The IAPT Manual, 2018:
The new IAPT Manual from NHS England (1) presents the Newspeak version of the expanding Improving Access to Psychological Therapies (IAPT) service. Duplicity is inevitable when non-medical interventions are forced to present themselves as medical. Otherwise, they would presumably not be funded as part of the National Health Service.
Medical terminology is apparent everywhere in the document. The focus is on ‘disorders’ (mainly ‘anxiety’ and ‘depression’) for people who suffer from these conditions. Evidence-based treatment must be administered at the appropriate dose. Adherence to protocols of NICE-recommended therapy is critical to good outcomes. Recovery in IAPT is defined in terms of caseness, in other words, whether a person scores above or below a threshold level of symptoms.
The chief (but not exclusive) IAPT therapy is CBT which is a psychological, not a medical approach. Consequently, there is a mismatch between the tasks and roles of a CBT therapist and the description of IAPT in this document. The impression given is also at variance with training curricula published elsewhere (2). The ‘stepped care’ method of providing the IAPT service means that the least intrusive/expensive intervention is provided first, and if this fails to resolve the problem, a person is referred up to increasingly intensive therapy provided by more highly skilled workers. I haven’t seen a description of the screening (triage) that is carried out on new referrals (or self-referrals) but it is presumably rather brief and based on an assessment of ‘symptoms’. In 2015-16, approximately one-third of new referrals (or self-referrals) were not accepted into the service and a further third who those who were accepted attended for only one session (3). What exactly is going on? Who is being rejected and why? What does one session of therapy amount to?
According to the IAPT Manual: A person-centred assessment completed by a trained clinician is a crucial part of the care pathway. Presumably, this takes place some way up the path, not at the triage stage. Judging by the very detailed specification of what the assessment covers, I estimate that it would take at least two hours to complete, which makes me question whether the prescribed assessment is simply aspirational. Based on extensive experience as a CBT therapist, I have never known one client’s problem to be identical to another’s. Assessment and formulation are crucial. However, IAPT therapy is strictly railroaded into Adherence to protocols of NICE-recommended therapy, which is said to be critical to good outcomes (1). Do we really know that is true or is it part of the Newspeak? This protocol-driven approach is not even consistent with the published curriculum for High Intensity CBT therapists (2). This states that a trainee must demonstrate self-direction and originality in tackling and solving therapeutic problems and to practise as a scientist-practitioner. How many ‘original’ deviations is an IAPT therapist allowed?
If the results for IAPT matched results that have been published in the journals I would be happy. The actual results do not match up. The IAPT Manual states that NICE recommends that a person should be offered up to 14-20 sessions depending on the presenting problem and the number of sessions should never be restricted arbitrarily. We have now entered Never-Never land. The average number of sessions for people who began therapy was between three and six (3). The success rate (according to criteria that can be questioned) was as low as 38 percent for so-called post-traumatic stress disorder and 37% for so-called agoraphobia. A successful outcome for agoraphobia has been reported in the journals as close to 80% since the 1980s (4). The low success rate for PTSD is entirely understandable if therapy is as brief as three to six sessions.
The cost and effort involved in training psychological therapists is high. It is stated (5) that High intensity interventions are usually delivered by therapists who will have received several years of specific training and supervision in a particular therapeutic approach, and will usually have been trained in a recognised health care professional role (e.g. counsellor, nurse, psychologist, psychiatrist, social workers etc.) and may be registered with an appropriate professional body (e.g. BABCP, BACP, UKCP). In other words, the training goes far beyond learning some recommended NICE protocols. The published curriculum for High Intensity IAPT training lasts one year and combines academic study and supervised practise in a service context (2). Applicants have probably already acquired a variety of skills. If they already have a professional qualification it is unclear why they should be attracted to a job in IAPT. Having worked as a trainer myself, I know how difficult it is to cordinate all the necessary facilities in one locality (academic, supervisory, selection and assessment, practice placements, etc.). Since 2008-2011, when a number of courses were set up to provide training for High-Intensity therapists, many of them have since closed: 29% of all courses are no longer offering places (6). This may reflect the practical difficulties just mentioned and the fact that Universities find it much easier to offer straightforward classroom-based teaching.
Nevertheless, IAPT marches on regardless. At what point will the emperor’s new clothes be revealed for what they are?
1. NHS England (2018) The Improving Access to Psychological Therapies Manual.
2. Department of Health (2008). Improving Access to Psychological Therapies. Implementation Plan: Curriculum for high-intensity therapies workers.
3. IAPT (2016) IAPT Annual report, 2015-16. http://content.digital.nhs.uk/catalogue/PUB22110/psych-ther-ann-rep-2015-16.pdf
4. Hofmann, S. G. & Spiegel, D. A. (1999) Panic control treatment and its applications. Journal of Psychotherapy Practice and Research, 8(1), 3-11.
5. NHS England (2015) Adult IAPT Workforce Census Report.
6. BABCP (2018) Accredited IAPT Training Courses.