Dear Colleagues
Since my last newsletter, when we moved to the Peak District in July 2023, until this week, it hasn’t stopped raining. Met Office figures for our annual rainfall totals, which date back to 1836, show a steadily increasing trend, in fact, from the time I left home to go off to the dreaming spires of Oxford in 1980. I’m not complaining. The Etherow, the peaty-golden-brown river that feeds the Longdendale Chain reservoirs, and supplies water to Manchester – bucking the trend? – has never looked so healthy. One of its denizens, the heron, is seen here (below) in Glossop Brook, a tributary stream that flows into the Etherow at Woolley Bridge.
Mental health and disability: a new front on the pre-election culture wars?
Earlier this Spring, the Times columnist and former Conservative MP, Matthew Parris, who lives not far away in the picturesque Dales of the White Peak, wrote a column encouraging Rishi Sunak to clamp down on the spiralling costs of mental health-related disability benefits.
This is how Parris saw the issue:
There will be skivers, of course, but the more general explanation lies in a culture of wide-eyed acceptance of mental health gobbledegook and the fact that there will usually be at least a measure of truth in most PIP claims. People do get depressed; they do feel beset by anxieties; they do become too easily distracted; life gets them down; relationships let them down; they lose heart; they stay in bed, stare at the telly; and wonder if they’ll ever get a job; finally, wonder if they even want one. Then they learn there’s a medical name for what afflicts them, and then they hear this could entitle them to substantially enhanced benefits.
The most telling aspect of this analysis is the phrase ‘mental health gobbledegook’. Yes, it signals being rumbled! For around two decades the claim that talking therapies – CBT – can ‘cure’ depression and anxiety has been unchallenged. NICE says so. Royal Colleges of Psychiatrists and General Practitioners say so. Mental health charities all say so. And, as you know, Lord Layard told the Treasury it was this fact that would save them billions in rising out-of-work benefits spending, back in 2007. I know. I was in the room where it happened.
But spending on benefits has risen ever since, as has the rate of prescribing anti-depressants. There is a conundrum – the treatment prevalence paradox – which has been recognised by leading international CBT and depression researchers, whereby more treatment is being provided by national health systems, but no less depression in the community is being found.
No doubt there will be lots of schadenfreude amongst psychoanalytic psychotherapists, as well as counsellors and others, who were rudely turfed out of working in their local GP practice, during the days of GP fund holding, by the land grab that was the IAPT juggernaut.
Claire Murdoch’s brand refresh for IAPT as NHS Talking Therapies – the kind of vacuous thing a National Mental Health Director is persuaded to do when they haven’t got a clue how to solve the real problem – will not fool anyone. IAPT’s critics will not be falling silent soon.
“We told you so”, they will be saying. Not me. Nor because I was one of IAPT’s National Advisers and one of NICE’s experts on its Depression guidelines. I have seen the difference IAPT’s brief talking therapies, primarily CBT, make in turning someone’s life around. And, unlike Claire Murdoch and Matthew Parris, I have also got the solution to the real problem.
Heron on the lookout in Glossop Brook
Changing subjectivities: time for a rethink on the MOU?
I will come back to Sunak’s plans for welfare reform, the politics of division that underpins them, and IAPT’s woes. Meanwhile, I have briefed Luciana Berger, who is advising Starmer on his mental health strategy, for what an incoming Labour government needs to do instead.
Before we get there, another issue in the culture wars will have been decided. Is the Minister for Equalities, Kemi Badenoch, able to galvanise a Cabinet staring defeat in the face to push through her own version of the legislative ban on conversion practices that is waiting to go? Badenoch wants to gold-plate recommendations from the Cass Review by making sure that young people struggling with their sexuality are not swept along an unnecessary medicalised pathway of puberty blockers, cross-sex hormones and gender re-assignment surgery. Strike one for the vocal critics of Mermaids and Stonewall. Cass has confirmed there is no evidence to support a specialist, affirmative and overly medicalised service model, as at the Tavistock.
On the other side of this polarised argument, leading voices within MOU and trans activism are equating the alternative to an affirmative approach, exploratory therapy, with conversion practices. Subjecting a young person to ‘intrusive, demeaning, unwanted questioning’, as they see it, as opposed to accepting and affirming their self-identified gender, is held by the activists to be akin to how psychiatry and psychoanalysis mistreated homosexuality for years.
Cass states unequivocally:
The intent of psychological intervention is not to change the person’s perception of who they are but to work with them to explore their concerns and experiences and help alleviate their distress, regardless of whether they pursue a medical pathway or not. It is harmful to equate this approach to conversion therapy as it may prevent young people from getting the emotional support they deserve.
Strike two against those in the Ban Conversion Therapy coalition and MOU, who argued for a definition of trans conversion that was anti-psychoanalytic. But are they dead in the water?
I stuck my own oar in when the Minister appeared on Iain Dale’s LBC show recently. You can listen to the exchange at 42.40 from the YouTube recording link below. The point that I was making has still not been grasped by the civil servants drafting the proposed legislation. They have understood, we are told, that conversion therapy is already covered by our various professional codes of ethics, and for all regulated practitioners (under the umbrella purview of the Professional Standards Authority, which BPC and APPPS as an MI are accountable to). Hence, as we understand, a clause in the Bill will exempt us from criminal prosecution and, instead, direct any complaints via a regulatory process that can provide far better protection.
If you listen to the Minister’s response, however, she states that divergence is baked into the devolution settlement, whereby Scotland, Wales and Northern Ireland can go their own way. We are seeing the consequences for the SNP of playing politics with gender recognition and conversion therapy – thumbing the nose at their counterparts in Westminster. But the fact that professional regulation (e.g. the criteria by which a psychiatrist could be struck off) is not a devolved matter, does not deter the campaigners. And if a professional is struck off for conversion therapy in one part of the UK, it will be used to litigate test cases in other parts.
Well, if a law is to be brought forward by this government, it must do so in May. We will see.
What should our own position be? UKCP have recently left the MOU, citing its inability to align itself, in effect, with the Cass review. Having previously been Deputy Chair of MOU, representing the Albany Trust, it is clear to me that MOU is not now fit for the purpose of advising either the government or the mental health profession on what it needs to do to bring in a legislative ban that will provide effective protection without harmful over-reach. Albany left the MOU in 2022, and I resigned as Deputy Chair, for this reason. Should BPC do likewise? Would it create a bigger headache if psychoanalysis is then at daggers drawn with Stonewall?
As I reflect, there have been two great reforms in relation to sexuality and gender in my lifetime, which psychoanalysis was on the wrong side of at first, and then flat-footed in its adjustment. Decriminalisation came in the wake of Lord Wolfenden’s report in 1957. The organisation that I lead, Albany Trust, was formed in response to this out of recognition there would be many individuals needing psychotherapeutic help – but not wanting to be cured.
Bion and Winnicott said to Wolfenden that no one would choose to be homosexual if psychoanalysts offered them a cure, and thereby took a wrong turn that led to our increasing marginalisation in the public sector. APP (as was) doubled down on this mistake at the height of the AIDS crisis when it invited the American analyst, Socarides, to give its annual lecture in 1995, to explicate pre-Oedipal origins of homosexual ‘perversion’, he said, in urgent need of cure. Our apology to LGBT+ communities in 2020 makes clear our different view today.
Since decriminalisation was achieved in 1967 the subsequent reforms, though important, have by and large been tidying up exercises from the original unfinished business. Apart from Mrs Thatcher’s foolish backward step by introducing Section 28 in the late 1980s, which led directly to the formation of Stonewall, all the liberalising measures, equalising the age of consent, for example, and ensuring gay members of the armed forces are protected from discrimination, have rectified anomalies and the concessions that had to be made in 1967. Same-sex marriage in 2013, arguably, has been the one radical new change. It endorses a conservative arrangement – marriage. Yet its social implications for gender non-conformity and for family structures are profound. How can psychoanalysis respond creatively to this?
There is a report from the Institute for Government that shows why same-sex marriage was a case study in how to achieve widespread support for a contentious reform. The conversion therapy ban is a case study in how to lose support. Even my own view has changed as I have seen up close how entrenched the hostility to psychoanalysis is amongst some of the activists.
We have Cass to thank, as well as courageous interventions by David Bell and others, for placing a pause on the assumption that affirmative approaches offer uncomplicated benefits. But we must also use this opportunity to rethink ideas about sexuality and gender afresh. And notwithstanding a ban on conversion therapy would be a tidying up exercise – in the sense we have no real evidence that it occurs in the UK, at least not in talking therapies – for us to be seen to oppose a ban whether in this or the next government, would be a mistake. It has been an ugly debate on both sides. We have a long way to go to repair damage from the fall out, even within the Tavistock. Is the symbolic aspect of a ban – a chance to place psychoanalysis on the side of the angels in international terms, given how homosexuals are still shunned as a corrupt disease across many parts of the world, part of what keeps the BPC still in the MOU?
If it uses this strategic opportunity, contemporary psychoanalysis, with the right leadership and vision, is well placed to forge a new relationship with LGBT+ communities. But we are better placed to embark upon this, in my view, outside of the current configuration of MOU.
Heron further downstream in Glossop Brook – feeding mainly on brown trout.
Other news – NICE, Talking Therapies Task Force, Staff Wellbeing
- NICE Depression Guideline, patient choice, and the NHS Workforce plan
NICE have been working on a Patient Decision Aid (PDA), which is intended to help patients make the right choice of depression treatment, amongst recommended options on offer in the Depression guideline 2022. (I was an expert adviser on the NICE guideline and have been an adviser also on the PDA). This heralds something of a potential breakthrough for public sector psychoanalysis, which is recommended by NICE as a potential first line and/or second line treatment across all presenting severities of depression, and specifically for use in more complex cases. No one else seems to appreciate this breakthrough. Senior figures operating in the dark at NHS England do, though. They are already back pedalling on implementing the NICE guideline properly and doing their best to water down NICE’s PDA, or to bury it quietly.
At the same time there is a commitment to expand the psychological therapy workforce by creating 3000 more psychological therapists in 2023/4. You might imagine these two policies would be joined up – but then again, why do something so sensible when you are a senior NHS England leader, if a more complicated and difficult path presents itself? That way, when you inevitably fail to deliver any real change, instead of anyone asking questions about your competence (and 6-figure salary, plus pension), it will be mental illness that is ‘too complex’.
The next government, and its new health secretary and work and pensions secretary (almost certain to be Wes Streeting and Liz Kendall, respectively), will be inheriting a benefits bill that has now topped £100 billion, an increase of 20% since the pandemic, largely due to a rise in disability claims for depression. By 2028, if Liz Kendall is still in charge of welfare spending by then – the single biggest budget of any government department – she is going to have to find a projected £350 billion pounds to cover the benefits bill. This was a problem the solution to which, said Lord Layard in 2007, was IAPT. (I discuss this in detail in an article published in the International Journal of Applied Psychoanalysis in 2023). It is entirely predictable, as with the Rwanda policy, that Rishi Sunak chooses to demonise the claimants. Mental health is set to become an election issue. What is the solution that we are offering?
- Talking Therapies Task Force (TTTF) & Staff Wellbeing: winding up the projects
The TTTF project that Sue Mizen has led, which APPPS provided some of the funding for, is winding up this year. It has looked at the business case for offering psychotherapy to some of the highest cost patients in the mental health system. The Centre for Mental Health’s health economist analysed the costs and outcomes data. It owes its origins to Layard’s intervention in that instead of starting out at the preventive end of depression-as-a-disability, low-cost patients, TTTF looked from the other end of the telescope. If we offer psychotherapy to the highest-cost patients, is there a Layard-type invest-to-save business case for the NHS to buy?
A report is being finalised that will be launched this year, albeit any promises on mental health that may make it into final party election manifestoes will have been agreed already.
Also winding up is a staff wellbeing project, funded by the British Psychological Society, with myself and Dr Amra Rao co-leading. This equally owed inspiration from Layard’s intervention in that subjective wellbeing, as opposed to symptom remission, was the yardstick used to measure impact. Across government spending, the argument put forward by behavioural economists in the ‘Nudge Unit’ is that evidence-based interventions will show change in population wellbeing better than older measures, namely GDP (gross domestic product). So, using a simple theory of change, we tracked the subjective wellbeing of staff delivering NHS talking therapy services since the advent of IAPT. Our findings have been highly unwelcome.
Up here, the Peaks appear unchanged; permanent. As is my message to APPPS members.
Psychoanalysis must wake up. If not, it will meet the same fate as the sleepy brown trout!
