NHS Talking Therapies for Anxiety and Depression provides snapshots of clients at each therapy session, using two psychometric tests. But these ‘pictures’ provide no indication as to whether the client would regard themselves as having returned to normal (or best ever) functioning for a meaningful period. Despite this NHS Talking therapies claims a 50% recovery rate! The time-frame used in the tests is the past two weeks, but remission in epidemiological [Bruce et l (2005)] studies and DSM-5-TR [American Psychiatric association (2022)] is defined as having no significant signs or symptoms for 2 months. NHS Talking Therapies has never used the 2 month real-world window, as the minimum period necessary for declaring recovery from an episode of anxiety or depression. Even this period would be insufficient for declaring lasting recovery. The changes depicted by the trajectory of the two psychometric tests, used without a reliable diagnostic context, have no more significance than an NHS Talking Therapies Flag stuck on top of its’ sandcastle, soon to be washed away.
The Service has this year made two switches that have not enhanced its’ credibility. The first, is to say its’ focus is now on the provision of ‘talking therapies’ and not ‘psychological therapy’. The latter term has historically been applied to psychological treatments that have been examined in randomised controlled trials (rcts). But there are no rcts of ‘talking therapies’, they are not evidence-based. The term can be taken to mean whatever the user wants it to mean. Is a person’s conversation with their hairdresser/barber a ‘talking therapy’, was my meeting, an hour ago, with an old school friend in a coffee bar ‘talking therapy’?
The second switch is to append the descriptor for ‘Anxiety and Depression’ to the Services’ role. But the Service takes no steps to ensure that established diagnostic gateway criteria for anxiety and depression are met. NHS Talking Therapies, is it seems dedicated to obscuring what it does, thereby ducking accountability.
On February 9th 2023, the NAO gave its’ seal of approval to NHS Talking Therapies (formerly the Improving access to Psychological Therapies, Service), legitimising the £752 million spent on it in 2021-2022. But the small print reveals that less than 50% of clients completed treatment (attended 2 or more sessions). Further the NAO, took at face value, the Service’s claim of a 50% recovery for completers. These are not the hallmarks of a legitimately funded public body. The NAO is strangely silent on the fact that there has been no publicly funded independent assessment of the effectiveness of NHS Talking Therapies. Nevertheless they recommend the Services method of self-audit, (repeated completion of 2 psychometric tests) for adoption by the rest of the mental health services!
diagnosis is not part of the repertoire of NHS Talking Therapies
to most people recovery means no longer suffering from the disorder/s that you presented with
psychometric tests measure the severity of a disorder, they are not diagnostic and cannot be the primary metric of recovery.
the duration of recovery is critical, and if not established talk of recovery is meaningless
the best independent evidence of recovery to date is that in fact the tip of the iceberg recover [Scott (2018) ]. The improvement identified by NHS Talking Therapies is most likely the effects of attention and regression to the mean. The burden of proof is on the Service to demonstrate that its’ clients fare any better than a matched group of clients attending say the Citizen Advice Bureaux.
If the NAO report were presented in a Civil Court, their findings would be dismissed because their conclusions are outside their area of expertise. NHS Talking Therapies is responsible to politicians and Integrated Care Boards, but to date the latter have failed to hold them accountable, `alongside the NAO. It is sadly reminiscent of Hospital Trusts not holding Senior Managers accountable.
NHS Talking Therapies has relied solely on two self-report measures in claiming a 50% recovery rate, in clients who attend more than two treatment sessions. But a study by Boals (2023) of self-report measures of posttraumatic growth (PTG) following a trauma, found that supposed beneficiaries were commonplace, 53% believing they were exceeding pre-trauma levels of functioning. However, Boals (2023) suggests the genuine growth rate is 0-10%. [This latter figure is strangely similar to the tip of the iceberg Scott (2018) that I found recovered in 90 clients going through IAPT (NHS Talking Therapies predecessor)]. The occurrence of genuine posttraumatic growth is very rare. Illusory PTG, occurs when an individual convinces themselves they have experienced PTG, mostly via fabricated illusions and motivated biases as a way to cope with the distress associated with the traumatic event. It seems likely this phenomenon would also occur when therapists ask clients how they have fared with the just delivered therapy in NHS Talking Therapies. The PTG self-report measures assess perceived PTG not genuine PTG. This suggests that the much publicised 50% recovery rate in NHS Talking Therapies should be treated with great caution. The recovery rate suggested by the self-report measures may also be largely illusory.
This is the bizarre mantra from NHS Talking Therapies digital partner, SilverCloud. The latter platform is based in Ireland and until recently it boasted ‘up to a 70% clinical recovery rate’. I protested to the Irish Advertising Standards that this was fraudulent, and Silver Cloud have since withdrawn any claim as to recovery. I explained to the ISAA that recovery has a clear meaning to a member of the public, as back to their old self or best functioning. As SiverCloud studies have never demonstrated achievement of this metric, it was highly misleading. Its’ new vanguard claim is ‘up to 65% of users achieve clinically significant improvement’. But I wouldn’t change my internet provider if the would be provider claimed an ‘up to particular speed’, I would smell a rat.
The term ‘clinically significant improvement’ only has meaning if the population being addressed is clearly specified. The mnemonic PICOT is recommended by the NHS and NICE to establish the credibility of an intervention. The ‘P’ stands for population, established with a ‘gold standard’ procedure. But in none of the studies cited by SilverCloud has the ‘population’ been crystallised using a standardised diagnostic interview nor has outcome , the “O” been determined by a blind independent assessor using a ‘gold standard’ interview. The cited SilverCloud studies lack any credibility.
It is disingenuous of SilverCloud to now claim ‘up to 80% of participants show improvement in depression and anxiety symptoms’. Once again we have the advertising gimmick of ‘up to’. With no specification of who the ‘participants’ are with regards to the P of PICOT. The platform has not used a credible attention placebo to determine whether any identified changes are any more than regression to the mean. Similarly stating ‘93% users satisfaction’ is no more compelling than restaurant owners saying 93% of customers said they were satisfied when asked, leaving the premises.
Why does NHS Talking Therapies associate itself with SilverCloud? It offers the alluring prospect of wide dissemination of a service at minimal cost. Quite simply it is fixated on a fantasy, such a state of mind is a recipe for abuse. The time is long overdue for NHS Talking Therapies and NHS Managers to be properly regulated.
The received mantra of NHS Talking Therapies is that 50% [ IAPT Manual (2019)] of its’ clientele recover. This is the basis for the £1billion a year funding of the service. But the small print states that that the claim is based on clients who completed a self-report measure at their last contact and had attended 2 or more treatment sessions. A just published study by Pigott et al (2023) shows the spin to be had from relying on a self-report outcome measure. These authors re-analysed outcome data on the efficacy of antidepressants. It was initially reported that the average remission rate was 48.4%, but Pigott et al (2023) pointed out that that this was based on the clinic-administered Quick Inventory of Depressive Symptomatology-Self-report, despite stating in the pre-trial protocol that all such measures would be excluded. The results of a blind independent assessment (the clinician Hamilton Rating Scale for depression) went unreported, but revealed a 25.5% recovery rate! The results for NHS Talking Therapies and antidepressants are likely no better than if a client was given attention and a credible rationale as to how to emerge from their chaos. In routine practice there is nothing to indicate that responses to therapeutic endeavours are any greater than placebo. Neither, the NHS Talking Therapies data nor the STAR*D data [Pigott et al (2023)] have involved a control condition. Nevertheless, the hype has continued, on November 8th 2022 the New York Times reported that ‘nearly 70% of people had become symptom free by the fourth antidepressant”’. Interestingly the dropout rate in the Star*D trial was 53.7%, much the same percentage as those who did not complete treatment in NHS Talking Therapies. With regards to NHS Taling Therapies there is no evidence of treatment integrity – a translation of the protocols of randomised controlled trials for CBT to routine practice.
Writing in 2009 the psychologist Oliver James wrote ‘Two years ago when the Department of Health announced it was investing £173 million in CBT, a press release claimed that the therapy permanently cures half of people with depression. But this was downright dishonest. There is not a single scientific study which supports that claim’. Fast forward 14 years and the re-branded service NHS Talking Therapies have proferred no study to justify the initial claims. Instead, we have a deafening silence. But it is regarded within BABCP and BPS as axiomatic that it is ok to spend a £1billion a year on the Service. This looks suspiciously like expansionism. History is unfortunately littered with such behaviour but it is not confined to nations. All that is necessary, is for expansionists to recruit powerholders, who want to be seen as on the side of the ‘good’ for their own agrandisement, and have no wish to ask probing questions. Enter stage right liberally minded politicians and civil servants. Doubtless many of the great and good in BABCP and the BPS would echo Mr Putin who claimed:
Right? And who is advocating an independent audit of NHS Talking Therapies?
It is not at all easy to put your head above the parapet and question the modus operandi of NHS Talking Therapies. Many fear it is the pathway to professional suicide. But the adage that ‘all that is necessary for evil to triumph is that good men remain silent’ has been very apt over the past 15 years. Discussion on NHS Talking Therapies is prevented in BABCP (see’ Vanquished by BABCP Presidents’ http://www.cbtwatch.com/iapt-the-myth-and-the-reality-vanquished-by-babcp-presidents/ ) and recently the Editor of the Psychologist (https://www.bps.org.uk/psychologist/weve-never-been-more-fertile-environment-psychological-approaches-expand-and-take-root) in an interview with Dr Whittington, totally failed to challenge the basis of the latter’s mission to expand the reach of the Service. A petition is a necessary voice of protest.
NHS TALKING THERAPIES PETITION
We are calling for:
A thorough independent review and audit of the NHS Talking Therapies
A diversity of talking therapies, including relational therapies, to be made available
A genuine response to community need
Improvement in staff pay and conditions
SIGN AND SHARE NOW:
NHS Talking Therapies Petition
One Size Does Not Fit All; Independent Review for NHS Talking Therapies Needed Now
We’re calling on Maria Caulfield Minister of State for Mental Health to urgently and independently review the provision of Community Mental Health Care via NHS Talking Therapies (NHS TT – formerly known as Improving Access to Psychological Therapies, or IAPT).
We believe that while more and more people are suffering from common mental health distress, the availability and accessibility of therapeutic help via the NHS Talking Therapies has become severely limited, indeed a denial of care. NHS TT claim to provide a successful adult mental health service but this is based on their own statistical data which is presented in a misleading way. Neither IAPT nor NHS TT has been subjected to independent audit. An independent review is now crucial to enable a change towards the provision of a service which can genuinely and flexibly respond to the psychological and emotional needs of our communities and support staff in their pay and conditions.
What is wrong with NHS Talking Therapies?
Restricted choice of therapy options, frequently limited to CBT, web based self- help therapy or non-relational therapies using scripts
An exceptionally high drop-out rate; only one third of people finish treatment
Misleading use of data to claim a 50% recovery rate
Misleading use of data to claim 90% of people referred are seen within 6 weeks
Very low follow up rate so no evidence of therapeutic benefit over time
Many therapists are working for low pay, long hours, in gig-economy contracts. Stress and burn out are very common due to pressure to produce ‘results’
Thousands of trained psychotherapists and counsellors are available but not employed in NHS Talking Therapies
A highly medical and individualised model, with little recognition of the social causes of mental health distress
Not cost effective, private companies providing ‘care’ for profit
More a denial of care than care responding to people’s needs
Fails to address inequality in mental health care
Little hope of providing ‘integrated care in local communities for people suffering severe and common mental health difficulties ‘ as promised in the NHS’s Community Mental Health Framework for Adults and Older Adults (2019-21)
An ideological project adapted to utilitarian and managerial values
Protect our NHS
Psychotherapists and Counsellors for Social Responsibility
Campaigning for universal Access to Counselling and psychoTherapy (uACT)
Informed decision making is obligatory not only with regards to physical but also with regards to mental health. But NHS Talking Therapies clients are never informed that they would likely fare just as well attending the Citizen’s Advice Bureaux or a Charity such as Anxiety UK, Scott(2018). The client has a right to know, at the outset, that the service haemorrhages clients.
The trajectory of patients in NHS Talking Therapies is rather like that of horses entering the Grand National. There were 1.69 million referrals to IAPT ( the predecessor of NHS Talking Therapies) in 2019-2020, 1.17 million left the starting gate, 30.77% (almost 1 in 3) were non-starters. Further only 1 in 3 (36.8%) got around the course (defined curiously by IAPT as attending 2 or more treatment sessions).
In the UK since the Montgomery Judgement of 2013 it is the patient who is choosing from the treatment/non-treatment options and it is obligatory on the professionals to present all the options the ‘patient’ might consider important and not those the professional considers salient. The Judgement arose from a case in which a mother was not informed of the dangers of a vaginal delivery and had she been fully informed, would almost certainly have opted for an elective Caesarean.
If a person attends the Citizen’s Advice Bureaux with mental health problems they likely have a fair idea of the limits of expertise of the CABx worker. But in attending NHS Talking Therapies a member of the public is likely to have an inflated view of the level of expertise of the personnel they first encounter. The Service takes no steps to address the client’s likely misjudgement, for example they do not state upfront that they are not qualified therapists. It is likely that NHS Talking Therapies violates the principle of informed consent.The Montgomery judgement has yet to percolate down to mental health.
It is only a question of time before NHS Talking Therapies is brought to task on this matter in the Courts.
Since the millennium, attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD) have entered the vernacular. It has become commonplace for concerned parents, teachers and mental health practitioners to place children on ‘pathways’ for these disorders. But what is the evidence that the children arrive and stay at, a better place? There are often alternative pre-millenium descriptions of the child’s difficulties, that were, at least in principle, the gateway to an evidence-based treatment. For example were child non-compliance was a major issue there were Group Parent Training Programmes Scott (2015). There were also cognitive-behavioural interventions for anxiety and depression. Reviewing GP records since the millennium, there is a conspicuous absence of fidelity to any evidence-based intervention for children. Instead the records are replete with mental health practitioners conjectures (‘formulations’) about the child being on the autistic spectrum or having ADHD. Yet no evidence of fidelity to any programmes for these ‘disorders’. Whatever the evidence for the efficacy of treatments for ADHD/ASD in randomised controlled trials, there is no evidence of its’ translation to routine practice. Pragmatically it may be better to concentrate on pre-millenium descriptors, keeping treatment relativity simple and straightforward. Importantly not allowing the premature use of ADHD/ASD, descriptors to distract from delivering evidence-based treatments. This is a specific exemplar of how to address the issue of possible comorbidity in routine practice see Nordgaard et al (2023).Nordgaard, J., Nielsen, K. M., Rasmussen, A. R., & Henriksen, M. G. (2023). Psychiatric comorbidity: A concept in need of a theory. Psychological Medicine, 1-7. (Link)
Since the millennium, attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorder (ASD) have entered the vernacular. It has become commonplace for concerned parents and teachers to place children on ‘pathways’ for these disorder.
The descriptors ADHD/ASD, in fashion since the millennium, refer to traits. This shifts the focus from treatment, with an implicit notion of recovery, to support, an offsetting of the ill-effects of the said traits. Demonstrating achievement of the latter is likely to be highly subjective. It is much less debilitating to have a professional agree that you are having difficulties or are in a ‘state’ than to be told that you have a dysfunctional trait. Keeping treatment simple has been lost since the millennium. This does not rule out the possibility of the use of a trait like descriptor if the ‘simple’ interventions Scott (2009) have not worked, but it means the exercise of great caution and journeying with the person if this territory is entered into.
See Nordgaard et al (2023) for the interplay of state and trait [Figure. 1. Illustration of state and trait conditions. (a) A state condition with a single episode of a disorder, e.g. major depression. (b) A state condition with recur- ring episodes, e.g. bipolar disorder. (c) A trait condition, e.g. schizophrenia. (d) A trait condition with a comorbid state condition, e.g. personality disorder with a single episode of major depression].
Adults with treatmentrefractory depression and/or longstanding interpersonal difficulties, desperate for a new direction, can experience a sense of relief when the ASD/ADHD labels are put to them. They may find themselves taking new medications without being told that at most only short term benefits have been documented. They are lured into thinking ‘it’s just the way I am’. Their humanity, freedom to choose is denied . The trait pathology can be underlined by giving a person labelled as having a borderline personality disorder an additional ADHD label as their abrupt mood swings and interpersonal difficulties continue. Whilst this may be welcomed by the individual competing simpler explanations are not considered e.g a child with great difficulty concentrating at school, living in a household with intense parental conflicts hidden from public view. Since the millennium mental health practitioners have failed to utilise the social axis of the biopsychosocial model making explicit excessive use of the psychological axis and implicit excessive use of the biological axis.
Problems at the starting gate
The problems begin with the many false positives for ASD/ADHD at the start of the pathway. In many cases it will transpire that the child does not have one of these disorders. Which, whilst undoubtedly good news for all, the GP records will show that the child was placed on the pathway. Many years later a potential employer when asked to chose between candidates with say, the same paper qualifications, may well ‘play safe’ and choose a person who was not put on a pathway. Whilst one rightly complain that they should not engage in such discriminatory behaviour, given their own agenda of a ‘trouble free’ workplace it is perfectly possible that they will.
Science works by categorisation but distinctions have to be meaningful
There is no sharp dividing line between having mild ADHD/ASD and being at the extreme of inattention and struggling to connect with others. The diagnoses are likely less reliable at the mild/normal interface. But a pyramid likely applies to both disorders with many more people with mild disorder as opposed to those with moderate/severe. Thus the group most likely to suffer the effects of misdiagnosis, is likely the largest group. Curiously the NICE Guidelines on ASD recognise this in that they state not only should diagnosis not be made on the sole basis of a psychometric test but there should also be evidence of at least moderate functional impairment. But in practice specialist clinicians operate primarily on the perceived degree of match between the person and their prototype of a person with ASD. Diagnostic criteria are not central, albeit that adherence is commonly claimed.
When it comes to BPD can a meaningful distinction be made between those with the disorder and those without. The concept of BPD has a long history, but this of itself is not evidence that the diagnosis is valid. Nevertheless clinicians have for a long time thought that they were describing a meaningful entity with regards to BPD. It can be contended that they were simply ‘deluded’ in this connection but this feels suspiciously close to a ‘pathologising’ of clinicians normal reactions.
The obscurity of the mechanisms by which these disorders arise
Along the pathway the ADHD/ASD person will encounter a specialist service for these disorders. But this can introduce a confirmation bias, on the alert for a disorder that justifies the agencies existence. This bias may operate non-consciously and may effect the level of attention given to an alternative, often simpler, explanation of, typically the young person’s behaviour. Documentation may be reviewed that simply confirms the suggested diagnosis. For example reports on family functioning might not be called for, had they been it could become apparent that the child was simply disturbed/agitated by family chaos including minimised drug addiction and domestic violence. One parent may be pursuing the ADHD diagnosis to increase his/her benefits. But for the busy professional there is a disincentive to consider the widest range of information.
A more recent development that I have noticed is an adult with a longstanding depression or difficulties in relationships being diagnosed as ADHD/ASD. The ‘specialists’ having ruled out significant childhood traumas have then gone on to make these diagnoses. But closer examination of the person with recurrent depression may have revealed that separation anxiety was a feature of early life and a predisposing factor for the depression. It may have also predisposed the person to over-idealise a relationship, over investing and then feeling total abandonment when the relationship does not deliver. Alternative simpler explanations would have been depression and possibly borderline personality disorder.
Does treatment work?
A case for these diagnoses can be made, Morehead 2023 but it carries dangers. Schools/parents have a right to be informed of these dangers. I have to date found no compelling evidence that medication or psychological treatment returns sufferers from these disorders to their best functioning and certainly not to have ‘recovered’ in the sense that a member of the public would understand the term. I suspect that there is even less evidence for effectiveness with mild levels of these disorders, the most numerous. Schools/parents have a right to be informed of this.
In terms of the 2013 Montgomery judgement it is not a matter of what doctors think a patient should be informed about, but what the patient would think are important considerations. The Montgomery Judgement has yet to percolate down to mental health.
At the behest of BABCP and BPS the ranks of those with a mental health orientation in schools is likely to be swelled. But the likelihood is that this will just increase the flood along the pathway.
After 15 years of the Service and £10 billion spent on it, we still do not know! If ever there was a matter for Health Ministers, the Office of Budget Responsibility and the Nation al Audit Office, this is it. To date NHS Talking Therapies have only ever taken their own snapshots of clients, discharging them as soon as their scores fall below ‘casenness’ on a psychometric test. But the natural course of anxiety and depression is a waxing and waning. A photo at any one point is next to meaningless, particularly if it is taken by a party with a vested interest in declaring recovery.
In a 2 year naturalistic study, of depressed, anxious and depressed plus anxious patients in the Netherlands, Penninx et al (2011) the criteria of recovery was at least 3 months free of symptoms as assessed by a diagnostic interview. This metric ensured that they were looking at how long it took to what could be taken as a real-world change. [A far cry NHS Talking Therapies studies]. With half of depressed patients recovering within 6 months. Half the anxious group recovered by 16 months and half the combined group by 24 months. Of those who remitted a quarter relapsed. Approximately half the population had psychological treatment and they fared no better than those who didn’t. There is no evidence that NHS Talking Therapies clients fare any better than those in the Netherlands or than those attending the Citizens Advice Bureaux.
In my capacity as an Expert Witness to the Court I reviewed 90 cases Scott (2018), some of whom had NHS Talking Therapies treatment before a personal injury and others who were treated afterwards, whichever was the case only the tip of the iceberg recovered. I called for a a publicly funded independent assessment of the Service, 5 years on, nothing, just a rebranding of IAPT earlier this year.