Dr David Murphy on IAPT workforce census
I’ve recently been blogging about Improving Access to Psychological Therapies (IAPT) as part of a research study and in this particular blog I’m giving a quick overview of the situation for employed therapists. I thought it might be of interest to those both in or out of IAPT circles, and to look into what the future might hold, especially for those seeking work. Being involved in training therapists I’m interested in the possibilities for employment and future prospects for trainees once qualified.
Several years ago, when the IAPT initiative was first announced, there was understandable excitement about the prospect of enhanced psychological therapy services in primary care. Trained counsellors and psychotherapists working in primary care could have the opportunity to gain reasonably well paid work whilst remaining faithful to the model in which they initially trained. However, then came news that IAPT would be tied to NICE Guidelines and that CBT was going to be the approach; into which millions of pounds would be invested. Of course CBT has received significant support from randomised control trial (RCT) evidence. But does RCT evidence translate to real world settings or can we questions whether CBT really is any more effective than other bona fide therapies when applied in routine practice? Probably not; yet the questions that were raised regarding the methodological inappropriateness of RCTs for psychological therapy research were ignored and the project rolled out all the same. The sad thing about this is that, despite the initial promise of increased access, many people actually lost their jobs and access to therapy was restricted to predominantly to CBT. This was the result not because therapists were doing their job badly, or that what they were doing was ineffective, rather they lost their jobs because their particular therapeutic model was not supported by NICE. However, here we are five years on and it’s interesting to look at the situation with the knowledge from recent history still in view.
The IAPT website recently published its workforce census report detailing the state of play as of August 2012. This link will take you to the full document (http://tiny.cc/egbevw). There’s some interesting figures to digest although there’s little by way of surprise. Predictably high intensity CBT workers make up the largest proportion of the 5860 workers employed in IAPT services across England that returned the census. Of this number 3870 are either high intensity therapists or working in psychological wellbeing practitioner (PWP) posts. This works out, when broken down further, to 40% of the entire workforce being CBT high intensity workers whilst 33% PWPs.
One noteworthy figure is a shift in the balance for the ratio of PWPs to high intensity workers. Initially, guidance for services setting up back in the early days of IAPT suggested a 60:40 split receptively; this now appears to be a 50:50 PWP:high intensity CBT ratio. What can we take from this? Perhaps the need for more high intensity therapists has increased in response to the steady increase in the severity of distress that is experienced by people being referred into IAPT. We might even expect this ratio to shift even further towards more high intensity workers. As IAPT continues to expand the range of people seen at the primary care level to include those with long term conditions and medically unexplained symptoms the need for high intensity workers is likely to grow. High intensity therapists are more highly trained that PWPs and posses more specialist skills. Other possible reasons for needing more high intensity workers is to cope the lengthy waiting lists that are often characteristic of IAPT services. Once a client is referred into step 3 PWPs become redundant. With more people being stepped up rather tan stepped down high intensity workers are ultimately more in demand.
But what about those therapists that stayed the course and didn’t retrain in CBT? Do they still have jobs and what are the prospects for those training in non CBT approaches? As many of you will be now aware four further therapies have approved by NICE for use in IAPT for depression. These are Counselling for Depression (CfD) based on Person-Centred Therapy, Dynamic interpersonal Therapy (DiT) based on brief psychodynamic therapy, Behavioural Couples Therapy for Depression (BCTfD) and Interpersonal Therapy (IPT). Well, the figures aren’t great but there is some hope. Of the total workforce in IAPT it was reported that 333 (5.7%) workers were trained in and offering these therapies. In addition to this a further 1110 (19%) therapists are working in services but not yet trained in one of the four other ‘approved’ therapies but are probably offering a version of these therapies. This means that, if all of the remaining non-CBT therapists were trained in one of the four approved therapies, that approximately 25% of IAPT staff would be offering approved alternatives to CBT. That’s more than I’d imagined had survived the cull when IAPT intially began to roll out. It suggests that counsellors and psychotherapists of all orientations have managed to find ways to protect positions and provide choice for clients. Therapists that have managed to do this really have beaten the odds and thank goodness for them! This is something to be really positive about and we need to recognise these workers for their commitment to staying the course in what has been a really difficult period.
So with this good news in mind what else can we expect to see in the future of IAPT? The report also suggested that CBT will continue to receive the greatest investment for training and new posts. However, the report also offers encouragement for commissioners to find more effective ways of training non CBT therapists in one of the four approved modalities. I Tweeted some time ago something like ‘has the CBT bubble finally burst?’ As I encounter more and more IAPT workers, go to more conferences on IAPT and speak to commissioners and managers alike, I get the feeling that IAPT is finally starting to broaden in its scope for increasing access to a range of therapies. There’s still a long way to go before the IAPT project really delivers on its potential. It’s still too tightly tied in to NICE Guidance and I’m sure there’s probably still too many people involved that have too much face to save by really increasing the access to a range of therapies. Those involved at the start got it badly wrong by investing so heavily in CBT. For sure there was a need for more CBT therapists. But there was also a plethora of richly diverse, creative and passionate, not to forgetting effective(!), therapy available. Standardising IAPT through NICE guidance was and remains a mistake.
I don’t particularly like the feeling I get when I have a thought about the possibility of IAPT being where it is because a bunch of the people involved saw IAPT as a crusade for CBT; an opportunity to build a CBT empire and in their manoeuvring crushing all else that stood in the way. From time to time I still do get this feeling, however, as time puts distance between the advent of IAPT and the initial CBT onslaught it feels as though, much like our long overdue spring this year, we’re beginning to see the shoots of something new. One final thought, anyone involved in the CYP IAPT, please learn from the grave errors that have been made in the early stages of the Improving Access to Psychological Therapies for adults of ‘working age’! (Yes, that was the original name of the programme!)
All views expressed in this article and are those of the author, and do not necessarily represent the views of Psychotherapy Excellence Ltd and it's employees.
This blog is reblogged with permission from Dr. David Murphy. For more information about David and his work and blogs please visit personcentredpsych.wordpress.com