Editorial

Lloyd, J. and Pollard, R., 2012. Editorial. Reformulation, Winter, pp.3-4.


The theme of this issue is the future of CAT and mental health services in the NHS. Fears for the future of CAT have been addressed previously in Reformulation (36, 2011) by Yvonne Waft when she observed how political criteria were taking precedence over clinical need in the targets set by Foundation Trusts; at times, she even heard clients being referred to as ‘product lines’ and the provision of services as ‘business developments’. With the Social Care Act becoming law in March 2012, the concerns she expressed have intensified as Primary Care Trusts subject to national oversight are replaced by ‘commissioning consortia’ accountable only to sections of local populations. The Act is widely regarded both by those in favour of it and those against it as the biggest reorganization of the NHS since it was founded. A legal analysis of the Bill concluded that once it became law the national duty to provide a comprehensive health service to the population as a whole would be lost and along with it accountability through the ballot box.[1] The Act has also been subject to stringent criticism by the BMA, not least because it will lead to far greater inequalities in health care as commissioning bodies exercise their own discretion as to what health care needs they are prepared to pay for.

As editors we have been both encouraged and alarmed by the response of ACAT members to our email asking for contributions – encouraged by the varied, informative and thoughtful articles on the NHS that are in this issue but alarmed by the highly distressing experiences described by others who contacted us, who felt that is was unsafe to speak or write publicly about what was happening in their Trusts for fear of intimidation or even victimization by their employers. Tony Ryle’s response was:

The present threats are not provoked by the wish to remedy problems in the service but by the malignant ideology of the Conservative government. There is no evidence in any NHS field of any service being improved by making it commercial---the need to make a profit can only stand in the way of supporting clinical staff in their provision of good care.

It was in a spirit of feeling angry not only about the damage that is being done to the NHS but the wider attacks on the welfare state, both its employees and the people it serves that we went on the TUC march in London on 29th October. Whilst it was cheering to participate in collective action infused with a ‘carnival’ spirit, the immediate future for mental health services and the role of CAT within them looks bleak and uncertain.

Robyn Vesey’s article offers a comprehensive overview of the Social Care Act with a considered analysis of how this could affect services in the future, drawing attention to how the fragmentation of health care provision will inevitably lead to variation in the range and standards of provision across different services and therefore greater uncertainty. She also shares with us her own personal experience and reactions to the changes that are happening around her, illustrating how clinicians are being increasingly required to contain not only the distress of their patients but the emotional fall out from a neo-liberal management ethos in which the welfare of staff and service users is subordinated to profit. Mark and Sophia Dunn’s article examines how CAT, as a relational therapy in the NHS, is suffering as part of a wider devaluing of relationships in society as a whole, in a culture where market forces predominate and people are dehumanized, sometimes with devastating consequences. Lawrence Welsh’s article describes how self- serving political and business interests have shaped the Social Care Act, despite having no democratic mandate to do so and how increasingly authoritarian target driven management affects us all at the ‘micro’ level of internalized RRPs. We were both moved by an anonymous (the author’s identity is known to the editors) contribution in the form of a reformulation letter to the NHS. The letter reminds us that the crisis in the NHS is not just a professional issue for us but a profoundly personal one as well as, like the majority of the population, we face the existential anxieties of living in a world in which the familiar, benign and containing structures of universal welfare are being broken up and replaced by the indifferent forces of the market.

The relational theme is taken up, from another perspective, by Elly Colomb and Julie Lloyd who describe how crucial the quality of the human interaction is to a successful outcome even when the concern being addressed is a physical rather than a mental health issue. In doing so they illustrate some of the versatile uses of CAT that could be lost in the imminent cuts to Learning Disability Services. Aoife Pettit describes how a creative use of the six-part story could be developed and adapted for use in LD services, giving a voice to people who are being bullied and might otherwise find it difficult to be heard.

Again, the fear is that there will be no place for developing imaginative ways of working such as this in the NHS of the future.

Jason Hepple’s and Barbara Williams’ contributions are both examples of the original, thoughtful and highly skilled ways in which experienced CAT psychotherapists work as therapists and supervisors, integrating a rich diversity of talent and knowledge from other areas into their CAT understanding of the complexity of human intra and inter personal relationships. It is hard to see how invaluable therapeutic work like this, that does not lend itself to easy categorization, will be accommodated in the mental health services of the future. Barbara William’s article sensitively explores what ‘wounded healers’ can offer and gain from collaborative therapy and invites readers’ acknowledgement, recognition and dialogue. However, if the success of healthcare were to be judged by arbitrary, profit lead accounting systems, paymasters would perpetuate the silence, dismissing this type of reflection as at best irrelevant and at worst not selling the right corporate image.

At the present time, the prognosis for the future of CAT as part of a vibrant and creative mental health service in the NHS could look profoundly gloomy but it is important that we do not allow demoralization and despondency to overwhelm us:- Lawrence Welsh argues that understanding how the macro economic forces that drive management have shaped our own internalized RRPs can help to facilitate an ‘adult to adult’ dialogue with managers and commissioners and lead to democratic resistance, whilst Robyn Vesey stresses the importance of solidarity and collaboration with other workers faced with similar complex work environments. It is important not to give up; as Nye Bevan said The NHS will last as long as there are folk left with the faith to fight for it.

The theme of the next issue of Reformulation will be on Ethics in keeping with the theme of next year’s conference in March. We hope that those giving presentations will consider writing an article or reflection on their work and, of course, we welcome contributions on this or other issues from everyone in ACAT.

[1] Stephen Wragg, Doughty Chambers (2011)

Full Reference

Lloyd, J. and Pollard, R., 2012. Editorial. Reformulation, Winter, pp.3-4.

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