IAPT Out Of Its’ Depth

a just published paper in the British Journal of Clinical Psychology by Martin et al https://doi.org/10.1111/bjc.12314 concludes:

‘Improving Access to Psychological Therapies provision and research at present does not adequately consider the complexity of its clientele in the context of treatment outcomes and service delivery’

The authors suggest that practitioners bear the following in mind:

  • Improving Access to Psychological Therapies (IAPT) has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged.
  • Given the ongoing focus on and investment in IAPT informed developments into long-term conditions and serious mental illness, this review considers whether additional elucidation of the model’s original objectives is required, as a precursor to its expansion into other clinical areas.
  • The review indicates that there is a stark lack of data pertaining to the generalisable, real-world clinical benefits of the IAPT programme as it currently stands.
  • Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.

I did throw IAPT a lifebelt with my paper ‘Ensuring IAPT Does What It Say On The Tin’ published in the BJCP  in
 
March 2021  https://doi.org/10.1111/bjc.12264 but the rebuttal from Kellett et al in the same issue of the Journal
 
DOI:10.1111/bjc.12268 suggests that  my comments fell on deaf ears.
 
 

Dr Mike Scott 

When Mental Health Screening Makes You Want to Scream

assessment in the Improving Access to Psychological Therapies (IAPT) Service takes up 25% of all resources, yet in the NICE approved protocols for depression and the anxiety disorders assessment takes about 8% of resources       (roughly an assessment session for 10-15 treatment sessions). Much of the IAPT assessment consists of telephone completed screening questionnaires by contrast the assessment in the NICE protocols consists largely of a reliable standardised diagnostic interview. But there is no reason to believe that the screening measures in IAPT (PHQ-9 and GAD-7) are pertinent to the client’s problems. Despite this in IAPT, these measures are re-administered every session and often made the focus of discussion, thus the actual total time spent in IAPT on ‘assessment’ is likely much more than 25% of the budget. The added value is? IAPT has a credibility gap. Is it really credible that with such a skewed distribution of resources, that IAPT should claim success comparable to that found in the randomised controlled trials that are the basis for NICE recommendations? IAPT claims fidelity to NICE protocols, so that it is not divorced from its’ paymasters NHS England/Clinical Commissioning Groups, but it is a well known philanderer. It provides no evidence of fidelity, just protestations.

I hear that IAPT is looking at introducing artificial intelligence into the assessment process! Whilst there are attempts to develop an algorithim for suicide risk by looking at records etc, the outcome is likely to be some marrying of this with clinician expertise. But this goal is quite a challenge. A meaningful algorithim for IAPT’s assessments  is likely to be a whole different ballgame. Time would be better spent doing the simple things such as really listening to clients and making a reliable diagnosis to direct treatment, this would be an exercise in intelligence. 

IAPT represents an extreme case of the tail wagging the dog when it comes to screening. A just published editorial in the Journal of the American Medical Association by Mitchell Katz, shows the more general problem of screening:

 
Editor’s Note
June 14, 2021

A Response to Excessive Screening Questions

JAMA Intern Med. Published online June 14, 2021. doi:10.1001/jamainternmed.2021.2925

‘Recently, JAMA Internal Medicine published a firsthand account of a trauma survivor who had disclosed over a series of years on multiple self-administered screenings that she had experienced trauma,1 yet none of her health care clinicians had ever followed up with her or provided any support or resources. In reading her account, I wondered how many of her clinicians had even seen the screening questionnaires she completed.

Standardized screening questionnaires allow primary care clinicians to learn important information about patients, especially in psychosocial areas (eg, depression, anxiety, substance use) that can be difficult to assess in short appointments. Adding to their efficiency, they can be completed in the waiting room. But for them to be useful, they have to be read, and the appropriate resources must be available.

Just as “alarm fatigue” can result in not paying attention to important warnings from electronic health records, use of screening questionnaires performed more often than necessary can deluge clinicians with more information than they can incorporate in a visit, decreasing the efficiency of the visit and leading to cynicism on the part of patients (eg, “Why do they keep asking me if I am depressed, when I keep telling them I am not?”) and on the part of primary care clinicians (eg, “Why are my patients repeatedly given these screeners, when I dealt with this issue on the last visit?”).

In this issue of JAMA Internal Medicine, Simon and colleagues2 estimated the proportion of standardized screenings performed at 24 federally qualified health centers in 2019 that were excessive, defined as performed when not recommended. Six screeners were evaluated (depression, anxiety, smoking status, passive smoke exposure, health literacy, and preferred learning style), all of which were tied to national performance metrics. The authors found that 34.9% of all screenings performed (2 067 152 of 5 917 382) were excessive’.

Dr Mike Scott

 

When Does Psychological Therapy Count As A Success?

always, if you lower the methodological bar low enough. The just published study by Chalder et al (2021), is an exemplar,  focussing on cognitive behaviour therapy for people with persistent physical complaints (PPS) https://doi.org/10.1017/S0033291721001793:

  • that there was no significant difference in outcome on the primary outcome measure, the self-report Work and Social Adjustment Scale
  • the authors of their report were evaluating their own protocol for PPS [hitherto known as Medically Unexplained Symptoms (MUS)]
  • there was no independent clinical assessment of outcome
  • the control group received ‘standard medical care’, there was no control for attention (the treatment group received 8,  1 hour sessions) 
  • there was no evaluation of effectiveness in a non research setting

Tolin et al ( 2015) https://doi.org/10.1111/cpsp.12122 have presented a clearly defined methodological bar as to what constitutes an Empirically Supported Treatment (EST), that has been adopted by  the American Psychological Association. Far from clearing this bar Chalder et al (2021) protocol  failed on each of the 5 criteria above. In addition Chalder et al (2021) fail to mention that total reliance on self-report measures, this makes the study especially prey to demand characteristics, in that those given attention are likely to want to please the therapists and not to feel they have wasted their own time by indicating a better response than otherwise.

Chalder et al (2021) fail to reference any work that challenges the very concept of MUS e.g Geraghty and Scott (2020) https://doi.org/10.1186/s40359-020-0380-2. The theoretical basis for Chalder et al’s CBT (2021) is that ‘Patients with PPS can develop unhelpful cognitions and behaviour which can consequently lead to a reduction in daily functioning, reduced quality of life, and an increased susceptibility towards developing depression and anxiety’. These authors inform the reader that all those in the study met criteria for fibromyalgia, but by Chalder et al’s (2021) rationale all with a persistent physical symptom require psychological therapy, this would just about swallow up all mental health resources in primary and secondary care. 

 In their statement of Conflict of Interest the authors Chalder et al (2021) indicate their background in the training of IAPT staff, unfortunately it is likely that the treatment protocol will find its way into the organisations ministrations, before any independent evaluation, despite the authors call for further research .  

 

References

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

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

Tolin, D. F., Mckay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015). Empirically supported treatment: Recommendations for a new model. Clinical Psychology: Science and Practice, 22(4), 317–338. https://doi.org/10.1111/cpsp.12122

Who Is Monitoring The Quality of Primary Care Mental Health Services?

Nobody, Clinical Commissioning Groups (CCGs) confine themselves to operational matters, number of patients seen, waiting lists.  The Improving Access to Psychological Therapies (IAPT) service has been allowed to self-monitor since its’ inception in 2008.  The National Audit Office abandoned its’ investigation of IAPT because of competing priorities citing the Carillion debacle amongst others in June 2018. Who is listening to the voice of the recipients of the mental health services?  

The mantra appears to be to get everyone to talk about mental health, especially celebrities, get everyone involved in mental health, teachers etc, secure more funding for anything with a mental health flavour on the basis that ‘it must be good’. But frenetic activity does not equal making a real world difference, achieving this has to be carefully monitored.

It goes without saying that we all need a more caring society nationally, for example assisting those who have been self-isolating for over a year to gradually venture out.  From an international perspective we should be giving a £1bn a year to fund the provision of vaccines in poorer countries. The need for compassion is never redundant.  But political correctness about mental health can obscure fully engaging with those in most need. 

Dr Mike Scott

The Future of CBT In Practice

niNext month is Aaron Beck’s 100th birthday and the journal which he founded ‘Cognitive Therapy and Research’ has a great editorial https://doi.org/10.1007/s10608-021-10232-6, wishing him well and looking at possible developments in CBT for depression, envy, schizophrenia and OCD. But there is a yawning gap between the experiences of the beneficiaries of randomised controlled trials (rcts) of CBT and what UK citizens receive in routine practice. In terms of the model below, going clockwise, there has been a fundamentalist translation of the rcts to determine policy, such that key elements of context such as ensuring reliable diagnosis have been left out, implementation has been determined in a ‘Stalinist’ way e.g the possibility of sanctions if a 50% recovery is not reached, there has been no independent monitoring of the policy, there is a claimed risk reduction, but this is based on responses to the ambiguous suicide item, item 9 on the Patient Health Questionnaire PHQ-9. But there is no evidence that the ‘Science’ is looking at these matters anytime soon. The deliberations of bodies like the British Association for Cognitive and Behavioural Psychotherapy (BABCP) appear to occur in a parallel universe.

Recently Drew et al (2021) https://doi.org/10.1016/j.socscimed.2021.113818 examined transcripts of IAPT (Improving Access too Psychlog ical Therapies)  sessions and the take home message was that clinicians were preoccupied with their own agenda and not really listening. This echoes what  Omylinska-Thurston et al (2019) https://doi.org/10.1002/capr.12249   found when interviewing former IAPT clients:

participants discussed difficulties with the outcome measures they had to fill in each week. Clients said they did not feel comfortable filling them in. Clare said it felt “disheartening… because … it brings it home…just how bad you’ve been feeling”. Clients also said that the scales felt disrespectful to their experience. For some, it was difficult to pinpoint the accurate answer and for others the measures did not reflect the nuances. For example, Jenny said about the self-harm question on PHQ9 “…to harm myself? No, but I know I wasn’t eating …well”. Also Jason said “there’s a difference between wishing you were dead and wanting to die … the question really is: do you think you should kill yourself rather than do you think you’d be better off dead?” Participants also commented that they learnt how to score the measures to get more services or sessions. Jenny said about the self-harm question “If I’ said ‘yes’ then they …‘right, shit’, but because you don’t put that they do ‘OK, see you next week’.” Jenny also worried that “if you put it was only one day this week, does that mean you don’t get any more sessions?” Measures were also reported as focusing on the negative side and did not catch positive change

Difficulties with assessment

Six clients discussed issues they had with the assessment process. Clients said that they were not assessed for the right type of therapy. For example, Adam said “if I had been…assessed better, that therapist doing CBT could have been helping another person”. Clients also said that CBT was not explained to them and Michael commented that he “didn’t know exactly what CBT things were going to entail”. Clients said that assessment involved a lot of paperwork and form filling and did not focus on their needs. Jason commented that he had to fill in a measure first and the score decided that he was depressed rather than a discussion first supported by a measure. Maurice talked a lot about the phone assessment and said it was “uncaring, robotic and intrusive”. He was concerned that people will not engage in therapy following telephone assessments’.

Yet what struck me when I met Beck in 1997 in Canterbury, was how much he genuinely listened. The rcts on CBT continue to generate high expectations but the jury is out on whether they have made or will make a real-world difference.

Dr Mike Scott

Psychological Therapy With Long Term Conditions

Improving Access to Psychological Therapies (IAPT) therapists working with long term conditions (LTC’s) have confidence and organisational, issues Carroll et al (2021) DOI: 10.1111/bjhp.12475. Whilst therapists working in secondary care, with LTC’s, face fewer obstacles to multidisciplinary working, with a focus primarily on the LTC and not on the associated depression/anxiety as in IAPT. Further the metrics for outcome in secondary care are likely to be much broader than in IAPT. LTCs by their very nature, wax and wane with a consequent impact on availability and concentration, creating a need for any therapy to be long term. But IAPT has a major focus on access and waiting times, such that any treatment is usually brief, comprising on average of 6 sessions, thus the service cannot readily accommodate working with LTCs.

The focus in the Carroll et al (2021) is on how the psychological treatment for those with LTC”s can be best integrated into primary and secondary care. They note however that the model they use to identify barriers and facilitating factors to implementation, first requires, evidence that the chosen intervention/s are effective. But they do not address this point. This is crucial, where is the evidence that the psychological therapies for disorders that are comorbid with LTCS make a real world difference?

A case has long been made that it is a matter of basic humanity to offer to accompany a person with an LTC if they so wish. A host of Charities have formalised this. The support may be social, e.g befriending, groups and/or instrumental e.g help with DWP application. The case for profferring ‘support’ is I think uncontestable. But many with LTC’s are wary of being defined by their condition. A dedicated support group may serve as a further reminder of their condition. They may decline involvement in such a group, but this is not necessarily a matter of avoidance, simply that they do not wish to define themselves or their world through the lens of their LTC. If psychological difficulties are grafted on to their LTC they may be even more likely to decline involvement with psychological therapists because it is an LTC type lens (a variant) through which they are being encouraged to view themselves and their personal world with perceived deleterious consequences. Arguably the LTC lens used in secondary care is likely to be less problematic than that used in IAPT. But the issue of centrality has not been systematically addressed with regards to LTCs. In the authors forthcoming work ‘Personalising Trauma Treatment: Reframing and Reimagining’ to be published by Routledge the issue of centrality [ Bernsten and Rubin (2006) (2007)] is addressed in detail with regards to trauma.

There is a distinction between long term physical health conditions and medically unexplained symptoms (MUS), the former are open to objective identification e.g diabetes, the latter are not. In considering the former the therapist feels that they are on solid ground, albeit that it is largely the domain of the medic, with whom there may be fruitful dialogue. But when it comes to MUS the therapist is in a fog, where are the signposts? There is no reference book for translating best practice with LTCs to clients with MUS. Because of this there is likely to be recourse to a powerful body insisting that the way forward is ‘x’ but without any evidence, a recipe for disaster. IAPT”s juxtaposition of LTCs and MUS, smacks more of pragmatism to secure maximum funding, rather than seriously addressing a clinical problem. Where is the therapeutic alliance in addressing MUS symptoms? What is the goal, What are the agreed tasks? Whither the bond, when the therapist covertly believes that the client is somatising and the client believes there physical symptoms are as real as toothache?

Carroll, S., Moss-Morris, R., Hulme, K., & Hudson, J. (2021). Therapists’ perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions. British journal of health psychology26(2), 307–324. https://doi.org/10.1111/bjhp.12475

Berntsen, D., & Rubin, D. C. (2006). Centrality of Event Scale: A measure of integrating a trauma into one’s identity and its relation to post-traumatic stress disorder symptoms. Behaviour Research and Therapy, 44, 219–231. https://doi.org/10.1016/j. brat.2005.01.009

Berntsen, D., & Rubin, D. C. (2007). When a trauma becomes a key to identity: Enhanced integration of trauma memories predicts posttraumatic stress disorder symptoms. Applied Cognitive Psychology, 21, 417–431. https://doi.org/10.1002/acp.1290

Dr Mike Scott

IAPT’s Processes Contribute Towards Death or Injury

transcripts of tape recordings of client’s first contacts with the, UK Government funded, Improving Access to Psychological Therapies (IAPT) service, analysed by Drew et al (2021) https://doi.org/10.1016/j.socscimed.2021.113818 reveal not only steadily increasing access,  but a steadfast refusal to let clients tell the story behind their distress. The double message is ‘come to us, but we don’t want to listen to your troubles’

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’

and 

‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’

Drew et al (2021) give an example of this surrounding risk assessment:

PWP: So just with regards to question nine, okay so we have a duty of care to yourself or others? .hhh.erm (.) > are we okay just to< have a bit of a chat around.hh what those thoughts might be for you at the moment. ‘Cos you’ve scored a one there haven’t you’ Pause 3 secs
 
PWP: Are you having current thoughts of wanting to hurt yourself or end your life? Pause 3.5 secs
 
Pat: No, may. hh Pause for 3.5 secs
 
Pat: It’s – It’s just feels like a really weird (.) week this week because –
(18 lines omitted in which the patient talks about the pressure they are under; only minimal responses and attempts to close from PWP)
 
Pat: I still feel like I – I’m not doing anything and not accompanying anything tearful/tremulous
 
PWP: Mm, mm, okay? .huh
 
Pat: MHHHH HHH [ and it’s tearful/tremulous]
 
PWP: Are you having any thoughts of wanting to be better off dead or off wanting to better off dead or hurting yourself
 
Dangerously The PWP is all at sea  – a disaster waiting to happen, there will be a death. The above exchange shows
 
the therapist unable to move beyond repeating question 9 on the PHQ9, like a broken record, without any reliable
 
exploration of suicide risk. But then the IAPT Manual provides no guidance in this respect, baldly stating risk
 
assessment is part of good assessment.
 
In the exchange above the PWP ignores the client’s story. Assessment and treatment are necessarily built on sand 
 
if the client’s narrative is not first distilled.  Making IAPT’s claim of a 50% recovery rate  beyond belief. [The average
 
session was 44mins for assessment and 33 mins for first treatment]. 

It is bad enough when a friend or relative will not listen to your troubles, but when a Government Agency does it routinely, that is unconscionable. Drew et al (2021) draw attention to the ubiquity of the problem which suggests that it is systemic. However Drew et al (2021) content themselves with recommending that IAPT’s assessors need to ask more open-ended questions at the start of their interviews. The authors claim no conflict of interest, but many of the authors have had previous privileged access to IAPT data, research data may not be so forthcoming if they take a more critical view of IAPT. In this respect they do not question IAPT’s recovery rate or cite data which may disconfirm it Scott (2018) https://doi.org/10.1177%2F1359105318755264.

 

Dr Mike Scott

Talking Therapies Con

the Improving Access to Psychological Therapies (IAPT) assessors are coaches, not trained treating clinicians. Clients and GPs are not made aware of this. The low intensity Psychological Wellbeing Practitioners see their low intensity role  as ‘coaches’ rather than therapists  see [https://thepsychologist.bps.org.uk/volume-24/edition-5 May 2011 Psychologist].  

The working alliance has been found to predict outcome in the treatment of a wide range of psychological disorders [Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy: a meta-analysis. J Couns Psychol. (1991) 38:139–49. doi: 10.1037/0022-0167.38.2.139] and most recently in the treatment of PTSD [Beierl ET, Murray H, Wiedemann M, Warnock-Parkes E, Wild J, Stott R, Grey N, Clark DM and Ehlers A (2021) The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder. Front. Psychiatry 12:602648. doi: 10.3389/fpsyt.2021.60264]. But the measurement of the working alliance requires a determination of the tasks involved, the goals elaborated and the assessment of the therapeutic bond [Tracey TJ, Kokotovic AM. Factor structure of the working alliance inventory. Psychol Assess. (1989) 1:207–10. doi: 10.1037/1040-3590.1.3.207]. Measuring the therapeutic working alliance in low intensity CBT would be a herculean task, in that 42% of those entering treatment only complete one session [Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14]. Further even if the working alliance could be reliably assessed in low intensity IAPT there can be no certainty it would relate to outcome. 

Given the uncertainties surrounding the role of the working alliance in low intensity interventions, doubts arise about the credibility of this intervention. Low intensity interventions do not make a clinically significant difference compared to usual care. BMJ 2013;346:f540 doi: 10.1136/bmj.f540 The situation is analogous to trying to asses the effectiveness of a fraction of a drug, that is demonstrably efficacious in full dose in a highly specified setting.

But the effect size of working alliance has in all studies been found to be in the small to medium range, for example in the Beierl et al study (2021) accounting for 13-28% of outcome depending on whether it was the patients perception of the therapeutic alliance or the therapists.  Thus though consideration of working alliance is of importance it is not of overriding importance and the specifics of the protocol matter.  

Dr Mike Scott

Talking Therapies Institutionalised Psychologising of Physical Health Problems

 

As a high intensity therapist working in IAPT, I’m finding an increasing amount of the people I see have chronic physical health conditions.  The training and supervision I receive emphasises my role as one of treating the depression/anxiety associated with these conditions, and not the condition itself.  This sounds plausible in theory, but my experience it just doesn’t work that way in practice. 
 
 
 
  1. Firstly, I get the distinct feeling that a lot of the time the people I see with chronic health conditions are not clinically anxious or depressed, they are just having a normal reaction to a really challenging situation.
  2. Secondly it is impossible for someone with my training and limited medical knowledge to know whether a symptom such as fatigue or poor sleep is down to anxiety or depression or other factors, including physical causes.
  3. I’m quite sure that I have treated people in the past, and will do so again, where symptoms arising entirely from an undiagnosed physical condition were misinterpreted as a mental health issue and I worry that there is a real danger, even with the best of intentions, of gaslighting people here, however sensitive and non pathologising I try to be. 
  4. Time and again I have had people tell me their symptoms were dismissed for years as being “all in their head”, and I worry I am inadvertently feeding into that damaging narrative. 
  5. Greater integration between physical and mental health care in the NHS can only be a good thing, but my experience is there is sizeable gap between the theory and practice on the ground.  IAPT is meant to be integrating more into physical health teams, in practice I am not sure how well this is really happening. 
  6. I know how hard staff on the ground in IAPT work and how dedicated the clinicians are, I worry we are being put in an impossible situation.  I’m very grateful to CBT watch for highlighting some of the predicaments that I can relate to in my day to day work.  

 

Identity withheld to protect the IAPT therapist

Dr Mike Scott

What Works For Whom In High Intensity Talking Therapies?

It doesn’t matter if the person has high intensity CBT or high intensity counselling or if they have had low intensity CBT beforehand, according to a study by Barkham and Saxon (2018) https://dx.doi.org/10.1186%2Fs12888-018-1899-0, of the Improving Access to Psychological Therapies (IAPT) service. This raises important questions:

  1. What has been the value of low intensity CBT for those who have high intensity treatment?  
  2. NICE recommends CBT for depression and the anxiety disorders, with different protocols for different disorders and not counselling, have IAPT proved them wrong? 
  3. Given that IAPT provides no evidence of the setting and monitoring of homework, a hallmark of CBT, can there be any certainty that CBT was actually delivered?
  4. What is the evidence that the stepped care model employed by IAPT works?
  5. Why has the British Government just given an extra £38 million to IAPT?
  6. On what basis does NHS England’s National Mental Health Director, Claire Murdoch claim proclaim our ‘world-leading talking therapies’?
  7. Are there conflicts of interest between being a Department of Health Adviser and playing a leading role in IAPT? 
  8. Why has IAPT been allowed to mark its’ own homework? In similar vein ‘why has there been no independent audit ion IAPT using ‘gold standard’, standardised diagnostic interviews?’.

In the 3 years since the publication of the Barkham and Saxon (2018) study there has been a deafening silence from IAPT in answering questions 1-4. The Government is likely to be similarly mute in answering questions 5-8, fearing that it would have to admit to having wasted about £5 billion on IAPT.

There is a clear need for a public inquiry to ask the above questions. The Government likes to portray itself as ‘progressive, waving the mental health banner’,  the last thing Labour wants is to appear otherwise. The unspoken mantra is don’t ask the consumers of mental health services about whether they have had their lives restored, ‘let us get on with being politically correct’.

 

Dr Mike Scott