As a high intensity therapist working in IAPT, I’m finding an increasing amount of the people I see have chronic physical health conditions. The training and supervision I receive emphasises my role as one of treating the depression/anxiety associated with these conditions, and not the condition itself. This sounds plausible in theory, but my experience it just doesn’t work that way in practice.
Firstly, I get the distinct feeling that a lot of the time the people I see with chronic health conditions are not clinically anxious or depressed, they are just having a normal reaction to a really challenging situation.
Secondly it is impossible for someone with my training and limited medical knowledge to know whether a symptom such as fatigue or poor sleep is down to anxiety or depression or other factors, including physical causes.
I’m quite sure that I have treated people in the past, and will do so again, where symptoms arising entirely from an undiagnosed physical condition were misinterpreted as a mental health issue and I worry that there is a real danger, even with the best of intentions, of gaslighting people here, however sensitive and non pathologising I try to be.
Time and again I have had people tell me their symptoms were dismissed for years as being “all in their head”, and I worry I am inadvertently feeding into that damaging narrative.
Greater integration between physical and mental health care in the NHS can only be a good thing, but my experience is there is sizeable gap between the theory and practice on the ground. IAPT is meant to be integrating more into physical health teams, in practice I am not sure how well this is really happening.
I know how hard staff on the ground in IAPT work and how dedicated the clinicians are, I worry we are being put in an impossible situation. I’m very grateful to CBT watch for highlighting some of the predicaments that I can relate to in my day to day work.
It doesn’t matter if the person has high intensity CBT or high intensity counselling or if they have had low intensity CBT beforehand, according to a study by Barkham and Saxon (2018) https://dx.doi.org/10.1186%2Fs12888-018-1899-0, of the Improving Access to Psychological Therapies (IAPT) service. This raises important questions:
What has been the value of low intensity CBT for those who have high intensity treatment?
NICE recommends CBT for depression and the anxiety disorders, with different protocols for different disorders and not counselling, have IAPT proved them wrong?
Given that IAPT provides no evidence of the setting and monitoring of homework, a hallmark of CBT, can there be any certainty that CBT was actually delivered?
What is the evidence that the stepped care model employed by IAPT works?
Why has the British Government just given an extra £38 million to IAPT?
On what basis does NHS England’s National Mental Health Director, Claire Murdoch claim proclaim our ‘world-leading talking therapies’?
Are there conflicts of interest between being a Department of Health Adviser and playing a leading role in IAPT?
Why has IAPT been allowed to mark its’ own homework? In similar vein ‘why has there been no independent audit ion IAPT using ‘gold standard’, standardised diagnostic interviews?’.
In the 3 years since the publication of the Barkham and Saxon (2018) study there has been a deafening silence from IAPT in answering questions 1-4. The Government is likely to be similarly mute in answering questions 5-8, fearing that it would have to admit to having wasted about £5 billion on IAPT.
There is a clear need for a public inquiry to ask the above questions. The Government likes to portray itself as ‘progressive, waving the mental health banner’, the last thing Labour wants is to appear otherwise. The unspoken mantra is don’t ask the consumers of mental health services about whether they have had their lives restored, ‘let us get on with being politically correct’.
I am not averse to IAPT, as a mental health nurse and, therefore, an ambassador for mental health (amongst other things) I’m working in IAPT because I want to help people and because I care.
I’m writing from the very front line of this so when I ask my patients what they want or what their ‘goals of therapy’ are they understandably look at me somewhat quizzically and say something along the lines of ‘I just want to feel better / someone to talk too’ – this is hardly a good starting point for a treatment that is so rigid in its ‘fidelity to the model’ that therapists are subjected to strict supervision which can result in performance management or even disciplinary measures if they do not adhere to the draconian protocols.
This creates a dichotomy for therapists (Mason & Reeves 2018), do we give the patient what they want or what the service tells us to give the patients? – this then leads to confusion for patients and disruption in the therapeutic relationship.
Therapeutic relationship did I hear you say? That most important feature of any talking therapy and predictor of a successful outcome (Knox 2015, Rogers 1951)?
I was once told by a clinical lead that the therapeutic relationship is not important, especially at low intensity where there is only 6-8 thirty-minute appointments (you can only imagine my sense of despondency).
The science says that CBT alone works, the science is convincing and backed up by NICE guidelines and academic research at an institutional and political level (Wakefield et al 2020), I’m looking at you School of Psychology University of Sheffield. If you look closely though, people can see through the bias, dubious points of reference and blatant nepotism (Scott 2018, 2021, Kellet 2020). I would argue if it is really that good anybody, even a robot could deliver it, and here the science fails because guess what, most people want to talk about their struggles of the human experience with another human, they want genuineness, unconditional positive regard, empathy and congruence, sound familiar? Just ask Carl Rogers.
When my supervisees come to me with the common struggles of working in IAPT, burnout and the dichotomy of care, I look at them knowingly and refer them to the best intervention I know in psychotherapy, I tell them to ask Carl and remember that genuineness, empathy, and unconditional positive regard is an intervention in itself, the rest comes down to getting to know the patient and wanting to work together for whatever the person needs, so long as it’s within the step two interventions of course…
My problem is the system, the Industrialisation of Care (Jackson & Rizq 2019) thanks in no small part to the neo liberal austerity politics creating an influential marriage with the science (Dalal 2018).
Don’t get me wrong I wanted an alternative to the over prescribed anti-depressants (Whitaker 2010) and lack of access to talking therapy but what we have created is a data eating, CBT advocating monster which offers patients no alternative talking therapy in most cases (Jackson & Rizq 2019) and is almost entirely unsuitable for people from areas of social deprivation who are therefore overprescribed anti-depressant medication (Destress 2019). This is a crime of health inequality where inscription of deficits-based thinking sees distressed people who are living in poverty as somehow deficient and in need of ‘correction’ through medical or therapeutic intervention (Destress 2019). But enough of the politics, don’t get me started on that, but if you are interested in more on this read the Destress Project report ‘Poverty, Pills and Pathology’ or Managerialism, Politics and the Corruptions of Science by Farhad Dalal.
Author: Name withheld for protection – how has it come to this (MS)?
Dalal (2018) CBT: The Cognitive Behavioural Tsunami: Managerialism, Politics and the Corruptions of Science. Published by Routledge, Abingdon, UK.
Jackson & Rizq (2019) The Industrialisation of Care: Counselling, Psychotherapy and the Impact of IAPT. Published by PCCS Books, Monmouth, UK.
Kellett, S. et al. (2021) ‘The costs and benefits of practice-based evidence: Correcting some misunderstandings about the 10-year meta-analysis of IAPT studies’, The British journal of clinical psychology, 60(1), pp. 42–47. doi: 10.1111/bjc.12268.
Knox, R. and Cooper, M. (2015) The therapeutic relationship in counselling & psychotherapy. SAGE (Essential issues in counselling and psychotherapy). Available at: https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=cat06100a&AN=btc.9781446282908&site=eds-live (Accessed: 7 April 2021).
Mason, R. and Reeves, A. (2018) ‘An exploration of how working in the Improving Access to Psychological Therapies (IAPT) programme might affect the personal and professional development of counsellors: an analytical autoethnographic study’, British Journal of Guidance & Counselling, 46(6), pp. 669–678. doi: 10.1080/03069885.2018.1516860.
Rogers, C. R. (1951) Client centered therapy. Constable. Available at: https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=cat06100a&AN=btc.0094539901&site=eds-live (Accessed: 7 April 2021).
Scott, M. J. (2021) ‘Ensuring that the Improving Access to Psychological Therapies (IAPT) programme does what it says on the tin’, The British journal of clinical psychology, 60(1), pp. 38–41. doi: 10.1111/bjc.12264.
Wakefield, S. et al. (2021) ‘Improving Access to Psychological Therapies (IAPT) in the United Kingdom: A systematic review and meta-analysis of 10-years of practice-based evidence’, The British journal of clinical psychology, 60(1), pp. 1–37. doi: 10.1111/bjc.12259.
Whitaker, R. (2010) Anatomy of an epidemic: magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. Broadway. Available at: https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,shib&db=cat06100a&AN=btc.9780307452429&site=eds-live (Accessed: 7 April 2021).
Homework is the missing hallmark of CBT In routine practice. Inspection of Improving Access to Psychological Therapies (IAPT) records provides scant evidence of agreed homework assignments. Rarely do they specify the behaviours that the client is to engage in, the coping strategy to be employed and the monitoring strategies. But given that client’s commonly have impaired concentration written specification is a must and helps to ensure compliance with homework [Cox 1988 Cox, D. J., Tisdelle, D. A., & Culbert, J. P. Increasing adherence to behavioral homework assignments. Journal of behavioral medicine, 11(5), 519–522. https://doi.org/10.1007/BF00844844].
Beck [Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press] suggested that homework should be a) clear and specific b) include a cogent rationale c) client reactions should be elicited to troubleshoot difficulties and d) progress should be summarised when reviewing homework. Homework provides a link between sessions. Meeting criteria a) to d) in a low intensity intervention is a tall ask and in the absence of written evidence to the contrary, it must be assumed that this active ingredient in CBT treatment is missing [Kazantzis, N., Whittington, C. J., & Dattilio, F. M. (2010). Meta-analysis of homework effects in cognitive and behavioral therapy: A replication and extension. Clinical Psychology: Science and Practice, 17, 144–156]. Whilst it is likely the case that the skilful assignment of homework will relate to outcome Kazantis (2021) [ Introduction to the Special Issue on Homework in Cognitive Behavioral Therapy: New Clinical Psychological Science. Cogn Ther Res45, 205–208 (2021). https://doi.org/10.1007/s10608-021-10213-9], such considerations are of little consequence if routine therapy is constructed in such a way that homework has difficulty thriving.
It is interesting to ponder that if a Civil Court Case was mounted on the basis that a supposed CBT treatment had not in fact happened, leaving ongoing debility, would a claim for compensation succeed? As an Expert Witness I would ask to see the treatment records and in over 25 years in this capacity I can think of few cases were I could be sure, on the balance of probability, that the said treatment had been delivered. Part of this evidence would be no evidence of homework assignment. IAPT has tried to keep out of the legal domain by asserting that its’ therapists do not make diagnosis. But a Judge might ask where is the accountability in this matter. A Nurse may be called to task for not following an evidence based medical procedure even though overall responsibility may rest with a Consultant. There can be no certainty that IAPT would not find itself in the dock. Its’ defence would likely be that its’ practitioners were only doing, say what most BABCP members do, but this would be skating on thin ice.