However, the broadcast aired doubts about the effectiveness of the IAPT approach, and behind the obvious doubts there were strong hints of much more serious doubts. You can listen to it online:
The broadcast featured three patients, though the first two did not appear to have been IAPT patients. Rather, they were there to illustrate how CBT works. Unfortunately, they only illustrated how badly-delivered CBT can fail.
The first patient, Tracey, had what I might call (thought the broadcast did not refer to any particular diagnosis) post-partum depression with mild psychosis — after the birth of her daughter she had very distressing and bizarre thoughts about harm coming to children. She was depressed, over-anxious, and developed a severe speech impediment.
But the CBT that Tracey received only taught her to counter her thoughts with other thoughts, in effect to argue with herself. She now feels much better and gives CBT credit for this (though these psychological after-effects of childbirth usually go away of their own accord after a time in any case).
The presenter summed up:
Tracey doesn’t consider herself to be cured. She still has these thoughts but now she’s learnt how to deal with them sooner, before she gets anxious. This is a key part of CBT.
Jane has had much therapy over the last thirty years, and she has always had issues around food. She explained how CBT had helped, but like Tracey’s CBT, Jane’s CBT left the underlying condition unresolved.
The whole process has enabled me to stop doing what I did automatically… Now I am able to actually stop at the point at which I might have in the past got up and gone to the fridge, and think “Well, OK, what do I want? Do I actually want a piece of cake?”
And if the answer is “Yes” then that’s fine, go and have one. But if the answer is “Well, actually, no, I’m feeling really angry because I’ve just had a distressing phone call,” or whatever, I can now actually think, “Well, that cake actually is not going to help at all, and in fact what I need to do is resolve whatever it is that’s brought me to that point.”
So, again, Jane only learned to argue with herself. There was no attempt to address the underlying issues.
Tracey and Jane’s experience of CBT is typical of well-meaning but relatively unskilled therapists, who are only able to help people to deal with very mild symptoms in a superficial way. Patients who, like Tracey and Jane, have quite serious disorders do not receive serious help to match. Instead, they are taught to maintain their disorders in an ongoing struggle, and this ongoing struggle actually hinders recovery.
Hannah was the only patient in the broadcast who had experience of IAPT. She had seen a therapist for what IAPT calls the ‘low-intensity’ form of CBT, where patients mainly need support and advice on how to help themselves.
But Hannah’s experience was dismal:
I didn’t really feel that I got much help…to do anything, really…
I was stuck for words a lot of the time. I didn’t know what to say. It was very uncomfortable.
Her experience is typical of people who encounter incompetent therapists — therapists who lack the skills to form any kind of therapeutic relationship.
Here is where things get interesting. The broadcast also featured two professors, whose role was to defend and promote IAPT. The first of these was Jan Scott of Newcastle University.
Prof. Scott’s self-help book, Overcoming Mood Swings, describes how to apply CBT techniques to a fairly common long-term emotional problem, although it was severely criticised in a detailed review by Kathy, who summed up:
…what looked like good advice, but very difficult to make any use of… As a self-help book it’s pants.
Nevertheless, Prof. Scott knows better than most people that CBT was originally developed to help patients who have significant mental illness, and her own work with CBT in bipolar disorder is a good example of how CBT has developed for severe disorders.
So it was astonishing to hear her in this broadcast singing to a completely different tune:
In actual fact for some people these beliefs seem to be operating almost all the time, and I think for them, if it’s that their ongoing problems are not part of a sudden change but rather a long-standing pattern that’s about personality and style and how they’ve learnt to cope with the world for many years, it can be quite difficult to do cognitive therapy, which is a relatively brief therapy.
You might be talking two to three months of sessions. So it could be quite difficult for some people with these problems that are rather more ingrained and longer term to actually get into the therapy and be able to make all the changes they’d like to in the time available.
In her defence of IAPT, Prof. Scott was prepared to contradict the whole of her own career, suggesting extraordinarily (and wrongly) that because CBT works quite quickly it is only useful for short-term problems.
The second professor was David Clark, National Clinical Advisor to IAPT.
Prof. Clark was specifically asked to respond to Hannah’s story. He, too, is very distinguished and knowledgeable. It is certain beyond any doubt whatsoever that he understands the importance of a therapeutic alliance in CBT. So you would expect that he would be shocked and dismayed to hear how Hannah’s therapist had mistreated her.
But no, Prof. Clark’s response on air was to deflect the issue by changing the subject:
I think it was very courageous of Hannah to come on this programme and recount her story. It’s disappointing that she hasn’t got more benefit…
In another part of the broadcast, Oxford psychologist John Marzillier criticized IAPT for relying on a conventional disease model. Prof. Clark’s response to this was to lie outright:
I don’t think it relies on a disease model at all. I think we see these psychological problems as just that — psychological problems, not diseases.
The reality, as John Marzillier pointed out in the broadcast, is that IAPT relies on conventional diagnosis to identify cases of depression and anxiety for its ‘low-intensity’ therapists, to choose between manualized treatments, and also to evaluate outcomes. The disease model, to the exclusion of understanding patients as people, is pervasive in IAPT.
So what’s up? Why do we hear two distinguished professors on air telling these unconvincing fibs? The only plausible reason for it can be that IAPT is in deep trouble.
Prof. Scott’s absurd claim that CBT cannot treat long-term conditions implies that IAPT is already failing in cases of serious illness. This can only be advance spin to lower expectations before the results of the outcome studies are known.
Prof. Clark’s avoidant reaction to a therapist’s total inability to form a therapeutic alliance implies that this kind of occurrence is commonplace, that IAPT is already failing to recruit therapists with the skills to relate to patients and understand them. His defensive bluster about IAPT’s disease model implies that IAPT relies on manualized treatments that are already proving inadequate.
Government plans require that the present thirty-five IAPT centres must be a success, so that IAPT can be rolled out to the rest of the country. Hearing this broadcast, and reading between the lines, it seems to have significant weaknesses in reality.
But these are government plans — they must be a success, regardless of reality. Perhaps these two professors hear the whispered words “Dame Jan” and “Sir David” for their part in spinning the reality to fit the plans — perhaps that’s the meaning of success.