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BABCP Response - NICE Consultation January 2022

Talking Therapies Institutionalised Psychologising of Physical Health Problems

 

As a high intensity therapist working in IAPT, I’m finding an increasing amount of the people I see have chronic physical health conditions.  The training and supervision I receive emphasises my role as one of treating the depression/anxiety associated with these conditions, and not the condition itself.  This sounds plausible in theory, but my experience it just doesn’t work that way in practice. 
 
 
 
  1. Firstly, I get the distinct feeling that a lot of the time the people I see with chronic health conditions are not clinically anxious or depressed, they are just having a normal reaction to a really challenging situation.
  2. Secondly it is impossible for someone with my training and limited medical knowledge to know whether a symptom such as fatigue or poor sleep is down to anxiety or depression or other factors, including physical causes.
  3. I’m quite sure that I have treated people in the past, and will do so again, where symptoms arising entirely from an undiagnosed physical condition were misinterpreted as a mental health issue and I worry that there is a real danger, even with the best of intentions, of gaslighting people here, however sensitive and non pathologising I try to be. 
  4. Time and again I have had people tell me their symptoms were dismissed for years as being “all in their head”, and I worry I am inadvertently feeding into that damaging narrative. 
  5. Greater integration between physical and mental health care in the NHS can only be a good thing, but my experience is there is sizeable gap between the theory and practice on the ground.  IAPT is meant to be integrating more into physical health teams, in practice I am not sure how well this is really happening. 
  6. I know how hard staff on the ground in IAPT work and how dedicated the clinicians are, I worry we are being put in an impossible situation.  I’m very grateful to CBT watch for highlighting some of the predicaments that I can relate to in my day to day work.  

 

Identity withheld to protect the IAPT therapist

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

Mental Health Bewareness Week

the deeply unpopular sibling of Mental Health Awareness Week, who can be found muttering in the corner, that only the tip of the iceberg of those who receive routine Talking Therapy  recover, (see link, https://connection.sagepub.com/blog/psychology/2018/02/07/on-sage-insight-improving-access-to-psychological-therapies-iapt-the-need-for-radical-reform/).   Whilst his sibling proclaims a new dawn awaits us if Society would just provide more funds for the UK Government Improving Access to Psychological Treatment (IAPT) service, secondary care and MIND. This increased funding would she believes help in the colonisation of more and more areas of human suffering from Birth Trauma (see CBT Today May 2020) to long term conditions, with IAPT recovery rates of 50% already for depression and the anxiety disorders.

The focus of this year’s Mental Health Bewareness Week, might well be on the absence of any publicly funded independent evaluation of routine psychological treatment despite over £4billion of the taxpayer’s money being spent on IAPT. In the dire financial circumstances that the UK government finds itself in the questions for this week are:

  1. ‘What is the evidence that this money has been well spent?
  2. ‘If we consider a period before such expenditure, is there convincing evidence that the funding of IAPT for the last decade has constituted an added value?’
  3. ‘Is it appropriate to continue to fund agencies who have only ever marked their own homework?

Unfortunately the devotees of Mental Health Awareness Week are blissfully unaware that there is another story, of clients having been failed for the past decade with little prospect of getting a service that they would consider would return them to their normal (or best functioning).

 

Dr Mike Scott

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BABCP Response - NICE Consultation January 2022

In Practice, Off-The Shelf Solutions Silence IAPT Client’s Concerns

the Talking Therapist does the ‘talking’ not the client: 

Noreen was held at knife point in the corner shop in which she worked, she had flashbacks and nightmares of the incident. She was fearful of another armed robbery. Then she was a passenger in a car in which the driver lost control, became fearful of travelling by car and postponed her driving lessons. Noreen completed an Improving Access to Psychological Treatment (IAPT) telephone assessment in which she was scored 8 on the PHQ9 and 11 on the GAD7.  No diagnosis was proferred and the letter from IAPT to her GP said ‘agreed with us to be put on a waiting list for computer assisted CBT’. 3 months later she received a letter from IAPT saying she had been discharged because she had not activated her online therapy accoun.

1. No Listening Ear In IAPT – Noreen had multiple concerns: memories of the robbery, fear of car travel and several bereavements but there was no space for her to vocalise all these in her assessment. Instead she was offered an off the shelf solution computer assisted CBT but with no indication as to how this would remedy her concerns.

2. No Meaningful Agreement to Treatment In IAPT – IAPT makes a play of offering ‘customer choice’ but Noreen did not know what computer assisted CBT involved, much less what the evidence base was on it resolving her presenting complaints and how it compared in efficacy to other treatment options such as face to face CBT. In short IAPT does not offer informed choice, it offers tokenism with regards to customer choice.

3. No Meaningful Assessment in IAPT – Noreen was none the wiser about her difficulties after the telephone assessment and it is not at all surprising that she did not go onto engage in the computer assisted CBT

4. IAPT Blames The Client For Not Engaging In Treatment – the letter from IAPT to Noreen and her GP says ‘sorry you have not activated your…online therapy account….discharged’

5. IAPT Engages In Pseudo- Science  – reporting psychometric test results to GP’s, as if they have a meaning without reliable diagnosis. The social context of the client’s difficulties are deemed not worth reporting.

Low intensity interventions are off-the shelf solutions, their very availability makes them more likely to be deployed, despite their inappropriateness to the task in hand. Even brief attention to Noreen’s difficulties, would suggest a differential diagnoses of PTSD, a specific phobia about travelling by car and depression. If that was as far as the assessor got, and there is no indication that he got even that far, how on earth would this suggest the appropriateness of a course of computerised CBT!

Availability Heuristic The Off-the shelf low intensity interventions have created a new availability heuristic. Traditionally this term is used to describe the way in which the vividness of an experience e.g graphic memories of a serious accident give a mistaken impression of how likely it is [ see Daniel Kahneman Thinking Fast and Slow. Penguin Pres]. It seems that for the Psychological Wellbeing Practitioners who are the usual assessors of clients coming into an IAPT service have a particular familiarity with the low intensity interventions leading them to deploy them inappropriately. Further they may have a graphic memory of one client who did really well in low intensity CBT, oblivious that such a case is very much the exception. This use of the availability heuristic is heightened by the IAPT organisation declaring that low intensity interventions are to be the bread and butter of PWP’s.  Possible shortcomings of low intensity interventions are often glossed over by PWP’s on the grounds that if they don’t work the client can always be stepped up to high intensity, but such stepping up is rare about 10%.  There is a failure to acknowledge that a) if the first intervention does not work a client can become demoralised and dropout  and b) there is no independent evidence that a significant proportion of low intensity clients lose their diagnostic status as a result of this minimalist approach.

Noreen is yet another example of how IAPT fails clients and the problems are systemic, not confined to some PWP’s not adhering to best practice.

 

Dr Mike Scott