Hello from the Therapy Factory

“Therapy for all. Wherever you are, whenever you are. Learn to live without the suffering that comes from depending on your partner, friends or other people with the help of a specialist.” “Therapy is all about the relationship. We ensure that if you don’t click with your therapist you can try another at no additional cost. No commitment, nothing to lose.” Quotes from online therapy platformsLike many of you old lags who read this blog, I’m used to being the spectre at the mental health feast. All matted hair and bleeding eyes, squeezed in between Zumba for Success and Professional Grit Bootcamp sessions, I’ve regularly been slow clapped out of mental health conferences. Often reality is hard to witness. I stopped going to mental health events some years ago, tired out by presentations made with the easy charm of people who aren’t actually affected by the crisis in services, with fake debates and people just saying clever stuff, I could no longer afford the time and money this non-activity demands. But nothing like a real mental health crisis to bring us to our senses and now we find ourselves in the luxurious position of going to talks about mental health with people not afraid to step outside of the matrix and look at the very bleak future for mental health services. Ah, money. It’s funny how hard it is to talk about who is making it and who is not. Most people working in mental health don’t earn enough to sustain themselves. Part time self-employed work, mixed with the culture of unpaid honorary contracts, and the myth of earning a crust in private practice has led to the situation where the vast majority of the people treating you for depression with anxiety are broke. This shameful situation is very hard to talk about within professional circles. Several years ago I did an event for a psychotherapeutic professional body about money with a well known academic of the heroic activist variety. It was my first time engaging with what I thought was a debate about the crisis of wages in the sector. After the first 20 minutes of listening to clever stuff about Nietzsche and some young men with beards unselfconsciously telling women about power and domination, I felt a bit sick because my talk was about, now wait for it, actual money. You know, actual facts about how much people are earning. Although better than the low point of popping the balloon of job security at an entire RCN conference in Newcastle 2017, I definitely left the room feeling stupid that at this evolutionary point we could only talk about money in the symbolic. Not put off by the very clear lack of demand from the professional bodies, this led to me running a series of events entitled “Do you have to marry a rich man to be a therapist in the UK?” At the time it also felt like running into a brick wall but piece by piece an alternative version of reality started to reveal itself through the brave minority of mental health workers who came to these events and spoke up. This then led to the surviving work survey of 1500 workers across the UK - which you can look at for free here. In just twelve months of Covid-19 the situation has become so bad - in terms of falling wages, declining conditions and downgrading across the sector - that suddenly it appears it really is time to talk. And this is just as well because things are about to get a lot worse. As an industrial model IAPT is a bad enough for the prospect of compassionate care, but what makes this pretty terminal to the future of mental health is that by standardizing, manualising and digitising services the foundations for the Uberisation of therapy have been put in place, now as a result of Covid-19. We are now entering a period where the large digital health companies are about to make a lot of money. If you are at all interested in mental health, you need to read this. The future of mental health services is digital. Large tech companies are developing healthcare products that ride the wave of ‘solutionism’ of government policy by providing services that are mechanised, scripted and online. Wading through the Neurolinguistic Programming and made up words, digiceuticals and digital therapeutics offer digital ‘treatment’ based on software plus clinically trailed ‘evidence’, plus prescriptions without face-to-face contact with a clinician. Unsurprisingly for the medical model of mental health that dominates globally, digiceuticals focusses on a range of our society’s major fund sucking health problems including diabetes, cancer, hypertension and addiction. Cheap cost per patient and large scale provision, not exactly the robots taking over but introducing a digital intermediary into care often focussing on software for addiction management and interventions for schizophrenia. Many of these companies are large American multinationals, including UnitedHealth and its digital wing Optum, the employer of Simon Stevens for much of his career before heading up the NHS. Worth mentioning because it’s hard to work out who apart from Matt Hancock thinks an App can cure depression because it's not people with actual depression. The creation of digital therapeutics lays open the door to the large scale companies that have the software packages all ready to go. So it matters enormously that health ministers and the current NHS leadership seem to have no problem with promoting digital technologies because they offer a financial solution, rather than a clinical one. Digitization raises massive questions about confidentiality and data protection. I might be a bit paranoid in my firmly held view that in the future job interviews will involve a blood test and management will be carried out using facial recognition technology. But it’s not paranoid to observe that the entire mental health service is being modelled so that it can be delivered via software. The second part of the Uberisation of Therapy relates to the  growth in online platforms in healthcare. Platform companies are the big providers of the future - made up of software and databases of workers and clients often providing services online. In a way this is nothing new just agency work carried out and managed digitally but the issue is the scale and speed at which platforms can become providers of services. The reasons why online platforms are so effective at recruiting crowd workers and clients is the size of their databases and the click-natured simplicity of accessing services. No waiting lists, no more the inconvenience of actual face to face contact. The advent of platform companies represents a key component of work in the gig economy, where workers are advertised by a platform, on self-employed contracts, to carry out hourly paid/pay per product tasks. In General Practice consultations are routinely offered online through platforms.This is now happening in the therapy world, with online platforms offering sessions for £40-50 per hour. With a platform taking a cut, this amounts to a 50% reduction in an average low hourly fee in private practice. So this is the first thing to say about platforms - they undercut the hourly rate because the temptation to swipe past a therapist demanding a living wage is too great. The Uberisation of therapy represents a model of digital Taylorism that exists right across the gig economy, increasingly not just in food and logistics but also in the professions. In Briken and Taylors’ study of Amazon workers there are some striking similarities with what is happening in mental health: work intensification, standardised tasks with no deviation, algorithmic control of work, the collection of personal data of both crowd workers and clients. Downgrade the task, you can downgrade the job and with it therapy that’s cheap as chips. As someone who has had a tonne weight of long term therapy and analysis, the thought of not having to be in a room with someone who challenges deeply held beliefs and self-destructive tendencies is really seductive. However, it kind of misses the point of what therapy is, based on an idea of a therapeutic relationship of trust and respect where complexity can be unpacked. The two quotes at the beginning of this blog were taken from the websites of two UK based therapy platforms offering online therapy. These quotes could be googled by a small child so nobody is hiding the change that is taking place. The threat to therapy is in plain sight. It’s that this introduction of an algorithmic model introduces a number of really compelling by-products. Firstly if you’re attached to the digital health industry you can make a lot of money designing software that allows you to provide ‘therapy’ on a smart phone that offers 50% recovery rates. This system will also provide you with the capacity to collect data that provides an evidence base that despite being so spectacularly perverse and counterintuitive can be rolled out at digital health conferences and meetings with DoH as if it’s actually true. It can be done so easily that nobody, including our governing bodies have to bother about actually understanding the technology enough to question whether it delivers. By the time the NHS has bought, tried and failed to use the software the money will have left the system. The Uberisation of therapy is not about care, it’s about making money. We’ve spent too long in mental health acting as if we’re living in a 17th century French court. Worrying about the minutiae of independent practice and wheeling out the ROIs of decent therapy. None of this was of any actual interest to the major and future providers of care and has subsequently failed to gain any political traction. Under any definition this represents a hostile organising climate. But since we can’t afford to waste this current crisis we have to start organising for the likely future of services online.This article was originally published in UberTherapy: Working in the therapy factory free to download here.