Making sense of the IAPT Cognitive Therapy takeover of Clinical Psychology
As far as psychological therapies go my career started in the mid 60s, around the early days of Behaviour Therapy and encompassed the many changes in theory, practice and service delivery which occurred up to my retirement in the late 90s.
Over that time there were many changes, some practice led e.g. the move from gradual exposure (desensitisation) to rapid exposure (flooding). In terms of theory this was a relatively minor paradigm shift, with habituation replacing deconditioning as the process. The effect on my practice was however revolutionary with much higher rates of improvement/recovery in much less time.
During the 70s I was developing my ideas that both the development of, and recovery from Panic Disorder, could be better understood in terms of Kelly’s concept of cognitive invalidation. Again this changed my practice, and the practice of most of my colleagues, many of whom extended the application of exposure to a wide variety of problems from the traditional birds, wasps, cats, dogs, travelling particularly flying, public speaking, balloons, to the more unusual (McFadyen and Wyness, You don’t have to be sick to be a behaviour therapist, but it can help! Treatment of a “vomit” phobia, Behavioural Psychotherapy,1983, 11) and the less traditional (Blakey R., Baker, R., an exposure approach to alcohol abuse, in Behaviour Research and Therapy 18, 1980). It was also readily adapted to OCD and other problems.
Over time we became more confident that we could quickly help clients to understand the normal process involved in the development of their panic disorder. Just asking what they thought they would need to do to prove to themselves that the panic attacks were not dangerous usually resulted in them telling us what needed to be done. And, more importantly, doing it.
Some variant of panic disorder constituted almost half of all GP referrals, and our ability to deal quickly and effectively with these allowed more time for clients with problems which required greater input.
Initially, I did not regard my contribution as anything other than offering another minor paradigm shift which enhanced the effectiveness of exposure based treatment techniques – an addendum to the work of Marks, Gelder and Rachman.
I remember being quite pleased to introduce Cognitive Invalidation as ‘a cognitive explanation of a behaviour therapy for an affective disorder’.
I had no difficulty accommodating what I saw as the ‘best bits’ of Beck’s Cognitive Therapy – the concept of cognition sometimes playing a primary role in the development of mood disorders. However I failed to see how this only applied to thoughts. Surely the same ‘automatic’ reactions applied to thoughts, feelings, and actions, and was something to be considered in formulation rather than thoughts being given a unique causal role in mood disorders (and eventually in many others).
There were so many obvious flaws in the Cognitive Theory underlying Cognitive Therapy that I anticipated that, as with other developments, the therapeutic insights would have a lasting influence while the theory would go the way of deconditioning as the basis for exposure based treatments. How did I get it so wrong?
Prior to Cognitive Therapy, new developments in psychological therapies in the UK were mainly of British origin and were disseminated within the professional community via academic journals and university courses.
In North America psychotherapy was a much more public matter. In 1970 I was working in London Ontario, a city with a population around 200,000, which had 200 practising psychotherapists. The psychological therapies market was major, with how to do it guides for both professionals and public a major section in every bookshop. It was natural that Cognitive Therapy came to the UK with a ready supply of literature for professional and public consumption of a quality not previously seen.
There is no doubt that the work of Dr David Burns in popularising Cognitive Therapy did more to disseminate Beck’s work than any academic paper. Feeling Good and the Feeling Good Handbook became the forerunner of The Matrix and IAPT, and with far higher quality.
Unfortunately we also imported the psychological therapies ‘Schools’ model whereby like-minded practitioners formed associations, with their own journals, training, and support networks. When you spend many years training to become licensed in a particular form of therapy, it does not take a psychologist to see the outcome, a lack of critical analysis, and pressure to either only take ‘suitable cases for treatment’ or extend its application beyond its applicability.
Being old enough to have seen the latter days of many of the leading figures in 20th century clinical psychology, I am pretty sure that cognitive dissonance and denial were much more in evidence than reflexive thinking.
It was a smart move for Cognitive Therapy to quietly absorb Behaviour Therapy on its way past – you never know when you might need it!
Matters of Evidence
Another feature which came with the Cognitive Therapy literature was the frequent reference to the scientific evidence which supported it. This again was related to the trend in North America for health insurance companies to seek to ensure that treatments they were financing were of proven effect. Their term ‘empirically supported’ became ‘evidence based’ in the UK. It didn’t matter that the science and the evidence was flawed, the terms quickly became established as a kind of Kite Mark.
The Cognitive Therapy package was compelling, not only at a lay level, but at the highest professional level. With the endorsement of figures like Marks, Gelder and Rachman the stage was set for The Great Cognitive Therapy (Non) Debate.
The CBT revolution coincided with the introduction of General Management in the NHS. In a very short space of time healthcare decisions shifted from a complex collaboration between clinicians, academics, and administrators trained within the NHS, to a management hierarchy with people at the top who had little or no experience of the services they managed. General Managers wanted simple concepts of the problem and of the solution. Clinical and academic involvement was simplified to, at best, committee generated ‘evidence based’ guidelines and protocols based on a standardized (and flawed) review of research evidence. At worst professional and academic advice to government was in the hands of a few ‘advisors’, with all the risks that this brings.
In the mid 60s Oxford Clinical Psychologist Professor David Clark, and LSE Economist, Professor Richard Layard, collaborated on a project which culminated in the IAPT initiative. Layard convinced the government that the cost of the program would pay for itself, and Clark’s concept of manualised treatments which could be taught to para-therapists, thereby resolving the ‘delivery problem’, had an obvious appeal to politicians and managers.
In the British tradition, dissent was allowed, even encouraged, with an opinion special in The Psychologist, (Marzillier and Hall, 2009. vol 22 no 5). Then ignored.
Best abstract ever? “There’s just one problem with the Layard initiative – it won’t work” Read the article!
And of course it didn’t, and doesn’t. See articles on Richard Hallam Blog, The Mental Health Conspiracy, May 2018,
CBT Watch, An Independent Mental Health Watchdog and Discussion Forum, Dr Mike Scott
Thus the combination of a well packaged product, and gullable customers who found the product too attractive to carry out due diligence before committing, brought about the end of Clinical Psychology as we knew it. Science? Evidence? Not a lot of either really.