Psychological Wellbeing Practitioners (PWPs) deliver the smallest dose of psychological interventions (low intensity CBT), less than 6 hours of contact per client (Shafran 2021). Making it cheaper than high intensity CBT. But there is little evidence that the PWPs ministrations make a difference the client would recognise. There are no randomised controlled trials of high or moderate quality (Cochrane Grade) that attest to low intensity CBTs efficacy. The PWPs are not psychological therapists, as such, most IAPT clients do not receive psychological therapy. The name IAPT, Improving Access to Psychological Therapies is therefore an example of doublethink. Here we have a classic example of false economy.
Low intensity CBT is intended to be the first step for those suffering from depression and the anxiety disorders, with PTSD and OCD clients going straight to high intensity interventions. Most clients first encounter low intensity CBT, should they not respond they are placed on a waiting list for high intensity CBT. In practice comparatively few, about 10%, are stepped up, but with wide regional variations.It is not so much stepped care as stopped care.
Implementation of the ‘stepped care’ model costs the taxpayer of over a £1bn a year. But there has been no independent evaluation of the package or its components. IAPT is the first ANGO (an autonomous non- governmental agency) funded by the government, as opposed to the intended and understood QUANGO – a quasi autonomous non-governmental agency. Perhaps the National Audit Office and MPs might care to explain why there has been this failure of governance?
as the magician Tommy Cooper would have said. The Improving Access to Psychological Therapies Service (IAPT) invites its’ paymasters Clinical Commissioning Groups (CCGs)/NHS England to fund a simple and cheap solution to mental health problems. If it sounds too good to be true, it probably is. But this hasn’t stopped IAPT becoming the over a £1bn a year magnet for investment and all without independent assessment.
Here is an extract from a Psychological Wellbeing Practitioner’s (PWP) letter to a GP:
Stress Control Course undertaken outcome was successful evidenced by the first and last questionnaire
The PWP is unaware that a score on a psychometric test is not an evidence-based construct. Such scores are not specific to anything. They cannot be used as a surrogate for a diagnosis. ‘Stress’ is a fuzzy, the terms usage in this context, resembles Alice in Wonderland where words mean whatever you want them to mean. Further, a change in the score is not evidence that the person’s needs have been met.
The mechanism’s of action in the original randomised controlled trials of CBT for depression and the anxiety disorders were clearly stipulated. As were outcomes e.g loss of diagnostic status as assessed by independent clinicians. But in the low intensity interventions there is no specification of an evidence-based mechanism for change. In effect we are invited to believe in the magic, it works just like described in the letter abstract. One can only gasp at the incredulity of CCGs and wonder what agenda they are working on. But the British Association for Behavioural and Cognitive Psychotherapy (BABCP), the ‘Lead’ organisation for CBT practitioners has a special section for PWPs and IAPT rejoices that its’ low intensity CBT courses are validated by the British Psychological Society. They have failed clients abysmally.
abound.These beliefs are inculcated by initial training and maintained by sharing ‘best practices’. For example, low intensity CBT therapists operate, on beliefs such as ‘if I go into the CBT superstore and choose a strategy it will be potent’, ‘my clinical judgement is sufficient to make the right choices’, and ‘improvements in test scores are sufficient basis for believing the clients needs have been met ‘. But these beliefs are not evidence-based.
For the past 50 years it has been taken as axiomatic that ‘arrested information processing plays a pivotal role in debility post-trauma and should be targetted’. In Personalising Trauma Treatment: Reframing and Reimagining Routledge’ (2022)https://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwj2r8v8m_j2AhWxQEEAHQrjAGgQFnoECAUQAQ&url=https%3A%2F%2Fwww.taylorfrancis.com%2Fbooks%2Fmono%2F10.4324%2F9781003178132%2F I examined this issue in detail, dissented and concluded that it is the centrality accorded to the trauma that is the driving force for debility post trauma. To the extent that clients utilise the trauma as their window on themselves and their world they are likely to suffer impairment in functioning, both personally and interpersonally. It is a magical belief that the problem lies with the traumatic memory, rather the issue is what the person takes the memory to mean for today (see youtube video https://youtu.be/3UeJ1Lux4pU) detailing how to help the client back to their old selves post trauma – Restorative CBT (RCBT).
‘All disorders are maintained by a negative belief system, making CBT appropriate’, this belief underpins the extension of CBT to the treatment of long-term conditions. But it would not stand up in Court. It would be suggested that the idea is promulgated to satisfy the acquisition of power by service providers.A relatively newly emergent, magical belief is that ‘if children are taught the elements of CBT model/adaptive coping it prevents the development disorder’ this may or may not be true but dogmatism here has no place.
In the Middle AgesIn it was believed that the earth was the centre of the universe and planets such the sun and moon orbited it in circles. This geocentric view of the universe persisted for a long time after it became evident that the earth was not at the centre and that orbits were elliptical rather than circular. Unfortunately the power of the current Teflonocracy will likely lead to the persistence of these magical beliefs for some time to come.
Homework is the missing hallmark of CBT In routine practice. Inspection of Improving Access to Psychological Therapies (IAPT) records provides scant evidence of agreed homework assignments. Rarely do they specify the behaviours that the client is to engage in, the coping strategy to be employed and the monitoring strategies. But given that client’s commonly have impaired concentration written specification is a must and helps to ensure compliance with homework [Cox 1988 Cox, D. J., Tisdelle, D. A., & Culbert, J. P. Increasing adherence to behavioral homework assignments. Journal of behavioral medicine, 11(5), 519–522. https://doi.org/10.1007/BF00844844].
Beck [Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press] suggested that homework should be a) clear and specific b) include a cogent rationale c) client reactions should be elicited to troubleshoot difficulties and d) progress should be summarised when reviewing homework. Homework provides a link between sessions. Meeting criteria a) to d) in a low intensity intervention is a tall ask and in the absence of written evidence to the contrary, it must be assumed that this active ingredient in CBT treatment is missing [Kazantzis, N., Whittington, C. J., & Dattilio, F. M. (2010). Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17, 144–156]. Whilst it is likely the case that the skilful assignment of homework will relate to outcome Kazantis (2021) [ Introduction to the Special Issue on Homework in Cognitive Behavioral Therapy: New Clinical Psychological Science. Cogn Ther Res45, 205–208 (2021). https://doi.org/10.1007/s10608-021-10213-9], such considerations are of little consequence if routine therapy is constructed in such a way that homework has difficulty thriving.
It is interesting to ponder that if a Civil Court Case was mounted on the basis that a supposed CBT treatment had not in fact happened, leaving ongoing debility, would a claim for compensation succeed? As an Expert Witness I would ask to see the treatment records and in over 25 years in this capacity I can think of few cases were I could be sure, on the balance of probability, that the said treatment had been delivered. Part of this evidence would be no evidence of homework assignment. IAPT has tried to keep out of the legal domain by asserting that its’ therapists do not make diagnosis. But a Judge might ask where is the accountability in this matter. A Nurse may be called to task for not following an evidence based medical procedure even though overall responsibility may rest with a Consultant. There can be no certainty that IAPT would not find itself in the dock. Its’ defence would likely be that its’ practitioners were only doing, say what most BABCP members do, but this would be skating on thin ice.
How seriously should we take claims for the efficacy of an intervention? The ‘Risk of bias” assessment tool developed by the Cochrane Collaboration (2011), see slide, helps distinguish clever marketing from the genuine article. All LiCBT intervention studies fail the Tools requirement for the blinding of outcome assessment, suggesting a high risk of bias.
In LiCBT studies, there are no independent assessments to determine whether those treated were no longer suffering from the primary disorder for which they first presented. LiCBT interventions is the most common treatment modality in the Improving Access to Psychological Therapies (IAPT) service.
But the LiCBT studies are not only subject to this detection bias, but in many instances they are also subject to allegiance bias, with the main author of the study evaluating their own manualised intervention e.g Williams et al (2018) evaluation of the Living Life To The Full Classes doi: 10.1192/bjp.2017.18
But the purveyors of LiCBT interventions do not have a monopoly on proclaiming effectiveness were non exists. A just published study by Kip et al (2020) DOI: 10.1002/cpp.2446 in Clinical Psychology and Psychotherapy claims that ‘psychological interventions can effectively reduce symptoms of both PTSD and depression in adult refugees’. But of the 14 studies on adult refugees only in 4 studies was outcome assessed by a ‘gold standard’ semi structured interview (the CAPS). The method of determining the diagnostic status of the refugees at entry to the study is unclear, but of the 9 questions asked to determine the quality of the included studies the lowest score was for whether the diagnosis was determined by using a semi structured interview. The next lowest score was for the item referring to fidelity checks i.e did the clients actually receive the treatment that it was purported they receive. Five out of six studies on Narrative Exposure Therapy involved at least one author of the published manual on NET. In total half of the trials researchers were involved in utilising manuals whose development they were involved in. There is clearly a pressing need for independent replication of these findings on refugees. There is also a need to higher the methodological bar, as it is impossible to say from this review what proportion of refugees were no longer suffering from PTSD at the end of treatment, nor how long that improvement persisted.
Like IAPT the understandable wish to further dissemination takes precedence over a determination about whether treatment makes a real world difference to clients lives.
of those who undergo an initial assessment with the Improving Access to Psychological Therapies (IAPT) Service 40% do not go on to have treatment, and about the same proportion (42%) attend only one treatment session, according to a just published study by Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133. These findings echo a study published last year by Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z, on a smaller sample, which suggested that 29% were non-starters and that the same proportion attended only one treatment session. Further scrutiny of the data reveals that about 3 out of 4 people drop out of treatment once begun. Unsurprisingly the authors’s independent study, of 90 IAPT clients, Scott (2018) revealed that only the tip of the iceberg (9.2%) recovered DOI: 10.1177/1359105318755264, raising serious questions about why the Government has spent over £4 billion on the service.
What Has Gone Wrong?
Kline et al (2020) consider that at an assessment by a clinician is supposed to: a) provide a credible rationale for the proposed treatment b) detail the efficacy of the envisaged treatment and c) ensure that the clients preferences are acknowledged. IAPT’ assessments fail on all counts, taking these in turn:
a. If the problem is ill-defined e.g low mood/stress it is not clear what rationale should be presented. It is doubtful that a 30-45 minute telephone conversation can provide sufficient space to define the primary problem and other problems/disorders that may complicate treatment. Initial assessments of patients for randomised controlled trials of psychological interventions are typically 90 mins plus, if this is the time deemed necessary to reliably diagnose a patient by a highly trained clinician, how can a much less trained PWP do it in less than half the time? Under time pressure a PWP may consider providing a credible rationale is part of treatment not assessment and in such circumstances it becomes more likely that a client will default.
b. How often do PWPs present clients with evidence on the efficacy of an intervention? Take for example, computer assisted CBT, does the therapist tell the client that only 7 out of 48 of NHS recommended e-therapies have been subjected to randomised controlled trials, ( see Simmonds-buckley et al J Med Internet Res 2020;22(10):e17049) doi: 10.2196/170490 and even in these a gold standard semi-structured diagnostic interview conducted by a blind assessor was not use to determine diagnostic status post treatment, i.e there was no determination of the proportion of clients who were back to their old self after treatment and for how long. Further the e-therapies had average dropout rates of 31%. They are not evidence based treatments in the way the NICE recommended high intensity treatments are. But approximately three quarters Of IAPT interventions (73%) are low intensity first, with 4% stepped up to high intensity and 20% in total receiving a high intensity intervention Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133
c. Client’s preferences are a predictor of engagement in treatment, but how often is a client given a choice between a low intensity intervention and a high intensity intervention. If both options are juxtaposed choice is likely skewed by informing the client that the high intensity intervention has a much longer waiting time.
Defining A Dropout
The generally accepted definition of a dropout is attending less than 7 sessions [see Kline et al (2020) https://doi.org/10.1016/j.brat.2020.103750], it is held that clients attending below this number will have had a sub-therapeutic dose of treatment and are therefore unlikely to respond]. Applying this metric to IAPT’s dataset is difficult as they only report data for those who complete 2 or more sessions and for which the average number of sessions attended is 6, thus the likely dropout rate from IAPT treatment, as most would understand the term, is about 75%. But IAPT has developed its’ own definition of a completer as one who attends 2 or more sessions. This strange definition serves only to muddy the waters on its haemorrhaging of clients. It makes no sense to continue to fund IAPT without an independent government inquiry into its’ modus operandi.
An Alternative Way Forward
Such has been the marketing power of IAPT over the last decade, that professional organisations such as the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Psychological Society (BPS) have sat mesmerised, as the Services fellow travellers have dominated accreditation and training. In ‘Simply Effective Cognitive Behaviour Therapy’ published in (2009) by Routledge, I detailed a very different way of delivering services, that represents a faithful translation of the CBT treatments delivered in the randomised controlled trials (rcts) for depression and the anxiety disorders. Unfortunately it is IAPT’s fundamentalist translation of the rcts that has held sway and has brooked no debate either in journals or at Conferences.
IAPT’s low intensity CBT should be re-branded ‘below intensity CBT’, as all the methodologically rigorous CBT outcome studies were conducted on full dose CBT. Guided self-help (GSH) interventions were first recommended by a NICE committee in 2007 and 2009 for depression and the anxiety disorders. In its’ wake IAPT enthusiastically adopted GSH such that by 2018, 70% of clients were being given it. But recently therapists have been told not to use the term ‘GSH’ but talk to clients instead of ‘low intensity CBT’. This re-labelling appears to have occurred because of the difficulties of engaging the public in this more obviously cheap option (see previous post).
But NICE did not conduct a systematic review of the outcome literature, rather its’ recommendations were simply the advice of its’ committee. It failed to acknowledge that there were no studies of ‘guided self-help (GSH)’ with a hard outcome measure i.e studies involving an independent blind assessor using a standardised diagnostic interview. Thus there was no evidence that the man/woman in the street would recognise that the GSH had returned them to normal functioning. However the recommendation of NICE was that the low intensity interventions had to be matched to the particular depression or anxiety disorder. But IAPT took what it wanted from the NICE guidance, jettisoned making a diagnosis and proclaimed that appropriate treatment could follow a problem descriptor, without any empirical evidence for the latter. The upshot is that for a decade IAPT clients have largely been subjected to ‘below intensity cbt’.
There has been a decade of ‘the below intensity CBT’ revolution and it has failed. This is not to say that there may not be cheaper effective options for service delivery such as group CBT, but the scope for such interventions is limited to depression and some anxiety disorders and much more methodologically rigorous outcome studies are necessary to confirm its place.
applying the acid tests of the Cochrane Collaboration Tool and the GRADE Handbook for the quality of randomised controlled trials, studies of low intensity CBT fail to clear the methodological bar. Whilst only high intensity studies for depression and the anxiety disorders make a successful jump. This calls into question IAPT’s penchant for disseminating CBT for everything, with an imprimatur from BABCP, paying travel expenses of upto £100 for special interest group members to attend a pre-conference workshop Revolution in Mental Health Service Delivery: The Evolution of Low Intensity CBT on Tuesday 3rd September.
One of the seven domains highlighted by the Cochrane Collaboration tool for assessing bias is the blinding of outcome assessment. I have been unable to locate one outcome study of low intensity CBT that fulfills this criteria whilst there are a significant minority of studies of high intensity interventions for depression and the anxiety disorders that do.
The GRADE handbook for assessing the quality of trials comments in section 3.4 ‘not infrequently, outcomes most important to patients remain unexplored’, with regards to psychological interventions clients are rarely asked by someone independent of the study whether and if for how long they are back to their usual selves since treatment. Instead most commonly reliance is placed on a surrogate measure a client completed questionnaire, as opposed to an independent clinicians assessment using a standardised diagnostic interview to determine whether there has been a loss diagnostic status.
These concerns are crystallised in a study of CBT for Health Anxiety conducted by Cooper et al (2017), Behavioural and Cognitive Psychotherapy, 2017, 45, 110–123 doi:10.1017/S1352465816000527
whilst 10 of the 13 studies in a meta analysis used the DSM or ICD-10 to determine whether people should be admitted to the meta analysis, in no study was meeting these criteria used as an outcome measure. To be no longer suffering from the identified health anxiety at end of treatment/follow up would have been a client important outcome. Instead the self-report Health Anxiety Questionnaire was used as surrogate. Cooper et al (2017) attempted to rate studies using the Cochrane Collaboration tool using a summary score for the seven domains, but this bore no relation to outcome and as the authors admitted was a questionable procedure. Despite this CBT was claimed to be an effective treatment for health anxiety.
I am afraid I can’t join in the jamboree for IAPT services that takes place at the BABCP annual conference. I doubt that the ‘House of Cards’ will be discussed and it would likely be seen as banned literature on IAPT training courses.
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)
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’:
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
‘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’.