The previous Health Minister, Dr Therese Coffey was asked 7 questions about the effectiveness of routine psychological therapy for depression and the anxiety disorders. Only 1 of the 7 questions was answered and that, only partially. The Department of Health advised that NHS England were better placed to answer my questions and so I put the queries to them. I wrote about this in my blog for Mad In America. Since then NHS England have replied, or rather not replied, suggesting that I put the questions to my local Integrated Care Board (ICB’s are the recent replacement for Clinical Commissioning Groups). My questions obviously relate to national policy and not local difficulties, it is completely disingenuous of NHS England to reply in this way. I have now asked them for a considered response to my questions.
For the sake of completion I have reproduced the questions below:
1.The Government Improving Access to Psychological Therapies (IAPT) Service is experimenting with public, direct access to a Psychological Wellbeing Practitioner. But PWPs are not trained in diagnostics nor are they qualified therapists. Why then are they being given this gatekeeping role?
2. The IAPT service has cost billions of pounds, since its’ inception in 2008. Why, then has there been no independent audit of the service?
3. With regards to physical health the Government is funding Community Diagnostic Centres, with regards to mental health why is there no facility for reliable diagnosis in IAPT?
4. With regards to mental health there is no evidence that those availing themselves of IAPT fare any better than those attending the Citizens Advice Bureaux? What then is the added value of funding IAPT?
5. How is the experiment of making PWPs gatekeepers being evaluated and who decided on the criteria?
6. IAPTs claimed recovery rate of 50% has not been independently verified. The independent evidence of an Expert Witness to the Court [Scott (2021) British Journal of Clinical Psychology] suggests that in fact only the tip of the iceberg recover. Is this not grounds for a publicly funded independent audit?
7. How do we know IAPT is value for money?
It seems likely that only politician-like responses will be forthcoming. Will nobody grasp the nettle?
I will never forget how, when I started working at the IAPT call-centre, I was stressed and rested my head for a few moments. I was interrupted by a “clinical psychologist” who in accusatory tone proclaimed that, “it does not seem that you are working”. The die it seems was cast. Not once in my 3 years as a Psychological Wellbeing Practitioner (PWP) have I felt that anyone at work cared for one another.
‘When I Want Your Opinion I’ll Give It To You’
Naively I thought that “psychological services” would be a haven of openness, not a venue as “hellish” as any other sales related job. Contentious issues were not allowed to be placed on the agenda at meetings. If I dared to bring up issues that mattered, the Managers would “have a word with me in private”. It felt like “The Twilight Zone” and “Twin Peaks”; you could feel something was not right, but everyone pretended that things were fine and that it was me who was the problem. If there was any issue with what I said, no one gently told me, instead they went straight to my manager. So, I always felt paranoid that whatever I say or do, may be reported.
I will never forget the moments where I would try to bring up a new approach or new knowledge only to be told “it is not in line with NICE and IAPT” and “do not read extra information because you will not need it”. A re-enactment of George Orwell’s 1984, rather than the delivery of a 21st Century psychological service. Worryingly this seems to be the norm in the NHS, with the frontline troops powerless.
What It Is Really Like At The Coal Face
The short end of it all is that being a PWP is very similar to run of the mill call-centre, telemarking and sales job. No matter what the average worker says “but we do a great service”, I feel they are a tad bit delusional. I do not blame them. To survive this job you either need to resort to trickery or delude yourself that you are doing something worthwhile. The latter group probably have a mortgage to pay. We are told what to say, how to say it, when to say it and constantly told “it’s all about the numbers/targets”. We also have a script, which is very similar to those phone contract customer service people. The hellish brilliance of IAPT is that if the targets are not reached, the organisation uses an attributional bias to blame the “practitioners”/miners and not the “system”/pit owners and fellow travellers.
The Re-Branding of What Doesn’t Work, Doesn’t Work
Pre-IAPT there were “mental health workers (MHWs)”, and the public had some idea of the discharge of this particular, professional role. But from 2008 MHWs became Psychological Wellbeing Practitioners, leaving the public and professionals scratching their head as to what the designation might mean. Where PWPs to be regarded as professionals or not? Despite the inherent confusion, I followed my work’s advice to the letter: did the questionnaires, kept the original scores and ploughed onwards. However, what I noticed is that many clients (I dislike using the term patients because it doesn’t feel like we are official clinicians either) were finishing treatment or dropping out with “high scores”. It was not too long until I was interrogated for a below 50% recovery rate.
Jumping Through The Hoops of ‘Recovery’
The recovery rate of 50% is impossible unless one manipulates the numbers or manipulates the clients to be compliant. I guess, good old fashioned “sales tactics” (convincing people they need a product or that they are better than when they started). Of course, the Managers did not care. Safe to say, I found a crack in the system: since the powers all care about numbers, if you deliver the numbers, they will not question you. However, dare you dip below what is expected of their Key Performance Indicators (KPIs), then they are like bloodhounds searching for you. But there has never been a real world KPI that a client would recognise, such as being back to their old selves for at least 8 weeks after treatment. Instead clients are expected at each session to doodle on questionnaires in the prescence of the PWP and bizarrely, these are used as the metrics of recovery.
At the coal face, I can conceal, to a limited extent what I am doing from the powers that be and deliver something of benefit. I do not hound them for the questionnaires every single time because let us face it, that creates a major barrier in treatment. Also, we are not MDs or Clinical Psychologists that can diagnose. It is a joke when we have to collect the data because it is meaningless.
The issue then becomes that I did not feel like I was learning anything. All I was learning was how to manage office politics and be a better liar. One could apply for High Intensity Training but they still focus on targets, so, no thanks. Any person of good conscience will not last long in IAPT. If you have any issues as a worker with IAPT, they will say it is a “you” problem. I once mistakenly vented my frustrations with how they were doing things at a meeting. This resulted in evident displeasure and near the end the next meeting was told to “this is not a space to vent grievances”. If the clients and workers had a platform to vent their frustrations, I do not think IAPT would still be operational.
PWPs Ambassadors For A ‘Failed State’?
Working in IAPT is robotic: clicking tabs, ticking boxes and collecting numbers – a de-humanising experience. There is little to encourage anyone to become a PWP. In fairness I suppose, at least a personal level, I have survived lockdown financially. But the service has in effect been “cooking the books” and making the company look good. I fear for the mental health not only of the ambassadors but for that of clients past and to come.
I am off to other pastures, can you wonder at the turnover?
despite the fact that the main provider of psychological services, the Improving Access to Psychological Therapies (IAPT) Service is ‘An Abject Failure’ https://www.madinamerica.com/2022/06/uk-iapt-abject-failure/. It is all about cost, with no regard for evidence. It is recommended by the National Institute for Health and Care Excellence (June 29th) that clients are offered 11 possible interventions for depression, presenting the least costly first, guided self-help, group cognitive behavioural therapy (8 sessions) progressing up to the 11th option, short term psychodynamic psychotherapy. With Psychological Wellbeing Practitioners (PWPs) providing the assessment and the least costly interventions. But PWPs are not trained therapists and the IAPT Manual states that its’ employees do not make diagnoses and they are not trained to diagnose. Yet bizarrely NICE states that assessors must be competent to make a reliable assessment of depression! A pig’s ear of monumental proportions.
There is no empirical evidence that 8 sessions of group CBT delivered by PWPs makes a real world difference to client’s lives as assessed by a blind assessor. Nor that the recommended 8 sessions of individual CBT for depression, presumably delivered by a high intensity therapists, constitutes a therapeutic dose of treatment.
The revision of the Draft Nice Guidance on Depression https://www.nice.org.uk/guidance/ng222 now recommends a stepped care approach to depression and sees Psychological Wellbeing Practitioners as contributing to treatment. This has brought a ‘hurrah’ from BABCP (British Association for Behavioural and Cognitive Psychotherapy), as it is exactly what they lobbied for https://babcp.com/About/News-Press/Revised-NICE-Guideline-on-Depression-in-Adults post the Draft guidelines. Dr Andrew Beck the BABCP President proclaims in the press release ‘the guidedInes highlight the amazing value of PWPs’. In addition antidepressants and CBT in combination are seen as the treatment choice for severe depression.
But these recommendations and changes are eminence-based not evidence-based. A paper published in the Journal of Psychiatric Research last year by Bartova et al (2021) https://doi.org/10.1016/j.jpsychires.2021.06.028 showed a 25% response rate for those who had antidepressants and manual-driven psychotherapy (mostly CBT), no better than antidepressants alone. This compares with a 31% response rate in those given a placebo Rutherford and Roose (2013) https://doi.org/10.1176%2Fappi.ajp.2012.12040474
Before BABCP issued the press release, I raised the following issues with its’ author Professor Reynolds:
I can find no randomised control trials of low intensity interventions that are methodologically robust enough to lead to the conclusion that such interventions should be the initial treatment of choice for less severe depression.
I can find no evidence that as a result of stepped care, the trajectory of clients with depression Is meaningfully better than if they were not treated in a stepped care model.
There was criticism of the initial draft for the ‘marginalising and undervaluing of PWPS’. However, it appears that under pressure from BABCP, PWPS are now to be lauded. But there is an absence of evidence of what PWP treatment works for whom and in what circumstances. As such their interventions are not evidence- based. Further they are not psychological therapists.
NICE have apparently indicated that the IAPT database may be used to inform the next set of guidelines. But this database tells us nothing of the course of any client’s disorder as the service does not make diagnoses or engage in long-term follow up.
I asked that my dissent from BABCPs press release be publicly noted, and was told simply that it would be passed to the BABCP Board. At the same time the comments of IAPTs lead, Professor Clark. on the importance of including relapse prevention in treatments, would be included in the press release and it was. An in-group clearly operates. I am reminded that when I submitted an article to the BABCP comic, CBT Today on IAPT, the article was rejected not by the editor but by the past (Prof Salkovskis) and current (Dr Andrew Beck) Presidents of BABCP. The matter was never addressed by the Board despite an assurance from Dr Beck. If ever there was a clique. Unholy alliances rule.
the Improving Access to Psychological Therapies (IAPT) assessors are coaches, not trained treating clinicians. Clients and GPs are not made aware of this. The low intensity Psychological Wellbeing Practitioners see their low intensity role as ‘coaches’ rather than therapists see [https://thepsychologist.bps.org.uk/volume-24/edition-5 May 2011 Psychologist].
The working alliance has been found to predict outcome in the treatment of a wide range of psychological disorders [Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy: a meta-analysis. J Couns Psychol. (1991) 38:139–49. doi: 10.1037/0022-0126.96.36.199] and most recently in the treatment of PTSD [Beierl ET, Murray H, Wiedemann M, Warnock-Parkes E, Wild J, Stott R, Grey N, Clark DM and Ehlers A (2021) The Relationship Between Working Alliance and Symptom Improvement in Cognitive Therapy for Posttraumatic Stress Disorder. Front. Psychiatry 12:602648. doi: 10.3389/fpsyt.2021.60264]. But the measurement of the working alliance requires a determination of the tasks involved, the goals elaborated and the assessment of the therapeutic bond [Tracey TJ, Kokotovic AM. Factor structure of the working alliance inventory. Psychol Assess. (1989) 1:207–10. doi: 10.1037/1040-35188.8.131.52]. Measuring the therapeutic working alliance in low intensity CBT would be a herculean task, in that 42% of those entering treatment only complete one session [Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14]. Further even if the working alliance could be reliably assessed in low intensity IAPT there can be no certainty it would relate to outcome.
Given the uncertainties surrounding the role of the working alliance in low intensity interventions, doubts arise about the credibility of this intervention. Low intensity interventions do not make a clinically significant difference compared to usual care. BMJ 2013;346:f540 doi: 10.1136/bmj.f540 The situation is analogous to trying to asses the effectiveness of a fraction of a drug, that is demonstrably efficacious in full dose in a highly specified setting.
But the effect size of working alliance has in all studies been found to be in the small to medium range, for example in the Beierl et al study (2021) accounting for 13-28% of outcome depending on whether it was the patients perception of the therapeutic alliance or the therapists. Thus though consideration of working alliance is of importance it is not of overriding importance and the specifics of the protocol matter.
Last week a PWP (Psychological Wellbeing Practitioner) ALIEE November 25th 2020 put a post on this blog, calling for Panorama to take note of the desperate plight of PWPs – the main providers of services in the Improving Access to Psychological Therapies (IAPT) Service. Unfortunately the track record of the media in this regard is not good. It is a year since Radio 4 chose to broadcast predominantly the voices of lead figures in IAPT and well known fellow travellers, rather than give expression to those at the coalface and their clients. One wonders what it takes for the media to wake up and ‘smell the coffee’ – £4billion has been spent on IAPT over the last decade all without any independent audit. Given the current, parlous state of Government finances this should at least come under independent critical review, perhaps by the Office for Budget Responsibility.
When a PWP candidly admits “I am trained to overlook the full picture”, it raises eyebrows. Then when ALIEE goes on to say that she operates purely with the ‘5 area model’, this is jaw dropping. This is not a model for any psychological disorder, by itself it is a heuristic for providing generic cbt, which has never been considered an evidence-supported treatment. Then this PWP states if clients still have high PHQ9 and GAD7 scores by the 4th session, it is the client who should be interrogated for their competence in scoring, with the threat that if such scores persist there is the spectre of criticism from superiors. This is tantamount to fiddling results. It is atrocious that AIEE has been placed in this invidious position. I do not believe she is weak but rather like a prisoner at Auschwitz charged with the removal of dead bodies from a gas chamber.
The burden of proof is with IAPT to demonstrate that it has procedures in place to make it impossible for ALIEE to have been operating in this way. Protestations that ‘there a few bad apples’ in every workforce simply won’t wash.
Getting the media and politicians to listen is like getting the post war German Government to take action against war criminals. Action was only finally taken following many years of work by children of Holocaust victims. Unfortunately in the short term the implicit plea is that ‘we have enough to do with the Pandemic and Brexit, not to say Climate Change’ but the climate of the upcoming generation is affected by the mental health of today’s adults.
Nobody doubts that testing for the the Corona virus is a necessary part of the treatment planning for those with a fever and persistent cough. However the test alone is not judged sufficient, it has to be complemented by other clues such as the result of X-rays, a CT scan, and consideration of whole range of Covid-19 symptoms before the clinician makes a judgement on diagnosis. This contrasts sorely with the position in routine mental health services where in the Improving Access to Psychological Therapies (IAPT) service the sole arbiter of treatment decision making and judgement of outcome is the PHQ9/GAD7, accompanied by an unbridled clinical judgement. Yet the authors of the PHQ9 [Kroenke et al (2001 )] and GAD7 [Spitzer et al (2006)] insisted that the tests results needed to be interpreted in the context of a diagnostic interview.
The completion of the PHQ9/GAD7 is mandated by the IAPT hierarchy, but clinicians have little or no interest in the results except that they may be disciplined if there is a pattern of non-recovery on these measures. IAPT Psychological Wellbeing Practitioners were asked to identify potential clients with GAD ( a score of 10 or more on the GAD7 ) for a study Kalpakidou et al (2019) https://doi.org/10.1186/s13063-019-3385-5 comparing the efficacy of CBT (delivered by high intensity therapists) to medication. But they put too few clients (only 12% of those potentially eligible) forward that the trial was cancelled. The take home message appears to be that for clinical purposes PWPS don’t take PHQ9/GAD7 measures seriously and operate on the basis of their own clinical judgement e.g whether a client’s stress is just a natural reaction to a difficult situation or whether simple psychological first aid is judged sufficient to address difficulties. There appears to be little believe in the importance of stepping up clients and indeed only 10% of clients are stepped up.
The judgement of PWP’s ( who provide over 70% of IAPT contacts) will likely be influenced by their training, the focus of which is on goal setting and tackling the most important problem see Richards and Whyte (2011) Reach Out 3rd Edition. But PWP’s are painfully unaware that such interviews have no more reliability that the standard open ended psychiatric interview with at most a 1 in 2 chance that different assessors seeing the same interview would agree on the way forward [see Spitzer RL, Fleiss JL. A re-analysis of the reliability of psychiatric diagnosis. Br J Psychiatry 1974;125(0):341–7]. Essentially judgements are idiosyncratic unless a standardised semi-structured interview such as the SCID, DIAMOND or MINI is included in the assessment. Without such reliable assessments PWPs are operating outside the sphere of evidence based interventions.
Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-1097.
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-613.
so writes Judith Beck, President of the Beck Institute for CBT (2019 Moorey and Lavender) in a book to be published next week, echoing what her father Aaron Beck wrote in 1979 in his seminal work Cognitive Therapy for Depression. But IAPT have made their own fundamentalist translation of Beck’s work, indoctrinating its’ footsoldiers, Psychological Wellbeing Practitioners (PWPs), one of whom from Liverpool (2019 p214 Jackson and Rizq) has written:
‘The PWP role is high volume low intensity, just churn them out… young PWPs straight from universities, who are naively prepared to do as required by the service…There’s a big gap between the data and the reality of what we’re trying to do’.
It is disturbing that the most vociferous critics of IAPT are also fierce critics of CBT, [ see Jackson and Rizq (2019)] creating a caricature of the latter as mechanistic and uninterested in the the therapeutic relationship. But I have just contributed a chapter the Moorey and Lavender (2019) edited volume. Anyone reading my chapter on Group CBT in this work can be in no doubt about the importance I attach to the alliance/ cohesion in a group.
I am still reading the Jackson and Rizq (2019) book and it contains many perfectly valid criticisms of IAPT. But it does engage in unnecessarily distracting polemics about the medical model and diagnosis.
The contributors to the Jackson and Rizq (2019) work seem blissfully unaware that no medic or psychologist has ever espoused anything other than a biopsychosocial model, it is only the mouthpieces for drug companies that have ever voiced purely biological explanations. To say that biology will be involved in psychological reactions isn’t at all to say that the former determines the latter or its course.
Breathtakingly Jackson and Rizq (2019) are profoundly mistaken when they assert that IAPT believes in diagnosis, they do not at all, they pay lip service to it to secure funds!. IAPT never ever perform a standardised diagnostic interview such as the SCID which is the ‘gold standard’ for establishing whether a person has a recognised psychiatric disorder. The first part of the SCID begins with an open ended interview in which clients are given the space to tell their story, only then is their systematic enquiry about each of the symptoms in a diagnostic set and a clinical assessment of which symptoms are significantly interfering with real world functioning. If IAPT started to use the SCID it would stop the production line referred to by the PWP above. There has to be space created for any relationship. But in my personal communication with David Clark, IAPT’s progenitor he baulked at the cost involved, but did not criticise my proposal per se.
Diagnosis provides a common language and it is the least worst way of communicating, try trying to talk about say ‘power threat meaning ‘ in a medico-legal case! Its’ usage does not at all depend on believing in a particular biological pathology rather it is pragmatic and subject to revision.
Jackson and Rizq (2019) reiterate the ‘Dodo verdict’ that all therapies are equal and must have prizes citing Wampold’s work, but Tolin’s findings
are very different. But notwithstanding this, in routine practice one does not find evidence of fidelity to any psychotherapeutic protocol, I have yet to see any written evidence in treatment notes of fidelity that would satisfy anyone from any of the psychotherapeutic schools. Manuals are seen as anathema, with a total ignorance that flexibility is an integral part of all such published manuals. Unfortunately the manuals have never been tested out by the Jackson and Rizq (2019) advocates, nor has the viability of using a standardised diagnostic interview, instead theirs is a fundamentalist view that they and their client will somehow find the right way. In their own way they are as ideological as IAPT.
Moorey, S and Lavender, A eds (2019) The therapeutic relationship in cognitive behavioural therapy. London: Sage Publications
Jackson, C and Rizq, R (2019) The industrialisation of care counselling, psychotherapy and the impact of IAPT. PCCS books
Alexandra Painter was for 2 years a Psychological Wellbeing Practitioner, in her doctoral thesis *, she reviews her experience and that of other PWP’s. She notes that in the so called ‘Case Management Supervision’ that PWP’s are subjected to, a core component of supervision, the opportunity to reflect on practice and talk about how you feel about cases is routinely absent. Alexandra calculates that approximately 2.5 minutes is allowed to discuss each case! It seems that the PWPs, who are the most numerous of IAPT workers, are at the ‘front line’, most commonly they have been health care assistants in the past, unlike the high intensity therapist’s in the rear with often clinical or counselling psychology backgrounds. In this war against mental ill health it is more likely that the troops at the front will bear the brunt.
Leaving the troops fearful of going over the top and disobeying commands from on high. The PWP’s plight resembles resembles the Charge of the Life Brigade, in that the powers that be refuse to accept that they are not on solid ground intent on reaching their target at all costs. There are no evidence based techniques, only evidence based treatments and all the so called EBT’s in low intensity treatment fail to meet criteria for evidence based treatment [ Scott (2017) Towards a Mental Health System that Works London Routledge].
At least two randomised controlled trials, on a clearly specified population, with independent assessment by a blind rater using a standardised interview
At least one of the rcts conducted by researchers independent of the developers of the treatment
Replication in routine practice using non-expert clinicians
How long will it be before there is a national outcry about such waste. Unfortunately the National Audit Office is still undecided about whether to publish its’ investigation into IAPT. People including myself and BACP made a submission to the NAO fully expecting the latter’s findings would be made public, if they and I knew that this was not necessarily the case, we would have wondered whether it was worth the effort! At the moment they appear to be countenancing a letter to NHS England, inspection of their website shows the latter’s wholesale support for and funding of IAPT! The NAO, to date, seems no better than Carillion’s Auditors!
Dr Mike Scott
* Painter, A. (2018) Processing people! The purpose and pitfalls of case
management supervision provided for psychological wellbeing practitioners,
working within Improving Access to Psychological Therapies
(IAPT) Services: A thematic analysis. DCounsPsych, University of
theWest of England. Available from: http://eprints.uwe.ac.uk/33351