Tag Archives: mental health

The questionable evidence base of SCoPEd

David Murphy, Associate Professor at the University of Nottingham, interrogates the claim that the SCoPEd framework is ‘evidence-based’.


 

A cornerstone of the SCoPEd approach to generating their competences is to arrive at their findings having drawn from an ‘evidence base’. This is apparent in two separate claims made in the opening two paragraphs. Here the SCoPEd projects’ members say, “The aim of the SCoPEd project is to agree a shared, evidence-based generic competence framework to inform the training requirements, competences and practice standards for counsellors and psychotherapists working with adults.” And they go on in the next paragraph to say that, “The draft framework has utilised an evidence-based process of mapping existing competence frameworks, professional standards and practice standards to identify areas of overlap and areas of difference between counselling and psychotherapy.”

In this blog, the first of two tackling the issue of an ‘evidence-base’, I shall point to the fact that any reference to the use of evidence is questionable and more likely not, and therefore lacks integrity. First, let’s look at one of these statements again in more detail, “The aim of the SCoPEd project is to agree a shared, evidence-based generic competence framework to inform the training requirements, competences and practice standards for counsellors and psychotherapists working with adults”. Here the aim clearly suggests that the differentiated competences between the role of counsellor and psychotherapist will be grounded in evidence. But what do the SCoPEd team mean by evidence? And what might be an example of ‘evidence based competence’ that could be differentiable and identify clear evidence for a difference between the activities carried out under these two adjectival titles?

To first address the issue what evidence is being used, it seems that the list of sources used to arrive at the differentiated competence framework have been taken from existing lists of competences used, or even sponsored, by the same institutions that are trying to the find the evidence for the claimed differences between these titles. One of the issues with this process is that the documents tend to identify something that isn’t real. They are a fiction in regards to what people actually ‘do’. This is a well-known problem with the development of competences designed for a ‘labour market’ and they fail to adequately identify both the specifics and idiosyncrasies of actual praxis. What would be better, and would provide real evidence, is to look closely at what people actually ‘do’ in their work under these different titles.

Doing this would, I am sure, show something quite different from what is presented in the framework and might even show some new or unexpected findings. But the chance of discovering something new through this process has been closed off right from the outset because the aim is really not as it appears on the surface. The idea that counsellors are not doing the same work as psychotherapists flies in the face of all the evidence one can find from spending even just a little time listening to counsellors talking about their work. The chance to find this out has been forgone because a decision was made, at the outset, to look for the evidence in the data that already tells the SCoPEd team what they wanted to know.

‘But what does the actual evidence say?’

Let us look at just one example of a differentiation offered in the SCoPEd report. That is, Competency 3.10 under Theme 3 – Relationship, and refers specifically to the idea of ‘alliance ruptures and repairs’ (competence 3.10, 3.10b, 3.10c). In the SCoPEd document it is suggested that where there is a lack of ‘empirical evidence’, ‘grey literature’ has been used. It is difficult to know what evidence or grey literature has been used for the differentiation of this particular competence; not least because the research on therapeutic alliance, including the more specific topic of alliance rupture and repair, is one the largest bodies of empirical research in the entire psychotherapy process-outcome literature. Yet there is no citation to the empirical evidence that has been consulted. However, as this area of the psychotherapy literature is so extensive we probably should assume that the SCoPEd team will have consulted a recent meta-analysis of alliance rupture repair and outcome studies.

Looking at the differentiated competences (3.10, 3.10b, 3.10c) it seems that the SCoPEd project claim that psychotherapists are more skilled in dealing with alliance ruptures and repairs than are counsellors. But what does the actual evidence say about such a claim? Well let’s take a quick look. In a recent meta-analysis published in the American Psychological Association journal Psychotherapy (not a lightweight publication by any means) the very issue of alliance rupture and repair was considered as was its association to the improvement or progress that clients might make. Let me just say that whether or not one is against or for the quantitative paradigm, given that SCoPEd is an advocate for evidence it is probably worth noting the findings of this type of research because that is the premise on which it claims to be able to differentiate competence.

Esteemed alliance researchers Eubanks, Muran and Safran (2018) examined the association between alliance rupture repair and outcome in 11 studies involving 1,314 clients. Overall the effect size for rupture resolution and positive outcome was pretty impressive (d = .62 for those interested). Clearly good news for those theoretical approaches that regard the alliance as an integral feature of their practice (mainly psychodynamic but also CBT and some integrative therapies). A number of the studies included in this meta-analysis included ‘trainee therapists’ (so not even ‘qualified’ counsellors). The researchers tested the data to see if there were differences between the trainees and qualified/experienced therapists in this association between repairing ruptures and outcome. This was a test of moderation to see if this can account for the variance in the effects. The findings showed those studies that included primarily trainees do not differ significantly from those studies of more experienced qualified therapists in showing an association between rupture repair and outcome. This finding cannot provide evidence for supporting the claim that the more qualified/experienced a therapist is the more likely they will show an association between rupture repair and outcome.

‘the competences drawn up by SCoPEd have been deduced rather than induced from the close observations and recording of what therapists actually do’

So, the evidence from this most recent, up-to-date, and rigorous meta-analysis is overwhelmingly in favour of there being no difference between experienced/more trained therapists and the unqualified/trainee therapists in the associations they show between alliance rupture repair and outcome. But wait, the psychotherapists will say, obviously we refute this claim. Psychotherapists will work with ‘more complex and more distressed clients’ so there would be a difference if you looked at that, wouldn’t there? Well it seems the answer to that might also be available in the ‘evidence’ provided by this cutting edge meta-analysis. The evidence is as follows. Eubanks, Muran and Safran (2018) addressed the issue that more complex client work (such as that with clients given a diagnosis of a personality disorder) might mean that there would be less chance of a positive association between rupture repair and outcome. Again this was not found to alter the effects, meaning that whether or not a study included a majority of clients with a diagnosed personality disorder or not, the association between rupture repair and outcome did not differ significantly from those studies where this was not the case. So the ‘evidence’ suggests that even if psychotherapists claim to work with more distressed cases it seems this cannot be used as evidence to suggest they require more skills in working with alliance ruptures.

But wait, surely psychotherapists would be ‘trained specifically to deal with ruptures and repair’ and that is why their training is at a higher level. So now the question is what effects does having specific training in managing alliance ruptures have on the association of alliance rupture repair with outcome? Well, the same researchers completed a second meta-analysis comprising six separate studies and 276 therapists that had undergone such specific training. The findings again point to some interesting ‘evidence’. Once more, status as a trainee or qualified therapist undergoing this specific rupture repair training did not moderate the association between rupture repairs and outcome, suggesting that the finding is not affected by level of qualification. However, interestingly those training in CBT had a much stronger association between rupture repair and outcome than did the psychodynamically oriented rupture repair training. In fact, for psychodynamically trained therapists, the association was in a negative direction – suggesting the less effective they were in rupture repair, the better were client outcomes!

So what are we to make of this? Well it seems that if we are to look at the empirical evidence, that drawn from the very latest and most up-to-date evidence from meta-analysis, it appears to be suggesting that there’s little difference in association of outcome and rupture repairs in terms of the level of training a therapist has had. Of course, if we look to the ‘grey literature’ it is highly likely that we will find such differences; not least because those differences are simply statements of intent and not reality of practice. The issue here is that the competences drawn up by SCoPEd have been deduced rather than induced from the close observations and recording of what therapists, regardless of their level of qualification, actually ‘do’.

But let’s be honest, the ‘aim’ of SCoPEd is, at best, to determine what the differences are between ‘counselling’ and ‘psychotherapy’ in order to protect the various financial interests of those involved in the accrediting the training of counsellors and psychotherapists. At worst the aim is about laying the groundwork for the next attempt at protecting these titles under statute by pursuing the Statutory Regulation of counselling and psychotherapy. Referring to an ‘evidence-base’ is merely an attempt to give this project legitimacy in the eyes of the membership, who are kept in the dark about the real agendas playing out. This is an attempt to try and convince the members of BACP, UKCP and BCP – run down into the ground by the lack of employment opportunities after training – that they will be better off having these titles first differentiated and then protected. But in truth this will do nothing to protect or enhance the employment opportunities for the tens of thousands of under-employed counsellors/psychotherapists already trained and looking for work, and will do nothing to protect the public from rogue practitioners.

 

Reference

Eubanks, C. F., Muran, J. C., & Safran, S. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55, 508-519.


 

Advertisements

SCoPEd: Denial, Distortion & Deception

The British Association for Counselling & Psychotherapy (BACP), the British Psychoanalytic Council (BPC) and the United Kingdom Council for Psychotherapy (UKCP) – collaborating under the banner of the SCoPEd (Scope of Practice & Education) project – recently published a draft ‘competence framework’, which attempts to differentiate counselling and psychotherapy.

Andy Rogers (BACP member and counselling service coordinator in further and higher education for two decades) submitted the following response to BACP’s consultation survey.


 

It is astonishing that the SCoPEd project claims this document will improve clarity for clients, employers, trainers and other stakeholders. I can only assume the competence framework exists for other political purposes, because there is certainly no clarity here, which might be forgivable if the document was at least more truthful.

But, as one of a number examples of the confused (unintentional?) deceptions in this framework, it is completely erroneous to identify 3.5.c (Ability to negotiate issues of power and authority experienced in the inner and outer world of the client or patient as part of the therapeutic process) as a ‘psychotherapist’ competency (one therefore presumably not held by mere ‘counsellors’), when for any person-centred counsellor worth their salt, this would be a central principle of everything they do! The same could be said of another ‘psychotherapist’ competency, 5.1.c. (Ability to evidence reflexivity, self-awareness and the therapeutic use of self to work at depth in the therapeutic relationship and the therapeutic process).

These examples demonstrate how formal differentiation between the adopted titles often means the imposition of something (i.e. simplistic, hierarchical separation and compartmentalisation) that isn’t actually there in practice among the human beings entering into therapy as practitioners and clients. In reality, there is much fluidity and complexity, which the framework attempts to iron out by positioning psychotherapists as doing the really deep stuff, counsellors as merely dabbling, and then a mysterious in-between group that does more than the basic counsellors but isn’t quite at the psychotherapist level.

“it is not the practitioner’s title that determines what happens in the therapy relationship.”

As most of us know, these levels – assumed in the document to be clear-cut enough to be separated into columns and boxes – are manufactured. At best they are only partially truthful, some of the time, in some situations, for some individuals. They certainly do not accurately represent the field, within which many practitioners who identify as counsellors will see their day-to-day work in the ‘psychotherapist’ column; while there will be plenty of ‘psychotherapists’ who have not yet developed the depth of practice (if we describe it that way) of some ‘counsellors’. After all, it is not the practitioner’s title that determines what happens in the therapy relationship.

That we end up working under one label and not the other is subject to all sorts of choices, influences, values, historical precedents and contextual factors, and often says little to nothing about what the experience of therapy will be like for clients, which could be vastly different between any two ‘psychotherapists’ or any two ‘counsellors’. For a whole swathe of the field, such as the humanistic section – and particularly in person-centred therapy – there is no distinction at all made between ‘counselling’ and ‘psychotherapy’ in terms of the actual work (which this framework purports to articulate); the different titles merely refer to the traditions and histories of various training programmes, professional organisations/groupings and work contexts (and the job titles therein).

“When did therapists become so uncritically disengaged from the roles of history and power in the narratives we hold about ourselves?”

The therapy field is a diverse and complex ecology, which, rather than celebrate, the framework appears to want to eliminate by reasserting hierarchies that are well past their use-by date. A historical aside here is that counselling as an alternative word for psychotherapy has roots in Carl Rogers’ mid-twentieth century tactical switch from the latter to the former at the University of Chicago, which was necessitated by a law that ‘psychotherapy’ could only be practiced by medical professionals. From the very beginning of ‘counselling’, then, the different words were not functional descriptors of differing activities, roles or levels of ‘competence’, depth, ability, skill or experience but were value-laden, politically charged and subject to the operation of power and professional (self-)interest. This is no less true today, but the SCoPEd project is in complete denial about it. When did therapists become so uncritically disengaged from the roles of history and power in the narratives we hold about ourselves?!

It’s notable in sections of the framework that ‘psychotherapist’ is apparently equated with greater alignment with psychoanalytic theory. Is the field not done yet with this power struggle, with the idea that psychoanalytic theory sits at the top of a hierarchy? The ‘note on terminology’ almost acknowledges this tension but concludes, absurdly, “Where terminology has been used that could be interpreted as being modality-specific, this is not the intention.” Oh, that’s okay then – it’s the thought that counts, eh? Being ‘expert’ therapists, I thought the Expert Reference Group (ERG) might have a bit more to say about the importance of language and the power that runs through it, looking beyond stated intentions towards the deeper meanings and influences when we choose one way of saying something over another (especially in a potentially influential document such as this). No?

I was also wondering how this apparent pro-psychoanalytic bias – with its implicit discrediting and delegitimising of humanistic/existential/person-centred counselling/psychotherapy (and their associated values, not least around language) – came about. Then I noticed the ERG was made up of 12 practitioners, 7 of whom were identified as psychoanalytic, whereas only 1 was clearly identified as humanistic (and even then, only as part of an ‘integrative’ model) (see pp.72-73 of the SCoPEd Methodology document). How can the framework produce an accurate picture of the field, when the ERG does not represent the diversity within it?

But the whole project is also skewed by other assumptions and value systems around therapy, which are perhaps even more important for the future of our professions. The Roth/Pilling UCL methodology used here was developed originally by manualised CBT proponents for the CBT competence framework, which was commissioned by the Department of Health as part of IAPT’s development. As this history suggests, breaking down the relational art of therapeutic work into lists of discrete ‘competences’ is not a neutral or objective activity (however ‘evidence-based’ it disingenuously claims to be); it is a technocratic pursuit that clearly derives from the NHS-appeasing assumption that therapy can be manualised into specific skills that, if applied in accordance with the manual, provide ‘effective’ ‘treatment’ for specific ‘disorders’. In other words, the project inevitably – via its very form – aligns therapy with an instrumental and medicalised healthcare model, again potentially delegitimising approaches that see therapy as, say, a meaning-making dialogical encounter or principled way of being.

That none of these biases or agendas, and the political expediency from which they spring, are acknowledged in the framework, highlights its failure to take a therapeutically informed, self-reflective, critical thinking approach to its own motivations, intentions, guiding principles, methodology or articulation. Presumably none of this matters much if your goal is to air-brush the imperfect, fallible, human complexity of relational therapeutic work, in order to prepare for the distribution of power that statutory regulation would involve for the organisations that have composed this empty but highly potent document.

andyrogerscounselling.com

@AndyCounsellor

 


 

 

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.

How do we get mental wealth? Labour Party Conference Fringe Event this weekend

If you’re in or near Brighton this weekend, check out this Labour Party Conference Fringe event on Sunday, led by mental health survivors and radical psy professionals, including the Mental Health Resistance Network, the Free Psychotherapy Network and the Alliance. All welcome (not just LP members).

For more than 30 years, we’ve suffered the violent exploitation and extraction of our mental wealth by successive governments pursuing neoliberal policies. So where are we now? And what do we need from a Labour Government?

How Do We Get Mental Wealth? Event details here

6 – 8pm, Sunday 24 September 2017. Ashdown Room, Holiday Inn, 137 King’s Road, Brighton BN1 2JF. Wheelchair accessible.

Alliance update: Letters to the press on the general election

Dear colleagues,

The Alliance has taken a lead in organising two recent press letters, aimed at the election campaign, on government policies around people with disabilities and the nation’s mental health.

In the Daily Mirror:

http://www.mirror.co.uk/news/politics/must-defeat-tories-sake-mental-10494187

And last week, this appeared in the Guardian:

https://www.theguardian.com/politics/2017/may/18/vote-labour-to-uphold-the-rights-of-disabled-people

For us, an important and exciting development over the past few years has been the involvement of therapists in campaigns of a wide nature, including  disability, psycho-compulsion, workfare, benefit cuts, and mental health. Crucially, these have been campaigns in which psychotherapists, counsellors, psychologists and other professionals have for the first time joined service users and welfare campaigners to plan and participate in protest, political lobbying and street actions on issues of social and psychological politics.

The initiatives for these alliances and for a more strident intervention in the social and political field have not come from the establishment of our profession (the regulatory professional bodies like BACP, UKCP, BABCP, BPC, BPS and RCP) whose voices have been slow to rise above the careful comprises of ‘realpolitik’, but from the growing energy of radical, more grass-roots organisations like the Alliance, Psychotherapists and Counsellors for Social Responsibility, Psychologists for Social Change, the Free Psychotherapy Network and the Social Work Action Network.

If you agree with the broad sentiments in the letters, we’d be most grateful if you would circulate and share the links far and wide through all your networks, including tweeting and social networking.

You can for the moment contribute your own comments below the line of the Mirror letter – please do! Thanks very much for your support.

Our warm regards,

Paul Atkinson (for the Alliance)

UEA Course Closures – An Attack on Values

The University of East Anglia (UEA) has decided to axe its renowned counselling courses, including the flagship intensive Post-Graduate Diploma in Person-Centred Therapy, from which I graduated in the late 90s.

It is twenty years since I applied for a place on this course, two decades since I first held the role of ‘counsellor’ in a conversation, and I’ve worked in and written about counselling and psychotherapy ever since, with many formative experiences along the way. Yet UEA, the course, the staff and students, the Centre for Counselling Studies and the University Counselling Service are all tattooed onto my psyche as a practitioner.

The psycho-geography hums with resonance – the flattening lands around the A11 up to Norwich, the walk into campus from the Unthank Road, the iconic ziggurat buildings, high up from which the counselling rooms once gazed. I sat with my first clients in those stacked glass and concrete boxes, held and encouraged and distracted and moved by the big-skied view across the lake and the acres of shifting weather, which would nonetheless dissolve into irrelevance most sessions.

I attended personal development groups in these rooms too, grappling with the entwined attitudes of acceptance, empathy and authenticity. Seeing the value of the form, I once plumped for a private weekend encounter group in the same space – hours with a bunch of strangers from beyond the course, the first day running open-endedly into the evening as the room’s squared windows blackened to an array of mirrors. Given the intensive, full-time nature of the training programme either side of that weekend, I realise now I must have spent 12 days straight completely immersed in varying forms of experiential work, plus supervision, counselling practice and skills and theory sessions, with only two days break at each end (when assignments would’ve been emerging from my primitive word processor).

Later, after the diploma ended, I would return to co-facilitate a similar group experience and occasionally visited Norwich semi-socially, but always via my connection with the training and the therapy community around it. Although I no longer have contact with most of my fellow students, I gained one deep and ongoing friendship and still speak here and there with people connected to UEA.

But so what? Perhaps my disquiet at UEA’s decision to scrap the courses might be construed as nostalgic. Things change, don’t they? Tattoos bleed into the surrounding skin, lose their vibrancy, and whatever meaning they hold for the subject – and sometimes it is a sense of a long since departed self – they are at best curious adornments to everyone else.

Perhaps. But I think the loss at UEA has a significance beyond my own idiosyncratic history.

‘Say the right things, when electioneering…’

In the same year that I applied to UEA, Tony Blair’s New Labour swept to power on the back of a desire for change. It was 1997 and pop culture fizzed with champagne bubbles and cocaine-dashed nostrils. A rampant patriotism – initially art-school-ironic and then stadium-flag-literal – was busy ignoring or shouting down the prophetic gloom of Radiohead’s latest album, OK Computer, released that same year. In spite – or perhaps because – of its incongruence with the times, the album was nonetheless lauded critically and was wildly successful commercially – it’s anguished cry from Britpop’s shadow cutting through the din of the party.

I heard OK Computer to death in my job at what we optimistically still called a record shop (actually a video and CD chain store) but just recently, in advance of the album being re-issued next month, I’ve been giving it another spin, which is where – unexpectedly – our nostalgia thesis begins to unravel. Because there is little rose-tinted comfort in revisiting these songs. As they hit their twentieth anniversary, we – the citizens of 2017 – find ourselves not in Blur’s chirpy Parklife or in a big-hearted mass sing-along at an Oasis concert, but in the very atomised, alienated, divided and tech-engulfed times that Radiohead’s stunning, if overplayed, work of art-rock predicted, and about which it voiced a bleak but very human form of protest.

‘One day, I am gonna grow wings…’

The Person-Centred Approach (PCA) was – and arguably still is – another protest against the state of things, albeit one rooted in a model of potentiality and growth, rather than alienated despair. It emerged in the US as a critique of – and embodied alternative to – the psychoanalytic and behaviourist strangleholds on individual subjectivity, and spoke of a ‘quiet revolution’. It certainly challenged the power of the highly medicalised psychiatric and psychotherapeutic establishments, both theoretically and in practice.

As counselling gradually grew in legitimacy here in the UK, establishing its own organisations, literature and courses, the development of UEA’s person-centred training in the early 90s had a similar sense of creative protest. While the PCA had become a mainstream approach in the British therapy field – with one of its core texts (co-authored by the UEA course director) on the way to being one of the best-selling counselling books of all time in the UK – it still stood in counter-cultural contrast to some of the evolving norms of the emerging profession, which in any case remained relatively – by today’s standards – on the margins of our culture.

It was (and still is) rare for the PCA to be taught in a university setting, yet the UEA programme offered post-graduate training that remained defiantly values congruent: it had a deeply experiential approach; it was highly focused on the personal development of the practitioner; the spiritual and political dimensions of therapy were core themes; and completion of the course was through self- and peer-assessment. And this congruence between theory, principle and practice was also expressed socially through its embeddedness within the campus and city communities: trainees had placements within the university student counselling service and were encouraged to take up linked placements within the city. In my time there, students offered counselling in a diverse range of settings, from an insurance company, to voluntary sector services, to my own placement working with inmates at Norwich prison.

Following the 2003 retirement of the founding director, a prominent figure in the professions, the Centre for Counselling Studies maintained a high profile internationally within both the PCA and the counselling field generally. It staged a number of conferences and developed a successful Masters and PhD programme and towards the end of the noughties was undertaking qualitative and quantitative research into ‘outcomes’ at the University Counselling Service.

But sources at UEA suggest that this research was effectively ‘buried’. Then, around 2011-12, the university withdrew the team’s ‘Centre’ status and some of the associated funding, reducing it to little more than a teaching operation for the courses. The ‘Centre’ title, I’m told, was reinstated around 2014 as a branding exercise for the trainings but the staff budget allowed for no research or enterprise remit to expand its international profile. Then, in a typically Kafka-esque turn, the diminished Centre’s lack of research and enterprise was taken by the university as a sign of its ‘failings’, which brings us to the recent decision to axe it completely.

Many people, not least the students themselves and the local MP, have rightly challenged the wisdom of this decision on the grounds that it is unfair to existing trainees who were hoping to progress onto the higher level courses and – crucially – that it will drastically cut the availability of the real, in-depth counselling provided by diploma students, both in the wider Norwich community and at the university itself, where short-term CBT-based mental health support and group work is little compensation, as this moving post from a person who used the service makes crystal clear.

‘It’s just business…’

This is exactly what’s been happening in other sectors, of course, particularly the NHS, where instrumental, short-term models (therapy-lite, if you will) have become dominant. These are ideally adapted to the current, highly medicalised regime around mental health, with its diagnose-treat-cure approach to human distress. In its atomised conception of people and quick-fix mentality, this is in turn ideally suited to our current political and socio-economic conditions – often referred to as ‘neo-liberalism’ – in which therapy’s role is perceived by the State and its agencies to be simply to return ‘ill’ workers (or students) to their jobs (or studies) after a short course of ‘evidence-based treatment’.

In all levels of education, one impact of this neo-liberal order has been to prioritise the needs of business over both critical thinking and holistic personal development. In higher education (HE) especially, organisations are run as businesses themselves, with students considered consumers and staff expected to be compliant employees. The institution’s branding must not be tarnished because it needs to compete with rivals in the marketplace and generate as much income as possible. This can create a climate of fear, particularly when the organisational agenda begins to turn against a specific department or area, as appears to have happened at UEA.

These aren’t the kind of conditions in which in-depth counselling trainings are likely to thrive. While the courses might be in demand and over-subscribed, they can also be costlier than some other programmes, due to the intensive, experiential element, which requires plenty of contact time between staff and students. In discussing the events at UEA with colleagues, I learned that a number of other long-established counselling courses in HE have closed or been threatened with closure in recent years.

How does this fit with our culture’s contemporary interest in addressing ‘mental health’? Well, in one sense, it’s obviously completely at odds with it; but it also highlights how not all ways of responding to psychological distress are valued within the cultural and economic conditions I sketch above. While we are talking about mental health more than ever – which part of me welcomes because a decrease in shame, embarrassment or toxic silence is a good thing – unfortunately most of the talk is funnelled through a very narrow channel of acceptability: our distress must be seen as ‘just like any other illness’ and therefore the treatments must be medicalised and efficient. This is therapy as a drug-like healthcare intervention (with the reductionist ‘evidence’ to match) rather than it being a relational, exploratory dialogue – a meaning-making human encounter.

So courses such as UEA’s person-centred training are not only a bit expensive to run, in a highly competitive and monetised system, but also they represent a direct challenge to the prevailing ideology in education, mental health and the culture at large. I’m sure many of us would hope that this kind of critical, creative and counter-cultural thinking and practice would be encouraged by our universities – even when it’s not much of an earner – but clearly this is no longer the case.

‘Fitter, happier, more productive…’

Tellingly, UEA is maintaining its training programmes in a highly manualised form of Cognitive Behavioural Therapy (CBT), which feed directly into the NHS Improving Access to the Psychological Therapies (IAPT) programme. The training resides in the Clinical Psychology department of the university’s Medical School. If you look at the web page, there’s a link for ‘IAPT and Other Modalities’ (meaning non-CBT approaches), which leads to an otherwise blank page saying, Coming soon. Let’s not hold our breath on that one.

IAPT has come in for heavy criticism on many fronts: using an overly manualised and bureaucratised (i.e. de-humanised) healthcare approach; discriminating against other therapies (and the clients who want them) due to a narrow and inappropriately medicalised understanding of evidence; massaging data to claim greater success; having absurdly long waiting lists and a dysfunctional triage system; not taking care of its staff, who burn out quickly; unethically colluding with the efforts of the Department for Work & Pensions to reduce the welfare bill; and more.

In my own work, I fairly regularly hear from people with unhelpful experiences of IAPT, not least that a person’s history – their childhood experiences particularly – are barely considered. Huge losses, abuses or other deeply significant events that clients begin to explore in counselling within the first session or two, might never even have come up with their IAPT practitioner. Yet across all therapy sectors outside of the private sphere, the pressure is to follow the NHS model, as if its legitimacy is unquestionable, as if its version of what distress means, and how we should respond to it, is reality itself.

This then delegitimises all other responses to distress, however valued they are by the people who use them. In my own sector, counselling in further and higher education, I have seen this creep occurring first-hand. The professional division for the field (BACP UC) recently followed its parent organisation’s desires by creating a ‘competency framework’ based on the same CBT-derived Roth & Pilling/UCL methodology that we see in UEA’s IAPT training. This despite the fact that relational work – humanistic, person-centred, psychodynamic, integrative – is far more widely practised in the sector. While the framework apparently welcomes all models of therapy, it is nonetheless skewed to a technocratic and instrumental healthcare approach, and has alienated a number of highly experienced practitioners in the sector who do not recognise their work in the final document.

‘We are standing on the edge…’

Where, then, do we go from here? On the brink of a general election, with a very different Labour opposition to that of 1997 but a very familiar Conservative government, which is apparently emboldened by the country’s divisions, how do we shift the language and practices around ‘mental health’ away from the thin comforts of ‘illness’ and ‘treatment’? How do we take back human distress from its enclosure by neoliberalism, healthcare and the State, and re-integrate it into our everyday lives and relationships so that we can respond with ordinary compassion, rather than professionalised diagnosis and treatment, even (or perhaps especially) when we seek out a therapist to discuss our concerns?

What still excites me about the spirit of the Person-Centred Approach, is its deeply respectful commitment to the right to self-determination; to the inherent value and potential in subjectivity; to honouring the connectedness between us as persons in a social world; to witnessing, exploring and embracing all of this with a principled and creative not-knowing, rather than dogmatic expertise. It is these precious things – despite all the mental health policies, initiatives and media campaigns – that we see being lost at UEA and beyond.

Recently, a small controversy bubbled up at UEA about the appearance of Anthony Gormley’s life-size human statues on the roofs of its concrete structures. One looks out from a building behind the ziggurats, gazing across the same land and skies as the view from the counselling rooms. It is mesmerising, unsettling, challenging. Some have complained they are reminiscent of suicide.

In a BBC interview, Gormley said,

‘These works are nothing to do with suicide, they’re actually to do with life… Universities are places where people spend a lot of time thinking about the thoughts of others… I think it’s a wonderful place to balance that intellectual life with an object that is silent. It doesn’t need to be read. It has to be felt, it has to be lived with.’

Let’s hope the statues are a defiant symbol of the persistence of these values and aspirations, rather than a memorial to their passing.

(Song lyrics from Radiohead’s OK Computer.)

Andy Rogers is a counsellor and service coordinator in a large FE and HE college and works in private practice in Basingstoke, Hampshire. He is a registered member of BACP and has written about the politics of therapy and the person-centred approach for the best part of twenty years.

andyrogerscounselling.com

@AndyCounsellor

*


 

Alliance video: protest against New Savoy Conference of psy-organisations

The Mental Wealth Foundation, supported by The Alliance for Counselling and Psychotherapy, challenge attendees at the 2017 New Savoy Conference.

Why, despite some of the recent rhetoric, are the professional psychological organisations colluding with the Department of Work & Pensions view that being out of work is a pathology requiring treatment? Why support psycho-compulsion by working in environments in which those claiming benefits can be coerced into a distorted form of counselling and psychotherapy? Why support the emergence of State therapy?

OiOiSaveloy from Denis Postle on Vimeo.