Some perspectives on improving access to psychological therapies (IAPT)

Socio-political dimensions, expressed and understood in the broadest terms, are the sum of everything that has gone before in the practice and profession of Counselling and Psychotherapy. This is characterised by images of distinguished, educated ‘men’ with graying beards poring over books in sepia tweed jackets. They are long dead, but have left a legacy that has been built on by successive generations; a group of men and women who have become increasingly more diverse but now invariably in more ‘comfy casuals’ and tapping on keyboards.

In order to bring further focus to this broad canvas, the socio-political dimensions are discussed here in the narrower context of what exists today; that is, the National Health Service (NHS) programme called ‘Improving Access to Psychological Therapies’ (IAPT). This programme has been delivered in England from 2008 and, according to Jules Evans, ‘is the biggest expansion of mental health services anywhere in the world, ever.’ (2013)

Aims and objectives

The aim of this article is to identify and discuss the ways in which the NHS – IAPT programme influences how work is managed and delivered in the agency setting and how it serves to promote individual mental health in the one-to-one person-centred relationship between therapist and client.

The national level is the socio-political dimension, the ‘public’ domain that sets the context and, to some extent at least, influences the work in the agency setting. Paul Gilbert (2009) says that:

'Cognitive behavior therapy (CBT)[1] has recently emerged as a dominant paradigm in psychotherapy, and is influencing training and even our professional organisation.’

Improving Access to Psychological Therapies (IAPT)  

The IAPT programme was built on evidence produced in 2004 by the National Institute for Care and Health Excellence (NICE)[2]. NICE demonstrated that cognitive behavioural therapy (CBT) was an effective first-line treatment for depression and anxiety and could offer impressive recovery rates. NICE was not saying that CBT was superior to other therapies but, in the case of other therapies, there was insufficient evidence to be able to make this comparison. Then, in June 2006, the London School of Economics (LSE) published ‘The Depression Report:  A New Deal for Depression and Anxiety Disorders.’ 

This report quantified the scale of both mental illness and ‘crippling depression and chronic anxiety’, affecting ‘one in six of us’ with just one in four receiving any kind of treatment. Whilst the report was clear about the extent of ‘human misery’ and the moral imperative for action, it was notable because it also made a compelling economic case for increasing the availability of psychological therapies which would be paid for from the savings generated from incapacity benefits and medication as ‘patients’ recover and return to work.

In other words, the new therapy services would pay for themselves because, as the report explained, ‘we now have evidenced-based psychological therapies that can lift at least half of those affected out of their depression or their chronic fear.’ These therapies would be made available ‘en masse’ and would involve ‘short, forward-looking treatments that enable people to challenge their negative thinking and build on the positive side of their personalities and situations’. The new seven year programme would make it possible to implement the NICE guidelines by training 10 thousand extra therapists and 40 new IAPT teams would be established across the country each year from 2008.

Then, in 2010 the Government committed an additional £400 million over the next four years up to 2014/15. Service-users would be required to fill out feedback forms after every session and the data would be collated and reported at a national level. In November 2012 a review was published reporting on the success of the first three years of the programme and ‘The first million patients’. They reported ‘recovery rates in excess of 45% and 45,000 people having moved off benefits’[3]. 

Discussion

Whilst the national IAPT vision has been ‘rolling-out’ locally, a fierce debate has been raging within the therapy community. However, before examining the critics, it is worth noting some of the developments that have taken place that have, in the main, been welcomed by most people with any interest in the provision of mental health services. These developments include a growing:

• recognition, at a national social and political level, of the extent and impact of mental ill health and the beginning of a wider more open debate – this includes the NICE and IAPT literature and celebrity experiences of mental health for example: Alistair Campbell, Stephen Fry, Frank Bruno and Ruby Wax.

• acceptance that there has been a level of denial and neglect of the issue in the past in terms of setting priorities and the allocation of an appropriate share of national healthcare resources – the 2011 NHS strategy entitled ‘No Health Without Mental Health’ states ‘We are clear that we expect parity of esteem between mental and physical health services’.

• belief in the value of psychological talking therapies in general – government investment in, and promotion of, talking therapies and attempts to make them available to all those who could benefit.

• funding, which is likely to have been welcomed by most colleagues working in the field and the wider debate applauded for reducing stigma and improving awareness of the experience of depression and anxiety disorders and the success of talking therapies. 

Certainly, clients seem to have a growing expectation now that talking therapies will be made available to them, that they will be free (or at least affordable) and that they may benefit from them. 

An older client recently said: ‘look at me…going along for therapy.’  She said, ‘my husband laughed at me and we said, who’d have thought it?’

She said that she had always thought that counselling was for wealthy ‘posh’ people with time on their hands and that she would not have been there at all if her mother had still been alive. Another client reported that she had been diagnosed recently as having ‘bipolar’, and then laughed and said she was pleased it was bipolar because: 

‘if I have to have a mental health condition, at least I want to have the celebrity-endorsed one!’ 

Andrew Samuels[5], named this class and exclusion issue when he wrote passionately in a letter to the Guardian on the day the Health Secretary announced further funding for IAPT:

‘Clients who enter CBT are approached in a mechanistic way, required to be passive and obedient. Hence what is going to be on offer is a second class therapy for citizens deemed to be second class.’ (2007)

David Veal[6] responded equally passionately defending CBT and he pointed out that:

‘…there are high rates of common mental health problems in our communities and that a vast number of people who might benefit from psychological therapies have no chance to access.’ (2007)

Whilst access to talking therapies through the NHS may be improving, at the end of 2011 the mental Health Charity, Mind, reported that there were still significant regional variations and in some areas 1 in 5 people were waiting over a year for treatment. 

Paul Gilbert (2009) says:

‘CBT has done a good job in getting us to a position where psychological therapies are seen as major players in health care, but there are concerns that CBT (as the name implies) only addresses a specified range of psychological processes. Cognitive processes cannot stand equivalent to all psychological processes.’  

Criticism of IAPT

The main criticisms that have fuelled the debate are around three separate aspects of the IAPT programme, namely:

• the prominence given to CBT and a limited number of other evidence based therapies

• the dominance of the ‘return to work’ agenda and the economic imperative

• an  over-simplification of the issues.

The prominence given to CBT

Darian Leader, a psychoanalyst who writes in The Guardian, criticised the IAPT programme for its reliance (mostly) on CBT. He argues that CBT has serious limitations because it treats symptoms rather than causes and says:

‘Instead of seeing a bout of depression or anxiety attack as a sign of unconscious processes that need to be carefully elicited and voiced, they become aspects of behavior to be removed.’ (2008)

He continues:

‘Most therapies aim to hear what is being expressed in a symptom:  not to stifle it, but to give it a voice and see what function it has for the individual.  CBT, by contrast, aims to remove symptoms.’ (2008)

Patrick Casement agrees and says:

‘From the position of any psychoanalytic practice we are bound to wonder about the effectiveness of a therapy that seems to suppress or change symptoms rather than to understand them. We are also concerned that there may be more trouble later from what is being suppressed or changed, and from what may remain unconscious, as symptoms are often an expression of unconscious conflict that is seeking resolution.’ (2009)

Colleagues who practice CBT would argue that their practice is not about suppression of faulty thinking and behavior but it is about re-focussing on to territory that is more helpful. But this may be semantics and Dr Oliver James agrees with Leader and argues that:

‘Methods which go beyond the symptoms to the heart of the matter are infinitely preferable to CBT.’ 

James also challenges the claims made about the effectiveness of CBT by Lord Layard and David Clark; two of the architects of the IAPT programme. He cites the clinical psychologist Dorothy Rowe Weston and says:

‘Weston found that two years after treatment, two-thirds of those who had CBT have relapsed or sought further help.’ (Hussain 2009)

Others who have concerns about the programme stress that they do not wish to be critical of CBT, which may be a perfectly reasonable option in certain cases, but they say it is not the panacea it has been made out to be and, in any event, the outcomes of therapy are not predicable and cannot, and should not, be predetermined – in fact, that is the point. They are concerned that, as CBT is unlikely to ‘cure’ clients in the way that has been suggested, there will be a backlash and this will have negative implications for the reputation of talking therapies in general. At the same time, there has also been some rivalry and hostility about CBT from professionals working from a different modality. Elaine Davies, a CBT practitioner writing in Therapy Today (July 2013) said:

‘I felt really sad when, at a recent conference, someone walked away from me when I said I worked for an IAPT service as a Cognitive Behavioural Therapist.’ She goes on to say: ‘ I am usually too busy drawing on the core conditions of Carl Rogers...to take part in complicated debates that choose to turn therapy into politics.’ (p15)

The United Kingdom Council for Psychotherapy (UKCP) has also participated in the debate complaining that the IAPT programme is damaging other services and says: 

‘Scarcely a week goes by when UKCP does not hear of yet another psychotherapy or counselling service being destroyed – and the destruction justified by reference to the development of a new IAPT service’.

Of course there is some vested interest here and unsurprisingly UKCP propose: 

‘We think patients should be able to access psychotherapists and counsellors to obtain private treatment in the therapist’s own clinical offices – but funded through the NHS.’

Despite the criticism, the IAPT programme has had an influence on the choice of therapies available locally, and some agencies now offer either long term counselling or a short course of CBT. This choice is both a reflection of the national strategy, the current preference for evidence based approaches, and a response to the requests from clients themselves, self-referred or referred by their GP, for a course of CBT. 

Increasingly many clients are arriving at agencies having heard that the answer to their difficulties is a quick course of CBT. Many agencies have responded to this, perhaps from a sense of social responsibility and a desire to be helpful and relevant, or simply from the need to persuade people to make use of their services so that they can continue to receive funding. Either way, CBT has emerged as the ‘go-to’ treatment and agencies and therapists who are not offering the six week ‘cure’ may be left feeling wanting.

Jules Evans (2013) issues a warning about the risks of ‘mass government sponsorship of CBT therapy’ and Leader (2011) voices his fears of some sinister almost ‘Orwellian’ quest for mental hygiene or of ‘imparting the values of the state in the counselling room’.  This may be a conspiracy too far as CBT is also criticised for not having a set of values to impart and no underlying therapy of human motivation or development. However, the IAPT programme is based on an economic model that relies on its running costs being met through the ‘recovery’ of clients (patients) and their ‘return to work’. 

The ‘return-to-work’ agenda

Many therapists working on the IAPT programme, like Elaine Davies referred to earlier, insist that the therapeutic alliance is essential for effective CBT. They adopt a person-centred approach and aim to be collaborative, congruent and open with clients. This raises the question, addressed by Wesson and Gould (2010), of whether a return-to-work agenda could ever be consistent with an authentic and collaborative therapeutic alliance. 

It seems obvious that a therapist who is working on the basis of service driven goals and targets is unlikely to be able to be genuinely collaborative and there may be an inherent tension between the client’s goals and the demands placed on the therapist by the service. For the therapist to keep the service goals hidden would be problematic (unethical and potentially incongruent) but to reveal them would suggest to the client that the therapist must prioritise the goals of the service over the client. The therapist may appear to the client to be authoritative and controlling and this may undermine the therapeutic alliance particularly where the client’s goals differ from those of the service.

Paul Barrett (2009) asks whether IAPT is in fact simply part of the governments ‘pathways to work’ and he says:

‘To patch people up psychologically so that they can be taken off benefits reveals IAPT as the state-sponsored psych-ops that it is. Another unpleasant side effect of the ‘getting folk back to work’ narrative that my colleagues and I have observed has been the attendant guilt that some service users have reported for claiming benefits to which they are entitled and their anxiety that these may be taken away.’

Rosemary Rizq introduces the concept of ‘disavowal’ in relation to incorporating something like the IAPT service governance requirements and at the same time dismissing them. She gives an example where service managers all agree that the data collection requirements and outcome targets are ‘pointless’; nevertheless, they all agree to comply simply to continue to receive funding. She calls this an act of disavowal - a way incorporating something at the same time as getting rid of it - ‘having one’s cake and eating it’. She goes on to say:

‘I want to use…the notion of disavowal as a stepping stone to thinking about what appears to be happening more generally within primary care mental health services today. My thesis is that the sweeping changes brought in by the government’s IAPT programme have resulted in what I term a perversion of care, exemplifying the way in which NHS services appear to be turning away from the realities of suffering, dependence and vulnerability and from the complexity of managing this.’ (p9)

An over-simplification of the issues

Darian Leader, writing in the Guardian in 2008, rages against the triumph of the market and the ‘accountancy of distress’. He says:

‘In today’s outcome-obsessed society, people must become countable, quantifiable, transparent. And this leads to a grotesque new misunderstanding of psychotherapy. Therapy is now conceived as a set of techniques that can be applied to a human being. This makes sense if we see it as a business transaction with a buyer, seller and a product. But it totally ignores the most basic fact: that therapy is not like a plaster that can be applied to a wound, but is a property of a human relationship.’

Marziller and Hall are also concerned about the simplistic ‘medicalised’ and manualised approach adopted by the IAPT programme, as if depression and anxiety are discrete conditions like measles and can be ‘cured’ if reliably diagnosed and then treated. They say:

‘We reject the one-size-fits-all, techniques-driven approach in favour of the virtues of initial psychological assessment, careful formulation and offering patients a range of options, amongst which therapy, CBT or otherwise, is just one.’

Certainly, the presenting issues for clients tend to be complex and are often around difficult life events such as bereavement, loss of employment, relationship breakdown and other age-related transitions. These issues may also be exacerbated by environmental factors like poverty or isolation, poor health, abuse and domestic violence and will be associated with levels of depression and/or anxiety. Marzillier and Hall (2009) identify two groups of clients that present particular challenges for such a standarised service. They discuss the need to modify techniques to reflect ‘non-Western’ modes of thought and culture and to be proactive in reaching out to those who are socially excluded.

The IAPT service has been characterised, by Stokes (1994) and others, as a move from the tradition of ‘care’ which tends to be messy and complex to a more cost effective and neat solution that is a manualised ‘cure’ and, says Lewis, excludes the:

‘..expression of the uniqueness of each person [which is the messy bit] and the unfolding of subjective experience within the therapeutic relationship.’

Summary and conclusion

This article provides a brief description of the NHS IAPT programme and the impact it has had on the wider therapeutic community. Several welcome developments have been noted, including the wider more open discussion of mental health issues, an increase in resources and the greater availability of talking therapies. However, the programme has also been challenged for being naively simplistic, distorting the therapeutic alliance with the return-to work-agenda and over-promising about recovery and ‘cure’. The response from the profession, in the main, has been for the NHS to use the additional funds to commission existing resources to provide genuine choice and a full range of interventions.

At the same time, there are also some professional rivalries and defensive behaviours as colleagues feel threatened within a profession undergoing significant change. If we recall the foundations of our profession and the rivalry between Freud and his peers, we might suggest that ‘it was ever thus’.

References

Barrett, P. (2009) An uncertain prognosis: helping people to get back into work is a key tenet of the Improving Access to Psychological Therapies initiative.  But, says Paul Barrett, it has been rushed through without awaiting evidence and without fully considering ethical, political and workforce dimensions. Mental Health Practice March 2009 

Casement, P. (2009) Beyond words – the role of psychoanalysis. The Psychologist Vol 22, no 5 May 2009  www.thepsychologist.org.uk 

Davis, E. (2013) We are all on the same side.  Therapy Today July 2013 Vol 24 Issue 6 p 15 www.therapytoday.net 

Evans, J. Five years of IAPT (Improving Access for Psychological Therapies)  2013

http://philosophyforlife.org/five-years-of-iapt-improving-access-for-psychological-therapies/

Evans, J. (May 2013) Their good life.  Governments are now providing free psychotherapy to their citizens.  Is there a limit to state-sponsored happiness?

http://www.aeonmagazine.com/living-together/jules-evans-legislating-for-happiness/

Evans. J. (May 2013) A brief history of IAPT:  the mass provision of CBT on the NHS http://philosophyforlife.org/five-years-of-iapt-improving-access-for-psychological-therapies/ 

Gilbert, P (2009) Moving beyond cognitive behavior therapy.The Psychologist Vol 22, no 5 May 2009  www.thepsychologist.org.uk

Hussain, A. (2009) CBT ‘does not work’ says second high-profile clinical psychologist.  In Psychminded.co.uk.  www.psychminded.co.uk/news/2009/march/09/oliver-james-cbt003.htm

Layard, R. (2006) The Depression Report:  A New Deal for Depression and Anxiety Disorders.  The Centre for Economic Performance’s Mental Health Policy Group June 2006. 

Leader, D, (2008) A quick fix for the soul.  The Guardian Tuesday 9 September 2008

www.theguardina.com/science/2008/sep/09/pschologyhumanbehaviour/ 

Leader, D. (2010) Therapy shows us life is not neat or safe.  So why judge it by those criteria?  The Guardian Thursday 9 December 2010

www.theguardian.com/commentisfree/2010/dec/09/talking-therapy-regulation-judgement/

Leader, D. (2013) Heed the new age of anxiety rather than bemoaning it.  The Guardian Monday 29th July 2013 http://www.theguardian.com/commentisfree/2013/jul/29/heed-age-of-anxiety-stress-exhaustion 

Lewis, A.M. (2012) Organisations adjusting to change: A discussion of the impact of an Improving Access to Psychological Therapies (IAPT) service on the organisational dynamics of an existing psychological therapies department.  Counselling Psychology Review, Vol 27, No. 1, March 2012 © The British Psychological Society.

Marzillier, J and Hall, J. (2009) The challenge of the Layard Initiative. The Psychologist Vol 22, no 5 May 2009  www.thepsychologist.org.uk [first accessed 25.08.2013]

Marzillier, J and Hall, J. (2009) Alternative ways of working. The Psychologist Vol 22, no 5 May 2009  www.thepsychologist.org.uk 

McInnes, B. (2011) Nine our of 10 people not helped by IAPT? Therapy Today February 2011, Vol. 22, Issue 1. P40-41 British Association for Counselling and Psychotherapy 

Mind responds to latest talking therapy figures Wednesday 21 December 2011

www.mind.org.uk/news/6203_mind_responds_to_latest_talking_thrapy_figures 

NICE (2004) Depression, Clinical Guideline 23 (replaced by Clinical Guideline 90 in 2009); NICE (2004). Anxiety, Clinical Guideline 22 (replaced by Clinical Guideline 113 in 2011).

IAPT three-year report: The first million patients

November 2012  Department of Health  www.dh.gsi.gov.uk 

Rowe, D. (2008) Cognitive behavioural therapy – no more than another Labour quick fix. Psychminded.co.uk www.psychminded.co.uk/news/news2008/October08/dorothy-rowe004.htm 

Rizq, R.  (2012) The perversion of care: Psychological therapies in a time of IAPT. Psychodynamic Practice, February 2012 Vol. 18. Issue 1. P7 – 24 Routledge © 2012 Taylor and Francis  www.tandfonline.com 

Samuels, A and Veale, D. (2007) Improving access to psychological therapies:  For and against.  Psychodynamic Practice. Vol. 15, No. 1 February 2009, 41 – 56 Letter originally published in The Guardian on 12 October 2007. Routledge © 2009 Taylor and Francis  www.informaworld.com 

United Kingdom Council for Psychotherapy UKCP response to Andy Burnham’s speech on mental health. Media release 1st February 2012.  www.psychotherapy.org.uk/nofollow/iqs/print 

Wesson, M and Gould, M. (2010) Can a ‘return-to-work’ agenda fit within the theory and practice of CBT for depression and anxiety disorders?  The Cognitive Behaviour Therapist, 2010, 3, 27 – 42 http://simonwessely.com/downloads/publications/Military/other/Wesson%202010%20-%20return%20to%20work%20cbt.pdf

[1] It is understood that the ‘CBT is not the unitary school its critics or supporters like to make out – there are major differences of view, with major advances in psychological research feeding into CBT all the time’ Gilbert (2009)

[2] Formerly the National Institute for Clinical Excellence

[3] Barry McInnes disputes these figures in Therapy Today (Feb 2011, Vol 22 issue 1, p 40.)

[4] Professor Andrew Samuels of the Centre for Psychoanalytic Studies, University of Essex and spokesperson on behalf of UKCP

[5] Dr David Veale Chairman of the British Association for Behavioural and Cognitive Psychotherapies