Has Routinely Collected Outcome Data Assisted In Answering, ‘What Works For Whom?’

 

Over 50 years ago Paul (1967) asked the fundamental question for psychotherapy “What treatment, by whom, is most effective for this in- dividual with that specific problem, under which set of circumstances” (Paul, 1967, p .111). The proud boast of the Improving Access to Psychological Therapies (IAPT) service is of a million referrals a year, with test results for 90% of treatment sessions [IAPT Manual 2019]. But despite the quantity of data IAPT has amassed over the last 14 years, it has been of no help to clinicians in answering this key question. It has simply been an added stress.

What is the function of the IAPT data? Is it to simply bamboozle paymasters NHS England/Clinical Commissioning Groups (CCGs)? Perhaps it is to improve the practice of IAPT staff? Even if this latter were the case, there is no evidence that this translates into an improved outcome for clients that they would recognise.

The irrelevance of the IAPT data set, can be gauged by inspecting the table below:

Treatment

Clinician

Characteristics of the client

Specificity of the Problem

Specificity of Psychosocial Functioning

There is no treatment typology within the service. Simply a claim that most clients get CBT in varying doses.

The service distinguishes deliverers of low and high intensity. But clinicians training varies enormously from clinical psychologists with Ph.Ds  to recent graduates who have done voluntary work.

Clients are not distinguished in terms of whether they may or not have a personality disorder or a neuro developmental problem.

The service has no typology of problems. It does not make diagnoses so cannot specify disorders, albeit that it allocates a diagnostic codes.

There is no framework within which to specify level of functioning

With IAPT’s data there are fuzzies in every column of Paul’s framework,  leaving its’ clinicians rudderless.

 

Dr Mike Scott

Paul, G. L. (1967). Outcome research in psychotherapy. Journal

of Consulting Psychology, 31, 109–118.

 

The Near Extinction of CBT

Evidence-based psychological therapies are near extinction. Their demise began in 2008 with the inception of the Improving Access to Psychological Therapies (IAPT) service. Aided and abetted by the British Psychological Society’s validation of IAPT’s Psychological Well-being Practitioner’s (PWPs) training programmes and the service’s fellow traveller, the British Association for Behavioural and Cognitive Psychotherapy (BABCP). Gone is the welcoming open door and the careful distillation of what ails the client, instead there is a 30 minute+ telephone conversation, with a third of people then not going beyond one treatment appointment.

 

The public most commonly receive PWP ministrations when they seek NHS psychological help. But the PWP’s do not follow any treatment protocol for any disorder, indeed they do not make diagnoses. How then can they be said to deliver CBT? By the spurious claim  that they can select a CBT strategy which is sufficiently potent. But they furnish no evidence of systematically following any strategy, notwithstanding that there is no evidence that CBT strategies delivered as stand alone interventions make any real world difference. The PWP’s deliver the Alice in Wonderland, Dodo verdict on CBT strategies ‘all are equal and must have prizes’. Raising the question ‘is CBT as dead as the Dodo?’

 

 

Where else might CBT be found? It is not impossible for it to be delivered in IAPT’s high intensity service, but few of its practitioners conduct a reliable standardised diagnostic interview which is the foundation for delivering CBT.  The  treatment integrity of high intensity CBT interventions has never been assessed.  No steps have ever been taken to ensure clinicians are dovetailing diagnosis appropriate treatment targets with matching treatment strategies. Is CBT to be found in private practice? It is possible, but private organisations have largely sought to ape IAPT in the mistaken belief that this confers credibility. Are the chances of finding CBT in private practice comparable to finding life on Mars?

Is CBT alive and kicking in secondary care? Here we enter the muddy waters of clients who might traditionally be regarded as having personality disorders (PD). But there is an understandable reluctance to use the term PD because of the associated stigma and because historically use of such a term has consigned people to the dustbin. Nevertheless Sperry and Sperry (2016) have produced the 3rd Edition of CBT for DSM-5 Personality Disorders (Routledge) but it is eminence-based rather than evidence-based. It is light on outcome studies. I struggled to find any where there was independent assessment of outcome by blind raters, use of an outcome measure that clients would regard as a minimally important difference and evaluations by those other than the creators of the protocols. It is a free for all with strategies such as ‘thought stopping’ recommended, without specification of any contraindications such as PTSD or OCD. Only eclipsed by recommending solution focussed therapy for anxiety. If clinicians in secondary care operate on this text it is very different to Beck’s own work on CBT for personality disorders. But no typology of what clinicians say they do and what they actually do in secondary care has been produced. Tertiary care seems preoccupied with crisis management and is not guided by any recognisable CBT protocol.

In neither primary or secondary care is there a differentiation of treatments or clients. Thus in the UK it is impossible to answer the question of ‘What Works With Whom?’. This leaves clinicians up a creek without a paddle.

Dinosaurs may have been wiped out by an asteroid hitting the earth 66 million years ago, but life survived, doubtless CBT will survive the impact of IAPT, but it is a close call and it is likely going to be down to individual practitioners doing what they know to be best for their clients.

 

Dr Mike Scott