Reflections upon 3 years of Orchard Therapy, a free therapy service

Niamh: Firstly, it would be great to hear more about what made you and your colleagues want to set up Orchard Therapy. In your article you mention a few factors such a COVID driven shift into online therapy, also the way COVID highlighted societal inequalities and the need for accessible mental health provision. Do you think if it weren’t for COVID, this project wouldn’t have happened or was this something you and your peers were thinking about for a long time?

Ally: It’s something I’d been thinking about for a long time. A few years before setting up Orchard Therapy, I’d read Elizabeth Danto’s book (2005) on the free clinics in Vienna and Berlin in the 1920s and 30s. It made me want to reach out to people who would never access what we do otherwise. And I really believe in the value of what we do.

Getting the project going wasn’t because of COVID, but COVID made the format possible. During the pandemic, the idea kind of came to me fully formed. I wanted to do something that would be manageable for therapists, a ten-session format where things were achievable for the patient and therapist in that time. The simplicity of the design was always really important, so that admin and oversight were kept at a minimum. I used my networks to contact GPs who were sympathetic to how we work and around then is when I got some colleagues on board. Quite a large group were interested initially, and this gradually condensed to a finalised group. I really got the sense, within the organisation, that people were desperate to do something, they were just waiting for the opportunity. That was an eye-opener for me. Learning that people really want to do something to help.

The simplicity remained key and another reason that COVID made it possible was that before that time people would rarely do remote sessions and then overnight everyone just had to make it work. So, that’s another way the structure was kept simple and accessible for people.

Niamh: It struck me from your article that the role of GPs was quite significant to the start and the running of The Orchard Therapy project. Could you speak more on your work with GPs? Were there lessons learned from this workflow?

Ally Kessler: I had a couple of contact GPs who passed the project onto their practices. Their practices tended to be in very deprived areas so they were aware of the social difficulties their patients were dealing with. On the whole, the GP referrals were really good and appropriate. We provided them with guidelines and criteria because we wanted The Orchard Therapy Project to be safe for patients. We wanted to try and avoid taking on people who would become disturbed by such a short span of therapy and then just sent back out into the world.

One of the initial criteria was that the patients shouldn’t be able to pay at all but we learned that a number of them could’ve paid something. But one of the crucial things we learned that was because of their background, they might never have been able to access private therapy. They had no knowledge of where to go, how to choose or how it all worked.

The GPs continue to be communicative by email to ask about when we’re taking referrals. For the patients, I think it’s been really important that they’ve come to Orchard Therapy via someone that they trusted, it’s a positive way to begin therapy.

Since writing the article for New Assocations, we’ve done a few iterations of Orchard Therapy and one of the things we’ve noticed is that it can often act as a prolonged consultation. For some patients, it’s been a way to enable them to find open-ended therapy. So we try to bear in mind that we might be helping people find the thing that they need. That they can now access the world of therapy.

Niamh: It would be great to hear a bit more about the various iterations of the project. Could you highlight some lessons learned along the way?

Ally: Keeping an identity with the therapists as a group has been important. We run a regular clinical meeting to talk about the work. It’s a really supportive environment and it’s well attended. One of the main reasons for this is because of the time-limit on the work we do. We’re not trained for that at all, although a lot of us have done it for charities, agencies and the NHS. Some of us have thought a lot about what it means to work to a time-limit and others haven’t. Ending therapy can be very hard for the therapist as well as the patient. You feel like the work is just getting started, so saying goodbye is really hard. Some patients want to know how they can get more therapy. But others have this internal timetable of the ten sessions in their mind that you can’t mess with. But it can be painful. People usually come in during a crisis, bursting to talk and most haven’t had talking therapy before. So, it’s a very powerful thing. It’s very immediate and stirring and that has to be managed by the therapist and the patient. For us, ten sessions feels incredibly short. Whereas from the GP’s point of view, this is an exceptionally generous amount of time. One of my guidelines to the therapists is, never say ‘just’ ten sessions, be optimistic about what this is, I find that important.

One of our criteria for the GPs is that the people they refer should want to talk and feel like talking is what they need. Often we’re talking to people about horrendous social situations that are unfixable but I think there’s enormous value in having someone to offload to and someone to help you think a bit differently.

Niamh: Is there anything you’d like to say about the other therapists that took part in this project? Do you feel some had different experiences or different takeaways?

Ally: There was a range of experiences. Some patients were easier to work with than others. Some didn’t make sessions and that threw up some questions. We asked the therapists involved about their feelings around working for free and there were a lot of different motivations. Some people felt relief that they could actually do something. Others wanted to support me by supporting the project. People often found themselves working in a slightly different way because of it. We would perhaps try to be more ordinary, more friendly, to make a quick connection.  But ultimately, the guidelines were: don’t do harm, don’t provoke anxiety, be straight with people. And my colleagues were generally happy with those guidelines. I think we also struggle with how much we should say in ten sessions and just how deep we should go in that time, there were varying ideas about that. But overall, there was enormous concern for the patients and an overwhelming urge to do well by them. So, there was a lot of very sensitive work done.

I’ve just started a new iteration of Orchard Therapy with eleven therapists signed up. But I’m about to send out my regular email to the organisation to check if anyone new would like to join us. I always come away being reminded that people really want to contribute and that I’m in a very caring profession.

My organisation in Bristol is beginning work on setting up a low-cost clinic that will be informed by what we’ve learned from Orchard Therapy and I’m working with a small group on that now. It feels like there’s a real momentum to make things happen for people who can’t currently access our work. I’ve been wanting a more accessible clinic ever since I started training and any opportunity to do with that, that came up, I did it. I finished training in 2008, so it’s been a long time coming but it’s happening.

For anyone interested in setting up something similar to Orchard Therapy, I have documentation I can share and would happily talk to anyone that would like to know more.