The Gagging of Clients as Storytellers

‘don’t listen to the story treat the symptom’ that is the advise to be given to IAPT’s PWP’s attending a 3 hour workshop on November 28th 2019 on groupwork. It reflects similar advise given to IAPT clients attending a 6 week course on ‘Understanding PTSD’ in which clients are instructed not to talk about their trauma rather to reflect on what they have found helpful so far. This gagging of IAPT clients is consistant with the Organisation’s 30 minute telephone assessment. But it is inconsistant with the need to help client’s overcome cognitive avoidance e.g in PTSD avoiding talking about their trauma.

In Simply Effective Cognitive Behaviour Therapy, Routledge (2009)

I suggested that clients need treatment simultanously for all the disorders from which they are suffering. This is to look at the totality of the clients story, not to elevate one part of it (e.g the disorder that is most impairing) and just treat that. Interestingly Barlow et al 2017 see link below compared focussing just on the main disorder from which a person was suffering (from amongst panic disorder, GAD, social anxiety disorder and GAD, even though most people had more than one disorder) with a protocol that could be adapted for any of these disorders ( termed a Unified Protocol) and retention of clients was better with the latter. This suggests that addressing the whole story is best as well as being more respectful.

Care has to be taken however with Barlow’s transdiagnostic approach, in that the term denotes just those suffering from an anxiety disorder excluding PTSD. Over half of clients had a degree. All treatments were developed by Barlow and his colleagues, there has been no independent replication. Treatment was individual, no evidence that it works in groups. The treating clinicians were highly qualified/trained and did both treatments, as the UP was the new kid in the block and their ‘kid brother’ that may explain the slightly better results with UP.

Barlow et al (2017) https://www.dropbox.com/s/22qz932flxroas3/The%20Unified%20Protocol%20for%20Transdiagnostic%20Treatment%20of%20Emotional%20Disorders%20Compared%20With%20Diagnosis-Specific%20Protocols%20for%20Anxiety%20Disorders.html?dl=0

Dr Mike Scott

IAPT Misses The Boat Using a Train Timetable

IAPT couldn’t find enough cases of generalised anxiety disorder that a randomised controlled trial comparing CBT with the antidepressant sertraline collapsed, Buszewicz et al (2017) see link below. The metric IAPT uses, problem description is clearly useless as GAD cases are ubiquitous, effecting 4.7% of the population, more common than depression,

Similarly adjustment disorders are ubiquitous but IAPT doesn’t use such a label and engages in treating them then discovers its mistake, what a waste of resources. Dana was distressed by the criminal behaviour of her ex and her children’s exposure to him, she had 4 treatment sessions which she described as helpful, but the service advised that treatment should be suspended and the outcome was ‘mixed’.

  PHQ9 GAD7
Pre 7 13
Post 6 12

:

Yvonne had a long history of anxiety but no problems in the months before she tripped, injured herself and this initially precluded her use of her main coping mechanism of exercise. She was given treatment for ‘anxiety’ in IAPT, which she described as helpful, but she only had fear of falling a specific phobia this was not addressed at all in treatment. Yvonne had not been asked what would constitute her being back to her usual self i.e what would be a clinically relevant difference post treatment, instead IAPT goes blindly on with its own idiosyncratic metric and claims success on the basis of the changes in scores below:

  PHQ9 GAD7
Pre 19 18
Post 6 7

For speed IAPT weds itself to problem specification, but it doesn’t take clients to their destination of a clinically relevant outcome.

Dr Mike Scott

Buszewicz et al 2017 https://www.dropbox.com/s/1wxuws089tj74er/IAPT%20none%20recognition%20of%20GAD%20lead%20to%20collapse%20of%20trial%202017.pdf?dl=0

Only The Client Knows Whether Psychological Treatment Has Made a Clinically Relevant Difference

trouble is nobody asks them! When was the last time you remember a client being asked ‘are you back to your usual self with the treatment you have had’? Organisations, such as IAPT have their own metric, a decrease on a psychometric test and in secondary care psychiatrists will opine ‘seems a bit brighter to day, increase…’. These ‘metrics’ ensure the survival of the Organisation, but have no demonstrated relationship to loss of diagnostic status as assessed by a clinician independent of the service provider.

In a study by Stegenga et al (2012) see link below depressed patients were followed up over 3 years whether there depression took a chronic (17%), fluctuating (40%) or remitting course (43%) course they all showed decreases in PHQ9 scores throughout the study and without any psychological intervention. The only exception was a worsening of PHQ9 score at 6 months for the chronic subgroup. Similarly a 12 year study of anxious patients Bruce et al (2005) showed they were only suffering from their anxiety disorder 80% of the time. Thus finding a decreased psychometric test score per se does not mean anything.

Bruce et al (2005) linkhttps://www.dropbox.com/s/9powmto8miw60a2/Natural%20recovery%20in%20Social%20Phobia%20Panic%20Disporder%20and%20Generalised%20Anxiety%20Disorder.pdf?dl=0

Stegenga et al (2012) linkhttps://www.dropbox.com/s/k0x2fm0ds01no0k/natural%20course%20of%20depression%20stegenga%202012.pdf?dl=0

Organisations and Clinical Commissioning Groups much prefer to talk about operational matters, numbers and waiting lists and show no interest or expertise in reliably assessing clinically relevant outcomes. But it is not just these bodies, the leading journals have for the past decade predominantly published papers on the efficacy of psychological interventions with no insistence that there should have been blind independent assessment. Instead self-report measures have ruled with little awareness that their completion is subject to demand effects and the measures often bear no obvious relationship to the construct under examination.

It is difficult to escape the conclusion that clients are largely fodder for the Organisations. A problem that will not be resolved by increased funding for mental health services albeit that this is clearly needed or by atypical clients as tokens on mental health bodies. The fundamental problem is a lack of respect/reverence for clients.

Dr Mike Scott

Populist Mental Health Myths

poor psychological therapy services are as much about populist mental health myths, as underfunding. Drill down beyond IAPT and NICE and you enter a sub atomic world very different to that of the orchestrators.

In the microscopic world people are concerned with:

‘will I get back to my old self with this therapy?’

‘what proportion of people like me, get over this with therapy?’

‘are the effects of therapy temporary or permanent?’

‘are you interested in and committed to me, or am I just a number?’

Moving up to the macroscopic world, real world outcomes are replaced by surrogates ‘a change on a questionnaire’ but without any certainty the questionnaire is measuring anything pertinent to what the person is suffering from! There is no independent assessment of outcome of routine practice.

Myth One: IAPT and NICE are at one

IAPT insists that it is NICE compliant, i.e its treatment protocols match the identified condition. But IAPT clinicians do not diagnose, instead they make a judgement using ICD 10 diagnostic codes, this weak surrogate ignores that NICE Guidance assumes a reliable diagnosis and advocates the DSM criteria not ICD10!

Myth Two: IAPT is credible because of its’ advocacy of NICE Guidelines

The NICE guidelines have called for a decade, for an evaluation of low intensity CBT vs counselling vs treatment as usual, which would include observer rating. Such is its’ ongoing uncertainty as to the value of low intensity CBT.

Myth Three: The value of low intensity CBT has been demonstrated

Not if one insists on methodologically strong studies involving independent outcome assessors.

Myth Four: CBT is the answer

NICE points out that even where there is the strongest evidence in favour of the use of CBT in depression the effects are ‘modest’. It also notes that there are comparitively few studies of Behavioural Activation (BA) and NICE makes a clarion call for more head to head research between BA and CBT. But stresses the need for inclusion of observer rated assessment in such a study, they also may have added that there is a need also for an attention control group. There is a need for more humility in IAPT about the contribution of CBT.

Myth Five: Approval by NICE equals evidence of efficacy

Not so, NICE guidelines are the fruits of a committee’s deliberations, about primarily, the results of randomised controlled trials, but there is no assessment of those rcts using the Cochrane risk of bias, which includes requirements such as observer rated outccomes.

Myth Six: IAPT never departs from NICE

With regards to ‘Medically Unexplained Symptoms (MUS) not otherwise specificied’ the recommended specialised form of CBT is entirely a product the IAPT Education and Training Group (ETG). The ETG is also a reference source for the specialised form of CBT for irritable bowel syndrome and chronic pain, albeit that 2 NICE guidelines are also referred to.

Myth Seven: IAPT is becoming more robust in evaluation

Not according to its’ recent forays into disorders like chronic fatigue syndrome were reliance is placed on a psychometric test the Chalder Fatigue scale of doubtful relevance to the CFS construct and without any independent observer rating.

Myth Eight: Real world change can happen without hospitality and commitment

Hospitality is notably absent in client’s first contact with IAPT , therapists are focussed on not becoming the subject of sanction. In the real world initial formulation of client’s problem/s is often in need of significant modification, the time constraints on therapists rarely cater for the necessary adaptations and the importance of persistence on the part of the therapist.

Myth Nine: It is ok to discharge a client as soon as their score hits recovery

For 40% of people experiencing depression, their disorder takes a variable course, whilst for the anxiety disorders, sufferers are only affected 80% of the time. Thus discharging at the first signs of a low score is simply capitalising on chance, there can be no certainty that lasting meaningful change has occurred. The stage is set for a revolving door.

This list of myths is by no means exhaustive, please feel free to add your own. However the microscopic and macroscopic worlds are different universes it seems.

Dr Mike Scott

and the added value of low intensity IAPT is?

compared to how people would have got on anyway if not referred to IAPT (in economist terms the appropriate counterfactual), the ‘added value’ has not been demonstrated. Yet most people receive a low intensity intervention such as computerised CBT, guided self help or groupwork.

I could find no independent outcome assessors involved in the randomised controlled trials of low intensity interventions that the NICE guidance largely relies on. Instead reliance has been placed on IAPT’s marking and marketing of its’ own homework.

In a review of randomised controlled trials published in 4 medical journals Kahan, Rehal and Cro (2015) only a quarter (26%) involved blinded outcome assessment. These authors write ‘Previous reviews have found that unblinded outcome assessment can lead to estimates of treatment
effect that are exaggerated between 27% and 68%’ see link below:

https://www.dropbox.com/s/aarqu8j95udwmpl/Blinding%20independent%20assessment%20rare%20%202015.pdf?dl=0

But the position appears worse when it comes to psychological therapies with no reliable rcts for low intensity interventions, and with regards to high intensity interventions the few blind outcome assesments are clustered around depression, the anxiety disorders and PTSD. Since the millenium there has been a drift away from the use of outcome assessors, this makes research cheaper, it is much easier to massage statistics to give a positive hue, the originators of an intervention and those with a vested interest are given a free hand.

Researchers on IAPT [seee Bower et al (2013)] play fast and loose with Cochrane risk of bias tool, see link below:

https://www.dropbox.com/s/bmr98o8z8fcfuzv/paths%20to%20mh%20Cochrane%20Risk%20of%20bias%20assessment%20tool.pdf?dl=0

and jettison the need for independent blind assessment implicit in the tool on the spurious grounds that ‘most outcomes are self-reported’ see link below:

https://www.dropbox.com/s/24qz5pdu6dfl0ce/Low%20intensity%20initial%20severity%20doesnt%20make%20a%20difference%202013.pdf?dl=0

Looked at from the perspective of independent outcome assessment the claims for low intensity interventions look spurious and the evidence base for high intensity interventions is more circumscribed than BABCP conferences or IAPT would suggest.

The IAPT Manual published last year recommends extension of the service to irritable bowel syndrome, chronic fatigue syndrome, chronic pain and medically unexplained symptoms not otherwise specified but makes no mention at all of the need for independent blind assessment of outcome, instead it suggests simply what self-report measures should be administered. See link below:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

Yet another marketing opportunity, when we need real world answers, how many people said to an impartial observer that they were back to their usual selves after the intervention? how long did this last?

Dr Mike Scott

Sham Psychological Therapy Rules

Bernard felt ‘ten times worse’ after his first session of IAPT, Group CBT. He didn’t return for further sessions. IAPT advised him to seek individual therapy via his GP, which he did but none was ever forthcoming. When I saw him it was three years after his industrial accident that rendered him unable to work, his depression had continued unabated. The GP records simply recorded that he did not attend 3 sessions and so was discharged, the implication was that he was at fault!

What had actually happened is that following an IAPT telephone assessment he was invited to therapy at a local centre. On arrival he and others were given a questionnaire to complete. He and about 15 others were then ushered into a room, but there were not enough chairs so some stood. The group leader began asking each of them in turn what their problem was. Bernard protested ‘ I can’t tell my problems in front of all these’, he said that he could see that the young men in the group were agitated and one ‘girl’ on the verge of tears. ‘it was more like a lecture with flipchart and screen’.

The IAPT treatment bears no relationship at all to the group CBT detailed, in my book ‘Simply Effective Group CBT’ published a decade ago by London: Routledge or to what I am trying to promote as Co-chair of the BABCP Group CBT Special Interest Group. A year ago the IAPT Manual was published but none of it confers any protection for a client suffering the same fate. The worry is that in the interest of a numbers game more people will suffer Bernard’s fate.How long is the cover up going to go on!

Dr Mike Scott

IAPT Hoodwinks NHS England

by alleging compliance with NICE recommended evidence-based psychological treatments. But, NICE bases its’ recommendations, largely, on randomised controlled trials conducted on specific disorders, with different protocols for different disorders. It is impossible to implement NICE guidance without reliable diagnosis, but IAPT have never claimed that its’ clinicians make a diagnosis!

Even the notion of a utilising a ‘provisional diagnosis’ was jettisoned in last years IAPT Manual, (see link below) in favour of a ‘problem descriptor’:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

On the basis of a client’s ‘problem descriptor’ the IAPT Manual requires its’ therapists to specify an ICD-10 [International Classification of Diseases 10th edition, World Health Organisation] code for a disorder, which would allegedly indicate the appropriate protocol. However there are 99 codes for Mental and Behavioural Disorders in ICD-10, there is no bridge between a ‘problem descriptor’ and a disorder. If such a leap were possible ICD-10 ( the World Health Organisation) would not have bothered to specify diagnostic criteria for the 99 conditions! Within IAPT clinicians come up with a ‘problem descriptor’ in just 2/3rds of cases, [ Clark et al (2018)] see link below:

https://www.dropbox.com/s/s7var6llzwt1otd/IAPT%20and%20Transparency%20Clark%202018.pdf?dl=0

and usually following a 20-30 minute telephone conversation, it is therefore a matter of ‘plucking a code’ from thin air for administrative purposes,


if the clinician can remember this particular ticking the box exercise.

The Clark et al (2018) 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. Where is the ‘transparency’ in this? In fairness in this paper they do state that a limitation of their paper is that their data is dependent entirely on client self report, but a conflict of interest stops them going on to say, that there needs to be an independent audit of IAPT, in which the diagnostic status of clients is assessed before and after treatment and at follow up.

My own independent analysis of 90 IAPT clients suggests that, contrary to IAPTs claims of a 50% recovery, just the tip of the iceberg loose their diagnostic status diagnostic status, see link below: https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

NHS England needs to clearly establish whether or not the public is ill served by IAPT and not to rely on the claims of those with a vested interest in providing the Service.

Dr Mike Scott

IAPT – Discrimination and Incredulous Claims

Dr Michael Kelleher, a Consultant Addictions Psychiatrist, interviewed in next months Psychologist has claimed ‘some IAPT services exclude patients that use or have used alcohol until they are many months post abstinent. This is contrary to positive practice guidelines that the National Treatment Agency brought out’ . He continues ‘if people get detoxed they shouldn’t have to wait an arbitrary length of time to be sober before they can have psychological therapy. They should be able to flow into an anxiety or depression programme straight away once a detox is completed’.

IAPT data on 16,723 clients in the North East of England, Boyd, Baker and Reilly (2019), see link below, suggests that the Organisation is superb at spurning those with an alcohol problem,

https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0

over a 4 year period the proportion of clients treated with ‘a mental and behavioural disorder due to alcohol use’ never rose above 0.1%, ( 1, 1, 4 and 3 people in successive years). By contrast the proportion with ‘mixed anxiety and depressive disorder’ was 26.8%, 30.5%, 30.1% and 39.6% over the four years.

Dubious Recovery Rate

The North East IAPT service claims a recovery rate of 40-49%, depending on which years are considered. With between a quarter and half of clients categorised as ‘mixed anxiety and depressive disorder’. However the IAPT Manual cautions against the use of the ‘mixed anxiety and depressive disorder’ label thus:

‘The ‘mixed anxiety and depression’ problem descriptor (ICD-10 code) should not be used unless the person’s symptoms of depression or anxiety are both too mild to be considered a full episode of depression or an anxiety disorder. Inappropriate use of the ‘mixed anxiety and depression’ problem descriptor may mean that patients do not receive the correct NICE- recommended treatment. For example, if someone has PTSD and is also depressed they should be considered for trauma-focused CBT as well as management of their depression, but this may not happen if they have been identified as having ‘mixed anxiety and depression’.

Given the common usage of an unreliable ‘mixed anxiety and depression’ label, is it at all credible that the recovery rate should approach IAPT’s claimed national average of 50%? It looks like massaging of data for public consumption.

Choose The Right Clients For Performance

The IAPT Manual published a year ago, see link below:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

clearly and rightly, states that it would be inappropriate for IAPT staff to provide therapy for clients who arrive at a session intoxicated. But delaying treatment once detoxified, smacks of special selection so the agencies performance figures look good – akin to a school selecting the brightest pupils in the area.

Studies generally show that the prevalence of depression and adjustment disorder are about the same, and psychiatrists diagnose them as often as each other, but curiously over half of IAPT clients in the Boyd et al (2019) study are declared to have depression but the prevalence of adjustment disorder doesn’t rise above 0.6% in any year! Either IAPTs population is incredibly skewed or there is no reliability at all in their diagnostic labels, such that therapists don’t have a clue what they are treating!

Non-Declaration of Conflict of Interest In IAPT Studies

IAPT staff have a penchant for not declaring conflicts of interest in published papers, in the Boyd, Baker and Reilly (2019) paper it is written ‘The authors have declared that no competing interests exist’ , but the lead author presenting at a Conference in Amsterdam in May 2016 is described thus:

Lisa Boyd, IAPT service, Tees Esk and Wear Valley Mental Health Trust, UK Impact of a Progressive Stepped Care Approach in an Improving Access to Psychological Therapies Service: An Observational Study

Dr Mike Scott

IAPT’s New Direction – ‘maybe, shove them all through low intensity’

that’s the take home message from a just published IAPT study conducted in the North East of England by Boyd, Reilly and Baker (2019), see link below:

https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0

This would mean that those with PTSD and social anxiety disorder would first fall into the orbit of low intensity interventions. Never mind that there is no empirical evidence from randomised controlled trials that these disorders respond to low intensity interventions.

Boyd, Baker and Reilly (2019) reiterate the populist myth that there is ‘sound evidence of the efficacy of low intensity interventions’ . This only becomes true if one lowers the methodological bar as low as in their own study, which was reliant entirely on self-report measures administered outside the context of a reliable diagnostic interview. These authors cite a study by Bowers et al (2013) in support of the effectiveness of low intensity interventions but these authors acknowledge that a key limitation of their study was generalisability, because patients were not reliably assessed for depression, see link below:

https://www.dropbox.com/s/24qz5pdu6dfl0ce/Low%20intensity%20initial%20severity%20doesnt%20make%20a%20difference%202013.pdf?dl=0

If the North East of England study is taken on board by IAPT, there is less need to worry about clients being on waiting lists for high intensity treatments, because they are allegedly already getting something worthwhile! Who needs high intensity therapists?

IAPT’s research and treatment is conducted on another planet from the lived experience of clients. Take the case of Tara, she suffered from depression after a fall and from a phobia about tripping, that I established with a diagnostic interview. She then had 6 IAPT face to face low intensity sessions which were described as guided self help, 2 of these involved behavioural activation. Her PHQ9 scores stayed at 19/20, which was not significantly different to when I 1st saw her with a PHQ9 score of 21. Treatment made no difference at all, though she valued the opportunity to talk she was very upset after the sessions. Tara was then put on a 3-4 month waiting list for high intensity CBT. The documentation revealed that there had been no evidence of fidelity to an evidence based treatment programme for depression and no attempt to address her phobia. Initially she had a telephone assessment with IAPT.

There is a wholesale abscence of appropriate treatment in IAPT and in practice its’ stepped care model violates continuity of care. It should try listening to clients and subjecting itself to independent audit, instead of playing with large sets of meaningless numbers, to justify funding.

Dr Mike Scott

Routine Psychological Treatment Is Like A Car Being Revved Stuck in Mud

Marija has had OCD for 30 years since adolescence, her treatment included exposure and response prevention at the Institute of Psychiatry, many years ago. Her most recent therapist has suggested she try this again. But closer examination of her notes reveal that she simply felt better for some months after exposure and response prevention. When I asked her did she return to her usual self after exposure and response prevention she said ‘no’, but was 80% better for a while. Whilst exposure and response prevention is a NICE recommended treatment, at most only 50% recover. The NICE guidance can as applied to routine practice create a tunnel vision. She is a classic example of how clinicians stop at the first identified disorder. Whilst she clearly has severe OCD, there is no mention at all in the voluminous records that she has also been suffering from panic disorder, depression and illness anxiety disorder, all of which have gone untreated. Her son commented ‘I always knew there was more than just OCD’.

Marija was relieved that there was some new potentially beneficial therapeutic targets and that a ‘light touch’ with her OCD rather than ‘battling with my thoughts’ might be useful. She entered a different mode when I suggested a) that she had performed an experiment by not completing her rituals when she was asleep and found she came to no more harm than when awake and b) would not ring the local radio station to tell them that everybody must perform her rituals to stop harm coming to their loved ones c) she had performed rituals for a year as a 8 year old but when she gave them up nothing happened.

Marija has gone through a revolving door of mental health clinicians, which could have been stopped by a careful reassessment and history taking using a standardised diagnostic interview.

Dr Mike Scott