The Age of Uncare
Last year I did a national survey of working conditions in therapeutic services, the results of which we’ll be presenting after the Easter break. In the process I fell in love with hundreds of people – from the community mental health nurse who coaches patients on surviving Work Capabilities Assessments, to the senior psychotherapists taking a sustained managerial beating for their teams. Along the way I stopped worrying so much about how to ‘solve’ services, because of the calibre of the people working in them. Far from their silent unworldly image, I have to tell you therapists are profoundly political, understand the economics of care and feel powerful stuff about their work. Here are two important contributions to the debate about the future of care from Ian Simpson and Ruth E Jones. Both clinicians with politics.
Managed Care Models
Although neoliberal economic theory purports to promote equality through unfettered free enterprise, this is based upon a false premise. We are not ‘all in it together.’ The inequality between the ‘haves’ and the ‘have-nots’ means that everyone does not start from the same position. In fact, as many eminent economists, including leaders at the IMF and World Bank, now recognise, increasing inequality has seriously adverse consequences for the productivity, wellbeing and effectiveness of any society.
The cultural paradigm lying behind the UK’s mental health system is rooted in neoliberal political and economic theory which argues that unfettered free enterprise, elevating self-interest over social and group needs, will optimally organise every facet of society, including mental health and social life. This is a belief system founded upon empirical, scientific principles, which conclude that the nature of reality can be understood by behavioural and materialistic theories of human development, discoverable by a particular form of evidence-based research, like randomised control trials.
Of course, evidence-based approaches are not bad per se; it is rather how the ‘evidence’ is construed and how alternative approaches or models are dismissively excluded which is problematic. The validity of the ‘evidence-based’ research culture is based upon a series of dogmas which fuel a fantasy of discovering a ‘perfect’, all encompassing understanding of how we function together, dangerously over-objectifying and reducing, rather than valuing, what is human.
My argument is that it is essential that this model is countered and mediated by a wider, more inclusive socially oriented group-relational understanding of how we live and interact together.
The current trend in social and mental healthcare systems is dominated by the ethos of a structural managed care model which prioritises manualised, individually oriented and focused clinical treatments, and the dominant model of Cognitive Behavioural Therapy (CBT) in the NHS. Imposing this model is, in my view, ethically and professionally misinformed. In its attempt to reduce anxiety and risk it actually does the opposite and creates conditions which increase anxiety and perversely cause trauma, resentment and a reactive defensiveness in staff.
The predominance of CBT as the panacea for mental distress sustains this fantasy that society’s ills can be contained within one limited model and views them as technical problems or medical illnesses, as if they were individual problems, divorced or separate from the social culture and context within which they occur.
Managed care models foster a cultural context where health and wellbeing become commodified and the human relational elements, which are intrinsic to care, become devalued. Tasks are organised with other aims in mind, like targets and depersonalised procedural mechanisms and this can create a context which distances clinicians and care staff from each other and from personal contact with those they care for.
Under the managed care model there has been an explosion in middle managerial jobs largely at the expense of clinical ones and, as a consequence, this has seen a large increase in the pursuit of ’targets’ and bureaucratic imperatives. As these are driven on by centralised directives, designed to increase efficiency and throughput, pressures increase upon clinical staff to fulfil what seem like incomprehensible and clinically irrelevant bureaucratic tasks, which, notwithstanding the necessity for properly evaluated practice, are extraneous, unnecessary and stultifying.
A disparity develops between the aims of the managers and administrators and those of clinicians. This is experienced as an imposition from above with little apparent concern for what is actually required to address the pressures of managing the clinical work. Staff stress is increased and levels of anxiety are raised.
Our anxiety increases if we are asked or required to do something we are unable to do because the conditions and the context of the working environment conspire to thwart us in the task. This can lead to situations where financial cuts are implemented in the name of efficiency and staff are still expected to maintain the same work levels with less resources available. If overstretched and overworked staff are asked to achieve unrealistic targets or are compelled to do clinically irrelevant paperwork, if staff are put into situations which leave them feeling impotent and traumatised in the face of patient needs by reducing the type or length of treatments against their professional judgement, then, of course, anxiety will increase.
If we sanction a health care system based on a business model where profit is the motive for efficiency or the rationale for decisions about resources we get one where the desire to reduce financial cost pressures triumphs over ethical, professional and clinical judgement. If we sanction a health care system where financial incentives are the priority we get a system which is likely to become less concerned about staff and patient needs and more likely to cut corners to maximise profit.
Group analytic theory and practice emphasise the social and relational nature of human beings and our essential interconnectedness. This is not to say that the social or group to which one belongs takes precedence or is elevated above the individual. In essence the focus is upon our interdependency. The aim is to consider the relationship between the individual and the social group as intrinsically and actively linked together dialogically in meaningful interaction. This is an open-ended, emergent process, which requires a safe-enough containing context to thrive, integrating and promoting healthy biological and social processes. A prerequisite for the establishment of any social care system should be based upon a bio-psycho-social understanding of human relationships.
Someone presenting with a mental health problem, for instance, should not be seen as only bringing a separate individual problem. Their problem represents only one aspect of an intricate and complex social/group phenomenon. Individual disturbances should be located in all the aspects of a person’s life and in their network of interpersonal relationships. We cannot conceptualise or consider individuals as if they were in isolation from the formative, social and cultural context in which they live and work.
A group analytic understanding is an essential prerequisite to enable healthy containment of anxiety, both for the individual clinician and for their colleagues in the working setting. The fundamental basis for social care systems and for communal life must be the acknowledgement of our interconnectedness in the living and working environments we share together. An organisation does not exist as a thing outside of ourselves. It is a dynamic, creative, evolving construct, which emerges in the relationship between the people who form it and are formed by it in lived experience.
I spent most of my working life trying to establish and develop with colleagues a safe enough context to optimise the therapeutic potential for staff and patients, in a psychotherapy service in a major teaching hospital. A lot of my time in the latter years was spent defending and protecting staff from the ever increasing imposition of bureaucratic measures, ostensibly designed to improve efficiency and the containment of anxiety generated by the pressures of our workload. As resources were being reduced and a new model implemented from above, this created an intolerable situation for clinicians as they struggled to look after the patients in their care and, equally as importantly, to safeguard their own health and wellbeing.
Of course, like any reasonably sized service with a hierarchical pay and status structure in place and the inevitable professional and personal dynamics colliding as they do, we were far from perfect. However, we were able to deal with and contain these at a manageable level because of the sense we had of the basic requirements needed to underpin and stabilize our working model.
This was based upon a set of holding principles formed by an analytic and thoughtful holistic understanding with reflective spaces for staff, which facilitate thinking and working through issues and difficulties and, most importantly, the maintenance of a safe enough/good enough context as a container that will hold staff and patients together throughout these processes. We were informed by our training and professional practice, which enabled us to move towards an understanding, reinforced by experience, that containment and holding staff and patients was a social phenomenon, embedded in our interrelatedness and connectedness rather than one which focuses solely or primarily on individual psychopathology or target-driven results.
A dismayed psychotherapist in the Midlands, struggling to re-build a private practice after a career break, recently came across an advert on Facebook for a local counselling course, promising ‘the career of your dreams’. Inevitably it had elicited an array of likes and questions about how long it takes and how much you can earn. Well-intentioned forwardings suggesting this would be a great way for someone’s friend to invest their redundancy money.
Over the last thirty years counselling and therapy trainings have proliferated in this country. Passionate people with creative energy and enthusiasm for new approaches have established courses to the extent that the British Association for Counselling & Psychotherapy (BACP) alone, just one of the statutory regulators, now has over 40,000 members.
The trends come and go. Brief Cognitive Behavioural Therapy (CBT) is frequently recommended in the NICE (National Institute of Health and Care Excellence) guidelines. Then there’s attachment therapy and a proliferation of mindfulness and mentalisation-based approaches, as well as the long-established paradigms of psychotherapy praxis. With all trends in therapy the ‘evidence base’ for each sooner or later shows that they are not a panacea for all ills but, quite reasonably, of help to some of the people some of the time. Meanwhile, NHS and statutory sector therapy services have been relentlessly eroded so that the rare advertised psychotherapy posts attract overwhelming numbers of applicants.
Trainings and professional bodies require candidates to accrue hundreds of clinical practice hours to become qualified and registered, shoehorning many into ‘voluntary’ placements. Indeed some large counselling organisations, and even NHS therapy services, rely on a continuous stream of unpaid trainee therapists. The business model involves employing a part-time clinician to manage whole teams of unpaid practitioners, citing supervision and the opportunity to gain experience as sufficient reward. While practicing lawyers and accountants do have a tradition of pro bono contributions to charity, which other field would accept this culture of free labour and the assumptions it creates, both within and about the profession?
Within the psychotherapeutic world there is a rather nostalgic idea that donating many unpaid hours to training and other committees is a way of ‘repaying’ what one has been given by professional forbearers. This ‘generosity’ is sustainable because these positions within the professional bodies provide contact with a steady flow of trainees who are required to have personal therapy and supervision. However, these days there can be a rather guilty acknowledgement that trainings are governed by the ‘bums on seats’ imperative for their own survival. Market forces apply, and a pyramid begins to emerge with trainee lifeblood sustaining the organisational infrastructure. If we then factor in the professional indemnity insurance, annual registration fees and ongoing requirement for CPD once qualified, the pyramid becomes more of an iceberg. From anyone’s inbox it is easy to see how the CPD market has burgeoned. Of course there is an important, healthy dimension to continuing to grow and develop, both as a person and as a professional but it’s important to recognise that becoming qualified is just the beginning of the ongoing financial outlay required.
In the absence of properly remunerated and structured jobs most therapists turn to private practice. This, as with other forms of ‘self-employment’, is not as profitable as is commonly believed. The erstwhile professional registers and collegial referral networks are being outpaced by strategically positioned website-based businesses, offering to put your name on the map for a fee. The sky is the limit for spending both money and time on marketing, websites, and social media presence to reach the Facebook and Snapchat generations. Outside the few remaining NHS and university departments is the marketplace which requires a whole other set of extroverted presentation skills, often at odds with core therapy and counselling aptitudes.
Increasingly therapists encounter that many-tentacled beast, the Employee Assistance Programme (EAP), which markets workplace ‘wellbeing’ packages to businesses and organisations. The EAP operates as a broker between the therapist and the employer, and then matches the employee-patient with a local practitioner, usually simply by trawling the established UKCP and BACP registers by postcode. The therapist accepts the referral for brief work (6-8 sessions usually but sometimes as few as 4) for a pre-set, low fee. Importantly, the clinician carries the clinical responsibility for the work while the EAP middleman harvests the profit.
Very good things can be done in short-term work, and many minimum wage EAP clients would be unable to pay for therapy privately. However, the therapist can find themselves working with all manner of distress and disturbance, without meaningful backing from the referrer who is usually an administrator and webmaster and almost never a clinician. Add to this the reality of working as a therapist in this ‘gig economy’, and it becomes clear that the reality for the clinician is one of precarity.
With the disappearance of many NHS mental health in-patient services, the distress that patients bring into the consulting room is growing. It is widely acknowledged that the population accessing therapy is increasingly so-called ‘borderline’ (usually defined as a combination of poor self image, lack of empathy, anxiety, depression, feelings of emptiness, dissociation and unstable relationships, among other things). Thus the work can be very difficult and requires great resilience. Mental health funding cuts mean that external support can be little more than the (excellent) Samaritans and other phone lines, even for the significant proportion of suicidal people who don’t respond to medication.
People are suffering and looking for help: newspaper and social media reports have recently highlighted unprecedented levels of teenage self-harm and anxiety, while the Mental Health Foundation continues to remind us that 1 in 4 in the UK will suffer from mental health problems in any given year. More and more robust, multi-disciplinary statutory services are being replaced by this extensive network of private practitioners with varying degrees of experience and training. Practitioners group together with like minded colleagues, creating their own support structures to try to sustain themselves in the work they love and in their commitments to the people they treat.
Mental healthcare in the ‘Big Society’ comes down to a tier of highly motivated, self-resourcing therapists struggling, often at great personal cost, to help heal their community. All this while being drained financially of their honest (not-for-profit) income, policed by ever more simplistic codes of ethics and bullied into defensive practice by naive and time-consuming outcome measures: the Squeezed Middle indeed.
Freud treated hysterical symptoms and neuroses and in so doing created a vocabulary for understanding individual and collective human experience, which revolutionised attitudes and social norms far beyond the clinic. A century later, rather than revealing the psychological realities in our society, the counselling and therapy professions are being increasingly coerced into repatriating people silently back into the very social malaise that is making them ill. It must be time for private practitioners to lift their heads from the grindstone, and speak from the heart about what they know is really happening to themselves and to the people they see.
Private doesn’t have to mean silent.