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BABCP Response - NICE Consultation January 2022

It’s not you it is us – anecdotal evidence and observation from 7 years clinical practice and leadership in IAPT

I am not averse to IAPT, as a mental health nurse and, therefore, an ambassador for mental health (amongst other things) I’m working in IAPT because I want to help people and because I care.

I’m writing from the very front line of this so when I ask my patients what they want or what their ‘goals of therapy’ are they understandably look at me somewhat quizzically and say something along the lines of ‘I just want to feel better / someone to talk too’ – this is hardly a good starting point for a treatment that is so rigid in its ‘fidelity to the model’ that therapists are subjected to strict supervision which can result in performance management or even disciplinary measures if they do not adhere to the draconian protocols.

This creates a dichotomy for therapists (Mason & Reeves 2018), do we give the patient what they want or what the service tells us to give the patients? – this then leads to confusion for patients and disruption in the therapeutic relationship. 

Therapeutic relationship did I hear you say? That most important feature of any talking therapy and predictor of a successful outcome (Knox 2015, Rogers 1951)?

I was once told by a clinical lead that the therapeutic relationship is not important, especially at low intensity where there is only 6-8 thirty-minute appointments (you can only imagine my sense of despondency).

The science says that CBT alone works, the science is convincing and backed up by NICE guidelines and academic research at an institutional and political level (Wakefield et al 2020), I’m looking at you School of Psychology University of Sheffield.  If you look closely though, people can see through the bias, dubious points of reference and blatant nepotism (Scott 2018, 2021, Kellet 2020).  I would argue if it is really that good anybody, even a robot could deliver it, and here the science fails because guess what, most people want to talk about their struggles of the human experience with another human, they want genuineness, unconditional positive regard, empathy and congruence, sound familiar? Just ask Carl Rogers.

When my supervisees come to me with the common struggles of working in IAPT, burnout and the dichotomy of care, I look at them knowingly and refer them to the best intervention I know in psychotherapy, I tell them to ask Carl and remember that genuineness, empathy, and unconditional positive regard is an intervention in itself,  the rest comes down to getting to know the patient and wanting to work together for whatever the person needs, so long as it’s within the step two interventions of course…

 

 My problem is the system, the Industrialisation of Care (Jackson & Rizq 2019) thanks in no small part to the neo liberal austerity politics creating an influential marriage with the science (Dalal 2018). 

Don’t get me wrong I wanted an alternative to the over prescribed anti-depressants (Whitaker 2010) and lack of access to talking therapy but what we have created is a data eating, CBT advocating monster which offers patients no alternative talking therapy in most cases (Jackson & Rizq 2019) and is almost entirely unsuitable for people from areas of social deprivation who are therefore overprescribed anti-depressant medication (Destress 2019).  This is a crime of health inequality where inscription of deficits-based thinking sees distressed people who are living in poverty as somehow deficient and in need of ‘correction’ through medical or therapeutic intervention (Destress 2019).  But enough of the politics, don’t get me started on that, but if you are interested in more on this read the Destress Project report ‘Poverty, Pills and Pathology’ or Managerialism, Politics and the Corruptions of Science by Farhad Dalal.

Author: Name withheld for protection – how has it come to this (MS)?

References

Dalal (2018) CBT: The Cognitive Behavioural Tsunami: Managerialism, Politics and the Corruptions of Science. Published by Routledge, Abingdon, UK.

Destress Project (2019) Poverty, Pills and Pathology, final report. Available at: http://destressproject.org.uk/wp-content/uploads/2019/05/Final-report-8-May-2019-FT.pdf (Accessed: 7th April 2021).

Jackson & Rizq (2019) The Industrialisation of Care: Counselling, Psychotherapy and the Impact of IAPT. Published by PCCS Books, Monmouth, UK.

Kellett, S. et al. (2021) ‘The costs and benefits of practice-based evidence: Correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’, The British journal of clinical psychology, 60(1), pp. 42–47. doi: 10.1111/bjc.12268.

Knox, R. and Cooper, M. (2015) The therapeutic relationship in counselling & psychotherapy. SAGE (Essential issues in counselling and psychotherapy). Available at: https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=cat06100a&AN=btc.9781446282908&site=eds-live (Accessed: 7 April 2021).

Mason, R. and Reeves, A. (2018) ‘An exploration of how working in the Improving Access to Psychological Therapies (IAPT) programme might affect the personal and professional development of counsellors: an analytical autoethnographic study’, British Journal of Guidance & Counselling, 46(6), pp. 669–678. doi: 10.1080/03069885.2018.1516860.

Rogers, C. R. (1951) Client centered therapy. Constable. Available at: https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=cat06100a&AN=btc.0094539901&site=eds-live (Accessed: 7 April 2021).

Scott, M.J. (2018). Improving access to psychological therapies (IAPT) – the need for radical reform.Journal of Health Psychology, 23, 1136–1147. https://doi.org/10.1177/1359105318755264

Scott, M. J. (2021) ‘Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin’, The British journal of clinical psychology, 60(1), pp. 38–41. doi: 10.1111/bjc.12264.

Wakefield, S. et al. (2021) ‘Improving Access to Psychological Therapies (IAPT) in the United Kingdom: A systematic review and meta-analysis of 10-years of practice-based evidence’, The British journal of clinical psychology, 60(1), pp. 1–37. doi: 10.1111/bjc.12259.

Whitaker, R. (2010) Anatomy of an epidemic: magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. Broadway. Available at: https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=cat06100a&AN=btc.9780307452429&site=eds-live (Accessed: 7 April 2021).

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BABCP Response - NICE Consultation January 2022

We Rejoice In Reliable Cancer Screens But Accept The Incompetence Of Mental Health Screens – Time To Sue

Nobody would accept unreliable cancer screens, but mental health screens are conducted in IAPT (Improving Access to Psychological Therapies) by Psychological Wellbeing Practitioners (PWPs), the least well qualified practitioners and conducted over the telephone in a 20-30 minute ‘assessment’.


Tell me this is ok:

  1. Ms B underwent a telephone assessment after which her GP was informed that she had a PHQ9 score over 10 and GAD7 score over 8 and was being placed on a waiting list f or a psychoeducational group at step 3. No indication of what she apparently screened positive for, nor what evidence based treatment was proposed for the said condition/s.
  2. 5 months later the GP writes in her notes that Ms B did not attend IAPT and is worrying about everything and added ‘tried counselling doesn’t feel useful’
  3. 15 months after her initial telephone assessment she has another IAPT telephone assessment, by a PWP from the Screening Team and the GP is informed that her PHQ9 is 19 and GAD7 is 9. Further she has suicidal thoughts but no plans and the GP is reminded that she took an overdose years ago. The PWP added that they were going to put her on a waiting list for a face to face assessment and had given her the phone number of the Samaritans.

If a patient had telephone consultations with a GP over an unexplained lump, with no face to face assessment or treatment conducted in 15 months, there would be outrage. A Personal Injury claim would likely be mounted, yet this is accepted without a raised eyebrow in the mental health sphere. I don’t think anything will change until someone sues IAPT.

Dr Mike Scott

Categories
BABCP Response - NICE Consultation January 2022

Better Than CBT?

‘Metacognitive therapy (MCT) is a new evidence based psychotherapy that is proving to be more effective than than CBT’ so runs the advert in the April 2019 issue of the Psychologist, promoting an MCT Conference at the end of next month. Inspection of the referenced supporting literature indicates that there is just one, to be published study, by Adrian Wells et al, on Generalised Anxiety Disorder, suggesting MCT outperforming CBT. In MCT their is allegedly a 70-80% recovery rate compared to average 50% in CBT.

But great care has to be taken in evaluating efficacy studies, those relating to GAD are an exemplar. Studies conducted only by the originator of a therapy (Adrian) are necessarily suspect, there needs to be at least one independent study by researchers without an allegiance to the therapy and in which there is blind assessment of outcome using a standardised diagnostic interview. Further the results should include blind rater assessments not merely self-report. Whilst Adrian’s work has not yet cleared this hurdle, a methodologically rigorous analysis of the CBT for GAD studies paints a less convincing picture than most CBT devotees would imagine. A review of CBT for GAD studies by Zhu and colleagues, found just 12 studies as worthy of consideration and commented:

‘Despite having blinded rater, in half the the studies the main outcome depended on the self-rating….The overall risk of bias was considered high in 8 of the 12 studies. And using the rigorous GRADE criteria the overall level of evidence was classified as ‘moderate’, which indicates that further research could change the widely accepted conclusion about the effectiveness of CBT. Thus the results in favor of CBT are strong, but not definitive’. Dropbox link to full article below:

https://www.dropbox.com/s/cng09hehty9qo02/GAD%20Meta-analysis.pdf?dl=0

When it comes to studies of CBT for long term physical conditions, the evidence is much weaker than that for GAD which raises the interesting question of ‘why IAPT is treating long term physical conditions’. This very question is to be addressed by a Psychological Welbeing Practioner at an IAPT PWP Conference on June 26th. Interestingly the Workshop is titled ‘Step 2 Support for long term conditions’. But there is surely a gross mismatch between a low intensity intervention and a long term physical condition! It rather looks like distinction between low and high intensity interventions is being blurred, not before time. However a colleague of mine working in high intensity has been trained in treating LTC’s but is restricted to 6 sessions! Despite none of the efficacy studies in this area offering just 6 sessions, I am off to a home for the bewildered and bemused.

Dr Mike Scott