‘You can’t have a therapeutic alliance where one of the partners has the power to make the other destitute.’ Case closed, surely? But how real is the threat raised by Lynne Friedli and co-author Robert Stearn in Your Views that Employment Support Allowance (ESA) claimants may have to agree to have CBT or risk losing their welfare benefits? Could IAPT practitioners find themselves offering therapy to a client who is there under what amounts to duress?
The issue hit national media headlines in early June when an article by Friedli and Stearn was published in the BMJ specialist journal Medical Humanities. The article, titled ‘Positive affect as coercive strategy: conditionality, activation and the role of psychology in UK government workfare programmes’, argues that psychologists, and more recently psychotherapists and counsellors, are increasingly involved in the Government’s programme to cut the welfare benefits bill by getting long-term unemployed people back into work, including those unable to work for physical and mental health reasons.
The article describes the application of ‘workfare’ methods, imported from the US, to motivate and prepare unemployed people for work. ‘Workfare’ includes job coaching, skills building and motivational workshops, training courses and unpaid work placements. Participation in these programmes is mandatory; non-compliance is punished by loss of benefits. This is ‘psycho-compulsion’, write Friedli and Stearn, and they warn that the Conservative Government intends to extend this conditionality to claimants’ health and treatment. In February this year Prime Minister David Cameron asked Professor Dame Carol Black, specialist advisor to the Government on work and health issues, to explore the possibility of refusing benefits to people who are obese or use alcohol or drugs unless they agree to medical treatment. In their 2015 election manifesto the Conservative Party said that claimants who ‘refuse a recommended treatment’ may risk having their benefits reduced. The pre-election budget allocated funds to place IAPT therapists in 350 Jobcentres throughout England; the possibility that claimants may be required to attend a course of CBT treatment to improve their ‘employability’ or risk losing benefits has become very real.
ESA sanctions
According to official statistics, 46 per cent of ESA claimants are receiving benefits for mental health reasons – some 260,000 people, at a cost of around £1.4 billion a year. In November last year Mind flagged up that people with mental health problems in the ESA work-related activity group (WRAG) – those deemed closest to re-entering the job market – are the most likely of all groups to be sanctioned: over 60 per cent of sanctions are imposed on this group, Mind says.
An independent study supported by Mind and published in June last year, Fulfilling Potential? ESA and the fate of the Work-Related Activity Group, explored the impact of the ‘workfare’ process on this group: they can be left ‘fearful, demoralised, and further away from achieving their work-related goals or participating in society than when they started’. A report by Church Action on Poverty, Time to Rethink Benefit Sanctions, published in March this year, found: ‘Sanctions have a financial impact on individuals, but the personal costs of shame, demoralisation and destruction of self worth are much harder to measure. This is a system that leaves many people feeling under suspicion and valueless simply because they do not currently have work.’
Lynne Friedli, who is a researcher with the Wellcome Trust funded project Hubbub, says that therapy under such conditions can only be profoundly untherapeutic: ‘It’s a deeply coercive enterprise and it’s difficult to see how any therapist could ethically take part in that. This is about state co-option of health professionals; the client’s need and interests are being subsumed under a whole different agenda. The other problem is that it presupposes that getting people off benefits and back to work is the primary therapeutic goal. But the work these claimants are being offered is often not the kind of work that pays a living wage and respects people’s dignity and rights.’ How can that help anyone’s mental health, she asks?
It would be impossible for a therapist to detach themselves from the context in which they were offering therapy, argues Stearn. ‘The coercive nature of welfare to work services creates huge inequalities in power. However careful you are as an individual practitioner, you are plugged into that.’
Protests
Psychotherapists, counsellors and psychologists have been among those protesting against these and other government measures to cut the amount spent on welfare benefits. In April the Alliance for Counselling and Psychotherapy published an open letter in the Guardian, signed by 400 psychotherapists and counsellors, condemning as ‘malign’ and ‘totally unacceptable’ the Government’s austerity programme and its impact on the most vulnerable in society.
Psychologists Against Austerity (PAA) was launched a year ago in protest at what its members believe are the damaging effects of the Government’s welfare cuts and the psychologising of unemployment. Says spokeswoman Laura McGrath, a lecturer in psychology at the University of East London: ‘Psychologists need to think very carefully about how their work is being used and the ends it is being used for. The workfare approach positions unemployment as a problem of the individual when it’s actually a structural problem. It’s pernicious. People are being made to feel they are to blame for not being good enough.’
The publication of Friedli and Stearn’s paper prompted statements from all the main psychotherapy professional bodies. Said BACP Chair Andrew Reeves: ‘Benefit claimants shouldn’t be expected to have therapy under the threat of their benefits being stopped – it is unethical and potentially harmful.’ The UKCP similarly declared: ‘To link either being unemployed, poor or disabled with a psychological deficit is inappropriate, unethical and deeply concerning to our profession.’ The BABCP, many of whose members work in IAPT services, declared itself ‘against any offer of any treatment, including CBT, based on coercion or associated with unfair or disproportionate inducements’. Said Rob Newell, BABCP President: ‘It is almost certainly against our code of conduct and almost certainly likely to be at the very best ineffective and at the worst quite possibly damaging to clients.’
BPS President Elect Peter Kinderman told Therapy Today: ‘It is a very basic principle of medical ethics that services should not be provided under compulsion, other than in very extreme circumstances. If the Government were to go down this route it would be wrong.’
He argues that the Department for Work and Pensions (DWP) could be making much better use of the skills and support psychologists and psychotherapists can offer in the package of measures to help the jobless back into work. As to the ethics of participation, he says: ‘Individual psychologists will have to make their own decisions about working in this way, bearing in mind that so many professional bodies, including the BPS, have made it clear that it is ethical to offer people therapy only in the context of a free and informed choice.’
Says Andrew Reeves at BACP: ‘There are, of course, people out of work experiencing mental health difficulties who would benefit from psychological intervention and should be offered the choice.’ But he says the ethics of involvement are clear; the BACP Ethical Framework states unambiguously: ‘The principle of autonomy opposes the manipulation of clients against their will, even for beneficial social ends,’ and that BACP members should ‘seek freely given and adequately informed consent’ from clients.
The UKCP likewise raises a caveat about the ethics of coercion: ‘We understand that some people may benefit from being offered therapy whether they are employed or out of work. But imposing it in this way is a badly thought out approach…Therapists involved in such work may wish to bear the ethical dimensions in mind.’
Not in our name
Others disagree that offering therapy in such a context could ever be appropriate. Psychotherapist Del Loewenthal, a signatory of the Alliance open letter and Director of the Research Centre for Therapeutic Education at the University of Roehampton, believes the talking therapy professions have been co-opted into the Government’s neoliberal political agenda. ‘What the Government is proposing is a perversion of what we understand to be counselling. Their agenda is to get these people back to work whether they are ready to go or not. To confuse that agenda with counselling or psychotherapy is just abusive. They should at least be called “compliance clinics”,’ he argues.
He doesn’t think counsellors and psychotherapists should be involved at all in DWP welfare-to-work programmes, and that it is a slippery path down which the profession is too eagerly stepping. ‘You can see the pressures. There are therapists who would like more work and you can see the way they can frame this as doing good within the system. But therapy has to be voluntary.’ He also objects that most people accessing this therapy through IAPT will be offered CBT; here too, participants should have a genuine choice of therapies, he says.
It is, says Loewenthal, part of a wider and worrying trend towards increased state intervention in the psychological therapies. ‘There is a danger that psychological therapists are becoming part of the problem rather than the solution. At what point does therapy become a form of social control? Some say psychologists and psychiatrists have already become agents of the state, and now psychotherapists and counsellors are being invited in, having been on the outside before. The prospect of the state entering the therapeutic space is very frightening.’
Loewenthal, with fellow critical psychotherapists, has just launched a Council for Critical Psychotherapy that will, they hope, provide a forum for informing and influencing public debate and alerting psychological therapists to what they perceive as the growing influence of neoliberalism in the therapy room.
Psychotherapist Paul Atkinson, also a member of the Alliance and of the Free Psychotherapy Network, agrees. ‘I think the talking therapies profession has been too keen to get on the gravy train. There has been an excitement about being recognised by the state as a profession. Even our professional associations have become brands in competition with each other to get their piece of the pie. I think this issue of coercion is a red line. It’s time we stood our ground and declared that certain psychotherapy values really need to be upheld.
‘We have to become more politicised,’ he argues. ‘We have turned ourselves into a group of experts in the psyche and now society is taking hold of that expertise and using it for its own ends. I hope this issue wakes people up to the fact that what we do has been put to political use and abuse and that we as a profession have a responsibility to stand up and state what we think about that.’
Partnership programmes
Getting people back to work has always been a major part of IAPT’s remit, and one of the main arguments that Professor Lord Richard Layard used to persuade the Government to provide funding in the first place. It has so far failed to achieve much impact in this respect. While the joint IAPT/Jobcentre Plus pilots are still some way from being implemented, there are a number of other government-funded pilot programmes exploring different models of collaboration between the DWP and IAPT services. NHS England is currently involved in a pilot collaboration with Work Programme providers in eight sites evaluating the effectiveness of offering ESA claimants talking therapies through IAPT. NHS England’s view is that people with mental health problems on ESA are very likely to include those least likely to be able to access talking therapies, and that placing IAPT therapists in Jobcentres is no different to placing them in other community sites that are more accessible to target groups, and is already common practice in IAPT services.
Separately, in December last year the Cabinet Office confirmed £12 million funding for four other pilot programmes – in Blackpool, Sunderland, Greater Manchester and West London. Three will offer IAPT therapies in parallel with Individual Placement and Support (IPS) – a model of intensive, individualised employment support that has been pioneered successfully with people with severe mental health problems. The Greater Manchester programme is based on a very similar model, ‘Working Well’, that the Greater Manchester Combined Authority has been trialling independently.
In these and the NHS England/Work Programme pilots, participation in any talking therapy is voluntary. But the experience of an earlier IAPT/IPS pilot suggests the issue is not so clear cut for participants. The Centre for Mental Health (CMH) led this pilot, which ran for six months at four sites. Participants were referred by local Jobcentre Plus work coaches, and the employment support and therapy were provided in IAPT or other premises. The aim was to offer the therapy and employment support in parallel. However the local IAPT services already had waiting lists and got no additional resources, so many participants started the IPS without the therapy and some never got therapy at all.
They recruited only 240 participants, of whom just 15 found paid work (although one participant got two jobs). The pilot was given too short a timescale, says Jan Hutchinson, CMH Director of Programmes. But what was clear was that participants really valued the intensive, personalised one-to-one employment support. The IPS employment specialists had maximum caseloads of 20, rather than the more usual 100–200 of Jobcentre Plus work coaches. ‘Participants got much more time with the employment specialist and a more responsive service. It was very unlike the conveyor belt process they were used to at the Jobcentre,’ she says. ‘It wasn’t me being forced into anything. It was just talking about some things I might be able to do,’ said one participant.
A small number didn’t want the therapy, and resented having to accept it if they were to get the employment support. Many more did want the therapy but they wanted it first, so they would feel more able to make the most of the employment support. Overall the feedback was positive and, even in that short time frame, participants’ mental health improved.
Some of the IPS specialists and managers did feel that the participants’ decision to take part was inevitably clouded by the context in which the help was offered: ‘As soon as you put the Jobcentre’s stamp on it and turn it into Jobcentre provision, it has an immediate negative effect on the claimant’s perception of the service,’ a Jobcentre work coach said. Critics have pointed to the high drop-out rate (roughly half dropped out after expressing an initial interest and failed to attend their first appointment) as evidence that the pilot was unsuccessful. But, says Hutchinson: ‘My feeling was that people attending Jobcentres just feel it’s not a good idea to say no to anything that’s offered, even if they don’t necessarily want it. They feel that if they then don’t engage with the offer they haven’t actually said no in front of their work coach.’
Hutchinson believes this model is a winning formula because it offers individualised, intensive support from caseworkers with specialist expertise and small caseloads. ‘We know that people with mental health problems generally want to work but need more help and more personalised support. IPS has the ability to get 50 per cent of participants back into work. It sounds expensive but if it works that is what it costs.’
But, she points out, participation in IPS is essentially voluntary. ‘I’m aware that critics fear this kind of collaboration is the thin end of the wedge to mandatory therapy, and there is always that possibility. Participation in IPS is voluntary and we have absolutely no reason to believe it would be effective for people who didn’t feel ready to go back to work.’
Read the Friedli and Stearn article