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Improving access to psychological therapies - but for who?

Improving access to therapy - where to go?

By Mark Brown - On the morning of Wednesday 21st March 2018 protesters unfurled banners and readied leaflets at London’s Millennium Conference Centre. The focus of their ire was not an exploitative corporation or a human rights flaunting armaments industry. Instead these were mental health demonstrators and their target was the single largest coordinated expansion of psychologically informed interventions the world has ever seen.

The 11th annual New Savoy Partnership Psychological Therapies conference, this year subtitled ‘A New Deal for Depression’, was a two day event discussing psychological therapies and the NHS. Inside the venue, delegates and speakers from a wide range of organisations discussed the practical issues in making more evidence based therapies available via the NHS to more people more effectively, including via digital services and other means. Yet outside the venue a leaflet being distributed read “Therapeutic support for people not bullsh-t 'health and work' and phoney evidence” while banners proclaimed ‘Welfare reforms are cuts that kill’; ‘Equality is the best therapy’ and ‘IAPT fails us all.”

The largest expansion of access to therapy ever

Improving Access to Psychological Therapies (IAPT) is key to understanding the protestor’s concerns. IAPT is the mechanism available across England where individuals can self-refer or be referred to time-limited forms of therapy based upon the principles of Cognitive Behavioural Therapy for mental health concerns such as mild depression and anxiety. Rather than focusing on narrative and exploration, CBT tends to focus on the overcoming of specific practical issues by helping people to change the ways they think about them.

In July 2017, The New York Times ran a story headlined “England’s Mental Health Experiment: No-Cost Talk Therapy” which barely concealed its wonderment at the existence of IAPT. “Mental health care systems vary widely across the Western world,” wrote Benedict Carey for the NYT, “but none have gone nearly so far to provide open-ended access to talk therapies backed by hard evidence.”

Since 2008, IAPT has enabled millions to access support

In England, since the policy was put into action during the twilight years of the New Labour government in 2008, IAPT has enabled millions to access psychologically informed, CBT-based support. According to Claire Murdoch, National Mental Health Director NHS England, speaking at the conference; over a million people has accessed IAPT services in the last year alone. In 2016-17 of 1,385,664 referrals, 965,379 entered treatment and 87.5 percent of those people waited for less than six weeks for treatment or support. Just under half, approximately 500,000 people, were considered as “moving to recovery.”

’Second class therapy and sticking plasters for austerity’

In a leaflet publicising the demonstration, conveners The Alliance for Counselling and Psychotherapy described IAPT as an “assembly line service” of “second-class therapy for people who can’t afford ‘real’ talking therapy” which is “partnering the DWP (Department of Work and Pensions) on welfare reform, psycho-compulsion and the work cure” while “failing the mental health needs of communities all over England” by “working with government policies that themselves generate psychological distress and social alienation.” The Alliance for Counselling and Psychotherapy itself formed in 2008 to oppose plans for regulation of counsellors and psychotherapists by the Health and Care Professionals Council, arguing counselling and therapy was more an art than a science. They were joined by demonstrators from Mental Health Resistance Network, The Psychotherapy and Counselling Union amongst others.

"counselling and therapy is more an art than a science"

While criticism is often couched in language suggesting it’s all a neoliberal plot; a sticking plaster to patch up the walking wounded of a capitalist war upon the souls of workers, giving people enough help to get back to the grindstone but not enough to make any changes to the world, there is a case to answer. Money spent on prevention arguably reduces costs overall but does not reduce costs to an individual for whom problems have not been prevented. People with long term mental health difficulties, the kind that do not go away but which can be mitigated with support and professional involvement are caught in the middle between prevention and acute hospital care. Caught, in fact, in exactly the space where longer term therapy and support might be considered most useful.

Psychological therapy, economic arguments

This issue of conflating therapy and employability has its roots in the New Labour era. The initial 2006 report produced by Richard Layard and colleagues at Centre for Economic Performance at the London School of Economics that began the foundation of IAPT argued an economic case for extending psychological therapies. They argued that such an expansion would pay for itself in increased productivity and reduce benefits and health spending. In 2008, Dame Carol Black’s review of the health of the working age population suggested that people who become unwell should be helped as early as possible with view to their remaining in the workforce and that those on benefits should return to work as soon as possible. Helping people get jobs and keep jobs was considered to be a prime target for reducing the spiralling of the effects and costs of mental health difficulty.

Report: "An expansion in psychological therapies pays for itself in increased productivity"

People with longer term mental health difficulties were caught in a pincer movement by austerity policies and have felt both under attack and underserved by increases in mental health spending. The introduction of benefit sanctions, which are considered by some to disproportionately affect those experiencing mental health difficulties, created a feeling that people with mental health difficulties were being set up for a fall. At the same time as local charitable and statutory support withered away and the employment market stagnated, rhetoric about benefits scroungers divided the world into strivers and skivvers.

Improving access but for who?

While there is intention that IAPT should be extended to treat a larger proportion of people with more severe and ongoing mental health difficulties within an existing stepped care model, it is not clear whether there still remain enough services in many places for people who require more specialist help and support. The IAPT workforce is specially trained and seperate from the ranks of psychotherapists and counsellors.

IAPT has often been the only game in town in a hotly contested area of public policy.

Theresa May has often trumpeted investment in mental health as one of the most important elements of her governments attempt to right the ‘burning injustices’ of inequality. Mental health is not one thing, but a multitude of different possible areas of spending and activity. IAPT, for good or ill, has often been the only game in town in a hotly contested area of public policy. A machine designed for a particular purpose, IAPT will remain contentious until the rhetoric of improving the lives of everyone with mental health difficulties becomes a reality. IAPT may well be improving access to psychological therapies, but until the needs of those with ongoing and more severe needs are met with equal success, the question ‘Yes, but who is it improving access for and what happens to the rest of us?’ will remain a vexed one.

Mark Brown is a guest-blogger for Minddistrict, blogs at thenewmentalhealth.org and was the editor of mental health magazine One in Four.