Policy is who turns up at meetings

Somewhere in 2009 policy died as austerity kicked in, so even going to a mental health policy launch made many of us feel a bit dirty. In the current legitimacy vacuum policy is determined by who turns up at meetings. It means that policies designed quietly in un-representative bodies should command our interest. 

The attempt to corrupt mental health services into delivering austerity policies and the degradation of therapeutic services means that increasingly neither the people using or delivering services are willing to bust a gut to argue for more mental health funding. One of the reasons why this is happening is that despite the efforts of mental health activists and champions we as stakeholders are not getting a place at the policy table. I want to argue that unless we can both organize around the principles that should underpin mental health services, and spend enough time in the same rooms defining our common interests, our legacy as mental health stakeholders stands to be one of failure.

The current policy bun fight

In mental health there have been a series of policy projects about the regulation and registration of counsellors and psychotherapists, most recently the UK Government consultation on the future regulation of healthcare professions. This might sound like a good idea, but potentially represents a further nail in the mental health coffin in part because most of the bodies carrying out ‘consultations’ about the future of the mental health workforce don’t really understand or care about how the therapy business works. 

The Scope of Practice and Education for the counselling and psychotherapy professions (SCoPEd) is a proposed competency framework for setting standards for counsellors and psychotherapists to practice in the UK. This was adopted by three of the largest psychodynamic professional bodies – principally driven by the BACP, UKCP and BPC - in ‘consultation’ with their memberships. Part of the regulation of therapists is to arbitrate on the ‘quality’ of training and clinical experience required to practice. 

In the 2021 survey I carried out for one of the largest and most progressive professional networks - Counsellors Together UK (CTUK) - we looked at the future financial landscape for therapists and the impact of SCoPEd. For those respondents who had a view on SCoPEd 47% felt that their employability would be lower. The minority of the 1200 respondents who are informed about SCoPED believe it will have a catastrophic affect on incomes. Further, 40% anticipate a decline in diversity within a sector already with low representation.

Even amongst the 64% of respondents registered with the largest professional body - BACP - who are relatively protected from the negative impact of SCoPEd recognise that it will create a ‘closed shop’ for psychotherapists and a downgrade of counsellors in the professional food chain.

Although this system of professional membership is voluntary, SCoPEd nudges the sector towards a de facto monopolization of the therapy business within the three largest professional bodies, and the most expensive and exclusive training route into therapeutic work. As a result, SCoPEd threatens both the diversity and earning capacities of the thousands of counsellors and psychotherapists who are not members or practicing modalities sanctioned by them, disproportionately impacting working class therapists and professionals from black and minority ethnic communities.

From an Industrial Relations perspective what this looks like is that instead of protecting the thousands of highly qualified counsellors and psychotherapists from the sector wide downgrading of clinical services and jobs, the strategy is one of ring-fencing the status of psychotherapists and letting the counsellors fight it out in the emerging realm of sub-therapy.   

SCoPEd was passed on the basis of a membership consultation within just three professional bodies engaging 13-15% of their memberships.

The Regulation of Therapy

Although there is a need for regulation of any clinical practice, the hardened amongst us might see the way the regulation debate is being conducted as signs of protectionism. Define the problem as the regulation of individual clinicians, rather than the systems in which they work and with one swoop of the policy hand, training and membership within the professional bodies becomes necessary to practice as a therapist in the UK. Voila a passing of the political and professional buck from the downgrading of services onto the individuals working within them. That might sound a bit mean spirited but the fear amongst mental health workers to even articulate concerns about where the sector is heading within their professional bodies is not to be underestimated. Many feel that even without any legal requirement to be a member of a professional body, articulating concerns will lead to blacklisting and job loss. 

This is partly because so many people working in mental health don’t work for the NHS where public sector protections still exist, but in the private sector, self-employed and on short term contracts. This means that professional membership is important and there is a massive reluctance to become a thorn in the side of the big players.

The fear of challenging the regulatory and professional bodies is reflected in the volume of critical debate on social media by membership about these new policies. That Twitter has become a safe place for therapists should legitimately cause you some anxiety.

The bigger picture
The crisis that is emerging relates to some bigger ideas about mental illness and its ‘treatment’.The concept of the medical model relates to the dominance of a psychiatric-diagnosis-plus-medication approach to distress. These two cornerstones of UK mental health services are closely tied to the financial interests of the Pharma companies and the prescribing professions. Drug development legitimises the new diagnostic categories used to herd people into a model of treatment that can become diametrically opposed to anything therapeutic. This is not to say that some people can’t benefit from medication but it is to say that the diagnostic framework is controlled by institutions with a financial interest in the medicalisation of distress. 

This is the background to the debates about therapeutic modalities - those that accept the medical model and those complex troublesome therapeutic approaches that don’t. Over the last two decades there has been the revival of an old ‘contentious’ debate about the different kinds of therapies that are practiced –  often concentrated on the differences between Cognitive Behavioural Therapy (CBT) and psychotherapy. This debate has been fuelled by the emergence of the ‘evidence base’ for the effectiveness of CBT on which the largest NHS programme, IAPT, depends for its legitimacy. The fact that many of us don’t think that IAPT is CBT hasn’t stopped them being positioned in opposition to each other forcing us to choose sides.

Another binary. Divide and rule. You get the idea. 

The stratification of therapists is even more baffling because most practitioners are over qualified. Overqualified in the sense that they have paid for years and years of psychodynamic and other trainings right throughout their careers such that it’s really hard to divide clinicians into CBT or Psychoanalytic tribes, counsellors and psychotherapists, good guys and bad guys. There is diversity in the length and quality of trainings, no doubt about it, but whether that translates into a hierarchy of therapeutic competency is another matter. 

The Organising Challenge Ahead

What is getting missed in this policy bun fight is that the prospect of decent therapy is actually decreased the more we dig the protectionist hole.

What is fundamental to therapy are the therapeutic relationships that are formed and the dynamic nature of what happens when people spend time together really listening and really talking. If you put an experienced and humane clinician in a room with a patient in conditions where both the clinician and the patient can say what they think, it’s hard to distinguish between people who define themselves as counsellors and those as psychotherapists.

It’s this space of free association that we should be trying to protect. 

The reason why the radical mental health networks aren’t that fussed about collaborating with therapists is because they experience this political and ethical conflict in the consulting room. In a system where the pressure to ‘recover’ trumps actual therapy we are involved in the widespread individualisation of social crisis. You can expect nothing less from a system that responds to unemployment by diagnosing a disorder and prescribing meds. 

This isn’t some liberal academic position on co-production (although I think it should be mandatory) – it’s about what happens to a mental health service when the people who use it are excluded from shaping it. It’s what happens when you wheel out yet another mental health report coordinated by Paul Farmer and involving only those organisations with a financial interest in business as usual. What happens is that we completely miss the harsh realities of service users and the too-scared-to-speak-up providers of care that should without exception form the basis of future policy and funding. 

It’s not clever to point out that the major professional and training bodies sometimes act as a conservative force in these debates. There exists an internal tension between their roles: they function both as regulators and gatekeepers of mental health work and as bodies charged with protecting the profession of counselling AND psychotherapy. Nobody who works for them has much of a vested interest in questioning the main sources of income – memberships and trainings – and increasingly as a matter of short-term survival they contain debates within professional silos rather than looking at the bigger crisis-fuelled picture.

In the ABCs of sectoral bargaining you have to be on the right side of history. People don’t risk their jobs over policy, but they will act on matters of principle particularly  when they are lived out in the consulting room. Without upholding the principles on which a genuine mental health service is founded, the current debates about the regulation of therapy increasingly put workers and their patients in direct opposition to the political and professional institutions charged with protecting them. 

The right to join a collective organisation is called Freedom of Association. This dual meaning of free association should be a fluorescent-pink-neon-sign for mental health workers about how to position themselves in relation to the important debates about the future of the sector. The political reality is that for any institution to have the privilege of representing us they have to allow us to say what’s on our minds, wherever we are in the therapy food chain.

Join the debate at the National Counsellors Day 2022 on the 18th June.