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
Neither NHS England, Clinical Commissioning Groups or BABCP have taken any steps to ensure that there is independent monitoring of the welfare of IAPT’s clients. Such clients suffer a double whammy, not only do they experience the sense of helplessness often accompanying psychological debility, but they are also powerless to say anything about their experience.
The CONSORT guidelines ( see link below) state that randomised controlled trials should address outcomes that are meaningful to the patient. The same should apply to services delivered in routine practice. Changes in psychometric tests scores are not meaningful to clients, whereas no longer suffering from the disorder they were suffering from at the start of treatment is. But IAPT obfuscates its’ true performance by sleight of hand with psychometric test results. Clients are fodder for providing psychometric test data at each session, no matter that there is no certainty that the test is pertinent to what they are suffering, that repeated administration means that they can remember their last score and will want to convince themselves that they are getting better and that the results are interpreted by their therapist, creating a demand effect.
A major feature of the CONSORT guidelines is that treatment should be evaluated by those independent of service provision. There is no opportunity to protest about incompetence or the arbitrary number of session limit. IAPT violates this and every aspect of the guidelines that might be pertinent to routine practice.
Unfortunately Editors of Journals such as Behavioural and Cognitive Psychotherapy, Behaviour Research and Therapy and the Lancet often ignore the CONSORT guidelines or any translation of them into routine practice. Consequently the evidence base for expansion of IAPT into areas such as psychosis in secondary care, is much less than understood by its’ workers.
I have just put the following post on the rarely used BABCP Discussion Forum, CBT Cafe, the only sanctioned vehicle for such expression:
‘BABCP has effectively gagged discussion of IAPT by refusing correspondence about Jason’s article (and David Clark’s response) in CBT Today. The suggestion that the CBT Cafe is the appropriate place for the discussion is ludicrous, as the most responded to thread there is the ‘Cafe with little Discussion’, with only two responses to Jason’s article and 30 views in the week since publication. By contrast CBT Today is seen by the 10,000 membership! If you wanted to sideline discussion this was the perfect way to do it. It would have been bad enough if this was an editorial decision (but editorial freedom is important) but when it was decided by the President this raises serious issues. Interestingly the two responses to Jason’s article were critical of IAPT, but criticisms are almost only ever made anonymously, such are the high levels of fear amongst clinicians. BABCP has studiously failed to grasp the nettle about IAPT, fear pervades the Cafe, people are ducking under the table’.
He reflects ‘the gap between what the literature advises and what management allow seems to be widening leaving the patients as the ones who are being given sub-therapeutic, watered-down CBT’.
Revolving Door and Burnout
Jason continues ‘The result? A revolving door where patients return in quick succession f or multiple episodes of treatment with a different therapist each time…..not only this IAPT also seems to be making its own workers ill with reports of compassion fatigue and burnout not uncommon’
David M Clark the leading light in IAPT was invited to reply (but his status in IAPT was not referred to) and in essence he says the Service should not be as Jason describes because of the IAPT Manual (www.england.nhs.uk) and re-iterates his claim that 5 in every 10 of those undergoing treatment (attending 2 or more sessions). This is very misleading (see Barry McInnes’s, independent analysis of the IAPT data set in a previous post).
The editor of CBT adds a tailpiece ‘Please note – no further correspondence on this will be entered into’. I have written to the editor asking who decided this and on what basis. I note that BABCP has never allowed any criticism of IAPT by anyone independent of IAPT in its pages. It is deeply disturbing that in the same issue of CBT Today there is a piece titled ‘BABCP Response to the NHS 10 Year Plan’ and states “BABCP welcomes the celebration of IAPT services in England as ‘world leading’…We support continued funding of IAPT training places”.
Stay and Change Things In BABCP?
There is a need within BABCP for a broad church with regard to IAPT, but opposing views, from anyone independent of IAPT are not represented in journals or at conferences. A colleague recently described the situation as Stalinesque, (indeed Jason may have committed professional suicide) the danger is that people will vote with their feet, but this is made difficult as BABCP accreditation is a pre-requisite for many posts. The ‘stay and change’ gong has been sounded loudly in our political parties and it is echoing in BABCP but some will think (if only privately) what’s the point? Perhaps going through the motions. I continue to do my bit, chairing the recently formed Group CBT SIG and running a workshop, but I have grave misgivings.
The promise of evidence based CBT treatments and antidepressants seems not to be realised in practice, an editorial in the current issue of the Canadian Journal of Psychiatry notes:
‘Despite a 3- to 4-fold increase in the use of antidepressant medications, the prevalence of depression and anxiety dis orders in Australia, Canada, the United Kingdom, and the United States has remained unchanged over the past .1 20 years In the absence of compelling evidence that the incidence of these disorders is on the rise, a natural conclusion is that depressed or anxious patients who could benefit from treatment are still not identified and treated, or that the duration of illness has remained unchanged in those who are treated. This is a striking and troubling finding, considering the known efficacy of antidepressants and psychotherapies. It emphasizes both a well-delineated treatment gap, whereby many patients with depression or anxiety do not receive treatment, and a quality gap whereby those who are treated either do not need to be treated or do not receive effective 2-7 treatment’. Click link below for full editorial: https://www.dropbox.com/s/kbmly9awq9diflb/Collaborative%20Care%202018%20mediocre%20usual%20care.pdf?dl=0
Jorm AF, Patten SB, Brugha TS, et al. Has increased provision of treatment reduced the prevalence of common mental disorders? Review of the evidence from four countries. World Psychiatry. 2017;16(1):90-99.
Jorm AF. The quality gap in mental health treatment in Australia. Aust N Z J Psychiatry. 2015;49(10):934-935.
Lin EH, Katon WJ, Simon GE, et al. Low-intensity treatment of depression in primary care: is it problematic? Gen Hosp Psychiatry. 2000;22(2):78-83.
Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet. 2009;374(9690): 609-619.
Simon GE, VonKorff M, Wagner EH, et al. Patterns of antidepressant use in community practice. Gen Hosp Psychiatry. 1993;15(6):399-408.
Kendrick T, King F, Albertella L, et al. GP treatment decisions for patients with depression: an observational study. Br J Gen Pract J R Coll Gen Pract. 2005;55(513):280-286
But the editorial posits that greater collaboration between services would usher in the promised land. Whilst this might be helpful, a failure to understand what constitutes a faithful translation of the positive results of randomised controlled trials for depression and the anxiety disorders [see Scott (2017) Towards a Mental Health System That Works London: Routledge https://www.amazon.co.uk/Towards-Mental-Health-System-Works/dp/1138932965/ref=sr_1_1?ie=UTF8&qid=1547819366&sr=8-1&keywords=Towards+A+Mental+Health+System] into routine practice will continue to nullify any actions. Unfortunately in the UK, IAPT continues to pursue its own fundamentalist translation of the randomised controlled trials, despite evidence that it doesn’t work, with just a 15% recovery rate [ Scott (2018) see link below:
Further IAPT has extended its’ empire well beyond the borders of reliable evidence based outcome studies e.g to medically unexplained symptoms. Staff are frightened to speak out publicly. It is difficult to escape charging IAPT with imperialism. Theirs is a dominant narrative in BABCP, British Psychological Society and in journals such as Behaviour Therapy and Research.
‘Very interesting and lots of new ideas for approaching what can be a complicated mind field’. Delighted Christine Roberts twittered this response, thanks. It was a full house at the Lakeside Centre, Crosby, Liverpool, super day except for a microphone that had a life of its’ own!
But there was unanimous agreement from the 80 participants that generally therapists are a) stressed out b) daren’t publicly voice there discontent with IAPT. One person voiced that the customary IAPT 6 sessions is like putting a sticking plaster on a wound and all you get is a revolving door of clients. We need to stop the bleeding.
The voices of dissent are not in evidence at Nationally Organised BABCP Events, indeed I did not go to the Annual Conference because it looked like a further feast of uncritical acclaim of IAPT, reflected in the current issue of CBT Today.
The great thing at the Workshop is that we were able to address participants concerns e.g comorbid PTSD and OCD in a 15 year old. But we were all at a loss as to how to break out of the current mode of IAPT delivery, it seemed to resonate with being a citizen of some totalitarian state.