The UK’s IAPT Service Is An Abject Failure

 

from ‘Mad In America’ https://www.madinamerica.com/2022/06/uk-iapt-abject-failure/

 

Rescued man in boat looking on shipwreck

Dr Michael J Scott Ph.D

In 2012, an editorial in the prestigious journal Nature claimed that the UK’s IAPT Service is “world-beating”—meaning that the service is the world’s best for treating mental health concerns. Now that 10 years have passed, it’s clear that this was not true. Despite the hype, the IAPT is hardly “world-beating.” In fact, it is a doubtful model for other countries to follow.

The IAPT (“Improving Access to Psychological Therapies”) was created in 2008 and fully funded by the UK government (though restricted to provision only in England). The program claims to provide evidence-based psychological treatment, most commonly in the form of cognitive behavioural therapy. It was initially focused on patients with depression and anxiety disorder diagnoses, but its scope has been gradually expanded to include the psychological treatment of long-term physical conditions such as chronic fatigue syndrome.

Patients either self-refer (at no cost) or are referred to the IAPT by their primary care physician/general practitioner. Clients are initially assessed during a 30-minute telephone conversation by a Psychological Wellbeing Practitioner (PWP) who is not an accredited therapist and is not trained to diagnose. IAPT clients initially receive low-intensity CBT (six hours or less of therapy contact) delivered by a PWP. If they are deemed not to have responded to this, on the basis of a psychometric test, they can be “stepped up” to high-intensity CBT delivered by an accredited psychological therapist.

How Well Is the IAPT Doing?

Proponents of the IAPT cite its outcomes for the clients who complete their treatment sessions—but over half of IAPT clients don’t even attend two sessions. The response of the IAPT to this massive disengagement with the service—clients “voting with their feet,” as it were—is currently to offer training to its staff to “streamline” matters by encouraging them to use a computer algorithm to decide which clients go where. This training, which was held on June 22, 2022, involves expert advice from the CEO of Limbic, an artificial intelligence Company. Thus, not only are IAPT staff to be distracted by clients having to complete psychometric tests at each encounter, but now additionally by the administration of the computer algorithm.

Yet Limbic claims it is “an AI assistant for clinical assessments in IAPT—improving access, reducing costs and freeing up staff time.” Where is the independent evidence for this? What clients really want is to be listened to, but there is little chance of this any time soon. Conquering disengagement in this manner is a forlorn hope. 

IAPT’s 2019 manual states that IAPT staff do not make a diagnosis. However, the treatment recommendations of NICE (the UK’s National Institute for Health and Clinical Excellence) are explicitly tied to a taxonomy of specific treatments for identified disorders (largely, diagnosis-specific variations on CBT). IAPT legitimises itself by a claim to be NICE compliant, but how could they be if they don’t make diagnoses? How can they follow NICE’s specific treatment guidelines without first assessing which condition they are treating?

Whilst the IAPT’s claim to be NICE-compliant might be music to the ears of NHS England and clinical commissioning groups, it is simply not true. No independent fidelity checks have ever have been made on IAPT’s ministrations. IAPT allegedly provides specific CBT protocols for different disorders, but it has provided no evidence that it does this.

In my examination of the physician’s records of 90 IAPT clients, I found no evidence of compliance with CBT protocols.IAPT operates simply as a business with superb marketing.

In no independent audit of IAPT, have clients been asked “are you back to your usual self since this treatment?” This is a goal that is meaningful to the client—with the possible supplementary question, “for how long have you been back to your usual self?” In papers published by IAPT staff, no such real-world outcome measures have ever been used. Instead, reliance has been placed on changes in psychometric test scores. Yet without a control group, it’s impossible to know whether these changes would have occurred with passage of time anyway. After all, people present to psychological treatment at their worst, and at any other time, they are likely to score better. In statistics, this principle is known as regression to the mean, and it is vital to account for this effect.

Further, the client knows his/her therapist sees their completed questionnaire, pushing them to respond more positively. A client may also not want to endorse negative responses on the questionnaire because it would mean acknowledging that they have wasted their time in therapy. These are known issues with self-report measures that are commonly cited as important limitations in research studies.

Finally, the questionnaire results also give no indication of whether any improvement has lasted for a period that the client would regard as meaningful, such as eight weeks or (hopefully) more.

In an era of personalised medicine, it is essential that the voice of the client is heard. It is an almost ubiquitous failure of studies to employ a primary outcome measure that a client can identify with—known as patient-centred outcomes. Perhaps the nearest proxy is loss of diagnostic status (full recovery) determined by an independent assessor. The burden of proof rests on providers of services to demonstrate that their treatments are making an important difference to a client’s life in a way that is clearly recognisable to the client. IAPT has not cleared this evidential bar.

Use of an algorithm is not incompatible with a clinician operating on a knowledge base of what works for whom. But it has to be first demonstrated that the former constitutes added value over the latter. The burden of proof is on AI advocates to demonstrate its relevance in a particular context. This cannot be done by a company with a vested interest in AI.

It is perfectly possible that using two systems, an algorithm and clinical judgement, might create confusion. Should an IAPT client not fare well (for example, if a client dies by suicide) when treated under such a dual system, could IAPT convince a court, on the balance of probability (the UK benchmark in personal injury cases), that its approach was evidence-based? After all, an AI approach is not something that NICE has recommended—so it flies in the face of the guidelines. Traditionally, courts are swayed by eminence-based evidence (such as the word of authority figures like psychiatrists), but they have become more aware (at least in the UK) of the perils of unbridled clinical judgement.

Inadequacies of IAPT’s Chosen Metric

IAPT’s chosen metric is a change in score on two psychometric tests. Clients are deemed to have responded if on the PHQ-9 (a measure of the severity of depression) their test score has gone from above 10 to below 10 with treatment, with a difference of at least 6 points, and if on the GAD 7 (a measure of the severity of generalised anxiety disorder) their score has gone from above 8 to below 8 with treatment, with a difference of at least 4 points. This approach has numerous deficiencies:

  • It is not known whether the completer of these two measures was actually suffering from depression or generalised anxiety disorder, because IAPT clinicians do not make diagnoses. Further, it is not known whether either of these “conditions” was the disorder that was causing most impairment in functioning.
  • When test results are observable by the treating clinician, clients may wish to be polite and relay a lower score, particularly as they do not want to feel that they have wasted their time in therapy.
  • No attention control comparator: Changes in test scores are meaningless unless there is a comparator group who have received the same attention and a credible rationale. It’s unclear whether the therapy resulted in the improvement, or if the client would have improved with a “placebo” therapy (simply receiving professional “attention” without CBT techniques).
  • Regression to the mean: Clients typically present at their worst, so with the mere passage of time they will score more modestly.
  • The vagaries of a minimally important difference (MID) in a score: MIDS are established by statistical comparisons between an “ill” and “well” group, but they do not necessarily indicate clinically important difference. They also fail to address the client’s perception and there is no personalisation of treatment outcome. Clients are given no voice.

Haemorrhaging

Last year about a third of referrals (30.1%) to the IAPT service did not access it. Of those who accessed the service over a third (38%) had just one treatment session. Thus, by the start of the IAPT race over half of people (57%) have not engaged in treatment (as defined by IAPT’s metric of attending two or more sessions). If these results applied to a physiotherapy service it would raise serious doubts about the suitability of the service! Why then does the UK National Audit Office studiously avoid scrutiny of IAPT, which costs the taxpayer over £1 billion a year?

Sub-Therapeutic Dose and Treatment Outcomes

Of those who engaged in IAPT, the average number of sessions was 7.5, which is well below the 12 to 20 sessions that NICE recommends for depression and anxiety disorders (IAPT’s primary targets). Are we to believe that IAPT’s clinicians are so skilled that they can achieve recovery with only half the dosage of therapy as that delivered by therapists in the randomised controlled trials of CBT for depression and the anxiety disorders?

The benchmark set by trials of therapy as a treatment for these conditions is that at least 50% must “recover” (no longer meet criteria for a diagnosis). But there is no evidence that IAPT has achieved this. My own research suggests that only the tip of the iceberg recover.

In my capacity as an Expert Witness to the Court, I examined 90 IAPT clients who had been through the service either before or after the personal injury. Only 9.2% of subjects lost their and diagnostic status, as assessed using the “gold standard” SCID interview. It mattered not whether subjects were assessed before or after their personal injury. (These findings are in need of replication by clinicians independent of IAPT with a non-litigant population.)

Diagnostic Creep

IAPT appears not to so much follow the data, but to follow funding opportunities. It has branched out into territory were angels fear to tread: Medically Unexplained Symptoms (MUS). MUS is an umbrella term embracing conditions as diverse as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. IAPT’s contention is that exaggerated negative beliefs about symptoms, and maladaptive behaviours (e.g., avoidance), play a pivotal role in the maintenance of symptoms in these conditions. The therapeutic task, as they see it, is to then to modify these cognitions and behaviours.

What happens if a client protests that they have valid medical symptoms? Well, IAPT clinicians are taught not to openly disagree and not to say ‘it is all in your mind’. But to nevertheless continue to focuss on the ‘exaggerations in beliefs and avoidance behaviours’, so much for honesty.

Along with Keith Geraghty from the University of Manchester, I have published a critique of this sojourn. We identified a series of seven core problems and failings of the IAPT, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment. We concluded that psychotherapy should not become the default option when patients have “medically unexplained symptoms.”

The term “medically unexplained symptoms” should be written in lowercase to avoid conveying the impression that a meaningful homogenous entity is being described. The term should not enter the taxonomy of disorders. Importantly, even the DSM-5 has shunned recourse to the term. But unfortunately, IAPT only pays lip service to the standard diagnostic criteria.

Big Pharma and IAPT

Whilst some large pharmaceutical companies have greatly served the public good with regard to COVID, their performance with regard to psychotropic drugs is much less impressive. Researchers like Read and Moncrieff pin their hopes on the efficacy of CBT demonstrated in randomised controlled trials, but make no mention that CBT as delivered in routine practice bears little relationship to the protocols utilised in RCTs. Just as the claims of pharmaceutical companies require critical appraisal so too does the UK IAPT service.

 In an article in the British Journal of Clinical Psychology, I explained what the IAPT needs to do to get back on track. I noted that in their published papers, IAPT staff do not declare their allegiances and indeed state that they have no conflict of interest! This dishonesty needs to change. I suggested that there is a need for IAPT to prove their case using the standards of proof that are required in other areas of medicine.  To this effect, they cannot simply claim that they deliver evidence-based treatment—there has to be documented evidence for it that would be persuasive to an independent observer.  The IAPT service has to demonstrate that it provides an added value over someone attending an advice centre or counselling service. Yet the IAPT has yet to demonstrate that it makes an important enough difference to clients’ lives that they would recognise it.

This catalogue of omissions may create a sense of déjà vu for those who have followed the machinations of Big Pharma with regards to mental health. Unfortunately, there has only been a deafening silence from the IAPT regarding my critique.

 

 

 

The IAPT Double Myth of Economic and Clinical Utility

 

The impetus for the Improving Access to Psychological Therapies (IAPT) service was derived from a) economic considerations and b) an assertion that the positive results of randomised controlled trials of, primarily CBT, for depression and the anxiety disorders would be realised in routine practise.

 

 

A Money-Saver?

In 2006 the Centre for Economic Performance stated that “the total loss of output due to depression and chronic anxiety is some £12 billion a year-1% of our total national income ”. The contention was that investment in psychological therapy would pay for itself by a reduction in such costs. But currently IAPT costs over £1 billion a year, where is the evidence of a substantial reduction in the loss of output? Where is the evidence that IAPT constitutes a no-cost talk therapy?

 

Poor Performance at the Coal-Face

In the randomised controlled trials on average 50% of clients lost their diagnostic status as assessed by independent blind assessors. But no such unbiased assessors have ever gauged the impact of IAPT’s ministrations. IAPT has always marked its own homework. Rather than the claimed recovery rate of 50%, the best available evidence suggests that only the tip of the iceberg recover, Scott (2018).

Each myth means that the other is not carefully examined and IAPT advocates can deftly switch the focus from one to the other under critical scrutiny – a politician’s dream.

 

Psychological Therapy – a history of exaggerated claims

T.S Eliot wrote ‘Humankind cannot bear very much reality’ this applies particularly to looking at the effects of mental heath treatment. In 1751 the scientist and Quaker, Benjamin Franklin petitioned the Pennsylvania colonial assembly for funds to build a hospital on the grounds that ‘it has been found , by the experience of many years, that above two thirds of the Mad People received into the Bethlem Hospital in England  and there treated properly , have been perfectly cured’. He was reiterating claims made in published books by English doctors. Fast forward over 260 years, to 2012 and an editorial in the prestigous journal Nature declares IAPT ‘represents a world-beating standard thanks to the scale of its implementation and the validation of its treatments’ (p. 473)’.  A decade later, NHS England echoes this declaring ‘the Improving Access to Psychological Therapies (IAPT) programme began in 2008 and has transformed the treatment of adult anxiety disorders and depression in England. IAPT is widely-recognised as the most ambitious programme of talking therapies in the world and in the past year alone more than one million people accessed IAPT services for help to overcome their depression and anxiety, and better manage their mental health’ and recommends the IAPT Manual (2021). In 2019, Pickersgill examined the proliferation of IAPT by canvassing the views of professionals and professional bodies, noting that IAPT fellow-travellers were in the ascendancy. But in this evangelisation for the in vogue psychological interventions nobody has asked the consumer or considered the operation of vested interests.

The Absence of Open Discussion

Psychological disorders are ubiquitous and can negatively impact the course of coexisting physical conditions. Since the days of Benjamin Franklin, UK data on mental health treatment, has been used to foster the belief that UK treatments are a ‘world beater’. But independent evidence to support this contention is lacking. There is not just a gap between the psychological treatments delivered in randomised controlled trials and what comes to pass in routine psychological services, such as the Improving Access to Psychological Therapies Programme (IAPT) service, but a chasm. Efforts to have a meaningful debate on the issue have been met with a deafening silence. In the silence, the scope of psychological treatments has gradually been expanded, beyond the initial focus of depression and the anxiety disorders to include patients with long term physical conditions – a psychological imperialism. The power-holders definition of the outcome of routine psychological treatment reigns.

 

Dr Mike Scott

Nature (2012) Editorial: Therapy deficit. Nature 489(7417): 473–474.

Pickersgill M. (2019). Access, accountability, and the proliferation of psychological therapy: On the introduction of the IAPT initiative and the transformation of mental healthcare. Social studies of science49(4), 627–650. https://doi.org/10.1177/0306312719834070

 

 

 

 

 

 

Low Intensity CBT, ‘Penny Wise & £ Foolish’

Psychological Wellbeing Practitioners (PWPs) deliver the smallest dose of psychological interventions (low intensity CBT), less than 6 hours of contact per client (Shafran 2021). Making it cheaper than high intensity CBT. But there is little evidence that the PWPs ministrations make a difference the client would recognise. There are no randomised controlled trials of high or moderate quality (Cochrane Grade) that attest to low intensity CBTs efficacy. The PWPs are not psychological therapists, as such, most IAPT clients do not receive psychological therapy. The name IAPT, Improving Access to Psychological Therapies is therefore an example of doublethink. Here we have a classic example of false economy.

Low intensity CBT is intended to be the first step for those suffering from depression and the anxiety disorders, with PTSD and OCD clients going straight to high intensity interventions. Most clients first encounter low intensity CBT, should they not respond they are placed on a waiting list for high intensity CBT. In practice comparatively few, about 10%, are stepped up,  but with wide regional variations.It is not so much stepped care as stopped care.

Implementation of the ‘stepped care’ model costs the taxpayer of over a £1bn a year. But there has been no independent evaluation of the package or its components. IAPT is the first ANGO (an autonomous non- governmental agency) funded by the government, as opposed to the intended and understood QUANGO – a quasi autonomous non-governmental agency. Perhaps the National Audit Office and MPs might care to explain why there has been this failure of governance?

 

Dr Mike Scott

An Impotent Approach to Psychological Therapy (IAPT)

there is no evidence that routine psychological therapy, as delivered in the Improving Access to Psychological Therapies (IAPT) programme either, resurrects a person or  returns them to their best functioning. As such IAPT is impotent.

Most of those entering the IAPT programme undergo low intensity cognitive behaviour therapy (LICBT). This latter involves a reduction of the multifaceted protocols from randomised controlled trials to single elements of those protocols eg avoidance or cognitive restructuring, in the belief that this may resolve client’s difficulties. But over a decade on, there is no evidence that this minimalist approach makes a real-world difference.  It is still unknown ‘what, if any, low intensity intervention works with whom?’. 

The problem with reductionism is that it fails to acknowledge that  the whole is more than the sum of its parts. The multifaceted CBT protocols distilled for randomised control trials likely work because of the synergistic interactions of components, delivered by a particular type of agent (therapist). Simply providing ‘an agent’ or ‘a technique’ is not evidence based.

A recent debate in the Journal Psychological Medicine, has focused around a paper by Read and Moncrief (2022)Moncrieff, J., & Read, J. (2022).[ Messing about with the brain: A response to commentaries on ‘Depression: Why electricity and drugs are not the answer’. Psychological Medicine, 1-2. doi:10.1017/S0033291722001088 https://www.cambridge.org/core/journals/psychological-medicine/article/messing-about-with-the-brain-a-response-to-commentaries-on-depression-why-electricity-and-drugs-are-not-the-answer/C93997DBF4D174D9807D0F65BD994999] highlighting the problem of reductionism when applied to antidepressants and ECT. Both treatments are based on the postulate that there is particular dysfunction in the brain largely responsible for depression, which these intervention rectify. However the search for such an organic deficit has been unsuccessful. These authors point that such interventions are no more effective than enhanced placebo for depression.  

Interestingly Read and Moncrief (2022) pin their hopes on psychological therapies by appealing to the results of randomised controlled trials of CBT for depression. However they are over-stepping the mark. The routinely provided CBT by IAPT has none of the hallmarks of CBT in the trials: the dosage of sessions is sub-therapeutic, no fidelity checks have been conducted to check that individuals actually receive appropriate CBT, there have been no independent assessors of outcome.

In their paper Read and Moncrief (2022) were quite specific about the population they were addressing ‘depressed patients’ but there is no such specificity about the populations treated in routine practice. IAPT clinicians do not make reliable diagnoses, (albeit that they have the temerity to ascribe a diagnostic code). Whilst it is comparatively easy to guarantee that an antidepressant or ECT has been administered, guaranteeing that an appropriate CBT protocol has been imparted, requires independent fidelity checks. No such checks have been applied to IAPT’s ministrations. Read and Moncrief (2022) may well be right, that psychological therapy is the best hope, but the way to hell is paved with good intentions. Currently IAPT is impotent.

Dr Mike Scott

Has Routinely Collected Outcome Data Assisted In Answering, ‘What Works For Whom?’

 

Over 50 years ago Paul (1967) asked the fundamental question for psychotherapy “What treatment, by whom, is most effective for this in- dividual with that specific problem, under which set of circumstances” (Paul, 1967, p .111). The proud boast of the Improving Access to Psychological Therapies (IAPT) service is of a million referrals a year, with test results for 90% of treatment sessions [IAPT Manual 2019]. But despite the quantity of data IAPT has amassed over the last 14 years, it has been of no help to clinicians in answering this key question. It has simply been an added stress.

What is the function of the IAPT data? Is it to simply bamboozle paymasters NHS England/Clinical Commissioning Groups (CCGs)? Perhaps it is to improve the practice of IAPT staff? Even if this latter were the case, there is no evidence that this translates into an improved outcome for clients that they would recognise.

The irrelevance of the IAPT data set, can be gauged by inspecting the table below:

Treatment

Clinician

Characteristics of the client

Specificity of the Problem

Specificity of Psychosocial Functioning

There is no treatment typology within the service. Simply a claim that most clients get CBT in varying doses.

The service distinguishes deliverers of low and high intensity. But clinicians training varies enormously from clinical psychologists with Ph.Ds  to recent graduates who have done voluntary work.

Clients are not distinguished in terms of whether they may or not have a personality disorder or a neuro developmental problem.

The service has no typology of problems. It does not make diagnoses so cannot specify disorders, albeit that it allocates a diagnostic codes.

There is no framework within which to specify level of functioning

With IAPT’s data there are fuzzies in every column of Paul’s framework,  leaving its’ clinicians rudderless.

 

Dr Mike Scott

Paul, G. L. (1967). Outcome research in psychotherapy. Journal

of Consulting Psychology, 31, 109–118.

 

Exaggeratedly Negative Beliefs Perpetuate LTCs and MUS?

This is answered resoundingly in the affirmative and prescriptively in a just published book ‘CBT for Long-Term Conditions and Medically Unexplained Symptoms’ by Philip Kinsella and Helen Moya (Routledge 2022). But the book represents a triumph of ideology over evidence. It carefully avoids any consideration of studies that challenge its modus operandi.  The take home message is

With evangelistic fervour these authors proclaim on P16 For the typical cognitive  behavioural therapists it’s not necessary to be fully understanding of the debates around medically unexplained symptoms it’s more helpful to be aware of what the contributing factors are how to recognise and consider them and how to consider whether they are relevant to current problems’.

The reader is not informed of the details of the debate or the range of opinion.

There is no mention of:

  1. The Editorial in the Journal of Health Psychology in 2021 hDttOpsI://1d0o.i1.o1r7g/71/01.13157971/103539210151302318103482042 The ‘medically unexplained symptoms’ syndrome concept and the cognitive-behavioural treatment model’  that I and others wrote. In this paper we explored the validity of the MUS construct and the proposed treatment model.
  2. A 2020 paper in BMC Psychology by Keith Geraghty and I [Geraghty, K., & Scott, M. J. (2020)] Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified]. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2]  in which we identifiedan unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under- reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment.
  3. The study by [ Serfaty et al (2019)] of treating depressed cancer patients. In this study patients were given CBT by IAPT staff in addition to treatment as usual (TAU) and the results compared with TAU alone. Whether the outcome measure was the PHQ9 or Beck Depression inventory there was no difference in outcome. Serfaty et al add ‘our results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness’.

Kinsella and Moya (2022) operate with a confirmatory bias, searching out studies that support their position and ignoring those that do not.

 

When research findings are presented they are not contextualised, for  the Liu et al (2019) meta analysis published in the Journal of Affective Disorders is cited by Kinsella and Moya (2022) and they report their broad conclusion that CBT is effective for somatoform disorders and medically unexplained symptoms. But fail to state that these authors concluded  that          

‘the overall quality of evidence is relatively low due to a high risk of bias with lack of blinding of the participants, therapists, and outcome assessors’. Further 12 of the 15 studies assessed patients using a ‘gold standard’ standardised diagnostic interview these are not used in IAPT making the generalisation from the studies problematic. None of the studies involved an active comparator in which a credible therapy rationale was given, thus there is no evidence that any effect of the CBT is specific to the CBT. Self-report outcome measure scores were used, these are likely to be subject to demand characteristics when people have invested time and energy undergoing treatment. There was no determination of whether the treatment made a real world difference to patients lives nor of how enduring such change was. 

No mention that the RCTs are of patients who find it acceptable to go for psychological treatment of their MUS, the likelihood is that many find it simply unacceptable to take this pathway. Thus the results of the RCTs may not generalise to all patients with MUS.

 A Gross Violation of Transparency

In our 2020 paper [Geraghty, K., & Scott, M. J. (2020). Treating medically unexplained symptoms via improving access to psychological therapy (IAPT): major limitations identified. BMC psychology, 8(1), 13. https://doi.org/10.1186/s40359-020-0380-2] we wrotepatients should be fully informed of the rationale behind psychotherapy, before agreeing to take part’

Kinsella and Moya take no heed of this and write in Chapter 14 identifying and helping patients who are fearful of recovery

page 180-1 ‘This phenomena is delicate Which may be conscious or out of awareness If there is a lot of resistance and and hostility and the general sense that the patient will be unable to contemplate a formulation that includes fear of recovery then it would be better to hold back…. If the formulation is not shared it can still be used by the therapist to guide their interventions…. Sometimes however one gets a sense of the reinforces for being nil being so strong or the fear of recovery being so powerful that therapeutic progress can’t be made for example if there’s a very attentive spouse a generous pay benefits payment under strong fear of going back into the old situation that triggered the symptoms then there is little of the therapist can do to overcome this a possible step by step approach to this problem is as follows’

Whatever happened to transparency and openness as a pre-condition for CBT?

 

CBT Treatments Bereft of An Evidence Base 

Somatoform Disorders They fail to mention that the DSM-5 dropped the construct of MUS, absenting if from the definition of somatic symptom disorder. None of the CBT studies of somatoform disorders included in the Cochrane review of 2014 https://doi.org/10.1002%2F14651858.CD011142.pub2 involved independent blind assessors and in the only comparison with an active placebo (Progressive Muscle Relaxation) there was no difference  in outcome. Cochrane concluded that the quality of the evidence in the reviewed studies was weak. Whether or not IAPT therapists do not use a standardised diagnostic interview to determine the presence of a somatoform disorder, so there is no sound foundation for the proposed interventions.

Chronic Pain  In 2021 NICE published guidance on the management of chronic pain https://www.nice.org.uk/guidance/ng193 Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain www.nice.org.uk/guidance/ng193. They made a recommendations to consider CBT for chronic pain rather than make a stronger recommendation to offer CBT because the evidence was not of high quality. Most of the evidence showed that CBT for pain improved quality of life for people with chronic primary pain. A consistent benefit was not demonstrated in other outcomes

ME/CFS In 2021 NICE published guidance on the management of this condition https://www.nice.org.uk/guidance/ng206/resources/myalgic-encephalomyelitis-or-encephalopathychronic-fatigue-syndrome-diagnosis-and-management-pdf-66143718094021 ‘The committee wanted to highlight that cognitive behavioural therapy (CBT) has sometimes been assumed to be a cure for ME/CFS. However, it should only be offered to support people who live with ME/CFS to manage their symptoms, improve their functioning and reduce the distress associated with having a chronic illness’. So that clients should be informed at the outset that the scope of CBT is limited. Further NICE adopts a different theoretical base to that of CBT therapists working in this area, it does not assume people have ‘abnormal’ illness beliefs and behaviours as an underlying cause of their ME/CFS, but recognises that thoughts, feelings, behaviours and physiology interact with each other. No mention of this in the said volume. 

ME/CFS Clients May Have a ‘Fear of Recovery’ claim Kinsella and Moya (2021), I am lost for words

Dr Mike Scott

 

 

 

 

Low Intensity CBT Is Devoid of “Intelligent Scaffolding”

As a consequence there are no protocols for Psychological Well-being Practitioners (PWPs) to follow. The scaffolding is on the back of a lorry but nobody knows what to do with it. Restoration or rebuilding is unchecked by any blueprint. There is no typology of PWP treatments. It is made up as you go along.

Consider ‘CBT for long term conditions and medically unexplained symptoms’, a book by that name has just been published [Kinsella and Moya (2022) Routledge], these authors note that their protocol isn’t deliverable within the 6 hours or less of low intensity CBT, so they suggest have just one target, say depression and with subsequent multiple referrals a comprehensive protocol can be covered! But there is no evidence that this piecemeal approach works, no evidence that such brief Behavioural Activation for depression that they recommend (nor that the entirety of the package) makes a real world difference.   

The above considerations makes IAPT’s claim  that 50% of its customers get what they want,  ‘recovery’, incredulous. The true recovery rate in IAPT is around 10% Scott (2018) https://doi.org/10.1177%2F1359105318755264 and is likely to be even less amongst those with long term conditions. Medically unexplained symptoms (MUS) is such a nebulous entity that it was dropped from the DSM. 

 

The randomised control trials of CBT for depression and the anxiety disorders, conducted before the millennium, had fidelity checks built in to ensure that clinicians were doing what they were supposed to be doing.  For each diagnosed disorder, there were specific treatments targets and matching treatment strategies. With adherence, competence and outcome assessed independently. IAPT’s mantra has been that it is compliant with these NICE approved protocols. However no fidelity check  has ever been been applied to either IAPT’s  high-intensity service or its low intensity service. 

If builders behaved in such a cavalier manner they would soon be out of business, ‘never mind about the restoration of your house, we have built you a nice bungalow’. A year ago I had published a paper ‘Ensuring IAPT Does What It Says On The Tin’ https://doi.org/10.1111/bjc.12264 but it has washed off the IAPT teflonocracy. 

Dr Mike Scott

The Near Extinction of CBT

Evidence-based psychological therapies are near extinction. Their demise began in 2008 with the inception of the Improving Access to Psychological Therapies (IAPT) service. Aided and abetted by the British Psychological Society’s validation of IAPT’s Psychological Well-being Practitioner’s (PWPs) training programmes and the service’s fellow traveller, the British Association for Behavioural and Cognitive Psychotherapy (BABCP). Gone is the welcoming open door and the careful distillation of what ails the client, instead there is a 30 minute+ telephone conversation, with a third of people then not going beyond one treatment appointment.

 

The public most commonly receive PWP ministrations when they seek NHS psychological help. But the PWP’s do not follow any treatment protocol for any disorder, indeed they do not make diagnoses. How then can they be said to deliver CBT? By the spurious claim  that they can select a CBT strategy which is sufficiently potent. But they furnish no evidence of systematically following any strategy, notwithstanding that there is no evidence that CBT strategies delivered as stand alone interventions make any real world difference. The PWP’s deliver the Alice in Wonderland, Dodo verdict on CBT strategies ‘all are equal and must have prizes’. Raising the question ‘is CBT as dead as the Dodo?’

 

 

Where else might CBT be found? It is not impossible for it to be delivered in IAPT’s high intensity service, but few of its practitioners conduct a reliable standardised diagnostic interview which is the foundation for delivering CBT.  The  treatment integrity of high intensity CBT interventions has never been assessed.  No steps have ever been taken to ensure clinicians are dovetailing diagnosis appropriate treatment targets with matching treatment strategies. Is CBT to be found in private practice? It is possible, but private organisations have largely sought to ape IAPT in the mistaken belief that this confers credibility. Are the chances of finding CBT in private practice comparable to finding life on Mars?

Is CBT alive and kicking in secondary care? Here we enter the muddy waters of clients who might traditionally be regarded as having personality disorders (PD). But there is an understandable reluctance to use the term PD because of the associated stigma and because historically use of such a term has consigned people to the dustbin. Nevertheless Sperry and Sperry (2016) have produced the 3rd Edition of CBT for DSM-5 Personality Disorders (Routledge) but it is eminence-based rather than evidence-based. It is light on outcome studies. I struggled to find any where there was independent assessment of outcome by blind raters, use of an outcome measure that clients would regard as a minimally important difference and evaluations by those other than the creators of the protocols. It is a free for all with strategies such as ‘thought stopping’ recommended, without specification of any contraindications such as PTSD or OCD. Only eclipsed by recommending solution focussed therapy for anxiety. If clinicians in secondary care operate on this text it is very different to Beck’s own work on CBT for personality disorders. But no typology of what clinicians say they do and what they actually do in secondary care has been produced. Tertiary care seems preoccupied with crisis management and is not guided by any recognisable CBT protocol.

In neither primary or secondary care is there a differentiation of treatments or clients. Thus in the UK it is impossible to answer the question of ‘What Works With Whom?’. This leaves clinicians up a creek without a paddle.

Dinosaurs may have been wiped out by an asteroid hitting the earth 66 million years ago, but life survived, doubtless CBT will survive the impact of IAPT, but it is a close call and it is likely going to be down to individual practitioners doing what they know to be best for their clients.

 

Dr Mike Scott

Psychologising Long-Covid and Anything Else

 

Under a heading ‘Long-Covid: interventions not proven’ the May issue of The Psychologist publishes  a letter (see below) I wrote with Joan Crawford. The same issue contains an interview with Jo Daniels, the newly appointed Chair of the Scientific Committee of the British Association for Behavioural and Cognitive Psychotherapy (BABCP) outlining her mission to apply CBT to all long-term conditions (LTC). This despite a paucity of evidence that CBT protocols matched  to a specific LTC make any unique contribution. She proclaims “It is now commonly accepted that CBT ‘works’ to a greater or lesser extent for most physical  health conditions”,  this is grist to the mill for the expansionism of the Improving Access to Psychological Therapies (IAPT) service. But contrary voices do not get a hearing in BABCP, echoes of Russia.

                

‘The underlying message of Dr Siddaway’s article ”We need to talk about Long-Covid” in the March 2022 issue of the Psychologist is that there is or will be an added value from psychological intervention for those affected by Long-Covid i.e Covid of more than 3 months duration.  But the Scottish verdict ‘not-proven’ seems appropriate.

There can be no doubt that offering emotional support to people like Grace, cited in the article, is an important resource for anyone suffering from a long-term medical condition. But there is a distinction between the provision of emotional support (travelling alongside) and delivering a psychological intervention (fixing). The latter is inevitably more costly, requiring more highly trained staff and therefore less likely to be available. Is it a proper use of scarce psychological resources to offer psychological treatments to those with Long-Covid?

Clearly if a person with Long-Covid suffers from an additional disorder such as PTSD or depression a case can be readily made for addressing the comorbid disorder. But the effectiveness of this treatment, in such circumstances, remains to be demonstrated. There are no randomised controlled trials of the psychological treatments of Long Covid plus or minus comorbid disorders. Thus, the evidence for the efficacy of treatment must be currently regarded as weak.

Siddaway suggests that it is possible to extrapolate from studies of chronic fatigue syndrome and pain and apply the strategies to Long-Covid. But there are significant problems with this: a) it assumes Long-Covid is in the same domain as CFS and pain, but arguably, there is little evidence that this is a homogenous category b) the evidence base for the efficacy of psychological treatment for CFS Is problematic if objective indices of outcome are insisted upon c) the evidence base for psychological treatments for CFS and pain, such as it is, is for protocols and not for the components of the interventions, such as pacing or distraction. Using strategies out of context is problematic.

Siddaway appeals to a biopsychosocial model to justify psychological intervention for Long- Covid, despite any evidence that mood and coping strategies make a significant difference to the physical symptoms of Long-Covid. The proposed model ” the complexity of Long-Covid” is not capable of falsification, any factor e.g a hostile working environment, could be proposed to be pivotal in the development of Long Covid, but not ruled out.  As such it is not a model.

It serves the interests of the powerholders of psychological therapies to transmute the physical disorders into candidates for psychological intervention. An extending of Empires. This is not to say that psychological intervention may not sometimes be helpful in the context of a long-term medical condition but unless the population is clearly specified clients will be failed by inappropriate treatments and services exhausted.

 

Mike Scott

 

Joan Crawford’

What Treatment by Psychological Wellbeing Practitioners (PWPs) Works for Whom?

 

This is a restatement of the question asked by Roth and Fonagy in their seminal work ‘What Works for Whom’ (2005) Guilford Press. This text formed the backbone for the National Institute for Health and Clinical Care Excellence (NICE) recommendations on psychological therapy. The Improving Access to Psychological Therapy (IAPT) service has made a formal commitment to observe the NICE guidelines. PWPs are the most common providers of psychological interventions in IAPT. They have been operational for over a decade, at a cost of £billions, answering this question with regards to this professional group is therefore long overdue.

PWPs Modus Operandi

The BABCP ‘PWP Registration and Renewal Policy’ under a heading ‘Core Principles’ states

‘PWPs are specially trained to work with people who have common mental health problems such as anxiety disorders and depression, to support them in managing their recovery…….are revolutionising our approach to the delivery of psychological therapies in a number of specialist areas…..Have graduated from a British Psychological Society (BPS) Accredited PWP training course/apprenticeship’.

PWPs deliver low intensity CBT, defined by Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803  as offering 6 hours or less client contact. The input can be any self-help material. This is a ‘revolution’ in that it is substantially less dose of therapy to that in the high intensity CBT prescribed in the randomised controlled trials of CBT for depression and the anxiety disorders, with 10-20 sessions being the norm.

IAPT’s Magical Beliefs Include:

‘ Six hours or less clien’t contact makes a real world difference to client’s lives’ and ‘inputting any self-help material will do the job’. But what is the evidence for these beliefs? At the advent of IAPT Lars-Goran Ost (2008) published a set of key questions (see the end of this blog) that researchers had to satisfactorily answer for a treatment to be considered an Empirically Supported Treatment (EST). No judge would declare that these injunctions/criteria have been comprehensively answered in any of the low intensity CBT studies. It follows that low intensity CBT is not an EST.

The Government and IAPT

The Government’s wish to push ahead with low intensity CBT parallels Priti Patel’s insistence that refugees are sent to Rwanda, over the heads of Civil Servants who claim that it should be first demonstrated that this makes economic sense. Once the powerholders decide on a course of action, they are unrestrained by any moral imperatives to show compassion and hospitality. It is immoral to offer a dose of treatment for which there is no evidence that it works and to treat refugees so despicably.

 

Dr Mike Scott

 

L.-G. O ̈st / Behaviour Research and Therapy 46 (2008) 296–321

 

  1. Do not use WLC as the control condition, since criterion I requires a placebo or another treatment.
  2. Do not use TAU as the control condition, since the methodological problems described above are so extensive.
  3. Use an active treatment as comparison, preferably one that has been established as effective for the disorder in question.
  4. Do a proper power analysis before the start of the study and adjust the cell size for the attrition that may occur.
  5. Use a representative sample of patients, diagnose them using suitable instruments in the hands of trained interviewers, and test the diagnostic reliability.
  6. Let an independent researcher or agency use an unobjectionable randomization procedure, and conceal the outcome of it from all persons involved in the study.
  7. Use reliable and valid outcome measures; both the ones that are specific to the disorder and general ones.
  8. Use blind assessors and evaluate their blindness regarding treatment condition of the patients they assess.
  9. Train the assessors properly and measure inter-rater reliability on the data collected throughout the study (not just during training).
  10. Use three or more properly trained therapists and randomize patients to therapist to enable an analysis of possible therapist effect on the outcome.
  11. Include at least a 1-year follow-up in the study and assess any nonprotocol treatments that the patients may have obtained during the follow-up period.
  12. Audio- or videotape all therapy sessions. Randomly select 20% of these and let independent experts rate adherence to treatment manual and therapist competence.
  13. Insert procedures to control for concomitant treatments that patients in the study may obtain simultaneously as the protocol treatment.
  14. Describe the attrition, do a drop-out analysis and include all randomized subjects in an intent-to-treat analysis.
  15. Assess clinical significance of the improvement of the primary measures.