Unsurprisingly the surveyed integrated care board (ICB) mental health leads and mental health trusts tell the NAO what a great job they are doing. The NAO also interviewed mental health stakeholder organisations such as the BPS and BMA. On this basis, the NAO [“Progress in improving mental health services in England”] declared last month, that ‘the government has achieved value for money’. The yardstick used by the NAO was whether the surveyed bodies ‘met ambitions to increase access, capacity, workforce and funding for mental health services’. No attempt to access the voice of the people.
Interestingly the NAO did not even attempt to make the claim of the prime movers in IAPT Layard and Clark (2015) that the Service costs nothing, due to savings on welfare benefits and physical healthcare costs! The response of the great and the good in mental health (the NHS Confederation, SANE and Mind) has been, that the report highlights the need for increased funding, to recruit and retain more staff. No awareness that more of the same is unlikely to make any difference to patients.
The report reveals that £752 million was spent on NHS Talking Therapies predecessor, IAPT, in 2021-22. But when the NHS acquired IAPT earlier this year no audit of the latter was conducted. No business would behave in this way. Yet the NAO report re-iterates the target of ‘at least 50% achieve recovery across the adult age group’. No mention that there is no independent evidence that this has ever been achieved. With the best evidence Scott (2018) suggesting that only the tip of the iceberg recover. What sort of auditors are the NAO? Under their watch acquisitions can be made without credible scrutiny.
In 2018 the NAO jettisoned an enquiry into the Improving Access to Psychological Therapies (IAPT) Programme. In response to a Freedom of Information request, the NAO responded on February 17th 2020 ‘We commenced work on the IAPT programme in 2017-18. However, the work on this programme was curtailed in June 2018 by the Comptroller and Auditor General (C&AG) of the time in response to changing priorities. The alterations to the work programme were made so that the C&AG could respond quickly on important topical issues, such as work on the UK’s exit from the European Union, the government’s handling of the collapse of Carillion, and on significant NHS spending increases in 2017- 18 on generic medicines in primary care’.
With no independent body assessing caring and effectiveness. It has been achieved by IAPT (the former brand name of the service) and BABCP (British Association of of Behavioural and Cognitive Psychotherapies) working under the radar. Their curious tango has prevented the delivery of evidence-based psychological therapy in routine practice. They dance for politicians, the Department of Health and Integrated Care Boards (the successors to Clinical Commissioning Groups).
The public face of NHS Talking Therapy and BABCP and their synergy can be seen in an advertised two day BABCP workshop for social anxiety disorder. To be led by Professor David Clark,NHS England’s National Clinical and Informatics Advisor for the Improving Access to Psychological Therapies (IAPT) programme. He and Lord Layard were the prime movers in the development of IAPT.
In advertising the Workshop Professor Clark describes very well an evidence based protocol for treating social anxiety disorder. But there is no evidence any such protocol has has ever been delivered in IAPT. The service has never performed integrity checks for this or any disorder. My own finding Scott (2018) is that only the tip of the iceberg of the Services clients recover in the sense of losing their diagnostic status. NHS Talking Therapies claims to deliver NICE treatment protocols and achieve a 50% recovery rate are self-serving claims, wholly without independent evidence.
The recommended protocol is based on a diagnosis of social anxiety disorder and as the IAPT Manual points out, its clinicians do not make diagnosis and 40% of them are not trained therapists. Both NHS Talking therapy and BABCP have shown no interest in what happens at the coalface, they operate like totalitarian Communist regimes concerned with ideology, operational matters production quotas, waiting times etc. Like the KGB and Stasi they are superb at working under the radar (see the book Putin’s People) and networking but leaving clients to disappear down a black hole, with almost half of clients not even beginning treatment.
It is inevitable that when a product fails, it is renamed, so to with The Improving Access to Psychological Therapies (IAPT) service, it is now NHS Talking Therapies, for anxiety and depression. In 2021 I published a paper ‘Ensuring IAPT Does What It Says On the Tin’ , over the last 2 years it has signally failed to put its’ house in order. On June 28th 2022 the Lets Talk IAPT website 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’. None of these problems have been addressed and so it has been given an air of respectability as NHS Talking Therapies.
The avowed focus is depression and the anxiety disorders, but it has extended its scope to include the psychological sequelae of long term physical conditions. Given that almost half the adult population have at least one LTC, this offers massive opportunities for expansion. But the evidence on effectiveness with this population is weak to non-existent. However given that IAPT has usurped the NHS this is likely to matter little.
Professor Clark and Dr Whittington announcing the name change note ‘”Many of those who do find their way to services are looking for help with other difficulties that the services are not set up to treat, such as psychosis or complex emotional needs associated with a diagnosis of “personality disorder”. Clark and Whittington claim ‘You don’t need a “diagnosis” to come for therapy, a skilled practitioner will help work out with you whether and how the service can help’ and add that they offer treatment not only for depression and the anxiety disorders but also OCD, PTSD, body dysmorphic disorder, health anxiety and mixed anxiety and depression. But given that its practitioners are not trained to diagnose according to the latest IAPT Manual, by what magic do they decide who to treat with what? No matter, Clark and Whittington proclaim that 50% of treated people recover, this strains credibility.
Clark and Whittington state ‘Within NHS Talking Therapies services most of the psychological therapy will be quite practical. It may involve working through self-help materials with guidance from a clinician, possibly via a dedicated online platform (which we call ‘digitally enabled therapies’). It may involve help with problem solving skills or practical exercises to examine and overcome your fears. It may involve facing and working through traumatic memories in a safe way’. Can trauma focussed CBT be really regarded as quite practical, in routine practice most clients find it quite toxic Scott and Stradling (1997).
A just published paper by Picariello et al 2023 singles out fatigue across 5 disorders, suggesting that certain cognitions and behaviours play a pivotal role in the worsening or maintaining of this symptom. In addition it is suggested that targeting such cognitions and behaviours would make a clinically significant difference to associated low mood and anxiety. The cognitions and behaviours are enshrined in the authors Cognitive and Behavioural response to Symptoms Questionnaire (CBRSQ-SF) short form. The authors posit that the scale could be a therapeutic aid, indicating treatment targets. Further they suggest that it may facilitate the development of a low intensity treatment for these conditions.
But the data Picariello et al 2023 present is all correlational, it does not establish causation. To establish causation it would be necessary to demonstrate that amongst those who had remitted from the conditions a high score on the CBRQ-SF was predictive of fatigue score, controlling first for the effect of mood. [Dysfuntional attitudes are known to be correlated with mood]. The partial correlation analysis would then need to be repeated with low mood and anxiety as the dependent variables. The danger is that the CBRQ-SF is promoted on the basis of its face validity and used to justify the expansion of psychological therapy into the Long Term Conditions Arena. Given that 43% the population of England have at least one LTC there is the prospect of rich pickings for service providers, such as the Improving Access to Psychological Therapies Service. One of the authors of the Picariello et al 2023 Trudie Chalder is a regular presenter to IAPT staff on the treatment of LTC’s.
Unfortunately it is unlikely that IAPT and its fellow travellers will take note of the study by Serfaty et al (2020) on the efficacy of CBT for the treatment of depression in patients with advanced cancer, which used IAPT therapists and revealed no difference to treatment as usual. Claims for the efficacy of CBT with LTCs rest on studies using self-report measures and without blind assessment.
Returning to the Picariello et al (2023) study although 5 populations are considered (chronic fatigue syndrome, multiple sclerosis, hemodialysis, irritable bowel disease and chronic dizziness) the focus was on a particular aspect of these disorders, fatigue. Thus, at best, targeting the dysfunctional attitudes and behaviours enshrined in the instrument would at most have a circumscribed impact on these disorders. With the possible exception of CFS sufferers, it is unlikely that most people with these disorders/difficulties would see fatigue as their primary issue. It could equally plausibly be suggested that irritability and low mood are accompaniments of these disorders and also of Long Covid. But there is no evidence to suggest that targeting CBRQ-SF items would have a clinically significant impact on this diffuse array of symptoms across a wide range of long term conditions, despite the intimation of Picariello et al 2023. Arguably the fatigue, low mood, anxiety and irritability are an epiphenomenon of these conditions. The elevation of fatigue to the status of a cardinal symptom of long-term conditions is without foundation. It is a heuristic designed to short circuit the assessment of multi-faceted disorders, accuracy is sacrificed for speed.
A pinch of salt is required for the claim of Picariello et al 2023that it is a ‘transdiagnostic measure of cognitive interpretations of symptoms, and related behaviours which are associated with the experience of more severe and disabling symptoms, low mood and anxiety’ and from a treatment perspective ‘the focus and content of therapeutic techniques may vary depending on the coping procedures employed by a client (avoidance/resting versus all-or-nothing behaviour); or developing lower-intensity interventions while retaining key therapeutic techniques in line with stepped-care treatment models’.
My thanks to Joan Crawford for help with this blog .
Best practise networking is in vogue. It is a central plank in the Improving Access to Psychological Therapies (IAPT) Service professional development programme. But who decides what should be marketed as best practice? Is it the powerholders within the Service in conjunction with those who are happy to eloquently re-iterate the party line? What assurance can there be that it is not a matter of the blind leading the blind? The dissemination of ‘best practice’ in psychological therapy rests primarily on a consensus. In Britain, the self-proclaimed lead organisation for cognitive behaviour therapy (CBT), the British Association of Behavioural and Cognitive Psychotherapy (BABCP) sees itself as the custodian of ‘best practice’ and has bestowed an imprimatur on IAPT.
But the British Medical Journal has a very different notion of what constitutes ‘best practice’. For each of the common mental disorders, it identifies screening psychometric tests complemented by standardised diagnostic interviews to identify the particular disorder. Then a treatment algorithm for each disorder. However IAPT clinicians are not trained to make diagnoses so that their ‘best practise’ must diverge from the BMJ’s. Who is right and on what basis?
The gulf between evidence-based practise and IAPT’s ministrations is shown in sharp relief if we focus on the latter’s low intensity guided self-help (LIGSH). I could find no study of LIGSH in which there was a blind assessor of the treatment and comparison with an active placebo. Thus any effects of LIGSH could be attributed to simply attention. By contrast over half (58.7%) of randomised controlled trials of CBT have employed blind assessors.
The behaviour of IAPT clinicians is highly prescribed. In a study of LIGSH transcripts of tape recordings of client’s first contacts with the Service analysed by Drew et al (2021) there is a steadfast refusal to let clients tell the story behind their distress. The double message is ‘come to us, but we don’t want to listen to your troubles’
To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:
‘We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’
‘routine assessment measure questionnaires prioritised interactionally, thereby compromising patient-centredness in these sessions’.
But not only does the IAPT Service refuse to listen to its clients, it refuses to listen to outside criticism. There has been no change in its’ modus operandi in over a decade as it pursues expansionism. But it is an expansionism to areas were there has been no demonstrated efficacy and evidence is at best circumstantial. Operating on the dubious premis that ‘it just might be the answer to the world’s problems’.
The networking of IAPT clinicians, whose operation is validated by BABCP, is an ‘In Group’ that talks amongst themselves, reinforcing their world view and refuses to engage in effortful processing of external criticism.
The afternoon session begins with my cross examination by the Defence barrister, ‘isn’t it the case that those who wrote the IAPT Manual and proclaim a 50% recovery rate are emminent in their field?’. I reply in the affirmative. The Defence barrister continues ‘Have IAPT’s findings been publicly questioned by bodies such as NHS England? To which I replied ‘no’. He continues ‘so you set yourself up against the acknowledged Experts? My response is ‘I am not setting myself up against anyone, this is not a gladiatorial combat. I am simply insisting that the psychological therapy provided by IAPT should be evidence-based and not eminence-based. The credibility of any service is called into question when it does not rely on the data of an independent assessment. The Expert’s you cite, authors of the Manual, NHS England all have a vested interest in proclaiming the merits of the IAPT Service’. The Defence barrister retorts ‘NHS England is responsible for the health of the nation, are you seriously suggesting that there has been a derogation of duty? I respond ‘yes, for over a decade it has unquestionably accepted IAPT’s claims, with staff holding posts in both Organisations. Recently at the behest of the Department of Health I asked NHS England seven questions with regards to IAPT, they simply told me to go and ask the questions of the Department of Health’.
I continued ‘With breathtaking skill, IAPT engages in eminence-based medicine, vehemence-based medicine and eloquence-based medicine. It also engages in ‘it won’t hurt to try’, for example running groups for those traumatised despite a paucity of evidence as too efficacy and under waiting list pressures assigning a clear PTSD case to a trainee’. My own findings of 90 litigants who went through IAPT whether or not before or after personal injury was that only the tip of the iceberg recover’. The defence barrister continues ‘this is using your own idiosyncratic view of recovery not that used by IAPT, is that not the case?. My response was ‘No, I was using the criteria that is used in Court in personal injury litigation, is the person still suffering from the disorder acquired as a result of the personal injury, it is very straightforward’. The defence barrister continues ‘IAPT uses a drop in score on a psychometric test as evidence of recovery, is this not more reliable?’ My response is if it were, such a metric would be in routine use in Personal Injury litigation, it has had no such status over my 30 years of medico-legal work. The danger of a psychometric test administered at the end of a treatment session is that the recipient of the services does not wish to appear ungrateful and makes an exaggeratedly positive response’.
Jury members are most likely to use a credible metric in determining whether a Service has failed to deliver and whether or not it has made exaggerated claims for its’ own ends. Expert Witnesses may protest their independence, but the possibility of bias cannot be excluded as they appear either for the Defence or Prosecution. Additionally they may have an academic bias, re-iterating current mainstream opinions, with scant regard for alternative views.
The natural recovery rate for depression is 50% within 6 months. The Improving Access to Psychological Therapies (IAPT) claim a 50% recovery rate for its clients. It is therefore not at all obvious that psychological treatment has conferred any benefit. The rate of natural recovery from depression is about 2% per week. Looking at natural recovery in generalised anxiety disorder (GAD), of those who had ever suffered GAD, 72% had not had it in the past year. Whilst recovery rate from depression and anxiety disorders at 2 year follow up was 41.7%. These high rates of natural recovery offer Service providers, such as IAPT, a golden opportunity to claim that they have played a pivotal role in client’s recovery.
Many, many years ago I had a Summer job working part of the time in a Mortuary, the day I began was a glorious Summer’s day and the most Senior pathologist remarked that ‘you’ve brought the good weather with you’. Much as I had a tendency to take credit when things went well, and to blame others when it didn’t, I did feel that even I couldn’t take credit for the good weather. But Service provider’s it seems have no such inhibitions. They operate with a self-serving heuristic in which the exact mechanisms by which they bring about change are left unattended and they invite others to believe their eminent representatives. In this way effortful processing of data is by-passed, by an appeal to ‘credible sources of persuasion’ as it is termed in the Elaboration Likelihood Model of Persuasion.
Within this ‘Capitalisation’ it easy to smuggle in other purported benefits of psychological therapy such as getting people back to work, improving their physical health without actually demonstrating either, see Layard and Clark (2015) by simply saying ‘it is likely’. All to the glee of politicians, Clinical Commissioning Groups and media. Thus the band wagon continues in a race to the bottom.
The Service would prefer to deftly switch attention to treatment completers, defined as those who complete at least two treatment sessions. But no Oncology or Physiotherapy service would define completion of treatment in such a minimalist way. This looks like sleight of hand. Nevertheless for ‘completers’, IAPT offers the defence of effectiveness across a range of disorders as evidenced by the effect sizes in the Table below:
Within Subject Effect Size using PHQ9 (for all cases initially at caseness) and only for those who completed two or more treatment sessions. The ES is pre-treatment mean minus the post-treatment mean/pooled standard deviation
Body Dysmorphic Disorder
Generalised anxiety disorder
Mixed anxiety and depressive disorder
Other anxiety or stress related disorder
Panic disorder [episodic paroxysmal anxiety]
Post-traumatic stress disorder
Specific (isolated) phobias
The mean ES in the above table is 1, this means that at the end of treatment the average client is better than 84% of those at the start. But it is not known how long this change lasts or what proportion of clients would consider themselves back to their old self. No independent person has asked them. The results are based on questionnaire responses made in the presence of the Santa like therapist. Who wants to displease Santa?
Science Has Progressed By Categorisation but IAPT Feigns This
The IAPT Manual states that its’ staff do not make diagnoses. How then are the IAPT staff supposed to know which label to attach to whom? It can be contended that the diagnostic labels don’t matter, but that is not what NICE says, they recommend specific protocols for particular disorders. IAPT has been dishonest since its’ inception, in claiming NICE compliance. It should publicly admit that its staff excercise unbridled clinical judgement in choosing a ‘diagnostic’ label. As a consequence the treatment it serves up is necessarily idiosyncratic. There is know knowing what this Santa will deliver!
IAPT squeezes its clients into 12 categories, one of which mixed anxiety and depressive disorder is still used despite the advice in the 2019 Manual. No room at the inn for those with an adjustment disorder, personality disorder, bulimia, substance dependence, bipolar or psychosis. The injunction from the Service is to treat the principal disorder, but comorbidity is the rule rather than the exception. The implication is that comorbidity is best ignored. Clients are made to fit the Service and not the other way round.
The Demise of The Supposed Medical Model and The Rise of Autocracy
There are many who see the ‘medical model’ as totally anathema and who should therefore be rejoicing at the de facto ignoring of diagnosis in IAPT. But they do so under their breath, as the prime movers in the development of the IAPT service, based their reputations on the efficacy of specific protocols for particular disorders e.g panic disorder.
The IAPT service is actually an experiment in determining what happens to clients if clinicians have free reign to treat clients as they see fit. The results of this clinician autocracy (or oligarchy if those who hold sway in IAPT/BABCP are considered) is that clients do not improve by any more than would be expected with the passage of time and attention.
The successors to Clinical Commissioning Groups make decisions locally as to how much money to invest in IAPT. But none have been prepared to open the ‘can of worms’ and insist that there is an independent assessor who at a minimum asks clients ‘compared to when you first went to IAPT are you the same, a little better, a little worse, much better, much worse? How long have you been the way you are now?
The Blatant Ignoring of Published Guidelines by IAPT
IAPT’s behaviour is in glaring contrast to that espoused in an Editorial in the most recent issue of the British Journal of Psychiatry who recommended observance of both NICE and Australian/New Zealand Guidelines for the treatment of depression with ‘robust diagnosis and re-evaluation’ at the start of treatment and at 4-6 weeks, to check that the diagnosis is correct and redirect treatment if no response. They re-iterate that the Guidelines also state that if a person is unresponsive after 4-6 weeks there is ‘a need to address problems that may not seem to be directly pertinent to depression, such as personal, social or environmental factors, and advises that other illnesses (especially personality dysfunction) should also be considered as potential contributors to depression’. No such detailed re-evaluation ever takes place in IAPT, by their own admission they do not diagnose and certainly not personality disorders.
A just published study by Duhne et al (2022)found that almost a third (29%) of those assessed by the Improving Access to Psychological Therapies Service (IAPT) and referred to Guided self-help (either face to face or computer assisted CBT) did not attend any treatment sessions. Whilst of those who attended treatment over half (54%) dropped out, defined as attending three or less treatment sessions. These figures are much higher than the 20% Swift and Greenberg (2012) of clients who typically dropout of psychotherapy.
Curiously the authors miss the obvious implication that GSH is misguided. Instead they recommend further investigating an algorithim for better matching those who would do better in cCBT or better in face to face! Why is this? The authors declare no conflict of interest, but the Department from which it emanates at Sheffield University has a long list of IAPT teachers. There is a complete absence of critical appraisal of IAPT’s metrics suggesting that the Sheffield researchers don’t want to bite the hand of a service that gives them a ready-made data set, it eases the research burden. The Journal in which it was published Behaviour Research and Therapy characteristically ignores any criticism of IAPT.
Concluding anything about the relative merits of cCBT and face to face GSH is problematic, in the Duhne et al (2022) study as the mean initial PHQ9 scores were respectively 12.32 and 15.01, which is statistically significant p < 0.0001, when the sample sizes and standard deviations are input into a the MedCalc comparison of means calculator. This suggests some systematic bias in the allocation of people to these modalities. 95,088 patients accessed diverse low-intensity interventions: GSH (n = 84,503; 88.4%), psychoeducation groups (n = 8671; 9.1%), cCBT (1611; 1.7%), and other interventions (n = 753; 0.8%).
The previous Health Minister, Dr Therese Coffey was asked 7 questions about the effectiveness of routine psychological therapy for depression and the anxiety disorders. Only 1 of the 7 questions was answered and that, only partially. The Department of Health advised that NHS England were better placed to answer my questions and so I put the queries to them. I wrote about this in my blog for Mad In America. Since then NHS England have replied, or rather not replied, suggesting that I put the questions to my local Integrated Care Board (ICB’s are the recent replacement for Clinical Commissioning Groups). My questions obviously relate to national policy and not local difficulties, it is completely disingenuous of NHS England to reply in this way. I have now asked them for a considered response to my questions.
For the sake of completion I have reproduced the questions below:
1.The Government Improving Access to Psychological Therapies (IAPT) Service is experimenting with public, direct access to a Psychological Wellbeing Practitioner. But PWPs are not trained in diagnostics nor are they qualified therapists. Why then are they being given this gatekeeping role?
2. The IAPT service has cost billions of pounds, since its’ inception in 2008. Why, then has there been no independent audit of the service?
3. With regards to physical health the Government is funding Community Diagnostic Centres, with regards to mental health why is there no facility for reliable diagnosis in IAPT?
4. With regards to mental health there is no evidence that those availing themselves of IAPT fare any better than those attending the Citizens Advice Bureaux? What then is the added value of funding IAPT?
5. How is the experiment of making PWPs gatekeepers being evaluated and who decided on the criteria?
6. IAPTs claimed recovery rate of 50% has not been independently verified. The independent evidence of an Expert Witness to the Court [Scott (2021) British Journal of Clinical Psychology] suggests that in fact only the tip of the iceberg recover. Is this not grounds for a publicly funded independent audit?
7. How do we know IAPT is value for money?
It seems likely that only politician-like responses will be forthcoming. Will nobody grasp the nettle?