Deluded Secretary of State for Health and Social Care

Mr Matt Hancock has just announced on BBC Radio 4 that ‘our (mental health) services are better than almost any other services in the world’.  But how can he possibly know this – there has never been an independent assessment of the Government funded Improving Access to Psychological Therapies Service (IAPT), the latter have only ever marked their own homework. The Secretary of State might ask the National Audit Office why it has never published the results of its’ investigation into IAPT. My own study published in the Journal of Health Psychology in February of this year

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

suggests the recovery rate in Adult Services is just 15% far short of the Government target and IAPT’s claim of a 50% recovery.

 

Dr Mike Scott

Yesterday’s CBT for PTSD and Beyond ‘A really great workshop it was too’ –

‘Very interesting and lots of new ideas for approaching what can be a complicated mind field’. Delighted Christine Roberts twittered this response, thanks. It was a full house at the Lakeside Centre, Crosby, Liverpool, super day except for a microphone that had a life of its’ own!

 

But there was unanimous agreement from the 80 participants that generally therapists are a) stressed out b) daren’t publicly voice there discontent with IAPT. One person voiced that the customary IAPT 6 sessions is like putting a sticking plaster on a wound and all you get is a revolving door of clients. We need to stop the bleeding.

The voices of dissent are not in evidence at Nationally Organised BABCP Events, indeed I did not go to the Annual Conference because it looked like a further feast of uncritical acclaim of IAPT, reflected in the current issue of CBT Today.

The great thing at the Workshop is that we were able to address participants concerns e.g comorbid PTSD and OCD in a 15 year old. But we were all at a loss as to how to break out of the current mode of IAPT delivery, it seemed to resonate with being a citizen of some totalitarian state.

Dr Mike Scott

Clients Cast Adrift By Individualised Treatment Without An Anchor

Psychological therapists in the UK and beyond almost universally believe that they are equipped to personalise treatment and jealously guard their autonomy. Services feed the quest for autonomy by taking no steps to ensure clinicians make reliable diagnosis. This, despite the fact that the NICE approved psychological treatments are almost all diagnosis specific. As therapists are promoted the system perpetuates itself.

Not too long ago it was believed that physical and mental disorders arose from an imbalance of the four humours – blood, yellow bile, black bile and phlegm. A person with disordered blood would obviously improve with bloodletting. Years of experience of people recovering after thoughtful personalised bloodletting were confirmation of efficacy.

 

Evidence based psychological treatment (EBT) still requires a clinical judgment as to whether a particular person could be matched to the population of a particular randomized controlled trial. But EBT’s prevent the unbridled use of clinical judgement .

Moving towards reliable assessment will need nothing short of a revolution because it runs counter to the current expert consensus. This consensus does not accept that current provision simply does not work, a 9.2% recovery rate, when assessed independently Scott (2018) https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0 and calls for replication studies have fallen on deaf ears amongst the power holders and the media [ Marks (2018) https://www.dropbox.com/s/uw47oh03k9uvpo0/Marks%20IAPT.pdf?dl=0 There is an understandable concern about an increased cost of assessment but this will be offset by a treatment that might actually work. There is a massive vested interest in the status quo that extends to courses and politicians. The latter want to be seen to be on the side of mental health, happy to be seen opening mental health facilities or advocating more mental health personnel in schools but they run shy of considering independent assessment of outcome, it is of no short term political advantage. Politicians have let the National Audit Office get away with not publishing the results of its investigation into Improving Access to Psychological Therapies  ( IAPT) .

Scott, M.J (2018) IAPT – The Need for Radical Reform, Journal of Health Psychology, 23, 1136-1147.

Marks, D.F (2018) IAPT Under the Microscope, Journal of Health Psychology, 23, 1131-1135.

 

Dr Mike Scott

My black cloud, revolving door and IAPT

‘I found Silvercloud ineffective, generic and not tailored to my personal situation. It wasn’t engaging or helpful and as such I didn’t engage with the website very much. Consequently, the following weekly call with the IAPT therapist  were sometimes made difficult by the fact I hadn’t completed the same questionnaire as the week before or read through articles. I wanted to talk about my situation, my feelings and find out why I was feeling the way I was, but I felt I was just being led back to using the online Silvercloud resource.

‘It was in 2017 that my doctor suggested I try Silvercloud online CBT with telephone support and in September 2017, I started speaking to another IAPT counsellor. He seemed to be a very nice man. After a few weekly calls, he stated that he didn’t believe I was depressed and so he changed the original Silvercloud course I had started and reset it back to a new series of 6 sessions. The weekly calls lasted between 20 minutes to an hour depending on what we discussed, but always concluded with him asking me to log onto Silvercloud and work my way through the programme before our next call. After the requisite 6 sessions finished in February 2018, that was it! No answers, no tools to help me cope, just signed off, discharged, but told I had 12 month access to SilverCloud. I haven’t used the resource since.

I had a very poor experience of counselling through IAPT around 2013. I had been scheduled 6 sessions, these hour long sessions were so ineffective and pointless I can hardly recall anything that was discussed. I may have missed a couple of sessions due to work, but once the 6 sessions expired, I was discharged even though I may have only seen the counsellor 4 times. All I can recall is going over the initial questionnaire about my mood over the previous week which I had been told to monitor through photocopied pictures and graphs which I was told to keep in a file and bring to each appointment’.

 

 

The above is the anonymous report of a depressed client of mine, who is responding very well to my cbt treatment. Not only is she scathing about her IAPT treatment but also about her treatment from her GP:

‘At its height, I was being prescribed 200mg sertraline, 80mg of propranolol. I went to see my doctor for something routine, when she commented on my ‘low mood’ and suggested increasing my antidepressants. I told her I was already taking the maximum dosage and said I didn’t want to take more prescription medicine. I was already taking 200mg of setraline and 80mg of propranolol at that time. My prescriptions had been increased over a period of time without much investigation. In a short 5-10 minute appointment, my ‘low mood’ was usually commented upon and an increase in antidepressant and/or beta blocker was almost automatically prescribed.
In early 2018, I went to see my doctor and insisted that we work together to reduce my medication as I felt so unwell and was sure that the amount of medication I was taking was actually making me feel worse rather than better’.

There is no substitute for really listening.

Dr Mike Scott

IAPT – A Crumbling Edifice and The Law

A friend has recently got a post as a Hi-Intensity therapist in IAPT, he is restricted to providing just 6 sessions, but can go up to 10 for PTSD and OCD.  He is expected to make 24 contacts a week, each session to be no more than 45 minutes. If he doesn’t reach the 50% recovery rate for 6 consecutive months he will have to attend a meeting.  Perhaps I should book him in for a reliable assessment in 6 months time, conducted not by telephone but with hospitality. I wouldn’t consider stipulating the number of sessions in advance. But I would be mindful not to pathologise his likely stress reaction – ‘saving normal’.

I might advise that he consider whether his employer has breached a duty of care in that it is known that 6 sessions is not an evidence based dose of treatment for any psychological disorder and it is reasonably forseeable, that a therapist charged with delivering this is likely to be stressed. It would then be a matter for the Health and Safety Executive and Personal Injury Lawyers. But there are also issues of informed consent, in that clients are not informed that they are to receive a sub-therapeutic dose of treatment – they could become litigants. Clinical Commissioning Groups have done absolutely nothing to ensure that clients receive a therapeutic dose of treatment and are open to a charge of medical negligence.

Will IAPT reform itself before it is too late? There is a glimmer of hope, in that I did not meet with open hostility recently when I suggested that it needs reconfiguring to ensure reliable assessment.  But the economic argument for IAPT will be in tatters after a new paper is likely published in the coming months, which will show what the National Audit Office has signally failed to make public – a matter for the House of Commons Public Accounts Committee.

Dr Mike Scott

‘What We Need Is Good Quality Talking Therapies’

Says Will Self talking on Radio 4 this morning, a must listen on BBC i-player. He was  distressed at his friend who had been sectioned, his visit to her on a locked ward resembled still, ‘One Who  Flew Over the Cuckoo’s Nest’. When she questioned the appropriateness and mechanism of action of the drugs prescribed for her bipolar disorder the psychiatrist became defensive. After  discharge no therapy was on offer.

 

 

He is absolutely right we do need good quality talking therapies but we have not got them, rather we have a 10% recovery rate for those undergoing treatment with IAPT http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264.  I very much doubt that IAPT or anyone has an evidence based psychological treatment for a person with bipolar disorder and it would be disingenuous to pretend we have. Nevertheless IAPT has trespassed into providing treatment for medically unexplained symptoms, which is an unfortunate precedent for claiming more than we can deliver.

Will Self makes the excellent point that we need small communities to support people like his friend. But it is very difficult to create them for people who are isolated, charities, churches etc do what they can but it is a tough road to make a real world difference

 

Dr Mike Scott

The Cost of IAPT Is At Least Five Times Greater Than Claimed

The British Medical Journal has just published the following letter of mine online with the above title:

‘Six years ago a News headline in the BMJ proclaimed ‘Increasing access to psychological therapies will cost NHS nothing’ BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e4250, citing a report of Lord Layard  of the Mental Health Policy Group of the Centre for Economic Performance http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp, that claimed ‘after an average of 10 sessions half the people with anxiety conditions will recover, most of them permanently, and half the patients with depression will recover’ .  Far from being substantiated an independent assessment by Scott (2018), http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264, using a standardised diagnostic interview, suggest a 10% recovery rate. This represents a five-fold increase of the cost of treatment per cured person.

The progenitors of IAPT, Clark and Layard in their book Thrive (2015) claim that the cost of treatment in IAPT is £650 per person, for people having attended 2 or more treatment sessions.  This leaves out of account the 40% of its clients who attend only one treatment session [IAPT (2018)] and the costs of the initial assessments which totalled £92 million in 2016-2017, with total costs of £367,219,192 in that period.  This means that the true cost of IAPT is at least 5 times greater than alleged, all without any government funded independent audit. Further average session attendance for those ‘treated’ in IAPT is 6.6 [IAPT (2018)] not the average of 10 sessions that Lord Layard deemed necessary, so that the average patient in fact receives a sub-therapeutic  dose of treatment.

In 2012 Lord Layard claimed ‘the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy’. This claim remains unproven and what limited evidence is available points in the opposite direction. How do Clinical Commissioning Groups justify paying such inflated sums? how can they be sure another agency could not achieve the same for less? how do they know that GPs simply tracking clients with depression and anxiety disorders would not achieve the same outcomes? NHS England should surely advise CCG’s to ask searching questions and organise a long overdue government funded independent audit of IAPT focusing on real world outcomes, such as loss of diagnostic status..

BMJ (2012) ;344:e4250 Increasing access to psychological therapies will cost NHS nothing, says report

Clark, D.M and Layard, R (2015) Thrive: The Power of Evidence-Based Psychological Therapies London: Penguin.

IAPT (2018) Psychological Therapies: Annual report on the use of IAPT services England, 2016-17 Data Tables. NHS Digital: Community and Mental Health Team.

Mental  Health Policy Group of the Centre for Economic Performance (2012) How mental health loses out in the NHS.   http://cep.lse.ac.uk/_new/research/mentalhealth/default.asp.

Scott, M.J (2018) IAPT: The Need for Radical Reform. The Journal of Health Psychology, 23, 1136-1147.

 

Dr Mike Scott

The Annihilation of The Therapeutic Relationship

The therapeutic relationship has withered under the blistering sun of IAPT. The latest IAPT annual report (2018) shows that 40% of clients attend only one treatment session, with the average client attending just 6 sessions. The therapeutic relationship needs the space of at least 10 sessions to flower according to NICE guidelines.  For assessed only referrals 43% were deemed suitable but declined treatment , 23% were deemed not suitable  and only 9% discharged by mutual agreement (IAPT 2018).

 

 

 

I’ve just edited the proofs of my contribution to ‘The Therapeutic Relationship In Cognitive Behavioural Therapy’ by Stirling Moorey and Anna Lavender to be published by Sage. The contributors cover all the  disorders and contexts (my own chapter is ‘CBT Delivered in Groups’ written with Graeme Whitfield). Most of the authors are well known and agree on the importance of the therapeutic  relationship. The approach taken in the book contrasts sharply with the practices in IAPT.

 

Dr Mike Scott

Independent Critiques of IAPT – Special Journal Issue Open Access

Independent assessments suggest that IAPT is not making a ‘real world’, socially significant difference to client’s lives, albeit that further research is needed. In the Special Issue of the Journal of Health Psychology for August 2018, ways forward are suggested.

 

 

Contents of Special Section of August 2018 Issue of the Journal of Health Psychology ALL OPEN ACCESS

http://journals.sagepub.com/action/showTocPdf?volume=23&issue=9&journalCode=hpqa

IAPT Under The Microscope David F Marks https://files.acrobat.com/a/preview/d142501a-6727-4002-b1c6-9222174610de

Improving Access to Psychological Therapies (IAPT) – The Need For Radical Reform              Michael J Scott

http://journals.sagepub.com/doi/pdf/10.1177/1359105318755264

The diagnosis is correct but National Institute of Health and Care Excellence are part of the problem not the solution Sami Timimi

http://journals.sagepub.com/doi/pdf/10.1177/1359105318766139

Attempting to reconcile large differences in Improving Access to Psychological Therapies recovery rates Scott H Waltman http://journals.sagepub.com/doi/pdf/10.1177/1359105318767158

Medical approaches to suffering are limited, so why critique Improving Access to Psychological Therapies from the same ideology James Binnie 

http://journals.sagepub.com/doi/pdf/10.1177/1359105318769323

Transforming Access To Psychological Therapies Michael J Scott 

http://journals.sagepub.com/doi/pdf/10.1177/1359105318781873

 

Dr Mike Scott

 

 

Clinical Commissioning Groups Fail To Check Compliance With Informed Consent – Have You Been Affected?

Clinical Commissioning Groups (CCG’s) fund IAPT (Improving Access to Psychological Therapy Services), but have failed to ensure that mental health sufferers are not given the cheapest option, guided self-help (GSH), without being informed of its poor performance compared to regular therapy. GSH is the most commonly proferred service by IAPT and its’ usage has breached informed consent. As Pim Cuijpers https://doi.org/10.1111/cpsp.12238 has observed ‘A self-help intervention cannot replace more usual  forms of psychological treatment and this should be made clear from the beginning’. CCG’s are risking legal action from patients given the cheapest treatment option without explanation of alternative treatments, risks and benefits.  There is a pressing need for CCG’s to seriously appraise IAPT and not blindly fund it because ‘it is the only show in Town’.

The response of CCG’s to any criticism of IAPT is typified by the letter below that I received from the

Liverpool CCG, published as an appendix in ‘Transforming IAPT’

https://www.dropbox.com/s/ie4yg6hgmt5fybw/EDITED%20Transforming%20IAPT.docx?dl=0https://doi.org/10.1177/1359105318781873

in the August issue of the Journal of Health Psychology

 

Footnote: In earlier work Cuijpers

https://www.dropbox.com/s/3zgy50ub5s5q1yx/Lewinsohn%27s%20Coping%20with%20Dep%20Meta-Analyses.pdf?dl=0

has noted that the effect size for GSH  for depression is small 0.28 compared to 0.6 or more (large to moderate) for the regular face to face therapy.

 

Dr Mike Scott