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

[Sean]

How did the human race make it so far without CBT?

 

[Sly Saint]

2019-2020 report on IAPT services
https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf

The integrated services pilot programme
From January 2017, a subset of IAPT providers are taking part in a pilot programme
offering psychological therapy that is integrated with physical healthcare for patients
with pre-existing long-term health conditions and/or medically unexplained symptoms
7
.
This pilot programme is being supported by the collection of additional data items
alongside routine IAPT submissions. An assessment has been made of the impact of
this new collection on the data submitted by providers taking part in this pilot that has
contributed to this report, which is summarised below.
The additional items collected are appointment-level fields; that is, they are collected
during each patient contact for relevant referrals and submitted as an additional data
table that is linked to the main appointment table in the IAP
T dataset. Where this additional information is not provided, it does not affect the main appointment table, and for referrals where the new information is present, it does not affect the
methodologies used in any of the analyses in this annual publication , or routine
monthly or quarterly IAPT publications. New data items are analysed and reported in a
separate publication product, available alongside monthly publications from March
2017 Final at www.digital.nhs.uk/iaptreports
.
Please refer to these monthly
publications for further details of the pilot including details of the providers who are
participating in the pilot collection

I can't figure out where the relevant data is out of this lot

https://digital.nhs.uk/data-and-inf...s-to-psychological-therapies-data-set-reports

maybe someone could take a look?

 

[rvallee]

This has been reported for several years, in identical terms. Nothing was done, so naturally nothing changed.


NHS mental health therapists pressurised to exaggerate success rates, expert claims
https://www.independent.co.uk/news/health/nhs-therapists-patients-manipulate-data-b1908629.html

Elizabeth Cotton, of Cardiff Metropolitan University, an expert in mental health at work, said that more than four in 10 – 41 per cent – of therapists working for the NHS’s talking treatments programme had been asked to manipulate data about patients’ progress.

The action is designed to improve the scheme’s apparent achievement rates, although NHS chiefs insist patients’ views are recorded when therapists are not present.

...

One therapist had reportedly been advised by their manager that “I could complete forms on behalf of clients to get the best results”.

Another said: “Actual human experience was secondary to creating data which would shore up the evidence base for the model to justify the economic argument and guarantee further investment.

“The whole system represents a big self-reinforcing loop relating to success in terms that had been self-defined by the system.”
​

 

[Sean]

Anybody here surprised?

 

[Hutan]

That's a pretty important find @rvallee- the therapists are exaggerating the benefits of talking therapy, and even with that, the performance data of IAPT still looks rubbish.

Elizabeth Cotton looks like she might have some useful things to say:
https://www.cardiffmet.ac.uk/management/staff/Pages/Elizabeth-Cotton.aspx

My current research focusses on the sociology of work and the link between working conditions and mental health. I am currently writing about the 'Uberisation' and digitalization of mental health services and the impact of Covid-19 on academic work, particularly for people with caring responsibilities.

I am an Editor in Chief of the British Sociological Association's ABS4 Work, Employment & Society (WES) which publishes on key debates about the future of work.

I am also a Senior Fellow of the HEA, Academic Member of the CIPD and member of the British Sociological Association and Association for Psychosocial Studies and a member of the Partnership for Counselling and Psychotherapy.

Research
My research currently focuses on mental health at work, digitalisation and AI and the impact of Covid-19 on mental health and public services.

The Future of Therapy

In 2017 I carried out a large survey of mental health workers in the UK looking at working conditions and employment relations as well as two subsequent surveys on working conditions in IAPT surveys (carried out for BBC Radio 5 Live November 2019) and current survey into the impact of C19 on therapeutic services. The research results have been published and disseminated through www.thefutureoftherapy.org. In 2019 I carried out a survey of IAPT workers including information on performance management and issues of workforce burnout. In 2020 I carried out a survey of mental health workers and the impact of Covid-19 on their work and own mental health. These surveys are being produced for publication during 2020.

Edit - oh, she does have interesting things to say, and features in the first post of this very thread:
UK: Improving Access to Psychological Therapies (IAPT) articles, blogs and discussion

No one who could do something about it is listening.

 

[Hutan]

“IAPT should be scrapped. I think this kind of business model in health is doomed. We need to accept that a thin scraping of care for more people isn’t care. Yes we would go back to huge waiting lists but at least those who were seen would get good care. Staff would be retained then as well and expertise would stay within the NHS.”

This thread and the links have information that I think is really relevant to the forthcoming NICE roundtable about the ME/CFS Guideline. Good therapists know that a lot of what they are required to do isn't helping anyone. If counselling services are stretched, target them to people who want them and might benefit from them, and stop pretending that they are going to fix ME/CFS or MUS.

 

[Invisible Woman]

"NHS chiefs insist patients’ views are recorded when therapists are not present."

What's that got to do with the price of fish?

I rarely saw my boss face to face. He still existed, expected certain standards from me and was a part of my appraisal process so even if he was in a different county he still had significant influence on me.

There are myriad ways in which a therapist can have influence on a patient and that doesn't stop the minute they are no longer in the room. If that were the case then therapists would be pointless because the effect they would have would instantly disappear the minute the patient left the session.

So either the therapists have an effect on the patient and influence them or they don't. If they don't there's no point to the therapy and the whole thing is a waste of money anyway.

Or am I missing something?

 

[rvallee]

"NHS chiefs insist patients’ views are recorded when therapists are not present."

What's that got to do with the price of fish?

I rarely saw my boss face to face. He still existed, expected certain standards from me and was a part of my appraisal process so even if he was in a different county he still had significant influence on me.

There are myriad ways in which a therapist can have influence on a patient and that doesn't stop the minute they are no longer in the room. If that were the case then therapists would be pointless because the effect they would have would instantly disappear the minute the patient left the session.

So either the therapists have an effect on the patient and influence them or they don't. If they don't there's no point to the therapy and the whole thing is a waste of money anyway.

Or am I missing something?

It's a way of saying that when the relatively small number of patients who do fill in the questionnaires, they are not influenced by someone, while they fill it anyway, nevermind that most of those "therapies" are about downplaying symptoms/issues, so the influence is basically everywhere but the moment they fill in the questionnaires.

It's a deflection from the issue that therapists sometimes fill in missing questionnaires, which is far worse, so they put the focus back on a misrepresentation of another issue, technically incorrect anyway, as the bias is baked into the whole process from the start. Basically a politician/shady prosecutor's answer of the type "your honor, the witness is not currently being intimidated", which may be true for the duration it takes to say it, technically speaking. As long as there is no duty of candor, or some inconvenient stuff like that anyway.

 

[Invisible Woman]

It's a deflection from the issue that therapists sometimes fill in missing questionnaires, which is far worse, so they put the focus back on a misrepresentation of another issue, technically incorrect anyway, as the bias is baked into the whole process from the start.

It's that it's so blatant that really annoys me.

Bad enough when people are treated like idiots but to so blatantly treat them. like fools is just rude.

I really wish it were unbelievable that they get away with it but ........ sadlyit isn't.

 

[Sly Saint]

BPS has been strangely mute on the fact that two self-report measures have been pressed into service to validate IAPT’s approach, with no suggestion that such an approach needs to be complemented by independent clinician assessments that go beyond the confines of the 2 disorders (depression and generalised anxiety disorder) that the chosen measures address.

If a drug company alone extolled the virtues of its’ psychotropic drug, BPS members would quite rightly cry ‘foul’ insisting on independent blind assessment using a standardised reliable diagnostic interview.

But from the BPS there has been a deafening silence on the need for methodological rigour when evaluating psychological therapy.

This reached its’ zenith In the latest issue of The Psychologist, September 2021, when the Chief Executive of an Artificial Intelligence Company, was allowed to extol the virtues of its’ collaboration with four IAPT services. No countervailing view was sought by The Psychologist, despite it being obvious that the supposed gains were all in operational matters e.g reduced time for assessment, with no evidence that the AI has made a clinically relevant difference to client’s lives.

 

[Sly Saint]

IAPT communications have an agenda, their focus is on persuading their source of revenue, local Clinical Commissioning Groups (CCGs) to expand funding, to cover staffing costs of £0.5billion by 2024. To achieve this goal it uses language that is familiar to the GPs that comprise CCGs, ‘NICE compliant’, ‘recovery’ and claiming a comparability of outcome to those in randomised controlled trials. But CCG’s are themselves under orders from NHS England, who have never critically appraised IAPT’s claims.

The secret to breaking the IAPT Code, is strangely its’ use of the ICD-10 code (the World Health Organisation’s labelling system for all disorders).

The recent IAPT Manual (August 2021)
https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf

recommends that IAPT clinicians give at least one code to each client, to characterise their debility.

But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis.
An ICD-10 code is only as reliable as the diagnosis made.

The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant.

However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol.

A key part of IAPT’s code is to gloss over that IAPT’s interventions are based, not on diagnosis but on ‘problem descriptors’.

http://www.cbtwatch.com/decrypting-the-improving-access-to-psychological-therapies-iapt-code/

 

[Sly Saint]

The Improving Access to Psychological Therapies Manual (updated Aug 2021)

Chronic fatigue syndrome*
Comprises a range of symptoms that include fatigue, malaise,
headaches, sleep disturbances, difficulties with concentration and
muscle pain. A person’s symptoms may fluctuate in intensity and
severity, and there is also great variability in the symptoms
different people experience. It is characterised by debilitating
fatigue that is unlike everyday fatigue and can be triggered by
minimal activity. Diagnosis depends on functional impairment and
the exclusion of other known causes for the symptoms.

Chronic fatigue syndrome
Graded exercise therapy, CBTi NICE guideline:CG53

i Specialised forms of CBT

33 Table 6 : IAPT outcome measures by problem descriptor

Chronic fatigue syndrome

Depression symptom measure: PHQ
Recommended measure for anxiety symptoms or MUS : CFQ

https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf

 

[Sly Saint]

The Spinning of CBT

Michael J Scott, Joan S Crawford and Keith Geraghty

There has been a massive expansion of psychological therapy services since the inception of the UK Government’s, Improving Access to Psychological Therapies (IAPT) Service in 2008. Offering principally and allegedly, cognitive behaviour therapy (CBT), by 2023/24 the IAPT Service hopes to see 1.9 million people a year [IAPT Manual, August 2021]. This represents a quarter of the community prevalence of depression and anxiety disorders. The intent of IAPT is clearly laudable, but it is much less clear that it meets the needs of clients? Is it worth the money? Given that the typical IAPT therapist earns £35K a year (twice that of a Care Assistant), and with salary costs reaching over £0.5 billion per year by 2023/24, there is a pressing need for independent audit.

By Services Marking Their Own Homework

The first author was alerted that all may be not well at IAPT’s coalface, when as an Expert Witness to the Court he reviewed 90 cases, treated with alleged CBT, and found a recovery rate i.e loss of diagnostic status, in just 10% of cases, using a standardised diagnostic interview Scott (2018). This applied whether or not service users were treated before or after their personal injury. This ‘tip of the iceberg’ response, contrasts sharply with IAPT’s claimed recovery rate of 50%. Curiously there has been no publicly funded independent audit of IAPT which would help to settle matters.

To Mask A Fault Line In the Provision of Routine Psychological Therapy

There is a fault line in IAPT’s approach which we thought might be rectifiable Scott (2018) [IAPT- The need for radical reform, Journal of Health Psychology] and Scott (2021) [Ensuring IAPT does what it says on the tin. British Journal of Clinical Psychology], but which may in fact make its’ ‘building’ of services inherently unsafe. IAPT declares usage of the ICD-10 code (the World Health Organisation’s labelling system for all disorders). The recent IAPT Manual (August 2021) https://www.england.nhs.uk/wp-content/uploads/2018/06/the-iapt-manual-v5.pdf recommends that IAPT clinicians give at least one code to each client, to characterise their debility. But nowhere in the Manual does it suggest that IAPT clinicians make a diagnosis. An ICD-10 code is only as reliable as the diagnosis made. The Manual claims that NICE Guidelines are based on ICD-10 codes and that IAPT is therefore NICE compliant. However the treatments recommended by NICE are all diagnosis specific, it follows that if there is no diagnosis there can be no fidelity to a NICE protocol. A key part of IAPT’s narrative is to gloss over that IAPT’s interventions are based, not on diagnosis, but on ‘problem descriptors’. The silent assumptions are that: a) there would be reliable agreement (reliability) between clinicians about what would constitute a client’s main problem and b) there is a body of evidence that a problem descriptor acts as a key to unlock the door to a specific protocol. Further that the specific protocol has been demonstrated to confer an added value, over and above an active placebo, for the chosen problem descriptor. There is an assumption of clinical utility. But there is no empirical evidence for either a) the reliability or b) the clinical utility. Whilst IAPT interventions contain elements of protocols used in randomised controlled trials there is no evidence of fidelity to such protocols i.e of comprehensive coverage of treatment targets for a disorder and matching treatment strategies.

A Pandemic of Spin


Spin has been identified in half the abstracts of papers in psychiatry and psychology journals Jellison et al (2020). In this context spin referred to a claim that an experimental treatment was beneficial, despite a statistically nonsignificant difference for the primary outcome or to distract the reader from statistically nonsignificant results. IAPT claims its sojourn into the treatment of persistent physical symptoms (PPS), such as chronic-fatigue syndrome, is evidence-based, but it is an exemplar of precisely what Jellison et al (2020) identified. Chalder et al (2021) compared the effectiveness of transdiagnostic cognitive behavioural therapy (TDT-CBT) plus standard medical care (SMC) to SMC alone. The primary outcome measure was the Work and Social Adjustment Scale (WSAS). There was no significant difference in outcome on this measure but in the abstract Chalder et al (2021) proclaim their intervention ‘may be helpful with a range of PPS’, with an appeal to some outcomes on secondary measures.

But arguably there are other additional markers of spin a) when the primary outcome is not independently assessed b) when the primary outcome is not clinically relevant and c) when there is no prior specification of what would constitute a minimally important difference in the primary outcome measure. In this connection none of the studies used to justify IAPT’s low intensity interventions have involved an independent assessor using a standardised diagnostic interview. For example, the Stress Control (SC) Programme is the most commonly delivered first line group intervention in IAPT Dolan et al (2021). In the SC studies outcome was assessed purely with self-report measures without any guarantee that the measures related to the disorders that the clients were suffering from. Dolan et al (2021) made no attempt to explain a) what a change of X on these measures would mean as opposed to a change in Y and b) whether the changes of scores would be meaningful to a client. The study showed an effect size difference in outcome between SC and active comparison conditions and passive controls of 0.12-0.15, but this is so small as to be of doubtful clinical significance. Nevertheless under a heading of ‘Practitioner Points’ they declare ‘SC is appropriate and effective for mild to moderate anxiety and depression’. Dolan et al (2021) found that the SC studies had a mean quality score of 18.21 but fail to mention that this is much lower than the mean score of 27.8 [Ost (2008)] in CBT studies. Ost (2008) commenting on a series of studies that had a mean score of 19.6 declared that this set of studies could not therefore be considered an empirically supported treatment (EST). IAPT does not provide EST’s in their low intensity provision. Further there is no evidence of fidelity to ESTs in the high intensity interventions. Additionally the dosage of therapy routinely delivered in high intensity IAPT therapy falls far short of that advocated in randomised controlled trials of CBT.

The Genesis of Spin

Spin is often related to undeclared conflicts of interest. In the Dolan et al (2021) study all authors declared no conflict of interest. But the corresponding author for the Dolan et al (2021) study is a programme director of IAPT and another of the authors has IAPT involvement. Unfortunately this is not an isolated example, Scott (2021) challenged a similar non-disclosure by these authors earlier this year.

A National Failure to Address Spin

The National Audit Office (NAO) began an investigation into the IAPT service but then stopped it in June 2018 without publication of findings. Following a Freedom of Information request to the NAO, the first author was told in a communication dated February 17th 2020 that the investigation was halted because of variously, the collapse of Carillion and Brexit, with no intention of resuming its’ investigation. Further the NAO response added ‘The investigation was not intended to comment on clinical judgements or the extent to which services meet patient needs’! IAPT has successfully enlisted NHS England, Clinical Commissioning Groups (CCGs), the British Psychological Society (BPS) and the British Association for Behavioural and Cognitive Psychotherapy (BABCP) to proclaim its’ ‘world-beating’ [Dr Claire Murdoch, NHS England Mental Health Director, Health Business August 26TH 2021] status. IAPT is however eminence-based not evidence-based.

The Demise of The Psychologist’s Role

IAPT is the major employer of psychologists, who risk becoming deskilled by the climate change brought about by the Service. Psychologists tend to stay in IAPT for a few years before heading for the exit to secondary care of private work. This leaves an IAPT workforce bereft of the means of critical appraisal of their work. Staff are ill-equipped to challenge the edicts from on high and disagreement is seen as disloyalty resulting in burn out and worse.

1. Michael J. Scott, Consultant Psychologist, Liverpool, UK

1. Joan S. Crawford, Counselling Psychologist, Mersey Care NHS Foundation Trust, Chronic Pain Management Service (CPMS), St Helens. https://orcid.org/0000-0001-6400-1158

1. Keith Geraghty, Centre for Primary Care, Division of Health Sciences and Population Health, University of Manchester, UK. https://orcid.org/0000-0001-5060-5022

http://www.cbtwatch.com/critiquing-iapt-and-the-psychologist/

 

[Sly Saint]

No Evidence That The Improving Access to Psychological Therapies (IAPT) Service Does Any Better Than Contact With The Citizen’s Advice Bureaux (CABx)

IAPT claims 50% of its treated clients recover. But this effectiveness claim refers to the minority sub-population, who attend two or more treatment sessions. There is a deafening silence about the majority and that IAPT has marked its’ own homework. By contrast the CABx reports results for all-comers and as assessed by independent researchers. In its’ latest report the CABx states that the proportion of people who reported improved mental health as a result of contact was 70% in the last quarter of 2020/2021.

In the CABx population almost 80% of clients said that their problems made them feel stressed or anxious and over 60% said they had difficulty in getting on with daily life. With just over 20% of CABx clients stating that contact had helped them a great deal to get on with their life, and just less than 20% saying that contact helped a little and 20% saying that it helped somewhat..The latest CABx report states that this year they carried out ‘robust client follow up research. National Outcomes and Impact Research (NOIR).

This asked detailed questions about why people came to us for advice, what their problems were and how we helped’. NOIR research was conducted over the telephone with a nationally representative sample of clients. The NOIR asked 60,000 clients about their experience of CABX in the last year. THE CABx research was funded by the National Institute for Health Research.

http://www.cbtwatch.com/no-evidence...ontact-with-the-citizens-advice-bureaux-cabx/

 

[Andy]

"italk is the Improving Access to Psychological Therapies (IAPT) service for most of hampshire", https://www.italk.org.uk/home/italk-service/

From the "Patient area", https://www.italk.org.uk/patient-area/, their offerings include;

"Building Resilience with Long-Term Conditions - Our 6 week course for people living with a long-term physical health condition such as diabetes, COPD, heart disease or chronic pain.", https://www.italk.org.uk/patient-area/building-resilience/

"Coping with Long Covid - Our 1.5hr session for people who are experiencing long-term physical symptoms after having the COVID-19 virus.", https://www.italk.org.uk/patient-area/coping-with-long-covid/

 

[Sly Saint]

 

[rvallee]

Even worse is that none of those numbers mean anything. They're just arbitrary values from biased questionnaires. Hitler moving around destroyed divisions on his map in the bunker was just as insane than this. None of this is even real, the numbers don't relate to anything in real life.

It isn't even a case of reducing lives to numbers, the numbers are completely fake and mean nothing. This is so much worse. Argh.

 

[Sly Saint]

The Health and Social Care Committee’s Expert Panel: Evaluation of the Government’s progress against its policy commitments in the area of mental health services in England
This is a House of Commons Committee Expert Panel report, evaluating Government commitments in the area of mental health services. The Government has two months to respond.

Second Special Report of Session 2021–22

3 Adult Common Mental Illness

In this section, we provide an assessment of the Government’s commitment to ensure that all areas commission IAPT services for long term conditions:

“[…] all areas commission IAPT-Long Term Condition (IAPT-LTC) services (including co-location of therapists in primary care)”

Adult Common Mental Illness
Commitment: All areas commission adult Increasing Access to Psychological Therapies-Long-term condition services (Requires Improvement)

• Significant work is required before the commitment to establish Increasing Access to Psychological Therapies (IAPT) services for adults with long term conditions across all areas can be met by the 2023/24 deadline.
• The provision of specialist services for adults with a long-term condition has the potential to have positive impact on service users’ ability to manage their physical conditions.
• In treating long term conditions through IAPT, savings could be made across the NHS and reduce the burden on these services, but this has not yet been achieved.

These services have had a positive impact for those who have accessed IAPT-LTC support. Early evaluations of integrated services reported positive outcomes for service users, who felt better able to manage their physical health conditions.223 In an evaluation carried out jointly by the Royal College of Psychiatrists and academics at University College London, service users reported positive views about the integration of practitioners with specialist knowledge of their physical and mental health conditions. Service users reported receiving more targeted support, which allowed them to better manage their physical health conditions:

“The one thing which was brilliant [was the IAPT-LTC practitioner’s] knowledge of [my long-term condition] because it was as good as speaking to a specialist nurse […] She really got it and really understood the issues and how they were impacting on my life.”224

https://publications.parliament.uk/pa/cm5802/cmselect/cmhealth/612/report.html#heading-5

eta:
"The FYFVMH outlined that the expansion of IAPT services should have specific focus on including services for those with long term physical health conditions (LTCs) or medically unexplained symptoms (MUS)."
"The deadline for services to commission IAPT-LTC services, including the co-location of therapists in primary care was the end of 2018/2019. In their submission to our evaluation the Government said this target had not yet been met, for example, only 77% of CCGs having at least one integrated pathway by March 2020.213"

 

[Sean]

In treating long term conditions through IAPT, savings could be made across the NHS and reduce the burden on these services, but this has not yet been achieved.

I'm shocked, I tell you, shocked.

 

[Mithriel]

The one thing which was brilliant [was the IAPT-LTC practitioner’s] knowledge of [my long-term condition] because it was as good as speaking to a specialist nurse […] She really got it and really understood the issues and how they were impacting on my life.

That has nothing to do with psychology. Specialist nurses or even training patients to sit and chat with the newly diagnosed would do just as well. It says nothing about the IAPT service though I can see it would be more pleasant than actually working with mental health problems.