Trial By Error: My First Post on the IAPT Program / David Tuller

Cheshire

Cheshire

Senior Member (Voting Rights)
New Trial by Error by @dave30th

Since 2008, the English arm of the National Health Service has been rolling out a program called Improving Access to Psychological Therapies, or IAPT. More than 900,000 people now receive IAPT services annually. This program arose out of the notion that many people were suffering from untreated depression, anxiety and other psychiatric disorders, and that a more streamlined system was needed to ensure that they received appropriate psychological therapies. In parallel with that, it was further suggested that the program should be expanded to people with long term conditions (LTCs), such as diabetes and cancer, as well as those suffering from so-called “medically unexplained symptoms” (MUS). The main but not the only therapeutic intervention offered through IAPT is cognitive behavior therapy.

The assumption behind the expansion was that IAPT, by reducing the medical demands of those suffering from LTCs and MUS, would generate significant savings in the overall health care budget—enough, in fact, to cover costs associated with the IAPT program itself. This prediction was based on the idea that psychological issues can exacerbate the health and medical problems of people with LTCs and actually generate the symptoms experienced by people identified as having MUS. Providing these patients with CBT or other psychological modalities would presumably then reduce their need to seek out expensive medical care for their physical complaints.
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An important issue that is regularly debated here but needs to be understood by a wider audience, thank you @dave30th.

Having put some effort into my comment on this on the Virology Blog, to feel I am getting full value, I have copied it here too, even though it is only repeating what many have already said on previous threads:

Thank you for continuing to raise the spectre of this bizarre invented psychiatric diagnosis of MUS, which lacks any supporting evidence base for its existence as a distinct condition.

As you point out David its proponents are leaping from the fact that there are patients seen in clinical practice whose symptoms are not yet fully understood medically to a belief that they all have a psychiatric condition that can be treated as a homogenous group from the point of view of intervention. This distorts a pragmatic classification into a false diagnosis. It makes as much sense to offer a single treatment to everyone with conditions beginning with the letter 'A' or to everyone aged over 65 regardless of their actual symptoms.

A significant number of English Health Authorities are seeking to impose this unevidenced belief system on their areas through such as this IAPT programme, in direct conflict with the WHO classification of ME as a neurological disorder.

There are many medical conditions that we do not understand fully the existence of which is not doubted. In contrast ME has many associated biomedical abnormalities including a disordered glut flora, abnormal energy production at a mitochondrial level, neurological abnormalities, cardiovascular issues, etc which the MUS advocates are happy to pretend do not exist. Because we do not medically understand a condition does not a priori make it a psychiatric condition, indeed the documented medical abnormalities strongly support the interpretation that the medical understanding is currently at fault rather than the condition being imagined. Worse than this, the recommended response makes the entire process a circular logically meaningless diagnosis in that doctors are told patients with MUS should not be offered medical assesment or intervention as this will reinforce their false beliefs. So a diagnosis of MUS can never be challenged as these patients are to be refused any opportunity to have their symptoms medically explained.

Given ME in some case can be fatal, but more over there are higher levels of comorbities such as coronary heart disease or cancer in people with ME, how many people will have to die before this nonsense is effectively challenged.
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Ability to help client feel that their experience of CFS/ME is being listened to and respected (i.e. acknowledging that they are experiencing real, physical symptoms)
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Is in reality more like:

"Ability to help con client feel that their experience of CFS/ME is being listened to and respected (i.e. pretend you are acknowledging that they are experiencing real, physical symptoms)"
 
Sly Saint said:
not relating to Cochrane, but Trudie Chalder and COI;
I knew she'd written a book (widely publicised on NHS sites), but found on Amazon that it's so much worse:
https://www.amazon.co.uk/Books-Trudie-Chalder/s?ie=UTF8&page=1&rh=n:266239,p_27:Trudie Chalder

Are the versions of her book/s that are translated into other languages also advertised on the various countries health services sites?
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I notice the description for the book co authored with Mary Burgess
Overcoming Chronic Fatigue: A Books on Prescription Title (Overcoming Books) Kindle Edition

Contains the following
The result is a proven reduction in symptoms and disability in up to two-thirds of CFS sufferers.

Based on recognized CBT techniques
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(Bolding mine)

Wonder if it's worth raising this with the advertising standards authority?
 
Trish said:
Thank you @dave30th. I'm glad you're tackling this.

Reading the quotes from the Chalder training document feels like a massive attack from a creature from another planet. How can she be so dumb and ignorant and dangerous and get away with it?
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Just looking at a small section on the first unit is disturbing:
HEALTH WARNING: May make you feel nauseous/angry/.....

"UNIT 1.3: Psychological processes associated with distress, depression and anxiety in the context of Long Term Health Conditions

Aims To give practitioners an understanding of psychological processes that contributes to the development and maintenance of distress, depression and anxiety in people with LTHCs

Competences covered in this unit

Ability to draw on knowledge of the relationship between distress, depression and anxiety and the negative appraisal of symptoms and illness

Ability to draw on knowledge that negative appraisals can be magnified by unhelpful beliefs

Ability to draw on knowledge that interpretations and appraisals are central to the development and maintenance of distress and disproportionate disability

Ability to draw on knowledge that maintaining processes can and do worsen negative interpretations (and physical as well as psychological functioning), so creating cycles of feedback (“vicious circles”) "
 
For those with strong stomachs/feeling resilient...

"Ability to draw on knowledge of specific psychological process that contribute to the development and maintenance of distress, depression and anxiety, such as:

 attentional processes that increase the perceived severity and pervasiveness of sensations and symptoms

 safety seeking behaviours (for example, excessive checking, avoidance of physical activity or situations, excessive reassurance seeking) which are understandable in the short-term, but which (in the long-term) tend to strengthen unhelpful beliefs, increase preoccupation and exacerbate concern

 rumination in the form of catastrophising and/or worry (“preparing for the worst”) which in turn primes negative ideas and increases preoccupation

 imagery and intrusive memories, increasing negative appraisals and impacting mood disturbance"
 
Last section for now:

"unhelpfully restrictive behaviour, such as generalised withdrawal from physical activity or from role-related activity (such as relationships, work, hobbies), leading to impaired mood, confirmation of unhelpful beliefs, reduced self-efficacy and disengagement from rewarding activities

 changes in mood (particularly anxiety and depression) contributing to mood-appraisal spirals

 emotional avoidance/suppression (for example linked to anticipated emotional responses and unhelpful beliefs about those emotions, or “blotting out” illness ideas, but with regular intrusions and unease as a consequence)

 all or nothing (“boom or bust”) behaviours (undertaking activities beyond the level of which the person is physically or psychologically capable, resulting in symptom surges (e.g. fatigue, pain) and leading to more negative appraisal

 interpersonal changes (such as those linked to a sense of unfairness, bitterness, mental defeat) eliciting negative or overly solicitous responses from significant others

 disengagement from significant others because of the health condition

 disuse and deconditioning originating from fear/avoidance patterns

Ability to draw on knowledge of factors and mechanisms that can potentiate (and mediate) vulnerability to distress, depression and anxiety, such as:

 perfectionism (setting unrelentingly high personal standards and concern about mistakes (both social and non-social))

 psychological inflexibility (becoming “stuck” in a particular view of the illness and situation, and so limiting access to alternative, less negative understandings"
 
It strikes me that all this provides the perfect means of dismissing / minimising / ignoring any complaints made by those suffering with LTC about service quality and delivery.

If you're not happy, no matter how you've been treated (or mistreated) then that's your faulty perspective. You are only as ill as you think you are.

Perfect set up to gaslight patients while you go about cutting services.
 
Each time I read Chalder's prose I feel like vomiting.
The lack of empathy, kindness and so on, of Chalder is beyond me. She should never be allowed to be near someone suffering.
A screening for sociopathic tendencies should be mandatory before anyone enters the field of psychology.

I remember reading this kind of stuff (because it's always the same processes that these so called psychologists recycle ad nauseam) for children with MS. The message is basically "Oh stop being a catastrophiser drama queen"

There's no limit to the scorn I feel for these people.
 
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There an answer for every type of behaviour. If you don't do things that might cause a crash it is 'avoidance' behaviour, if you do things that cause a crash it is 'all or nothing' behaviour, meaning there is an answer for any behaviour regardless of any internal logical consistency. Any behaviour no matter what it is, is used as confirmation of the somatisation. This is not science in a traditional Popperian sense, which requires an hypothesis that can be falsified.

Chalder is practising what @dave30th decribed as 'woo woo' therapy. The only other time I have come across such blatant self fulfilling theorising was when I foolishly allowed myself to be persuaded to see an homeopath: when a 'prescription' was associate with improving symptoms this meant that it was working, and when it was associated with worsening symptoms it meant that it was working (though quietly you switch to something different).

Such blatantant anti-science behaviour is unacceptable in any health care researcher or professional. When will she use Occam's Razor and realise that the simplest explanations is that patients are responding rationally to an underlying medical condition.
 
MEMarge said:
Last section for now:

"unhelpfully restrictive behaviour, such as generalised withdrawal from physical activity or from role-related activity (such as relationships, work, hobbies), leading to impaired mood, confirmation of unhelpful beliefs, reduced self-efficacy and disengagement from rewarding activities

 changes in mood (particularly anxiety and depression) contributing to mood-appraisal spirals

 emotional avoidance/suppression (for example linked to anticipated emotional responses and unhelpful beliefs about those emotions, or “blotting out” illness ideas, but with regular intrusions and unease as a consequence)

 all or nothing (“boom or bust”) behaviours (undertaking activities beyond the level of which the person is physically or psychologically capable, resulting in symptom surges (e.g. fatigue, pain) and leading to more negative appraisal

 interpersonal changes (such as those linked to a sense of unfairness, bitterness, mental defeat) eliciting negative or overly solicitous responses from significant others

 disengagement from significant others because of the health condition

 disuse and deconditioning originating from fear/avoidance patterns

Ability to draw on knowledge of factors and mechanisms that can potentiate (and mediate) vulnerability to distress, depression and anxiety, such as:

 perfectionism (setting unrelentingly high personal standards and concern about mistakes (both social and non-social))

 psychological inflexibility (becoming “stuck” in a particular view of the illness and situation, and so limiting access to alternative, less negative understandings"
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Psychological inflexibility? I assume they are referring to the psychologists who are completely inflexible.
 
from CBTwatch (comment):

"I would suggest that all those at the top of policy making and management know very well that the statistics produced about IAPT are rubbish but they all carry on living the lie so that they can claim to all those not in the know of how these stats are produced that they are running a well funded and effective service."

"Look closely at the stats and you will see ever diminishing reporting of anxiety disorder specific questionnaires (so recovery only based on the basic GAD and PHQ), a reclassifying of people who do not recover as non IAPT (so you will see less people in the stats finishing therapy than starting it), and of course nothing done about the fact that “entering treatment” gets classified as happening at triage because a few bits of information are given out to the patient, while the real waiting lists are not reported on."

http://www.cbtwatch.com/deluded-secretary-of-state-for-health-and-social-care/#comments

the whole set up smacks of PACE style manipulation.
 
Sean said:
At what point does this appalling drivel become fraud and assault?
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About 20 years ago. Their legacy will reflect this and the class action lawsuits will be huge and numerous.

But the main culprits aren't the researchers, it's the enablers, those who knowingly fail at their basic duties in the face of harmful pseudoscientific crap and blatantly fraudulent research. It's not exceptional that quack researchers driven by ideology exist in any field of science. What is exceptional is that they have monopoly on a topic they have negative knowledge of (in that they genuinely understand less than those who know nothing about it) despite being a minority in the field itself and not having a single bit of objective evidence.

Over time I'm feeling myself more and more driven by a need to dispense some justice (the legal kind, don't worry). It's as good a motivation as any, I guess. But having insulted and maligned a group of patients that include some damn smart folks, including medical professionals, will severely blow up in their face. It's just a shame that it will do so late, they will hardly pay any price for it. The enabling institutions will, however. They will pay heavily, literally.
 
rvallee said:
About 20 years ago. Their legacy will reflect this and the class action lawsuits will be huge and numerous.

But the main culprits aren't the researchers, it's the enablers, those who knowingly fail at their basic duties in the face of harmful pseudoscientific crap and blatantly fraudulent research. It's not exceptional that quack researchers driven by ideology exist in any field of science. What is exceptional is that they have monopoly on a topic they have negative knowledge of (in that they genuinely understand less than those who know nothing about it) despite being a minority in the field itself and not having a single bit of objective evidence.

Over time I'm feeling myself more and more driven by a need to dispense some justice (the legal kind, don't worry). It's as good a motivation as any, I guess. But having insulted and maligned a group of patients that include some damn smart folks, including medical professionals, will severely blow up in their face. It's just a shame that it will do so late, they will hardly pay any price for it. The enabling institutions will, however. They will pay heavily, literally.
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You've been very kind to retweet/like my tweets regarding this on Twitter. I feel very strongly about this. I would be astonished if at least one person has not already died as a result of them being seen as an MUS 'type'. This is so going to court.
 
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