In 2012, an editorial in the prestigious journal Nature claimed that the UK’s IAPT Service is “world-beating”—meaning that the service is the world’s best for treating mental health concerns. Now that 10 years have passed, it’s clear that this was not true. Despite the hype, the IAPT is hardly “world-beating.” In fact, it is a doubtful model for other countries to follow.
The IAPT (“Improving Access to Psychological Therapies”) was created in 2008 and fully funded by the UK government (though restricted to provision only in England). The program claims to provide evidence-based psychological treatment, most commonly in the form of cognitive behavioural therapy. It was initially focused on patients with depression and anxiety disorder diagnoses, but its scope has been gradually expanded to include the psychological treatment of long-term physical conditions such as chronic fatigue syndrome.
Patients either self-refer (at no cost) or are referred to the IAPT by their primary care physician/general practitioner. Clients are initially assessed during a 30-minute telephone conversation by a Psychological Wellbeing Practitioner (PWP) who is not an accredited therapist and is not trained to diagnose. IAPT clients initially receive low-intensity CBT (six hours or less of therapy contact) delivered by a PWP. If they are deemed not to have responded to this, on the basis of a psychometric test, they can be “stepped up” to high-intensity CBT delivered by an accredited psychological therapist.
How Well Is the IAPT Doing?
Proponents of the IAPT cite its outcomes for the clients who complete their treatment sessions—but over half of IAPT clients don’t even attend two sessions. The response of the IAPT to this massive disengagement with the service—clients “voting with their feet,” as it were—is currently to offer training to its staff to “streamline” matters by encouraging them to use a computer algorithm to decide which clients go where. This training, which was held on June 22, 2022, involves expert advice from the CEO of Limbic, an artificial intelligence company. Thus, not only are IAPT staff to be distracted by clients having to complete psychometric tests at each encounter, but now additionally by the administration of the computer algorithm.
Yet Limbic claims it is “an AI assistant for clinical assessments in IAPT—improving access, reducing costs and freeing up staff time.” Where is the independent evidence for this? What clients really want is to be listened to, but there is little chance of this any time soon. Conquering disengagement in this manner is a forlorn hope.
IAPT’s 2019 manual states that IAPT staff do not make a diagnosis. However, the treatment recommendations of NICE (the UK’s National Institute for Health and Clinical Excellence) are explicitly tied to a taxonomy of specific treatments for identified disorders (largely, diagnosis-specific variations on CBT). IAPT legitimises itself by a claim to be NICE compliant, but how could they be if they don’t make diagnoses? How can they follow NICE’s specific treatment guidelines without first assessing which condition they are treating?
Whilst the IAPT’s claim to be NICE-compliant might be music to the ears of NHS England and clinical commissioning groups, it is simply not true. No independent fidelity checks have ever have been made on IAPT’s ministrations. IAPT allegedly provides specific CBT protocols for different disorders, but it has provided no evidence that it does this.
In my examination of the physician’s records of 90 IAPT clients, I found no evidence of compliance with CBT protocols. IAPT operates simply as a business with superb marketing.
In no independent audit of IAPT, have clients been asked “are you back to your usual self since this treatment?” This is a goal that is meaningful to the client—with the possible supplementary question, “for how long have you been back to your usual self?” In papers published by IAPT staff, no such real-world outcome measures have ever been used. Instead, reliance has been placed on changes in psychometric test scores. Yet without a control group, it’s impossible to know whether these changes would have occurred with passage of time anyway. After all, people present to psychological treatment at their worst, and at any other time, they are likely to score better. In statistics, this principle is known as regression to the mean, and it is vital to account for this effect.
Further, the client knows his/her therapist sees their completed questionnaire, pushing them to respond more positively. A client may also not want to endorse negative responses on the questionnaire because it would mean acknowledging that they have wasted their time in therapy. These are known issues with self-report measures that are commonly cited as important limitations in research studies.
Finally, the questionnaire results also give no indication of whether any improvement has lasted for a period that the client would regard as meaningful, such as eight weeks or (hopefully) more.
In an era of personalised medicine, it is essential that the voice of the client is heard. It is an almost ubiquitous failure of studies to employ a primary outcome measure that a client can identify with—known as patient-centred outcomes. Perhaps the nearest proxy is loss of diagnostic status (full recovery) determined by an independent assessor. The burden of proof rests on providers of services to demonstrate that their treatments are making an important difference to a client’s life in a way that is clearly recognisable to the client. IAPT has not cleared this evidential bar.
Use of an algorithm is not incompatible with a clinician operating on a knowledge base of what works for whom. But it has to be first demonstrated that the former constitutes added value over the latter. The burden of proof is on AI advocates to demonstrate its relevance in a particular context. This cannot be done by a company with a vested interest in AI.
It is perfectly possible that using two systems, an algorithm and clinical judgement, might create confusion. Should an IAPT client not fare well (for example, if a client dies by suicide) when treated under such a dual system, could IAPT convince a court, on the balance of probability (the UK benchmark in personal injury cases), that its approach was evidence-based? After all, an AI approach is not something that NICE has recommended—so it flies in the face of the guidelines. Traditionally, courts are swayed by eminence-based evidence (such as the word of authority figures like psychiatrists), but they have become more aware (at least in the UK) of the perils of unbridled clinical judgement.
Inadequacies of IAPT’s Chosen Metric
IAPT’s chosen metric is a change in score on two psychometric tests. Clients are deemed to have responded if on the PHQ-9 (a measure of the severity of depression) their test score has gone from above 10 to below 10 with treatment, with a difference of at least 6 points, and if on the GAD 7 (a measure of the severity of generalised anxiety disorder) their score has gone from above 8 to below 8 with treatment, with a difference of at least 4 points. This approach has numerous deficiencies:
- It is not known whether the completer of these two measures was actually suffering from depression or generalised anxiety disorder, because IAPT clinicians do not make diagnoses. Further, it is not known whether either of these “conditions” was the disorder that was causing most impairment in functioning.
- When test results are observable by the treating clinician, clients may wish to be polite and relay a lower score, particularly as they do not want to feel that they have wasted their time in therapy.
- No attention control comparator: Changes in test scores are meaningless unless there is a comparator group who have received the same attention and a credible rationale. It’s unclear whether the therapy resulted in the improvement, or if the client would have improved with a “placebo” therapy (simply receiving professional “attention” without CBT techniques).
- Regression to the mean: Clients typically present at their worst, so with the mere passage of time they will score more modestly.
- The vagaries of a minimally important difference (MID) in a score: MIDS are established by statistical comparisons between an “ill” and “well” group, but they do not necessarily indicate clinically important difference. They also fail to address the client’s perception and there is no personalisation of treatment outcome. Clients are given no voice.
Last year about a third of referrals (30.1%) to the IAPT service did not access it. Of those who accessed the service over a third (38%) had just one treatment session. Thus, by the start of the IAPT race over half of people (57%) have not engaged in treatment (as defined by IAPT’s metric of attending two or more sessions). If these results applied to a physiotherapy service it would raise serious doubts about the suitability of the service! Why then does the UK National Audit Office studiously avoid scrutiny of IAPT, which costs the taxpayer over £1 billion a year?
Sub-Therapeutic Dose and Treatment Outcomes
Of those who engaged in IAPT, the average number of sessions was 7.5, which is well below the 12 to 20 sessions that NICE recommends for depression and anxiety disorders (IAPT’s primary targets). Are we to believe that IAPT’s clinicians are so skilled that they can achieve recovery with only half the dosage of therapy as that delivered by therapists in the randomised controlled trials of CBT for depression and the anxiety disorders?
The benchmark set by trials of therapy as a treatment for these conditions is that at least 50% must “recover” (no longer meet criteria for a diagnosis). But there is no evidence that IAPT has achieved this. My own research suggests that only the tip of the iceberg recover.
In my capacity as an Expert Witness to the Court, I examined 90 IAPT clients who had been through the service either before or after the personal injury. Only 9.2% of subjects lost their diagnostic status, as assessed using the “gold standard” SCID interview. It mattered not whether subjects were assessed before or after their personal injury. (These findings are in need of replication by clinicians independent of IAPT with a non-litigant population.)
IAPT appears not to so much follow the data, but to follow funding opportunities. It has branched out into territory were angels fear to tread: Medically Unexplained Symptoms (MUS). MUS is an umbrella term embracing conditions as diverse as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome. IAPT’s contention is that exaggerated negative beliefs about symptoms, and maladaptive behaviours (e.g., avoidance), play a pivotal role in the maintenance of symptoms in these conditions. The therapeutic task, as they see it, is to then to modify these cognitions and behaviours.
What happens if a client protests that they have valid medical symptoms? Well, IAPT clinicians are taught not to openly disagree and not to say “it is all in your mind.” But to nevertheless continue to focus on the “exaggerations in beliefs and avoidance behaviours”—so much for honesty.
Along with Keith Geraghty from the University of Manchester, I have published a critique of this sojourn. We identified a series of seven core problems and failings of the IAPT, including an unproven treatment rationale, a weak and contested evidence-base, biases in treatment promotion, exaggeration of recovery claims, under-reporting of drop-out rates, and a significant risk of misdiagnosis and inappropriate treatment. We concluded that psychotherapy should not become the default option when patients have “medically unexplained symptoms.”
The term “medically unexplained symptoms” should be written in lowercase to avoid conveying the impression that a meaningful homogenous entity is being described. The term should not enter the taxonomy of disorders. Importantly, even the DSM-5 has shunned recourse to the term. But unfortunately, IAPT only pays lip service to the standard diagnostic criteria.
Big Pharma and IAPT
Whilst some large pharmaceutical companies have greatly served the public good with regard to COVID, their performance with regard to psychotropic drugs is much less impressive. Researchers like Read and Moncrieff pin their hopes on the efficacy of CBT demonstrated in randomised controlled trials, but make no mention that CBT as delivered in routine practice bears little relationship to the protocols utilised in RCTs. Just as the claims of pharmaceutical companies require critical appraisal so too does the UK IAPT service.
In an article in the British Journal of Clinical Psychology, I explained what the IAPT needs to do to get back on track. I noted that in their published papers, IAPT staff do not declare their allegiances and indeed state that they have no conflict of interest! This dishonesty needs to change. I suggested that there is a need for IAPT to prove their case using the standards of proof that are required in other areas of medicine. To this effect, they cannot simply claim that they deliver evidence-based treatment—there has to be documented evidence for it that would be persuasive to an independent observer. The IAPT service has to demonstrate that it provides an added value over someone attending an advice centre or counselling service. Yet the IAPT has yet to demonstrate that it makes an important enough difference to clients’ lives that they would recognise it.
This catalogue of omissions may create a sense of déjà vu for those who have followed the machinations of Big Pharma with regards to mental health. Unfortunately, there has only been a deafening silence from the IAPT regarding my critique.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Seems like your article is still based on the premise that people still need some sort of therapy or treatment. That supports the mental health system.
IAPT actually do diagnose people after their initial assessment. I sat next to them for months. The first telephone assessment is a script. They do PHQ-9 and GAD-7 and they score these. They then say ‘you suffer from mild/moderate/severe anxiety/depression based on the scores’ which is a diagnosis. I did see someone with IAPT and yes scoring every session was too much.
I do not agree however with your assessment as compared to other countries where people get no access to therapy IAPT is better than nothing. Also we still have hidden sometimes 2 year waiting lists in secondary care teams for psychology.
Also in my view some criteria for secondary care services are made up by psychologists to cherry pick their low risk, anxious and middle class people they like to see. I was told ridiculous reasons for refusal to see, for example, people cannot be seen because they were not in stable housing.
I agree IAPT is not great but the reality is that most people have GP giving antidepressant or IAPT. Plus access to secondary care psychotherapy is an big issue.
We need to eradicate the entire mental health system.
It is also the abject failure of CBT. In his book “CBT: The Cognitive Behavioural Tsunami” Farhad Dalal sums up the simplistic thinking behind this approach as follows:
“We observe a dog wagging its tail. We notice that only happy dogs wag their tails. We notice that unhappy dogs do not wag their tails. We deduce from this, that if unhappy dogs wagged their tails, they would become happy. We develop a treatment protocol which teaches unhappy dogs to learn to wag their tails. If they learn how to wag their tails, and then choose to wag their tails, then they will become happy. CBT techniques assume that it is possible to use this kind of reverse engineering to change feeling states. Happy dogs wag tails; therefore tail wagging should generate happiness.”
IAPT is a business selling snake oil. The therapists hate delivering it as they can’t do a proper job, some are off sick with depression – lol – the good ones leave and go private. The assessment interviews are gruelling and pointless apart from IAPT providers gathering data to use for there next grant application. I met a guy who worked doing admin for them, he did a bit of research for his own interest and found out they got loads of returnees, which basically showed the treatment length is arbitrary and insufficient, the manager didn’t want to know as it would upset the business modle. They screen out the very distressed leaving the mild to moderate but there is evidence that these folk will get better in six months anyway.
IAPT is one of the worst examples of marketised, tick box medicine ever imho.
THAT’S mainstream psychiatry – maketized, tick-box medicine –
I don’t doubt that IAPT is better than nothing. But people did not always get nothing before the advent of IAPT in 2008. The pre-IAPT studies of counselling showed changes on psychometric tests of the same magnitude as IAPT. This means that IAPT has demonstrated no added value. Further the changes in psychometric test scores in IAPT are comparable to those in patients followed up by GPs without any psychological intervention. Thus, to a very limited degree time is a healer. All this raises the question of why fund an IAPT like service?
Matters have today taken a further turn for the worse in the UK, as the National Institute for Health and Care Excellence (NICE) has recommended that the PWPs who assess people, should market the following to depressed clients, in order of least costly first, guided self-help, group CBT (8 sessions), group behavioural activation and onwards to the 11th item short-term psychodynamic therapy. It is the PWPs, who are not trained therapists, who provide the cheapest options. But there is no empirical evidence that 8 sessions of the least costly interventions delivered by PWPS makes a real-world difference to clients lives as assessed by a blind assessor.
It is possible to see everyone as a totally unique individual and formulate a treatment for them. To a degree this is what I have done in my most recent book ‘Personalising Trauma treatment: Reframing and Reimagining’. But it is difficult to provide guidance without saying ‘this sort of thing works with that type of problem’. Diagnosis is just a convenient, imperfect taxonomy of problems, if there had been proven to be a better categorisation, that would be great and I would use it. But at the moment it is the ‘least-worst’ and as I say in my book one has to go ever so carefully with it. The bizarre thing in the UK is that PWPs are tasked with treating depression, yet their Organisations Manual says they don’t make diagnosis. Yet many PWPs use diagnostic terms in passing. But this is regarded as wholly unreliable in a UK Court, anyone can have an elevated score on a PHQ 9 for a myriad of reasons.
The thing about seeing a GP being as good as a few weeks IAPT treatment implies any friendly contact is helpful – duh, like we didn’t know that!
Late capitalism can be a lonely place and IAPT is no cure for that.
The reductionist, internalising, stigmatising language of ‘disorder’ is everywhere in IAPT. It is unavoidable and most everyone uses it. It is also all over the IAPTus digital system.
Furthermore it is not just PWP’s that offer screenings to people. Services are structured slightly differently across the UK. In many there are 3 levels of brief support PWP, Intermediate and High Intensity. All three offer screenings and all three have to label someone as disordered in order to have completed the digital system.
I find it thoroughly saddening that I am literally forced to use the reductionist, stigmatising, internalising language of disorder at every turn. We need less not more of this I know what I am ‘treating’ its a human being right in front of me and i’ve no illusions any talking and listening that I do will make much of a difference over the long term.
As someone that used to work in secondary care and have sat in on hundreds of psychiatric assessments leading to diagnosis I can tell you its dangerous unscientific nonsense. Mike suggests diagnosis is a ‘convenient, imperfect taxonomy of problems’ convenient for who? These are powerful stories that people take to be real malfunctions within themselves so they become self limiting self full-filling prophesies and everyone around them can also often see the person as mentally ill – all behaviour becomes viewed in this way.
The problems that cause us to suffer are most often in the world and yet diagnosis reduces this complexity down to a ‘trigger’ again for your own personal disorder and it is YOU that must be adjusted to simply get on with it.
As the critics have pointed out NO psychotherapy has ANY robust evidence supporting it whatsoever read William Epstein’s works, Farhad Dalal, The Therapy Industry by Paul Maloney, David Smail and many others.
Therapy itself is the abject failure and of course it has to be because we are diagnosing the treating the wrong thing – what we have are myriad cultural disorders that must be changed if we are ever to realise human wellbeing.
Topher says, “….diagnosis.….it’s dangerous unscientific nonsense….they become self limiting self fulfilling prophecies….and all behavior becomes viewed in this way….Therapy itself is the abject failure….because we are diagnosing and treating the wrong thing – what we have are myriad cultural disorders that must be changed if we are ever to realize human well-being” –
How can one person change the myriad cultural disorders?
By avoiding THE BIGGEST cultural disorder out there – the diagnostically based “mental health system”, and – believe it or not – as the word gets out, it becomes a process of attrition.
No one person can change cultural disorders the point is the causes of our distress are in the world not personal issues – we need to fight for changes to our political and economics to make the world a better place for us all.
Yes, our problems are in the world, and one of those problems is the “mental health” system. And politics and economics don’t change until people’s minds change. And how do people’s minds change? Through websites like this –
:These are powerful stories that people take to be real malfunctions within themselves so they become self limiting self full-filling prophesies and everyone around them can also often see the person as mentally ill – all behaviour becomes viewed in this way.”
I met someone who was doing that today. He had completely swallowed the various diagnosis put on him by the system and was now seeing all his problems through that lens. He said talking therapies will give him a bit more therapy and then he will train for a job
He has been saying it for years.
I totally agree that the way diagnoses are made in the UK i.e using wholly open-ended interviews is no help to clients at all. IAPT’s use of diagnosis is totally cavalier. The levels of reliability of such interviews is so poor as to make them useless. But it is possible to use a standardised semi-structured diagnostic interview that also gives full scope to assessing social problems. In our trial of CBT for depression in Toxteth, Liverpool (the scene of the 1981 riots) I addressed the social problems as well. It is useful to clients and therapists to know what sort of strategies can deliver with what sort of problems, without at all minimising real-world constraints. For depression and some anxiety disorders there is credible evidence that CBT is a reasonable starting point, in that about half of sufferers appear to recover in the randomised controlled trials Cuijpers et al 2016 https://doi.org/10.1002/wps.20346. But great care has to be taken in the translation of this finding: it applies to a limited number of disorders (depression, generalised anxiety disorder, panic disorder and social anxiety disorder), there has to be certainty that the person before you is suffering from one of those disorders and that is the main problem, not something else. Further there has to be fidelity to a treatment protocol in that targets and strategies must match but there also has to be the flexibility of a human encounter. In addition there has to be certainty that the person before you could be regarded as member of the population e.g age, education that was involved in the trial. So it is important not to exaggerate the importance of CBT and minimise the difficulties in translation. To echo Cuijper et als claim (2016) ‘We conclude that CBT is probably effective in the treatment of MDD, GAD, PAD and SAD; that the effects are large when the control condition is waiting list, but small to moderate when it is care-as-usual or pill placebo; and that, because of the small number of high-quality trials, these effects are still uncertain and should be considered with caution’. But what IAPT does bears no relationship at all to what was done in any trial.
I notice that you seem to continue to view clients from a viewpoint of “diagnosis” and “treatment.” CBT to me is simply one of many techniques that can help certain people get a perspective on what THEY can to do improve their lives in ways that they find helpful. I never cared one whit what “diagnosis” they had. All I cared about was what THEY saw as the problem (often requiring some pretty good interviewing skills to help them figure out) and what THEY felt was helpful in moving forward. Sometimes CBT was perfect, sometimes it was useless, not depending on the “diagnosis” but on the person’s personality and goals and viewpoint on what they are trying to accomplish. Similarly, some people did REALLY well with regressive techniques, others wouldn’t consider it or it wasn’t really realistic given the circumstances or timeline or it just plain didn’t work. Some do well “brief therapy” techniques (what did you do the last time this happened?), while some find them insulting. Sometimes I made stuff up on the spot specific to that particular person. My primary rule was, “Gather information. Try something that seems to make sense. If it works, do it more! If it doesn’t, stop doing it, gather more information, and and do something else!”
Milton Erickson said that therapy needed to be “reinvented” for every client/case. He was correct. I tried to approach each case with a “Beginner’s Mind,” as they say in Buddhist teachings, open to experiencing what is before me, no preconceptions or judgments or plans. I found that “diagnoses” did nothing but confuse and distract me from getting to know the PERSON in front of me, which was the key to my success in the field. The question to me was never, “What is his diagnosis” or “what is wrong with her?” or “what school of therapy should I follow?” It was more like, “Who is this person? What’s important to them? What are their goals and what do they see as barriers to those goals? What kind of fixed beliefs or behavior do they seem committed to that don’t make sense to me, and why do they make sense to them? How can I assist them in stepping out of their normal ‘scripts’ and see what alternatives might exist?” There is no formula for doing this – one has to simply roll up one’s sleeves and be humble enough NOT to “know” things about this client that you really don’t know at all.
People are mysterious. Psych “diagnoses” don’t help us understand the mystery, they trivialize and confuse the real issues that we ought to be looking at. If I were you, I’d consider dropping them from your vocabulary.
I wonder have you read any of the critics of the research literature Mike? I would urge you to read all of William M Epstein’s books – Over most of them he takes the best of the best research and takes it apart – what he presents is not at all what is advertised – The titles everyone in therapy ought to read are The illusion of Psychotherapy, Psychotherapy and the Social Clinic in the United States, Psychotherapy as Religion The Civil Devine in America. Consider the broader disaster that is Psychology research https://www.madinamerica.com/2022/07/psychs-winning-streak-failure-science-not-success/ and https://www.madinamerica.com/2022/04/psychology-incompatible-hypothesis-driven-theoretical-science/
I wonder if you have read Adorono? He wrote that women will come to fear there social worker more than there drunken husband. He saw therapy as adjusting people to a sick society.
I don’t entirely agree but it is seems a good place to start an investigation.
In many ways I totally agree, people are mysterious, deserving of great reverence. They are ill-served by IAPTs reductionism of therapy, which has an irreducible complexity, with the whole being much greater than the sum of its parts. But without recourse to diagnosis I would not have been able to demonstrate that IAPT’s claimed recovery rate is absurd. Diagnosis, reliably made, can act as a check on self-serving claims, it can also indicate which ball park might be fruitful. But it all has to be personalised and I have tried to explain how I do this recently in my book Personalising Trauma Treatment.
How can a “diagnosis” be reliably made when the criteria are totally subjective in almost every case? What is the standard for reliability, merely that other people’s opinions agree with yours? And if that’s the case, shouldn’t we be using language such as “people typically labeled as ‘bipolar'” or “people typically labeled with ‘major depressive disorder?'”
By the way, I do support doing research on “diagnoses,” but only for the purpose of demonstrating the fecklessness of “diagnosing” people in this slipshod manner, or the lack of effectiveness of a given “treatment” for such “disorders.” I consider any research done using the DSM categories to be prima facia false, as the groupings of people on that basis have no scientific validity (they are heterogeneous groups having no known, measurable qualities in common). The main error in the DSM is assuming that people who have the same “diagnosis” have something wrong with them, or the SAME thing wrong with them all. The DSM itself even admits to this failing. But what is the use of a “diagnosis” that groups together people who have nothing in common? It is literally possible for two people to have “Major Depressive Disorder” or “Generalized Anxiety Disorder” and have not one single trait in common with each other! From a scientific viewpoint, the DSM is utter garbage!
I think in UK services are changing and now there are options instead of IAPT. It’s still however has huge numbers of referrals and waiting lists. I don’t believe therapy access was better before IAPT was created.
We have the following locally that offer brief support where people are sign posted and are funded
– counseling organisations
– social prescribing link workers
– mental health peer workers
I also find charities like MIND helpful which are long term support
However things are changing. Other charities have got better in assessing funding so IAPT has competition. We have a charity locally which offers therapy, however, you have to be risky to be accepted so there model is to take the people who have just overdosed or self harmed. These groups of people id argue need support but when they try to access it they are referred to iapt and told they are not suitable or get rejected by secondary care for not been suitable enough (my favourite reason for rejection was as I said not having a stable house !). So they get no therapy or if they do are on a long waiting list so people who go in and out of crisis may never get it.
Interesting article but what is your solution exactly ? You are critic this on an American website where I don’t think IAPT exists at all. I’m not sure we can ever meet the demand for tgerapy. Some people go for years privately. Does it really help them?
UK therapy is being outsourced to charities. They now compete for a slice of the pie which means there critical voice is weakened an overall services are cut.
If you go back to the 1960s, research on psychological treatment was impossible because one persons case of x was another persons case of y. A common language is necessary to conduct any research, so that we are not talking at cross purposes. There are no biological markers for. any psychological ‘disorders’ so that the description of them as disorders is problematic. So the ‘disorders’ are constructs which may be more or less useful. How then does one begin to try and make sense of the plethora of emotional problems people experience? What would be the most useful ways of carving up the joint? Some problems seem more threat related, future oriented and for want of a better term, could be subsumed under an anxiety umbrella. Others problems are more to do with a negative view of self and have a sadness/melancholy hue and we might be regarded as being in the depression domain. In some people you get a state of ‘terrified surprise’, a combination of exaggerated startle response and hypervigilance, which I have argued is a hallmark of PTSD.
To make sure we are all singing from the same hymn sheet, we have looked at particular constellations of symptoms that seem to go together e.g there are 9 symptoms in DSM for depression, so all the symptoms within a constellation have to be enquired about (technically controlling for information variance) but a symptom is only endorsed if the person judges that symptom as significantly impairing their functioning (technically criterion variance is controlled for) clearly those with more symptoms are more impaired, and somewhat arbitrary cut offs are used to try and distinguish what could be regarded as normal functioning to functioning that is problematic for many. With this type of procedure using a standardised semi-structured diagnostic interview you can get independent raters coming to the same conclusion around 80% of time, without such an interview the chances of agreement are no graeater than chance. The high inter rater reliability makes research possible and its proven possible to distinguish disorders by their different cognitive content and to establish that different’ disorders’ respond to different foci. e.g those with panic attacks often benefit from having 2nd thoughts about their catastrophic cognitions about bodily sensations. The most common scenario is that people have a number of ‘disorders’ and need to be treated holistically for all as they experience them as a whole entity they are not just a collection of all the disorders, see Personalising Trauma Treatment, there is no substitute for really listening it is the starting point for everything and IAPT fails miserably on this.
It is possible to have an a priori belief that anything to do with diagnosis is unscientific, but there is nothing within science that proves that this is the case. Rather than pre judge the issue it is important to follow the data were it leads, we have had some limited success in treating some of the commonest disorders with cbt but exporting that to routine practice is not easy and it is extremely unlikely that cbt contains the whole truth, it just lightens the pathway a bit. CBT may only be a candle and I would happily use a torch if available but Ive not been able to find one.
I should add that I think there is much more to life than psychological therapy, social problems, philosophy, religion are massively important. I do not believe that psychology has a monopoly on truth.
I don’t think that diagnosis is a priori wrong in the “mental health” area. I just think that such diagnoses should represent something actually distinguishable from a different “diagnosis.” The DSM itself admits it fails to do this (actually that it doesn’t even ATTEMPT to do this) in its introduction. CBT is just a way of engaging a person’s thinking process in interfering with their habitual behavior. It’s possible it may be more effective in disrupting anxious thoughts than in stopping, say, hyperactive behavior, but that’s just a percentage based on the kind of “symptom” we are dealing with. The fact that CBT may be more useful for someone feeling anxious does nothing to confirm that anxious people are anxious for the same reason, that anxiety is de facto a “disorder” or “disease” state in all or in fact in ANY case, and studying “anxiety disorders” means studying people who most likely are quite diverse and heterogeneous, meaning that even if 80 percent of people can apply the list of definitions and come up with the same “diagnosis,” there is no reason to believe that these people have anything in common other than the fact that they happen to fit the list. It’s sort of like saying that if 80 percent of people can be identified as suffering from “knee pain,” it means that “knee pain” is a valid diagnosis. Of course, it’s nothing of the sort. Knee pain can be caused by a score or two of different actual diagnoses, including a bruise, water on the knee, arthritis, a torn ACL, MCL, or other ligament, a torn cartilage, etc, etc, etc. “Knee Pain” is simply not a useful diagnosis. Pretty much every psych diagnosis is similarly useless. What if one person is depressed because of thyroid issues, one because of childhood abuse/neglect, one because he’s in a dead end job, another because she’s suffering from domestic abuse, another because he can’t figure out the meaning of his life, another because he just got diagnosed with cancer, and another because she’s got severe anemia. Feeling depressed, losing sleep, losing joy in things we used to like, these are subjective, almost arbitrary items that could all be caused by dozens of reasons. It’s scientifically incredibly weak to try and do “research” on these so-called “diagnoses,” not because diagnosis is wrong but because these diagnoses don’t provide any explanatory model for what is wrong and what might be done about it, except on the most superficial level. It’s very much like diagnosing “knee pain disorder.” If we accepted that as a diagnosis, guess what would always be the most effective “treatment?” That’s right, drugs. Do you think the “atheoretical” diagnostic plan was created by accident? Or is it perhaps intentionally done to make marketing biological “solutions” a lot easier.
Hi Steve, I’m not suggesting that the way I use ‘diagnosis’ in the mental health arena tells us everything about the person or anything like it. It is just a part of a bigger picture including the social stressors, physical difficulties, values that the person has – their story. In Personalising Trauma Treatment I am very much looking at what the person takes their trauma/s to mean about today, how they do their mental time travel. I just noted that the most debilitated of trauma sufferers seem to be in a state of ‘terrified surprise’ coupled with having lost their sense of being me, treatment focuses on the restoration of their old self or in some cases a rebuild, what I term rcbt.
Sorry A.M, only just noticed your blog. Getting heard in the UK is extremely difficult, there is no open discussion about IAPT, people fear for their jobs if they criticise it. Hence this blog. To see how I have become persona non grata in the UK have a look at todays blog on cbtwatch.com. I think the way forward is to approach CBT along the lines I described in my Simply Effective trilogy of books, the 1st of which was written a year after the inception of IAPT. The process has been updated in the just published Personalising Trauma treatment. But basically it all starts with really listening to clients, giving them the time they need, not speeding through checklists. It is not rocket science and comes down to respect.
LISTENING to clients? No wonder you were blackballed! That’s radical crazy talk, that is! Next thing you know, you’ll be CURING people, and then where would the psych professions get their clients?
Thanks Steve really do appreciate that
People aren’t “clients” to be “ treated” – they are human beings to be respected.
Most psych professionals know only three things:
1. Cookie-cutter thinking (checklists)
2. Sand castles in their minds (“treatment” theories)
3. How to complicate things
And none of these respect the person or deal with reality –
Can I just ask where you got your data from.
I went through IAPT, and a lot of what you’ve said here resonates with me.
I was going through a particularly low period at the time, which tends to happen to me every now and then, but this was the first time in years that I was experiencing suicidal thoughts and urges to self-harm, so I decided to finally try and get help. I saw a mental health advisor at work who referred me to IAPT, and following a short assessment over the phone, I was short-tracked (because of the suicidal thoughts I guess) and given weekly over the phone appointments.
My therapist was nice enough, but the sessions were highly impersonal, stilted, and even patronising at times. In the first session I explained that I had issues with anxiety, that I’d read up about mindfulness etc. but had never been able to make anything work. My therapist then proceeded to explain what anxiety was, the fight or flight response and it’s supposed origins in our hunter-gatherer past. Things I’d read a gazillion times already, as he might have known if he’d asked, or even guessed from what I’d already said. Worse than that, every week I had to remind him of the details of our previous conversations, and he would often repeat things we’d already gone over. His advise was never personally catered to me or what I was saying. Once we reached the 6th session (I think) he told me that I was going to be discharged because my scores showed I’d improved. I was a baffled, I didn’t even realise I had given higher scores, and I didn’t feel as though I’d really made any progress. As you allude to in this article, I’ll hit a low and then come somewhere closer to normal after a few weeks. That doesn’t mean I’m cured or have progressed mentally in any fundamental way. When I said to him that I didn’t feel like I was done, he said that because of my test scores, unless there was some specific issue I needed help with, his “boss” would tell him to discharge me. So I said that actually I was still feeling worried about bumping into an ex-friend I’d had to cut-off recently (whom we’d talked about in previous sessions). He was pretty dismissive of that, he made me feel like I was making a big deal out of nothing, saying something along the lines of “you know eventually it might happen and it will be fine when it does”.
I thought that maybe I’d just been unlucky with it, and could give it another go if I got bad again. But over the next few months I found out a few of my friends had also been through the service, and they’d all had very similar experiences. None of them had found it helpful, all 3 mentioned it feeling awkward and that they felt their therapist was patronising them (which is more likely just a byproduct of the impersonal process than the fault of the therapists themselves).
To give some credit, when I did my initial assessment I had mentioned that I wasn’t happy in my work, and that I found filling out application forms really brought out feelings of self-loathing, so they also put me onto a job coach, who was much, much more helpful than IAPT. She actually listened to me, remembered the things I would say, and catered her approach to me personally. She was great, and I actually managed to change jobs with her help. Thinking about it now, if my scores did improve, it was certainly more thanks to her than the IAPT.
Whilst full of excellent critique, and I think it is healthy to be wary of systems (how else can they improve!), this piece would benefit from using more accurate and reliable sources. Direct citations to data gained from reputable research would too be helpful, because otherwise the things said here are just conjecture.
One thing mentioned early on about the percentage of people who are referred vs the number of people who go ahead with treatment can be easily explained by reasons you do not allude to here. Firstly, some patients simply do not attend the initial assessment appointments, or they may not have the motivation themself to change/work on their mental health. This is very common, as struggling with mental health often leads to a loss in motivation, and you can’t force people to change…that wouldn’t be right.
Some people may be so busy in their lives that they are unable to attend appointments during the working day, meaning IAPT in the traditional sense doesn’t work for them, and they may opt for private which tends to have more flexibility and work on weekends.
Lastly, not all patient referred to IAPT are suitable for IAPT. GPs (family doctors basically) really do not understand IAPT and what it deals with…they will refer people with, for instance, unmanaged bipolar disorder or complex PTSD, to IAPT. These patients may have their initial assessment, but when these conditions are discovered the patients will then need to be signposted to more suitable services that specialise in this area of care. It would be irresponsible for instance for IAPT to take on someone with complex PTSD, because there is a limit on the number of sessions they can offer. Imagine opening up complex trauma with a patient, and then having to discharge them without them having processed it all…
Yes, IAPT is not a perfect system, it is hugely underfunded and understaffed. But it is something which people who do not have the means to pay can access, and I think that is better than nothing.
Moreover, just wanted to add as an aside, as I feel like your piece is anti-CBT. CBT focuses on symptoms happening now, which is not going to work for everyone (heck, it didn’t work for me!), but in certain situations it has been shown (and reliable research has proven this) to help pave the way to recovery so I think it is disingenuous to imply this is not the case.