Improving Access to Psychological Therapies (IAPT) services are out of bounds to Care Quality Commission inspection. In 2016 the National Audit Office (NAO) asked the Department of Health to address this issue and it has done nothing. The Department sets the agenda and budget for NHS England, who in turn do the same with Clinical Commissioning Groups to determine local provision of services. But NHS England staff are lead players amongst service providers, these conflicts of interest exacerbate the parlous governance of IAPT. There is a need for Parliament to step in and take the Department of Health to task.
Whilst no one doubts the importance of improving access to psychological therapies, it was remiss of the NAO in 2016 to take at face value IAPT’s claim that it had the appropriate monitoring measures in place. Incredulously the NAO accepted at face value IAPT’s claim that it was achieving a 45% recovery. It is always tempting to look only as far as evidence that confirms your belief. But it is equally important to consider what type of evidence would disconfirm your belief. The NAO has failed to explain why it has not insisted on independent scrutiny of IAPT’s claims.
The The Improving Access to Psychological Therapies (IAPT) programme has exercised a confirmatory bias in its’ audit by focussing only on self-report responses on psychometric tests (the PHQ9 and GAD7). The service has never looked at a categorical end point, such as whether a person lost their diagnostic status as assessed by an independent evaluator using a standardised diagnostic interview.
Organisations, are inherently likely to be self-promoting and will have a particular penchant for operating, not necessarily wholly consciously, with a confirmatory bias. It is for other stakeholders, NHS England, Clinical Commissioning groups, MPs, the media, Charities and professional bodies (BABCP and BPS) to hold IAPT to account. For the past decade they have all conspicuosly failed to do so. How have IAPT evaded critical scrutiny, despite the taxpayer having paid £4billion for its’ services? Friends in high places is the most likely answer. I have called for an independent public inquiry for years and will continue to do so but there is likely to be an echo of a deafening silence as the only beneficiary would be the client with mental health problems.
of those who undergo an initial assessment with the Improving Access to Psychological Therapies (IAPT) Service 40% do not go on to have treatment, and about the same proportion (42%) attend only one treatment session, according to a just published study by Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133. These findings echo a study published last year by Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z, on a smaller sample, which suggested that 29% were non-starters and that the same proportion attended only one treatment session. Further scrutiny of the data reveals that about 3 out of 4 people drop out of treatment once begun. Unsurprisingly the authors’s independent study, of 90 IAPT clients, Scott (2018) revealed that only the tip of the iceberg (9.2%) recovered DOI: 10.1177/1359105318755264, raising serious questions about why the Government has spent over £4 billion on the service.
What Has Gone Wrong?
Kline et al (2020) consider that at an assessment by a clinician is supposed to: a) provide a credible rationale for the proposed treatment b) detail the efficacy of the envisaged treatment and c) ensure that the clients preferences are acknowledged. IAPT’ assessments fail on all counts, taking these in turn:
a. If the problem is ill-defined e.g low mood/stress it is not clear what rationale should be presented. It is doubtful that a 30-45 minute telephone conversation can provide sufficient space to define the primary problem and other problems/disorders that may complicate treatment. Initial assessments of patients for randomised controlled trials of psychological interventions are typically 90 mins plus, if this is the time deemed necessary to reliably diagnose a patient by a highly trained clinician, how can a much less trained PWP do it in less than half the time? Under time pressure a PWP may consider providing a credible rationale is part of treatment not assessment and in such circumstances it becomes more likely that a client will default.
b. How often do PWPs present clients with evidence on the efficacy of an intervention? Take for example, computer assisted CBT, does the therapist tell the client that only 7 out of 48 of NHS recommended e-therapies have been subjected to randomised controlled trials, ( see Simmonds-buckley et al J Med Internet Res 2020;22(10):e17049) doi: 10.2196/170490 and even in these a gold standard semi-structured diagnostic interview conducted by a blind assessor was not use to determine diagnostic status post treatment, i.e there was no determination of the proportion of clients who were back to their old self after treatment and for how long. Further the e-therapies had average dropout rates of 31%. They are not evidence based treatments in the way the NICE recommended high intensity treatments are. But approximately three quarters Of IAPT interventions (73%) are low intensity first, with 4% stepped up to high intensity and 20% in total receiving a high intensity intervention Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133
c. Client’s preferences are a predictor of engagement in treatment, but how often is a client given a choice between a low intensity intervention and a high intensity intervention. If both options are juxtaposed choice is likely skewed by informing the client that the high intensity intervention has a much longer waiting time.
Defining A Dropout
The generally accepted definition of a dropout is attending less than 7 sessions [see Kline et al (2020) https://doi.org/10.1016/j.brat.2020.103750], it is held that clients attending below this number will have had a sub-therapeutic dose of treatment and are therefore unlikely to respond]. Applying this metric to IAPT’s dataset is difficult as they only report data for those who complete 2 or more sessions and for which the average number of sessions attended is 6, thus the likely dropout rate from IAPT treatment, as most would understand the term, is about 75%. But IAPT has developed its’ own definition of a completer as one who attends 2 or more sessions. This strange definition serves only to muddy the waters on its haemorrhaging of clients. It makes no sense to continue to fund IAPT without an independent government inquiry into its’ modus operandi.
An Alternative Way Forward
Such has been the marketing power of IAPT over the last decade, that professional organisations such as the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Psychological Society (BPS) have sat mesmerised, as the Services fellow travellers have dominated accreditation and training. In ‘Simply Effective Cognitive Behaviour Therapy’ published in (2009) by Routledge, I detailed a very different way of delivering services, that represents a faithful translation of the CBT treatments delivered in the randomised controlled trials (rcts) for depression and the anxiety disorders. Unfortunately it is IAPT’s fundamentalist translation of the rcts that has held sway and has brooked no debate either in journals or at Conferences.
‘what proportion of IAPT clients have maintained recovery from the primary disorder for which they first presented?’ . The Improving Access To Psychological Treatments (IAPT) Service prides itself on its’ large comprehensive database, as if this was somehow a guarantor of the effectiveness of the service. But it is not possible to interrogate this database to determine the extent of restoring clients to their normal functioning, as they don’t do diagnosis.
Not only don’t they do diagnosis, they refuse to share a platform with anyone known to be critical of them. To date IAPT has not published written rebuttals of its’ critics charges. IAPT uses the muscle of the British Association of Cognitive and Behavioural Psychotherapies (BABCP) when challenged. Later this month the BABCP has its Annual Conference. I have had no indication from the President Elect as to how they are going to address my concerns over conflicts of interest and editorial freedom, but I do know that pride of place is to be given to IAPT’s leading light. BABCP is IAPT’s apologist. It might better spend its’ time investigating why the IAPT documentation indicates that its therapists, who are invariably BABCP members, make it up as they go along, sprinkling their notes with CBT terms, without any evidence of fidelity to an evidence based protocol for anything.
here is the CBT Today article rejected not by the Editor, but by the power holders, I wrote:
The Improving Access to Psychological Therapies (IAPT) Programme has only ever marked its’ own homework, making claims for its’ effectiveness suspect. IAPT and its’ devotees (see February issue of CBT Today) are it seems undeterred by the absence of a publicly funded independent evaluation. The CBT Today articles cite no contrary evidence to IAPT’s claim of a 50% recovery rate, despite a whole issue of the Journal of Health Psychology for August 2018 being devoted to the matter and in which my work suggested a likely 10% recovery rate. In my paper ‘IAPT – The Need for Radical Reform’ I also detailed the stories of the recipients of IAPT’s services. None of the powerholders have actually spent time systematically listening to the experiences of IAPT clients.
IAPT Is Highly Persuasive and Misleading
Unfortunately, the NHS, Clinical Commissioning Groups, BABCP, BPS and the Media hierarchies have bought into IAPT’s outstanding marketing, with dissenters not allowed a voice. When the crowd is behind you, you are probably facing the wrong direction. It is disturbing when only the powerholders and progenitors express support for the IAPT programme.
The ‘gold standard’ of independent assessment using a standardised diagnostic interview has been jettisoned with regards to IAPT, yet it was the hallmark of the randomised controlled trials that it professes to base its’s treatment on. Espousal of compliance with NICE guidelines has become a key marketing ploy by IAPT, richly rewarded – £4billion since its’ inception over 10 years ago. Yet there is no evidence that IAPT reliably establishes a base of diagnosis on which is built disorder specific treatment targets and strategies.
The Way to Hell Is Paved With Good Intentions
Nobody doubts the importance of improving access to psychological therapies, but by 2015 from conversations I was having with former IAPT clients, it was becoming increasingly obvious that they thought the system was radically failing them. Analysis of 90 clients assessed using a standardised diagnostic interview revealed a 10% recovery rate i.e only the tip of the iceberg lost their diagnostic status whether or not they were treated pre or post their personal injury [Scott (2018)]. The National Audit Office began an investigation into IAPT, its’ stated mission was to assure healthcare bodies such as Clinical Commissioning groups of the integrity of the IAPT data but it never got around to doing this. In June 2018 the NAO stopped its’ investigation because of other pressing concerns including Brexit and the collapse of Carillion.
IAPT’s Ministry of Propaganda
On November 13th 2019 BBC Radio 4 and Radio 5 Live voiced the concerns of some IAPT therapists that they were pressured to falsify test results, but their voices were drowned out by that of the President of the BABCP and Lead Clinicians for IAPT, the media went with the powerholders – none of the 3 hours of my recordings were aired, nor that of the hour long interviews with an IAPT worker and a client who had been through IAPT twice. A former IAPT client treated by them after the Manchester bombing was unfortunately too upset on the day to give a live interview and only a minute of hours long pre-recorded interviews was broadcast. The media approach amounted to ‘let’s show we are on the side of mental health, it takes too much effort to think the issues through, so let’s go with the powerholders and present a positive message’, an approach that mirrors journals propensities to only publish positive results.
In the same month I sent a letter to my local Clinical Commissioning Group protesting that Talk Liverpool’s just published claim of an 89% recovery rate was suspect as the IAPT’s national claim was a mere 50% recovery rate. I expressed a view that these exaggerated claims may have fuelled the 25% increase in Talk Liverpool’s funding, rising to £10 million in the coming financial year. The Liverpool CCG have not even bothered with the courtesy of a reply. If Talk Liverpool had truly discovered some clinical secret they would be top of the agenda at IAPT’s Best Practice meetings, this is not the case.
The BABCP Has Become An Ambassador for IAPT
It has done nothing to look after the two thirds of IAPT workers suffering burn out. It has squashed debate on IAPT in the pages of CBT Today, pays lip service to evidence-based treatment and fosters alleged CBT. The very credibility of BABCP is at issue, my hope is that the new President addresses these issues.
Scott, M.J (2018) IAPT – The Need for Radical Reform, Journal of Health Psychology, 23, 1136-1147.
Scott, M.J (2017) Towards a Mental Health System That Works London: Routledge.
To disagree with my article is fine but not to engage in open debate is totalitarian. I am not holding my breadth as Andrew Beck takes the matter to the BABCP Board.
last week I received an extraordinary e-mail, not from the editor of CBT Today, to whom I had submitted the aforementioned article, but from the President of the British Association of Behavioural and Cognitive Therapies (BABCP), Paul Salkovskis and the President-Elect, Andrew Beck declining my article. I protested that this was an infringement of editorial freedom. Further there was a conflict of interest (COI) because my article was written in response to one by Paul extolling the virtues of IAPT. This issue of editorial interference was highlighted a year ago when the Editor of CBT Today and Paul declared that there would be no further discussion of IAPT following a piece by Jason Roscoe ‘Has IAPT Become A Bit Like Frankenstein’s Monster?’ and a rebuttal by David Clark. In a response Andrew Beck has now agreed to take the issues of editorial freedom and conflict of interests to the BABCP Board. But this also happened 5 years ago under the Chris William’s Presidency, to no effect!
the then President sent me an e-mail on December 16th 2015 which read:
‘I don’t want to pre-empt what the Board might decide – as I am only one member of that board – however I am the Board member on the journal committee and am personally very keen we have clear COI statements. My own view is that probably most of these authors doing research in IAPT and also employed in such services aren’t even considering this as an issue as they don’t see themselves as being influenced by IAPT centrally – however that isn’t the point. What matters is perceived conflict and it’s quite clear that you and at least some others have a concern. I would be very happy on a personal basis to advocate we remind authors and associate editors of COI more in such cases and will do so in person or by email at the next journal committee meeting and provide you with feedback as to what happens then’
The IAPT Skulduggery Has Continued
In answer to Jason Roscoe’s question ‘Has IAPT Become A Frankenstein’s Monster? ” – I can answer in the affirmative – the latest issue of the British Journal of Clinical Psychology DOI:10.1111/bjc.12259 contains a supposed 10 year review of IAPT data. The authors all declare no conflict of interest, but the corresponding author for the study is Stephen Kellet who is an IAPT Programme Director!
Other Examples of IAPT’s ‘Failure To Declare’
In an article that mirrors the Kellett et al paper, by the prime lead in IAPT David Clark, in the Lancet (2018) https://www.dropbox.com/s/s7var6llzwt1otd/IAPT%20and%20Transparency%20Clark%202018.pdf?dl=0 there was no declaration of a conflict of interest. Ironically the title has in it the word ‘Transparency’!
In a paper by Boyd, Baker and Reilly (2019) https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0 interventions it is written ‘The authors have declared that no competing interests exist’ , but the lead author presenting at a Conference in Amsterdam in May 2016 is described thus: ‘Lisa Boyd, IAPT service, Tees Esk and Wear Valley Mental Health Trust, UK Impact of a Progressive Stepped Care Approach in an Improving Access to Psychological Therapies Service: An Observational Study’
In the paper ‘How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study’ was written by Ali et al (2017) , Behaviour Research and Therapy 94 1-8. the authors declared no conflict of interest but the corresponding author was Chair of the Northern IAPT Practice Research Network
Enough is enough the very credibility of BABCP is at stake and as for IAPT! But I guess this blog would be found ‘unsuitable’ for CBT Today!
this morning BBC Radio 4 focussed on the problems caused by the Improving Access To Psychological Therapies (IAPT) long waiting lists (half more than 28 days) but reiterated IAPT’s claim of a 50% recovery rate. But IAPT has only ever marked its’ own homework on recovery rates. I spent hours explaining to Radio 4 reporters that the true recovery rate is more likely 10% as detailed in my paper published in the Journal of Health Psychology last year, but they totally ignored this – shortening waiting time for something, that is most likely to be ineffective approaches pointlessness:
billions of £s have been spent on IAPT over the last decade all without any publicly funded independent assessment of outcome, this would never have been permitted in evaluating a drug. NHS England claimed IAPT has exceeded expectations , but can cite no independent evidence. NHS England have failed the public in terms of accountability. There are so many vested interests in IAPT that the great majority of patients are likely to continue to be short changed. The yardstick has to be the proportion of people who get back to their old selves post-treatment, my study of 90 IAPT clients found that only the tip of the iceberg recover. NHS England need to commit to a publicly funded independent assessment of IAPT using real world outcome measures such as loss of diagnostic status for at least 8 weeks.
There is a troubling alliance of powerholders BBC, IAPT, BABCP and BPS that is ignoring the real needs of those with mental health problems.
there are no limits to IAPT’s ambitions, making failure inevitable. IAPT’s target in practice is, “whatever the client complains of” and treatment is operationalised as “whatever its’ therapists do”, Both focii are so loose that it cannot fulfill it’s promise, like a totalitarian revolution that runs out of steam.
The IAPT Manual published a year ago leaves both targets and treatment ‘fuzzy’, whilst proclaiming a commitment to NICE Guidelines. A target of ‘client complaints’ makes no distinction between ‘ disorder’ and everyday unhappiness/stresses. Yet the treatments advocated by NICE are quite specific to disorders.
At most IAPT staff ask about some symptoms of a disorder, but without coverage of all the symptoms of a disorder. But they are not taught to ask whether a symptom is present at a clinically significant level, i.e whether it is making a real world difference to a client’s life. Only clinically significant symptoms count in DSM. As a result IAPT client’s are typically treated for disorders they don ‘t have, without any fidelity check on compliance with a protocol.
There is tremendous vested interest, financially, emotionally and intellectually in IAPT continuing as it is, marking its’ own homework with applause from BABCP and the BPS.
If IAPT were a Hospital, operating without any consideration as to whether patients are returned to their usual selves with treatment, they would likely be placed in Special Measures. IAPT has eskewed accepted definitions of recovery.
IAPT’s Meaningless Yardstick
If you are departing IAPT (or wish to commit professional suicide!) tell your IAPT manager/supervisor the psychometric test results are not measuring anything meaningful, they are simply impositions from above! IAPT claims that the psychometric tests it uses (PHQ9 and GAD7) measure clinically significant change/ recovery. But this is not true.
The validity of clinically significant change criteria relies crucially on whether the test used taps the same construct as the identified disorder1. IAPT’s use of the PHQ9 and GAD7 violates the requirement for construct validity, specifically as IAPT make no standardised reliable diagnosis it is a lottery as to whether the psychometric test matches the diagnostic status of the client. A client could be suffering from for example variously, no recognised disorder, an adjustment disorder, OCD, panic disorder, the changing scores on the PHQ9 and GAD7 would say nothing at all about the outcome of an intervention for these disorders. To compound matters in the IAPT set up it is not possible to know when these measures are actually tapping depression or generalised anxiety disorder in a particular client.
IAPT’s Idiosyncratic Use of Tests
IAPT have never stipulated any criteria for enduring improvement. Therapists discharge clients as soon as their scores dip below casenness on a self-report measure, neglecting to consider that what is being observed is likely natural variation than any return by the client to their usual self. Matters are compounded because clients can complete the questionnaires to either please the therapist (particularly likely if completed in front of the therapist) and/or convince themselves that they have not wasted time in investing in therapy.
IAPT Training At Fault
CBT therapists per se are not trained in methodology – there is rarely any understanding of concepts such as construct validity, reliability, the limitations of psychometric tests, bias introduced into such tests by the ways in which they are administered or of accepted criteria for recovery. The deeply flawed IAPT training has arisen without a murmur of protest from the British Psychological Society and BABCP hierarchy. The rationale appears to be so long as IAPT secures increased monies for mental health services that is all that matters, this is a dereliction of care to both clients and therapists.
How Outcome Should Be Assessed
The passage of depressed clients through IAPT has never been judged by accepted definitions of response, remission and recovery2, 3.
Response is defined as a clinically
meaningful improvement in depressive symptoms that has continued for a
sufficient length of time (3 consecutive weeks) to protect against
misclassification owing to symptom variation or measurement error2. Response
is typically operationalised as an improvement
of ≥ 50% over pre-treatment scores.
Remission relies on a definition of
an asymptomatic range, defined as the presence of no or very few symptoms. A
person can be judged to be in the asymptomatic range only if neither of the two
essential features of depression (sad mood and loss of interest or pleasure) is
present and fewer than three of the additional core symptoms of depression are
present2. Remission requires that the person remains in this range
for at least 3 weeks, again to protect against factors such as natural symptom
Recovery is defined as an extended length of time in remission, which has been operationalised as at least 4 months4.
The passage of anxious clients through IAPT has never been judged by accepted definitions of recovery4. In the Bruce et al (2005) study of the trajectory of anxiety disorders a participant was considered to have recovered from anxiety disorder if he/she experienced 8 consecutive weeks at psychiatric status ratings of 2 or less (Table 1). Subjects who met this condition were virtually asymptomatic for 2 consecutive months.
2. Residual The patient claims not to be completely his/ her usual self, or the rater notes thepresence of symptoms of no more than a mild degree (for example, mild anxiety in agoraphobic situations).
1. Usual self The patient is returned to his/her usual self, without any residual symptoms of the disorder. (The patient may have significant symptoms of some other condition or disorder; if so, a psychiatric status rating should be recorded for that condition or disorder.)
1.Fisher PL and Durham RC Recovery rates in generalized anxiety disorder following psychological therapy Psychological Medicine 1999; 29, 1425-1434
2. Dobson KS, Hollon SD, Dimidjian S, Schmaling KB, Kohlenberg RJ, Gallop RJ, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. J Consult Clin Psychol 2008;76:468–77
3. Dombrovski AY, Lenze EJ, Dew MA, Mulsant BH, Pollock BG, Houck PR, et al. Maintenance treatment for old-age depression preserves health-related quality of life: a randomized, controlled trial of paroxetine and interpersonal psychotherapy. J Am Geriatr Soc 2007;55:1325–32
4. Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, Shea MT and Keller MB (2005) Influence of psychiatric comorbidity on recovery and recurrence in generalised anxiety disorder, social phobia and panic disorder: A 12 year prospective study. Am J Psychiatry 162:1179-1187.
search as you might, CBT is a scarce commodity in routine practice. In Coleridge’s poem ‘The Ancient Mariner’, the sailor bemoans that there is ‘water, water everywhere/ Nor a drop to drink’ because it is salt water. The CBT prevalent in routine practice is just this, ‘salt water’. The myth is that this ‘salt water’ can make a real world difference – return the psychologically dehydrated to their usual selves. Dear Clinical Commissioning Group the CBT that you see is salt water.
The reality is that services are populated by terrified therapists, clutching their papers, glancing hurriedly from the PHQ9 to the clock, which will soon announce the arrival of the next test of their exhausted therapeutic skills. The client departs with a promise of intervention strategies that never materialise, because of repeated derailments. The IAPT therapist has the added threat of being shamed in front of colleagues over their poor recovery rates.
But the story from IAPT and BABCP is that therapists are ‘scientist-practitioners’, carefully reflecting on the effectiveness of homeworks set and distilling with the client new, specific challenges.
Nothing will change until we challenge this stereotype of CBT therapists at the coal face.
CAMHS and secondary care are unikely to be the promised land for either clients or CBT therapists. In CAMHS there is a penchant for declaring that everyone is in need of family therapy, even if you are the victim of the Manchester arena bombing! In secondary care the cbt therapist is often a token gesture in a service dominated by a consultant psychiatrist. In private practice it is the ‘Wild West’ with almost anything on offer, from alleged cbt to the real thing.
Ongoing discussion of this matter in CBT Today would have reached an audience of the 12,000 BABCP members. The Editor agreed with the President that the appropriate Forum was not the magazine but the online CBT Cafe. On March 12th I protested about this with a post on the CBT Cafe, there was just one response 8 days later by the BABCP President, Paul Salkovskis. Nearly a month since there has been no further post from anyone on the CBT Cafe! Whatever the intent of the President and the Editor of CBT Today, discussion has been clearly sidelined and the matter of Editorial freedom in CBT Today has not been addressed at all.
Jason Roscoes’ critique of IAPT in CBT Today, can be accessed below