Talking therapies for depression: finding a therapist

Accessing talking therapies

Current government policy aims to make talking therapies more easily available on the NHS. Guidelines for the treatment of depression advise doctors to refer patients with a new diagnosis of mild to moderate depressive symptoms for talking therapies before prescribing antidepressants. Types of services and the availability of them vary enormously across the country. The NHS in England is increasing the availability of talking treatments through their Improved Access to Psychological therapies (IAPT) programme. You can access these services via your GP, although many IAPT services allow you to self-refer.

Unfortunately, there are shortages of talking therapy practitioners in the NHS, and so there are waiting lists. Some GPs may provide basic counselling themselves their surgeries have a counselling and/or psychotherapy service in-house. Online CBT may be quicker to access than other talking therapies. Some people found their own NHS counsellors/therapists (e.g., from talking to friends or other health professionals) and asked their GP to refer them.

The waiting times for NHS therapies reported by the people we interviewed were in the range of 6 months or longer though this has improved slightly in recent years. MIND the mental health charity did a survey of 2,000 people in 2014 and found ‘Half had waited more than 3 months for an assessment, with 1 in 10 waiting more than a year for assessment’.

A few of the people we talked with felt they had to really fight to get to see a therapist on the NHS. One woman fought to see the only NHS therapist in her area.

Shopping around for a therapist that suits you on the NHS can be difficult because of long wait times and the potential for disappointment if after a delay the therapy is not suitable. For these reasons, some people chose to pay privately for talking therapies, and to find therapists through various means (e.g., internet, recommendations from friends or professionals, through professional associations). Private therapists usually charged between £20 and £50 per session (this often varied with ability to pay). Some people liked having some control where they could choose their private counsellor/therapist more carefully and pay them to listen.

The NHS offers no sure path for getting a referral to a talking therapist, and it’s easy to fall…

Age at interview 27

Gender Female

Age at diagnosis 16

View profile

That probably echoes a lot peoples experiences, that it’s (NHS) just very, very patchy and ad hoc and sort of really random. So it’s like you might get referred somewhere, you might not. You might get help, you probably won’t. It depends, probably, what doctor you get, where you are in the country, what day it is. And you have to pay, which I couldn’t afford to do.

And I got put on this list when I went to see the psychiatrist people, they put me on a list and what they usually do is to say ‘Oh yes, I’ll put you on the list. And then you go back and they go, you say, ‘Did you put me on the list?’ They go, ‘Oh dear, yes, I forgot, I’ll do it now. And then eventually I got this referral and I was like, ‘Wow, I’ve got the referral, I’ve got an appointment. Went in, this woman basically said, ‘Yes, it seems like you’ve got depression and anxiety or whatever. I suggest you go and see a psychoanalyst, go for a student, you have to go 3 times a week and it costs you ‘7 a go because it’s a student so it’s cheap. And I’m like, I don’t have ’21 a week to spend, because at that point I was earning like hardly anything.

Embed Print Transcript

Choosing a therapist

People gave advice on how to choose a private talking therapist, and suggested you needed to visit several therapists before deciding. While approaches were different, the key question was ‘Is this talking therapy good enough for me?’ In the UK, people can call themselves counsellors or therapists with minimal training, so it is important to check their credentials. It was also suggested that people need to trust their instincts and reject therapy that feels wrong, even if you are not sure why.

She realised that a counsellor was not skilled enough to recognise her needs, including her…

Age at interview 60

Gender Female

Age at diagnosis 27

View profile

And [pause], she certainly hadn’t the ability of the counsellor. Straight away I could suss that out. That she even on the first interview, there were things she was going back on shed already asked, or misunderstood things I’d said. And that sounds as if, as if she was at fault and I wasn’t. I think I’d explained myself clearly to her. The counsellor had never questioned me. Shed never come back and sort of given me something I hadn’t said, whereas the, the psychologist was doing that.

And I, how many times did I see her, 3 times I saw her, and she decided that I wasn’t, you know, I wasn’t sort of needy, needing that. And I felt obliged to say, well there are other people and you’ve got such a long waiting list, you know, I’ll go away. And you know, sort of, after that I thought, you know what a waste of time. And a priority appointment of 3 months it just’ when I was telling her things that happen to me when I’m really bad like, I think it’s because thereve been accidents on the railway lines with people, and it brings it to your attention.

And when I’m, it didn’t happen to me this morning when I met you but, when I’m really down it occurs to me when I see a train coming to jump in front of it. And again I get these compulsions, and I have to physically take a step backwards so as not to do it. And these are strong urges. And I was told, ‘Oh, well everybody feels like that from time to time.

Embed Print Transcript

One problem is that when very depressed, it is difficult to judge whether a therapy is good enough. It was suggested that people should make decisions about therapy when they are feeling relatively well. Various ways were suggested for working out if a therapist was OK, depending on what you were after. Clearly one therapist/approach might suit one person but not another.

Among those we talked to, men and women tended to have different attitudes to therapy. Women looked at therapy as an important relationship; you don’t just form a relationship with anyone. Instead, you look for qualities like honesty, positive regard, and trust. One woman liked her current counsellor: she could relate to her as a real human. She appreciated the honesty and challenges in the relationship that helped her to get to the root of her problems.

Her therapist told her she needed to be more stable on medication and have more social support…

Age at interview 40

Gender Female

Age at diagnosis 37

View profile

Yeah, but she (the therapist) wouldn’t see me then. She interviewed me and said that I wasn’t. at that point I wasn’t suitable for therapy. And bearing in mind what I’d said about me choosing to go into, you know choosing to go and see a counsellor before, it came as something of a surprise to be told that I wasn’t well enough.

And I was thrown by that. And she said, no I need a proper support network I need to be a bit more stable on the medication, and I was quite amazed, because I thought, well I need to talk about my problems, I don’t understand the delay. I guess I do now, I think that was probably the best thing for me, that actually I did need to concentrate on – if I’m going to have therapy properly, who was going to support me?

But nobody had ever said to me before, ‘Wheres your support network? What are you doing to get yourself to the point where you can have therapy?’ And I think that kind of almost withdrawing, not withdrawing, holding back on treatment, was actually very, very, it was a really strong thing.

Strong in what way?

It’s not quite the right word. But it was a very powerful thing that I felt, initially I felt, well I need this help, and I thought, well, they obviously know what they’re doing, and if they say I have to be better, then clearly I’m not better. And I think there was a reality check there – that, hang on a minute, I’m actually not well enough to have somebody help me. And they put in a community psychiatric nurse for a couple of months before I started seeing a psychotherapist, so they didn’t completely leave me hanging.

Embed Print Transcript

Says that once you are well and can judge, you need to view your sessions with your potential…

Age at interview 47

Gender Female

Age at diagnosis 32

View profile

You know when you’re in hospital, or you’re severely depressed, you just have to hand yourself over and think, you know, ‘I’m just going to have to work with this. Or, ‘these people are going to have to look after me because I can’t look after myself. But then when you get better, it’s like anything, you need to feel that you can relate to the person you might go and see, I’ve been lucky in that I’ve seen three psychiatrists, and the current guy that I see I get on like a house on fire with. I trust him.

He is open, he tells you, he doesn’t pussyfoot around, he tells you. You have to feel comfortable this is dealing with your psyche, and unless you feel you can trust the person and you like the person’ You have to like them, you have to like them, you may’ On occasions you may not like what they tell you, but you have to like them. And you have to understand that they’ve got your best interests at heart and that they’re interested in you.

I’m sure there are psychiatrists who are not, but you have to feel that they are interested in you. That they are worried that you do stay well, or that you don’t stay well and that they like you as well.

I guess it’s like marriage, you’ve gotta kind of work with someone initially to sort of figure out whether or not you can work with them because you’re gonna be seeing them for a while

Embed Print Transcript

It takes time to know if you can trust a therapist and divulge sensitive information, but you can…

Age at interview 43

Gender Female

Age at diagnosis 40

View profile

I think when you actually have therapy, it’s not easy until you get to know the person who’s giving you the therapy, because it’s a, it’s a trust thing. Because you’re going to divulge an awful lot of very intimate things to somebody that… you don’t know whether you can trust.

Because you might have had a lot of let downs in your life and it doesn’t matter whether it’s just, for example like, OK work set on… because of my job it set on my depression, but I’ve had depression previously, but never a bad as it was this time. But it can dig up all the dirt from previously and you… it’s knowing whether you can gel with a therapist. I mean when you first have your first meeting with a therapist, it’s usually about for half an hour to see whether you gel with each other. And I think when you meet someone you kind of either feel relaxed or you can’t…

And then it’s, they will say to you, “Well yes, you know, I feel fine, I feel quite happy to take you on.” And then they will say to you, “How do you feel about it” and if you say you feel that you are comfortable with that person, then you go ahead with it. And your sessions go on from there, depending on whether you, you know, I mean privately I was on 2 sessions a week, in mental health I’m on 1 session a week on NHS. But it can take months before you can divulge enough to start making the therapy work.

Embed Print Transcript

Describes what she likes about her counsellor, including her human approach, honesty and the way…

Age at interview 33

Gender Female

Age at diagnosis 24

View profile

She is a human being. I know she is human. She is present as a human and shes honest. If I piss her off shell tell me [laugh] because she has feelings too. And this is good for me to know. You know, there has been one, only one occasion I think, she said, ‘What you said then actually hurt me.

And that was difficult for me to hear but in another sense that was good for me to hear because it let me know I’m dealing with a human here, another human being. Shes not a counsellor, shes [name]… I don’t know how I think of her. I don’t think of her as a friend or a sister or anything like that, Shes [name] that’s it. But that’s how I think of her. She is a human being.

She is absolutely honest with me and she is challenging. [laugh] To put it in mild form, she challenges me very much which is good for me because nobody’s ever challenged me before really. I would say, ‘When I was ill’, and shed say, ‘You were ill were you? You weren’t ill. And I would say, ‘Yes I was’ and wed get to the bottom and I would get upset.

And it all boiled down to the fact that I had a big thing about other people and what they thought of my illness because depression is an illness. But a lot of people don’t think it is, they don’t understand that I have been very ill. And weve got to the core, weve got to the root of it, we do tend to, I do tend to with my [counsellor] get to the root usually because she is so challenging. You know, I could have just taken that comment. Well actually I did take that comment a few, it took a few turns before I did actually come back to her about it but shes very challenging.

Embed Print Transcript

The men tended to focus on practicalities and finding solutions when evaluating therapies. Many men liked cognitive behaviour therapy for this reason. One man liked a therapy called ‘systemic consultation’ where his needs were acknowledged, real attempts were made to understand his point of view, the focus was on present difficulties rather than the past, and practical, positive ways forward were discussed. He had previously tried several less helpful approaches to therapy.

Liked the therapy approach called ‘systemic consultation’, which attempted to understand his…

Age at interview 35

Gender Male

Age at diagnosis 17

View profile

I eventually got put on a waiting list for the local clinical psychology team and they have a very interesting approach, which years later, I found out is called ‘systemic consultation… in practice it was. I was sitting in a room with not one therapist but 3 therapists or at least 2 therapists, and somebody in training.

And I was also welcome to bring along other people, friends and my brother on one occasion. And that had the idea of unlike the private therapist, I didn’t feel there was any danger that she might. that they might be keeping me for longer than I needed, or giving me more attention than I needed.

I felt like they could see that I was a person in need, and I needed to come and talk things through. And, basically, they made an effort to try and understand me, and try to see things from my point of view, and slowly’ possibly to put a more positive spin on it. They tended to use a few cognitive techniques.

In cognitive therapy you’re given homework to do. I wasn’t, but they did make suggestions about things I might concentrate on. And I think, by that stage, by 1995, I had put a lot of it together for myself and I really needed a bit more help getting reassurance that I was getting there, and help in putting the pieces together. In trying to develop my social skills a bit more, and maybe get out more, and just try a few things that were a bit more challenging, and I think they were quite encouraging, really.

They’ it didn’t. it wasn’t anything magical this time. I wasn’t expecting them to be able to take what I’ve given them, and come up with a prescription in a sense, a cure. I think they focused on the real world a lot more, rather than some of the previous experiences I’d had where it was all talking about the past and my feelings and my sensation of being adrift and very miserable and talking about the depression itself.

Embed Print Transcript

Suggested checklists for assessing good practitioners included:

  • Do you like them?
  • Do you feel you have been heard?
  • Do you feel they acknowledge and respect your views?
  • Do you respect them?
  • Do you feel safe?
  • Are boundaries in your relationship respected?
  • Will you be able to be honest and tell them the things you are ashamed about in your own behaviour?
  • Do they respect your confidentiality?
  • Is your therapist warm towards you?
  • Do you come away from therapy with a better understanding of yourself?
  • Do you feel they are non-judgemental?

Choose your counsellor/therapist carefully – you need to be able to trust them so you can be…

Age at interview 37

Gender Male

Age at diagnosis 22

View profile

Make sure you are happy with your counsellor if you are going private and paying for it. Because if you can’t be totally honest, it is a waste of money. It is like the way that certain people will get on and others won’t, it is the same. If you come away from any appointment feeling like you haven’t been honest then I think there are problems with that. The first time I saw a psychiatrist, I wasn’t honest. If I had been honest, perhaps I would not have got so desperate.

Embed Print Transcript

One problem in choosing a therapist is that the inevitable imbalance of power favours the therapist. However, a skilled therapist should be able to facilitate a discussion around inequality in the therapist-client relationship to help you better understand how you feel about it. Also, settling on a counsellor/therapist can be confusing because even when talking is helpful in the long run, some sessions can be uncomfortable, leave you feeling angry, or seem like a waste of time. Skilled therapists can help clients work through such feelings.

Another problem with choosing a therapist is that they can sometimes turn out to be wrong for us many months or years down the track. One woman felt a good deal of hurt and rejection when her counsellor suddenly announced after 6 months that she could no longer work with her. Ordinarily, a therapist should be able to tell you after an initial assessment period (approximately 1–6 sessions) whether they feel they can work with you.

She felt hurt and rejected when after 6 months of counselling, her counsellor announced flatly…

Age at interview 33

Gender Female

Age at diagnosis 24

View profile

But what happened, I turned up one day, I’d been seeing her for about a year, but wed had a six-month break in the middle, so I suppose all in all I had been seeing her for six months but I began to trust her and like her and wed begun to talk about things. And I felt as if we were going somewhere.

One day I turned up. She was on, she had fallen out with my GP actually about the medication because she felt I was sedated, over sedated.

And she had had various conversations with my GP and the hospital about my medication, which she didn’t actually have my approval to do so. But what happened, I went to see her one night and I sat down and literally immediately she said to me, ‘I’m very sorry but I don’t feel as if there is any trust in the relationship, it’s completely broken down. I’m not able to work with you anymore.

And this was like, well to me, it came out of the blue. I hadn’t seen it coming at all. There had been no warning signs to me. What was going on with her I have no idea. And as a kind of knee jerk reaction, I said I do trust you and she said, ‘I’m sorry, I can’t work with you anymore,’ and didn’t say anything else. And it was as if she didn’t want to talk, you know, as if it wasn’t really open for discussion so I walked.

I’ve tried to stop analysing it because I’m never going to find out unless I speak to her again and that’s very unlikely that I will ever contact her again. So I don’t know, something was going on with her, it must have been. At the time I thought, my thoughts were, I mean it kind of cut me in half really. I was very upset, ‘God there must be something really wrong with me, even my counsellor is rejecting me. My God I must be so bad’ I must have been in a kind of shock. I was bent over crying and I literally couldn’t walk straight to my car, I was so upset. And it took a while to get over to be honest.

Embed Print Transcript