The original key aims of those who developed IAPT were “to provide NICE approved, evidence-based therapies for people with depression and anxiety disorders. The other aim was not only to improve the quantity of the therapy but the quality of the therapy, and to ensure that psychological therapy was freely available throughout the NHS. Also to measure the outcomes for people who had gone through treatment so that we could learn from our mistakes and what we had done well”.
These are laudable aims indeed and ones which can surely be endorsed by clinical psychologists and all those whose lives are blighted by depression and anxiety problems.
How did we get from such lofty aims to where IAPT is today. Has it fulfilled its aims? What is the evidence for “evidence-based therapies delivered according to a matched stepped care model?” What have we learned? My short answer is “no”, “none that matters”, and practically nothing. McFadyen (2020). But we learn very little from short answers.
Leaving aside the strength of the case, there can be no doubt that the success of Clark and Maynard in persuading the Blair government of the great need to expand mental health services for common mental health problems was one of the greatest achievement there has ever been in mental health services.
Unfortunately, because of the way the IAPT service has been implemented, it has become one of the greatest failures. How did that happen?
There was and is no generally agreed discipline-wide support for IAPT. It has been a body somewhat apart from its base in Clinical Psychology. From the earliest stage of development views were, and still are, highly polarised, with the IAPT development team expressing strong satisfaction with progress, against the increasing concerns of its critics. The support of NICE for the central position given to the IAPT brand of CBT, the pseudo-medical nature of problem classification, and the service delivery system, are not universally approved.
This polarisation also applied to the evaluations of the initial demonstration sites, which were hailed as a success by the IAPT development team, and taken as confirmation of the troubles ahead by IAPT’s many critics.
Possibly the diversity of its critics has made it easier for the IAPT developers to resist criticism.
Some critics are of the view that the Cognitive Theory underlying CBT is essentially flawed, both logically and psychologically and therefore unsuitable as the ‘flagship’ therapy of IAPT. Indeed many of its supporters, like Rachman, acknowledge the flaws both of theory and clinical practice, but Rachman goes on to say that “there is no plausible alternative explanation for the effects of cognitive therapy at present”. Many others who endorse Beck’s position that ‘faulty’ thinking causes depression and anxiety/panic disorders have shown a similar commitment to Beck’s Cognitive Theory. This confirms that for many the commitment to Cognitive theory/therapy is more than an academic position. According to Clinical Psychology students there is still a strong teaching bias in favour of IAPT Beckian CBT.
Other critics questioned the way in which IAPT CBT was being applied, and evaluated. Yet others questioned the quality of the training, and the commercial conditions of those required to dispense the ‘therapy’. Others still were concerned at the value for money aspects and the practice of the developers also being the auditors.
A major concern was related to who effectively ‘licensed’ those working within IAPT. There were a number of claims including, of course, the BPS, the universities, and the various associations which appear to increase with each edition of The Psychologist. The British Association for Behavioural and Cognitive Psychotherapies appears to have become the winner by declaring itself “The lead organisation for CBT in the UK and Ireland”. Individual and course accreditation was acquired. Of course it was already experienced in the politics of Clinical Psychology having been quick to drop its original reason for being, as an organisation dedicated to behaviourist principles, to accommodate the new wave of cognitive theories and therapies. Unfortunately the BPS, which is the only organisation representing Clinical Psychology not restricted to any particular ‘ism’, seems to be the loser.
There has also been something of a scrabble for a place at the NICE table which resulted in a few crumbs being thrown to ‘the others’ who considered that they also deserved a prize. No matter; IAPT CBT was by then in what seems like an impregnable position. There were some unseemly inter-group rivalry with squabbles over such issues as whether counselling should be, or not be, recognised as psychotherapy. This Seuss-like feud over who was in or out at NICE has continued to perturb critics of IAPT (including staff) who often feel that legitimate concerns are simply not being addressed by IAPT, NICE, NHS, Government, Professional bodies, or universities.
After many years of extremely positive reports of the continuing success of IAPT in delivering on the key aims, albeit by the developers of the scheme, there are many, more recent critiques from independent reviewers which seriously question whether all, or any of the aims are being met, or indeed whether the scheme is fit for purpose.
Certainly in terms of the developer’s original stated aims, it would now be difficult to award a pass mark to any of these. After many years of endorsing CBT as an evidence-based therapy, NICE has had to acknowledge what was already widely known, that there is no evidence that IAPT CBT is any more effective than most other therapies for depressive and anxiety/panic disorders. In its present condition it is likely to be less effective than most other therapies which focus less on volume. Likewise there is no real evidence of the value of a ‘stepped’ delivery system whereby most of the therapy is delivered by the least trained staff members.
Users of the IAPT service have given their evaluation of the service by dropping out. Unfortunately many of the staff have also dropped out to the point where the aim of increased access to psychological services within the NHS is no longer deliverable unless through increased privatisation and commercialisation focused on throughput rather than output.
If this sorry state of affairs is to be reversed Clinical Psychology has to reclaim both the discipline and the service of Clinical Psychology.
Evidence-based has to be something more than a mantra.
There must be practice-based evidence of evidence-based practice.
Those assessing the evidence have to be able to separate the science from the nonscience. This will require better training of both practitioner and academic researchers.
As Wampold (2001) says,“Slavish adherence to a theoretical protocol and maniacal promotion of a single theoretical approach are utterly in opposition to science.