A report in The Psychologist several years ago asked the question,” Are mental health services inherently feminised?” out of a legitimate concern that if so, this is likely to be off-putting for men who are known to be less likely to seek help in the first place. Recommendations were made to increase gender awareness in the NHS with the aim of developing more gender-sensitive provision of mainstream services.
As important as this issue is I can’t help but think that an equally if not more critical question, is how on earth do we protect and support the women on whose labour these services depend. And at the risk of sounding shrill, “ Whose bloody fault is it anyway?”. Answer: The Patriarchy.
It is an established fact that people who tend to look after people tend to be women. Sorry about that. It’s our female brain. We are simply programmed full of empathy and an insatiable need to care for all and sundry. These areas Gina Rippon, (The Gendered Brain) points out, the gendered waters in which we swim. We are simply fulfilling our biological destiny.
Rippon reminds us that the female brain has historically been viewed as ‘wanting’ and that gender roles have been determined by the essence of innate and immutable structures and functions. For women, our value from birth has been linked to nurturing so it shouldn’t surprise us that the vast majority of staff providing care in England are female (around 70-85%) and that women also predominate in the immediate management of psychological services, with around 65 per cent of managers being women. This figure is also reflected in the NHS overall where women make up over three-quarters of all NHS staff.
However, when it comes to shaping NHS mental health services the boardrooms have a distinct male odour. Women are still in the minority in senior roles and are under-represented amongst the politicians, senior civil servants and commissioners instrumental in developing the service delivery structures under which the predominantly female handmaids toil.
And I say toil because we know that working in mental health care is not without its hazards. Findings from the British Psychological Society (BPS) and New Savoy staff wellbeing survey of more than 1,300 psychological professionals in the NHS in 2015 showed that 46% of psychological professionals surveyed reported depression, with 49.5% saying they felt a failure. One quarter considered they now have a long-term, chronic condition, and 70% said they find their jobs stressful.
“The overall picture is one of burnout, low morale and worrying levels of stress and depression in a key workforce that is responsible for improving the mental health of the public. The majority of respondents made negative comments about their work environment, with only 10% of comments being more positive:
Some of the complaints respondents made included:
- “Being target driven is the bane of our lives.”
- “IAPT [Improving Access to Psychological Therapies] is a politically-driven monster which does not cater for staff feedback/input in any way. All we are told is TARGETS!!! And work harder.”
- “It is invigorating to work in a team where thoughtfulness, understanding, support and compassion are central to what we do, not seen as an optional extra or a luxury.”
- “I am so disappointed I have just resigned.”
- “I carry my resignation in my diary now as I feel that I’m on the verge of giving up battling.”
The 2015 survey shows psychological therapists now have lower levels of job career satisfaction than other NHS staff, with poor employee engagement and loss of autonomy”.
And again it is women who are bearing the brunt. Data from the 2015 IAPT census shows that the workforce is predominantly female (79%) White British (83%) and relatively young (66%<46 years old). As you’d expect from a public service caring role the pay is not great. A PWP’s salary starts at approx £20,000. After qualification, this goes up to £23,000 progressing one pay point annually until you reach £29,000 (top of the scale). The Joseph Rowntree Foundation states that a single person needs to earn £18,400 pa to maintain a minimum standard of living. Even if you reach the top of the scale you’ll fall far short of The Office of National Statistics (ONS) provisional update of the UK Average Salary 2019, showing that the average full-time salary is £36,611.
So poor pay and challenging work conditions where workers are encouraged to employ “self-help” when the going gets tough would I imagine characterise pretty much every public sector job where women are over-represented from nursing to primary school teaching, to social work. Men who have over-identified with the masculine gender stereotypes of strength , toughness and domination choose not to self-select into jobs that seem to require a ‘woman’s’ touch’ even if, in the current work climate, these female-dominated fields may offer more employment stability and where white men especially, cash in as they are paid more and promoted faster than women, a phenomenon known as the glass escalator.
In a gendered world that for hundreds of years has treated the sexes differently, there is clearly a colossal amount of work to be done to dismantle gender stereotypes before attitudes change and we see more men entering the caring professions. Furthermore, the attitudes and beliefs, policy changes and financial investment needed to make these roles less feminised is unlikely to happen with fewer women holding positions of power and influence and also not least because there will be many people ideologically wedded to maintaining the status quo.
Politicians around the world view gender ideology as a” threat to the fundamentally different and “natural” roles that women and men play in society”. In Hungary students entering University, this year will no longer be able to take courses in gender studies, the Brazilian President has called for a ban on ‘gender ideology in elementary schools, in Poland the government has banned gender and gay and lesbian studies and in America, hostile sexism is flourishing under Trump.
Back home we are still struggling to reconcile the many inequalities experienced by women and black women in particular. The planned exodus of female MP’s after the next general election who simply cannot tolerate the abuse they are subject to anymore is seriously alarming.
So what can women working in mental health care services do to protect themselves? In her book “Rage Becomes Her “, Soraya Chemaly explains the difference between self-help and self-efficacy, “ Self-help , different from self- efficacy is frequently what you do when you aren’t getting the help you need from your society. We cannot self-help our way to being heard, taken seriously, paid fairly, cared for adequately or treated with dignity”.
I was reminded of this by a recent thread on my twitter feed which powerfully illustrated the point. The tweets stabbed me right in the heart and brought back all the feelings of despair and frustration I felt after deciding to leave the NHS after 20 years service. Back then I didn’t quite know what to do with my anger and reckoned resigning was the only available solution that didn’t involve a police record. I recall crying with a colleague after a particularly frustrating team meeting where I had been pressured to take on extra patients when my caseload was already overflowing. She well meaningly wondered whether I might be depressed? “No, I’m just fucking angry and you asking me if I’m depressed is making me even angrier,” I replied.
Back then there was no social media and it was harder to tap into and cultivate a sense of connection and community. I felt isolated in my distress and was advised on more than one occasion that my habit of raising concerns at team meetings was demoralising for everyone else. These days women are driving the social media revolution providing a platform for a diversity of voices from all around the world. They understand the risks of verbalising their anger in an professional setting, an automatic red card gender norms violation for non-white women but are prepared to do it anyway. That’s why the two young women on my feed posting tweets about working in IAPT stood out.
“It’s Tuesday but it feels like Thursday. My PWP days are coming to an end. I am so burnt out that I don’t know what it’s like to not be burnt out. And before the advice comes, I am extremely organised and do all the self care I can. I just have a tough job.” @Whitnexxi
“I just had such a great evening of clinical work. I did my best to ensure my patients felt heard. I normalised their symptoms, I really truly empathised. I wish I could hold onto this feeling- the reason I went into this field- in these moments of despair and exhaustion”. @sheevsb
To hear these accounts echo the exact same experiences I had over 20 years ago from the current generation of mental health workers was heart breaking and infuriating . I wondered whether IAPT founders Richard Layard and David Clark had ever imagined the toll this well intentioned service would eventually take on those trying to realise their vision and in my rage wondered whether they actually cared ?
When David Clark was challenged about the issue of therapist burnout in CBT Today he acknowledged that written plans for supporting staff wellbeing were not universal and was of serious concern. He pointed members to the 78 page IAPT manual which outlines quality standards and encouraged them to use it to facilitate collaborative discussions to raise awareness of the quality standards. Helpful up to a point but I didn’t find anything in the appendices that directly addressed what to do when these discussions fall on deaf ears. What was much less helpful was a statement accompanying his response on behalf of BABCP which advised readers that, “No further correspondence on this will be entered into”. This heavy handed, tone deaf message regrettably sounded an awful lot like , “Shut up now and go away”.
With regard to emphasising the fact that decision making at the highest levels is typically male dominated it’s worth pointing out that Lord Layard has named several others as having helped gain the initial political traction for the IAPT initiative – MP Ed Miliband, psychiatrist Louis Appleby (then National Director for Mental Health), David Halpern (psychologist), psychiatrist David Nutt, MP Alan Millburn and eventually the PM Gordon Brown.
So, if women are to survive mental health care work they need to find ways to be seen, heard and taken seriously. Many women are acutely aware of feeling stressed tearful, frustrated and angry but are also hampered by gendered ideas about anger. These ideas cause us to,” question ourselves, doubt our feelings, set aside our needs and renounce our capacity for moral conviction. Ignoring anger makes us careless with ourselves and allows society to be careless with us. Treating women’s anger and pain in these ways makes it easier to exploit us – for reproduction, labour, sex and ideology”. (Chemaly)
If this feels like you then MP Jess Phillips in ‘Truth to Power’ gives straightforward, no-nonsense counsel by saying, “If something doesn’t sit right, it probably isn’t right” whilst Audre Lorde reminds us that “ our feelings are our most genuine paths to knowledge”.
Phillips warns that the powerful will seek to shut down a crisis as quickly as possible with those speaking truth to power being discredited or blamed for their plight. The recent despicable comments by Leader of the House , Jacob Rees- Mogg regarding the Grenfell victims is a particularly ugly example of this .
However, persistence, activation and solidarity together with collective action is transformative and whilst anger if misdirected can be destructive it is loaded with energy and information which can help people find solutions to the problems they face.
I am entering the final chapters of a career in health care spanning over forty years. It has taken me a while to cotton on to the weight of emotional burdens I have been carrying since childhood. They’ve not all made me angry, some have been and continue to be an utter delight but they have at times been heavy. Here is my non-exhaustive list:
- Managing and worrying about the effect of a government decision in the name of pension equality, to push back my pensionable age to 67 without giving me and almost 4 million other women time to make the necessary financial provision.
- Caring for sick elderly parents who were unable to care for me
- Supporting a chronically ill partner
- Providing emotional support for my adult children (who are doing just fine by the way )but it never really ends.
- Managing a full-time private practice
- Volunteering for my professional organisation (20 years racked up so far )
- Supporting my local political party in the run-up to the general election
- Supervising colleagues
- Reassuring friends that I really do care
- Managing the seemingly endless symptom smorgasbord of a post-menopausal body
- Doing pretty much all the Christmas shopping
- Doing 70% of the housework
I wonder if you’ve stopped to think how much you are currently carrying and how much lighter the load for those who have others to do the carrying for them.
In the Ken Loach film, “Sorry We Missed You “ there is a scene at the end where Abbie a professional carer, wife and mother turns herself inside out trying to stop her family from fracturing under the weight of the effects of austerity. Mild-mannered, kind, tolerant, gentle, patient, nurturing and calm throughout she eventually breaks and ends up swearing in a crowded A&E department. She‘s thoroughly mortified and just keeps repeating, “ I don’t usually swear, I care for people”. You seriously fear for the family’s future if Abbie becomes permanently unmoored.
The celebrated feminist, writer and social-political activist Gloria Steinem recently wrote,” I think it takes us a while to experience the ways in which women are treated, and that radicalises us as we age”. She’s really not wrong but my message to younger female colleagues is please, please don’t be like Abbie. It’s really not your job to defeminise mental health services. You’ve got enough on your plate.
Focus instead on tuning in to your anger and what you’re angry about. I‘ve never worked in an IAPT service but I know that my colleagues, my sisters are suffering an injustice. I am following Rebecca Traister’s advice when she says,” Don’t forget them, don’t write off their anger. Stay mad for them. Stay mad with them. They’re right to be mad and you’re right to be mad alongside them”. ( Good and Mad The Revolutionary Power of Women’s Anger).
And I am.
Thanks to @whitnexxi and @sheevsb for lighting the blue touch paper.