IAPT and NICE Compliance – panic disorder a case study in infidelity

the infidelity starts with IAPT’s emphasis on psychometric tests to determine treatment. NICE (2020) http://pathways.nice.org.uk/pathways/panic-disorder, observes there are no appropriate screening instruments for panic disorder. The guidelines highlights the importance of a) detailing a timeline for the emergence of various symptoms and b) clinicians being aware of the common comorbidities of depression and substance abuse. But it is doubtful that this can be done within the typically 30 mins IAPT telephone triage assessment by Psychological Wellbeing Practitioners, the least well qualified of all IAPT staff. NICE suggests the monitoring of the frequency and severity of attacks as an outcome measure. But in IAPT notes I have never seen this systematically recorded. 

IAPT is non-compliant with NICE recommended dosages:

  1. Low intensity treatment is likely as the first step in panic disorder treatment. NICE recommends that brief CBT be around 7 hours and integrated with structured self-help materials. But Saunders et al (2021) Journal of Affective Disorders 294 (2021) 85-93 found that the average client in the Improving Access to Psychological Therapies  (IAPT) low intensity therapy has 3 sessions ( a mean of 2.85 sd 2.81). Thus over 84% of those in low intensity CBT receive less than the than the number of NICE recommended treatment  sessions for brief CBT.  But Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803 have defined low intensity treatment as consisting of 6 hours or less therapist contact. Thus IAPT’s low intensity therapy is of such low dosage that it would not qualify for NICE’s brief CBT. 
  2. For high intensity treatment NICE recommends 7-14 hours of treatment, involving weekly sessions of 1-2 hours and completed within 4 months. But IAPT clients in high intensity treatment typically receive 5 sessions Saunders et al (2021) Journal of Affective Disorders 294 (2021) 85-93 ( a  mean 4.79 sd 5.51)]. 

IAPT has never systematically monitored compliance to NICE protocols. There is no evidence that IAPT has obeyed NICE’s guidance that ‘CBT should be delivered only by suitably trained and supervised people who can demonstrate that they adhere closely to empirically grounded treatment protocols’.

IAPT pays lip service to adherence to NICE protocols for funding purposes. But this is unacceptable, the NICE guidance is important, for example it warns that benzodiazepines are an inappropriate treatment for panic disorder. The NICE guidance is a means of challenging not only the inappropriateness of pharmacological treatment but also of psychological therapy. 

 

Dr Mike Scott

Fundamentalism and The Improving Access To Psychological Therapies (IAPT) Service

The IAPT Service is a fundamentalist translation of evidence-based psychological therapy. ‘The power of evidence-based psychological treatment’ is the sub-title of the book ‘Thrive’ by Layard and Clark (2014,) the prime movers in the development of IAPT. Whilst acknowledging the potency of evidence-based psychological treatment, it is disingenuous of IAPT fellow-travellers to muddy the distinction between the latter and the IAPT service. IAPT is like a guest at a ball, masquerading as evidence-based psychological treatment. But the hosts: politicians, NHS England and Clinical Commissioning Groups consider it impolite to make detailed enquiry of the guest, they enjoy the company. Further the National Audit Office cares not that, the ‘ball’ costs £1 bilion this year. 

The important differences between the IAPT service and the psychological therapies delivered in randomised controlled trials are apparent in the extract from Table 1 Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803 summarised below:

A comparison of low intensity CBT and brief traditional CBT

 

 

‘Low Intensity’CBT

Brief Traditional ‘High Intensity’ CBT

Who – is it suitable for?

 

Widely used to address anxiety and depression across the age range and behavioural problems in children (e.g., Bennett et al., 2019; Cuijpers et al., 2010). Evidence supports its use for cases of all severity (Bower et al., 2013; Karyotaki et al., 2018). Typically not advocated where there are significant risk issues.

 

Typically used widely for disorders where longer traditional CBT would be appropriate

What – is delivered?

 

Interventions are based on the principles of generic CBT to enable individuals to learn specific techniques (for example graded exposure, cognitive restructuring, problem solving) with the goal of alleviating emotional distress and improving functioning. Between-session reading and excercises are central.

 

Intervention is an abbreviated version of full CBT, supplemented with provision of between session materials and excercises.

 

How long is the therapy?

Any input is typically 6 hours or less of contact, often delivered in 20-30 minute sessions

Therapy contact time is typically 50% or less than the full CBT intervention, usually delivered in 50-60 minute sessions

 

It is implicitly assumed by the advocates of IAPT that the identified differences in Table 1 do not matter. But they provide no evidence for this. The IAPT powerholders declare how therapy is to be delivered, in the absence of independent evidence of effectiveness. It represents the operation and implementation of a fundamentalist translation of the randomised controlled trials of primarily CBT for depression and the anxiety disorders. In keeping with a fundamentalist zeitgeist there is no open debate within IAPT or BABCP of the evidence for the effectiveness of the ‘alleged CBT’ in routine practice.

IAPT claims that it obtains results comparable to those achieved in rct’s but is this credible when in high intensity therapy ‘Therapy contact time is typically 50% or less than the full CBT intervention’ according to Table1? Is it credible that the organisers of the rct’s made the treatments they examined more than twice the length that was necessary? If this was indeed the case, the luminaries responsible for the trials would have been sanctioned by their funding bodies and their ability to attract further research funds, severely curtailed. The more plausible hypothesis is that IAPT does not in fact deliver evidence-based psychological treatment This despite its’ claim to do so to appease NICE, whose seal of approval is the gateway to funding..IAPT muddies the distinction between the power of evidence-based psychological treatment and the power of its’ service. 

Table 1 specifies that ‘low intensity CBT’ consists of ‘generic CBT’ but there has never been an rct of ‘generic CBT’, the rcts are of diagnosis specific protociols. Low intensity CBT cannot be regarded as an evidence-based treatment. Nevertheless, Shafran et al (2021) claim that low intensity CBT is evidence-based but inspection of the cited references reveal a different picture.

  1. The study by Karyotaki et al (2018) https://doi.org/10.1016/j.cpr.2018.06.007 is an analysis guided internet-based interventions for depression compared to control groups, with respective remission rates of 38.51% and 21.5%. But patients in the predominantly waiting list control groups do not expect to get better, so that any differences may reflect a placebo effect. There were no active control groups with a credible rationale. The studies did not involve blind assessors and there was no determination of diagnostic status at the start or end of treatment. Patients chose to enter the study online and there could be no certainty that they were representative of depressed patients in general. The mean Beck Depression inventory score at entry to the internet studies 19.4, was almost a standard deviation down on mean scores of about 27 in established rcts [Scott and Stradling (1991)]. It is doubtful that the studies reviewed by Karyotaki et al (2018) provide any evidence that this low intensity CBT makes a real-world difference to clients lives.
  2. The study by Bower et al (2013) https://doi.org/10.1136/bmj.f540 focused on whether the initial severity of depression influenced the effectiveness of low intensity interventions. As such it is not germane to the question of whether low intensity CBT is an evidence based treatment, however it cites the Cuijpers et al 2010 study doi:10.1017/S0033291710000772 as demonstrating the effectiveness of the latter. This study is also cited by Shafran et al (2021) in Table 1. In the Cuijpers et al (2010) study guided self help was compared with face to face therapy, but both treatments were determined largely by the results of a diagnostic interview (15 out of 21 studies), so that the intervention matched the diagnosis. No such diagnostic interview is conducted in either low or hight intensity IAPT.  The IAPT service has once again performed its’ own translation of the results of randomised controlled trials. Further in the Cuijpers et al (2010) review  the majority of the studies, 17 out of 21 involved media recruited clients, making the study of doubtful relevance to routine practice. In none of the studies was outcome assessed by a diagnostic interview involving a blind assessor. 

The clinical case for low intensity CBT has not been made, it is simply a short term economic convenience.Evidence that being stepped up to high intensity therapy makes a real-world difference is lacking.

 

Dr  Mike Scott

It’s A Myth That The Improving Access to Psychological Therapies (IAPT) Service Pays for Itself

IAPT has flourished over the last decade by proclaiming that it pays for itself [see Layard and Clark’s book Thrive  (2014)]. It has been music to the ears of politicians, NHS England and Clinical Commissioning Groups  but none, including the National Audit Office, has bothered to question it. Despite the £1bn price tag this year, see footnote 1. Anyone with the temerity to raise doubts, risks being accused of lacking a commitment to mental health, a pre-requisite of being considered progressive, whatever one’s political hue. 

 

When will the funding and professional bodies such as the British Psychological Society (BPS) and British Association for Behavioural and Cognitive Psychotherapy (BABCP) see that the ‘Emperor Has No Clothes’? IAPT claims the service pays for itself by getting people off unemployment benefit (16.8% of IAPT clients) Davis et al (2020) http://dx.doi.org/10.1136  and/or long term sick or disabled benefit (6.9% of IAPT clients).   It is therefore a change in the employment status of minority of IAPT clients that may justify the belief that the service pays for itself. But further elaboration of this population shows that the proportion of clients who could make an economic difference is smaller still. Further when the psychological mechanism by which a change of occupational status may operate is considered, it is improbable that the service pays for itself.  

 IAPT could in principle get 20-25% of clients off benefits. Assuming the target clientele this year is 20%, i.e 0.3 million people, how would the service pay for itself?  Well 40% of IAPT clients do not attend their 1st treatment appointment, so only 0.18 million will be exposed to an IAPT treatment therapist. Of these 42% attend just one treatment appointment, thus 0.1044 million have exposure  to IAPTs treatments and are in the categories of unemployed or long term sick, and potentially might have their employment status changed by the Service i.e 104,440. Those undergoing IAPT treatment ( defined by the Service as attending 2 or more treatment sessions) have an average of 8 treatment sessions in 2018-2019 Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173 but the unemployed and those on long term sickness benefit are less likely to attend a treatment session, Davis et al (2020)http://dx.doi.org/10.1136, as are those who have been referred previously. Thus one might expect this 104,440 to attend a mean of 6 sessions and treatment typically spans 12 weeks according to Saunders et al (2020) https://doi.org/10.1017/S1754470X20000173 . But the population who may return to employment is smaller still because of the following considerations:

  1. There will be a sub-population of the ‘unemployed’ whose unemployment is  related to a work related negative life event, e.g now being physically unable to do the manual work they were employed to do or maltreatment at work. It is difficult to see how 6 sessions of psychological therapy  delivered over 12 weeks would change the diagnostic status of this sub population. There is absence of evidence that such a dosage of psychological therapy can change the employment status of this sub-population. If the sub-population of clients for whom work has been an iatrogenic factor in their debility, are excluded from the analysis, then the population that IAPT’s ministrations could conceivably address is much less than 100,000.
  2.  There will be a further ‘sub-population’ of the unemployed for whom work within their training is simply not available e.g a redundant fisherman. IAPT does not have the resources to conjure up new opportunities, albeit it might direct a client towards re-training.  

Thus the range of action of IAPT with regards to employment status is very limited and even more so when one considers by what mechanism could the typical 6 sessions change employment status over the 12 week span? To return a person to occupational functioning means addressing three key areas a) persistence – the ability to persist with a task b) pace – the ability to complete a task in a timely manner and c) adaptation – the ability to handle the inevitable hassles of the workplace. There is no evidence that IAPT specifically targets these difficulties or has provided training in tackling them. Neither has it been demonstrated that 6 sessions of psychological therapy can resolve such difficulties in 12 weeks and even less evidence as to whether such treatment is enduring.

IAPT lacks the potency to make a real world difference to the unemployed and those on long term sick. Layard and Clark (2014) muddy the distinction between the power of evidence-based psychological therapies and the power of their offspring, IAPT. It can be objected that IAPT pays for itself by increasing the productivity of those already employed, rather than by changing occupational status. But there is no evidence that it does so anymore than the pre-IAPT counselling services.

IAPT’s claim that it changes the employment status of its’ clients is akin to a Dickensian Government’s claim that Workhouses resolve employment issues.

Footnote and reference

 

  1. According to The IAPT Manual 2021 the target for 2021 is 1.5 million clients at a cost of £680 per client [data from Clark (2018) https://doi.org/10.1146/annurev-clinpsy-050817-084833] making the anticipated cost of the service this year, £1.02 billion.
  2. Layard, R and Clark, D.M ( 2014) Thrive: The Power of Evidenced-Based Psychological Therapies Penguin Limited

Dr Mike Scott

 

‘What Is Going On, When The Dose of Psychological Therapy Is Less Than Half That Recommended By The National Institute for Health and Care Excellence (NICE)?’

 

a recent study by Saunders et al (2021) Journal of Affective Disorders 294 (2021) 85-93 found that the average client in the Improving Access to Psychological Therapies  (IAPT) low intensity therapy has 3 sessions ( a mean of 2.85 sd 2.81) whilst the average client in high intensity therapy has 5 sessions ( a  mean 4.79 sd 5.51). But the IAPT Manual (2021) p51 states ‘should be offered up to the NICE-recommended number of sessions for the relevant clinical condition. For high-intensity work this would generally be in the range of 12 to 20 sessions’, Further the low intensity intervention such as the Stress Control Programme typically involve 6 sessions. Clearly IAPT clients are receiving a sub-therapeutic dose of treatment. Yet astonishingly IAPT claims that it is NICE compliant!

But IAPT uses a language that is reminiscent of Alice In Wonderland, treatment is defined as attending at least two treatment sessions. This means that those who miss their first treatment appoint [40% according to Davis, A., Smith, T., Talbot, J., Eldridge, C., & Betts, D. (2020). Predicting patient engagement in IAPT services: a statistical analysis of electronic health records. Evidence-based mental health, 23(1), 8–14. https://doi.org/10.1136/ebmental-2019-300133] or attend only one session [42% according to Davis, A., Smith, T., Talbot, J., Eldridge, C., & Betts, D. (2020). Predicting patient engagement in IAPT services: a statistical analysis of electronic health records. Evidence-based mental health, 23(1), 8–14. https://doi.org/10.1136/ebmental-2019-300133] are not counted as part of those treated, but they in total constitute 64% of those passing through the IAPT starting gate. Thus approximately two thirds of the would be beneficiaries of IAPT’s ministrations refuse to take their medicine! Add this into the equation and the services performance looks woeful.

 

IAPT uses a sleight of hand to claim NICE compliance (a sine qua non of funding by Clinical Commissioning Groups CCGs). It asks its’ therapists to use ‘problem descriptors’ to select an ICD code (the World health Organisations coding system for diagnosed disorders). But an ICD code is only as reliable as the diagnosis and IAPT therapists do not make diagnoses, how then can they provide treatment ‘for the relevant clinical condition’ p51 IAPT Manual (2021)?  GPs clearly make diagnoses and their records often mention problems associated with the diagnosis, but they do not make the diagnosis on the basis of those problems, they are qualitatively different types of information. An IAPT therapist like a social worker may note psychosocial stressors but any mention of disorder would not be taken as evidence of disorder in a Court of law.  Where IAPT therapists to claim they made a diagnosis that would be subject to legal challenge and the Organisation steers its employees away from this.

Many IAPT therapists are delighted with this as they see ‘diagnosis’ as akin to blasphemy. NHS England and CCG’s, refuse to acknowledge the elephant in the room, they have chosen to totally avert their gaze from this problem, preferring to sup with the IAPT hierarchy.

 

Dr Mike Scott

 

Group Interventions A Manager’s Dream But A Clients….?

As the pandemic recedes and concerns about scarcity of individual therapy continues, there are likely to be increased calls for group interventions, whether psychoeducational or psychotherapeutic.  But the vexed question has to be asked, does the particular group intervention envisaged make a real world difference to client’s life? Is the group intervention more to do with appearing to have done something? 

There are 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

But I have a number of concerns about the utilisation of group interventions in the IAPT-ification of psychological therapy services. There is a danger of spin with regards to group CBT. This can happen easily by taking the abstracts of studies at face value, when many of the authors have developed the protocols that they are evaluating – allegiance bias. I doubt whether, despite the best efforts of any training institution, there will be a monitoring of fidelity to evidence-based protocols and a meaningful assessment of outcome. In practice clients may be short-changed by Group CBT and may then be put off further therapy. Whilst the group interventions may be intended as part of a stepped care package, clients are least likely to attend the appointment that marks the start of the new dawn [ Davis et al (2020)https://doi.org/10.1136/ebmental-2019-300133].  The following critique of group studies may be useful:

  1. Group psychoeducation interventions have an appeal that belies evidence of their effectiveness. I can find no study in which there has been independent assessment of effectiveness using a standardised diagnostic interview. Thus it is not known what proportion of sufferers with a particular disorder would lose their diagnostic status as a result of treatment, much less how enduring recovery would be. ‘No longer suffering from a disorder’ is a metric that a member of the public can readily understand, but to be told that you no longer require treatment because you are now below ‘caseness’ on a psychometric test is likely to produce a puzzlement, that the client is too polite or disadvantaged to challenge.
  2. It may be to the advantage of Managers  and Academic institutions to promote psychoeducational groups but to the pay-off for the client is what? The experience of group involvement may not be adverse, they may have even enjoyed the sense of belonging that has come from group attendance, but if at the end of the day it has not made a real world difference to the client’s life, was it worthwhile? The issue of group psychoeducation has to be approached from a bottom-up perspective not top-down.  Ost (2008) Outcome studies Quality Ost 2008  has published a 22 item measure of the reliability of psychotherapy outcome studies, each item is rated 0-2, so that a score of 44 is possible. Applying this measure to the most popularly delivered psychoeducation group Stress Control, I found yielded a score of 9, but the mean score in CBT outcome studies was 28 and Ost suggested that studies with scores of 19 or below could not be considered empirically supported treatments. Failings of the recent SC studies (the original White et al study fared slightly better because it specified a particular diagnosis, GAD) included amongst others the following domains: reliability of the diagnosis, specificity of outcome measure, blind evaluation, assessor training, design, assessment points, controlling for concomitant treatment, and assessment of clinical significance.

3. In a paper titled “Are individual and group treatments equally effective in the treatment of depression in adults? Cuijpers et al answered with a cautious ‘yes’. They drew upon my own study [ Scott and Stradling (1990)https://doi.org/10.1017/S014134730001795X ] comparing individual and group CBT with a waiting list, but did not mention that in order to get the group CBT to be a viable entity, we had to offer up to 3 individual sessions concurrently, though interestingly few took up all three.  Selling the group CBT was a challenge, however both modalities were equally effective and I think Cuijpers et al’s conclusion is appropriate. 

4. In 2018 carpenter et al published https://doi.org/10.1002/da.22728 a study of the efficacy of CBT for anxiety disorders. They considered only studies in which the comparison condition was a psychological placebo e.g supportive counselling i.e one in which there is a credible rationale, this controls for common factors such as the therapeutic alliance. Carpenter et al found only 7 studies comparing individual and group CBT with these provisos, and for only 2 disorders social anxiety disorder and PTSD was their sufficient data to reach conclusions and in both instances individual CBT was superior to group CBT.

But in 2020 Barkowski et al Group CBT for anxety dsorders 2020 published a meta analyses of group psychotherapy and claimed that group psychotherapy  for anxiety disorders  is more effective than active treatment controls.  They cite a Hedges g effect size of 0.29. But these authors fail to point that this effect size is small. A Hedges g of 0.2 would mean that the average person in the largely CBT groups would have done better than 58% of those in the control condition. Whether these differences are clinically significant is a matter of debate. Further only 3 anxiety disorders were considered GAD, panic disorder and social anxiety disorder, the results do not apply to OCD or PTSD (which historically was placed in the anxiety disorders but now no longer is). The authors proclaim that mixed-diagnoses groups are equally effective as diagnostic specific groups. But this is misleading, the most recently published group trans diagnostic study by Roberge et al (2020) Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clini had approx half of clients (52.8%) suffering from generalised anxiety disorder and approx a third (29.4%) suffering from social anxiety disorder, thus over 80% of the clients are suffering primarily from either one or the other of just 2 disorders, more accurately it should be termed limited transdiagnostic therapy.  Further clients were recruited via newspaper advertisements, 86% of the clients were women and 42% had a University Diploma, only half of clients were completers i.e attended 8 or more of the treatment sessions, and only half lost their principal diagnosis.  Making generalising from these studies problematic.

The danger is that group devotees look simply at the abstracts of the group studies, without realising that the authors were the developers of the protocols and their findings need taking with a great deal of caution. My worry is that IAPT in particular will seize on groups as a way forward in a numbers game and clients will be short changed.

Dr Mike Scott

Stopped Care Replaces Stepped Care in IAPT

over 70% (73.3%) of the Improving Access to Psychological Therapies (IAPT) clients are offered low intensity treatment (such as computer assisted CBT, group psychoeducation or guided self-help) first, and only 4% (4.1%) are then stepped up to high intensity treatment. The first transition appointment is the least well attended [ Davis et al (2020) https://doi.org/10.1136/ebmental-2019-300133]. 

IAPT clients haemorrhage from the system at the outset, 40% of first appointments are missed and 42% of clients attend only one treatment session. But IAPT’s claimed recovery rate of 50% applies only to those who complete two or more treatment sessions. The suspicion is that real world recovery rate is much less. Examination of the trajectory of 90 IAPT  clients using a gold standard diagnostic interview [ Scott (2018) IAPT The Need for Radical Reform, Journal of Health Psychology https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0.] suggests only the tip of the iceberg recover.

A small proportion of IAPT clients (16.4%) are offered high intensity first. The IAPT Manual recommends that this should occur for clients suffering from PTSD, social anxiety disorder or severe depression.  But offers no reliable methodology for deciding who is in what category. The agency claims it does not do ‘formal diagnosis’. 

 

How are clients to be directed to appropriate care?

 

Dr Mike Scott

Constant Breaches of Conflict of Interest By IAPT and NHS England

the latest example comes from Saunders et al  (2021) in the Journal of Affective Disorders 294 (2021) 85-93 https://doi.org/10.1016/j.jad.2021.06.084. None of the 9 cited authors acknowledge any conflict of interest. But the database they draw upon is from the Improving Access to Psychological Therapies (IAPT) treatment programme, 2 of the 9 work for iCope an IAPT service, as well as being part of a research network of IAPT and academics, 4 others are also part of the IAPT Service Improvement and Research Network (SIRN). Their paper is titled ‘Older adults respond better to psychological therapy than working age adults: evidence from a large sample of mental health service attendees’.  The authors note that their finding runs counter to other studies that have suggested interventions for depression are equally effective when comparing older to working age adults and even that older adults suffering from anxiety disorders have worse outcomes than working-age patients. They are curiously blind to the possibility that the IAPT database is suspect, that it does not measure what it purports to  do so. There is a clear operation of allegiance bias. Readers and Journal editors have a right to be alerted to the possibility of allegiance bias by a transparent declaration of conflicts of interest. I wrote to the Journal Editor about this but he declined to publish my letter.

 

  1. Earlier this year I wrote a blog on  a study by Barkham et al (2021) https://doi.org/10.1186/s12888-018-1899-0 which involved comparison of person-centred counselling and cognitive behaviour therapy (cbt) in a high intensity therapy service delivered by IAPT. Curiously patients were screened for the study using the Clinician Interview Schedule Revised but neither this nor any standardised diagnostic interview was used as an outcome measure. Further Barkham et al (2021) chose to adopt the Improving Access to Psychological Therapies (IAPT) primary outcome measures the PHQ-9 [Kroenke et al (2001)] and GAD-7 [Spitzer et al (2006)], without any discussion. There is no comment that these are self-report measures, subject to demand characteristics and that changes are impossible to interpret without comparison to an active placebo treatment. Why such apparent blindness? The answer is apparent reading the declaration of conflicts of interest, the authors are either devotees of person-centred counselling or have links with IAPT. Their take home message is that person centred counselling might be better than CBT for depressed patients. But there is no attempt to address the question of what proportion of patients lost their diagnosis status and for how long, as determined by an independent blind clinical assessment using a standardised interview. Service-users interests are ill-served by this type of study which additionally ignored data that suggest the recovery rate in IAPT is just 10% [Scott (2018)]https://doi.org/10.1177/1359105318755264 .
  2. IAPT is the biggest provider of group psychoeducation and it was given a boost by a Dolan et al (2021) study all authors declared no conflict of interest. But the corresponding author for the Dolan et al (2021) study is a programme director of IAPT and another of the authors has IAPT involvement.Dolan, N., Simmonds-Buckley, M., Kellett, S., Siddell, E., & Delgadillo, J. (2021). Effectiveness of stress control large group psychoeducation for anxiety and depression: Systematic review and meta-analysis. The British journal of clinical psychology60(3), 375–399. https://doi.org/10.1111/bjc.12288

 

3. In March 2021 the British Journal of Clinical Psychology published my Commentary ‘Ensuring IAPT Does What It Says On The Tin’ I wrote ‘In the Wakefield et al. (2020) paper all the authors declare ‘no conflict of interest’. But the corresponding author of the study, Stephen Kellett, is an IAPT Programme Director. The study is therefore open to a charge of allegiance bias. It is therefore not surprising that Wakefield et al. (2020) fail to make the distinction between IAPT’s studies and IAPT studies. By definition, the former have a vested interest, akin to drug manufacturer espousing the virtues of its psychotropic drug. Whilst an IAPT study is conducted by a body or individual without a vested interest, in this connection Wakefield et al. (2020) have implicitly misclassified this author’s IAPT study, Scott (2018). In their study, Wakefield et al. (2020) make reference to the Scott (2018) study with a focus on a subsample of 29 clients (from the 90 IAPT clients) for whom psychometric test results were available in the GP records. But in Scott (2018) it was made clear that concluding anything from such a subsample was extremely hazardous. The bigger picture was that 90 IAPT clients were independently assessed using a ‘gold standard’ diagnostic interview, either before or after their personal injury (PI) claim. Independent of their PI status, it was found that only the tip of the iceberg lost their diagnostic status as a result of IAPT treatment. Wakefield et al. (2020) were strangely mute on this point. They similarly failed to acknowledge that the ‘IAPT’s studies’ involved no independent assessment of IAPT client’s functioning and there was no use of a ‘gold standard’ diagnostic interview.’

 

Failure to declare conflicts of interest is not confined to Journals but also operates in NHS England who direct Clinical Commissioning Groups. IAPT staff are employed by NHS England, the latter has no independent body overseeing IAPT and it is therefore unsurprising  that the expansion of the service is given wholesale backing.

Current NHS England team

Sarah Holloway, Head of Mental Health, NHS England
Xanthe Townend, Programme Lead – IAPT & Dementia, NHS England

David M. Clark, Professor and Chair of Experimental Psychology, University of Oxford; National Clinical and Informatics Adviser for IAPT

Adrian Whittington, National Lead for Psychological Professions, NHSE/I and HEE; IAPT National Clinical Advisor: Education

Jullie Tran Graham, Senior IAPT Programme Manager

Hayley Matthews, IAPT Programme Manager, NHS England

Andrew Armitage, IAPT Senior Project Manager, NHS England

Sarah Wood, IAPT Project Manager, NHS England

 

Dr  Mike Scott

References

Barkham, M., Saxon, D., Hardy, G. E., Bradburn, M., Galloway, D., Wickramasekera, N., Keetharuth, A. D., Bower, P., King, M., Elliott, R., Gabriel, L., Kellett, S., Shaw, S., Wilkinson, T., Connell, J., Harrison, P., Ardern, K., Bishop-Edwards, L., Ashley, K., Ohlsen, S., … Brazier, J. E. (2021). Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial. The lancet. Psychiatry, 8(6), 487–499. https://doi.org/10.1016/S2215-0366(21)00083-3

Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology23(9), 1136–1147. https://doi.org/10.1177/1359105318755264

 

Scott M. J. (2021). Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin. The British journal of clinical psychology60(1), 38–41. https://doi.org/10.1111/bjc.12264

 

 

 

IAPT – Many Visitors But Few Customers

 

If you are a visitor to the Improving Access to Psychological Therapies (IAPT) service there is a 1 in 4 (27%) chance of recovery [Walker, C., Speed, E. & Taggart, D. Turning psychology into policy: a case of square pegs and round holes?. Palgrave Commun 4, 108 (2018). https://doi.org/10.1057/s41599-018-0159-8] using the services’ own metric. But IAPT claims a 50% recovery rate. However if you read the fine print, this claim actually relates to those clients who complete two or more treatment sessions – a completer rather than intention to treat analysis.

 

According to the UK Governments Improving Access to Psychological Therapies (IAPT) annual report for 2019-2020 – 489,547 people curtailed involvement after having one treatment appointment, whilst 606,192 had two or more treatment sessions. Thus almost as many people have just one treatment session as two or more. Of 1.69 million referrals to IAPT in 2019-2020, 1.17 million left the starting gate, 30.77% (almost 1 in 3) were non-starters. IAPT’s compiler analysis is misleading.

But applying the metric of the proportion of clients who lose their diagnostic status, only the tip of the iceberg recover, Scott (2018) IAPT The Need for Radical Reform, Journal of Health Psychology https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0. If the consumers of services ruled, the Improving Access to Psychological Therapies (IAPT) service would go out of business.

But IAPT is answerable to no one. NHS England monitors the quality of inpatient mental health services  via the Care Quality Commission (CQC). For example CQC feedback persuaded NHS England to challenge the quality of Child and Adolescent Mental Health Services run by Cygnet. But the CQC has no such remit over IAPT. 

 
Turning psychology into policy: a case of square pegs and round holes?
Carl Walker1, Ewen Speed2 & Danny Taggart2

ABSTRACT

This paper problematizes the ways in which the policy process is conceived in published psychological research. It argues that these conceptions of the policy process fail to ade- quately reflect the real-world dynamism and complexity of the processes and practices of social policy-making and implementation. In this context, psychological evidence needs to be seen as one type of evidence (amongst many others). In turn this requires researchers to take account of broader political processes that favour certain types of knowledge and disparage others. Rather than be regarded as objective and scientific, policy in this characterisation is regarded as a motivated form of politics. This multi-layered, multi-level hybrid structure is not immediately amenable to the well-intentioned interventions of psychologists. While the tendency of many psychologists is to overestimate the impact that we can have upon policy formation and implementation, there are examples where psychological theory and research has fed directly into UK policy developments in recent years. This paper draws on the recent Improving Access to Psychological Therapies (IAPT) initiative and the work of personality researcher Adam Perkins on the UK’s social security system to ask whether psychology has a sufficiently elaborated sense of its own evidence base to legitimately seek to influence key national areas of public policy. The article cautions against dramatic changes to policy pre- dicated upon any one reading of the variegated and, at times, contradictory psychological evidence base. It concludes that, in order to meaningfully contribute to the policy develop- ment process in a way which increases equality and social justice, psychologists need to be more strategic in thinking about how their research is likely to be represented and mis- represented in any particular context. Finally some possible directions for psychologists to take for a more meaningful relationship with policy are suggested.
1 Applied Social Science, University of Brighton, Brighton, UK. 2 School of Health and Social Care, University of Essex, Essex, UK. Correspondence and requests for materials should be addressed to C.W. (email: C.J.Walker@brighton.ac.uk)
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RTepresentations of policy in psychological research
he original ‘scientist of happiness’ Jeremy Bentham is commonly regarded as the individual who, more than any other, brought the phenomenon of ‘evidence based policy making’ into being. The sociologist Will Davies states that, “Whenever a policy is evaluated for its measurable outcomes, or assessed for its efficiency using cost benefit analysis, Bentham’s influence is present.” (2015). It is important to bear this influence in mind therefore, when almost 250 years later, the discipline of psychology (via the ‘measurement’ of human experience), is aiming to stake a claim for a central role at the heart of the UK policy agenda.

At issue here is the way in which much academic research, and psychological research in particular, conceives of, and engages with, policy processes. Typically, this involves a naïve reading of policy context (which happens somewhere else, away from the disciplinary context of the research) which is painted as uni- dimensional and something that can be relatively easily influ- enced, with no need to address questions of complexity, or other disciplinary and professional boundaries. The assumption tends to be that policy should come to their research, rather than thinking (concretely) about how they, themselves, not some ghostly, ill-defined (and supplicant) policy actor, might make their research policy relevant for them. This fundamental lack of connection with existing policy processes, demonstrates as Cair- ney (2016) has argued, that researchers are engaging with the policy process that they wish existed rather than the processes which actually exists. The policy processes which do exist are predicated upon internal and external hierarchies of evidence, and processes and practices of influence, patronage and lobbying which are far removed from two throw away lines in the con- clusion of an academic paper stating that the preceding research has policy relevance and impelling policy makers to sit up and take notice (whomsoever those policymakers might be-they are seldom if ever identified). This is to say nothing of the wider ideologically framed political and discursive formations that influence what it is possible to imagine in a policy arena at any one place or time.

To illustrate this complexity, and the attendant constraints upon psychological research impacting upon the policy process, we take an example where psychological research has been adopted in a highly selective way; the development of psycholo- gical treatments for common mental health issues. Our argument is that, in order to meaningfully contribute to the policy devel- opment process in a way which increases equality and social justice, psychologists need to be more strategic in thinking about how their research is likely to be represented and misrepresented in any particular context. This requires a political awareness and engagement that historically psychologists, in the interests of scientific distance, have been wary of.

In terms of the political context, the ghost of utilitarianism looms large. A rigid hierarchy of evidence, primarily predicated upon questions of economic value (broadly construed), dom- inates the field (Cairney, 2016). Even then, even if the paper has the highest standard of evidence, this does not necessarily guar- antee that this evidence will be picked up by policy makers or politicians. If there is no political case for the policy, there will be little chance of the evidence being implemented in a policy context. The point is that demonstrating economic value is not enough, there is also a clear and present need to demonstrate the political expediency of any proposed policy, (regardless of the evidence). It is in this context that we see policy-based evidence, rather than evidence based policy (see Cairney, 2018), where policymakers may make very selective use of the evidence in a
way that supports their view and denigrates another view. Con- sider the implications of this dynamic process for an academic paper which claims policy relevance, but does not direct this to a when or a where. In this context the academic research could, it is argued, be up for grabs, ready and able to deployed in any number of ways, that may, or may not contradict the intention of the original research.

Earlier we argued that this insistence, on the part of psychol- ogists, reflects a naïve reading of the policy context. Furthermore, this failure to engage with the dynamic complexity of policy practices and processes runs the risk of reifying this mis- characterisation. Such is the vagaries and iniquities of the policy process that there is a need to acknowledge and address these vagaries if research is to have a meaningful and significant impact. There is a compelling evidence that outlines the way that policies are often driven by ideology and biases rather than evidence (Fishbeyn, 2015, Prinja, 2010). Cleary then, there is a danger that psychological research, which argued position X, can and will be taken up by politicians or policy makers and deployed in a way which argues position Y. And, if the characterisation of the policy process envisaged by researchers is the reified mischaracterisation we outline above, the danger of this misrepresentation of the tone and tenor of academic research becomes far more likely to occur, as policy makers and politicians assert their dominance (over the evidence makers, i.e., academic researchers) in the policy arena.

All of this talk relates to issues in and around the policy pro- cess, that is to say, the practice of social policy, how it works. But there is also a need to address issues of context, those social, political, economic and cultural spheres where the practice of social policy is enacted. There is a clear need to conceive of the relation between these different spheres in terms of the influence and impact that psychology might have on policy process and practice, but also, in terms of the influence and impact that policy might have on psychology. Failure to consider this ‘to-and fro’, or ‘ebb and flow’ would run as much of a risk of policymakers reifying psychological research as the obverse process we set out here.

This requires psychologists, as a professional group, to give serious discussion and debate to what they are doing in a broader social, political economic and cultural context. It requires psy- chologists to raise questions about how they should (or should not) contribute to policy. Moreover, questions about the relia- bility of the psychological evidence base, as well as a tendency to celebrate the statistical flukes left standing after researchers have cast around to find publishable positive results (Rhodes, 2015) has left psychologists Farsides and Sparks (2015) to suggest that ‘psychology is liberally sprayed with bullshit’ (p368).

IAPT, the welfare trait and ‘policy-ready’ psychology
While the tendency of many psychologists is to overestimate the impact that we can have upon policy formation and imple- mentation, there are examples where psychological theory and research has fed directly into UK policy developments in recent years, with some influence. By focusing on a high profile example we can then examine not only if psychology has an impact but more importantly what that impact has been.

The Improving Access to Psychological Therapies (IAPT) initiative is arguably the jewel in the crown of applied psychol- ogy’s influence on UK mental health policy, with the rest of the world taking note (NYT, 2017). Based on an elegant economic cost-saving calculation (the ghost of Bentham again), by the UKs‘Happiness Tsar’ and economist Richard Layard, combined with evidence-based psychological therapies (primarily CBT), one could reasonably ask what’s not to like? While we of course can see the value in the opportunity for many thousands of people to
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undertake a course of psychological therapy to alleviate their mental health issues and to bring an important psychosocial dimension into mainstream mental health care, there are unin- tended and unhelpful consequences of the IAPT agenda that need to be considered.

Firstly, as with many policy initiatives, there is the gap between the political rhetoric and the clinical reality. IAPT has, from the beginning, made ambitious claims about its effectiveness, offering treatment to 900,000 patients annually and achieving a 50% recovery rate for depression, anxiety and related ‘common mental health problems.’ (Clark, 2011). It should be borne in mind that this level of treatment was necessitated in order to produce the ‘zero net cost’ of IAPT at the policy development stage through promising savings in physical health care, numbers of welfare claimants and a reduction in mental health related sick days (Clark, 2011).

Whilst IAPT has lived up to some of these promises, with undoubted successes in treatment effectiveness (recovery figures approaching 50% for those who complete treatment, NHS Digital, 2017), there is some cause for concern around evidence that the ‘IAPT effect’ has not been entirely benign. For example, in IAPT monthly data summary for December 2017 NHS data (NHS Digital, 2017), 89,485 new referrals were received with 68,205 referrals entering treatment. Of this number 39,834 completed a course of treatment with 37,238 starting treatment with ‘caseness’ (the referral has enough symptoms to be regarded as clinical) and 49.9% of those approaching recovery by the end of treatment. This data means that only 22.25% of the total referrals were considered to be getting better. That means that in this month over 72% of referrals coming for help either did not receive any treatment at all, did not receive a full course of treatment or did not get better by IAPT’s own metrics.

If we are more conservative and remove those who did not start treatment from our calculation, the situation improves slightly to 27% of referrals achieving recovery and even if we assume that one referral does not equate to one person, that is still a lot of disappointed, disillusioned and worried people. Given that these dropout figures are roughly comparable with other time points in IAPT’s history (McInnes, 2014) this is cause for con- cern. Add to this the study which found that, for a sample who did achieve recovery using low intensity forms of IAPT, 53% relapsed within one year (Ali et al., 2017) and we can see that the more carefully we look at the psychological evidence base for IAPT policy the more questions arise.

Given widespread reductions to specialist mental health ser- vices, it seems likely that IAPT, a brief, often self-directed form of psychological treatment for mild to moderate mental health issues is being expected to plug the gap left by the reduction in longer term community services. As Watts (2016) points out, in IAPT’s own analysis dropout figures are not seen as a criticism of the initiative itself as they are not counted in recovery figures. Fur- thermore, in trying to bring people into services in order to meet policy-based treatment targets we may inadvertently be creating need in people and then not meeting it, a particularly ‘perverse form of care’ likely to have a detrimental impact on the mental health of many left behind by the IAPT revolution.

Additional evidence demonstrates that the number of people not recovering through IAPT approved CBT are dis- proportionately from poorer communities (Delgadillo et al., 2015). In the 2015–2016 IAPT annual report (NHS Digital, 2016), 55% of referrals in the least deprived 10% of areas achieved recovery, while in the most deprived 10% of areas only 35% achieved recovery. This can be likened to an extension of the ‘inverse care law’ whereby not only do people in more disadvantaged com- munities struggle more to get access to healthcare, when they do it is less effective in helping their mental health. To what extent this is a failing of IAPT per se and how much it reflects the causes of
common mental health issues in disadvantaged communities being less psychological and more social (Speed and Taggart, 2012) is beyond the scope of this paper but is also worth con- sidering when assessing psychology’s readiness to take an intrapsychic perspective to the exclusion of other models.

From this we can begin to see that laudable claims of treating common mental health issues for hundreds of thousands of people annually involves unintended consequences of alienating many from trusting services and repeating the pattern of further mar- ginalising those already structurally disadvantaged. Indeed, it is our argument that it is the very ‘policy ready’ nature of IAPT that has precipitated many of these unintended consequences. Its grand, possibly hubristic vision of ‘curing’ common mental health issues and reducing the economic burden of the ‘mentally ill’ undoubtedly plays well in a political era that privileges an instrumentalist, Fordist and market-oriented approach to public services, but the scale of the claims needed to provide a ‘bottom line’ appeal was always likely to demand much and leave many staff and patients behind. This is largely because Benthamite cost-benefit analyses are not a sufficient basis upon which to predicate the policy and practice of mental health care because they ignore the processes and contexts of mental health, out there, in the world.

Another source of ‘policy-ready’ psychological research comes from the personality researcher Adam Perkins in his work ‘The Welfare Trait’ (2015). Perkins makes a case for a fundamental restructuring of the UK’s social security system based on an assertion that overly generous welfare provision for out-of-work parents results in the proliferation of what he describes as an ‘Employment Resistant Personality’ profile that leads to welfare claimants having more children and negatively impacting national productivity. Whilst questions have been raised about whether this work is of merit as psychological science, the issue we want to address here is whether psychology has a sufficiently elaborated sense of its own evidence base to seek to influence a key national area of public policy as social security?

To take the Welfare Trait example, even Perkins notes the perverse logic in cutting welfare payments for families with multiple children, thereby depriving already disadvantaged chil- dren of resources. On this point there is a consensus of agree- ment. However, Perkins draws from a 1975 study (Tonge et al. 1975) of 33 Sheffield families to suggest that this perverse logic can be ignored as welfare claimants all “spend their welfare benefits on unnecessary purchases such as electronic gadgets and luxury chocolates, instead of using the money to improve the lives of their children.” (Perkins, 2015 p.177). This conclusion seems emotive and polemical rather than being based on any robust evidence. This conclusion on the part of Perkins is clearly not the type of psychological evidence that we want to use to determine the life chances of millions of children.

When we add a competing example of psychological evidence, an analysis which found that levels of referral for maltreatment were causally related to the income variation in low income families in the US (Cancian et al. 2010) with reductions in income leading to an increases in maltreatment cases, we can see that dramatic changes to welfare policy predicated upon any one reading of the variegated and at times contradictory psychological evidence base can be downright dangerous.

Concluding thoughts

We would like to end by urging caution on psychologists who aim to have a ‘policy impact’. Instead, we suggest a level of professional engagement in policy processes, whereby psychological evidence is used to forge alliances with common interest groups, for example, to lobby ministers for particular reforms or new initiatives. So rather than merely referencing policy implications in research
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papers, there is a wider social undertaking to make research evi- dence available to communities impacted by the social problems under investigation in order to enable them to petition for change.

In some mental health research contexts this is already hap- pening, where alliances have been formed between psychological researchers and mental health service user groups. In the Understanding Psychosis (2014) project there is a clear move towards the dissemination of research findings regarding aetiol- ogy, symptomatology and treatment for psychoses and associated mental health issues that largely draws upon preexisting psy- chological research alongside first person testimonies and acti- vism from people with that diagnosis. Therefore, in this case the research acts as a form of social activism in which evidence is used explicitly in the interests of those it purports to be about, allowing them a very real, present and active voice in talk about their mental health. However, there is a bind that comes with this ‘bottom up’ approach to influence, and it is one that resonates with the naivety (even futility) of claims regarding the policy relevance of psychological research that we critiqued in this paper. Unless there is a vested interest policy actor working with the psychological researchers, the chance of any research gaining any degree of purchase in the field is at best limited.

The great achievement of the IAPT agenda was the alignment of psychological evidence, the vested interests of the profession of clinical psychology wanting to expand its sphere of influence in an historically medically dominated field with the social democratic, utilitarian ethos of a key policy influencer in Richard Layard. This placed psychology and its practitioners in a position of previously unimaginable influence within mental health service development in the NHS, with the opportunity for future mission creep into other areas. But, to return to Cairney (2018), this was largely because the psychological evidence corresponded to the policy reality (i.e., for IAPT, psychology was able to present policy-based evidence, rather than IAPT being drawn from evidence-based policy). As such, its policy influence had material, resource-based advantages in a way that alignment with the service user movement will not, because, it is much more unlikely that service user based evidence is going to align so comfortably with the evidentiary needs of policy makers, psychiatrists or psychologists (and once we move to consider the psy-professions, we are already one degree removed from influen- cing policy processes). So, in order for psychological evidence to be utilised by community stakeholders, it may have to risk being ‘sidelined’ in other forums. This question is as much ethical as scientific and will confront psychologists trying to influence policy with the challenging question, what are the implications of this evidence not for policy but for the communities many of us are paid to serve? As we have argued in this paper, this question is less straightforward than we might like to think.

Received: 30 April 2018 Accepted: 3 August 2018

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Dr Mike Scott

Jettisoning the CBT Model of Medically Unexplained Symptoms

 

In a just published Editorial in the Journal of Health Psychology MUS and CBT Editorial we have called time on this model. The abstract reads:

The ‘medically unexplained symptoms’ syndrome concept and the cognitive-behavioural treatment model

First Published September 23, 2021 Editorial

The American Psychiatric Association’s, 2013 DSM-5 abandoned the use of the term ‘medically unexplained symptoms’ for non-neurological disorders. In the UK, treatments for various medical illnesses with unexplained aetiology, such as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia, continue to fall under an MUS umbrella with cognitive behavioural therapy promoted as a primary therapeutic approach. In this editorial, we comment on whether the MUS concept is a viable diagnostic term, the credibility of the cognitive-behavioural MUS treatment model, the necessity of practitioner training and the validity of evidence of effectiveness in routine practice.

Dr Mike Scott

Critiquing IAPT and The Psychologist

The October issue of The Psychologist features a letter of mine and the Editor’s response:

‘In the September issue, Ross Harper – CEO of Limbic, providing AI software for mental healthcare – extolled the virtues of their collaboration with four IAPT services. The supposed gains were all in operational matters, e.g. reduced time for assessment, with no evidence that the AI has made a clinically relevant difference to client’s lives. 

This is merely the most recent example of the biased reporting of The Psychologist with regards to IAPT. I raised these concerns in a 2014 submission, ‘IAPT – The Emperor Has No Clothes’, and the Editor rejected it with the line ‘I also think the topic of IAPT, at this time and in this form, is one that might struggle to truly engage and inform our large and diverse audience’. This response was breathtaking given that IAPT was/is the largest employer of psychologists. 

Fast forward to 2018, and I had published a paper ‘IAPT – The Need for Radical Reform’ in the Journal of Health Psychology, presenting data that of 90 IAPT clients I assessed independently using a standardised diagnostic interview only 10 per cent ‘recovered’ (in the sense that they lost their diagnostic status). This contrasts with IAPT’s claimed 50 per cent recovery rate. The paper has received only a passing mention in the pages of The Psychologist [‘Letters’, Flatt and Lido, April 2021]. This year I wrote a rebuttal of an IAPT inspired paper that was published in the British Journal of Clinical Psychology, ‘Ensuring IAPT Does What It says On The Tin’, but again no mention of this debate in The Psychologist.

In my view the BPS is guilty of a total dereliction of duty to mental health service users in failing to facilitate a critique of IAPT. If psychologists cannot pick out the log in their own eye, how can they pick out the splinter in others? 

Dr Mike Scott 
michaeljscott1@virginmedia.com

Editor’s reply: Funnily enough, we’ve also received strong criticism over the years for being too critical of IAPT! While I stand by my ‘at this time and in this form’, those are ever-shifting considerations and I’m pleased to now be in contact with you about a potential contribution to the magazine’.

 Further to the editor’s reply I have submitted an article ‘Spin In CBT’ see below, alas the Editor said ‘no’ . I am off to a home for the bemused and befuddled.

The Spinning of CBT

 

Michael J Scott, Joan S Crawford and Keith Geraghty

 

There has been a massive expansion of psychological therapy services since the inception of the UK Government’s, Improving Access to Psychological Therapies (IAPT) Service in 2008. Offering principally and allegedly, cognitive behaviour therapy (CBT), by 2023/24 the IAPT Service hopes to see 1.9 million people a year [IAPT Manual, August 2021]. This represents a quarter of the community prevalence of depression and anxiety disorders. The intent of IAPT is clearly laudable, but it is much less clear that it meets the needs of clients? Is it worth the money? Given that the typical IAPT therapist earns £35K a year (twice that of a Care Assistant), and with salary costs reaching over £0.5 billion per year by 2023/24, there is a pressing need for independent audit.

By Services Marking Their Own Homework

The first author was alerted that all may be not well at IAPT’s coalface, when as an Expert Witness to the Court he reviewed 90 cases, treated with alleged CBT, and found a recovery rate i.e loss of diagnostic status, in just 10% of cases, using a standardised diagnostic interview Scott (2018). This applied whether or not service users were treated before or after their personal injury. This ‘tip of the iceberg’ response, contrasts sharply with IAPT’s claimed recovery rate of 50%. Curiously there has been no publicly funded independent audit of IAPT which would help to settle matters.

To Mask A Fault Line In the Provision of Routine Psychological Therapy

There is a fault line in IAPT’s approach which we thought might be rectifiable Scott (2018) [IAPT- The need for radical reform, Journal of Health Psychology] and Scott (2021) [Ensuring IAPT does what it says on the tin. British Journal of Clinical Psychology], but which may in fact make its’ ‘building’ of services inherently unsafe. IAPT declares usage of the ICD-10 code (the World Health Organisation’s labelling system for all disorders). The recent IAPT Manual (August 2021) https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf recommends that IAPT clinicians give at least one code to each client, to characterise their debility. But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis. An ICD-10 code is only as reliable as the diagnosis made. The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant.  However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol. A key part of IAPT’s narrative is to gloss over that IAPT’s interventions are based, not on diagnosis, but on ‘problem descriptors’. The silent assumptions are that: a) there would be reliable agreement (reliability) between clinicians about what would constitute a client’s main problem and b) there is a body of evidence that a problem descriptor acts as a key to unlock the door to a specific protocol. Further that the specific protocol has been demonstrated to confer an added value, over and above an active placebo, for the chosen problem descriptor. There is an assumption of clinical utility. But there is no empirical evidence for either a) the reliability or b) the clinical utility. Whilst IAPT interventions contain elements of protocols used in randomised controlled trials there is no evidence of fidelity to such protocols i.e of comprehensive coverage of treatment targets for a disorder and matching treatment strategies.

A Pandemic of Spin

 

Spin has been identified in half the abstracts of papers in psychiatry and psychology journals Jellison et al (2020). In this context spin referred to a claim that an experimental treatment was beneficial, despite a statistically nonsignificant difference for the primary outcome or to distract the reader from statistically nonsignificant results.  IAPT claims its sojourn into the treatment of persistent physical symptoms (PPS), such as chronic-fatigue syndrome, is evidence-based, but it is an exemplar of precisely what Jellison et al (2020) identified. Chalder et al (2021) compared the effectiveness of transdiagnostic cognitive behavioural therapy (TDT-CBT) plus standard medical care (SMC) to SMC alone. The primary outcome measure was the Work and Social Adjustment Scale (WSAS). There was no significant difference in outcome on this measure but in the abstract  Chalder et al (2021) proclaim  their intervention ‘may be helpful with a range of PPS’, with an appeal to some outcomes on secondary measures.

But arguably there are other additional markers of spin a) when the primary outcome is not independently assessed b) when the primary outcome is not clinically relevant and c) when there is no prior specification of what would constitute a minimally important difference in the primary outcome measure. In this connection none of the studies used to justify IAPT’s low intensity interventions have involved an independent assessor using a standardised diagnostic interview. For example, the Stress Control (SC) Programme is the most commonly delivered first line group intervention in IAPT Dolan et al (2021). In the SC studies outcome was assessed purely with self-report measures without any guarantee that the measures related to the disorders that the clients were suffering from. Dolan et al (2021) made no attempt to explain a) what a change of X on these measures would mean as opposed to a change in Y and b) whether the changes of scores would be meaningful to a client. The study showed  an effect size difference in outcome between SC and active comparison conditions and passive controls of 0.12-0.15, but this is so small as to be of doubtful clinical significance.  Nevertheless under a heading of ‘Practitioner Points’ they declare ‘SC is appropriate and effective for mild to moderate anxiety and depression’. Dolan et al (2021) found that the SC studies had a mean quality score of 18.21 but fail to mention that this is much lower than the mean score of 27.8 [Ost (2008)] in CBT studies. Ost (2008) commenting on a series of studies that had a mean score of 19.6 declared that this set of studies could not therefore be considered an empirically supported treatment (EST). IAPT does not provide EST’s in their low intensity provision. Further there is no evidence of fidelity to ESTs in the high intensity interventions. Additionally the dosage of therapy routinely delivered in high intensity IAPT therapy falls far short of that advocated in randomised controlled trials of CBT.

The Genesis of Spin

Spin is often related to undeclared conflicts of interest. In the Dolan et al (2021) study all authors declared no conflict of interest. But the corresponding author for the Dolan et al (2021) study is a programme director of IAPT and another of the authors has IAPT involvement. Unfortunately this is not an isolated example, Scott (2021) challenged a similar non-disclosure by these authors earlier this year.

A National Failure to Address Spin

The National Audit Office (NAO) began an investigation into the IAPT service but then stopped it in June 2018 without publication of findings. Following a Freedom of Information request to the NAO, the first author was told in a communication dated February 17th 2020 that the investigation was halted because of variously, the collapse of Carillion and Brexit, with no intention of resuming its’ investigation. Further the NAO response added ‘The investigation was not intended to comment on clinical judgements or the extent to which services meet patient needs’! IAPT has successfully enlisted NHS England, Clinical Commissioning Groups (CCGs), the British Psychological Society (BPS) and the British Association for Behavioural and Cognitive Psychotherapy (BABCP) to proclaim its’ ‘world-beating’ [Dr Claire Murdoch, NHS England Mental Health Director, Health Business August 26TH 2021] status. IAPT is however eminence-based not evidence-based.

The Demise of The Psychologist’s Role

IAPT is the major employer of psychologists, who risk becoming deskilled by the climate change brought about by the Service.  Psychologists tend to stay in IAPT for a few years before heading for the exit to secondary care of private work. This leaves an IAPT workforce bereft of the means of critical appraisal of their work. Staff are ill-equipped to challenge the edicts from on high and disagreement is seen as disloyalty resulting in burn out and worse.

  1. Michael J. Scott, Consultant Psychologist, Liverpool, UK

 

  1. Joan S. Crawford, Counselling Psychologist, Mersey Care NHS Foundation Trust, Chronic Pain Management Service (CPMS), St Helens. https://orcid.org/0000-0001-6400-1158

 

  1. Keith Geraghty, Centre for Primary Care, Division of Health Sciences and Population Health, University of Manchester, UK. https://orcid.org/0000-0001-5060-5022

           

Corresponding author:   Michael J Scott michaeljscott1@virginmedia.com

 

 

 

 

 

Key resources

Chalder, T., et al. (2021). Efficacy of therapist-delivered transdiagnostic CBT for patients with persistent physical symptoms in secondary care: a randomised controlled trial. Psychological Medicine, 1–11. https://doi.org/10.1017/S0033291721001793.

 

Dolan, N., Simmonds-Buckley, M., Kellett, S., Siddell, E., & Delgadillo, J. (2021). Effectiveness of stress control large group psychoeducation for anxiety and depression: Systematic review and meta-analysis. The British journal of clinical psychology60(3), 375–399. https://doi.org/10.1111/bjc.12288

Jellison S, Roberts W, Bowers A, et al. BMJ Evidence-Based Medicine 2020; Evaluation of spin in abstracts of papers in psychiatry and psychology journals  25:178–181.

Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology23(9), 1136–1147. https://doi.org/10.1177/1359105318755264

 

Scott M. J. (2021). Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin. The British journal of clinical psychology60(1), 38–41. https://doi.org/10.1111/bjc.12264

 

 

 

 

 

 

 

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