Broadening Support

The NHS Talking Therapies Service is filtered through the Improving Access to Psychological Therapies (IAPT) programme, an NHS initiative set up in 2008 aiming to expand the provision of psychological and therapeutic support to hundreds of thousands more people per year. That figure is likely to grow further, signalled by an announcement from the National Institute for Health and Care Excellence (NICE) in November that more people will now be offered different treatments for anxiety and depression before anti-depressants and other forms of medication: those who have fewer than five symptoms and are therefore classed as experiencing ‘less severe depression’ will be offered therapy, mindfulness, exercise, or meditation first.

IAPT’s Talking Therapies Service uses a medical model that treats mental illness like physical illness. There’s an acknowledgement that socio-economic factors like debt may make someone’s mental health worse, but treatment is focused on self-management. Cognitive Behavioural Therapy (CBT), for example, is the most popular treatment used by Talking Therapies, carried out either in person, on the phone, or online, and sees users given activities and exercises to reframe their thinking or to practice mindfulness.

Under this model, though, there’s limited room to understand a person’s background and the role it might play in their health and treatment. But mental health is heavily influenced by social factors. In the UK, children from the poorest twenty percent of households are four times as likely to have serious mental health difficulties by the age of eleven compared with those from the wealthiest twenty percent, and BAME people are more likely to suffer from poor mental health than white people.

Accordingly, recovery and completion rates for IAPT are lower in poorer and more deprived areas: thirty-nine percent of those living in more deprived areas, on average, are recorded as having recovered, compared with fifty-eight percent of those in the least deprived areas.

The Function Focus

These unequal outcomes are compounded by the fact that the short-term support the service offers is highly categorical. The type of treatment given is decided through tick-box questionnaires based on behaviours like sleep patterns and ability to work, get on public transport, or focus on a task. Support depends on a person’s capacity to function and sees them placed either into a low or high-intensity course, with many of the former receiving support from therapists still in training: in July 2021, 55,703 appointments out of the total 434,000 which went ahead involved one or more practitioners who did not have an accredited IAPT qualification.

Treatment then looks into correcting behaviour around functioning rather than dealing with an individual’s mental health issues at a more fundamental level. Someone may be encouraged to do exercises to socialise more, for example, rather than discussing what caused their anxiety. Recovery and progress are also mapped out through continued questionnaires on daily function.

This narrow understanding of recovery is part of the emphasis placed on the service being ‘evidence-based’. Yet many therapists—as many as forty-one percent, according to some surveys—have said they were asked to skew data to make the service appear more successful than it is. Therapists and IAPT workers have reported suffering from mental health problems themselves as a result of their work, too, following pressure to churn out quick recovery rates.

Pressure to move people quickly through the service and to focus solely on their ability to function is ultimately a reflection of IAPT’s neoliberal philosophy. The service was established following economist Richard Layard’s 2006 Depression Report, which emphasised the impact depression and poor mental health have on the economy and employment. As a result, it argued, offering psychotherapeutic treatment offered on the NHS would eventually pay itself off on the basis that it would increase productivity and reduce the numbers of those claiming employment and/or disability benefits.

This is reflected in the current IAPT’s manual’s section called ‘The Impact on Society’, which lists the economic consequences of widespread poor mental health: like, for example, the fact that anxiety and depression are estimated to reduce England’s national income by over four percent due to ‘increased unemployment, absenteeism… and reduced productivity’.

Relatedly, employment advisers have recently been piloted as part of the IAPT’s service—an addition that some worry may risk pathologising unemployment and obscuring its political basis. The government’s Way to Work scheme has recently announced that unemployed people will now have just four weeks (rather than three months) to find work in their preferred sector before facing possible sanctions, a tactic which seems guaranteed to force people into low-paid and insecure jobs in the face of a cost-of-living crisis—which, in turn, will likely compound poor mental health.

Social Factors

Others are refused help, or not offered sufficient help for their diagnosis. IAPT offers support for people with bipolar disorder, for example, but focuses on reducing depression rather than mania. In the few analyses that included people with bipolar, no reduction for depression was reported; sometimes it was even heightened.

This is in part a result of the aforementioned rigid tick-box categorisation system. Others are passed elsewhere, such as those who openly disclose intent or plans to commit suicide. Individuals who have previously attempted suicide, on the other hand, will be offered support, highlighting a glaring flaw: no support is offered by this service before an attempt.

When it comes to treating those with active addiction, meanwhile, the IAPT’s manual is vague. If their drinking or drug use is considered ‘problematic’, individuals must be referred to a service until ‘appropriate stability’ is achieved. Users should be assessed based on their ‘traumas’ rather than ‘traumatic events’, and only those with ‘1-3 traumas’ can receive treatment, implying that anyone with more than three cannot.

But what distinguishes a trauma from a traumatic event? And how are they counted? Given NICE’s new recommendations regarding medication, it’s possible that people may find themselves passed between their GP and the assessment process, and then packed off to another service (with long waiting times between) without any support—including those with plans to attempt suicide.

It’s been acknowledged that the pandemic has heightened the mental health crisis in the face of job precarity, debt, and other changes to material conditions. These social conditions are political conditions: ten years of Tory austerity have shown a twenty percent rise in zero hour contracts, 1.1 million in poverty, Universal Credit cut, wages failing to keep up with cost of living, and private rent rising. Meanwhile, mental health services have had their funding cut, with twenty-five percent less mental health beds on wards since 2010.

The resulting limits of IAPT and Talking Therapies lets too many slip through the net. In the face of these shortcomings, the genuine plea at the heart of the eponymous Beatles song—’Help me if you can’—tells us all we need to know. Half measures are not enough: if the government wants to really address the need for better mental health support, it must start by taking responsibility for the past decade of destruction that has already caused so much suffering.