Talking therapies for depression: considering talking therapies

A range of different professionals provide various kinds of counselling, therapy and psychotherapy in the UK. When we talk about counselling and psychotherapy here, we usually group the different approaches together for the sake of simplicity and call them ‘talking therapies,’ or just ‘therapies’. Therapies aim to reduce symptoms, increase wellbeing and help people to function better.

Talking therapies generally involve one-to-one interaction over quite long periods of time. For this reason, they are expensive to provide and their availability through the NHS remains patchy. 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. Many GP surgeries were encouraged to take on counsellors as part of their practice teams in the 1990s, and more recently there has been an emphasis on cognitive therapy, or cognitive behavioural therapy (CBT).

Some counsellors use CBT as part of a range of treatments, but others do not, and there is a wide range of access and funding arrangements which vary from one area to another (the so-called “postcode lottery”). Whereas traditional types of psychotherapy and counselling involve long sessions to explore deep underlying issues, others such as computer-led CBT (self-guided CBT exercises accessed online) or brief cognitive therapy seek mainly to teach practical ways of overcoming negative thoughts and behaviours. The cost of computer-led CBT such as ‘Beating the Blues’, developed by the Institute of Psychiatry, is lower than traditional types of counselling and is approved by the National Institute for Clinical Excellence (NICE) as a cost-effective treatment for depression. In some areas this type of treatment is more readily available and paid for by the NHS.

Before deciding on therapy several things need to be considered. For instance, therapy usually costs money, takes time and can be challenging. People can also discover difficult things about themselves. Some people need to be in a safe space to ‘unravel’ as they get in touch with their feelings and gain insight. People can get worse before they get better in therapy. For this reason, people need to decide if they are ready to undergo therapy.

One woman we interviewed was surprised when a psychotherapist told her she was not ready for therapy. The therapist explained that she needed to be more stable on her medication and gather more social support around her. A community psychiatric nurse was assigned to help her prepare for therapy. One young man found he had unresolved issues after therapy because he was not ready to deal with some of the problems at the time.

Was surprised when her therapist told her she needed to be more stable on medication and have…

Age at interview 40

Gender Female

Age at diagnosis 37

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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.

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Says that counselling helped him to talk about troubling issues, but he was not ready to deal…

Age at interview 39

Gender Male

Age at diagnosis 32

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I went for counselling between like ’83 and ’86, it was 3 years almost. There were occasions when I felt [pause] it was very helpful because I was going there and talking about things that were going on at the time… that were troubling me. And having that space to talk made me feel better afterwards; that I’d come away and felt a little more confident and lighter. But on the whole, the kind of issues that were going on at the time, I didn’t manage to get anywhere near resolving any of them.

Why was that?

I think partly it was more to do with me because I felt a strong connection with family, it was always going to be a hindrance in my plans to move away. And I felt that was probably something on my part that I didn’t have that courage to just go out and do what I felt was right for me at the time. I didn’t address the anger issue as importantly as I should have done.

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While some people take to therapy easily, others had to overcome a fair amount of prejudice and fear to benefit from talking therapies. One Brazilian man felt that while therapy was an ordinary thing for the middle classes in Brazil, it was more stigmatised in the UK because the benefit of talking about feelings was not so readily understood.

One woman described herself as initially ‘petrified’ of counselling, fearing she would be forced to talk about painful issues and forgive her parents against her will.

An English acquaintance was surprised he was having psychoanalysis, but in Brazil seeing a…

Age at interview 45

Gender Male

Age at diagnosis 45

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When I told them I was having psychoanalysis, the guy was really, the English guy was really shocked and he said, ‘But why?’ And I said, ‘Well, if you cannot understand why someone has psychoanalysis or whatever, I have to tell you. I had to kind of shock him more and I said, ‘because I was feeling suicidal, is this enough?’

But I said to him, ‘In Brazil or in the US.if you don’t see a psychoanalyst, you have a problem. [laughing]. So it’s almost like, for me it was’ it is still very easy for me to talk about my feelings.

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Her GP dispelled her fears about counselling by explaining what would not happen in counselling,…

Age at interview 24

Gender Female

Age at diagnosis 14

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So she (her GP) tried to explain to me that people don’t have to have the same experience as me in order to try and help me. She wouldn’t put words in my mouth. She would just try and help me get some of it out of my system.

So she explained to me that you know they’re not going to patronise me, they’re not gonna make me feel bad, they’re not gonna force me to talk about anything, they’re not gonna make me forgive. they’re you know. all of these fears and concerns and worries that I had, she brought down a level I suppose.

And, I only agreed to see the counsellor, if she, if she had specifically arranged for as far as I was concerned, the right counsellor to see me. So obviously she knew a lot of them, so she knew the counsellor that I saw, on a very good level. She knew that she would be able to deal with me.

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Men, in particular, can be very resistant to therapy, at least until they have had therapy. One man initially thought that therapy was for ‘anorexic upper-class women’ to talk about their feelings. Instead, he found that he liked his therapist, enjoyed the problem-solving aspects of cognitive therapy, and was able to talk about his emotional vulnerability in a safe environment.

People were sometimes unsure what format talking therapies took, and this made them more anxious about therapy. One man who was struggling with suicidal thoughts wanted to phone the Samaritans (see ‘Resources’ section) but worried that he did not even know what to say.

Unfortunately, some people who have a counsellor/therapist resist seeing them when they are depressed and most need to talk, because they do not want their therapist to think poorly of them. However, skilled therapists always have a warm and positive approach to their clients, depressed or not.

He initially thought therapy was for the mad upper classes and anorexic girls, but then found…

Age at interview 31

Gender Male

Age at diagnosis 17

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I don’t come from the kind of background that goes to therapy. Therapy is anathema in my family, you know you just, were not from that world, were not from’ that class. And so it took a hell of a lot for me to go to therapy. You know A’ nutters go to therapy, B’ therapy makes you a nutter. These were the kind of things that I grew up with. And it doesn’t help. You know, so hostile kind of lower middle class sort of feeling about that sort of thing. Were not the sort of people that do it, do you know what I mean, it’s like people from Hampstead go to therapy, we don’t.

I was sent to the counselling at university, and I fucking hated that, it was probably just the wrong time of life. The sort of walking in, and you’re surrounded by pale skinny fucking anorexics you know and you think A’ I’m a bloke, B’ I’m not one of you lot. I’m sorry I’m voicing what I felt then, I’m not saying what I feel now. You know, I looked around the room and there was these sobbing anorexics and I’m just thinking fuck you, you know what am I doing here?

And you get in there and theres the little box of tissues and you just think oh piss off. And, “How did you feel?” and all that stuff, that’s how I felt it was just like my whole thing was completely negative about it. So you can see where I was coming from. It’s not easy for blokes, especially not blokes from that kind of background.

You know if you’ve got parents who’ve been through this stuff then it’s alright, I’m not sure many people have, but I can still access the kind of hostility I felt then. So it was hard first of all to get over the thing. But I liked the therapist, she was good, and I felt it was practical, it wasn’t about saying oh yeah I really feel your pain. I think again, getting over your prejudice is extremely important.

It was actually about problem solving and at first it was about, “Okay what can we do about this?” And we did talk about experiences, I accessed you know, I don’t know what her method was, I’m not really interested, but we talked a lot about childhood experiences and we, I definitely, it sounds clichd but I did reconnect the pain that I felt as a child, and that I hadn’t properly processed or hadn’t been told it was okay. That was incredibly powerful and it hurt a hell of a lot.

I tended to lead it wherever I wanted to go you know. I found it very good, I quite like, I like talking, it makes me feel better. It was nice to be paying someone [laughs] a lot of money to talk.

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Most, but not all, therapy on the NHS was short-term (e.g., 6 or 12 sessions). Given the scarcity of long-term therapy available on the NHS, some people strung together various short courses of therapy to get the help they needed. Also, a few lucky people were able to benefit from long-term therapy on the NHS. These people found that their issues were complex and painful, and could be addressed only through therapy over the course of years. One woman who started a local support group in her area 20 years ago reflected sadly on her observation over the decades that there was still much need for short-term and long-term therapy for depressed people, and yet so little was available in the NHS. Another woman made an emotional plea for more help from the NHS with talking therapies.

Therapy can involve a long and meaningful relationship where you work on highly personal issues,…

Age at interview 40

Gender Female

Age at diagnosis 37

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I think one of the things about therapy as well is that it’s a relationship. It’s probably one of the longest, most meaningful relationships in my life, and the fact that that person is there, pretty much week in, week out, for you exclusively, for the purpose of helping you get better, is really quite awesome, but you have to want to get better.

Even if you don’t know what getting better looks like, you have to trust the other person that they know what they’re doing enough to be guiding you in the right direction, and that comes from that relationship. And I’m only at the point now of saying things to the therapist that I wouldn’t have dreamed of saying two years ago, because it is a long relationship, and it only exists in that room, and you have to work between the sessions. You have to go away and assimilate what’s happened, you have to think about what you said, what you didn’t say, why didn’t you say what you didn’t say – you know theres an awful lot to process.

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She felt lucky to get long-term therapy on the NHS, since the lack of resources means that so…

Age at interview 59

Gender Female

Age at diagnosis 19

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But I was working for consultant physicians who got me in. So I had a helping hand. If I was anybody, maybe I wouldn’t have got it. I mean I know very few people in all these years who have had psychotherapy. I don’t know what the criteria [are] for choosing who has it, who doesn’t. I know there are very long waiting lists. I know people wait for 3 years, and 3 years is a big chunk out of somebody’s life. It’s just very sad… you know, because I do believe that whilst medication helps people keep going, it’s not necessarily the answer.

But then again that comes from two schools of thought. You’ve got your psychologists, you’ve got your psychiatrists. Psychiatrists are quite happy to write you a prescription for medication. And perhaps that’s when they believe there is a chemical imbalance in the brain, which is OK, I can go along with that… Your psychologist is probably going to say, it’s events in your life, it’s things that have happened, or what is happening… Let’s put the two together, you know, they can go hand in hand.

But because there are so few psychotherapists, because it is so expensive, you know, even within the health system it’s expensive because of the time.

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Pleads for more talking therapies to be provided to help people sort out their problems.

Age at interview 43

Gender Female

Age at diagnosis 39

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And I don’t think theres enough help. You get your bad days, and you need to talk to somebody and it’s…. you need to talk to somebody instead of talking to the wall. And so that’s how it is basically. I don’t think theres enough help out there and enough understanding of it because… I don’t know if it is just depression, or you need help… and you have the bad day, maybe I suppose if you was in a relationship, and you could talk to somebody, then when you go home it might help, I don’t know.

But sometimes you do need to talk to somebody who you don’t know, who understands, instead of chatting to the brick wall. And instead of it going round in your head and trying to sort it out. Or you need somebody to talk to you and push the right buttons to help sort yourself out, basically, yeah.

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For more information on talking therapies see ‘Experiences of antidepressants- Talking therapies and antidepressants’.

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