Starting therapy: everything you need to know
Are you thinking about starting therapy? There’s a lot to consider, and choosing a therapist can feel overwhelming.
In this post, I’ll cut through the confusion and tell you everything you need to know.
Do you need a therapist, counsellor or psychiatrist?
If you want medication for a mental health condition, you’ll need to see your GP or a psychiatrist. If you’re looking for talking therapy without medication, then you want a therapist or counsellor. The terms therapist, psychotherapist and counsellor tend to be used interchangeably, though sometimes counsellors have less training than therapists/psychotherapists.
How do you find a therapist?
There are three main providers of therapy in the UK: the NHS, charities and private practices. There are pros and cons to each:
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Pros:
it’s free to access
Cons:
waiting lists can be long
the number of sessions you can have is limited
it requires a GP referral on the basis of significant mental health need
you are unlikely to be able to choose your therapist
heavy caseloads can mean therapists have less ‘headspace’ per client
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Pros:
usually free or low cost
if the charity focuses on a particular issue, they may have specialist expertise
Cons:
services are often provided by trainee therapists
waiting lists can be long
the number of sessions is usually limited
you are unlikely to be able to choose your therapist
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Pros:
it’s usually possible to start straight away
you can have as many sessions as you want
therapists manage their own caseloads so can avoid taking on more clients than they can handle
therapy rooms tend to be nicer than at charities or NHS clinics
you can choose your therapist
Cons:
more expensive than charities and the NHS
If you are looking for a therapist in private practice, good places to search are the BACP Directory and Counselling Directory.
Do you need a specialist?
For most issues, you don’t need a specialist. Any therapist will be able to work with common issues, such as anxiety, depression and bereavement. There are a few areas where specialist knowledge is important, particularly gender dysphoria, addiction and eating disorders.
Which type of therapy should you choose?
When you look through therapists’ profiles, you will read about the modalities that they are trained in. To explain these modalities concisely is a challenge, so most therapists don’t bother! That may leave you perplexed, but don’t worry about modalities too much - they’re less important than you might think. The most important thing is how comfortable you feel with the therapist.
If you’re new to therapy, I suggest you choose an integrative therapist. They are trained in multiple modalities, so can adapt how they work to suit each client. It saves you the guesswork of trying to predict which modality is best for you.
And if you really want to understand more about the different types of therapy, here’s my simple overview.
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Key characteristics:
use of the relationship between client and therapist to explore how the client relates to others
bringing unconscious material into consciousness
relating current difficulties to childhood influences and experiences
Modalities include:
psychoanalysis
attachment theory
cognitive analytic therapy (CAT)
Adlerian therapy
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Key characteristics:
focus on the client’s ‘here and now’ experience
trust in the client’s potential to move themselves towards psychological wellbeing
emphasis on the therapist being genuine and providing acceptance and empathy
Modalities include:
Gestalt therapy
psychosynthesis
person-centred counselling
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Key characteristics:
focus on problem-solving and enacting change
attention to thought processes and corrective cognitive distortions
experimenting with changes in behaviour
Modalities include:
cognitive therapy
cognitive behavioural therapy (CBT)
rational emotive behaviour therapy (REBT)
solution-focused therapy
The British Association for Counselling and Psychotherapy provides more information on various types of therapy.
How much does therapy cost?
There’s quite a range of fees available, from free to over £200 per session.
When it’s hard to differentiate between therapists’ profiles, it can be tempting to think you might as well go for one at the cheaper end of the scale. Be aware though that there is an element of “you get what you pay for” in therapy. Therapists sometimes lower their fees because they’re having troubling attracting and retaining clients; good therapists don’t need low fees to attract clients. So my advice is to pay as much as you can afford on an ongoing basis.
There are various websites that offer low-cost models of therapy where you are matched with one of their hundreds of therapists. I don’t recommend them because the rates they pay their therapists are low, so I wonder whether therapists are on the sites because they struggle to keep clients. Also, some of the sites require therapists to take on high caseloads in order to be able to make a reasonable living, so your therapist may not have as much headspace available for each client.
Should you have sessions in person or online?
This is a matter of personal preference - both work. Here are some points to consider before making your decision.
Online sessions need you to have somewhere you can talk freely without fear of being overheard.
Meeting in person enables your therapist to pick up on your body language more.
With online sessions, you can choose a therapist in another part of the country, for example if you are looking for a specialism that isn’t available near you.
In-person sessions give you the journey to and from therapy, which can be a really valuable time in which to think about what you want to discuss, reflect on what you have discussed and gradually transition between therapy and everyday life.
A poor internet connection or other technical issue can make talking about something sensitive much harder in online sessions.
Many clients choose to have most of their sessions in person, with online available as back-up for those times when getting to the therapy room is difficult because of work, illness, etc.
What should you look for in a therapist?
First of all, do look for a person! While AI chatbots are great for occasional problem-solving or validation, what they offer is not therapy. Ultimately, you know you’re talking to a computer, and understanding and acceptance mean more when they come from a person. Also, a chatbot can’t see your body language or pick up on which parts of your story make your voice quiver or bring tears to your eyes. Therapy with a person is a much richer experience than support from a chatbot.
For many years I’ve recruited therapists for a central London practice. Seeing how those hires have worked out has given me a lot of insight into what makes a good therapist and what are red flags. When choosing your therapist, I recommend you look for someone who has:
strong boundaries - you want to know that your therapist is willing to say things that might be hard for you to hear; if a therapist is too accommodating, for example they don’t charge for missed sessions, I wouldn’t trust them to say the hard stuff in the therapy room
a photo you’re drawn to - the most important factor in whether therapy works well is whether you feel comfortable with your therapist, so listen to your gut instinct
at least five years’ experience - most therapists take a few years to become confident in the work
a professional online presence - a well-written, clean website and a professional-looking photo suggest someone who takes their work seriously and will be reliable and conscientious
nothing on their website about their personal life - being able to resist talking about one’s own life is an important skill for therapists, as it allows clients to talk more freely.
What should you say when you first contact a therapist?
There’s no need for a lot of detail in your first contact. I recommend saving your story for the initial consultation, when there will be time to go into it more fully and for the therapist to understand you better. So when you first make contact, all you really need to do is arrange an initial consultation.
What will happen at your initial consultation?
I can tell you what happens in initial consultations with me; other therapists may do things a bit differently.
I welcome you into my therapy room, which is a calm and private space.
I explain that we have 50 minutes together, mostly to talk about you and what’s bringing you to therapy, but that you should also feel free to ask me any questions you might have.
I ask you to fill in a short form to find out, for example, whether you have any mental health diagnoses and whether you are on any medication that impacts your mental health.
We talk a little more about your answers on the form.
I invite you to tell me about what’s bringing you to therapy. This part takes most of the session. If you find it hard to talk about or don’t know what to say, I help you by asking questions. I make it clear that you don’t have to talk about anything you don’t want to talk about.
I may ask for brief information on any aspects of your life we haven’t already talked about, for example work, family or relationships.
I ask if you want to continue with regular weekly sessions. There’s no pressure.
If you want to continue, we find a time that works for you and I book you in.
If I don’t have a time available that works for you or if you don’t think I’m the right therapist for you, I offer to refer you to one of my colleagues. If you want that instead, and I send them my notes from our session so you don’t have to start from scratch with them.
I take payment by debit card, credit card, cash or bank transfer. As I appreciate there’s a gamble involved in booking a therapist you don’t know, I charge 50% for initial consultations so the gamble isn’t so great.
How many sessions should you have?
I’m afraid it’s impossible to answer this one, as everybody is different and there are lots of factors involved. If your issues have been in place for decades, don’t expect to change them in a few weeks. That said, you can expect to feel some improvement within a few weeks.
I work in an open-ended way, which means you continue to come for as long as you find it helpful and are free to end at any time.
How often will your sessions be?
Most therapists see their clients weekly. Some therapists offer fortnightly or ad hoc sessions, but I’m not a fan. There’s something very helpful about having therapy at the same time each week. Fortnightly or ad hoc sessions can feel like dipping a toe into therapy rather than engaging in it fully. Some therapists (mainly psychoanalysts) see their clients multiple times each week. This can be very helpful for doing in-depth work, but isn’t needed (or practical) for most people.
If you have any questions about starting therapy that I haven’t answered, do please let me know and I’ll be happy to answer them.
If you’re thinking of starting therapy, I encourage you to take that next step and book an initial consultation.