The Future of Psychological Therapy

From Managed Care to Transformational Practice

John Lees

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317482413
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

The psychotherapy and counselling profession has recently experienced far-reaching changes because of the development of evidence-based medicine and managed care systems. The Future of Psychological Therapy brings together leading counsellors, psychotherapists, psychological therapists and managers to address how these changes are beginning to affect all aspects of the psychotherapy and counselling profession. It evaluates the impact of these developments, shows how they affect practitioner's capacity to care, anticipates future developments and offers a coherent and viable approach to research and practice.

The book draws on psychotherapeutic theory to develop insight into managed care and engages in qualitative microphenonena research into the complexities of clinical practice drawing on cutting edge developments. It aims to establish a balanced counselling and psychotherapy profession by:

opening up a debate about these far-reaching developments which threaten the profession,

challenging the rhetoric of accountability, audit, transparency and measurement of care,

exposing the danger of sleeping through these momentous changes in the counselling and psychotherapy profession.

The Future of Psychological Therapy is a timely and important book, examining the psychotherapy profession's approach to managed care and evidence-based research, and discussing whether a balanced, coherent and viable counselling and psychotherapy research and practice culture can be established. It will be of interest to practitioners, academics and policy makers in the field, non-clinical professionals and anyone who is interested in psychological therapy and addressing the worldwide deterioration in psychological health.

1 Introduction

John Lees

DOI: 10.4324/9781315708294-1

The Tao which can be expressed in words is not the eternal Tao the name which can be uttered is not its eternal name. Without a name, it is the Beginning of Heaven and Earth.

Lao Tsu, Tao Te Ching¹

I want to begin this opening chapter of the book by talking about fantasy and reality. We build a great part of our lives and aspirations out of the lives we would like to live rather than the lives that we are actually living (Phillips, 2013). The same thing could be said of mental health policy. The promises, predictions and rhetoric of policy makers, politicians and researchers are based on the reality that they want us to think we can live rather than the reality we actually live.

Over the years I have learnt that the most difficult thing in the world is to see reality as it is, as Lao Tsu noted some 2,500 years ago:

The Tao which can be expressed in words is not the eternal Tao the name which can be uttered is not its eternal name. Without a name, it is the Beginning of Heaven and Earth.

One of my primary aims as a counselling and psychotherapy (therapy) practitioner is to help clients to move ever closer to the mysterious and unfathomable ideal of seeing reality as it is. It is a driving force not only of my clinical work but also of my own development, my approach to the counselling and psychotherapy (therapy) profession and to life in general.

The future of the therapy profession is now in the balance. The commonly used term in the UK for therapy is now ‘psychological therapy’: the term used in the Government sponsored Improved Access to Psychological Therapies (IAPT) scheme in the NHS. The principles underpinning this scheme and its underlying managed care mind-set are beginning to determine the development of the profession as a whole and, in so doing, overwhelm the strong and varied traditions of therapy practice and research which have developed since the 1890s. Its rhetoric is based on fantasies about what can be achieved as opposed to realities, and it is essential that the transformative principles of counselling and psychotherapy are not forgotten as this ‘revolution’ takes place.

The managed care principles underpinning IAPT and ‘psychological therapy’ provide the starting point for this book. However its central aim is to argue for an approach to therapy based on the full range of discoveries that have been made since the origins of the profession for the benefit of the therapy profession itself, other professions, our clients and humanity at large. It will remind us that the profession did not begin with IAPT in 2006 but at the end of the nineteenth century. It is concerned with establishing a profession which is based on transformational, as well as managed care, principles.

The authors make frequent reference to neo-liberalism, managed care, evidence-based practice and the New Public Management (NPM) system. Neo-liberalism is based on laissez faire notions of leaving the market as free as possible to determine its own direction – and now the direction of public services including healthcare and therapy. It came to the fore in the Reagan administrations in United States and the Thatcher governments in United Kingdom in the 1980s. Business thinking began to rule in healthcare from the late 1980s and specifically in the therapy profession from 2006 in the form of the IAPT.

The NPM system in the UK began in 1983 when Margaret Thatcher’s government commissioned Roy Griffiths to write a report on the management of the NHS. It espouses the three m’s of managers, markets and measurement (Ferlie et al., 1996) – four m’s if you consider another central element: money. This was supplemented by the introduction of evidence-based medicine in 1992, which provided the research basis for this approach to healthcare.

NPM gives, at first, the impression that the practice is well-managed, orderly and transparent. However, this is far from the truth as demonstrated by a suc cession of scandals, subsequently leading to major public enquiries in the UK; for instance, the 2001 report on the Bristol Royal Infirmary (Kennedy, 2001) and the 2013 report on the Mid-Staffordshire NHS Foundation Trust (Francis, 2013). These reports have documented failures in the NPM systems. The problems have fallen into two categories: generalised systemic problems and problems arising from vagaries in human behaviour which affect the way in which professionals implement the systems. Indeed, there is a tension between these aspects of healthcare – between the varied interests of the institutions and the systems and the quality of care provided for patients and the unpredictability of the behaviour of people (Roberts, 2013). Moreover, the problems are persistent. In spite of the warnings and recommendations of the 2001 report, very little, if anything, had changed by the time of the 2013 report.

As regards the systems themselves, there are several problems. First, they are based on a task-based culture which prioritises targets over the quality of care (Fisher & Freshwater, 2014): targets are ‘pursued with a reckless disregard for the well-being and safety of patients’ (Roberts, 2013). Second, Francis (2014) speaks about problems in reporting critical incidents; in particular, a ‘lack of clarity into what constitutes an incident that should be reported’. He notes how reports of incidents led to little or no action. For instance, complaints by family members in Mid-Staffordshire did not produce changes (ibid., p. 74). Third, Tingle (2014), reviewing the effects of Francis’ report, notes inconsistencies in measurement and evaluation. A survey of the response of the NHS Trusts to Francis, conducted by the Nuffield Trust stated that ‘one of the case-study trusts, for example, had been flagged as “green” by the Care Quality Commission (CQC) for its performance on a specific quality measure, but had been failed by Monitor, which had declared the trust as being “in breach” for poor performance against the same dimension of quality’. Finally, Tingle (2014) also makes the general comment that the ‘top down’ systems of ‘targets and finance rather than quality of care’ seemed to be worse one year on, and the creation of a ‘culture of compassion, support and mutual learning’ was proving to be difficult to implement as long as management was seen as external and punitive.

As regards human behaviour, Francis (2014) speaks about defensiveness among carers and managers. For instance, managers defend themselves against failures to meet targets, which is not surprising since many of them fear that they will lose their jobs if they do not achieve targets (Roberts, 2013). Francis (2014) also reports cases of staff victimisation while Newdick and Danbury (2014) speak about a ‘failure to recognise’ patients’ ‘humanity and individuality and to respond to them with sensitivity, compassion and professionalism’.

A limitation of the Francis report is that it does not engage with the strengths and expertise of health practitioners. The report only addressed problems with the systems themselves. Recommendations about practitioner behaviour included such admirable statements as the need for practitioners to ‘contribute to a safer, committed and compassionate and caring service’ and for care to be provided by a ‘caring, compassionate and committed staff, working within a common culture’ (Francis, 2013). But it did not have a plan to do this. There was no theoretical framework and no methodology of practitioner research. Transformational therapy-inspired practice and research methodologies can help with the problems. This book can contribute to this as it draws on a wealth of practitioner expertise in the field of therapy practice and research.

An underlying concern of the book is that we are perpetuating the same systems in the therapy profession in the form of IAPT in spite of such well-documented failures. Clearly, the supporters of IAPT consider that their approach to managed care and evidence-based practice is the best approach to psychological therapy research and practice. They see the scheme as building up an ‘integrated and high quality psychological therapy provision’ and argue that it will ‘strive to make these services safe, effective and successful in improving mental wellbeing, reducing stigma and health inequalities’ thereby ‘making the United Kingdom a world leader in psychological therapies’ (New Savoy Conferences, 2012). This policy is laudable.

The scheme is to provide psychological therapy on a scale that has never been done before. But it can be enhanced by research done by therapists in several ways. First, it can contribute to the quality (as opposed to the quantity) of the care provided by IAPT. Second, it can help to integrate the findings of 100 years of psychotherapy research into the scheme. Third, it can go beyond the rhetoric and open up space for independent thought and reflection about the full range of therapeutic possibilities. Fourth, it can prevent a gradual spreading of the principles underpinning the scheme, as a result of its extension into such services as student counselling and other aspects of counselling and psychotherapy provision.

Many of the chapters in this book refer to the fantasy nature of the scheme. I have chosen a short sample of these phrases:

• whilst National Institute for Health and Care Excellence (NICE) recognises many of the issues concerning its methodology, it ends up acting as if they don’t exist;
• approaches to therapy today ‘take clients’ minds off their problems rather than attempting to help them work through ‘what is bothering them’;
• there are enduring efforts to impose symbolic order on an anxiety that can never be completely managed;
• IAPT operates in a virtuality, focusing on performativity and surveillance rather than real encounters;
• there is an ‘unrecognised, imaginary or fantastic basis of much public health policy-making’;
• the ‘evidence based’ research culture is ‘a series of dogmas which fuel a fantasy of discovering a “perfect” all-encompassing understanding of how we function together’;
• there is a fantasy that ‘everything that happens in our world must be safe’;
• it ‘seems particularly absurd to think of many therapists all trying to “provide” the same “intervention” in a standardized fashion’.

Another theme running through the book is that the managed care dominant discourse, the dominant metanarrative, the juggernaut that is driving the thera peutic, caring and educational professions (and basically the world) forward is not only built on fantasies but also on exercising power over people. With this in mind I collated another set of phrases which are interspersed throughout the book:

• the state is using psychotherapy, psychoanalysis and counselling as a form of social control;
• it creates a climate of ‘distraction and fear’;
• it is ‘the culture of monitor, watch, control which chillingly echoes the grim predictions of Orwell’;
• there is a tendency for impersonal systems to determine ‘what is or is not permitted to occur within the organisation, between staff and within psychological treatment’;
• the systems are heightening ‘anxiety levels by over-controlling the policy and procedural structure’;
• one day there may be ‘a CCTV camera in the corner of the therapy room ceiling, ready to alert the Therapy Police to break down the door’;
• there is ‘a critical shift in the locus of power away from the professional autonomy of practitioners themselves’;
• the NHS and IAPT are perhaps the last vestiges of Weberian bureaucracy in the current neo-liberal age.

The chapters are divided into three broad overlapping parts: the context of therapy (Mainly Context), the influence of NPM and IAPT (Mainly IAPT) and clinical practice (Mainly Practice). Each part highlights the principal focus but also includes elements of the other areas as well.

In Part I Del Loewenthal, Stuart Morgan-Ayrs and William Bento look at the broader context of therapy and research today. Del Loewenthal speaks about the restriction of our freedoms in therapy, as in life in general, and how this limits the ‘subversive’ nature of therapy which takes place in a ‘confidential space where clients can explore anything that comes to their minds’. He challenges us to think about the futility of theory and suggests that we re-vision therapy as a cultural practice. He also outlines the flaws in the systems and approaches of research which are increasingly bearing down on therapists and oppressing them, whether they are aware of it or not (such as randomised controlled trials, NICE and IAPT) and refers to the commodification of therapy. This echoes some of the themes in the chapter by Stuart Morgan-Ayrs. The main focus of this chapter is the drive towards regulation in all its forms, the dangers of therapy becoming ‘highly formulaic and inauthentic’ and, even worse, the ‘sterilization’ of therapy and the ‘creation of a specific box which is pre-defined for the therapist to live in’. He looks at how this mind-set, which is beginning to dominate the therapy profession, severely limits therapeutic possibilities by becoming too defined and colonising the minds of practitioners (Foucauldian subjectification).

William Bento points out that, as in many aspects of our lives today, new developments, such as managed care, began in the United States before they came to the United Kingdom. Managed care in the United States can be traced back to 1973, ten years before the systems were introduced into the United Kingdom in 1983. The language is different – and there is of course no National Health Service – but the principles are the same. A central idea is the Health Maintenance Organizations (HMOs) which exercise a great deal of power over practitioners. The chapter includes such familiar themes as the dominance of money, with an emphasis on dollars saved as opposed to quality of care, the ‘disparity between the medical science oriented approach and the humanistic/holistic views found in psychological and sociological paradigms’ and the problem of treating symptoms rather than seeing the client as a ‘developing human being’.

Part II of the book consists of chapters by Ian Simpson, Rosemary Rizq, Jay Watts and John Nuttall, all of whom look at the limitations of the managed care systems in the United Kingdom and the IAPT scheme in particular based on their direct experience of these systems. Ian Simpson, drawing on his experience of managing a therapy service, looks at the process of dismantling a service and the effect of this on practitioners and their clients. He describes how the service had been managed using the therapeutic principles of containment and holding and how the service was ‘actively undermined’ by the business and target orientation of the neo-liberal NPM system. Like many chapters in the book, he highlights how the realities of the political, cultural and social context on the service were denied and led to what he calls the denigration of the human. He examines splits which develop between the objectives of managers and administrators and the practitioners running and working in the service.

Rosemary Rizq looks at how the policies of managed care with its ‘growing demand for transparency, accountability and governance’ is driven by anxiety ‘at both individual and organisational levels because they bring us into unwilling contact with our own abjected vulnerability’. Using a case example, she shows how the realities of human suffering are ‘deemed to be repulsive or untouchable’ and how contemporary managed care systems constitute a ‘symbolic attempt to gain mastery over feelings unconsciously deemed to be abject reminders of the body’. Jay Watts draws on her experience of working in an early IAPT site and supervising many IAPT practitioners. She demonstrates the gap between the ideals of IAPT and the reality and shows how ‘its promises’, far from achieving what they purport to achieve ‘may actually increase the level of anguish in society’. She examines the privileging of CBT, the lack of thorough assessments, high-dropout rate...

Table of contents

• Cover
• Halftitle Page
• Title Page
• Copyright Page
• Contents
• Notes on contributors
• Foreword
• Acknowledgements
• 1 Introduction
• PART I Mainly context
• PART II Mainly IAPT
• PART III Mainly practice
• Index