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

IAPT’s Hidden Agenda

we can only deal with one problem, because that fits into the 6 sessions of therapy that we start with’, but the Improving Access to Psychological Treatments (IAPT) service makes no  public declaration of this.  Clients want a holistic approach in which all their problems are catered for. It is magical thinking to believe that a) a mental health problem can be resolved in 6 sessions b) the benefits gained from addressing the chosen mental health problem will, by a process of osmosis, resolve the other mental health problems. This represents delusional Organisational thinking, unfortunately I think it would take a lot more than 6 sessions to treat!

Recently I saw Ms X and she related to me her two sojourns through IAPT. I also had access to the IAPT correspondence, for confidentiality reasons, some of the details have been changed:

Five years a ago, Ms X found out that she had been adopted, she felt that she had never fitted in with her adoptive family, though they were kind. She felt that she had always been a ‘worrier’, her adoptive mum had chronic health problems and shortly after learning of her adoption she became concerned over any blemish on her skin. Ms X saw her GP and she advised self-referral to IAPT. She had a telephone assessment with a Psychological Wellbeing Practitioner and was advised that her PHQ-9 score was normal and her GAD-7 score at ‘caseness’. But no diagnosis was given. A letter from IAPT indicated that she ‘agreed to attend a worry management course’ but she said only a group programme was on offer. Ms X dropped out after attending one group session. Her GP had recorded that the treatment had not helped. I assessed her using a standardised diagnostic interview and it was clear that she had been suffering from illness anxiety disorder and general anxiety disorder (GAD) at the time of seeking help form IAPT and her diagnostic status was unchanged by IAPT’s ministrations.

Two years later she was at work, when her hair got caught in machinery at work causing a scalp injury. However the injury was under the hairline and not visible, but she could feel an indentation on her scalp. She developed a phobia about being around machinery leading to poor attendance at work and possible disciplinary action. The accident re-ignited her illness anxiety disorder that had been in remission for about 6 months. I noted that she continued to meet diagnostic criteria for GAD. Her GP advised self-referral to IAPT and she had a telephone assessment with a Trainee Psychological Wellbeing Practitioner, both PHQ-9 and GAD-7 scores were at ‘caseness’.  No diagnosis was given. Ms X was told that they could only treat one of her problems and she chose her health anxiety concerns. She was placed on a 6 week waiting list for the Silver Cloud computerised CBT. During, the course of her cCBT she had 4 interactions with IAPT staff responsible for the smooth functioning of the Silver Cloud programme. They said that she was ‘depressed and anxious’ but gave no diagnosis. During treatment her specific phobia was not addressed at all. The diagnostic interview that I conducted revealed comorbid illness anxiety disorder and GAD but she was not depressed. She understood that there was to be a review of her progress at the end of cCBT to see what if any further help might be appropriate. This never happened. The Silver Cloud programme had no impact on her diagnostic status. IAPT’s treatment was ‘in the Clouds’.

This case raises important questions:

  1. Why was a minimalist intervention repeated when the first such intervention had not worked?
  2. Why are the least well-trained clinicians given the power to direct treatment?
  3. Why are the least well-trained clinicians given the power to re-direct treatment?
  4. Why is IAPT allowed to behave in a way that would not be tolerated in physical care vis a vis a focus on just one problem and continued management by the most junior clinician when treatment fails?
  5. Where is the publicly funded independent audit of IAPT?

Unfortunately, this is not an isolated case, my own review of 90 cases suggests just a 10% recovery rate Scott (2018) https://doi.org/10.1177%2F1359105318755264) . There has been a dereliction of duty by NHS England, Clinical Commissioning Groups and the National Audit Office. The British Psychological Society has rubber stamped whatever IAPT has proposed. The British Association for Behavioural and Cognitive Psychotherapy have become an IAPT mouthpiece, its’ journal CBT Today intolerant of dissent.

 

Dr Mike Scott

 

 

IAPT and Special Measures

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 variation.

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.

Table 1

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.)

References

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.

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