Olivia shared some of her experience of initially training as a Pluralist Counsellor in Scotland and her decision to then to join ‘IAPT’ (Improving Access to Psychological Therapies), in the main to learn more about the Cognitive Behavioural Therapy model (CBT) but also, she said, to have paid work. She continued in her frank and straightforward way to give us an insight into the service that is I.A.P.T. (often termed just IAPT) illustrating both its positive and sometimes failing aspects.
Initially though, for those who like a little historical background information, IAPT was a concept of Professor Lord Richard Layard, an unemployment economist at the London School of Economics who was interested economically in trying to measure people’s levels of ‘happiness’ and so be a guide for public policy. Lord Layard’s father John, an anthropologist, who had suffered severe suicidal depression and subsequently retrained as a Jungian Psychologist after psychoanalysis with Carl Jung and was, therefore, possibly a significant influence on his son’s future career. Lord Layard wrote a Report on Depression: ‘A new deal for depression and anxiety disorders, 2006’. The conclusion of which suggested there was ‘massive distress’ and ‘cost to the economy’ due to mental health issues. He campaigned along with Professor David M. Clarke, a leading CBT practitioner and others, for an NHS service which would be evidenced based on CBT as recommended by NICE (National Institute of Health and Care Excellence) and so IAPT was subsequently set up in 2007 on World Mental Health Day.
The key founding principles included: a desire to relieve human distress; to be cost-effective; to be a medical model and offer evidence-based treatment.
Olivia shared research data showing 1 in 6 of us could be diagnosed with chronic anxiety or depression, but only 1 in 4 would receive any kind of treatment. Mental health issues costs the economy up to £12 billion p.a. which includes increased absence from work, tax loss and benefit costs. Mental health is the ‘biggest health issue impacting on the working population’. IAPT would only cost about ‘£0.6 billion and would therefore pay for itself’.
IAPT is not for the ‘worried well’ who will recover with the help of friends, family or colleagues, working and speaking with their GP etc., because this is not about the medicalisation of ordinary human distress. It is only for those who cannot function enough to lead productive lives and, therefore, might be at risk of longer term sick leave.
Patients can be referred by their medical practitioner, Occupation Health or self-referred.
Step 1: the patient with anxiety and/or depression visits their GP for help/medication.
Olivia explained that when a patient comes into IAPT they complete an Assessment Template the aim of which is to identify risk (the system is very risk adverse). If self-harm is involved the young patient would be referred to CAMHS or an adult to the appropriate service. If not involved, and the client needs something more than Step 1, the decision is made to forward them to the appropriate support within IAPT.
Step 2 – low intensity treatment with a Psychological Wellbeing Practitioner (PWP), Band 5, who offers, 6 1:1 telephone sessions, on-line treatment of mild/moderate conditions.
Step 3 high intensity treatment with a CBT Therapist (Band 7) offering approximately 12 to 20 weeks face to face 1:1, and CBT groups treating moderate to severe conditions.
Counsellors (Bands 5 & 6) are available. They must, it was explained, have completed their training and experience as Psychological Wellbeing Practitioners first, regardless of their current therapeutic qualifications or experience.
Couple counselling, mindfulness, EMDR are all considered if necessary. Person Centred Experiential Counselling for Depression, a collaborative and integrated approach might also be found helpful in allowing clients to encompass change and greater self-acceptance.
Apparently, each IAPT service needs to include an employment advisor – getting people back to work and off benefits – ‘the bottom line goal’. This is an evidence based, standardised service which uses various evaluation tools such as PHQ9/GAD7; Phobia Scales and Work and Social Adjustment Scales to assess patient progress. The patient completes the appropriate forms at the beginning of each session, the data is collected and is available for assessment and for transparency of the IAPT service. The work is goal orientated and patients are guided to experience emotions within a range that is accessible and useful.
Some recent figures Olivia showed, recorded that IAPT services had made 900,000 assessments, 550,000 people received treatment, 2 in 3 showed significant improvement,
50% recovery rate (Jan 2017), 98% scores recorded at the start and end, 86.5% seen in less than 6 weeks. Clients are reported to have found the service helpful to their wellbeing.
A number of counsellors attending the Talk said they had experienced both clients and IAPT therapists saying they wanted to have external counselling or psychotherapy in order to explore their stories, issues and feelings in a client-centred atmosphere. One key issue for IAPT practitioners is the lack of autonomy which in the counselling world allows us to be holistic in approach and not prescriptive or goal orientated.
Olivia also explained how the IAPT professionals are having to deal with the overspill from an overstretched mental health service. Level 4 is deemed mental health issues, whereas level 3, IAPT deal with moderate to severe conditions. The trickle-down effect of this means, there is a huge demand on IAPT services and creative ways are being used to hit targets of getting everyone support within 6 weeks of requesting it. In some cases it can be support via a computer system or groupwork, the latter being a less attractive offer for those who struggle to deal with their anxiety, let alone share it in a group. Therefore the attendance rate can be a lot lower than the intended capacity.
There was concern raised about the fact that PWPs do not have to have personal therapy whilst training or later when working with patients, nor do they have supervision as it is understood in the counselling and psychotherapy world. They do have clinical supervision which can be beneficial but again a concern was that it could be construed to be more like line management as it seems a good deal of the focus is on the ‘outcomes or results’ of each patient’s scores. And another concern was raised asking whether the voluntary services are becoming the ‘go to place’ for people who did not fit the IAPT model?
From Olivia’s significant knowledge of this service and the IAPT results published it was clear that patients can gain significantly from the interventions used and in the recorded results of their improved wellbeing from the evidence based strategies. It will certainly suit patients who prefer and feel they would benefit most from a structured, brief practical model.
Concerns were around the strong sense of a medical model driven by fiscal need and demands rather than human needs. The medicalisation of this work and the term ‘patient’ implies a strong power dynamic in favour of the practitioner or organisation, which is somewhat at odds with the client focused collaborative journey of counselling and psychotherapy. We were made aware of the high turnover of PWPs, and others, sometimes through burnout, which does not encourage the slower insightful, thoughtful development of therapists who over time, sometimes years, become masters of their art and then mentors, coaches and/or supervisors of those beginning their own journeys within this rewarding profession.
Thank you Olivia for offering us a such an informative Talk which held depth, a balanced view and a real sense of honesty.