Therapy: State of Play in the UK 2022 – A Personal View

In the following blog, ‘therapy’ is used as a term to describe both ‘counselling’ and ‘psychotherapy’ and the term ‘therapist’ is used to describe both ‘counsellors’ and ‘psychotherapists’ . I do not recognise any substantial differences in the meanings of the two terms or the two titles. Of course, this has implications for my views on and around the ‘politics of therapy’ as they have evolved up to this point in April 2022, in the UK context. I also need to acknowledge the influence of the online launch of the universal Access to Counselling and psychoTherapy (uACT) on Saturday January 29 2022 which has inspired me to clarify – at least somewhat – where I stand on some of the issues concerning therapists in the current climate.

Counselling, Psychotherapy, CBT, SCoPEd and Regulation

There is a lack of clarity around substantial differences between ‘counselling’ and ‘psychotherapy’ because, in my view, there aren’t any. Similarly cognitive behavioural therapy (CBT) has positioned itself as something superior and different to therapy even though it is just one of many therapeutic approaches. One argument, with regard to perceived differences between ‘counselling’ and ‘psychotherapy’, is that because the ‘core training’ — as the Scope of Practice and Education (SCoPEd) describes it — for psychotherapy is usually longer than for counselling it deserves and its practitioners deserve to be recognised as superior and different to counselling and counsellors. The core training is the training which leads to educational qualifications and SCoPEd, thus far, places less emphasis on pre- and post-qualification trainings. Qualified therapists are likely to undertake the latter as part of their continuing professional development (CPD) throughout their careers. Although a longer initial training costs more money it is extremely arguable if it really produces better therapists in the long run. There might be some justification for recognising and valuing longer trainings at the point of qualification but most therapeutic skills are gained via practice post-qualification. This practice is also enhanced by continuing professional development (CPD) and supervision.

It is important to highlight that my thoughts about therapy mostly apply to the UK. Although there are similarities between the politics of therapy here with other places, such as the USA or Europe, there are not enough to comprehensively generalise. For instance, in the USA, therapy practitioners calling themselves both ‘counsellors’ and ‘psychotherapists’ often train as part of a social work qualification which is unheard of in the UK. Many concerns we have in the profession about the provision of therapy are specific to our locality.

The on-going discussion about SCoPEd is the most visible change in what some call the ‘therapeutic landscape’. According to the British Association for Counselling and Psychotherapy (BACP) this framework will clarify the ‘training, practice and competence requirements’ for therapists ‘working with adults’ (https://www.bacp.co.uk/about-us/advancing-the-profession/scoped).

The latest version of the SCoPEd framework was published in January 2022. Initially a project started by three bodies, the BACP, the United Kingdom Council for Psychotherapy (UKCP) and the British Psychoanalytical Council (BPC) it has more recently included, in its discussions, a few more professional bodies who are also accredited by the Professional Standards Authority (PSA).

According to the BACP: ‘it is an important step as part of our wider work to deliver a number of our members’ priorities – to set standards for the profession, protect clients from unsafe or unethical practice and provide members with the resources and support needed to practice’. Further, the BACP also believes that SCoPEd will prove effective in ‘demonstrat[ing] the value of counselling and psychotherapy to employers, commissioners and government’.

The driving force behind all this activity seems to be an uncritical assumption that the therapy profession, over a hundred years since a ‘patient’ lay on Freud’s couch, are not sufficiently ‘credible, diverse and thriving’ or ‘understood, valued and trusted’.

It seems to me that the BACP, in particular – since the motivations of the UKCP and BPC are much more comprehensible (of which more later) – are suffering from a kind of institutional ‘imposter syndrome’. If they do not consider themselves to be ‘good enough’ then it is not too much of a stretch to think their members are not good enough either.

Overall, I do not share their gloomy view. It seems to me that therapy is currently extremely credible. It is being represented in film, TV, radio and old-fashioned newspapers more than ever. And, although it is sometimes the butt of satire, it is mostly represented with respect and varying degrees of realism.

In terms of diversity, it is undeniable that there is a lack of access to being able to qualify as a therapist for a variety of disadvantaged people. However, there are convincing arguments that SCoPEd is likely to increase this exclusion. In addition, if SCoPEd does come into play, an expensive and time-consuming accreditation process might become a necessity rather than a voluntary addition to a therapist’s CV. If this becomes the case then it would seem to mostly be advantageous to the BACP’s income rather than therapists or clients per se (each application costs £115 to £230). When I applied for accreditation in the late 1990s-early 2000s I don’t remember it being so expensive or having the same level of ‘audit’ as it seems to have now. Various professions have post-qualifying accreditation processes so I am not against accreditation but it must be fairly accessible to all qualified therapists and not used as an excuse to keep perfectly employable therapists stuck in voluntary or low-paid roles.

As well as diversity of ‘backgrounds’ the BACP also refers to the diversity of ‘approaches, philosophies and professional training’ and assure us that SCoPEd will ‘enhance and embed that diversity’. Some bemoan the abundance of different approaches and yearn for an integrative therapy based on common principles of therapeutic change. To my mind, this abundance is more reflective of a creative and fertile culture. As therapists and clients we are struggling with nothing less than the meaning of life (or sometimes lack of meaning) – with such a remit, why wouldn’t we expect different people to be coming up with new and different therapeutic ideas all the time? The expectation that therapy should somehow let itself be fixed into something static and objective profoundly misses the point. The BACP says it is supporting a diversity of approaches and trainings, yet the more it tries to own what the standards and competencies of therapy should be the less it empowers others to consolidate, innovate and evolve different ways of teaching and training. It also dismisses educational levels, with their own external assessors, as having credible meaning. In other words, if the already established hierarchies of Certificates, Diplomas, Degrees, Masters and Doctorates – and numbered educational levels — have credible meaning then why is there any need at all for the BACP to establish alternative hierarchies?

The last time the government attempted to regulate therapy was in 2009 – it caused a lot of problems then, much like SCoPEd is doing now. With a change of government the plans were dropped and eventually we ended up with the PSA which accredits the registers of membership bodies like the BACP. The PSA seems to be enacting a reasonable compromise between self-regulation and statutory regulation (SR) yet a surprising number of therapists, perhaps a majority, are still in favour of SR.

Despite protestations that SCoPEd is all about extra clarity for therapists, clients and providers, it could actually be – and I hesitate to state this as a fact — about the institutionalisation of ‘psychotherapy’ as something better and different to ‘counselling’. I don’t mind this being a goal of the UKCP and the BPC – after all, they are representing their members – but the BACP — whose very name suggests that counselling and psychotherapy inhabit the same professional world — rather than getting behind SCoPEd’s hierarchical emphasis would be better off suggesting a common entry point for both counsellors and psychotherapists, with additional ‘badges’ available to those who either want or need them. As it stands, it seems likely to fail on the same grounds it did last time, in 2009: therapists cannot agree on what the differences between counselling and psychotherapy are and many (both ‘counsellors’ and ‘psychotherapists’) do not recognise that substantial differences exist in the first place. This debate will run and run, and although it would be beneficial to get beyond it, SCoPEd fires up the debate rather than extinguishing it.

More people need the chance to become therapists. A bar needs to be set but it shouldn’t be a bar to keep people out. I can agree with a major aim of SCoPEd – to attempt some kind of clarification – but I am against it because it confuses rather than clarifies and manages both to over-simplify and over-complicate at the same time. The columns need to go and be replaced with a framework which allows everyone to achieve perceived competencies.

The ‘psychoanalysts’, as represented by the BPC, despite being part of the SCoPEd project, seem to exist outside its parameters. CBT therapists, similarly, do not have anything to do with SCoPEd and trust their membership bodies – the British Association for Behavioural and Cognitive Psychotherapies (BABCP) and British Psychological Society (BPS) – to access employment opportunities, at all pay levels, by ensuring CBT remains the top choice for therapy in the NHS. The CBT lobby have successfully gained and held power in the Increasing Access to Psychological Therapies (IAPT) organisation and in NICE’s ‘guidelines’ for various mental ‘disorders’. There has been a long, brutal turf war and therapists (particularly those who belong to psychodynamic, humanistic and transpersonal orientations) have lost out.

Our membership bodies are helping the therapy profession to a certain extent. For instance, good work has been done within the BACP on the new NICE depression guidelines. But therapists, as a whole, continue to be marginalised. Besides the controversial SCoPEd project – which the BACP asserts is supportive of therapists’ interests – the BACP does not seem to have many other ideas or hold the same kind of influence and power as the BPS and the BABCP.

This is the status quo and this is what needs to be challenged.

Challenging the Status Quo

‘Without Contraries is no progression’ wrote William Blake and in a much needed counterpoint to mainstream attitudes to therapy as exemplified by organisations such as the NHS, IAPT, NICE, BACP, UKCP and BPC (those presently holding overt political power) there are also organisations springing up which attempt to articulate and promote different views about therapy and what it means to people (both therapists and clients). These organisations wield at least some influence for thousands of therapists whose voices are marginalised and whose talents are underestimated by systems getting lost in ‘audit culture’. The organisations therapists can join which offer critical counter-narratives include: Partners for Counselling and Psychotherapy (PCP), Drop the Disorder! (DtD), Psychotherapy and Counselling Union (PCU), Radical Therapist Network (RTN), Disabled People Against Cuts (DPAC), Counsellors Together UK (CTUK) and more recently uACT. Support for more therapy in institutions such as the NHS might also come from critical psychiatrists.

Increasingly, therapists have no option but to work privately as their trainings – of whatever level, up to and including doctoral — are being shunned by the NHS. We are in the middle of a political battle in which therapy, as most people know and understand it, is losing out to more powerful ‘psychology’ lobbies and so-called ‘evidence-based’ therapies.

Politicians, on the whole, think that what’s on offer is enough. The IAPT service has a lot of funding but unfortunately and paradoxically does not provide many different types of therapies/therapists so people don’t end up getting who or what they want. Consequently they are unable to explore, understand and change their lives in ways that resonate with them. Unsurprisingly, there is a high drop-out rate: the idea of ‘personalising’ therapy (Norcross & Cooper, 2021) is nowhere to be seen in an NHS dedicated to their own in-house ‘evidence-based’ therapies. It is also reported that IAPT is pushing out smaller providers, who have the skills and knowledge to direct people to appropriate therapies/therapists, in favour of larger providers who are not in touch with the communities they serve.

Our mental suffering cannot be separated out from our environments and the demands of those environments. This has become even more apparent in the post-COVID world in which our everyday assumptions about education, work, home life and childcare have all been challenged. Some, such as James Davies in his book Sedated (Davies, 2021), suggest contemporary mental health crises have been created more by capitalism as a system than by individuals not having enough ‘resilience’ (for example).

CBT has done a good job as promoting itself as the ‘answer’. And there are some who are anti-CBT. I don’t think CBT is the answer or the problem. And a lot of CBT therapists would agree. CBT is not different to or above therapy – it is, in fact, just one type of therapy, useful for some people some of the time and completely alienating for some people some of the time. ‘Personalizing’ therapy rather than idealising or demonising certain approaches would be more beneficial for clients (Norcross & Cooper, 2021). And it is useful to remember that even some CBT therapists do not recognise IAPT-CBT as proper CBT. I do not object to ‘IAPT therapy’ per se – what I object to is ‘therapy therapy’ not being on the menu. For instance, Counselling for Depression (CfD) is not the same — at least, theoretically – as person-centred therapy (PCT). But, undoubtedly, there are therapists doing work in the NHS and even IAPT who are sneaking in ‘therapy therapy’ even if, on paper, it is called CBT, CfD or interpersonal psychotherapy (IPT).

Schools are offering pseudo-therapy via ‘pastoral support’ and it would be preferable if there were therapists in every school. This is a symptom of the wider encroachment of therapy by other professionals/paraprofessionals with new and different titles. The message that therapists are actually the most suitable practitioners to be delivering therapy needs to be loud and clear.

The public know what they want even if policy makers and commissioners don’t. That is why those who can afford it go private and give up on the possibility of free provision. So many people have had positive experiences of therapy. Somehow we need to get their voices heard and their support for others to get what they have had. We need to bring about a situation in which everyone can access what is already available in the private sector (and to a limited extent via EAPs and insurance). The public need to make it clear that they want alternatives to medication and medicalised responses.

The IAPT/NICE/NHS conglomerate is central to problems in the provision of therapy. The battle with that conglomerate is worth fighting but there are other fronts e.g. in communities, the third sector, and social services rather than health services. It always strikes me as a slightly difficult challenge to convince a medical service they should not be conforming to a medical model… maybe the NHS isn’t the right place for therapy?

IAPT is a ‘failing service’. Waiting lists for CfD in some districts are over a year. This is not universal access and it is not taking the problems of those requesting therapy seriously. For the time being, whilst IAPT holds such hegemonic power within the NHS we do need to work ‘with as well as against’ IAPT in the hope that different kinds of therapists and therapies might be added to what is already there. There are good practitioners within IAPT and it is not so much about being against what is already provided (although there are many valid critiques) but for the provision of therapy as most people, therapists and the public alike, understand it. There needs to be more client input and more client choice. There is no reason why clients should not be able to choose how they access therapy, for instance via video, phone or in person. They could collaborate with therapists on how many sessions they want and they could make choices about how relational or how instrumental they want their therapeutic experience to be. Some clients might also want to venture into transpersonal approaches which are completely unavailable in the NHS (notwithstanding ‘mindfulness’ getting in the back door on the back of ‘CBT’). If the NHS does not respond to the demand that therapy (as it is understood by most people) be available in its services then the only place where therapists can work according to what clients actually want, rather than what other people say is good for them, is in the private sector. Everyone should be able to access that – either as it is via subsidisation – or if that is not possible via the public and third sectors (with fair pay and conditions).

Davies, J. (2021). Sedated: How Modern Capitalism Created Our Mental Health Crisis. London: Atlantic Books.
Norcross, J.C & Cooper, M. (2021). Personalizing Psychotherapy: Assessing and Accomodating Patient Preferences. Washington: American Psychological Association.