‘It’s OK Not To Be OK’: Britain’s In Therapy And We’re Ready To Talk

It's the message that broke down mental health stigma – can NHS services now meet the demand?

Mental health issues — especially among young people — are on the rise, but so are the number of people willing and able to talk. Therapy shouldn’t be the preserve of the wealthy or privileged – that’s why we’ve launched The Therapy Edition, a series of stories on how to seek support and embrace it once you do.

When Claire Murdoch started out as a mental health nurse more than 30 years ago, the building where she worked was a Victorian-era asylum – a bricks-and-mortar reminder that for centuries, people with mental illnesses had been locked away, out of sight, out of mind

She’s now the national mental health director for NHS England, but Murdoch vividly remembers the climate around mental health back then. In the early 1980s, society was seeing the very beginnings of a slow-burn revolution. There was talk of moving patients from asylums into homes in the community, she tells HuffPost UK, a concept that was considered “radical” at the time.

“I was very much part of a movement, along with thousands of others, of feeling that there needed to be a more just approach to mental health, that we needed to challenge discrimination and stigma, that people had a right to equal rights,” she says. “We’ve been on that journey steadily ever since.”

Three decades on, the mental health landscape is “unrecognisable” from what it was, says Murdoch, particularly when it comes to people’s attitudes towards seeking help. “It’s unbelievably different – people are much more willing to talk.”

Natalie Weaving, 37, from Hampshire, is one of these people. She chose to find herself a counsellor when she started feeling increasingly depressed. “My mum was terminally ill and my marriage wasn’t great,” she says of life at that point. The counsellor, recommended by a friend, helped her cope through her divorce and the death of her mum – and she continues to pay for fortnightly sessions.

“I don’t ever see myself not having her in my life,” says Weaving, who feels no shame in mentioning therapy to others, no matter how close they are to her. “Everyone who knows me, works with me and has followed me on social media will see me talking about it because I am not ashamed of saying that I keep my mental health in shape as much as my physical health.”

“Even those you deem as ‘dealing with it all’ have help to do so.”

- Natalie, 37

Weaving, the co-owner of a marketing agency, says she feels more equipped to deal with her work and home life, plus any “huge hurdles” that come up. “I can be a better mum to my son and support his mental health and emotions as well. It shows even those you deem as ‘dealing with it all’ have help to do so.”

She’s not the only one embracing this new openness. On Twitter at the time of writing, there were 300 tweets per hour for #mentalhealthawareness with people sharing stories and letting others know, “it’s ok to not be ok”– activity that tends to spike around World Mental Health Day on 10 October.

Murdoch cites a number of factors that have helped nudge British attitudes – from the younger Royals and celebrities talking about their own struggles to grassroots and social media campaigns by people living with mental illness and mental health issues. In the news, rarely a day goes by when mental health isn’t in the headlines in some shape or form.

This has created a snowball effect, bringing conversation into the mainstream. There are bestselling books about mental health and mental illness, such as Matt Haig’s How To Stay Alive (now a touring theatre production) and it’s also infiltrating TV programmes, podcasts and films – though some portrayals in popular culture still fall short.

National surveys from Time To Change paint a picture of a nation with improved attitudes towards people with mental health problems. The overall attitude trend between 2008 and 2016 saw a 9.6% upswing – that’s an estimated 4.1m people with better attitudes towards mental health in a relatively short period of time.

The NHS programme IAPT – or Improving Access To Psychological Therapies – appears to have lived up to its name since it was rolled out on World Mental Health Day in 2007. The therapies you can access through IAPT are evidence-based and aimed at people with common mental health problems including depression, generalised anxiety disorder, phobias, post traumatic stress disorder, panic disorder and obsessive-compulsive disorder.

While there are many talking therapies available, cognitive behavioural therapy (CBT) is most commonly offered – though this pictures varies in Scotland, Wales and Northern Ireland, where the IAPT programme is not currently available.

Data suggests more people than ever are accessing therapy. There were 1.2m IAPT referrals in 2014-15 and almost half a million more (1.6m) in 2018-19. Of the latter, 70.2% were self-referrals, rather than through a GP. And of those treated through IAPT over the past 30 months, half have gone on to make a full recovery, says Professor David Clark, national clinical advisor for IAPT. This suggests not only a greater willingness to talk – but the positive impact of doing so. Dig a little deeper, however and there are issues still to be addressed.

Joseph Croft is a CBT therapist working for the NHS in London. He says that while anecdotally he has noted a shift in attitudes towards therapy among his patients – he sees a mix of age groups, from 80-year-olds who have managed anxiety all their lives to young people straight out of school – there are still certain groups that aren’t reaching out for help.

“A lot of my clients are coming because they’re desperate and they have no-one else to talk to.”

- CBT therapist Joseph Croft

In some Asian communities, discussing mental health is still taboo, he says. Meanwhile young black men are less likely to show up in primary care and more likely to show up in secondary care, when their mental health has worsened.

“From my own experience, a lot of my clients are coming because they’re desperate and they have no-one else to talk to,” says Croft, who adds that their mental health problems often overlap with wider societal issues such as housing, immigration, jobs, welfare, education and money.

In some parts of the UK, doctors are witnessing patients who “somatise” – showing up at their GP practice with physical symptoms that are actually the result of psychological distress. Stigma is a big reason why people don’t seek help or admit to having problems sooner, suggests Dr Michael Shooter, president of the British Association for Counselling and Psychotherapy (BACP), – and a “huge barrier” to some individuals accessing talking therapies, he adds.

Even when they do find the courage to turn up for therapy, NHS targets are throwing up other issues. “Services are overloaded but I know that I need to hit [the targets],” says Croft, who sees it as a double-edged sword. “We don’t get new therapists but we’re expected to see two new clients a week, per therapist, in this service, which is about 80-100 more people a month. That’s just expected of us.”

This puts added pressure on staff who are trying to cram more sessions into their day and could result in lower quality treatment, he suggests. “Increasing awareness is great. But then we need to see it backed up.” Last year, figures from the Department of Health and Social Care (DHSC) showed 2,000 mental health staff a month were leaving their posts in the NHS in England.

“We have a crisis now in CAMHS [Children and Adolescent Mental Health Service], we have a crisis in adult mental health, but we need to think about what’s the best in terms of a new long-term solution,” Croft continues. “We’ve got to mop up the mess but also turn off the tap.”

Among certain groups, particularly a millennial cohort in their twenties and thirties, therapy is growing in popularity, whether they’re accessing it through IAPT, paying for private therapy (at an average of £50 per session) or making use of employee assistance programmes at work.

Dr Fenella Quinn, a private counselling psychologist based in Manchester, says most of the clients she’s seen in the past five years have been aged between 19 and 30 years old and a lot have been men. This is encouraging given that data suggests men are less likely to access psychological therapies than women.

“Gender seems like less of an issue now,” agrees Philip Karahassan, a psychologist based in London and Counselling Directory member. “I was looking recently and have more men on my books than women at this moment in time, which is a big shift from even a few years ago.” Both say, anecdotally, that their patients are seeing it as “normal” to have therapy and talk about their problems.

Oliver, 31, sought the help of a professional in the run up to hitting 30 as he felt stressed and overwhelmed at work but also, more generally, lacking direction in life. ”It really helped to talk things through,” says the marketing manager, who preferred not to share his surname. “It helped me make some big career decisions, try new things and connect with friends on a deeper level.”

He went to a psychotherapist weekly for about six months, but hasn’t spoken openly about attending therapy with friends, though a few know. “It’s not because I’m hiding it, but because it’s not something that needs to be shared, unless there’s a relevant conversation,” he says. “In some ways therapy is probably more accepted, but I think it still has a long way to go – we’re not like America, but we probably should be.”

Increasingly, suggests Karahassan, people like Oliver are opting for therapy because they want help finding out what drives them and how to reach their full potential. Clients arrive to their first appointments already aware of different counselling styles and what it is they are looking for, he says of his work.

Access to shared knowledge also plays a part in the trend towards therapy in the UK. We live in an information age where we can nip on to Google and find others who feel the same way as us, search NHS Choices for symptoms, and research the latest medications and treatments. And a well-informed public is one that can more readily shape change.

“The public are now demanding better access to mental health services,” says NHS England’s Claire Murdoch. “They don’t want to wait so long and they want their children and young people to access care in a more timely way.”

In her view, this rise in demand is not a sign of greater morbidity (or illness) rather that people are talking more and beginning to accept that evidence-based treatments can help them. “It’s unbelievably uplifting, actually, for someone like me,” she reflects. “It’s almost unrecognisable from where I entered mental health all those years ago to where we are now.”

“Those who cannot afford it are unlikely to get the help they need.”

- Dr Fenella Quinn

The NHS is not running a perfect model of care – and provision varies in Scotland, Wales and Northern Ireland. A report by Rethink Mental Illness revealed a significant gap in access to health services with severe mental illness, with an average waiting time of 14 weeks for this demographic. Murdoch acknowledges “there have been too many people waiting” and says it is something they are focused on improving.

There are other issues at play, too. Dr Quinn points out that long-term therapy is hard to come by on the NHS (with six to 10 sessions the standard offering with IAPT) and suggests people who cannot afford private therapy might fall between the cracks if they can’t access long-term support.

“There is hardly any state-funded family therapy or intensive long-term work for children available from my experience working with families,” she says, adding that individuals and families are increasingly forced to seek out private therapy and counselling. “This means that those who cannot afford it are unlikely to get the help they need.”

When it comes to mental health care, experts have been banging the drum for what they call “parity of esteem” – giving equal priority to physical and mental health – for some time now. Funnelling more money into stretched community and specialist mental health services can only have a positive impact on waiting times and access, they argue.

Mental and physical health are closely interlinked. Poor physical health can lead to an increased risk of developing mental health problems, according to the Mental Health Foundation. And, conversely, poor mental health can negatively impact on physical health, leading to an increased risk of some conditions.

According to the NHS’s 10-year plan, at least £2.3bn a year will be ring-fenced to improve mental health services on the NHS by 2023-24. But that’s from an overall funding pot of around £27bn. BACP’s Dr Michael Shooter says he has seen social attitudes starting to “soften” in recent times and an improvement in “NHS treatment of, and for, those with poor mental health”, but that the journey to true parity of esteem might take decades.

The future of mental health care in the UK is something that Adrian Massey, an occupational physician of 17 years and author of Sick Note Britain: How Social Problems Became Medical Issues, writes and thinks about a lot. While he agrees that therapy has become more “normalised” in many people’s lives, he warns against what he calls the “Americanisation” of treatment.

“Generally people are happy to talk about their problems,” says Massey, who finds millennials and Gen-Z in particular to be “very upfront” about their feelings and the issues they face. “On balance I think it’s been a good thing,” he says – people are less likely to suffer in silence and those with mental health problems worry less about being judged if they do speak up – but he believes that we risk “overdoing it”.

By way of example, Massey cites a referral he received from the line manager of an employee with Parkinson’s disease. The reason for the referral was because the employer didn’t know how to talk to his staff member about what they were going through. Massey argues that what was needed here was “empathy” – that it wasn’t a medical issue.

As mental health awareness grows there is a danger of repackaging emotions as illnesses, he says. “If you look at the trends in the western world, rates of antidepressant prescriptions have been rising for 20 to 30 years now, rates of talking therapy utilisation have been rising year on year, but the problem isn’t going away,” he says. “The problem is actually growing.”

The most common reason why people are absent from work in the UK is due to work-related stress, anxiety and depression. Meanwhile the World Health Organisation (WHO) defines depression as the leading cause of disability in the world. “How much of our healthcare budget and resources do we have to deploy in this way before we say it can’t be the answer because the problem itself continues to grow in size?” says Massey.

“The anti-stigma message has worked brilliantly to broaden the public conversation. Our next challenge is to deepen it.”

- Nathan Filer, author

“We need to be not so narrow in our thinking. The medical model is great when we have a very simple cause and effect relationship – so if you look at the areas where medicine has been miraculous, it’s been in cancer care, cardiovascular medicine, infectious diseases. But we’re talking about problems that are much more existential, much wider than that.” People’s jobs have become more tenuous and insecure, adds Massey, the quality of people’s jobs has declined, and people don’t feel safe. There is a bigger picture to consider.

Nathan Filer, author of The Heartland: Finding and Losing Schizophrenia, says we now need to move conversations beyond stigma. “The anti-stigma message has doubtless worked brilliantly to broaden the public conversation. Our next challenge is to deepen it,” he wrote in a piece on HuffPost UK. By this, he means we need to look at the origins of people’s problems, the life circumstances that factor in to peoples’ declining mental health.

It’s something psychologist and author Dr Lucy Johnstone also has a strong view on. “Look at the politicians and policy makers shouting loudest about anti-stigma,” she told Filer. “They’re the very people who are reinforcing the policies that are driving people crazy.”

While nobody knows what mental health care will look like in even five years, Prof Clark believes there will be a greater focus on digital therapies like online programmes and virtual reality treatments, especially when it comes to anxiety. Some phobias can be treated by showing people their fears in a virtual setting, he says, while people with PTSD could revisit places where they faced trauma through programmes incorporating tools such as Google street view.

“There are a lot of ways digital innovation can help us,” he says, adding that he hopes to see a growing interest among the public in developing their own mental health and wellbeing, even if they don’t have a clinical problem.

As for what it’s like to have spearheaded a talking therapy programme taken up by millions, Clark says: “It’s an enormous thrill, it is so good to see people who have suffered immensely finally get the help they need.

“But I am also aware we still have a long way to go.”

Useful websites and helplines:

  • Mind, open Monday to Friday, 9am-6pm on 0300 123 3393
  • Samaritans offers a listening service which is open 24 hours a day, on 116 123 (UK and ROI - this number is FREE to call and will not appear on your phone bill.)
  • The Mix is a free support service for people under 25. Call 0808 808 4994 or email: help@themix.org.uk
  • Rethink Mental Illness offers practical help through its advice line which can be reached on 0300 5000 927 (open Monday to Friday 10am-4pm). More info can be found on www.rethink.org

• This article was updated on 8 October to reflect where references to the NHS refer to NHS England alone, rather than NHS Scotland, NHS Wales and HSNCI.