The big issue: Is EAP counselling really working?
Therapy Today, November 2020

My first experience of therapy was more than 20 years ago. I was working at the BBC, feeling overworked, tearful, unable to sleep and exhibiting all the symptoms of work-related stress. A colleague introduced me to something called an employee assistance programme (EAP). I didn’t know what it was but she recommended that I call them and reassured me that no one at work need ever know.

A week later, I had my first appointment with a counsellor. The speed and ease of my referral was remarkable and today, with mental health services so stretched, it’s a huge positive that it’s possible for employees to get timely access to help when they need it. True to BACP’s slogan, ‘Counselling changes lives’, my experience led me to a career change and ultimately to where I am now: a specialist in workplace mental health and editor of BACP Workplace.

Some 50% of UK employers offer some kind of EAP and counselling provision.¹ Despite my long involvement with the workplace sector, I find the EAP world opaque and difficult to grasp. While I’ll remember my therapist for the rest of my life, I’ve no memory of what the EAP was called. Some change their name and relaunch themselves with such frequency, it adds to my sense that EAPs can appear elusive.

It’s not known how many BACP members work as EAP affiliates but discussions about EAPs populate the message boards with polarising views. For some counsellors, EAP clients are the bread and butter of their caseload and they love the work. Others report horror stories about low pay, late payments and onerous bureaucracy and paperwork. At networking events, I’ve also heard practitioners ask, ‘What is an EAP?’ This article explores the key issues for practitioners, talks to the EAP sector and finds out what BACP is doing to address concerns from members and industry.

Search for ‘EAPs’ online and you’ll find the corporate giants offering employers a support package for their workforce to help with all aspects of their personal and professional lives. The concept arrived in the UK from the US in the late 1970s, due to the growing demand for counselling and psychological services. It was a series of high-profile occupational stress cases that led to their expansion here. The most significant of these is said to be Sutherland v Hatton in 2002, where workplace counselling was cited in Lady Justice Hale’s judgment: ‘An employer who offers a confidential advice service, with referral to appropriate counselling or treatment services, is unlikely to be found in breach of duty.’²

The development of EAPs since then has really helped the national conversation about mental health at work, says Andrew Kinder, professional head of mental health services at Optima Health, who has a long history of working with EAPs and an interest in the employability of counsellors. ‘When I started out, it was difficult to talk to employers about things like stress at work,’ he says. ‘It’s expected now that good employers will provide access to a range of services to support employees with their mental and physical health but without the trouble and cost of procuring services from an individual counsellor or physiotherapist; instead it’s all bundled up in the cost of the EAP or packaged within an overall occupational health service.’

Typically, a full employee assistance programme will include access to a helpline 24/7, 365 days of the year and include telephone, online and in-person counselling, critical incident support, advice on physical health, medical and legal matters, relationships, gambling, signposting to debt and financial help, digital self-help, as well as the management of the account, case management and clinical oversight. It sounds good but, as with all purchases, the principle of ‘buyer beware’ applies.

Force for good

Whether EAPs are seen as a force for good depends on who you’re asking. BACP accredited counsellor and supervisor Sarah Anderton has a private practice in Stroud and works as an affiliate for eight different EAPs, which makes up 60% of her caseload. ‘I love the diversity of clients and workplace cultures. They come from charities, global consultancy companies, banks, legal firms, call centre staff and the public sector,’ she says. ‘Most haven’t had therapy before, but if the client has a good experience of counselling, they will consider counselling in the future, or tell others about it, and this promotes the role of counselling in society.’

The large EAPs tend to work with employers with thousands of staff but a leading EAP provider can offer a small-to-medium employer a 24/7 counselling information and advice service, including critical incident advice and support, medical information, and telephone and in-person counselling, among other services, at a cost of £8.37 per year per employee. That’s less than £1,700 a year. So how do they do it?

I asked Sharon McCormick, clinical director of The Listening Centre, an EAP provider in the Midlands, which she established 20 years ago. Her company has 30 affiliates, who speak as highly of her as she does of them. McCormick says that a national EAP approached her some years ago with a view to buying her business. She asked how they made a profit. ‘I was told that, out of 1,000 calls, they signpost 60% to self-help. About 20% need financial and legal help, and those who need debt advice are signposted to a national charity at no cost to the EAP. Another 20% may need counselling but they left it to them to contact the counsellor and many didn’t,’ she says. ‘They could usually convince the remainder to have telephone counselling, so they were left with a small minority who then accessed in-person counselling, the most expensive part.’

This is where problems often occur for therapists and their clients, says McCormick. ‘I’m first and foremost a therapist but I bring ethical integrity to support local employers with their business and to do what is best for the client. A priority for the big national EAPs is to make a profit and, too often, this can come at the expense of the client and the therapist.’

It’s a view that I often hear from experienced affiliates and supervisors. ‘It’s the same EAP names that crop up time after time in supervision,’ says one supervisor. ‘There’s one EAP that always gives the client the minimum number of sessions, regardless of the client assessment and the complexity of presentation. I urge counsellors to go straight back to the case manager and discuss this but learning to negotiate the contract with the EAP can be a big issue for therapists new to EAP work.’

Anderton defines a ‘good EAP’ as one where affiliates won’t feel alone: ‘You’ll have a case manager who you can talk to, you’ll get good client assessments and short-term therapy (usually six sessions) will be an appropriate intervention. I’ve been interviewed by the case manager and my premises checked and that’s good professional practice.’

To find out more, I posted on BACP’s LinkedIn and Facebook groups, calling for members to share their experiences of working with EAPs. There were positives such as: ‘My experience is good – a caring organisation that values what I offer and offers a sense of belonging.’ But the majority posted about what they weren’t happy with. Kris Ambler, BACP’s Workforce Lead, confirms that the responses I received tally with members’ concerns: ‘The top three concerns are rates of pay, the time it takes for some EAP providers to pay invoices and the requirement EAPs have for accreditation.’

Rates of pay

Affiliates report a range of session rates, from £20 for telephone counselling up to £55 for in-person work. ‘The hourly rate is really variable,’ says Anderton. ‘I’m paid £35-£60 per hour for counselling or CBT sessions. But my view is, if I don’t like the rate of pay, I won’t agree to the work because I don’t want to collude with low rates.’ That’s one solution, but it’s arguably harder to do if you’re new to EAP work and turning down work means turning down a crucial source of income.

The issue of EAP rates of pay came to the fore earlier this year when some providers refused to pay the agreed in-person rates for therapists who were now delivering telephone counselling as a result of the enforced lockdown. Some cut rates to as low as £20 an hour instead of their usual in-person rates. After a response by BACP to EAPA, the UK Employment Assistance Programme Association, several providers agreed to back track and pay full rates.³

A survey of almost 300 EAP counsellors’ experiences of the COVID pandemic, published by EAPA in August 2020, points to long-term changes to the EAP counselling landscape as a result of the pandemic experience.⁴ More than half the counsellors (58%) said they would be formalising video counselling as a new offering, and 45% said they’d be providing telephone counselling. However, the issue of rates of pay remains. One counsellor in the survey said, ‘This health pandemic causes enough anxieties and uncertainty, without the added burden of EAPs deeming it acceptable to pay less fees. My supervisor has not halved their fee due to my halved income, and I absolutely would not expect them to.’

EAPA says it exists to ‘represent the interests of the industry and to expand knowledge and understanding of EAPs in the UK’.⁴ I spoke to its Chair, Eugene Farrell, about the disparity in hourly rates paid to affiliates. He said that EAPA stepping in would be akin to BACP setting a rate for an hourly rate of counselling. ‘As an association, we would not want to start setting rates of pay because that is a commercial decision and providers must set their own rates,’ he says. ‘Some providers have clearly taken the view that, because affiliates are working remotely and don’t have to pay room rent, there is a reason to lower the hourly rate to take account for this.’

Room rent aside, as any private practitioner knows, the bulk of professional costs (supervision, insurance, professional membership fees, training and CPD, marketing and website maintenance, ICO registration etc) remain the same, whether you are working remotely or in-person. And while EAPs may provide regular income, it’s not secure. ‘The employer is the customer and that means, if they decide to take their business to another EAP, you can end up losing all your client work, which is why I work for a variety of EAPs,’ says Anderton.

Another point of contention is that some EAPs only take on accredited counsellors, with many practitioners saying they feel forced to absorb the expense and time-commitment of undergoing accreditation for this reason. ‘Many feel aggrieved at this but these EAPs often tell us that they do this to achieve a common standard across all areas of their business portfolio,’ says Kris Ambler. ‘For others, this is a commercial decision driven by their own contractual obligations. This gives us very little room to challenge employers as they’re free to apply any standard that they deem appropriate. However, we are working with employers to better understand their needs and align these with the qualifications, experience and expertise of our members.

‘We always stress the point that all BACP members are on a PSA-accredited register, and that individual accreditation is a voluntary standard. There are often occasions where a client’s needs might be better, or only, served by a therapist who possesses specific expertise, from someone who might not be an accredited member of their professional body. In such cases we have engaged in constructive dialogue with employers, both on behalf of members and to help organisations understand the complex professional standards landscape in which our members sit. It takes time to build and maintain these relationships and we continue to work with employers of all kinds, to increase paid employment opportunities for our members.’

Delays

As most EAPs will include support for employees looking for help with financial planning and debt management, it’s impossible to ignore the irony that the top concerns for EAP affiliates both relate to money, or lack of it. Many EAPs are notoriously late payers, and it’s disempowering and stressful for therapists not knowing if, or when, they’ll be paid. And given that it can be experienced as an abuse of power, it is hard to see how it wouldn’t impact on the therapy.

Many object to the inequity and the dual standards by which some EAPs operate. One practitioner told me: ‘I’ve waited 120 days for payment but I’ve heard of therapists waiting more than 200 days to be paid. Yet, as part of our contract, we agree to see the client within five days and complete all the paperwork on time. Why can’t we have consistent agreement from EAPs about payment times for affiliates?’

It’s a good question and one I put to Farrell at EAPA. ‘It’s always shocking to hear stories like this and these concerns are legitimate,’ he says. ‘I’d like to see an agreed standard that providers agree to when they contract with the affiliate, which includes the time it will take for their payment to be processed.’ While this would be a step in the right direction, it begs the question why this isn’t already in place and why it’s left to practitioners to challenge.

For many practitioners, the only solution is to stop working for large providers. Some have set up their own companies. It was the need for financial security and professional standards that prompted Julie Hughes and David Leckie to develop Mind Matters Counselling nearly 20 years ago and it is now an EAP with more than 600 affiliates nationwide. Hughes, the clinical lead and also Chair of BACP Workplace, is committed to improving professional standards in the delivery of workplace counselling. She’s keen to point out that this includes how affiliates are treated: ‘I am privileged to work with some exceptional therapists and we pride ourselves on prompt payment. It’s in the contract that our affiliates will be paid within 14 days of invoicing, and they are. It’s clearly unusual because we often get emails saying, “Thank you so much for paying me so quickly”.’

Opportunities

Sharon McCormick points to the research that suggests that half of all employers in the UK have access to some kind of EAP, and says therapists should ask themselves what’s happening to the other half.1 ‘National EAP providers work well for large employers with thousands of staff but it doesn’t suit their business model to work with smaller employers with 500 staff or less. However, the overwhelming number of businesses in the UK aren’t big companies; they are small and medium-size employers and that’s who we cater for at The Listening Centre. That’s what the counselling profession needs to wake up to,’ she argues.

‘My mantra is “think local”. I know the employers in my area and I’ve got good relationships with the managers and directors. If they’ve got a problem, they give me a call. I’ve got a fantastic team of affiliates who have local knowledge and often understand the culture of local companies. I offer a fair and transparent fee and I’m really proud of this.’

McCormick has an encouraging message for therapists who are business minded: ‘If you don’t like how you’re being treated by a big EAP, you don’t have to put up with it. You can get to know your local businesses and do what I did, because the work is out there.’’

Changing the landscape

It’s clear that EAPs will continue to play a key role in supporting the psychological recovery of the workforce across the four nations as the COVID-19 threat continues, says Kris Ambler. He believes what’s needed is more transparency and communication between providers and affiliates. ‘The immediate focus is on working with individual members and accredited services to gain a better understanding of the landscape and key challenges,’ he says. ‘We want to create opportunities for members to work with EAPs, sharing concerns and ideas, and we’re developing a collective platform where BACP members can focus on some of the key issues with a view to affecting positive change.’

It’s an idea that interests those affiliates looking to improve communication and collaboration, as one practitioner explains: ‘Ultimately, I’m really interested in talking to BACP and EAPs to ensure that everything works better for all parties. If EAPs engaged more with BACP and the wider profession, I think it could add value to EAPs when they are out there selling their products to employers.

BACP Workplace Chair Julie Hughes is optimistic that the forthcoming BACP Workplace Competence Framework will provide a clearer understanding of how specialised the work is and increase the value of workplace counselling across industry. ‘We need therapists experienced in delivering high-quality workplace counselling and psychological interventions across the sector and they need to be paid accordingly,’ she says. It’s timely that a new report⁵ by the Institute for Employment Studies (IES), commissioned by BACP and EAPA, highlights a link between workplace counselling and improved wellbeing and organisational outcomes.

Action for change

Undoubtedly, there are EAPs and practitioners that work well together in service of the client and their employer. Yet in researching this article, I can’t ignore the persistent theme of therapists feeling exploited and undervalued. It would be good to see our profession push back to challenge the EAP industry to redefine what constitutes high standards of practice in the delivery. If an EAP’s role is to support better mental health at work and foster wellbeing in the workplace, why doesn’t this begin with how affiliates are treated?

I’m hopeful that UK EAPA is open to exploring this question. ‘The average EAP works with 800-1,000 affiliates and I think we do need to have a better understanding across the EAP sector of where the tensions are so that we can work collectively to address the issues,’ says Farrell. ‘I think that the incredible work that counsellors do in supporting employees and employers with workplace mental health is highly valued by the EAP world, but truthfully, it’s probably not said often enough.’

While verbal validation is of course important, it’s meaningless if the conditions of engagement offered by EAPs don’t reflect this. My sense is that, in the current economic climate, many counsellors have been forced into a ‘don’t rock the boat’ position – they may not like the terms offered by some EAP providers, but they also can’t risk losing the income. Established counsellors often vote with their feet in favour of private practice, but as long as there is a cohort of newly trained practitioners ready to take their place, nothing will change.

How can we be braver and more vocal? My hope is that this article will start a much-needed conversation, and that the work of EAP affiliates delivering workplace counselling can be properly understood and valued.