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…?
Photo by Dyana Wing So on Unsplash
19 thoughts on “Equality is the best therapy: What does this mean for the pluralistic tribe?”
Thought provoking article. I have long since believed that emotional well-being is an integral part of a person’s overall health, and in that capacity feel that much more could be accomplished by the provision of more counselling services to people (via the NHS), which I believe would ultimately result in less of a dependence upon medical interventions for people struggling with chronic mental health conditions.
When the Pandemics first lockdown started I offered free online counselling to frontline workers, now I offer donations based counselling and supervision, pay what you can afford. for the counsellors that work for free and make no money from their counselling work, I offer this for free, though most pay a donation.
the thing is though, I feel really guilty asking for money, and actually being a counsellor in Private Practice. The culture of working for free has become so ingrained in my mind that I really would not know where to start or when I could find that mindset that would allow me to charge.
I want to offer a service that is so accessible to all, yet I really want to just cover the costs of my insurance, membership bodies ICO costs, even some CPD… last year I got about half my costs recovered, this year, practically nothing so far.
Also, in my area (Northumberland) the average cost for counselling is between £35 and £45 pounds, for me, this would be unattainable £140 to £180 a month! being in one of the most economically deprived areas in England, and being raised in what some call a ‘sink hole’ estate, my desire is to give an affordable service. But really, I have no idea how to mesh my desire for service to all, over the wish to just recover the cost of being a counsellor.
Thank you for articulating this so beautifully.
This is so close to my heart. I’ve worked with the homeless for 5 years and have seen how this system repeatedly traumatises. I often see the same people come back to live in the hostel. Making therapy equal and accessible to all is one of the main factors to why I am currently training to be a therapist.
This blog is amazing…..change is needed
This really struck a chord with me. Thank you, Alison.
It’s bleak to consider that so many people are unable to access support they so desperately need because they can’t afford it. It can feel as though a person’s worth is contingent on how much they can work and how much they can earn.
I spend a lot of time thinking about the ways we can collectively survive under capitalism, and what alternatives might exist. I feel there is a lot to learn from queer and BIPOC communities that prioritise mutual aid and redistributing wealth to support fellow community members. These communities have always known that, no matter the promises made, wealth will never trickle down, but there is power in sharing responsibility for your own community and the needs of the individuals within it. I myself have accessed the support of the queer community in accessing healthcare that I would still be waiting for had I not been able to ask for help, and now I’m in a better position I give when I can to others like me.
I’m also massively inspired by co-operatives, and I’ve been a member of two co-operatives over the past few years. Working co-operatively can offer people an opportunity to pool resources, adding to the pot when they’re able, and taking when they are in need.
Both mutual aid and co-operatives rely on people working together to solve problems, and perhaps this is something we could consider as Pluralistic practitioners? Pooling resources so therapists can supplement their income when working with people that cannot afford to pay the full rate for therapy?Raising funds for scholarships so people from marginalised communities can train as therapists? I believe wholeheartedly that there are solutions that will allow therapists to support those most in need without compromising their own happiness, and those solutions won’t come from government initiatives, but from real people willing to turn away from the individualism fetishised under capitalism, ready to get down to the messy business of being in community.
Thank you – this is something I continue to wrestle with
A deeply thought provoking, well articulated article that covers topics very close to my heart.
For me personally there is such a deep dichotomy between what I need and what I want in my professional practice.
I want to offer low or no cost counselling to the people who are challenged financially; what I need is to provide an income to live.
In an ideal world there would be counselling provision available through government funding that was easily accessible without the horrendous waiting lists.
Thank you for this.
Such a powerful article and one that raises so many questions around the way our National Health service runs for mental health and well-being. It certainly needs change with the way in which services are delivered so that well-being is a priority and access to counselling is easily accessible. As we are all aware, low-cost counselling services are completely overwhelmed and have very long waiting lists. Urgent action is required as the situation is not going to improve any time soon. I am wondering whether there will be organisations in the future with counsellors choosing to donate their time, rather than clients paying a reduced fee like many charities currently offer. This may be a bridge for those who are unable to access counselling due to long waiting times or finances.
The frequent counsellor retort about valuing the work we do just feels like a verbal technique to silence uncomfortable discourse. How does anyone value anything? Of course there is the necessary debate about working for nothing but this shouldn’t prevent open dialogue about access to counselling by those who don’t have the financial resources to pay.
We have to be the change. Who’s ready to organise? I agree with Hywel that those with a like-minded perspective can cooperative and make change. We have to be the change, together, after all, ‘there’s power in a union’ (Billy Bragg).
Yes Lisset, totally agree and love the Billy Bragg reference! I know you are doing some fantastic ground level work. Maybe you could share some of it here?
Thank you so much for your Blog. It resonated deeply with me and was very thought provoking. The question of privilege in counselling and the ability of people to access good therapy is something which has crossed my mind often. I wish I knew the answer. In answer to your question though – No, I don’t think we should be charging if it were viable to do so. Counselling should be no different to seeing your GP and ought to be free at the point of contact. The Welsh government has been progressive in its attitude to mental health but despite this it seems it is not enough. They have invested a good deal in training school practitioners especially in trauma informed work. Unfortunately, it seems that it doesn’t go beyond that with results taking precedent, I wonder how relevant that is in all areas outside of education and how we take the next step from being passive to active about trauma.
I have wondered if eventually the answer is for a further increase in services in the NHS in particular local GP surgeries. A system like that of the dentists and the pharmacies who charge the NHS for the clients they see. For this to happen I suspect our profession would need to become regulated a whole separate argument and problem, not to mention the money! I am an idealist at heart,not an easy position in this economy led world.
It’s important the question is raised and hopefully the conditions will come right for us to pick up the mantle and move towards greater equality (If only magic wands were real!).
Wow, so powerful reading everyone’s comments and ideas. This feels like a shared experience. It sounds as though we are all working with so much heart, but we also need to be able to live well and free from guilt ourselves. Hywel, I love what you offer from your experience of co-operatives and the idea of communities becoming self-supporting. A book I am finding helpful as I too wrestle with all this is Trauma Stewardship by Laura van Dernoot Lipsky. She shares her belief that we can work to make the world a better place AND stay well and happy ourselves. This is a link to her website https://traumastewardship.com/
Marvellous. Thank you.
Such a powerful thought provoking piece, thank you Alison for raising the questions that we as counsellors very much seek the answers. An NHS under immense strain and mental health awareness being increased within society, very much open ups the financial gap that many are experiencing when trying to seek the help so desperately needed. I agree with Hywel that like ‘pooling resources’ maybe a way forward and as a collective we may indeed see a difference.
thank you for articulating my heartfelt thoughts and feelings long held. I’m now in private practice having worked in recovery and statutory services in the past. I offer a sliding scale of fees for my clients depending on circumstance and reduction for NHS workers since the
pandemic hit. However, these measures feel like a balm for me rather than constructive help for potential clients. Private therapy is mostly out of reach for those who need it. ‘Equality being the best therapy ‘ Is surely the foundation of a caring, inclusive egalitarian society. We are so far away from obtaining this. Onwards and upwards , thanks for the links (:
Very interesting, thanks a lot!
Very interesting article thank you. As a student of pluralistic counselling and psychotherapy you have given me much to think about in terms of how I will work with clients who have experienced inequality and what this means to them. I can feel the ongoing dilemma that you have about charging clients especially in light of long waiting lists in the public system. This is extremely difficult for the counselling profession and needs to be addressed at government level. As highlighted by others on this page if we address inequality and access to mental health services it can only benefit society as a whole. Thank you
My hope is that, in a hundred years time, people are looking back on this period of mental health and wellbeing treatment and are shocked to discover that if you wanted to provide human beings with the access and support to psychotherapy that they needed, the people providing that support would not be able to adequetely support themselves or their families if they chose to do so.
I am in only my early experiences of pluralistic practice, but when there is, hopefully, a meaningful change that prioritises people’s psychological wellbeing, pluralism and specifically working with clients preferences and needs could be the philosophical and practical approach that best supports people.
Totally agree with that hope, Murray. We had a powerful discussion yesterday with our students at University South Wales about the impact of the fuel crisis on people’s mental health. Having to choose between heating and food amidst the ongoing covid uncertainty must be putting an unimaginable strain on so many people right now.
These latest figures from Young Minds are a call to action,
Let’s keep thinking and talking here.