NHS therapy is a quick fix for the state – and the poorest patients lose out

The middle classes can pay to find the space they need to break down and recover from mental illness, but those on benefits are left with a system which puts sticky plasters on the gaping wounds of pain

The poorer you are in this country, the more difficult it is to access therapy – a space one can speak freely and in detail about mental breakdown. This discrimination, which is indexed to class and other structural inequalities, is getting worse.

In the past 10 years or so, the NHS has radically altered the way its therapy services are structured. The introduction of the Improving Access to Psychological Therapies (IAPT) scheme which, as we are told continuously, has offered therapy to more people than ever before. The focus on treatment for people with mild to moderate mental health problems is admirable. However, the emphasis on getting as many people through as possible often means that treatment benefits the state more than that of the individual.

The state wants one thing: to reduce mental health symptoms such as depression and anxiety as quickly as possible to get people back to work. For some people, the way IAPT focuses on educating people about the symptoms of depression, panic and so on works well. For others, however, the unrelenting focus on managing symptoms comes at the price of the time and space to collapse and to investigate the root causes of their malconent, such as the precarity of modern living, oppression and personal experiences of trauma.

This process gives the government dazzling figures to present itself as helping more and more people – which it needs to do with voters now seeing mental health as a voting priority. Yet these figures are also used to mask the effects of NHS cuts on people who suffer the most: those with severe or complex mental health problems, who are more likely to be on benefits, or who have suffered multiple disadvantages in life.

Where treatment in secondary or tertiary care is available, the emphasis is nearly always on therapy techniques that are based on carrot-and-stick principles of behavioural modification. For example, in an approach called Dialectical Behaviour Therapy, patients are generally required to attend "pre-commitment sessions" to ensure that they are "owning their diagnosis". What is missing here, again, is the space to explore who one is and why one has broken down. It means patients demanding to have space to speak about their lives are told it is a sign of their pathology, as opposed to a sign of a problem with our treatment models.

Those with class privilege can look elsewhere – mainly to the private sector – to find these spaces to collapse and to talk freely. While nearly all therapy training courses have low-cost therapy spaces, they are mainly available in big cities and priced at between £20 and £40. This, as a weekly expense, is unaffordable for most people in precarious gig economy jobs or on benefits, where a few quid can mean the difference between being able to eat or not. Thus we have a situation where the middle class and the very well off can access long-term therapy to process the chronic trauma of living in today’s world – bluntly, to deal with the s**t that has happened to you – but poorer people are left with a system which puts sticky plasters, replete with a drawn on happy face, on the gaping wounds of pain.

This is not to idealise the private therapy sector, which has its own problems, nor to demonise therapists in services like IAPT who do some amazing work often under relentless pressure from commissioners to see people quicker, faster and cheaper.

The point is that free speech is – as it always has been – dangerous for the establishment. Citizens who see themselves as ill, rather than oppressed, are so much more likely to accept an exhausted, precarious existence, to attack one another or to seek refuge in the bottle or needle rather than look at the operations of power in families and society and work together for change.

Dr Jay Watts is a consultant clinical psychologist and psychotherapist