Public Sector Practice THE GHOST IN THE MACHINE: IAPT AND ORGANIZATIONAL MELANCHOLIA
Rosemary Rizq abstract The introduction, funding and roll-out of the NHS’s Improving Access to Psychological Therapies (IAPT) programme represents one of the biggest changes to mental health service provision ever seen in the UK. Drawing on Hinshelwood’s (1994) notion that public mental health services may be regarded as a defence against overwhelming anxieties relating to psychological fragility and emotional distress, I explore the tendency for IAPT services to systematically disavow feelings of loss and vulnerability in both staff and patients. I propose three mechanisms by which this disavowal occurs: the promotion of a consumerist ethos and a ‘patient choice’ agenda; the deployment of discourses minimizing notions of fragility and dependence; and the proliferation of bureaucratic and surveillance systems aimed at continually monitoring and evaluating staff and clinical activity. Drawing on Freud’s (1917) distinction between mourning and melancholia, I go on to argue that a sense of unconscious loss may come to be constitutive of the culture within IAPT services where the institutionally-sanctioned repudiation of containment cannot be spoken about, addressed or mourned. Through a short case example, I illustrate the way in which organizational melancholia may be hidden within the structures of an IAPT service and enacted by both staff and patients. Key words: IAPT, melancholia, organizational dynamics, primary care
Introduction The UK’s Improving Access to Psychological Therapies (IAPT) was introduced by the Labour government in response to the influential Layard (2004) report, Mental Health: Britain’s Biggest Social Problem. Layard made a forceful economic case for treating those with anxiety and depression which resulted in an initial investment by the government of £173 million to fund the implementation of evidence-based psychological therapy services. Drawing on the stepped care model recommended by the National Institute of Clinical Excellence’s (NICE) Guidelines, the IAPT model introduced large numbers of newlytrained NHS mental health workers offering ‘low-intensity’ psycho-education and guided self-help based on cognitive–behavioural principles as well as ‘highintensity’ staff offering face-to-face therapy. The Coalition Government now intends to expand its provision of psychological therapies, investing a further £70 million in services for children and young people, older people and those with long term physical or mental health conditions. It has also expanded the ROSEMARY RIZQ PhD CPsychol AFBPsS is a Chartered Counselling Psychologist and Senior Practitioner Member of the British Psychological Society’s Register of Psychologists Specializing in Psychotherapy. She is Principal Lecturer at Roehampton University where she teaches psychoanalytic theory and practice on the Doctoral programme in Counselling Psychology. Her clinical work is based at an NHS Primary Care Trust, and she also maintains a private practice in West London. Her recent papers have focused on the topic of organizational dynamics within public mental health services and on psychotherapeutic training and clinical practice.Address for correspondence: Department of Psychology, Roehampton University, Holybourne Avenue, London SW15 4JD. [
[email protected]] © The author British Journal of Psychotherapy © 2012 BAP and Blackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. DOI: 10.1111/j.1752-0118.2012.01281.x
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range of ‘NICE-compliant’ psychological therapies available within IAPT services to include brief dynamic psychotherapy (dynamic interpersonal therapy), counselling, interpersonal therapy and couple therapy. The introduction, funding and roll-out of the IAPT programme within NHS primary care mental health services undoubtedly represent the biggest shake-up of mental health services ever seen in the UK. Not surprisingly perhaps, this has sponsored considerable debate, anxiety and unease in a field already rocked by dissent concerning statutory regulation of psychotherapy, the development of National Occupational Standards for differing models of therapy and the introduction of competency frameworks for staff working in public sector services. In a recent publication (Rizq, 2011) I explored some of the unconscious dynamics experienced by staff working within IAPT services, drawing on Menzies Lyth’s (1959) work on social defence systems. Noting the emphasis on ‘well-being work’ within IAPT services, as opposed to the traditional ‘anxiety work’ that society allocates to mental health services (Hinshelwood, 1994), I argued that IAPT services are underpinned by structures that defend against and minimize notions of anxiety, vulnerability and dependence, surrounding themselves with systems of bureaucracy and governance that constitute what writers such as I (Rizq, 2012) and Long (2009) characterize as a perverse social defence. In this paper, I want to develop the idea that this dis-identification with an anxiety-containing function sponsors an unconscious sense of loss or what I have termed ‘organizational melancholia’ within mental health services in general and IAPT services in particular. I start by exploring the unconscious significance of the NHS and the role of mental health services as containers of anxiety and emotional distress. I then attempt to clarify the various mechanisms by which IAPT services disavow the need for psychological containment and repudiate feelings of loss and vulnerability in their patients. Drawing on Freud’s (1917) distinction between mourning and melancholia, I argue that a sense of unconscious grief may come to be constitutive of the culture within IAPT services where the institutionally-sanctioned repudiation of containment cannot be spoken about, addressed or mourned. Through a short case example, I illustrate the way in which organizational melancholia may be hidden within the structures of an IAPT service and enacted by both staff and patients.
The NHS as Container The Beveridge Report of 1942 was an opportunity for the Labour Attlee government to address its role in meeting collective welfare needs alongside the introduction of its post-war reforms. The proposed new welfare state attempted to tackle what Beveridge described as the ‘five giants on the road of reconstruction’: disease, idleness, ignorance, squalor and want, and included the move to full employment, the institution of state education until the age of 15 and the introduction of public housing. The founding of the National Health Service in 1948 established a universal state health service in the UK for the first time, providing free diagnosis and treatment for those who were ill at home or in hospital.
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From its inception, however, the rising costs of the NHS, in part due to its success in treating an ever-growing range of illnesses and conditions, were a source of concern. During the 1980s, New Public Management (NPM) reforms were introduced within health, education and social services, based on private sector notions of market forces, managerialism and economic rationalism. Since that time, an increasingly forceful health policy has emerged emphasizing clinical governance, quality and safety and privileging transparency, visibility and public accountability over professional regulation. Clinical behaviour is now shaped and regulated via increasing government scrutiny, self-surveillance and the application of audit, evaluation, league tables, targets and performance indicators to health professionals’ work. Bodies such as the National Institute for Health Research (NIHR) and the National Institute for Clinical Excellence (NICE) produce and disseminate research, clinical techniques and ‘evidence-based practice’, sponsoring a clinical governance discourse that has percolated into the professional field ensuring compliance with current regulatory procedures. Throughout these changes, public support for a universal, tax-funded NHS has remained high, and it is probably fair to say that the NHS is held in greater esteem than any other public institution in the UK (Page, 2004). Indeed, it was an ex-chancellor of the exchequer, Nigel Lawson, who commented that the NHS ‘is the closest thing the English have to a religion’ (1992, p. 613). By highlighting the tremendous significance of the NHS in the psyche of the public, Lawson raised the prospect of a health service policy driven less by rational economic and political arguments and more by unconscious motives and anxieties that become enacted and embedded within the structures and organization of the healthcare system. Obholzer and Roberts (1994), in line with Lawson, argue that a national health service is used as an unconscious receptacle for the nation’s anxieties about frailty, illness and death, pointing out that: ‘Hospitals are as much an embodiment of a social system that exists to defend society and its citizens against anxieties about death as are churches; from a psychic point of view, doctors occupy a similar niche to priests’ (p. 171).This suggests that, n addition to its acknowledged, normative, healthcare aims, the NHS has always performed an existential or symbolic role in society by establishing and maintaining a ‘keep death at bay’ service (Obholzer & Roberts, 1994, p. 171).
IAPT and the Loss of Institutional Containment This symbolic function, underpinned by a huge investment of emotional, social and political energy, I suggest, means that the NHS has from its inception been powerfully cathected by the British public as a collective, if idealized, internal object capable of containing and managing considerable unconscious anxiety. Containment of such anxiety is seen by Hinshelwood (1994) as one of the crucial functions of mental health and psychiatric services, which are tasked with ‘anxiety work’ on behalf of a society unable or unwilling to manage such intense feelings and fears. However, one of the policy papers influential in the development of IAPT was the Foresight project on ‘Mental Capital and Well-Being’ (Cooper, 2009).
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Commissioned by the Labour Government, the report defined mental capital as the ‘metaphorical bank account of the mind’ which gets enhanced or depleted throughout the life course (Cooper, 2010, p. 1). By establishing the costs of mental illness to society, the project aimed to develop an evidence-based policy for mental health to the UK and other European governments. It is perhaps unsurprising that IAPT was developed in part at least on the basis of the above financial metaphor. As a model of service provision, IAPT emerges from a socio-cultural context characterized by a frankly consumerist ethos and a neo-liberal subjectivity that increasingly repudiates notions of dependency and vulnerability (Layton, 2009) in favour of omnipotent fantasies of self-protection, invulnerability and security. The current global financial crisis, the Zeitgeist of corporate greed, ineffective government and threats to security mean that we are increasingly losing what Peltz (2005) calls ‘reliable and just symbols of communal/governing authority’ (p. 357). This is evident in the increasing disavowal of the need for social and institutional containers, obvious examples of which in the UK include the recent abolition of universal child support, the instigation of ‘parent-led’ schools, the demise of final salary pension schemes and shifts in the labour market that offer little or no job security. Within public healthcare services too, the Coalition Government’s recent Health and Social Care Bill, introduced into parliament in January 2011, points to a government progressively absolving itself of the responsibility for service provision in favour of service commissioning. These and other factors have considerably destabilized the traditional containment offered by public service, raising anxieties akin to those identified by Cooper and Lousada (2005) in their notion of ‘borderline welfare’. The repudiation of human need for and dependency on reliable institutional containers is now embodied within the structures and processes of healthcare organizations and services themselves. I see three interlinked mechanisms by which IAPT services systematically disavow the basic human need for trust in and relatedness to health professionals: via the embodiment of a consumerist ethos that privileges the patient choice agenda; via a discourse that minimizes and denies feelings of psychological frailty, fragility and dependence; and via clinical governance, surveillance mechanisms and bureaucratic structures that exert pressure on staff to achieve ever-increasing activity targets and better clinical outcomes.
IAPT: Choice, Discourse and Bureaucracy The patient choice agenda within the NHS was explicitly introduced in 2003 by the Secretary of State for Health, John Reid, who argued that the Labour government’s ‘choice agenda’ would empower people, provide them with increased autonomy in their healthcare decisions and help to reduce inequality within the health service (Reid, 2003). This ideology of independence and equal opportunity together with the continued conceptualization of patients as proactive and self-regulatory consumers of health services is exemplified within the IAPT service model. ‘Successful psychological therapies’, claimed Patrica Hewitt, the Secretary of State for Health in 2007,‘ensure that the right number of
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people are offered a choice of the right services at the right time with the right results’ (DoH, 2007, p. 1).To this end, the current DoH leaflet for patients‘Which Talking Therapy for Depression’ (IAPT, 2011) offers the following statement: If you have depression or are worried you might have, you need good information to make the right choice about different kinds of help. This booklet tells you about the range of evidence-based talking therapies that are approved by the National Institute for Health and Clinical Excellence (NICE) for treating adults with depression. It aims to give you the information you need, help you ask the right questions and decide which therapy suits you. These therapies have been shown to be at least as effective in treating depression as flu vaccines are in preventing flu, betablockers in treating high blood pressure or surgery in removing cataracts – and they can be safer and more effective in the long term than prescribed drugs. So you can choose these therapies with confidence. (2011, p. 3)
Aside from the evident medicalization of psychological distress in the above quote – ‘treating’ depression is like treating a physical illness such as flu – there are a plethora of assumptions embedded in this short text. Most obviously, that the person with depression will be willing and able to make their own decision about what they need, and about which therapy to select; and that the available range of ‘talking therapies’ which are ‘approved’ by a government body can be relied on to ensure effective outcomes and so on. From a wider perspective, however, Fotaki (2006) argues that, whilst the patient choice agenda: is about achieving better service outcomes and simultaneously meeting the real or perceived expectation of post-modern users of health services, on a deeper and symbolic level it alludes to dispensing once and for all with any notion of vulnerability, infirmity and death by replacing them with consumerist ethos. (p. 1726)
The discourse within which such services are introduced to the public thus implicitly endorses the moral undesirability of adopting a position of dependence on the health professional. Fotaki (2006) goes on argue that the role of patient choice in government strategy: becomes a single and unequivocal one: it shifts the balance of power from professionals and the NHS itself, in favour of the user–consumer while self-appointing itself as guardian of patients’/users’ rights to healthcare that is redefined in terms of a consumerist commodity. (p. 1732)
From this perspective, the shift from ‘patient’ to ‘purchaser’ ensures that illness and suffering are converted into a satisfying and rewarding consumer activity – you can ‘decide which therapy suits you’; you can ‘choose with confidence’. This consumerist ethos and discourse are bolstered by a vast managerial and bureaucratic structure aimed at implementing a tightly regulated and highly standardized culture within IAPT services. This organizational culture is designed to permit what I suggest is an unprecedented level of public and governmental surveillance and regulation. This includes, most controversially, the central requirement for all clinical staff to record multiple clinical outcome measures for each client contact. A range of measures is collected electronically
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via software systems such as PC–MIS or IAPTUS, monitored by servicemanagers and made available to a central IAPT administration, to be used for national and regional reporting purposes. This emphasis on data collection is sponsored by the continual pressure to meet clinical and activity targets, to which end there is an injunction to ensure that: ‘Patient distress or objection should be minimized wherever possible in order to meet at least 90% complete patient outcomes data’ (IAPT Data Handbook,Version 2.0, March 2011).Targets for the year 2010/11 included treating 900,000 people for common mental health problems, ensuring that at least 50% of those treated ‘move towards recovery’ and that 25,000 fewer patients were on sick pay and state benefits. The central emphasis on the taking and recording of multiple clinical outcome measures is perhaps what most clearly divides the IAPT model from the more traditional models of therapeutic services. Staff are closely monitored to ensure they record each and every contact with patients, and case management supervision is aimed at reviewing the number of sessions and evaluating clinical progress according to the full IAPT data set. Managers too are required to participate in a variety of quality assurance and regulatory activities, and to justify staff activity and clinical outcomes to a centralized IAPT administration. I have elsewhere discussed the fetishization of bureaucracy within IAPT services, which I take to be evidence of a perversion of care within contemporary primary care mental health services (Rizq, 2012). What I wish to point out here is simply that the emphasis on activity and clinical outcome targets alongside all the existing panoply of the ‘audit society’ (Power, 1997) within the NHS not only encourages an instrumental view of relations between people (Long, 2009), but operates as a social defence (Jaques, 1955; Menzies Lyth, 1959) that protects staff and managers from acknowledging and realistically managing the psychological distress, vulnerability and dependence of those referred to IAPT services.
Melancholia: The Loss of Containment I have now reached the point of suggesting that the above features of the IAPT model, along with the interpersonal relations to which such features give rise, exemplify and enact a very specific organizational dynamic. My thesis is that a mental health service’s explicit repudiation of its anxiety-containing function, and its subsequent inability to acknowledge and thoughtfully engage with the suffering, fragility and dependence of patients in its care, results in both conscious and unconscious feelings of loss, anger, grief and guilt within its clinicians, its managers and its patients. The clinical and theoretical understanding derived from psychoanalytic theory is potentially helpful here in fleshing out our understanding of some of the mechanisms by which this loss is managed. In mourning, says Freud, the lost object or person is gone: Reality testing has shown that the loved object no longer exists, and it proceeds to demand that all libido shall be withdrawn from its attachments to that object. This demand arouses understandable opposition . . . Each single one of the memories
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and expectations in which the libido is bound to the object is brought up and hypercathected and detachment of the libido is accomplished in respect of it. (1917, pp. 244–5)
In melancholia, or depression, however, Freud sees a loss ‘of a more ideal kind’ (p. 245): The object has not perhaps actually died, but has been lost as an object of love . . . one feels justified in maintaining the belief that a loss of this kind has occurred, but one cannot see clearly what it is that has been lost, and it is all the more reasonable to suppose that the patient cannot consciously perceive what he has lost either. (p. 245)
Freud is suggesting that, in mourning, we abandon the object and find consolation in reinvesting libido in a substitute. In melancholia, however, rather than withdrawing libido from the lost object, the ego withdraws the object into itself, identifying with the lost object and incorporating it as a means of magically retaining it. Freud (1923) goes on to propose in his later paper, The Ego and the Id, that: There quite often ensues an alteration in the ego which can only be described as a setting up of the object inside the ego . . . it makes it possible to suppose that the character of the ego is a precipitate of abandoned object-cathexes and that it contains the history of those object-choices. (p. 638)
Freud here seems to be refashioning the notion of identification associated with melancholia as central to the formation of the self and to mourning. The ego is itself, he suggests, established and consolidated via the process of loss and its refusal. The identification of the ego with the lost object ensures that the loss is not eradicated, but instead continues as an unconscious or ghostly presence via a feeling of melancholia. Is there a way in which we could usefully think of some organizations as entities that are themselves constituted by a sense of loss? Such analogies, of course, are fraught with problems. Most obviously, an organization is not a person, although both may have dynamics in common arising from their systemic nature (Long, 2009). It is also important to recognize, following Menzies Lyth’s (1959) examination of social defence systems in hospitals, that it is not a mental health service as an organization that itself has conscious or unconscious feelings of loss: these can only be felt and expressed by individuals. It is in and through the behaviour of individuals and groups that we can link unconscious feelings and fantasies with the culture and work of the service. With these caveats in mind, I want tentatively to proceed at this point by proposing that, insofar as our publicly funded mental health services have traditionally, if unconsciously, been experienced as containers of our deepest fears of vulnerability, insanity and fragmentation, the politically and socially sanctioned repudiation of their anxiety-containing function and the resulting disavowal of the suffering, fragility and dependence of patients in their care are likely to create deep and far-reaching anxieties, in both staff and public alike. It is precisely this unambiguous repudiation that I suggest is constitutive of IAPT services – a refusal that instates a profound loss, a forfeiture of the
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phantasied, idealized container that to date has been unconsciously symbolized by mental health services accepting the call to ‘anxiety work’ on behalf of society. But this is not the only kind of loss. For if, as Freud argues, mourning involves knowing what you have lost, then melancholia involves an inability to acknowledge what it is that has been lost, a refusal of loss and a disavowal of mourning. In melancholia, then, it is not only the object that is lacking. The loss itself is lost, hidden within an absence, a lacuna in which the melancholic appears, to all intents and purposes, to have lost nothing: ‘[O]ne cannot see clearly what it is that has been lost, and it is all the more reasonable to suppose that the patient cannot consciously perceive what he has lost either’ (Freud, 1917, p. 245). The unconscious identification with the lost object ensures that its disappearance is neither seen nor voiced. But the loss is not eliminated by such disavowal. Rather, Freud is clear that, in incorporating the lost object, the ego unconsciously, if melancholically, identifies with it and is thereby altered in the direction of becoming like the lost object: ‘The character of the ego is a precipitate of abandoned object-cathexes’ (p. 638). How does Freud’s complex notion of identification with the lost object in melancholia help us understand the culture of organizations such as IAPT? Butler’s (1997) reading of Freud argues eloquently that gender is formed by identifications that are in part composed of repudiated grief; that the disavowal of early homosexual attachment, for example, founds the gendered subject via both the disavowal of love, and the subsequent refusal to grieve its loss. She goes on to argue that masculinity and femininity: are strengthened through the repudiations they perform. In opposition to a conception of sexuality which is said to ‘express’ a gender, gender itself is here understood to be composed of precisely what remains inarticulate in sexuality. (1997, p. 140)
I find Butler’s ideas remarkably compelling in the context of organizational dynamics. Borrowing her notion of refused identifications in the formation of gender, I want to consider the possibility that a similar process may occur in the formation of the characteristic culture or ‘ego’ of an organization. For insofar as mental health services have traditionally been identified with an idealized anxiety-containing function, I propose that services such as IAPT, now radically dis-identified with this function by virtue of privileging consumerism, choice and productivity over relatedness, dependence and need, may in part be constituted by a repudiated identification with the lost container. In this way, the distinctive socio-political and structural features of IAPT that I have discussed in this paper can be seen not only to announce the loss of psychological containment, but also to act as guarantors of a continuing disavowal of that loss.The inability to manage, think about and contain states of distress, emotional need and vulnerability in the organization is underwritten, as it were, by the negation of that very failure. In fact, denial of loss and the inability to mourn become essential to sustaining, consolidating and strengthening the organizational culture; the lost object, to paraphrase Butler (1997), ‘continues to haunt and inhabit the [organization] as one of its constitutive identifications’ (p. 134).
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The relentless transparency of the IAPT culture, the organizational ethos of targets, clinical outcome measures and the continual surveillance of staff activity – what Cummins (2001) has evocatively termed the ‘auditable surface’ – can thus be viewed, paradoxically, as an index of that which is unseen, that which is hidden or concealed in the organization: visible traces of an invisible, unmourned loss that may come to be unconsciously experienced by staff and managers within a service as form of melancholia. Signifying a loss, according to Freud, ‘of a more ideal kind’ that can be neither acknowledged nor grieved, it remains to haunt the ‘ego’ or culture of service, enacted within the interpersonal relations between staff and their patients and embedded within the structures and processes of the service. As a consequence, I suggest that feelings of loss, dependency and vulnerability in both staff and patients are foreclosed; as abject reminders of the need for psychological containment, their expression must continually be barred as a means of unconsciously sustaining and reinforcing the organizational status quo. In contrast to Freud, Klein (1935) viewed depressive feelings as linked not only to the real or phantasied loss of an internal object, but to the feeling of having damaged the object oneself. The emphasis here is on the child’s own aggressive and hostile phantasies which are unconsciously felt to have damaged, maimed or killed the image of the good mother. The task for the child thus exceeds what Freud argues is the crucial capacity to mourn his or her loss. For Klein, it is the experience of guilt at damage done and the acceptance of personal responsibility for the loss that sponsors the decisive wish to repair the destruction done to an ambivalently loved object, either in reality or in phantasy.This reparative drive is central to ensuring that the child can make good the impact of its own aggression and sadism. However, mourning can be avoided via manic reparation, an activity that wards off guilt and the acknowledgement of personal destructiveness. Indeed, within the framework of an IAPT service a sense of personal anxiety or guilt is not really permitted or affirmed, but rather dismissed as unnecessary in the face of compliance with externally-validated policies, regulations and standards that are assumed to govern clinical decision-making (Rizq, 2012). Certainly, the bureaucracy and governance systems in IAPT services, together with their consumerist discourse and rhetoric of choice and empowerment, engender what appears to be a near-manic level of activity in its staff. Alongside the colossal network of administration and training that has sprung up throughout the UK as well as the astonishingly high level of documentation produced by the IAPT central administration (at the time of writing, 158 document downloads are available on the IAPT website), I see such activity as a form of manic reparation aimed at avoiding a sense of loss and guilt, and upholding an idealized view of what mental health services can and should be offering. Drawing on my work as a psychologist and psychotherapist in a recently expanded primary care mental health service, I will try to illustrate something of this unspoken sense of loss can become enacted and experienced within an organization.
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Case Example In this particular primary care mental health service, referrals had traditionally been allocated to specific clinical practitioners based on the nature, complexity and urgency of the referral. This meant, in brief, that referrals for psychological problems such as simple panic, anxiety or recent depression were allocated to IAPT Psychological Wellbeing Advisors (PWPs), whilst referrals for more complex cases of depression and anxiety, including obsessive–compulsive disorder or post-traumatic stress were allocated to CBT therapists. Referrals that indicated a history of abuse, neglect, loss or trauma, or long-standing relationship problems were allocated to psychotherapists or counsellors. This system was designed to enable the different clinical practitioners to make an individual assessment of each patient, accepting them for short-term therapeutic work, or referring them on to other services as appropriate. However, since expanding into an IAPT service, senior management had come under pressure to meet the required activity target of 5000 assessed referrals per year, and this old system was increasingly regarded as rather time-consuming, clinically indulgent and administratively inefficient. Moreover, since not all practitioners within the service were using the same data collection procedures, referrals that were assessed by non-IAPT staff were not recorded on the IAPT software system and so did not contribute to the required overall activity data for the service. In order to meet this new target, which was deemed key to ensuring the continued funding of the service, a decision was taken by the senior management that all referrals to the service would now be offered a ‘telephone screening’ by PWPs who would log the referral onto their central database, and would subsequently allocate referrals either for further assessment by themselves, or to counsellors, cognitive–behavioural therapists or other specialist services where appropriate. Most of the clinical staff were unhappy with this decision: counsellors and psychotherapists felt that their experience and skills were being relegated in favour of more junior and less experienced colleagues; and many of the PWPs were concerned that they would be overwhelmed with referrals they lacked the clinical skills to understand and manage. As one of the psychotherapists within the service, I was often asked to help the PWPs discuss their referral decisions, particularly if there was any question of patients being referred to counselling or to the local secondary care psychotherapy service. Recently, a young PWP asked to see me to discuss an assessment that she had recently undertaken.At our meeting, she told me that she had undertaken a telephone screening of a middle-aged man who had been experiencing feelings of acute depression in the context of difficulties with his elderly mother with whom he was living. On the basis of this telephone conversation, my colleague had invited him to attend a face-to-face assessment with a view to offering him some brief CBT-based ‘guided self-help’, and he had agreed to attend. My colleague had obviously prepared conscientiously for the session and had undertaken the IAPT manualized assessment procedure with great care. She ascertained that this patient had lived with his mother all his life and, whilst this had been bearable when she was well, her age and infirmity meant that he was
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now progressively burdened by the demands of her physical care, housekeeping and financial concerns. He was quite clearly, said my colleague, at the end of his tether, feeling increasingly resentful at the limitations this enforced care of his mother placed on his own needs. During the course of the interview, however, she found that her patient started to become rather belligerent and aggressive in response to her questions, asking about her experience and qualifications. She felt that he was being dismissive of her and his growing irritation and subsequently outright anger with her inquiries eventually resulted in his refusal to complete the clinical outcome measures that she had requested and a threat to lodge a complaint against the service. She said that she in turn had become increasingly heated and defensive and felt woefully unable to manage the situation in a satisfactory way. In the end, she had finished the session by rather desperately telling her patient that he would be better off going to a local voluntary sector counselling service. As my colleague recounted this story to me, she started to become rather distressed and tearful, saying that she did not really know why she was doing this job; she felt she was clearly useless and unable to help. She said that she had felt frightened in the session and she did not expect to feel scared of patients; after all, she had only been doing her best to help. I was concerned for her and tried to help her to think about what her feelings of vulnerability and anxiety might mean in relation to her client. After a pause, where she seemed to rally, she suddenly announced that, in any case, she would never have been able to help this man as he had not presented with any clear symptoms of depression. ‘After all, I do need him to have symptoms if I’m going to treat him,’ she said rather briskly. ‘He doesn’t really have any symptoms that I can see, so I don’t know how he would show any improvement on my outcome measures. And my supervisor says I can’t spend time worrying about this: I’ve got lots of other people on my list who do have symptoms; I’ve got to get on with them’. I was very taken aback by this volte-face and in response felt somewhat attacked, or on the receiving end of some kind of aggression – a feeling that I was being slapped on the wrist for wasting time bothering to think about this patient. To counteract my own rather irate reaction, I found myself as the discussion went on increasingly drawn into an appeasing, pragmatic stance where I too began to think that perhaps my colleague really did need just to ‘get on’ with her other patients and forget about this unreasonable, demanding and depressed man. In my wish to support, validate and reassure I seemed increasingly unable to sustain a thinking space where her patient’s angry and depressed feelings could be considered. This then led, by the end of our conversation, to my guilty sense of ‘selling out’, a weary giving up of the effort which seemed hopeless and pointless in the face of all the ‘other people on the list’. In contrast to my colleague, who now seemed energized and relieved, I felt something akin to depression myself.
Discussion The purpose of this brief example is not of course to question or critique the capacities of a colleague who in any case was clearly doing her best in a difficult
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clinical situation. I want to use this quite ordinary example of a piece of informal supervision to consider my colleague’s difficulties in the light of organizational decisions and processes that appeared to undermine the service’s capacity to think about, acknowledge and contain the reality and indeed the intractability of many people’s psychological problems. In particular, it is important to note that the decision to offer ‘telephone screening’ by PWPs to all who were referred to the service was not a clinical decision. It was a choice taken by senior management in the interests of expediency to ensure the service could continue meet the rising patient activity targets set by the IAPT central administration and thus receive continued funding. However, it meant that it was the youngest, most inexperienced staff, those who were least able to manage the often very powerful feelings projected on to them by patients, who were required to assess and work with the majority of individuals referred to the service. Against this political backdrop, my young colleague was subsequently asked to assess an individual on the basis of a manualized procedure. However, the existence of a written protocol, part of the IAPT model of proceduralism, standardization and regulation, not only clearly failed to help my colleague think about and address her patient’s very real anxieties about coming for help, it also appears to have had a dismaying impact on her patient. His palpable anger and disappointment when faced with a series of pre-established questions and outcome measures were understandable; but his aggressive confrontation and threat of a formal complaint masked what could be seen as a potentially important unconscious communication concerning his expectations of care and containment from the service in general, and perhaps from a woman in particular. But his feelings of disappointment could not be processed, thought about or contained by my colleague; the very discourse within which she, as a Psychological Wellbeing Practitioner, is operating, the framework within which she is required to work, leaves an absence, a lacuna – what Kristeva (1997) has termed an ‘asymbolia’ – within which her patient’s experience can be neither acknowledged nor voiced. He does not have the correct ‘symptoms’ that can be fitted into what the service provides; the feelings that he comes for help with cannot be itemized, objectified, quantified, evaluated or measured according to the service’s policies and protocols, which themselves serve to abolish any acknowledgement of the very loss they engender. However, the patient’s feelings of pain and distress are not thereby eliminated. Indeed, his feelings of loss and disappointment are amplified and become relocated within my colleague who herself becomes overwhelmed with feelings of guilt and anxiety at what she sees as failing to deal with the situation in a therapeutic way. From a more Kleinian perspective we could argue that my colleague has projectively identified with her patient’s unconscious feelings of uselessness and inadequacy which lead her to question her own capacities to do the job. In discussing this with my colleague, however, I started to realize that she had somewhere been acutely concerned at not being been able to help this man; this seemed to be a source of much self-criticism as she felt she ‘should’ have been able to offer him more understanding and support. Instead, however, she
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admitted that she had, in fact, felt very angry and rejecting towards him because of his contemptuous behaviour towards her. This turned out to be the basis of considerable feelings of guilt because such a hostile reaction was not something that she felt was acceptable as a professional; in her role she felt she was ‘supposed’ to feel empathic and to offer neutral advice. What I want to highlight here, however, is not only how difficult it was for her to give weight to and think about these so-called unacceptable feelings, but also how swiftly such feelings were transformed during the course of our discussion from inadequacy, regret and self-criticism at the loss of what she held to be her idealized therapist-self into what appeared to be a rather manic denial of her own feelings as well as those of her patient. Indeed, within the service, there seemed little opportunity to acknowledge or process feelings of loss or guilt. My colleague’s self-criticism and sense of personal responsibility to her patient quickly gave way to a harsh organizational superego akin, perhaps, to the self-beratement that Freud sees as characteristic of the melancholic state. This administratively-sanctioned aggression demands that she achieve her targets and punishes her for failure to reach them. In this scenario, responsibility (and aggression) is quickly transferred to the patient instead: he does not have the right ‘symptoms’ and therefore cannot contribute to the service’s clinical outcome measures by which her work, and the work of the service, is judged. With the apparent support of her supervisor, my colleague legitimately turns to the many others ‘on the list’ who do have the right symptoms, people who will be able to contribute to the service’s required targets. This manic round of actual and psychic activity – characteristic, I suggest, of a service-wide disavowal both of the loss of emotional containment and the failure to register its forfeiture – seems to serve a collective phantasy of ridding the service of unwelcome disturbance which then substitutes for thoughtful engagement with the patient’s dilemma. Indeed, that responsibility seemed to be passed on to me, and I later understood this unconscious demand for containment to be the main purpose of our meeting. My own feelings of anger, guilt and depression during the conversation, however, I think reveal another possibility in relation to an important, but hidden psychic undertow within the organization as a whole. It seemed that a feeling of depression – the unconscious registration of an unacknowledged, unmourned loss – was percolating down from patient, to colleague and from there to me in the discussion. My colleague’s difficulty in managing her patient’s feelings of anger and depression can be seen, in part at least, as the clinical consequence of a managerial decision permitting the youngest and least experienced members of staff to be placed in the ‘front line’, and required to assess all patients. The a priori repudiation of vulnerability in both patients and staff implicit in this decision and the concomitant refusal by management to acknowledge the necessity of containing this by having more experienced staff available instead to manage and think about the psychological distress of patients were thus embedded within the policy of the service with psychic consequences cascading down to patients and staff members themselves. But my feelings in the above conversation, I think, registered an emotional experience that illuminated what I began to see as a central dilemma constitutive of
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the service as a whole: that is, how to manage the unconscious sense of loss, guilt and anger resulting from the organizationally-sanctioned denial of psychological vulnerability and the consequent failure of the service and its staff to provide emotional containment for patients in their care. In this sense, my experience of something akin to an ‘unthought known’ (Bollas, 1987) brought into focus a hidden – albeit repudiated – feeling of loss: something that could be described, perhaps, as a ghostly presence within the IAPT machine that, whilst not cognitively formulated or acknowledged by staff, was nonetheless existentially lived and known. A sense of unmourned loss is, I think, characteristic of organizations in the malignant grip of what Gabriel (2008) terms ‘organizational miasma’. He argues that organizations that undergo sudden transformations involving drastic cuts, staff redundancies and downsizing, particularly those that move from a public service ethos to a market-driven one, seek to obliterate or disavow a state of loss without recognizing or honouring it through the necessary separation rituals. Feelings of loss and grief are repressed as old systems; colleagues, leaders and practices are denigrated in favour of narratives that privilege excellence, entrepreneurship and organizational prowess. In the case of UK mental health services, we are familiar with such overblown notions as ‘world-class commissioning’ and ‘cutting edge’ services as well as the rhetoric of ‘evidence-based treatments’ all of which have all become part and parcel of the idealized standards against which organizations such as IAPT judge themselves and their staff. In the teeth of such ideals, it is hardly surprising that staff in general – and my young colleague in particular – feel themselves to be lacking in some way. Indeed, shortly after my conversation, a number of PWPs left the service, citing exhaustion, stress and the need for further training as reasons for their departure. Successful mourning, says Freud, implies recognition, acknowledgement and acceptance of loss; in this case, acknowledgment that the perfect NHS service, the quintessential container, does not, cannot and never did exist. Recognition of this painful reality – and of the fact that some mental health services were very far from able to provide effective containment (indeed in some cases harboured regimes of systematic abuse and marginalization of patients) – was in part the basis on which the IAPT programme was predicated. But its astonishingly high caseloads and activity targets, the expansion of its services and training, the proliferation of theoretical models deemed to be ‘IAPTcompliant’, as well as the continual pressure to achieve increasingly successful clinical outcomes, all arguably attest to the circulation of an unconscious omnipotent phantasy that now resists precisely such an acknowledgement. Fotaki (2006), in her trenchant critique of what she sees as the idealized policy objectives within the NHS, suggests that such idealization is ‘necessary in sustaining grand political schemes driven by semi-utopian ideas’ (p. 1728). These schemes, and the health services and practices they sponsor are, she argues, a means of unconsciously protecting us from the fundamental ‘givens’ of human existence: mortality, death, dependence on others and the inevitably ambivalent feelings that these sponsor. This leads to the pursuit of grandiose or
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unachievable policy aims, rather than more realistic, ‘good enough’ policy objectives (p. 1729) that can contain and manage the realities and limitations of what is achievable. Cooper (2001) too, drawing on Kleinian theory, argues that a realistic awareness of our limitations in working with and managing those in psychological distress is a crucial aspect of working in mental health services, one that gives rise to the wish to repair the damage done in phantasy to the loved object: a reparative drive that most often underlies the wish to work in a psychotherapeutic profession. Blocking, or invalidating the reparative drive within a service by short-circuiting awareness of loss and guilt – in short, preventing mourning – thus sponsors and sustains an omnipotent or manic relationship to reality where all things become possible and achievable. Certainly, it is evident that the politically ambitious scale of the IAPT agenda currently being marketed to the public is engendering inflated expectations in health service users, expectations that will result in disappointment and disillusion unless they are met. Indeed, my colleague’s experience of her patient’s rage and frustration may be taken as one small example of the way in which the reality of what is offered within IAPT appears to be drastically at odds with what the public expects it will receive. If unaddressed, I suggest this disturbing state of affairs may lead to a deadening of life within services, where staff turnover, burnout and cynicism are likely to prevail and where patients, denied the dependency intrinsic to their psychological needs, may increasingly adopt confrontational or litigious attitudes commensurate with the ethos and rhetoric of the marketplace.
Conclusion and Reflections It will not have escaped the reader that there is a more difficult task ahead for those, like myself, who attempt to critique the deficiencies of new services. Cooper and Lousada (2005) suggest that: Any attempt to examine modern welfare. . . . must negotiate a difficult path, between idealization of the new and concomitant denigration of the past on the one hand, and nostalgic identification with the past and possible resistance to innovation and change on the other. From a psychoanalytic perspective, these potential positions must be seen as detrimental to the sustained effort to remain open-minded and integrative, to be aware of both creative possibility and destructiveness. (pp. 5–6)
It is certainly difficult to create and sustain a ‘third position’ with respect to the changes that are currently taking place within primary care mental health services today. Perhaps the central question raised by this paper is whether the putative ghost in the IAPT machine can really be acknowledged and tolerated; whether recognition of lack or loss – a prerequisite, according to Freud, for turning melancholia into mourning – can be permitted and given legitimate expression. It is heartening that, following the initial high expectations of IAPT services, there is beginning to be some acknowledgement of the realities, frustrations and complexities of mental health provision. For example, the IAPT report, Enhancing Recovery Rates in IAPT Services: Lessons from an Analysis
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of Year One Data (IAPT, 2011), examines in detail – and with some humility – the considerably varied and sometimes disappointing clinical outcomes from different IAPT services. Some IAPT services and commissioners are already establishing second- and third-tier psychoanalytic services for complex cases that fall outside the IAPT remit. The introduction of dynamic interpersonal therapy into the IAPT range of therapies has also sponsored important and progressive dialogues between psychoanalytic and cognitive–behavioural clinicians. These and other tentative steps are modest but undoubtedly hopeful signs of services potentially driven more by realistic, innovative and co-operative thinking than by overblown political rhetoric, economic short-termism and professional vested interests. At the end of this paper, however, I find myself reserving judgement about whether and to what extent this potential for organizational creativity and co-operation can be sustained and developed in the face of pressure from current neo-liberal cultures, the free market economy and the information revolution. Gramsci (1929) famously called for ‘pessimism of the intellect, optimism of the will’ as both a spur to action and the resilience to believe that such action will result in constructive change, despite adversity. In that spirit, I hope that, by recognizing rather than minimizing the complexity and intractability of many mental health problems and by acknowledging the limitations of our capacity to ameliorate suffering, we may yet find ways of working together to offer good enough containment for those in psychological distress.
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