The big issue: Counting the cost
Therapy Today, December 2022 / January 2023

'It wasn’t until the pandemic that I fully understood the isolation of private practice. We are holding a mental health crisis. You get these referrals coming in and your heart bleeds every time you have to turn someone down. You wish you could take them on, but you can’t.’

BACP registered therapist Caz Binstead has been in private practice for 10 years and for the past four years a member of the BACP Private Practice division executive committee. She surely speaks for thousands of private practitioners who right now are facing what feels like a gathering monsoon of clients – adults and children and young people – needing counselling and psychotherapy. Much of this need stems from the COVID pandemic; in the aftermath of the crisis, problems with re-engagement in ordinary life and buried anxieties and relational difficulties are emerging; statutory services weren’t coping even before the pandemic, as repeated surveys reveal. But on top we now have a major economic crisis and steeply rising costs of living, along with the probability of yet more searing cuts in essential health and social services.

We are looking at a long, hard winter ahead.

In BACP’s 2022 Mindometer survey, published in September 2022,¹ two-thirds of our members were already reporting that cost of living concerns were having a detrimental impact on clients’ mental health. Sixty per cent said their clients were anxious about how they could afford to pay their household bills; the same proportion said clients were cutting back on therapy sessions in order to save money, and 47% said clients were cancelling or pausing sessions because they couldn’t afford them.

For evidence of the impact of financial difficulties on mental wellbeing, a stark report from the House of Commons Library,² published on World Mental Health Day on 10 October, paints a very worrying picture. It isn’t all about biology, the report states very clearly; we know already that the 2008 economic recession had a major impact on mental health and led to an increase in suicides, particularly among middle-aged, male wage earners. According to the briefing:²

• financial loss as well as living in poverty can worsen mental health
• people can end up in a downward spiral of financial problems because poor mental health prevents them earning
• financial difficulties and problem debt are a major cause of suicidal ideation and suicide attempts
• financial worries cause chronic stress and limit healthy choices in other areas of life
• housing instability causes insomnia, stress, anxiety and depression
• fuel poverty is associated with poor maternal mental health, as is lack of money to pay for transport to socialise and attend appointments.

The list goes on. And, inevitably, when the family is struggling with poverty, children’s mental, physical and emotional wellbeing is at greater risk.

A recent Lancet study³ confirms what might seem obvious to most of us – that improved financial circumstances improve mental health and that ‘to best support population mental health, welfare policies need to reach the most socioeconomically disadvantaged’.

But, points out BACP registered counsellor Maria Albertsen, founder of Counsellors Together UK (CTUK), too often it is forgotten that counsellors are also part of the general population: ‘What the BACP survey found out about counselling clients applies equally to counsellors. We need to be asking those questions of BACP members too,’ she says.

Talk money

A CTUK survey of 1,265 counsellors and psychotherapists (89% qualified, all of working age, 79% women, 28% disabled, 25% single, 63% self-employed) carried out in 2021, titled bluntly ‘It’s time to talk about money’,⁴ found a significant level of poverty. Fourteen per cent were claiming income-related benefits, 30% were relying on non-counselling work for their main source of income, five per cent were not working, three per cent of qualified practitioners and four per cent of trainees had used food banks, 30% earned less than £100 a week and the majority took home less than £400. Worryingly, 30% didn’t think they could earn a living as a counsellor or psychotherapist, and all respondents were doing some kind of unwaged work, from one to four hours a week for 25%, up to five to nine hours for eight per cent and 10-14 hours for two per cent. Moreover, 51% of respondents went into debt while training, which is perhaps understandable given the costs and the time commitment, but 30% did so while working. As one respondent pointed out: ‘Training, insurance, CPD, supervision and professional bodies membership fees are all due even when income drops. Universal Credit does not accept these professional expenses as essential business costs. This is a huge problem for therapists who become ill or unable to work.’

Says Albertsen: ‘We as a profession don’t talk enough about money. From my work with CTUK, I know therapists are struggling like everyone else. If two-thirds of clients’ mental health is being affected, my guess is that would apply to therapists too. And, if we are worried about money and have the added worry that clients aren’t coming, or aren’t paying or are having to take breaks, and we are already a low-waged profession, this will make it a lot worse.’

Albertsen adopts the approach of numerous counsellors, which is to offer a few low-cost spaces for clients who can’t afford the full fee – trainees and clients on benefits, in her case.

But, she argues, it isn’t the job of counsellors to personally subsidise an essential health service: ‘Therapy should be free to access for everyone and it should be funded by the Government, with more jobs for counsellors so they have the security that comes with employment. We don’t have a guaranteed income so counsellors can’t afford to offer their services for free. Though I think a lot would if they could.’

The profession is notoriously bad at taking care of its own, she says. ‘Therapists don’t talk openly about their struggles; they find it shaming. People tell us that having space to offload means they are more able to hold their clients. And we know that the financial landscape of therapists is just shocking.’

In January CTUK will be launching a new initiative called Therapists Talk Money – an online hub with a weekly YouTube show where therapists can get financial and benefits advice and discuss money, income and its significance for the profession. ‘We need to be OK for our clients and part of that is about addressing our financial support needs as well as our professional support needs,’ Albertsen says.

Recruitment issues

Based in Gloucestershire, TIC+ works closely with the local NHS CAMHS to provide counselling to troubled children and young people who don’t meet the threshold for NHS treatment. The need is huge, says Director of Clinical Services Judith Bell, and the work is increasingly complex and demanding, especially since COVID. She has enough funding to meet the demand; currently, her problem is finding counsellors to fill the posts, as she has lost several who weren’t able to afford to continue to work part-time, and the work is so tough that it is not sustainable as a full-time post. ‘The cost of living plus the acuity we are seeing among clients coming out of COVID are taking their toll. Some counsellors have had to take on other jobs or increase their private hours. But we have seen counsellors leave because they find the nature of the work too much. We are now seeing on average 25% suicidal ideation among caseloads, so a lot of time is spent managing that risk and it is a challenge. It’s not what they signed up for.’

TIC+ has just introduced a programme to train its own therapists because there aren’t enough qualified children and young people’s counsellors coming through from local colleges, Bell says. ‘We are doing what we can to improve the sustainability of the workforce, not just for our agency but for local and national workforce needs as well. They are also desperately looking for more counsellors. We pay the equivalent to what you would be paid in the NHS in a similar band, but in the NHS you are generally working full-time and getting all the employee benefits, pensions, extended sick leave and so on.’

Motherwell Cheshire is a charity providing support, counselling and information to women of all ages facing difficulties. CEO Kate Blakemore is similarly finding it hard to recruit counsellors, but in this case it’s to do with Universal Credit rules. Many of her sessional counsellors can’t risk earning overtime as it messes up their payments and can take months to sort out. ‘I can’t offer the work regularly,’ Blakemore says. ‘That makes it financially impossible for them to take on occasional extra hours.’

Motherwell Cheshire is already taking steps to keep its counselling service accessible to clients. The trauma counselling for new mothers is free, and Blakemore is confident of continued funding through a local NHS initiative. ‘In September we did a cost of living review of what we offer as a charity. We recognised that cost of travel is a major issue for women getting to us, so we are now sharing space with other local charities. We use each other’s premises if a client is closer to them. We are also providing online counselling as one of our core offers, which we didn’t pre-COVID. And there’s much more take-up of that.’

Her concern is primarily about finding funding for their work in schools. ‘We work with girls from Year 9 upwards. It’s mainly around self-harm, body image and eating disorders, and sheer high anxiety. All of these have been increasing since COVID and there’s nothing local that would replace what we do. CAMHS isn’t taking referrals as the threshold is so high. It would have a massive impact on the schools if we have to pull out. The Government has to start taking charities seriously. If we all pulled out, there’d be a black hole that nobody is filling,’ she warns.

Client cancellations

Sarah Fender is an integrative counsellor working in private practice in the Milton Keynes area. When we spoke in early October, she was looking back on a truly terrible week, when eight out of her 12 booked clients either cancelled with weak excuses, or didn’t show, and failed to pay for their sessions. ‘Last week I just sat down and cried,’ she says.

She has seen a steady drop-off in client numbers since September, when there would normally be an upsurge after the end of the school summer holidays: ‘Quite a few haven’t come back. And last week there was an onslaught of cancellations, failures to attend and clients saying they’ll pay and then not doing so. It’s been a big shock.’ What she finds most distressing is when parents don’t bring their children for therapy, but it applies to her adult clients too: ‘It feels very unsafe. They are coming for therapy for a reason, and if they can’t afford it, it’s uncomfortable that they aren’t talking about it so I can’t move towards them and offer any alternative.

‘I feel I am on a hamster wheel, and I am going to fall off. Last week I was wondering, what do I do now? Give up my practice? I can’t operate on the number of clients who are coming through the door. If this is going to be the pattern, I have either got to get a lot more clients on my books or stop altogether.’

Fender doesn’t claim any right to special protection; she says she chose this career, knowing the insecurities and risks: ‘I love my job, the working side by side with clients, but counsellors in private practice don’t get all the support that people working in the statutory sector receive. We have to supply all the CPD, supervision, insurance and accreditation ourselves; we don’t get any breaks. And that does feel wrong when we are dealing with people’s lives. During the first COVID outbreak I had four clients who were actively suicidal within a two-week period. It was horrendous.’

She talks to other practitioners locally and to her colleague who shares her office space. ‘They are also struggling. It helps to know I am not alone. In private practice you have to network or you would lose it.’

Denise Sturges-Allard co-ordinates the BACP Private Practice Network in Kent and says she is hearing similar reports from counsellors and supervisors, although she isn’t experiencing any client drop-off herself. ‘I have no mortgage, which means I am more financially stable than some, and that enables me to be a bit more… I never know what term to use… “charitable”? – I hate that term – about my fees. I don’t want to be greedy, and I also find I have a more interesting spread of clients from keeping my fees at the lower end of the scale. It’s the balance between valuing yourself and putting a fair price on what you offer. I am comfortable with what I charge.’

But she is going to implement a small rise from the New Year, she says: ‘That gives me time to discuss it with current clients and see how impacted they will be. I work from home but there are still the running costs, especially the heating. It’s something clients often give me feedback on, that the room is warm and safe. The warmth is very important to the therapy. I’ve tried lowering the thermostat but I need it at a certain level not to feel cold myself. I don’t want to be distracted by concerns about either of us being cold.’

Caz Binstead was the Private Practice divisional lead and one of the main writers of the BACP Private Practice toolkit and specialises in supervising people new to private practice. Her advice to members experiencing a drop-off in clients is ‘don’t panic’: ‘Confidence is a huge part of private practice. So hold out, believe in the value of what you offer, and talk to others in your area and find out if they are experiencing the same. Don’t suffer in silence, because you won’t be alone. Once the immediacy of the current crisis dies down, people will come back.’

Go-between

It can take some of the heat off the individual practitioner if they can work through an external organisation or network to manage their ‘charitable’ work. The Free Psychotherapy Network has been in existence since 2014, providing a forum through which clients can find skilled and qualified practitioners offering long-term counselling at greatly reduced rates. It was inspired by the 2012 Occupy London campaign at St Paul’s Cathedral, as a way to respond to people most in need.

Says Peter Ryan, one of the Free Psychotherapy Network contact members: ‘I see people from all walks of life, so I am able to balance out my fees. Those who can afford it are essentially paying for those who can’t. I have four low-cost places and one free place, and the low-cost clients pay £5. Even then, some of them are really struggling, and I am having to be careful to hold that, as some paying clients are also slipping into non-paying. And that’s hard. I’d like to respond to more clients, but there’s such a high demand, it can be overwhelming.’

He is very aware that he treads a fine line between enacting his principles of social justice and devaluing the worth of what he offers. ‘How I square it is, I can afford it by redistributing the income from my paying clients, and it is how I can respond to people in need. I’m not one for campaigning and going on protest marches. I prefer to nudge change in a therapeutic setting. When they come here, clients don’t feel judged, they feel embraced, and they can express whatever comes up. It’s their hour.’

When he has agreed to pause the fee for a paying client or let people pay what they feel they can afford, it disrupts the therapeutic alliance – the client can then feel under an obligation to perform, he says. ‘They feel almost obliged to demonstrate that they are working hard and they aren’t wasting my time. You try to reassure them that nothing has changed except the money, but it can be hard to get back to where we were in the therapy.’

The Bath Centre for Psychotherapy and Counselling (BCPC) has come up with a neat way of offering a low-cost service for local people while also helping its trainees complete their placement hours, and their graduate counsellors and psychotherapists establish themselves in private practice. The centre runs a foundation course, a psychotherapy MA and a diploma in integrative and humanistic counselling. Alongside, it offers a referral service that is open to anyone in the Bath, Bristol and South West region. The client logs in their details, presenting issue, where they live and how much they can afford to pay, and any member of BCPC (members are all graduates of the college) can offer their services if they wish. BCPC then provides the client with details of the therapists, and the client can contact the one they choose. BCPC members can also advertise for free via the referral service, so all their details are there.

In addition, BCPC offers a low-cost service where clients are seen by students training with them. The trainees are not paid and have to pay for their supervision (which is also low-cost), but it means they get the benefits of additional specialist training where needed and placement experience in a supportive environment. The fee for clients is between £5 and £7 per session for 10 sessions, and clients can then pause and re-refer if they feel they need further sessions.

‘We are supporting the community in accessing therapy they can afford, and also late-stage students and graduate members in finding clients at a time when things are difficult,’ says BCPC Deputy Director Rhianwen Gilson. ‘It’s a win-win situation.’

Role of charities

There is no question that charities will continue to be ever-more vital as providers of affordable counselling outside the NHS. But increasingly this is likely to be at the cost of the counsellors providing the service. Local Mind organisations are a major source, nationwide, of low-cost counselling. Leeds Mind, for example, offers an ‘affordable’ service charging a sliding-scale fee from £25 a session if the person is in employment down to £12.50 if not. (The fee for clients able to afford the separate private practice service is £50 a session.) There is consistent high demand for the affordable service, says Rhys Toone, Operations Manager. ‘Since January, 62% of our clients were seen through our subsidised counselling service, and 38% accessed our full-cost service. We are consistently in very high demand for the subsidised service.’

But Leeds Mind is reliant on trainees and unpaid qualified volunteers to provide the subsidised service. Like many such organisations, the justification is that it ‘offers good experience for people working towards their qualification and allows us to provide a more affordable option to clients’. But the expectation that qualified counsellors will continue to provide their skills for free remains hugely problematic for our profession as a whole – would, say, a qualified psychologist agree to those terms and conditions?

Psycho-compulsion

The Government’s announcement on World Mental Health Day 2022 that an additional £122 million is being injected into IAPT to improve employment support to clients might be cause for some celebration, but it has revived ripples of concern among some counsellors. Back in 2015, the Department of Health and Department for Work and Pensions got together in a scheme to help people back into work faster by providing psychological support in Jobcentre Plus premises and employment support in IAPT teams. Concerns were raised about ‘psycho-compulsion’ – unemployment being seen as due to an individual’s psychological flaws, not the lack of suitable, decently paid, safe and secure employment.⁵

Counsellor, trainer and supervisor Nicola Blunden is deeply concerned by the move. She has supervised people working in these roles: ‘The work is full of ethical dilemmas,’ she says. Essentially it is a judgmental policy within a judgmental system that separates people into ‘deserving’ and ‘undeserving’, she argues. ‘If you are trying to force someone back into work or into a certain type of functioning to meet goals that have been set externally, it feels – and it’s a strong word – abusive to that person, and it has to be traumatising to be the therapist in that position, using control or power to abuse somebody’s vulnerability. When I am supervising, I am always keeping an eye on the therapist’s self-care because it is really draining to be crushed in that system and to be unable to access the natural resources of the client that would be available if the client were pursuing their own goals.’

She says she is often asked by students if training to work in IAPT is a way into a stable job in the NHS, with the regular income, status and career structure it can offer. ‘I have to hold myself back from asking if they really want to work in that context. Having to cut corners and manipulate clients put people in a horrible dilemma. And the client has to be affected by that field of stress and prioritising financial and statistical concerns over their wellbeing. It can only reinforce the social inequality the client is experiencing.’

Can counselling help?

A benefit of accessing an organisation like Leeds Mind is that it also offers services that address mental health, finance and wellbeing. Counsellors faced by someone in distress due to their financial circumstances may understandably question how and if they are helping when, as the research shows, what may be most helpful is purely and simply money. Motherwell Cheshire now includes a booklet with information about local debt advice and support services, and other sources of help for those in financial difficulties, in its clients’ introductory ‘goody bag’. ‘It’s a stigma-free way of ensuring women have all that information in one place to look at when they have time,’ says Kate Blakemore. ‘All the team are having training in debt management, and we are upskilling our knowledge, so we know who to signpost to.’

Maria Albertsen faced this dilemma when she worked as part of a local co-operative providing counselling to GP surgeries in Liverpool. ‘This was in 2018 in a really deprived area. Quite a high percentage of clients were prescribed antidepressants, and I’d say to the GPs, they don’t need antidepressants, they need money. I’d say to my supervisor, I’m not being a counsellor with these clients; I’m firefighting all the time. But when clients are in crisis because of poverty, when they’re homeless and they are having to walk to therapy because they don’t have the bus fare, what can you do? If someone asked to use the phone to ring the food bank, I couldn’t say no – it was more important that they ate that day than they had a full 50 minutes with me, but it wasn’t actually counselling. My supervisor would support that decision, but as counsellors we like to think what we are offering can help people change, and sometimes counselling isn’t the answer. Sometimes you have to accept you are limited in what you can do.’

Counsellors are facing tough ethical dilemmas, tough decisions and increasingly desperate people wanting their help. It’s a balancing act that few, if any other, professions face.

• If you or your practice has been impacted by the cost of living crisis, please share your experiences by emailing therapytoday@thinkpublishing.co.uk