The big issue: Learnings from lockdown
Therapy Today, June 2020

Leading up to lockdown, therapists emptied their therapy rooms without knowing when they might return to work. Files and data were transferred as people shifted themselves and their systems to spare rooms and home offices across the country. Clients were notified that therapy would now be delivered virtually and the most vulnerable prioritised as many of us stepped into the unknown. Waiting to welcome us into the world of online work were the training providers, ready to help an army of new recruits to become good enough to hold their clients through life in lockdown and the threat of Covid-19.

While our physical worlds shrank, our need for connection grew. If, before the pandemic, we had a love-hate relationship with our screens, suddenly they became essential in ways that would once have been unimaginable. One therapist said: ‘A few weeks ago the idea of doing EMDR trauma therapy via Zoom was unthinkable. Now it’s routine.’ Another said: ‘I think, as a profession, we’ve been so open to learning new skills to help our clients and I’ve been overwhelmed by the generosity of practitioners sharing their skills on webinars.’

‘Unprecedented’ is a word that’s been used repeatedly to describe the deadly virus but, according to Jelena Watkins, a psychosynthesis psychotherapist who specialises in disaster mental health, this outpouring of collaboration and community is to be expected in the early phase of a crisis. ‘There is so much that we can learn from previous collective traumas to help us both to understand our early responses to the pandemic and to prepare for what will be required of the therapy profession in the future,’ she says. So, three months on, what has our profession learned?

The rush to help

As a profession of helpers, therapists were drawn to offer support for people affected by the pandemic. Media reports of the loss and suffering, people losing their jobs and living in isolation, and of exhausted front-line workers, often included the prediction that a mental health epidemic was coming our way. Louise Chunn of the therapy directory site Welldoing.org recalls the response from therapists after the Grenfell fire and was not surprised that therapists have rushed to offer help again.

‘We were all hearing reports on the news about the pressure on NHS front-line staff and it was so shocking. Of course, therapists who understand trauma wanted to help,’ she says. ‘A couple of therapists asked us whether we were going to support the NHS workers. So we did some research, and the majority of that group said they would be interested in volunteering.’

More than 250 therapists signed up to volunteer by ticking a box on the Welldoing.org site. Chunn stresses that it’s important that ‘each therapist decides how much or how little they can give and negotiates this with the client – it could be an hour or two’.

There have also been requests from a flurry of organisations for therapists to volunteer their services for free, all offering access to ‘accredited therapists’ for NHS front-line workers and signposted on the NHS Practitioner Health website.¹ They include Project5, Harley Therapy, The Relational School, Duty to Care, Frontline19 and Heather Wellbeing. Some are business start-ups that come with a crowdfunding campaign and a request for the public to donate, along with liberal use of the NHS logo on their website.

But while it is right that our profession plays a central role in providing mental health support during this crisis, is it right that we offer our services for free? ‘I understand that counsellors want to help in a crisis, but colleagues who are already working in the NHS or via EAPs are being paid, quite rightly,’ says Sharon McCormick, Clinical Director at The Listening Centre, an EAP based in the Midlands. ‘When there are counsellors volunteering their services for free, I feel it’s sabotaging our own profession. We are inadvertently eating ourselves from the inside.’

At the start of lockdown, BACP released a statement saying: ‘As a profession, we believe we would be in a much better place to support anyone who needs our services if our members and the services they offer are financially stable. It is vital that therapists are paid for their work.’² BACP is also calling on the UK Government to ensure there is a workforce to deliver the comprehensive mental health response to the Covid-19 crisis.

This is where our energy is needed, says Watkins. ‘Covid-19 is going to be a long haul. There’s a danger that, in the rush to help now, the help won’t be there when it’s really needed,’ she says. ‘This is the time when the profession needs to mobilise and make the case for funding.’

Help or hindrance?

It’s not surprising we feel compelled to do something when we hear that NHS and care staff are ‘breaking down’, as recently reported by Labour’s shadow health minister, Dr Rosena Allin-Khan, who has returned to her role as an A&E doctor during the pandemic.³ ‘I see it first-hand, working shifts. It is simply heartbreaking to see the toll this virus is taking on our front-line staff,’ she says. ‘There’s the fear of spreading the virus to patients and loved ones, the lack of PPE, the increased workload owing to the number of cases and staff absences, redeployment to ICUs and witnessing more patients die – staff are experiencing greater pressure, which is inevitably taking its toll on their mental health.’

But providing counselling to these staff is more complex than simply setting up a service and saying, ‘We have qualified therapists ready to work for free’, as a therapist with more than 14 years’ experience in the NHS explains. ‘My role is to co-ordinate the psychological support for staff in our NHS trust and we have been absolutely overwhelmed with voluntary offers of support. But as an employer, every NHS trust has a duty of care, due diligence and governance, not to mention recruiting procedures to ensure that anyone working with NHS staff is appropriately qualified, registered and trained to meet the needs of the staff in the current climate.

We already have a team of paid counsellors employed to meet those needs and a bank of counsellors who I can call on. Arrangements are in place for enhanced provision of counsellors, EAP access, a chaplaincy team, health psychologists and trauma risk management (TRiM) practitioners to support individuals, managers and teams alongside the free to NHS staff apps.’

This is what good employee support looks like and it’s not unusual in the NHS. But if you don’t work in this area, there is no reason why you would know, so it’s understandable that the offers of free therapy to front-line workers have rushed in. The result for many has been frustration that their services have not been called on. Chunn says, ‘There has not been a massive uptake yet; we are still in the NHS approval queue.’

In the long term, it remains to be seen whether the newly formed free services prove to be a threat to paid counsellors. Barry McInnes, a BACP-accredited private practitioner, wonders if we are already seeing the impact. ‘It seems that most of us who take EAP referrals have noticed it’s gone awfully quiet,’ he says. ‘I wonder about the extent to which newer organisations that have sprung up offering free counselling or “wellbeing support” have a part in this.’

It’s a complex issue and some argue that offering free support may ultimately help our profession by giving people who would perhaps have never considered therapy a (hopefully) positive experience of it. And does it show us acting and responding to the pandemic in a way the public can understand?

Sue Monckton-Rickett thinks so. She is Chair of the Association of Christian Counsellors, which has set up a Covid-19 crisis counselling support service to offer NHS front-line workers and those bereaved during the pandemic up to 10 free counselling sessions, provided pro bono by registered counsellors. ‘Not everyone wishes to access workplace schemes,’ she says. ‘Those in contracted ancillary or agency roles in the NHS may be outside of employee provision and many NHS staff and the bereaved will not have the financial resources to secure private help. Even in “normal times”, local services such as IAPT have long waiting lists and target only certain conditions.

‘We felt that the degree of suffering for some people impacted in these ways by Covid-19 is likely to be so intense that we wanted to offer an uncomplicated and timely way of getting professional support as a humanitarian act and as part of our identity as a Christian organisation. We also see offering our services in this way as an opportunity to raise awareness about the vital role that counselling plays in the mental health of our nation not just in crisis, but also in the long-term.’

Referrals and EAP work

Free counselling aside, there have also been reports of practitioners being offered lower rates of pay by EAPs for telephone or online work, resulting in some losing up to 75% of their projected income.⁴ Kris Ambler, BACP’s Workforce Lead, took up this issue on behalf of members. One company, Health Assured, announced it would pay the in-person rate for telephone and video counselling, recognising the situation as out of the therapists’ control. But not every EAP provider has followed suit and therapists are still being offered as little as £20 a session for telephone work. As any therapist who is working remotely will attest, remote working can be harder work than in-person counselling. Many of us have also invested time and money to get trained up quickly to work this way.

Practitioners who coach have also suffered, with many seeing their work cut or suspended since lockdown. Michèle Down, an executive coach who works exclusively within organisations, says that her coaching and training work was suspended at the start of lockdown. She has chosen to work pro bono with existing clients out of a duty of care, and has extended this to others too, until budgets restart. ‘Some clients have offered to pay, some said they’d like to donate to a charity and others have just expressed their thanks for the ongoing support,’ she says.

In theory, there may be an increased demand for coaching after lockdown as companies help employees transition back to working in physical teams again. But, like therapy, coaching and training are often seen as a luxury that can be cut when times are lean, even though they are intrinsic to the health of any working environment.

The future is also uncertain for therapists in private practice, with many reporting a significant downturn in new client enquiries, perhaps reflecting the economic uncertainty that the country as a whole is facing. In the long-term, counsellors without an established practice, an organisational component to their work or a varied portfolio may well struggle. One counsellor in practice for more than 10 years said: ‘My finances have always been insecure, and each year I wonder if I will be able to continue but this year particularly so.’

Opportunities

Much has been written about the predicted impact on the nation’s mental health because of the financial insecurity,⁵ and anyone who was in practice during the 2008 crash will know from experience that it can be deep and far-reaching. If we are to be part of the solution, we must be vocal about people getting access to the therapy they need. Yet the threat we face from the economic downturn is real – organisations make cuts to non-essentials in recessions, including counselling, and services provided by charities often struggle to keep going. So it’s not just our clients who will suffer. Could a further reduction in paid employment for counsellors mean more of us working in private practice, competing for a smaller number of paying clients?

Ambler urges therapists to keep an eye on what is happening at a local level. ‘I’m seeing that there are commercial opportunities for therapists now right across the UK,’ he says. ‘Constraints have been lifted on local authority commissioners and there is now money to be spent on mental health support because of Covid-19.’

Rachel Walker, a therapist in West Cumbria, says that, while her private practice has all but stopped, her work with a local domestic abuse charity has increased. Vicky Pike is her manager at West Cumbria Domestic Violence Support, which offers long-term counselling for victims, children and perpetrators of domestic abuse. ‘The calls to our helpline were up by eight per cent during lockdown and we had 89 on our counselling waiting list, which was really worrying,’ she says. Pike applied for two grants and received £20,000.

‘It’s been amazing, because we get a phone call from someone needing help and we can connect them with a counsellor and they don’t have to wait. They shouldn’t have to because it’s about their survival,’ says Pike. The waiting list has gone down from 89 to eight and Pike has increased the counselling hours of her team. ‘I’ve also applied for other grants because we predict a spike after lockdown ends, and I’m hoping to employ another couple of counsellors to meet the demand.’

Trainee counsellors

The lockdown has also had a significant impact on trainees, many of whom are now being taught online by tutors and course providers who have no experience of delivering training in this way. For providers, the challenge was getting online courses up and running in a short space of time. Lynne Kaye, Director of CPPD, says: ‘We had 200 students on three different counselling courses, at certificate, diploma and advanced diploma level. All the courses had students coming to the end of their training. We also had to create training for our diploma-level students transitioning from in-person counselling to working online with clients in our own service. There was anxiety but I think our students have coped well with the changes,’ she says.

A point that is coming through from trainees on social media message boards is that it’s easier to cope with change when it’s well managed. Many trainees have been effusive in their praise for tutors who have helped them through the process with sensitivity, including one tutor who was taken ill and subsequently died from Covid-19. Many students have reported a positive transition. One said: ‘Our online training day was so engaging, it felt like I was almost back in our room with the group.’

But not everyone’s experience has been positive; some trainees have reported feeling unsupported, with little or no communication or clarity about placements or whether online client hours will count. Perhaps it’s not surprising that we have seen a broad spectrum of student experiences during the pandemic, given the increasingly eclectic way that counselling training is now delivered in the UK, with university courses closing and independent training courses springing up.

Rory Lees-Oakes is Co-Director at the online training site counsellingtutor.com and says that counselling courses also need to adapt to the change in the way counselling will be delivered. ‘Social distancing is here to stay and I think we’re going to see a fundamental shift towards a demand for online counselling, even after lockdown,’ he says. ‘Counselling training needs to reflect the world we’re living in. Stakeholders all need to come together to reconfigure what training will look like in the future.’

Longer-term changes

The longer-term impact on our work is unclear, but having adapted to new ways of working, many practitioners are rethinking their practice. ‘Mental health professionals are leading a working life that they said could never be done. I see a future where tele-therapy, while not being exclusively used, will be far more available. There are too many advantages in being able to offer remote therapy for us to discard it,’ says Dr Sandi Mann, a workplace consultant and lecturer at the University of Central Lancaster. It’s a view shared by service manager Vicky Pike: ‘As a domestic abuse charity, we’ve learnt that online therapy is possible, it works and the feedback from clients is so positive.’

According to Down, this time in lockdown has pressed a much-needed pause button for many of her clients. ‘Slowing down means that the people I work with are reassessing all aspects of their lives,’ she says. ‘They’ve worked long hours, involving a lot of travel, and I wonder how many people are going to want to go back to their jobs, if indeed those jobs still exist. People are starting to ask what they want to do with their life?’ And we coaches and therapists are ideally placed to help them explore this.

Valuing care

One emerging hope is that in this new world we may reappraise how we value care work. Providing carers with the counselling support they need may be a potential new market for counsellors. ‘I hope our society will have a better understanding of the work of carers in care homes,’ says Jeremy Bacon, BACP’s Older People Lead. ‘Staff are so skilled, and we need to insist that carers deserve better and must not be left to the vagaries of the market. We’ve equated low pay with low skill and we need to totally turn that on its head.’

This change is called for in a recent report by the Institute for Public Policy Research,⁶ which calls for a new social contract to offer ‘care fit for carers’ for both NHS workers and carers. A key priority is the mental health and wellbeing of workers, and our profession has the skills to meet that need and provide that care.

Post-traumatic growth

I am sure I am not the only practitioner to believe that, if we are to learn from our early response to this crisis, we’d be wise to avoid a rush to offer care workers free therapy where services already exist. As a profession, we need to build on the foundations in place and strategically make the case for the provision of professional, paid counselling.

We have navigated uncharted waters in the last three months and, in many ways, there is much we can be proud of as a profession. We have shown ourselves to be a flexible, agile and responsive workforce whose skills are needed more than ever before. Yet it remains to be seen whether those skills are recognised and paid for accordingly.  

Looking ahead, Watkins reminds us of the potential for post-traumatic growth as we come through this crisis. ‘Something significant is happening at a local, societal and global level as we collaborate,’ she says. ‘We’ve done well so far in our response to Covid-19 but, as a profession, our real work hasn’t even started yet.’