Mental Health Sufferers Vote With Their Feet and Government Does Nothing At All

 of those who undergo an initial assessment with the Improving Access to Psychological Therapies (IAPT) Service 40% do not go on to have treatment, and about the same proportion (42%) attend only one treatment session, according to a just published study by Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133. These findings echo a study  published last year by Moller et al (2019) https://doi.org/10.1186/s12888-019-2235-z, on a smaller sample, which suggested that 29% were non-starters and that the same proportion attended only one treatment session. Further scrutiny of the data reveals that about 3 out of 4 people drop out of treatment once begun. Unsurprisingly the authors’s independent study, of 90 IAPT clients, Scott (2018) revealed that only the tip of the iceberg (9.2%) recovered                 DOI: 10.1177/1359105318755264, raising serious questions about why the Government has spent over £4 billion on the service.

What Has Gone Wrong?

Kline et al (2020) consider that at an assessment by a clinician is supposed to: a) provide a credible rationale for the proposed treatment b)  detail the efficacy of the envisaged treatment and c) ensure that the clients preferences are acknowledged. IAPT’ assessments fail on all counts, taking these in turn:

a. If the problem is ill-defined e.g low mood/stress it is not clear what rationale should be presented. It is doubtful that a 30-45 minute telephone conversation can provide sufficient space to define the primary problem and other problems/disorders that may complicate treatment. Initial assessments  of patients for randomised controlled trials of psychological interventions are typically 90 mins plus, if this is the time deemed necessary to reliably diagnose a patient by a highly trained clinician, how can a much less trained PWP do it in less than half the time? Under time pressure a PWP may consider providing a credible rationale is part of treatment not assessment and in such circumstances it becomes more likely that a client will default. 

b. How often do PWPs present clients with evidence on the efficacy of an intervention? Take for example, computer assisted CBT, does the therapist tell the client that only 7 out of 48 of NHS recommended e-therapies have been subjected to randomised controlled trials, ( see Simmonds-buckley et al J Med Internet Res 2020;22(10):e17049) doi: 10.2196/170490 and even in these a gold standard semi-structured diagnostic interview conducted by a blind assessor was not use to determine diagnostic status post treatment, i.e there was no determination of the proportion of clients who were back to their old self after treatment and for how long. Further the e-therapies had average dropout rates of 31%.  They are not evidence based treatments in the way the NICE recommended high intensity treatments are. But approximately three quarters Of IAPT interventions (73%) are low intensity first, with 4% stepped up to high intensity and 20% in total receiving a high intensity intervention Davis A, Smith T, Talbot J, et al. Evid Based Ment Health 2020;23:8–14. doi:10.1136/ebmental-2019-300133

c. Client’s preferences are a predictor of engagement in treatment, but how often is a client given a choice between a low intensity intervention and a high intensity intervention. If both options are juxtaposed choice is likely skewed by informing the client that the high intensity intervention has a much longer waiting time.

Defining A Dropout

The generally accepted definition of a dropout is attending less than 7 sessions [see Kline et al (2020) https://doi.org/10.1016/j.brat.2020.103750], it is held that clients attending below this number will have had a sub-therapeutic dose of treatment and are therefore unlikely to respond]. Applying this metric to IAPT’s dataset is difficult as they only report data for those who complete 2 or more sessions and for which the average number of sessions attended is 6, thus the likely dropout rate from IAPT treatment, as most would understand the term, is about 75%.  But IAPT has developed its’ own definition of a completer as one who attends 2 or more sessions. This strange definition serves only to muddy the waters on its haemorrhaging of clients. It makes no sense to continue to fund IAPT without an independent  government inquiry into its’ modus operandi.

 

An Alternative Way Forward

Such has been the marketing power of IAPT over the last decade, that professional organisations such as the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and the British Psychological Society (BPS) have sat mesmerised, as the Services fellow travellers have dominated accreditation and training.     In ‘Simply Effective Cognitive Behaviour Therapy’  published in (2009) by Routledge, I detailed a very different way of delivering services, that represents a faithful translation of the CBT treatments delivered in the randomised controlled trials (rcts) for depression and the anxiety disorders. Unfortunately it is IAPT’s fundamentalist translation of the rcts that has held sway and has brooked no debate either in journals or at Conferences.

 

Dr Mike Scott

 

Simply Too Complex CBT!

abandon ‘what treatment works for what’ and you end up with a free for all of imagined complexity.

What Works for Whom?: A Critical Review of Psychotherapy Research

With stressed clinicians lost in a fog, arguing interminably about possible landmarks (formulations) for treatment. Not surprisingly the issue of ‘complexity’ now figures highly on IAPT’s list of workshops. Paradoxically formal IAPT training eskews trainees working with ‘complex cases’. IAPT specifies the importance of following the NICE guidelines but without a reliable procedure for determining what cases they do and importantly do not apply to.

The IAPT Courtroom

An obvious defence for IAPT workers failing to consistently obtain the 50% recovery rate is to contend that they were dealing with complex cases.

In rebuttal the Organisation can contend that complex cases are: ‘namely primary or comorbid psychosis, personality disorder, autism spectrum disorder, substance dependence, severe and/or treatment-relevant physical health conditions, and severe psychosocial difficulties Liness et al (2019) see link’ https://link.springer.com/article/10.1007/s10608-018-9987-5 and that the clinicians case falls outside this definition. But in areas of high deprivation it is relatively easy to claim that a particular client falls within this definition of complexity e.g ongoing pain from an injury or associated with a condition such as MS, having to use a Foodbank.

Flexibility Within Fidelity As A Defence

Flexibility has to be constrained by fidelity, if it is not then arguments between clinicians and line managers/supervisors have no arbiter. The clinician will lose out simply because the line manager/ supervisor has more power, at its’ worst ‘my way or no way’.


If fidelity is safeguarded, then there are agreed issues/concerns that need to be addressed with a particular client. It also sets limits on the range of interventions (flexibility) that are permissible for those particular issues/ concerns. Without a twin focii on fidelity and flexibility the clinician is up a creek without a paddle. But a hostile work environment can nevertheless ignore or more commonly pay lip service to fidelity and flexibility – they need to be admitted to the IAPT courtroom for the sake of both clinicians and clients.

Clinicians and Constructive Dismissal

Nevertheless there is a vagueness about the debate of simplicity vs complexity, that could mean that an IAPT therapist is hounded from office, without the case being put to anything like a jury, with no procedures in place to ensure any transparency and accountability.

The Need To Rediscover A Biopsychosocial Model

But actually matters are nowhere as simple as this simple/complex distinction. Steve Stadling (1990) and I https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/group-cognitive-therapy-for-depression-produces-clinically-significant-reliable-change-in-communitybased-settings/ADFC2B6A2D2BBCCC37CD41820DFD5287

were involved in a randomised controlled trial of individual and group CBT for depression in Toxteth, Liverpool, and managed to make important lasting differences using Beck’s protocol for depression. But because we were using a biopsychosocial model I saw it as much a part of my work to say write a letter to a Housing Association for a client as conduct the CBT. Similarly many patients were prescribed antidepressants, again in keeping with a biopsychosocial model. This holistic approach to client’s problems appears to have been lost in IAPT’s fundamentalist translation of the randomised controlled trials. An alternative perspective is presented my trilogy of Simply Effective CBT books


Dr Mike Scott

Clinical Commissioning Groups, IAPT’s Fairy Godmother

bestowing their munificence without any audit by GPs of local benefit, at a cost nationally of billions of pounds. Yet it should be a simple matter for any GP to interrogate the practice database of IAPT ‘beneficiaries’ and ask the patient the basic question ‘are you back to your usual self since seeing IAPT’? and to further determine whether recovery is stable and reliable by asking ‘for how long have you been back to your usual self?’ Then to integrate the responses with any recent record of functioning in the record of Consultations. Such data can then be presented to the local GP reps on the CCG’s to decide whether the local IAPT is value for money.

CCG’s need to move beyond simple operational matters of numbers of patients seen and waiting times, to a determination of the percentage of people recovering. The randomised controlled trials of cognitive behaviour therapy for depression and the anxiety disorders have suggested a 50% recovery rate when there has been blind assesment of patients. This was the original justification for IAPT. The suspicion is from my independent analysis of 90 IAPT cases that in routine practice the recovery rate is about 10% see link below

https://www.dropbox.com/s/flvxtq2jyhmn6i1/IAPT%20The%20Need%20for%20Radical%20Reform.pdf?dl=0

However when IAPT marks its’ own homework it miraculously comes up with a 50% recovery rate and has seduced CCGs with its own data. The response of most GPs to this is ‘give us a break, but I am nevertheless grateful for a respite from the patient if they are seeing someone else, so I can get on with my core tasks’. We need to move on to a point where GPs are to a degree advocates for their patients, if they don’t do it no one else will. Without such advocacy mental health patients become not just Cinderellas compared to patients with physical problems but confined to their own personal asylum.

Image result for clinical commissioning groups

It is perfectly possible transform IAPT so that it properly translates the findings of rcts into routine practice, see my trio of Simply Effective Cognitive Behaviour Therapy books published by Routledge and my last book Towards a Mental Health System that Works (2017) London; Routledge. But we need to wake up and smell the coffee.

Dr Mike Scott