Low Intensity CBT, ‘Penny Wise & £ Foolish’

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?

 

Dr Mike Scott

What Treatment by Psychological Wellbeing Practitioners (PWPs) Works for Whom?

 

This is a restatement of the question asked by Roth and Fonagy in their seminal work ‘What Works for Whom’ (2005) Guilford Press. This text formed the backbone for the National Institute for Health and Clinical Care Excellence (NICE) recommendations on psychological therapy. The Improving Access to Psychological Therapy (IAPT) service has made a formal commitment to observe the NICE guidelines. PWPs are the most common providers of psychological interventions in IAPT. They have been operational for over a decade, at a cost of £billions, answering this question with regards to this professional group is therefore long overdue.

PWPs Modus Operandi

The BABCP ‘PWP Registration and Renewal Policy’ under a heading ‘Core Principles’ states

‘PWPs are specially trained to work with people who have common mental health problems such as anxiety disorders and depression, to support them in managing their recovery…….are revolutionising our approach to the delivery of psychological therapies in a number of specialist areas…..Have graduated from a British Psychological Society (BPS) Accredited PWP training course/apprenticeship’.

PWPs deliver low intensity CBT, defined by Shafran et al (2021) https://doi.org/10.1016/j.brat.2021.103803  as offering 6 hours or less client contact. The input can be any self-help material. This is a ‘revolution’ in that it is substantially less dose of therapy to that in the high intensity CBT prescribed in the randomised controlled trials of CBT for depression and the anxiety disorders, with 10-20 sessions being the norm.

IAPT’s Magical Beliefs Include:

‘ Six hours or less clien’t contact makes a real world difference to client’s lives’ and ‘inputting any self-help material will do the job’. But what is the evidence for these beliefs? At the advent of IAPT Lars-Goran Ost (2008) published a set of key questions (see the end of this blog) that researchers had to satisfactorily answer for a treatment to be considered an Empirically Supported Treatment (EST). No judge would declare that these injunctions/criteria have been comprehensively answered in any of the low intensity CBT studies. It follows that low intensity CBT is not an EST.

The Government and IAPT

The Government’s wish to push ahead with low intensity CBT parallels Priti Patel’s insistence that refugees are sent to Rwanda, over the heads of Civil Servants who claim that it should be first demonstrated that this makes economic sense. Once the powerholders decide on a course of action, they are unrestrained by any moral imperatives to show compassion and hospitality. It is immoral to offer a dose of treatment for which there is no evidence that it works and to treat refugees so despicably.

 

Dr Mike Scott

 

L.-G. O ̈st / Behaviour Research and Therapy 46 (2008) 296–321

 

  1. Do not use WLC as the control condition, since criterion I requires a placebo or another treatment.
  2. Do not use TAU as the control condition, since the methodological problems described above are so extensive.
  3. Use an active treatment as comparison, preferably one that has been established as effective for the disorder in question.
  4. Do a proper power analysis before the start of the study and adjust the cell size for the attrition that may occur.
  5. Use a representative sample of patients, diagnose them using suitable instruments in the hands of trained interviewers, and test the diagnostic reliability.
  6. Let an independent researcher or agency use an unobjectionable randomization procedure, and conceal the outcome of it from all persons involved in the study.
  7. Use reliable and valid outcome measures; both the ones that are specific to the disorder and general ones.
  8. Use blind assessors and evaluate their blindness regarding treatment condition of the patients they assess.
  9. Train the assessors properly and measure inter-rater reliability on the data collected throughout the study (not just during training).
  10. Use three or more properly trained therapists and randomize patients to therapist to enable an analysis of possible therapist effect on the outcome.
  11. Include at least a 1-year follow-up in the study and assess any nonprotocol treatments that the patients may have obtained during the follow-up period.
  12. Audio- or videotape all therapy sessions. Randomly select 20% of these and let independent experts rate adherence to treatment manual and therapist competence.
  13. Insert procedures to control for concomitant treatments that patients in the study may obtain simultaneously as the protocol treatment.
  14. Describe the attrition, do a drop-out analysis and include all randomized subjects in an intent-to-treat analysis.
  15. Assess clinical significance of the improvement of the primary measures.

 

A Psychological Wellbeing Practitioner’s Damning Indictment of Her Role

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. 

Dr Mike Scott