this is the title of a Workshop I’m delivering on Feb 22nd in Liverpool, it is also the inaugral meeting the BABCP Group CBT Special Interest Group. Whilst the workshop is full you can join in the discussion on Group CBT simply by posting a reply to this post. There are also other posts on group CBT on this blog just type in ‘group CBT’ in the search box.
Manuals for depression and the anxiety disorders, assessment protocols etc from Simply Effective Group Cognitive Behaviour Therapy (2009) London: Routledge are freely available by clicking the link below:
The questions to be addressed at the workshop include:
are a rarity compared to individual therapy, despite the fact that barely more
than the tip of the iceberg of clients are likely to be offered therapy in the
forseeable future, Why is this? Is changing attitudes to the running of
groups likely to be sufficient to ensure wider dissemination of group therapy?
you believe you have got the skills necessary for running a group? What are
they and how do you know if you have got them? How can you get the skills?
you believe running a group would make a worthwhile difference? What outcomes
constitute a real world difference? How
would I know if marketing is outstripping evidence?
group treatment works for whom? What
about transdiagnostic groups? How transdiagnostic can you go? What is the
minimum dose of group CBT? What happens if you don’t ensure full recovery?
What are the organisational obstacles and plusses?’
Do join the SIG by contacting Nicola, email@example.com
the comments of an IAPT worker when he was told by management to make sure that the client completed the PHQ9/GAD7 face to face at the 6th session. Normally the client completes the measures before each of the first 5 sessions at home. Face to face completion introduces a demand effect, politeness, wanting to please the therapist, lowering scores so that IAPT’s results look better. Matters are compounded for him by only being allowed to provide usually 6 sessions in high intensity. Where is the evidence base for 6 sessions doing anything?’
This behaviour echoes IAPT’s, misrepresentation of its’ own outcome data. A more realistic and independent picture has been painted by Barry McInnes
IAPT 2018: Why do less than 1 in 5 referrals reach recovery?
Clients are waiting less time than ever to access IAPT services, and recovery rates have reached their highest ever level at 50.8%. So why am I not throwing my hat in the air? In a nutshell, the astonishingly high levels of attrition. With less than one in five that are referred and one in four that enter therapy achieving recovery, what is the experience of those that IAPT is serving less well?
Below is a graphic which shows clients at key stages of their journey through the Improving Access to Psychological Therapies (IAPT) programme in the year 2017 – 18. It’s an update of the figures that I provided for 2016 – 17 in a previous blog. As was the case then some of the performance data for 2017 – 18 show an improvement over the previous year. I also said previously that some aspects of performance start from an already worryingly low baseline. Having looked at the latest data I see grounds only for modest optimism.
Once again, the main story behind the numbers is one of extraordinary levels of attrition at each stage of the journey. The detail follows in subsequent sections.
The recovery rate for 2017 – 18 was 50.8%
30% of all referrals don’t enter therapy
45% of clients that enter therapy don’t complete
Only 26% of clients that enter therapy achieve recovery
Almost as many (49%) don’t recover, as do
The best performing areas achieved a recovery rate roughly double that of the poorest
First, the headlines. In the year 2017 – 18, the report and supporting datafile show that:A
There was a total of 1,439,957 referrals
an increase of 54,293 on the previous yearA
Recovery rates were 50.8%
This is up one and a half percentage points on the previous year, and for the first time exceeding the target of 50%. (definitions for recovery and caseness are shown in the panel below).A
89.1% of referrals were seen within 6 weeks, and 98.8% within 18 weeks
exceeding their respective targets of 75% and 95%
The term used to describe a referral scoring highly enough on measures of depression and anxiety to be classed as a clinical case. If a patient’s score is above the clinical cut off on either anxiety, depression, or both, that are classed as a clinical case
A patient is ‘recovered’ if they finish treatment and move from caseness to non-caseness by the end of the referral. The patient needs to score below the caseness threshold on both anxiety and depression measures. Referrals that started treatment not at caseness are not included in recovery counts
Headlines aside, there’s a story behind the numbers which I’ve broken down into four chapters. They are:
The stages from referral:
30% of referrals don’t enter therapy.
The stages from entering therapy:
45% of clients that enter therapy don’t complete.
The outcome at therapy ending for all clients:
53% of clients don’t achieve recovery
The outcome at therapy ending for clients that were at case level at the start:
51% of clients achieve recovery. 49% do not.
In each chapter I’ll show data for 2015 – 16, 2016 – 17 and 2017- 18.
The journey from referral – 30% of referrals don’t enter treatment
The journey starts with all referrals for the three years. The table below shows those referrals as 100%. Subsequent stages in the process, and the proportion of clients referred that still remain are also shown. In 2017 – 18, 70% of those referred entered therapy. This is defined as having one or more sessions of therapy. The proportions in both of the previous two years were broadly the same.
As we progress through their journey we can see an emerging story of attrition. By the end of therapy, only 39% of clients that were referred now remain(down from 41% in 2016-17)Those that reach recovery represent just 18% of the total referred . That’s less than one in five clients.
Why did only seven in ten referrals enter therapy? I can only speculate, but in doing this it’s important to note that nearly nine in ten referrals were seen within six weeks. Hence length of wait may not be the most important factor. Otherwise, they may no longer have needed therapy, their referral may not have been appropriate, or they may simply not have liked what was offered to them.
Chapter 2: The journey from entering therapy – 45% of clients that enter therapy don’t complete
We begin this chapter with all clients that entered therapy. That is, all those that had one or more therapy sessions. In 2017 – 18, 55% of those entering therapy are recorded as ending it. This figure is down 4% from 2016 – 17. Whichever year we’re talking about, however, the fact that more than four in ten clients do not complete should be a concern.
Following the journey through, we can see that just 26% of those entering therapy achieved recovery. In other words, clients entering therapy appear to stand just over a one in four chance of recovering.
Why are only 55% of clients recorded as ending therapy? Again, it’s hard to know. In my experience, however, clients more commonly drop out because they feel that therapy isn’t working for them for some reason. Often, they simply disappear without the opportunity to explore this with their therapist, and make adjustments that may better serve their needs.
Chapter 3: The outcome at therapy ending for all clients – 53% of clients don’t achieve recovery
Here we start with all the clients that are recorded as finishing a course of treatment. The first point to note is that not all clients were at a case level of symptoms or distress at the outset. No matter how much improvement they make, therefore, they cannot achieve recovery. In the 2017 – 18 population, 93% of clients were at case level, and could potentially recover. This is the same as in the previous year.
Those reaching recovery represent 47%of all those that finished treatment. For 2017 – 18, this is an increase of 1% over the previous year.
The outcome at therapy ending for clients that were at case level at the start – 51% of clients achieve recovery
The final leg of the journey, starting with clients who finished treatment that were at case level at the point they started. In this population we have all the clients who have the potential to achieve recovery.
In 2017 – 18, 51% of clients achieved recovery, of those that finished therapy and were at case level at the start. To be precise, the figure given in the IAPT report is 50.8% (against 49.3% for 2016-17).
The figure for those achieving recovery for 2016 – 17 is 1.5% higher than in the previous year. This is the first time that the recovery rate has exceeded the target of 50% that was established for the IAPT programme.
While this improvement is clearly welcome, however, it remains the case that almost as many clients do not recover as do. At nearly 51:49, the odds of recovering or not recovering are almost even.
Not all services perform equally
Using the tools that accompany the IAPT annual report, it’s possible to explore local and regional performance. Sadly, the datasheet which houses all of the raw data is now structured in such a way that it’s no longer possible to get a single improvement rate for each Clinical Commissioning Group (CCG) area and easily filter those to see the range of performance.
What I am loving, however, in this new reporting structure, is the IAPT Interactive Dashboard, which you’ll find at the foot of the Resources section of the summary page. It’s the tool from which the image of the interactive map (main blog image at the top) is taken, and also the screenshot below.
The interactive tool allows you to filter performance data at a local level, either by hovering over the map or entering the CCG or commissioning region, for example. In the image above right, I’ve selected two CCG areas towards the lower and higher ends of the improvement range. If you’re interested in finding the performance for your local area I’d encourage you to go and have a play.
In summary, then, there is some good news and some bad news. The good news is that clients are able to access services more rapidly than before and that for those that end therapy, their chances of recovery are more than one in two for the first time.
The bad news is that attrition is alive and well. 30% of referrals do not enter therapy. Only 39% of referrals reach the end of therapy, and only 18% achieve recovery. In that context, I find it hard to find too much to celebrate.
How do services improve?
I concluded the previous blog with a simple five-point plan that will assist any therapy service, IAPT included, to improve on its current performance. Rather than repeat myself here’s a link that will take you straight here.
I’d love to hear your thoughts on what you’ve read, whether you have a personal connection with IAPT or otherwise. Leave a comment below and please let us have your thoughts.
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This is the Alice in Wonderland take home message from IAPT workshops, BABCP conferences and CBT courses. But beyond depression and the anxiety disorders outcomes are fudged, massaged for public consumption.
At best admission to a randomised controlled trial is based on meeting the DSM criteria for the disorder. But there is no symmetry, outcome is not based on not meeting the criteria at the end of treatment. Instead dubious definitions of ‘remission’ and ‘recovery’ are used, which obfuscate whether there has been a real world change in the client’s life. It is impossible to determine whether or not they are back to their usual self.
By way of example Troscianko, in the May 2018 issue of Psychology Today, looked at CBT for bulimia, see link below:
she points out that the CBT outcome studies for bulimia use a criterion for remission as bingeing/vomiting less than twice a week for 28 days and recovery as not bingeing/vomiting for 28 days. Yet the DSM diagnosis of bulimia requires duration of the disorder of at least 3 months, transparency requires a similar period to obtain for recovery. The published results cite a 45% recovery rate but the small print indicates that this actually refers to a 28 day period. Further 30% of those who ‘recovered’ relapsed in a year, this casts doubt on the original definition of recovery. In addition the ‘positive’ findings have not been replicated by researchers independent of those who developed the protocols.
Matters become more Alice In Wonderland when studies are conducted , without the DSM criteria, for example in the case of chronic fatigue syndrome see link below
and there are prepostorous claims for success which evaporate when objective measures are used. This does not bode well for the development of an evidence base f or IAPT’s work with medically unexplained symptoms (MUS) and long term physical conditions (LTC’s). Doubtless there will be proclamations of success , but the yardsticks need to be published in advance and agreed before IAPT’s marketing exercise gets underway.
As a matter of respect clinicians necessarily focus on a client’s pressing concerns, but the time constraints imposed by routine services, such as IAPT, means that this becomes the sole focus. The upshot is that initially the client’s focus is say on their depression but at the next appointment on disturbing flashbacks/nightmares of child abuse and at the next appointment they may mention occasional excessive use of alcohol causing arguments at home. The clinician doesn’t know where they are working is this depression? PTSD? relationship problems/ alcohol dependence? or some combination thereof. This means the clinician is unable to help the client navigate through the fog of their difficulties, changing tack with every gust of wind.
Alternatively the clinician might simply pursue the first disorder ‘identified’ because the client doesn’t mention any other, discharging the client at the first signs of an improvement on some psychometric test or when progress has been made on that disorder. Despite the client actually suffering from a number of other disorders, making any gains in the ‘successful’ domain likely short lived. The client’s then go thru a revolving door. It seems that clients are rarely asked ‘are you back to your usual self following this treatment? and importantly ‘how long have you been back to your usual self for? [ anything less than 8 weeks is likely nothing more than the waxing and waning of the natural course of a client’s symptoms].
One of the ways of getting the bigger picture is to first use an open ended interview that contains the screen below, the dropbox link for this
APPENDIX A. SCIP screening questions
Codes: 0=absent, 1=present, 8=unsure, 9=missing data, unless otherwise
specified in the question
Questions apply to the present episode, typically the past month, unless otherwise
specified by the interviewer.
Felt very anxious and afraid out of proportion to the situation (with or
without physical symptoms) for more than one month?
Had panic attacks, when you suddenly felt anxious and frightened and
developed physical symptoms, such as fast heart beat, shaking, or
Been afraid of going out of the house alone, traveling alone, being alone,
being in crowds?
Been afraid and anxious doing things in front of people, such as eating in
public, speaking in public?
Had unpleasant and unwanted thoughts or images coming into your mind
over and over even if you try to get rid of them? Examples: Contamination
or aggressive, sexual, or religious thoughts.
Had the urge to do things over and over and could not resist doing them
(such as washing your hands even if they are clean, checking doors,
counting up to certain numbers, reciting phrases)?
Witnessed or experienced a traumatic event that involved actual or
threatened death or serious injury to you or someone else (e.g., physical or
sexual abuse, terrorist attack, natural disaster, war)? Did you feel intense
fear and helplessness?
Re-experience the traumatic event in the last month in a distressing way
Had physical symptoms or physical illness for which doctors did all
necessary work up and could not find medical explanation?
Had pain and your doctor did all necessary work up and could not really
Worried about gaining weight to the point that you self-induced vomiting,
or used diet pills, laxatives, or heavy exercise?
Eaten a large amount of food within an hour or so, that is binge eating?
Felt or described your mood as sad, downcast, gloomy, low in spirits, or
Been unable to enjoy things like walking, working at your hobbies, or
socializing with friends as usual?
Had thoughts about harming yourself or even made an attempt at suicide
(Include whether thought was due to depression or not)?
Felt very happy, elated without reason, or very irritable without reason?
Had mood swings: periods of depression and elation or irritability?
Felt that people are spying on you, follow you around, talk about you?
Felt that there is a plot or conspiracy against you?
Felt that people are trying to harm you or poison your food?
Had experiences of hearing voices or noises that other people cannot hear?
Had experiences of seeing things (images, flashes, shadows, objects,
people, whole scene) that other people cannot see?
Been violent in the past (with or without the influence of alcohol or drugs)?
I would like to ask you questions on alcohol use over the past year:
A. On days when you drank, did you drink >5 alcohol drinks per day
B. Did you have any problems resulting from drinking alcohol?
I would like to ask you questions on illicit drug use (e.g. marijuana) over
the past year:
A. Did you use the illicit drug >10 times per month?
B. Did you have any problems resulting from using the illicit drug?
The promise of evidence based CBT treatments and antidepressants seems not to be realised in practice, an editorial in the current issue of the Canadian Journal of Psychiatry notes:
‘Despite a 3- to 4-fold increase in the use of antidepressant medications, the prevalence of depression and anxiety dis orders in Australia, Canada, the United Kingdom, and the United States has remained unchanged over the past .1 20 years In the absence of compelling evidence that the incidence of these disorders is on the rise, a natural conclusion is that depressed or anxious patients who could benefit from treatment are still not identified and treated, or that the duration of illness has remained unchanged in those who are treated. This is a striking and troubling finding, considering the known efficacy of antidepressants and psychotherapies. It emphasizes both a well-delineated treatment gap, whereby many patients with depression or anxiety do not receive treatment, and a quality gap whereby those who are treated either do not need to be treated or do not receive effective 2-7 treatment’. Click link below for full editorial: https://www.dropbox.com/s/kbmly9awq9diflb/Collaborative%20Care%202018%20mediocre%20usual%20care.pdf?dl=0
Jorm AF, Patten SB, Brugha TS, et al. Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry. 2017;16(1):90-99.
Jorm AF. The quality gap in mental health treatment in Australia. Aust N Z J Psychiatry. 2015;49(10):934-935.
Lin EH, Katon WJ, Simon GE, et al. Low-intensity treatment of depression in primary care: is it problematic? Gen Hosp Psychiatry. 2000;22(2):78-83.
Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009;374(9690): 609-619.
Simon GE, VonKorff M, Wagner EH, et al. Patterns of antidepressant use in community practice. Gen Hosp Psychiatry. 1993;15(6):399-408.
Kendrick T, King F, Albertella L, et al. GP treatment decisions for patients with depression: an observational study. Br J Gen Pract J R Coll Gen Pract. 2005;55(513):280-286
But the editorial posits that greater collaboration between services would usher in the promised land. Whilst this might be helpful, a failure to understand what constitutes a faithful translation of the positive results of randomised controlled trials for depression and the anxiety disorders [see Scott (2017) Towards a Mental Health System That Works London: Routledge https://www.amazon.co.uk/Towards-Mental-Health-System-Works/dp/1138932965/ref=sr_1_1?ie=UTF8&qid=1547819366&sr=8-1&keywords=Towards+A+Mental+Health+System] into routine practice will continue to nullify any actions. Unfortunately in the UK, IAPT continues to pursue its own fundamentalist translation of the randomised controlled trials, despite evidence that it doesn’t work, with just a 15% recovery rate [ Scott (2018) see link below:
Further IAPT has extended its’ empire well beyond the borders of reliable evidence based outcome studies e.g to medically unexplained symptoms. Staff are frightened to speak out publicly. It is difficult to escape charging IAPT with imperialism. Theirs is a dominant narrative in BABCP, British Psychological Society and in journals such as Behaviour Therapy and Research.
according to a recent editorial in the American Journal of Psychiatry, by Dr Robin L Aupperie, he continues ‘evidence is mounting that non trauma focused therapies may have at least equal efficacy for the treatment of PTSD’. See the link below:
he points to only 30-40% of veterans with PTSD losing their diagnostic status following trauma focussed cbt. Dr Aupepperie raises doubts about ‘the presumed essentiality of trauma processing for the effective treatment of PTSD’. I have also raised doubts about it in a paper ‘PTSD an Alternative Paradigm’ which is under submission.
But there is a need to tread carefully in that there needs to be replication studies of the non-trauma focussed interventions in real world settings i.e not just with patients volunteering for a treatment, and across a broad range of settings i.e civilian and military. Nevertheless it does raise an eyebrow when a study comparing 8 individual sessions of mantram therapy with 8 individual sessions of present centred therapy [ Borman et al (2018) Am J Psychiatry, 175:979-988] concluded that 59% of the former no longer met criteria for PTSD at 2 month follow up compared to 40% in the latter. However psychology in general is replete with studies that have not been replicated [ Chris Chambers The 7 Deadly Sins of Psychology (2017) ‘After spending fifteen years in psychology and its cousin, cognitive neuroscience, I have nevertheless reached an unsettling conclusion. If we continue as we are then psychology will diminish as a reputable science and could very well disappear’] because positive outcomes are more likely to be published [ the file drawer problem] and the originators of a theory/intervention tend to be very charasmatic, creating a placebo effect. I have a feeling that the replication crisis is not taken as seriously in clinical work, with a paucity of studies in real world settings, using ordinary therapists and employing gold-standard assessments.
Just a footnote: the mantram therapy involved the repetition of a spiritually meaningful word, initially in non stressful situations e.g before bed, then applying this flashbacks and when woken from nightmares. The idea is to slow down thoughts and induce relaxation. The present centred therapy discusses current stresses and the problem solving of them in a non formal way. But in neither intervention was there a trauma focus.
IAPT specialises in poorly defined problems, making it easy to claim success. Good marketing ensures its’ claims are taken on board by politicians and NHS decision makers. None of the problems it addresses have been as sharply defined as necessitated in the randomised controlled trials of CBT. Dealing in fuzzy problems leads to trading in fuzzy outcomes.
This fuzziness makes it easier for practitioners to convince themselves they are doing a good job. For example remembering in graphic detail a case that worked and ignoring the many failures (the operation of the availability heuristic). But it all begins to lack credibility when there are high levels of burnout (68% in low intensity and 50% in high intensity) and a 22% annual staff turnover in low intensity. In addition some staff are subjected to league tables, incentivised to perform better by the promise of extra holidays and told to limit sessions to six.
IAPT’s original remit was depression and the anxiety disorders, but these terms had a very specific meaning in the rct’s. The boundaries of these disorders were defined by what Aaron Beck termed controlling for information variance (the range of symptoms considered pertinent for a particular disorder) and criterion variance (whether a symptom was present at a level that constituted impairment) as gauged by a standardised diagnostic interview. Neither type of variance has been addressed by IAPT, instead it has developed its own fundamentalist definition of what anxiety and depression are, eskewing reliable diagnosis. IAPT’s fuzziness has reached a new level as it extends its’ scope to medically unexplained symptoms, despite the injunction from DSM5 that just because something is medically unexplained that is not sufficient basis for saying that it is psychological.
IAPT marches ever on, perhaps it can ‘solve’ BREXIT
Clinical Commissioning Groups (CCG’s) should consider why other parts of the UK have not followed England’s lead on IAPT, after more than a decade. Wales, Scotland and Northern Ireland have remained unimpressed by IAPT’s groundbreaking claims and have not followed suit. In Wales almost 40% of people surveyed said ‘yes’ or ‘mostly’ when asked had the services they accessed led to improved mental health and wellbeing [Gofal (2016) Peoples experiences of primary mental health services in Wales Three Years On]. The results show that the largest proportion of respondents (79%) were offered prescription medication. The proportion of people who felt that they has been offered advice and information was 77%. 21.5% were offered Cognitive Behavioural Therapy, while 32% were offered another form of psychological therapy. 36% were offered a further mental health assessment. 26% were referred to another service and 17% were signposted to another service. Just 12% were offered physical exercise, 10% were offered books on prescription and 3% were offered befriending. If you have a mental health problem in Wales it is not obviously worth the trip across the border to an English IAPT service.
There are undoubtedly serious problems with mental health services across the UK, but these are no less in England despite IAPT. .
this is the conclusion of a recently published study in the Journal of Health Psychology
Scott Steen, the author of the the new cost-benefit analysis, comments ‘The first limitation concerns the high proportion of early disengagement which, according to the latest annual report, around 40 per cent of those entering treatment attend one session only (IAPT, 2018). Within the same annual report, approximately 43 per cent of assessed-only referrals were deemed suitable but declined treatment, while
23 per cent were deemed not suitable, and only 9 per cent were discharged by mutual agreement following advice and support (IAPT, 2018). The second limitation concerns the heavy reliance on brief, self-report measures and lack of long-term outcomes which, when using more in-depth and longitudinal techniques, have found intervention effects to be diminished or even temporary (Ali et al., 2017; Cairns, 2013; Hepgul et al., 2016; Marks, 2018; Scott, 2018)’.
Steen continues ‘research used to justify the economic benefits of the IAPT programme has little relevance for how it delivers and evaluates interventions. For instance, Layard and Clark (2014) cite a study conducted by Fournier et al. (2015) to justify the potential rate at which individuals move from incapacity benefits into employment. However, this specific study focuses only on patients who had recovered from severe depression, were assessed using structured clinical interviews and diagnostic criteria, and were treated by highly trained practitioners, the majority of whom had PhDs. Similarly, research into the long-term effects of interventions appears to have been selectively chosen, omitting the generally limited to mixed findings in this area (Marks, 2018)’.
In summary Steen opines:
‘Taken as a whole, the IAPT programme seems to be delivering treatment at an inefficient cost. Although outcome targets are being reached, this appears to be due to an increased emphasis on low-intensity styled provision which not only drives up costs-per-IAPT outcome but also potentially reduces the appropriateness of treatment allocation and sustainability of these outcomes’.