Interview with Mind CEO Paul Farmer

INTERVIEW WITH PAUL FARMER, CEO MIND, FRIDAY OCTOBER 23, 2009. STRATFORD

Janet: So, my question is to do with centralization – regulation is a form of centralization, state regulation is a form of state centralization – and in this case is having a negative distorting effect. I’d like to start here, because Mind, of all places, is set-up on a grass roots principle and has traditionally argued against crass generalizations, insisting instead on specific local detail, and on ‘keeping things real’.

Paul: Yes, I’ll start by saying how our organisation works. The Mind network, as you correctly say, is what’s called a federated structure. In charity terms we’re like the Citizens Advice Bureau, Samaritans, or RSPCA. We have in effect a ‘parent’ or central body, and the local organisations (each a separate registered charity) affiliate to us (also a separate registered charity). They are all self-governing organisations with their own Trustees. Its a good model for meeting the needs of people who experience mental distress; owned, in the charity sense, by their local stakeholders, by local people, for local people.

We, here in the central office, are an enabler of a network. We bring together a network of people, so they can better understand their experiences, and we use that to help inform our national role. We also help them share their experiences with each other, so it’s not just an up down feed, but also a cross feed. A local association will contact us saying ‘we are setting something up, has anyone else done that?’ and we’ll say ‘yes, Glossop have done it, go talk to them’. Keeping people talking to each other.

JL: So, that involves you running around a lot?

PF: Yes, it’s a key part of what I think I should do, and we have a team of people in LMA (Local Mind Association) services. Not a very big team, but we allocate as much as we can to that network.

The second area is that of Quality. We have a Quality Standards Framework. If an organisation is to become associated, it has to fit this framework. The system is in its second generation. The first generation was begun 5 years ago for a three-year period. We are now in version 2.0 of that structure (laughs). The basic principles behind that framework is not to replicate other regulatory environments but to make sure our organisations are well managed and well governed and that they provide good quality services to people, to their service users.

JL: Did you initiate this?

PF: No I came in half way through phase one.

JL: I’m interested in the rise of what is called ‘audit culture’ and this sounds very much a part of that. Was there a struggle when it began?

PF: I don’t know very much about how people received it, but I do know, having come in at the end, that the general sense coming from local associations is that they found it a positive experience. There were of course some aspects that they found difficult but they found that the process was an enabling one and led to general improvements in the work they were able to do.

JL: What did they find difficult?

PF: Like any system you have to ensure that the areas we put in place, the themes we put in place for people, really match the needs of those organisations. There were some aspects of providing support for people which some local organisations found difficult but others didn’t. We have such a varied network, and different orgs would have found different aspects differently challenging. In a sense our clear ambition is not to prescribe a common offer but to be clear and confident that the services that are provided by local organisations, are provided by people who understand what their responsibilities are. You then have to set up a framework they want to join - given that affiliation is a voluntary act, we don’t ask people to affiliate to us, they ask to affiliate to us. So we are keen to see that they are providing the best possible support for people.

JL: I’m interested by the way the language shifts from what local organisations do and how the network supports them, to what the organisations must do in order to join.

PF: There are environments, and providing mental health services is one of those environments, where there is a requirement on people who provide those services, to have frameworks in place.

JL: Is Mind a mental health service provider?

PF: We share a view that the individual experiences are important, that a community based approach is a good way to go. We have a whole variety of different ways and networks for people to engage with us. We are lucky, we have that local engagement. Local Mind associations don’t solely provide contracted services. Many do because that’s part of the landscape, but many of them also run wholly voluntary support. They provide places for people to gather, opportunities for people to do things, and to share experiences. The relationship that those individuals have with us is very helpful, and very, very important to us and to our whole ethos. Our mission is that people who experience mental distress drive everything that we do. User involvement and participation is the DNA of the organisation, or the words through the stick of rock. Pretty much everything we do is informed by that. Over two thirds of our Trustees and over half our staff are users of mental health services. It is also part of what we do in our day-to-day work.

We have a formal structure called Mind link: a network of people with direct experience. There is a formal link where a rep sits on our Trustee Board, and an informal link - a place to consult and understand what people would like us to do. In our campaigning and policy work, we have people constantly coming to us on a much more informal basis (because people want to) telling us about their experiences. Our aim is to have a multi-layered multi-factorial kind of approach. I’m sure it isn’t perfect, but we are grounded in the here and now experiences and their understanding of things in the past and of what they would like to see in the future. We don’t claim to speak on behalf of everybody but we can promise to be informed by those experiences.

JL: So how did you end up in favour of HPC as regulator?

PF: We’re in favour of a regulatory framework. Yes. We don’t particularly want to get involved in a discussion about the rights and wrongs of the HPC. Our interest in this starts from the position that over many, many years people who have been in and out of mental health services and not in it all have told us that the only option they were given was an anti-depressant and they felt it wasn’t what they wanted. There’s a backdrop of concern about the efficacy and side effects. Mind has been prominent playing a role in that agenda, because people wanted a choice, an options menu was important. When we ask people ask what kind of choice they want, they say ‘some kind of talking therapy’.

Over many years we’ve advocated an increase in access to psychological therapies.

JL: people are asking to be heard as subjects, not treated as objects.

PF: I’d put it in terms of equity. What they want is a framework of recovery dialogue. People generally want to be seen as an equal partner in care. Sometimes that’s about choice of medication, choice of therapy, or support from people. What they were also saying was that people wanted to feel safe, and safety is an issue powerfully articulated in the journey of mental health service users over generations. Many people experienced very unsafe conditions in the asylums, many people still do, sadly, in in-patient units. And, in this context people have also told us about unsafe experiences in therapy, in the NHS. Given the nature of our experience over a very long period of time, we have been campaigning for a better deal for people with mental distress both in favour of greater choice and less institutional care. It was also important that we reflected the concerns that people have about safety, so our twin message around ‘psychological therapies’ (I know it is a contested term, but I hope you won’t mind if I use it, its difficult to know what to call it otherwise) is that we would want to encourage an expansion of the availability of psychological therapies, and an expansion to people who couldn’t afford it, so they become entitled to receive it in an NHS context.

Secondly, in that environment, people have to be confident that the experience and the situation are conducted in a safe and appropriate environment. Therefore, in that context when we were thinking about the issue of regulation, I think we felt that it was important that from perspective of safety there was a framework for people to receive protection of a statutory regulatory framework. That’s how we arrived at our position, informed by strong messages about safety and increasing availability.
JL: what kind of information do you have about the rotten experiences that people had outside of the NHS?

PF: are you saying they did not exist?

JL. No, I understand there to be two different kinds of problem. One is a general enlightenment problem, which would be solved when people better understand the dynamics of power and love, and the other is a problem of, lets call them predators. This requires a different kind of response. How can we make use of the testimonies to better understand the nature of the problem we are confronted with, so we actually solve the problem.

PF: I wouldn’t necessarily want to go into detail. We hear a lot of people talk very positively about their experiences in therapy, very positively indeed. For many people it is their life-line. That’s why we have consistently advocated an increase in access to therapy. If we didn’t think that people fundamentally thought it helpful we wouldn’t advocate it. These documents are driven primarily by a desire to make that more accessible to people. It’s a key part of our ethos. If there is an approach that people find helpful, it’s that.

So, yes, we know that lots of people are very supportive of this counselling and psychotherapy. But, because we are the network we are, we also hear of experiences of abuse. When you hear about those experiences, you know they are very painful, and that it is very difficult for the individual to speak about it. These are not frequent experiences. The vast majority, and we’ve said this publicly many times, the vast majority of therapists are doing a perfectly good job and they are absolutely understanding of the appropriate boundaries they should use. BUT there are some people whose experiences are telling us that this is not the case. If you’ve got your two categories those are - in your language - the predators. They are few and far between but it is not in the interests of therapists (though this is not our concern) and it is not in the interests of those who could benefit from therapy, particularly in the NHS environment: it is not safe. Something has to be done. There are not many of them. But in an environment where the very nature is intense and exclusive – private – it is really important that there is a mechanism that enables individuals to be able to pursue their concerns about individual therapists.

JL: Yes, predators are a pest. But, one of the most difficult things to bear in this press towards regulation, is the obfuscation of the facts. Do you have any sensible straightforward information about these predators?

PF: No. But there’s a slightly circular problem. It is the regulatory framework that will generate that data.

JL: There is already much reason to question that assumption. What is needed at this stage is to be able to ‘touch the source of information’, to gain confidence in it, to be at ease with it, before setting up a hugely expensive and elaborate bureaucratic machine that could as easily exacerbate the problem (this is a point made both by Ken Pope and Daniel B Hogan). What happens at the moment, in the absence of sensible data, is that a Bogey Man appears, reason is obliterated and the bureaucratic machinery gains speed – it is an effect of the discourse of security.

PF: The evidence gathered is testimony. But because there are so many therapists delivering so many different kinds of therapy, all differently linked to different organisations, it is difficult to see how that can be easily sewn up, sorry, joined up (laughs). But you know, the way we shape our decisions is based on individual testimony. We take a broad view about what research would be, but we do have a basic view that if one therapist oversteps the mark it is one too many . That should be the starting point. Inevitably, there are thousands of people practising a variety of different modalities, and I think that there is a chance that sometimes a very, very small number of people will be overstepping the line, and so there should be a system to address that.

JL: So, is there anything we can say about the volunteer sections in Mind?

PF: It’s an important point to make. We are a provider. Local associations are, I think, running about 60-70 services across the country. They are differently structured. There’s a wide range of approach. This is sometimes to do with the locality, the nature of commissioning, or the nature of service. But quite a lot of people run counselling services, which are staffed by people undertaking training. A lot of people who are currently active as therapists, have found that a very helpful and valuable experience in their training. It is actually very difficult to find environments to get this kind of experience, and its great then that people who qualify have had a good experience at a local level with us at Mind.

In the context of a new framework, the local Mind associations, in the main, are quite used to operating in a regulatory framework. In fact they are used to operating in several regulatory frameworks [laughs]. If you’re in housing environment or other services, eg, dementia, they each have a set of frameworks, so for a local association the prospect of a regulatory framework is something that they are reasonably used to. So, I think they will respond to that and work with it. I do think, and this is the only thing I’m prepared to say about the HPC and their proposed regulatory framework, I do think that there is a need to ensure that the framework is not overly bureaucratic.
JL: In Mind’s experience of providing counselling, have you had difficulties to deal with between client and counsellor?

PF: the structure that we have is that local associations administer a complaints procedure, and we are a third party that might intervene in certain circumstances. I am not aware that we have intervened in a particular case. I’m not saying no-one ever complained about our service, but I’ve certainly seen evidence, testimony, about problems in other places.

JL: Thank you very much for your time.


Foot Notes

1 We Need to Talk, a report commissioned by 5 leading mental health charities to make the cause for greater access to psychological therapies on the NHS. ISBN 9781903645918
While We Are Waiting, experiences of waiting for and receiving psychological therapies in the NHS, by Emily Wooster, MIND July 2008

2 When I sent the transcript in for approval I mentioned that the structure of this argument, ‘if one x does something wrong, then all x must be controlled” is something that Mind usually has to struggle against (“if one schizophrenic abuses someone, then all schizophrenics must be put on a register and controlled more carefully”). The logic of the argument is pernicious, and trades on an impossible idealisation which effectively brings a sub-class into existence.