Recent posts
Solomon. S, 2024, The Empty Seat, Reformulation 57, p.24-26
Saffia Solomon, Poverty Expert, Client with Lived Experience
The NHS, in its infancy, boasted an idealistic perspective of free and equal access to healthcare. 36 years after it was established, CAT was formalised, and Tony Ryle was founding the Caversham Centre, “described by the local bookie’s runner as the poor man’s ‘arley Street’” (ACAT, 2023).
I found myself pondering what Ryle’s perspective of our NHS Long Term Plan would have been, following his retirement in 1992. We’ve no doubt progressed into an era of embracing equity over equality, and NHS services have made huge efforts to provide suitable levels of support for those who need it, doing away with the idea that everyone thrives with the same level of resource. Ryle’s efforts to creatively integrate CAT into the NHS came with his intelligent understanding of the complexities of the lives of clients beyond relational difficulties. What he was getting at, was what we know to be the social determinants of health (SDH), namely, the ‘non-medical factors that influence health outcomes’ (WHO, 2023). What social determinants go some of the way to explaining, is that the conditions into which we are born, including our access to a supportive working environment, money, resource, and the area in which we live, govern our choices about our mental health, on a daily basis.
I was once subject to the musings of a therapist who had decided that stagnation in their client’s progress, was because of their perceptions of the world being ‘unfair.’ Of course, there’s argument to the perception that this could be a Trap, but with the knowledge we have about the stark mental health inequalities that people in poverty face, it’s probably no surprise to hear that children growing up in poverty, are more likely to be exposed to Adverse Childhood Experiences than their affluent peers. We’re four times more likely to have been excluded from school, three times more likely to suffer from mental health problems, and twice as likely to suffer violence with injury (Marmot et.al. 2020). To begin to understand the needs of clients, is to start with an empathetic understanding of the unfair reality they face.
What we know, is that Adverse Childhood Experiences are contributing to a rise in the number of clients presenting to the NHS’ mental health treatment services – but where do we make room for poverty, in our discussions around trauma? The effects of financial disadvantage and negative outcomes associated with social determinants of health are transgenerational, and our relationship with our caregivers and peers, during our formative years are governed by a scarcity mindset, disguised by society as ‘justifiable’ choices we had to make about the social world we live in. Deciding not to eat because you knew your parent wouldn’t, has transitioned to the nation’s new ‘Heat or Eat’ debate, but let’s not kid ourselves - these choices aren’t really choices. They’re unjust circumstance in our UK.
How can we testify that our therapeutic practice is as progressive as Ryle imagined it to be, if we fail to understand the depth and gravity of the lived experience of poverty that is affecting clients in today’s economic climate? It begs the question, about whether the NHS is actually free at the point of access, if clients can’t access it. I don’t just mean the bus fares, the taxi fares for those in rural poverty, or the poorly informed parking costs. I mean the multiple ways in which poverty is not only a part of the lived experience of the client, but it also informs the power differential experienced by their client when they’re in the chair.
Take for example, that there’s a parking meter of a hospital car park where I attended therapy, containing £25 of my hard earned money. It may not seem a lot, but that £25 was taken from a salary that so far, has amounted to an approximate figure of £19,000 less than my affluent peer in the same job roles over the course of seven years. I’m thankful that there aren’t two kids to feed at home, because £25 goes some of the way to a meal for three people, if we eat according to the recommendations of the NHS wellness plate.
Beyond the barrier of getting to your appointment, battling the elements in your borrowed coat, and hoping the kids are okay with the neighbour for the three hours you’re out of the house, you’re faced with the genuine recommendations made to you during therapy. Taking a walk in the countryside, using the gym, developing better sleep hygiene, and eating well, are all effective ways to better our long term mental health struggles, and we don’t doubt that they’ll work for those that can afford them. We nod politely, interject at the expected points, and agree that writing our reformulation letter is a good idea. The unspoken struggle, however, is the lack of paper at home with which to write upon, the financial cost of a gym membership, or thoughts of purchasing a first-hand mattress that isn’t 12 years old. Identifying alternative patterns of behaviour are easy to imagine, but harder to execute when the resources aren’t really there.
We hear your exasperation:
“…but, why would the client neglect the issue?”
“… but we contracted that the client can challenge any suggestion that doesn’t feel appropriate.”
“…but the client won’t get what they need unless they tell us their reality.”
The thing is, the psychosocial impacts of poverty compound the shame and inadequacy associated with the taboo subject of ‘lack of money’ (Chase and Walker, 2012). Continuous, careful re-contracting is of crucial importance to helping a client feel heard by their therapist, particularly when we bring a cultural understanding to the shame of poverty we see in the media. The stereotype of the British ‘stiff upper lip,’ will impact a client’s perception of care, particularly when we consider that clients in poverty are simply people in poverty, navigating social impacts to our health, who want to show you that they’ll work hard, listen, and trek that uphill journey with you to wellness (and if we tell you we can’t afford walking boots, or weather proof clothing, we sound like we’re making excuses).
This complex intersection of multiple disadvantage, needs space to be understood, not as a product of the client’s ‘choice’ to make their lives difficult, but as a product of the ‘postcode-at-birth-pot-luck’ society in which we live, and the discrimination we face as a result. Life isn’t fair, and within the context of poverty, we’re not complaining, we’re just stating a fact. A fact that needs to be acknowledged at a theoretical starting point to therapy for a client with lived experience of poverty.
I turned up for therapy, as challenging as the journey was, but when a client doesn’t show and you’re staring at their empty seat, the answer as to why it’s empty doesn’t always lie in the difficulties associated with the client’s effort, or forgetfulness. Sometimes, it’s that we couldn’t make it, because we waited for two buses in the rain that didn’t show. Sometimes, it’s that we couldn’t ask the neighbour for the taxi fare again. Sometimes, it was the lone-parent responsibility that meant the kids came first. Sometimes, it was the unsupportive boss threatening that your zero-hour contract would stay at zero if you didn’t take the shift. Sometimes, it was the idea that facing your anger at your relational connection (or lack, thereof) with the society around you and the privilege in it, with your white, middle-to-upper class, educated therapist, and the envy associated with it, was just too hard to bear. Whatever the reason, society’s expectation of the ‘undeserving poor’ has made it impossibly difficult to call ahead on your pay-as-you-go-phone and use your credit to explain the situation to a receptionist that will hopefully take your call, and after interrupting your explanation, simply scribble ‘Did Not Attend, no notice.’
Clients understand, without doubt, that therapists have the best of intentions, and genuinely want to support their client in their relationship with themselves, others, and the world. We’re fortunate to have the NHS, and we’re grateful for the opportunity that it provides to access the therapy we so justly deserve, but when we don’t have the resources to see us through our homework, and our scarcity mindset is governing our journey, we need you to understand that poverty is just as important as all the other intersectional factors that get in the way of effective therapy and successful relationships between therapist and client.
I haven’t the space to delve into the advantages of private therapy for those who are affluent, and have the agency therefore, to choose their therapist and their modality, race, gender, language, and location without a waiting list. What we can do for now in NHS services, is be more aware that access to transport, clarity of information, consideration over the nature of recommendations, and reflection upon the power differential for those in poverty who are yet to have poverty recognised as a protected characteristic, are all integral to supporting a client in poverty. If we time travelled back to Caversham Centre’s humble beginnings and told Ryle about the current reality of DNAs by those of us in poverty, we’re sure he’d be disheartened; that empty seat isn’t just costing the NHS, it's costing us, too, in more ways than you know.
About the author
Saffia Solomon is a previous client of CAT, Public Speaker, and Poverty Expert. She has lived experience of poverty, and uses this to empower personal and organisational change in others in Teaching, Coaching, Organisational Development and Service Improvement.
saffia.solomon@gmail.com
References
Association for Cognitive Analytic Therapy (ACAT) (2023) Dr Tony Ryle 1927 -2016, Available at: https://www.acat.me.uk/page/tonys+biography [Accessed: November 2023].
Chase, E. and Walker, R. (2012) The role of society in shaming people living in poverty: views and perceptions of the general public, Poverty, Shame, and Social Exclusion, pp. 1-21, Available at:https://www.spi.ox.ac.uk/sites/default/files/WP4PublicperceptionsUK.pdf [Accessed: November 2023].
Marmot, M., et al. (2020) Health Equity in England: The Marmot Review 10 Years On, Available at: https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on [Accessed: November 2023].
World Health Organisation (2023), Social Determinants of Health, Available at: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 [Accessed: November 2023].