there is no evidence that routine psychological therapy, as delivered in the Improving Access to Psychological Therapies (IAPT) programme either, resurrects a person or returns them to their best functioning. As such IAPT is impotent.
Most of those entering the IAPT programme undergo low intensity cognitive behaviour therapy (LICBT). This latter involves a reduction of the multifaceted protocols from randomised controlled trials to single elements of those protocols eg avoidance or cognitive restructuring, in the belief that this may resolve client’s difficulties. But over a decade on, there is no evidence that this minimalist approach makes a real-world difference. It is still unknown ‘what, if any, low intensity intervention works with whom?’.
The problem with reductionism is that it fails to acknowledge that the whole is more than the sum of its parts. The multifaceted CBT protocols distilled for randomised control trials likely work because of the synergistic interactions of components, delivered by a particular type of agent (therapist). Simply providing ‘an agent’ or ‘a technique’ is not evidence based.
A recent debate in the Journal Psychological Medicine, has focused around a paper by Read and Moncrief (2022)Moncrieff, J., & Read, J. (2022).[ Messing about with the brain: A response to commentaries on ‘Depression: Why electricity and drugs are not the answer’. Psychological Medicine, 1-2. doi:10.1017/S0033291722001088 https://www.cambridge.org/core/journals/psychological-medicine/article/messing-about-with-the-brain-a-response-to-commentaries-on-depression-why-electricity-and-drugs-are-not-the-answer/C93997DBF4D174D9807D0F65BD994999] highlighting the problem of reductionism when applied to antidepressants and ECT. Both treatments are based on the postulate that there is particular dysfunction in the brain largely responsible for depression, which these intervention rectify. However the search for such an organic deficit has been unsuccessful. These authors point that such interventions are no more effective than enhanced placebo for depression.
Interestingly Read and Moncrief (2022) pin their hopes on psychological therapies by appealing to the results of randomised controlled trials of CBT for depression. However they are over-stepping the mark. The routinely provided CBT by IAPT has none of the hallmarks of CBT in the trials: the dosage of sessions is sub-therapeutic, no fidelity checks have been conducted to check that individuals actually receive appropriate CBT, there have been no independent assessors of outcome.
In their paper Read and Moncrief (2022) were quite specific about the population they were addressing ‘depressed patients’ but there is no such specificity about the populations treated in routine practice. IAPT clinicians do not make reliable diagnoses, (albeit that they have the temerity to ascribe a diagnostic code). Whilst it is comparatively easy to guarantee that an antidepressant or ECT has been administered, guaranteeing that an appropriate CBT protocol has been imparted, requires independent fidelity checks. No such checks have been applied to IAPT’s ministrations. Read and Moncrief (2022) may well be right, that psychological therapy is the best hope, but the way to hell is paved with good intentions. Currently IAPT is impotent.
Dr Mike Scott