Exclusive: Mental health charities bend rules to try and help more patients

“We’re seeing people we probably shouldn’t be", one counsellor says, as charities resort to listing personality disorders as 'depression' and allowing students to treat increasingly complex cases.

By Jessica Bradley

TW: References to suicide

Mental health charities across the country are taking on cases beyond their capacity and skillset as they try to accommodate patients despairing of an already overloaded NHS, The Lead can report. Their patients are often people who face years-long waitlists caused by over a decade of chronic underfunding, but can’t afford private care.

Most people coming to the Blackpool charity Counselling in the Community have complex needs, trauma, severe depression or severe anxiety, says founder Stuart Hutton-Brown.

“We’ve had people here in crisis, and when we’ve rung the ambulance they’ve said there aren’t any, and we’re not insured to take people to A&E,” he says.

In North Yorkshire, Wellspring Therapy and Training has found it increasingly difficult to support people in the earlier stages of mental health difficulties, which it was set up to do.

“Now, we’re more likely seeing people who’ve crossed into severe mental illness, which requires more intensive treatment, which means people with mild to moderate conditions are waiting longer to see us, and the worse their condition gets,” says the charity’s chief executive, Nick Garrett.

And in North Somerset, Wellspring Counselling, which offers 12 weeks of counselling to people referred by local GPs and CAMHS, is experiencing similar challenges.

Over her three years in her role, the charity’s director, Wendy Griffin, has seen an increase in clients with more complex needs - who, she says, should be picked up by the NHS.

The service sometimes tries to help people who are having suicidal thoughts.

“It’s a massive problem,” she says. “We don’t know what to do with these people.”

The problem is particularly acute with young people who can’t get timely support from child and adolescent mental health services (CAMHS), Griffin adds.

“We get desperate parents ringing up with suicidal or self-harming kids,” she says.

Postgrad students instead of qualified therparists

The challenges begin further upstream. Numerous charities say they’re receiving more referrals from overstretched GPs and NHS community mental health teams.

Around half of those referred to Blackpool’s Counselling in the Community come from the NHS, Hutton-Brown says, including people with schizophrenia and psychosis.

“It feels like they’re sending us the people they don’t want to deal with,” he says. “Some people come from a lifetime of trauma. But they’re out of our paygrade. We don’t work to a medical model, which some people need.”

But while they should be referred back to an NHS psychologist or psychiatrist, Hutton-Brown knows that would leave them waiting for two years.

There are too many people seeking help and too few therapists, says Tim Carter, associate professor of mental health at the University of Nottingham, and services aren’t funded enough to give enough sessions with professionals trained to a high enough standard. Carter trains therapists in cognitive behavioural therapy.

In the 16 years since the NHS launched IAPT (Improving Access to Psychological Therapies), the goalposts have shifted, Carter adds. Initially, people with mild to moderate mental health issues were given a short course of cognitive behavioural therapy (CBT)-informed therapy with post-graduates who’d had one year of training, Carter says. But this is now the default level of support for people with more complex issues, who historically would’ve been seen by fully qualified therapists.

“Like charities, NHS talking therapies are set up to work with relatively straightforward, mild to moderate conditions, like anxiety disorders and depression, but most people coming into these services have enduring and severe mental illnesses, which short-term therapy can’t touch,” he says.

CBT, Carter says, isn’t designed for the level of complexity at which it is often being applied. While evidence shows it’s effective when people are given between 12 and 16 sessions, he adds, most NHS services across England have an unofficial cap at around eight. This means that secondary NHS services often have no choice but to discharge patients, or refer them to third sector services, Carter says, as their threshold is too high (and typically based on risk and safety) to treat people with complex problems.

But in the third sector, many other counselling charities are also finding it increasingly difficult to find funding.

“They’re under huge pressure, with rising overhead costs and increasing referrals from NHS sources without accompanying funding, and I’m often hearing about community-based counselling services closing due to lack of resource to meet demand,” says Jeremy Bacon, BACP's third sector lead.

“This vital resource propping up the NHS is starting to buckle,” says Bacon, who wants to see greater recognition of the role of the third sector in delivering and supplementing NHS Talking Therapies.

Bending the rules

Professionals also know the longer people wait, the worse their mental health gets, Carter says.

“People access therapy when they’re at crisis point. Relationships can break down, life gets more difficult. The more a person limits or changes their life, often makes the condition worse,” he says.

This is why some NHS services are now unofficially bending the rules.

“The curriculum is to deliver specific treatments and approaches for mild to moderate disorders, but people often don’t present with these in isolation. So we set up students to deal with complexity, which means sometimes veering away from the curriculum,” Carter says.

For example, the official line is that short-term therapy isn’t suitable for someone whose central problem is a personality disorder, he says.

“To get around this label, we put it down as depression, then work on the bits around that. Because therapists tend to be compassionate, they’ll let them in anyway and maybe put in their electronic notes that they’re working on something else, such as low mood and anxiety,” he says.

However, he adds, this is rarely effective because the patients still only get eight sessions.

A similar approach is emerging in the third sector, where therapists also can find it difficult to say no.

This was the case at Wellspring, but when Garrett spoke to The Lead in May this year, he had a plan. He was going to start telling staff to focus on preventing people’s mild to moderate mental health, so that they could focus on preventing people’s mild to moderate mental health issues getting worse.

But in June, the charity was forced to accelerate this process when it discovered its income was significantly lower than expected. This means that the charity’s two trained adult counsellors, who work with people who have the most complex issues, won’t be getting their contracts renewed in April next year.

“We don’t know who will be picking up that demand if we’re not here,” he says. “Our pricing, as little as £5 per session, meets a real need in our community.”

The risk

Taking on more than charities are designed to deal with can be challenging also for staff.

“We had a woman with us who had been discharged by her GP and secondary care, and was self-harming. I had to support the counsellor through this because it held a lot of risk,” Griffin says.

This is made more complicated by the large proportion of students that work at counselling charities as part of their studies.

“We’ve had people referred to us who are having a psychotic episode, which can be very scary for the client and for the counsellor, who wants to do their best for the clients,” says Elizabeth Rose, counselling services coordinator at Life Changes Counselling in Southampton.

“Some of our counsellors are students, and we have to be mindful of their competence. Despite making sure counsellors are supported, it still has an impact.”

Ensuring the wellbeing of staff and volunteers can be especially hard when they aren’t trained therapists, says Leigh Trimble, chief executive officer of Red Balloons, a Stockton-on-Tees charity where people with lived experience of mental illness offer peer support.

The charity is supporting a rising number of people with serious and complex issues who are falling into gaps between services, Trimble says.

“There's a limit to what we can do. We're not clinical, and we're not resourced as a crisis service, but we're delivering crisis support. We'd never say to someone that we can't help them, and we deal with people on a daily basis who are feeling suicidal,” she says.

Sometimes, according to several counsellors, people are required to go to a third sector counselling service before they can be referred on for more help.

“We’re seeing people we probably shouldn’t be, but if they don’t see us first, they often won’t be sent on to secondary mental health services. It’s not right for us to be holding so much risk,” says Emma Howarth, a counsellor at Wellspring in North Somerset.

“It’s had a big impact on me; it makes me sad to have to fight for people as much as I have to, it takes a toll on me,” she says.

“It’s increasingly hard for me to take care of myself. I shouldn’t be working like this, but if I don’t I’ll be letting people down. We feel a pressure to say ‘yes’ to everyone.”

The dilemma

UK therapists and therapy organisations aren’t regulated by law, or by the Care Quality Commission, which regulates the NHS, despite NHS bodies referring people to them.

Some third sector services and charities can become BACP accredited, which involves annual reviews to ensure they meet certain standards of professional conduct. But this isn’t legally required.

Many therapists who spoke to The Lead are BACP accredited, or working towards this. But despite most charities telling The Lead they offer sessions to people with more complex needs than they were set up to deal with, the BACP’s Bacon says all only work within their competence, relating to their level of training.

“Services need a model that allows them to deploy therapists if they've got increased complexity coming into the service. They must work within these competencies for public safety,” he says.

“Because services work within competencies, at times this means they’re not able to provide service to someone. You wouldn’t struggle to find a service manager facing those challenges, but they know the risks of working beyond their competencies and experience.”

According to the charities that spoke to The Lead, some work around this by supporting people without directly treating their severe and complex mental health issues. They explain that it’s either this, or nothing.

“A lot of people become very despondent when they feel like they’re getting tossed from pillar to post. They feel abandoned,” Rose says.

Hutton-Brown often has to challenge the charity’s trustees on who his service should and shouldn’t be helping.

“If people can come here once a week and get their frustration at the lack of services out in a room where they’re comfortable, it’s better to do it here than at a receptionist somewhere and get barred from the service” he says.

“Sometimes, people just need a glimmer of hope. It could be we’re the only person in their corner that can offer that, so I’m okay with what I’m doing.”

More funding, more systemic changes

“A proportion of any government investment into mental health needs to be allocated to grassroots services, and organisations that don’t have layers of management and bureaucracy,” says Hutton-Brown.

This will allow decisions to be made swiftly, with local knowledge guiding the outcomes, he says.

“It’s a win-win; if investments were made and the sustainability stress was taken away from third sector providers, more people could be helped, freeing up GPs , A&E, community mental health and crisis teams,” he says.

Carter says that NHS Talking therapies also need to be appropriately funded to meet the number of people that need to be seen and the complexity of the problems they have.

“We need more therapists trained and employed to share the workload in a way that is actually feasible,” he says. “Currently, full time therapists in NHS services have caseloads that are too high with people who often have complex needs. Consequently, they are faced with a lot of pressure to meet unrealistic targets, resulting in burnout and, ultimately, lots of therapists leaving the NHS.

He also calls for services that offer people more sessions, and that look after their therapists by reducing their caseloads, and increasing access to high quality ongoing training that reflects the complexity of their caseloads.

And Griffin urges the government to set aside statutory funding to sustain services.

“Too often, funders expect already fantastic organisations like ours to create a new project or idea to secure funding,” she says. “But one-to-one counselling is a lifeline - why would we come up with something different? These and other obstacles should be removed to help us provide a valuable and much needed service for those who could not otherwise afford it.”

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In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. Youth suicide charity Papyrus can be contacted on 0800 068 4141 or email pat@papyrus-uk.org.

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