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INTRODUCTION
Cognitive analytic therapy and the politics of mental health
Julie Lloyd and Rachel Pollard
How far has cognitive analytic practice lived up to its initial radical agenda as restated by its founder, Anthony Ryle, in 2010? There is a tendency for radical ideas to drift towards the centre and sometimes even further and for previously radical discourses to become entangled with more conservative and authoritarian discourses (Parker, 1992). This could be seen as a measure of their success as values and beliefs once regarded as belonging to the left-wing radical fringes become accepted and even promoted by the mainstream. However, equally as dangerous, is the complacency and stagnation of the imagination that can follow when new ideas and progressive values become more widely accepted by and even embedded in conservative institutions.
Bringing politics out of the shadows
The relationship between the psychological and politics is troubled because from Freud onwards, psychotherapyâs main concern was the private sphere confined to what is going on inside peopleâs heads. For too long psychoanalysis and cognitive behavioural therapy (CBT) have located the causes of individual distress (and by implication the fault), in the mind of the suffering individual. As the various chapters in this book will show, what goes on âinside peopleâs headsâ is very much a function of what is going on in the world around them. Therefore, it is a delusion of great folly to imagine that whatever context we work in, what we do as therapists can ever be untainted by âpoliticsâ.
Therapists who claim to be outside politics are deluding themselves; even the most transitory human interactions take place in a political context, so therapists have to engage with the politics of the society in which they and their clients live. The pretence of non-engagement with these issues, is itself a political act of control that risks heaping sole responsibility on to our clients and their immediate families for their distress (see Figure 1.1).
These blockages collude with the neoliberal agenda that devolves all responsibility onto individuals and absolves the state and wider society from its mutual responsibility for the welfare of all its citizens. This leaves the social, political and material causes of poor mental health uninterrogated. Our engagement with peopleâs sufferings as therapists inevitably confronts us with political and social issues because the forces they are up against are structural, not individual.
The limits to therapeutic dialogue
A primary aim of psychotherapy is to facilitate and encourage the clientâs freedom to speak and/or express themselves in other ways, particularly facilitating what otherwise could not be expressed, could not be thought about or could not brought into consciousness and integrated. Constraints on what can be expressed too often come from the political and cultural context concerning issues beyond the clientâs control that render the therapistâs interpretations or techniques useless. Talking therapies that confine themselves to merely addressing the clientâs symptoms depoliticise pain from the outside by locating it inside.
The constraints on freedom of speech in the therapy room are echoed in the constraints that govern the politics of the provision of mental health services. When politics are barred from our formulations, we ignore the ways in which the inequalities that structure our society create misery and despair for so many people. In the UK, cuts to mental health services have eroded the space for freedom of speech and thought that psychotherapy potentially opens up. The alleviation of mental distress is no longer seen primarily as relief from suffering but as an economic problem to be âmanagedâ in the most cost-effective way.
The bio-medical model of mental ill health that informs government policies fails to address the actual causes of mental health in the circumstances of peopleâs lives, causes that are gaining increasing recognition in non-governmental organisations. This is a paradigm shift in that mental health concerns are reconceptualised as a human rights issue and the application of the bio-medical model, particularly the use of psychotropic medicines and nonconsensual treatments are seen as human rights violations. Nevertheless, the UN Special Rapporteur in 20171 notes that:
Neoliberal politics peddles the myth of individual autonomy and self-determination, discounting the privileges that the rich and powerful were born into as contributing to their âsuccessâ and blaming the poor and disadvantaged for their failure to gain a toehold on the ladder out of poverty and relative powerlessness. It peddles the myth that the causes of depression and anxiety are personal and attitudinal rather than socio-political. It peddles the myth that very brief âpsychologicalâ therapy that is linear, prescriptive and âdeliveredâ by minimally trained mental health workers is sufficient âtreatmentâ. It serves as a smokescreen for forcing people into poorly paid insecure jobs when in poor mental and/or physical health often leading to homelessness, even greater degrees of poverty and worsening mental and physical health. Children in families affected are then left to carry a burden of economic deprivation and social disadvantage into their adult lives.
This places a straitjacket on freedom of expression for both client and therapist. The therapistâs capacity to respond to clients as unique individuals has been severely compromised. Therapists are told to âdeliverâ a prescribed model of therapy and clients forced to tailor their âsymptomsâ according to the model of therapy being offered over which they have no or little choice. For many people, inhibitions due to anxieties and issues of trust are barriers to communication that take time to dismantle. For example, the survivors of trauma such as abuse, violence or torture, who risk finding themselves âdiagnosedâ in ways that are considered amenable to âtreatmentâ by the limited range of therapies available, or as not eligible for therapy at all.
The reductive aims in commissioning public mental health services and resultant crisis in lack of service provision inevitably isolates and marginalises people further, as public interest is conflated with narrowly defined authoritarian economic interests that favour the rich.
The politics of psychotherapy
In order to destigmatise the need for mental health services, we need to challenge what Samuels (2015) has referred to as a two-tier system in which those who can afford to pay for it have access to counselling and psychotherapy while the poor and less powerful have to make do with very brief manualised treatment if they are lucky. The Health and Social Care Act 2012 passed by the coalition of the Conservatives and Liberal Democrats is one of the most singularly damaging pieces of legislation of recent times that forced an increasingly fragmented and market-led internal structure on the NHS in the UK. Predatory private companies such as Virgin Care, who avoid tax in the UK, by 2018 held over ÂŁ2 billion worth of contracts and sued the cash-strapped NHS in Surrey when they lost a contract. The Private Finance Initiatives (PFIs) cost the NHS a further ÂŁ2 billion every year despite a large fall in NHS spending as a share of GDP (gross domestic product). Cuts in NHS and local authority social services have had a devastating impact on what help therapists in the NHS can offer.
Since CAT began to be more widely practised in the 1980s, the political landscape has changed: The âNew Labourâ governments of 1997, 2001 and 2005 advanced the neoliberal agenda of the Thatcher years, failing to address the housing shortage brought about by the sale of social housing, accelerating the privatisation of public services, failing to control the financial sector, pandering to the agenda of an expanding middle class and failing to represent the interests of the working class. During the same period, inequality became greater and as has been shown conclusively, the more unequal a society is the greater the extent of physical and mental ill health for everyone (Wilkinson, 2005). The politics of âausterityâ in which drastic cuts to public expenditure are made to âbalance the booksâ have further widened the gap between the privileged few and the majority who have seen their living standards and quality of life eroded. For those at the sharp end of the cuts it has led to the loss of their mental health and for some their lives due to increasing suicide rates (OâHara, 2017). Psychologists Against Austerity,2 have documented how government cuts have produced the psychological conditions for increasing rates of mental ill health while drastically reducing mental health provision relative to the need for it.
The economic context
(Fraser, 2017, p. 24)
State-managed capitalism, failed because of falling productivity â stagflation and because it promoted an androcentric model of social reproduction i.e. the bourgeois family and failed to draw on the labour potential of women and other minoritised groups (Fraser, 2017). The current neoliberal or global financialised capitalism is more pernicious in its effects on people and the environment. It is marked by higher levels of instability due to deregulation and as a result its internal contradictions are even starker. For example, while neoliberalism has been associated with a liberalisation of social attitudes in some countries, creating employment opportunities for a more diverse range of people as well as creating new consumerist demand, as Pankaj Mishra (2018, p. 18) points out, this has only benefited a few:
This contradiction is even more noticeable when considered on a global scale when liberalisation of social attitudes towards LGBTQ people, women and ethnic diversity in some parts of the world seem to be matched by regressive attitudes and policies in others, despite the tentacles of neoliberalism reaching into all but the most remote corners of the planet. It is clearly not in the interests of capital to alienate large numbers of the potential workforce as well as the consumers of its products.
A Social Reproduction Theory (SRT)3 approach would suggest that the policies of the current and recent governments in the UK have been peculiarly lacking in imaginative foresight when it comes to the welfare of the current and future workforce. The reduced availability of affordable quality childcare for working parents, the savage cuts in welfare benefits that have led to increasing levels of poverty for families with children, the failure of the state to address the housing crisis, the callous and often inhumane treatment of refugees are all examples of how the welfare of the current and future potential supply of labour is being vitiated. SRT regards the unpaid labour involved in reproducing and caring for the workforce as indivisible from labour in the monetary economy as the latter could not take place without the former. However even when this socially reproductive work is paid for it is undervalued, usually carried out by women and as levels of inequality widen both nationally and internationally outsourced to women from poorer households and poorer countries who increasingly staff our care homes and hospitals as well as caring for the children of wealthier families.
As mental health workers we are all involved in social reproduction in that our economic function is to restore people to the work place. The financial priorities of neoliberal capitalism mean that the satisfaction and individual fulfilment that mental health workers used to derive from their roles has been eroded, both due to the restrictive aspects of subordinating social and individual welfare to profits, alongside the deteriorating social conditions that adversely affect mental health in the population and the prospects for recovery. The dynamic non-linear processes that are involved in caring for and nurturing other people in hospitals, mental health clinics and care homes as well as schools and nurseries are now subject to meaningless attempts at economic quantification in a way that could be termed a reification of process by abstracting snapshots that have no meaning outside their given evolving context.
Many psychotherapists have lost their jobs in the NHS due to cuts in psychotherapy services and, despite government rhetoric about the importance of mental health, psychotherapy and counselling are extremely difficult for most people with mental health concerns to gain access to, unless they are able to pay for them. Those that remain are subjected to target driven âmicro-managementâ pushing them towards offering low cost brief therapies of 4â6 sessions or running psycho-educational groups. IAPT (the UK NHS front-line therapy service âIncreasing Access to Psycho...
