The prospect of talking to someone about your personal and emotional issues can be a frightening experience, especially if you are not accustomed to sharing in this way, worry what it will all mean or feel concerned about what others may think of you. Deciding to get help is a huge first step, and actually heralds the beginning of your therapy or counselling process. Then there is the minefield of who to see, where to find them, and how to get there. It can be a complicated journey, with many unknowns. Your GP, Health Visitor or Practice Nurse may be some of the first ports of call, to get some advice and direction for getting the ball rolling. If you have trusting relationships at work or in the school that you are attached to, there should now be Mental Health First Aiders, with whom to have a chat.
Sadly, if you are seeking counselling or therapy through NHS services, there is unlikely to be much in the way of choice as to who you see, given the fact that mental health services try hard to cope with ever increasing demands and increasingly stretched staff teams. However, the gender of the counsellor or therapist is something that most services will consider, if this is an issue for you. If there are cultural or language based preferences, some services may be able to assist in this regard too, even if it means recruiting a translation service. The good thing is that mental health services are generally staffed with clinicians from diverse backgrounds, and hopefully you can see someone you best relate with - if this will help you to talk more freely or in a manner that you will feel better understood. The same holds true for clients who may worry about seeing someone who will best appreciate their LGBQT status. It is always right to ask the question and let services know what you need.
If you are fortunate enough to have health insurance or the financial capital to afford private psychological therapy, the prospect of finding the right therapist for your needs is more open, although no less daunting. There are countless directories, and so many different terms to describe services that seem quite similar, that you just can’t be sure. Your mind may swoon with questions - are you looking for a counsellor, and how is this different to a therapist? Why might you look for a psychologist or psychotherapist instead? What exactly is a life coach, and why do people keep talking of CBT, CAT or EMDR !!!! I hope to iron some of these dilemmas out, in the paragraphs that follow.
But, why look for therapeutic help at all?
People look for therapeutic help for a wide range of reasons, so don’t worry about fitting a certain definition or criteria. Simply put, if life does not feel as fulfilling and vibrant as you would like it to be, or once was, you may benefit from talking to someone who is trained to listen and offer constructive ways forward. This is especially so if your feelings are impacting on your day to day functioning and ability to sustain and complete basic tasks to a decent standard. Examples may be not being able to sleep or wake in time, struggling with housework, missing or falling behind in your work role, school refusal (for children), not gaining pleasure in things you used to enjoy, and growing distances in relationships with others
The issues brought to therapy may be manifold, but in my experience the most common concerns are difficulties with mood (sometimes called depression), anxiety (often used interchangeably with words like stress, worry or nerves) or self-esteem (sometimes talked about as low confidence). These three issues - depression, anxiety, and low self-esteem can be the underlying concern for a range of other issues that affect day to day life.
Of course, there are more severe and enduring mental health needs, such as eating disorders, suicidal or self-harm behaviour, psychosis, post traumatic stress disorder, personality disorders and so on, but many of these are often picked up in acute NHS settings, so will not be the focus of this article. This is not to say that clients with such needs should not have a choice in who they see, or the kind of therapy offered. I’d be happy to offer tailored advice, if anyone reading this wishes to get in touch via the website email.
'Outward’ symptoms of depression, anxiety and low self-esteem are often seen as an expression of ‘inner’ or ‘underlying’ emotional difficulties, which need to be resolved. These may be connected to past trauma (e.g. significant loss, life threatening incidents or abuse). Whilst there is a place for working with the symptoms (the outward expression of distress), and making life feel more manageable, there may be a need to address these underlying issues if you are to truly move forwards towards better emotional and mental health. Drug treatments tend to address the symptoms only, sometimes for better or worse, and cannot work on the underlying or psychological aspects of the problem. For that, you will need to seek some form of talking therapy. Infact you should always question why you are being given medication, unless there is a plan for talking therapy attached.
Who should I see?
And here we come back to the conundrum of who to see, which therapy modality will work, and how do you access it? To help you with these issues, allow me to give a very general description of the range of therapeutic services available;
Reflective listening - where you do most of the talking and thinking, with a practitioner who facilitates this process, usually through the use of person-centred counselling which is based in principles of therapist authenticity, empathy and unconditional positive regard for their client. Expect the counsellor to say less than you do in this form of support - some people find this disconcerting, but there is a rationale for why the approach is used.
More prescribed interventions - where the practitioner (usually called a therapist of some kind) is more active in setting tasks and teaching skills to manage how you feel, usually through evidence based practice (i.e. therapy techniques that have been used in clinical trials, and known to be effective in treating certain mental health difficulties).
Development of deeper psychological awareness of yourself - where you are supported over a relatively longer period to analyse and find meaning for your history, feelings, actions and relationship experiences. These therapies are usually carried out by psychologists or psychotherapists with additional training and tend to be concerned with the root of the issue whilst also addressing the symptoms.
It is often contentious to try to differentiate between schools of therapy, or to make evaluations as to which therapeutic approach is more or less effective, more or less deep. There is also much overlap between each of the modalities, such that they are not mutually exclusive. In terms of what works, much depends on the therapeutic relationship, which is an interplay between your need (the kind of problem you are struggling with, but also your personal resources, support networks and resilience), what works for you (which may change over time) and of course the personal characteristics and life experience of the counsellor, therapist or psychologist you see. Any worker in the mental health field should have the skills and integrity to undertake a first assessment and consider the kind of approach that is best indicated for you - even if this means they need to recommend someone or something other than themselves. Always be willing to ask why your practitioner feels they can help, and what you may expect in further appointments that may be arranged.
At risk of being even more contentious, I have attempted to describe key differences in support services available, in the categories below. Where I offer typical fee structures, these are basedservices on the 2019 context, but please also be aware that fees do vary across and certainly around the country. If you are London based, it would be conservative to add an extra £15-£20 onto each fee structure for privately funded sessions. Major cities and conurbations tend to be at the upper end of fee structures, simply because of costs and outgoings for the therapists, counsellors or psychologists themselves.
Counsellors - typical fee £45-£65 per session
Counsellors tend to be very well schooled in reflective listening, although increasingly gain additional training in other aspects of therapy. Counsellors tend to describe themselves as Person Centred, Integrative and some use the phrase ‘Psychotherapeutic Counsellor’, depending on their style of training. Person Centred Counselling, as described earlier, is based on the core principles of authenticity/congruence, empathy and unconditional positive regard. Integrative Counselling tends to draw upon a number of models and approaches to helping. Psychotherapeutic Counsellors tend to have additional, specific skills training, such as Hypnotherapy or NLP (Neurolinguistic Programming). Counselling in its various forms tends to be indicated where the issue is not protracted or enduring, and you are broadly managing to keep up with your daily functioning without significant disturbance. If you wish to work out how you feel, what leads you to behave as you do (including unhelpful habits and addictions) and move towards goals for change, counselling can certainly help.
Psychotherapists - typically £55-£85 per session
Psychotherapists tend to be trained in a particular form of prescribed therapy, for example Cognitive Behaviour Therapy (CBT), Dialectical Behaviour Therapy (DBT), Cognitive Analytical Therapy (CAT), Eye Movement Desensitisation and Reprocessing (EMDR), Systemic Family Therapy (SFT) and so on. They will usually have undertaken a longer period of training, often to Masters or Postgraduate Diploma level, using evidence based treatments which are offered in a time limited period (at maximum 20-30 sessions, but sometimes as few as 3-6 sessions). Psychodynamic or Psychoanalytic is another form of Psychotherapy, and typically involves longer term provision (e.g. it would not be uncommon for a client to see their therapist weekly, for 1-2years or more). Other Psychotherapists are specifically trained to offer creative psychotherapy in the form of Art, Music or Drama, which works for many client groups but can be especially helpful for the elderly, children or those with developmental, learning or sensory difficulties.
Psychologists - typically £85-£100 per session
Clinical or Counselling Psychologists tend to have a relatively longer period of Doctoral level training, and are usually adept with at least one of the above mentioned prescribed and evidence based therapies, often having secondary or third wave training within these approaches. However, Psychologists will also be able to draw on a number of other therapy models to tailor the approach to the person they are seeing. Psychologists have their core training in psychological, personality, cognitive and emotional development. This allows them to conduct in-depth assessments, using psychometric analysis where necessary, to reach a psychological formulation that allows them to both ‘make’ and ‘look beyond’ formal mental health diagnoses, thereby clearly defining the issue at hand and drawing upon the most relevant evidence base for intervention and change.
Psychiatrists - typically £150-£200 per session
It isn’t usual to include Psychiatry in the talking therapies milieu. Psychiatrists are medically trained Doctors, who have expertise in prescribing psychoactive medication to relieve symptoms of mental ill-health. Psychiatrists are trained to make differential diagnoses, based on systems of psychiatric classification – ICD systems in the UK and DSM systems in the USA (which together seem to influence diagnostic conversations around the world). Occasionally they offer talking therapies, but their higher fee structure would usually be a contraindication to their ongoing involvement in this regard, given the regularity and frequency of sessions needed for talking therapy. They usually offer an assessment, and infrequent reviews (3-6monthly) where indicated. If your mental health needs are severe, you may not be able to access or benefit from talking therapy, without the addition of psychoactive medication. Psychiatrists therefore tend to work very closely with Psychologists and Psychotherapists, and vice versa. Some, but fortunately not all, health insurance providers stipulate the need for a Psychiatric assessment before talking therapies can be funded.
Now that I may have enflamed age-old rivalries between professional groups, I must offer a disclaimer! Look at the credentials and experience of the counsellor, therapist or psychologist before you. Ask for their qualifications and experience. Seek references, testimonials or recommendations. You will find excellent provision across any of the modalities that I have described, and you may (rarely) come across a practitioner at any level, who is consistently poor at servicing the needs of their clients. If you come across someone who is less than helpful, do consider giving them feedback and if necessary look at escalating the concern to their professional or registering body (see later in this article).
To conclude, therapy and counselling can be a tough undertaking and there are a few steps that need to be navigated before you start to really make the change that you wish to see in your life. Remember that nothing worthwhile in the world has ever been accomplished without a dose of effort, courage and sacrifice (i.e. an investment of time, money and your ability to exchange doubt for trust within the therapeutic endeavour). The decision to start or return to counselling, therapy or psychological consultation is often the most important one that you can make - my belief is that everyone deserves to use their lives to flourish, grow and become the best version of themselves possible. My question is, why should this be any different for you?