Improving access to psychological therapies (IAPT) and treatment outcomes: epistemological assumptions and controversies.

Cognitive behaviour therapy (CBT) is recommended as a primary treatment choice in England, for anxiety and depression, by the National Institute for Health and Care Excellence (NICE). It has been argued that CBT has enjoyed political and cultural dominance and this has arguably led to maintained government investment in England for the cognitive and behavioural treatment of mental health problems. The government programme 'Improving Access to Psychological Therapies' (IAPT) aims to improve the availability of CBT. The criticism of the NICE evidence-based guidelines supporting the IAPT programme, has been the dominance of the gold standard randomized controlled trial methodology, with a focus on numerical outcome data, rather than a focus on a recovery narrative. RCT-based research is influenced by a philosophical paradigm called positivism. The IAPT culture is arguably influenced by one research paradigm and such an influence can skew services only towards numerical outcome data as the only truth of 'recovery'. An interpretative paradigm could assist in shaping service-based cultures, alter how services are evaluated and improve the richness of CBT research. This paper explores the theory of knowledge (epistemology) that underpins the evidence-based perspective of CBT and how this influences service delivery. The paper argues that the inclusion of service user narrative (qualitative data) can assist the evaluation of CBT from the user's perspective and can understand the context in which people live and how they access services. A qualitative perspective is discussed as a research strategy, capturing the lived experience of under-represented groups, such as sexual, gender and ethnic minorities. Cognitive behaviour therapy (CBT) has enjoyed political and cultural dominance within mental healthcare, with renewed government investment in England for the'Improving Access to Psychological Therapies' (IAPT) programme. The criticism of the evidence-based guidelines, published by the National Institute for Health and Care Excellence (NICE), which supports the IAPT programme has been the dominance of the gold standard randomized controlled trial methodology. The definition of 'recovery' used by IAPT is based on a positivist position, with a focus on numerical outcome data garnered through psychometric measures. An interpretative perspective of recovery, which would include a subjective individual patient/service user narrative and would include a collaborative qualitative dialogue, is arguably absent from the IAPT programme. The challenge inherent in the IAPT programme is the high demand/high turnover culture, and psychometric measures are quick to administer; however, this culture is driven from one research paradigm. An interpretative paradigm may assist in shaping service-based cultures, alter how services are evaluated, and improve the richness of CBT research.

Cognitive behaviour therapy within assertive outreach teams: barriers to implementation: a qualitative peer audit.

Assertive outreach is an evidence-based intervention, with over 30 well-designed randomized studies demonstrating its effectiveness, predominately in the USA. Assertive outreach teams have recently been implemented in the UK, and it has been recommended that teams should offer cognitive behaviour therapy (CBT) to service users; however, it has been reported that barriers exist in the routine delivery of CBT for psychosis (CBTp). The aim of the peer audit was to gauge current opinion from clinicians whether their experiences of barriers to implementation of CBTp reflected that outlined in the literature. A qualitative peer audit was undertaken at the National Forum for Assertive Outreach Annual Conference in 2006. The team representatives were invited to outline the barriers to the implementation of psychosocial interventions within their local areas. Teams identified organizational, managerial, supervision and local specific barriers to implementation. Specific comments included a lack of organizational investment, the structured nature of CBT, caseload issues, medication issues, application to people with sensory impairments, staff apathy and staff burnout. The analysis was limited by the metholodology employed; however, further recommendations are explored. It was evident from this peer audit that teams are experiencing barriers relating to the implementation of evidence-based therapy interventions and further research is required on the outreach model and the use of CBTp.