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7
IAPT AND THE IDEAL IMAGE
Jay Watts
‘. . . In the name of psychological science we seek fulfilment’
Foucault (1984, p. 261)
‘It is the very pursuit of happiness that thwarts happiness.’
Viktor Frankl (1985, p. 85)
It is 2006. You are an MP, part of a New Labour once adored, now subject to
ridicule. Your leader Tony Blair is now a figure of fun. It is unclear if you will
win the next election. Suddenly, The Depression Report lands on your desk. The
first page tells you that ‘one in six of the population suffers from depression or
chronic anxiety disorder’. This report promises results. You read on:
At least half of them could be cured at a cost of no more than cou. . . For
depression and anxiety make it difficult or impossible to work, and drive
people onto Incapacity Benefits. We now have a million people on Incapacity
Benefits because of mental illness – more than the total number of
unemployed people receiving unemployment benefits. . . . Mental illness is
now the biggest problem, and we know what to do about it. . . . But can
we afford the biggest problem, and we know what to do about ititspeople
onto Incapacity Benefits. We now haveo Incapacity Benefit costs us e bi a
month in extra benefits and lost taxes. If the person works just month more
as a result of the treatment, the treatment pays for itself!
(Layard et al., 2006)
The language is sterling, but the message is better. Cure, no less, and in such a
way that the country will actually save money. And an implicit promise of a happier
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IAPT and the Ideal Image 87
1111 voter, a voter – perhaps – more likely to want to keep the government the same.
2 Who could blame our hypothetical MP for feeling keen.
3
4
A Personal Experience of IAPT
5111
6 I too read the Depression Report in 2006, but I was less convinced for I was already
7 one year into my Improving Access to Psychological Therapies (IAPT) experience.
8 When I first qualified, in 2005, I started a job in East London. Within days, I heard
9 that the area was being put forward as one of two pilot sites for a new project
1011 called IAPT. Local clinicians were in two minds. Was this an opportunity for us,
1 in the most economically deprived area in the country, to have an injection of
2 funding first for once? Or was this initiative, based as it was on CBT, a pipe dream,
3111 introducing a model of therapy, based on norms which just did not fit with our
4 deprived, diverse, local community? Over the coming years, I would attend round
5 after round of consultations. Would it work, had it worked, couldn’t we see it
6 had worked? As evidence from the local pilot study was used to roll out the
7 programme nationally, many of us became confused. Had our feedback not been
8111 considered – the exponential increase in new referrals to secondary services, the
9 people who had been ‘cured’ but came back for more, the success stories, yes, but
20111 envy that was bubbling up between the old and new workforce. The version of
1 IAPT that was being storied was one glossier and more evangelical than the reality.
2 My concern for the chasm between the image of IAPT and the actuality of
3 IAPT has only increased over the years as I have supervised dozens of IAPT workers,
4 listened to hour upon hour of tapes of IAPT sessions and heard the stories of patients
5 who have been through IAPT. These experiences have all led me to believe that
6 IAPT operates in a virtuality focusing on performativity and surveillance rather
7 than real encounters between clinician and patient. I believe this can be a huge
8 strain on IAPT clinicians and is the main reason that vast numbers of people referred
9 to IAPT never successfully complete a treatment (e.g. McInnes, 2014).
30111 Arguments for IAPT are presented as so commonsensical that to answer ‘no’
1 to the question ‘Are you against improving access to psychological therapies?’ seems
2 ridiculous. Yet some times we need to trouble common sense, to listen to what
3 does not quite fit, to wonder what becomes of those burnout workers, the
4 hundreds of thousands – of referrals that disappear before receiving a ‘successful’
35 treatment (e.g. Griffiths, Foster, Steen, & Pietroni, 2013). This chapter is about
6 wondering what does not fit the image of IAPT and how the seeming gloss of its
7 promises may actually increase the level of anguish in society.
8
9
The Right Treatment, The Right Choice
40111
1 As I started to write this chapter, a flyer came through my letterbox, part of an
2 initiative to sell online IAPT Cognitive Behavioural Therapy (CBT) to all Camden
3 residents. It insists that my personality is worthy of attention – that I can have any
41111 sadness, anxiety, unhappiness that might get in the way of who I would want myself
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to be excised. It is an exciting option. The promise of finding out if I am sadder
than I should be brings back echoes of quizzes in girls magazines when I was a
teenage – tantalising promises to answer the question ‘does he fancy you?’ ‘are you
popular?’. A chance to quantify exactly how I am doing, a promise to conquer
sadness! Who wouldn’t be tempted by such an idea? Yet at what cost?
To address these questions, we need to explore the treatment that is being
proposed, CBT. Over the past twenty-five years, CBT has become the treatment
of choice in England (Harvey, Watkins, Mansell, & Shafran, 2004). There are many
reasons for its dominance, but briefly it is cheaper than most therapies, highly
marketable and fits well with the grand narrative of evidence-based medicine (House
& Loewenthal, 2008). Unlike many psychotherapies, CBT has a model of psychic
change which allows it to be tested through Randomised Controlled Trials
(RCTs), the gold star of the NICE guidelines, which structure service provision
in the UK (Slade & Priebe, 2001). CBT has come to replace older treatments such
as family or psychodynamic therapy in the hearts and minds of commissioners and,
increasingly, the public with young generations increasingly referring to it as a
lifestyle option.
CBT is storied as ‘forward looking’ and ‘positive’; not ‘endless nor backward-
looking’ (The Depression Report, 2006, p. 1) as other therapies are caricatured.
This is an inviting narrative, the forward, progressive narrative (good) implicitly
opposed to a backwards (bad) one. These discursive moves to rubbish what was
before and present CBT as exciting are necessary to engineer a position where
CBT is picked as a treatment in an era of consumer choice. Consider this piece
of prose:
If you have depression or are worried you might have, you need good
information to make the right choice about different kinds of help. This
booklet tells you about the range of evidence-based talking therapies
that are approved by the National Institute for Health and Clinical Excel-
lence (NICE) for treating adults with depression. It aims to give you the
information you need, help you ask the right questions and decide which therapy
suits you. These therapies have been shown to be at least as effective in treating
depression as flu vaccines are in preventing flu, beta-blockers in treating high
blood pressure or surgery in removing cataracts – and they can be safer and
more effective in the long term than prescribed drugs.
(‘Which Talking Therapy for Depression? 2011, p. 1)
Though the purpose of the leaflet is purposively to help the reader choose ‘which
talking therapy,’ the words explicitly and implicitly encourages the reader to ask
the ‘right questions’ to make the ‘right choice’ consistent with the grand narrative
of evidence-based medicine – a ‘choice’ storied as so commonsensical that it is
akin to choice in physical medicine. Fluent in the grand narratives of evidence
base and cost–benefit analysis, CBT is the ‘right choice’ for the era of New Public
Management (Hood, 1991, p. 59), whereby ‘market discipline has been applied
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IAPT and the Ideal Image 89
1111 to public bureaucracies through reforms which have attempted to increase
2 competition’. NPM is the bureaucratic manifestation of neo-liberalism – the
3 merger of liberal ideas with free-market economics that originated in the 1980s.
4 CBT fits well in an era which combines a competitive, economic focus with an
5111 ‘audit explosion’ (Power, 1997). To understand why, we must first explore what
6 CBT is like in IAPT and the experience of the IAPT worker.
7
8
Excision versus Exploration
9
1011 CBT is a set of techniques that focus on problems in the here-and-now (Harvey
1 et al., 2004). CBT aims to remove ‘symptoms’ or alter a patient’s relation to them,
2 and not look for their hidden meanings. CBT promises to allow us to cut out bits
3111 that do not fit with our ‘ideal image’ of ourselves. There is no unpacking of the
4 ‘ideal image’ of what we should be, what is normal, what is desirable, and how it
5 has been created from the remnants of our upbringing, our histories, the socio-
6 political reality that we have been raised in. The emphasis is less on ‘why’ a problem
7 emerged rather than ‘how’ an individual contributes to its ‘maintenance’ in their
8111 current thought patterns and beliefs.
9 CBT is focused on a ‘case conceptualisation’ or formulation. In IAPT services,
20111 as opposed to with CBT with more complex presentations like psychosis or so-
1 called personality disorders (e.g. Morrison & Barratt, 2010), a case conceptualisation
2 takes the form of tailoring the patient’s experiences to a model of their designated
3 problem which is set out in (quite literally) boxes and downloadable from the central
4 governing IAPT organisation and organisations such as UCL’s CORE unit.
5 Problems are seen as a result of faulty reasoning or behaviours in the individual.
6 In contrast, most other therapeutic approaches have attempted to contextualise
7 distress, be they psychodynamic approaches which contexualise the symptom with
8 the psychodynamics of competing mental systems, family therapies which entexture
9 the system in wider systems, or feminist therapies which politicise and gender
30111 personally embodied distress. While the CBT literature pays lip service to the
1 increased prevalence of distress in certain populations and increasingly, the
2 importance of early trauma, such as bullying, in the origins of problems (e.g.,
3 Corrigan & Hull, 2014), clinical practice communicates something different. For
4 though sometimes, nowadays, there may be a box in the formulation for ‘early
35 childhood experiences’ where bullying or sexual abuse may be written, the focus
6 of the work is not on acknowledging or working through these experiences. This
7 communicates to the patient that the responsibility, now, is theirs.
8
9
Collorating with Empiricism?
40111
1 Though there is surface talk that CBT for common problems does not follow the
2 medical model (e.g. Department of Health, 2011), the models for particular
3 problems taught on IAPT training programmes are strangely familiar to anyone
41111 who knows the diagnostic system (i.e. specific phobias, panic disorder, social phobia,
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OCD, PTSD, Generalised Anxiety Disorder and Health Anxiety and Body
Dysmorphic Disorder). The use of problems akin to diagnostic categories give an
implicit impression that the faulty cognitions and behaviours are due to a disorder
and that this provides an actual explanation as opposed to a mere label. This
problematises the ‘collaborative empiricism’ between patient and therapist that is
used in CBT to brand the approach, for the style of questioning is steeped in a
presumption not just that this way of seeing the ‘problem’ is correct, but that this
is a value neutral, invisible activity.
Most assessments are carried out on the telephone. The clinician’s task is to
assess risk and establish which ‘problem’ the patient has so they can be placed on
the Psychological Wellbeing Practitioner’h (PWP) or High Intensity Worker’s (HI)
waiting list (or stepped up to secondary care if need be). Thus a thorough
psychological assessment is not carried out, nor does the question and answer
protocol driven format allow a chance to listen to the patient’s complaint. This
may be an important defence against anxiety (e.g., Menzies-Lyth, 1959) for the
overwhelmingly social causes of mental distress (e.g. World Health Organisation,
2014) cannot be cured in IAPT’s average of 3.94 sessions (Griffiths & Steen, 2013).
Under such circumstances, we can understand, perhaps, the desire not to know.
The IAPT patient will then start treatment with a different clinician who will
have been primed to which problem s/he is expected to work through from the
assessment. Sessions last for up to half an hour for PWP workers, but many are
just ten minutes in comparison to 50 minute session times within psychotherapy
(e.g. Feltham & Horton, 2012). The pressure to meet session number deadlines
mean techniques must be taught as quickly as possible after a brief ‘socialisation
into the model’ of CBT. The patient has already been primed into the idea that
internal problems can be readdressed through changing faulty thinking or
behaviours through the way assessment questions are formulated and the implicit
messages about the model in referral information and leaflets. The extortionately
high rates of drop outs at this stage suggest many vote against CBT with their feet;
these drop outs are not seen as failures of CBT in the analysis of outcome data as
presented by IAPT (McInnes, 2014).
Socialising or Indoctrinating?
For those patients who remain, an ‘agenda’ is set at the start of each session, and
the homework set at the previous session is discussed.1 Agenda and homework setting
are both storied as collaborative endeavours in the CBT literature. However, when
supervising tapes of IAPT workers, it is clear that in the majority of cases clinicians
suggest or steer patients to IAPT consistent goals such as applying for a job or
going out in public. This is less because of malevolent intentions but because of
the twin evils of a) lack of time so severe that procrastination of decision making
is not just possible and the patient needs to be encouraged and b) socialisation into
the idea that therapy is about doing things, getting somewhere, rather than listening.
Thus, for the IAPT worker, it seems perfectly natural that homework tends to
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IAPT and the Ideal Image 91
1111 focus on either attempted ‘behavioural change’ or monitoring existing thoughts
2 to replace them with alternatives rather than going on a march or painting. The
3 resistance to this implicit in the high rate of non-compliance with homework –
4 40 per cent not completing it (e.g. Schmidt & Woolaway-Bickel, 2000) – is
5111 attributed to faulty technique on behalf of the therapist who, we we will see,
6 is perpetually monitored herself.
7 The majority of sessions is spent on ‘eliciting key cognitions,’ ‘eliciting and
8 planning behaviours’ and ‘guided discovery’. The choice of words here are
9 revealing. For example, ‘eliciting’ means to evoke or draw out with the assumption
1011 that we extract from someone what we know to already be there. This is an apt
1 description of the CBT model because, for common problems as the models of
2 social anxietyand others, the practitioners do purport to know what the main fault
3111 cognitions and behaviours to drawout. The therapist and patient need to go through
4 a performance of finding this out, as if it were not already predetermined, before
5 applying a set of ‘change methods’ or techniques to fine tune the muscle of the
6 human machine. Thus, techniques are applied to individual subjectivity initially
7 from outside, which the individual is encouraged to absorb, creating new
8111 subjectivities at the cost of what the symptom was, perhaps, trying to tell us. Darian
9 Leader has compared this facet of CBT with the Maoist Cultural revolution in
20111 China, where depression was reframed as due to faulty thinking rather than the
1 trauma of displacement or poverty (Leader, 2008). Certainly, the ‘technologies of
2 the self’ the CBT patient is taught carries echoes of Foucault’s ‘disciplinary power’
3 (e.g. Foucault, 1984b) where the state uses subtle power to mould its subjects into
4 acquiescence. Nikolas Rose (1990) has argued that this modern ‘governmentality’
5 of selfhood ‘conducts the conduct’ of citizens in line with a neo-liberal ideology
6 which construes the self as psy self-improvement project for which the state has
7 minimal responsibilities. This makes listening to IAPT tapes sound like listening
8 to torture – but what I hear is patients giving up what they want to talk about
9 for what the IAPT worker wants to, needs to, introduce. They do this often for
30111 what psychoanalysts might call ‘transference love’ (Freud, 1958); the power of the
1 relationship to make us suggestive to what the other would have us be may sound
2 far-fetched, but it is perhaps the only explanation for why all therapies, whatever
3 the model, however different the epistemology work equally well (e.g. Norcross
4 & Lambert, 2011).
35
6
Second-Wave versus Third-Wave CBTs
7
8 Defenders of CBT argue critics do not know what contemporary CBT is like (e.g.
9 Samuels & Veale, 2009), confusing so-called ‘second wave’ CBTs, which focus
40111 more on trying to control or alter thoughts, with ‘third-wave’ CBTs, which focus
1 more on challenging emotional avoidance and troubling people’s habit of taking
2 thoughts seriously. However, though it is true that third-wave CBTs use the
3 relationship more (e.g. Churchill et al., 2013), the type of CBT practices in IAPT
41111 is overwhelmingly second-wave as this is easier and quicker to teach through guided
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bibliotherapy and short-term change techniques. As CBT in IAPT is so time
squeezed, there is no space to question these implicit values. Such a CBT is more
akin to a fitness programme for the mind, an analogy explicitly used (IAPT, 2011).
The CBT patient in IAPT services, devoid of space to explore his or her own
values to angle towards must take in lieu the ready-made norms provided by the
state.
The CBT practiced by PWPs is not akin to the more sophisticated therapy offered
by HIs or in secondary services – PWPs are not therapists, we hear. Yet the headlines
and policy documents group PWPs as ‘the new workforce of therapists’ (IAPT,
2011) blurring the loss of what even the IAPT and CBT communities recognise
as a different experience. The need in a short period of time to provide a solution
dictates the incorporation of a set of ideas about the cause of problems imposed
from outside into the subjectivities of patients. We find this phenomenon equally
with the new treatments that are slowly beginning to be available in IAPT –
Dynamic Interpersonal Therapy (Lemma, Target, & Fonagy, 2011) and Behavioural
Couples Therapy for Depression (e.g. Bodenmann et al., 2008). These therapies
– from psychodynamic and couples therapy traditions – ignore the deconstructionist
elements of these modalities for a practice that shores up defences and normalises
the subjectivities of those with symptoms trying to speak. Hence it is not just CBT
that falls into the remit of what Langs (1979) called a ‘lie therapy’; it is the neo-
liberal insistence on the proceduralization of practice, the surveillance of workers
and the forces of the market which impose on the patient a framework of who
they are and how, from now on, they must act.
I hope that I have begun to trace how, though there are specifics to CBT which
make it complicit with neo-liberal ideology, the very structure of IAPT worsens
this tenfold. I now turn to the position of the IAPT worker – a clinician under
more pressure, monitoring and surveillance than any talking therapist in history –
and the socialisation into one way of seeing the human psyche which IAPT training
consists of.
Workability as a Good Outcome
As a general rule what we find today is that the further removed observers
(i.e. managers, policy makers, politicians) are from the reality of the front-
line the more they are likely to be taken in by the illusion they themselves
have been instrumental in creating.
Hoggett (2010, p. 61)
Most IAPT teams consist of a manager, senior supervising clinicians (most often
Clinical or Counselling Psychologists), High Intensity Workers, Psychological
Wellbeing Practitioners and Employment Advisers tasked with helping attendees
get back into employment. The presence of Employment Advisors is crucial to
IAPT, for it is the cost–benefit reduction for society which was used to justify
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IAPT and the Ideal Image 93
1111 initial funding (Guardian, 2006). Many critiques of IAPT have examined the
2 problems with such analyses, based as they are on cure rather than ‘reliable
3 recovery’, which more likely sees many ‘successful patients’ still falling within
4 diagnostic criteria (e.g., Department of Health, 2010). Here, I focus more on the
5111 insidious effect their presence has on how ‘therapy’ is practised. Let us start with
6 an example from one IAPT’s website ‘Help to Get and Stay in Work’ (2010):
7
8 Many of our treatments will look at ways of helping you get a job, or secure
9 a job you already have. We know that many of the symptoms of depression
1011 and anxiety make being in work difficult, so we will work with you to manage
1 these negative effects.
2
3111 This discourse, the physical presence of the employment worker in meetings,
4 and collection of outcome data on employability and benefits all serve to
5 indoctrinate the IAPT worker into an ideal of what ‘cure’ should look like. The
6 link between IAPT and workability was made explicitly by politicians in charge
7 of funding the initiative. For example:
8111
9 Imagine there was a new policy, sitting on a shelf somewhere, that could,
20111 at surprisingly low cost, and in just a matter of months, transform millions
1 of people’s lives. Imagine . . . it would make people more employable and
2 better parents, thereby increasing productivity, cutting the benefits bill and
3 reducing antisocial behaviour. New Labour Advisor Derek Draper.
4 (Guardian, 2006)
5
6 The unexplored assumption is that health = work = good. Accordingly,
7 homework tasks frequently linked to increasing workability by sending in an
8 application or attending a job centre. The patient receives a clear message that the
9 ‘invisible standard’ is that of a working, compliant person whose sadness is not so
30111 devastating, his anger not so forceful as to bother others. This presumption of what
1 a good outcome is differs dramatically from the traditional ethics of a psychotherapy
2 where a good outcome cannot be named (e.g House & Loewenthal, 2008) and
3 quite often takes the form of a patient abandoning introjected societal norms to
4 pursue a passion. For example, a patient might leave a career as a bank clerk – a
35 good, safe career desire by a parent – for the much desired instability of being a
6 freelance artist. Such a psychotherapy is not as consistent with the neo-liberal agenda,
7 the world of ‘rights and responsibilities,’ which the modern subject is socialised
8 into. The association of workability with changing faulty cognitions rather than
9 social position serves to equate worklessness with what Scanlon and Adlam (2010)
40111 call ‘worthlessness’. The emergence of psy-welfare thus provides a way for
1 politicians to blame the individual as opposed to their policies without appearing
2 to point blame. This psychologisation of fault is left with the patient, with the
3 IAPT worker acting as an unassuming go-between for the state to communicate
41111 this message to the individual.
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The New Therapists who are not Therapists
PWPs are 61 per cent of the ‘new workforce’ that is central to IAPT’s endeavour
(IAPT, 2011) and hold an even higher percentage of the caseload as HIs see far
fewer patients. In IAPT propaganda – policy document, government announce-
ments, newspaper headlines – they are constantly included in the numbers as new
therapists. Yet PWPs are explicitly and continuously told they are not therapists
and do not carry out therapy. The best practice guidelines for PWPs focus on a
core skill: not to ‘Carry out “medium intensity” therapy’ or ‘drift from using
evidence-based low-intensity principles like CBT self-help resources aimed at step
two, into doing “therapy »’ (IAPT, 2011). Rather:
A PWP’s professional relationship with patients can be likened to a CBT
self-help ‘coach’ role, such as an athletics coach or a personal fitness trainer.
If people go to the gym or play sports, fitness trainers do not do the actual
physical work of getting them fit. That is up to the individual. However,
the trainer will help devise a fitness plan, monitor a person’s progress and
keep encouraging them when the going gets tough. A PWP will act in the
same way.
(Psychological Wellbeing Practitioners: Best Practice
Guidelines. IAPT, 2011, p. 5)
PWP workers are thus therapists when it is politically expedient only. This
blurriness has real consequences as the existence of IAPT’s new workforce has been
used to convince commissioners that therapy can be carried out by a cheaper
workforce leading to the deletion of qualified posts. Further, GPs and the public
are given the impression patients are getting ‘psychological therapies’ rather than
guided self-help. This distinction is not merely academic, for if someone has had
something once, they are less likely to be offered or seek it again. The therapy
box has been, seemingly, ticked.
PWP training consists of a one year course with four days supervised practice;
HIs receive two days training a week for a year with three days supervised practice.
During training, PWPs hold an average annual caseload of 170 patients in
comparison to psychotherapy trainees who will see a handful of training cases over
three or four years. The training for PWPs tends to be carried out by senior
professionals, such as clinical psychologists, nearly all of whom have never worked
by telephone, carried out guided self-help or had such time constraints on their
work. This allows trainers to maintain and teach an idealised version of IAPT
treatment for a patient wholly imagined. It is the workers who face the reality on
the ground:
My training was poor and did not prepare me well for seeing ‘actual’ people
with ‘real’ problems that cannot be solved with some insincere empathy and
a problem statement! I saw people with sometimes a 20 or 30+ year history
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IAPT and the Ideal Image 95
1111 of mental health difficulties all of which impact on them in the here and
2 now and very little of which I could actually, realistically help with. All of
3 our therapy practice was done through role plays with each other and then
4 trained actors.
5111 PWP Worker (Internet Forum)
6
7 I’ve so often witnessed HI CBT trainees bouncing back cases to the wait-
8 list because the course has deemed them ‘not suitable training case’. When
9 80 per cent of your wait-list are ‘not a suitable training case,’ something is
1011 going very wrong in what you are training people to do. In contrast,
1 placement people from other trainings seem to take on a far wider selection
2 of cases.
3111 HI (Internet Forum)
4
5 Some IAPT workers enjoy their work of course – it has given a huge number
6 of people entry level positions in an area that enjoys increasing cultural authority.
7 Yet the huge caseloads place a huge strain on PWPs. This is not something that
8111 those in power wish to hear:
9
20111 There is no emphasis on looking after you as an individual with a potentially
1 ridiculous caseload and high stress levels due to the complex nature of the
2 people you are asked to see (don’t be fooled by the mild to moderate labels
3 you might have heard!) (my caseload at one point was 75+) in PWP
4 supervision – it is literally a numbers exercise e.g. how many people are you
5 carrying, their difficulty and what you are going to do to help them. When
6 I raised concerns that I was stressed I more or less got told to ‘put up and
7 shut up’.
8 PWP Worker (Internet Forum)
9
30111
Proceduralism versus the Personal
1
2 The simplicity of the prototypical patient trainees are taught about and the
3 perceived commonality of patients in the various groups serves an important function
4 – to decrease interest in the lived experience and reality of the patient once the
35 trainee is in a service setting:
6
7 I found the role-plays outside the Observed Clinical Structured Exam fairly
8 useful if only because other trainees are likely to get bored and add in
9 complicated stuff just to stay interested.
40111 PWP Worker (Internet Forum)
1
2 This proceduralism is an important defence if one is being asked to encounter
3 250 patients a year (IAPT, 2011).
41111
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Apart from caseload, the most pernicious pressure on IAPT workers is to gain
outcome measures for each session. During training, workers are sold into the
excitement of producing the largest database on wellbeing in history. There is no
attention paid to the problematic nature of evidence-base in mental health (e.g.,
Slade & Priebe, 2001) nor the effects the taking of routine outcomes have on human
subjectivity. For, being asked to score oneself on criteria sets up an ‘invisible standard’
of how one should be thinking or feeling. This process is made worse in IAPT
for the outcome measures in the dataset – the PHQ-9 and GAD-7 – only ask
questions about the patient’s internal state. This choice of outcome measures
solidifies the individualisation of distress. Other choices were available, for example,
if the minimum data set used is an ‘empowerment scale’ (e.g. Rogers, Chamberlin,
Ellison & Crean, 1997), sub scales such as ‘righteous anger’, ‘power, and ‘com-
munity activism’ would be seen as central to the direct treatment for the elimination
of anxiety one finds in the GAD-7. Thus messages sent to the patient about good
wellbeing, are shaped by the outcome messages used. Resistance often takes the
part of parapraxes on behalf of the patient or worker, which, untheorised in the
CBT model, go unnoted.
Because, quite often, people don’t come for their last session, you know,
their therapy is completed and we weren’t aware that the last time we saw
them was going to be the last session. That’s been fairly disappointing. I think
a lot of the time the therapist, including me, forgets them.
HI worker (cited in Griffiths et al., 2013’, p. 46)
The way suggestion can steer what is said is acknowledged though.
You can easily do it: ‘Oh you’re much better now, aren’t you – I’m sure
thats a six. . . I think you’ve been doing much better this week, don’t you
think that’s a two?
Commissioner (cited in Griffiths et al., 2013, p. 27)
There is little real chance to escape the pernicious shaping of outcome measures,
for they are required to be reviewed for each patient every 4 weeks in weekly case
management supervision and tapes supervised for adherence to the model. Given
the limits of supervisory time, looking at the numbers takes the place of listening
to what the patient has said or the worker has experienced.
Performativity
The pressure to be able to perform effectiveness, rather than actually be effective,
has increased since the introduction of ‘Payment by Results’ (Appleby &
Jobanputra, 2004) and ‘Any Qualified Provider’ (Reynolds & McKee, 2012),
whereby the contract for local IAPT service is given based on a competitive, bidding
process. Thus we hear from one manager:
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IAPT and the Ideal Image 97
1111 Does everyone miraculously get healed in week 11 because payment stops
2 in week 12. . . or week six for the low tariff? I remember many events, where
3 I was suspicious of the motivations of some of the clinicians, and I was
4 harangued for such prejudice and you know, no clinician would ever extend
5111 a session beyond its natural clinical usefulness. Incentives kick in, and the
6 need to pay the mortgage.
7 IAPT Manager (cited in Griffiths et al., 2013, p. 22)
8
9 There are, as one commissioner told me recently, ‘incentives for the data not
1011 to be accurate,’ leaving some patients alienated between how they seem to have
1 progressed and their actual lived experience. No wonder, then, that so many IAPT
2 workers intend to leave, with a quarter of workers leaving in the first three years
3111 (source North West IAPT program).2 But leave for where?
4 The dominance of the mantra ‘what is recordable and measurable is good’ has
5 had ripple effects on service organisations and other professions. Therapists from
6 other modalities, often with decades of experience, have found themselves
7 considered an expensive, often expendable luxury in comparison to IAPT workers.
8111 This ‘new workforce’ of ‘competent professionals’ carries in its discourse an
9 implicit criticism of other therapies as being old and incompetent. Yet such ‘old
20111 and incompetent’ clinicians must also bear the patients whose symptoms cannot
1 be boxed into the IAPT symptom, often those with the most chaotic lives and
2 intransigent symptoms. The old workforce must also bear considerable envy for
3 their higher wages, they’re seeming capacity to work with fewer patients, and often
4 their capacity to contain the anxiety of another subjectivity and real madness.
5 Moreover concern about IAPT from outsiders and the ‘old workforce’, such as
6 the authors in this book, is rubbished for being anti-progressive and old-fashioned;
7 the venom here perhaps carries with it the lopsided fear that perhaps the project
8 is problematic after all. Yet it is difficult to find space to resist when formally radical
9 community organisations such as MIND have rebranded themselves as excellent
30111 organisations for IAPT tenders, and training courses find their accreditations
1 contingent on teaching IAPT curriculums. Under such pressure, it can be reassuring
2 for the ‘new workforce’ to return to the rhetorical certitude of the IAPT literature
3 with its seeming promises of cure, recovery, the new and a few juicy vignettes of
4 success to lure one in. In anxious times, the rhetoric of conviction is especially
35 appealing.
6
7
A Patient’s Experience
8
9 The fuel that has made me write this chapter is the experience of patients whose
40111 stories are not represented in the ever so short glossy vignettes one finds in IAPT
1 leaflets. I would like to present one, in brief.
2 A few months ago, I received a call from a woman I will call Rachel who3 I
3 had seen for a few sessions prior to her move to University a couple of years before.
41111 Rachel was on a bridge, about to jump. I said I was here to listen to her, made
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sure she got to a safe place, then asked her what had happened. She was in a
relationship with a man, John, who consistently and sadistically emotionally abused
her to the extent that she would rip at her hair and cower in the corner. He had
cut her off from her friends, family and former life. The relationship had been
good until he cheated, whereafter he projected all his hate feeling like his cheating
onto Rachel. He said she was nothing, ugly, most likely infertile, that no one would
marry her, ever want her, she was disgusting. This he said: ‘one centimetre’ from
her face, sometimes with his hand clasped around her throat. Such violence
repeated something of Rachel’s brother’s rage at her, a rage that emerged quite
suddenly when she started puberty, a rage taken out at her quite unmediated by
any parental intervention. After weeks of abuse, Rachel would sometimes crack
and scream or throw things at John or shout in a desperate bid to get him to give
her some space. This allowed him a new line of attack – to say that she was mad,
and ‘had an anger management problem,’ an accusation he repeated hundreds of
times. After some months of this attack, desperate to appease him, Rachel agreed
she had a problem and went to her GP. She was referred to IAPT and took this
fact as a present to John – it was she who had the problem, not him, not his infidelity,
not his rage. When I spoke to her on the bridge, it was a week since her assessment
with IAPT. The assessor had given her no space to talk, but seen ‘anger problems’
on the GP’s letter and seen this as a problem within Rachel, following a pro-forma
and asking a series of predesigned questions without finding out anything about
her context. At one point the question ‘Had she ever hit anyone,’; Rachel
answered ‘yes’ and was told immediately she was too serious a case for IAPT, that
domestic abuse to men was ‘just as bad as to a woman,’ and that the worker was
duty bound to call the police. A week later not only was John using this encounter
as evidence he was right and escalated his violence, but the promise the police
would be involved – for the wrong partner, but still an action – had not
materialised. There was nothing left for Rachel but to jump, except the faint
memory of an encounter a long time before where she had been asked to speak
freely, an activity she would start again as a step to disentangle the discourses of
individualised pathology which threatened her life.
Rachel’s unconscious desire in going to the GP was perhaps a flailing attempt
to seek the input, help and intervention that mum had never managed between
her and her brother. The presumption of what is going on once a key signifier –
‘anger,’ ‘sadness,’ ‘anxiety’ – in IAPT stops this being heard. As Rachel said later
‘even the most basic, simple questioning of why I was angry would have led to
me talking about John’. Rachel’s case would not come across as a failure of IAPT
as it is performed currently. She must be part of a statistic somewhere of people
‘not suitable for IAPT,’ an extra digit in an assessor’s contact figures for that week.
Yet the contact was near fatal. We cannot know how John came across the idea
of ‘anger management’ as a way to attack her, nor what would have happened had
she not had an experience of therapy once before. However what we can tell from
her experience – for I know it is not exceptional – is that proceduralism stops even
basic relational contact between a mental health practitioner and someone in anguish.
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1111 The fault for this cannot be laid at the door of any particular worker, for
2 structurally IAPT does not allow them the time to wonder why and what. The
3 IAPT worker is the most scrutinised clinical worker in history – constantly
4 monitored for their clinical work adherence to the CBT model, supervised on a
5111 case-by-case basis by supervisors needing to see progress in outcomes, watched
6 by managers to ensure they reach the fewest number of contact hours with the
7 most number of patients to meet service outcomes. The sheer volume of checklists,
8 let alone the caseload, reminds us of Menzies-Lyth (1959) work on how depersonal-
9 isation, categorisation and denial of the significance of the individual are used to
1011 defend against the anxiety of death, despair, the body and fragility. Checking off
1 symptoms is an effective way to not be with them, a collaboration that may serve
2 the interests of both therapist and patient. This ‘fetishisation of bureaucracy’ in the
3111 NHS (Rizq, 2012) is part of a wider rise in ‘audit culture’ (Power, 1999) as numbers
4 become a safer site of worship than professions or even science. The worship of
5 ‘evidence’ at this moment of history, unfortunately, forecloses the fact that numbers
6 are only collected specific to particular ideologies and can be massaged to particular
7 ends. Thus the ‘auditable surface’ (Cummins, 2002) is a compelling way to make
8111 things seem a certain way, but the reality will be different. As Terkel (1978) noted
9 in an early study on the effects of performance target, ‘developing the arts of impres-
20111 sion management’ becomes the key defence. It is one that stops pain being listened
1 to and the meaning of symptoms heard.
2
3
Shaping Minds
4
5 IAPT gives to its patients ‘techniques of the self’ (Foucault, 1974) to make them
6 govern themselves with the eaten-in norms that make the state run smoothly. The
7 rolling out of CBT and IAPT are heightened examples of a relatively new idea –
8 that the self is a project which can be moulded and chipped away at so as to become
9 attractive to the market. Such ideas have been building since the self-help slogans
30111 of actualisation began to enter the cultural landscape in the 1970s (e.g Lasch, 1979).
1 IAPT promotes these ideas as demands on the individual. Thus though the title
2 of Lord Layard’s latest book ‘Thrive’ is presumably supposed to be an invitation,
3 it also comes across as an edict. We can and must erase parts of our personality
4 which do not sell well in the modern market place of the self, and CBT – the
35 implication goes – can help us do that. The promise that this is possible, that we
6 can ‘cure’ depression and anxiety, only fuels the lack we feel in comparison to the
7 images of perfection on our computer screens and in our magazines. This lack in
8 itself creates what is called mental illness. The discourse around CBT implies that
9 we can alter bits of the self that we do not like in the ultimate self-fashioning project.
40111 If the only options for understanding not thriving are moral failure or mental illness,
1 then most will choose the latter. Even more so as the idea of mental illness can
2 now be used to situate the self within an arc of recovery, a transformative narrative
3 almost ubiquitous now in biographies, reality TV shows or successful blogs. The
41111 insistence that common feelings, such as sadness and depression, can be cured are
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highly specific to our time and reflects what Rimke and Brock (2011) have called
‘the shrinking spectrum of normalcy’. As Nikolas Rose (1990) traces out in
Governing the Soul, the psyche has traditionally been seen as a site of a structurally
unwinnable war between passion and reason, desire and society. The promises of
happiness and wellbeing that IAPT propounds and inserts into our letterboxes
constitutes an ever more impossible-to-reach ‘ego ideal’ or ‘image of the perfect
self towards which the ego should aspire.’ (Chasseguet-Smirgel, 1975) The chasm
between this ego ideal and our lived reality only increases the level of anguish and
pain in our communities.
This finding is clear from an exploration of what happens when IAPT is
introduced into an area. It is perhaps for this reason that the NHS mental health
services have been subject to unprecedented service redesign since IAPT was
launched in 2005. In East London, the first two years of IAPT produced a
substantial increase in referrals to secondary services. This was storied as due to the
uncovering of ‘hidden populations’ of those in anguish who had suffered in silence
beforehand and thus been excluded from analysis of the pilot site results. When
four years after the introduction of IAPT, this phenomenon refused to cease, it
became clear that IAPT was making people question their own mental health and
doubt their capacity to cope. It made people demand more of themselves, and
more of the NHS. We found our secondary care service redesigned once the reality
of the effect of IAPT on secondary care became apparent – our service served the
same function but was relabelled so that, theoretically, it was a new service. Thus,
before and after comparisons could no longer be made. Similar smoke and mirrors
are being used up and down the country to mask the reality of managed care.
There is a virtual reality to welfare governance today, an ‘as if’ character of
achievement with the fetishisation of number crunching giving an image of success
increasingly blurry with what is actually happening on the ground. IAPT makes
it appear ‘as if’ problems were internally produced – as if they could be separate
and distinct from social conditions and opportunities despite an international
evidence base that this is not the case (WHO, 2014). The powerful get something
from this cultural shift. Politicians get a way to appear to help problems their policies
have helped create. GPs get to feel they are offering something to get the repeat
attendees with no real physical symptom to go away. Psy staff get more prestige
and cultural authority. Yet it is impossible to maintain a ‘thick skin’(Cooper &
Lousada, 2005; Hoggett, 2010) between how numbers perform according to
IAPT and the lived experience of so many whose referral led to nothing or who
are charged with providing a treatment to those whose reality does not meet the
textbook. We cannot, should not, allow their voices to go unheard.
Notes
1 All the words in quotations in the following section come from the main adherence scale
to CBT (CTS-R – Blackburn et al., 2001). They are the core competencies for CBT.
2 This scuppers IAPT’s cost projections, which are based on the presumption that IAPT
workers, once trained, would stay.
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IAPT and the Ideal Image 101
1111 3 This former client – who I have called ‘Rachel’ – has given written consent for her
2 experience to be used. Nonetheless, I have anonymised potentially identifying features
of the case.
3
4
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