The Myth of CBT In Routine Practice

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.

Dr Mike Scott

The Ongoing Gagging of Discussion About IAPT Following ‘Has IAPT Become A Bit Like Frankenstein’s Monster?’

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

https://www.dropbox.com/s/myz53dyn8zqhj13/Has%20IAPT%20become%20a%20bit%20like%20Frankenstein.docx?dl=0

BABCP is undoubtedly very powerful and well connected but its’ credibility as the ‘lead organisation’ for CBT must be in doubt, given its’ unswerving support for IAPT.

Dr Mike Scott

IAPT’s Clients – Vulnerable Adults With No Protection

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.

https://www.dropbox.com/s/vj2hp1q43hz4lh8/CONSORT%202010%20Explanation%20and%20Elaboration%20Document-BMJ.pdf?dl=0

Dr Mike Scott

The Gagging of Discussion About IAPT Following ‘Has IAPT Become A Bit Like Frankenstein’s Monster?’

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’.

Dr Mike Scott

IAPT Teacher’s Blistering Attack On The Service

writing in the current issue of BABCP’s in-house magazine CBT Today, Jason Roscoe, comments that the service may be likened to Frankenstein. His intentions were good but the outcome monstrous.

https://www.dropbox.com/s/hozljbsbz21ceso/20190301_092733.jpg?dl=0

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’

IAPT’s Reply

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).

Stalinesque

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.

Dr Mike Scott

Mental Health Systems Not Fit For Purpose

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

  1. 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.
  2. Jorm AF. The quality gap in mental health treatment in Australia.
    Aust N Z J Psychiatry. 2015;49(10):934-935.
  3. 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.
  4. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in
    primary care: a meta-analysis. Lancet. 2009;374(9690): 609-619.
  5. Simon GE, VonKorff M, Wagner EH, et al. Patterns of antidepressant
    use in community practice. Gen Hosp Psychiatry. 1993;15(6):399-408.
  6. 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:

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

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.

Dr Mike Scott

Yesterday’s CBT for PTSD and Beyond ‘A really great workshop it was too’ –

‘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.

Dr Mike Scott

Life Beyond Trauma Focussed Therapy

I have just been preparing for a Workshop, I am delivering to the Merseyside Branch of BABCP, on October 4th 2018, titled ‘CBT for PTSD and Beyond’. At this Workshop I shall  unveil my KISS Model of PTSD. KISS for the uninitiated stands for Keep It Simple Stupid. Unlike trauma focussed models of CBT and EMDR, it does not assume a flawed traumatic memory or arrested information processing.

 

 

As part of the presentation I will be saying that therapists should beware of questionnaires as they will overidentify symptoms because:

a) they don’t tease out whether a particular symptom is making a ‘Real World’ Difference e.g a respondent might indicate upsetting dreams, but if they are not woken by the dream and distressed this is not significant functional impairment and so would not count as a symptom that is ‘present’

b) in completing a questionnaire client’s are often not clear about the time frame under consideration, endorsing flashbacks/nightmares when they did have them initially but they are past, and also endorsing symptoms currently present such as poor sleep. For a diagnosis of disorder symptoms have to be simultaneously present and each must make a ‘real world’ difference. Only in an interview can you tease out both and request concrete examples of the extent to which a symptom is impairing functioning

Dr Mike Scott

Delivering Group CBT – A Special Interest Group

For many years I have been running a ‘Delivering Group CBT’, Workshop following the June 15th Workshop in Manchester, there were 25 signatories for a BABCP Special Interest Group. An application for a SIG has now been made. Anyone interested in joining this merry band would be appreciated, just e-mail me at michaeljscott1@virginmedia.com.

 

The following is a link to the Powerpoint for my recent workshop https://www.dropbox.com/s/6sq5mvrhyvtnz1q/Delivering%20Group%20CBT%20Manchester%20June%2015th%202018.pptx?dl=0. A key feature is that it avoids the dichotomy either individual or group CBT.

 

Dr Mike Scott

Current Supervision Practices Have Not Prevented the Poor Outcomes In IAPT

 

With a 10% recovery rate in IAPT https://doi.org/10.1177/1359105318755264, serious questions have to be asked about the quality of supervision.  But it could be that Supervisors in IAPT feel that their role is constricted or the use of practitioner league tables sabotages their endeavours. Clearly something is going badly wrong. However it could also be that current supervision practices whether or not they take place in IAPT are not fit for purpose, they are eminence rather than evidence based.

 

‘Its’ about monitoring, personal development – a bit like treating a client, has to be tailored to the supervisee’ this seemed to be the consensus at a BABCP Supervision Workshop I attended with about 40 others in Liverpool last week.  The presenter Jason Roscoe, asked the 40 attendees what model of supervision they followed, there was a deafening silence. He then presented the Roth and Pilling competencies for supervision, I opined that just looking at the rows and columns gave me ‘mental  indigestion’.  Given the outbursts of laughter I think that this was a widely shared view.  I had a sense that people feel rudderless with regards to supervision, and there was no enthusiasm about becoming a BABCP accredited supervisor.

I suggested that the prime function of supervision is to act as a conduit for evidence based treatment. Since the Workshop I have reflected that no alternative definitions of the prime  function were offered rather the Bennett-Levy model of supervision involving 3 different types of knowledge declarative, procedural and reflective was recommended. The implication was that one might need to do more or less on any one of these forms of knowledge with any particular supervisee. Hmm I thought, this is no different to what one would do with a client in treatment. The offering at the Workshop was I found typical of what passes for evidence in BABCP with regards to supervision, but there is sparse evidence such supervision makes a real world difference to client’s lives. What is known is that supervision has been an integral part of randomised controlled trials and that type of supervision can be considered evidence based. It follows that to the extent that this type of supervision is adopted, with its’ emphasis on reliable diagnosis and fidelity checks for adherence and competence one is still in the ball park of evidence based supervision ( see Simply Effective CBT Supervision London: Routledge).

Dr Mike Scott