Sham Psychological Therapy Rules

Bernard felt ‘ten times worse’ after his first session of IAPT, Group CBT. He didn’t return for further sessions. IAPT advised him to seek individual therapy via his GP, which he did but none was ever forthcoming. When I saw him it was three years after his industrial accident that rendered him unable to work, his depression had continued unabated. The GP records simply recorded that he did not attend 3 sessions and so was discharged, the implication was that he was at fault!

What had actually happened is that following an IAPT telephone assessment he was invited to therapy at a local centre. On arrival he and others were given a questionnaire to complete. He and about 15 others were then ushered into a room, but there were not enough chairs so some stood. The group leader began asking each of them in turn what their problem was. Bernard protested ‘ I can’t tell my problems in front of all these’, he said that he could see that the young men in the group were agitated and one ‘girl’ on the verge of tears. ‘it was more like a lecture with flipchart and screen’.

The IAPT treatment bears no relationship at all to the group CBT detailed, in my book ‘Simply Effective Group CBT’ published a decade ago by London: Routledge or to what I am trying to promote as Co-chair of the BABCP Group CBT Special Interest Group. A year ago the IAPT Manual was published but none of it confers any protection for a client suffering the same fate. The worry is that in the interest of a numbers game more people will suffer Bernard’s fate.How long is the cover up going to go on!

Dr Mike Scott

IAPT Hoodwinks NHS England

by alleging compliance with NICE recommended evidence-based psychological treatments. But, NICE bases its’ recommendations, largely, on randomised controlled trials conducted on specific disorders, with different protocols for different disorders. It is impossible to implement NICE guidance without reliable diagnosis, but IAPT have never claimed that its’ clinicians make a diagnosis!

Even the notion of a utilising a ‘provisional diagnosis’ was jettisoned in last years IAPT Manual, (see link below) in favour of a ‘problem descriptor’:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

On the basis of a client’s ‘problem descriptor’ the IAPT Manual requires its’ therapists to specify an ICD-10 [International Classification of Diseases 10th edition, World Health Organisation] code for a disorder, which would allegedly indicate the appropriate protocol. However there are 99 codes for Mental and Behavioural Disorders in ICD-10, there is no bridge between a ‘problem descriptor’ and a disorder. If such a leap were possible ICD-10 ( the World Health Organisation) would not have bothered to specify diagnostic criteria for the 99 conditions! Within IAPT clinicians come up with a ‘problem descriptor’ in just 2/3rds of cases, [ Clark et al (2018)] see link below:

https://www.dropbox.com/s/s7var6llzwt1otd/IAPT%20and%20Transparency%20Clark%202018.pdf?dl=0

and usually following a 20-30 minute telephone conversation, it is therefore a matter of ‘plucking a code’ from thin air for administrative purposes,


if the clinician can remember this particular ticking the box exercise.

The Clark et al (2018) study was published in the Lancet, and funded by the Wellcome Trust, and headed ‘Transparency about the outcomes of mental health services (IAPT approach): an analysis of public data’ and states:

‘Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation, or writing of
the report. The corresponding author had full access to
all the data in the study and had final responsibility for
the decision to submit for publication’.

But there is no mention that the lead author is the leading light in IAPT, and that with one of the other authors, Lord Layard, they were the architects of IAPT. Where is the ‘transparency’ in this? In fairness in this paper they do state that a limitation of their paper is that their data is dependent entirely on client self report, but a conflict of interest stops them going on to say, that there needs to be an independent audit of IAPT, in which the diagnostic status of clients is assessed before and after treatment and at follow up.

My own independent analysis of 90 IAPT clients suggests that, contrary to IAPTs claims of a 50% recovery, just the tip of the iceberg loose their diagnostic status diagnostic status, see link below: https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

NHS England needs to clearly establish whether or not the public is ill served by IAPT and not to rely on the claims of those with a vested interest in providing the Service.

Dr Mike Scott

IAPT – Discrimination and Incredulous Claims

Dr Michael Kelleher, a Consultant Addictions Psychiatrist, interviewed in next months Psychologist has claimed ‘some IAPT services exclude patients that use or have used alcohol until they are many months post abstinent. This is contrary to positive practice guidelines that the National Treatment Agency brought out’ . He continues ‘if people get detoxed they shouldn’t have to wait an arbitrary length of time to be sober before they can have psychological therapy. They should be able to flow into an anxiety or depression programme straight away once a detox is completed’.

IAPT data on 16,723 clients in the North East of England, Boyd, Baker and Reilly (2019), see link below, suggests that the Organisation is superb at spurning those with an alcohol problem,

https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0

over a 4 year period the proportion of clients treated with ‘a mental and behavioural disorder due to alcohol use’ never rose above 0.1%, ( 1, 1, 4 and 3 people in successive years). By contrast the proportion with ‘mixed anxiety and depressive disorder’ was 26.8%, 30.5%, 30.1% and 39.6% over the four years.

Dubious Recovery Rate

The North East IAPT service claims a recovery rate of 40-49%, depending on which years are considered. With between a quarter and half of clients categorised as ‘mixed anxiety and depressive disorder’. However the IAPT Manual cautions against the use of the ‘mixed anxiety and depressive disorder’ label thus:

‘The ‘mixed anxiety and depression’ problem descriptor (ICD-10 code) should not be used unless the person’s symptoms of depression or anxiety are both too mild to be considered a full episode of depression or an anxiety disorder. Inappropriate use of the ‘mixed anxiety and depression’ problem descriptor may mean that patients do not receive the correct NICE- recommended treatment. For example, if someone has PTSD and is also depressed they should be considered for trauma-focused CBT as well as management of their depression, but this may not happen if they have been identified as having ‘mixed anxiety and depression’.

Given the common usage of an unreliable ‘mixed anxiety and depression’ label, is it at all credible that the recovery rate should approach IAPT’s claimed national average of 50%? It looks like massaging of data for public consumption.

Choose The Right Clients For Performance

The IAPT Manual published a year ago, see link below:

https://www.dropbox.com/s/pgmbsoqjqmq04qz/IAPT%20Manual%202018.pdf?dl=0

clearly and rightly, states that it would be inappropriate for IAPT staff to provide therapy for clients who arrive at a session intoxicated. But delaying treatment once detoxified, smacks of special selection so the agencies performance figures look good – akin to a school selecting the brightest pupils in the area.

Studies generally show that the prevalence of depression and adjustment disorder are about the same, and psychiatrists diagnose them as often as each other, but curiously over half of IAPT clients in the Boyd et al (2019) study are declared to have depression but the prevalence of adjustment disorder doesn’t rise above 0.6% in any year! Either IAPTs population is incredibly skewed or there is no reliability at all in their diagnostic labels, such that therapists don’t have a clue what they are treating!

Non-Declaration of Conflict of Interest In IAPT Studies

IAPT staff have a penchant for not declaring conflicts of interest in published papers, in the Boyd, Baker and Reilly (2019) paper it is written ‘The authors have declared that no competing interests exist’ , but the lead author presenting at a Conference in Amsterdam in May 2016 is described thus:

Lisa Boyd, IAPT service, Tees Esk and Wear Valley Mental Health Trust, UK Impact of a Progressive Stepped Care Approach in an Improving Access to Psychological Therapies Service: An Observational Study

Dr Mike Scott

IAPT’s New Direction – ‘maybe, shove them all through low intensity’

that’s the take home message from a just published IAPT study conducted in the North East of England by Boyd, Reilly and Baker (2019), see link below:

https://www.dropbox.com/s/q1120m0cbvqb882/IAPT%20Stepped%20care%20model%202019.pdf?dl=0

This would mean that those with PTSD and social anxiety disorder would first fall into the orbit of low intensity interventions. Never mind that there is no empirical evidence from randomised controlled trials that these disorders respond to low intensity interventions.

Boyd, Baker and Reilly (2019) reiterate the populist myth that there is ‘sound evidence of the efficacy of low intensity interventions’ . This only becomes true if one lowers the methodological bar as low as in their own study, which was reliant entirely on self-report measures administered outside the context of a reliable diagnostic interview. These authors cite a study by Bowers et al (2013) in support of the effectiveness of low intensity interventions but these authors acknowledge that a key limitation of their study was generalisability, because patients were not reliably assessed for depression, see link below:

https://www.dropbox.com/s/24qz5pdu6dfl0ce/Low%20intensity%20initial%20severity%20doesnt%20make%20a%20difference%202013.pdf?dl=0

If the North East of England study is taken on board by IAPT, there is less need to worry about clients being on waiting lists for high intensity treatments, because they are allegedly already getting something worthwhile! Who needs high intensity therapists?

IAPT’s research and treatment is conducted on another planet from the lived experience of clients. Take the case of Tara, she suffered from depression after a fall and from a phobia about tripping, that I established with a diagnostic interview. She then had 6 IAPT face to face low intensity sessions which were described as guided self help, 2 of these involved behavioural activation. Her PHQ9 scores stayed at 19/20, which was not significantly different to when I 1st saw her with a PHQ9 score of 21. Treatment made no difference at all, though she valued the opportunity to talk she was very upset after the sessions. Tara was then put on a 3-4 month waiting list for high intensity CBT. The documentation revealed that there had been no evidence of fidelity to an evidence based treatment programme for depression and no attempt to address her phobia. Initially she had a telephone assessment with IAPT.

There is a wholesale abscence of appropriate treatment in IAPT and in practice its’ stepped care model violates continuity of care. It should try listening to clients and subjecting itself to independent audit, instead of playing with large sets of meaningless numbers, to justify funding.

Dr Mike Scott

IAPT’s Class Answer to Improving Access

Use classes. Forget about disorders just call it ‘stress’. Offer something CBT flavoured and capitalise on time and the placebo effect to demonstrate an effect, label the package ‘good practice’. Encourage IAPT providers to write about it in the Cognitive Behaviour Therapist (the online BABCP Journal) special issue to be devoted to IAPT, introduced by the lead clinician in IAPT.

The Stress Control (SC) programme of White et al. (1995) is more of a public health intervention than a psychotherapeutic group. It is run as a night school class, and though there are questions and answers between attendees and presenters, personal problems are not discussed.

IAPT’s Implementation

In an IAPT implementation of the programme, at Step 2, Burns et al. (2015) had a mean group size of seventy-four and a range from twenty-three to 106, with six weekly, two-hour sessions. The programme consisted of week 1, introduction to psychoeducation and the cognitive behavioural model; week 2, management of physiology; week 3, management of mental events; week 4, management of behaviour; week 5, management of panic attacks and sleep; and week 6, self-care. At the end of each session, material for the next session was distributed containing homework exercises. At the final session, relapse prevention materials were distributed.

Outcome

Three quarters of the 1,062 clinical cases [PHQ-9 greater than or equal to 10 and/ or GAD-7 greater than or equal to 8] attended three or more sessions. Of those attending pure stress control alone 37% ‘moved to recovery’, defined as an improvement of 6 points on the PHQ-9 and 4 points on the GAD-7. With mean PHQ-9 scores for the clinical case sample reducing from 15.50 to 11.58.  Burns et al. (2015) claim that ‘SC appears comparatively clinically equivalent to other IAPT interventions’. However Gilbody et al. (2015) looked at how GP patients with a PHQ-9 score of greater than 10 fare with usual treatment, over a four-month period; their mean PHQ-9 score reduced from 16 to 9. It is thus not at all evident that the SC programme is of social significance.

The Case For Classes Is Built on Sand And A Distraction From Providing CBT That Makes a Real World Difference

The methodological quality of the SC studies are poor when assessed by the Foa and Meadows (1997) criteria, in that there are no clearly defined target symptoms, no diagnostic interview was conducted to establish which if any disorder the person was suffering from and the proportion ‘cured’ by the end of the intervention. Further there is no independent evidence that six or fewer sessions constitute an adequate dose of psychotherapeutic intervention.

Burns, P., Kellett, S. and Donohoe, G. (2015) “Stress Control” as a large group psychoeducational intervention at Step 2 of IAPT services: Acceptability of the approach and moderators of effectiveness. Behavioural and Cognitive Psychotherapy, 44, 431– 443. http:// dx.doi.org/ 10.1017/ S1352465815000491

Foa, E.B. and Meadows, E.A. (1997) Psychosocial treatments for posttraumatic stress disorder: A critical review. Annual Review of Psychology, 48, 449– 480.

Gilbody, S., Littlewood, E. and Hewit, G. (2015) Computerised cognitive behaviour therapy (CCBT) as treatment for depression in primary care (REEACT) trial: Large scale pragmatic randomised controlled trial, BMJ, 351, h5627. DOI: 10.1136/ bmj.h5627

Scott, Michael J. Towards a Mental Health System that Works: A professional guide to getting psychological help (p. 116). Taylor and Francis. Kindle Edition.

White, J., Keenan, M. and Brooks, N. (1992) Stress control: A controlled comparative investigation of large group therapy for generalised anxiety disorder. Behavioural Psychotherapy, 20, 97– 114.

White, J., Keenan, M. and Brooks, N. (1995) Stress control: A controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural Psychotherapy, 20, 97– 114.

Williams, C., Wilson, P. and Morrison, J. (2013) Guided self-help cognitive behavioural therapy for depression in primary care: A Randomised controlled trial. PLoS ONE, 8( 1), e52735. DOI: 10.1371/ journal.pone. 0052735

Dr Mike Scott

IAPT and Special Measures

If IAPT were a Hospital, operating without any consideration as to whether patients are returned to their usual selves with treatment, they would likely be placed in Special Measures. IAPT has eskewed accepted definitions of recovery.

IAPT’s Meaningless Yardstick

If you are departing IAPT (or wish to commit professional suicide!) tell your IAPT manager/supervisor the psychometric test results are not measuring anything meaningful, they are simply impositions from above! IAPT claims that the psychometric tests it uses (PHQ9 and GAD7) measure clinically significant change/ recovery. But this is not true.

The validity of clinically significant change criteria relies crucially on whether the test used taps the same construct as the identified disorder1. IAPT’s use of the PHQ9 and GAD7 violates the requirement for construct validity, specifically as IAPT make no standardised reliable diagnosis it is a lottery as to whether the psychometric test matches the diagnostic status of the client. A client could be suffering from for example variously, no recognised disorder, an adjustment disorder, OCD, panic disorder, the changing scores on the PHQ9 and GAD7 would say nothing at all about the outcome of an intervention for these disorders. To compound matters in the IAPT set up it is not possible to know when these measures are actually tapping depression or generalised anxiety disorder in a particular client.

IAPT’s Idiosyncratic Use of Tests 

IAPT have never stipulated any criteria for enduring improvement. Therapists discharge clients as soon as their scores dip below casenness on a self-report measure, neglecting to consider that what is being observed is likely natural variation than any return by the client to their usual self. Matters are compounded because clients can complete the questionnaires to either please the therapist (particularly likely if completed in front of the therapist) and/or convince themselves that they have not wasted time in investing in therapy.

IAPT Training At Fault

CBT therapists per se are not trained in methodology – there is rarely any understanding of concepts such as construct validity, reliability, the limitations of psychometric tests, bias introduced into such tests by the ways in which they are administered or of accepted criteria for recovery. The deeply flawed IAPT training has arisen without a murmur of protest from the British Psychological Society and BABCP hierarchy. The rationale appears to be so long as IAPT secures increased monies for mental health services that is all that matters, this is a dereliction of care to both clients and therapists.

How Outcome Should Be Assessed

The passage of depressed clients through IAPT has never been judged by accepted definitions of response, remission and recovery2, 3.

Response is defined as a clinically meaningful improvement in depressive symptoms that has continued for a sufficient length of time (3 consecutive weeks) to protect against misclassification owing to symptom variation or measurement error2. Response is typically operationalised as an  improvement of ≥ 50% over pre-treatment scores.

Remission relies on a definition of an asymptomatic range, defined as the presence of no or very few symptoms. A person can be judged to be in the asymptomatic range only if neither of the two essential features of depression (sad mood and loss of interest or pleasure) is present and fewer than three of the additional core symptoms of depression are present2. Remission requires that the person remains in this range for at least 3 weeks, again to protect against factors such as natural symptom variation.

Recovery is defined as an extended length of time in remission, which has been operationalised as at least 4 months4.

The passage of anxious clients through IAPT has never been judged by accepted definitions of recovery4. In the Bruce et al (2005) study of the trajectory of anxiety disorders a participant was considered to have recovered from anxiety disorder if he/she experienced 8 consecutive weeks at psychiatric status ratings of 2 or less (Table 1). Subjects who met this condition were virtually asymptomatic for 2 consecutive months.

Table 1

2. Residual The patient claims not to be completely his/ her usual self, or the rater notes thepresence of symptoms of no more than a mild degree (for example, mild anxiety in agoraphobic situations).

1.  Usual self The patient is returned to his/her usual self, without any residual symptoms of the disorder. (The patient may have significant symptoms of some other condition or disorder; if so, a psychiatric status rating should be recorded for that condition or disorder.)

References

1.Fisher PL and Durham RC Recovery rates in generalized anxiety disorder following psychological therapy Psychological Medicine 1999; 29, 1425-1434

2. Dobson KS, Hollon SD, Dimidjian S, Schmaling KB, Kohlenberg RJ, Gallop RJ, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. J Consult Clin Psychol 2008;76:468–77

3. Dombrovski AY, Lenze EJ, Dew MA, Mulsant BH, Pollock BG, Houck PR, et al. Maintenance treatment for old-age depression preserves health-related quality of life: a randomized, controlled trial of paroxetine and interpersonal psychotherapy. J Am Geriatr Soc 2007;55:1325–32

4.  Bruce SE, Yonkers KA, Otto MW, Eisen JL, Weisberg RB, Pagano M, Shea MT and Keller MB (2005) Influence of psychiatric comorbidity on recovery and recurrence in generalised anxiety disorder, social phobia and panic disorder: A 12 year prospective study. Am J Psychiatry 162:1179-1187.

Dr Mike Scott

CBT, Cancer and IAPT

a just published study of CBT for depression in patients with cancer has shown no effect [ Serfaty et al (2019)]. Patients were given CBT by IAPT staff in addition to treatment as usual (TAU) and the results compared with TAU alone. Whether the outcome measure was the PHQ9 or Beck Depression inventory there was no difference in outcome, see link below:

https://www.dropbox.com/s/iitvhyk5eyqjmyi/CBT%20for%20depression%20in%20cancer%202019.pdf?dl=0

The results suggest more generally, that if IAPT’s performance was compared to TAU no difference would be found. The study also casts doubt on the wisdom of IAPT’s sojourn into treating long term physical conditions.

Problems With Engagement

The intervention comprised up to 12 individual sessions (either face to face or over the phone), but the mean number of sessions received was 4.7 and over a third (35.6%) did not take up any sessions. They were all patients expected to live for 4 or more months. Interestingly 60% of patients had a previous history of depression. Of 2224 cancer patients only 10% (230) were found suitable and consented to treatment.

Some Methodological Issues

  1. There was no blind assessment of outcome using the standardised diagnostic interview (MINI) that was used to assess whether a patient was initially clinically depressed.
  2. TAU is a poor comparator as it does not control for the attention and expectations generated by being offered a special treatment (CBT). The appropriate comparator should have been an active placebo
  3. Therapists were rated using the Cognitive Therapy Rating Scale Revised but there is no mention as to whether this predicted outcome.

But CBT Can Make A Real Difference In The Right Hands

At The Right Time

One of the authors of the above study Kathryn Mannix, A Palliative Care Physician, has written a stunning book, With The End In Mind

With the End in Mind: How to Live and Die Well

Her capacity to be with people is truly amazing, this clearly is not just a job, for example her use of CBT with a patient with breathlessness as he awaits a lung transplant (he has cystic fibrosis) is truly exemplary. But she is a very credible source of persuasion with a detailed knowledge of the difficulties of those in Hospice care. I would wholeheartedly recommend you read this book.

Dr Mike Scott

Clinical Commissioning Groups Need To Know What Actually Happens Behind IAPT’s Closed Doors

this can be achieved by asking local GPs to ask patients about their experience and crucially to determine what proportion of patients returned to normal functioning after referral to IAPT.

Most IAPT clients receive low intensity CBT, with only 20% recovering, half of whom relapse in a year [ Ali et al (2017)]. Only 10% of LICBT patients are stepped up to high intensity. Independent assessment suggests the overall recovery rate in IAPT is just 15%.[ Scott (2018)] https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

Results Show IAPT To Be No Better Than Pre-existing Services

A study from 2006 profiled the improvement rates of 32 primary care counselling services using the CORE Outcome Measure. (CORE-OM). The mean level of reliable improvement (including clients that also recovered)  was 72%. Across IAPT, the reliable improvement figure was 66%. But services can be re-organised to transform IAPT Scott (2018)

https://www.dropbox.com/s/zhr1fkg71aqvno0/Transforming%20IAPT.pdf?dl=0

The Failure To Inspect

CCG’s and the National Audit Office show a conspicuous lack of interest in what is happening behind the closed doors of IAPT, preferring to take the Organisations marketing at face value. IAPT appears not to be accountable to the Care Quality Commission. But the CQC’s failure to effectively monitor institutions catering for those with learning difficulties and autism has unearthed a scandal, and instils little confidence in a critical appraisal of IAPT anytime soon.

An Illustration Of The Travails of a Low Intensity IAPT Recipient

Ted’s case illustrates the dire quality of service, he met IAPT in 2014, the records stated that he had been a worrier all his life, but no diagnosis was made. He was no better after 18 months of low intensity cbt. A lost soul:

Initially Ted was directed to a Psychological Wellbeing Practitioner and computerised CBT, Beating the Blues. Ted is recorded as finding the sessions helpful. At the end of LICBT it is recorded that

‘he would prefer not to access cbt again as good understanding of how his negative thoughts impact his behaviour regularly reads his previous cbt notes but implementation does not improve mood’ his psychometric test results are shown below, ‘his billboard’:

    PHQ9GAD7  
Feb 14   10   14  
 March 14 8   7
  May 14 5   9
  July 16 21 15
  August 16 20   18
     
     

At the end of his low intensity journey, there was again no assessment of his diagnostic status and he was understandably not enthusiastic about further CBT. It seems likely that few people are stepped up from low intensity to high intensity because cbt is at best seen as having limited utility.

Ali et al (2017) How durable is the effect of low intensity CBT for depression and anxiety? Remission and relapse in a longitudinal cohort study Behaviour Research and Therapy 94 (2017) 1-8

Dr Mike Scott

Simply Too Complex CBT!

abandon ‘what treatment works for what’ and you end up with a free for all of imagined complexity.

What Works for Whom?: A Critical Review of Psychotherapy Research

With stressed clinicians lost in a fog, arguing interminably about possible landmarks (formulations) for treatment. Not surprisingly the issue of ‘complexity’ now figures highly on IAPT’s list of workshops. Paradoxically formal IAPT training eskews trainees working with ‘complex cases’. IAPT specifies the importance of following the NICE guidelines but without a reliable procedure for determining what cases they do and importantly do not apply to.

The IAPT Courtroom

An obvious defence for IAPT workers failing to consistently obtain the 50% recovery rate is to contend that they were dealing with complex cases.

In rebuttal the Organisation can contend that complex cases are: ‘namely primary or comorbid psychosis, personality disorder, autism spectrum disorder, substance dependence, severe and/or treatment-relevant physical health conditions, and severe psychosocial difficulties Liness et al (2019) see link’ https://link.springer.com/article/10.1007/s10608-018-9987-5 and that the clinicians case falls outside this definition. But in areas of high deprivation it is relatively easy to claim that a particular client falls within this definition of complexity e.g ongoing pain from an injury or associated with a condition such as MS, having to use a Foodbank.

Flexibility Within Fidelity As A Defence

Flexibility has to be constrained by fidelity, if it is not then arguments between clinicians and line managers/supervisors have no arbiter. The clinician will lose out simply because the line manager/ supervisor has more power, at its’ worst ‘my way or no way’.


If fidelity is safeguarded, then there are agreed issues/concerns that need to be addressed with a particular client. It also sets limits on the range of interventions (flexibility) that are permissible for those particular issues/ concerns. Without a twin focii on fidelity and flexibility the clinician is up a creek without a paddle. But a hostile work environment can nevertheless ignore or more commonly pay lip service to fidelity and flexibility – they need to be admitted to the IAPT courtroom for the sake of both clinicians and clients.

Clinicians and Constructive Dismissal

Nevertheless there is a vagueness about the debate of simplicity vs complexity, that could mean that an IAPT therapist is hounded from office, without the case being put to anything like a jury, with no procedures in place to ensure any transparency and accountability.

The Need To Rediscover A Biopsychosocial Model

But actually matters are nowhere as simple as this simple/complex distinction. Steve Stadling (1990) and I https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/group-cognitive-therapy-for-depression-produces-clinically-significant-reliable-change-in-communitybased-settings/ADFC2B6A2D2BBCCC37CD41820DFD5287

were involved in a randomised controlled trial of individual and group CBT for depression in Toxteth, Liverpool, and managed to make important lasting differences using Beck’s protocol for depression. But because we were using a biopsychosocial model I saw it as much a part of my work to say write a letter to a Housing Association for a client as conduct the CBT. Similarly many patients were prescribed antidepressants, again in keeping with a biopsychosocial model. This holistic approach to client’s problems appears to have been lost in IAPT’s fundamentalist translation of the randomised controlled trials. An alternative perspective is presented my trilogy of Simply Effective CBT books


Dr Mike Scott

IAPT Training – ‘jump through our hoops and make no difference to client outcome’

that’s the take home message from a study conducted by Liness et al (2019). IAPT trainees were evaluated using the Cognitive Therapy Rating Scale Revised (CTRSR) and client outcome assessed, mainly with the PHQ9 and GAD7, and no relationship was found, either at the end of training or 12 months later, see link below:

https://www.dropbox.com/s/e26n191ie09sngs/Competence%20and%20Outcome%20IAPT%20no%20relation%202019.pdf?dl=0

Instead of the author’s concluding that something is seriously amiss if there is no relationship between competence and outcome, the authors celebrate that they could keep the newly trained therapists scoring highly on the CTRS!

Curiouser and Curiouser


It is a truly bizarre paper, on the one hand the authors acknowledge that it is important to assess adherence, competence and outcome but proceed only to analyse the relationship between competence and outcome. Treatment fidelity involves a combination of adherence (highlighting the appropriate disorders/difficulties and matching treatment strategies) and competence (how skillfully treatment is delivered). Thus the assessment of a surgeon’s key hole skills (competence) would make no sense at all if he/she were not using them in an appropriate context , e.g this week it was reported that a 26 week old unborn child with spina bifida was operated on with key hole surgery in the womb to help ensure some mobility after birth. By contrast key hole surgery, no matter how competently delivered, for say a person with simply diabetes would make no sense at all, it would be a matter of infidelity.

Inept IAPT

IAPT’s procedures make it impossible to ensure adherence. In order to guarantee adherence an open ended interview needs to be conducted to let the client tell their story. This is then the springboard for a reliable diagnostic interview, designed to elicit the prescence of disorder/s. Such a two-fold procedure protects against the use of misleading rules of thumb e.g ‘nightmares of extreme trauma, must be PTSD’. There can be no appropriate matching of protocols to reliably identified disorders without taking the time to get a comprehensive client story [see Scott (2009) Simply Effective Cognitive Behaviour Therapy London: Routledge]. Taking shortcuts means that the individual receives a hotchpotch of generic CBT for which there is no evidence base.

Trying to determine competence within IAPT’s structures is a will o’ the wisp exercise.

The Mis-Selling of the CTRS

On October 2017 I wrote a blog on this topic. Liness et al (2019) maintain that the CTRS addresses the issue of adherence, but it does not, whilst there is an agenda item on the CTRS, keeping to the agenda does not at all mean that an appropriate agenda has been identified!

The authors note that the CTRS has become the ‘gold standard’ on courses, but their is a weak evidence base for it’s predictive power for depression (see earlier blog ), an even weaker power for anxiety disorders and none outside this range. I have suggested that what should be employed are fidelity measures that incorporate both adherence and competence. Scott (2015) Simply Effective Supervision, London: Routledge.

Re-focussing on Real World Outcomes With Routine Clinicians In Customary Contexts

It appears not to have occured to Liness et al (2019) that changes on the PHQ9 and GAD7 may not be actually measuring outcome. Rather they are most likely measuring a) improvements with the passage in time as people inevitably enter therapy at their worst point and b) a placebo response because the therapists in the study (42% of the IAPT therapists were clinical or counselling psychologists) created an expectation the alleged CBT would make a difference and they gave clients attention (an average of 11-12 session).

Clients were not assessed by someone independent of IAPT using a standardised diagnostic interview to determine whether they had got back to their usual self with treatment and the results were not contrasted with an attention placebo. It is thus impossible to actually determine whether the alleged CBT made a real world, socially significant difference. Nevertheless the IAPT luminaries in the study will doubtless use the ‘findings’ to promote their brand in the UK and beyond!

The study also lacks ecological validity: where else are there such a high proportion of qualified clinicians, where else are IAPT staff routinely providing 11-12 sessions, where else are there clients without severe psychosocial problems and staff given weekly group and 1.5 hr long individual supervision. Further the therapists in the study chose sessions to be rated on.

The Hi-jacking of Supervision

Within IAPT training supervisors are expected to attend courses run at Universities at which there supervisees are being trained. But there is no evidence that this form of supervision results in better client outcome. It is possible to operate with a wholly different model of supervision in which its’ major function is to act as a conduit for evidence based treatment.

The New Totalitarians

Disturbingly IAPT is like a totalitarian state determining, mental health job opportunities and the way in which assessment, treatment and supervision are conducted. Further it controls journals such as Behavioural and Cognitive Psychotherapy, Behaviour Research and Therapy and even it seems Cognitive Therapy and Research in which the Liness et al (2019) paper appeared (this was the journal to first publish Beck’s seminal study on the efficacy of CBT for depression). It is extremely difficult to get an airing if one sees IAPT in practice as deeply flawed

Dr Mike Scott