IAPT Is Efficacious For What and By What Psychological Mechanism?

IAPT claims to be efficacious but there is no specification of for what. No treatment is universally effective, an evidence supported treatment (EST) has by definition a clearly defined focus either a disorder or a particular syndrome. There is no EST for IAPT’s fuzzy construct of ‘anxiety/depression’,  for which it claims a 50% recovery rate. IAPT’s therapists pluck an ICD-10 (World Health Organisation) code out of thin air to describe a clients functioning, but paradoxically claims that the agency does not make a diagnosis (IAPT Manual)! This process gives respectability without accountability.

A psychological therapy must work via a recognised psychological pathway, it is not sufficient that the intended target is a psychological problem/disorder (however fuzzily defined).  In not one of the 100+ missives from IAPT staff to GPs that I have seen has the mechanism of client change been clearly indicated. Rather a collection of keywords from the CBT literature is offered up, favourites in this fruit salad include, ‘reprocessing the trauma’, ‘behavioural activation’, ‘cognitive restructuring’ never is there specificity, for example ‘reversed the negative alterations in cognitions about self, others and world that led to client no longer meeting diagnostic criteria for PTSD’. Fake psychological therapies rule.

Little wonder that clients and GPs are bewildered by the IAPT process – a home for the bemused/befuddled awaits, maybe a high PHQ9 score will be the entry ticket, with promised teletherapy with an IAPT worker! 

Dr Mike Scott

IAPT’s Training Of Therapist’s On Working With Long Term Physical Conditions Muddies The Waters on Efficacy

the evidence base that CBT works with the psychological sequelae of physical conditions is of a wholly different order to that for depression and anxiety disorders (the original remit of IAPT). As a consequence therapists entering this area could become quickly demoralised, increasing the already high rates of burnout. To my knowledge, there are no studies in the LTC area that a) compare the CBT treatment with an active credible attention control group and b) involve independent assessment by a person blind to treatment. Rather outcome assessments are entirely by self report measures such as the PHQ9 and GAD7 of dubious relevance to the destabilisation that can arise from having an LTC.

Training appears to focus on what the therapist should do and the needed competences. But therapists should be aware that these are largely expert consensus statements, the least credible type of evidence and not something derived from an established evidence base.

There are all sorts of minefields in this area not least the diagnostic confusion between say cancer and depression both result in tiredness, insomnia and loss of appetite. Yet training appears not to address this.

One is reminded of the adage ‘fools rush in where angels fear to tread’, is it enticement by empire building and the availability of funds?.

Dr Mike Scott