The Improving Access to Psychological Therapies (IAPT) gatekeepers, Psychological Well-being Practitioners (PWPs) appear not to learn from their experience Cairn et al (2014). A product of unfettered discretion.
In a study of 50 re-referrals Cairns et al (2014), failing to engage or dropping out from treatment accounted for a large proportion of referrals: two referrals, 75%; three referrals, 60%; four referrals, 58%; and five referrals, 50%.
A Failure of Supervision
This debacle is not surprising as Painter (2018) found PWPs had an average of 2.5 minutes to discuss a case with their Case Manager. PWPs are not supervised in any meaningful sense of the word, there is precious little opportunity for reflection or emotional support. Supervision is a necessary part of any organisations monitoring of the quality of output. But the only ‘supervision’ PWPs receive is admonishment if IAPT’s 50% recovery rate is not achieved and for which they are the judge and jury.
Disagreement Between Therapists Is Rampant
IAPT fails to grasp that there is no evidence amongst PWPs of agreement on which are the important difficulties, which ones should be tackled first and with which protocol. By its’ own admission IAPT staff do not diagnose. As such they fail the entry requirement for accessing NICE protocols. They are like burglars caught holding the loot protesting that they are NICE compliant. Rather IAPT staff operate with unfettered discretion.
Kahneman et al 2021 in their book ‘Noise’ have shown how, unfettered discretion wreaks havoc from judicial sentencing to psychiatry. The ‘Noise’ from IAPT is positively deafening, with clients ushered in every conceivable direction. The IAPT orchestra plays as the Titanic sinks.
How PWPs Become Disorientated
Cairns et al (2014) put the workings of PWPs under the microscope and found that in their sample of 50 re-referrals, the taxonomy of problems, was represented by Table 1. But they had no signpost to indicate which problem should be the focus or of which order to tackle the problems or which NICE protocol to follow. IAPT’s ‘Problem Descriptors’ are in Kahneman et al 2021 terms a heuristic (rule of thumb) to bypass the effortful demands of a standardised reliable diagnostic interview, resulting in chaos.
| Two referrals 31 patients | Three referrals11 patients | Four referrals 6 patients | Five referrals2 patients | |
|---|---|---|---|---|
| Alcohol | 4 | 2 | 1 | 2 |
| Anger | 4 | 2 | 1 | 2 |
| Anxiety | 18 | 8 | 6 | 2 |
| Bereavement | 7 | 2 | 0 | 0 |
| Body image | 1 | 1 | 1 | 0 |
| Debt | 2 | 0 | 0 | 0 |
| Depression | 24 | 10 | 6 | 2 |
| Drugs current | 2 | 1 | 1 | 0 |
| Drugs history | 4 | 0 | 0 | 0 |
| Domestic violence | 0 | 0 | 2 | 0 |
| Eating disorder – bulimia | 0 | 3 | 1 | 0 |
| Mental disorder | 1 | 2 | 1 | 2 |
| Obsessive-compulsive disorder | 3 | 1 | 2 | 0 |
| Physical abuse | 6 | 0 | 0 | 1 |
| Panic attacks | 0 | 1 | 0 | 0 |
| Post-natal depression | 0 | 1 | 0 | 0 |
| Relationships | 9 | 3 | 5 | 0 |
| Sexual abuse | 3 | 4 | 1 | 0 |
| Self harm | 2 | 3 | 0 | 0 |
| Social isolation | 1 | 1 | 0 | 0 |
| Stress | 2 | 0 | 1 | 0 |
| Unemployment | 2 | 0 | 1 | 0 |
| Violence | 0 | 1 | 0 | 1 |
| Work issues | 4 | 0 | 0 | 1 |
The problem is that one PWPs anxiety case could be a colleagues depression case, like in Alice in Wonderland the terms mean whatever the PWP wants them to mean. Further the list is arbitrary, no mention of PTSD, specific phobias or social anxiety disorder. IAPT has I think the record on ‘Noise’, with no published kappa’s – a measure of interrater reliability.
Dr Mike Scott