More people than ever before are getting therapy, but with over 500 types of therapy available and no regulation, how can you ensure you get therapy that works and avoid the cowboys and charlatans?
By Matt Wotton & Graham Johnston
A recent YouGov poll found that 85% of people now think that it’s a good idea to get therapy.
The UK has moved on from its ‘stiff upper lip’ caricature. People go to therapy for everything from serious depression to feeling stuck at work to struggling to connect with their partner.
And therapists feature in every TV show from The Sopranos to Succession. What do Pope Francis, Harry Styles, Adele, Barack and Michelle Obama have in common? You guessed it — they’ve all had therapy and they all talk about its benefits.
The Problem is that Public Health Systems Cannot Cope with the Demand
Despite massive investment in the UK, described by the New York Times as “the world’s most ambitious effort to treat mental illnesses”, the NHS can’t cope. Although nearly two million people are referred for NHS therapy each year, and another half a million undertake therapy online, that still falls far short of the demand — according to one of the architects of the scheme. Recent BMA research found thousands of patients waiting more than six months for therapy, and as long as two years in some cases.
That Means Going Privately
That’s obviously a problem for those who can’t afford it, but maybe not such a big deal if you’re lucky enough to be able to pay, right? Wrong! Therapy and counselling are lightly regulated compared to other areas of health care. To put it at its most stark, therapy can be provided by someone calling themselves a ‘psychotherapist’, a ‘psychoanalyst’, a ‘psychologist’, a ‘counsellor’, or ‘coach’ — none of which are defined by law, meaning literally anyone can call themselves any of those titles without a single day of training.
In short, you’re wading into a minefield.
Therapists Matt Wotton and Graham Johnston are the co-founders of The London Centre for Applied Psychology (LCAP).
Choosing the right therapist could change your life — that’s what the myriad celebrities say when asked. And choosing the wrong therapist doesn’t just mean wasted time and money. Research shows that some therapists, even those properly trained and accredited, can actually make your problems worse. More generally, some studies have found that the top 25% of therapists are twice as effective as the bottom 25%.
So, how do you make the right choice? Below are the five most important ideas, drawn from our recent book on how to get good therapy, A Straight Talking Introduction to Therapy: What It Is, Why It Works, How To Get It. It offers a simple, factual explanation, based on the latest research, of what works (and doesn’t work) and provides practical suggestions about how to navigate the minefield.
How Do You Choose the Right Type of Therapy and Therapist?
- Pick a tried-and-tested form of therapy.
The good news is there are a range of treatments which have been subject to the same rigorous tests as those used for physical illness, with success rates just as high. Therapy is more effective than almost all interventions in cardiology and research shows that more than three-quarters of people who have therapy are better off than those who don’t. Cognitive Behavioural Therapy (CBT) is the most thoroughly researched, but there are others evidence-based treatments, too. We list them in A Straight Talking Introduction to Therapy and evaluate the evidence for each.
2. Ask lots of questions.
Ask lots of questions about your therapist’s training, specialisms, qualifications, and how they keep up to date with research. Question your therapist as you might a doctor about to operate on a loved one: why this particular approach, and what’s their track record with people in a similar position? Check they are who they say they are too, via the relevant statutory or professional register, or by using directory sites like psychologytoday.com and welldoing.org, which only list verified therapists. Use your intuition too: do you feel comfortable with them and do you trust them to help you?
3. Don’t assume all therapy is the same.
Teenagers with OCD need a different approach to a couple who are constantly arguing. Dealing with addiction requires a different approach to dealing with depression. Some therapists claim to do it all. Be wary of those claims. Be wary of fads, too. As a rule of thumb, if the treatment is not recommended by NICE (The National Institute for Health and Care Excellence, which produce independent evidence-based recommendations available via their website), steer clear. At best, you’ll be paying for something unproven; at worst, you’ll be paying for snake oil.
Therapy can be a minefield. This eye-opening book will guide you through.
4. Take your preferences seriously.
Counselling, coaching, and psychoanalysis are very different approaches. If you want tools and techniques, you’ll benefit from a different kind of therapy to someone who wants to explore their unconscious motivations and the impact of their childhood. Numerous studies show that therapy matched to clients’ preferences result in more positive outcomes.
5. Be honest about how serious you are about change.
Therapy is hard work; you get out what you put in. If you turn up late, aren’t honest about what you’re feeling, and constantly blame others, therapy won’t do much for you. If you’re not ready, save your time and money.
There are many more ideas in our book, plus questionnaires and links to online assessments which will give you the best chance of finding the right therapist. There’s also a summary of the NICE guidelines and a chapter on psychiatric drugs, apps, and AI.
Conclusion
Mental health has never been more important; it’s arguably the UK’s biggest social problem, with at least a third of us expected to experience problems with our mental health at some point in our lives. Yet it remains chronically under-resourced. If you, or someone you love, wants help quickly, you will need to see a therapist in private practice. In that case, you need to know the right questions to ask. That will not only save you time and money, it will give you the best chance of getting the life-changing help that therapy offers.
A Straight Talking Introduction to Therapy: What It Is, Why It Works, How To Get It by Matt Wotton & Graham Johnston (PCCS Books) is out now on Amazon in paperback and eBook formats, priced £12.99. For more information visit www.lcap.co.uk or follow The London Centre for Applied Psychology on LinkedIn, Twitter, or Facebook.
Q&A Interview With Matthew Wotton & Mr Graham Johnston
With their new book, A Straight Talking Introduction to Therapy: What It Is, Why It Works, How To Get It, leading therapists Matt Wotton and Graham Johnston have delivered nothing less than an essential ‘Good Thought Guide’. To mark its publication, we spoke to them to find out more.
Q. How can we be sure that therapy actually works?
A. The evidence proves it. Time and again, for the last 50 years or so, the research shows that therapy works. It doesn’t work for everyone, but what intervention does? The effect size for therapy is bigger than almost all interventions in cardiology and greater than the success rate of flu vaccinations. Seventy five people in every 100 who have therapy end up with better mental health than those who don’t.
We’ve seen the anecdotal evidence, too — in our own lives, and in our clients’ lives. They leave therapy feeling more confident, making better decisions for themselves, and living richer lives.
Q. Given the prevalence rates of mental illness in the UK, isn’t the only sane answer more resource for NHS provision?
A. Ideally, yes. But pushing that agenda is like shouting into the wind. Mental health gets about 15% of health spending at present. That obviously needs to change, and probably will. But it’ll take decades to get anything like parity of esteem with physical health.
So, inevitably, people are looking instead to the private sector. That’s where we’re trying to help: how do you get the best help you can if you need to spend money on your mental health outside the NHS?
Q. If we’re relying on the private sector, then why not call more clearly for it to be properly regulated?
A. There should be more regulation, as literally anyone can set themselves up as a therapist at the moment with no training at all. That debate is underway, and other industries have achieved it, but it’s going to take a while. What’s more immediately important than regulation at the moment is ensuring that people have decent information available to get the best treatment for them in a field where literally anyone can set themselves up as a therapist.
So, that might involve making sure that their therapist is a member of one of the main industry bodies like the BACP or UKCP. It might mean asking the right questions of their therapist at their first session, to make sure they’re in safe and competent hands. It might mean changing therapists early if they’re not the right fit. It might mean having a quick check of the NICE guidelines that deal with their specific issue, to make sure they avoid fad interventions that have little if any evidence to support them.
Q. Isn’t the answer to the question of how to get good therapy just ‘follow the NICE guidelines’?
A. There are many problems you might be experiencing for which the NICE guidelines are a useful guide to what the evidence shows is best placed to work for you. For example, if you struggle with obsessive compulsive disorder, the NICE guidelines show that the best treatment is exposure and response prevention therapy, a form of CBT. That’s hugely helpful.
But loads of therapy doesn’t fit into neat boxes. Knowing who is most likely to be able to help you deal with a break-up, the death of a parent, the decision to end the relationship you’re in — these are life issues where finding the right therapist is less about the NICE guidelines and more about your preferences, and whether the therapist is the right fit for you.
Q. Surely technology and apps mean things have moved things on from sitting and talking for an hour a week?
A. Yes and no. AI is likely to help even more in the near future: helping clients identify in between therapy sessions how they’re feeling and what’s likely to help, for example. Tech like virtual reality has decent results on helping with specific problems like phobias and PTSD. But the bulk of work will remain human-to-human for some time to come — working out what cycles of behaviour and patterns of thought you get into, where those patterns come from, and identifying what’s likely to help get you out of them.
Q. There has been a boom in therapeutic guidance being sought and delivered via social media. Is this a good or bad trend?
A. It’s neither good nor bad. It’s great that people are taking their mental health more seriously, and doing so publicly. Some brilliant interventions are so simple they can be distilled easily on social media: eat well, exercise more, prioritise sleep, talk to someone. But, of course, there are downsides: too much victimhood using therapy-speak, too much simplicity where there needs to be nuance, and too much opportunity for unhelpful fads to gain traction. Some problems are complex, sticky, and take time to work through, and lots of hard work to improve day by day, week by week.
Q. A Straight Talking Introduction to Therapy talks about a variety of mainstream therapeutic approaches but you don’t show your hand. What approaches do you use?
A. We tend to use a combination of CBT, ACT, and attachment approaches. What does that word salad mean in practice? That means we help you to accept the way the world is, rather than the way you want it to be. It means we help you understand how your earliest relationships might be shaping the difficulties you’re having and the mistakes you’re making in your current relationship. It means us encouraging you, challenging you, and supporting you to take responsibility for changing the way you live your life and act in relationships.
For all our clients, we work in a way that takes into account their preferences: do they want us to set them tasks outside of the session? Do they want a bit of challenge or does that intimidate them? The evidence shows that therapists who work in line with client preferences get much better results.
Q. At the end of the day, don’t we all just need to toughen up and become a bit more resilient?
A. That’s a dichotomy that just doesn’t work in reality. Obviously, there are times in life when your feelings just don’t matter and you have to get your head down and get things done. But opening up, being vulnerable, acknowledging your demons, and — crucially — taking responsibility for them, are the best ways to build resilience. That’s not wallowing in victimhood. You build resilience and courage by understanding yourself, your impact on others, and stepping into new ways of behaving when that’s required.
Q. There is a conception that therapy can work for anything but is this really the case? Are there times when even if it would work, it’s best avoided?
A. For therapy to work, you have to want to change. You have to be willing to put in the work. There are all sorts of reasons why that might not apply to you or to this point in your life. For example, you’ve just taken the big promotion, or you’ve got a young family and can’t get the headspace you need to make best use of the therapy. But if you are committed to changing, and committed to the therapy, chances are that it’ll help.
Q. How can it be the case that the differences between the best and worst therapists have nothing to do with age or experience? No other field of expertise shows that.
A. It’s an industry that separates practitioners into ‘schools’ of thought. You spend your working life as a Freudian, or a Jungian, or a behaviourist, or an attachment specialist. But those theories can’t be right for dealing with everything. It’s like going to a personal trainer who says, “I’m going to show you a completely different way to the majority of other PTs to lift weights that’s going to get you strong”. They might be right, but chances are, it won’t work for you. It’s still frustratingly rare for a therapist to say to a client, “I’ll check what the NICE guidelines say, as I haven’t dealt with your issue for a while” or “I don’t tend to work with anxiety, let me refer you to a colleague who does”. A lot of therapists try to treat everything and, inevitably, only help a portion of their clients. The best therapists know the evidence, know what they don’t know, and base their work significantly around client preferences.
