A Pragmatic Guide to Low Intensity Psychological Therapy: Care in High Volume

By Elizabeth Ruth and James Spiers

With the rapidly growing demand for mental health care there is a need for efficient and effective psychological treatment options. Low Intensity Psychological Therapy has become well established in the England Improving Access to Psychological Therapies (IAPT) programme as a beneficial and versatile treatment option for mild-moderate symptoms of depression and anxiety. A Pragmatic Guide to Low Intensity Psychological Therapy: Care in High Volume, provides a guide to Low Intensity Psychological Therapy from the perspective of the Low Intensity Practitioner. This book describes the Low Intensity role as part of a multi-disciplinary approach to psychological care. The authors use a series of case vignettes, personal experience and current literature to help navigate the context of the role and its potential for ethical and safe expansion.

• Offers a practitioner perspective on the efficacy research of Low Intensity psychological interventions in adult populations, with a focus on working with diversity
• Aims to support Low Intensity Practitioners in developing competency within the role, with a focus on reflective practice, supervision, and personal wellbeing
• Includes case vignettes and examples to explore the real world implementation of Low Intensity interventions in group and individual settings including the management of long term physical health conditions
• Explores the benefits and pitfalls of the current role of the Low Intensity psychological practitioner within the IAPT programme
• Discusses the expansion of the Low Intensity psychological practice to international regions

• Language: English
• Publisher: Academic Press
• Release date: May 17, 2023
• ISBN: 9780323904513

Elizabeth Ruth

Elizabeth Ruth is an Assistant Professor and Psychological Wellbeing Practitioner Course Director at the University of Bradford. Elizabeth worked as a Low Intensity practitioner and supervisor in various roles within the Improving Access to Psychological Therapies programme for eleven years and developed an interest in adapting Low Intensity CBT for patients with long term physical health conditions. Elizabeth writes about the experience of work as a Low Intensity psychological practitioner, and has provided training, consultancy and supervision for NHS and third sector organisations. As a volunteer, Elizabeth has supported the formation of an independent IAPT Workers peer-support service and held various roles within the British Association of Behavioural and Cognitive Psychotherapies, including election to the Board of Trustees in 2022.

Book preview

Introduction

Elizabeth Rutha, a The University of Bradford, Bradford, United Kingdom

James Spiers

We offer a warm welcome and a thank you for picking up our book. Whether you are delivering, managing, or using psychological services, we hope to offer you a perspective on low-intensity psychological therapy that is both accessible and interesting. As you are reading, we encourage you to think about this book as a dialogue written from different perspectives in the hope that this will offer a broader picture of low-intensity practice. Our intention here is not to write a low-intensity therapy training manual or how-to guide. Instead, we draw on our personal experiences of working in the Improving Access to Psychological Therapies (IAPT) programme, as well as utilising a series of fictional patient case vignettes and in-depth case discussions that are based on the common themes and characteristics across our clinical experience. The aim of doing this is to provide an opportunity for deeper learning whilst protecting patient confidentiality. Combining our reflections from realistic clinical practice, teaching and supervising, alongside references to existing literature, we hope to offer you an insider’s perspective.

One of the purposes of this book is to highlight that low-intensity psychological interventions are not a rival or replacement for other therapeutic modalities. This is sometimes confusing because we borrow a lot of language from Cognitive Behavioural Therapy (CBT). Low-intensity psychological practice is a distinct way of working that requires different competencies. To practice low-intensity interventions, you currently have to complete an accredited 1-year training programme or an accredited apprenticeship. Once a person is qualified, the experiences of delivering psychological therapy one to one, in groups, and supporting computerised CBT are varied. Most low-intensity practitioners go on to qualify as low-intensity supervisors, which adds another dimension to the role. The people who are typically attracted to the role tend to be deeply compassionate, intelligent, self-aware, and effective. Working with and alongside such people has driven and informed this book.

At the time of writing in 2023, the Improving Access to Psychological Therapies (IAPT) programme has recently changed its name to NHS Talking Therapies. Our personal experience outlined in this book pre-dates this change, and we will be referring to the programme as IAPT throughout. We welcome the progression of professional independent structures set up to support IAPT staff and to develop low-intensity interventions beyond the IAPT system. Professional registration became available in 2021, which is a step towards this.

Throughout our various chapters, we draw on different aspects of the existing arguments around the IAPT programme; our case vignettes are also heavily situated within a socioeconomic context. Mainly, this is due to the majority of both our careers in the IAPT programme being embedded in areas that were historically linked with deprivation. However, health inequalities are a global problem, and this is no exception in the United Kingdom. There is a lot of evidence, more rapidly emerging due to the impact of the Covid-19 pandemic, that both physical and mental health is disproportionately impacted based on intersections of identity and socioeconomic factors. In recent years, the health, social care, and welfare reforms stemming from government austerity measures in the United Kingdom have led to reduced healthcare budgets, reconfiguration and shrinkages in secondary care mental health services, and increased poverty in areas already impacted as a result of low social mobility.

The founders of the IAPT programme claim that it was never intentionally set up to replace existing healthcare services, but was meant to expand access to psychological therapy to the milder end of the spectrum of poor mental wellbeing within England (Clark et al., 2009). However, its implementation in 2008 has been paralleled by cuts in secondary care mental health services. The ‘Mental Health Under Pressure’ report (Gilburt, 2015) found that staffing levels in around half of the community mental health teams in the United Kingdom meant that a full multidisciplinary team was not offered. It also found evidence of inadequate provision of crisis services, reduced inpatient bed capacity, and a reduction in social care services by around a quarter between 2009 and 2015. Worryingly, suicide rates in the United Kingdom have also risen throughout that period (Stuckler et al., 2017) and sadly are still rising.

This is not to implicate the inception of IAPT as a causal factor here, but to contextualise how IAPT is positioned as a programme against the continual changes in the social and political landscape in which it resides. The IAPT remit is aimed at mild to moderate low-risk mental health populations. Secondary care services are aimed at higher risk, severe, and enduring difficulties. In a climate of increased poverty, disproportionate health outcomes, and reductions in secondary and specialist health and social care provision, people can often move up and down that continuum depending on timing and context. Many people are impacted by the tightening of service criteria and thresholds on both sides. Inevitably, there are many who fall into the gaps between services. Essentially, we have a mental health and social care system in the United Kingdom that is free at the point of access, and whilst there is work under way to attempt to address some of those gaps, currently NHS mental health services are not entirely open (or at the very least equally accessible) to all.

Ultimately, the ongoing debates concerning the efficacy of the IAPT programme can land with scepticism as well as damage at the low-intensity coal face where the real work is happening in pressured and sometimes hazardous conditions. However, our intention here is not to try and bottom out the debate as to whether the IAPT programme works or doesn’t work. Naturally, we hold our own individual opinions and to a degree, the way we individually lean into the broader arguments in the public domain differs. What we can offer are our lived experiences of the utility and clinical realities of the role that underlies those arguments, meaning how we were personally affected by them, how they impacted the work we did with our patients, and how we see the gains and harms from them. Whilst we cannot speak on behalf of all low-intensity practitioners, our offer here is to throw our 10 cents into the mainstream of psychological literature, from the coal face.

As with all humans, our history and experiences shape our personal worldview and contribute to biases in our thinking. Our personal experiences also influence our values and sharpen the focus of our different lenses in some areas whilst skewing it in others. This is also true of seasoned academics, service managers, and clinical leaders within the health service. Equally, researchers presenting their findings from randomised controlled trials as well as the accrediting bodies who petition for patient choice, ethics, and safety all have their blind spots. They all hold elements of their own personal truths that are inseparably entwined within their personal, professional, social, political, and economic experience. Whether we like it or not, human psychology is a messy and muddy business.

Throughout the chapters in this book, you will see explicit references being made to different psychotherapeutic approaches when discussing low-intensity practice. This is intentional and the hope here is to try to demystify the often idealised world of high-intensity therapy for the low-intensity practitioner. We also hope to demonstrate to those working in high-intensity psychotherapy or counselling that the low-intensity practitioner role is not easy and is not simply about handing out leaflets and ignoring the sources of problems, as it can sometimes be portrayed by people who have never worked in the role; partly because it pushes a little at the politics that often dominate the low-intensity arm of the IAPT programme.

What we mean here is that our experience of working in the low-intensity role is that it is mostly packaged using language and terminology relating to CBT, which is most likely to deter practitioners who might be tempted to engage in clinical drift away from low-intensity practice into unqualified pseudocounselling and psychotherapy. Our take here, however, mostly stems from our reflections on the problems that we have personally encountered when working in the role, teaching, and supervising trainees. Our take is that low intensity practitioners require a good understanding of clinical drift that is specific to the low intensity approach, as well as an understanding of the interpersonal processes that occur in clinical sessions. This understanding would support practitioners to recognise how interpersonal processes might contribute to clinical drift and provide a rational for why interpersonal elements in the work need to be actively managed. This should enable faster recognition and effective response to clinical drift when it occurs. The current poverty of education in interpersonal processes for low intensity therapists leaves them blind to the impact and risks of interpersonal dynamics and how this may affect the outcomes of their clinical work.

It is also our experience that there is a distinct policing in the current low-intensity literature and training in terms of any explicit reference to the interpersonal processes that are common in psychotherapy more generally, and encouragement for inward reflection during the low-intensity training year is typically superficial, limited only to the low-intensity manuals and tools. However, simply stating that your delivery model is low intensity does not eliminate millennia of knowledge accumulated in the broader profession of counselling and psychotherapy. Just because you do not use it, don’t mention it, or prefer to call it by another name does not mean it ceases to exist or that it is not of value. The interpersonal processes that are present in every human interaction, including low-intensity practice, are vital to consider if we are to improve outcomes and engagement for our patients.

As we hope to relay, low-intensity therapy—offered flexibly and adaptively—can help a large and diverse group of people. Low-intensity practitioners can work at the cutting edge of technology and deliver digital therapy remotely from their homes whilst also offering what looks more like traditional therapeutic work in a community-based setting. However, low-intensity intervention is not a cure-all. There are significant limitations to the depth of problems and therapeutic exploration that a low-intensity practitioner can work with, and low-intensity interventions cannot simply replace existing psychological therapy or health and social care services. Equally, there is also a potential for harm from misusing low-intensity interventions to manage demand in overstretched healthcare settings and services. In our opinion, any notion that low-intensity practitioners are either delivering truly evidence-based standardised care that is paid for through savings in the welfare bill or working as the Uber drivers of the health service hellbent on destroying community engagement falls very short of the clinical realities of the role.

Once again, we thank you for picking up and reading our book this far. We are excited about the work and aim to provide an accessible sense of low-intensity psychological therapy and the low-intensity practitioner role whilst weaving in a memoir of our personal experiences. We hope that you will enjoy reading our book and that you find something useful in the following chapters.

References

Clark D.M., Layard R., Smithies R., Richards D.A., Suckling R., Wright B. Improving access to psychological therapy: initial evaluation of two UK demonstration sites. Behav. Res. Ther. 2009;47(11):910–920.

Gilburt H. Mental Health Under Pressure. London: The King’s Fund; 2015.

Stuckler D., Reeves A., Loopstra R., Karanikolos M., McKee M. Austerity and health: the impact in the UK and Europe. Eur. J. Pub. Health. 2017;27(4):18–21.

Chapter 1: Low-intensity psychological interventions

Elizabeth Ruth    University of Bradford, Bradford, United Kingdom

Abstract

A description of how the concept, methods, and practice of low-intensity psychological interventions has evolved over time. This chapter provides a brief summary of the factors that contributed to the initiation of the Improving Access to Psychological Therapies (IAPT) programme in England and some insights into the experience of practicing low-intensity interventions in the IAPT context. This chapter incorporates brief vignettes and images to illustrate concepts that might be less familiar to the reader. This chapter includes a consideration of some of the controversies around the IAPT programme. The purpose of this chapter is to provide context and introduce themes that will be explored throughout the book.

Keywords

Low-intensity interventions; IAPT; Guided self-help; Bibliotherapy; NICE; Stepped care; Psychological Wellbeing Practitioner; Low-intensity therapist; Graduate Mental Health Worker; NHS Talking Therapies

This chapter provides an introduction to the development of low-intensity psychological interventions in England and their implementation within the Improving Access to Psychological Therapies programme. Using personal experience and highlighting key developments in the published literature, we attempt to track the interweaving of clinical and system developments that brings us to the present day and provides a foundation for the subsequent chapters in this book.

Learning aims:

●Considering how low-intensity psychological interventions developed in England

●Explore the principles of low-intensity psychological practice

●Understanding the rationale for the implementation of low-intensity practice in a stepped care system

●An awareness of some of the criticisms and ongoing dilemmas surrounding the system and the approach

●An opportunity to reflect on the experience of the patient and practitioner within the system.

Who are you?

‘What do you do?’ We have all been asked that question. Most of you can answer it quickly, in a way that makes sense to the people who you meet. I am a builder, a teacher, a biochemist, and I curate a gallery, most occupations are familiar, or at least easy to describe to other people. So now imagine what happens when you say ‘I’m a Psychological Wellbeing Practitioner’.

Glazed stares and slightly nervous laughter are good responses. You find yourself starting to explain ‘You know, I’m an IAPT worker, a low-intensity practitioner?’ Your conversational partner starts to look around the room as if for an escape route. In desperation you throw in the one profession that everyone has heard of and use it as an analogy ‘I’m the psychology equivalent of a nurse’. That usually buys you some breathing room. Then, lulled into a false sense of relief and security by the familiar and reassuring word ‘nurse’, they ask ‘so how does that work?’ You grip your glass more tightly and breathe out a slow breath. Here goes… ‘Ok, so in the old days it was really hard to find help if you were low in mood or anxious...’

I started to train as a low-intensity therapist, or Psychological Wellbeing Practitioner (PWP), in 2010 and I still can’t describe what I do in one sentence, not in a way that makes sense to my friends and family. In the summer of 2022, I tried to explain this approach to my cousin, and the best that I could offer was ‘it’s for people who might be feeling depressed or anxious who want some help getting back to themselves. We’re easy to get to, can offer some quick ideas, and we won’t make you talk about your relationship with your mother’. What I have learned in the last decade is that whilst the theoretical model and clinical methods that we describe as low-intensity psychological therapies are very straightforward, practising the approach is not.

You want to guarantee that you’ll sleep well after we’ve spoken? Ask me about work because once I start to talk about it, I find it difficult to stop. Low-intensity interventions are exciting, if you look at them from the correct angle (that would be from inside the emotional equivalent of a bomb shelter a couple of miles away from where it’s all happening). As I worked in an Improving Access to Psychological Therapies (IAPT) team and practised low-intensity psychological interventions for over a decade, I became increasingly frustrated by the fact that none of the literature that was published about this field of work described what it was like to do it. There was nothing that I could point to and say, ‘this is what I do’.

Published research papers and textbooks seemed to be written by people who had vaguely heard of the idea of what we do or who had got no clue (or didn’t care) about the day-to-day realities of our work. The literature described a sanitised and theoretical version of low-intensity therapies, without the complex overlap of components, that is, the experience of the role in practice. Speakers at our events, those who might have access to publishers and a platform from which to speak, sometimes have a paternalistic, self-aggrandising and controlling attitude. More than once I’ve compared IAPT with a feudal system, with low-intensity practitioners as the serfs working the fields at the bottom of the hierarchy and the academic ‘kings’ at the top. In fairness, this has started to change in the last few years, and the relationship between low-intensity practice and the academy has started to shift to something more respectful and collaborative; an example of this can be seen in the work of initiatives like the IAPT Practice Research Network (2021; Lucock et al., 2017).

There is still debate about the language that we use to describe our role, model, and methods. For example, a paper published in 2016 comparing psychological interventions for depression referred to the Psychological Wellbeing Practitioners who contributed as ‘junior mental health workers’ (Richards et al., 2016), depriving the practitioners of the dignity of their job title. It’s also an inaccurate description; there is an important distinction between ‘mental health work’ and the low-intensity psychological interventions that Psychological Wellbeing Practitioners deliver in the Improving Access to Psychological Therapies teams. So, in an abundance of enthusiasm and frustration, I started to write.

This book is our answer to that question ‘what do you do?’ and, more than that, we will describe what it has been like to be a low-intensity practitioner, and what we think this emerging profession could become. This book is more concerned with the nature and philosophy of low-intensity psychological therapies than the ‘how to’ of specific interventions. We, the authors, recognise that our experience isn’t universal; low-intensity psychological therapies are delivered in a number of different contexts and for different purposes worldwide. Even within the IAPT programme in England, there are significant variations in how low-intensity interventions are implemented, taught, and supported, based on the local need and commissioning decisions. Even so, we hope that our experience will give some insights into how we can develop this approach and support the global workforce in future.

This chapter will give some context and a short, selective history of our role and introduce the themes that we will explore in more depth in the later chapters of this book. We’ll know that we have succeeded in our aims for this book if, in a year or two, I ask you ‘what do I do?’ and your reply is a broad and hopeful smile.

‘Low intensity’ defined

This book will be full of jargon, that’s an unfortunate inevitability when we talk about this field of work. I’m going to kick us off with an attempt at explaining the phrase ‘low-intensity interventions’ and fill you in on the development of the Improving Access to Psychological Therapies (IAPT) programme.

‘Low intensity’ refers to the amount of contact that a patient, service user, or client has with a practitioner during a course of treatment. In psychoanalysis or psychodynamic therapy, a patient and therapist might meet for sessions between one to three times a week, and depending on the model of therapy being used, they may continue to meet for months or years. In humanistic and person-centred counselling, the patient and counsellor typically meet for 50–60 min once a week for a period that can vary between 6 weeks to several years. Cognitive behavioural therapy (CBT) tends to be more time limited, with appointments typically of 50 min (although some treatments require longer appointments) and a typical course of treatment lasting from 6 to 20 weeks in primary care IAPT services, and often longer in specialist therapy services. All of these vary significantly depending on what the presenting problem is.

Low-intensity interventions can be accessed in a lot of different ways, and each delivery method takes up different amounts of practitioner time (Table 1.1). But whatever ‘health technology’ is part of the treatment and whatever delivery style is used, low-intensity interventions are intended to be less burdensome than traditional talking therapies.

Table 1.1

Something new

One of the most common grounds for criticism of low-intensity interventions is that they do not do what other theoretical models and clinical methods of psychological therapy offer. This is born from a misplaced idea that low-intensity interventions were implemented to replace other approaches to talking therapy. That is not the function of low-intensity interventions, we provide a new, distinct model that adds to the array of psychological interventions, we do not provide ‘lower’ versions of CBT, or counselling on the cheap.

The use of ‘low intensity’ as a description for the approach is unfortunate because it suggests a lower place on a hierarchy of interventions and models. Ideally, all psychological interventions would be perceived as equal but different, expanding choice, providing more opportunity to find the best fit between the patient and their presenting problem, and the services that are available. The true meaning of ‘low intensity’ is simply that it involves less contact with a therapist than other approaches, it’s got nothing to do with the hierarchical status of the approach, or how well the interventions work.

One of the great benefits of low-intensity therapies is the reduced costs for the patient and for the system that hosts these interventions. Traditional and ‘high-intensity’ talking therapies demand a significant commitment from the patient: hours of emotional labour through in-depth self-examination and close engagement and disclosure with a therapist, the ability to make sense of complex formulations, and often significant travel and financial costs. Low-intensity therapies are designed to reduce these costs to the patient. We also have to consider the cost of providing therapy from the perspective of the therapist, and the system as a whole. In England, the Improving Access to Psychological Therapy (IAPT) programme is part of the offer from the National Health Service (NHS). Care within the NHS is free at the point of access; the financial cost of training, equipping, and providing salaries and benefits for staff comes from the national healthcare budget. The relatively low cost of low-intensity training and salary compared with other psychological therapists is a benefit to the healthcare system that hosts it, with some caveats that we will explore in later chapters.

‘Low intensity’ does not mean ‘low worth’ but lower cost (with ‘cost’ having a broad definition) than other approaches in psychological therapies. After working in IAPT services for 11 years, I understand the low-intensity approach and workforce to be the foundation of our primary care psychology provision, not the lowest rung on a hierarchical ladder.

A bigger picture

The Improving Access to Psychological Therapies programme was not the first implementation of low-intensity psychological and wellbeing interventions in a progressive or stepped care system. Low-intensity psychosocial interventions have developed in a number of low- and middle-income countries over the last decades, often in response to high need, such as in the aftermath of war, and where resources are scarce. In particular, school and community-based interventions for children have utilised psychoeducation interventions and nonspecialist counselling (Betancourt et al., 2013; Jordans et al., 2016). This book will have a focus on developments in England specifically; we do not claim that these developments are unique in the world.

Who are we, and where did we come from?

Every so often I come across psychologists who seem to be in mourning for the days before the IAPT programme was rolled out. They feel that IAPT is an attempt to homogenise psychological interventions in primary care and has shut down innovation and undermined good quality, patient-centred care. When these comments are made on social media, the replies usually include a reminder that before IAPT, the waiting times for any kind of talking therapy were astronomical, and talking therapy was not offered to most of the people who could benefit from it, no matter how long they waited on a list. The informal consensus seems to be that IAPT isn’t perfect—we are going to dig into some of the criticisms in this book—but it’s a darned sight better than how things used to be. This isn’t a book about IAPT, but it’s a book about low-intensity psychological therapies that can be practised effectively in other care settings. However, James and I have carried out the majority of our low-intensity practice within an IAPT system; IAPT is our context when we write about our work.

I’m going to try to describe the olden days before England had a stepped care system for the delivery of psychological therapies in primary care; hopefully, that sentence will make sense by the time we get to mid-chapter. So much work coalesced in the implementation of IAPT and the development of low-intensity psychological interventions that I will have either missed some of the papers that I should have read, or not had room here to include all of the detail that makes up this story. My apologies to anyone whose work is not appropriately acknowledged here.

Barefoot therapy

A lot has been done to develop low-intensity psychological interventions in the last quarter century. England’s IAPT programme is possibly the largest scale experiment in making low-intensity interventions available, but there are many other settings where this approach has been adopted worldwide. In fact, our philosophical roots go all the way back to China in the 1960s (Brady, 2016).

In 1965 Mao Zedong initiated a programme to train ‘barefoot doctors’ to equalise access to medical care between urban centres and rural populations. The programme acknowledged that most of the population in China lived in rural communities where there were very few doctors with modern medical education. Essentially, there were disparities in the provision of care on socioeconomic lines. The programme gathered local recruits who underwent a short training programme, just a few months, in the essential medical interventions that were most needed in their district: vaccination, nutrition, and curing whatever the most common ailments were locally, but above all their role was in disease prevention. After training, they went back to their communities, able to provide medical primary care when it was needed.

Isaac Marks, a psychiatrist and behavioural psychotherapist, brought these same principles into the realm of psychotherapy in 1973, when he developed a post-qualification training course in behavioural interventions for nurses who worked on a psychiatric ward at the Maudsley Hospital in London. This caught the shift in mental health nursing on in-patient wards from observational and custodial to a more autonomous therapeutic role, recognising and utilising the interpersonal competencies that these nurses had. A review of Nursing in Behavioural Psychotherapy: An Advanced Clinical Role For Nurses (Marks et al., 1977) in the journal Behavioural Psychotherapy (Thorley, 1978) describes that ‘adequately selected and correctly trained nurses can achieve levels of clinical assessment and treatment effectiveness equivalent to those already established by psychologists and psychiatrists…’ This doesn’t mean that practitioners with training in a limited range of behavioural techniques have equivalent qualification to psychologists and psychiatrists, it means that they can be as skillful in the delivery of specific interventions as someone with a more comprehensive qualification.

Marks and colleagues went on to publish an account of this early work and a description of the first training course for ‘nurse therapists’ in Marks et al. (1977). The nurse therapists who were trained in behavioural therapy would be called ‘high-intensity’ therapists in IAPT, or CBT therapists in other settings. Still, features of this work that felt familiar, and are pertinent to low-intensity interventions:

●Recognition that a practitioner does not need many years of training to provide safe and effective psychosocial interventions for common mental health problems.

●The idea that specific skills and core interventions, strategies, or change methods from the psychological approaches can be isolated and taught effectively, without a requirement to become a qualified psychotherapist in the whole therapeutic modality and clinical method (although on completion of the nurse therapist training nurses were recognised as CBT therapists and eligible for accreditation with the British Association of Behavioural and Cognitive Psychotherapies (Gournay et al., 2000)).

●In an environment with limited resources you have to make the most of what is already available. The nurses on the ward had the essential abilities and interpersonal competencies to deliver psychological interventions, and this hadn’t previously been utilised.

●It helps if you know what the most prevalent problems are in the target population, and you then focus the training of low-intensity practitioners on the interventions that will address those specific problems.

Evolution

I’ll admit that the description of the presenting difficulties on the ward and the behavioural interventions that were offered in those early days makes my hair stand on end. Flooding and electric aversion therapy are not offered by PWPs in IAPT services. The psychological theory and practice have evolved in the intervening decades, and Marks has been a significant contributor to those developments, including pioneering computerised self-help for phobias (Marks et al., 2007).

The principles of Marks’ barefoot therapist idea are still current: Train able people in the specific interventions that are most helpful for the problems that arise most often in the therapist’s local community. Training of this type is neither costly or time-consuming (Marks’ first training course was 18 months in duration, IAPT low- and high-intensity CBT training in England is one academic year, approximately 9 months) nor are the interventions that these practitioners offer. The psychological interventions or strategies are as effective when they are delivered by a low-intensity practitioner as by someone with doctoral-level training.

Training programmes based on this work persisted, and dual-qualified practitioners with general and mental health nursing and social work qualifications who had completed postqualifying training in CBT-based psychological interventions were still around in various settings when the IAPT programme rolled out in 2008.

The land before IAPT

It is helpful to put the development of low-intensity interventions into the context of other talking therapy provision. In English primary care before IAPT (our version of The Land Before Time (Don Bluth and Bluth, 1988)), the provision of talking therapy of any kind in the NHS was a postcode gamble. Some GP practices invested specifically in a ‘practice counsellor’. A practice counsellor was a talking therapist who would offer sessions of cognitive behavioural therapy (CBT), humanistic counselling, or psychodynamic counselling according to their training and competence. This would be available to the patients who were registered with that GP practice. Some GP practices commissioned services from a local team of counsellors, maybe 1 or 2 days in the week, where talking therapy would be available to their patients. This generous provision by teams of GPs was lifesaving for many, but not usually adequate to the needs of the patient population. Waiting lists could be years long, and there was little patient choice. If you didn’t find that the therapist or their approach was a good fit for you or your problem, you were out of luck. The Department of Health Mental Health Policy Implementation Guide, published in 2001, described that around 50% of GP practices provided access to counselling services and admitted that access to ‘effective psychological therapy and counselling services is commonly problematic’. Which is a great example of the wry understatement that we should all pause to appreciate.

No help

Patients with mild to moderately severe depression and anxiety disorders who were registered in a GP practice that did not have access to a counselling or therapy service would be offered the choice of medication, or nothing. Thanks to a common fear of becoming addicted to medication, amongst other factors, many people declined medication and went untreated (Farrand et al., 2007). The more severely unwell might be put onto an unpredictably long waiting list for an assessment with a clinical psychologist or the local community mental health team, which may or may not include talking therapy in its offer. Most people just struggled on alone. The problem of how to treat common mental health problems in primary care was significant and well documented in the literature by the end of the twentieth century. Approximately one-fifth of primary care appointments were due to a common mental health disorder (Table 1.2).

Table 1.2

In primary care, these difficulties will often present with symptoms that are mild enough that the patient doesn’t need hospital care, but severe enough to cause significant difficulty and misery.

PHASING

There was a recognition that the burden of treating all of these patients fell on the GP. Primary care nurses and other health and social care professionals reported that they were not trained or competent to work with mental health disorders and would need further training if they were to expand their role to include mental and physical healthcare (Department of Health, 2001). The phase randomised controlled trial (Richerds et al., 2003) found good results with a brief self-help programme for depression that primary care nurses could deliver across three appointments, but ultimately, there was a problem with capacity; demand far outstripped provision; and the workforce needed to be expanded.

In 2000 the Department of Health issued the NHS Plan (the Department of Health, 2000), a substantial document that highlights areas for reform and improvement in the NHS, quickly followed by the Mental Health Policy Implementation Guide (the Department of Health, 2001). The Mental Health Policy Implementation Guide explicitly recognised that psychosocial interventions can be successfully taught to staff who do not have a mental health professional qualification. It also proposed a role for ‘new mental health workers’ (p.69), envisioning a role for recent psychology graduates in primary care mental health (Lucock and Frost, 2004). This idea was developed into the training of Graduate Mental Health Workers, more on them in a moment.

Self-help

The earliest example of self-help literature is possibly the book Self Help by a Victorian doctor called Samuel Smiles, first published in 1859. The original Self Help was a manual that promoted self-reliance and the development of personal character along specific lines, addressing attitudes of perseverance and hard work, social status, financial management and specific gender roles and attributes that, predictably, feel old-fashioned to a 21st century reader.

The self-help genre has progressed since then. In the field of mental health services, when we say ‘self-help’, we usually mean health technologies like books, computer programmes, and audio material that present methods of treatment for depression and anxiety disorders in a way that would enable a patient to learn the treatment method and use it on themselves. The material in these packages is usually based on cognitive behavioural techniques. CBT, of all of the approaches to psychological interventions, relies on ‘specific factors’ to produce change. That is, it is not the relationship between the therapist and the patient that helps the patient to feel better but the specific ideas and techniques that the therapist teaches to the patient, and the patient’s self-practice of these techniques, that produces change. Therefore CBT, of all of the approaches to psychological therapy, is most easily ‘manualised’; it can be written down in an accessible way so that the principles and techniques can be learned and used independently.

Bibliotherapy

With the demand for treatment for common mental health conditions far outstripping the provision of qualified therapists, one potential answer to the pressure on systems was bibliotherapy. By the second half of the 1990s, several studies had shown that self-help could be an effective intervention for depression and anxiety (Williams, 2001b). There was enough evidence for NICE, in the 2004 CG22 guidelines, to recommended that patients with panic disorder and generalised anxiety should be offered a selection of treatments in primary care, one of these was ‘self-help (bibliotherapy—the use of written material to help people understand their psychological problems and learn ways to overcome them by changing their behaviour—based on CBT