Surviving Work was created to look realistically at working life and build our capacity to form good relationships with the people around us. We will not make you richer or thinner but we will help you to survive work.
I’ve wasted a lot of beach holidays stressing over the state of my employment relationship. Psychically speaking, I’m a Goth on a beach. Black rimmed eyes staring out under a crimped fringe, my Cassandra complex diametrically opposed to having any actual fun.
In my defence, for those of us working in public service some summers present us with a real existential crisis. Traditionally summers are a time reserved for public sector restructuring and workforce planning. A familiar routine of 4pm Friday redundancy emails peppered with neurolinguistic programming. The witching hour is upon us.
I realise this is not a good look to say this but Surviving Work started in 2011 when I was put in a compulsory redundancy pool and really got stuck into deep feelings of redundancy. It triggered a period of profound disorientation and disillusionment in me. After 15 years working in unions, I realised I didn’t know so much about defending myself or the mechanics of my own solidarity.
I’m not saying this to annoy anyone I’m just going to tell you a fact. That every single one of my colleagues who were working in the solidarity business in trade unions didn’t lift a finger to help me. Not one. At the time this blindsided me, comrades.
The people at work who actually helped me were a motley crew made up of a Turkish teacher, a Scottish communist economist and someone I shared an office with who I always thought hated me. This was so unpredictably random that it caused a profound shift in the way that I think and work. To understand that saying is not doing, and nothing is a substitute for actual experience. That to have experienced the cold chill of redundancy and the prospect of losing your home leaves a mark. It raises your chances of seeing what’s on the horizon before some others. At best it allows you to step in to support colleagues, at worst it leaves you with a legacy of 4am panic attacks and a deep cynicism regarding political showmanship.
This is not a piece about bad unions. Almost without exception globally, if you have a union in your workplace you should join it. But a huge generalisation now follows. After working in adult education for 20 years I’m pretty sure that the most self-confident and articulate are often the least capable of action. One of the occupational hazards of being politically active is that its a small step from being right to being self-righteous. What always gets under articulated in our political culture is the quiet steady developmental work that many of us do to build solidarity at work. I’m eternally grateful that I did get the help I needed but none of it came through the self appointed voices of my workplace.
This experience taught me something that the universe was literally begging me to understand. That for all of us, we can’t delegate building our relationships with other people or with ourselves. Solidarity is less an ideological construct and more an everyday practice, something that those of us with an intellectual persuasion often fail to understand.
Over the last seven years Surviving Work has been a project essentially asking people how they do it. For many years I’ve interviewed and recorded people’s experiences of work. All of them were smart and funny, some felt like taking a bullet and you can read and listen to them at the Surviving Work Library.
This is what I’ve learned so far. This is going to smart a bit but might be worth packing in your beach bag.
Don’t blame yourself: Do not internalise the downgrade that is taking place in our profession. It’s neither our fault, nor is it true that we are redundant. We just might be facing redundancy and there’s the profound difference.
Don’t keep calm and carry on: Probably the most consistent piece of advice I received while in the seventh circle of a compulsory redundancy pool was ‘don’t get angry’. Well, that’s a lot less useful than it sounds. Given that I was working in a progressive business school environment, surrounded by expertise in mentoring and people development, I found this really disappointing. My response to my sudden vulnerability was to design an App called No Punching or Spitting which kind of tells you where my leadership skills were at the time. In the current climate, it’s very important that we accept that we will feel things about what’s happening and that we don’t roll out the NLPs every time something important needs to be looked at. We have to learn to tolerate each other’s anger and distress and create a space where that can be expressed without losing our jobs. So when you see someone you work with cry or channel Genghis Khan walk towards them rather than away. Seriously, accept that we’re all a bit more red-sweaty-faced than we were. The only footnote is don’t swear because then the HRM will have the perfect excuse to come for you.
Don’t be brilliant: We are all subject to the downgrading underway in public services where potentially no-one is special. If its true that many working people are not recognised or progressing because of the impossible targets that are being set for us, we are all failures. Even the ‘successful’ are working under a system that is ultimately un-winnable. Can’t have it both ways and the sooner we understand that the sooner we can get on with treating each other as equals, including in the face of redundancy. Once our professional egos have worked through the implications of that, the up side is that no longer do we have to respond to systemic failure by just working harder and more. Actual weekends and summer breaks are returned to us.
Don’t go it alone: In the public sector we are entering a situation of professional cannibalism where we could end up eating each other just out of fear. Noa’s-arkism runs deep, dividing the workforce between people who think they’ve got a place on the boat and those of us who know we don’t. If the entire history of workplace organising tells us anything, it’s that we can all be split and divided unless we work at the everyday of our relationships. A part of going through a redundancy is the realisation that you never know who is going to help you. There are inevitable mistakes and betrayals in our working lives but the key is not to let this force you to give up on humanity. Forget those who talk but don’t walk. There are some very helpful people out there with experience of surviving work. Find them. Hold onto them. If you’re worried about colleagues don’t wait until you find their desk cleared in October, stay in touch. And since you may be wondering if your work email is being monitored, remember to get colleagues’ personal emails and phone numbers now before the summer break.
Create Safe Spaces: We all have to get creative about where we look for solidarity. A book club could do more actual solidaristic work than a branch executive. It depends on finding the people who you can depend on and protecting those spaces where people can say what is really happening to them. Invite colleagues for coffee, set up a women’s group, anything that opens up a space. This is the real organising work ahead.
Take a pregnant pause: There is a profound moment of pause that is required to realign to this reality. We’re all vulnerable to the fear of being redundant. It is precisely at this point we need to re-engage our self-confidence and our confidence in other working people. Rage and campaigns alone won’t answer this because survival requires an internal reorganisation about what can sustain us. A pregnant pause is required for digesting and creating a sense of what’s next. To locate an idea of a labour that feeds rather than leaves us feeling that we’ve failed at life. To nurture something that brings life and love and a promise of being worth it.
Surviving Work will be back in the Autumn with a practical series about the methods of solidarity.
This is going to come as an awful shock but therapists have actual feelings. Yup, far from the awkward silence/punative parent routine, people who work in mental health services use their feelings to do what they do. They feel stuff because their patients need them to and its from this bodily, rather than intellectual, exchange that things get worked through.
As a result, how mental health workers are treated at work has consequences. Bluntly, working with distress is distressing and if we want our therapists to contain what we bring, they have to have a certain level of containment themselves. Whether its job security or safe settings, our therapists can only take so much.
In our final blog in The Therapy Industry series, here is what our survey respondents said about how they feel about their work. Just read it.
Has austerity affected the way we work in mental health? Over the summer you can contact @freethepeeps and @survivingwork to have a collective think about how austerity is changing mental health services and the way we treatment is delivered in the UK #futureoftherapy #mentalhealth&austerity
The largest NHS mental health programme in the UK is the Increased Access to Psychological Therapies (IAPT) service. Over 23% of our survey respondents work in IAPT services, but many more are working under services that have adopted an IAPT model. This is what they said. Obviously, our survey was anonymous which is why you might have an eye watering moment reading these quotes.
Just to repeat, these quotes are from workers providing the largest NHS mental health programme in the UK. If you go to your GP asking for help this is the service you will be referred to.
What emerges from www.thefutureoftherapy.org is that it is through the use of the IAPT model of performance data and performance management techniques there is a systematic downgrading of clinical practice across mental health services. This is not the contentious debate about cognitive behavioural therapy versus psychotherapy, it is about degradation of clinical into non-clinical work. A growing number of people working in mental health services have ambiguous clinical status. Psychological Wellbeing Practitioners (PWPs) were introduced through IAPT to provide manualised short term interventions and carry out initial phone assessments. This trend of employing non-clinical roles to provide services is reinforced in the UK Government’s mental health workforce strategy announced in July 2017 which includes the employment of 8000 non-clinical jobs to deliver mental health services. And this is before the digital healthcare industry manages to convince government ministers that you can cure depression with an App.
This downgrading is justified on the basis of an ‘evidence base’ of the impact of the IAPT model claiming that it achieves 50% recovery rates. With the best will in the world, this is an obvious gaming of the recovery data fabricated through the use of feel good questionnaires the completely fail to ask the patient how they actually feel. In 2017 the National Audit Office carried out an inquiry into performance data in IAPT services. Despite the evidence submitted by practitioners and the 10 page summary of the findings of www.thefutureoftherapy.org, the NAO has failed to produce a public report. When I submitted an FOI request for the correspondence between the NAO and the Department of Health in relation to the decision making process not to make this report public this is what I received.
Ironically for the talking profession, it appears the NAO doesn’t really want to talk about any public safety concerns raised about our government’s mental health policy.
There has been a deep reluctance on the part of IAPT providers, training and professional bodies to challenge this fabrication of the evidence base for IAPT because of the financial interest in the sector to keep this system in place. IAPT is one of the largest and growing sources of employment in mental health explaining the fear of clinicians to raise their concerns that the wrong things are being measured and the that the failures in patient care are being evaded.
Where mental health workers do raise concerns about patient care and working conditions, the vast majority of issues are not resolved. In our survey 38% of people raised concerns about patient care but only 25% were adequately resolved. This cuts against the received wisdom that if you present workplace issues as a matter of patient care then management take it seriously. This compares to 36% of mental health workers who have raised concerns about working conditions. Only 6% were addressed adequately. There is a significantly higher propensity for IAPT workers to raise concerns about working conditions at 55% and 58% in relation to patient care.
Within the sector, IAPT is one of the largest and growing sources of employment in mental health explaining both the number of experienced clinicians working in the service as well as the fear of clinicians to raise their concerns about the impact on patient care. The insecurity of jobs in the sector is important in explaining why it is that the IAPT model has been introduced without much internal resistance. The dominance of the IAPT model combined with a shrinking independent psychotherapeutic sector and limited sustainability of private practice, whatever your views are as a practitioner, securing paid work is becoming dependent on an acceptance of the IAPT model.
There’s a problem in mental health services that nobody feels secure enough to face up to. This is something worth banging on about.
Dr Elizabeth Cotton’s book chapter “The Industrial Relations of Mental Health” will be published in 2019 in The industrialisation of Care: counselling and psychotherapy in a neoliberal age edited by Risq & Jackson, PCCS Books.
Uncomfortable as it is to imagine that the people providing mental health services are themselves insecure, our research showed that the majority are feeling pretty vulnerable at work. That’s a bit bleak for a bank holiday Monday but maintaining a grip on even grim realities is pretty fundamental to the therapy industry.
Anne Kearney’s book Counselling, Class & Politics is both timeless and exactly of its time. In many ways, not much has changed in therapy during the lifetime of this book published in 1996: the distortion of public service by neoliberal economics and the resistance within our society to frame mental health as a political arena and a reluctance within the profession to see the concerns of therapists as genuinely political ones.
But as the conditions of work for therapists decline, there is a renewed possibility for therapists to think and act collectively. Four things are happening right now in our mental health services that make this book important and urgent. Whether in IAPT or third sector, performance management is being used to drive the wholesale implementation of short-term and diluted forms of therapeutic work, downgrading both the services and the jobs within them. As the jobs are downgraded, a growing number of therapists are unable to afford training or find work that financially supports them. The growing majority of therapists work in multiple jobs and settings, far from our professional fantasies of career progression or the comfort of a sustainable private practice. As a result of the fragmentation and flexibilisation of work, we are tempted to retreat into professional silos that stop us developing collective thinking and challenging the breaking up of services. An emerging workforce crisis is reaching its peak as people without independent incomes increasingly cannot afford to enter a profession that requires long trainings and working unwaged in order to qualify. To read more about this, go to www.thefutureoftherapy.org
Subsequently, there is a growing concentration of wealth in therapy, involving both the patient and the therapist, as increasingly only some can afford to buy or provide therapy. When neither therapist or patient can afford therapy, and wages and working conditions decline, the assumption of the privilege of the therapist is eroded. For the next generation of therapists, the prospect of earning a sustainable income becomes remote, and the need to speak openly of what it means to work as a therapist in the context of economic crisis has become explicit.
The most profound political attack on therapeutic work involves the current government strategy to introduce ‘psycho-compulsion’ as therapeutic services are co-opted into implementing welfare reform. Even two decades ago, there were attempts to enlist mental health services to implement cuts in welfare; the only change now is that the front line of reform is the introduction of mental health ‘services’ into job centres and employment support services into primary care.
This is not just a therapeutic problem of working with class in the consulting room; it is a political one about how the therapy industry and the people working in it are able to address issues of power. So far, issues around money and inequality have been easily evaded in our trainings and supervisions. With the notable exception of the critical networks and self-organised groups of therapists, the debates so far about the future of therapy have been institutionally defended and professionally territorial. This has a cultural aspect within the mental health professions of what the psychoanalyst Sally Weintrobe (2002) calls Noah’s Ark mentality – the belief, at an individual and collective level, that enough people have a place on the boat for us to keep things as they are.
What Anne’s book gently does is to argue that the practices of therapy and the relationships that they rest on demand that a political perspective be allowed and encouraged within those professional networks that can bear to look at the emerging reality. If nothing else, this is because patient safety requires us to build our own and each other’s political awareness and with it a practice of solidarity.
Anne’s book is a clever piece disguised as simplicity. The methods used in this book are important, based on a longstanding tradition of adult and dialogic education. Each chapter includes tasks and discussion points with a simple writing style and absence of intellectualisations and political posturing. As often happens when people use this approach, the result looks simple, even mundane, but this undervalues the space that such a book offers to us to ask the right questions and to negotiate the different interests of the people we work with.
Although this model of education is not a therapeutic practice per se, it shares important developmental concepts with psychoanalysis, including its emancipatory aims, the emphasis on understanding internal and external realities and building ego strength, using dynamic and dialogic processes and providing a containing framework for building relationality between people. For all its current weaknesses, therapeutic training offers us the potential of safe spaces to build emotional ties sufficient to build a sense of identification and collectivism in the sector.
This is an opportunity to build not just social capital but political capital as well – the resources to make political gains and address power dynamics at work. It is through the development of collective interests that the politics and principles of collective action are determined.
It is rare in the current climate to find a book that generously offers a way to think about what is happening to mental health services without flinching and without feeling the shame and splitting that often accompanies our conversations. Although the political economy debates have been revived so that people talk about neoliberalism in an ordinary way, the politics of therapy require more than superficial posturing it will require genuine attempts to re-invent solidarity.
This book is helpful. Helpful in encouraging the future therapeutic workforce not to back away from the political nature of their work but to understand it and work through to a position of survival and solidarity.
Dr Elizabeth Cotton will be speaking at Edinburgh Napier University’s Working in Healthcare tomorrow about thefutureoftherpy.org. Join us here.
One of the striking things about the public debates on talking therapies is the absence of informed discussion about the working conditions and pay of the people delivering services. During 2016-17 the Surviving Work Survey was carried out to try to get a picture of what is happening in the therapeutic professions and ask some blunt questions about pay, promotion prospects and the decline in decent jobs. 1500 mental health workers completed the 50 questions about working conditions and 68 were interviewed. The national survey results are freely accessible on www.thefutureoftherapy.org with infographics, video, eBook and guidance on setting up Survival Surgeries in your area.
Because of the fear and reluctance in the sector to talk about our working lives, the survey took a long run up involving a campaign of discussion events, blogs and public engagement through www.survivingwork.org to create a safe and critical space where people could talk about their experiences. The survey went out through the main trade unions and professional bodies, including mental health nursing networks. Because of the fear of blacklisting and losing referrals, the survey and the results are anonymous.
We had originally planned to design an online map of working conditions, to highlight regional variations. Although it is true to say that working life in mental health is diverse – with teams and individuals trying to build sustainable services everywhere and with many experienced clinicians being able to influence how work is done – the trends that our survey highlights are uniform across the UK presenting a bleak prognosis for earning a living as a therapist.
The Industrial Relations of Therapy
The industrial relations of mental health services is still in its infancy. Despite the restructuring of the NHS data service – into NHS Digital – and the explosion of Freedom of Information requests being made about health services, we do not know how many people are working in mental health, for whom and how much they are getting paid.
This leaves us with a national mental health policy that is not underpinned by actual facts. We have had a series of workforce strategy documents – from the Taylor report on the future of work, the Stevenson/Farmer review of mental health and employers, to the mental health workforce plan for England slipped in just before the summer break – that have failed to inquire. Seduced by the proposal to increase the mental health workforce by 21,000 these reports have failed to report that they are implementing a strategic downgrading of services. Launched from the shiny safety of London think tanks, and created by individuals and organisations with a profound financial interest in the downgrading and outsourcing of services. Nobody actually working in mental health services is convinced by this rhetoric over the reality that the increasing majority of services are provided by insecure workers in non-clinical roles, often working remotely, with no clinical supervision and, ultimately, without a future prospect of providing good care.
The absence of industrial thinking means that still, despite the growing concerns within services, there is no analysis of what is happening across the sector. It is still largely not known that this is part of a larger degradation of work taking place in the UK labour market implemented through the dramatic rise in self-employment and deprofessionalisation that is established through the ‘gig economy’.
This lack of an industrial perspective is linked to the professional silos that our sector suffers from. Despite a growing number of people working in a range of clinical jobs, in different settings, on different contracts, we still do not quite understand that the working conditions of a psychological wellbeing practitioner in IAPT services is directly related to those of a psychotherapist in private practice.
This is not just an industrial relations problem, it is a political one. As mental health services are co-opted into implementing the government’s attack on welfare provision through introducing mental health ‘services’ into job centres and employment support services into primary care, the lack of informed debate means that so far mental health workers have not been able to respond to the strategic corruption of therapeutic services that is taking place. With the notable exception of the critical networks and new unions such as the Psychotherapy and Counselling Union (PCU), the debates so far about the future of therapy have been institutionally defended and professionally territorial. During the process of carrying out this research, I had been blacklisted by two of the main psychotherapeutic bodies. Despite the recognised lack of mental health workforce data, it appears that independent research is not welcome in the ever-decreasing-circles of our professional institutions.
Combined with this lack of informed policy, is a cultural aspect within the mental health professions of what the psychoanalyst Sally Weintrobe calls, Noas-Arkism. This belief, held at an individual and collective level that enough people have a place on the boat for them to keep things as they are.
Despite the shocking picture presented on www.thefutureoftherapy.org. the research comes from a position of hope. One of the privileges of coming from a trade union background is that you get to see what happens to working people when they have reached a point where they cannot accept their working conditions. What we know is that people can and do organise successfully in the most precarious environments – often self-organising as their institutions fail to represent their interests. This is not principally an ideological response, rather one of necessity.
It is this important and ordinary organising work that often gets missed in the mental health debates. As a result, the principle objective of my research is to help open up a debate about the dual purpose of organising in mental health services – how to make real changes in our working conditions and pay while at the same time sustaining ourselves in the current climate.
What the data shows
Because of the distribution of the survey through unions and professional bodies and networks, there is an over representation of senior clinicians and an under representation of the new generation of non-clinical functions. However, all categories of mental health workers are included in the survey and what the results show is three significant trends.
Trend 1. Growth of precarious work
It is no wonder nobody seems to know anything about therapeutic jobs because it is a complex picture. Although 74% of respondents said they worked for the NHS, 54% are working in multiple settings, many are on short term contracts or hourly paid, running from one job to the next.
There is a very clear picture of ‘flexible’ work in the sector. This is not just about the growth of fixed term or hourly paid contracts – it is also about the emergence a growing majority of people who are working in multiple settings, with several employers and using different modalities.
The first problem that this leads to is that people are confused about who they work for and what their employers’ responsibilities are. When you ask people who their employer is 20% say they are self-employed but when you ask people what kind of contract of employment they have it is 30%. From our survey 8% do not know what kind of contract they have and 8% have no written contract at all.
The nature of flexible work means that people are stretched across a range of services. From our survey, 22% of NHS workers have multiple employers, 54% of respondents work in multiple settings with 91% of self-employed work in multiple roles and settings.
As part of this flexibilisation we have seen the growth of part time work – 29% of survey respondents work part time with 59% of part-time workers work in the NHS and 38% are self-employed. Many people said in the survey and interviews that they cope with work intensification by going part time. These tended to be NHS workers and more senior clinicians. On the other hand newly qualified and trainees were setting up in private practice although with low patient numbers. Nobody I spoke to from this second group was optimistic that they could earn a living from working in private practice.
It is unavoidable to point out that many therapists are not earning enough. A staggering 18% of respondents earn less than £300 per week, with an average income of £401-500 after tax. This is partly explained by one third of people working part time but also relates to two key trends; the growth of unwaged work and self-employment.
Our survey shows that 21% of therapists work unwaged as honoraries but interestingly only 15% were trainees, with 6% representing an emerging group of mainly senior clinicians working for free – most working in the Third Sector and the NHS. The NHS and the Third Sector are quietly sustaining many services on unwaged work with 15% of honoraries estimating a loss of income of over £401 per week. It is worth pointing out that as our professional bodies require clinical hours for training and professional registration we have the curious situation that the bodies charged with protecting the profession are undermining it. It leads to the prospect that the future therapeutic workforce will need to be people only from affluent backgrounds – hence the title of our discussion events last year being “Do you have to marry a rich man to be a therapist in the UK?”. Although there are movements in the BACP and UKCP to challenge the culture of unwaged work, we are a long way from halting the expectation that a large percentage of therapists work for free.
Connected to the low wages in the sector is the growth of self-employment in the public sector, a much misunderstood category of work in the UK. Just under 30% of therapists are self-employed – but living far from the powerful fantasy of a full-time psychoanalyst in an Afghan rugged consulting room. What the survey implies is that self-employed therapists are increasingly being used by employers to avoid social costs of direct employment. They work less hours and earn less pay. No more pensions, no more sick pay, no more CPD. This raises important questions not just about professional liability but also the duties of care of employers. Many mental health workers when asked who they work for will say the NHS but the reality is that as self-employed clinicians there is a growing confusion over clinical and employers’ responsibilities, not least in terms of who is insured for what.
Trend 2. Downgrading & deprofessionalisation
Although 24% of survey respondents work in England’s Increased Access to Psychological Therapies (IAPT) services, many move in and out of working for it. More profoundly, the research shows that the regime of performance data and management introduced through the ‘evidence base’ of IAPT, is now mainstream in mental health services. The use of targets around patient numbers, waiting times and recovery rates goes right across the NHS and primary care meaning that the issue of performance management has become the primary cause for professional concern in the sector.
This is one of the greatest shames for public sector workers of how we have allowed the spread of performance data and performance management to dominate public service. This has led to a growing challenge to the claims of IAPT that it can achieve 50% recovery rates – an obvious gaming of data for anyone working in the service. There has been a deep reluctance on the part of IAPT providers, training and professional bodies to challenge this because of the financial interest in the sector to keep this system in place. IAPT is one of the largest and growing sources of employment in mental health explaining the fear of clinicians to raise their concerns that the wrong things are being measured and the that the failures in patient care is being evaded. The 2017 National Audit Office inquiry into performance data in IAPT services has failed to produce a public report. I am currently waiting for an FOI request to reveal the decision making process in government not to make this report public, as presumably the findings raise public safety concerns about government policy.
In the survey, we asked people “what would improve your working life?” as an open ended question, and the majority of people raised concerns about poor management. This came out vividly in the questions about raising concerns where only 25% of patient concerns were resolved adequately and only 6% of concerns about working conditions. Unsurprisingly patient concerns are taken much more seriously but the 75% of cases left unresolved breaks with the received wisdom that if you present a workplace concern as an issue of patient care then management will respond. The resounding picture is of a management who take a ‘hands-tied-headless-chicken’ school of management.
An average of 5% of people who raised concerns were victimised, many losing their jobs or facing constructive dismissal. This may not sound like much but nothing puts a downward pressure on people raising concerns again than seeing a colleague lose their income. This was the saddest part of the survey for me, how little impact we are having in bringing about real changes at work.
Two things come through in the open questions about working conditions. Firstly that the vast majority of respondents raised concerns about the ethics of working in a system that is based on manipulation of what is really going on in services. This was particularly clear in CAMHS services where the rollout of IAPT directly challenges model ethical services. Secondly, the devastation that people experience through working under this system of performance management, and the everyday grinding down and demoralisation that this results in.
This internal pressure is matched by an external one where, although not yet significant, the crisis in mental health services is a major strategic opportunity for private and third sector contractors and private employment agencies who are literally buying up the growing NHS waiting lists. From our interviews, there appears to be a particular growth in private employment agencies providing IAPT services in Child and Adolescent Mental Health Services (CAMHS) as the Child and Young Persons (CYP-IAPT) services are being rolled out in England. There is also a strategic growth of ‘non-clinical’ jobs – from PWPs to digital CBT programmes, such that many of these jobs will not require clinicians to deliver them. With the advent of Sustainability and Transformation Plans and the oblique Integrated Care Organisations, this process of contracting out mental health services is due to accelerate.
Trend 3. The Jobs Gap
What emerges from the research is that it is through the use of performance data and performance management techniques there is a systematic downgrading across mental health services. On the website we call this the ‘IAPT Juggernaut’ representing the dominance of a particularly rigid modality of what many practitioners are calling ‘sub-therapy’ that extends beyond IAPT services. This is not the contentious debate about cognitive behavioural therapy versus psychotherapy, it is about degradation of clinical into non-clinical work.
Just on the basis of the demography of people working as therapists, the existing workforce crisis will threaten services over the next five years. This relates to two key issues; the gap between qualifications and jobs levels and the ageing workforce.
In the survey we estimated the gap between qualification and clinical seniority – the gap between what we are trained to do and what we are paid to do. We used an analysis of qualification seniority that probably underestimates the qualifications of the respondents partly because respondents did not put down all their numerous qualifications and where qualification level was unspecified. Our categorisation of clinical seniority depended on factors such as clinical lead, team leader/ service management plus clinical role, supervision, clinical training role, specialist psychotherapeutic role, complex case load. Given the downgrading of jobs this is not to say that many of our respondents are not working at a high clinical level – most are – only that their job titles and descriptions do not require it.
Our survey revealed that 37% of respondents have senior psychotherapeutic qualifications but only 26% have clinically senior jobs. This goes up to 48% working below their qualification level in IAPT services.
We are moving away from a professional structure towards a much more generic system of ‘mental health’ professional. Many of the people in the survey raised concerns about the growth of mechanised and short term therapy being offered through IAPT and more generally across mental health. We know that increasingly senior positions are not being filled above Band 8a, and as more and more people become unable to fund their own training, the NHS will face a skills deficit as people cannot afford long term psychodynamic clinical training.
This gap is compounded by the ageing workforce. 60% of respondents are older than 47 years, 21% born before 1959 – going up to 29% in London. Only 19% of respondents are younger than 37. The UK working population average is 35%. Although many experienced therapists are successfully working in a combination of private practice and NHS work, the demography of the sector indicates that they are only able to earn a living having spent most of their working lives in the NHS leaving their pensions and mortgages intact. Unsurprisingly a third of respondents said that the best thing they could do to improve their working lives was to retire.
As the private employment agencies and digital health companies mop up the NHS contracts fully aware of the workforce trajectories, the myth of the self-employed therapist as a sustainable job will become exposed. This has implications for our professional and training bodies, particularly those that are currently recruiting on the basis of a professional fiction.
What lies ahead for mental health services
It is a growing possibility that we are within a decade of the genuinely therapeutic professions dying out. The current economic argument for mental health services is based on the unacceptable working conditions of mental health workers. From the thousands of counsellors working in IAPT to the honorary psychotherapists propping up the Third Sector, working in mental health is posing significant health risks to both clients and clinicians. As we become de-professionalised, downgraded and demoralised and our experienced leadership retired, this leaves the gates open to private providers to fill the gap ‘going forward’ towards a mental health service made up of tick boxes and compulsory wellness with psychoanalysis relegated to a heritage industry.
What is happening now is not an accident. There is a strategic objective behind this promotion of manualized/non-clinical/virtual therapies combined with the growth of self-employment in that it opens up the mental health sector to non-clinical providers. Based on the experience in the public and other sectors we will see the rise of private employment agencies (PrEAs) and large scale contractors and with it the risk of failed contracts and lack of corporate accountability when the lights start to go off.
Despite the resistance to look at the facts, we will inevitably see over the next year more information about the workforce crisis about to hit health and social care. Some of the reasons for this are general – that the UK is a low wage economy, the impact of Brexit, and the unsustainable costs of clinical training and professional registration. All of these factors are bad news for keeping genuine health services alive but mental health services are facing a much deeper crisis over the emergence of sub-therapy and psycho-compulsion and with it the corruption of the therapeutic field.
Firstly, genuine psychotherapy increasingly is not being offered in the NHS because it cannot be done as cheaply as IAPT interventions. This is not to say that the return on investment (ROI) of psychotherapy cannot be argued – it can if you are actually interested in treating actual people with actual mental health problems. But the ‘evidence base’ for IAPT is based on a model of telephone assessments using scripted questionnaires where nobody can actually say how they feel, allowing assessors to refer patients to short term interventions that are not, for example, designed to treat depression. Although increasingly real therapy is not being delivered through IAPT, what matters to the government is that in the short term it is cheaper, particularly if it is delivered by unwaged trainees provided by clinical training and professional bodies.
What may be more problematic in arguing for mental health funding is that because psychotherapy helps people to take control of their own lives it means that the ‘evidence base’ for psychotherapy can not be manufactured around the demands of politically set targets. Although research shows that psychotherapy is highly effective in the long term, it does not compel people to become well in a 6 week period.
Ironically for therapists in the business of talking and thinking, the psychoanalytic professional structures are not doing that when it comes to the future of public mental health services. Although there are some extraordinary people in these systems, the prevalence of Noas-Arkism and the strains of managing decline has provoked both a freezing and a folding inwards. This is not principally a problem of innovation – in my experience clinicians are always having good ideas – rather a problem of professional ethics. That the bodies charged with defending psychotherapy are failing to defend the principles on which they depend.
This might explain the reluctance of the professional bodies to engage in the much needed debate about the future of mental health services with a wider audience including those critical insiders and outsiders who are researching workforce issues. Add to this the temptation to blacklist critics and you end up with a system that cannot hear different views and becomes entrenched in defending their own existence. Although this freezing and folding is understandable as a response to threat, it is about to create a split between the interests of the people providing the services and the people accessing them.
The Organising Challenge
In the long term we know that mental health services deserve a public inquiry into the current regime of performance management – one that is run by a group of people who are not financially invested in the outcome. Co-production and practicing what we preach might be a good idea too. We also know that we need to set up a platform for negotiating over the issue of wages in the sector. Again this should not be populated by the professional bodies alone, stuck between rocks and hard places in defending clinicians and keeping the registration and training gig on the road. Inevitably a public and publicly accountable structure needs to be fought for, but we are a million miles away from achieving this because of the absence of workplace organising that protects therapists’ ability to participate in shaping their working lives.
Something else stood out in our survey – the low number of people who went to a trade union or directly to colleagues with their problems. Outside of the NHS, only 4% of therapists spoke to a colleague about problems at work. For people trained to increase relationality there is a real question why we do not seem to be doing that with the people we work with.
In a context of downgraded mental health services, the fact that mental health workers are unorganised and silenced is a matter for both professional and personal ethical concern. Sometimes working in healthcare forces you to walk a very thin line between the personal and the political – an awkward place somewhere between the consulting room, Whitehall and the board room...
As a woman writer, I don’t slag off other women’s books and use the Feminist Fight Club rule of thumb. This book however rattled my cage as it is an uncomfortable hippy read for a trade unionist for whom everything in politics is a chess move. There’s nothing like a Celtic folk story to expose my psychic thuggery.
If Women Rose Rooted is a book about women’s lives and their relationships with the land. There are conversations with contemporary women, mixed in with ancient stories of the cycles of life. There is actual poetry and whole paragraphs on hormones. The blatant spirituality of this book evoked an immature reaction in me. Blunt, concrete, questions to try to put this book into a political position and work out what side Blackie is on.
Exhibit A: Housing. Throughout the book there are stories of women who have regained their belonging by moving to rural retreats. As someone who doesn’t own anything I’m more than a bit curious where did they get the money? If I could afford a shabby-chic bunker in Gloucestershire, where I grew up, I would go. Right now. But I rent in London and increasingly stare over the abyss of insecure housing. Like most people living in London I can neither afford to stay or go.
I can give you the exact coordinates of the place where I belong. It’s along the river banks and cool woods of the Coln valley. Only problem being is that my entire generation had to leave because the county has become the Florida of the UK. Second homes, retired rich folk, bankers. That’s not resentment, its an important point that this is a part of the country where the rivers are running dry because there is no stewardship along the public and private waterways. To preserve the Coln river would require belonging and the responsibilities this implies, not just owning something.
Exhibit B: Jobs. Nowhere in these radical stories of reinvention is the issue of earning-a-living discussed. Coming from a trade union background that’s a big premise taken out of the meaningful-life equation. As a writer who survives by wage labour these women who have found their voice without finding a basic income are objects of my quite significant envy. It’s also an unnecessary evasion, as environmentalists have under-utilised leverage through the potential for green jobs. Although the trade union proposal for 1 million climate jobs was met with indifference and then a financial blocking by the last government, the reality is that for ordinary folk to really support environmental change the link to jobs is key.
Exhibit C: Husbands. I’ll run the risk of sounding absolutely beaten-up by life, but my next question is about all these husbands casually thrown into the mix of these women’s stories. The contemporary cast are all married. I’m not against marriage but we live in a society where 2 million people stay in bad relationships to keep their homes. Belonging has become a dual income project. I’m just saying that because I think it makes a difference to the credibility of our narratives.
I’m half way through the book clocking up a critique angrily scribbled in the margins and then three things happen.
Firstly, I went to see the Inconvenient Truth sequel. The film is a recap on climate change and a whizz through Gore’s diary of high level meetings and carrying out his training programme. Bad supporting roles for women as professional politicians in the current blow-dry-figure-hugging-n-heals leadership uniform. No frizzy hair or hot flushes here. As the film was shown across the UK on the same night, there was only a sad trickle of debate on social media. Nothing radical happening here, just a bunch of over-40s talking to the usual suspects. The thuggish part of me noted that the tickets were £18 a pop, missing the unavoidable truth that young people don’t have the money to engage with this particular demographic. Worse is the political tiredness promoted in the film.
Despite his old school charm, there’s something really dodgy about a political punch line that its our primary responsibility to monitor the psychopaths in power and engage in representational systems. As a response to climate change this falls flat to say that the democratic crisis that feeds the environmental one can only be solved by voting and lobbying. Gore makes the joke that he’s a ‘recovering politician’ as if somehow he was not a key player in the political class that created the conditions for this democratic deficit. In one way this story is too old, an outdated view about how environmental change will come about, but in another way this story is not old enough. For change to take place it will need to appeal to the profound and deep need that we all have for care and caring.
The second thing that happened was the story of a woman being shoved onto a road by a jogger running across a London bridge. I couldn’t stop watching the video of a man casually jogging past another man and then just shoving a young woman randomly into a road, with a bus narrowly missing her head. The story that emerged was that this man was a banker. True or not, it made a shockingly banal and coherent narrative. Nobody was surprised that now the veneer of equality has been peeled off our society, real hatred emerges. I’m guessing I’m talking to the converted here, but its worth pointing out that misogyny exists unchallenged in our society in a way I have never experienced in my lifetime. In one sense we are tapping into previous generations, going backwards rather than going forwards on the equality stakes. Then these glorious and precious months of #timesup and the radicalism of this book hits me.
So, defences down, let me tell you about this book.
The book describes the pilgrimages that we are all able to make in these times when so much is being lost. The chapters describe a primitive journey; of travelling the wastelands, entering the ‘cauldron of transformation’, finding the pilgrims path, entering the enchanted forest and fertile fields, then the mountains. The colours of dark old landscapes that we can return to, to fuel us emotionally and psychically. Stories of the menopause, of love and betrayal. Of the wisdom of growing up, of age.
This is a book that tells stories, to stimulate and provoke the creation of our own narratives within which we can find a home. A place where women are not redundant, if they no longer strive to be represented or believe in having-it-all fairy stories. The book offers new stories of women who found a place to belong and with it a profound reorientation to the earth. Old stories of Celtic folklore, of witches and wise old women. Yes, stories that value old women. A vivid vocabulary of deep wells and dark caves, fruits and of our bodies. Of a maternal love for the planet, caring about what happens next and to the next generation. It is a book that offers a taste of a different way of feeling about our environment. To feel an enchantment, not the rush to formulate yet another strategic campaign.
There are sections of such profundity it’s like taking a bullet.
‘Scream if you will, but let yourself fall. We have to let ourselves fall. If we want to become Voices of the Wells, we need to plumb their depths. And in order to kick-start the process of transformation to which we’ve now committed ourselves, we have to destroy old ways of thinking, remove old limits. So grope your way blindly into the darkest cave, let yourself sink to the bottom of the deepest lake. Jump into the black, bottomless well.’
It captures beautifully the drama and the ordinariness of the cycle of life. That things become lost, things die, that learning and change are painful and involve an acknowledgement of the dark stuff of the heart. These sections of the book feel like a familiar walk along the line between depression and the depressive position, a fearful line between despair and hope. A long way from the optimism of popular psychology and the happy-ever-afters.
At the end of the book is a postscript ‘The Eco-Heroine’s Journey: A Guide’. Oh how my heart sank. As someone who writes ‘Survival Guides’ with a sarcasm health warning, I needed this section not to be a retreat into a psychic cul-de-sac of positive psychology. I’m happy to report that this chapter is safe and useful, no checklists or tick boxes, rather a series of questions for the reader to think about how these epic stages in our journey exist in our own lives. I found it quite helpful to think about how these ancient stories of women’s journeys could be mirrored in my own life. Radical even to think something so desperately uncool, thoughts that you wouldn’t say out loud or on twitter.
This book caught me off guard, back to crying on the tube and staring out of windows during meetings. Back to the brave and foolish emotional journey of psychoanalysis that preoccupied my life until last year. Back to a relationship with depression and a lovingly brutal understanding my own grim story. Back to an acceptance of the blood and guts of bodily experience that underpins our internal and external worlds. Back to a period of burnout after years of activism, and learning through that loss. The realisation that my actual relationship with the planet can’t be fitted into this very limited political model that I learned to navigate. This book speaks to me, that as a woman of a certain age my survival depends on the defence of my capacity to care about the next generation. To keep my heart beating, my blood pumping. To continue to care.
There’s a quietness about whether Sharon has kids that at the beginning of the book I felt was an evasion. By the end of the book I felt this wasn’t the right question. This book is confident. A confident discourse on what it would feel like to be unashamed of being a woman finding her way towards belonging. With or without a mortgage. Some books are both timeless and exactly of their time.
Treat yourself to your free copy of Unpsychology: The Climate Minds Anthology here. Seriously, you’ll like it. Download HERE.
Michael: The response to whistleblowers – shooting the messenger – is about what happens when people find that their “not-knowing” is challenged. One of the responses in the NHS is to become forceful in blocking unwelcome knowledge.
David: The experiences that nurses have on the ward is fundamentally counter to the motivation for entering nursing in the first place which is caring for ill and vulnerable people.
Michael: As welfare systems themselves become persecutory people now feel not simply that there’s a problem of how do I cope with the patients but how do I cope with the authorities that are supposed to be managing care.
David: These defences don’t work at the end of the day. They give rise to anxiety themselves. Our defences make things worse.
To hear the full conversation between Michael Rustin, David Armstrong and Elizabeth Cotton go here.
To listen to the podcasts of this conversation click on the links below:
Surviving Work in Healthcare is a free online resource Surviving Work in Healthcare designed for people working on the frontline. The website is a joint project by Surviving Work and the Tavistock & Portman NHS Foundation Trust offering podcasts, videos and survival guides that take a jargon free, de-stigmatizing and practical approach to addressing the real problems of working in healthcare.
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