Leaving Versailles

For those of you who attend the largest annual therapists’ event in the UK, National Counsellors Day, you’ll know how long it’s taken the profession to actually talk about money. So it’s no small achievement that on the 29th June (book here) we’re talking about it in the real, not the symbolic or from our clients’ perspectives but from the granular realities of a deepening earnings crisis for therapists.

As happens every year, Surviving Work gets wheeled out at NCD to deliver the bad data-driven facts of no-to-low-wages in the sector and to draw out any prospects for positivity. Desperate really, that I would be the person charged with looking on the bright side but since therapists are versed in staring into the abyss it doesn’t take much to make me look like Marie Antoinette offering up some cake.

So this year, in addition to mapping out the spectacularly awful prospect that things are about to get even worse, I’m going to be focusing on the bright side by asking the question what would it take for us to rise above an industry standard of £40 per hour?

Here goes.

Last year I presented the findings of two financial landscape surveys looking at the impact of the cost of living crisis on earnings of therapists. Based  on 1500 responses in 2021, 750 in 2023 from right across the therapy sector. Apart from the sad statistic that 4% of therapists continue to need to access food banks and 49% are worried about covering their basic costs of living, there was one statistic that really got me thinking over the last year. Between 2021 and 2023 the level of unwaged work went down from 36% of therapists to 18% while the number of people moving from part to full time work increased at around the same rate. So therapists were working more but the average weekly income did not go up.

For those of you who don’t work in the therapy world one of the most embarrassing things about the profession is that most therapists at some point have to work unwaged in order to get through their training, get professional accreditation and build their client base. It means years and years of working part time both within the NHS and in the third and private sector for free in order to clock up clinical hours. It sets the bar for earning anything as a therapist very very high. In industrial relations research we no longer call this unwaged work, instead the more aggressive term of wage theft, to account for the cost to us of not earning enough to live. The debt, the insecure housing and insecure consulting rooms, miniscule professional prospects and the death of our dreams, a lot has been stolen from people working in the caring professions including the likelihood of their ability to care.

The therapy business has form. An old story of systemic underfunding and the intentional failure of public services but also a forever story about gender, class and race. A system of professional regulation something like a 17th century French Court  - precariously placed patronage creating a professional aristocracy fussing about their lace cuffs and independent practice while bread runs out. The architecture of the therapy industry is founded on a system of professional cannibalism where bad therapy is blamed on bad therapists and the only way to navigate this is to round up anyone with a pitch fork. This aristocratic logic distracting us from the reality that we are set up for failure as we eat our own. Deaf to the thud thud thud of the peasants marching on Versailles.

In our defence the political economy context within which therapists are working has shifted so disastrously to the right its hard to catch your breath. We exist within the car crash of an actual mental health crisis where demand far outstrips supply both in terms of quantity and quality of therapy that is available. Add to that the almost negligible prospect of earning a secure income and the need to take multiple jobs combined with burnout at 70% it’s predictable that we’re disorientated but at the same time a wonder that anyone thinks they are not a peasant.

Before we implode into a state of professional self-loathing its worth knowing that two things under the heading of uberization have happened that have been a profound attack on therapy.

Firstly there has been a professional uberization in the creation of, big sigh, SCoPEd, the new system of professional standards that has been introduced in the UK quietly and without any real debate within the profession over the last few years. SCoPEd divides therapists into categories A-C, with the majority of trained therapists now hovering somewhere in Category A which, despite its Class-A-ness exists in a growing realm of non-clinical non-therapeutic practice. As such SCoPEd offers a new-not-new system of professional aristocracy which entrenches the same old inequalities of gender, class, private vocational education and race that are on the ascendance across the professions.

In April I wrote a submission with CTUK to the Professional Standard Agency’s consultation around therapy regulation raising our evidence based concerns about deepening inequalities, further de-professionalisation, and failure to address digitalization and platformization along with the continuing degradation of our professional standing in the public eye.

We also outlined how it is that SCoPEd deepens the lack of financial sustainability for therapists and counsellors. We are concerned that SCoPEd will further deepen the financial unsustainability of working in the therapy and counselling sector. Only 3% of 2023 survey respondents felt that SCoPEd offered them higher opportunities for paid work and 1% felt it would lead to income increase, rising to 13% responding they anticipated a fall in income. As a result of these financial realities, a high level of 33% (30% in 2020/21) of respondents cannot see a future earning a living as a counsellor or psychotherapist.

Within the psychotherapy and counselling profession there is a two tier system which is based on pre-existing inequalities in terms of class, race, gender and disability both for the clients and their therapists. The SCoPEd framework will entrench those inequalities already inherent in the profession by formalizing a system of unwaged work and presenting disadvantage as a personal and professional failing. Rather than as a result of the professional bodies having created a regulatory and accreditation structure that many existing and future therapists simply cannot afford.

I just want to note that I wrote the first draft of our submission to the PSA overnight to send to Maria who runs CTUK with one of those really annoying red exclamation marks. I did that because I got the submission date wrong, underestimating the timeline by a month and neither of us noticed. That was something to do with the fact that as single parents our eyes were literally bleeding. In this increasingly resentful exhaustion I did ask Maria if either of us had the energy to go through the patient listening and mansplaining to consult across our sector. We decided that our own states of mind were so fragile that we should just do the work that we so very often silently do on the behalf of others and send it out as a template for people who were borderline about whether this is worth making a fuss about. I’m just saying that every time we raise our heads above the parapet it comes at a cost. So I add to my own calculation of wage theft, the cost to my health entailed by the loss of a night’s sleep when you’re a single parent to a five year old with a 2.5 hour commute to work.

The second part of the uberization of therapy involves platformization. Right now in the UK there is a rapid expansion of online therapy platforms. This is a changing business model – including Business-to-Business (B2B), Business-to-Client (B2C) and hybrid providers including the expansion of the Employee Assistance Programme (EAP) sector.

In March this year I was involved in a BBC Radio 4 programme by File on Four about a multinational B2B therapy provider. The point that needed to be made is about the widespread gamification of recovery built into digital therapy and that the business model relies on attrition by design.  Whether the NHS’s SilverLining or the multinational HealthGuaranteed, the ROI on digital therapy is based on the very fact that it stops people accessing services. Whether overstating the recovery rates or discharging early to losing complex cases somewhere in a call-centre-cul-de-sac, the logic of digital therapy is to game the results. Add a bit of gaslighting anyone with lived experience using the algorithmically curated evidence base into thinking it was all their fault and, literally, who knew?

Why this is important is that the UK is moving rapidly into a system of private medical insurance and B2B/B2C private providers. There is an explosion in EAPs in the UK – snaffling up all those highly qualified NHS therapists wanting to avoid the trauma of Friday night triage. It might feel that we have a vibrant therapy sector with high demand for therapists but whichever way you cut it platformization brings with it low wages especially for women something to note in a profession with 80% women. For the big B2C platforms a therapist earns on average £18 per hour if they’re not willing to intensify case loads to over 40 hours a week. In other platforms there is a growing Uberisation through dynamic pricing and therefore a tiered system of payment. The increasing split between what is charged and what is paid to therapists is reliant on a lack of transparency between client and therapists, between therapist and the platform and all the disorienting absence of hard facts in the grey market of self-employment. Reinforced by the absence of solid regulation for platform workers and the increasing majority of us who are algorithmically managed.  

The digital shift in the therapy business model opens up the doors to the next decade of responsible business as a matter of competitive advantage. The ‘good business’ debates setting the fault lines of what a better model of digital therapy might look like. But even if we allow ourselves to imagine a MuchBetterHelp it still leaves us with the thorny question of money. Because what we are seeing now is that even the progressive EAPs and the therapist campaigns to move us beyond wage theft into demanding actual money have settled for £40 per hour. An industry rate that ignores the history of industrial relations and collective bargaining in the professions that says if you set the bar too low you’ll spend the rest of your working life defending the indefensible.

I’ve spent the last year writing my book UberTherapy and when I started I agreed to writing a book with no corporate names to reduce the risks of being sued and having my book pulped on the alter of the commercial interests of the big online therapy providers. Last week the final manuscript went to the lawyers to assess the risk of being sued by right wing Christians. Turns out that in the current climate my book’s exploration of the legal cases now being taken against the institutions of therapy by the American right housed at 55 Tufton Street are my legal risk. In just one year the real political fault lines have become clear, that this is a fight for a human rights basis for mental health, both from the perspective of clients and their therapists.

The de facto acceptance of a £40 industry standard is the next fault line for the future of therapy and for the very many undervalued women who work in it. This is not just a matter of money, it is a matter of human rights. To reject the emergence of a labour aristocracy and make a demand for decent wages whatever our proximity to Versailles.  

National Counsellors Day will be online on the 29th June from 10am : Book your tickets here.