Tag: IAPT

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Mis-Guided Self Help In IAPT

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%). 

Dr Mike Scott

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The Health Minister and NHS England Pass The Buck on Answering Key Questions on Mental Health

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?

 

Dr Mike Scott

 

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The Seriously Flawed Psychological Therapy and Dementia Study

 

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. 

 

Dr Mike Scott

 

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IAPT Outperformed by Anxiety UK

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:

  1. Both Anxiety UK and IAPT have marked their own homework. There has been no independent assessment of these two service providers.
  2. 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).
  1. 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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

 

Dr Mike Scott

 

 

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Mental Health Triage Practitioners Don’t Know Who Is Suffering from What, or What Needs To Be Done

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.

Dr Mike Scott

 

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Unreliable IAPT Gatekeeping – Questions Sent To The Health Secretary, Dr Coffey

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?

I await the response with interest

 

Dr Mike Scott

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A Psychological Wellbeing Practitioner Breaks The Wall of Silence

 

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?

 

Bernice ( a pseudonym)

 

 

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Antidepressants and CBT in The Real World

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.

 

Dr Mike Scott

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When is evidence based practice not evidence based practice?

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.

 

 

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NICE Rubber Stamps Business as Usual

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:

  1. 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.
  1. 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.
  2. 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.
  1. 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.

Dr Mike Scott