Children In Care Go Down A Rabbit Hole When It Comes to Diagnosis and Treatment

Their world becomes Alice In Wonderland like. A recently published study by McGuire et al (2022) gave one of two alternative vignettes to 270 mental health professionals. The only difference in the narratives was that in one the child was described as being in care and in the other as living with their mother. For the sample in which the child was described as living with their mother, the rate of diagnosis of PTSD was more than double (31.0% vs 14.5%). According to NICE, children with PTSD should follow a particular treatment pathway, trauma focussed CBT. Thus for every child in care placed on the  correct NICE pathway, another would be misdirected. Matters were even worse than this, as only one half of those who diagnosed PTSD recommended a NICE approved treatment (trauma Focussed CBT or EMDR).

Overall the most popular diagnosis was developmental trauma (57.3%)  followed by attachment problems (22.1%) and PTSD (14.5%). But these clinicians seemed unphased, that there is no evidence-based protocol for either developmental trauma or attachment problems. The use of such diagnostic labels is an exercise in unbridled clinical judgement that serves the interests of neither the children in care  nor the troubled child not in care.

Unfortunately the use of idiosyncratic rules of thumb (heuristics) is commonplace, 9 out of 10 of those diagnosed with ADHD are boys, but boys are only 3 times as likely to have ADHD as girls, Bruchmuller et al (2012) the representativeness heuristic operates, in that boys are seen as prototypical. Heuristics short circuit decision making, sacrificing accuracy for speed. But they are not the exclusive preserve of clinicians working with children, their usage is ubiquitous  amongst mental health professionals. It is an article of faith amongst aspiring mental health clinicians that the ‘medical model’ must be derided at every turn, diagnosis is anathema to be replaced by the autocracy of the clinicians judgement. But it is unfettered clinical judgement, imagine what would happen if Judges engaged in this with regards to sentencing! Diagnosis is built on explicit criteria and another clinician can challenge whether there is sufficient evidence that those criteria are/were met. We can even distil more reliable diagnostic criteria. There is no appeal against the autocracy of unbridled clinical judgement, it is an exercise in power without responsibility. We are back to the era that pre-dated the randomised controlled trials of psychological interventions in the 1970’s. It was like being at the Mad Hatter’s Tea Party, I remember having the timidity to ask on a social work course ‘does this social casework, work?’ and arriving late for a T Group, to be told this was a manifestation of ‘resistance’, my remonstration that I had missed the bus counted for nought.  The social casework totally failed, with failures to protect children abounding and idiosyncratic decision making, supplemented with box ticking.

 

Dr Mike Scott

Spurious Claims For The Impact of Transdiagnostic CBT on Persistent Physical Symptoms 

 

In a just published study James et al (2022) extol the virtues of their transdiagnostic CBT therapy (plus standard medical care) for Persistent Physical Symptoms.
s. In an earlier study  these authors found no difference in outcome at 52 weeks follow up on the Work and Social Adjustment Scale (WSAS: the declared primary outcome measure) between those undergoing the transdiagnostic CBT plus standard medical care and those having the latter alone. Not to be outdone they have gone on a fishing expedition in their latest paper  James et al (2022) and focus on two secondary outcome measures, WSAS score at the end of active treatment  and the PHQ-15 score at 52 weeks, claiming that there was a significant difference between the transdiagnostic CBT  and standard medical care using both these secondary measures.

 This looks a little fishy as they are the originators of the treatment. No mention of the need for independent replication of their findings. Further the comparison group was standard medical care, but this design does not control for attention or the presentation of a credible treatment rationale. Scepticism seems in order. This intensifies when the outcome measures used are considered.

The WSAS (Mundt et al 2002) was designed to assess the impact of mental health on functioning in 5 domains work, home management, social leisure activities, private leisure activities and close relationships. As such there is clear separation between the causal agent (mental health) and effect (functioning). In the initial validation study the WSAS was administered to a sample of depressed patients and a sample of OCD patients, the WSAS scores correlated with the severity of each disorder.  

Mental Health can affect one’s ability to do certain day-to-day tasks in their lives. Please read each item below and respond based on how much your mental health impairs your ability to carry out the activity. 

Table

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If however the term ‘mental health’ in the above table is replaced with “Persistent Physical Symptoms’ the distinction between causal agent and effect is lost. Consider, a person who is terminally ill with cancer or a progressive neurological disorder, they would likely score high in each domain. But it would not be anticipated that any psychological intervention is going to attenuate their physical symptoms, because there is a fusion of physical symptoms and impairment. [In the original validation study the term ‘disorder’ was used because they were known to have either depression or OCD].

The burden of proof is on those who would reword the WSAS so that it related to PPS to demonstrate a meaningful distinction between say fibromyalgia and impairment in functioning or irritable bowel syndrome and functioning or between chronic fatigue syndrome and functioning. The WSAS was not validated for PPS  but that has not stopped James et al (2022) using it as their primary outcome measure in their study of transdiagnotic CBT for PPS compared to standard medical care.

 

The PHQ-15 is a measure of symptom severity and is rated on a 3- point Likert scale. This brief validated measure looks at a range of symptoms and asks patients to report to what extent their symptoms bothered them in the past four weeks. The PHQ-15 contains 15 items and the total score can range from 0 to 30 where a higher score indicates greater symptom severity (Kroenke et al., 2010). The items include several related to pain, (stomach pain, back pain, pain in arms and legs or other joints, headaches, chest pain), fatigue, as well as other symp- toms related to the different systems of the body i.e. shortness of breath, dizziness, bowel symptoms.

But there is no clear mechanism by which a psychological intervention impacts such an array of symptoms. The authors considered 9 possible mediating variables (7 of which were cognitive), but only 2, catastrophising and symptom focusing appeared operative (Type 2 error). Suggesting that the supposed mediating variables may be chance findings. One of the suggested variables related to depression (PHQ-9) and the other anxiety (GAD-7) but for the supposed cognitive mediation model evinced by James et al (2022), they cannot be mediators, depression is known to covary with WSAS as such it cannot be an explanatory variable.

Assessment in the study is entirely by self-report measures but the authors totally ignore that they are subject to demand characteristics e.g wanting to please the therapist by reporting improvement or to convince oneself that time has not been wasted. It would have been more meaningful for an independent assessor to ask since ‘x’ have you felt the same, a little better, a little worse, much better, much worse.  

James et al (2022) justify their transdiagnostic therapy on the basis that ‘people with different PPS share some cognitive and behavioural responses to symptoms, including catastrophising, symptom focusing, fear avoidance beliefs, avoidance behaviour and lack of acceptance (Deary, Chalder, & Sharpe, 2007)’. This is a sweeping statement certainly catastrophising and avoidance behaviour have been implicated in the development of chronic pain, but this is not to say that they are germane to the category of PPS (MUS). The use of the term ‘some’ makes the Deary, Chalder, & Sharpe, 2007 model incapable of falsification.

 

The  term PPS as used byJames et al (2022), is a smokescreen for the construct Medically Unexplained Symptoms whose validity Keith Geraghty and I have challenged.

Dr Mike Scott

 

Mis-Guided Self Help In IAPT

A just published study by Duhne et al (2022)found that almost a third (29%) of those assessed by the Improving Access to Psychological Therapies Service (IAPT) and referred to Guided self-help (either face to face or computer assisted CBT) did not attend any treatment sessions. Whilst of those who attended treatment over half (54%) dropped out, defined as attending three or less treatment sessions. These figures are much higher than the 20% Swift and Greenberg (2012) of clients who typically dropout of psychotherapy.

 

Curiously the authors miss the obvious implication that GSH is misguided. Instead they recommend further investigating an algorithim for better matching those who would do better in cCBT or better in face to face! Why is this? The authors declare no conflict of interest, but the Department from which it emanates at Sheffield University has a long list of IAPT teachers. There is a complete absence of critical appraisal of IAPT’s metrics suggesting that the Sheffield researchers don’t want to bite the hand of a service that gives them a ready-made data set, it eases the research burden. The Journal in which it was published Behaviour Research and Therapy characteristically ignores any criticism of IAPT.

 

Concluding anything  about the relative merits of cCBT and face to face GSH is problematic, in the Duhne et al (2022) study as the mean initial PHQ9 scores  were respectively 12.32 and 15.01, which is statistically significant p < 0.0001, when the sample sizes and standard deviations  are input into a the MedCalc comparison of means calculator.  This suggests some systematic bias in the allocation of people to these modalities. 95,088 patients accessed diverse low-intensity interventions: GSH (n = 84,503; 88.4%), psychoeducation groups (n = 8671; 9.1%), cCBT (1611; 1.7%), and other interventions (n = 753; 0.8%). 

Dr Mike Scott

IAPT Fails The Traumatised

The Improving Access to Psychological Therapies (IAPT) latest annual report states that the recovery rate for PTSD sufferers (24,097) given CBT was 13.1% . Whilst the recovery rate for those receiving EMDR (4,908) was 11.4%. By its own metric only the tip of the iceberg recover. 

 

In total IAPT treated (defined as attending 2 or more sessions) 34,328 PTSD cases and offered 15 different therapies, despite only 2 (CBT and EMDR) being NICE compliant. 15% of cases were given a non-NICE compliant treatment – whither the Services claim of NICE compliance?. With 70.2% given CBT and 14.3% EMDR. For those undergoing EMDR 4153 are on their first course but 2268 are on their second course i.e of those undergoing EMDR over a third 35.32% are on their 2ndcourse. This is not what a person expects to happen.

The metric of recovery used by IAPT for these PTSD cases is the PHQ9. This is clearly bizarre, as the PHQ9 is a measure of the severity of depression. A possible defence of IAPT’s dismal failure to help the traumatised, would be to admit that its method of auditing, of PTSD cases in particular, has been seriously flawed. But unfortunately IAPT behaves like politicians when confronted with manifest failure.    

In IAPT if a person has PTSD there is a 97% (31,570/ 34,328) chance  of them scoring above 10 on the PHQ9. But if a person does not have PTSD (591, 492) only 1077/592,623 or 0.18% would be correctly identified by a PHQ9 score of below 10. Thus using the PHQ9 for detecting PTSD has poor specificity. It is a totally useless metric for identifying PTSD, and would yield an enormous number of false positives. The same results apply if the GAD7 is used as the metric. Whichever metric is used these two measures are useless for detecting PTSD and create false positives resulting in unnecessary treatment.

 

IAPT details the trajectory of PTSD clients going through its’ service yet claims in its Manual that the Service does not make diagnoses. Only politicians can square such circles, alas for us mere mortals. The gold standard in a PTSD outcome study is to use a standardised reliable diagnostic interview, IAPT is yet to overcome its lifelong phobia about their use. One can only suppose that there is a fear of starkly revealing their inadequacy and it is easier to hide behind expressions of concern over cost.

In my own study, Scott (2018) of 90 cases going through IAPT assessed using the SCID diagnostic interview, for those with PTSD the recovery rate was 15%. Again we are looking at the tip of the iceberg of recovery.

IAPT’s training of its therapists with regards to trauma is clearly amiss, it may be that the positive (50% recovery) trauma focussed trials that they draw upon are not sufficiently user friendly to deliver in routine practice and I have detailed an alternative Scott (2022).

Dr Mike Scott

The Health Minister and NHS England Pass The Buck on Answering Key Questions on Mental Health

The previous Health Minister, Dr Therese Coffey was asked 7 questions about the effectiveness of routine psychological therapy for depression and the anxiety disorders. Only 1 of the 7 questions was answered and that, only partially. The Department of Health  advised that NHS England were better placed to answer my questions and so I put the queries to them.  I wrote about this in my blog for Mad In America.  Since then NHS England have replied, or rather not replied, suggesting that I put the questions to my local Integrated Care Board (ICB’s are the recent replacement for Clinical Commissioning Groups). My questions obviously relate to national policy and not local difficulties, it is completely disingenuous of NHS England to reply in this way. I have now asked them for a considered response to my questions.

For the sake of completion I have reproduced the questions below:

1.The Government Improving Access to Psychological Therapies (IAPT) Service is experimenting with public, direct access to a Psychological Wellbeing Practitioner. But PWPs are not trained in diagnostics nor are they qualified therapists. Why then are they being given this gatekeeping role?

2. The IAPT service has cost billions of pounds, since its’ inception in 2008. Why, then has there been no independent audit of the service?


3. With regards to physical health the Government is funding Community Diagnostic Centres, with regards to mental health why is there no facility for reliable diagnosis in IAPT?

4. With regards to mental health there is no evidence that those availing themselves of IAPT fare any better than those attending the Citizens Advice Bureaux? What then is the added value of funding IAPT?

5. How is the experiment of making PWPs gatekeepers being evaluated and who decided on the criteria?

6. IAPTs claimed recovery rate of 50% has not been independently verified. The independent evidence of an Expert Witness to the Court [Scott (2021) British Journal of Clinical Psychology] suggests that in fact only the tip of the iceberg recover. Is this not grounds for a publicly funded independent audit?

7. How do we know IAPT is value for money?

 

It seems likely that only politician-like responses will be forthcoming. Will nobody grasp the nettle?

 

Dr Mike Scott

 

What Is The Added Value of  IAPT? 

Last year the Improving Access to Psychological Therapies Service (IAPT) lost 46% of clients before their 2nd treatment session. No other psychological therapy services has such a sink hole.

IAPT ignores the sink-hole casualties in its’ proclamation of a 50% recovery rate. My own independent study, using a standardised diagnostic interview, Scott (2018) suggests that only the tip of the iceberg recover.  

IAPT has a major problem engaging clients. The ratio of those who had one treatment session to those who completed treatment (at least 2 treatment sessions) was 1244386/664087, 1.87 i.e almost twice as many people have just one treatment session  compared to those who complete treatment IAPT Annual Report.

The latest IAPT Annual Report states  that the recovery rate, with CBT, in IAPT is 40.7%, this is less than the 50% recovery rate claimed for the service as a whole.  Its’ 50% recovery rate has been deemed by IAPT  as comparable to the results of randomised controlled trials of CBT for depression and the anxiety disorders. Thus, by its own metric IAPT is underperforming.

                                                         % overlap               Probability of superiority

Effect size is a measure of change. In IAPT for those  at caseness on PHQ9 ( a sore of 10 or more),  the mean initial score was 15.4 (standard deviation 5.5) for those completing treatment (attending 2 or more sessions) and a score of 9.3 (standard deviation 6.4) at the end of treatment, a within subject effect size of 1.1. But a sample of patients undergoing treatment as usual by their GP (with PHQ9 scores of 10 or more and 87% of the sample not treated by IAPT) Gilbody et al 2015  and followed up for 4 months, show an  effect size  score of 1.9. This is based on an initial PHQ9 score of 16 (standard deviation 4.2) and an end score of 9 (presumed standard deviation 4.2), adjusted for the size of the correlation between beginning and end of treatment, using IAPT’s correlation of 0.6, inferred from its data analysis.  This data was input into an Effect Size Calculator, yorku.ca for a within subjects design. There is thus no obvious added benefit to IAPT, rather the reverse.

The burden of proof is on IAPT to demonstrate that it confers any added value.

Dr Mike Scott

The Seriously Flawed Psychological Therapy and Dementia Study

 

Psychological therapy for people living with dementia (PLWD), is the way forward according to a study by Bell et al (2022) focussing on Improving Access to Psychological Therapy (IAPT) clients. The authors reported a 40% recovery rate for people living with dementia, compared to a recovery of 47% in the matched control group without PLWD, they claimed ‘our findings are important for encouraging referrals of PLWD into primary care psychological therapy services, as our work suggests that these services are likely to be useful in treating anxiety and depression in PLWD’. But their study did not demonstrate a real-world benefit for treating PLWD sufferers in IAPT. This is spin in favour of IAPT. The study was funded by the Alzheimer’s Society, who not surprisingly endorsed the author’s conclusion.

Don’t Psychoathologise The Reactions of People Living With Dementia

The twin outcome metrics were the PHQ9 and GAD7, and to enter the study people had to be initially at ‘caseness’ on one of these measures, a score of 10 or more on the former or 8 or more on the latter. Recovery was defined as being below the threshold for ‘caseness’ on both measures at the last treatment encounter. But data was only analysed for clients who completed 2 or more treatment sessions. Data from the most recent IAPT Annual Report (September 2022) , indicates that almost half (46%) of IAPT clients attend one or no treatment sessions. Thus if Bell et al (2022) had included in their analysis those who attended only one or less treatment sessions, i.e they had performed an intention to treat analysis, the true recovery rate would have been significantly less than that claimed. Strangely the authors make no mention of this.

Bell et al (2022) do not consider whether reliance on two self-report measures as the sole outcome metric is problematic. No mention that independent assessments may be important, as the self-report measures that are completed are subject to treating clinician scrutiny and comment. Further there is evidence that patients score lower on the PHQ9 in order to motivate themselves Robinson et. al (2017).  This leads to a mismatch between scores and patients global ratings of change ‘How are you feeling in comparison to 2 weeks ago? [(1=feels much better, 2 = feels better, 3= feels the same, 4 = feels worse, 5= feels much worse]). The within subject effect size for the PHQ9 was 0.83 and for the GAD7 0.80. A less than 1 standard deviation reduction is just what would be expected of an attention placebo control condition, (absent in the said study) involving regression to the mean, with people presenting initially at their worst. The blindness of the authors to these limitations is breathtaking.  The authors declare no conflict of interest, but fail to state that one of the authors works for Icope an IAPT service.

It is likely that volunteer supporters for PLWD would be more welcome than psychological therapists and at least as useful.  The Alzheimer’s Society should look to such a body of volunteers. This is not to say that there will not be PLWD who are suffering from depression and anxiety and need evidence based treatment, but there is no sign of it coming from IAPT any time soon.  IAPT has a remarkable ability to secure funds and endorsements without its therapists having a unique knowledge or training in this case of dementia. There is a credibility gap between IAPT and its’ fellow travellers  and what happens on the ground. 

 

Dr Mike Scott

 

Non-Reply From Health Minister’s Aide On IAPT’s Gatekeeping

Last month I asked Dr Coffey, the Health Minister the following questions, in italics I have summarised the responses from an aide. The full text that I received on October 12th 2022 follows.

1.The Government Improving Access to Psychological Therapies (IAPT) Service is experimenting with public, direct access to a Psychological Wellbeing Practitioner. But PWPs are not trained in diagnostics nor are they qualified therapists. Why then are they being given this gatekeeping role?

Best answered by NHS England


2. The IAPT service has cost billions of pounds, since its’ inception in 2008. Why, then has there been no independent audit of the service?

Not answered


3. With regards to physical health the Government is funding Community Diagnostic Centres, with regards to mental health why is there no facility for reliable
diagnosis in IAPT?

Interesting, but diagnosis in mental health  is ‘less straightforward’, it would be too costly, no plans.

4. With regards to mental health there is no evidence that those availing themselves of IAPT fare any better than those attending the Citizens Advice Bureaux? What then is the added value of funding IAPT?

Not answered

5. How is the experiment of making PWPs gatekeepers being evaluated and who decided on the criteria?

Not answered

6. IAPTs claimed recovery rate of 50% has not been independently verified. The independent evidence of an Expert Witness to the Court [Scott (2021) British Journal of Clinical Psychology] suggests that in fact only the tip of the iceberg recover. Is this not grounds for a publicly funded independent audit?


7. How do we know IAPT is value for money?

Not answered

Dear Dr Scott,
 
Thank you for your correspondence of 18 September Improving Access to Psychological Therapies (IAPT) programme. I have been asked to reply.

NHS England has oversight for the IAPT programme, so would be best placed to respond to your queries. However, delivery of IAPT services is the responsibility of local commissioners. Integrated care boards (ICBs) replaced clinical commissioning groups in the NHS in England from 1 July 2022. A list of ICBs can be found at www.nhs.uk/nhs-services/find-your-local-integrated-care-board/.

In response to question 4, people seek treatment through talking and psychological therapies provided through local IAPT services for anxiety, depression and a range of other mental health conditions such as agoraphobia, post-traumatic stress disorder, obsessive compulsive disorders, panic disorders and social phobias. Treatments can include therapies like counselling, cognitive behavioural therapy (CBT) and peer support. In 2021-22, 1.24 million referrals accessed talking therapies through IAPT services.  The recent annual report available at https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-annual-reports-on-the-use-of-iapt-services/annual-report-2021-22 contains information on referrals, waiting times and patient outcomes such as recovery. In addition, the report covers a range of demographic analyses including outcomes for patients of different ages, ethnic group and separately for ex-British Armed Forces personnel.

For your questions relating to Psychological Wellbeing Practitioners, the IAPT workforce consists of low-intensity practitioners and high-intensity therapists who together deliver the full range of NICE-recommended interventions for people with mild, moderate and severe depression and anxiety disorders, operating within a stepped-care model. All IAPT clinicians should have completed an IAPT-accredited training programme, with nationally agreed curricula aligned to the National Institute for Health and Care Excellence (NICE) guidance (or they should have acquired the relevant competences or skills before joining an IAPT service). All clinicians should be accredited by relevant professional bodies and supervised weekly by appropriately trained supervisors.

Many people with mild to moderate depression or anxiety disorders are likely to benefit from a course of low-intensity treatment delivered by a psychological wellbeing practitioner. Individuals who do not fully recover at this level should be stepped up to a course of high-intensity treatment. The NICE guidance recommends that people with more severe depression and those with social anxiety disorder or post-traumatic stress disorder (PTSD) should receive high-intensity interventions first. NHS England’s available at www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdfcontains further detail on the IAPT workforce, including PWPs.

Question 3 raises an interesting point; however, there would be significant challenges to making this approach work for mental health conditions. Diagnosis for mental health is less straightforward and replicating Community Diagnostic Centres would require a significant expansion in numbers of mental health staff, above and beyond what is already set out in the NHS Long Term Plan that there will be additional 27,000 mental health professionals in the NHS workforce by 2023/24. Therefore, we have no plans at present to replicate this model for mental health.

I hope this reply is helpful.

Yours sincerely,

K Jarvis
Ministerial Correspondence and Public Enquiries
Department of Health and Social Care

 

Dr Mike Scott

IAPT Outperformed by Anxiety UK

In a recent study by Than et al (2022,) outcomes for attendees of the Charity, Anxiety UK have been compared with the results of attending the Improving Access to Psychological Therapies (IAPT) service. The authors claim a higher recovery rate, 62.4%, for Anxiety UK compared to 51.1% in IAPT. Anxiety UK clients attended a mean of 8.53 sessions compared to a mean of 6.9 sessions in IAPT. The results apply for treatment completers only, defined as attending two or more treatment sessions. But only 4.4% attend only one treatment session in Anxiety UK, but for IAPT in the year running up to the pandemic the figure was 44.7%. It seems that Anxiety UK is massively more able to engage clients than IAPT, strangely a point that Than et al (2022) completely missed.

Anxiety UK operates outside the NHS and does not use IAPT’s stepped care model of low and high intensity interventions. Raising the obvious question of why bother with such a distinction? The minimum access standard set for IAPT for 2020/2021 was 25%, suggesting that potentially 75% will not access the service. This makes the case for the provision of non-commissioned services external to the NHS.

But there are reasons to proceed with caution:

  1. Both Anxiety UK and IAPT have marked their own homework. There has been no independent assessment of these two service providers.
  2. They have adopted the same metric, changes in score on two psychometric tests,the PHQ-9 and GAD-7 between the first and last administration of these measures. Neglecting that clients a) may score lower on re-administration, because they don’t want to feel that they have wasted their time in therapy b) may not want to appear ungrateful by scoring near their initial score and c) present initially in therapy at their worst and there is some naturally occurring resolution of difficulties (regression to the mean).
  1. There can be no certainty that the self-report measures are measuring what they purport to measure. The PHQ-9 is a measure of the severity of depression and only has validity if the individual has been reliably diagnosed (using a standardise semi-structured interview) as suffering from depression. Similarly, the GAD-7 is a measure of the severity of generalised anxiety disorder (GAD) and only has validity if the individual has been reliably diagnosed (using a standardise semi-structured interview) as suffering from GAD. It is perfectly possible to score highly on both measures but to have neither disorder, for example a Ukrainian refugee with a sub-syndromal level of post -traumatic stress disorder/ adjustment disorder and for whom psychological treatments might be misplaced as opposed to watchful waiting/support. The danger of relying entirely on self-report measures is that normality is pathologized.

 

  1. Despite the claim of Than et al (2022) measuring outcome by a change of score on on self-report measures is not the most ‘client centric’ form of evaluation. It is essential that an outcome measure must be intelligible to the client, changes in psychometric test scores lack any clear meaning to clients. What clients do clearly understand is whether or not they are back to the former self’s post-treatment or at least back to their best selves and the duration of those gains. Inquiry into these domains by an independent observer is the only way of reliably determining whether there has been real world benefit from treatment. Both service providers have jettisoned, rigorous independent assessment.

 

  1. Neither service provider has run fidelity checks to guarantee that the alleged CBT, clinical hypnotherapy, counselling etc was actually delivered. They both claim NICE compliance, but this necessitates matching a protocol with a reliably diagnosed disorder. Given that neither make diagnoses the claim of compliance has to be fraudulent. It appears an exercise in impression management with Anxiety UK but in IAPT it is arguably more insidious , a mechanism by which funds are secured.

 

  1. The Anxiety UK authors totally ignore the controversy in the British Journal of Clinical Psychology Scott (2021) about the validity of IAPT’s chosen metric and that most plausibly only the tip of the iceberg recover Scott (2018). One service provider might be concerned to demonstrate a better performance than another but the crucial question is what is actually happening at the coal face? Nevertheless, I suspect working conditions are much better at Anxiety UK.

 

Dr Mike Scott

 

 

Mental Health Triage Practitioners Don’t Know Who Is Suffering from What, or What Needs To Be Done

The Government’s Improving Access to Psychological Therapies (IAPT) programme has decided to experiment with enabling the public to directly book an appointment with a Psychological Wellbeing Practitioner (PWP). But IAPT and the Government are keeping quiet, that PWP’s are not trained in making diagnoses nor in providing psychological [ IAPT Manual (2019)]. They have made it impossible for the public to give informed consent. The public are being conned. In the interest of ‘efficiency’, IAPT is by-passing managerial and admin staff. 

For the most part PWPs have nursing or social work backgrounds with a first degree. A recent patient of mine could easily have made direct access to a PWP, I shudder to think what they would have made of his abrupt mood changes, sometimes changed image as he looks in the mirror and periodic disengagement from life. Though not abused himself as a child, he witnessed parental abuse. To put it bluntly they wouldn’t have a clue what was wrong, much less what to do about it. What then is the unique body of knowledge of PWPs?

Given that successive Governments have never conducted an independent audit of IAPT since its inception in 2008, who can say that the billions of £’s service, is value for money? It is to be expected that a service itself will claim itself essential, and in support of this IAPT claims a 50% recovery rate [IAPT Manual (2019)]. But my own independent study Scott (2018) suggests that only the tip of the iceberg recover. As far as mental health is concerned there is no evidence that those  availing themselves of IAPT fare any better than if they had attended the Citizen’s Advice Bureaux. But the CABx is upfront with no pretence at having mental health expertise.  Is the Government running a production line or endeavouring to improve mental health? No answer from the Health Secretary yet.

Dr Mike Scott