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Since the introduction of the Improving Access to Psychological Therapies (IAPT) programme in NHS England, psychological therapy has gained traction as 'evidence-based' and 'effective' in both clinical and economic terms. In the process, psychotherapeutic care has been reconstituted as highly manualised, standardised, and quantifiable. Drawing on anthropological fieldwork with mental health practitioners, this paper examines some common tensions that practitioners experience in their daily work where psychotherapy is sought within the framework of evidence-based medicine (EBM). For therapists working within IAPT, extensive monitoring and practices of accountability have come to undermine psychotherapeutic efforts to care for patients as 'people'. As a result, many practitioners now feel that they are working in a 'factory of therapy' whereby psychological treatment is recast in the service of outcome measures, and by which critique of the IAPT service, as well as caring relations within it, have been precluded. [ABSTRACT FROM AUTHOR]

The City and Hackney Primary Care Psychotherapy Consultation Service is an innovative, public sector service designed to support GPs in meeting the needs of patients with complex psychological/physical health issues throughout the London Boroughs of Hackney and the City. This paper provides an account of how this new model for the National Health Service (NHS) developed in the context of psychotherapy provision within the NHS, within the national and local context in the UK and gives an overview of some the service's key features and how it differs from other services operating in primary and secondary care. A linked paper, in this journal, explores the reality within which the service functions and describes clinical outcomes, health economic data, the modifications to the original model and prospects for the future. [ABSTRACT FROM PUBLISHER]

Background: High numbers of people present with common mental health disorders and co-morbid personality disorder traits in primary care 'Improving Access to Psychological Therapies' (IAPT) services in England and they receive sub-optimal treatments. No previous studies have explored the treatment experiences or needs of this patient population in England. Aims: This qualitative study explored the treatment experiences of patients (n = 22) with common mental health difficulties and co-morbid personality disorder as indicated by a score of 3 or more on the 'Standardised Assessment of Personality – Abbreviated Scale' (SAPAS) in receipt of primary care-based IAPT treatment. Method: A qualitative health research approach was used. Qualitative individual face-to-face semi-structured interviews were conducted. All interviews were audio recorded, data were transcribed verbatim and analysed using a framework analysis approach. Results: Findings revealed a need to adapt away from prescriptive cognitive behavioural therapy (CBT) treatment models towards more flexible, personalised and individualised treatment with this patient group. Time to emotionally offload, build a therapeutic relationship and link past experiences to presenting problems were highlighted as important. Conclusions: For the first time, the needs and treatment experiences of this patient group have been explored. This paper provides a unique patient experience insight that should be considered when exploring new approaches to working with and developing effective interventions via a stepped care approach. [ABSTRACT FROM AUTHOR]

Whilst an earlier paper (Part 1) in this journal describes the historical, political and economic drivers behind the creation of the City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), this paper (Part 2) focuses on exploring the context within which the service functions. The paper provides an overview of its operational model and is organised into 10 sections. The first section outlines the service's clinical practice, whilst the second addresses the value of GP consultations as a core part of the PCPCS's provision. The third section addresses how the service, as departure from a more ‘pure’ psychoanalytic tradition of providing longer-term therapy, has managed its provision of brief treatments. There is a description of how the service manages its team of multi-disciplinary clinicians and their work in a variety of micro-cultures, conveying some of the challenges faced by the service and the team since its inception. Thereafter, the quantitative and qualitative evidence for the service's clinical and cost effectiveness is assessed, including outcome results and findings from a health economic evaluation. To illustrate some of the service's work in practice, some disguised clinical vignettes are presented. The paper also summarises the service's recent clinical innovations, as well as its contribution to the field of research, audit and training. Finally, the way forward for the service is considered in the context of current and emerging trends in psychological provision in primary care. [ABSTRACT FROM PUBLISHER]

Purpose – The IAPT programme has been rolled out across England in the last ten years. Although undoubtedly many people have benefited from having greater access to psychological therapy there are several issues with the practicalities of Improving Access to Psychological Therapies (IAPT) and also with its ideology. The paper aims to discuss these issues. Design/methodology/approach – This is a personal reflection of working within the IAPT system for several years. Significant statements heard or interpretations of what has been said are presented alongside an analysis of the implications. Findings – A number of important concerns are presented. The overarching concept of the “McDonaldization” process is discussed as a way of encapsulating the IAPT experience; with its theoretical reliance on the medical model and the real world impact of tendering for services in the modern NHS. The impact of IAPT on cognitive behavioural psychotherapy is also highlighted. Originality/value – A lot has been written in the press and online about IAPT. Many of the criticisms seem to derive from people outside of the IAPT system, many of whom have their own personal or professional agenda for attacking IAPT and Cognitive Behavioural Therapy (CBT); often the criticisms are uninformed. This paper is a reflection of working within the IAPT system and not just an uninformed critique of CBT. Several concerns are raised that without remedy may seriously hold back the progress that psychological therapy has made in recent years. [ABSTRACT FROM AUTHOR]

Over the past decade, provision of cognitive behaviour therapy has expanded massively in the UK, both within the private sector and through the Improving Access to Psychological Therapies (IAPT) programme. Our aim in this study was to explore and compare the brand names adopted by IAPT and private CBT services. We obtained the names of all the IAPT and private services in England and created a word cloud for each sector. There was no significant difference in the proportion of services that adopted a brand name (72% of IAPT services vs 67% of the private services). In those with a brand name, IAPT services were significantly more likely than private services to contain positive words, and to have a theme of togetherness and collaboration. However, private services were more likely to include a psychological therapy in their name and have a theme of efficacy compared with IAPT. The most common keywords in IAPT services were 'talking' and 'thinking'. IAPT services use a variety of euphemisms such as 'talking' for a psychological therapy. There is no theme for 'doing' in the IAPT or private services, despite behavioural interventions being one of the most common therapeutic components. The brand names in IAPT are overwhelmingly positive and convey the hope of a good outcome. They do not include the experience of difficult emotions, such as sadness and fear during therapy. We found just one private service that evoked the history of CBT named after Vic Meyer. Perhaps we will have some Clark and Layard centres in the years to come! Key learning aims: After reading this paper, the reader should: (1) Recognise the importance of a brand name in shaping service user expectations. (2) Understand the differences between how private CBT and IAPT services present themselves to the public. (3) Recognise the omission of words conveying an active 'doing' theme in IAPT and private CBT service names. [ABSTRACT FROM AUTHOR]

It is widely recognised that a diagnosis of a long-term physical health condition (LTC) is likely to have a significant impact on a person's mental health. This is highlighted in the Five Year Forward View for Mental Health (NHS England, 2016) where significant numbers of patients projected to be seen through the expansion of Improving Access to Psychological Therapies (IAPT) services are to come from within the LTC community. IAPT services offer evidence-based therapeutic interventions for common mental health issues – anxiety disorders and depression. The South East Staffordshire IAPT services have developed an integrated pathway as a Wave 2 site for the delivery of cognitive behavioural therapy (CBT) adaptations for LTC. The main themes outlined in this paper focus on the innovations and service developments of IAPT-LTC including: the importance of engagement between mental health and medical healthcare professionals, identifying the key professionals in medical healthcare to enhance engagement, extended training for clinicians with in-house continued professional development, as an extension to the National IAPT-approved top-up training for LTC, and developments in clinical supervision structures and practice, along with future developments in the field of IAPT-LTC. These themes have direct relevance to CBT practitioners working within the LTC community in IAPT services. The four contrasting case studies demonstrate how the application of CBT can successfully be adapted to condition related beliefs and behaviours, despite the complexity of the medical condition. Findings show how integrated services and engaging with medical healthcare professionals had profound benefits for the patients, IAPT therapists and medical healthcare professionals. Key learning aims: (1) The good practice points in the development of the IAPT-LTC pathway within South East Staffordshire IAPT services. (2) The successful design and implementation of the IAPT-LTC pathway within South East Staffordshire IAPT services. (3) The key considerations of the interaction for patients between their physical and mental health symptoms. (4) The application of CBT adaptations for people with complex LTCs can be effective in improving psychological wellbeing and physical condition management. [ABSTRACT FROM AUTHOR]

Low‐intensity interventions for common mental disorders (CMD) address issues such as clinician shortages and barriers to accessing care. However, there is a lack of research into their comparative effectiveness in routine care. We aimed to compare treatment effects of three such interventions, utilizing four years' worth of routine clinical data. Users completing a course of guided self‐help bibliotherapy (GSH), internet‐delivered cognitive behavioural therapy (iCBT) or psychoeducational group therapy (PGT) from a stepped‐care service within the NHS in England were included. Propensity score models (stratification and weighting) were used to control for allocation bias and determine average treatment effect (ATE) between the interventions. 21,215 users comprised the study sample (GSH = 12,896, iCBT = 6862, PGT = 1457). Adherence‐to‐treatment rates were higher in iCBT. All interventions showed significant improvements in depression (PHQ‐9), anxiety (GAD‐7) and functioning (WSAS) scores, with largest effect sizes for iCBT. Both propensity score models showed a significant ATE in favour of iCBT versus GSH and PGT, and in favour of GSH versus PGT. Discernible differences in effectiveness were seen for iCBT in comparison with GSH and PGT. Given variance in delivery mode and human resources between different low‐intensity interventions, building on these findings would be valuable for future service provision and policy decision making. [ABSTRACT FROM AUTHOR]

Although histories of cognitive behaviour therapy have begun to appear, their use with people with psychosis diagnoses has received relatively little attention. In this article, we elucidate the conditions of possibility for the emergence of cognitive behaviour therapy for psychosis (CBTp) in England between 1982 and 2002. We present an analysis of policy documents, research publications and books, participant observation, and interviews with a group of leading researchers and senior policy actors. Informed by Derksen and Beaulieu's articulation of social technologies, we show how CBTp was developed and stabilised through the work of a variety of overlapping informal, academic, clinical, professional, and policy networks. The profession of clinical psychology played a key role in this development, successfully challenging the traditional 'division of labour' where psychologists focused on 'neurosis' and left 'psychosis' to psychiatry. Following Abbott's systems approach to professions, we identify a number of historical factors that created a jurisdictional vulnerability for psychiatry while strengthening the jurisdictional legitimacy of clinical psychology in providing psychological therapies to service users with psychosis diagnoses. The National Institute for Health and Clinical Excellence played a significant role in adjudicating jurisdictional legitimacy, and its 2002 schizophrenia guidelines, recommending the use of psychological therapies, marked a radical departure from the psychiatric consensus. Our analysis may be of wider interest in its focus on social technologies in a context of jurisdictional contestation. We discuss the implications of our study for the field of mental health and for the relationship between clinical psychology and psychiatry. [ABSTRACT FROM AUTHOR]

Objective: Improving Access to Psychological Therapies (IAPT) services in England have established a long‐term condition (LTC) pathway in recent years, meaning that LTC therapies are now delivered via varied modes and by professionals with varied experiences. To gain insight into how this new pathway is functioning in practice, this study aimed to explore therapists' perceptions of barriers and facilitators to uptake and engagement with therapy in LTCs. Design: A qualitative design was employed using semi‐structured interviews. Methods: Fifteen therapists were recruited from IAPT and physical health care settings. Interviews were first analysed using inductive thematic analysis. A deductive approach was then taken to map themes onto Normalisation Process Theory constructs (coherence, cognitive participation, collective action, reflective monitoring) to guide steps towards improving implementation. Results: Four key themes highlighted patient, therapist, and service‐level factors related to uptake and engagement: Working flexibly with barriers within the National Health Service context; Acceptability of 'embedded' versus 'separate' psychological care; Confidence in working with people with LTCs; and Navigating implementation of online therapies. Therapists recognized the need for tailored LTC therapies, though opinions about online therapies varied. Therapists expressed commitment to flexibly adapting their practice to suit patient needs, but felt their flexibility was limited by system and service constraints. Conclusion: Barriers to uptake and engagement need to be addressed to optimize LTC pathways. Findings demonstrated the importance of offering flexible, tailored therapy to people with LTCs, and equipping staff and services with adequate training and resources to improve functioning of LTC pathways in practice. [ABSTRACT FROM AUTHOR]

Background: Despite growing evidence of the effectiveness of cognitive-behavioural therapy (CBT) for psychosis, typically only about 50% of patients show a positive response to treatment. This paper reports the first comprehensive investigation of factors which predict treatment outcome.Method: In a randomised controlled trial of CBT for medication-resistant psychosis (see Part I) measures were taken at baseline of demographic, clinical and cognitive variables. Changes over time were assessed on the Brief Psychiatric Rating Scale and the relationship between potential predictor variables and outcome was investigated using analysis of variance and covariance.Results: A number of baseline variables were identified as predictors of good outcome in the CBT group. Key predictors were a response indicating cognitive flexibility concerning delusions (P = 0.005) and the number of recent admissions (P = 0.002). Outcome was less predictable in the control group and was not predicted by any cognitive variable.Conclusions: Good outcome is strongly predicted in patients with persistent delusions by a cognitive measure, while this was not the case in controls. Thus we argue that positive outcome in CBT is due in part to specific effects on delusional thinking. [ABSTRACT FROM AUTHOR]

BackgroundTo test whether receiving care from a health visitor (HV) trained in identification and psychological intervention methods prevents depression 6–18 months postnatally in women who are not depressed 6 weeks postnatally.MethodThe study was a prospective cluster trial, randomized by GP practice, with follow-up for 18 months in 101 primary care teams in the Trent area of England. The participants were women scoring <12 on the postal Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks postnatally (1474 intervention and 767 control women). Intervention HVs (n=89, 63 clusters) were trained in identifying depressive symptoms using the EPDS and face-to-face clinical assessment and in providing psychologically orientated sessions based on cognitive behavioral or person-centered principles. The control group comprised HVs (n=49, 37 clusters) providing care as usual (CAU). The primary outcome measure was the proportion of women scoring ⩾12 on the EPDS at 6 months postnatally. Secondary outcomes were mean EPDS score, Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM) score, State–Trait Anxiety Inventory (STAI), 12-item Short Form Health Survey (SF-12) and Parenting Stress Index Short Form (PSI-SF) scores at 6, 12 and 18 months.ResultsAfter adjusting for individual-level covariates, living alone, previous postnatal depression (PND), the presence of one or more adverse life events and the 6-week EPDS score, the odds ratio (OR) for EPDS ⩾12 at 6 months was 0.71 [95% confidence interval (CI) 0.53–0.97, p=0.031] for the intervention group (IG) women compared with the control (CAU) group women. Two subgroups were formed by baseline severity: a ‘subthreshold’ subgroup with a 6-week EPDS score of 6–11 (n=999) and a ‘lowest severity’ subgroup with a 6-week EPDS score of 0–5 (n=1242). There was no difference in psychological effectiveness by subgroup (interaction term: z=−0.28, p=0.782).ConclusionsThis study provides new evidence of a universal, enduring preventive effect for depression in women who screen negative for depression postnatally. [ABSTRACT FROM PUBLISHER]