Critique Of IAPT On BBC TV

here is my 5 minute interview with BBC TV, https://vimeo.com/316124732

the main points are:

  • only the tip of the iceberg of those attending IAPT fully recover https://journals.sagepub.com/doi/10.1177/1359105318755264 this contrasts with the Organisations claim of a 50% recovery rate
  • IAPT has only ever marked its’ own homework, despite over £3 billion being spent on it in the last decade. There has been no independent assessment of outcome, of the quality that would be expected were the effectiveness of a drug was being evaluated
  • IAPT fails to effectively engage and treat people. The IAPT Annual Report (2018)/2019] see link below, reveals that a third (31.2%) of new referrals drop out before treatment and approximately two thirds (61.1%) do not complete a course of treatment (using IAPT’s liberal definition of treatment as attending 2 or more session) with almost a third (29.54 %)  attending only one treatment session.

    https://www.dropbox.com/s/hwn9ncuuyds8qfa/IAPT%20Annual%20Report%202018-2019.pdf?dl=0

  • the most common gateway into IAPT is via a 20-30 minute telephone assessment with the most junior members of staff who are trained to signpost people via problem descriptors they do not make diagnoses
  • most IAPT clients do not get psychological therapy rather they are given either guided self help, computerised cbt or invited to attend a class/group i.e they receive low intensity interventions which are without the evidence base of the psychological therapies (high intensity)

Dr Mike Scott

Expansion Into Long Term Conditions By IAPT Is Quackery

so challenge Clinical Commissioning Groups on the value for money – no better than homeopathy. Studies of CBT  for long term conditions (LTCs) show either no effect, see Serfaty et al study (2019) on cancer https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/effectiveness-of-cognitivebehavioural-therapy-for-depression-in-advanced-cancer-cantalk-randomised-controlled-trial/E9264C516634EC7BC3FF9E80B551A8C5

and/or rely on a self report measure of questionable real world significance, see the Everitt et al  (2019) study of irritable bowel syndrome https://www.thelancet.com/journals/langas/article/PIIS2468-1253(19)30243-2/fulltext In the Everitt et al (2019) study outcome was assessed primarily by the patient’s completion of a 5 item measure of the severity of IBS (IBS-SSS) rather than a clinician independent of the study asking the IBS-Adequate Relief  question ‘ since… have you had adequate relief of your IBS’. Usually the IBS-AR uses the time frame of the past seven days but in the context of assessing CBT it could be since entering the study for a control group or since cbt for those having cbt.  The correlation between the IBS-AR and IBS-SSS though significant is small see Passos et al (2009) http://nrs.harvard.edu/urn-3:HUL.InstRepos:35859644

The authors of the Everitt et al (2019) study appear not to realise  that use of a self-report measure as the primary outcome measure introduces a demand effect for clients undergoing cbt, they don’t want to feel that they have wasted their time. Further the Passos et al (2009) study showed that the IBS-AR is much less subject to fluctuation than the IBS-SSS. Arguably the IBS-AR is of much greater social significance, addressing whether an intervention makes a real world difference. 

It is worrying that Everitt et al (2019) opine:

‘Offering both web-CBT and telephone-CBT in NHS services such as Improving Access to Psychological Therapy could allow many patients to gain substantial benefits with web-CBT with minimal therapist input while allowing a step-up approach to telephone-CBT for those needing additional
support’

IAPT will surely jump on this to justify empire building and likely ignore the caution of Serfaty et al (2019) 

‘our results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these  findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness’

If as seems likely Clinical Commisioning Groups fund IAPT’s expansion into LTCs they should be asked to justify this expenditure in the abscence of any empirical base.  

Dr Mike Scott

‘Go To Hell, If You Don’t Jump Through Our Hoops’

that’s the take home message absorbed by a partner of an ex-soldier with PTSD, broadcast on BBC Radio 4’s Woman’s Hour yesterday, available as a podcast . Her partner was referred by his GP several times for psychological treatment, but he didn’t go though the ‘opt in’ procedure (ringing up and agreeing a telephone assessment) so in the words of the agency the referral was not ‘activated’.  He then developed a psychosis when she developed cancer and there was a further episode of psychosis before treatment got underway. But it doesn’t stop there she was never involved in the treatment despite that they could no longer sleep in the same bed because of his nightmares and his response. The treating clinicians it seems are unaware that social support is the biggest predictor of recovery from PTSD and that the disorder has a devastating impact on relationships.   Fortunately she got some help for herself from an online forum for partners of those with PTSD run by combat stress.

Clinical Commissioning Groups need to be made aware of what goes on in the mental health services they fund to the tune of £6-7 billion a year, with over £300 million being spent on IAPT each year, this amounts to billions of £’s being spent on IAPT since its’ inception, it is surely criminal that this has taken place without any independent evaluation of outcome.  

The ‘go to hell approach’ is unfortunately not confined to the process of engagement with the services, it also features in treatment – a client of mine with PTSD was told in an IAPT service the focus of the session was trauma focussed CBT/EMDR but he was concerned to talk about the devastating impact the Manchester bombing had had on his niece and he was given no such opportunity to discuss these concerns, the trauma focussed treatment proceeded relentlessly, all to no avail. 

I think it would be excellent if people sent the Radio 4 broadcast to their Clinical Commissioning Groups, the links can be accessed below, asking that they critically appraise the operation of IAPT.  Both Radio 4 and Radio 5 Live are making more broadcasts on these matters in the coming weeks and it would be great if people could disseminate the material as far as possible

https://www.england.nhs.uk/ccg-details/

Dr Mike Scott

 

 

Sorting Assessment of CBT Competence

the assessment of CBT competence has become a mess within IAPT, with poor agreement between assessors on whatever measures is used and an inability to predict outcome (see references at the end of this blog). The problem goes to the very heart of IAPT, a failure to ensure a reliable diagnosis. In randomised controlled trials when the competence of clinicians is being assessed it is known that there has first been  a reliable diagnosis of the disorder under study, and this determines what are appropriate targets, whether a skill appropriate to each target is being deployed and the skill of that deployment.  Without the anchor of reliable diagnosis  assessments of CBT competence will be highly idiosyncratic.

In Simply Effective CBT Supervision (2013) published by London: Routledge, I made the point that fidelity to an evidence based treatment protocol has 2 components a) adherence to a protocol for the reliably identified disorder and b) competence in the skill used to tackle an appropriate treatment target.  Thus competence is meaningless if discussed outside the context of adherence.  A supervision workshop that I delivered in 2014 includes a slide of ‘The Competence Engine’ and an example of a Fidelity scale, see link below:

https://www.dropbox.com/s/jv22q8lv00orcd6/Simply%20Effective%20CBT%20Supervision%20Workshop.pdf?dl=0

The book contains Fidelity Scales for depression and the anxiety disorders

Liness et al https://www.dropbox.com/s/e26n191ie09sngs/Competence%20and%20Outcome%20IAPT%20no%20relation%202019.pdf?dl=0

Liness et al  Behavioural and Cognitive Psychotherapy (2019), 47, 672–685
doi:10.1017/S1352465819000201

Roth et al  Behavioural and Cognitive Psychotherapy (2019), 47, 736–744 doi:10.1017/S1352465819000316

Dr Mike Scott

 

IAPT’s Unreliable Assessment of Competence, Incompetence and Spin

the competence of trainee CBT therapists is routinely assessed using the Cognitive Therapy Rating Scale-Revised (CTRS-R), but a just published study by Roth et al (2019) has shown poor  levels of agreement on the performance of IAPT trainees, using this measure.  The levels of agreement were no better when an alternative measure of competence the University College London CBT Scale was used. On both measures of competence the intra-class correlation coefficients were less than 0.5, indicating poor reliability (on a scale poor, moderate, good, excellent). The UCL Scale is rooted in the competence framework developed by Roth and Pilling (2008) as part of the IAPT programme.

The chaos is underlined by a study conducted by Liness et al (2019), published in Cognitive Therapy and Research which assessed the competence  of IAPT trainees using the CTRS-R with client outcome assessed, mainly with the PHQ9 and GAD7, and no relationship was found, either at the end of training or 12 months later, see link below:

https://www.dropbox.com/s/e26n191ie09sngs/Competence%20and%20Outcome%20IAPT%20no%20relation%202019.pdf?dl=0

But the same set of authors as in the Liness et al (2019) study, have published a further paper in Behavioural and Cognitive Psychotherapy, again of IAPT trainees, evaluated using the CTRS-R. But this time, in the abstract, they reported that ‘CBT competence predicted a small variance in clinical outcome for depression cases’ with no reference to the findings of their other paper!  In the body of their Behavioural and Cognitive Psychotherapy report one discovers that for depression cases the CTRS-R explained 1.3% of the variance in outcome, it is extremely doubtful if this is of any social or clinical significance. There is also a failure to mention in the abstract that CTRS-R did not at all relate to anxiety.  The abstract is dominated by the message that training helped trainees score highly on the CTRS-R, without acknowledging that this might be without meaning. Three of the 6 authors have links to IAPT  and spin is not therefore unexpected. 

Liness et al  Behavioural and Cognitive Psychotherapy (2019), 47, 672–685
doi:10.1017/S1352465819000201

Roth et al  Behavioural and Cognitive Psychotherapy (2019), 47, 736–744 doi:10.1017/S1352465819000316

Roth, A. D. and Pilling, S. (2008). Using an evidence-based methodology to identify the competences required to deliver effective cognitive and behavioural therapy for depression and anxiety disorders. Behavioural and Cognitive Psychotherapy, 36, 129–147. doi: 10.1017/S1352465808004141

 

Dr Mike Scott

 

 

IAPT No Better Than Treatment As Usual

that is the conclusion of a just published study in the British Journal of Psychiatry by Serfaty et al, (2019).  In the study manualised IAPT-delivered CBT was compared to treatment as usual in treating depressive symptoms in people with advanced cancer. These authors concluded: 

‘our results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these  findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness’

Interestingly the IAPT therapists were all High Intensity Therapists  with mean Cognitive Therapy Rating Scale Score of 47.6  “at the upper end of the ‘proficient range’.” The primary outcome measure was the Beck Depression Inventory II and both the treatment as usual and the CBT group showed a mean reduction of 5 points. Curiously the MINI diagnostic interview was used to assess whether people were in fact depressed and would thereby qualify for the study but it was not re-administered at the end to determine how many were no longer depressed. Nevertheless even using a diagnostic interview trying to determine whether symptoms such as sleep disturbance and fatigue should count as part of a depression or as a feature of the illness   is realistically probably an impossible task.  The appropriate model with severe illnesses is probably support ( both tangible e.g heating allowance and emotional) rather than psychological therapy.

Serfaty et al Effectiveness of cognitive-behavioural therapy for depression in advanced cancer: CanTalk randomised controlled trial British Journal of Psychiatry (2019) Page 1 of 9. doi: 10.1192/bjp.2019.207

Dr Mike Scott

The Treatment of PTSD Has Been Destabilised……

by the advent of stabilisation groups and overvaluing trauma focussed CBT. In the wake of an extreme trauma IAPT clients can be referred to stabilisation groups. Such groups will often meet weekly for 6 weeks and participants are encouraged not to talk about the trauma but rather about its effects. However there is no empirical evidence that such groups make a real world difference. In support of such groups the work of Judith Herman  [ Group Trauma Treatment in Early Recovery (2019) Guilford Press] is often cited, her groups are for those in ‘early recovery’ but there is no specification of what is meant by ‘early’ or from what the person is recovering. IAPT’s assessment process is as vague as Judith Herman’s.

 

Sienna, a Civil Servant had a horrendous rta and after an IAPT telephone assessment was referred to a stabilisation group, she assumed it was for PTSD. The group made no difference to her functioning, nor did the 3 individual sessions of trauma focusssed cbt afterwards. Sienna dropped out of the TFCBT because it was too painful but she never did have PTSD!

 

But the problems in the treatment of PTSD are not confined to IAPT. Although trauma focussed CBT (TFCBT) is the NICE recommended treatment for PTSD, inspection of the randomised controlled trials reveals that on average only one in two people recover. NICE’s guidance can be overvalued, with clinicians continuing to pursue TFCBT when it is clearly not working. With a parallel insistence that they confront the scene of their trauma. Client’s are often more pragmatic thinking that they could get by without re-exposure to the scene, but with the therapist urging the client not to be ‘defeated’. Given the power imbalance the client is unlikely to be able to effectively voice their opinion. There is a pressing need for creative solutions when TFCBT doesn’t work and for a re-examination of the theory on which the latter rests.

I am proposing to run a ‘Getting Back To Me’ workshop next year.

 

Dr Mike Scott 

PWP’s Floundering – Problem Descriptors Are Unreliable

whilst they may describe to a greater or lesser extent the psycho-social context in which the client is operating, different therapist would disagree about the relative importance of the psychosocial stressors and have a different collection of them.  One may emphasise the clients current relationship another a harsh/ ? abusive childhood another poverty. 

At a recent workshop I gave a PWP (Psychological Wellbewing Practitioner)defended reliance on the use of problem descriptors on the basis that they could be complemented by the therapists intuition. But this was precisely the therapeutic task centred approach adopted by social work in the 1970’s, it failed to demonstrate effectiveness  and by the 1990’s social work had become confined to largely a policing role, replete to this day with meaningless checklists. I speak as a former social worker, consumer of social services for over three decades and as a psychologist.

With my psychologist hat on I am very aware of the the work of Daniel Kahneman on the use of rules of thumb (heuristics) in decision making, for example the use of the availability heuristic – the vividness of a description giving a mistaken impression of its’ likelihood, so that a therapist hearing the horrific details of a trauma assumes it must be PTSD. Loretta whom I saw recently simply had a specific phobia about driving/travelling as a passenger in a car as a result of very serious rta. Nevertheless the PWP directed her to a 6 week stabilisation group that did nothing at all for her  difficulties. But the stepping up procedure offered no protection, she attended 3 individual sessions in which she was asked to talk about and write about the trauma, she dropped out because she found the procedure too toxic.   Loretta’s difficulties in driving and travelling as a passenger were not addressed at all. I broke the good news that her problems could be simply addressed.

The PWPs were totally unaware that Beck’s first paper was on the unreliability of the standard interview. This led to the inclusion of standardised diagnostic interviews in CBT outcome studies. In my view the PWP training however quick and simple is not fit for purpose.

 

Dr Mike Scott

Ps Do listen to Radio 4 on Tuesday Sept 24th at 8.0pm  for its’ investigation into ‘The Therapy Business’