the typical client presenting at the Improving Access to Psychological Therapies (IAPT) service, 58%, are suffering from three or more disorders , with 14% suffering from two disorders [Hepgul et al 2016 https://doi.org/10.1186/s12888-016-0736-6]. The interventions delivered by IAPT are most commonly minimalist, little contact with a therapist other than to supervise the client’s use of computerised CBT. Strategies on offer in IAPTs low intensity intervention can be found in any CBT self-help book. It can reasonably anticipated that its’ treatments are destined for failure.
The complexity of IAPT’s target population is highlighted further by a) the study of Zimmerman et al (2005) https://doi.org/10.1176/appi.ajp.162.10.1911 which suggests that a third of IAPT clients likely have a personality disorder b) Hepgul et al’s (2016) finding that 21% reported moderate or severe sexual abuse and 16% moderate or severe physical abuse and c) Hepgul et al’s (2016) finding that 18% had alcohol dependence and 7% substance dependence. The IAPT manual (2019) claims that its’ therapists provide treatment according National Institute for Health and Care Excellence (NICE) guidelines, but the latter recommend treatments for single disorders. Further IAPT provides no evidence of fidelity to any particular protocol. The NICE recommended treatments are based on randomised controlled trials (rcts) of CBT for single depression and anxiety disorders with limited concessions to comorbidity, not for the range of complexity encountered in routine practice. Thus whilst it is the the case that on average 50% of those in the rcts for depression and the anxiety disorders are in remission at the end of treatment, it is most unlikely that this could be achieved with the IAPT population, yet the service claims exactly this success rate!
New IAPT staff are like army recruits in the 1st World War, full of optimism, ill prepared for what they find at the front e.g one in four with alcohol/substance dependence. The IAPT practitioners at the front line have little understanding of the prevalences, multiplicity and complexity of disorders they will find. Training is insufficient to allow them to distinguish PTSD from a specific phobia, situational bound panic attacks from panic disorder. This is legitimated by the IAPT Manual that claims the Organisation doesn’t make diagnosis, making treatment like playing roulette. No wonder IAPT therapists are burnt out.
Unsurprisingly I found that when I examined 90 IAPT clients independently using a standardised semi-structured interview the recovery rate was just 10% Scott (2018) https://doi.org/10.1177/1359105318755264 . The Government has never independently audited any of the services that it is spending £500 million on. The Minister for Mental Health, Nadine Dories has said £2.5 million is to be spent on ‘new approaches to support children who have experienced complex trauma’ she appears not to know that the whole notion of ‘complex trauma’ is a matter of considerable debate. Doubtless many have been stressed by the pandemic, but it would make more sense to wait for the storm to pass and assess the storm damage before throwing money at it. There is a danger in pathologising normal responses to an abnormal situation and not being guided by evidence based interventions.
Dr Mike Scott