Did England’s Ambitious Mental Health Care Experiment Deliver?

Almost 10 years ago, England embarked on what would become one of the nation’s largest expansions of mental health care coverage. The architects of the Improving Access to Psychological Therapies (IAPT) initiative had an ambitious goal: to expand mental health care to as many people who needed it as possible, through evidence-based methods like cognitive behavioral therapy (CBT). In 2005, when the plan was first pitched to Parliament, one in four adults suffered from at least one diagnosable mental health problem, according to statistics from the National Institute for Clinical Excellence (NICE), the government body that sets standards on clinical treatments. And according to research published a year earlier in The British Journal of Psychiatry, depression alone was costing the English economy nearly nine billion pounds annually in lost productivity and unemployment benefits. If at least some suffering people recovered and went back to work, proponents argued, unemployment payouts would drop and the program would pay for itself. But could psychotherapy—at its core, most clinicians would argue, a process based on the development of relationships—really be systematized on a nationwide scale?

What began as a highly anticipated experiment quickly fell flat. To start, retention rates have been low: reports released in 2015 by the National Health Service (NHS) revealed that only 37 percent of those who’d entered the IAPT program—after going through the required referrals from their general practitioners—completed the allotted 12-session treatment, while those providing treatment have been criticized as unprepared. Exclusively green-lighting methods like CBT has also caused an uproar among many in the clinical community. An October 2014 article in The Daily Mail, “Is the NHS’s Therapy for Depression a Total Waste of Time?” was just one to take IAPT to task. In the piece, contributing psychologist Oliver James offered a withering critique. “Cognitive behavioral therapy is all about marketing—it is a cheap, quick fix,” he wrote, citing research that claimed those who received CBT showed no more signs of recovery than those who forewent treatment.

IAPT also took heat for its multitiered treatment system, including many practitioners with little training. Clients can eventually see therapists in person, but the first gatekeepers in IAPT are call center workers with little professional experience and only one year of CBT training. A January 2016 article in The Guardian, “Can Call Center Therapy Solve the Mental Health Crisis?” profiled a “cramped call centre” in Oxford, painting a picture of overworked staff, some of whom called the program a “clumsy cure-all for complex and profound traumas.” Another critic referred to the call centers as “the clinical equivalent to online dating.”

So how did a program like IAPT even get off the ground? The principal architect is Richard Layard, an economist, professor, and director of England’s Centre for Economic Performance. When he developed the IAPT initiative, Layard was nearly five years into his tenure as an honorary peer in the House of Lords. During the 1990s, he’d become captivated by happiness economics, the study of forces that lead people to a happy or unhappy life. After a chance encounter at a party in 2003 with clinical psychologist David Clark, a leading CBT researcher, Layard was won over by the potential that Clark touted CBT had to stem the nation’s growing depression and anxiety rates. Knowing the issue of mental health care would be a hot topic in the 2005 general elections, the two co-wrote a manifesto on behalf of the Labour Party, vowing “to invest in and improve our services for people with mental health problems at primary and secondary levels, including behavioral as well as drug therapies.”

After the Labour Party won by a narrow margin, the two set about reinventing British mental health care, the goal being not “wealth creation,” but “wellbeing creation,” Clark said in a 2016 study published by the London School of Economics. In the past, he stated, “the state has successively taken on poverty, unemployment, education, and physical health. But equally important now are domestic violence, alcoholism, depression and anxiety conditions, alienated youth. . . . These should become centre stage.”

Under Layard and Clark’s plan, England’s mental health care budget more than doubled—from nearly 80 million to 170 million pounds—so that a minimum of 15 percent of adults with depression and anxiety would receive treatment, up from just 3 percent. It’s a level of spending on mental health care that’s unmatched in the developed world. In July 2017, The New York Times dubbed IAPT “the world’s most ambitious effort to treat depression, anxiety, and other common illnesses.” And it continues to grow. According to NHS estimates, more than 900,000 people access IAPT services annually, a figure the NHS hopes to boost to 1.5 million by 2021. The program, according to Layard, currently employs more than 6,000 therapists.

Psychotherapist Iain Caldwell, director of Starfish Health and Wellbeing, a England-based clinic, says he’s seen the benefits of IAPT. Conducting service reviews with clients who’ve received treatment through the program, he says most of the feedback he receives is positive. Under IAPT, he adds, people almost anywhere in the country can access treatment free of cost. And with more support for evidence-based methods and reliance on standardized client questionnaires, he says more therapists are being held accountable for their work.

Acknowledging IAPT’s critics, he says that with any program of this magnitude, “some issues are bound to crop up.” But he adds that the program was never designed to replace England’s mental health care system; rather, it’s augmenting existing treatment options while providing valuable data about who needs therapy and how they can best be served. Overall, he says, “IAPT has been a step in the right direction.”

Scott Miller, a psychologist who codirects the Center for Clinical Excellence, an international consortium of clinicians and researchers dedicated to promoting best practices in mental health, says Americans can learn—and should admire—much in IAPT. “First of all, look at what England was willing to invest in mental health care—billions upon billions of pounds,” he says. “Sure, there have been problems in terms of implementation. But access to psychological care has increased every year since the program’s inception.” In England, he adds, “there’s no shortage of people interested in therapy.”

Would a program like IAPT work in the US? “It would be more challenging,” says Miller. “Our population is five times as large, and services are managed by multiple groups with different rules and regulations, unlike England’s single-payer system.” The passage of the Affordable Healthcare Act—“in many ways, also a mess, but also with its good parts”—was a similar experiment, he says, and as with IAPT, many people got healthcare who hadn’t had it. But for whatever reason, Americans are split when it comes to the prospect of overhauling a broken mental health care system. “We can all stand up whenever there’s a mass shooting or a suicide and say we need services, but we’re soon on to the next news story,” Miller says. “What we’re missing is vision.”

Still, for many, IAPT’s benefits are overshadowed by its poor execution. The most frequent point of contention among therapists seems to be the exclusion of any methods that aren’t considered evidence based. “Before IAPT, I used to have freedom to use different modalities with clients,” says London-based psychotherapist and former NHS employee Martin Pollecoff. “I don’t anymore.” Many therapists, Pollecoff recalls, felt optimistic when IAPT was first introduced. “This was going to be a revolution in which every person who needed therapy would get it,” he says. “But what we wound up with instead was a manualized process in which any therapy that wasn’t CBT was derided.” By nature, Pollecoff says, therapy isn’t a science. And Layard and Clark, he continues, saw therapy not as a relationship between two people, but as a matter of economics, IAPT’s questionnaires and manuals “reducing therapy to a lab test.”

Gillian Proctor, a counseling professor at the University of Leeds, spent nearly 10 years training therapists to work within IAPT. Like Pollecoff, she argues that an overreliance on statistics and clinical trial recovery rates holds clinicians to unrealistic standards. “A lot of people are saying their clinical expertise and responsibilities as they’ve known them are no longer applicable,” she says, adding that IAPT employees are often managed by government officials who have little to no clinical background, and are paid only if they meet the strict recovery-rate standards put in place by NICE. “IAPT operates using a very top-down managerial approach,” she adds, “where people are told what to do, and if they’re not providing good enough outcomes, then there’s a lot of pressure put on them as to why they’re not delivering.” Between off-site management, little room for collaboration between clinicians, and low-intensity therapy that “barely qualifies as CBT,” Proctor says that among IAPT therapists, morale is low and burnout high.

As for client services, Proctor says they aren’t much better. Clients who use call center services “will be asked a lot of questions, and a lot of boxes will be checked before they’re referred to the most appropriate service,” she explains. Most of the low-intensity clinicians Proctor says she encounters are talented and committed, but they “aren’t allowed to do any meaningful work because they’re constrained by the system.” Even worse, many of those she trained reported clients feeling demoralized when they couldn’t get adequate help within their first few IAPT sessions—which exacerbated their feelings of hopelessness and, she suspects, discouraged them from seeking treatment down the road.

By some standards, says Proctor, English mental health care has made significant strides. “For the first time in a long time,” she explains, “a lot of government money is finally being put toward public mental health. And truthfully, mental health seems to be in the public consciousness” much more since IAPT came about. “But what we expected and hoped for,” she adds, “just isn’t coming true.”

In response to criticism, David Clark reported in the April 2015 issue of The British Journal of Psychiatry that IAPT would “support the training and employment of therapists who can deliver [four other] therapies that NICE recommends”—counseling, couples therapy, interpersonal psychotherapy, and brief psychodynamic therapy. But he also offered a rebuttal to the pushback that therapy should prioritize the therapist–client relationship, and to the chagrin of many clinicians, restated that IAPT would stand exclusively behind evidence-based methods. “There is no such thing as a therapeutic alliance therapy,” Clark stated. “Even if therapeutic alliance were the most important factor, one would still need to train therapists in procedures that allow the therapeutic alliance to emerge. Clearly, it makes sense to choose procedures from treatments that are known to work.”

In a 2016 statement, the NHS acknowledged its low recovery rate and promised to investigate specific problems in low retention, particularly among black and ethnic minority communities. “There is more work to do in some areas,” the statement read. “Peer support from commissioning groups who are taking an exemplary approach is helping improve other services.” However, problems persist. In 2017, the NHS again announced its intention to build in more robust follow-up measures for IAPT, although it’s not yet clear what this might entail.

In the meantime, there’s been no slowing down in government investment in IAPT. With a current annual budget of more than 350 million pounds, spending on IAPT programs is expected to double over the next few years. For now, the clinical community is keeping watch, taking stock of what IAPT has accomplished, and making note of what needs to be improved. But therapists like Pollecoff say they’ll be fighting an uphill battle. “Psychotherapy has always been about the human relationship,” he explains. “But IAPT has created industrialized therapy, and like any industrialized process, the sole objective is more productivity.”

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