IAPT’s Modus Operandi: ‘squeeze the client into the briefest cbt, then eject’

and repeat the mantra that it is ‘world beating’ [ see Thrive by Layard and Clark (2014) and Can We Be Happier? Layard (2020)]. For Mariella her 7 IAPT (Improving Access to Psychological Therapies) sessions were a                     re-traumatisation of the abuse she had suffered in childhood. Four years after her IAPT treatment she was still suffering from low mood and likely chronic fatigue syndrome. The letter from the IAPT therapist said that she had responded to treatment because there had been a 6 point improvement on her PHQ9 and a 2 point improvement on the GAD7 and was therefore being discharged. Mariella refused to countenance a return to IAPT because she regarded it as having been a waste of time. IAPT specialises in putting square pegs in round holes:

Mariella’s maltreatment highlights several important issues:

  1. IAPT Gives Clients No Meaningful Choice At Either Entry or Exit. Mariella’s first face to face contact with the IAPT service was at a group meeting were she was invited to consider which of the services available might be most suitable for her. As she had spent years trying to discover what was really wrong with her she simply did not know what was appropriate for her.  She wondered whether her mood just changed like a bipolar relative. Mariella was convinced she had some underlying rheumatological disorder despite repeated negative testing. She was depressed that a few years ago she had been an exceptionally fit person and now it was total change. Mariella had no say in her discharge from treatment, her understanding was that she had had the allotted number of sessions. No follow up was arranged.
  2. IAPT Doesn’t Ask If Treatment Has Returned You To Your Old Self Mariella was never asked whether she was back to anything like her old self following treatment. The therapist simply pressed the eject button  after the predetermined number of sessions. There was no follow up to see whether improvement was enduring and whether treatment could be regarded as having made a real world difference.
  3. IAPTs Fixation on the PHQ9/GAD7 Mariella’s  score improved by 6 points on the PHQ9 during her IAPT treatment, this is held to be a ‘response’ by the service. This is to over interpret a test result. Such a change can occur with the passage of time e.g Gilbody et al (2015) particularly as people initially present at their worst. Further the test is administered without a reference standard, it was unknown whether Mariella’s primary disorder was depression, PTSD or CFS. No ‘gold standard’ assessment such SCID interview was conducted, making it impossible to a) gauge whether the selected test was actually tapping the primary disorder b) assess for comorbidity in Mariella’s case.  Yet comorbidity has treatment implications. 
  4. IAPT Not Only Fails To Identify Recognised Disorders But Also Fails To Recognise Personality Disorders In 2015 Goddard et al   used a personality disorder screen the SAPAS to gauge  whether it predicted outcome, it did https://doi.org/10.1016/j.brat.2015.07.006.. But it has since taken no steps to help therapists reliably recognise the presence of a personality disorder. Given Mariella’s history it is not at all impossible that this was a factor in her being refractory to treatment.
  5. IAPTS Failure To Access GP Records Means That Important Information Is Missed The records revealed that despite the NICE approved graded exercise Mariella, would spend days of exhaustion after such exercise suggesting that something in the CFS domain is occurring. IAPT totally ignored this dimension. 
  6. IAPTs’ Usage of the PHQ9/GAD7 Has No Predictive/Prescriptive Value It is of no more value than Physiognamy in bygone centuries were it was thought that from a photograph of a person one could infer character traits.
  7. IAPT Repeats The Mantra That It Is ‘World Beating” But there is no evidence that it is any better than a) the passage of time b) previous ways of organising psychological therapy. See forthcoming blog ‘No Added Value’. IAPT should try repeating this mantra to Mariella. 

Mariella is not the exception.  IAPT spectacularly fails its’ clients, operating in some parallel universe, unfortunately hooked up to the power holders.  When will they ever learn?

 

  Dr Mike Scott

 

 

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