‘A factory of therapy’: accountability and the monitoring of psychological therapy in IAPT

Abstract 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.


Introduction
This paper deals with some aspects of mental health practitioners' daily work in the Improving Access to Psychological Therapies (IAPT) service, established in 2008 as part of the National Health Service (NHS) in England. 1 Through the invention of IAPT, cognitive behavioural therapy (CBT) and related therapies have become a hallmark of evidence-based psychological therapy.In the process, psychotherapeutic care has been reconstituted as a highly manualised, standardised, and quantifiable intervention.The material on which this paper draws has been gained through long-term anthropological fieldwork with IAPT mental health practitioners in England from 2016 to 2018. 2 My first period of fieldwork was carried out in a community centre in London in my role as a full-time volunteer.In and around the community centre, I worked with therapists from the IAPT service.My second period of fieldwork was carried out among therapists and their teachers on an IAPT-accredited master's programme in CBT.Some of the ethnographic material of this paper is also drawn from fieldwork carried out in mental health conferences.
This paper explores how IAPT's emphasis on the monitoring of psychotherapeutic care has resulted not only in the seeming success of the service but also introduced new ideas about public mental healthcare in the UK, with self-monitoring at the heart of its vision of 'evidence-based psychological therapy' .It is in the provision of therapy, as we shall see, that practices of monitoring have been felt to be important but also persistently burdensome.There is a central tension in the relation between monitoring and care that is explored in this paper.It is a tension that is marked out ethnographically by IAPT's model of clinical and economic accountability vis-à-vis practitioners' experiences of working therapeutically with patients in the terms set by this model.IAPT therapists have situated practices of accountability in the ambitions (and constraints) of an avowedly medical model of treatment; a model which for many of these practitioners has become difficult to reconcile with psychotherapeutic efforts to care for patients as 'people' .We will see that many practitioners now feel that they are working in a 'factory of therapy' whereby psychological intervention is recast in the service of outcome measures, and by which critique of the service, as well as caring relations within it, have been precluded.

The invention of IAPT
The IAPT programme was introduced after a period of lobbying of the former Labour Government in the mid-2000s by its founders the economist Richard Layard and the clinical psychologist David Clark.It was widely promoted as an initiative to improve access to 'evidence-based psychological therapy' .A majority of mental health professionals appear to have been supportive of the initiative at the time; the introduction of the IAPT service into primary care was felt not only to be an official recognition of the scientific validity of clinical psychology (and related professions) but also a much-needed improvement of UK mental health services (e.g.Hall, Pilgrim, and Turpin 2015).IAPT introduced cognitive behavioural therapy (CBT) as the leading form of psychotherapy due to its reported scientific evidence-base in the treatment of 'common mental health problems' , particularly depression and anxiety (The Centre for Economic Performance 2006; Clark et al. 2009).Since IAPT's implementation in NHS England, the programme has received significant international acclaim for its reported effectiveness as a large-scale psychological healthcare service.
We could summarise Clark and Layard's promotion of the IAPT programme as proposing two overarching and interlinked objectives: 1) to improve access to evidence-based psychological therapies in order to 2) meet the apparently growing demand for psychological healthcare in the UK.These objectives did not emerge unrelated to circumstances that were already taking shape in and around the NHS.Issues relating to questions of access, evidence, and accountability had been a concern across several public sectors since at least the 1990s (Strathern 2000a) and were also of central concern in the movement of evidence-based medicine (EBM) of the same period (Timmermans and Berg 2003).Some commentators have seen EBM's influence on mental health services in the UK as a reaction to a growing dissatisfaction among public health experts that a large part of mental health interventions had relied on empirically unsupported treatments (Department of Health 2010; Clark 2018).While the question of the empirical status of psychotherapy is historically longstanding (Hatfield 1995;Derksen 2000;Marks 2015), the significance of 'evidence' has been reconstituted more recently through the positivism of EBM and its scientific persuasions (Bruun 2019).EBM has been described as a methodological framework for assessing the effectiveness of clinical practices and interventions, with the randomised controlled trial (RCT) as the hallmark of what counts as 'evidence' in biomedicine (Bothwell et al. 2016;Lambert 2006).Within the framework of EBM, evidence is ranked according to the reliability and verifiability of the research design used.The RCT figures as the gold standard of evidence-making, followed by meta-analyses and systematic reviews (Timmermans and Berg 2003).In England, EBM can be said to have become formally institutionalised with the foundation of the National Institute for Health and Care Excellence (NICE) in 1999.Clinical practices, such as psychological therapies, are assessed and regulated by the NICE institute, which serves as the official advisory board for evidence-based practice in the UK.NICE was also specifically designed to evaluate the cost-benefits of particular treatments within the framework of a state-funded healthcare system and to provide clinical guidelines for the NHS (NICE 2011).In 2004, CBT was recommended as the 'choice of treatment' for people diagnosed with mild to moderate depression and anxiety (NICE 2004). 3The NICE guidelines were a significant turning point for the scientific status of psychological therapy as CBT became formally recognised as an evidence-based intervention within the NHS (Marks 2012).Indeed, CBT is now so prevalent in UK public healthcare that it has become somewhat synonymous with the term 'evidence-based psychological therapy' .The 2004 NICE guidelines also laid a political foundation on which IAPT could be lobbied successfully by Clark and Layard.In designing the IAPT programme, Clark and Layard were instrumental in framing a putative mental health crisis in UK as a problem of 'access' to care, and to then delineate the solution to this problem in simultaneously clinical and economic terms (Bruun 2019;Pickersgill 2019).In lobbying the government, Clark and Layard argued that public mental health services would be optimised by improving access to psychological therapy while such improved access would, in turn, have immense economic benefit for the UK, in particular by reducing unemployment benefits (The Centre for Economic Performance 2006; Layard et al. 2007).Underscoring this argument was a claim derived from Layard's model of 'happiness economics' (Layard 2005a) according to which, rather than being separate objectives, improvement in 'psychological wellbeing' is seen to enable 'economic welfare' .Layard's vision was linked to an older notion constitutive of the NHS itself that saw 'the physical and mental health of a nation' to be generative of a 'healthy' national economy (Busfield 1998).Thus, framing economic problems as a consequence of mental health problems, specifically 'depression' , Layard (2005b) proposed that the solution was to be found in an extensive investment and expansion of psychological therapy.'Depression'that old category of economics -was summoned to join forces with the discipline of psychology, at the same time as 'mental health' was reified as both obstacle and solution to the UK economy.The invention of IAPT thus took shape as a joint psycho-economic enterprise.Not only was psychological therapy in the form of CBT deemed psychologically effective in 'evidence-based' terms, it also offered a 'cost-effective' approach in economic terms: IAPT, it was argued, would eventually pay for itself by increasing employment and thus reduce state benefits.IAPT seemed to promise something for everyone involved.Despite IAPT's continued reported success (Department of Health 2010; NHS Digital 2018; Helliwell, Layard, and Sachs 2012), criticisms of the service have also pervaded (e.g.Jackson and Rizq 2019; Lees 2016;Williams 2015).Notably, points of contention have recently been voiced by IAPT's own mental health practitioners.Drawing on their professional experiences of working in IAPT, practitioners have taken issue with various aspects of the service (e.g.Binnie 2015;Roscoe 2019).Yet criticism from within the service, as well as external critical commentary upon it, have tended to be sidelined.The perceived demand for psychological therapy against a continued increase in the use of psychopharmaceuticals (especially antidepressants) has meant that IAPT, as a public mental health service that offers 'talking therapy' as opposed to 'drug therapy' , has been hailed as greatly 'needed' .Since the launch of the service, however, other mental health practitioners have mourned the end of what they regard as a more 'relational' approach to psychological healthcare (Lees 2016).'IAPT' , as one critic puts it, offers 'second class therapy for citizens deemed to be second class' (Samuels 2016, xii).
While this paper might be read as adding to such critique -or even subsumed under one of two banners as either 'for' or 'against' IAPT -the aim here is rather to take ethnographic note of how both advocacy and critique of IAPT have proliferated.What is of particular ethnographic interest is the way in which ideas of monitoring and accountability have been mobilised in efforts to either endorse or criticise IAPT.This paper suggests that IAPT has effected an elision of notions of effectiveness and evidence with monitoring and accountability.Consequently, IAPT can be seen to merge therapeutic and institutional modes of self-monitoring in its (pro)vision of mental healthcare.In all of this, efforts to care for 'people' were deemed to be at stake.

'We don't talk about people'
'There is no doubt that CBT works.It really works' .Paola 4 said unreservedly as we sat down in her office to discuss her work as a practising psychotherapist in IAPT.She wanted to assure me that she was not naïve about the service's shortcomings either.'The problem is' , she explained, 'that IAPT doesn't leave a lot of space for people to be human: to be contradictory and complex beings' .She looked rather worried.'However' , she interjected quickly, 'evidence-based psychological therapy is the only way to run an NHS service like IAPT.The medical model is the only way to do it' .
According to Paola and other practitioners like her, psychotherapy had become conceivable and workable within a 'medical model' of public healthcare.Paola was one of the therapists I met who worked in a community centre in London.She was employed by the local NHS Trust to work with communities deemed 'hard-to-reach' in order to improve access to IAPT.She also worked within IAPT as a therapist.Paola had initially trained as a 'psychological wellbeing practitioner' (PWP) in the early days of the IAPT service, before qualifying as a CBT therapist.The professional role of the PWP was specifically created to enact IAPT's central 'therapeutic workforce' in meeting the purported demands of psychological therapy on a nationwide scale.When I discussed my research with Paola in one of our first staff meetings, she described how she had initially struggled with what she considered to be the medical model of IAPT, with its emphasis on accountability measures articulated through practices of manualised diagnostic assessment and intervention, and through extensive monitoring of performance outcomes as integral to the therapeutic work with patients.
On the university course where I followed the training of IAPT therapists, I met Alex, a lecturer in CBT and a practising psychotherapist.Alex's professional working hours were divided between training psychology students at the university and working as a CBT therapist in one of the local IAPT services.She began her career in the NHS as a young woman, working first as a PWP, the lowest ranking clinical profession in IAPT, before qualifying as a CBT therapist and taking up a university lectureship.As we sat down in her office, Alex recounted her worries about 'the direction in which IAPT is going' .She had initially been excited to see psychotherapy becoming more available to the public through the IAPT initiative, but, after working in the service for almost ten years, she felt that psychotherapeutic care had been hindered by IAPT's monitorial requirements: First there was all this excitement about improving access to mental health services.And it was exciting![…] IAPT was trying to counter the imbalance of all the resources that were being ploughed into physical healthcare and the neglect of mental healthcare in the NHS.In that sense, the initiative of IAPT is good.But IAPT is becoming more about monitoring a service than providing therapeutic care.
Alex was attracted to CBT for its 'evidence-based' and 'effective' approach.IAPT, she explained, offered a scientific platform for psychotherapy to be taken seriously.It offered credibility and accountability.I met other practitioners who had trained as CBT therapists because, like Alex, they found the scientific promise of evidence-based psychological therapy incredibly persuasive.CBT was widely felt to set the scene for a mode of psychotherapeutic care with a tried-and-tested evidence base.Moreover, CBT was a type of psychotherapy that promised to trump the purported effectiveness of psychopharmaceuticals (such as antidepressants) in the treatment of mental health problems (cf.Layard and Clark 2014).
Alex worried nevertheless about the increasing constraints put on IAPT therapists.'The more I do evidence-based psychological therapy, the less I believe in it' , she remarked gloomily as we were heading out for lunch after a staff meeting at the university department where she taught CBT.It was important to Alex that psychotherapy still means that someone is taking care of you: 'there is a relationship in psychotherapy and that's what matters' .She deplored how she often felt restricted when it came to caring for patients whom she considered most in need of care because of the demands of meeting outcome targets.'The more complex cases we ascribe to our services, the lower the target and recovery rates' , she explained.'Seeing more complex patients means that you are less likely to keep your job' .Back in London at the community centre, I had met IAPT therapists with similar concerns.'The financial implications matter more to the CCGs [Clinical Commissioning Groups 5 ] than the quality of care' , one therapist told me.Another complained that too many of his clinical working hours were spent on laborious administrative tasks in meeting the 'target goals' of the service.Others reported how they had to 'move around patients' in the steppedcare system 6 in order 'to cope with the pressure' .Consequently, these practitioners were particularly worried about the stipulated monitoring of outcomes as part of the auditing of recovery rates.'Putting all these measures into practice and keeping up with recovery outcomes mean that I often can't do my work properly as a therapist' , Paola complained regretfully after one of her weekly team meetings with members of the local CCG.She was interested in 'caring for people' , she pointed out, 'not only numbers': We don't talk about people in our meetings anymore.We talk about numbers and recovery rates.People -the patients -are gone from our conversations.If someone attended my team meetings, they probably wouldn't realise that we were talking [about] mental healthcare.
Measures of performance and a demand on 'meeting outcome targets' meant that a meaningful relation to patients -allowing people to be 'complex' and 'human' , as Paola expressed it -was deemed difficult to cultivate.For many therapists, this perceived neglect of a therapeutic relationship revealed the underbelly of IAPT's apparently 'evidence-based'driven ambition of providing psychotherapy within a medical model that values numbers over people.

Quantifying care: self-monitoring and (ac)countable selves
A multitude of regulatory procedures -from patient recovery evaluations and other clinical outcome measures to CCG-stipulated service performance targets -has come to define the monitoring of mental healthcare in IAPT.This complex of monitoring has been justified by reference to public service governance including clinical and economic accountabilities in the provision of state-funded healthcare.In general, such regulations can be understood to form part of an ambition to quantify care in the service of accountability and health surveillance.Anthropologists have already written a great deal on questions of accountability, bureaucracy, and audit culture (e.g.Shore and Wright 1999;Strathern 2000a;Bear and Mathur 2015).While there is no space to rehearse these debates here, a few key points are worth noting from the historiography of monitoring.In the UK, important aspects of monitoring were part of the very foundation of the NHS in its nascent post-war days in which certain practices of health surveillance took shape, and their moral justification.Such monitorial practices of 'watching over' came further into being within clinical contexts of new accountabilities and regulations in the 1970s onwards -influenced by a growing critique of 'trained judgement' in biomedicine and associated calls for a more rigorously scientific objectivity (Daston and Galison 2007) -which fed into what subsequently became known as the movement of evidence-based medicine.The monitoring of public health was shaped, moreover, by management theory that came out of post-WWII operations research and, in particular, by Thatcher's 1983 initiative of New Public Management that became the gold standard of administrative reform (Dalingwater 2014).As in other contexts of accountability in Europe, managerialism (the management of management) and manuals (the procedures of procedures), accompanied by international practices of standardisation, have become foundational to the operation and governance of public services in the UK, as much as they now inform a general model of monitoring and ethics in research and beyond (including anthropology, see Simpson 2011;Strathern 2000b).These monitorial practices have thus historically played a key role in constituting 'not only visible, calculable, governable spaces but also […] governable persons who were ideally reflexive, calculating selves' (McDonald 2000, 109-10).
When we move to the context of IAPT, practices of monitoring and self-monitoring (notably in the form of self-observation, self-inspection, and self-reporting) have informed the kind of therapeutic work mental health practitioners are expected to carry out, as well as the CBT-model of selfhood in which the patient is construed as an inherently accountable self (see Bruun 2019, 166-95).People who undergo psychological therapy come to participate indirectly in outcome measurements as they are asked to complete questionnaires and evaluative tasks before and after their therapy sessions.It is not only mental health practitioners who are required to do the work of monitoring, therefore, but also those classified as 'patients' or 'users' .The use of patient health questionnaires (e.g.Patient Health Questionnaire 9 for Depression ) is not only central to IAPT's diagnostic approach but also its generation of patient data that feed into statistical measurements of performance.On the therapeutic level, particular assumptions are built into the practice of completing such tasks on the part of the patient.A capacity to perform self-monitoring is now taken for granted everywhere in IAPT.Patients are granted this assumed capacity of reporting on 'self ' at the same time as they are required to take up a subject position in which their interiority is readily available for observation, assessment, and measurement.For example, assessment questionnaires are integral to IAPT's treatment procedures as a means for patients to conduct self-reporting.Before and after therapy sessions, patients are asked to evaluate their experiences of their mental health.Psychological self-assessment of this kind relies on the itemised patient questionnaire as a technology of quantification -a technology of 'numbering the mind' (Young 2017).It is commonly used as a means to render patient experience into a numerical score, and as an evaluative tool to quantify the effects of psychotherapy; in the language of IAPT, the 'outcome' of the therapeutic work with patients.Mental health is here understood to be located in an individuated body-self comprised of cognitions, emotions, and behaviours; this is a particular rendering of human interiority often aligned with notions of the psyche, mind or brain (Bruun 2023).In CBT, patients are asked to report on and evaluate their 'feelings' , 'thoughts' and 'actions' .As patients undergo therapy, they are thus required to learn particular techniques of self-monitoring as part of the practice of CBT.
'Recovery rates' figure here as the statistical products of the practice of quantifying care.Financial decisions such as funding allocation or cuts to services, and hence staff, are often concluded on the basis of these outcome measures.Failing to meet one's outcome targets might mean being at risk of losing one's job.These were issues that received little, if any, explicit attention at the IAPT conferences I attended.Yet professional anxieties of the sort I have described loomed large at these conferences.They were discussed instead behind closed doors in meetings among trusted colleagues, during lunch breaks and in the pub.Some therapists felt that the constraints associated with the mass collection and submission of clinical datasets were now so commonplace that it had become somewhat banal to even raise it as an issue in their staff meetings.Others felt that this kind of monitoring was a 'necessary evil' .In other words, it was reasoned that the scientific status of IAPT hinged on the extent to which one could account for the effectiveness of therapy in terms of accumulated recovery rates.Many therapists worried nevertheless about the reporting of patients' recovery in an attempt to fulfil stipulated outcome targets.'Patients' , I was told on more than one occasion, 'have become numbers' .
Contrary to these experiences, the founders of IAPT have contended that the mass generation of outcome data is a requisite for making psychological therapies accountable on an equal footing with biomedical interventions (Layard and Clark 2014).One of the main aims of the IAPT initiative was to promote psychological therapy in the form of CBT not simply as an alternative to medication (psychopharmaceuticals) in the treatment of depression and anxiety, but as an altogether more scientifically rigorous solution.Better still, psychological therapy was also deemed to be more effective in economic terms: […] until recently there was little that could be done for people who are mentally ill.But there have now been great psychological discoveries, which have produced treatments for depression, anxiety, and conduct disorder more cost-effective than most treatments for physical illness.(Layard and Clark 2014, 258) It was likewise by way of accounting for IAPT's clinical effectiveness through the annual statistical display of recovery outcomes that its proponents were able to show that, as a government-funded, public mental health programme, IAPT proved far more cost-effective than its pharmaceutical counterpart.According to Layard and Clark, this meant that 'talking therapy' could finally be seen to replace 'drug therapy' .As Martyn Pickersgill (2019, 639-41) notes, accounting for the clinical effectiveness of psychological therapy has therefore also rendered IAPT 'countable' in economic terms.The collection and dissemination of quarterly and annual statistics of IAPT's performance data constitute the continuous efforts to represent the service as a case of successful accountability in terms of both therapeutic and financial efficacy.
IAPT's vision of monitoring reflects broader trends in contemporary UK public health, which has seen a rapid increase in health surveillance and digitalisation over the past decade.Formed in 2013, NHS Digital has become the central institutional instrument of digital monitoring of public health data.Tasked with the provision of data services for the NHS, it collates and manages health informatics and produces around 300 annual statistical publications.The effects of the Covid-19 pandemic have further intensified practices of digital health surveillance, as well as offered a moral rationale to justify them.Monitoring now extends across the NHS in a way that not only involves operational observation through recording and checking but constitutes new practices of 'datafication' that provide and regulate digital services that in turn produce clinical and economic accountabilities (Hoeyer, Bauer, and Pickersgill 2019).IAPT has from its inception encouraged this vision of digitalisation and datafication, and it is a product of it.This generation and management of data are central to what some social scientists see as a 'regulatory objectivity' (Cambrosio et al. 2006) that guides evidence-based practice in contemporary biomedicine.It is however an ambition that, according to IAPT's own therapists, has been difficult to reconcile with caring practices in the context of psychotherapy.The value placed on care here did not only concern therapeutic care with patients but was a matter of concern extended to the therapists themselves who grappled with working conditions that apparently failed to 'care for their needs' as mental health practitioners.Related to these concerns were the therapists' experiences of IAPT as a necessary but unsettling 'factory' .

'A factory of therapy'
Mental health practitioners frequently evoked a language of 'industrialisation' to describe their experiences of working in the IAPT service.During my fieldwork with therapists in the community centre, weekly networking meetings and 'wellbeing hubs' were facilitated to bring local health services, NGOs, and practitioners together with a common goal to foster mental health by creating connections between services, groups, and individuals.In these meetings, developing meaningful relationships with your patients was often a topic of discussion.It was also in these meetings that practitioners frequently talked about what they saw as the main problem of working in the service.IAPT, I was told, had become 'a factory of therapy' .
Paola explained how she and many others were trying to 'put care back into therapy' .They were seeking to change the apparently 'industrial' course that IAPT had increasingly encouraged.While Paola readily commended IAPT for advocating the importance of accountability in mental health services, she felt that its contribution to accountability was somewhat paradoxical because the service simultaneously failed to take into account the very basic premise of psychological therapy, namely that psychotherapeutic care is a matter not simply of 'access' or 'recovery' but of caring for 'people' .In her experience, the practice of psychotherapy, in which people figure as 'complex beings' , did not 'fit' IAPT's medical model of treatment in which speedy recovery -treating patients-as-numbers -took precedence over the caring practice of dealing with human distress, its causes, and circumstances.Paola elaborated: The reality is that nobody in government or the CCGs [Clinical Commissioning Groups] are going to give you money if you are telling them: "Actually, people sometimes leave psychotherapy feeling more distressed than when they arrived because they are exploring their sense of self and who they are in the world, and it is often a very painful process." Getting well takes time, and, even if you successfully complete twelve consultations, life doesn't stop causing distress -and you don't simply "recover" from it.
For many therapists, this was a tension that was experientially confirmed every working day in a struggle to meet outcome targets while simultaneously wanting to 'care for people' .They worried about how the 'quality' of care was compromised by an emphasis on 'moving people into recovery' as quickly as possible.'It's a factory' , I was told repeatedly.
The notion of factory was significant in more than one sense.First, and most obviously, it imparted an understanding of IAPT as a service that expeditiously produces a mass quantity of a specific product.The outcome target of recovery rates was regarded as the metaphorical product of the therapeutic factory.To many therapists, this model of treatment was also suggestive of a mode of market capitalism in which quantity eclipses quality and whereby numbers come to account for -and justify -the conditions under which treatment is provided.Secondly, the juxtaposition of 'factory' and 'people' or 'industrialisation' and 'care' that has been conjured up here was a language supplied by the practitioners themselves in which the perceived merits and difficulties of their professional work were situated.And, thirdly, the notion of factory was invoked to discuss the professional changes effected by IAPT in the landscape of mental health professions more broadly.Introducing a psychological healthcare programme within primary care organisations in England was initially praised as an important expansion of 'talking therapies' .Some considered it a long overdue recognition of the scientific status of psychotherapy.Yet, other mental health practitioners have since criticised IAPT for its 'de-professionalisation' of psychotherapy (Jackson and Rizq 2019).
There seems to have been overall support of IAPT across different mental health professions, at least at its early inception.Some practitioners I met recounted how senior clinical psychologists and psychotherapists had worked in close collaboration with the programme at every stage of its implementation.At the same time, those who started to work under the new professional label of 'psychological wellbeing practitioners' -the PWPs -were seen to carry out assessment and treatment within a 'quick fix' framework.This role was a result of Layard and Clark's proposal of providing an extensive but cost-effective workforce on a national scale.PWPs have often been criticised for providing care of 'inadequate quality' due to a perceived lack of clinical training.In professional conferences where these issues were sometimes discussed, criticisms of the PWP workforce were often countered by arguments that improving access to psychological therapies to the general population entailed the need to deliver care on an 'industrial scale' .This rationale was also articulated by senior practitioners in an edited volume on the history of clinical psychology in Britain published by the British Psychological Society (Hall, Pilgrim, and Turpin 2015).For example, clinical psychologist Glenn Parry endorsed IAPT by drawing an analogy to 'the industrial revolution' wherein 'the therapist becomes a technician within the prespecified machinery of delivery rather than a cottage industry of artisan practitioners, customising interventions for each individual' (Parry 2015, 193).He contended that the misgivings of many clinical psychologists about IAPT, many of whom apparently saw it as a 'threat' to their profession, concerned the new arrangements in the provision of psychological therapy which were seen to undermine their role as therapists by offering a less expensive alternative (ibid: 191).In the meantime, IAPT has relied predominantly on the use of PWPs and CBT therapists, most of whom are not clinical psychologists.The issue at hand was summarised to me by an IAPT director at a conference: 'the problem with clinical psychologists' , she asserted, 'is that they are too expensive to employ' .This director argued that CBT therapists were just as competent as psychologists in providing psychological therapy: 'There's simply no evidence that clinical psychologists do a better job at CBT than CBT therapists themselves' .
Importantly, PWPs have themselves commented on the seemingly 'industrial' aspects of working in the service.The newly trained CBT therapists I met on the university course, many of whom had first worked as PWPs, expressed their overall dissatisfaction with the 'insufficient, short-term training' they had initially received when qualifying for the role of PWP in providing 'Low Intensity' intervention or 'step 2'.They felt that the clinical skills and knowledge they had obtained did not meet the therapeutic needs they were required to deal with in their daily clinical work.'I was dealing with many patients that far exceeded my therapeutic expertise in psychotherapy' , said a former PWP who went on to train as a CBT therapist: 'It's because we kept receiving patients that weren't suitable for step 2′, interrupted another.'The thing is' , she explained, 'we were getting referred step 3 patients [High Intensity cases] and we were trying to treat them with step 2 interventions.All of us were working as PWPs but without step 3 training [CBT training]' .While these seemed to be common matters of concern among IAPT therapists, they were not topics of discussion in the rather different professional setting of the IAPT conferences I attended.Here, it was generally maintained that the IAPT programme had consistently trained well-qualified mental health practitioners, including PWPs.This sentiment has been supported in reports published by the Department of Health (e.g.2010).Contrary to the concern of many therapists, then, to these advocates, IAPT's model of short-term training and short-term treatment has been commended as a necessary and effective change to improve access to psychological therapy.IAPT's ambition of 'improving access' has relied in turn on practices of monitoring that equate 'improving' with 'increasing' numbers of patients.While IAPT has accomplished, in its own terms, this particular notion of improvement, it has likewise, as reported by its own practitioners, made caring relations difficult to improve.

A preclusion of care and critique
Critiques of IAPT's perceived shortcomings -whether such have been framed as lack of training and therapeutic competence (Lees 2016), for instance, or the model of care itself (Jackson and Rizq 2019) -have generally resulted in advocates justifying the mental health service as 'rational' and 'realistic' (or framing the putatively biomedical framework as 'inevitable' , see Pickersgill 2019, 642).As a result, critics of IAPT have tended to be characterised as uninformed and irrational (see e.g.Fonagy and Clark 2015).These justifications and responses to critique both internally and externally appear to resort to what might be seen as a discourse of 'realism' .In addition, evoking a rhetoric of rationality seems to have enabled IAPT's founders and advocates to circumvent critique.It has also encouraged otherwise concerned therapists to see IAPT as 'not merely a way of developing public mental health' , as Pickersgill reports but, on the contrary, 'the only way' (2019, 642).Pickersgill's account of a persistent language of inevitability that deflects critique, drawn from his interviews with IAPT practitioners, is supported by similar observations from my own fieldwork.While the mental health practitioners I worked with in the community centre, as well as those I met on the CBT training course, took issue with various aspects of the IAPT service, many however were equally determined to curtail a space of further critique, reminding themselves and each other 'to be realistic' .
Related to such critiques was another common response which highlighted the difficult institutional conditions under which the service operates.These conditions were often framed as fundamentally 'economic' and difficulties that arose in the provision of care were due to therapists being required to think in 'business terms' .As one therapist explained: There's a strong business side to IAPT.The service isn't going to work unless 80% of all the people who get referred go through step 2 -if you think about it as a machine with all the different costs.But, if you look at it clinically, 80% of the people referred aren't step 2 [Low Intensity] patients.They just get shoehorned into that diagnostic category because services are commissioned.That's where the business aspect comes in.
Another of his colleagues then commented, in terms more accepting of what was perceived to be not a matter of business but rather a case of 'economic' constraint: I think the idea of IAPT is great -but in my experience, there isn't enough money to carry it out properly.When the government first brought it out, they didn't realise how many people were actually going to use the service.There are now so many issues [with the service] and not enough money to deal with them.[…] Now we're just trying to get patients through the service as quickly as possible before waiting lists get too high.
It was in this experience of either 'business' or the 'economic' that psychotherapy in the form of CBT within IAPT was felt to have left behind some of its own principles of care in favour of a type of intervention required to be cost-effective, quantifiable, and amenable to auditing.If I asked, as I often did, if there was another way to make psychological therapy accessible as a public health service without abandoning principles of care, a common response was that 'you've just got to be realistic' .To these practitioners it seemed rather infeasible to imagine other modalities of care than the one IAPT offered.'Psychotherapy must deal with the economic facts of society' , it was asserted in a conference where attending therapists had voiced their concerns about lack of funding.It is common in the UK, as it is elsewhere in Europe and beyond, to think of the 'economic' as fundamental to 'society' , an ontological base on which everything rests (Mitchell 1998).The economic poses here as a metaphor of the 'real' and the notion of the factory has long offered a related metaphor in constructions of scientific objectivity (Daston and Galison 2007).IAPT's vision of psychotherapy was once again presented as 'the only way' to run a public mental health service.The language of 'management' was therefore not uncommon either.'It's about effectiveness' , retorted a keynote speaker at an IAPT conference when members of the audience commented critically on how their therapeutic work was being monitored.'It's how healthcare is managed' , we were told.'It's evidence-based practice' .Such rectifications would later be accompanied by an acquired self-conscious 'realism' on the part of the same concerned therapists, reminding themselves and others to 'just do our best' in the face of an 'unmanageable' management model of mental healthcare.
As we returned from one of her lectures, Alex, reflecting on the medical model of IAPT, remarked: IAPT's heavy reliance on medical diagnostic criteria is probably the only way to manage a large-scale service for a large population like the UK.Because how else would you do it?Without spending too much money, of course.Or not being able to justify the spending because psychotherapy takes time.
Providing effective psychotherapy is what most therapists expect to do when they train as IAPT professionals.Upon graduating from their university, many therapists find that a focus on psychotherapeutic care and patients is no longer what they can expect to do in practice.In other words, when IAPT-trained CBT therapists take up positions in the IAPT service, commencing their work as fully-fledged clinicians, their acquired understanding of what constitutes evidence-based therapy does not easily match up with the institutional requirements of putting 'evidence-based' therapy into practice.Consequently, a disturbing sense of discrepancy emerges among new therapists who experience a lack of fit between their psychotherapeutic training and the kind of work which is demanded of them in IAPT.
Therapists are taught that 'the patients come first' , even if they 'know' that this might not always be true.Patients are nevertheless what therapists are taught to care about.'The basic goal' , as the supervisor often reminded us in the training course, was 'helping people get better' .But not only does this therapeutic 'helping' or 'care' take many forms when put into practice, its significance shifts radically into other matters of concern when we enter the institutional context of IAPT.Other circumstances are present here, other things matter: 'the economy' , 'waiting lists' , 'transparency' , 'funding cuts' , 'recovery rates' , and so on.Many of these circumstances, whether seemingly abstract or concrete, were not easily reconciled with the therapists' daily efforts, in their own words, to care for their patients.Monitoring psychotherapy was therefore not what most therapists expected to do when they started working in IAPT.As a result, therapists are required to be persuaded by new strategies of measurement and performance.New sensibilities must be acquired.Those who have not already acquired such sensibilities -who might, in their colleagues' words, fail to get 'realistic' about their jobs -might well find themselves questioning the 'quality of care' whereby, as more than one therapist told me, 'patients are numbers and therapists are managers' .In all of this, psychotherapeutic care was not felt to translate seamlessly into a world of monitoring in which treatment is construed as a measurable entity that must end up as numbers on a page.
Psychological therapy can seem, therefore, to collide with managerialist measurements of performance in the institutional setting of IAPT.Attempts to deal with this tension are apparent in the day-to-day working lives of practitioners, such as when therapists explicitly worry about the lack of a 'therapeutic relationship' , a disquiet which is then often met with instructions from colleagues or superiors to 'make it work' .For many practitioners then, IAPT's model of care emerges through such assertions and instructions as the only 'realistic' approach to running a public mental health service, even if, as Paola contended, 'it doesn't leave a lot of space for people to be human' .It is an approach to mental healthcare that tends to be seen as resting on a biomedical model of treatment in which psychotherapy is measured and evaluated according to the principles drawn from psychiatric contexts of treatment.As we have seen, economic and clinical accountabilities have been mobilised as the prime justification of IAPT's model of healthcare, but they are also what seem to get in the way of other therapeutic modes of caring for patients beyond these conventions.
At the same time, IAPT's reputed medical model of treatment, together with the general deflection of critique by IAPT's founders, have served to both obscure and prevent certain forms of critical scrutiny through which other models or approaches to mental healthcare could be appropriately envisaged and enacted (Pickersgill 2019).There has been some resistance more recently though, with other psychological 'futures' delineated by critics of IAPT (Lees 2016).We have seen, moreover, that IAPT has effected an elision of notions of 'effectiveness' and 'evidence' with practices of accountability, most notably in the shape of performance measures.As a result, taking issue with the monitoring of therapy in IAPT has been felt more broadly to be an objection to, or subversion of, evidence-based practice and even, by extension, 'science' itself.Hence for practitioners and commentators alike, taking up this critical position has meant joining the ranks of the unscientific, ill-informed, and unrealistic.

Conclusion
For many practitioners the monitoring of psychological therapy has been confirmed, in discourse and experience, as giving rise to a factory of therapy.Monitoring can be seen to figure twice in IAPT, and to work recursively.Firstly, it figures in the office through daily practices of measurement and evaluation in the monitoring of psychotherapy, and, secondly, it figures in the clinic where patients are learning, and are required to perform, different forms of self-monitoring that make up the therapeutic modality of CBT.The therapeutic modes of self-monitoring (observing, recording, evaluating, inspecting) that patients come to engage in through IAPT's psychological therapies eventually feed back into the institutional modes of service monitoring that allow IAPT to demonstrate -in largely statistical terms -its accountability in accordance with clinical and economic rationales.Monitoring in the context of IAPT is thus recursive in the sense that its therapeutic techniques of self-monitoring, combined with the technology of the itemised questionnaire, render patients into measurable and accountable selves, which in turn enable IAPT to quantify psychological therapy as a measurable and accountable intervention within the framework of evidence-based practice.
In the context of UK mental health services, the provision of psychological therapy has thus taken shape within a 'value-for-money' auditing and its concomitant 'trust in numbers' (Porter 1996).IAPT might therefore be seen to enact and serve particular logics of monitoring as it combines principles of clinical accountability drawn from the conventions of EBM with broader managerialist ideas of 'good practice' .IAPT's extensive monitoring of its services, therapists, and patients, has thus made it possible to locate and validate psychological therapies, spearheaded by CBT and CBT-based therapies, as well as the IAPT programme as a whole, under the banner of 'evidence-based practice' .IAPT has obtained broad scientific recognition as a result, and this has been quite an achievement in its own terms.
As we have seen, however, practices of monitoring in IAPT have been experienced as precluding certain aspects of care that were encapsulated in the notions of the therapeutic relationship and a care for patients-as-people.The figure of the relationship emerged as a way of conceptualising needs, circumstances, and qualities seemingly lacking from IAPT's intervention model as a matter of 'caring' practices (Mol 2008).The therapists' experiences of a curtailment of 'relational' aspects of their work thus spoke to a professional concern with the specificities of psychotherapeutic care.After all, treating patients as 'people' (as 'complex beings') were seen as central to what makes psychotherapy work well.
IAPT therapists are not alone among professionals of various kinds in Europe in encountering a sense of mismatch and a conflict of concerns in the context of new accountabilities (see e.g.Shore and Wright 2000;McDonald 2000).IAPT seems to move mental healthcare from 'the clinic' to 'the office' while simultaneously blurring their distinction.The office has long been associated with the emergence of audit and accountability (Strathern 2000a) and it is perhaps no surprise that the practice of evidence-based psychological therapy relies on many of the assumptions and problems of accounting.In IAPT, one such key problem has revolved around measures of performance and outcome accomplished through a quantification of care.
Finally, IAPT presents us with a novel ethnographic context of mental healthcare in which the longstanding division of the 'biomedical' and the 'psychotherapeutic' have been brought together in different ways, and with different consequences for patients and practitioners alike.One immediate consequence dealt with here has been the professional experience of a curtailment of relational aspects of psychotherapeutic care within a public health context of accountability.Yet it is precisely because of this complex of monitoring that IAPT appears to have successfully situated itself as an effective and evidence-based service.For many therapists, however, this achievement accomplished on an apparently industrial scale has meant that 'people' -construed as a recognition of care devoid of measurement -are now missing from this factory of therapy.

Notes
1. IAPT was renamed 'NHS Talking Therapies' in January 2023.See https://www.england.nhs.uk/blog/whats-in-a-name-nhs-talking-therapies-for-anxiety-and-depression-the-newname-for-iapt-services/.2. The term 'mental health practitioner' is used here to refer collectively to the professionals working in IAPT.These consist primarily of a) psychological wellbeing practitioners (PWPs) or 'Low Intensity' therapists, and b) CBT or 'High Intensity' therapists, including other accredited psychotherapists and clinical psychologists.
Looking back on my work in IAPT, I find myself thinking: what on earth were we doing?I think we all thought we knew what we were doing.You see, we were working on step 2 [Low Intensity intervention] for several years doing what we thought was CBT or a CBT-type model.But then we learned CBT on this course and realised, aha! -a lot of the stuff we were doing was wrong.Another colleague added: What I am doing now as a CBT therapist makes me question step 2 [Low Intensity intervention].I feel sorry for them [the patients].Because the therapy I was doing wasn't the most effective.