Category Archives: Paul Atkinson

How do we get mental wealth?

In his address to a Labour Party conference fringe event, Paul Atkinson examines the social and political forces at work in our society’s current approach to psychological distress and asks what we need from a new government to support and nourish the nation’s mental wealth.


For whatever reasons – reasons that I think are very important and need to be explored – the emotional and psychological difficulties of living in this society are becoming increasingly visible and alarming: in our families; in our schools and colleges; in our local communities; in the attention drawn to mental ill health by (social) media, charities and celebrities, as well as politicians and social policy makers.

Should we think of this growing attention to mental health and the emotional conditions of contemporary life as a sign of growing awareness of the pain and suffering that has always been with us, hidden away in the private closet of social stigma and shame? Or are we witnessing the symptoms of an increasingly dysfunctional, disturbed and disturbing political and social structure? However we interpret it, I think we can say that there is something very, very wrong. It has either always been wrong, or over the last two to three decades we have been getting something very wrong. Certainly both Tory and Labour governments have been getting something very wrong, and are continuing to get it wrong.

To my way of thinking, there is something very wrong with a political economy which simply carries on, blindly it seems, propagating and prioritising the same fundamentally alienating and corrosive values:

economic growth before all else;

the accumulation of status and worth through money, wealth and conspicuous consumption;

generating and acquiescing in deep inequalities of material wellbeing and of the opportunities to make creative, satisfying lives.

To my libertarian socialist mind, capitalism has always generated toxic side effects in its exploitation of people’s mental wealth – in the service of profit and the accumulation of the few. Neoliberal capitalism – its extractive and kleptocratic offspring – seems to be generating an accelerating pandemic of fear, insecurity and anxiety which is splintering and dividing us as communities and individuals.

So my message to the Labour Party is that we need a government that is prepared to redefine what society is for, who society is for. A government that acknowledges the priority of people’s emotional and spiritual lives, their relationships, their need to give and receive care, support and love from each other. We need a government that is prepared to put our mental wealth before our economic wealth.

Yes mental health services need more money, far more money and human resources. But better funding alone is not the answer.

I am not a mental health service user or survivor of the psychiatric system. I am not poor, black or gay. But let me give you an example from my professional world in which I can claim some small expertise by experience. Let me give an example of how more of the same as far as mental health funding is really not the answer; an example of how what seems like a major step for improving the nation’s mental health is turning out to be as much part of the problem as part of the answer.

In an article in the New York Times in July 2017, titled Englands Mental Health Experiment: No-Cost Talk Therapy, Benedict Carey – US journalistcelebrated as a globally inspiring initiative the UK’s programme of short courses of cognitive behavioural therapy (CBT) in every primary care service in England – the Improving access to Psychological Therapies (IAPT) programme:

‘England is in the midst of a unique national experiment, the worlds most ambitious effort to treat depression, anxiety and other common mental illnesses.’

Colleagues and I on the left of the psychotherapy profession groaned in despair.

In 2008, Richard Layard and David Clark persuaded the Blair government to roll out an ambitious programme of CBT, offering psychological therapy for one million referrals a year through GPs. Layard, an economist specialising in unemployment and welfare to workfare policies, argued that mental ill health was the primary burden on the welfare budget of unemployed people receiving Employment and Support Allowance, and psychological therapy provided by the state would pay for itself by getting people off benefits.

On the face of it, it has been a huge success. Its champions call it the ‘IAPT revolution’. Every CCG in England offers psychological therapy under IAPT. Roughly 1.3 million referrals (some self referrals) were made to IAPT last year. It claims a 45% recovery rate. People in therapy that otherwise would never see therapy.

In reality…

Despite its value to probably many thousands of clients, the reality of NHS psychological therapy is far from the rosy picture Benedict Carey or its champions paint:

At an operational level, IAPT is an assembly line mental health fix.

Of the 1.3 million referrals last year, one third actually finished a course of treatment. In the end, only 12% of all referrals “recover”.

Almost half of these received what is called low-intensity (LI) treatment – something most psychotherapists would not recognise as talking therapy. For example, the most successful LI “therapy” was through non-guided self-help books.

The average number of sessions for all IAPT treatments is nine. A fifth consist of just two sessions. Recovery rates are falling, and the number of patients returning for repeat treatment is growing.

Almost all state funded talking therapy is now CBT, which has replaced virtually all other kinds of psychotherapy previously available free on the NHS.

The gold-standard evidence base for IAPT, based on random control trials, is in fact an avalanche of statistics highly manipulated towards maintaining state funding. Waiting lists are growing. Recovery rates within more deprived areas of England are significantly lower than in wealthier communities.

Meanwhile, according to a recent report by the British Psychological Society, the mental health of IAPT therapists and psychological practitioners is suffering a monumental nose-dive – 50% suffering depression, anxiety and acute work stress.

*

And yet, for the moment at least, there seems to be little recognition at government level that something is amiss – the programme is expanding. IAPT is doing an important political job. As far as I and my fellow campaigners are concerned, that political job looks like this:

First, IAPT has no brief, no money and no time to be thinking about the causes and meaning of the mental health issues it is managing. It deals with symptoms on an individual basis and aims to get people back into their everyday “normal” lives as quickly and cheaply as possible. As far as I can see it has no interest in the social model of mental health or in the influence it might have on getting government to think about the emotional impact of economic and social policy generally.

Second, I think of IAPT as a partner of Big Pharma in the growing mental health/happiness industry. CBT with its tick-box inventories, like the mass consumption of anti-depressants, has grown rapidly since the end of the 1970s. They are both contemporaries of the neoliberal turn. IAPT therapy is essentially courses of positive thinking, encouraging you to take more responsibility for your states of mind and adapting a little more flexibly to the realities of the world you are in – including of course the world’s markets.

Third, like antidepressants and other psychotropic drugs, IAPT is administered from the top down, on the medical model of diagnosis and allocation of treatment by a health professional. While the client hopefully has a say in the content of a talking therapy session, she has little say in who she works with, in what kind of setting, with what kind of frame, for how long and so on. If you want a choice of psychotherapy approaches, if you want a therapeutic relationship that is on-going and open-ended, led by your own sense of need, pain and distress, then it’s private practice at £60 – £90 a session.

Fourth. IAPT is an NHS service, state funded and state led. Its basic brief is to get people back into the flow of a “normal” life as quickly and cheaply as possible. This has always included getting people back to work. From its inception, IAPT has occupied and helped create a space in which the government’s policies on mental health, employment and welfare meet up within the toxic framework of workfare, cutting welfare, maintaining a low wage labour market.

“psy professionals have allowed themselves to be drawn in to a system of psychocoercion”

What we as psy workers have been witnessing, as New Labour’s workfare iniatives have progressively developed into the Tories’ vicious – yes, murderous – attacks on people with mental and physical disabilities and on welfare provision generally, is that psychotherapists, psychologists, occupational therapists and mental health workers have been increasingly drawn in – and have allowed themselves to be drawn in – to a system of psychocoercion of people on welfare benefits, a system which glorifies work as the ultimate goal and obligation of citizenry.

As we know, the experience of many claimants with mental health difficulties is one of being terrorised by benefit cuts (whether in work or not), sanctions, fitness to work assessments, PIP, and now the further cuts of Universal Credit. For many, being driven off benefits is not into work: it is onto the streets, into the food banks, into an early grave through ill health, addiction, self harm and tragically, suicide.

The New Savoy Conference, IAPT bosses’ annual trade conference, welcomed with open arms the Tories’ welfare to work policies and the opportunities they offered for state funded therapy to get involved in “helping” people get off benefits and into work.

When George Osborne announced in his spring budget 2015 that he was co-locating teams of IAPT therapists in Jobcentres, that DWP employment coaches were going to be located in GP surgeries and at one point in food banks, finally some of us psy professionals woke up and realised our own professions were becoming agents of psychological terror. That our professions were allowing themselves to be drawn into the violence that is at the heart of the neoliberal project. We got together in 2015 and formed the campaigning alliance that organised this meeting.

*

So, coming back to the question, what do we want from a radical Labour Party and Labour government to support and nourish the nation’s mental wealth?

Looking at this year’s Labour Manifesto:

Do I think it’s enough to talk about restoring Tory cuts to mental health services, putting more resources into attending to children and young people mental health, reasserting the need for parity of esteem with physical health, and offering a wider choice of therapy options under NICE guidelines?

Do I think it’s enough to restore Tory cuts to ESA, get rid of sanctions, the bedroom tax, WCA and PIP assessments, to talk about support and care for people who cannot work, and the social model of disability – or even Universal Basic Income?

Well, no.

Of course mental health services need more resources. The hypocrisy of every party declaring their distress at the lack of such services while doing bugger all except to cut funding further is shocking. The only way of understanding this is that mental illness is still regarded as a shameful, frightening shadow of our culture which politicians can get away with ignoring and attacking, as they do with welfare claimants.

Yes, we need more safe spaces for people with acute and severe mental health problems. We will continue to need more people with specialist trainings. And yes we need more talking therapy without a doubt.

But, FIRSTLY we need these services as part of a very different understanding of the kind of society and the kind of relationships that promote and support our mental wealth. Most of what gets called mental ill health is facilitated by the social, cultural and emotional conditions people are living in from day to day, and the conditions we have been in most of their lives.

We need housing policies, education and early years policies, transport policies, policies on working conditions, as well as health policies, that give the first priority to how people feel about themselves and their world, not to how they can be managed to maximise GDP.

And SECONDLY, absolutely crucially, if we are going to take seriously the priority of mental over material wealth at all, we need a society in which people feel that they not only have a say in how their world is developed and run; we need a society in which people feel they have THE say, the FIRST and LAST say, day to day, in how their world is organised.

Top down mental health services, administered by psychiatrists, psychologists, therapists, nurses and other professionals disempower and isolate individuals as mental health problems. To as high degree as possible these services need to be designed, managed and developed by service users and survivors. Professional services need to be in service, really in service, not driven by their own managerial ambitions, their profit making, or the fear of hanging on to an impossible job.

“Work remains the absolutely critical structure of social control in these capitalist societies of ours.”

For how long are we going to carry on preaching and believing in the insanity of the capitalist work ethic? That your value as a citizen is dictated by having a job? That it is your obligation to society to be in waged work? Are we absolutely bonkers?

Only 13% of people worldwide actually like going to work, according to a Gallup poll conducted in the States and published in the Washington Post October 10th 2013. According to new research by the London School of Business and Finance, which interviewed 1,000 male and female professionals of different age groups from across the UK, an overwhelming 47% want to change jobs and more than one in five are looking to career hop in the next 12 months. And over 60% of people living in poverty in the UK are in working families.

Forcing people with mental health difficulties into work says it all. Work remains the absolutely critical structure of social control in these capitalist societies of ours. Those who cannot work are to be treated as pariahs. They are the worthless lazy dependent scroungers that everyone can hate and treat with contempt – along with the homeless, the poor, the food bank users and the immigrants.

How appalling do the conditions of work have to become for us to say STOP. Something is very, very wrong. Why on earth can a parent, and especially a mother of young children, not say I don’t want to work, I want to focus on bringing up my kids?

Why is it treated as a utopian fantasy that work should be enjoyable – ‘adult play’, the psychoanalyst Donald Winnicott wanted to call it – that work be defined in all sorts of ways but basically as creative effort?

What the hell is wrong with us?

Yes, let’s have trade union power, workers’ power established at the centre of everyone’s working life. But also let’s get rid of the workerism that’s embedded in traditional left visions of a transformed society. We need so much more than the dignity of labour defining what life is about.

So let me just end on this. No, I don’t think more of the same is at all good enough. Yes, I think Corbyn’s Labour Party is beginning to take seriously the possibility of a world transformed. But there is a long way to go before mental wealth becomes the real standard by which we measure society and our political economy.

Advertisements

Nothing about us without us? Are you bonkers?

In May this year, I joined members of the Mental Health Resistance Network at an event at the Old Vic. It was a panel debate on the state of mental health provision in the UK, one of their Voices Off events linked to the production of Harold Pinter’s The Caretaker. The original panel was Luciana Berger MP, Shadow Minister for Mental Health; Paul Farmer, CEO of Mind; and Simon Wessely President of the Royal College of Psychiatrists. MHRN members protested that there were no service user speakers, and eventually Peter Beresford and Alice Evans were invited onto the panel.

Inspired by the desperate lack of service user voices, mental health activists rapidly got together a zine to distribute at the meeting – a passionate collection of first-hand experiences of living on the sharp end of mental health disability in the UK. Jay Watts of the Alliance contributed a cartoon strip. I promised a short piece but couldn’t finish it for the deadline. Here it is – my belated contribution.

Read the full zine here


What’s wrong with people wanting to talk in public about other people’s mental health without including them in the conversation?

We psychotherapists definitely like to talk about our clients in the third person, though we don’t usually do it when they might be in the room. We do it behind their backs.

We like to exchange anecdotes about how difficult so and so is; about the terribly interesting unconscious meaning of what so and so said; about the clever little interpretation we were ‘able to offer’; about how narcissistic, borderline, dissociated, manic, aggressive, negative or just plain bonkers… so and so is.

So and so is not usually there when we speak about them, which is a good thing. If they were, we wouldn’t feel quite so free to show off how clever we are to our colleagues, or our students, or our partners and friends. We might feel a little inhibited, just a little caught out. A little wanting in ethical authenticity.

For the Mad Old Vic panel, the rationale for talking about, not talking with, is surely that three of the panel members have professional authority in the field.

A senior psychiatrist, the CEO of Mind, and the shadow Minister for Mental Health surely have something intelligent and authoritative to say about people who suffer psychologically. Could it be they have their own psychic pain somewhere tucked away inside them? Better not to ask. We are here to talk about people with mental health problems, not to talk about our own problems.

If you ask me, an awful lot of people are scared shitless by madness. Like they are terrified of poverty. Poverty and mental illness – handmaidens of hell. What they have in common is their contagion. You know, if you get too close the lurgy spreads from you to me. We psychotherapists are scared of this. We fend it off with the technologies of our trade, our magic words like ‘countertransference’ and ‘projection’ – spells we cast to keep the horrors at bay. They make it clear that it’s your problem not ours.

Sitting up there on their panel’s rostrum, I am hoping our trio of professional experts will be able to make a few basic facts clear.

First, that there has been a growing epidemic of mental ill-health in the UK from the 1980’s onward, as evidenced by the massive increase in anti-depressant prescriptions and the need for a huge expansion of primary care psychological therapies to millions of citizens. Thank goodness for pharmaceutics and CBT.

Second, that there is no connection between increasing mental ill-health and the introduction of neoliberal economic and social policies by Mrs Thatcher and Ronald Reagan, under the sway of ideologues like Hayek and Friedman. Atomising communities, destroying social housing, breaking the trade unions, deskilling labour, generating massive inequalities of wealth and income, increasing poverty, undermining social welfare provision, consistently cutting the mental health budget, creating a precariat of low pay, part-time, zero hour employment; overseeing a staggering increase in household debt, manufacturing a global financial crisis, following it up with austerity policies aimed at the least well-off, waging imperialist wars in the Middle East – all of this has no bearing on the mental health of the nation. It is NOT true that it is our society that’s sick.

In fact, third, psychological pain and distress is located in the individual. A good proportion of it is probably genetic and/or the embedded dysfunctionality of troubled families. A lot of it is negative thinking, laced with self-pity and dependence on a welfare culture. People need to strive more, skive less. With a judiciously administered balance of encouragement, nudge, threat, bribery and coercion most people will recover their capacity to join in our happy society.

Finally, we need to trust our psy experts up there on the podium, give them more money and more power. Let them get to work on this contagious epidemic of loneliness, depression, fear and anxiety. Trust the technologies of diagnosis, treatment and cure that are so successfully defining and dealing with the epidemic, offering each suffering individual recovery into happiness, optimism and the chance of being part of our hard-working family. Stop putting money into the welfare state, stop putting money into old fashioned care and treatment. Focus on building the innovative, practical recovery strategies that are quick, easy and cheap.

I suppose when we come down to it, talking with people is not very easy, and not very conclusive. All too often it turns out that, like you, people are really very complex and confusing human beings. Before long, talking with people at any depth over a decent period of time undoes your sense that you may know something more about being a successful person than they do. In fact, talking to people soon leads you to realise that you don’t really know very much at all, once you’ve been taken outside your comfort zone. Soon you are flying by the seat of your pants in that intersubjective realm that is so human and yet so disturbing. Most of us, quite rightly, get busy trying to establish anchors, to impose narratives of meanings that are familiar enough to our poor old egos and their ‘entitlements’.

Otherwise, this is exactly how the contagion gets going. Whose pain, love, fear and loss am I feeling? Yours or mine? When we begin to experience our differences, who is right, who is wrong? Why is it so bloody hard to be me and let you be you? What am I frightened of? Like the testimonials to lived experience in the zine, people move us and not necessarily into worlds we want to visit.

This is not the kind of experience that facilitates handy diagnosis, treatment regimes and evidence-based efficacy.

In an age when a tide of depression and anxiety is overwhelming us, when the loud and increasingly disingenuous promises of more resources for mental health services are outdone only by the savagery of regular service cuts, and when the rhetoric of a revolutionary expansion of psychological therapies is being swamped by mushrooming waiting lists, shorter courses of treatment and undertrained and underpaid workers – surely the very last thing we need are the voices of service users and survivors muddying the waters.

If we are not very careful, the conclusion that neoliberal society itself is a mental health disability afflicting all our citizens will be difficult to disguise.

Paul Atkinson

‘Welfare Reforms and Mental Health – Resisting Sanctions, Assessments and Psychological Coercion’. Conference Report – Part One

On 5 March 2016 at a community centre in south London, mental-health activists, psy-practitioners and academics gathered for a day of consciousness-raising around welfare reforms and mental health.  In the first of four reports, we share the conference film Resisting Psychological Coercion, and Paul Atkinson looks at how this landmark event came about.


Kicking it off

Roy Bard of the Mental Health Resistance Network (MHRN) and I cooked up the conference. I’d called a meeting of lefty therapists to respond to the news last Spring that Osborne and co. planned to put IAPT therapists in Jobcentres. It seemed to me to be a golden opportunity to try and get us psych’s out of the bubble of our familiar concerns into the world of social class, poverty, welfare benefits, and mental and physical disability. The connection was being made for us by Ian Duncan Smith, George Osborne and, in fact, a next logical step in the recuperation of the psychological professions for neoliberal agendas. A few connections through Occupy St Paul’s prodded me to invite Disabled People Against Cuts (DPAC) and MHRN. I didn’t expect them to be interested, but they were.

Thirty of us met at the Jagonari Centre in Whitechapel. In true psych fashion we went round the group introducing ourselves. Someone – I think it was Roy – said, almost in desperation I discovered later, “Well, we’re doing an action at Streatham Jobcentre. You could join us”. We did. Mental health activists and therapists, and plenty of other campaigners, marched on Streatham Jobcentre in June and a few of us gatecrashed the MH hub’s opening do on the second floor. And then we went to the pub.

A view of the Alliance’s spanking new banner from the second floor of Streatham Jobcentre Plus, 26th June 2015
A view of the Alliance’s spanking new banner from the second floor of Streatham Jobcentre Plus, 26th June 2015

Six months and some relationship building later, with the Tories’ welfare to work and Health and Work policies mushrooming, I thought it might be time for another meeting to talk strategy on how psychs and mental health activists might work together with a bit more coherence. I was conscious all the time that it was my survivor partners who had all the brownie points. They were the activists. We were the Johnny-come-latelies who had basically been part of the problem for a very long time. I was thinking another meeting of twenty to thirty people. Activists were not too keen this time. “We are really busy. We’ve got a lot going on – our own conferences…” As it turns out they also had a major action brewing, at an Islington GP practice protesting at the introduction of DWP/Remploy/Maximus ‘employment coaches’ into six Islington surgeries. Roy, however, thought it was a good idea anyway and that it should be a ‘mini-conference’ – a daylong meeting with workshops… “Er, okay, me and Roy will organise a conference… er, alright then…”  So we did.

Roy had the contact with Gary at Wade Hall, the tenants and residents association hall for the Dickens Estate in Bermondsey. I loved it. A real community venue, hidden away in the middle of a housing estate. Gary really wanted us to use his hall. It turned out he is a lefty himself and has his own mental health connections. The hall could take 80 people without a sweat. He was immediately on about doing food for us. We were on about wheelchair access to the loos. There were grab rails in the women’s loo, but the doorway wasn’t wide enough. Gary thought the pub across the road had an accessible loo, or maybe the church hall down the road. And council workers had a building round the corner for storage and tea that had a disabled loo. He might be able to borrow the key. And by the way, Wade Hall had a licence and why didn’t we have a social in the evening – he would open the bar and if people paid a pound to become members for a year… I was busy fantasising about showing a DPAC activist in a wheelchair the way to the church hall somewhere down the road, probably in the rain, so they could have a piss.

“There is a serious hunger out there to do something about the horrific attacks on disabled people, on our welfare state, on our basic belief in social justice”

I eventually got the Eventbrite link up with a pretty cursory description of the conference and networks started to tweet. Thirty-six hours later the conference was full, and within a week nearly a hundred people were on the waiting list. There is a serious hunger out there to do something about the horrific attacks on disabled people, on our welfare state, on our basic belief in social justice and our values as a society generally.

We now had a conference of anything up to 200; we had thought maybe 50. We wanted the day to be mainly workshops – short introductory plenary speakers, then down to work. What are we planning to do about the DWP’s violence, the coercion of welfare to work, the terror of Work Capability Assessments, of sanctions and conditionality rules? The hall might take 100 at a push, but how do we break out into workshop groups? We reckoned we needed three, preferably four workshop spaces. There were two at Wade Hall.

Wade Hall
Wade Hall

Gary raised his game. There was another hall we could hire for two workshop sessions fifteen minutes away. And there was a pub by the river that advertised free meeting space in its bar for local community groups – it was called The Winnicott (yes, that Winnicott). A mini-conference spread over a community ‘campus’ on three sites. Colleagues were saying, “Book a bigger venue”. They hadn’t met Gary. On the spot he phoned the other hall and negotiated a discounted rate. Later he walked us over to negotiate transitional space with The Winnicott.

So far, strangely easy. Eventbrite and social media opens a door with a crowd of people waiting to get in. Gary provides a Tardis-like venue with bells and whistles. Lucky, because apart from me most of the people who were going to make this event happen were suddenly a lot busier organising the Islington GP demo, timed for the day before the conference. We joked that key players may well still be in the nick on Saturday morning. We’d have to call in the reserves on the waiting list.

A small group of organisers – Paula, Denise, Andrea, Lynne and Jay – joined Roy and me. Over coffee at the BFI and a few emails, we sorted out the workshops, the administration and the domestics, talked about the videoing of the event, the process of the day and what we hoped might come out of it.

“The warmth and the gratitude from all sides for an opportunity to meet to talk political action on mental health and the attacks on the welfare state were palpable.”

I became a bit addicted to Eventbrite. All those names and email addresses. How many did I know? Hardly any. People started to get in touch to ask about travel directions, to apologise and cancel their tickets, to say they really wanted to come but were too late for a ticket, can I get them in. I got the sense that people were coming from all over the UK. We used the survey monkey link to ask everyone who they were – survivor, professional, campaigner; about access and dietary needs; permission to film and to contact after the conference. Fabulously, of the people who replied there were equal numbers of people who identified themselves as service user/survivors and professionals (some of course were both). From the numbers registering and the open enthusiasm of people getting in touch, it was quickly feeling like a really special event. The warmth and the gratitude from all sides for an opportunity to meet to talk political action on mental health and the attacks on the welfare state were palpable.

The Islington GP action on Friday 4th was a big success. A massive amount of careful planning had gone into it. The energy on the day was electric. In its closing phase, as we stood around ‘occupying’ Old Street roundabout in the rush hour, I wondered how on earth people were going to manage to get up next day and get a conference to happen. Surely it was going to be mainly down to me. At about 10 that evening, I began to get anxious. Were there enough chairs? I couldn’t remember what Gary had said. Was it totally mad to expect people to wander around Bermondsey – in the rain the forecast said – looking for a pub to have a one hour workshop? Did Denise and I have time at 10am, as arranged, to put up signage from Bermondsey station into the labyrinthine recesses of the Dickens Estate? Had I printed off the maps and the registration list, did I have enough pens? What about buckets for donations – aargh, no! At 4 on Saturday morning I woke up in a panic and emailed Gary to say we needed the hall open earlier than we’d arranged. Carol tried to get me back to bed. We just lay there wide awake like two anxious and excited new lovers, except not. “I’m going to bloody kill you later today, you nutcase! Do you want me to come over with you in the morning and help you get going?” Oh yes, please.

“These people want to be here, they want to be together. And they want to do something together.”

When we arrived at 9.30, Gary and Mandy were already rushing around. “We’ve been cacking it”, he said. I gave him a therapist’s understanding smile. “So has he”, said Carol, spotting my subterfuge. “He had us awake at 4 in the morning cacking it”. Mmmm.. always good to have you around, darling. Other people start to arrive. Chairs are put out in rows. Tony carries the PA system in from his camper van. Paula sets up the registration table. Denise and I set off with the plastic envelopes and cable ties. By 10.30 we have a few conference goers. They look good. Pretty happy despite the rain and the struggle to find Wade Hall. All sorts of people looking almost instantly at home and glad to meet each other. By kick-off at 11 we have maybe 40 people in the hall, less than half the number registered. “People don’t turn up to a free event, you know”. We hear this a lot in the Free Psychotherapy Network. “They don’t value the work if they don’t have to pay”. We hang on a bit. People are still piling in. By lunch, it’s going to be 90 or so.

But now, I’m relaxing. Paula’s in the chair. Denise and I will kick things off. It feels good; very, very good. These people want to be here, they want to be together. And they want to do something together.


See part two of our conference report – by Richard House – here.

The Ethical Dilemmas of Back-To-Work Therapy

This dialogue is taken from an email conversation held in 2015 between Paul Atkinson and Andy Rogers and was inspired by the dilemma described in the vignette below.

An earlier version was published in the journal Self & Society – An International Journal for Humanistic Psychology , Vol 43, Issue 4, 2015. Subscribe to Self & Society here.


Izzy is a qualified psychodynamic counsellor, with a supplementary training in CBT. She has a small but growing private practice working from home and recently began a part-time job as a mental health advisor in a Well-Being Hub located above a Jobcentre Plus. She feels increasingly caught in a conflict of feelings and loyalties between the two settings of her working life.

Her Hub clients are nearly all working class, on welfare benefits and from a variety of ethnic minority communities. Many are on medication and have patchy experience of work. Some have been sanctioned by the Jobcentre staff downstairs and have had to survive on reduced benefits for weeks or months. Via the Hub, she can offer a maximum of 12 weeks support. Meanwhile, her private clients are predominantly white and broadly middle-class, and she sees them once or sometimes twice a week for open-ended therapy on a sliding-scale of £15 to £55 per session.

She feels a profound ethical and social commitment to her Hub clients and the value of their work together, but is concerned she might be supporting an inadequate and potentially punitive system of mental health provision, on an hourly rate of about one sixth of her average private practice fee.


Andy Rogers: Can you say a little about your own work in and around the therapy field, Paul, and what first strikes you about Izzy’s situation and her ‘conflict of feelings and loyalties’?

Paul Atkinson: I have been involved with therapy and left libertarian politics since the early 1970s. I’ve worked in private practice as a Jungian analytical psychotherapist and supervisor since 1990, and chaired two training organisations along the way. As a member of the Alliance for Counselling & Psychotherapy and the analytic college of the UKCP I campaigned against state regulation and the ‘medicalisation’ of the therapeutic relationship. Most recently I have been working to undo the separation of psychological life and social and economic life, a separation through which psychotherapy has played its part in neoliberalism’s growing capture of subjectivity. I helped set up the Free Psychotherapy Network (FPN), and am working with mental health and welfare campaigners to oppose the Department for Work and Pensions’ (DWP) psychological coercion of benefits claimants.

Izzy’s situation and her ethical dilemmas feel very familiar. I think many therapists experience a tension between wanting to work with ordinary people in psychological difficulty through the public and voluntary sectors, and the potential freedoms, satisfactions and income of private practice and its largely white, middle-class clientele. Over the last two decades, these two worlds have become increasingly polarised – in parallel with most other trends in social cohesion and the distribution of resources. As we all know, most counselling and psychotherapy in the public and third sectors is now very short-term, instrumental and behavioural. In the self-employed private sector, open-ended work is the norm, but is affordable to the more well-off only.

My fantasy is that Izzy wants to build up her private practice but is experiencing a lot of anxiety about getting enough clients, setting herself up as a self-employed business and bearing in relative isolation the responsibility she feels for her private clients. The part-time job at the Hub gives her a reliable if modest income and places her in a team with a framework of guidelines, shared responsibility and focussed goals and outcome measures – alongside the satisfaction of working with people experiencing social and economic deprivation and considerable psychological suffering.

The trouble is her job at the Well-Being Hub places her right on the cutting edge of the most vicious campaign in post-war Britain of state violence against welfare claimants, and especially people on mental health disability benefits.

AR: So Izzy’s anxieties, comforts, conflicts and satisfactions aren’t just individual or interpersonal matters, but are in direct relationship with the push and pull of the political and socio-economic environment. Most starkly, she finds herself involved with a government policy that’s having a direct and devastating impact on some of the least powerful people in society.

What really stands out here to me is the mention of Izzy’s ‘profound ethical and social commitment’ to her Hub clients. This brings with it the dilemma of whether or not she can honour – or do justice to – that commitment in such an environment; or is it just too contaminated? How do we begin to answer that question?

PA: Well, there are surely conflicting ethical perspectives for Izzy to wrestle with, and as always the realms of ethics and politics are interwoven.

There is a broad ethical debate about the difference between working in the public and private sectors, a debate which has deepened with the replacement of most NHS talking therapy with the Improving Access to Psychological Therapies (IAPT) programme. As a private practitioner, I would say the primary scene of ethical action is the quantum flow of the intersubjective moment. The existential, let’s say ‘Levinasian’ space of interpersonal encounter is undoubtedly relevant to any institutional setting, but has become increasingly circumscribed by neoliberal utilitarianism and the devastations of austerity ideology. Private practice potentially offers more scope for ethical integrity, say in relation to respect for unconscious process, but it is slave to the market in its own way, and can hardly make more than a limited, individualised claim to serve social justice.

Many therapists in Izzy’s position would argue that something is better than nothing, that the value to her Hub clients of several hours of empathic attention, a taking seriously of their very personal experience of distress and an attempt to offer some kind of useful perspective on how to better live with that experience is primary in the ethical balance. The exponential growth of short-term, outcome oriented therapy over the last decade and more has appalled many practitioners, while others claim the ethical core of the relational encounter remains viable.

In general, I hesitate to make principled judgements on the ethics of someone’s work based on the restrictions of their setting and job description. A practitioner’s capacity for ethical work can overcome, or at least survive all sorts of environmental enclosure. The ethical environment of Izzy’s mental health Hub, however, has and is being deeply undermined under the Coalition and Tory governments, especially in relation to the increasing collaboration between the NHS and the DWP to get claimants suffering mental health issues off benefits and into work.

AR: What’s some of the recent political history around these developments?

PA: From the start, the IAPT scheme promised to pay for itself by reducing the welfare bill. Richard Layard was clear in his Depression Report 2006 that more people were claiming benefits with a mental health diagnosis than for any other reason, including unemployment.  Getting people off benefits and into work was to be a major outcome goal of IAPT provision.

From 2010, DWP welfare policies have become increasingly punitive towards anyone claiming social security benefits, and the pressure to get claimants off benefits has created a toxic environment of fear and coercion, fuelled by a massive increase in benefit sanctions, work preparation courses and compulsory workfare.  The number of claimants sanctioned doubled within a year of new rules introduced in 2012.  Thousands of people with mental and physical disabilities have been subjected to repeated rounds of Work Capacity Assessments and declared fit for work. Deaths through suicide or other causes associated with people being sanctioned or declared fit for work have climbed.  On October 14th 2015, responding to an approach from Disabled People Against Cuts, the UN launched its first ever investigation in a developed economy into the effects of UK welfare cuts on people with disabilities.

Following the Rand Report of 2009 on the value of work as a treatment for mental health sufferers and its recommendations for the joint Department of Health/DWP piloting of a number of return-to-work programmes offering psychological therapies and well-being courses to benefit claimants, return-to-work therapy has begun to dominate the discourse of ‘treatment’ approaches for mental health service users on benefits.  In his 2015 spring budget statement, George Osborne announced the ‘co-location’ of IAPT teams in 350 Jobcentres around the country. The Conservative Manifesto a month later suggested compulsory treatment for benefit claimants with obesity and substance misuse issues.  As I write, Ian Duncan Smith is putting job advisors in food banks.

I want to ask Izzy what she thinks about the ethics of mental health work located in the same building as a Jobcentre Plus? What does she think about working with clients, many of whom will be claiming benefits and will be subjected to a regime of sanctions, workfare, fit-to-work assessments and so on? Does she not think that her work is becoming profoundly contaminated by a “get to work” ideology that is a major source of distress, anxiety, fear and humiliation for many of her clients?

Part of the response from the Hub’s management will be that their work and the DWP’s work are separate, that sharing a building does not mean that they are collaborating in any way, that any course of treatment or support they are offering is strictly by the informed consent of the client, and in so many cases their clients want to work – in fact are desperate to get out into the world of work and all the benefits of self-respect, feeling useful and having a bit more money a job brings.¹

But what does Izzy think as a therapist?

AR: I wonder whether part of the difficulty here is that a practitioner such as Izzy might ‘think as a therapist’ a bit too much! That her commitment to therapeutic process and the assumed value of therapy discourse and practice, and its associated conventions (we sit in this room and we talk in this way about you etc.) might narrow her field of vision when trying to see a way through her dilemma.

Perhaps Izzy and the rest of us need to think more like sociologists or political theorists, or at least apply our critical faculties not just to what happens ‘in the room’ but to the relationships and structures beyond. Interestingly, this seems almost fashionable to say at the moment, which is rather incongruous with our field’s ever more cosy relationship with the State!

Yet even with a fairly conventional therapist hat on, it’s pretty clear that a coercive context (or a physical location and referral  process that directly links therapy with coercive practices nearby) will influence what is going on in the therapy relationally, however noble our intentions to provide a facilitative space for personal exploration.

PA: I imagine all therapists recognise that work is an important issue for most people, whether they are in paid work or not. Work and family are probably still the primary sources of meaning, identity and social connection for most of us. Everyone needs the means of keeping body and soul together, and we live in a society that puts a high value on individuals and families taking responsibility for those needs, mainly through paid work. What is going on for a client in relation to work and money is going be an important arena of therapeutic endeavour, and an endeavour which forcefully brings the world into the room with the client and the therapist.

Obviously, not everyone can work, wants to work or needs to work. Having a job is not a goal of psychotherapy.²  If there is a therapeutic desire around the issue of work, it is surely to explore and open out what work means to someone. The individual complexity of those meanings, as every therapist knows, can be dense, contradictory and fascinating. Ideally, the ethics of the profession call for as open an exploration as possible of the meanings both the client and the therapist associate with work.

If I were offering Izzy supervision for her Hub work, we would inevitably be thinking together about the restrictions of the setting for exploring what things mean to her clients – including work. I have no doubt she will be seeing people who want to work, have a history of difficulties finding and holding down a job, and perhaps find it hard to identify and articulate what kinds of working conditions would be best for them and so on. Izzy and her colleagues in occupational therapy, confidence training and practical support may well do a great job supporting these people, including offering some insight into the clients’ difficulties around work.

“It is impossible to imagine how the toxicity of the DWP culture would not undermine and contaminate Izzy’s hope”

But she will also be seeing people for whom the whole process of being in work or looking for work has been a traumatic nightmare alongside coping with combinations of housing problems; bouts of depression; panic attacks; family breakdown; single parenthood; low wages and benefit claiming; excruciating feelings of uselessness, failure and despair; domestic violence; physical disability; caring for dependents; self-harm; substance misuse; psychosis. Many people with this kind of experience of emotional and social problems will be on benefits and will be in the hands of the DWP regime in the Jobcentre Plus downstairs from her Well-Being Hub.

It is impossible to imagine how the toxicity of the DWP culture would not undermine and contaminate Izzy’s hope to offer a space in which someone’s feelings and associations about work or anything else can be explored.  How in these circumstances can anything approaching an ethical frame for counselling or psychotherapy be tenable? On the contrary, return-to-work and any real therapy will be at loggerheads.

What should Izzy do? This is where your question comes in, Andy. ‘Do we therapists need to think more like sociologists or political theorists, or at least apply our critical faculties not just to what happens ‘in the room’ but to the relationships and structures beyond?’ Yes of course, but what does that mean? Thinking critically about the interplay of the social, political and psychological dimensions of a person’s life, and working within that interplay as a therapist are not necessarily the same thing.

Most of our trainings will include reading and thinking about ‘social diversity, inequality and social justice’. Some make a lot of post-modern critical thinking. There is a growing literature on psychotherapy and politics.  A therapist’s background in terms of class, race, gender, sexual orientation and life experience generally is likely to have a crucial influence on how socially-minded they are and therefore how social and political understandings get into their work. In reality, though, I think the psychodynamics of social difference remain primitive everywhere. Among therapists – because of the intensity and depth of the encounter – fear of difference and associated defensive strategies can be especially powerful. For example, thinking of Izzy, how much thought do we give to our fear of poverty and the poor?

“As a profession, we are more part of the problem of neoliberal capitalism than we are part of the solution. “

At the same time, the separation of the psychological from the socio-economic is at the foundation of psychotherapy and counselling. As a profession, we are more part of the problem of neoliberal capitalism than we are part of the solution. Psychotherapy’s creation and marketing of the intra-psychic individual, like Big Pharma’s creation of the depressed and anxious brain, represent very successful enclosures of lived experience as marketable solutions for the failing denizens of “modern life and its challenges”.

Izzy has some kind of political take on her work, expressed as an ethical tension within her. I would encourage her to experience this ethical discomfort as a guide in her development as a person, a citizen and a therapist. I would want her to allow the unfolding of her discomfort and her effort to work, think and live with its nagging voice to become a passion in her life. Where it takes her is not really the point.

She may think that the ethical environment of her Hub work is too toxic to bear, and leave as soon as she can. Many newly qualified therapists who take up work in the public or voluntary sector and find themselves doing very short term, regulated, outcome-driven therapy can’t stick it for long. It is not what they have trained to do and can accept as real therapy. A recent blog on the Critical Mental Health Nurses Network tells the moving story of a student nurse who decided to leave his training in the face of what he discovered to be the political context of the profession: ‘In short, I felt more like a prison guard than a nurse. Mental health nursing is much more of an authoritarian role – which made me feel more like I was more part of the problem than the solution.’

Izzy may feel she wants the experience of working with and getting to understand the experience of the people she meets in the Hub work – people she is unlikely to meet in private practice. With a growing awareness of how the politics of mental health operate, she may want to explore how to find trust between herself and service users, how she might begin to challenge the Hub’s ethos, and get involved in arguing for changes in the service and in the DWP policies whose impact she is experiencing first hand. She may find herself in deepening conflict with her employers, looking for support from sympathetic colleagues and her union. She may end up losing her job. But in the process she will deepen her understanding of the politics of mental health and of how to work more creatively with people who want positive change.³

But as I say, where it actually takes her is not really the point.


References

  1. In June 2015, the Mental Health Resistance Network and a number of claimants’ organisations and psy-professionals protested at the location of a Well-Being Hub being located above a Jobcentre Plus in Streatham: http://www.swlondoner.co.uk/protesters-rally-against-streatham-jobcentre-forcing-unemployed-people-into-mental-health-treatment/. The Hub staff and representatives of the protesters met a few months later to talk about issues raised.
  2. The moral power of work in our wealthy society is unrelenting. However meaningless, under-paid and demeaning, with a labour market increasingly dominated by ‘voluntary’ and unpaid, low-paid, part-time, zero-hour contract and desperate self-employment work, we are to obey a moral duty to want to work. Benefit claimants are regularly declared to be scroungers, cheats and liars. On the debilitating influence of the current ethos of work, see: http://www.theguardian.com/commentisfree/2015/aug/25/work-cure-disability-benefits-sickness and for a refreshing rebuttal of the return-to-work philosophy, see http://freepsychotherapynetwork.com/2015/03/05/middle-class-solutions-to-working-class-problems-is-why-charities-like-mind-keep-getting-it-so-wrong/
  3. For the beginnings of a discussion in Therapy Today on the ethics of return-to-work therapy and how practitioners might respond see: http://www.therapytoday.net/article/show/4899/should-counsellors-work-with-workfare/ and http://www.therapytoday.net/article/show/4968/counsellors-helping-the-unemployed/

About the authors

Andy Rogers trained at the University of East Anglia in the late 1990s and has worked in and written about the therapy field ever since. He now coordinates a counselling service in a large college of further and higher education and is an active participant in the Alliance for Counselling & Psychotherapy.

Paul Atkinson is a Jungian psychotherapist in private practice in London. Political activism has flushed him out of his consulting room over the last few years, nicely timed to coincide with his state pension and the arrival of grandchildren. He is a member of the Alliance for Counselling & Psychotherapy, and has been centrally involved in setting up the Free Psychotherapy Network.