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Over the last thirty years counselling and therapy trainings have proliferated in this country. Passionate people with creative energy and enthusiasm for new approaches have established courses to the extent that the British Association for Counselling & Psychotherapy (BACP) alone, just one of the statutory regulators, now has over 40,000 members.
The trends come and go. Brief Cognitive Behavioural Therapy (CBT) is frequently recommended in the NICE (National Institute of Health and Care Excellence) guidelines. Then there’s attachment therapy and a proliferation of mindfulness and mentalisation-based approaches, as well as the long-established paradigms of psychotherapy praxis. With all trends in therapy the ‘evidence base’ for each sooner or later shows that they are not a panacea for all ills but, quite reasonably, of help to some of the people some of the time. Meanwhile, NHS and statutory sector therapy services have been relentlessly eroded so that the rare advertised psychotherapy posts attract overwhelming numbers of applicants.
Trainings and professional bodies require candidates to accrue hundreds of clinical practice hours to become qualified and registered, shoehorning many into ‘voluntary’ placements. Indeed some large counselling organisations, and even NHS therapy services, rely on a continuous stream of unpaid trainee therapists. The business model involves employing a part-time clinician to manage whole teams of unpaid practitioners, citing supervision and the opportunity to gain experience as sufficient reward. While practicing lawyers and accountants do have a tradition of pro bono contributions to charity, which other field would accept this culture of free labour and the assumptions it creates, both within and about the profession?
Within the psychotherapeutic world there is a rather nostalgic idea that donating many unpaid hours to training and other committees is a way of ‘repaying’ what one has been given by professional forbearers. This ‘generosity’ is sustainable because these positions within the professional bodies provide contact with a steady flow of trainees who are required to have personal therapy and supervision. However, these days there can be a rather guilty acknowledgement that trainings are governed by the ‘bums on seats’ imperative for their own survival. Market forces apply, and a pyramid begins to emerge with trainee lifeblood sustaining the organisational infrastructure. If we then factor in the professional indemnity insurance, annual registration fees and ongoing requirement for CPD once qualified, the pyramid becomes more of an iceberg. From anyone’s inbox it is easy to see how the CPD market has burgeoned. Of course there is an important, healthy dimension to continuing to grow and develop, both as a person and as a professional but it’s important to recognise that becoming qualified is just the beginning of the ongoing financial outlay required.
In the absence of properly remunerated and structured jobs most therapists turn to private practice. This, as with other forms of ‘self-employment’, is not as profitable as is commonly believed. The erstwhile professional registers and collegial referral networks are being outpaced by strategically positioned website-based businesses, offering to put your name on the map for a fee. The sky is the limit for spending both money and time on marketing, websites, and social media presence to reach the Facebook and Snapchat generations. Outside the few remaining NHS and university departments is the marketplace which requires a whole other set of extroverted presentation skills, often at odds with core therapy and counselling aptitudes.
Increasingly therapists encounter that many-tentacled beast, the Employee Assistance Programme (EAP), which markets workplace ‘wellbeing’ packages to businesses and organisations. The EAP operates as a broker between the therapist and the employer, and then matches the employee-patient with a local practitioner, usually simply by trawling the established UKCP and BACP registers by postcode. The therapist accepts the referral for brief work (6-8 sessions usually but sometimes as few as 4) for a pre-set, low fee. Importantly, the clinician carries the clinical responsibility for the work while the EAP middleman harvests the profit.
Very good things can be done in short-term work, and many minimum wage EAP clients would be unable to pay for therapy privately. However, the therapist can find themselves working with all manner of distress and disturbance, without meaningful backing from the referrer who is usually an administrator and webmaster and almost never a clinician. Add to this the reality of working as a therapist in this ‘gig economy’, and it becomes clear that the reality for the clinician is one of precarity.
With the disappearance of many NHS mental health in-patient services, the distress that patients bring into the consulting room is growing. It is widely acknowledged that the population accessing therapy is increasingly so-called ‘borderline’ (usually defined as a combination of poor self image, lack of empathy, anxiety, depression, feelings of emptiness, dissociation and unstable relationships, among other things). Thus the work can be very difficult and requires great resilience. Mental health funding cuts mean that external support can be little more than the (excellent) Samaritans and other phone lines, even for the significant proportion of suicidal people who don’t respond to medication.
People are suffering and looking for help: newspaper and social media reports have recently highlighted unprecedented levels of teenage self-harm and anxiety, while the Mental Health Foundation continues to remind us that 1 in 4 in the UK will suffer from mental health problems in any given year. More and more robust, multi-disciplinary statutory services are being replaced by this extensive network of private practitioners with varying degrees of experience and training. Practitioners group together with like minded colleagues, creating their own support structures to try to sustain themselves in the work they love and in their commitments to the people they treat.
Mental healthcare in the ‘Big Society’ comes down to a tier of highly motivated, self-resourcing therapists struggling, often at great personal cost, to help heal their community. All this while being drained financially of their honest (not-for-profit) income, policed by ever more simplistic codes of ethics and bullied into defensive practice by naive and time-consuming outcome measures: the Squeezed Middle indeed.
Freud treated hysterical symptoms and neuroses and in so doing created a vocabulary for understanding individual and collective human experience, which revolutionised attitudes and social norms far beyond the clinic. A century later, rather than revealing the psychological realities in our society, the counselling and therapy professions are being increasingly coerced into repatriating people silently back into the very social malaise that is making them ill. It must be time for private practitioners to lift their heads from the grindstone, and speak from the heart about what they know is really happening to themselves and to the people they see.
Private doesn’t have to mean silent.
♣♣♣
Notes:
- For the full list of articles in the Surviving Work in the UK series, click here; for a list of contributors to the series, click here.
- The post gives the views of its author, not the position of LSE Business Review or the London School of Economics.
- Before commenting, please read our Comment Policy
Ruth E Jones is a Psychoanalytic Psychotherapist, Clinical Supervisor and Organisational Consultant in Private Practice in Medway, Kent. She has a background in international community projects, working with people with AIDS, with sex workers and with migrants in Europe, and with children, families and adults here in the UK. Initially trained as an Art Therapist she co-edited Psychodynamic Art Therapy Practice with People on the Autistic Spectrum (2014) and has written Foreshoring the Unconscious, Living Psychoanalytic Practice (2010). Ruth is currently exploring how Psychoanalytic Energy Psychology can offer new healing paradigms for the 21st Century.
Psychotherapy/Counselling call it what you will, as a ‘profession’ being practised in the UK will soon be dead. Except, of course, for that travesty of a figure, IAPS. The usual toxic mixture of Capitalism, market forces and government after government that has never really cared for its citizens to be happy in the slightest have all contaminated the original spirit of helping. Yes, what fine polemic.
I live in Telford, Shropshire, where within my postcode there are no less than SIXTY EIGHT counsellors offering everything. I have just finished a two-year part-time course at a local FE college for the award of Level 4 Diploma in Therapeutic Counselling. I say ‘finished’ but I won’t be awarded the Diploma. This is because I can’t get the necessary placement which would give me the required 100 hours of supervised counselling practice. I’ve tried but the paucity of placements in this area is marked. After making 6 applications I have received 6 ” Thanks but sorry we are not…” To pay tuition fees I made use of the government 24+ scheme so that’s almost £3000 to start, then there’s the 20 personal counselling sessions which is a another course requirement. These could cost anything from £0 to £700. However the real jewel in the crown is the supervision fees if you’re lucky enough to get a placement. One of my fellow students was paying £55 per session per month over some 12 months! ( Her husband has a good job) Total so far, around £4000. Net result on the basis of jobs secured by my class? Expensive volunteers. And this is just ONE FE college, never mind all the other institutions that are training therapists.
The ‘market’ has become saturated, job prospects are poor. The only people entering this profession of expensively trained volunteers are the usual suspects: bourgeois married women with children and time on their hands. Who in turn are ‘supervised’ by the same for anything from £75 per hour.. Somehow these two parties hold this profitable, mutually appreciation society together.
As for the client? He/she will just have to take pot luck and hope that the NHS, charity organisation provide something or the agency they’re more likely to turn to will offer some kind of fee reduction.
I began my training 4 years ago with some enthusiasm. I’m 64, taught Maths for 17 years, worked at a lot of doss jobs. No, I wasn’t going for Counselling because of the money. During a period of sheer stupid nievety, I thought I could do something meaningful for which I might get paid. But it seems society doesn’t want or need that and the best I could have hoped for would have been my travelling expenses?
This article, whilst being more articulate, doesn’t really tell me what I don’t already know. Which I staed at the beginning::Counselling is dying and will one day be dead. Long live counselling.
Finally how interesting to see that the esteemed author of this article is a psychotherapist, a superviser, and a consultant IN PRIVATE PRACTICE. Great bank balance….
How pessimistic and a chip on shoulder to boot! I’m enjoying my career a counsellor and psychotherapist a practice that a computer just cannot mimic with the same effect.
its true counselling is dying out, I myself have just completed a three years masters degree in counselling and psychotherapy and it isn’t worth anything, more useful as toilet roll. The only way I would get a job doing it is to train as a counselling psychologist which means more money in education and time I am 29 and not getting any younger, I have housing worries and bills to pay. I hate this economy and I hate the education system for selling lies to graduates. Screw the UK and screw counselling as a profession as a whole.
Can you please amend your comment stating BACP is a statutory regulatory body, it is not. We have no statutory bodies at all just membership bodies.
To clarify: BACP are not and have never been a regulatory body. Counselling remains unregulated. They are a membership body with an attached ethical framework which people register themselves to to demonstrate their willingness to work within such a framework.
Some very good points; it is very difficult at first glance to see how a living can be made. Hence my career of nearly a decade running a business as a self-employed tutor and supply teacher. I needed to develop business skills first, an area not attended to fully on most courses.
That said, there are now many careers that utilise counselling skills within the role e.g. helpline advisers, advocacy, support work so there is plenty of employment opportunity developing.
Counselling training also puts me head and shoulders above many teachers in the marketplace; but most importantly, it was the best investment in my personal development ever made!
I echo the dislike of the reliance of providers on trainees, it devalues what is highly skilled, difficult work within our community. Perhaps the bodies that we register with need to support us more by challenging the status quo in this practice.
Lots of food for thought, good to hear these issues being aired at last, thank you!
Unfortunately, on reading the assertion that the BACP is a statutory regulator in the UK, I stopped reading.
The BACP is a membership club, membership of which is not required by any law or statute.
There are many membership clubs, some older, some newer, but as matters stand, there is no legal requirement to belong to any club.
If the error in this assertion of statutory standing can be amended and corrected, I would be more confident in the words and ideas that follow that assertion.
Good points, well made. It’s hard not to be pessimistic about our profession and its future at times. At the risk of being rather a Pollyanna, the only good reasons to train as a therapist are deep commitment to – and belief in – the work, and a robust personal capacity and intelligence to carry it out. In some respects I was ‘lucky’ in that I had a very realistic picture of my earning potential before I started, and I did not want or expect to gain full-time employment. I feel deeply for friends who are struggling with two or more jobs and who are facing some stark decisions about whether they can afford to continue with their ambition to work as therapists. I work on a voluntary basis with clients who cannot afford private therapy. I’m also trying to build a private practice. I do this work because I can’t imagine finding anything else that would be as personally satisfying and meaningful, but we live in a society that makes it hard to sustain dedication.