Psychological therapy for people living with dementia (PLWD), is the way forward according to a study by Bell et al (2022) focussing on Improving Access to Psychological Therapy (IAPT) clients. The authors reported a 40% recovery rate for people living with dementia, compared to a recovery of 47% in the matched control group without PLWD, they claimed ‘our findings are important for encouraging referrals of PLWD into primary care psychological therapy services, as our work suggests that these services are likely to be useful in treating anxiety and depression in PLWD’. But their study did not demonstrate a real-world benefit for treating PLWD sufferers in IAPT. This is spin in favour of IAPT. The study was funded by the Alzheimer’s Society, who not surprisingly endorsed the author’s conclusion.
Don’t Psychoathologise The Reactions of People Living With Dementia
The twin outcome metrics were the PHQ9 and GAD7, and to enter the study people had to be initially at ‘caseness’ on one of these measures, a score of 10 or more on the former or 8 or more on the latter. Recovery was defined as being below the threshold for ‘caseness’ on both measures at the last treatment encounter. But data was only analysed for clients who completed 2 or more treatment sessions. Data from the most recent IAPT Annual Report (September 2022) , indicates that almost half (46%) of IAPT clients attend one or no treatment sessions. Thus if Bell et al (2022) had included in their analysis those who attended only one or less treatment sessions, i.e they had performed an intention to treat analysis, the true recovery rate would have been significantly less than that claimed. Strangely the authors make no mention of this.
Bell et al (2022) do not consider whether reliance on two self-report measures as the sole outcome metric is problematic. No mention that independent assessments may be important, as the self-report measures that are completed are subject to treating clinician scrutiny and comment. Further there is evidence that patients score lower on the PHQ9 in order to motivate themselves Robinson et. al (2017). This leads to a mismatch between scores and patients global ratings of change ‘How are you feeling in comparison to 2 weeks ago? [(1=feels much better, 2 = feels better, 3= feels the same, 4 = feels worse, 5= feels much worse]). The within subject effect size for the PHQ9 was 0.83 and for the GAD7 0.80. A less than 1 standard deviation reduction is just what would be expected of an attention placebo control condition, (absent in the said study) involving regression to the mean, with people presenting initially at their worst. The blindness of the authors to these limitations is breathtaking. The authors declare no conflict of interest, but fail to state that one of the authors works for Icope an IAPT service.
It is likely that volunteer supporters for PLWD would be more welcome than psychological therapists and at least as useful. The Alzheimer’s Society should look to such a body of volunteers. This is not to say that there will not be PLWD who are suffering from depression and anxiety and need evidence based treatment, but there is no sign of it coming from IAPT any time soon. IAPT has a remarkable ability to secure funds and endorsements without its therapists having a unique knowledge or training in this case of dementia. There is a credibility gap between IAPT and its’ fellow travellers and what happens on the ground.
In a recent study by Than et al (2022,) outcomes for attendees of the Charity, Anxiety UK have been compared with the results of attending the Improving Access to Psychological Therapies (IAPT) service. The authors claim a higher recovery rate, 62.4%, for Anxiety UK compared to 51.1% in IAPT. Anxiety UK clients attended a mean of 8.53 sessions compared to a mean of 6.9 sessions in IAPT. The results apply for treatment completers only, defined as attending two or more treatment sessions. But only 4.4% attend only one treatment session in Anxiety UK, but for IAPT in the year running up to the pandemic the figure was 44.7%. It seems that Anxiety UK is massively more able to engage clients than IAPT, strangely a point that Than et al (2022) completely missed.
Anxiety UK operates outside the NHS and does not use IAPT’s stepped care model of low and high intensity interventions. Raising the obvious question of why bother with such a distinction? The minimum access standard set for IAPT for 2020/2021 was 25%, suggesting that potentially 75% will not access the service. This makes the case for the provision of non-commissioned services external to the NHS.
But there are reasons to proceed with caution:
Both Anxiety UK and IAPT have marked their own homework. There has been no independent assessment of these two service providers.
They have adopted the same metric, changes in score on two psychometric tests,the PHQ-9 and GAD-7 between the first and last administration of these measures. Neglecting that clients a) may score lower on re-administration, because they don’t want to feel that they have wasted their time in therapy b) may not want to appear ungrateful by scoring near their initial score and c) present initially in therapy at their worst and there is some naturally occurring resolution of difficulties (regression to the mean).
There can be no certainty that the self-report measures are measuring what they purport to measure. The PHQ-9 is a measure of the severity of depression and only has validity if the individual has been reliably diagnosed (using a standardise semi-structured interview) as suffering from depression. Similarly, the GAD-7 is a measure of the severity of generalised anxiety disorder (GAD) and only has validity if the individual has been reliably diagnosed (using a standardise semi-structured interview) as suffering from GAD. It is perfectly possible to score highly on both measures but to have neither disorder, for example a Ukrainian refugee with a sub-syndromal level of post -traumatic stress disorder/ adjustment disorder and for whom psychological treatments might be misplaced as opposed to watchful waiting/support. The danger of relying entirely on self-report measures is that normality is pathologized.
Despite the claim of Than et al (2022) measuring outcome by a change of score on on self-report measures is not the most ‘client centric’ form of evaluation. It is essential that an outcome measure must be intelligible to the client, changes in psychometric test scores lack any clear meaning to clients. What clients do clearly understand is whether or not they are back to the former self’s post-treatment or at least back to their best selves and the duration of those gains. Inquiry into these domains by an independent observer is the only way of reliably determining whether there has been real world benefit from treatment. Both service providers have jettisoned, rigorous independent assessment.
Neither service provider has run fidelity checks to guarantee that the alleged CBT, clinical hypnotherapy, counselling etc was actually delivered. They both claim NICE compliance, but this necessitates matching a protocol with a reliably diagnosed disorder. Given that neither make diagnoses the claim of compliance has to be fraudulent. It appears an exercise in impression management with Anxiety UK but in IAPT it is arguably more insidious , a mechanism by which funds are secured.
The Anxiety UK authors totally ignore the controversy in the British Journal of Clinical Psychology Scott (2021) about the validity of IAPT’s chosen metric and that most plausibly only the tip of the iceberg recover Scott (2018). One service provider might be concerned to demonstrate a better performance than another but the crucial question is what is actually happening at the coal face? Nevertheless, I suspect working conditions are much better at Anxiety UK.
The Government’s Improving Access to Psychological Therapies (IAPT) programme has decided to experiment with enabling the public to directly book an appointment with a Psychological Wellbeing Practitioner (PWP). But IAPT and the Government are keeping quiet, that PWP’s are not trained in making diagnoses nor in providing psychological [ IAPT Manual (2019)]. They have made it impossible for the public to give informed consent. The public are being conned. In the interest of ‘efficiency’, IAPT is by-passing managerial and admin staff.
For the most part PWPs have nursing or social work backgrounds with a first degree. A recent patient of mine could easily have made direct access to a PWP, I shudder to think what they would have made of his abrupt mood changes, sometimes changed image as he looks in the mirror and periodic disengagement from life. Though not abused himself as a child, he witnessed parental abuse. To put it bluntly they wouldn’t have a clue what was wrong, much less what to do about it. What then is the unique body of knowledge of PWPs?
Given that successive Governments have never conducted an independent audit of IAPT since its inception in 2008, who can say that the billions of £’s service, is value for money? It is to be expected that a service itself will claim itself essential, and in support of this IAPT claims a 50% recovery rate [IAPT Manual (2019)]. But my own independent study Scott (2018) suggests that only the tip of the iceberg recover. As far as mental health is concerned there is no evidence that those availing themselves of IAPT fare any better than if they had attended the Citizen’s Advice Bureaux. But the CABx is upfront with no pretence at having mental health expertise. Is the Government running a production line or endeavouring to improve mental health? No answer from the Health Secretary yet.
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?
I will never forget how, when I started working at the IAPT call-centre, I was stressed and rested my head for a few moments. I was interrupted by a “clinical psychologist” who in accusatory tone proclaimed that, “it does not seem that you are working”. The die it seems was cast. Not once in my 3 years as a Psychological Wellbeing Practitioner (PWP) have I felt that anyone at work cared for one another.
‘When I Want Your Opinion I’ll Give It To You’
Naively I thought that “psychological services” would be a haven of openness, not a venue as “hellish” as any other sales related job. Contentious issues were not allowed to be placed on the agenda at meetings. If I dared to bring up issues that mattered, the Managers would “have a word with me in private”. It felt like “The Twilight Zone” and “Twin Peaks”; you could feel something was not right, but everyone pretended that things were fine and that it was me who was the problem. If there was any issue with what I said, no one gently told me, instead they went straight to my manager. So, I always felt paranoid that whatever I say or do, may be reported.
I will never forget the moments where I would try to bring up a new approach or new knowledge only to be told “it is not in line with NICE and IAPT” and “do not read extra information because you will not need it”. A re-enactment of George Orwell’s 1984, rather than the delivery of a 21st Century psychological service. Worryingly this seems to be the norm in the NHS, with the frontline troops powerless.
What It Is Really Like At The Coal Face
The short end of it all is that being a PWP is very similar to run of the mill call-centre, telemarking and sales job. No matter what the average worker says “but we do a great service”, I feel they are a tad bit delusional. I do not blame them. To survive this job you either need to resort to trickery or delude yourself that you are doing something worthwhile. The latter group probably have a mortgage to pay. We are told what to say, how to say it, when to say it and constantly told “it’s all about the numbers/targets”. We also have a script, which is very similar to those phone contract customer service people. The hellish brilliance of IAPT is that if the targets are not reached, the organisation uses an attributional bias to blame the “practitioners”/miners and not the “system”/pit owners and fellow travellers.
The Re-Branding of What Doesn’t Work, Doesn’t Work
Pre-IAPT there were “mental health workers (MHWs)”, and the public had some idea of the discharge of this particular, professional role. But from 2008 MHWs became Psychological Wellbeing Practitioners, leaving the public and professionals scratching their head as to what the designation might mean. Where PWPs to be regarded as professionals or not? Despite the inherent confusion, I followed my work’s advice to the letter: did the questionnaires, kept the original scores and ploughed onwards. However, what I noticed is that many clients (I dislike using the term patients because it doesn’t feel like we are official clinicians either) were finishing treatment or dropping out with “high scores”. It was not too long until I was interrogated for a below 50% recovery rate.
Jumping Through The Hoops of ‘Recovery’
The recovery rate of 50% is impossible unless one manipulates the numbers or manipulates the clients to be compliant. I guess, good old fashioned “sales tactics” (convincing people they need a product or that they are better than when they started). Of course, the Managers did not care. Safe to say, I found a crack in the system: since the powers all care about numbers, if you deliver the numbers, they will not question you. However, dare you dip below what is expected of their Key Performance Indicators (KPIs), then they are like bloodhounds searching for you. But there has never been a real world KPI that a client would recognise, such as being back to their old selves for at least 8 weeks after treatment. Instead clients are expected at each session to doodle on questionnaires in the prescence of the PWP and bizarrely, these are used as the metrics of recovery.
At the coal face, I can conceal, to a limited extent what I am doing from the powers that be and deliver something of benefit. I do not hound them for the questionnaires every single time because let us face it, that creates a major barrier in treatment. Also, we are not MDs or Clinical Psychologists that can diagnose. It is a joke when we have to collect the data because it is meaningless.
Helplessness
The issue then becomes that I did not feel like I was learning anything. All I was learning was how to manage office politics and be a better liar. One could apply for High Intensity Training but they still focus on targets, so, no thanks. Any person of good conscience will not last long in IAPT. If you have any issues as a worker with IAPT, they will say it is a “you” problem. I once mistakenly vented my frustrations with how they were doing things at a meeting. This resulted in evident displeasure and near the end the next meeting was told to “this is not a space to vent grievances”. If the clients and workers had a platform to vent their frustrations, I do not think IAPT would still be operational.
PWPs Ambassadors For A ‘Failed State’?
Working in IAPT is robotic: clicking tabs, ticking boxes and collecting numbers – a de-humanising experience. There is little to encourage anyone to become a PWP. In fairness I suppose, at least a personal level, I have survived lockdown financially. But the service has in effect been “cooking the books” and making the company look good. I fear for the mental health not only of the ambassadors but for that of clients past and to come.
I am off to other pastures, can you wonder at the turnover?
A 24% response rate combining the two, and manual driven psychotherapy conferred no added benefit Bartova et al (2021). In the podcast from Mad In America these findings are set against a 31% placebo response rate. Further no evidence that the interventions altered the course of a disorder, which is the prime objective of treatments for physical disorders. Rather the focus was on symptomatic relief. Articles covered in podcast include:
Pies and Dawson (2022) have today taken up the cudgel to attack the findings of Moncrieff et al (2002) that were the springboard for the podcast. But they are disingenuous in claiming that no one of academic credibility has ever suggested that low serotonin causes depression. For decades, at least in the UK this has been the dominant message given to patients, with the implication that they need antidepressants to restore the chemical imbalance. Pies and Dawson (2022) have recourse to a biopsychosocial model which posits interactions of thoughts, feelings, social factors and biology, in which will be found some biological factor that is of key importance in the development of depression and through which antidepressants will be found to work. But given the track record to date this seems unlikely and provides little basis for current pharmacological practice with the exception of the use of lithium.
In the Bartova et al (2021) study the therapists claimed that they were adhering to a manual driven psychotherapy protocol, but no fidelity checks were made. A similar scenario to the claim made by IAPT in the UK that it delivers CBT, but without any independent corroboration. It is I believe the case that CBT can make a real world difference for depression and the anxiety disorders if appropriately delivered.
When it is not using the latest evidence. An article in the Cognitive Behaviour Therapist, much lauded by the Editor of the Journal, highlights this. There was no review of the latest group CBT for PTSD outcome studies see Scott (2022) Personalising Trauma Treatment: Reframing and Reimagining London: Routledge. Instead the authors relied upon the conflicted, dated, recommendations of guideline producers. Guidelines are produced by Committee decisions with all the vagaries that entails, they are not the results of a systematic analysis of data. My book includes a review of group CBT outcome studies for PTSD (reproduced at the end of this blog), indicating the inferiority of a group approach.
In this study of group CBT for PTSD, the results of 3, 8 session (2hrs per session) group programmes are summarised by the treating IAPT workers. But no standardised diagnostic interview was used at any point, so it is unknown what proportion of people lost their diagnostic status for how long. Nor whether they were truly suffering from PTSD in the first place, making independent replication impossible. It is claimed that the treatment was given to those who ‘preferred’ group therapy but this is disingenuous. In practice people are offered more immediate treatment with a group or a long wait for individual therapy, whilst they may opt for the former, it is not a preference.
8 is The New Magic Number
The tail is wagging the dog, in that the authors have fitted in with the growing fetish for 8 sessions. Those who complete IAPT treatment typically have 7.5 sessions. Further NICE recommend, 8 group CBT therapy sessions for depression as the first line treatment for depression. But there is no empirical evidence that 8 sessions of anything makes a real-world difference. It is simply what the powers that be have decided to ration out. There is no indication of the mechanism of action of 8 sessions. If it is not possible to specify how a claimed result is achieved then the latter is suspect. BABCP has just celebrated its 50th birthday by a return to magic.
Group Treatments
Groups are an attractive option for service providers, offering the prospect of reduced waiting lists and greater access to therapy. But comparisons of group interventions show them to be inferior to individual therapy post-trauma and to offer no added benefit to treatment as usual. Kearney et al. (2021) compared the effectiveness of group cognitive processing therapy (CPT) for the treatment of PTSD with group loving-kindness meditation (LKM) which involved the silent repetition of phrases intended to elicit feelings of kindness for oneself and others. The proportion of veterans who lost their diagnostic status i.e. who no longer suffered from PTSD did not differ at the end of treatment (CPT – 29%, LKM – 27.5%). Each intervention consisted of 12 weekly 90-minute group sessions but the mean number sessions completed was only six in CPT and seven in LKM. Resick et al. (2017) found that in a population of veterans group CPT was inferior to individual CPT. Preparatory group treatment for CPT or prolonged exposure does not enhance outcome. Dedert et al. (2020) examined whether a preparatory group with a focus on psychoeducation, coping skills, sleep hygiene and an introduction to PTSD treatment options added benefit to the trauma-focussed interventions, it did not. Further, those who went through a preparatory group did less well than those who did not in whatever trauma-focussed CBT they went onto in terms of PTSD symptom reduction. There is no evidence that initial Stabilisation Groups contribute to treatment effectiveness. However, the aforementioned studies were all on veterans, so care has to be taken in generalising from the results. But a study by Mahoney et al. (2020) of women prisoners who reported a history of interpersonal violence and trauma found that a ten-session group psychoeducational programme, Survive and Thrive, conferred no benefit over treatment as usual.
There appears to be no benefit to a phase-based approach, in which the first phase has as its goal safety and stabilisation, despite the inherent attractiveness of this option.
Scott, Michael J. Personalising Trauma Treatment (p. 293). Taylor and Francis. Kindle Edition.
despite the fact that the main provider of psychological services, the Improving Access to Psychological Therapies (IAPT) Service is ‘An Abject Failure’ https://www.madinamerica.com/2022/06/uk-iapt-abject-failure/. It is all about cost, with no regard for evidence. It is recommended by the National Institute for Health and Care Excellence (June 29th) that clients are offered 11 possible interventions for depression, presenting the least costly first, guided self-help, group cognitive behavioural therapy (8 sessions) progressing up to the 11th option, short term psychodynamic psychotherapy. With Psychological Wellbeing Practitioners (PWPs) providing the assessment and the least costly interventions. But PWPs are not trained therapists and the IAPT Manual states that its’ employees do not make diagnoses and they are not trained to diagnose. Yet bizarrely NICE states that assessors must be competent to make a reliable assessment of depression! A pig’s ear of monumental proportions.
There is no empirical evidence that 8 sessions of group CBT delivered by PWPs makes a real world difference to client’s lives as assessed by a blind assessor. Nor that the recommended 8 sessions of individual CBT for depression, presumably delivered by a high intensity therapists, constitutes a therapeutic dose of treatment.
The revision of the Draft Nice Guidance on Depression https://www.nice.org.uk/guidance/ng222 now recommends a stepped care approach to depression and sees Psychological Wellbeing Practitioners as contributing to treatment. This has brought a ‘hurrah’ from BABCP (British Association for Behavioural and Cognitive Psychotherapy), as it is exactly what they lobbied for https://babcp.com/About/News-Press/Revised-NICE-Guideline-on-Depression-in-Adults post the Draft guidelines. Dr Andrew Beck the BABCP President proclaims in the press release ‘the guidedInes highlight the amazing value of PWPs’. In addition antidepressants and CBT in combination are seen as the treatment choice for severe depression.
But these recommendations and changes are eminence-based not evidence-based. A paper published in the Journal of Psychiatric Research last year by Bartova et al (2021) https://doi.org/10.1016/j.jpsychires.2021.06.028 showed a 25% response rate for those who had antidepressants and manual-driven psychotherapy (mostly CBT), no better than antidepressants alone. This compares with a 31% response rate in those given a placebo Rutherford and Roose (2013) https://doi.org/10.1176%2Fappi.ajp.2012.12040474
Before BABCP issued the press release, I raised the following issues with its’ author Professor Reynolds:
I can find no randomised control trials of low intensity interventions that are methodologically robust enough to lead to the conclusion that such interventions should be the initial treatment of choice for less severe depression.
I can find no evidence that as a result of stepped care, the trajectory of clients with depression Is meaningfully better than if they were not treated in a stepped care model.
There was criticism of the initial draft for the ‘marginalising and undervaluing of PWPS’. However, it appears that under pressure from BABCP, PWPS are now to be lauded. But there is an absence of evidence of what PWP treatment works for whom and in what circumstances. As such their interventions are not evidence- based. Further they are not psychological therapists.
NICE have apparently indicated that the IAPT database may be used to inform the next set of guidelines. But this database tells us nothing of the course of any client’s disorder as the service does not make diagnoses or engage in long-term follow up.
I asked that my dissent from BABCPs press release be publicly noted, and was told simply that it would be passed to the BABCP Board. At the same time the comments of IAPTs lead, Professor Clark. on the importance of including relapse prevention in treatments, would be included in the press release and it was. An in-group clearly operates. I am reminded that when I submitted an article to the BABCP comic, CBT Today on IAPT, the article was rejected not by the editor but by the past (Prof Salkovskis) and current (Dr Andrew Beck) Presidents of BABCP. The matter was never addressed by the Board despite an assurance from Dr Beck. If ever there was a clique. Unholy alliances rule.
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 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 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.
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 science, 49(4), 627–650. https://doi.org/10.1177/0306312719834070
