‘Too Complex for IAPT’ – Dumping on Secondary Care?

I work in secondary care as a band 7 CBT therapist within a CMHT. Often I will have referrals sent directly from IAPT who describe the patient as being too ‘complex’. Indeed this seems to have become an actual care pathway (not that we have too many of those). As far as i can tell at this stage  the patient may have not had a face to face assessment, rather has been deemed too complex simply because of the stated diagnosis e.g if they have a so  called personality disorder. I have also been told that if someone scores a above a certain score on the HADS scale (I don’t understand why this particular measure is being used as the ‘cut off’)  they too are apparently ‘too complex’. I am also told that  the outcome measures used by IAPT apparently mean that the ‘too complex clients’ would impact on these performance scales which in turn  could mean further funding for the service is jeopardized.

This concerns me on two fronts. Firstly in principle… this seems to completely  go against the ethos  of  the IAPT envisioned by Layard & Clark (although how workable or realistic this ever actually was in another thread) and another example of how it  seems management  are ‘cooking the books’ . Secondly on a more  personal level  I am employed in same Trust as a band 7 cbt therapist , i have no support from care coordinators and supposedly have the same amount of sessions to offer patients so how can possibly i offer anything different to IAPT? I suspect management know I can’t , but i ( and my colleague) serve as  i convenient sponge to soak up all the pts that may threaten the outcome measures…

 

I wonder has anyone else working in secondary care had  similar experiences  or is this an isolated thing ?

Wasting The Taxpayers Money – Fire and Fury Over CBT

‘The results are, at best, unreliable, and at worst manipulated to produce a positive-looking outcome’ so write the editors of the current issue of the Journal of Health Psychology, (http://journals.sagepub.com/toc/hpqa/current). They are writing in relation to a study of the efficacy of CBT for chronic fatigue syndrome ( CFS – the PACE trial). The essence of the editors’ criticism is that when objective measures of outcome were used the effectiveness of CBT disappeared, but the authors of the PACE trial relied instead on subjective self-report measures to ‘promote’ the cognitive behaviour therapy and graded exercise therapy protocols that they themselves had developed. The Times of August 1st 2017 reported a ‘trade’ of ‘insults’ between both sides.

                       PACE Trial £5 million

                                                                                           IAPT £400 million +

But the same criticism that the editors make of the evaluation of CBT for CFS can be applied to how CBT for ‘depression and anxiety’ (the alleged focus of IAPT) is evaluated in routine care in the UK Government’s IAPT Service. Evaluation is entirely based on subjective measures (the PHQ-9 and GAD-7), there is no objective measure (a standardised reliable diagnostic interview), assessment has been entirely by the service providers with no independent assessment. The cost of the PACE trial was just £5 million, a drop in the ocean compared to the cost of IAPT which saw the Coalition Government invest up to     £400 million over the four years to 2014–2015. [Department of Health (2012). IAPT Three-year Report—The First Million Patients. London: DH] .

Dr Mike Scott

 

Disseminating Group CBT – What You Need To Know

Clients often have similar stories, so it is a no-brainer to treat those with the same story in a group. But groups can go badly wrong – a colleague of mine was unavailable to lead a group because of illness, one of the group ‘stepped-in’ and ran the group at his flat, suggesting that he would be a much better group leader!

On September 6th I am giving a 1 Day Workshop on Delivering Group CBT to Bedford IAPT, one of many I have delivered to BABCP local Groups and IAPT. In 2013 when I gave the workshop in Copenhagen I discovered that  there Group CBT is the usual mode of service provision and therapists have to justify individual therapy, they found it surprising that in the UK we  did not operate that way. There are free group materials for depression, anxiety disorders and PTSD if you click the Resources button on this site, from Simply Effective Group Cognitive Behaviour Therapy (2011) London: Routledge. The Workshops have raised a whole host of questions that might be worth discussions in your locality and/or on this forum:

 

 

The learning objectives for the Delivering Group CBT workshop are for attendees to be able to answer most of the following questions by the end of the day:

  1. How do we ensure that we don’t play a numbers game with regards to groups?
  2. Why not admit all-comers?
  3. Aren’t classes a better use of resources than groups?
  4. How do we select the right people?
  5. Is group CBT really an answer to a Manager’s prayer?
  6. How do you identify and circumvent special problems in marketing group CBT?
  7. How can you integrate individual and group cbt?
  8. What is the structure of a session?
  9. What might the session by session content look like for depression and the anxiety disorders?
  10. How do you capitalise on group members assembling and/or departing?
  11. Do you have to specify groundrules?
  12. How do I handle clients with more than one disorder/difficulty in a group?
  13. How do you handle the difficult client?
  14. How do I know if the group is making a socially significant, real world difference?
  15. Which groups are best to start with?
  16. How do I manage group processes?
  17. How can I know whether I am managing group processes well?
  18. How does group cbt compare to individual cbt in terms of effectiveness?
  19. What if you are expected to run a group alone?
  20. How do you divide up the work between leader and co-leader?
  21. How should leader and co-leader debrief each other?
  22. Can you really do Socratic dialogue in a group?
  23. Are there advantages to a story telling/narrative approach in groups?
  24. What are useful materials?
  25. What can you do if your supervisor has no experience of group CBT?                                                    Dr Mike Scott

Mental Health Services Expansion Before Completion of Investigation!

On July 31st 2017, the Health Secretary, Jeremy Hunt announced funding for an extra 2,900  new therapists in Adult Mental Health talking therapy services. A week earlier the National Audit Office invited submissions for its’ investigation into IAPT, with a closing date of this Autumn. It is clearly the time of the year for the Mad Hatter’s Tea Party:

 

be careful that you don’t mutter under your breath at such gatherings that ‘evidence should precede action’, if heard it could be ‘off with your head’.

But beware, the historian High Trevor Roper wrote in the Last Days of Hitler ‘mythopoeia is a far more common characteristic of the human race than veracity’. The wholesale endorsement of IAPT by BABCP and to a lesser extent by BPS reflects mythopoeia:

 

IAPT with its low intensity modality has attempted to make therapy ‘simpler’ than simple, resulting in ineffective treatment.  When it comes to the high intensity modality it has made matters ‘simpler’ than simple, by abandoning reliable diagnosis/high specification of problem/s as a Sat Nav for treatment again often resulting in ineffective treatment.

 

Dr Mike Scott

 

National Audit Office IAPT Investigation, Whistleblowers

Below is the National Audit Office’s request for evidence re: IAPT, I note they have a whistleblower’s policy. It may be possible to ask for anonymity. I would hope that BABCP and BPS would make a submission to the National Audit Office, but to my knowledge this is not on the agenda of either, why not?

Investigation: Improving Access to

Psychological Therapies performance data

The ‘Improving Access to Psychological Therapies’ (IAPT) programme increases access to

National Institute for Health and Care Excellence approved treatment for depression and

anxiety disorders. In October 2014, the Department of Health and NHS England

jointly published Achieving Better Access to Mental Health Services by 2020. This set new

standards for the time people should wait for mental health treatment and the care they should

be able to access. In the case of IAPT services, the standards are that 75% of people referred

should be treated within six weeks, and 95% within 18 weeks of referral, and that 50% of

those who complete treatment will recover. NHS Digital publishes monthly statistics

that report performance against these standards. This investigation will establish the facts

around how the national statistics are prepared.

If you would like to provide evidence for our study please email the study team on

enquiries@nao.gsi.gov.uk, putting the study title in the subject line. The team will consider the

evidence you provide; however, please note that due to the volume of information we receive we

may not respond to you directly. If you need to raise a concern please use our contact form.

IAPT Performance Investigation – National Audit Office Request

‘The National Audit Office is currently carrying out an investigation into the performance data of IAPT services. The investigation is focussing on waiting times, but also refers to the reported 50% recovery rates and can accept information about the collection and measurement of data across IAPT outcomes.  

This is a genuine opportunity for us to challenge the data on which mental health service targets are being set.

Many of you have important experience of what is happening in IAPT services that is crucial for the NAO in building an accurate picture of what is going on.

Please submit your evidence to Jenny George Jenny.George@nao.gsi.gov.uk and David Rarity David.Raraty@nao.gsi.gov.uk  who will be writing the report during August. It’s a tight deadline so please submit what you can as soon as possible.

The NAO website is HERE and below is the information provided about the inquiry.

Improving Access to Psychological Therapies performance data

The ‘Improving Access to Psychological Therapies’ (IAPT) programme increases access to National Institute for Health and Care Excellence approved treatment for depression and anxiety disorders. In October 2014, the Department of Health and NHS England jointly published Achieving Better Access to Mental Health Services by 2020. This set new standards for the time people should wait for mental health treatment and the care they should be able to access. In the case of IAPT services, the standards are that 75% of people referred should be treated within six weeks, and 95% within 18 weeks of referral, and that 50% of those who complete treatment will recover. NHS Digital publishes monthly statistics that report performance against these standards. This investigation will establish the facts around how the national statistics are prepared.

This is a really significant opportunity for us to share our experiences of what is going wrong in performance management of services. Please, take the time to contribute to the report’. 

 Thanks to Steve Flatt for alerting me to the above from the ‘Surviving Work’ website
Dr Mike Scott

 

Copyright © 2013 The Resilience Space, All rights reserved. www.theresiliencespace.com

NHS Psychological Therapy Services In Tatters – Lifting the Veil, Press Release

NHS Psychological Therapists feel so threatened by their employer that Consultant Psychologist,           Dr Michael Scott has set up an independent online support group for them at cbtwatch.com. A Therapist from the Government funded, Improving Access to Psychological Therapy (IAPT) Service, in the South of England, wrote to the forum:

 

I am leaving… .. while many patients have a very positive experience of IAPT, a significant number have had a far more negative, even sometimes damaging experience:

  • I have spoken to people who have I have spoken to people who have told me their 30 minute telephone assessment left them distressed and confused, having talked about highly sensitive topics without the time to process the emotional aftermath.
  • I have spoken to people who dropped out of treatment and decided CBT was a waste of time, after being misdiagnosed and offered unsuitable guided self-help.
  • I have come across people with deep seated trauma being offered six sessions of telephone therapy, and feeling that this left them ultimately worse off.
  • I have also spoken to people dismayed and angry because they unavoidably missed one appointment and subsequently received a letter telling them they had been discharged and would need to re-refer, and go back on the waiting list’.

Dr Scott commented  that ‘it speaks volumes that I have to use a pseuodonym, Zara, to express the therapist’s voice’.  He is author of ‘Towards a Mental Health System That Works’ published by Routledge earlier this year and said ‘I had to set up a safe harbour for therapists like ‘Zara’ at cbtwatch.com. My own research, conducted without any conflict of interest, across services across Merseyside suggests that the recovery rate from a diagnosed disorder in IAPT is just 15%’.   ‘Zara’ added ‘I won’t miss the lost sleep worrying that I may be put on performance management measures if I fail to maintain a 50% recovery rate, and I certainly won’t miss witnessing, and indeed experiencing, some of the management bullying tactics I have seen in IAPT’.  Dr Scott commented       ‘ IAPT have always marked their own homework, there has never been an independent audit, using a ‘gold standard’ diagnostic interview. Not only is it likely that taxpayer’s money is being wasted but the average therapist and patient far from being helped, is stressed by the experience, MPs, Clinical Commissioning Groups and the National Audit Office need to take up this issue’.

Dr James Davies, Reader in Social Anthropology and Mental Health at the University of Roehampton, author of the forthcoming  book ‘Mental Health and Neo-liberalism’ comments ‘an impartial observer looking at the IAPT data, could not help but conclude that the Service haemorrhages clients, and that the criteria it uses for success are very suspicious’.

 

Dr Mike Scott

‘Psychometric Tests, Administered In Isolation, Are Not Footprints of Anything’ – IAPT’s Big Mistake

IAPT uses psychometric tests to identify ‘cases’ and changes in test score to gauge effectiveness.  This is not an evidence based assessment and without it there can be no evidence based treatment.

Image result for wrong direction

A psychometric test can’t exist in a vacuum it has to refer to something tangible i.e it must have criterion related validity. For example in last month’s British Journal of Psychiatry, Quinlivan et al [‘Predictive accuracy of risk scales following self-harm’] assessed the ability of risk scales to predict whether a person will make a further suicide attempt  (the criterion). It was found that the much used scales, did not in fact predict self-harm, i.e they lacked criterion validity. Thus when psychometric tests such as the PHQ-9 (an intended measure of depression) and GAD-7 (an intended measure of generalised anxiety disorder) are used, individual test results are only meaningful if they are actually the ‘footprint’ of the construct under examination. Imagine seeing a footprint in the snow:

 

 

does it relate to the abominable snowman, a polar bear, a human being or the great yeti? Without a specification of what it refers to changes in the footprint found are meaningless.  Thus when IAPT use the PHQ-9 and GAD-7 in isolation it is not known to what they refer, as no reliable diagnostic interview has been performed. Is the person simply stressed, depressed, worried well or what? The myriad possibilities likely have very different trajectories e.g the stressed improving as the stressor passes. Lumping them altogether, creates confusion, prevents any evidence based assessment, which is the foundation for evidence based treatment. Clients cannot be reliably signposted to anything, resulting in the wrong tools being used:

Worryingly, I wrote a rejoinder to a paper by Ali et al in this month’s  Behavior Research and Therapy, on relapse after IAPT low intensity intervention, making the point that they had abused psychometric test results in just this way, it was rejected, the reviewers pointed out that I hadn’t included a reference supporting criterion related validity!  I despair. The reviewers tried to justify the approach of Ali et al on the grounds that the PHQ-9 is a reliable instrument, identifying 80% of those who are depressed (sensitivity) and 80% of those who are not depressed (specificity), which is true. But this provides no basis on which to judge whether Mr X who scored say 25 on the PHQ-9 should a) be regarded as a ‘case’ of depression and relatedly b) whether his progress should be charted with this measure, a) and b) can only be determined by a reliable standardised diagnostic interview, which is absent from the IAPT assessment protocol. If you found your electrician was measuring current with a voltmeter you would, forgive the pun be ‘shocked’, we need to create a similar state of alarm about the quality of audit in IAPT. There is a pressing need for independent rigorous assessment.

Dr Mike Scott

Casualties of Foolhardiness

The more I listen to, read about and consider the progress (or lack of it) of the project that is called Improving Access to Psychological Therapies (IAPT) the more thoughts of the actions of the generals in World War One spring to mind. Haig was a classic study in the unwavering belief of cavalry even in the face of machine guns, he had no idea of the conditions his troops were fighting in, he believed that numbers would win out, just like MacNamara fifty years later in Vietnam.Both believed in numbers, sheer volume would win the war for them.

Image result for mental health casualties

Clark, and his side kick Lord Layard, like his ignominious predecessors, consider that sheer volume of numbers will be sufficient to defeat the epidemic that is mental illness. While Clark and Layard’s numbers are statistics, people are still dying as a result, those sent to fight the war are still being burned out by sheer effort of trying to help others in impossible conditions. For example, 50% of professionals working in front line mental health services are suffering psychological distress, the conditions are intolerable yet most are too frightened to say so. The pressure to achieve a “50% success rate” means that statistics are skewed or even changed to achieved the necessary figure. Professionals are sent for retraining if they don’t achieve and then sent back into the frontline. In the First World War, many soldiers had their wounds stitched up and were then sent back into the front line. As I type this it reminds me of the horses ridden by the toreadors in bull fights; if the horses were gored by the bull they were taken out of the ring stitched up and sent back into ring immediately – amazing cruelty. The same is happening to frontline staff in IAPT.

Yet the politicians are being fed an amazing story of success, in exactly the same way that Haig and others in the First World War sent back messages that told the politicians how well they were doing.

This quote from Historynet really sums it up:
“Haig waged the ensuing political battle with customary remorselessness and prevailed in the bureaucratic trenches. He got everything he wanted in the way of men and materiel for what became known as Third Ypres or Passchendaele, a battle remembered for, among other things, terrain so wet the entire world seemed to consist of nothing but mud and shell holes filled with vile water. Indeed, in no land battle in history did so many men die by drowning.”

Image result for casualties of mental health

So many people are drowning as a result of the disaster that is the Project called Improving Access to Psychological Therapies, clients and professionals alike; yet the politicians remain enamoured of the project’s ability to blame the individual for their failure. It matters not whether it be client or professional, the failure lies within the individual, this is the overbearing ideology of the current government and those who seek to prove the model that is supposed to be Improving Access to Psychological Therapies.

Like Haig, Clark seeks to prove his model by asking for more troops (which, like Haig, will be refused; the worst of all worlds) rather than look at the overwhelming evidence that it is not working. For example, of all those who are referred to the service only 16% make some kind of recovery based upon the analysis of psychometric tools. From a service point of view this is a disaster. No company would continue to function on that basis. Yet the government continues to prop up the project on the basis that it is making a difference. What makes it worse is that IAPT continues to mark its own homework – it is time for an independent review.

There has been no measurable difference to the well being of the country as a whole, and only a few lucky people have benefitted as individuals. With regard to the overall well being of the country we are slipping behind that of other nations and if austerity continues the environment will only continue to get worse. As I have said so many times before, a toxic environment cannot be combatted by providing a leaky gas mask. Therapy and resilience training are no match for a cruel and heartless environment created by cruel and heartless politicians.

References:
http://www.historynet.com/field-marshal-sir-douglas-haig-world-war-is-worst-general.htm

Steve Flatt

The Silencing of Dissent and IAPT

 

This month’s Behavior Research and Therapy features a paper by Ali et al in which IAPT data on relapse after low intensity (Li) interventions is reviewed, and it is concluded that further attention to relapse prevention may be needed. I submitted a rejoinder essentially saying that Li-interventions have been a false economy and complaining that it had not been declared that Ali headed the Northern IAPT Research network, but it was rejected.

The editor began her letter of explanation with ‘Each of the reviewers is a highly experienced researcher in the area of low-intensity treatments for depression anxiety’.  But that is precisely the problem, researchers in low intensity see no pressing need for independent assessment using a ‘gold standard’ diagnostic interview (unlike their forbearers who conducted the bench-marking studies that gave CBT its’ credibility), although they pay lip service to it.

In practice, low intensity researchers find it ‘reasonable’ to conduct research on outcome solely on the basis of changes in a psychometric test. This strategy enables research to be done on the cheap, produce lots of papers and get brownie points in academia. There is a mutually beneficial groupthink amongst low intensity researchers and the IAPT hierarchy. Low intensity interventions fail an evidence based assessment test with a shameful lowering of the bar of methodological rigour. I will return in future blogs to editors/reviewers scant regard for criterion related validity and the misuse of Jacobsen’s Reliable and Clinically Significant Change Index, an abuse that is rampant in IAPT.

Dr Mike Scott