How Can You Know Best Practise When You See It?

 

Best practise networking is in vogue. It is a central plank in the Improving Access to Psychological Therapies (IAPT) Service  professional development programme. But who decides what should be marketed as best practice? Is it the powerholders within the Service in conjunction with those who are happy to eloquently re-iterate the party line? What assurance can there be that it is not a matter of the blind leading the blind? The dissemination of ‘best practice’ in psychological therapy rests primarily on a consensus. In Britain, the self-proclaimed lead organisation for cognitive behaviour therapy (CBT), the British Association of Behavioural and Cognitive Psychotherapy (BABCP) sees itself as the custodian of ‘best practice’ and has bestowed an imprimatur on IAPT.

But the British Medical Journal has a very different notion of what constitutes ‘best practice’. For each of the common mental disorders, it identifies screening psychometric tests complemented by standardised diagnostic interviews to identify the particular disorder. Then a treatment algorithm for each disorder. However IAPT clinicians are not trained to make diagnoses so that their ‘best practise’ must diverge from the BMJ’s. Who is right and on what basis?

The gulf between evidence-based practise and IAPT’s ministrations is shown in sharp relief if we focus on the latter’s low intensity guided self-help (LIGSH). I could find no study of LIGSH in which there was a blind assessor of the treatment and comparison with an active placebo. Thus any effects of LIGSH could be attributed to simply attention. By contrast over half (58.7%) of randomised controlled trials of CBT have employed blind assessors.  

The behaviour of IAPT clinicians is highly prescribed. In a study of LIGSH transcripts of tape recordings of client’s first contacts with the Service analysed by Drew et al (2021) there is a steadfast refusal to let clients tell the story behind their distress. The double message is ‘come to us, but we don’t want to listen to your troubles’

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’

and 

‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’.

But not only does the IAPT Service refuse to listen to its clients, it refuses to listen to outside criticism. There has been no change in its’ modus operandi in over a decade as it pursues expansionism.  But it is an expansionism to areas were there has been no demonstrated efficacy and evidence is at best circumstantial. Operating on the dubious premis that ‘it just might be the answer to the world’s problems’. 

The networking of IAPT clinicians, whose operation is validated by BABCP, is an ‘In Group’ that talks amongst themselves, reinforcing their world view and refuses to engage in effortful processing of external criticism.

Dr Mike Scott