How to survive work as a psychotherapist

This article was produced for the British Psychoanalytic Council's New Associations and will be part of the BPC's event Life as a Therapist- How to Survive It! taking place in London on the 28th November 2015. Click here.  I’ve been wanting to talk about money for a long time, mainly because I don’t have enough of it. When that opportunity came up, to present along with David Graeber about money at the BPC's PPNow! we seized it and asked the question how we might organise ourselves into a better position to think about, talk about and negotiate money within our profession.  Like many people working in mental health, this is not my first career. Coming from a union background I am dogged by an anger about how hard it is to raise the subject of wages. My political position is influenced by working as an adult educator and organiser for 15 years and is sufficiently digested to be mercifully short. I believe that adult education and psychoanalysis are both emancipatory projects and whichever way you cut it growth means facing up to both internal and external oppression.  Moving between these two worlds of activism and psychoanalysis is increasingly straight forward, held together in our minds by some bearded blokes including the educator Paulo Freire who understood the deep developmental stream from which these two crafts come. Activists and psychotherapists clearly share some important tools - dialogic methods, seeing the world as it is, building our sense of ourselves as agents in the world, a reliance on collectivism and the bitter pill of dependency.  Working within a context of economic crisis helps to re-establish these connections, with professional audiences ready and willing to think about the basics. Increasingly people working in mental health are on the political frontline of welfare cuts and social justice - and many define themselves as activists. All that’s happening now is that crisis is drawing out the essentials of what we do, with the exception of an honest debate about money.  So why is it so hard to talk about money? One of the reasons is that we have superegos like tanks: huge, defensive and aggressive. Despite everything we know from Freud, we can retreat into a world of magic solutions and magic ideological wands and nurture a deep need to take the moral high ground. There’s nothing wrong with being right, but we are dogged by punative and often sadistic states of mind which blunt our humanity to ourselves and each other and with it our need for such things as wages and decent jobs. The love between us is powerful - but we make massive demands and judgements on each other and find it very hard to respond to each others material needs. We work in situations where all of us at points work for free, made to feel the guilt and shame of not being able to articulate a need for cash.  As work gets more traumatic in health and social care we defend ourselves by splitting the working world into the them’s and us’s. This next bit might smart because its an internal conversation that many of us dedicated open minded and thoughtful folk fall into.  Splitting divides our profession between women who married rich men and can afford psychoanalytic training, experienced NHS clinicians who have retreated into private practice taking with them the last generation of pensions and all the world’s resources with them. Versus the chippy lefties, community mental health workers, NHS whistleblowers etc etc who couldn't get over their own needs and trauma enough to become real psychoanalysts and are left stewing in their own righteousness.  This is a very depressing thought for the anarchosyndicalist-feminists amongst us to live with.  One of the ways in which we might find a more humane perspective which respects our political, professional and personal needs might be to understand the context within which we do it using an employment relations perspective.  Last week the CQC produced a sobering report about the crisis in mental health services. Chaotic commissioning and sustained cuts in mental health services leading to the profound conclusion that if you reach a crisis on your life and you need some compassion or care you should head to the nearest police station rather than A&E.  In the same week the Guardian’s ClockOff survey came out measuring the stress levels of public sector workers. People working in health are the most stressed out public servants, with 61% reporting that they are stressed all or most of the time.  These reports are not about failures of individual compassion or positive thinking, rather it highlights the impact of precarious work on our states of mind. Mental health has always been the poor cousin of public services, affecting not just those of us using those services but also those of us providing them. Working in mental health has become a text book definition of precarity.  The debate about precarious work is a defining one in the field of employment relations, making the research link between between nationally set cuts and targets, privatization of services and growth of externalised labour, the use of command and control management, work intensification and bullying cultures.  The confusion and ignorance about the employment relations system of psychotherapists is very much about the continuous privatization and restructuring of the NHS and the 2013 shift of commissioning powers to local level. However it also exposes a range of employment relations problems faced by psychotherapists, including the growth of contract and agency labour, the use of unwaged labour, the insecurity of ‘permanent’ psychotherapists in the NHS and the retreat into private practice. We will look at each problem in turn.  The advent of agencies is nothing new in healthcare but with the massive rise in demand for mental health services, NHS cuts and waiting lists of between 6-18 months we are now seeing the creation and expansion of private contractors and employment agencies for therapists. Because of the intense insecurity of agency work and the fear of blacklisting of individual therapists, nobody wants to talk about this growth of third parties in mental health and, as a result, not much is known about them.  The growth of contract and agency labour is part of a national campaign to downgrade mental health services. Under the NHS’s Increased Access to Psychological Therapies (IAPT) the main bulk of services are low intensity ‘wellbeing’ programmes, based on a diluted model of Cognitive Behavioural Therapy (CBT). This service is delivered by Psychological Wellbeing Practitioners, a formalized and standardized role with intense targets of 8-10 satisfied clients a day. Under this system if a patient does not pick up the phone for an initial assessment within the allotted 15-minute time period they are referred back to their GP, presumably to wait for a further 6 months.  This model of ‘wellbeing’, to be clear, can under no description be considered as therapy. Although most of the people working as PWPs are highly qualified their job is not to provide a space where patients can actually say what is on their mind. The work is scripted, manualized and always leads to one compulsory outcome which is that everyone feels well. Computer says no. PWPs who 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.  To add insult to injury, tucked away in the 2015 Budget is the proposal that IAPT services should be introduced to 350 job centres in the UK. The ‘psychologization’ of poverty where unemployed people are forced by precarious PWPs to internalise a global economic and social crisis. In this scenario its hard to imagine who needs the most help, the client or the clinician.  A growing percentage of IAPT services are provided by contractors and labour agencies who are literally buying up the growing NHS waiting lists. As with all externalised employment relations, it is not just the contract of employment that gets passed over to third parties, it is also the responsibilities of employers. Many people working in the NHS via agencies receive no training or supervision raising questions about the duty of care to clients and employees.  The second employment relations problem in psychotherapy relates to internships, or the widespread use of honorary psychotherapists. The most important part of your training as a psychotherapist, along with your own personal therapy, is to carry out clinical work. In order to train as an adult psychotherapist and become an accredited member of a professional body you have to work part-time - usually 1-3 days a week for between 4-8 years. The problem is that the trainee is not paid. There is currently no comprehensive data on how many psychotherapists work unwaged as honoraries, but with 6,000 psychotherapists being trained every year a conservative estimate is that 2,000 full time jobs in mental health are covered by unwaged workers. This includes a substantial percentage of the psychotherapists working for the NHS, the big 3rd sector providers such as Mind and many local mental health charities providing clinical and wellbeing services in the UK.  The professional bodies are complicit in this system of unwaged work leading to the curious situation that the bodies charged with building a sustainable profession are currently not able to do that. If there is a political cause worth fighting for it is to make the demand for our professional bodies to organise a platform to negotiate wages.  As a result this is a profession open primarily to people from families rich enough to support them. There are some who work full time and do the training on top, but there is a real risk that (as in other fields such as the media and the arts) the great majority of practising therapists will be people from affluent backgrounds. That 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.  The third employment relations problem relates to therapists employed directly by the NHS. In most cases the days of ‘permanent’ contracts are over, with cuts in funding and increasingly short funding cycles meaning many of the jobs are fixed and short term. Most NHS services are understaffed, particularly in Child and Adolescent Mental Health Services (CAMHS) leading to an emerging gold rush for private contractors and agencies. The insecurity of NHS workers has profound implications for ‘workplace fear’ and creating cultures where clinicians are reluctant to raise concerns about patient care. Despite the important debate going on now about raising concerns in the NHS the reality is that precarious workers are unlikely to speak up for fear of victimization and job loss.  As a result, many experienced psychotherapists have retreated to private practice, unable and unwilling to navigate a broken system. Many make enough money to survive, but only having spent most of their working lives in the NHS leaving their pensions intact. This generation of psychotherapists will retire within the next 5-10 years leaving behind a whole generation of self-employed psychotherapists, many of them working within social enterprises and charities, who will never earn enough to cover the basics of pensions or sick pay. It is not to say that private practice does not offer massively needed services, it does, and a careful assessment and referral can make the difference between life and death. But it increasingly means that services are accessed only by those that can afford it.  The current economic argument for mental health services is based on the unacceptable working conditions of thousands of mental health workers. From Psychological Wellbeing Practitioners, to IAPT workers in job centres, to the clinicians employed by Maximus and Atos to carry out welfare assessments, working in mental health poses significant health risks to both clients and clinicians. As long as psychotherapists are working quietly and diligently under precarious conditions the NHS as an employer will never respect the people who work for it. In a context of deteriorating mental health services, the fact that psychotherapists are an unorganised and silenced group of public servants is a matter for both professional and personal ethical concern. To book your place on Life as a Therapist - How to Survive It! click here.  Note: this piece had an unusually lovely response from some of you working as psychotherapists. On a very bad day I found myself at 9pm ducking out of the cinema with friends to write a work email. Despite EVERYTHING I KNOW about not doing that I opened my work email account while sitting in a toilet cubical and was stopped in my tracks by this email from a bloke called Phil. People, the way we talk to each other really matters. Dear Elizabeth,I have just read, and very much enjoyed, you article in the BPC New Associations publication. As someone who has just stood down from my role running an Arts & Mental Health organisation http://www.hootcreativearts.co.uk I concur that the precariousness of proper funding impacts negatively on the mental health of staff in the Third Sector as well.But my real reason for contacting you is to share a poem inspired by your piece. Don't worry, it's quite short, and probably better fun than most e mails you get! The Happiness AgendaThey’re privatising madness now, they’re contracting it out.You’re a valuable commodity if your sanity’s in doubt.A team of eager therapists require you to attend aProgramme for wellbeing and the happiness agenda.I know you think your problems are complex and deep seated,But the therapists are highly trained with mantras that, repeated,When you find yourself in crisis, will get you back on trackAnd permanently banish that monkey on your back.Your psychological repose can now be guaranteedWith only 6 week’s sessions of regular CBT.The script is very simple, life need not be HellAnd the mandatory outcome is that you WILL feel well.The fact that you were sodomised by someone that you trustedCan easily be put aside when the technique has been mastered.Everything you thought was wrong, can now be circumventedAnd the miserable bastard you once were can just be re-inventedIt’s fifty quid a pop my friend, but at the last electionThe Government sold off the rights to manage your correctionTo a proper state of happiness, to make sure you were fitTo get yourself a shitty job and feel the benefit.From mad to poor it follows on; the CBT invasion.It’s coming to the Job Centre as a new form of persuasion,Because the economic crisis might not have come to lightIf the poor had been more positive and got their thinking right.A businessman has bought the rights to treat our mental health.There used to be an NHS, but gradually, by stealth,They are flogging off our madness for the lowest unit costAnd in the process something quite important will be lostNot just the common decency to face up to distressAnd see it as a facet of our general humanness,To lend a gentle helping hand, to listen when it hurts,To have the courage to stand by, to know it might get worse.But also in our lunacy, a loosening of the tight,Resides the seeds of genius and the power of human flight,The instinct that a journey might not need a destination,That being lost might be the start of all our inspiration.They’re privatising madness, it’s going for a songThey think they’ve got a bargain but they got the price all wrong.They think that we want happiness, no matter what the cost,But some of us are happier when we’re a little lost. Good luck with your work - at least Jeremy Corbin has appointed a shadow minister for Mental Health.Cordially,Phil