What's wrong with the mental health service?

“The [IAPT] role is high-volume low-intensity, just churn them out. It’s viewed as an unskilled job. The managers would say don’t take on counsellors in this role because they are just trouble and not prepared to do tick-box services. It’s an uncomfortable dynamic with the young psychological wellbeing practitioners (PWPs) straight from universities, who are naively prepared to do as required by the service. In reality most of our patients have lots of life problems - we work in a really deprived area, lots of housing and drugs problems and severe depression and anxiety. That’s kind of ignored by the service providers because they have to answer to their commissioning group. There’s a big gap between the data and the reality of what we’re trying to do.”Psychological Wellbeing Practitioner, Liverpool  On the 15th June a new book, The Industrialisation of Care will be launched in London town. This is part of the emerging literature that takes a sharp intake of breath and digs deep into the mental health crisis. Far from the positive stuff of taking the time to talk and deep breathing, this book suggests that the problem is both profound and political. It looks with rare honesty at England’s largest mental health programme - Increased Access to Psychological Therapies (IAPT) - and argues that this model of a mental health service is actually based on a strategic downgrading. An emerging sub-therapy that is dangerous both for the staff delivering it and the people who are prescribed it, exposing the real mental health crisis we’re in. This is not to denigrate the work of people working in IAPT, the vast majority of whom are qualified and experienced providing what care they can. IAPT services are also diverse, with often heroic efforts by teams to protect the principles on which real care is based. But increasingly whether you work in IAPT or not, the model of mental health dominates across services, peddled without due diligence combined with a strategic intention to use mental health services to cut the benefits bill. When 60% of disability benefits are paid on the basis of mental illness is combined with IAPT's fantastical claims of 50% recovery rates, you don't need a maths GCSE to work out why IAPT has such political traction in the age of austerity. Currently there is no political will within our institutions to address this attack on our collective mental health. This book is part of the growing movement that challenges policy makers to take a position on the future of therapy. The following section from my chapter - The Future of Therapy - using the results of the Surviving Work Survey (you can view this for free at www.thefutureoftherapy.org) of 1500 mental health workers and looks at the industrial relations of therapy. What’s wrong with IAPT?The Increased Access to Psychological Therapies programme provides short-term results-oriented cognitive and behavioural therapy, and has been introduced as a ‘talking therapy’ that efficiently addresses individual psychological states. The ‘evidence base’ for its effectiveness has been established through the widespread use of performance data, drawn from a system that has itself become highly contested - in terms both of the relevance of what it measures (such as waiting times) and of the accuracy of its claims (such as a 50 per cent recovery rate). The IAPT model is based on a system of patient assessments that uses tightly scripted questionnaires that allow only minimal freedom of discussion between therapist and patient. Though most service users have complex needs, the superficiality of the assessment and performance-data collection process allows clinicians to refer them to short-term interventions that are not, for example, designed to treat depression, and to make claims about recovery that do not relate to the mental health problems that service users are actually living with. Because of the relative low cost of IAPT services, in comparison to the long-term talking therapies and specialist services that require experienced clinicians, the economic argument for rolling out IAPT services has prevailed across the UK’s mental health policy. Although, as campaigners legitimately argue, the financial case made for IAPT has excluded any consideration of the real costs to the UK economy of not treating mental illness adequately - including consequent costs to acute services, police and prison services - the direct costs of IAPT have dominated the debates about how to provide mental health services. As a result, despite the genuine concerns about the ethics and quality of care being provided through IAPT that have been expressed by service users, particularly the many disability and mental health networks in the UK, this downgraded model of ‘talking therapy’ now dominates across the UK’s mental health service. The economic logic for providing mental health services now dominates over any clinical logic. IAPT is also a central part of the political crisis that is emerging for mental health services as a result of its positioning as a key component within the government’s austerity programme and its plans for changes to welfare benefits. There has been a merging of mental health services with the DWP’s programme of welfare reform, as outlined in the DWP’s 2017 green paper Improving Lives: the Future of Work, Health and Disability, and the establishment of the Work and Health Programme, which has replaced the Work Programme. For the first time, health and unemployment services in the UK have been explicitly linked. The adoption of the IAPT model has been central to these plans, since it is cheap to administer, and people who are ‘cured’ are then disqualified from benefits based on the state of their mental health. This is in part a response to a growth in the proportion of Employment Support Allowance (ESA) claimants (the benefit that replaced incapacity benefits) who experience mental health problems. This rose from 37.3 per cent in 2010 to 49.3 in 2016, when ESA claimants numbered 1,178564.DWP Stat Xplore A primary target for reducing the benefit bill is to ensure the return to work of people living with mental health problems.  In order to implement this reform (which is also closely associated with the introduction of universal credit), the DWP and Department of Health have created a series of ‘pilot’ programmes and partnerships between Jobcentre Plus, Work Programme and IAPT services. In 2014, the introduction of Jobcentre staff and employment support workers into IAPT services took place, and there was an initial pilot programme to introduce IAPT services into Job Centres. This was met with strong rejection from mental health activists, despite the initial engagement of five of the large psychotherapeutic professional bodies in establishing this new area of work. The programme has nevertheless been rolled out regionally, and has involved the carrying out of ‘wellbeing’ workshops for claimants, and ‘psychoeducation’ group-work to encourage job applications and skills to secure employment.  At the core of this policy is the introduction of the new ‘fitness for work’ welfare assessment process (where fitness for work, rather than extent of disability, is measured). The process targets claimants with Personal Independence Plans (PIP), or who receive Employment Support Allowance or disability living allowance. This has resulted in a dramatic decline - by an estimated number of 2 million claimants - for these schemes since austerity measures were introduced in 2008 - either through claimants being declared fit-for-work or through claims being withdrawn.  It is very clearly understood by claimants who have ‘volunteered’ for these programmes that the way it links work and mental health raises ethical concerns about confidentiality, the therapeutic relationship and professional conduct. And one of the  implications for mental health workers of this re-orientation of mental health services has been that it has created a significant credibility risk for the sector and for the people working within it; The deployment of the IAPT model as part of a strategy for delivering welfare cuts has raised profound ethical and professional concerns for workers. Indeed, one result of the entanglement of mental health with welfare reform designed to exclude people from benefits, and the weakness of the IAPT model, has been that, despite the acknowledged attack on mental health services from a decade of austerity, there is an ambivalence within the service about government attempts to increase mental health funding by rolling out the current IAPT model.^{Kings Fund, 2017} For many people working in and accessing these services, IAPT is considered a threat rather than an expansion of decent care. All this raises a profound question about what kind of services should we should be spending money on. A further strategic objective of IAPT has been that is an enabler of the opening up of the mental health sector to private, third sector and non-clinical providers. This is partly because it paves the way towards a downgrading of clinical roles and jobs across the mental health sector. The delivery of the new welfare programmes has been carried out almost exclusively by large private contractors, including Maximus and Atos, and the majority of assessments have been carried out by staff who are not clinically trained. The ‘new’ mental health jobs created in these programmes do not require clinicians, and the whole process therefore represents a clear move towards generic and non-clinical jobs in the sector. The manualised and online nature of much of IAPT’s interventions also opens the door to digital providers. Much is now being made of digital healthcare, including grand claims for digiceuticals and the use of App technologies to measure health levels, including mental health; and these have been supported by successive health ministries. The benefits of this tech ‘alternative’ to complex long-term treatments provided by clinicians are clearly empirically exaggerated, but they are heavily supported by the normative logic of austerity on which decisions about mental health are actually based. .  Despite a number of recent mental health inquiries and workforce reviews, there has yet to be any genuine engagement with the emerging crisis in the sector. It may be that one explanation as to why the expansion of IAPT services has not been subject to public inquiry is the vested interests of the individuals and organisations involved in all the reviews (for a selection see below). Given the almost universal criticism of the direction of mental health services on the part of clinicians and service users, the question has to be asked: who benefits from the uncritical continuation and expansion of the IAPT model? To join us at this launch, with speakers including Rosie Risq, Phil Thomas, David Murphy, Gillian Proctor, Maeta Brown and me click here for tickets. To buy the book The Industrialisation of Care click here Counsellors Together UK: National conference of this national network of counsellors in Lincoln on the 22nd June. I’ll be speaking about UberTherapy and the organising challenge ahead for counsellors. For your ticket click here.