The Service was set up to address cases of depression and anxiety, with a mirroring of treatment for these disorders in the CBT randomised controlled trials (RCTs). In the RCT’s there was an average recovery rate of 50%. But these trials excluded patients with a personality disorder. Given that personality disordered clients are commonplace in NHS Talking Therapies, it is scarcely credible that the Service should achieve a claimed comparable recovery rate.
In a representative sample of IAPT clients, Hepgul et al (2016) found that 69% had a high risk for a personality disorder with 16% meeting criteria for borderline personality disorder. However, NHS Talking Therapy clinicians do not have the skills to either identify or treat personality disordered clients. Their clinicians literally do not know what they are dealing with.
Stepped-Care More Apparent Than Real
The intent was that NHS Talking Therapies would focus on straightforward cases of anxiety and depression, with severe pathology: personality disorders, bipolar and psychosis, managed by secondary care. But it hasn’t quite worked out that way. As many as 35% of IAPT clients (the predecessor of NHS Talking Therapies) exhibit clinically significant psychotic experiences [Perez et al (2017) and 61% scoring above the screening threshold for bipolar disorder Knight et al (2020). Those scoring highly on a Psychotic Experience scale had a lower recovery rate. But NHS Talking Therapie’s gatekeepers, Psychological Wellbeing Practitioners do not have the skills to identify, much less treat severe mental illness.
Within NHS Talking Therapies cases of PTSD, social anxiety disorder and body dysmorphic disorder are supposed to bypass low intensity and go straight to high intensity. But this presupposes that the PWPs can reliably identify them. However there is nothing in their typically 45 minutes telephone assessment that is a guarantor of reliable assessment of these, or indeed any disorder. The stepping up is again more apparent than real.
In mental health, stepped care is an attempted replication of what occurs in physical health, where therapeutic resources are maximised by using the least costly intervention first, proceeding to more invasive/costly intervention if the cheaper option does not work. But in physical health there is more reliable diagnoses.Whereas in routine mental health scarce attention is given to diagnosis and for many practitioners it is anathema. With no agreement on what ‘works’, it is welcome to ‘Bedlam’.
Zavlis (2023) has observed:
‘UK national data suggest that: (1) of the 1,647,716 IAPT referrals in 2019/20, 63.21% did not complete treatment and (2) of those who completed treatment, around 60% did not achieve clinical recovery. [ Using the Service’s own metric – my Comment] Although speculative, it may not be farfetched to assume that many such cases of treatment resistance are due to comorbid personality difficulties (among other comorbidities, of course)’.
Complexity Bias
The ‘get out of jail card’ for psychological therapists is that their client is ‘complex’. Service providers too, can easily appeal to ‘complexity’ to cover poor performance. ‘Complexity’ has become a selling point for workshops and books. However it is chameleon-like, with no agreed and consistently applied definition. The American Psychiatric Association has, in my view, rightly refused to recognise ‘complex PTSD’. A complexity bias operates in UK mental health:
Starting in 2009 I wrote a trilogy of books under the ‘Simply Effective’ title published by Routledge. The starting point was simple, an open-ended interview in which the client has the space to tell their story. Followed by questions about each of the symptoms that comprised, possible diagnoses. With treatment targets pertinent to the diagnoses and matching treatment strategies. It was the antidote to ‘Complexity’ and the ‘complexity bias’, involving Sat Nav’s for the 10 most commonly occurring disorders. But for 15 years Services have travelled the ‘Complexity’ pathway, with no discernible added value. Unfortunately it does not appear that this bandwagon will stop anytime soon. Perhaps the tide will only turn when people question the economic case for ‘Complexity’?
Dr Mike Scott