IAPT’s Hall of Mirrors Feedback

negates improved practice. The Organisation’s usage of the Patient Experience Questionnaire (PEQ) violates all the key requirements for eliciting feedback, which has to involve:

a) a response to questions that have an unambiguous real world meaning e.g ‘are you back to your old self  since treatment? i.e questions have to have validity

b) drawing upon a consecutive series of clients

c) completion anonymously and not in the presence of the therapist

d) a representative sample.

IAPT makes a token gesture of soliciting feedback using the Patients Experience questionnaire,  but its’ modus operandi is such that it cannot furnish a body of evidence that would demonstrate that it is not a ‘world beater’. In effect it has operated with a confirmatory bias only seeking information that would confirm its’ prior belief.

In 2016-2017, of 219 Clinical Commissioning Groups in England, 55 (25%) produced no PEQ data at all, i.e that a quarter of CCGs were funding a service in the absence of any evidence that the IAPT Service was eliciting feedback. In 2017-2018 of the 554,709 clients who completed a course of treatment  only 22% Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z completed the treatment questions on the PEQ.

There is no evidence that IAPT took active steps to ensure completion by consecutive cases or that therapists were blind to the results of the PEQ. The questions on the PEQ are themselves of doubtful validity e.g ‘how satisfied are you with your assessment’, this  question presupposes that the client has the knowledge base as to what constitutes a good assessment, imagine  if asked this question as a possible COVID patient most of us would believe ‘it is outside my expertise to judge the matter’. The question on the PEQ ‘on reflection, did you get the help that mattered to you’ is ambiguous, is it asking about the emotional significance of the encounter with the therapist, for example did they really listen/seem to care or about whether as a result of treatment you had returned to normal functioning.

Government and Clinical Commissioning Groups have turned a blind eye to IAPT’s failure to systematically elicit feedback from clients. At a cost of £4billion over the last decade and an incalcu cost to mental health. sufferers.

Dr Mike Scott

 

 

‘CBT Is Not A Treatment Or Cure for ME/CFS’

announced NICE in its’ draft guidance, https://t.co/OWJjzbQGqK?amp=1 on November 10th 2020. This is likely to come as a shock to Improving Access to Psychological Therapies (IAPT) Service clinicians charged with delivering treatment to patients with Medically Unexplained symptoms, a term which embraces chronic fatigue syndrome (CFS) sufferers, those with musculo- skeletal pain and those with irritable bowel syndrome.  Will the IAPT clinicians explain to CFS sufferers that they are not providing treatment, just helping them ‘manage their symptoms’ as NICE now recommends?.

Will they tell their client that they don’t know what the odds are that the programme will make them ‘manage their symptoms’ better?  

It will no longer be credible for IAPT workers to present the CBT model of MUS which posits that the latter is a product of an interaction of personality factors like perfectionism, illness beliefs (attributions), cognitions (catastrophising), and behaviours such as symptom focusing (somatising) and avoiding activity (due to fear-avoidance or anxiety), (albeit that biological factors are acknowledged but given no explanatory powers). If indeed this CBT model is at the core of the pathology underpinning CFS, then CBT treatments should have resolved the disorder and not simply have helped sufferers ‘manage their symptoms’.  

IAPT assesses the competence of its CFS clinicians, in part, by whether they explain the CBT model of MUS. They need an urgent rethink.  How many of its’ therapists have they stressed out by asking them to promulgate a model that doesn’t deserve the term. It is not surprising that when Keith Geraghty and I (2020) reviewed IAPT data doi: 10.1186/s40359-020-0380-2 we found that only 4.6% of the MUS patients IAPT taken into treatment, complete intensive CBT.

NICE have taken seriously the views of sufferers and the experiences of clinicians and have been unimpressed by the quality of studies on the effectiveness of CBT for CFS. Unfortunately consumer and clinicians views on CBT meted out in routine IAPT practice,  for supposedly depression and the anxiety disorders, have yet to be elicited and what we have been offered is research evidence that is far from compelling,  Scott (2020) https://doi.org/10.1111/bjc.12264. 

Professor Jonathan Edwards submission to the NICE guideline Committee are a must read he highlights the importance of support over treatment:

much more emphasis is needed on ongoing support, rather than the use of short treatment courses. Perhaps the greatest missed opportunity of trials focussing on stereotyped treatment modalities is a failure to recognise the value of support from experienced carers that simply aims to make life easier to cope with, rather than address a theoretical model’

His is a clarion call  for basic humanity, being with people rather than believing that everything is fixable, walking the road with them. This should not be put under a CBT umbrella, to do so is a gross imperialism. Professor Edwards strictures  on the research are exemplary:

 ‘all the studies that claim to show benefit from therapist-delivered treatments in ME/CFS are unblinded trials that make use of subjective outcome measures… ….unblinded trials with subjective outcomes are specifically considered unreliable’ 

He goes on to  detail why such methodological rigour is required such as finding that repeating an experiment with unblinded assessors has discredited the initial positive findings and the problems of not taking seriously allegiance bias and none declaration of conflicts of interest. professor Edwards addresses the issue of honesty thus on p10 of his submission:

Patients are entitled to be fully informed, based on reliable evidence. As I understand it, patients receiving CBT are not told that the explanation given for the illness is speculative, that there is no reliable evidence for the efficacy of the treatment or that objective measurements and long-term follow-up suggests there is none of consequence. Convincing the patient that the explanation of the illness is correct, and that the treatment is effective, appear to be inherent to the way CBT is supposed to work. It would therefore appear to be unethical to continue development and use of CBT based on the current approach of altering beliefs about e.g. disease causation or effects of exercise’.

But exactly the same critique can be applied to IAPT’s low intensity CBT interventions.

 

 

Dr Mike Scott

 

Spinning Low Intensity CBT and Treatments for Refugees

How seriously should we take claims for the efficacy of an intervention?  The ‘Risk of bias” assessment tool developed by the Cochrane Collaboration (2011), see slide, helps distinguish clever marketing from the genuine article. All LiCBT intervention studies fail the Tools requirement for the blinding of outcome assessment, suggesting a high risk of bias.  

In LiCBT studies, there are no independent assessments to determine whether those treated were no longer suffering  from the primary disorder for which they first presented.  LiCBT interventions is the most common treatment modality in the Improving Access to Psychological Therapies (IAPT) service.

But the LiCBT studies are not only subject to this detection bias, but in many instances they are also subject to allegiance bias, with the main author of the study evaluating their own manualised intervention e.g Williams et al (2018) evaluation of the Living Life To The Full Classes doi: 10.1192/bjp.2017.18

But the purveyors of LiCBT interventions do not have a monopoly on proclaiming effectiveness were non exists. A just published study by Kip et al (2020) DOI: 10.1002/cpp.2446 in Clinical Psychology and Psychotherapy  claims that ‘psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees’. But of the 14 studies on adult refugees  only in 4 studies was outcome assessed by a ‘gold standard’ semi structured interview (the CAPS). The method of determining the diagnostic status of the refugees at entry to the study is unclear, but of the 9 questions asked to determine the quality of the included studies  the lowest score   was for whether the diagnosis was determined by using a semi structured interview. The next lowest score was for the item referring to fidelity checks i.e did the clients actually receive the treatment that it was purported they receive. Five out of six studies on Narrative Exposure Therapy  involved at least one author of the published manual on NET.  In total half of the trials researchers  were involved in utilising manuals whose development they were involved in. There is clearly a pressing need for independent replication of these findings on refugees. There is also a need to higher the methodological bar, as it is impossible to say from this review what proportion of refugees were no longer suffering from PTSD at the end of treatment, nor how long that improvement persisted.

Like IAPT the understandable wish to further dissemination takes precedence over a determination about whether treatment makes a real world difference to clients lives.

Dr Mike Scott

 

Mental Health Sufferers Vote With Their Feet and Government Does Nothing At All

 of those who undergo an initial assessment with the Improving Access to Psychological Therapies (IAPT) Service 40% do not go on to have treatment, and about the same proportion (42%) attend only one treatment session, according to a just published study by Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133. These findings echo a study  published last year by Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z, on a smaller sample, which suggested that 29% were non-starters and that the same proportion attended only one treatment session. Further scrutiny of the data reveals that about 3 out of 4 people drop out of treatment once begun. Unsurprisingly the authors’s independent study, of 90 IAPT clients, Scott (2018) revealed that only the tip of the iceberg (9.2%) recovered                 DOI: 10.1177/1359105318755264, raising serious questions about why the Government has spent over £4 billion on the service.

What Has Gone Wrong?

Kline et al (2020) consider that at an assessment by a clinician is supposed to: a) provide a credible rationale for the proposed treatment b)  detail the efficacy of the envisaged treatment and c) ensure that the clients preferences are acknowledged. IAPT’ assessments fail on all counts, taking these in turn:

a. If the problem is ill-defined e.g low mood/stress it is not clear what rationale should be presented. It is doubtful that a 30-45 minute telephone conversation can provide sufficient space to define the primary problem and other problems/disorders that may complicate treatment. Initial assessments  of patients for randomised controlled trials of psychological interventions are typically 90 mins plus, if this is the time deemed necessary to reliably diagnose a patient by a highly trained clinician, how can a much less trained PWP do it in less than half the time? Under time pressure a PWP may consider providing a credible rationale is part of treatment not assessment and in such circumstances it becomes more likely that a client will default. 

b. How often do PWPs present clients with evidence on the efficacy of an intervention? Take for example, computer assisted CBT, does the therapist tell the client that only 7 out of 48 of NHS recommended e-therapies have been subjected to randomised controlled trials, ( see Simmonds-buckley et al J Med Internet Res 2020;22(10):e17049) doi: 10.2196/170490 and even in these a gold standard semi-structured diagnostic interview conducted by a blind assessor was not use to determine diagnostic status post treatment, i.e there was no determination of the proportion of clients who were back to their old self after treatment and for how long. Further the e-therapies had average dropout rates of 31%.  They are not evidence based treatments in the way the NICE recommended high intensity treatments are. But approximately three quarters Of IAPT interventions (73%) are low intensity first, with 4% stepped up to high intensity and 20% in total receiving a high intensity intervention Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133

c. Client’s preferences are a predictor of engagement in treatment, but how often is a client given a choice between a low intensity intervention and a high intensity intervention. If both options are juxtaposed choice is likely skewed by informing the client that the high intensity intervention has a much longer waiting time.

Defining A Dropout

The generally accepted definition of a dropout is attending less than 7 sessions [see Kline et al (2020) https://doi.org/10.1016/j.brat.2020.103750], it is held that clients attending below this number will have had a sub-therapeutic dose of treatment and are therefore unlikely to respond]. Applying this metric to IAPT’s dataset is difficult as they only report data for those who complete 2 or more sessions and for which the average number of sessions attended is 6, thus the likely dropout rate from IAPT treatment, as most would understand the term, is about 75%.  But IAPT has developed its’ own definition of a completer as one who attends 2 or more sessions. This strange definition serves only to muddy the waters on its haemorrhaging of clients. It makes no sense to continue to fund IAPT without an independent  government inquiry into its’ modus operandi.

 

An Alternative Way Forward

Such has been the marketing power of IAPT over the last decade, that professional organisations such as the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Psychological Society (BPS) have sat mesmerised, as the Services fellow travellers have dominated accreditation and training.     In ‘Simply Effective Cognitive Behaviour Therapy’  published in (2009) by Routledge, I detailed a very different way of delivering services, that represents a faithful translation of the CBT treatments delivered in the randomised controlled trials (rcts) for depression and the anxiety disorders. Unfortunately it is IAPT’s fundamentalist translation of the rcts that has held sway and has brooked no debate either in journals or at Conferences.

 

Dr Mike Scott