What do the ex-Chancellor of the Exchequer Kwasi Kwarteng and the founding principles of the Improving Access to Psychological Therapies Programme (IAPT) have in common? Answer: A hopeful start, after which both have failed to survive contact with reality. The difference? One has had a vanishingly short half-life, while the other, despite recovery rates falling to their lowest for five years, limps on.
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Table of contents
In which Kwasi encounters reality
Kwasi Kwarteng, remember him? The man who, as Chancellor of the Exchequer in his Growth Plan 2022 speech, promised “…..a new approach for a new era.” The man who, through a combination of reduced taxes and deregulation, promised to so turbocharge our economy that it would grow to fill the gap between taxation and spending commitments.
Superficially, it made for a compelling argument. Unfortunately for Kwasi, it didn’t survive contact with the markets. Potential investors took one look and said ‘no thanks’. The value of the pound fell, the cost of government borrowing rose, and the hole in the nation’s balance sheet widened further.
IAPT: The promise we were sold
IAPT was sold to the last Labour government by Professor Lord Richard Layard as a means of alleviating the burden of common mental health conditions such as anxiety and depression, one that would be cost-effective and eventually pay for itself by increasing productivity and reducing state benefits.
Again, a compelling argument. The broad premise is illustrated below. Take a very large cohort of people with the most common mental health problems and give them a NICE approved course of treatment. Two-thirds will complete treatment. Of those, one-half will recover. A significant proportion of those on benefits will move off them.
As we’ve highlighted before, the reality has been rather different. For 2020 – 21, nearly four in ten clients that started treatment had one session only. Clients that achieved recovery represented just 21.3% of those that were referred to IAPT, and 29.9% of those that started treatment.
As with Kwasi Kwarteng’s Growth Plan, the idea that IAPT is a success seems to reside only in the minds of those who conceived it. And now, according to latest IAPT Annual Report, the programme’s recovery rate has fallen to its lowest rate for five years.
IAPT: The reality it’s delivering
I take no pleasure in bringing you the picture presented by the latest IAPT performance data. It’s pretty dispiriting, so I’m going to keep this brief.
Of those clients that entered treatment, the proportion of those that ended treatment having had two or more sessions was 57.7%. Put another way, more than four in ten clients didn’t end treatment. That figure, as shown below, is a full four percentage points below that of the previous year. The proportion of clients finishing treatment is falling.
Not surprisingly, the proportion of clients that achieve recovery at the end of the treatment is also falling. For the year 2021 – 22, it stands at more than two and a half percentage points lower than the previous year.
The headline recovery rate most often shown for IAPT is based on the percentage of clients that start treatment at ‘case’ level and end below it. The rate shown in the 2021 – 22 annual report is 50.2%. Having filleted the numbers myself I come up with a figure of 50.3%, but I’m not going to quibble over the difference.
Whichever it is, the recovery rate for the past year has fallen to its lowest level for five years.
Are we doomed never to learn?
There’s an old saying – if it looks too good to be true, it probably is. Had Kwasi, and our erstwhile Prime Minister Liz Truss, not been so ideologically driven, they might have realised that its implementation would be infinitely more challenging than they imagined.
Similarly, the premise behind IAPT is, on paper at least, a seductive one. Take a manualisable psychological therapy, deploy it on an industrial scale, alleviate a lot of misery, and recoup the costs. What’s not to like?
Where human processes are concerned, however, real life delivery is so much more complex than producing widgets. The gap between IAPT’s aspirations and reality is stark. As well as woeful attrition levels and mediocre outcomes, one estimate puts the true cost of IAPT as at least 5 times greater than has been claimed. All very predictable, all very avoidable.
It’s high time for a full independent audit of IAPT. Just don’t hold your breath…………….
Just like you we thrive on feedback.
Please leave your thoughts on what you’ve read in the comments section below.
Hi Barry,
well, depressing, for sure. Do the BACP know about this? – I’m not sure I’ve seen them making much of a fuss about it.
Anyway, I guess there’s little to be said. I saw that no-one else had commented, and wondered if, like me, they just couldn’t think of anything to say, although the information is helpful to me.
You mention the costs of treatment. Did you come up with an estimate?
Hi David and thanks for the comment. Sadly I think that people are getting a little desensitised to news of IAPT’s poor performance. I’m among them to be honest, which is why I kept the blog briefer than usual. As for BACP I can’t believe they don’t know, but perhaps don’t feel able to be overly critical, preferring to influence from within? Better in the tent than out? I really don’t know any more.
On the issue of costs I haven’t seen much of great value since the Radhakrishnana M., Hammond G., et al study in 2013. https://mentalhealthpartnerships.com/resource/cost-of-improving-access-to-psychological-therapies-iapt-programme-an-analysis-of-cost-of-session-treatment-and-recovery-in-selected-primary-care-trusts-in-the-east-of-england-region/
The estimated average cost of a high intensity session was £177 and the average cost for a low intensity session was £99.
The average cost of treatment was:
£493 (low intensity)
£1416 (high intensity)
£699 (stepped down)
£1514 (stepped up), and
£877 (All)
The cost per recovered patient was:
£1043 (low intensity)
£2895 (high intensity)
£1653 (stepped down)
£2914 (stepped up),
and £1766 (All)
Bear in mind now way out of date!
Cheers
Barry
When are they going to take action? It’s incredibly demoralising to work within a system that is not working due to it’s design.
Hi Janet and thanks for your comment. IAPT should have been subjected to an independent audit long ago, but I think there are too many vested interest to make this likely.
Keep hoping!
Barry
Its not just IAPT and its nonsense data and empty notions of what constitutes a ‘recovery’ which is essentially a score on the Pfizer funded PHQ9 and GAD7 – two measures that have likely helped to medicalise more and more people as ‘depressed’ and got them on to drugs misleadingly called ‘anti depressants’ while telling us nothing meaningful about ‘recovery’ in IAPT. IAPT and the mental heath industry in general causes millions of staff to burn out too – se we have mental health services doing almost nothing for those its tasked to help and causing massive harm to staff.
Consider this ladies work
https://thefutureoftherapy.org/iaptsurvey
Its not just IAPT – From my reading and experience there seems to be three main camps on the claimed effectiveness for any from of psychotherapy and we know the drugs don’t work. We have a range of cultural disorders not personal ones.
One camp is occupied by the main players in each modality or therapeutic school. They are all competing in a market place of ideas, for power and status – most of the research is done by therapists themselves, so those with the most to gain from their approach coming out on top. It also seems that the approaches that are elevated over others are those that are a best fit for the broader political, economic and cultural zeitgeist. Given the research is done mostly by those with the most to gain its horribly biased and therefore of little merit
Another camp is also occupied by those with the most to gain and the research is done mostly by therapists – however this camp eg Bruce Wampold in the great psychotherapy debate etc – are at least attempting to get us closer to truth by looking in greater detail at the research.
This camp assumes therapy is efficacious and they they are interested in what bits of therapy make it useful – dismantling studies and other forms of research have been carried out to try and understand what is it that actually helps in any therapy. What they have shown is the following.
The most important, indeed key factor in any psychotherapy’s success is absolutely nothing to do with psychotherapy – The most important factor is all about the individuals resources coming into therapy – resources in the broadest sense, finances, health, family, friends, meaning, purpose etc.
Next most important is placebo, then how comfortable the person feels with the therapist or the pseudo relationship, then comes shared goals/hope and right at the bottom is modality/theoretical orientation/techniques.
Then we have a third camp, also made up of therapists and people in related fields – these people are even more interested in getting us closer to truth and they assess psychotherapy in relation to its cultural position. There are many authors here but William M Epstein over several books including The Illusion of Psychotherapy, Psychotherapy as Religion and Psychotherapy and the Social Clinic, Soothing fictions has taken the best of the research apart and analysed it on methodological grounds. What he demonstrates is there is no evidence for any psychotherapy being effective and it can be harmful.
It’s really incredible that a field with such terrible research and routine poor outcomes and clearly making absolutely no difference to human wellbeing as evidenced by the ever rising numbers of people suffering manages to maintain any sort of cultural power position.
This brings us back to psychotherapies usefulness to power and maintaining the status quo by obfuscating the real causes of so much distress in myriad cultural disorders. As David Smail highlighted it then loads individuals with responsibility to somehow adjust to ever worsening conditions. This constantly and falsely advertised transcendent heroic individualism or delusion is also picked apart by David Smail and William M Epstein.
In my own experience working in the sector most of the people I know and come across aren’t aware of the critics of the research literature and simply carry on like it doesn’t exist even when its pointed out.
It seems so often the case that the road to hell is paved with good intentions.
Believe it or not, here in Québec (Canada), our provincial government have decided to copy this IAPT programm…. and to ignore all the problems we have tried to denounce…
Il seems to me that the attrition problem here resemble to yours. In addition, a majority of the psychologist have quittted our services to work in private practice.
Hi Lulu – sometimes words fail, along with reality testing! Thanks for the comment!
Barry, given your position that the challenges of successful implementation are grossly underestimated, and that you have used such feedback in your own practice to correct your own very human blind spots (e.g., higher dropout rate in a subpopulation (non-EAP clients), I’d like to know what your specific suggestion for remedial measures. Audit the program, yes…but that will take awhile.
This is happening in real time.
Outcomes data must be actionable.
The data suggests unacceptably high attrition.
Would you agree that the immediate priority should be that the IAPT group start studying why and testing remedial interventions (as you did in your own practice)?
Perhaps a trial of real-time monitoring and collaborative management of adverse initial client responses, using the best-supported available tools?
It’s always tempting to assume the grass is greener elsewhere. Systems take decades to re-direct. Maybe walk before we run?
Hi David and thank you so much for asking such an important question. All very well pointing out what’s wrong, but what to do about it? So here are my thought in outline:
1. Get therapists looking at their data if they’re not already and support them in the process of properly understanding it.
2. Emphasise it’s about understanding not judging, and make sure you mean it!
3. Make it a collective endeavour – more heads make lighter work
4. Focus on endings before outcomes. Look at your rates of attrition – clients unilaterally dropping out. Try figure out what’s going on and what would help…see also below.
5. Study individual cases to try and understand what worked for this one and not for that one.
At the end of the day it’s about getting therapists to own their own data and work with it. Most of the time we haven’t a clue how we’re doing till we start measuring AND paying attention.
It doesn’t need to take ten years. Somewhere between ten and never depending on how you approach it. At the RCN we made a big difference over two years https://therapymeetsnumbers.com/how-we-grew-a-remarkable-service-at-the-royal-college-of-nursing-part-2/
Happy to correspond further, and maybe you’d like to consider a blog at some point. Real life ‘how we did this/are doing this’ are gold dust IMHO!
Good luck! Hope that helps, Barry
Something that Isn’t always considered is the natural rate of recovery from the ‘mild’ depression that IAPT is meant to be treating. Estimated as approx a quarter recovered in 3 months, a third at 6 months and half at a year. Subtract these percentages from the claimed IAPT recovery rates, and what are you left with???? A very expensive way of marginally improving outcomes for a very small number of people. It would be better just to give them the money. Seriously. Research shows that helping people out of poverty – not surprisingly – significantly improves their mental health.
Now that would make an interesting comparative study!