Populist Mental Health Myths

poor psychological therapy services are as much about populist mental health myths, as underfunding. Drill down beyond IAPT and NICE and you enter a sub atomic world very different to that of the orchestrators.

In the microscopic world people are concerned with:

‘will I get back to my old self with this therapy?’

‘what proportion of people like me, get over this with therapy?’

‘are the effects of therapy temporary or permanent?’

‘are you interested in and committed to me, or am I just a number?’

Moving up to the macroscopic world, real world outcomes are replaced by surrogates ‘a change on a questionnaire’ but without any certainty the questionnaire is measuring anything pertinent to what the person is suffering from! There is no independent assessment of outcome of routine practice.

Myth One: IAPT and NICE are at one

IAPT insists that it is NICE compliant, i.e its treatment protocols match the identified condition. But IAPT clinicians do not diagnose, instead they make a judgement using ICD 10 diagnostic codes, this weak surrogate ignores that NICE Guidance assumes a reliable diagnosis and advocates the DSM criteria not ICD10!

Myth Two: IAPT is credible because of its’ advocacy of NICE Guidelines

The NICE guidelines have called for a decade, for an evaluation of low intensity CBT vs counselling vs treatment as usual, which would include observer rating. Such is its’ ongoing uncertainty as to the value of low intensity CBT.

Myth Three: The value of low intensity CBT has been demonstrated

Not if one insists on methodologically strong studies involving independent outcome assessors.

Myth Four: CBT is the answer

NICE points out that even where there is the strongest evidence in favour of the use of CBT in depression the effects are ‘modest’. It also notes that there are comparitively few studies of Behavioural Activation (BA) and NICE makes a clarion call for more head to head research between BA and CBT. But stresses the need for inclusion of observer rated assessment in such a study, they also may have added that there is a need also for an attention control group. There is a need for more humility in IAPT about the contribution of CBT.

Myth Five: Approval by NICE equals evidence of efficacy

Not so, NICE guidelines are the fruits of a committee’s deliberations, about primarily, the results of randomised controlled trials, but there is no assessment of those rcts using the Cochrane risk of bias, which includes requirements such as observer rated outccomes.

Myth Six: IAPT never departs from NICE

With regards to ‘Medically Unexplained Symptoms (MUS) not otherwise specificied’ the recommended specialised form of CBT is entirely a product the IAPT Education and Training Group (ETG). The ETG is also a reference source for the specialised form of CBT for irritable bowel syndrome and chronic pain, albeit that 2 NICE guidelines are also referred to.

Myth Seven: IAPT is becoming more robust in evaluation

Not according to its’ recent forays into disorders like chronic fatigue syndrome were reliance is placed on a psychometric test the Chalder Fatigue scale of doubtful relevance to the CFS construct and without any independent observer rating.

Myth Eight: Real world change can happen without hospitality and commitment

Hospitality is notably absent in client’s first contact with IAPT , therapists are focussed on not becoming the subject of sanction. In the real world initial formulation of client’s problem/s is often in need of significant modification, the time constraints on therapists rarely cater for the necessary adaptations and the importance of persistence on the part of the therapist.

Myth Nine: It is ok to discharge a client as soon as their score hits recovery

For 40% of people experiencing depression, their disorder takes a variable course, whilst for the anxiety disorders, sufferers are only affected 80% of the time. Thus discharging at the first signs of a low score is simply capitalising on chance, there can be no certainty that lasting meaningful change has occurred. The stage is set for a revolving door.

This list of myths is by no means exhaustive, please feel free to add your own. However the microscopic and macroscopic worlds are different universes it seems.

Dr Mike Scott

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