Book Review: The Industrialisation of Care: Counselling, psychotherapy and the impact of IAPT

The Industrialisation of Care: Counselling, psychotherapy and the impact of IAPT

Catherine Jackson & Rosemary Rizq (eds.), 2019. Monmouth: PCCS Books.

This is a horror story. More than that, it is a grim, relentless journey through a wasteland of, well…waste. If you faint at the sight of misshapen public funds, butchered therapeutic practices, dismembered health services, rotting economic ideologies and the living dead of bureaucracy, then look away now.

The story begins in 2003 when the economist Richard Layard, wading well out of his depth into thinking about psychotherapy, met David Clark, an academic psychologist stuck far up in the ivory towers and also unfamiliar with therapeutic practice despite a filing cabinet full of research papers.

With the help of successive UK governments eager to make unhappy unemployed people happy and productive for the least possible public expenditure, Layard and Clark developed the UK's Improved Access to Psychological Therapies Programme (IAPT). By training people (and programming computers) how to serve up a set menu of brief cognitive behavioural therapy (CBT) interventions, by standardising session-by-session outcome monitoring and by outsourcing services to private companies and charities, IAPT promised a cost-effective 'evidence-based' approach to fixing the underperformance of an anxious, depressed workforce.

The programme started in 2008, with initial funding of £173 million. In 2018, 900,000 people accessed IAPT services – the current plan is to reach 1.9 million by 2023/24. On the surface, it looks like a growing success story.

Beneath the headline numbers, however, IAPT's failings and ideologies have been the subject of extensive criticism (but not an independent public audit). This volume provides a welcome antidote to IAPT propaganda, bringing together a comprehensive range of critiques by different authors. These range from economic and political assessments to scrutiny of the clinical and practical elements of the programme.

Rosemary Rizq, one of the editors, summarises IAPT's conception in terms of three myths:

• 'How the myth of the sovereign consumer holds that the needs of psychologically-distressed patients are best served by market-style reforms within the public sector;
• How the myth of transparency is embedded in the assumption that collecting increasing amounts of information will lead to a corresponding increase in knowledge and understanding; and
• How the myth of the medical cure is rooted in the belief that the practice of therapy can be understood and evaluated in the same way as a prescribed drug."

Among those contributors critiquing the first myth, Philip Thomas argues that Layard's neoliberal assumptions and Clark's 'science' of happiness ignore both the role of ethics and values in our emotions, as well as the social and other contexts in which our emotions arise. CBT dovetails nicely with these, he notes, emphasising the importance of individual self-care and reducing the role (and cost) of the therapist. Meanwhile, Thomas notes, under a political mode of 'austerity' since the financial crisis of 2007/08, public spending has been cut and mental health and wellbeing have deteriorated. Between 2007 and 2014, reports of self-harm in adults in the UK doubled and suicides increased. Thomas argues that neoliberalism has amplified divisions in society; urging individual responsibility, productivity and freedom in order that we consume more, it ensures that "those perceived as skivers are stigmatised, controlled, coerced and transmuted into strivers."

Among the other critiques of the sovereign consumer myth, Penelope Campling examines how industrial processes intended to make IAPT efficient "have created an impersonal, de-skilled, rule-driven environment, where staff feel treated like machines and patients feel objectified". In an NHS that is "over-reactive, driven by panic and an unrealistic fantasy of control", she argues that IAPT's fetish for monitoring and regulation is "not the same as cultivating quality and success" and that "being a good therapist is not necessarily the same as complying with the systems that supposedly show one is a good therapist".

The initial funding for IAPT involved a transfer from the Department of Work and Pensions to the Department of Health – in the hope that better mental health would reduce the numbers of ill and absent workers, and save spending on welfare benefits. Lynne Friedli and Robert Stearn argue that cajoling people into positive affect and motivation, as a condition for retaining their social security payments, is a form of 'psycho-compulsion' taking place in a 'black box' of privatised employment offices without oversight, accountability or the possibility of appeal. Most damningly, they say that "there is no evidence that work programme psycho-interventions increase the likelihood of gaining paid work that lasts any length of time. In perpetuating notions of psychological failure, they shift attention away from the social patterning of unemployment and from wider trends: market failure, precarity, the rise of in-work poverty, the cost-of-living crisis and the scale of income inequalities".

In terms of the myth of transparency, Rizq writes that "IAPT practitioners are among the most closely monitored of any mental health practitioners in the NHS today". Among other things, they are expected to "take and record multiple clinical outcome measures for each client contact; to receive frequent case management rather than clinical supervision, and to achieve ever-higher activity and clinical outcome targets". Patients and managers are also surveyed as part of the 'audit culture' she notes.

The impact of this valourisation of quantitative measures and efficiency has had an impact on NHS therapists, argue contributors Gillian Proctor and Maeta Brown, and shifted the culture of mental health from an individual patient-centred relational approach to an industrial, privatised model in which one size fits all: "The agency and individuality of both the client and the counsellor disappear into the well-oiled, smoothly working cogs of the system."

This shift has a number of ethical consequences related to professional ethical guidelines, say Proctor and Brown. These include lack of choice for clients, cherry picking less-complex clients who will allow IAPT to meet its targets, inability to respond to individual client needs, and using "superfluous and even intrusive" symptom measures that cut across the client-therapist relationship and bear no relation to what the client is thinking and feeling. Their qualitative research on ethical conflicts indicates heavy workloads for counsellors and a resultant lowering of quality conversations, the overreach of managers using case management targets to dictate the clinical work, and mental and physical stresses on the counsellors.

The less immediately visible impacts of IAPT also extend to 'third-sector' non-profit organisations, where a small qualitative study contributed by Judy Boyles and Norma McKinnon Fathi suggests that IAPT funding and its audit culture have turned the brief, goal-directed pathologising model into a default therapeutic approach and reduced the accessibility and effectiveness of community-based agencies. They conclude: "It seemed clear to us that IAPT has shut down diversity within the therapy sector and closed off therapy from diverse communities and those whose needs are regarded as outside the perceived norm."

Transparency is also in short supply when it comes to IAPT's impact on employment and the economy. As well as the lack of an independent audit, it seems there are very few cost-benefit analyses, and these have reported mixed findings. Scott Steen's carefully researched contribution asks whether Layard and Clark's claim that IAPT would pay for itself can be substantiated. The answer seems to be complicated by many uncertainties about the real costs and actual effectiveness of the programme beyond the headline numbers. Among the many wrinkles are high non-attendance and non-completion rates, the hidden costs/impact of serial re-referrals of clients, the sickness absence costs of stressed IAPT staff, and the short-termism of IAPT's outcome measurements.

Stepping back from the detail to look generally at the impact of IAPT on unemployment and mental healthcare costs, Steen reports damning evidence. Mental healthcare disability benefit claims have more than doubled since the programme's inception. And when it comes to the use of doctors and pills, the work of GPs in treating mental health issues has remained steady, while antidepressant prescriptions have risen by ten percent annually.

Finally, the myth of a medical cure for unhappiness is dealt with by, among other contributors, Sami Timimi, who examines IAPT's problems fetishising CBT based on a technical understanding of mental health; obscuring of the social and economic origins of much anxiety and depression; and relocating their source to the individual mental space. Given the scientifically untenable concept of 'diagnosis' in psychiatry, he also suggests IAPT's reliance on diagnostic thinking "renders it vulnerable to contributing to, rather than alleviating, harms at the population level".

Timimi also describes a range of research suggesting that CBT has no advantages over other treatment methods, that glowing IAPT reports omit any comparison with costs and services of other providers and do not account for the fifty percent of referrals that drop out without entering treatment. This research also puts forward the reality that IAPT's cost effectiveness is lower than for pre-IAPT primary care counselling and voluntary-sector counselling.

Meanwhile, Michael Guilfoyle argues that CBT's success is perhaps not to do with its effectiveness (no better than any other talk therapy) but the way it fits into the requirements of prevalent institutional and political power; it looks scientific, standardised and time-efficient, uses psychiatrically accepted terms and claims to return people to a taken-for-granted 'real' political and economic world. He suggests that "challenges against CBT on scientific, ethical or political grounds are likely to be fruitless. This relative impotence is itself already an indication that something very significant – and very troubling – has happened in the therapeutic world".

Existential therapists in private practice will find the book shocking but outside their armchair bumit, at least until the creeping industrialisation of therapy discourse finally bleaches all signs of life from their professional societies. For those who have survived the McDonaldisation of NHS counselling through clever circumventions and managerial blind eyes, the volume will confirm much of what they already know.

In summary, this book is timely and well-researched but also thoroughly disheartening. It would appear that the myths of IAPT and CBT are unstoppable. The one bright spot is not exactly bright – the possibility that the country's mental health deteriorates and its consumption of happy pills increases to the point where the failure of these misbegotten beliefs becomes visible even to the likes of Layard and Clark and their political puppet masters. But that is not likely any time soon.

Andrew Miller

A Gentleman in Moscow

Amor Towles, 2016, London: Windmill Books.

I should confess at the outset that I have been steeped in the era of this novel, the end of the Russian Revolution and the immediately previous era of Tsarist Russia, for most of my life, as my brother was a pre-Soviet Russian historian. The novel begins in 1922 Moscow within the walls of the Hotel Metropol, which had been one of the grand hotels, and ends some thirty-five years later.

The Russian Revolution created a strong binary which dominated much of the twentieth century. So it is fascinating to read A Gentleman in Moscow a century later, during what historians, in due course, may view as the first twenty-first century social revolution, less violent, but no less significant.

All that said, the book is simply a really good read, an absolute delight, thoroughly absorbing, vivid and captivating; a keenly observed study of human relating and relationships, thoughtful and philosophical.

The central character, Count Alexander Ilyich Rostov, is under permanent house arrest in the attic of the Hotel Metropol, where previously his aristocratic family had had a palatial suite of rooms. How uncanny it was to have encountered and be reading this book during the lockdown of late 2020, under my own relatively brief experience of house arrest.

Rostov lives within the confines of the Metropol, up in the attic of the hotel with a few sparse but elegant pieces of furniture and a handful of his family's possessions. He has discovered a sort of secret room through a door in the closet, with its Alice Through the Looking Glass overtones. How long his confinement lasts is not actually specified but one can safely estimate that about thirty years have passed, as the nine-year-old Nina who befriended Rostov early in the story has grown, joined the Communists, had a child and died, leaving the child, Sofia (who is herself a young woman by the end of the story), in Rostov's care. In fact, the reader has to make a double take at the end of the novel, to remind oneself that the whole intricate, evocative and absorbing story encompassing both longstanding and unfolding relationships and friendships, with numerous adventures of one sort or another, takes place within the walls of this one building.

Towles's writing is in some ways reminiscent of an Austen novel, or of the more recent writing of Edmund de Waal or Julie Orringer: vivid and detailed with an astute social commentary and, like other culinary novels, his evocations of the preparation and enjoyment of food is thoroughly absorbing, as in this little moment of eating a bowl of soup:

Turning his attention to his Okroshka, the Count could tell at a glance that it was a commendable execution – a bowl of soup that any Russian in the room might have been served by his grandmother. Closing his eyes in order to give the first spoonful its due consideration, the Count noted a suitably chilled temperature, a tad too much salt, a tad too little kvass, but a perfect expression of dill – that harbinger of summer which brings to mind the songs of crickets and the setting of one's soul at ease.

(p40)

The reader is literally sitting beside Rostov in the restaurant as he lifts the spoon to his mouth and is transported into the Russian countryside in summer. Here, as elsewhere, we are alongside Rostov as he enters wholeheartedly into the moment.

Throughout the novel, the reader is ushered through the hotel: the lobby; the rooms; the kitchen; the wine cellar; the restaurants and bar; the staircases; and the newly created suite of rooms occupied by Rostov, alongside all the other characters: his old friend, Mishka, the hotel manager; his rougher successor, Andrey, the chief chef; Emile, the maître d'; Marina, the seamstress; Rostov's young protégée, Nina' his lover Anna; and, finally, his adopted daughter, Sofia.

Gently woven into the narrative are philosophical musings offered with a seemingly effortless light touch, as in this reflection during a conversation with Mishka, Rostov's fellow poet and lifelong friend:

…For it is a fact that a man can be profoundly out of step with his times.…As he proceeds through life, he looks about in a state of confusion, understanding neither the inclinations or aspirations of his peers…Then like a lone sailor adrift for years on alien seas, he wakes one night to discover familiar constellations overhead. And when this occurs – this extraordinary realignment of the stars – the man so long out of step with his times experiences an extreme lucidity…

(p.86-7)

What a vivid description of the experience of the outsider, so familiar to many of us. I am reminded of the philosopher and critic George Steiner, delivering a talk at the Liberal Jewish Synagogue in February 2013, saying "that he thought everyone should be a refugee"; that the perspective of the outsider is unique and valuable, a vantage point only available to "the other".

Having said that, we have no sense of Rostov ever being the outsider. Throughout, he wears his class background lightly and seems well able to adapt and embrace his chastened living arrangements and lifestyle, while at the same time demonstrating a fine sense of appreciation for every small detail of daily life. This is a particularly significant and intriguing aspect of the novel; the theme of thrownness and the fluidity of identity. Some characters in the hotel refer to Rostov as "Your Excellency", harking back to his aristocratic status. As it happens the novel opens with the court case in which Rostov receives his sentence of ongoing house arrest, during which the prosecutor says of his titles – Count Alexander Ilyich Rostov, recipient of the Order of Saint Andrew, member of the Jockey Club, Master of the hunt – "You may keep your titles; they are of no use to anyone else".

But the reader is left wondering, "Is that true?". What do titles mean, what do they contribute to Rostov's sense of himself, and how do they impact on his relationships? To what extent are the titles a declaration, a statement of sorts? In our present client, where there is a great desire by some for transparency, what does it mean to have a full disclosure of sorts, prior to actually encountering the person attached to the titles, or the pronouns, or whatever it may be? So many questions to ponder.

Without doubt, one of the key features of the novel is friendship, in all its guises. We bear witness to the power and pain of a special and life-long friendship with its burdens and responsibilities borne out of a deep sense of history and loyalty. There are friendships cultivated as colleagues of sorts in the hotel, revolving around food; hospitality; expertise; sensuality and social management; mutual respect; and nostalgia and imagination. There are also extraordinary intergenerational friendships spanning class and eras, a sort of transitional object for the reader. There is more: the cycle of life; parenthood; coming of age; fleeing the nest; and escaping into the world. All are present within the story.

There is something paradoxical and insightful about the story, with its ever-present backdrop of confinement, so relevant to the period we have just lived through. But until the very end (spoiler alert), what is particularly noteworthy, is that there is literally no sense of confinement in the novel. Any sense of limitation, frustration, incarceration, restriction or anxiety that one might expect is glaringly missing. Rather, there is a sense of the expansive world of the hotel, a sense of the society that existed there, the power and intensity of relationships created, as well as simply, the riches of human imagination and memory.

A Gentleman in Moscow was both a full and easy read, evocative and thought-provoking. Towles chooses his words carefully. He not only creates a world to absorb the reader, but leaves them wiser and, in the terminology of the novel, replete.

Harriet Goldenberg