In Practice, Off-The Shelf Solutions Silence IAPT Client’s Concerns

the Talking Therapist does the ‘talking’ not the client: 

Noreen was held at knife point in the corner shop in which she worked, she had flashbacks and nightmares of the incident. She was fearful of another armed robbery. Then she was a passenger in a car in which the driver lost control, became fearful of travelling by car and postponed her driving lessons. Noreen completed an Improving Access to Psychological Treatment (IAPT) telephone assessment in which she was scored 8 on the PHQ9 and 11 on the GAD7.  No diagnosis was proferred and the letter from IAPT to her GP said ‘agreed with us to be put on a waiting list for computer assisted CBT’. 3 months later she received a letter from IAPT saying she had been discharged because she had not activated her online therapy accoun.

1. No Listening Ear In IAPT – Noreen had multiple concerns: memories of the robbery, fear of car travel and several bereavements but there was no space for her to vocalise all these in her assessment. Instead she was offered an off the shelf solution computer assisted CBT but with no indication as to how this would remedy her concerns.

2. No Meaningful Agreement to Treatment In IAPT – IAPT makes a play of offering ‘customer choice’ but Noreen did not know what computer assisted CBT involved, much less what the evidence base was on it resolving her presenting complaints and how it compared in efficacy to other treatment options such as face to face CBT. In short IAPT does not offer informed choice, it offers tokenism with regards to customer choice.

3. No Meaningful Assessment in IAPT – Noreen was none the wiser about her difficulties after the telephone assessment and it is not at all surprising that she did not go onto engage in the computer assisted CBT

4. IAPT Blames The Client For Not Engaging In Treatment – the letter from IAPT to Noreen and her GP says ‘sorry you have not activated your…online therapy account….discharged’

5. IAPT Engages In Pseudo- Science  – reporting psychometric test results to GP’s, as if they have a meaning without reliable diagnosis. The social context of the client’s difficulties are deemed not worth reporting.

Low intensity interventions are off-the shelf solutions, their very availability makes them more likely to be deployed, despite their inappropriateness to the task in hand. Even brief attention to Noreen’s difficulties, would suggest a differential diagnoses of PTSD, a specific phobia about travelling by car and depression. If that was as far as the assessor got, and there is no indication that he got even that far, how on earth would this suggest the appropriateness of a course of computerised CBT!

Availability Heuristic The Off-the shelf low intensity interventions have created a new availability heuristic. Traditionally this term is used to describe the way in which the vividness of an experience e.g graphic memories of a serious accident give a mistaken impression of how likely it is [ see Daniel Kahneman Thinking Fast and Slow. Penguin Pres]. It seems that for the Psychological Wellbeing Practitioners who are the usual assessors of clients coming into an IAPT service have a particular familiarity with the low intensity interventions leading them to deploy them inappropriately. Further they may have a graphic memory of one client who did really well in low intensity CBT, oblivious that such a case is very much the exception. This use of the availability heuristic is heightened by the IAPT organisation declaring that low intensity interventions are to be the bread and butter of PWP’s.  Possible shortcomings of low intensity interventions are often glossed over by PWP’s on the grounds that if they don’t work the client can always be stepped up to high intensity, but such stepping up is rare about 10%.  There is a failure to acknowledge that a) if the first intervention does not work a client can become demoralised and dropout  and b) there is no independent evidence that a significant proportion of low intensity clients lose their diagnostic status as a result of this minimalist approach.

Noreen is yet another example of how IAPT fails clients and the problems are systemic, not confined to some PWP’s not adhering to best practice.

 

Dr Mike Scott

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