Therapy, and how to find one that works

People choosing therapy generally start by researching modalities, which is the least predictive variable in the outcome research.

What predicts outcome

Decades of comparative research have found that different bona fide therapies produce broadly comparable outcomes for many common presentations — a finding robust enough to have its own name in the literature.

What consistently predicts outcome is the therapeutic alliance: the quality of the relationship, agreement on goals, and agreement on the tasks of therapy.

Client factors and expectancy account for a substantial share.

Specific techniques account for less than the debates about them would suggest, though they matter more for some conditions than others.

Which means the practical advice is to prioritise fit and competence over school, while noting the exceptions below.

Where the modality does matter

Specific conditions with specific evidence.

Exposure-based cognitive behavioural therapy for phobias, panic and obsessive-compulsive disorder, where exposure and response prevention is the active ingredient and generic talking is not equivalent.

Trauma-focused therapies — trauma-focused CBT and EMDR — for post-traumatic stress disorder.

CBT for insomnia, which is a specific protocol rather than general therapy.

Dialectical behaviour therapy for emotional dysregulation and self-harm.

Family-based treatment for adolescent eating disorders.

And behavioural activation for depression, which is simpler than it sounds and as effective as more elaborate approaches.

If your presentation is on this list, the modality is worth insisting on.

The main approaches in brief

Cognitive behavioural therapy: structured, time-limited, focused on the relationship between thoughts, behaviour and feeling, with homework between sessions.

The most extensively researched.

Psychodynamic therapy: exploring how past relationships and unconscious patterns shape current difficulties, generally longer and less structured, with a growing evidence base.

Person-centred and humanistic therapies: focused on the relationship itself and on the client's own direction.

Acceptance and commitment therapy: changing the relationship with difficult thoughts rather than their content, organised around values.

Systemic and family therapy: treating the relationship system rather than the individual.

Integrative practice, which most experienced therapists actually do regardless of their original training.

How to check someone is legitimate

An important practical point, since in many countries the title of therapist or counsellor is not legally protected.

Check registration with a recognised professional body, which can be verified on their register rather than taken from a website.

Check that they carry insurance and receive supervision, which is a professional requirement rather than an optional extra.

Check specific training for specific problems — a therapist treating trauma should have trained in a trauma modality.

Be wary of anyone promising cures, guaranteeing timescales, or discouraging you from seeing other professionals.

The first sessions

Most therapists offer an initial consultation, and it is reasonable to speak to more than one before committing.

Useful questions: how they work, what a course might look like, roughly how long, how progress will be reviewed, and what happens if it is not working.

What to notice: whether you feel heard rather than assessed, whether they can explain their approach without jargon, and whether you can imagine being honest with them.

Feeling uncomfortable is not itself a bad sign, since therapy is uncomfortable; feeling judged, dismissed or unsafe is.

When it is not working

Worth planning for.

Raise it with the therapist, which is a legitimate and useful conversation and which a competent therapist will welcome rather than take personally — ruptures repaired in therapy are associated with better outcomes than therapy without them.

Expect to feel worse at points, particularly in trauma work, which is not the same as it not working.

Review at an agreed interval rather than drifting.

And change therapist if there is no shift after a reasonable period, which is not a failure of either party.

Access

The practical constraint for most people.

Public provision exists in many systems with waiting times that vary from weeks to years.

Charities and voluntary organisations offer low-cost or free counselling in most countries.

Training institutes offer reduced-cost sessions with supervised trainees, which can be very good.

Employee assistance programmes provide short-term work-funded therapy.

Guided self-help based on the same principles has genuine evidence and is worth starting while waiting.

And sliding-scale fees are offered by many private therapists and are worth asking about directly rather than assuming.

General information only, not medical or psychological advice. Consult a qualified clinician about mental health concerns, and seek urgent help if you have thoughts of harming yourself.