The Psychotherapy & Counselling Union’s submission to the NICE ‘exceptional’ second consultation on its depression in adults draft guideline
At the level of policy to service delivery, IAPTs own end of treatment outcome data reports an outcome probability to increasing well-being that is equal to chance i.e. around 50%/50% (treatment/no-treatment; NHS England, 2018). IAPT treated 1 million people (2009-2012) with a recovery rate of 45% (Department of Health, 2012). Of more serious concern is that from its own data, IAPT may be reducing levels of well-being. Gyani, Shafran, Layard, & Clark, 2013) reported that 6.6% of patients showed reliable deterioration. Translating this to experiences, 66,000 people experienced IAPT as iatrogenic. IAPT is due to scale-up to treat 1.5 million people annually (Clarke, 2016), which could translate into 99,000 people feeling harmed by attending public sector therapy (Cox, 2018). For socio-economically diverse or marginalised populations, public sector therapy may be the only support available. Therefore, it needs to be fit for purpose.
At one-year follow up the outcome data reports a recovery rate of 40% (Gyani et al., 2013) of the 50% i.e. at best 20% of those who began treatment. A fine grained analysis of Pybis, Saxon, Hill, & Barkham’s (2017) analysis of IAPT’s data suggests that only 7% of those referred to IAPT show improvement. Additionally, alternative approaches to IAPT report outcomes for counselling and CBT in the treatment of depression that are comparable, and that efforts should focus on factors other than therapy type, which may influence outcomes (Pybis et al., 2017). Therefore, and by its own assessment, IAPT is not delivering the claimed social or economic programme to the general population (Timimi, 2018). The Centre for Social Justice’s (2012, p. 2) review of the effectiveness of IAPT services found only 15% of people referred to its project were achieving ‘recovery’ by the time they left. From this finer analysis of IAPT’s data, serious philosophical, political and ethical questions emerge regarding the continued support of IAPT.
The Psychotherapy and Counselling Union’s submission suggests that diverse and marginalised patient populations are particularly vulnerable to their health being affected in the negative direction. Since alternatives to treat adult depression that are comparable or greater than IAPT are effective (Pybis et al, 2017), there is reason to question whether IAPT in its current form is suited to meet the needs of adults experiencing depression. Members of the Psychotherapy and Counselling Union (PCU) who are both providers and receivers of NHS well-being care, report that such issues are particularly pertinent for their clients from diverse and marginalised backgrounds. Although beyond the remit of the consultation, we ask that consideration be given to a key concern strongly registered by our members; the extension of IAPT into Jobcentres, also known as psycho-compulsion (Friedli & Steam, 2015).
The Psychotherapy and Counselling Union appreciates that many submissions will provide concerning Evidence-based practice, critiques of the quantitative research data supporting IAPT. This is because marginalised groups are particularly impacted by IAPT’s narrow data perspective and its narrow focus omits consideration of alternative ways to work with adult depression, to meet the needs of those connected with IAPT, or the impact of political, economic and social factors. The PCU represents members who work in a range of settings. Similar to IAPT staff, our members report increasing dissatisfaction with their roles, measured by increasing works days lost to sickness, low staff morale and the low retention rate of staff relative to similar services. As these issues are well-documented in NHS and IAPT reports we will not reiterate them here (Rao et al., 2016; Westwood, Morison, Allt, & Holmes, 2017).
The PCU’s submission will focus on equality, diversity and marginalisation. For instance, the LGBT+ communities experience poorer outcomes of NHS therapy (King et al, 2008: Semlyen, King, Varney, & Hagger-Johnson, 2016). Also, ethnic minorities consistently report receiving poorer access to, and levels of, therapy (Ade-Serrano & Nkansa-Dwamena, 2016). Due to space restrictions, the PCU’s will focus on one diverse group, which reflects the issues experienced by all diverse groups. The Union’s rationale is that we are particularly concerned about diverse groups who remain hidden within the perspective of the draft consultation.
The 2010 Equalities Act (Legislation.gov.uk, 2010) is required to also address faith. Generally, IAPT does not. The lack of cultural awareness in specific relation to adult depression means that ethnic identifications are often conflated with religious identifications. This is particularly serious given the current social climate of islamophobia, where many patients from Muslim backgrounds are subject to increasing levels of antagonisation and poor practice in regard to IAPT provision. Muslims represent approximately 5% of the population. Approaching a faith community primarily with a secular model to address their psychological well-being may be at worst damaging, and at best lead to low levels of engagement. The 2016 IAPT report shows that recovery rates are highest amongst Jain, Christian and Jewish patients, and lowest amongst Pagan and Muslim patients (NHS England, 2018). There is a strong correlation between relative deprivation and mental ill health with nearly half (46%) of the Muslim population residing in the bottom 10% of the most deprived local Authority Districts in England, and are therefore more likely to be impacted by poor mental health (Bhui et al., 2005). IAPT has identified its poorest outcomes are in socio-economically deprived areas (House of Commons, 2018).
Within this frame, diverse and marginalised communities are expected to be able to move to recovery within 6 sessions. This is also assuming that the assessment has developed a shared understanding between patient and practitioner of the presenting problem and the underlying cause - the levels of somatisation in communities where English is not the first language indicates the degree to which this is not possible. This has not been addressed through widespread use of PHQ 15 testing, or any other strategy. Black and minority ethnic (BAME) communities also experience complex life events that lead to complex mental ill health presentations. These can include asylum seeking, previous experience of war, Domestic Violence, Female Genital Mutilation and intergenerational trauma. To expect that such complex experiences can be unpacked and addressed in short standardised interventions risks introducing iatrogenic practices into a process intended to enhance well-being.
The Cultural Formulation Interview (CFI: APA, 2013), assesses both the cultural or ethnic groups that the patient belongs to, and the ways in which those groups understand a problem such as depression, and how this affects a person’s experience of DEPRESSION. Many diagnoses don’t take into account cultural formulation at all. The significance of this in relation to assessment compounds the invisibility of BAME experience of mental illness and related outcomes. This needs to be highlighted within the guidelines and pathways identified specifically with regard to mental health inequalities.
With regard to hyper-diverse communities, IAPTS provision is not available in many of the languages patients use to make sense of their social world. Translation facilities within the NHS are also often inadequate with interpreters ill equipped to work with mental health or counselling. In addition, translations of IAPT assessments GAD7 and PHQ9 are not available in the variety of languages. The PCU suggests that, “What is being suggested here is that racism and other environmental stress factors can cause psychic collapse and ... Therapists who will be challenged to work with this particular form of ‘mental health’ presentation should take into consideration ... Eurocentric notion[s, ideologically-driven motivations to control resources, patriarchal- and colonial-based power relations and cisgendered views] of disease and mental illness” (Allyene, 2009, p. 166).
When revising the guidelines, the PCU recommends: within the UK’s pluralistic society, consideration be given to how the above points impact notions and treatment of adult depression; that IAPT investigates the factors which lead to lower recovery rates in socio-economically deprived areas; that a greater consideration of diversity be given to all minority communities; that the strategic revision of IAPT monitors the lack of impact in the Muslim community and addresses the underlying mental health inequalities experienced; and the Cultural Formulation Interview (CFI) be applied where appropriate. Examples of good practice be consulted such as the Lateef Project’s community led Islamic counselling service (Birmingham) and Adapted behavioural activation (Leeds: Mir et al., 2015).
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