Over Christmas, three professions will have been rubbing their hands in anticipation of what the New Year always brings. Estate agents. Divorce lawyers. And therapists.
I’m no expert on matters of the heart or mortgages, but I can tell you how to find the right therapist. And that means finding the right therapy for you. People don’t always realise that the term ‘therapy’ is incredibly broad, covering lots of types of treatment with a variety of approaches.
Every so often I see a new patient who tells me they are a lost cause. When I ask them why they feel like this, they say it’s because they’ve already had therapy and it hasn’t worked – yet closer questioning reveals that’s because they haven’t had the right therapy. It’s estimated there are at least 500 types, but they don’t all work on all problems.
It’s worth noting that the word can mean different things. Therapy is often used interchangeably with ‘psychotherapy’ – a type of talking therapy that uses key psychological principles to help a patient. But sometimes it’s also used to mean ‘counselling’, which is a little different and isn’t typically considered a treatment for a mental illness. Counselling is a space for an individual to explore their thoughts and feelings to a compassionate listener.
The problem is, when a patient with depression Googles ‘therapy’ and unwittingly ends up having counselling, they won’t be getting an actual treatment for their condition, such as CBT (I’ll explain what this is later on). Many doctors don’t really understand this either – I’ve heard GPs say a patient needs ‘counselling’ when they actually mean CBT.
Psychotherapy, meanwhile, is broadly divided into two areas, defined as cognitive and psychodynamic (sometimes called ‘analytic’). The cognitive approach looks specifically at someone’s thoughts and behaviours and helps them make tailored changes. It’s very problem-focused and good for someone with a mental illness with specific symptoms.
The psychodynamic approach is broader, exploring deep-seated, often unconscious issues. It looks closely at interpersonal relationships, and often focuses on childhood. There are different ‘schools’ of psychodynamic therapy: Freudian (following Sigmund Freud’s ideas), Jungian (following Carl Jung) or Kleinian (following Melanie Klein), for example. In reality most use a combination of different schools.
Sigmund Freud, the founder of psychoanalysis. His ideas form the basis of the Freudian schools of psychodynamic therapy
In the NHS, psychodynamic psychotherapy has largely been overtaken by the cognitive version, though courses are still sometimes offered for personality disorder. What the NHS almost never provides is psychoanalysis (sometimes called ‘analysis’) – this is the same approach as psychodynamic psychotherapy but with sessions three or four times a week over many years.
If you’re not sure what type of therapy is best, don’t guess. If you’re seeing someone through the NHS, then this is usually less of a problem because you should be directed to a service offering evidence-based therapies. But waiting lists are long and the threshold for receiving treatment is often high, so many opt for private therapy. This, I think, is where the problems lie because most people don’t know what type they need.
Some people have private health insurance through their employer. If so, don’t assume they will necessarily direct you to the correct kind of therapist. A psychiatrist will be able to guide you towards the best therapy for your specific issue.
Some charities provide subsidised therapy but again, make sure it is the right, evidence-based therapy for the problem you have.
You can always arrange a one-off private appointment with a psychiatrist to get some advice and guidance. Starting therapy is a big undertaking – you’re putting your mind in someone else’s hands and it’s important you get it right.
One problem is that the term ‘therapist’ is not protected, meaning anyone can claim to be one regardless of their qualifications or training. For that reason, I tend to recommend that people see a psychologist rather than just someone calling themselves a ‘therapist’.
Patients sometimes ask whether they should try online therapy, which can certainly be more convenient and easier to fit into your day. The other benefit is that if you want to see someone with specialist training or experience, you can access them easily wherever they are in the country.
My list below isn’t exhaustive but gives you an idea of the sort of therapies to explore…
Feeling depressed
The gold standard treatment is CBT (cognitive behavioural therapy) which focuses on people’s thoughts and behaviours. It aims to address symptoms of depression and ‘re-train’ people’s brains into a more positive mindset. Typically, it lasts ten to 16 sessions and requires a degree of effort and motivation – there’s homework!
Feeling anxious
Anxiety can be really crippling but again, CBT has the best evidence base for treating it. People often find combining CBT with mindfulness – focusing on the here and now and clearing the mind of noise and clutter – can help knock their symptoms on the head. Anxiety is actually more common than depression, although the two are frequently seen together.
OCD
Obsessive compulsive disorder is very amenable to CBT, too. Depending on how severe the symptoms are, people will typically need between six and 16 sessions.
Panic attacks
Again, CBT is the best for this type of problem. People often need fewer sessions compared to, say, OCD.
PTSD
The most popular treatment for PTSD is EMDR (eye movement desensitisation and reprogramming). During EMDR, in addition to some of the same techniques used in CBT, the therapist asks the patient to think about the trauma while moving their eyes back and forth rapidly.
Eating disorders
A specially adapted version of CBT called CBT-ED is the gold standard. CBT-ED doesn’t address why you have problems with food, but does address the specific behaviour and helps stop it. People will often then go on to have more exploratory therapy such as psychodynamic psychotherapy, or compassion-based therapy, see below.
Self-harming
DBT (dialectical behaviour therapy) is the most common treatment. This is specifically geared towards people who experience emotions very intensely and struggle to cope with their feelings. It is also useful for people who have suicidal thoughts. Once the self-harm has been addressed, people will often go on to do more exploratory work, such as psychodynamic or ‘schema’ therapy, which aims to tackle inbuilt patterns of thought and behaviour.
A difficult childhood
Psychodynamic psychotherapy is incredibly helpful in allowing someone to explore and understand the difficulties they had in childhood and the impact this has had on their lives. Schema therapy is also often used, as is CFT (compassion-focused therapy) and MBT (mentalisation-based therapy), where the therapist helps you think through problems for yourself.
Personality disorder
People with a diagnosis of personality disorder will often be able to have psychodynamic psychotherapy on the NHS. CAT (cognitive analytic therapy) is also sometimes offered – this is a cross between the cognitive and psychodynamic approaches and will typically last 16 weeks.
People don’t always realise that the term ‘therapy’ is incredibly broad, covering lots of types of treatment with a variety of approaches, says Dr Max Pemberton (picture posed by models)
Bereavement
Coming to terms with a death can be tough. Bereavement counselling has good evidence for helping people understand the grieving process and work through it with someone.
Abusive or difficult relationships
CFT (compassion-focused therapy) aims to promote emotional and psychological healing through compassion. It’s very helpful for people who struggle with feelings of shame, inferiority and self-criticism.
Drug/alcohol problems
Addressing addiction is a long process so often needs several types of therapy. In the first stages, a modified version of CBT is often used, specifically aimed at tackling the unhelpful thoughts around a substance. Once they’ve successfully maintained a period of abstinence, people will often consider psychodynamic psychotherapy to explore the underlying reason for their addiction. Supportive counselling or group therapy (including support groups such as AA) can also help someone maintain sobriety.