In the past, counselling and psychotherapy were available on the NHS, usually through GP referral. However since the IAPT (Improving Access to Psychological Therapies) initiative, provision of counselling and psychotherapy has been drastically reduced and what is on offer is almost exclusively CBT (Cognitive Behavioural Therapy). CBT has become the favoured modality within the NHS for a number of reasons. It is a ‘prescribed therapy’ i.e. all practitioners are trained in the same techniques and adhere to the same model and series of steps in delivering therapy. Adaptation of technique is made according to client ‘diagnosis’. CBT is the most common choice of therapy within the NHS for the following reasons:-
It is readily understood within the ‘medical model’ context – the patient has a diagnosis (e.g. Panic Disorder, Generalised Anxiety Disorder, Depression etc), CBT is the treatment and outcomes are measured by questionnaires – the PHQ9 for Depression, the GAD7 for Anxiety. This seeks to make success quantifiable.
Because CBT is structured and prescribed, it can submit itself more readily to the usual ‘medical model’ formats for testing effectiveness – Randomised Control Trials (RCTs), which are used by pharmaceutical companies and medical researchers to ascertain the effectiveness of drugs and medical treatments. Thus it can be evaluated within the familiar medical frameworks.
The term ‘evidence-based’ is used to denote therapies which are sufficiently standardised that they can be subject to Randomised Control Trials. Many Integrative, Psychodynamic and Humanistic approaches are much more creative, dynamic and responsive to individual need and difference. This does not mean that they lack evidence to support their effectiveness, though this can sometimes be the implication! It means actually that the diversity in the way that practitioners achieve their results is such that it is impossible to use RCTs to evaluate it. Neuroscientific research in particular, is beginning to support the effectiveness of relational therapies.
Practitioners within the NHS using CBT are doing really good work, in some cases life-saving for their patients. But most experienced CBT clinicians would probably agree with the following points.
CBT is great where there is depression and anxiety and the patient benefits from learning better thinking strategies and techniques for coping with negative thoughts and difficult feelings.
Where it is not so effective is when the problems are complex, multiple, of long-standing, about relational difficulties or where the anxiety and depression (or whatever symptom gives rise to the diagnosis) are more deeply rooted in past experiences. Here there is a danger that working exclusively in CBT may simply treat the ‘current manifestation’, rather than the underlying causes of distress.
Diagnosis is only useful to a point. Human beings are unique in their psychology and layers of ‘history’ are usually intertwined in a complex way, which is unique to that individual. So treating psychological distress is not like dispensing treatment for say, chicken pox or the common cold – nor are psychological conditions acquired in the same way as medically definable diseases or syndromes.
IAPT (Increasing Access to Psychological Therapies)
Is NHS funded and therefore, as one would expect, needs to be subject to budgetary constraints. This means that:-
- Not everyone seeking therapy will arrive at what is known as a ‘Step 3 intervention’ – i.e. the chance of sessions where they interact directly with a practitioner. Much provision is through online programs or group psycho-educational workshops.
- Many Step 3 interventions do not involve face-to-face therapy e.g. sessions may be online, via a text messaging service.
- Wait times for therapy can be long.
- Recovery rate targets are 40%, though in fairness, given the measures, ‘recovery’ was originally restrictively defined and is quite hard to achieve.
- Therapy is always time-limited – so although many patients will have their needs met, for a substantial proportion, what they receive will not be sufficient to enable them to make the long-term change – and provision for longer-term therapy is very scarce. This can result in a ‘revolving door’ effect, where patients present over a period of time, repeatedly with the same or different symptoms, but the underlying cause is not addressed.
For those are in a position to fund their own therapy, choices are much wider and provision is much more capable of addressing peoples’ need.
I hear/read comments from time to time that ‘counselling and psychotherapy is an unregulated profession’ – which is simply not true. We missed the opportunity to have HPC regulation a few years ago and so it is true that ‘Counsellor’ or ‘Psychotherapist’ are not protected titles. However, most consumers are fortunately rather more discerning – and realise that not all practitioners are equal or equally effective. Like any other industry, there are ‘kitemarks’ which indicate safety and quality of service. These are:-
UKCP Registration – usually means Masters Degree level training (MA or MSc), takes around five years to complete, involves significant training input and clinical experience and supervision. Most practitioners at this level have their own personal therapy for at least five years and undergo exacting requirements to achieve their registration. (Differently to CBT practitioners, psychotherapists would see personal therapy as essential part of their training, as the relationship between therapist and client is central to the work.)
BACP Accreditation – is the better known ‘kitemark’, and usually requires at least Diploma level training and specific criteria for training, clinical hours, personal therapy and supervision. However, it is less exacting than UKCP registration.
You the consumer, are largely in charge of how long we can work for. I do quite a lot of short-term work – and for many people 6-10 sessions is perfectly adequate and they leave feeling different and with their difficulty addressed. For people with a longer history of psychological problems or who have complex issues, usually it takes a longer time for therapy to be effective. It can take time to achieve a relationship of trust sufficient to do the necessary work, gain insight, process emotionally what needs to be processed, work through the history of ‘how come I am like I am?’ and then to facilitate change. However, people with longer-term difficulties would usually see results if they are in therapy for 3 – 6 months. And some clients come for a great deal longer than this.
Being Integrative and working in private practice also gives further scope for how we can work. We are free to be creative in our work in all kinds of ways – and I believe that the flexibility and creatively on offer through private practitioners mirrors more effectively the huge diversity and uniqueness of human beings and the problems that they bring.
Advantages of Private Practice provision
- Generally little wait time.
- The flexibility of meeting times/frequency.
- Open-ended contract – as much or as little therapy as you find you need.
- You choose the practitioner and have the chance to ‘try’ before committing.
- Flexibility in modality – not constrained to a particular way of doing therapy
- Although my normal mode is face-to-face, I am also happy to do sessions over Skype where people have moved out of the area, or travel away frequently.
- Private practice is effectively consumer-driven – only practitioners who are effective will be able to maintain a viable practice. It is up to private practitioners to keep pace with what people need.
- Private practice offers clients a huge amount of choice in the type of therapy, and the ability to choose your own practitioner. Psychotherapy research indicates that the greatest predictor of successful outcome is the relationship with the therapist – so being able to choose someone who suits you is tremendously important to the process.
Voluntary Agencies, Charities and Low-Cost Counselling Services
Really good therapeutic work is done in these settings. Low-cost counselling is the only provision open to some people – and a good thing that it is there. Much of the therapy here is done on a voluntary basis – often by people who are in training to become counsellors and psychotherapists. As long as practitioners are adequately supervised, this is not normally problematic and clients can still derive great benefit.
Sometimes the problem here is that the complex cases, which have not or cannot be adequately helped within NHS provision end up being treated by the least experienced practitioners. This means that the work may take longer or be limited in its depth or efficacy Services may also be restricted too – some operate ‘time-limited’ therapy or only offer therapy for certain conditions.
Counselling and psychotherapy training is hugely expensive, so often practitioners move on to seek paid work once they gain a certain level of experience. This is a good thing – it would not be right for the profession to be populated solely by people of independent means, who do not need to earn and should be seen as a worthy, high level profession, not simply a hobby! But it is the norm for the vast majority of practitioners to have had to do a voluntary placement as part of their training.