The big issue: Riding the wave
Therapy Today, April 2022

If anyone doubted the estimate first published by the Centre for Mental Health back in October 2020 that, post-pandemic, some 20% of the UK population (10 million) would need new or additional mental health support, the statistics now emerging seem to be playing out the gloomy forecast.

The latest Government data update states that the number of people contacting the NHS seeking help for mental health problems is at a record high, ‘in the context of underfunded mental health services facing a care backlog, waiting lists and a stretched, exhausted and understaffed workforce, which will likely make services harder to access’.¹

The Centre for Mental Health itself reviewed its estimate in May 2021, and concluded that its original forecast was correct:² ‘Key groups of people who face an especially high risk of poor mental health include people who have survived severe COVID-19 illness (especially those treated in intensive care), those working in health and care services during the pandemic, people economically impacted by the pandemic and those who have been bereaved.’

And another major concern is that the figure of 10 million includes 1.5 million children and young people. According to a recent Government research summary,³ the more vulnerable children and young people have experienced worsening mental health throughout the pandemic, particularly during the lockdowns, although ‘most remained mentally well’. The impact is due largely to the effects of social isolation and school closures, the research says. The impact is highly variable, with different surveys finding conflicting results on the relative incidence of depression and anxiety, PTSD and behavioural issues. However, what is incontrovertible is that the overall rate of mental disorder rose from one in nine pre-pandemic to one in six in 2020, and referrals to child mental health services reached record highs in May 2021. From April 2020 to March 2021, there was a 37% increase in child mental health service referrals, and a 59% increase in referrals for child eating disorder issues over the previous year, reflecting greater demand, rather than a knock-on effect of families delaying help-seeking during the pandemic, the statistical summary states.

In the counselling room

In June last year, BACP released the findings of its own ‘Mindometer’ survey of the impact of COVID-19 as reported by a sample of 5,000 members.⁴ This revealed a highly varied and complex pattern of presentations in counselling. Anxiety (87%), stress/feeling overwhelmed (82%) and loneliness/social isolation (72%) were the top three most commonly presented problems, and members also reported people who are seeking help for mental health issues for the first time in their lives. Almost half (46%) of members said incidences of trauma increased; a quarter (26%) reported an increase in eating disorders; two-thirds (65%) saw an increase in relationship pressures and breakdowns; 26% in obsessive compulsive disorder and 20% in addiction, addictive behaviours to substances or substance misuse, while seven per cent reported an increase in addiction to the internet, and five per cent an increase in gaming addiction. Nearly three-quarters (71%) reported a rise in demand for their help and 47% an increase in clients asking for more sessions. 

In terms of issues discussed in counselling, the most common at 81.7% was anxiety, followed by stress (81.5%), loneliness/social isolation (71.8%), depression (68.1%), relationship pressures and/or breakdowns (64.7%), social anxiety (64.3%), feeling lost or hopeless (60.5%), bereavement and grief (58.6%), family issues (56.5%), trauma (45.6%), pressures of combining work and home schooling (43.8%), and issues linked to domestic violence/abuse (28.1%).

Therapists also reported increases in people from minority communities seeking support, as well as an increase in those presenting with racial trauma in the context of COVID-19, the death of George Floyd and the Black Lives Matter movement. Others listed mothers feeling overwhelmed due to the combination of pressures and demands from being a parent, working, home schooling and their usual support network not being as readily available. There were also reports of more young people and men seeking therapy, possibly due to reduced social opportunities and other activities that provided a release for emotional build-up, such as going to the gym.

Recovery strategy

The Government’s COVID-19 mental health and wellbeing recovery action plan⁵ talks of a focus on prevention and early intervention, but for many of the people going to their GP or seeking counselling, CBT self-help exercises and psychological ‘first aid’ may not be enough. Certainly this is the view of BACP, which in February hosted a roundtable discussion in central London with the Minister for Mental Health, Gillian Keegan, Shadow Mental Health Minister Rosena Chantelle Allin-Khan, and Sir Norman Lamb, former Liberal Democrat MP and Minister for Mental Health in the Coalition Government, to discuss how we as a nation are going to meet the needs emerging in the post-pandemic era.⁶

BACP Chair Natalie Bailey told the assembled experts and BACP members: ‘It’s affected young people, older people, people working in the NHS and education, blue-light services and people affected by bereavement, poverty and debt. Counselling and psychotherapy are part of the solution to a major issue. They’re critical to the recovery from the pandemic. More funding for counselling will help tackle some of the deep-rooted inequalities. Investment ensures appropriate, culturally sensitive and accessible choice before the problem escalates.’

In its recovery action plan,⁵ the Government acknowledges that, while many people will regain their usual sense of mental wellbeing once the threat of the pandemic recedes, some people’s mental health has taken a harder, longer-lasting hit during the pandemic: ‘Groups who had the highest risk of mental ill-health before COVID-19, including those living with pre-existing conditions, seem to have been worst affected. The mental health impacts of the pandemic have also been felt keenly by those directly affected by the virus – people who have been bereaved, people who have survived an acute illness, people living with long COVID, and our amazing frontline and key workers.’

The plan sets out a range of one-off and specific investments aimed at boosting the overwhelmed mental health system, including bringing forward further roll-out of mental health teams in schools by a year, and putting more money into IAPT to boost its capacity to meet escalating need – £38 million to enable an additional 380,000 people to be seen. IAPT is also named as the main point of treatment for people with psychological problems due to long COVID.

But the strategy does not deliver what BACP has been pressing for – more employment within the NHS for qualified counsellors and psychotherapists to increase access to talking therapies at primary care level. So, while Mental Health Minister Gillian Keegan used
the roundtable event to point to the £110 million going into expanding adult mental health services, including talking and psychological therapies, and another £111 million to increase the workforce to deliver services and train more staff, this didn’t answer Hadyn Williams’ point: ‘Why create new roles when we already have a highly skilled, trained and available workforce? Workforce expansion is cited as one of the biggest barriers to delivering the expansion of mental health services as set out in the NHS long-term plan. The NHS often overlooks the highly qualified, experienced, skilled counselling and psychotherapy practitioners who already exist and don’t need to be trained up. We’d like to see an enhancement of the role of counselling and psychotherapy within the NHS, which better uses our trained workforce. IAPT has a significant role to play but isn’t the only solution.’

Back in September 2020, the BMA released a report highlighting what it predicted would be the long-term impact of COVID-19 on mental health services. Its prescient forecast highlighted precisely those areas where the Government now records the highest need:⁷ social isolation, people with long-term mental health problems, people on low and no incomes, black and minority ethnic communities, and NHS and other frontline workers. For those most immediately impacted, ‘a strong public health response is required to address concerns about an increase in certain mental health conditions, such as depression, anxiety, substance abuse, post-traumatic stress disorder and complex grief,’ the BMA said. But its call for parity of spending with physical health, which BACP has also been seeking in relation to psychological therapies, has still not been answered.

Children and young people

Amid the panicked media headlines about the rising incidence of severe mental health problems in children and young people post-COVID and the focus on growing waiting lists for specialist CAMHS services, it can seem – oddly – as if the children and young people around which all this is flying are forgotten. There’s an apparent (and unfounded) faith that getting to the holy grail of a CAMHS appointment will cure the whole problem. Meantime, little is done to treat the debilitating symptoms along the child’s journey.

Numerous surveys have highlighted that children and young people are more anxious, more hopeless, more eating disordered and more likely to feel suicidal and to self-harm because of COVID, but given that the experience of the pandemic can’t be cured, how do we help them live in the here and now and regain their resilience to pick up their journey into adulthood?

Ben Nuss is a school counsellor based in Denbighshire, north Wales, where he covers two large secondary schools. He says what he has primarily noticed in the young people in his schools since they returned post-lockdown is a sense of all-pervading anxiety. ‘The presenting and predominant issues aren’t necessarily different, they are just magnified – more complicated, more severe, a higher level of risk in terms of self-harm, suicide ideation and adverse childhood experiences. COVID took away the coping mechanisms – sports clubs, after-school clubs, hobbies, interests – a lot disappeared and haven’t been replaced, or the young people just haven’t gone back to them,’ he says.

Sonia Winifred is both a counsellor and a councillor – she works for a charity providing individual counselling to children and young people in primary and secondary schools across south London, and is also the cabinet member for equalities and culture in Lambeth Council. Among children and young people in the 11–17 age group especially, she has observed a new apathy: ‘There’s a lack of enthusiasm, of interest in anything or anyone. School is a chore, they don’t want to go there, they say the lessons are irrelevant and boring, the teachers are inadequate, and when I ask where this is coming from, they tell me it’s since lockdown.’

She says the young people seem to have lost sight of who they are and what they once enjoyed, and lost their sense of agency: ‘They feel they have lost control. So much was taken away from them by the pandemic. But my worry is that this isn’t just one or two, it’s collectively all the young people I work with, telling me the same thing.’ She’s also noticed a new problem with eating habits in young men in particular, which in turn is affecting their sense of self and self-esteem: ‘Some have been bingeing out of boredom and put on weight, some are excessively exercising. They feel they are just not good enough. There’s a loss of a positive sense of self, of who they are and how they look. I find it alarming and disturbing. They are also angry, very angry – at themselves and at the world.’

Niki Gibbs, a former school counsellor who now works as a supervisor to school counsellors and pastoral staff in secondary schools, says the Government needs to invest now in a greater school counselling presence in every school. ‘A year ago I was already seeing problems emerging as pupils returned to school – impeded social development, disconnection from friends, worsened family relationships, anxiety generated by the loss of predictability and security, a rise in extreme feelings of hopelessness and helplessness, an increased exhibition of distress through eating disorders and self-harming behaviours – these are all still being experienced by our young people.

‘There’s a chronic lack of timely access to therapeutic services that means these problems are now becoming entrenched in our young people’s psyches – which I believe early intervention via therapeutic help could have avoided. There is a large pool, a sea even, of distressed young people who have not only experienced deterioration in their mental health during the pandemic but who are now still suffering and still deteriorating, as they are denied the support they need to recover and heal. This is undoubtedly a crisis in the making.’

Gibbs is co-chair of BACP’s school-based counselling expert reference group, which has been playing an active role in taking forward the ongoing campaign for a counsellor in every school in England, as is the case in the other three UK nations. ‘Having a school counsellor in every school would mean that pupils could access therapeutic care at the point of need, early on in their distress, to avert the deleterious effects we are seeing on our young people’s mental health,’ she believes.

Inequalities

Agrani (she wished to remain anonymous) is a trainee therapist and a Hindu, and describes vividly how families and whole communities have been devastated by COVID, not just in terms of deaths (and Asian communities were particularly hard hit, along with African and African Caribbean people) but in the impacts of multiple bereavements. ‘What I see in my community is collective trauma. There has been no way to process the grief individually and it has affected the wider population too,’ she says. ‘When someone dies, there is normally a period of 13 days of mourning, when every person for whom the deceased was significant comes to visit the immediate family to pay their respects and share their stories and memories. It’s an incredibly precious thing and not to have it is heart-breaking for the family but also for those who would normally have offered that support – we’ve lost that opportunity to show those people we really care about them. It means families are left with their feelings of loss without the support of the community around them.’

And this was happening repeatedly, and often concurrently, throughout the height of the pandemic. ‘I attended a dozen funerals online and it was really challenging because you can’t show your feelings or show your support. I had a real sense of dissociation,’ she says. ‘Those wounds are hard to heal.’ Her little boy has lived through repeated periods of mourning, sometimes overlapping. ‘What effect will that have?’ she asks. ‘It was too young and too soon for us to be having those kinds of conversations with him.’

She finds it hard to be around people who haven’t been touched in this way. ‘For some people, their experience of COVID is that it slowed down their life and gave them more time and space to be with their families. It’s been a time of growth for them – luxurious, even. And I find it massively triggering to hear that.’

In her role as councillor, Sonia Winifred is once again able to get out and knock on doors, finding out how people in her community are coping post-pandemic. What she is seeing in Lambeth is, she says, a massive and growing accumulation of stress among the least advantaged – financial and housing pressures on top of coping with all the losses of the pandemic. Moreover, many bereaved families have had to bear the costs of several funerals. ‘They came to the council asking for help,’ she says.

‘As counsellors, we try to help people find meaning so they can carry on, recognise what they are going through and find that strength within themselves to go forward and survive and manage the guilt that they could have done more when in fact they weren’t allowed to, so they don’t pile it onto themselves. Listening to people on the TV and radio – yes, people feel a sense of injustice, but others I think just want to be left alone to grieve because they haven’t been able to. They want to be able to think about their loss and have time and that quiet space to grieve. They are just coming out of this and some will come out sooner than others, but so many have lost so much, they need time now to quietly and respectfully deal with that loss. And facilitating that is part of our role too.’

Meeting the demand

School-based counsellors like Ben Nuss are aware that they are only reaching the tip of a much larger iceberg. ‘I have a lot of sympathy for the pastoral staff in schools; they are incredibly oversubscribed,’ he says. ‘The pastoral staff are under constant bombardment. Whatever pops up, they have to respond there and then. They are on the frontline, more than I am as a counsellor, and I don’t think they get the support and clinical supervision they should.’

But, he says, ‘In the same breath, I have been astonished and incredibly impressed by young people’s ability to rise above this – yes, it’s hard and the deck does seem to be stacked against them, but it’s not a situation beyond hope. You do still see these resilient young people finding ways to rise above it.’

Trainee counsellor Diane Pummell works in a large primary school in Twickenham, and has been looking for ways to rekindle and nurture the children’s resilience and support them to readjust and regain a sense of safety now they are back in the classroom. With the head teacher’s blessing, she set up a club called Wellbeing Warriors – a lunchtime drop-in club, open to anybody in years four to six. ‘I was also aware that there’s never enough of me to go round. I see this as an early intervention – a quiet, safe, creative space where children can chat and things may come up that I can pick up early on,’ she says. ‘We discuss topics like self-care and feelings, and a peer support culture is beginning to emerge; they are making new friendships and several children are finding their voice by talking about worries or sharing their experiences in a safe space.’

In Birmingham, Citizen Coaching, a counselling service and social enterprise run by former BACP Board member Martin Hogg, has launched a specialist new service, Citizen Navigator, to signpost clients to non-counselling resources, to help meet local needs for support. The project is funded by a £50,000 grant from social investor Key Fund. The Citizen Navigator programme is building relationships with charities, social enterprises, statutory and voluntary groups so Hogg and his colleagues can refer people on for advice on housing, debt and other such day-to-day practical issues. ‘We came up with the idea of Citizen Navigator after we noticed people who came to us for counselling had so many fundamental problems going on in life, it got in the way of the counselling,’ Hogg says. ‘GPs don’t have the time or capacity to signpost patients to other support services, so they come straight to us. We want them to empower themselves for the future to take some of the resources we give them, so they can be more self-sufficient when they need help.’

Future planning

According to the Centre for Mental Health’s 2021 report,² the predicted levels of demand for mental health services are two to three times that of current NHS capacity, and this will continue for up to five years. ‘This is not a scenario where services can grow incrementally to meet steadily rising levels of need. Instead, Government and the NHS must take action now to meet a very steep increase in demand for mental health support,’ it says.

For BACP CEO Hadyn Williams the solution comes down to Government investment at a primary care level to deploy an available counselling workforce: ‘We’d like to see much greater investment to ensure fully funded and appropriate counselling and psychotherapy which use the capacity of our trained workforce, across all settings including schools and colleges, across our NHS and through community settings.’

Counselling has much to offer, both individually and at a public health level through early intervention in our most vulnerable communities. The aftermath of COVID-19 is, essentially, a collective problem affecting us all, but mostly affecting those who have least to lose.