Working in IAPT can exact a heavy toll. Anecdotal evidence is plentiful, but there are survey statistics to prove it too. Since 2014, a team of researchers from the BPS and the New Savoy Partnership has been conducting an annual survey of the wellbeing of all psychological therapy staff in NHS psychological therapies services, across primary (IAPT) and secondary care. The overall picture it consistently reveals is of a stressed and distressed workforce, driven to depression, self-doubt and job-change by the constant pressure to meet demanding targets despite inadequate staffing, not enough time to work genuinely therapeutically with clients, and not enough management support and professional supervision. The surveys reveal a culture described as lacking compassion for staff and clients alike.1,2
In the 2017 survey,1 43% reported feeling depressed over the previous week; 42% had felt like a failure; 28% had experienced bullying and harassment in the previous 12 months, and 46% had thought about leaving their job at least once or twice a week. Three-quarters (72%) felt their service was inadequately staffed to deliver safe and effective care. Highest on the list of factors that they said were affecting their wellbeing were the pressures of having to meet targets for waiting times and recovery rates; lack of supervision, CPD, management and peer support and career progression; stress, burnout and low morale; limited resources, including poor pay and the complexities and demands of the work itself (limited time for clients, complexity of presenting issues, effectiveness of their interventions).
Back in February 2016, commenting on the findings of the second (2015) survey, the then Minister for Community and Social Care, Alistair Burt, told delegates at the annual New Savoy Partnership Conference: 鈥業 can鈥檛 be on platforms day in, day out talking about a world-leading service if I鈥檓 standing on something that鈥檚 rusting away beneath me鈥� it can鈥檛 be done unless you feel valued and unless you feel your wellbeing is taken seriously.鈥� Indeed. How can a therapist provide compassionate, healing care when they themselves are not valued and treated with compassion and respect? How and why is that OK?
Counselling has survived and even thrived within IAPT, after a sticky start. CBT, supported by the evidence-base used by NICE in its guidelines on the management and treatment of anxiety and depression, continues to be the overwhelmingly predominant model offered (some 60% of referrals, compared with counselling at 20% and 20% the other NICE-approved therapies available 鈥� mainly couple counselling for depression, interpersonal psychotherapy and EMDR). Person-Centred Experiential Counselling for Depression (PCE-CfD), the IAPT-approved manualised form of counselling, is increasingly offered, although accessing it is still a postcode lottery.
Yet working as a counsellor in IAPT, for some at least, can still exact a grievous toll, reflecting the picture painted by the BPS survey.
Gillian Proctor, programme leader of the MA in psychotherapy and counselling at the University of Leeds, recently led a small-scale qualitative study into the ethical dilemmas faced by counsellors working in IAPT. She and her research team interviewed 15 practitioners. All spoke of the exhaustion, stress and pressure of trying to work according to their ethical principles and professional standards within the IAPT machine. 鈥楾hese practitioners were absorbing the pressures of working in a system that is focused on outcome measures and recovery, of their work being judged by those data and having to get the numbers through in order to get the funding for the service. The clients are caught up because they have to become compliant clients to make the numbers work,鈥� Gillian says.
The stress comes from trying to bridge the gap between the model of therapy they have been trained to provide and what the IAPT programme permits 鈥� to shield their clients from its adverse impact, she says. Yet, at the same time, these counsellors felt compromised by being part of a system that they felt was not congruent with the values of their profession.
They described services 鈥榗herrypicking鈥� clients who would achieve the recovery rates, and having to turn others away as 鈥榥ot suitable for service鈥� or referring them to join long waiting lists for secondary care or counselling from a third-sector service. Some talked of feeling pushed to work with clients beyond their ethical competence so the service could hit its access targets, and of not being able to work relationally with clients: 鈥業 came into this work to be a therapist, to work with human beings, but it feels like more and more and more I鈥檓 being pulled to work with numbers and targets,鈥� one said. They described how the lack of appreciation of the importance of the therapeutic relationship meant that clients were 鈥榖lamed for attempting to form a relationship, which is fundamental to how [counselling] works鈥�. The collection of Minimum Data Set (MDS) symptom measures took up valuable time in sessions and 鈥榗ut across the relationship鈥�.
Says Gillian: 鈥極verall, participants felt that a need to present IAPT to clinical commissioning groups and budget-holders as delivering successful and cost-effective therapy has replaced care for the needs and wellbeing of clients.鈥� She quotes another interviewee, who told the researcher: 鈥業 feel that there鈥檚 the organisation, there鈥檚 me in the middle and then there鈥檚 the client, and I feel like I鈥檓 protecting the client from the organisation.鈥� 鈥楾hese counsellors were putting so much energy into fighting the system that they couldn鈥檛 keep focused on their clients and their self-care suffered too,鈥� Gillian says.
Some described how they tried to circumvent the requirements for recording outcomes data, which then provoked anxiety. They talked of feeling emotionally exhausted by the corrosive effects of not being able to deliver the kind of care they knew could help: 鈥榌I felt such] sadness with the clients, when they send client after client that really need support, you know you could offer something鈥� this little bit could make a difference, but we can鈥檛.鈥�
Driven by the data
I recently got a phone call from a counsellor who (for self-evident reasons) asked to remain anonymous. They had, for the past 10 years, been providing talking therapies to black and minority ethnic people in their local IAPT service, most of whom were, in fact, refugees and asylum seekers. They had just been told to stop doing this work and join the generic team 鈥� their clients鈥� recovery rates were bringing down the service鈥檚 overall performance rates and the managers were worried the commissioners would put it out to retender. IAPT is not for refugees and asylum-seekers, they were told; their needs are too complex.
鈥楾hey have raised the bar so the people I have been seeing are now regarded as too unwell for IAPT, and secondary care say they are not ill enough for them. These people have complex PTSD, they are severely depressed and anxious.
I can only offer six sessions. My clients used to come back so they could see me over a longer period of time in batches of six. Now my managers are saying, if they come back for more therapy, then clearly the initial treatment didn鈥檛 work, so there鈥檚 no point in my seeing them again,鈥� the counsellor told me.
As someone with personal experience of seeking refuge from persecution, this counsellor is distraught: 鈥楢sylum seekers come to this country for help and succour and they are getting rejection.鈥�
A 2016 study by Jaime Delgadillo and colleagues3 found that IAPT services in poorer areas, where needs are much higher, are far less likely to be achieving the target recovery rates. IAPT鈥檚 focus on throughput would seem to militate against service providers reaching out to offer effective relational counselling to marginalised groups and communities with more complex needs. They simply don鈥檛 fit the IAPT model. I recently spoke to the manager of a third-sector service in an inner-city locality, who asked to remain anonymous. They talked feelingly of the impossibility of meeting all the targets in combination.
鈥楾he targets are well-nigh impossible when put together. If we get enough people into the service, then the waits increase because we haven鈥檛 got enough staff to deliver the treatment. It鈥檚 completely sensible to have targets around waiting times, but it鈥檚 just not resourced properly so you don鈥檛 have enough staff to deliver the therapy.鈥�
IAPT鈥檚 model may work where clients are mainly needing step 2 interventions (guided self-help, primarily). But, as the Delgadillo research found,3 and this manager told me: 鈥楾he recovery targets militate against you taking on people with greater severity or higher needs because you need them to recover quickly. I think we are doing a good job here, but our recovery figures are slightly lower than most. We have a much more challenging client group. Our reliable improvement rate is really good and to me that speaks far more about what is happening in the room with the therapist. Reliable improvement gauges how far you have moved from where you started, which is the point of therapy, surely. I think IAPT should use that as its primary target; it鈥檚 a much better measure of the effect of the therapist input.鈥�
Jude Boyles and Norma McKinnon Fathi both work with refugee populations. They repeatedly see how the IAPT model discriminates against people who don鈥檛 respond within the prescribed time frame to the prescribed dose of therapy. What worries them is the way this ethos and the IAPT model have crept into the third sector, which they believe has, wittingly or by default, had to compromise its independence and political principles in order to win IAPT contracts to survive.
They recently carried out a small-scale qualitative study, interviewing 10 counsellors and managers in third-sector organisations about their perceptions of the influence of IAPT on the sector and how they work with clients.
Says Jude: 鈥楾he main pressure is the lack of funding, which means that, in order for these organisations to survive, they think that they have to deliver a very similar model or become IAPT compliant. But even if they aren鈥檛 actually seeking to be commissioned to provide a service within IAPT, its influence is still there. The language has changed. Counsellors in the sector talk about diagnoses, about 鈥渟tabilising鈥� people and 鈥渞educing the symptoms they present with鈥�. Of course you want to reduce people鈥檚 difficulties, but these clients are the most marginalised; they are coping with poverty and abuse; their lives and experiences are so complex 鈥� you can鈥檛 change these things quickly, in any depth, with a model that is so manualised and so focused on reducing symptoms. The IAPT culture has got into our veins.鈥�
She worries that counselling has lost confidence in its own values and efficacy: 鈥業 sometimes think therapists themselves don鈥檛 believe in therapy any more 鈥� that offer of a containing and supportive relationship where people can make quite significant changes in how they manage their lives.鈥�
Counsellors described to them the erosion of the principle of anti-oppressive practice within their organisation: 鈥業t takes six to seven sessions to develop relationships. Clients have stories to tell and it takes time to build trust and learn what therapy is. In IAPT, you have the power; you are not reducing it but using it,鈥� one said. 鈥業t鈥檚 all about moving people on,鈥� said another. 鈥業t鈥檚 not like delivering therapy, it鈥檚 like feeding the machine.鈥�
They described how they adjusted their thinking to make the way they had to work feel OK: 鈥業n the past we worked to a social model, we didn鈥檛 diagnose, but now we just must translate it all, reassuring yourself that it means labelling but within an anonymised data set 鈥� at least we get to stay open.鈥� Working to a brief intervention model is more than simply a different way of working; 鈥業t鈥檚 changed me, and I don鈥檛 like it,鈥� one said; 鈥業t鈥檚 changed the reason why I went into this work... This is not how I want to work,鈥� said another. And it also changes the nature of the therapeutic relationship with the client: 鈥榊ou are always mindful of how deep you can go. It鈥檚 just not safe, you are always reining the work back in. The therapeutic relationship needs to be based upon an open dialogue, and honesty, but instead there are all these forms and a need for a diagnosis and this constant focus on the presenting issues.鈥�
鈥業 came away from the research with a sense of victim shaming,鈥� says Norma, who previously worked as a psychotherapist in the third sector and now directs her own community interest company. 鈥楾hese counsellors were being told: 鈥淵our clients are not progressing, your outcomes are not what we want to see, stop working with these people, they are not getting well in the way that we want them to.鈥� The counselling was a lifeline for their clients, and the fact that they weren鈥檛 marching in step towards recovery was their fault.鈥�
She has been left with worrying questions about the impact on the practitioners鈥� sense of integrity and ethics. 鈥楾here was a lot of talk about getting around things, trying to show the system works even though you know it鈥檚 not working, and it was presented as a way to protect the client 鈥� but actually, it鈥檚 preserving a system that is fundamentally flawed. And the level of unhappiness that people were expressing 鈥� they were asking, is there a place for counselling in the future? And the clients were nowhere in all of this. It had become all about the symptoms, not the person. The practitioners knew it, but they were just trying to get through their working day.鈥�
Fighting their corner
Catherine Hayes has been running the Person-Centred Experiential Counselling for Depression (PCE-CfD) course at the University of Nottingham since 2012, training counsellors to deliver this IAPT-approved model. The training is mandatory for delivering PCE-CfD in IAPT but, she says, participants find it鈥檚 a reviving and supportive experience that reconnects them to person-centred values.
鈥楨mpathic understanding and giving expression to that understanding are key elements of the person-centred approach to emotional distress. However structured and solution-focused participants have become, you see them shift towards being with the client, tracking them, not advising them, and it鈥檚 a palpable change,鈥� Catherine says. And they sustain it back in their workplaces, as the recordings of client work that they submit over the next 12 months, as part of the qualification, show. However, this is more likely if they have a PCE supervisor 鈥榳ho can keep that clear water between the relationship with the client and the demands of the service鈥�. She tries to equip counsellors with the confidence to argue their case, and to link them in with peer support from others on their course and through follow-up sessions. 鈥榃hen the case manager says a client has to be discharged because their scores are reaching recovery, we encourage the counsellor to fight their corner and offer an argument as to what the process is, and why the client needs to continue in the service for as long as they need and the service permits. On average, most clients end at 8鈥�10 sessions, but having the freedom to determine that is essential. The managers don鈥檛 understand what the person-centred relationship is about. They just want to get their money鈥檚 worth.鈥�
Jessie Emilion agrees that supervision by experienced counsellors is vital if IAPT services are to use this resource to its best potential. She has worked for many years in IAPT services as a counsellor and clinical lead and supervises IAPT counsellors across the London region. She isn鈥檛 against cross-modality supervision; it can encourage cross-fertilisation and learning, she believes. But counselling is very different from CBT, she says; counsellors give of themselves in the relationship, and the quality of that relationship is an essential part of the therapeutic process. 鈥業n IAPT, supervision is often about case management, about numbers and targets. It often isn鈥檛 valued as a space where the counsellor can work through their own process. Counselling asks us to use ourselves, it鈥檚 not about doing things to the other person. We are doing high- intensity work with clients with complex relational problems and the service needs to look after us. We have an ethical responsibility for the supervisee鈥檚 wellbeing too.
鈥榃e are not asking for special treatment; the NHS wouldn鈥檛 expect a clinical psychologist to be supervised by someone who wasn鈥檛 also a clinical psychologist,鈥� she points out.
She also argues that it鈥檚 helpful for supervisors to have external supervision with an experienced counsellor. 鈥業t helps them contain and process all that anxiety that the IAPT culture generates, with its emphasis on numbers and targets, and enables them to go back to the workplace and argue the case and support and empower their supervisees.鈥�
Vicki Palmer is a counsellor by profession and Chief Executive of Oasis-Talk, which she set up with colleagues in 2012 to provide IAPT services in the south west. She says the pressure from targets has intensified over the years: 鈥楾here is always the threat for commissioners that, if their service isn鈥檛 hitting the targets, NHS England will send in the intensive support team, who will look at everything, down to the last detail, and are CBT focused. They often remove any counselling that is not IAPT-PCE-CfD, without providing counsellors with PCE-CfD training. It is up to the service leads to support counsellors and hold that pressure so it doesn鈥檛 cascade down to staff,鈥� she believes.
Counselling and counsellors tend to suffer most in services where all the clinical leads are CBT practitioners, Vicki says. 鈥業f you ensure you have counsellors among your clinical leads, then there is some understanding of these nuances and you can work more intelligently with the system, and also the staff feel more supported, whether they are CBT or counselling.鈥� She has persuaded her supervisors to include a brief, 15-minute review of their supervisees鈥� caseloads, once a month, as part of the weekly (fortnightly for part-timers) supervision. She admits the supervisors were reluctant at first, 鈥榖ut I think it鈥檚 helpful because it gives them an overview of the supervisee鈥檚 caseload, and the levels of complexity and severity of scores. It is clearly delineated so supervision isn鈥檛 swamped by case management鈥�.
But, she argues, IAPT was only ever designed to be an early-intervention service delivering brief talking therapies for people with mild-to-moderate difficulties. Even the previous GP-attached counsellors only ever offered six to eight sessions; there have to be compromises, and there is plenty of evidence that brief therapy works, she says. It is the only fair way to meet the volume of demand. 鈥榃e are talking ethical principles of justice: if you have huge numbers of people coming through the door, you can鈥檛 give some of them long-term treatment because you are creating a block in the door.鈥� She says a lot of third-sector providers who still offer long-term work are finding the same problem. 鈥楾heir wait lists are going up to a year, 18 months, and they are coming to the same conclusions. Thanks to IAPT, most people in England are now able to access therapy in primary care, and often it is 12 or more sessions of counselling or CBT. This is an improvement and a significant achievement.鈥�
The inner-city IAPT service manager I spoke to thinks IAPT has been a victim of its own success. They say what鈥檚 needed is a total review of primary mental health care and a bigger range of interventions that can help people with life problems at an early stage. 鈥楥ounselling can鈥檛 be managed in isolation from the rest of the system. That鈥檚 where community mental health support workers come in, and social prescribing, to offer alternatives, rather than everyone being sent down the IAPT route. A lot of people don鈥檛 need counselling. There are other ways of dealing with unhappiness that aren鈥檛 counselling.鈥�
Norma McKinnon Fathi agrees: 鈥楶eople set out to do a good thing 鈥� to improve access to counselling. What could be a better mission? But is this the right way to go about things? Is IAPT the place to put all the energy and resources?鈥�
Gillian, Jude and Norma write about the impact of IAPT in a new book, The Industrialisation of Care: counselling psychotherapy and the impact of IAPT, edited by Catherine Jackson and Rosemary Rizq ()
Catherine Jackson is Editor of Therapy Today.
References
1. bit.ly/2FBjVQw (accessed 4 July 2018).
2. bit.ly/2YEL1Ps (accessed 4 July 2018).
3. https://doi.org/10.1192/bjp.bp.115.171017