Are We Fudging IAPT Data?

In my PWP training today we were taught how we are supposed to record our targets and recovery rate data, and I think I’ve just realised one way that IAPT services might potentially be overestimating their success rates…

We were told that if, by the end of the 6 Low Intensity CBT sessions we offer (outcome measures for depression and anxiety are taken at each session), the client’s scores on the two main measures have gone to ‘recovery’ (meaning below caseness, so scoring below 9 for the PHQ-9 or below 7 for the GAD-7) then we mark the final session as a ‘treatment session’, the system will count that client as ‘recovered’ – which makes sense, and that’s all fine and well.
But if we arrange a ‘follow up session’ with them in a few weeks time, and find that their scores have risen to now above caseness, then we are told to mark that session as a ‘follow up session’, and it will not count towards our recovery rates. So, we would have learnt that the person has not in fact really benefitted from the sessions that we have given them, or at least not in any lasting way, but on the system that rise in scores will essentially be ‘invisible’, so ours, and our companies recovery targets, will be unaffected. It will look like IAPT did its job and was successful in ‘curing’ the individual, even though the benefits of our treatment have actually not had too much of a lasting impact, and so weren’t so good after all.

We were also taught another way that might overestimate IAPT’s success rate. If, at the end of the 6 sessions the client’s scores have not lessened enough for them to count as ‘recovered’, but at the follow up session a few weeks later we find that their scores have dropped to below caseness, we are told to mark that extra session as a ‘treatment session’ (not a ‘follow up session’ as in the situation that I’ve described above) so that on the system it will count as thanks to our treatment, and so count towards our recovery rate. If we’re feeling generous to IAPT, we may say that our sessions and support just ended up having a bit of a delayed effect – maybe they were a bit slow to apply all the ‘tools’ we gave them and so we do deserve to pat ourselves on the back. But, you could just as well argue that maybe their life just improved slightly (nothing to do with us), or it was a purely natural recovery (generally consistent low mood does tend to improve over time even with no treatment). So basically we’re allowing natural recovery to count as IAPT-caused, when there is no true measure as to whether this was actually the case.

Neither of these situations are explicitly fiddling with the data – we are still trusting and taking at face value someone’s scores (this is to say nothing of the problems that may inhere in using the outcome measures that IAPT services do, for more on this see Levis et al. 2020), but it’s easy to see how they might lead to a slight bias towards favouring IAPT Guided Self-Help treatments which may not reflect their actual efficacy…

Would be very interested to hear people’s thoughts on this!

Coaches or Clinicians?

I’ve recently started training to become a Psychological Wellbeing Practitioner in an IAPT (Improving Access to Psychological Therapies) service, and what that means is that I will soon be able to deliver Low Intensity Cognitive Behavioural Therapy to ‘clients’ with mild to moderate common mental health problems such as depression and anxiety.

The training is delivered 2 days per week by lectures and seminars from University College London, and the remaining 3 days per week I spend working at my IAPT service doing assessments and low-intensity treatments.

One thing in particular that we learnt in the first week threw myself and my fellow Trainees: the fact that we should not think of ourselves as therapists or clinicians, but as coaches. We didn’t do so big-headedly, but in our previous role (when we were doing Triage Assessments and offering people Step 2 Guided Self-Help, or Low Intensity CBT), we always thought that Step 2 was a sort of CBT-lite, and so the Step 2 clinician was therefore a sort of therapist-lite.

Also, when I was learning about IAPT as an outsider, I was wrongly led to believe that the program is training ‘therapists’ not coaches. David Clark says so himself in his ‘IAPT at 10: Achievements and Challenges’ post, he writes (under the dramatic title ‘A revolution in mental health’), that to overcome the shortage of psychological therapy available to people suffering from common mental health problems, ‘the NHS has trained over 10,500 therapists and deployed them in new psychological therapy services’ (emphasis added).┬áThis is misleading, and I often find evidence of IAPT’s main advocates (usually people with a stake in the game), claiming more for the service than it deserves. I think Clark and others should be more cautious in over-selling IAPT, because it will eventually lead to disappointment when people’s expectations aren’t managed.

Thanks to that misinformation, when I used to allocate people whom I had triaged to Step 2 treatments, I always sold it as a ‘guided cognitive behavioural therapy over 6 weeks, for 30 minute sessions’. But now that we are training to be those Step 2 ‘clinicians’, we find that we are not that at all, and what we offer isn’t Cognitive Behavioural Therapy, but rather a life-coaching session.

But – I agree with this. We shouldn’t think of ourselves as clinicians or therapists because we don’t have those skills – we aren’t taught about what happens within the therapeutic relationship, and how to more supportively guide our clients through more long-lasting psychic change. I think it also serves to prevent us from feeling also like counsellors, whose role is to sit and listen to the client as they talk about whatever they feel like getting off their chest. By reminding us that we are there to encourage behaviour change (and that’s essentially it), it makes a lot of sense to call us coaches.

Having said that, however, it’s now clearer to me just how difficult I’m going to find this year in how it jars with my fundamental values and assumptions as to how psychological therapy should be. It’s odd, and I must try to check it, but I have an almost instinctual aversion to CBT and the phrase ‘evidence-based treatment’. Aaron Beck (the founder of CBT), gives me an uncomfortable feeling, I can’t help but think he’s getting something terribly wrong, or turning something complex into something robotically simple (to its detriment). I don’t have enough learning or experience to quite put into words what exactly I distrust about Beck’s cognitive approach, and I know that it has changed and improved a lot since his day so I’m probably being hugely unfair to modern practitioners of CBT, but I have read a couple of things recently that have started to confirm my uncomfortable feeling about it…

The first was a blog post by philosopher and clinical psychologist Richard Gipps, on how Beck’s turn away from psychoanalytic psychotherapy was caused by his own misunderstanding of the theory, rather than with any fundamental flaw in the approach itself.

And the second was a journal article by Michael McEachrane on the flawed assumptions that Cognitive Therapy is based on to do with what it really means to ‘think that p‘.

I’m tempted to share these two articles with the other Trainees on my course to see what they think, but I don’t want to be the bad, critical one in the bunch.

And, I do understand why IAPT uses the CBT model so religiously. The aim of IAPT is to ‘democratise psychological therapy’ – it wants to make it accessible on the NHS, and this I fervently agree with. Unfortunately, however, CBT is the only kind of therapy that can be made ‘efficient’ and ‘wide-spread’ in this way, because it’s less about the relationship that the client has with their therapist, and more about the ‘tools’ that they learn from them. So, the therapists can be quickly and inexpensively trained, because it’s not really about them and their skills.

Research has shown that this can be effective (with about a 50% recovery rate; not bad, not good?), but the jury’s out as to how long those benefits last for, and I have a feeling that the main function of having Step 2 low-intensity treatments available on the NHS isn’t so much for the good they do, but as a sifting mechanism for finding out who are the really serious cases on the waiting list who need longer-term therapy. Without Step 2, we would have one big, long waiting list for CBT Proper (Step 3), and that wouldn’t be good for anybody.

First Day as a Mental Health Support Worker

Yesterday I had my first shift as a Support Worker at a Recovery House; it was both exhausting and fascinating.

I arrived for 8am, which was when the night staff give us the hand-over on each individual staying at the house, how their night went, etc. so that we know how everyone is feeling in the morning. Then myself and a colleague went around each room at 9am to say hello to everyone, even if that’s just a sleepy grunt, and give some people their morning medication. The rest of the day was spent checking various inconsistencies (one lady had much less medication left than we would have expected given how much she is supposed to take), or issues (to do with housing, mis-remembered doctors appointments…). We also keep regularly checking-in on everyone, and take notes throughout of everything that happens so that we can then hand over that info to the night staff that will follow us when we leave at 9pm.

One of the most interesting parts of the day for me was shadowing a 1-on-1 chat between my colleague and a service user who had only recently come to the house, and listening to how we first get a sense of the individual joining us – what they are struggling with, what they hope to achieve, what particularly distresses them, and general background information…To be totally honest, the conversation was heartbreaking. What seemed to be the major problem for the service user, apart from her mental health difficulties (which were being relieved somewhat by medication, I think), was her lack of social networks. She said that she had no friend or family member who was there for her outside of the house. The only person ‘in her life’ was her Care Co-Ordinator. That must be so frightfully painfully lonely and horrible. I don’t think many of us can even imagine what it must be like to have literally no one that we could turn to if we were ever in a difficult situation (aunts, friends from school, neighbours…). And, in a cruel turn of fate, it is as if having that support network there is even enough to prevent us from actually needing them. I think that the very fact that we know that they are there, is enough to comfort us and stop us slipping into a spiral wherein we really need to rely on them.

In talking to this woman I suddenly realised how powerful those invisible support networks (and, of course, the less invisible ones that we get joy and love from on a regular basis) are to our mental health and stability. Her affect felt completely hopeless, and I really felt and shared her suffering as I listened to it.

Since the ‘social networks’ box that my colleague ticked seemed to be the major problem, (I must add that I really didn’t like the very obviously ‘structured’ interview style that we were doing, I understand that it is useful to quickly measure and compare over time, but it felt inhumane and insensitive when discussing such intimate difficulties.) – she tried to suggest ‘ways to improve’, such as to hang out in the lounge or kitchen more, and get to know other service users, or join one of the activities that the house runs like yoga or a film night.
These are all great ideas, but, to me it almost felt too soon to ask this lady to ‘get out a bit more’. I would have wanted to talk to her a bit more personally first, try to understand what kinds of things she as an individual could imagine enjoying doing, get a little bit more of a sense of herself first, so that she wouldn’t feel overwhelmed and incompetent while trying to socialise. I say this because she really struggled to even look either of us in the eye during the conversation. Though, actually, trying to socialise could probably only help, and maybe she would be pleasantly surprised by the ease with which everyone seems to get along in the house. So, both efforts could be used at once, I think. And of course my own presence probably didn’t help the conversation, as I was just awkwardly sitting there watching. A genuinely 1-on-1 conversation would have been easier for everyone involved.

So, those were my first day thoughts! I am very very much looking forward to getting comfortable with all the admin-stuff of the house, the millions of forms to fill, and which keys open which doors, etc., so that I can concentrate fully on providing the best possible service to the residents. Will keep you updated.