After Quarantine

I’ve been in quarantine since my 15 month old son got chickenpox. The flat is now just rubble and every object of beauty I’ve ever cherished has been ruined by Calamine. We’ve been adopted by a robin called Robin and learned how to count by pox. I turn out to be a complete natural at unemployment which, as a friend reminded me, is maybe unsurprising as it offers the same broke/humiliated/vulnerable-to-institutional-bullying status as being employed these days. 

I’m tempted to give you a sociological analysis of Love is Blind and Celebrity Dating in this week’s blog but that will have to wait until Corvid-19 kicks in. After any more isolation with a non-verbal reason-resistant animal it will be all I will be able to talk about. Bet you can’t wait.

Instead I’m going to give you the final infographic from our survey of 650 IAPT workers, looking at what people working in the service think should happen to the largest public mental health service in this country. 

This is a long blog, the last in our IAPT survey series, just in case you have more time on your hands than usual.

SO, everyone who answered the survey had something to say about what needed to change. You can ignore it or you could listen to some of the people who have a genuinely informed viewpoint on how to stop the downgrade of services that IAPT represents.

There were some common themes on what macro and micro measures could improve mental health services:

• stop using recovery and patient number targets
• de-linking IAPT from disability and unemployment benefits systems 
• use IAPT appropriately for mild/moderate depression 
• look at how to support primary care services that are failing
• investment in high intensity and high skilled therapists in the NHS so that complex cases can be treated and IAPT be reserved only for low intensity needs.
• capping the number of clients per day
• stop gaming data and misrepresenting the service
• change the measurements so that they are measuring something meaningful
• flexibility in the modality and therapeutic process

Rather than paraphrasing I’ll just let you read what some respondents said.

‘Tell the truth. Put all those people who decided not to engage with the service after it was explained to them in the NO SERVICE category. Stop lying to the kids training to PWPs. They are told that they are offering a 'person-centred service' and they believe it. Recognise that the 'therapeutic alliance' is ultimately the most important element in any intervention. IAPT takes the human OUT of the relationship. I think if the statistics were more truthful it would be clear that CBT is not the be all and end all and that to do things on the cheap does no-one any favours. The model is WRONG and lots of people get managed because if that.”

‘IAPT needs flexibility and client empowerment and choice. It needs to be able to accommodate messy (normal) presentations and support PWPs to work with flexibility and sensitivity in their approach. Session numbers and therapy focus and style should be defined by client presentation and individual recovery/improvement rate. IAPT should be able to accommodate changes and disclosures during therapy that change the track if therapy and demand more time and/or a different approach. Psychometrics should be critically examined and need to give voice to the client’s self-definitions of improvement, and should all be administered in the same way. Stats need to be honest so that we can see that the current system fails people and risks putting them off talking therapies for life.’

‘Honestly, I think the IAPT programme is great and really works if you're a white, middle class patient with mild-moderate problems, likely to work and 'recover' quickly and buy into the model of manualised CBT i.e. "the problem is your faulty thoughts, do something about it…quickly". Other than that, IAPT will not recognise your problem or your progress. High numbers of referrals to IAPT include people with histories of racism, social inequalities, severe mental health problems, abuse, neglect and multiple event traumas. The current model does not include these people and is therefore not fit for use as a primary UK public service. What do I think should happen to IAPT? Ideally, reduce it to what it has evidenced that it can do; successfully treat only 25% of the people who present with a primary care mental health problem. Then, re-invest the surplus in 'actual' therapy services (equity of access to counselling and psychotherapy) with IAPT reserved exclusively for people who 'can' and 'will' benefit from manualised CBT (as is realistically already the case).’

“There are many illnesses and conditions that was known to vary widely between people i.e. MS. Mental illness is no different except that a relational connection also needs to be made for therapy to work and the IAPT system does not get that. For Primary Care Mental Health Services to actually work we need to get back to it being in-house, varied, client-centred and much bigger, with people who understand therapy needs from the client and the therapist perspective. An integrated system with connections with secondary care, the GPs, other disciplines within the NHS and social care is needed. Mental health is being talked about more which is a great thing but the IAPT system fundamentally flawed, getting worse not better and is not able to provide what is needed.”

“IAPT should be scrapped. I think this kind of business model in health is doomed. We need to accept that a thin scraping of care for more people isn't care. Yes we would go back to huge waiting lists but at least those who were seen would get good care. Staff would be retained then as well and expertise would stay within the NHS.”

Whether you agree or not, it’s hard to ignore the expertise that people working in mental health services offer us in working out what do we do about IAPT. For some this means scrapping it, for others just change the current system and this is where the dilemma for us rests. 

Given the lack of political will in the UK to address problems before we’ve been broken by them, my own view is of the revolutionary rather than reform variety. This isn’t because I am a teenager, but because I don’t think anything good will happen in mental health services without forcing the point. 

For too long services have been based on the mental health business just grinding on, chewing up patients and clinicians along the way. I could get stuck into the 30 year preoccupation of the regulatory bodies of the details of professional regulation and the bun-fight-of-vested-interests that is the SCoPEd discussion in psychotherapy and counselling. 

But I won’t because whatever the future governance of mental health services turns out to be and no matter how important regulation is, there is a bigger political point that we need to attend to which is who shapes services and whether the people doing the therapeutic work are paid enough and often enough to earn a living.

You know my view about the financial interests in mental health because I’ve been banging on about this forever. Literally forever. But in these deeply authoritarian times, I want to say something about how decisions are being made. 

Isn’t it just possible that we could risk setting up a system where the people who know the most about what should happen to mental health services in the UK should be given the space to speak, think and influence what happens next? Both from the perspectives of the people delivering the service and those who are receiving it, if you don’t put the people actually in the system at the heart of decisions basic stuff like health equalities and minimum wages get missed off the agenda for another half century. 

Last week yet another report about inequalities in mental health came out. More data about BAME experiences of mental health services from the Race Equality Foundation last week - ‘Traumatic, inappropriate and discriminatory experiences of services’ continue.

Nothing said about what’s happening to mental health workers right now. You don’t need to be Freud to understand that the financial hit taken by self-employed therapists is pretty terminal for offering a safe, containing and long term relationship necessary to do real mental health work (Freud by the way was really preoccupied about how to earn a crust, another reason just to love that man for his shear rudeness). And no amount of policy or promises of mental health funding will address the reality of job insecurity and poverty in the sector. 

The people who took the time to answer this and the previous survey www.thefutureoftherapy.org raise a number of questions including how do mental health workers get to the point of organised industrial activity – a point from where they can make demands about wages and working conditions across the mental health sector? How do we open up a debate within the sector about the political project ahead for defending quality mental health services, and how can we start to organise around this agenda?

Firstly, on a policy level, mental health services deserve a public inquiry into the current regime of performance management and the IAPT model – to be run by a group of people who are not financially invested in the outcome. There is an emerging leadership in the campaign against the IAPT model and the co-option of therapies to deliver welfare cuts – which, unsurprisingly, is led by disability and mental health service user networks. The most radical challenge to the current mental health system has not come from workers or their collective institutions, but rather from disability and mental health networks such as DPAC, NSUN, Recovery in the Bin, Mental Health Resistance Network and the Mental Wealth Alliance. These networks are uniquely placed to provide political direction combined with data and information about what is happening to service users, particularly those on benefits. 

From the perspective of the mental health workforce critical and outspoken networks exist and will continue to emerge as the crisis deepens. There is an important and growing constituency of self-organised groups of professionals that are emerging and offer a workplace perspective and front-line memberships that are crucial to any serious strategic response. These currently include Psychotherapy and Counselling Partnership - a new network of progressive organisations including Counsellors Together UK, Alliance for Counselling and Psychotherapy, Psychotherapists and Counsellors for Social Responsibility, Free Psychotherapy Network - Critical Mental Health Nurses Network, Social Work Action Network amongst others organising in the mental health sector. All of these networks offer important perspectives and support to frontline workers. All have highly experienced and well networked activists within their ranks that could form a key constituency within any negotiating platform. Many organisations and activists are involved in this data collection, and in raising concerns within the sector. If pooled this work could be developed to help create a platform for national engagement on the key workforce issues.

Secondly, there is a need for the development of a new network of interested parties  (including trade unions, service user groups, alternative networks and those professional bodies that have an interest in political action) that can start to research and debate the workforce crisis in mental health services, and work towards creating a platform for negotiation on wages and working conditions in the sector. I’m not going to say anything about the current government apart from the fact that at some point it will end and there will be other political actors we can then lobby the hell out of. Instead of securing our place in the current food chain by lobbying and dabbling with APPGs couldn’t we create a genuine political force to be reckoned with?

As experienced campaigners know, the process of creating an inclusive body is a hard one and must be driven by the explicit objective to create inclusivity rather than suppress  it. Splitting and territorialism run right through the histories of political and workplace activism and has potential for undermining even the most determined efforts to organise in the sector. As a result the primary principle of any platform must be inclusivity and an openness to new networks and organisations as they inevitably come into existence during the current crisis. Without that premise then the debates about mental health will continue to focus on defending an ever decreasing professional circle rather than addressing the strategic downgrading that is actually taking place. 

To do any of this ordinary organising work requires us to challenge the performance management systems within which we work, and, maybe more importantly, to support each other in doing that. This rests entirely on our capacities to build relationships with the people with whom we actually work. The dual meaning of free association is important here, offering us a way to utilise both our experiences of freedom of association – to collectivise at work – and our abilities in developing deep relationality with the people around us.

In the current mental health context, this organising work is not principally an ideological project but rather a developmental one. We need to devote resources and time to organising groups of mental health workers across professional silos and employers, in a process that enables the emergence of spaces for dialogue between diverse interests and provides safe environments out of which new political and psychological ideas can grow.

Maybe most importantly, in order to move on from the grievances and sadnesses of IAPT workers to making a change we have to transform ‘individual dissatisfaction into collective grievance’; whatever organisations or networks or groups we are part of, they have to create a collective sense of injustice, including a sense of who is responsible for the situation, and sufficient organisation to shape collective demands and action. This is why an IAPT inquiry is important - because it offers us a starting point for those of us with real experience of a failing service and a political view informed by actual facts to carve out an alternative. 

When the period of isolation has ended, some of us will be ready to talk about the future of mental health services. Whether it turns out that we meet face-to-face or online, join us. 

Places to meet

IAPT Workers’ Cafe: Are you a current or past IAPT worker? Interested in building spaces for us to come together & talk about changes we'd like to see in IAPT? Join our 1st meeting, in person or online, on Saturday, April 4th, 11.30am in Bethnal Green. DM us  @IAPTworkers for info & to RSVP 

People Not Pathology: Humanising Counselling & Psychotherapy is holding the next big debate in Birmingham 2-3 May. No keynotes, no big names just us talking about the future of services. Book your tickets here.

Breaking or Making of Professional Bonds in Psychoanalysis: College of Psychoanalysts, Institute of Education Room 731 5th June 6-8pm. Book your tickets here.

National Counsellors Day, 20th June 2020 London. An event organised by Counsellors Together UK, to book click here

Counsellors Together UK are attempting to crowdfund a series of retreats for mental health workers free of charge. If £1500 is pledged by the 6th April then NatWest will provide the necessary funding. You can pledge your support here.

Social Media

@survivingwk @PCSRuk @PCP_uk @clareslaney @MHResist @UK_Counsellors @Glennademeter @aclientfirst @X_TaraS_X @MariaAlbertsen_ @Alliance4CP @freepsynet @SchrebersSister @AsylumMagUK @Paulananke @PCU_union @Skourkos1 @IAPTWorkers