The Food Chain
Somewhere in 2009 policy died as austerity kicked in, so even going to a mental health policy launch made many of us feel a bit dirty. In the current legitimacy vacuum policy is determined by who turns up at meetings. It means that policies designed quietly in un-representative bodies should command our interest.
I’d like to say some things before I get stuck into the current policy bun fight. I know some very brave and progressive people are operating within the institutions of mental health. This blog is intended for all of us – from activists to institutions, the many and diverse professional bodies, trade unions and political parties, the self-organised groups of workers that are emerging, the mental health alliances of survivors and service users, researchers and academics. If you can, I want you not to feel this blog as a personal attack.
The attempt to corrupt mental health services into delivering austerity policies and the degradation of jobs and therapeutic services means that increasingly neither the people using or delivering services are willing to bust a gut to protect NHS services and argue for more mental health funding. One of the reasons why this is happening unchallenged is that despite the efforts of mental health activists and champions, at times literally heroic, we as stakeholders are not talking enough either to each other or about the issues that matter.
I want to argue that unless we can both organize around the principles that should underpin mental health services, and spend enough time in the same rooms defining our common interests, our legacy as stakeholders stands to be one of failure.
So here goes.
The current policy bun fight
In mental health there have been a series of policy projects about the regulation and registration of counsellors and psychotherapists. This might sound like a good idea, but potentially represents a further nail in the mental health coffin.
Currently, the regulation involves three apparently separate but actually very much connected policy initiatives: The SCoPEd consultation, the Counsellors and Psychotherapists (Regulation) and Conversion Therapy Bill and the soon-to-be-announced All Party Parliamentary Group on Counselling and Psychotherapy.
This is a framework for setting standards for counsellors and psychotherapists to practice in the UK. This was adopted by three of the largest psychodynamic professional bodies – BACP, UKCP and BPC – in ‘consultation’ with their memberships. Part of the regulation of therapists is to arbitrate on the ‘quality’ of training and clinical experience required to practice. That’s the good bit. Regrettably SCoPEd has played into the psychotherapy-good-counselling-bad debate that gets wheeled out to protect jobs and has been used to establish a division of labour between counsellors and psychotherapists. This goes against the heated debates ten years ago by exactly the same people who ended up rejecting this split on the basis that it makes no sense at all. The outcome of SCoPEd has left us collectively scratching our professional heads.
From an Industrial Relations perspective what this looks like is that instead of protecting the thousands of highly qualified counsellors and psychotherapists from the sector wide downgrading of clinical services and jobs, the strategy is one of ring-fencing the status of psychotherapists and letting the counsellors fight it out in the emerging realm of sub-therapy.
Although the system of professional membership is voluntary, SCoPEd also nudges the sector towards a de facto monopolisation of the mental health business within three bodies. Whether unconscious or not, this framework could potentially create a closed shop across the sector for BACP/UKCP/BPC trained and registered therapists. It also potentially threatens both the diversity and earning capacities of the thousands of counsellors and psychotherapists who are not members or practicing modalities sanctioned by them.
SCoPEd was passed on the basis of a membership consultation within just three professional bodies engaging 13-15% of their memberships. For an analysis of the consultation process go here who voted. Unsurprisingly now that the implications of this policy are becoming clear, the workforce has engaged critically with SCoPEd. Counsellors Together UK has set up a petition to drop SCoPEd, signed by thousands of therapists and can be signed anonymously here.
For a very good summary of the issues around SCoPEd you can read the Alliance for Counselling and Psychotherapy blog here.
Counsellors and Psychotherapists (Regulation) and Conversion Therapy Bill.
This is a strange sorry story of a private member’s Bill proposed by Labour’s Gerant Davies. The bill’s motivation is hard to understand as it’s not clear how many, if any, counsellors and psychotherapists offer conversation therapy in the UK. Stranger still is the proposal embedded in the Bill that Counsellors and Psychotherapists be subject to statutory regulation under the Health and Care Professions Council (HCPC), joining the majority of health and social care workers in the UK. Enforcing statutory regulation is a move that was fought hard by the Accredited Voluntary Registers (including the professional bodies) in 2008-2011 on the basis that the nature and diversity of therapeutic work would be undermined by rigid regulatory frameworks, ultimately at the cost to patients. Despite attempts to rush through a second reading two days after the first, as a private member’s Bill it stands very little chance of passing. But the Bill raises another red flag, where enforced regulation is justified by peddling a scapegoat-version of therapy. Poor services come down to the individual therapist’s lack of training and absence of statutory regulation, rather than the systemic failure involving all of the mental health actors and political parties.
For a summary of the debate around the Bill you can read the correspondence between a psychoanalyst Julia Evans and the Health and Social Care Committee here.
All Party Parliamentary Group for Counselling and Psychotherapy
Recently there have been excited whispers that the BACP, UKCP and BPC have been invited to participate in a new APPG looking at counselling and psychotherapy. This has been naively sold by insiders as a good move for members rather than one that will compound the protectionism that has become enshrined in SCoPEd. The kindest interpretation of this is that the people involved are genuinely unaware that more of the protectionist-same doesn’t count as protecting members in the long term.
With the best will in the world, it profoundly misses the point about the future of the therapeutic professions. The crisis, as we tried to capture in our survey www.thefutureoftherapy.org, is more the quality of the jobs, rather than the competencies of the clinicians competing for them. The only way to set up a legitimate and purposeful policy debate about this is to include all of the stakeholders. Five minutes on Twitter and anyone can establish who these stakeholders are. Just invite us to the policy party and I promise we will come.
The Regulation of Therapy
Although there is a need for regulation of any clinical practice, the hardened amongst us might see the way the regulation debate is being conducted as signs of protectionism. Define the problem as the regulation of individual clinicians, rather than the systems in which they work and with one swoop of the policy hand, training and membership within the professional bodies becomes necessary to practice as a therapist in the UK.
Voila a passing of the political and professional buck from the downgrading of services onto the individuals working within them.
That might sound a bit mean spirited but the fear amongst mental health workers to even articulate concerns about where the sector is heading within their professional bodies is not to be underestimated. Many feel that even without any legal requirement to be a member of a professional body, articulating concerns will lead to blacklisting and job loss. This is partly because so many people working in mental health don’t work for the NHS where public sector protections still exist, but in the private sector, self-employed and on short term contracts. This means that professional membership is important and there is a massive reluctance to become a thorn in the side of the big players. This is reflected in the volume of critical debate on social media by membership about these new policies.
That sentence should legitimately cause you some anxiety.
That’s not to say that there aren’t debates going on about the future of mental health jobs in professional circles. Currently these are focusing on the issue of unpaid work that forms a key component to trainings and professional registration. Some bodies, such as the more progressive UK Council for Psychotherapy (UKCP), are attempting to take the lead on unwaged work. This is by necessity because their membership thinks the routine exploitation of free labour to secure professional accreditation isn’t acceptable any more. But sadly there’s no reason to think that this is leading to a genuine agenda for change across the sector that can protect members from the widespread downgrading of mental health jobs.
The bigger picture
The crisis that is emerging relates to some bigger ideas about mental illness and its ‘treatment’.
The concept of the medical model relates to the dominance of a psychiatric-diagnosis-plus-medication approach to distress. These two cornerstones of UK mental health services are closely tied to the financial interests of the pharma companies and the prescribing professions. Drug development legitimizes the new diagnostic categories used to herd people into a model of treatment that can become diametrically opposed to anything therapeutic. This is not to say that some people can’t benefit from medication but it is to say that the diagnostic framework is controlled by institutions with a financial interest in selling drugs. To understand this debate two good places to go are Recovery in the Bin and the Drop The Disorder twitter feeds as well as a new book published by PCCS books.
This is the background to the debates about therapeutic modalities – those that accept the medical model and those complex troublesome therapeutic approaches that don’t. Over the last two decades there has been the revival of an old ‘contentious’ debate about the different kinds of therapies that are practiced – often concentrated on the differences between Cognitive Behavioural Therapy (CBT) and psychotherapy. This debate has been fuelled by the emergence of the ‘evidence base’ for the effectiveness of CBT on which the largest NHS programme, IAPT, depends for its legitimacy. The fact that many of us don’t think that IAPT is CBT and most therapists use multiple modalities hasn’t stopped them being positioned in opposition to each other forcing us to choose sides.
Another binary. You get the idea.
The stratification of therapists is even more baffling because most practitioners are over qualified. Overqualified in the sense that they have paid for years and years of psychodynamic and other trainings right throughout their careers such that it’s really hard to divide clinicians into CBT or Psychoanalytic tribes, counsellors and psychotherapists, good guys and bad guys. There is diversity in the length and quality of trainings, no doubt about it, but whether that translates into a hierarchy of therapeutic competency is another matter.
The Organising Challenge Ahead
What is getting missed in this policy bun fight is that the prospect of decent therapy is actually decreased the more we dig the protectionist hole. What is fundamental to therapy are the therapeutic relationships that are formed and the dynamic nature of what happens when people spend time together really listening and really talking. If you put an experienced and humane clinician in a room with a patient in conditions where both the clinician and the patient can say what they think, it’s hard to distinguish between people who define themselves as counsellors and those as psychotherapists. It’s this space of free association that we should be trying to protect.
The reason why the radical mental health networks aren’t that fussed about collaborating with therapists is because they experience this political and ethical conflict in the consulting room. In a system where the pressure to ‘recover’ trumps actual therapy we are involved in the widespread individualization of social crisis. You can expect nothing less from a system that responds to unemployment by diagnosing a disorder and prescribing meds.
This isn’t some liberal academic position on co-production (although I think it should be mandatory) – it’s about what happens to a mental health service when the people who use it are excluded from shaping it. It’s what happens when you wheel out yet another mental health report coordinated by Paul Farmer and involving only those organisations with a financial interest in business as usual. What happens is that we completely miss the harsh realities of service users and the too-scared-to-speak-up providers of care that should without exception form the basis of future policy and funding.
It’s not clever to point out that the major professional and training bodies sometimes act as a conservative force in these debates. There exists an internal tension between their roles: they function both as regulators and gatekeepers of mental health work and as bodies charged with protecting the profession of counselling AND psychotherapy. Nobody who works for them has much of a vested interest in questioning the main sources of income – memberships and trainings – and increasingly as a matter of short-term survival they contain debates within professional silos rather than looking at the bigger crisis-fuelled picture.
Within all of these mental health organisations there exist outspoken individuals and networks who make important challenges to their institutions. I include in this the BACP members who have submitted motions to end unwaged work and most recently to reject the SCoPEd proposal. If you’re a member of BACP and engaged in these debates you can support your colleagues in pursuing this through the formal channels. Although dissent is patchy, there is potential here for the professional bodies to contribute towards reform in the sector.
But, and it’s a big but, as it stands none of the institutions of mental health, including trade unions and political parties, have operated in a strategic way to address the crisis. The positioning of individuals and institutions in relation to these debates depends ultimately on where they think they are in the food chain. Protectionism through the institutionalization of a hierarchy of care, rather than working strategically as one mental health sector.
I raise this bitter point because the professional bodies have form. In response to the government’s austerity programme, five of the largest therapeutic professional bodies signed a profoundly ill-advised memorandum of understanding with the DWP in 2016 about the introduction of psychological therapies into job centres. Long gone from the websites of the organisations involved, the paper trail remains in the correspondence between the professional bodies and the Mental Wealth Alliance, who raised their concerns (click here to read) . The collusion of the mental health professional bodies with the DWP in this catastrophic policy was political naivety in the extreme. Doing it once is a mistake. But it will be a matter of historical fact whether by not engaging with other stakeholders on the broader issues of mental health policy they run the risk of defending the indefensible.
In the ABCs of sectoral bargaining you have to be on the right side of history. People don’t risk their jobs over policy, but they will act on matters of principle particularly when they are lived out in the consulting room. Without upholding the principles on which a genuine mental health service is founded, the current debates about the regulation of therapy increasingly put workers and their patients in direct opposition to the political and professional institutions charged with protecting them.
The right to join a collective organisation is called Freedom of Association. This dual meaning of free association should be a fluorescent-pink-neon-sign for mental health workers about how to position themselves in relation to the important debates about the future of the sector. The political reality is that for any institution to have the privilege of representing us they have to allow us to say what’s on our minds, wherever we are in the food chain.
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