It’s not you it is us – anecdotal evidence and observation from 7 years clinical practice and leadership in IAPT

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)?

References

Dalal (2018) CBT: The Cognitive Behavioural Tsunami: Managerialism, Politics and the Corruptions of Science. Published by Routledge, Abingdon, UK.

Destress Project (2019) Poverty, Pills and Pathology, final report. Available at: http://destressproject.org.uk/wp-content/uploads/2019/05/Final-report-8-May-2019-FT.pdf (Accessed: 7th April 2021).

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. (2018). Improving access to psychological therapies (IAPT) – the need for radical reform.Journal of Health Psychology, 23, 1136–1147. https://doi.org/10.1177/1359105318755264

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).

IAPT Teacher’s Blistering Attack On The Service

writing in the current issue of BABCP’s in-house magazine CBT Today, Jason Roscoe, comments that the service may be likened to Frankenstein. His intentions were good but the outcome monstrous.

https://www.dropbox.com/s/hozljbsbz21ceso/20190301_092733.jpg?dl=0

He reflects ‘the gap between what the literature advises and what management allow seems to be widening leaving the patients as the ones who are being given sub-therapeutic, watered-down CBT’.

Revolving Door and Burnout

Jason continues ‘The result? A revolving door where patients return in quick succession f or multiple episodes of treatment with a different therapist each time…..not only this IAPT also seems to be making its own workers ill with reports of compassion fatigue and burnout not uncommon’

IAPT’s Reply

David M Clark the leading light in IAPT was invited to reply (but his status in IAPT was not referred to) and in essence he says the Service should not be as Jason describes because of the IAPT Manual (www.england.nhs.uk) and re-iterates his claim that 5 in every 10 of those undergoing treatment (attending 2 or more sessions). This is very misleading (see Barry McInnes’s, independent analysis of the IAPT data set in a previous post).

Stalinesque

The editor of CBT adds a tailpiece ‘Please note – no further correspondence on this will be entered into’. I have written to the editor asking who decided this and on what basis. I note that BABCP has never allowed any criticism of IAPT by anyone independent of IAPT in its pages. It is deeply disturbing that in the same issue of CBT Today there is a piece titled ‘BABCP Response to the NHS 10 Year Plan’ and states “BABCP welcomes the celebration of IAPT services in England as ‘world leading’…We support continued funding of IAPT training places”.

Stay and Change Things In BABCP?

There is a need within BABCP for a broad church with regard to IAPT, but opposing views, from anyone independent of IAPT are not represented in journals or at conferences. A colleague recently described the situation as Stalinesque, (indeed Jason may have committed professional suicide) the danger is that people will vote with their feet, but this is made difficult as BABCP accreditation is a pre-requisite for many posts. The ‘stay and change’ gong has been sounded loudly in our political parties and it is echoing in BABCP but some will think (if only privately) what’s the point? Perhaps going through the motions. I continue to do my bit, chairing the recently formed Group CBT SIG and running a workshop, but I have grave misgivings.

Dr Mike Scott