The foreword from The Industrialisation of Care: counselling, psychotherapy and the impact of IAPT
by Nikolas Rose, Professor of Sociology in the Department of Global Health and Social Medicine at King's College London
If only there could be a technical, a technological, solution to the burden of mental distress, mental disorder and mental illness on individuals, families, economies and societies. If only mental distress was like a disease, a specific pathology, and we could find a specific treatment, that would rapidly restore the individual to a fully functioning, responsible subject, sustaining her or himself through paid employment. And if only that could all be shown to provide a rational and evidence-based way of managing the messy problems posed by those who have previously been exempted from the obligations of contemporary subjectivity by virtue of their disturbed mental states.
Perhaps that was the dream that lay behind the invention of Improving Access to Psychological Therapies (or IAPT) and why it has proved so attractive to our governors: its justification on economic grounds, its claim to be based in scientific evidence, to be targeted at the causes of the disorder, its outcomes achievable in a few weeks and measurable and amenable to the objective judgment of audit.
This, indeed is what Richard Layard and David Clark seemed to promise when they campaigned, successfully, for the implementation of IAPT:1 the ‘evil of mental illness’ – as they termed it – was a sixth great giant to be slain, in addition to Beveridge’s Want, Idleness, Ignorance, Squalor and Disease, and if we were to tackle it, we would have a better, yes even a happier society. The scandal, for so it seemed to them, was that we did indeed have ways of addressing this problem: therapies that people want, that are not expensive, that have good success rates measured by clinical trials: thus the ‘evil of mental illness’ must be tackled and could be tackled in a way that would ‘not cost us an arm and a leg. Dealing with it is... a “no brainer”’.
From the outset, then, IAPT embodied what Rosemary Rizq refers to in her introduction as ‘the myth of consumer sovereignty; the myth of transparency; and the myth of the medical cure’. Central to this programme was its economic rationale – if those with mental illness do not work, national economic output is lower, not to mention the costs of absenteeism, disability benefits and ‘presenteeism’ – for, even when people with these conditions do work, their work is less effective because ‘their mind is a mess’. And they are more likely to suffer from physical illnesses, use expensive healthcare facilities and take up much costly doctors’ time. So, obviously, if one gets those people back to working effectively, national economic output would increase, costs of benefits would reduce, physical health would improve along with mental health – the programme would more than pay for itself! In fact, unemployment is itself a psychological condition, as much as an economic one, and so a suitable case for psychological evaluation and treatment. But there is yet another advantage, for work itself is therapeutic – it integrates people into society, it combats isolation, teaches all sorts of social skills and, crucially, provides those previously mired in dependency with the dignity of a wage. A programme of this sort is indeed a ‘no brainer’.
We do not have to question the motives of those who proposed this approach, or even those who put it into effect, in order to characterise the inevitable effects of this strategy. While there is a long history to the belief that work is itself an antidote to mental ill health, the context in which IAPT took shape embodied some of the central premises of the welfare strategies that have appeared across Europe and in many other regions since the 1980s. These pre-existed the ‘financial crisis’ of 2008, but they have undoubtedly been exacerbated by the policies of austerity that made the poorest pay for the high-risk, high-return gambles of those who inhabited the corrupting world of hedge funds, credit default swaps, collateralised debt obligations and all the other shady dodges designed to make profit without creating value. Thus, the more or less explicit aim of this strategy at the start was to gain the political benefit of reducing the unemployment figures by transforming into active ‘job seekers’ and then back into the workplace as many as possible of those who had been placed on incapacity benefit on account of their mental ill health. This would simultaneously improve budgetary economy and enhance moral economy, through the civilising and disciplining consequences of employment.
Paradoxically, the belief in maximising virtue through entry into wage labour and the constraints on future conduct imposed by the need to secure one’s employment career were being extolled at the very moment when that image of secure work was already becoming a thing of the past: its belief in a universal and timeless pattern of life – the move from the disciplines of the family through those of schooling to those of a job for life, followed by a brief retirement and then death. This pattern, which underpinned the welfare strategies that took shape over the 20th century, the forms of industrial employment that they were predicated upon, the family forms that they valorised and sought to promote, the moral order of probity and prudentialism that they sought to protect and not undermine by social security – all these and more now largely exist as images in our rear-view mirror, already coloured in the sepia tones of nostalgia, their own inequities and injustices rapidly fading from memory.
Nonetheless, the practice of IAPT has become integral to the work of jobcentres, and hence inextricably linked to repeated assessment of capabilities to work devised with physical disabilities in mind and administered by poorly trained operatives employed by commercial organisations paid by ‘results.’ As Diana Rose has pointed out, it is impossible to read the advice on completing the Work Capability Assessment questionnaire given by the mental health NGO Rethink’ without recognising how humiliating this process is for those who are forced to undergo it (Rose, 2018).2 The ‘therapies’ IAPT practitioners administer are undertaken in a disciplinary context where missing an appointment with the IAPT practitioner can result in a reduction in benefits. They are constrained by manuals that prescribe exactly the course of the interventions and managed by targets where the throughput of subjects is the key criterion, and entry into work counts as a health outcome. Psychological therapy is conceived along the lines of a course of pharmaceutical treatment, with its effects being ‘dose dependent’ – that is to say, the benefits depend on the number of ‘doses’ , or ‘treatment episodes’, up to the completion of the prescribed course. No wonder that, as elsewhere in our audit culture, data are manipulated to seem to demonstrate the efficacy of these interventions.
But, even in its own terms, IAPT has proved expensive, its effects on social security budgets have proved minimal, its results disappointing in terms of those returned to enduring employment, and the consequences of the recurrent humiliation experienced by so many at the hands of those charged with enacting this strategy have increased, not reduced, human misery.
Should one then reject the whole idea out of hand? Perhaps not. Proponents of IAPT were far from alone in stressing the role that paid employment can have in restoring dignity and self-sufficiency to individuals who are excluded, isolated and stigmatised by their dependence on benefits. One thinks, perhaps, of the research carried out by Loren Mosher on the prejudice and discrimination that still today prevents many with a history of mental distress and psychiatric treatment obtaining the employment opportunities that match their skills and capacities, and prevents many in employment from disclosing their status as mental health services users.3 But those who thought like Mosher did not regard the unemployment of mental health service users as a consequence of the psychological deficits of the person on benefits; rather, it was seen as a structural problem of widespread, institutional discrimination. Mosher’s strategy of ‘moral treatment’ – of empathy, of ‘being with’ the other person, of developing a shared understanding of the social and biographical events that contributed to a person’s current plight – was precisely the reverse of the moral premise that seems to underlie IAPT: that what is necessary is attitude and behaviour change in the unemployed person in order to reactivate the psychological motivation for work.
And, while IAPT has largely failed to restore to full citizenship those isolated and excluded on grounds of their mental ill health, we have not yet seen the assertive demand for an alternative strategy, expanding the bandwidth of ways of being a citizen, recognising and attuning policies and strategies to the changing realities of work, exploring alternatives such as a guaranteed basic income, or recognising that there are other ways of contributing to society than wage labour. That would certainly require a radical change in the ways in which support was offered, eliminating the deplorable ‘for-profit’ organisations that have sprung up to leech on those in receipt of disability benefits, with their procedures that would be pitiful if they were not so damaging, and their targets that incentivise the worst practice.
And what of ‘therapy’ itself? There is no doubt that the particular form of psychological therapy that has come to characterise IAPT is mechanistic at best, risible at worst. But there is also no doubt that psychiatric medication, though often helpful in symptom reduction in the short term, is largely ineffective and often damaging in the long term. We do not need a massive programme of short-term, cognitively oriented psychological therapy, for all the reasons set out in the contributions to this book, but we do need a massive programme to fund and support a myriad of small projects at local level4 that can not only increase access to multiple forms of supportive facilities – not just talking therapy but self-help groups, drop-in centres, short-term crisis houses, peer support and so forth – and also tackle the social and environmental processes that throw so many of us into mental distress, isolate and exclude, and inhibit the path to full and equal citizenship of those who are differently abled.
Nikolas Rose is Professor of Sociology in the Department of Global Health and Social Medicine at King's College London. His many books include (most recently) Our Psychiatric Future: the politics of mental health (Polity, 2018) and Governing the Soul: the shaping of the private self (Free Association Books, 1999). His work has covered many fields. including the sociology of the biomedicine, the history of the human sciences, the genealogy of subjectivity, law and criminology, and changing forms of political power.
Layard R, Clark DM (2014). Thrive: the power of evidence-based psychological therapies. London: Penguin Books.
Mosher LR, Hendrix V, Fort DC (2004). Soteria: through madness to deliverance. Bloomington, IN: Xlibris Corporation.
Rose D (2018). A hidden activism and its changing contemporary forms: mental health service users/survivors mobilising. Journal of Social and Political Psychology 6(2): 728–744.
1. All quotes and glosses of phrases are from Layard & Clark, 2014). I will not dwell on the use of the phrase ‘the evil of mental illness’ – perhaps the authors are merely ‘channelling’ the phrase used by Beveridge, though of course one would want to point out that most mental health problems are not ‘illnesses’ and, however debilitating they can be, to refer to them as ‘evils’ is, to put it mildly, insulting, and, indeed, likely to exacerbate all the problems encountered by those who experience such difficulties.
2. See Mental Health and Money Advice. How do I fill in the health questionnaire? [Online.] www.mentalhealthandmoneyadvice.org/en/advice-topics/welfare-benefits/will-i-need-a-work-capability-assessment-to-claim-benefits/how-do-i-fill-in-the-health-questionnaire (accessed 15 February 2019)
3. This research was described in a compelling talk given by Loren Mosher at the Institute of Psychiatry shortly before his death in 2004. For details of Mosher’s approach, see Mosher, Hendrix & Fort (2004).
4. We could start by recognising and resourcing the mutual support groups – formal and informal – that service users have been organising for themselves for decades. We could also build on the alternative strategies of ‘thriving’ that one finds in Thrive NYC, Thrive LDN and a growing number of urban thrive programmes that, with wholly inadequate financial support, are beginning to do just this.