An Impotent Approach to Psychological Therapy (IAPT)

there is no evidence that routine psychological therapy, as delivered in the Improving Access to Psychological Therapies (IAPT) programme either, resurrects a person or  returns them to their best functioning. As such IAPT is impotent.

Most of those entering the IAPT programme undergo low intensity cognitive behaviour therapy (LICBT). This latter involves a reduction of the multifaceted protocols from randomised controlled trials to single elements of those protocols eg avoidance or cognitive restructuring, in the belief that this may resolve client’s difficulties. But over a decade on, there is no evidence that this minimalist approach makes a real-world difference.  It is still unknown ‘what, if any, low intensity intervention works with whom?’. 

The problem with reductionism is that it fails to acknowledge that  the whole is more than the sum of its parts. The multifaceted CBT protocols distilled for randomised control trials likely work because of the synergistic interactions of components, delivered by a particular type of agent (therapist). Simply providing ‘an agent’ or ‘a technique’ is not evidence based.

A recent debate in the Journal Psychological Medicine, has focused around a paper by Read and Moncrief (2022)Moncrieff, J., & Read, J. (2022).[ Messing about with the brain: A response to commentaries on ‘Depression: Why electricity and drugs are not the answer’. Psychological Medicine, 1-2. doi:10.1017/S0033291722001088 https://www.cambridge.org/core/journals/psychological-medicine/article/messing-about-with-the-brain-a-response-to-commentaries-on-depression-why-electricity-and-drugs-are-not-the-answer/C93997DBF4D174D9807D0F65BD994999] highlighting the problem of reductionism when applied to antidepressants and ECT. Both treatments are based on the postulate that there is particular dysfunction in the brain largely responsible for depression, which these intervention rectify. However the search for such an organic deficit has been unsuccessful. These authors point that such interventions are no more effective than enhanced placebo for depression.  

Interestingly Read and Moncrief (2022) pin their hopes on psychological therapies by appealing to the results of randomised controlled trials of CBT for depression. However they are over-stepping the mark. The routinely provided CBT by IAPT has none of the hallmarks of CBT in the trials: the dosage of sessions is sub-therapeutic, no fidelity checks have been conducted to check that individuals actually receive appropriate CBT, there have been no independent assessors of outcome.

In their paper Read and Moncrief (2022) were quite specific about the population they were addressing ‘depressed patients’ but there is no such specificity about the populations treated in routine practice. IAPT clinicians do not make reliable diagnoses, (albeit that they have the temerity to ascribe a diagnostic code). Whilst it is comparatively easy to guarantee that an antidepressant or ECT has been administered, guaranteeing that an appropriate CBT protocol has been imparted, requires independent fidelity checks. No such checks have been applied to IAPT’s ministrations. Read and Moncrief (2022) may well be right, that psychological therapy is the best hope, but the way to hell is paved with good intentions. Currently IAPT is impotent.

Dr Mike Scott

Has Routinely Collected Outcome Data Assisted In Answering, ‘What Works For Whom?’

 

Over 50 years ago Paul (1967) asked the fundamental question for psychotherapy “What treatment, by whom, is most effective for this in- dividual with that specific problem, under which set of circumstances” (Paul, 1967, p .111). The proud boast of the Improving Access to Psychological Therapies (IAPT) service is of a million referrals a year, with test results for 90% of treatment sessions [IAPT Manual 2019]. But despite the quantity of data IAPT has amassed over the last 14 years, it has been of no help to clinicians in answering this key question. It has simply been an added stress.

What is the function of the IAPT data? Is it to simply bamboozle paymasters NHS England/Clinical Commissioning Groups (CCGs)? Perhaps it is to improve the practice of IAPT staff? Even if this latter were the case, there is no evidence that this translates into an improved outcome for clients that they would recognise.

The irrelevance of the IAPT data set, can be gauged by inspecting the table below:

Treatment

Clinician

Characteristics of the client

Specificity of the Problem

Specificity of Psychosocial Functioning

There is no treatment typology within the service. Simply a claim that most clients get CBT in varying doses.

The service distinguishes deliverers of low and high intensity. But clinicians training varies enormously from clinical psychologists with Ph.Ds  to recent graduates who have done voluntary work.

Clients are not distinguished in terms of whether they may or not have a personality disorder or a neuro developmental problem.

The service has no typology of problems. It does not make diagnoses so cannot specify disorders, albeit that it allocates a diagnostic codes.

There is no framework within which to specify level of functioning

With IAPT’s data there are fuzzies in every column of Paul’s framework,  leaving its’ clinicians rudderless.

 

Dr Mike Scott

Paul, G. L. (1967). Outcome research in psychotherapy. Journal

of Consulting Psychology, 31, 109–118.

 

A Gentler Approach to Fergal Keane’s Post-Traumatic Stress Disorder

Last night the BBC broadcast the experiences of its’ intrepid reporter, Fergal Keane, in battling with PTSD and alcohol. He has performed an invaluable service in normalising responses to extreme trauma. In the program he described being sometimes wiped out for days after a session of EMDR. Fergal showed great fortitude in continuing with such treatment. But it raises the question the question of how many others would persist? Particularly if they were not attending an exalted Private Hospital. 

Unfortunately the treatment that he had had  is predicated on the assumption that he needs to confront  all the horrors that he experienced in different lands.  Fergal returns to Rwanda and relives the smells and sights of extreme traumas. He feels guilty that he left Rwanda in the first place. Fergal is annoyed with himself that he left a hotspot in Ukraine at the beginning of the current conflict. In the program he is reunited with an adult from Rwanda who as an older child escaped under a blanket hidden by younger children. He is amazed that  she has not suffered his debility. De facto she has not seen her traumatic memory as relevant to her day-to-day functioning in the UK, but works in mental health. The key point I make in ‘Personalising Trauma Treatment: Reframing and Reimagining’ Routledge 2022 is that traumas only need to be confronted in the sense of addressing their relevance for today. Thus this lady might well write to Priti Patel about the obscenity of routing refugees to Rwanda, whilst not letting the traumatic memory be her central window through which she views the world.

In the programme the EMDR therapist is seen trying to replace Fergal’s thought ‘I am going to die’ whilst under a mortar attack in Lebanon, with the installation of a positive thought ‘I survived’. But this replacement is unnecessary, more parsimoniously it could  have been pointed out that he made a negative prediction and was wrong and may have developed a penchant for making negative predictions that turn out to be wrong. He would be advised to have second thoughts when he makes negative predictions or damns himself.  Fergal appears to believe that he has to be successful in his endeavours encountering horrors rather than just do what he can. He berates himself  for returning to war zones but I think he’s simply trying to ensure that horrors don’t have the last word – a noble task if ever there was one!

The programme featured groups for survivors and whilst they are useful, groups to resolve PTSD appear not to be effective. Interestingly one group member highlighted the problem with a sequential approach to PTSD treatment, an insistence that drink problems is sorted 1st before PTSD. People want treatment for all their conditions now. 

 

Dr Mike Scott

Exaggeratedly Negative Beliefs Perpetuate LTCs and MUS?

This is answered resoundingly in the affirmative and prescriptively in a just published book ‘CBT for Long-Term Conditions and Medically Unexplained Symptoms’ by Philip Kinsella and Helen Moya (Routledge 2022). But the book represents a triumph of ideology over evidence. It carefully avoids any consideration of studies that challenge its modus operandi.  The take home message is

With evangelistic fervour these authors proclaim on P16 For the typical cognitive  behavioural therapists it’s not necessary to be fully understanding of the debates around medically unexplained symptoms it’s more helpful to be aware of what the contributing factors are how to recognise and consider them and how to consider whether they are relevant to current problems’.

The reader is not informed of the details of the debate or the range of opinion.

There is no mention of:

  1. The Editorial in the Journal of Health Psychology in 2021 hDttOpsI://1d0o.i1.o1r7g/71/01.13157971/103539210151302318103482042 The ‘medically unexplained symptoms’ syndrome concept and the cognitive-behavioural treatment model’  that I and others wrote. In this paper we explored the validity of the MUS construct and the proposed treatment model.
  2. A 2020 paper in BMC Psychology by Keith Geraghty and I [Geraghty, K., & Scott, M. J. (2020)] Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified]. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2]  in which we identifiedan unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under- reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment.
  3. The study by [ Serfaty et al (2019)] of treating depressed cancer patients. In this study 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. Serfaty et al add ‘our results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness’.

Kinsella and Moya (2022) operate with a confirmatory bias, searching out studies that support their position and ignoring those that do not.

 

When research findings are presented they are not contextualised, for  the Liu et al (2019) meta analysis published in the Journal of Affective Disorders is cited by Kinsella and Moya (2022) and they report their broad conclusion that CBT is effective for somatoform disorders and medically unexplained symptoms. But fail to state that these authors concluded  that          

‘the overall quality of evidence is relatively low due to a high risk of bias with lack of blinding of the participants, therapists, and outcome assessors’. Further 12 of the 15 studies assessed patients using a ‘gold standard’ standardised diagnostic interview these are not used in IAPT making the generalisation from the studies problematic. None of the studies involved an active comparator in which a credible therapy rationale was given, thus there is no evidence that any effect of the CBT is specific to the CBT. Self-report outcome measure scores were used, these are likely to be subject to demand characteristics when people have invested time and energy undergoing treatment. There was no determination of whether the treatment made a real world difference to patients lives nor of how enduring such change was. 

No mention that the RCTs are of patients who find it acceptable to go for psychological treatment of their MUS, the likelihood is that many find it simply unacceptable to take this pathway. Thus the results of the RCTs may not generalise to all patients with MUS.

 A Gross Violation of Transparency

In our 2020 paper [Geraghty, K., & Scott, M. J. (2020). Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2] we wrotepatients should be fully informed of the rationale behind psychotherapy, before agreeing to take part’

Kinsella and Moya take no heed of this and write in Chapter 14 identifying and helping patients who are fearful of recovery

page 180-1 ‘This phenomena is delicate Which may be conscious or out of awareness If there is a lot of resistance and and hostility and the general sense that the patient will be unable to contemplate a formulation that includes fear of recovery then it would be better to hold back…. If the formulation is not shared it can still be used by the therapist to guide their interventions…. Sometimes however one gets a sense of the reinforces for being nil being so strong or the fear of recovery being so powerful that therapeutic progress can’t be made for example if there’s a very attentive spouse a generous pay benefits payment under strong fear of going back into the old situation that triggered the symptoms then there is little of the therapist can do to overcome this a possible step by step approach to this problem is as follows’

Whatever happened to transparency and openness as a pre-condition for CBT?

 

CBT Treatments Bereft of An Evidence Base 

Somatoform Disorders They fail to mention that the DSM-5 dropped the construct of MUS, absenting if from the definition of somatic symptom disorder. None of the CBT studies of somatoform disorders included in the Cochrane review of 2014 https://doi.org/10.1002%2F14651858.CD011142.pub2 involved independent blind assessors and in the only comparison with an active placebo (Progressive Muscle Relaxation) there was no difference  in outcome. Cochrane concluded that the quality of the evidence in the reviewed studies was weak. Whether or not IAPT therapists do not use a standardised diagnostic interview to determine the presence of a somatoform disorder, so there is no sound foundation for the proposed interventions.

Chronic Pain  In 2021 NICE published guidance on the management of chronic pain https://www.nice.org.uk/guidance/ng193 Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain www.nice.org.uk/guidance/ng193. They made a recommendations to consider CBT for chronic pain rather than make a stronger recommendation to offer CBT because the evidence was not of high quality. Most of the evidence showed that CBT for pain improved quality of life for people with chronic primary pain. A consistent benefit was not demonstrated in other outcomes

ME/CFS In 2021 NICE published guidance on the management of this condition https://www.nice.org.uk/guidance/ng206/resources/myalgic-encephalomyelitis-or-encephalopathychronic-fatigue-syndrome-diagnosis-and-management-pdf-66143718094021 ‘The committee wanted to highlight that cognitive behavioural therapy (CBT) has sometimes been assumed to be a cure for ME/CFS. However, it should only be offered to support people who live with ME/CFS to manage their symptoms, improve their functioning and reduce the distress associated with having a chronic illness’. So that clients should be informed at the outset that the scope of CBT is limited. Further NICE adopts a different theoretical base to that of CBT therapists working in this area, it does not assume people have ‘abnormal’ illness beliefs and behaviours as an underlying cause of their ME/CFS, but recognises that thoughts, feelings, behaviours and physiology interact with each other. No mention of this in the said volume. 

ME/CFS Clients May Have a ‘Fear of Recovery’ claim Kinsella and Moya (2021), I am lost for words

Dr Mike Scott

 

 

 

 

Low Intensity CBT Is Devoid of “Intelligent Scaffolding”

As a consequence there are no protocols for Psychological Well-being Practitioners (PWPs) to follow. The scaffolding is on the back of a lorry but nobody knows what to do with it. Restoration or rebuilding is unchecked by any blueprint. There is no typology of PWP treatments. It is made up as you go along.

Consider ‘CBT for long term conditions and medically unexplained symptoms’, a book by that name has just been published [Kinsella and Moya (2022) Routledge], these authors note that their protocol isn’t deliverable within the 6 hours or less of low intensity CBT, so they suggest have just one target, say depression and with subsequent multiple referrals a comprehensive protocol can be covered! But there is no evidence that this piecemeal approach works, no evidence that such brief Behavioural Activation for depression that they recommend (nor that the entirety of the package) makes a real world difference.   

The above considerations makes IAPT’s claim  that 50% of its customers get what they want,  ‘recovery’, incredulous. The true recovery rate in IAPT is around 10% Scott (2018) https://doi.org/10.1177%2F1359105318755264 and is likely to be even less amongst those with long term conditions. Medically unexplained symptoms (MUS) is such a nebulous entity that it was dropped from the DSM. 

 

The randomised control trials of CBT for depression and the anxiety disorders, conducted before the millennium, had fidelity checks built in to ensure that clinicians were doing what they were supposed to be doing.  For each diagnosed disorder, there were specific treatments targets and matching treatment strategies. With adherence, competence and outcome assessed independently. IAPT’s mantra has been that it is compliant with these NICE approved protocols. However no fidelity check  has ever been been applied to either IAPT’s  high-intensity service or its low intensity service. 

If builders behaved in such a cavalier manner they would soon be out of business, ‘never mind about the restoration of your house, we have built you a nice bungalow’. A year ago I had published a paper ‘Ensuring IAPT Does What It Says On The Tin’ https://doi.org/10.1111/bjc.12264 but it has washed off the IAPT teflonocracy. 

Dr Mike Scott

An Engaging Trauma Treatment

Take a look at ‘Personalising Trauma Treatment: Reframing and Reimagining’ here https://doi.org/10.4324/9781003178132. To access the abstracts of each chapter you have to first register with Taylor and Francis Publishers

The Near Extinction of CBT

Evidence-based psychological therapies are near extinction. Their demise began in 2008 with the inception of the Improving Access to Psychological Therapies (IAPT) service. Aided and abetted by the British Psychological Society’s validation of IAPT’s Psychological Well-being Practitioner’s (PWPs) training programmes and the service’s fellow traveller, the British Association for Behavioural and Cognitive Psychotherapy (BABCP). Gone is the welcoming open door and the careful distillation of what ails the client, instead there is a 30 minute+ telephone conversation, with a third of people then not going beyond one treatment appointment.

 

The public most commonly receive PWP ministrations when they seek NHS psychological help. But the PWP’s do not follow any treatment protocol for any disorder, indeed they do not make diagnoses. How then can they be said to deliver CBT? By the spurious claim  that they can select a CBT strategy which is sufficiently potent. But they furnish no evidence of systematically following any strategy, notwithstanding that there is no evidence that CBT strategies delivered as stand alone interventions make any real world difference. The PWP’s deliver the Alice in Wonderland, Dodo verdict on CBT strategies ‘all are equal and must have prizes’. Raising the question ‘is CBT as dead as the Dodo?’

 

 

Where else might CBT be found? It is not impossible for it to be delivered in IAPT’s high intensity service, but few of its practitioners conduct a reliable standardised diagnostic interview which is the foundation for delivering CBT.  The  treatment integrity of high intensity CBT interventions has never been assessed.  No steps have ever been taken to ensure clinicians are dovetailing diagnosis appropriate treatment targets with matching treatment strategies. Is CBT to be found in private practice? It is possible, but private organisations have largely sought to ape IAPT in the mistaken belief that this confers credibility. Are the chances of finding CBT in private practice comparable to finding life on Mars?

Is CBT alive and kicking in secondary care? Here we enter the muddy waters of clients who might traditionally be regarded as having personality disorders (PD). But there is an understandable reluctance to use the term PD because of the associated stigma and because historically use of such a term has consigned people to the dustbin. Nevertheless Sperry and Sperry (2016) have produced the 3rd Edition of CBT for DSM-5 Personality Disorders (Routledge) but it is eminence-based rather than evidence-based. It is light on outcome studies. I struggled to find any where there was independent assessment of outcome by blind raters, use of an outcome measure that clients would regard as a minimally important difference and evaluations by those other than the creators of the protocols. It is a free for all with strategies such as ‘thought stopping’ recommended, without specification of any contraindications such as PTSD or OCD. Only eclipsed by recommending solution focussed therapy for anxiety. If clinicians in secondary care operate on this text it is very different to Beck’s own work on CBT for personality disorders. But no typology of what clinicians say they do and what they actually do in secondary care has been produced. Tertiary care seems preoccupied with crisis management and is not guided by any recognisable CBT protocol.

In neither primary or secondary care is there a differentiation of treatments or clients. Thus in the UK it is impossible to answer the question of ‘What Works With Whom?’. This leaves clinicians up a creek without a paddle.

Dinosaurs may have been wiped out by an asteroid hitting the earth 66 million years ago, but life survived, doubtless CBT will survive the impact of IAPT, but it is a close call and it is likely going to be down to individual practitioners doing what they know to be best for their clients.

 

Dr Mike Scott

Psychologising Long-Covid and Anything Else

 

Under a heading ‘Long-Covid: interventions not proven’ the May issue of The Psychologist publishes  a letter (see below) I wrote with Joan Crawford. The same issue contains an interview with Jo Daniels, the newly appointed Chair of the Scientific Committee of the British Association for Behavioural and Cognitive Psychotherapy (BABCP) outlining her mission to apply CBT to all long-term conditions (LTC). This despite a paucity of evidence that CBT protocols matched  to a specific LTC make any unique contribution. She proclaims “It is now commonly accepted that CBT ‘works’ to a greater or lesser extent for most physical  health conditions”,  this is grist to the mill for the expansionism of the Improving Access to Psychological Therapies (IAPT) service. But contrary voices do not get a hearing in BABCP, echoes of Russia.

                

‘The underlying message of Dr Siddaway’s article ”We need to talk about Long-Covid” in the March 2022 issue of the Psychologist is that there is or will be an added value from psychological intervention for those affected by Long-Covid i.e Covid of more than 3 months duration.  But the Scottish verdict ‘not-proven’ seems appropriate.

There can be no doubt that offering emotional support to people like Grace, cited in the article, is an important resource for anyone suffering from a long-term medical condition. But there is a distinction between the provision of emotional support (travelling alongside) and delivering a psychological intervention (fixing). The latter is inevitably more costly, requiring more highly trained staff and therefore less likely to be available. Is it a proper use of scarce psychological resources to offer psychological treatments to those with Long-Covid?

Clearly if a person with Long-Covid suffers from an additional disorder such as PTSD or depression a case can be readily made for addressing the comorbid disorder. But the effectiveness of this treatment, in such circumstances, remains to be demonstrated. There are no randomised controlled trials of the psychological treatments of Long Covid plus or minus comorbid disorders. Thus, the evidence for the efficacy of treatment must be currently regarded as weak.

Siddaway suggests that it is possible to extrapolate from studies of chronic fatigue syndrome and pain and apply the strategies to Long-Covid. But there are significant problems with this: a) it assumes Long-Covid is in the same domain as CFS and pain, but arguably, there is little evidence that this is a homogenous category b) the evidence base for the efficacy of psychological treatment for CFS Is problematic if objective indices of outcome are insisted upon c) the evidence base for psychological treatments for CFS and pain, such as it is, is for protocols and not for the components of the interventions, such as pacing or distraction. Using strategies out of context is problematic.

Siddaway appeals to a biopsychosocial model to justify psychological intervention for Long- Covid, despite any evidence that mood and coping strategies make a significant difference to the physical symptoms of Long-Covid. The proposed model ” the complexity of Long-Covid” is not capable of falsification, any factor e.g a hostile working environment, could be proposed to be pivotal in the development of Long Covid, but not ruled out.  As such it is not a model.

It serves the interests of the powerholders of psychological therapies to transmute the physical disorders into candidates for psychological intervention. An extending of Empires. This is not to say that psychological intervention may not sometimes be helpful in the context of a long-term medical condition but unless the population is clearly specified clients will be failed by inappropriate treatments and services exhausted.

 

Mike Scott

 

Joan Crawford’

What Treatment by Psychological Wellbeing Practitioners (PWPs) Works for Whom?

 

This is a restatement of the question asked by Roth and Fonagy in their seminal work ‘What Works for Whom’ (2005) Guilford Press. This text formed the backbone for the National Institute for Health and Clinical Care Excellence (NICE) recommendations on psychological therapy. The Improving Access to Psychological Therapy (IAPT) service has made a formal commitment to observe the NICE guidelines. PWPs are the most common providers of psychological interventions in IAPT. They have been operational for over a decade, at a cost of £billions, answering this question with regards to this professional group is therefore long overdue.

PWPs Modus Operandi

The BABCP ‘PWP Registration and Renewal Policy’ under a heading ‘Core Principles’ states

‘PWPs are specially trained to work with people who have common mental health problems such as anxiety disorders and depression, to support them in managing their recovery…….are revolutionising our approach to the delivery of psychological therapies in a number of specialist areas…..Have graduated from a British Psychological Society (BPS) Accredited PWP training course/apprenticeship’.

PWPs deliver low intensity CBT, defined by Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803  as offering 6 hours or less client contact. The input can be any self-help material. This is a ‘revolution’ in that it is substantially less dose of therapy to that in the high intensity CBT prescribed in the randomised controlled trials of CBT for depression and the anxiety disorders, with 10-20 sessions being the norm.

IAPT’s Magical Beliefs Include:

‘ Six hours or less clien’t contact makes a real world difference to client’s lives’ and ‘inputting any self-help material will do the job’. But what is the evidence for these beliefs? At the advent of IAPT Lars-Goran Ost (2008) published a set of key questions (see the end of this blog) that researchers had to satisfactorily answer for a treatment to be considered an Empirically Supported Treatment (EST). No judge would declare that these injunctions/criteria have been comprehensively answered in any of the low intensity CBT studies. It follows that low intensity CBT is not an EST.

The Government and IAPT

The Government’s wish to push ahead with low intensity CBT parallels Priti Patel’s insistence that refugees are sent to Rwanda, over the heads of Civil Servants who claim that it should be first demonstrated that this makes economic sense. Once the powerholders decide on a course of action, they are unrestrained by any moral imperatives to show compassion and hospitality. It is immoral to offer a dose of treatment for which there is no evidence that it works and to treat refugees so despicably.

 

Dr Mike Scott

 

L.-G. O ̈st / Behaviour Research and Therapy 46 (2008) 296–321

 

  1. Do not use WLC as the control condition, since criterion I requires a placebo or another treatment.
  2. Do not use TAU as the control condition, since the methodological problems described above are so extensive.
  3. Use an active treatment as comparison, preferably one that has been established as effective for the disorder in question.
  4. Do a proper power analysis before the start of the study and adjust the cell size for the attrition that may occur.
  5. Use a representative sample of patients, diagnose them using suitable instruments in the hands of trained interviewers, and test the diagnostic reliability.
  6. Let an independent researcher or agency use an unobjectionable randomization procedure, and conceal the outcome of it from all persons involved in the study.
  7. Use reliable and valid outcome measures; both the ones that are specific to the disorder and general ones.
  8. Use blind assessors and evaluate their blindness regarding treatment condition of the patients they assess.
  9. Train the assessors properly and measure inter-rater reliability on the data collected throughout the study (not just during training).
  10. Use three or more properly trained therapists and randomize patients to therapist to enable an analysis of possible therapist effect on the outcome.
  11. Include at least a 1-year follow-up in the study and assess any nonprotocol treatments that the patients may have obtained during the follow-up period.
  12. Audio- or videotape all therapy sessions. Randomly select 20% of these and let independent experts rate adherence to treatment manual and therapist competence.
  13. Insert procedures to control for concomitant treatments that patients in the study may obtain simultaneously as the protocol treatment.
  14. Describe the attrition, do a drop-out analysis and include all randomized subjects in an intent-to-treat analysis.
  15. Assess clinical significance of the improvement of the primary measures.

 

Low Intensity CBT Works ‘Just like That’

as the magician Tommy Cooper would have said. The Improving Access to Psychological Therapies Service (IAPT) invites its’ paymasters Clinical Commissioning Groups (CCGs)/NHS England to fund a simple and cheap solution to mental health problems. If it sounds too good to be true, it probably is. But this hasn’t stopped IAPT becoming the over a £1bn a year magnet for investment and all without independent assessment.

Here is an extract from a Psychological Wellbeing Practitioner’s (PWP) letter to a GP:

Stress Control Course undertaken outcome was successful evidenced by the first and last questionnaire

 

PHQ9

GAD7

Nov 2018

6

12

Jan 2019

1

5

The PWP is unaware that a score on a psychometric test is not an evidence-based construct. Such scores are not specific to anything. They cannot be used as a surrogate for a diagnosis.  ‘Stress’ is a fuzzy, the terms usage in this context, resembles Alice in Wonderland where words mean whatever you want them to mean.  Further, a change in the score is not evidence that the person’s needs have been met.

The mechanism’s of action in the original randomised controlled trials of CBT for depression and the anxiety disorders were clearly stipulated. As were outcomes e.g loss of diagnostic status as assessed by independent clinicians. But in the low intensity interventions there is no specification of an evidence-based mechanism for change. In effect we are invited to believe in the magic, it works just like described in the letter abstract. One can only gasp at the incredulity of CCGs and wonder what agenda they are working on. But the British Association for Behavioural and Cognitive Psychotherapy (BABCP), the ‘Lead’ organisation for CBT practitioners has a special section for PWPs and IAPT rejoices that its’ low intensity CBT courses are validated by the British Psychological Society. They have failed clients abysmally. 

Dr Mike Scott