The Near Extinction of CBT

Evidence-based psychological therapies are near extinction. Their demise began in 2008 with the inception of the Improving Access to Psychological Therapies (IAPT) service. Aided and abetted by the British Psychological Society’s validation of IAPT’s Psychological Well-being Practitioner’s (PWPs) training programmes and the service’s fellow traveller, the British Association for Behavioural and Cognitive Psychotherapy (BABCP). Gone is the welcoming open door and the careful distillation of what ails the client, instead there is a 30 minute+ telephone conversation, with a third of people then not going beyond one treatment appointment.

 

The public most commonly receive PWP ministrations when they seek NHS psychological help. But the PWP’s do not follow any treatment protocol for any disorder, indeed they do not make diagnoses. How then can they be said to deliver CBT? By the spurious claim  that they can select a CBT strategy which is sufficiently potent. But they furnish no evidence of systematically following any strategy, notwithstanding that there is no evidence that CBT strategies delivered as stand alone interventions make any real world difference. The PWP’s deliver the Alice in Wonderland, Dodo verdict on CBT strategies ‘all are equal and must have prizes’. Raising the question ‘is CBT as dead as the Dodo?’

 

 

Where else might CBT be found? It is not impossible for it to be delivered in IAPT’s high intensity service, but few of its practitioners conduct a reliable standardised diagnostic interview which is the foundation for delivering CBT.  The  treatment integrity of high intensity CBT interventions has never been assessed.  No steps have ever been taken to ensure clinicians are dovetailing diagnosis appropriate treatment targets with matching treatment strategies. Is CBT to be found in private practice? It is possible, but private organisations have largely sought to ape IAPT in the mistaken belief that this confers credibility. Are the chances of finding CBT in private practice comparable to finding life on Mars?

Is CBT alive and kicking in secondary care? Here we enter the muddy waters of clients who might traditionally be regarded as having personality disorders (PD). But there is an understandable reluctance to use the term PD because of the associated stigma and because historically use of such a term has consigned people to the dustbin. Nevertheless Sperry and Sperry (2016) have produced the 3rd Edition of CBT for DSM-5 Personality Disorders (Routledge) but it is eminence-based rather than evidence-based. It is light on outcome studies. I struggled to find any where there was independent assessment of outcome by blind raters, use of an outcome measure that clients would regard as a minimally important difference and evaluations by those other than the creators of the protocols. It is a free for all with strategies such as ‘thought stopping’ recommended, without specification of any contraindications such as PTSD or OCD. Only eclipsed by recommending solution focussed therapy for anxiety. If clinicians in secondary care operate on this text it is very different to Beck’s own work on CBT for personality disorders. But no typology of what clinicians say they do and what they actually do in secondary care has been produced. Tertiary care seems preoccupied with crisis management and is not guided by any recognisable CBT protocol.

In neither primary or secondary care is there a differentiation of treatments or clients. Thus in the UK it is impossible to answer the question of ‘What Works With Whom?’. This leaves clinicians up a creek without a paddle.

Dinosaurs may have been wiped out by an asteroid hitting the earth 66 million years ago, but life survived, doubtless CBT will survive the impact of IAPT, but it is a close call and it is likely going to be down to individual practitioners doing what they know to be best for their clients.

 

Dr Mike Scott

‘We Are Not Going To Give You The Tools To Do The Job’ – IAPT Becomes INEPT

this summarises the blog https://notaguru.blog/2020/02/16/resilience-its-time-to-change-the-conversation/  from Low intensity Therapist,  James Spiers.

Yesterday I gave a one day workshop on ‘Getting Back to Me Post Trauma’, arranged by the Chester, Wirral and North Wales Branch of BABCP at Chester Rugby Club with over 65 attendees. It went down very well,  what was very striking was the level of demoralisation of IAPT staff, complaints of the numbers of contacts to be made, being hauled over the coals about recovery rates, the meaninglessness of the questionnaires completed and the powerlessness of staff to get their employer to listen. Will do a blog on the Workshop shortly.

 

Dr Mike Scott

Bias in CBT Journals

When the organs of communication are controlled by a single ideology we are on a short road to hell. Recently I protested to the Editor of Behavior Research and Therapy (BRAT), that no conflict of interest had been declared in a paper authored by Ali et al published in this month’s issue of the Journal, focusing on IAPT data on relapse after low intensity interventions. I pointed out that the lead author headed the Northern IAPT research network, not only did the editor ignore the conflict of interest but so to did the two reviewers, of a rejoinder to the paper that I wrote. But it is not just BRAT, IAPT sponsored papers regularly appear in Behavioural and Cognitive Psychotherapy without declarations of conflicts of interest.  I have protested to the editor about this, but again to no avail. Unfortunately it is not just a matter of what Editors of CBT Journals allow through the ‘Nothing to Declare’ aisle but also their blocking of objections to the current zeitgeist that is a cause for concern. More about this anon.

Dr Mike Scott

CBT on the Cheap – IAPT’s Failed Experiment With Low Intensity CBT

If you are anxious or depressed and wish to seek psychological help on the NHS you are most likely to be offered low intensity CBT (LICBT) via the Government funded Improving Access to Psychological Therapies (IAPT) service. But don’t expect it to make a real world, socially significant difference to your life.  Two just published studies, one focussing on Adults [Ali et al (2017)] and the other on children [ Cresswell et al (2017)], highlight the paucity of evidence in support of this cost-cutting approach.

Ali et al (2017) looked at low intensity IAPT clients who had remitted by the end of treatment and found that half had relapsed within 12 months. Far from suggesting that this sounds like a ‘failed experiment’ the authors suggest that the programme should be simply amended to include relapse prevention despite stating earlier in the paper that relapse prevention was part of the protocol! Some weeks ago I wrote a Rejoinder to the paper which is currently being considered for publication in Behavior Research and Therapy.  Interestingly the Research Digest of the Psychologist for June 13th 2017 headlines its’critique of the Ali et al (2017) paper ‘False Economy?’

Father, Son, Bloom, Spring, Child

Cresswell et al (2017) looked at the effectiveness of parent guided CBT self-help  vs parent guided solution focussed self-help in children aged 5-12 with an anxiety disorder and concluded that they were equally effective but the latter was  more costly. In an accompanying commentary Stallard (2017) heralds the study as marking the way forward for children’s IAPT.  But there is no comment by him that a) the outcome measure used, the Clinical Global Impressions of Improvement was designed for use with regards to the trajectory of specific disorders, it was not intended as an across the board measure and is of doubtful validity in this study, b) there was no waiting list control group – children’s debility is likely to be particularly transitory c) that the study did not include any children with OCD or PTSD and in the CBT arm 50% had generalised anxiety disorder and 25% a specific phobia – generalising from this study to children with anxiety disorders is therefore problematic or d) that 40% of parents in the CBT arm had higher education, this is unlikely to be the case in many areas.

There are conflict of interest concerns with both papers Shehzad Ali heads the Northern IAPT Practice Research Network and Paul Stallard is joining Cathy Cresswell in running a randomised controlled trial. Demand of MPs, GPs and Clinical Commissioning Groups that psychological therapy services make a socially significant difference and are independently rigorously evaluated. Remind them there is good news: fully implemented CBT protocols result in over 50% of clients with depression and anxiety disorders no longer meeting diagnostic criteria for the condition by the end of treatment.[Scott (2017)].

Dr Mike Scott

References

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

Cresswell, C et al (2017) Clinical outcomes and cost-effectiveness of brieg guided parent-delivered cognitive behavioural therapy and solution-focused brief therapy for treatment of childhood anxiety disorders: a randomised controlled trial. Lancet Psychiatry published online May 17th 2017

Scott M.J (2017)} ‘Towards a Mental Health System that Works’ London: Routledge

Stallard, P (2017) Low-intensity interventions for anxiety disorders. Lancet Psychiatry published online May 17th 2017