this is my critique of the IAPT paper published in the current issue of the British Journal of Clinical Psychology, and the Editor has just accepted it for publication. Wakefield et al (2020) will be invited to respond.
Not quite sure when it will see the light of day, but hopefully it is at least the beginnings of open discussion.
An area I’ve not touched on, in my paper is the effect of IAPT on its staff. Some are taking legal action against IAPT for bullying and have highlighted massive staff turnover. But it is very difficult for them to go into detail with litigation pending. Others are suffering in silence to become financially secure enough to leave. Staff are in an invidious position, at best they might hope for an out of Court settlement. But unsurprisingly there is no great Organisational demand for whistleblowers. Gagging clauses it appears are still about and I heard of one being used recently by an employer against a victim of the Manchester Arena bombing.
We need a national independent inquiry not only about the speed with which lockdown was imposed, but also about what has been happening in IAPT. But today I was talking with a survivor of the 1989 Hillsborough Football disaster, that I’ve kept in touch with since shortly afterwards, and we reflected on how long it has taken to get anywhere. He was too exhausted to follow through on the Statement he gave that was doctored by the police.
Bullying tends to centre on what the Organisations contend are ‘one or two bad apples’, which at a push they might make some compensation for, to avoid adverse publicity, and without admitting liability. But I think there is a bigger phenomenon of Organisational Abuse that operates in an insidious way akin to racism, that needs to be called out.
last week I wrote to Professor Grisham, the Editor of the Journal complaining, inter alia, of IAPT’s failure to declare a conflict of interest over the paper by Wakefield et al (2020) in the current issue, see link https://doi.org/10.1111/bjc.12259. The Journal has responded by formally inviting me to write a commentary, which subject to peer review, will appear alongside a response by the said authors. The text of my letter was as follows:
Dear Professor Grisham
Re: Improving Access to Psychological Therapies (IAPT) in the United Kingdom: A systematic review and meta-analysis of 10-years of practice-based evidence by Wakefield et al (2020) https://doi.org/10.1111/bjc.12259
In this paper all the authors declare ‘no conflict of interest’. But the corresponding author of the study Stephen Kellett is an IAPT Programme Director. This represents a clear conflict of interest that I believe you should alert your readers to. The study is open to a charge of allegiance bias.
I am concerned that in their reference to my published study “IAPT – The Need for Radical Reform”, Journal of Health Psychology (2018), 23, 1136-1147 https://doi.org/10.1177%2F1359105318755264 these authors have seriously misrepresented my findings. They chose to focus on a subsample of 29 clients, from the 90 IAPT clients I assessed for whom psychometric test results were available in the GP records. I warned that concluding anything from this subsample was extremely hazardous. The bigger picture was that I independently assessed the whole sample using a ‘gold standard’ diagnostic interview and found that only the tip of the iceberg lost their diagnostic status as a result of IAPT treatment. Wakefield et al were strangely mute on this point. They similarly fail to acknowledge that their study involved no independent assessment of IAPT client’s functioning and there was no use of a ‘gold standard’ diagnostic interview.
The author’s of Wakefield et al (2020) compare their findings favourably with those found in randomised controlled trials efficacy studies, suggesting that IAPT’s results approach a 50% recovery rate. But there can be no certainty of matching populations. In the said study there was no reliable determination of diagnostic status, thus there is no way that this heterogenous sample can be compared to homogenous samples of different primary disorders e.g obsessive compulsive disorder, adjustment disorder etc.
It is unfortunate that the British Journal of Clinical Psychology has allowed itself to become a vehicle for the marketing of an organisation which has only ever marked its’ own homework. The published study also calls into question the standard of the peer review employed by the Journal.
Dr Michael J Scott
At least we are getting to open debate, which is more than can be said for BABCP’s in-house IAPT comic, CBT Today.
here is the CBT Today article rejected not by the Editor, but by the power holders, I wrote:
The Improving Access to Psychological Therapies (IAPT) Programme has only ever marked its’ own homework, making claims for its’ effectiveness suspect. IAPT and its’ devotees (see February issue of CBT Today) are it seems undeterred by the absence of a publicly funded independent evaluation. The CBT Today articles cite no contrary evidence to IAPT’s claim of a 50% recovery rate, despite a whole issue of the Journal of Health Psychology for August 2018 being devoted to the matter and in which my work suggested a likely 10% recovery rate. In my paper ‘IAPT – The Need for Radical Reform’ I also detailed the stories of the recipients of IAPT’s services. None of the powerholders have actually spent time systematically listening to the experiences of IAPT clients.
IAPT Is Highly Persuasive and Misleading
Unfortunately, the NHS, Clinical Commissioning Groups, BABCP, BPS and the Media hierarchies have bought into IAPT’s outstanding marketing, with dissenters not allowed a voice. When the crowd is behind you, you are probably facing the wrong direction. It is disturbing when only the powerholders and progenitors express support for the IAPT programme.
The ‘gold standard’ of independent assessment using a standardised diagnostic interview has been jettisoned with regards to IAPT, yet it was the hallmark of the randomised controlled trials that it professes to base its’s treatment on. Espousal of compliance with NICE guidelines has become a key marketing ploy by IAPT, richly rewarded – £4billion since its’ inception over 10 years ago. Yet there is no evidence that IAPT reliably establishes a base of diagnosis on which is built disorder specific treatment targets and strategies.
The Way to Hell Is Paved With Good Intentions
Nobody doubts the importance of improving access to psychological therapies, but by 2015 from conversations I was having with former IAPT clients, it was becoming increasingly obvious that they thought the system was radically failing them. Analysis of 90 clients assessed using a standardised diagnostic interview revealed a 10% recovery rate i.e only the tip of the iceberg lost their diagnostic status whether or not they were treated pre or post their personal injury [Scott (2018)]. The National Audit Office began an investigation into IAPT, its’ stated mission was to assure healthcare bodies such as Clinical Commissioning groups of the integrity of the IAPT data but it never got around to doing this. In June 2018 the NAO stopped its’ investigation because of other pressing concerns including Brexit and the collapse of Carillion.
IAPT’s Ministry of Propaganda
On November 13th 2019 BBC Radio 4 and Radio 5 Live voiced the concerns of some IAPT therapists that they were pressured to falsify test results, but their voices were drowned out by that of the President of the BABCP and Lead Clinicians for IAPT, the media went with the powerholders – none of the 3 hours of my recordings were aired, nor that of the hour long interviews with an IAPT worker and a client who had been through IAPT twice. A former IAPT client treated by them after the Manchester bombing was unfortunately too upset on the day to give a live interview and only a minute of hours long pre-recorded interviews was broadcast. The media approach amounted to ‘let’s show we are on the side of mental health, it takes too much effort to think the issues through, so let’s go with the powerholders and present a positive message’, an approach that mirrors journals propensities to only publish positive results.
In the same month I sent a letter to my local Clinical Commissioning Group protesting that Talk Liverpool’s just published claim of an 89% recovery rate was suspect as the IAPT’s national claim was a mere 50% recovery rate. I expressed a view that these exaggerated claims may have fuelled the 25% increase in Talk Liverpool’s funding, rising to £10 million in the coming financial year. The Liverpool CCG have not even bothered with the courtesy of a reply. If Talk Liverpool had truly discovered some clinical secret they would be top of the agenda at IAPT’s Best Practice meetings, this is not the case.
The BABCP Has Become An Ambassador for IAPT
It has done nothing to look after the two thirds of IAPT workers suffering burn out. It has squashed debate on IAPT in the pages of CBT Today, pays lip service to evidence-based treatment and fosters alleged CBT. The very credibility of BABCP is at issue, my hope is that the new President addresses these issues.
Scott, M.J (2018) IAPT – The Need for Radical Reform, Journal of Health Psychology, 23, 1136-1147.
Scott, M.J (2017) Towards a Mental Health System That Works London: Routledge.
To disagree with my article is fine but not to engage in open debate is totalitarian. I am not holding my breadth as Andrew Beck takes the matter to the BABCP Board.
the Government and the Criminal Injuries Compensation Authority (CICA) should be put in the dock for the abuse of the poor.
I recently came across ‘X’ she was seriously assaulted a few years ago by a group of youths and thought that she would never see her daughter again. For the past 18 months she has been effectively housebound with panic attacks and PTSD. She is unemployed and not eligible for Legal Aid. The CICA told her that she would need a report from a Consultant Psychiatrist or clinical psychologist to stand any chance of reversing their decision not to give her an award. But she did not have the financial resources to secure such a report nor to instruct a solicitor.
The CICA looked at her records and concluded that because she had had a previous post traumatic stress reaction her debility was entirely due to that. By definition PTSD is tied to a clearly specified trauma, and I found that her flashbacks nightmares were entirely of the assault and not of earlier negative life events. Further her significant avoidance of going out only began after the assault. This was corroborated by her GP records and notes from her IAPT therapist. The CICA totally failed to distinguish normal distress in response to negative life events from disorder. The CICA were intent on mis-attributing her ‘PTSD’ to pre-existing difficulties.
‘X’ has found the whole business of mounting an appeal overwhelming and has been re-traumatised by it. She had 8 telephone counselling sessions with IAPT which she said helped ‘slightly’ in that she learnt breathing exercises for her panic attacks. But she has continued suffering from PTSD, depression, panic disorder and social phobia. IAPT failed to flag up any specific disorder/s. She can’t afford private psychological treatment.
Earlier this week a woman was interviewed incognito on BBC television, she had been raped and had 12 months of counselling with Rape Crisis. She then sought NHS treatment and was told she could not have it because she had already had ‘speciality treatment’. This came after she had already been re-traumatised by the defence Barrister in the rape trial! I am lost for words to describe this secondary abuse. It wasn’t clear from the interview which NHS service she had sought help from.
The Government should be put in the dock for not holding the CICA, IAPT and barristers to account. They should be challenging their public health officials who sanction the funding of an IAPT service to the tune of £4 billion and which makes no real world difference to those like ‘X’.