Can we talk about Talking Therapies?

After graduating from Cambridge in 2019, I dove straight into clinical practice: first as a peer support coach in a Neighbourhood Mental Health Team, and then a Low Intensity Therapist for IAPT (Improving Access to Psychological Therapies – now named NHS Talking Therapies). It has been striking to compare how theories learnt in books at university look in practice in the clinical world.

IAPT services strive to meet three targets: the number of people accessing the service; the waiting time from referral to treatment; and the recovery rate. Several practices are employed to reach these targets when operating within overstretched, under-funded services. These practices cut short-term costs, but can negatively impact patients and staff, as well as wasting limited resources.

I have now worked in these services, but I have another perspective too. For much of my life I have struggled with various common mental health disorders like OCD, depression, social anxiety, and general anxiety. At times, I've had the double role of patient and practitioner.

I've been filled with hope and admiration for the passion and dedication of hardworking practitioners; but I've also felt hopeless, frustrated by the prescriptive practices of the system within which we work, that prevent us from delivering truly patient centred care. The existence of primary care mental health services is invaluable: preventative care is paramount in reducing severe mental illness. Our primary mental health services allow over a million people each year to access services they wouldn't be able to in other countries, because they wouldn't be deemed mentally unwell enough. However, for the betterment of the system, it is essential that we recognise its weaknesses and call for change.
From my personal experiences of working and being treated in various services, and from purposeful discussions with colleagues, a few issues stand out.

Postcode lottery

All services work within the finite means of whatever they are allocated from their local Clinical Commissioning Group. A mix of this funding, and the community's mental health needs, creates a stark 'postcode lottery' of timely access to appropriate treatment.

For example, the average wait for first treatment in 2022 was 50 days (despite many services employing the tactic of coding initial assessments as 'assessment and treatment' to give the false appearance of a shorter wait before treatment). However, this number ranged from 4 days to 229 days across services (House of Commons Library, 2023).

I had a recurring bittersweet feeling in my second service where after assessment, clients consistently began treatment within days, a fortnight at most – leaving me simultaneously pleased for them, and aggrieved on behalf of my previous service's community, who often waited months. In underprivileged areas, the prevalence of mental health problems is often greater: the most recent report by the House of Commons Library (2023) found that in 2021/22, there were 89 per cent more referrals from the 10 per cent most deprived areas of England compared with the 10 per cent least deprived areas of England. Unfortunately, access to appropriate therapists does not necessarily rise in proportion with the mental health demands of the community.

High or low?

A second, related point regards how we misuse our resources by offering inappropriate treatment. Low Intensity CBT (LICBT) is the therapeutic treatment for mild-moderate symptoms of common mental health disorders; more severe, complex, or long-lasting symptoms should be treated with High Intensity CBT (HICBT) or another NICE recommended treatment such as counselling. With severe depression and some types of anxiety disorders, high-intensity intervention should be offered first because LICBT has not proven effective for their treatment. However, waiting times for HICBT usually exceed those for LICBT (up to three times as long last year) (House of Commons Library, 2023) which encourages some services to push for HICBT-appropriate patients to have LICBT instead. We can imagine this is more common in services receiving greater numbers of clients with more complex presentations, as well as in services with less funding and fewer therapists – adding to the postcode lottery.

Some services assign clients to LICBT whenever it is their first treatment within that specific service, regardless of whether they have already tried LICBT at another service, and regardless of how long-lasting and severe (to an extent) their mental health is. Not only does this fail the client (by offering unevidenced treatment) but it fails the clinicians, too. LI therapists experience very high rates of emotional burnout, and often refer to the combination of client complexity and volume of caseload as a reason for this (Scott, 2018). Most LICBT staff have neither the appropriate training nor time allocation to offer the correct therapy to clients with more severe presentations. 

Patients can feel powerless trying to advocate for themselves to access more specialised therapy straight away, and LI therapists can feel powerless trying to advocate on behalf of their patients, too. As a patient, I felt this first-hand. As someone with enduring mental health disorders, a long list of tried and failed treatments, and a severe presentation on the depression and general anxiety questionnaires, I was offered LICBT when first attending a new service. Despite knowing the system, and being fairly mental-health and CBT informed, I was unable to sway it so that I could first attend HICBT: the more appropriate and evidence-based treatment dose for my presentation. This story is too common, and I can't imagine the disappointment and desperation felt by those with more pressing mental health issues than my own, who lack the vocabulary to express it, or the strength to continue jumping through the hoops that might eventually permit them to access the correct treatment.

Some argue that offering LICBT first gives the client some tools and support while they wait. However, for some, being offered the wrong treatment must be damaging: working through months of ineffective therapy could imaginably worsen negative self-thoughts that they are letting themselves and others down, or worries that their anxiety may never get better because the 'evidenced based' treatment is not working for them. They then struggle through an extended time of no support once this treatment often (predictably) does not work, and they rejoin the longer waiting list for HICBT. Depression and anxiety, self-harm and suicidality all feel very urgent, serious, and everlasting when you're in the thick of them. While riding out a period of inner torment, these systematic and procedural obstacles can feel like someone is poking the fire instead of dousing it with water. What's more, giving this treatment to those we know statistically won't benefit from it, stops it from being given at that moment to someone who more likely will. In a system where scarce resources are a fact of life; we cannot afford to be wasteful.

But if all HI-CBT appropriate clients are given the option and choose to wait instead of try something else first, won't this make the waitlists impossibly long? Won't we see an increase in complaints about year-long waits for therapy? Yes. Whilst there are no easy answers, a first step must surely be to recognise that we neither serve our client or our practitioner community well if we focus on what is measured (the point of treatment) over what matters (access to appropriate and effective treatment). The current system isn't better, it just conceals enough that decision makers can plausibly ignore the fact that we need to increase investment into the training and hiring of more specialised therapists.

The homogenisation of therapy

A third issue regards the homogenisation of IAPT therapy. The high-volume, fast-paced nature of IAPT reduces the scope for individualised practices and true patient-centredness. LICBT is highly structured, scripted, and time limited. Common mental health disorders come in a myriad of presentations and are caused by highly complex interactions of factors, but each client is treated with (more or less) the same 6-step work booklet as the person before them. They are given a low-cost toolbox of thought diaries, ABC cycles and management techniques. Great LI-therapists will make adaptations where they can, but are limited by the prescriptive nature of LICBT, and IAPT's practices and protocols. 

I am reminded of Binnie's article on the 'McDonaldization' of IAPT (2015). Standardisation of therapy increases the ease of training, delivery, and quality-monitoring. However, mental health does not come in identical McDonald's burgers with just the right amount of lettuce and tomato – neither should  treatment. Mental health is the product of the confluence of highly individualised combinations of genetics and life experiences. Yes, symptoms emerge in meaningful clusters based on things like disorder type, sex, ethnicity, religion – but the highly standardised way of delivering treatment has only been effective for 50 per cent of the population (and I would take this data with a pinch of McDonald's salt – short term reductions in questionnaire scores don't always validly reflect recovery, and recovery rates varied from 16-61 per cent across services last year) (House of Commons Library, 2023). The rate is even lower for those facing additional barriers to treatment such as those with disabilities or from specific ethnic groups.

Towards realistic conversations

Now, I don't want to be overly critical. The focus of CBT – identifying unhelpful thoughts, feelings, and behaviours and replacing these with healthier ones – is important, and something I wish we were all taught from a younger age. A mental health toolbox with detailed and easy-to-follow instructions is exactly what many people desire. My colleagues and I have had some incredibly rewarding experiences working with people for whom this formula worked wonders, alleviated their suffering, and guided them to recovery. Further, low recovery rates are not always the fault of the therapy model used, but could, for example, indicate patient motivation or access barriers; external circumstances that are not conducive to recovery; or a lack of therapeutic rapport between practitioner and client.

However, I wonder if we could improve recovery rates by investing in the research and implementation of alternative therapy options or practical and social solutions for clients with mild-moderate symptoms (alongside LICBT). Different people benefit from different treatments differentially. Yes, some other approaches tend to require longer treatment periods, reducing their cost-effectiveness, but if they help to increase the amount of people recovering, won't this reduce costs long-term by preventing repeat IAPT referrals and preventing escalations in symptoms that necessitate referrals to secondary care services? The world of politicians and decision makers need to be convinced of the unsustainability of short-term cost-cutting practices, which are increasing longer-term mental health and economic costs. More realistic conversations around these issues by those higher up in the system could pave the way to meaningful improvement of this much needed service.

References

Binnie, J. (2015). Do you want therapy with that? A critical account of working within IAPT. Mental Health Review Journal, 79-83.

House of Commons Library. (2023). Mental health statistics: prevalence, services and funding in England. London: Commons Library.

National Collaborating Centre for Mental Health. (2018, June). Improving Access to Psychological Therapies Manual. United Kingdom: National Collaborating Centre for Mental Health.

Scott, C. (2018, September). An Exploration of Burnout in Improving Access to Psychological Therapy (IAPT) Services: An Interpretative and Phenomenological Analysis. Bristol: Faculty of Health and Applied Sciences, University of West England.