IAPT’s Processes Contribute Towards Death or Injury

transcripts of tape recordings of client’s first contacts with the, UK Government funded, Improving Access to Psychological Therapies (IAPT) service, analysed by Drew et al (2021) https://doi.org/10.1016/j.socscimed.2021.113818 reveal not only steadily increasing access,  but a steadfast refusal to let clients tell the story behind their distress. The double message is ‘come to us, but we don’t want to listen to your troubles’

To quote Drew et als’ (2021) study of telephone-guided low intensity IAPT communications:

We show the ways in which the lack of flexibility in adhering to a system-driven structure can displace, defer or disrupt the emergence of the patient’s story, thereby compromising the personalisation and responsiveness of the service’

and 

‘routine assessment measure questionnaires  prioritised interactionally, thereby compromising                        patient-centredness in these sessions’

Drew et al (2021) give an example of this surrounding risk assessment:

PWP: So just with regards to question nine, okay so we have a duty of care to yourself or others? .hhh.erm (.) > are we okay just to< have a bit of a chat around.hh what those thoughts might be for you at the moment. ‘Cos you’ve scored a one there haven’t you’ Pause 3 secs
 
PWP: Are you having current thoughts of wanting to hurt yourself or end your life? Pause 3.5 secs
 
Pat: No, may. hh Pause for 3.5 secs
 
Pat: It’s – It’s just feels like a really weird (.) week this week because –
(18 lines omitted in which the patient talks about the pressure they are under; only minimal responses and attempts to close from PWP)
 
Pat: I still feel like I – I’m not doing anything and not accompanying anything tearful/tremulous
 
PWP: Mm, mm, okay? .huh
 
Pat: MHHHH HHH [ and it’s tearful/tremulous]
 
PWP: Are you having any thoughts of wanting to be better off dead or off wanting to better off dead or hurting yourself
 
Dangerously The PWP is all at sea  – a disaster waiting to happen, there will be a death. The above exchange shows
 
the therapist unable to move beyond repeating question 9 on the PHQ9, like a broken record, without any reliable
 
exploration of suicide risk. But then the IAPT Manual provides no guidance in this respect, baldly stating risk
 
assessment is part of good assessment.
 
In the exchange above the PWP ignores the client’s story. Assessment and treatment are necessarily built on sand 
 
if the client’s narrative is not first distilled.  Making IAPT’s claim of a 50% recovery rate  beyond belief. [The average
 
session was 44mins for assessment and 33 mins for first treatment]. 

It is bad enough when a friend or relative will not listen to your troubles, but when a Government Agency does it routinely, that is unconscionable. Drew et al (2021) draw attention to the ubiquity of the problem which suggests that it is systemic. However Drew et al (2021) content themselves with recommending that IAPT’s assessors need to ask more open-ended questions at the start of their interviews. The authors claim no conflict of interest, but many of the authors have had previous privileged access to IAPT data, research data may not be so forthcoming if they take a more critical view of IAPT. In this respect they do not question IAPT’s recovery rate or cite data which may disconfirm it Scott (2018) https://doi.org/10.1177%2F1359105318755264.

 

Dr Mike Scott

IAPT at Sea On Risk Assessment

A study just published by Na et al (2018)  in the Journal of Affective Disorders*  suggests that item 9 of the PHQ-9 is an insufficient assessment tool for suicide risk and suicide ideation, creating large numbers of false positives. Yet within IAPT, GP’s may be informed that either there are no risk issues on the basis of a ‘not at all’ response to  item 9, ‘thoughts that you would be better off dead or of hurting yourself’ or that there are risk issues on the basis that they have been bothered by these thoughts for at least several days in the last 2 weeks. The message is usually communicated to the GP following a telephone assessment conducted by the most junior members of staff a Psychological Wellbeing Practitioner. The GP then feels obliged to call the patient in for an assessment which turns out to be invariably pointless, not good for the patient or for the GP who may be seeing 40 patients that day!

A (2012) paper on IAPT by Vail et al ** stated ‘that IAPT clinicians did not have set procedures or questions for assessing mental health risk, and were  flexible in the approaches they adopted. They often relied upon their own clinical judgement and experience about how to approach the topic of mental health risk’. This chimes with what I found in an analysis of 90 cases going through IAPT, Scott (2018) in only three cases was there mention of risk in the documentation. Inspection of item 9 on the PHQ-9 shows that it confounds passive suicidal ideation with active planning making it unclear what the frequency response refers to, creating many false positives.

More direct questionning based on the C-SSRS * is probably more appropriate:

Have you started to work out or worked out details of how to kill yourself? Do you intend to carry out this plan ?

Have you made a suicide attempt- purposely tried to harm yourself with at least some intention to end your life?

Have you  taken any steps to prepare to kill yourself or actually started to do something to end your life or were stopped before you actually did anything?

A negative response to all of the 3 questions would indicate no suicide risk.

* Na, P.J et al (2018) The PHQ-9 item 9 based screening f or suicide risk: a validation study of the Patient Health Questionnaire (PHQ) – 9 item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS) Journal of Affective Disorders, 232, 34-40.

** Vail, L (2012) Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRIST. Mental Health in Family Medicine, 9, 57-67

Dr Mike Scott