There’s a news item in the latest issues of Therapy Today which I thought was interesting but also rather worrying.1 The story is based on remarks made by the chair of the BACP, Andrew Reeves, in a debate at the 8th New Savoy Partnership conference on Psychological Therapies. Reeves told delegates that:
People (NHS psychological therapists) are leaving the profession because they are struggling to deliver a service that falls short of what the client might need.
Earlier on in the conference there was a report on the findings of a joint survey conducted by the British Psychological Society (BPS) and the New Savoy Partnership, which stated that levels of depression and stress were on the rise amongst psychological therapists in the NHS. Nearly 60% of respondents reported that they found their job stressful all or most of the time, and 70% said they felt pressured into meeting targets all or most of the time. 40% reported episodes of depression, 42% reported feeling a failure some or all of the time, and nearly 70% reported sleep problems. The Chair of the BPS Division of Counselling Psychology, Richard Pemberton, told the conference:
It’s great to have improved access to evidence-based psychological therapies but the whole target culture has had a toxic effect. We did need to improve access to psychological therapies on an industrial scale but in doing so we seem to have damaged our own workforce.
The implication in this story is that a target and outcomes driven culture in NHS psychological therapy services is causing serious mental health problems for those employed to deliver such services. Undoubtedly there is some truth in this, but I think it’s important to avoid the notion that somehow everything was hunky dory in NHS psychotherapy, counselling and other ‘talking therapies’ before they became ‘industrialised’ in the form of the Improving Access to Psychological Therapies (IAPT) programme.
To start with, it was actually quite hard simply get talking therapies on the NHS at all, which is why IAPT came about in the first place. If someone turned up at their GP exhibiting signs of anxiety, depression or some other mental health problem, the chances are they would either be referred straight to a psychiatrist or be prescribed medication. When I worked in the NHS for three years as an honorary psychoanalytic psychotherapist (the traditional route by which trainee psychotherapists learnt their trade) I only saw patients who were deemed to be very disturbed; in other words, those who used to be described as the ‘worried well’ (i.e. most of us), who were suffering from anxiety, depression or stress, had to make do with anti-depressants or, more likely, nothing at all.
However, I think it’s worth considering why people become psychotherapists, counsellors, CBT practitioners, and other types of psychological therapists in the first place. Often, it’s because they’ve experienced some form of psychological distress in their own lives, or have been close to someone who has. In other words, they know just how fragile human subjectivity can be and want to do something to address it. Another motivation can be that they want to find an alternative to a world that is becoming increasingly dominated by targets, outcomes, and a pseudo-scientific ideology that attempts to quantify every aspect of human subjectivity. This is certainly my experience of talking with colleagues in the psychotherapy and counselling world, many of whom have very reluctantly entered into what they see as a Faustian pact with IAPT and similar programmes simply in order to earn a living. The irony in all this, of course, is that in trying to ‘escape’ a world of targets, outcomes, etc, they come face to face with it in their own practice.
Another issue which is probably worth considering is that it is very difficult to show ‘success’ in the world of talking therapies. IAPT attempts to show this using various measures, but there are serious issues regarding all such attempts to quantify ‘cure’ in the realm of the psyche. One simply measure, of course, is to see if particular symptoms have been alleviated or even removed, but this is to equate the symptom with the underlying problem; strangely enough, clinical psychology and psychiatry do this all the time, whereas physical medicine would never dream of doing so. Just because someone is no longer feeling as depressed as they were before they started therapy doesn’t mean they are ‘cured’ or have addressed the underlying problem that gave rise to their depression in the first place.
There is also the related problem that many clients or patients are determined not to be ‘cured’ in the first place; Freud realised this early on in his practice and spoke of the ‘gain from illness’. A lot of people who come for psychological therapy on the NHS have been referred by someone else, usually their GP, and have no particular desire to be there in the first place, especially if they are on sickness benefit which is likely to be removed if they get ‘better’.
And finally there is the question of the role (or rather fantasy) of the therapist as ‘rescuer’. This links closely to what I writing about earlier regarding the therapist’s own experience of mental health problems – either their own or someone close to them. In a previous post I explored this issue in some detail with regards to NHS workers in general.2 In that post I drew upon some research by Bicknell and Liefooghe which looked at the relationship between workplace stress and enjoyment.3 Their basic argument was that workers can become ‘hooked into’ stress as a form of enjoyment, even though it can be potentially harmful or even fatal. And the fantasy of being a ‘rescuer’ (and of the person being rescued as ‘victim’) can feed this drive for enjoyment. However, and this is the crucial twist to the argument, it’s precisely when the ‘rescue’ fails (which it often does in the NHS) that the ‘rescuer’, i.e. the doctor, nurse, therapist, is driven to try again, to try and ‘get it right’ next time. And it’s this repeated attempt to ‘get it right’ that perpetuates the suffering (enjoyment) of the individual, which is what produces stress and ultimately burnout.
So, going back to the ‘toxic’ environment that is NHS psychological therapy (according to Richard Pemberton), what we have here is potentially a significant number of therapists who are working in a way they are not comfortable with, but have to in order to stay employed; who may already be quite psychologically fragile themselves; who have very high case loads of patients/clients, many of whom may not be that interested in ‘getting better’ in the first place; and who are motivated by the fantasy that they can somehow ‘rescue’ these very same patients/clients, even though it’s hard to gauge ‘success’ or ‘cure’, and much of time they keep ‘failing’ in their efforts.
- Therapy Today news, 2015. ‘NHS therapists at risk of burn-out.’ Therapy Today, 26(2), p.6. [↩]
- http://www.therapeia.org.uk/wp/blog/2015/02/11/enjoy-your-stress/ [↩]
- Bicknell, M. & Liefooghe, A. (2010) ‘Enjoy your Stress! Using Lacan to enrich transactional models of stress’. Organization, 17 (3), pp.317-330 [↩]