the Improving Access to Psychological Therapies (IAPT) pantomine is likely to continue, with Dr Adrian Whittington, National Lead for Psychological Professions, NHS England and IAPT National Clinical Adviser about to chair a Conference with the leading light of IAPT, Professor David Clark for IAPT staff. IAPT afficionados seem inherently incapable of understanding what constitutes a conflict of interest, see forthcoming issue of the British Journal of Clinical Psychology, ‘Ensuring IAPT Does What It Says On The Tin’. https://doi.org/10.1111/bjc.12264.
Finding the Evidence
A key step in the information production process
Caroline De Brún
NHS England should reflect on their own document published in 2013 ‘Finding the Evidence’ in which clinicians are asked to seek the ‘best research evidence’ by looking at how an intended treatment has fared compared to a credible alternative. Taking the IAPT service as the intended treatment there has never been a comparison with a credible alternative. IAPT cannot be considered a repository of ‘best evidence’
The power holders, wish to believe their fairy tale ‘we are committed to mental health, we have shown this in supporting our world beating IAPT service, as far as possible we will fund expansion of the service, we have broken new ground’ and in small print ‘it is not politically correct to say other and we are too busy with the pandemic/physical health to critically analyse IAPTs data’. But this is a dangerous story offering no protection for the mental health sufferer. It is time that sufferers are seen as ‘vulnerable’ people and offered societal protection.
IAPT therapists do not ask the client, at the end of treatment, whether they are back to their old selves again. Outcome is determined by the Genie that arises out of the psychometric test lamp that IAPT polishes incessantly.
The Genie could be pressed ‘how does low intensity CBT work?’ A coughing and spluttering might ensue. It is known that CBT works for the depression and anxiety disorders, using the specific cognitive model for those disorders. But there is no evidence that simply describing the reciprocal interactions of cognition, emotion, behaviour and physiology, then targeting one or more of them leads to an evidence supported treatment. It is a fundamentalist translation of the treatments conducted in the randomised controlled trials of depression and the anxiety disorders. It is a translation born of the exigencies of the situations, such as vast monies available for treatment, but it is akin to using a religious belief system for political purposes.
The CBT protocol for panic disorder is entirely dependent on David Clark’s model (2020) of catastrophic misinterpretation of bodily sensations perpetuating the symptoms of panic https://doi.org/10.1007/s10608-020-10141-0. None of the procedures in the protocol would make sense without reference to his model.
A cognitive model of a disorder is the nucleus around which orbit all the procedures of a protocol. Beck enshrined this in his theory of cognitive content specificity, that disorders are distinguished by their different cognitive content and connive profiles see Baranoff, J., & Oei, T. P. S. (2015). The cognitive content-specificity hypothesis: Contributions to diagnosis and assessment. In G. P. Brown & D. A. Clark (Eds.), Assessment in cognitive therapy (p. 172–196). The Guilford Press, and Eysenck and Fajkowska (2018) https://doi.org/10.1080/02699931.2017.1330255.
But the procedures in low intensity CBT have no nucleus. For example the strategies in Williams et al (2018) doi: 10.1192/bjp.2017.18 Living Life to The Full classes ‘covering key CBT topics such as altered thinking, behavioural activation, problem-solving and relapse prevention’, are not derived from any specific cognitive model of disorder – they are the equivalent of displaced electrons, the atoms have no credible name and the targets ill defined. For example in the Williams et al study (2018) the target is ‘low mood and stress’, the latter has no specific cognitive content or cognitive profile. If it is not known how a psychological therapy achieves its goal then the therapy itself cannot be considered evidence supported. There has to be a plausible scientific explanation of the mechanism of change. The low intensity cbt protocols represent an ad hoc usage of cbt techniques, it is impossible to distil the mechanism of change, if any, in such a collage. In this respect the low intensity interventions are found wanting, they are poor translations of the protocols in the ‘gold standard’ randomised controlled trials, they are advocated in a fundamentalist way by IAPT, driven by perceived economy than any considered view of effectiveness.
Dr Mike Scott