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Albert Ellis

A brief history of IAPT: the mass provision of CBT on the NHS

I’ve a long article in Aeon magazine this week, looking at Improving Access for Psychological Therapy (IAPT), which is the first ever provision of talking therapy on a mass scale by a government. Before IAPT, the NHS spent just 3% of its mental health budget on talking therapy. IAPT has tripled that budget, and aims to train 6,000 new therapists in CBT by 2014, who will treat 900,000 people for depression and anxiety annually in England and Wales. It is, as one therapist put it, ‘the biggest expansion of mental health services anywhere in the world, ever’. Quite a feat.

In the piece, I tell the story of how IAPT occurred because of a chance meeting at a British Academy tea party:

In 2003, Lord Richard Layard was made a fellow of the British Academy. He’d made his reputation as an unemployment economist at the London School of Economics, but he’d always had an interest in depression and happiness. He inherited this interest, perhaps, from his father, the anthropologist John Layard, who suffered from depression, shot himself in the head, survived, was analysed by Carl Jung, and then re-trained as a Jungian psychologist. Layard junior was more interested in hard data than the collective unconscious, but he’d become interested in a new field in economics that tried to measure individuals’ happiness, and use the data to guide public policy. Layard wondered: what if governments started to take happiness data as seriously as they took unemployment or inflation? He tells me: ‘The most obvious policy implication was for mental health services.’

At the British Academy tea party, Layard struck up a conversation with the man standing next to him, who was called David Clark. ‘It was a fortuitous meeting’, Layard tells me. Synchronicity, his father might have said. Layard asked Clark if he happened to know anything about mental health. Clark replied that he did. He was, in fact, the leading British practitioner of CBT. He had helped to set up a trauma centre in Omagh after the Provisional IRA bombing of that town in 1998. The centre treated Omagh citizens for post-traumatic stress disorder, and kept careful measurements of the outcomes. The data showed that front-line provision of CBT in the field showed comparable recovery results as in clinical trials: roughly 50% of people recovered. Clark explained to Layard that trials of CBT showed similar results for depression, anxiety and other emotional disorders. He also explained that there was very little CBT (or any other talking therapy) available on the NHS for common problems like depression. Layard, who is nothing if not a doer, decided he wanted to ‘get something done about mental health’. So, at the age of 70, that is what he did.

With Clark’s help, Layard assembled a powerful argument for the British government to increase its spending on CBT. Depression and anxiety affect one in six of the population. Besides causing a lot of human suffering, this costs the economy around £4 billion a year in lost productivity and incapacity benefits. This problem has a solution, Layard argued: CBT. The government’s own National Institute for Health and Care Excellence (NICE), which evaluates evidence to guide NHS spending, recommended CBT for depression and anxiety in 2004. Yet for some reason, the NHS just £80 million a year on talking therapies, out of a total NHS annual budget of £100 billion. Layard and Clark recommended doubling the budget, so that 15% of adults with depression and anxiety would get access to psychological therapy. Some of them would get off incapacity benefits in the process, it was argued, so the service would pay for itself.

Layard and Clark presented their recommendations at a seminar at 10 Downing Street in January 2005. They managed to get IAPT into New Labour’s manifesto for the 2005 election, and were then faced with the task of turning it into a reality following Labour’s election victory. Clark designed the service. Firstly, and radically for the NHS, it allowed for self-referrals. Secondly, the service would have a ‘stepped-care’ approach: for mild cases of depression and anxiety, people would be treated by ‘Psychological Well-Being Practitioners’, who had a year’s training in CBT, and who provide ‘psycho-education’ and guided self-help, often over the phone. If that wasn’t adequate, people were encouraged to ‘step up’ to more intensive face-to-face therapy for a longer period of time, with a fully-trained therapist. Thirdly, IAPT would only offer NICE-recommended evidence-based therapies, which meant mainly CBT. Finally, IAPT centres would measure outcomes at every therapy session, and make this data available online, so both patients and politicians could see the results.

The reason Layard and Clark convinced politicians to put serious money into talking therapies is that CBT had built up a big evidence base to show it worked. I look at the origins of this evidence – the invention of the ‘Beck Depression Inventory’:

Beck developed Cognitive Behavioural Therapy in the early 1960s. He tells me: “I was also influenced by the Stoics, who stated that it was the meaning of events rather than the events themselves that affected people. When this was articulated by Ellis, everything clicked into place.” While Ellis was content to be a free-wheeling rebel, Beck was more of an institution man. He wanted to transform clinical psychotherapy from within, by building up an empirical evidence base for cognitive therapy.

Before Beck, evidence for psychotherapy mainly consisted of therapists’ case studies. The reputation of psychoanalysis, for example, was built on a handful of canonical case studies written by Sigmund Freud, like ‘the Wolf-man’, ‘Dora’, and ‘Anna O’. The problem with that approach was the evidence was anecdotal, non-replicable, and relied strongly on the therapist’s own account of a patient’s progress. The therapist might exaggerate the success of a treatment, as Freud arguably did in the foundational case of Anna O.

Beck’s radical innovation was to develop a questionnaire which asked patients how they felt on a four-point scale. In 1961, he created the Beck Depression Inventory, a 21-question survey which measured a person’s beliefs and emotional state through questions like:

0 I do not feel like a failure.
1 I feel I have failed more than the average person.
2 As I look back on my life, all I can see is a lot of failures.
3 I feel I am a complete failure as a person.

By measuring the intensity of a person’s negative beliefs and feelings, Beck discovered a way to quantify emotions and turn them into data. Using the BDI, he could quantify how a person felt before a course of CBT, and after it. According to the BDI, after 10-20 weeks of CBT, around 50% of people with depression no longer met the diagnostic criteria for major depressive disorder. And, crucially, this result was replicable in randomised controlled trials by other therapists. CBT showed similar recovery rates for anxiety disorders like social anxiety and post-traumatic stress disorder.

Beck launched the era of ‘evidence-based therapy’. In doing so, however, he made some drastic alterations to the ancient philosophy that inspired him. He pruned out anything that was not scientifically measurable – including any mention of God or the Logos, virtue or vice, the good society, or our ethical obligations to other people. I once asked Beck if he agreed with Plato that certain forms of society encouraged particular emotional disorders. He replied: ‘I am loath to toss out an opinion that is not based on empirical evidence.’ There is much about which CBT is silent. It teaches you how to steer the self, but does not tell you where you should steer it to, nor what form of society might encourage us to flourish.

I wax lyrical about the place of IAPT in the history of ideas:

IAPT is an interesting moment not just in the history of psychotherapy, but in the history of philosophy. It is an attempt to teach Stoic – or ‘Stoic-lite’ – self-governance techniques to millions of people, an exercise in adult education as much as healthcare. The scale of it is beyond the dreams of the ancient Stoics, teaching on the street corners of Athens. Although the early Stoics wrote political works, they were all lost in antiquity, and later Roman Stoics viewed Stoicism more as a sort of individual self-help for the elite. Marcus Aurelius, the Stoic emperor of Rome, was in a position to spread Stoicism to the entire empire if he so wished, but he had a pessimistic sense of the limit of politics. ‘I must not expect Plato’s commonwealth’, he told himself. ‘[For] who can hope to alter men’s convictions, and without change of conviction what can there be but grudging subjection and feigned assent’.

Stoicism’s therapy of the emotions remained popular with intellectuals, but few believed it could be taught by the state to the masses. David Hume wrote that the majority of humanity is ‘effectually excluded from all pretensions of philosophy, and the medicine of the mind, so much boasted…The empire of philosophy extends over a few, and with regard to these, too, her authority is very weak and limited.’

The early results of IAPT have been better than Hume might have predicted, with recovery rates of 44.4%. IAPT is now being rolled out into child services, into the treatment of chronic physical conditions which have an emotional toll, and into the treatment of unexplained conditions like Chronic Fatigue Syndrome. An IAPT-style programme is also being piloted in Norway.

And finally I consider whether the state has any business providing therapy for our emotions. My position is basically that I’m all for the provision of CBT because it doesn’t try to tell people what ‘flourishing’ or the meaning of life is. But I’m wary of state support for Positive Psychology precisely because it does try to tell people what flourishing ‘is’. In place of Positive Psychology, I’d like to see something else – call it Positive Philosophy – which is more open-ended and Socratic when it comes to discussing the good life.

Once more, with feeling: the latest attempt to teach flourishing in schools

This week I’d like to examine the latest attempt to teach young people how to flourish in schools, via a new randomised controlled trial of a new Personal and Social Health Education curriculum, which is being launched in 30 English schools this autumn. As regular readers know, the attempt to teach people how to flourish is a subject close to my heart- indeed, my book, Philosophy for Life, imagines a ‘dream school’ that does just that.

Teaching flourishing has a long history. We could go back to the 19th century, when private schools tried to teach character through a combination of muscular Christianity and the classics, or all the way back to philosophy schools like Plato’s Acaedemy or Aristotle’s Lyceum. But let’s start more recently than that (I hear you breathe a collective sigh of relief) and begin in the late 1990s, when New Labour became interested in bringing psychotherapy into politics.

The idea of teaching well-being in schools took off in the UK after the publication of Daniel Goleman’s pop psychology book Emotional Intelligence in 1995. That book inspired a local education authority in Southampton to introduce EI classes in its schools, through a subject called Social and Emotional Aspects of Learning (SEAL). Other LEAs followed Southampton’s example, and in 2002, Ed Balls, the minister for education, made SEAL a non-statutory component in the national primary curriculum, as one part of a new subject called Personal and Social Health Education, or PSHE (sorry for all these acronyms). In 2007 it was introduced in the national curriculum for secondary schools. Although it was voluntary, around 80% of comprehensives taught SEAL in some form.

Despite the enormous, almost religious enthusiasm of LEAs and New Labour, SEAL rapidly attracted controversy. Some, like Kathryn Ecclestone at the University of Birmingham, criticised the ‘dangerous rise of therapeutic education’, where children were taught that a certain model of emotionality was ‘good’ and other models ‘bad’ or ‘sick’. Indeed, Goleman’s EI argues that the healthy child is socially-skilled and happy to publicly share their emotions – in other words, the healthy child is a girl. Boys or introverts, who may be reluctant to publicly discuss their emotions in circles, are immediately pathologised.

Schools were given a SEAL starter-pack and not much other guidance from Whitehall.

Another problem with SEAL was that schools were given very little guidance in how to teach it beyond a SEAL pack sent out from Whitehall. Only a fifth of teachers have any training in SEAL or PSHE. Many schools made it up as they went along, and SEAL classes included everything from CBT to rainbow rhythms. This, to some extent, reflected the intellectual incoherence of Goleman’s pop psychology book (Goleman wasn’t a trained psychologist, he was a journalist for the New York Times).

The big problem with SEAL, which a team at the University of Manchester discovered and reported in 2010, was that it didn’t do what it was meant to do. It had no impact either on children’s emotional well-being or their academic performance. Somehow, in all the enthusiasm, no one had thought to evaluate it until it had been in our schools and imposed on our children for a decade. I find that cavalier attitude pretty shocking, and a classic example of the policy risks of good intentions without good evidence.

The realisation that SEAL lacked any evidence base seriously undermined the idea of teaching flourishing in schools, and also undermined LEAs in the eyes of the new Coalition government. When Michael Gove became minister for education, he rolled back many of New Labour’s well-being initiatives in schools, abandoning Every Child Matter and insisting that OFSTED no longer try to evaluate the well-being of pupils. Gove also ordered a review of PSHE. That review is on-going – it was supposed to have published its results by now, but apparently the Department of Education has its hands full with its academy and free school programme. The government has at least made clear it doesn’t think much of SEAL.

The Penn Resilience Project

However, there was another attempt to teach young people how to flourish in a more evidence-based way. This was the Penn Resilience Project (PRP), which was designed by Karen Reivich, Martin Seligman and colleagues at the University of Pennsylvania. It was an attempt to introduce the basics of Cognitive Behavioural Therapy into classrooms, with the same evidence-based scrupulosity with which Penn’s Aaron Beck brought CBT into the mainstream of therapy.

In 2007, three local education authorities (Hertfordshire, Manchester and South Tyneside) paid to send around 100 teachers to Penn to be trained in the PRP, and then to teach it in 22 schools. The impact on students’ academic results and emotional well-being was then evaluated by a team at the London School of Economics. One of the driving forces behind the PRP was Richard Layard, professor at the LSE and the author of Happiness: Lessons From A New Science, who had also been instrumental in getting government support for the huge expansion of CBT services in the NHS.

The PRP was the great hope of enthusiasts for well-being education, because it was supposed to be carefully scientific and evidence-based compared to SEAL. Unfortunately, when project evaluation was published by the LSE in 2011, the results were not a home-run. Amy Challen, one of the project evaluators at the LSE, tells me:

There was a 0.1 standard deviation for participants on the Beck Depression Index, and that quickly tailed off after the project finished. That’s quite small. There are lots of possible reasons for that. Most young people don’t have depression in the first place. Also children were only taught 18 hours of the course in total – as Richard Layard said, you can’t learn French in 18 hours and it may be the same for well-being. There were problems with recruitment of teachers as well. Twenty of the teachers didn’t teach any PRP workshop, and some only taught one. And some teachers had excessive expectations – they thought you could teach the programme and everyone’s life would be transformed. They would focus on individual cases where they saw transformations, and not understand why that impact didn’t show up in the data. It’s because that was just one child among 30.

During the PRP pilot, Richard Layard and two colleagues decided to be more ambitious, and to try and gather together the best evidence-based programmes from around the world (well, the US, UK and Australia) not just for emotional well-being but for the entire PSHE curriculum, which also includes topics like sexual and physical health, media awareness, and also occasionally citizenship, environmental awareness, and even (shock horror) moral philosophy. Last year, they published a report outlining their new, evidence-based curriculum for PSHE, which brought together around 16 evidence-based programmes, including PRP and other CBT and mindfulness-based programmes. Layard wanted to test this curriculum out over a longer period, to give the children the time to really learn the cognitive and behavioural skills embedded in the course. James O’ Shaughnessy, former head of the Downing Street policy unit under David Cameron, who is a big enthusiast for teaching flourishing, told me: ‘One of the things we know from the evidence is the importance of habit formation. That takes time.’

Emma Judge, one of the two founders of How To Thrive

The new curriculum is now being road-tested in a randomised controlled trial at 30 schools around the South-East of England, starting in autumn of this year. The RCT is being funded through a £687,000 grant from the Education Endowment Fund, and is being evaluated by the LSE. The teaching and teacher-training is being organised by Emma Judge and Lucy Bailey, who helped to run the original PRP pilot for Hertfordshire local education authority, and who subsequently set up a not-for-profit called How To Thrive. Through that, they have trained 700 teachers to teach the resilience programme in 80 schools around the country. Emma Judge says: ‘The initial PRP pilot was just 18 hours. The research suggests that people can learn new habits but it’s hard work and takes practice.’ The new project will teach children an hour a week, over four years, and will cover all the topics of PSHE, including media / advertising awareness, drug awareness and sexual health, bringing together evidence-based programmes like the PRP, Mood Gym from Australia, and the Parents Under Construction programme from Houston.

Lucy Bailey says: ‘An important idea is that this is a proper subject, which is valued in schools, which teachers can talk about, which students see as valued by the school. In the initial project, some schools felt ‘don’t go into that classroom, they talk about feelings there’.’ Emma adds: ‘We used to get a lot of nervousness from teachers with the original PRP, who were worried they would be opening up a can of worms by venturing into the emotions. But that’s reduced now, because teachers realize it’s not about that. Some experiences would not be suitable for the classroom and would be handled differently, through the school’s counseling services.’

The tricky question of values

I ask Lucy and Emma if the new curriculum is trying to teach young people values. This seems to me the thorny question for both PSHE and Positive Psychology in schools. On the one hand, they are attempts to help young people to flourish. On the other hand, there is an understandable nervousness about state schools promoting a particular ethical vision of the good life (there’s much less nervousness about this in private schools, perhaps because they’re less multicultural in their pupil demographics, and because parents know what sort of ethical culture they’re paying for).

Emma says: ‘Positive Psychology does face that value question, and we’re involved in the designing of a Positive Psychology whole-school approach for Wellington College. But this PSHE curriculum is much more about skills and awareness than values. Of course, we don’t want kids to take drugs, or get drunk, or have unprotected sex, but there’s nothing more invasive than that.’ Lucy adds: ‘We want to strengthen young people’s capacity to make their own decisions. Of course at year 7 or 8 we say ‘it’s better not to take drugs’, but at year 9 or 10 we say ‘what’s your view?’ We want to help people develop their own value system. A Catholic school might have a very particular set of ideas about sex, for example, while we’re not trying to influence young people in any one way on that topic. We’re not saying how they should be.’

This is, of course, a tricky area. It’s one I grapple with in my book too. You can leave out values from the curriculum altogether and say you’re just teaching ‘life-skills’, but that risks leaving children in a moral vacuum, where you sacrifice children on the altar of your own liberal tolerance (wow, quite a melodramatic metaphor there). Or you can opt to include explicit values in the curriculum, but then you risk indoctrinating young people in your own unexamined dogma, drilled into them Madrasah-style, rather than enabling people to develop an autonomous and sceptical mind-set. The challenge is balancing indoctrination with skepticism, balancing inherited wisdom with a freedom to choose one’s own path. This is not an easy trick to pull off, and requires a great deal of skill, wisdom and humanity from the teacher.

I would still love to see more ethical discussion in PSHE, perhaps to combine it with Religious Education and moral philosophy, or at least to introduce more Socratic discussions about different models of the good life into the classroom – particularly in year 11, year 12, and at university. Life-skills are the means, but it’s useful also to think about the ends. I wish the new project the best of luck over the next four years. I’m not sure what the government plans to do with PSHE in the meantime.


Here is a new brief collection of brief articles by Tory MPs on mental health. It’s interesting as an example of how mainstream mental health policy has now become. The MPs argue for new policies including greater provision of mental health services for soldiers and veterans, and greater choice of therapies for people besides CBT on the NHS.

Here is a new report from the World Economic Forum on creating a more evidence-based and quantifiable approach to well-being in the workplace.

Action for Happiness has published an interesting new report on the role of values in happiness and well-being.

A great article in Nature magazine on ritual and its role in societies.

The New York Times notes a new genre, the self-help memoire. The Guardian thinks that Sheila Heti’s new bestseller work of 20-something funny angst could be described as a self-help mash-up. And of course, Lena Dunham, creator of the HBO series Girls, is writing a sort of self-help mash-up too. Self-help is gradually becoming hip, mark my words…

I just read Jaron Lanier’s brilliant You Are Not A Gadget, which is a wonderful meditation on how the internet is not necessarily making us more free and authentic, and may be making us more conformist and enslaved to ‘Lords of the Cloud’ like Google and Facebook. In that somewhat dystopian vein, check out this interesting Aeon magazine long-read from Claire Evans about how the internet haunts us with the ghosts of past relationships.

Can autism be outgrown, asks Time Magazine.

My brother and another friend are both involved in the complex attempt to come up with new UN Millennium Development Goals. Not an easy task, as this Guardian editorial notes.

This week I have been mainly listening to new albums by Toro Y Moi (weird indie R&B) and Matthew E. White (sort of intelligent and quiet soul); I have been mainly reading Elijah Wald’s excellent book on the history of rock and roll; and mainly watching this wonderful documentary, also about the history of rock ‘n roll. Can’t wait to see Zero Dark Thirty this weekend.

See you next week,