Declining IAPT – Clients Reject The Service

Rejection of the Improving Access to Psychological Treatments (IAPT) service continues to be the norm. Yet it has been funded to the tune of £4 billion without any independent demonstration that it has better recovery rates than its’ predecessors.

Nearly a decade ago, Richards and Borglin https://doi.org/10.1016/j.jad.2011.03.024 examined the pathway of over 7000 Improving access to Psychological Treatments (IAPT) clients – of those referred, 27.3% did not materialise for an assessment. Of those assessed 26.8% did not go further. Of those attending treatment 29.5% completed only one session. Of those initially referred  the rate of non completion of treatment was 62.5%. [Were ‘completion’ was defined by IAPT as attending 2 or more sessions]. This pattern of engagement is identical to that found in my 2018 study   https://doi.org/10.1177/1359105318755264    there are no signs of improvement, see the Table from my paper ‘IAPT – The Need For Radical Reform’

IAPT’s engagement and retention of clients (n=90).

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1. 23.6% of clients either did not initiate contact with IAPT (an opt-in arrangement) or IAPT were unable to contact them to arrange an assessment
2. 13.3% attended only an initial assessment
3. The mean number of treatment sessions attended was 5.5 with a median of 4.0 sessions, with missing data on one client

4. 39.3% attended 2 or less treatment sessions 5. 57.3% attended less than 6 treatment sessions 6. 23.6% attended 6–8 treatment sessions
7. 80.9% attended 8 treatment sessions or less 8. 4.5% attended 20 more treatment sessions

If such rates of ‘decline’ of treatment had been present in the randomised controlled trials  of the efficacy of CBT, then the latter would have been summarily dismissed.  There would have been no NICE guidance advocating CBT for depression and the anxiety disorders. In the IAPT service the average number sessions attended by those who engage in treatment is 6, this would be regarded as a sub-therapeutic dose of treatment in any of the rcts for CBT. No trial of CBT has ever been conducted with the average dosage delivered in IAPT. It strains all credibility to believe IAPT’s claim that it has achieved the 50% recovery rate that is common place in the rcts of CBT.

IAPT ignores the haemorrhaging and deftly switches the public focus to waiting times and numbers seen. The advantage of such key indicators is that it can always be claimed that with more funding waiting times will reduce and numbers seen increase and so the Titanic continues at speed. The crucial question that is avoided is ‘do waiting times matter in a context in which most decline to engage or complete treatment?’.

An unholy alliance between NHS England and IAPT has meant that the latter’s definition of the key indicators of success has been allowed to hold sway. The public are the victims of a failed duty of care.

 

Dr Mike Scott

8 thoughts to “Declining IAPT – Clients Reject The Service”

  1. “If such rates of ‘decline’ of treatment had been present in the randomised controlled trials of the efficacy of CBT, then the latter would have been summarily dismissed. ”

    Those rates were found in most CBT trials for MUS, especially for ME/CFS. In fact it’s a common theme in the literature, expressing frustration at how difficult it is to get participants in the first place but also to get them all the way through. Every step in those experiments had dropouts, including follow-ups, even in the larger trials like PACE. Reasons for dropouts are never examined, or never make it into publication anyway. They are always framed as non-compliance but otherwise dismissed. In finance this would be creative accounting, the kind that doesn’t end well.

    This may apply differently to IAPT for common mental health issues but for LTCs and MUS those problems are significant enough to be a common, even growing, theme in the published literature. Did not stop IAPT from going ahead despite having found those problems at every step of the process and despite incorrectly citing the costs of MUS to the NHS, a figure that had to be corrected with efforts by David Tuller as it was clear that the inflated figures were cited incorrectly on purpose. Even after acknowledging they were incorrect BMJ editors had to be pushed and prodded to actually correct them, even saying “what’s the point of correcting those old figures?” even though they are the basis to justify the program.

    IAPT extension for LTCs and MUS was justified on those costs and the expected savings it would bring, despite the trials themselves, like PACE, having not found any of those benefits. As PACE did not show any clinical benefits, it’s hard to justify why there was an economic analysis other than to fabricate the evidence for the IAPT-LTC expansion. All those issues, dropouts at every step included, were superseded by the lure of imaginary savings, still going strong to this day.

    I think that an examination of the process those trials and experiments went through, what did not make it into cherry-picked papers, will show this was a widespread problem that was simply buried as otherwise, as you say, it would have cut the whole project short. There seemed to have been an ends justifying the means attitude.

    Although maybe notable is that none of those were adequately controlled trials. That was always a major issue in itself but it can’t really be defended that the evidence was ever convincing enough to keep going.

  2. Hi Richard
    I was thinking of the depression and anxiety disorder trials when I wrote my piece, but the CFS trials are a totally inadequate basis for anything. it beggars belief to think they were used to fuel the IAPT expansion to MUS and LTCs.
    There is a very interesting piece in Richard Layards new book on happiness in which he said that he had 61 face to face meetings with politicians to get IAPT off the ground but he had the assistance of a powerful persuader David Clark. You then add the BABCP hierarchy and BPS as apologists for IAPT and one gets an insight into how David must have felt against Goliath.
    Take care

    Mike

    1. Hi Michael
      Your comment prompted me to re-read again the IAPT chapter in the CBT: the Cognive Behavioural Tsunami book, it makes sobering reading. It highlights the pressure that the IAPT approved AQP (Any Qualified Provider) are under, the simply won’t get funds if they don’t reach certain numbers, or depict a 50% recovery rate as defined by IAPT . They are under the cosh. The pressure to distort results is enormous, yet IAPT totally fails to ensure any independent audit. It is collusion between IAPT and AQPs that needs exposing
      Mike

  3. Hi Mike, [You could, usefully, put CBT Watch on Facebook, for easy messaging.]

    Thought you might like an interesting Lancet letter that puts another slant on the damage ‘talking therapies’ do: the time they waste is often the only contact patients get with people who might have any power to help them, but they are often commanded to ’empty their minds’ of all that.

    It’s a brilliant letter about what I think has been an entirely overlooked aspect of the fashion for psychosocial ‘talking therapies’: their wasting crucial time that should have been used for addressing powerless patients’ real physical concerns.

    This example is in the context of traumatised refugees, but it has general application in the mental health world. Those compulsory ‘relaxation therapy’ sessions, where the ‘therapist’ just silences the ‘class’ and plays a stupid, patronising-voiced, and time wasting cassette tape or CD, are often, if not invariably, the *only* attention mental health patients get from actual ‘therapists’ at all (They probably will never see an actual psychiatrist except at admission and discharge.).

    When you really start to look into it, this whole misguided money-saving exercise of replacing objective treatment of individual cases, with continuously rebranded simplistic brainwashing or hypnosis sessions, must be ruining countless lives, the world over. 🙁

    ” My ethnographic analysis shows that in this context, mental health interventions (eg, didactic counselling and cognitive behavioural treatments) have become outlets for beneficiaries to voice the very real problems that they are experiencing in daily life in the settlement. Most frequently, these are issues concerning scarcity of food, ineffective and inconsistent medical care at the health facilities, an absence of financial support to afford basic needs that fall outside of humanitarian aid (eg, soap and basic hygiene products or school supplies for children), and security concerns related to threatening living conditions in the settlement (including but not limited to domestic, sexual, and gender-based violence). Heavily scripted interventions like Self-Help Plus risk exacerbating the feeling of voicelessness and powerlessness that refugees are so accustomed to, silencing one of the few channels that people employ in an attempt to be seen and heard. Such interventions also risk shutting down the deeper political backdrop to their suffering.”

    This letter goes well with the recent ‘The Conversation’ piece I posted on FB yesterday, where it was suggested that ‘mental health’ problems would be better addressed by attention to the anxiety-causing circumstances under which so many people now live.

    https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30106-6/fulltext

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