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Five years of IAPT (Improving Access for Psychological Therapies)

It’s been five years since the launch of the government’s flagship mental health programme, Improving Access for Psychological Therapies (IAPT).

IAPT is the biggest expansion of mental health services anywhere in the world, ever. It has already trained 4,000 new therapists in Cognitive Behavioural Therapy, and 2,000 more therapists are being trained. It’s doubled the NHS spend on mental health services (from 0.3% to 0.6% of the NHS annual budget), and is on course to treat 900,000 people for depression and anxiety in England every year, many of whom would never have had access to therapy in the private sector. The recovery rate for people requiring two or more sessions of treatment is approaching 45%, with others making improvements even if they remain depressed by clinical standards. That is a lot of human suffering healed, though still only 10-15% of those afflicted by depression and anxiety.

It is also, by the by, been five years since I started blogging.  Five years ago, I became fascinated by the direct link between Cognitive Behavioural Therapy and ancient Greek philosophy, and also by how governments were beginning to ‘roll out’ CBT on a mass scale, in the NHS, in schools, in the US Army and elsewhere. It seemed to me an interesting moment in the history of politics, philosophy and psychology. I started the blog, which back then was called The Politics of Well-Being, in February 2008, and I’ve really enjoyed it. For a prickly Stoic like me, it’s allowed me to be the master of my own fate, not dependent on the whims of commissioning editors, able to explore what interests me at the length I want.

I’m now researching a long article on the first five years of IAPT, which hopefully a magazine will publish. This week I interviewed David Clark, the CBT psychologist who masterminded IAPT, as well as several other therapists and service-users, and next week hopefully I’ll interview Richard Layard, the economist who made the economic case for IAPT to the Labour government in 2006. IAPT only arose, by the by, because Clark and Layard happened to meet when they were both made fellows of the British Academy in 2003. They met during the tea break, and Layard said he was writing a book on happiness and was interested in mental health. Clark told him a bit about CBT, and the rest, as they say, is history.

David Clark, left, having some more tea

Here are five interesting things I’ve learnt so far about IAPT:

1) IAPT is the prime example of psychotherapy in the age of big data

Back in the early 20th century, the evidence for psychotherapy consisted of therapists’ personal case histories, anecdotal evidence like Freud’s Anna O or Wolfman cases. These were interesting to read (who doesn’t love a good story) but they also turned out to be misleading and not very scientific (some of Freud’s patients didn’t recover, like he said they did). Today, psychotherapy is embracing the era of big data, and IAPT is the prime example of that. Service-users fill out feedback forms before each session, which are used to assess how well the treatment is working. These forms are then collated to assess how well the programme is working at the national level too.

So far, the data from IAPT has been fairly rudimentary, only really looking at recovery rates. But as of next month, the data sent through will be much richer, taking account of what conditions patients have, what treatment they received, what ethnicity and demographic they are, which region they’re in, and so on. All of this will be available to the public through the NHS’ information centre, which will which therapies have worked well for which conditions, and where the service is failing to reach people, in particular regions, demographics or ethnicities. There are already signs, for example, that IAPT is not sufficiently reaching the millions of people who suffer from social anxiety – so this group may need to be encouraged to self-refer for services.

2) IAPT needs improving

There is a risk that IAPT will suffer from ‘mission creep’ and end up being allocated serious cases it was not designed to treat. It’s designed for the treatment of common mental disorders like depression and anxiety. Unfortunately, in some local authorities, commissioning boards have cut funding for other types of psychotherapy which are used for more serious conditions, so IAPT services are now treating patients with, say, bipolar disorder or personality disorders. David Clark says that’s not happening at a national level, but may be happening in some regions (it is).

IAPT also remains controversial in so far as many psychotherapists in non-CBT traditions say it only really provides CBT. This is because the National Institute for Health and Clinical Excellence (NICE) mainly recommended CBT when it reviewed the evidence for psychotherapies for depression and anxiety (it also recommends Interpersonal Therapy, Couples Therapy, Counseling and Behaviour Activation Therapy). But psychodynamic and psychoanalytic therapists say NICE is wrong, and that in fact the evidence suggests all talking therapies work roughly as well as each other. They also suggest studies comparing CBT to other treatments are often biased because the researchers have an allegiance to CBT. And, finally, they insist randomised controlled trials aren’t necessarily the best assessment of how therapies work in practice.

These issues remain very contested within psychotherapy. This is unsurprising – IAPT must have arrived like a bomb into the world of private psychotherapeutic practice. Suddenly, there were 4000 new therapists providing therapy for free, many of them with only a year’s training. That was bound to annoy older therapists in the private sector.

Peter Fonagy

There are signs that other forms of therapy are beginning to embrace the IAPT methodology. Several prominent psychoanalysts from the Maudsley Clinic, including Peter Fonagy, are trialling Dynamic Interpersonal Therapy, which is a form of brief psychoanalytic therapy for depression. If the trial is approved by NICE, it might mark an interesting moment of mass Freudian therapy.

3) The NHS’ mental health services are about to become a free market

Just a few years after IAPT created a free national mental health service, the Coalition government’s NHS reforms are about to open it up to competition. Starting this year, Health and Well-Being Boards will be able to commission ‘any qualified provider’ to provide mental health services in their area. That might be the existing IAPT service, or it might be some new organisation competing for tenders.

Well-Being Boards will have to decide how to choose between competing organisations. They could decide to give money to the organisation with the best recovery rates. But that might create what David Clark calls “a skewed incentive” for organisations to only take on easy cases where recovery is much more likely, while turning away any harder cases. It also creates the risk of unscrupulous organisations simply faking their results in order to win NHS contracts. The Department of Health is considering how best to evaluate organisations at the moment – perhaps ‘progress made’ is better than recovery rates, in that it takes account of difficult cases who have made a lot of improvement even if they’re still clinically depressed. Some therapists think outcome measures should also assess actual changes people have made in their lives, rather than simply how they’re feeling.

4) IAPT is being expanded into new areas, and new countries

IAPT is now being rolled out for children and young people, though it appears to be happening on a smaller scale than the adult roll out. It’s also being expanded to treat patients with chronic physical health problems that may be co-morbid with emotional problems, like say cardiovascular disease or chronic pain; or for physical conditions that may be partly psychosomatic, like Irritable Bowel Syndrome. There are also trials underway of IAPT-style services for psychotic illnesses like Bipolar Disorder, Manic Depression and Personality Disorders, often using CBT but also Dialectical Behaviour Therapy. I would be interested to see if CBT might become one tool the NHS uses as it tries to reduce national obesity levels: there is some evidence it’s useful as part of a diet plan.

In terms of other countries, Scotland and Northern Ireland have still yet to put serious investment into mental health services, although their national mental health strategies have suggested they should. Canada’s new national mental health strategy also calls for greater provision of talking therapies. Norway has recently launched an IAPT-style pilot programme, with around 12 IAPT-style centres around the country.

Sweden already has a CBT programme to help people back to work, which hasn’t alas proved very successful. IAPT in the UK has more modest targets for helping people back to work, which so far it’s met – but a new article in the British Journal of Psychiatry suggests that Richard Layard’s original estimate of IAPT’s contribution to QALYs (Quality-adjusted Life Years) was “highly inflated” – so it may not be quite as good economic value as Layard originally argued.

5) There is a role for community arts organisations to work with IAPT services

IAPT services sometimes try to help patients beyond their course of therapy, so that they carry on their recovery and also meet other people working to get better. Sometimes, IAPT services will run post-treatment groups  – for example, some services run mindfulness-CBT groups for people with histories of depression. And sometimes they will connect with local community groups, such as MIND or Re-Think. That includes connecting with community arts groups – Lambeth’s IAPT service, for example, works with local sports organisations, a theatre group called Kindred Minds, an African culture group called Tree of Life, a debating club, even a circus-trapeze training group, as well as with several peer-led recovery groups. These groups have their own funding sources, by the way, they’re not funded by IAPT.

Some local authorities are also developing Recovery Colleges, which take a more educative approach to mental health recovery, treating people as students learning how to take care of themselves. I’m teaching a workshop in ancient philosophy at one such Recovery College next month, and I think there’s a lot of room for arts and humanities academics to connect with IAPT services or Recovery Colleges for their own expertise, whether that’s in art history, drama, history, literature, philosophy or other disciplines.

One therapist I interviewed, Nick McNulty from Lambeth’s IAPT centre, said he’d just met a client who was interested in Stoic philosophy, and wanted more of a values-based approach to mental health recovery. IAPT’s job is not to tell people what the good life is, it’s to help them through crises and to get them to a position where they can begin to seek the good life for themselves, according to their own definition of it. I think at that stage, after IAPT, there is potentially a role for practical philosophy, if it offered a broader ethical context for some of the CBT skills that people have recently learned. However, it would obviously need to avoid being dogmatic or preachy, helping people explore various different models of the good life without imposing one onto them.

In general, IAPT strikes me as an educational project as much as it is a health programme. A lot of what it provides is ‘psycho-education’, or ‘guided self-help’, trying to teach people to learn how to take care of themselves, as Socrates tried to do, and become ‘doctors to themselves’ as Cicero put it. NICE clearly sees the benefits of self-help, which is a big validation for people like me who believe that self-help isn’t a load of junk, although clearly the relationship with a therapist is very important for some people too. By providing a ‘stepped care’ approach, IAPT tries to help both people like me, who are interested in learning how to take care of ourselves, and other people who are really seeking a relationship of care.

We, as users of the service, need to learn how to ask for what we want – how to self-refer for talking therapy even if our GP wants us to take Prozac, how to ask to step up to a higher level of care if guided self-help isn’t enough, how to ask for specific types of therapy, and also how to ask how to change therapist if we don’t have a rapport with the one allocated to us. We need to learn how to take care of ourselves and each other, not entirely relying on the NHS to do the work for us. And, finally, we need to learn how to support the young service politically, if it’s something we think is worth keeping.

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In other news:

The Atlantic magazine considers the ‘touch-screen generation’ – what impact will their immersion in digital technology have on children’s development?

The New Yorker reports on a new text-analysis study of the history of hip-hop, charting such nuggets as the first appearance of the word ‘bling’ and the number of uses of ‘Nike’ versus ‘Adidas’.

Are the French ‘taught to be gloomy’?

In the US, President Obama has launched an ambitious new project to make pre-school childcare universal, at the cost of $10 billion a year. This blog post looks at James Heckman, the psychologist whose work on childcare and early interventions has been an inspiration for Obama’s policy.

Polly Toynbee penned this excellent crie de couer over a new round of benefit cuts set to be introduced on Easter Monday, including slashing the budget for financial advice from the Citizens Advice Bureau from £22 million to £3 million.

Also in the Guardian, a report on the Care Quality Commission, which has found a fifth of hospitals fail to treat the elderly with the dignity they deserve.

In the London Review of Books, John Lanchester gets excited about fantasy fiction, and the new series of Game of Thrones (spoiler alert – he gives away some of the plot).

The BBC has a new 30-part series on the History of Noise, presented by David Hendy of the University of Sussex. The TLS, meanwhile, reviews a new book on the history of silence in Christianity.

Finally, I recently finished Alex Ross’s excellent history of 20th century classical music, The Rest is Noise. There was also a BBC TV series to accompany it, called The Sound and the Fury, which is available on BBC Four’s wonderful archive of TV on modern classical music. Here is a clip from it, of Messiaen’s Quartet for the End of Time, which he composed when a POW in Stalag VIII concentration camp. He and three other prisoners performed it in the camp, in the rain, on January 15, 1941.

See you next week,

Jules

The re-birth of Stoicism

We’re coming to the end of Stoic Week. People all over the world have been practicing Stoic exercises and reflecting on Stoic ideas this week, thanks to this wonderful initiative, launched by a young post-grad at Exeter University called Patrick Ussher. Some of Patrick’s students have been sharing their thoughts on the exercises via YouTube. This is what studying philosophy at university should be like – experimenting, practicing, reflecting, sharing.

Of course, hardcore Stoics might say we shouldn’t share the fruits of our practice – we should ‘tell no one’, as Epictetus puts it. But I actually think it’s good to share your practice with other Stoics, as long as you’re not showing off. My own rather humble practice this week has been to knock off the booze for a week. Small steps, I know – but I’ve stuck to it out of the thought that it’s not just me practicing – there are lots of us out there, committing to this week. We’re stronger when bounded together.

It’s also been a good opportunity for people to say how they’ve been helped by Stoic writings in their life. People like Dorothea from Vancouver, who this week tweeted:

I went through an extremely difficult time a few years ago and one of the things that helped was Stoicism. Reading Epictetus was like having a wise friend sit with me in a situation that no one, not my friends or family, could understand.

Right on Dorothea! As I discovered when I was writing my book, there are loads of people out there who have been really helped by Stoic writings through difficult times, for whom Stoicism means a great deal to them. Everyone from Wen Jiabao, the prime minister of China, who says he has read Marcus Aurelius’ Meditations over 100 times, to Elle MacPherson, who named her son Aurelius, to Tom Wolfe, who got into Stoicism a decade ago and is still very into it today (he said he’d write a quote for my book – Tom, if you’re reading this, get in touch…I need your help!)

So here’s my question: is Stoicism really enjoying a revival or a rebirth now? Or is that a gross exaggeration? And if there is a revival happening, where could it go?

I think there is something of a revival taking place, in large part thanks to Albert Ellis and Cognitive Behavioural Therapy, but also thanks to the revival of the idea of philosophy as a therapy or way of life. And, finally, I think Stoicism fits quite well with our increasingly crisis-prone era. I’ll go through these three factors, quickly.

Stoicism and CBT

The biggest driver for the revival of Stoicism is its direct connection to Cognitive Behavioural Therapy. When I discovered this link, back in 2007, I couldn’t understand why it wasn’t more written about. I found it amazing that ideas and techniques from ancient Greek philosophy should be at the heart of western psychotherapy (2007 was the year the British government started putting hundreds of millions of pounds into CBT and also the year CBT started to be taught in British schools via the Penn Resilience Programme). And no one was writing about it. So I started to write about it. In 2009 I came across Donald Robertson, a cognitive therapist and scholar, who was also writing about it. I interviewed him for my first ever YouTube video.  Check it out and enjoy the trippy special effect at the end illustrating the Stoic idea of the ‘view from above’.

In 2010, Donald published the first ever book properly exploring the relationship between CBT and ancient philosophy. It’s a great book and helped me a lot.

Sam Sullivan, the Stoic mayor of Vancouver, accepting the Olympic flag in Turin

Then, this year, I brought out my book about ancient philosophies and CBT (not just Stoicism, also Epicureanism, Cynicism, Platonism, Scepticism etc),which featured interviews with lots of modern Stoics – Major Thomas Jarrett, who teaches Stoic warrior resilience in the US Army; Chris Brennan, who teaches Stoic resilience in the US Fire Service; Jesse Caban, who is a Stoic in the Chicago police force; Michael Perry, a Stoic Green Beret; Sam Sullivan, the Stoic former mayor of Vancouver, and others. I was helped a lot by the NewStoa community set up by Erik Wiegardt, which helped me get in touch with all these modern Stoics.

Since the book has come out, I’ve done a lot of talks about the connection between Stoicism and CBT, like this one on Radio 4. The book got a nice review in The Psychologist this week (behind a pay-wall alas), and I hope it has encouraged more of a dialogue between psychology and philosophy. The same month my book came out, Oliver Burkeman of the Guardian brought out his book, The Antidote, which also interviewed Albert Ellis and made the connection with Stoicism. We were both interviewed in this Guardian Books podcast talking about Stoicism and CBT.

Then, at the end of this year, Christopher Gill in Exeter’s classics department organised a seminar on Stoicism and CBT, which brought together Donald, me, Tim LeBon, a cognitive therapist and philosophical counsellor;  classicist John Sellars; Patrick Ussher, occupational therapist Gill Garratt and others. The Exeter Project has been a great help in making the connection between Stoicism and CBT a bit more explicit and academically credible.

The revival of philosophy as a practical way of life

Secondly, Stoicism has revived in the last few years thanks to a broader revival of ancient philosophy and the idea of philosophy as a way of life. When Alain de Botton brought out the Consolations of Philosophy in 2000, he was widely reviled by academics for dumbing down philosophy. A decade on, however, more and more academic philosophers have come round to the idea that philosophy can and should be an everyday practice, and even a form of self-help. That’s partly through the influence of de Botton and the School of Life network, but also through the work of academic philosophers like Pierre Hadot and Martha Nussbaum, who have pushed forward a more personal and emotional form of philosophy (by emotional, I don’t mean gushing and sentimental, I mean it works on the emotions, it tries to help people flourish). So academia has played its part in the revival, but I’d suggest self-help writers like De Botton, Eckhart Tolle and Tim Ferriss have been key in bringing Stoic ideas to a wider public.

Stoicism is popular in times of crisis

Exeter during Stoic Week

Finally, I think Stoicism is enjoying something of a revival because it fits with our crisis-prone era. It’s a good philosophy for coping with volatile and chaotic times. You wouldn’t expect it to be that popular during an age of affluence, for example  like we were in from 1955 to 1975, although it was popular then among some officers in Vietnam like James Stockdale. But you would expect it to be popular in times like now, an age of austerity and emergency, when our economies are crashing and our cities are being constantly buffeted by floods and hurricanes. It is appropriate that, in the very week Exeter University hosts ‘Stoic Week’, floods are coursing through the town. Our imagination has become more apocalyptic – whether that be in films like Deep Impact, books like The Road, or TV shows like Derren Brown’s Stoic-inspired Apocalypse. We’ve started to wonder how we’d fare if some of our affluent accoutrements were stripped from us. How would we, poor bare forked animals, cope upon the heath without our lendings?

There has been a growth in nostalgia for the Stoicism of our grandparents – the generation before the baby-boomers, who went through the war with a calm Stoic spirit (or so it seems to us). Hence the popularity of the old war poster, Keep Calm and Carry On. Hence the interest in the history of the ‘stiff upper lip’. Hence the call this week by a Tory MP and GP for a return to the values of ‘post-war Stoic Britain’, when people took care of themselves and didn’t burden the NHS with all their self-indulgent lifestyle illnesses. We are in the midst of an austere reaction to the consumer excesses of the baby-boomers, and Stoicism goes quite well with that reaction. Though of course, the baby-boomers are a part of the Stoic revival too – not least in the increased interest in assisted suicide. The baby-boomers want the freedom to choose their own death, as Seneca put it. If death became the ultimate lifestyle choice, that would be a huge cultural shift, away from Christianity, and back towards Stoicism (the word suicide, by the by, was invented by a 12-century theologian in a tract written against Seneca).

Where could the revival go?

So, there is something of a revival happening. But where could it go?  Well, I think we’re all learning how to take care of ourselves better, learning how to be the ‘doctors to ourselves’ as Cicero put it. I don’t think that necessarily means we’re all going to become card-carrying Stoics, but I do think and hope we’re becoming more intelligent about our emotions and how to heal them, and more DIY about our health in general and how to take care of ourselves.  I suspect and hope that this will involve a continued growth of interest in ancient philosophies – Greek, Buddhist, Taoist, Confucian, Sufi and so on. One of the most encouraging phenomena in this difficult era is the synthesis of ancient wisdom and modern empiricism – the Shamatha project in California is one of the great examples of it. I hope that my psychology colleagues in the Exeter project, Donald Robertson and Tim LeBon, can do more empirical work on Stoic ideas.

However, I personally think Stoicism itself is lacking some things. As Martha Nussbaum told me in this interview, it’s part of an ‘anti-compassion’ tradition. It lacks compassion, is too cold, too uncaring. I remember, on Stoic email lists, when someone has said that something terrible has happened to them, no one would say anything consolatory to them. They would just stiffly quote Epictetus – the philosophical equivalent of a punch on the shoulder. And I would feel like giving that person a hug and saying ‘yes, that’s pretty shit, but you’ll get through it’. The Stoic position of ‘nothing is fucked here, Dude’ seems to me too cold. We’re not Gods, we’re humans. I think we should be careful that the revival of Stoicism does not become too libertarian, part of a backlash against the welfare state. We also need to make clear that Stoicism does not mean repressing your emotions. Far from it. Nor should it mean coping entirely on your own with difficulties. Stoicism today should mean taking care of each other, not just of yourself.

A key contemporary challenge is that Stoicism lacks a proper sense of community, and if you look at modern attempts at building a Stoic community – the NewStoa group, or the Stoic Yahoo list, I don’t think either of them have been that successful, because they are too logical and not caring enough, so they end up with men bickering over terminology, rather than humans caring for each other.

Nonetheless, let me end on a positive note: the Stoics taught us some amazing stuff about how to transform the emotions, and how to take care of ourselves.  It’s just that, in my opinion, those lessons are best taught alongside other philosophies of the good life. Again, I come back to the same point I often ask myself: can we build philosophical communities that are genuinely caring, compassionate, nurturing?

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Tobias Jones

Next week, hopefully, I am off to meet a hero of mine, Tobias Jones, who runs a community like that in Dorset, for recovering addicts. Tobias wrote a fantastic book called Utopian Dreams, asking the same sort of communitarian questions that we are discussing. Do read it, it’s brilliant. I’ll hopefully be interviewing Tobias for a new podcast I’m putting together for Aeon magazine. Should be a really fun, exciting venture. Here’s a piece Tobias wrote for Aeon on his commune.

Next Tuesday, come to hear Angie Hobbs talking about the future of philosophy at the London Philosophy Club, at the Bethnal Green Working Men’s Club. She’s a fascinating speaker, and it’s a brilliant venue.

This week, my friend Sara Northey arranged a brilliant LPC evening, with a talk by clinical psychologist Peter Kinderman. Peter put forward a radical and (in my opinion) quite persuasive argument about why most psychiatric diagnoses and unscientific and deeply unhelpful, and we should instead switch to a problem-based analysis of emotional problems. Here’s an interesting write-up of the event by Natalie Banner, a philosopher at KCL’s Centre for Humanities and Health.

The accuracy of social psychology studies is under the microscope, after Dutch psychologist Diederik Stapel was found to have faked some of his studies, without being found out by the social psychology journals in which he published his results. A new report condemns not just him but the whole field of social psychology for its ‘sloppy’ research culture.

This New York Times article (forwarded to me by Matt Bishop) has been widely discussed in among therapists – it says business is declining for therapists, as people increasingly want problem-fixing rather than long-term counseling (Peter Kinderman would approve!). So therapists are having to hustle to get more business, which means putting more effort into branding. I’ve often thought that therapists should, at the least, put a video of themselves on their website explaining who they are and what sort of problems they can help with (in fact I considered setting up a business to help therapists do this).

Talking of therapists making videos, here is a video of Windy Dryden, a leading cognitive therapist in the UK, doing a song-and-dance version of CBT to the tune of ‘Moves Like Jagger’. Bizarre! Though it did make me think – perhaps I could put together some CBT songs..

Tomorrow, I’m speaking at this conference in Amsterdam along with Alain de Botton, Philippa Perry, Roman Krznaric, Stine Jensen and others. Still a few tickets left I think, if you’re in Holland and fancy coming along. My Dutch publisher, Regine, has been really amazing in promoting my book in Holland, and it’s got into the top 100. She is a force of nature.

The book is now out in Germany. One of my readers, Julia Kalmund, has arranged for me to come and speak at Munich University.  Nice one Julia! She wins this week’s awesomeness prize. It’s also just come out in Turkey….any Turkish readers of the newsletter??

A guy called Ahmad from Pakistan got in touch with the London Philosophy Club this week. He wrote:

Philosophy should be promoted in every community because it is usually above any caste and creed…Unfortunately there are not favorable conditions in Pakistan for such activity, London has a certain attitude for this,as it provided shelter to Volatire and Marx when Europe wasn’t ready to tolerate them…I want to become an active member of London Philosophy Club and to try to go to London for studies,it would be a pleasure for me to remain in the company of such creative social minds.

I find that great and inspiring – that’s why I love philosophy, because it connects us beyond any caste or creed. Good luck to you, Ahmad. Meanwhile the British government has succeeded in lowering immigration…by putting off foreign students from studying here. Doh!

See you next week,

Jules

PS, if you fancy some weekend reading, download my report on Grassroots Philosophy