As the effect of the credit crunch starts to hit and the economy sinks further into recession, more and more people will experience depression, anxiety and other stress-related problems as they fall into debt. Is enough being done to address the high cost of debt on mental health?
One in 11 people in Britain say they are in debt or arrears – and for people with a mental health issue that figure rises to one in four1. A 2008 report published by Mind2 states that, for some people, mental health problems are ‘a pathway to debt’; for others debt is ‘a pathway to mental health problems’. Yet, continues the report, health professionals are failing to engage with the issue. Why? Apparently because they lack the relevant knowledge to do so3.
In a market where a search for books on Amazon using the phrase ‘money problems’ brings up some 40,000 results, including such titles as Money Isn’t the Problem, You Are, it’s hard to believe that counsellors and psychotherapists haven’t in some way engaged with this as a psychodynamic or a cognitive behavioural issue. Yet neither BACP nor the British Psychological Society even provide a tick box for practitioners to list debt problems as an area of interest or expertise. In both cases, this is apparently because there has been no call from practitioners for such a category to be created.
Gap in support
Chris Fitch is a medical sociologist and research fellow at The Royal College of Psychiatrists. He has written two papers – one for psychiatric nurses, the other for psychiatrists4, 5 – flagging up the need for mental health support for people with debt problems. So why is there such a gap in this area?
‘Health professionals are either unconfident in tackling the issue or they feel that it’s kind of supplementary to their therapeutic work,’ he says. ‘They quite correctly probably don’t want to frame themselves as debt experts. They may also lack the time to take this work on if you think about the number of cases someone might see.’
However, Fitch says, a school of discourse is now opening – much of it in the United States – about the relationship between a person’s disposition and spending problems, including difficulties like compulsive buying. Fitch is currently involved in reviewing the literature in this area with the national mental health membership charity, Rethink, and he argues that it’s time to get therapists thinking about this and talking with their clients about it. ‘I don’t think it’s about creating specialists per se,’ he says. ‘I think it’s about everyone being able to incorporate these issues into their routine.’
In his view, this could take the shape of a practitioner including at least one or two basic questions on debt as part of an assessment when they take on a client, and also developing their links with debt advice services so that they know who may be able to offer the client specific financial advice, even whilst they are continuing the therapeutic process.
The confusing world of debt counselling
What’s clear is that for a vulnerable person seeking specialist help, alone or on the internet, the world of ‘debt counselling’ is at best confusing. The very term – which many of us might imagine suggests some form of psychological expertise – is something of a misnomer. Debt counselling is offered via phone lines like Credit Action, Consumer Credit Counselling Service (CCCS) and Business Debt Line and consists of independent but purely financial advice. In the event of any associated psychological issues, such services say they refer straight on to organisations offering generic counselling.
For money saving expert Martin Lewis, this division in provision can be problematic. ‘We have a real problem,’ he says, ‘in that there are people out there who are very good at debt counselling and there are people who are very good at counselling and they are not the same people. When you are in severe debt and it’s causing stress, anxiety and catastrophe in your life, you want one person.’
He points out that therapists are right to be careful about giving any form of financial advice because, unlike the field of counselling and psychotherapy in Britain, the area of financial advice is regulated. However, depending on a practitioner’s orientation, he wonders whether it might not be possible, as part of the therapy process, to go through a simple budget planning exercise looking at the relationship between a client’s income and their outgoings.
Judging by the posts on his website, moneysavingexpert.com, Lewis says the impact of debt on people’s lives is increasingly concerning. For example, he says there is a rapidly rising number who say they feel suicidal. He argues that young people in Britain are these days ‘educated into debt’ by a system which forces them to borrow to go to university, but they are not ‘educated about debt’. As a result they ‘get the credit card habit’ early on, which, in an increasingly materialistic society, he warns, is dangerous. ‘We are going to see more and more of this,’ he says. People value themselves in terms of how much money they are worth and what they have got. That causes debt problems. This is something that we are not going to be able to move away from as a society, so we need to be able to deal with it.
Supporting people with mental health problems
One project set up specifically to deal with debt and mental health together is based at Solent Mind in Southampton. It’s a joint venture between Mind and the Citizens Advice Bureau (CAB) started in 2007 with Big Lottery funding to provide help with debt and money issues to people diagnosed with severe and enduring mental health issues such as depression, schizophrenia and bipolar disorder. The project, which today receives between eight and 12 new referrals a month, offers practical help, working with clients to ensure that they are claiming all the benefits to which they are entitled, as well as negotiating on their behalf with everyone to whom they have built up debts. At times this may result in getting the debt written off, at others agreeing a realistic timescale for it to be repaid. The project also offers psychological support.
‘You might be talking about a person’s debt,’ says project worker Michelle Vickery, ‘and whilst doing so they feel comfortable enough to discuss other things that have happened in their lives. This is quite often the first time they have talked about their issues to anyone. They know you are just there to support them.’
Whilst Vickery and her co-workers have experience of offering psychological support to such client groups, they are not, she stresses, trained counsellors – and what they offer is not formal counselling. So would it, I wonder, be helpful for some of the people she works with to have access to counselling around their debt and money issues? ‘In an ideal world, it could be quite beneficial to do this work in tandem with counselling,’ she says. ‘For some of them, it would be useful to identify behaviour patterns around spending earlier before debts build up.’
A worsening problem
This kind of thinking is key to an area of work rapidly expanding at The Priory Hospital in Glasgow. The centre, which takes private as well as NHS referrals, is a psychiatric hospital dealing with general psychiatric problems including drug and alcohol addiction and eating disorders. In the last 12 months, director Dr Alex Yellowlees reports a significant increase in the numbers of people being referred for depression, anxiety and other stressrelated problems – and has just opened a new clinic in Edinburgh to cope with greater demand. ‘Not only has there been an increase in the numbers of patients with these kinds of conditions,’ he says, ‘but the factors they cite when telling their stories include much more commonly, and very frequently, issues directly related to financial pressure and therefore job pressure. There is undoubtedly a connection between the global economy, the credit crunch in our country and the kind of problems that people are presenting with.’
Yellowlees points out that the kind of psychological conditions he generally works with are almost always triggered by life events and says what is happening currently is that these life events are impacted by the general economic situation. The resulting symptoms, he points out, can then lead to further difficulties as people try to cope by turning to drugs or increasing their intake of alcohol.
Whilst The Priory Hospital has no specific programme to work with these issues as yet, Yellowlees says they are currently appearing frequently in clinical supervision and are now becoming a significant point of discussion. His approach is what he calls the standard evidence based practice for anxiety and depression of a combination of antidepressants, CBT and/or supportive psychotherapy. What can be slightly different in this area is the flavour of the work, which has a hint of coaching about it. It may, for example, involve reviewing a person’s work life, their finances, thinking about this with their partner and evolving an action plan that enables them to start feeling empowered. ‘I would say we are giving more guidance here,’ says Yellowlees. ‘It’s more of a structured piece of help in terms of supporting people to cope with the financial situation they are in.’
Private life coaching may be another avenue for those with enough money to be able to review their money problems in this way. Former financial advisor and Windsor-based chartered occupational psychologist Kim Stephenson charges £100 an hour for his consultations, so he rarely sees those at the lower end of the income scale. His clients generally come via their employer to talk about their difficulties. He describes his approach as eclectic, drawing on CBT tools and working to strengthen an individual’s resources.
‘I talk a lot about goals with people,’ he says. ‘What tends to happen is that people set their expectations according to what they have now. But, once they get to their goal, the expenditure goes up. They buy the organic stuff, the bigger car that uses more petrol, they do the extension to the house and so on, and then they need more money.’
He encourages clients to set goals for where they want to be, rather than where they are now. This involves starting to think about what is important to them – and if they arrive in debt, the initial target may simply be to be debt free. ‘If someone has £20K on credit cards – which is not unusual – it may take one or two years to get and keep it under control,’ he says.
Stephenson uses the GROW model6 as a simple behavioural plan:
G Goal: what do you want now?
R Reality: what situation are you in now?
O Options: what could you do about this?
W Will: what is your motivation here and what change are you willing to make?
He says he tries not to come up with suggestions himself, but rather to facilitate the client to think for themselves about their possible solutions. He holds in his mind the transtheoretical stages of change7, working in many cases with motivational interviewing to help a client move from a precontemplative stage to a contemplative one before they can engage with the planning, action and maintenance of change.
He also draws on existential approaches to think with a client about the meaning that money holds for them in their world. And he has his own views on the shifting social mores around how much people earn. ‘No one is quite sure of what his or her role is anymore,’ he says. ‘Women are earning more money, so men have lost their roles as breadwinners and are meanwhile making bigger and bigger displays of the money they have. Women without children are keeping quiet about the amount of money they earn, whilst those with children are feeling guilty about not bringing in the same amount of money as their partners. There’s a spiritual void and people are starting to equate everything with money.’
Financial recovery counselling
Surely, one might think, an interesting area for psychotherapy work. So, if few practitioners currently feel comfortable entering this territory, perhaps the answer is to train them to do so? This is the current project of California-based Karen McCall who 20 years ago created the Financial Recovery Institute to help people discover the root of their ‘self-defeating money behaviours’ and implement the changes needed for ‘financial wellbeing’. McCall is not a psychotherapist, but pulls together her academic interest in psychology and experience of the corporate world, with her years as a therapy client working towards understanding her own ‘reckless’ spending habits, and ongoing supervision from a therapist as well as a financial consultant.
From her own therapy, McCall says she learned about the connection between money problems and being psychologically shame-based with low selfesteem, not having had modelling in early life about how to meet basic needs.
Today it informs her way of working with clients, a model in which she views money as a ‘tool’ through which it is possible to explore a person’s whole value system, the areas of physical and emotional deprivation in their life and their sense of guilt and shame.
Over the years, she has evolved her own aids for the work, including a chart to enable a client to visualise themselves on a recovery scale, the ‘personal money autobiography’ to explore their historic experience of and relationship to money, a ‘work history’ to connect them – perhaps via a meditation – to their feelings around earning and a minutely detailed ‘roadmap’ of spending for the month. For many, she argues, such a holistic approach is transformational. But it doesn’t come cheap. Whilst her graduates charge upwards of $100 an hour, McCall charges $300 and works for anything from a few sessions to 15 years.
Training is the main focus of her business today. She began this more than 10 years ago and has launched a range of professionals, including qualified counsellors and psychotherapists, into the field of financial recovery counselling. Her current training programme, at a cost of $17,000, is a 10- month experience which accepts a maximum of eight people a year from across the world and covers business vision, education, working with clients and marketing your business.
It’s run in an experiential way and each trainee goes through his or her own financial recovery process as part of the process. Once qualified, of course, those who are practising counsellors or therapists have to be clear about the boundaries between this work and their general therapeutic practice. Unlike the situation in Britain, the field of counselling and psychotherapy is regulated in the US, whilst the financial advice sector is not.
Back in Britain, there are clearly the beginnings of a clinical debate about how to work with people who bring their money problems into the consulting room. And, whilst there may not yet be a formalised system for training or CPD for this, there are indications that this could change. Money saving expert Martin Lewis, who describes himself as ‘passionate about the interaction between debt and mental health,’ would like to see this happen.
And he doesn’t discount the possibility that his own Money Saving Expert Charity Fund could be involved. ‘I would be interested in an organisation that was looking into providing training in this crossover area – to help therapists get equipped to do this kind of work,’ he says. ‘I believe it is extremely important and I would certainly be happy to give a talk to therapists about issues around money and what might be provided as part of a training course.’
1. Office for National Statistics. The social and economic circumstances of adults with mental disorders. London: Stationary Office; 2002.
2. Mind. In the red. 2008. www.mind.org.uk/mindweek/
3. Sharpe J, Bostock J. Supporting people with debt and mental health problems. Community Psychology. Northumberland: Health Action Zone; 2002.
4. Fitch C, Chaplin R, Trend C, Collard S. Debt and mental health: the role of psychiatrists. Advances in Psychiatric Treatment. 2007; 13:192-194.
5. Fitch C, Simpson A, Collard S, Teasdale M. Mental health and debt: challenges for knowledge, practice and identity. Journal of Psychiatric and Mental Health Nursing. 2007; 14:128-133.
6. Alexander G. In Passmore J (ed) Excellence in coaching. London: Kogan Page; 2006.
7. Prochaska JO, Diclemente CC. The transtheoretical approach: crossing the traditional boundaries of therapy. Malabar FLA: Kreiger Publishing Company; 1994.
|Money is a tool through which it is possible to explore a person’s whole value system, the areas of physical and emotional deprivation in their life and their sense of guilt and shame|
|There is undoubtedly a connection between the global economy, the credit crunch in our country and the kind of problems that people are presenting with|
|There are people who are very good at debt counselling and there are people who are very good at counselling, but they are not the same people|
© British Association for Counselling and Psychotherapy 2011.