The demise in 2023 of the Westminster Pastoral Foundation (WPF), one of the UK’s most respected training organisations and counselling charities, sent shock waves through the sector. An established institution in the psychodynamic world, its story is an increasingly common one post-COVID, as organisations seeking to provide affordable counselling and psychotherapy to local communities struggle to keep their heads above water.
‘Counselling charities are closing yet demand is going up,’ says BACP Third Sector Lead Jeremy Bacon. ‘It is gravely concerning when organisations that are used to delivering a lot for very little are now being squeezed to unsustainable levels.’ Small to medium-sized charities, he says, play a vital role in the landscape of mental health and social care provision. Rooted deeply within their communities, these services are trusted and accepted by that community and have first-hand knowledge of its challenges and how best to deliver support. But a worrying number are shutting up shop.
Although many rely on trainee counsellors to provide the bulk of the sessions unpaid, the costs of running such services have become crippling, says Nick Hall, former Training and Development Officer for Bedford-based charity BCaT. ‘Funders want lots of people going through and getting help, but many charities still believe in the value of offering a decent length of therapy so individuals are able to make real and lasting changes in their lives.’ The question these organisations are now facing is whether providing long-term, low-cost therapy remains tenable in today’s economic climate.
Culture change
This was the dilemma tackled by Toby Ingham when he took on the role of Clinical Director of South Bucks Counselling (SBC) in 2019. When Ingham arrived, SBC was offering open-ended psychodynamic therapy to a limited number of clients who tended to stay several years. ‘If you have 18 counsellors seeing three clients a week each on an open-ended basis, once you get to around 50 clients, you are full,’ Ingham points out. ‘By contrast, if you offer time-limited counselling, you have a predictable rotating capacity and your doors are open. My aim was to achieve a very low waiting list so we were genuinely meeting local needs.’
By reducing the offer to six months maximum, SBC was able to release its client log jam. By the time Ingham left in June 2023, SBC was receiving and assessing around 150 applications for therapy, compared with 40 in 2019. ‘You can still do good work within six months if you set out with that intention and are clear about the boundaries,’ says Ingham.
Training
WPF’s closure had much to do with the wider economic climate, running costs and specific problems with its premises, but the key factor was a steady decline in its main source of income – its training. Students weren’t signing up in sufficient numbers for the psychodynamic model it offered.
The lesson, says Catherine Matheson, former Clinical Director, is clear: ‘The profession has to take account of the changing context around it. People want shorter-term accessible therapies these days. There is a place for short-term models such as EMDR and CBT, and WPF had recognised that; it had introduced an 18-month time-limited service and a brief 12-week psychodynamic model of therapy some years back. But it ran out of road.’
Mixed economy
Bacon argues that one way forward is a mixed economy of healthcare provision where the big players – the NHS, local authorities, bigger charities and grant-making bodies – nurture and support the smaller organisations who are out there doing vital in-person work with individuals and communities that they, uniquely, can reach because of their local roots and greater flexibility. ‘There needs to be more investment, and a recognition by the statutory sector that smaller organisations may need business support to deliver on contracts, or larger contracts subcontracted by the bigger umbrella charities to the smaller organisations,’ Bacon says.
But very few third sector organisations and community interest companies (CICs) have the capacity to deliver counselling over whole counties and regions. And is there another cost to their values and principles of what is effective therapy? Have they had to compromise their values, standards and beliefs to fit the NHS model?
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Flexibility
Vicki Palmer is enjoying a quieter life these days, running her own community therapy space, the Manu Centre, in the rural west of England. Until 2021 she was CEO of Oasis Talking Therapies, a CIC that had, over many years, delivered NHS therapy services across Bristol and South Gloucestershire. As such she was responsible for a multimillion budget and managing an organisation employing large numbers of both counselling and CBT practitioners and psychological wellbeing practitioners, based in numerous centres. Her triumph was to have worked with local commissioners to retain counselling as an offer initially back in 2005, and thence through the early days of IAPT and onwards, when the introduction of ‘Any Qualified Provider’ competitive tendering, under the 2012 Health and Social Care Act, opened up the NHS to outside bidders to deliver its services. ‘Being a relatively small organisation, we could flex quickly to changes in the NHS landscape, and we could use the IAPT outcome measures to demonstrate that we were offering cost-effective services with better outcomes than local NHS trusts,’ Palmer says. The strong relationships they developed with commissioners and other local statutory and voluntary sector organisations were central to their success, she believes.
Then, in 2019, Oasis Talking Therapies’ bid to continue supplying the IAPT service failed – the contract went to an organisation from outside the area, with roots stretching into the private equity sector. It was, Palmer says, down to politics with a small and a large ‘p’. To anyone seeking to set up a new counselling CIC right now, she would say: ‘Don’t do it alone. You’ll need to partner up with other organisations if you are going to have the capacity and resources even to bid in the first place.’
Diversification
In the north-east of England, Toby Sweet is one charity CEO currently navigating this challenge. He says his service has grown and developed through what he calls ‘considered compromise’ – delivering what he knows works, to a high standard, and diversifying so he can offer NHS commissioners what they need to deliver on the priorities set for them by Government and NHS England. Sweet leads Sunderland Counselling Service (SCS), a charity that provides not just counselling but also CBT, low-intensity psychological therapies and mental health and wellbeing services under contract to the NHS across the north-east region. Alongside, it runs a number of specialist counselling services – for children and young people, for people with cancer and for survivors of sexual violence – mainly funded through grants from a range of sources. It directly employs around 165 people, including office and administration staff, and has a turnover of some £6 million. When Sweet joined the organisation there were 12 employees and it had an annual turnover of £250,000.
‘Diversifying was one key factor in how we got here,’ he says. ‘It was a strategic decision the trustees and I took when IAPT started being rolled out. So long as it was psychological support in its broadest sense, we wanted to be part of it. Of course, everything we do has to be in line with our charitable objectives, which are fundamentally about meeting need and are not restricted to solely providing counselling.’
Being open to working with NHS contracts does inevitably mean some level of compromise, says Sweet. ‘You take the models that NICE and NHS Talking Therapies endorse, and you work with them. When I first came into this sector counselling tended to be open-ended, and that meant you had a small number of people getting great therapy and a lot of people on a waiting list who weren’t getting anything. That isn’t fair, it isn’t equitable, and it doesn’t make sense organisationally. So in the early years I was doing a lot of work to shift the culture and change those models.
‘We’ve always taken the view that we want counselling free at the point of delivery. And if the way to do that is through the NHS, then that is what we will do. Alongside, we get grant funding for the other specialist services we offer, which means they are free at point of delivery too.’
For Sweet, it’s about being clear about your red lines and what compromises you are prepared to make to achieve the greater good: ‘It would be wonderful if there were limitless funds and people could have therapy for as long as they needed, but we have to be realistic and we have to be fair.’
Specialising
For other organisations, the key to survival lies in specialising and identifying an unmet need, like TIC+ in Gloucestershire, which provides counselling to children, young people and their families who need help but don’t meet the NHS criteria for CAMHS. Last year TIC+ worked with around 4,000 children, young people and families in the region, and delivered some 20,000 sessions, roughly 80% of which were under contract to the local NHS commissioners. And, thanks to its long-standing relationship with the commissioners, it has carved itself a recognised place in the regional landscape, delivering what it can demonstrate is most effective for the children, young people and their families, says Judith Bell, its Director of Clinical Services, who jointly heads up the charity with Claire Power-Browne, Director of Operations.
In 2013, TIC+ was surviving on grants and fundraising while seeing increasing numbers of children and young people sent – unfunded – by CAMHS. So Bell approached CAMHS and ‘began a conversation’, which led initially to a direct referral relationship, whereby CAMHS supported TIC+ to see children and young people who didn’t meet their criteria, and TIC+ referred to CAMHS the children who needed more specialist input. Then they successfully applied for a Government grant which enabled them to move to a formal commissioning arrangement with the NHS.
A significant decision in their progression was to stay within their area of specialism, Bell says. ‘There is a real gap for those young people who don’t meet the criteria for CAMHS but need more than a self-help approach.’
They are commissioned to provide a seven-session model but, like SCS, they are able to have a high degree of flexibility within that; their guiding value is what is best for the child or young person, Bell says. And because it is funded by the NHS, TIC+ can hold to its primary value, that the counselling should be free to the client – as it was when they were self-funding through grants and fundraising. ‘Our commissioners could see the need to support our team to make our service sustainable so the waiting list doesn’t creep up and up,’ Bell says.
Symbiosis
The York St John Communities Centre is another initiative that has found a way to meet an unmet need in the community and remain financially viable. The centre, which was established in 2016 to provide both low-cost counselling to the city of York community and ensure placements for students enrolled on the York St John University’s counselling courses, is a shining example of mutually beneficial symbiosis.
The centre costs the university very little – that was, says Lynne Gabriel, Founding Director of the centre, President of BACP, and Professor of Counselling and Mental Health, part of their pitch when she and colleagues negotiated its development: they would not be a drain on university resources. The university has recently provided the centre with newly refurbished premises on the campus and pays the salary of an administrative manager to co-ordinate its activities. The centre has diversified over the years, but its core offer is the counselling – an initial eight to 10 sessions with the option to extend to 20 maximum, at rates on a sliding scale that starts at £12 a session.
We’ve also supported people by providing various forms of payment support, such as extending the payment period,’ says Gabriel. ‘We also offer a lot of free groups, and when we do have to charge it’s always at a fair and affordable rate.’ And it’s busy. These days the centre offers counselling to some 100 clients at any one time, and plans to increase this.
The centre is part of an active research consortium along with four similar counselling centres attached to a university, at Abertay University, Birmingham Newman University,
University of Roehampton and University of Salford. ‘It’s a win-win arrangement,’ Gabriel says.
Putting the client first
Not every small to medium counselling service is a charity or CIC – some of the most robust grassroots counselling organisations are run as businesses. But how easy is it to be successful and deliver a quality service that keeps the client at the centre, especially when you are seeking contracts from organisations wanting counselling and mental wellbeing packages and your primary client is the organisation?
‘To run a viable business in the corporate arena, I have to be able to strike a balance between meeting the commercial imperatives of running a successful EAP and protecting my integrity as a counsellor,’ says Sharon McCormick, Clinical Director at The Listening Centre, an EAP provider based in the Midlands. ‘I don’t want to lose the customer, but I will not compromise my integrity, because that to me is everything. I don’t advocate a prescribed approach and really value my affiliate team.’
Working within a six-session model was a challenge initially, she admits, but over the years she has gained the trust and confidence of her customers to negotiate a more flexible approach that ensures she can provide what the individual receiving the therapy needs. ‘If it’s clear that a company doesn’t value staff wellbeing, I am now in the unusual position that I can just walk away. I’ve managed to align the therapy and our starting point is always, “What is the right thing to do for the client?” And then I design, build and deliver services that do just that.’
She doesn’t charge by ‘average annual take-up’; instead, she has adopted a pay-as-you-go pricing structure: ‘As we are a relatively small business, we’re able to track and monitor each case for both quality and progress. It means we place the individual client’s needs first while satisfying the employer’s duty of care.’
She is actively encouraging other counsellors to get into the EAP business. During the pandemic, she developed a training course for potential entrepreneurial peers, which she still runs annually where there’s demand. ‘There’s definitely a gap in the market for small-scale providers who can offer a more personalised, tailored service to local firms than the national EAPs,’ she says
Dialogue
Alexis Powell-Howard is Managing Director of Fortis Therapy and Training, a limited company that she launched in 2012 to provide mental health and wellbeing services across the UK. Its offer includes therapy and coaching for individuals, couples and families, adoption support services, and wellbeing, coaching, leadership and training for businesses, schools and emergency services. She started with just one counsellor – herself – and now works with a team of 50, both directly employed and self-employed, depending on the work and the client. ‘I have not gone for big NHS tenders. We’ve looked at them but if it’s going to compromise our offer and doesn’t fit our values I just don’t do it. I don’t want to be ticking the box that says we are delivering what the service says it will deliver when it isn’t meeting the person’s needs. There is a need for those statutory services – there are some very poorly people out there. For me, it’s about how we can work alongside the statutory services.’ She believes in paying her counsellors a fair rate for their work so works in partnership with a local fundraising charity, the O’Flynn Foundation, which can subsidise therapy for people in particular need. Fortis also offers free sessions to a small number of clients, if they are willing to see a trainee counsellor on placement and it is appropriate.
In Powell-Howard’s experience, it hasn’t been necessary to compromise on the quality of the therapy Fortis offers in order to thrive. ‘I’ve learned that often the person commissioning the therapy doesn’t understand what it is; they just want the person to feel better. So, if we are delivering a service to an organisation, we have that dialogue with them. If it seems we are setting an individual up to fail and may possibly even do them harm because we aren’t able to offer the level of therapy needed, then we won’t do the work in the first place. It’s not about money for me and never has been.’
Grassroots
It’s clear there is no one-size-fits-all response to the economic challenges many services are currently facing. Whichever route an organisation chooses, they are going to struggle if they want to provide an equitable service without statutory or other reliable sources of funding. Some might argue that counselling and psychotherapy will always remain on the fringes of mental health provision, and that is how it should be; that it would be unethical for counsellors to practise in an environment that is not conducive to effective work and where they have to compromise on the fundamental principles of their profession and what research tells them works. Others argue that the profession needs to be more pragmatic and adaptable if it wants to make itself and the benefits it can offer available to all on an equal basis. Time will tell which strategy is most likely to ensure survival. But in the meantime, every time a grassroots initiative closes its doors, another lifeline is lost for those who otherwise couldn’t afford counselling.