The Ghost in the Machine: IAPT and Organizational Melancholia

The introduction, funding and roll-out of the NHS's Improving Access to Psychological Therapies (IAPT) programme represents one of the biggest changes to mental health service provision ever seen in the UK. Drawing on Hinshelwood's (1994) notion that public mental health services may be regarded as a defence against overwhelming anxieties relating to psychological fragility and emotional distress, I explore the tendency for IAPT services to systematically disavow feelings of loss and vulnerability in both staff and patients. I propose three mechanisms by which this disavowal occurs: the promotion of a consumerist ethos and a ‘patient choice’ agenda; the deployment of discourses minimizing notions of fragility and dependence; and the proliferation of bureaucratic and surveillance systems aimed at continually monitoring and evaluating staff and clinical activity. Drawing on Freud's (1917) distinction between mourning and melancholia, I go on to argue that a sense of unconscious loss may come to be constitutive of the culture within IAPT services where the institutionally-sanctioned repudiation of containment cannot be spoken about, addressed or mourned. Through a short case example, I illustrate the way in which organizational melancholia may be hidden within the structures of an IAPT service and enacted by both staff and patients.