Primer: Reflections on the long wait for Psychological Therapies and Counselling
The Scottish Government will publish the Psychological Therapies Waiting Times update on the 3rd of December: the day before it publishes the budget. I’m writing this to try and influence the conversation that happens around waiting times, and to offer some insight into what those stubborn waiting times do and don’t tell us.
I’ve delivered over 1,500 sessions of counselling since qualifying last year. I’ve worked with an online provider that links its subscribers with therapists at scale; people have found me on social media when I’ve opened up pay what you can sessions; I have worked with people directly through my website after listing myself on the myriad of counselling directories that exist online; and set up a community based practice that I volunteer in one day a week. I think what I am trying to say with all of that is that after qualifying - it has been a lot of hustle.
I gained my Masters in Counselling and Psychotherapy from the University of Strathclyde. I applied for a job as a counsellor at the University of Strathclyde shortly after graduating and was told that I wasn’t qualified to even get an interview. My £8,000 Masters from the University of Strathclyde didn’t qualify me to work as a counsellor at The University of Strathclyde. What greater example of dysfunction can I give?
I studied with people who, rather than offer their skills and talents as counsellors, have gone back to working the jobs they were in before they retrained - because they want the stability that comes with employment.
It has shocked me and people I know that despite all the public calls to ‘reach out’ and to ‘ask for help when you need it’, there is no clear way for my skills as a counsellor to be used for the public good.
The answer to long waiting times is to either reduce demand, or increase supply. We are not, as a society, heading in the direction of reducing the distress and challenges that people face. So I think it is safe to say that increasing supply is our best hope. However, year after year, therapists are graduating expensive courses into a wild west industry.
I’ve put some thoughts below in the hope that it can expand our thinking when those waiting times come out.
1. How Therapists Become Therapists
Training to become a therapist is a deeply personal and costly commitment. Aspiring counsellors typically pay tens of thousands of pounds in tuition fees for their qualifications, often over several years. The one year Masters that I did no longer exists. Many training programs also require students to complete one hundred hours of unpaid therapy as part of their placement, working for free in some places that don’t even cover their travel costs. This financial burden disproportionately affects those from lower-income backgrounds, creating barriers to diversifying the profession - counselling is a middle class industry, with training much more accessible to those with wealth, and this is why.
Additionally, these unpaid placements mean trainees provide therapy under supervision, often in charities or public health settings, where they are expected to deliver high-quality care despite their limited experience and lack of financial compensation. This system ensures that while clients may benefit from reduced-cost or free therapy, trainees face burnout, financial stress, and uncertainty about their futures.
2. The Jobs Market for Therapists
Once qualified, therapists enter a fragmented and competitive jobs market. Unlike other professions, there is no structured pipeline for employment, leaving many to work as self-employed practitioners or in temporary roles with charities or private practices. Many full time, permanent roles will demand that people are individually accredited - a process that takes at least two years post qualification, and requires delivery an additional 450+ hours of counselling.
This setup is like a college running a course for bricklayers and then telling graduates that they can only make a living by forming their own construction companies to compete for contracts. Therapists must navigate building private practices from scratch, often contending with costs like professional insurance, supervision fees, and room rentals. For those lucky enough to find salaried roles, these are often limited to charity or NHS settings, which are themselves overstretched and underfunded.
The lack of cohesion in the industry leaves many therapists unable to secure stable employment, forcing them to leave the field or supplement their incomes through unrelated work—worsening the supply and demand mismatch that underpins long waiting times.
3. The Fragmentation of Care Pathways
When someone visits their GP and is referred for psychological support, the outcome is unpredictable. In Scotland, the referral process can take us in all sorts of directions;
NHS Mental Health Services: People might access therapy through NHS-employed practitioners. However, these services often come with extensive waiting lists, limiting timely access.
Charity-Supported Therapy: Charities often offer therapy provided by a mix of qualified counselors and trainees working unpaid placements. The consistency and amount of care can vary significantly depending on the charity’s resources.
Payment-Based Therapy: Some people are directed to services that require payment, either at reduced rates or full cost, putting financial strain on those seeking help.
This fragmentation creates inequities in care. Two people with identical needs might receive vastly different levels of support depending on where they live, which GP they see, and what resources are available locally. Someone might get referred to a service that tells them they don't meet their threshold for support - this will still be counted in the stats as someone being moved off the waiting list.
4. The Role of Private Provision
The dysfunction in the public and charity sectors has normalised private provision as a cornerstone of mental health care. Those who can afford it often bypass waiting lists entirely, accessing therapy on-demand through private practitioners. Counselling is also increasingly framed as a workplace benefit, offered through Employee Assistance Programs (EAPs) or wellness packages.
While these private and corporate services can provide timely care, they exclude individuals who lack financial means or employer support. This dual system—public and private—has led to growing inequities in access to therapy, where care is more accessible to those with financial privilege.
5. What the Waiting Time Figures Don’t Show
When the Scottish Government releases its latest Psychological Therapies Waiting Times, the focus will inevitably be on how long people are waiting for help. While these figures are crucial, they don’t tell the full story about:
The Quality of Care: Are people receiving therapy that meets their needs? Are they being matched with experienced professionals or trainees? Did the therapy last long enough to help someone address their deepest challenges?
Accessibility: How easy is it for people in rural or underserved areas to access services?
Impact: Are the therapies provided making a meaningful difference in people’s lives?
These unanswered questions highlight the need for systemic reform. Waiting times are only one indicator of a dysfunctional system that fails to deliver consistent, accessible, and high-quality care.
Scotland’s Psychological Therapies Waiting Times are a symptom of deeper structural issues. The pathway to becoming a therapist is expensive and unsustainable, the jobs market is fragmented and inequitable, and care delivery is inconsistent, often privileging those who can afford private services.
To address these challenges, we need bold political leadership that prioritises reform, aligning training, employment, and service delivery to create a cohesive, equitable mental health care system. By doing so, we can ensure that therapy is not just an option for the privileged few but a resource available to all who need it.