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I was struck by the news last week that GPs are so overwhelmed with mental health patients that they are directing them to the care of unregulated charities. Complex cases are now in the hands of therapists who are not always qualified to treat them.
In one case, an autistic girl with an eating disorder was asked to self-refer to a local charity that offered “one-to-one support” – given by someone untrained in psychotherapy or counselling. Her mother, a former psychiatric nurse, became concerned that the treatment was doing more harm than good and put a stop to the sessions.
The numbers aren’t small, either. A counselling charity in Blackpool estimates that about half of the patients its therapists see each week are referred through the NHS.
This touches on a wider problem in the world of talking therapies: they are not regulated. Anyone can call themselves a “therapist”, “psychologist”, or “counsellor”. A recent BBC investigation found that dodgy online courses have exploded – some with very basic requirements, others that allowed candidates to cheat. But there is no legal obligation even to do a weekend counselling course before you start taking paying patients.
While medical doctors are overseen by the General Medical Council, which can strike them off its register and prevent them practising again, regulation for psychotherapists and counsellors is entirely voluntary. You can choose to get accredited by respected organisations such as the British Association for Counselling and Psychotherapy (BACP) or the UK Council for Psychotherapy (UKCP). But if you are struck off, there is nothing to stop you setting up shop again. In short, this is an industry with no unified ethical code or complaints system, and no minimum qualifications, dealing with sick and vulnerable people.
What makes this worse is that just one in 10 people are aware of the lack of oversight. The onus to check whether or not a therapist is on an accredited list is entirely on the patient, who might not be in a state of mind to do so. The problem is compounded if GPs are directing people to dubious counsellors, which patients might interpret as a formal NHS referral.
This crisis is likely to worsen, as therapy is booming. About 1.6 million people are on waiting lists for mental health services – numbers that have risen almost a third over the past two years. Little wonder that those who can afford it choose to go private. Talking therapies, once taboo, are also increasingly accepted and promoted as life-enhancing. Some companies offer therapy as a perk to employees. With rising numbers of potential clients, more people are looking to counselling as a career. Between 2019 and 2023, the number of students registered with the BACP, training to become therapists, increased by 44%.
Therapy can change lives for the better, of course. But amid the success stories lurks horror. Of the 72 therapists struck off by the BACP and UKCP between 2005 and 2015, nearly one in four are still practising. An investigation by the i newspaper reported that therapists expelled from professional bodies for having sex with vulnerable patients, bullying, racism, giving patients illegal drugs or being drunk in therapy sessions were still offering their services to clients. One psychotherapist who had sexually exploited female patients was struck off for posing an “extreme danger to the public… if he was permitted to recommence practising”. He was still practising.
Why have we been so slow to regulate? Amid rising awareness of the benefits of therapy, there has been too little discussion of the ways it can also be damaging. After all, treatments of any sort rarely have a neutral effect – if they are powerful enough to help, they may also be powerful enough to harm. One survey from the Royal College of Psychiatrists found that as many as one in 20 say they suffer from a “lasting bad effect” from their therapy. Failed treatments may exacerbate depression, low mood and self-sabotaging behaviours.
Therapy by its nature involves vulnerability and a one-way power dynamic, which also makes it dangerous. There is a long history of therapy being used for abusive purposes – whether in religious cults, in which “therapists” employ techniques to manipulate and brainwash members, or as part of “conversion practices”, now on course to be outlawed, that attempt to change someone’s sexual orientation, and in extreme forms can involve exorcism and physical violence.
But a practitioner does not have to be abusive to do harm: clumsy approaches can cause damage, too. Consider the fact that several physical diseases – including metabolic and immune disorders and brain tumours – can manifest with psychiatric symptoms. A talking therapist who does not recognise key signs and continues treating the patient psychologically may be making the situation worse.
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Tighter regulation is needed. Some job titles – including “clinical psychologist” and “occupational psychologist” – are already protected in law, with minimum training requirements. Similar rules could be extended to anyone who wishes to use the word “psychologist”, or indeed “therapist” or “psychotherapist”, to set themselves up treating patients with mental health problems. Many other countries are stricter. In the Netherlands, Sweden and Switzerland, you need six years of training before you qualify for the title of psychotherapist.
Regulating therapy more tightly may deal with one problem at the cost of exacerbating another, however. Mental health services could hardly be more stretched. But that is an argument for greater investment. By the last estimate, mental health problems cost the UK economy £117.9bn a year, much of it in lost employment from patients and their families.
We heard last week that mental ill health is behind soaring disability benefits, accounting for 44% of claimants in 2024, up from 25% in 2002. Assigning mental health treatment a greater portion of public funds would therefore not only be humane, but efficient.
