The Near Extinction of CBT

Evidence-based psychological therapies are near extinction. Their demise began in 2008 with the inception of the Improving Access to Psychological Therapies (IAPT) service. Aided and abetted by the British Psychological Society’s validation of IAPT’s Psychological Well-being Practitioner’s (PWPs) training programmes and the service’s fellow traveller, the British Association for Behavioural and Cognitive Psychotherapy (BABCP). Gone is the welcoming open door and the careful distillation of what ails the client, instead there is a 30 minute+ telephone conversation, with a third of people then not going beyond one treatment appointment.

 

The public most commonly receive PWP ministrations when they seek NHS psychological help. But the PWP’s do not follow any treatment protocol for any disorder, indeed they do not make diagnoses. How then can they be said to deliver CBT? By the spurious claim  that they can select a CBT strategy which is sufficiently potent. But they furnish no evidence of systematically following any strategy, notwithstanding that there is no evidence that CBT strategies delivered as stand alone interventions make any real world difference. The PWP’s deliver the Alice in Wonderland, Dodo verdict on CBT strategies ‘all are equal and must have prizes’. Raising the question ‘is CBT as dead as the Dodo?’

 

 

Where else might CBT be found? It is not impossible for it to be delivered in IAPT’s high intensity service, but few of its practitioners conduct a reliable standardised diagnostic interview which is the foundation for delivering CBT.  The  treatment integrity of high intensity CBT interventions has never been assessed.  No steps have ever been taken to ensure clinicians are dovetailing diagnosis appropriate treatment targets with matching treatment strategies. Is CBT to be found in private practice? It is possible, but private organisations have largely sought to ape IAPT in the mistaken belief that this confers credibility. Are the chances of finding CBT in private practice comparable to finding life on Mars?

Is CBT alive and kicking in secondary care? Here we enter the muddy waters of clients who might traditionally be regarded as having personality disorders (PD). But there is an understandable reluctance to use the term PD because of the associated stigma and because historically use of such a term has consigned people to the dustbin. Nevertheless Sperry and Sperry (2016) have produced the 3rd Edition of CBT for DSM-5 Personality Disorders (Routledge) but it is eminence-based rather than evidence-based. It is light on outcome studies. I struggled to find any where there was independent assessment of outcome by blind raters, use of an outcome measure that clients would regard as a minimally important difference and evaluations by those other than the creators of the protocols. It is a free for all with strategies such as ‘thought stopping’ recommended, without specification of any contraindications such as PTSD or OCD. Only eclipsed by recommending solution focussed therapy for anxiety. If clinicians in secondary care operate on this text it is very different to Beck’s own work on CBT for personality disorders. But no typology of what clinicians say they do and what they actually do in secondary care has been produced. Tertiary care seems preoccupied with crisis management and is not guided by any recognisable CBT protocol.

In neither primary or secondary care is there a differentiation of treatments or clients. Thus in the UK it is impossible to answer the question of ‘What Works With Whom?’. This leaves clinicians up a creek without a paddle.

Dinosaurs may have been wiped out by an asteroid hitting the earth 66 million years ago, but life survived, doubtless CBT will survive the impact of IAPT, but it is a close call and it is likely going to be down to individual practitioners doing what they know to be best for their clients.

 

Dr Mike Scott

Psychologising Long-Covid and Anything Else

 

Under a heading ‘Long-Covid: interventions not proven’ the May issue of The Psychologist publishes  a letter (see below) I wrote with Joan Crawford. The same issue contains an interview with Jo Daniels, the newly appointed Chair of the Scientific Committee of the British Association for Behavioural and Cognitive Psychotherapy (BABCP) outlining her mission to apply CBT to all long-term conditions (LTC). This despite a paucity of evidence that CBT protocols matched  to a specific LTC make any unique contribution. She proclaims “It is now commonly accepted that CBT ‘works’ to a greater or lesser extent for most physical  health conditions”,  this is grist to the mill for the expansionism of the Improving Access to Psychological Therapies (IAPT) service. But contrary voices do not get a hearing in BABCP, echoes of Russia.

                

‘The underlying message of Dr Siddaway’s article ”We need to talk about Long-Covid” in the March 2022 issue of the Psychologist is that there is or will be an added value from psychological intervention for those affected by Long-Covid i.e Covid of more than 3 months duration.  But the Scottish verdict ‘not-proven’ seems appropriate.

There can be no doubt that offering emotional support to people like Grace, cited in the article, is an important resource for anyone suffering from a long-term medical condition. But there is a distinction between the provision of emotional support (travelling alongside) and delivering a psychological intervention (fixing). The latter is inevitably more costly, requiring more highly trained staff and therefore less likely to be available. Is it a proper use of scarce psychological resources to offer psychological treatments to those with Long-Covid?

Clearly if a person with Long-Covid suffers from an additional disorder such as PTSD or depression a case can be readily made for addressing the comorbid disorder. But the effectiveness of this treatment, in such circumstances, remains to be demonstrated. There are no randomised controlled trials of the psychological treatments of Long Covid plus or minus comorbid disorders. Thus, the evidence for the efficacy of treatment must be currently regarded as weak.

Siddaway suggests that it is possible to extrapolate from studies of chronic fatigue syndrome and pain and apply the strategies to Long-Covid. But there are significant problems with this: a) it assumes Long-Covid is in the same domain as CFS and pain, but arguably, there is little evidence that this is a homogenous category b) the evidence base for the efficacy of psychological treatment for CFS Is problematic if objective indices of outcome are insisted upon c) the evidence base for psychological treatments for CFS and pain, such as it is, is for protocols and not for the components of the interventions, such as pacing or distraction. Using strategies out of context is problematic.

Siddaway appeals to a biopsychosocial model to justify psychological intervention for Long- Covid, despite any evidence that mood and coping strategies make a significant difference to the physical symptoms of Long-Covid. The proposed model ” the complexity of Long-Covid” is not capable of falsification, any factor e.g a hostile working environment, could be proposed to be pivotal in the development of Long Covid, but not ruled out.  As such it is not a model.

It serves the interests of the powerholders of psychological therapies to transmute the physical disorders into candidates for psychological intervention. An extending of Empires. This is not to say that psychological intervention may not sometimes be helpful in the context of a long-term medical condition but unless the population is clearly specified clients will be failed by inappropriate treatments and services exhausted.

 

Mike Scott

 

Joan Crawford’

Another Nail In The Coffin of IAPT

A year ago the British Journal of Clinical Psychology published my paper ‘Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin’  60(1), 38. https://doi.org/10.1111/bjc.12264. This month in the Journal there is a further damning indictment by Martin et al (2022) ‘Improving Access to Psychological Therapies (IAPT) has potential but is not sufficient: How can it better meet the range of primary care mental health needs?’ 61, 157–174, DOI:10.1111/bjc.12314.

Here are the main points from Martin et als’ BJCP paper:

  •  Improving Access to Psychological Therapies(IAPT)has significantly increased access to psychological therapies within primary care over the last decade, though it is unclear whether its interventions are sufficiently tailored to meet the actual levels of complexity of its clientele and prevent them from needing onward referral to secondary care as originally envisaged.
  •   Given the ongoing focus on and investment in IAPT informed developments into long-term conditions and serious mental illness, this review considers whether additional elucidation of the model’s original objectives is required, as a precursor to its expansion into other clinical areas.

  •   There view indicates that there is a stark lack of data pertaining to the generalisable, real-world clinical benefits of the IAPT programme as it currently stands.

  •   Recommendations are provided for future areas of research, and practice enhancements to ensure the value of IAPT services to clients in the wider context of NHS mental health services, including the interface with secondary care, are considered.

 

The British Association of Behavioural and Cognitive Psychotherapies (BABCP) ought to look seriously at the promotion of its’ IAPT comic ‘CBT Today’. Interestingly in its’ recent issue it managed to omit that I was one of those who made a submission re: the proposed NICE Guidance on depression. Further, only one of the others who made submissions were given their adjectival title, the leading light in IAPT. The British Psychological Society (BPS) should reconsider its validation of low intensity IAPT courses, in the absence of any credible evidence base on real-world effectiveness.

Dr Mike Scott

Ignoring Mental Health Outcomes That Matter

this is a speciality of Government provided services. Studies of the natural history of depression and the anxiety disorders insist on using evidence of enduring freedom from the disorders of                     8-12weeks [Bruce et al 2005https://doi.org/10.1176/appi.ajp.162.6.1179 and Penninx et al (2011) doi:10.1016/j.jad.2011.03.027] as evidence of remission, distinguishing the latter from a new episode of the disorder. This reflects the general public’s understanding of having a disorder or not having a disorder. But inspection of the Government’s Improving Access to Psychological Therapy (IAPT) service reveals no such clarity. Instead funders of services and clients are invited to believe that the latter endorsing a below 10 score on the PHQ9, over the previous two weeks,  is evidence of appropriate treatment. Further the scoring is discussed with the therapist, usually resulting in an exit from the Service when this promised land is reached. But it is entirely a mirage, that suits IAPT’s need to secure funding. The narrow interest of the Service is put above the public good. 

IAPT’s metric ignores the complexity of presentations, client’s may present with depression an anxiety disorder or a combination of the two, each follows their own trajectory [Penninx et al (2011) doi:10.1016/j.jad.2011.03.027]. But there is no reliable identification of who is on what pathway, as IAPT clinicians do not make diagnoses [IAPT Manual (2019)]. It is therefore impossible to match treatment to diagnosis. Further IAPT takes no steps to ensure treatment fidelity i.e the matching of a treatment strategy to a target. 

The mnemonic PICOT has been used by NHS England and NICE to help determine evidence based treatment. The P stands for population  or the problem being addressed. IAPT’s gateway criteria for disorders are scores over 10 on the PHQ9 or over 8 on the GAD7. But what does this tell us about this population? Are they suffering from depression and/or an anxiety disorder? which anxiety disorder? Can there be any certainty that they are not suffering from an adjustment disorder or possibly PTSD? In what way would this population differ from another population that they might resemble? The ‘P’ of the PICOT in IAPT is so fuzzy that it sabotages any pretence by the service to deliver an evidence based treatment (EBT). IAPT has no fidelity  checks, making it impossible to specify the I. IAPT has never attempted to compare its’ service effects with effects of pre-IAPT counselling, thus it has never attempted C a comparison, making it impossible to state the ‘added value’ of its ministrations. IAPT has declared its’ own outcome of interest and measured in its presence, it is not a primary outcome used in any randomised controlled for depression and the anxiety disorders. The selected outcome measure is self-serving. IAPT takes a photo of the client in a 2 week period when with their assistance they appear to be doing well. This is like defendants Insurers taking video footage of client claiming  an acquired injury, with snapshots of him/her going to the shops, sometimes accompanied,  over a 2 week period.  It says nothing of their fitness to persist in a pre-existing manual job. There is no meaningful distilation of the T in PICOT. IAPT’s practice makes it impossible to evaluate the service according to the NHS and NICE recommended PICOT framework.The IAPT data set is insufficient to meet the PICOT criteria above, at each level.

IAPT operates in a pre EBT mode, relying simply on the judgements of practitioners and by reference to the designated ‘Experts’ within the Organisation, oftentimes nominated by the British Association of Cognitive and Behavioural Psychotherapies (BABCP). The ‘nominations’ are not advanced by BABCP’s claim to be the ‘lead organisation’ for CBT, it certainly does not lead to the promised land. My own research Scott M. J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical Reform. Journal of health psychology, 23(9), 1136–1147. https://doi.org/10.1177/1359105318755264suggests that only the tip of the iceberg recover in IAPT.

The IAPT training courses fail to equip clinicians with the skills to avoid being led astray, making my real world findings of effectiveness or the lack thereof, unsurprising.

 

Dr Mike Scott

The Extraordinary Claims and Behaviours of IAPT’s Backers

who exhibit power without accountability. They include companies such as SilverCloud and limbic and professional bodies such as the British Association for Behavioural and Cognitive Psychotherapy (BABCP) and the British Psychological Society (BPS).

I reported SilverCloud to the ASA over its claim of ‘up to 70% clinical recovery rates’ for its computerised CBT. Unfortunately they could not act on it as it comes under Irish jurisdiction. The matter has  been passed to the Irish ASA, from whom I have heard nothing. The reach of SilverCloud is extensive, with its’ claim to be “supporting 80% of the NHS Improving Access to Psychological Therapies(IAPT) services”. It is a major financial backer of IAPT workshops. But there has been no independent verification of SilverCloud’s claimed recovery rates.

IAPT workshops are also now funded by limbic ‘An A. I. assistant for clinical assessment in IAPT – improving access, reducing costs and freeing up staff time’. Recently the British Psychological Society Journal the Psychologist devoted an article to the claims of the CE0 of limbic. I protested, and furnished a critique which the Editor declined. I note that in the current issue of the American Journal of Psychiatry that there is a paper by IAPT researchers Delgadillo et al 2022 JAMA Psychiatry. 2022;79(2):101-108. doi:10.1001/jamapsychiatry.2021.3539 published online December 8, 2021 in which they have been unable to substantiate the claims of limbic.

But Delgadillo et al (2022) do claim a 7% increase in the likelihood of recovery if IAPT therapist use the limbic algorithm i.e inputting data on depression, anxiety, history etc to determine whether the particular clients needs are better met by IAPT standard stepped care or by a stratified procedure where clients are allegedly better matched to high or low intensity CBT initially. However they do observe that the apparent difference could be due the therapists involved in stratification devoting more time to clients!

Delgadillo et al (2022) accept without question IAPT’s definition of recovery, a change of score on a self-report measure, the PHQ9, to below caseness. They fail to point out that their metric does not a) involve independent assessors to counter the demand characteristics involved in usage of a self-report measure i.e the focus on this measure in client-therapist interactions b) the IAPT data provides no indication that clients see the claimed changes as clinically meaningful, i.e back to old self or best functioning c) symptoms of depression and anxiety wax and wane, so that any improvement on a self-report measure can be simply a flash in the pan, particularly when people present initially at their worst. It has to be determined that any change is lasting e.g at least 8 weeks. It appears that Delgadillo et al (2022) simply rejoice in the large data set furnished by IAPT, it is a case of ‘never mind the quality, feel the width’.

When the power holders collude in this way, it is difficult make headway. I think limbic should also be reported to the ASA and BABCP and BPS should be asked to justify their commitment to Psychological Wellbeing Practitioners (PWPs), the deliverers of low intensity CBT – it looks suspiciously like cronyism, however unintentional.

Dr Mike Scott

IAPT Has Been A Law Unto Itself and is Rightfully Being Ignored by NICE

The National Institute for Health and Clinical Excellence (NICE)  can only base its treatment recommendations on studies that have a rigorous methodology. In generating the proposed recommendations on the treatment of depression &source=web&cd=&ved=2ahUKEwic8KOfmcD1AhVOasAKHVt8C_EQFnoECAcQAQ&url=https%3A%2F%2Fwww.nice.org.uk%2Fguidance%2Findevelopment%2Fgid-cgwave0725&usg=AOvVaw01CPXDGEYzB5NZCOPcgTFr NICE has ignored all studies that  emanate from the Improving Access to Psychological Therapies (IAPT). Yet the lead organisation for cognitive behaviour therapy, the British Association for Behavioural and Cognitive Psychotherapy (BABCP) BABCP response – NICE consultation draft https://www.google.co.uk/urlsa=t&rct=j&q=&esrc=s has protested vehemently about this. But applying the ‘Psychotherapy outcome study methodology rating form’ developed by Ost (2008) OST the original randomised controlled trials of CBT for depression and anxiety disorders had a mean score  of 27.8, (SD 4.2). Applying the scale to studies by IAPT related personnel, they struggle to score into double figures – a fate shared by studies of low intensity CBT.  To put these scores in context, Ost (2008) dx.doi.org/10.1016/j.brat.2007.12.005 found the total mean score for ACT was 18.1 (SD 5.0) and for DBT 19.4 (SD 3.9). He considered the scores for ACT and BDBT too low, for them to be regarded as Evidence Supported Treatments (ESTs). How much less of an EST then are the IAPT interventions? BABCP defends itself by saying the IAPT studies need to be evaluated by some other metric, but don’t specify which. This sounds suspiciously like the defending of a family member, rather than being data driven.

It should be noted that IAPT does not measure either adherence  (item 15 on the rating form) nor competence (item 16 on the rating scale). Thus there is no assurance of treatment integrity in IAPT. IAPT clinicians have been a law unto themselves. NICE therefore cannot be sure that IAPT’s alleged treatment interventions were delivered.

The studies by IAPT related personnel fail abysmally on almost every index of reliable methodology. Running through the rating form: IAPT therapists do not make diagnoses, making for ‘0’ scores for items 1-6, similarly ‘0s’ would be awarded for no blind evaluators (item 7), no assessor training (item8), no random, assignment to treatments (item 9), no control groups (item 10), treatment as usual (item 11), no power analysis (item 12), only pre and post assessment points  (item 12), effects of therapist were not assessed, nor level of training  [items 14 & 15generously a score of 1 could be awarded on both these items, no control of concomitants (item 18), no intention to treat analyses (item 19), statistical analysis confined to completes (item 20),  no evidence of real world clinical significance (item 21 but a case could be made for awarding a 1 score, no equality of therapy hours because no comparison condition (item 22).  

The low intensity rcts similarly rate very poorly on the rating form. Studies of these cheap offerings rely on establishing statistically significant differences with a comparison group. Never stopping to assess whether any found difference is clinically  meaningful. Any differences do not pass the ‘Does it matter? test, or the ‘So what? test or the ‘Why should anyone care?’ test. In none of the studies have clients been asked independently post treatment  ‘are you back to your usual self, now?’ Importantly if they reply ‘yes’,  then asking ‘for how long have you been back to your usual self?. Studies of the natural history of anxiety disorders have utilised a period of 8 weeks free of  meeting diagnostic criteria, to define recovery, Bruce et al (2005)] The absence of data on the proportion of clients returned to their normal and enduring functioning  by these ‘cost-saving’ interventions, means that prospective clients cannot make an informed choice about engaging in such treatments. NICE needs to proceed more cautiously in recommending low intensity CBT.

 

Dr Mike Scott

The Bell Tolls for IAPT if NICE Has Its’ Way

according to the BABCP’s submission BABCP response – NICE consultation draft  to the National Institute for Health and Clinical Excellence (NICE ). Implementation of the latter’s proposed guidance would mark the end of the Improving Access to Psychological Therapies (IAPT) service. 

Interestingly BABCP recommend that assessment should begin with a reliable diagnostic interview and acknowledges that IAPT’s Psychological Wellbeing Practitioners (PWPs) are not equipped to do this. Further BABCP recommend that outcomes should be assessed from the client’s perspective but do not specify how. Ironically some of BABCP’s own recommendations undermine the functioning of its over-induIged prodigy, IAPT. BABCP are alarmed that the proposed guidance would, in their view, herald the end of stepped-care.

BABCP are aghast that NICE have not included studies by IAPT related personnel in determining the way forward. In defence of IAPT, BABCP cite the Wakefield et al(2021) https://doi.org/10.1111/bjc.12259 study published in the British Journal of Clinical Psychology but fail to mention my rebuttal paper Scott(2021) https://doi.org/10.1111/bjc.12264 published in the same issue of the Journal. Quite simply NICE does not consider studies that are based on agencies marking their own homework as having any credence. This is thoroughly reasonable.

The BABCP have rightly pointed out to NICE that in recommending group interventions as the starting point for offering clients help, they have not properly looked at the context of the group studies. As I pointed out in my submission to NICE COMMENTS ON PROPOSED GUIDANCE (and simultaneously submitting via BABCP as a stakeholder), there are considerable hurdles in engaging clients in group therapy, see Scott and Stradling (1990)Group cognitive therapy for depression produces clinically significant reliable change in community-based settings Behavioural Psychotherapy, 18: 1-19 and Simply Effective Group Cognitive Behaviour Therapy Scott (2011) https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwiph5Hlvbb1AhWKX8AKHRSJDZ0QFnoECAUQAQ&url=https%3A%2F%2Fwww.amazon.co.uk%2FSimply-Effective-Cognitive-Behaviour-Therapy%2Fdp%2F0415573424&usg=AOvVaw0nam02gszlQ0HqCktSCB0s. 

In fairness, I think Prof Shirley Reynolds from BABCP has done a great job in reviewing the extensive documentation provided by NICE and collating the individual submissions, all within a very brief period of time. I understand from her that these matters will feature in the next issue of CBT Today and whilst I was happy to have my name noted as having submitted, there are important aspects of the submission on which I wish to dissent.

NICE make its’ formal recommendations in May, interesting times

 

Dr Mike Scott

People Cannot Benefit from a Treatment To Which They Have Not Been Exposed – The Undermining of IAPT

The Improving Access to Psychological Therapies (IAPT) Service does not assess treatment fidelity. Thus, there can be no certainty that clients receive an evidence-based treatment treatment.  IAPT therapies are not EBTs. Despite this, the major funder of IAPT training days SilverCloud, claims on its’ website ‘up to a 70% real-world recovery’ using its computer assisted products, for all common disorders except PTSD and OCD!  The Advertising Standards Authority need to look at this, the ASA has a complaints form that can be completed online. SilverCloud’s UK address is Suite 1350, Kemp House, 152 City Road, London, EC1V 2NX., My own study of 90 IAPT cases suggests just a 10% recovery rate, Scott (2018) https://doi.org/10.1177%2F1359105318755264).

IAPT have produced no evidence that its’ therapists using SilverCloud make any added difference to their clients over and above that of those who didn’t use it. see SilverClouds Space for Depression programme   NICE Guidance ‘Space from depression for treating adults with depression’ Medtech innovation briefing published May 7th 2020. Strangely the NICE IAPT Expert Panel concluded that the case for adoption is ‘partially supported’ despite in the body of report noting lower depression scores, at the end of treatment for the clients of therapists who did not use the computer assisted CBT. An example of spin and conflict of interest.

 

The SiverCloud website cites 10 references appearing in peer-reviewed journals to support its work.  But none of the studies cited by SilverCloud involve blind independent assessors of outcome using a ‘gold-standard’ diagnostic interview. In the cited review study by Wright et al (2019) Wright JH, Owen JJ, Richards D, et al. Computer-assisted cognitive-behavior therapy for depression: a systematic review and meta-analysis. J Clin Psychiatry. 2019;80(2):18r12188 the third author is employed by SilverCloud.

 ‘Real-world’ recovery represents a change that a client would care about, such as no longer suffering from the disorder that they were suffering from before treatment or a return to best functioning. In a footnote SilverCloud defines recovery as ‘Moving from clinical caseness to non-caseness, i.e. lowering the score on PHQ-9 and GAD-7 from above the clinical threshold to below the threshold’. Such changes are meaningless to clients they are not ‘real-world’.

Here is what one client told  me:

‘I found Silvercloud ineffective, generic and not tailored to my personal situation. It wasn’t engaging or helpful and as such I didn’t engage with the website very much. Consequently, the following weekly call with the IAPT therapist  were sometimes made difficult by the fact I hadn’t completed the same questionnaire as the week before or read through articles. I wanted to talk about my situation, my feelings and find out why I was feeling the way I was, but I felt I was just being led back to using the online SilverCloud resource.

‘It was in 2017 that my doctor suggested I try SilverCloud online CBT with telephone support and in September 2017, I started speaking to another IAPT counsellor. He seemed to be a very nice man. After a few weekly calls, he stated that he didn’t believe I was depressed and so he changed the original Silvercloud course I had started and reset it back to a new series of 6 sessions. The weekly calls lasted between 20 minutes to an hour depending on what we discussed, but always concluded with him asking me to log onto SilverCloud and work my way through the programme before our next call. After the requisite 6 sessions finished in February 2018, that was it! No answers, no tools to help me cope, just signed off, discharged, but told I had 12 month access to SilverCloud. I haven’t used the resource since’.

In general the claims of clinicians and supervisors with regards to treatment fidelity do not match those of independent blind-raters [ Waltman et al (2017)https://doi.org/10.1016/j.janxdis.2021.102407], there are vested interests at play.

The author knows of no study of low intensity CBT (guided self-help, group psychoeducation, computer assisted CBT) that has assessed treatment fidelity. Usage of a manual does not guarantee treatment fidelity. Approx. three quarters of IAPT clients receive low intensity intervention on entry to the Service [Davis et al (2020)https://doi.org/10.1136/ebmental-2019-300133].].

IAPT’s approach ostensibly depends on the results of randomised controlled trials of CBT, but a study of remission rates in CBT for anxiety disorders (including OCD and PTSD) Levy, Bryan and Tolin (2021) https://doi.org/10.1016/j.janxdis.2021.102407 showed that in half the studies (8 out of 17) there was a high risk of bias because of a failure to address treatment fidelity. Further in 7 of the 17 studies there was a high risk of bias because of the failure to use blind assessors. [A re-view of psychotherapy trial reports published in 6 top psychiatry journals in 2017 and 2018 revealed that only 59% of the included trials reported adequate blinding of outcome assessors Mataix-Cols et al (2021)]. https://jamanetwork.com/journals/jama/fullarticle/10.1001/jamapsychiatry.2021.1419?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jamapsychiatry.2021.1419].Thus, the research base that IAPT draws upon is far from rock solid.  The remission rate in rcts for anxiety disorders is approx. 50% [ Springer et al (2018) https://doi.org/10.1016/j.cpr.2018.03.002]and this is the ‘gold standard’. But IAPT claims comparable results despite a total disregard for blinding and treatment fidelity! The faked goods ought perhaps to be reported to Trading Standards as well as ASA, in lieu of any interest in the matter from the British Psychological Society (BPS) or the British Association for Behavioural and Cognitive Psychotherapy (BABCP)!

The real story of SilverCloud is that it provides morsels of CBT when what is really needed is a proper meal. It is insulting to clients to in effect say ‘let’s see how you get on with morsels and then we will see about a proper meal’.

 

Dr Mike Scott

The Improving Access to Psychological Therapies (IAPT) Programme and The British Psychological Society (BPS)

 

The BPS has enthusiastically supported IAPT from its’ inception in 2008.  Improving access to psychological therapies is clearly a laudable goal, as most people with a mental health problem are not offered psychological therapy. The Society has led the course accreditation process for IAPT’s, Psychological Wellbeing Practitioners (PWPs) low-intensity training since 2009. Features on individual PWP’s have featured periodically in the pages of The Psychologist. In 2009, The Psychologist published a letter from the then President of the British Association for Behavioural and Cognitive Therapies (BABCP) stating that BPS members on the IAPT Education and Training Project Group supported BABCP’s accreditation of high intensity training programmes and noted that there were BPS members on the Accreditation Oversight group.

But the enthusiasm of BPS to give away psychological therapy has not been matched by a concern, to listen to the concerns of service users. Specifically:

  1. At no point has BPS suggested that it is inappropriate for IAPT to mark its’ own homework. The latter’s reliance entirely on self-report measures completed often in the prescence of the IAPT therapist, should have had any self-respecting psychologist crying ‘foul’ and calling for independent assessment.
  2. A concern for service users, should have led BPS to insist that a primary outcome measure must be clearly intelligible to the client. But there has been no specification of what a change in X as opposed to a change of Y would mean to a client on the chosen yardsticks of the PHQ-9 and GAD-7.
  3. BPS has been strangely mute on the fact that two self-report measures have been pressed into service to validate IAPT’s approach, with no suggestion that such an approach needs to be complemented by independent clinician assessments that go beyond the confines of the 2 disorders (depression and generalised anxiety disorder) that the chosen measures address.
  4. If a drug company alone extolled the virtues of its’ psychotropic drug, BPS members would quite rightly cry ‘foul’ insisting on independent blind assessment using a standardised reliable diagnostic interview. But from the BPS there has been a deafening silence on the need for methodological rigour when evaluating psychological therapy. This reached its’ zenith In the latest issue of The Psychologist, September 2021, when the Chief Executive of an Artificial Intelligence Company, was allowed to extol the virtues of its’ collaboration with four IAPT services. No countervailing view was sought by The Psychologist, despite it being obvious that the supposed gains were all in operational matters e.g reduced time for assessment, with no evidence that the AI has made a clinically relevant difference to client’s lives.

 

In 2014 I raised these concerns in an article ‘IAPT – The Emperor Has No Clothes’ I submitted to the Editor of the Psychologist which was rejected and he wrote thus ‘I also think the topic of IAPT, at this time and in this form, is one that might struggle to truly engage and inform our large and diverse audience’. This response was breathtaking given that IAPT was/is the largest employer of psychologists.

Fast forward to 2018 and I wrote and had published in 2018 a paper ‘IAPT – The Need for Radical Reform’ https://doi.org/10.1177%2F1359105318755264 published in the Journal of Health Psychology, presenting data that of 90 IAPT clients I assessed independently using a standardised diagnostic interview only 10% recovered in the sense that they lost their diagnostic status, this contrasts with IAPT’s claimed 50% recovery rate. The Editor of the Journal devoted a whole issue to the IAPT debate complete with rebuttals and rejoinders. But no mention of this at all in the pages of The Psychologist.

It appears that BPS operates with a confirmation bias and is unwilling to consider data that contradicts their chosen position. If psychologists cannot pick out the log in their own eye how can they pick out the splinter in others? In 2021 I wrote a rebuttal of an IAPT inspired paper that was published in the British Journal of Clinical Psychology, ‘Ensuring IAPT Does What It says On The Tin’, https://doi.org/10.1111/bjc.12264 but again no mention of this debate in the Psychologist.

In my view the BPS is guilty of a total dereliction of duty to mental health service users in failing to facilitate a critique of IAPT. It has an unholy alliance with BABCP who are similarly guilty. Both organisations act in a totalitarian manner.

Dr Mike Scott