Not so long ago, many Britons dismissed therapy as a lifestyle indulgence, a short cut used by those not robust enough to work out life's challenges on their own, a byword for a profession peppered with charlatans. Those who did see a therapist, to help with a relationship crisis, say, or an abusive childhood, kept it to themselves, as if needing help was shameful, even taboo.
Recent changes – notably the economic crash of 2008 and its aftermath, government cuts, unemployment, the high cost of living and advances in technology – are subjecting us all to mounting stress, and redefining our attitudes towards therapy in the process. One in four Britons will experience some kind of mental health problem in the course of a year, according to the Mental Health Foundation. An LSE economic thinktank report published last year found that mental illness now accounts for nearly half of all ill-health in the UK, but its share of the budget is so small that three out of four sufferers are not getting the treatment they need.
It is estimated that at least one million adults have seen a therapist in the past year. Aside from the NHS, those in need are turning to specialist charity counselling services, employee-assistance programmes or private consultation. The fact that the profession has been partially regulated, with psychotherapists and counsellors now able to register, voluntarily, with the Professional Standards Authority, enables potential clients to check that they have done the requisite training and achieved the professional qualifications necessary for good practice.
With all these changes in how people access therapy, and the increased pressures on so many parts of society over the past five years, what are therapists and counsellors hearing in their consulting rooms as we come to the end of 2013? Ten therapists, from all across the UK and in a range of disciplines, reveal who is coming to see them and why. Some of the answers are familiar enough: sex, not enough sex, money, not enough money. Others, such as addiction to internet pornography, body dysmorphia, racism, childhood obesity and fears about personal safety – coupled with the fact that clients are getting younger and younger, and more men are coming forward – serve as a startling barometer of the nation's psyche and its sense of uncertainty.
Internet porn addiction
Helen Rowland, psychotherapist, practising for 17 years, Skipton, Yorkshire. Fee: £48 for 50 minutes
You don't tell people your problems in Yorkshire. That's what they say. But people come for therapy anyway. In fact, I have a waiting list.
In terms of who I see, I've probably got a leaning towards educated middle-class professionals, but I'm always astonished that people on a low income will find the money if they have found a therapist useful. They might start with referral by their GP, but when that runs out, they'll keep coming. I charge £48, which is about as much as you could get away with in Yorkshire.
The fundamental issue is always, who am I? How can I be in the world? The questions people used to take to the priest and the wise woman: self, relationship, existence. It's the content that people hang it on that changes. At the moment, I'm seeing sex and sexuality from young people, often in their 20s. A lot of young men make daily use of porn on the internet. I've worked with quite a few who have been sent by their girlfriends because they think they have a porn addiction. And they probably do. But they don't see it as a problem, so they tend not to stay. I said to one man, "Excuse me for saying this, but asking a woman to spit on your hand does not constitute foreplay." It's what he'd seen on porn sites and he couldn't see anything wrong with it.
I've got one young man who realised he had a preference for masturbating rather than having sex with his girlfriend. He came to me because he'd been offered child porn and was horrified. While I don't subscribe to "evil internet" theories, there is a way of engaging with sexual fantasy on the internet that interferes with people's ability to form genuinely intimate, erotic and satisfying sexual relations.
It's immensely sad to see so many people in their 20s. There's a lot more depression, anxiety and general unhappiness than people of that age group used to suffer. I have no scientific evidence, but this is my feeling. My generation – I'm 47 – would talk about hard work and compromise and mutual agremeents, but this generation has a strong sense of entitlement. They are much more comfortable talking about I – I need, I feel, I deserve – but struggle with talking about we. It's a culture that's reinforced the inflated ego. Young people have a discourse of success around having a well-paid job, big house, nice car, and that's much harder to achieve in this economy. Mind you, the Thatcher success story was a myth for most people north of the Midlands.
Jenny Halson: psychotherapist, practising for two and a half years, Leicester. Fee: £50 for 50 minutes
I advertise that I am interested in worries about appearance, and I do get a lot of people with body dysmorphic condition. It's mostly women, but not exclusively, and it's not just about dieting and size. For example, someone may be very concerned about what they see as really dark bags under their eyes, but the therapist is not seeing that. This is not just younger women. There's a huge pressure on everyone to look a certain way, and it's coming from everywhere. Someone might be worried about thinning hair one day and go online for information. Later, they won't feel anxious, but when they go back on the internet, there will be ads popping up about it, reminding them of their worries.
Internet culture is coming up a lot. One concern is an undertone of watchfulness. I hesitate to call it stalking, but it is close. What I mean is the distress people can feel when they become addicted to watching their ex during a relationship breakdown. A lot of clients say they don't want to check – by looking on Twitter, Facebook, etc – but feel they have to. They are seeking the relief of not finding something. If you then come upon a tweet about an ex on a night out, proving they don't miss you, it's painful. It used to be that the effort of leaving your house and driving past your ex's would stop you, but now it's too easy and people can't stop themselves. I want to say, "Just don't do it!" But I don't work directively like that, and it wouldn't stop them anyway.
As a partner in a city-centre practice, about a third of my clients are Asian. When racism comes into the news – an EDL march, say – it comes into the consulting room, too. Among a lot of my clients, whether they are Sikh, Hindu or Muslim, there will be anxieties, such as, "Am I safe?"; "Will people think I am Muslim because I have brown skin?"; "What do people really think when they're talking to me?"
Susanna Abse, psychoanalytic psychotherapist, practising for 25 years, north London. Fee: sliding scale, with no minimum
As the director of the Tavistock Centre for Couple Relationships, what I see is an awful lot of anxiety and feeling stuck. I hear it over and over again: couples feeling that they can't make a decision, feeling too anxious to take risks and clinging on to things, which leads to a lot of avoidance.
There's an economic term, "radical uncertainty", that you can see emerging in people's daily lives. They are talking a lot more about money than before. I'm seeing people like me – middle-aged, whose careers haven't been straightforward, who have been used to lots of choices – suddenly realising that their future is very uncertain. So there's a lot of trying to shore up something that is unsatisfactory.
We have much higher numbers of people coming, more without any money, and more complexity, such as domestic violence and alcohol and drug abuse. There hasn't been as much unemployment as we may have thought, but there is so much fear about work: that there isn't enough, that you'll be kicked out, that there aren't the same bonds underneath us as there were. It's been much worse since 2008. Whether I'm with children's centre managers, or parents' groups in deprived areas, or middle-class couples, I'm hearing the same things: people are under a lot of stress.
There are a lot of very vulnerable families out there, and I think we're going to reap what we have sown. If we don't provide a strong base for families, the consequences are not good; children's capacity to thrive, on all levels, is affected by their family life. Look at something like obesity. Why don't we assume that children overeat because of stress and depression? We know adults do, so why shouldn't children? Instead, we say it's because of diet. The reason these families develop unhealthy patterns of living is that they're stressed and are facing too many pressures.
Andrew Samuels, Jungian analyst and psychotherapist, practising for 41 years, north London. Fee: from £1 to £100 for 50 minutes
It was part of my original training that we offer three hours a week at a very low rate for those who can't afford therapy. I specialise in male vulnerability and have always seen a lot more men than most therapists. Nearly everyone I see has a relationship problem, including not having one. The biggest change is that people are experimenting with all kinds of relationship styles: not living together, not having children, constructing three- and foursomes that exist over time, and much more involvement in what is known as BDSM or kink. At the same time as the growing trend in polyamory, the government is trying to privilege traditional marriage with tax breaks and so on. It's fascinating to see how people are rebelling against the government in their intimate lives.
One man I'm seeing has a female partner who says she's bisexual and wants to bring a particular woman into the structure, but just for her. She doesn't want him to have a sexual relationship with the new woman. He's extremely unhappy: does he end it, what are his limits? He doesn't know. It's the voices that tell you what you should do, rather than those that tell you what you shouldn't do, that are the pernicious ones in life, such as, "You are a man, so you should be strong and stop this from happening." Many men don't realise that they carry in their minds and hearts very rigid notions of what they should be.
Rebecca Woods, counsellor and psychotherapist, practising for 17 years, Liverpool. Fee: £41 for 50 minutes, plus concessions
I see people of all ages, three-quarters of them women. At the moment, there's a lot around anxiety, self-esteem/doubt and shame – people questioning themselves, feeling socially anxious and worrying about things such as identity and class and appearance. And there are existential crises: who am I? What am I doing in life? Some of these issues relate back to childhood experiences, emotional abandonment and also school, where they may feel they didn't fit in.
I'm also seeing a lot of people in their 30s. There's a feeling that life is difficult and complex, that it isn't working out. Interestingly, these feelings are not to do with the economy, but with expectations and social pressure: what they really want in life versus what they feel is expected of them. Our internal world is often in conflict with the world we occupy with others and society.
One client, now in her 20s, saw her father kill her mother when she was three years old. It seems she's never talked fully about it except to her current partner. She was struggling with a lack of confidence and working in a job well below her abilities. She also simply wanted to grieve for her mum. I started seeing her every week a year ago, and now she comes about once a month. She's getting on with her life, and that's my aim: that people don't need to come. She told me that she felt more at peace and no longer felt the urge to self-harm. She said, "I don't hide behind my smile any more. It's real."
Leilani Mitchell, transactional analyst, practising for 20 years, Crowborough, Sussex. Fee: £60 for 50 minutes
Much has changed in the time I have been a therapist. I used to be told, "Don't phone me at home because my husband doesn't know I see you", but that doesn't happen any more. There have also been changes in what we know – for example, how a baby's brain develops and the huge effect nurturing by the mother or main carer has on the infant. It's very significant. On the one hand, I see women struggling with work, family and higher expectations of life. But I also see people overwhelmed by the pace of work who have decided they want a better quality of life, rather than material gain. It's happening earlier, from around 30.
The number of clients using medication for depression and anxiety is much higher than it was 20 years ago. A lot of doctors are misdiagnosing. A young woman whose father has died is grieving because of the horrendous experience. She's not depressed.
Here is a typical case of a woman torn between career and family. She wanted children, but didn't feel she could give up work, so went back. Then she felt under social pressure to have another child. But that child was more challenging. She was trying to be the perfect wife and mother, with a perfect house, while still working. Then she started having panic attacks. After working at curbing the high demands she put on herself, then realistically looking at the situation, she resigned from her job and got something local and part-time.
As the culture has changed and women have become more independent, the idea that we can do it all has emerged. We can, but there's a huge price to pay, including its effects on the children.
Kate Mollison, therapist, practising for 12 years, Glasgow. Fee: £40 for 50 minutes
I do cognitive behavioural therapy (CBT) for depression, anxiety, work-related stress and relationships, in an employee-assistance programme. I'm seeing a lot of people who are struggling. Mothers juggling way too many balls – working, managing the finances and the family, and not feeling supported by anyone. Fathers feeling trapped either in work or unemployment, needing to pay the mortgage, feeling like wage slaves and unappreciated in the household.
One client in his late 20s was working long hours and also doing a lot of childcare, getting his four-year-old son up in the morning, giving him breakfast and getting him to nursery. His wife had had postnatal depression, so he took on all the responsibilities, including cooking in the evening. He would get very resentful, have a Friday night drink and get aggressive. He came to see me after throwing a glass of wine at a wall. There's a lot of that self-sacrificing for Scotland feeling going on: being both unappreciated and responsible for the other person. This man was terrified that something might happen if he didn't keep working like this. We set him boundaries. He stopped taking his wife's calls at work and taking the child to nursery, clearly stating what he needed to do and what she needed to do.
In workplace counselling, I'm seeing a lot of stress. One woman who'd worked for 30 years in a bank was moved into a different division and told she was too slow. Her name was put on a whiteboard every day because her productivity wasn't as high as the others. This is a lady in her 50s, who helped everyone, but none of that counted.
Social media addiction
Darren Magee, psychotherapist, practising for four years, Belfast. Fee: £40 for 50 minutes, plus a sliding scale
I see a wide range of people – students, couples, professionals, semi-skilled people – and 60% of my clients are men. Internet addiction is something I'm seeing a lot of. Not just pornography but social media: YouTube, online gambling, forums, it is addiction across the whole range. It's interfering in their day-to-day life – studies, work or relationships – so they come to me to try to break away from that or manage it. At the moment they're all male, from a student to a businessman in his 40s. In the short term, we look at how to manage their addiction. In the long term, we look at what they are avoiding.
There seems to be a culture of harshness in the workplace that wasn't there before, as in, I'm lucky to have a job, so I have to put up with being talked to in this way. Staff appraisals, which were once for the employees' development within the organisation, now seem to be more like a tool with which to beat them over the head. Some just leave without having jobs to go to. There is a fear of asking for help: if I'm seen to be struggling, will that count against me?
In Belfast, we are quite open to therapy. I wonder if it's because of our troubled past. If you go back to the early 70s, when things were at their worst, a lot of people dealt with their difficulties with a bottle of whiskey. A generation or two of therapy has changed that. The sectarian divide has never come into this consulting room. I have worked with people who describe themselves as ex-combatants – and I wouldn't say what side – but they come with much the same problems as any ex-service people. That generation, now grandparents, never talk about what the other side did; they focus on what happened and how it affected them. They might have been with the police in the 80s, or they might have been in prison. Many of them have already had therapy, 10 to 15 years earlier; they come back to me with something else, but the past is always there.
Janet Reibstein, psychologist and psychotherapist, practising for 35 years, Exeter. Fee: a sliding scale
I am seeing a large number of people in mid-affair or dealing with the aftermath of an affair. The gender fluctuates. If the affair has been found out, then the women will say, "I want you to see a therapist" and the men will do so if they are terrified they are going to lose their marriages or because they've suddenly realised the huge risk they've taken. Women who have affairs that are not discovered sometimes come to see me because they have reached the point of wanting to leave their marriage. They come to discuss what they will do. Women are more able to be introspective like this.
I'm also seeing younger people. These days, there is much more chance of meeting people at work and making relationships earlier.
My clinic is for depression. I'm seeing people who have had a diagnosis of emotional disorder, not people who are thinking, "Gee, I'm feeling a bit stuck – I'd like to talk to someone." Having said that, I use many of the same techniques as we use in couple counselling to treat the problem. Here's an example. A man who had a good job was made redundant, which totally destabilised him and he had a psychotic depressive break. His marriage was based on a traditional relationship, and suddenly his wife had to do everything. He couldn't get better because she was angry and it kept getting reflected back to him that he was useless. It was a very clear example of redundancy being the blow that created the problem. They got through it, but the hardest thing was to deal with her feelings of disappointment.
Across all cultures, hardiness and adjustment to life is very dependent on having good relationships. Whatever the stressors or conditions, you can resource yourself – or not – by having open, mutual relationships that can make you feel OK about life. Research shows that an intimate partner is most protective, but many good relationships – friends and family – are even better. Some people choose to be on their own, but it is often a question mark that people bring to me: "If I can't be in a relationship, why not – and can I live with that?"
Nicola Blunden, psychotherapist, practising for 15 years, Aberdare, Wales. Fee: £40 for 50 minutes, with a sliding scale for low-income and corporate clients
I work in a former mining town where I see working-class and middle-class professionals, and students. This area has a lot of unemployment. Most of my clients are women, but I am getting more men, especially young ones. They see me as more like a consultant who can be helpful. Counselling is a good resource for people to talk in a way that won't affect family members, as well as a way to find helpful methods and strategies, and men enjoy that. They're looking for tools.
There's a lot of stress now surrounding work. Where there are lay-offs, those left behind are having to do more as their funding is cut and everyone's responsibilities increase, but without more support. Managers are finding it very stressful and everyone is much more scared about losing their jobs.
I use the story of the boiling frog to explain their stress. If you put a frog in hot water, it will jump out. Put it in tepid water and slowly turn up the heat, however, and it will stay there. Stress is incremental and clients have become acclimatised. It's the body that calls a halt to the situation. There's so much adrenaline that you have panic attacks, or get weepy, or can't sleep. It's a red warning light that you are in a dangerous situation.
Many clients present with almost identical symptoms and fears. Everything that used to feel comfortable doesn't any more, such as socialising, shopping, driving, going to work. Your brain associates that as a threat, and people feel that they are going crazy. I explain that shortness of breath, dizziness, thoughts of losing control, tingling in the fingers and nausea are the natural physiological response to danger, but now that danger is associated with lots of different places. If they relax, it can subside. I also encourage them to give their day boundaries, to limit their involvement, and to pass on to senior staff that adjustments need to be made.
I also signpost clients towards mindfulness techniques. If a client uses them daily for a couple of months, they can see the difference. Mindfulness is like a muscle: it gets stronger the more you apply it. Clients become much more compassionate towards themselves. A big contribution to anxiety and stress is negative self-image: I'm not coping, I can't trust myself. With mindfulness, you won't ruminate so much and you have less fear of your thoughts.
• The privacy of each interviewee has been protected and, where necessary, permission to use individual stories has been secured.
Louise Chunn is the founder of welldoing.org, a self-development, wellbeing and mental health website.