Moving beyond a single-model philosophy: Integrating relational therapies in front-line psychological therapy services in England.

Abstract

This article critically reflects on controversial aspects of the English service model of frontline psychological therapies. The Improving Access to Psychological Therapies (IAPT) program in England has had worldwide influence and embodied core psychotherapy debates between clinical practice, research evidence, and politics. The article initially focuses on the definition of evidence-based therapy in the program and the resulting dominance of protocol-based, specific-disorder, Cognitive Behavioral Therapy (CBT), which has ostracized other treatment models. The medical model, the outcome research paradigm, and the English clinical guidelines, treated as the pillars of the CBT hegemony, are critically examined. Omissions are highlighted, including the therapist's effect, the effectiveness of psychodynamic psychotherapy and integrative practice, and the contribution of client-related factors to treatment outcome, all which contradict key principles of the IAPT philosophy. An innovative initiative to integrate a relational pathway, including brief psychodynamic and relational integrative therapy, into the English service model is then presented. The article discusses the potential remedying effect of injecting relational therapies into the program philosophy. In particular, the IAPT framework has extended beyond a service model to represent a certain paradigm of what psychotherapy should look like, emphasizing diagnosis and technical manuals. On the contrary, a relational pathway places the client, the therapist and an individualized approach to treatment at the heart of therapy. Thus, integrating relational therapies in IAPT would entail renegotiation of core psychotherapy dialectics, including technical knowledge versus clinician's expertise and diagnostic-driven versus individually tailored treatments. The wider implications of such renegotiations are pointed out.

“A gentle balance of pushing, pulling and sitting with”: An interpretative phenomenological analysis of psychological therapists’ experiences of working with goals in adult pluralistic private practice

“…There are also likely to be differences in service structures. For example, in private practice compared to more time-limited NHS settings such as Increasing Access to Psychological Therapies (IAPT) services, where reflective capacities might be limited due to service pressures or economic or political factors (Leonidaki, 2021). These pressures are likely to impinge on the therapist's ability to hold reflective awareness, including mindfulness of their own agenda and goals for their client.…”

Choice, voice and collaboration: using preference accommodation and feedback in trauma therapy

“…Such treatments have obtained evidencebased therapy status by using the randomised control trial (RCT), and as such, are largely based on cognitive and behavioural hegemony. That is, therapies that can be manualised, with supposedly specific ingredients for specific disorders based on the medical model (Leonidaki, 2021;Norcross and Wampold, 2019).…”

A comparison of completion and recovery rates between first‐line protocol‐based cognitive behavioural therapy and non‐manualized relational therapies within a UK psychological service

“…However, less than 15% of the clients seen in IAPT are offered non-CBT treatments with less than 1% accessing IPT or brief psychodynamic therapy (NHS Digital, 2019). An elaborate discussion of possible reasons for the under-presentation of non-CBT therapies in IAPT, including scarcity of specialist supervision and training, can be found elsewhere (Leonidaki, 2021). This apparent CBT hegemony is not universally accepted.…”