The Uberization of Mental Health
This article first appeared in the January 2020 issue of Healthcare Counselling and Psychotherapy Journal, published by the British Association for Counselling and Psychotherapy©. To download the PDFs of this article click here and here.
The Industrialisation of Care1 was published in June 2019 and forms part of the emerging critical literature that explores the industrial and political implications of England’s largest mental health programme – Improving Access to Psychological Therapies (IAPT). The contributors to the book, of which I am one, argue that this model of a mental health service is based on a strategic downgrading of therapy, which is dangerous both for therapists and clients, exposing our real mental health crisis.
IAPT is one of the most quickly expanding sources of employment in the mental health sector. Other sources of paid employment, both inside and outside the NHS, are correspondingly drying up, which might go some way to explain the fear among clinicians of raising their concerns about the impact of the IAPT model on patient care. It might also explain why the IAPT model has been introduced without much internal resistance. When the entire talking therapies system has been moved towards an IAPT model, with a shrinking independent psychotherapeutic sector and limited sustainability of private practice, securing paid work as a counsellor is largely dependent on an acceptance of the IAPT model, whatever your views as a practitioner.
This is not to denigrate the work of people involved 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 IAPT teams to protect the principles on which real care is based. But increasingly, whether you work in IAPT or not, this model of mental health dominates across services.
The IAPT model was introduced by the UK Government as a strategic attempt to cut the cost to the UK economy and the benefits bill.2 If you combine the statistic that 50 per cent of disability benefits are paid on the basis of mental illness3 with IAPT’s claims of 50 per cent recovery rates, it explains, in my view, why IAPT has such political traction in the age of austerity.
The creation of an ‘evidence’ base for the IAPT model has caused the wholesale downgrading of therapy, such that services can employ people who are not clinically trained,4 many of whom are working online. In my opinion, the introduction of IAPT has led to a standardisation and manualisation of services. A so-called ‘uberisation’ of mental health is therefore about to take place, which makes the sector vulnerable to the large-scale digitisation of therapy, both as a modality and as a condition of work.5
The IAPT programme provides short-term, results-oriented, cognitive 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 of both the relevance of what it measures (such as waiting times) and the accuracy of its claims (such as a 50 per cent recovery rate).6
The IAPT model is based on a system of patient assessments that use tightly scripted questionnaires, allowing 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 enables clinicians to refer them to short-term interventions that are not, for example, designed to treat depression. Clinicians can also make claims about recovery that do not relate to the actual mental health problems of service users.
The economic argument for rolling out the IAPT model has prevailed across the UK’s mental health policy because of the relatively low cost of IAPT services, compared with long-term talking therapies and specialist services that require experienced clinicians. Although campaigners legitimately argue that the financial case for IAPT has excluded any consideration of the real costs to the UK economy of not treating mental illness adequately, including costs to acute, 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 provided through IAPT that have been expressed by service users, particularly many disability and mental health networks, this downgraded model of ‘talking therapy’ now dominates across the UK’s mental health service.
A strategic consequence of IAPT has been to enable the opening up of the mental health sector to private, third-sector and non-clinical providers. Every week, new contracts and digital services are commissioned in healthcare, with an increasing emphasis on wellbeing and mental health interventions.5 The delivery of the new welfare programmes has been carried out almost exclusively by large, private contractors; the majority of assessments have been performed by staff who do not hold senior qualifications or who are not clinically trained. The ‘new’ mental health jobs created in these programmes do not require clinicians6 and, in my view, this workforce strategy represents a clear move towards generic and non-clinical jobs in the sector.
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. Digital healthcare has also been supported by successive health ministries. The benefits of this technological alternative to complex long-term treatments provided by clinicians are, in my view, empirically exaggerated,7 but they are heavily supported by the normative logic of austerity on which decisions about mental health are based.
We are now entering a period where the large, digital health companies are about to make a lot of money. Many are developing healthcare products that ride the wave of ‘solutionism’ of government policy by providing services that are mechanised, scripted and online. The emergence of digiceuticals and digital therapeutics as a model offers digital ‘treatment’, based on software and clinically trialled ‘evidence’, and prescriptions, without face-to-face contact with a clinician.
The second part of the uberisation of therapy relates to the dramatic growth in online platforms in healthcare. Platform companies, made up of software and databases of workers and clients, often providing services online, are the big employers of the future. 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 workers and clients are the size of their databases and the click-natured simplicity of accessing services. No waiting lists, no more ‘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 hired by a platform, on self-employed contracts, to carry out hourly paid or pay-per-product tasks. In general practice, consultations are routinely offered online through such platforms and it is now happening in therapy.
The uberisation of therapy is a version of digital Taylorism – a standardised and manualised model that reduces complex work to small, simple tasks. There are some striking similarities between Briken and Taylors’ study of Amazon workers8 and the mental health profession: work intensification, standardised tasks with no deviation, algorithmic control of work and the collection of personal data of both workers and clients. If you can downgrade the task, you can downgrade the job and with it the mental health budget.
The uberisation of therapy, in my view, is not about care, it’s about money. I believe we have 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 return on investment of decent therapy. None of this, in my opinion, was of any interest to the major and future providers of care and has subsequently failed to gain any political traction.
Mental health workers are left walking a thin line of professional and personal ethics. Most workers will only talk about their concerns if offered a confidential space to do this, for fear of victimisation and job loss. Although many IAPT workers will attempt to deliver the best care they can they do this despite working within an IAPT model, not because of it. But increasingly, as public opinion starts to move against IAPT, we have to work towards change – both to challenge the current model and to build alliances across the sector to form alternative models of care. As the 2019 Mental Health Crisis Summit revealed, there is a growing call for an inquiry into IAPT carried out by service users and their families 9. It is on the basis of this new political fault line that mental health workers now need to take a position.
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. 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?
The Surviving Work Survey
The Surviving Work Survey,10 carried out during 2016-17, reveals a picture of employment in the therapeutic professions. Survey respondents included the full range of mental health workers, with a high response rate from mental health nurses, who continue to dominate mental health jobs in the NHS. However, the majority of respondents had qualifications in psychotherapy and counselling. Many worked in a number of roles and used different therapeutic modalities. The survey results are published online on a dedicated website www.thefutureoftherapy.org
The survey highlighted four main trends: the growth of precarious work, the jobs gap, the age gap, and the dominance of the IAPT model across services.
A clear picture of ‘flexible’ work emerged in the research. A growing majority of people, working in multiple settings, using different modalities, increasingly provide generic rather than specialist care. Although 74 per cent of respondents said they worked for the NHS, many reported that they worked on short-term contracts for multiple employers, both directly for third-sector or private providers and indirectly on self-employed contracts (30%).
The 23 per cent of respondents who worked in IAPT services reported the same issues of precarity as those working across the mental health sector. About a fifth (19%) were employed indirectly and worked for external contractors, 14 per cent worked for third sector organisations, four per cent for agencies, and 28 per cent were self-employed. A high number of people worked in IAPT services in an honorary (unpaid) capacity as part of their clinical training (28%).
The second issue that came out in the research findings was that many therapists were earning low wages. Some 18 per cent of respondents earned less than £300 per week in take-home salary. The average income across all respondents was £401–£500 after tax. A third of people worked part time, which partly explains the low earnings. But the low wages also relate to the widespread practice of using unpaid workers within the sector.
A total of 21 per cent of therapists were in unwaged, honorary positions. The survey showed they worked across the range of public and private mental health employers, with 50 per cent in the third sector and 45 per cent in the NHS. The survey also revealed that a third were qualified practitioners, not trainees, yet still worked many hours without pay, both in the NHS and the third sector.
Downgrading of clinical jobs
The survey identified a significant gap between the qualification seniority of IAPT workers and the clinical seniority of their job – 48 per cent of IAPT respondents were working below their clinical qualification levels.
In the interviews, a number of IAPT counsellors also reported using their psychotherapeutic training and experience to support clients, which meant going ‘off script’. They would not, however, divulge any such intervention to their teams or management for fear of reprisals.
The age gap
In the survey, 60 per cent of respondents were older than 47 and 21 per cent were older than 58, rising to 29 per cent in London. Only 19 per cent of respondents were younger than 37. Within the UK working population, the percentage in this latter age group is nearly double, at 35 per cent. Among the IAPT respondents, 80 per cent were born in 1970 or earlier.
The lack of progression available to clinicians, both within IAPT and more generally in the sector, was one of the significant problems raised in the survey and interviews. It was found that services were not replacing senior staff when they retired and there was no opportunity for clinicians to progress to more senior grades as they gained in experience and qualifications.
Trainees in psychotherapy and counselling are generally older than most people starting out on their professional career (they are often in their 40s and 50s, pursuing a second career). However, there is a growing concern that services are failing to recruit the next generation of mental health workers into training and retain them through career progression. If the trend continues, it’s possible that in the foreseeable future the costs of clinical training and securing professional registration will not be balanced by paid and secure employment in the long term, inevitably affecting recruitment into the sector.
The IAPT model
In both the survey and interviews, respondents raised concerns about the standards and quality of services in IAPT. The principal concern was the limited number of sessions offered to patients, the pressure on throughput and the rigidity of the CBT model, which is manualised, often scripted (especially in the case of low-intensity treatments) and increasingly provided remotely, either by telephone (assessments) or online (guided CBT).
There were also concerns about the number of people working in mental health services with ambiguous clinical status. Psychological wellbeing practitioners (PWPs) were introduced through IAPT to provide manualised, short-term interventions and carry out initial phone assessments. However, there is little clarity about the clinical framework, including training and supervision, within which they are working as the next generation of IAPT workers enter the profession.11
Respondents in IAPT services also reported high caseloads, ranging from five to eight patients per day, and consequent problems with work intensification, particularly for the more senior staff with more complex patients.
It is notable that IAPT workers were more likely than those working in other NHS services to raise concerns within their place of work about working conditions – 55 per cent, compared with a survey average of 36 per cent; and 58 per cent, compared with a survey average of 38 per cent in relation to patient care.
The research involved an online survey of 50 questions, including multiple response and open-answer questions, and received 1,500 responses. Additionally, 68 one-hour phone interviews were carried out, using a template that looked in more detail at interviewees’ experiences of work and workplace issues, including their own mental health. All the data in this article come from the survey. The survey and interviews were carried out by me, in my capacity as an academic, with the data analysis carried out collaboratively with Professors John Grahl (Middlesex University) and Ahmet Suerdem (Istambul Bigli University). The survey also involved a campaign of discussion events, blogs and social media. The campaign was carried out through www.survivingwork.org, an online network of an estimated 30,000 people that I founded in 2012 to create a safe and critical space where people could talk about their experiences of work.
1 Jackson C, Rizq R (eds). The industrialisation of care: counselling, psychotherapy and the impact of IAPT. Monmouth: PCCS Books; 2019.
2 Friedli L, Stearn R. Positive affect as coercive strategy: conditionality, activation and the role of psychology in UK government workfare programmes. Medical Humanities 2015; 41(1): 40–47.
3 Banks J, Blundell R, Emmerson C. Disability benefit receipt and reform: reconciling trends in the United Kingdom. Journal of Economic Perspectives 2015; 29 (2): 173–190.
4 Cotton E. The future of mental health services: the organising challenge ahead. Soundings 2018; 70. https://www.lwbooks.co.uk/soundings/70/the-future-of-mental-health-services-the-organising-challenge-ahead
5 Cotton E. UberTherapy: working in the therapy factory. London: Surviving Work; 2019. ISBN 978-1-9998637-9-1
6 Durcan G, Stubbs J, Appleton S, Bell A. The future of the mental health workforce. Centre for Mental Health on behalf of The Mental Health Network. 2017. https://www.nhsconfed.org/resources/2017/09/the-future-of-the-mental-health-workforce
7 Cotton E. The Industrialisation of mental health. In: Jackson C, Rizq R (eds). The industrialisation of care: counselling, psychotherapy and the impact of IAPT. Monmouth: PCCS Books; 2019.
8 Briken K, Taylor P. Fulfilling the ‘British way’: beyond constrained choice – Amazon workers’ lived experiences of workfare. Industrial Relations Journal 2018; 49(5): 438–458.
9 Mental Health Crisis Summit. https://keepournhspublic.com/its-time-to-act-mental-health-crisis-summit-launched/ (accessed 18 October 2019).
11 Proctor G, Brown M. Industrialising relational therapy: ethical conflicts and threats for counsellors in IAPT. In: Jackson C, Rizq R (eds). The industrialisation of care: counselling, psychotherapy and the impact of IAPT. Monmouth: PCCS Books; 2019.
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