Some reflections on the recent IPSIG workshop : Developing CBT and building your business
One of the themes to emerge from the workshop presented by Sarah Rees and Heather Howard was the discomfort felt by many independent practitioners accepting that in order to make a reasonable living fees had to be not only set by the therapist but paid for by the patient. Omitting this central tenet makes what you do a charitable gesture and of course none of us attending were in a position to offer our services entirely for free thereby depriving Jacob Rees- Mogg of further uplift. Bright side.
Whilst the NHS flounders under the weight of increased demand and chronic underfunding it is clear that for many patients who’ve been let down or harmed by NHS mental health care provision the means to fund high quality CBT privately can be transforming and for some literally life- saving. Speaking to delegates the effects it seems on therapists choosing to leave an IAPT target driven culture for independent practice is not dissimilar. Nonetheless, many found themselves drawn to supplementing their income by contracting to work with pioneering digital therapy providers.
As someone who has worked in health care for nearly 40 years I have witnessed wave after wave of innovation and change in mental health care , desinstitutionalisation being the most radical. A brief history lesson via The Kings Fund reminds us of the factors that drove this revolution :
“There was a growing emphasis on human rights as well as advances in social science and philosophy critiquing psychiatry and the boundaries of what constituted mental illness, which reached its height in the 1950s and 60s. A series of scandals in the 1970s around ill-treatment of mental health patients and a strong, vocal service user movement provided harrowing stories of people’s experiences of care, which contributed to this critique. As one of our interviewees, who was involved in the process of hospital closure, noted: ‘The over-riding fundamental reason was that it was the right thing to do.’
However, the drive towards community and home based mental health treatments whilst well intentioned had unintended consequences. The lack of mental health beds being the most obvious. Instead of mental hospitals being located ‘around the bend’ more than 5,400 mental health patients had to travel out of area for a psychiatric bed last year. Figures obtained from 42 of England’s 56 NHS mental health trusts under the Freedom of Information Act revealed 5,411 patients were sent to out-of-area hospitals in 2015-16. One trust had to declare a major incident due to bed shortages”.
This spectacular throwing the baby out with the bath water surely provides a salutary lesson and it’s not a stretch to draw parallels between the seemingly unquestioning surrender of face to face therapy for the next big thing in mental health , digitally provided psychotherapy. The continuing expansion of digitally delivered CBT has attracted the attention of investors like Touchstone who recently announced £8 million investment in IESO Digital Health in an £18 million funding round clearly demonstrating the financial rewards of a good business plan . Clearly there are huge profits to be made although how much of this trickles down to the therapists who I understand from delegates earn £40 an hour remains to be seen. The company is currently going through an investment round to fund its ambitious growth plans, initially focused around further technological development, expansion in the UK and entry into the US market. According to Touchstone ,” The therapy has been clinically validated within the NHS across a range of conditions and has been shown to be comparable or better than face to face therapy”.
As IP’s we often struggle to think of ourselves as business people and there’s a reason for this. Most are single handed practitioners, ( a few have affiliates ) operating a very basic operational model where probably the most expensive monthly outgoing is room hire. Upscaling, maximising profit and market share are not the reasons why most IP’s practice independently . We will never be rich and unlike IESO will not attract so called business angels, wealthy entrepreneurs who provide capital in return for a proportion of company equity. I’ll eat my receipt book if any of us develop a therapy franchise opportunity that gets picked up by Dragons Den but if you’re interested in how it’s done check out these folk.
In the absence of plans for world domination peer group discussions focused more on the small scale business issues faced by IP’s i.e. whether to publish fee’s on websites, how to manage sliding scales, what to do about DNA’s , late cancellations and non-payment ,how to protect our income in the face of ill health and how to combat therapist isolation. The recent debacle the BBC found themselves in over the gender pay gap demonstrated just how illuminating it can be to have these conversations and it was interesting to hear about the variations in fee’s charged and how therapists calculated them. Sarah Rees who co-led the discussions wondered afterwards whether female therapists who significantly outnumbered our male colleagues on the day , were lacking in confidence in placing a value on their worth as clinicians and this was reflected in marked fee variations amongst the group.
Some delegates viewed providing digital therapy a useful addition to face to face delivery and it is easy to see the appeal of working within a system that provides you with an endless stream of clients, training and supervision and allows you to conduct therapy in your onesie. However, you are still working for the man and life as a worker ant will inevitably compromise your independence and creativity.
Delivering mental health care in this way is a world away from the approach investigated by Psychiatrist Alan Kellas who is tasked by the Royal College of Psychiatrists to develop nature based mental health care in an attempt to promote sustainable mental health. We are reminded that humans are animals whose disconnection from the natural world has harmful psychological effects. He advocates a move away from focused and directed interventions and towards the natural environment, exploring nature as a resource. The effects on well-being are profound. Attention changes, senses become heightened and deep memory is activated. These processes are important to restore sense of sanity and for mood regulation.
This approach could not be more different from computer delivered services and reminds us of our humanity. As IP’s we should strive to preserve physical embodiment in the therapy room and experiment with more creative ways of delivering CBT. If we don’t then CBT risks being parodied as a simplistic, manual driven intervention which alienates patients as depicted in the BBC Radio 4 afternoon play by Chris Entwistle aired on 21st September. You’ll need your toes straightened after listening.
So let’s remember the history. Wholesale dismantling of asylums a good thing. Insufficient in- patient beds not so much. Improving access to psychological therapies an excellent thing but promoting a false equivalency with face- to face therapy diminishes us. Digitally provided therapy is a behemoth that has huge potential for good but also the power to degrade human relationships. Face to face CBT delivered in a mechanistic, manualised fashion makes us ripe for parody . It may well fall to independent practitioners to preserve and protect a human touch . In this brave new world we should place a high value on that. It is, after all, the right thing to do.