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The danger of pathologising

Over the past year and a half there has been increasing concern about how mental health services will cope with the expected tidal wave of referrals as a result of the COVID-19 pandemic. As a social worker and mental health officer in a joint mental health team, I already frequently hear anxiety about this: how will we screen all these referrals? How can we protect GP services from the pressure? Where can more resources be allocated within psychological services with time-limited input based on tight diagnostic criteria to guarantee throughput?

My instinct is that it’s not helpful to pathologise many of the understandable responses to the pandemic. These are, it seems to me, often natural, though clearly increased, levels of anxiety and fear following a very difficult period of sickness, death, loss and disruption.

Of course, for some, the distress may reach such levels that some kind of intervention is required. The pandemic has undoubtedly exacerbated already existing conditions such as OCD; some with conditions such as schizophrenia have felt an increased sense of isolation and loneliness without the social support and interaction that was their lifeline before the pandemic.

But for most, I would contend, what is needed is acceptance – to know that it is OK to feel worried, to feel anxious about what is and has happened, to grieve for those we have lost, for the difficult way they were lost, to feel perhaps survivor’s guilt, and to worry for the future.

I believe these emotions would be better managed via therapeutic interventions that help the person explore and accept their experiences. Rather than alarming headlines about a mental health crisis, leading to the kind of ‘gatekeeping’ conversations I hear, I believe a more balanced approach that provides a therapeutic support for those who are struggling with their experiences of the pandemic would be more helpful – something that normalises the feelings people have at the moment rather than pathologises them. This would allow clinical resources to focus on those who need them.

Ian Catterall MÏã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ

SCoPEd: refining the blunt instrument

Having recently attended a Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ listening workshop on SCoPEd, I feel frustrated. The panel repeated some well-rehearsed arguments, but several key issues were not adequately addressed. I am therefore writing to outline my particular concerns and to suggest a potential way forward.

Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ claims that SCoPEd is not creating a hierarchy, simply ‘mapping what exists’. I have no quarrel with identifying different types or lengths of training or specialisms so they are plain for all to see. But what currently exists is being mapped onto a three-tier system with higher status accorded to each successive tier. In my view, that is a hierarchy.

More worrying, however, is Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ’s admission that some competences in the highest tier are more relevant to service provision than to individual practice. We are reassured that this does not matter because practitioners can carry on using any competences in which they are proficient. But will clients realise this?

What Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ consistently fails to address is the impact the tier system may have on how the public views practitioners. It is naive to suggest that clients (private clients in particular) will not judge a practitioner by their tier (or title).

By randomly conflating competences in the highest tier, SCoPEd becomes a blunt instrument that belies the true capabilities of many therapists. This begs another question: if the SCoPEd hierarchy is adopted, will members have a say in whatever titles are eventually conferred? Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ’s position used to be that there is no clear difference between the practice of counselling and psychotherapy. After 20 years of working alongside practitioners with a range of qualifications and experience, I respectfully suggest that this is true. And yet, under SCoPEd, the position seems to be changing.

I fear I may be expected to use a title which doesn’t make clear the psychotherapeutic nature of the service I provide, unless I’m prepared to add competences to my skill set that have no direct bearing on my work.

There is a potential solution. Why not separate out specialist and service-related competences, and give this grouping an appropriate title? Therapists may include this with their primary title (in the same way that many practitioners refer to themselves as ‘psychotherapist and supervisor’), so that employers and commissioners can recognise these specialisms at a glance.

Do not, however, conflate these specialist, knowledge-based and service-related competences with the capacity to work at relational and psychotherapeutic depth. This association is highly misleading for members of the public, and could be damaging for many of Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ’s membership, the majority of whom are in some form of private practice.

I urge Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ to address this issue before SCoPEd goes any further.

Fiona Morrison MÏã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ (Accred)

White paper concerns

There is great concern about the recent Health and Care Bill and the Reforming the Mental Health Act white paper and their effect on the future of therapy and counselling.

While the aim of the Reforming the Mental Health Act white paper appears good in strengthening people’s rights, expanding and providing more culturally appropriate advocacy and offering treatment choice to patients, this is contradicted by the changes proposed in the Health and Care Bill. The new integrated care systems (ICS), which are similar to the old regional health authorities, threaten to further fragment, destabilise and privatise our NHS.

Private sector providers will be on decision-making boards, leading to loss of accountability and transparency and more of the type of cronyism witnessed during COVID. Private companies such as the US-based Centene are already running many NHS services and are keen to take many more ICS contracts. This could quite easily turn the NHS into a US Medicaid model. Private sector involvement in mental health to date has led to downgrading and reducing access to specialist therapies, diminishing choice for clients.

The Reforming the Mental Health Act white paper claims to tackle the racism inherent in the current Mental Health Act, but it is not abandoning the community treatment orders that are eight times as likely to be given to people of colour. Also, if alternatives to detention are to work, there needs to be genuine community support, much of which has deteriorated during the past 10 years of austerity.

In spite of its laudable goals, the white paper falls short of full human rights, remains strongly based on a medical model of mental distress/trauma, and fails to tackle multiple discrimination. In addition, the Health and Care Bill reforms will ensure further fragmentation and deterioration of all NHS services and psychological services in particular. Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ needs to oppose these proposals and work towards a more equitable therapeutic system that works for all in the UK.

Gavin Robinson MÏã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ (Accred) and Ruth Jones, Psychotherapy and Counselling Union NHS Campaign group

The case for volunteering

The charity I helped to set up 23 years ago, a Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ accredited service, has only survived by contributions made by volunteer and placement counsellors, alongside paid employees. Our clients pay what they can afford.

Our volunteers choose to offer their services for free as a contribution to their community, and only receive expenses. They work to the same professional guidelines as all others and make an invaluable contribution to the viability of the service. Placement counsellors usually join us with a level three qualification as a minimum and will mostly be working with clients for the first time. As with a surgeon, competency can only be achieved with practice. They are progressing towards Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ accreditation and can receive expenses until they achieve the qualification.

Having gained confidence through their experience in the service, some set up their own practices prior to becoming accredited and many of these say they could not have done this without the experience offered by the service. The service provides them with supervision, consulting rooms, insurance and administrative support at no charge, together with free in-house training opportunities.

This is the model that we have chosen to adopt and many of our clients would have had nowhere else to go for longer-term treatment. After completing a four-year advanced diploma in psychodynamic counselling in 1990, I did not regard myself as being a truly qualified counsellor until achieving Ïã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ accreditation a few years later, after many hours of practice. Clearly the criteria for qualification is contentious and perhaps this is an issue that SCoPEd is setting out to address.

David Lewis MÏã¸ÛÁùºÏ²Ê¾«×¼×ÊÁÏ (Accred), CEO, Compass Counselling (New Forest) Ltd