Friday 16 April 2010


The Improving Access to Psychological Therapies (IAPT) programme is seen in different ways.

Okay, I chide myself to remember as Billy Shakespeare penned in The Life Everlasting, "There is nothing good or bad, but thinking makes it so," yet I still think of IAPT and think, "Yes, but . . ."

It's a big "but" too. A really big arse of it all. Because IAPT piques me.

I had the fortune to work with pioneers (they really were called pioneers) who pilotted IAPT and wrote up how ace it all was. Of course, it wasn't, but who could present their work as a failure when their career/credibility and national policy and being seen to do something positive was necessary?

Subsequent external criticism and internal comment from IAPT workers 'fessing up that it's a service which is self-selecting the "worried well" generates concern. Why? Because IAPT uses a "step tiered" model and, arguably, uses it in an unhelpful manner.

If you're having mild problems, in theory there's "watchful waiting" but in practice these individuals who have contact with IAPT and then over time get better are evaluated by outcomes which suggests that IAPT have facilitated the recovery of someone who, through waiting, got better anyway. Okay IAPT may have a role in surveillance, but to argue that IAPT have improved this person's wellbeing in a meaningful and cost effective and active manner is rather overstating the case.

With mild and self limiting problems being seen within IAPT and then getting better, in spite of (rather than because of) anything that is done, simply through time passing and people recovering, IAPT claims success. Again I think it's disingenuous to suggest IAPT have major impact here because, of course, mental health services aren't amazingly brilliant at curing folk. Shock, horror, but usually we're good at facilitating improvement, hurrying along restoration of wellbeing as nature takes it's course, giving support to make things more understood whilst processes are unfolding, but by and large interventions aren't as miraculous as people would wish to believe.

People had depression before there were antidepressants. People got better. Effectiveness of antidepressants were reviewed in the Journal of the American Medical Association this year and found to work as well as placebo in mild, moderate and severe depression, with drugs only starting to work better than placebo in very severe depression.

We know that drugs, psychological therapy and ECT can help with depression for some people, some of the time. Some people get stunningly good results. Would paying for a good holiday help people with mild depression feel better? Probably. Would talking with IAPT mean that, 2 months on, things were better for someone with mild problems? Probably. Would not talking with IAPT but talking with friends/having a moan/challenging your boss/getting more sleep, mean 2 months on, things were better for someone with mild problems? Probably.

IAPT is attractive to politicians, it's seen as delivery of psychological therapy to large numbers of people. The presence of such a programme then satisfies the desire to do something, to have something.

But what of the process, what of the content?

The people usually have telephone advice. My patients have not felt listened to and heard and understood. IAPT screens for suicidality every contact. My patients weren't suicidal so felt that asking questions that weren't relevant meant they clearly weren't being listened to, with their agenda/needs not being addressed. This switched them off IAPT so much they disengaged. I asked IAPT what had happened in their care, after their GPs referred them to us. In 3 cases IAPT replied that the patient had worked with IAPT and, having made progress, then no longer needed contact. The patient sees their contact with IAPT as an unresponsive self-serving protocol driven process that's not helping them, with failure, resulting in GP contact and referral to mental health services. IAPT report it as a success with a positive patient outcome. In all 3 cases the patient was going through a normal bereavement and didn't need specialist psychological work or medication, yet IAPT couldn't support peoples' mental wellbeing through a normal but unpleasant time.

IAPT should, in tier 3, deal with "high intensity" need such as severe depression and PTSD delivered by CBT trained therapists but they don't. They say they're complex patients who need specialist services so turf them to us.

Mild, self limiting problems are seen within IAPT and reported to do well. Patients who drop out with bad outcomes are seen by IAPT and reported to do well. High intensity severe problems are part of IAPT's role which they fail to deliver on but since it's their role and they've no failures (referring them all) they report they do well.

IAPT therefore paint themselves as stunningly successful, seeking expansion and resourcing. There's only finite cash. Colleagues have described how psychological therapy that was historically accessed in Primary Care or Secondary Care no longer exists because IAPT has consumed those resources and is seen to meet the need, so alternatives aren't commissioned/delivered.

A cheap and cheerful high volume largely telephone advice protocol driven service, to meet most of the psychological needs of most of the patient population needing help . . . I can't help but think it's all gone spectacularly wrong. But we've an election, so I'm sure since the NHS and spending and return to work and family life are such big issues, parties will be offering us choices, no?

Erm, no.

So it goes.


cbtish said...

Yes, the feedback you're getting about IAPT is very similar to the feedback I've been getting. However, I read somewhere that IAPT funding is now tending to be diverted for other purposes. That could turn out to be a good thing.

ruggedbadger said...

In my neck of the woods GP's have referred so many people since IAPT began, the waiting lists are now longer (9 months) than they were before they hired the 30 extra people.

lizzydripping said...

we call IAPT inadequate access to psychological therapies in my area due to the long waiting lists and crap service, i work in a cmht and by accident they faxed us their telephone screening questionaire instead of a referral, it was appaling lots of empty questions followed by (empathy) so for example are you feeling suicdal? (empathy)
really a monkey could do the telephone screening and from some of the reports from service users i see they probably do.

Unknown said...

It's probably worth mentioning, btw, that the finding that anti-depressants aren't much cop for mild depression, is being mis-used a lot in the popular press to mean "depression isn't a real illness, what you need is to pull your bootstraps up and get on with it".

Be careful how your posts are interpreted....

I am of course, that well known blogosphere character, the single-issue bee-in-bonnet who weighs in on the same thing over and over....

Antidepressants have transformed my life....

Mark p.s.2 said...

re:DeeDee"Antidepressants have transformed my life..."

Antipsychotics may have tranformed my life... for the worse

God knows.

Unknown said...

I'm interested in your comments about IAPT. I'm researching an article about IAPT, to which the Guardian's 'Society' section seems to be receptive. I'd very much like to contact you directly and talk to you about IAPT and the new mental health strategy - not necessarily for quotes at this stage but for greater understanding. If you're willing, can you contact me on Yours, Bernard Lyall

Babbler said...

In my patch, step 2 lo intensity workers are used only for telephone triage and dont see much face to face work, as said earlier step 3 are only working with manualised interventions for depression/anxiety, and anything remotely complex or relational comes back to would think "High intensity" band 7 cbt therapists would/should have some competencies in working with people facing normal bereavement... what a waste of money...decomission IAPT- hire a boatload of counsellors and psychotherapists and you've solved the problem. there was NO need to go out and train people to deliver on a faulty framework when you had trained counsellors and psychotherapists out there.

Nicola said...

IAPT isn't a failure in every region of the country, unfortunately it does seem to be a bit of a postcode lottery. The services that work well are usually the ones built on the foundations of a well run Primary Care Mental Health Team that was well established before IAPT. I think it would be unfair to generalise all practitioners who work in IAPT in the same way that you do in this post.

Not every IAPT service just uses telephone interventions and we certainly aren't just seeing the mild cases, they just don't present to GPs.

The Shrink said...

Fair comment Nicola, I think the "fresh start" we had, rather than development of an established credible base, meant ideology and concepts got in the way of patient's wishes and common sense.

I'm sold on psychological therapies, they work, so I'm sure IAPT can be constructed to be effective, it's just my local IAPT that's beyond grim . . .