Main themes/points emerging from uACT meeting Sat 15 Oct 2022: Jay Beichman’s view
In the following, ‘therapy’ is used as a term to describe both ‘counselling’ and ‘psychotherapy’. Even though I do not recognise any substantial differences in the meaning of the two terms, the main point in this instance is to avoid writing out the two terms over and over again rather than start any theoretical arguments!
Ideas/themes discussed in the chatroom and live
Trainees/students:
A therapy tutor suggested that trainees/students would be enthusiastic to get involved with campaigning via uACT. Maybe reaching out to students/trainees more proactively might be a useful way to get more support.
Workfare:
There was discussion about the £122 million being given to ‘employment advisors’ as the government’s misguided attempt to improve ‘mental health’. JL, the chair of the PCU, stated that the PCU are supporting the uACT campaign and that they will continue to do so.
Clear messaging to the public about therapy:
The view that the public needs to better understand what therapy is and its strengths and limitations; the myth of therapy being a ‘cure’ needs to be challenged. Agreed — but a difficult challenge to make in or to the NHS and the Medical Model (MM).
The manifesto needs to be really clear. And as well as a manifesto the need for a concise 2-line or so ‘elevator pitch’, very easy to understand, which anyone aligned with the cause can repeat over and over again until the message gets through.
The need for statistics and figures to back up our views/claims.
Urgent need for the uACT message:
As suicide rates rise and therapy provision remains substandard and inappropriate (at least for many) the message that there needs to be universal access to a range of therapies is literally a matter of life and death.
Personalised Therapy / Personalised Medicine:
I (Jay Beichman) mentioned that the idea of personalised medicine has not successfully transferred over to the world of therapy in systems like the NHS. My meaning in terms of personalised therapy is really about ‘assessing and accommodating patient [or client] preferences’ (Norcross & Cooper, 2021). There is a lot of evidence that outcomes improve when people have more power/choice in getting the therapy/therapists they want rather than having limited or no choice. This makes a strong evidential case for therapy and different kinds of therapy to be available.
However, one attendee pointed out:
the agenda for personalised medicine in non-acute areas is to introduce “personal health budgets” with limited state money to spend in the developing health marketplace/ digital ecosystem. Psychotherapy seems to be have been a vanguard in this move towards “value-based” care and indeed ACOs [Accountable Care Organizations – USA system] (ICS [Integrated Care Systems – UK system] equivalent) in the US talk about behavioural medicine as the element of psychological input provided by Medicaid funding aimed primarily to reduce referrals to expensive physical and mental health secondary care services to enable ACO/ ICS providers to balance budgets or indeed generate profits
I understand that principles of personalised medicine which may have noble objectives might be taken advantage of in this way to cut rather than add provision but the way I mean personalised therapy is really about people being as empowered in the public/third sectors as they are in the private/independent. This could mean the NHS accessing directories of registered therapists. I am okay with that idea but I can see some people might prefer therapists to be directly employed by the NHS.
Communications/Media:
CB continues to take the lead on this and a few people gave their email addresses to be contacted by CB. And once the YouTube channel is established they would be happy to be interviewed for that channel.
CB mentioned that the communications team will need people who are willing to speak/write in public about the campaign and related issues. Some people responded to that.
Other ideas included a template letter which people could just sign and send to their MPs, making contact with Select Committees in Parliament, talking to journalists, writing letters to newspapers and journals and using social media.
YouTube Channel:
AM is taking the lead on this. But he was clear the YouTube Channel needs several people running it as a team to be successful and keep the workload reasonable for everyone involved. It will take the form of a ‘magazine’ interviewing a variety of people involved in ‘mental health’. AM and PA are already in the midst of making a pilot but Andy wanted to make a call out to increase the team numbers to maybe 6+ to keep it going. PA envisions a monthly programme where people sympathetic to the aims of a more progressive outlook on engaging with mental/emotional issues can find a platform.
Political ideologies/politics/diversity/universality etc:
One attendee mentioned they were willing to be involved if ‘[uACT] doesn’t start driving political ideologies’. I am not entirely clear about what was meant by this but I have heard similar things from people who want the PCU, for instance, to be specifically about pay and conditions for therapists and avoiding other political issues not directly relevant to therapy. There have also been some differences of opinion on how specifically uACT should be about ‘universal access to counselling and psychotherapy’ or whether it should go further and wider than that. I think the only way to decide these kinds of issues is democratically and then people can stay on board or leave depending on how they sit with the decisions reached.
One attendee said:
I just want to make a brief point about diversity. We talk about universality but there is no… explicit mention of diversity and I think there is an assumption that universality means diversity and yet on the manifesto there is no mention of that which does not feel right, or rather it feels like diversity has been explicitly missed. What do people think of that?
I am of the view that universal implies everyone of as much diversity as can be imagined and like the word. But there mostly seemed to be agreement that ‘the assumption that universality means diversity’ was problematic and the manifesto as it stands does need to be changed to more explicitly state a commitment to diversity.
However, another attendee challenged the word ‘diversity’ as a ‘political buzzword’ and supporting the use of ‘universal’. They suggested that the word ‘diversity’ has become a ’PR and marketing term’. Moreover, that ‘those who fit into “diverse” communities are not buying it anymore’.
These differing views led to a discussion about how our support of diversity might be expressed using different words such as ‘marginalised and under-represented’ amongst other descriptors.
In general there is some resistance to being ‘political’ by some people so there is a kind of divide between those who want the aims to be more narrow and others who link up issues related to the lack of universal access to counselling and psychotherapy to wider political realities e.g. the current cost of living crisis affecting more and more people.
This led into an interesting discussion about the use of language. This was near the end of the meeting and it feels to me that the issue had not been resolved by the end of the session.
National and local campaigns:
The importance of campaigning at both national and local levels.
IAPT/NICE/NHS:
Problems associated with not providing open-ended and/or relational therapy. A need to raise awareness about different types of therapy with other professionals and the public more widely so they are aware that there are more choices when it comes to seeking therapy or a therapist than the IAPT/NICE/NHS conglomerate are currently offering (to any substantial extent). The point was reiterated that criticisms of IAPT and the hegemonic position of CBT as an approach are not directed at practitioners (of whatever title) but at the system which has failed to ‘increase access’ to a whole range of meaningful and effective therapeutic interventions.
PA encouraged people to look into their local IAPT annual reports so that IAPT can be challenged via its own reports and statistics. For example, IAPT often claims a 50% recovery rate but this is 50% of the 33% who actually complete treatments so it is really more like 16.5%. If lots of people did this then a comprehensive challenge could be made that IAPT is, in fact, a systemic failure.
Someone suggested it is ‘unethical to limit a client to six sessions’ if more sessions are wanted.
More broadly, how the new Integrated Care Systems (ICSs) in the NHS function was explained by one attendee and the implications of these for therapy. ICSs are designed for non-acute conditions and the attendee expressed the view that ‘mental health’ is a vanguard for what is happening in the rest of healthcare. There are 42 ICSs in England and each ICS is responsible for the budget it has been allocated.
They are extremely keen on digitalisation and are trying to make services as digitalised as possible. Because digitalisation is cheap and also because digitalisation creates a marketplace which might boost the economy. Also there are financial incentives to exploit the NHS database. An underlying motive for ICSs, especially in light of tight budgets, is to do the minimum and keep people away from relatively expensive treatments/professionals (relative to providing a digital service of some kind). The attendee gave an example of how people with dermatological issues often don’t get to see a dermatologist but rather a photo of their skin is sent to a computer and a treatment plan is generated by computer from the photo.
The attendee said a similar process is underway for therapy. The whole future of the NHS is in peril to these ideologies of digitalisation/efficiencies versus relationship-based care. It isn’t just therapy which is threatened by these developments. It is getting more difficult to see trained professionals of all kinds. They don’t really want trained professionals sustaining long-term relationships/treatments. The attendee cited the example of a day hospital he worked for, at which patients used to be able to go until they felt they didn’t want/need to go anymore. Now they are only allowed to go for a fixed amount of time. This makes it easier to cost and therefore ‘compete’ with other providers in terms of cost. The ICSs are all about obtaining ‘value’ rather than best treatment. These systems are not designed with the best interests of patients or actual human professionals in mind.
Focus:
It was suggested that it might be better for the campaign to focus on 2 or 3 key areas rather than have a ‘scattergun approach’ e.g. IAPT. And how the failings of not providing access to counselling and psychotherapy costs lives via increased suicide rates etc.
Charity: becoming a charity and related issues
It was suggested by one attendee that uACT become a charity. The attendee said that it was apparent what we see as problematic e.g. IAPT, the NHS’s understanding and provision of therapy, Workfare, the hegemony of CBT etc. but that by offering therapy to those who want/need it (and thereby also contributing to ‘universal access’) we would be operating more proactively. Such a move the attendee suggested would also create a base which could include funding and be more effective.
She cited the example of NAPAC (National Association of People Abused in Childhood) who from a starting point of being a charity has become an influential contributor and influencer of government policy. This strategy, she suggested, might get us beyond just ‘complaining’. It was pointed out that there is a lot of third sector provision and the Free Psychotherapy Network (in which individual therapists offer free sessions) and there is some opposition from some therapists at least to encouraging a ‘culture of unpaid work’ e.g. Counsellors Together UK (CTUK).
However, there is a difference between voluntary work which actually seems compulsory (in order to jump through hoops on the way to paid work) and voluntary work which is felt to be truly voluntary. A possibility but the details would need to be carefully thought through to reach a consensus. It was suggested we need to be especially careful with the use of language in this area. For example, words such as therapists being ‘compassionate’ for providing free therapy could imply that therapists who charge fees or are paid are not ‘compassionate’. This kind of perception encourages the view of therapy being a voluntary or low-paid activity.
Therapy as a mostly female ‘caring profession’, like nursing, also probably contributes to this and we certainly don’t want to be part of that patriarchal disempowerment (see Aldridge, 2011). However, the view that therapy as a voluntary activity and a paid activity can exist together was expressed by at least a couple of attendees so the idea of uACT maybe having a role in the provision of therapy might be an idea worth pursuing both in itself and also for potentially increased influence/power.
Complaints:
The possibility of membership bodies (MBs) having a more therapeutic, less combative approach to handling complaints.
PCU:
At least a few attendees encouraged people to join the PCU.
Access via big funding:
Therapists need to persuade big funders (whether NHS or not) to set up non-IAPT therapy services for longer-term and/or more flexible approaches to therapy including groups etc.
Within the NHS one attendee said they were able to ‘infiltrate’ the current system via ‘social prescribing’. They have put therapists into GP surgeries via this route. The therapists working in these surgeries have a surprising degree of autonomy, great feedback from clients/patients and are able to provide flexible and longer-term therapy from a variety of modalities.
Social/Economic Factors vs the Medical Model (MM):
There were various contributions critiquing the MM and pointing out correlations between socio-economic factors and distress, sometimes severe. For instance one attendee said it did not surprise her that the North-East as one of the poorest areas in the UK also had one of the highest suicide rates.
Books and other resources recommended by attendees:
The Government’s New Mental Health Funding Will Be Spent on ‘Helping’ Depressed People Into Work – Jay Watts – 14 October 2022 article in Novara Media: https://novaramedia.com/2022/10/14/the-governments-new-mental-health-funding-will-be-spent-on-helping-depressed-people-into-work/
Psychotherapy and Counselling Union: www.psychotherapyandcounsellingunion.co.uk
Free Psychotherapy Network: https://freepsychotherapynetwork.com/
Teo, T. (2018). Homo neoliberalus: From personality to forms of subjectivity. Theory & Psychology, 28(5), 581–599. https://doi.org/10.1177/0959354318794899
My references:
Aldridge, S. (2011). Counselling – An Insecure Profession? A Sociological and Historical Analysis. Ph.D. thesis, University of Leicester.
Norcross, J.C & Cooper, M. (2021). Personalizing Psychotherapy: Assessing and Accommodating Patient Preferences. Washington: American Psychological Association.
Wampold, B.E. & Imel, Z.E. (2015). The Great Psychotherapy Debate: The Evidence for What Makes Therapy Work, 2nd Edn. Hove: Routledge.
uACT 