The Social Impact of the Industrialisation of Mental Health Work
By Dr Elizabeth Cotton
There are some benefits of hitting a crisis in that difficult things become easier to think about and the spectres at the feast who have been critical of national mental health agendas find themselves increasingly amongst friends.
Those of a sociological persuasion are used to going to the dark side of working life. Although low on positive thinking, the critical space that we inhabit is increasingly of value in understanding and preparing for what is happening on the mental health frontline post Covid-19.
One of the realities that has come into focus for millions of people in 2020 are the consequences of reforms in the UK’s social security and mental health services and the growing policy link between these two services. A process of triangulation has taken place in the social security system and the health service such that two bilateral relationships – between the social security system and its clients and between mental health providers and patients – are being entangled in ways which threaten to instrumentalise mental health service.
One of the things that is less well understood is how the industrialisation of mental health work has driven this reform through the introduction of a diluted model of cognitive behavioural therapy (CBT) through the rolling out of the UK’s largest public mental health programme, Increased Access to Psychological Therapies (IAPT). The ‘evidence base’ for IAPT services has been established through the introduction of performance data and management techniques that have become highly contested within the sector. The gaming of performance data, both in the DWP and in the IAPT programme, disguises the frequent failure of the treatments involved and obscures the scale of recycling which puts patients and claimants repeatedly through the same, often oppressive, procedures. When 60 per cent of disability benefits are paid on the basis of mental illness, combined with IAPT's claims of 50 per cent recovery rates it explains why IAPT has such political traction in the age of austerity.
Increasingly mental health and disabilities campaigns argue that a model of productivity (Fervers, 2019) promoted within welfare systems combined with ‘wellbeing’ techniques can be understood as undermining the core principles of adequate care and promotes a system of “psycho-compulsion”. As the real impact of psychological interventions within the welfare system come to light (Peterie et al., 2019) and the consequences of inadequate services on suicide rates and self-harm start to be exposed the mental health crisis is now widely understood as a social one (Woods et al., 2019).
The co-option of mental health services by austerity has re-drawn the political line in mental health debates. No longer can we restrict ourselves to talking about mental health services as if they are simply-benign-needing-more-funding. Increasingly therapists are not considered the good guys and many activists do not see the NHS as a safe place for therapeutic work to take place. This also means that increasingly the ‘defend the NHS’ campaign strategy lacks political weight when neither the people using or delivering mental health services are prepared to fight to the last if it just keeps the IAPT juggernaut on the road.
Then Covid-19 happened and the whole mental health debate took a dramatic digital turn. Though this adoption of a manualized and downgraded model of therapy, digital providers are able to make a rapid redesign of what services people will be referred into. The rapid emergence of online platforms, online Employee Assistance Programmes, and digital providers will soon dominate the sector, with no challenge from the institutions of mental health. It means that understanding the future threats to quality services, and the potential for the emergence of ‘UberTherapy’ requires looking at the nature of services from industrial and political perspectives, not just clinical ones.
The sociological papers published in Work, Employment and Society (WES) referenced here — and free to download — lay some important ground in preparing for what lies ahead. They reflect some of the research mapping the precise relationship between labour processes and the impact on our states of mind (Woods et al., 2019). As well as the experience of unemployment and the brutal removal of choice and self-determination with the strategic use of compulsion and sanctions (Egdell & Beck, 2020).
An important paper is Deborah Foster’s The Health and well-being at work agenda: Good news for (Disabled) workers or just a Capital Idea? (2018). When I first read this I remember breathing deeply with relief that this challenge to the all-work-is-good principle behind much of welfare and work reform could now be articulated. A much needed humane and political perspective on resilience and wellbeing interventions challenging the fetishisation of techniques and their enlisting by employers and state precisely to individualise collective problems as ‘personal problems’ (Holmqvist, 2009).
The seminal work of Taylor et al. (2003) looking at the job design of call centres on health and safety is important reading for mental health workers navigating digital work not least because it underlines the consequences of low trade union density in protecting basic HSE rights. The particular risk factors of high involvement health work in a gig-like sector while negotiating digital performance and control mechanisms (Sutherland et al., 2020) leading to fatigue and stress (Boxall & Macky, 2014). Compounded by the expectation that many will work for free during their training and early careers, encouraging self-sacrifice and self-exploitation that is perversely tolerated within the caring professions (Baines, 2004). The analysis of staff of NHS Direct and their attempts to navigate systems of algorithmic control (Smith et al., 2008 ) is a warning of the threats to genuine care that we are now confronted with. Wood, Niven & Braekel’s 2016 paper underlines that it is the unfairness that really depresses mental health workers resulting in a cruel irony that the people helping us talk about our experiences are less likely to be able to talk about their own.
So what are the organising challenges for those of us invested in quality mental health services? One of the privileges of researching work is that we know that people can and do organise successfully in the most precarious environments – often self-organising, when their institutions fail to represent their interests (Pero, 2019). This is not principally an ideological response; it is one of necessity. To do this ordinary organising work requires us to challenge the systems within which we work and, maybe more importantly, our support of each other in doing that.
On the 8th October 10-12.30pm WES will be holding a discussion about the emerging political fault lines in the mental health debates in the UK. This session will look at experience of activists - both from service user and worker positions and look at the future of mental health.
The WES papers referenced are free to download:
Caring for nothing: work organization and unwaged labour in social services by Donna Baines
High-involvement work processes, work intensification and employee well-being by Peter Boxall and Keith Macky
A Capability Approach to Understand the Scarring Effects of Unemployment and Job Insecurity: Developing the Research Agenda by Valerie Egdell and Vanessa Beck
Healing or Deepening the Scars of Unemployment? The Impact of Activation Policies on Unemployed Workers by Lukas Fervers
The Health and Well-Being at Work Agenda: Good News for (Disabled) Workers or Just a Capital Idea? by Deborah Foster
Medicalization of unemployment: individualizing social issues as personal problems in the Swedish welfare state by Mikael Holmqvist
Indie Unions, Organizing and Labour Renewal: Learning from Precarious Migrant Workers by Davide Però
Emotional Compliance and Emotion as Resistance: Shame and Anger among the Long-Term Unemployed by Michelle Peterie, Gaby Ramia, Greg Marston, and Roger Patulny
Knowledge and the discourse of labour process transformation: nurses and the case of NHS Direct for England by Chris Smith, Raffaella Valsecchi, Frank Mueller, and Jonathan Gabe
Work Precarity and Gig Literacies in Online Freelancing by Will Sutherland, Mohammad Hossein Jarrahi, Michael Dunn, and Sarah Beth Nelson
‘A unique working environment’: health, sickness and absence management in UK call centres by Phil Taylor, Chris Baldry, Peter Bain, and Vaughan Ellis
Managerial abuse and the process of absence among mental health staff by Stephen Wood, Karen Niven, and Johan Braeken
Mental Illness, Social Suffering and Structural Antagonism in the Labour Process by Megan Woods, Rob Macklin, Sarah Dawkins, and Angela Martin
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