Socially Prescribed

Drunk on hope and suffering from a democratic hang over I woke up on Friday feeling profoundly lonely. Weeks of life affirming contact with other human beings was welcome confirmation that most people are way ahead of the political leadership in actually practicing their politics. Just 48 hours later and we’re in sight of making concessions around human rights, a red flag that we have entered a period where our institutions are ruthlessly focussed on their own survival, not ours.  I’ve watched Season 5 of House of Cards, but this is like taking a bullet. On Friday I had the self-preservation to meet Chris, a retired GP with a steady mind who has literally done everything in primary care that is now being described as ‘innovation’. Chris is a genuine human being as well as or despite his medical training. It’s through him that I have established a respect for science and an acceptance that biological determinism is not a right wing conspiracy against feminists. As often happens when two very different people meet, we talk about stuff I’ve never thought of before, on this occasion the nervous system, parasympathetic systems and our reactions to stress. He heroically ignores my inability to retain whole facts while maintaining a deep respect for my capacity to think about stuff. I’ll save you my failed-human-biology-GSCE description of the nervous system and skip to the point that in this conversation we talked about freezing and folding, the less well known cousins to fight and flight, and two of our automatic reactions to threat. Although I’m not trying to excuse bad politics, this conversation helped me to process the paralysis and inward looking responses of the current healthcare ‘leadership’ to the very clear writing on the wall for mental health services in the UK.  The Writing on the Wall Last week two things happened that really shook my faith in our ability to turn round the crisis in mental health. The first was that I attended yet another conference at a well known health policy institute in London about the future of mental health in primary care. Honestly, I’m not sure why they still let people like me through the door because by inviting well meaning clinicians to talk about the roll out of the main NHS mental health programme - Increased Access to Psychological Therapies (IAPT) - all they are doing is spelling out on power point slides the government’s strategy to destroy the welfare state. In amongst the graphics on care pathways and integrated services, the corruption of mental health services to facilitate cutting benefits was exposed. I’m going to be blunt now and tell you that this new policy heralds the shift from publicly accessible mental health services to a system of psycho-compulsion designed to cut the benefits bill. The IAPT programme has gone through several waves since its creation in 2008, introducing short term cognitive behavioural therapy and ‘wellbeing’ interventions into the NHS. Much has been written critically about the quality of IAPT services and conditions of the people working in it, but this hasn't stopped the roll-out of IAPT from adult to children’s services and primary care. The growth of IAPT has led to the dominance of a short term and diluted model of cognitive and behavioural therapy (CBT) despite the ‘evidence-base’ for it’s effectiveness being widely challenged. What I had not realised until last week was that the next wave of IAPT now rests on delivering services designed specifically to reduce welfare claimants. Welfare is being reformed with the introduction of the new Work and Health Programme in Autumn 2017. This new strategy is being delivered under a partnership between the Departments of Health and Work & Pensions, and the many private sector providers operating in both sectors, designed to increase the physical and mental ‘wellbeing’ of claimants to get them off benefits. This link between mental health problems and benefits is clear - we know that 50% of disability claimants are living with mental illness and that the ‘problem’ of mental health has an evidenced link to growing poverty and inequality in the UK. But the new Work and Health programme does not attempt to increase incomes through decent jobs because, as any honorary psychotherapist working for Mind or AgeUK will tell you, finding a job that pays a living wage is an increasingly remote possibility. Reform will happen by partnering employment and mental health services in GP surgeries and Job Centres. This includes the introduction of employment support workers (ESWs) and wellbeing services into GP surgeries funded through the DWP while the Third Sector provides trainees and volunteers to bulk up the numbers. Additionally ‘Allied Healthcare Professionals’ will provide mental health services for Job Seekers Plus and the private contractors delivering ‘employability’ interventions for the DWP such as Reed. Much of this work will be online or using ‘psycho-education’ workshops to build individual psychological wellbeing. Despite the image of a Job Seekers Plus wellbeing workshop being delivered by an unwaged trainee having the depressing feel of careers advice in the 1980s, I’m a big fan of adult education. My experience of delivering psychosocial education for the last few decades is that if you put a group of people in a room together and allow them to talk freely, good stuff can happen. This is doubly so if you have an experienced and kind facilitator. However this wellbeing and psychoeducation ‘service’ involves an appropriation of participatory and therapeutic methods in an attempt to stifle non-compliance. Discussion groups and listening exercises, used to silence rather than empower because of the inherent threat of benefit sanctions and recovery targets. Although the methods might in principle be sound, they are being delivered in a context of compulsory wellness where both service users and service providers must be fit for work. A laugh-or-cry aspect of these new wellbeing services is the use of social prescribing. This is an actual thing that is talked about with a straight face, where people are prescribed through the NHS social activities that will help their wellbeing. I don’t want to be rude but there’s a strange twisted feeling in getting a prescription for being social from my lost and burnt out GP. It’s true that loneliness and lack of recreation is a massive problem in our society, but for most of us this is due to a lack of time, money and public services, not the absence of a prescribed social activity. I’m just not sure that the NHS is a centre of excellence for having fun. The use of these prescriptive methods in the current mental health service is a long way from the emancipatory aims and free association on which psychotherapy is based. What is happening here is the perversion of mental health services through the industrialisation and bureaucratisation of care. The wellbeing checklists, self-guided apps, the fitness for work assessments are not some benign mistake, it is precisely through them that a psyco-compulsion is being introduced. This is not my paranoia, it’s literally through the compulsory reporting of a 50% recovery rate in IAPT that people will be deemed fit for work and their benefits cut. Under this regime, people are being silenced and herded into ‘voluntary’ wellbeing programmes through the threat of sanctions. This radical reform of mental health services is being slipped in under the radar because we have put people who are financially invested in maintaining this system in charge of the professional and political bodies that govern it. They have been seduced by the prospect of 3000 new mental health jobs by 2020 and the warm glow of a safe retirement in the next five years. Whether conscious or not, our current leadership have allowed us to enter a period of freezing and folding inwards rather than fighting the necessary fight to defend genuine therapy. If the motivations of the people designing and delivering mental health services are just to keep this industrialised model of care on the road then what comes out of mental health services will be radically different from any concept of patient led care that we’re familiar with. As is common at such events, it takes a working class service user from Nottinghamshire in the last session of the day to bring some sanity into the debate and point this out. Having patiently participated in the power points he says out loud that despite being on the left, he won’t campaign for more mental health funding until the system is worth defending. He said that the best thing for his mental health was to spend time with friends for which you don't need to set up a whole industry of social prescribing delivered by third sector volunteers. You just pay people a basic income enough to make their own decisions about how they live. Therapy in the current political climate is being used to normalise the fact that more and more people in the UK don’t earn enough to live a decent and secure life. Rather than engaging in wage bargaining or progressive reform of welfare benefits, the state is using mental health services to evade their social responsibilities to establish a functioning industrial strategy. Silencing the People on the Edges The second thing that happened last week was that I was told that I had been blacklisted by two of the main psychotherapeutic bodies in advance of my publishing the results of the Surviving Work Survey that looks at working conditions in mental health services. Despite the recognised and chronic lack of mental health workforce data, it appears that independent research is not welcome in the ever-decreasing-circles of our professional institutions. Despite this fact-phobia, we will inevitably see over the next year more information about the workforce crisis about to hit health and social care. Some of the reasons for this are general - that the UK is a low wage economy, the impact of Brexit, and the unsustainable costs of clinical training and professional registration. All of these factors are bad news for keeping genuine health services alive but mental health services are facing a much deeper crisis over the emergence of sub-therapy and psycho-compulsion and with it the corruption of the therapeutic field. As someone who has a long term relationship with psychoanalysis, as a patient and a clinician, I do not in any way underestimate psychotherapy’s powerful and, under the right circumstances, political framework. I believe it helped me stay alive and grow up to be an ordinary human being. I also think it has made me a better activist and more likely to bring about social change. Although most of the people working in mental health still use this core tradition in their work, the principles and practices of psychotherapy are being perverted by the implementation of IAPT and the Work and Health Programme. Firstly, genuine psychotherapy increasingly is not offered in the NHS because it can’t be done as cheaply as IAPT interventions. This isn’t to say that the ROI of psychotherapy can’t be argued - it can if you’re actually interested in treating actual people with actual mental health problems. But the ‘evidence base’ for IAPT is based on a model of telephone assessments using scripted questionnaires where nobody can actually say how they feel, allowing assessors to refer patients to short term interventions that aren’t, for example, designed to treat depression. Although increasingly real therapy isn’t being delivered through IAPT, what matters to the government is that in the short term it’s cheaper, particularly if its delivered by unwaged trainees provided by clinical training and professional bodies. What may be more problematic in arguing for funding is that because psychotherapy helps people to take control of their own lives it means that the ‘evidence base’ for psychotherapy can’t be manufactured around the demands of politically set targets. Although research shows that psychotherapy is highly effective in the long term, it doesn’t compel people to become well in a 6 week period. Ironically for therapists in the business of talking and thinking, the psychoanalytic professional structures are not doing that when it comes to the future of public mental health services. Although there are some extraordinary people in these systems, the prevalence of Noasarkism and the strains of managing decline has provoked both a freezing and a folding inwards. This is not principally a problem of innovation - in my experience clinicians are always having good ideas - rather a problem of professional ethics. That the bodies charged with defending psychotherapy are failing to defend the principles on which they depend. This might explain the reluctance of the professional bodies to engage in the much needed debate about the future of mental health services with a wider audience including those critical insiders and outsiders who are researching workforce issues. Add to this the temptation to blacklist critics and you end up with a system that cannot hear different views and becomes entrenched in defending their own existence. Although this freezing and folding is understandable as a response to threat, it is about to create a split between the interests of the people providing the services and the people accessing them.If you think I’m exaggerating, ask an IAPT worker if they would let their family use the service. ParasympatheticI relate all of this along with swearing and hand gestures to Chris. As often happens when you find yourself talking to someone who is actually listening to you, you end up learning what you believe. Out of the blue I found myself saying “I don’t know whether I believe in mental health any more”. That’s a gulp-moment for someone who has just spent the last ten years trying to build their own and other people’s. Just as I say this tear-jerking-statement-I-never-thought-I’d-make, a familiar face comes up to our table, all glowing and smiling and invites us to an anti-war event. This beatific creature is Bruce Kent of CND. Not a day older, not a whiff of cynicism or despair, just a man secure in his beliefs. We then try to tell him how much he means to us without actually licking his face. Hope incarnate. One of the tyrannies of witnessing the speed at which mental health services are being corrupted is that its hard to resist the urge to act. There is a battle ahead about the future of public mental health services in this country and although there’s nothing wrong with being an activist or a therapist or both, sometimes doing is a way of avoiding reality. Not wishing to get all Freudian on you, but understanding is the foundation of change. Everyday politics is a long-game requiring enormous stamina and a good sense of humour. When something important has to be understood it requires the mind to slow down and enlist the parasympathetic system that allows the body to relax and be still. Rather than launch myself all-fists-and-teeth into the next fight or go off-grid living with wolves, I’m going to spend the summer thinking and writing about the future of mental health services from the perspective of the people delivering them. I’m going to do something that does not come naturally to me and be pedantic about my methods and measured in my analysis. I’m doing this because the facts need to be delivered in a way that demand they be heard rather than dismissed as the rant of an angry insider/outsider taking a pop at her parental objects. I am all of those things, but goodness only knows what would happen if we had a discussion about the future of therapy based on actual facts.  Surviving Work will be back in the Autumn. In the meantime you can join us at the Freud Museum on July 15th to think about the unthinkable: from thought blocking to everyday fascism. To book a ticket click HERE.