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

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

Guided Self-Help In IAPT Breaches Informed Consent

‘That self-help is not a regular treatment should be clear from the beginning…A self-help intervention cannot replace more usual forms of psychological treatment and this should be made clear from the beginning’ so writes Pim Cuijpers in the most recent issue of Clinical Psychology Science and Practice

https://www.dropbox.com/s/4d9z23p1xttv7nl/Cuijpers-2018-Clinical_Psychology%253A_Science_and_Practice%20ethics%20guided%20self-help.pdf?dl=0 ,

but it never is in IAPT.

 

Cuijpers points out that guided self-help (GSH) for depression has a small effect size around 0.28 and this is substantially less than the O.6 or higher of traditional psychological treatments https://www.dropbox.com/s/3zgy50ub5s5q1yx/Lewinsohn%27s%20Coping%20with%20Dep%20Meta-Analyses.pdf?dl=0.

Further the impact of GSH may be even less when compared to active control conditions as opposed to the common comparisons that have been made with inert waiting lists. In addition a diagnostic interview has been used in only at most half of the GSH studies.

It is unethical not to let clients know that what they will most likely receive initially in IAPT is a substandard treatment. The risks and benefits of any procedure need to be clearly spelt out for informed consent. Service users are entitled to provider track record information. There would appear to be grounds for complaint from former IAPT clients, whether to NHS England or perhaps via a lawyer. The NHS guidance on consent to treatment states ‘the person must be given all the information in terms of what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment doesn’t go ahead’.

Dr Mike Scott