abandon ‘what treatment works for what’ and you end up with a free for all of imagined complexity.
With stressed clinicians lost in a fog, arguing interminably about possible landmarks (formulations) for treatment. Not surprisingly the issue of ‘complexity’ now figures highly on IAPT’s list of workshops. Paradoxically formal IAPT training eskews trainees working with ‘complex cases’. IAPT specifies the importance of following the NICE guidelines but without a reliable procedure for determining what cases they do and importantly do not apply to.
The IAPT Courtroom
An obvious defence for IAPT workers failing to consistently obtain the 50% recovery rate is to contend that they were dealing with complex cases.
In rebuttal the Organisation can contend that complex cases are: ‘namely primary or comorbid psychosis, personality disorder, autism spectrum disorder, substance dependence, severe and/or treatment-relevant physical health conditions, and severe psychosocial difficulties Liness et al (2019) see link’ https://link.springer.com/article/10.1007/s10608-018-9987-5 and that the clinicians case falls outside this definition. But in areas of high deprivation it is relatively easy to claim that a particular client falls within this definition of complexity e.g ongoing pain from an injury or associated with a condition such as MS, having to use a Foodbank.
Flexibility Within Fidelity As A Defence
Flexibility has to be constrained by fidelity, if it is not then arguments between clinicians and line managers/supervisors have no arbiter. The clinician will lose out simply because the line manager/ supervisor has more power, at its’ worst ‘my way or no way’.
If fidelity is safeguarded, then there are agreed issues/concerns that need to be addressed with a particular client. It also sets limits on the range of interventions (flexibility) that are permissible for those particular issues/ concerns. Without a twin focii on fidelity and flexibility the clinician is up a creek without a paddle. But a hostile work environment can nevertheless ignore or more commonly pay lip service to fidelity and flexibility – they need to be admitted to the IAPT courtroom for the sake of both clinicians and clients.
Clinicians and Constructive Dismissal
Nevertheless there is a vagueness about the debate of simplicity vs complexity, that could mean that an IAPT therapist is hounded from office, without the case being put to anything like a jury, with no procedures in place to ensure any transparency and accountability.
The Need To Rediscover A Biopsychosocial Model
But actually matters are nowhere as simple as this simple/complex distinction. Steve Stadling (1990) and I https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/group-cognitive-therapy-for-depression-produces-clinically-significant-reliable-change-in-communitybased-settings/ADFC2B6A2D2BBCCC37CD41820DFD5287
were involved in a randomised controlled trial of individual and group CBT for depression in Toxteth, Liverpool, and managed to make important lasting differences using Beck’s protocol for depression. But because we were using a biopsychosocial model I saw it as much a part of my work to say write a letter to a Housing Association for a client as conduct the CBT. Similarly many patients were prescribed antidepressants, again in keeping with a biopsychosocial model. This holistic approach to client’s problems appears to have been lost in IAPT’s fundamentalist translation of the randomised controlled trials. An alternative perspective is presented my trilogy of Simply Effective CBT books
Dr Mike Scott
3 replies on “Simply Too Complex CBT!”
I would suggest that the main reason why complexity features high in IAPT workshops now is because IAPT is being targeted at patients with LTCs and MUS towards the goal of 2/3rds of new IAPT clients coming from these groups. These are sick patients with complex medical needs, and PWPs do not have the skills to address them. In addition, I suspect a large number of clients don’t know exactly why they have been directed by their clinicians to IAPT.
I didnt know about the expectation that 2/3rds of new clients should come from these groups, have you got the reference Liz. I’m doing a blog on CBT, Cancer and IAPT in the next few days. Take good care
IAPT-LTC Full Implementation Guidance – Royal College of Psychiatrists
– “The Improving Access to Psychological Therapies (IAPT) Pathway for People with Long-term Physical Health Conditions and Medically Unexplained Symptoms Full Implementation Guidance” – page 7
IAPT-LTC 31 October 2017 – Yorkshire and the Humber Clinical …
– “Yorkshire and the Humber Mental Health Network IAPT-LTC 31 October 2017”
Page 18 of 155 – presentation by David Clark (I think)