Note: Many people cannot afford private therapy or are not able to successfully claim PIP. We understand this as does the author. If however you are in this position of having an income or a PIP award this offers some very useful experiences and lessons. For advice on Benefits see these resources Here
I am not a user of NHS mental health services but I choose to be a client seeing a private therapist on an open-ended basis. I have no private health insurance cover. I live in a housing association flat on an estate with its share of anti-social behaviour and police attendances. Until this new financial year my income as a single adult was low enough to qualify for Working Tax Credits. I am employed by the NHS and believe in care available to all regardless of wealth. I value my GP surgery immensely and their endless care provided without complaint. I don’t seek transformational change through private therapy but ‘life support.’
Due to the scarcity of long-term therapy on the NHS there are more people with enduring mental health issues finding we need to look to the private sector. I must admit that in 2012 I did receive a year’s psychological therapy from a psychologist in the local Community Mental Health Team (CMHT) before being discharged back to my GP, no doubt to the relief of that service which had ‘held’ me for ten years. I have since been re-referred to the CMHT during crises where the practitioners triaging the referral have been astonished to meet someone who has received individual therapy from their psychological services. I have been discharged immediately after these ‘assessments’, told to use the tools that I was given in that therapy. I am seen as having used up all of my chances with mental health services and can be turned away as a time waster. I have exhausted what psychology input used to be available but is now a rarity.
Unfortunately, some problems still remain even though I had this one year’s therapy six years ago that should have converted me into a person who would never be distressed again. In 2014 I was granted some ‘top up’ sessions before being discharged and told that I wouldn’t be seen by the CMHT in future while I still had the ‘same presentation.’ I wasn’t able to explain to the mental health services then or now that the clumsy and final way in which I had been discharged exacerbated my difficulties, resulting in a sense of failure and tarnished ending.
With over seven years’ experience of seeking and receiving private therapy support I can share what I have learned here in case you also find you are abandoned by the NHS but don’t feel ready to go it alone yet. I appreciate that there will be many readers with counselling qualifications and years of practice who will find my account lacking. This will be subjective writing but that reflects how each unique individual will react differently to therapy and needs to find the right match of therapist. No therapist will be perfect, but where a therapist is open to thinking about walking in your shoes then there is potential.
I am conscious that for so many people private therapy is out of reach financially. The lowest price I ever paid for a therapy session was £40. I currently pay £90 a session but, as I will later explain, this experience has provided the best value. I receive Personal Independence Payment (PIP) which mostly covers the session fee. However, my first PIP claim has ended and I wait with trepidation as to whether I will be awarded PIP again. Though I am receiving weekly specialist psychology support, the DWP tend to only recognise medical evidence provided by an NHS service. I was turned down for PIP the first time I applied even though I provided a letter from a private counsellor who called herself a psychotherapist. The Atos report repeatedly stated that I received no specialist input. When I complained that most questions in the assessment were about what NHS services I accessed and not how my disability affected me, the written Atos response was that the DWP used secondary services as an indicator of severity. In practice, the DWP decision maker favours NHS or Atos evidence over that of a private psychologist even when that practitioner also does NHS work. If I lose PIP then my therapy will be at risk but I would still prioritise this investment over other living expenses.
There are several online facilities to find a private therapist especially the BACP website and the Counselling Directory. Counsellors and therapists will pay to be included on these sites and can indicate the areas of counselling they deal with. I feel sceptical about the wide choice on the Counselling Directory where some, apparently newly qualified, counsellors will indicate they deal with all of the 93 categories listed. I doubt that a counsellor would have an interest in areas as diverse as Autism, Abortion, HIV, Personality Disorders, hearing voices and gambling. Since I object to my diagnosis of ‘borderline personality disorder’ I could make sure the therapist didn’t have an interest in this area by excluding that option, but then I may miss a practitioner who was critical of the label too. No therapist is likely to go public with a critical view of current mental health practice and so one profile is much like another. These bland profiles may say how the counsellor wants to help you to live a fuller life and will provide a safe space. There are photos of the practitioners, making the site feel like the therapists’ equivalent of Tinder.
There are some definite warning signs to look out for in profiles. I avoid therapists who are clearly looking to supervise trainees rather than troublesome clients and boast of their skills. A psychotherapist who comes up in my postcode search on the Counselling Directory describes himself as one of the leading psychotherapists in the field with a national and international reputation. He has written books on the erotic transference and countertransference within the therapeutic relationship, suggesting erotic feelings and fantasies can bring about transformation. Where a professional has a research interest or psychoanalytic focus then it is advisable to steer clear since they are likely to see you through their filter. I have negative experiences of therapeutic communities so would discount a therapist prepared to say he had worked in these places which would mean he had facilitated group cannibalism.
The fees of therapists may be another deciding factor. My experience is that psychologists charge a lot more than counsellors and psychotherapists, even outside London. A few years ago I worked close to a psychology practice where fees started at £130 for an associate psychologist. An assessment report by one of their psychologists would cost several hundred pounds. The average session fee for a counsellor or psychotherapist is usually £50-£60 though some offer sliding scale which may take it down to £40. There are charities such as local Mind associations where they offer free or subsidised counselling. Some employers provide an Employee Assistance Scheme though my experience is that these are call centres where any counselling offered amounts to six phone calls with someone who only gives their first name.
Most psychotherapists and counsellors operate a 50 minute hour. I have resented paying £1 for every minute and so £3 may go on a long pause or £10 on a pointless interpretation which I didn’t recognise. Given the high cost it is important that you find a therapist who allows you to direct the time and doesn’t impose a particular model on you that doesn’t make sense. I used to end sessions sooner than 50 minutes as I would worry so much about causing the therapist to overrun, though they kept looking at the clock so this was probably unnecessary. It has felt as though I was toxic and could only be handled carefully within the allowed slot before ceasing to exist once time was up.
With counsellors registered with the BACP you may want to look at whether they have worked to gain accreditation or senior accreditation. A person centred counsellor can be as skilled and able to deal with complicated issues as a psychotherapist. It can feel as though a psychotherapist’s training, with years of costly self-analysis, leads to them becoming less authentic as they are able to objectify and distance clients. There is a professional mystique around psychoanalysis and psychotherapy which now seems outdated. Don’t be afraid to ask the therapist about their qualifications and experiences. If they are defensive about this question then look for the door.
Therapy approaches (whether you like them or not)
I don’t wish to generalise, but my experience of therapists is that their style and demeanour is influenced by their training and treatment modality. The therapist appears to believe entirely in their single modality. I find CBT therapists dogmatic in their promotion of CBT with an insistence on it being evidence based, making sure they give you ‘homework’ and that you do not look to them for support. Last year I made an appointment to see a CBT practising psychologist willing to offer five sessions of CBT before we reviewed progress. The first thing she said to me was: ‘this is a business arrangement’. She made me justify why I wanted therapy again when I had tried other therapies in the past which obviously hadn’t worked. When I voiced my sense of rejection by local services she said that they wouldn’t be able to see me as: “they only have capacity to see those who are in the severe and enduring mental illness group which isn’t you.” I didn’t go back to her as why would I want to pay someone who made me feel as bad as NHS services did at the time of discharging me.
I had tried CBT before privately for around six sessions. The psychologist again acted as though she didn’t really want to see me. She challenged me during the assessment when I asked if she was only at the clinic on Fridays. The relationship ended since I emailed her after I collapsed due to bleeding out from a self-harm injury on the way to A&E. When we met after this trauma, she said that she wasn’t there for support, this was time limited therapy and asked why I had contacted her about the incident. I felt very dismissed and distressed by this response after an episode where I had to be revived by paramedics since I had gone into medical shock. The attitude of CBT therapists is that they want you to cope on your own, which is a great aim but ignores the realities of people’s lives which may involve poverty, loneliness, trauma and loss.
My worst and most extended spell of therapy was with a psychoanalytic therapist for 18 months. When I ended with NHS psychology services I did ask my CMHT psychologist if he could make any recommendations. He told me not to use Increased Access to Psychological Therapies (IAPT) as they were only trained to a certain level and would not be used to seeing someone who had been through as much as I had been. At first he refused to make any suggestion because he felt this was my wanting him to provide for me after we ended. Eventually he did suggest two names (one being the therapist who writes books on erotic transference already mentioned) who also did sessions for the CMHT. I did opt to see the therapist without the interest in erotic transference knowing that as a self-identifying asexual I wouldn’t appreciate that imposed focus. His website was inoffensive though there were no real selling points or personality there. On reflection I chose him in order to keep some connection with the CMHT and the psychologist who I had liked working with. I remember when we first spoke on the phone and this new psychotherapist said that he did have ‘vacancies’ and gave me an address for his ‘consulting rooms’. He practised at his home though we never called it that. Everything was impersonal, robotic and guarded. He once came to the door on crutches and wouldn’t say what had happened to incapacitate him.
The psychotherapist’s fee was £50 a session which I had to pay in arrears once a month. I was not allowed to pay him any sooner or later than a week after he handed me the slip of paper. The ‘invoice’ said ‘for professional services’ and he signed his initials along with the dates of the sessions. I then would take a cheque to him the following week which he received in silence. I was earning around £16,000 a year and wanted to pay him weekly to help with my budgeting. However, any mention of a change in payment arrangement was refuted and analysed; his theory was that I needed to hold onto the payment for him as this was similar to my unwillingness to contain my emotions. It was another ‘boundary’ in the relationship which I had to keep or face heavy discussion. I was not allowed to email him except about practical meeting arrangements. If I missed a session, no matter how much notice I gave or how ill I was, then I would have to pay for it. This is in line with other therapists I have seen where even giving many months’ notice of cancellation meant I still had to pay at least half ie £25 in order to keep open my ‘slot.’
The relationship with the psychotherapist was rocky though he told me to give it no less than a year. If I emailed him saying I wanted to end he would ask me to come to the next session to discuss it. I wasn’t able to end as it still would have felt like a rejection and treatment failure, mirroring the botched ending with the CMHT. I felt beholden to his clever but empty interpretations, for instance whether eating sandwiches as a child meant that I avoided them now or was my mother not breast feeding me a cause of my eating distress. I felt too passive at times to say the obvious ie ‘what rubbish.’ We kept returning to the relationship and what was happening in the room even when my mind was elsewhere since not all of my feelings were about him. It is hard to feel much about a therapist who is deliberately a blank page. He found everything I said ‘fascinating’ while offering no warmth, humanity or ability to be real in return. Therapy felt like an intellectual exercise and not a therapist acting as a witness or helping me deal with expressed difficulties.
It was clear that the psychotherapist always had to be in control. When I decided to apply for a lay position on a committee of the UKCP he saw this as a direct attack on him. I felt that he would welcome my interest in user involvement but he felt that I was going for a job with his regulatory body to gain power over him. When I asked if I could start his first session of the day ten minutes early in order to catch a bus to work he said he needed a week to think about the ramifications.
After paying the psychotherapist over £3,300 he terminated the therapy due to my self-harm. He had given me an ultimatum, in effect a contract not to self-harm. When I challenged how this would help he said I was ‘playing games’. He only reacted to the self-harm when I had let him know I had been to A&E. It felt as though he was safeguarding his reputation rather than thinking about what happened to me once I was completely unsupported. He told me that if I felt I couldn’t stop self-harming then I should go back to the NHS, which was the same CMHT he worked for. Unsurprisingly the CMHT rejected the referral and expected me to go back to seeing him or another therapist who I should find in an instant.
It can be possible to be trapped in a therapy relationship like this and I imagine it to resemble domestic abuse in some ways. You hope for change in yourself and for the therapist to actually like you. You keep going back only to get the same cold, controlling treatment again. Paying so much to a therapist who stopped seeing me since I was distressed enough to self harm felt abusive.
Still not found what I am looking for
Needless to say, there have been many other therapists I have seen who felt unsatisfactory. I have often had to wait in the rain for my time to knock on the door of the therapist, as arriving even two minutes early was breaking a boundary and forbidden anyway since they had no waiting room. At times I wondered why I was paying £50 to a therapist with a house which must cost close to a million pounds when I was going back to a flat with neighbour problems. I have seen two well meaning counsellors who, while lovely, just seemed to agree with me as their way of validating everything. This agreement then entrenched my sadness and led to a sense of going round in circles. One of the counsellors said things that felt trite or weird, like describing us as ‘the dynamic duo’ as a way of compensating for the fact that no-one else, including the GP, was interested.
I have tried the only NHS therapy available to everyone through IAPT. This experience, while free, felt rushed since the therapist kept saying: “you know we only have six sessions.” Ten minutes of each session was spent filling out a self-assessment questionnaire for my anxiety and depression scores. This exercise was about her outcomes monitoring and had no therapeutic purpose. I gave up after the first session since I knew that my scores were unlikely to improve within such an irritating and imposed format.
A good match
I do now see a psychologist who treats me as a fellow human being. There can be misunderstandings, as in any relationship, but we discuss and repair. She is relaxed about me emailing which is important to me given my anxiety means I sometimes have to communicate in that moment. While she does have vast secondary care experience of working with clients with a label of BPD she views the underlying complex trauma and understands the prevailing discrimination. I prefer the way that she can draw on many different therapeutic approaches rather than deciding we must do DBT, MBT, Stepps etc because that is what is in a NICE guideline for BPD. I don’t see her as part of the PD industry, another expert who will get me to mentalise even though we can never truly know what someone else is thinking about us. I like that I don’t know much about her personally, though I guess we are not far apart in age. She is intelligent but not over intellectual and I can talk to her about the most intimate or embarrassing problem without shame. Most of all I see how she really wants to help and see me free of mental torment, while avoiding any rescue attempt when I do sometimes self-harm. I see her in a clinic where she hires a room so have somewhere to wait if I want to stay out of the rain and cold weather before an appointment. She puts up with me being gloomy at times without demanding I think more positively as she hears the life circumstances that make this challenging. I can take everyday issues to her such as work obligations and family relationships, looking for new perspectives and coping strategies.
I have spent tens of thousands of pounds getting to this point, too much to just put down to bad experience. At best I helped the psychotherapist I saw for 18 months pay for holidays for his secret family when he took the whole of August off. But I also think that all of the misses make me appreciate my current therapeutic relationship more, I feel grateful that there is someone who ‘gets’ me and that I can still benefit from therapy. As my therapist she listens and learns from me, whereas the analytic profession will search for unseen and hidden meanings which would cost me more money but answer nothing. It feels interactive and equal, a gift of therapy and not another missed connection.
I would always want long-term therapy to be available on the NHS. In the new real world though I am using what is available to survive, stay in work, gain insights, practise self-compassion and acceptance of what can’t be changed.
This isn’t an advertisement for private therapy as I know it will continue to come down to affordability for most people. If you want CBT then don’t pay a penny to a private therapist but go to IAPT along with perhaps buying self-help books. Private therapy can though lead to a special relationship but this is far from automatic. So much choice in the private sector and personal vulnerabilities can certainly lead you down wrong paths.
Note: PIP is awarded on functional descriptors about how your condition/difficulty/impairment AFFECTS you. Saying on a form ‘I need PIP to Pay for Therapy’ will get you zero points, you must phrase all answers in the form of how you are affected and with reference to the legal descriptors, see Advice Links