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.

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About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

11 Responses to CBT in Job Centres: Five Objections

  1. Dandelion says:

    That’s a terrifying prospect. It’s only a couple of steps away from Jobcentre staff sending jobseekers to the mental health services for having the wrong attitude. Don’t get me wrong, some are lovely and supportive, but get the wrong one, or one trying to find someone to sanction and and the Jobcentre becomes a horrid place for anyone with mental health issues. I’ve been harrassed by a Jobcentre member of staff for not making eye contact (er, I have Asperger’s), had snarky comments while yawning through a 9:10am appointment (after taking sedating antipsychotics the night before) and some seem quite happy to leave you in tears.

    You can imagine what would happen to a jobseeker for whom CBT isn’t a good fit and they drop out of therapy, or aren’t considered to have been putting in enough effort because it’s not right for them.

    Another thing is services like the Jobcentre have no concept of privacy. Jobseekers are expected to spell out, sometimes literally, their mental health problems, ‘could you spell psychiatrist for me please?’ Even their private rooms are in full view with glass walls….AND NO SOUNDPROOFING. It’s possible to pick up the thread of a conversation inside our interview rooms. And the PCs for searching for jobs are so close together it’s easy to read what the next person is typing on their screen. Which is a complete anathema to the confidentiality of mental health services.

    Nick Clegg is welcome to come round to my local Jobcentre and discuss the most intimate and embarassing aspects of his personal life and his private thoughts round at my local Jobcentre. Preferably next time I’m signing on.

  2. onesmallgift says:

    Mental health services have become a joke, they are using CBT as a one size fits all approach across the service so the fact that it is being rolled out now in job centres is a scary one.

    It may work for some but the dangers are that people who are in real crisis are going to be overlooked, the added pressure of being forced into therapy they are not ready for could well push some over the edge.

    It is a not a miracle cure they make it out to be and being told by someone that you just need a change in attitude when you just want out is a disaster waiting to happen.

  3. Judy says:

    Great article, unbelievable waste of money. It’s hard enough getting mental illnesses diagnosed and treated as it is, without more money being wasted.

  4. Judy says:

    Not able to work out twitter – could you do a post on NICE guidelines on schizophrenia and bias. Have relative with schizophrenia successfully on clozapine, Guidelines which I have just skim read seem incredibly biased against anti-psychotics and pro CBT. It’s hard enough staying on antipsychotics without NICE saying it’s your choice ……and why do you need them anyway…

    • I don’t think anything I could write would be as good as the BJPsych editorial I just tweeted about. Here is a link to the full paper, which hopefully is largely understandable to the layperson. https://www.dropbox.com/s/ktx1xrdhylokinj/357.full.pdf?dl=0

      • Judy says:

        Thanks great article. Worrying guideline, my relative spent years from the age of 14 struggling with (possibly) undiagnosed psychosis, with some CBT , some anti – depressants, some anti-psychotics, various diagnoses before finally being prescribed clozapine at 20 which saved her life. Sounds like NICE guidelines are saying that everything was done correctly, which is scary for families who see lives being destroyed by a lack of treatment. And yes, clozapine isn’t a bundle of laughs to take, but it is certainly better than untreated schizophrenia. Rant possibly over……

  5. Ellie says:

    What does parity of esteem mean between physical and mental health? Obviously, someone needs to ask Nick Clegg this, concerning this worrying proposal.

  6. secretwombat says:

    Reblogged this on secreteyes4.

  7. Pingback: An open letter to Alistair Burt, the new Minister of State for Health | The Psychiatry SHO*

  8. Pingback: CBT in Job Centres: Five Objections | 25+2

  9. davesoapbox says:

    Reblogged this on davesoapbox and commented:
    Great, spend money on mental health therapy on people who don’t need it as much and stop their benefits if they refuse. So save money by cutting job number (it may well help some people get jobs) save money by not paying those who refuse the “training” and look like your spending money on mental health which will never get used by those who need it most

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