Psychological Therapy With Long Term Conditions

Improving Access to Psychological Therapies (IAPT) therapists working with long term conditions (LTC’s) have confidence and organisational, issues Carroll et al (2021) DOI: 10.1111/bjhp.12475. Whilst therapists working in secondary care, with LTC’s, face fewer obstacles to multidisciplinary working, with a focus primarily on the LTC and not on the associated depression/anxiety as in IAPT. Further the metrics for outcome in secondary care are likely to be much broader than in IAPT. LTCs by their very nature, wax and wane with a consequent impact on availability and concentration, creating a need for any therapy to be long term. But IAPT has a major focus on access and waiting times, such that any treatment is usually brief, comprising on average of 6 sessions, thus the service cannot readily accommodate working with LTCs.

The focus in the Carroll et al (2021) is on how the psychological treatment for those with LTC”s can be best integrated into primary and secondary care. They note however that the model they use to identify barriers and facilitating factors to implementation, first requires, evidence that the chosen intervention/s are effective. But they do not address this point. This is crucial, where is the evidence that the psychological therapies for disorders that are comorbid with LTCS make a real world difference?

A case has long been made that it is a matter of basic humanity to offer to accompany a person with an LTC if they so wish. A host of Charities have formalised this. The support may be social, e.g befriending, groups and/or instrumental e.g help with DWP application. The case for profferring ‘support’ is I think uncontestable. But many with LTC’s are wary of being defined by their condition. A dedicated support group may serve as a further reminder of their condition. They may decline involvement in such a group, but this is not necessarily a matter of avoidance, simply that they do not wish to define themselves or their world through the lens of their LTC. If psychological difficulties are grafted on to their LTC they may be even more likely to decline involvement with psychological therapists because it is an LTC type lens (a variant) through which they are being encouraged to view themselves and their personal world with perceived deleterious consequences. Arguably the LTC lens used in secondary care is likely to be less problematic than that used in IAPT. But the issue of centrality has not been systematically addressed with regards to LTCs. In the authors forthcoming work ‘Personalising Trauma Treatment: Reframing and Reimagining’ to be published by Routledge the issue of centrality [ Bernsten and Rubin (2006) (2007)] is addressed in detail with regards to trauma.

There is a distinction between long term physical health conditions and medically unexplained symptoms (MUS), the former are open to objective identification e.g diabetes, the latter are not. In considering the former the therapist feels that they are on solid ground, albeit that it is largely the domain of the medic, with whom there may be fruitful dialogue. But when it comes to MUS the therapist is in a fog, where are the signposts? There is no reference book for translating best practice with LTCs to clients with MUS. Because of this there is likely to be recourse to a powerful body insisting that the way forward is ‘x’ but without any evidence, a recipe for disaster. IAPT”s juxtaposition of LTCs and MUS, smacks more of pragmatism to secure maximum funding, rather than seriously addressing a clinical problem. Where is the therapeutic alliance in addressing MUS symptoms? What is the goal, What are the agreed tasks? Whither the bond, when the therapist covertly believes that the client is somatising and the client believes there physical symptoms are as real as toothache?

Carroll, S., Moss-Morris, R., Hulme, K., & Hudson, J. (2021). Therapists’ perceptions of barriers and facilitators to uptake and engagement with therapy in long-term conditions. British journal of health psychology26(2), 307–324. https://doi.org/10.1111/bjhp.12475

Berntsen, D., & Rubin, D. C. (2006). Centrality of Event Scale: A measure of integrating a trauma into one’s identity and its relation to post-traumatic stress disorder symptoms. Behaviour Research and Therapy, 44, 219–231. https://doi.org/10.1016/j. brat.2005.01.009

Berntsen, D., & Rubin, D. C. (2007). When a trauma becomes a key to identity: Enhanced integration of trauma memories predicts posttraumatic stress disorder symptoms. Applied Cognitive Psychology, 21, 417–431. https://doi.org/10.1002/acp.1290

Dr Mike Scott

Expansion Into Long Term Conditions By IAPT Is Quackery

so challenge Clinical Commissioning Groups on the value for money – no better than homeopathy. Studies of CBT  for long term conditions (LTCs) show either no effect, see Serfaty et al study (2019) on cancer https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/effectiveness-of-cognitivebehavioural-therapy-for-depression-in-advanced-cancer-cantalk-randomised-controlled-trial/E9264C516634EC7BC3FF9E80B551A8C5

and/or rely on a self report measure of questionable real world significance, see the Everitt et al  (2019) study of irritable bowel syndrome https://www.thelancet.com/journals/langas/article/PIIS2468-1253(19)30243-2/fulltext In the Everitt et al (2019) study outcome was assessed primarily by the patient’s completion of a 5 item measure of the severity of IBS (IBS-SSS) rather than a clinician independent of the study asking the IBS-Adequate Relief  question ‘ since… have you had adequate relief of your IBS’. Usually the IBS-AR uses the time frame of the past seven days but in the context of assessing CBT it could be since entering the study for a control group or since cbt for those having cbt.  The correlation between the IBS-AR and IBS-SSS though significant is small see Passos et al (2009) http://nrs.harvard.edu/urn-3:HUL.InstRepos:35859644

The authors of the Everitt et al (2019) study appear not to realise  that use of a self-report measure as the primary outcome measure introduces a demand effect for clients undergoing cbt, they don’t want to feel that they have wasted their time. Further the Passos et al (2009) study showed that the IBS-AR is much less subject to fluctuation than the IBS-SSS. Arguably the IBS-AR is of much greater social significance, addressing whether an intervention makes a real world difference. 

It is worrying that Everitt et al (2019) opine:

‘Offering both web-CBT and telephone-CBT in NHS services such as Improving Access to Psychological Therapy could allow many patients to gain substantial benefits with web-CBT with minimal therapist input while allowing a step-up approach to telephone-CBT for those needing additional
support’

IAPT will surely jump on this to justify empire building and likely ignore the caution of Serfaty et al (2019) 

‘our results suggest that resources for a relatively costly therapy such as IAPT-delivered CBT should not be considered as a first-line treatment for depression in advanced cancer. Indeed, these  findings raise important questions about the need to further evaluate the use of IAPT for people with comorbid severe illness’

If as seems likely Clinical Commisioning Groups fund IAPT’s expansion into LTCs they should be asked to justify this expenditure in the abscence of any empirical base.  

Dr Mike Scott

‘What, If Anything, Is Beyond The Glitz Of IAPT?’ Asks Journal Editor

‘IAPT Talking Therapies All Glitz and No Substance?’  is the title of a Press Release from the Editor of the Journal of Health Psychology, Dr David Marks, The Press release reads:

 

 

‘The Journal of Health Psychology is calling for an urgent independent review of patient recovery rates
with the NHS ‘Improving Access to Psychological Therapies’ (IAPT) talking therapies programme.

A recent study by Dr. Michael Scott revealed that only one in ten mental health patients actually
recovered (http://journals.sagepub.com/doi/full/10.1177/1359105318755264).

Now JHP editor, Dr David F Marks, is calling for IAPT recovery rates to be closely scrutinized. He
wants solid evidence that patients who have recovered stay well over the long term.

Michael Scott’s study found that overall just 9.2% of patients recovered with IAPT therapies. There is
an enormous gap of 40% between these findings and IAPT’s claimed recovery figure.
The study’s recovery rates were: Post-Traumatic Stress Disorder – 16.2%, depression – 14.9%, other
mental disorders including anxiety – 2.2%.

Dr Scott, Consultant Psychologist and Expert Witness to the Courts, suggested “a pressing need to reexamine…the service”. IAPT’s economic model hinges on good recovery rates and high recruitment.
The contributors to this Special Issue of the journal, “IAPT Under the Microscope”, have all expressed
doubts about the veracity of IAPT’s recovery claims. They agree that there’s a need for an independent
assessment of the type that a drug treatment would require before being approved for use.
The theory is that better mental health will lead to fewer physical health problems so that patients will
need less care. High recovery rates should then yield the promised hefty ‘efficiency’ savings to the
physical healthcare budget that will pay for the IAPT service.

The IAPT spotlight is on patients with ‘medically unexplained symptoms’ (MUS) and ‘long-term
conditions’ (LTCs) such as diabetes and COPD. This expansion into areas beyond its already
questionable expertise is likely to be clinically risky. Experts and patients are worried about the motives behind this and concerned that a mental health diagnosis will allow providers to restrict access to healthcare and other benefits. Can these therapies really reduce patients’ physical problems and their need for care, or is this an NHS version of a ‘hostile environment’?

The programme continues to grow as more local therapy services are rolled out across England. IAPT
aims to enrol over a million patients per year but the system is already creaking under the strain.
In his Editorial, Dr Marks proposes an open debate about England’s flagship IAPT project that has so
far cost the taxpayer around £1 billion. He calls for an independent, expert review to determine if IAPT
is likely to reap the promised rewards or asks if is it all glitz and no substance?

Notes to editors

Marks, D.F. (Ed.) (2018). “IAPT Under the Microscope” published online and in print on 26 July 2018.
http://journals.sagepub.com/home/hpq [see copy attached to email]

Scott, M.J. (2018). Improving Access to Psychological Therapies (IAPT) – The Need for Radical
Reform. Journal of Health Psychology, http://journals.sagepub.com/doi/full/10.1177/1359105318755264

Contact

Dr Michael J Scott, author of the IAPT study, is available at: 07580 644 038
michaeljscott1@virginmedia.com

Dr David F Marks, Editor of the Journal of Health Psychology, is available at: 07930 753 206 ;
editorjhp@gmail.com

 

Dr Mike Scott