Today an important report about mental health came out from the LSE, How Mental Illness Loses Out in the NHS, arguing coherently the economic case for building a mass mental health service in the UK. There’s the striking statement in the document that the type of therapy offered through the NHS is cheap, really cheap, not something you often hear in these austere times.
This is a long blog, but I want to explain why mental health services are cheap as chips.
A glaring deficit in the report is an exposure of the chronic working conditions for the therapists that are delivering the UK’s mental health service. With an employment relations system more frightening than the industrial revolution, you don’t have to be crazy to work in mental health but it’s very likely.
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 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.
The viability of that 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 and UKCP, 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 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. These difficult choices are then passed onto the patient, where therapists in these subcontracted choose between 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.
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 don’t need any more mental health policies that do not address the mental health of the people that are expected to deliver these services. Without a basic employment relations system that offers a clinically safe environment, pay (!) and a sustainable profession attractive to talented people then the policy falls flat. The current economic argument for cheap therapy is based on the profound and unacceptable working conditions of the thousands of young and dedicated therapists in the UK.
Doesn’t sound sane does it.
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