The Improving Access To Psychological Therapies (IAPT) Programme Is Spreading Into Prisons – Why?

 

The July/August 2020 Issue of the Psychologist has a one page advert from the Forward Trust recruiting IAPT workers and others for positions in  five prisons. The Service Development Manager of the Trust speaking to the Psychologist said  ‘Many of our clients present with complex issues that would preclude then from community IAPT’. Which raises the interesting question of what body of evidence are they to call upon in dealing with these complex cases. Doubtless the Trust has done valuable work in for example giving out self-help leaflets to help prisoners manage the Covid crisis and facilitating connections with family. But such work was done hitherto by probation officers. The Trust was founded 30 years ago to support people in prison with drug problems. Where is the added value of an IAPT input?

IAPT has already published data showing clients with personality disorders do less well in community IAPT.  But IAPT clinicians have no way of reliably identifying clients with personality disorders. Further there is no evidence that they can faithfully administer a treatment protocol for personality disorder.  It seems that this is yet another example of IAPT’s expansionism,  matching its’ foray into treating long term  physical conditions that are medically unexplained. The lack of demonstrated evidence seems not to bother the service, it will likely proceed by running workshops of alleged best practice. It takes it for granted that its’ expansion is an obvious good. This is actually incredibly arrogant, demeaning of pre-existing services.

 

British Journal of Clinical Psychology Commentary and Rebuttal Of IAPT Paper

the Journal yesterday published my critique, ‘Ensuring IAPT Does What It Says On The Tin’ https://onlinelibrary.wiley.com/doi/10.1111/bjc.12264#.XzwEMhZvXuk.email of the recent IAPT ( Improving Access to Psychological Therapies) paper, by Wakefield et al (2020).

£4bn has been spent on IAPT without publicly funded independent audit. This is a scandal when the best-evidence is that only 10% of those using the service recover. There is no evidence that the Service makes a real world difference to clients’ lives, returning them to their old selves/no longer suffering from the disorder that they first presented with for a significant period. The claimed 50% recovery rate by the service is absurd.  Not only has the now defunct Public Health England  mishandled the pandemic, but it has had a matching performance on mental health. It is too early to judge whether the newly formed Health Protection Board will grasp the nettle of mental health. But I doubt that it will until there is open professional discussion that the present IAPT service is not fit for purpose. It will likely need the involvement of politicians to ensure radical reform of IAPT and that mental health is not again kicked into the long grass.

Dr Mike Scott

 
 
 
 

Public Health England’s Breathtaking Naivety On Mental Health

the Government’s flagship mental health provider, Improving Access to Psychological Treatments (IAPT) has been a serial offender when it comes to non-declarations of conflicts of interest. If this were not enough, IAPT has been allowed to mark its own homework. It has not been subjected to publicly funded independent evaluation. All despite the taxpayer paying IAPT’s bill of £4billion. Unfortunately determining which publicly funded ‘Experts’ decided what, when and in collaboration with whom is likely to be as daunting as discovering who decided what with regards to the pandemic.  It’s about as transparent as our major rivers. But there is a pressing need for a public inquiry.

Latest Violation

IAPT’s latest violation occurred in a paper examining the agencies data in last months British Journal of Clinical Psychology https://doi.org/10.1111/bjc.12259., when an IAPT Programme Director and corresponding author  declared no conflict of interest. I protested to the Editor Professor Grisham about this violation and  that the authors, though citing my study of 90 IAPT clients failed to mention the key message of the study was that the recovery rate was 10% https://doi.org/10.1177%2F1359105318755264. These authors positively framed their findings to underline the frequently re-iterated claim of IAPT that it approaches a 50% recovery rate. My Commentary on the Journal article has been accepted for publication in it  in the near future.

Violation By The Prime Movers In IAPT

 In 2018 a study was published in the Lancet, and funded by the Wellcome Trust, and headed ‘Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data’ and states:

‘Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of
the report. The corresponding author had full access to
all the data in the study and had final responsibility for
the decision to submit for publication’.

But there is no mention that the lead author is the leading light in IAPT, and that with one of the other authors, Lord Layard, they were the architects of IAPT.

A Systemic Problem 

In July 2017 I protested to the Editor of Behavior Research and Therapy (BRAT), that no conflict of interest had been declared in a paper authored by Ali et al published in that month’s issue of the Journal, https://doi.org/10.1016/j.brat.2017.04.006 focusing on IAPT data on relapse after low intensity interventions. I pointed out that the lead author headed the Northern IAPT research network.

In October 2015 Behavioural And Cognitive Psychotherapy published a paper by Kellet et al about an IAPT service ‘Large Group Stress Control’ https://doi.org/10.1017/S1352465815000491 this was authored by an IAPT teacher and researcher and appears without any statement of conflict of interest. 

 

Dr Mike Scott

“What’s The Odds Of Getting Back To My Old Self, With This Psychological Treatment?”

the response is likely to be a deafening silence, from those most likely encountered, a Psychological Wellbeing Practitioner (PWP) or a GP. Alternately, they may reply  ‘it’s complex’, leaving you bemused or patronised with a reply of ‘we don’t know until you try’. But the cancer sufferer and those close, would not tolerate being fobbed off about the likely success rate of a proposed oncology treatment. Further they would deem  it necessary for a face to face consultation, with a Consultant, for this question to be satisfactorily answered.

Contrast this  with the likely scenario in mental health, following a self-referral you would undergo a  20-30 minute telephone assessment by a Psychological Wellbeing Practitioner (PWP) [ from the Improving Access to Psychological Therapies (IAPT) programme]  the most junior member of staff.  Unfortunately their training totally precludes their being able to answer this question. The problem is that the PWP simply does not know the answer. His/her stock in trade is low intensity interventions such as guided self-help or computer assisted therapy, delivered in six or less sessions. The PWP’s training courses inform them that such interventions outperform usual treatment. More than that they do not know. Their ambition is usually to become a high intensity therapist delivering psychological therapy, over a much greater number of sessions.

The PWPs are unaware that the success of Cognitive Behaviour Therapy (CBT) in low intensity outcome studies has been gauged solely in terms of a metric called effect size. The (within subject) effect size is calculated by subtracting the post treatment mean of a sample from the pre treatment mean and dividing by the spread of the results (the pooled standard deviation). [Alternately if there has been a comparison group in the CBT studies the means that are subtracted, are the post treatment means of each group, again divided by the standard deviation, to yield a between subjects effect size].  Assuming that a between subjects effect size has been calculated all this tells one is the size of the difference between the two groups, it does not tell you whether everyone improved a little, or some greatly improved whilst some did very poorly. Thus the effect size gives no information  that can be passed onto a client that would give them a guide as to the likelihood of their recovery after low intensity  intervention.  

By contrast the psychological therapies to be delivered in high intensity IAPT, are supposed to be based on protocols approved by the National Institute of Clinical excellence. At first sight this is good news because many of these studies indicate the proportion of people who lost their diagnostic status as a result of psychological treatment i.e these studies were concerned with an end point and not just with whether there had been a response to treatment as indicated on some psychometric test. But IAPT has only ever relied entirely on psychometric test results. This exclusive focus on response by IAPT however lacks any validity because it is not known what the person was suffering from in the first place!. IAPT eskews diagnosis, there is a consistency in this  in that because they don’t do end points, they don’t do beginning points i.e they do not establish what the person is suffering from in the first place. It is not possible to substitute measures of response for categorical endpoints, the latter are determined independently using standardised diagnostic interviews. Matters are compounded further because IAPT uses no measure of treatment fidelity, thus it is totally unknown whether IAPT actually delivers an evidence supported treatment. 

 

Dr Mike Scott