There is always a delicate balance when presenting a public face as a counsellor. My personal politics, religious beliefs, life experiences tend to be irrelevant to the building of a therapeutic relationship. At the same time the supposedly blank sheet on which the client projects their emotions and insights is impossible. This blankness was in fact an assumption that the identities of the founders of therapy (white male cisgender hetrosexual) were not an influence on how they practised.
Not taking up space from the client is vital, however when writing my own thoughts and opinions will be made clear. Trying to negotiate this duality has meant that I have not written formally of my deep concerns about the attitude towards therapy, particularly within the NHS, however I feel I can remain silent no longer.
I am compelled to write at this time after reading the article in the Guardian, Is Mindfulness Making Us Ill? Along with many in the counselling profession I have been aware of how mindfulness is the new fad, and courses are springing up everywhere. These courses are often offered by unqualified “life coaches” or whichever title seems to be fashionable this week.
Triggers are real
The Guardian article starts with an exercise that frankly makes my jaw drop. The participants were asked to eat in public, and concentrate on the sounds, feelings and sensations of eating. As someone who practiced Zen buddhism for over 15 years this is the kind of exercise you would attempt after many sessions of mediation. It ignores totally the existence of eating disorders, misophonia, cultural attitudes around eating in public, anxieties that food can induce in many people. To begin with something so loaded with triggers as food indicated no understanding of mental health, meditation, or psychology.
Later in the article it mentions someone who found that mediation (these exercises are not mindfulness, but meditation, more of that later) resurfaced memories of childhood abuse, and they had to be hospitalised. Again a complete lack of professionalism, training and understanding of therapy is shown. As an integrative therapist I use various techniques, including Mindfulness, visualisation, and meditation for relaxation. It is a basic rule, perhaps the basic rule, that those who disassociate (and survivors of childhood abuse are highly likely to) may not find these suitable interventions. If they are used, it is done after discussion, with an awareness of the risks, and most importantly with ongoing support.
Meditation is not Mindfulness.
A common feature of the accounts in the Guardian article is that people are being told they are “doing mindfulness” when in fact they seem to be learning basic meditation techniques for relaxation. When I use mindfulness the discussion and explanation of why, what the intention is, and the blocks the client experiences, matter as much as the techniques. The point of mindfulness is to learn let go of thoughts, and to be aware of how thoughts can be in the driving seat. I use transport analogies quite a lot. Many people are aware of the experience of travelling between two places, and being unaware of every stage of the journey. When you struggle with anxiety or panic attacks being aware of the start of the journey can be incredibly useful. It is also very helpful for those with substance abuse issues. If you practice self awareness you are less likely to end up in the off licence buying alcohol. However this isnt an app you can just download or the result of learning how to meditate. Learning to identify your own triggers takes time, and the building of a therapeutic relationship.
The results for Mindfulness based CBT were for in person therapy sessions with a trained, qualified practitioner. I am unsurprised they were so positive. For me the biggest drawbacks of CBT are the promotion of the idea of logic and reason, when our emotions are so often illogical. When I explain the “letting go” of thoughts, I compare it to leaving the room when you are having an argument. CBT can encourage you to argue, to remain, (metaphorically) whilst Mindfulness is focused around removing the energy from the interaction, letting the thoughts go. Although as I write here, that’s also a feature of person centered counselling. This, combined with the “what’s the worst that can happen” line leaves many people feeling that CBT does not understand what it is to be a survivor of abuse, disabled, mentally ill or a whole host of other things. I have always suspected part of the reason NHS accountants like CBT is it works for those without complex issues, what some would call the worried well (although I am aware that term may seem disabilist to some). There does seem a lot of evidence that NHS provided CBT is popular as a quick fix with those for whom a quick fix works, a circular piece of reasoning if there ever was one.
Why is the NHS failing with talking therapies?
Towards the end of The Guardian piece issues are highlighted which many of us within the talking therapies are all to aware of. At some point, based on no research or evidence the NHS decided that 6 sessions of what it calls CBT would be offered to people with certain symptoms. As I discuss here, they ignored the need for qualified therapists and the limits of such a short number of sessions. Anecdotally I am aware of just how poor most peoples experience within the NHS IAPT services is. Whilst it may help some people, overwhelmingly I hear negative accounts. It is worrying, but unsurprising that the same people who refused to look at offering decent therapy for so long are now turning to a similarly bastardised form of Mindfulness. To quote from the Guardian
Mindfulness has also been adopted by the NHS, with many primary care trusts offering and recommending the practice in lieu of cognitive behavioural therapy (CBT). “It fits nicely with the Nutribullet-chugging, clean-eating crowd, because it doesn’t involve any tablets,” says Bethan, a mental health nurse working in east London. “My main problem with it is that it’s just another word for awareness
This is where I have to give my own views, which may be controversial to some. The piece goes on to discuss cost, and, frankly as an independent therapist in private practice I wonder if sessions are being conducted at the Ritz.
Part of the drive is simple cost-cutting. With NHS budgets squeezed, resource-intensive and diverse therapies that involve one-on-one consultations are far more expensive to dispense than online or group therapies such as mindfulness. A CBT course costs the NHS £950 per participant on average, while mindfulness-based cognitive therapy, because it’s delivered in a group, comes in at around £300 a person.
If a course of CBT is costing £950 then the NHS is burning money. I believe that currently the forms of talking therapies offered are about gatekeeping, not putting the patient/client first. For the £300 mentioned as a lower cost group solution a client could have ten one on one sessions with me. This is not an advert, I say this to highlight that money is being deliberately wasted, on ineffective counselling, offered by often poorly trained NHS staff. As an aside it also needs to be pointed out that group therapy work is highly skilled, and if managed badly can be exceptionally damaging.
In order to keep talking therapies “in house” and in order to enhance wage scales for its workers the NHS has invented a variety of courses, qualifications and hurdles which mimic the idea of competency. However all they qualify people for is competency in offering the ineffective, failing, model. Its a vicious circle which is letting service users down. Given this it is no surprise that another article out today shows a spike in mental health deaths. Some of the opinions expressed here may seem strong, but it is clear the current system is not working, and I fear that the NHS is going to try to paper over the cracks by replacing inadequate CBT with inadequate and dangerous mindfulness.