the privatisation of madness

 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.  Psychotherapists offer us a graphic case study in the precarious work underpinning the UK’s mental health services. A very important report has been produced by the British Psychoanalytic Council and the UKCP about the working lives of psychotherapists. It concludes that with a 77% increase in complex cases and 63% of clients reporting that NHS therapy was too short to do any good, the reality of working in mental health is that it is literally maddening.  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.  Please help us build up a picture of what is happening in health and social care by sending us your Stories from the Frontline here. This blog was produced for theconversation.com for our column Battles on the NHS frontline: Stories from the vanguard of health and social care.