUS arise when benign bodily sensations, such as those resulting from normal variation, emotional disturbance or minor pathology, are selectively attended to and misinterpreted as evidence of illness [4]; the resulting changes in behaviour (e.g. reduced activity) and physiology (e.g. increased autonomic arousal) then create a vicious cycle that maintains symptom reporting.” [5]. The apparent rarity of misdiagnosis is often cited as good reason to proceed with a MUS approach. Of note, Newton [6] reviewed 375 patients attending a CFS clinic in England and found that 40% of patients did not to have CFS. Caution is required.

What evidence does the practitioner have that their option is sound other than their own belief? Should the patient not return, does the doctor then conclude that the patient has been cured of a false belief? Or has the patient abandoned hope that their practitioner can help them? Deary’s cognitive behavioural model [5] is potentially self-blaming and shaming which can silence patients discouraging them from further medical interaction and emotional and social support. Patients’ can experience disbelief about their symptoms as an assault on their sense of self. This causes harm and unnecessary suffering. This can have tragic consequences for patients and their families.

Openly sharing the speculative MUS model in the clinical context would allow the patient to decide if it has face validity. Worryingly in the UK, IAPT clinicians are encouraged to not use the term MUS [7]. This is duplicitous. Obfuscation here is dishonest and unethical [8]. It is encouraging to note that, “healthcare providers are cautious when raising psychosomatic attributions” [1] as the evidence base for such is flimsy. The absence of good quality evidence-based objective, real world changes for psychological or behavioural interventions for MUS was omitted and therefore not subject to critical analysis [9]. The paper does approach the importance of the psychosocial context; however, it fails to critically analyse the social and emotional consequences for the patient.

It is unfortunate that some doctors continue to have negative experiences. This may well be true for those who are not up to date in their knowledge. When current information is shared with patients, they are enlightened and appreciative of clinician’s honesty and skills.

There is a sense from this paper that clinicians should continue fear encounters with patients. Perhaps there is nothing to dread from such consultations if one approaches this with a sense of humility [8] and a science-based model and positive mindset. There needs to be honesty in the clinical and therapeutic environment. This needs to hold the tension with uncertainty, without the ethically dubiously, “subtle persuasive conduct” [1] imposing a blaming and shaming model on the patient due to lack of clinician resilience or knowledge [8]. Share the model openly [4,5] and allow the patients to vote with their feet. Those who find it meaningful will stay. The key here may be to build healthcare providers’ resilience to cope with and tolerate uncertainty and ambiguity.

[1] I. Stortenbeker, W. Stommel, S. van Dulmen, P. Lucassen, E. Das, T. I. Olde Hartman, J. Psychosom. Res. 132 (2020).
[2] World Health Organisation, International Statistical Classification of Diseases. https://www.who.int/classifications/icd/en/

[3] The British Pain Society, Guidelines for Pain Management Programmes for Adults (2013).
[4] V. Deary, T. Chalder, M. Sharpe, The cognitive behavioural model of medically unexplained symptoms, Clin. Psych. Rev. 27 (2007) 781–797.
[5] R. Brown, Explaining the unexplained, The Psychologist, 26 (12) (2013) 868-872.
[6] J.L. Newton, H. Mabillard, A. Scott, A. Hoad, G. Spickett. The Newcastle NHS Chronic Fatigue Syndrome Service: not all fatigue is the same, J R Coll Physicians Edinb. 40 (2010) 304–307.
[7] NHS IAPT Medically Unexplained Symptoms/Functional Symptoms – Positive Practice Guide, (2014).

[8] D. O’Leary, Ethical management of diagnostic uncertainty: Response to open peer commentaries on, “Why bioethics should be concerned with medically unexplained symptoms,” Am J. Bioethics. 18 (8) (2018) W6-W11.
[9] K. Geraghty, M. Scott, Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified, BMC Psychol, 8 (13) (2020).’

Well argued Joan

Dr Mike Scott