IAPT’s New Direction – ‘maybe, shove them all through low intensity’

that’s the take home message from a just published IAPT study conducted in the North East of England by Boyd, Reilly and Baker (2019), see link below:

https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0

This would mean that those with PTSD and social anxiety disorder would first fall into the orbit of low intensity interventions. Never mind that there is no empirical evidence from randomised controlled trials that these disorders respond to low intensity interventions.

Boyd, Baker and Reilly (2019) reiterate the populist myth that there is ‘sound evidence of the efficacy of low intensity interventions’ . This only becomes true if one lowers the methodological bar as low as in their own study, which was reliant entirely on self-report measures administered outside the context of a reliable diagnostic interview. These authors cite a study by Bowers et al (2013) in support of the effectiveness of low intensity interventions but these authors acknowledge that a key limitation of their study was generalisability, because patients were not reliably assessed for depression, see link below:

https://www.dropbox.com/s/24qz5pdu6dfl0ce/Low%20intensity%20initial%20severity%20doesnt%20make%20a%20difference%202013.pdf?dl=0

If the North East of England study is taken on board by IAPT, there is less need to worry about clients being on waiting lists for high intensity treatments, because they are allegedly already getting something worthwhile! Who needs high intensity therapists?

IAPT’s research and treatment is conducted on another planet from the lived experience of clients. Take the case of Tara, she suffered from depression after a fall and from a phobia about tripping, that I established with a diagnostic interview. She then had 6 IAPT face to face low intensity sessions which were described as guided self help, 2 of these involved behavioural activation. Her PHQ9 scores stayed at 19/20, which was not significantly different to when I 1st saw her with a PHQ9 score of 21. Treatment made no difference at all, though she valued the opportunity to talk she was very upset after the sessions. Tara was then put on a 3-4 month waiting list for high intensity CBT. The documentation revealed that there had been no evidence of fidelity to an evidence based treatment programme for depression and no attempt to address her phobia. Initially she had a telephone assessment with IAPT.

There is a wholesale abscence of appropriate treatment in IAPT and in practice its’ stepped care model violates continuity of care. It should try listening to clients and subjecting itself to independent audit, instead of playing with large sets of meaningless numbers, to justify funding.

Dr Mike Scott

Gifting Evidence Based Assessment

Evidence based assessment (EBA) is like unwrapping a Christmas present, the first layer is ‘What are we dealing  with (prediction)?, the next what are the options for use, ‘what can we do about it (prescription)? the core is whether the present has made a real world difference ‘ how will we know if we are accomplishing our goals (process)?

 

The three phase approach to EBA, prediction, prescription and process is described (minus the Christmas present!) in December’s Clinical Psychology Science and Practice by Youngstrom et al with an accompanying commentary (including the questions above) by Steven D Hollon.   Youngstrom et al suggest screening for the 10 disorders that most likely comprise 80% of your workload. This can be achieved using the First Step questionnaire from Simply Effective CBT, Scott (2009) London: Routledge an updated free version for 10 disorders is on this blog. Then using a standardised semi-structured interview for positive screens to reliably identify disorders.  Knowing the disorder/s it is possible to predict what is likely to be the best treatment, and prescribe appropriate treatment targets and matching strategies.  Assessment is not just a front end process, assessing whether there has been appropriate process can only be gauged at the end when the assessment is repeated to determine whether the client has got their life back.

 

 

 

In practice many therapists paddle their own canoe, if they stop long enough to really listen they would find that despite the client’s politeness, oftentimes scoring a psychometric test low to please the therapist (weekly administrations have also been found to artificially lower scores), there has not been the real world change.

A very Happy Christmas to Everyone

 

Dr Mike Scott

I’ve Had 10 Diagnoses, Got This Disorder For Life

A teenager Bex’s despair at our mental health system . Twice she has been refused Hospital admission when suicidal. ( Radio 4 today full transcript on Newsbeat ‘Me and My Mind’ available on i-player.  Jeremy Hunt Health Secretary responded ‘only had Crisis Teams 3 years ..it takes time, help isn’t happening everywhere’, he might have added nor does it look like happening anytime soon.

Bex complains that she has OCD, repeatedly checks windows etc, her thoughts sometimes make her too fearful to leave home ‘all thoughts going over, no off switch, tight, chest. It is extremely unlikely that she actually has 10 disorders, but as comorbidity is the norm doubtless she has a couple of disorders. It is inecusable that these  disorders have not be reliably identified and treatment pathways for each illuminated. Making treatment available doubtless requires increased funding but just as importantly the monitoring of fidelity to evidence based treatment protocols for the identified disorders.

I’d like to think of Bex’s case as exceptional, but she reminds me of a former client of mine who unquestionably had a primary diagnoses of borderline personality disorder (BPD). I discovered yesterday that she dropped out of treatment at the behest of a drug taking boyfriend. Since she has done the rounds of local mental health services who have labelled her as having bipolar disorder and she is taking Lithium and having therapy in secondary care. To her family’s dismay she continues to create chaos, her mum has to look after her baby etc. Once again a failure to address the key problem.

 

Dr Mike Scott

The Failure To Deliver Quality Child Mental Health Services

Children and adolescents are failed not only by an underfunding of services  ( see The Guardian, Sunday  December 3rd) but by an aping of models based on IAPT for adults.

I have just seen a 10 year old who had 8 counselling sessions, completed a wide range of psychometric tests, mum was allowed to attend the first ‘assessment’ session. At the end of treatment the agency declared that he had made ‘excellent progress’ and the child thought treatment was ‘fine’. But the reality is that the only disorder he was suffering from before counselling was separation anxiety disorder, when I re-examined him with his mum after treatment there had been no significant change in his diagnostic status. He was happy to chat about anything other than being separated from mum. Inspection of the counselling notes  mentioned working on self-esteem, work with play dough and breathing techniques. Mum had felt excluded from treatment and reported his recent ‘melt down’ when she briefly lost him coming out of a cafe.

Unfortunately neither a diagnostic competence nor ensuring fidelity to an evidence based protocol figure anywhere in IAPT and when agencies ape it, it is no surprise that the results are very poor. Appointing a counsellor in every school sounds good in that the child does not have to go to a mental health establishment and teachers could act as reality checks that ‘treatment’ is making a difference.  But the ‘caseload’ and training remain to be determined. In principle working in a school gives the opportunity  for the counsellor to engage in preventative work, but we have no hard evidence that this works. Nobody it seems has yet addressed the question of the right balance between preventative work and treatment. I can foresee a situation in which the counsellor becomes overwhelmed by the volume of work and redefines their role in a Citizen’s Advice Bureau manner acting primarily as a signpost, doubtless labelled Step 2 making no real world difference

Dr Mike Scott