When checking the IAPT website, as I do on a daily basis, details inviting new IAPT partnerships for Children and Young People (CYP) providers had been published. If you’re interested follow the link below and you’ll find a number of documents outlining information on how to sign up to the new CYP IAPT venture (http://www.iapt.nhs.uk/downloads/). In this blog I’m going to highlight just a few issues, as I see them, concentrating mainly on issues of learning from the experience of IAPT with adults; as this is claimed by the authors of the document to be something the CYP IAPT has done (http://www.iapt.nhs.uk/silo/files/cyp-iapt-2013-offer-for-new-partnerships-apr-13.pdf). We know in the field of psychotherapy training that experiential learning is deeper, lasts longer and better enables the transfer of theory into practice; I’ve read the documents and I’m still interested to know precisely where the learning has taken place.
Prior to unpacking a little of the content on the CYP IAPT website let’s remind ourselves of a few of the errors that arose in IAPT for adults (of working age). One of the major criticisms has been that IAPT tied itself to NICE, too rigidly in my view, and that doing so meant a reduction in or, in some areas, complete absence of choice. That is, investing too heavily in a small range of therapies resulted in losing the diversity of therapies that were once available in primary care psychological therapies services. Some of these therapies are growth oriented and able to respond to the full range of human functioning and needs and not just deficits.
In contrast to needs based services, people would get access to therapy that had been shown to be ‘effective’ based on evidence from RCTs for medicalised problems; people would not get access to a therapy that was supported to work through non RCT based evidence. Thousands of counsellors lost their jobs or had to retrain in a therapy that was supported in the NICE guidelines for depression and anxiety. CYP IAPT is on the verge of doing exactly the same thing. Why? Because the therapies being supported lend themselves to the hierarchy of evidence (which is in serious need of being revised) and not, as we know from adult IAPT, because they are necessarily more effective in routine practice. We’re now going to invest millions of pounds in training staff to do specific type of therapy (CBT) for CYP with depression or anxiety. The furore that followed the arrival of IAPT and its emphasis on CBT for adults has given way to (re)training therapists in the therapy they had already been trained in but now to deliver a form of that same therapy (DIT, CfD, BCTfD) and for which there isn’t as yet any RCT evidence to support them. Instead they are supported by a ‘pick n mix’ approach to the RCT evidence that leads to integrative practice. Something that resembles what was there before IAPT. PEople doing what their clients informed them that worked. So whatever happened to the NICE hierarchy of evidence here then?
Rant alert! This is not to mention the lower than target completion of therapy, poor recovery rates, and a dissatisfied workforce, that followed – make any sense? Of course not!!! So one would hope that later iterations of the IAPT project, extending as it is into CYP, would have learnt from this and done something different. Have they? Well it’s not obvious if they have so they’ve also failed in creating a successful PR campaign and in getting everyone on board. So let’s have a look at what services will be required to do and what they’ll need staff to focus on developing.
To begin its important to note the positive. The report outlines that the project has been developed in partnership with young people and parents. This is an important feature of any service design and transformation and whilst it isn’t clear how they were involved, or what influence they have actually had over the type of help they will get, it’s still good to know that they have been consulted. The cynic might be inclined to think that this is simply a case of being seen to do the right thing but I’ll reserve judgement on that until there’s real evidence that’s the case. So the new CYP IAPT project is inviting Child and Mental Health Services (CAMHS) to form partnerships with existing collaboratives. There are five regional collaboratives set up in the UK that will act as the central hubs for CAMHS partnerships to coalesce around. The learning seems to have been primarily in the sense of transforming organisations. There seems to be an emphasis on partnerships being formed from cooperatives of statutory and charitable sector organisations. In the report this is emphasised as an important issue for CYP and families. Children and young people, in my experience, generally don’t like receiving services from the NHS. Many say they don’t consider themselves as ‘mentally ill’ and don’t see themselves as needing or getting what they need from CAMHS. School counsellors, when of a good quality, are often preferred by young people.
Under the new CYP IAPT it seems that existing staff will be re-trained in CBT, Behaviour Therapy or parenting support programmes. Financial support is in place for back filling staff positions whilst they are away on training courses. There is money to back fill training positions for therapists, supervisors and managers. Universities are involved as training providers and a curriculum has been developed (http://www.iapt.nhs.uk/silo/files/cyp-iapt-national-curriculum-v6.pdf). If you follow the link above to the document there are some interesting projected costs for implementing CYP IAPT. Services will, like adult IAPT, have to complete a minimum data set and they will be monitored on their compliance with returning full data for 90% of the clients they see.
So where’s the problem? For me the problem is that CYP IAPT is being tied in to the medicalisation of children. Once again the medical model language of ‘depression’ and ‘anxiety’ are foremost in the documentation. there’s nothing about growth and development, of a spectrum of functioning, of disentangling human distress from the language and discourse of the medical model. There’s no critique or even a hint of reflective process to raise a question or two about whether there might be alternative ways of working with CYP and their families. It’s depressing for anyone that doesn’t have a medical model leaning in their practice and there’s one thing that worries me more than anything, the lack of emphasis on the therapeutic relationship and social support.
Now this might sound a bit extreme but I did a quick search for terms in the curriculum that sets out the skills and knowledge base for prospective CYP IAPT workers. Searching for the term ‘therapeutic relationship’ turned up a very disappointing, wait for it, single hit! Yes, afraid so. This document is a 20,000 word document detailing the development of services and training therapists for working with CYP and families. Where’s the relationship? A quick change in the use of terminology to ‘therapeutic alliance’ didn’t fare much better either returning only three matches. So why is this important? Well it might be a simplistic view but one of the fundamental issues underlying much of the distress experienced by CYP can be linked to either poor quality or entirely absent good quality relationships in their life. Relational capacity is essential to wellbeing. The emphasis and balance is clearly tipped to a focus on treatments, diagnosis, medicalising CYP and consequently lacks a spirit of care, compassion and relationship. Just the things the NHS has been criticised of needing to develop.