UK: Improving Access to Psychological Therapies (IAPT) articles, blogs and discussion

Moved from this thread

Blog on current state of IAPT

https://survivingwork.org/after-quarantine/

 

Weird how all the failures that were obvious and poo-pooed while building this monstrosity by pureeing us into a false narrative of "ground-breaking benefits" are there in the final product. It's almost as if trying something and seeing it fail every single test along the way but pushing ahead regardless of cost or consequences is a terrible idea.

But, hey, to be fair, it was extremely obvious all along. Which is.... uh.... very extremely bad. It's almost as if if you have to cheat to get to the starting line, you have to keep cheating the whole race. Almost.

 

cbt watch
Declining IAPT – Clients Reject The Service
21st April 2020

full blog
http://www.cbtwatch.com/declining-iapt-clients-reject-the-service/

 

I would imagine they systematically were. We know those trials always have difficulty finding participants. They also have high dropout rates. I mean, a dominant theme in BPS literature is how difficult it is to get the patients to agree to participate in the first place. That didn't happen by chance, it's because they face those problems all the damn time.

We even now conveniently know this happened in FITNET-NHS, FINE and SMILE, given the doctoral thesis published trying to analyze why there was such widespread rejection from possible participants.

I would actually feel confident in suggesting there were very high decline rates all throughout that simply were never publicly acknowledged because why would they have, it would have looked bad. For all CBT for MUS experiments. All of them. About every condition I'm sure they faced the same difficulties of: finding willing participants, having those participants agree to weird nonsense, having those participants actually follow through with the weird nonsense and then getting those patients to report back for follow-up. At every stage they lose participants. The same as they see with IAPT.

I'm pretty sure PACE did? Or pretty close to. Probably several others by the PACE gang as well. They all showed no meaningful benefits. I have no doubt that when the history of how this happened is examined we will see the exact same problems, or even worse. It was entirely predictable that IAPT would face the same problems. Hell, PACE experienced it despite having had dozens of attempts over nearly two decades at getting it right and they still had all of those.

 

Duplicity In IAPT On MUS
1st May 2020

full post here:
http://www.cbtwatch.com/duplicity-in-iapt-on-mus/

 

In Practice, Off-The Shelf Solutions Silence IAPT Client’s Concerns
10th May 2020
"the Talking Therapist does the ‘talking’ not the client"

http://www.cbtwatch.com/in-practice-off-the-shelf-solutions-silence-iapt-clients-concerns/

 

Moving The Goalposts So That The Cheapest Talking Therapy Option Always Wins

full post
http://www.cbtwatch.com/moving-the-...-talking-therapy-option-always-wins/#comments

 

OK so I don't have statistical skills but I'm wondering how this is sustainable long term.

Perhaps someone can help me understand. If the Liverpool (for example) catchment area for serving IAPT is 100,000 people (for example) and 5% of that catchment used the service and 87% of them were cured then as time goes on long enough won't they surpass (eventually) the full population of people being served?

Of course in this scenario it would be good to know what % were initially served out of the whole.

Or have I made a wrong assumption in this?

 

Many thanks for sharing this:

'There were some common themes on what macro and micro measures could improve mental health services:

• stop using recovery and patient number targets
• de-linking IAPT from disability and unemployment benefits systems
• use IAPT appropriately for mild/moderate depression
• look at how to support primary care services that are failing
• investment in high intensity and high skilled therapists in the NHS so that complex cases can be treated and IAPT be reserved only for low intensity needs.
• capping the number of clients per day
• stop gaming data and misrepresenting the service
• change the measurements so that they are measuring something meaningful
• flexibility in the modality and therapeutic process'

As a psychologist who has also worked in the past in an IAPT service I've got a few comments:

• The clients I saw (as a cbt therapist) were never mild / moderate. Everyone was severe initially when I assessed them. Then it was often about doing a piece of work and then they would have to re refer later on to complete the work sometimes with a different therapist.
• The patients coming into the service were screened by PWPs. They had the least training and conditions like PTSD was frequently missed.
• This means that the most evidenced based therapy was not given. Either they would disengage or re refer when the computer cbt was over. The later is rarely useful.
• There was no link between benefits and unemployment benefits system. Since I left there are work advisors in the IAPT service. They are fantastic at keeping people with health conditions in work. Really knowledgeable and I use them in another NHS service.
• IAPT was sold as a way if reducing benefits bill. Suspect with such low overall outcomes (see Scott) this has been overstated.
• The majority of the people being seen by IAPT do not receive evidence based therapy. It's mainly group work on 'stress management' and so forth which has dubious evidence base. About 5 to 10% received CBT or counselling where there is an evidence base but my view would be that this can be at less than necessary therapeutic dose to be effective.
• Therapists need to be trained in highly effective therapies across the board and patients matched with appropriate therapists and working models.
• Structured clinical interview (SCID) etc as a way of assessing patients was not used routinely. I was the only psychologist in my service (I qualified when I was working in the service) so I could do whole person assessments. No one else in the service was trained or proficient in doing this. Result was many conditions and difficulties were missed and therefore not treated. Assessment is often therapeutic if done well. Measures need to be meaningful in the real world.
• The is an over reliance on PHQ9 and GAD7 measures. They give an indication of change but tell us nothing about whether the patients still meet criteria for x or y condition. And I suspect as the measures are completed at each session that some will give socially acceptable answers. Others like impact of events scale were also used which is helpful in trauma work.
• IAPT have never been externally audited. NAO did start an investigation which was dropped due to Brexit. I recently did a FOI request and there are no plans to audit or investige. IAPT can continue to mark their own homework.
• People on the wait list who didn't respond to phone calls would routinely be discharged.
• I think that is it from me for now.

Please let me know if you would like to discuss further.

I'm super critical of the idea IAPT can incorporate ME via MUS. I'm actively chasing this up with IAPT services, CEOs of NHS advertising which includes MUS, Action for ME taking this matter further. It'll be a slow burn with covid I suspect.

Bw
Joan Crawford
Counselling Psychologist
Chester
Uk

 

I recently had a letter rejected from the Journal of Psychosomatic Research re MUS. My colleague Dr Mike Scott has popped it on his blog:

http://www.cbtwatch.com/duplicity-in-iapt-on-mus/

Bw
Joan Crawford
Counselling Psychologist
UK

 

Bolding mine.

This is definitely true. In addition to wanting to give socially acceptable answers -
- Patients may fear that if they don't respond favourably, or ro show willing/cooperation it may impact on further care. Especially if a negative report might be sent to the GP.
- With benefit advisors in the mix they may feel answering negatively might negatively impact claims for benefits.
- Patients might be temporarily enthused during the session, purely by dint of someone spending some time with them and so may be overly positive or optimistic in responses.
- Patients with ME or any other conditions where stamina is limited and overexertion can lead to adrenaline spikes may well be running on adrenaline by the end of a session. In my own case this usually leads to me overestimating what I can do and underestimating what it will cost me. It's when I make some very poor decisions.

To gain an accurate picture from.the patient and make best use of a therapist's time, surely it would be more appropriate for the patient to take the forms home with them and fill them in at their leisure at home? This will still leave some of the possibilities of bias open but I understand there may be some need to "measure" something in the individual patient's progress.

The overall value of such clinics shouldn't rely on forms or questionnaires filled in to record individual patients progress however. This is far too.open to risk of bias. This type of form should be wholly anonymous.

 

I could write for hours on this, but to be brief: I've just started counselling which of course is currently over the phone. I made it clear from the start that I do not rate the questionnaires and PHQ9 / GAD7 scoring at all. My counsellor agreed. We also spoke about how the answers largely depend on how my ME symptoms are. I asked whether I should try separate out my M.E from my mood/anxiety problems to answer the often vague and poorly thought-out questions, to generate the scores. She said yes, but I found I couldn't.

Just a load of crap!

 

Hi there,

"To gain an accurate picture from.the patient and make best use of a therapist's time, surely it would be more appropriate for the patient to take the forms home with them and fill them in at their leisure at home?"

That can be done for sure - especially for those who struggle to focus and so forth. The forms being filled in each week (GAD/PHQ) is ridiculous. It's overkill. Something that might be helpful in a clinical trial. Therapists ideally would be able to use their clinical discretion and be empowered to do so. When I see a client/patient (not in IAPT - I don't work there any longer) I assess difficulties and agree these with the patient. Part of this process is to use appropriate psychometrics to guide the process of therapy. I might redo them if things were not working or if the person had other event that impacted a lot on therapy. And redo them at the end of therapy (if necessary or appropriate) they'd get done to allow the progress made (or not) to be contextualised. This ideally would be openly discussed with the client and it's aim is to make the process intelligible and to ensure that the clients issue are focused upon. That's my aim along with discussing how we might go about therapy, the process, the model of therapy being used, expectations, the work to do and to gain informed consent.

"This will still leave some of the possibilities of bias open but I understand there may be some need to "measure" something in the individual patient's progress.

The overall value of such clinics shouldn't rely on forms or questionnaires filled in to record individual patients progress however. This is far too.open to risk of bias. This type of form should be wholly anonymous."

Bias is going to be a problem if psychometrics are overused and patients know what is expected of them. It's not all negative as patients can see when they have engaged well and made a lot of changes / hard work and it's nice for them to see this work reflected in the questionnaires and so forth and how meaningful this is for them.

On entering IAPT, ideally people would be assessed independently by experienced clinician using SCID, semi-structured interview, psychometrics and so forth. Currently PWPs (the least qualified clinicians in IAPT do the triage and assessment - bonkers). Then their therapy completed by another clinician - the most appropriate for the work - and the best method of therapy - and the scope and focus. After therapy they return to the original clinician for a review and summary. That independent overview can be really important. This is what happens more often in medico-legal cases. That requires resources which I don't think are beyond IAPT. And the dose of therapy needs to be optimal to the person. And the frequency needs to be workable too. Weekly is often way too much for pwME. A canny clinician in IAPT can achieve a lot but they need to know their evidence base and be prepared to stand up for their work and clients. I think many do not know evidence base and some feel a bit overwhelmed by the system.

 

Frustrating for sure. The system just doesn't get it...... It's a bit much to ask you to separate out symptoms. They overlap a lot. Ir's up to the clinician to figure this out - not the patient. This is why pwME need experienced clinicians otherwise it can become a bit complex for no good reason. No gain in it.

I hope you can focus on what's important for you. It is your time and energy

 

The reason for the completion of forms before the start of every session is so that they can report a 'successful completion of treatment' after just a minimum of 2 sessions of CBT. It's almost as if they predicted when designing the IAPT system that a large proportion of clients would become quickly disillusioned with the quality of the service and drop out after just 2 sessions...

If I was taking a week's course of antibiotics and only took them for 2 days because I felt 'better', would the doctor be able to spin this as a 'successfully completed treatment?' Or 2/6th of a course of chemotherapy? Why is IAPT the exception? Oh let me think...

 

I don't recall why IAPT have evolved to ask pt's to complete PHQ9 / GAD7 at each therapy session. That info has fallen out of my head.... I suspect it is a relic from what researchers have done in CBT trials.

GAD/PHQ can be helpful to track therapy progress but this is not necessary on each clinical encounter and should be at the discretion of the treating clinician based on clinical need for the information. IAPT has a tendency to undermine clinicians in this regard unless they have the confidence to gently challenge it. Psychologists would develop this skill during training but PWPs and CBT therapists are not routinely taught to defend their practice i.e. by giving an opinion based on evidence and clinical judgment. Essentially a referral into IAPT is asking for an opinion and treatment plan (if possible) along with willingness / ability / readiness of pt to engage. This in my view needs to be done by the most experienced and not the least experienced/qualified clinicians. IAPT get this cart about horse which is where things are missed and appropriateness / readiness for therapy is not often established competently before therapy begins.

The CBT in IAPT is not set up to be 'completed' successfully within 2 sessions - that's bonkers. The only case where this might become close to being true is CBT for health anxiety. That often resolves with 2-3 sessions - but it'd be realistic that an uncomplicated case would be scheduled 8-10 sessions. Every other area where CBT is used (trauma, social anxiety, phobias and so forth - largely the anxiety conditions) the evidence base is for 8 (and I argue this is often too little) to 12 through to about 16-20 when you have complex, chronic trauma along with perhaps onset of chronic pain. IAPT pretty much limits clinicians to 12-16 sessions - on average - so there is a driver or pressure to limit / minimise that can lead to sub optimal doses of therapy - and that then suggests the service does not believe the equity of physical and mental health - which the NHS ideally needs to be moving towards. If IAPT competently assessed before therapy started and an estimate of number of sessions was made - and then delivered - and then evaluated. That would be better and would make better, more targeted use of resources.

For the pt's what currently happens is that:

- the pt feels let down and disengages early on
or
- the pt completes a significant block of therapy work (this makes more sense for trauma) and then takes a break and re-refers to the service when they feel that they want to move on to work on further material.
or
- pt works for 8-12 sessions and largely resolves their difficulty successfully and feels competent to move on.

The former is clearly unhelpful and IAPT should be help to account for how they manage this. The second can be useful but clinicians should be managing this anyway - no matter where they work. The 3rd makes sense for many of the issues IAPT are supposed to work on - but life is messier than this and many referrals to IAPT are complex and need advanced skills. More funding in secondary care would be helpful here....

Pt's need flexibility to some degree to be able to say - this is not for me now - but I'd like to come back later on when I am ready and I have the resources to engage well in therapy. That's a basic of clinical practice for clinicians to navigate this and to be honest with clients - that's not failure - it's life. So within IAPT, that outcome would not be recorded with enough detail - the why pts stopped therapy after starting? That needs to be examined and recorded. And why pts feel let down and disengages - there are multiple factors here. Again independent assessment would be a help to unravel this.

So much to improve

 

It was built into the IAPT model from the very beginning:

http://ipnosis.postle.net/PDFS/iapt-outcomes-toolkit-2008-november(2).pdf

 

Thanks for that. More about gathering of data than anything.

"The IAPT programme’s success has been defined by its participant’s ability to collect routine outcomes data." Wow defining... really.

Every NHS service collects routine clinical outcomes. Services are commissioned in part by these. It's not defining - it's the norm.

For example, I complete the internal audit of the outcomes - both qualitative and quantitative - from my service and report this to commissioners (CCG). That's normal - not defining. What defines our service is that we provide good quality service to GPs and patients and therefore the taxpayer. And we can defend what we do with evidence of effectiveness and so forth........ and I would happily demonstrate this to external audit too.

I'm sure there are lengthy debates about the usefulness / appropriateness of GAD/PHQ at every session..... I mean it is helpful to have data - but if there is no data about 'why' people drop out then it becomes a bit of a 'so what'. It's not necessarily a good measure of success or failure (who's success or failure - IAPT or pt...??) without qualitative data and / or independent review / assessment / re-evaluation. Only one side of the process is being evaluated. It's IAPT's version of events only. Marking their own homework without determining the validity of the process. No external audit. One positive is that pts can see how their levels of distress have changed week to week which can be encouraging. Periodic (not every week) review and feedback is part of therapy anyway.

From a quick skim read of the 2008 document above it smacks of lack of trust / belief in the clinicians and the service. Little about quality of therapeutic relationship and so forth. Sad.

No examination as to the impact on the therapeutic relationship of endless form filling each session either. There is mention of possible qualitative data collection but that wasn't in place in 2016/2107 when I worked in IAPT - it wasn't a requirement or an outcome.

From my experience in IAPT, most pt's will oblige and feel neutral about GAD/PHQ at each session - I would ask them about this. However, to some it will be annoying, irritating and upsetting. Poor reading and writing skills is pretty common, dyslexia, cognitive problems and so forth. It is, I think, important to check it out - it might be embarrassment re skills. A well trained therapist would do this as it informs. It can reveal more about a person's view on therapy and so forth i.e. do they see it as demeaning (the whole process - not just the form filling) and if so, why?

For illustration: One severe ME example: I had a pt who I saw in the community due to her severe ME. She was seen later on at home by another clinician who insisted on PHQ/GAD each session. That was after she had been given my neuropsychological report....sigh.... Anyway, this was way too much and would take her pretty much all of the session to compute and complete the Q's with the therapist's help!!! So, no time for what she wanted to discuss..... Hugely frustrating.... There has to be flexibility to allow occasional use - and even then for some pts that'll be too onerous. It should be led by clinical necessity and judgement. Plus clinicians need to ideally check out problems when they witness them. For the few that this would apply too it's hardly an issue....

IAPT have more than 10 years now in operation. It must be time for a review of the operating model so that it benefits the therapeutic process not for it to be defined by form filling for evidence....... Haven't they got enough evidence by now? And what is the quality of that evidence and does to gather the data that is needed to demonstrate effectiveness and value? An external view / audit / review is needed and I'm pretty sure that this has not been undertaken. This really needs to be done by professionals from outside the CBT / IAPT bubble.

Joan Crawford
Counselling Psychologist
UK

 

Oh so this is like what they did with PACE for people who dropped out they just used the last score.

When you normalize fraud you get more fraud. When you need fraud to push something to the starting line you have to keep the fraud all the way through the race. But fraud gets heavier and heavier to bear as you progress because people expect results and you can only scam so many people for so long.

I'm really not big into that fraud-based evidence thing but whatever I'm not a professor of reliability of evidence or some fancy title like that.