As unemployment rises and the economic situation shows little sign of improving, it should come as no surprise that mental health in the UK is deteriorating. In the fifth article of her continuing series on public policy, work, and mental health, Elizabeth Cotton argues that at the time when they are under the greatest pressure, the expected cuts to mental health services will make it even harder for those who need therapy to get the help they require.
It has taken decades of campaigning, with some help from American television, to shift the UK’s attitudes towards therapy. Now that we’ve finally understood the importance of therapeutic help, what are the chances of getting it? With an employment relations system more frightening than the industrial revolution combined with ineffectual call centres, will psychological therapies survive the recession?
The UK’s largest therapeutic programme, Increased Access to Psychological Therapies (IAPT) is an ambitious one aimed at getting people back to work. It uses high and low intensity Cognitive Behavioural Therapies (CBT) interventions for between four to sixteen weeks, mainly at primary care level or dedicated psychotherapy providers. This is a particularly standardised form of CBT not designed to deal with serious mental illness or depression and as a result much of the therapy is done over the phone or is “self-guided”. The justification for this huge increase in talking therapies is firmly economic. It’s about money. There are high hopes that by increasing mental health services we will see a rise in employability, productivity and a way out of this recession.
Mental health services operate within a wider context of public sector cuts and reform of health and social care. There’s a word that you might not recognise in that sentence – cuts. Yes you heard it here first, cuts not savings. Statements about NHS reform resemble a demented “yes/no” game where the words “cuts” and “lying” cannot be uttered. For reasons of public safety, I can almost understand why nobody wants to admit to the £20 billion cuts that are going to have to be made to the NHS over the next three years. So maybe we can borrow some language that policy makers might understand, that as demand goes up, supply goes down. Still, underpinning current mental health services is the first coalition government policy to actually be a serious grown up one, with emphasis on early interventions and based on a £400 million money commitment. Reasons to be cheerful?
Well that, comrade, depends largely on whether you are delivering these services or not. In the main, and I don’t wish to get too technical for you here, the therapists delivering mental health services are chumps and I say that as one of these chumps. The reason is that we are working under an employment relations system which is essentially Dickensian but without the laughs.
There are a lot of different kinds of therapists ranging from the hard core psychoanalysts to the art, child and family, group therapists. There has been a concerted effort to standardise training under the BACP (British Association for Counselling and Psychotherapy) and UKCP (UK Council for Psychotherapy), and there is a system of professional accreditation in place. Most of the people that I have had the honour to meet during my training have been smart, caring and genuinely interested in their patients, but coming from a trade union background I’ve often been left speechless at how this precious breed of people consistently undervalue their own work.
It’s partly the nature of the game – any therapist that thinks they are brilliant is unlikely to be. To say you’re a good therapist is a bit like saying to someone that you are really funny. If you need to say it then it’s probably not true. But it’s also about the employment relations systems within which they operate that have consistently downgraded the quality of work that therapists do. The people that deliver IAPT services are no longer called therapists, they are Psychological Wellbeing Practitioners (PWPs), many of whom are in fact experienced therapists and clinical psychologists, punching below their weight and wondering whether it was worth the many years of clinical training and internships.
UK employment relations have changed dramatically over the last 30 years, brought on by an intense period of privatization and deregulation. The privatization of healthcare has been ongoing for several decades, but intensified over the last five, bringing with it a profound change in contracts of employment, including the introduction of contract, agency and temporary labour. The changing nature of the employment relationship affects therapists in three main ways and I will be calling on the ideas of two bearded blokes, Marx and Freud, to understand them.
The first relates to internships, or the widespread use of honorary psychotherapists. Adult psychotherapy training involves a minimum of 4-6 years of part time training. During that period the most important part, along with your own personal therapy, is to carry out clinical work. In the case of adult therapy, this work is carried out under supervision with the support of high quality training and practitioners. The problem is that we don’t get paid, hence the reference to chumps. In order to train as an adult psychotherapist in this country you have to work part time (usually a day a week) for free for between 4-6 years. The fact that we learn a trade means that this is not literal bonded labour, more like an apprenticeship for quite old people.
One consequence of this is that this is a profession open to primarily independently wealthy people. There are some who work full time and do the training on top, but over the last few years the NHS and other employers have become less accommodating to the kinds of long, complex and down-right argumentative training that is provided in this country. If we are not careful the vast majority of practicing therapists will be rich people. This is not to say that rich people make worse therapists than poor people, but it does raise important questions about class and power both clinically and within the profession.
Marx had something to say about honorary psychotherapists. Well, not exactly, but he had a lot to say about the role of the unwaged and unemployed putting a downward pressure on employment. As long as we are offering our work for free, and doing it quietly and diligently, the NHS as an employer will never get its act together and pay the people that work for it. This then becomes a collective responsibility on our part to raise our consciousness sufficiently to argue the point. Therapists should be paid.
The second employment relations issue is that of externalisation or triangulation (Oh Oedipus!) where a third party is involved in the employment relationship. The advent of Private Employment Agencies (PrEAs) is nothing new in healthcare with cleaning, catering and even nursing relying heavily on intermediaries to supply labour. But, with the massive rise in demand for IAPT services, cuts and waiting lists for between 6-12 months, we are now seeing the creation and expansion of private employment agencies for therapists. Because of the secrecy around this shift there is no comprehensive data about how many therapists now work for PrEAs but anecdotally it’s on the increase as private companies steadily buy up IAPT waiting lists.
As with all externalised employment relations, it’s not just the contract of employment that gets passed over to third parties, it’s also the responsibilities of employers. There is a large body of literature dedicated to how employers avoid their responsibilities through subcontracting and the subsequent difficulties in regulation. Many people working for agencies do not have a written contract of employment, receive no training or supervision. This is particularly true for therapists who can find themselves working in conditions no better than a call centre, providing therapy without any idea who their employer is and no clear duty of care.
This change in employment relations involves a perversion – sadism actually – which according to Freud is what happens when love goes wrong. Freud understood perversion as a defence and internal organisation that is used when the thing that we love is not available. The infant experiences intense aggression towards this loved thing that is not there and tries to grab hold by sadistically controlling it (think screaming baby). Sadism is the controlling of another person through pain, in order to keep a relationship with them alive. In this cruel economy hurting someone is preferable to losing them. What is happening to therapists in these subcontracted environments is that they are presented with a sadistic choice of caring for the patient in a way that may be hateful and humiliating or not treating them at all.
An example. PWPs’ work is formalised and standardised to the extent that if a patient does not pick up the phone for an initial assessment, within a 15 minute allotted time period they are referred back to their GP, presumably to wait for a further 6 months. Within these services there is a hatred for the patient that keeps us on the phone for too long, making it impossible to meet the quota of 8 satisfied clients a day. Reaching the quota involves not listening to the real and deteriorating situation of patients. Under these conditions the only way to responsibly help patients is to refer them on to other more intensive services. Hatred is passed on, dump and run. PWPs that offer more support, mainly through giving more time and going off script, are forced to keep this secret from employers because it breaks their contract of employment, leaving them to carry the full ethical and clinical consequences of their interventions. I doubt you could get clinical insurance to cover this situation and it exposes therapists to precarious states of mind, counterproductive for people employed to contain the anxieties of others.
The third impact relates to those therapists left within the NHS system. Often scared, overworked and definitely feeling guilty for raising their concerns with colleagues who will never see sick leave or pensions again. It’s often the people with the best contracts who end up with the worst jobs, internalizing the guilt of a system which treats its workers as if they were ancillary to their survival.
So the workforce is made up of these three precarious groups: interns, temps and scared public sector workers. Many experienced and wonderful therapists have retreated to private practice, unable and unwilling to navigate a broken system. This means that there is some great therapy available out there, but only for those people that can afford it. It’s not to say that private practice doesn’t offer massively needed services, it does, and a careful assessment and referral can make the difference between life and death. But it also means that anyone without money is left behind, looking at therapy as a kind of psychic pilates, available to those that can pay but probably don’t desperately need it.
The NHS definitely has to regain its responsibility towards patients, but it is not just a one way shift that needs to take place. In a context of deteriorating mental health in the UK the fact that we are a disorganised and chaotic group of people is a matter of both professional and personal ethics. We as psychotherapists have to take some responsibility for the ways in which we are prepared to work and the structures within which we do it. This will mean finding new forms of organisation, including forming social enterprises and voluntary associations of therapists that offer quality services and provide adequate supervision and training. It might also mean organising ourselves into a precarious workers’ union, but one which makes no demands on political orientation or class identity. Although organising such a diverse and difficult group of people offers a sizeable challenge, the need for consciousness raising is not seriously questioned by anyone working in mental health and could be a sound basis for collectivisation. We need now to take advantage of the new forms of organising and structuring services coming into play to engage aggressively with public debates and the new structures that will in the future commission services.
You don’t have to be a revolutionary to organise, just a good therapist.
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