Equality is the best therapy: What does this mean for the pluralistic tribe?
Alison O’Connor, Senior Lecturer, University of South Wales
For the first time in my career, I have begun to charge money to clients. It’s been a disorientating dilemma, forcing me to re-examine my relationship with privilege and inequality and acknowledge the uncomfortable limitations of our profession. Like many of us drawn to pluralism, my professional life straddles multiple worlds, both inside and outside of the counselling room. Over the last 25 years I have been privileged to work in prisons, theatres, with military veterans, on dementia wards, and in rehab; driven by a need to connect, bear witness, and offer the possibility of change and healing. Providing therapy or therapeutic contact free of charge, to people who may not have the means or the motivation to pay for it, has been a treasured component of my professional identity. I confess I may have silently judged those who charged seemingly extortionate hourly rates to clients, smug in my socialist tower where all are equal and equally deserving. It was its emphasis on social justice that drew me to the pluralistic approach and remains for me its most powerful characteristic. The notion of a counselling framework that explicitly invites consideration of clients’ social and political environments and encourages a collaborative recognition of the link between fairness and wellness feels both radical and long overdue. Committing to this ethos, however, raises challenging ethical questions.
I began lecturing a few years back and for a while navigated the balance of Higher Education with an NHS therapist role. As the challenges of the pandemic intensified, I found the juggle of working remotely within two complex systems, while supporting teenagers with home schooling and undertaking research, overwhelming. Something had to give. I tentatively explored the possibility of private practice, sensing this might enable me to balance my academic and practitioner roles with enough autonomy to stay closer to thriving than surviving. So far the evidence suggests this may be the case. I have found, to a degree, the balance I hoped for.
But the money, the money. Despite my supervisor’s wisdom and rigorous dialogue between us around the worth of the service I am offering and the choice that clients are making, there is a conflict that feels existential. As my client, who came to therapy to make sense of the suicide of a loved one during the pandemic, shares with me a life story shaped by intergenerational trauma and racism, my heart tells me it is deeply wrong that he has to pay for this work. As another client, finding the courage at the age of 60 to unpick and challenge the legacy of shame inherited from her mother’s mental illness, abuse and poverty, tells me that, due to the £20 cut in Universal Credit, she can no longer afford the reduced rate I have been offering, I am devastated. And angry. ‘Equality is the best therapy’ is the mission statement of Psychologists for Social Change, whose call for activism within our profession echoes that of pluralism and is surely now more pertinent than ever. This week I heard of three young people being put on a six-month waiting list for CAMHS only to receive a one-off consultation and then be put back on a waiting list. I supported a desperate mother to source a private psychiatrist for her son and shared her disbelief that £300 was the cheapest option we could find. The young people I have counselled in the past year are not from wealthy families, they are from families squeezing their finances rather than risk the uncertainty of a long wait. I know we are all hearing these stories. Is it time, I wonder, to stand in solidarity with our clients and examine what it really means for us, as pluralistic therapists, to work from a social justice position?
Many of the clients I have worked with in the past year are people of colour, from immigrant backgrounds, and/or people who grew up with socioeconomic disadvantage. The scars of discrimination are woven into their life stories and seep into their current difficulties. As we collaboratively explore the interplay of social, cultural, and political factors and their wellbeing, I experience an added layer of complexity in my attempts to reconcile my dilemma of charging for therapy. Am I asking people to pay to repair the impact of oppression, racism, and inequality? Whose responsibility should it be to pay for mental health support for a client who was regularly beaten by his traumatised mother and bullied at school for being a different colour to his peers, who has managed to survive to adulthood but finds himself in mid-life, lost and overwhelmed? Considerations of difference and diversity and their intrinsic links to power and privilege are embedded in the pluralistic approach. Winter et al. argue this places responsibility on therapists to ‘level the field’ where possible, highlighting the danger that we may at times, reinforce the injustice of the current status quo by operating within a framework that is fundamentally unjust. I was mindful of this precariousness when working in prisons, questioning each day the ethics of trying to work with humanity within a system that is retraumatising our most vulnerable.
The UK government has, in the last decade, committed large sums of money to the wellbeing of military veterans, through the Armed Forces Covenant Fund, acknowledging that there is a moral responsibility to support the recovery of people who experienced harm through military trauma. Might a similar argument be constructed in relation to people who have been—and continue to be—traumatised through inequality, poverty and transgenerational oppression? Van der kolk wrote in 2014 that ‘we are on the verge of becoming a trauma informed society’. I fear that the accumulative toll of the pandemic may set us back many years unless there is a radical shift in acknowledging and responding to the need for universal mental health support. As NHS capacity creaks and waiting lists for charities grow, I wonder if private therapy is becoming the only available option for many who had not previously considered paying for mental health or emotional support. As Brian Dow, Deputy CEO of Rethink Mental Illness, said in a recent interview with The Independent, ‘for the average person… £60-£100 on average, a session, that’s a very, very expensive form of healthcare. Would we tolerate that as standard for cancer? If we said 50 per cent of people had to get treatment at a private hospital and pay for it themselves?’
There is of course no easy solution, the pandemic has exacerbated and deepened existing inequalities, revealing a problem that is complex and multi-layered and our solutions will need to reflect this complexity. I wonder how we might, as an emerging pluralistic tribe committed to social justice, add our voices and contribute in a meaningful way to the levelling of the land? Drawing on the central ethos that different clients need different things and that tasks and methods can be generated through collaborative dialogue, do we need to invite our clients into these discussions? How might we work towards systemic change in a way that empowers our clients and respects their struggle, while maintaining our humility and optimism? Our profession has an opportunity to reinvent itself, could pluralism lead the way…?