Sunday, 27 March 2016

IAPT outcomes post Critical Psychiatry 26Mar16; and my comment

'How do we know that IAPT outcomes are not just expectancy effects?' Critical Psychiatry blog post, 26 March 2016:

"It's some time since I commented on IAPT - Improving Access to Psychological Therapies, now often called Wellbeing Services (eg. see previous post). I've just looked at a recent lecture from David Clark (see video). He's still making claims about outcomes based on lack of comparative data. How do we know that so-called recoveries in the IAPT programme are not due to the placebo effect or spontaneous improvement?

For example, in the lecture Clark makes much of the changes in Buckinghamshire Healthy Minds following a review of notes of the unrecovered patients to identify themes and recurrent patterns in the data (see powerpoint presentation). National figures are that 46% of people are said to recover and a further 15% improve. These are average figures and there is considerable variability by Clinical Commissioning Groups (CCGs). Buckinghamshire was below 50% and by telling staff to increase recovery rates to 65%, lo and behold they did! Isn't this just a Hawthorne effect?


There's a lot of money invested in IAPT so I'm sure Clark doesn't want to think about whether IAPT therapists are mere placebologists. There will always be a problem with assessing the effectiveness of psychotherapy because of the issue of the adequacy of control groups (eg. see my BMJ letter). Psychotherapy trials cannot be conducted double-blind because subjects always know whether they have received the therapy under investigation or a control intervention"


and my comment:

"Thanks for blog post. I am keen to see psychological therapies offered on an equal basis to psychiatric drugs for people experiencing mental distress, altered mind states, psychoses and in emotional crises.  Therefore I want the research on talking therapies to be thorough and relevant, to focus on people's voices, their stories about recovery.

You say that there will "always be a problem assessing the effectiveness of psychotherapy". I can't see the BMJ letter because of paywall (got a copy from a colleague, see below).  However surely the testimony of the people receiving psychotherapy and other talking therapies has to be of value?  How they feel about the service, whether they have increased confidence and wellbeing.

I think that psychiatric drugs may appear effective in the short term by reducing symptoms but in the longer term are counter-productive.  I speak from personal experience, my own and many family members who have had to live with the side effects of the drugs.  Many of which cause anxiety and other disabling conditions.  Antipsychotics depressed me.  I had to taper and get off them to have a life.  And did so under my own steam.  Although in 2012 my youngest son was supported in the taper by a psychiatrist.  But we got NO other support from services.  We were left to get on with it.  Solo.  No CBT which we asked for.  So I had to support my son cognitively, helping him to work through negative thinking.  He did the work, I was a listener.

My son, who has a bipolar disorder diagnosis, is very gradually recovering from the psychiatric abuse of the locked seclusion room and other indignities.  The flashbacks in the first year after his discharge from hospital were terrible.  We did not expect the sub-human treatment, it was a shock.  And we are still living with it, coming to terms with it. 

Therefore I welcome your blog post and challenges about IAPT outcomes.  For we need valid, proven alternatives to drug "therapies" for mental health treatment.  And I believe we need research partnerships and co-collaborations between people who provide talking therapies and people who have survived psychoses, psychiatric treatment and mental illness prognoses.  A level playing field where life experience is of equal value to academic qualifications.  Although some of us who have survived psychiatry are academically qualified in other areas (community education, FE lecturing)."


--------------------------

Dr Duncan Double's BMJ Letter, mentioned in blog post:
EDITOR—In discussing the future of psychotherapy, Goldbeck-Wood and Fonagy comment on the difficulties in providing meaningful evidence about efficacy.1 However, they do not explain that the specific problem is about the adequacy of control groups.2
Comparison of active with control treatment in psychotherapy cannot be conducted double blind as subjects inevitably know to which group they have been allocated. Drug trials may seem to have an advantage over psychotherapy trials in claims for scientific legitimacy because they can be conducted double blind by using placebo drugs. However, the degree of bias remaining in apparently double blind trials should not be underestimated.3 4
Goldbeck-Wood and Fonagy may have focused too much on evidence as factual without acknowledging the importance of interpretation and have therefore not spelt out the role of ideology in assessing efficacy. Evaluation of psychotherapy is controversial. Psychotherapy may be in conflict with biomedical psychiatry in its conceptualisation of mental illness. Moreover, statutory responsibilities under the Mental Health Act take precedence within mental health services over psychotherapy, which is a voluntary activity. Psychotherapy therefore struggles against the hegemony of biological psychiatry.
For reasons such as this, psychotherapy has established itself primarily outside the state sector, as Goldbeck-Wood and Fonagy note. Their solution is for the NHS to create a proper career structure for psychotherapists. Politically this may be less likely to be successful than taking advantage of the government policy for choice in the NHS.5Primary care trusts need to look for alternative providers to meet the public demand for psychological therapies. Psychotherapists could organise themselves into provider organisations. These alternative providers should meet standards of training approved by such bodies as the UK Council for Psychotherapy and the British Confederation of Psychotherapists.
Footnotes
  • Competing interests None declared.
 
References
  1. 1.
    1. Goldbeck-Wood  S
    2. Fonagy  P
    .The future of psychotherapy in the NHS: more evidence based services are taking shape to meet growing demand.BMJ2004329:2456 (31 July.)
  2. 2.
    1. Bergin  AE
    2. Garfield  S
    .Handbook of psychotherapy and behaviour change. 4th ed. New York:John Wiley,1994.
  3. 3.
    1. Fergusson  D
    2. Glass  KC
    3. Waring  D
    4. Shapiro  S
    .Turning a blind eye: the success of blinding reported in a random sample of randomised, placebo controlled trials.BMJ2004328:432.
  4. 4.
    1. Moncrieff  J
    2. Double  DB
    .Double blind random bluff.Mental Health Today2003;Nov: 246.
  5. 5.
    1. Department of Health
    .Building on the best: choice, responsiveness and equity in the NHS.London:DoH,2003.

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