Blogging about professionally political issues can be a risky business for a number of reasons (http://tiny.cc/wjpzvw). So I was relieved when, over recent days and weeks, I received some encouraging messages from people reading the Psychotherapy and everyday life blog. Project IAPT entries seem to be catching the interest of a modest number so they must be speaking to something that resonates within our community. These messages of support have arrived totally out of the blue or occasionally off the back of other unrelated conversations. It is so heartening to hear from readers. Thank you. But what might it be and why does project IAPT seem to touch on something so meaningful for so many in our profession? A clue to my take on this is in the title of this post.
Offering a critical voice on any subject can feel risky and I’ve certainly felt that at times publishing these blogs is a risk. It’s risky because I don’t necessarily want to be or get labelled or pidgin holed as some sort of hostile dissenter. Interestingly, it feels more risky now than when Paul McGahey and I published a critically reflective piece on IAPT back in 2008. Back then we shared concern about what might be lost under IAPT. So much of what we discussed then is sadly now coming to be reality. Being a voice that dissents, someone that stands in opposition to a dominant discourse, or offering an alternative perspective in questioning the way things are is not only risky but challenging and sometimes scary too. Professionally, I wonder what might be the repercussions. However, much like the title for this blog implies, there is a need for people to question authority, challenge attempts at power being used over people and against formalising and standardising psychotherapy and our practice and training. Project IAPT has done all of these things and I think that it is this experience, when pointed out, people unite through a sense of injustice and a sort of responsive dissent.
At a recent conference in Leicester I asked some searching questions of those invited to speak on the successes of IAPT. I ended up feeling as though I was being a bit of a thorn in their side…which probably I was. But there’s something more for me to this feeling. Group responses can be very telling. It’s not uncommon for people to set about marring the character of someone when they voice a counter argument rather than actually addressing the argument. We saw this in action within the psychotherapy profession when there was a movement to oppose the statutory regulation of psychotherapists. Rather than addressing the critiques being voiced it was the personalities of the opposers that were focused on and defamed. It’s an effective tool used by the media too and I guess we see it also in politics. Needless to say at the Leicester event I was so pleased (and relieved) that a number of practitioners came to speak to me during the break for coffee. At lunch I had a lovely discussion with a group of PWPs about their work. The discussion was flowing and they shared how my questions spoke precisely to the issues they were discussing and wrestling with in supervision or in their offices but that felt too risky to voice in a public arena. It was obvious they were worried about speaking out and, when the rhetoric is decorated with such strongly positive sentiment about project IAPTs success, trying to voice a counter argument can be very difficult. These people were literally frightened for their jobs and livelihoods! What kind of culture and work environment is that for providing psychological therapy?
With the exception of the Chair of the event, all but one of the speakers gave me an extremely wide birth (or I am just being paranoid). Not only this but I could see people fidgeting when I raised my hand to ask another question or decided to respond to the speaker providing an answer that bore little connection to an initial question. Of course, my fantasy is they wanted to say something like “SHUT UP” but couldn’t or wouldn’t be publicly so authentic. The seeds of self doubt can easily take hold at these moments. I’m inclined to start thinking, is it just me that thinks IAPT is problematic, am I the only fool seeing things this way? Another part of me is quite satisfied being an irritant. I’ve been accused on more than one occasion of ‘dancing on the head of a pin’. Perhaps it’s the narcissistic bit of me that enjoys the detail, the ‘small’ differences often underlying ‘big issues’. But these differences are rarely small in my view. They are so often the very crux of the issue that competing sides don’t want or can’t bear to be revealed. Sure it’s uncomfortable when difficult questions are raised. But without having to answer for the way we do our work, and here I refer to being accountable and not audited a la King and Moutsou (http://tiny.cc/beqzvw) a kind of ‘groupthink’ can set in. What I experience as being uncomfortable when raising difficult issues might also be something of the discomfort and awkwardness that can be felt when groupthink is revealed.
So where’s all this heading? Well, three people have indicated to me, in personal communications, their growing concerns about the way that psychological therapies are being developed through IAPT. Nothing new there some might say but now I’m being told these stories from people that reach across the entire project. Firstly, just a short time ago I had a communication from someone holding quite a significant and senior role in IAPT that openly expressed a growing disillusionment and concern. Once a staunch supporter and advocate they now expressed serious concern and were questioning whether IAPT is actually doing what it claims to be doing, i.e. ‘improving’ access. Is the IAPT groupthink starting to dissolve? Are people on the inside, and in positions where they can really influence change, starting to see the situation differently?
Improving access to psychological therapies has become something of a ‘slogan’. And as we know most slogans often are shown to have little by way of substance beneath them or at the very least least they tend to bear little resemblance to actual experience. In a second communication a senior therapist shared experiences of working under the the new AQP system, whereby the organisation they were working for, a new commissioned QP contracted for a specialist service arrangement, were being paid, in line with national guidance, a set fee for completed cases. However, the therapist was not being paid anything when the client did not attend for one of their planned sessions. The new commissioning arrangements mean that providers are paid a set fee based on an assessment plus two further sessions and for up to an agreed amount of sessions (usually around 12 for step 3 services).When a client misses a session you might reasonably now question if you’ll be paid for that session, chances are that you won’t. Yet your employer will. Unlike when therapists in the NHS were paid a salary, now they are working to something more akin a production line!
The final communication came from a new trainee for CYP IAPT. I’ve quoted it pretty much in full as it captures something of the CYP IAPT initiaitve unfolding in much the same way as IAPT for adults did. It shows the groupthink of those involved in developing and training and how any kind of critical voice is squashed. This message came from someone currently being trained in CBT preparing to work in one of the new CYP IAPT partnership service.
“I have been reading your Tweets and blog posts with keen interest. I just wanted to get in touch to say, thank you for being a critical voice ‘out there’! Your writings are truly a breath of fresh air from the rhetoric that my CYP-IAPT peers and I are constantly being asked to swallow without question, and you have articulated some concerns that we can’t seem to find ears for. Please continue critiquing!
I work in a CAMHS service whilst also currently undertaking the CYP-IAPT CBT training. On my CYP-IAPT course it is a shame that I have both witnessed and experienced that to question, is to make yourself incredibly unpopular and labelled a ‘troublemaker’. This is a stark contrast from my previous training, where critical voices were encouraged. Willing for us to be uncritical automatons is causing a lot of difficulties for my peers. I find it disconcerting that in my cohort on my CYP-IAPT training, a number of my training peers left within the first term; others are planning on leaving imminently; and others are currently considering their options (as many have jobs tied to the training, and therefore choosing to leave the course could possibly equate to losing one’s job). I have also witnessed frequent tears from my peers related to both the confused delivery of the course (for many reasons), as well as how we are supposed to operate within our services, especially alongside colleagues who very much wish to reject what we trainees represent (i.e. unpopular service redesign). Therefore, trainees unfortunately end up getting squeezed from both sides, and it is nigh on impossible to find anyone in a position of power who will entertain conversations about this. I don’t feel that the experiences of my cohort are an anomaly in the world of CYP-IAPT training. I know of other peers and supervisors who are linked to a different CYP-IAPT collaborative. Our experiences appear to be very similar, and there is a developing sense of having to resign oneself to a position of passive hopelessness.“
Hey teacher! Leave them kids alone…(you know the rest!)