The big issue: A fair slice
Therapy Today, September 2024

With a new Government in place for the first time in 14 years many are hopeful for change. According to BACP’s latest Public Perceptions Survey, published earlier this year, 68% of people think that addressing mental health should be a priority for Government, with only 14% feeling that the previous Government had done enough on the issue.¹ But the task ahead for Keir Starmer’s cabinet is considerable, says Kris Ambler, BACP’s Workforce Lead: ‘Legacy impacts of the pandemic, alongside massive strain to household and business finances, have created a perfect storm of pressure and challenges which, taken together, have exceeded our capacity to cope.

These impacts have not been felt equally and have served to widen existing mental health inequalities for women, young people and minoritised groups.’ Some 74% of survey respondents reported that their mental health was worsened by the current cost of living crisis, up from 53% in 2022. Ambler adds that BACP’s work with partners has long revealed a need for ‘better targeted, more nuanced’ support – support that many are still waiting for.

But is hope in a better future misplaced? Can a million-pound fund here or there really fix the web of problems affecting mental health care in the UK? Averting the escalating mental health crisis needs more than lip service and grand pledges, says Steve Mulligan, BACP Four Nations Lead. ‘Successive Government strategies, including the Five Year Forward View and the NHS Long Term Plan, made mental health a priority. However, these plans have failed to successfully address the chronic shortage in workforce, meaning that any service expansion is hampered by a lack of recruitment of mental health professionals to deliver the services,’ he says. ‘In their manifesto, Labour made a number of important policy commitments to extend accessible mental health services – including counselling and psychotherapy – across primary care, in schools and in community settings. But they are facing significant challenges in making meaningful change happen, and specifically in addressing growing demand for mental health services.’

Given the challenges facing the new Government, what key issues are a priority? We asked stakeholders and practitioners for their insights on where efforts and funding need to go: 

1 Investment in the workforce

Some 1.9 million people are currently on waiting lists for mental health support – just one index of the UK’s far-reaching mental health crisis.² The latest Office for National Statistics figures on death by suicide found that the rate rose 6% from 2022 to 2023.³ The Centre for Mental Health has warned that the cost of mental ill health in the UK is now economically equivalent to ‘a pandemic every year’.⁴ Demand from young people in particular has more than doubled since 2017.⁵ 

Many stakeholders believe long-term lack of investment in services and workforce is the key driving force behind the lack of provision. ‘There is a significant and undeniable mental health crisis in the UK,’ says Gemma Byrne, Policy and Campaigns Manager at Mind. ‘People are telling us that they are feeling overwhelmed and hopeless.’ 

Byrne highlights the staffing crisis at all levels of mental health care: ‘Staff on the ground are doing their very best with extremely limited resources and unprecedented demand. However, there are significant workforce issues, with retention and staffing shortage issues impacting the safety of patients and staff.’ 

A Public Accounts Committee report last year found that staff vacancy rates in acute inpatient services run at 20% or more.⁶ Figures from the British Medical Association show that, as of March 2023, around one in seven full-time equivalent doctor roles in NHS mental health services in England were vacant.⁷ The NHS Confederation has described how this has left mental health services in ‘persistent crisis mode’. ‘Therapeutic relationships are essential in making sure people fully engage with treatments and interventions,’ she adds.

Byrne also notes the under-reported problem of crumbling NHS premises: ‘People detained under the Mental Health Act against their will often have to stay in unclean, barbaric, subhuman conditions. The properties from which many mental health services are delivered have experienced years of underinvestment – these estates are some of the oldest in the NHS.’ Data for 2021/22 show that 15.5% of mental health and learning disability sites in England were built before the NHS was established.⁸ ‘It is not good enough that people in mental health crisis, many of whom are experiencing psychosis or suicidal thoughts, are subject to run-down and squalid environments,’ says Byrne. 

Martin Bell, BACP’s Head of Policy and Public Affairs, also highlights workforce issues as a core problem facing the sector. A recent BACP policy report revealed that the workforce crisis has also hit the wellbeing of counsellors and psychotherapists who face overwhelming demand and increasing complexity and severity of client symptoms. 

‘School counsellors are being expected to work overtime, often for free, to help address the mental health crisis among children and young people in chronically underfunded schools,’ he says. ‘Organisations delivering third sector counselling services are reporting increased numbers of referrals from statutory services without any accompanying funding, putting added pressure on services that were already struggling with rising costs, falling income and limitations of short-term contracts.’ 

Ambler reports a similar problem facing workplace therapists. ‘Counsellors working with EAP providers have seen an increase in the complexity and volume of caseloads. 

This has led to growing fears of compassion fatigue and secondary trauma, where therapists are increasingly working with clients with difficult or distressing problems. The increase in trauma-focused cases and those involving occupational suicide are examples of this.’ 

In the financial sector, for example, there have been recent high-profile cases of employees taking their own lives due to work and financial pressures. Ambler says: ‘Often therapists are at the front line after these deeply distressing events, supporting co-workers and managers, and this takes its toll. More organisations from across the sectors are seeking trauma-informed therapists to help meet these challenges, recognising that one-size-fits-all provision is no longer adequate.’ 

Therapy Today, September 2024

2 Support for marginalised groups

Claudia Turbet-Delof is a councillor and a person-centred therapist in Hackney, east London, with previous experience as a welfare benefits officer. Last November she led a successful call to enshrine mental health as a human right in Hackney. Today she remains deeply concerned about the impact of austerity and the cost of living on her borough and the rest of the UK. Clients she sees who are on long-term sickness leave struggle with isolation, lack of confidence and lack of opportunity to integrate back into work. ‘The numbers are speaking,’ she says. ‘Young people’s suicide rates are higher than before, especially women. We need to look at the data. We can’t just say that people are lazy. It’s not a culture – it’s a crisis.’ 

After a year of inflammatory headlines about the UK’s ‘sick note’ culture and the ‘pathologising of normal emotions’, we need to focus on the impact of people’s social context on their mental health, says clinical psychologist Dr Lucy Johnstone, who developed the Power Threat Meaning Framework and co-founded the campaign group A Disorder 4 Everyone with therapist Jo Watson. ‘Why do we live in a society where nobody feels that they fit in? Why are people feeling so genuinely insecure and worthless and fragile about their sense of identity? Those much bigger social and political questions get obscured when the individual is labelled as the problem, not their social context.’ 

Bell says a focus on upstream preventative measures is key to address problems before they become a crisis and require more expensive solutions: ‘We would like to see more focus on early interventions like counselling and psychotherapy across a range of accessible settings, including the NHS, voluntary, community and social enterprise settings, and in workplaces and schools.’ 

Graham Johnston is a therapist and co-founder of the London Centre for Applied Psychology who worked in policy for around 15 years before retraining. One of the problems holding back meaningful change is that ‘different parts of Whitehall often don’t talk to each other’, he says. ‘For example, you won’t necessarily have the Department of Health and Social Care talking to the Department for Work and Pensions, talking to the Treasury, talking to the Home Office and making sure that there’s a cross-government strategy for helping this cohort of people back to work. Focusing on “sick note culture” and the role of GPs, as the last Government did, may make headlines but the problem of long-term unemployment due to physical and mental illness has a number of reasons and factors playing into it.’ 

Addressing the social determinants of mental ill health such as poverty, racism and ableism by tackling systemic inequalities and expanding support for preventable mental health conditions should be a priority, says Bell. ‘Third sector services are often best placed to support marginalised communities underserved by mainstream services. Targeted funding for third sector counselling services could alleviate pressure on statutory services, especially for issues transcending the scope of NHS Talking Therapies. It could increase access to mental health support for marginalised groups requiring specialist, culturally sensitive and trauma-informed psychological support.’

3 More NHS resources for neurodiversity diagnosis and support 

Since 2019 waits for autism assessments have gone up fivefold according to a report published by the Nuffield Trust last spring.⁹ Between 1998 and 2018 there was a 787% rise in autism diagnoses in the UK, and ADHD prescriptions are up 51% since 2019.⁹ A recent report from the BBC found that many areas of the UK have such a backlog for adult ADHD referrals it would take eight years to clear them.¹⁰ Long waits have led to desperate measures – last year, a BBC documentary questioned the validity of diagnoses by some private clinics.¹¹ 

There have been criticisms that neurodivergence is now ‘overdiagnosed’, but a diagnosis is the key to getting help, says Kat Brown, author of It’s Not A Bloody Trend: understanding life as an ADHD adult (Robinson), who has previously written about her ADHD diagnosis for Therapy Today. ‘The diagnosis just helped to make sense of everything – anxiety, depression, insomnia, binge eating disorder, all of these issues that I’ve been trying to deal with separately,’ she says. ‘People who are healthy, the “worried well”, do not start thinking, “Do you know what, I think I’m autistic or ADHD” or “Do you know what the secret of making me interesting would be? It would be to give me quite a stigmatised neurological condition”.’ 

Sarah Worley-James is a neurodivergent therapist who was diagnosed in her 50s. She says she didn’t recognise her ADHD traits until recently, despite working with neurodivergent clients and attending a training on ADHD last year. ‘It can give you that sense of validation, but at the same time you’re still going to get people who are sceptical, who don’t believe it.’ 

Worley-James now runs a support group for neurodivergent students, where they can share lived experiences and challenges. She looks forward to a time when neurodivergence is no longer treated as a disorder or disability. ‘I hope that we get to the point some day where we don’t have these separate categories,’ she says. ‘We categorise things into boxes, but of course, that’s not what people are.’ 

According to the Nuffield Trust, the pandemic and sustained underfunding are two factors that have led to growing backlogs in diagnosis and longer waiting times. Research by the charity Autistica estimates that 2.5 million neurodivergent adults in the UK have not been diagnosed.¹² The social and economic costs of undiagnosed autism and/or ADHD, according to a review of research led by Dr Blandine French from Nottingham University, includes higher rates of depression, anxiety, self-harm and suicide.¹³ Studies have also found that lack of diagnosis impacts educational and work prospects, as well as relationship difficulties.

Martin Bell

Kat Brown

4 More information about medication 

Lack of available talking therapy and other support services has been linked to the rise in use of medication for emotional distress. In 2022/23 antidepressant prescribing was up 2% year-on-year, equivalent to 200,000 more patients.¹⁴ Four in five of the British National Formulary sections covered in the report have seen increases. Antidepressant prescriptions had already doubled between 2008 and 2018, according to the report. 

In 2017 the Beyond Pills All-Party Parliamentary Group (APPG) for Prescribed Drug Dependence commissioned an international survey on drug withdrawal from 1,700 respondents. Results showed that two in three patients claimed not to have received information on the risks of antidepressants, and one in four had no advice on withdrawing from them.¹⁵ The APPG now recommends that the UK sets up a deprescribing helpline, not just for those currently withdrawing from psychiatric medication but for those who have been poorly prescribed in the past, who experienced or still live with its lifealtering effects. Dr Anne Guy, co-ordinator for the APPG and project lead for the 2019 Guidance for Psychological Therapists: enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs, says people are still struggling to get help: ‘They need ideas about how to cope with withdrawal symptoms, and they need emotional support.’  

5 Parity of service across devolved nations 

While England struggles with long waiting lists, crumbling NHS premises, staff shortages and burnout, the devolved nations face their own unique challenges. Following the return to power-sharing in Stormont last winter, Northern Ireland needs time, collaboration and funding to get its health service back on its feet. The latest figures show more than one in two children and young people seeking mental health care wait more than nine weeks to be assessed.¹⁶ Funding for counselling through the Extended Schools and Healthy Happy Minds programmes was scrapped last year, and funding from Barnardo’s also stopped in 2023. 

‘While the return of Stormont is hugely important, Northern Ireland’s Health Minister recently warned that the latest budget from Westminster leaves an £85 million shortfall in funding, which will delay implementation of the mental  health strategy,’ says Steve Mulligan. ‘This will impact funding of critical nonstatutory third sector services and prevent reinvestment in important interventions like primary school counselling provision.’ He called for urgent action from the UK Government to address the shortfall. 

In Wales, the Government’s consultation on its new 10-year Mental Health and Wellbeing Strategy could transform the situation on service provision. In its response to the consultation, BACP called for changes to legislation to enable members to undertake local mental health assessments, to address barriers to working in NHS settings, and for investment in primary school counselling and therapeutic interventions for children and young people from age four onwards. 

Meanwhile in Scotland, problems with access to mental health services continue to impact patients and their families, says Mulligan. Last year the Scottish Health Survey found mental health was at an all-time low. Only one in two children and young people got treatment within six weeks, and last March those starting treatment appeared to be bottlenecked – numbers are down 10% on the previous quarter and 18% on the quarter before.¹⁶ 

BACP worked with Scottish Government and First Minister John Swinney, in his previous role as Cabinet Secretary for Education and Skills, to implement counselling across Scottish secondary schools. Now BACP is calling for longterm funding for university and further education student counselling from the Scottish Government, as well as better support for GP hubs to hire counsellors, better funding for NHS referrals to counselling, and more multi-year contracts for community counselling providers. 

While the challenges facing the new Government are complex, what’s plain and simple in mental health care across the country is the case for change. 

Steve Mulligan