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Catherine Altson University of Roehampton What are the perceived implications, if any, for non-IAPT therapists working in an IAPT service? RCTE

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2008-2011: CBT & Evidence Based Practice Initial focus on Cognitive Behavioural Therapy (CBT) and training of psychological therapists specifically in this approach. Historically, IAPT has been governed by guidelines set by the National Institute for Health and Clinical Excellence (NICE). NICE provides guidance, advice, quality standards and information services for health, public health and social care (www.nice.org.uk).www.nice.org.uk Includes national guidance on which psychological therapies should be recommended by doctors and provided by the NHS in primary care. uses the approach of Evidence Based Practice (EBP) to determine which therapies are endorsed.

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2011 onwards: CBT was still only recommended intervention for depression and anxiety disorders, but 4 new interventions for depression: CfD (Counselling for Depression) IPT (Interpersonal Therapy) DIT (Dynamic Interpersonal Therapy) CofD (Couple Therapy for Depression) These recommendations based on evidence gathered from Randomised Controlled Trials (RCTs)

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IAPT client sessions NHS Referral - 6, 8 or 12 sessions determined by a triage telephone assessment Medical Setting - Client seen in GP surgery Compulsory Forms PHQ-9: Patient Health Questionnaire scores each of the 9 DSM-IV criteria for depression. GAD-7 : For the screening and severity measuring of Generalized Anxiety Disorder. CORE-10: 10 questions described as a generic measure of psychological health and well-being. IAPTus - Centralised computer system for collection of patient data.

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Research Design Research question: 'What are the perceived implications, if any, for non-IAPT therapists working in an IAPT service? Participants: 5 interviewed. Different approaches identifying as: Existential (2), Post-Existential (1), Person- Centred (1) and Integrative (1). Data Analysis: Foucaldian Discourse Analysis (Willig, 2008).

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Foucauldian Discourse Analysis Foucaults work has been invaluable in drawing attention to the way language is organised around different systems of meaning which offer positions of power to certain categories of people while disempowering others. These systems of meaning are discourses (Parker et al, 1995: 10). Language does not passively reflect reality, but rather it is language that imposes the reality on us that we end up perceiving (Foucault, 1972). Language contains and reinforces ideology: objects and institutions are given power by the way in which they are spoken of.

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Wider Discourses Identified Professional participants talked about the various IAPT services that they worked for as if they were large corporate businesses or professional companies ...and so I took the opportunity... I wanted experience in IAPT because I thought it would look good on my CV... (Anne) ...maybe I am doing it in order to get the experience to make myself more um... sellable... you know that I can perhaps get a job in the NHS one day because there are positions out there but I need a reference... (Claire)

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Wider Discourses Identified Institutional IAPT constructed as being governed by institutional rules and processes (eg: compulsory weekly questionnaires and assessments). Different to professional discourse; more about a top-down managerial approach to business? ...I have to report to my supervisor what the clients CORE score is... she wants to know from week to week whether its gone up or down... (Claire) ...I also got a sense it's used to measure my performance... they're measuring me and [voice goes up to a higher pitch] this can feel a bit... intrusive... (Claire)

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Wider Discourses Identified Scientific Approach participants seemed to draw on an empirical epistemology, where evidence is spoken of as something that can be measured and recorded through systematic observation and subjected to certain principles of reasoning. ...oh IAPT it's just a system it's a black box... (Anne) ...I already had a prejudgement about it [IAPT] so I wanted to have my own experience... I guess in a way I'm doing research on myself on what working with IAPT means for me and whether it gets in the way or whether it helps... (Ben)

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Crossing Discourses Non-IAPT vs IAPT discourses seemed to emerge in those instances where participants discussed their training background and/or private practice/own practice, which then contradicts with way in which they felt they had to work within an IAPT setting: ...the way I like to be in my own practice... well its more about the client really and the relationship he has with me... if he wants to work deeply if he can manage the emotion if he can establish a trust with me... it can be a very intense relationship and very rewarding... (Anne) ...[IAPT] is like a conveyor belt... ticking boxes with the clients... data and graphs are generated on the computer... in supervision we tick more boxes... we're dealing with a system rather than people... (Anne)

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Crossing Discourses Psychological vs Medical Power language was used appeared to construct a development towards psychological wellbeing in clients, while attempting to draw on concepts such as diagnosis and treatment that might belong to the medical system. Seemed to contrast the way in which participants positioned themselves outside of this system. ...the computer plots a graph week by week and you've got a blue line and a red line and the red line is [ ] indicating if there is any risk (.) its bad if they dip into the at risk area yeah (.) and the blue line measures psychological wellbeing and health... (Emma) ...they can detect from the data whether or not the client is getting better or worse... (Emma)

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Discussion Subject positions open up or close down opportunity for action. Drawing on dominant discourses (IAPT discourses) constructs IAPT as a powerful service provider, but positions participants outside of it: - could serve to legitimise feelings of powerlessness? - no room left to think about counselling in terms of human relationships? (clients could only be spoken about in detached way). Conversely, when participants drew on a non-IAPT discourse when speaking about training or private practice, an IAPT discourse was subverted. In terms of subjectivity, it could allow another self to step in & power is renegotiated. In this way power seems to be constantly circulated and negotiated and renegotiated in an endless cycle through language.

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Discussion NICE has explicitly adopted a biomedical model in its process to produce clinical guidelines for issues of mental health (Mollon, 2009; Guy et al 2012). One of the initial aims of the IAPT programme was to greatly increase the availability of NICE recommended psychological treatment for depression and anxiety within the NHS (Clark, 2011). Dissonance for non-IAPT therapists: what happens when we work within a model to which we have no allegiance? IAPT (and the psychological therapies it represents) seems to fit within NHS commitment to health and well-being, but as soon as it is placed within the medical setting of the NHS, it has to be medicalised and becomes something other than what was originally intended.

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Conclusion Through language IAPT is given power and the therapists are positioned as powerless to resist; but therapists do have a choice whether to take it up or not. My research question was already creating a subject position? Is it possible to criticise a discourse from within that discourse? Possible future study with IAPT-accredited practitioners?

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References Altson, C., Loewnethal, D., Gaitanidis, A. and Thomas, R. (2014). What are the perceived implications, if any, for non-IAPT therapists working in an IAPT service? British Journal of Guidance and Counselling, published online 02/10/2014, [http://www.tandfonline.com/doi/full/10.1080/03069885.2014.962485].http://www.tandfonline.com/doi/full/10.1080/03069885.2014.962485 Clark, D.M. (2011). Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders; The IAPT experience. International Review of Psychiatry, August (23), 318-327. Foucault, M. (1972). The Archaeology of Knowledge (trans. A.M. Sheridan Smith). London: Routledge. Guy, A., Loewenthal, D., Thomas, R., Stephenson, S. (2012). Scrutinising NICE: The impact of the National Institute for Health and Clinical Excellence Guidelines on the provision of counselling and psychotherapy in primary care in the UK. Psychodynamic Practice, 18 (1), 25-50. Mollon, P. (2009). The NICE guidelines are misleading, unscientific and potentially impede good psychological care and help. Psychodynamic Practice, 15 (1), 9-24. Parker, I., Georgaca, E., Harper, D., McLaughlin, T. and Stowell-Smith, M. (1995) Deconstructing Psychopathology. London: Sage. Willig, C. (2008) Introducing Qualitative Research in Psychology. Berkshire: Open University Press.