IAPT’s Class Answer to Improving Access

Use classes. Forget about disorders just call it ‘stress’. Offer something CBT flavoured and capitalise on time and the placebo effect to demonstrate an effect, label the package ‘good practice’. Encourage IAPT providers to write about it in the Cognitive Behaviour Therapist (the online BABCP Journal) special issue to be devoted to IAPT, introduced by the lead clinician in IAPT.

The Stress Control (SC) programme of White et al. (1995) is more of a public health intervention than a psychotherapeutic group. It is run as a night school class, and though there are questions and answers between attendees and presenters, personal problems are not discussed.

IAPT’s Implementation

In an IAPT implementation of the programme, at Step 2, Burns et al. (2015) had a mean group size of seventy-four and a range from twenty-three to 106, with six weekly, two-hour sessions. The programme consisted of week 1, introduction to psychoeducation and the cognitive behavioural model; week 2, management of physiology; week 3, management of mental events; week 4, management of behaviour; week 5, management of panic attacks and sleep; and week 6, self-care. At the end of each session, material for the next session was distributed containing homework exercises. At the final session, relapse prevention materials were distributed.

Outcome

Three quarters of the 1,062 clinical cases [PHQ-9 greater than or equal to 10 and/ or GAD-7 greater than or equal to 8] attended three or more sessions. Of those attending pure stress control alone 37% ‘moved to recovery’, defined as an improvement of 6 points on the PHQ-9 and 4 points on the GAD-7. With mean PHQ-9 scores for the clinical case sample reducing from 15.50 to 11.58.  Burns et al. (2015) claim that ‘SC appears comparatively clinically equivalent to other IAPT interventions’. However Gilbody et al. (2015) looked at how GP patients with a PHQ-9 score of greater than 10 fare with usual treatment, over a four-month period; their mean PHQ-9 score reduced from 16 to 9. It is thus not at all evident that the SC programme is of social significance.

The Case For Classes Is Built on Sand And A Distraction From Providing CBT That Makes a Real World Difference

The methodological quality of the SC studies are poor when assessed by the Foa and Meadows (1997) criteria, in that there are no clearly defined target symptoms, no diagnostic interview was conducted to establish which if any disorder the person was suffering from and the proportion ‘cured’ by the end of the intervention. Further there is no independent evidence that six or fewer sessions constitute an adequate dose of psychotherapeutic intervention.

Burns, P., Kellett, S. and Donohoe, G. (2015) “Stress Control” as a large group psychoeducational intervention at Step 2 of IAPT services: Acceptability of the approach and moderators of effectiveness. Behavioural and Cognitive Psychotherapy, 44, 431– 443. http:// dx.doi.org/ 10.1017/ S1352465815000491

Foa, E.B. and Meadows, E.A. (1997) Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449– 480.

Gilbody, S., Littlewood, E. and Hewit, G. (2015) Computerised cognitive behaviour therapy (CCBT) as treatment for depression in primary care (REEACT) trial: Large scale pragmatic randomised controlled trial, BMJ, 351, h5627. DOI: 10.1136/ bmj.h5627

Scott, Michael J. Towards a Mental Health System that Works: A professional guide to getting psychological help (p. 116). Taylor and Francis. Kindle Edition.

White, J., Keenan, M. and Brooks, N. (1992) Stress control: A controlled comparative investigation of large group therapy for generalised anxiety disorder. Behavioural Psychotherapy, 20, 97– 114.

White, J., Keenan, M. and Brooks, N. (1995) Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural Psychotherapy, 20, 97– 114.

Williams, C., Wilson, P. and Morrison, J. (2013) Guided self-help cognitive behavioural therapy for depression in primary care: A Randomised controlled trial. PLoS ONE, 8( 1), e52735. DOI: 10.1371/ journal.pone. 0052735

Dr Mike Scott

IAPT and Special Measures

If IAPT were a Hospital, operating without any consideration as to whether patients are returned to their usual selves with treatment, they would likely be placed in Special Measures. IAPT has eskewed accepted definitions of recovery.

IAPT’s Meaningless Yardstick

If you are departing IAPT (or wish to commit professional suicide!) tell your IAPT manager/supervisor the psychometric test results are not measuring anything meaningful, they are simply impositions from above! IAPT claims that the psychometric tests it uses (PHQ9 and GAD7) measure clinically significant change/ recovery. But this is not true.

The validity of clinically significant change criteria relies crucially on whether the test used taps the same construct as the identified disorder1. IAPT’s use of the PHQ9 and GAD7 violates the requirement for construct validity, specifically as IAPT make no standardised reliable diagnosis it is a lottery as to whether the psychometric test matches the diagnostic status of the client. A client could be suffering from for example variously, no recognised disorder, an adjustment disorder, OCD, panic disorder, the changing scores on the PHQ9 and GAD7 would say nothing at all about the outcome of an intervention for these disorders. To compound matters in the IAPT set up it is not possible to know when these measures are actually tapping depression or generalised anxiety disorder in a particular client.

IAPT’s Idiosyncratic Use of Tests 

IAPT have never stipulated any criteria for enduring improvement. Therapists discharge clients as soon as their scores dip below casenness on a self-report measure, neglecting to consider that what is being observed is likely natural variation than any return by the client to their usual self. Matters are compounded because clients can complete the questionnaires to either please the therapist (particularly likely if completed in front of the therapist) and/or convince themselves that they have not wasted time in investing in therapy.

IAPT Training At Fault

CBT therapists per se are not trained in methodology – there is rarely any understanding of concepts such as construct validity, reliability, the limitations of psychometric tests, bias introduced into such tests by the ways in which they are administered or of accepted criteria for recovery. The deeply flawed IAPT training has arisen without a murmur of protest from the British Psychological Society and BABCP hierarchy. The rationale appears to be so long as IAPT secures increased monies for mental health services that is all that matters, this is a dereliction of care to both clients and therapists.

How Outcome Should Be Assessed

The passage of depressed clients through IAPT has never been judged by accepted definitions of response, remission and recovery2, 3.

Response is defined as a clinically meaningful improvement in depressive symptoms that has continued for a sufficient length of time (3 consecutive weeks) to protect against misclassification owing to symptom variation or measurement error2. Response is typically operationalised as an  improvement of ≥ 50% over pre-treatment scores.

Remission relies on a definition of an asymptomatic range, defined as the presence of no or very few symptoms. A person can be judged to be in the asymptomatic range only if neither of the two essential features of depression (sad mood and loss of interest or pleasure) is present and fewer than three of the additional core symptoms of depression are present2. Remission requires that the person remains in this range for at least 3 weeks, again to protect against factors such as natural symptom variation.

Recovery is defined as an extended length of time in remission, which has been operationalised as at least 4 months4.

The passage of anxious clients through IAPT has never been judged by accepted definitions of recovery4. In the Bruce et al (2005) study of the trajectory of anxiety disorders a participant was considered to have recovered from anxiety disorder if he/she experienced 8 consecutive weeks at psychiatric status ratings of 2 or less (Table 1). Subjects who met this condition were virtually asymptomatic for 2 consecutive months.

Table 1

2. Residual The patient claims not to be completely his/ her usual self, or the rater notes thepresence of symptoms of no more than a mild degree (for example, mild anxiety in agoraphobic situations).

1.  Usual self The patient is returned to his/her usual self, without any residual symptoms of the disorder. (The patient may have significant symptoms of some other condition or disorder; if so, a psychiatric status rating should be recorded for that condition or disorder.)

References

1.Fisher PL and Durham RC Recovery rates in generalized anxiety disorder following psychological therapy Psychological Medicine 1999; 29, 1425-1434

2. Dobson KS, Hollon SD, Dimidjian S, Schmaling KB, Kohlenberg RJ, Gallop RJ, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. J Consult Clin Psychol 2008;76:468–77

3. Dombrovski AY, Lenze EJ, Dew MA, Mulsant BH, Pollock BG, Houck PR, et al. Maintenance treatment for old-age depression preserves health-related quality of life: a randomized, controlled trial of paroxetine and interpersonal psychotherapy. J Am Geriatr Soc 2007;55:1325–32

4.  Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, Shea MT and Keller MB (2005) Influence of psychiatric comorbidity on recovery and recurrence in generalised anxiety disorder, social phobia and panic disorder: A 12 year prospective study. Am J Psychiatry 162:1179-1187.

Dr Mike Scott

Terrorfied By Bomb Attacks

Victims of terrorists attack may suffer from post-traumatic stress disorder, living in terror of a further attack. Treatment needs to change to help victims deal with their state of ‘terrified surprise’ [ Scott (In submission) PTSD – An Alternative Paradigm and Scott (2013) CBT for Common Trauma Responses London; Sage Publications]. Clients should be encouraged to swap the glasses gifted by the extreme trauma and through which today is seen as a ‘war zone’, for the glasses they wore the day before the trauma. Below is a handout to help terrorist attack victims gauge the actual personal threat level:

If you have been the victim of a terrorist attack and have PTSD as a consequence, you likely feel ‘there could be another attack anytime’. Life is spent avoiding anywhere remotely like the scene of the attack.  You probably also take flight at the sight of anyone or any object that reminds you of the attack.  Life is lived in a state of ‘terrified surprise’, jumping out of your skin at unexpected noises or sudden movements, perhaps getting angry when this happens. You repeatedly check for signs of danger, seek to minimise risk by for example keeping the exit in sight in enclosed spaces. This all comes to feel normal and that the only safe place is home, but home has actually become a ‘bunker’ and you get cross with others not staying in a ‘bunker’, relationships become strained and there’s an increasing sense of isolation.

  Numbers Murdered In Attack   Odds of Being Killed 1 in…   Numbers Injured  Odds   of being injured 1 in….
2016   97.3 million     19   3.5 million
2017     37   1.8 million   300   220,000
2018    0   infinite   3   23 million

The above odds should be contrasted with the far greater odds of being killed in a car crash at some point in your life, of 1 in 103  or as a pedestrian 1 in 556.

The chances of exposure to an extreme trauma at a public gathering are about 1 in 11,000. [ 6000 had people brought tickets for the Manchester Arena Concert in which 22 people died as a result of the bombing]. Would you bet on a horse in the Grand National at these sort of odds?

The real risk of danger from a terrorist attack is nothing like the PTSD sufferer imagines, the vividness of the memory sounds, smells, feelings of helplessness give a very distorted impression of the likelihood of being a victim. Life is then about daring to live as if you are not in this ‘hall of mirrors’/ ‘war zone’.

Dr Mike Scott

CBT, Cancer and IAPT

a just published study of CBT for depression in patients with cancer has shown no effect [ Serfaty et al (2019)]. Patients were given CBT by IAPT staff in addition to treatment as usual (TAU) and the results compared with TAU alone. Whether the outcome measure was the PHQ9 or Beck Depression inventory there was no difference in outcome, see link below:

https://www.dropbox.com/s/iitvhyk5eyqjmyi/CBT%20for%20depression%20in%20cancer%202019.pdf?dl=0

The results suggest more generally, that if IAPT’s performance was compared to TAU no difference would be found. The study also casts doubt on the wisdom of IAPT’s sojourn into treating long term physical conditions.

Problems With Engagement

The intervention comprised up to 12 individual sessions (either face to face or over the phone), but the mean number of sessions received was 4.7 and over a third (35.6%) did not take up any sessions. They were all patients expected to live for 4 or more months. Interestingly 60% of patients had a previous history of depression. Of 2224 cancer patients only 10% (230) were found suitable and consented to treatment.

Some Methodological Issues

  1. There was no blind assessment of outcome using the standardised diagnostic interview (MINI) that was used to assess whether a patient was initially clinically depressed.
  2. TAU is a poor comparator as it does not control for the attention and expectations generated by being offered a special treatment (CBT). The appropriate comparator should have been an active placebo
  3. Therapists were rated using the Cognitive Therapy Rating Scale Revised but there is no mention as to whether this predicted outcome.

But CBT Can Make A Real Difference In The Right Hands

At The Right Time

One of the authors of the above study Kathryn Mannix, A Palliative Care Physician, has written a stunning book, With The End In Mind

With the End in Mind: How to Live and Die Well

Her capacity to be with people is truly amazing, this clearly is not just a job, for example her use of CBT with a patient with breathlessness as he awaits a lung transplant (he has cystic fibrosis) is truly exemplary. But she is a very credible source of persuasion with a detailed knowledge of the difficulties of those in Hospice care. I would wholeheartedly recommend you read this book.

Dr Mike Scott

Clinical Commissioning Groups Need To Know What Actually Happens Behind IAPT’s Closed Doors

this can be achieved by asking local GPs to ask patients about their experience and crucially to determine what proportion of patients returned to normal functioning after referral to IAPT.

Most IAPT clients receive low intensity CBT, with only 20% recovering, half of whom relapse in a year [ Ali et al (2017)]. Only 10% of LICBT patients are stepped up to high intensity. Independent assessment suggests the overall recovery rate in IAPT is just 15%.[ Scott (2018)] https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Results Show IAPT To Be No Better Than Pre-existing Services

A study from 2006 profiled the improvement rates of 32 primary care counselling services using the CORE Outcome Measure. (CORE-OM). The mean level of reliable improvement (including clients that also recovered)  was 72%. Across IAPT, the reliable improvement figure was 66%. But services can be re-organised to transform IAPT Scott (2018)

https://www.dropbox.com/s/zhr1fkg71aqvno0/Transforming%20IAPT.pdf?dl=0

The Failure To Inspect

CCG’s and the National Audit Office show a conspicuous lack of interest in what is happening behind the closed doors of IAPT, preferring to take the Organisations marketing at face value. IAPT appears not to be accountable to the Care Quality Commission. But the CQC’s failure to effectively monitor institutions catering for those with learning difficulties and autism has unearthed a scandal, and instils little confidence in a critical appraisal of IAPT anytime soon.

An Illustration Of The Travails of a Low Intensity IAPT Recipient

Ted’s case illustrates the dire quality of service, he met IAPT in 2014, the records stated that he had been a worrier all his life, but no diagnosis was made. He was no better after 18 months of low intensity cbt. A lost soul:

Initially Ted was directed to a Psychological Wellbeing Practitioner and computerised CBT, Beating the Blues. Ted is recorded as finding the sessions helpful. At the end of LICBT it is recorded that

‘he would prefer not to access cbt again as good understanding of how his negative thoughts impact his behaviour regularly reads his previous cbt notes but implementation does not improve mood’ his psychometric test results are shown below, ‘his billboard’:

    PHQ9GAD7  
Feb 14   10   14  
 March 14 8   7
  May 14 5   9
  July 16 21 15
  August 16 20   18
     
     

At the end of his low intensity journey, there was again no assessment of his diagnostic status and he was understandably not enthusiastic about further CBT. It seems likely that few people are stepped up from low intensity to high intensity because cbt is at best seen as having limited utility.

Ali et al (2017) How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study Behaviour Research and Therapy 94 (2017) 1-8

Dr Mike Scott

Simply Too Complex CBT!

abandon ‘what treatment works for what’ and you end up with a free for all of imagined complexity.

What Works for Whom?: A Critical Review of Psychotherapy Research

With stressed clinicians lost in a fog, arguing interminably about possible landmarks (formulations) for treatment. Not surprisingly the issue of ‘complexity’ now figures highly on IAPT’s list of workshops. Paradoxically formal IAPT training eskews trainees working with ‘complex cases’. IAPT specifies the importance of following the NICE guidelines but without a reliable procedure for determining what cases they do and importantly do not apply to.

The IAPT Courtroom

An obvious defence for IAPT workers failing to consistently obtain the 50% recovery rate is to contend that they were dealing with complex cases.

In rebuttal the Organisation can contend that complex cases are: ‘namely primary or comorbid psychosis, personality disorder, autism spectrum disorder, substance dependence, severe and/or treatment-relevant physical health conditions, and severe psychosocial difficulties Liness et al (2019) see link’ https://link.springer.com/article/10.1007/s10608-018-9987-5 and that the clinicians case falls outside this definition. But in areas of high deprivation it is relatively easy to claim that a particular client falls within this definition of complexity e.g ongoing pain from an injury or associated with a condition such as MS, having to use a Foodbank.

Flexibility Within Fidelity As A Defence

Flexibility has to be constrained by fidelity, if it is not then arguments between clinicians and line managers/supervisors have no arbiter. The clinician will lose out simply because the line manager/ supervisor has more power, at its’ worst ‘my way or no way’.


If fidelity is safeguarded, then there are agreed issues/concerns that need to be addressed with a particular client. It also sets limits on the range of interventions (flexibility) that are permissible for those particular issues/ concerns. Without a twin focii on fidelity and flexibility the clinician is up a creek without a paddle. But a hostile work environment can nevertheless ignore or more commonly pay lip service to fidelity and flexibility – they need to be admitted to the IAPT courtroom for the sake of both clinicians and clients.

Clinicians and Constructive Dismissal

Nevertheless there is a vagueness about the debate of simplicity vs complexity, that could mean that an IAPT therapist is hounded from office, without the case being put to anything like a jury, with no procedures in place to ensure any transparency and accountability.

The Need To Rediscover A Biopsychosocial Model

But actually matters are nowhere as simple as this simple/complex distinction. Steve Stadling (1990) and I https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/group-cognitive-therapy-for-depression-produces-clinically-significant-reliable-change-in-communitybased-settings/ADFC2B6A2D2BBCCC37CD41820DFD5287

were involved in a randomised controlled trial of individual and group CBT for depression in Toxteth, Liverpool, and managed to make important lasting differences using Beck’s protocol for depression. But because we were using a biopsychosocial model I saw it as much a part of my work to say write a letter to a Housing Association for a client as conduct the CBT. Similarly many patients were prescribed antidepressants, again in keeping with a biopsychosocial model. This holistic approach to client’s problems appears to have been lost in IAPT’s fundamentalist translation of the randomised controlled trials. An alternative perspective is presented my trilogy of Simply Effective CBT books


Dr Mike Scott

IAPT Training – ‘jump through our hoops and make no difference to client outcome’

that’s the take home message from a study conducted by Liness et al (2019). IAPT trainees were evaluated using the Cognitive Therapy Rating Scale Revised (CTRSR) and client outcome assessed, mainly with the PHQ9 and GAD7, and no relationship was found, either at the end of training or 12 months later, see link below:

https://www.dropbox.com/s/e26n191ie09sngs/Competence%20and%20Outcome%20IAPT%20no%20relation%202019.pdf?dl=0

Instead of the author’s concluding that something is seriously amiss if there is no relationship between competence and outcome, the authors celebrate that they could keep the newly trained therapists scoring highly on the CTRS!

Curiouser and Curiouser


It is a truly bizarre paper, on the one hand the authors acknowledge that it is important to assess adherence, competence and outcome but proceed only to analyse the relationship between competence and outcome. Treatment fidelity involves a combination of adherence (highlighting the appropriate disorders/difficulties and matching treatment strategies) and competence (how skillfully treatment is delivered). Thus the assessment of a surgeon’s key hole skills (competence) would make no sense at all if he/she were not using them in an appropriate context , e.g this week it was reported that a 26 week old unborn child with spina bifida was operated on with key hole surgery in the womb to help ensure some mobility after birth. By contrast key hole surgery, no matter how competently delivered, for say a person with simply diabetes would make no sense at all, it would be a matter of infidelity.

Inept IAPT

IAPT’s procedures make it impossible to ensure adherence. In order to guarantee adherence an open ended interview needs to be conducted to let the client tell their story. This is then the springboard for a reliable diagnostic interview, designed to elicit the prescence of disorder/s. Such a two-fold procedure protects against the use of misleading rules of thumb e.g ‘nightmares of extreme trauma, must be PTSD’. There can be no appropriate matching of protocols to reliably identified disorders without taking the time to get a comprehensive client story [see Scott (2009) Simply Effective Cognitive Behaviour Therapy London: Routledge]. Taking shortcuts means that the individual receives a hotchpotch of generic CBT for which there is no evidence base.

Trying to determine competence within IAPT’s structures is a will o’ the wisp exercise.

The Mis-Selling of the CTRS

On October 2017 I wrote a blog on this topic. Liness et al (2019) maintain that the CTRS addresses the issue of adherence, but it does not, whilst there is an agenda item on the CTRS, keeping to the agenda does not at all mean that an appropriate agenda has been identified!

The authors note that the CTRS has become the ‘gold standard’ on courses, but their is a weak evidence base for it’s predictive power for depression (see earlier blog ), an even weaker power for anxiety disorders and none outside this range. I have suggested that what should be employed are fidelity measures that incorporate both adherence and competence. Scott (2015) Simply Effective Supervision, London: Routledge.

Re-focussing on Real World Outcomes With Routine Clinicians In Customary Contexts

It appears not to have occured to Liness et al (2019) that changes on the PHQ9 and GAD7 may not be actually measuring outcome. Rather they are most likely measuring a) improvements with the passage in time as people inevitably enter therapy at their worst point and b) a placebo response because the therapists in the study (42% of the IAPT therapists were clinical or counselling psychologists) created an expectation the alleged CBT would make a difference and they gave clients attention (an average of 11-12 session).

Clients were not assessed by someone independent of IAPT using a standardised diagnostic interview to determine whether they had got back to their usual self with treatment and the results were not contrasted with an attention placebo. It is thus impossible to actually determine whether the alleged CBT made a real world, socially significant difference. Nevertheless the IAPT luminaries in the study will doubtless use the ‘findings’ to promote their brand in the UK and beyond!

The study also lacks ecological validity: where else are there such a high proportion of qualified clinicians, where else are IAPT staff routinely providing 11-12 sessions, where else are there clients without severe psychosocial problems and staff given weekly group and 1.5 hr long individual supervision. Further the therapists in the study chose sessions to be rated on.

The Hi-jacking of Supervision

Within IAPT training supervisors are expected to attend courses run at Universities at which there supervisees are being trained. But there is no evidence that this form of supervision results in better client outcome. It is possible to operate with a wholly different model of supervision in which its’ major function is to act as a conduit for evidence based treatment.

The New Totalitarians

Disturbingly IAPT is like a totalitarian state determining, mental health job opportunities and the way in which assessment, treatment and supervision are conducted. Further it controls journals such as Behavioural and Cognitive Psychotherapy, Behaviour Research and Therapy and even it seems Cognitive Therapy and Research in which the Liness et al (2019) paper appeared (this was the journal to first publish Beck’s seminal study on the efficacy of CBT for depression). It is extremely difficult to get an airing if one sees IAPT in practice as deeply flawed

Dr Mike Scott

‘ A Strong Therapeutic Alliance Is an Essential Element of (CBT) Treatment’

so writes Judith Beck, President of the Beck Institute for CBT (2019 Moorey and Lavender) in a book to be published next week, echoing what her father Aaron Beck wrote in 1979 in his seminal work Cognitive Therapy for Depression. But IAPT have made their own fundamentalist translation of Beck’s work, indoctrinating its’ footsoldiers, Psychological Wellbeing Practitioners (PWPs), one of whom from Liverpool (2019 p214 Jackson and Rizq) has written:

‘The PWP role is high volume low intensity, just churn them out… young PWPs straight from universities, who are naively prepared to do as required by the service…There’s a big gap between the data and the reality of what we’re trying to do’.

It is disturbing that the most vociferous critics of IAPT are also fierce critics of CBT, [ see Jackson and Rizq (2019)] creating a caricature of the latter as mechanistic and uninterested in the the therapeutic relationship. But I have just contributed a chapter the Moorey and Lavender (2019) edited volume. Anyone reading my chapter on Group CBT in this work can be in no doubt about the importance I attach to the alliance/ cohesion in a group.

I am still reading the Jackson and Rizq (2019) book and it contains many perfectly valid criticisms of IAPT. But it does engage in unnecessarily distracting polemics about the medical model and diagnosis.

The contributors to the Jackson and Rizq (2019) work seem blissfully unaware that no medic or psychologist has ever espoused anything other than a biopsychosocial model, it is only the mouthpieces for drug companies that have ever voiced purely biological explanations. To say that biology will be involved in psychological reactions isn’t at all to say that the former determines the latter or its course.

Breathtakingly Jackson and Rizq (2019) are profoundly mistaken when they assert that IAPT believes in diagnosis, they do not at all, they pay lip service to it to secure funds!. IAPT never ever perform a standardised diagnostic interview such as the SCID which is the ‘gold standard’ for establishing whether a person has a recognised psychiatric disorder. The first part of the SCID begins with an open ended interview in which clients are given the space to tell their story, only then is their systematic enquiry about each of the symptoms in a diagnostic set and a clinical assessment of which symptoms are significantly interfering with real world functioning. If IAPT started to use the SCID it would stop the production line referred to by the PWP above. There has to be space created for any relationship. But in my personal communication with David Clark, IAPT’s progenitor he baulked at the cost involved, but did not criticise my proposal per se.

Diagnosis provides a common language and it is the least worst way of communicating, try trying to talk about say ‘power threat meaning ‘ in a medico-legal case! Its’ usage does not at all depend on believing in a particular biological pathology rather it is pragmatic and subject to revision.

Jackson and Rizq (2019) reiterate the ‘Dodo verdict’ that all therapies are equal and must have prizes citing Wampold’s work, but Tolin’s findings

https://www.dropbox.com/s/r3bja27takbicnc/Tolin%202015%20Dodo.pdf?dl=0

are very different. But notwithstanding this, in routine practice one does not find evidence of fidelity to any psychotherapeutic protocol, I have yet to see any written evidence in treatment notes of fidelity that would satisfy anyone from any of the psychotherapeutic schools. Manuals are seen as anathema, with a total ignorance that flexibility is an integral part of all such published manuals. Unfortunately the manuals have never been tested out by the Jackson and Rizq (2019) advocates, nor has the viability of using a standardised diagnostic interview, instead theirs is a fundamentalist view that they and their client will somehow find the right way. In their own way they are as ideological as IAPT.

References

Moorey, S and Lavender, A eds (2019) The therapeutic relationship in cognitive behavioural therapy. London: Sage Publications

Jackson, C and Rizq, R (2019) The industrialisation of care counselling, psychotherapy and the impact of IAPT. PCCS books

Dr Mike Scott

CBT Is Overeaching Itself – Clients and Therapists Are The Likely Casualties

A re-examination of the evidence base for CBT, using published guidelines for the evaluation of randomised controlled trials [ Guidi et al (2018)], suggests that low intensity interventions and interventions for ME, long term physical conditions and psychosis are not evidence based. Such studies lack credibility either because of the abscence of blind outcome assessment or when blind assessment has been conducted the results have been negative. Further the number of blind credible trials supporting the efficacy of CBT for depression and anxiety disorders is about half the number of studies usually considered as evidence. Dissemination of CBT beyond the boundaries of an evidence base hampers finding real world solutions to a clients difficulties and will likely result in demoralisation of the latter and therapists. This casts doubt not only on the wisdom of IAPT’s expansion beyond depression and the anxiety disorders but the ethics of its’ treatment of staff.

An international team of Experts [Guidi et al (2018) see link below] have developed evaluation guidelines stipulating the need for blind independent assessment of psychological interventions, particularly when psychometric tests are the outcome measure.

https://www.dropbox.com/s/hizta38yqm4lfh3/Methodological%20Recommendations%20for%20Trials%20of%20Psychological%20Interventions.pdf?dl=0

The PACE trial for chronic fatigue syndrome was heavily criticised [ Edwards (2017)] because it relied on self-report measures of outcome without blind assessment, a methodology that is unacceptable in medicine and in the evaluation of pharmacological products see https://journals.sagepub.com/doi/full/10.1177/1359105317700886

To my knowledge there are no blinded assessment of outcomes for any low intensity interventions. Efficacy has a way of disappearing when there is blinded assessment, for example Morrison et al (2018) conducted a blinded outcome assessment of CBT for schizophrenia and found no clinically meaningful difference, see link below:

https://www.dropbox.com/s/2jqwurf2z9ydyb7/Schizophrenia%20CBT%202018.pdf?dl=0

One other stipulation of the Guidi et al (2018) guidelines is that studies of an intervention should involve an active placebo, in order to ensure that any impact of treatment is not just due to raised expectations and attention. But more than 80% of trials in the anxiety disorders have used waiting list control groups [Cuijpers (2016)] as opposed to active placebos .

https://www.dropbox.com/s/d2tu2ymzp9it7v5/CBT%202016%20Cuijpers.pdf?dl=0

Carpenter et al’s (2018) , study of anxiety disorders see link below found that there were only 41 studies using an active placebo and in only two thirds of them was there a low risk of bias because outcome assessment was blinded. Thus though CBT was still regarded as efficacious, this number of studies spread across all the anxiety disorders does not make the case for CBT being irrefutable.

https://www.dropbox.com/s/js2bljurdwijxkf/Carpenter_et_al-2018-Depression_and_Anxiety%20%281%29.pdf?dl=0

As Zhu et al (2014), see link below, put it with regard to generalised anxiety disorder, the evidence for CBT is ‘strong but not definitive’. They point out that although the 12 randomised controlled trials they reviewed all had blind assessors, in 6 of them outcome was not based on the assessors assessment but on a self-report measure.

https://www.dropbox.com/s/cng09hehty9qo02/GAD%20Meta-analysis.pdf?dl=0

Of the 144 studies of depression, generalised anxiety disorder, panic disorder and social anxiety disorder reviewed by Cuijpers et al (2016) only half (48.6%) had a blind outcome assessment,

https://www.dropbox.com/s/d2tu2ymzp9it7v5/CBT%202016%20Cuijpers.pdf?dl=0

Further Cuijpers et al (2016) found that the effects of CBT are small to moderate when the comparison condition is usual care or active placebo compared to a large effect size when the comparison is a waiting list control condition.

In view of Guidi et al’s (2018) strictures around the evaluation of randomised controlled trials, it is wholly inappropriate for IAPT to admonish its therapists for ‘poor performance’ based solely on a psychometric test. There are surely grounds here for a therapist to claim constructive dismissal.

Dr Mike Scott

Groups and Trauma

Group CBT treatments for PTSD leave 70% of participants still suffering from the condition and it appears less effective than individual PTSD. Further, other active group treatments appear as effective as group CBT for PTSD, but are slightly better able to retain people, probably because they are not trauma focussed, see link below to the Sloan et al (2018) study:

https://www.dropbox.com/s/qoly0wkquhzu44x/Simply%20Effective%20Group%20CBT%20All%20Appendices.pdf?dl=0

Stabilisation Groups


Groups/classes are a great attraction for Organisations pre-occupied with numbers and waiting lists, reflecting the prime concerns of Clinical Commissioning Groups. IAPT has a penchant for running groups/classes without an evidence base for effectiveness. For example, it offers trauma victims a Stabilisation Group, here is how two participants fared:

Mr X had two accidents within weeks of each other and attended a 6 week course. My independent assessment found the course had no effect on his mild PTSD and mild depression and he was then put on a waiting list for individual CBT. The group sessions began with 12-15 participants and went down to 4 people. Topics covered included calming down after nightmares, mindfulness and deep breathing. Nevertheless he described the course as ‘helpful’ but was given no diagnosis at any point either in the telephone assessment or on the course.

Mr Y attended a 6 week course with initially 8-10 people and 3-4 dropping out before the end he also found the course ‘helpful’, albeit that he felt that he was not back to his usual self after the course. My independent assessment revealed that he was still suffering from PTSD after the course and he received a letter stating ‘ have now success fully completed the Stabilisation Symptom Management Course … .. you have opted to complete therapy at this time  discharged you from the service’ but IAPT made no attempt at reliable diagnostic assessment before or after the course, patronisingly ‘success’ is now defined as completing an IAPT course!

Background to Stabilisation Groups

The impetus for the IAPT stabilisation groups probably derives from the Institute of Psychiatry 10 week programme teaching coping strategies for dealing with symptoms of PTSD, but in which trauma histories are not discussed . The programme uses cbt, mindfulness and relaxation techniques. But with no published study on effectiveness. IAPT has run a cut down version of this, just 6 sessions. Robertson et al at the Traumatic Stress Clinic offer 5-8 weeks of 2 hour group sessions for up to 10 people for refugees with a focus on managing hyper-arousal, anxiety, re-experiencing and dissociation but again there are no outcome studies. Like in IAPT it is intended as part of a phased treatment model but there is no evidence that it in any way adds to established treatments for PTSD.

Evidence Based Delivery of Group CBT

The Trauma Groups run in the UK bear no resemblance to those described in the Sloan et al (2018) study. The latter involved 14 2hr sessions and an adequate dose of treatment was regarded as attendance at 10 or more sessions. Though only a minority of study participants recovered from their PTSD there were high levels of satisfaction with both the trauma focused CBT intervention and with the non-trauma focused intervention. The trauma focused intervention involved writing about their trauma in 2 sessions and at home for homework. Further the trauma focussed group treatment was based on a group programme developed originally for victims of road traffic accidents. Interestingly both the trauma focused group CBT programme and the comparison Present Centred Therapy had bigger effects on coexisting generalised anxiety disorder and depression than on PTSD, the main target!

There are evidence based group protocols for depression and the anxiety disorders described in my book Simply Effective Group CBT (2011) London: Routledge.

The content for the group sessions I detailed in the book can be downloaded by clicking the link below:

https://www.dropbox.com/s/ys0ogfo3k93qmwb/Ptsd%20Group%20treatments%202018.pdf?dl=0

I will be circulating this blog to the BABCP, Group CBT Special Interest Group, anyone interested in joining can contact Nicola at nicoladrurywalker@fastmail.com

Dr Mike Scott