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The Surviving Work in the UK series is produced by Surviving Work.
A dismayed psychotherapist in the Midlands, struggling to re-build a private practice after a career break, recently came across an advert on Facebook for a local counselling course, promising ‘the career of your dreams’. Inevitably it had elicited an array of likes and questions about how long it takes and how much you can earn. Well-intentioned forwardings suggesting this would be a great way for someone’s friend to invest their redundancy money.

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.



  • 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.
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ruth-e-jonesRuth 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.