CBT in Job Centres: Five Objections

In March, Nick Clegg announced his plan to improve access to mental health care for people who are out of work. It started off so well, but had a bizarre twist.

He said that he’d found an extra £25 million for mental health, to be invested over the next three years. So far so good.

And that this money might end up helping 40,000 people. Great.

And that this money would fund ‘specialists in mental health support’ to provide talking therapy in 350 Job Centres across the UK. Sorry, what?

On the face of it, you might mistake this for a good idea. Unemployed people are statistically more likely than average to have a mental health problem, and CBT can be pretty effective.

But there are at least 5 reasons why this is a disastrous plan:

  • It feeds into the belief that people with physical health problems should get better but people with mental health problems should get back to work. You won’t be seeing 350 new physiotherapists in Job Centres trying to get people with back pain back to work, even though back pain is a hugely significant cause of sickness absence. This is because we know that recovery comes first, is the primary goal, and happens in a recovery-focused setting, not a Job Centre, where the intentions of those doing the ‘treating’ become murkier.
  • There were already brewing concerns that people with mental health problems would feel coerced into accepting such treatments when the Tories simply came out and said it in their manifesto – some people will lose their benefits if they say no. This baulks against the very fundamentals of medical ethics, of being able to make an uninfluenced decision about what treatment to accept. Furthermore, doing therapy with people who simply don’t want to be there is at best a waste of money and at worst downright harmful.
  • It targets help at people who have something to offer in return, i.e. getting back to work and paying some tax. This is firmly against the principles of the NHS, which state that a person’s means (including, if you have any common sense, their potential) should have no say in their access to treatment. People with equally troublesome mental health problems but no likelihood of ever working again won’t see a penny of this £25 million.
  • What on earth are ‘specialists in mental health support’? According to these contracts for over 80% of the £25 million they appear to be online CBT assistants. These types of resources can be valuable and effective, but working in isolation, as I presume these guys will be, could be unsafe and result in downright quackery. Mental health conditions are complex and require a commensurate amount of assessment – not a quick meeting with someone who is barely qualified. Is there a chance that sub-standard assessments could diagnose problems where there are none, or worse, conclude that not being able to get back into work is a CBT-suitable problem in itself? This is a hair’s breadth from seeing unemployment as illness.
  • Despite it being sold in some articles as ‘co-location’ (i.e. multiple services working closely together in the same place), I can only see this project fragmenting services even further. It will simply add another layer of complexity and miscommunication to pathways which are already needlessly arcane and soul-destroying. Put it this way – the ‘specialist in mental health support’ isn’t going to be ringing the GP or psychiatrist with a thorough summary of treatment and progress, are they? If you want joined up services, put more employment advisors in mental health settings. Fund OT and social work better.

Clegg has been a positive figure for mental health in recent years, so I can’t be too harsh on him. But if he wants people with mental health conditions to recover and get back to work, my suggestion is simple. Fund mental health services better. Don’t create a coercive, work-orientated, untried, discriminatory and disconnected treatment model staffed by isolated and weakly trained staff.

Mental health in the manifestos: what are the parties promising?

The general election is nearly upon us.  After five years of fierce discussion, debate and dispute, we finally get a concrete chance to influence the political landscape of this country. And for the first time, mental health has been acknowledged as a key issue. Last year The Mental Health Policy Group, a collection of six leading mental health charities and organisations, published it’s own ‘Manifesto for Better Mental Health’, outlining where they felt the main political parties needed to commit their energies following this election. In summary, they lobbied for:

  • fair funding for mental health services
  • giving children a good start in life (including perinatal care and education on MH at school)
  • improving physical health care for people with mental health problems
  • improving the lives of people with mental health problems (anti-stigma and pro-employment)
  • enabling better access to mental health services

The Royal College of Psychiatrists published their own ‘6 months, 6 asks’ manifesto around the same time, detailing what they felt should be priorities for the next government:

  • tackling the mental health bed crisis
  • introducing maximum waiting times
  • improving crisis care
  • improving liaison psychiatry services
  • introducing a minimum unit price for alcohol
  • investing in parenting programmes

So let’s see how well each of the main three parties lives up to these expectations in their manifestos.

The Conservatives

The Tory manifesto is light on references to mental health. The first mention it gets is in the scandalous segment on how people with long-term but treatable conditions will be ‘helped back to work’ by having their benefits cuts if they refuse a treatment. The same segment does also offer the following rather nebulous promise, again tied in closely to being able to get back to work:

“We will also provide significant new support for mental health, benefiting thousands of people claiming out-of-work benefits or being supported by Fit for Work”

Later on in the manifesto, there are marginally more specific pledges, namely that that the Tories will ensure…

“…that there are therapists in every part of the country providing treatment for those who need it. We are increasing funding for mental health care. We will enforce the new access and waiting time standards for people experiencing mental ill-health, including children and young people. Building on our success in training thousands of nurses and midwives to become health visitors, we will ensure that women have access to mental health support during and after pregnancy, while strengthening the health visiting programme for new mothers.”
 
It should be noted that mental health nursing numbers have dropped like a rock rock over the last 5 years, and mental health funding has probably fallen too, so this passage felt a little trite. But although the promises are vague and the pledge to increase funding is unquantified, the commitments are there.
 
Finally, there is an acknowledgement of the vital need for improvement in care for people who come to the attention of the police:
 
“We will ensure proper provision of health and community-based places of safety for people suffering mental health crises – saving police time and stopping vulnerable people being detained in police custody”
 
 
 
Labour
 
In their manifesto, Labour are keen to push the fact that we need more joined-up, integrated services:
 
 
“Our health reforms will focus on prevention and early intervention, and joining up services from home to hospital. When people cannot get to see their GP, many go to A&E instead. When mental health problems are not spotted early, people can deteriorate and need more intensive support”
 
 
“The current system is too fragmented. It was not designed for the growing numbers of people living with chronic conditions or multiple needs. Rather than having three separate systems for dealing with physical, mental and social care, we will create a whole person approach: a single service to meet all of a person’s health and care needs”
 
 
And they go on to briefly mention parity and improving access to services, with a particular focus on children:
 
 
“Mental health will be given the same priority as physical health. People will have the same right to psychological therapies as they currently have to drugs and medical treatments. To help address the problem of undiagnosed mental illness, NHS staff training will include mental health. We will increase the proportion of the mental health budget that is spent on children, and make sure that teachers have training so they can identify problems early and link children up with support. To support young people’s health and wellbeing, we will encourage the development of social and emotional skills, for example through the use of mindfulness to build resilience. And we will set out a strategy with the goal of ensuring that the great majority of patients can access talking therapies within 28 days, and that all children who need it can access school- based counselling”
 
 
This, I felt, was slightly more encouraging than the Tory effort. Still no hard figures, but Labour at least seem sympathetic to the plight of people with mental illness, and aware of the inefficiency and turmoil of having such fragmented care. The nod towards funding ‘wellbeing’ interventions, which the Chief Medical Officer warned against last year due to a limited evidence base, was probably included to make the manifesto’s commitment to mental health resonate with the public at large. I also note that Labour only promise to increase the proportion of the mental health budget spent on child services, effectively committing to cuts elsewhere unless funding is increased overall. This is cheeky.
 
 
 
Liberal Democrats
 
As promised by Nick Clegg there is a pledge to ‘guarantee equal care for mental health’ on the front cover of the Lib Dem manifesto. There is also a more intentful mention of mental health in their introductory paragraph than in any of their competitor’s opening statements:
 
 
“Those facing anxiety and depression will be seen swiftly, people struggling not to harm themselves will find emergency help at A&E and teenagers suffering from eating disorders will get the help they need close to home”
 
Indeed, mental health is alluded to more frequently in this manifesto than in the others. Apprenticeships are to be tailored better for people with mental health problems, and foster carers are to be better educated on the topic. Later, in the health section, they become the only major party to offer an exact figure for investment:
 
 
“…£500m [extra per year by 2016/17] to transform mental health care with waiting time standards to match those in physical health care”
 
 
When added to previous pledges, as reported this week, that that would add up to £3.5bn extra for mental health over the next five years, to be partially paid for through changes to capital gains tax.
 
This promise is part of a solid two pages of text on mental health. Assurances given in this generous space include:
 
  • “a waiting time standard from referral of no more than six weeks for therapy for depression or anxiety and a two-week wait standard for all young people experiencing a first episode of psychosis”
  • “increased access to clinically and cost-effective talking therapies”
  • “transforming care for pregnant women, new mothers and those who have experienced miscarriage or stillbirth, and help them get the early care they need”
  • implementing the proposals outlined in the report of the Government’s Children’s Mental Health Taskforce. For example, “building better links with schools, ensuring all children develop mental resilience, and getting support and care quickly to those who are struggling”.
  • “ensure no one in crisis is turned away, with…better crisis care in A&E, in the community and via phone lines. This will enable us to end the use of police cells for people facing a mental health crisis”.
  • “extending the use of personal budgets, integrating care more fully with the rest of the NHS, introducing rigorous inspection and high-quality standards, comprehensive collection of data to monitor outcomes and waiting times and changing the way services are funded so they do not lose out in funding decisions in future”
  • “introduce care navigators so people get help finding their way around the system, and set stretching standards to improve the physical health of people with mental health problems”
  • “publish a national wellbeing strategy”, with a “public health campaign promoting the steps people can take to
    improve their own mental resilience” and “ensuring people with mental health problems get the help they need to stay in or find work”
  • “establish a world-leading mental health research fund, investing £50m to further our understanding of mental illness and develop more effective treatments”
  • “continue to support the Time to Change programme to tackle stigma against mental health”
  • “ensure all frontline public service professionals, including in schools and universities, get better training in mental health”

There’s also a vow to offer more “support for personnel and veterans with mental health problems”.

It doesn’t take a PhD in politics to work out that the Lib Dem manifesto is head and shoulders above the Conservatives and Labour in terms of engagement with the issue and promises made. They have ticked pretty much every one of the Mental Health Policy Group’s boxes for suggested improvements. Again, there is an infatuation with wellbeing, but the groundwork done by Norman Lamb with his Crisis Care Concordat has gone some way to engendering trust in the party when it comes to tackling more weighty issues. The real question is, will they have any power to implement these changes on May the 8th?
 
 

The Green Party

The Greens dedicate a generous proportion of their  to mental health, not least because one of their main focus points – equality – is tied in with it so closely. They state clearly, and in a way that no other party does, that their policies are all intertwined, for example that reducing mental ill health will have a positive knock-on effect on the economy, crime and drug use.

They pledge to ‘increase investment in mental health care’ as part of a general £12bn increase in NHS funding per year, but don’t say exactly how much of that £12bn mental health will get.

They highlight the huge disparity between the proportion of illness that is due to mental health problems (28%) in UK society and the amount of NHS funding dedicated to mental health services (23%), before going on to make a series of promises:

 

  • Ensure that no one waits more than 28 days for access to talking therapies.
  • Ensure that everyone experiencing a mental health crisis, including children and young people, should have safe and speedy access to quality care, 24 hours a day, 7 days a week.
  • The use of police cells as ‘places of safety’ for children should be eliminated by 2016, and by the end of the next Parliament should only occur for adults in exceptional circumstances.
  • Ensure that everyone who requires a mental health bed should be able to access one in their local NHS Trust area, unless they need specialist care and treatment. If specialist care is required, then this should be provided within a reasonable distance of where the patient lives.
  • Implement a campaign to end the discrimination and stigma associated with mental health through supporting the Time for Change programme and offering employment support to those with mental health problems.
  • Invest in dementia services, ensuring that support is available for all affected by this debilitating disease, including families and carers.
  • Pay special attention to any mental health issues of mothers during and after pregnancy, children and adolescents, Black and Minority Ethnic people, refugees, the LGBTIQ communities and ex-service people and their families.
  • Improve access to addiction services, including both drugs and alcohol addiction.
  • Give higher priority to the physical healthcare of those with mental health problems.

 

These are ambitious pledges, but rather unembellished ones. Such changes would take huge about of reinvestment and substantial reorganisation of services, but I haven’t seen any finer detail from the party on how this would happen. On the plus side, the manifesto has a lengthy but understandable appendix which lists every revenue and expenditure the party would implement, evidencing their financial plans.

 UKIP

To be fair to UKIP, there is a promise to ‘invest £1.5 billion into mental health and dementia services’ in the introduction to their manifesto and they do mention the need for parity. They also acknowledge how important liaison services are, pledging to end the ‘postcode lottery’ in that respect. To continue being fair to UKIP, the rest of their commitments to mental health are very dilute and feel like token statements. For example, they promise:

  • Directing patients diagnosed with a debilitating long-term condition or terminal illnesses to mental health professionals when appropriate
  • Recognising there is often a link between addiction and mental illness and offering appropriate treatment where this is the case
  • Offering direct access to specialist mental health treatment for pregnant women and mothers of children under 12 months of age
  • Fighting the stigma around mental illness and supporting those seeking to get back into work.

Hardly groundbreaking – they sound more like standard expectations of the current service.

In a bizarre move, they also pledge to bring in a ‘veteran card’ so that ex-serviceman and women can be ‘fast-tracked’ into NHS services, including when they need mental health care. There is no need for such a two-tiered system – it would surely be a better aim to make services accessible to all in a timely manner.

 
The SNP
 
The SNP manifesto notes that they would pledge and additional £100m over 5 years for mental health (in Scotland), mainly to be directed at primary care and children’s services, but doesn’t have a dedicated section on mental health. In fact, that’s pretty much the only mention of it at all. 
 
So ladies and gentlemen, if mental health is the issue dearest to your hearts, then there are your contenders. Vote for whoever you choose, but please, please, do vote.

Starving you back to work: Why Tory policy of cutting benefits if you refuse treatment is vile

The Tory manifesto it out. Like many others I was immediately drawn to page 28, where David Cameron explains how he will ‘help you back into work if you have a long-term yet treatable condition‘. But their spellchecker must be on the blink because they obviously don’t mean ‘help’, they mean ‘threaten’.

‘We will review how best to support those suffering from long-term yet treatable conditions, such as drug or alcohol addiction, or obesity, back into work. People who might benefit from treatment should get the medical help they need so they can return to work. If they refuse a recommended treatment, we will review whether their benefits should be reduced’

The idea of starving sick people back to work was first raised by the Tories last year, but despite the fact that it went down like a sack of lead crap, they’ve stuck with it.

I viscerally object to this policy in so many ways it’s hard to know where to begin.

Firstly, it only seems to target people who have an illness or condition that they can (mistakenly) be blamed for. Cameron won’t be threatening poorly-controlled diabetics with benefit cuts if they don’t take their insulin, and he won’t be nagging people to attend their physiotherapy following a stroke. He’ll only be threatening people who he thinks, from his ivory tower, chose to become ill. This shows just how ignorant the Tories are when it comes to difficulties like addiction, obesity and mental health problems. People with these problems hardly ever choose to be that way. The causes of their suffering are often as external to them as any ‘physical health’ problem – poor housing, employment, lack of affordable healthy food. But Cameron thinks their difficulties are a lifestyle choice, and this is sheer discrimination. He wants people with physical health problems to return to health, but people with mental health problems to return to work.

Secondly, it is hideously naive of the Tories to assume that change is easy for people with these conditions. It isn’t, and there are good reasons for that. Therapy for a mental health problem can be an emotional pressure cooker, and medications all have side effects. I assume that losing weight when you can afford only the cheapest, most unhealthy foods is pretty difficult too. Any kind of help for these problems requires insight and motivation, which can take years of careful mental and social preparation. To force someone into treatment too soon using the threat of financial penalties actually risks wasting money and might actually make people worse. As an aside, I’ve never done therapy with or prescribed a tablet to someone who had to accept it or they’d lose their benefits, and I wouldn’t want to. It’s not a great place to start a therapeutic relationship and sits in stark opposition to good medical ethics.

Finally, the fundamental ethos of this policy sickens me. A caring government, who want a ‘brighter, more secure future’ and a ‘good life for all’, would create a society in which people wanted to take up treatment of their own accord. They would provide adequate services to provide that treatment and explore the reasons why people might be struggling to accept it, instead of cutting services to the bone then denying it). They would fix the root causes of social problems like obesity and addiction. But instead, we have a government who delight in the use of the stick over the carrot, placing unfortunate individuals as solely to blame for complex conditions then punishing them for not taking up treatment for which they probably aren’t ready.

The incentive for recovering from a mental health problem or addiction should be recovery itself, not starvation from benefit cuts. This policy needs to be scrapped, and quickly.

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